"Just to take a picture"

Another typical crazy night.  Incompetent Charge Nurse (ICN).  Packed waiting room; 14 patient rooms full.  What else is new.  At least I have good docs with me & an excellent 2nd nurse to back me up.  I get report & jump right in.  One of my patients is a 3 year old requiring sedation to undergo imaging.  That's a first for me, how bouncy is this kid, geez!  By 11pm we're ready to sedate & as typical with children & sedation, the oral Chloral Hydrate doesn't even touch him, but instead makes him more hyper.  He's blabbering about eating chips & is trying to pull his cardiac leads off.  We add a mg of Versed & he instantly turns into a miniature, loveable drunk.  Previously reassured about the imaging that he's "just going to get a picture taken" he looks at his mom & slurs: "Ma!   Maa!!  Take a picture!" as a groggy smile spreads across his cute face.  Mom starts laughing hysterically, on the verge of tears from exhaustion.  Thank god for normal parents.  We head off to CT, the remaining Versed vial in my pocket.
We come back & the amount of people waiting to be seen appears to have doubled.  The down-side of doing sedation is that it eats up time, often a LOT of time, because you have to monitor the patient at the bedside, 1-on-1 until he's stable & breathing well on his own without any assistance or supplemental O2.  The ICN seems to have her own idea about sedation as she barks "I don't have any one to give you to monitor your patient.  How long does sedation take, anyway, an hour?!"  When I remind her that post-sedation monitoring alone can take up 30-45 minutes she rolls her eyes & blurts out "What do you think we do over here (in the Adult ER) when someone had sedation? We put them on the monitor & everyone watches them.  Why don't you have a tech watch your kid?"  My jaw hits the floor.  I love my techs, they're very helpful & great but they are simply not trained to monitor or rescue someone from procedural sedation.  So glad I'm leaving this job before I lose my license.

"Frequent Flier"

We're dispatched for an older gentleman having trouble breathing.  At this time of night I'd guess either anxiety or orthopnea (either due to fluid build up or obesity), in this case it was all three.  The dispatcher stresses several times that this is "your usual", i.e. a "frequent flier" - great, either he's non-compliant with his meds and treatment regimen or he's someone that the system simply forgot & tried to sweep under the rug.  Regardless, arriving on scene I'm happy to hear that this is a ground floor apartment and the gentleman is ready to walk out to the ambulance.  My partner moves the truck while I quickly get report from the medics & eye the patient up & down, figuring out the logistics for our next move.  He appears calm & comfortable, without worsening of symptoms upon ambulation in the apartment.  We walk outside to the ambulance together & he eyes the bus up & down, hesitant about how he could get in, and after one attempt it's apparent that he cannot get in under his own power.  We secured him to the stretcher and try to lift >400lbs (~70lb stretcher + >350lbs dead-weight patient), unfortunately on the count of 3 the only thing I feel moving is my back into a tight knot.  "@$&%^!!!" flies through my head.  A few minutes and an extra pair of hands later he's loaded into the truck.  A frequent flier who calls for an ambulance every day, sometimes more than once a day and expects to be carried and lifted into the ambulance each time and we, EMS, are helpless, cannot tell him exactly what's on our mind: get your fat ass up and move around a bit, it'll do your body good, I'm not risking a career-ending injury over your non-compliant ass, especially when you will probably be dead within the next year anyway because you don't take care of your condition.  No, instead we patiently ride in to the hospital, do routine sets of vital signs, and happily report to our next shift that the frequent flier is alive & relatively well, and will most likely be calling them back sometime in the late afternoon for another bogus complaint to hitch a ride to the hospital.  And everybody asks why EMTs & Paramedics are so gruff, pessimistic & irritable; what nobody asks is how many of us are out on temporary or permanent disability because of selfish people like this.  And please, please save me the story of how obesity is a disease, but if you seem to think so, I've got a cure for you - put the fork down!  Same thing goes for alcoholism, drug & nicotine addictions - it's not a disease it's a weakness, perhaps a weakness some cannot overcome, but it is NOT a disease that you have no control over.

"Alphabet Soup: AMA, RSV, RR, SpO2, VBG, pCO2, pH, PICU"

01/02/2011 1845hrs: I come in 15 minutes before my shift as usual & overhear "RSV baby going home AMA". Putting my things down, out of the corner of my eye I see the frustrated parents bundling up a tiny baby, an 8-weeker born 5 weeks premature so he's really only 21 days old. The parents seem anxious to get home & are content that the baby appears to be breathing better & is more comfortable, their reasoning is "we live so close, we'll come right back if anything happens" according to the other nurse & doctor who let them sign out. The ER is packed to the rafters as usual, but I take note of the litte guy leaving, his cute little face covered up with a hat & a bulky winter jumpsuit, and his brief story stays in the back of my mind.

01/03/2011 0500hrs: I instantly recognize the father's voice: "We were here last night & now our baby is having trouble breathing." In a minute I count the little baby's respiratory rate at 60 & the SpO2 is only 91% on room air. In seconds we're in the resuscitation room adjacent to the triage room & by the providence of God I have an albuterol neb in my pocket. The doctor sees me carry the baby in & judging by my facial expression she understands the severity. We take off the familiar blue winter jumpsuit: a further assessment reveals that the baby is struggling severely, with sternal, intercostal & subcostal retractions, wheezing in all fields, and continues to desat to the low 90's on room air; he's also incredibly irritable, truly inconsolable, the only way he knows how to express air hunger. The distraught father comes outside and asks "so how serious is this thing?" - briefly hesitating (how do you tell someone their 2 month old baby could die if his body gives out trying to keep up with these demands) I tell him it affects different babies differently, sometimes it can be very, very serious, as it appears to be in this case. Labs are still current, I start his little IV & draw a venous blood gas off the IV, immediately putting it on ice for the lab to run. The pulse ox probe lights up his entire foot like a little alien limb that glows in the dark, cardiac leads the size of a dime are attached to his chest & plugged into the monitor, revealing a heart rate above 160bpm at all times as the baby continues to cry & struggle. The albuterol & saline nebs calm him down & he dozes off but the respiratory rate never drops below 50-55, at times climbing up to 85 per minute at rest without agitation. More alphabet soup comes in: a critical value is reported by the lab to the doctor: pH 7.11 (the comfortable range for all bodily functions is 7.35-7.45, anything outside that window & the condition can quickly turn fatal) & the pCO2 is 67 - the baby meets criteria for intubation but he's stable with supplemental O2 & saline/albuterol nebs round the clock, his respiratory rate & heart rate decrease to more appropriate levels for a neonate and his SpO2 is stable. At 0730 we go up to the PICU, my little guy sleeps the whole ride up there, with the saline neb propped up next to his face.

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Follow Up:
01/08/2011 0300hrs: While re-reading the ER chart, as I often do, trying to re-live the situation and make sure everything possible was done for the patient, I notice new xray reports that have merged with the chart: my little man has been intubated for the last 2 days and has developed pneumonia. I wish I hadn't looked.
01/11/2011 0300hrs: The little man got extubated yesterday.

"An Accidental Finding"

A gentle, sweet-looking 13 year-old girl comes in with her parents complaining of facial & jaw tenderness, facial droop & slurred speech.  The back of my mind is flashing the warning sign, "STROKE"!, but common clinical sense tells me it's obviously not, another quick glance by the ER physician & she's diagnosed with Bell's Palsy (a muscle disorder), an uncomfortable but non-life-threatening condition, before she's even triaged.  Except for being a little nervous & uncomfortable, the child is fine with stable vitals and no other history.  Blood-work is done & she's scheduled for a head CT as a routine protocol.  The ER is surprisingly busy for Christmas Eve - shouldn't these kids be home opening presents??  Why is an abdominal pain for the last 2 weeks suddenly an emergency tonight?  The radiologist calls the ER doc with the CT results & suddenly everyone else's complaints are miniscule - "8mm mass in the Pituitary, suspicious for a macroadenoma".  Merry Christmas.

"Would you like to make a reservation sir?"

Online Reservation System

"those with truly non-emergent conditions" - shouldn't they NOT be using the ER then????!!!! Why are we encouraging this now with the convenience of waiting at home??!!! What's next, orderyourworkup.com where you pick all the tests you want done regardless of clinical presentation? And this, America, is what really grinds my gears!

"Code 40"

Dispatch: “Ambulance XYZ, you’re going to the South Gate for the fall in the stairwell”

Ambulance XYZ: “Received & responding.”

Cursing under my breath I switch to tactical driving to fight through the game-time traffic.

Cursing even more under my breath I hike up a gigantic flight of stairs that didn’t seem nearly that bad from the bottom.  “Where the hell is the elevator here?!”  A small crowd is huddled around a young man laying at the bottom of the stairs.  His clothes have been stripped off rapidly and I can hear it already, the raspy, ragged breathing.  A quick peek reveals that he’s lying in a pool of blood ("OH SHIT!" is the only thing that comes to mind) but the airway is patent with no secretions or vomit.  Another quick listen with the stethoscope confirms what I can see already, he’s struggling to breathe, with deep, irregular, wheezing respirations.  I shout his name and pinch his shoulder; nothing, completely unresponsive, his body resembles a fish out of water as he shudders with each gasping breath ("will that one be his last?" rushes through my mind; I block out the demon and focus on the tasks ahead).  C-spine precautions are already in place, a collar is applied & he is log-rolled onto a backboard to reveal an even more gruesome picture.  His face in unrecognizable (FUBAR in EMS terms), with multiple fractures, a black eye, and a gigantic blood clot coming out of his nose.  Unbelievably, he starts to moan.  GCS just got upgraded from a 3 (that of a rock) to a 4.  His airway is cleared and the oxygen mask re-applied to his face.  In seconds I evaluate his now obvious injuries: a rigid, bruised belly, a grossly deformed wrist, and bloodied, deformed fingers of the opposite hand.  Looking around for witnesses and trying to keep my cool I ask for the story: the cop relates that the young man fell 30 feet onto concrete and landed on his head, possibly striking the steel railing with his arm.  He doesn’t look much taller than 5’8”.  A fall more than 5 times his height?  Forget major trauma criteria, the fact that he is still breathing seems to defy all laws of physics, gravity and physiology; how can anyone survive this kind of impact?  In just a few more minutes he is loaded up into a waiting ambulance, and in another few minutes he’s in the capable hands of the trauma team at the hospital.  He starts to groan and moves his arms and legs upon transfer; not a good sign – his brain is panicking from the building pressure inside.  My heart sinks, CTD ("circling the drain")?.  He’s intubated and we have to leave.  He’s just 3 years younger than me, a life that has barely started and already seems cut short.  Outside in the parking lot we pack up the trucks and the crude jokes start flying as we suppress our fears, devastation, anger, shock, insecurities, worries and personal problems that suddenly seem so insignificant compared to the phone call his family is about to receive.  We seem like a truly sick group of individuals with bad coping mechanisms, but within minutes we all get back in our ambulances, and like a cavalry returning to battle, we leave the ambulance bay en-route to the next job, the next emergency, the next personal crisis, the next “worst day” of somebody else’s life.  That night we are all left with the gruesome images of the day and an odd sense of wanting to protect our own families by not saying a word about what we witnessed.

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Follow Up:
12/10/2010 0611hrs: I found out via a blog the patient's family has created that 2 days ago he was released from the hospital and walked into his own home!  Back to his normal self, walking, talking, hearing, seeing and joking around.  Absolutely unbelievable, an absolute miracle!

"Charts"

The hardest part about being a nurse are the charts - not even the amount of them or the constant lawsuit looming over you. No, it's the fact that we have to put into words what we see - the incompetence, the neglect, the stupidity, the failure of a system (bodily as well as social) & the "mistakes" people claim to make.  Within seconds we have to recognize all the presenting ailments & conditions & put them into words that the healthcare team will understand and react appropriately based on the severity.  A bathtub too hot becomes an emergent circumferential burn requiring specialized transfer, a five hour delay to seek care because of fear becomes a call to child protective services, mac & cheese for dinner for a child with a milk allergy becomes an anaphylactic reaction nearly requiring resuscitation, a bottle of Tylenol results in a PICU admission, a croupy toddler weakly crying “I’m sorry mommy, I’m sorry” while an IV is started is instantly classified as delirious with air-hunger.

Putting it all in words gives it reality, gives it strength, gives it power. It has the power to consume you, to destroy you, to bring you down to your knees and break you down. The key is to learn how to be able to type “3 y/o with 2^nd degree circumferential burn to the R foot with significant blistering & serous drainage” and not feel it.  We seems insensitive when we say “the foot pain in 15A” but really we’re trying to distance ourselves so that we can do this all over again tomorrow night, and the night after that, and the night after that.