"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.

"Credibility"

Some sound advice from my perspective of your dire emergency:

If you chief complaint involves anything in the belly (nausea, vomiting, diarrhea, or pain) DO NOT show up in the waiting room with a piping hot bag of McDonalds takeout.  Your credibility for this complaint and all others just went out the window.  Likewise, do not let your vomiting children eat in the waiting room, because you will see how food exponentially expands in the stomach just prior to being vomited; suddenly just one French fry becomes 2 gallons of vomit on the floor.

In fact, if you or your companion had time to stop for any kind of food on the way over here, it can’t be that big of an emergency, so please don’t badger me and ask me how much longer it will be.  I will eventually stop being nice and simple say “people are seen in order of acuity/severity, not in the order that they arrive” which in my head means your complaint is bogus and you will wait until all the truly sick people are seen.

Don’t tell me that you came to the emergency room because it’s closer or more convenient than your primary care doctor.  It’s like me parking in your drive-way in the wintertime because it’s more convenient for me to have you shovel out my truck.

If you take medication, chances are you have a history of medical problems.  An antihypertensive does not cure your high blood pressure, it simply helps you manage it so that your head doesn’t explode.  Insulin doesn’t cure your diabetes, it simply helps you manage it so that your blood isn’t the consistency of cake icing.  So please, when I ask you if you have any medical problems, do not say “no” if you’re going to rattle off a laundry list of meds after that.  And please don’t answer “not really” when I ask about medical problems, surgeries or allergies; you can’t be “a little bit pregnant”, you either are or you’re not.

Everyone from a secretary to the brain surgeon will instantly assume that if you say you’re here in pain and allergic to Ibuprofen, Tylenol, Toradol, Naproxen, & Dolobid you’re drug seeking.  That’s just how it is, so you better start coming up with something more creative than that.  ER hopping (like bar-hopping) in one day doesn’t work either, everybody knows everybody in this field.  And we are far, far too immune to the “my doctor is out of town and my prescription was stolen last night” excuse, that’s just comical.

If you say you or your child has a fever, to avoid looking like a moron, measure the actual temp so that you have an answer when I ask how high it is.  “Baby feels hot” is not a quantifiable fever, whereas 103.2 rectally is.  For further reference, 99.9 is not a fever either.  And for Pete’s sake, medicate! Under 6 months it’s Tylenol, over 6 months you can give Motrin or Tylenol, or even both together.  Yes, yes I am well aware that Tylenol has been recalled, but there are generic options.  What are generic options, you ask – well it’s like GAP jeans & Target jeans, you’re looking for the Target ones; yes a mother really did ask me what “generic” means and that was the exact analogy I used.

If you scream in my face that you can’t breathe, I will point out the opposite to you – you are moving enough air to scream, you can breathe.

Just because you come by ambulance doesn’t mean you will be seen first, or even second.  End of story.