Recovering from Christmas in the ER

Christmas Eve was a solid-gold nightmare. We had one open bed in the entire hospital, and the private ambulance services were bringing in critically-ill people without calling us, because they knew if they did, we would divert them to hospitals that we knew had open beds. But they make their living on calls, not on mileage. (This may differ in other states. Armed & Christian may correct me on this point.) So after the fifth "patient dump," the staff in my ER and the private ambulance services were not experiencing a lot of good will toward each other. And of course, the practice of patient dumping so saturated our ER that we had to place the hospital on "divert," meaning we were so full that there was neither room nor staff to care for any more patients until we cleared out the patients we had. There was no room at the Inn.

Most of the patients we had on Christmas Eve were genuinely sick. On my shift I cared for two patients who had had strokes, one patient who had a heart attack, a family of four who had carbon monoxide poisoning (a non-English-speaking family), one patient with acute appendicitis, two female patients having miscarriages, one elderly female with a hip fracture, and one psychotic female frequent flyer who neglects herself in order to get attention and pain medications. (This time she nearly killed herself by laying in her bed for nine days without getting up to go to the bathroom. She was, of course, a frigging mess. All this to get attention. She was also one of our private ambulance "patient dumps.")

That was one long, long Christmas Eve. I dragged myself to bed, sore and tired, at 9PM and awoke, sore and tired, at 5AM on Christmas Morning.

Man, this is going to be a long day, I thought to myself. Christmas in the ER usually is. I was not worried that someone would die in my ER on Christmas; people die every day (but as it turned out, none died in my ER on Christmas). I suspected that if Christmas Eve was any indication, Christmas was going to be a rough ride.

Boy, was I right.

It started off ominously. I schlepped in at 7AM to find only one patient in the entire ER. I went through my area checklist (trauma cart inventory) and sat down, sipping my coffee. Nobody dared say the word: "Quiet."

That one word, when uttered by an on-duty ER staffer, can send the whole day spiraling into hell. The whole staff sat in uneasy silence. Then the medic line rang. Five minutes later, it rang again. And again, and again, and again. And then the aid cars began calling in with short reports; six in a twenty minute period. By 9AM, the walk-ins came flooding in. By 9:30, the ER was full, and the triage area was filling fast.

Now, let me acquaint the reader with the demographic of the Christmas day ER patient, because it is not comprised of the usual crowd. Nobody in their right mind wants to come into the ER on Christmas, for the love of Pete. So what we see are the really, really sick people, the people who slice their fingers while preparing the meals, the people who slip and fall on whatever causes them to slip and fall (ice, gravy, beer, etc.), the people who get together when they shouldn't, and of course the absolute lunatics.

In the morning, the usual crowd comprised of the genuinely sick ones. Heart attacks, appendicitis cases, one full-term lady in labor (on Christmas- cool!), a couple of strokes, a couple of really sick kids, a seizure, and a bowel obstruction. But as the morning wore on, we got more and more lacerations (knife vs. finger). And then the psych cases began rolling in.

We had one obese young woman with the classic hallmarks of Meth addiction who insisted she be classified NIK (no information known) because the Mafia was after her. Never mind that she dragged her whole family with her. They also decided to check themselves in for various reasons. Her mother began loudly and obnoxiously retching in the triage area (BLEEEEEEAAAAACHH!!!! BLEEEEEEEAAAAACCCCCHHHHH!!!!). She didn't produce anything, of course. She just sat there and retched, loudly and with great flourish, whenever she saw someone looking at her. She fell strangely silent when nobody acknowledged her. Situational nausea, I guess.

As the day wore on, we saw the usual assault victims.

"Usual assault victims," you ask?

Yep.

You see, Christmas is one of those holidays that brings families together, even when they have no business being anywhere near each other. Uncle Phil arrives, gets drunk and obnoxious, and someone decides to tell him to pipe down. He declines, and rudely so. He takes a swing at Cousin Ed. Ed parks a left hook in Uncle Phil's mouth. Uncle Phil arrives at our ER drunk, belligerent, swinging, spitting bloody froth at us, and with a BAC of 384. I'm not making this up.

Never mind decking the halls. Somebody "decked" Uncle Phil, I thought.

So the twelve hours I spent in the ER on Christmas Day were not idyllic. Guess who had the Mafia runaway, her mother (BLLEEEEAAAAAAHHHH!!!!!!) and Uncle Effing Phil?

Where's the frigging eggnog?

Behold, the Awesome Power of Human Stupidity

There are some days that I encounter patients whose actions, driven by an utter absence of common sense, cause me to leave a treatment room shaking my head in dismay and mumbling to myself.

I'm not talking about the basic run-of-the-mill honest mistakes here. These are not the "I thought I had shut off that circuit before cutting the wires" kind of crowd. These are the runner-ups for the Darwin Awards who tried very hard to kill themselves but failed through sheer incompetence, thus disqualifying themselves from glory. Their survival was not so much a matter of God mercifully wrapping His arms around these people. It would be more accurate to say that the Angel of Death simply rejected these people because his pals at the bar would never have believed the story- it would have just been too easy. Even the Angel of Death has his standards, you know.

But just when I think I have seen something that officially qualifies me for the "I Have Seen It All" Hall of Fame, someone else discovers a new and creative way to come this close to finishing himself/herself off, only to survive to tell the tale to his/her grandkids. And oh, yes: they do procreate.

In fact, I think that there is a lost race of human beings whose origins have vanished in the mists of time; a race whose progeny now walk among us, wearing our clothes, eating our food, and sending their children to our universities; and yet these homonids have not quite shed the self-immolating tendencies of their predecessors. This race might very well be the missing link between the Darwin Laureates who managed to extinguish themselves on their own merits, and the Robbie Knievels of today. (By the way: I know a guy who claims, proudly, to have been shot in the foot by the younger Mr. Knievel. But I digress...)

I call this lost race Homo hey-watch-thissicus.

The hallmark of the species is its absence of a state of being merely accident prone, which is more the manner of H. jerrylewisium. Rather, the defining characteristic of the race is its ability to operate in a realm of logic that defies the laws of physics, thermodynamics, organic chemistry, common sense, and fire codes. The three most commonly-observed subspecies (that is, those who wind up in Emergency Rooms across the nation more often than any others) are Homo jackassii, Homo webmedicus and Homo mindblowinglystupidiens.

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H. jackassii are a subspecies who instinctively choose to do things, without giving due thought to the empiricals of physics, that invariably lead to great personal physical anquish and embarrassment. These are the numbskulls who sit in shopping carts and let their idiot friends push them down a steep hill with parked cars on either side. (I've met them- or more to the point, I've met their parents, who tend to be exceedingly embarrassed when I come out to explain to them why their stupid kid is in the ER this time.) Others of the species choose to car-surf (I've scraped acres of real estate out of their backsides). Still others try to jump their BMX bikes over a busy street during rush hour (not realizing that a mere human on a lightweight bike has inadequate mass to achieve either the velocity or the momentum to carry himself/herself aloft on a trajectory spanning the minimum fifty feet required to clear the cars on the opposite side of the street... and even on the exceedingly rare chance that they do make it to the other side, then landing on both wheels without sustaining a screamingly-painful testicular crush injury or vaginal contusion upon impact of the rider's perineal area with that teensy-weensy bicycle seat... yikes!). These yobbos end up with shattered feet, shattered ankles, shattered tibias/fibulas, shattered knees, shattered pelvises, internal injuries, shattered femurs, compression fractures of the spine, skull fractures, facial avulsions... And do they wear helmets? Nooooooooooooooo...

ERs across the country attest that the jackassii gene is not exclusive to either the X or Y chromosome.

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The second subspecies, H. webmedicus is marked by a set of ideas and thought processes regarding illness and treatment that are completely divorced from reality and logic. These are the people who, sometimes without benefit of a high school diploma, consider themselves more medically-savvy than the folks who go to college for an entire frigging decade, since they can now "google" their symptoms and treat themselves with mail-order medications from the internet. Of course, by the time these people arrive at my ER, the damage has been done- often irrevocablly so.

One such H. webmedicus case immediately comes to mind. Her husband stated that she had "chronic chest congestion" (self-diagnosed) and decided to manage it herself; after all, she had read a number of internet articles on the disorder.

"Well, that's all that you guys do, isn't it?" He concluded. (At that moment I fervently wished that slapping was considered a therapeutic intervention.)

Never mind the fact that MDs and RNs go through continuing years of education throughout our entire careers to understand the intricacies of a human body that even now remains insanely, humblingly complex to even the greatest minds among us. All we really do is just google the stuff anyway. Hmph.

Somehow, the woman managed to obtain Prednisone without a prescription. She then arbitrarily decided that 100mg daily should do the trick. We met about a month later when she arrived at my ER in full-blown Multiple Organ Dysfunction Syndrome (MODS). The boyfriend told me that she had discontinued the prednisone the other day without tapering off.

As it turns out, she lived- but she was so physically deestroyed that the rest of her life (such as it is) promises to be an ordeal of physical, emotional, and psychological agony. Her major organs are ruined, and she emerged from her ordeal a different person.

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The final subspecies is characterized by sheer abject stupidity with regard to self-care. One shining example of H. mindblowinglystupidiens can best be described in the following recent encounter:

A young man came to my ER treatment room with a garbage bag over his lower leg. He was whisked back to me before being fully triaged. The triage nurse apologetically told me that when she saw how badly he was bleeding through his dressings, she made the decision to bring him straight to the available trauma room.

I said, "No worries. My other folks are stable. I can triage him."

Well, the guy was simply lolling back and forth in the wheelchair, deathly pale and clammy. The ER Techs and I gowned up and gloved up. We chair-lifted the guy from the wheelchair to the gurney and put him on the monitor. He was tachycardic (fast heart rate), tachypnic (fast breathing rate), and just not at all well. I removed the garbage bag that covered his leg and noted at least a pint in there. I began to move faster. His full-length wool sock was wringing wet with blood. There's another pint. Blood was pouring through the dressing. I figured that this guy had been bleeding for at least half an hour, since he drove himself to the ER.

I sloughed the sock off the foot and it fell into the bag with a wet slap. I then noticed the dressing: thick layers of tape covered the gauze below. The tape was wrapped completely around the patient's leg haphazardly, as if in haste. There was no way to find the end of the mess, so I had to cut the dressing off. I ordered one tech to hold up the leg, ordered another to get me a couple of pots of 4x4 gauze and Kerlix rolls, and whipped out my trauma shears.

As I began cutting carefully through the dressing, I asked the man to tell me what happened. He informed me that he had been seen in the ER yesterday because he was cutting down cardboard boxes with a fresh box knife and accidentally cut his leg while bracing a box against it. Honest mistake, I thought to myself. The automatic assumption is that the sutures failed, or an artery suddenly decided to "let go."

As I finished cutting, I told the two techs to get ready and I carefully peeled back a section of the dressing. A jet of bright red blood shot from under the dressing and painted the drape four feet away, Jackson Pollack style, before arcing straight up and narrowly missing the Tech holding the patient's leg. She, a new Tech on her first week in the ER, let out a startled yelp and jerked her head away reflexively. I clapped the dressing back over the leg, grabbed gobs of gauze from the other tech (a veteran of the ER who simply said "Hmph"), and calmly (I think) told him to get more Kerlix pronto.

I once again raised the old dressing, prepared for the "pumper" this time, and slapped new gauze moistened with sterile saline over a distinctly new and very deep wound just below the wound that was sutured last night.

"Where did you get the new cut?" I asked.

"I did it today," the guy moaned. "I was changing my dressing."

"You cut yourself again when you were changing your dressing?"

"Yes. Ohhhh," he moaned.

"Okay. How do you slice the heck out of your leg changing your dressing?"

"I didn't have any scissors. Ohhhhhhhh."

Uh-oh.

I ordered the rookie tech to hold pressure, ordered the veteran tech to continue wrapping the leg, and I stepped over to the meet the patient's gaze. I leaned over the man, directing his eyes toward mine.

"Please tell me you didn't use the box knife," I whispered. "Please."

"I used the box knife," he moaned. "Ohhhhhhhhhhhhh."

I stripped my gloves off and walked out of the room to get the MD, shaking my head in dismay and mumbling to myself.

Life and Death in Darkness

Last Thursday night/Friday morning, more than a million people in my region were plunged into darkness by one of the worst windstorms in modern Washington State history. Whole cities were still, dark and lifeless. Other than the drivers around me, not a single person was seen outside. The atmosphere was made all the more strange by the moaning of the wind through the power lines that bowed, dead and useless, from their poles. Huge old-growth trees were ripped from the ground by the thousands, blocking roads, demolishing houses, and killing drivers.

And of course, I had to drive to work that night.

My work does not stop when the weather comes up, no matter how severe. If I don't show up, the poor nurse whom I am to relieve has to stay put at his section and take up the slack, which is a lot to ask of someone who has already spent twelve hours working in a level 3 disaster setting in an ER packed with humanity. So I drove to work, picking my way along detours and around fallen trees, and nearly getting killed myself on four separate occasions by drivers who simply blasted through blacked-out intersections instead of treating them like 4-way stops. Seattle has more than its fair share of weather morons. These were probably the same dilrods who parked their cars in the middle of the road during the winter storm (of which I wrote a couple of weeks back)- but I digress. At any rate, having finished an hour-long drive that must have left my guardian angels shaking their heads in dismay and mumbling to themselves, I pulled into the hospital parking lot.

The hospital was an oasis of light in wasteland of utter darkness. The Interstate stretched out for miles either way, a brilliant white-red artery coursing through the black. I zipped up my parka and trudged to the entrance. Every main floor public-access area was simply packed with people from the local region who were not sick but were just looking for some warmth, light, or hot food. They milled around, sat in the cafeteria, parked themselves in corners as far away from the entrances as possible, and tried- many quite apologetically- to stay out of the way of hospital personnel. We gave people blankets and pillows, hot tea, coffee, cocoa, and as much encouragement as we could.

As difficult and hazardous as the evening had been thus far, I still felt a charge of excitement as I contemplated the potential challenges that I as a nurse would be called upon to meet this night on a professional and personal level. The ER was full of some very sick people, and the horrendous weather and power failures compounded the challenges we had to overcome in order to care for our patients. Now, it was not merely a matter of treating the patients and sending them home. "Home" may be blacked out and freezing, or flooded, or inaccessible due to downed power lines; getting "home" may not be a safe endeavor, either. So we all worked together to find some place to put these people, and the lobbies were filling fast. Other area hospitals faced the same dilemma. But this is part of the reason that many medical professionals choose to specialize in emergency/trauma care. You never know what's going to happen next.

As I walked through the doors into the ER, I immediately noticed the distinctly thick and pungent smell of wood smoke that permeated the place. As if the darkness and freezing cold were not bad enough, a thermal inversion had formed over the region, holding the pollutants close to the ground like a foul blanket. The asthmatics are going to be flooding in tonight, I thought. I clocked in and walked over to the nurse whom I would replace. She visibly relaxed, gave me a hug and said, "Thank God you're here!" She gave me report and I briefly paused to consider what I had just gotten myself into.

My patients I inherited were sick, sick, sick. The least severely-ill was a 30-year-old man with propane burns to his hands who would do alright with some minor debridement, silver sulfiadazine cream and a bulky "softball" dressing. The second worst was an 80-year-old with CHF and pneumonia who was simply waiting for a room upstairs. The worst was a 19-year-old college girl in the middle of a severe asthma attack who was looking minutes away from being intubated because she had been working hard to breathe for hours and was rapidly running out of steam.

The hours ripped by. The girl was intubated, put on a ventilator, stabilized and sent up to the Unit. The older lady was sent upstairs to MedSurg, and the burn victim went back "home" to his nice warm RV. No sooner would I discharge a patient than another would occupy the room. And as I returned from taking yet another very sick patient up to the Unit, I noticed that the briefly-vacant room had been filled by not one but four patients who had carbon monoxide poisoning- a whole family that could easily have died had not the oldest daughter come home and seen what her mother, who lacked a little something in the common sense department, was doing to heat their house. Thankfully, they all were fine and five hours later were discharged. They, too, found a corner in the lobby to park themselves for the night.

The rest of the night, all two hours of it, was occupied by a couple of GDFDs who somehow managed to find one another in a night blacker than Hitler's heart. They shared some booze, and then found enough reason to get mad at each other. One had the bottle broken on his head, and the other had his face smashed into a tree, breaking his nose and blackening his eyes. Keeping them separate was a real joy.

My shift finally over, I drove once again through the wasteland, going ten miles out of the way to avoid downed power lines, roadblocks, and managing once again to dodge the weather morons who blasted through the intersections. On the radio, I heard that one woman had drowned in her basement as rescuers struggled frantically to reach her. They could hear her screams, and finally, they heard no more. They broke through fifteen minutes too late. Those guys will remember this night for a long, long time. Say a prayer for them, will you?

Keeping Things in Perspective

Tonight was one of those shifts that puts the world into perspective for me.

I was the primary nurse for a man who had a sudden-death cardiac arrest; his wife heard a loud thud, turned on the light, and saw her husband of fifty-two years crumpled in a heap in the doorway of the bathroom, blue and dead. She was a small woman, and he was rather tall. She could not get him out of the doorway.

She called 911, and seven minutes later, the paramedics arrived, find the guy asystolic (no heartbeat) and then started CPR.

Mark this: seven minutes dead. No oxygen to the brain. If CPR had been started the moment the guy dropped dead, he would have had a seventy percent chance of getting out of the hospital alive. With every passing minute, the survival rate drops like a cow off the high dive.

Paramedics work on the guy for 30 minutes. Nothing works. Not the drugs, not the shocks, nothing. And the man has an internal defibrillator that goes off every once in awhile. It was obviously not working either.

So the medics get authorization to call the code. The man is pronounced dead. The medics start packing up their gear.

But then, somebody thought it would be a good idea to check for a pulse. He had one.

So the medics open their bags, call us, give report, and arrive ten minutes later.

I was the primary nurse for this guy. We got the word from the MD about what had gone on, and I say to the Doc, "So this guy's been dead for about 45 minutes so far?"

"Yup."

"Advance directive?"

"Nothing."

"Is this the same guy you gave authorization on a while ago?"

"Yup."

"Okay," I said with an exasperated sigh. "I'll square the room away."

So the ER Tech and I gather the tools and get the staff together. Since I am primary, I will receive report and direct the nursing care. There will be at least two other nurses and two other ER Techs involved. Ten minutes later, he arrives.

I take one look at the man and know he is "circling the drain." His extremities are ice cold, his eyes are open, his pupils are fixed, irregular, and nonreactive; his legs are mottled; he has no bowel sounds; His heart sounds are disorganized. He is breathing with the help of a ventilator. His BP is 81/64, pulse 134 at the wrist, and he looks just horrible.

But he had a good pulse.

The medics gave me report while my team descended on the man like a Formula One pit crew. Every appendage the man had had a tube sticking out of it within three minutes. After receiving report, I checked with the team that all the major stuff had been taken care of. I then assessed the patient myself. It was not reassuring.

Then the wife came in. She was a lovely woman in her mid-seventies who looked much younger. She carried herself with grace and calm. I introduced myself and hurriedly tidied up the room. I explained what my role was, what we had done so far, and what we intended to do. She signed the necessary forms and sat in a folding chair just near the man's head.

After a few minutes, she got up and pulled some papers out of her purse. It was a living will. I looked at it, and said, "So your husband does not desire resuscitation?"

"No, he doesn't."

I looked at her quizzically.

"I was afraid to tell the ambulance people to stop. I was just afraid."

I paused and asked "Do you have power of attorney?"

"Yes, I do."

"Let me get the doctor."

I got the doctor and had her run the whole thing by him. The doctor finally asked, "Ma'am, what do you want us to do?"

The woman paused for a little while, reached out and put her hand on the patient's forehead and said, "He's been gone too long. We need to let him go."

The doctor verified the woman's legal status, verified her request, had her sign all the necessary forms, and the team withdrew life support in accordance with the stipulations in the living will and the woman's power of attorney.

I hovered over the man, watching his vital signs, listening to his heart and lungs, and then stepped back.

Suddenly, the man's body stiffened, his hands flailing outward. His internal defibrillator had fired. I looked at the monitor. He was in asystole. I looked at the woman. Her eyes were on me. I wished they weren't.

I got the doctor in the room. He looked at the monitor, assessed the man, and finally told the woman, "He has no pulse, no heartbeat, and he is not breathing."

The woman looked at the doctor, and looked at me. The she said, "Let him go."

She stood up, took her husband's hand, and kissed him on the forehead. I moved her chair closer so she could sit down next to him. The doctor looked at me, said "Time of death, so-and-so," patted the woman on the shoulder and asked, "Is there anything more I can do?"

"No, thank you. I am fine."

I asked her likewise, and she answered likewise.

Over the following hour, the woman sat in the room with her head on the man's chest. I busied myself with the postmortem arrangements, and finally informed the woman that whenever she was ready, her husband could be transported to the morgue.

She said, "I'm ready now. I'll be going." Her son had arrived and was to drive her home. She kissed her husband's forehead and left the room with her son holding her hand. Her husband's body was taken to the morgue upon her departure.

I had no other patients and my shift was over, so I simply punched out and went home.

When I got home, I went to the internet to check my email, as is my habit. The glaring headline on my ISP was "TOMKAT TO HOLD NUPTIAL BASH IN LOS ANGELES."

So frigging what?