Thursday, April 19, 2007

Losing One of Our Own

One thing about ER Nurses: We know, probably more than any other nursing specialty, the combination of medications that can make a suicide attempt successful.

One of our own ER Nurses successfully demonstrated her personal knowledge last week.

Of course, none of us who knew her- even those closest to her- has a clue why she killed herself.

The usual grief counselors were on hand a few days ago to help us discuss our feelings about the decision our friend and colleague made to take her own life. I did not attend. A wake was held at the local watering hole in the evening (of course) after the counseling session. I did not attend.

The funeral will be Friday. I cannot attend.

I have lost friends before. Years ago, in another life, I watched horrified as one of my closest friends was washed overboard in a severe storm at sea. I have since come to the understanding that even if I wanted to, there was not a thing I could have done to save him.

But this is different. She never gave anyone the chance to try to help her. And that is what bites at us.

There was no valiant fight against some grave illness. There was no horrible traffic accident. She was not murdered. She did this to herself. And because she did this to herself, people feel both sorrow and resentment toward her. That's hard to equate.

How do I feel? I don't know. I am not weepy, and I have not really agonized over it. She made her decision, and that's that. We all are dealing with this in different ways. I have said my goodbye; I am moving on. What more can I do?

Wednesday, April 04, 2007

The Time Bomb: Epilogue

In my last post, I described the frightening story of a patient who was diagnosed with an aortic dissection and whisked away by airlift to a Super-Hospital for treatment. Due to the demand of all and sundry who have threatened to lynch me if I did not tell the rest of the story, here is the rest of the story, as far as I know it.

The patient faced a truly brutal and frightening surgery. I had it described to me by a nurse who has sat in in one, and here is my best attempt to relate it. Anyone out there who knows more, feel free to correct me because this is all brand-new turf for me. But here is the bare-bones version.

The patient's body temperature is cooled down to 60 degrees- at which point the brain is nearly completely inactive. The patient is then nearly completely exsanguinated in order to reduce the risk of a high-pressure bleedout when the aorta is disrupted. The affected section of the aorta is resected, and a large-bore graft made of synthetic material is carefully and meticulously sewn in. Once the grafting is complete, circulation is slowly restored, while the graft is watched for any sign of a leak. If no leak is found and the patient stabilizes sufficiently, he is closed up and taken to intensive care for monitoring.

Fifty percent of the patients who undergo the procedure die on the table. Of the survivors, a majority end up with renal failure and spend the rest of their lives on dialysis or looking for a kidney transplant. Many suffer brain damage of varying degrees. Some suffer catastrophic embolisms, strokes, and heart attacks. The other side of the surgery is not a pretty picture, unfortunately.

The patient in question made it through surgery. I am told that he did exceptionally well, that although he came out of it all just a little on the "goofy" side, that seems to be resolving. His kidneys were a little slow to get going again, but his creatinine is almost normal. I don't know if he remembers what happened.

But he's alive and doing well. You can all breathe again.

And regarding Nurse Dynamite: She's fine too. She says that this was a case that scared her. And when a veteran like her gets scared about a patient, you can bet that it's a close-run thing.

The Time Bomb


It started innocuously enough.

A male in his mid-forties came to the ER because he had turned while lifting a box and felt a sudden sharp pain in his back. When he arrived at Triage, he was walking, talking, alert and oriented, and his blood pressure was high-normal. The front was full, but the Fast Track area had an open bay and there was nobody else waiting.

He was walked back to our Fast Track area and given a gown and a couple of warm blankets. Standard procedure is to strip a patient with back pain down to the skivvies in order to facilitate an assessment and x-ray (if needed) of the entire spine. It's a procedure that has helped us discover some pretty serious back problems in the past.

Well, we discovered something serious this time, too. And it had nothing to do with his spine.

On entering the patient's exam bay, the first thing I noticed was that the patient was looking at his legs. The second thing I noticed, having reflexively followed the patient's gaze, was the patient's legs.

The left leg was normal in color all the way down to the toenails. The right leg was pale blue and mottled, and his toenails were white.

Oh, crud, I thought.

You know that horror movie music that plays when the victim is chased into a hallway and sees a door, the monster is breathing down the victim's neck, and the hallway suddenly gets really, really, really long and the doorway gets farther away? You know, the music that accompanies the stretching hallway scene?

I call that music The Song of "Oh Crap" in D Minor.

And that ominous dirge was swelling in my ears as I rather begged the patient to lie on the stretcher- gently, please... for Pete's sake- GENTLY. I checked for pulses in both feet. The left foot had a good strong pulse. The right had none. I then laid my hand on the patient's abdomen and felt the peculiar, strong whooshing pulsation underneath my hand that I really hoped wouldn't be there but knew had to be. I could feel it all the way from the epigastric region to three finger-widths below the belly button.

Music swelling, hallway stretching, bad feeling getting worse...

I stepped away from the patient and his extremely bewildered wife and came as close to dragging a Medical Doctor into the room by the scruff of the neck as ever I could. In the seconds that transpired for the journey, I rattled off everything I knew at the speed of one of those disclaimer guys at the end of a car commercial.

I finished with "Take a look, Doc," as I knocked on the wall and swept the curtain aside.

The doctor introduced himself as he lifted up the blanket covering the patient's legs, and his eyes just about did that bah-WOOO-gah thing in the cartoons. He checked pedal pulses and asked if the patient was feeling alright. The patient said he felt fine other than the pain in his back and the numbness in his right leg. The MD and I excused ourselves and exited. My MD called the MD overseeing the trauma rooms up front, and I called the charge nurse and told her (as opposed to asking her) to clear a trauma room pronto, because my patient was coming in.

The charge nurse initially voiced her dismay at this rather abrupt breach in professional decorum. I cut her off (which I never would ordinarily do) and laid out the situation. She said she'd bump the asthmatic smoker into the hall for my patient, and to give her two minutes for the room to be ready.

Two minutes later, I was wheeling my patient into the trauma room. RNs and Techs swarmed the man, slapping monitor leads, a blood pressure cuff, and a pulse oximeter sensor on him. Capitalizing on the great big bulgy veins the patient had in his antecubital fossae, I shoved a 14-gage catheter into each arm. As we worked, the doctor explained the reason why we were moving so fast, and that a CT scan would tell the tale.

Fifteen minutes later the MD, Charge RN, ER Tech and I stood in the film room, staring wide-eyed and aghast at a monster. The source of the patient's back pain and leg numbness was a huge aortic dissection going almost the entire length of the patient's abdomen.

Ominous music getting louder, panic welling up in the throat...

The MD ordered meds to keep the patient's blood pressure down and immediately got on the phone with a local hospital that specialized in the procedure that this patient had to have if he was to survive the night. And that was a big, big if. While the MD made his connections, I did everything but pack the patient in egg crates- for all the good it would do if his aorta split open. If it happened, the patient would die within seconds and there would not have been a thing any of us could have done about it.

By this time, the patient and his wife were fully aware of what was happening. We told them the whole story, including the part about how he could simply start bleeding to death at any moment, and that he would barely have enough time to say goodbye before he was gone. Also by this time, the entire Emergency Department was electrified by the case. Everyone was hushed and tense. The other nurses gave me supportive pats on the back and looked after my other patients as I remained in the patient's room, watching for signs of sudden exsanguination as the patient and his wife quietly talked.

The wife had at one point called their children and told them to come to the hospital right now. Apparently, one of her kids balked and she snapped, "If you don't come now, you may not get to say goodbye!" All the kids were in the room amazingly fast. They were quiet, too, as if even a whisper would set off the bomb.

All this time, the patient was extraordinarily calm. Somber as hell, but calm. I am still amazed at his fortitude.

The Charge RN came in and told me that the Life Flight was enroute and to get the patient ready. The patient's wife collected her things and she and the kids left for the other hospital after saying their optimistic chorus of "See you later."

The chart was copied and everything was in order by the time we heard the first faint vibrations that increased rapidly to that distinct, chest-thumping, head-splitting thrum of the Agusta helicopter flown by the airlift team.

I waited with the patient in the ER entrance, shielding him from the rotor wash as best I could. The Agusta settled on its landing gear and the ear-splitting racket died down to the more tolerable roar of the turbine as the rotors lost their lift. The flight nurse (a 5'4" keg of pure dynamite and a dear friend of mine for many years) met us halfway out.

"Hey, Willster!" she shouted.

I patted her helmet and said, "Dang, I gotta get one of these! What's shakin', Bird Woman?" I then rattled off a fast report as we trundled the patient to the whirlybird with our backs hunched. She introduced herself to the patient with a bellow as I helped her get him into the aircraft. I shook the patient's hand and said, "She's the best nurse in the whole universe. You got the first team tonight, buddy."

"I know. Thanks for everything."

Smiling ear to ear under her big ol' helmet, Nurse Dynamite patted me on the cheek and shouted in my ear, I got him, sweetheart!

I scooted out of the helicopter and shouted "Away, flying nurse creature!" with a shooing motion. I scurried back out of the rotor wash as the Agusta's characteristic thunder again filled my brain with fuzz. As the aircraft broke ground, Nurse Dynamite waved. I waved back and walked back into the ER to call report to the receiving RN at the other hospital as the sound of the rotors rapidly dissolved in the cold night.
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