Thursday, June 28, 2007

To Dream of Flight

My dad flew in the Navy in attack jets. He flew multiple tours over Vietnam, was shot down once (made it out okay) and crashed off the carrier once (made it out that time, too). He retired with a chestful of medals, many of which he won multiple times. He was a scrappy, 5'8" wiry terrier of a guy, a Golden Gloves bantamweight boxer in his youth. He left home when he was 16 and lied about his age to get into the Navy. He became a nurse after retiring from the Navy, specializing in Geriatrics throughout his career. He was a warrior and he was a minister of mercy. I knew almost nothing about his heroics, trials, ordeals, defeats and triumphs until after his death from cancer in 2001, when I "inherited" his service records and papers.

He is more of a hero now to me than he was in life. And he was my number one hero in life.

Dad always missed flying. He spoke often of his love for it: the freedom, the noise, the speed, the smell of jet exhaust, the thrill of the catapult shot, the sense of duty and honor he carried with him to the grave. Even after the Navy forced him out of the cockpit, he still loved flight.

I caught the bug myself. I wanted to be a Naval Aviator... but not enough to work hard in school. The closest I got to slipping the surly bonds of earth was when I slipped the surly bonds of a C-130 as I, along with 60-odd other paratroopers, were unceremoniously shat out of the "Herky Bird's" tail end. Bird droppings, indeed.

I often flew with a friend in his private plane. The moment we broke ground, he'd tap me on the knee and say, "You got 'er." I flew the small single engine plane around the Puget Sound, banking along the clouds, navigating by way of familiar landmarks and the "concrete compass" (the Interstate highway) below us. As the sun slid toward the horizon and the shadows grew long, we would wing our way home. When we slid into the final leg, my friend would say, "I got 'er" and land us safely.

I never got a chance to get my own pilot's license. I still want to, but it isn't a priority right now, and I haven't got the time.

But when I became a nurse, the thought crossed my mind: Why not become a flight nurse? I shelved the idea, of course.

But I have a friend who, it turns out, trains flight nurses for the local life flight organization. We ended up talking about flight nursing and I mentioned my dream of flight, but ended by saying that I doubted if it could ever be done at this stage in my life.

My friend laughed, "Why the hell NOT!?"

"I'm forty-two!" I replied rather defensively. "I have a wife and kids. I don't have time to go for that now."

"Crap. Nonsense," my friend retorted. How old do you think the average Life Flight nurse is?"

"I dunno," I said, preparing myself for an alswer that would make me look like a fool.

"Late thirties to mid-fifties- even older, if you are in good shape."

"Really?" I asked, not daring to hope.

"Really. Go for it!" He said.

Well, I talked to my wife about it tonight. She snorted, "Why not!? You always wanted to fly, didn't you?" I guess that means she has given me her blessing.

I wonder if I'll get my own helmet?

Wednesday, June 06, 2007

Pediatric Code Blue

Let me say here and now, for all and sundry, that deathly sick kids just flat scare the hell out of me. They always have and they always will. I am glad we have established that. So bringing one back from the brink of death has the tendency to cause old goobers like me to pump my fist up and down and shout, "Hell yeah, woo-hoo!". And when a kid dies, it rips the heart out of the entire department and it takes weeks- sometimes months- to recover from the shock and grief. So we get pretty uptight when a sick kid comes in and we fight like cats in a dark bag with a snake in it to keep that kid alive.

A 4-year-old little girl was brought straight back from the triage desk. I mean, right now. She was the kind of case that flat scares the hell out of a nurse. She was sitting bolt upright even as she was carried in by her dad; her nose was way up high in the air, and the air she sucked down her constricted airway was honking, goose-like, as if forced through a pinched straw. Her eyes were watery and red-rimmed, and she looked septic and scared. One look at her and the horror-movie music started. This kid was Oh-My-God sick and about to crash and burn any second.

As soon as I saw her I stormed to the Broslow (pediatric resuscitation) cart and dragged it into the room, busted the seal, whipped out the measuring tape, measured the kid, and popped open the appropriate drawer. I rifled through, found the intubation tray, and plopped it onto the Mayo stand (a stainless steel bedside table). I just knew we were going to have to drop a tube into this kid.

I then dashed to the Med room and grabbed the Rapid Sequence Intubation (RSI) medication box and rushed back into the room. By the time I made the round trip (about 30 seconds), every extremity the kid had was covered by a nurse or ER Tech. The MD (who had just started here that night) was at the patient's head. Since I could not get to the kid, I stayed with the meds. We all donned lead aprons.

Dad was in the room, holding the girl's hand and saying soothing words. We put a lead apron around him so he could stay with his little girl while we snapped a portable soft-tissue neck x-ray and did really, horribly noxious things to his baby.

Respiratory Therapy was pumping racemic epinephrine into the kid's airway as the Xray was taken. One of the nurses managed to get a line in the kid's ankle and I immediately took station there. That was my IV site now and there was no way in hell I was gonna lose it.

I cracked the RSI medication box and pulled out the Etomidate (very fast-acting knock-out drug), Succinylcholine (fast-acting paralytic), and Vecuronium (another paralyzing drug). I calculated the doses of each medication based on the Broslow tape measurement. I drew up the meds, nodded to the MD, and stood by.

The X-ray tech brought in the film, parked it onto the wall screen, and snapped on the light. Sure enough, sticking out like a pimp in a monastery, was the thing we hoped not to see but knew we would- the "thumb sign," indicating that the girl's epiglottis was swelling and shutting off her airway.

[Cue Symphony of Oh Crap in D Minor.]

The girl seemed to be holding her own. Her work of breathing lessened for a minute or two. Then suddenly, she sat bolt upright, her eyes wide, wide open and panicked, and turned blue.

"She's hypoxic!" one of the nurses blurted. The oximeter showed the girl's oxygen saturation at 74 percent and falling like a cow off the high dive, with good signal. (We get worried if it gets below 89 percent.)

"Okay, either we drop the tube now or we cut her. Give her the Etimodate," the MD ordered. I pushed the drug into the girl's vein and said clearly, "Etomidate in at 0243." A nurse standing by the Broslow cart noted the time on the medication administration record (MAR). The girl went limp within seconds.

"Give her the 'Sucks' (succinylcholine) now." I pushed the drug and barked, "Sucks in at 0244."

At that point, the MD thrust the girl's jaw forward, inserted the laryngoscope, and said "I have a lumen. Gimme the tube!" A nurse handed an endotracheal tube to the MD, the MD inserted the tube, and the kids's oxygen saturation jumped to 100 percent within seconds. The RT slipped in and taped the tube at the teeth while another nurse began bagging the little girl.

"Vecuronium now," the MD ordered. I pushed the Vec and said calmly, "Vecuronium in at 0244." I stood back and took in what was happening. The little girl was pinking up rapidly. Gradually, everyone stood back and watched. Her vital signs stabilized. We visibly relaxed and started breathing ourselves.

Dad broke down and sobbed. The MD asked him to step out to talk. I collected the trash that I had generated and accounted for all my sharps. I noticed that my hands had started shaking (when did that start?) as I dropped the needles into the receptacle. On auto-pilot, I took the used RSI box back to the med room for Pharmacy to pick up and went to the nurses desk to sign off on the code sheet. One of the nurses who had trained me way back when I was a snot-nosed graduate RN threw her arms around me, gave me a big hug, and said "You were wonderful!"

That was my first pediatric code as a nurse.

I excused myself for a moment, stepped outside into the rain, and just lost it. I cried for just a few minutes, but what it lacked in time it made up for in intensity. I didn't feel sad- it was more of a release of tremendous tension and fear. I never did it before, and I haven't done it since.

When I returned a few minutes later, soaking wet and somewhat more composed, the girl was being prepared for transport to the regional children's hospital. The room was clean, and dad was again in the room. The primary RN was squaring away arrangements for transfer. The medics took her away, the dad thanked us and left, and we finished the remaining four hours of our shift in peace.

We got a card a couple of months later from the dad. The girl recovered completely and was doing great. I cried again. It still feels like it happened last night, although it was a long time ago.

A brief update

Hi, all. It's been awhile since I posted. I'm not sick, just busy opening up a new Emergency Department at my hospital. We are shorthanded so I am working a lot of extra shifts. It's very lucrative.

I promise to post soon. There is much to catch up on. Bear with me!