Mister B's Midnight Serenade

The shift had been an exciting one from the time I arrived. I had some very challenging and complex patients for the first half; all but one of them ended up in our ICU. The one exception was sent to a higher level trauma center for his injuries. That patient was a teenaged Homo jackassii who had attempted to car surf and had managed to get up to somewhere around 30MPH when the car reached an intersection and the dufus kid's "friend" slammed on the brakes. The kid shattered both of his ankles, nearly tore one of his feet completely off, shattered both wrists, had an open fracture of his left clavicle, had most of the skin on his right face gouged away, and suffered skull and facial fractures. (He lived, and he'll have the rest of his life to contemplate the error of his ways.)

In spite of those highlights, most of the cases were pretty much what our ER sees on any given day: nausea/vomiting/diarrhea, pregnant/spotting, migraine, back pain, kidney stones, appendicitis, and an angry gall bladder.

And then there was Mister B.

Mister B was an elderly gentleman who came in by aid car at 0200 from his nursing facility with a complaint of "altered mentation." What that meant was that he was acting strangely for some unknown reason.

We immediately began working to rule out the life-threatening stuff, which took all of ten minutes. The first clue to the cause of Mr. B's confusion was his urine. Without going into too fine a description, the best terminology with which to describe it would be "just naaaaaaasty"

Soon, the lab results confirmed what our eyes (and noses) had already deduced: Mr. B had himself a rip-snortin' kidney infection.

A note about the elderly and how they respond to infection: They don't always show the same set of symptoms as younger people do when they have infections- even severe infections, such as the one suffered by Mr. B. The elderly human body's response to infection is blunted; their immune systems are not nearly what they once were. So more often than not, the first sign of infection in an elderly person is not fever, but confusion- or in medical jargon, "altered mentation."

Mr. B was demonstrating "altered mentation" in rather spectacular style. While the MD was examining him, Mr. B. got out of bed and asked her to dance in a clipped Hoboken accent: "Come on, babe- let's have at it." This MD is a real prizewinner- she's one of the keenest, wittiest docs I know; she is also a dyed-in-the-wool Ole Miss Southern Belle. She deftly parried Mr. B's advance with a flash of a smile as she relplied, "Lookit yew, askin' me ta dance and Ah don't even know yew. Darlin', let's just set a spell and get to know each other first." She took Mr. B's hand and with her free hand patted the stretcher.

"Mr. B winked at the MD, clapped his big paws together and and said with a grin, "Dat's just wonderful!" as he parked his butt right back down on the bed. I breathed a sigh of relief as Mr. B settled down, because had Mr. B so much as tried to jitterbug he would have pulled his Foley catheter right out.

Having averted that crisis, we managed to get Mr. B settled into bed. He fell asleep after a few minutes and I set about catching up on my charting. It was now around 0300, and the ER was empty save for another elderly man and his sick wife in the room next to Mr. B.

And then, from Mr. B began singing:

Ohhhh, the liquor was spilled on the barroom floor and the bar was closed for the night...

Every head in the staff area snapped upright and tilted toward Mr. B's room. The MD cocked an inquisitive eyebrow at me. I shrugged and looked into the room; Mr. B was lying flat in bed, and he continued to the next line:

When out of his hole came a little brown mouse that sat in the pale moonlight...

"What is he singing!? the MD whispered.

I recognized the song. It was a drinking song my dad (who flew attack jets in the Navy during the Vietnam war) and his squadronmates sang whenever they got together and had put a couple of scotches into the tank. Then I recalled seeing a faded tattoo on the patient's forearm: it was the badge of a Navy fighter squadron that had gained considerable acclaim during the Second World War in the South Pacific.

So Mr. B was a Navy fighter pilot, I thought. That explains why he knows that song.

I came about this revelation by pure chance; I am an amateur WW2 naval aviation historian. It's been my hobby for decades. I have just about every book written on the subject, including squadron rosters and listings of aces (pilots credited with five or more confirmed aerial victories). So as I tumbled the emerging data in my mind, I suddenly made the connection with Mr. B and the fighter squadron whose badge was tattooed on his arm, and I sat up and blurted, "Wow!".

"What is it?" The MD asked with concern.

I explained my discovery to all within earshot: Mr. B was a gen-u-ine WW2 fighter ace with 9 confirmed victories to his credit. This guy was an honest to goodness hero!

"Wow..." The gang replied in awe.

"...But what about the song?" The MD prodded after a few moments of courtesy.

"It's called Little Brown Mouse," I whispered, still a little amazed about the identity of this amazing man who was now lustily bellowing that old Naval Aviator's drinking song.

"You actually know this song?" the MD challenged.

"Oh, heck yeah. I learned it when I was about five years old. It took years for my mom to forgive Dad," I recalled with a laugh. (It would not have been so horrible had I not chosen to sing it at catechism. Sister Margaret was not amused.)

Mr. B pressed on with a startlingly pleasant, sonorous baritone voice:

Well, he lapped up the liquor from the barroom floor as back on his haunches he sat...

"It sounds harmless enough," one of the nurses added. It's kind of charming."

"Ohh, just wait," I said with a wicked grin.

And all night lonnnnnng, you could hearrrrrr himmmm roarrrrrrrrr...

We all waited. And waited. And waited.

Then Mr. B repeated: And alllllll night lonnnnnnng, you could hearrrr himmmm roooooooooooar...

More silence ensued. Once again, and with an edge of what sounded like impatience, Mr. B reiterated:

And ALLLLLLLLL NIGHT LONNNNNNNNG, you could HEARRR HIMMMMMM RRRRRRROOOOOOAR...

"Oh my gosh! He must have forgotten the last line!" I said with a laugh.

"Well, go help him out!" the MD shot, slapping me on the back to urge me on.

"I dunno, guys..." I said with some trepidation. Are you sure you want to hear the last line?"

"YES!" replied every nurse, MD and ER Tech at the station.

The elderly man next door to Mr. B added from the darkness of his room, "It's driving me crazy! For God's sake, help the poor SOB out!"

"AND ALLLLLLLL NIGHT LONNNNNNNNNNG, YOU COULD HEARRR HIMMMMM RRRRRRRRRRRROOOOOOAR...

"Okay. But But don't say I didn't warn you!" I disclaimed with a wag of my finger. I stood up with a sigh and strode resolutely into the room as Mr. B repeated the line with an "I-can't-remember-that-last-frigging-line-and-it's-really-ticking-me-off" bellow:

AND ALLLLLLLLLL NIGHT LONNNNNNNNNNG, YOU COULD HEARRR HIMMMM ROOOOOOAR...

As he finished the line, I bent over and whispered in his ear. His eyes snapped open with a start; Mr. B looked at me, grinned wickedly, shook my hand and said, "Say, thanks, sport!"

"It is my pleasure, Commander B," I replied with a wink as I pointed at his tattoo. I patted his shoulder, stepped back, and rendered a salute. Mr. B looked at the tattoo with dismay, looked at me, made the connection in his mind, and returned the salute smartly.

As I exited the room, Mr. B picked up where he left off, and I leaned against the sliding door to his room with my arms folded and my eyes cast heavenward in mock reverence, and mouthed the words as he bellowed:

And alllllllll night lonnnnnnng, you could hearrrr himmmmm rrrrroooooooar...

BRING ON YER G*DD*MNED CAT!

Somebody shrieked- I think it was the MD. I also heard a stifled snort from the elderly gentleman and his wife in the next room.

And in spite of the bawdy humor of the song, I took a bow back out at the staff area amid rousing applause. Our genteel Southern Belle MD was doubled over, clutching her sides and shrieking.

I escorted the hero upstairs shortly thereafter. He recovered and went back to the nursing facility, clear-headed and stronger, two days later.

Overwhelmed

Looking back, I can't really explain why or how it happened. The moon was not full. Quite the contrary; it was a mere silver cutting of a fingernail in a pristine, clear sky. It wasn't Friday, Payday, State Welfare Check Day, Psych Facility Dump Day, Rehab Reject Day, or even Taco Tuesday. Tent City was nowhere near my location. It wasn't raining, and yet it wasn't particularly hot outside either. It was really just a run-of-the-mill, clear, and comfortably warm, middle-of-the-week summer evening that gave me absolutely no warning that it planned on going straight to hell in a spectacular and brutal fashion by 10PM.

It ended as one of the most horrendous and tragic days I have ever lived.

I arrived for my shift already exhausted from having been woken up three hours early by my doorbell.

I should note here that it is a rare and odd thing to hear the doorbell, since a couple of years ago I taped a professionally-made, fade-proof sign right over the frigging thing that read, DO NOT RING THE DOORBELL.
I answered the door with ideas involving a slow death on my mind, only to find a gorgeous young woman with lovely pale skin and dark brown hair cut in a pixie-bob that framed a hauntingly beautiful face that stared innocently back at me with big, big, brown eyes.

She introduced herself with a smile and a tilt of her head that would have reduced a bloody-minded robber baron to a puddle of mush, and then said that she was representing [a nationally-recognized nature conservation society], and she was in the neighborhood asking for donations.

I introduced myself with an instinctive smile formed from years of genteel Southern upbringing, and I informed her that I happened to be an avid birder and photographer. She brightened noticeably- which, of course, only made her even cuter.

I informed Her Loveliness that I was a very tired and sleep-deprived trauma nurse who had gotten home from his shift a mere five hours ago, and who had only been asleep for three hours when she rang the doorbell and had to get up in only three more.

I then directed her attention to the doorbell (which by the way still had a sign taped over it that read DO NOT RING THE DOORBELL) and asked the little faun-eyed goddess, "My dear girl, what does that say?"

She looked at the sign, looked at me wide-eyed, looked down at her feet, sighed again, and said, "Do not ring the doorbell."

"That is correct. Was the sign not there when you arrived on my doorstep?"

"I... I honestly wasn't paying attention."

"That's okay. I understand. You're human. But your margin for error is a bit wider than mine. So, since I am only going to have three hours of sleep when I go to work tonight, can I use your excuse when I screw up and kill your mother?"

"Well, no!" She exclaimed in wide-eyed horror.

"Well, there you go, dear girl. Your ringing of my doorbell- when the sign clearly says NOT to- has cost me some much-needed rest; and I still have to be perfect when your mother rolls through the door with a cerebral hemorrhage."

"Uhh..."

"So since you could not follow simple directions that were posted right under your beautiful nose, bless you," I concluded, "I am going to buy stock in Halliburton with the money I would have donated to your charity."

"I didn't mean..."

"Next time, read the damned sign," I said acidly, closing the door coldly on the lovely young woman. The last I saw of her were her big brown eyes, looking down at the ground.

I managed to cram another hour or so of sleep into me, but I when I got to work, my butt was dragging so low that sparks were flying off the ground. I pounded down a gallon or so of high-octane Starbucks on the way, so I was exhausted and yet completely jittery to a degree that would have made Don Knotts recoil in horror.

Okay. I have been sleep-deprived before. I actually endured nearly a hundred sleepless hours when I was a sailor, during a Book-of-Revelation magnitude storm. It's just a horrible thing, really; It's indescribable. You talk to people who aren't there. You scream and rant and cuss about things that happen only in your mind. You blubber like a preschooler. You do things that simply make no sense; one of my shipmates actually walked straight off the deck into the sea. As he strolled casually toward the bulwark before falling twenty feet into the sixty-foot seas, he waved and said, "I'll be right back." He wasn't.

So in the big picture, having only three hours of sleep was not really that big of a deal. But still, I was pretty damn tired, and it certainly did not set me up well for what was in store.

I arrived to find the ER in chaos. We were three RNs and two ER Techs short. I shook my head and made haste to my area. I received report in the trauma room to which I was assigned. The patient I inherited was in a state of constant, continuous seizures and had crawled down to the front desk of the hotel in which he was staying during a lull after being in his room, seizing, for three full days. He was, of course, a bloody, stinking mess. And yes, he was still seizing when I got there. It turns out that his seizures were brought on by a huge brain tumor, about which he knew nothing until he was told later.

Like it or not, an ER nurse has to get his/her crap together pretty damned quick in a case like this, sleep-deprived or not. So within five minutes of dragging my sorry butt into the ER, I was wide awake and pushing what seemed to be a gallon of Phenobarbital into this guy in an effort to stop his One Big Seizure, all the while ensuring that I was within the dose parameters, ensuring that the chart was up-to-date, tackling the neurologist to get him to sign off on his verbal orders before he left the ER, and preparing to call report to ICU.

By the time I got him to ICU, he had been seizure-free for nearly an hour. Better living through chemistry.

I got back to the ER to find every one of my three assigned rooms occupied. No biggie, I thought, picking up the charts. But in looking at the chief complaints, I got that horror-movie feeling: the patient in Room 1 was a young developmentally-disabled adult female with a history of congenital heart defects, whose complaint was shortness of breath and a "fluttery feeling in the chest." In room 2 was a factory-fresh baby with a fever. The new occupant of the trauma room was a really old man who fell and hit his head and was brought in with an altered level of consciousness.

I began to mentally chew the Triage RN out, but then I looked on the computer at the waiting list for triage: we were royally and disastrously swamped. All 3 of my patients came in by ambulance or Medic unit. We were empty when I got to work an hour ago; what the hell happened!?

So, let's see here... I thought. The newborn could have life-threatening sepsis; The young woman could have a life-threatening cardiac arrhythmia; the old man could have a life-threatening head bleed. Who the hell do I see first!?
The baby trumped them all. I called the charge RN and told her that I was up to my eyeballs in really fouled-up people, but that I needed to see the baby first. She held the line while I tended to the baby. And the baby was really, truly, desperately, sick.

While the young mom held her mewling, shuddering newborn first child in her arms, I managed to punch a 24-gauge catheter into the baby's left hand. I got it on the first try, but it was still a nerve-wracking, brutal business that left my hands shaking, my scrubs wet with sweat, and the poor young mother an emotional train wreck. Dad stood by mom quietly, holding her hand and being a rock of stability, but he was horribly pale and drawn by the time my awful (but necessary) work was done. I left the room with a full "rainbow" of pediatric blood tubes plus a blood culture. It was hard to look Mommy in the eye after putting her little boy through that torture, but I knew worse was to come for him. Leaving the room, I looked at my watch: I was barely two hours into my shift.

While a wonderful ED Tech assisted the MD with the baby's lumbar puncture, I swept into the room of the patient with heart palpitations. She was a quiet, sweet, happy young woman who was in supraventricular tachycardia. Basically, her heart's natural pacemaker had decided to run amok, and needed to be dope-slapped back into the program. She was pain-free and her sats were 99% on 2 liters of oxygen, but she still had that "icky" (her words) feeling in her chest. The MD was waiting for Respiratory Therapy to arrive so we could attempt a chemical cardioversion with Adenosine. And that meant that I had to be there to push the meds and monitor the patient's physiological response.

I drew a deep, deep sigh and pressed on.

Trauma 1 was a a sheer, bloody nightmare. He was taking Coumadin for atrial fibrillation and a beta blocker for his blood pressure, had stood up too quickly (according to the caregiver as stated in the medic's "run" sheet), and promptly fell like a tree to the dining room floor. His right face was a bloody pulp and was swollen so severely that his eye socket was completely obliterated save for a small narrow slit. I could almost see the hematoma grow with each passing second. Oh, damn, I thought. This guy's got a head bleed for sure.

The guy already had a large-bore line in him courtesy of the medics who transported him. Off he went to CT.

I called the charge RN again and told her my status. She monitored the baby and watched for the elderly man to come back from CT while I slammed the Adenosine into the young woman and got her heart squared away. She went home a half hour later, in sinus rhythm.

The old man had a devastating head bleed that wiped out the entire right hemisphere of his brain and invaded his cerebellum, and he was not long for this world. I called his family. It really sucked. They came in and insisted that we reverse the DNR on the patient. The MD told them that no matter what we tried, the man was going to die because the bleed was just too far advanced. They finally realized that this was it, said their goodbyes, and let the man die in peace.

Meanwhile, I got the baby ready for transport up to the Neonate ICU and called report. Mommy was pale, shocky, and silent. I tried to reassure her as best I could, but what can you say to a mother whose only baby might still die in spite of a perfect pregnancy and delivery, and whom you had just tortured by shoving a needle into his tiny hand?

I filled out the after-death paperwork on the elderly man while the family spent an hour saying goodbye to someone who had left long, long ago. They could have stayed all night, if that's what it required; I didn't mind at all. I know how tough that is, having lost both my parents some years ago. The family finally left, singly and as couples, and the empty shell that had once housed Grandpa/Daddy was sent to the basement in a plastic bag.

It was now three AM.

I had a brief respite, and I finally ate lunch- a roast beef sandwich with baked potato soup I had picked up from the store on my way in since I had no time to make something at home.

Then the soul-crusher came in.

He was a 42-year-old man who was playing baseball with his kids at a picnic the previous evening. He and his wife had been intimate later that night. He woke up at roughly 3:30 AM with "heartburn," got up to take an antacid, and collapsed on the bedroom floor. He was blue, pulseless, and his extremities were stiffened when he arrived. His wife was with him, clad in her robe and slippers. She stood in the corner of the trauma room watching, terrified, as we tried every frigging trick in the book to bring her husband back to her. The Social Worker finally took her out to the waiting room when the poor woman had hit her limit.

Not that we had much of a chance. His youth had ultimately been his undoing. Older people tend to do better with heart attacks than younger people do. When younger people have them, the heart just seems to "blow out." And her husband had the huge misfortune of having what we refer to as a "widowmaker"- a blockage right above the junction of the Left Anterior Descending and Left Circumflex Arteries, both of which provide blood to the left ventricle. As a result, his left ventricle was utterly destroyed.

(Now the brutal reality of life is that if a person was to drop dead right in front of the you with a cardiac arrest and you immediately started CPR, that person would still probably die. His chances are certainly better than if you did nothing, but they're still crappy. But the reason we teach CPR is that even a crappy chance is better than no chance at all.)

We tried everything on this man for the best part of an hour. I mean, everything. We had ER people pulling out their ACLS books trying to find something they may have missed, but finding that we had missed nothing. No drug, no compressions, no amount of energy delivered to the heart was going to bring this guy back.

Time of death, 0627.

We failed. And this lovely woman, his bride, his lover, the mother of his three boys, was a widow. Just like that. I stood quietly in the counseling room with the MD as he told the woman that her husband was dead. I stood still and silent, dumb and useless, as she screamed No! again and again into the carpet and her fatherless sons, shocked and pale, held onto her.

The charge RN kicked me off the floor for the last bit of my shift, all of twenty minutes. She did the paperwork. She did the processing. I walked down to the snack machines and dropped coinage for a butter horn and some milk. I sat in the cafeteria silently, watching the TV in the break room but not really attending. I threw the uneaten butter horn in the trash. When I returned to the ER at 0700, change of shift was in full swing and all of my rooms were empty.

The Social Worker stopped me on the way out. She gave me a hug and reminded me that she was there for me too, and not only for the patients and their families. This SW is a real pearl, one in a million, and a dear friend. I think she saw something that I didn't. I was just functioning on adrenaline by that time.

I tossed my stuff in the locker and left. I remembered during the drive home that there was a mandatory ER staff meeting that morning. I shrugged and kept driving home through a cloudless morning that promised high temperatures.

I dragged myself up the steps to my front door. As I fumbled with the keys to unlock the door, I noticed an envelope resting on the threshold. I stooped to pick it up with a sore, graceless "Oof," and noticed that, oddly, no writing was on the envelope.

I fumbled to tear the envelope open, and I pulled out the card. ON the front was an Audubon watercolor of a Cedar Waxwing. Inside the card were a couple of lines written in plain script with pencil:

Dear sir: I am very sorry for having woken [sic] you up. I didn't mean to. Please forgive me, because I feel so bad about it.

I'm really sorry.

Sincerely,

xxxx

I bonked my head against the door with a dull thud and stared at the card for awhile. I thought about how rude I had been to the beautiful, harmless young woman whose only sin against me was ringing a damned stupid doorbell. I remembered the venom with which I spoke to her, and I felt unfathomably horrible for it, wishing that I could do it over. I unlocked the door, hobbled inside the quiet house, shut the door behind me, slid down to the floor with my back against it, and cried.


EPILOGUE: I was able to contact the local chapter of the organization for which the lovely young lady was collecting contributions. I gave her a dozen roses and my most heartfelt apologies, in person, and a large contribution (which is to an organization to whom I habitually contribute). She and I have since become great friends, and she enjoys coffee and bird watching with my wife and me.

Nurse William at Work

 

Well, here I am, in all my (ick) glory.

Forty-Two

I turned 42 years old yesterday. There are a few ways of looking at this age. A pessimist, of course, would say that I'm already halfway to 84. On the other hand, there is some significance attached to this age. For example:

I'm twice as much fun as a 21-year-old;
I'm young enough to be naughty and old enough to appreciate it.
My age also happens to be the Answer to the Ultimate Question of Life, the Universe, and Everything.

It isn't so bad. Except maybe when I try to get into/out of my car, chair, bed, etc. and make the same oof! sound my dad made when he was 42. That gets a little irritating. And I have noticed that the women who flirt with me are older.

But to a 70- or 80- year-old, I am still a "young man." I'll take it where I can get it.