Sunday, September 28, 2008

Road Fest Part 4: Busman's Holiday in Kingman (Or, Melanie and the Toe of Doom)

The deep, exhausted sleep into which I initially fell proved to be woefully short-lived.

I was jolted awake around 1AM by the simple act of rolling over. My left great toe, which I had injured the previous morning when I struck it against a heavy chair in Susanville, was proving itself to be in far worse condition than I originally thought. I did not detect any deformation at the time of injury, and I could bend the joint fairly well. I had done everything that we would have done in the emergency department for this type of injury, and had been a good patient for myself.

Well, mostly good. There was this one little detail of keeping my foot down and using a clutch for nearly twelve straight hours...

I turned on the bedside lamp and swung out of bed to reassess the toe. I was shocked to find that the bruising had extended to above the toe and that the nailbed was an ominously-dark purple. I was unable to bend the thing at all. Of course! I forgot: I had been taking aspirin for the last four days to reduce the risk of getting blood clots associated with long-distance car trips. Aspirin reduces platelet aggregation, which means the initial bruising to my toe, which should have been fairly minor, was exacerbated by my inhibited platelet clustering as well as my keeping the foot dependent for so long. Thus was the unintended consequence of my diligent efforts to avoid taking rat poison (Coumadin) for a year or dying from a pulmonary embolism. Silly me.

I knew what I had to do...

Popping 600mg of ibuprofen and a gram of Tylenol, I hobbled to the ice machine to freshen my icepack. Returning to the room, I opened my "Hero Bag" (a first-aid kit modified for both survival and to treat traumatic injuries encountered outside the hospital setting) and looked through it for the tools I needed to perforate the toenail and relieve the pressure, which was the cause of my intense pain. As I rifled through the kit, which was contained in a surplus Army rucksack stuffed (and I mean stuffed) full of goodies, it slowly became clear that while I easily had enough supplies to perform an emergency cricothyrotomy, I could not find anything with which to puncture a damned toenail.

This situation rated a 9.95 on the Suck-O-Meter. I groaned a tired, "Aww, crap!" and propped my left foot up on a chair. As I glared balefully at the offending toe, I found myself on the horns of a dilemma that every ER nurse absolutely hates, hates, hates to encounter:

Do I stick it out a little longer and hope it gets better, or do I go on in?

Of course, I already knew the answer. The two factors of taking aspirin and having my foot down (and doing all that footwork on the clutch) for an entire day had combined to make my situation untenable. I was in so much pain that I was actually sweating and nauseated. I could almost see the toe pulsating. I resolved to grit my teeth and wait an hour, hoping that the ibuprofen, Tylenol, and icepack would win the day. One hour later, the ibuprofen, Tylenol, and ice pack handed in their respective resignations and trudged, under the black pall of defeat, into history.

I had to go in. Craaa-haa-haa-haaaaaap!

I consulted the phone book to find the number for a local hospital. Not knowing exactly where I was in relation to where I was calling, I rolled the dice and called the hospital with the most impressive-sounding name. The operator answered, giving the name of the hospital, and asked with whom she could connect me.

"Emergency Department Triage desk, please," I replied.

"Is this a life-threatening emergency?"

"Well, my toe is trying to kill me," I said with a grim chuckle. "Honestly, I just need to know how to get there from my hotel."

"What hotel are you staying at?" Asked the operator. I gave her the name and location. She laughed and said, "Dear, you are just around the corner. If you get in your car, turn right out of the parking lot, and turn right at the next light, you'll be at our ER in about thirty seconds."

"God bless you, Ma'am," I gushed. "I may yet save my toe." The operator laughed and wished me- and my toe- good luck.

I grabbed my wallet, my beat-up baseball cap (Toledo Mud Hens, in case you were curious), and cell phone, gimped to my car, and drove the shockingly short distance to the local Emergency Department. I arrived at about 2:30AM and limped into the waiting room, which was encouragingly empty. I trekked over to the information desk to get things started.

"What brings you in this morning?" asked the young woman at the desk.

"Left great toe injury," I said flatly, displaying the horrible-looking appendage.

"Ouch! Let's get you started, then." The young lady quickly registered me, and I took a seat. Five minutes later, I was called to the Triage booth. The Triage RN also cringed when she saw my toe.

"I know it looks bad, but it's actually merely horrific," I joked. The Triage nurse quickly finished with me and I was escorted into the main Emergency Department and placed in an examination room. The nurse gave me a fresh ice pack, a pillow, and a very sympathetic (not to mention cute) pout. After another few minutes, my nurse came in.

"Hi, I'm Melanie," she said as she pumped a glob of Cheap Scotch-scented hand sanitizer into her palm. "I'm your nurse tonight." She directed her gaze toward my toe and her eyes widened. "Holy cow, man!"

"Holy cow indeed, Melanie."

"When did you hurt it?" Asked Melanie as she gloved up, pulled up a stool, and began her assessment.

"Yesterday morning. I found furniture in the dark." Melanie winced again, and was tentative with her examination of the toe, appearing quite reluctant to touch it. She probably suspected- justifiably so- that the merest featherweight of pressure would cause me to scream like a girl. I am so glad she spared me of that embarrassment.

"Ooh, I hate bonking my toe against stuff! Still, they usually don't get this bad..." The RN pondered as she examined the toe.

"They do when you have been taking aspirin to prevent travel-related pulmonary emboli and have your affected limb hanging dependent for twelve hours," I replied.

Melanie sat bolt upright and eyed me with suspicion. She tilted her head and flatly stated, "You know the terminology..."

Her eyes searched me, looking for telltale signs that would betray me as one of those Effing Know-It-Alls who try to impress or intimidate ER staff either by (a): spouting terminology, or (b): wearing some article of clothing with an EMS or hospital logo on it. I had taken great pains to avoid either of those.

"Well, yeah. Sorry," I said self-consciously.

"Are you EMS?" She asked.

"No. I'm a trauma nurse."

"Really," Melanie responded flatly. I pulled my creds out of my wallet and showed them to her.

"I'm the real deal- See?" Melanie observed my license, ENA membership card, and Trauma Nurse certification card. Relaxing visibly, she said, "I'm sorry. You know how it is."

"Oh, yeah," I said with a laugh. "My favorites are the family members of patients who come in wearing a shirt that says "[insert resort name here] SEARCH AND RESCUE" and they try to actually pass themselves off as EMS. I had a ratty old morbidly-obese, greasy-haired broad with three teeth- all rotten- try that on me once. She pushed her daughter into Triage in a wheelchair and started barking orders at me- (I imitated the broad's cigarette-ravaged, slobber-flinging voice): 'My daughter has a history of seizures and needs Ativan STAT!'"

"Oh, no!" Melanie said, covering her mouth in horror. "Please tell me she didn't really say 'STAT!'"

"Nope. She really said 'STAT'."

Melanie threw her head back and laughed. She had a really cute, bubbly, disarming kind of laugh. I continued:

"And all the while, my dear colleague, this beast was taking every opportunity to wave her grotesquely huge chest at me to show off her MOON VALLEY SEARCH AND RESCUE sweatshirt," I said with a chuckle.

Melanie laughed and slapped her thigh.

I continued: "The woman just came unhinged when I smiled at her and told her, with all my genteel Southern charm, that I had bought that same shirt when I went on vacation at Moon River Resort!"

Melanie let out a squeak, her face red.

"And, AND, the daughter was totally faking her post-ictal symptoms, and she was reeeeeeeally bad at it. She would pretend to be all limp and unconscious with her head lolling around and her arms hanging over the sides of the wheelchair- even though she had tucked her elbows in when coming through the Triage doorway- and then every once in a while I would catch her opening her eyes and peeking at me to see if I was buying what they were selling. I caught her every time, and whenever I did she would sort of jerk a couple of times and go limp again..." I finished with tears in my eyes and my gut sore.

Melanie shrieked with laughter and stomped her feet.

"Oh gawd, yes!" Melanie said, wiping the tears from her eyes, and finally exclaimed, "Oh, I have one! Listen to this: About a year ago, I had a well-known drug seeker come in when I was working Triage. I am not kidding when I tell you that she weighed maybe a buck with lead boots on, and was seriously cachectic from years of poly-drug use. If you took all the bad teeth in her mouth and put them all together, you might get the same aggregate mass as half of a good tooth. And she was wearing a GRAND CANYON SEARCH AND RESCUE tee shirt." Melanie broke into a fit of laughter, then continued: "This woman was so tweaked on meth that she practically vibrated herself to the triage desk."

"Yeah, kind of like those old football game toys where we would put plastic football players on a metal table and flip a switch, and they would vibrate across the table," I offered.

Melanie looked at me strangely. "Oh, yeah. That was before your time..." I said sulkily. Melanie patted my knee sympathetically and gave me an 'It's okay, you poor old demented man' look.

"Anyway," Melanie pressed on, "This woman came up to me and actually shoved her nasty old shirt into my face, and identified herself as a SAR team member. She then gave me this story about someone breaking into her truck and ransacking her first aid kit, taking all the morphine and demerol. She actually ordered me to provide a replacement supply!"

I dropped my jaw in shock. "No way! She really expected you to believe her?"

"I'm not kidding, sweetheart," Melanie said. "She actually thought that she could get away with it. And you know what the really funny thing was?"

"No, what?" I asked.

"She was in three days before that and told us that she was new in town and was out of pain meds. She's lived in this town her entire life! But she wore sunglasses and a black wig to try to disquise herself. And a few days after the SAR thing, she came in again using the same out-of-town story."

"Wow. That's really, really... sad." I responded with a twinge of empathy.

"Yeah, you're right," Melanie said with a sigh. "It's sad. But you know what? It's also really, really dumb. We give them all kinds of resources to get clean. Our social workers bang their heads against the wall trying to make something happen for these people. I don't know how they come up with half of the resources they find. But these people, the really hardcore ones, don't want to get clean. They abuse the system, they bounce from ER to ER, they make up stories, and they spit in our faces when we give them what they need instead of what they want. And then, they have the audacity to show up in Triage a week later. Doesn't it drive you crazy sometimes?"

"Yeah, sometimes it does," I replied. "But ERs are beginning to wise up. I don't know about this ER, but my ER began to address it about a year ago by way of a standing policy that requires doctors to cease arbitrarily giving narcotics to drug seekers 'just to get them out of there,' and dictates that the first-line treatment be through non-narcotic medications that have proven to be effective for the same types of pain. We have seen a huge drop in the number of chronic patients who used to come in sometimes seven or eight times a month fully expecting- even demanding by name- narcotics for their pain."

"Hey, we started doing that about six months ago," Melanie said. "Many of the 'frequent flyers' stopped coming because they got genuine relief from their pain without narcotics, and they went to their doctors with this information. We got a 'Thank you' note from one of them. It was really nice. The others stopped coming simply because we stopped giving them narcotics. Whatever the reason, that's one less major drain on our healthcare system, and that will help to make healthcare less expensive for the rest of us."

"Amen, sister," I said.

Redirecting the conversation, Melanie asked, "Speaking of pain: How bad is the pain in your toe?"

"Bad enough for an ER nurse to decide to come in and get the toenail drilled," I answered in total seriousness.

"Hmm, yeah. I believe you." Melanie scribbled some notes on my chart and stood up. "Is your tetanus up to date?"

"November of 1999," I answered. "I'll renew my subscription at home, if you please. Driving with a bum foot is one thing; Driving with a bum foot and sore arm is another."

Melanie laughed again. "Okay. Just don't forget."

"I won't. I promise."

"Okay. The doctor will be in in a few minutes to do the deed."


"I'll be back in a little while, friend. Can I get you anything else in the meantime?"

"A stunt toe would be nice."

"Hah, hah. Back in a few." Melanie spun on her heel and exited.

A minute later, the doctor came in with a thermal lancet and a vial of lidocaine.

"I heard that you are an Emergency nurse. So I assume you are familiar with this procedure," the MD declared. I eyed the vial of Lidocaine with honest trepidation.

Clearing my throat, I answered, "Yes. You will perform a digital block on the toe and then perforate the nail with the thermal lancet. I am to keep the toe clean and covered with a gauze dressing and observe for signs of infection."

"Okay. Let's do it." The MD drew 5ml of Lidocaine from the vial, cleaned the proximal metatarsal phalanx with betadine, and spoke the ritual words: "Okay, you'll feel a stick and a burn..."

Oh. My. GAWD.

Let me tell you: I have had fingernails ripped out by towing hawsers, dislocated my fingers, fractured my ankle, and broken my nose. That was all tickle torture compared to this. I was ready to confess to everything from the Lindbergh baby kidnapping to being Paris Hilton's publicist just to get this guy to stop. Lidocaine H-U-R-T-S! I bit my lip so hard it bled. I was not about to cry out. I had a reputation as a badass trauma nurse to uphold, after all.

When he was done torturing me, and once I had regained consciousness after my vasovagal reaction, the MD smiled and said, "That went well."

"Oh yeah, doc. Piece o' cake." My head plopped back down on the sweat-soaked pillow.

The MD pulled out the thermal lancet and said, "Let me know if this hurts" as he lowered the tip to my toenail.

"Doc, compared to the digital block, this is nothing."

I did not feel a thing as the lancet hissed against my toenail, and I could not even express relief when I knew that the pressure had been dramatically relieved. I just did not feel it. Talk about anticlimax...

Melanie returned and gently applied a dressing to my toe. I was then shipped off to x-ray to rule out a fracture. It turns out that I did break the damned thing. So Melanie again gently buddy-taped my great toe to my second toe. She did a fantastic job of it. Returning with the discharge instructions, she advised me to keep the foot up as often as possible. I laughed and told her that I was scheduled to be in Phoenix to see some family later today.

"Cancel." She commanded. "You'll be really sorry if you don't."

I pled my case (that is, I sniveled): "But Melanie, dear girl, I only have my room for tonight. Every hotel in town is booked solid today. I really have no choice."

Melanie paused for a moment, then said, "I'll be right back." She got up and left the room. Melanie returned a few minutes later.

"My husband says you can stay with us for a day."

I was stunned. "Are you sure? I mean, you don't even know me! And I snore."

"I have four older brothers," Melanie replied. "I know all about snoring. Besides, judging from that ring, you're obviously married. We both have pistols, my husband was a linebacker in college, and we outnumber you." Looking at my wounded toe, she concluded: "Anyway, we could probably outrun a broken-down old gimp like you on our hands and knees."

"Wow, I'm touched, Melanie," I said drily. Pondering my plight for a moment, I finally surrendered. "You know you don't have to do this. I really don't know how to thank you."

"No worries. I trust you and your wife would do the same for us if we were in the same jam."

"Yeah. You know, we actually would," I said with complete certainty of my wife's amazing generosity.

"Okay. Let's check you out of here. Go back to your hotel room and grab some sleep for a few hours. My hubby and I will meet you there when we get off, and you can follow us to our place. I expect you to keep off of that foot for a full day."

"Fair enough." I gave Melanie my hotel name, room number, and cell phone number just in case they changed their minds. I drove back to my room and zonked out until about 8AM, when Melanie and her husband (a Critical Care nurse)collected me and made me feel at home on their couch after stuffing me full of one of her husband's delicious Southwest omelettes.

God wraps His arms around knuckleheads like me, sometimes. And next spring, our dear new friend Melanie and her husband will be staying with my wife and me for a few days of Pacific Northwest sightseeing.

Ya just never know what the day will bring...