Tuesday, July 12, 2011

Desert Adventure, Part 5: Where Weasels Dare

My first shift in the Indian Hospital ER was over, and I walked the short distance back to my house with a lot on my mind. I entered the house, walked to the refrigerator and pulled out a Guinness. Tossing my keys on the desk in my room, I changed out of my scrubs and into a ratty old T-shirt and baggy shorts. I opened the bottle, flopped into a chair, put my feet up, and took a drink. The ice-cold stout was like a balm for my dry throat.

I opened up the orientation folder and waded through the paperwork until my stomach signaled its readiness for dinner with an unseemly churning growl. I looked up at the clock and was shocked to find that nearly three hours had passed. Darkness had settled over the high desert, and outside the window I watched a bat as it shot recklessly back and forth through the bug-crowded cone of light cast by a nearby streetlamp. Somewhere in the darkness, a coyote emitted a high, rather feeble cry. The reality of how far removed from my family and home I was- and the disappointment of my first shift- set in at last, and I fell into a dark and sullen mood.

This won’t do, I thought to myself. You’ve slept in mudholes in the rain. You’ve been ten thousand miles away from your family without any way to contact them. You’ve been in some really crappy predicaments, far worse than this. This is nothing. Pull your head out, doofus.

I shook my head, stepped away from the window, picked up my cell phone from my nightstand, and called home.

After a ten-minute pep talk courtesy of my wife, I was finally ready to give in to my stomach and trooped into the kitchen, where I whipped up a skillet of Hamburger Helper (I love the stroganoff) and popped another Guinness as I stuffed my face with comfort food. I went to bed with the uneasiness somewhat improved, and slept hard.

The next morning I awoke, showered, dressed, and walked in the chilly dawn back to work at 0700. I noticed the doctor, asleep in his chair at the desk, his head lolled back, and his mouth wide open. A rattling, nasal wauggghh came forth from his gaping maw. After stuffing the paperwork I had completed the night before into the slot by the manager’s office door, I settled into a corner of the charting area to continue my slog through the remaining forms. Not long after, Ramona the ER Tech approached me.

“Lucille is a no-show. You’re in charge.”


I stared blankly at Ramona for a few seconds, blinked a few times, and summoned the presence of mind to ask, “Did you call her?”

“Yep. No answer. I tried three times, on both her home and cell.”

“I see…”I said. Then, I asked hopefully, “Is anyone else coming in?”

“Not until noon, but it’s a new traveler.”

At least the place is empty right now, I thought. I set aside my paperwork and stood up.

Trying hard to suppress any hint of panic in my voice, I said, “Okay, Ramona. I’m going to need your help. I have to call pharmacy so I can get an access code to the med room and a logon to the Accudose. I also need to know where the important stuff is at. I’m going to need the protocols and standing orders book so I can get up to speed. Are there any RNs on standby?”

Ramona shook her head.

Of course not.

“Does the manager help out on the floor if we’re short-staffed?”

Ramona horse-laughed. And it was not just any horse-laugh. This was a throw-the head back, full-throated, “Haw-Haw-Haw-Snort-Snort-Haw-Haw-Haw” horse laugh.

Waaaaaauuuuuuuuughhhhhhhhh , offered the narcoleptic MD.

The next hour, with the department mercifully empty of patients, was spent obtaining access to the med room and Accudose, cramming the protocols into my head, and poring over the crash carts and code medications. The somnolent MD was replaced by a pleasantly alert one.

As I walked our first patient back to a treatment room, I passed the manager, who had settled into his office. I heard the rattle of a newspaper.

God smiled on me during my brief tenure as charge nurse. Only three patients came through the door, and none of higher acuity than a poor gentleman whose foot was trodden upon by his horse. During a lull in the activity later in the morning, I retired to my little corner to resume my paperwork. I had almost completed the last form when I looked up to see Lucille standing over me with her hands on her hips.

“Do you know what that weasel did?” She huffed.

“Uh, by ‘weasel’ I assume you to mean ‘the guy reading the paper in his office’…”

“Yes, him!

“Okay. What did he do?”

“That little SOB called me last night and told me I wasn’t needed for today.”

Cue ‘stunned silence.’

“Ramona got hold of me and told me you were all by yourself. I’m really sorry!”

“It’s not your fault. However, I think I’ll have a chat with the Weasel.”

I got up from the desk and walked with slow deliberation to the Weasel’s office, speed-dialing my agency’s recruiter along the way. I rapped sharply on the door and invited myself in before hearing otherwise. Weasel lowered his newspaper and stared at me over his reading glasses. Lucille caught up with me presently.

“Is there something I can help you with?” asked the Weasel.

“No, but I think I can help you with a little advice,” I replied as I hit “speaker” on my cell phone.

“Is that so? And what might that be?”

“Simply this: I suggest you figure out how you are going to explain to my agent your rationale for creating an unsafe working environment by pulling all nursing staff but me off the floor and putting me in charge without even an hour of orientation to the unit.”

”He did WHAT!?” screeched a tinny voice from my cell phone. The Weasel blanched.

”Put him on the phone. NOW.”

I took the phone off ‘speaker’ and handed it to the Weasel, whose face displayed a variety of emotions ranging from displeasure to wide-eyed shock over the ensuing two minutes of one-sided conversation. I couldn’t hear what my agent was saying, but if the Weasel’s facial expressions were any indication, it was gooooooooooooood.

Finally, the Weasel said, “Yes, of course,” and handed the phone to me.

“Put me on speaker,” demanded my agent. I did so, and my agent informed all in the room that an agreement had been reached on this matter, to which the Weasel, pale-faced and sweaty, verbalized his affirmation.

“Do you have anything else for me, William?” asked my ass-kicking, no-names-taking agent.

“Nope. I think we’ve about covered it, Phil. Thanks.”

“You betcha. Stay in touch, partner.”

Phil signed off and I put my phone away. “Ah, modern conveniences,” I sighed. The Weasel made a sour face.

“Cell phones are not allowed in the department.”

“Yeah, well sue me,” I shot back. “I’ll be turning my completed orientation paperwork in before lunch.”

“That will be fine. Is there, ah, anything else?”

“No, sir,” I replied. “I’m glad we had this discussion.”

Lucille and I departed the Weasel Den, closing the door behind us. Coincidentally, we ran into Ramona (who was grinning like a maniac and trying hard to stifle her laughter but could not contain the occasional snort) just outside the office. Lucille managed to hold her laughter until we were back in the main department. I sat down to complete my paperwork.

Tuesday, July 05, 2011

Desert Adventure, Part 4: "Nothing Ever Happens Here"

My three-day orientation was over in less than three hours. The mountain of paperwork, through which I had only begun to wade, would have to wait to be filled out on my off time. Within a twenty-minute stretch, our waiting room was packed with patients sent over from the hospital's clinic (because, according to the clinic nurse, the MD was busy planning a rafting trip). To top it all off, we had three ambulances coming with assault victims who had also, according to the medic's radio report, "seemed intoxicated." I had no idea where any equipment was located. I had no access code to the medication room yet. I didn't even know what we had on hand in the trauma rooms. I was thrown into the deep end, sink or swim.

I remembered what Vera (the cynical, gloomy nurse whom I would come to refer to as "Vee-yore") said earlier: "Nothing ever happens here." But when 'nothing' happened, it seemed to happen all at once and in the worst possible way.

I drew in a deep sigh and stretched. One learns by doing the thing... I thought as I hastily performed a quick scan of the trauma rooms to orient myself and prepare for as much as I could given my previous experience. The environment may change, but the fundamentals of trauma nursing do not. Failing all else, I still had my extensive training and experience on which I could rely. I would have to do the best I could and learn the department-specific protocols while I worked. I just hoped I would not violate any major policies in the process. My guess was that the manager would let me know soon enough if I did...

The three ambulances rolled up at the same time and disgorged their bleeding, cursing passengers, who were routed to separate rooms. The first one in was the worst off, with cervical collar and backboard in place and sporting a gaping, 6-inch laceration to the right forehead, diminished level of consciousness (LOC), and alcohol on his breath; he went to a trauma room. The other two were not boarded or collared, and had various facial lacerations and scrapes, but also had diminished LOC. One was a male in his early twenties; the other was a female who appeared to be in her teens. They were routed into separate rooms at opposite ends of the department.

Lucille the charge nurse asked me: "Who do you want?" I smiled wryly and asked for the boarded patient in the thrash room.

"Oh. We have a trauma junkie, do we? Suit yourself. I'll send Ramona (ER Tech) to help you and show you where stuff is. Call if you need help. Have yourself a grand old time!" With that, Lucille spun around with a laugh, shaking her head as she walked away.

I found Ramona waiting for me in the thrash room, wearing an eye-shield mask and a gown. She jerked her head toward a locker containing masks, gowns, and shoe-shields.

"Careful, man. He's a spitter."

"Thanks, Ramona. Is he spitting because he's belligerent?"

"I think he's just trying to clear the blood out of his mouth."

"I'll get suction going." I walked over to the wall, hooked tubing and a Yankauer wand to the suction unit, turned it on, and handed it to Ramona, who suctioned the patient's mouth.

"Aggh... gonna puke..." the patient groaned.

I quickly had Ramona come over to my side of the patient and we log-rolled him, backboard and all in a single unit, onto his side towards us. We carefully stepped aside from the EPS (estimated path of spew), and waited for him to finish. I observed the appearance of his vomit for blood or other materials. I didn't see much blood, but I did see a couple of teeth.

"Feel better, sir?" I asked the patient. He grunted to the affirmative. Ramona and I carefully returned the patient to a supine position and re-confirmed cervical-spinal stability. I instructed Ramona to keep suctioning the patient's mouth to keep his airway clear, and I began my trauma assessment, beginning with the airway which, at least for now, was reasonably patent. The patient's breathing was unlabored but shallow, and as I listened to his breath sounds I heard and felt crepitus (crunching) at the left lower ribcage. He had a couple of broken ribs. But the rise and fall of his chest was symmetrical, and I heard air movement in all lobes.

His blood pressure was 179/104, and his heart rate was 116. Part of that could be attributed to alcohol intoxication, as could his altered mentation. He ended up being alert and oriented, and he had no neural deficits. Either way, he was getting a CT scan from head to hips. He was cooperative and even apologetic.

I asked Ramona, "Where do we keep the IV stuff?"

"In the cart behind you, first two drawers."

I threw a couple of towels on the vomit, got out my IV equipment, and started a couple of beautiful large-bore lines. I hung a liter of Normal Saline on one side as Ramona hooked the patient up to the monitor. Finally after the primary and secondary assessments were completed, I asked the patient if he remembered what happened.

"I sure do. That little bitch attacked me."

"Who do you mean?" I asked.

"My granddaughter. She and her boyfriend beat me up because I wouldn't give them money. But I gave as good as I got, by God."

I assumed the young man and teenage girl were the 'them' in question. I asked the patient if he was hurting anywhere. He said, "My ribs feel like they're broken. It hurts to breathe, but it's not too bad."

I asked the 64-dollar question: "Have you been drinking today, sir?"

"Yeah. Had some whiskey."

"How much whiskey?"

"Hell, I dunno. A lot of whiskey."

"Okay. Well, we're going to keep you on the backboard until we know your neck is not injured. I'll keep you as comfortable as I can. You still nauseous?"

"Naw. I'm okay."

I stepped out of the thrash room in time for pandemonium to break out. The teenage girl was thrashing around and throwing punches at both Mary and security, screaming "I'm gonna kill that old bastard!" The young man in the other room was doing pretty much the same thing, but he was on the floor and two gigantic security guards had him pinned good. The young man tried to bite one of the guards, who deftly avoided the patient's mouth and squashed the patient's face into the floor as he quietly cautioned the patient not to do that again. The patient said something, but I couldn't really hear what it was since his face was mashed into the floor. At any rate, security seemed to have that situation well in hand.

Navajo PD arrived a few minutes later and unceremoniously hauled the two belligerents off to jail. I asked Mary about why they left before getting X-rays or sutures.

"The doctor wasn't about to go near those two with a sharp. He gave them both the once over and gave his blessing."

"That quick?"

"Yep. He stuck his head in the room, saw that they were breathing and active, and said 'Good enough for me, get 'em outta here'. I think he's in with your guy now."

I returned to my patient, who was sitting up in bed with the cervical collar off. A wiry, scholarly-appearing man was speaking to the patient and numbing his laceration. He looked over his shoulder and said, "You the nurse?"

"Yes. Judging from the use of sharp objects and the fact that my patient is no longer immobilized, you must be the doctor."


"So you think his spine is okay?"

"Probably. But he wanted off the board."

"But he has a head injury and is intoxicated. Don't we keep him on the board whether he likes it or not until a CT shows no injury?"

"Not on the Rez, we don't. They want off, we have to let them off. These folks can refuse everything, including restraints, and we can't go against their wishes."

"Wow. That's an eye-opener."

My patient spoke up: "I want to go home now."

The doctor stopped what he was doing and said, "You know, you've got a really big cut on your head. I could stitch you up and have you on your way in a half hour."

"No. I want to go home now," the patient said as he sat up on the edge of the gurney and, quicker than you could say "Aw crap," pulled both IVs out. He watched with intoxicated detachment as blood ran down his arms. I hurriedly clamped the IV tubing so the normal saline wouldn't run all over the floor.

"You sure about this? You could get a pretty bad infection," I offered as I attempted to dress his IV sites.

"Leave me the hell alone. I'm getting out of here now." The patient pushed me away, stood unsteadily, and took a lurching step toward the door, his eyes half-closed with intoxication. He attempted to steady himself on the portable stainless steel table nearby and toppled it, sending the table and its now non-sterile contents crashing to the floor.

"Dude, you can't even walk. How are you gonna get home?" I challenged.

"I'll get home just fine. Let me be." He lurched toward the door again.

"Can I at least put a bandage over your cut?"

The man shouted "NO!" and pushed past me. I gave a pleading look to the doctor, who only shook his head and shrugged. The patient staggered out of the trauma room and passed through the ambulance doors and outside.

"What do we do now?" I asked.

"We call the Navajo PD, and they'll pick him up and take him to jail," replied the doctor as he collected the instruments from the floor. He'll sleep it off, and then maybe he'll decide to come back in when he's sober enough to figure out how bad his laceration really is."

I paused in my cleanup efforts to offer a thought: "Wait a minute. The other two have been taken to the Navajo jail. Just how big is the jail?"

"One holding cell."

"You mean, those three are gonna be in the same cell?"


"Wow. Just wow."

I finished cleaning the room with Ramona's help, then finished my documentation. The manager came out and called me into his office. I stood as he sat down behind his desk, rested his chin on his entwined fingers, and looked at me from over his reading glasses.

"What do you think you were doing?" he finally asked.

"What do you mean, sir?"

"You're supposed to be doing your paperwork."

"We had a situation and I was needed. The charge nurse assigned-"

"The charge nurse does not manage the ER. I do."

"I understand. I will concentrate on my paperwork until I am finished."

"Good. Your shift is almost over for today. Are you finished documenting on that patient?"


"Fine. Make sure you clock out on time."

"I will, sir."

The manager turned away from me and started typing at his computer. I guess we were done with our conversation. I closed the office door behind me.

I ran into Vee-yore in the hall by triage, where she had holed herself up.

"So whaddaya think now?" She asked with a crooked smile.

I shrugged and walked away, answering over my shoulder, "It was nothing."

Desert Adventure, Part 3: Orientation at the Indian Hospital

Starting my first shift at the Indian Hospital was an exercise in uncertainty. I did not know what to expect. Having worked for the better part of a decade at my previous hospital, I was pushing myself out of the comfort zone that inevitably forms with staying in one place for a long time. After encountering a bloated carcass and being nearly drowned, struck by lightning, and beaten to death by hailstones, I walked into the Emergency Department of the Indian Hospital with a vague sense of unease.

Seeing the layout of the department, it occurred to me that this five-year-old building followed a thirty-year-old "horseshoe" design. Most concerning was that the two "thrash" rooms were the farthest away from the charting area. They were cramped and did not allow for much movement around the beds. On the plus side, the rooms each had computers. I was also struck by how small the department was. This 11-bed department was a far cry from the gee-whiz state of the art 40-bed ER where I had previously worked.

I found the charge nurse, who greeted me warmly and instructed me to report to the ER Manager's office in the back of the department. I knocked on the door and was invited in, where I came to stand before a pudgy, bookish fellow who was busy studying some papers through narrow reading glasses. He said nothing for nearly a minute; he did not look at me, and he did not invite me to sit. When at last he put down the document, I saw that it was a flyer for an upcoming rodeo.

Finally, the manager peered at me over his reading glasses, but said nothing. I was becoming less impressed with the man with each passing moment. After another long interval, he handed me a manila folder, inch-thick with forms, and spoke.

"Here is your orientation packet. Return the completed forms to me by the end of your first week. You'll be working 0700-1930, seven days on, seven off, starting next Monday. Today and tomorrow you will be orienting to the unit and the hospital, then you have the weekend off."

Having finished speaking, he turned to his computer and began typing for a few seconds, stopped, then looked at me again over his reading glasses.

"Was there something you needed?"

"I was just unsure if we were done here," I replied. The manager blinked a couple of times, sighed, and returned to his computer.

"Please close the door behind you."

Well, this should be an interesting three months, I thought as I returned to the nurses' station. Seeing the charge RN again, I formally introduced myself. She stood up and offered a firm handshake and a warm, cordial smile. She was one of the very few Navajo RNs who worked at the hospital.

"I'm Lucille. Welcome."

"Thanks. I'm looking forward to learning new stuff," I said.

"Oh, I doubt you'll see much," replied a nurse who approached us. "Nothing ever happens here."

I studied my new colleague: she was pasty, sweaty, tired-appearing, morbidly obese, and smoked heavily, as evidenced by her hoarse voice and stale tobacco breath. Her voice also had a vague slur to it. Her name was Vera. She didn't smile for her badge photo, either.

"What kind of cases do you see most often?" I asked.

"Drunks, non-compliant diabetics, fights, and drug-related stuff," Vera replied with a dismissive wave of her hand. If you want to learn anything or see something exciting, you came to the wrong place, sweetheart." Having spoken her piece, Vera turned and propelled her ponderous bulk around the corner and out of sight.

I turned to Lucille, who simply shrugged and explained, "That's just Vera."

Lucille poured a cup of some dark, hot, acrid liquid presumed to be coffee, and offered it to me as she gestured for me to sit down with her at the desk. She picked up my folder with a grunt, dropped it on the desk to land with a heavy thud and sighed.

"That packet gets thicker by the week. But before you get started on that, we need to get you up to Security for your badge." She turned and called another nurse over. "Mary, this is William. He's a new travel nurse."

Mary smiled engagingly and offered her hand. Like Lucille, she was Navajo, and the only other native nurse in the department.

Lucille continued: "I'm going to take William to Security for his badge. Will you watch the unit for me?

"Sure," Mary replied.

As we walked through the hospital, Lucille pointed out the various departments and clinics. The main lobby was naturally-lit, and its walls were adorned with beautiful murals depicting Navajo culture. The place was cool and had a peaceful air.

"I heard that the hospital administration is being taken over by the Navajo Nation."

Lucille sighed and answered, "Yes, but it's opened up a whole set of problems for us."

"What kind of problems?"

"Well, for starters, did you notice all the moving vans in the IHS housing area?"

"Now that you mention it, yes. Are these people moving in?"

Lucille laughed. "No! They're all IHS staff leaving. If they stayed on, they'd be losing their GS pay scale and would be taking a big cut in income. So they decided to leave in a mass exodus, since all their assignments ended at the same time. We've lost about ninety percent of our staff, and now we're scrambling to find replacements."

"Didn't the administration see this coming before they took over?"

"I don't know," Lucille answered with another shrug. "Maybe they assumed that more IHS people would transfer over. That certainly proved not to be the case."

"What are you going to do?" I asked as we arrived at the Security office.

"Hire lots of travelers and hope we can find more permanent staff."

Security was crisp and efficient as they processed me and took my picture. In less than five minutes, I walked away with a shiny new badge. The picture looked better than I hoped. I'm not the most photogenic guy on earth, after all.

Lucille walked me over to Information Services, where I got my logon and password for the hospital's internal and email systems and the computer charting program. Upon our return to the ER, Lucille paired me with Mary, would would serve as my preceptor for the rest of the week. Mary sat me down at an open computer, had me log on and make sure my passwords were working, and said, "Just do your paperwork for now. We'll go through the department later."

My interlude with the paperwork turned out to be short-lived. Mary approached me and informed me that we had three ambulances coming in with assault victims. Alcohol was involved. On top of that, the waiting room was beginning to fill up with patients referred to ER by the clinic. Lucille was talking heatedly to the clinic RN:

"Why are you sending your patients to us... You're too busy? I'm looking at your census right now. You're not even half full! How can you be too busy if you are fully staffed and only half full!? Oh, the doctor told you to divert the patients. What's he doing right now... planning a rafting trip? PLANNING A RAFTING TRIP!? That figures. Oh well, nothing we can do about it, then. Yeah, I'm sorry too. Tell your jerkwad of a doctor that the ER sends our regards."

Lucille slammed the phone down the receiver and groaned. She looked at me and said, "Your orientation is over. How fast can you pick things up?"