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."