Nurse William

Desert Adventure, Part 6: Of Pogues and Diversion

2011-10-04T16:51:00.000-07:00

I walked home at the end of my second shift deep in thought. If the Weasel’s behavior was any indication, I was in for an arduous three months. The Annoying Little Chihuahua of Discouragement that had stalked me for days began to nip at my ankles.

Screw this, I said to myself, shaking off the imaginary dark cloud that hung over me. I’m not going to let that little fink wear me down.

I took a deep breath and looked up; it was then that I noticed, for the first time, the genuine black cloud- a very angry and large black cloud- that loomed menacingly over me. The sky unloaded on me, and by the time I got to the house, I was soaked and shivering. Jack met me in the hallway with a scotch.

“Here,” he said, holding out the glass. “You look like you could use this.”

I thanked Jack and went in my room to dry off and change into an old pair of jeans, a ratty tee shirt my wife had threatened to throw out about five years ago, and flip-flops. I went downstairs to find Jack on the patio, slumped in a lawn chair and watching another approaching storm. The air was dead calm and muggy. I sat down next to Jack and let the scotch warm me up.

“The good doctor has split the scene for greener pastures,” Jack mentioned casually.

“Oh?” I said without the slightest trace of interest.

“Yep. We’re getting two new housemates; a kid in pharmacy school and a PA student. They’ll be here in the next day or so.”

“Great,” I said. “I hope they’re more fun. The doctor was a fart in the crowded elevator of life.”

Jack snorted into his scotch.

We sat quietly for a while, commenting on the tendrils of lightning that squirted randomly out from the storm. As long as I wasn’t caught outside in the middle of it, I have always loved a good old Southwest gully-washer. I sipped the last of my scotch and went into the kitchen.

“Feel like eating a steak with me?” I called over my shoulder.

“If you’re offerin’, I’m acceptin’,” Jack replied.

I pulled a couple of monstrous top sirloins (apparently carved from a brontosaurus) out of the refrigerator and proceeded to rub in some seasoning I had mixed beforehand as Jack got out the briquettes and got the barbecue started. I wrapped a couple of ears of corn in aluminum foil and pulled out some baked beans. I replaced the steaks in the fridge to keep until the charcoal was ready, pulled out a Guinness, and rejoined Jack on the patio. As I emerged through the sliding door, a brilliant branch of lightning shot completely across the dome of the sky and thunder boomed across our little valley, shaking the house and rattling the windows. Jack and I channeled our inner little boys and jumped up and down, whooping and slapping each other on the back. We grilled and dined in the middle of a high desert electrical storm, commenting between bites of succulent corn and perfectly seared steaks about the quality, duration, magnitude, and frequent alarming closeness of the lightning strikes.

As the storm worked out its frustrations on the earth, my friend and I put our forks down and our feet up to take it all in. My blood was shunted from my brain to my stomach to process my dinner, and I sank into a warm state of complacency. Finally, Jack broke the silence.

“You know, once you settle in a bit you’ll find that this is a pretty nice deal. This is a beautiful part of the country, and the Navajo are some of the nicest people you’ll ever meet.”

“Yeah, I sense that already,” I replied. “I don’t even mind the relative isolation, really. That’s just culture shock after having lived in the city for so long. But dealing with my manager is going to be a drag.”

“You mean the Weasel?” Jack asked with a knowing grin.

“Oh, you heard about it, huh?”

“Within the hour, buddy,” Jack answered with a chuckle. “You sure hit the ground running. I heard what he did to you, though. He pulls stuff like that on the agency nurses all the time; guess he likes to feel omnipotent or something. But you’re the first one to stand up to him like that. It must have rattled his cage.”

“Yeah, well I’m not exactly crowing about it myself. And I’m not looking forward to tomorrow, either.” As I said this, I could sense that obnoxious Chihuahua of Doubt lurking in the shadows. I shook off the feeling and pulled another Guinness out of the cooler. “You know, Jack, this is the reason why I have worked night shift my entire career.”

“Don’t like being around the pogues, huh?” Jack chuckled.

“Aw hell, I can deal with them if I have to. But our job is challenging enough without the added hassle of tripping over a bunch of self-absorbed dweebs who dispense rules that have no practical basis and often hinder the staff’s ability to function as an effective team. And I hold a particular dislike for pogues who think they can do whatever the hell they want to staff with impunity.” I paused to take a sip of my stout and to cool down from low boil. I concluded, “I just think it’s better for me to not have to be around them. And hell- I make more money from the shift differential on top of that. Avoid the pogues and make more money doing it; that’s a winning proposition any way you cut it.”

“Can’t argue with that logic,” Jack said as he poured another scotch. He watched the amber liquid as it swirled around in his glass and continued: “But you will find that the number of pogues per capita is much higher here than in any non-rez hospital. This has been IHS Country for decades. And you know as well as I do that once a government program becomes entrenched, it’s nearly impossible to even change it a little. And let me tell you, buddy: the pogues have found their way to the top here. They are the ones who elected to stay on when the hospital went Tribal, and they are making serious bank because of it. The hospital needed administrators, chiefs of medical staff, chief nursing officers and department managers in place to get this thing up and running. And where do you think the Tribe got all those people?”

“IHS,” I replied.

“Hell yeah, IHS. And not just any IHS. These holdovers are people who have been in the government-service bureaucracy for decades. They’ve learned how to connive, sneak, manipulate, and bully their way up the food chain. They became very, very good at what they do best- protect their asses and make everyone else expendable. And right there,” Jack said as he waved his glass of scotch toward the hospital, “is the perfect setup for them.”

I sighed and took a long pull of my Guinness. “So the pogues get fat, the Navajo Nation gets soaked, and the people get screwed. Does that about sum it up?”

“That about sums it up, “Jack answered.

“Well, it isn’t the first time I’ve had to deal directly with the pogues, and I know it won’t be the last. I just hope the Weasel gets a clue and leaves me alone. Pogues get pretty vindictive and mean when their cages get rattled.”

“It’ll work out,” Jack said, patting me on the back as he stood- rather unsteadily- and put the lid on the barbecue grill. “Well, I have to hit the sack. I’ll see you tomorrow.”

“Yep.”

I looked up at the sky. The clouds, thinned out now and almost translucent before the bright full moon, scudded past on the heels of the spent storm. I buttoned down the patio, locked the house up, and went to bed.

I arrived in the ER the next morning and was greeted by Ramona’s smiling face.

“Hey, Don Quixote, how’s it goin’?”

“Oh, ha-ha.” I retorted as I scanned the staffing sheet. “Nobody’s been called off, I hope?”

“Not today. Lucille is putting her stuff away and powdering her nose. That new agency nurse is here, too. We got a full crew. Yee-haw!”

From around the corner, Veeyore trundled her immense self into the nurses’ station. Her face was pale and sweaty, her hair was straggled around her face, she was out of breath (go figure), and as she saw me she threw her hands up in the air and exclaimed, “Oh, thank God you’re here! I can go home now!” I caught Ramona rolling her eyes. I smiled and asked Veeyore if she had any patients to hand off to me.

“No, honey. We cleared them all out for you. Try to return the favor, huh?”

As I faced her, I sensed something was amiss. The lights in the department were dimmed (which is not all that uncommon for night shifts in the ER), but as I looked into Veeyore’s eyes, I noticed that her pupils- which should have been dilated in the low light, were tightly contracted pinpoints. Her speech, appearance, and mannerisms were a little sloppy- even for her. I made a mental note of my observations and bade her goodnight.

As Veeyore exited huffing and groaning from the department, Ramona sat down next to me and whispered conspiratorially, “I think she’s high.”

I chose not to comment. Diverting medications is a career-ending offense, and I was extremely reluctant to participate in a conversation that could damage a colleague’s reputation when a number of plausible alternative reasons for her behavior existed. I offered a noncommittal “Hmm,” And logged on to the computer. Ramona set off to stock the rooms.

Lucille came to the desk and asked me quietly, “Did Vera leave?” I turned to face Lucille and noted the grave look on her face.

“Yeah, she just left,” I answered.

“Did you happen to notice if she came out of the med room?”

“Well, she came around the corner from that direction, but I wasn’t in a position to clearly see if she was in the med room before coming around the corner.” Clearly something was wrong. “What happened?”

“The medication dispenser drawer is wide open. The door to the med room is also wide open and a key is still in the lock.”

“Is it Vera’s key?” I asked, forcing myself to remain objective.

“Let’s see…” Lucille grabbed the key assignment log, traced her finger down the list, and in frustration shut the book with a soft whomp .

“She never signed for a key,” Lucille said. “Dammit, she always does this!”

“Are the other keys accounted for?” I asked, hoping to help Lucille refocus. She reopened the log and checked the keys in the box with what was on the list.

“Hmm… yeah. All the keys are accounted for, signed in and out by each nurse. The only key that isn’t signed for is the one with the red clip that I pulled out of the med room door. Nobody else signed for it. Vera was the only nurse here after 0100. She’s the only person who needed a key. And she’s the only nurse that didn’t sign into the key log. And she never signed for any other key.”

“Can we call her?”

“She never answers,” Lucille said. She sat down with a sigh. “The Weasel is gonna be pissed.” Ramona snickered, but straightened up the moment she caught Lucille’s icy glare. “We’re gonna catch all kinds of hell from him if we don’t get this straightened out.”

I suddenly remembered something. “Oh, crap. I just had a thought.”

“What is it?”

“The off-going nurse is supposed to do a count of all controlled substances with an ongoing nurse. I completely forgot about that, and I didn’t have Veeyore- I mean Vera- do the count before she left. I’m used to the charge nurses doing that where I used to work. I totally goofed.”

Lucille put her hand on my shoulder and said, “This is only your second full day here. You can’t be expected to know all of the rules yet. Don’t beat yourself up.”

“But I know how the Weasel is going to look at this. He’ll ask who Vera reported off to, and of course it was me. And the first question he’ll ask is, ‘What is our policy regarding med counts between off-going and oncoming nurses?’ I know the rule. I read the rule. I just forgot it because it isn’t habit yet. And the Weasel will conclude that no matter how new I am, if I already know the rule I am responsible for following that rule. And you know I can’t argue with that. Aw, crap- he’s got me dead red,” I groaned. “And I’m sure he’ll have yesterday fresh in his mind, and I don’t think he’s exactly the forgiving kind.”

Lucille doinked me on the chest with her finger. “Calm down.” I took a breath and settled a bit. “Let’s do the med count, and whatever the result is, we’ll go from there.”

I followed Lucille to the med room and we commenced the count. Five minutes later, we stared at each other in quiet horror. The inventory was short by six 2mg vials of Dilaudid and four 10mg vials of Valium. They were signed out about fifteen minutes before Lucille and I had arrived, and the patient for which they were obtained was manually entered into the dispenser’s computer rather than by the pharmacy. There were no patients in the department at the time the meds were obtained.

And the nurse who obtained the medications was Vera.

Lucille and I stood shocked, bound in a moment of sad revelation. Finally, Lucille collected herself and ripped the count printout from the machine, secured the dispenser, and led me out of the med room. She locked the door with the red key and went to the nurses’ desk, where she sat down and quietly stared at the floor. I sat down next to her and carefully rejoined her in discussion.

“Lucille, I have some other data to go along with this.”

“What is it?”

I shared my observations from my conversation with Vera, including the pinpoint pupils, slurred speech, and euphoric mannerisms. Lucille lowered her head and sighed. When she looked up again, she was crying.

“This sucks. Dammit, this just really, really sucks,” she said softly. I nodded.

I stood up and patted her on the shoulder. “We need to talk to the Weasel. We need to do it now.”

I followed Lucille to the manager’s office. Lucille knocked on the door and we were invited in. The Weasel looked up over his reading glasses, first at Lucille, and then at me, at which point his eyes narrowed slightly.

Folding his hands with his elbows on his desk, he sighed and said, “I sense that we have a problem.” He looked at me again, perhaps curious if I was the problem. I shifted uneasily.

Lucille spoke up: “We have found a discrepancy in our med count this morning.”

Weasel’s eyebrows raised slightly. “Are you unable to resolve it?”

“Yes, sir, we think it can be resolved,” I answered.

“Then I don’t see a problem.”

“The problem is that it’s possible-“Lucille paused and took a deep breath- “Actually, it’s probable- that the meds were diverted.”

Weasel took off his reading glasses, rubbed his eyes, and looked at me again. Seeing what must have been obvious unease in my expression, the trace of a smile tugged the corners of his mouth and he asked, “And this is why he is here?”

“No, sir,” Lucille answered emphatically. “He is here because he found the discrepancy.”

I stole a glance at Lucille. That wasn’t exactly how it happened. Why would she put it that way? Still, Weasel’s demeanor changed to that of a cat that had lost its prey. He sighed and invited us to sit down.

“Tell me what happened.”

Lucille explained the events, my observations, and our findings. She laid the printout on Weasel’s desk. Weasel did not interrupt, and he sat quietly for a minute after we finished. Finally, he drew a deep breath and spoke.

“Thank you both for bringing this to my attention. I’ll take it from here, but I may need to speak to each of you later on today if I need clarification. William, if I could have a word with you in private, I would appreciate it.”

Lucille left. I stayed. Weasel tapped his desktop idly as he considered his words.

“Did you do the count with Vera before she left?”

“No sir, I did not.”

“Did Vera provide the end of shift report to you?”

“Yes, sir, she did. May I speak, sir?”

“Go ahead.”

“I realize that it is the responsibility of the oncoming nurse to go through the count-“

Weasel raised his hand, and I stopped talking.

“Even if you had caught the discrepancy, I’m sure Vera would have provided a plausible explanation. She could have just said she wasted it and forgot to enter it because she was busy, or didn’t because there was no other nurse to witness it. It’s a pretty generic scenario with these sorts of things.”

“Knowing that doesn’t make it suck any less for me, sir.”

Weasel smiled. “But that’s not where I’m going with this. I want to be clear in my mind that you are certain without a doubt regarding your observations. Is there any possible alternative explanation for your findings that you can think of?”

“I have actually tried to avoid coming to any conclusions and to remain objective. This kind of thing is a career killer, and if I cannot be completely certain, then I am extremely reluctant to offer my personal opinion. The only appropriate input I can offer is what I saw and heard in such a form as to be admissible in court. I would be wrong to offer more or less than that.”

Weasel pondered my answer and concluded, “I agree. However, we may need to talk to you later for further clarification. Right now, I have some phone calls to make. Thank you for your help. Please close the door behind you.”

I left the office thoroughly puzzled, and I had a vague impression that in spite of my previous clashes with Weasel, perhaps he was not the pogue that I had thought him to be. In spite of the stunt he pulled yesterday and the resulting verbal blast he got from my agent, he clearly could not have been fairer to me that morning. We didn’t exactly like each other, but on a purely collegial level we had made a positive- if tenuous- connection. Time would tell if we could reach a mutual understanding. I hoped we could. It would really suck pond water if I had to spend the next three months having to worry about it.

Vera did not show up for her shift that evening, and nobody here ever saw her again.

Desert Adventure, Part 5: Where Weasels Dare

2011-07-12T06:07:00.000-07:00

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.”

Waaaaauuuuuuuggggghhhhhhhhhh.

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.

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

2011-07-05T15:08:00.000-07:00

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."

"Yep."

"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?"

"Yep."

"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?"

"Yes."

"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

2011-07-05T10:55:00.000-07:00

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?"

Desert Adventure, Part 2: Thor's Playground

2010-11-14T22:06:00.001-08:00

Ever the optimist, I began to rationalize as I unpacked my things and settled in to my new, if temporary, abode in IHS housing. So what if my initial impressions of the reservation were not what I expected? What did I expect, anyway- A John Wayne movie? I had yet to really explore the natural beauty of the place, and with the exception of the obnoxious MD with whom I shared the house (as noted previously), the people seemed rather nice. The house itself was clean and had air conditioning. The topographical features were pretty amazing, too. On that front, I looked forward to exploring more of the region on hikes and drives.

Baby-san (my faithful steed, a 2007 Ford Mustang) seemed to be performing just fine in the 7,000 feet elevation. Having unloaded her, I cleaned out the trash and, armed with a shopping list, started on my way to the teeming metropolis that is Gallup, New Mexico. I made my way through the IHS housing area and experienced my first encounter with what the people who built the place euphemistically call a "speed bump."

Bang! Scraaaaaatchhhhhhhhhhhh!

"Holy crap, what was that!?" I blurted as I pulled of to the side of the road to inspect the damage. Finding none (thank God), I looked back at the bump. No wonder I bottomed out. It was as high as a curb! I'd need a jacked-up 4x4 to clear those monsters straight on. I cautioned myself to take the bumps diagonally (which I did over the remaining ten bumps on my way to the highway) and managed to keep from high-centering. I drove past the cow carcass (now being inspected by a small band of curious dogs) in the middle of town and turned eastward toward Gallup. The sky was a clear and brilliant blue, and it was hot. A single fragile wisp of white cloud was showing itself in rebellion against the beauty of the day.

Ten minutes later, as I looked in my rear-view mirror I noted that the little white wisp had mutated into a rapidly-building cumulus. Thirty minutes later, as I pulled into the Wal-Mart parking lot, I looked westward and noted that the cumulus cloud had not only discovered steroids, it had also called some of its friends over for a party. The wind, which had been a gentle westerly breeze when I left my house, had completely backed and was blowing from the east at a steady twenty miles per hour. The weather system was creating its own energy by now. I stood, transfixed for a few minutes, watching these now massive clouds as they boiled upward and began to flatten up against the stratosphere. Tangled orange strings of lightning squirted menacingly from the darkest parts of the storm.

Ah, that's right, I thought. Monsoon season. I actually looked forward to seeing a good old Southwestern thunderstorm.

I entered Wally World to pick up my sundries, a set of linen (they have 400-thread count stuff for super cheap there!), car wash supplies, and some vitamins. As I exited a mere half-hour later, I was ambushed by the storm.

It was as if I was standing in Hell's car wash. The air was so completely full of water that I felt I would drown if I took a deep breath. I had nearly summoned the will to dash the two hundred or so feet to my car when a blinding, blue-white bolt of lightning struck about that far away from me.

BOOOOOOOOOMMMMMMMMMMMMM!

The thunderclap reached me almost simultaneously, and it was loud as hell. I heard a small voice from within, which I took to be that of my guardian angel, begging to inquire of me regarding just where the hell I thought I was going.

Having suddenly discovered the merits of abject cowardice, I retreated back into the alcove of the building from whence I had so foolishly ventured. Now shivering in the air-conditioned environment, I found it necessary to purchase a long-sleeved chamois shirt. What the hell- I was here anyway, right?

There was no delightful patter of raindrops like I was was used to back home in Washington. The torrent smashed against the aluminum roof like an avalanche of gravel, creating a steady, deafening, high-pitched roar similar to a jet's afterburner. I could not see my car- in fact, I could not see the nearest cars, which were only twenty feet away.

After what seemed like an hour of this (but was perhaps twenty minutes or so), the downpour seemed to let up. Figuring to try my luck, and I stepped out and made it about ten feet when almond-sized hail began to strike me on my senseless head. I can proudly say that at that moment, true to my valiant and heroic self, my first thought was not for myself. It was, in fact, for my beloved Baby-san.

Aw, cra-ha-ha-haaaaaaaaaap! Not hail! Damn it, I just WAXED my car! I whined while scampering like Chicken Little back to the safety of the alcove. I could easily imagine my car being shot-peened by Mother Nature into a formless, paintless, and valueless blob.

And the roar became far worse. It was all-consuming, seizing complete and brutal dominance over the full sensorium. Time stopped. Nobody talked- it was pointless to try. Hardly anybody moved. Hundreds of shoppers moved slowly and trance-like, around the place with their heads down, not saying anything. The mouths of small children gaped widely, wailing, but nobody could hear them. I just stood off to one side of the alcove by myself, a safe distance from the glass, and watched with a sense of dread and awe as the sky seemed to collapse on top of me. I felt myself retreating inward, feeling vulnerable, beset, powerless, and humble.

God must have sensed that we got His point. The rain abated as rapidly as it came. For a while, people seemed hesitant to go to their cars. I crept timidly out of my shelter and looked up at a clear, blue sky. The parking lot was ankle-deep in water. Tendrils of steam wafted eerily from the asphalt surface in the intense sunlight. The wind had completely died. It had become hot and humid. And miracle of miracles, my fears about Baby-san turned out to be unfounded (I guess the hundred coats of Nano-Wax saved the day).

The drive back to housing was uneventful (just about anything but the Apocalypse would have been, at that point in my day). I picked up some groceries, waved to the dogs gathered around the bloated carcass (now thoroughly soaked and spattered with red mud), and gingerly tiptoed Baby-san through the world's tallest speed bumps.

As I put my linens in the washer, I heard a distant thunder. Looking out the window, I saw another line of huge thunderstorms marching across the desert towards my happy little slice of heaven. The weather was establishing a pattern that would continue for the next two months.

Yee-Haw.

Nurse William's Not-So-Excellent Desert Adventure

2010-10-14T10:32:00.000-07:00

After more than eight years of employment at a busy hospital in the Seattle area, I felt it was time for a change. I had considered travel nursing in the past, but either the timing was not right or the opportunity was not there. I wanted to learn different approaches to emergency nursing and see new sights. And I wanted to make more money doing it. My household was knee-deep in debt and the extra money made by traveling was going to help us reach solvency. Once we got to that point, I would look for a permanent job again.

Once I made my decision, it was simply a matter of choosing an agency and waiting for the job to come to me.

And waiting… and waiting.

I finally got a call from an agency about an immediate opening at a hospital serving a large Native American population in Arizona. The hospital, I was told, had a “Level 2” trauma designation and saw a lot of “interesting” cases since it was the only “major” hospital in the region. I was told that the hospital was brand-new, was “state of the art,” and was very “traveler-friendly.” And, of course, I would be making more money. The only hitch was that the start date was less than two weeks out, and I was still employed at my permanent hospital. I would have to quit with less than two weeks’ notice, which meant I would forfeit about 800 dollars in vacation pay.

I took a leap of faith, accepted the offer, and gave my notice.

Two days after I finished my final shift (topped off with a goodbye party that genuinely moved me to tears), I packed up my faithful Ford Mustang named Baby-San and drove down to northeast Arizona- wondering all the while if I was embarking on a new adventure or making one of the biggest mistakes of my life. I had traveled around the world years before when I was a merchant seaman, and was no stranger to traveling light. But never before had I laid so much on the line. There were no permanent nursing jobs to come back to in Seattle. I was seriously stepping out in faith that I had made the right decision (this after much prayer). But as I drove through Washington, Oregon, California, and Arizona, a biblical proverb kept pecking at my mind like a bird on the windowpane:

“There is a way that seems right to a man, but in the end leads only to death…”

…Which, needless to say, had a rather dampening effect on any excitement I might have otherwise entertained.

Three days after leaving the crisp, green scenery of the Northwest, I arrived at my housing on the Indian Reservation. The scenery was impressive, with rock formations jutting from the ground as if the Almighty had simply planted them there like 200-foot-tall brick-red croquet spikes. At 7,000 feet above sea level, the air was clear and sharp. But that’s as far as my positive impression went.

Garbage was strewn everywhere. Weather-beaten junk cars dotted the landscape. It was understandable for a high-desert location to be dusty and grungy; But this place was just filthy. The houses were dilapidated, and the trailer homes were in a far worse condition. Scruffy and emaciated stray dogs wandered everywhere. The grotesquely bloated carcass of a cow that had been dead for at least a couple of days lay on the side of the road in the middle of town, its legs rigidly jutting parallel to the ground. (If the inhabitants claim to be "grooms of the earth," it was a wonder they were not incarcerated for spousal abuse.) The living environment appeared as unwholesome as any third-world country that I have ever visited. And the first thought that came to my head was one of dismay: “My tax dollars are paying for people to live like this!?”

(Ironically, the first sign I saw when I pulled into town said “Paid for by the American Recovery and Reinvestment Act.” Well, holy crap. At least now I know a little more clearly the extent to which I was robbed.)

After driving down another ten miles of crappy road paid for by us unwitting victims, I picked up my house keys and garage door opener from the housing manager and drove along the rows of identical, stuccoed, red aluminum-roofed houses to the cracker box that bore my number. If it was not for the occasional parked car or moving van, I would have guessed the community was abandoned. Not a soul was in sight. I pulled into my driveway, opened the garage door, and began hauling my stuff upstairs to my room.

In the hallway, I ran into one of my housemates. I introduced myself informally. He, in turn, replied that his name was DOCTOR so-and-so. He ignored my cordially outstretched hand.

Well, screw you and the magic carpet you rode in on, doc, I thought as I dragged my gear into my room and unpacked. As I stepped out of the room, I ran into my other housemate. Taking the chance, I offered my hand and introduced myself. My new friend eagerly shook my hand, introduced himself as Jack, and began to tell me about some of the nicer points of the area. He was a genuinely nice fellow (with whom I remain in contact). I asked him if there was any place nearby where I could pick up some bedding and other sundries- and maybe have a beer, too.

“Oh, there’s a Wal-Mart that’s about forty miles away from here.”

“How about a place where I can watch some baseball and have a beer?”

“You’ll have to go about forty miles for that, too. This is a ‘dry’ reservation. No alcohol is allowed. (My friend declared this between sips of scotch and water.) If you get caught bringing alcohol onto the res, the cops will confiscate it and give you a ticket.”

“Well, at least now I know why there are so many drunken driving fatalities around here.”

“Oh, it’s worse on the reservation. The natives still bring alcohol in, even though it’s illegal. The cops just give the natives a wink and let them pass. Hell, they’ll probably be partying with them after work. You’ll see a lot of alcohol-related stuff in the ER.”

“Peachy,” I responded with a weary roll of the eyes.

Jack changed the subject: “But if you like exploring and sightseeing, there’s a ton of stuff here. You have Monument Valley, Grand Canyon, Mesa Verde- all kinds of stuff.”

My mind filled with images of John Wayne riding among the monoliths. “I would love to see Monument Valley. Is it close?”

“Well, it’s about four hours away on a bunch of back roads that might not suit your Mustang. Come to think of it, there isn’t a lot around here that your car would tolerate, because the roads are pretty bad.”

So much for John Wayne and monoliths.

“I guess I’ll stick to what I can get to, then. Is there anything close that I could get to in my car?”

“No, not really…” Jack answered with his eyes averted.

“Jack, just tell me straight. I’m in the middle of frigging nowhere for three months, huh?”

Jack pursed his lips and nodded slowly. “That sums it up.”

“Got any more scotch?”

The Ultimate Narcissism

2010-03-15T02:19:00.000-07:00

Psychologists (alleged "practitioners" whom I hold in quite dubious regard due to page 51 of the DSM-IV) have often described suicide as a 'cry for help'.

I ain't buyin' what they're sellin'.

What it really is is a declaration of "I don't give a rat's ass about how finding my body or watching me blow my brains out or splatter myself on the concrete fifty stories down will utterly traumatize another human being for life."

The complete stranger who took out a pistol and blew his brains out last week right in front of my daughter certainly didn't care. But you can bet your ass that my daughter is going to remember it for the rest of her life.

I know how callous this reads. But I have seen enough proof of who really gets hurt by a suicide attempt to know that the real victims are not the suicides, but rather the people who have to go on with the memory of what was done to them by the suicide- whether successful or not.

I care about those victims. I have no sympathy for a person who thinks so little of others that they would scar them for life.

So if you're thinking about ending your life, at least have the courtesy of doing it in a manner in which nobody will have to (a) see it, or (b)ever find your sorry, selfish, narcissistic ass.

The Witching Hour

2009-03-25T03:02:00.000-07:00

0430...

It was hard to believe that less than two hours ago our 40-bed Emergency Department was nearly full. We managed to admit or discharge nearly all of our patients in that short time. Only two occupants remained: one was a 17-year-old habitual "cutter" who had gone off her bipolar medication; we had stitched her up and she was just waiting for Daddy to come get her. The other patient was a harmless professional drunk whom we named "Otis." Otis was currently sleeping off his two-bottles-of-Old Crow dinner and getting IV vitamins.

Nurses and ER Techs had been busy for the previous hour, putting the department back together after a particularly vicious night with a patient demographic chock full drunks, punks, and bipolar funks. Hooray for Welfare Check Weekend. Yay.

Having completed the tasks associated with my particular section, and having no patients, I sat down at my station, stretched, yawned obnoxiously, and pulled out my copy of Patrick O'Brian's The Golden Ocean.

The housekeeper (a truly endearing gentleman named Moe, who is believed to be around 800 years old) arrived in the department riding his Super-Awesome Floor-Cleaning Vehicle. The machine functioned pretty much like a Zamboni. It kept our special rubberized floors nice and clean- until, of course, we walked on them with our filthy-soled shoes.

The Zamboni was universally hated by the nursing staff, and rumor had it that the machine was manufactured somewhere in the lowest plane of Hell by the devil himself. As innocuous as the thing appeared to be (it kind of looked like a prematurely-delivered SmartCar), its true sinister origins were revealed by its noise. The thing emitted a constant, bellowing screech reminiscent of a skinned banshee with a pitchfork up its arse. Its nightly rounds created an environment that was about as therapeutic as trench warfare.

Moe drove his infernal steed with a great big grin on his face and a cold gleam of bloody-minded determination in his eye. No puny mortals would deter Moe from his mission as he screamed through the Emergency Department at the blinding speed of 0.5MPH. Moe made it clear that he would not waver from his intended course; we had best get out of the way and the devil take the hindmost. He emphasized his point by honking the Zamboni's horn.

Oh yes, it had a horn. It sounded exactly like one salvaged from a 1967 Volkswagen Beetle- specifically, a Beetle that had just been discovered after forty years of being buried in the slimy muck of a freshly-drained swamp:

Mmmmmmmmeeeeeooooooooooooooouuuuuuuuuuuuunnnnnnnngggggggghhhhhhhh....

It was a soft, plaintive, mournful sound that carried through the early-morning air and evoked from Otis a slurred "WazzahellizZAT!?"- immediately after which the Sirens of Bacchus recaptured him with their wine-fueled song and returned him to snoring, slobbering, farting oblivion.

Having completed its infernal rounds, the hell-spawned steed with Moe at the reins retreated to the black pit from whence it came. A traumatized silence, similar to that which is experienced after witnessing a bad accident, ensued.

0500...

The change in the atmosphere was palpable. Staff slowly drifted towards the two large resuscitation (or "thrash") rooms that remained active- to one of which I was assigned. I put away my book, got up from my desk, went into my thrash room, and methodically prepared for a patient who did not yet exist. I pulled out a sheet and laid it on the stretcher, placed two disposable absorbent "chucks" on it, and elevated the bed to waist level. I pulled out an assortment of IV needles, skin prep supplies, and blood collection tubes, neatly arraying them on a stainless steel rolling table called a "Mayo stand." I brought out a Foley catheter kit, nasogastric tube supplies, and other sundry invasive instruments. I set up three suction points and checked for proper function. I pulled out a Bag-Valve-Mask and hung it over an oxygen flowmeter. One of the ER Techs casually parked a portable EKG machine outside the room.

This is the ritual of the Witching Hour.

The Witching Hour is what we call that period of time, roughly from five-ish to six-ish in the morning, when most heart attacks occur. It has to do with rising cortisol levels that occur during the body's sleep/wake transition cycle. It is unnecessary to go to great lengths in describing the pathophysiology behind the phenomenon. It can simply be explained thus: There is something about waking up that really gets a sick heart pissed off. And the heart, perhaps like no other organ, has a magnificent way of letting its owner know that it is really pissed off- especially if said heart has been abused by decades of overeating, smoking, substance abuse, and laziness. (Or sometimes it's just crappy genetics. Ask Jim Fixx, a 1970s-era marathon runner who was in ludicrously excellent shape. Oh, wait... he's dead. Heart attack. I think his last words were, "Oh, crap. You gotta be friggin' kidding!")

0540...

The medic phone rang. The MD took report, handed the run sheet to Mindy the Charge Nurse, and returned to his computer. Mindy turned around and quite by coincidence (I swear, really!) ran into me.

"Howdy," said I.

"Gee, I know how you hate these things, but can I trouble you to take this one, pretty please?" Mindy asked with a flat and rather sarcastic tone of voice. She batted her eyelashes.

I drawled, "Well, okay ma'am, since you asked real nice and all..." and took the sheet from Mindy's hands with a wink and a crooked grin. She snorted, rolled her eyes, and walked away shaking her head and mumbling something to herself about "code junkies."

I returned to the thrash room to recheck my preparations. I turned to my colleagues and recited the details from the run sheet: A 46-year-old man woke up at 0500 with crushing chest pain, nausea, lightheadedness, and cold sweats. He had no known medical conditions (until now). He was hypotensive and bradycardic (this raised a few eyebrows in the room). He was to arrive in 5 minutes. (Why medics choose to wait until they are only five minutes away to tell us they are enroute with a super-sick patient is a perpetual mystery to us.)

Having provided the background, I then gave each colleague a set of specific assignments to perform throughout the process. I would act as Primary RN.

The role of the Primary RN is highly management-intensive. My responsibilities as a primary nurse are to assign, oversee, document, and insure the completion of all nursing and tech-related tasks as long as the patient is in my care. Additionally, when a task was completed I must either provide a new task or release that RN or tech from the room in order to keep the area clear of all nonessential persons. I am to insure that the administration of all medications, the call times and arrival times of other specialists and departments, all interventions by medical and nursing staff, and the patient’s responses to those interventions are accurately and succinctly documented. Additional tasks for which the primary nurse is responsible include obtaining accurate information regarding the patient’s health and medication history and verifying any allergies to medication, the type of reactions, and the severity thereof. On top of all of this, the primary nurse is responsible for reporting all adventitious findings to the MD, carrying out preparation of the patient for transfer to the receiving department, providing an accurate ‘handoff’ report to the receiving nurses, and insuring that the patient arrives at his or her next stage safely and with all possible speed. I am also responsible for maintaining an environment that facilitates calm and clear communication. I do not allow cross-room talk, elevated voices, or needless chatter. While the physician "ran" the code, I ran the room; I was Chief of the Boat.

Because of the extreme depth of my involvement with the oversight of those matters, I typically will not lay a hand on my patient for the first time until five to ten minutes after arrival- and sometimes not at all. I do try to introduce myself at the soonest opportunity, ask the patient how he feels, and explain what is happening. But until the patient has been stabilized, this will be the extent of our relationship. More often than not, I will slip unknown and phantom-like in and out of my patient's life.

0547...

When the patient arrived, we were gowned and ready. I took station off to the patient's side where I had counter space and could see the monitor and every machine in the room. The other RNs and Techs transferred the patient onto our stretcher, stripped him, gowned him, and covered him up. He was fully hooked up to the monitor and a full set of initial vital signs was written down in less than a minute. A second large-bore IV was started. The MD stood at my right side, and while we both listened to the medic's report, I kept my eyes on the process.

Something about the patient's EKG was just funky. Clearly, the man was having a heart attack, but it wasn't the front part of the heart that was damaged. The MD looked at it, looked at the patient's monitor, and instructed the tech to perform a posterior-placement EKG. A minute later, it all made sense. The focus of the MI involved most of the backside of the heart- something we don't see all that often. It also explained the patient's bradycardia and low blood pressure.

This kind of MI really sucks for the patient, because all those great medications that would ease his horrific pain and protect his heart from stress (nitroglycerin, morphine, and beta blockers) would also cause his blood pressure and heart rate to drop like a cow off the high dive. So he was going to have to hurt for a little while longer.

0552...

The monitor alarmed. The patient went into ventricular tachycardia. CPR commenced while the defibrillator charged up. Per MD order, an initial shock of 300 joules was delivered. The patient jerked, sat bolt upright in bed and bellowed "Holy crap! What the hell...?" He blinked a few times, then settled himself back down.

"Well, that worked," Mindy said dryly.

The patient's heart returned to a perfusing (though still ominous) rhythm. Breathing resumed among the team members.

0605...

The cardiologist arrived in the room and received a briefing by the ER MD. He approached the patient and introduced himself.

"Sir, I am Doctor So-and-So. You're having a heart attack."

"Ya think!?" gasped the patient.

"We're going to take to look at which artery is causing your heart attack and try to unplug it so you can get better. There's a small chance that it could cause other problems like a stroke or a worse heart attack, but that doesn't happen very often. Do you consent to allow us to do the procedure?"

"Oh, what the hell. My dance card's empty. Sure."

The cardiologist looked at our documentation and walked out to see if the Cath Lab crew had arrived. He returned to the room and asked me if, rather than have the Cath Lab come get the patient, we could bring the patient so that his gang could complete setup. I told him we could. Mindy picked an RN and tech to package the patient up and get him going while I completed the documentation and made sure all vital signs were uploaded into the computer. I called the Cath Lab chief RN and gave her a report as my patient was wheeled out of the room.

The cardiologist found that a posterior branch of the patient's Right Coronary artery had occluded nearly 100 percent, and he was able to clear the jam. The patient stabilized immediately and was whisked up to CCU to begin a pretty rapid recovery. Door-to-balloon time: under thirty minutes. National standard: ninety minutes. (Does my team kick ass? Heck yeah!)

0630...

My thrash room was finally squared away, my documentation was complete, and after making the rounds to thank my colleagues I again settled down to my book. Once again a welcome silence settled over the department- broken only once by a single loud, lonnnnnnnnnnnnng belch, courtesy of Otis.

Road Fest Part Five: Leaving Kingman

2008-11-24T01:51:00.000-08:00

Kingman, Arizona; 0800 (8AM for the rest of you) on day 4:

I awoke to the bewitching aroma of coffee, sizzling bacon, and Southwest omelettes. Melanie (ER nurse) and Kevin (ICU nurse)- the married couple who so graciously took this wayward colleague and his wrecked toe into their home for a day- had just arrived home from their shifts and were preparing what was shaping up to be a smashing breakfast.

I pulled the blanket from over my eyes and sat up on their couch, squinting against the brilliant sunlight that streamed in from the living room window. With some trepidation, I carefully lifted the blanket from my left foot and was relieved to see that my big toe had returned to normal proportions. While the bruising to my foot looked like hell, it had not extended; and I felt only very mild pain, although the ibuprofen had worn off at least two hours ago. I had good distal capillary refill and sensation. The perforated nail looked, well... perforated; but no signs of infection were evident.

I stood up tentatively, testing my ability to bear weight on my left foot. Standing was okay, and walking was... well, not so much; but it was quite bearable, and I could probably get by alright with ibuprofen and stops every two hours for ice and elevation. I tested my ability to withstand using the clutch pedal by putting all my weight on the ball of the left foot, and had no trouble. I was ready to hit the road again.

I hobbled over in my scrubs (which also serve quite nicely as pajamas) to the breakfast nook as Kevin turned around to greet me with a big mug of coffee.

"Morning, friend. How's the toe?"

"Much better than I thought, thank you. But if this ever happens again, I think I'll forego the digital block. How was your night?"

"Mine was uneventful," Kevin replied. "Mel's was busy."

"Nothing awful, I hope." I said, resting my elbows on the counter and lifting my coffee up for a sip.

"Nothing awful. Just your typical Sunday Night crowd. But every time we would discharge a patient, we'd get another one back there. We never really had anyone waiting in triage; they just kept coming in one or two at a time all bloody night long. Nobody had a break all night, and I'm starving." Mel emphasized her point by staring sad-eyed and waif-like (with a boo-boo lip thrown in for good measure) at her husband as he flipped an omellete.

"Oh, stop," Kevin retorted as he reached out with his free hand to ruffle Mel's Tinkerbell pixie-do. "You're going to make me cry and I'll ruin breakfast."

I snorted in my coffee. Mel snickered and handed me a paper towel to dry off my nose.

"Thanks," I said. "Listen, guys: I can't tell you how much I appreciate your hospitality. I'm glad I listened to you and stayed off my foot for a day. It made a huge difference. But I ran through all my crossword puzzles and I have to say that daytime television ranks a ten/ten on the Suck-O-Meter."

Kevin nodded. "That's one of the greatest benefits of working the night shift: sleeping through Oprah."

I nodded and sipped more coffee.

"So are you heading to Phoenix this morning?" Kevin asked as he placed a plate of bacon and eggs before me.

"No, I have to skip Phoenix. I already called my kin down there to let them know. I will be going to San diego today. My sister is graduating from nursing school at San Diego State tomorrow."

"SDSU?" Mel asked over her tea. "Didn't they just have a huge drug bust there?"

"Yeah. My sister told me about it. She said the bust has prompted the Administration to give up any pretense of dignity, embrace its licensious culture, and change the school's name to "SDEASU."

Mel laughed. I handed her a napkin to dab the tea from her nose.

Kevin asked, "When are you leaving?"

"Well, as soon as I help you clean up I'll load up Baby-san and be off."

"Baby-san?" Mel furrowed her brow. "Who is that?"

"My car."

"Oh, my God," Mel laughed and set down her tea. "You gave your car a name?"

"Yes, I gave my car a name," I answered with a childish defensiveness. "It creates a kind of bond."

"I gave our car a name," Kevin offered. Mel turned to her hubby with her hands on her hips.

"Oh, really? And just what did you name our car?"

"Squeaky," Kevin said with a grin.

"'Squeaky'? What inspired you to name our car 'Squeaky'?

Kevin answered in the form of a smirk and an upward roll of his eyes.

Melanie shrieked and punched Kevin on the shoulder. It was an odd, Newlywed Show kind of moment. I covered my face in my hands and cleared my throat.

"So Mel, would you like me to help you clean up the blood and hide Kevin's body before I head out?"

"Naw. I can take care of that," Mel replied as she launched a fiery glare at her imperiled husband (who laughed), and punched him again.

An hour later, freshly showered, I emerged wearing a pair of baggy shorts, wide-soled Keens, and a Hawaiian shirt loud enough to strip the paint off a Buick at fifty meters.

"Wow," Mel said as she shielded her eyes. "I guess I'll cancel my chemical peel now."

I packed up my things and got squared away for departure. After an exchange of telephone numbers and email addresses, Mel gave me a hug and a peck on the cheek and instructed me to call when I got to San Diego and let them know how the toe held up. I promised I would (and I kept it). Kevin shook my hand in that huge paw of his and wished me well. I told him I would pray for his safety, since upon my departure there would be no witnesses to his impending demise at the hands of his 5'3" powderkeg of a wife. He laughed and kissed his bride. She punched him on the shoulder again, but followed up with a kiss, so I guessed he might live to see another day.

After stopping at a market for more ice and snacks, I gassed up and headed west toward San Diego with a roar, a cloud of dust, and two new friends.

The ER: Stuff You Need to Know. Part 1: Triage

2008-11-04T01:02:00.000-08:00

Introduction:

I recently wrote an article describing a variety of examples of poor behavior demonstrated by patients in the Triage section of my Emergency Department. While the article was written primarily to introduce the reader to some of the actual (rather than media-generated) challenges encountered by an ER nurse in a humorous vein (which is the modus operandi for all of my writing), my article evoked a tremendous negative response with regard to the readers' personal ER experiences. A majority of responders related their unpleasant experiences when they or a loved one was treated in an ER.

The most common complaint was that an extraordinarily long time was spent simply waiting: waiting to get back to a room while others who arrived in Triage later were brought back first; after arrival in a room, waiting for the nurse to come in and perform an assessment; waiting for the MD to come in; waiting for medication; waiting for tests to be performed; waiting for test results to come back; waiting for diagnosis or treatment; waiting for transfer up to a unit bed; or waiting for discharge instructions and prescriptions. Furthermore, more deeply entrenched in these woes was a complaint common to all: not being informed about what was going on with the process. These people were simply never told what was happening at any point throughout their ER experiences. (It is perfectly understandable that a person in that situation would feel forgotten and ignored, and thus become upset.)

After considering these problems, and at the suggestion of a colleague, I have determined to do something about it. I hope that this series of articles will inform and enlighten the reader regarding the challenges and intricacies of emergency medicine. I hold the firm belief that a well- and accurately- informed public makes for a great patient, because a better-informed patient is far better equipped to actively participate in the care process and is able to more effectively advocate for oneself. I have found that patients treated in this manner nearly always described a far more positive and satisfactory experience, even if an extended wait was involved. Thus, when I teach new nurses (and students), I pound into their minds the following adage:

Keep them SAFE, Keep them WARM, Keep them COMFORTABLE, and Keep them INFORMED. When a nurse does this, it goes a very long way towards making the patient feel cared for- which is the whole point of nursing, if memory serves me correctly.

Returning to the issue at hand, I begin this series where the ER process begins: Triage.

The Purpose of Triage

In the civilian sector, triage was adopted by emergency departments in the early 1960s when the demand for emergency services grew beyond capacity to provide everything to everyone at the same time. The process enabled overloaded emergency departments to quickly identify and treat the "super-sick" patient from among the crowds. (Interestingly, it also proved a useful tool in identifying malingerers who were inappropriately using the ER.)

With the advent of government-subsidized medical entitlement programs, emergency departments were rapidly overwhelmed with non-emergent and non-urgent cases that slowed the entire emergency care process down. The need for, and value of, an effective triage system became immediately evident. As a result, four-tier and 5-tier triage systems were developed. With either system, patients are classified by level of acuity (how sick they appear based on objective data such as vital signs, obvious trauma, or body system affected).

Level of acuity is generally classified as follows:

Level I: LIFE-THREATENING condition requiring immediate care. Not stable. Examples: CPR or intubation in progress, acute MI, major trauma, acute respiratory distress, or major burn;

Level II: EMERGENT but stable. Seen ASAP (within 30 minutes); Examples: Open fracture, kidney stone, testicular torsion, "hot" (surgical) abdomen, sickle cell crisis, frankly-ill child, neonate with fever, eye injury, narrow-angle glaucoma, suicidal ideation.

Level III: URGENT. Stable, no distress. Seen ASAP if no Level I or II patients ahead of them. Can wait up to one hour before being seen. Examples: Closed fractures, laceration without bleeding, Drug ingestion > 3 hours prior to visit with no signs or symptoms.

Level IV: NON-URGENT. Stable, no distress, can wait at least one hour before being seen. Examples: Typical migraine, rash (without fever), abrasion, anxiety, cough/cold.

Level V: DELAYED. Can wait four or more hours before being seen. Examples: out of medications, routine exams.

The patient is classified according to objective findings (abnormal vital signs, obvious distress, etc.) The experienced and astute triage nurse also develops a "sick sense" (being able to quickly visually assess a patient for the appearance of a life-threatening illness as they come through the door).

It is absolutely essential that the reader understand this system because it governs the entire flow of the emergency medical process. The patient is not merely classified randomly and arbitrarily by the triage nurse. It also provides the inarguable reason why one person may arrive first but be seen later than another person who comes in after them. While one person my have a migraine and be completely and undeniably miserable, if another person arrives with signs and symptoms of a higher-acuity condition, that person is going in first, and no amount of complaining is going to change this fact. Furthermore, screaming, crying, or otherwise acting out will never qualify a patient to receive a higher acuity "just to shut them up." It just upsets everyone else who has to endure the tantrum.)

Challenges of Triage

Triage is one of the trickiest, most challenging functions for the ER nurse. Symptoms of a potentially life-threatening condition can be subtle, and can even be discovered "accidentally" when a patient is complaining of a problem that would itself provide for a lower acuity assignment. In my career, I have had at least six patients who complained of abdominal pain without vomiting or diarrhea (which at face value, merits an acuity of II to IV, depending on vital signs). But every single one of those six made a seemingly-offhand remark, or described their pain in a particular way, that my "suspicion index" sent up massive red flares. In each case, acting merely on my suspicion through the simple act of looking at and feeling both legs revealed one being colder and paler than the other- and that the patient's pain was not gastrointestinal at all, but that he or she was suffering from a dissecting abdominal aortic aneurism, which merits an acuity level of I with an exclamation point. (Only one of those patients died, and that was because his aorta completely tore within moments of sitting down in my triage booth. When the aorta blows out, there is nothing anyone can do; death occurs in ten seconds or less- there often isn't even enough time for the patient to say more than a startled, "Oh!" (It happened once). He just said, "I can't breathe," and he was gone. But had I been less experienced, I might have missed all six.)

Traits of the Effective Triage Nurse

The effective and safe triage nurse demonstrates experience, awareness, astuteness, coolness under pressure, and razor-sharp critical thinking skills. Where I work, no nurse with less than two full years as a full-time ER nurse is allowed to go anywhere near triage- even if only to give the triage nurse a 30-minute break. It is no place for the neophyte or any nurse who is still in the process of gaining confidence of his or her abilities. As illustrated above, people live and die on the quality of the triage nurse's assessment. When a waiting room is packed and more people are coming in, and just when three rooms are opening up the charge nurse informs triage that three medics have arrived with Level I patients, the triage nurse has no choice but to hold the line.

I have had many nights like that in Triage. In some ways, it is more difficult than working in a Level I thrash. Instead of one patient, I have thirty or forty with variable levels of acuity. This, again, is where experience and calm is an absolute requirement. Nobody likes to be stared at; and the awkwardness is amplified when every one of the people staring at the triage nurse is not feeling well and has been waiting for hours. How does one cope with this potentially-volatile situation? The question introduces two more equally-vital traits of the triage nurse: empathy and compassion.

In my experience, it really does not take much effort to help even a miserably uncomfortable person endure a long wait. It is amazing how calming to a room full of patients it is to simply circulate around the waiting room periodically, offer a blanket or pillow, and say "I know you've waited a long time. Has anything changed? We are working as fast as we can. We haven't forgotten about you. As long as you are out here, you are my patient and I will look out for you."

When people see you actively following up on them and looking after them, they feel cared for. All it requires is one minute of time to infuse calm into a crowded, highly-charged waiting room. Granted, there are times when it may not help (a demented patient with "sundowner's syndrome," a belligerent drunk or drug user, for example). But otherwise, I have never, in all my experience, known this approach to have failed me in calming down a room full of upset patients.

In fact, the triage nurse is required to re-assess everybody waiting on a regular basis. Making rounds is a quick and efficient means of doing that.

Concluding Remarks: Doing Your Part

I cannot speak for the practices of every nurse, hospital, or emergency department. Many factors not mentioned here can create a positive or negative experience for the patient. But I strongly encourage you, the reader, to advocate for yourself or your loved one. This is not Cuba; our medical system is still driven by a free-market economy. That means if enough patients get upset, they can tell their friends not to go to that hospital, and so on. People will start avoiding that hospital. The hospital is a business. No patients means no revenue. State agencies will begin to wonder what is going on at that hospital. The hospital will either change, lose accreditation, go bankrupt, or lapse into backwater obscurity.

Here is what you can do: If there is a problem, speak up! If more than an hour has passed since you have been informed or have seen your nurse, speak up! If you have not been seen, gone to a diagnostic test, received results, been treated for the diagnosis, or received your discharge instruction more than an hour after being informed of the step, speak up! And if you feel that you are not being informed about any part of the care process, speak up!

You, the patient, do not exist for us; We, the Emergency Department, exist for you. If we work together as a team, we both will be the more satisfied and enriched for it.

How To Be Taken Seriously by Your Triage Nurse

2008-10-26T02:04:00.000-07:00

Okay, I know this is a bit of a chronological jump, considering I was last writing about my recent odyssey. I'll get back to that soon.

I am back at work now, and since returning I have encountered an unusually-long parade of ER patients who have displayed, shall we say, less-than-sound judgment with regard to the way they chose to conduct themselves in ER Triage.

I am a man of great forbearance and restraint. I have never told any patient that he/she was a slack-jawed, mouth-breathing idiot before- even if the patient's actions clearly prove such to be the case. But some people make it very difficult to restrain the urge. Happily, only a rare few have ever caused me to fervently wish that dope-slapping was approved as a therapeutic nursing intervention.

For the sake of brevity, I'll cut to the chase:

To all of the exasperation-inducing patients described in Paragraph Two of this entry, and to all potentially-exasperating patients, I offer the following pearls of advice. If you follow these maxims, I guarantee that your name and the word "idiot" will never be uttered in the same sentence when you are mentioned in verbal handoff report by your Triage Nurse.

1: Do not come into the ER with a chief complaint of "high blood sugar" and then sit, in full view of the Triage Nurse, gulping down a can of Coca Cola and eating a candy bar.

2: Please do not use "I have (insert disease name here)," "Googled," and "My symptoms" in the same sentence.

3: Do not sprint full-tilt boogie into the ER from the parking lot (having been observed by the Triage Nurse for the 100 feet of your medal-winning dash), burst into the waiting area, and yell at the registration clerk in a full sentence that you are having a heart attack and need morphine.

4: Do not ask the Triage Nurse for any sample packets of Tylenol, Ibuprofen, antibiotics, the "Morning After Pill," Valium, Ativan, Zanax, Methodone, Oxycontin, Surgi-Lube, or medicinal marijuana.

5: Do not tell the Triage Nurse that you don't want to see a doctor but just want to have your blood pressure, blood glucose, lung sounds, or that "icky lump" in your bikini area (I am not kidding) checked by the Triage Nurse. You have to be registered before the Triage Nurse will listen to you say anything about that "icky lump" in your bikini area. Otherwise, go to the fire station or your clinic. And wash your "icky" frigging hands.

6: Don't get out of your car, walk ten feet to the wheelchair your relative provides for you, sit down in the wheelchair, and then go limp and pretend to be unconscious the remaining twenty feet to the Triage Desk. (Yes, I did see you peeking, you rascal!)

7: Don't ask for a five-gallon barf bag, be given one, pull your face out of it to spew all over the Triage Room, Triage Computer, Triage Floor, Triage Tech, and Triage Nurse- and then say, "Sorry, I missed."

8: Don't refuse to wear a mask if you are coughing or sneezing. If you do refuse, then don't be surprised if you are thus regarded on the same level at which any other mindless, disease-carrying vermin would be.

9: Don't talk on your cell phone while being triaged and tell the Triage Nurse to "shush!" for interrupting when you are asked about your migraine. And don't get angry when you are ushered out of Triage to finish your phone call and the Triage Nurse moves on to the asthmatic 3-year-old who just came through the door.

10: Don't walk in and tell the Triage Nurse you were involved in a rollover motor vehicle crash an hour ago when all you are really looking for are narcotics. You will be slapped into a cervical collar and duct-taped onto a very uncomfortable backboard faster than you can say "I'm never using this frigging story again." Just tell the truth. Honesty serves two purposes: 1) We can laugh at you without you having to go through all that unnecessary discomfort, and 2) You can haul your drug-seeking carcass over to the neighboring ER without any telltale patches of tape-induced depiliation on your head.

11: Please be sure to leave the ID bracelet from the neighboring ER that you just left on your wrist when you arrive at our Triage. This enables us to contact that ER and find out why you were dissatisfied with the service they provided.

There you go. Have a safe Halloween, think before you drink, avoid anyone who says "Hey, watch this!," and stay inside any moving automobiles.

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

2008-09-28T02:03:00.001-07:00

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."

"Yay."

"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...

Road Fest, Part 3: The Drive Across Mars

2008-09-01T01:33:00.000-07:00

Fallon, Nevada to Kingman, Arizona:

I have been all over the world, and have seen some interesting terrain in my travels. But the landscape of western Nevada was just, well... eerie. The outside temperature was 110 degrees and rising, and it was only mid-morning. I had cast a lot of glances out of the side windows for the first 100 miles of this leg, but as the environment became more barren and forbidding, and the atmosphere thinner and drier, I found myself retreating inward with a strange sense of isolation and vulnerability. And that only caused me to become more aware of my injured toe, which seized upon the opportunity and commenced to hurt like hell since it had no competing distractions.

I concluded that whatever it was that pressed down upon me and triggered my brooding thoughts, it was certainly not the sense of being at great personal peril. Having nothing better to do, and rather desperate to get my mind off that damned throbbing toe, I cast about for a single word that most accurately described the sterile nothingness across which I drove. Looking out at the vast, gray-brown, treeless valley over which loomed a jumble of distant hazy and sinister-looking mountains, I found the word: Desolate. All that was needed was a big sign that read: SAURON WAS HERE.

I nodded to myself. "Desolate" covered it. I sped up a little without really thinking about it, and yelped a startled Whoops! when I looked at the speedometer and found I had reached 110mph. I prudently curbed my urge at that point-I say prudently, because as I rounded a curve at a more sensible speed I passed a Nevada State Trooper going the other way- a trooper who was clearly giving me the Evil Eye as we neared each other. I guess a lot of drivers get a little "goosey" out here. I took a deep breath and shook off the spookies as I pulled into Hawthorne.

Hawthorne, Nevada: an idyllic paradise where one can find a girl behind every tree- provided one can actually find a tree. The place is notable for being home to a US Army munitions factory and depot. I imagined that its placement in the middle of frigging nowhere was probably due to the nature of the munitions being produced. Just a guess, mind you. But think about it...

I gassed up, grabbed some hot chow and high-tailed it out of town, eager to get to my next stop on this traveler's paradise: the teeming metropolis of Tonopah, home of the Fighting Muckers. (It's a good thing that the sign over their high school wasn't painted by a person with dyslexia.) Tonopah is basically Nome, Alaska at 6,100 feet above sea level: Dusty, tiny, and wind-swept. Except for being about a hundred degrees hotter, I could swear I was in Nome again. (I made a vow that the next time I saw Nome, it would be through a bombsight. But that's another story.)

I had droned through half of my day already, and I felt somewhat peeved that I still had a long, long way to go to get to Kingman. This would not do; it was time to push things a bit. When Tonopah had vanished from my rearview mirror, I decided to see if Baby-san felt as inclined to kick up some dust as I did.

She did, in fact, feel so inclined. I accelerated through to fifth gear and when I hit a long, long straight stretch, I gradually opened her up as fast as I dared. My engine has a rev limiter at 6,000 RPM, and I buried the needle at 120MPH before I hit 5,000RPM, and I was still accelerating. In this realm of her performance envelope, Baby-san's voice was no longer the sultry resonating rumble for which I loved her- it became a malevolent, tooth-rattling bellow that vibrated the mirrors and drowned out all thought. From this, I understood her answer to be It's about damned time, loverboy!

Having successfully scared the crap out of myself, I backed 'er down to just under 100 and started breathing again.

The Pirellis were loud as hell at this speed on the baking asphalt. They were nice and hot and sticky. Baby-san and I ripped through the gently banked curves and long straightaways, howling through unpopulated central Nevada like a hellbent banshee. I flexed my fingers around the wheel and, wearing a truly wicked grin, danced with Baby-san right along the ragged edge.

I reeled in my evil twin long enough to gas up and snack in Death Valley, and then let him out to play some more until a little north of Nellis Air Force Base. I droned on into Vegas at a sedate 90MPH, but sensed from the number of cars that passed me that I was actually being a little pokey. Still, I felt that I had tempted fate sufficiently for one day. Deafened slightly from the engine noise, I stopped to recover and eat at Vegas before heading to the second item on my list of Landmarks I Have Never Seen Before (Lassen Peak was the first): Hoover Dam.

It was really big. I took lots of pictures. My foot hurt a lot. Okay, time to go.

The drive to Kingman took place as the sun began to descend towards the horizon. The desert was a most incredible shade of red, the sky was clear, and my backside was ready to call it a day. My injured left great toe was beginning to throb from being in a dependent position, in spite of the ibuprofen and tylenol. I was ready to be done.

I pulled into the hotel, paid for the room, then went across the street to a Sonic Drive-In that beckoned me. I gorged myself on a coney, fries, sundae and root beer. I ate at an outside table, massaged by a hot desert breeze as I watched a distant thunderstorm light up the eastern sky, it's towering cumulonimbus clouds painted a shocking pink by the setting sun.

I hobbled back to my room and examined my seriously hurting foot. The toe was bruised and swollen. I took some more ibuprofen, applied ice, propped my foot up and I pulled out one of the bottles of a very potent Belgian ale I had stocked for the trip and pulled out my laptop to post my experience. At that point, I discovered that the infernal thing had decided to eat its operating system and become an expensive paperweight. Cutting my losses, I pulled out my summer book and was asleep within seconds.

Road Fest, Part 2: Beth, and the Entrance to Nowhere

2008-09-01T01:16:00.001-07:00

I had not slept so well in years. It was the kind of deep and dreamless Rip van Winkle sleep from which one awakens with the impression that no time had passed at all. The first objective data to the contrary was presented by the merciless blaring of the alarm clock in my hotel room. My eyes snapped open and I fumbled hastily across the unfamiliar, darkened room with a single-minded determination to stop that damned bleating instrument of chaos and evil. It was during this effort that I encountered the second (and far more effective) means of ensuring that I was awake, in the form of the chair leg against which I struck my left great toe.

Oh yeah. I was awake now.

I held my afflicted foot and spoke the Official Ritual Chant for Toe Trauma (Ow, ow, ow, oh crap ow) for the prescribed minute, then tearfully crawled the remaining distance to the source of that hellish squawking. I dragged myself up into the chair whose leg had caused me such woe and sorrow, and with some trepidation turned on the light to assess the extent of the damage. I noted some stiffness to the toe and mild pain with articulation of the joints, and gingerly palpated along the digit to assess for deformity. While still exquisitely tender, the toe and nail seemed otherwise intact. I knew that even if the toe was broken, so long as no deformity was present the course of treatment was the "I-Cubed" method: Ice, Ibuprofen, and Immobilization. And if the toe continued to swell under the nail, I would do as we do in the ER: Puncture the nail with a sterile object, apply a sterile dressing, and keep the offending digit clean.

I hobbled to the ice machine with a sandwich bag, returned to the room, popped 600mg of Advil, carefully buddy-taped the first toe to the second toe (leaving a little room for swelling), put my foot up, and applied the ice pack. I spent the next twenty minutes cursing that damned chair and watching an inane infomercial about some device that promised to be the "next revolution in potato peeling." The product was all chromed-up and slick-looking, but I felt no compulsion to buy it. The man demonstrating the device was loud, and his behavior led me to suspect that he was on the manic swing of his bipolar disorder. The token well-endowed, mini-skirted female co-host, however, was serious eye-candy (if they were real, they were spectacular). Now if she had been demonstrating that device, I'd have been more interested...

Twenty minutes later, I reassessed the toe and became reasonably certain that I would indeed live. I got dressed, got my stuff together, checked out, and loaded up the slumbering Baby-san. She started with a throaty, popping snort (her way of saying, "What- already!?, I guess), but quickly warmed up to a low and pleasant rumbling purr that told me, "Alright, darling, I am ready for you now."

I pulled onto Susanville's main drag as the eastern sky was just beginning to pink up, and I made my way to an open local restaurant for breakfast. After being led to my booth by a tired man, I pulled out my map, calculator, notebook and pencil, and set to rechecking my route. Country music played softly in the background. It was the perfect soundtrack for the open road. I smiled to myself as a fortyish, suntanned, brown-haired, attractive woman approached me. She tilted her head, observing my navigational efforts.

"Hi, my name's Beth and I'm your server," she began as she gently placed a cup of seductively aromatic coffee before me. "Where ya goin'today, hon?" the waitress inquired with a cigarette-husky voice a la Julie London.

"Well, hello Beth," I responded. "I'm driving through Nevada to Kingman, Arizona."

"Wow. That's a lonnnnng day right there, hon."

"Yeah, I figure about twelve hours..." I replied tentatively. Beth stepped back, placing her hands on her hips as if to preparing to deliver a Great Truth.

"Ya got kids? Make it 14 hours if ya got kids," Beth advised with empirical certainty. "Kids always slow ya down..." she said, her voice trailing off. I looked up at her. She looked weary, and the lines around her mouth and eyes bore evidence of a tiresome life. Every human is a saga, I thought. I shook it off and decided to steer the conversation toward a more positive region.

"Actually, I'm driving solo," I said with a boyish grin.

"Are ya?' Beth asked with a frown as she scrutinized me down the length of her straight and narrow nose with searching eyes. She again placed her hands on her hips and concluded, "Hmph. One of those 'finding yourself' things, huh?" Wow. Cynical too, I thought. This may take some work.

"Not really," I replied with my best and genuine you are important to me smile. "It's more of a 'driving a fast car as far as I can go in two weeks' kind of thing."

"Ahh..." the cynical waitress replied as she scrutinized me again. Looking out the window, Beth jerked a long-nailed thumb toward Baby-san. She asked, "That your car out there?"

"Yes, it is," I answered with the enchantment of a twelve-year-old boy who had just discovered that girls are pretty damn cool after all.

"Niiiiiiiiiiiiiiice," she said with a slow, approving nod. She paused for a second and concluded, "Hmm. Make it maybe ten hours. Just watch out around the border and around Vegas, sweetie. They love guys like you."

"I'll do that. Thanks, dear girl." I gave Beth a sincere and wide smile and she seemed taken aback. She finally responded with her own quite lovely, warm smile and retreated with my order in hand and a stride that would evoke, from a single man, a Pavlovian drool.

I ate at a leisurely pace (while Beth doted upon me with her wonderful coffee and attention) and revised my fuel stops based on yesterday's mileage data. (I was pleasantly surprised with the discovery that in addition to being sleek of beauty and menacing of voice, Baby-san had herself some nice, long legs.) After finishing my breakfast and my calculations (remaining conservative on the issue of travel time despite Beth's assurances), I dropped a big tip on the table and walked up to the cashier's counter where Beth met me.

As she cashed me out, she offered her hand and said, "I'll be praying for your safety, darlin'. You be careful, you hear?"

I took her hand, shook it, and replied, "I promise, Beth. Thank you for your hospitality." She smiled a distinctly un-cynical smile, gave me a pat on the shoulder, and retreated to the kitchen with that drool-inducing stride.

Ahem.

The eastbound approach toward Reno on Highway 44 was a perfect warmup stretch. The highway snaked down from Susanville into the light-brown, gently rolling hills below and provided long straight sections and pleasant banked curves that were taken with ease. I suspected that this was a section of road worthy of Beth's warning, which called for a light foot on the accelerator. My hunch was confirmed by the good half-dozen hapless speedsters pulled over by CHP and NSP troopers between Susanville and Reno. Nodding in self-congratulation (and silently thanking Beth for her generous advice), I rolled merrily along at a prudent speed into that garishly-lit oasis that attracted so many seekers of unearned wealth, night-of-passion weddings, and morning-after divorces. Feeling neither the need nor the desire to stop at Reno, I pressed eastward on I-80, and then on alternate Route 55, toward Fallon.

At Fallon, I prudently checked the air pressure in the Pirellis and made sure that the engine oil, coolant, and belt tensions were all satisfactory. The prospect of having a breakdown along the next leg, which ran through a very hot and unforgiving bunch of real estate, did not appeal to me. I topped off the gas tank and stocked up on nonperishable foods and a flat of bottled water (just in case the unthinkable occurred). My cell phone had a full charge, I had a disaster survival backpack in the trunk (as I always do), and I was as ready for the run down Highway 95 as I would ever be. I felt a little knot of tension as I gave sober thought to the possible problems and incidents that provoked my preparation for the worst. At 0900 the temperature was already well past 90 degrees, and it was expected to reach 115 before noon along my route.

But at the same time, I felt a bit of that long-exiled, youthful adventurer awaken in my soul. It was that same thrill that drove me to spend nearly a decade on the sea just to see the sea. It was kind of like the old cliche of having an angel on the right shoulder and a devil on the left. I compromised between the two, pressing on with nervous excitement while taking every precaution. That's the nice thing about being my age; I'm young enough to stand on the edge, and old enough to know when to step back and just appreciate the view.

With a preparatory sigh, I strapped on Baby-san and launched with a roar, leaving Fallon- and civilization- far behind. Settling myself into my seat, I took a deep breath and let Baby-san go free. Cruising at 90MPH in 5th gear, the engine was barely touching 2,250RPM. The noise was deep, entrancing, and consuming. The car seemed to take the curves of her own volition, as if my control of her was merely an allowance. I surrendered to her as she enticed me into the barren, forbidding wasteland of Western Nevada...

McCain Selects Alaska Governor Palin as VP Candidate!

2008-08-29T16:25:00.000-07:00

Those of you who have known me over the years also know that a couple of years ago I decided to avoid discussing politics on my blog. I do not regret my choice. I much prefer- and fully intend- to keep the tone of this blog as apolitical as possible. I am a staunch conservative (most ER nurses are), and I thrive on open discussion. I have learned far more from you and about you, dear readers, through my current format than I ever would have by maintaining this blog's former, confrontational.

But Senator McCain's choice of Alaska Governor Sarah Palin as his Vice Presidential candidate has really piqued my interest in the election, and I would like to share my thoughts with you and also to know your thoughts on the matter if you choose to share them. I promise that politics will not be a frequent issue of discussion here, and will return to the standard format after this brief interlude. So without further ado, here are my thoughts:

The selection of Gov. Palin was a shrewd move on Sen. McCain's part. He has just accomplished in one bold swipe what some say the Democratic party has just failed to do- create a ticket that can electrify and unify the party and boost support for a run to the White House. I disagree with most of Sen. McCain's ideas (McCain-Feingold, McCain-Kennedy, the Gang of 14, etc.), and I am not a fan of his, but I have to admit I think that that he and his staff have pulled off a masterful coup. I also must admit that before today, I had pretty much written off the Republican Party as a total loss. By choosing Gov. Palin as his VP candidate, Sen. McCain (of all people!) has caused me to wake up and pay closer attention to what is going on. That in itself is a good thing anyway.

The irony alone of Sen. McCain's choice is delicious. Follow along:

Senator Obama, running on the platform of being a Beltway "outsider," nevertheless picks one of the most notorious Beltway insiders to be his VP, publicly clotheshangs a popular female candidate, and exacerbates the division within his party in the process. Of even greater import is that Sen. Obama has never even been mayor of so much as an unincorporated hamlet, and yet he wants to become the most powerful man in the free world.

On the other hand: Sen. McCain, accused of being a Beltway insider (hard to argue that point) reaches over the crowd of established (and jaded) GOP old guard -who are viewed with distrust and even contempt by most Republicans and Americans after the Great Elephant Sellout of 2005- and plucks a ripe plum from the outer fringes of the orchard.

And two things are particularly striking about this choice: (1)Gov. Palin is decidedly NOT a Beltway insider; (2)Gov. Palin has far more executive leadership experience than Barack Obama has. Of much less material consequence, yet compounding the irony, is the fact that Gov. Palin also happens to be a woman. And did I mention that Gov. Palin is a conservative? Did I also not yet mention that Gov. Palin has accomplished what our Congress refuses to do- pushing ahead with opening up petroleum (natural gas) production and transportation?

Anyone- from either side of the aisle- who harps on Gov, Palin's "inexperience" forgets the fact that the Sen. Obama has (1)never even been a mayor; and (2)never governed a state. And I would wager that Gov. Palin has probably accomplished more to the benefit of her state constituents than Sen. Obama has for his own. It will be interesting to see how this plays out.

High-Test Road Fest, Leg One: Outbound

2008-08-04T04:26:00.000-07:00

I rose in the very early morning for my much-anticipated trip to San Diego with a sense of excitement and my three good companions: A cooler full of snack, my souped-up 2007 Ford Mustang named Baby-san, and the open road. Fully-prepped for the trip, waxed, and buffed until her fireglow scarlet paint took on a fathomless gleam, Baby-san communicated her eagerness to boogie with a throaty, crackling snarl as I fired her up and blipped the accelerator. I throttled up, released the clutch and let 320 horses out of the corral. With a saucy chirp from the Pirellis, we lunged into our coming adventure as the crisply-starlit night began its slow change of shift with the day.

Ahead of us lay 15 days and 3,000 miles of carefully-selected, winding, go-fast blacktop.

Wriggling my shoulders and hips for a few seconds, I settled myself more deeply into my seat until at last it curved into perfect conformance to my body. I dropped the steering column down until I was able to rest my wrists on my knees and still easily rotate the wheel a full turn either way without fully extending my arms. I closed the windows and took a sip of coffee. Drawing a deep sigh of contentment, I melted into the car and settled in for the long, dull, slow shot down a criminally-crappy stretch of bad concrete that Washington State has the audacity to call "Interstate 5." I gave myself a mental pat on the back for leaving well before rush hour and being far south of Seattle's stupidly-narrow bottleneck, which by 0630 always becomes, including weekends, the automotive equivalent of a large bowel obstruction.

By 0530 I had left the liberal septic tank of Olympia behind, having taken notice of how our state capitol's stretch of I-5 is so modern and lovely. ("It's your nickel," the roadside WSDOT signs declare, "Watch it work." The trouble is, you have to be in Olympia to do that, unless you actually expected to see your whopping gas tax go toward building a wildlife bridge or a bike path.)

I skirted Portland via the 205 bypass and made a beeline for Eugene, my first fuel stop. Oregon's speed limits being even more pedestrian than Washington's, it took a few hours to get to Eugene- and I still had a quarter of a tank of gas remaining when I got there. (Brute force and good mileage: who could ask for anything more?)

I took ten minutes to stretch and walk around in order to reduce the risk of deep vein thrombosis associated with long car and plane trips. (I also started taking 325mg of Aspirin a day two days before the trip in order to reduce platelet clustering. I reasoned that while I may bleed more in a bad MVC, that alternative was a helluva lot better than spending six months taking rat poison after developing a pulmonary embolus.) Rejuvenated after my stretch, I settled back into the car and returned to the interstate with a roar.

A little over an hour later, I reached the hills and curves leading up to Medford, Ashland and California beyond. The car seemed to wind up a little tighter, standing on her tiptoes, eager to prove herself. The Pirellis gobbled up the curves and asked for more. The engine, responding to the additional loading of the uphill climb, produced a deep, menacing rumble from the exhaust that reverberated off the rock walls, resonated throughout her frame and in my head and chest, and filled my heart with impish delight. I flexed my fingers around the steering wheel, dropped down a gear, and with a wicked grin led Baby-san in a jubilant dance on a hot, cloudless day through the serpentine passes and canyons of Southern Oregon and into California.

I passed into the Golden State just past noon and dined at the Denny's in Yreka (more on that surprisingly rowdy little town in an upcoming entry). After once again stretching and massaging my calves, I led Baby-san into the Siskiyous for another tango. The car was really kicking out her stride now, and the breathtaking Siskiyous were traversed with Stevie Ray Vaughn in the player and a really big grin on my face. (Man, Lake Shasta is seriously down this year!)

Just south of Mount Shasta, I left I-5 and turned eastbound on Highway 89 towards Susanville, where I would stop for the night. The road was occupied mostly by lumbering, lethargic motorhomes and lifeless construction equipment. The sweltering red-earthed high desert flew by, and the stands of spindly old pine trees flashed past like picket fences. I swung Baby-san through the awe-inspiring, tortured landscape surrounding Lassen Peak (watch that sharp left turn, boy!) and stopped at a nearby observation point to stretch my legs and gawk. If the reader ever wants a good picture of what an entire mountain exploding looks like, I recommend the trip there. Unlike the sloughed-off half-dome of Mount St. Helens, Lassen Peak looks like some enraged giant chose to vent his fury here and hacked the place the shreds. The place had an ominous, somehow-unsettled atmosphere. Munching on my ham and cheese on wheat and my Cheetos, I sat and contemplated my smallness. I finally took a last, deep drag of the hot-dry, clean air and returned to the road.

One does not merely 'arrive' at Susanville; Susanville hides behind a mountain and when you least expect it, jumps out and says, "Boo!" I was just driving along minding my own business, and suddenly- bla-DOW!- I was in Susanville. It's kind of like driving to Leavenworth, Washington from Seattle. (You have to watch out for those sneaky towns.) Also like Leavenworth, the town marks a dramatic change in landscape from winding mountain passes into broad, sweeping high-desert hills with the Great Basin lurking just beyond a distant rim of ancient, scarred hills. It was simply breathtaking. I fought off the urge to sing a Woody Guthrie song and pulled into the parking lot of my motel at around 5PM.

I checked in, changed, let the folks back home know I made it without incident (or speeding ticket), soaked in the pool, and baked languidly in the delicious early evening heat. Having broiled myself thusly, I bent to the task of finding a place to give Baby-san a good bath and wax and, having accomplished that, stuffed myself senseless at the local Black Bear cafe amid cheerful locals, a sooty-sweaty Forest Service fire crew, and a cute little pixie-haired waitress (who, while filling my water, regarded one of the above-mentioned sooty-sweaty firefighters with doe-eyed enchantment). I must say that in spite of her distraction, the girl provided fantastic service. I left a tip that was in direct proportion to my sincere, lethargy-inducing, overfed satisfaction.

Back at the room, I reflected on the long, richly-gratifying day. My hands were red and tired from gripping the wheel, and I still felt that distant vibration as if I had just finished pushing the power mower. I picked up my summer book (Samurai! by Saburo Sakai) and read for a minute, but could not focus. I closed the book, shut off the light, and went to sleep anticipating the coming day- and the long, long drive through the tortured, barren, eerie landscape of western Nevada that awaited me.

Road Trip! Road Trip!

2008-05-15T23:15:00.000-07:00

It's been two years since I have had a break. It wasn't that I didn't have the opportunity; it's just that I never really thought about it. But a coming event has provided the opportunity for me to take a much-needed (and eagerly-anticipated) break from the trenches.

What's the event? Well, dear friend, I am glad to tell you: One of my older sisters is graduating from nursing school down in Southern California.

(Can I tell you all how proud I am of her? I am just busting at the seams. She's a good one, she is. And she has also become a dear, dear friend. How lucky can a brother get?)

So, in honor of this auspicious occasion, I have undertaken the heavy and onerous task of driving my customized Mustang down the Pacific Coast Highway all the way (heavy sigh) down the coast to my sister's abode, where I will watch her receive her Bachelor's degree in Nursing Science. She has a job waiting for her in the Pediatric Oncology (her first choice) department of a very prestigious hospital down there. I am so proud of her!

And I get a much-needed rest. I asked my wife if she was at peace with the trip. She said, "God seldom gives us opportunities like this. You need this. Take it. Besides," she said with a wicked grin as she wrapped her arms around me and flashed her amazing grey eyes, "Think about the homecoming."

"Wellll... okay. If you put it that way..."

So tomorrow I am off to drive, drive, drive. The weather is going to be awesome, and so is my vacation. I'll keep you all posted, since I am bringing my laptop.

Hybrid Cars: Death in a Bunny Suit

2008-03-18T10:48:00.000-07:00

If the public ever stopped to think for themselves, the 'eco-friendly' hybrid would be banned from our highways.

They are not 'green.' They are, in fact, blacker than Hitler's bastard heart.

Do any of these bunny-hugging, sign-waving morons stop to think about what it takes to make just one of those big-assed batteries? Come to think of it, do any of these idiots stop to think about what it takes to recycle one- which is necessary every five years!?

Of course not. And you can bet your sweet ass that none of the proponents of these toxic deathtraps is about to tell you, either. All they say is that they use less gas. And after all, isn't that what it's all about?

Last summer, when I asked these questions of a greeniac sign-waver who preached the Gospel According to Al "St. Fat Dumbass" Gore, the poor little fly cleared his throat and said tentatively, "Well, that's still a problem that hasn't been solved. But we should still do it, because by the time the mass of batteries has to be exchanged, we'll have the technology to do it."

I smiled wickedly and rejoined, "So what you are saying is that in spite of the fact that these batteries are shockingly toxic to produce, and shocking toxic to recycle, we should still buy only hybrid cars?"

"Well, yes, because they still use less gas."

I must have looked as appalled at his lack of critical thinking as I actually was, because he defensively asked, "What...?"

"Do you have any idea how utterly and patently stupid your rationale is?"

"What do you mean?" The young man bristled.

"I mean, you rail and rant about how America is destroying our ecosystem because of the huge so-called 'carbon footprint' we leave due to our use of petroleum, but you are more than happy to advocate forcing us to buy cars that are even more toxic to the environment- and far more dangerous to the consumer- when you don't even have a frigging clue as to what's really going on here."

"They are not dangerous!" retorted the misguided idiot.

"Oh, yes they are," I shot back, leaning forward. "Think about it. How much does that big-assed battery weigh?"

"I dunno."

"A helluva lot. And if you are driving at 60 miles an hour and aren't watching where you are going while texting your Earth Mama and have a head-on collision with someone else, or a bridge median, guess what the last thing to go through your mind will be?"

"What?"

"That big-assed battery, pal. And if you manage to survive being crushed by the battery, what do you think will be all over your mangled body?"

"I dunno."

"The stuff that was in the battery, Brainiac. And you know what else? No medic team in its right frigging mind is gonna come anywear near your sorry mangled ass while that big old battery is dicharging all of its energy and acid all over you and that ugly-assed car. So you'll sit there in your carbon-neutral happy-wagon and boil your skin off until a hazmat team shows up to make it safe, which could take a long, lonnnnnnnnng time, considering how fast the Department of Transportation moves these days."

I paused for another breath while a few other Berkenstock Boneheads directed their attention towards our exchange, then continued: "Now just suppose you survive your traumatic injuries and the additional insult of being stewed by your battery. Let's even go so far as to say that you survive the trip to my ER in a bumpy, cold medic unit. Do you think I'm going to let your sorry, toxic ass into my ER and jeopardize the health and safety of my staff and other patients? HELLLLLLLLLLL, NO. You're getting your ass scrubbed down of ALL toxic materials OUTSIDE before you get into one of my rooms. Here's a brutal truth, bud: Someone who is stewing in battery acid because he didn't think for himself before buying one of your Utopia-Mobiles isn't even close to being worth four of my people getting poisoned trying to save his stupid ass."

I turned on my heel, walked to my 26 MPG, 320HP Mustang, revved up with a lusty, throaty roar, and rolled down my window.

"Peace out, dude," I said as I roared out of the parking lot and drove to work.

Heroes

2008-02-25T03:24:00.000-08:00

He was sick, sick, sick.

I inherited him at the change of shift. He was completely with it, but his body was failing him fast.

The offgoing nurse offhandedly reported that the patient was a bomber pilot because his wife of nearly sixty years had mentioned it. (Sixty years! Can you imagine being married that long?)

This man was the only person I had at the beginning of my shift. I signed off on the report and, after reviewing the chart, went into the room to introduce myself as the oncoming nurse.

The patient was asleep, so I spoke with his wife. She informed me that the man was a B-24 "Liberator" pilot. I informed her that I was an amateur World War 2 aviation historian, and she brightened visibly.

"Are you familiar with the B-24 forces that flew out of North Africa in 1943?"

I answered excitedly, "Are you telling me that your husband served in that theater?"

"Yes, I am. He was there."

Something in our conversation awakened the patient, who asked his wife who was there.

"It's your nurse. Do you know that he knows what you did?"

The man raised himself up from the stretcher. "What makes you say that?"

I approached him and said one word: "Ploesti."

My patient looked me straight in the eye for a moment, and then he began to cry.

"Oh, sir!" I said. "I am sorry that I have said somthing to hurt you!"

"It's not you," he said. "I lost so many friends that day..." he said, his voice trailing away.

"Sir, you are one of my heroes. I have read so much about your friends, and of you. I can't tell you how honored I am to serve you."

The patient looked at me as if I was joking.

"I mean it. I've read abut the Ploesti run."

"What do you know?" He asked.

So I shared all that I had read about the B-24 raid on the German oil refineries at Ploesti, Romania, over the years. He filled in the gaps. He was my only patient for more than an hour. And what an hour! The stories he told- I must have seemed like a child at his feet, listening wide-eyed to his accounts of the hardships and terror he and his friends encountered during one of the most horrific parts of the war.

I was finally told by the charge nurse that I had another patient coming in- a young man who got drunk and hit his head, and who was belligerent and combative. I stood up from the bedside and excused myself. The patient took my hand and thanked me.

"How can you thank me after all you have done for me?"

He took my hand in his big paw, and answered simply, "You remember."

That's Just So Wrong! -Then Again, It Makes Sense...

2008-02-18T00:01:00.000-08:00

It was about 4PM on a Sunday. The waiting area was packed with malingering whiney-baws, harried soccer moms and their bruised, violent hooligans, armchair football warriors who tripped over their coffee tables and sacked themselves- right into the TV-, and the "Bucket Brigade" (seasonal GI bug sufferers). I was float RN and I was covering the Charge RN for a lunch break when the Charge RN's phone rang; I picked it up. On the other end was the Triage RN. Her rather hushed tone was laden with, oh, I don't know... a strange, pressured awkwardness, I suppose.

(I am here to tell you: it's damned hard for an ER nurse to feel awkward. Just think of all those tubes we wave around and where we put them.)

Awkwardness usually is not an issue with us unless we encounter something so shockingly unexpected that our brains just sort of go Gah-WOOOOO-gah. It doesn't happen often, but when it does, it can be entertaining.

...Such as in the case of the conversation I was having with the triage nurse.

"Why are you whispering?" I asked.

"I don't want them to hear me," she answered with a very strange lilt and timbre to her voice.

Let me try to recreate the nurse's tone of voice for the reader. Imagine you and your friend are in Dracula's castle and you have found your way to the vampire's crypt. It's pitch dark down there, and your friend lights a match while you are turned the other way. There, illuminated before your friend's eyes by the frail light of the lit match, is the Ole Bloodsucker himself... sound asleep in his coffin.

...But the Count also happens to be dressed in a neon yellow tutu, a huge green foam-rubber cowboy hat, a blue feather boa, and bright red patent-leather seven-inch platform shoes. Oh, wait, wait... And he has on those really, REALLY HUGE plastic sunglasses.

(I know what you're thinking: "Hey, wait! That's Elton John!" Well, that's just ridiculous. Stop being silly.)

Anyway, having recovered from the inital shock, your friend says to you in a voice that tries to convey the full color of what he sees without waking the monster, "Um, there is something over here that might interest you..."

Are you imagining that tone of voice? Yes, that's what I was hearing.

"Okay," I said with an exasperated sigh. "You don't want who to hear you?"

"The strippers!" she snapped in a hissed whisper over the phone (which was, I may point out, actually loud enough to awaken the Count and send him into a frenzy of... of... hmm... well, into a frenzy of whatever the hell he was doing wearing that preposterous getup).

"Strippers!?" I blurted out. The entire Western Hemisphere turned around to look at me. I smiled wanly. It was my turn to feel awkward.

"Yes. Strippers."

"How many?" I asked. Now I really had coworkers tilting their heads toward me to listen. This was looking bad- really bad.

"Six," the triage nurse reported.

"Well, what do they want?" I asked, as if they were a 60 Minutes crew coming to do an ambush interview. (I still roll my eyes at myself.)

"Umm, they say they want to be seen," The triage nurse replied.

"Why else would they be strippers?" I asked drily. (I'm sorry, but I really did say it. It just sort of slipped.)

"Dammit, that's not funny!" she hissed.

"Okay. Okay. I'm sorry." I said, drawing another very heavy sigh. "What are their chief complaints?"

"They are all the same," she answered.

"Hmm... okay, I'll ask. What is it?"

"Rash," the nurse answered flatly.

"Rash?"

"Rash."

After fighting very, very hard to keep imagery and snappy remarks at bay, I asked, "Do they have fevers?"

"Umm..." I heard the nurse rifling through papers; then, "No."

I looked at the bed board. Quick Care was just opening, and had ten beds. All the other patients were going to need more complex care, and those beds were opening up soon.

"Okay. Send the six of them to Quick Care along with the two people with finger lacs (cuts), the migraine patient, and the one with the ankle injury.

"The ankle injury has a nine-year-old son with her."

"Put her in a room that has a DOOR."

"Okayyyyyy. Bye-bye."

I hung up the phone. The Charge RN arrived from lunch a few minutes later.

"Everything okay?" she asked.

"Yep. No problems," I said.

"Great. Let's see here," she said, looking at the assignment sheet. "Oh!" Quick care is full, and there is only one nurse and no ED Tech. Why don't you go help them out until 1900?"

(Cue Symphony of "Oh, Crap" in D minor.)

"Uh, sure. Okay."

The Charge nurse tilted her head, looked closely at me, and asked, "Are you okay?"

I must have actually gone pale. I thought I just thought pale.

"Yeah. I'm okay."

I walked like a condemned man to Quick Care.

The, um, entertainers were given their own rooms, handed warm blankets, and instructed to change in to the gowns provided to them. I gave them time by seeing first the ankle injury, and then the migraine (a frequent flyer). Grabbing the first clipboard, I knocked on the wall and asked the patient if I could come in.

"Sure," she answered.

I pulled the curtain and walked through. The woman had her gown on "Hollywood style" (that is, open in the front). And untied. Hanging rather loosely open. (If they were real, they were spectacular.)

While looking at my shoes, I instructed the patient that the gown was to be open in the back (in the BACK, for God's sake) and exited the room.

It was the same with the other five strippers.

During the interval in which the strippers were correcting their gowns, the MD came in. It was the darling, slight, quiet, staid MD from Ole Miss herself.

Dear God, I am sorry for whatever it was I did to deserve this fate. Please can you make it stop now?

The MD hummed to herself as she looked through the charts. Looking at the migraine sufferer's chart, she asked, "Typical migraine?"

"Yes, Ma'am."

"She has a clinical alert. No narcotics for the Princess. It's Toradol and Compazine in the butt for her," she said, scrawling the order on the chart.

"Got it. I have also put in the order for a three-view ankle X-ray for the patient in Nine. Status-post hysterectomy."

"Great!" chirped Ole Miss.

"Both finger lacs have up-to-date tetanus shots, and have been infiltrated by Mags (the other RN).

"Awesome." The MD then began looking over the remaining six charts. After the third stripper's chart, the humming stopped and Ole Miss furrowed her brow.

"We have six patients with rashes."

"Yes, we do. They are all entertainers from the same, um, establishment."

Ole Miss looked up at me and cocked an eyebrow. Then she caught my meaning.

"You mean they're all strippers..." The MD said flatly.

"Uh, yes. They are all strippers."

"Oh, crap. They never learn, do they?" the MD said as she turned on her heel and strode to the first stripper's room. After knocking, the MD entered the room as I followed her with the patient's chart.

"Where is your rash?" asked Ole Miss.

"Oh, it's all over!" answered the stripper, who stripped off her entire gown to emphasize her point.

Oh, God. Get me out of this.

The reddened areas were, indeed, everywhere, but in a discreet pattern. The patient had red areas to her inner forearms, her inner upper arms, between her breasts, running in a straight line down her abdomen, along both inner thighs, and on her inner calves.

"That's not a rash. That's cellulitis." The MD said.

"What's that?" the stripper asked.

"A bacterial skin infection." The MD answered. She scribbled an order for an oral antibiotic on the chart and departed the room. I told the stripper to please (PLEASE!) put her gown back on and left the room.

I caught up with the MD in the next stripper's room. Same nonchalant exposure, same pattern of reddened skin, same diagnosis. Same plea to re-cover. Same hasty retreat.

The scene was repeated on down the line. Finally, completely exasperated, the MD had all six strippers get dressed (inasmuch as their street clothes allowed for it) and come into one exam room.

Having gathered the girls together, the MD handed discharge instructions and prescriptions to each girl, sat down heavily, sighed, and finally poleaxed the six of them with four words:

"WASH. THE. DAMN. POLE!"

The MD then stood up and left the room, shaking her head.

The strippers looked at each other with "Hey, wowwwwwww" expressions. The light came on for a moment- perhaps flickering and crackling from a short in the wiring somewhere, but at least it was on.

I handed each a large, hideously bitter antibiotic tablet and a cup of water.

"Umm... any questions?"

A Long, Dry Spell

2008-02-10T00:19:00.000-08:00

To all of my readers,

Thank you for your patience. I have been very busy. I will post again as soon as time allows. I've been working extra shifts and my butt is dragging so low that sparks are flying off the ground. I love you all. Please stay safe. -NW

Chicago Attorney Keys Marine's Car, Hides Behind Law

2007-12-31T00:45:00.000-08:00

Okay, I try to stay away from politics and hot-button topics on my blog, but what is being done to one of our nation's finest by a suckegg, military-hating attorney really pisses me off.

BlackFive has taken up the clarion call against the felonious damage perpetrated by the hateful, arrogant Chicago family attorney (that's right- family attorney) Jay R. Grodner. Grodner has committed his own brand of hate crime.

Grodner is trying every dirty trick in the legal book to see to it that justice will not find him. Grodner even stated to the Police that his victim accused him of keying the car because Grodner is Jewish.

I know my readership is not nearly as large as the other blogs. But I know that you are among the finest, most intelligent people that I could ever have the pleasure to call my friends.

Read the story. Get the facts. Draw your own conclusions. My own conclusion is that disbarment and prosecution is too good for this SOB.

Building a Boat (Or, The Coolest Christmas Present Ever!)

2007-12-27T01:24:00.000-08:00

My closest friends know that my pre-nursing years were spent in the Merchant Marine, sailing around the world and living in exotic tropical island locales. When I was a sailor, I spent a period kicking around the South Pacific on a great big sailboat courtesy of my former employer (who lent a shipmate and me use of his 40' sailboat in lieu of a bonus).

We spent the better part of three months sailing to the Marquesas and back to our home in Tahiti. It was one of the most treasured experiences of my life, simply for the sheer adventure of it.

But I am married now, and I have settled down a bit (although that point is up for debate by many who know me).

My beloved bride met me when I was still very much a wild, brash, untamed sailor. We fell madly in love at first sight, and we married less than three months after we met. I was at sea for more than half of that time. That was nearly nineteen years ago.

Well, she tamed me. And she opened up a life for me that I had never dared imagine. Nineteen years later, I am still absolutely nuts about the girl, and she is lovelier than when I first met her (and let me tell you- that's saying a LOT).

But I still missed the feel of a deck beneath my feet, a sail above my head, and the smell of the sea in my head. I never missed the going away- after meeting my beloved, I hated parting with her- but I loved the sea. I still do.

My beloved knew this. She knew it for years. I tried to get a boat some years ago, but it fell through. I did not realize it at the time, but she knew how I missed it.

Well, this year, she gave me the best Christmas present I have ever received: The plans and finances for a sailboat I will be building myself!

The sailboat is called The Weekender. The design has been around for decades. But the boat itself it perfect for me.

My bride, she hates the sea and everything in it. But she loves me, and she knows how I miss sailing. Now, I get to build my own boat, sail when I can, and never go away from my beloved bride. I have the best of everything. God has blessed me.

Touching Base

2007-12-15T13:40:00.000-08:00

I was recently shadowed by a high school senior during a couple of shifts. She was considering becoming a nurse and had an interest in Emergency Nursing. She followed me as I provided care for patients with a broad spectrum of problems- from a known narcotic seeker who demanded (read: screamed) that we address his pain, to a homeless patient with a peritonsilar abscess and no access to continuity of care, to a nonagenarian woman who suffered cardiac arrest and whose family had kept her on "full code" (all measures to maintain life) status because they could not let her go. My young shadow saw everything from the mundane to the life-shattering. She didn't understand sometimes why we try so hard. She didn't understand sometimes why we gave up so quickly. She asked a lot of questions. Sometimes the only answer she got was "I don't know." But she certainly left with a stronger awareness of emergency nursing than when she came in. And in the end, she expressed a stronger desire to pursue nursing than when her two long nights with me began.

It was a good experience for me because it served to reaffirm the reasons I became an emergency nurse in the first place. While those initial guiding altruisms have been purified through the crucible of hard experience, the fact that they remain essentially unchanged reinforces my conviction that I have followed this calling for all the right reasons. It is good to "touch base" once in awhile- to step back and look at the big picture as it applies to this craft and my place in it.

And it really is a craft: it is more than mere science, more than mere art, and more than mere aesthetics. It is a dynamic entity comprised of all of these things and more; it is fluid, malleable, and flexible. The careful practice of the craft enables the experienced nurse to bring the fullness of his or her skill and expertise to bear in a manner that is custom-tailored to the unique needs of each and every patient. The craft thrives in an environment of constant purposeful increase of knowledge and experience; The diligent nurse carefully nurtures and grows his or her craft as if it was the rarest of flowers in a garden. The nurse who neglects this ultimately does so to the great peril of the patient.

There is a Great Abyss that nurses talk about but seldom recognize in themselves. I have known nurses from many disciplines who perhaps should have stepped away but continued to work. It is a danger faced by anyone who suffers daily exposure to the darker, meaner side of humanity, or to the pressures that accompany rigorous, demanding routine. And it is a soul-wrenching thing indeed to watch a nurse walk blindly, as most who go there do, into that abyss. Psychiatrists call it "Caregiver Role Strain." We nurses call it "Burnout."

There have been times in my own comparatively brief career when I have had to pull myself up short, step back, and coldly correct myself when I was too quick to judge or when a case rattled me- or if I got too emotionally enmeshed in an intense case. It happens to every nurse from time to time- more often in the high-stress specialties, but no nurse is immune. I don't think a nurse can avoid burnout by simply avoiding the situation; rather, he or she must develop the ability to maintain clinical objectivity. And sometimes, my friends, that is a hell of a hard thing to do. Because while a nurse may be simply maintaining objectivity, it can be misconstrued by the patient or family as being "cold," "uncaring," "rude," or "judgmental," even when a nurse has also expressed genuine concern for the patient.

So then, we nurses must not only carefully practice clinical objectivity; we must also show that we genuinely care. This is a tricky business. It's damned hard to do sometimes. Yet both are equally necessary all the time. It is a devil of a thing, a delicate balance. If one loses sight of the guiding altruism of nursing, certain disaster awaits- if not for the nurse on a personal level, then for the patient. For we practice upon living human beings, for whose benefit we live by the principle of First, Do No Harm. Thus, if altruism is sacrificed for the sake of pure objectivity, we also lose the ability to empathize. Yet at the same time, if we become too emotionally enmeshed in our patients' situations, we lose clinical objectivity and thus cannot see the thing that, while hard for them, will ultimately do the greatest good.

As an Emergency nurse, I perform some noxious- and sometimes brutally harsh- interventions in order to save a patient's life. Many times, the patient is fully awake when I perform them because they must be. It bothers me to do painful things to another human being who trusts me to do the right thing for him or her because I know that it hurts. I often find myself apologizing during the process because I know how much pain I am causing- and yet for the greater good of the patient, I continue. I do not apologize about having to do it; I apologize for the pain it causes. And not all procedures can be preceded by local anesthetics.

Yet if I explain the procedure beforehand to the patient according to his or her ability to understand, then he or she is generally better-equipped to endure these things. They understand that I am doing what must be done, that it may cause quite a bit of discomfort, and that while their discomfort may not necessarily be lessened, their active participation in the process is likely to shorten the duration of their discomfort. And I try every trick in the book to make things as easy for the patient as possible. Clinical objectivity is thus married with the altruism of compassion.

It's great when time permits gentleness. Sometimes, it does not. When a patient came in after a Tylenol and Benadryl overdose and I had to unceremoniously slam a nasogastric tube into her without fanfare or time-consuming preparation, it had to be done right frigging now. I am fine with that. But I talked to her while I was doing it- sometimes barking a command to swallow, and then at the end, just putting a hand on her forehead and telling her, "You did a great job, kiddo. I know that hurt, and you were wonderful." It's funny: she looked me right in the eye, gave me a nod, and smiled at me. In spite of the hundred Benadryl that raised black hell on her nervous system, I connected with her.

And that is the marriage of clinical objectivity and compassion: As horrible as a procedure may be, there is always time enough for a little gentleness afterward.

"Do you ever cry?" My shadow asked at one point.

I answered that I did cry sometimes for my patients. It's heartbreaking to see some of the cases that come through the door. But God is my healer, and so I am not afraid to care. I am thus free to be clinically objective and to genuinely care about my patients. I am convinced that if it was not for God, I would have fallen apart long ago. But because of God's grace, I do not merely endure; I thrive.

My astute young friend closed her experience with a question: "If you could tell me one thing that could guide me as a nurse, what would it be?"

After a few moments of thought, I answered: "Never forget that the person in that bed is somebody to somebody else- and even if the patient doesn't have a friend in the world, he is still somebody to God. The patient is not there to serve you; you are there to serve the patient. Sometimes that means telling them something they don't want to hear. When you care for someone, it means that you also care enough to warn them that their choices put them at risk for imminent harm or illness."

The young lady looked down, sighed, and nodded.

These are the things I told the young lady who shadowed me throughout two long and often brutal nights. And that wide-eyed young lady who shadowed me and plied me with questions (which begat more questions) had in her own way served to reignite my own passion for this craft. In reflecting on my experiences with her I came to realize that, if such is possible, I am more passionate about the craft now than when I first felt the call to become a nurse and to focus on emergency nursing. I found, to my delight, that it had never gone away- had not even paled from its original blush. And that, I think, is a most gratifying thing.

The Truth about MRSA (Without the Media Panic)

2007-10-31T21:23:00.000-07:00

Okay, my friends. For the last week or so, the media have gotten Americans all worked up into a froth about this "deadly new bacteria" called MRSA. My ER is now inundated with frantic phone calls from people who have no idea what they are looking at, or what the disease really is.

One charming woman (who clearly smoked wayyyyyyyy too much) called amid the throes of a panic attack because she found a pimple and was convinced beyond all attempts to reason with her that she was "gonna die of Melissa."

"Ah, you mean MRSA." I corrected the hyperventilating woman on the phone.

"What's that?" she asked with a voice that reminded me of Bosley from Charlie's Angels.

"Never mind," I sighed, rubbing my eyes.

Well, after a full rotation of charming phone conversations such as that one, and a waiting room filled with wild-eyed impressionable souls, I have had just about a dang nuff of this.

I get tired of the media feeding crap to the public about infectious diseases. This case is no different. (But that perky anchorwoman wouldn't BS you about something that involves your well-being, would she? After all, she furrowed her brow when she said it. Furrowed! Her! Brow! And with all that Botox on board, that takes some effort, Spanky!)

Oh, of course that cute little newsbabe wouldn't BS you. She cares about you. Kum-bah-frigging-yah. Please clean up before you leave.

Well, here is the real scoop, Alley Oop.

I am an Emergency Department nurse, and I have encountered patients with MRSA a gajillion times. (By "encountered" I mean, "assisted in cutting open and draining their wounds, packed their wounds, and changed their wound dressings." And by "gajillion," I mean "gajillion.") I have- gasp!- touched a person who has MRSA. And wouldn't you know- I never got it. And I don't pass it on to other patients, either.

(Gosh! How can this be? He touches the leper and he does not become unclean! What manner of man is this!?)

Look, folks. It is really very simple. I know how to protect myself from it, and I know how to protect my patients from it. And because I understand MRSA, I don't get freaked out when I see an ingrown hair on my arm. I will tell you why. And when you read this, you will become just as confident as I am, because you will know the truth.

Are you ready? Here we go.

1. Wash your hands with soap and WARM water.

Any soap will do. It doesn't have to be Hibiclens(TM), or any other ludicrously expensive antimicrobial soap for that matter. Just plain old soap and water. ANY old soap is "antibacterial" when used correctly; All you have to do is make LOTS of suds. Its the suds that make a soap antibacterial. "Really?" you ask. "How so?" you ask. Well, settle down and I will tell you: Suds form micelles around dirt and bacteria and lift them from the skin's surface to be rinsed away to the black hell from whence they came.

Don't use hot water, because hot water dissolves the natural oils on your hand that keep your skin from drying out and cracking. (Cracks are openings deep into the skin. Openings deep into the skin invite bacteria.) Don't use cold water, either, because cold water will not produce decent suds, and it will not rinse all the soap away from your skin, so your skin will dry and crack. (Again, cracked skin says, "Hey bacteria! Par-tay over here!") So remember: not too hot, not too cold, but just right.

Wash- and rinse- AND dry- under those pretty rings on your fingers. Rings hide light- that means darkness. Moisture hides under rings- that means bacteria. Darkness + bacteria= EEEWWW.

And come on, folks. REALLY wash your hands. For fifteen seconds. None of that "happy birthday" song crap (which I can sing in five seconds). Sing your ABCs; THAT's a fifteen-second song. Fifteen seconds should also cover roughly two limericks, if that's more your style. That includes slurring of speech secondary to alcohol consumption.

Dry your hands completely, including under those stylish rings. Water = bacteria. If you don't dry, you just defeated the purpose of step 1.

And don't you DARE just splash your hands in the water and then shake them off! If you do that, you are the one spreading this crap around. Stop it! Bacteria L-O-V-E-S moisture. And where you just had your hands- bacteria loves that place too. So when you exit the bathroom and go smoke that cigarette and eat your sushi, guess what else you're putting in your mouth- or into the mouth of that hottie of yours when you try to be cute and feed her an hoeurs-d'oeuvres?

Nothing says "I love you" like a mouthful of Enterococcus faecalis or Candida albicans.

2. Use enough alcohol-based hand sanitizer to cover ALL of your hands, including under the nails and rings. With Brylcreem, a little dab'll do ya. With hand sanitizer, you need enough to wash EVERY FILTHY BIT of your hands for the same length of time as demonstrated in part 1, above.

3. Take a shower. I mean on a daily basis. Good personal hygiene is your friend. Remember those micelles? They do the same thing wherever you create them.

4. Cover your boo-boo. Even if you don't have MRSA, if you rub that boo-boo over someone who has it or something upon which MRSA rests, guess what? You get MRSA! See how this works?

5. Don't touch someone else's boo-boo. Wherever it is. Draw your own picture. Leave me out of it.

6. Don't touch any bandages that cover someone else's boo-boo. That's self-explanatory.

7. Don't share your towels, razors, or anything that touches your or someone else's boo-boo. Yes, that means you married/joint domicile people, too. Think about where that towel/razor/dressing has been. Can somebody give me a BLEEEEEEYAAHHHHHH!?

If you want a version of the game that tells you the same thing but spares you the rapier-like wit, go to The Official Center For Disease Control MRSA Website and fall asleep in the middle of it.

And one last thing: MRSA has been around for years. And that cute little news-floozy is just playing you for ratings.

UPDATE: It has been pointed out to me, and correctly so, that MRSA can stay viable on a hard surface for a long time (some studies state for three months). There is a way to defeat this threat: Simply wash all contact surfaces (countertops, toilets, sinks, doorknobs, etc.) with a bleachy solution. Those Clorox (TM) handy-wipes that you can pull out one at a time will do just fine. Just wear gloves while you use them, as bleach can irritate the skin.

The Living Dead

2007-10-29T08:57:00.000-07:00

I saw a woman at the store near my house last Wednesday morning after I got off work. The moment I saw the woman, I knew she was on Meth. Her face was covered with black sores; she was pale, scrawny, dirty, and absolutely wild-eyed. She was practically dancing in place. Her speech was a jumble of pressured and confused babble; her movements were grandiose and repetitive. She constantly rearranged the items she placed on the checkout counter. At one point she looked right at me. Her expression was chilling.

She managed to pay for her groceries, but then loitered outside the entrance, pacing back and forth and mumbling to herself. She approached one or two people outside. I told the clerk to call the police. They would probably haul her to a local ER and dump her there, and the ER wouldn't really be able to do anything for her but watch her, but at least she wouldn't run into traffic or assault someone.

When people are 'cranked,' they seem to suffer a total disruption of reality. The laws of physics and of cause-and-effect seem to be suspended for them. They're stolen away to a kind of 'parallel universe.' On their side of reality, they race unfettered at light speed and are bombarded from every direction with pure stimuli; yet on this side of reality, their bodies literally fall apart from neglect and abuse. They are animated rotting corpses. They are real-life zombies. They are the living dead.

Yet because they still exist (the word 'live' no longer applies for their hell on earth) in our reality, they carry along with them the attachments of the people who love them. They are still somebody to somebody else: somebody's daughter, son, brother, sister, mother, father, husband, or wife. And we can only watch in powerless horror as our loved one is stolen away from us and, day by day, cut by cut, over months and years, butchered and left to decompose before our eyes.

This is Meth. This is what it does to us. Why have we as a society allowed our leaders and law enforcement agencies to pussy-foot around with this?

Why Pregnant Women Frighten Me

2007-10-07T01:09:00.000-07:00

I had spent the first half of my shift in the "Fast Track" section of the Emergency Department. Cases that are a level 4 and 5 on the 5-point triage scale are sent to Fast Track in order to make room for the more acute cases in the main ER. Cases that rate a 4 or 5 are cuts, sprains, bumps, bruises, series antibiotics, migraines, the mother who brings her six kids in because the ER is her family clinic, and such.

(I am a fervent proponent of "Fast Track." It keeps the patients suffering from non life-threatening ailments from having to wait too long to be seen, and it keeps the really sick people from having to wait for a bed.)

But this night was tough. Every patient I had was a pregnant woman. One had a headache (she was dehydrated, and needed to drink enough water for two instead of only one). Another woman had abdominal cramping but no spotting. (fetal heart tones were reassuring, she was not spotting, and she turned out to have gastroenteritis.) Others were there for coughs, colds, fevers,and so on. In all cases, FHTs were obtained and the 'passengers' were all just fine. But I was ready to be done with pregnant women.

Don't get me wrong. I think that pregnancy is, in itself, an amazing process. But at the same time, even a "normal" pregnancy is fraught with danger to both child and mother. Pregnant women are like the X-planes of the 1950s: awesome things happen inside them, but they can self-destruct in spectacular fashion without warning and without the slightest provocation. Pregnant women scare the crap out of me.

Fast Track closed at Midnight, and I was assigned the Float RN position until 0300.

At about 0100, the medic call came, signified over the intercom system by a soft,sweetly-intoned, bong-bong-bong that belied its urgency. The MD picked up the phone to receive the report. As he took notes, his brow furrowed and he rubbed his forehead with his free hand. He hung up the phone and handed me the Medic Call sheet.

A pregnant 25-tear-old woman had an on-scene BP of 226/116. Heart rate was 52. She complained of severe headache and numbness to her left arm. ETA was 10 minutes. I groaned.

We had taken care of pre-eclamptic patients before. Magnesium is the weapon of choice because it reduces the risk of seizures associated with eclampsia. Lopressor (a beta blocker) is also favored because it protects the heart and lowers blood pressure. But since this woman's heart rate was less than 60, we could not give Lopressor and thus intended to use magnesium as aggressively as possible. She was really rummy from the Mag; her speech was slurred, her limbs were floppy. But her vital signs were great. So we sent her to CT. Since I was the 'float' RN at the time, I went with the patient. She was on a portable monitor so I could continue to see what her body was doing.

She made it through CT like a champ. No evidence of a brain injury was found. As we were exiting the CT control room I said to the CT tech with a sigh, "Taking care of pregnant women scares the crap out of me. It's like being a demolitions expert." The CT tech said a heartfelt "Amen!" We carefully transferred the woman from the CT table to the stretcher for the trip back to her room. I looked up to reach for the oxygen tubing, and then looked down at her.

At that moment, she seized.

I rolled her onto her left side and barked to the CT tech, "Get the doctor NOW!" The other tech in the room frantically stuck a Yankauer wand onto the end of some suction tubing and handed the wand to me. I suctioned the secretions out of her mouth to keep her airway clear and waited the thousand years it seemed to take for the MD to get there. He finally arrived, breathless, and asked, "How long has she been seizing?"

"About a minute," I replied. The seizure was just beginning to abate.

"Let's get her back to the room now."

We pushed her back into the exam room (which was only thirty feet away from CT) while keeping her on her left side. The seizure had stopped by the time we got her back on the full monitor. She then entered the post-ictal phase and became combative. She swung, punched, kicked, and screamed gibberish.

"Give her 1mg of Ativan. Ramp up the Magnesium to 4 grams per hour. Keep her in soft restraints. I don't want to lose that IV, and I don't want to intubate her. Get her back on the fetal monitor," the MD said as he left the room.

We followed the orders. The patient was hemodynamically stable soon thereafter, and the Ativan helped settle her down. But the problem was not solved yet. Her passenger was in grave danger, and she was not out of the woods yet, either.

The on-call OB-GYN came in the room and said, "Get her ready to transfer to the University. I've already signed the orders." I set about getting the paperwork ready while the patient's primary nurse continued direct care. Within the hour, the patient was on her way to the other hospital.

We heard the next day that the patient underwent an emergency cesarean section. The baby was in very bad shape and not likely to make it. The mom had a massive stroke during the procedure and was also not likely to survive. It was her first pregnancy.

8 things About Me (Or: I've Been Tagged, and I feel so... dirty!)

2007-09-08T19:08:00.000-07:00

I was minding my own business when my dear cyberfriend Not Nurse Ratched slipped the old tag-eroo on me. And according to the tag, I am to offer up 8 fascinating facts about myself.

Well, okay. Although I fear I may lose the mystique that makes me oh-so-fascinating and alluring, I think I can dredge up some stuff for my dear readers. Here goes:

1. I spent 14 years as lyricist and lead vocalist with an obscure progressive rock band before stepping away to devote more time to being a nurse and working on disaster research. My fans-all three of them- couldn't keep their hands off me... now that I think about it, I think I may owe them some money...

2. I was a merchant seaman, sailing all over the place, and during that era I lived in Tahiti. Are' maru!

3. I have not read fictional literature in years (unless you count the Seattle Times). My reading consists of naval history and research papers. (Wow. I'm living on the edge. Hold me back before I hurt myself!)

4. I held a beating human heart in my hands once. Having my hands on someone's chest is pretty much an everyday occurrence. (Stop thinking dirty: it was therapeutic, people!!!) But having my hands in someone's chest was really weird.

5. I have a thing for cars that are powered by large engines that go VROOOOOM loudly enough to make strong men faint. And I drive them very, very fast. Cough...on a closed circuit, of course... ahem.

6.I consider ER one of the best situation comedies ever written about people who work in the field of emergency medicine.

7. I always take the time to point and laugh at people who spend 20 thousand smackers on a blob-like, shockingly unsexy Toyota Prius (The official car of Birth Control) and then slap two dozen bumper stickers on the back end of it. I can't blame them for it... after all, it's the only way they can voice their opinions without being challenged to defend them. (By the way... if such a person happens to read this post, welcome and all that. And by all means, express yourself. Slap those stickers on! But if you do, then at least have the presence of mind (I know, I'm reaching here) to oh... I don't know... maybe, update your slogans or something so as to keep up with current events and at least not appear to be some uptight whiney-baw who simply cannot let things go. Look- I am here to help, and I am in a giving mood: so I urge you to heed the following: Kerry lost three years ago. Remove the damn sticker, already.)

8. I am the youngest of four children, and the only son. It wasn't all that bad... except maybe for the hand-me-downs [rimshot]. Thank you! I'm here all week! Don't forget to tip your waiter!

Okay, sports fans. While I feel somewhat less enigmatic, I think that if this tawdry expose' draws me closer to my dear readers, then it is a good thing.

Okay, everybody... Group hug!

Mister B's Midnight Serenade

2007-08-30T15:24:00.000-07:00

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

2007-08-28T22:46:00.000-07:00

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

2007-08-10T00:22:00.000-07:00

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

Forty-Two

2007-08-09T11:49:00.000-07:00

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.

Nurse Convicted of Horrific Murder Gets Life Sentence: My Thoughts

2007-07-19T13:32:00.000-07:00

Rebecca Santana of the AP reports that a nurse convicted of murdering her husband, dismembering his body, stuffing the parts into designer luggage and tossing them into the sea has been sentenced to life imprisonment.

According to Santana, "...prosecutors argued that [Melanie McGuire] organized her husband's murder using her expertise as a nurse to drug him, shoot him and cut him up."

The motive was as repulsive as the crime. Melanie McGuire was not a battered woman trying to escape a brutal relationship; she killed and mutilated her husband so that she could continue an extramarital affair with her boss. It is no small irony that McGuire was a nurse at a fertility clinic. It seems that her regard for human life was not as profound as one would imagine.

Because I am a nurse who takes particular care in establishing and maintaining a relationship with my patients founded on trust, it sickens and angers me when I read stories like this.

To be sure, no profession is immune from the element of human depravity, since professionals are human beings. But certain professions carry with them much higher expectations of fidelity, beneficence and non-malfeasance (i.e., nurses, doctors, counselors, social workers, special advocates, clergy, firefighters, policemen, etc.). So when someone in my profession commits a crime as heinous as this, the public also becomes the victim to a certain extent because nurses are no longer above murder. This is especially true when a nurse murders a patient, such as happened only a few months ago when an ICU nurse murdered multiple patients over a span of time.

Nursing is at the top of the list of the most trusted professions in America. In view of the high degree of trust that the public places in nurses, I personally think that any nurse who has been convicted by a jury of his or her peers for committing premeditated murder- particularly murders so vile as the examples presented here- should be sentenced to death.

The Dream of Flight Continues...

2007-07-14T21:04:00.000-07:00

I went to an EAA Fly-In with my son today. We noticed a sign that read:

FLY IN AN ANTIQUE BIPLANE! $60.

I looked at my son. My son looked at me.

Minutes later, we were strapped into the front seat of a radial-engined biplane of 1920s vintage, rolling onto the duty runway and grinning like a couple of mischievous scoolboys on a lark. The radial engine chugged and purred in that manner for which I dearly love radial engines. As we lined up, the pilot opened up the throttle. The purr changed to a roar and away we went. Suddenly, we were aloft and climbing into a clear summer sky. The wind sang through the struts and wires, buffeting my ears and tugging at the sleeves of my tee shirt.

I settled into my seat and rested my arms on the edges of the cockpit, luxuriating in the whole sensorium of this trip back in time to when flight was still a very dangerous and arcane craft. The slipstream combed back the hair on my arms, a quite pleasant sensation. My olfactory senses were filled with the heady melange of rubber, canvas doping, oil, high-octane avgas exhaust, and of fresh-cut fields. The sky was hazy above but clear below.

The pilot began gently turning, banking, climbing and diving, translating the laws of physics into a sensory playground. I felt that odd, ticklish feeling in my abdomen with the change from positive to negative Gs, as if I was going over the apex on a rollercoaster. The pilot banked steeply over the fields below, allowing us to fully appreciate the wonderful view afforded by an open cockpit.

I was in heaven.

I had been taking videos the entire time. I finally swung around around as the pilot's headphone-ensconsed head filled the viewfinder, he gave me a big grin and a thumbs up. He knew what we were feeling, and his grin told me he felt that way too. I briefly envied him for having the opportunity to do this all the time.

The flight lasted longer than usual- almost an hour- because the runway was clogged with other traffic. Dang.

Our landing was so gentle that the only way I knew we were down was by the brief screech of the tires as they made contact with the abrasive, inflexible earth. We taxied back to the grassy field and the engine coughed and chugged to a halt. Slowly and with great reluctance, we climbed out of the cockpit. I thanked the pilot for the experience, my jaw aching from the grin that seemed to have taken permanent residence on my face.

I sighed, preparing to re-enter the my mundane, earthbound world. Then, as I turned to walk away from the vintage aircraft, I saw it.

The Life Flight helicopter swooped into view, descended, swung around sharply, and landed with a kind of flair that seemed to say, "Ha. Look at that."

My heart went thumpity-thump. I looked at my son. My son looked at me.

By the time we got to the helicopter, the pilot had walked away to a nearby Honey Bucket. The flight nurses were facing away from me. One of them removed her helmet, revealing the page-bobbed, flaming red hair of my dear friend Nurse Dynamite. She gave me a big hug and shrieked, "Ahh! There you are, my darling!" She turned and gave my son an equally rib-crushing hug and said, "Boy, you are about ten feet taller than the last time I saw you!"

"I hear you will soon be joining us." she said with a conspiratorial smile.

"I'm thinking about it," I said sheepishly.

"Thinking about it!?" she said.

"Yeah."

"Have you ever sat in one of these beasts?"

"Well, no."

"Come along," Nurse Dynamite chided as she took my hand and pulled me along. "I shall help you to make up your mind." I felt like an errant schoolboy on his way to the dunce's chair. She led me to the door, pointed inside the helicopter, and commanded, "Park it right there, sweetheart."

I looked at her with a "Can I do this, really?" look. She smiled impishly and pointed again. I clambered into the cramped, narrow seat and surveyed the surroundings.

Holy CRAP, it is tight in here, I thought. I noticed the stretcher. It was locked onto a kind of trolley. The foot was tucked into the left front cockpit next to the pilot's seat. The head was parked neatly between two narrow forward-facing seats bolted to the after bulkhead of the cabin. I looked at Nurse Dynamite and said, "This doesn't look like a therapeutic environment. You can't reach the whole patient."

Nurse Dynamite cocked her head and smiled, saying, "Think about it. In a major trauma, we are interested in everything from the waist up because that's where all the vital organs are, and that's what we are trying to save."

"Oh, that makes sense."

"On the other hand, you can see how difficult starting an IV can be."

I looked again at the cramped quarters. "Yes, I can."

"But you can also see how the seats are situated perfectly for dropping an endotracheal tube."

I looked again and said, "Of course. Well, now it makes perfect sense. It's all ABCs, after all, isn't it?"

"Yep! So what are you waiting for?"

"Experience. I need a couple more years in the ER."

"We'll be waiting."

I looked down at Nurse Dynamite's helmet. I noticed a huge sticker of that cartoon bunny smiling and pointing at its butt. That figures, I thought, and I chuckled.

Suddenly, a childlike excitement overcame me, and I hurriedly asked, "Will I have to buy my own helmet?"

"Naw! They give you one. But you have to put something on it," she answered mischievously. "Like a nickname or something."

"That's easy," My son snorted. "Call him 'Duke'."

Nurse Dynamite's jaw dropped and she looked at me with a shocked expression. "Duke!?"

"Yeah, like John Wayne. You know, The Duke," my son explained. "Dad loves John Wayne."

"How perfect!" Nurse Dynamite exclaimed, her voice squeaking, as she clasped her hands onto my arms. "Duke!"

I blushed. I really blushed. I smiled and surreptitiously shot my son an "I'm gonna kill you" look. He laughed, of course.

The pilot broke our reverie by jogging to the helicopter, stuffing himself into the cockpit, and flipping switches.

"Whoops! Gotta go, darling!" Nurse Dynamite said as she pulled on her helmet with the "You smell like butt" sticker on it. She gave me a hug and a peck on the cheek, and did the same for my son, telling him, "Give your mom my love, will ya?"

The boy nodded.

"See ya, Duke!"

"See ya, firecracker," I answered with a pat on her helmeted head, and we dashed out of the landing area. The hatch shut with a thump. The Agusta wound up quickly, its turbine whining. The rotors bit with their chest-thumping thrum. The helicopter lifted off and sped into the distance.

I saw myself there, with more clarity than ever I had before.

To Dream of Flight

2007-06-28T21:42:00.000-07:00

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?

Pediatric Code Blue

2007-06-06T17:44:00.000-07:00

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

2007-06-06T10:21:00.000-07:00

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!

Beyond Mere Science

2007-05-05T07:38:00.000-07:00

God has a way of bringing patients into my life who serve to remind me of what this nursing stuff is all about. Through these encounters, He restores my sense of the holy purpose of nursing. Without this sense of altruism, nursing becomes nothing more than an application of mere science and aesthetics; The patient is reduced to nothing more than a problem to be fixed- the "kidney stone in room 3"- rather than a human being in need of care.

Dealing with malingerers and drug-seekers on a daily basis tends to make me more cynical and suspicious than I can comfortably admit. After dealing with at least one malingerer per shift for nearly a week, I have to admit that I can get pretty jaded.

Sometimes a patient will come in for emotional distress. There may be no underlying pathology. But an emotional or spiritual emergency is still an emergency. The person's life is a shambles and he or she has run out of ideas and hope. If ignored, it can be devastating. (The reader need only refer to my recent post about a coworker's suicide to see my point).

Some may suggest that a counselor or a church would be a more appropriate place to take one's personal demons. My answer to such a statement is simply that while counselors and churches are not open 24/7, Emergency Departments are. And when there is nowhere left for a distraught, frightened or hopeless person to go, the ER is the perfect place to come for help. Why shouldn't they come here?

I had a patient a couple of weeks ago who came through triage complaining of "loneliness" (her stated chief complaint). She was three months pregnant, and her boyfriend had left her. She had come with him from the East Coast, and she had no way to get back home. She had been living day-to-day and roof-to-roof for nearly a month and had run out of friends, money, shelter, and strength. She was tearfully apologetic about taking up my time as I assessed her in the treatment room. She never asked for any medication. She never asked for so much as a blanket, although it was chilly and her arms were covered in goosebumps. I gave the woman three blankets fresh out of the warmer.

It is amazing how therapeutic a fresh warm blanket can be, and how strongly it can communicate compassion. It says, "You're safe here." The woman visibly relaxed and smiled with a sigh as I wrapped one around her shoulders and covered her body and upper legs with the second, and wrapped the third around her lower legs and feet.

We ran some basic tests on the woman just to make sure she and the baby were okay, and everything checked out fine. I assessed fetal heart tones and pointed out the fast, loud wow-wow-wow-wow of the baby's heartbeat under the doppler head. The woman brightened when she heard the sound of her baby's heart rocking steady in her belly.

A nurse's responsibility is not for a heart, a lung, a brain, or a lacerated toe, but for the whole patient. Certainly, the woman and her baby were physically fine, and there was nothing medically to be done for her. But emotionally, the woman was a train wreck. She was a harmless, stranded, frightened and lonely human being whose toolbox was completely devoid of coping skills. She was isolated from her family, cut off from a way home, and cold. And she was pregnant. She didn't want drugs; she just wanted to feel safe and that she was cared for- or more to the point, cared about.

Some might criticise the woman for abusing an already-overstretched Emergency Department. I must confess that I fought hard to suppress an involuntary rolling of my eyes as I read the patient's chief complaint. But as her story unfolded, God softened my heart. He reminds me about how important to Him human beings are. And by the time I finished listening to the woman's story, I had a good idea of what God expected me to do for her.

I approached the MD, who was sitting at his computer and sat down. He paused from his dictation and turned to me.

"You have that look," he said suspiciously. "Who is it?"

"The pregnant woman in 12," I said. "I know you haven't examined her yet, but she isn't physically ill."

"Why is she here?"

"Her heart is broken," I answered. The MD raised an eyebrow and I held up a hand. "She isn't asking for meds, she isn't in pain, and the baby is fine. But she's in a heckuva jam, she's scared, and she needs some help. I'd like to get Social Work involved."

"If you think she needs it, go for it. I'll go in and examine her so we can get things going."

I entered an order in the computer for a Social Work consult. I then called the SW to see how soon she could come.

"What's going on?" the SW asked. I laid out the problem and she said, "I'll be right there."

ER Social workers amaze me. These people can conjure up support resources seemingly from thin air. IN my ER, we nurses love our SWs and view them with something close to awe. This particular SW was a real veteran and one of my favorites. She came to the desk and chatted with the MD and me about what we felt should be done. The MD and I agreed that getting the woman back home would be a great goal if possible, and that finding shelter for her in the meantime would be icing on the cake.

The SW sighed. "You don't ask for much, do you?" She stood up, grabbed her papers, and went into the woman's room. She was in there for nearly an hour, and at one point I clearly heard the woman sobbing. At last, the SW stepped out. I noticed her left shoulder was wet. She sat down next heavily next to me at the nurse's station and said, "She is a wreck."

"Yep. What did you find out?"

"Well she doesn't fit the mold, for starters. She's smart and very articulate. She has a degree in economics. She came out here because her boyfriend got a job at the Geek Palace. They were going to buy a house together and she was going to try to get on at the University. Then she got pregnant. He didn't want the baby, and she wouldn't get an abortion, so he threw her out. She couldn't find a job and ran out of money and friends. She hasn't called her family for help because she was afraid they would be angry with her. But she gave me her parents' phone number and gave me her consent to give her folks the whole story. I'm going to go call them before it's too late over there. I'll be in my office if you need me."

Twenty minutes later, the SW came back and sat down. I looked at her expectantly. She sat down and folded her hands in her lap.

"Well, we can get her home and put her up in the meantime," she said at last.

"I never doubted you for a moment. What did her folks say?"

"They had no idea. They said she sent letters and called almost every day until about a month ago. Then she just vanished. They were worried about her and I had to convince them that their daughter was not dead. They want to talk to her, but I told them that I had to let the patient know first. I'll go in and give her the news. When I give you the high sign, call this number-" she handed me the paper- "and then transfer them to the phone in her room."

The SW went into the room with another warm blanket and closed the door. A minute later the SW opened the door, stuck her head out, nodded, and closed the door again. I called the parents, introduced myself, and then transferred the call. Within seconds the woman was sobbing again. Shortly thereafter, the SW stepped out.

"How's it going?"

"Just fine," the SW answered with a smile. Her parents have old friends here, and they gave me the number. They live about thirty miles north. I called them from the room, and they're on their way to pick up our patient as I speak. Her parents are going to arrange for a flight home in the next day or so."

"Wonderful! How is our patient?"

"Remorseful, but relieved. She'll have some things to work out for herself, but she'll be home in a few days and her parents are just happy that she's alive and healthy."

I informed the MD that things were squared away for our patient and gave him the plan. He smiled and printed out discharge instructions for pregnancy-related nutrition. The patient was already dressed when I entered the room; I gave the patient her instructions and informed her that she could wait in the lobby until her parents' friends showed up.

As we stepped into the hall, I offered my hand and said, "All sorts of good luck to you, ma'am."

She shook my hand and said, "Thank you. I'm glad I came here."

"Me too."

Losing One of Our Own

2007-04-19T04:15:00.000-07:00

One thing about ER Nurses: We know, probably more than any other nursing specialty, the combination of medications that can make a suicide attempt successful.

One of our own ER Nurses successfully demonstrated her personal knowledge last week.

Of course, none of us who knew her- even those closest to her- has a clue why she killed herself.

The usual grief counselors were on hand a few days ago to help us discuss our feelings about the decision our friend and colleague made to take her own life. I did not attend. A wake was held at the local watering hole in the evening (of course) after the counseling session. I did not attend.

The funeral will be Friday. I cannot attend.

I have lost friends before. Years ago, in another life, I watched horrified as one of my closest friends was washed overboard in a severe storm at sea. I have since come to the understanding that even if I wanted to, there was not a thing I could have done to save him.

But this is different. She never gave anyone the chance to try to help her. And that is what bites at us.

There was no valiant fight against some grave illness. There was no horrible traffic accident. She was not murdered. She did this to herself. And because she did this to herself, people feel both sorrow and resentment toward her. That's hard to equate.

How do I feel? I don't know. I am not weepy, and I have not really agonized over it. She made her decision, and that's that. We all are dealing with this in different ways. I have said my goodbye; I am moving on. What more can I do?

The Time Bomb: Epilogue

2007-04-04T21:48:00.000-07:00

In my last post, I described the frightening story of a patient who was diagnosed with an aortic dissection and whisked away by airlift to a Super-Hospital for treatment. Due to the demand of all and sundry who have threatened to lynch me if I did not tell the rest of the story, here is the rest of the story, as far as I know it.

The patient faced a truly brutal and frightening surgery. I had it described to me by a nurse who has sat in in one, and here is my best attempt to relate it. Anyone out there who knows more, feel free to correct me because this is all brand-new turf for me. But here is the bare-bones version.

The patient's body temperature is cooled down to 60 degrees- at which point the brain is nearly completely inactive. The patient is then nearly completely exsanguinated in order to reduce the risk of a high-pressure bleedout when the aorta is disrupted. The affected section of the aorta is resected, and a large-bore graft made of synthetic material is carefully and meticulously sewn in. Once the grafting is complete, circulation is slowly restored, while the graft is watched for any sign of a leak. If no leak is found and the patient stabilizes sufficiently, he is closed up and taken to intensive care for monitoring.

Fifty percent of the patients who undergo the procedure die on the table. Of the survivors, a majority end up with renal failure and spend the rest of their lives on dialysis or looking for a kidney transplant. Many suffer brain damage of varying degrees. Some suffer catastrophic embolisms, strokes, and heart attacks. The other side of the surgery is not a pretty picture, unfortunately.

The patient in question made it through surgery. I am told that he did exceptionally well, that although he came out of it all just a little on the "goofy" side, that seems to be resolving. His kidneys were a little slow to get going again, but his creatinine is almost normal. I don't know if he remembers what happened.

But he's alive and doing well. You can all breathe again.

And regarding Nurse Dynamite: She's fine too. She says that this was a case that scared her. And when a veteran like her gets scared about a patient, you can bet that it's a close-run thing.

The Time Bomb

2007-04-04T19:59:00.000-07:00

It started innocuously enough.

A male in his mid-forties came to the ER because he had turned while lifting a box and felt a sudden sharp pain in his back. When he arrived at Triage, he was walking, talking, alert and oriented, and his blood pressure was high-normal. The front was full, but the Fast Track area had an open bay and there was nobody else waiting.

He was walked back to our Fast Track area and given a gown and a couple of warm blankets. Standard procedure is to strip a patient with back pain down to the skivvies in order to facilitate an assessment and x-ray (if needed) of the entire spine. It's a procedure that has helped us discover some pretty serious back problems in the past.

Well, we discovered something serious this time, too. And it had nothing to do with his spine.

On entering the patient's exam bay, the first thing I noticed was that the patient was looking at his legs. The second thing I noticed, having reflexively followed the patient's gaze, was the patient's legs.

The left leg was normal in color all the way down to the toenails. The right leg was pale blue and mottled, and his toenails were white.

Oh, crud, I thought.

You know that horror movie music that plays when the victim is chased into a hallway and sees a door, the monster is breathing down the victim's neck, and the hallway suddenly gets really, really, really long and the doorway gets farther away? You know, the music that accompanies the stretching hallway scene?

I call that music The Song of "Oh Crap" in D Minor.

And that ominous dirge was swelling in my ears as I rather begged the patient to lie on the stretcher- gently, please... for Pete's sake- GENTLY. I checked for pulses in both feet. The left foot had a good strong pulse. The right had none. I then laid my hand on the patient's abdomen and felt the peculiar, strong whooshing pulsation underneath my hand that I really hoped wouldn't be there but knew had to be. I could feel it all the way from the epigastric region to three finger-widths below the belly button.

Music swelling, hallway stretching, bad feeling getting worse...

I stepped away from the patient and his extremely bewildered wife and came as close to dragging a Medical Doctor into the room by the scruff of the neck as ever I could. In the seconds that transpired for the journey, I rattled off everything I knew at the speed of one of those disclaimer guys at the end of a car commercial.

I finished with "Take a look, Doc," as I knocked on the wall and swept the curtain aside.

The doctor introduced himself as he lifted up the blanket covering the patient's legs, and his eyes just about did that bah-WOOO-gah thing in the cartoons. He checked pedal pulses and asked if the patient was feeling alright. The patient said he felt fine other than the pain in his back and the numbness in his right leg. The MD and I excused ourselves and exited. My MD called the MD overseeing the trauma rooms up front, and I called the charge nurse and told her (as opposed to asking her) to clear a trauma room pronto, because my patient was coming in.

The charge nurse initially voiced her dismay at this rather abrupt breach in professional decorum. I cut her off (which I never would ordinarily do) and laid out the situation. She said she'd bump the asthmatic smoker into the hall for my patient, and to give her two minutes for the room to be ready.

Two minutes later, I was wheeling my patient into the trauma room. RNs and Techs swarmed the man, slapping monitor leads, a blood pressure cuff, and a pulse oximeter sensor on him. Capitalizing on the great big bulgy veins the patient had in his antecubital fossae, I shoved a 14-gage catheter into each arm. As we worked, the doctor explained the reason why we were moving so fast, and that a CT scan would tell the tale.

Fifteen minutes later the MD, Charge RN, ER Tech and I stood in the film room, staring wide-eyed and aghast at a monster. The source of the patient's back pain and leg numbness was a huge aortic dissection going almost the entire length of the patient's abdomen.

Ominous music getting louder, panic welling up in the throat...

The MD ordered meds to keep the patient's blood pressure down and immediately got on the phone with a local hospital that specialized in the procedure that this patient had to have if he was to survive the night. And that was a big, big if. While the MD made his connections, I did everything but pack the patient in egg crates- for all the good it would do if his aorta split open. If it happened, the patient would die within seconds and there would not have been a thing any of us could have done about it.

By this time, the patient and his wife were fully aware of what was happening. We told them the whole story, including the part about how he could simply start bleeding to death at any moment, and that he would barely have enough time to say goodbye before he was gone. Also by this time, the entire Emergency Department was electrified by the case. Everyone was hushed and tense. The other nurses gave me supportive pats on the back and looked after my other patients as I remained in the patient's room, watching for signs of sudden exsanguination as the patient and his wife quietly talked.

The wife had at one point called their children and told them to come to the hospital right now. Apparently, one of her kids balked and she snapped, "If you don't come now, you may not get to say goodbye!" All the kids were in the room amazingly fast. They were quiet, too, as if even a whisper would set off the bomb.

All this time, the patient was extraordinarily calm. Somber as hell, but calm. I am still amazed at his fortitude.

The Charge RN came in and told me that the Life Flight was enroute and to get the patient ready. The patient's wife collected her things and she and the kids left for the other hospital after saying their optimistic chorus of "See you later."

The chart was copied and everything was in order by the time we heard the first faint vibrations that increased rapidly to that distinct, chest-thumping, head-splitting thrum of the Agusta helicopter flown by the airlift team.

I waited with the patient in the ER entrance, shielding him from the rotor wash as best I could. The Agusta settled on its landing gear and the ear-splitting racket died down to the more tolerable roar of the turbine as the rotors lost their lift. The flight nurse (a 5'4" keg of pure dynamite and a dear friend of mine for many years) met us halfway out.

"Hey, Willster!" she shouted.

I patted her helmet and said, "Dang, I gotta get one of these! What's shakin', Bird Woman?" I then rattled off a fast report as we trundled the patient to the whirlybird with our backs hunched. She introduced herself to the patient with a bellow as I helped her get him into the aircraft. I shook the patient's hand and said, "She's the best nurse in the whole universe. You got the first team tonight, buddy."

"I know. Thanks for everything."

Smiling ear to ear under her big ol' helmet, Nurse Dynamite patted me on the cheek and shouted in my ear, I got him, sweetheart!

I scooted out of the helicopter and shouted "Away, flying nurse creature!" with a shooing motion. I scurried back out of the rotor wash as the Agusta's characteristic thunder again filled my brain with fuzz. As the aircraft broke ground, Nurse Dynamite waved. I waved back and walked back into the ER to call report to the receiving RN at the other hospital as the sound of the rotors rapidly dissolved in the cold night.

NurseWilliam Gets Thinking Blogger Award

2007-03-28T10:02:00.000-07:00

I have been by tagged by The Angry Medic for the Thinking Blogger Award meme. This is a singular honor for me, particularly since it comes from among my peers in the medical profession.

Here is the lovely emblem:

The award originated with The Thinking Blog.

In turn, I would like to tag the five bloggers who have given me the most food for thought:

Jennifer Gallagher of Now For Something Completely Different;

Stefan Sharkansky of Sound Politics;

Ed Morrissey of Captain's Quarters (whom I credit for getting me interested in blogging in the first place);

Hypnokitten and PaedsRN at Mediblogopathy;

And last, but certainly not least: The Cassandra Page

Note that not all of these bloggers focus on nursing issues, but they all do one thing most admirably: they make me think. Thus they are most worthy of this award.

Night of the Knotheads

2007-03-12T21:26:00.000-07:00

They came out without warning. They seemed to have been dumped off by the busload (both short and long). They clogged our ER triage area all night long with non-acute complaints. They also filled the ER treatment areas with the high-acuity consequences of their stupidity. They caused highly-educated and battle-hardened ER doctors and nurses to bang their heads against the walls in frustration and dismay. They became fodder for endless hours of break room stories for months to come.

The ER was awash in knotheads.

On the night about which I write, it seemed like the Great Big Knothead Circus had come to town, and one of those little clown cars had pulled up to the ER door and the knothead clowns just kept on pouring out. All that was lacking was the calliope playing that silly circus song. (You know the music, don’t you?)

Dee-dee doodle-doodle dee-dee dee- dee, Dee-dee doodle-doodle dee-dee dee-dee…

I felt like if the ER became a haven for the knotheads, my assigned rooms were Knothead Central. It was just wrong. Everyone marveled at how many stupid people decided to hurt themselves at the same time. It's as if they were doing their things and the Great Cosmic Knothead spoke to them all at once, saying:

"Okay, everybody! One, two, Three...!"

I can’t remember the last time that happened on a non-holiday, moonless weekday between paydays. It wasn’t Friday, so the psych units weren’t dumping their patients. Tent City was in a different part of town this month. Mardi Gras was long gone, and there was no WTO convention or peace demonstration going on.

I strongly suspected that some ER staff member had incurred the wrath of the overly-sensitive gods of emergency medicine by uttering the heretical words “Gee, it’s kinda quiet today.”

Behind Door Number One I had a teenage boy who decided to blow through a red light while flipping off a police officer who was at the same red light. He got so caught up in watching the police cruiser’s flashing lights in his rearview mirror that he forgot that it was rather important to watch where he was going. So he drifted off the road at around 50mph (in a residential area) and into a stand of new-growth alder trees.

This would not have been all that bad, had it not been for the fact that behind those spindly alders lurked a rather large old oak tree. We were going to be picking pieces of tempered glass out of his head for awhile, and he will henceforth have the smile of a hockey player.

Behind Door Number Two was the teenage girlfriend of the teenage boy behind Door Number One. Evidently, she dared her boyfriend to blow through the red light. So it is now proven that not all the stupid decisions of teenage boys are self-generated. It often happens that stupid teenage girls are behind them. She also had deep facial lacerations and a broken nose. I hope Mommy and Daddy can afford a plastic surgeon.

Oh, I almost forgot: both kids had alcohol on their breath.

Behind Door Number Three was the Queen of the Knotheads: a woman who had a history of anxiety, panic attacks, and chronic pain. She was also well-known among all the ERs in the county to be a malingerer and drug-seeker. Her primary doctor was an excellent physician who had a reputation for being careful yet effective in dealing with patients who had chronic pain issues. But evidently, my patient had taken umbrage with her physician’s caution. So on this day, she arbitrarily decided that her doctor did not prescribe enough methadone to cover her pain. One 10mg tablet of Methadone was not sufficient. (I’d have been intubated after taking that much.) So she took ten. When her “friend” (a scruffy-looking cuss if ever there was one) found her, he called 911. The medics found her in complete vascular collapse and respiratory arrest. They could not find a vein. So they punched a 16-gage intra-osseous (IO) needle into her right tibia and pumped 2mg of Narcan into her while bagging her on 15 liters/minute of oxygen. As if on cue, she snapped back into our world in less than a minute.

When she arrived at my ER, she was agitated and begging for Ativan. “Pleeeeeeeeeze give me Ativan,” she whined. “You have to give me Ativan! I have a history of seizures!” She kept thrashing that leg with the IO needle in it. I got in her face and made her look at me.

“Take a look at your leg,” I said firmly, "Look at your leg right now." She looked at her leg. “Do you see that thing sticking out of it?”

“Yes,” she replied.

“That’s a great big honking needle that goes right into your bone. If you bonk that against something, it’s going to HURT. And if you knock it out of your leg, it will HURT and it will BLEED a lot. Savvy?”

She looked at me defiantly and declared, “I will calm down if you give me Ativan. I need it. I have a history of seizures!”

Oh, yeah, lady. Hurt yourself. That'll teach me, I thought.

I found it hard believe that she did not recognize me, because I had been her nurse on many of her previous visits to my ER. And she was alert and oriented to person, place, time and situation. She was pretending not to know me. But I sure recognized her. And I knew her long, long history of visits to the ER (more than twenty in the last 12 months, either for “pain,”,“anxiety,” or because she "just had a seizure"). She did not have a history of seizures. She had a history of benzodiazepine abuse. (Ativan is a benzodiazepine.)

She was squirming, whining and kicking, and that IO needle had to stay in her leg, so we put her in restraints per MD order. She of course did not like that, and asked us to please give her Ativan if we were going to do it. The MD told her that considering she had overdosed on narcotics, it was necessary to keep her conscious and alert. Therefore, Ativan was out of the question.

“But I have a history of seizures!” the woman whined.

The MD looked up from a sheaf of papers and replied, “No, you do not have a history of seizures. I looked at your history and nowhere in there is a single seizure documented.”

“Well, my boyfriend (the scruffy gent) saw me have one!” The MD and I looked at the boyfriend, who suddenly developed an acute interest in something on the floor.

“OK,” the MD said with a grin. "I see you go to Medical Associates.” The MD looked at his watch. “They’re still open. I’ll give your doctor a call and ask him about your history of seizures.”

“He won’t know!” the woman shot back. "He doesn't know what he's talking about!"

The MD flipped once more through the patient’s history that he had printed out before coming into the room. “You have been seeing Doctor So-and-So for more than three years, according to our last encounter less than a month ago. That's a long time to stick with a doctor who doesn't know what he's talking about.”

“Please.” The patient pleaded, evading the challenge. “I need Ativan to calm down. I promise I’ll be still if you give me some Ativan.”

“Nooooo, I don’t think so,” the MD said with a smile and in a wickedly smooth tone as he shook his head. “We’ll take the restraints off as soon as we can, but we have to make sure that you can stay calm first. But I am not going to give you any Ativan since you just nearly killed yourself by taking too many narcotics. We have to keep you awake and alert.”

The MD turned, signed off on the “restraint order for medical necessity” form, wrote for a bolus of one liter of warm normal saline through the IO access and for a new IV line to be started ASAP, to be followed by the removal of the intraosseous needle. Sure enough, the patient was able to stay calm in spite of the fact that we had not given her any Ativan. She never so much as gave a twitch. We were able to remove all the restraints within the hour. I started a peripheral IV and removed the IO needle without incident. I then called report to the Progressive Care Unit RN and get the patient ready for transport upstairs.

While at the nursing station, I sat next to the MD as he called the patient’s doctor and talked to him about our patient. I could clearly hear her physician shout “She did what?!” through the phone and our MD caught my upraised eyebrow. Our MD then asked about the patient’s statement regarding a history of seizures and apparently got an earful of spleen-venting from the poor guy. After saying, “Uh-huh,” “I see,” and “Well, that’s good to know” a few times, our MD thanked the patient’s doctor for his time and hung up. He then drew a deep sigh, rubbed his eyes, and then related to me how the patient’s doctor explained the whole “seizure” thing.

At some time in her past, when she had collapsed after an overdose of some unknown drug, her “friend” told the EMS responders that he saw her twitch a couple of times and that it must have ben a seizure. Subsequently, every neuro test in the book was done, and at no point was anything found to be indicative of seizures. Yet the patient had been claiming to have seizures ever since as a means to scare ER doctors into prescribing Ativan, which the patient’s physician refused to prescribe without objective data to support her claims- much to his credit. But since then, she has been hopping from ER to ER in search of a doctor- and a nurse- who hasn't met her yet. And even if she doesn't find one, she'll pretend they never met.

The patient never got her Ativan. She got sent upstairs, relapsed, the Methadone outlasted the Narcan, she got more Narcan, and when the Methadone finally wore off she ended up being discharged the next day. She’ll probably be shopping for a new primary physician after this.

The ER treatment room she vacated was filled with another knothead before I even got back from transferring her upstairs. The new patient, a leathery-faced 32-year-old woman who looked all used up, was a GDFD (Got Drunk, Fell Down) from one of the local taverns who did a faceplant against a barstool. She had a 7cm full-thickness laceration extending from above her right eyebrow well into her hairline. The slick, white connective tissue covering the skull was laid bare underneath. She was a bloody mess, and of course- lucky me- she was also belligerent.

Great fancy Moses, I thought. It's not even 10 PM yet! I sighed, picked up her chart, and walked in.

Dee-dee doodle-doodle dee-dee dee- dee, Dee-dee doodle-doodle dee-dee dee-dee…

For All the Marbles

2007-02-26T18:13:00.000-08:00

Sometime around 2AM a couple of weeks ago, a woman came into the ER complaining of nausea and epigastric pain that went up into her left chest and shoulder. She was old enough to be in the prime age group for heart attacks, and she was having a couple of the symptoms that make us a little nervous. That was reason enough for us to suspect that she was having a heart attack.

Remember the ER chest pain creed, kids? Come on, say it with me... "Every human being who comes through the door is having a heart attack until proven otherwise."

Well, okay. Not every human being. I would exclude those who have not yet been born, and those who have already died. All others are suspect.

Well, guess what? The woman was having an antero-lateral wall ST-elevation myocardial infarct (STEMI). For the laypersons out there, that means the front/side part of the woman's heart muscle was dying because of lack of oxygen. When that happens, it friggin' hurts.
And after 3 spritzes of sublingual nitroglycerin, 325mg of aspirin, the start of a 10mcg/minute nitro drip, 12 mg of Morphine, and 5L/minute of oxygen, the woman was still having 10/10 crushing chest pain. Nothing was helping.

I was just getting ready to place a Foley catheter when I looked up at the patient's monitor and saw her go into what looked like ventricular tachycardia. The patient immediately lost consciousness.

At a loss for words, all I could do was slap the MD on the shoulder with the back of my hand and say "Hey!" as I directed his attention to the monitor.

Okay. I admit it isn't as sexy as saying, "Doctor, I believe our patient has gone into ventricular tachycardia," but it got the job done.

The MD said "Oh, crud," and stepped over to the patient as I moved over to the defibrillator, to which the patient had already been hooked up. After feeling for the patient's femoral pulse, he looked up at me and simply said, "shock her."

I hit the "charge" button on the machine and it made its usual bwooooooooop, rising in pitch until 200 joules (biphasic) was reached. Then it made an irritating warble that could have made Helen Keller wince. The machine was ready.

"Everybody clear!" I barked. Everyone jumped back from the patient and I hit the "shock" button.

Clunk.

The patient jumped, her arms and legs snapping outward. Her heart, having been dope-slapped, decided to get back with the program. That little rhythm strip at the top of this post shows what the defibrillator captured.

Turns out the rhythm was not V-tach, but Torsades de pointes. That's a lethal arrhythmia often talked about, but seen rarely. (Some medicos have never seen it in their entire careers, I am told.) The term is French, and it means "twisting of the points." Click on the picture. If you look closely, you will note that the points of the short, fast waves on the strip appear somewhat twisted around themselves- hence the name.

Be that as it may, the patient's heart found its way back into sinus rhythm, and the patient woke up within seconds afterward.

"How do you feel?" The MD asked.

The patient looked around foggily for a second or two, and finally said, "My chest pain is gone."

"Well, there you go," the MD said.

The patient was hastily packed up, shipped off to the cath lab, had her right coronary and left circumflex artery roto-rootered out, and made a quick recovery. She'll be fine.

That's what it boils down to, folks. Years of education, further years of experience, and hundreds of hours more of training are all packed into what totalled a mere ten seconds of time.

Yeah. It happens that fast. No Hollywood gomer can wrote this stuff. It just happens.

And you know what? I felt pretty damn good walking to my car after that.

The Stupid Awards, Inaugural Edition

2007-02-19T22:32:00.000-08:00

The prizewinner of this week's Stupid Award is a Hispanic woman who brought her child to the ER three times on the same day. The kid had a viral upper respiratory infection and the family's clinic was closed. The first time in, the kid got a chest x-ray (which was negative), a Rapid-Flu nasal wash (which was also negative), and a Rapid-RSV screen (which was also negative). Although the illness was viral, the mom demanded that her son be given an antibiotic. The MD refused. The kid was given Tylenol for a low-grade fever, the family was given a recommendation for an OTC cough suppressant, and the family was sent home with supplemental written discharge instructions in Spanish. She left muttering something in Spanish.

By the way... Who is Ben Dayho?

The second time in, about five hours later, the mother was upset because the kid's fever came back and his cough had not gone away immediately after she gave the kid the OTC cough suppressant; she was also upset that she had to wait to be seen. She was informed that Tylenol can be given every 4 hours, as her previous discharge instructions clearly stated. The MD wrote a scrip for a cough medicine containing phenergan and codeine and the woman was instructed by the MD through a Spanish medical interpreter about how and when to give it. Once again, supplemental written discharge instructions in Spanish regarding the prescription cough medication were provided.

The third time around, about four hours later, they came back. This time, the kid was carried in his dad's(?) arms, while mother stormed angrily into the ER ahead of them. The kid's head was lolling back and forth and his eyes were staring dazedly off into the great whatever.

When questioned, Mother stated that she had given the phenergan/codeine cough medication as prescribed. But when the cough did not go away after a half-hour, she gave him another dose, because the kid's coughing was keeping her awake. A half-hour later, the cough was still there, so Mom gave the kid a third dose. Without a pause, she then accused the MD of writing a prescription for too weak of a dose. Mom found the kid curled up in a ball on the floor in front of the bathroom.

The kid was simply stoned out of his gourd. He turned out fine. Mom, on the other hand, won a complementary chat with the social worker and an expenses-paid referral to CPS by the MD who had seen her all three times and had at last grown weary of Mom's BS.

Let Me Re-Phrase That...

2007-02-14T17:19:00.000-08:00

Language is the capital that drives the economy of human communication. Each social or professional culture presides over its own unique lexicon. The observer will also note further subdivisions related to slang or specific specialty.

Nurses and physicians often use abbreviated terms among ourselves. We do this for two reasons:

1: It saves time;
2: The other person knows what we are saying (as long as the speaker is not just making something up in order to sound cool, which happens from time to time).

But I was reminded this week about how easy it is to fall into the terminology rut in front of patients, and about how important it is to communicate clearly and understandably with my patients. It was a simple matter, really, and not life-threatening at all; but the misunderstanding between the patient and her nurse (yours truly) might not have happened had I been more careful. And I would not have become fodder for the comic enjoyment of my fellow nurses.

The patient came in during the "dinner rush" (between 6PM and 11PM) complaining of bilateral lower abdominal pain. She was well within childbearing age. She was also suffering from a self-care deficit which was related to her lifestyle choices. She had a poor grasp of basic concepts related to her health and hygeine (namely, bathing). Her ability to communicate her chief complaint and her history was poor. Her education level was poor.

The standard practice related to any woman of childbearing age who presents in the ER with a complaint of lower abdominal pain involves ruling out female disorders such as ovarian cysts, pelvic inflammatory disorders, and so on by means of a pelvic examination. (We also perform other tests and draw blood to rule out other possible differential diagnoses.) In my ER, we have many beds available than are designed to facilitate pelvic exams. Unfortunately, my patient was not on one of them. I finished my nursing assessment of the patient and then called an ER Tech over. Then I spoke the words that set the scene about which I now write.

I told the tech, "The patient needs a pelvic stretcher."

In front of the patient.

The patient's lack of understanding related to my terminology was evidenced by her sitting straight up in bed and bellowing, "THE H*** I DO! YOU AIN'T GONNA STRETCH MY PELVIS!

The following silence was oppressive. I heard a snicker from the nurse's station.

I turned to the patient and calmly explained to her what a pelvic stretcher was. She straightened her blankets, tossed her hair, and said, "Well, alright then."

I had a very hard time summoning the courage to exit the patient's room and walk red-faced to the nurse's desk, where I was greeted by hoots of laughter.

I don't know if this could have been avoided, but it reminds me that I need to be more careful about what I say in front of my patients. Very humbling, indeed.

For Nurses: A Great New Online Forum

2007-02-02T13:59:00.000-08:00

I tend to avoid advertising on my blog because I dislike clutter and do not wish to bombard my dear visitors with extra stuff. However, when I see a good thing I like to let my readers know about it.

As a nurse, I look for online forums in which I can connect with other nurses in a professional and collegial atmosphere. I envisioned the ideal nursing forum to be free of clutter, easy to navigate, and without any of the trashy advertising and sexual overtones that are so prevalent on sites such as MySpace (which I detest). I had yet to find that ideal forum and was tired of other nursing sites that seem to have devolved into forums for debate on such merry-go-round issues as whether or not nurses should revert to wearing starched whites. I had essentially given up on my search.

Until now.

Allow me to introduce NurseLinkup, a brand-new online community and forum for nurses. It's free, it's easy to navigate, and it appears to focus on issues and discussions that are driven to enhance nursing knowledge and to strengthen collegial communication among nurses. The site allows for blog posting, internal communications, email, and chat. It also allows for total privacy of information should the nurse so desire. And it is free of charge.

If you are a nurse who is looking for a better way of communicating with other nurses, I invite you to take a look at NurseLinkup for yourself.

Famous Last Words...

2007-01-23T23:52:00.000-08:00

He came in at 1 in the morning, and I triaged him. His chief complaint: "Well, my chest kind of hurts, and my girlfriend made me come in." His girlfriend sat next to him, appearing fretful and unhappy. The patient was a 37 year old who appeared to be in general good health.

I was tired. It had been a long shift so far, having been spent sticking IVs into dehydrated babies suffering from GI bugs that have been particularly vicious this year. I was shipping demented elderly people to the floor at a record pace, and the nurses in MedSurg were threatening to form a lynch mob. I was 9 hours into a 12-hour shift that I worked because my opposite has decided to break his leg skiing.

But medical emergencies don't care how tired or busy I am. My triage assessment had to be thorough, and that meant that I had to elicit as much information as possible in order to find out what was really going on. I've been doing this long enough to suspect when a patient was not giving me the whole story, and I could tell that this guy was not being very candid about what was going on. Generally speaking, when a patient evades the questions it is likely that either the patient was doing something he should not have been doing, or he is in denial of an emergent problem. So we went through the sparring ritual at triage, with me probing and he evading while his girlfriend fretted on.

The training that has been pounded into my brain took over as I attempted to classify the patient's chest pain. Is this a heart attack, a pulmonary embolism, a bad gall bladder, gastroesophageal reflux, an anxiety attack, or what? I'm trying to get as much information from the guy as I can, but he is not helping.

The patient's vital signs were stable. He was not sweaty, he was not clutching his chest, and he did not appear anxious. Finally, agitated with her boyriend's evasiveness, the girlfriend could stand nor more. She interrupted him and told me: "His brother had a heart attack when he was 35, and his dad had one when he was 36."

This guy was 37.

Uh-oh.

In that instant, the lesser possibilities were automatically disqualified and I began to operate on the assumption that this patient was having a heart attack.

Now let me acquaint the reader with a big fat truth. If you have a heart attack, it may not necessarily feel like your textbook heart attack. You know, the elephant on the chest, the sweating, the horrible left-sided chest pain that radiates down the left arm and up into the left jaw. People are all unique. While that's a beautiful altruism, the fact also makes my job a lot more challenging.

I had one patient whose only symptom was a severe case of the hiccups. He was having an acute myocardial infarction (MI). I had another MI patient who simply fainted. I had yet another who had pain in both elbows. Diabetic patients often feel no pain at all (called a "silent MI"). These seemingly innocuous manifestations and vague complaints are why thorough patient assessment will always be at the top of the Challenge-O-Meter.

This is also, of course, is why ER nurses tend to jump all over a patient and stick monitor leads and IV lines in them in a hurry any time someone verbalizes symptoms that trigger our alarms- which is exactly what I did to my patient within 0.5 seconds of his girlfriend's statement.

In the Museum of Famous Last Words, three words are at the center exhibit. Here they are:

"It's probably nothing."

(Hah. I bet you thought it was "Hey, watch this." Those actually run a close second.)

And guess what the patient snapped at his girlfriend when she interjected?

"Stop it! It's probably nothing."

But with his familial history, my suspicion index was going bonkers and I was not about to be caught flatfooted if it turned out to be something. So I unceremoniously took the patient back to a cardiac room (dragging a bewildered ER Tech with me) had the patient strip out of his shirt, and slapped the blood pressure cuff, pulse oximeter, and the cardiac monitor leads on him. The patient shot his girlfriend a "see what you did?" look, but cooperated.

Now, a note on the 5-lead cardiac monitor: In terms of monitoring heart rhythm, the 5-lead monitor is great. But for diagnostics, it's like taking a picture of the Grand Canyon using the camera on your cell phone. It's informative, but not precise. So I ordered the tech to do a 12-lead.

The plot thickened.

The patient had some suspicious aberrations in his inferior-septal EKG tracings. That means that the electrical impulses that travel through the part of his heart containing the SA node (the natural pacemaker) and the AV node (which regulates the ventricular contraction) were not traveling as they should. The artery that supplies these parts of the heart may be occluded, and if that part of the heart dies, the result is a "negative patient outcome" (i.e., death). Furthermore, if that region is affected, the patient may not show classic signs of cardiac injury. Isn't that encouraging?

I know that alot of this is arcane to the reader who is not well-versed in heart attacks. Suffice it to say that I was not reassured in any way after looking at the EKG. Could it be that he was having a heart attack? Maybe. But then again, maybe not. But again the old adage applied: when in doubt, assume that the patient was having a heart attack. I was not reassured at all when I showed the MD the 12-lead, and he became immediately suspicious and got on the phone to the on-call cardiologist right now. Meanwhile, I stuck an IV into him and drew blood for more tests. I tossed 325mg of aspirin down his throat. I put him on 4 liters of oxygen.

With every minute that passed waiting for lab results, the patient became more and more impatient. And he was still not communicating his symptoms. We found out that the patient was again having chest pain only because his girlfriend came out and told us. When she did, the MD and I rushed in. I did another 12-lead EKG and as it spit out the results, the top of the page had this:

************************************* ACUTE MI **************************************

I was not reassured.

The cardiologist arrived and reviewed both EKG results with the MD, and then strode into the patient's room and informed him that he was going to be admitted to the CCU and would be going to the Cath Lab for angiography.

"Oh, no I'm not! I have to be at a meeting in the morning."

"Sir, you are having a heart attack."

"I feel fine. You don't understand- I have to be at this meeting. My business depends on it. It's not an option."

"No, sir, you don't understand." The MD countered. If we don't fix this problem right now, you will probably miss your meeting anyway because you will be dead.

The patient opened his mouth to say something to the MD, thought otherwise, and then turned on his girlfriend. "Thanks a lot! None of this would have happened if you'd have just SHUT UP!"

"I don't want you to die," she answered weakly.

"I'm not going to die! I'm FINE!" The patient turned on the ER MD. "You can't keep me here if I don't want to be here."

"That's true."

"I don't want to be here. Take this stuff off of me NOW. I'm leaving."

The girlfriend stood and declared, "If you leave you'll be walking home, because I won't drive you."

"FINE!" the patient roared. I caught the girlfriend's attention and motioned her out of the room and into the waiting area. She turned to me with tears in her eyes.

"I don't believe him! He's in total denial of this. How can he be so stupid?"

"I can't explain his attitude; but I can say that bringing him in was a wise choice on your part. Right now, the most important thing is to keep him calm. Getting angry is the worst thing he could do. How well do you know him?"

"I've been with him for a little over a year."

"Is he under any stress?"

The woman threw her arms up and said, "Oh, yeah! He works two jobs: He owns his own construction company but he's also the top loan officer for a mortgage company. He's their Golden Goose. He works constantly, and he never lets up." She paused, then added: "He has a lot riding on that meeting. Could he really die if he goes home?"

"Yes, he could."

"If he could possibly die, can't you keep him without his consent?"

"Not in this case, no."

"I have to talk him out of leaving," she concluded. I put both hands up.

"No, ma'am. Right now, we need to get him calm. Can I offer a suggestion?"

"Sure. I'm all out of ideas with him."

"Just have a seat in the waiting room for a little while. Let me get you something to drink. Getting away from the room will help both of you to calm down right now. Do you agree?"

"Yes."

I heard commotion in the treatment area, and a lot of feet. I excused myself and rushed to the patient's room to find him ashen, sweaty, and limp. His monitor showed a disorganized and slow rhythm. He was in full heart block, meaning that the connection between his SA node and AV node had been completely severed by the injury to his heart.

Oh, crap.

I joined the rest of the code team and slapped the pacer pads onto the patient, hooking it up to the defibrillator. The MD ordered sedation, which another nurse was in the process of giving. As the patient slipped out of consciousness, he slurred, "Stop it. I'm fine."

The MD looked at me and rolled his eyes. "Famous last words."

After the patient was unconscious, we managed to "capture" his heart and pace its rhythm. His vital signs began to stabilize, and we all started to breathe again. I prepared the patient for transfer to the Cath lab and gave report to the receiving nurse.

As the Cath lab team pushed the stretcher down the hall, I turned and found the girlfriend beside me.

"I'm sorry I couldn't come get you sooner," I said. "Are you going to be okay?"

She sighed. "Yeah. I'm glad it happened this way. Is that wrong?"

"Well, for what it's worth, I would rather he did it here than at home."

The woman paused and then asked: "Is it my fault that he got upset and his heart attack got worse?" She lowered her head and looked at the floor.

I turned to face her and told her, "Look at me." When she met my gaze, I continued: "Consider the possibilities. What if you had not brought him here? Upset or not, it's likely that if he was not here, he might be dead right now. So you tell me: was bringing him in worth making him upset?"
"Yes," She replied. She began to cry. "He's never snapped at me before like that."

"I can't give you an answer for why he did," I said, handing her a box of Kleenex. "You know him better than I do. But I've seen alot of people who come in with heart attacks who refuse to believe it even when they can hardly breathe and the staff is swarming them. It is a frightening thing to face, and people respond to the prospect of mortality in their own ways."

I then asked, "Would you like to go to the Catheter Lab waiting room and wait for him there?"

"I'll go there. How long will it take?"

"Maybe a half hour to an hour. I'll call over so the team will be expecting you, and I'll have one of our Techs walk you over there. I have to finish charting, so I'll say goodnight now."

She extended her hand. "Thank you. You all were very good with him."

"It's our pleasure. Try to get some rest, Okay?"

"Okay."

I found an available Tech to escort the woman to the Cath Lab and turned to the arduous business of documentation so that I could run the chart over to Cath Lab quickly. As I sat down, I looked up at my watch: two hours more, and I would be off. I stretched, yawned a long and obnoxious yawn, and set to work.

Hey, We Can Fix That.

2007-01-20T13:34:00.000-08:00

The ER is a complex and challenging environment where success is not always achieved, and where futility rears its ugly head far more frequently than we would wish. In such an environment, the quick successes can often have the effect of restoring confidence, especially after a long string of difficult cases where success has been elusive. The confidence factor is magnified when the case involves a scared patient with a heart that has decided to do its own thing.

I arrived for the beginning of my shift and received report from the offgoing RN about a patient who had just arrived in one of my treatment rooms. He was an otherwise healthy middle-aged male who came to us with a complaint of dizziness and a "really weird feeling in his chest." An EKG revealed atrial fibrillation, a condition in which the atria of the heart stop working in a organized fashion and simply begin quivering. The condition is dangerous because it can cause clots to form in the left atrium, which can be "sprayed" into the left ventricle and thus to the the rest of the body, leading to heart attack, stroke, pulmonary embolism, or kidney infarct- none of which are happy things. Both the patient and his wife were highly apprehensive, to say the least- and certainly appropriately so. In such a circumstance, it is important for us to establish the patient's and family's trust that we knew what to do, how to do it, and where to start.

I swept into the room with an ER Tech at my heels, exuding confidence and optimism. I wanted the patient and his wife to get the message: This guy knows what he's doing. I made a point of clearly explaining everything I was doing and why I was doing it. I have assisted with synchronized cardioversion many times, and I made sure that the patient and his wife were as comfortable with the process as possible. I made sure they had no doubts that this stuff is our bread and butter. The whole team was on the same page, and the MD running the procedure is top-notch. He's brilliant, he's personable, and he is a pure joy to work with.

I should mention here that when the members of a team are familiar with one another and they have a mutual high professional regard for each other, it is pure magic. It is simply thrilling. There is no easy way to describe it, and the word chemistry is overused in my opinion, but when that strong professional relationship exists, the patient notices. And the patient saw that the MD, the ER Tech, and I were completely "dialed in on each other" (his words).

That goes a long way toward alleviating some of the patient's apprehension, especially when his life is literally in our hands for a split second. During a synchronized cardioversion, the patient is literally one push of the button away from meeting his Maker. If the timing is wrong, we will stop his heart. Technology removes some of the dicey aspects of the procedure, but there is always that chance...

Synchronized cardioversion is a fancy way of describing shocking the heart into a normal rhythm. We don't smack the heart with alot of energy, but just enough to get its attention. But the tricky part is the timing. It has to be done exactly when the ventricles contract. Otherwise, we put the heart into ventricular fibrillation- that means death, which is what we euphemistacilly refer to as a "negative patient outcome." As I mentioned, our machine is able to hold off delivering the charge until it senses the ventricular contraction- that's the "synchronized" part of cardioversion. Better living through technology, eh?

Finally, the forces are gathered around the patient. He gives his wife a kiss. Respiratory therapy is present just in case we need to intubate or if the patient needs to have assistance with breathing. I drew up 15mg of Etomidate, a potent sedative agent with a very short half-life. The drug stays in the system for a mere 30 seconds. After that, the patient wakes up almost immediately. So I have to "slam" it, meaning I push it as fast as I can, but not too fast since it can burn like a mother.

The MD gives me the nod. I push the Etomidate. Ten seconds pass with no response. The patient says, "I'm still here, guys."

Then he is out. Just like flipping a switch. The MD makes sure the patient is unconscious, then he pushes the charge button and makes certain everyone is clear of the patient. The machine emits a beep that rises in pitch, and when fully charged and ready, it emits a noxious warble. The MD pushes the Shock button.

Clunk!

The patient's body jerks with the energy, then settles. All eyes are on the monitor. The patient's heart settles from its previous chaotic rhythm to a normal one. Twenty seconds have passed.

The patient's eyes begin to flutter open. As if on cue, he shakes his head and says, "I'm ready when you are, guys."

I tell him, "We're done."

"You're kidding," he said, incredulous.

"Nope. Take a look," I replied, directing his eyes to the monitor. "You're in sinus rhythm. Nice and normal."

He breathed a huge sigh of relief. His wife came to his side and kissed him on the cheek. They were both tearful with relief.

I finished charting my procedural assessments and asked if they needed anything else. They did not. I discontinued the monitor when appropriate to do so, cleared away the extra paper, and left the room.

It's nice to have one we can fix once in awhile.

Weather Idiots, Part Two

2007-01-16T21:06:00.000-08:00

I posted a month ago about Seattle drivers who simply were not meant to go outside any any but the most mild weather, and even then only in the kind of cars that have external airbags. Apparently, Portland (Oregon) has its share of weather idiots, too, as evidenced by this video from KING 5 News. Enjoy.

The Family Fun Pass

2007-01-13T20:09:00.000-08:00

I just love it when people get angry at me for telling them they can't circumvent the rules and that they must play fair. It makes going to school for all those years feel so worthwhile.

I had a whole family come in recently: two little destructive spawns of Satan, their unhygienic-looking parents, and the patient who was apparently the matriarch of the family. She had begun feeling poorly over the last two days. Small wonder; she had COPD, heart failure, renal insufficiency and diabetes.

The triage tech walked them all past the nursing desk in my section. I heard the two children roaring and bawling like a couple of sawed-off soccer hooligans all the way from Triage, and looked up from my charting in time to see the mom put her cell phone to her ear and start chattering.

"Ma'am, you can't use your cell phone in here. Turn it off, please." I said to her politely but firmly. She shot me a dirty look, rolled her eyes and kept talking as she passed by. Fortunately, our security guard saw the whole thing and blocked the woman's path. She snapped, "What?"

"You were asked politely to turn off your cell phone, Ma'am. Please do it now."

"What's the big deal?" snorted the woman.

I answered, "Other than the fact that it is posted plainly on the entrance to the ER, it interferes with our telemetry equipment. Please turn it off. Now."

"Just a minute." She turned away and continued to talk on the phone. The security guard faced her once again, deftly took the phone out of her hand, turned it off, and handed it to her. The woman, whose husband had now joined her, voiced her dismay in rather unladylike language. The husband asked me in a challenging tone, "What's the deal, man?"

The security guard (who was just shy of being as tall and solid as Mount McKinley) replied with a smile, "The deal is that if you do not obey the safety regulations of this hospital then you will have to leave... Man." The man (who had no business challenging a guy who could break him into kindling with his eyelids) took his wife by the elbow, shot the guard a sour look, and disappeared into one of my assigned rooms behind the wheelchair-bound, hunch-backed, hacking old woman and the two little hounds of hell snapping behind her.

Oh, this is just prime, I thought. The ER tech hurried out of the room a minute later, handed me the chart while guiltily averting her eyes, and flung the word "Sorry!" over her shoulder as she retreated toward Triage.

Under normal circumstances, I really don't mind having family in the same room as the patient; even a comparatively large family does not bother me if the room is large enough and if they are well-behaved. But I could already tell that this was not going to go well for me if these people continued as I suspected they would. And the closer I got to the entrance to the room, the more my suspicions were confirmed. Just before I knocked on the doorjamb, I heard the man say "Please don't touch that, Satchel. Please behave and come sit by Daddy."

Of course, Satchel ignored Daddy. He instead shouted "No!" and dumped what he was touching- the stainless steel Mayo stand- over with an almighty crash. The little girl screamed and Mommy scolded lil' Satch with a sarcastic "Do you feel better now?"

I decided that now was as good a time as any to make my appearance. Knocking on the jamb, I parted the curtain and introduced myself.

"Oh, it's you," the mom sneered.

"Yes. I am assigned to this section, and I am going to be the nurse for-"

"Where's the doctor?" the dad demanded, cutting me off.

"He's with another patient and will be in after I perform my assessment." As I turned to the patient, the mom said, "Since we are already here... our kids have been sick the last day or so and I'd appreciate it if you could check them out, too." These were the same kids, of course, who had been running and bellowing around the Triage area for an hour and making life miserable for everyone else in the room.

I turned to her and said "No, ma'am, I will not." The woman looked as if I had slapped her.

"Well, why not?!"

"If you want your children to be seen, you will have to take them out to triage and have them checked in, and wait for them to be seen."

"But we are already here!" She insisted. Why can't you just look at them?"

"Because, ma'am, that would be allowing them to go ahead of patients who are still waiting in the triage area to come back to a room. That's not fair. And except in an emergency, I won't see them before they are triaged."

"It's not my fault that they aren't back here. We're already in here, and so I don't understand why you can't just be nice about it and look at my sick kids. Just triage them here," she said, throwing her hands up in exasperation.

"I will not. You have to go through triage like everyone else. I can tell right now just by observing their, ah, activity, that they are actually doing quite well."

"You mean we have to go all the way back to triage and wait in line?"

"That is what I have been saying, ma'am, yes."

"You are such a selfish ass. If you're like this with your patients, God help them." the woman hissed. She stood up, grabbed her kids and dragged them out of the room. The dad stood, glared at me, and followed his wife.

I turned to the patient at last, and she looked up with tired eyes, her lids heavy, like tired water balloons, from fluid overload. She raised a hand to my cheek and patted me softly.

"Thank you."

A Most Unusual Demise

2007-01-04T14:27:00.000-08:00

I reconciled myself to the reality of patient death a long time ago. I came to realize fairly early in my career in the Emergency Department that as hard as we try, we cannot “cheat” death. We can put it off for awhile; we can even snatch a patient out of its very jaws from time to time, and pat ourselves on the back for our determination and ingenuity; but once a person crosses a certain point, there is no hope of bringing that person back. Sometimes the patient’s body shuts down in a manner so baffling that it may only be encountered once in an entire career, or perhaps only read about in a medical journal. This is the story of such a patient. She happened to be the first patient demise of the year at my hospital, and she also happened to be my patient.

At 6:45 PM on January 1, I dashed in the dark through a stinging, wind-driven rain toward the staff entrance of the Emergency Department. I was working a 7 PM to 5:30 AM shift after four day’s rest. The often-tremendous challenges of the holiday shifts behind me, I was eager to get back to work. This was an extra shift for me that I had volunteered to work some weeks before. Since the shift was classified as “high-need,” an attractive pay incentive was involved. The extra money would help to pay off some of my Christmas debt, so I jumped on the opportunity like a starving chicken on a Japanese beetle.

Convinced that I had filled my personal quota of the oddball cases peculiar to this time of year, I was eager for a return to normalcy (or as close to such as can be imagined in a busy emergency department serving a large population). The diminishing number of assault victims, alcohol-related injuries, suicide attempts, and panic attacks coming to the ER indicated that visiting relatives were now leaving town.

In my experience, the lower-acuity cases tend to stay home on New Year’s Day; they don’t want to miss the Bowl games. (Sometimes, even the very ill will wait. A few years ago, I cared for a patient with acute appendicitis who had delayed coming in because he did not want to miss watching his team’s bowl game- a deferral which very nearly killed him. His appendix ruptured at some point during the game and he was in septic shock by the time the medics brought him in. He ended up undergoing emergency surgery and spent a week in the Critical Care Unit and another week on the Medical-Surgical Unit. To add insult to his injury, he was delirious during most of the game and doesn’t remember watching his team win a nail-biter in the final seconds.)

Thus, we braced ourselves for the sudden influx of patients that invariably occurs soon after the conclusion of each game. I was pleased to note that I was assigned to my favorite section, which included one if our resuscitation rooms. I received report from the day shift RN and assumed nursing care for a patient waiting to be transferred to surgery for an emergent appendectomy, and for an elderly woman with pneumonia and mild heart failure who was to be admitted to the Medical Unit for treatment. My nice, ordered world came to an abrupt end when we received a call from an incoming medic unit at 8:20.

The medics were bringing in a 32-year-old female who had been complaining of shortness of breath and general malaise for the last few days. She happened to have also been smoking cocaine and shooting black tar heroin all day. She had been staying with a friend, who called 911 when the patient suddenly became extremely agitated and began coughing up blood and crying “I can’t breathe! I can’t breathe!” By the time paramedics arrived on the scene, she was in respiratory arrest. They inserted an endotracheal tube within minutes, and began bagging the patient with great difficulty. It took a lot of effort to get any chest wall expansion. They suctioned her and observed bright red blood- and lots of it. Hearing no lung sounds, they suspected a tension pneumothorax and inserted large-bore needles into the patient’s upper chest on either side of her sternum. They again noted bright red blood. They put her on the stretcher and initiated transport, at which time they called my ER to give report.

I began setting the resuscitation room up to receive the patient, having asked the Unit Coordinator to page the Respiratory Therapist to come to the room with a ventilator. Five minutes later, the medic unit called to inform us that they had initiated CPR. The MD ordered the Unit Coordinator to call a Code Blue in order to get the necessary people in place ahead of the patient’s arrival, and paged the duty cardiologist- who this night happened to be one of our most brilliant and experienced doctors, with three decades of experience. Within minutes of the call, every essential person was gowned up, gloved up, masked up, and in position. As primary nurse, I stood at the head of the empty stretcher with a clipboard and triage sheet in hand. My role was to take report from the medics and oversee all nursing interventions. Looking around the room, I saw that all of the necessary equipment was broken out and ready: the suction tubes, orogastric tube, Foley catheter, monitor lines, thermometer, IV tray, fluids, ventilator, and crash cart were arrayed around the bed ready for use. Two veteran ER nurses and two ER Technicians stood by to assist me. At precisely 8:35 PM, the patient arrived.

The moment the patient arrived, every person in the room was simply aghast. Of all the patients I have seen in clinical death, this woman was easily one of the most dreadful-appearing. Her entire body was stiffened and inflexible. Her skin was cold, waxy and mottled, and blood had already settled into her back and bottom. Her right forearm was raised from the bed at a crazy angle and hands curled inward toward her body, fingers stiffly bent in spastic flexion at the proximal knuckle. I applied tension to the end of one of her fingers, not believing what I was seeing. Sure enough, the finger would not extend. Her eyes were already dry and dull, with the frosted appearance characteristic of the dead. The woman’s body was already set in unmovable, inflexible rigor mortis. I looked at the monitor.

Her heart was still beating.

The staff immediately swarmed over the patient, cutting the clothes from her body and working feverishly to obtain vital signs. I noted the two huge needles that protruded from her chest capped by small cylindrical flutter valves to keep air from re-entry into the chest cavity. I directed my attention to the medics, who gave me an unusually-sketchy report. They knew next to nothing about this woman. The friend who called 911 was himself high on heroin. I became frustrated because the data we needed was not coming. I snapped requests for data to the techs, who patiently informed me that what I had ordered was done and that there was simply no data to report.

“Does anyone have a blood pressure yet?” I called out.

“No,” the lead tech responded. “We can’t find a pulse anywhere but in the femorals.”

I turned to the MD with a quizzical look. “Do you want to do a femoral line?”

The MD looked at the patient for a moment, shook his head and said, “No. At this point we would only be using it to monitor her pressures. We have a femoral pulse. Her carotid pulse is thready but present. I’m guessing she’s probably around 70 systolic.” He put his hands on his hips and shot me look of exasperation. “What the hell is going on here?” I shrugged my shoulders and shook my head.

In spite of our best effort, we continued to suffer from an infuriating lack of data and it seemed to be many long, long minutes before numbers and values began to trickle in- and it seemed that with every new piece of information the case slipped that much further into the Twilight Zone. Good grief, nothing makes sense! I thought.

When we finally got a rectal temperature, it was 31.4 degrees Centigrade (88.5 F). Her limbs were ice-cold. Her chest x-ray revealed that her lungs were completely obliterated with blood. We were never able to obtain a blood pressure through any means including palpation or Doppler. The respiratory therapist drew a syringe of thick, nearly black blood from the patient’s femoral artery for an arterial blood gas assessment. We also obtained a blood sample for a blood glucose reading. We began to get our first real inkling that we were seeing something that none of us in all our careers had ever encountered before.

Her blood glucose was zero. Her blood pH was 6.1 (far beyond compatibility with life). Her serum creatinine was 3.9, which was far beyond normal. Her hematocrit was 7 percent (normal range for a female is 36 to 46 percent). A Foley catheter was inserted, with no urine output. I ordered a urinary bladder scan, which revealed no urine in the patient’s bladder. The woman’s kidneys were gone. Had she bled out somewhere, somehow? Nothing we were doing was helping this woman. And all the while, her limbs continued to stiffen at awkward angles. Blood was going nowhere. Her vital organs had long ago ceased to function. Her pupils were blown and her eyes were fogged over. She had no metabolic activity. This woman was dead.

But her heart was still beating.

Word travels fast when an unusual case hits the ER. Suddenly, the room was crawling with cardiologists and neurologists, all of whom were standing off to the side discussing the findings, reviewing the figures, and trying to figure out what on earth was going on. I noticed a lot of head-shaking and shoulder-shrugging among them as I glanced in their direction. I went through my hundredth mental checklist, ensuring every nursing intervention had been performed. Nothing had been omitted, and everything was in place. All that remained for me to do was to square away the documentation and prepare the patient for transfer to diagnostic imaging for a CT of her head, from whence she would go straight to the Critical Care Unit.

When I called report to the CCU nurse (a veteran nurse with more than 20 years’ experience) and gave her the story, she was incredulous. I had to repeat myself when I read off the information we had obtained thus far. I repeated myself many times that evening.

At last, we transferred the patient to the CT room for a scan of her brain. The moment we shifted her to the CT table, her heart stopped. We called a Code Blue and within seconds the team was in the room, once again trying everything we could think of to bring the woman back. Finally, after another ten minutes of feverish activity, the MD ordered, “Stop CPR.”

All eyes turned to the monitor. The heart rate slowed to 30… 25… 15… 10… 0.

“Guys, I’m out of ideas. Can anyone think of anything we have not already tried?” Everyone shook their heads, including a couple of cardiologists and neurologists who had responded to the code.

“That’s it, then. Time of death is 9:58 PM.”

We disconnected the defibrillator, transferred the body to the stretcher, and trundled her back to the resuscitation room. The charge nurse took the papers from me and ordered me to take a 30-minute break. I am still uncertain of what I was feeling. Was it grief or bewilderment? I was sad, I was angry, I was frustrated by the slow flow of data we had experienced. But more than anything else, I was completely baffled. What on earth had just happened?

By the time I returned, the charge nurse had done all the after-death paperwork and notified the Medical Examiner’s office. An autopsy was most definitely called for in this case. We certainly had no idea what killed her. Yet as far as this case was concerned, all my work was completed. I called the CCU nurse to let her know that the patient had died; she was still incredulous.

As I walked back toward my nurses’ station, the chief cardiologist took me aside and asked me excitedly, “Do you know what you just saw?”

“No, Doc,” I replied. “I have no idea.”

“You have just seen something that none of us have ever seen before either.”

“What’s that?”

“A stone-cold corpse with a beating heart.”

I stared blankly at the doctor.

“None of us are sure exactly how it happened, but the consensus is that perhaps all of the drugs that were given in the field, coupled with her youth and having a strong heart, may have been enough to keep the heart beating in spite of the fact that there was nothing left to perfuse.”

“So then you all think that she really was dead before she got here?”

“Dude, she was in rigor mortis when she hit the room!” The doctor said, waving his arms. “That’s what we were all talking about. She was dead, dead, dead.” He shook his head in amazement. “I suppose that something like this is chemically possible, but what are the odds that such a thing could actually happen?” He lifted his coffee cup, took a drink, pointed it towards me and continued: “I suspect that we have just observed the amazing automaticity of the human heart. Even when the body is dead, it still has the capacity to continue beating if the conditions are perfect. And in this extremely rare instance, they were.” The cardiologist took a drink, grimaced, and said, “None of my fellows has ever seen anything like this. You and I will probably never see it again in our lifetimes.”

He put his hand on my shoulder encouragingly, gave me a pat, and walked briskly down the hall and out of the Emergency Department, still shaking his head as he disappeared through the doors. I walked into the resuscitation room and looked into the dull, fogged eyes of the first person to die in our Emergency Department this year. I put my hand on her forehead, drew a heavy sigh and said to her, “Lucky me.”

Recovering from Christmas in the ER

2006-12-29T09:48:00.000-08:00

Christmas Eve was a solid-gold nightmare. We had one open bed in the entire hospital, and the private ambulance services were bringing in critically-ill people without calling us, because they knew if they did, we would divert them to hospitals that we knew had open beds. But they make their living on calls, not on mileage. (This may differ in other states. Armed & Christian may correct me on this point.) So after the fifth "patient dump," the staff in my ER and the private ambulance services were not experiencing a lot of good will toward each other. And of course, the practice of patient dumping so saturated our ER that we had to place the hospital on "divert," meaning we were so full that there was neither room nor staff to care for any more patients until we cleared out the patients we had. There was no room at the Inn.

Most of the patients we had on Christmas Eve were genuinely sick. On my shift I cared for two patients who had had strokes, one patient who had a heart attack, a family of four who had carbon monoxide poisoning (a non-English-speaking family), one patient with acute appendicitis, two female patients having miscarriages, one elderly female with a hip fracture, and one psychotic female frequent flyer who neglects herself in order to get attention and pain medications. (This time she nearly killed herself by laying in her bed for nine days without getting up to go to the bathroom. She was, of course, a frigging mess. All this to get attention. She was also one of our private ambulance "patient dumps.")

That was one long, long Christmas Eve. I dragged myself to bed, sore and tired, at 9PM and awoke, sore and tired, at 5AM on Christmas Morning.

Man, this is going to be a long day, I thought to myself. Christmas in the ER usually is. I was not worried that someone would die in my ER on Christmas; people die every day (but as it turned out, none died in my ER on Christmas). I suspected that if Christmas Eve was any indication, Christmas was going to be a rough ride.

Boy, was I right.

It started off ominously. I schlepped in at 7AM to find only one patient in the entire ER. I went through my area checklist (trauma cart inventory) and sat down, sipping my coffee. Nobody dared say the word: "Quiet."

That one word, when uttered by an on-duty ER staffer, can send the whole day spiraling into hell. The whole staff sat in uneasy silence. Then the medic line rang. Five minutes later, it rang again. And again, and again, and again. And then the aid cars began calling in with short reports; six in a twenty minute period. By 9AM, the walk-ins came flooding in. By 9:30, the ER was full, and the triage area was filling fast.

Now, let me acquaint the reader with the demographic of the Christmas day ER patient, because it is not comprised of the usual crowd. Nobody in their right mind wants to come into the ER on Christmas, for the love of Pete. So what we see are the really, really sick people, the people who slice their fingers while preparing the meals, the people who slip and fall on whatever causes them to slip and fall (ice, gravy, beer, etc.), the people who get together when they shouldn't, and of course the absolute lunatics.

In the morning, the usual crowd comprised of the genuinely sick ones. Heart attacks, appendicitis cases, one full-term lady in labor (on Christmas- cool!), a couple of strokes, a couple of really sick kids, a seizure, and a bowel obstruction. But as the morning wore on, we got more and more lacerations (knife vs. finger). And then the psych cases began rolling in.

We had one obese young woman with the classic hallmarks of Meth addiction who insisted she be classified NIK (no information known) because the Mafia was after her. Never mind that she dragged her whole family with her. They also decided to check themselves in for various reasons. Her mother began loudly and obnoxiously retching in the triage area (BLEEEEEEAAAAACHH!!!! BLEEEEEEEAAAAACCCCCHHHHH!!!!). She didn't produce anything, of course. She just sat there and retched, loudly and with great flourish, whenever she saw someone looking at her. She fell strangely silent when nobody acknowledged her. Situational nausea, I guess.

As the day wore on, we saw the usual assault victims.

"Usual assault victims," you ask?

Yep.

You see, Christmas is one of those holidays that brings families together, even when they have no business being anywhere near each other. Uncle Phil arrives, gets drunk and obnoxious, and someone decides to tell him to pipe down. He declines, and rudely so. He takes a swing at Cousin Ed. Ed parks a left hook in Uncle Phil's mouth. Uncle Phil arrives at our ER drunk, belligerent, swinging, spitting bloody froth at us, and with a BAC of 384. I'm not making this up.

Never mind decking the halls. Somebody "decked" Uncle Phil, I thought.

So the twelve hours I spent in the ER on Christmas Day were not idyllic. Guess who had the Mafia runaway, her mother (BLLEEEEAAAAAAHHHH!!!!!!) and Uncle Effing Phil?

Where's the frigging eggnog?

Behold, the Awesome Power of Human Stupidity

2006-12-19T21:22:00.000-08:00

There are some days that I encounter patients whose actions, driven by an utter absence of common sense, cause me to leave a treatment room shaking my head in dismay and mumbling to myself.

I'm not talking about the basic run-of-the-mill honest mistakes here. These are not the "I thought I had shut off that circuit before cutting the wires" kind of crowd. These are the runner-ups for the Darwin Awards who tried very hard to kill themselves but failed through sheer incompetence, thus disqualifying themselves from glory. Their survival was not so much a matter of God mercifully wrapping His arms around these people. It would be more accurate to say that the Angel of Death simply rejected these people because his pals at the bar would never have believed the story- it would have just been too easy. Even the Angel of Death has his standards, you know.

But just when I think I have seen something that officially qualifies me for the "I Have Seen It All" Hall of Fame, someone else discovers a new and creative way to come this close to finishing himself/herself off, only to survive to tell the tale to his/her grandkids. And oh, yes: they do procreate.

In fact, I think that there is a lost race of human beings whose origins have vanished in the mists of time; a race whose progeny now walk among us, wearing our clothes, eating our food, and sending their children to our universities; and yet these homonids have not quite shed the self-immolating tendencies of their predecessors. This race might very well be the missing link between the Darwin Laureates who managed to extinguish themselves on their own merits, and the Robbie Knievels of today. (By the way: I know a guy who claims, proudly, to have been shot in the foot by the younger Mr. Knievel. But I digress...)

I call this lost race Homo hey-watch-thissicus.

The hallmark of the species is its absence of a state of being merely accident prone, which is more the manner of H. jerrylewisium. Rather, the defining characteristic of the race is its ability to operate in a realm of logic that defies the laws of physics, thermodynamics, organic chemistry, common sense, and fire codes. The three most commonly-observed subspecies (that is, those who wind up in Emergency Rooms across the nation more often than any others) are Homo jackassii, Homo webmedicus and Homo mindblowinglystupidiens.

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H. jackassii are a subspecies who instinctively choose to do things, without giving due thought to the empiricals of physics, that invariably lead to great personal physical anquish and embarrassment. These are the numbskulls who sit in shopping carts and let their idiot friends push them down a steep hill with parked cars on either side. (I've met them- or more to the point, I've met their parents, who tend to be exceedingly embarrassed when I come out to explain to them why their stupid kid is in the ER this time.) Others of the species choose to car-surf (I've scraped acres of real estate out of their backsides). Still others try to jump their BMX bikes over a busy street during rush hour (not realizing that a mere human on a lightweight bike has inadequate mass to achieve either the velocity or the momentum to carry himself/herself aloft on a trajectory spanning the minimum fifty feet required to clear the cars on the opposite side of the street... and even on the exceedingly rare chance that they do make it to the other side, then landing on both wheels without sustaining a screamingly-painful testicular crush injury or vaginal contusion upon impact of the rider's perineal area with that teensy-weensy bicycle seat... yikes!). These yobbos end up with shattered feet, shattered ankles, shattered tibias/fibulas, shattered knees, shattered pelvises, internal injuries, shattered femurs, compression fractures of the spine, skull fractures, facial avulsions... And do they wear helmets? Nooooooooooooooo...

ERs across the country attest that the jackassii gene is not exclusive to either the X or Y chromosome.

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The second subspecies, H. webmedicus is marked by a set of ideas and thought processes regarding illness and treatment that are completely divorced from reality and logic. These are the people who, sometimes without benefit of a high school diploma, consider themselves more medically-savvy than the folks who go to college for an entire frigging decade, since they can now "google" their symptoms and treat themselves with mail-order medications from the internet. Of course, by the time these people arrive at my ER, the damage has been done- often irrevocablly so.

One such H. webmedicus case immediately comes to mind. Her husband stated that she had "chronic chest congestion" (self-diagnosed) and decided to manage it herself; after all, she had read a number of internet articles on the disorder.

"Well, that's all that you guys do, isn't it?" He concluded. (At that moment I fervently wished that slapping was considered a therapeutic intervention.)

Never mind the fact that MDs and RNs go through continuing years of education throughout our entire careers to understand the intricacies of a human body that even now remains insanely, humblingly complex to even the greatest minds among us. All we really do is just google the stuff anyway. Hmph.

Somehow, the woman managed to obtain Prednisone without a prescription. She then arbitrarily decided that 100mg daily should do the trick. We met about a month later when she arrived at my ER in full-blown Multiple Organ Dysfunction Syndrome (MODS). The boyfriend told me that she had discontinued the prednisone the other day without tapering off.

As it turns out, she lived- but she was so physically deestroyed that the rest of her life (such as it is) promises to be an ordeal of physical, emotional, and psychological agony. Her major organs are ruined, and she emerged from her ordeal a different person.

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The final subspecies is characterized by sheer abject stupidity with regard to self-care. One shining example of H. mindblowinglystupidiens can best be described in the following recent encounter:

A young man came to my ER treatment room with a garbage bag over his lower leg. He was whisked back to me before being fully triaged. The triage nurse apologetically told me that when she saw how badly he was bleeding through his dressings, she made the decision to bring him straight to the available trauma room.

I said, "No worries. My other folks are stable. I can triage him."

Well, the guy was simply lolling back and forth in the wheelchair, deathly pale and clammy. The ER Techs and I gowned up and gloved up. We chair-lifted the guy from the wheelchair to the gurney and put him on the monitor. He was tachycardic (fast heart rate), tachypnic (fast breathing rate), and just not at all well. I removed the garbage bag that covered his leg and noted at least a pint in there. I began to move faster. His full-length wool sock was wringing wet with blood. There's another pint. Blood was pouring through the dressing. I figured that this guy had been bleeding for at least half an hour, since he drove himself to the ER.

I sloughed the sock off the foot and it fell into the bag with a wet slap. I then noticed the dressing: thick layers of tape covered the gauze below. The tape was wrapped completely around the patient's leg haphazardly, as if in haste. There was no way to find the end of the mess, so I had to cut the dressing off. I ordered one tech to hold up the leg, ordered another to get me a couple of pots of 4x4 gauze and Kerlix rolls, and whipped out my trauma shears.

As I began cutting carefully through the dressing, I asked the man to tell me what happened. He informed me that he had been seen in the ER yesterday because he was cutting down cardboard boxes with a fresh box knife and accidentally cut his leg while bracing a box against it. Honest mistake, I thought to myself. The automatic assumption is that the sutures failed, or an artery suddenly decided to "let go."

As I finished cutting, I told the two techs to get ready and I carefully peeled back a section of the dressing. A jet of bright red blood shot from under the dressing and painted the drape four feet away, Jackson Pollack style, before arcing straight up and narrowly missing the Tech holding the patient's leg. She, a new Tech on her first week in the ER, let out a startled yelp and jerked her head away reflexively. I clapped the dressing back over the leg, grabbed gobs of gauze from the other tech (a veteran of the ER who simply said "Hmph"), and calmly (I think) told him to get more Kerlix pronto.

I once again raised the old dressing, prepared for the "pumper" this time, and slapped new gauze moistened with sterile saline over a distinctly new and very deep wound just below the wound that was sutured last night.

"Where did you get the new cut?" I asked.

"I did it today," the guy moaned. "I was changing my dressing."

"You cut yourself again when you were changing your dressing?"

"Yes. Ohhhh," he moaned.

"Okay. How do you slice the heck out of your leg changing your dressing?"

"I didn't have any scissors. Ohhhhhhhh."

Uh-oh.

I ordered the rookie tech to hold pressure, ordered the veteran tech to continue wrapping the leg, and I stepped over to the meet the patient's gaze. I leaned over the man, directing his eyes toward mine.

"Please tell me you didn't use the box knife," I whispered. "Please."

"I used the box knife," he moaned. "Ohhhhhhhhhhhhh."

I stripped my gloves off and walked out of the room to get the MD, shaking my head in dismay and mumbling to myself.

Life and Death in Darkness

2006-12-17T18:31:00.000-08:00

Last Thursday night/Friday morning, more than a million people in my region were plunged into darkness by one of the worst windstorms in modern Washington State history. Whole cities were still, dark and lifeless. Other than the drivers around me, not a single person was seen outside. The atmosphere was made all the more strange by the moaning of the wind through the power lines that bowed, dead and useless, from their poles. Huge old-growth trees were ripped from the ground by the thousands, blocking roads, demolishing houses, and killing drivers.

And of course, I had to drive to work that night.

My work does not stop when the weather comes up, no matter how severe. If I don't show up, the poor nurse whom I am to relieve has to stay put at his section and take up the slack, which is a lot to ask of someone who has already spent twelve hours working in a level 3 disaster setting in an ER packed with humanity. So I drove to work, picking my way along detours and around fallen trees, and nearly getting killed myself on four separate occasions by drivers who simply blasted through blacked-out intersections instead of treating them like 4-way stops. Seattle has more than its fair share of weather morons. These were probably the same dilrods who parked their cars in the middle of the road during the winter storm (of which I wrote a couple of weeks back)- but I digress. At any rate, having finished an hour-long drive that must have left my guardian angels shaking their heads in dismay and mumbling to themselves, I pulled into the hospital parking lot.

The hospital was an oasis of light in wasteland of utter darkness. The Interstate stretched out for miles either way, a brilliant white-red artery coursing through the black. I zipped up my parka and trudged to the entrance. Every main floor public-access area was simply packed with people from the local region who were not sick but were just looking for some warmth, light, or hot food. They milled around, sat in the cafeteria, parked themselves in corners as far away from the entrances as possible, and tried- many quite apologetically- to stay out of the way of hospital personnel. We gave people blankets and pillows, hot tea, coffee, cocoa, and as much encouragement as we could.

As difficult and hazardous as the evening had been thus far, I still felt a charge of excitement as I contemplated the potential challenges that I as a nurse would be called upon to meet this night on a professional and personal level. The ER was full of some very sick people, and the horrendous weather and power failures compounded the challenges we had to overcome in order to care for our patients. Now, it was not merely a matter of treating the patients and sending them home. "Home" may be blacked out and freezing, or flooded, or inaccessible due to downed power lines; getting "home" may not be a safe endeavor, either. So we all worked together to find some place to put these people, and the lobbies were filling fast. Other area hospitals faced the same dilemma. But this is part of the reason that many medical professionals choose to specialize in emergency/trauma care. You never know what's going to happen next.

As I walked through the doors into the ER, I immediately noticed the distinctly thick and pungent smell of wood smoke that permeated the place. As if the darkness and freezing cold were not bad enough, a thermal inversion had formed over the region, holding the pollutants close to the ground like a foul blanket. The asthmatics are going to be flooding in tonight, I thought. I clocked in and walked over to the nurse whom I would replace. She visibly relaxed, gave me a hug and said, "Thank God you're here!" She gave me report and I briefly paused to consider what I had just gotten myself into.

My patients I inherited were sick, sick, sick. The least severely-ill was a 30-year-old man with propane burns to his hands who would do alright with some minor debridement, silver sulfiadazine cream and a bulky "softball" dressing. The second worst was an 80-year-old with CHF and pneumonia who was simply waiting for a room upstairs. The worst was a 19-year-old college girl in the middle of a severe asthma attack who was looking minutes away from being intubated because she had been working hard to breathe for hours and was rapidly running out of steam.

The hours ripped by. The girl was intubated, put on a ventilator, stabilized and sent up to the Unit. The older lady was sent upstairs to MedSurg, and the burn victim went back "home" to his nice warm RV. No sooner would I discharge a patient than another would occupy the room. And as I returned from taking yet another very sick patient up to the Unit, I noticed that the briefly-vacant room had been filled by not one but four patients who had carbon monoxide poisoning- a whole family that could easily have died had not the oldest daughter come home and seen what her mother, who lacked a little something in the common sense department, was doing to heat their house. Thankfully, they all were fine and five hours later were discharged. They, too, found a corner in the lobby to park themselves for the night.

The rest of the night, all two hours of it, was occupied by a couple of GDFDs who somehow managed to find one another in a night blacker than Hitler's heart. They shared some booze, and then found enough reason to get mad at each other. One had the bottle broken on his head, and the other had his face smashed into a tree, breaking his nose and blackening his eyes. Keeping them separate was a real joy.

My shift finally over, I drove once again through the wasteland, going ten miles out of the way to avoid downed power lines, roadblocks, and managing once again to dodge the weather morons who blasted through the intersections. On the radio, I heard that one woman had drowned in her basement as rescuers struggled frantically to reach her. They could hear her screams, and finally, they heard no more. They broke through fifteen minutes too late. Those guys will remember this night for a long, long time. Say a prayer for them, will you?

Keeping Things in Perspective

2006-12-07T05:57:00.000-08:00

Tonight was one of those shifts that puts the world into perspective for me.

I was the primary nurse for a man who had a sudden-death cardiac arrest; his wife heard a loud thud, turned on the light, and saw her husband of fifty-two years crumpled in a heap in the doorway of the bathroom, blue and dead. She was a small woman, and he was rather tall. She could not get him out of the doorway.

She called 911, and seven minutes later, the paramedics arrived, find the guy asystolic (no heartbeat) and then started CPR.

Mark this: seven minutes dead. No oxygen to the brain. If CPR had been started the moment the guy dropped dead, he would have had a seventy percent chance of getting out of the hospital alive. With every passing minute, the survival rate drops like a cow off the high dive.

Paramedics work on the guy for 30 minutes. Nothing works. Not the drugs, not the shocks, nothing. And the man has an internal defibrillator that goes off every once in awhile. It was obviously not working either.

So the medics get authorization to call the code. The man is pronounced dead. The medics start packing up their gear.

But then, somebody thought it would be a good idea to check for a pulse. He had one.

So the medics open their bags, call us, give report, and arrive ten minutes later.

I was the primary nurse for this guy. We got the word from the MD about what had gone on, and I say to the Doc, "So this guy's been dead for about 45 minutes so far?"

"Yup."

"Advance directive?"

"Nothing."

"Is this the same guy you gave authorization on a while ago?"

"Yup."

"Okay," I said with an exasperated sigh. "I'll square the room away."

So the ER Tech and I gather the tools and get the staff together. Since I am primary, I will receive report and direct the nursing care. There will be at least two other nurses and two other ER Techs involved. Ten minutes later, he arrives.

I take one look at the man and know he is "circling the drain." His extremities are ice cold, his eyes are open, his pupils are fixed, irregular, and nonreactive; his legs are mottled; he has no bowel sounds; His heart sounds are disorganized. He is breathing with the help of a ventilator. His BP is 81/64, pulse 134 at the wrist, and he looks just horrible.

But he had a good pulse.

The medics gave me report while my team descended on the man like a Formula One pit crew. Every appendage the man had had a tube sticking out of it within three minutes. After receiving report, I checked with the team that all the major stuff had been taken care of. I then assessed the patient myself. It was not reassuring.

Then the wife came in. She was a lovely woman in her mid-seventies who looked much younger. She carried herself with grace and calm. I introduced myself and hurriedly tidied up the room. I explained what my role was, what we had done so far, and what we intended to do. She signed the necessary forms and sat in a folding chair just near the man's head.

After a few minutes, she got up and pulled some papers out of her purse. It was a living will. I looked at it, and said, "So your husband does not desire resuscitation?"

"No, he doesn't."

I looked at her quizzically.

"I was afraid to tell the ambulance people to stop. I was just afraid."

I paused and asked "Do you have power of attorney?"

"Yes, I do."

"Let me get the doctor."

I got the doctor and had her run the whole thing by him. The doctor finally asked, "Ma'am, what do you want us to do?"

The woman paused for a little while, reached out and put her hand on the patient's forehead and said, "He's been gone too long. We need to let him go."

The doctor verified the woman's legal status, verified her request, had her sign all the necessary forms, and the team withdrew life support in accordance with the stipulations in the living will and the woman's power of attorney.

I hovered over the man, watching his vital signs, listening to his heart and lungs, and then stepped back.

Suddenly, the man's body stiffened, his hands flailing outward. His internal defibrillator had fired. I looked at the monitor. He was in asystole. I looked at the woman. Her eyes were on me. I wished they weren't.

I got the doctor in the room. He looked at the monitor, assessed the man, and finally told the woman, "He has no pulse, no heartbeat, and he is not breathing."

The woman looked at the doctor, and looked at me. The she said, "Let him go."

She stood up, took her husband's hand, and kissed him on the forehead. I moved her chair closer so she could sit down next to him. The doctor looked at me, said "Time of death, so-and-so," patted the woman on the shoulder and asked, "Is there anything more I can do?"

"No, thank you. I am fine."

I asked her likewise, and she answered likewise.

Over the following hour, the woman sat in the room with her head on the man's chest. I busied myself with the postmortem arrangements, and finally informed the woman that whenever she was ready, her husband could be transported to the morgue.

She said, "I'm ready now. I'll be going." Her son had arrived and was to drive her home. She kissed her husband's forehead and left the room with her son holding her hand. Her husband's body was taken to the morgue upon her departure.

I had no other patients and my shift was over, so I simply punched out and went home.

When I got home, I went to the internet to check my email, as is my habit. The glaring headline on my ISP was "TOMKAT TO HOLD NUPTIAL BASH IN LOS ANGELES."

So frigging what?

Traumatized Seattle Digs Out of Whopping 2-inch Snowfall

2006-11-30T11:27:00.000-08:00

This week, Seattle was plunged into chaos when a monster snowstorm of Biblical proportions dropped a fantastic two inches of snow on the Metropolitan region.

Seattleites, who are horrible drivers in the best of weather, immediately set out to show the world how uncommonly stupid they are in a mind-bogglingly short span of time.

Before the first inch of snow had accumulated, Seattleites threw all semblance of reason out the window. (This is not much of a stretch, considering the demographics in these parts.) Suddenly, eco-conscious metrosexual urbanites in their blob-like Toyota Priuses found themselves occupying ditches without so much as an environmental impact statement. Snazzy Range Rovers, Porsche Cayennes, and BMW X-5s also fell prey to the savage onslaught of the howling winter tempest that left the city paralyzed under two inches of frozen hell and soccer moms scratching their heads in bewilderment.

I confess I had it easy. I learned to drive in West Virginia in the winter. I knew how to go up and down hills. Furthermore, knowing full well the importance of torque and traction in winter conditions, I ignored the shrill urgings of Al Gore and bought my wife a big, bad, heavy, 4-wheel-drive Chevy Suburban. Thus, getting up down hills was a piece of cake. Nevertheless, navigating the 8 miles to my ER for work was a sheer nightmare. Not merely because of the snow or ice; but also because of the incredible number of cars abandoned in the middle of the frigging road by their amazingly stupid owners.

My wife informed me that some expert stated that two inches of snow in Seattle is equal to 14 inches of snow in New York City simply because of the hills in our area.

I disagree. If the city, county and state transportations departments had any shred of common sense, they would be prepared for this kind of thing that happens every year. But instead, the Seattle mayor is more interested in sinking billions of dollars into a tunnel, and the county is more interested in buying stretches of commercially-viable railroad and turning them into dog walks. Seattle may be bogged down in snow, and Seattle natives may be pathetic drivers, but Mayor Greg Nickels and King County Executive Ron Sims are simply frozen solid in criminal stupidity.

Happy Thanksgiving, Everybody!

2006-11-23T07:01:00.000-08:00

Here's to you and your loved ones today. What do you have to be thankful for? I'd love for you to share with me.

My wish for you all can be summed up in an old Scottish toast:

"May the best you've ever seen be the worst you'll ever see,
and may you all be just as happy as I wish you now to be."

God bless you all. Thanks for making this humble blog an enjoyable and educational experience.

Please take care today. Be safe. Slow down. Turn away that lst drink before you go. I am working tonight, and I would really hate to meet you in person.

The Republican Remedy for Defeat: Promote Defeatists.

2006-11-16T08:22:00.000-08:00

Let us consider the events of the first week since the day before the Republicans got their arses handed to them. Three major things leap immediately to mind.

1: After the departure of Ken Mehlman from the chairmanship of the GOP, everyday Republicans (that is, those who actually have to work for a living) were hopeful that the Party leadership had understood our supreme dissatisfaction with their abysmal performance and their abandonment of the principles for which they ascended to majority status. (For a more detailed analysis, see my 11/8 postmortem of the election). Much to our dismay, a promising conservative candidate for the chairmanship was stiffarmed in favor of Mel Martinez (R- Mexico City), a pro-amnesty limpwrist liberal who also favors our dependence on foreign oil.

2. In their search for leadership after the thinning of their herd, surviving Republicans searched far and wide for a strong Minority Leaderwho could steer the Party out of shoal water and found... Trent Lott. The same Trent Lott who defended earmarks and backroom party hack who faithfully carried the banner for the Old Boy Network and enabled the minority to take the initiative.

3. Party leadership immediately set out to widen the gap between themselves and the conservative Citizens who actually are Republicans. This is not isolated to the national level. In my state, even the Precinct Committee Officers are blaming conservative Republicans for the loss.

This is simply pathetic. The people who have usurped control of the party from the citizens at all levels have learned nothing, and thus have proven their unworthiness for leadership. The time has come for every conservative Republican to gird up, link up, and get active.

A Brief Postmortem of the Republican Loss

2006-11-08T16:40:00.000-08:00

Now that the handwringing over the election of over and Sean Hannity and Mark Levin have started the official Boo-Hoo Fest, I would like to take this opportunity to point out that the GOP leadership was well and truly warned by all the hardworking grassroots Republicans that this day would surely come.

Remember us Mr. Mehlman? The Americans whom the Party leaders have treated like a floozy on the morning after since 2005? I bet you do now.

As I am one of those abused grassroots Republicans, I can say with no small sense of vindication that after what the Republican Party leadership did to divorce itself from- and to overtly demonize- its conservative majority base, the GOP in situ deserved to be dope-slapped, and so it has come to pass with ridiculous ease of predictability. (What was that word again? Oh, yes: hubris.) The GOP began sewing the seeds for their 2006 defeat way back in January 2005 under the limpwristed, obsequious, and obstinate leadership of Ken Mehlman, Bill Frist, Dennis Hastert, John McCain, Arlen Specter, and yes, even moderate wunderkind George W. Bush.

As far back as the Summer of 2005, I warned that unless the Party leadership pulled their heads out of their colons and started doing what they told the people who elected them that they would do, November 2006 was going to be a very cold month indeed for them.

I repeated the warning last summer (scroll down to Aug. 15), in the midst of the GOP leadership's arrogant attempt to circumvent the will of the American people by granting amnesty to millions of illegal aliens. I was roundly accused by the "electability" wing and the RINOs of being everything from a hyperconservative lunatic to a Democrat mole. I held my ground. I declared that because of the moral failure and political cowardice of the elected leadership of the Republican Party, November was going to be a cold month indeed.

I was right.

The reasons why the Republicans lost are connected with one overarching theme: the abandonment by the GOP leadership of the founding principles and values of the Republican Party. Yet the "electability" wing of the Party thought those principles were old-fashioned and unimportant- the rallying cry of the extreme right wing whackos. What was needed, they reasoned, were candidates whose views were not do "extreme." My response to that is this: your "electability" lost the election.

Holding our Party's leadership accountable for their betrayal of the people who fought hard for them in 2004 is necessary, and it is correct. Accountability must be swift, and it must be decisive. It is absolutely necessary if the rennaissance of the true-to-values Republican Party is to take place. Every man and woman who calls himself or herself a true Republican must take responsibility for the reformation that is required if our party is to ever be fit to lead again. The Republicans who fought so hard in 2004 and were burned by the party need to take the lead on this. What exactly has the "electability" wing done to the Republican Party? Read the following indictment.

Capitulation to liberalism by our Party leaders is exactly what cost the GOP this election. It is also the worst possible direction our Party could have taken. Yet this was the direction that was stupidly taken by the "electability" crowd that comprises the current leadership in the GOP on the federal and state levels.

We everyday people (myself included) who endured the hate- and violence-filled onslaught that Democrats and anarchist liberals poured upon us during the 2004 elections feel more than a simple sense of betrayal by the Party leadership and key elected leaders. No sooner did the 2005 Congressional session begin than these same grassroots torch-bearers for the 2004 victory were escorted off the dance floor. All that the elected leaders promised was immediately discarded, and the American people perceived a distinct lack of moral courage among the pantheon of Republicans in the House and Senate. These recipients of our hard-won political capital promptly abandoned every key issue for which they were elected to champion, as they promised they would. They turned yellow faster than a traffic light in a speed trap.

Examples of the "Great GOP Sellout" are:

The capitulation to the Democrat minority vis a vis the McCain-led "Gang of 14";
The First Lady and GOP leaders calling conservatives "sexist" and "narrow-minded" for opposing the SCOTUS nomination of the spectacularly-unqualified Harriet Miers;
Dennis Hastert's expression of arrogant indignation about being accountable to the People of the United States and his defense of William Jefferson;
Willful intent among Republican Senators to violate the will of the people through granting amnesty to illegal aliens; out-of-control pork spending;
President Bush's perceived failure to prosecute the war in Iraq in a decisive manner and his perceived refusal to modify the plan when the existing one failed to achieve results, etc.

The rationale among Americans for voting the GOP out of leadership was that since they were acting like Democrats anyway, why not just vote for Democrats (which I, for one, did not)?

I think that the another thing that angered Americans enough to cause us to withdraw our support was the fact that our Republican leadership stiffarmed us and called us "crybabies," "extremists," "nutjobs," and "lunatics" when we rightly expressed our dismay regarding their abandonment of the principals upon which they ran, and upon which we elected them. It further angered us to watch as the Party leadership either ignored, refused to support, or outright smeared Republican candidates who were running on a more conservative platform.

There may be some Republicans who simply give up on the party after this. This is a bad idea. If anything, the defeat in this election underscores the absolute requirement for core-values Republicans to take responsibility for their Party and start cleaning house. I am not advocating a "great purge" of all moderates from the party; that is damned nonsense. But I am definitely advocating a purge of all of the RINOs who went against their party's core values, and of any among the GOP leadership who persist in undermining the party's core values through propping up RINO candidates and stiffarming core-values Republicans. These people are poisonous to this Party. The fact that RINO-led Republican leadership was shown the door two nights ago is enough data to underscore the truth in what I say.

Let us not continue to fall under the delusion that Mehlman and company have foisted upon us. If Republicans ever want to hold the majority again, the RINOs have to go. Now. Without fanfare. And with a complementary road map to the DNC. The Party then can be left to return to the values that reflect the base as demonstrated in the "Contract with America," and that made our Party great from the day of its inception.

What I strongly urge every man and woman who calls himself or herself a Republican (myself included) to do is to read the founding values of our Republican Party carefully and with sober reflection. Then let's get busy, because we have a lot of work to do to square this party- and our country- away.

The GOP has lost their majority in the House and the Senate. The American people can now look forward to 24 months of gridlock. Our federal government will spend the next 2 years bogged down in "investigative hearings" and "litmus tests." Our borders will be thrown open. Our troops will be glad to hear that John Murtha, the man who called our troops "butchers," will head the House Armed Services Comittee. Oh, yeah- that'll draw people into the recruiting offices, won't it? And now the people who "voted before the war before they voted against it" are in a position to waffle this nation right into oblivion.

And we have the current "electable" leadership of the Republican Party to blame for that. It's time to clean house.

Reflections of an ER Nurse, Part One.

2006-11-06T03:29:00.000-08:00

Want to know what is really, truly sad? Stop for a moment and consider the extreme lengths to which people will go just to temporarily alter their perception of reality- even if for only a few minutes. Consider all of the human wreckage that results from this vain pursuit. That's a real frigging waste of such a priceless creation.

How can one look at the utter devastation that people wreak upon themselves just for a temporary escape from reality and not be affected? Dude, I love my craft. I love the interaction. I love the victories. I love being part of the successful effort to snatch a human being from the jaws of death and all of that altruistic stuff. But I hate seeing people who used to be moms, dads, mailmen, truck drivers, teachers, wives, husbands, scholars, and even nurses, come though the doors of my ER pale and drawn, toothless, scabbed over, crusted with filth, crawling with lice, fleas and ticks, smelling of stale urine and feces, pockmarked with old infections and rat bites, and stripped of any intrinsic beauty they may have had.

And with a few extremely rare exceptions, they don't come looking for answers or deliverance by the time it gets that bad. They just come looking for whatever they can get to just keep them going. All because they saw no other means to rise above some critical point in their worlds. Or sometimes because it all seemed like a lark at first. Whatever the reason, nobody ever decides willingly to throw away a healthy body, a brilliant career, or a marriage so they can go sleep in filth and die utterly alone.

Sometimes I want to shake them, shout at them, whatever- try to get them to see. But they have the right to autonomy, even if it destroys them. Sometimes I want to hug them but I can't, because I'll get infested and I have to protect my other patients. Man, I hate that. It makes me furious sometimes. It makes me cry sometimes. And it affects me always.

Sometimes I think I should try to protect myself from being affected, but how can I demonstrate compassion and yet not care? It is impossible, and so it is impossible to not be affected. But by the grace of God I don't drink it off, I don't toke it off, I don't shoot it off, I don't freebase it off, I don't get ulcers over it. I let myself feel whatever I feel about it and I talk about it with my Savior, with my wife, with my peers, and with myself.

And because of the faith that sustains me and the love that supports me, I can still go in as idealistic, eager and excited about being a nurse as the day I got my license. In that regard, I am the most blessed man in the entire world.

Little Miss Adventure

2006-11-04T09:11:00.000-08:00

Last night a "GDFD" (get drunk, fall down) was brought into the Emergency Department by aid car. She arrived, as most drunks do, bellowing obscenities and calling the staff vile names. And this young lady was also a spitter. Nice.

The law allows us to restrain a patient who poses a threat to himself or to staff, and our MD, a particularly excellent one, wasted no time in decreeing that it be made so. Security is always down there, so we summoned them to help us put the leathers and a spit sock on the young lady. We then shifted her over to our bed and unceremoniously strapped her down.

While all this was going on I was getting report from the very beleaguered-looking aid car crew. It seems that the patient was with her friends at a bachelorette party and the patient had a little more than her share of the alcoholic beverages, and when the staff decided that enough was enough about four shots of Jagermeister ago, they cut her off. Little Miss Adventure got up to voice her dismay and wound up on her backside, having struck her head on the way down.

It is interesting to note that although the young woman was maybe only 5 feet 3 inches tall and weighed perhaps a buck-five soaking wet, she fought like a wildcat in a burlap sack with a snake in it. Some people hold their liquor; with others, their liquor holds them. This lady was simply awash in the Nyquil-like stench of Jager.

The staff got Little Miss Adventure settled in (read: strapped down), and I obtained IV access (in this case with a big ol' 18-gauge in her antecubital fossa- that's the inner elbow for you laypersons) and drew blood for lab assays.

Oh, yeah. Little Miss Adventure was also a "biter."

Now, we needed to get a urine toxicology screen as well. Since I am male, obviously I was not the one to go in and do it. But I did inform her that yes, Nurse so-and-so was about to put a catheter down there.

"The f--- she is!" she declared.

So after the catheter was in place and the urine sample was obtained, I sat down do do my charting, a voice from behind me says, "230."

Then I hear, "Naw. She's tiny. 180."

Suddenly, numbers are being called out as if this was the set of The Price is Right.

Now, a brief explanation is called for here. Any time we get a GDFD into the Emergency Department, an informal bet about the blood alcohol content (BAC) immediately forms. It usually starts by someone saying, "249" (or 0.249). So without fail, within thirty seconds the entire front staff of the ED has a number except for me. After some prodding and some quiet consideration, I call out, "310."

"Get out!" says Nurse So-and-So. "She's maybe a hundred pounds soaking wet."

"No," says I, "I will bet you a pizza it's at least 300."

"Okay, Boy Wonder. What makes you so sure?"

"I think she's got a tolerance, that's what. Anyway, 310 is my number and I'm sticking with it."

"Have it your way," says Nurse So-and-So with a dismissive wave.

So all the while, Little Miss Adventure is screaming, kicking, spitting, and offering her pointed and graphic opinions about the lineage and sexual orientation of every staff member she can see, even the poor little housekeeper who came in to change the linen bag in her treatment room. (It's a good thing she doesn't habla the Ingles, or at least much. Still, the darling woman came out of the room shaking her head and muttered, "stupid drunk b----."

About a half hour later, the labs came back. Yes, I was wrong. But we were all shocked. Her BAC was 0.418. What that means is that this little firecracker had herself a helluva tolerance for booze. I've seen worse, but not in a little chicka boom-boom as small as her. Her tox screen also showed THC. That's the groovy stuff found in marijuana.

Also around this time, a couple of the patient's girlfriends filtered sheepishly into the ED. They all seemed genuinely concerned, a little anxious, and shockingly underdressed for the weather. At last, one of them pipes up in a nasal, whiny tone that would have been stereotypically applied to a stripper, "Can we see so-and-so?"

"And you are...?" I asked, looking over my computer screen.

"We're her friends. And we work with her. She was at my bachelorette party," says she.

"I'll tell her you're here. What's your name?"

"It's Nikki. With an I." she says, spelling her name and holding out her hand.

"Charmed," I answer, shaking her hand and stiflng the urge to guffaw. I went into Miss Adventure's room and told her she had some friends here, and asked if she would like to have them in- one at a time.

"Oh, pleeeeeeeeze?" She whined.

"Sure." I exit, motion to Nikki-with-an-I, and tell her to go in alone, and to speak quietly, and that she has only five minutes.

Well, of course, the moment Nikki-with-an-I enters the room, the Boo-Hoo fest begins. Miss Adventure escalates, and we remove Nikki-with-an-I. Miss Adventure calls me more names. Nikki-with-an-I looks a little shaken.

"Wow, she's really plowed, huh?" says Nikki-with-an-I.

"Like Farmer Brown's back forty," says Nurse So-and-So from behind me.

"How long will she be like this?"

"I dunno. Depends on her. It'll be awhile. Can't really tell you much more than that."

Well, do you think she will be able to work Monday?"

"Well, I don't know. What does she do?"

"Oh, we're both kindergarten teachers."

I have never heard the entire staff of my Emergency Department fall completely silent before. It was as if the breath had been sucked out of our lungs. But Nurse So-and-So, bless her, recovered first:

"Thank God I homeschooled."

Nursing Students Ignored in Washington State Disaster Response Plans

2006-10-28T18:31:00.000-07:00

Recent disasters such as hurricane Katrina have underscored the need for skilled volunteer workers. In every state, there are hundreds- if not thousands- of Nursing students who can be useful to healthcare organizations during public health crises. Yet some states, such as Washington, ignore the large group of people who can effectively augment and enhance a disaster response.

In particular, senior-level nursing students can provide a broad spectrum of services due to their advanced level of training. Furthermore, senior Bachelor's Degree nursing students are capable of performing not only basic healthcare, but also of performing more advanced work such as community health assessments, research, and team leadership. (This is not a dig on Associate's Degree nursing (ADN) programs, but simply reflects the enhanced level of education that Graduate nursing students receive.)

It is not as if utilizing volunteer nursing students is without precedent.

In the aftermath of Hurricanes Ivan and Frances, Florida State University School of Nursing Dean Katherine Mason offered the services of her senior nursing students, and the results were most impressive.

There are hundreds of student nurses in the metropolitan King County region in Washington State. Five of these programs provide Bachelor's Degree-level preparation. There are at least five more Associates Degree nursing programs in the same region. Figure an average class size of 34 you get between 60 and 70 students in every BSN nursing program. Now factor in the average class size of the other programs in the region, and you will arrive at somewhere between 600 and 700 student nurses (counting both juniors and seniors)in the Metropolitan King County region alone who can rovide much-needed assistance in a disaster; and the County will not use them if a disaster occurs.

And when you look at the entire state, that means that thousands of skilled people are forbade from serving their communities with the skills they possess if a disaster strikes. To that end, it is the opinion of this writer that a great disservice is being done to the citizens of Washington State through the government's failure to recognize and utilize a large and valuable resource.

The subject of student nurse volunteers is not specified anywhere in the language of the Washington State laws specific to nursing education. Even Nursing Technicians (an interim licensure for senior nursing students) are barred from medical-related volunteer service simply because the possibility is not addressed in the existing law, and because medical disaster response teams are exluded from the group of approved facilities for employment of Nursing Technicians.

Nursing students in Washington State would jump at the chance to put their newly-gained knowledge and talent to use for the public service in time of crisis. As described above, the precedent for their use exists; likewise their effectiveness. Yet in the most densely populated region of the state, hundreds of them will be barred from volunteering to serve in a way that they have trained to serve.

Public Schools are Run by Liberal Idiots, Part 678

2006-10-18T09:41:00.000-07:00

Just when I thought that the mouth-breathers who have taken over the leadership of our public schools could not possibly do any more to erode the ability of our children to develop valuable social skills, I read this story. It seems that a Massachusetts elementary school has taken turning America's children into spineless, soft, socially-vapid drones to a whole new level.

Now, don't get me wrong. Dodgeball can be a pretty brutal game. But we learned valuable life lessons from dodgeball: namely, "If you can't take it, don't play." But you won't see games like that on playgrounds in very many public schools anymore. These games are "dangerous and exclusionary."

What that means is that some candyass socialist liberal ACLU gender-blender twit is upset that when he/she was a kid he/she got his/her ass kicked in a competitive game. Now that he/she is all grown up and a self-important school superintendent, he/she will make those mean little bastards on the playground pay, and no little child of parents who never got over it will have to endure the terrible meat-grinder known as "four-square" again. Doesn't that make you feel just dandy?

So what games will we see on the playground? Here are my predictions, based on the PC liberal idiots who have overrun our schools:

"Burn the Flag"
"Dodgeresponsibility"
"Hide and shred"
"Go to the Head of the Madras"
"Pin the label on the Bible-thumping Christian Right-wing Fundamentalist"
"Chase the Jew"
"One-Circle" (Because four-square is dangerous and exclusionary and we want our children to be one in consciousness, Kum-bah-yah... except for Christians and Jews.")

Did you ever wonder where all those playground whiners went? You know, the ones who always pitched a royal hissy-fit when they got called out, or got pummelled in dodgeball, or were out in the first round of four-square, and then they tattled on you to the teacher with some made-up story just to get back at you?

Behold, our public school leaders of today. Kum-bah-frickin'-yah.

A Bronx Cheer to "Peaceful" Islam

2006-10-09T18:07:00.000-07:00

Dear Moslems:
I for one am sick of hearing the whining coming from the Moslem community about Islam being a "religion of peace" when they refuse to condemn the violent and hateful acts of butchery perpetrated by their brethren on an hourly basis. Islam is not a religion of peace. And their refusal to condemn the slaughter of innocents in the name of their religion betrays Islam for the terrorist-breeding hate-incubator that the world knows it to be.

What has Islam done except keep its adherents in the dark ages, brutalize women, enslave people who would rather not subscribe to its poisonous doctrine, encourages its adherents to lie, cheat, and steal in order to stick it to the infidel, and threaten anyone who dares draw a funny picture of Mohammed with torture and death?

Nothing. So the "religion of peace" is no such thing.

To the Moslems out there in TV Land, I suggest that you either publicly condemn the actions of your radical brethren or shut up about Islam being a religion of peace. Americans saw your "religion of peace" in action on 9/11/01 and every time since then that your brethren torture and kill anyone who does not agree with Islam. Your definition of "peace" is a lie, and your refusal to condemn Islamic brutality betrays you for the liars that we always suspected you to be.

Is "Wonkette" French for "Stupid Cow?"

2006-09-29T23:54:00.000-07:00

Evidently, the slouches at Wonkette are unable to carry on conversations that don't involve genitalia, Michelle Malkin-bashing, or sewer-level humor.

The funny thing is, I never even heard of Wonkette until after I heard of Michelle Malkin. Malkin says something, Wonkette throws a rock and posts some made-up picture with the trademark racial slur that can only come from a puerile liberal cybertramp like Wonkette, and round and round, forever and ever amen.

Seems that with all the Malkin-bashing, Wonkette must not be able to live without Malkin. They must all be Democrats over at Wonkette, because parisitism just comes so naturally to them.

That's all the bandwidth I'm going to waste on the stupid cow.

Democrats Show True Colors in House/Senate Vote

2006-09-29T12:05:00.000-07:00

The Dissociated Press brings us a story that describes the debate between Republicans and Democrats that will determine the ability of the United States to defend ourselves against a ruthless, unorthodox, and brutal enemy.

At long last, we are seeing the congealing of opposing ideas in the halls of our government regarding the prosecution of our war against Islamic murderers. One idea is to give our President every tool possible to command a changing military in a highly fluid and unstable battlefield, with the oversight of Congress.

The other idea is to elevate the civil rights of our enemy over the civil rights of American citizens- an idea that motivates Democrats to oppose every meaningful and effective strategy at our disposal in this war; to demand immediate withdrawal from regions in which the enemy is being killed wholesale and democracy is being established; to put forward no plan whatsoever as an alternative to the current one; and to push legislation that would further erode America's ability to secure our borders and prevent illegal immigrants from insinuating themselves into our society without penalty.

The Democrats have abandoned all pretense at long last. The protestations are still there for the media to propagate, but at this point the cards are all on the table and America stands at the threshold of one of the most important elections in her history. We can choose to press on in the fight, or to capitulate to the terrorists. While there are other issues to consider in the upcoming election, if our ability to defend ourselves is forfeited then none of the other issues will matter all that much.

The passage of House Bill H.R. 5825 and Senate Bill S. 3931 will go far to uphold our ability to prosecute the most unorthodox war in our history. Yet the Democrats, in their usual fashion, vehemently oppose them. Patrick Leahy, who singlehandedly caused the deaths of CIA agents by exposing them to our enemies, called the senate bill "bad" and "dangerous." And Leahy knows all about being bad and dangerous.

AP Reporter Laurie Kellman cites House Speaker Dennis Hastert (R- Illinois) as saying that "Democrat Minority Leader Nancy Pelosi and 159 of her Democrat colleagues voted today in favor of more rights for terrorists... So the same terrorists who plan to harm innocent Americans and their freedom worldwide would be coddled, if we followed the Democrat plan."

House Minority Leader Nancy Pelosi (D-Iran) shot back, "Would you think that anyone in our country wants to coddle terrorists?"

Well, there's a rhetorical question if ever I saw one.

As a matter of fact, Nancy, Americans do think that there are people in our country want to coddle terrorists. We call them Democrats, and the Democrats themselves convince of of this fact through their obstinate and consistent obstruction of America's capacity to wage war against our enemies, through their scorn of American citizens' rights in favor of defending terrorist murderers, through their continued enablement of extraordinary dispensation for illegal aliens (driver's licenses, ocllege scholarships, health insurance, etc.) , and through their constant assault on the Constitution regarding the rights of Americans to defend themselves against all enemies, foreign and domestic.

As Ted Kennedy (D- Chappaquiddick) declared, "In 40 days, we can put an end to this nonsense". Of course, Ted Kennedy was referring to the "nonsense" of defending ourselves against a determined enemy in favor of outright capitulation and a return to the Clinton Dark Ages.

In a rare flash of truth, Pelosi and the Democrats who voted with her in lockstep clearly articulated the single most defining characteristic of the modern Democrat Party, to wit: an abiding hatred of America that drives them to assault our national security in time of war in hopes that our defeat by a foreign enemy will at last force our submission to the United Nations and do away with our Republic once and for all.

Kumba-frickin'-yah.

Bill Clinton, Failure

2006-09-26T19:54:00.000-07:00

Bill Clinton passionately vented his wrath at Chris Wallace earlier this week, defending his policy of selling national security wholesale while looking good doing it. He summed up his eight years of turning the White House into a trailer park in five little words: "I tried, and I failed."

But that's the problem. He did not try. He confessed on tape that he was offered Osama bin Laden by the Sudanese, and Clinton turned them down. The self-serving creampuff displayed that rare audacity reserved only for the morally bankrupt when he told the American people that he tried. Can a person be any more bereft of moral direction than Bill Clinton?

And he follows with the accusation that the Bush administration had eight whole months to do something about bin Laden, and did nothing.

Mr. Clinton, you had eight years and you had bin Laden offered to you. And you did nothing. You could have saved 3,000 Americans. You turned down a chance to actually do something good during your administration because you were afraid of looking bad.

Well, you sure look bad now, Billy boy.

The Clinton legacy that Bill and Hillary have lied, cheated, stolen, and killed to prop up for themselves is falling to pieces around their ears. And that is a good thing.