Desert Adventure, Part 6: Of Pogues and Diversion

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

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"

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

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

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

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

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

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.