I was half way through discharge instructions with one of my patients when I heard the page overhead. "Available ER physician to room 2A stat!" I put down the papers. That was one of my rooms. I jogged quickly out of the room, mumbling something to the effect of "I should check on that" as an explanation.
As I exited the doorway I saw my coworkers swinging around the corner from the ambulance doors to the opening of my room with an ashen young man in his twenties lying sprawled on a gurney. They had pulled him, blue, mottled, and not breathing, from the backseat of a car where he'd been lying face down in bloody vomit. It seems for every sprained ankle that calls an ambulance we pull a half dead person out of a car.
One of the nurses was doing a jaw thrust to hold his airway open while another searched intensely for a pulse while simultaneously pulling him into the trauma room. One of our docs came jogging up at the same time. "Get me set up for an intubation" he said calmly and firmly.
"I'm not finding a pulse!" My coworker called, beginning chest compressions as the gurney came to a halt by our monitors and crash cart. As in all such cases, many things began to happen at once. I quickly combed through our IV start kit, grabbing a large bore needle and tubing as the doctor slid the metal tongue blade down the young man's throat to visualize his wind pipe. Other hands were slapping on cardiac monitor stickers, oxygen monitor, and blood pressure cuff while others continued pumping his sternum down to compress his heart then allow it to fill with blood again.
"Lets analyze his rhythm" the doc called as he placed the round plastic breathing tube and the respiratory therapist connected it to the ventilator. Stopping chest compressions we all stood back and watched the heart monitor to see what sort of picture would materialize.
"We have a rhythm, do we have a pulse?"
"No pulse"
"Resume CPR and given a milligram of epinephrine."
Two of us placed IVs and began hooking them up to fluid boluses to support his circulation and pushing medications designed to help the heart's pumping system re-initiate itself.
"Another round of epi"..."atropine"..."sodium bicarb"... "pulse?" "resume cpr"...
After three rounds of CPR we finally had a pulse. The monitor showed an ugly looking electrical pattern with a heart rate in the 140s, but that's all we needed. We had him back. His skin color was returning to a more natural pink. The doctor placed a central line, I placed a tube from his nose to his stomach to decompress it. Blood and urine were sent to the laboratory to begin unearthing the cause of a cardiac arrest in such a young man.
"Do we know the story?" The doctor asked.
"Only that he was at a friend's bar. A few guys were giving him a ride home when he stopped breathing, so they brought him here."
How does an otherwise healthy young man with no signs of trauma end up mostly dead in the back seat of a car? Common culprits to rule out for anyone brought unconscious to the hospital are drugs/alcohol, diabetic blood sugar problem, stroke, or bleeding in the head. He surprisingly didn't smell of alcohol, was not diabetic, and his urine toxicology screen would come back negative.
Maybe 40 minutes after he rolled through the doors of the room, I pushed my patient with his entourage of IV bag and pump laden pole, Respiratory therapist and ventilator, and er tech for extra muscle around the corner and down the hall to our cat scan. Working tentatively around IV tubing, monitor cables and oxygen tubing we moved him onto the stretcher that would carry him into the imaging machine.
I stood in the back room with the CT technician and the computers as the machine scanned an image of his brain. I didn't need to be a radiologist to interpret the picture that materialized on the screen. His brain was being crowded to the left side of his skull by a large density. He was bleeding into his brain.
"Ew, this guy's done" the technician quipped.
Slowly all the satisfaction of a successful resuscitation faded into the sad reality of the inevitable. A life saved only to be lost again at a later time. We would go through the motions of sending him to a trauma center to have the bleeding in his brain stopped and cleared out, but by this time the damage to his brain would be too extensive. I stared through the glass at the young man lying still on the stretcher. Yesterday he got up like it was any other day. How could he know that was his last one?
The story of how he ended up where he was from the people that brought him was inconsistent and suspicious at best. The type of bleeding in his brain could only be the result of some sort of blunt force trauma. Although he had no obvious signs of trauma, a well placed bat or other object to the back of the head can do plenty of internal damage without showing much on the outside.
The police came and took statements as our young patient journeyed by helicopter to the hospital where he would later die. We would never know the real story behind what happened to him.
I left that day with the reminder that the power of life and death will never rest in our hands, no matter how advanced our tools. Only God know the days of a man's life and He alone decides.
Tuesday, November 9, 2010
Wednesday, June 9, 2010
For Good
Every now and then I leave work feeling like a good nurse. Like perhaps I actually made a difference in someone's life that day. I had the blessing of that experience earlier this week.
My patient was an old man, brought to us for a general decline in function and some signs of maybe an infectious pneumonia. He had a history of a stroke and his right arm was curled into his body where it had been useless for years. He could move his left arm slightly, but his hand was so gnarled from arthritis that its usefulness was limited. He watched me as the paramedics moved him from their stretcher to ours, recounting their understanding of his past and present medical issues. His eyes seemed lucid, like he was aware of what was happening, but any question I asked him was met with silence, or at best a slight grunt.
“Do you have any idea of his baseline mental status?” I asked the paramedics.
“Mmm… not sure. He’s had a few strokes… doesn’t sound like his wife will be coming in either, she has the flu.”
A few minutes later while sitting at the nurses’ station with his chart the doctor approached me. “I can’t stand how that medic or whoever she was talked to that patient.”
“What do you mean?” I asked.
“She’s talking to him like he’s stupid or 5 months old. A grown man doesn’t appreciate that kind of condescending attitude. He knows what’s going on – he just has expressive aphasia.”
I paused for a moment to take in the irony of that statement coming from the most condescending doctor I know, but what he said influenced the way I treated my patient the rest of the day. Expressive aphasia is the fancy medical term for when a stroke leaves you with the ability to understand everything said to you and everything going on around you, but robs you of the ability to be able to form and express words. It’s like being muzzled… you try to speak, but can’t seem to ever get the words out. I’ve seen it in patients with a brand new stroke, and the frustration and fear in their eyes is a truly horrible thing. In an older person with this condition, it is far too easy for caretakers and others to make the assumption that they no longer have their mental faculties and to fail to explain things to them or treat them like they would someone who can grasp what’s happening.
Taking all this in mind, I made a point the rest of the day to address my patient by name, to look him in the eyes and explain everything that was happening, what we were waiting on, and what he could expect. He could nod yes and no, and I did my best to help him communicate his needs in this way. I listened when he tried to make words and reinforced that I knew he was trying to communicate, but wasn’t able to find the words.
At the end of my shift I went in to say goodbye and to let him know he would be admitted to a hospital bed shortly and dinner would be waiting for him with someone to help him eat it. As I was about to go he was reaching over to me with his one usable arm. Very slowly he took my hand and reached it over to his mouth to kiss it. Then he held my hand to his chest for a while and looked up at me with glistening eyes and a small grateful smile. All the thank you cards in the world could never amount to that moment and that gesture of gratitude by a little old man.
As I left that day, I was so thankful for the reminder I had from the doctor about the man’s need for respect. It’s too easy when you are busy and under pressure and when someone can’t communicate with you, to fail to give it to them. To buzz in and out, taking blood and starting IVs and pushing medications without ever letting them know what’s going on. It was good to be reminded that what I do can affect people for good or for bad, even if I never know it. This time it was for good.
My patient was an old man, brought to us for a general decline in function and some signs of maybe an infectious pneumonia. He had a history of a stroke and his right arm was curled into his body where it had been useless for years. He could move his left arm slightly, but his hand was so gnarled from arthritis that its usefulness was limited. He watched me as the paramedics moved him from their stretcher to ours, recounting their understanding of his past and present medical issues. His eyes seemed lucid, like he was aware of what was happening, but any question I asked him was met with silence, or at best a slight grunt.
“Do you have any idea of his baseline mental status?” I asked the paramedics.
“Mmm… not sure. He’s had a few strokes… doesn’t sound like his wife will be coming in either, she has the flu.”
A few minutes later while sitting at the nurses’ station with his chart the doctor approached me. “I can’t stand how that medic or whoever she was talked to that patient.”
“What do you mean?” I asked.
“She’s talking to him like he’s stupid or 5 months old. A grown man doesn’t appreciate that kind of condescending attitude. He knows what’s going on – he just has expressive aphasia.”
I paused for a moment to take in the irony of that statement coming from the most condescending doctor I know, but what he said influenced the way I treated my patient the rest of the day. Expressive aphasia is the fancy medical term for when a stroke leaves you with the ability to understand everything said to you and everything going on around you, but robs you of the ability to be able to form and express words. It’s like being muzzled… you try to speak, but can’t seem to ever get the words out. I’ve seen it in patients with a brand new stroke, and the frustration and fear in their eyes is a truly horrible thing. In an older person with this condition, it is far too easy for caretakers and others to make the assumption that they no longer have their mental faculties and to fail to explain things to them or treat them like they would someone who can grasp what’s happening.
Taking all this in mind, I made a point the rest of the day to address my patient by name, to look him in the eyes and explain everything that was happening, what we were waiting on, and what he could expect. He could nod yes and no, and I did my best to help him communicate his needs in this way. I listened when he tried to make words and reinforced that I knew he was trying to communicate, but wasn’t able to find the words.
At the end of my shift I went in to say goodbye and to let him know he would be admitted to a hospital bed shortly and dinner would be waiting for him with someone to help him eat it. As I was about to go he was reaching over to me with his one usable arm. Very slowly he took my hand and reached it over to his mouth to kiss it. Then he held my hand to his chest for a while and looked up at me with glistening eyes and a small grateful smile. All the thank you cards in the world could never amount to that moment and that gesture of gratitude by a little old man.
As I left that day, I was so thankful for the reminder I had from the doctor about the man’s need for respect. It’s too easy when you are busy and under pressure and when someone can’t communicate with you, to fail to give it to them. To buzz in and out, taking blood and starting IVs and pushing medications without ever letting them know what’s going on. It was good to be reminded that what I do can affect people for good or for bad, even if I never know it. This time it was for good.
Friday, January 29, 2010
Root of Bitterness
“But if you do not forgive others their trespasses, neither will your Father forgive your trespasses.”
At work the other day, I had a startling reminder of the consuming and destructive power of bitterness. Something about holding onto and meditating on offenses begins to dissolve someone from the inside out… like acid.
******
His hair and beard where unkempt and matted. His feet were stained from raw sewage he had been walking in. At first sight you would assume he was your average homeless guy, hygiene and mental function highly corroded by years of various street drugs and alcohol. The door to his room was open wide, and he was lying face up on the stretcher wearing nothing but a sheet, mumbling in low, angry tones to himself.
He’d had the pleasure of being escorted to our humble facility unwillingly after loudly threatening to kill himself and his niece after some sort of fallout with his landlord. Threaten bodily harm to someone else… you go with the police to jail. Throw in yourself…you go with the paramedics to the ER.
He’d been in the ER for hours already when I came on shift. During his stay he had loudly cussed out several crisis workers and threatened to hang himself with the call light cord. Now his room was stripped of even standard equipment like blood pressure cuffs and oxygen monitors; anything with cords long enough to become weapons of self detriment. He would mumble and shout and engage anyone who made the mistake of loitering outside of his room in a recounting of the many various wrongs done to him by his landlord, niece, authorities, and hospital staff.
“They took my f&*king cat, man! My landlord threw me out for no f&*king reason, now I’m f&*king homeless! And I’m starving to death, but these f&*ckers won’t f&*king feed me! And I’ve been yelling my head off about this f&*king headache I have, but they won’t even give me any f&*king Tylenol!” He rambled in circles; to himself… to the wall…to the wide-eyed family member of the patient next store… to every member of the medical staff that set foot in -or near- his room.
But between his long repetitive rants on the injustices of his life, he had surprising interludes of … well… normalness. During these interludes I learned that he’d been married, was well traveled, and was fluent in Japanese. The stark contrast between what sounded like a once normal, productive, even interesting life and the cursing, sneering, pouting man now before me was unsettling. The offenses and injustices of his life, whether real or imagined, had been allowed to take root. He had fostered them, dwelt on them, built on them until they destroyed the very foundation of a once rational mind.
When I last glimpsed him that day he was walking around his room, naked but for the sheet he held loosely around his dirty body. Face contorted and indignant, he was recounting to the walls once again his injustices. His bitterness had literally driven him mad.
Now when I find myself mulling over an offense, I picture his face, and remember the stern warning Christ gave regarding our bitterness.
At work the other day, I had a startling reminder of the consuming and destructive power of bitterness. Something about holding onto and meditating on offenses begins to dissolve someone from the inside out… like acid.
******
His hair and beard where unkempt and matted. His feet were stained from raw sewage he had been walking in. At first sight you would assume he was your average homeless guy, hygiene and mental function highly corroded by years of various street drugs and alcohol. The door to his room was open wide, and he was lying face up on the stretcher wearing nothing but a sheet, mumbling in low, angry tones to himself.
He’d had the pleasure of being escorted to our humble facility unwillingly after loudly threatening to kill himself and his niece after some sort of fallout with his landlord. Threaten bodily harm to someone else… you go with the police to jail. Throw in yourself…you go with the paramedics to the ER.
He’d been in the ER for hours already when I came on shift. During his stay he had loudly cussed out several crisis workers and threatened to hang himself with the call light cord. Now his room was stripped of even standard equipment like blood pressure cuffs and oxygen monitors; anything with cords long enough to become weapons of self detriment. He would mumble and shout and engage anyone who made the mistake of loitering outside of his room in a recounting of the many various wrongs done to him by his landlord, niece, authorities, and hospital staff.
“They took my f&*king cat, man! My landlord threw me out for no f&*king reason, now I’m f&*king homeless! And I’m starving to death, but these f&*ckers won’t f&*king feed me! And I’ve been yelling my head off about this f&*king headache I have, but they won’t even give me any f&*king Tylenol!” He rambled in circles; to himself… to the wall…to the wide-eyed family member of the patient next store… to every member of the medical staff that set foot in -or near- his room.
But between his long repetitive rants on the injustices of his life, he had surprising interludes of … well… normalness. During these interludes I learned that he’d been married, was well traveled, and was fluent in Japanese. The stark contrast between what sounded like a once normal, productive, even interesting life and the cursing, sneering, pouting man now before me was unsettling. The offenses and injustices of his life, whether real or imagined, had been allowed to take root. He had fostered them, dwelt on them, built on them until they destroyed the very foundation of a once rational mind.
When I last glimpsed him that day he was walking around his room, naked but for the sheet he held loosely around his dirty body. Face contorted and indignant, he was recounting to the walls once again his injustices. His bitterness had literally driven him mad.
Now when I find myself mulling over an offense, I picture his face, and remember the stern warning Christ gave regarding our bitterness.
Monday, January 4, 2010
For love or duty
I think that there are jobs that you love in the sense that you look forward to going to work each morning and jobs that you love but... have just the slightest feeling of impending doom each time you drive to work. I can honestly say I love my job. There isn't any other place I could see myself at this point in my life than the noisey, chaotic churning of humanity that is the ER. Yet at the same time, I don't think I could honestly say I ever look forward to going.
My quick drive to work is my prepping session. I try to vamp myself up for whatever unknown is around the corner. I make my ritualistic plea to God to help me do the best I can, not screw anything up, and not get more than I can handle. I pray for skill, for patience, and for compassion.
I gauge the fullness of the parking lot as I pull in to try and get a feel for what possibly awaits on the other side of those sliding glass doors. Not much parking... three ambulances blocking the view of the doors... not a great sign. So what will it be tonight... Steady? Crazy? Pure unadulterated chaos?
I slide my badge through the electronic reader at the doors to our trauma bay and they slide open with a click. I'm greeted by the familiar pulse of fluorescent lighting and din of voices punctuated by monitor alarms and the ring of the base station phone. Paramedics are sliding someone strapped to a backboard with a cervical collar around their neck onto one of our hallway gurneys. Somewhere in the background someone is screaming obscenities at the top of their lungs.
Welcome to my world...
My quick drive to work is my prepping session. I try to vamp myself up for whatever unknown is around the corner. I make my ritualistic plea to God to help me do the best I can, not screw anything up, and not get more than I can handle. I pray for skill, for patience, and for compassion.
I gauge the fullness of the parking lot as I pull in to try and get a feel for what possibly awaits on the other side of those sliding glass doors. Not much parking... three ambulances blocking the view of the doors... not a great sign. So what will it be tonight... Steady? Crazy? Pure unadulterated chaos?
I slide my badge through the electronic reader at the doors to our trauma bay and they slide open with a click. I'm greeted by the familiar pulse of fluorescent lighting and din of voices punctuated by monitor alarms and the ring of the base station phone. Paramedics are sliding someone strapped to a backboard with a cervical collar around their neck onto one of our hallway gurneys. Somewhere in the background someone is screaming obscenities at the top of their lungs.
Welcome to my world...
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