Monday, August 29, 2011

Hurricane Aftermath

Walking through the "hurricane" just two blocks to the hospital was an odd experience yesterday. The day was beginning to brighten through the clouds and wind whipped around me gently. Leaves and branches were scattered about the street and the first cars were beginning to make an appearance on the roads. In front of the hospital, a battered little tree had split in half, but it was removed by the end of my shift.

It was oddly quiet, strangely silent. I normally associate the area in front of the hospital with lots of activity- from the researchers, physicians, students gathered around the little tables and benches, the food carts and their billowing fragrant smoke clouds, to the constant battle between pedestrian and motor vehicle in the crosswalk. All of that was gone. I was the sole, silent figure walking on the rustling, deserted street.
The normally busy employee entrance was closed and I made my way through the main entrance guarded by one lone security guard. Inside the hospital, life was also suspended. Valhalla, or the "section above", was unfortunately still being used to quarter my night-shift co-workers who had to work again the following night, so I was assigned elsewhere. In my new section, I arrived to see we had 6 providers/doctors for only 6 patients! Where normally our census boasted at least 80-90 patients at any given time in the ER, we had less than thirty in house, some of which were already discharged to go home. With each new EMS arrival, we would ask- how is it outside? Not bad, they would reply- the sun is coming out.

Sure enough, our patients started arriving. After staying 24 hours indoors, they flooded our gates, eager, angry, anxious. My first patient that came in during this rush was a young man and his hood rat friend, who sassed us from the moment she walked in. She would not elucidate her relation with him, whether familial, fraternal, or professional, but proceeded to try to speak for him, demanding amenities such as blankets, pillows, and food. He apparently arrived because he 'asked someone for a cigarette and when he smoked it, felt high." Good riddance when we kicked both of them out after determining no foul play.

We had, oddly enough, several very amply padded patients come in by ambulance. Their chief complaints were: firstly because they had lost power, secondly because they were alone and scared and thirdly because they wanted us to refill their at-home oxygen tanks. It took a lot of staff-power to move and shift them about, as they barely fit into our 700lb capacity bariatric stretchers. After whatever action we had to perform, whether it was holding legs open for a foley catheter for a UTI or moving them up from sliding too much in the stretcher or even just moving them to our stretcher, four of us would be breathless and incredulous. I will refrain from repeating some of the names I heard referring to these poor immobile folks. But wow, what are the chances we would get three of them within the same hour?

I had a very sweet old lady who then came in, for bleeding gums. If I should live to be 95 and my only problems were bleeding gums from a tooth extraction and deafness in one ear, I should be a very happy little old lady, grinning every day ear to ear with the bloody gauze in my mouth. My sweet LOL was totally with it and even chastised the nurse for pulling her clothes off unnecessarily- it's just a tooth, for goodness sake! She reprimanded. As I was helping her get up and dressed, she commented to me, it's so much harder to manage the motions of dressing with somebody else, isn't it? I gently squeezed her foot into her brown loafers and pulled her pants up for her and thought about what she said. How many babies, children, invalids, and elderly people must have passed through her life that she must have cared for. I pushed her in her wheelchair to the waiting room to await her daughter's car so she wouldn't have to sit in the draft.

More and more patients started coming in- and our tube system was down, again. I made 4 courier trips to the blood lab... on my return, the team leader nurse pulled me aside apologetically and said, "I'm sorry S, you have to sit." Soon, I had the prattling pretender (again) on my hands and passed the evening in more or less of a stupor, listening to him gab.

What a night! Our manager was wonderful through it all and had stayed the overnight shift, didn't sleep, then continued to work until the end of my shift. He ordered pizza and soda (white birch beer is delicious with pizza!) for us as a morale booster for coming in during the hurricane. Free food is the best morale booster there could be. <3 Our hero!


Disappearing into the Background

It was dark and still outside- the wee hours of a late summer night. A man limped through a long outdoor hallway lined with construction tarp and concrete into a brightly lit room. It was large room and had many chair and several people- he chose one in the very back where no one would pay much attention to him. Nobody saw him, or rather, nobody paid attention to him. Scruffy, muddy, and quiet, he hid in a chair that could not be seen by the triage desk. The people sitting around him paid him no mind. They were too worried about getting into our busy emergency room, never mind the bundle over there in the corner. A storm was coming, you see, and everyone wanted to avoid going outside.

The last time I saw this man- his pseudo-scholarly build, straight nose, glasses, beard, balding head, khaki shorts and polo-style shirt- he was covered in feces in critical care. The last time I saw him before that, he was stealing my things. Mr. Poopy was the stuff of legend in my mind. I felt guilty, but I disliked him on a personal level. I recoil at the thought that he had touched my life by touching my things. He was an unwelcome and dangerous intruder once to my polite academic community at a prestigious research institution and given me nightmares (before I became the tough old cat I am now from working in the ER). He was a homeless man in academic garb, a total counterfeit, opportunist and leech of the system. My co-workers know him on first-name basis because he had been there so many times. My tech hated him- called him the scum of the earth... yet, my tech died, and this cucaracha continued to live. I am ashamed to admit thinking these unbecoming thoughts last week in critical care, but I won't lie- I didn't have even a single reason to like the guy.

No one paid attention to Mr. Poopy (Tales of an Emergency Tech: Coming Back Full Circle) as he sat down in that chair, huddled down in the middle of the night. Maybe he felt pain- he had an extensive cardiac history... More likely, he might have just wanted to take refuge in a place he had been hundreds of times, away from the churning winds and penetrating wet. He curled up and closed his eyes, as he was apt to do. He was a very quiet man- shy, and addled in some ways. He couldn't answer questions quite the way you wanted him to. In any event, he probably went to sleep. It was going to be a long wait.

It was mid-morning before someone realized that he died in that chair in the corner. He was already blue- had probably been so for about 10 hours. And nobody noticed... not the triage nurses, not the visitors to the ER, not the security officers... Who would have thunk?? His body was taken to a private room for a last chance revival- but I'm sure it didn't last long.

Suddenly, a name, a face, a smell we've known hundreds of times, permanently seared into our memories- was gone. He was swiftly wiped from the face of the earth with no further questions nor inquiries. There was a general feeling, more of relief than sadness- the expensive interventions and work-ups he received gratis wouldn't happen anymore, we were minus 200 visits/year on our census, and the city was minus a limping, quiet, and creepy old homeless man. Just like that, he became a memory, if anybody else remembers, that is. How terrible and profoundly sad it is to die like that.
Rest in peace, Mr. Poopy. I hope wherever you are now is better than where you were.


Sunday, August 28, 2011

The Section Above All The Rest

There is a section in our Emergency Room that is different from the others. It looks like a real hospital ward and smells like fried chicken and warmth. Compared with our real Emergency Room downstairs, it is like a hotel. Here, patients with stable vital signs, screened against drunks and the seriously ill, come to rest. They have call buttons, they have TV's, and they have yours truly, S, to serve them during their stay at Hotel ER.

After a few ghoulish shifts downstairs, working in heaven isn't bad at all. The isolation with a select few co-workers is ripe for camaraderie as well as vicious gossip, depending on who is there. It is a place where cougars can fawn over a new nurse and nothing gets done until closing time so no new patients are sent upstairs, or a really great team-leader nurse and attending physician can lead an organized healthcare battalion.

Last night, we had to close the section down early, in the wake of Hurricane Irene's approach. Our day staff did not want to drive home in the weather and drive back in the middle of the storm this morning, so they get to stay in "heaven". A charge nurse even sent cleaning people up to sterilize the room she was staying in. I made sure to stock the closets with extra blankets. I hope they don't ravage my section because I will have to restock everything before patients arrive today!

Stay safe in the storm and if I don't blow away, I will be back to update with adventures of storm-day.


Saturday, August 27, 2011

Adventures in Sitting: The One that Broke Me

There was a time, y'all, not too long ago, that I was living in the valley of kittens and rainbows. Every patient, regardless of ailment or creed would get a blanket, a sandwich, and a smile (if the medical situation allowed). People weren't incapable of evil- sometimes their disease states just made them grumpy. Even my rowdy drunks didn't mean any harm- their curses and threats were forgotten by them before the next time they request an urinal or sandwich. If you were kind to them, I thought, people would respond in kind.

Oh to be young and naive! A shift in the drunk tank soon cured me of that.

Entering my shift in the drunk tank, I was given report of my 3 patients. There was Ms. Opportunist in the middle, Mr. Passed Out in the back, and Mr. Two-faced in the corner. Mr. Passed Out was passed out, Ms. Opportunist was sitting comfortably, and Mr. Two-faced was sleeping in his stretcher- he had been like that all day, the tech told me. Ok, that's fine, I replied, anything I need to know? Nah, they've been quiet all day, she said.
I was all set. My cart was equipped with water, sandwiches, and whatever else. Mr. Two-faced rolled over and woke up.

Mr. TF: Hi, miss, can I get a drink of water?
S: Sure, here you go.
Mr. TF: Thanks a lot, you're really nice.
S: It's my job.
Mr. TF: Miss, can I get just another glass? I'm parched.
S: Sure.
Mr. TF: Thank you so much. That really hits the spot.

He was very polite and kept to himself- he was easy-going and quiet. He asked for a sandwich half an hour later, stating he hadn't eaten in a day or two. No problem. He was very thankful for it- so thankful, he asked for another one. Again, no problem. He was comfortable, I was comfortable, things were good.

I checked his vital signs and breathalyzer- he was on the cusp of sobriety where the residents might release him, but still a few points higher than the dogmatic new resident might like. He asked whether he was going home, so I let him know it would be a little while longer. No problem, he said.

He was as sober as was possible for a chronic drunk, I could tell, and was getting restless. I let him go to the bathroom. When he returned, he perched on the edge of his stretcher. He acquiesced when I asked him to sit back all the way, though.

Without warning, he got up and walked to the side of his stretcher. Warning bells sounded in my head.

S: Hey Mr. Two Faced, what are you doing?
Mr. Two Faced: Just looking to see my stuff is here.
S: When you're done, can you please sit in the stretcher?
Mr. Two Faced: Sure, honey, anything you ask. Where is my stuff?
S: Isn't it back there?
Mr. Two Faced: No, where is it?
S: Let me check in the back closet..
Mr. Two-Faced: is it there? My big bag full of all my clothes?
S: Hmm, no, I didn't see it. I will call the nurse to see if she saw anything in the section you came from.
Mr. Two-Faced: Aw ****, I can't believe you guys lost my ****. again! Twenty times I come here, twenty times I lose every *** **** thing I own. I am homeless, y'know, I dont have much. **** me. **** you.
S: I'm calling the nurse, hold on.
Mr. Two-Faced: No, Get a manager over here, right now.
S: Mr. Two-Faced, I am doing all I can to locate your belongings. Will you please give me a minute, sit for a bit and we'll see what's going on?
Mr. Two-Faced: All my clothes! I don't have nothin'. All my ******** clothes. You guys better have a lawyer, cause I'm suing your ******* ****** for all it's worth. Take my clothes, eh? You'll pay for it.
S: Nobody here wants your clothes, Mr. Two-Faced, we're searching for your stuff right now.
Mr. Two-Faced: **** you. All of you are losers. You're phony. You pretend like you care then you lose all my ****. Well **** you.
S: I didn't lose anything. You were here before I came in.
Mr. Two-Faced: You work here, you lost my ****. End of story. You don't give a **** if I live or die or if I lose all my ****. You rotten *****!
S in a soft voice: I do care, Mr. Two-Faced. I'm really sorry you lost your stuff- really, I am. We're doing our best to find it and it has only been a minute since I made that call. Please, just hold on and I'm sure your stuff won't just disappear. Nobody here would want your clothes.
Mr. Two-Faced: **** you. I want a manager. RIGHT NOW. Go on, do your job, call the ******* manager cause I am gonna sue all of you *******. Dirty ******, what are you waiting for?

At this moment, Ms. Opportunist- can I please go to the bathroom?
S: Sure, but come right back.
I watched her from the door as Mr. Two-Faced starts pacing and screaming at me again. I have never had anyone scream at me like that, voice breaking from all the strain. What did I do to deserve this? I FED him, I thought with revulsion. I am keeping homeless psychotics like this alive so they could abuse me and abuse the system.
Mr. Two-Faced: This place sucks! All you could do is feed me bull**** about how you care and ****, but you don't give a ****. None of you care. You're heartless ******* who don't care if I live or die.
S: I do care, Mr. Two-Faced. I'm sad you can't see it.
I watched Ms. Opportunist come back out of the bathroom... and run out the door. I had completely lost control. Backing out of the room as Mr. Two-Faced tried to swing at me, I called security, and to my horror, burst into tears.

He had turned a switch and I was unprepared for his sudden outburst, after 12 hours of mind-numbing work already. He had been testing me and knew exactly which buttons to press. I cried for you, Mr. Two-Faced. You are just too broken, biting the hand that you were so thankful for, that fed you not too long ago.

Security jumped on Ms. Opportunist, pinned her down, brought her back, and restrained her. Mr. Two-Faced was thrown out. Mr. Passed Out was still passed out. And I grew up a lot that day. I will never forget the screeching voice, the angry eyes, and the semblance of civility that he put on when I first met him. Should we meet again, I have some choice words for Mr. Two-Faced.


Friday, August 26, 2011

Weak Acid, Strong Consequences

In Urgent Care, we are supposed to receive patients that triage nurses deem to have minor problems. Because triage nurses are not omniscient, however, occasionally we get something that is very serious. For example, we had a "minor motor vehicle accident" victim arrive, whose symptoms started and worsened while she was being treated, eventually leading to one-sided numbness and tingling. I transferred her to the trauma room soon after as a full-trauma so they could do a full work-up for spinal cord/nerve damage.

The other day, I saw that we had a "chemical burn" coming. The man and his relative were non-English speaking, but handed me a materials safety sheet that listed concentrated "Hydrogen Fluoride". He had accidentally submerged an index finger at work while cleaning masonry. I saw that the finger was inflamed with small, dark, funnel-like holes. HF, as I learned in high school and college chemistry, is a relatively weaker inorganic acid. Neither the PA nor I knew much more before we looked it up online.

Apparently, HF burns of less than 3% of a person's body can cause systemic failure and kill a person.
According to medscape, these are mechanisms behind how that can happen:

"The 2 mechanisms that cause tissue damage are corrosive burn from the free hydrogen ions and chemical burn from tissue penetration of the fluoride ions.

Fluoride ions penetrate and form insoluble salts with calcium and magnesium. Soluble salts also are formed with other cations but dissociate rapidly. Consequently, fluoride ions release, and further tissue destruction occurs.

Systemic toxicity occurs secondary to depletion of total body stores of calcium and magnesium, resulting in enzymatic and cellular dysfunction, and ultimately in cell death. Majority of deaths are resulting from cardiac arrhythmias that were precipitated by hypocalcaemia and consequent hyperkalemia."

Yikes!! How long had it been since he was exposed? A day and a half ago! The inflammation might have been from the acid already etching away at the bones in his hand. That's much too long to not have been treated, so we sent him immediately to critical care. Our critical care physician deemed it serious enough to be immediately sent to the burn unit at a nearby hospital and the man was sent there by ambulance.

However, we found that the other hospital, through a serious oversight, did not look up how to treat HF burns and ignored the suggestions by our own physician to treat him immediately with intravenous calcium gluconate... and discharged him with bacitracin ointment and a few band-aids.
I've been thinking of him for the past few days, hoping that the polite young man will be able to keep his finger/life. It's a dangerous world we live in....


Thursday, August 25, 2011

Drunk Tank Pentameter

The night was waning, shift was ending fast,
when charge had tracked me down with this request:
please open up the doors to yonder room,
where idiots who drink avoid arrest.

Thus far I *had* been very fortunate,
escaped the boring fate it is to sit.
Well bring them on, this can't be all that bad,
With forty minutes left, why not commit?

The dank and dim-lit room was prepped and set,
the stretcher sounds came drifting to my space,
a million miles away my mind had rest',
in girlish dreams of etiquette and lace.

Hi ho- the first intoxicated hailed,
but why and how did I end up o'er here?
You're drunk, the tech who brought him in had sneered,
with that, she turned her fat and ugly rear.

Come back! My resident had yelled- in vain,
and anger, seething, hot, and fueled by drinks-
induced the large and dang'rous brute to leap
from bed with limber strength to strike the minx.

Now I had no desire to be thus stuck-
though no immediate danger came my way.
against the wall I slunk to freedom safe,
escaping waving limbs and spittle spray.

Security came quickly at my call,
my boor became a gentleman in haste.
And all was peaceful, only for a while,
because the tech returned, smirk unerased.

Now I don't really mean to yell, she said,
the panic button, you have heard of it?
Stay *in* the room, and you will be okay,
Six years, I've worked and I have not been hit.

I thanked her with a smile upon my lips,
with irony appropriately placed.
When you're here, which will happen soon, I'm sure,
You might not boast an injury-less face.

When there is malice brooding in your breast,
don't instigate my drunks and cause a mess.
Naivete may seem to be my fault,
advice like yours, I could not ---

---regardless, shifts were changing very soon,
my soft and comfy bed was calling me to sleep,
which rare occasion is a cause for glee,
though even dreams are not immune from creeps.


Wednesday, August 24, 2011

Sundown Talk-down

"Can you please help me?" A nurse looked frazzled, "I have an old lady sundown-ing in room 12. She's pulled her IV out."

"Sure," It was the end of my shift, but I still hurried into the room to see little Mrs. Hallucinating sitting with her legs hanging over the railings.

She had undressed herself, sitting on a half-undone diaper, and thrown all her bloody bedding on the ground. Staring at it, she was exclaiming, "look at all that blood!"

S: "That sure is a lot of blood, Ms. H. Let me take a look at your arm."
Mrs. H: "It's not MY blood- I was watching it appear all of a sudden from that wall over there. I'm sure glad it's not mine. It's an awful lot!" She tried to snatch her arm away.
S: "Oh look, you got it all over you. Let me clean some of it off!" She acquiesced to my cleaning motions. Meanwhile, I held pressure over the bleeding vein until it stopped.
Mrs. H: "Well I'm in no hurry- I'm waiting here for the vets to get back."
Nurse: "The vets? You mean veterans?"
S: (I cut in) "Where do you think you are, Mrs. H.?"
Mrs. H: "I'm at the vet's. I'm waiting for the dogs."
Nurse: "What dogs?"
Mrs. H looked very confused.
S: "Do you have dogs, Mrs. H?"
Mrs. H: "No, I don't have any dogs. But you do, right there." She pointed at the wall.
Nurse: "There are no dogs here..."
The nurse and I exchanged looks.
Mrs. H: "There are two!"
Nurse 2: "I don't have dogs, I'm a cat person."
S (under breath): "Though we have dogs in the center hallway right now..." Referring to the 8 rowdy drunks in the makeshift drunk tank.

Meanwhile, Mrs. H. is struggling against us as we are trying to clean her. The nurses were exasperated. It was time to distract her, as terrible that it is, so we could get her situated.
S: "Mrs. H., are you English?"
Mrs. H: "No. I married an Englishman, but I am German."
S: "Oh, that's nice."
Mrs. H: "Yes, it is, isn't it?"
S: "Absolutely, can I see your arm so I can wipe it with this wet towel?"
Mrs. H: "You don't have to bother."
S: "Oh, but wouldn't it be nice to be cleaned up?" She let me take her arm.
Mrs. H, accepting: "I suppose it would be." She looked into my face and as I smiled, she smiled back and I took the opportunity to slip her hands through the sleeves of a new hospital gown. At least now she was dressed.

We had similar struggles with trying to get her diaper off, trying to stuff her legs back through the bars, and to replace the sheet she had soiled. Each time, I would distract her, then as a group effort, we'd sweep the sheets/diapers/cleaning pads under her. At first, she resisted lying down, but then I convinced her she must be tired (it was past midnight), at which suggestion, she laid back comfortably and stopped trying to climb on the "staircase" she apparently saw protruding from our blank wall. Then she did not want me to tuck her in a blanket, so I talked her into allowing me to make her comfortable and snug.

I stuck around for a little while, trying to keep her calm, because she would speak normally, then warn me about the bedbugs crawling all over the sheets, at which point, she would spring up and try to pick at them with her fingers.

Because the present was confusing and distracting for her, I tried to keep her in the distant past, where she told me about her parents, siblings, and husband. Using the ring on her finger as a prop, I would ask her to tell me the story behind the ring, and she would be distracted long enough not to rip out the second IV she discovered on her forearm.

Twenty minutes after I was supposed to leave, I mentioned how late it was and asked whether she was tired.
Mrs. H: "You young girls are just so sweet. I think I will take a wink right now, if you don't mind."
S: "Not at all, Mrs. H. Sleep well!"
Mrs. H: "All right, I will turn in, then."

She pulled the covers up to her chin. I quickly changed out of my scrubs and passing the hallway on my way out the door, looked in to see Mrs. H. being chastised by another tech for trying to climb out of the bed. Oh Mrs. H... I hope they don't tie you to the bed upstairs.
Though she is active and confused, she is also quite manageable and sweet. I hope I can be half as spry when I'm in my 90's...

Tuesday, August 23, 2011

Idle Tongues

At work tonight, I found out I am an exotic bisexual, great at performing oral sex, and wild in bed. Great to know- I always wondered about that, but now I'm sure, since I heard it from my co-workers who know much more about it than me. While I was covered in (other peoples') blood, much less. Silly me. Who needs to watch TV dramas when you can live the real thing working in the Emergency Room? I wish I lived half as exciting a life as they think I do. ;-)


Monday, August 22, 2011

Because Dentistry is just like Emergency Medicine

"Hi Mrs. Dentist's Wife, my name is S and I am a technician here. There will be a lot going on at once, so I'd like to explain what will happen. First, I will help you into this hospital gown and put you on our monitor. Then, I will be taking an electrocardiogram and nurses will come in to insert an IV and draw labs..."

"Now just wait a minute," her husband interjected, "I'll tell you exactly what she needs." He puffed up his chest, and straightened to his full height to try to intimidate me. "She doesn't need an EKG or labs, she needs to go to the OR now because she has a small bowel obstruction."

"Sir, I'm sorry I don't know about any of that, but it is protocol for us to get a cardiogram for every patient of a certain age that comes to our critical care section."

"I know you don't know anything. But I'm here telling you that she doesn't need an EKG."

"I'm not in charge of that, sir, but..."

"Well find me someone who is."

As it turns out, this gentleman was a dentist; he and his wife were visiting from the midwest when she had abdominal pain and decided to stop by our fair establishment. What possessed him to try to bully us into treating her as he thought fit was a mystery to me, but he remained surly the whole visit. Luckily, I did get my cardiogram after several rounds of different people explaining that if she were to be admitted and to go to the operating room, she would definitely need an EKG.
I sure wouldn't want this guy pulling any of my teeth!


It Doesn't Matter How Far You're Gone

It seems to be the week of repeat visits by patients over 90 years old. I had seen Mr. Far Gone many times before. He could not walk nor move nor talk- he was not mentally cognizant, hence incapable of putting the thought processes together to do so in a deliberate way.

The EMT's plunked him down on the bed and he quietly let us do our work-up with the monitors, ekg's, labwork, etc. He had an innocent look about him, with a mouth-agape, toothless expression as his eyes followed what we were doing, but did not process any further.
Hi Mr. Far Gone! I had greeted him when I walked in, and his head swiveled toward me, recognizing the sound of his own name.

For several hours, he was very quiet. Suddenly, I heard from his room a terrified "Help me! Please!" Rushing in, I found him terrified and shaking "please!" he looked in my eyes, "please help me!" Tears flowed down his cheeks and I did not know what to do but take his hand. I realized that he suddenly became aware and scared that he was in an unfamiliar place. Stroking his hand, I cooed to him, "You are in the hospital, Mr. Far Gone, the hospital. They will take good care of you here." He looked at me, not processing my words. He only knew that I was stroking his hand. He grasped mine in a childish way and I just stood there with him, holding his hand, letting him watch my face smiling back at his.

It was the most basic and primitive of human needs- to know you are safe. It was the most basic and primitive of human actions- to hold hands. Maintaining eye contact with a mind far gone but not entirely, I did my best to reach that basic human understanding that things were going to be ok, despite a large list of other things I had to do. In that short moment, time stood still as I waited for him to comprehend. His eyes were locked on mine, desperate and full of tears. After a few minutes, I was called into another room, and patting his hand, I tucked it carefully under the covers. He watched me leave the room. Maybe he was much farther gone than before or maybe I had calmed him this time, or maybe something had happened to him during his time in the nursing facility that had silenced him for the most part- I don't know, but he did not make another peep during his visit. On previous visits, he would plead and plead with us to help him every few minutes with no hope of appeasing him.

It is so hard to know the right thing to do with the old and demented patients; for some, the attention would spur more attention-seeking behavior. For others, it would help, but then they would forget the calmness in a minute and cry out again. For yet others, it would not make a difference.

Every day here is a learning experience- I am thankful for that.

Sunday, August 21, 2011

The Anzianos

The first time I saw Mr. Anziano come into my critical care section, little Mrs. Anziana followed the EMS stretcher closely with the dedication and concentration written on every wrinkle of her face. It was extremely busy and everyone was milling about so the nurses tried to shoo her out, stating that they wanted to get Mr. Anziano settled in and many tests done. "I 'ave been taeking care of him my whole lahfe!" Mrs. Anziano declared, "there eez nahthing about him I 'ave not seen." She stood resolutely by his bed.

This would have been fine if she did not start coming in while the nurses were drawing blood to inspect their work, or talking to anxiously him in melodramatic Italian. They asked me to escort her out. She refused, of course, but I coaxed her to at least take my arm and walk to the waiting room, just for a few minutes, I promised. She kept staying her steps and looking back, bemoaning that it was ludicrous she should be "shut out" when they had been married over 60 years as teenagers in Italy and how much she hated Germans. "You don't have a German boyfriend, do you?" Err, no- "Good! Those gooud for nahthing---" I let her talk on and left her sitting impatiently in the waiting room.

Returning to perform an EKG, I was putting stickers on Mr. Anziano's chest when the curtains rustled and Mrs. Anziana burst through- "I wanted to see eef I could help." The nurses escorted her out again and again and again, but she came back each time as soon as we left her in the waiting room. She was frail and elderly, but resolution made her strong- it did not seem appropriate to call security on her, but I never forgot how tenaciously the little old Italian lady clung to Mr. Anziano's side for the many hours until he left the ER to go to his hospital bed.

Mr. and Mrs. Anziano returned on an almost weekly basis for the next few months. The first time I helped treat him, Mr. Anziano was still verbal and barely ambulatory. Through the many hospitalizations and strokes he had, his face became locked in a terrible open-mouthed twist and Mrs. Anziana was always shuffling resolutely behind him, jabbering, making a general fuss, and clutching her purse in both hands.

Last night in critical care, I walked into a treatment room to greet a new patient who had arrived... I was taken aback- sitting quietly in the stretcher was Mrs. Anziana, more quiet than I had ever seen her. I called Mrs. Anziana by her name and her bright eyes scanned my face; she did remember me and was touched I remembered her name. Mr. Anziano had died a week ago, she told me. Her daughter brought her in because she had a fever and waning appetite. "I remember you took great care of him." I said. "The best care," her daughter agreed. I wrapped her frail little body in a blanket and mused on how she must have been feeling. When you've been taking attentive 24/7 care of someone you love dearly, it hurt, but at least you always had something to do, something to be of help. In a moment, she lost the love of her life and her daily occupation. Such people rarely take the same good care of themselves, though, and I worry for her. I had always admired her incorrigible spirit.


Saturday, August 20, 2011

Coming Back Full Circle

Last year this time, before I was an emergency tech, I was deep in the world of research and volunteering at the emergency room that is now my full-time employment. One day, I was using the conference room at my research laboratory for non-research-related purposes on a weekend. I had set it up with the secretary that the door was to be unlocked.

Imagine my surprise when I walked in, turned the lights on, and jumped at seeing an older man sleeping in one of the soft office chairs. He was balding and wore the khaki pants and polo shirt that many researchers down the hall would wear. I did not want to wake him, so I trudged to another room with all my belongings. My music students were arriving and we made use of another room until there was a lull in activity. I took a peek in the conference room once more- the man was gone. Hooray! I put my instrument and purse in the room and went outside to greet more students.

Upon re-entering the room, I saw the man standing over my belongings. He quickly shuffled by me after seeing me and as he went by, I noticed 2 things: 1, his shirt was covered with specks of blood and 2, he had a hospital bracelet on. Quickly, I ran to the area he had been handling my belongings and I was so mad! My Student Researcher ID and Driver's license were gone (and a roll of Starburst, as well)! A possible psychiatric patient had just made off with two of my photo ID's. I called the police, who knew who it was- a commonly seen homeless man. They made no effort to find him to retrieve my long-gone ID's. I then called my tech, who knew exactly who it was based on my description, and reassured me that he would keep an eye out for him. Two days later, this patient made it back to the ER, whence my tech frisked him on my behalf and unfortunately did not find my ID's. I had to go to the DMV and research department secretary for new ones. I have not thought of Mr. Poopy since... until this morning.

Working in critical care today, I saw a patient wheel in. The nurses had their noses wrinkled and asked me to find peppermint spirits. When I came back and got a good look at him, it was Mr. Poopy. Although he was naked and covered in smeared feces, his face had a scholarly build- balding, wide-set blue eyes, a hooked nose, glasses, and a beard. I suddenly remembered it was almost exactly a year ago that I had seen him last, standing over my purse and wanted so badly to call my tech and laugh about it with him. Mr. Poopy seemed almost normal in his interactions with the nursing staff, but I was tempted to ask him if he remembered me. >: (

Friday, August 19, 2011

Wormy or Crazy?

Through the 8 hours I spent with her, Ms. Wormy was a hot mess.
She had fallen after fainting and couldn't bear any light to touch her eyes. I put a rolled towel over her eyes, much to her relief, and began taking her clothing off to put her on the monitor. My gloved hands were orange after touching her. I realized with a jolt that it was her heavy dose of spray-tan.

She recounted the story of how she fell, then calmly interjected "I know it sounds crazy, but I have worms under my skin." She showed us the pockmarks from where they 'broke out of her skin'. They came out in a ball from her reproductive tract, and when she stuck a (gloved, she added) finger up her anus, she found them there too.

She told us about how she would cover her legs with paper towels at night, then find puncture marks in her skin where the worms would break out during the night. They looked like fingernail picking pockmarks, but I just watched the spectacle of her trying to convince the doctors about her worm problem.

In order to get urine, we had to walk her to the bathroom so she could use a straight stick catheter- apparently, this is how she always urinated.

A nurse commented that Ms. Wormy was the kind of crazy that should be locked behind padded walls. I wasn't sure- but I sure wanted to see the worms she was talking about!

Ms. Wormy wore dentures at an age most women still can have children. She was a near impossible stick, but I got her labs using our smallest gauge needle. She showed us her ileostomy, pulling it tight so we could see all the fibrous material floating about. They were worms, she insisted, I pass thousands of them a day. She pulled my hand to feel the coarse roughness under her skin where "worms were nesting."

How did such a young woman end up with so many problems? I didn't know, but I kept stopping by her room to listen to her terror about the worms infesting her body.
When I left 8 hours later, nobody had lifted a finger to examine her for these worms she kept talking about coming out of her nether regions. Was I the only one who fell for some sort of joke? She seemed too genuinely scared to be making it all up...

Nevertheless, I took an extra hot shower when I got home. All her talk of worms made me scrub harder than usual... you know, in case the crazy was catching.
Edit: Later, I looked up some symptoms. She might be a meth addict- it would explain the anxiety, itching under the skin, and dentures... but I don't know. So strange.

Wednesday, August 17, 2011

Abscess Obsession

I admit it. I am weird when it comes to abscesses. I don't want to flee the room or leave it to the doctors. I want to be front row and center to watch the drainage.

Abscesses are like the perfect emergency. They are an emergency because not treating them could cause them to burst into the bloodstream, a direct point access to the bloodstream by the pathogen, which could be hard to treat, like MRSA. They also hurt- a lot. All the pressure from the pus build-up can really dig at a person. Once you lance them, the pain, pressure, danger is immediately gone. The patient usually can go home with an antibiotic if there are no complications or cellulitis. Abscesses are a quick trip to the emergency room and something can be physically done to relieve the patient. Perfect.

My patient that brought all this to mind was a nice guy I had yesterday. When I took his vital signs, I noticed tracks all up and down his arms- a heroin user. He must have tried to stick himself in the femoral vein, because on his upper thigh, he had an egg-shaped and sized hard lump. There was a small bump at the top... it was ripe for slicin'.

The doctors came in with gowns and masks- injected lidocaine, and lanced it with a scalpel. I swabbed the output to send to the lab. It wasn't a big deal- but later I laughed at myself for how excited I got to see the abscess being lanced. There's something so relieving about seeing something so swollen, red, hot-to-the-touch, painful-looking get fixed immediately. The pain and suffering is visible. The foul, purulent drainage is symbolic for the pain and suffering- when it comes out, the pain and suffering is also released.

The patient thanked us and then asked to see his girlfriend. Girlfriend? She was in the next room, with 3 abscesses in the same area!!

I gowned up and went next door for round 2.

Tuesday, August 16, 2011

The Little Old Man Who Said He Could

Mr. Wobbly came in from a nursing home. His cheeks were hale, he was wearing big sneakers, he seemed mostly with it... So when he said he had to go to the bathroom, I said, ok, let me wheel you somewhere private with a urinal. Oh, no, he exclaimed. Ahh- he had to go #2.

"Sir, can you walk?"
"Of course I can! I can walk."
"Can you walk well?"
"Yes, yes."

I had a feeling he needed assistance, so I wheeled him to the bathroom. He stared at me.

"Do you want me to help move your legs?"
"Yes. That would be nice."

I swung his legs over the side of the bed. He stared at me expectantly.

"Do you need me to pull you up?"
He nodded.

I pulled his hands so he could stand. His legs were very, very wobbly. I had half a mind to wheel him right back and put him on a bedpan, but he was elated at his success (probably at having manipulated me into giving him his way), so I made up my mind to let him enjoy his moment and catch him should he fall. With my two hands guiding his, I pulled him step by wobbly step to the toilet, where I put his hands on the guiding bars. Carefully, we bent him over so he could sit down.

Silently, I was worrying if he'd ever be able to get up. Call me if you need me, my name is S- I told him before I closed the door behind me. Presently, I heard him calling, and went back inside.

I pulled on his hands to help him back up to no avail.
I pulled after a countdown, but his legs wouldn't hold him up.
Finally, I bent my legs and put my arms around his ample waist and lifted him. He couldn't stay standing.
Worried, I tried one last time, lifting him up- 200lb of dead weight, before he could stay standing long enough for me to pull his pants up and start guiding him back to his bed.

The whole ordeal took me about half-an-hour on a day we had 27 patients for an area that only is supposed to treat 18. Oh Mondays...
Mr. Wobbly just made it to his bed when the transporter came to take him upstairs to his admitted hospital bed. Poor guy- the next time he needs to use the bathroom, I hope there is someone out there who will take the time to help him walk. He is right on the cusp of no longer walking around- the edge of ambulatory- the cliff of losing what little freedom he has left.

Monday, August 15, 2011

Of Broken Hearts and Octopi

A lady came in today with chest pain. She was breathing a little heavy and when I was placing EKG leads on her chest, I asked her about her pain and whether she had had it before. "Yes," she said, "last month, I was here because I had a terrible argument. I was hospitalized and something similar is happening . I had another argument today just now."
"What did they diagnose you with?"
"Something called stress-induced cardiomyopathy."

I repeated this to the attending, who looked up the previous file. "Oh, this is that Japanese syndrome," she said excitedly.

Takotsubo is a rare cardiac pathology that occurs when certain people get very upset. In break-ups, or job losses, or deaths of relatives, these people exhibit real EKG changes and heightened troponin levels (measurement of cardiac muscle damage). The left ventricle loses a lot of its normal function and looks like a diving octopus.
Luckily, this time my patient was not quite as worked up. Her heart did not exhibit the massive damage it had the last time she was here. I just thought this was a very cool case, so I had to share. :-) I am such a dork.

Maybe next time I feel that twisting in my chest when I get really upset, I should get it checked out- maybe there's an octopus in there...

Manipulative Manics

All was well this morning. The rain was pouring outside where I couldn't see it anyway :-), the patient load was still low :-), I was saved from being in the drunk tank yet again :-) :-)... Then, around noon, I heard a commotion coming from our waiting room. Never one to miss the action, I stuck my head around the corner to see a normally chill nurse flip out at somebody.

Mr. M&M was young- around my age- with a baby face.
Mr. M&M: "All I want is my wallet. That's why I'm here. I want my wallet."
Nurse: "Ok, we'll call the psychiatric unit you were in, just stay right there."
He took steps forward, "but I want my wallet. I have everything in there- my whole life is in that wallet."
Nurse: "I already told you, I'm calling- look I have the phone."
Mr. M&M: "It might be in the bathroom, it might be in the room, it might be anywhere. Maybe you locked it in those security lockers."
Nurse: "They don't have those kind of lockers in that unit, but they said they'll take a look for you."
Mr. M&M: "Ok, thank you, can I go back in?"
Nurse: "No, sir, you were discharged this morning."
Mr. M&M: "But there is something wrong with me."
Nurse: "There is nothing wrong with you. That's why you were discharged."
Mr. M&M: "Well, how could you just say that there's nothing wrong with me? What if there was? I am going to sit here," He sat defiantly in the triage chair, "and wait."
Nurse: "You can't sit there. There are patients that need to sit there."
Mr. M&M: "Well I'm a patient."
Nurse: "No, you're not, you were discharged this morning."
Mr. M&M: "My legs and back hurt real bad. I can't walk. Can you admit me as a patient?"
Nurse: "No!"
Mr. M&M: "Then I want to hurt myself. I want to kill myself."
Nurse: "Don't say that..."
Mr. M&M: "I mean, I don't actually want to, but that will get me in as a patient, right?"
Nurse, eyeing all the people lined up: "Uh, no, please get out of the chair. There were other people who signed in before you."
Mr. M&M: "I'm not moving out of this chair."
Psychiatric Nurse: "You definitely did not leave your wallet back there with us. Please leave- we're not going to see you again today... you just left a few hours ago."
Mr. M&M: "Wait, you're kicking me out?"
Nurse: "Get security."
S: "Hey, sir, since your back and legs hurt and all, do you want to sit in this wheelchair?"
Mr. M&M: "Sure. Thanks a lot."
Nurse: "Wheel him faaaar back over there."
S: "Ok."
Mr. M&M: "You don't have to, I was going to go outside for a cigarette anyway."
S: "... Oh... Ok, whatever you like."
Mr. M&M: "What's your name?"
S: "S."
Mr. M&M: "Thanks, S."

I turned around and suddenly heard a scuffle. Mr. M&M was trying to wheel himself outside to smoke a cigarette. Security caught up to him and made him get up and get out. We thought it was the last we'd see of him....

Around 1400, I heard the ambulance bay doors open and then a nurse say "you've got to be KIDDING me."
"Nope," I heard an EMT reply. I rushed, out, and there was Mr. M&M sitting on an EMS stretcher, staring at us.
Mr. M&M: "So since I came in by ambulance, I can get admitted, right?"
Nurse: "No, no, no. Get out. Seriously. The exit is over there."
Mr. M&M: "I can't believe you're refusing me. What if there was something wrong with me?"
Nurse: "Get off the stretcher. We're not dealing with you again. You were discharged this morning, you came back a few hours later, and now you called an ambulance to come here again. Please leave."
Mr. M&M: "I'm not getting off this stretcher!"
EMT: "Come on, man, we need this stretcher."
Mr. M&M opened his mouth and started wailing. The ER came to a standstill as everybody heard and wondered what was going on in the ambulance bay.
Mr. M&M: "I want to kill myself! End it all! I mean, I don't really want to, but I tried before, see this?" He pointed to a small scar on his arm. "I did this to myself when my grandmother died! I could hurt myself out there!"
Nurse: "You gotta get off that stretcher right now."
Mr. M&M: "I want to hurt other people. I want to kill them."
Nurse: "Why are you saying that now? Do you really want to hurt other people?"
Mr. M&M: "Saying that will get me back in the psych unit, right?"
Nurse: "Uh, that will get you arrested, actually."
Mr. M&M: "So arrest me! Do it now!"
Nurse: "Ok, I'm getting a headache. Just go sit on that stretcher over there. We'll ask the mental health team to come talk to you one last time."
Mr. M&M cheerfully hopped onto the stretcher. "Why aren't you guys doing your jobs? Aren't you supposed to register me? Don't I need a new name-band?" He took one out of his pocket. "This was from when I was admitted yesterday. Hey, aren't you going to take my vital signs? Oh, God I don't want to live a life of crime! Don't let me back out on the streets! I need to live! Please admit me!!!!!!!" He was roundly ignored.

Meanwhile, patients had been coming in and I was completely ignoring him. "Hey, S." Mr. M&M called- "Yessir?" Despite it all, he still looked wide-eyed and a bit naive/slow to me, so I humored him and answered him.
Mr. M&M: "Why are those security officers and all those nurses talking to me like I'm garbage?"
S: "Well... when you say you want to kill yourself and you don't- is that right? You don't want to kill yourself?"
Mr. M&M: "Well, no, I don't, but nobody takes me seriously unless I say that."
S: "Well, when you say things like that and you don't mean it, don't you think that comes off a little... manipulative?"
Mr. M&M: "Well I don't mean to be manipulative or anything..."
S: "I'm only pointing out that that's how you come across."
Mr. M&M: "I appreciate that. You're the only one here that talks sense."
S: "Mmm..."
I was a little disturbed to be the only one that made sense to him. Soon, he was carted off, once again, to the sidewalk. He might have tried to come back a few more times, but I was off on another shift area by then.

Sunday, August 14, 2011

A Love Story

He was very handsome- a student at a prestigious university, a curly lock of chestnut hair hanging jauntily over one eye, an attitude of nonchalance.

She was gorgeous- straight aquiline nose, large bright eyes, dressed in carefully put-together careless chic- short flower sundress with a princess waist and sneakers.

He was trying to make jokes and stop her from crying.
She was crying uncontrollably.

He was stuck on a backboard with a C-collar on after fainting outside the restaurant.
She was beside herself, walking around, trying to be brave, control her tears for him.

He stayed the jokester, making sure to tease her for crying through my EKG, the insertion of an iv, the splurting of blood everywhere, through his shivering fits (before I ran for a warm blanket from the trauma bay), through a rectal exam. He laughed at her.
She could do nothing but watch, pace, and worry... maybe make a phone call or two. She cried silently, since he couldn't sit up to see her, tears flowing down her beautiful face.

His temperature was 103.2. He might have meningitis.
She stayed at his feet and stroked them silently, watching only his face and none of our action around her.

He went to CT scan and x-ray.
She came back in from a phone call and waited in the room... pacing, bracing her arms around herself, worry etched in every line of her young face.

He was still there... for an hour.
She was still waiting. Would always be waiting. I got her a warm blanket she could wrap around her to protect her from the cold, stark, lonely room.

They were in love. It was beautiful to see.

Saturday, August 13, 2011

Bringing it Home

As ER workers, we might deny it, say that we have everything under control. But it is unavoidable; whether occasionally or often, we bring our job home with us. What we do is an integral part of us, whether we want it to be or not.

This is evidenced by the wide array of adrenaline-laced hobbies we have, from working out like crazy, marathon running, re-enactment battles using medieval weaponry, rock-climbing, sky-diving, pole-dancing, motorcycle racing, going out drinking just to toe the line between having a good time and ending up in the drunk tank at work.

As for me, I like to go running- I can go as fast or slow as I want, depending on my patience. There is the perception of cardiovascular health benefits and an afterglow that I like to bask in after a long run that nothing else really compares to. I also play music- all kinds of music, whether it be celtic fiddle, or 50's oldies, or classical, or top 40, or eclectic pop, alternative, heavy metal, I will like it if it's good, if it was thought out... I like music with intention. Sometimes I draw or make paper animals or eat. Never mind sometimes- I always come home to eat and it does make me feel better/sleepy.

Nevertheless, I still get dreams or nights where I lie awake wondering what happened to Mr. So-and-so or Little Mrs. Itty-bitty. Those are the nights that my coping mechanisms fail and I am at the full mercy of my very active imagination and pervasive little pessimistic streak. Usually, my optimism shines brightly through and through, but in the small hours of the night, that's when fairytale monsters freely reign over a mostly sleeping world.


Thursday, August 11, 2011

Anything Can Change in a Moment

You could be sitting in your car one afternoon on a gorgeous summer day in your driveway. Maybe you just got home after depositing your paycheck plus some cash-back for a little shopping. Girl needs a reward after working so hard for that paycheck. Middle-aged, successful, well-coiffed and adorned with real-precious-metal jewelry, you've got a good job, a husband, children, in-laws that live close-by who care a lot about you. You're a religious woman, with a large cross pendant on a chain around your neck, or maybe you just like to show people how religious you want to be. You live in a great neighborhood-expensive, even- everyone knows everything about everyone, because they care, you know... not because they're super nosy.

What happens next is unknown, but your neighbors start to notice that you've been sitting there a while... they think you're just sleeping, taking a nap, maybe. Something doesn't feel right, though, so someone calls 911. The EMTs show up and realize you're pulseless and not breathing. Suddenly, they begin pushing up and down on your chest and attaching you to all sorts of wires. A mask is pushed on your face and a bag used to push air into your lungs. That might not work well, since you've already lost control of your breathing, so some air might get pushed into your stomach. The simultaneous pushing on your chest might make all that air and lunch come spewing out. But that's ok, as long as they keep your blood circulating around your body.

More people show up- paramedics, this time. They begin IV's and attach pads to your chest and back. The fancy defibrillator machine will rev up, beep, and announce "No Shockable Rhythm" because you're asystolic- you have no heartbeat. In the wailing ambulance, the paramedics will call our hospital, give us an arrival time and shortly, you will wheel into our prepared room filled with people and meet yours truly, S, gowned up, masked, and ready to go.

When you get transferred to our bed, you'll find it's rather uncomfortable- there is a hard board under your thoracic spine. As soon as you are transferred to our bed, you'll find yours truly next to you. I will quickly cut off all your lacy, feminine clothes with some sharp trauma shears, place you on a cardiac monitor, an oxygen reader on your finger, and a blood pressure cuff on your arm. Many fingers will be probing your neck, groin and upper arm for a pulse at this time. Before you can process all this, if you can, I will hop up onto the bed, kneeling next to you. At the doctor's order "begin compressions", I will push up and down on your chest, manually pumping your heart for you at about 30% of its natural capacity. This buys us time to keep your tissues perfused and alive for now.

Nurses will be pushing IV's in, doctors will be pushing a tube down your throat to help you breathe, and I will be pumping away at the rhythm of the Bee Gee's "Stayin' Alive." It's hard work for me, but worth it if you come back to us. I've had people come back before, but you were sure stubborn yesterday. "Hold compressions." I guess I couldn't bring your pulse back this time. The doctors would check your heart with a bedside-ultrasound machine, but it decidedly wouldn't budge. "Resume compressions" might sound again, so I might just lock my arms again and keep going. My breathing might get a little harder, but that's ok- this is why I run miles and miles at a time, so I can keep up with the physical demands of pumping your heart for you. After several cycles of this, the doctor might ask me to hold compressions a final time. "Would anybody mind if I called it?" ("No" is thought by everyone, but no one voices it.) "Does anybody object to my decision to call it?" the doctor tried again. Again, nobody wants to take responsibility. The doctor sighs- he knows the responsibility is his. "Time of death, fifteen oh three."

Everybody will leave the room, leaving the tattered room and your tattered body alone, except for me, your trusty tech. I will stay by you. It will be strange, where there were so many people surrounding you just a few seconds before, there will be just me. First, I will be removing all your jewelry- don't worry- I will document everything, removing it all with care, locking it up with security for safe-keeping before your family gets here. Likewise, I will take your tattered clothes and put them in a bag, they might want those, too. Finally, it's time to clean your body, wipe off the vomit, blood, debris, urine, feces. Another tech will be lining a stretcher with our post-mortem bag and clean sheet. I will tie another hospital gown over your neck for your privacy. We'll transfer your body over to the new stretcher, fixing a toe tag and more ID-bracelets.

The move might make your eyes pop open, but I will gently close them again. Your jaw will be slack and I will try to close it (this is the hardest part)- open-jawed rigor mortis looks terrible. Your body will be outfitted with clean sheets and blankets folded just so. I will pull out an arm, still warm, to lie on top of the blanket for your loved ones to hold when they come in soon. We will wheel you out with a little mask on your face, so as not to scare the other patients, into the special mourning room. I will look around the corner for any grieving relatives. If any are in sight, I will wait until they leave- the grief sometimes causes people to become homicidal. I need to stay around and stay healthy because I have 12 other critical patients begging me to come in to help them.

Finally, you will be parked in your temporary place of rest in the mourning room, awaiting loving family, the chaplain, and a doctor to come in and explain everything was done, and truly, everything was done. The mortician technicians will come for your body when all is said and done, where you'll be placed with the other bodies for a little while until your funeral home picks you up.

I am so sorry. So sorry that you didn't get to go shopping this afternoon, sorry that your family is grieving, sorry you had to meet me. But who could predict that moment in your life, whether you are young, middle-aged, or old, that you might meet me in your dire moment of need?
Anything can change in a moment.

A Crappy Day

In the last 36 hours, I have worked 25 of them... Some moments were great, such as when I got to hold someone's kidney stones in my hand. He had four of them stuck in his urethra, lined up like b-b's in a toy gun and the urology resident plucked them out one by one with a scope and balloon attachment.
Others were just crazy, such as the whole shift when I worked critical care and trauma at the same time, handling over 15 very sick patients at a time.

My sickest patient was Ms. C-Diff. She was at home with her daughter when her daughter noticed she wasn't making any sense and called 911. The paramedics thought Ms. C-Diff was borderline between coming to the hospital and staying home, but luckily decided to take her along just to get checked out and maybe raise the census numbers a bit for their ambulance company. In the ambulance, Ms. C. Diff crashed and burned- when she arrived, her heart-rate was in the 20's and I was preparing the code-cart and gowning up for CPR.
Ms. C-Diff had shingles all over her face and a diaper full of ... C-diff.

She also had no veins to speak of and so received an IV in her neck and a central arterial line. She was breathing poorly with snoring respirations and we used a bag to push air into her lungs. Soon after, the doctors made the decision to intubate Ms. C-Diff.

Having a patient like Ms. C-Diff is very time-consuming. We needed EKG after EKG and everyone is high-pitched. They forget things or need more than one of something and I run across the department as fast as I can without startling other patients around me. The alarms are always beeping because her vital signs are unstable. There are plastic wrappers everywhere, blood flying everywhere, tubes, adapters, plastic parts, bottles, needles everywhere. And then the inevitable... "S, can you clean her up? Also, don't forget to take a sample."

(Disclaimer: You probably don't want to read this)
It was difficult to ignore the stench coming from her overflowing diaper through everything we were doing, but... It was time to clean her up. Armed with warm bath towels, various pads, blankets, and a new diaper, I cut it open to reveal vile, green, rotten liquid that just went everywhere. I scooped up a few q-tips full and put it in a specimen cup. (Showing the cup to an off-duty tech who just came in to see the action, I punned- You should be working here with me. You're missing a lot of good ****!) It was the consistency of pond scum and the subsequent double-handed scooping with a towel was terrible. I enlisted the help of another tech so we could turn her to clean her back side. "Make sure you wipe front to back like mother taught you, heeeheeheee..." ER workers have such warped senses of humor. It took us over half an hour to clean her up, then gown her, cover her with a blanket, sweep away all the debris, clean the blood from her face, arms, floor, and all the crap off her bed. The doctors were very thankful for my opening of 2 bottles of peppermint spirits to dispel some of the smell.
The effort was worth it. She looked like any other old lady with a tube down her throat. (You know, like they usually look.) Her daughter came into a very clean room, with her mother newly diapered and a clean, warm blanket over her poor invasively resuscitated body. The daughter was thankful and I was spent... but there were 7 more patients I had to see...

This morning, my Dove Chocolate had a fortune in the wrapper: You're invited to relax today.
I think I will.

Tuesday, August 9, 2011

Prescription Parables

Once upon a time, there was a young woman who came to Urgent Care and said she fell. She proclaimed to have a lot of pain. Upon the doctor's asking, she revealed that she fell over a month ago. X-rays revealed nothing out of place, but when the doctor prescribed her Motrin, she protested she needed something stronger. However, her record showed she was allergic to all narcotics, which she contested with all her might. This all was to no avail, however, as she was prescribed Tramadol, which she incorrectly identified as an anti-inflammatory. The brash young witch then argued with and threw a pen at the doctor, angry that she could not get a narcotic prescription, revealing that she stopped coming to our hospital because we wouldn't give her anything in the past either, at which point, security escorted her out, amidst a volley of curses very unbecoming for any young lady.

Moral: Be a lady, leave with dignity. Contesting the competency of the doctor will get you red-flagged, not the Rx you want to sell. Threatening to go to patient-services is also futile.

Corollary A:
Once upon a time, there was another young woman who claimed to have fallen. Pathetically lethargic in a wheelchair, she said she couldn't move. Upon entering the room, I asked her to hop onto the bed, which she did with lightness and grace that one expects from a young lady. She proclaimed not to remember when she fell, where she fell, nor why she didn't remember she fell. As her x-rays came back normal, and interviews with her proved futile as she was high as a kite, we concluded she was in need of nothing stronger than Motrin. Of course, she protested this decision, naming Percocet as her drug of choice. When she realized she could not budge the doctor, she threw out her prescription in our pail, laughed in our faces, saying, thanks but no thanks, *****. Threatening to go to patient-relations, she was too high to notice our stone-cold faces as we calmly called security to escort her out.

Saturday, August 6, 2011

A Social Faux Pas

A month or two ago, a bunch of nurses were talking about Nurse Needy- a huffy-puffy, heavy-set, short, and reeally needy nurse. There is something in the water in our ER- everybody is pregnant- about 15 nurses at a time. Anyway, they were saying how Nurse Needy was expecting, was slowing down a bit at work, looked good being pregnant, etc etc. That stuck in my mind for the past month and I had a silly moment last night.

NN: S, can you go move bed 4 into 7 and 11 into 7 for me?
S: Sure.
NN: Ugh, what is wrong with today? There are so many people and yadda yadda yadda and I get so tired and cranky, as if enough wasn't on my plate already, yadda yadda yadda and it's hard to move around, yadda yadda yadda.
S: Is it that you're expecting?
NN burst into bewildered laughter. WHAT? What are you talking about? I'm not pregnant.
Insert foot in mouth.
S: Oh, I am so sorry- I was just thinking to myself, I see you all the time and you never mentioned it. A bunch of people were talking about it and they were so sure, like it was a done deal. I am so sorry.
NN: It's ok, don't bite your tongue about it (more loud, high-pitched laughter)- it's just that I have no children and can't have any children, ever.
S: I am so sorry. Really.
NN: It's ok. It's just really funny to me. I can't believe anybody would think that.
S: :-( Ok, I'll go move the beds now.

I was going without eating for 8 hours, on my feet for the past 11, and caused a terrible moment for somebody. There was no excuse, though, and I just felt so young, so inexperienced, so socially awkward. But I had patients to see so I bit my lip, refocused, and continued with my crazy night. I'm so sorry, Nurse Needy!!!

And I work with some real a-holes. And I am not referring to patients.


Punintended Joy

Call me S-ilvertongue. I finagled my way out of being in the drunk tank for 8 hours out of the 12 I was working tonight. Thank goodness, because we had the rowdiest, most foul-mouthed, foul-spirited, putrid drunk patients ever, evidenced by the fact that all 4 of them were put indefinitely into 4-point restraints and some had spit-masks. On top of that, we were completely inundated with patients. So in the spirit of recuperating from the night's trials and tribulations, I will tell you a story with a happy ending.

I had a half-hour conversation with a nice old man. It was only when he told me that I realized he was totally and completely deaf. One could never tell because his elocution was perfect and he told a lot of punny jokes.
How do you transport blood to Europe? Through blood vessels. Where is it taken? To the Red Sea.
I got hit with a fish as a child. That's why I have a herring problem.
He was hilarious. His stories looped round and around- and I must admit, I dearly love a silly pun. I got a notepad and a pen for him. This was my lame joke that I told him:
What's the most dangerous vegetable to have on a boat?
A leek.
He loved it. "You really love doing what you do, don't you? I can tell." Yes, sir, I do.
"Through all my years of (extensive and very serious) health problems, I have come to find that humor really is the best medicine."
Oh, delightful LOM, I totally agree.
He was discharged with no complications. :-) It's nice to see that humor really does keep him going.


Friday, August 5, 2011

Critical Heat

I had some very ill patients today that should not have been in the general emergency section I was working in.

Lady #1 had a blood-glucose level of 35mg/dl. Normal is 70-100mg/dl. At such a low number, she could go into seizures or coma, so we kept a very close eye on her.

Lady #2 had uncontrolled diabetes and a critical high glucose that the meter could not read. She was still "CRITICAL HIGH-NOTIFY NURSE" 4 hours later when I checked again.

But my most worrisome was a middle-aged man, Mr. HMH (Huge medical history). Mr. HMH could barely speak; when he did, it was in a high, whiny, breathless voice. Noticeably weak, he could barely lift his arm for me to wrap a blood pressure cuff around him. His pressure was 80/50, much too low because he kept nodding off with his eyes wide open. Because his skin felt hot, I fetched a rectal thermometer. As the nurse rolled him over, I pulled down the diaper and saw a large stool stuck in the rectum. We also found a bedsore that was unknown to us before. We tried to clean the stool, but soon found that he was completely and deeply compacted with feces. Then, we unwrapped the dressing and found an advanced stage bedsore ( with tunneling into the wound. Ouch! His rectal temperature was 100.0degF, so he had a low-grade fever. When I asked him his pain level 1-10, 10 being the worst you've ever felt, he replied 10.
"Where is your pain, sir?"
"Is there anywhere that hurts the worst?"
"My butt."
"Can we roll you off your sore? Maybe that will help."
"Yes, please."
With shaking hands, he held onto the railing and I stuffed a pillow under him to take pressure off his hip.
"Is that better?"
"Yes, thank you, thank you."
"Ok, is there anything else I can do for you?"
"Can I see your arm?"
"...Sure." I handed him my arm. He held it slowly to his lips and kissed it, murmuring, "God bless you. Thank you."
I felt tears spring to my eyes. I patted him a few times on the shoulder. Later, I brought him some orange juice with a straw, that he drank slowly. It must be a terrible experience to be sitting in a stiff stretcher for 10 hours with nothing to eat and not being allowed to move around much.

And then they pulled me out to sit with combative drunks, one of whom told me "you're too nice to live in this country"- thanks buddy... but that's a story for another day. I went to my ER for a ceremony this morning. Upon seeing me, I was recruited to come into work early. It will be a veeery long shift- I know it already. At least I cajoled the charge nurse to switch me out of the drunk tank tonight. :-)


Thursday, August 4, 2011

Dalliances with Drunks

Mr. Slick began his ER hallway drunk-tank adventure as an explorer. He sailed through the halls, through uncharted wildernesses of unused stretchers and linen closets, stopping man and beast alike to chat and build local street cred. He sensed the triage nurses were inattentive and slow and he knew the system like the back of his hand. Eventually, he was caught by the native security guards and escorted back to his bed without being tied down. He tried to talk me out of his involuntary stay on his stretcher, but it was to no avail. Grumbling, he covered himself with a sheet and passed out for a few hours. His BAC was .380.

Mr. Scumbag then wheeled in with a BAC of .327. He refused to admit he drank anything and proceeded to ask directly for a sandwich as soon as he was settled on the stretcher. He also needed a glass of water and needed to go to the bathroom, too. Despite these needs, the floor was "too dirty to walk on" for him. Eventually someone fetched him a sandwich. He didn't eat a bite before he asked me to throw it out, "not to be a scumbag or anything." Winking at me, he kept making a come-hither sign, saying "hey, hey, pssst, come'ere." The first time, I did go near him and all he said was, "you're gorgeous." Uh, thanks. "Wait, come back, come'ere." He looked conspiratorial- "whatever you have to say to me, you can just say it out loud." "Tsk... no, really, come here, it's important." "You know you're into me." Half an hour later, he gave up, "you don't want to talk to me because you know I'm a scumbag." I did take him to the bathroom and suddenly, he put me in a bear-hug. Feeling his arm around my throat was not a good feeling, so I called security and he tried to laugh it off. He was escorted back to his stretcher and warned. He soon became bored and woke up Mr. Slick.

They became great buddies, feeding off each other. Mr. Slick knew our system well from coming in all the time and taught Mr. Scumbag what "AMA" means- against medical advice. This prompted a chorus of "I want to sign out AMA! I want to sign out AMA!" Of course, as I explained calmly, this was impossible considering they were intoxicated and therefore incompetent to make that decision. Then, Mr. Slick pulled out a cellphone, which was not allowed. I told the nurse, who totally undermined me by saying "I don't care if they have it if it makes them calmer." Way to go for standing up for your co-workers and workplace morale. Mr. Scumbag snatched the cell phone and tried to use it, too, to no avail. Our radiology department was next door and the leaded walls blocked out signal. Mr. Scumbag declared my explanation as "a crock of ****", and Mr. Slick became convinced the hospital was full of voodoo that blocked cellphone signals instead. "Hey, I'll give you $100 if you go get Burger King for me," Mr. Slick offered me. I laughed at him and turned to help the nurse with Mr. Scumbag.

A nurse tried to take vital signs on Mr. Scumbag. The cuff kept popping off. His arms weren't that big and I watched him to see why- he was flexing as the meter read and being a general d-bag. He started bragging "You can't take my blood pressure because they're DIESEL," posing for all to see. The nurse gave up. Soon, Mr. Scumbag realized nobody was watching him flex and he got bored, declaring "I just wanna go home and get laid."

Mr. Slick shook his head, deciding he did not like his new friend. That was when Mr. Slick's neighbor, Mr. Goldfish, wheeled in. Mr. Goldfish was looking for his phone, which was in his pocket the whole time. Security took it out and put it in the bag under his stretcher because he was not allowed a phone. He had some sort of short-term memory loss- he didn't remember anything that happened about 10 seconds before. So he kept asking for his phone. Pleading for it. Pleading for us to find it. So he could call our hospital. He did not stop and mournfully wailed for it, even crying large tears out of both eyes. Why are you crying, Mr. Goldfish? My mother died! he wailed. He continued crying inconsolably. He refused to breathalyze for about half an hour despite our most insistent nurse drilling at him. Finally, I asked him- when did your mother die? 20 years ago. Geez, the way he was crying, one would have thought it was yesterday. Soon, Mr. Goldfish was put in 2-point restraints because he kept flailing and refusing to sit back. When he was taken out of restraints, based on a verbal agreement that he'd behave, 30 seconds later, he had to be put back in. He didn't register there ever was any sort of agreement. Completely incapable of normal cognition, my hours with him wailing and asking for his phone really grated on my nerves.

"This is a sobering experience," observed Mr. Slick. "I wanna go get laid," interjected Mr. Scumbag. "WHERE IS MY PHONE? CAN I HAVE MY PHONE?" asked Mr. Goldfish.

8 Hours later, the noise level was still the same and I was beat. Drunk tank tech is done for the day. Time to go for a long run.


Wednesday, August 3, 2011

Fencing, ER-Style

Mr. Mumble-de-Gook is incomprehensible. He is one of my regular drunks that I ignore completely because the last time he begged me for a sandwich, he thanked me by eating it, then peeing in the box for me.

Ms. Prissy Regular comes in like clockwork- every week. There is usually nothing wrong with her, but she likes to come in for a nap and a sandwich under the guise of some problem related to her morbid obesity.

Our ER was full to capacity again last night and both of them were put in the same back hallway to await sobriety. The stage was set for disaster because Ms. Regular is spoiled and Mr. Mumble-de-Gook does not ever shut up. I have never understood a word he said except that time I figured out, he was saying "hungry" and gave him the sandwich.

Ms. Regular: Can you please be quiet?
Mr. Mumble-de-Gook: Hrrrrngh! muauambuleaa-aggh.
Mr. Mumble-de-Gook: Arrrm aerrddd nyumm uh huhh errdaastt meehh
Mr. Mumble-de-Good: auyumm aereeedsss miisssto miiiikkk meraamernumer astimurkat
Ms. Regular: What is wrong with you? I'm trying to sleep here.
Mr. Mumble-de-Gook: aghg-mummbrrr orrr ehhhh
Ms. Regular: I don't need to sit here and listen to you all night. You sound retarded.
He stands up and makes a menacing motion.
Ms. Regular: You get any closer I'm gonna clock you with my cane. (She swings it for effect)
Mr. Mumble-de-Gook swings out *his* cane and says the first comprehensible sentence I have ever heard from him: MMRM I'mmmm gonnarr knock mrrr your wigg offf.

There was to be a cane fight as both of them started brandishing the canes in menacingly, but I called security and Mr. MdG was released back onto the street because he was walking as steadily as he ever did. Oh, the joys of sitting...