Monday, November 21, 2011

Of Chance and Drugs

This is my 100th post! And I worked a double shift- out of the last 32 hours, I worked 24 of them...  It doesn't feel so bad, but looking at it that way makes it look that much worse! Luckily, most of these past 16 hours in a row were  not on my feet, as I was in Urgent Care and had a lot of paperwork to do.

And little did I know, I missed the memo that declared today the unofficial Drug-Seeker Day!
It's the holiday where opiate addicts of all ages, shapes, sizes, and intelligence levels come to the ER to feed their gambling vice.  Will they score? Will they score big? And on our tab? (That would be the jackpot) Or will they get escorted out by security and blacklisted? Take a roll of the dice- somewhere along the way, many have apparently found reward in this terrible game.

Naturally, this game of opiate-collecting is equally one of chance and skill.  As far as chance goes, they might meet one of our new providers that doesn't know them by name/face/habit.  Perhaps they might come when we are tired/distracted/discontented and hope we might not notice how regularly they visit every 30 days to get that magical prescription. Maybe they might have a legitimate (self-inflicted) injury.  Or perhaps they might be skilled players and alternate between different pharmacies and providers every few days. Maybe they developed incredible powers to break down the will of providers or just the gift of gab and persuasive power.

In any event, I was working with a well-seasoned veteran APRN who knows the numbers to local pharmacies, certain pharmacies outside state borders, the websites to trace narcotic prescriptions for certain individuals, and  has an exceptional sensitivity for people.  His sarcastic pen broke many dreams and wrote many prescriptions for motrin and tylenol today. Becoming rather seasoned myself, I made sure security was already awaiting our problem clients on their escorted walk back outside.

There were quite a few seekers from out of state that were found on our databases to have been flagged in multiple states. They were very surprised to be found out so quickly, but I am sure they will find other places and other ways to gain these prescriptions lawfully.  Or they will come back tomorrow for another roll at the dice in urgent care.


Saturday, November 19, 2011

The Right to Fight

Have you ever heard a person scream? Really scream? The primal, wordless screech of pain or despair that issues from deep within the lungs, blasting through the vocal cords? The kind that will make you unconsciously grit your teeth until you realize your jaw hurts?

Mrs. Independent was found unconscious. She lived alone into very old age with no known family and a history of Alzheimer's. She woke in the ambulance and put up a violent fight. Apparently she had been a veteran of some sort.  As she entered our trauma room, she let a loud, frustrated scream free.  She wanted nothing to do with us and was determined to let us know.

She balled up her fists and struck at us, but we had to restrain her arms in order to put an IV in.  She thrashed her neck, but we had to hold it still to avoid damage. She tried to kick, but we had to hold her still to check her back.  We pleaded, cajoled, chastised, but it was no use. She had a mental will of steel and would not submit.  Sadly, she knew exactly what was happening and made it purposefully difficult for us to do anything.  She continued her long, high-pitched screaming.  It was barbaric, but we had to hold her down as the knock-out medicine was pushed through her IV.

She went into a fitful sleep, but as we tried to continue interventions, she woke and began her long, sharp scream.  "I don't want any of it! Let me Gooooo(escalates into scream)!!!!!!!!!!!!!" "AEEAAAEEGGH"

And so it went- I stayed by her side for most of the shift, holding her head down firmly, fingers planted on her clavicles so she couldn't sit up.  Her screams echoed through the busy adjoining rooms and there was a silence after each, punctuated by beeping monitors.

"Were you a veteran?" I tried to talk to her. She paused for a split second and I took this as acknowledgment.
"Where did you serve?"
"Let me gooooo (octave increase)!!!!!!!!!!!!!!! Pleeeeeee (octave increase) aseeeeeE!!!!!"

It became an interesting case for me to watch. Usually, a patient acting out tends to demonize certain workers and reach out to others. Despite our best efforts, each new provider or service worker, whether it was a surgery resident, nurse, technician, chaplain, or social worker, she gave the same response. In fact, she screamed louder.  As I was a constant presence throughout the ordeal, I found it enlightening to observe the different methods of approach.

I usually approach distressed patients in a solemn, sincere, and calm manner, whereas there are others that try to meet the patient at their level of energy.  Although this other method can be very successful in certain cases, I find it distressing to acquire so much negative emotional energy on a regular basis.  For Mrs. Independent, nothing worked- she had  created her own impermeable self-discipline in her former life and has since held tightly onto her own ideals of dignity and independence.  Hard-headed, intelligent, fearful, she had estranged her own family to live here alone to the advanced age of 90.  She'd been through so much and now she had to put up with us and the folksy b-s of "so young lady, how did you come to be here today?"

Her high cheekbones were defined, but not gaunt. Her brow, though cut open, was still proud. She was absolutely furious with our intrusion into her well-controlled life and let us know it. There was nothing demented about what she was doing, but from a cursory glance from the busy modern healthcare system, it was easy to dismiss her to be psychologically incompetent.

Much against her wishes, I'm sure, Mrs. Independent was admitted for further observation and tests. As I watched her wheel down the hallway without screaming, I knew she was merely saving her energy, planning her next method of escape.  If anything, we had probably wakened her survival instincts.  Woe be unto the unsuspecting civilians upstairs!


A Stitch in Time Saves Nine

Mrs. Trip was leaving church when she mis-stepped on the curb and fell. It wasn't a serious fall in her estimation, but her side and neck hurt, and so she came to the emergency room to get checked out.

A stately lady, Mrs. Trip had aged very well into her 80's.  She was well-spoken and surrounded by loving friends and family. Her injury seemed potentially serious, but her scans all came back negative, so she was set to go home. Before she was to put her clothing on, she requested to go to the bathroom. Since she felt shaken and weak from the fall, she did not want to walk the distance to the bathroom, so I placed her on the bedpan.

As I removed the bedpan, my stomach flipped a little. It was full of bright-red blood.  Something was terribly amiss.    Yet Mrs. Trip felt fine, besides feeling a bit weak.  Several more scans located a bruise on her kidney that would otherwise have been missed.

She is a lucky lady to have discovered the bruise while she was in the hospital. Imagine having gone home, then seeing so much blood in the bathroom!


Friday, November 18, 2011

Vital Signs

On a busy day, it is easy to depend on the bright screen in the middle of the main area that shows patients' vital signs when they are hooked up to our monitor system.  Instead of having to trudge down the hall to a curtained room to see someone face-to-face, you could just pull the information from the screen.  Blood pressure, check. Pulse, check. Breathing rate, check. Pain level? Eh, just scribble something down.

Part of being a good tech, however, is taking those extra few steps to make sure your patients are comfortable, and more importantly, doing well.  The other part comes with experience- it has been almost a year since I began as a tech and I am developing an instinct for recognizing when someone is about to crash.  Mrs. Blotchy did not look well.  I knew as soon as I laid eyes on her. Although she was rather short of breath, she answered me crisply and politely.  I looked at the monitor and her breathing was in the high 30's-low 40's.  Other than her high breathing rate, there was nothing else in her vital signs that was exceptional.  I had seen much worse than her, but there was something about her that I can't quite put into words- my gut instinct formed the words before I could stop it. "She's going to get intubated, don't ask me why, but I can tell," I murmured to Newbie.

The nurse took his time putting her on oxygen and getting labs, but in my heightened alertness, I performed Mrs. Blotchy's EKG deftly and tracked down the attending.  The doctor was talking with another doctor about non-work-related subjects as I fidgeted and waited for him to sign the EKG, which contained irregular, non-sinus rhythms.  His distraction irked me and I used that as an opportunity to teach Newbie to make sure the attending always signs paperwork that is presented.

When I returned to Mrs. Blotchy's side, I asked her if she needed anything. Oh, no, she replied, I'm... quite all right, just a little... short of breath.  I felt her hand- it was cold. I grabbed her a blanket.  Her breathing had dropped to 25 breaths/minute. Usually, we are taught that people breathe at 12-20 breaths per minute. On monitor, she was pitch-perfect. She seemed to be getting better, right? Her color, however, told a different story. She was paler than before. Purple splotches were beginning to collect in mottled patterns on her ample flesh.  I alerted the nurse, and soon, we moved her bed to an open room near our nursing station.  Her heart rhythm was now settling into a very irregular pattern and the rate was quickening.  In a mere moment of suspended time, the whole room seemed to come to the same conclusion and everyone rushed toward her bed.

I grabbed the code cart and as soon as I made it to bedside, I heard "do you feel a pulse?" A nurse dug her hand into Mrs. Blotchy's inner thigh to feel for the femoral artery.  "No pulse," she reported. The attending physician folded his hands behind his back and stated calmly, "begin compressions." A male tech was at the bedside and began the violent rhythmic thrusts.  As the doctors at the head of the bed began the intubation process, the nurses were at the sides, trying to establish peripheral IV access to no avail- Mrs. Blotchy's heart was no longer perfusing her circulatory system. I ran for the intraosseus gun, which shoots an IV directly into the bone, oxygen saturation probes, saline flushes, defibrillator pads... In passing, I heard "Oh no, I never saw an EKG for Mrs. Blotchy," from the attending to my manager. I smiled at Newbie- lucky I had the doctor's signature- otherwise I might have lost my job in that moment.

"Halt compressions," we heard. Wiping sweat from his brow, the other tech stepped down.  It was my turn. I hadn't gotten a chance to put a gown on yet.  I climbed onto the bed, wedging my knee by her sweat-soaked side as the ultrasound probe checked her heart for activity. "Resume compressions." I felt her ribs crackling under my hands; the compressions had broken them.  The cold ultrasound jelly smeared onto my forearms as many hands moved around me. "Halt compressions."  A pulse had returned! Our happiness was short-lived as it slipped away once again just as quickly.  Mrs. Blotchy's face was now a deep purple. "Resume compressions." And so my sole concentration and purpose dangled on the thin cusp of life and death for a complete stranger. Yet she wasn't a complete stranger. We were intimately acquainted- as physically intimate as it was possible to be. I was pumping her heart for her and it was slippery, hard work.  She was defibrillated several times.  After about half an hour, I nudged Newbie to line up and I passed the baton. It was his first time, but he was good at it.  It was then that Mrs. Blotchy's daughter was escorted into the room.

She nearly collapsed from the shock at the sight- hanging onto the arm of the nurse manager.  "That's my mother in there!" She sobbed. The attending asked the nursing staff to give full report on the rounds of medications administered so far.  I don't think the younger Ms. Blotchy heard any of it.  The debris from a million packages littered the ground and bed. Newbie was doing compressions and six other hands were on the body of the woman who raised her.  "Please, please," she begged, "Please God don't let this happen to me, please." We defibrillated her for the fifth time.  "I didn't even get to say good-bye! Please, don't let this happen, please!" The doctors looked around uncomfortably. The monitor was still beeping with what seemed to be a pulse.  It was not a pulse, unfortunately. The ultrasound confirmed it. The only rhythm were agonal spasms in the heart muscle. This was one heart that would never beat again.

As the time was called, I could hear a rush of blood in my ears.  I always get that sensation in the surreal, suspended minutes right after everyone else exits the room.  As we began the process of preparing the body for viewing behind our curtain, the room around us was already noisily reorganizing itself.  The cycle of life and death revolves quickly in the emergency room.  I gave Newbie a pat on the shoulder. He had done well and learned a lot. If nothing else, he should remember that when taking vital signs, one should always assess the patient and not the monitor.


Sunday, November 13, 2011

Dancing in the Moonlight

There is a superstition in Emergency Rooms... that when psychiatric patients suddenly collectively crawl out of the woodwork at once to overwhelm and abuse us, it is not a random act of terrorism but rather an organized, meaningful migration controlled by the phases of the moon. You may scoff at my apparent lunacy, but remember, I used to be just as logical and scientific as you are.  Back before I started working here, I didn't believe in ghosts, cold-blooded murderers, priapism, human cruelty, nor prolapsed urethras either.  Well, I still don't believe in ghosts, but I am otherwise that much more accepting of weird happenstances from my experiences in the ER.   

In any event, whether you believe in the correlation or not, last week's full moon coincided with one of the gnarliest weekends ever at the ER.   All surrounding hospitals, psychiatric treatment centers, urgent care facilities, even our own inpatient areas were totally overwhelmed. Patients were not moving and more kept pouring in. In our ambulance bay, plastic dividers were set up so patients didn't have to watch each other being sutured and otherwise cared for.  Psychiatric emergencies filled the corridors with jungle-like hoots and hollers.  

Mr. Man-child constantly made drawn-out whining noises like an opera student warming up and exhibited less self-control than an advanced dementia patient.  He was tied in 4-point restraints when I took over the job of sitting with him. 
"You's better get me out of these restraints. I'm gonna sue you like nobody's business. Enjoy your freedom now, ********, 'cause I'm gonna own ya when I sue you for all you're worth!"
Intoxicated and naked, he took another approach when I ignored him. "Fine, if you don't let me go, I'm gonna get naked." He tried to throw his blankets off him, though his 4 limbs were tied down. After a fuss and much struggling, he managed to expose his chest and copious rolls of fat.  Livid, he tried to stare me down. Nonchalantly, I ignored the large slitted eyes and closed the curtain to spare innocent passersby the unpleasant visage.  Then came the death threats. "When you walk out of here tonight, expect to get jumped, you ****, don't expect your kungfu skills will do you any good, cause ya know what? You're not bulletproof." 

(P.S. How scary is this... I usually do get affected by death threats like this because the possibility is a little too high to be ignored entirely...

As charmed as I was by his way with words, I had to put an end to the yelling. I met his fury with a calm, collected air, taking him by surprise.  "Mr. Man-child, you are running a fever of over 102 degrees, which is a dangerous condition. You are tied down because you're not making any sense. Think about it." He looked at me in nervous astonishment. "We are trying to help you. Please don't try to struggle and go home because this is really serious."  Careful not to sound like I was condescending to a child, I took him down layer by layer until his noise output was reduced to a quiet whimper every few minutes.  We had no opportunity to celebrate our small victory with Mr. Man-child, though, because Ms. Misogyny decided to start yelling at me to stop "doing a man's job, because you can't do it right. Just stand there and look pretty cause that's all you're good for."  

Twelve hours of this later, I was more than ready for a hot shower and the comfort of some peace and quiet.  
Walking into the brisk night on my way home, I saw the silvery full-moon slipping behind a cloud. Seeing is believing.  


Saturday, November 12, 2011

New Blood

The first new tech, Newbie, has been hired! Hitherto, I had been the newest tech for about a year now.  Interestingly enough, I was chosen to train him for my 12 hour shift last night, which was great. His unadulterated enthusiasm and appreciation for his exciting new job was heartwarming.  Moreover, his focus is on patient-care and making sure our patients were happy and comfortable.  This aligned well with my own philosophy and we worked very well together.  The best part of Newbie was that he wasn't lazy. He followed me throughout my high-energy day with no complaints, though I realized at the end of the night that his legs were very sore from standing all day.

In direct contrast there had been another tech-hopeful that visited the ER often, hoping to get a foot in the door. A manager had approached me and asked me about her performance. Although our tech-hopeful had a lot of ER experience in another hospital and seemed to really want to be here, I had a feeling she had too much prior experience.  Experience can make a person more adept at a job, but it can also give a person insight into how to take shortcuts and become inert.  Although she stated she had worked many codes before, when we received one, she did not jump into the action and I worked the code alone, compressions and all.  Her manner and upturned nose suggested a weary boredom of her current job and an apathy for getting to know our ER and our people.  Therefore, to the manager, I replied that she was not a good fit for us, despite or because of her experience.

Newbie, on the other hand, wanted to get into everything, but not in a competitive way.  I was resolved to give him some organization in his training and showed him at least once, in detail, how I performed each task.  My own tutorage followed a "thrown to the wolves" philosophy.  I had to learn everything by trial and error.  Secretly watching the person "training" me helped me grasp details of the trade; otherwise, there were many instances in which I could have gotten in trouble.  It felt good leading Newbie into the rooms and jumping in with a plan of attack.  We cleaned up a massive GI-bleed, helped with draining abscesses, helped set up a lumbar puncture, etc. Though the amount of information was overwhelming, he was beyond satisfied with his new job.  It was also interesting seeing him perform his own little brand of personable magic with our patients.

I was holding Ms. Lumbar Puncture's hand when she said "I can't believe I'm getting a spinal tap on 11/11/11. This is going on my Facebook!" I laughed at the reference, but Newbie went further and launched into a spirited discussion with her about various obscure movies with the same actors. I have never been a movie-person, but watching them form an instant bond because of movies was enlightening.  Everyone has different skill-sets. Whether a person can be bothered to use these skills to relate to and help other people is what makes the difference. Newbie has this wonderful quality and I am proud of him.

Yesterday's shift helped me realize I wasn't doing myself any favors by abstaining from blogging.  The plan was that I used my weekly blogging time to work on applications for medical school, but that is a very different kind of writing that I don't enjoy nearly as much.  If anything, my informal little stories will help me get back on track.  Therefore, I am back.  Sorry for the wait.