The Man Who Lived

Poppy Lucky was at a popular upscale restaurant in a nice part of town.  His big Italian family was celebrating his birthday or some equally important event, as one can imagine, with extravagant Italian food, wine, and dancing.  In the middle of  his celebratory dance, Poppy suddenly clutched his chest, fell to the ground, and usually, this is the last memory Poppy would have.

Not this day.  Poppy Lucky opened his eyes to twenty concerned and astonished faces and bright fluorescent lights. "What are you all doing here? Where am I? Why does my chest hurt?"
"Dad!" His son and daughter rushed to his side.
"Why is everybody crying?" Poppy was perplexed.
He would not know until later that the EMTs and Paramedics had performed CPR on his body that had no heartbeat and no breath for half an hour, and even shocked him once with a defibrillator.

"Poppy Lucky, what day is it today?" RN Muscles asked.
"Why, it's Sunday, isn't it?"
"Yes, yes it is," RN Muscles replied, "And do you know my next question, Poppy?"
"No, what is it?"
"Did you go to Church today?"
Poppy thought this was funny and gave us his warm smile.  I could tell that the deep creases in his face were shaped by his frequent use of that big smile throughout his life. He was also pure astonishment. He had many questions, as well as he should have.

As what seemed to be dozens of his offspring, their spouses, their children, cousins, siblings, and family friends took turns to come see him, he began to realize the gravity of his situation.  I could tell that though he was accepting their professions of fear, love, well-wishes, and gratitude with graciousness and well-practiced  humor, he was troubled. It was nearly impossible for him to understand that he had collapsed and almost died.  I don't think he could reconcile nor process the minutes in his life in which he technically ceased to exist.  After all, who really could?

"I'm sorry to interrupt you," I interjected once, "but I'd like to write down your blood pressure and see how you're doing, Poppy." "Well of course, young lady, please come in," he waved me in.
"So, how's his heart-rate?" his red-eyed son asked nervously.
"You know, it is a very stable 70 beats per minute right now," I answered.
"What about his blood pressure?" his son continued perplexedly.
"I think it looks like right where it generally should be at 110/70," I answered.
"What is that blue line? Why is it flat?" his daughter tried, "Why did the machine start beeping?"
"Oh, Poppy, you need to keep this sat probe on your finger, see? It stopped beeping. The blue line is his oxygen level, and it's quite good at 99%" I answered.
"So everything is...okay?" the son asked, a bit incredulously.
"It certainly looks that way," I replied.
"Oh Dad, it looks like the machine still thinks you're alive and that you'll be with us a while longer," he squeezed Poppy's hand and wiped his tears with the other.  This would be an awkward conversation in any other situation, but his words were oddly appropriate for that moment.
"So are you feeling any pain right now, Mr. Lucky?" I asked.
"No, not really, except my ribs, where they apparently worked on me." Poppy shrugged, but I could still strongly sense his uncertainty and sense of wonder at all that had passed.

Perhaps in future days, he will tell his grandchildren and great-grandchildren stories of bright lights, tunnels of darkness, flying angels and the voices of loved ones calling him back into the world of the living, but I saw in those first moments I spent with him an acutely incredulous man.  Those he loved best had convinced him of the biological facts, but it will probably take a long time for Poppy to find peace with how/why he beat the odds of staying asystolic/apneic, of sustaining brain injuries, of being intubated, of not coming back.

Poppy knew he had been given another chance at life the moment he understood what had happened to him.  As he described to me his family, the meal, the dancing, his eyes gained a dream-like state and his voice softened.  I could tell that he was habitually proud and extroverted, but during his stay, he became increasingly contemplative and humble. He will undoubtedly be a changed man after that day. And in some ways, so will I.

S

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.

S

First Time for Everything

I can log a few firsts tonight:

My first confrontation with a co-worker.
My first instigation of a confrontation ever.
My first time trying to speak French with a patient.
My first time observing a glass eye at close range.
My first time taking a break to let off steam.
My first traumatic code
Working my first traumatic code death without help.
My first time being directly appreciated and recognized by a co-worker.

Which of these should I start with in my next entry?
S

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.

S

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.

http://en.wikipedia.org/wiki/Herpes_zoster

http://en.wikipedia.org/wiki/Clostridium_difficile

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.

S