Saturday, December 25, 2010

Alone On New Year's Eve



New Year’s Eve,New York

"Jenny, please, can you come in to the ER?". An urgent call from her frantic supervisor roused Jenny from her bed and derailed her New Year’s eve plan to brave the throng of New Yorkers in Times Square to witness the ball drop with her friends.

Her whole family lived far away in the Philippines, so she always made sure that she spent the holidays with friends. They were all in their mid-twenties, all single and enjoying the freedom of youth. The pangs of homesickness are better dealt with when amongst friends.

Two of her co-workers had figured in a minor accident but would not be able to make it for their shift. And since she was single and lived alone, she was the most obvious choice for her supervisor to cajole into submission.

Jenny was supposed to spend this New Year’s Eve with someone special. She thought that Reese would break through the defenses she had put up, but just last week, she finally conceded that their relationship was not meant to be. Dr. Reese Walton had pursued her for about six months, but it looks like he had just given up. Maybe he could not understand her reluctance to open her heart again. Just when she had decided to accept him, she heard that his ex-girlfriend had claimed his attentions again.

Jenny, once again, was alone on New Year’s Eve.

At 5pm, the Emergency Department was bursting at the seams. The masses had descended upon the ED with a spectrum of complaints ranging from the minor in-grown toe nail to the major gunshot wound traumas. Patient volume was high; there was no open stretcher in sight. It used to be that the presence or absence of stretchers lined up in the hallway leading to the ED spelled the difference whether the ED staff would have a good day or not.

Well, it looked like the neighborhood drunks decided to spend their holiday in our ED. Free meals, a clean stretcher, and an occasional smile from a pretty nurse. And a chance to blow off the excess alcohol through their system, out from the cold winter streets, in the sanctuary and warmth of the ED.

Jenny had often joked that one can get drunk passing through the hallways, just from breathing the off-gases from the inebriated patients as they kept a cacophony of snores through their stay. The nurses had given up trying to undress these patients; priorities made them concentrate their efforts on the truly sick, especially when they’re two nurses short. And besides, all that was needed was time… when these patients wake from their drunken stupor, they demand to be released back into the streets. The ED was a merry-go-round for those who cannot get rid of their addiction to liquor.

A patient caught Jenny’s attention. He was usually a happy drunk, not shy in expressing his appreciation to the female form by way of wolf whistles and suggestive remarks. Now, he laid back on the stretcher, and accepted the intravenous with no protest at all. Jenny whipped out her ever-present penlight and shone it on the patient’s eyes.

A frisson of fear snaked down Jenny’s spine as she saw the unequal pupils, one sluggish and dilated. True enough, a quick CAT scan revealed a huge subarachnoid bleed. The patient was quickly rushed to the OR. Whew, another life saved. But looking at the mass of humanity in the crowded waiting room, it would be back-breaking work for the personnel of this busy New York City ED.

Resigned to the long night ahead, Jenny worked with the other triage nurses until at about 1000 pm, all was quiet in the triage area. The EMS crew had hunkered down to their station to watch the ball drop…until the next 911 call.

A transport clerk brought an old woman to the triage area. Denise guided the woman to a triage chair. “I found her wandering in the lobby. Couldn’t understand what she’s saying.” She whispered to Jenny, “I can smell alcohol on her.”

The woman looked Asian, probably in her 70?s. Clutching a big bag close to her chest, she shook her head when Jenny asked her questions. She was well-groomed with sensible shoes and a thick wool coat, but she was reeking of cheap beer. With tears in her eyes, she presented a worn picture to Jenny. The sepia picture showed a young couple holding hands amidst a backdrop of what looked like a Chinese temple. The woman was dressed in a dark-colored cheongsam, while the man‘s attire looked like a loose-fitting, light-colored shirt with an upturned collar.

Jenny commandeered a Chinese doctor to interpret for the patient. When asked about the alcohol smell, Mrs. Chen looked embarrassed but finally admitted that she bought a pack of beer from the grocery so that she can sleep through the night. She spilled the first can of Heineken all over clothes. She started to feel dizzy, so she decided to leave the pack of beer to a group of homeless men on the streets. But she felt disoriented on her way back home, and was then picked up by a passing EMS van. She managed to get out of the guerney and walked out to the hospital lobby.

According to the translator, the woman’s husband of 55 years passed away about six months ago, and she lived alone in her house. Mrs. Chen had always been independent but during the holidays, it had been their tradition in their close-knit family to spend New Year’s Eve together. Mrs. Chen had expected a call from her two children who lived in New Jersey, but when no call came, she decided she did not want to spend her New Year’s Eve alone.

The woman continued to reminisce about the good old days with her husband, and she started to cry miserably. Her sobs filled the small private room. At that time, the doctor was called to the Trauma Room, and Jenny was left alone with the woman. Unable to comfort the woman because of the language barrier, Jenny just patted Mrs. Chen’s frail shoulders. Jenny knew too well about holiday blues.

Because there was no social worker on duty at that time, the hospital administrator volunteered to find help to locate Mrs. Chen’s family. The patient could not remember her children’s and friends’ phone numbers. At that time, it looked that she needed to remain in the ED.

It was already 11:30 pm. Almost time for the ball drop. The table at the employee lounge was heavily laden with ethnic food and the TV played the pre-show celebration in Times Square. There was excitement in the ED; half of the staff gathered in front of the TV to wait for the countdown. No EMS crew stayed around. All the admitted patients had gone up to their floor beds. The doctors had discharged most of the patients, except the drunks… and Mrs. Chen.

The administrator brought back the good news that NYPD had gotten Mrs. Chen’s family’s telephone numbers. They had been frantic to locate their mother who had initially told them that she was spending her holidays with friends. The sons would be coming to pick up their mom after midnight. Mrs. Chen looked relieved that her family had located her, but admitted her disappointment that she would be away from her family at midnight.

It was Jenny’s meal break, and she should have been in the employee lounge joining the festivities, but she took two plates of food to share with Mrs. Chen. She did not want Mrs. Chen to spend New Year’s Eve alone. Two other nurses followed her to Mrs. Chen’s room. As the TV screen in her room displayed the revelry in Times Square, Mrs. Chen happily ate the food that Jenny brought.

11:59 pm. Sixty seconds to go and the glittering Waterford crystal ball had already started its 77-foot descent. Mrs. Chen clapped her hands in delight as the nurses counted down.

“Ten…nine… eight… seven… six… five…four… three…two… one. Happy New Year!!!!”

Jenny hugged Mrs. Chen and pretended she was her mother back home. A flood of emotions gripped Jenny as the two women shared their loneliness. The older woman reminded her of her mom- talcum powder and cooking oil.

Jenny missed her mom terribly and wished she was with her own family celebrating the season noisily as her big family always did. Their house would have been filled with relatives enjoying a sumptuous meal after a night of fireworks display. The Filipino New Year celebration was always boisterous. It is during the holiday season when Jenny feels homesick for the familiar comforts of home.

The old woman’s eyes filled with tears but she was smiling this time. “Xie-xie”. Thank you in Chinese.

Jenny was thankful for the chance to help Mrs. Chen, and for, even for a minute, just be able to hug someone who reminded her of her own mother. She didn’t spend her New Year’s Eve alone after all.

She responded with “Salamat po.” Thank you in Tagalog.

Happy New Year!

A new year had just begun. At one o’clock in the morning, Jenny made her way to her car, resigned to the idea of spending the first day of the year sleeping off the loneliness.

Reese came up behind her, armed with a bouquet of flowers.

“I’ve been calling you since last week, Jenny. Why are you avoiding me?, he sounded tortured.

“Just leave me alone, Reese. Stay with your ex.”

At the confused look on Reese’s face, Jenny exploded in anger and recounted all the stories she heard of the reconciliation between Reese and his former girlfriend.

Reese vehemently denied all her accusations, and proclaimed his love for Jenny. It was there in the middle of the deserted parking garage, with fireworks in the background that he hugged Jenny tightly. His voice quivered when he said, “Believe me, Jenny, it’s you who I love.”

Here was a man, successful in his career, with everything going for him, but he laid his heart open to her. Jenny hugged him back, and with tears in her eyes, kissed the man she loved.

She thought, I’m not alone after all.






* not her real name

Wednesday, December 8, 2010

Dog in the ER


“Woof!”

I am hallucinating. That couldn’t be a dog who just went through the revolving door of the ER and is now just outside my triage booth. No way!

The Waiting Room in the ER was quiet; at 3am, only the sickest of the sick venture out, and most come via ambulance. Adrienne had finished triage for all her waiting patients, and now the waiting room is like a ghost town with just a few family members staring blankly at the plasma tv screen.

Adrienne prefers being in the middle of the action in the Cardiac and Trauma Room. With nothing to do at External Triage, she was trying to stay awake through the questions for her nursing certification review. The coffee didn’t help; the words swam before her eyes.

“Woof! Woof!” The insistent barks pierced through her consciousness.

I’m not hallucinating. It really is a dog!

“Hi Adrienne! Is that your dog right outside your booth? ” The clerk came back from his break and saw the little Yorkshire terrier.

“Bill, I don’t know whose dog this is. I just saw him go through the door, right at the time when a patient’s family member went through.”

“Really? Are we accepting dogs now in our ER?”

Curious, Adrienne got out of her booth. A dog lover, she felt comfortable enough to approach the strange dog with the puppy eyes. The dog’s blue-black and tan coat was silky and appeared well-groomed; obviously not a stray dog. The dog whimpered as if in pain, and he shifted his weight off his right leg. Adrienne squatted down in front of the terrier who accepted a pat on the head.

Bill’s inquiries with the occupants of the waiting room were met with more blank stares. The dog didn’t belong to them.

Adrienne noticed streaks of blood trailing from the ER entrance to where the dog was sitting. Lifting the dog’s right paw, the triage nurse saw a piece of glass sticking out from the lateral aspect of the terrier’s right paw.

There was no other choice but to bring the dog to Fast Track. The medical resident on duty took one look; not his usual patient but he ushered the dog to a patient bed. Surprisingly, the terrier appeared to accept all their ministrations with just a soft whimper, but did not attempt to bite anybody. Two physician assistants held the dog as the medical resident pulled the offending glass.A quick wound clean-up was followed by a bandage on the dog’s paw.

Maybe as a thank you, the dog licked the hands of everybody in Fast Track. He happily accepted a piece of Adrienne’s hamburger.

Bill later reported that he could not find the dog’s owners either outside the ER ramp and entrance. The administrator volunteered to notify ASPCA, as soon as office hours open in the morning. Several nurses and PAs volunteered to take the dog home while the owner is being located.

The nurses named the dog Andrew in honor of the medical resident who removed the glass on the dog’s paw. Andrew the dog went home with a physician assistant. Sadly for Rochelle’s three young kids, the dog was reunited with the owner three days later.






Based on a true story.

Saturday, November 20, 2010

Cooling


"I've got a pulse. He's back."

The EMS tech triumphantly declared as the crew rushed the patient to the Cardiac Room.

The patient was only 18 years old; much too young to die. “Oscar” just wanted to get some extra money for a date with his girlfriend of six months. But he fell off the ladder while at his construction work after a live electric cable rendered him unconscious and stopped his heart. His co-workers had confirmed that he fell onto a tent. There was no head injury but the electric shock caused his heart to go into ventricular fibrillation.

Bystander CPR and EMS CPR gave the patient the chance he needed. Upon arrival to our ER, his heart started beating again, but he remained unconscious. His endotracheal tube and the ventilator ensured that his lungs are relieved of the work of breathing.

The question on our minds: have we saved his life but left him brain-damaged? All those free radicals in his brain needed to stop wrecking havoc on his neurons. We needed to inhibit those excitable neurotransmitters and stop further cell death. As per the latest recommendation, we should cool the brain to reduce oxygen consumption, to give his brain a chance to heal.

Induced hypothermia is an evidence based practice that was fully endorsed by the International Liaison Committee on Resuscitation: Unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32°C to 34°C for 12 to 24 hours when the initial rhythm was ventricular fibrillation (VF). “Cool them” is the mandate.

He was only 18 years old, and we would not let him die. Our hospital was considered the most prolific in New York City; we were gungho about cooling. And since Oscar met all the criteria, we cooled him to give his brain a fighting chance to normalcy, so that he can go to as many dates as he can.

Iced fluids ran through his veins, and the cooling blanket was wrapped around him burrito-style. Target temperature is 34 degrees centigrade. As the nurses monitored his esophageal temperature, they checked his shivering and sedation status. Fentanyl kept him deeply sedated, and there was no sign of microshivering: he was a Zero on the Bedside Shivering Assessment scale. He was to be maintained on hypothermia for 24 hours before he can be rewarmed; that is, if he did not succumb to his injuries, or if we could still save his brain. We prayed that he would not end up to be a “vegetable”.

Oscar was sent to the ICU, still cold at 34. His parents and girlfriend followed him, afraid of the journey ahead; their questions unanswered, his life uncertain. At that point, they were just grateful that his heart was beating again.

A week later, Oscar walked out of the hospital, hand in hand with his girlfriend. Neuro check: alert and oriented x 3. Even if he could just afford fast food for a date for now, he now has a lifetime to plan for more dates.

Monday, November 15, 2010

Who Says Medical People Can't Rap and Sing?"


Just in case this nursing job doesn't work for us anymore, maybe we can do something like these...






"UAB ER Rap"





"Waking Up is Hard To Do" by Laryngospasms






"Anaesthetists Hymn"






"Colorectal Surgeon Song"






"Pink Glove Dance"

Friday, November 5, 2010

In a World of Icons

No, I don't mean those iconic figures we put on a pedestal. The icons that populate my world are the multi-colored symbols on our electronic tracking board. Icon progression serves as visual alert for real-time lab and x-ray results. Who can ignore that Panic alert icon for blood results with critical values?

We can glean a lot of information from the icons on the board. More symbols mean that the patients have been in the ED much longer than we want.

Some icons explain themselves: NPO, Needs exam,, Same Name. Others defy explanation.

Green gowns mean patients are in danger of elopement. I should create one to show a nurse running away from the doctors and patients alike. Tracking board should be discreet enough so as not to raise complaints of violation of patient confidentiality. And yet, we advocate for transparency in our reports.

To really make a difference with the icons, I propose the following:




Guess what the above icons mean. These are the suggested meanings (not in any particular order):

1. Cholesterol-rich diet
2. Grandma and motorcycle: Bad combination.
3. Will the doctor please stop monkeying around and see my patient now?
4. Darn! I didn't see the posted "No swimming" sign
5. Fireman: VIP (roll out the red carpet)
6. Quit bothering the nurse! Can't you see she's busy?
7. Yes! We're back. Downtime is over!
8. Waiting for Disposition; what are you waiting for?
9. Bipolar Disorder
10. Sex: Undetermined
11. Spell-check
12. I wish I didn't drink too much mojito!

Saturday, October 23, 2010

Caring for Mr. G (Frequent Flier)



Original text: New York, February 2005
Published March 2012- revised version for the Nursing 2012 March edition



IN EVERY ED, there are two true constants. One is that patients come and go, no matter what the weather, in the dead of night and most certainly at change of shift when the ED is in gridlock. Another is that despite all the frustration and high-intensity stress, we, as nurses, care.

We care, even for our "frequent fliers."


One of the regulars

Mr. G was one of our most frequent visitors. With a long history of alcoholism, he showed up at our hospital every day, delivered by the emergency medical technicians or staggering in on his own, asking to be taken to the ED.

Mr. G was part of our daily lives. We showered him, lectured him, fed him, and discharged him before he went into withdrawal.

The ED social worker tried to place him in a local shelter, but he rarely stayed long. Sometimes he’d be admitted to the hospital for management of his withdrawal symptoms, in part to give him time to heal, but also to reassure ourselves that we were doing our best for him. In our naïveté and optimism, we hoped that someday Mr. G would hit rock bottom and reverse his life’s downward spiral. But he didn’t want to detox and refused admissions to rehab.

Mr. G was unlike most other alcohol abusers who frequented our ED. He never was violent, never cursed us, never hit us. He just couldn’t seem to stay sober long enough to go home.


Road to recovery?

Once, we didn’t see Mr. G for a month. All the nurses kept asking about him. We thought that maybe he’d relocated or was tired of being brought over and over again to our hospital. It turned out that the social worker had finally convinced Mr. G to enter rehab, and he had a job. One day he surprised us all when he walked, with a steady gait, into the ED. Sober and smiling, he blushed and grinned from ear to ear as we stopped and greeted him. We high-fived with him and gave him words of encouragement. We felt there was hope.

A month later, however, Mr. G returned to the ED drunk and seizing. And so the cycle continued once again.


Gesture of faith

Just after the New Year, emergency medical workers found Mr. G on a street at dawn, unconscious with a core temperature of 35ºC. He was brought into the ED and the team worked on him for 2 1/2 hours. We thought he’d eventually wake up, as he always did. But his luck finally ran out.

His mother and brother came. They said they’d tried to get him help for years, but he’d always refused their offers. He chose to live on the street. They didn’t have enough money for a burial, and their only option was Potter’s Field in Hart Island, N.Y., where unknown people and indigents are laid to rest. It’s not open to public, and Mr. G’s family wouldn’t be allowed to visit his grave.

One of the nurses started to collect money to help defray burial expenses for our frequent flier. The ED nurses opened their hearts, without question. Even though it was too late to save Mr. G, the last humane thing we could do was help him be laid to rest, to give him a final good-bye.

It was a beautiful gesture, something that reaffirmed my faith that, whatever reasons that have made us choose nursing as a profession, the one true thing is that we do care.





http://nurses.definitelyfilipino.com/index.php/2010/10/frequent-flier/

Saturday, October 16, 2010

Only in the ER


The nurse instructed the patient to undress and to provide a urine specimen. She handed the patient a clothing bag and a specimen container. Minutes later, he handed the nurse the clothing bag with a dark amber colored fluid in it. He reasoned out that the specimen container was too small to hold all his urine.


@@@
Whenever I come out into the ED Waiting Room to call a patient, I always feel like a celebrity. Patients and families rush up to me like I'm a goddess who's going to sweep them into the examination rooms. Right! Don't they know that the ER is like a madhouse and that it's almost Standing Room only?
Sometimes I feel like the hungry crowd is closing in on me. I can feel their hot breaths of anticipation and see the hostile glances from those who are left behind.


@@@
The EMS is between a rock and a hard place. Because of the EMTALA/COBRA laws, NY EMS cannot refuse transports for the following:
1."I have a clinic appointment and I can't afford a taxi."
2. "I didn't make it to the Methadone clinic before closing time. I need to go to the hospital for my dose."
3. "It's too cold out in the streets and I don't want to stay in the shelter. Bring me to the hospital."
4."I just wanna talk with somebody."


@@@
Sometimes at triage, it's like pulling teeth just to get the right information from the patient. They either bring all their chronic complaints, or they expect you to deduce their medical history from their medication bottles.
Then, after all that, their complaints change when they see the physicians.


@@@
Most alcoholics are Houdinis. They can get out of the fanciest restraints. One advice I've followed through the years: Undress these patients and keep their clothes inaccessible. And if they do get out of restraints, it's easier to catch them. Just follow the ones running naked through the ER.


@@@
Overheard at Triage, in the middle of the blizzard...
Patient 1: "I have ingrown toe-nail.'
Patient 2: "So what if I have this arm pain for 15 years?"
Patient 3: "I need a sonogram, my head is buzzing."
Patient 4: "Is lunch served yet?"
Patient 5: "I have itching down there. Do you want to see?"
Patient 6: "I need a physical."
Patient 7: " Is Psych open?"
Nurse: "Oh yes, they still have room for one more patient."

@@@
The nurse heard grunting from the other cubicle. Thinking "Dolly" (one of our ER alcoholic regulars) was in pain, she drew the curtain. Dolly and her boyfriend were in a compromising situation.


@@@
"Are you pregnant?",the triage nurse asked the female patient who rushed into the room. The patient was puffing hard and writhing in pain.
"No way! I'm just fat."
Minutes later, the patient's spandex began to sag at the crotch. The nurse barely had time to catch the baby.


@@@
When undressing a patient for exam, be ready for the barrage of scents that assault the senses and challenge your gut. Don't remove the socks unless absolutely necessary.


@@@
Sometimes, my ears ring because of the constant onslaught of curses from patients and families. I handle them as firm and as professional as I can be. And in my mind, I curse them back in my own language. It helps.


@@@
A doctor looks around wearily, "Who's my nurse?"
I ask him back, "It's 12:00 o'clock already, don't you know who your nurses are?"


@@@
For the umpteenth time, I had to explain to the irate relative. "Sorry, sir, there's a lot of patients today. Many much sicker than your wife. Yes, we know that her ingrown toenail is hurting too much."





Wednesday, October 13, 2010

Pediatric Trauma: Pedro and his Mets Baseball Cap ("When the Boy's Heart Stopped")


In honor of Emergency Nurses Day (Oct. 17), here's a reminder of the many rewards that keep us sane, as well as make us grateful for the chance to make a difference.

Author's note: This is an updated version of the article I renamed "When the Boy's Heart Stopped" with an 8th place finish at a US writing competition. 11/5/11



August 1997...

"This is EMS. You're getting a 9-year old boy in traumatic arrest after a direct blow to the chest with a baseball. He's intubated; we'll be there in 2 minutes. " My hands shook when I replaced the EMS notification phone.

After years of dealing with gunshot wounds and stab wounds in our Level 1 Trauma Center , I was not easily fazed, but taking care of pediatric patients scared me. I worked at the Adult Emergency Room but hospital policy dictated that pediatric traumas come to the Adult side for the initial rescue interventions. Many of the ED staff have young children at home, and cases involving kids always evoked strong responses among the parents in our group. I could almost imagine some of the parents in my staff calling on the phone for their family.

The baseball stunned our patient's heart, and it was being squeezed to life by the frantic efforts of the paramedics who initiated cardiopulmonary resuscitation at the field. Commotio cordis describes a sudden cardiac arrest from a blow to the chest. The baseball had caused a disruption on the heart rhythm at a critical point during the cycle of a heartbeat resulting in ventricular fibrillation. The quivering heart did not produce a heartbeat. There's a 65% mortality rate. A nightmare coming to our doorsteps.

The ER staff's collective groan when I told them about the notification reflected all our anxieties. The sight of the trauma surgeons and the pediatric doctors and nurses rushing to our side was met with some relief. We expected them to lead the rescue efforts.

The ambulance doors whooshed open, and the Trauma Team who was called in advance stood in attention. I was standing at the Trauma entrance and saw a paramedic perched on top of the guerney doing CPR on the patient, while another paramedic was giving breaths to the patient via an ambubag. Several pairs of hands reached up to hold on to the EMS guerney. I could smell the sweat of fear around me. Everybody took a deep breath.

The Trauma team swung into action. At that moment, everyone was focused on the small kid; he was ours and we would exhaust all efforts to bring him to life. Without question, this kid demanded our full attention.

"Check the pulse!". The ED attending physician barked. CPR was held as one doctor felt for the carotid pulse. The cardiac monitor confirmed the negative reply. External defibrillation failed. We knew that prognosis was bleak.

The decision was made to open the chest for the internal cardiac massage. Within minutes, the chest lay open and the surgeon started to massage the young boy's heart. Anxious eyes watched for any sign of response. A short burst of applause broke out when the heart started to beat on its own.

"We are not done here yet so hold the applause" was the curt reply from the Trauma Chief. The patient needed to go to the OR stat.

A commotion at the door caught my attention. The mother had arrived. I grabbed one of the residents to talk to the mother. She let out a piercing wail before she collapsed to the floor.

In a plaintive voice, she sobbed, "Please help my son, please." I heard sniffling behind me and saw the other nurses wiping tears. The mother was trembling, her cries of agony filled the Emergency Room. We assured her that the Trauma Team was doing their best. Empty words. Vague promises.

"His name is Pedro. He loves the Mets." The mother said softly, as she showed me the picture of her boy. He was in full Mets uniform , complete with the baseball cap. Pedro's face beamed in delight as he struck a pose for the camera.

Not knowing what to say, I replied, "Me too." It was a stupid remark, I thought, but it brought a tentative smile to the mother's face. Perhaps she thought that a little humor meant that her son was not that sick.

The mother wanted to see her son, but the Trauma Team had gathered around the patient's bed. The surgeon was issuing orders to his residents while the nurses were busy preparing the patient to the mad dash to the OR.

Being a mother myself, I shared the fear that gripped Pedro's mother. Knowing that her son was extremely critical, I wanted to give the mother a chance to see her son. In my mind, I wanted her to say goodbye.

I cleared the pathway so that the mother can finally kiss her son's blood-caked face. The surgeon did not want to wait and impatiently glared at me. I raised my eyebrows at him in defiance and said, "Just one moment."

For some of the team members, I could sense their annoyance at the interruption but I pulled the mother to the head of the bed and motioned for her to kiss her son. At that point, a sterile drape covered the hole on Pedro's chest, but the mother reacted to the intubation tube on her son's mouth with an anguished cry before she finally leaned over to kiss her son on the cheek. She closed her eyes and muttered a short prayer.

I gently pulled the mother away as the trauma team rushed the patient to the operating room. The Trauma Coordinator offered to accompany the mother to the OR Waiting Room. I ran after them to give the mother the Mets cap that Pedro had left behind.

The case had shaken the ED staff. As we cleaned up the trauma room in preparation for the next patient, we spoke in hushed tones about little Pedro. I worried about the boy's family as they struggle to keep their hopes alive. Pedro's distraught father had arrived a few minutes after. He was being held up by his friends as they all rushed to the OR waiting area.

We got word that the boy survived the operation but was placed on sedation. There was the unspoken fear that the boy will emerge brain-damaged when he is weaned from the medications.

The emotions that had churned in me that day left me feeling drained. As I walked towards the hospital parking lot, I met the boy's mother in the lobby. She kept her face composed but I could feel that she would be unleashing her emotions pretty soon. As soon as she saw me, she asked where the hospital chapel was. Alarmed, I asked about her son's condition. She informed me that her son was still being sedated.

I accompanied the young mother to the chapel. She appeared to be Catholic but I am not so I turned around to leave. My steps were halted when the mother burst into heart-wrenching sobs, so I stayed behind and patted her back in consolation. After sometime, she stopped crying and knelt down on the pew. I remained seated as I uttered my own prayers to God. Our different religions did not matter, but we both prayed to our Supreme Being for the little boy in the Mets cap.

When I went home that night , I enveloped my seven-year old son in a tight embrace. I thanked God for my precious son, then added an extra prayer for the boy named Pedro. The next day, I learned that all my fellow nurses did the same thing with their own children.

Several days later, the Trauma Coordinator informed us that Pedro was transferred to a children's specialty hospital in Long Island.

Three weeks later, the Trauma Coordinator surprised the ER with a most welcome sight.

A mother was guiding a young boy with a shy, tentative smile towards the group of ED personnel in the Nursing Station. Pedro stood in front of us, in full Mets uniform, his blood-stained Mets baseball cap clutched in his tiny hands. His mother explained that Pedro refused to part with his baseball cap. Pedro pulled his shirt up to proudly show the scar on the left side of his chest.

All the patients around us looked bewildered at the sight of nurses with tears in our eyes as we grinned and high-fived with Pedro. I said a silent prayer of thanks.

Saturday, October 2, 2010

Organized Chaos


At Triage...
EMS#1: "My patient inhaled cockroach spray. You have to triage me first."
EMS#2: "I was here first. My patient was found sleeping in the subway station and the police couldn't wake him up."
Patient: "Nurse, you can't keep me against my will. I know my rights. I'll call my lawyers."
Clerk: "Triage nurse, you have a call from the clinic on line three."
Tech: "Did you order these bloods? I need your signature."
Family: "Miss, did you see my father? He's the one with the rash."
Police: "When will the doctor see this perp? She's got to sew him up before I can take him back to Central Booking."
Visitor: "How do I get to the clinic?"
Clerk: :The head nurse is in a meeting. Can you answer this call?"
EMS#3: Nurse, your patient is getting out of his restraints."
Triage nurse (martyr and victim): "Help!"
(Published Journal of Emergency Nursing, Volume 24, No 4)





Complaints
The physicians meet and complain about the nurses.
The PAs meet and carry on about the nurses.
The administrators meet and want to cut the nurses.
The nurses meet and complain about each other.
Just going with the flow.
(Published Journal of Emergency Nursing Volume 24, No.4)





Cacophony
The phones ring incessantly. The patients groan, moan, wheeze, and curse. The stretchers squeak by. The doctors yell orders and the nurses yell back. The intercoms blare. The monitors beep. The sirens wail. The ventilators hum. The inmates's handcuffs clang against the side rails. The families complain. The escort aides giggle. The babies cry.
And I try to listen to my patient's lungs.
(Published Journal of Emergency Nursing, December 1999)

Saturday, September 25, 2010

Life, Death, and Renewal



A sense of foreboding gripped me as I entered the department. The aides were pushing a morgue stretcher away, leaving sharp intakes of breath and a muffled cry. Three nurses huddled around the triage desk, one nurse was visibly upset.

Outside the trauma room stood two burly policemen. The aftermath of a trauma resuscitation greeted me: the blood-splattered floor was strewn with discarded clothes, a used stylet, wadded gauze, and the blue overwraps from the instrument trays.

The night nurse looked shell-shocked. On Bed A, an unconscious male patient lay in a tangle of wires and tubes. The ventilator hummed and the monitors bleeped. Endotracheal tube to the ventilator, sinus rhythm on the monitor, an arterial line, two large-bore IV lines, a urinary catheter, right chest tube, right leg splint, dried blood on bandaged head, and his left hand cuffed to the side rails.

"Here's our 20 year-old trauma patient... this..." the night nurse bit her lip to stifle an expletive. "This person just murdered his girlfriend, her two children and her grandma. Shot them point-blank. He jumped four stories off the roof after he was chased by the police. All this because she tried to leave him after a night of beatings. That was the youngest child we just sent to the morgue. " Her voice broke and we both shuddered.

We stood at the bedside and shared each other's anger. The thought of the carnage this man left behind made me recoil in disgust. I felt a need to cry; bile rose up in my throat. Even in repose, this man's face looked so evil, almost satanic. Despite all the repulsion I felt, I had no choice; I had to take care of this patient. My training and my ethical responsibility will ensure that I give this patient the best of care, no matter what.

No matter what… it was the mantra that I kept repeating to myself that day. I had never had a problem with being non-judgmental, but that day, the case touched me. Like everyone, my heart bled for the innocent ones who lost their lives.

The night nurse struggled to finish the report. She was rambling, obviously wanting to simply put the ugliness behind her. I could only pat her back. "He's pending the CAT scan results. His pupils are fixed and dilated; he's unresponsive to any stimuli, no corneal reflexes, and he's posturing." This patient is as good as dead, I thought. The machines keep him alive.

As if on cue, the physician strode over. "He's got a huge subarachnoid bleed. No surgery for him. We're starting brain death protocol on him... and surprise! The cops just found his organ donor card."

Somehow, my anger simmered away. I clutched at one straw of sanity... in one rational moment, this man has willed his organs so that in his death, others could live. The organ donor card tells me that at one point in his life, this man cared enough. A little too late. Why couldn't he be as generous in life?

Then I reminded myself that in his death, he would be lending a gift to someone else. Would his gift of life a renewal for his soul? I doubt it will be, but a gift is a gift, and somewhere, somebody else will live.


Friday, August 27, 2010

Counting my Blessings



At Triage...

I worried about buying a new sofa and matching curtains for the living room,
a patient said he is homeless.

I fretted about not getting a pay raise and complained about the stress on the job,
the 55-year breadwinner with the chest pains was just laid off.

I whined about the high cost of hair color and how my highlights do not last long,
my chemotherapy patient was depressed about her alopecia.

I grumbled about my being stressed out with demands of my time from family members,
the elderly gentleman just lost his wife and now is all alone.

I ranted and raved about the nation's state of affairs,
this bright-eyed refugee from a third-world country gushed about free speech.

I complained about being tired from shopping all day long,
this young, gaunt HIV patient whispered, "I'm dying.".

And now that I am being inconvenienced by a little snow and rain,
the horrific images of the tsunami, typhoons, and mudslides just make everything else trivial and insensitive by comparison.

How can I complain?
I had learned long ago to count my blessings.



Nov. 2013- The aftermath of Typhoon Yolanda (Haiyan)











“Imagine being born without arms. No arms to wrap around a friend ; no hands to hold the ones you love; no fingers to experience touch ; no way to lift or carry things. How much more difficult would life be if you were living without arms and hands? Or what about legs? Imagine if instead of no arms, you had no legs. No ability to dance, walk, run, or even stand. Now put both of those scenarios together… no arms and no legs. What would you do? How would that affect your everyday life”- Nicholas Vujicic

http://www.lifewithoutlimbs.org/about-nick/

Monday, August 23, 2010

Life in my ER






“Oh, what a beautiful morning. Oh, what a beautiful day”, sang this 250-lb flushed-face, alcohol-reeking man who graced our ED one day. He was a happy drunk, winking at the nurses, and even trying to slap a female clerk’s behind as she passed. After we restrained him up, and pushed him into a private room, he stopped singing. He was silent, but not for long.
Out he came, walked out of the room, buck naked, with the stretcher still strapped on his back.

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What’s worse than a hypochondriac patient?
A gullible nurse.




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Superstitions in the ED:
1. Do not ever say the “Q” word.
2. Cardiac arrests come in threes.
3. Full Moon brings in patients.



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She looked haggard, walked like a Zombie, and snapped at everybody. Beware the Burned-out-nurse. Time for vacation again.



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We keep a running tab on what’s the weirdest thing we found in any body cavity. Such is the life of an ER nurse. We live for the simple pleasures.




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My non-medical friend asked, “How come when you nurses get together, you take so much pleasure in grossing each other out with talk about the hospital? Imagine talking about these fluids during meals. Yuck!”

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A friend dropped by one day when the ER was in gridlock. It was 12 noon and the EMS stretchers were lined up all the way down to the ER ambulance door. Patients were cursing, and telephones were ringing. Nurses and doctors rushed through the crowded corridors to respond to a Trauma Team call.

With such disbelief in her face, she gasped, “You must be crazy to work here.”
The staff around us chorused, “We all are!”.

Friday, August 20, 2010

Letting Go


(Excerpt from my published article)

Redefining 'survival' in a profession that does so much business with death.




I remember when I was still untouched by death-when I was a child who believed in immortality and invincibility. It all changed when I became a nurse and came face to face with the harsh realities of death. Suddenly, the finality of it forced me to see us as the mortals we are. I dealt with my patients' dying by maintaining a "qué será será" attitude. It didn't mean losing my humanity; it didn't mean that I cared less for my patients. It just meant survival for me in a profession that sees a lot of suffering and death.

Until Mr. C came to the ED to die.

It was a warm spring day, and on Bed 3 *Mr. Contreras lay dying. Brain cancer with metastases-and the devastation of the disease was finally taking its toll on his 80-year-old body. He was unconscious, but a single tear clung to his right eyelashes.

The ED staff knew him as one of our "frequent fliers." He liked to be called "Abuelo"-Grandpa. He was always pleasant, even when he was in pain. His wife, Rosa, was a proud and feisty woman, and a bit protective of her husband. She used to complain to hospital administration that we were slow in giving him pain medication. "Why can't you give him more attention?" she grumbled.

Now, Rosa sat with hunched shoulders at the bedside. She looked tired and resigned. Her face reflected her fears; her eyes, unspoken misery.

The cardiac nurse told me that the family had signed the DNR papers. Marco, the couple's only child, stood vigil on the opposite side of the bed, gently caressing his father's wrinkled forehead. His face was in agony, but I sensed a quiet strength within him. He would need it now.

I tried to leave to give the family some privacy, but Rosa held on to me with her other hand. "We've said our good-byes. Now I'm letting him go. He wants to die in peace. We're all ready now." Rosa's voice quivered. I nodded because I knew that Marco had reconciled with his father four months ago after a long estrangement.

The intravenous line was removed. The patient wore a clean white shirt. The Foley catheter was discontinued. We all stared in silence at the flickering cardiac monitor, mesmerized by the even graceful strokes. Sinus bradycardia ... pulse 50 and thready. BP steadily going down ... now barely palpable at 70 systolic ... respirations shallow. Abuelo was at the threshold.

The numbers held our attention. Heart rate 40 ... 34 ... 29 ... then asystole. The ED resident shook her head. A gasp escaped from Marco, and Rosa broke into sobs. I stood transfixed as a life ebbed away and the single tear rolled down Abuelo's cheek. His face stunned me. I expected to see suffering, but instead I marveled at a face that in death looked peaceful, almost ethereal. He died in peace, surrounded by love.

Rosa hugged and kissed her husband of 50 years. I tried to say something that I knew would comfort no one but me, but there was a lump in my throat. I just hugged her and we cried together for this wonderful man whose life had made such a difference. "Thank you for everything," Rosa finally said. Mother and son then walked away to begin a new life, and I said a silent prayer for the family.

I remember them to this day, several years later. I hope that their memories of togetherness sustained them through their grief. And I'm thankful that it was a quiet day in the ED, and that I had time to listen and to grieve. From them, I learned what strength there is in just letting go.



* Names were changed. http://journals.lww.com/ajnonline/fulltext/1998/08000/letting_go_of_abuelo.44.aspx

Wednesday, August 18, 2010

ED Vignettes





Before the ED had our electronic documentation, patients sign up on a paper form. Liz, the triage nurse, loudly called for the next name... “Culo Grande, Culo Grande”. Nobody responded, and instead most of the patients were grinning, some with chests heaving with laughter every time Liz called out the name.
A Hispanic hospital police officer sidled up to Liz, “Do you know what ‘Culo Grande’ means?” It means “Big Ass.”.
Liz refused to triage after that.



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Do you know you can get drunk just from breathing the off-gases from the patients in the ED on New Year’s Day?




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Everybody knows CG, our resident drunk. He came via EMS, he came walking, he came in any which way he can especially on cold winter nights. He slipped in and out of the ER in sync with our mealtimes. Then he was gone for a month.
He came back one day, all cleaned up, dressed up in clean dress pants and shirt and a blazer. His sister got him into Rehab. We patted him on the back, even high-fived with him. “Way to go.”, “Keep it up”. TL smiled ear-to-ear, and blushed beet-red as he accepted all the compliments from the staff. We all felt that there was still hope in life.
A month later, he came back drunk and seizing.

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The red EMS notification phone rings. All ED personnel stopped in their tracks and listened with bated breath. The triage nurse answers, “No, sir, this is not a pizza parlor.”




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Everybody gasped. On the endoscopy machine screen, the patient’s stomach lining was littered with debris of her experiments with exotic food: an eraser, a paper clip, a teaspoon, a capped syringe, and a ring.
The GI consultant exclaimed, “So, that’s where my wedding ring went!”.

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The medical intern volunteered to do the chest compressions during a code. The strong, even strokes reflected on the defibrillator screen. Then the compressions became weaker, slower until the intern dropped on the floor.
Somebody said, “Uh-oh, there’s still Nitropaste on the patient’s chest.”