Saturday, October 23, 2010
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.
Saturday, October 16, 2010
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
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
"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
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)
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)
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)