Wednesday, August 17, 2016

"Oh, No! Trauma Again?"

EMS notification
The red phone rings above the din of the mid-day controlled chaos of the emergency department.

Gloria, the charge nurse sighs and picks up the phone. The resuscitation room nurses and Dr. Cooper, ED attending, approach the nursing station with expressions on their faces something akin to dread. The weariness of the back-to-back cardiac arrests and trauma cases in the past three hours is still visible on their faces. “Oh, no! Trauma again?" is the collective response from the ED staff.

Gloria writes furiously on the log book, her script almost illegible in her haste. “Stab wound to the chest, patient hypotensive 90/50, tachycardic 118, alert and responsive, paramedic, 3 minutes ETA”. The word “Trauma” is like a magic wand that transforms the frenetic atmosphere in the ED to an even more hyped-up vibe. With a quick consultation with the ED attending, Gloria activated the Trauma Team. The phone operator repeats her every word “Trauma Level One, Adult, stab wound to the chest, Resus 1”.

Team in action
The ED team galvanizes into action. Three minutes before all hell breaks loose again. The EMS notification gives them time to prepare. Sometimes, patients walk in from a trauma incident. Other times, victims from gang-related incidents are dropped off by their friends at the ambulance area. Usually, the friends scamper away when the police authorities come around to investigate.

The team leader, Dr. Cooper, calls for a brief to reinforce the roles and responsibilities of his team. There is a diagram on the wall and painted squares on the floor to remind the team. Gloria pulls one of the triage nurses to act as the scribe nurse. The team members all suit up with gowns, gloves, and goggles. The airway physician checks his airway equipment, and pulls the glide scope from the other room. The nurses prepare the chest tube set-up and the rapid infuser. The survey physician is the intern who is visibly shaking since this is his first month on the job.

Other ED staff and visitors try to come into the trauma room, only to be rebuffed by Gloria. The diminutive charge nurse is intimidating as she takes her place outside the trauma room; she will not allow any other non-essential personnel in the room. Somehow, a trauma case attracts rubber-neckers and it is Gloria’s duty to do crowd control, until the nurse manager comes to take over.

The patient comes. Gloria could not help think “It’s show time”. The EMS paramedic directs her report to the team leader, not losing her beat as her partner motions for the transfer of the patient to the trauma stretcher. The other team members work in silence as they half-listened to the report while they undress the patient and hook him to the cardiac monitor.

The paramedic intones “This is a 20 year old male who was involved in a battle between two gangs. He was stabbed on his right chest. The knife is with the police now. He was carrying on at the scene cursing a streak, then he became hypotensive and tachycardic so we just rushed him in here.

The ED attending glances quickly at Gloria when the paramedic mentions the gang. Gloria instinctively scans the crowd gathered outside the room. She mouths “gang activity” to the nurse manager. Marlene is an experienced ER nurse who had seen her share of gang-related traumas in her previous hospital. She immediately summons a security officer who then moves all the on-lookers away from the door. Security will need to contact NYPD to apprise them of the situation of the potential for gang retribution and to secure all entrances to the emergency department and the hospital.

The team leader asks the survey physician to report his primary assessment. “Airway is intact but there is decreased breath sound on the right. I will put a chest tube”. The secondary nurse readily hands over the 38-french chest tube and insertion kit. The chest tube drains three hundred mls of blood. The patient is still alert and awake but no longer belligerent. He finally realizes that he is in big trouble and he silently endures the poking from the survey physician after he received an intravenous pain medication.

Like clockwork, the nurses effortlessly insert 16-gauge IVs antecubital bilaterally. The primary nurse, Rick, hands the labeled blood tubes to Gloria who then hands them off to the patient care tech to run over to the Blood Bank. Dr. Cooper activates the massive transfusion protocol. The nurses prepare the new rapid transfuser. Gloria retrieves two units of O-negative blood from the room refrigerator.

Crowd Control
However, the responding surgeons come in droves and crowd control becomes a losing battle. Marlene tries to question everyone who responds to the trauma activation. All this talk about crowd control has to be directed to the surgeons and the consultants who bring three members of their team inside the crowded room. Everyone thinks they’re indispensable.

Initially, the ED team communicated quietly with each other. The arrival of the surgeons shatters the peace, but only for a few minutes. The team leader takes control and says in a firm but controlled voice, “Everybody shut up. The only person to talk is me and the chief surgeon and the nurses or whoever I ask to speak”.

The scribe nurse Aysha calls out the vital signs. The blood pressure responds to the blood transfusion with the blood pressure slightly higher. “BP- 100/52, heart rate- 100”. She keeps track of the vital signs and guides the survey physician as he does the secondary assessment.

The chief surgical resident discusses the patient disposition with the ED attending. He then says to his junior resident, “Call the OR now.”

Case closed

Dr. Singh calls out, “Team, thank you. Our in-situ simulation is over. Please stay for a few minutes for a quick debriefing. Great job, everybody. ” He covers the simulation manikin and turns off the lap top with the programmed scenario.

Monday, July 25, 2016

Ignorance and Bigotry

Readers, this past week, I heard of two ugly encounters in the emergency department. Two patients disrespected the nurses who were trying to help them because of the color of their skin. Sadly, this is nothing new. I wrote this letter about 15 years ago after a similar experience. Somehow, the hateful vitriol is further emboldened by xenophobic rhetorics from bullies and haters. I have always worked with an exemplary diverse staff who see patients as human beings. I stand proud as an American citizen and as a nurse, even as we face all these challenges with professionalism and decency. As the incredible First Lady of the United States Michelle Obama elegantly said, "When they go low, we go high".

Dear patient,

I wish I can erase that hatred in your heart, that xenophobic attitude against anyone who doesn’t look like you. You cursed at me and told me to “return to my country”, even as I was just trying to triage you. I swallowed the bile in my throat as you ranted about immigrants who stole your job. I have two college degrees, dear patient. Based on your incoherent and ungrammatical ramblings, I am pretty sure you could not perform my job.

I knew you were sick so I ignored your blatant racism. I allowed my orientee to interview you just so I can get enough information why you have tachycardia and back pains. I did not call security to escort you out because I realized that you needed medical help, despite the obscene gestures. You are an ignorant and a bigot, but you are my patient.

You don’t know that I was the one who recognized that you were dying. You even refused to be seen by our Asian ED doctor and the African-American resident. But then, you collapsed in front of us. You don’t know that I was the only one who could insert a good IV line in your fragile veins. Now that you are unconscious, you would never realize that the emergency team who took care of you was a diverse group, a multi-colored group of professionals. If you knew you were dying, would you have accepted our ministrations?

The rainbow of ethnicities in our emergency team did not divide us but instead united us in our efforts to serve the diverse community. Our team of doctors, nurses, and other ancillary staff did not care about the color of your skin. There was no question about your sexual orientation, or political and religious affiliations. All we were concerned was to race against time to save your life.

You are our patient. If you are conscious, we would not tolerate your disgusting behavior. But unfortunately, you are now intubated and brain-dead. So we have to be blind to your faults. We will not respond in kind to your ignorance and bigotry. Despite your evil thoughts, we will remain true to our sworn oath to take care of you, as we do with all our patients. I see you as a human being. No matter what.

Your Filipino-American nurse

P.S. You signed an Organ Donor Card. It is great that you did not state a preference for the recipients of your organs. I'm sorry that you would not be able to read this letter. I was hoping this would open your eyes and touch your heart.

Saturday, July 16, 2016

Nurse Cartoons

Cartoons paint eloquent visuals of a nurse’s life. There are so many stories to tell, sometimes sad, mostly funny. We cannot take things too seriously while at the work place. For there is so much more that we can poke fun at. After a hard day’s work, we need to take a deep breath to remind ourselves why we go through the stress of taking care of others.

Laughter is the best medicine, so they say. Laughter is a tonic that releases endorphins. It’s a feel-good chemical, a natural high. It is an antidote to a negative vibe. A chuckle is a start to a rumbling roar of a hearty, ROFL laugh. We should always share a smile, a chuckle, a giggle, a guffaw, and a belly laugh. Negative out, positive in. Leave the work drama behind. Come and draw a cartoon.

More to see at:

Saturday, March 12, 2016

Dear Angela

Dear Angela,

I would never know how your own family feels right now. I just know this is a difficult time for them.

It shouldn’t be like this that our Elmhurst ED work family would see each other again. Not at your funeral. Old familiar faces returned to pay respect to you, one of our own. There was no joy at the unexpected reunion, just profound shock and melancholy at such a sad occasion.

It was tough to say Goodbye. You’re gone too soon. I have always thought of you as fierce, vibrant, and invincible. The soldier and the nurse; you’re twice a hero. I am heart-broken.

Wasn't it just yesterday when you came for your interview for an LPN position? I was impressed at how articulate and confident you were. Through all these years, you showed your strength, tenacity, and courage to finally get your RN license. As a soldier, as a nurse, and as a union representative, you were one tough cookie. I salute you. I just wish I had seen you one more time. Isn't it tragic that we always want to have that one more day to remember someone special by?

Someone said “Death leaves a heartache no one can heal, love leaves a memory no one can steal”. I have many fond memories of you, Angela. You were an excellent nurse, a straight-shooter (no pun intended), firm yet compassionate, and meticulous yet with a wicked sense of humor. You were there in our parties, baby showers, retirements, birthdays, and summer picnics. I heard you suggested a summer picnic before your untimely death. Maybe you missed the fun and games; maybe you longed to play with your work family.

Your Elmhurst “peeps” showed up en force, even those of us who have left to work elsewhere came back to share the grief. The White Rose Nightingale tribute was a poignant homage to your tremendous contribution to the department. After the nurses read the words to the poem "She was There", they gently laid a rose on your reposed body. It was a touching image, especially with the nurses dressed in white and the military guards standing in attention next to your casket. You have made a difference in people's lives many times over, Angela.

We've lost too many through the years. Kathy, Angel, Beckley, Ruthie, Siony from PAC, Derrick, Timmy, Kettly, Jennifer, Phyllis, Brad, and Dr. Neil Oster. There were two more who we lost, their names forgotten but their absence was nevertheless mourned. One was a new nurse who was a victim of domestic violence. Another one was a PA who took his own life. With every passing, our hearts break not only for the family but also for the co-workers they left behind.

The ED is a challenging place to work at, but it has certainly brought us together. We struggled, we saved lives, we laughed, and we cried. We grieved for every single co-worker we lost. In the process of keeping our heads above water, we became a family. Nurses, doctors, PCTs, PAs, clerks, transporters, and many more. And Elmhurst, our home.

And now you... You will be missed. More than you will ever know. My deepest sympathy to the Palmer family.