"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 of 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 but 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 in 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's 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 laptop with the programmed scenario.

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 rhetoric 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 on 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 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 about 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.

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 workplace. 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: http://jocerrudosese.blogspot.com/

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 heartbroken.

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?

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 at 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 in 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.

The Heart Remembers

One New Year’s Eve many years ago, EMS brought an elderly man with dementia to the emergency department. The patient had become increasingly agitated due to the loud fireworks outside the nursing home. I have assigned a nurses’ aide to stay with the patient as we tried to sort out the bolus of patients who came into the ED.

At the same time, a “happy drunk” staggered into the ED. Thankfully, the patient, who was a regular in the ED, just wanted an audience for his singing. The “happy drunk” entertained the triage area with opera songs like Pavarotti. His impassioned O Sole Mio was surprisingly well-modulated and brought a smile to everyone, even to the ED staff who worked on the holiday, away from their family.

The elderly man stopped squirming in his stretcher. Somehow, the familiar melody broke through the cobwebs of his mind and he joined our happy drunk in total harmony. We later learned that he was an accomplished tenor in his prime. He remembered what he loved most.

I remembered the elderly man a few days ago when I accompanied my friend Anita when she visited her mother in the nursing home. Mrs. D. sat by the window, her stares focused at the gardens outside. Was she enjoying the beautiful flowers or was she lost in her own memories? Her gnarled fingers were gently caressing the lace shawl on her lap.

My friend Anita approached her mother. “Mom, I brought my friend today.”

Mrs. D. looked at us. I didn’t expect her to recognize her daughter’s friend from our apple-picking outings when we were still new in the United States. After all, she didn’t even recognize her own daughter.

Alzheimer’s disease had robbed Mrs. D. of her memories. She looked at her daughter like a stranger. She didn’t even respond to her daughter’s embrace. Her lined face was raised in fear at the sudden intrusion into her physical space.

Mrs. D. used to be a human dynamo. After she was widowed, Mrs. D. ran her daughter’s home with such efficiency as her daughter and son-in-law worked hard at their careers as nurses. She was a loving but firm grandma to both of her grandkids. I remembered her humming her favorite songs whatever she was doing at that time.

Anita’s family had no choice but to transfer her to a nursing home when she started wandering away from home. Mrs. D. had been missing for two days until an alert hospital worker notified the police of an unknown woman who was dropped off at the emergency department. She was lost in her own world. Mrs. D. was now a shell of her former self.

The deterioration was slow but equally painful. What was once a vibrant woman was now profoundly changed. During the early stage of the disease, she expressed frustration for not remembering, and for being a victim of her forgetfulness. Now, she looked calm, probably because she did not even realize what she was powerless to do.

Anita was sobbing in frustration. Mrs. D. was not responsive to any of her daughter’s attempts at conversation. I remembered my old patient from several years ago and suggested to Anita to sing some of her mother’s favorite songs.

“Saan Ka Man Naroroon” (Wherever You Are) is a Filipino love song about a woman’s promise of loyalty to her loved one. This was the theme song of Anita’s parents. As soon as Anita sang the song, her mother’s face relaxed and her eyes focused on Anita. Mrs. D. smiled and caressed her daughter’s hair.

At that moment, with the sweet melody of a beloved song, there was a respite from the darkness in her mind. Her heart remembered, even for just a few minutes.

Thank You From Our Patients

I heard a voice behind me, “Nurse, nurse”. When I turned around, I saw an elderly man leaning heavily on his cane as he tried to get my attention. The ED was extremely busy at that time and the noise level was high but the gravelly voice had a desperate note to it that made me stop. The elderly man just wanted to thank me for staying with his anxious wife while he parked the car. It was just a simple gesture, just a few minutes of my time. To this couple, this meant that the wife’s anxiety did not unravel into a full-blown panic attack. I was just doing my job. But the appreciation from the couple made my day. The elderly man didn't know that just a few minutes ago, I came from assisting in a cardiac arrest of a young man who succumbed to an overdose. His Thank You was a God-sent relief for me.

In our nursing lifetimes, we treasure those moments that validate the reason why we stayed in this profession. The “thank yous” are our emotional rewards. The appreciation from our patients and from our peers lifts our spirits and keeps us going. How wonderful it is to know that we have made a difference.

The following are excellent examples of how nurses changed lives:

Renee, NICU nurse, received a wonderful surprise from the babies she cared for. She is a miracle worker.

Lawrence O’Donnell, a news anchor from MSNBC, delivered an emotional tribute to the doctors and nurses who cared for him after an accident.

Bailey Murill, 17 years old at that time, was paralyzed for 11 days after a freak accident horse-playing with her family at home. She landed awkwardly on her back and was unable to move her legs. Through all the harrowing experiences of finding out the reason for her illness, she developed a close relationship with her nurses at Zale Lipshy University Hospital. She came back from Rehab after regaining the use of her legs to surprise her favorite nurse.

Amanda Scarpinati sustained severe third-degree burns to her body when she was a mere baby. Just three months old, she rolled off a couch into a steam vaporizer. Over the years, she underwent reconstructive surgeries. She took comfort from a picture of her in the arms of a nurse at Albany Medical Center. Thirty-eight years later, she was able to reunite with Susan Burger, the nurse who took care of her.

"I don't know how many nurses would be lucky enough to have something like this happen, to have someone remember you all that time," Berger said. "I feel privileged to be the one to represent all the nurses who cared for her over the years." http://www.today.com/health/burned-baby-woman-finally-meets-nurse-who-cared-her-t47151

When things get rough, when the pressures of being a nurse threaten to overwhelm us, let us remember the special moments of appreciation from the patients and their families who deserve our very best to offer.



Happy Emergency Nurses Week to all the courageous nurses at the frontline of our emergency departments.

Addendum: 9/17/2016

Gary Bentley held on to a photograph of him and a nurse named Kathy for 40 years. In 1975, Gary and his siblings were placed in foster care because of an abusive father. He also underwent open heart surgery at that time. In those difficult times, Nurse Kathy made a long-lasting impression on young Gary. See the emotional reunion.



http://www.littlethings.com/nurse-kathy-reunion/?utm_source=ftap&utm_medium=social&utm_campaign=dad

Stethoscope

Dear The View hosts,

That was a token apology. In fact, your misguided attempt to explain made your original ridicule even much worse. That was a prime example of ignorance and disrespect about a profession that deserves much more recognition.

Flashback to last September 13, 2015, in the Miss America pageant. For the talent portion, Miss Colorado opted out of a gown and proudly wore her nurse’s uniform with a stethoscope draped around her neck. Kelley Johnson offered an impassioned and heartfelt monologue about her experience as a nurse to an Alzheimer’s patient.




The View hosts proceeded to ridicule her choice of talent presentation. Michelle Collins remarked, “She came out in a nurse's uniform and basically read her emails out loud and, shockingly, did not win.". Joy Behar, who just recently returned to the show, wondered "Why does she have a doctor's stethoscope on?". A female with scrubs and a stethoscope. The implication is that a nurse does not have the right to use a stethoscope.




Of course, the backlash from the nursing community was explosive. Social media erupted with rightful indignation from the nurses, the doctors, and the general public.

And you call that an apology? Thanks, but no thanks. Joy Behar said that she “was not paying attention”. Did the neurons misfire and you were not able to associate the scrubs with a healthcare worker? Aren’t you being paid to know what you are commenting on?

Michelle Collins profusely praised the nurses, even asking our “bosses” to give us raises. Poor Michelle, her statement was just “misconstrued”. Whoopi accused nurses of taking things out of context and of not knowing that the stethoscope statement was just a joke. Raven Symone called out the nurses for not listening to the intent.

No, I am not too sensitive. I listened to everything you said in defense. And I do have a sense of humor. At this point, you should have been educated enough about the many uses of the stethoscope in the nursing world. The internet is full of stories about how nurses make a difference every day. Even better, you should realize why the outrage from the nurses is justified.

How about spending an hour or two following an emergency department nurse around? And then maybe, you can try another apology.