Goodbye, Kettly

Emergency Department... a place where we see deaths up close and personal. The ED staff who choose to stay do so because they love the rewards that come from saving lives. We are hardened (crazy) souls who have accepted life's realities. But it is difficult when you lose one of your own.

Today, we said goodbye to Kettly.

Through life’s ups and downs, Kettly managed to smile her way into her fellow nurses’ hearts. She reveled in the deep friendships that blossomed amidst stressful times in the ED. As she struggled with illness, she persevered and impressed her hospital family with her indomitable spirit of resilience and tenacity. Her easy wit and sense of humor brightened our days as we all commiserated with each other at the end of each day. Kettly cared for her patients, even as she needed caring herself. She offered hope.

It is difficult to imagine that the once-vibrant nurse who delegated cooking duties like a drill sergeant for the holiday party is no longer with us. Could she have been preparing us for her untimely passing by creating special memories of friendships and by showing us the value of team work? Did she realize that the new triage nurses would remember the words of encouragement she gave them on her last day in the unit?

As she held her family in her heart, she reserved a special place for her hospital family.

Last night, we gave Kettly a White Rose tribute and showed our appreciation by honoring her with our Nursing flag. The nurses, all dressed in white, stood en masse in solidarity with a few of our colleagues who struggled to read lines from a poem written by another nurse:

To witness humanity—its beauty, in good times and bad, without judgment,
She was there.
To embrace the woes of the world, willingly, and offer hope,
She was there.
(“She Was There” is copyrighted by D. Jaeger)

Kettly, we will miss your carrot cake, your de-boned turkey, and your words of wisdom. But most of all, we will miss the nurse who showed us quiet strength and resolve through adversity. We will miss your regal presence.

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.

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.

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, 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

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.

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.

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"

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!

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/