Anna-Ruth’s Neighborhood

Sometimes, on the really long nights, everything runs together. I walk out having forgotten half my patients, and I get confused as to what happened which night. It almost always feels like more than twelve hours pass in any given night.

Of course, if I was there tonight, I'd be working thirteen hours, thanks to the time change. Thank goodness I'm not working tonight.

But after a few intense nights in a row, the only things that stand out are the really remarkable cases.

I walked in to a mess, again, in the purple zone. I was the purple people-eater. Except for the part where the purple zone essentially eats you. Alive. I started with four patients, but essentially only laid eyes on three, and mostly just took care of one. It was a GI bleed, something about a weak spot in the esophagus. There had been some disagreement between the ER docs and the GI docs about putting a tube in his stomach to relieve a little pressure, see what was in there. Now, I don't know about it from a continued care of a GI bleeder point, but considering that we got about two liters of brownish-black coffee-ground appearing sludge out, it was probably a good thing. Otherwise, I get the feeling we would've been cleaning up a whole lot of nasty puke.

So with all the blood out, they decided to put a little more in. Unfortunately, the patient had, according to the blood bank, an "unusual marker" when they did his blood type and cross-matching, and he ended up having a transfusion reaction to the O-type blood we use as emergency release blood. So when we got specific typed blood, I couldn't give it because of the bright red rash my patient had. Fortunately, he was responding well to IV fluids and bits of Benadryl, so by the time we got him to the hard-won ICU bed, he was about back to normal and ready for the second round of blood.

See why it all blends together? And all this, again, by about 8:30. Me taking unstable people to the unit at the beginning of the shift seems to be a theme.

My next patient was there for continual seizures, or "status epilepticus," except it was all fake, which made things interesting. Especially for the part where we had to chase down her ER doc and get him to sign commitment papers so she could head where she really needed to be. When her ride from the sheriff's department to the psych facility arrived, we had an interesting time getting her to go, particularly because she refused to talk to us and refused to move, but eventually she shuffled outside with the officer.

And in the middle of all this, my poor patient in the hallway who'd fallen off a roof or ladder really felt neglected. But we did get him off the backboard in good time, and in the end, all he had were a bunch of bumps and bruises.

As the night progressed, it all turned into abdominal pains and good IV sticks, highlighted by a visit from a frequent-flier asthmatic.

Then, just when it seemed like things were winding down and going to stay that way until shift change, the EMS radio went off at about 5:40.

We heard the crackle, the ringing, the initial call-in. Somebody picked up the receiver, "Unit calling, go ahead."

There's always a sense of anticipation, even if minute, when waiting for that report. They could have anything - trauma, stroke, heart attack, cardiac arrest, ear ache, flu symptoms, sprained ankle... you get the idea.

Finally the radio picked up again: "Medic 733, inbound non-emergency with a 60 year-old female, patient initially called 911 and reported that she was dead, or was about to be dead. Patient is alert and oriented times three, vital signs are currently stable, BP 143/84, pulse 79, respiratory rate 18, 100% oxygen saturation on room air, no distress noted. We'll be with you in three to five minutes."

We spent approximately five minutes laughing hard enough that we were getting cramps, then we finally answered, "Good copy, Medic 733, glad to know your patient isn't dead. Room assignment on arrival."

Yeah. Just... yeah. There must've been some higher issues there, because when we got down to it, she called the ambulance because she and her boyfriend were arguing. Which, as we all know, is definitely a medical emergency. Needless to say, when our doctor's evaluation revealed that she was stable, she was discharged to the lobby. I think her whole visit took about thirty minutes.

See? This is why there will always be stories with what I do. People amaze me. Really. Stay tuned for stories of that nature.

While working on the floor, I noticed a trend. Each nurse seemed to attract a certain type of patient. One always got young patients with drug problems, another always got patients with somewhat disgusting conditions, and somebody else seemed to get problem patients from one specific doctor.

My particular brand of patient was the ones with a weird condition or unique, unknown medication. I can't tell you how much I had to look up on MicroMedex, or online, or call a pharmacist about.

In the ER, I do tend to collect patients with unique problems.

Tonight, it was this.

This patient had a hemorrhoid-ectomy the day before, which I didn't even realize was an operation. Tonight, she came with abdominal pain, cramping, and inability to pass gas or have a bowel movement. Now, I'm all for keeping your farts to yourself, but when it comes to assessing the function of somebody's intestines, we like to know that the gas-passing parts are functioning.

Well, her problem was that her sphincter had spasmed and closed.

Yes, that sphincter.

So what does the doctor do? Mix up an interesting paste. First ingredient, topical lidocaine, which helps numb whatever you smear it on. Second, a healthy squirt of nitro paste. Nitro is a muscle relaxant, and its primary application is in cardiac situations. We use it to keep persistent chest pain at bay, and to manage blood pressure. But, as the doctor so helpfully pointed out, it'll relax whatever muscle you put it on.

So between the nitro-caine paste and the IV morphine, the sphincter relaxed, and despite the pain of the hemorrhoid-ectomy, the patient started feeling much better.

If you can believe it, though, this was only a thirty minute chunk of my night.

Last night was one of the times that the attraction of the ER, the excitement and challenge of having to be prepared for whatever comes in next, was definitely, well... I haven't decided. Either a turn-off or a point of weakness.

Lately I've had the feeling that I spend the whole night chasing my tail. At least until 3AM or so. Not a nice feeling, but you usually just have to keep running.

Tonight, I walked into a... a... I don't even know. I think I walked into a hurricane. It was a whirlwind of nurses and doctors, trauma and ICU, patients and families, charts and vital signs and medications and a rather nagging lack of supplies and beds.

I had one of a few ICU patients, and this patient was a wreck. He was on levophed, which is one of the strongest vasoconstrictor drugs we use. Its primary use is to raise and maintain blood pressure (but vascular damage to smaller vessels is an unfortunate side effect). They thought he was septic (infection in his blood, in this case to the extent of a dangerously low blood pressure), but there were complicating factors in his history and condition that prevented an immediate diagnosis. So when I got him, the levophed was doing its job, but the morphine wasn't. So I employed a little more and spent the next hour taking him to CT scan, Xray, and finally to a bed in the ICU.

Which was a very good thing for many reasons. The most important was that he was receiving much, much better care in the ICU. The other good thing is that he was in a much better setting for coding and dying, which is what happened in the wee hours of the morning in the ICU. Why? What happened? Don't know. There are so many different potential explanations, and I'll never know. Which, somehow, is okay with me.

The whole situation is pretty sad. Sometimes when people come in, we do CPR and push the right drugs and everything we can reasonably do to resuscitate them, but on those, you can usually tell what the outcome will be when they roll through the door. Others have a good fighting chance. This guy was the latter. It's not like I felt we were wasting time and resources, because he really did have a fighting chance. He did. But it didn't work out.

My immediate response is to ask what happened, to wonder how he died. At the very least, though, he was in the ICU, and his family was with him. The family is key, I think, and things seem to be so much better when they're there.

Unfortunately, work is not the most opportune time to ponder such things.

But I digress.

Can you tell that it was a little long and tiring? This is one of the mornings when I'd pay so much money for a foot massage at 7AM. Would've been so mice.

I think I'm going to go to bed and ponder that.

In the week since I've blogged, here's what I didn't get around to posting...

Patient with a potassium of 1.4. EKG looked like crap. Didn't know that was compatible with life. Apparently it took more than 100 mEq IV potassium to get it up to 3.5, minimum safe acceptable potassium level. Moral of the story: don't be anorexic and abuse laxatives.

Yet another night opening heart/stroke. During which Adam told a few stories that involved a Canadian fishing trip, bags of milk, and the beer store (initials of which were LCBO, which they expanded to Local Canadian Beer Outlet).

Staff meeting, wherein lots of good changes were proposed. Hope they happen according to plan.

Second night in triage by myself. I wasn't as quick as I was the first night, but I kept a pretty good pace. I think the flow coordinator hated me for calling with so many and saying, "Um, here's this critical vital sign or other symptom and where can I send them, because they don't need to go back out to the lobby..."

Highest temperature I've ever seen, which was 104.6, in an immuno-compromised patient. Not good. And actually had another 104.0 temp. Also had a patient with malaria. And one who was really, really jaundiced. Another rolled up to the front and said, "Yeah, I accidentally shot myself in the foot, so I drove myself here..." We almost delivered a baby in the lobby, and then almost in the elevators on the way up.

Also a few cute little 90-year-olds with urinary tract infections and CHF exacerbations, quite pleasantly confused, and quite a nice contrast with all the pneumonia and sepsis. Oh, the weather change.

Last night, I braved my first solo night in triage.

Triage is always, well, interesting, because of the people you talk to and the stories you hear. You have to sort through all the information, decide what's pertinent, summarize it in a small box, and get all the other information appropriately checked off in the computer.

I felt like a broken record by the end of the night... Can't count how many times I said the phrase: "Hi, I'm Becky, I'm one of the nurses. I'm going to do your triage, get some vital signs, and ask some questions. What's going on with you tonight?"

One guy, who we can nickname "Smiley" due to his lack of half of his upper teeth, had quite an interesting complaint. His answer to my question was, "Well, I got this shot on Friday, and I'm having a reaction to it."
Me: What kind of reaction:
Smiley: Well, I've been feeling funny ever since I got it.
Me: What's been feeling funny?
Smiley: I'm just tired, and my ears hurt. Will they look at my ears?
Me: Probably. Now what sort of shot did you get?
Smiley: It was a new medicine they're trying.
Me: Okay, what was it?
Smiley: I don't know.
Me: You don't know? You didn't ask?
Smiley: They wouldn't tell me. I just didn't feel right. So I called the ambulance. I need you to do a blood test to see what they gave me.
Me: Where did you get the shot?
Smiley: At the health department.
Me: Was it a flu shot?
Smiley: No. I don't get those. They make you sick.
Me: (moving on to all the mandatory questions in the triage form) Are you hurting anywhere right now?
Smiley: I have a headache. Can you give me an aspirin?
Me: Well, you have to see a doctor first. How bad is your head hurting?
Smiley: They're going to look at my ears, right?
Me: Are you allergic to anything?
Smiley: No.
Me: Do you take any medications on a daily basis?
Smiley: No, but I get a haldol shot once a month.
Me: What do you get that for? (note: this is for agitation and various other psych problems)
Smiley: It's like 100 cc's, and I get it every month. And I take this other thing every day to offset the effects of the haldol shot.
Me: Okay, great. Let's take you through and get you registered.

I didn't even know what to do or say to this guy. Not knowing about the shot, if he even got one, wanting to be tested for something random and unknown, calling the ambulance, the whole Friday to Tuesday thing, the ears, the aspirin, the shot of 100 cc's of haldol once a month (when we can only give 2 ccs max in a shot, and that stuff for sure doesn't last a month), taking something to offset the haldol... amazing. Or sad. I don't really know. Maybe he was just lonely. But he was certainly a little bit more than odd.

There were definitely enough of the odd folks, and the folks with flu symptoms, and wrist/ankle/knee/finger/shoulder injuries, but there were some pretty sick ones, too. I had two that were having allergic reactions to nuts to the "I couldn't find my Epi-pen so I took some Benadryl and it helped but I still feel funny" degree.

And in the back, they had some excitement, too.

Like, a guy whose blood sugar was 2500. Yes. That's 250 times what it should be. Highest most of us had ever seen. He thought that we were on the lowest level of a space ship and he needed to get to the top level. As we equalled out his blood sugar, blood pH, and potassium levels, he started to come back, so that by the time he went to the ICU, he knew that we were at UT, and he was going to the middle of the space ship.

He was fortunate, though, because he got the last bed in the place. Which meant that at 3 or 4 in the morning, I handed over the triage phone and helped open the second extra holding area.

This really has become a weekly occurrence. Monday or Tuesday, it seems, we go on acute and critical care hold, and open overflow areas. I don't know what will solve the problem - if we need more beds in our hospital (which is in progress, thanks to the heart hospital under construction out front), or if we need other hospitals to reopen in town, or something else. That or we need a better system for admitting and discharging patients. Or a better system for handling the overflow. I know there are a few projects in process, but it'd be nice if they could step it up.

Looks like it could be a long winter on the UT spaceship.

So last night I took over orange at eleven. Fortunately, the black hole of death room only had two patients, and both were quite pleasant. Even if they were somewhat sick.

I didn't realize how sick one was, though, until I checked a blood pressure right before trying to send him to the floor.

They'd all been fine, right up until that last one, and it was a little lower than I was comfortable with. Usually when this happens, you tell the doctor, you give some IV fluids, and if the pressure gets better, you move on. If it doesn't, you try a few other things that get more and more involved. Either way, though, the blood pressure doesn't usually stay the same.

Well, this patient's didn't budge after fluids. Didn't go down, but didn't go up. The patient wasn't really symptomatic, so with the doctor's okay, I sent him on to the floor.

Later, we learned that, upon arrival to the floor, the patient had the same crappy blood pressure. Literally. Apparently he had been stuck in the middle of a bowel movement for a while, so they cleaned him up. And rechecked his blood pressure.

And it was fine.

The only thing we could figure was that the bowel movement caused a prolonged vagal response, hence the sustained lower blood pressure.

Not so sure that butt-wiping is a practical intervention for many patients with hypotension, but definitely one of those things where you go, "What? Really? That's so weird."

Earlier this morning, while writing my previous post, I encountered an untimely computer error that resulted in me getting pissed off and going to bed, and my post getting posted unfinished. Now that I fixed it, though, you should go back and read the whole thing. Much better. Involves a velcro suit.

After last night, I'd say it definitely has to be a full moon, or close to it.

It was an odd night to say the least, but the green zone was hopping. All the regular hall beds were full with people actually needing psych evals (as opposed to the drunks that have been present in abundance lately), the one regular patient room kept having intensive care unit patients, and the seclusion room and hallway... damn.

The seclusion room is an eight by ten foot room furnished with a mattress and a one-piece surgical steel toilet. There are two video cameras so the patient can never be out of sight, and the door, complete with lock, has a four by eight inch window in it.

Tonight, the lovely patient occupying the hall and seclusion room certainly gave us a run for our money. First she was sleeping, then swearing and yelling and promptly placed in restraints, then was nice and the restraints came off, then was singing, then crying, then violent and in restraints again, then got out of restraints, then screaming, then in seclusion.

Yeah.

For a while she behaved herself, but then she decided she needed more attention. So she used the gown to try to strangle herself.

It only lasted for all four seconds it takes to turn the key in the door, and then a nurse tackled her to the ground and started cutting off the gown. In return, the patient bit the nurse. Then, the patient received a shot of an antipsychotic drug to help reduce her agitation. It did its job, and she was still asleep when we left.

The whole incident, while interesting and somewhat entertaining to retell, brought up some interesting conversations about seclusion and restraints.

First, that room literally does need to be padded. Hell with the germs and whether or not you can get it clean. You need it because one favorite patient activity is banging the head on the concrete walls.

Second, a revolutionary new idea about restraints. We really need something that holds the torso in place. You put on wrist and ankle restraints, they can still move their torso around, and even sit straight up in the bed. And start banging their head on the wall. There are a number of additional types of restraint, including waist belts and vests, but the use of these is frowned upon and some are even prohibited because of the risk of strangulation. So one of our nurses proposed an idea he'd had about this.

The solution? Velcro.

You make a mattress covered in velcro, and a bodysuit made of velcro. You dress the patient in the suit, or lay it on the bed and strap them into it. Then you just stick them down really good, and suddenly you have a safe, effective full-body restraint. It would have no real pressure points, and much less risk of strangulation. And they couldn't sit up.

Now, pottying would pose a problem, and you could certainly make some very frustrated. Laundering said suits and mattresses would also be challenging, but, well, details, details. Just think of the velcro suit!

See how productive we can be sometimes?

Oh, and speaking of productive, we have another data point to add to the "Who Shot/Stabbed You?" theory. Stab-wound with a paring knife to the face that, fortunately, didn't break through into the mouth, but tunneled straight back in the flesh. The verdict? "My crazy buddy." I think it fits into the "My buddy" category.

Also, while stocking the empty rooms at 2 in the morning, we had a chance to discuss some of the stupid movies we watched at home in the wee hours of the morning, but that could get a little embarrassing.

We'll see what happens tonight with the crazies. Hopefully, nothing.

To all our motorcycle patients from last night:

Thank you, thank you, thank you for wearing your helmets! You have no idea how much easier this makes life for us, and how much better it makes your life after an accident.

True, maybe you didn't make some great decisions, such as riding on the Dragon in the rain at night, but you got the biggie right. And yes, your broken pelvis, or ribs, or clavicle, or that nice hemothorax do hurt, but at least your brain is in good enough shape to process that. Because the alternative would be a mushy brain and an inability to feel, well, anything.

Yeah.

It was a night for trauma. Can you tell? At one point, they called and said there were five patients from a car accident that we'd be getting. We only have four trauma bays, and at that point, we only had three nurses to take traumas.

Definitely interesting.

When we hit about one AM and the traumas quit coming, we then had amputee night. For sure saw a guy whose prosthetic was black with green skulls painted on.

The most interesting activity, though, was when I got to remove an IO needle from one of my patients. IO is an intra-osseous needle. It functions essentially the same way an IV does, but we use it when we can't get a needle into your veins. The downside is that it hurts like hell when you flush it. Salt water going through a cavity in your bone that goes to your blood supply is not a pleasant thing. We don't get to use them often, but they really are great little things.

Now, I'm sure my slightly confused patient, who complained that her leg where we stuck the IO hurt more than her belly, and who also kept asking to talk to the doctor who put a hole in her leg, didn't like it so much. But that was okay, because eventually somebody got a regular IV line. Which meant I got to go take out the IO.

It was almost like pulling a nail out of drywall - grab near the entry point, brace around the thing with the other hand, pull steadily out with a slight twisting motion, until it's out.

This was, of course, accompanied by some screaming and crying, but that subsided when her leg started feeling better.

Over all, I think it doesn't quite translate into a cool or interesting story, but it was. The feel of the thing under my fingers while I pulled it out, the tension relaying which part of the bone it was in... really interesting.

And something about everybody else going, "Well, I've never done it before, but they say you should..." and just getting to try it was pretty cool.

Yep, check that off the skills list.

Okay, so maybe the death part is an exaggeration. But the black hole part isn't.

I have to say, though, there was one pretty entertaining moment in orange. A patient who had a small brain bleed after hitting her head was in the bed on the far end, and the main evidence of her head trauma was repetitive questioning. So every five or ten minutes, she'd ask "What happened? Where am I? Did I fall down the stairs? Was I in a car wreck? Where's my husband?" And when her daughters explained that she fell off a ladder while painting her kitchen, or gave any other answer, she'd gape at them and say, "No" or "You're lying." Unfortunate for her, a little trying for the daughters, but especially interesting for the other patients in the room, who now know this patient's new kitchen design better than the patient.

And you know, now that I've expressed my feelings for the orange zone, I'll probably get to play there all weekend. But as long as they have beds upstairs and we're not opening our extra areas, I'll take whatever.

I think.

Last night at work we had Trauma Thursday.

Now, I always wondered about things like this happening, but this was the first time I'd experienced it.

Walked into work, saw that my assignment for the night was trauma, saw on the tracking board that we had a full alert, went back to take over for that nurse. While the patient was still in the scanner, she gave me report. It consisted of our made-up ID names that run along the lines of "Alpha, Alpha" and "Metro, Metro," an age, the car wreck scenario, and a preliminary run-down of injuries. But no real name.

Usually it takes a little while, but we do establish the patient's real identity, history, etc. And it does usually happen before they leave the ER.

But last night, well, we had a little issue.

There had been a two-car accident in a county in a neighboring state, involving a high school age student hitting a mother and her early-teenage son. We had two of the three people involved as patients, none of the original first responders to tell the story, and no family whatsoever.

I was told that I had the high school age patient, and just at a glance, that seemed reasonable. There was a fair amount of facial trauma, though, to the nose, mouth, and a good gash on her forehead. So it was anybody's guess. Then somebody said that her son had been in the car with her, and we had him as a patient, too.

But when they rolled a stretcher back with a younger-teenage kid on it, and said that was her son, we got a little confused. Unfortunately, the kid couldn't help because he'd gotten pretty goofy after some morphine and versed, and my patient couldn't help because she was intubated. And had, among other injuries, a torn aorta.

So here we are, sitting in the trauma bay, prepping my patient for surgery, and I have the trauma attendings and anesthesiologists and vascular surgeons coming over, examining the patient, and asking questions like "How old is she? Do we have any medical history? Do we have any family? What was her mechanism of injury? What all injuries does she have? What drugs do you have her on?"

Yeah.

Lots of fun looking these upper-level docs in the face and saying "Here's what I was told, but we're not really sure, oh and no family, no seatbelt, on sedation and a beta-blocker drip..."

Finally, finally, when everybody had made the ask-the-important-but-in-this-case-useless-questions rounds, one of the registration ladies came to me and said, "Well, we think we've got family, but we don't know, because there are two families claiming her. Does she have any tattoos, unique piercings, clothes, anything we can identify her with?"

Right.

We did a thorough check. Nothing. Definitely a plus of getting a tattoo somewhere.

Eventually, they figured it out through her clothes. This was literally at the moment the surgeons were ready with a graft in the OR and the anesthesiology residents had come to help transport the patient. So we sort of did a roll-by visit with the family which involved lots of tears and family members grabbing their chests and panting like they were having chest pain.

Somehow it was surprising to have such an issue with identifying her. These days, we all carry around so much stuff with our personal information, it seems like it should be easier. Not that knowing a patient's identity changes how we take care of them, which is the beauty of ER, but it is helpful to know about allergies or medical problems that don't show up on on CT scans, like diabetes.

I'm not going to go nuts and tattoo "DNR" on my chest or my name and date of birth on my thigh, but maybe a tasteful, unique tattoo somewhere discrete shouldn't be out of the question.

I guess I do have a few good ear piercings, though.