NURSE ME

…..rebuild him, make him stronger. I only hope it doesn’t cost as much.

Saw this on Good Morning America this morning and thought it was beyond cool. Check it out.

watch?v=jVehGfI7Ka0

I find this story incredibly cool.  And not just because it’s Black History Month.

Patient:    I’m allergic to morphine, dilaudid, toradol, latex and ham sandwiches.

Nurse Me: Oh? What happens?

Patient: I go into cardiac arrest.

Nurse Me: Wow. That’s pretty serious.

Patient: Yeah, it’s happened to me 11 times.

…..just to be nominated. Or so they say. And they’d be right. It seems that Nurse Me has a fan in Doctor D over at AskAnMD and he has nominated Nurse Me for the “Big D Award”!

What is the “Big D Award,” you ask? Well its Doctor D giving a shout out to nurses for being awesome. So visit his site and vote for me. I’m nominated against some very talented competition and currently losing to a c*nt. You’re just going to have to click on AskAnMD to see why that is funny.

On a serious note, I really would like to thank Doctor D for being supportive of nurses for all the hard work we do, for the intelligence and skills we have, and for the dark humor we express.

Go. Vote today*. Now.

*voting ends Friday

….but the best complaints usually are! My most recent favorite patient complaint can be filed under the “I can’t make this shit up” category.

Nurse Me:     Why did you come to the ER today?

Patient:          My left arm is  shorter than my right arm.

Nurse Me:         

Patient:          It’s kinda hard to pick things up.

Nurse Me:                

Patient:          It’s been this way my whole life.

Nurse Me:    How old are you?

Patient:         23.

Nurse Me:    Why are you here?

“I don’t resuscitate dead people.”

At first pass this comes off as a callous, contentious statement, especially coming from a nurse. And Young Nurse Newbie reacted exactly in that manner, giving me a look as if I were the most un-American person in America and questioning my morals/ethics. Although the facial expression on Young Nurse Newbie’s face gave me pause, the statement holds true. Sometimes letting someone die (or stay dead) is the compassionate, moral/ethical thing to do.

One of the most efficient machines you’ll ever see is the activation of the medical team once a full arrest is called into the ER. Every one’s heart rate goes from 60 to 160 in the blink of an eye. Resident #1 rushes to the head of the bed, checking the intubation and suction equipment. Resident #2, usually resident #1’s senior, stands to the side quizzing resident #1 on the steps of a full arrest. The Attending positions himself/herself somewhere in the room as Overseer. The respiratory therapist runs to set up the ventilator, one nurse stands at the foot of the bed, clipboard in hand ready to record EVERYTHING. A second nurse grabs the Code Box containing all the necessary medications to restart a heart, buffer acidosis, counteract arrhythmias and correct electrolyte abnormalities and a third nurse readies herself to push the medications through the IV lines as they’re called for. A tech stands-by for chest compressions. Chest tubes are set up for insertion, the defibrillator is turned on and checked and we’re all gowned, gloved and masked.

Every med student, nurse, doctor, secretary, medical assistant with free time hoping to see something cool crowds the room, too. Notably absent at this point is the patient as the gleaming, pristine white stretcher stands in the center ready to receive whatever hot mess is about to roll through the doors. The patient has yet to arrive but by the crowd that has gathered you’d think he already had.

One reason why I don’t aparticipate in the resuscitation of dead people is because I don’t have to; the crowd I just mentioned is already in place with each and every member readying his/her hands in chest compression formation. I can participate by being recorder, drug pusher, lab drawer, time clock watcher, gopher…. But I don’t have to do that either, the crowd’s there for that, too.

I chose not to participate in this code because 1) I was not assigned to the floor that night and 2)  I took the call over the radio:

“44 year old male, found down, unresponsive. Down time unknown. Past medical history includes renal failure with dialysis 3 times a week, hypertension, CHF, diabetes, morbid obesity and a failed gastric bypass. No pulse on paramedic arrival. CPR in progress, being bagged. IV line, drugs (Epinephrine and Atropine) pushed. No response to CPR or drugs. ETA 6 minutes.”

This was a lot of information to receive prior to transport to the hospital which immediately revealed to me two things:

1. There was family at the scene to provide the background medical history, or

2. This patient was known to the paramedics secondary to his poor state of health.

Both were true in this case.

This information that screamed that this man was meant to die on March 12th, 2007.

The disappointing, disgusted and crushed look on Young Nurse Newbie’s face reminded me of why I do participate in codes such as this, because I am a mentor, teacher and coach. I have no idea when the transition from Young Nurse Me Newbie to Seasoned Veteran Nurse Me occurred but it’s a role vital to my profession. I hear attendings and senior residents say it all the time,

“Pay attention to Nurse Me. You’ll learn a lot from her.”

And it doesn’t have to be me, specifically. I hear attendings and senior residents say this all the time to med students and interns of many of my fellow nurses. It’s only now that I’ve begun to hear it as an honor and achievement. So I looked at Young Nurse Newbie and said,

“Come on, let’s get in there.”

You would have thought I just gave Young Nurse Newbie a puppy for Christmas.

“It’s OK to be excited. This is an adrenaline rush.”

And with that Young Nurse Newbie and I entered the resuscitation room, which is no place for the timid. With adrenaline and hormones, not to mention egos pumping, you have to be ready to throw elbows and hip check people out of your way if you expect to participate. Young Nurse Newbie was timid, so I hip checked our way to the side of the bed for us.

“Young Nurse Newbie will start out doing chest compressions,” I announced. She looked like she was about to vomit.

CPR continued during tranpsort to the ER as well as the administration of 2 more rounds of drugs and the delivery of one shock. The paramedics burst through the ER doors, one EMT straddling the patient performing chest compressions.

“OK Young Nurse Newbie, take over chest compressions……NOW!”

One look at This Man and you knew the valiant efforts were in vain. This Man had dead man’s feet, mottled and dusky. This Man had dead man’s face, dusky with blue/gray lips and cloudy eyes. This Man was dead but the resuscitation continued for 14 minutes because there was return of cardiac activity on the monitor. First it was Vtach, which was shocked into asystole then compressed into sinus brady, before ending up in wide complex Vtach, which was really PEA.

Once time of death was declared, I took Young Nurse Newbie aside and we talked through everything she saw and everything that happened. A debriefing, if you will.

I reviewed the most recent literature related to CPR survival rates and listed all the factors This Man had against him.

I talked about that in the “real world” i.e. a non-county, non-teaching hospital the code would not have lasted as long as it did here, especially given This Man’s medical history. Teaching institutions tend to throw the kitchen sink in situations such as this, letting each and every med student, young nurse, nursing student take a crack at CPR. Bad joke since sometimes resuscitators are  little over-zealous with chest compressions and ribs and sternum are sometimes broken. This Man’s were.

I talked about what we’re saving, since life is terminal and we’re all meant to die….someday. March 12th, 2007 was This Man’s day. Even IF we were able to get This Man back, what would come back? The man who lived before or Teri Schiavo? This is the ultimate in philosphical debates: quantity versus quality of human life. We, the medical team, are not gods. There is only so much we can do and we need to realize our own limitations, which is not to say that we don’t try but we need to accept that ultimately we are powerless in The Big Plan, try as we might to control it, to reverse it.

I told Young Nurse Newbie that the deciding factor for me was hearing This Man’s past medical history, having an unknown down time and that 13 minutes (transport time) of CPR hadn’t restored This Man’s pulse. It was his time.

Sure this is the rational, logical approach but my flippancy is only a veil  I use to shield myself from the death and inhumanity I witness on a daily basis so that I can get up the next day and do it all over again. For every life that is lost, dozens more are saved.

Come to find out later, This Man was hospitalized in mid February for an insulin overdose and was pissed off when he awoke from his coma, realizing that his life had been saved. Looks like This Man’s next insulin overdose did the trick.

With the new year having come and gone, I have finally recovered enough to post a new blog. No, I was not hungover, although my body ached, my head throbbed and I barely got off the couch New Year’s Day. That’s because I worked New Year’s Eve and got my ass kicked. I’m recovered now so that I can vent, make fun of and comprehend everything that happened that night.

As predicted, the ER was quiet when I first came on shift. So quiet in fact that we didn’t staff the waiting room because NO ONE was in it. Sure some people did trickle in the old fashioned way, but the majority of our patients arrived by ambulance, whether they truly needed the ride or not, whether their complaint was a true emergency or not (always NOT). This has been an annoying epidemic for years, people arriving by ambulance because they needed a ride to the hospital for a non-emergent complaint. If health care is truly going to reform, this is one abuse I’d like to see changed.

So all was quiet… ish. Steadily ambulances would come, dropping off amateur drinkers and partiers who couldn’t make it to midnight. Or those who were too drunk to walk and fell over. Just as we’d get one settled, there’d be another one to assess. There were several raves in town NYE and good ole “X” isn’t what it used to be. It’s been super-sized, cut with GHB, formaldehyde and who knows what else because they don’t show up in our standard tox screens. The “kids” also aren’t what they used to be, for that matter. They seem to believe that they’re entitled, to nothing specific but everything in general.

“I don’t want your shitty  hospital food. Order me something amazing to eat. That rave worked up my appetite,” entitled Raver demanded.

“You’re not in here for broken hands. Pick up your cell phone and order it yourself. The number’s 411. The hopital’s address is on your ID band on your wrist. Your other wrist.” Nurse Me slides curtain closed.

And because you’re altered (drunk/ high) Mr. Raver, I nor my co-workers needed your permission to perform the tox screen. You see, the “do-gooder” who called 911 for you because you couldn’t seem to get up off the floor, put you in a precarious spot. Because you’re drunk and high, we can’t legally release you but you can continue to refuse care, as you have been doing which is going to get on my nerves the second someone who REALLY needs my help and REALLY needs to be in an ER is put in the bed next to you.  And because you have yet to demonstrate that you can be cooperative and play by the rules, we have assigned you a babysitter. Now I’m going to have to be without a valuable, skilled nursing attendant who can check patient vital signs, perform basic wound care, check blood sugars, hemoglobins, and transport patients to and from radiology, because YOU and 9 others can’t handle your X. Jimi Hendrix, Chris Farley, Dee Dee Ramone, Janis Joplin…never came to the ER for a bad trip or overdose and neither should you.

The rest of the patients in the ER thank you.

“No I don’t want to hear ‘one more thing.’”

“No, I’m not ordering food for you.”

“No, I’m not sharing my dinner with you either.”

“Yes, you are getting on my nerves.”

“No, I’m not going to ‘let you go then.’”

“Your attempt at reverse psychology is pitiful. And frankly you’re too high to be any good at it. You’ll get to go home once your tox screen comes back clean and you can show that you’re cooperative.”

“A couple of hours. So lay back, relax and take a nap. It’ll be easier for you that way.”

“And you don’t get to cry. Trauma nurses and docs are immune to tears.”

Well, we are. At least the tears that accompany a drunken temper tantrum attempted manipulation. We are not immune to the tears that accompany a wife’s tears as we crash intubate her husband for agonal breathing from bleeding in the brain after being hit by a car crossing the street. This man, Mr. Raver NEEDS to be here and NEEDS MY attention as well as the attention of 6 or 8 of my co-workers. Don’t even think of acting up Mr. Raver because the attention is no longer focused on you. Don’t do it, don’t try to bite through your restraints. Now you’ve done it, kicking and flailing your legs so that your stretcher is about to tip over buys you 5 mg of Haldol. A wonderful anti-psychotic drug which you’ve just demonstrated you need. Nite nite.

Now the ambulances are arriving 2, 3, and 5 at a time! Shit. I guess the respiratory therapist, 2 med students and myself can take Mr. Hit By A Car to cat scan (CT) by ourselves. Better yet, I’m going to grab one of the residents from the Fast Track part of the ER. That makes me feel better.

“Cat scan. This is Nurse Me.”

“Mr. Raver is awake and doing what?”

“Thanks, Nursing Attendant. Peek your head around the corner and call for the first doctor you see. Ask him/her to have a nurse give more Haldol to Mr. Raver. Thanks.”

My team and I return from cat scan, Mr. Hit By A Car needs a neurosurgeon stat and neurosurgery stat-er. What? We’re getting an air bus (helicopter) twofer? One in and out of consciousness, ETOH (alcohol), facial fractures and open femur fracture and the other awake with abdominal pain and distention and left ankle deformity? Shit. What, a multiple stabbing 14 mintues out? A found down-unresponsive-heavy odor ETOH-vomited on self but vital signs stable 7 minutes out? Shit, shit, shit. Divide and conquer.

“Med students, stay with Mr. Hit By A Car. Come get me if his heart rate drops below 65, if his blood pressure shoots up or tanks or if there are any arrhythmias on the cardiac monitor. Neurosurg should be here in a minute.”

Work, work, work. Assess, assess, assess.  Found down ETOHer, hypothermic. 2 large bore IVs (thanks Fire Rescue!!) with warm saline wide open, foley inserted so ETOHer doesn’t pee himself, labs sent, oxygen by face mask. Respirations 9 and regular. Nasal trumpet inserted “just in case.” Heated blankets piled on, heart rate and BP OK. Lights out on to…

ETOH air bus facial fracture patient #1 surprisingly stable and airway patent. Lethargic, but rousable and answers questions appropriately. Ortho doc at bedside cleaning and splinting open femur fracture, then transport to CT, then to ICU. Distended abdomen air bus patient #2 with blood in the belly via ultrasound being run upstairs to the OR with trauma team.

Multiple stabbing man woke up Frankenstein style while having his chest cracked (emergency thoracotomy)? COOL! I mean here’s the Propofol and #8.0 OETT (endotracheal tube). Foley inserted into hole in right ventricle, running up to the OR.

Time to check on the rest of the patients. Mr. Raver, snoring. Perfect. Found down ETOHer warming up, still not conscious. OK. Drunks (7) sleeping it off in the hallway, IV fluids running. Wow, it really stinks in this hallway. Mr. Sucker Punch To The Face difficult to rouse? Shit. Crash intubate, run to cat scan. Holy crap, that’s a big head bleed. Did his pupil just blow? Shit. Neurosurgery? You’re gonna have to have someone scrub out of Mr. Hit By A Car’s surgery to come assess Mr. Sucker Punch To The Face, he needs a ventriculostomy until you can replace Mr. Hit By A Car on the (OR) table with him.

High speed MVA vs tree? Car splint in half? Patient found belted to 1/2 a car seat unresponsive, bilateral open tib-fib (tibia-fibula) fractures? 3 minutes out? Rally, rally, rally. Distracted by hot fireman showing pictures of the accident.

“I am looking closely.”

“Wait. Is that an upper body in the tree?”

“Didn’t see the lower half of him?”

Holy shit. Happy New Year.

Multiple GSW 20 minutes out? Time to pee.

“Wakey, wakey Mr. Raver. Wakey, wakey. There you are, good morning, sunshine. Ready to go?”

“You’ve been here since 9:15 last night.”

“It 6:25 am. Happy New Year.”

“Yes, I’ll untie your hands.”

“Here. Let’s watch this video we took of you. This will fill in some blanks for you and also show you why you ended up in restraints and with a tube in your penis.”

“All clear now?”

“No, you can’t have this tape. But what you can do is press the erase button. Now sign here and you’re free to go.”

“No, I don’t know where your friends are.”

“No, no one called or came looking for you. Maybe you and the 23 other drunk/high “overdosers” can go to breakfast together? You still want something better than shitty hospital food, right?”

Phew. Time to sit down. High speed MVA? 4 patients? One with brain matter coming through the nose, 2 with multiple orthopedic injuries, and one with a head lac complaining of wrist pain? 6 minutes out? Oh look, it’s 0702! Tag, dayshift, you’re it! Anyone want to go for margaritas at This Bar Always Opens At 7AM? Great! Let’s go!

And there 9 of us sat, drinking our first New Year’s Day cocktail of choice in silence, beaten down by the previous 12 hours. Aaaah. With the first round guzzled and the second round on its way, we were able to speak. And speak we did. “Holy shit! What the hell just happened?” And we were off, each recounting the highlights of NYE in the ER. Of course we all had our favorite Raver story, laughing and harassing their silliness, stupidity and ultimately entertaining behavior. Those of us that were “lucky” enough to work in the trauma zone recounted the gory highlights. And then another moment of silence. 8 people died (or were brought in dead) to the ER that night. 27 people were hospitalized with broken bones, internal organ injuries and lacerations. 5 people were still to drunk/high to be discharged by 7am and 12 frantic people called into the ER looking for their loved ones. Only one of those callers found their loved one in our ER. None of the trauma patients were brought in sober. Happy New Year. Now, who’s ready for round 3?

….has been on my mind a lot lately. Hell, it’s been 21 days since my last post! When I began this blog, I committed (to myself) to post once a week. Slacker.

What is traditionally known as “the most wonderful time of year” when relatives separated by distance rush to be with each other is often replaced with the melancholy of relatives rushed through emergency room doors. Half of me is playing Now That’s What I Call Christmas Vol I and Love Actually over and over and over again while hanging greenery and ornaments while drinking Baileys and hot chocolate. The other half of me is constantly thinking of all the patients I have taken care of over the years and how I’ve let them down. I think of the tragedies that await me each shift. With each parting of the sliding glass doors, death, debilitating disease and destruction of human life await. So much for ”the most wonderful time of the year.” 

Mr. G.I. Joe served our country and was also a POW in the Vietnam War. One Spring day seven years ago he was involved in a rollover MVA. He broke 2 bones in his neck, ruptured his spleen, lacerated his liver, fractured his left femoral head and broke several ribs that punctured his lungs.

At first G.I. Joe was the perfect patient, unidentified (which equals no family), intubated, sedated and chemically paralyzed. Aaah. I could go about my nursely duties uninterrupted, sometimes meaning that if I wanted to sit and chat with my coworkers about the latest selections in the Victoria’s Secret catalog, I could do so without the disapproving looks of my patient’s family. Uninterrupted also means that I can share information with G.I’s team of doctors over his sedated and chemically paralyzed body without worrying how to phrase our discussion so as not to offend or demean Mr. Joe. We could talk freely about his current condition, where it needs to be and how best to get it there. I could change his dressings, complete oral care, pin care (G.I’s type of neck fracture necessitated him being in a halo and the pins securing the brace to his skull required cleaning every 8 hrs), hang new I.V’s, change tubing, change his position and activate the percussion/vibration mode of his bed all without having to make idle conversation. I’m not good at that.

All was going well, until G.I. Joe woke up after being weaned from his sedation and chemical paralysis. Don’t get me wrong, waking up is a good thing because now we get to find out G.I. Joe’s identity, determine the presence and in Joe’s case, absence of brain injury and get physical/occupational therapy on board to ready Joe for transfer to rehab. Plus  it had been nearly 3 weeks, so it was time for Joe to be awake.

But he was confused. And scared. And uncooperative. Not surprising. And he was having war flashbacks. This is one way of things not going well when we wake a patient. I have to admit that one of the weaknesses of medical staff is to dismiss psychological breakdowns as delirium and use restraints and medication as an antidote. Now, I am the last person to rope and dope my patient. OK, maybe not dope, but Joe was so deep in the recesses of his Vietnam capture that he would swing and kick (with his good leg) at anyone who came near him. He would also spit, which is gross, and try to bite. So one of my colleagues applied restraints as another asked for an order of Haldol (Vitamin H as we affectionately call it). This was a distressing site, much more so than the broken, pale and deformed body of a fresh accident victim. Once Joe was more sedate and manageable thanks to Vitamin H, the reality orientation began. Every hour, sometimes as much as 8 times an hour, Joe would be reminded that it wasn’t 1964, that he was no longer in Vietnam, that he was involved in a car accident and in the hospital recuperating and that he was safe. This was tedious and annoying but in a few days time paid off.

Then came the crying that accompanies the realization of one’s injuries, the uncertainty of making a full recovery and the loneliness. And the loneliness isn’t what I like to think about. Some patients aren’t fortunate to have loved ones visit, to occupy the dead space which is basically 24/7. Another failure of medical professionals is that of spending any quality time with their patients, that’s what family and friends are for. Joe’s sister and nephew lived states away and once Joe’s companion was able to track him to the hospital 80 miles from the scene of the accident, he was only able to come down on weekends because of work. So that left us, his nurses who prefer social interaction among ourselves over talking with our patients. At first I rationalized that Joe had plenty of interaction, physical therapy stopped by every day to work with him. For one hour. Oh, his meal trays were delivered by our nursing assistants who would chat with him. Another 15 minutes occupied. And let’s not forget housekeeping, xray and his doctors. 7 more minutes down. This is pitiful which is why I brought a deck of cards with me to work and would play Gin Rummy, 5 Card Draw and even Go Fish whenever I had some down time and wasn’t looking through the Victoria’s Secret catalog. It was the least I could do.

But for now I’ll go back to hanging my decorations, watching my DVD and drinking Baileys hot chocolate. And when my mind drifts to thoughts of G.I. Joe, I’ll try to remember that he was eventually discharged to rehab. He came back to visit my unit 3 months later, walking with a cane and thanked me for taking the time to play Gin Rummy and the like with him, the 4 times that I did. Turns out it’s not necessarily the amount of time spent with the patient but the quality of the time spent.

http://www.youtube.com/watch?v=gFtb3EtjEic&feature=related

Patient: “I was gonna be a nun til my brother raped me. Oh, and tell the doctor I want one of them urinary suspension things, too.”

Me:

Dear Lance Corporal McDrunkerton,

First of all, thank you very much for enlisting. I appreciate that you have choosen to protect America and her citizens and I hope you have a long and safe career. However, the next time you get drunk, and you will, could you please refrain from activities that land you in the ER? It’s not very becoming and may the laceration above your eyebrow be the only “battle wound” you receive.

I realize you are a young man of 21 and are being sent to Iraq. Maybe you’re scared shitless about that but threatening to skull fuck me and everyone I work with if you’re not released immediately is a bit much. And not at all intimidating. Frankly I’ve heard worse from a 92 year old lady. Besides, you’re really in no position to make threats. No one from your unit is in the ER with you, your extremities have been restrained because you’ve been highly uncooperative and I’m pretty sure you’re unrestrained appendage is saluting me. That “stabbing” you’re feeling isn’t some torture device, it’s me starting an IV to draw your blood, hang some fluids and give you medicine.  So once you sober up and we’ve flushed the other drugs you ingested from your system, I hope you give me more than your name, rank and serial number. I’d really like to hear your story.

Sincerely,

Nurse Me