NURSE ME

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

I’m grumpy and here’s the blog about it.

As a nurse, I treat patients regardless of insurance or ability to pay. But there is one group of patients that I am beginning to loathe:

Mr. and Mrs. China got off the plane planning to spend some time with their daughter and her family. Mr. China deplaned with a history of heart disease and in need of an operation. He, as well as his American based family knew this. So I really shouldn’t have been surprised when he showed up to the hospital with wife and suitcase in tow complaining of  “chest pain.” Mr. China purposely denied his pre-existing cardiac condition and thus received the “full work-up” which ended with a trip to the cath lab to reveal…duhn, duhn, duhn….. 4 blockages in 3 arteries. He would need surgery. But they already knew that.

Once admitted to his private ICU suite complete with plasma TV, air flow mattress multi-positional bed, internet access, suitcase and wife, our financial service team went to work, oddly at the request of Mr. and Mrs China and their daughter. You see, they wanted to apply for the state’s emergency medical insurance program for the poor/uninsured. So Mrs. Financial asked all the appropriate questions: name, age, DOB, U.S. citizenship…. It was this last question that angered and annoyed Mr. and Mrs. China and their daughter. They went on the defensive. Mr. and Mrs. China were honest enough to identify China as their country of origin but listed their daughter’s address as their place of residence. When asked for a visa, passport, naturalization papers, anything that would establish them as residents/citizens of this country, it seems they conveniently forgot to pack them in Mr. China’s suitcase.

“That’s OK,” we said, “your daughter can bring them the next time she comes in.”

Mr. and Mrs. China Daughter: “I didn’t think they’d have to pay. We have friends who had an uncle come here and he didn’t get a bill or anything.” Well, he was probably a little better at lying about his information and I’m sure a bill was sent somewhere but by that time he was already snug in his own bed, back in his own country. The hospital will never be paid.

Mr. and Mrs. China Daughter would remember to bring her father’s passport 2 days after Mr. China had his heart surgery, finally succumbing to the statement “we’ll just send all bills to your address since your parents live with you.” (The hospital bills will be mailed to Mrs. China Daughter and her husband anyway since her parents were kind enough to provide us with her address.)

This scenario is not unique to Mr. and Mrs. China, the story also belongs to Sr. y señora El Salvador, Ms. Belize, Mr. Philippines, Señora Mexico, Señor Nicaragua, Mrs. Vietnam, Grandma Panama, Poppy Colombia, Г-н и Mrs. Russia, …. you get the picture. Funny that Mr./Mrs./Miss Denmark, England, Canada, Australia, Sweden, France are noticibly absent. Hmmm. With the number of illegal immigrants at an estimated 11 million, I’ve adopted an “us vs. them” mentality and not really proud of it.

I would like to say that I’m a proud American but not proud to be living in a country that has neglected its own for a profit. I am overwhelmed. At every corner is a stretcher with an uninsured patient on it, some are American born, some are not. One patient is discharged only to be replaced by another before the previous patient is even off the stretcher. The stories are depressing, “I was laid off,” “I would die in my country, that is no way to live,” “they cancelled my policy,” “I can’t get coverage because I’m a diabetic,” “I can’t afford the COBRA…..”

But what’s my point? My point is that I’m a nurse and I take care of patients. I recognize that these are desperate times and that desperate people will do anything, even if illegal or immoral. While I can’t begrudge anyone’s efforts to save his/her own life, I don’t have to like the system or those who abuse it. For the millions of Americans who were sacrificed for a 24 karat toilet, $30k umbrella stand, a $3 million executive office make-over, or a $250k spa retreat, I am here for you. For the other citizens of the world, I am here for you too BUT be prepared for me to give you a mop to clean up the vomit/blood/body fluids spilled by the patient in the room next to yours or for me to give you decontamination wipes so that you can clean everything in the unit, from keyboards to telephones to door handles to bed rails. You know, the hospital equivalent of the restaurant having you wash dishes for not being able to pay the bill. In addition maybe, just maybe we should start sending a bill to your home country to cover your ”free” healthcare?

Patient:  “Baby, you gots kids?”

NurseMe: “No.”

Patient:  “That’s OK, baby. I’ll have kids wich you.”

Mom, Dad? Good news. Grandkids are on the way!!

Hit me.

Really? The dealer’s showing a 4!!

But we take the hit with fantasies of sailing away on a yacht. Against all odds. Against the warning from the dealer,  against the wishes of the man sitting at 3rd base (last position at the Blackjack table) and against our intuition. But let’s get real for a moment, who isn’t lured by the thought of Benjamins dancing in her head, by telling her boss to “fuck off” before quiting, leaving a trail of 50s behind her as she walks out the door?  And when we bust, we walk away saying “WHY DID I DO THAT?”

In healthcare we take the hit, too, only it’s in the form of joules or chest compressions despite evidence of its failure.  Because with CPR comes the the ultimate payoff….  life, or so we think. Last month during my PALS recertification, I learned that  survival rates for in hospital CPR is 20% and 27% for the pediatric and adult populations, respectively, with post CPR to hospital discharge survival hovering near 15%.   It’s OK to be stunned, I was too.  

Mr. and Mrs. Latvia were set to celebrate their 70th wedding anniversary in April when she was re-admitted to the ICU from the nursing home. They were 91 & 92 years old. Cute. Until I looked at Mrs. Latvia’s aged, frail and pale body, life fading from her eyes. She had suffered strokes, respiratory failure and was trached. She had undergone heart valve replacement surgery, had CHF, a malignancy on one of her kidneys and now she was bleeding internally. Mrs. Latvia didn’t look good, as we say, and I knew she was not going to leave the hospital alive.

Mr. Latvia was so attentive, loving, caring, inquisitive as well as informative. He knew her lab numbers for one of the medications she was on and knew what they should be, he knew how she liked to be positioned in bed, he knew her medical history, medication list and doctors’ names without having to look at a piece of paper. He knew he loved her and he knew he wanted to celebrate their 70th wedding anniversary. He didn’t know why she was back in the hospital, he didn’t know why I couldn’t make her better, he didn’t know why she wasn’t allowed to eat.

I knew I wasn’t going to code Mrs. Latvia because I knew I had a whole team of people who would. I knew that Mrs. Latvia’s body had taken so many hits, especially in the recent months that she would not be in the 27% saved by CPR or the 15% to survive to discharge.  I knew I wouldn’t have to ask Mr. Latvia about an advanced directive or if he wanted us to perform CPR in the event Mrs. Latvia’s heart stopped, they wouldn’t be in the hospital otherwise. I knew that I would hold Mr. Latvia’s hand during the code, explaining everything that was happening.  I knew that I would talk to Mr. Latvia about their years together, good times and bad, I knew I would reassure him that we would find and stop the source of Mrs. Latvia’s bleeding and I knew I would never promise him that they would celebrate their 70th wedding anniversary. I knew that I would ask him if there was anyone I could call to the hospital for them and I knew I would ask the doctor for a palliative care consult, a request that was denied. Crazy.

So why are survival rates for in hospital CPR so low? Existing research offers many conclusions but ultimately all the research ends with the same conclusion, that we are performing CPR on individuals who have reached the end of his or her life. So why do we procede in the face of futility?  It’s partly because  too many of us are afraid to die (understandable), too many think medical technology can do more than it does, and too many believe (or want to believe) that God or Dr. House will save us in the 11th hour. But mostly it’s because too many of us don’t have an advanced directive and now some of our “leaders” are heinously proposing such conversations to be immoral, illegal and irrelevant. Maybe Sarah Palin should actually spend time with nurses and doctors (her lobbyists don’t count) and in hospitals before spewing drivel from her mouth! In 2010, the AHA will release the new statistics regarding survivability after CPR. I don’t expect the numbers to be any different. I do hope the number of people talking about advanced directives with doctors and nurses increases, contrary to the thoughtless idiocy spewed by some of our “leaders”.

The code to “save” Mrs. Latvia’s life occurred at 2130, after I had gone home. Mrs. Latvia was pronounced dead at 2142. I was not there to hold Mr. Latvia’s hand but I hope someone was.

“Nurses just don’t dress like nurses anymore,” lamented Old Man. The look on his face said it all, sadness over an era lost and disappointment over a profession lost into a collage of ill fitting draw string cargo pants, ciel blue, celadon, Sponge Bob and dancing bears scrubs. I prepared myself for the lecture sure to follow, it never came. And I never engaged him. Now I wish I had. After I had started his IV, drew his labs and ran his EKG, I walked away feeling a little offended. Did he not know how hard I worked to earn my BSN, MEd, CCRN, TNCC, ACLS, PALS…?  I earned my right to wear my “galaxy blue” scrub pants with “orchid” top!

But as I sat to chart Old Man’s assessment, I thought about the fact that my scrub pants hang too low in the crotch, ride a little too high above my clogs and my top fits me like a box. I scanned my coworkers: unit clerks, fellow nurses, nursing attendants, x-ray techs, med students, interns, and respiratory therapists, all in the same ill fitting and mostly wrinkled scrubs. And finally the message of what Old Man lamented sank in. Nursing has lost its identity in its poly cotton holiday themed blend; there is nothing to distinguish us as nurses.

The RN, BSN that appears on my name tag doesn’t read well, especially with the pace I walk. My badge bounces off my sternum like a paddle ball. “The Cap” exists only in plastic containers and old-timers’ hearts. The white orthotic lace up shoes have been replaced with sneakers, clogs, and Crocs. And who wears stockings anymore? Although I have become highly adept at dodging arterial sprays, evading projectile vomit and sidestepping my way around weeping abscesses, my turkey chili lands center mass on my box top which is why I’m not in favor of going back to “the whites.”

So what’s a nurse to do? How are we to distinguish ourselves as a recognizable entity? Maybe ACT more like nurses, which doesn’t mean giving up our chairs so a doctor can sit down, not even when Dr. Hissy-Fit throws a phone at your head. (If you can dodge a phone…. Dodgeball fans? Anyone?)

We also don’t introduce ourselves in a professional manner. The more formal “Good morning, Mr. Finland. My name is Nurse Belarus and I’ll be in charge of your care today,” has been replaced with the younger, more hip “Hi, dear. I’m Minsk and I’ll be your nurse for today.”

So if we don’t have a distinctive dress code and if we’ve lost our formal introduction /title, then maybe we should SPEAK more like nurses. And I don’t mean “Yes, doctor, right away doctor” which carries with it the impression that nurses or nursing is subservient.  Speaking like a nurse means sharing the knowledge (with doctors as well as patients/families) that we have cultivated through hours upon hours of bedside care, participation during rounds, attendance at organizational conferences and from reading our chosen professional journals. Instead, I hear many of my colleagues quip ”you’re going to have to ask the doctor about that.” What?! We HAVE the answers to their questions! And we’ve all heard the way doctors talk to patients and families,

“Doctor, how is Madagascar?”

“As you know Madagascar suffered a traumatic aortic tear, fractured T3 – T8, and sustained some head injuries as well. We had to take him to the OR for an ex-lap to look for other injuries after we repaired the damage to his aorta. We’re probably going to have to get neurosurgery, plastics and OMFS to fix his other injuries, but he’s stable for now.”

Huh? WHAT DOES THAT MEAN?!?!?!?!?!?!?!?!?!?!?!?!?!?!?!?!?!?!?!?!?!?!?!

You and I know and the many nurses I’ve worked with know but sadly, most don’t feel it’s his/her responsibility to share this type of information with the patient or family. “That’s the doctor’s job,” they say. And this is one reason the nursing profession has difficulty advancing its image beyond bedpans and bed baths.

It IS our duty and NOT outside of our scope of practice to keep the patient and family informed. We’re not being asked to diagnose or prescribe anything, to “read” an x-ray or CT scan or to perform surgery. You, we, are being asked what we know and we know a lot. If you’re not up to date on the latest research, then say “It’s been my experience….” If you’re not comfortable telling the patient or family what they want to know, then be present when the doctor speaks so, at the very least, you can translate what was said and what it means. If knowledge is power, then sharing ours makes the powerful statement that we are an intelligent and skilled body of professionals… whether we wear white or not.

“Hey, guys, watch this.”

Nothing good ever comes from uttering these few words. Especially when alcohol is involved. Instantly images of frat boys lighting their farts on fire flash through your mind, right? Well it does mine, and it’s not the smartest way to pass the time. Especially if you’re particularly hairy. Or inadvertently Praire Dog or Hershey Squirt. Do you know how much pain is involved in debriding testicles? Not for me, of course. Do you know how dehumanizing it is again, not for me, to assume positions no man ever thought possible so that I can apply burn cream after I have pulled the burned skin from your scrotum?

Think of this as your very own gynecological exam minus the stirrups. Sometimes there are stirrups. Sometimes I’m asking you to touch the soles of your feet together, bringing them toward your burned scrotum (this is called frogging it, frog position or frogging). Sometimes I’m asking you to roll onto your side, stretching one leg out completey while holding the other high in the air slightly in front of you, and sometimes I’m asking you to get on all fours and spread your ass cheeks apart. Sometimes I’m asking you to be in all four positions. Good times. And every time I’m tempted to give you a hand mirror so you can “watch this” as I peel layers of skin off your scrotum as though I’m peeling grapes. For the dozen or so males on which I have performed this spa-like service, none of them have taken me up on the hand mirror when I’ve offered. Pity they don’t want to witness my handiwork. And yes, I give myself points for pulling off a full sheet of skin as opposed to a small tear.

And with each piece of skin peeled, with each layer of burn cream applied like icing on a cake the only name to flash (repeatedly) through my mind is Darwin. This couldn’t be what he meant by natural selection, that the stupid survive?

And it’s not. Natural Selection, as defined by Wikipedia, “is the process by which heritable traits that make it more likely for an organism to survive and successively reproduce become more common in a population over successive generations.” Clearly Darwin did not consider intelligence or judgement heritable traits. Herbert Spencer, Darwin’s colleague and fellow polymath, interpreted Natural Selection into a more recognizable phrase, “survival of the fittest.” This phrase has been mainstreamed to such a degree that it now carries with it the false belief that only the physically strong and mentally superior persist.

“22 year old male impaled by an arrow. Alert and oriented, vital signs stable. ETA 4 minutes.”

That’s how the call came in and visions of a hunting accident gone wrong or a man caught cheating flashed through our heads. The trauma room was set and ready. We were gowned, gloved and masked. Units of blood had been removed from the refridgerator. The crash cart, open chest tray and chest tubes positioned at the ready with intubation equipment at the head of the stretcher. The doors to the trauma room swung open, and there he sat, straight up and whimpering. If Doha could have cried, I’m sure he would have.

You see, that arrow? The one we were alerted to that had impaled an individual? That arrow had impaled Doha from under his chin, passing through the roof of his mouth and through his nasal cavity before coming to rest with the tip of the arrow visible at his hair line. No way! This is one of the coolest things I’ve ever seen. We all stood, frozen for a moment, in awe. Doha appeared to be totally fine, minus the arrow through his face, of course. And we didn’t know what to do about that, the fine appearance not the arrow. Once our paralysis wore off, we were that unified team who connects the patient to the monitor and goes through the ABCs before drawing blood, giving IV fluid and pain medicine and moving through Xray and CT scan in concert-like precision.

The trauma room doors swung open again, “Dude, no way. You did it, man. Way to go.” 

Doha in all his watery eyed, bloodied face and whimpering glory raised his eyes to look at his fellow Darwinites. He smiled, well as much as the arrow through his mouth would allow. It seems that Doha and The Darwinites were partying around a campfire, drinking, when Doha picked up the bow and arrow then said, “Hey, guys, watch this.” Unfortunately those were not to be Doha’s last words. But one day they just might be. A quick surgical procedure and 3 days later, Doha left the hospital just as brilliant as the day he came in.

So now in a modern adaptation Darwin’s brilliant observations and discoveries, cultivated from a lifetime of work and devotion, explaining why species from bacteria to plants to civilizations persist has been highjacked and applied to individuals who behave in a way that should be incompatible with life. Aaah….Darwins. Here for our enjoyment. Sorry Charles, they mean no disrespect, I’m sure.

“An American monkey, after getting drunk on brandy, would never touch it again, and thus is much wiser than most men.”   Charles Darwin

….that’s when I’ll get the H1N1 flu vaccine. Besides, I don’t fall into any of the high risk categories although I am at high risk for exposure. Click on my “Things You Should Know” tab where I have posted a couple of  links to some information about the swine flu that is not being reported by mainstream media. In addition to those links, you can also check out www.cdc.gov and www.who.int for more information regarding swine flu.

I have only received the flu vaccine once, when it was required before starting my freshman year of college. I’ve only had the flu once, AFTER I graduated college. Not even when I was in the 4th grade and my fellow classmates were dropping like flies with the flu, so much so that all 4th grade classrooms combined to form 1 class of 19 students, did I get the flu. Boy did I want to, though, so I could be like everyone else.

In my 12 years as a nurse, I have never contracted the flu. Ever. And I’ve worked in the ER through 5 flu seasons. I don’t know why I seem to have an immune system made of steel while others around me seem to catch every itch, bug and sniffle known to man. Perhaps it’s because I wash my hands more than Obama appears on TV. Perhaps it’s because I stay away from those who are sniffly, snotty, and sneezy. When I’m at work, I wear gloves, wash my hands constantly and don’t allow my patients to cough, sneeze or spit in my direction. Or my coworkers for that matter. It’s easy when you slap a mask over their nose and mouth! (patients but boy would I love to do that to some of my coworkers, only for other reasons!) Perhaps it’s because I wipe down every piece of common property (computer keyboards, phones, IV pumps, bedrails, countertops, etc with antiviral/bacterial wipes) throughout my shift. Perhaps it’s because I carry my own pen for use whenever I pay by credit card, go to the bank or am anywhere else where someone offers you a pen to sign something. And I DON’T SHARE my pen! Perhaps it’s because I get plenty of rest (most of the time), keep myself hydrated, eat my fruits and vegetables, work out, don’t smoke and take my vitamins. Am I nervous about possibly contracting swine flu? A little but I’ll take my chances. But that’s just me.

As always, do your own research before deciding what’s best for YOU. I’m just giving you a place to start.

www.theatlantic.com/doc/200911/brownlee-h1n1

….just get the facts. Those were the words I heard the night nurse I had just given report to tell his student as I walked away. And I can only surmise that Jeff’s student must have asked “that’s it?” A change of shift report isn’t the time for details, details are to be discovered during the head to toe assessment, by reading the chart, reviewing lab tests and, oh yeah, by working your shift! But as I walked away, I thought through the long history of reports I’ve given and received over the years, and how I’ve given and received reports. They’ve been short, sweet and to the point. To this day, I still use the format learned when I was a fresh trauma ICU nurse: Reason for hospitalization, Diagnosis, Surgeries/Procedures/Pending Procedures, Head to toe BRIEF review of systems which includes date/location of IV lines, ventilator settings and presence/location of tubes and drains. I’ve also added an additional category, “Family/Psychosocial” because sometimes it is useful to know if you have a family member who will lift up the patient’s gown and remove the abdominal dressing WITHOUT washing her hands OR WEARING GLOVES just to make sure “it’s done right.” This list might seem lengthy, but takes 5 minutes, 6 tops, but of course we stretch it out to gossip.

       Given that my patient was an end of shift admission from the ER, there really wasn’t a whole lot to include in my report. I covered reason for hospitalization (trip and fall – unknown loss of consciousness with altered mental status – read “combative”) working diagnosis ( Sepsis with bilateral lower extremity cellulitis – more like elephantitis) and past medical history (NKDA, IVDA, Hep C). I gave his vital signs, including a very truncated neuro assessment (sedated but arousable, mumbles name) as well as what was done in ER (Head CT – negative and pan cultured for temp 101.8 treated effectively with good ole soap and water). I concluded with a “good luck getting any additional info, he was also treated with 200 of Fentanyl and 4 of Ativan for his combativeness, he’s in a happy place.” All of that took 30 seconds.

        The format I use is basic, to the point, logical but surprisingly not universal. 12 years later and I’m stunned that some nurses start his/her report with whether or not the patient has a foley (pee tube). Really??? That’s where you start??? If I had any brains at all I’d create a shift report template to be sold to nursing programs nationwide. (Note to self, create shift report template) And now I’m off point, which is how I feel about details versus facts. Specifically, are facts sometimes dismissed as details?

       “No, Timbuktu is not showing any signs of life. We have him connected to an EEG which is showing seizure activity that we haven’t been able to stop.” Am I really having this conversation? On the phone? With a father?? 500 miles away??? Yes, yes I am. From this conversation I learned that Mr. and Mrs. Timbuktu have been waiting for THIS phone call for nearly 10 years. They are somewhat relieved that “it’s over.” Mr. Timbuktu explained that their son has battled depression since he was 16 and has multiple suicide attempts. Looks like this one is successful. What am I supposed to do? How am I supposed to feel when a father and mother have mourned the loss of their son so many times? Questioned their worth as parents? Wondered where or how they went wrong? When knowing is no more of a relief than not knowing? How am I supposed to feel when Mr. Timbuktu gives his consent to stop life support so that his son, Mrs. Timbuktu and their 3 other children, can finally be at peace but a certain neurologist believes that HE can save this boy’s life? Believes that Mr. Timbuktu is naïve and giving up too quickly? Who adamantly opposes and arrogantly dismisses the parents’ point of view? Clearly Dr. Narcissist wasn’t concerned about the details.

       If I believe what I’ve been taught (and I do), that above all else I’m a patient advocate, then I should be on the side of Timbuktu and his family. If 8 years of therapy couldn’t help this boy, then who the hell am I to think I have the magic cure? Even IF Timbuktu’s brain was able to survive the anoxia AND uncontrolled seizure activity he’d be, well, Terri Schiavo** at best. And that’s a whole other limbo for Timbuktu’s family to navigate. Sometimes ending pain and suffering is the healing, compassionate thing to do. 

       Thankfully, the neurologist was not Timbuktu’s primary doctor; therefore his opinions were dismissed as details. After we followed hospital protocol for phone consent for withdrawal of care, I walked into Timbuktu’s room and turned off the ventilator. And those are the facts, facts that in no way made the detail of turning off the ventilator any less disturbing.

**I will explain my love for Terri Schiavo in a subsequent blog.

Click.
“What are you doing?”
Silence.
“You can’t take pictures in here.”

Sound familiar? I once asked a woman why she wanted to take pictures of her broken, bruised, puffy and intubated husband. “’Cuz maybe he’ll stop drinking this time,” she replied. Made sense to me, so I let her click away. I hope it worked, I really do.

But what are we so afraid of? Exposure? Judgment? Mistakes caught on film? Maybe, but we’re more afraid of being sued, and that puts the medical community on the defensive. In the moving-at-the-speed-of-light technology market, cameras are being incorporated into everything, phones, iPods/MP3 players and pens. Someday we’ll be able to blink, capture an image in our heads and print it from a computer by attaching a cable to our temple. OK, that’s farfetched but perfect for Sci-fi. But with every click of a pen, snap of a finger or twist of a USB stick, an image can be captured for life to be used as “evidence.” My hospital’s photo policy is simple: obtain the appropriate form from the Risk Management office, read the disclaimers, time, date and sign on the dotted line and viola! Snap all the Kodak moments to your heart’s content, provided, of course, that no other patients, families or hospital personnel appear in the photo AND a hospital representative (lawyer) is by your side.

A picture’s worth 1000 words…. as long as you know the language.

Yes, I know his heart rate is 132.
Yes, I know that is not normal.
Yes, I know that normal is 60 – 100.

No, you can’t sue me but yes, you can click away.

Given his condition, I’m not surprised that it’s 132. I am surprised it’s not higher. And yes, I’m doing everything I can to fix it. So don’t think that just because you snapped a photo of the bedside monitor you can sue me for malpractice. Know the language, first. You see that big silver and orange machine next to his bed? That’s called a Rapid Infuser and I’m using it to replace all the blood that he’s losing.  That’s it there, collecting in those canisters on the floor; it’s cleaner, safer and easier for me that way. Click away.

Why is he bleeding so much? He was shot. 5 times as best we can tell. It seems that at least 1 of those 5 bullets went through some of his arteries, intestines and veins which is why he’s losing blood almost faster than I can replace it. No, you can’t sue me for giving him blood that you or he didn’t consent for, but now that you’re here, would you mind signing this form so that we can legally continue giving him blood? He’ll die if you don’t. Thought you’d see things my way. Thanks. Click away.

Continue clicking away as my colleagues and I sweat to near dehydration as we’re hanging blood and IV fluids in rapid succession, titrating medications to keep his blood pressure above a certain number, usually 90 and change blood soaked sheets for clean, dry ones. Yes, you can click away because his foot is dangling over the side of the bed, because there is dried blood under his finger nails and because the dressing covering his open leg fracture is nearly saturated with blood. Also make sure you click away as I’m recording how much blood is pouring out of him, how much urine he has (or hasn’t) made, as I’m constantly calling the trauma surgeons with updated vital signs, loss of blood (hopefully lack of loss of blood), answering phone calls from the lab, “Yes, I know his H&H is 4.8 & 10.4. Yes, I know his potassium is 2.1, PTT 146.2. Yes, I know….”  I don’t have time for this, my patient is bleeding out! Please click away as the hour rushes from 0742 to 1512 and I haven’t left the room to pee (because I’ve sweated it all out), eat or rehydrate. Click away as I repeat to the pharmacist “Yes, I want Levophed 16 in 250. Yes, I know it’s double the standard concentration. No, I don’t know how expensive Factor 7 is.” Click away as I tell the blood bank for the 3rd time “Yes I want all 6 units of blood, 4 FFP, platelets and cryo AT THE SAME TIME.” Click away as a stream of colleagues enter and exit his room bringing me supplies as I run out, send blood samples to the lab and relay orders from the trauma surgeons. Click away as I push medication through his IV to help (hopefully) slow down his bleeding. And click away as I’m finally able to call the trauma surgeons telling them that I‘ve finally stabilized his vital signs and blood loss and this is the most stable he’s going to get so it’s time to rush him into life saving surgery.

But please make sure you continue clicking away as I’m left behind, cleaning his crime scene-esque room. Click away as I account for all the empty units of blood by charting them in his flow sheet. Click away as I toss all the full canisters of blood and body fluids into the biohazard bin, replacing them with empty, clean containers. Click away as I dance around the “housekeeper” as she sweeps up the layers of bloody gauze, empty drug boxes, used syringes, plastic caps and anything else that may have landed on the floor so that I can clean and refill the IV pumps, restock the window sill with every resuscitation fluid available, wipe down every surface of the room, grab new drug boxes from the pharmacist, and finally chug a gallon of water in less time than it took SNL to parody Sarah Palin (which was awesome). Now maybe I’ll be able to pee. Please click away as I reset his room so I can do this all over again once he gets out of surgery.

I hate practicing defensive medicine. I know that hospitalizations are traumatic, overwhelming and difficult to navigate. I also know that it stirs the deepest fears in all of us, especially if you don’t know the language or how the body or a hospital system work. Yes, I know I’m asking you to trust a complete team of strangers but this is what we do. This is what I do and I’m damn good at it. I will take you through every step of the journey, or as many steps as you want (or don’t want). So trust me. Wait. Maybe that’s why you’re snapping pictures? You want to show them to someone you trust. Well go ahead, but just make sure they know the language.