Meditations on Mortality

Dolphin Boy

noreply@blogger.com (The Inkling) — Fri, 20 Jun 2008 03:34:00 +0000

There was a sick kid in room 20. He was one of the types of patients that make you want to pull your eyeballs out. We all have them, the patients that we really don't like to take care of for some reason. He was actually middle aged but some sort of head injury as a child had left him stunted and barely human, a Dolphin Boy.

Medicine, like the kind I practice, rarely considers the final outcome. We pour our heart out when a trauma victim comes in — whatever it takes to give them a shot at surviving. We can’t look at outcomes because you can never tell. Some who should live have died and some who should have never survived walked out of the hospital to a normal life. If we start to contemplate which is which or how to tell them apart, we will start down a slippery slope that slimes us into the bowels of those fictional insane asylums like Arkum of Batman fame.

Still, Johnny could have used someone looking out for him in that ER sometime in the 70s. Thirty years of drooling, crapping, and making animal noises when someone gives you rice pudding. God love his parents. I don’t think I am that brave or strong.

I eyed Johnny and his parents as I walked through the door. I wonder if they could see into my soul to know that I wanted to be anywhere else. My inner monologue something very close to, “Oh great, a Dolphin boy. Who did I piss off today? Does God hate me?”

Here is the problem with these kids, they aren’t normal. I know that sounds stupid to you but how do you know how ill someone is unless you compare it with “normal.” Surgeons had cut Johnny open two dozen times. The largest section of his legs were slightly smaller than my wrist. His chest was malformed and grossly thickened from pulmonary disease. He’d probably sucked more pureed green beans into his lungs than a small backyard swimming pool. What was normal for him?

Today wasn’t normal. Mom and Dad said he was sick. As a medical person there is a golden rule with these type of parents — if you don’t know them, they are telling the truth. Here is why - a kid like that demands constant medical attention. He sees the doctor every two weeks to a month. If they have avoided the ER enough that they are strangers then they have done a good job and they have intercepted a ton of illness's before they became emergencies. These parents in front of me know more about medicine as it pertains to their child than I do. They learned it the old fashioned way, OJT.

The overhead pager blared, “Nurse to room four.”

“That is me,” I say with a little too much relief in my voice as I hastily beat feet out of the room. Whew, I dodged that bullet or at least I put it off.

Right about then is when the ER goes to hell. Ambulances pour through the back door. The guy in room four is having a heart attack. Pizza is in the lounge getting cold. The doctors felt sorry for the nurses who had to skip lunch on their 12 hour shift so they sprung for some pizza — only none of us can make it to the lounge to shovel down a slice or two of pie (or four in my case).

Johnny is going to take some time and manpower to work up. He isn’t going to sit still and let us start an IV. He isn’t going to handle a foley catheter to get urine. This is going to be a wrestling match with Dolphin Boy and his parents. They aren't going to casually wait as I invade their childs body with tubes and needles. No, there will be questions. They will want me to do something "this way." They are invested and that means I can't just do my job. I just don’t have the time for this right now.

Dr. Shoe ordered some oral medicine to help with nausea for Johnny, which I had given. I didn’t think much about it at the time cause it mercifully bought me a few more minutes to get other tasks completed. I remember thinking that I didn’t like the way he looked. His skin was clammy and his pulse was racing.

A few minutes later we received news that a helicopter was inbound with a trauma victim, they were due in about 8 minutes. Throw more gasoline, I thought.

“Nurse, discharge room twenty,” said Dr Shoe.

There was the look. That dog-like cocking of the head. “What do you want me to discharge them with,” I said.

“Nausea, resolved. The kid is doing a lot better since the zofran. I had one of the techs check his vitals and the heart rate is down so he is good to go.”

I did as instructed. At the bedside I looked at dolphin boy. He sure didn’t look any better to me. “Dr Shoe wants to discharge Johnny with nausea today,” I said expecting some push back. This mom and dad didn’t run willy-nilly to the ER because of some nausea.

Still the mantra of “Thank you Jesus,” droned in my skull, I can't believe that we weren't going to work this kid up. No wrestling with Dolphin Boy for me.

“What do we do if he gets sicker,” asked dad.

Mom gave him the “look.”

“We will do fine. Let’s take him home and sing with him for awhile,” she said.

I felt like Captain Kirk had just sent the Enterprise into red alert with all the red strobing lights and that annoying alarm clock sound raping my ears at 80 decibels.

“Look, if you think he is sick, I can talk to the doctor about getting some lab and urine. We can run some fluids into him and go from there,” I said.

Mom gave me the look of an angel who had been on a ten day bender. “No, Johnny has suffered enough. We will take him home and sing to him. He loves it when we sing.” There was a twinkle in her eyes as she spoke. I don’t know if it was madness or serenity.

The thump of the helicopter hitting the roof let everyone know it was show time.

“Alright, sign here,” I said proffering the paperwork. Business.

The kid did not look alright but that wasn’t my responsibility. Mom, Dad, and the Doctor Shoe were all ready for him to go home.

Me, I was on my way to grab some well earned pizza before that bird unloaded their patient onto our laps.
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I got to work early the next morning. The had gym summoned me in the pre-dawn peace before the world wakes. Sweaty and still a little limp, I headed into the ER. I would shower in a bit but first I could use something to drink.

A middle aged man in a suit that could not hold more wrinkles stood next to a gurney with one of those heavy red felt drapes over the outline of a small body.

“Someone had a bad night,” I think.

The night shift charge nurse looked over at me, “Hey, do you remember any of the history on that FLK you took care of yesterday?”

“Yeah, he was a train wreck. Why?” I ask.

She nodded toward the lumpy gurney, “He died last night but the parents did not come in. We don’t have any history. They are looking for the old chart but if you could tell Nancy what you know it would be a big help.”

I never told Nancy what I knew about the body under that heavy pseudo-velvet drape. I never said, “The patient had a history of a nurse who really didn’t want to be there with that kind of patient. He came at the wrong time, when we were busy. He had an illness which coincided with the one chance I would have to eat. Most importantly, he had a nurse who failed to remember that his job is to advocate for the patient — not the family, not the doctor.”

I was dolphin boys last safety net and the net failed. Sure, I didn’t do anything legally wrong. I didn’t even do anything morally wrong. I just didn’t do it right. Sometimes that makes all the difference in the world. Johnny won't be making animal noises for rice pudding anymore.

They don’t teach you about living with that in nursing school.

The Carmex Kid

noreply@blogger.com (The Inkling) — Tue, 17 Jun 2008 13:07:00 +0000

He's Crazy!

Johnson was a schizophrenic who lived in the basement. He'd pretty much lived in the basement since puberty has set the chemical balance in his brain on fire. His parents only heard whispers of his coming and going. They noticed food missing. That was how they knew he was OK. Slowly, they noticed that less and less food was missing.

They set up a little surveillance to spy on their child. What are parents of schizophrenics to do?

Johnson hardly got out of bed at all and when he did he walked with a pronounced limp. God help them, but they were going to have to see what was wrong. Disturbing the routine of Johnson's type of schizophrenia was always a major ordeal.

With the help of the police and fire crews Johnson was brought in to the ER. His testicles were the size of very, very large softballs. I would say "cantaloupe" sized but I hate to compare gonads to food.

Testicular cancer.
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Surgery and therapy went well. Johnson actually handled the routine of the hospital with amazing grace. Staff worked hard to give him some routines that might help him cope with being out of control. Carmex was his mecca. He loved smearing the caramel flavored variety on his lips. Every few minutes or whenever people made him nervous the Carmex came out.

We took care of him in the ICU for a week or so which is where I met him. He moved down to another floor after he stabilized. That was fine with me, examining a crotch in fine detail first thing every morning was beginning to invade my dreams and give my hard boiled eggs an unhealthy association .
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The overhead speakers blared the warbling tone that is a mix between old school and science fiction. "CODE BLUE, CODE BLUE."

I wonder why we bother with the code system. Presumedly, it spares the docile masses from the knowledge that someone is having their first face-to-face with God a few feet away. Supposing that there may be a few people in America who haven't saturated themselves in medical drama shows - someone, somewhere might not know what a code blue meant. However, the sudden rush of nurses, doctors, and respiratory therapists just might give it away. Sure, we don't yell "STAT" like the TV shows and most people look like they may be wiping pizza off their mouths instead of coming from an exotic surgery but even Paris Hilton can figure out that the free ice cream is in the cafeteria not a patients room.
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I was the first one there. Well, a moment to clarify. I was the first person who could manage the code on the scene. There were several nurses and aids standing around looking at poor Johnson. He was still breathing and had a very weak pulse. His blood pressure was in the toilet.

I put him on the monitor I had carried up and about that time others started to arrive. "Let's get him a fluid bolus," I said to no one in particular. I am tempted to write "Stat" so that everyone reading this will feel like they are reading some high drama.

Dr Blue finally got there after the fluids were started. He really wasn't needed at this one. It was a near arrest. No intubation needed. Us nurses can follow the ACLS guidelines as well as anyone else. As he backs out of the room he catches my attention, "Go ahead and start him on dopamine and get him to the ICU."
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The trip to the unit was uneventful. I was going to be taking care of him in the ICU at least for awhile. The dopamine and fluid had brought his blood pressure up to the low 100's systolic (the top number). He was talking to me as we moved him into bed. Johnson was an adult but his innocence and mentation was closer to a ten year old.

It took about 10 minutes to get him hooked up to all the equipment. "Can I have some water," he said.

Not just no, hell no. You just brushed up with death and ruined half the hospitals lunch, I thought. "Let me see but it will take me a few minutes," is what I said.

The chart was thrown all over two desks. Good god, a small forest was hacked down to document all Johnson's care.

"I am going to go look at your chart." I pointed to the desk a few feet away - I mean spitting distance. I could hit the desk with my morning stream if you know what I mean.

"Ok," he replied meekly.

"Can I have my carmex?" Oh yeah, I forgot the Carmex. How could I forget the Carmex? I found the tube laying next to some meds I had pulled "just in case." The Carmex was probably the most essential item there.

As I walked out Johnson looked up at me again. "Do you need anything else?" I said.

Johnson looked around the room, his eyes roving to every surface. The move was more over the top than Mel Gibson in Conspiracy Theory.

"Close the curtain, I don't want them to watch," he said.

Freak. What an nut. I pulled the curtain partially closed. From my desk I could lean forward and see Johnson. Now satisfied to see him smearing more Carmex than Tammy Fae I walked over to the desk.

"CODE BLUE ICU, CODE BLUE ICU"

What the hell. I hadn't even sat down. There were 20 patients in our unit. We started scrambling to see who had tried to check out without paying the bills. I took a quick glance in at Johnson to make sure he wasn't freaked by the alarm.

"$#^@, it's Johnson," I said as I ran in the room. The Carmex was still in his hands but his paranoid eyes had changed into that distinctive fish look that I had seen so many times before.

An hour later I am sitting at the desk looking at the paperwork. Johnson was the first patient of mine who had ever died. Sure, I had seen dozens... maybe hundreds of people die but none of them on my watch. None of them under my care.

None of them ever said, "Close the curtain. I don't want them to watch" 20 seconds before they simply went asystole.

I had my own come to god moment that night. What the heck did he mean? Why did he have to say those words? Why do I get the feeling that this freaky young man knew that the valkeries had roosted upon his IV pole and were simply waiting for me to leave the room. If I had turned around would I have seen Brunhilde taking him by the hand and saying, "Your war is over troubled one. We have a seat for you next to Odin in the halls of Valhalla. You earned it."

Following the Rules

noreply@blogger.com (The Inkling) — Sun, 15 Jun 2008 21:53:00 +0000

I am something of a rabble-rouser in the ER. I guess you could say an independent thinker. The following story happened years ago and has to do with basic human dignity and the courage to respect rights over rules.

I hate rules. The rules I hate the most are hospital rules. I am a frakkin professional charged with the responsibility of the lives of others and some "suit" wants to decide how many visitors can see my patient cause I can't determine what is safe and/or reasonable. Thanks for acknowledging your respect for my ability.

Johnson (all my stories will feature "Johnson" as a patient to preserve privacy.. also these narratives are not verifiably true - in fact I deliberately change change things to protect identity and privacy. The spirit is true) was in pretty poor shape. The situation had gone down hill in the last 3 hours and now Johnson was beginning to get tired from the labor of breathing through all that fluid in his lungs. Johnson could occasionally talk in short winded bursts like a sprinter after a thousand yards.

It was time to intubate. This is the best time - before Johnson was so far gone that the stress caused other changes. We knew that it was impossible to keep Johnson from the ventilator. It was a matter of when.

Doctor Blue joined me at the bedside with the significant other. "We need to stick a tube down Johnson's throat to help with the breathing," Blue said in the doctorly way, as if this was as common as getting a shot of antibiotics.

Johnson looked scared. "Will it hurt?"

"We will put you to sleep while the tube goes in but you should only be out for about 15 minutes or so," came the standard reply. We have done this a thousand times.

"Will I be OK?" the question was delivered with some poise. Johnson could only manage about three words in a single gasp.

"I am going to slide a little tube in and it will breath for you so you can rest." said Blue. We could be car salesmen. No answer was given but one was received.

"Can I see" huff... "my family before" huff.... "you do this."

Dr Blue looked at me. I nodded yes. He nodded no. An impasse. "We need to get this done soon," the doctor replied. Not one to be so quickly beaten I added, "But we can get your family in here for a minute. How many are outside."

The Significant Other said, "Around fifty or sixty." Crap on a spoon.

Johnson looked at Dr Blue. "You do what has to be done doctor. I trust you." (the kiss of doom).

The doctor walked out. He wasn't pleased with me. This should be a simple thing and the family could come visit in the ICU. Two at a time, when they allowed visitors which wasn't often.

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When I came through the ER with a sixty person soul train the charge nurse nearly came out of her skin. "Two at a time in the room, PERIOD!"

Charge nurses are like that... Their job is to see that the whole ER runs as smoothly as possible. They hate nurses like me who could care less. I care about what is best for my patient. The two goals are not always compatible.

I looked toward her, "It's OK. I am leading this bunch and we won't be but five minutes." I swear she could have shot beams like the Deathstar at that moment.

_____________________________________________
From the littlest Johnson to the Largest Johnson and everywhere in between they marched up to tell Johnson they loved him and wanted him to get better. Johnson children and Johnson siblings cried and kissed. Johnson parents graped hands and stood as the rock for all the other Johnsons to cling to...

I stood aside. This wasn't a moment for nurses, it was a moment for loving.

Questions came. Fears were soothed. My titanic frame giving authority to my words and my confidence.

All the Johnson shapes were ushered from the room. While they smiled and cried and patted or kissed, I had been getting everything ready. Little time had been wasted, maybe three minutes.

________________________________________________

Dr Blue laid Johnson back, "We are getting ready to start. Pretty soon you'll get sleepy and when you wake up we will have the ventilator breathing for you."

Johnson was already feeling the happy juice and said, "I know that you'll help me doctor. I don't want to die. You just get me through this."

In ER terms that is like someone pushing the great red "ABORT" button. Immediately all of us looked to each other. Twelve double quarter pounders with cheese hit rock bottom in our guts.

But we are professionals and don't buy into primitive superstitions. "Forward Hooo"

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Johnson never woke up. His last words, as far as I know his last thoughts were "don't let me die" to a roomful of strangers.

All the little Johnson's, all the old Johnson's, all the tall Johnson's and all the funny shaped Johnson's got to say goodbye. Johnson was surrounded by so much love in those final moments that I was afraid that a "love-healing miracle" would render our services as unnecessary.

I received notes and cards for weeks afterwards. I was even invited to attend the funeral.

The charge nurse wrote me up for violating hospital policy.

It was a fair trade.

NOTE:Unfortunately, all my stories have the inherent value of me in them, otherwise they would be your stories. Like all humans, I tend to minimize my mistakes. In reading the stories, it may seem like I don't make mistakes or think myself to be totally awesome!. Trust me, I do make mistakes and I have to live with them. There is no rationalizing to the dead body in front of you that was discharged 6 hours earlier. You will forever hear your voice telling the patient and their family that everything would be "just fine." Well, it isn't. A dead body lays on the gurney and grieving loved ones stand all around you. "I did my best," just doesn't cut it with the family and it doesn't cut it with that part of you that has to go to sleep every night. So, while most of these stories may make me look superhumanly cool they are only one side of the coin. The side I can share.

Failed Expectations or Sick, Not Sick

noreply@blogger.com (The Inkling) — Sat, 14 Jun 2008 04:41:00 +0000

I always find it vaguely humorous when people tell me, "last time I was here you said I had X and gave some pills. It didn't get better and my doctor said that I actually had Y. He gave me some pills that made me better."

This is a case of failed expectations. See the patient expects the ER doctor to properly diagnose and treat a routine illness. The ER doctor has expectations of ruling out anything that might be life or limb threatening and then shipping you off to another doctor who performs routine care.

One of my favorite docs told me that he only had to answer two questions.

Sick or Not Sick
If Sick - to whom and where does the patient get admitted.
If not Sick - to whom and when does the patient follow up and what do I need to give them in the meantime.

The ER is the nuclear bomb of medicine. We don't have any ability to operate discretely. It is all blinding furor, splattering body fluids, and hastily thrown together cocktails of pharmaceutical yumminess. Does that cover a gunshot? Yeap. Does it cover a heart attack or stroke? Yeap. Does it cover your cold that just won't get better? Nope. Sure, we can splint that broken one and give you some "Scooby Snacks" but we don't actually deal with it at all. Your ortho doc will do the treatment and get you better.

Stabilize those who are at imminent risk until the proper doctor/surgeon can see them. That is what we do. Really, that is all we do.

The poor ER doctor is part gynecologist, orthopod, cardiologist, plastics, gastro, pediatrician, psychologist, intensivist, infectious disease, and family practice (I am sure I missed a few). It is no wonder that they are the masters of none of these fields. Those are entirely separate fields of medicine. Would you expect your shrink to deliver your baby? Why expect the ER doctor to tell you why your back has been hurting for 2 years despite seeing 15 specialists?

Sick or Not Sick... That is what your ER is striving to determine. God help us when we are wrong on that one.

And first, some levity

noreply@blogger.com (The Inkling) — Sat, 14 Jun 2008 04:23:00 +0000

A friend reminded me that there are some hunkered experiences had by those of us wading in the nasty side of life ~ Emergency Room Medicine. I'll share a few of the rules I have learned for surviving a trip the the ER.

There are tropes and stereotypes from the various TV shows, I'll just skip right by those. Don't go there.

Things you can do to impress the staff....

Nothing is more enlightening than explaining to someone that "X" only kills people on TV.
Or, when people explain to me that this wasn't how they did it on Trauma Life in the ER... That is a sure way to demonstrate your knowledge to the friendly ER staff, quote an entertainment show as a standard of care.
Also, if you googled something, please keep that information to yourself. Your google-fu may be strong but it makes you look coached, "I am having a deep peritonitis-like pain around McBurney's point." Does not sound like an appendicitis to me it sound like a crazy person... just say, "Do you think this could be an appendicitis."
Last but not least, that fact that your brother in law is a doctor does not transmit the information via osmosis through a marriage certificate.

Things you should avoid doing in the ER

Eat from the vending machine while complaining of belly pain or vomiting.
Check in more than one person with the comment "while we were here we figured you could look at..."
Utter the following statement to your doctor or nurse, "My doctors office opens in an hour but I really needed to be at .... [insert movie, work, date]"
Utter the following to your doctor or nurse, "I need to be out of here in .... [insert an hour, 2 hours, or a week]"
Cuss in some language other then English... give it to me strait up.
Try to leave the ER while drunk, high, suicidal, or after you have hit your head.
Taking a dump on the bed because your headache was sooo bad that you could not sit on a bedside commode.
Tell anyone, "Help me I'm having a seizure."
Talk on the cell phone when anyone is present (unless you are calling for a ride home or telling significant others that you are going to emergency surgery).
Have more then a handful of allergies (and all of those allergies to pain killers)
Have the staff greet you by name when you walk in the door or say "What brings you in TODAY Frank."
Tell the triage nurse, "I'm having Chest Pain" and then tell your doctor or nurse - "I didn't want to wait out there with all the sick people. I know I said chest pain but I have this terrible back pain."
Say, "Ish din'tt has anisting to drunk or du ani druggz" Trust me, we will figure it out. Just own up.

Things that result in uncomfortable experiences in the ER (other than the fact that you are in the frakkin ER)

Spitting on the staff. Result = some lingering jaw pain for a few days (from fingers wedged into your cheek to keep you from spitting). If you have a known communicable disease you may wind up in jail.
Hitting or Kicking Staff. Result = most likely you will be hog tied to the bed after your are submitted by folks who understand exactly how far your arm can bend without breaking.
Include "I'll kill everyone in this place" in any sentence. Result = bad juju.
Intimidate or threaten that cute little 23 year old baby nurse taking care of you. Result = the rest of us find her just as adorably innocent as you did. We treasure innocence.
Try to wrestle or box me while bleeding, drunk, and naked... in the hall. Trust me, you really don't want to do this one.
This one is X-rated so I'll leave it to your imagination.

What NOT to bring to the ER

The snake that bit you. Really. I don't need to see it. You don't think I need to see the gun that shot you, so why would I need the snake that bit you? Leave the snake outside the ER!!! We got slow people in wheel chairs and walkers. Watching them freak out and try to run when the escaped snake comes slithering around is the nightmare of othro doctors everywhere. The snake is a bowling ball for broken hips - It just depends on how many pins you started with.
Your gun. Hey, I love guns as much as the next person and own a few myself. A gun in the ER says, "Hey, Look at me. I'm Tim McVeigh." That is never a good thing in the ER. Never.
The whole graduating class of 2007. If you are under 20 and injured in a car accident or some other freak of nature event. Do not call your friends while strapped to the backboard telling them, "Call everyone. I think I am dying." I know that you have little experience with pain and trauma but trust me if you want to call - you are not dying. Having your 85 "best friends" crying and wailing in the lobby won't help. In fact, they probably blocked the sight of that 58 year old man who could not breath from the triage nurse. Thanks, once you all clear out someone will tell us there is a dead person in the lobby - some 58 year old dude.
Razors... I know you like to cut on your freaky little arms and that is why you are here. But, I got to search your pockets to make sure you don't "ad lib" while in our care. Mostly I just make you strip and cut all the pockets out of your clothes so that I can see into them. Reaching into the pockets of strangers in the ER is like that horror movie when the cute 19 year old coed reaches into that dark hole for the thing she dropped. You just know she is going to have her arm eaten off.
Your body fluids in a wal-mart sack. I know you think I want to see that neon colored gelatinous vomit that has cooked in the wal-mart sack for 3 hours. It isn't going to help me in the least. I never looked at vomit or crap in a bag and yelled, "I need epi, stat!"

Up next time.... anecdotes and things that might have happened somewhere but you can't know. Sometimes funny, sometimes tragic, delivered with the not-so-deft touch of yours truly [I got a bad case of bull-in-the-china-shop syndrome]. Also, tell-tale signs that your nurse is a moron.

*Try not to take this thread personally. If I took everything said to me in the ER personally, I'd have blown out the ol brain pan years ago.