Life in the Green Zone

It's been a long few weeks, and it seems like it doesn't matter how much sleep I get - I'm still exhausted. Good thing I don't work five in a row anymore. I think I would've totally lost it.

A few nights ago, I was in the yellow zone, which has a tendency to kick your ass, and I had a night filled with two different groups of patients. The first was sick enough to merit an ER visit and earn an admission to the hospital - pneumonia, COPDers, a new-onset A-Fib, and a couple with resolved chest pain who would have heart caths or stress tests in the morning. Legitimate patients. The second group were the ones with whom I had trouble holding my tongue. I can't tell you how much I wanted to say, "This isn't an emergency! Go home! Quit making me pay for your pointless ER visits!"

The latter really, really got on my nerves. One lady was in her 40's, came by ambulance for a rash.

A rash.

Somehow that seems even worse than the one with an ear ache/ear infection.

This woman was overweight, on disability, and unable to walk. This I learned the hard way when she said she had to go to the bathroom, and I asked where her shoes were. When she said, "I can't walk" and looked at me like I should've known this, I bit my tongue to avoid telling her A: tough shit, then, I can't help you right now, I have higher priorities, or B: why the hell can't you walk?

Instead, I tactfully if tersely asked, "Well, then how are we going to do this?"

She explained that at home, she hung her ass over the side of the bed and peed into a bucket.

Right.

After much grimacing and mental debating on how I could avoid dealing with this, I rolled her back to a trauma bay, handed her a wash basin, and let her do her thing. This was also a mistake, because she peed half in the bucket and half on the floor, then decided she was stuck and couldn't get back in the bed, and kept trying to grab onto me in ways that would've permanently disabled my back, shoulders, neck.... You get the idea. I was so pissed, so over this woman I couldn't stand it. She was definitely one of the ones who made me want to go be a Minute Clinic nurse.
Later, I had my second "What makes you think this is an emergency?" patient. She was one of those with a shopping list - the initial complaint of cough and congestion also became rectal bleeding, vaginal discharge, and breast lumps.

But before I could get too pissed by her, and before I found out that she had a primary care doctor and still felt it necessary to come at 2:30 in the morning, we had a real emergency.

I was sitting in the middle of the nurse's station when the charge nurse hung up the phone and leaned over to one of our emergency response nurses and said, "Your next MI just rolled in the door."

And he wasn't talking about the ambulance bay, either. He meant the front door.

And he wasn't talking about one of the ones that rolls up in a wheelchair complaining of chest pain.

This one was pretty much dead.

We raced through the lobby to the front door with a stretcher, propping doors open along the way. The guy slumped out of the car, and they yanked him onto the stretcher, stripping off his shirt along the way. After checking for a pulse and not finding one, the smallest nurse out there hopped on the stretcher with him and started chest compressions.

They started rolling, and I ran ahead to the nearest room, yanking out the stretcher and making way for the code cart.
It was another one of those moments when some sort of reflex I didn't know I had kicked in, and I shouted to the nurse's station.

"I need a doctor, now! We're doing chest compressions!"

Instant action.

Stretcher in the room. Chest compressions. Code cart. Defib pads on, check the rhythm on the monitor. V-Fib. Shockable.

"Everybody clear! Oxygen clear! Ready!"

A high-pitched beep as 120 joules travel down the cords and go directly into the man's heart.

Immediate chest compressions.

Rhythm check, pulse check. There's a pulse, but the rhythm looks like shit. Classic heart attack, so advanced that what should be spikes look like tombstones.

Ominous but accurate comparison, because when you're that far gone, you've got a good chance of dying.

IV lines, drugs, intubation, a very important phone call to get the cath lab on their way in, lost pulse,  a few more chest compressions, a few more drugs, pulse back, a little bit more of the story, chest xray, vital signs, more drugs.

I watched and wrote furiously, absorbing without processing.

Thirty minutes flew by, and suddenly we were rolling to the cath lab with drugs, defibrillator, ventilator, and extra hands.

On the way, check the pulse. Faint. Good enough for now, fifty yards from the cath lab.

Throw the laundry cart out of the way, get the housekeeper to move, and finally.

You roll into that room, and the attitude changes. You're handing over the patient, and as much as you want them to do well, there's a secret relief that it's somebody else's turn to be responsible.

But the doctor wasn't there yet, and we couldn't agree on whether or not there was a pulse.

Chest compressions, drugs, vital signs, phone calls to the ER docs, phone calls to the cardiology docs, and a pulse check.

It did the trick, kept him in there long enough for the docs to arrive, for us to get him on the table and let the cath lab work their magic.

I sat in the adjacent monitoring room to chart, and the primary nurse who'd started chest compressions aeons ago in the ER lobby stayed, too, waiting to see where the blockages in the vessels to his heart were, waiting to see how bad it was.

It wasn't until after we'd heard the rest of the story, how blocked his arteries were, after I'd written out the whirlwind of the past forty-five mninutes, after we were back downstairs laughing, until it all sunk in.

We made a difference.

It wasn't me, it wasn't anybody else alone. It was the team.

I can't tell you how much I love that, how much I absolutely love working with people who know what to do, who can handle themselves and can handle the situation in a crisis.

As I write this, that patient is still in critical condition, but he has a chance.

Deep breath.

That's why I do this.

Not sure how, but I was able to go back to the shopping list patient and give her discharge instructions and prescriptions on pneumonia, STDs, and how it's important to follow up with your primary care doctor. Particularly for a breast exam, since we usually don't do those emergently.

I think I spent the rest of the morning taking deep breaths.

And laughing about our housekeeping lady who, for the past week, has decided that it's fashionable (or perhaps empowering) to wear a bandanna wrapped around her head not like a headband, but like a sweatband from the 80's. And after a week of laughing about this, we couldn't help but imitate her by wrapping our stethoscopes around our heads.

Yes, this is life in the ER.

This is why we love it.

And we don't care if you call us adrenaline junkies. It's true. We can own up to that.

I started to get all worked up because of all the stories I was forgetting to tell by not blogging regularly, but then I realized that even if I did miss a bunch of good opportunities, it doesn't matter, because there will always be more. People are crazy enough, dumb enough, and sick enough that there will always be more stories.

Here's what I didn't miss.

Great, great stab wound the other night.The original report we got was short and sweet - multiple stab wounds to chest and abdomen. No gender, no basic status, nothing. When the transporting ambulance called more of a report, we figured it was a good thing that we could hear the patient moaning and babbling in the background.

When they rolled through the door, he was moaning between answering questions, writhing in the blood pooling on the backboard. There was a shredded shirt and a few other unrecognizable pieces of cloth marinating in the blood. We could see a shallow cut to his belly and a small cut to his temple that was bleeding a substantial amount.

And then I picked up the wad of bloody cloths on his chest.

And gasped and promptly put them back.

About the same time, the EMTs said something to the doctors about the chest cut, and the attending came over and took a look.

There was a gaping ten inch slash running through his pectoral area down the side of his ribs. It was moderately bloody, and when we dabbed it away, you could see the lovely yellow globules of fat, the hearty red muscle, and even hints of ribs. Now, it wasn't bubbling like it had cut down to the lung, but while I was holding pressure on it, it sure felt like something was popping or oozing through in addition to the blood.

After that, there was a quick call to the operating room, a few drugs, a little intubation, and a mob of us who bypassed CT and took him straight to the OR. Within twenty minutes of arrival.

Pretty good night, actually.

Must be ER in technicolor, because around that time we also had this guy in liver failure who was a very festive, seasonal shade of harvest gold. Not quite pumpkin, but definitely an orange-yellow decorative gourd color.

What gets me is this: you don't go to bed one night normal and wake up orange the next morning. Not how it works. Really? You didn't notice a difference? Your eyes are even yellow like a hilighter. And you didn't notice? It's like the half-ton super extra morbidly obese people. You didn't go to bed skinny and wake up fat. And those people on "I Didn't Know I Was Pregnant."

Speaking of which, I had an almost-candidate for them. She made it to about six months before the persistent abdominal and back pain brought her to the ER in the middle of the night. What I especially don't get is that she has a toddler! It's not like she doesn't know what it's like to be pregnant. I know your pee-stick pregnancy test might have said nay, but use your brain, please.

So, as far as people who don't use their brains, recent green zone misadventures, you ask? Right.

Most of these stories start with the phrase "So there was this drunk guy." This is no different. He'd come because while drunk at home, he fell and got a huge cut on the back of his head. Sutured, done. Except for the part where he got pretty rowdy down the green hallway and got to spend some time in seclusion. When his time was up and he started behaving again, we let him go back to his stretcher. When they brought the next patient back to join him in the green mile, he sat up and told her, "You better behave, or else they'll throw you in the hole back there."

I bet if we paid him ten bucks a night, he'd stand back there and tell that to all the patients. Might have some better-behaved crazies. And we'd also get to laugh at the fact that, as this guy slept it off, he slid further down in the bed, which slid his turban-like head dressing further up, so by the time his blood alcohol level got down into the legal zone, it was a perfect picture of middle-eastern headgear.

What else...

Well, on my chest-slasher, we didn't get a chance to ask who did it to him, but this morning, we did get an almost-confirmatory result for the 911-dispatcher version of whodunit. The EMS radio crackled, produced a weird chirping noise, and eventually someone came on and said, "All area hospitals, be on the lookout for a suspect, unknown description, unknown gender, with a suspicious leg injury..." then a fair amount of mumbling, then, "Uh, we have an update, you're looking for a black male possibly involved in a home invasion who kicked through some glass, so probably some injuries, like lacerations, to the lower leg."

He didn't specifically say that it was a black guy in a hoodie, but since it's cooler outside right now, and this was in the middle of the night, surely we can assume the hoodie.

We didn't end up seeing the guy with the suspicious leg injury, but I did still have some excitement at the end of the night.

Confused little old guy started grabbing at his third IV of the night, and his newly-placed Foley catheter, yanking like he was going to pull them out. So I ran in and grabbed his hands, disentangled the oxygen tubing from the IV tubing, and firmly took hold of the arm with the IV in it. He didn't exactly appreciate my firm touch, and he expressed it by grabbing back and trying to break my fingers. I called for a little assistance, and when the other nurse walked in, he turned to her and said, "Get this damn heathren off me!"

Yes, I got called a heathen. Definitely a first. Been called "chil'rens" (children) before, but not a heathren.

And just think. He was that entertaining and he wasn't even drunk.

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.