Posts (page 2)

Pardon the recent neglect... I've been trying a new routine that involves getting in bed right after I shower, instead of staying up to decompress. Not so sure how it's working so far, but I had to eat some breakfast this morning, so here I am.

No stories now, particularly, but I have this weekend off, and Taylor has to study for tests, so I'll catch you up on things like how the Orange zone is actually a black hole, and how masks work when you're the one with the germs, and that yes, we are a little twisted, but it's not hurting anything to bet on somebody's blood alcohol level.

You might also get a little bitching about our scheduling methods. But I'll try to avoid that.

Remember the "Not an emergency" and "Wow good catch" awards? I'm adding one. The Quote of the Night award.

"Did she get up and ambulate?"

From a nurse I was giving report to, regarding a patient with a femur fracture. After I already said she had a femur fracture.

Really? The femur is pretty tough to break. It's a big bone. That top bone in your leg. Between your knee and your hip. If it's broken, you're not going to be hopping up and walking around. True, we do have you walk if you have pelvic fractures in certain places, but that's with minor ones. And specific places.

There's also the part where I'd told her the leg was already in traction.

Yeah...

Gotta find the funny moments and enjoy them. Because it was definitely a longer night. Not a good night from a cardiac standpoint.

First, we had one come in with CPR in progress - fell out in the WalMart down the road. At the same time, we had one having a heart attack with really bad EKG changes and a few other complications. Then, we had two traumas in a row that had been found unresponsive on the side of the road. How odd is that? Well, not so odd as having a third one later in the morning. And what else...

Making bets on alcohol levels, gallbladders versus appendixes (appendices?), a couple "heavy ETOH" drunk patients...

And to top off the night, we had one come in at 0645 who'd been experiencing worsening shortness of breath over the last week. On the little heart monitor, heart rate of 220. Oops. No wonder you can't breathe! Your heart isn't pumping blood right! That little ABC thing - airway, breathing, circulation. We at least got that heart rate down to 140 before we turned it all over to dayshift. Thank goodness for cardizem.

Also, thank goodness for DVRs, through which I am catching up on NCIS and House.

Just another night at work.

So I had a whole entry typed out, and then it screwed up, so I'll do my best to recreate it, but no promises.

The Guinness thing?

At shift change, we only had one patient. Yes, one. And even then, they weren't in the department - went off for an ultrasound or MRI or something.

Otherwise, it was an unremarkable night. Typical for a Monday - steadily busy until about 2 or 2:30, then much more calm. Almost eerily calm. But when it lasted for an hour or so, we stopped worrying and started enjoyed.

Nothing particularly new, just a renewed sense of awe at, well, at people. Especially the ones who ask, regarding antibiotics that they've been told are antibiotics, "Will this make my tooth quit hurting?"

Yes. Yes, it will. After it kicks the infection out.

Sigh.

And if you're wondering about the lack of follow-up on the horror stories from our really terrible days last time I worked, I do apologize. In an attempt to take a physical and mental vacation, I took a last-minute trip to Colorado to hunt down leaves and wear out my camera. I was attempting to post pictures here when the original version of this entry got sucked into the black abyss of the internet. Sometime, I will.

Until then, keep taking your antibiotics. It'll make the suspense quit hurting.

And I thought the hospital had been full before.

Ha.

Last night, we were seriously full. No patient-shuffling, no nothing. Total gridlock.

Around eleven or midnight, we opened two of our "retired" areas - those that had a purpose but have since been deemed inefficient or irrelevant, and are now used for staff meetings and equipment storage.

Oh, and under extenuating circumstances, a place to park patients while waiting for beds.

Sometimes we walk into work at night to find just one such area, CDU, with a couple patients in it, but opening both was a little unusual.

At the worse, we were double and triple parking people in hallways, still had ambulances rolling in, had tons of sick patients in the lobby, many of whom had been there for a while, and others who were still waiting to be triaged. Fortunately, we did not simultaneously have a trauma arrest or something come in.

Once I got over to my holding area, the former Heart/Stroke center, I realized that, on top of having tons of patients, we had a few ones with pretty unique problems.

Every single day we have tons of people come through with some form of abdominal pain. I'd even say that up to a third of the ones that go through the main ER, not fast track, have abdominal pain. On a good night, you might get one that goes for an appendectomy, and the really occasional ectopic pregnancy, gallbladder, or bowel obstruction. But tonight, I had two in H/S alone that were other things. More unique. One had an intra-abdominal abscess - a three-inch pocket of infection in the middle of his abdomen. The other had a one-inch aneurysm on her splenic artery, and a significant ovarian cyst.

Now, I know the symptoms of an abdominal aortic aneurysm (AAA) rupture, but what about a splenic artery rupture?

Fortunately, I didn't learn the hard way. But, you know, something to look up. Someday when I'm not working.

I also had the joy of dealing with patients going out to smoke again. We went through that on the floors, and it was kind of irritating.

I don't know as much as I should about Obamacare, but it damn well better include something about not providing care for health problems caused by smoking. Or at least not providing healthcare for those who continue to smoke after they have problems and are told to stop. Might mean developing a nicotine detection system, just so you can document it, but still. I wonder how much that would cut down on healthcare costs.

Not that I want those people to suffer and die, but aren't we kind of enabling them? Because they'll get all the treatment in the world, even when they keep smoking, in the current system.

Personally, I'm all for using scare tactics, too. Just take them up to the pulmonary floor and let them listen to the hacking and coughing all night long, and see the phlegm those people produce, and just get a better understanding of the misery. I'd really like to do the same for drug-users, show them the people who are brain-dead or permanently at a mental age of four because they OD'd on crack and various other goodies.

But I digress.

I have one more night. I hope I've paid my bi-weekly night-from-hell dues, but there's no telling. 

Last night, night 3 of 5, I was the purple nurse. Don't you love how we color-code ourselves? If only they could come up with appropriately colored scrub tops or armbands or something, so doctors and other nurses wouldn't have to ask around for "Who's taking care of grey?"

A lot of the beginning of the night was a blur - busy, but time passed slowly, and it included things like vague abdominal pain, coughing up bright red frothy blood, and some hypertension here and there.

Then, oh, then. You know the phrase "It's all fun and games until somebody loses an eye"?

Well, it's true. Don't let your grandkids sword-fight with broken-off car antennae. It might end up in your eye, which could blow your pupil out, make you go blind, and get you a middle-of-the-night trip to our ER and then OR.  The experience will be punctuated with an ambulance ride from somebody else's ER to ours, where you might have a puke-your-guts-out reaction to being "dilaudid-ized" that results in your lower dentures ending up in the toilet.

Then, the nice doctor who was just trying to get the aerosolized puke smell out of the room might flush the toilet, thereby flushing your dentures away to the waste plant because, according to maintenance, pipes going off toilets don't curve or bend.

One of those things that wasn't funny, but was.

That room seemed to attract a lot of puke tonight, because my next one did the same thing, except his was because his blood sugar was 789. He was a little nutty, too, which was figured out when he told us he weighed fifty pounds, then five hundred pounds, then he was in the hospital because he drove his tractor off the road, and then he started talking about a horse eating a girl's hair and said we should go out in the hall and take a look.

Let's just say that I really need to work on my self-control so that I don't laugh in a patient's face.

We ended the night with only a handful of patients with things like headaches and the flu, which meant we could sit together and tell stories. Pretty great stories, really, that mostly involved strategies for getting people to quit faking seizures, unconventional administration routes of various drugs in the field, stories that support the efficacy of practicing punitive medicine, and an ambulance-on-fire story.

I'd like to think that I'll soon be able to add my stories to that collection.

I'd also like to think that this was a typical night, but I'd probably be kidding myself.

Summary: good night with an unusual flow of patients, wherein we didn't get busy until one AM.

First, one of my patients set a new record tonight. She was a non-critical-care medical patient, there for less than an hour before she had a bed upstairs. Amazing.

Then, we added evidence to support the "Whodunit" theory of shootings. The answer tonight was "Some dude."

It's amazing to see how differently the night flows according to which docs are there. The guys we had tonight are sort of the old hands - the kind who have enough experience that they don't work up every out-of-place sneeze or weird eyeball twitch. They're good at saying the professional equivalent of "Shit happens," and at enforcing rules about dispensing narcotics. And at the teamwork thing. Love it. How many other doctors know you by name?

Let's see, what else... Now that I'm off orientation, I do miss getting pulled to do the good traumas. Apparently I missed an interesting one involving a motorcycle vs. guard rail, and the guard rail won. As in, arm pulseless and broken in nine places, spleen/kidney/liver bleeds, crushed pelvis, oh, and an evulsion of a hip wherein you could see the bones and tendons and everything. Not good.

Oh, and the one that I inherited. Want to talk about SNAFU? Situation normal, then some rural out-of-state EMS folks f'd it up big time. We have this little test we always try to do when you have a patient who isn't acting in their right mind. It's quick and easy, and there are probably millions of people who do it to themselves multiple times every day.

We like to call it, checking a blood sugar.

But, instead of trying that first, somebody thought it would be good to attempt to intubate a breathing but unresponsive patient, then needle decompress one side when they didn't get good breath sounds, then not sedate the patient and have him rip out the needle. And probably extubate himself. When all it took to fix him was a little injection of the medical equivalent of Karo syrup in his veins.

Granted, he did need to sleep it off, and IV fluids certainly expedite that process, but ultimately, not the easiest way to accomplish that.

I also went through a few nursing home patients, all into the same room, all there for about two hours, who came and went right straight back. Thank heavens. I hate fighting with contractures.

To top the morning off, we got a rather sickly medical patient at about 0600. We were managing the symptoms as usual, which in this case meant intubating and treating crazy-high blood pressures, and then we saw the CT scan.

I could never be a radiologist who reads those things. I have a hard enough time as it is being objective, detatched, and professional when I chart sometimes. I can't imagine being completely academic and nonchalant about some of these things. I have too much of a love of adjectives for that.

Fortunately, we didn't have to wait for the read to know how bad it was. I'll never get that picture out of my head. Huge area of bleeding in the brain, enough to shift the midline of the brain 2cm. That's almost an inch. We call this sort of shift a deviation, and they usually seem to be measured in milimeters, not centimeters. In a tight, rigid cavity like the brain, you don't have a lot of room for error, hence the occurrence of concussions and the like. So when your brain is squished a whole inch to the side because of all the blood gushing into your brain, it's not a good thing.

Dramatic image, and I'm sure the patient's course of care will be similarly dramatic. And probably tragic.

It was a chicken-or-the-egg sort of debate. Did she wake up, fall, hit her head, and cause this? Or did she wake up with the worse headache of her life, try to stand up, and fall because she was bleeding out in her brain? But, much like the original debate, it doesn't matter what came first - the outcome is the same.

So, another night down. Baby-steps of progress. Toward more independence. And most immediately, toward a good night's sleep.

This morning when I left the hospital, we were ensconced in fog. I'm not great at estimating visibility distance, but it had to be fifty yards or less. I couldn't even see the hills on the back side of the hospital. There certainly are advantages to being right on the river - primarily the gorgeous view and easy helicopter access. The legendary fog, particularly here in east TN, is the main disadvantage.

This morning, it emphasized the sense of isolation regarding the hospital that seems to arise at random times.

Such monumental things are housed in one tall set of brick buildings. Looking from the outside, you'd never know.

That's when it amazes me most, I think - looking from the outside.

From our church on the other bank of the river, a few curves back, we have a great view of the hospital through the sanctuary windows. Sometimes this juxtaposition is frustrating, because it feels like I can't get away, but other times I can't help but think that so few people in the room have any idea of what goes on there. The great extremes, hope and despair, and how hard we work to swing between them, to battle and struggle and then walk back out into the morning and drive away.

The fog this morning was like another wall, almost - keeping in the nightmares, making sure they don't follow us home.

A few nights ago, I spent my first two nights solo, off orientation, taking teams of patients all by myself. They were busy nights. The first was in grey, and every single patient I had was admitted to the hospital that night. The second was in green, full of crazies and drunks and families of not-so-sick-patients who filed complaints every hour. I kept up, but it was crazy busy, much like the tail end of a full moon. And what did I learn? I suck at female catheters, the type of drunk you are determines what type of patient you are,it makes a huge difference when the FlowCo (charge nurse) brings a big bag of candy,  and I definitely need to rethink what kind of food I bring to work. Didn't get to eat those two nights.

I did tonight, though, thanks to an evening in fast track, which is more of the urgent-care-clinic side. Lots of Flu A, lots of abscesses, and various other non-emergencies. Then I spent four hours with a handful of patients, wherein I learned that there is such thing as a dental emergency, and that it's really important to take your coumadin after having a blood clot in your lungs. Among other things.

And the beautiful part? I got to leave it there. I even had an extra wall this morning, the fog that enveloped me, kept me company on the drive home.

Waxing poetic, yes? Well, sorry. I think that by the time it makes it here, I've told the story, the thoughts, had time to lose the brilliant originals and present you with a semi-polished version

Stay tuned, though - more tales from my clipped wings/cut umbilical cord will most likely follow. Because, realistically, however much I get to leave at work, the stories come home. Ah, the stories.

Last night was my first night by myself, nobody looking over my shoulder checking every move.

It was kind of nice.

Granted, it was a busy night, and all my patients were pretty sick, since every single one got admitted. I even hit each of the three types of ICU - CVICU, SCC, and MCC. The patients seemed to come in waves, and each wave had a theme. I walked into kidney transplant hell, then a bunch of possible pulmonary emboli (blood clot in the lungs. Not good), an odd blood sugar problem and a head bleed, and I left the dayshift nurse with a couple kids with the flu.

Definitely a long night... I only got to pee once, no lunch break, and I walked about four and a half miles. Time passed slowly for a while, then after midnight, sped up.

No crazy stories, no moral objections, no major screw-ups. Some of the orders on one of my patients went MIA between the ER and the unit, but once I found out at 6:30, I didn't have the energy to worry about it.

I'll elaborate more later. For now, I need to go to bed, to be ready for more.

When we go in to work, in order to walk by our time clock without backtracking, we have to walk through the ER lobby.

When you walk through that lobby and see a lot of people in it, you know you're going to be busy.

Such was last night. And before we could even lament the injustice of a full lobby, a full overflow area, and a full hospital, we got to work. I "floated," which means picking up random tasks and helping out whoever's busy. Then a trauma, who we took to the operating room for some fancy fixing of a smashed tibia/fibula. No, no massive amounts of blood, thank heavens, just a couple big gashes and lots of little pieces of bone.

Then I picked up a zone at midnight, and that's when I immediately felt the effects of the sheer volume of people. Earlier, the hospital was full. No rooms. As the discharges slowly went through and vacant rooms were cleaned, we slowly cleared out the patients that were to be admitted. And made space for the patients who had been waiting in the lobby for forever. Not a short list of people.

The amazing thing was that a fair number of the people really did need attention. Granted, a lot just needed stitches, or a few bags of IV fluids, but when you've got a straightforward problem like that and have to wait six hours for a fix, you're not going to be happy.
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Sigh. Not so sure if I'm enough of a smooth-talker for this.

I do, however, have an important piece of advice.

Keep in mind that we in the medical field like numbers and measurements. We like to know them, exactly. All of them. So much so that we write them down. Often. Our computers even track a lot of it for us. So when you say, "I've been here for ten hours" and our timer says four and a half, you're probably not going to win.

All I can do for the next few days is hope and pray that it's more calm. And empty. For us and the floor.

I wish I could process these experiences faster. It all happens so fast, especially when it comes to trauma, and each patient is a new and different storyline.

Saturday night was incredibly busy, filled with trauma after trauma, back to back.

Would you believe that last night was worse? A Sunday night, of all nights. But it was worse.

We have four trauma bays.

When we have more trauma patients than we have bays, and they're unstable, or intubated, or both, we just double-park them in the bays. They're wide enough that you can park two patients against opposite sides, complete with ventilators, and still have an eighteen inch corridor in the middle.

How did I learn this? Well, we did it last night. I think at one point we had six intubated patients.

I wish I could list the situations in brief, and that could convey everything. They become such long nights that things start to blend together, and you start to forget.

But there are a few things about tonight that I don't think I will.

First patient of the night - three year old, blonde angel, tiny, just a face in a sea of blankets, intubated after a no-helmet bicycle accident. She was pretty sick but had a pretty good prognosis. My first really sick little one, so it was a little scary, a lot sad. But, again, good prognosis.

She and my double-parked patients were the least sick ones I had all night.

After her, I played the sedation game, tweaking drugs to control vital signs and movement. Fortunately, the patient was relatively stable, and responded appropriately to sedation. So it was a really good learning experience.

Meanwhile, however, oh, excitement.

I'll give you the lesson of the rest of the night: NO MOTORCYCLES.

Or at least don't do anything stupid on them, don't ride without protective gear, don't ride without a helmet, don't overload the weight limit of the bike, and don't run around on your motorcycle at four in the morning.

Two full alerts arrive while we already have three trauma patients. Hence the double-park.

First, the driver, big guy, above-the-knee traumatic amputation, open arm fractures, possible bleeding in the belly. That bleeding didn't matter, though, because all his blood was going out the arm and the stump. He became a massive transfusion protocol, where somebody runs over to bloodbank every few minutes to fetch another four-pack of blood (PRBCs), and they thaw units of fresh frozen plasma as fast as they can.

Ultimatley, this goes back to the ABCs thing. Circulation is the key - when you don't have enough volume, circulation sucks (some physics property, related to pressure), so if you're losing volume quickly, you need to replace that volume. Hence, mass transfusions. We use this awesome machine called the Level 1 Infuser that can infuse a unit of blood into a high-flow line in thirty to forty-five seconds.

For this motorcycle guy, he got 56 units of blood. That's a shitload of blood. Each unit has 250 - 265 mL in it.

When they finally rolled him up to the OR, they left a trail of blood drips behind, all the way to the elevator.

At the same time he came in, the passenger riding behind him came in, a few slightly messy external injuries, bad vital signs, who turned out to have completely obliterated her spleen and a kidney. She got blood, too, but not as much, because she was rushed to surgery.

Enough yet?

Deep breath.

We ate, we spent three hours stocking the trauma bays and the main ER, and then got a heads-up that we would be getting two patients flown in.

Want to talk about deja-vu? First one called, my patient, motorcycle accident, below-the-knee traumatic amputation, lots of blood lost at the scene, etc, etc. When he came, there was no bleeding, and shortly thereafter, no pulse. Some CPR, some drugs, and starting to give blood, and he came back. Massive transfusion number two for the evening. So we went to CT scan, and I took my new buddy, the Level 1. We had a runner, who literally ran back and forth, fetching blood for me to slam into this guy.

While the scanner is running, I'm standing there, wearing a water- and blood-proof gown and a lead apron over it, running this machine.

Spike a bag of blood, peel a sticker, hang, close compartment. Flip pressure switch on, open tubing, visualize flow through the tube. Spike second bag of blood on separate extension, peel a sticker, hang, close compartment. Flip off first pressure switch, close tubing. Turn on second pressure switch, open tubing. Remove old bag, spike new bag, peel, hang, close. Flip, close, flip, on. Toss, spike, peel, hang, close. Flip, close, flip, on.

For 54 units of blood.

Somewhere in there, his stump started pouring blood.

I'd been doing my thing, in the zone, and heard a splashing noise. I looked up and realized the problem. I don't think I realized what I said until afterward, but it was definitely a gut reaction to shout, "Oh, shit. Guys, he's bleeding."

Yeah.

Ended up running him to the operating room, too.

Can you see where the adrenaline comes from?

Yeah... more later, where I will muse on things like the color and smell of blood, the occurrence of "hot offloads" for Lifestar, the crazy things we can get people through, and what all the family members standing in the halls outside the ICUs must have thought when we were running and shouting, then rolling through with a seriously bloody mess.

In the meantime, please, don't do anything stupid on your motorcycle.