ER Requiem, chapter one. By Linda Allison.
The hospital lot was full of cars and people as I drove in and parked. Lit with the unforgiving orange of sodium vapor lights, everyone in the parking lot looked like terminal liver patients.
I prayed for an easy night, steady work, not a flood. I wanted managed chaos. Oh, please, dear Lord and Lady, I thought, the moon is full, and its been days since last I slept. Keep it smooth for me.
Walking into the covered ambulance bay at the back of the hospital, I looked around at the emergency only parking. I counted vehicles: four police cars parked as if a giant child had tossed them down, in the bay its self, there were three ambulances sitting with back doors gaping open like raw, toothless mouths howling into the night. The floor of each rig was littered with the debris saving lives generates.
At a glance, I could tell what had arrived in each unit. The first rigs floor, littered with yellow, purple and green boxes, could only mean a cardiac patient. Each of those boxes came with a pre-filled syringe, containing cardiac medication, in unit doses to make it idiot-proof.
The middle unit had soft restraints wadded up on the floor, and the jump seat compartment was torn open, standing empty. Somebody had arrived in leather restraints, we almost never used the leathers, but for an out of control psychiatric patient they were necessary.
The last unit had a half full basin sitting on the floor along with large-bore IV catheter covers and the wrappers for several liters of normal saline. A bloody NG tube, a tube that is passed through the nose and into the stomach for evacuation, was discarded and lay crimped, dangling from the inside of the ambulance like a long, fat, blood bloated leech escaping from the light. If not for the smell, I could have mistaken the mess for a drug overdose. But that harsh, coppery, new penny smell of partially digested blood stained the night air screaming, GI bleed! as did the glistening, slippery red contents of the wash basin. I pulled a pillowcase from one of the rigs cubbies and tossed it over the basin. Sometimes the voice of illness should be shrouded, silenced. This much I could do in passing.
I stopped for a minute and looked up, whispering aloud to the patron god and goddess of ERs, I guess that would be no to a quiet night?
Three ambulances may not seem like much compared to ER on TV. For this tiny, rural, eight-bed ER, three ambulances meant two units borrowed from other cities. Four police cruisers meant the entire city was left unprotected. I knew it was my fault. I had come prepared for an easy night, with a good book and sewing project in my bag. The only way to avoid the wrath of the ER Goddess is to stick a book in my bag on my day off and forget its there. That way, no bad luck can be drawn by my actions on work days.
Every ER nurse has a quirk or superstition. No one ever says the word quiet out loud, as in sure is a quiet night. Just thinking it is enough to open the flood gates and fill all our beds with constipation, diarrhea and F.D.G.B. For laymen thats fall down, go boom, now Ive got a broken hip, have to have surgery that Im too damn old to survive, so Ill die in the ICU. Dont say the Q word where a nurse can hear you. You might get hurt.
I hovered outside the ER door, like a cliff diver terrified of heights. It is not really the fall, the water, the swim or the climb; its that first step off the cliff. My personal path to the edge of the ER cliff is well worn after twenty years. It comforts me not at all to know that once I leap, I will eventually be in the water. I love water and swim well. So even when I should be in over my head, I tread water just fine. But my fear of stepping off that damn cliff makes me want to vomit on the way to work every single night.
Why do I work in the ER if it makes me vomit? I work for the adrenalin spike. I was born in a fog and have wandered through my life thinking foggy thoughts. I wondered why I always felt so stupid. A diagnosis of ADD at age thirty helped make sense of things. This is why that tiny adrenaline spike all us ER junkies get when a really sick one rolls through the door is so amazing. It is natures version of Ritalin.
For some adrenalin junkies its the high they feel; for me, its the clarity. I love it when the fog rolls back and I can kick it into warp speed. I can think fast and clearly; I can act in anticipation of the MDs orders and be right. Nothing escapes me, not the looks on the families faces, the byplay among staff, whether the doctor is comfortable with the situation or whose toes feel stepped on. These and other observations run through my mind as I let my hands leap into practiced patterns. The newbie docs can be nudged in the correct direction with verbal cues so subtle I know they dont realize that a nurse is directing them. I am not a good floor nurse, not enough adrenalin to clear up the brain fog. But in ICU or the ER, I can rock, baby.
Unfortunately, like that agoraphobic cliff diver, I need my adrenalin spike to feel comfortable in the ER, so I self medicate. I drink massive amounts of caffeine. It is my drug of choice. Espresso, yes, give me a 911 latte, please! Thats two double shots of espresso and a splash of steamed milk. If my hair is standing on end, I had my 911.
With a sigh of resignation, I walked past the chicken-wire reinforced, bullet proof windows to the heavy double doors that open off the ambulance bay into the ER. With hesitant fingers, I touch the electronic key pad and punch the numbers 51 * 50 into the panel by the door. The heavy double doors give a venomous hiss as they swing open.
The code is a bit of dark humor: 51-50 is the penal code that refers to a 72-hour involuntary hold, placed on a person determined to be a danger to self or others. In other words 51-50 is the code for a nutcase. And we all understand that to voluntarily enter the ER, we are all nuts.
Mark, a long lanky balding RN with a bad back, sat in the nurses station. He was a quirky guy, he tossed pencils into the acoustic tile ceiling, and counting them gave you the story of Marks night. Hey, got your skates on? he said as he wound up his collection of moving Happy Meal Toys, and sent them clanking across the desk. I swore, once again, I was going to start giving those noisy damn things away to kids.
Then there was Aaron, The Prince of Darkness. For him, there seemed to be nothing worse than being a smart, bitterly seasoned, angry, ex-military, male, licensed vocational nurse finding himself forced to work with a civilian female RN. Though he seemed not to mind working with me so much, I think between us we had anything that happened covered.
Aaron had been an ER medic in the military, used to doing everything. Here in the civilian world, his scope of practice was narrower than mine, and he had to get me to do the things that the law said he couldnt. I never hesitated or questioned his judgment.
There he stood, in the lounge, making the first of his many pots of coffee, in all his I am fed up with this shit, get out of my face, you are seriously mistaken if you think I give a damn glory.
Hey he greeted me. A real mouthful for the prince, I think he likes me. As Aaron walked out of the break room he began running off non-ER people, hit the road to the Paramedics, dont you have blood to lose? to the lab people. I had to smother my snicker; he said things that could only think. His nightly ritual was to stalk out to the ambulance bays, smoke a cigarette and have that first cup of coffee. If no one was looking hed pet the hospitals stray cat, open the can of food he kept in his jacket and watch Sutter the cat eat. A man who likes animals cant be all bad.
My working style involves finding ways to get along with prickly personalities. Maybe that worked, or, maybe it was because under his studied, sarcastic, moody, cold exterior, he had feelings. Aaron knew he was good at his job, and he knew I liked working with him. Despite how negative he could be, I knew the prince had my back, regardless of what rolled in.
Tolerance for individuality was never in vogue. And most definitely not the fashion for jaded, dispassionate, disconnected, burned out, bitchy, overworked ER nurses. Thats why it worked so well for me; no one knew what the hell I was doing.
I have huge flaws, I dislike demented patients. Dementia robs people of their ability to appreciate the fine vintage of the milk of human kindness that I pour out upon them.
Posy restraint vests, wrist restraints coupled with bed alarms, sedatives and Q fifteen minute bed checks add to an already intolerable workload. The words that no dementia patient ever forgets, Help and Nurse, grate on my teeth like a missed bit of tin foil in that last bite of brownie when it hits a filling.
Once in the ER there is no turning back. Slipping over to the nurses station I pulled down the schedule book to check the schedule, there was still the chance that I was not scheduled to work. No such luck, so I got tools of my trade from my bag, stethoscope, pen and coffee cup. I knew Aaron was around; his signature coffee was fresh, black, and strong with a skim of oil on it. It was strong enough to soothe even me.
Mark, going off shift, started his lightening report, labs, what needed to be done, what was already done. We sent the bleeder to OR, then hell be admitted to ICU, the MI went up to ICU about ten ago, our portable monitor isnt back yet, and you have a 51-50 in four point leather restraints, a leather cuff on each limb, in 3, waiting for Mobile Crisis, they say they are about an hour out. Damn I said, I was hopeful that the ER goddess would give us a bed in a psychiatric ward, any ward really, as long as it was some place that was not my ER. Mark handed me the 10 minute check sheet that the law requires for a patient in leather restraints.
Mark had barely finished speaking; Aaron was already making rounds on the patients, checking vital signs and IVs. The triage bell rang and the entire evening shift scrambled to get out the back door, like cock roaches scrambling away from the light, without touching another god damn patient. Thanks for all the support Mark I called to rapidly retreating backs.
I walked into the triage hole and opened the door to the waiting room. Leaning weakly in the doorway supported by a friend was an extremely waxen looking young Hispanic male, his left hand cradling the bloody ruin of his right. His shoulders were hunched forward, his whole body curled around his injury, his sweaty face still showing shock at the insult to his hand. Looks like you need to lie down I said as adrenalin hit me like a truck. I moved him into the trauma bay; and sent his friend to start the registration process, but also to get him away from the bedside.
My brain kicked it; Aaron was suddenly there, cutting away the ruined leather work glove from the injured hand. Almost done here partner said Aaron as he delicately trimmed the ruined leather away from mangled flesh. I called for the doc, stat x-rays, and labs, then got the line cart. The Prince got the injury compressed with gauze pads lifting it up in the air to help with the direct pressure bleeding control. I got a large bore IV in place and filled a big syringe with blood. The lab tech took my syringe and filled several blood tubes, including the all important red top, for type and cross match for a blood transfusion.
Hey I said, "are you allergic to anything? Can you tell me what happened? my rapid fire interrogation came in short staccato bursts. I had started asking questions as I walked him in and seated him.
His name was Manny, he was an eighteen year old teamster, and about forty minutes ago a fork lift had dropped a wooden pallet on his hand. The hand was trashed, all of his fingers were partially amputated, the bones snapped and protruding from the flesh, each finger hanging by shredded tissue. His whole hand had been de-gloved of skin; making it look like some bizarre, disarticulated, mound of raw meat, not quite human.
Dr. Roberts, crisp and sharp as always arrived and snapped orders: Run the IV wide open, lets get some morphine on board, but keep his systolic above 90. Morphine, lots of morphine and antibiotics, can you get me some lidocain with Epi please? Oh and lets update his tetanus, and draw a clot for type and cross.
With the sudden influx of Saline, Mannys mangled hand spewed blood, like a high pressure hose gone wild, the thin stream of blood whipped around, spattering the ceiling, walls, and floor. Blood dripped in long, heavy, crimson bullets, from the ceiling tiles and ran, still warm, and sticky, down my back, as I grabbed the spurting tissue trying to help Aaron stem the flood.
Dr. Roberts injected the hand with local anesthetic paired with epinephrine, a powerful vasoconstrictor that would make all the blood vessels in the area of injection constrict, slowing the bleeding. Dr. Roberts made a few ligatures with thick black silk and the bleeding was blocked. He didnt waste time suturing anything but the bleeders. The Prince got moist dressings in place and elevated the hand. Our orthopedic hand specialist was already on the way as was the OR crew. Manny was headed for pins, plates, screws and skin grafts. But for right now, he was stable.
Ruth the house supervisor gave me a short break so I could change out of my bloody clothes; I had spare scrubs in my locker. I washed the blood out of my hair, and wished for a clean bra.
I started rounds, checking into rooms, seeing all the patients in the ER. One little four year old with huge brown eyes and silky brown hair caught my heart. Her tummy hurt and she had been vomiting for about twelve hours. She needed an IV for her CT scan. A CT or a computerized tomography scan was considered the least risky way to diagnose appendicitis without actually opening the belly. The big machine could display her midsection in slices so that her internal structures could be viewed.
I greeted her with a cheery Hola, ¿cómo sientes?, and was relieved to find that both she and her parents spoke more English than I did Spanish. Wheeling the IV cart to the door, I got out my supplies and turned to patient and her family.
The doctor thinks that you Miran might have appendicitis I said touching her right side very gently, thats probably why your side hurts enough to make you throw up.
Now, Im going to slip a little soft tube into your arm so we can give you medicine to make you feel better. I opened an IV catheter and pulled the cannula off the needle. Handing it to her I said Im not going to leave a needle in your arm, Im going to leave one of these, see? But it kind of hurts while I do it, but Ill go really fast then itll be all done. Can I do it now or do you want your mom to hold your hand? I tried to never say anything that would l let a child say no. But I did try to give choices.
As I set up my IV starting supplies I asked do you know what you are going to be for Halloween? I let her tell me about her fairy princess costume as her mother held her hand. She was great, and I got my IV in very quickly. I pulled a pink Barbie Band-Aid from my pocket and put it on over the IV dressing. And I handed her a pony sticker. I blew a rubber glove up into a rooster like balloon and then I taxed my drawing skills to the max putting a face on it. Miran gave me a charming little grin.
I was standing in ER bay 5 giving discharge instructions to a parent, when I looked up to see Miran as she rode by on her way to Radiology. I called to her to be sure to get stickers from X-ray; because they had better ones than we did. She waved as her gurney and her parents disappeared with her through the heavy doors to X-ray.
I finished my instructions and escorted parent and patient to the door. The desk phone began ringing; Ruth our house supervisor picked it up. I was looking at her face as she listened. Ruth long ago had taught me to how to be a nurse and I respected her. But now, as I saw the color leave her face and her eyes get that oh my GOD look, I knew something bad was happening. She scrambled for the door and yelled for Dr. Roberts. Both of them blasted through the doors toward X-ray. I pulled the empty gurney out of bay five and ran for the Pediatric crash cart. Aaron came to my exclamation of shit! a nursing term for everything is going to hell right now.
The doors to the back hall exploded inward, Mirans gurney came flying in. I raced to help get the gurney stopped and a blood pressure cuff, oxygen saturation monitor and heart monitor in place. Aaron got the oxygen on her. She was parchment pale, lips slightly blue, and way too still on the gurney, her chest stuttering with her labored breathing. As I placed the monitors, she went into an agonal respiratory pattern, followed very quickly by respiratory arrest.
We could take only seconds to start treatments, so we had to use our best assumption of what was wrong then treat the symptoms. I shot epinephrine into her upper arm and massaged the site, not for pain relief but for rapid profusion; we thought it might be anaphylaxis due to the IV contrast used in CT. Benadryl, a powerful anti-histamine was next as Dr. Roberts placed an Endo Tracheal tube, or a breathing tube, and called for a stat chest x-ray. Aaron placed a second IV for medications, as her father crumpled to the floor; I had no time for him. I stepped over him as I moved around the bed.
Back up started arriving, Aaron started chest compressions as Mirans little heart fluttered and stopped. Dr. Johns the anesthesiologist arrived to manage the airway. The Respiratory Therapist took over the ambu-bag, huffing, tiny lung sized breaths into our girl, RT also secured the ET tube with tape. Aaron counted quietly, one, one thousand, two, one thousand, three, one thousand.
We fought on, sweat dripping from our faces, Martin; another military nurse stepped in to relive Aaron. Ruth put the parents in chairs; they refused to leave their child. I understood that, I wouldnt leave if she had been mine. I sang out my song, Epis in pacing pads in place, pacing now, no capture, no pulse. We tore open those green and purple cardiac boxes and threw all the trash on the floor in our fight for this child.
Quietly Martin resumed Aarons count one, one thousand, two, one thousand. Dr. Rogers and I attempted to float a Trans thoracic pace maker into place, a stop gap measure that is rarely done, but Marins cardiac tissue did not respond to the electrical impulse of the pacemaker. Again and again we checked our connections, oxygen, fluids, and Medication drips. But Marin remained unresponsive. She was a tiny perfect porcelain child among the wires and tubes. And I was frightened for her. I have seen lots of ugly things, but I have never seen a child go down so fast and hard. This was my nightmare made flesh and blood.
Our pediatric critical care intensivest arrived, because he was also my daughters pediatrician I knew him well and I was grateful to see him. We gave him our status and what had already been done as we labored, sweating and praying to revive this little girl. We had run out of magic. The pediatric intensivest had to step in, It's time to stop guys, this is over he said. He had to order us to stop; we had been working for ninety minutes, and that, is way too long. We were done, devastated by the wrong outcome for a simple diagnosis of belly pain. None of us understood what went wrong, unless this was a fatal reaction to our CT scan IV contrast. It didnt make sense.
There could be no break for us to compose ourselves; ours was a very small hospital with an even smaller nightshift ER staff. We had no choice but to continue. There was a never-ending flood of other patients waiting for our attention. It was so busy I had no time to compose myself, yet the night dragged on, agonizing in its slowness.
At least twenty frantic relatives arrived in the ER. One young woman rushed toward me, I opened my arms to her, offering comfort. But she caught me with a left to the jaw, staggering me, and slamming me into the wall with the force of her fist and her rage, screaming that I needed to bring her niece back right now. The breath whooshed out of me as I hit the wall behind me, in my heart I felt as if I deserved that blow. I dont remember who wrestled her off me; I simply continued to work, blindly.
I went from bedside to bedside, from task to task, unable to stop the tears. I apologized over and over; because, I was leaking and just couldnt stop. There was no respite from the flood of the sick and injured that poured into our ER that night.
I have waded into blood that seeped into my shoes, walked calmly beside a gurney toward the OR, my gloved hands the only thing holding sixty feet of slick, sliver, gleaming intestines in place. I have used my breath to give life back to those silenced by injury. I have slipped tubes into the tiny veins of newborns, when no one else could. Tonight, I smashed into the reality of my work; I wandered away from that bedside, devastated by the loss of a life.
At the shifts end, I walked out of the ER on feet of lead. Aaron and I stepped into the now empty, parking lot, squinting into the light of the cool, early morning. With a tentative touch on my shoulder; the prince gave me the briefest of hugs. You did good last night, he said, high praise indeed from the Prince of Darkness.
Each of us, surround by our own demons, moved, mute and alone into the shattered colors of the silent dawn.
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