Sunday, February 14, 2010

PUSH!

Finally when the baby's head was crowning, just after midnight, I heard the irritating sound of the downstairs doorbell. Knowing that Jason (who was actually the first nurse on call) was not downstairs and that he hadn't radioed me to expect anyone--the midwifes and I decided whomever it was--was going to wait.

It seems that often in the crux of situations; when you are taping a baby's IV in place, suturing in a sterile field, or doing a pelvic exam, the phone or doorbell will ring. Most of the time, it is a relative just calling to see how so and so is doing. When you're on call at night in the clinic you have to be the janitor, the nurse, the doctor, the mental health counselor, the medevac coordinator, and secretary-- so these interruptions can be aggravating to say the least.

So as the PING PING PING sound of the doorbell chimed over our shouts of "PUSH!! KEEP PUSHING!! YOU'RE ALMOST THERE" we didn't think much of ignoring it.

I saw a contraction starting to wane and decided I should run downstairs and just make sure everything was copacetic. I got down there and no one was in the foyer, I wasn't surprised as in other health centers kids often would hit the buzzer and run off at night  This doorbell needed only be touched once and it would ring until someone unlocked the front office and manually turned it off. 

I unlocked the office and turned off the bell. The shouts on the other side of the door startled me to a new level of adrenaline. I found two men banging on the door and shouting at the window which separated us. One had a fat lip and a wild look on his sweaty face. I jumped back initially and then went into the corridor which lead upstairs. No way in hell was I opening the door to these two menacing creatures who were obviously pissed about something and more than likely pissed drunk. They both looked like the usual Friday Night Crowd that we stitch up, either when their friends drag them in or when they start to sober up and feel the throb of the cut. I pointed upstairs and yelled back through the glass that I was dealing with a birth, turned and ran up the stairs. Dammed if I was going to miss something happy and beautiful happening at the health centre for once.

As I took the stairs two at a time I radioed Jason , "Call the RCMP, there are a couple of drunks banging on the entrance to the health centre and there is no way I am letting them in down there alone. You better come down here to see what's up".

"I'm on my way".

Jason was  a 1 minute ride from the health centre and he had confessed to an America's Next Top Model addiction-so I knew he wasn't in bed yet.  I got back into the birthing room just in time to see another contraction starting and again the baby's head peeking out then deciding not to stick around, ducking back behind the skin of his mother. 

The doorbell starting ringing again and the midwives looked at me for the update. I told them about the two guys, that Jason was calling the RCMP, and that he was on his way down.

My radio cut into the silence between pushes,

"Get down here now."

I pulled myself away from the evenings climax and ran down the hall. Took the stairs as fast as I could and opened the door to the main floor. There I saw the foyer door propped open, a stain of blood  more than a foot in diameter marked the spot. Bloody smears covered the hand railings and buzzer, the floor showed footprints of blood leading to the emergency room. Yelling came from the room and my adrenal glands were pinched into action once more, with the main thought in my head a clear "ohhh shit!!!"

Jason stood over a man, naked but for his underwear and caked in dried blood. His clothes lay in a saturated heap on the floor. Jason looked as though he'd just had a walk through in a meat processing plant. The man lay with his back toward the door,  the white gauze Jason was holding against a hole in the mans back was quickly becoming red like the rest of the bed.  I couldn't tell if Jason was putting pressure on the wound or holding the guy down as the patient yelled and struggled beneath him.

"I WANT A DRINK OF WATER"  he yelled over and over.

"Call Doctor Friedman, tell him Bobby's been stabbed, get O2 on this guy and try to get a set of vitals, he needs 2 large IV's going NOW".

"Friedman, we need you in here now. Bobby D has been stabbed in back, he's bleeding profusely, combative. No we haven't got vitals on him yet, it's just the two of us and Jason is trying to keep pressure on the wound".

Friedman showed a few mintues later while I was in the middle of trying to keep Bobby still long enough to get an IV in him, he kicked and yelled about wanting water. No matter how much we'd give him to sip he wouldn't settle. Plus we could be sure this guy would be going to the O.R and so the less in his stomach the better. Bobby flailed around grabbing angrily at anything he could. In no time my arms were covered in bloodly hand prints.

"That bitch did this to me--she punched my face and when I said I was leaving, she stabbed me in the back! That fucking bitch! Hey leave me alone! Stop pressing on my back so hard! It fucking hurts. FUCK OFF".

"Bobby. Calm the fuck down! We are trying to help you. If you don't let us press on your stab wound you will bleed to death." Friedman yelled to his face.

"Get me some fucking WATER".

"Bobby! Look at me---look into my eyes--NO--LOOK INTO MY EYES! You are FUCKING BLEEDING TO DEATH! You need to let us help you, now calm the fuck down. We'll get you some water as soon as we get an IV going and get your blood pressure back up okay?"

I hadn't ever heard a doctor drop and F-Bomb on a patient before, but if there ever was an appropriate time, this was it. Bobby was yelling. Jason was yelling. Friedman was yelling. I was yelling. For a minute it felt like we were locked in a power struggle in which there were only losers. This guy could tear a bleeder that was barely staying together, or maybe he was bleeding into his belly as much as he was onto the floor. His bowel contents could be seeping through a hole into his peritoneal cavity, his lung could be filling with blood, or air, or both.

Jason took over the IV attempts after my first one was pulled out by Booby's thrashing, the dripping catheter being dragged along the floor with the sweeping arc of his arm. I was facing him now, hunched over as I pressed on his right flank, feeling his heartbeat under my fingers.

Friedman came to the other side of the bed and I pulled off the soaked gauze to take a look at what we were dealing with here. Down through the thin layer of fat and fascia a shiny encapsulated mass reflected the ER lights.

"Looks like his kidney there..." I remarked.

The dark red glistening sponge of liver also appeared in our field of vision--"and there's his liver" said Friedman, "put pressure back on".

Friedman went to the phone and called Aparna, the resident, and Sue the X-ray tech. They both arrived in short order despite the hour.

We were a montley crew to say the least, Sue in her "I Like to Show My Dog" cartoon shirt and sweat pants, Aparna in wool sweater and sandals, me in my running pants and blood soaked scrub top. Jason in dark bloody jeans, hikers and a scrub top, Friedman in a holey t-shirt and kakis.

Enter Bobbys extremely intoxicated parents. Neither of them looking like they'd been sober, or in a clean change of clothes for a week.  His mother weaving unsteadily to the only unoccupied space at the bedside. His father staring glassy eyed at nothing in particular was riveted in the middle of the room. Aparna relieved me of my pressure duty as my back and arms began to cramp from the sustained position and effort required to do such a task on an uncooperative person.

"Let 'im sit up if he wants, he can shhht up if he wants" his mother slurred at me, her eyes not focusing on anything in particular, just in my general direction. I really didn't have the patience for this right now. I escorted them to the door of the trauma bay to wait and look on from there.

Finally, some vital signs on the monitor. Two lines running wide open. With the x-ray machine warmed up we maneuvered him into the room and were able to get him to sit up, supported by the bed, for a dodgy chest x-ray. We knew that having him stand was not only a danger but an impossibility at that time, thus leaving anything that would show on an abdominal x-ray useless.

From what we could tell no major lung damage, but soft tissue or bowel injury was unknown to us. His belly did seem to begin to swell as the minutes ticked on.

During the lull with x-rays I was able to take a few breaths and organize my thoughts. I had taken a bag of blood from the lab and was trying to remember how to hang it. I had given blood dozens of times in the south, but it had been a long time. I knew if I made any errors the blood would be useless. I also remembered that there was a technique to priming the bag and tubing that contained a filter for the blood to pass through. If I rigged it wrong the saline would back flow out into the bad of blood and it'd have to be chucked. Something about gravity, clamping off certain lines....shit!!! The thick red liquid flowed down into the chamber, through the filter and down the tube. It wasn't running as it should. The saline should be dripping in the chamber as well-diluting the blood. Now the droplets spattered on the floor next to Bobby's own splatter pattern.

"Shit". I clamped the line off with a bloody thumb.

"Don't run it if you don't know what you're doing!" Freidman was watching me try to figure it out. No one knew how. Having blood up north was such a rare occurrence none of us could do it with any confidence. I was frustrated and angry with myself, this was a simple task and I needed to be able to perform it now more than ever.

I stood over the garbage can, sticky IV line in one hand, saline bag in the other I took some deep breaths. I closed my eyes. Just for a second. And then, with just a little more coaxing of the clamps and a slight modification to the height difference the saline flowed into the chamber, diluting the blood as needed. The two solutions swirled together and flowed through the filter. Becoming one brightly colored infusion as I let dribble out the few cc's of undiluted blood.

"Now I've got it. Ha! It just took me a few minutes."

Bobby returned into the x-ray department and I felt a small serving of pride cover the insecurity I'd been feeling after the failing to secure the I.V's and my initial botched priming of the solution. The blood was running in. A conservative estimate might be that he'd already lost over a litre since arriving at the health centre. This infusion might prove to be vital depending on how much was being lost in his ever-firming abdomen.

We were told by the people who organize medevacs that the flight crew would be 'timed out' once they returned from their last flight to Winnipeg and thus we'd be waiting until at least 6 am for a team to arrive to fly him the three hours south. Not knowing what was happening internally that delay meant a possible death sentence. He had already received our only supply of blood and there was nothing more we could do with our limited  resources.

Despite the strict aviation guidelines against pilots flying when they are 'timed out' Friedman was able to convince the powers that be that the situation was a life or limb emergency and this man needed to be transferred immediately. A quick letter drafted and faxed in the middle of the night from his office took care of the red tape. At around 3 am the flight team showed up.

The usual chaos ensued when the flight nurses arrived. In their blue flight suits, they unloaded their large bags packed full of the kind of gear one needs for any possible emergency situation. Our lines were changed over to theirs, their monitors were applied.  The dose of black humor, friendly chiding, ego overlapping, and introductions began. Through the bustle a catheter was inserted with much difficulty, another pressure dressing was applied to the wound, and an ativan was given to calm the patient down.

His vital signs remained stable and he was much more compliant now. Not necessarily a good sign, but certainly easier to deal with than he had been upon arrival.

Soon he was 'packed and stacked'. The ground transport arrived with stretcher in tow. Gingerly we lowered him, mindful of the various tubes, bags, and monitoring devices present. And off he went.

The clinic looked like a disaster had blown through it. A bloody disaster. Both stretchers had torn and stained sheets, the floor still held on to a film of blood despite Donna's quick mop job. The IV poles, the BP cuff, the O2 sat machine, counters,  garbage, side tables...everything had the same blood smeared horror-film appearance.

Jason rolled up the mat in the front hallway. Aparna busied herself scrubbing the hand rail and the buzzer with some windex and pilling paper towel. I bleached the stretchers a couple of times, washed the pillows and again mopped the trail from the emerg to the front door. The heavy metallic stench of drying blood still hung in the air.

Friedman, Aparna, Jason and I were the only ones left now. We chatted excitedly in the entrance. An informal debriefing over the way the night had unfolded. Each of us cutting the other off as we took over to tell our view of things. Friedman started doing one liners from the old television show "Emergency" yelling about ringers lactate and various code words. We all laughed and breathed sighs of relief with it all. The nervous energy and adrenaline of the night was starting to flow out of us. Soon it'd be replaced with the unavoidable adrenaline hangover of gut-and-head-ache.

"What are we supposed to do now??? Go home and sleep! What I wouldn't do for a beer right now...Jesus!" Jason shook his head and walked toward his office.

"Come look at this!!" He hollered from down the hall.

"I must have come in to grab something in the middle of it all..."

A bloody hand print covered the light switch in his office. Enough to make us all shake our heads and chuckle with laughter again.

And so.

I long hot shower later I crawled into bed knowing in a couple of hours I'd be up again for a full day of clinic.

Closed my eyes and played out many scenes from the night. I berated myself for not opening that door when I first saw them. My thin slice of the situation in that snapshot of time had been totally off. My instinct had been wrong. Just as I was thinking that I was getting some of that "spidey sense" that experienced health practitioners get.

It is frustrating to realize that sometimes your gut instinct isn't right. Scary to think that man could have bled to death in the foyer if he'd been more badly injured and if I hadn't called Jason.

But maybe that is what forms a more accurate instinct. The near misses (or the misses in some cases). That is what makes us take a step back at our assumptions and what we think we know and realize that sometimes we need to go deeper than the thin slice. Skirt around what we hope it is and look at a situation for what it is, what it could be. Unbiased. Objective.

Impossible.

Of course we are fallible.

Turns out Bobby survived. A nicked liver and kidney. A litre of blood in his belly when they got him into the OR.

I guess we all were lucky that night.


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10 comments:

PiperPreMD said...

What happened to woman in labor?!

Albinoblackbear said...

Yes, the woman in labor! She delivered a very healthy baby girl into the hands of the two highly skilled midwives attending.

I wanted some mat experience so I had asked them to call me in (on the nights when I wasn't on call) to see some deliveries. That was one of those nights.

Hence why I was already at the health center when all hell broke loose.

WordDoc said...

I did an externship in the desert southwest on the Ute Indian reservation. I was on first call to ER one night, called in to find a drunken fellow stabbed in the neck, dark venous blood flowing in sheets from his jugular. He fought, cursed, bled, and died on operating table from aspirating the liquor in his stomach. Hadn't thought of that in ages until I read your story.

Old MD Girl said...

Tell me again why you decided to go to med school again? Your old job sounds like it was awesome.

Keet said...

Whew!
I was wondering about the baby as well!

Maha said...

Wow! Just wow.

It's scary to think of the what ifs, but I'm glad that the patient was okay. And the delivery went well!

Paula said...

Remember those first aid lessons, when they told you the first thing to do was avoid getting hurt yourself? You called for help, rather than opening the door alone. I probably would have done the same.

Albinoblackbear said...

WD--I hadn't thought of this event in ages either until this weekend...I was backing up my hard drive and I saw this story buried in an old documents folder, thought I'd resurrect it.

OMDG--My old job had it's awesome moments to be sure...but I couldn't live in the Arctic full time. Whenever I would go home to work I'd want to bang my head against the wall because I had to lose all of that autonomy and keep my mouth shut when I disagreed with patient management/care.

Plus for the most part the Health Center work was walk-in type stuff and I spent a large part of my days explaining to people why I wasn't going to give them ABX for their runny nose and why I wasn't going to give them codeine for their knee pain. My nights were often seeing the babies of anxious mothers and stitching up drunks.

In 98% of the communities I worked in there were no doctors so when the really acute things were happening I mostly felt in over my head and basically prayed the medevac would arrive soon. So the cases I found most interesting were also the scariest.

Maha--Yeah, I try to not think of the what ifs. :) Knock on wood I was really lucky in the North for the most part. Some of my colleagues could tell you some real horror stories.

Paula--I hadn't thought of it that way but yes...I was a bit gun shy because of the fact that during my first contract up North I ended up in the health center alone one night stitching up a man--who I found out the next day---had just gotten out of prison for sexual assault. Thankfully that night he was so bazooed he actually passed out while I was suturing him. (Don't worry people I HAD him on a monitor and his snoring was enough for me to keep track of his resp rate).

K said...

holy crap

Nature Nerd said...

Freakin' awesome story!