An Unexpected Test--Part II

I'd get to the girl, first I wanted to make sure Maggie was stable.

Maggie was well bundled up which made a quick primary survey almost impossible. I put my hands under her jacket and tried to feel along the bony aspect of the back of her neck. I pressed down on each vertebrae while asking if she was having any pain, numbness, or tingling. She said no.

I tried to move my fingers systematically around her skull feeling for any ridges, deformities, warm tangles of blood, boggy swelling. Nothing.

I quickly checked the pulse in her wrist—strong. That was a good sign, she had a decent blood pressure and wasn’t tachycardic, which meant she wasn’t going into shock (yet) from some hidden injury that was causing blood loss.

Maggie was alert and talking to me the whole time, she said one of the girls on the hike had lost control coming down too fast from the top. Maggie lunged after her, also losing her footing and going head first down the steep and rocky terrain. Now I was getting worried about this unknown girl and felt fairly certain that Maggie had no immediate threats to life or limb (despite my woefully brief and incomplete initial survey).  I asked the 3 young girls with her to try their best to keep each other warm, to continue talking to Maggie. I asked them to send someone over to me if she suddenly became confused, nauseated, or started complaining of numbness or tingling. 

I scurried over the slippery rocks to the second cluster of people, perched on the lateral aspect of the slope. A young girl was buried under a similar assortment of raingear and jackets, crying out in pain. Two of her teenaged friends were huddled against her, shivering in their thin hoodies and track pants. Her legs were splayed awkwardly but with no visible deformity, blood spattered the rocks near her feet. Under the hood of a green raincoat I could see that her hair was thickly matted to one side of her face with blood that appeared to have come from her scalp. Her cheek was also cut, just under the eye. She opened her eyes when I asked her to and told me she’d started coming down the mountain and couldn’t slow down, she didn’t know how she’d fallen or if she’d been knocked out.  Her pupils were of equal size, they constricted when she focused on my face, she knew where she was, and who she was there with.

Again I wrestled with the tangle of clothing trying to feel her neck and scalp. She said she had no neck pain but yelped whenever I touched her head, especially near her forehead. It seemed impossible to locate the cut as all the blood had dried in the lumpy nest of hair.  I looked in her ears and under her nose for blood or clear fluid that might indicate she had fractured her skull. Dry. She didn’t have the characteristic pattern of bruising associated with basal skull fractures, the bluish tinge behind the ear or black circles referred to as ‘raccoon eyes’.

I felt her wrist, trying to locate her pulse. As I measured her heart rate, which was fast but not worrisome, she complained of pain. I was reassured though, by the lack of a sickening crunch or odd angle to the joint, something I’d come across many times in the Whistler emergency department. I put my hands under her jacket, asking her to take deep breaths while I felt her chest rise and fall. Her rib cage felt stable and she said she had no troubles breathing. Good. She had a blood pressure and no breathing issues.  I felt her belly, tested the bones of her pelvis for pain or instability. She cried out in pain when I brought my hands down her left thigh and leg. I couldn’t feel any swelling or grinding under my pressure, the leg didn’t seem shortened but it was hard to tell and I didn’t want to move her limbs unnecessarily.

Somewhere in all of this I found out that the man with them was Father Henry, the priest who had been escorting a church group up the mountain, which is a famous pilgrimage for Catholics.  Maggie was the other leader of the group, which left him running back and forth between the two huddles, with one cell phone (and sometimes two) pressed to his face. 

It was during my assessment of Tina that I too started to shiver. Suddenly the combination of wind, fog, sweaty T-shirt, and stillness left me very cold and wishing I’d brought more clothes. I pulled on my damp wool shirt and windbreaker. Once I was crouched behind Tina with my hands along side her jaw and neck to stabilize her cervical spine, I realised that if I was that cold, the girls lying on the ground were in even bigger trouble.

At this point an athletic Swiss couple, each dressed in layers of hi-tech looking gear, arrived and offered extra coats to pile on the injured hikers. The woman pressed up against Tina’s legs, the man against her right side. Tina’s two friends took up positions on the left. A tall middle aged Scotsman came up and suggested we use his large backpack as something to put underneath Tina. 

I cringed with the realization that I should have thought of that ages ago.

CAcBCDE. Catastrophic bleed. Airway/c-spine. Breathing. Circulation. Disability. Environment. 

All of this had been drilled into me again only weeks ago at the Advanced Trauma in Community course I’d taken. Environment. As in, assess complications due to environment such as cold temperatures and adjust to protect against these dangers. 

And so there we were.  All of us freezing, worried, and wondering how long it would take for the mountain rescue crews to arrive, if they were sending a helicopter, and if the helicopter would even be able to land amidst the fog and wind.  I asked one of the girls to take over c-spine for me as I went back to check on Maggie. She was well bundled up and had a similar gathering surrounding her. The tall and quick thinking Scotsman and his wife were monitoring her. This gave me peace of mind over the nagging thought that I was ignoring one of the casualties. Maggie was still alert and oriented, nothing had changed since I had first assessed her. She said she was more worried about Tina than anything else. I tried to reassure her before running back to my post: holding on to Tina’s neck.

We heard ambulance sirens in the distance which gave us hope that help was soon to arrive, hopefully with blankets at least and and possibly stretchers.

“Wait!!!” I asked Matt, the teen to my left, to grab my nearby camelback.

“I had an emergency blanket in there this morning…did I leave it in or put it in my other pack?? Ohhh…” 

And then I remembered the brief conversation I had had with myself before heading off this morning. “I am only going on a road ride and a run, I am definitely not going to need my emergency blanket or my headlamp.”

Of course.  Dammit! We really could have used that emergency blanket now.  Tina was shivering uncontrollably to the point where her teeth chattered causing her to cry in frustration, “Get me OFF this mountain!!!! Where are they??”

We tried to calm her by talking about Justin Bieber, the hot blankets that awaited her, the exciting helicopter ride she was going to have…it distracted her for short periods of time. Father Henry would threaten to start singing if Tina went quiet for too long. This proved to be an effective technique for getting her to start talking again.

By now, over an hour had gone by since I arrived on the scene.  I thought about sending the teens down with one of the hikers who was offering to help. Were they going to get hypothermia while trying to keep their friend warm? Were we only creating more casualties by keeping them with us? What was the legality of sending minors down the mountain with strangers? What if we were up here until the middle of the night? I remembered only a couple of months ago a woman being stuck on Carrantuohill until 4am waiting to be stretchered off the mountain with a broken ankle.  At least now they could get down safely in the daylight. For the time being we decided to keep them with us. 

Surely mountain rescue was going to arrive any minute.

 

Kicked in the Face

This morning we got report about a woman who was in the trauma bay waiting to be sutured by the doctor of the day. She had come in during the night, a head injury with two facial lacerations. There was alcohol on board so she had no recollection of how she had received said injuries. She denied that it was her husband that had inflicted them. He was at the bedside, in faded blue jeans and a thick black sweatshirt. When I walked by I saw that he was holding her hand through the siderails of the stretcher.

I had a brief glimpse at half of her face as I proceeded into the ICU to say good morning to my cardiac patient. What I saw momentarily jarred me. Her head looked deformed from the swelling. I didn't want to stare but it seemed her skull was double the size it ought to be. Jagged streaks of dried blood still criss-crossed her face. I heard howling coming from the room later as she was being frozen for her sutures. I tried to block the sound out.

I busied myself with my ICU patient and then went back out to the floor to bring in emergency patients.

I went into her room to start a saline lock in order to give her some I.V antibiotics. The sutures were perfectly aligned and identical. A vertical line of knots traversed her face in two places, each about 8-10cm long. Her eyes were nearly swollen shut. Her mouth looked almost like a snarl due to the swollen, abnormal position of her lips. Her nose was broken, but not displaced. Sadly, I doubt it was the first time.

I asked her how she had received the wounds to her face. She said she'd been at a party and had gotten into a fight with some people. I asked if it was fists that had cut open her face. She said, "no, their boots".

I remember the first domestic abuse patient I had as a shiny new grad working in the emergency department. She came in because she was having a hard time breathing. Her story was that she had fallen down a flight of stairs. There was a perfect imprint of a boot tread on her neck, starting to turn bluish-purple.

A boot tread.

That image haunted me for years, though time caused it to fade into the background. I had forgotten that woman until today.

I worry a little about the shell I have developed in the past 7 years. Back then, the image would have been right behind my eyelids every time I closed them for a couple of weeks. This time, I felt a pang of sadness and despair for the patient, but was able to carry on my day without much more thought.

When I scrubbed away in the shower tonight I wondered how I had gotten so callous. The irony is I devote myself to this work because I believe that health care is a way to make a positive impact on humanity. Yet somehow it seems that through the years I've lost some of mine along the way.

Interweb Machine Connection Again

Hello Blog-land.

How I have missed you so.

It has been a wonderful whirlwind, travelling from the vibrant Gatineau area to the familiar prairies of Alberta. Too short of a holiday with Tobie and too many people to see out West. I had to compromise for quality not quantity.

Now I am in my new digs in Northern BC. Staring at the ocean from my wood and brick bungalow, decorated with circa 1970's teal couches and ivory appliances.

My luggage, however, is in Nanaimo, BC.

I realized that things were not good when I was waiting for my connecting flight out of Vancouver and noticed my baggage tags were marked with the wrong last name to the wrong destination. The initial flight customer service agent threw out my bag tags and told me there was no record of my luggage in the system and that there was nothing he could do.

Um. No. Unacceptable.

I had to politely ask him to remove my bag tags from the garbage and return them to me. Thankfully a competent agent came to my rescue and actually made phone calls and tacked away on his keyboard for a while.

Apparently the bags are going to arrive this evening, fingers crossed. My first shift back in the ED wearing scrubs and heels would have been interesting.

Now I must forage for food, nap, and hope that my belongings arrive*.

A bald eagle just flew past my window. Actually. God I love this province.


*Update: Everything has arrived, intact and unmolested. The lady is pleased.

CPR Refresher

On Thursday we had to take our CPR first responder training. I was trying not to be bored out of my mind as we sat through 8 hours of "one-and-two-and-three-and-four-and" chest compressions and how to perform the Heimlich maneuver.

Interestingly though, when we pulled out the baby models for the infant CPR I felt my heart rate pick up ever so slightly and a knot tie itself in my stomach. At first I tried to step back and figure out what was happening...and then realised that it was just a little too much of a reminder seeing a lifeless looking baby in front of me. I briefly touched on the neonatal code that I was involved in last summer when I was working as an ER nurse in Canada.

It had been a very very busy day in the emergency department and we were short staffed as the connected ICU had two very heavy patients which required 1:1 nursing. Earlier a woman had walked in holding her soccer sized belly and we had directed her upstairs to the maternity ward. We hadn't paid much attention and were just happy we could tell at least one patient that they could be seen somewhere else. Just before lunch we heard the announcement on the hospital PA, "CODE BLUE...NURSERY....CODE BLUE...NURSERY".

My colleague and I were both standing in the nursing station when this announcement was made. For a split second we just looked at each other, the main thought running through my head was that I was pitying the nurses who had to deal with that situation. On the heels of that thought was the realization that as an emergency nurse I was likely responsible to respond to that code. One of the points that no one mentioned during my 4h orientation. My colleague who was in charge stood rooted to her spot with wide eyes and said, "Go".

I turned and ran up the three flights of stairs to the maternity/medicine ward. Remembering that I have only ever run once before in the hospital...years ago when a patient I had escorted to CT crashed during the scan and there was no bagger in the CT area. I got to the top of the stairs and took a moment to catch my breath and collect myself. There is nothing worse than staff who BURST onto a scene. What was that saying about taking your own pulse first?

Walking onto the floor I saw a crowd of patients, family members, and staff had gathered around the periphery of the nurses station. When I rounded the desk two of the medicine nurses pointed me to the room I was destined for.

Going in the first thing I felt was the heat. The doors were closed and this was during a very unusual hot spell--in a hospital with no air-conditioning. The warmer was also on and no windows could be opened. With 9 or so bodies in the room the air was thick and sticky. Two anesthetists were at the head of the warmer finishing up the intubation, one was already peeling off her gloves and saying, 'well you've got things under control here...' An emergency physician was standing to the side of them finishing up with inserting the umbilical line. None of the family was present in the room. The maternity nurse was getting the buretrol and IV lines going and the charge nurse was on the phone with the lab and xray department. I grabbed a pen and started writing.

Sometimes I like recording, especially when it is a patient that I know nothing about. Being the recorder allows me to go through what needs to be done (in my head) and gives me an opportunty to keep other nurses organized. Some people get a little 'chicken with their head cut off' in code settings (and I am certainly not excluding myself from this group) but I find if you say, 'hey what size catheter are you inserting?' or 'where is a second IV line going to go?' then folks seem to get on task and off the circular merry-go-round-wheel-of-stress.

This code was being run by one of our most pleasant and experienced ER docs. Even during arrests he uses the words 'please' and 'thank you', never raises his voice, and never looks ruffled. I instantly calmed down and was grateful for him and his demeanor. In fact, it was almost comical how he raised his eyebrows to me when a clearly very flustered nurse came running into the room with the syringe of broad spectrum antibiotic in hand...the door banged against the wall causing everyone to jump. It was sort of a 'hey lady, we're all cool in here! What's with the Grey's Anatomy entrance??' kind of look.

The baby was not doing well. I had finally gotten report and learned that mum had arrived with no previous prenatal care, and no physician following her pregnancy. She had a vaginal delivery a few hours ago at 32 weeks gestation. The baby was just over 2900gms and had gone into respiratory distress and then cardiac arrest.

The code blurred into the various stages I was used to in adult situations...the arrival of the lab and attempting to work around them...the x-ray technicians and the portable machine forcing us out of the room for a momentary breather...then the hurry up and wait aspect until some reason for all of this happening presents itself.

The x-ray came back showing the 'ground glass' appearance to her lungs. My role in the code had shifted to providing ventilation with our neonatal bag valve mask. Along the side of the bed with the warmer heating my already sweaty neck I counted out respirations and watched the monitor for her wildly fluctuating oxygen levels.

Now my memory shows me only slices in time from the rest of the event. I can see the surfactant bubbling around the ET tube and I can hear the gurgling hiss. I can see the flushed cheeks of the maternity nurse and the two bowls of untouched tomato soup sitting on the bedside tray. I see the rise of that tiny chest with each squeeze of my hand on the bagger. It is strange to feel that tenuous line between life and death strung between yourself and another, another very helpless individual. Where else in the world does that exist? When in our lives do we feel that responsibility and connection to another human?

I remember feeling very in the moment and calm, detached and interested from a medical point of view but not sad or upset. I remember thinking that I found the differences between being in an adult code vs a pediatric one very interesting...and I wondered if I shouldn't dismiss pediatrics for my future.

A nurse from the floor came in saying the ED was a zoo and they had phoned up to see if things were under control so I could go back downstairs. The child was as stable as she'd been for the past couple of hours so the mat staff said they could take it from there. The infant transport team was due to arrive shortly anyway so I was relieved of my duties. I headed back though the doors of the ED and picked up the first chart with orders on it;

IV ancef 2gm
dressing
Td IM

On I went into the room to find a cheerful man with a sailors lexicon who had traumatically amputated his right 2nd finger just past the knuckle while he was at work. And from there the rest of the shift swallowed me up in the usual more mundane presentations and chief complaints.

When I wrote about this event before I mentioned that I drove home and sat in my car parked in the driveway for quite some time after the shift. I looked at my feeling of detachment, I thought about how intriguing it was. Another example of professional self-preservation? I replayed in my mind how frustrating it was trying to use equipment I wasn't accustomed to and made a mental note to familiarize myself with the pumps and lines we had stashed away for peds cases.
It wasn't a good night. I talked about it at length with a friend via skype...one of the downsides of travel nursing is you don't necessarily have the people you need around you to informally debrief with.

Then the incident travelled to the back of my mind until this CPR exercise.

And so it goes, the recall. The questions that almost never get answered--the long term outcomes, if our interventions were effective, if we gave the best care possible? The images arrive in your mind and the present is abandoned for a few moments while someone talks about how many compressions per minute and someone else makes a joke about having babies in medical school. No one really wants to hear about the fact that your last code was a pediatric code so you tuck all of it away again and allow time to do its job. Moving right along..

Fly Like A Butterfly...

Last night a mother came in with her 9 year old who had just been stung by a bee.

He had had allergic reactions to stings 3 times in the past and was already showing some hives on his face, neck and arms. Very mild swelling to his eyelids was also starting to appear.

I was at triage and we were slammed but he was a priority so I whisked him into the department and poured some liquid diphenhydramine (benadryl) down his gullet before you could say "histamine response".

Mom was a nice, middle aged woman. We chatted about the risks of stings and the fact that she might want to look into an epi pen and liquid benadryl. Kid was sniffly and upset but not getting any worse. Mom told me last time he had a reaction it took 3 nurses to hold him down for the injection. I said he may not need one today depending on how the benadryl took effect (it seemed to be working).

Doc and med student saw him and he ordered an I.M injection of benadryl. I drew it up and went in the room to give it.

The child completely flipped out, running and hiding behind his mother, screaming, crying.

Mom just sits there with her hands folded in lap,

"oh Honey...the nurse is busy, let her give you the shot, remember we talked about where we will go eat after?"

Kid continues to freak out. I do not have time for this little episode...I walk away and tell mom to get him settled and I'll return with some more nurses. In the meantime I talk to the doc and see if we can give some oral ranitidine or maybe more oral benadryl...he is responding to the P.O meds so is an injection necessary? It is not going to be easy, I explain. But no, he says it will not absorb fast enough. Fine.

I come back with our male site leader and nursing student and ask them to hold with mom's help.

Mom continues to be useless at disciplining or calming child. The two other nurses are trying to hold him, I attempt to wrap him in a sheet which completely doesn't work.

Now kid is ballistic. Freaking out, screaming, kicking and punching as hard as he can. I am bent over trying to hold his hip still so I can give him the injection in the glute. In the process I get a kick to the abdomen (with shoes on, thanks) and punches/flailing arms to my upper body. My two colleagues are also getting kicked and punched by the child. Mom is the most impotent disciplinarian I have ever encountered. Her child is assaulting three health care professionals and all she's doing is saying, "oh, don't do that, stop it, come on....donnnn't...".

Finally I get the injection in after telling the kid to stop several times (and calling him a brat--I couldn't help myself). We walk out.

I was trying to mix some gentamycin up for a septecemia patient and my hands were shaking to the point I could hardly hold the vials. I have never been so furious at work in my life. Not only was I angry for being assaulted but I was also extremely upset that the mother didn't even apologise or discipline the child. Plus, the staff all just brushed the incident aside.

I was shocked at how upset I was actually. I was fighting tears over the whole thing and I couldn't figure out why I was so emotional after the event. When I had calmed down I returned to the room. Sat down and looked him in the eye. I apologised for calling him a brat. He evidently hadn't even heard me but accepted my apology anyway. He apologised for kicking and punching me. I offered, "friends?" and we shook on it.

I told him, sometimes at work people punch me, scratch me, kick me, even bite me.

"They BITE you???"

"Yes."

I went on to explain that we are nurses who are trying to do our jobs and it is very upsetting when the people we are trying to help are trying to hurt us. He said sorry again and said he wouldn't do it in the future. I walked out of the room, but have to admit, I couldn't bring myself to say what I wanted to the mother.

When I got home from my shift I took a long walk.

It was a beautiful night, just dark but still the warm air was hanging heavy. I was trying to unravel the nights events in my mind and look at my reaction to everything a little more objectively.

Why did only one co-worker ask me if I was alright?

Why did that mother not react to the way her child was acting?

Why is nursing the one job where being assaulted at work is an accepted job hazard?

I don't care that it was from a 9 year old. The whole event was unacceptable but I was unable to articulate it at the time. Or take the appropriate actions to deal with it. The "suck it up" mentality is very clear in nursing.

By the time I got home my lower back had completely seized up due to my poor body mechanics during the wrestling match avec needle. It's still very sore today despite my early morning hot yoga class in an attempt to work it out. I was in pain all day today at work but no, of course I didn't fill out any incident forms or make any complaints. Yeah, what am I going to say, "kicked and pulled by 9 year old, now suffering from lower back pain." Right.

To think about the monotonous regularity with which these events occur in the nursing profession makes me wince.

I just needed to vent a little.

Next time you see a nurse, give her hand a shake for all the sh*t we have to put up with. And then, when she sits down...give her a nice little shoulder rub (really get to those traps...).