|
|
by Judy Gilbreath, RN 530 Sherwood Lane Clyde, Tx 79510 Phone 915-893-3375, Work 915-6912400 Twas Night Shift in ER "Only three shopping days left till Christmas", harked Daryl from the front desk. "Thanks for the update, Walter Cronkite," called Jana from triage, "Does that mean I can take off and go to WalMart for a few hours?" "Walter who?," Daryl asked. "Never mind, Punk, he was before your time." "Oh one of those golden oldies ." He shot back, "Next thing I know you’ll be playing that Elvis Christmas CD again. "Don’t mess with Elvis, Boy" The ER was packed. The first two hours of her twelve hour shift had flown by. From the time the narcotic count was done, and the day shift had flown through the double doors she had been barraged at the triage desk She kicked the white rubber clog off her foot and rubbed it with her other shoe trying to massage the fallen arch for just a few seconds before the next patient came up to the triage desk. So far she had checked in a possibly broken wrist, three children varying in age from 4 days to 4 years with complaints ranging from fever to constipation. She replaced the shoe and walked to registration calling out for the next patient to be triaged. "Mr. Robinson, would you please come back up to triage and I’ll check you in" She reviewed the patients in the rack. The 4 day old had been relieved when the rectal thermometer with its ample lubricant had caused him to screw up his wrinkled face and squirt yellow mustard across the baby scales. Being a nurse with 22 years experience had it’s advantages. Jana had ducked back just in time to miss being spattered with baby poop. The baby’s mother was both relieved and shocked at what the infant had done and was sputtering apologies. Jana laughed with gusto. "Don’t worry about it mom!’ she assured her. "It happens all the time." "I promise I wont hold it against him." "Just make a note of it in the baby book." There were also five other patients who had been triaged by the previous shift but had not been seen yet due to a lack of nurses, a lack of rooms, and a general lack or urgency. There was a migraine, checked in at 1500. Two young adult patients with fever and flu like symptoms had also been there for several hours. One laceration to the thumb with a pizza cutter would require a few stitches. A man with a complaint of back pain was pacing in the ambulance bay smoking. Jana casually moved his chart back behind the febrile patients. If he could walk and smoke he could wait. An elderly gentleman seated himself before her at the triage desk. "How can I help you tonight Mr…., She glanced down at the log in front of her, Robinson? He immediately began fumbling for his wallet and shuffling through his cards. "That’s OK sir, I don’t need your insurance card. They trust me with your life but not your money. I just need to know what brought you to the ER tonight and then I’ll get your vital signs and check you in so the Doctor can see you. I have to warn you though with the holiday’s and all there may be quite a wait tonight. We have to see patients based on the severity of their illness and not by when they arrive." A well dressed and meticulously groomed woman in her late 60’s had walked up behind him and heard the last. "My husband is a heart patient and he can’t wait. He has a heart condition. I have his senior gold card right here." She started fumbling in her purse. Jana sighed and walked around the desk to wrap the automated blood pressure cuff around his arm. "I understand Ma’am We will take care of him. I promise I just wanted to warn you about the wait in case something more urgent comes in." "Are you having Chest pain tonight?" "No." " I can’t pass my water, I haven’t been able to go since before noon and I am having a backache." "But he is a Heart patient! He can’t be put off! You call his doctor and he will come right in." The woman was looking frantically for the gold card that she was sure would grant him instant service. Jana went through the long list of questions and documented the answers. She completed the vital signs noting that Mr. Robinson had a fever of 101.3 on the tympanic thermometer. From the look of his flushed face and the heat of his skin when she laid her hand on his shoulder while listening to his lungs he was probably closer to 102 degrees orally. "Have you ever had a urinary tract infection, or any problems with your prostate?" "Not that I recall. My plumbing has been pretty good. But, I’m here to tell you there’s something wrong with my waterworks today." I haven’t felt this bad since I had that heart attack she keeps going on about." Jana scanned the big board hanging on the ER wall and noted that all the rooms were still full except Trauma 1 which they held for life threatening emergencies. She called back to Jerry, "Any of these folks ready for discharge? I need a room for this gentleman." Jerry was frantically typing in orders on the computer for lab, xray and medications on patients who had been seen by the doctor. Without looking up he yelled to the walls. "We need a room! Anybody going out? He simultaneously picked up the ringing phone by his right hand and blurted out, "ER this is Jerry EMT." Two voices bounced back from the hallway to her left. "Room four is leaving as soon as his shot time is up?" called Dr. Mathis from behind the blue and gray striped curtain that marked off bed six. " Everybody else is at the mercy of lab and Xray. Who’s on in radiology tonight anyway? They are slower than death." The second voice bellowed, "No one going out or up until those prima donnas in ICU decide they are ready to take a patient. It’s damn funny when they don’t have any nurses they just close beds and refuse to take admissions. When we get swamped we are just supposed to stack them in the halls and make do." "Daryl! Don’t shoot the messenger!" Jana’s voice was sing songy and light to soften the rebuke. She couldn’t afford to upset what little staff they had.This was a never ending saga. You couldn’t send the patients upstairs when they were admitted because their weren’t enough nurses to take care of them. They stayed in the ER taking up precious space and clogging up the system so that patients could not be brought back for treatment. The ER was staffed based on the number of patients that checked in.There was no provision for how sick they were, or how many hours they would stay due to the nursing shortage elsewhere. It was a vicious cycle that it seemed only the nurses and a handful of the doctors could see. Administration appeared oblivious, and the patients didn’t want to hear excuses they just wanted to be taken care of. Middle management was so busy trying to meet their budget and running to mandatory meetings to stay on top of the latest federal regulation or penny ante policy that they were rarely seen in the patient care areas. That didn’t mean their hours weren’t counted as patient care hours. It just meant one less nurse to actually give patients care. Jana mumbled under her breathe, "I’m sorry Mr. Robinson but the nurse who is budgeted to take care of you is currently unavailable please take a number and we will call you back as soon as possible." "I am just trying to triage them I’m not offering green stamps. I have a male patient who is going to need a foley. Can we move one of the less urgent patients to the hall until their discharged. I have to get him in a room with a curtain. I can’t put a foley catheter in in the hallway. Actually I could, but I don’t think he would appreciate being the center of attention. He has a fever and urinary retention since ten o’clock this morning. I can’t let him sit out here till he bursts. So stop busting my chops and get me a room!. By the way, he is going to be yours since you are the only male type person down here tonight. I don’t want to embarrass him by assigning him to a female nurse. Oh! That’s right I don’t have another female nurse anyway. What was I thinking?" she said sarcastically as she hit herself in the forehead with her palm in mock dismay. "Bring him back," Daryl’s voice was both resigned and frustrated," Hell, I haven’t even started the paperwork on the last three, what’s one more?" Jana was already walking Mr. Robinson to the bathroom. She handed him a sterile cup and asked him to try once for a specimen before they put him in a bed. She turned back and saw that Jerry was off the phone. "Can you move bed four to the hallway and put another stretcher in there for the patient I just put in the bathroom?" "Dr. Mathis, I am putting a 68 year old male with urinary retention and fever in bed four. I’ve already told Daryl to put a catheter in and check for residual. He has a cardiac history and takes an entire Walmart sack full of medicines." I’ll have Jerry put in for routine labs. Is there anything special you want? "Is he on coumadin or dig?" "No, those are about the only two drugs he’s not taking." "Good! How high is his temp?" "101.3 tympanic but considering he may have a little wax in his ears I would give him a strong 102." "Get me two sets of blood cultures then, and water him down. A 500 cc bolus of ringers , 1000 if you think he can tolerate it without going into congestive heart failure." "We’ll start with 500 and see if he rattles, his O2 saturation is 99% and his lungs are clear right now." Jana scribbled the orders on the chart and wrote a note that she had given report to both Daryl and Dr. Mathis. It is no wonder they can’t read our writing, she thought. Speed writing was essential if you were going to record even half of what was expected and that would only be a fourth of what the attorneys would expect if you ever got involved in a law suit. Just as she swung around to check the triage camera Jerry held out the phone. "Nurse call." He bellowed as he picked up the chart. Jana took the phone and listened, grabbing her pen and a scratch pad. "Do you have an ETA? OK! Thanks." She hung up the phone and turned to Dr. Mathis who was dictating into the phone. "That was the police department they just got a 911 call from someone on a car phone saying they are on their way here by private auto with a baby that is not breathing." She heard someone screaming in the hallway. "Help! Somebody help! He’s not breathing!" A young man and two women were frantically trying to break through the double doors that only open outward and only with the electronic button on the wall. "Get back away from the door." she yelled through the square glass pane as she reached over and hit the metal square on the wall. The doors opened out and the man sprang through thrusting an infant out in front of him. Jana grabbed the baby as he thrust it into her arms. She put the infant in a football hold with her left hand and began checking for breathing with her ear over his mouth and checking his inner upper arm for a pulse as she swung back toward the trauma room. "Call the code!" she yelled as she ran past the desk. Dr. Mathis sprang up and was behind her as she entered the trauma room. She laid the limp, little body on the stretcher and placed her mouth over his mouth and nose giving him puffs of her air. There was no time to wait for equipment. This baby had obviously been without oxygen for awhile. Daryl and Jerry had already sprung into action. Dr. Mathis was gathering his equipment from the pediatric crash cart to place a tube in the baby’s airway. Suddenly the room was bustling with activity. An ICU nurse miraculously appeared to keep the peace with the other patients in the department. Everyone else including Dr. Nance, the neonatal specialist who had appeared out of nowhere were totally focused on trying to revive the lifeless little body. Jana was doing CPR with 2 fingers and Dr. Mathis was now breathing for the baby with a tiny mask and bag connected to the oxygen supply. He stopped and in just a few seconds had a tiny tube in the trachea. The baby’s chest rose and fell and someone yelled out that breathe sounds were present indicating the tube was in place. Voices came from everywhere at once. "Get a line!" "What monitor are we on?" "Does anybody know how long he’s been down?" "Do we have a pulse with compression?" ":Good pulse with compression. He’s pinking up, O2 sat is 91% with ventilation. Get an Xray to confirm tube placement." "Xray is in the hall with the portable as soon as we can make room for them. Is anyone recording? Do we have a line yet?" "He was cyanotic but still warm when I took him,." Said Jana as she searched the crash cart with one hand and held a bag of fluid up with the other to run it through the tubing. The man who had been holding the child was standing in the corner of the room watching with a look of shear horror on his face. A woman of about the same age, mid twenties, stood just outside the door weeping loudly with her face in her hands. A gray haired woman who Jana had just noticed, was wearing only her nightgown and socks, paced back and forth in front of the door hugging herself and swaying from side to side. "Are you the father?" She asked the man in the corner, "Can you tell us what happened?" "We just put him down for a nap. We are visiting my mother for Christmas and we put him on a cushion on the floor. When I went to check on him he wasn’t breathing. I didn’t know what to do. We jumped in the car and brought him straight here. I was trying to do CPR but I don’t know if I did it right." The woman in the hall now stood in the doorway. "You have to save him, she sobbed, "He’s my baby. Please God, don’t take my baby!" The code continued for well over an hour with no response from the tiny body on the stretcher. He remained limp and his body began to cool despite the efforts to revive him. Jana had made contact with his mother and father a couple of times during the hour and when she again stepped into the hallway she noticed that even though the ER was packed with patients you could have heard a pin drop, except for the now soft sobs of the child’s Mother, the whispers of the father as he tried to comfort both his mother and his wife, there was not a sound from any of the other rooms. Jana crouched down on her heels to speak to Mom and Dad who were sitting huddled on the stretcher in the hall. "We are still trying everything we can but Eric has not responded at all." His mother looked out through her tears. "How long are you going to keep going? Jana placed her arm around the mothers shoulders and touched Dad’s hand. "We will keep going as long as it takes for you to feel comfortable that we have done everything in our power to save this baby!" Mom and Dad looked at each other and seemed to speak without words. "Lets go in and say goodbye to Eric" She said. They held each other up as they walked back to the trauma room gathering the grandmother as they went. "I think Mom and Dad are ready for us to stop now", Jana said to the room at large. The movement and activity continued until Eric’s parents stepped to the bedside. Dr. Mathis spoke softly from behind them. "Call it, 2238" he said as the recorder noted the time of death on the chart. All activity stopped and the room slowly emptied except for the tiny body on the stretcher, the mother who had given birth to him less than 6 months before, the father who had taken such pride in his new son, and the grandmother who had anxiously awaited his arrival to celebrate his first Christmas with her. Jana, wrapped the baby in a warm blanket and handed him to his mother. "I’m sorry that I can’t take all the tubes out. Because the doctor believes this is SIDS, or sudden infant death syndrome, we will have to call the JP and he will, in all likelihood, request an autopsy. "I want you to know that you didn’t do anything wrong! No matter what you think now, or in the future ,there is nothing that you could have done, and nothing that you have done that could change what happened here tonight." "We don’t have a good explanation for SIDS. It just happens. Here Mom," She said as she handed the tiny bundle into his mothers arms. "You take as long as you need to hold him and say goodbye. I will be right outside the door. I have to make some phone calls. Is there anyone you would like me to call to be with you. Do you have a chaplain or other family that need to be notified.?" Eric’s mother sat down with him on the stretcher and began rocking him as his dad leaned over comforting her and stroking the baby’s head. Jana left the room with tears streaming down her cheeks as she passed the other rooms where patients were once again stirring and whispering. She poked her head in at each curtain and apologized for the wait, explaining that they had just had a code and the doctor would see them shortly. Each patient was uncharacteristically gracious and assured her it was not a problem. What is really sad she thought is that it takes a tragedy like this to make them realize how lucky they are. Jana continued to triage other patients and bring back those who had been waiting. Her movements were mechanical. The police department came, they performed all the required procedures. The JP arrived and ordered the autopsy as predicted. The family’s chaplain arrived and Jana carefully washed the baby and placed him in a gown and wrapped him in a blanket for baptism. When Eric was ready Jana went to the family room and brought his parents and the chaplain into the room. She quietly closed the door behind her. And continued with her other patients. Daryl, and Jerry were both being very quiet and solicitous. Their usual banter was absent. Dr. Mathis was glancing up at Jana every so often as if to determine whether or not she was going to go totally over the edge at any moment. "Are you going to be OK?" he finally ventured. "Sure,’ she said, "I’ll be fine. This ain’t my first rodeo you know. I just take it a lot harder with the little ones." "So do I. That’s why I have to keep moving. If I stop and let it sink in I’ll be blubbering around here like you. We have to treat the living not the dead. It was a good code Jana, we did everything right, it just didnīt work this time." " I know , but right now the parents and grandmother are the ones I’m treating." "Unfortunately as far as the government and hospital administration are concerned my job with this patient was finished hours ago. I wish they would come and spend a night like this so they could see the reality of what we deal with and that you can’t staff by numbers based on some bean counter’s statistics." It had been three hours since the code was called and the final paperwork was completed except for a signature to release the body. Jana tapped the stack of papers on the counter to align them and then pulled the form off the top. She stood up and started around the desk to the family room where the family was gathered with the chaplain. As she rounded the corner she stopped in front of the little Christmas tree they had put up with toys for their pediatric patients to take home after they were treated. On top of the tree was a pure white angel with silver strands running through the pristine robe and a silver bell in her hand. Jana reached out and plucked it from the top of the tree. As she entered the room the soft sobbing was heard. She sat down on the floor in front of the baby’s parents. "I have just one form that needs to be signed so that we can release Eric’s body." Dad held out his hand and took the paper and pen. As he signed it, Jana placed the angel in his mothers arms. She said, "We want you to have this so that you can remember your special angel ,Eric, watching over you. At that the babies mother burst into tears and hugged Jana. "You have been so sweet. Thank you for everything that you did." Jana hugged her back as tears streamed down both their faces unchecked. A few minutes later as Jana was running an Influenza swab to the lab she watched Eric’s family leaving the building. The mother had the angel clutched tightly in her arms. Although the clock seemed to move in slow motion the rest of the shift they made it through. They were quiet and subdued when the day shift began to straggle in that morning. "How was the night?’ Mandy asked as she put her purse in the closet. "Same old story, Too many patients , too little time", said Daryl. "We had a pedi code that was unsuccessful. I have already called for the cart to be changed out but the supervisor hasn’t brought it yet. Are you ready to count?", asked Jana. She was nonchalant. Like nothing significant had happened. When the narcotics were all counted and the forms signed, Jana, Daryl, Jerry, and Dr. Mathis filed out of the ER. She hit the big metal button and the doors swung out just as they always did. "Just another night in the trenches", Jana said as she slid her badge through the reader. "Go home and Hug your kids," said Daryl, "See you tonight."
|
|