Thursday, October 25, 2007

It Was a Long, Long Night

I worked a 21 hour shift the other day. Short staffing does wonders for my soul. It makes me grouchy, pissy, mentally unstable, and slightly unsafe. But hey - what's an ER without a nurse like that?

I started the day with the worst epistaxis patient I had ever seen in my life (for those not in the know, epistaxis is a nose bleed). This man was seriously HEMORRHAGING out his nose - arterial spurting and everything. Can I just say now that I don't mind blood? Not at all. I can handle blood from any human or animal, any orifice, anytime. But this set off my gag reflex like nothing before. He had blood spurting out of his nose, running out of his mouth, completely covering his shirt and pooling in his lap. It had even coagulated in a big pile of blood clots in his lap.

Lucy was the primary RN on his case. She pulled him back to the ENT room and attempted to place a clamp on his nose while we paged the physician. Um............didn't work. The man was holding his mouth open over an emesis bag and it was slowly filling up with blood. He had 200 cc in the bag in the first five minutes.

Stat IV started with trauma tubing for blood infusion, stat page to MD, CRNA, and RT. We weren't quite sure about maintaining this man's airway.

I looked to my left and saw Lucy standing in the corner with a mask over her face - just staring at the patient. "Lucy!" I said. She jerked like she'd been slapped. "Huh?" she replied.

"I need your help over here."

"Oh, yeah. Yeah. Sorry." She ran over to help and started a second IV. She then became Miss Queen Bossy Pants.

"Send a rainbow to lab, get the difficult airway cart, check his B/P again, CHECK IT AGAIN! GRAB THE SUCTION AND GET ME THE DAMN DOCTOR!" she progressively got louder as she railed at me.

Well, allrighty then - I thought. Lucy's gettin' her big girl pants on. Good for her.

It turns out the patient had recently had surgery for cancer inside his nose. The ENT specialist had completely re-worked his anatomy inside his nose and nothing was where it should have been. Dr. Q came in to see the patient, took one look inside his nose as we suctioned him out, and said "Send him out!" He couldn't even attempt cautery because the anatomy was so different he wasn't sure what he would be cauterizing. We packed the nares with nasal tampons, which held the bleeding off for about 5 minutes. Then the dam burst loose again. He repacked with regular packing which helped enough to get him into the ambulance and sent off down the road with a couple units of blood infusing.

Before Mr. Epistaxis was even out the door, my first chest pain of the day walked in. He was clutching his chest, pale, cool, diaphoretic. "I feel like someone is sitting on my chest," he said. Oh shit. Seriously? I haven't even called report to the receiving hospital for Mr. Epistaxis. Ah well, gotta keep moving.

Mr. Chest Pain is escorted to the cardiac bay and placed on a monitor. Oxygen applied, EKG done, IV started X 2, Nitro given, blood sent to lab, and portable chest Xray performed. 45 minutes later we transferred him out to the Cardiac Center.

I cleaned the Cardiac bay and thought "I'm a bit hungry, think I'll take my lunch now." I turned to walk out the door and was met by a man holding a bloody towel over his hand. "Can you help me with this?" he said. I should have just told him no, that I was going to lunch.

He removed the towel. I blinked. I blinked again. He had no hand. What he did have was a bloody stump with a mangled mash of flesh and bone on top of it. He had gotten in a little altercation with a table saw. The table saw won.

I saw a few more patients with broken bones, fevers, abdominal pain, and another chest pain or two. I went to dinner (my first meal of the day) around 6 PM. Then all hell broke loose.

"Julie, we have someone in triage you need to bring back."

Let's just pause here to say........well, I don't know what but let's just pause a moment. Sometimes you just need a break. Sometimes you should turn around and walk out the back door before you see what's on the other side of the front door.

It started simple enough. I walked out to triage and saw a man sitting in a wheelchair with 2 police officers in attendance. Not an unusual sight, but enough of one to make you go 'hmmmmm....." The man was holding his head and telling me how nauseated he was. The left side of his face was swollen and deformed. His left ear was hugely swollen and bruised and he had bruising behind his ear extending down the side of his head and neck. The bruising was slightly difficult to see through all his tattoos, but it was there none the less.

Mr. HeadInjuryMan was taken to exam 2. Neuro assessment revealed pupils equal and reactive, though slightly sluggish. Oriented X 3 but becoming progressively lethargic. I hooked him up to the monitor, turned around to talk to him and he was not responding. Shit. "Mr. HeadInjury, Mr. HeadInjury..." I called. No response. Airway? Check. Breathing? Check. Pulse? Check. Brisk sternal rub........ "What the fuck are you doing to me???!!!" he yelled. Sigh.......good. He's still in there somewhere.

Dr. Q came to evaluate ("I think I feel a depression here") and ordered a head CT. I called the Paramedic on duty to go with him as I couldn't leave the ER. The officers had disappeared somewhere in the middle of all this. The story I got from the wife is that her son came home drunk and got pissed off at her, but decided to beat up his dad instead. His dad was sleeping in the recliner when Mr. Dandy Son decided Daddy's head needed a little lesson authority. Wonder what Freud would think of that one - son pissed at mom so beats dad's head in.

The whole time Mr. Head Injury is in CT, his wife is on the phone telling the entire town what has happened. She's calling everyone looking for her son, threatening to kill him if she ever sees him again. Then she says "He took all of our medicines with him and I think he might OD on them." Oh reeeeeeaaally? At that exact moment, the EMS tones go off.

"Medic 1, please stand by at East Park per police request. Received report of male who has OD'd on multiple pharmaceuticals and police are trying to find him in the park."


I needed to pee.

Mr. HeadInjury returns from CT scan with a negative read. Thank the Lord. We hold him in ER until a bed opens up. Neuro checks every 30 minutes, frequent airway checks. He's vomiting all over the place and telling me "If you don't fucking take care of this pain in my head I'm leaving." Um, yeah.....go ahead. I'd like to see you walk out of here.

Here's a little saline for your pain.

OK, not really. I did give him the morphine. Eventually.

While I'm waiting for the ambulance, I get another patient from triage. Miss Alcoholic complaining of abdominal pain. She hasn't eaten for 3 days, has been vomiting the whole time, and has an alcohol level of .350. And she smells just peachy.

After about 20 minutes my phone rings. "ER, this is Julie."

"Julie? It's Jimbo from Medic 1. They found the OD patient and are bringing him in via police escort."

"Why police? Is he stable?"

I hear laughter. Not a good sign. "Oh yeah, he's stable. Have fun." Click.


I walked back into Miss Alcoholic's room to start her IV. She apparently thought I was her best friend as she started to tell me all about her sex life and how big her boyfriend's willy was. Thankfully we were interrupted by screaming in the hall.


I stepped out into the hall and saw 6 police officers dragging a 20-something male down the hall. He was kicking at them, spitting at them, trying to bite them. Ah hell..........this was going to be interesting.

"AIEEEEEEEE!!!" A flying female form came screaming out of Exam2 and threw herself into the officers. It was his mother, who was still in the room with his father, who he had beaten up earlier. "I'm going to kill you, you mother fucker!" She screamed at him. "You BItch!" he screamed back.

The officers finally got them disengaged and dragged the mom back into Exam 2 and the son into the Hold Room. More officer materialized out of nowhere and the wrestling match began. They were attempting to get him onto the stretcher, and he apparently didn't want to go there. Arms were flailing, feet were flying............

"What do you need?" one of the officers asked me.

"He's got an airway so I'm OK at the moment," I replied. He just laughed.

Eventually they got him onto the stretcher and we put the 4 point soft restraints on. Mr. Overdose was spitting at me and calling me all kinds of beautiful names like bitch and cunt and whatnot. I just smiled and said "Oh, what a sweetie. You must want to marry me."

"Fuck You" was his reply.

Dr. Q came in to evaluate the patient. "What medications do you take?" he asked.

"Heroine and cocaine"



"Bitches and cunts"

Super Duper.

We started an IV (which he screamed over and over about how we needed a warrant to do that), hooked him up to the monitor (again - he felt we needed a warrant to do this too), and called Poison Control. He had taken Percocet, Ativan, Klonopin, Heroine, and Cocaine. Nice cocktail there.

The percocet and ativan eventually kicked in. And his airway started to go bye-bye. We inserted a nasal trumpet which helped tremendously. We cathed him for urine, during which he woke up enough to ask us if we were impressed with his male anatomy. "Um.....nope."


Sometimes I love my job.

After about an hour, he woke up and decided he didn't want the nasal trumpet in anymore. He was trying to blow it out his nostril, but only succeeded in blowing snot and blood across my wall, over the bedside table, across the supplies laid out, and over the sharps container. "What the hell? I'm gonna make you clean that up when we're through here." I said.

"Fine. I'll do it bitch. Let me outta these cuffs."

One of the officers came back in and asked when they could take him to jail. Mr. Overdose spouts off "Take me now. I'll go back to prison. 3 squares a day and I get fucked."



I looked at the clock. 2 AM. Sigh...... Can I go home now?

An hour later, Dr Q decided he was stable enough to be transported to jail. He was oddly cooperative when we removed the restraints and put him in the cuffs. His fight was gone.

So was mine. I was exhausted.

I finally went home at 6 AM, fell into bed and slept.

Overall, it was a pretty good night.


Sandy said...

i CANNOT believe you worked that many hours. That's just nuts. and dangerous! i worry about med errors or silly mistakes at the end of my 12 hour shift because i am so beat. What's worse is that we don't get any gratitude for our hard work, especially from the patients who take the most work!

The T-Dude said...

Holy crap...there is a special place in heaven for you, you know that right?

NocturnalRN said...

It cracks me up you ended that with "pretty good night" Very entertaining to read, but I am glad i didn't have to deal with all that. Hope you slept well when you got home.....and for a long time!