Emergency! (23 page)

I talked to the patient and to the patient's mother about the necessity of the exam. The nurse also talked to both of them. I returned in fifteen minutes. The patient's pain had increased. She writhed and screamed periodically, her pain now severe enough to persuade her to allow the pelvic.

I inserted the speculum into her vagina and saw a smooth, bloody, shiny mass covered with hair. She screamed and it shot out at me and into my lap, nearly sliding down my legs onto the floor. I wrangled the slippery mass back within my grasp. The mass wriggled. It screamed. I clamped and cut its umbilical cord. We broke open the emergency delivery bag and suctioned the eight pound baby. I placed the baby cautiously upon the mother's abdomen and held it there.

“Aaaaaah,” she screamed. “That didn't come out of me!”

“That didn't come out of her!” yelled the mother.

“Well it certainly didn't come out of me,” I said quickly, impulsively.

“I'm fixed. Hysterectomy,” the nurse said.

We called the obstetrician, the pediatrician, and social services, then moved along to the next patient.

MICHAEL ERICKSEN, M.D.

Los Gatos, California  

W
e receive many letters in the Emergency Department. Some express gratitude, others do not.

An elderly, female patient was brought to the emergency room and pronounced dead on arrival. Some weeks later, a letter arrived from her family thanking the ER personnel for the kindness shown to their aunt. The family was particularly appreciative that the staff had donated a set of false teeth, making the patient look especially beautiful at the wake. The letter also related how the deceased had always
wanted to get false teeth but had been unable to afford such a purchase.

The hospital wrote back thanking the family for their kind remarks, but everyone remained perplexed by the comments about the teeth.

The mystery was solved with the receipt of another letter. This one was from a former patient complaining that she had been made to wait in the ER for three hours before being admitted to a hospital room. She was most disgruntled by the fact that the hospital had lost her false teeth and caused her a great deal of stress and inconvenience.

Thinking it best not to explain, the hospital sent a letter of apology and agreed to reimburse the cost of new dentures.

JOHN DENTE, M.D.
       

Wilmington, Delaware

T
hree men walked through the entrance door that was immediately beside the triage desk. Sharon, an excellent nurse, could tell at a glance the one in the middle was in trouble. He was being assisted by the men on each side. He had on a bicyclist outfit—jacket over tight, light blue shorts and bike shoes. He had one hand loosely over his groin, which was covered with blood. Sharon was told he had fallen.

She quickly got him onto a stretcher with his friends helping on either side. With rapid precision, she pulled down his shorts, removed the athletic supporter, spread his legs, and elevated his testicles,
looking for the source of the bleeding. “What are you doing?” asked one of his friends.

“Trying to see where he's bleeding,” she responded.

“It's my shoulder that's hurt,” said the startled patient.

Under his waterproof jacket, the patient had a compound clavicle fracture that had bled down his chest and abdomen and covered his pants with blood. The hand that appeared to be protecting his groin was actually his injured arm being held by his other arm to protect it from movement.

The nurse won the award for the most thorough physical exam performed for a shoulder injury.

MARILYN J. GIFFORD, M.D.
    

Colorado Springs, Colorado

T
he ER day shift started out as usual, somewhat slow and under control. The staff was chatting about things going on with their home lives when the radio alarm went off. “AV Hospital, this is Hall Ambulance 242 with a pediatric full arrest.” I handled the call, thinking, “Probably another SIDS baby.” After twelve years as an ER nurse I know that not many of these kids survive. I thought of the parents and, as I was a new father, I felt especially bad.

I went outside to make sure the door was held open for the paramedics. My coworkers prepared the room for the patient. When the ambulance arrived, a paramedic came out of the back holding the child in one arm, doing compressions on the lifeless little body with the other.

As he hurried past me I looked at the child's face. A lump formed in my throat as I thought, He looks just like my baby. I realized this was the first dead baby I'd seen since my child was born. I followed the paramedics into the ER, dazed and dizzy. As I entered the room, one of the nurses looked at me and said, “Don't even come in here. We'll take care of this.”

I mumbled, “Thanks,” walked into the radio room, shut the door, and fought back the tears.

The child didn't survive. The parents arrived and were told of the outcome. Their screams and cries tore a hole right through me. I wanted to go to them, hug them, and cry with them, but I couldn't lose control of myself.

I fought my feelings hard, kept myself semicomposed, and yearned for my son. I wanted to see him and hold him. Now! The time passed slowly. I felt like I was in a different body. I spoke to my wife a couple of times over the phone throughout the rest of the day. I never mentioned to her what had happened for fear of losing control. She worries about our baby enough as it is.

The shift finally ended, and as I drove home, the knot in my throat began to disappear. I walked in the door, said hi to my wife, and gave her a kiss. I walked over to my son, Nathan. He was sleeping in his playpen. As I looked to make sure he was breathing, the tears welled up in my eyes again. I turned to look at my wife. She saw my face just as I said, “I had a SIDS baby today.” We embraced, crying out loud, each other's necks wet with tears. I don't remember ever crying that hard in my life.

We calmed down a bit after about ten minutes, and I explained what had happened. I went to the sink to get a drink of water. The image of the lifeless baby came back. I thought of the parents and began crying again.

My son woke up and I held him close.

BRIAN COAKLEY, R.N.
  

Lancaster, California

T
here aren't many times that I hate to go to work, but Christmas is one of them. It's hard to be in the ER knowing that my family is home enjoying companionship, good food, and the joys of the holiday.

I was really feeling sorry for myself and quite resentful as I drove in to work following your plea for help. I'd already worked most of Christmas Eve, and had returned for a while on Christmas morning. And now you want me to come back Christmas night? But you'd sounded desperate, so I came.

Actually, I felt a little guilty. I thought back a few hours to Christmas morning and remembered noticing how you cheerfully greeted the patients as they streamed in. (Didn't they know what day it was?) I remembered noticing how you hid your own distress as you comforted the parents of the baby that had coded and died. I remembered noticing the caring support you gave on Christmas Eve to the husband and children of the woman dying of leukemia, not knowing if she would live through the night. I remembered noticing all these things and never complimenting you for them. By the time I arrived in the ER on Christmas night, my resentment was fading. The waiting room was crowded and the chart rack was full, but when I saw your tired faces and felt your welcome smiles, my resentment was gone. I slipped into my ER role and felt the energy that comes with true collaboration.

I suspect you wanted to be home as much as I did, but there wasn't any grumbling. We saw ninety patients that night. Most were sick,
some weren't. For a few it was their last Christmas. The kitchen sent Styrofoam trays, holiday dinners for the staff, since no one could get away. When I finally left at 2
A.M.
, most of the trays were still sitting there, untouched.

I thought about us as I drove home. I thought of how we work together through the good and the bad, and of the experiences that bond us to each other. I realized that I had spent my Christmas with a great bunch of professionals I am proud to call friends. I realized how much you all mean to me and I just want to say thank you.

DAN CALIENDO, M.D.

Wichita, Kansas    

8:07
A.M.
:
A call comes in over the radio, “Code three.” We are getting the victim of an auto-vs.-pedestrian accident, a seven-year-old girl. “Severe head trauma” is the description. Later we will find out that she had been dropped off at school by her car pool, had walked out between two cars to cross the street, and had been hit by the father of a classmate as he pulled up to drop off his own child.

The ETA is fifteen minutes. This patient will almost certainly need to be put on a ventilator. I scribble some orders on another chart, pull off my white coat, grab my stethoscope, and head for the resuscitation suite. I am the junior ER resident today, and my job is to take care of the patient from the neck up, including managing her airway. The senior resident will run the resuscitation, making management decisions.

8:09:
I don a lead jacket to protect myself from all the X rays we'll be shooting, put on two pairs of gloves, and begin assembling all the equipment I think I'll need. I'm very nervous, because I haven't intubated many children and I'm not sure how big she is or what size endotracheal tube I'll need. I go through a formula in my head and grab a size 6 tube, with a 5.5 and a 6.5 for backup, placing them within easy reach on a Mayo stand. My hands are shaking. I insert a flexible metal stylet into the 6 tube to help guide it, and check the cuff balloon to be sure it inflates properly.

8:12:
I am relieved to see the respiratory therapist arrive. She puts together a pediatric bag and mask to ventilate the patient by hand if necessary while we are getting ready to intubate. I hook up the suction, check to make sure it's working, and stuff the tip under the gurney mattress, where I can easily reach it.

8:14:
I am rummaging through the drawers, looking for the right size laryngoscope blade to fit in this patient's mouth, so I can see her vocal cords when I intubate her. Finally I settle on a Miller 2, attach it to a handle, and make sure the light works. A Macintosh is also out and ready as a backup. The senior resident walks in, looking very cool, and puts on some lead.

“Have you called pharmacy?” he asks the nurse in charge.

“They're on their way.”

“Why don't you draw up some etomidate, sux, and atropine. We'll figure out the doses.”

8:18:
I'm ready. I think.

8:21:
The pharmacist, trauma surgeons, and neurosurgeon have all arrived. We all lounge around the doorway, looking down the hall for the paramedics.

8:22:
“Rescue Twenty-eight in the parking lot with a code three,” blurts the loudspeaker. I run to my spot at the head of the gurney and double-check all my equipment. My palms are sweating.

8:23:
The paramedics wheel their gurney into the room, talking as they come and holding IV bags up in the air.

“She needs to be intubated,” I hear one of them say. And indeed it is true. The child is breathing on her own, but her breathing sounds gasping and ragged. Each time she exhales she moans, an eerie, high-pitched moan, like a hurt animal; the same with each breath. She is unresponsive to stimuli. We transfer her to our gurney and everyone gathers around in the intimate frenzy of accomplishing our individual tasks. The X-ray techs are pushing people out of the way to get a chest X ray, while the trauma techs strip off her clothes, the surgeons feel her belly, and the nurses try to start additional IVs. The respiratory tech places oxygen on her to get as much as possible into her lungs before intubation. The pharmacist and the senior resident have agreed on the doses of medicines needed to sedate and paralyze her so that I can intubate her, and they signal a nurse to begin injecting the drugs.

I don't have much time. My heart is racing. I check her pupils: fixed and dilated. I look in her ears: no blood. I feel her bloody head for hematomas and instantly get a sickening feeling in the pit of my stomach—her entire skull is unstable. Even the slightest pressure on part of it results in clicking bone fragments and the squish of soft tissue against my other hand on the opposite side. Her left cheek is swollen and purple; there is probably a facial fracture as well. I call out my findings.

8:25:
The drugs are beginning to work. The child gradually becomes flaccid, her teeth unclench, and she stops breathing. The cervical collar has been opened in front, and the respiratory tech puts pressure on the child's cricoid cartilage in her throat to keep the esophagus closed, preventing stomach contents from refluxing into her airway. The senior resident stabilizes her head for me, and I open her mouth and insert the laryngoscope.

My first view is of blood and saliva; I can't see anything that I need to see. Adrenaline and terror surge through my body. “Suction!”

Someone hands it to me, and the blood swooshes up into the plastic
tube. I push the laryngoscope in a bit further and finally see the diamond of her little white vocal cords, like broken toothpicks guarding the blackness of her trachea.

“Tube!” Again it is handed to me, and I guide it into her trachea, never once taking my eyes off those vocal cords. “It's in!”

My left hand is clutching the tube at her lips for dear life. I pull the stylet out of the tube. The tech attaches a bag and begins hyperventilating the patient to reduce the swelling in her brain. The senior resident listens for breath sounds in the chest to confirm that the tube is in the right place.