She came in with her mother and her son. Crying a bit, because of the embarassment, she was also raging mad. At him.
“I hope they’ve got him in jail by now,” she muttered from underneath the ice pack held against her head.
As I entered the room, she smiled at me. A tired, half-crooked smile. The swelling on the right side of her face pushed the corner of her mouth downwards just a little, making her smile look a bit like a sideways question mark. Her left eyebrow lifted at the inside corner in anticipation of bad news she didn’t want to hear.
“I have good news for you,” I said. “There are no fractures.”
She beamed at the news and her little boy laughed in response to his mother’s joy.
“But you do need to get stitches,” I said.
“But they told me I didn’t need stitches last night. My neighbor came over and said it was just a little cut, and that since the bleeding had stopped i didn’t need any.”
The small gash through her eyebrow had already started to heal, but an unfortunate gap of about one-eigth of an inch would leave a visible scar and an ugly reminder of the night.
“Mommy, you need to stay so the doctor can make you better,” said the two-year old with oversized non-latex gloves on each hand.
I turned to him and leaned over. “You are a VERY (pause) SMART (pause) young man.” He smiled at me. “When I’m all done fixing up Mommy, I’ll get you a popsicle.” (A little bribery never hurt a two year old).
The patient laid down on the stretcher as I set forth repairing the unsightly cut. I numbed it up, separated the edges that were starting to heal in the wrong alignment, brought them back together again and placed six small sutures.
By this time, the little boy was jumping with glee and clapping his gloved hands together.
As promised, we marched over to the freezer and each got ourselves a Steeler’s Pop. We’d both had a rough evening.
Schizophrenic lady comes to the ER needing a change of scenery. Tries her best to get admitted to Hotel Urban Memorial, but instead gets dragged back to her group home by her case worker.
Fast forward 8 hours and she’s back again, called 911 from a convenience store on the corner near her group home. She REALLY wants to be admitted this time, in fact, she wants to go to the BIG psych house to be with her roommate who was moved there earlier in the day.
She even tries the “I’m suicidal” trick.
While waiting for her caseworker she wants to go for a smoke. We tell her no, she can’t leave the hospital by herself.
“When is my room going ot be ready?” She cackles in a harsh tobacco voice.
The charge nurse patiently tells her she needs to wait.
“Can I have a blanket?” She shrieks.
Yes we’ll get you one.
When it doesn’t arrive within five seconds, “Why are you being so mean to me?” she whimpers.
“Can I go out for a smoke?”
No, we tell her for the umpteenth time.
“Then I’m going home!”
You can’t leave, we tell her.
“Where is my case worker?” She demands
She’s on her way, the nurse repeats.
“I’m going home with her. ”
Fine, just wait in your room please.
“Can I have a smoke?”
Four sequential codes in the ER today. Four. One, two, three, four.
Two of them were mine.
One arrived dead, but was coded just the same…young adult, overdose. At least it wasn’t intentional, said a nurse. Hmm. I think drug abuse is intentional. Sorry, no sympathy, I’ve got other dying patients to see that actually have a chance. ( I think she was referring to an intentional suicide. IV heroin use might as well be. Idiots.)
I may write about the others or I may not, just wanted to share.
The child was dead.
I heard it over the radio first. “Not breathing,” said the dispatcher. “The ambulance is on it’s way to the house. The baby is 1 year old.”
Crap. “That child is dead,” was my first thought, even though I heard the information second hand.
I grabbed my airway card (one of three I carry in my bag) and reviewed dosages and equipment sizes for one year olds as I use the technique of denial in hoping they aren’t really on the way, that there isn’t really a one year old who is not breathing.
Moments later another call. “The ambulance is on it’s way to you.”
They literally picked the child up and ran it to the truck, driving to the hospital lights and sirens all the way. Believe it or not we were ready in the short period of time. Well, we had a room and pediatric equipment at the bedside. But we were not really ready for what we saw. My partner jumped to the head of the bed as I arrived seconds later (was this deliberate on my part?).
“This child is dead,” someone said.
In many ways, it was easy. ABC. Airway. Begin ventilations. Breathing. Check ventilations. Circulation. Asystole. Begin CPR. It was my first time doing CPR on this sized child, with my hands nearly wrapping around the whole chest, two thumbs pumping away.
My partner tried to intubate and the jaw was rigid. Her arms were rigidly fixed in the position she had been laying in the crib. Violaceous lividity had begun to settle in the back of her scalp and buttocks, a sign of blood no longer circulating and settling to the gravity dependent body parts. The child was dead.
But we continued. An interosseus line in each tibia, fluids, meds. It was like working on a doll, a resuci-doll from Pediatric Life Support class. While the body had the look and shape of a child, it was clear that this was a lifeless body.
The child was dead.
Neither my partner nor I had the guts to pronounce her DOA. So we continued with a little bit of everything until the room was satisfied we had tried every reasonable intervention including shocking her. We were trying last ditch efforts and had run out of everything. I charged the unit while the nurse applied the paddles and discharged them. A click from the machine without the typical muscular contractions and body jerk.
“Did these paddles discharge?” the nurse asked.
I increased the energy and charged it again.
“CLEAR!” Click. Nothing.
It dawned on me later why the little body didn’t jump the way it should have. There were no living cells left to contract. Rigor Mortis had set in to the point where the muscles were locked and unresponsive. It was equivalent to shocking a mattress or a log.
The child was pronounced. Dead.
Warning: Morbid Post Ahead.
The twisted car had trapped him in the drivers seat, steering wheel crushing his chest. Firefighers and medics worked in full turn-out gear for 45 minutes trying to get him out. Placing him on a backboard as is standard care, the man was gratefully thanking them, nearly crying in happiness that he was out of the mass of metal, smoke and gasoline.
Then a few drops of blood came out of his mouth. He began coughing and blood sprayed the nearest EMT in the face. The man’s eyes grew large and widened, a look of fear overcame him. He could no longer speak. The medics tried to get him to talk again, but instead, his eyes rolled back into his head and his arms fell limp at the sides of the stretcher.
When he arrived and I first saw him in the ER, the story was obvious without being told. Trauma arrest. Talking at the scene and shortly after extricaiton his heart stopped. The sight of the man on the gurny told the entire tale. Firefighter performing CPR. Medic attempting one handed bag mask ventilations while the stretcher was on the move, blood spray covering the patient’s face.
The mans belly was large. Ridiculously large. Like he was pregnant with twins.
The physicians in the room (there were many), jumped into action while the charge nurse barked orders for equipment and supplies. Things went (mostly) smoothly with a few exceptions.
As I was ready to make my first quick incision to insert a chest tube, I hear a nurse call out, ” He’s on Coumadin.” I hesitated for only a second. He was dying, died, nearly dead…it didn’t matter. IF this could save him then it didn’t matter if he bled. Meanwhile his belly grew larger. A second chest tube went in on the other side. He was intubated and the blood spray finally stopped.
I stuck a needle into his heart to blindly decompress a tamponade when the whole time I knew he was dying…he was already as good as dead.
Traumatic arrest. Good and dead on the spot, unless you have an surgeon and OR immediately at hand. THis man needed an operating room that was fully staffed ready to go, on the spot, right at the scene of his accident.
As his belly continued to fill with blood, I sucked more fluid from around the heart.