Lost on the Floor

The other night started off like any other. Got my assignment, looked...OK, at least everyone is A & O and mostly independent. "So far so good." I thought to myself. It's funny, I no longer look to see what the actual reason they are admitted for anymore, just if they are going to either:

a. curse me out
b. try to get out of bed and go boom
c. yank at their lines
d. all of the above (usually the most popular.)

Good nursing practice? Maybe a little judgmental, yes, but this is tempered by experience. I figure, more than likely, I can deal with their admitting diagnosis, but if they are demented or delirious or just plain psychotic, that task just became a whole lot harder. But I digress.

So I was going along, and everything was actually OK. Then someone mentioned the "q" word. A chill swept over the nurses station as we all looked at them and in near unison said, "Did you just say the "q" word?" Mentioning the "q" word in the medical world is akin to mentioning "MacBeth" to a stage actor. Not sure what else we could say, for sure the alternative for the actor is far worse. Who really goes on a nursing unit and tells someone to "break a leg?" No one in their right mind. But it brought me back to the time that I had used it.

I was a senior nursing student doing my senior preceptorship in the ER of a smallish rural hospital. On the night shift. At the beginning of the month. During a full moon. Surrounded by black cats and broken mirrors ( OK the last part wasn't quite true.) But there I was. It had been a slow night, nothing too crazy. So I said it. the "q" word. No more than 30 seconds later we heard the tones come over the radio,

"Rural ER, this is unit 55, how do you copy?"

The nurse sitting there, "We copy, over:"

"55 y/o male, found down in apartment, in full arrest, we're coming code 3."

I looked over at my preceptor, she said, "You're on compressions, OK?"

As the thought ran through the back of my head that this was all my fault for saying that dreaded word, I said, "OK." Lead vest on, shoe covers, gown and mask, gloves and goggles. We had just barely gotten the trauma bay ready when we heard the sirens outside in the bay. They piled out of the unit, one in front, one in back, one surfing the gurney performing compressions. Rolled them into the trauma room, stopped compressions only to transfer to the table.

Now it was on me. I started, feeling the ribs grate under my hands, just keeping my mind on the rhythm, 80 a minute. I heard report in the background.

History of esophageal varices and alcoholism. Found down in apartment after wife had called it in after the patient had passed out while talking on the phone to her. 80 a minute.

1 and 2 and 3 and 4 and...keep the rhythm.

7 french ET tube, 21 at the lips. Left and right EJ IVs, got 3 liters in the field. RT is standing to my left bagging as I do compressions. The doc holds compressions for a moment to find the femoral vein. Then back at it. 1, 2, 3, 4,...

I'm hearing orders being given, rapid infuser, get 6 units of blood ready, continue NS until the blood's ready, get me an ultrasound machine. The doc calls out again to hold compressions. Has the femoral line. Compressions resumed.

I'm getting tired now, starting to look around for someone to spell me. Arms feel like lead. Now I look down and see with every compression fluid spurting out of the ET tube, a pink mix of blood and saline. But I keep going. As a student I can't do much, but I can do this.

The monitor shows asystole. The doc halts again, uses the ultrasound to see if the heart is doing anything. Nothing, just a little bit of movement. Finally, I switch out with another nurse. I can't feel my arms, sweat runs down my back and face. And then it is over. The doc calls it. I look at the clock, 7 minutes since they arrived in the ER. Then I nearly lose it. I run out the door to the ambulance bay, into the cold night air overwhelmed by the fact that we couldn't save him. Someone's father, husband, son. In spite of our best efforts, we couldn't save him.

That wasn't the worst. That came when his wife showed up. He came in covered in blood, I mean caked on. The police had said the scene looked like a murder scene there had been so much blood. So we cleaned him up as best we could. Cleaned his hands, his head, his hair. Made him presentable so that his wife could come and say good-bye. My nurse gave me the rest of the night only giving me the easiest cases. As we sat down and talked about it I asked,

"Does it ever get easier?" To which she replied, "Not really. You just forget to feel it anymore."

I knew she meant that you insulate yourself as you get exposed to it frequently, but it sounded a little cold, but I understand it much better now. Rationally, I know that even though I said, "quiet" that didn't cause this to happen, it was bound to happen regardless, sometime. It just happened when I was there. So I never say, "It's kind of quiet tonight." Not anymore.

Oh that other night? It went just fine.

As I was walking down the hall on the unit doing midnight rounds I heard it. Faint at first, just enough to prick my ears up, then more distinct, "let me out! Let me out!" in an ongoing chant. I knew that it wasn't anyone on my end of the unit, it had to be coming from the other side, 40-50 yards down the hallway. When I got back to the nurses station, it started again. Someone jokingly said, "sounds like a nurse!" We all laughed.

Later that night, I heard what it was all about. It was one of our patients, screaming out about being kept in the room. Guess she liked to wander. (Later heard that day shift had found her half-way down the fire escape at one point.) In the course of all of this, the nursing supervisor cam by and asked why the door had been closed, y'know, against JCAHO regs and all. They simply told her that the woman's yelling and abuse had finally gotten too much, so they closed the door for a little bit of quiet...maybe to let the other patients sleep.

"Well," she said, "I'll go and see what is going on." She walked over to the door and opened it, stuck her head inside.

The patient looked up and said. "What the f*ck do you want?!" Then began cussing her out, using more four-letter words than the proverbial sailor. The supervisor, quickly exited, closed the door and without another word about it, went on her way. Just smiled and nodded.

I wonder what JCAHO would really have us do in this situation? I know that closing the door is probably not the best thing, but it was what we had to do. (She was being checked on frequently and sitting in a geri-chair, so she was safe at the time.) Really, there is the ideal world that the surveyors and policy makers inhabit, way up in the ivory tower of administration and then there is the reality of life on an acute nursing care floor. Considering the new report out that nearly 5 million adults in the US has Alzheimer's, we better figure this out, or else instead of being greeted warmly by our patients, we'll be asked "what the f*ck" do we want on a more regular basis.

The Basics:
The Health Insurance Portability and Accountability Act is a group of legislation designed to make it easier to share your health information between providers, i.e. insurance companies, health professionals, while securing that information. It also has provisions regarding insurance coverage, pre-existing conditions and quite a bit more. It is also the genesis for a whole new industry of consultants and companies focused on implementation of its regulations.

How it applies here:
While I couldn't seem to find anything that prohibits medical blogging, within the framework of HIPAA, certain guides need to be followed. Like anywhere, confidentiality of a person's personal health information is to be guarded at all costs. This makes it difficult, especially for newer clinicians or those without a flair for fiction, to accurately present their topics without disclosing too much about the patient.

The Bottom Line:
Names, dates, locations, genders etc. are all modified to ensure patient confidentiality. It is not my goal here to point fingers, talk about people behind their backs, snicker and generally speak ill of those who are ailing, it is a chance for education and a glimpse into the life of a floor nurse in a busy metropolitan hospital. I am trying my best to sanitize each and every account to ensure patient confidentiality, to eliminate things where the reader may say, "I know who he is talking about." With the exception of diagnoses, any relation to persons real or imagined has been identified and eliminated. This is fiction, flavored with fact. The ideas and stories are real, the people are not. The patients are an amalgam of patients done well enough that even their family members would not know it was them.

Thank you for your discretion and ability to understand this.


Addendum - July 11, 2007
With the recent furor over medical bloggers and HIPAA, privacy and all of that, let me add a couple of things.
1. "The other night" means just that. Could be last night, a week ago, a year ago. I have a very long view of time and use that as a way to identify that it happened. Just not when.
2. I try not to identify gender, but when I do, it is usually wrong. Granted that gives me 50/50, but hopefully it takes away further ID.
3. Age. There's old, older and pre-historic. No dates or ages associated...infer as you will.
4. Finally, I know that it is pretty easy to track people down via the interwebs, so my anonymity isn't iron-clad. I'm OK with that. Hopefully you can respect that.

New day, new location, new name. As I lay thinking about writing about work, I realized that it ws probably a good idea to keep my personal blog and work blog separate. If nothing more than to ensure privacy and comply with HIPAA, than to present with a greater degree of freedom than previously.