Kevin’s a nurse. He works in the emergency department near you. It’s a big place. Lots of sick people. Oh man, so many sick people. But mostly they’re not that sick. Mostly it’s just a lot of people. I mean don’t get me wrong, a lot of them are sick with the cold and stuff but not like sick. At least most days.
Hundreds of people come into the ED every day; and yes you should probably get used to the abbreviation since it is now so much more than a single room with a thin cloth hung between patients. Sure it’s called ER sometimes but it’s also called ED, which, is a much more common abbreviation than the other ED. Unless of course you work at a urologist’s office, or for a company that makes sildenafil (look it up if you still haven’t figured it out). The point of all of this is that the ED is a whole department now with its own crew of managers and conference rooms and everything. Sorry, that was a painful tangent.
The people that keep the ED in business come in for everything. Stomach pains, chest pains, broken bones, migraines, hangnails, papercuts, positive pregnancy tests (to the person that pees on a stick, sees that they are now growing a human and decides they should come to the place filled with the most exotic ways to catch all sorts of illnesses that can get you and your fetus sick: maybe you deserve whatever you might catch here, just sayin’).
The ED where Kevin works is a busy place, particularly busy this time of year because in addition to the increase in pneumonia and positive flu tests, people still insist on coming in for back pain they’ve had for the past three months as well as that sore throat they woke up with this morning and “it hurts so much to swallow, it’s like an 11”. More on the incompetence of people to understand the 0-10 pain scale on a later date…possibly an entire post.
But yeah, so busy that the worst job by far is the intake desk where people get their first chance to speak with a medical professional, kind of like an interview where the sickest people ‘win’ the first available room and the people that aren’t going to die within the next couple hours have to wait. That’s where Kevin finds himself for the final four-hour stretch of his day. It also happens to coincide with the busiest time of the day. Luckily there’s just about twenty minutes left in his shift.
“So then I had a blood clot in my left leg and they had to put a stent there. But that was after they put in my other stent, I also had a blood clot in my right leg and they said it might have traveled to my lungs. I was in the hospital for a week for those.” That seemed to be the whole point of her story, a bit anticlimactic for Kevin’s taste.
The 72-year-old woman shifts uncomfortably in the plastic seat. Perhaps she’s wondering how she got to be in such a place; sharing about the scariest time of her life with a man forty years her junior. Kevin can almost hear the mental Rolodex frantically spinning to determine how many more facts are pertinent to her visit today.
It’s been going on like this for at least three minutes. Kevin would usually just let the bird talk until she dried up; throwing in a few choice ooh’s and ah’s, maybe a ‘that sounds difficult’ if he was feeling generous while he was finishing up his BS charting. Unfortunately this was triage and the line was already growing four or five deep. It was time to cut off the autobiography.
“So why are you here today?”
“Oh didn’t I tell you that; my leg is hurting. And it feels just like the time I had the blood cl—”
“Sorry ma’am but we don’t have an available room so you’re going to have to wait until something opens up.” Or until four hours rolls around and you decide this little cramp in your leg isn’t worth the additional two hours it takes to get a room. Hell with the number of people waiting, it could be a blood clot and she would still have to wait that long. Unless it turned into a PE and she coded in the lobby; that would break the shift up a little at least…
The old woman with a long night ahead of her sits in the chair as if she’s waiting for Kevin to continue but he has already turned toward his computer, jotting down a quick note about her complaint: Pt here for leg pain, concerned for DVT: hx of the same. He’s technically not supposed to use that many abbreviations and should probably put down more information but he’s too close to the end of his shift to care about that sort of thing. After he finishes plugging in the vital signs he says “thank you” and turns back toward the computer, silently counting to see how long it takes her to get the hint. After about ten seconds she finally gives up on him and creaks up out of her chair, fumbles for her walker and limps over to sit down next to a similarly decrepit looking older man.
Well on the bright side, Kevin thinks, when she’s super pissed she’s been waiting for so long I’ll most likely be on the other side of the double doors. Those sad sicklings in the lobby have no idea. If the past two shifts are any prediction of tonight, unless someone is having a stroke, an actual heart attack, actively bleeding out or claims they are suicidal, the wait is going to be a minimum of four hours. Poor saps.
The ER lobby is at least as big as the dining area of a fast food restaurant with similarly dejected faces and rowdy children running around. Luckily the security desk is front and center so they get to handle the brunt of the complaints and confused people looking for the coffee shop or radiology. Next comes the registration desk where they find out very basically why the patient is here, in addition to getting their demographics and insurance (if they have it). Finally there’s the triage desk where Kevin is now, required to have his butt glued to an uncomfortable desk chair and sift through the aches and pains to figure out which fraction of the people that walk in the front door are having a true emergency.
“Hey Rachel, can you call the next one?” Kevin takes a sip of his lukewarm coffee and contemplates taking five minutes to grab another cup from the stand around the corner while Rachel tries to track down the next patient. As he waits he overhears a father starting to check his son in.
“…and the tube of super-glue said to seek emergency medical attention if you glue your skin together.” The dad sighs. You can tell he’s already had a long day at work and the last thing he wants to do is bring his kindergartner to the emergency department and spend a huge chunk of what he made that day on copays.
Sometimes Kevin thinks hospital administrators and whomever it is that makes anything with a harsher chemical than H2O in it are behind this grand conspiracy to extract every extra dime they can from the general public. Lucky for this dad, Kevin’s 90% sure he can save them and their insurance hundreds of dollars and it will only cost the hospital about 2 cents.
“Hey Rosalie, freeze, stop checking them in.” Kevin reaches into his pocket where he keeps a generous supply of alcohol wipes and hands the dad two of them.
“Here, use these to gently rub along the area of adhesion until you can pry his fingers apart. It shouldn’t take more than a few minutes.”
“Thank you!” The dad looks hopeful and miraculously slightly less exhausted. If more people had alcohol wipes lying around and knew how to use them, this world would be a better or at least more sanitary place.
Kevin is busy congratulating himself at taking money out of the pocket of the greedy administrators he calls boss when he sees the next soon-to-be patient flop into the chair.
“She says her throat hurts.” Here we go again, Kevin thinks.
He looks up at the pair that waded through the flu-infested waiting room to force their way into his life and it’s not exactly what he expected. The mom is not a thrown together mess that put ‘bring kid to ER about sore throat’ on her to-do list in between buying groceries and picking up the non-sick kids from school. She’s mid-thirties, well dressed in a tan-ish sweater-thing with jeans that have subtle but strategically placed holes that makes Kevin think they would have cost at least as much as an eight-hour paycheck. The kid is also surprisingly well-behaved for being an ER kid, no fidgeting or grabbing things when mom’s not looking; she’s just sitting there with her hands folded in her lap, periodically swallowing and grimacing in response.
He goes through the rest of the Triage questions and it still seems like another overreacting parent taking their kid in for a sore throat that should have been treated at home.
Kevin starts to input the vital signs when he sees the dad of the other kid waving wildly in the background. “It worked! Thank you!” He calls out as he practically skips through the double-doors, dragging his kid to freedom.
Kevin smiles to himself and turns back to the computer then pauses as he looks at the number he typed for the heart rate: 128. A bit high, he thinks. Not abnormal for a kid fighting a fever or maybe a bit dehydrated.
“How old are you?”
The kid swallows then grimaces, “I’m 8.” Her voice has that raspy quality of someone who hasn’t spoken in a while. She sits back in the chair and glances toward her mom with a pained look in her eyes. Unlike many kids that come to the ER, she doesn’t appear to think this is a bit of an adventure. She seems to truly feel like crap. That’s when Kevin begins to take notice of her.
She’s a petite girl, tall for an eight-year-old and thin as a rail like so many other girls her age. She’s wearing a princess on her shirt and has pants that appear to be some sort of tights but thicker, one of the new things the girls are wearing these days. Pretty soon the men will be wearing them too, Kevin speculates.
She had removed her coat for the blood pressure reading and was wearing a thin long sleeve shirt. That’s why Kevin can see how labored her breathing is and how her ribs seem to be moving with every breath, far too rapid for any healthy kid. Dyspnic. Tachypnic. The words floated into his subconscious like the hints for an exam question.
He leans in close on a hunch, turning his ear towards her as he arrives mere inches from her throat. The girl doesn’t even flinch but stares vaguely towards her mother, eyes locked in a daydream. At Kevin’s apparent peaked interest in her daughter, the mother’s face grows more concerned.
In emergency nursing and emergency medicine in general there’s a tool called the pediatric assessment triangle. It assists a clinician in determining, right off the bat, how sick a child is based on their work of breathing, circulation to their skin and general appearance. By easily checking off the increased work of breathing and generally crappy overall appearance, this kid needs some help before she crumps. What he heard when listening close to her throat solidified his decision. He got Rachel’s attention and pointed to a wheelchair. She’s been working with Kevin long enough to know when to hurry and she goes to grab one at a clipped pace.
“We seem to have just had a room open up. I’ll have Rachel here help…” Kevin pauses to look at the name on her chart, “Emma into the wheelchair. I’ll walk with you so I can get a couple more questions in before the doctor takes over.” Rachel has already loaded the kid in the wheelchair and started for the badge-entry doors by the time the triage summary prints. He cuts in front of the patient and forces her mother to jog to catch up.
“So where were we, oh yeah, I forgot to ask about medical history.” Kevin never goes over medical history during triage unless the patient brought it up themselves.
“Has…” he has to look at the name on the chart again, “Emma received all her childhood immunizations?” Even as he asks the question, Kevin can feel the answer coming. There are certain things that working in the ED will teach you, Kevin likes to think of them as powers, like super powers. The longer you work there the more fine-tuned they can become. Some people can just tell when any patient is faking pain to get a hold of narcotics, even before they say they’re allergic to every NSAID and only Dilaudid works for their headaches. Or some can always find the urethra the first time in a confusing jumble of flesh that a hundred extra kilos will do its best to obscure.
Kevin once knew a nurse that could predict blood pressures simply by looking at a patient. And she was right by a margin of 5 points systolic and diastolic nearly every time. She was so confident that she rarely ever checked pressures on the machine and would chart how she felt the patient’s pressure was. That was pretty cool to see, up until she was wrong on a septic shock patient that ended up dying in the CCU. As the age-old saying goes, ‘with great power comes…still the need to actually check your patient’s blood pressure.’
Digressing aside, one of the things Kevin could usually recognize before words were said was when a patient or their family thought they knew better than their doctor, the medical community, or science in general. That little sense is what tugged at his clinical suspicions when the upper-middle class mom brought her daughter to the ED of all places, for what most people would write off as a sore throat.
At hearing the seemingly benign question, the woman gave an annoyed sigh and straightens herself up to her full 5’ 4” height. Her voice turned from that of a concerned parent to a condescending know-it-all “Unfortunately we let her have the first few until we realized all of the poisons these corrupt pharmaceutical companies put into their products. It makes me sad that they bully or bribe doctors into shaming so many people into filling their bodies with unnecessary chemicals.”
“I’m so glad you care enough to look into these things.” The look on her face turned rapidly to that of affection, the look of someone that knows you have their back against a corporate behemoth who exploits others for money. That’s when Kevin made sure they were just out of earshot from the kid. That’s also when he went in for the kill.
“You know, one of these unnecessary shots is to prevent the infection of a nasty little bacteria called Haemophilus influenzae type B, Hib for short. When given, the body produces a swell of antibodies that prevent this bug from infecting the body and potentially causing diseases like pneumonia or worse.”
Her face showed deep confusion, betrayal even; But you were on my side, she seemed to say.
“Sure, it could be something as simple as strep throat, a peritonsillar abscess, or something as uncomfortable as uvulitis but my guess is that whistling sound I heard when I leaned in close was epiglottitis. If we follow it back to your previous statement of no vaccinations, she probably has it after being infected with Hib.” Kevin made sure they were still out of earshot from the kid’s wheelchair.
“Just know it’s incredibly important that you stay calm and try to keep Emma calm because the more freaked out she is, the higher chance the swelling will completely cut off her airway and we may have to cut a hole in her throat to make her breath.” That last part was really just in the most severe cases but Kevin wasn’t going to tell this woman that.
The woman was silent as they finished walking to the exam room. They safely deposited Emma on the stretcher and told them the doctor would be in soon. As he closed the door he caught a glimpse of the kid’s mom crawling up next to her daughter in the stretcher. Kevin turned around and was met with a death glare from his charge nurse.
“That room had an ambulance hold on it, what in the hell are you doing bringing someone back there?” Well Evie was certainly in a mood tonight, although her British accent did have a way of softening her profanity. “I don’t remember getting a call from you saying you were rushing a critical patient back and taking the only fucking room we have in the whole ER. I am still charge nurse, aren’t I? I’m pretty sure I remember you making a lengthy and persuasive argument to our not so fearless manager against you ever having to hold the charge phone and pretty much make any grown-up decisions.” Kevin let her revel in her anger. Evie was a good charge; made decisions quickly and intelligently but most importantly didn’t take crap from anyone. He liked her well enough and didn’t want to embarrass her in front of the gathering crowd so he leaned in and spoke so only she could hear.
“Yes, I 100% should have called but by the time I reached you they’d of already got in the room and I would have lost it. Here’s the story: granola mom in there decided to not vaccinate her spawn and now the kid’s got a bad one. Sudden-onset throat pain, difficulty swallowing and there’s the kicker: audible inspiratory stridor. My money’s on Hib since mom confirmed she never got the vaccine.”
“A kid. Epiglottitis. Damn I hate you.” Evie spun on her heels and walked away without saying another word. Kevin called after her, “Love you too E!” He started towards the doctor’s desk but not before he saw Evie intercept the ambulance crew as they were turning the corner. They looked like they had won the lottery and actually landed a bed for their patient instead of waiting with their puking/crying/cramping patient before the EMS triage nurse got through the line of ambulance stretchers. Kevin could see the exact second they realized they would be waiting along with the rest of their comrades in the impressive line-up of ambulance crews. Both of their faces fell the same time their patient threw up bile into an emesis bag.
Kevin made it to the dictation desk where Dr. Parker was signing a prescription.
“Are you what passes for a doctor around here? You know they won’t accept a script signed in crayon, right?”
“You know nursing is for women, right?”
“Mostly women, where else would a guy like me get paid to spend every day surrounded by them?”
“What do you need Kev? Despite what you always seem to assume, I am busy. I also shouldn’t have to point out the backward way you go about asking me for something by insulting me first.”
“You know that’s what makes you take me more seriously than all the suck-ups. We’ve got epiglottitis in a non-immunized 8-year-old. I don’t trust the other idiots to not freak the kid out. Oh and also the mom’s an uber-granola type that would probably drink her own urine if Oprah told her it was healthy.”
Dr. Parker pulled up Epic. “Where?”
He and Kevin coordinated the timing of the girl’s room placement in the computer so there wouldn’t be an issue with Parker picking her up.
“I’ll keep you updated Kev.”
Kevin makes it back to the desk and Bradley is there to send him home.
“I see we have had an exceptionally busy evening Kevin, I trust the shift has not been too hard on you?” Bradley has a certain condescending way of speaking to everyone that makes them feel the instantaneous urge to punch him in the face. If he looks straight at it, Kevin can see a slight bend in the bridge of his nose where someone did just that.
“Yup, I saw you were taking over for me so I’ve been taking my time to do a full triage on each patient. The line’s pretty long now but I figured you understand the importance of making sure we have full medical history on everyone. That birth control question is always awkward on the 80-year-olds, am I right Brad?” Kevin gave Bradley a sharp nudge with his elbow.
“I’ll ask you again, please call me by my preferred and legal name, Bradley. If there’s nothing to report then I will see you tomorrow.
“Nope, nothing to report. I took care of all the tricky ones so you didn’t have to!”
“G’night Braddy boy.” Kevin ran off to grab his second 20 ounce white mocha of the day before having to clock out.