Featured

Disclaimer (or something like that)

Other gray nurse.png

This is a work of fiction. The author, in no way agrees with, condones or would ever participate in the majority of the thoughts or actions of the characters depicted in this work of writing (besides the epic life-saving things that happen, of course). Any similarities to real-life people, places or actual emergency stories are merely coincidental. Of course sometimes there is a blur in the line between fact and fiction. That blur can most certainly not be helped and if you find that in reading this the unruly visitor or annoying patient closely resembles members of your family or that face staring back at you in the mirror, maybe you’ll remember this and only ask for a blanket from the warmer every hour instead of every fifteen minutes. Either way, I’ll try to keep the fact in the hospital and fiction on the page.

I decided to write this for a few different reasons. People are continually asking me to tell them the most interesting, grossest, gut-wrenching stories from my work as an ER nurse. It’s not that I don’t like sharing those stories (preferably around the dinner table, much to my wife’s revulsion) but I’m not always quick on the spot with a story. And sometimes the most interesting (and character-revealing) cases aren’t the most bloody or grotesque. It’s just easier to write them into fiction than plan, outline, and try to make them as factual as possible.

This is also an experiment for myself. I’ve been writing for a few years now but never in this way. I had a blog for about a minute that sputtered and died when I went to nursing school and I’ve started a couple different books that I’ll come back to in the future. This is a way for me to show small samples of completed works that are part of a greater story. I hope you enjoy it. Message/comment/ask questions to your heart’s content, I’ll do my best to respond.

Advertisements

Episode 4.5 Blood and Stuff

Kevin exits the room and hears the alarm for a staff assist. He looks up and sees a flashing lights across the zone at the same time he hears someone calling for help.

Staff assists are frequently false alarms. To call one you simply pull the call light cord out of the wall. Easy to do by accident when you wrap it around the stretcher rail or if there’s not much slack and it falls on the ground. When you hear someone yelling help at the same time then you’d better book it to the room, there’s a good chance someone is either dead or trying to die.

 

            I’m going to pause here as the author and give you, the reader, a warning: some people might find this next part gross. It’s hard for me to judge what’s gross since I routinely go directly on my lunch break five minutes after cleaning up explosive adult diaper diarrhea. You might have hoped for more blood and gore in the previous episodes and been disappointed. I hope you won’t be disappointed any longer. If you’re squeamish, now’s a good time to cut your losses and part with Kevin on a somewhat amicable note. You’ve been warned.

 

Blood. Dripping everywhere.

At first it was difficult for Kevin to figure out what was going on. The blood was mainly coating the head of the bed; rails, sheets, the nurse; so he was pretty sure it wasn’t a GI bleed. The really bad ones leave a sticky pool of the stuff covering the foot-end of the stretcher, that or the patient leaves a bucketful on the John before they pass out from blood loss. But I digress, this was not a GI bleed.

After a few seconds Kevin was both finally able to make out who was attempting to assist the patient and what must have happened.

It was Jasmine, one of the nurse residents. Based on Kevin’s recollection, the residency would have started about two months ago so Jasmine probably had never experienced a scene quite like this one. She was frantically trying to keep the patient’s head turned towards the side so she wouldn’t choke on the blood that was sputtering out of her mouth. It looked like she was just finishing up with a seizure and if Kevin had someone to bet with he would guess there was a half-inch size chuck missing from her tongue. (Ya know, ‘cause of all the blood).

The patient had missed spraying Jasmine’s face with blood but that seemed to be the only area that had been spared. The tonic-clonic movements of the seizing patient had helped spread the blood over her crisp blue scrub top, pants and Dansko’s.

Jasmine seemed close to tears as she was trying to avoid the stuff and also keep the patient’s head tilted to the side. For the life of him, Kevin couldn’t figure out why she decided to turn the blood sputtering face towards her instead of away from her but he chose not to mention it. At least she was wearing gloves.

“Woah there Jazz, let me help you with that.” Kevin grabbed a mask with face shield and looped it around her ears (since her hands were coated with blood) then placed one on himself. He nudged her aside, stood at the head of the bed and placed his hands under the patient’s jaw to open the airway, holding her head away from where Jasmine was standing.

It took a quick glance for Kevin to realize the patient didn’t have an IV yet. He saw the cart and told Jasmine to start an IV so someone could give Ativan once they brought the code box in. He continued maintaining the patient’s airway, or what was left of it. He made a mental note to ask respiratory to deep suction the tongue chunk that probably tried to lodge in the patient’s bronchiole.

The patient’s seizing was beginning to slow down and to Kevin, Jasmine was taking her sweet time to figure out which vein she was going to poke for the IV. She carefully set out all her supplies, tied the tourniquet and methodically assessed the patient’s AC, forearm and hand veins. Kevin didn’t understand why she had to palp every possible vein on the patient’s arm when he could see two or three perfectly pokable veins from his vantage point.

“Doesn’t matter which one you pick Jazz, just need something to give Ativan if she starts to seize again.”

“Oh I know, just making sure I get a good one…” She trailed off as she went through the cycle of checking out each vein again.

“Okay, okay, just…be quick.”

Kevin glanced at the door, hoping Jasmine’s preceptor would get in here and take over. He was about to tell her to switch him places so he could start the line when the patient began to seize again, just what he had been afraid of. The slowing of movements was just a small reprieve; the patient began to convulse even more, spraying blood on the other wall.

“Just pick a damn vein!” He bellowed, trying to keep the patient’s head to the side so the blood wouldn’t clog her airway. With shaking hands Jasmine grabbed the chlorhex swab and rubbed vigorously on the patient’s arm. The patient’s arm was flailing so she had to anchor it down pretty hard with her right elbow and hold traction with her left hand. She tossed the swab aside and picked up a 20 gague IV catheter then plunged the needle deep into the patient’s skin.

Immediately as she did this, Kevin knew she busted through the back of the vein, a rookie mistake when you’re going too fast and forget to adjust the angle of the needle before sliding the catheter in. Easy to do when you’re in a rush.

“Come on Jasmine, you gotta back it up and decrease the angle. Didn’t your preceptor teach you how to do IVs?” Kevin was about to shove her aside and start the IV but at that moment a tech, Katelyn, and Jasmine’s preceptor, Rachel rushed into the room.

“Sorry! We were stuck next door arms deep in C-Diff, what’s going on here? Jazzy you need help?”

Jasmine responded with odd clipped words, “I’m. Fine. Just trying to—agh!” She had been digging around the arm, trying to thread the catheter in the blown vein but a deep bruise started ballooning out from the vessel she destroyed. She covered the bloody mess with gauze, slammed the retracted needle down and violently threw her gloves in the garbage, bringing her arms up to her face as she rushed out of the room. Her bloody footsteps following her out the door.

“What the hell was that? Kevin, what’d you do?” Rachel’s eyes narrowed accusingly.

“I didn’t do anything. I was just telling her we needed to start this IV quickly and she was taking her sweet time. It’s not like veins are hard to find on this patient!” It’s also not like he missed the juicy antecubital vein.

“Besides I was the only one in here helping out when your student was all alone with an obviously unstable patient, maybe you should have been keeping a closer eye on her.”

“Yeah, sure, on the patient that was brought in today just ‘feeling tired’? No seizure history, blood sugar stable in the field? I’m sure you would have been all over rushing in to start the line early. You’re such a jerk, don’t you remember what it was like to start your first IV under pressure?”

Rachel had taken Jasmine’s place and easily started the IV on an adjacent vein while she was talking to Kevin. Despite the fact that she wasn’t looking at him, it still felt like her eyes were cutting into him like daggers. He would have left already but was still holding the patient’s airway so he was captive to her verbal lashings.

“I remember plenty of times when even the great Kevin actually had to ask for help. I knew you were selfish but I thought you at least remembered when you were a resident.”

How dare she talk to him like that?  He wasn’t being overly cruel, he was just reminding Jasmine to speed it up. And to think that he could have forgotten being a resident! That was only three years ago, during the time…

Kevin suddenly felt the room shift and heard a ringing in his ears. He could feel the blood drain from his face and he didn’t have to see himself to know he was as white as a sheet. Then there was an odd sense of déjà vu and he knew he had to get out of that room.

“I-I gotta go, can you uh, Katelyn h-hold the—” He trailed off as Katelyn, a confused look on her face, took his place maintaining the patient’s airway.

The anger on Rachel’s face softened into one that might have been concern but Kevin was too busy leaving the room to see.

He glanced around for someplace to go, peeling off his bloodstained gloves and dropping them in a trash can. The room next door was mercifully empty. He could feel his heartbeat in his ears, pounding. He slid the door closed behind him. He laid on the stretcher and closed his eyes.

Most of his flashbacks happen at home, that’s where most of the memories were. But there are still a few that slide through while he’s on shift. Most are manageable but a few trigger his flight reaction. Things he regretted, times he should have been a better man.

Episode 4: Psych

 

Kevin was late again. This time of year always made the alarm easier to snooze, even with his annual 2-week-long road trip a couple days away.

As he rushes to the nurse’s station to check out his assignment he hears a horrendous noise coming from one zone over. It sounded like some sort of large mammal being slowly strangled with a rope.

“What the hell is that noise?” Kevin said to the nurses who were gathered around giving report to one another.

“Oh you’ll find out soon enough dear.” It was Evie, getting report from the night charge nurse.

Kevin eyed the schedule posted on the wall and found his name under one of his least favorite assignments.

“You stuck me on the psych wall today? C’mon, it’s my Friday!”

“I’m sure Beth would love to trade you for triage if you’d prefer?” Kevin took a quick glance at the waiting list that was growing before his eyes.

“Well played. I’ll take my chances with the Yeti noises. How ‘bout a hint on what I’m walking into?”

“Show up when you’re supposed to next time and you’ll get a hint, now off with you.” She jerked her chin in the direction of the zone in which Kevin was destined to spend the entirety of his day.

He sighed heavily but Evie just ignored him as he trudged through the smells and sounds of the ED to make it to his assignment.

He took over for Jaq; a bleary-eyed night nurse that always seemed to either be on the verge of tears or falling asleep, Kevin could never tell. His patient load consisted of a kidney stone workup, a teenage SI overdose on acetaminophen, a schizophrenic off her meds and whatever was making that horrendous noise.

The psych wall is no ER nurse’s favorite assignment. It’s loud, always smelled of stale urine and body odor, and there was never a finite resolve to most of the problems the patients came in with. Not in the emergency department at least.

The patients have to be medically cleared by the doctor, then it’s left in the hands of the usually overworked crisis counselor to evaluate the patients and determine the best and safest place for them. For many it’s a referral to an outpatient psych facility, for others it’s a psychiatric hospitalization in order for a psychiatrist to balance their medications and therapies, making sure they are safe for home. Ultimately, ER nurses want to be ER nurses, not psych nurses. So that’s what makes this assignment a special sort of challenge. The patients tend to make for interesting stories at least.


“So what exactly is making that noise Jaq? And don’t tell me it’s someone’s ‘support animal’ that got loose again.” The worst one was the “support pitt bull” that tried to bite any staff members attempting to provide care for the owner. Animal control can be a good friend sometimes.

“Well the ambulance drivers weren’t able to tell me much; just that he took some drugs, probably meth, and has been making those noises ever since they picked him up outside of McDonalds. But why don’t you follow him in, he might get more of a story than I did.” Jaq nods towards Dr. Meade who had picked up the chart and started walking towards the sounds of agony or ecstasy—Kevin wasn’t sure he really wanted to find out which.

“Coming in with you doc.” Kevin called out as he walked up behind the doctor.

“Sure, sure.” Dr. Meade is always off in his own world and barely gives Kevin a second glance. He slides open the door to reveal a tall, skinny man about 25 years old sliding around on the stretcher like his skin is inhabited by a hive of fire ants.

Most of the time when you see someone writhing like that in the ED it’s due to pain but the man on the stretcher was closer on the demon possession spectrum than anything else. His eyes stayed closed and along with the writhing he was letting out these embarrassingly loud animal noises every few seconds. If Bigfoot’s real then he might pay a visit to the department to find out why we’re torturing his son.

“What the hell are you doing meth on a Thursday for?” Well that’s one way to start an assessment. Dr. Meade was never known for his subtlety.

By all common sense that statement should have done nothing. The methed-out guy should have continued being his methed-out self; making his methed-out noises with his methed-out jerky body. But that’s not what happened.

What happened was methed-out guy (we’ll call him Jesse; Kevin knew a guy from high school named Jesse that’s probably also on meth right now) suddenly stopped all of his movements and noises. There was the sort of stillness in the air that only comes after a harsh and abrasive noise suddenly stops. It took Kevin a full second to make sure he was still breathing. Jesse slowly opened his eyes and stared directly at the doctor without moving.

If Kevin was honest, this freaked him out more than pretty much anything else he’d seen in the department. It felt like he was in the middle of a horror movie where one of the side characters that got lost and tortured at the beginning of the movie finally shows up to reveal something critical to the rest of the characters before he dies a horrific and bloody death.

The man slowly opened his mouth, causing Kevin and Dr. Meade to lean forward on instinct. He licked his lips, moistening his dried out meth mouth and prepared for a single sentence: “It’s Friday.” The silence following his statement was deafening.

The man slowly lowered his head to the back of the stretcher, closed his eyes and let out a loud moan.

Kevin broke that silence, “well I guess he’s more alert and oriented than you doc.”

“Hmfh.” Was all he said as he finished a quick exam of the patient and then exited the room. Jesse commenced his writhing and groaning. Kevin paused to cement the spectacle in his memory then left the room. You never know when you’ll have to paint a vivid picture of the true promise of drugs for an unsuspecting teenager.


The morning went quickly. The yeti-man got an IV, fluids and some benzo’s to calm down and shortly after that Kevin discharged the kidney stone workup with a script for narcotics and Zofran. Then the labs for the acetaminophen overdose came back with barely a bump on the radar so the patient fessed up that he made it all up to get out of a test today, had a stern talking to by the ER doc and was discharged to a pair of pissed-off parents.

Before he knew it, Kevin was sent on break, ate a quick lunch, and was back to a zone in chaos.

It took him a minute to find the nurse that was giving him a break. Luckily there were some pretty loud shrieking noises coming from a seclusion room in the back of the zone. All he had to do was follow the most insane noises.

“You can’t do this to me, the fluffy bird told me I would be your master! If you leave now I’ll tell them to set you freeeee!”

The woman they were restraining had a spit sock on that had loogies coating the inside of the mesh. There were four security guards holding her limbs down, two techs and two nurses going around locking the restraints in place.

“I hope you don’t have bad news for me Jen.” Kevin walked in the room and eyed the patient warily.

“Don’t worry about this one Kev, she’s gonna be Karen’s.” Jen grunted while tightening the thick straps on the patient’s wrist then pushing the metal clasp with all her strength until there was a resonant ‘click’. “You’ve got a different set of issues in your other rooms.”

“Not exactly what I like to hear but what do we got?” They stepped out of the room as the rest of the staff finished restraining the schizophrenic patient. Kevin could hear Karen start to recite how the patient will need to act to work her way out of the restraints but the woman just starts humming loudly and bangs the back of her head against the padded stretcher.

Jen tells Kevin that the yeti was starting to wake up again but with less noisy sounds than before so it might be getting close to his discharge. Kevin also inherited a woman that had been primed for discharge but claimed she would kill herself if she wasn’t admitted.

“Wonderful, counselor been in to tell she’s not suicidal yet?”

“She’s making her way down. Oh and here comes your fourth patient.”

They both turn toward the sounds of a man in a wheelchair being pushed by Derek, one of the MSTs. The patient’s making a noise that’s somewhere between groaning, crying, and screaming in pain

“Triage said he’s got some back pain, good luck with that.” Jen winked, handed him his work phone and spun on her heels to find the next nurse to break.

“Great.”

Kevin follows the wheelchair into the room and helps Derek carry/drag the man onto the stretcher. The man flops onto the sheet and makes nearly identical movements as the yeti man a couple doors down.

“Well it’s great to have a theme at least.” Kevin mutters to himself.

“Good luck with your ‘theme’ man.” Derek slaps him on the back and takes the wheelchair back to triage.

“So it sounds like you’ve been having back pain for…” Kevin references the triage note on the clipboard, “the past two months. Have you been in this much pain the whole time?” Kevin can’t keep the skepticism out of his voice.

“Yes!” The man groans.

“And what do you take for your pain?”

“Heroin!” Ah there it is.

“So what happened, did you run out?”

“Run out of what?” Oops, apparently the doctor decided to pick this time to start his own assessment.

“Hey Doctor Sharpe, Mr…Blake here has been treating his back pain with heroin. Seems like it hasn’t been working too well as of late.”

“Where’s your pain at?” Dr. Sharpe takes more of an interest than Kevin thought he would, performing a thorough assessment as well as he was able to with the patient continuing to writhe in pain.

“All right Kevin, I’m going to put in some orders. Can you do the MRI checklist and start an IV?”

“MRI check…oh, right.” He realizes it late, sometimes it’s hard to see past the veil of prejudice to consider there might be something to the pain.

IV drug users: heroin, cocaine, and meth addicts, among others, tend to not be the cleanest of creatures. When they use dirty needles or contaminated products they essentially break through the best defense the body has: it’s skin, and push those bugs into circulation. Most of the time the little pockets of bacteria, called abscesses, grow where they are injected: the dermis. Doctors can drain these, prescribe antibiotics, and discharge the patient home on the same day.

When the bacteria (which should never have gotten past the skin) migrate to the spinal cord, the abscesses that grow may cause extreme pain and could potentially result in paralysis. Oh the joy of IV drug use.

Kevin flies through the checklist, making sure a hidden tongue or nipple ring doesn’t get ripped out by the dreadnought of a magnet. He finishes the questions, starts the IV, gives some Ativan along with a touch of some pain meds and then a transporter is there to take him to the scanner.

 

Episode 3.5 Brooke

All things considered it hadn’t been a bad day. Brooke had been stuck with the same assignment for the past eight hours but she had turned her four rooms over twice already and was feeling pretty good about her contribution to the department.

That was one thing she was always very aware of; making sure she worked hard throughout the day and proving she was a good nurse. She was never one to sit around the nurse’s station and talk, even when all her tasks were complete. That might have been why her IV carts were always stocked, and also why she was finding it hard to find friends at work.

Brooke still isn’t sure how she landed her dream job as an ER nurse immediately after graduating but she feels like she’s living someone else’s life. Ever since she started the residency program it’s as if she’s been waiting for someone to jump in and tell her there’s been a terrible mistake and she has to go back to making lattes and smelling like stale coffee at the end of the day.

She had already given report on her patients but had told the night shift nurse that she would discharge the patient in room 29 before she left. This is the one that Dr. Parker said might put up a fuss since he wouldn’t be prescribing any pain medications for the patient’s chronic back pain.

“We wouldn’t be doing her any favors if we provided her the means to go outside her pain contract,” he had said. A nice thing about EDIE reports is that any ED can look up a patient and tell how many narcotics they’ve been prescribed in the past. Pain clinics can also provide information about patients that are undergoing chronic pain management. This patient had a numerous notes about narcotic-seeking behavior and was on a strict pain contract.

Brooke paused outside the patient’s room and settled her nerves before knocking on the door.

“All right Miss Patch, I spoke with Dr. Parker and he said he went over all your instructions for follow-up. Do you have any questions?

“Do you have my prescription?” There it is, the question that Brooke saw as a red flag—this discharge wouldn’t be as smooth as she had hoped.

She had overheard the patient speaking at length with Dr. Parker about her use of the ER and the need to follow up with her pain clinic if she wasn’t being appropriately treated for her chronic pain. He had even given her a shot of pain meds while she was in the ER but explicitly told her that she would not be getting a prescription.

Nursing school never trained Brooke for this particular situation. They always talked about ‘preparing for discharge even before the patient walks in the door’ and ‘make sure your care plan outlines all the steps for…blah, blah, blah’. In fact, all of the practical knowledge about how to deal with the patient as a person came directly from actually working in the department.        The vast majority of her textbooks were written by nurses that lived in academia, not the real world. Not one of them taught her how to deal with the scenario of what to do when a patient refuses to leave, not to mention all the nasty things they would say to her.

“Dr. Parker hasn’t written you for anything, what is it you were wanting?”

“What I need is Norco, I don’t know why it’s so hard for you people to understand. I told your doctor this but he obviously didn’t believe me: my backpack with all my pills in it was stolen and now I’m out of my pain pills.”

“I’m sorry, he never said…”

“I want to see another doctor! This one obviously doesn’t know what he’s doing.” With that statement she crossed her arms and laid back on the stretcher.

Now this was the real moment Brooke didn’t know how to handle. All she wanted to do was help people but this job continued putting her in a place where she had to misbelieve them. From people claiming they haven’t taken illegal drugs that show positive on a drug screen to those that will dance around the issue that really brought them to the hospital, she hates that there are times when she feels she just can’t trust anyone.

“Now you’re just standing there judging me with that look you all give, ‘oh that little druggie just looking for her fix.’”

Brooke knew she was just trying to make her mad but that didn’t make it hurt any less.

“No, it’s not that I don’t care, it’s just th—”

“You are not going to give me the ‘we care so much spee—YOU!” The patient was staring over Brooke’s shoulder with a mix of fury and something that just might have been fear.

“Hello Tamara, I heard you were making a fuss at my friend Brooke here so I decided to stop by. It seems like you keep misunderstanding your discharge instructions. Tell me what doesn’t make sense.”

It was Kevin. Here to help Brooke or just here because he disliked this patient, either way she couldn’t help but hope he was going to save her.

“I’m not an idiot Keh-Vin,” she had a strange way of pronouncing his name, “…I’m just sick of you people judging me for taking care of myself.”

“Call whatever it is you’re doing to yourself whatever you’d like, it’s time to go. I think you’ve used up your ER punch-card for the week.” She started to interrupt but he continued talking over her.

“And don’t give me the BS about you calling my manager or suing me or whatever line you’re using this week, it’s not going to give me a second of regret. Hell, I’ve already been to my manager today and she only checks on me every month so I’ll likely forget this interaction after everything else I’m sure to do this month.”

“How dare you, I’m going to—“

“Careful now, remember what happened last time you said you were going to get back at me.” Kevin was tapping a sign in the exam room that stated ‘threatening a hospital employee is a criminal offense’.

Tamara stared at him and her face turned red. She clenched her fists together a couple times then abruptly grabbed her purse, scattered her discharge instructions across the ground and stormed out of the room. It took Brooke a few seconds to realize that she was holding her breath and waiting for Tamara to return, which she never did.

She let her breath out slowly. “Wow, thank you. I honestly had no idea how to handle her.”

“She could tell an easy target when she saw one.” That stung but Brooke knew it was true.

“I mean, you just gotta come in with an attitude that you’re in charge and they can’t push you around to get what they want. You’ll figure it out.” He turned and started walking out the door towards the breakroom. Brooke quickly followed.

“Either way, no one deserves to be talked to like that. Though there are some that could certainly being knocked down a notch or two…” His voice trailed off and she followed his gaze toward one of the night nurses who was pushing an IV cart out of a room. The cart had two or three spent IV needles and several stray drops of blood on it.

It was Bradley pushing the cart, a nurse that never seemed to approve of any report she gave him. He usually had an air of superiority about him but Brooke could tell even from twenty feet away that he was flustered and had a sheen of sweat on his brow.

“You’re not one of them.” Kevin finished. Brooke supposed that was the best ‘you’re welcome’ she was going to get.

“Are you off now? We can walk to the garage together.” Brooke felt an odd desire to keep the fragmented conversation going. She also couldn’t help but let a bit of hope enter her voice when she asked him.

“I’m gonna shower before I head home. Good work with Tamara though, a lot of people would run begging the doc for a script to appease that addict.”

“Thanks, well if you hadn’t shown up I’m not sure what I would have done.”

“Just remember, don’t let them,” he gave a head gesture toward the department, “talk to you like trash. You’ve got to stick up for yourself and be tough sometimes.” They entered the breakroom and he started to walk away.

“Wait before you go, why was Tamara so angry with you when you walked in the room? It seemed like there was some serious tension between you guys.” He paused for a minute and she wasn’t sure he would answer her but he finally did with a sigh.

“She thought I was bluffing the last time I reminded her about the policy to threaten staff, ‘course she was threatening a lot more than just me; that time she was taken away in handcuffs.” Kevin turned towards the men’s bathroom to find his shower and raised his arm in a half-wave, “‘night Brooke.”

“Bye Kev.”

Episode 3: Trouble

As Kevin left the room with the code box in hand he heard a sing-song voice that could only belong to one of his nurse managers. “Keeevin! I need to see you in my office as soon as you can!” He can barely even tell their voices apart anymore. You’d think being here for nearly a decade would help him distinguish between those he reported to but they just seemed to meld together anyways.

He turned towards the voice. At least it’s Kathy and not the Other One. Kevin raised the RSI kit in acknowledgment and as an excuse to delay for at least the next few minutes. But not too long.

There was a time when Kevin would try and postpone such a cheerfully ominous meeting but he realized from those years of experience that it was just easier to meet than to draw out the inevitable. They seemed to be relentless about these sort of things: peppering him with emails on his personal address (since it had been years since he checked his work email), pestering him in the halls and generally just wearing down his resolve until they got him into their office.

It took a disappointingly short period of time to track down another nurse, waste and return the appropriate medications then make his way to Kathy’s office. He walked in without knocking and flopped down on the chair in front of her desk.

“Okay, just to be clear: this isn’t about another Daisy award is it? I keep asking people to stop nominating me for those and give the other nurses a chance but I guess people can’t ignore quality nursing when they see it.”

“Oh Kevin, always the jokester aren’t we?” There was an unusual amount of bite to her response. “But no, unfortunately this is about a few of the complaints we have been receiving from your patients about you.” This should be entertaining, Kevin thought.

“The first of these is from a twenty-seven year old woman that was being seen for back pain. As best I can tell from her complaint, you told her she couldn’t have any narcotic pain medications. The charting is a bit unclear as to what had happened but it appears that she argued with you and then you rebuffed with an explanation that she demonstrated classic signs of narcotic seeking behavior.”

“She was though! I even remember this one, she was saying some very unfriendly things about her doctor.”

“It says here you told her she was acting more immature than your three-year-old when she’s throwing a tantrum. To which she replied she doesn’t believe you have a daughter and if you do then prove it with a picture. You then called her a pedophile and conveniently avoided the room until she was up for discharge.”

“That’s absurd.”

“Are you saying she’s lying?”

“Yes she most definitely is. I told her that there’s no way I can be certain she was NOT a pedophile and since one can never be sure if someone is a pedophile, how dare they share pictures of their kids to total strangers? I then avoided the room to save her from the embarrassment.” Kathy took off her glasses and rubbed her eyes like she was trying to push them back into her skull. When she began speaking again there was less of the syrupy cheerfulness in her voice and more of the bite.

“You do know I know you don’t have a daughter, right? You also know that I have to go through each of these complaints and account for your actions?”

“That’s why I don’t envy your job. Though I must be doing better, this is the first time this month you’ve called me into your office and the month’s almost over!” Kevin attempted to stand but Kathy gestured him back to his seat. He stayed though only on the same principle that led him to get the inevitable over with.

“There are too many complaints about you Kevin, we had to boil it down to a greatest hits once a month to save on time. Why don’t we just skip to the last one? This was from a patient with a two inch laceration that needed sutures: ‘after I told my nurse I was in 10/10 pain, he asked me if I would be in any more pain if I were punched repeatedly in the face until my nose was broken.’ Kevin, what the hell are you doing threatening patients?” This might have been the most irritated Kevin had ever seen her.

“I never once said that I would punch a patient, you read it there for yourself: ‘if I were punched repeatedly’ not ‘if he punched me repeatedly’, completely different scenarios. Besides that would go completely against the nursing oath I took when I graduated school. I’m pretty sure there was a line in there about ‘trying my best to not hit my patients or threaten them, unless they threaten me…’ something like that. Besides I told her that to put the pain scale in perspective, there’s no possible way a two inch lac on her arm was the worst pain she could imagine. Aren’t we supposed to educate people?”

“Kevin first of all, you never said an oath after you graduated nursing school. Secondly, there are things you just can’t say to your patients! Despite all that you’ve been dealing with in the past couple years we still need to address the way that you interact with those that come in the front door. We’ve been giving you a bit of leniency up until now but the interactions with your patients need to improve drastically in the near future. If these complaints continue, the next step will be formal probation and potential termination.”

She certainly had bigger balls than Kevin had given her credit for. A part of him respected her for that. The reckless part of him wanted to just quit there on the spot, yell something about how this hospital didn’t appreciate quality nurses and they only cared about sucking up to the patients.

Then he’d probably say something horrendously personal that would cut to her insecurities and make her forever question her own worth. That was certainly something he was good at; finding something personal that made someone self-conscious then exploiting it for his own sick ends.

He was sure he could get another, higher paying job by next week; respond to one of the dozen recruiting emails he received every month or maybe try that travel nursing gig and bounce from hospital to hospital. But thankfully he hadn’t sunken to such lows yet. There was something stronger that held him back. This hospital held both good and terrible memories that he wasn’t yet ready to part with.

“I will work on how I treat those people, Kathy.”

She seemed to be expecting a response closer to Kevin’s initial thoughts, or at least something sarcastic but wisely chose to give him the benefit of the doubt. “Thank you, that’s all for now Kevin.” She stood from her chair and opened the door for him. The look on her face made it seem like she wanted to say something more, something motherly, but Kevin left before she committed on anything.

He left the office and walked back to his rooms, unsure if anyone had even been covering for him during the intubation, let alone the impromptu meeting. It was about five minutes to shift change so he could at least catch his bearings before having to give report on whichever patients he might have to hand over.

The track board showed that of his four assignments two rooms were closed, one was up for discharge and a belly pain had just been picked up by a doctor. There wouldn’t be any orders yet but if he was feeling generous after the discharge he might help the nurse taking over for him by starting the inevitable IV and labs that would be ordered. He removed the holds on the other two rooms, letting the triage nurse know they could use them for the waiting patients and grabbed the discharge papers for the patient that was ready to go.

“Hey there, I’ve got your papers. Do you have any questions about what the doctor went over? The kidney stone should pass in the next couple days but you can take the pain meds we prescribed to get you through the worst of it.” Kevin sat down on a rolling stool and began removing the young man’s IV. “You can pick up your prescriptions in the pharmacy on the way out; looks like Norco for the pain and Zofran for nausea. Just make sure you don’t drink or drive while taking the Norco and you’re going to need to get a ride home since we gave you all that morphine here.”

He winced when Kevin ripped off a patch of hair with the tape that held the IV catheter in place and taped down some gauze to cover it. Rubbing the spot on his arm, he stood to get dressed.

“Well about that; I wasn’t able to get a ride home, I told the doc I could get a cab since you guys gave me the pain meds here but those things cost a ton these days. Besides, it’s not like anyone can stop me from driving. It’s my own car!” He gave Kevin a look that seemed to say he made up his mind about the issue. A challenge, maybe.

“Hmm, interesting.” Kevin said. Then he rose and walked towards the door. The man might have thought Kevin was going to just leave there with little more than a second thought but instead of walking through the opening, Kevin just slid the door shut and turned to face him. With Kathy’s warning still ringing in his ears he began vigorously editing away the first things he was planning on saying. Apparently he really did want to keep his job.

Kevin knows he isn’t physically intimidating, 5’ 9” on a good day and a despite actually being in good shape from moving dead weight patients around, his scrubs had a way of hiding any sort of muscle behind their pajama-like appearance. The thing he is pretty good at is shaming people, and logical arguments, but mostly the shaming.

“The thing is…” Kevin had to look at his name on the discharge summary. “Ben, there really isn’t anyone stopping you from getting into your car and making the bad decision to drive while under the influence.”

“Oh come o—” Kevin held up a hand and cut him off.

“Alcohol, narcotics, pot; you drive after taking any of those and try to explain to a cop how you’re ‘fine to drive’ on any of them. I’ve seen it firsthand when people choose to take the chance and end up paying with their lives or the lives of others…”

Kevin’s words trailed off and his eyes lost focus, remembering. For the most part he was able to compartmentalize the horrors he saw on a daily basis but that day always stuck with him…

“And anyways, I’m off in about a minute and if I’m the least bit suspicious you will still decide to drive, I’ll call up one of my police buddies and have him follow you home. I’m pretty sure a DUI isn’t worth the thirty bucks for a ride home.” That last part was a bluff; Kevin didn’t have any friends, let alone the cell number to a police officer but he felt it got his point across.

“All right man, fine, you win.” There was a resigned sort of way he said it that led Kevin to believe he was telling the truth. Logic wins again.

Despite that, he was still going to tell the security guard out front to make sure he called a cab instead of driving himself home; this job taught him a lot about how much you could trust others. With nothing else to say, Kevin opened the sliding door and left the room.

He slowly closed the door behind him and held onto the handle for an extra second. No matter how fleeting, the flashbacks always left him a bit rattled. He did pretty well at keeping those memories bottled up but they always seemed to take on a life of their own this time each year.

Kevin went back to the nurse’s station and finished his charting on that last patient before he discharged him out of the computer. As soon as he hit the ‘discharge’ button he heard The Swarm approaching.

Unlike on a med-surg floor, in the ED people start at all hours of the day (or night, if that’s your thing). There are shifts that start as early as 5am and as late as 11pm with everything in between. There are typically also enough open shifts that you could piece together a custom shift each time you work by adding on hours before or after your usual start time. Despite all of this, by and large the most common times for people to start their day is at 7: am or pm. This was the night crew he could hear coming around the corner.

Leading the charge was Spike. That, of course wasn’t his real name but Kevin had a hard time remembering names and decided it was just easier to nickname everyone whose name he couldn’t remember. Spike got his name because he always lathered his hair in what Kevin assumed was beeswax or actual glue because of the shapes he was able to create; today’s was a 6 inch mohawk. Flanking Spike were Muscles and Chest Hair who were followed by Barbie 1, Barbie 2, Tall Barbie and Ken (not his actual name, he just always followed the Barbies around and looked like he stepped out of an Abercrombie and Fitch ad), then came Flirt, Spray Tan, Garlic (breath), and Lashes.

You probably think you can assume the gender or at least the physical appearance of each individual but here’s a clue: Spray Tan’s a man and Muscles is a woman. I’ll let you guess the gender of Chest Hair.

Part of the swarm broke off, settling in Kevin’s zone and the rest moved on to their assigned work areas. After simmering in the smells of vomit and body odor for the past twelve hours, the sight and smell of these freshly washed, perfumed, make-uped (we’re gonna pretend that’s a word) people made Kevin want to cry. It was an experience every night that simultaneously made him want to awkwardly sniff at everyone that walked past yet stay far enough away so he could keep his undoubtedly sub-par stench from mingling with theirs.

He saw people dispersing, searching for the nurses or techs they would be taking over but after the dust settled and everyone had paired off he realized there was one nurse missing, his relief. No sooner did he stand up and start walking toward his rooms than he nearly ran into…

“Braddafer! Do you get the pleasure of taking over my patients again?”

You could usually count on Bradley to get to work and clock in a couple minutes early so he could silently judge all the people that arrive two minutes later than him. As best Kevin could tell, Bradley had been lurking in the zone, reading the history on the patients he was about to get report on or doing something equally annoying like answering call lights and making sure the patients he spoke to were aware that he was doing them a huge favor by helping them since they weren’t his patients.

“Kev—that’s not even a nickname, you made my name even longer than what I go by.”

“I know, confusing right? Anyway, why don’t we go into the next room and do a little bedside reporting like you love so much, eh? And can you grab the IV cart? This one’s gonna need a line.”

“But you never want to—yes of course we should do that. After you.” Bradley said, taken aback. Kevin led the way into one of his assigned rooms, the patient he hadn’t seen yet.

“Hi there, my name is Kevin and this is going to be your nurse for the evening. His name is Bradley but he prefers to go by Brad.” Kevin went to write ‘Brad’ on the whiteboard and could almost feel the glare tickling the back of his neck. It’s as if Bradley was incapable of learning from his previous Kevin encounters and foolishly believed Kevin could change. That or he had masochistic tendencies and enjoyed the torment. Either way Kevin felt it was his duty to keep his self-righteousness in check.

“Now Brad here has a heart of gold, I know it sounds silly but his policy is to update you just as soon as each lab test or scan result comes in. If you haven’t heard from him after thirty minutes, just hit the call light and he’ll be sure to come running. Blankets, ice chips, whatever it is you need; he will be sure to bring it to you. He just loves to feel helpful.”

Kevin could feel the glare increasing in intensity and he turned to look at Bradley. There was a painted on grimace that probably started as a smile but each word from Kevin’s mouth drained the life out of it. Bradley was probably imagining the wasted time with questions and requests until the patient was discharged.

“Now I told Brad here that he could try to start your IV and it looks like he’s brought his little cart in with everything he needs. He’s definitely been getting better at this, don’t worry about the shaking hands; he should still be able to start your line and get some blood work started. That still sound okay with you Brad or would you like me to do this for you?”

The woman’s eyes were wide with uncertainty but Kevin had picked his subject well, she seemed to be the easygoing type that would have probably volunteered a new nurse to practice on her. The irony was that Kevin had been a new nurse under Bradley’s supervision when he first started.

“I can do it Kevin, you can go now.” He forced the words out through clenched teeth and Kevin decided not to press his luck on Bradley’s patience.

“All right, well just call me if you can’t find a vein like you did last time. I don’t mind helping you out before I leave.”

Kevin turned and walked past the IV cart, there was a moment there when he felt like Bradley was going to slam the cart into him. The look in his eye told him as much. Then he passed the cart and reached the door to safety. He smiled to himself as he closed the curtain.

It’s not that he hated Bradley or even disliked him that much. It was just that Bradley was too easy for Kevin to let out his daily frustration on. It also didn’t hurt that the majority of the department loathed him for his condescending tone, the way he always made unnecessarily minor adjustments on pointless things and just being a generally horrible coworker. He and Bradley were both a sort of outcast though Kevin chose to believe his own situation was self-imposed and Bradley’s was innate to his personality.

Kevin checked his pockets for any drugs he needed to waste. Finding them reassuringly empty of narcotics, he started walking back to the breakroom to shower off the stench of the day.

 

Episode 2: Tubes

The ER of the movies and TV is different than the ER of real life. People don’t come in with gunshot wounds, acute MIs and ruptured appendices (appendixes?) every five minutes. If they did then just based on simple math, a significant number of them would die before anything could be done (unless of course you have a limitless supply of nurses, doctors and exam rooms). The thing is that all of those conditions do happen, in addition to others that are, frankly, more difficult (or at least less straightforward) to manage in the ED. Things like septic shock, DKA, CVAs and surely several other three-letter abbreviations.

Sometimes those conditions happen to the patient of a nurse that has three other complex (or equally needy) patients. In a perfect world there would be enough float nurses to alleviate the stress of such a burden. In the real world even the float nurse (if there is one) is busy starting IVs on heroin addicts, helping restrain a homicidal/manic/schizophrenic or answering that damn ambulance phone that will sometimes ring ten times an hour.

One of the less glamorized conditions that frequently requires 1:1 nursing care is a head bleed, especially in a patient that has a decreased level of consciousness and is going to be intubated. Exactly what’s about to happen to Kevin’s patient right now.

Now I could bore you with details about each type of head bleed and dazzle you with terms such as “mid-line shift” but that’s frankly beyond the scope of an ER nurse’s immediate management of such a patient. I would also have to dust off a textbook or two and work far too hard to remember the difference between subdurals, subarachnoids and all the other subs (see, still took that opportunity to dazzle you with terms anyways!)

In preparation for a procedure such as an intubation it’s ideal to have a tech or two, two to three nurses, two doctors and a pharmacist. But during the busy days that dream team will rarely come together. What Kevin gets to work with is a resident physician (still in training), his attending (board-certified doctor), one other nurse and one tech. Barely enough to do the job but you know what they say about beggars…


“Okay everybody! I’m going to need 10 cc’s of Etomodate and 50 of Roc ready to intubate. But make sure you actually draw up 20 of Etomodate in case we need to give it. And make sure we have an ambu bag ready. And suction!” The resident glanced around the room with a look of concern as if hoping for someone to challenge his requests. Everyone was already busy setting up the room and Kevin was the only one paying attention to him. “And can we move the gurney away from the back of the wall? I’d love to not have to sit on the counter while I tube him.” The resident smiled halfheartedly and those that heard him were oblivious to his attempt at a joke. He continued rambling about how he wanted the room set up but Kevin was attempting to zone him out so he wouldn’t make a medication error.

There’s a certain rhythm and flow to medical speak, something that is gradually acquired as you spend more time around it, just like any second language. And similar to a second language there are those who are more proficient at it and some that should just speak English. The meaning of words like appy (appendicitis), S.O.B. (short of breath, not the other SOB, though sometimes both abbreviations are appropriate) miggs (referring to milligrams) or CC’s (cubic centimeters) if you’re old school. Knowing that 4 of morphine, 20 of dilt or 2 of Dilaudid all refer to milligrams but 25 of Fentanyl refers to micrograms.

At this point in the resident’s career he was attempting at medical speak with a hellish accent. It was as if his medical school consisted of House and Gray’s Anatomy reruns combined with How to be a Doctor for Dummies. Kevin decided that if he started calling everyone around him “orderlies” and began talking about transferring the patient to the “ward” he was going to demand the resident show his credentials before he would follow through on any of his future orders.

The resident was one of the older ones, someone that probably decided mid-career he was going to fulfill that childhood dream of becoming a doctor and go back to school in his thirties. The guy’s probably pushing forty now; his once jet-black hair is now mostly gray and the worry lines on his face undoubtedly aged him an extra decade.

To his credit, he did glance over to where Kevin was drawing up the meds and did a double check on the sedative and paralytic. Even experienced providers will make a mistake and over-sedating a patient is not one of the ‘acceptable’ med errors, as if there were any. There are certain things Kevin will bend the rules for but giving a patient “just a touch more” Ativan than ordered or “accidentally” bolusing propofol to knock someone out is a medical error entirely outside his playbook.

He was pretty positive 10 of Etomodate was going to be sufficient sedation for the patient that hadn’t even been arousable to an 18g IV in his wrist but he chose to take the high road and actually follow through with the resident’s request to draw up 20. When Kevin made suggestions to people they didn’t tend to be gentle; ruthlessly condescending and bitterly sarcastic were a few of the terms people had used to describe his helpful recommendations. The last thing he needed was a resident cracking under the strain and bursting into tears immediately prior to inserting a tube down someone’s airway, again. There will be plenty of time for breaking the new doctor in at a later date.

“Oh sh— did someone call RT?” The rezzy looked up, still flustered.

“I’m here, I’m here.” Jess, the respiratory therapist swung around the corner, pushing a respirator past the small collection of staff.

“Hey Rez, you want lidocaine for this one?” Kevin was trying to pull him back to the present and gestured towards the code box sitting on the back counter next to him. At his comment the resident stared at the bright orange box, his eyes out of focus. It’s a look Kevin’s seen many times with these ER residents, the look of the search engine starting up and the medicine lists scrolling. Lidocaine: topical/local anesthetic used to relieve pain—nope. Other uses: antiarrhythmic—ding, ding!

“Why not, how about we start with 100 cc’s. Good idea.”

In all fairness it was a drug that Kevin had only just seen used on his last intubation, also with a resident. Apparently the insertion of the endotracheal tube can cause cardiac arrhythmias; specifically in head injury patients and especially when not done smoothly (i.e. when an inexperienced doctor, like a resident, does it). A medication like lidocaine is used to stabilize the conduction pathways in the heart so it doesn’t start firing off electricity and generally just freaking the heck out when a pseudo-skilled doctor inserts a glorified PVC pipe down the patient’s throat. Kevin cracks into the code box and pulls out the appropriate medications.

At this point he’d like to say he’s on autopilot, drawing up medications, making sure the IVs are all patent and simultaneously charting everything that’s going on in the room down to the time each staff member arrives. In reality he’s still making sure the appropriate drugs are in the appropriate places and second-guessing the double-check the resident performed when he was obviously distracted by this being one of his first intubations in an unfamiliar emergency department with unfamiliar and unfriendly staff members that probably wish he would just go away and let a real doctor take over. But really, Kevin’s fine.

He was finally comfortable that all the medications were properly drawn up and labeled so he turned to the computer at the back of the room to begin charting the pre-procedure stuff when he heard his name from the door to the room.

“Hey Kevin…?” The quiet voice floated across the room. It somehow cut through the rest of the noise. “Room 40 was wondering if they could have some more pain meds…” The voice trailed off when its owner locked eyes on the nurse in question.

Kevin has never hit a woman and has generally stayed away from any physical altercations; that being said the look he gave Brittany had a gravity to it that was nothing less than physical. It was so full of wrath that she took a step back, gave what could only be described as a whimper and shuffled back the way she came. After she left Kevin tried to remind himself to give her some sort of an apology when he saw her next.

He looked around the room and realized they were ready, the resident had the ET tube and laryngoscope, Jess was in place with the respirator, one of the new techs was taking vitals and the other nurse, Dez was finally able to help give meds.

“Here!” Kevin pushed the pile of meds, towards Dez and opened up the sedation narrator. She only looked as flustered as he was for a second before she realized they were already drawn up and labelled.

“Okay so were going to be performing an endotracheal intubation on Mr. Scott here. We will be using Etomodate to sedate and Rocuronium to paralyze for intubation. I will be performing the procedure with Dr. Seer assisting. Does anyone have any questions? Concerns?” After that mess of a pre-procedure, at least the resident knew how to do a time-out. They probably had a whole class about it in med school now—the syllabus detailing the importance of making sure you’re doing the right procedure to the right person, not amputating the wrong limb, and counting your tools so you don’t leave something in a patient during surgery. It really is the little things…

“Okay push the Etomodate now, just 10 to start.” Dez did as ordered and Kevin wrote it on the whiteboard next to him with the corresponding time, 18:05.

“And now the Roc. 50 please.” Dez did as instructed and Kevin put it on the board. Jess had been pre-oxygenating the patient and put the ambu bag aside to make sure she was ready to hook the respirator up.

“All right, here goes.” The resident opened the airway, held the tongue down with the blade and stuck the ET tube down the patient’s trachea. Everyone paused as Jess checked the CO2 detector and determined that the resident hadn’t started filling the man’s belly full of air instead of his lungs. She nodded and got to work securing the tube and hooking the patient up.

Kevin began to chart the times of the medications, the patient’s vitals during the procedure and by the time he looked up the room had cleared out besides Jess, still fiddling with the respirator settings. It never ceased to amaze him how much time it took to prep everything, get everything in place and make sure everyone knew what their roles were. Then just as soon as everything is ready the procedure is done and everyone involved takes off. Kevin likened it to a good meal in that way, at least that’s what he’s been told. Lately the most complicated meals he’s been cooking have been ramen with an egg dropped in.

He tried to finish charting but saw that the chest x-ray order was just added to confirm tube placement and like any good nurse he knew it was best to have all the tubes in the right place before excessively radiating someone.

That’s another thing about the ER and probably about the medical field in general: the more you need others to care for you, the more tubes you get. If all that’s wrong with you is too much vomiting, you’ll just have an IV to get fluids and nausea meds. If the fluids are coming out of your back end too much you’ll get a rectal tube or ‘fecal management system’ if you want to call it a more proper term (literally a tube up your butt, secured in place by a gigantic balloon that lets your diarrhea drain into a bag; not the most pleasant of experiences for anyone involved). For those as sedated or unresponsive as Kevin’s patient, they get the works: multiple IVs, an ET tube, an OG tube and a catheter at minimum.

The first after the ET tube would be the OG—orogastric. This one goes down the throat, fist bumps the ET tube and heads into the stomach by way of esophagus: either that or it coils in the patient’s mouth until a more experienced nurse is able to coax it down the right way. Kevin slips that one in no problem.

Next comes the Foley, something he fervently hopes will never happen to him. It’s hard for Kevin to think anything can possibly go that far up a man’s junk without serious psychological or physical scars. After a bit of shoving and twisting he gets it past the swollen prostate and into the bladder where he’s rewarded by a flash of dark yellow urine down the plastic tube. He’s just glad the man’s sedated for this.

Kevin goes through his mental checklist and determines that all the tubes are in the right place. Now just to chart them…

“Have you been taking care of Mr. Scott? We’re here to take him to surgery, now!” A crowd of people materialize in the room as if beamed in, led by a tall man who must have been the surgeon or anesthesiologist barking orders to no one in particular. He began asking questions about the patient’s condition and medications he was given and “The head of the bed needs to be 45 degrees, don’t you dare go higher!’ that was directed towards the surgical staff prepping the patient.

Kevin answered as fast as he could, barely having enough time to be annoyed at their intrusion into the room. It took him a minute to even process that the patient was going to be having brain surgery to fix the bleed. No one, let alone the resident, had told him that emergency surgery had been scheduled until this moment. Par for the course…

Suddenly x-ray appears and everyone is whisked out of the room for the bedside scan of the patient’s chest. The surgeon or anesthesiologist, whomever it was that Kevin was talking to, was replaced by the surgical nurse. She seemed, if possible, less interested in the report than the doctor was.

“He’s got two IV’s, an 18 in his right wrist and a 20 in his left AC.”

“Mmhmm.” She didn’t even look at Kevin and didn’t seem to be listening to him as she went through a pre-op checklist independent from what he was telling her.

“Prior to the intubation we threw ice water on his face to make sure he wasn’t faking it, once we dried him off we determined that he did in fact have a GCS of 5 and went through with the intubation.”

“Ice water, good…wait, what did you do!?”

“10 of Etomodate and 50 of Roc, weren’t you listening?”

“Yeah I was but I thought you said…never mind. Anything important to note about the intubation?”

“Nope, tube went down like a lubed up…well, went down fine.”

“Okay, great. Very good. Um, thank you.” Some people were born to only ever deal with unconscious patients.

As soon as they finished their rushed report and before he can think about what just happened, the patient is whisked away by the crowd of strangers and Kevin is left in the dirty room all by himself. He turns back to the computer.

He finally finishes charting the meds and tubes and drains and looks around at the disaster that the exam room has become. The garbage is overflowing with dirty gloves and the packaging from a dozen or so different supplies; a small mound of refuse litters the ground around the metal container and attests to the lack of basketball skills of medical providers. In the space that the stretcher vacated there are old blood stains that had probably been there for the past dozen patients, congealing on the floor for hours. The back counter is littered with a half-dozen empty vials and the RSI kit with meds that needed to be accounted for.

He sighs, leaves the mess and grabs the RSI kit. Tonight’s gonna be one of the nights he leaves it to the tech to clean up alone. Besides, there are meds to account for that would probably have a high street value if left unattended. He locates the Fentanyl and rolls it between his fingers, reading 100mcg/2mL under the tamper-resist seal. His heart starts pounding as he sees sublimaze on the side of the vial, remembering…but no it’s not worth dwelling on what he might have done back then. He replaces the unopened vial and walks out of the room.

Episode 1.5

Kevin walked to his car, a six year old Camry that had twice as many miles on it as it had any right to have. He was alone, freshly showered and out of his stale smelling scrubs. It was more efficient to shower at work, less hassle. The main reason he did so was to avoid the group of coworkers that would linger and want to walk with him, sharing in the inevitable small talk that people make when they’re forced to be together. What was he doing on his weekend off? Does he have any vacation plans for the summer? How’s your spouse/kids/mother? Why can’t people just walk together without saying anything?

They asked again. A small group was going to The Shot for after work drinks. A different group than last time, some of the newer nurses that hadn’t known him from before. For some reason people still think he would be fun to bring to the bar scene, as if they would really want to hear what came out of his mouth after a few. Besides, don’t they spend enough time around intoxicated people at work? Though, of course those that live with a blood alcohol above 350 tend to not be able to afford a drink in a bar. Much more efficient to crack open a bottle of the hard stuff and pass out at the grocery store down the road. That would guarantee you a free ride to the ER, a bed to sleep it off in and virtually no repercussions. What were they going to do, sue you for your piss-stained pants?

Kevin couldn’t remember which excuse he used this time. Just that it wasn’t the truth— that he had a bottle of Grey Goose chilling in his freezer at home and he preferred to drink alone.

It’s harder at night, the memories seem to float to the surface amidst the buzz of the fast food signs and the glare of the oncoming headlights. Was it just him or were the headlights getting brighter and more offensive every year? They never seemed to bother him in his twenties, when the night seemed more of an open template than a closed book. He was going to technically be in his mid-thirties this year, with the few gray hairs multiplying faster than a pack of horny rabbits. There was a time when he cared more about his appearance but his slow transition to middle-age with the receding silver hair and failing natural fitness came with a “don’t give a crap” attitude.  His wife used to…

Working in the Emergency Department had a way of keeping his mind occupied. There is always something to busy yourself with, something to fix. IVs to start, medications to give and wounds to dress. Life is more real there, the problems tangible and if the solutions aren’t immediate then there are surgeons, specialists, or morgues.

Kevin pulls the car in the garage of his town home and kills the engine. He sits in the driver’s seat as the popping and cracking from under the hood dies out. It’s 8pm and despite his exhaustion he feels a long night ahead of him. The insomnia wouldn’t be so bad if he could just turn his brain off. Luckily the alcohol helps with that.

For some reason he can’t get the kid off of his mind. The one with the granola mom. She’ll be fine with Parker, Kevin has no worries about that. It’s just the look she had in her eyes, the one that told him her story. That life just got real, so much more real than the princess on her shirt. Kevin hopes that after this episode she can go home and forget about the time she had to spend the night in the hospital. That her life can get back to fairy tales and happy endings. Once you grow up you realize some stories end in tragedy.

Episode 1: Winter is (Still) Here

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.”

“Yup.”

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!”

“Goodbye, Kevin.”

“G’night Braddy boy.” Kevin ran off to grab his second 20 ounce white mocha of the day before having to clock out.