The shift starts out like any other. I get report from the outgoing charge nurse, I have complaints to deal with, nurses that want to bitch about something trivial, doctors who aren’t happy with the flow in the department, families that are mad they are waiting for what they consider to be an exorbitant amount of time. I’m barely awake, still shaking off the haze of a rough night the previous night, and the night before that, and the night before that. The days start to run together when you work night shift. When you arrive at work it’s one day, then it’s the next and you leave work, but it’s still the same day when you come back that night. It’s enough to drive anyone to madness, but this is my life. All 13 years have been spent in the same ER. I walk through the ER, stopping to say “Hi” to a few staff members, the docs are glad to see me. They usually are because it assures them that their one or two shifts a month they spend on nights isn’t going to be a complete clusterfuck because I’m here, and they know I don’t take any shit. I settle in and start writing reports, doing assignments for later, answering emails and dealing with problems. In addition to running a Level 1 trauma center, I also have to field phone calls from patients or their families that have been seen recently and have questions, I have to do staffing for the next day, I have to complete all the log books and checks that need done in a department this size. It’s not an easy job, and I don’t get paid much more than the regular staff nurse who is only responsible for 4 or 5 patients at a time. I don’t have time to get even my log done before the traumas start rolling through the door. It’s trauma season, or summer as non-emergency personnel like to call it. That means anything and everything. Guns, ATVs, MVCs, trampolines, go carts, motor cross, bows and hunting, bikes on the street, kids on the street, alcohol and fireworks and everything in between. It’s job security and I know it, I profit from others misfortune. Before I can even catch my breath, all my critical care and trauma rooms are full with more on the way. Nurses are starting to freak out, and I’m going to have to calm them the fuck down. Nobody gets good care when people are freaking out. I start moving people around, anyone that isn’t critical is going to a regular room in a different part of the ER. Anyone that is critical is obviously going to need admitted, and the doctors usually need a push in the right direction to get that going. I will give them that push that they need. Squads come and go, I send some out to triage, some go straight to rooms. Patients scream and moan because they think by calling a squad they’re going right to a room. Sorry fucker, just because you think 911 is your personal taxi service, doesn’t mean it becomes my problem. Have a seat in the lobby like everyone else who took a taxi here tonight. What people don’t understand about a large trauma center is this. We don’t operate like the urgent cares in your cozy little suburban neighborhoods where you show up and get seen right away. We don’t care where you’re from, we don’t care who you know. ER is a shit show, and the person with the best performance wins first in line to be seen. I don’t care if your non-urgent problem has to wait 8-10 hours to be seen. It’s the name of the game. If you didn’t die after the first four hours you sat and waited, chances are you won’t die in the next 4 DAYS of sitting and waiting. Go blow off an extremity with a homemade Molotov cocktail and then we’ll talk. Even when you walk in with chest pain, what you don’t understand is, I am EVERY bit as capable as a doctor (probably more so, depending on the day) at recognizing an MI. We are the gatekeepers, we will draw your labs, do your EKG and then sit your ass right back in the lobby unless you have a positive EKG or positive cardiac enzymes. You just got moved to the back of the line. Also, if I see you sitting in the lobby wolfing down a Big Mac with a large side of fries and a super gigantic size Coke, you are automatically losing out on your place in line. If you have an emergency, you don’t need to be EATING! The people I tend to keep my eyes on are the ones who sit quietly, waiting, not moving, not talking, not doing anything but waiting anxiously. They are always the ones that stand up and say, “I think I might pass out” and then fucking code on my lobby floor. They make me nervous. I’d always rather have a lobby full of screaming, cussing idiots than a lobby full of super sick, ready to die patients anyday. The screamers and the Bitchy McBitchersons aren’t going to die, even though they would LOVE to make you think they are one step away from deaths door. Somewhere in the night, a patient comes in to critical care with difficulty breathing. I know him. He’s a frequent flyer, but not the bad kind. Just a poor kid that got dealt a shitty hand of cards, and is playing it to the best of his ability. He has Downs Syndrome, and CHD, TOF, AVSD and has had enough surgeries to bankrupt Bill Gates. He has pneumonia, I can tell as soon as I walk in the door. I exchange pleasantries with his parents. They are always right there, by his side, even though he is an adult, he is dependent on them for care. They bring suitcases… They know they’re here for the long haul this time. I take a quick look around to see what my staff is doing. They are all busy getting him situated, monitors and IV’s and breathing treatments. It’s apparent pretty quickly that our usual arsenal isn’t going to help this time. He’s breathing harder, his lips are dusky and the breathing treatments aren’t doing the job. I call our attending and we quickly adjust our plan. See, it’s not a quick fix with patients like this. Treating one problem often exacerbates another. I can see it in his eyes that he’s scared. I hold his hand and crack a couple jokes to lighten his mood. My team starts moving faster, his oxygen levels are dropping and it’s apparent we’re going to have to make a choice relatively quickly. Before I can even stop myself, the words escape my lips, “You’re going to be okay” I tell him. I know the minute I say it that I shouldn’t have. It’s a promise I can’t keep. It’s not something that should be said in these situations. I’ve taken care of him for the last 13 years, and he always winds up ok. I’ve seen him much worse off than this, I tell myself. He’s already maxed out CPAP and we know that dropping an ET tube and placing him on a ventilator could be very difficult. He has a difficult airway, and even if we do get him intubated, weaning him off could be very difficult, if not impossible. My attending is talking to his family. Even though he is an adult, and they include him in all their decisions, they are still his medical power of attorney. They decide to go ahead with the intubation. My patient agrees that this is what’s best. If we don’t do it, he’s going to die. We explain that there’s still that possibility even if we do intubate. I watch the mom talking to her first born, and only child, her only son. She strokes his hair away from his face, holds his hand and talks to him softly. I can see him start to relax as the medication starts to take effect. She backs away from the bed and we take over. The endotracheal tube slides into place, almost effortlessly. We all breathe a sigh of relief. The air in the room automatically goes from heavy and overbearing to light again. We’ve saved him we think. I silently say a prayer of thanks that I was right, he’s going to be ok. His mom stands at the head of the bed stroking his forehead while we prepare to take him to the Cardiac ICU. I decide to walk up with them when they go. He’s doing well as we leave the ER, his oxygen levels are doing much better than we expected. I tell myself he was just tired, breathing that hard for that amount of time isn’t easy and the body can’t keep up that kind of work for long on its own. We took over the breathing for him, and now he can rest and get better. In the elevator, on the way up to the ICU, his mother thanks us again for the work we do. It’s a much appreciated thank you, because it’s not often that people are appreciative of our work. As we round the corner to the ICU, his oxygen levels start to drop. I check the probe on his finger, thinking it may have come loose. It’s still firmly attached. My respiratory therapist checks her connections, I listen to his lung sounds, they are much more diminished than when we left the ED. He hasn’t moved a muscle, thanks to the paralytics, but it’s possible the tube could have come dislodged during transit. I grab the suction and the other nurse does a couple quick passes down the tube to check for obstruction. His oxygen levels begin to drop. By this time we are in the ICU and calling for the attending to come to the bedside. He’s now in the low 50’s and his heart rate is starting to drop. We quickly move him from our cart to the other, and the cardiac ICU takes over. They’re doing everything we just did, checking the tube over and over. They decide to pull the tube and re-intubate. His heart rate continues to drop and now he’s below 40. They start chest compressions. His mother and father are standing at the bedside speechless… I don’t even realize it until several seconds later, but his mother is holding my hand. They’re pushing drugs and placing tubes and even after they get him re-intubated, they can’t get his oxygen levels to come up. They can’t get his heart to start beating again. For a moment, they think he may be in V-Fib. They shock him, his mother squeezes my hand when his body jumps on the cart. Asystole. They start compressions again. They’re pushing Epi every 3 minutes. There’s nothing they can do and we all know it, but we continue to go through the motions. At some point, searing hot tears start to run down my cheeks, as much as I don’t want them to, they still come. I don’t know how long it went on, but at some point, the CTICU attending asks if there’s anything else anyone would like to try. His mother drops to her knees, praying and crying, and begging God for it to not be true. I help her into a chair. They’re cleaning up so the family can spend some time with him. I feel like my feet weigh a thousand pounds and I can’t seem to pick them up to move out of the room. I want to console the family, but at the same time, I feel like crawling under the bed into the fetal position because I told him he was going to be ok. His mother looks up at me, our eyes meet and she says, “You couldn’t have known.” At that instant, I’m not a nurse anymore, I’m not the charge nurse in a Level 1 Trauma Center. I’m a mom, and I’m crying, huge, gasping sobs, trying to tell her how sorry I am. I’m sorry those words came out of my mouth. I don’t want the parents to have to comfort me, so I catch my breath and wipe my eyes, and hug them one last time. I tell them to call us if they need anything. They promise they will. I turn to walk the long, lonely walk back down to the ER by myself, head hanging, sniffling, trying to compose myself before the doors open back to the chaos of the ER.
