Life and Death

She looked about 8 years older than I am, yet she was two years younger.  She was distraught, talking a mile a minute, and it was difficult to understand why she had come other than "my knee hurts".  She was about 5 feet tall and very, very overweight.

As it happens, her knee had been hurt a week ago in a fall; she had had a chest xray a week ago, and an injection in her knee by her primary care two days ago. It took awhile to pry out of her the details of her injury.

"I fell down. Then my son picked me up under the arms and threw me back down. I think he kicked me".

No, she didn't want to report it to the police.  "A mother's love".  There were other circumstances, no he's never done it before.  Yes, I feel safe; he doesn't live with us.

The only medication she was on was ibuprofen.  Her only  medical problem was fibromyalgia.

The extenuating circumstances?  Her husband had just been diagnosed with terminal cancer and had less than 3 months to live, she cried.  And cried.  And cried.  The son had "overreacted" when they had told him about his dad's diagnosis.  Perhaps the wife had "exaggerated" a bit about what actually went down said the husband with a sidelong glance at me.

Ah. 

The husband looked pale, and none too healthy himself.  Yet it was clear that he loved her and had probably done most of the physical and emotional lugging and tugging for most of their marriage.  She was not a small woman.  She was demanding and dependent.  He knew everything right down to the color of her last bowel movement.  He was a one-man band; caretaker, cheerleader, enabler.

I took her back to a treatment room and settled her into a bed where she was seen by Henrietta. Shortly thereafter I overheard her on the cell phone, "Yes, unless I can walk and get around they are going to admit me".  What?  She had walked in.  I shot a quizzical look at Henrietta; were we on the same page, here?  "No, I never said that", Henrietta whispered, "they seem to have a lot going on right now".

The patient seemed to have no difficulty walking to the bathroom, although the husband was never more than an arm's length from her side tucking in the blankets, fluffing the pillows,dialing her cell phone.  Between phone calls, she wept.

She did not have a fracture.  Henrietta ordered a knee immobilizer but the widest one we have is 29 inches at the top; this lady measured about 9 inches larger than that around the thigh.  Crutches were just not going to work at all.  The only thing I could offer was a couple of large ace  bandages which were nothing more than a band aid, but it seemed to make her happy. That, a Percocet and some Ativan.

As I was going over her follow-up instructions, she suddenly burst into a fresh wash of tears.  "What am I going to do?", she wailed to the husband.  "You only have two months to live, then what will happen to me?"

I was....stunned.  So was the husband, who was now a whiter shade of pale.

"Well....I HOPE I have more time than that.  We never know, we never know.  The doctors aren't always right on the money about these things".

"I know, I just feel so....ALONE", she blubbered.

I have never felt worse for another living human being then I did for that husband.  He had trained her to be so dependent on him that now his death had become solely about her.  My first instinct was a desire to slap her, and it embarrasses me to say that.  But it really wasn't her fault completely.  He had created it and now was helpless to fix it.  I put my arm around his shoulders and said, "Sounds like you need some help", but I included the wife with a glance.

As I mentally ran through my social contact options, community resources, pastoral care, etc, the husband said that they had just talked to their pastor.  Their church was very giving and kind, and they had lots and lots of resources. They just needed to get the ball rolling and plugged in.  I asked if there was anything I could do for them at the moment, or help them in some other way.  They declined, with thanks. The wife wiped her eyes and off they rode into the sunset; he to a death sentence, she to cope with her anticipated loss and grief. As for the son....I can only imagine.

Sometimes the complaint has nothing at all to do with why they are here, we know that.  These people were simply overwhelmed.

Mac is either all-in or all-out when it comes to sketchy pain complaints.  He will do drug screening on some of the complaineurs of the Holy Trinity of Pain (back pain, migraine, and dental pain) if he has seen them a lot.  On occasion he will give them narcotics if they agree to the piss test.  Sometimes he just tells them to hit the road with ibuprofen.  It's still a pitch 'til you win situation since most will keep hacking away at us until they get what they want, day after day after day. 

Yesterday, a guy with chronic back and neck pain came in.  On top of the chronic pain, he had some sketchy injury and claimed to have difficulty moving his arm, as well as way increased pain.  Although he had no insurance and no primary care physician, he stated he had an MRI scheduled in two weeks.  Mac decided that this guy needed it sooner. 

Call to MRI (we NEVER do this); they had an opeining, send him down. It was stressed to him that time was of the essence since MRI was going to hold the spot for him. We did the appropriate paper work and sent the patient on his way by private car.  The procedure is that patients check into the ER, the test is ordered, and then the ER doc has the responsibility for giving the patient results and follow up.

Three hours later, we got a call from the ER that the patient never showed up and further more, when they called to see WTF was going on with that, the wife started yelling at them that they had FREE CARE, and her husband wasn't given gas money to get the 12 miles there and back. 

Wow, really?  First we heard of it, and what a lovely concept.  He didn't need an ambulance, although we could have gone that route but somebody would have had to pick him up.  If transport was a problem, we could have given him a cab voucher but again, you only get one per day and somebody would have had to pick him up.  The MRI that we so thoughtfully arranged was just not as much of a priority to him as it was to Mac.

 Lisa came in while this was being debated to work a few hours for Kate.  She had come directly from an appearance at Bear Went Over the Mountain ER which is 15 miles away. Guess who had showed up there about 40 minutes after we had discharged him?  Yep.   His story was similar except HE HAD A COPY OF AN MRI FROM ANOTHER HOSPITAL with him.  That is never, never fishy.  I'll give you one guess as to what he wanted;  if you guessed "gas money", you are incorrect. Two of the nurses had recalled that he had been a  dick at another visit, which is what we find to be one of the most endearing qualities about dealing with the public.  ER nurses have VERY long memories.

Maybe You Should Quit Watching the News When You're Bored

What is wrong with people? Honestly, who really gives a crap what Demi smoked, shot up, snorted, or ingested?  Especially if it leads to her simply seeking help for "exhaustion" as opposed to substance abuse?  Seriously, making her 911 tape available to the public just gives people stupid ideas.  Monkey see, monkey do.

Overheard ambulance patch to our Mothershp last night:
EMS: "Transporting a 35 year old female complaining of nausea and shaking.  She reportedly smoked some 'herbal incense' about one hour prior to our arrival.  She is conscious and breathing.  Vital signs....."

ER: "Are you bringing the substance the victim smoked?"

EMS: "No, it was confiscated by police".

Just because you can roll it up, stick it in a bong or stuff it in a pipe doesn't mean you should. 

It's All About the Privacy

A 31 year old female came in with a female friend for a sebaceous cyst, a nice big ripe one behind the ear.  It had obviously been brewing for some time, so Bobo elected to I&D it.  But first, Ativan, then  nice big does of Dilaudid.  She screamed such a string of obscenities so inconsistent with what he was doing that the usually unflappable Bobo was unnerved; he who as a general practice gives out Percocets like Pez and is not stingy with the lidocaine or giving it time to work.  He actually mouthed, "WTF" to me.  I had to dive under the table on that one.

Eventually I managed to scrape her off the ceiling, apply a dressing and send her off to the pharmacy to fill her antibiotic and narcotic prescriptions.

Two hours later (and the woman had been in the department at least 2 hours), I got a phone call. 

"Hi, I'm calling to see if my girlfriend is there".
Me: "I'm sorry, I'm not allowed to give out that kind of information, it is against privacy laws" (in other words, stupid, she's not here for me to ask her if she wants to take a call or have me take a message).
Idiot: "Well, I know she came there, and I know she needs a ride home so just tell me if she's there or not"
Me: "I can't give you any patient information.  Sorry".  (You could also be a stalker, maybe she has a restraining order on you, maybe you have a gun, and maybe you are crazy.  Or not, but I don't really care)
Idiot: "Listen, I just have to know if she was there, um, I mean, I just need to know if I need to pick her up.  You don't have to be a bitch about it"
Me: "I'm hanging up, have a nice day"
Idiot:: "I'll just come down and see for my-..."
Click.  Hey she came in with a friend, obviously she doesn't tell him everything.

We walk a fine line with the kind of patient information we give out over the phone.  Obviously, we want to do what's best for patients.  We talk to caregivers, and lots of times we talk with family members.  Do we try to ask for permission first? We do if it is a non-urgent problem.  Are we going to talk to three aunts, a cousin and a grandparent for someone with a minor laceration?  No.  Are we going to talk to family members who have been alerted by the nursing home  that their demented  elderly loved one has has been brought in with stroke symptoms or chest pain?  Hell yes. 

We don't leave messages on routine call-backs or for lab tests, but do suggest they call us.  Nor do we give information for  such requests as "I just wanted to see what my girlfriend's/boyfriend's STD test showed".  Sorry, you'll have to that information from her/him.  But if you are worried about that nasty discharge, come on down.

Once I had a director of nursing at a big hospital call me, the charge nurse, looking for information about her adult daughter.  She was being seen in my ER for a non-urgent problem.    I told Mom that I was sorry, but  giving her any information would be a patient privacy violation and that she would have to ask the daughter.  She thanked me and agreed that it was.  My next move was an immediate call to my boss to cover my ass.  Five minutes after I hung up with her my boss called me back to say the director had called her to praise me for protecting patient privacy and to congratulate my boss on training her charge nurses so well; she was embarrassed that she had been so careless about this issue.  You would think she would have known better, but the Suits and Clipboard Nurses who make policy rarely have any idea how these things work in the real world. 

Sometimes it is just a ridiculous game that puts us in the middle of family issues.  An example of this is a 25 year old with a minor laceration who was know to be an IV drug user.  It was not an injury that in any way, shape or form would have needed narcotics, so he left an unhappy camper and was quite nasty about it.  An hour later his mother called saying how much pain her son was in so could she please come down and get a prescription?  And his tooth was hurting too.  I said I couldn't discuss her son's care without his permission.  A short time later Sonny called and said we could give the prescription to his mother but we weren't allowed to give any details about his care or any part of his medical record.  Um, no. You are still not getting a narcotic prescription.  You have my permission to talk to your mother.

Code Rainbow

We don't have security.  When there is trouble the local police are but a 911 call away.  They are always prompt in coming to our aid to either kick ass or talk people out of a tree.  They also know what time we close, and unless they are really busy there is always an officer waiting for us as we alarm the bulding and disperse to our cars in a dark and secluded parking lot.

 It is nice that they are protective like that even if we rarely get the aggressive or dangerous patient.  Drunks?  Never come by ambulance.  Overdoses?  Occasionally thrown out of cars onto our doorstep, but they are the exception rather than the rule. I truly don't miss that about working in a city hospital. 

One night we got a 6 ft 2 inch 18 year old male whose parents had come home to find him lying on the floor, " not responding".  I don't know how, but he was  carried in by his father.  He could walk, but wasn't really doing what he was told; he also had slurred speech and was "not really cooperative" (he took a swing at me).  He was drunk, of course.  Shocker.  So I was concerned enough about my/our safety to call dispatch and have them send over some hefty police presence. 

Cripes: "Why did you do that?  Don't we have any leather restraints?"
Funny.  Real funny.

Cripes told us, "When I was in residency, I tackled a psych patient in the hallway.  We were wrestling around, and I yelled for the nurse to call a Code Grey for security.  She got all huffy and said, 'Well, that would be a Code Green'.  Seriously?"
Me: "Ha.  More like a Code Black and Blue".

I get it.  What Cripes was referring to was the method utilized by most health care facilities to immediately broadcast some sort of internal threat or emergency situation which are often color coded so that visitors and patients aren't  freaked out.  It would be chaotic and dangerous, especially to bed-bound patients if some things were broadcast in an overhead page like, "Bomb Threat, GET OUT IMMEDIATELY", or "FIRE!  As if anybody is fooled by an overhead "Code Red!  Code Red!  Code Red" even if it is just the ICU nurses burning popcorn. 

"Did you order the Code Red?"
"Your damn right I did!  But the popcorn is inedible!"

 A Code Red in our community also means a  reverse 911 system to notify citizens of school closings, tornadoes, or local flooding with road closures which we are prone to, and other natural and unnatural impending disasters.  I generally have a surge of adrenaline when I pick up the phone at home and hear "This is a Code Red alert!" when the water is up to the door of my barn and the road is impassable.  This usually means I have to find another way to get to work, but I can generally just look out the back door to determine that the creek is overflowed.  The car lying in a puddle up to its roof is a dead giveaway.

These codes are not standardized from place to place.  This makes it confusing so other than codes for a cardiac arrest or a fire I can never remember what some of the colors are. A Code White, Grey, Green, Yellow or Orange might be  used for different emergencies or not exist at all at some of the various facilities I have worked over the years.   Obviously we never use them where I am working now, but if I had to work at the Big House I would need a cheat sheet.  Good thing the codes are printed on my ID badge.

Super-secret codes for emergency situations in the hospital undoubtedly fool nobody.  The cat is kind of out of the bag when  "Dr. Ambu", "Code Blue", "Doctor Blue, Stat", and "Code 99" is paged for a cardiac arrest, especially when a dozen people rush by with an automotive cart trailing jumper cables.  I worked at the "Code 99" hospital for many years, and had more than a few adrenaline rushes at the  local supermarket when they paged "Code 9" for a manager check approval. 

There are codes of various colors used for things like Haz Mat alert, Internal Disaster, Mass Casualty, Missing Infant from the nursery (in which the entire hospital goes into immediate lock down), and others. Some of us added to the list over the years during times of intense boredom.  "Code Rainbow" referred to the choice of a liver entree in the cafeteria, notable for the lovely rainbow colors it took on when sitting in its un-appetizing-looking liquid.  One of the lab techs had an odd habit of wearing an entirely color-coordinated ensemble from head to foot.  If she was wearing red, for instance, she would have on red hose, shoes, jewelry, slip, hair appliances and underwear (we took her word for that).  We referred to some of her more bizarre outfits as a "Code Puce and Chartreuse" as she had a weird penchant for those particular shades of purpley-brown and yellow-green.

Among the  re-tooled  emergency codes include  "Code Squirrel",  when we are overrun with drug seekers, "Code Blah"  for something boring in the cafeteria, and "Code Chicken Little", which meant that the charge nurse was spinning in her own orbit and the sky was falling.

The latest code is an ID-10t.   Lisa started using it when dealing with persons of less than average intelligence.  I have since learned that it is actually a tech term humorously used to describe user errors in individuals with limited computer skills.   I have no idea where this originated, it wasn't me but I like it a lot.  Look at it.  It spells.....