Squatters on the list

Retrospect.  It gives us such insight and perspective.  Can we use it in the present to effect change?  Perhaps that is the use of stories.  Your’s, mine – everyone’s story.   The linkages that allow us to identify ourselves as human.  A shared experience.
 
Crouched in the tiny space between the bags, monitors and emergency survival equiment, the stretcher and the respiratory therapist I was able to zen right out to the thwak thwak thwak of the rotors and the surge and wane of the static over the headset.  There was another noise that I have never been able to identify – a sort of airvent opening and closing.  All told, with the panoramic view of snowbare fields and drought raveged sloughs, I was in a mindful zoneout state in an attempt to curb the discomfort.  The therapist beside me was in fact able to doze off as evidenced by his occassional start into wakefullness.
 
I shifted and attempted some one sided yoga of stretching my left leg out sideways over the bags.  My mantra through the hour and 15 minute flight was "If you cannot change the number, you must be one with the number.  If you cannot be one with the number, you must stop measuring the number".  A  long mantra, I know, but one that I have developed in the past few years.  It has replaced my previous mantra which was "This is all a TV show, I just have to hit my mark".  That one was during the Chicago Hope/ ER eras where no matter how bizzare and out there the scenarrios the  writers of the shows came up with, we were able to duplicate or best it in sheer unbelievablity.
 
Now I just try to maintain my inner peace.  It has been very difficult of late.  Several people have taken up squatting rights on my shit list.  Chief among the squatters in the medical director.  He has always been a rather absentee attending, prefering to leave the unit to the hands of the nursing staff and the rotating residents, who it must be said, are generally terrified enough to do as the nhursing staff recommends.  This behaviour of his has irked my sense of responsiblity but not led to right out pissed off and loss of respect.  However he crossed the line in the past weeks.
 
We admitted an 11 year old hanging at evening shift change.  She was intubated and minimally responsive – mostly posture like movements of arms and legs – a stiffening and turning on arms inward.  The resident was present, I was in charge and the bedside nurse and respiratory therapist were resporting condition states and changes requireing interventions.  The attending staff dr however was MIA.  Well not so much missing, we knew well where he was – at the end of his cell phone at the hockey game.
 
Cool her he said.  An appropriate intervention to minimize the cerebral swelling that occurrs following a hanging.  She began to shiver violently.  An appropriate response of the body to laying on a cooling blanket.  Now shivering increases the pressure in your brain – which is the main thing we are trying to avoid when treating any type of head injury.  The usual course of action is to administer a paralytic to stop the muscle action and to administer a sedative so the patient is unaware that they are now paralysed.  Nope, no paralysis he says.  So now due to the shivering and other factors we cannot ventilate her adeqately.  Her CO2 is rising, she is competing with the ventilator and she is hypoxic – another very bad thing for head injuries.  The main aim of treating head injuries is to keep the brain getting oxygen, keep the glucose level in the brain normal and reduce the metabolic activity of the brain.   All of which we were not doing despite our efforts to communicate with the staff dr over the phone.  We needed to paralyse her to control her ventilation, control her shivering and we needed to do something about her rapidly increasing blood glucose level.  Finally after several urgent phone calls he stopped the shivering and granted us the power to sedate the child thus allowing appropriate ventialtion to occur.
 
During this whole less that optimal treatment incident the parents sat wheeping at the bedside.  They were so distraught at what their daughter had done that they could do nothing more than cry on each other.  They saw only the urgency of our actions and determined that it was due to the critical condition of their child rather than the unnecessary delay in proper treatment.  3 and a half  fucking hours later the dr came in.  The hockey game was now over of course, so he could spare time for the parents and their daughter. 
 
I lost my respect for him.  I am reminded of another incident with another medical director in conneticut.  The big name centre there has a smaller PICU that I went to work in as a travel assignment for 13 weeks.  With a 10,000 dollar completion bonus how could I not? 
 
The work was less intensive than what I was used to, the medicine about 15 years behind our centre and despite the several tragic children that I knew would have been treated much better at our non-big name centre, I was quite enjoying the experience.  I loved conniticut and it was a nice working vacation.  There were a couple other nurses from the unit I came from there who were horrified at what they were seeing, but I just kept contending that they were way behind us and didn’t know any better.  One night we were treating a young girl who had developed HUS as a result of either swiming in the ocean or eating a hotdog.  Either way her kidney fuction was being monitored and was still on the slow side but seemingly improving.  Her parents were at her bedsdie as was her grandfather who was a neurologist.  The child began to have seizures.  It initally started as one focal seizure.  A seizure consisting of one small area of her brain affecting just the muscles on one side of her body and a loss of awareness.  I notified the resident thinking we would want to be prepared to give ativan should another one occurred.  She called the staff dr and he said watch.  So watch we did…thoughout the entire night as she seized repeatedly in status epilepticus for 7 hours.  Repeated phone calls to the staff and urgent consults with the regular nursing staff brought no results of medication to stop the seizures.  The staff dr didn’t want to give ativan because then she might need intubating.  "Wholy fuck", I remember thinking and probably saying out loud, " she is in a ICU, isn’t intubating what we do here?"
 
After 7 hours of status she went into a generalized seizure.  She seized for an hour before he finally opted to come in and give her ativan.  Of course by now she needs a great swak of ativan to stop her seizing and she needs to be tubed as well.  During this whole esisode she was attended by her parents watching their small daughter’s body wracked and convusled with wave after wave of clonic tonic seizures, wiping away the drool and froth when she had the breaks in between seizures ealier in the night and then just holding her hand while I suctioned and provided oxygen as it got so that she had no breaks between seizures.
 
Never once did they voice a doubt in the care she was recieving.  Never once did they get angry or show frustration.  Not even the grandfather voiced a concern that this was something that would be better taken care of early instead of allowing his grandadughter to seized for 8 hours.  I wondered afterwards about the myth of american medicine and it’s proactive approach to dodge malpractice suites.  For here was malpractice, pure and simple and there was no proactive stance on the dr’s part, there was no apparent concern on the staff’s part that they could be sued for not providing best practice, there was not even a murmur from the parents.  Only my inner voice clamouring for better care for the children.
 
For who would question the dedication and care of the medical director at the world renouned big-name centre?   Sometimes I want to take parents aside and tell them that they SHOULD question their child’s care.  They should question and question again….but not the mindless nitpicking they do in their current level of impotence but truely question the medical treatments and best interests of their child.   Why did it take the staff doctor 3 and a half hours to come and see their child when she was admitted?  Why was their child seizing for 8 hours before treatment?
 
Ahh, my shit list.  It flutuates daily but the squatters remain. 
 
Back crouched in the hellicopter we finally flutter down in small-town Some-girls’ nameville and crawl out to stretch and move our bags to the waitng ambulance.  Amid the swirling snow from the slowing rotors I can see the sun is shining and it is going to be a nice day….I can only hope it is also a good one.
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night shift

I was just finished my bowl of cereal, my start to the night shift when the code pager went off.  It sounded sort of sickly and as I checked it I was puzzled by the numbers displayed.  It is supposed to be a code telling us where the code is….unfortunately it is one of those things I always have to think about to decipher the code, but this one I knew made no sense, the numbers were all wrong.
Fortunately switchboard always follows up the page with an overhead anouncement of where you are supposed to be heading.
I sprint out the door with the herd of staff at my heels.  Half way down the hallway I get passed by the much taller and much younger code team members.  By the time I reach the stairs there is just me and some other out of shape staff labouring up the 2 flights and then wheezing our way down the hall to the unit.
 
The room is full of people, most of them standing looking on.  I may be old and slow but I can still push my way to the front, which I do.
 
"someone tell me what happened", I yell over the din.  I get a garbbled story of coughing, possible choking spell and take a look at the small mottled infant on the bed with a bagger and mask pressed to his face.  He is showing some signs of struggling.
"get some leads on him, we need a BP", I demand and many hands are trying to accomodate my wishes.
The intensivist arrives and asks me to notify the unit that we will be bringing the patient down and to get some intubation drugs up.
I call down and relay the information I ahve about the child then head back to the room.  I spy the mum sitting in the ahllway with one of the floor staff wiping tears away.  I stop and tell her what we will be doing and get the story form her.  Much more cooherent than the one I got from the nursing staff, she had been feeding the baby and he was fussy so she tried just a bit more and then he became apnic.
 I relay the new information about feeding, full belly, coughing and probably aspiration and a child admitted for an Acute Life Threatening Event (new term for almost a sids)
 
Much confusion and disorder later I am trying to draw up intubation drugs for our trip downstairs – just in case.  The resident is looking for the larygescope blades – the intubation tray seems to be missing from the cart.  Suddenly he and the transport nurse are sniping at each other each one insisting that what they are getting ready is more important. 
"knock it off", I tell them, "No one is dying"
 
And yet the tension level in the room would make you think we were opening his chest.  Honestly, I think we need more codes so people learn to relax.
 
We set out down the hall with the small child attached to monitors and IV pumps.  Moving way too fast I drag on the end of the bed trying to slow the train running out of control down the halls.  People really need to learn to manage their adrenalin.
 
We get him in the unit and admitted and everyone disappears.  During the course of the night he needs frequent fluid boluses and has difficulty accepting the ventilator settings.  Once again we are left with a doctor who has limited experience with this kind of thing.  We suggest paralyzing the child to facilitate ventilation, we suggest dopamine to facilatate blood flow.  Six hours without urine and 40ml/k of fluid later I make up a dopamine infusion anyway and start on a norepinephrine infusion as well.  It is obvious that he needs the inotropes and yet the resident wants to wait until the staff man comes in.
 
God help us.