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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