A step to the left

Four years ago on this date the world became a much scarier place. My world shattered and I just knew it would never be OK again. My father died that day four years ago and like millions of other children who experience the death of a parent, I felt alone, frightened and suddenly 6 years old again.

Grief is a funny thing. It tears you wide open and leaves you raw, weeping and unable to gather your insides back into the safety of your body. The world shift a step to the left and you move through places and activities feeling that step out of time. The first six months after my father’s death are gone from my life. I can’t remember anything much about that time other than I was struggling. I made mistakes, could not focus and likely did a terrible job at work. I was fortunate to have a very supportive boss – I got a month off for bereavement leave. There is no way I could have stepped into an emergency room or the PICU before then.

When I did return to work it wasn’t too long before I was face to face with an older man who was experiencing some vague respiratory distress. He didn’t look right although he had been triaged as a 3. I can’t remember how long he had languished in the waiting room, but by the time I got him he was rapidly deteriorating and was in the wrong area for care.

Triage is a tricky process. Originally developed in WWI to filter out who will live regardless, who will die regardless and who will live if given treatment, it is a necessary component of our emergency system. Everyone traiges you from the first health care provider to the last, but in the ER it is a formal defined part of your admission to the world of health care. It is a very useful tool, especially in the hands of a skilled provider, for situations where you have mass numbers of people all needing care now, and all needing different levels of care.

The Canadian triage system (CTAS) categories you according to injury and physiological findings with scores from 1-5 (1 being emergent intervention required now, 5 being could wait days and still be OK). As with every triage system there are problems. While using physiological evidence helps sort out the truly ill from the truly melodramatic, it still does depend upon what the patient says is the reason they have come to the emergency. A complaint of “I can’t breathe” along with sats of 85%, respiratory rate of 24 with signs of laboured breathing and a heart rate of 120 will get you a higher score in traige than the same complain with a normal respiratory rate, sats and heart rate. The problems come with the vague patients. “I don’t feel well” is not a helpful complaint to arrive in the ER with. The traige nurse has a few minutes to determine what is the best thing to do with you – yes, ideally it would be to get you back onto a bed where you can sit and watch the daily ER drama unfolding, BUT, there are several other people with much more life threatening complaints also in need of the same bed sapce and provider care.

A big problem though is that wait after traige for the bed. Patients in the waiting room can and do deteriorate. ER waiting rooms were not designed to make you all clearly visible to the staff at the traige desk. There are often hidden nooks and cranies and often very sick people will, like ill animals everywhere, seek to isolate themselves in one of those hidden nooks.

 Back in my pod, I give the patient a fast look and listen, I slapped on O2, paged the ER physician and ran an EKG. When the physician arrived we ran the patient over to the A pod where I gave a very abbreviated report to the recieving RN which several others prepared to intubate him, started IVs, got blood work, ordered medications and basically went about the work of saving his life.

I went back to work, seeing the walking wounded of the world, and at teh end of shift, slipped back in to see the man before I went home. He was all alone in his cubicle, still not intubated but breathing better. He looked scared. He had glimpsed behind the mysterious veil that follows us all around. He was alone and frightened. I knew how he felt, but more, because my father had died in an ER just a few months early, I was afraid for him. I wanted him to be alright. I hadn’t been there for my dad so I held this man’s hand and told him they would take good care of him and he would be OK.

I had said he words we know not to say. “You will be OK” I needed to give him reassurance and comfort because he was afraid, but mostly, I needed him to be OK, because I was afraid he would not be. I was afraid he would die, just like my dad, in the ER. And so, for my own comfort, I gave the patient what I needed to be true.

We are human afterall, with the same fears and needs as those on the stretcher. Most of the time we can seperate ourselves from our patients. We are caustioned to develop this at all costs, but I wonder, often if this is really the best approach. Patients need and want us to see them as individuals. They need us to conect, on a huma level, just for a few minutes during our inspection , pokings and prodings of orifices. They let us in to their most intimate circle of life and we often fail them by not recongizing this and by remaining at a distance. It takes so little to hold a hand and offer the human recogniztion of the individual and the need for him to be OK. He has worth, and we care.

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