What should I tell the kids??

It has always amazed me, how I, being a nurse , a total stranger to the patients I care for, share with me the most personal aspects of their lives. As a nurse I have been allowed to see and know details that no other profession is privy too. I have considered it a privilege .... I have received many lessons through the lives of others ...Many patient and family encounters.. have changed my path.... This is an encounter that did just that...

Rural ED: 1999

Its night shift. Around 11:30. I'm the RN.

The ambulance has brought in a 68 year old male in full cardiac arrest. he was found down in the bedroom by his wife . He has a long history of cardiac disease. He has had Bypass surgery and is on multiple medications for Hypertension and hyperlipidemia. He has had two MI's.

He is cyanotic , his pupils are fixed and dilated. The cardiac monitor shows asystole or flat line. He was given every 1st line resuscitation drug in route to the ED by the paramedics. He is intubated and is being bagged with a BVM (bag valve mask).. to deliver O2 to his lungs. He has been under CPR for 30 minutes.

He is gone.

The nursing supervisor is helping me. The Doc asks that I find the wife and give her an update. He is going to give one more round of drugs and then cease with all measures, or call the code.

I am to prepare her for the inevitable.


I find her in the quiet room next to the ED. She is alone. She is dry eyed. A handsome women in her late 60's. I explain what has been done for her husband and what the plann is..She says: "He was gone when I found him...I just knew .. may I be with him when you stop?" Of course I tell her. We should go now. Follow me. I prepare her for what she will see.

She holds my hand when we enter the trauma suite..she has the hands of a women who knows work.

I share with the code team her wishes. They nod, their eyes are full of sympathy...The Doc tonight is a kind man. He is comfortable in the face of death, he slowly slips his arm around her shoulder and leads her to the bedside...He gently explains that there is no hope.

"Tell him what you want him to know, we don't know when the brain stops hearing."

There is not a dry eye in the room.

She smiles at her husband and bends down until her lips touch his ear. She tells him wonderful things,I ,by this know they were in love and their life together was good, she whispers a last endearment and turns away.

She looks at the doctor and nods. We stop. The team slowly begins to leave the room, she reaches out and touches each hand.

She looks lost now. What is next .

I walk back to quiet room with her. I explain the next steps. Is there someone I can call for you, I ask.

" I called my children before I left home. They will be here in an hour, she looks panicked...they don't know he is gone."

A look of anguish and doubt crosses her face. "What will I tell them.?"

Just tell them the truth...I reply..I'll stay with you, if you wish.

She starts to cry and her face does not display grief, but conflict and quilt. "They will never forgive me!!!!IF I JUST HADN'T.... her sobs take over. Her anguish is palpable. She bows her head and covers her face with her hands.

I'll go make some coffee. I say. Ill be back... If you need to talk..ill listen.


I go to do this..something is not right... my thoughts are racing...Shes the loving wife....right??? why the guilt??? OH MY GOD DID SHE KILL HIM!!! Is that why the guilt??? If she JUST HADN'T WHAT??? Did she slip him an extra dose of his heart medicine??? Impossible. Maybe they had a BIG fight and right in the middle of it HE HAD THE BIG ONE. Oh my.

I return to find her calm.

We sit and sip coffee.

"I need to get this off my chest". She finally says.

She begins.

We had a romantic evening tonight...champagne... candles... I made a special dinner.. and we made love...good love....Great sex...!!!! we have always had a good sex life...it was important to both of us....after his heart surgery..well... we slowed a bit... But tonoc...it was like old times....I know what the kids think , that,...that part of our lives is over ...they would be shocked... we are old....to them.....she smiles...but to us.... She continues...

I left him on the bed.....and went to the bath room .. I was gone no more than 1o minutes....when I came out , he was on the bed, where I left him.. except...he was blue.. his face....she chokes....

I knew..he was gone...I called 911...the rest you know. She looks devastated.


She had shared..... such wonderful secrets of their last minutes together...Her guilt makes sense now....

What did I know of this..nothing. I had made wrong choices.. I had never known love like this....... I felt jealous!!!! I envied her...She had what I was convinced I would never have

I said what I felt.....no longer nurse to patient.....but women to women.

You are lucky.

She looks puzzled.

What you have had....what I wouldn't give...you had what others only dream of having...

She quietly reached out and patts my arm....be patient..wait...learn what to look for.

She spent a bit sharing things about their lives together....memories now....
yes I was lucky.. she ended... I have enough memories to see me through the rest of my life.

More coffee....

What do I tell the kids???

You can tell them as much or as little as ..you choose. This is personal...


Ill tell the the truth.. they would know...could you be here.. they will have medical questions..

Of course.

We wait....

The family arrives.. 2 sons and a daughter. Tense faces..expecting the worse yet hoping for the best....

They embrace and their mom tells them that dad is gone....tears and sobs...they huddle together on the couch..questions...now...How?? What happened?? What was he doing???

I watch....

Her face is calm..her eyes sad. She tells them...I am not prepared for what happens next.

The oldest son jumps from his chair...."WAY TO GO DAD!!!!!!!!He clapps his hands.
The daughter hugs her mom.. I know you feel horrible...don't. Please don't....its just the way it is...You must feel like it's your fault....its not.
The youngest has been quiet...He speaks.. he has a grin.. Its just the way dad would want to go. He lived life...he would want it to end as he lived.....Fully....No rest home for my dad....

They ask me a few questions... My part is done.. I hear crying and words of support...As I walk out the door I hear...

What are we going to tell the rest of the family..????

Judgement

Rural ED 1992:

This Emergency Department is in a county that has a prison. Prisons contract with the local hospital to provide care for the inmates that they cannot provide. As always, the patent having an emergency must go to the closest receiving facility..to a higher level of care.. this does not change because you are an inmate.

I'm the night nurse. I'm pretty new to ER nursing. It's me and the Doctor. Its been a good shift. Nothing I could'nt handle. I feel good. Untill.....

0500:The Met-net radio blasts: Base this is Medic 1, we are responding code 3 to the prison for a inmate hanging. Eta 10 minutes.

I've never taken care of a hanging victim.

Will the ambulance get here before the day shift nurses arrive? Oh yeah.

I call in the xray tech. on call.

I leave the radio to get the trauma room ready. I open the crash cart and get out the airway bag..open it up.... and set up a intubation tube and the laryngoscope. I spike an IV. . I may not need them.. It does not matter..its the doing that is important. It creates a sense of purpose...it has always been a comfort in the set up routine ..its calming and gives me a chance to focus.

Med net radio sounds:

Base: this is medic 1 we are in route code 3 with a 22 year old male,found hanging in his cell,down time unknown. He is apneic and pulseless. CPR in progress. We have intubated with a #8 ET tube, established an IV and have given 1 round of code drugs. He is c-spined. We will be at your back door in 15 minutes.

Time to wake up the doc.

I brief him with what I know. He is not a new Doc. He is calm. That is calming for me. It is good to work with people who know more than you.

He tells me about the mechcanics of hanging: you either dislocate your upper cervical spinal vertebrae and sever you spinal cord.. that is if you can obtain enough height from which to hang from.. or you are asphyxiated (strangled).. by shutting off your airway. You can survive asphyxiation, if caught in time... a hangmans fracture is not surviveable.

I know this... however I don't know how you can hang yourself in a cell. I picture a rough sturdy rope with a noose, a rafter in a garage and a chair...I am puzzled. Its early...I don't ask about this. I have no knowledge of prisons.. that comes much later in my career.

I hear the sirens, see the reflection of the ambulance lights on the back doors of the ER.

As they enter the trauma room.. I look at the paramedic he is calm..he does not have that feverish flush of working hard to save someones life, that look of battling to bring someone back from the brink. he just looks tired. He has done his part. He is done.

As he gives his report, the correctional officers settle into the trauma room...looking bored and disgusted..... I hook the patient to the monitor, flat line.I attach the BP cuff and pulse oximeter, nothing , just alarms..there are no readings.I look at the patient.

He is young..his features are flawless. He is handsome and has the look of youth and innocence. He looks like a kid in college, clean cut, prepy. His ankles are cuffed with chains and attached to the gurney. He has a waist chain around his mid-section and his hands are cuffed in front. His boxer shorts and tee shirt are faded orange. The lettering across the front spells CDC PRISONER.

The EMT is bagging the patient through the plastic airway that is inserted through his mouth into the trachea to deliver O2 into his lungs. The IV is intact and running wide open. The Doc examines the prisoner. He orders a dose of epi and atropine. I give it. No change.

I hear the day shift nurses coming in through the back doors.

The Doc calls the code. We stop all efforts. The time is noted.

I begin to remove all the equipment. I cover the patient. I will not remove the IV of ET. tube. He will be a coroners case. I am puzzled. So young.. a whole life ahead...why choose this path?

The officer reads my face. He thinks I am sad.

" Don't feel sorry for him. He was a child molester, he raped little kids. He is better off dead." His tone is filled with disgust

It makes sense now.

I think to myself.. that sometimes the judgements we extend to ourselves..equals if not exceeds the judgements of others.

Looking in

Rural Ed: 1990:

I'm the RN : Early AM

The first call of the day:

Med net radio:
Base we are in-bound to you with a eta of 5 minutes. On board we have a 68 year old male in full cardiac arrest, witnessed. He was in the garden with his wife when he went down. Volunteer fire was first on scene and started CPR. We have the patient intubated and are administering first line drugs. We have asystole on the monitor.we are a minute out.

I here the sirens. I hurry to move an non-emergent patient out of the trauma room.

I'm a seasoned ED nurse now. I have gained the knowledge I need to perform my job competently..I'm past that tingling excitement of charging into the unknown, about to do something you have not done before, and aren't quite sure about...
that shimmering magic shield that surrounds and protects the new, as they learn.......is no longer surrounding me.....

This in-coming patient means medical interventions that probably will not work, weeping families as they are given the news, the coroner, organ donation issues and paper work.... The new is gone..replaced by experience and reality. The reality of death and the certainty of it. I have not found my new shield yet........of: acceptance with grace.

Enters the paramedic with a fist full of monitor strips... and the volunteer 1st responders doing CPR and bagging the patient.

Their eyes are wide with the excitement of the challenge.They are young and new .....and think their still might be a chance.

The doctor on duty today is very experienced and practices teaching....in the moment.... during patient care. He sees the eager faces.... and he is going to run this resuscitation a while longer. He ofton irritated the nurses with his prince valiant haircut and gentleness and patience to show and teach.....but it worked..he was able to pass along knowledge.

The patient shows no signs of life. He has been apneic and pulseless for 30 minutes.

The doc starts to go over all the drugs the patient has had....and assesses his airway to make sure the ET tube is in place....Speaking out loud and showing...hands on....letting the EMS staff work along with him.... I feel like rolling my eyes.....I glance over to the closed ambulance doors.

And for a brief moment my jaded ED self ......sees....REALLY SEES.....this young face..pressed against the door trying to see into the ED Trauma room.

She was maybe 20, dressed in fire turnouts, hands cupped around her sweat streaked face..... leaning into the glass. Trying to catch a glimpse of the action.....

Her eyes....held the look...the look ....of hunger..

hunger for knowledge.....and the glint of wonderment and awe...THE MAGIC

The look I once had....

I opened the door and pulled her in.....

"Stand in this corner and don't move. Watch everything. We'll talk later." .

She had something...... Something bright .

Afterwards...

We talked. I showed her how we prepared the deceased patient for the coroner. I pointed outed out the physical signs of death. I talked about the drugs we tried and why they didn't work this time..I didn't know it but.....
She was helping me forge my new shield......

She was taking her pre-nursing classes...
Her dream .... Flight Nursing..

Turns out we talked a lot... as the years dashed by...

She earned her RN.. and worked with me..in that ER....Cutting her teeth..

And she was fast and bright and funny.....and damm good...I called her "little sprout"

We had good times and bad..... We agreed and disagreed...we butt heads... We worked hard .....We laughed....We sulked....we ignored each other.. we embraced....

I watched as she excelled.....and passed..... beyond me.....with her skills and knowledge....

She became that Flight Nurse...and my Chief Flight Nurse for a time....roles reversed..... She soared....

She was reaching the top of her mountain........just as I was I was headed down the other side..... of mine

Both us carrying our gifts.

The Picture

2003...Flight Nurse

All my nursing career, I dreamed of becoming a Flight Nurse. I was sure once I made this climb, I would be at the top of the Nursing mountain. Nirvana reached.

For years I watched as the flight nurses in their sleek flight suits ....laden ed with pockets, brimming with scissors and tourniquets ,penlights and gloves, radios, hemostats, and tape.. the wide strip of tape.. on the thigh of the jumpsuit... .. I must admit.. I envied that more than anything. To be able to chart on my leg while soaring through the sky.What more could their be?? In they sauntered, with Life packs and mini ventilators and THE DRUG BAG. What power. I believed that there was nothing they could not handle, a belief I still hold.

This is a story about one of my experiences as a flight nurse, perhaps the best. I made it to the top of that mountain..I conquered the climb...but that's another story.

Flight Base.. at a small airport..0800 Hand held radio blasts.. 911 call for 62 year old male, CPR in process. Sleepy flight crew scrambles.. we had been up most of the night on another call...1 helicopter pilot..2 flight Rn's. We stride out to the tarmac and the helicopter.

Our roles are tightly defined. One nurse mans the radios and keeps in touch with dispatch and communicates with the fire crew on the ground that has the all important job of landing us safely .. be it on a road or field. The other nurse will be the first to leave the helicopter and make initial contact with the patient. After the scene is deemed safe, both nurses join up take care of the patient. The pilot stays with the ship.

We have landed on a road lined with nice coastal houses. The day is sunny, and cool,light mist on the ground, the roadway is wet and the grass on the lawns is coated with dew. Everyone is out of their houses.. lining the road. We have landed on one end of the road.. at the other end sits an ambulance, lights flashing.

This time I'm the first out.. I carry the trauma pack and cardiac monitor. I start down the road toward the ambulance.I don't really see the people on the roadside, I just note that they are there... I'm on a mission.

The back doors of the ambulance are open. I enter.

I see a man in his 60's..undergoing CPR..he is intubated and being bagged..He is on a cardiac monitor, showing a flat line rhythm, he has an IV running wide open, a Paramedic is at his head and 2 EMTs are at his side switching off, performing CPR. The man is not responsive. He is dead. The first question in my mind is "Why did they call us???"

The Medic speaks: "We were called to a man down. His wife discovered him this morning at 7am UN-responsive on the bath room floor. She last saw him at 930pm before going to bed. She called 911 and started CPR. When we arrived volunteer 1st responders were doing CPR. We placed him on a monitor, intubated, started a line and have given 2 rounds of EPI and ATROPINE with no response.He has remained in asystole, pupils are fixed and dilated.We have an unknown down time, we have a 40 minute ETA by ground to the ED, 15 by air.I have contacted the ED and they are awaiting your decision."

My question is answered...I was there determine if this patient should be transported to the hospital, by us, or pronounced dead in the field...
Who has the ability to deem if a patient is without hope of saving... is determined and granted by the Emergency Medical System that you work in.. and each county is different..

My partner was standing at the rear of the ambulance and heard the report.. the paramedic had done everything..she had been this mans last best chance. We looked at each other and nodded, I ran a strip from the monitor took my stethoscope and and put it on the mans chest, listening for a heart beat.. none. I pronounced the man dead and asked the EMT to stop CPR, remove the monitor and call the coroner...I said: job well done to all there.

Now the family.... His wife, daughter an a few close neighbors were waiting...They already knew...But the words must be said.

As I walked back to the ship.. I felt the heaviness you sometimes feel in the presence of death...The street was still lined with people..Waiting to watch us leave.. the sun was shining....

Out from the crowd stepped a young boy, he raised his hands and waved, and smiled and snapped a picture of me as I passed...And I smiled and saw it all.

Your wife is on the phone....

ED 1998:

"Base station this is Medic 2 with code 2 traffic how do you copy??.."

"Copy you .. go ahead medic "

"Base we are in-bound with a 42 year old male with psych history...at this time the patient is alert but disoriented to time and place..He has hx.(history) of violent behavior and suicide attempts, with past 5150's.(code for danger to self or others) Family called S.O. due to concerns for their safety as well as his. S.O. is following and will meet us at the the E.D. He is non-violent at this time and calm. ETA is 10 minutes."

"Base copies."

The ED is packed,there are no empty beds and no one can be moved. My plan is to have S.O. wait with the patient in the ED quiet room... until I can clear a bed.
The mental health worker will not come to evaluate the patient until we have done a blood alcohol and drug screen, if positive, mental health will not see the patient until all alcohol and drugs are out of the patients system and tests return negative. Any patient that has any medical problems must have an examination by the ED doc and be "medically "cleared.

Once this criteria is met mental health is called and a request is made for an evaluation. The county I'm currently working in has 1 mental health worker. If the worker is at another facility doing an eval.. they cannot leave until that eval. is done and if the patient needs hospitalization into a psych. facility..a facility with an open bed must be found and ambulance transfer must be arranged.The law dictates that the worker must stay with the patient until the transfer is complete.

The whole process can literally take days. If your psych patient has medical problems that are unstable.. and needs to be PUFFED.(term for admittance into a psych facility) the wait will be longer. For those of you who remember.... in the 1980s most state mental institutions were closed. Reagan days.

When a patient with suicide thoughts or an attempt arrives in your ED they require close observation. I Have seen patients harm themselves in EDs when observation waned for minutes.
One patient who was being held in the ED awaiting evaluation for 16 hours slipped out the ambulance doors as a crew was bringing in a critical patient...unnoticed due to the chaos and confusion. She walked 2 blocks to her home and was stopped by S.O. as she stood on a latter with a noose around her neck...

The medic arrives with the patient. There is not a Sheriffs Officer with them. I look puzzled. The Medic tells me the officer was diverted to another call.

No problem the Medic says. I'll wait in the quiet room with Frank, he's cool... while you clear a bed...He leads the patient into the room. The medic takes the chair closest to the door, the patient sits in the chair next to him....

This is not good...The quiet room is across the hall from the ED. We use it as a waiting place for families who have loved ones in the ED who are in critical condition... It is the place we give bad news...

I do not recognize this patient. He is a large man, unkempt and very quiet. I get a bad feeling from him....however choices are few.. I nod and hurry to the ED to bump a patient into the hallway and clear a room.

I return in less than 10 minutes. As I approach the quiet room.. I smell the odor of fear... and sweat....

I am at the doorway..

I see in a split second....

The medic is bathed in sweat..the patient is holding a HUGE hunting knife at the Medics side..the tip touching his uniform shirt...

Without hesitation or thought........

I grab the medics sleeve and yank him up............To his feet
PETE.. YOUR WIFE IS ON THE PHONE.....GOTTA GO.....

The patient is stunned and does not move... Pete and I are out of the room and running to the ED.

S.O. arrives.. in numbers....subdues the patient with force and transports him to jail...his mental health problems will be sorted out there....

The medic and I never spoke of this... There were too many what ifs...and it was very close to having another ending....As the years passed...we both stayed in this community...and worked together ... I noticed.....though

He never transported a mental health patient again without law enforcement....I never put a mental health patient in the quiet room.

I had to fight the dogs

Rural ED: 1999

Some one left the back ambulance doors open, they are normally locked for security purposes. They automatically opened, and in walked a tall, lean , weathered man, ageless. He had ranching clothes, clean, but dust covered, with a well worn pair of boots. In his snap down shirt pocket was a pack of pall malls.

He strode into the heart of the ED with a casual, confident, non-imposing manner. His hand was wrapped in a bloody shop rag. He was not armed.. but a holster and 45 would not have seemed out of place for him. His face was deeply lined and friendly. No threats here.

I was irritated.. we were busy.. hell, can't he read... AMBULANCE ENTRANCE ONLY... All rooms were full.. one more thing to deal with...Sometimes the ED can make you forget that HE IS YOUR JOB.

I walked toward him.. he smiled and I my heart melted.... That attitude was snatched away..

"Missy.. I've got myself some trouble here" and he held up his wrapped hand".

" Well I see that.. what happened?"

I was expecting an explanation.. but I soon found out he was not a man to beat around the bush.... He reached into his cigarette pocket, and I thought he was going to light up.....is this man lost in time????From his pocket he pulled out his index finger... cleanly severed from his hand, complete with dirt under the finger nail.. odd what you notice.

"Shut my finger in the cattle gate...my dogs went crazy.. had to fight "em for it.. but here it is."
"I reckon its goin be too much bother to sew it back on, I have work to do...and don't want the fuss, didn't seem right to let them have it though." How about stitching it up and I'll be gitten back to my business if its all the same to you."

Yes sireee. And a that's just how it went...

can you tell me who the president is?

Ed 2000

An elderly gentleman presented to the triage area in the ED with his 80 year old wife, he was upset and nervous.
He stated to the triage nurse that something was wrong with his wife.. he explained to the nurse that she was very confused.. she had awoken this a.m. thinking it was time for dinner.

The first- step in triage is to determine the patients level of consciencness. This is done by observing the patient, looking at the way they walk, talk, and their attention level. Followed by some simple questions to determine if they are: alert and oriented to time place and person. Below are the basic questions.

Whats your name?
Do you know where you are right now?
Do you know the date? (you can also ask: Who is the president, if its a holiday time, you can ask which one.)
These let you know if they are in the here and now...

The triage nurse has the patient and husband take a seat..She explains that she will be asking some questions and taking the patients blood pressure and temperature.

The husband is irritated.. he wants to see the doctor NOW.
This is very common..most patients who come to an ER want ...A Doc.. A Diagnosis... and Discharge. And they want it now.

After the nurse explains the ED procedure and reassures the husband.....she begins..

Nurse: Hello mam, I'm the nurse, my name is Julie. I'm going to ask you a few questions. What is your name???

Patient: My name is Mary Beth Bonham.

Nurse: Why are we going to see you today?

Patient: I don't know, my husband thinks I'm crazy. I am not.

Nurse: Do you know where you are ??

Patient: I'm at the only hospital in town.

Nurse: Do you know the hospitals name???

Patient: No, not really. It was bought out a couple of years ago, this used to be the County Hospital.

Nurse: Do you know what the date is??

Patient: Well, I know it is November, around the 10th or 11th. 2000.

Nurse: Who is the President??

Patient: Now miss, that's a good question. Everyone says that its Bill Clinton...but if you ask me..Id say its Hilary. That gal has a grip on what is going on..if you ask me....
She smiles.. folds her arms across her chest and relaxes into the chair.

She seemed just fine to me....