basric | LJIDOL SEASON I PROMPT 20 "OPEN TOPIC"

*W A R N I N G* This is a true, visually descriptive activities in a Level One Trauma Center. Do not read if you have triggers to violence, pain or blood. This is my life, so it's mostly everyday happenings to me. I've been told it is not for the squeamish or faint of heart. This mean you Judith. I'd rather go without your vote than traumatize you.

Let me make it clear, I am NOT a superstitious person. I walk under ladders if no one is on them, of course. I brake for black cats and allow them to saunter across the street before me. Friday the 13th, well except the fact the she-demon that was my mother was born on, means nothing but another workday.

I don’t discount ghosts for I have seen them along with other staff haunting the hospital hallways, if they all stayed where they died then trauma would be over-run with them. However, one has never been seen in trauma, yet.

^^^^^^^^^^^^

Saturday night Rene was working triage with me along with Gabe and another new nurse, Carly – who at twenty knew everything.

Usually we get one resident who looks at the staff as part of his team and one jackass who knows everything. Tonight we had two jackasses Dr. J. and Dr. R.; both considered us their personal servants. It was also their first night flying solo in triage without the watchful eyes of their Attending.

LifeFlight is the critical care air medical transport service of Vanderbilt University Medical Center. Supporting the Level 1 Trauma Center at Vanderbilt, LifeFlight uses 3 American Eurocopter EC145 helicopters, 2 American Eurocopter EC135 helicopters and a King Air 200 fixed wing aircraft based in Lebanon. All service Middle Tennessee and Southern Kentucky.

Tonight we heard one big transport after the other lift off from their pads. Four helicopters heading different directions. It was going to be a busy night. I walked into triage to set up and passed through a cold spot. It was icy enough that I looked around for the source. Not finding one, I shrugged and set up for the first arrivals. Rene found me shortly thereafter and asked me what was up with the draft at the entrance way.

When Gabe asked me about it also, I called maintenance but it would be Monday before they'd get to it. It is kept cold in triage but not icy.

First delivered were two victims of GSW's; one took two to his chest the other had one in the back and two in his thighs. I gave the first to the secondary resident and Rene.

Dr. R. took the second. Immediately he began barking orders. The wrong orders.

“You need to intubate and place the line first so labs can be drawn. This is protocol, doctor -- ABC’s – airway, breathing, circulation. Basic stuff."

“Don’t argue with me, cut off his clothes first so I can examine the gunshot wounds.”

RT spoke up, “Doctor. He’s in respiratory distress.”

“Don’t tell me my job.”

Bill our RT is an easy going guy, but you don’t screw with his work, “Either intubate him or I’ll be forced to do it. Then write it up. I know Dr A. (the Attending) taught you this.”

Dr. R. glared at him then snapped at us to get busy. We removed the patient’s clothes putting the shreds into a large bag. Still Dr. R. after three tries had not gotten the patient intubated. The patient was blue; his heart rate skyrocketed to 150 bpm then dropped to zero. The EKG alarmed the patient’s heart rhythm went straight into asystole.

“Why are you standing around, start C.P.R.” Was that panic in Dr. I Know Everything’s voice?

“Doctor, he’s bled out. There’s no blood to circulate oxygen through the body. You need to call TOD.” TOD 23:59

About that time the alarm sounded in Bay 1. T.O.D. 00:05 was called, too. We could not assist as the next patients were arriving. Four victims of an MVA whooshed through the auto-doors – SUV versus an eighteen-wheeler, the eighteen wheeler won. Three patients were given into the bays for the secondary resident with various fractures and lacerations.

Our patient had crushed ribs and a sucking wound in the chest, a neck brace and back board.

I ripped the shirt open and exposed the wound. I peeled the package and slapped a Vaseline dressing over the wound. The sucking noise ceased but Dr. R. began yelling at me, "You do not treat without my permission."

“Then YOU rip it off and you can put it back on.”

"I didn't even get to look at it." He sounded like a sullen child.

“Listen to me you . . .” whatever he was going to call me was interrupted by Bill saying, “He’s in distress.”

"Take the neck brace off and I'll intubate him."

"If it's there he could have cervical fractures. You could paralyze him from his shoulders down and condemn him to a life on a respirator. Trach him. He can't wait for x-ray."

While Dr. R. fumbled with finding his marks I applied the leads, alarms sounded, “He has a hyperkalemic rate, doctor.”

“I’ll trach him, I just need a minute, give me a minute.”

“He—has—a—hyperkalemic–rate. There’s nothing you can do. You know that.”

I popped the leads and stopped him from removing the Vaseline bandage. “Everything must remain until the coroner’s autopsy.” He blanched at that. “This is Trauma; you know state law says anyone who dies within twenty-four hours of entering the hospital must call the coroner. Any deaths in triage have to call the coroner for autopsy. Call it.” TOD 01:40

Alarms blasted from all bays. The simple fracture’s turned into catastrophic heart episodes. All three died one after the other. TOD 01:45, 01:50, 01:52 even with everyone's help, it was to no avail.

The triage was just put into pristine condition by our rocking janitorial staff when LifeFlight brought two more mid twenty males with GSW’s. The first was a neck wound, the patient brought to us only because he hadn’t died yet but he finished bleeding out in Bay 1 within two minutes of arrival.

The second had a high chest wound. Dr. R. intubated.

“It’s in the stomach not the lungs,” Bill and I chorused together.

“I put it in the lungs where it’s supposed to be,” growled Dr. R. back at us.

“Watch his stomach as Bill squeezes the Ambu-bag. The belly inflates.”

Dr. R. jerked it out and replaced it correctly this time.

“Doctor, his pressure is dropping.”

He called for Dr. J. and together they read the scan unanimously deciding it was his subclavian artery that had been nicked and since both had been through their general surgery rotation decided to cut and clamp.

“Hang two units of packed cells and I need a scalpel and hemostats.”

“Doctor he is throwing PVC’s, and his heart rate is 40. Could it be his aorta and he is bleeding out internally.”

"Are you a doctor? Then shut the hell up. Get those units up, now." He made the first cut. I looked at Bill and he shrugged at me a ‘what are you gonna do?’

The third cut separated muscle from bone. An eruption of blood that would have made any volcano proud geysered up to hit the ceiling and rebound to splatter everyone and everything in the vicinity. Less than ten seconds for his heart to empty the remaining blood in his body onto us.

I felt blood saturate and soak through my yellow “protection” gown, through my uniform and lay warm against my skin. My hair was drenched in blood through the cap. I kept my mouth tightly closed until I ripped my mask off at the utility sink and scrubbed my face and lips with harsh antiseptic soap. I removed the cap and gown, and Rene’s “Oh, Barbara, your hair," did nothing for my temper. I slapped two caps over my bloodied tresses and stalked to the patient. Still I tasted copper on my lips.

“I guess it was the aorta?” Dr. R. ventured.

“You think, call TOD.” TOD 02:04

Another LifeFlight landed and I opened Bay 4 and 5 to form an arena while the main room was disinfected.

The next two were victims both barely nineteen who on a dare tried to jump a freight train traveling through town. Both slipped and missed. Both had double leg amputees and massive blood loss. Both lived less than five minutes after being wheeled into trauma. TOD 03:25. TOD 03:27

Rene whispered to me, “How many does that make tonight?”

“All of them.” I walked to the entrance and paused, the cold spot remained. As I said I am not superstitious, I am not prone to histrionics, nor am I particularly religious. Either someone had cursed our triage tonight or the grim reaper had set up shop.

The next victims were thirty minutes out. I showered and watched the blood swirling down the drain. It looked as if I'd been slaughtered. I took my hair down pulling fist sized gelatinous masses of blood clots from it. It was times like this I wish I had cut my hair instead of leaving it waist length and winding it up on top of my head. Paula got someone to watch her patients and it took all of the thirty minutes to comb out clots. I dragged it back into a ponytail, twisted it wet on top of my head and pinned it.

"Oh, I see other small clots."

"Leave them. I'll get them at home. They can't get any worse."

Once more triage was pristine. Our next victim came in with an injury I’d never seen. He had been wrapped chest to thigh in one continuous pressure bandage. As Dr. R. and I received report from the on-board Paramedic; Carly decided to help prepare the patient for assessment and pulled the Velcro holder. Her scream pierced the air.

Our victim was sliced in half from groin through intestines, kidneys separated, slicing a piece of the liver and stopped at the diaphragm which guards the thoracic cavity where the heart and lungs are housed.

Blood again, so much blood. Forty hemostats were placed. Nine units of blood through the infuser was given. We had had him stable, ready for surgery. We never heard how the injury occurred but as the surgical techs arrived he arrested. Everything shut down. The human body can take only so much. “He’s gone into shock, neurogenic or traumatic shock, doesn't matter. We’ve lost him. He's gone. Asystole. Call it. TOD 04:14.

Carly shrieked through this entire procedure and though I was sorely tempted to slap her I chose instead to shut her up by breaking an ampule of ammonia under her nose. She sputtered and coughed and gasped for breath while the charge nurse led her out as she sobbed her excuse.

Right on the heels of this loss we were brought a MVA twenty-one year old female with a fractured pelvis, bones protruded through her skin at her hips. Intubation, lines were placed, blood in the infuser, clothes cut from her body, leads placed; Rene and Gabe secured her fractures for surgery.

Alarms sounded, I hit the mute button and glared at the cold spot. I quickly pulled out the syringes with the drugs used for resuscitation and put them in order. “Carly get in here.” I pushed the first drug while Gabe performed CPR and Bill breathed for her with the Ambu-Bag. Carly slunk back into triage, “Listen to me. I have the syringes lined up. After each shock wait until he tells you then inject the next in line. No deviation. Do YOU understand?

After ten minutes still in V-TACH Dr. R. was ready to call it.

“Hell NO! Gabe lift me up onto the gurney. She’s only been down ten,” I looked over at the entrance way, “And I’ll be damned if you get her. Fight. Now we fight.

No one seemed surprised or questioned to whom I spoke. The doctor thought it was himself. Carly pushed, I circulated by compressions and Bill breathed for her. Gabe lifted me away as the paddles charged and she rose off the gurney as electricity flowed through muscles to her heart. Gabe returned me immediately after each jolt. For twenty more minutes we fought for her life, until—sinus rhythm, she was back just like that. “Mike, you and Carly push us toward surgery. Call report, tell them we’re coming, Dr. R. and to be ready.”

“Why are you going?”

“I have the defibrillator. Rene, triage is yours.”

When I returned the cold spot was gone. Our young woman survived and we did not suffer through another death that night.

For every patient who codes and lives or codes and dies you figure twenty to thirty minutes of paperwork for the committee of bureaucrats with no medical experience just law degrees to review and tell us our missteps and how to correct them in the future. And neither doctor stayed around to notify the families out in the waiting room either. They left that for me, too, though it is their job. Be certain I left the Attending a note.

That night a nurse discovered she still had a lot to learn, a doctor almost learned what it meant to be a team player. As for me, I pay closer attention to cold spots.

**A note: there is no way to know if things would have gone differently; if any of them could have been saved. Some came to us already in death’s hand. Nothing could have saved them. Others a more experienced doctor. . .I honestly don't know. But when they won't let you and your team's expertise help, we can point out errors and assistance but I am bound to follow their orders. That is until I've had enough and my temper takes over.

ABBREVIATIONS:

Ambu-Bag: used by RT to breath for the patient tube connects to oxygen

aorta: see vascular below
asystole: or flat lined (no electrical activity in the heart)
bpm: Beats per minute
GSW's: gun shot wound(s)
hyperkalemic: high potassium
MVA: Motor Vehicle Accident
PVC: premature ventricular contraction (SKIPPED BEATS IN THE HEART)electrical misfiring of a pacemaker of the heart in the ventricles.
subclavian:See vascular below
RT: respiratory therapist
Vascular: an up close look at the upper body's main arteries & veins

V-Tach: electrical current in the heart where only one ventricle pacemaker is firing. Heralds the onset of death.