Sunday, December 25, 2005

What Makes It

The car driver had smashed into him while he was motorcycling, circled around to view the damage, then sped away leaving the patient down on the street. The sharp ends of fragmented tibia and fibula sprouted like long nasty thorns from his pulpy lower leg.

Man, that is cold. I marvel at the meanness of so many people. I would think that eventually I would become numb to it all. After all, what that hit-and-run driver did was really no worse than what the Bush administration has done to New Orleans.

Recurrently bombarded with meanness. All of us. Daily.

But I do not go numb. Instead I am resolved, despite my inner sloth and zen-like moral indifference, to work. That, and play classical guitar music. We all need some kind of release, and I'm getting too long in the tooth for marathon running anymore.

It wasn't bad for a Friday that was to begin a holiday weekend. But then I walked into a room to announce that a patient had been formally discharged, as her repeat labwork was fine, when their spouse said that they had to get to their pharmacy by 5 p.m. closing or the patient wouldn't be able to get their Lovenox prescription filled. It was 4:50 by my Casio.

I rushed to call their pharmacy while the spouse hurried over there, only to find out when the pharmacist called back that the medication was not covered. The patient was your basic charity case who probably had been surviving on doctor's office medicine samples and mercy care for quite some time.

Trouble. This would be a hassle. Lovenox is so pricey that there was no way they could purchase it out-of-pocket.

The in-house on-call case manager didn't return my page, and when I tried to page the daytime case manager they also were unable to get back to me. The resident for this patient, one of my very favorite doctors, did take my calls even though he was out of the hospital.

In the midst of this 5-minute period of great hassledom, two of my other patients had called out for pain medications. The leg guy obviously needed this frequently and regularly. But I had just given him 6 milligrams of morphine 40 minutes ago. The other patient was known to be threatening to staff if he did not get what he wanted when he wanted it. I had been getting along with him perfectly well and I did not want to spoil that therapeutic relationship by holding him up on a little Dilaudid.

Busy times three.

Then the grand-daughter of my other patient down the hall came up to me, while I was on the phone with the resident about the foiled Lovenox, to tell me that "her grandfather had blood on his diaper."


I followed her to the room to find him amongst a pile of bloody Attends and hospital pajamas. Though incontinent, he was fairly independent, but apparently he had pulled out his running intravenous line while freshening up. He'd had a bit of a stroke way back when, so his mentation was just a little off, too.

Four places to be, one nurse.


I think when he bled all over the fresh brief and pajamas, he just put on another set, which subsequently got bloodied, and then he would change out to another set of briefs and clothing, only to have that get red and messy, too, not realizing that his arm continued to drip blood from the intravenous site.

He just kept changing clothes, probably for all of about ten minutes. But a little blood goes a long way, and as he moved his arm to pull up his clothing, the intravenous site pumped a little blood instead of clotting off.

There were probably four or five bloody briefs, bloody hospital gowns, and bloody pajama bottoms lying on the bathroom floor around him. Bloody towels and washclothes, too. His left side was painted red in blood from his chest down. Like I said, a little goes a long way, and a lot can happen in ten minutes.

All nurses know this feeling. Waiters and waitresses call it "in the weeds." A mad rush to be in four places at once.

Well, stopping the bleeding is usually a good place to start.

So I did that, then went to get a bunch of linen and IV supplies for Mr. Red. Another nurse offered to medicate one patient, while I mixed a cocktail for the other, then I cleaned up Mr. Red and got him tucked into bed.

The resident called in the meantime and gave me orders to hold the discharge on Lovenox lady, because without it she would be at risk for tossing a clot. She had a history of having done that before, hence her lack of toes on one foot. Both feet, actually, but it was just the one that had no toes at all.

I just now see some irony in these two particular problems: one patient bled while the other was a clot risk.

Sometime in this madcap half-hour I had lost my composure. I took the Lovenox lady's chart to the charge nurse, urgently explained the problem, and said that I didn't have time to address it immediately because these other little problems were "pissing me off."

She naturally offered to help, but I couldn't really expect her to sort it all out. She did help type up the discharge paperwork, but that turned out to be a waste as the patient ended up staying.

Another night in the hospital probably goes for a good grand. Half that would pay for the Lovenox she needed. Oh well. It's the best health care system in the world. That, and Halliburton is the best food provider on the planet.

Within the hour I had replaced Mr. Red's intravenous line and everything else slipped into place as the next shift started to trickle in. Pain under control for those two, Lovenox lady merrily ate her supper, dinnertime insulin coverage for everyone. Day three was coming at last to its end.

I saw Andre walking in, and went to give him a hug. I'd known him for years at work in another hospital. When I asked him how things were he said "not good" and I could see the moisture welling up in his eyes.

His significant other, with whom he'd been living for the better part of a decade, had just decided to leave him after he had spent time and money supporting her through school. He was taking this hard. We all would.

She was even seeing, among all the other people she was now rotating through her life, someone who worked here, and she was also a good friend of Mr. Pulp-Leg, and Andre feared she would come to visit him but with a new lover in tow. Not pretty, that.

And Andre then told me his doctors had just found a lung tumor, after he explored his developing shortness of breath. He was not told of its size, and he was worrisome about having to wait weeks for more follow-up diagnosis and treatment.

Plus, his ex-lover's sister had come to live with them, but after the break-up she had taken Andre's second car and a cell phone and disappeared into the big city swirling masses. $600 cell phone bill in Andre's name, then he had it turned off.

I had been having a good day until it all broke loose at 5 p.m. Then it fell together.

Andre had been having a good life until recently, but it is against all hope for it to resolve as easily as my piddly troubles did.

I do not go numb. I am humbled and chagrined at my break with composure in the face of self-pity and stress, but I remain resolved.

Never give up, even if everybody else does.

Andre and I talked, him tearfully, for a half-hour. That's eons in "nurse-time." Then he was called by his patients, interrupting us, and I finished up my documentation, leaving an hour-and-a-half after my shift ended.


may said...

man, that is such a hard time. i feel for you, as i exactly know what you mean or felt. many times, you go around trying to figure out how you can be at different places with all your patients at the same time, then there is that coworker friend who just needs a little time. it is not only heartbreaking, it is frustrating not to be able to do it all sometimes.
anyway, i just remember you sort of implied your birthday is on a holiday. is it on christmas? or i was reading you wrongly? if i am right...have a happy birthday...

Eric said...

You know, it really is weird how far a few mls of blood will go. It seems you could cover several square meters with a drop or two. Absolutely amazing. And I've run into the Lovenox thing before, and have kept patients for an extra night or two because of it.

We never can escape the 4-places-at-once phenomenon. As charge, I try to take over the one action that is causing the log jam. Most nurses will recover quickly if they can just get that 5 minutes of overlap back. Even if it's a little thing, the good ones can recover pretty quickly.

Then there are those that you just have to take over for, straighten it all out for them, and give them report all over again. (I know you are definitely not one of these.)

I hope you are having a good holiday (oh and I guess possibly a nice birthday too?) --eric

Nurse2B said...

Wow - what a day. I am amazed at your stamina. Funny how your friend's pain can make your own seem trivial - even when it isn't. I hope things work out for both of you. Happy Birthday and Happy Holidays.

Eli Blake said...

Great post. Hope you don't mind, I'm featuring it in a board on Deep Thought.

It points out how cruel and twisted some people can be, and how cruel and twisted our healthcare system is, all while intermixing it with just enough humanity that I have to smile.

I hope they pay you well, because I wouldn't want your job even if they paid me twice what I'm making now (but I know you're a nurse, so I already know they don't pay you well enough).