Decompensation, The Downhill Slide of Burnout

We were having a day like I read about over at Madness. I was standing over an evolving CVA patient pushing something or other and the moans and bells and call lights and ambulance reports on the radio were going off. The patient's son, late 50's, his mom lying there, probably dying, asks me, "Do you ever get used to this?" 
"Yeah, you do but then you begin to decompensate," says I, the ravages of burnout mirrored in my eyes.  "I'm on the downhill side of that, now". 

He never said another thing to me. The next day I thought about what I said. Might've instilled a little unease in the guy, reckon? His mother's caregiver? Shouldn't have asked me.

No Words

The other day was like amateur night in the ER.  Bogus “hurt my arm 2 weeks ago, need pain meds” guy from a town 40 miles away, one with a hospital and ER of it’s own, incidentally.  Carried a 44oz Styrofoam cup full of soda into the triage room with that horribly injured arm but when I began questioning him about his symptoms, he began to writhe in pain and whimpering.  Piss poor actor. 

In a few minutes after getting this rather odiferous individual out of my triage room, comes yet another pre-triage sheet through the slot with the same last name on it.  This is something people do.  At least in our area.  They all come to the ER together like a sporting event.  Friends all sitting around the living room watching TV and Jerry Springer gets over and nothing good on so they load up and head to the ER to kill some time before Walker, Texas Ranger comes on at 4, or something.  

The other triage was hurt arm man’s tweaker mother.  The family that smokes rocks together, stays together.  They were both so fucked up they could barely put any sentences together.  Drug-seeking, I suspected but they weren’t at themselves enough to even get any appropriate symptoms or stories straight in their heads.  Her chief complaint was lice for which she’d treated herself with olive oil and dog flea shampoo and then, as a last resort, lice shampoo.  Okay.  And?  Let me guess.  You’re here for admission to our adult psych unit?

Soon after, we got a 22-year-old girl in who’d fallen off a horse.  Abraised her great toe and broke her radial head right off.  In the words of Walter Mattheau, fortunately for her, she’d had a few glasses of whiskey just prior to the accident so it wasn’t as painful as it might have been.  She kept us in stitches with her nonsense.  Her blood alcohol was 165.  Funny gal.  And not a faker.  And too drunk to act.  What’s not to like?

Then the thorn in my side.  A 70-year-old man who came in for a 2-week history of constipation and weakness.  No obvious distress.  I had to bite my tongue hard during that triage.  The whole time.  He really got under my skin and I had to fight hard to not ask him what the fuck he thought he was doing in there wasting our time.  I was busy in triage for the rest of the shift but I could see him come out to the desk every once in a while wanting to know how much longer it was going to be.  I couldn’t believe this guy, coming into the ER for  something he could have fixed by going to Walmart and buying some colace.  Hadn’t called his doctor.  Couldn’t even remember his doctor’s name.  He was still there when I left at the end of my shift and I forgot about him except a mental note to use him in my writing as an example of ER abuse. (Something about his case really irritated me). 

The next day I was at work and I heard the unit secretary talking about a CT report.  In the ER, the xrays and CTs are all read by the radiologist in person, if it’s during daytime hours, or remotely if it’s after hours.  The results get called to the ER doctors as soon as they’re read but the actual transcription isn’t usually done until the next day and then prints out on our copier.  So I’m hearing the unit secretary talking about a patient with cancer and on and on until I realize she’s talking about that guy from the day before, the 70-year-old.  She’s got the CT report in her hand so I took it from her and read it. 

Masses in his liver, bladder, around his aorta and, probably the origin, his prostate.  Clearly terminal.  Clearly very soon.  

Maybe Baby?

"That girl in 1...I hope she's not pregnant."  My coworker was talking to the nurse beside her, a doctor's wife who prides herself on what she perceives to be her superiority over the other nurses.

I'd put a 19-year-old, female accompanied by her "fiance" in room 1.  She weighed 300lbs and wore a huge, dirty t-shirt, flannel pajama pants and a pair of work boots.  Her medications included a statin drug, an antidepressant and a blood pressure medication, all of which she receives once a month at the free clinic.  She was here today for a large, painful, draining abscess, probably MRSA, on her, uh, right love handle.  Her last menstrual period?  Six weeks ago. I figured it was she they were referring to.

"I know," this from the doctor's wife,  "some people just shouldn't be allowed to procrastinate."

Do You Walk to Work or Take Your Lunch?

Dr. Lindly:  "Did your chest pain come on suddenly or all at once?"
Long pause while patient thinks.
Patient:  "All at once."

Time for Classifieds

Kimberly comes in about once a week.  Early 20's, about 5’2”, weighs 85 pounds and cries the whole time she’s in the ED.  Typical of anorexics, she sits with both legs folded up in front of her on the chair. Obviously plagued by deep-seated mental issues, she pretends she can’t get to the bathroom without help, crumpling into a heap on the floor and crying until someone helps her up and to her room.   

I must confess that I do, on occasion and for experimental purposes only, merely offer the slightest touch on the forearm or lightly hold a hand at moments like these.  The patient will almost always miraculously get right up and walk now that they're being "helped".   

Same thing with wheelchairs. People load their family members into a vehicle, rush to the emergency room, run inside to the admissions desk and demand someone to help them get the patient out of the car.  Our first response is often, "How did you get them IN to the car?"  Nine times out of ten, I go out with a wheelchair, roll it up to the car and stand there holding it in place, a concerned expression on my face, and the patient gets right up and sits down in the chair and nobody realizes they didn't need to drag a nurse away from another patient to roll a wheelchair to the curb, unnecessarily.  I'm tellin' ya, I shoulda been a faith healer.     

I was ready to go home when Kimberly came in at five after six (less than one hour before my shift was over).  Her chief complaint form reads,   I can’t stop throwing up.  A truer statement was never made. 

She was, of course, crying when I called her into triage.  Her Dad, the spitting image of the father in the movie Juno, waited outside but somehow the knowledge of his presence just outside the door concerned me as our interview turned rapidly ugly.

"What's going on today?

Sobbing, "What?"

"Why are you in the ER today, Kimberly?"

“I’m sick,” she drones, eyes closed.  Then more sobbing. 

Another observation:  When a patient keeps their eyes closed throughout the triage interview, there's always a mental component. 

“In what way are you sick?”  I ask her, the back of my neck beginning to tighten.

But of course, she only sobs, burying her face in one hand.

Answering pertinent questions is always too much of a demand for people like Kimberly.  They are disgusted by our need to interview them, expecting instead, that we should intuitively know by some unknown mechanism, not only the nature and duration of their symptoms, but all their medications and the dates of their immunizations.  Or possibly expecting we should rush them to a stretcher, turn the lights down dimly, and stand silently sentinel as her family and friends file solemnly past them, wishing they'd treated them better,  until the patient's condition improves enough to remember the information requireded to provide their safe care. 

Turning back to my computer, I girded myself for what I knew was going to be the dental extraction of information from her.

Meanwhile, I needed to discharge a patient who'd been waiting for 5 hours for CT results which had never been submitted to the distance radiologist by the radiology tech.  Once discovered, it took only minutes to recieve an "all clear" and her chart was ready to go, waiting on the other side of the wall for me to finish with Kimberly's nonsense. 
 

“I’m going to need your arm so I can do your blood pressure,”  I said, my eyes on the computer screen.  When I turned to start her vital signs, I saw she hadn’t removed the heavy sweater she wore despite the 85 degree outdoor temperature, but had, instead, merely stretched her arm toward me still holding her face with her opposite hand, crying without tears.  “I need your arm out of your sweater so I can do your vital signs.” 

A new crop of sobs poured forth.  “I didn’t know what you meant, you don’t have to be cranky!”  

She had no idea how wrong she was about that.  Being cranky is the last thing I have any control over.

Once I sent her back to the waiting area, chart in hand, I was relieved to see another triage slip in the door.  If I stretched this next triage out until I heard the admissions clerk bring Kimberly’s chart back and put it in the rack on the wall, somebody else would have her in a room and take over her care and my role in her ED stay would be officially over. 

 

As I brought the second triage patient's chart back to place in the waiting rack, I heard Kimberly's familiar bellowing emitting from a treatment room down the hall alerting me that my plan had unfolded seamlessly and once completing the next triage, I was back to my original patient in room 2A, finally discharging her home with a prescription and instructions on constipation. 

Cha ching!  I love it when plans come together!

Ready or Not, Here I Come

Last week, it was Friday the 9th, I had a gal in the ER who cut off her finger using a table saw.  She was a country girl but intelligent, very capable and with good, common sense.  I've had her there before with other family members.  She told me that about 2 weeks before, she had a dream and when she woke up, just before she opened her eyes, she heard God's voice.  It was like she and I were talking, she said. 

"You'll be okay, " God said to my patient.  "But be ready for Friday, March 9th."

Like Tommy Lee Jones in No Country For Old Men, I don't know what to make of that.

Look Around

I went to a funeral last week.  The son of one of my old hospice patient's died.  He was young.  The funeral was in a little, country church in the woods.  The preacher wore a blue plaid button-up shirt, not tucked in.  He was pretty country and when he spoke, I fell in love with him.  That's unusual for me, by the way.  I don't, as a rule even like preachers.  But there were two of them there that day and I liked them both quite a bit.  I liked the way they talked to the...sort of... "rough" crowd packed inside the tiny church that day.  Not like others I've seen, not
condescending.  Anyway.

At one point, one of the young man's friends got up and spoke about the deceased.  He kept saying, "Look around the room.  You never know who may not be here next week."  He said it more than once.

Skip to today.  It was my day off.  About 4:30 this evening the hospital called and said they had a big wreck with pediatric injuries flooding in and could I come and help out for a while.

It's been a long time since I got called in on a trauma.  Used to happen all the time.  In fact, I remember back before I was burned out, I'd be in a restaurant and hear a bunch of ambulances and just go on in to the ER when I got through eating to get in on it.  Now, not so much.

So I got dressed and went in.  Long story short, the guy who was speaking at his friend's funeral last week?  He was the driver of one of the vehicles.  He had his 3 kids with him.  They all had broken bones.  The middle one herniated his brainstem and died in the ER.  He was 14.