Memoirs of an Emergency Nurse (3 page)

The anaesthetist took charge of the ventilation of the now quiet girl and we turned to take off the blood stained gloves and glass scratched aprons, when we heard the bang of the resuscitation doors being pushed open by a paramedic trolley with another bloody casualty.

The doctors had prearranged a bed in high dependency for the girl and I had called to give a handover to the nurses in preparation of the transfer.

The radiology department called to inform us they were ready to start the CT scan on the girl and I took her down the corridor to CT with the anaesthetist. Four people assisted in transferring the girl from the emergency trolley onto the CT scanner bed. I ensured her neck remained in a stable position whilst the anaesthetist ensured the ventilator was secure and we all helped glide the girl onto the CT scanner bed. We stood behind the glass as she was automatically moved slowly through the scanner as sections of head and neck were scanned and the pictures appeared on the radiologist’s screen. We waited with baited breath looking at the layers of her brain and skull the CT had produced; there appeared to be no patches of blood in her brain and the radiologist confirmed no brain abnormalities were found. There were, however, multiple fractures to her mandible,
eye socket
and nose. We transferred the girl straight to the High Dependency Unit from CT. I was told later that she remained on a ventilator for only twenty-four hours. A maxillofacial surgeon performed surgery to plate her broken facial bones and she went home after a few days.

After I transferred the girl to HDU, I returned to the resuscitation room. The young man with minor injuries had been taken to the ward. I aimed to tidy the mess and found the resuscitation room quiet and emptied of people, but for one doctor sitting on a stool at the end of the third resuscitation trolley and another nurse. It felt very calm compared to half an hour before and the
emergency team were now in the main department treating less serious
patients.

In the third cubicle, the one I hadn’t been attending, was a new patient. One of the doctors was sitting calmly at the end of his bed writing up his notes. As resuscitation was my allocation for the shift, I took over the patient’s care and was given handover by the nurse.

The patient was the unconscious patient that had been mentioned when the paramedics initially asked for the fast response team.  Dave was the third victim involved in the same RTA.

The doctor sat peacefully in the now quiet empty room but for his patient and me. There was glass and blood all over the floor and boxes with equipment open. Empty fluid bags hung on the ceiling drip holders, paperwork and outer packaging covered the work surfaces and the drugs cupboard was still wide open. Remnants of the treatment were left in drug trays. It looked like a bomb had hit the place. Having been heavily involved with the treatment of the screaming girl, it was eerie to have this room so silent and empty.

The patient was another male, the driver’s friend and girl’s boyfriend. He was lying still on the trauma bed; again, he had a hard collar around his neck. I moved my eyes up his body, past the bright orange hospital blanket covering his lower limbs. His left arm was speckled in red cut marks from the glass, he had an ET tube inserted in his mouth and the once white bandage holding it in place was blood red.

I moved closer to his head. His short hair was matted with blood and stuck in clumps; his eyes were tightly closed with purple swelling, his face distorted beyond recognition. Lying still on the bed, he looked half dead. I glanced at the monitor to check his vitals; he had a strong pulse and stable blood pressure. The soft breathing of the ventilator was the only noise. The doctor saw me taking in this poor man’s injuries; both of us understanding that his prognosis was poor and that it was likely he might not pull through. He was my age; 23.

The doctor asked if I was all right. I gave a large sigh and said ‘yes.’ I
put a new set of gloves
on and tried to remove some glass shards from the young man’s hair and then I went to get something to wipe the pooling blood from his face. The police had contacted his parents and they had been told to come to emergency because their son had been involved in a car accident. I went to the sink, got some wipes, soaked them in water and went back to the young lad and wiped the pooling blood from eyes and face gently. I didn’t want his family to see him like this.  I tried to reduce the shocking visual experience his family would have when they arrived to see and hear the traumatic news of their son.

The girl had taken the last available HDU bed and therefore the young man was being transferred to another hospital for treatment. He ended up having a basal skull fracture as well as bleeding on the brain and severe facial fractures. He had been in the passenger seat of the car when the accident happened. Evidence showed he hadn’t been wearing a seatbelt.

Most people, after hearing I work in emergency, express their inability to do my job, and then ask if I have any funny stories of things stuck in people.

Well, a very regular occurrence is children sticking things up their noses. They do tend to have a habit of pushing it very far up their nose with their fingers. On some occasions, parents would not be aware of this until the smell gives it away.

So picture this; a four year old boy comes into emergency. He had stuck an eraser up his right nostril. This eraser was on the end of a pencil and he couldn’t tell me why he put it up his nose. His parents accompanied him into the brightly coloured children’s room and, after he had been playing with some toys for a while, the doctor went in to assess him. After a few upbeat and friendly words, the doctor looks up the child’s nose with a handy ophthalmoscope attached to the wall. The doctor turned on the bright light and asked the boy to sit on the bed and look up. The doctor could just see the object in the distant part of his nostril canal. It was far too embedded to pull out with suction or attempt to retrieve with forceps. The child would be forever traumatised if we attempted to retrieve it with forceps, so we avoided it if we could.

In our emergency department, we had an interesting way of retrieving foreign bodies up little children’s noses and we let the parents do all the work.

Children have small airway passages and of course, the nose passage connects to the mouth passage and forms a bit of a semicircle. With this thought process, if the nose is blocked by a foreign object, potentially it can become unblocked by forcing air up the back of the sinus cavity. We asked one of the parents to put their lips over the child’s mouth and blow. The child is happy enough to have mum or dad kiss them on the lips and the whole process is over in about 3 seconds. The force of air into their mouth shoots up the back of the nostril passage and forces the foreign object out of their nose. The only downside is the snotty secretions surrounding the foreign body usually lands on mum or dad’s face as they are blowing into their kid’s mouths; however, this is much better than holding down a screaming child while the doctor pokes around their small nostril with metal forceps.

We asked which parent would like to do this and the child’s mum was happy to assist. The little boy sat on the bed with his head facing down, while mum put her lips around his whole mouth, closed her eyes and blew hard once into his mouth.  The small eraser rolled onto mum’s face and dropped down onto the floor with force. The child was not distressed, I gave mum a paper towel to wipe her face where the eraser had hit her and the family left emergency with a good future tip.

The doors of emergency are always open and we never know what may walk through them. We have a security door and usually keep it open in the daytime so that people could walk through to the main area to visit relatives or talk to staff.

One day, I was attending a patient in an open waiting area when a man walked through the waiting room, through the security doors and into the main department, patted me on my back and said in a raspy voice, "I don't feel very well." I hadn’t see him walk in as I had my back to the waiting room, talking to a patient sat down about to be discharged.

I turned around to behold the walking dead.

The man stood before me a ghastly shade of pale white and grey, his skin had a waxy glow from sweating profusely; he struggled to get his words out and was breathing heavily.  He had a very confused look on his face, clearly from the lack of oxygen. As there were no seats available, I moved him over to hold on to the wall, grabbed the nearest wheelchair and moved him into the resuscitation room. This man was clearly unwell and about to collapse at any minute.  He had the classic signs of a heart attack.

He was in serious need of treatment and I dared not leave him for a minute. He was very slow to do anything, due to the lack of oxygen getting to his heart and brain and I could only encourage him to sit on the wheelchair so I could move him into resuscitation and start assessing him. Once in the resuscitation room, the patient’s confused priority was clearly different to mine.

Firstly, he didn't want to get on the trolley with his shoes on. He stopped, looked down and was about to take his shoes off until I firmly stopped him. He then turned 360 degrees to get his bum on the trolley rather than just doing a right turn, all taking seconds off his treatment time. Once he was on the trolley, I told him to take his jumper off and he obviously didn’t comprehend my urgent tone of voice. He slowly took his jumper off and started to fold it ever so carefully while I was preparing the observation machine. He then started to undo the first few buttons on his shirt slowly.  At this point, I could wait no longer. This man looked as if he would die any second and his inability to act quickly gave me even more cause for concern. With swift efficiency and a sense of urgency, I slid the top layers of clothes over his back and head to reveal his chest, without pausing to fold them
             

I was talking to him to gain information as I assisted him to get undressed. I attached ECG leads and a blood pressure cuff, set the machine to start recording and placed an oxygen mask over his face at full maximum flow rate. I was gaining vital information about the presenting complaint and how long he had felt unwell for, allergies and medical history. I recorded an electrocardiograph, which interpreted the electric current in the heart, and I could interpret that this patient was having an acute myocardial infarction. I called over the intercom for a doctor to come to the resuscitation room and swiftly gained intravenous venous access and blood samples while waiting for whichever doctor was free to attend. The man remained a pale shade of grey; he found it hard to talk and was very sleepy.

At the very moment the doctor walked through the resuscitation doors, no more than five minutes after I got him there, the patient stopped talking mid- sentence, let out a deep breath, laid his head back in the trolley and closed his eyes. I couldn’t believe it. Although I had known it was going to happen, I still couldn’t believe it happened in front of my eyes.

I pulled the emergency buzzer to get other staff members to assist with this now unconscious patient and I knew staff would run in to help me. I collapsed the trolley so the patient was laid flat, gave one hard sternal thump with my fist on the patient’s chest but with no effect, then literally ripped open the defibrillation pads and
smoothly stuck them in position on his chest and looked at the cardiac machine for a reading. The doctor was on the other side of the patient and, after looking at the ECG monitor, saw he was in ventricular tachycardia, without a pulse. He charged the defibrillation paddles and was saying “Clear” as other staff members came in.

The defibrillation joules were administered, causing the patient to arch his back and lift his head from the trolley with full force. Within seconds, he was conscious again. He sat bolt upright, his face remained a pale
grey
colour and was dripping with sweat beads. He looked like a wild animal, not knowing where he was or what had happened. His eyes were glazed over and he looked around without focusing on anything, He let out an animal like growl and then vomited down his chest. He began climbing over the side of the trolley and thrashing his arms around. He was strong and severely confused. ECG wires
were being pulled off his body and
he was pulling over the defibrillation machine as staff tried to restrain him from falling off the bed. He pulled out his IV line and blood spattered the floor, along with the vomit. I wasn’t able to hold the man up but I grabbed his bleeding IV site with my gloved hand in a bid to save all the nurses that were helping from a spraying of blood as he waved his arms around.

He was lowered to the floor by the staff, where he sat down. A nurse tried reattaching the oxygen to his face but it hissed as the tube had come away from the wall. Another nurse wiped the sweat and vomit from his head and chest. The patient was breathing hard. He was conscious and had a palpable radial and brachial pulse. He was uncontrollably strong and confused from lack of oxygen; my gloved hand remained firm around his IV site, but my unprotected arm was covered in his blood from attempting to apply pressure while he was climbing off the bed.  Oxygen hissed where the attachment had been pulled away from the wall supply and people were trying to calm the patient, reassuring him and trying to guide him back to the bed. The defibrillation had been successful; however, to minimise stress on his heart, it was ideal that he la
y
on the bed rather than sit on the floor. His right arm hung in the air, still attached to the blood pressure machine and wires limply fell across the trolley where he had been lying moments before.

I was amazed at how strong he was and that he could even stand up after dying two minutes ago and having 360 joules of electricity rage through his body. Having guided his slippery sweaty body back onto the trolley, the oxygen mask was replaced over his face at high flow and I put a swab over where the IV line used to be, securing it with Micropore tape.

All looked calm again. The patient’s heart had stopped beating and he was unconscious for seconds prior to being shocked back into life.  The confusion that followed had been unusual, but was over now and the patient was settled. Members of staff started to walk back to what they were doing prior to the emergency buzzer sounding.

After reattaching all the leads back onto the patient and reassessing his condition, he spoke to me about it getting dark and he wanted to know what had happened. I looked at the patient and was about to explain when he did exactly the same again. He went quiet, his head slumped back onto the trolley and his heart stopped. Repeat scenario. I pulled the emergency buzzer again, pads were already in place and the doctor charged the paddles. I removed the oxygen and stood back. One shock caused his body to convulse, but his heart reading showed he was back into a normal reading.

The nursing staff ran through the resuscitation doors for a second time to see the patient being defibrillated, but luckily, he did not give the same confused response.

This time around he was more lethargic. He vomited again on the pillow and remained on the trolley, just moving his head right to left, looking around. A short explanation and reassurance was given to him.

After two cardiac arrests and two successful defibrillations, this patient sat up on the trolley and chatted to his wife about how he had driven himself to hospital because he ‘didn’t feel quite right.’ He reported having two episodes of amnesia where everything went black and there was only a small light amongst the blackness.

I did not leave his side and accompanied him all the way to coronary care unit with a doctor and a defibrillator ready for action. I went to see the patient the next day as I still couldn't believe we had saved his life twice. He was so lucky.