Memoirs of an Emergency Nurse (9 page)

I was triaging one day when I pulled the next card off the printer - female, aged 22, allergic reaction. She had probably waiting 10 minutes before I pulled her card off the printer as it was a really busy day and I was triaging alone. I called her name and two women stood up together and walked towards me. The girl was wearing a large hat on her head and this covered most of her face. She was guided in by someone I assumed to be her mother. The girl’s face was red and so swollen that she could hardly open her eyes
h
er lips could have been collagen implants gone wrong. She had a shiny stretched appearance to her taut skin.

Before we even got into the triage room, I asked her to stick her tongue out and she could hardly open her mouth. Her tongue was twice its normal size and filling most of her mouth so I made an executive decision to take her to the resuscitation rooms myself. She was a category one, needing urgent treatment. Once she was sitting on the emergency trolley in the resuscitation room, I asked her to remove her hat and started gaining the history from her. She had had an acute allergic reaction and was embarrassed. She didn’t want to show anyone her face, which had doubled in size.

Once her hat was off and no longer shadowing the full extent of her appearance, she looked incredibly swollen. I had noted that even her hands were swollen with chubby fingers and taut skin. Her earlobes were bright pink and enlarged.

She had been eating a Snicker’s bar and suddenly felt her face swell up. It is quite unusual to not know what you are allergic to at the age of 22, and this was such an impressively large allergic reaction, it surprised everyone.

I couldn’t stay too long as my role was in triage. I called for the resuscitation nurse and a doctor to the takeover. Once the resuscitation nurse came, they would take over the patient’s care once I had stabilised her. I got her to take her jumper off and saw her discoloured red chest. It was the same shiny texture of her face with red blotches showing in the V-neck of her t-shirt.

I listened to her chest and surprisingly she had no wheeze, which was a good sign considering how progressed her swelling had become. Usually in allergic reactions, the airway tightens and you can hear an inspiratory and expiratory wheeze when breathing; however, it was a good sign that this was not present and it meant that she wasn’t a high risk for respiratory arrest. I applied the monitor machine to get an accurate pulse and blood pressure and continued asking questions while getting my equipment ready for cannulating the girl so we could give her some antihistamines. I gained most of the history from her mother and gave the patient a tissue to hold so she could wipe her saliva if needed; with a tongue twice the size of normal, it is hard to swallow saliva. The doctor and resuscitation nurse came in together and I gave a brief handover to them and gave the cannulation equipment to the doctor.

I returned to my role as triage nurse, but I did go back  a little later in the day once the volume of patients had decreased. She was a new woman. She was still a little red and her fingers were still a little swollen, but her face had dramatically reduced and her tongue was back to normal size. She was still highly embarrassed about the whole episode but she didn’t need to be.  I am very glad she came in and didn’t wait it out at home. She would go on for further allergy testing and avoid peanuts until the test came back.

We often receive psychiatric patients from the community when they have self-harmed and need suturing. There was one girl who came in quite often. She had scars along her arms, vertical and horizontal red and white scar tissue indicating old wounds and some red raw from recent cutting. She also had old white scars on her chest showing above her low-cut t-shirt. She attended emergency purely to get sutured rather than any other treatment. She had a community case worker and was very open about her need to self-inflict pain to take away the mental pain she felt from previous abuse. The triage nurse had taped a gauze pad over the abdomen and had drawn a small picture of where the cuts were on th
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triage card.

The girl was well known to us and was always well presented and upbeat when she came to get sutured. She told me that she had already seen her case worker after cutting herself and this was the follow up treatment for her wounds. She had inflicted the wounds with a razor blade she had bought from the local shops. I carefully removed the pad from left to right and as some areas had stuck to the open wound, it tugged slightly on her flesh. The wounds had stopped bleeding. There were four deep cuts, each about five centimetres long, all showing baubles of yellow fatty tissue with either side gaping open due to its deepness. I spoke with a senior doctor and he was happy to write up the local anaesthetic for the girl and for me to take over her treatment, to give him more time to see other patients.

I asked her to lie on the trolley and I got the suture kit ready to repair her wounds. I brought back a suture dressing trolley with the equipment needed on the lower level and cleaned the top of the trolley with alcohol in front of her. We talked as I was getting ready and she was just a normal girl, who had a job and enjoyed life but needed to cut herself to relieve the pain of past abuse. She was fully informed about her mental health condition and was happy to meet for regular visits with her case worker.

I put an apron on and washed my hands thoroughly before opening the suture pack, gauze swabs and suturing tread. The packaging was sterilised blue cloth and I draped two covers over the girls t-shirt and trousers to give me a sterile field around her wounds. The suture pack was silver and had all the instruments needed, so I just had to add water for cleansing and the suture size I would use. I had drawn up the local anaesthetic and began to inject the liquid into the areas of skin I would be suturing. The local anaesthetic usually stings a bit and I warned the girl who responded with, “I know. I’m used to it now.” After waiting for the local to work effectively, I then donned the sterile gloves and commenced cleaning the wounds and removing any dried blood or putting a gauze swab on any cuts that were still oozing a little. I clamped the needle into the forceps and held it in my right hand and held another pair of suturing tongs in my left to pinch the skin and hold it out. I started to pierce the skin flap at the top and thread the needle through the skin and then the bottom bit and in a delicate movement, tie a knot and cut with scissors. I sutured one by one for 45 minutes, suturing all four wounds neatly. I advised the girl of when to attend her GP for the sutures to be removed and she said “Yes that’s right, 10-14 days.” I saw her again on several occasions in emergency and did the same each time.

I have seen many acts of desperation while working in accident and emergency, ranging from small attempts at suicide to full blown nervous breakdowns, but nothing touched me as much as a patient I will name Sam. I remember I was getting sheets for a bed as the paramedics wheeled him along the corridor. I took a good look at him, and then I looked at the paramedic and pointed to my face. He nodded. The patient had bulging eyes and bruised occipital area. The paramedic asked if the psychiatric room was free.

The psychiatric room is usually where   we care for patients who have a psychiatric history or intoxication. There isn’t any equipment on show, it is all locked behind a cupboard so patients cannot harm themselves and can only cause limited damage to hospital property if they get aggressive due to intoxication or drugs. It also has a water hose hidden in a cupboard so that we can easily clean the room.

The paramedics had put Sam onto the bed before I could get to him and hear the history. Sam looked like he had poor circulation as his face was a deep blotchy purple colour; the paramedic pulled me to one side and told me what had happened.

Sam had a long history of depression and had been found by his wife, trying to kill himself. He had tied his dressing gown cord around his neck and was pulling it so tightly he caused both his tongue to swell up and his eyes to bulge and bleed. Sam’s wife had the quick wittedness to untie the cord, call 999 and then help Sam catch his breath. Sam hadn’t spoken since the incident and his wife was following in her car.

Sam’s eyes were glazed over.  It seemed that he was unaware of his surroundings, he didn’t answer  my welcoming words nor did he react to me moving his limbs. I gave him a good hard look. He seemed paralysed and completely out of it, even though his observations were stable. Surprisingly, he had no difficulty in breathing after the incident.

He was unresponsive to any intervention we made, yet he was awake and his airway clear. He appeared to be catatonic. Despite the doctor initiating painful stimuli, the patient did not react; he just stayed there lying on the bed staring upwards. After much pondering and discussion between myself and the doctor, we concluded he was so depressed, he did not react. The doctor made his way to the nurses’ station to refer Sam to the medics and psychiatrist and I was left looking after him. I asked him if it hurt anywhere and cleaned his face and lips, ensuring that his tongue was decreasing in size so not to block his airway.  As I was writing down his observations, he made a sound.

I moved closer to his face and asked him to say it again. His voice was rough.  Obviously, it was painful for him to talk and the oxygen was also drying his mouth. He asked me what had happened. I told him he had been found by his wife with his dressing gown cord around his neck. At first, it shocked him and he could not comprehend doing that, but he realised he was in hospital and his throat hurt.  He broke down and cried.

Sam was so distressed at the thought of what he had done, but at the same time, it was as if a different Sam had done it. His eyes were bright with shock and not glazed over as he wiped away the tears.

Sam asked me for water and I obliged with a cup of water and ice cubes to help ease his red raw throat. His family had arrived and the receptionist asked Sam if they could come in. With his permission, his wife and two children came into the resuscitation room and hugged him and held his hand.

I put the trolley cot side down and gave them some chairs, which was when Sam’s wife asked if she could speak to me privately. I left Sam in the capable hands of his teenage children, his observations were stable and he was crying and apologising to his kids.

Sam’s wife was a remarkable lady. She told me that he had a long history of depression.  His father had killed himself because of depression and the same thing was happening to Sam. She told me that after several
inpatient stays in a local psychiatric hospital, he was discharged but always reverted back to depression and had attempted many suicides. She would find windows open on the top floor and knew that Sam was anticipating jumping out of them; he had tried to drown himself in the bath and tried to kill himself twice on the psychiatric unit. She had known he was getting bad a couple of days before and had called the psychiatric crisis team, but they did not come to visit him or offer any help.

I was amazed at what she had told me. Her poor husband was so severely ill with depression, he just wanted to end his life and his wife was so intent on never giving up on him. She was like a rock. She remained calm and understanding, never criticised or blamed, just helped. It really shook me that depression, which is so common and lightly discussed, can cause such a profound change in a person and make them so unwell, that they can inflict such pain on themselves. Many people take antidepressants but I have never seen such a depressed person, unwilling to communicate or move because they are so depressed.

I went back to Sam and his children with his wife. He couldn’t stop apologising to his family but it clearly wasn’t his fault; it was his illness. He didn’t really want to leave his family behind but he couldn’t live with the illness any longer. I supplied him with many cups of iced water and a straw, while waiting to transfer him to a medical ward. He told me that he was not worth my trouble and he didn’t deserve my care. I told him he deserved any help we could give him and that he was a lovely man and not to think that he wasn’t worth anything. I think we all had tears in our eyes.

On a quiet evening through the week, a patient walked through to the main emergency department area and said, “Can you help me with this“?

He had an 8-inch cooking knife sticking out of his forehead. Amazing as it may seem, he just walked in with the knife sticking out of his forehead. It was just solidly stuck there with no support and no bleeding around the edges. It was just like a knife sticking a knife out of a wooden chopping board.

He was pretty calm about the whole incident and just stated that he had had a disagreement with a mate. He seemed to have no neurological injury, he was speaking normally, his reactions were normal and his mobility had not changed. The knife could easily have punctured his frontal lobe and caused bleeding inside his skull.

He was sat in a cubicle and was assessed by the doctor. There seemed to be no signs of injury caused by the knife and it seemed to be stuck into the skull bone rather than piercing his brain. He was able to walk, so a nurse accompanied him to x-ray, making sure he didn’t bump into anything and embed the knife any further. He walked down as if nothing was unusual. It was the medical staff reactions that were the unusual thing in this situation. The nursing staff and medical staff crowded around the x-ray light box to look at this man's x-rays. They revealed the knife was millimetres away from his brain. He was so lucky. If he was to shake his head around, the knife could easily pierce his brain.

After having the all clear from the doctor and a look at the x-rays himself, the procedure to remove the knife began. The man lay flat on the cubicle trolley. With his head supported in place, the doctor pulled the knife out with force. It was embedded in his skull and it took a few attempts at pulling to release it. The doctor got it out on the third attempt, nearly hitting the wall behind him with the momentum and force it took. The doctor then sutured the wound to prevent infection getting into the site and informed him of what to look out for to prevent infection. Stitches were to be removed in 10 days by his GP. The man was appreciative of the help and asked to have his kitchen knife back. The doctor gave back the man’s property and he left in good spirits, feeling like it was his lucky day.