Memoirs of an Emergency Nurse (10 page)

Drugs

We often had regular intravenous drug users attend emergency after overdosing. Often paramedics would bring them into the department, having administered Narcan, a drug that reverses the effect of opiates. They would often last less than half an hour in the department before making a hasty exit.

On one occasion, a person spent no longer than five minutes in the department. He was given Narcan by the paramedics and just after being assessed by the nursing staff, he woke up, jumped off the emergency trolley and started to run out of the department. He saw a window of opportunity through the waiting room door and ran through the crowds of people waiting patiently, nearly knocking a few over, and outside into the daylight.

A few of us walked out of the department to see how far he would get. We found him on the grass outside of emergency, laid out flat, unconscious again. Narcan has a very short half-life and the waking effects only last for a short period of time. We scooped him up and returned him to the trolley he had just ran away from andensured he was safe to sleep off the rest of his heroin overdose.

A teenager had been drinking alcohol in the local park when he became unresponsive and, despite his friend slapping his face with full force, he would not respond. His friends called an ambulance and he was brought into emergency. The teenager was given immediate treatment by the paramedics.

When he was brought in, paramedics had already placed a Geudel airway in his mouth to keep his tongue from falling backward and blocking his airway. He also had a cannula in his right forearm and a litre of fluid attached. The paramedics wheeled him in on a trolley, his long hair draped over his sweaty face, his breath reeked of alcohol with every deep breath he blew out and he had vomit stains on his t-shirt. His skin was cold from being out in the night air with not much warmth or protection. The paramedics lined up the two trolleys together and unfastened the teenager’s seatbelt. Removing the blanket, they rolled him over onto the emergency trolley and placed the blanket back over his body.

His Glasgow Coma Score was nine out of fifteen. Fifteen would be fully conscious with no neurological deficit. The alcohol made the teenager extremely sluggish to any response and his pupils were like large black buttons, slow to constrict to any light when his eyelids were forced open. The intravenous fluids the paramedics had administered had diluted the effects of the alcohol somewhat and he was responding by moving away from painful stimuli. This meant his airway was less at risk and he didn’t need to be intubated. The teenager made no attempt to spit out the Geudel airway and he was laid on his side just in case he vomited.

I checked his pockets for a wallet or a phone as the friends wouldn’t give any information to the paramedics at the scene. I found a debit card with his name on it and a mobile phone with Mum and Dad programmed into the memory. I called them from the hospital phone and delicately asked if they had a son whose name was on the debt card. They were devastated that their son had ended up in the emergency department on a Friday night when he should have been at a friend’s house. They came into emergency within half an hour. The well-dressed couple were really angry that their son was taking up our precious time, treating his self-inflicted drunkenness rather than treating people who were really injured. The parents wanted to get him home quickly and were highly embarrassed that their family member had needed non-emergency treatment. They asked how they could help get him home and off my hands. The doctor had checked over this sleeping teenager and suggested we give him an antiemetic drug so he didn’t vomit again and another litre bag of fluid. His parents took it upon themselves to nudge him and pinch him and shout at him to encourage him to wake up. They were even pulling the hairs out of his legs to get him to wake up.

After an hour, the teenager started to rouse and was able to slur some words together. His dad was so annoyed he got his mobile phone out and took a picture of his son lying in a hospital bed,  drunk at the age of thirteen. The bag of fluid had finished and I capped his cannula and removed the fluid line. Once I disposed of this, I did another neurological assessment and suggested that he start to walk around and get some fresh air rather than being curled up under the hospital blankets. His parents were keen to get him home and agreed to assist him to mobilise. I put down the cot sides of the emergency trolley and allowed them to take control. The next moment there was noise coming as the trolley moved under great weight. He was up and on his feet, wobbling on each leg with one parent under each arm holding him up. His parents held the boy under each arm and were more or less dragging him up and down the corridor in front of the nurse’s station. The teenager was making slow progress lifting his legs for each step, but after several lengths and being forced to drink several cups of water, he was more awake. 

Luckily, he didn’t vomit any further and had enough fluids administered to potentially reduce his headache the next day. I removed his cannula and held pressure on his arm for a good three minutes as his alcohol-thinned blood wouldn’t clot as easily as normal. After advising his parents to let him sleep on his side and check on him every hour, he was discharged into the care of his embarrassed parents. I would have loved to be a fly on the wall at his house the next day. I hoped he wouldn’t vomit in the car on the way home. The joys of having children!
             

It is always with foreboding when you see a butcher at the triage desk. It’s always a bit of a shock when you see knife injuries, even if you are expecting them to be bad. Usually wearing the blue and white striped uniform and the long white apron; well, it’s never any good when you see a large amount of blood poured down the white apron and a towel wrapped around his hand.

On one such occasion, a butcher waddled into emergency trying to apply pressure to his bleeding hand and walking quickly against the resistance of his long apron. The first thing I did was check to see if he could feel his fingers. I gently pressed on the end of all of his fingers one by one to see if he had sensation and also to see how slow his capillary refill was. The colour in each finger returned in about 4 seconds, slower than it should be; however, the butcher could feel his fingers despite a pulsing throb in all his fingers. The towel was doing a good job of soaking up all the blood but I needed to assess the severity of the wound so I could triage him appropriately. I gently and slowly lifted the towel off his palm and saw the damage.

This particular butcher had severed all four fingers at the palm side of his hand in a perfect line. The index finger was the worst with the bone being chipped and the wound gaping open. The fatty white round tissue around the wounds had a steady trickle of blood flowing over them and ingraining blood in the wrinkles of his fingers and palm. The butcher was in a great deal of pain and had been bleeding continually from the accident until now, a 30 minute car journey.

The department was quiet and he was able to go straight into a cubicle to get stitched up. He needed Adrenalin and Lignocaine to stop the bleeding and anesthetise his hand. The doctor ended up performing a nerve block to all four fingers. After many deep internal and external sutures, his fingers were dressed with a large gauze pad, his hand and fingers were bandaged and placed it in a high arm sling.

Today, a patient was brought by helicopter through to the emergency department. He was a 58-year-old male who had been involved in an accident at the stock car races. Usually the stock car races happen every Sunday and both young and old take part. For those who are not familiar with stock cars, they are old banger cars that race around a designated track, often circular and made out of mud and gravel. There are many collisions and is an activity that often brings a crowd. St John’s ambulance is usually on site and at the ready.

The patient came in wearing rough clothes, covered in the usual muck and oil and had on a yellow hazard apron. His left leg was supported in a vacuum splint given by the paramedics, a split that is pumped up with air to securely hold a limb in place. My parents used to rally cars and I knew immediately what position he played in the stock car races. He wasn’t a driver, but a marshal umpiring the races. The marshal of the race should usually be stood well away from the track, a safe distance away to avoid fast moving cars.

This marshal had indeed been standing at the side of the track with a good distance between himself and the cars, He was standing next to a metal post attached to a metal gate when a stock car lost control and careered towards him. The car was aiming straight for him, sliding along the mud and gravel with all brakes on and the marshal’s first instincts were to get out of the way. With seconds to spare, he moved behind the metal post, but as the car slide towards him, it impacted the metal post and caused a ripple effect of force on the gate it was attached to. The gate swung open with full force and speed, allowing no time for the marshal to get out of the way before the metal gate slammed into his legs, dropping him to the floor.

The ambulance crew initially thought that he had amputated both his legs in the accident, but when they reached him, they saw both legs were intact and only the left one injured by the crushing force of the metal gate.

In emergency, the marshal was in a comfortable state. He had been given gas and air in the ambulance and his leg remained in the vacuum splint. I assisted taking off his high visibility vest and his jumper, so we could get an accurate blood pressure and pulse recording. He talked me through the accident again and he said he was so lucky, he absolutely didn’t see the gate coming at him. He told me his medical history, which was minimal and asked if he could call his wife on his mobile.

The paramedics were due a tea break and I invited them to use our staff room while we removed their vacuum splint; then they could take it away with them when they repacked the ambulance equipment. The marshal’s boot had been left on due to fear of the amputations and as I was not able to see firsthand, it was reassuring that the marshal said he could feel his feet and wiggle his toes. With the doctor present, I started to release the air in the vacuum splint, this caused the plastic to wrinkle up around his leg and I was able to gently open the splint so I could see the full leg. I didn’t want to lift his leg on my own and started undoing his laces on his steel toe-capped boots. I gently lifted the shoe from his heel and away from his foot without causing him too much discomfort. The next off was his sock and I was pleased to see the only discoloration was the blue from his sock fluff, his foot was nice and pink and capillary refill acted as normal perfusion would. Indeed, he could wiggle his toes; however, now without the security of the splint and boot, pain was rushing down his leg and he could only wiggle a little without stabbing pains in his leg.

I cut up his trouser leg to provide continued immobilisation rather than lifting, and called for another nurse to assist me. With the doctor holding the marshal’s leg at the thigh and another nurse supporting it at the shin and heel, a swift exchange occurred. On the count of three, we lifted his leg, I slid out the vacuum splint form underneath his leg and replaced this with a hospital Zimmer splint; this happened in less than 30 seconds and was there was just enough time for the marshal to let out a small yelp of pain. Without his jeans covering his
leg, I could see a deformity where a break in the bones was suspected. It was very swollen but luckily no skin was broken so the fractures hadn’t punctured his skin.

As the marshal’s condition was stable, we moved him into the main area of emergency and waiting for an x-ray room to be free to get more insight into his leg injury. He appeared well after the shock and impact he had just had and his other leg was unscathed. On return from x-ray, the doctor reviewed his scans and it showed breaks in his shin, the tibia and fibula. He was lucky to only have two breaks indicative of one single metal bar on the gate causing the damage.

In our emergency department, we were jacks of all trades, bandaging, hip traction, suturing and plastering.  My colleague and I brought the plaster trolley to the marshal’s bedside and with one nurse holding his leg up and the other applying plaster of Paris, we immobilised his leg.

The plaster of Paris comes in a sheet and layers need to be cut to the length of his leg from joint to joint,  toes to knee allowing for both to bend. My colleague and I wrapped wool padding bandage from toe to knee in an even overlap up the marshal’s leg. I measured the layers and cut with my trauma scissors three lengths for each side of his leg and one for the back. We would leave a space at the front of the leg for swelling and tie the entire plaster of Paris by wrapping bandage from knee to toe. The plaster of Paris, once cut to length, is soaked in lukewarm water to start the process of hardening. Application was done quickly with the side layers applied first, smoothing the wet and warm plaster onto the wool padding bandage layer, then the last length of plaster was applied to the back all the way down his calf to the ball start of his toes and the entire leg was secured with gauze bandage which would stick to the plaster of Paris when it dried.

After letting the plaster of Paris set for a while, I assisted the marshal to get off the emergency trolley. As he stood slowly on one leg, I measured his height for axilla crutches. I gave him a quick lesson in how to use them and not cause pressure under his arm pit and then he made his way home with his wife.

No time to care

No Time to care is a piece I wrote about a typical day as an emergency nurse.

0640

I walk to work in the peaceful morning hours, birds are chirping, all is quiet, it’s just getting light but it feels like it’s not quite day yet. My hair is down, blowing dry in the wind, my jeans feel warm against my legs and I'm wrapped up in my big coat.

It’s not far to walk and I feel good for the exercise; I’m looking forward to my shift and think about where I want to be allocated to today.

I look ahead.

I can see an ambulance outside work, early start.

I walk through the doors past the computer screen, indicating less than an hour wait.

I walk through the waiting cubicle. It looks a mess, drinks spilled, empty cans and cups, bloody dressings on the floor, crisp packets spilled on seats and I'm met with a bloody hand mark streaked across the glass on the security door.

I change in the changing cubicle, put my hair up in a bun out of the way, spray on double doses of deodorant  and go out onto the shop floor.

0655

I hit the floor running, patients are still in from last night and we have breached the four-hour target because there was only one doctor on.

I picked majors today. I’m ready for the challenge.

I like it busy; it keeps me on the ball.

I just hope there are beds today on the wards.

0700

I get handover and start the morning cleaning, checking and restocking.

Cubicle five oxygen empty, suction used, only one oxygen mask left, blood on the floor, emergency alarm working.

Cubicle six looks good. Restock eye ointments, oxygen full, suction working, ophthalmoscopes working, alarm working.

Cubicle seven has an elderly patient with chest pain who has been waiting for a medical bed for six hours. I have a chat with the patient and hear the ambulance doors; I go out and look at the CCTV, which shows the paramedics are bringing in another patient.

0720

I go to greet the paramedics. They give me handover and the patient looks like she has fractured her left neck of femur, after falling in the middle of the night. Poor lady, she couldn’t get up and was laid on the carpet until the milkman heard her shouting.

Patient is in pain. Ignore the rest of the checks. I undress patient, measure and record observations; ask medical history and next of kin. . I grab a doctor ask him to look at this patient to give analgesia and assess hips for x-ray. “Who’s got the keys, can someone check some morphine with me, please?”

0730

I push the patient to x-ray myself because porters will be busy taking breakfast to the wards at this time. Fracture neck of femur protocol patient is to be admitted within 90minutes of attending.

0735

I get back from x-ray, leaving the patient there, and was told medical assessment unit are ready to accept the chest pain patients, so I call the porters. Porters take fifteen minutes to answer, get the paper work ready,
I
hand the keys over to another staff member walk to the ward with the porter pushing the trolley

It takes me 10 minutes to reach the medical assessment unit, I don’t know why is so far away from the emergency department.

I reach the ward, there’s no nurse to greet me.

I find the patient’s bed, the porter and I pat slide the patient on our own onto the waiting bed and make the patient comfy. I plug in oxygen to the wall and walk to the nurses’ station to find a nurse. The nurse in charge appears and I give her handover and start walking back quickly to emergency.

0815

Lots to do.

0825

I get back to department; look at the patient board. Another admission, patient with abdomen pain cubicle five, another nurse took the handover but didn’t have time to do the assessment. I need to do obs, give pain relief and undress the patient.

0830

I continue checking cubicle seven, the patient is back from x-ray, I look at the x-rays, confirmed fractured neck of femur. I chat with the patient she’s still pain free and comfortable, I talk with the doctor; he needs to refer to orthopaedics, take blood, I’ll get a bed.

I request a bed.

I phone the ward, they need time to make the bed, need to phone porters, 70 minutes gone already.

0845

I hear the paramedic bell, DING DING DING; another patient.

A doctor asks me for medication for a patient.

I get the keys from another nurse and draw up the drugs as prescribed, I ask the paramedics to wait a minute and I will be with them and administer to the correct patient.

I take paramedic handover, put patient in cubicle nine. DING DING DING; another patient.

0850

I pop my head out of the curtains, ask the paramedics if the patient is a major category, they say yes and I direct them to my last trolley, cubicle ten.

I assess the patient and put his triage card in box to be seen by doctor.

The orthopaedic bed is now ready for the patient, I call the porters and take the patient to the ward, handover and then get back to department.

0905

I re-evaluate.

I prioritise.

All majors’ cubicles are now full.

Cubicle 5, overdose, needs blood levels taking, patient looks stable.

Cubicle 6, eye patient, doctor is assessing.

Cubicle 7
,
cubicle now vacant but not for long.

Cubicle 8, patient is referred to surgeons, needs paper work and bed on ward.

Cubicle 9, patient waiting to be assessed by doctor.

Cubicle 10, bring relatives in, await doctor to assess.

I need to finish checking cubicles are all stocked.

0915

DING DING DING.

I take handover, assess patient, possible stroke patient.

0930

Last medical bed taken on the medical assessment unit taken by a GP referral, there are no more medical beds until a patient is discharged home.

Last emergency department trolley taken.

DING DING DING

I re-evaluate.

I make cubicle ready.

0950

I move minor patient out of cubicle, paramedics have collapsed patient who needs the bed. “I’m sorry to move you out but I need this bed for another patient, would you mind waiting in the waiting area, please?” I say to a disgruntled patient.

I call porters for a surgical ward transfer.

I assess, record obs, record ECG and take history of new patient.

1015

I transfer surgical patient to Surgical Assessment Unit, patient been in
the Emergency Department
2 hours
.

1030

I re-evaluate.

1035

I do an observation round.

Poorly patient cubicle 7, I must keep an eye on.

Majors is full, management is called.

1050

Patient having an asthma attack walked into department, need a cubicle, need oxygen, move minor patient out of cubicle, reassure patient, do obs, get doctor, give nebs, document.

1105

DING DING DING.

They’ll have to wait, no cubicle, too busy, get drugs for cubicle 7, mobilise cubicle 10 and need medical bed for cubicle 5. “I’ll be with you soon, I’m tied up at the minute and I’ll have to make room,” I say to the paramedics.

1115

Last trolley cubicle 6, patient collapsed, I take handover and do obs, ECG and take bloods…I hear the emergency buzzer sound.

All stop.

Adrenalin kicks in.

I run to the resuscitation room.

Patient is in cardiac arrest.

Lisa is bagging the patient.

Asystole on the cardiac monitor.
             

I start cardiac compressions.

Doctor arrives and gives IV adrenalin.

Still no output.

Continue compressions.

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