The shift starts out like any other. I get report from the outgoing charge nurse, I have complaints to deal with, nurses that want to bitch about something trivial, doctors who arenāt happy with the flow in the department, families that are mad they are waiting for what they consider to be an exorbitant amount of time. Iām barely awake, still shaking off the haze of a rough night the previous night, and the night before that, and the night before that. The days start to run together when you work night shift. When you arrive at work itās one day, then itās the next and you leave work, but itās still the same day when you come back that night. Itās enough to drive anyone to madness, but this is my life. All 13 years have been spent in the same ER. I walk through the ER, stopping to say āHiā to a few staff members, the docs are glad to see me. They usually are because it assures them that their one or two shifts a month they spend on nights isnāt going to be a complete clusterfuck because Iām here, and they know I donāt take any shit. I settle in and start writing reports, doing assignments for later, answering emails and dealing with problems. In addition to running a Level 1 trauma center, I also have to field phone calls from patients or their families that have been seen recently and have questions, I have to do staffing for the next day, I have to complete all the log books and checks that need done in a department this size. Itās not an easy job, and I donāt get paid much more than the regular staff nurse who is only responsible for 4 or 5 patients at a time. I donāt have time to get even my log done before the traumas start rolling through the door. Itās trauma season, or summer as non-emergency personnel like to call it. That means anything and everything. Guns, ATVs, MVCs, trampolines, go carts, motor cross, bows and hunting, bikes on the street, kids on the street, alcohol and fireworks and everything in between. Itās job security and I know it, I profit from others misfortune. Before I can even catch my breath, all my critical care and trauma rooms are full with more on the way. Nurses are starting to freak out, and Iām going to have to calm them the fuck down. Nobody gets good care when people are freaking out. I start moving people around, anyone that isnāt critical is going to a regular room in a different part of the ER. Anyone that is critical is obviously going to need admitted, and the doctors usually need a push in the right direction to get that going. I will give them that push that they need. Squads come and go, I send some out to triage, some go straight to rooms. Patients scream and moan because they think by calling a squad theyāre going right to a room. Sorry fucker, just because you think 911 is your personal taxi service, doesnāt mean it becomes my problem. Have a seat in the lobby like everyone else who took a taxi here tonight. What people donāt understand about a large trauma center is this. We donāt operate like the urgent cares in your cozy little suburban neighborhoods where you show up and get seen right away. We donāt care where youāre from, we donāt care who you know. ER is a shit show, and the person with the best performance wins first in line to be seen. I donāt care if your non-urgent problem has to wait 8-10 hours to be seen. Itās the name of the game. If you didnāt die after the first four hours you sat and waited, chances are you wonāt die in the next 4 DAYS of sitting and waiting. Go blow off an extremity with a homemade Molotov cocktail and then weāll talk. Even when you walk in with chest pain, what you donāt understand is, I am EVERY bit as capable as a doctor (probably more so, depending on the day) at recognizing an MI. We are the gatekeepers, we will draw your labs, do your EKG and then sit your ass right back in the lobby unless you have a positive EKG or positive cardiac enzymes. You just got moved to the back of the line. Also, if I see you sitting in the lobby wolfing down a Big Mac with a large side of fries and a super gigantic size Coke, you are automatically losing out on your place in line. If you have an emergency, you donāt need to be EATING! The people I tend to keep my eyes on are the ones who sit quietly, waiting, not moving, not talking, not doing anything but waiting anxiously. They are always the ones that stand up and say, āI think I might pass outā and then fucking code on my lobby floor. They make me nervous. Iād always rather have a lobby full of screaming, cussing idiots than a lobby full of super sick, ready to die patients anyday. The screamers and the Bitchy McBitchersons arenāt going to die, even though they would LOVE to make you think they are one step away from deaths door. Somewhere in the night, a patient comes in to critical care with difficulty breathing. I know him. Heās a frequent flyer, but not the bad kind. Just a poor kid that got dealt a shitty hand of cards, and is playing it to the best of his ability. He has Downs Syndrome, and CHD, TOF, AVSD and has had enough surgeries to bankrupt Bill Gates. He has pneumonia, I can tell as soon as I walk in the door. I exchange pleasantries with his parents. They are always right there, by his side, even though he is an adult, he is dependent on them for care. They bring suitcasesā¦ They know theyāre here for the long haul this time. I take a quick look around to see what my staff is doing. They are all busy getting him situated, monitors and IVās and breathing treatments. Itās apparent pretty quickly that our usual arsenal isnāt going to help this time. Heās breathing harder, his lips are dusky and the breathing treatments arenāt doing the job. I call our attending and we quickly adjust our plan. See, itās not a quick fix with patients like this. Treating one problem often exacerbates another. I can see it in his eyes that heās scared. I hold his hand and crack a couple jokes to lighten his mood. My team starts moving faster, his oxygen levels are dropping and itās apparent weāre going to have to make a choice relatively quickly. Before I can even stop myself, the words escape my lips, āYouāre going to be okayā I tell him. I know the minute I say it that I shouldnāt have. Itās a promise I canāt keep. Itās not something that should be said in these situations. Iāve taken care of him for the last 13 years, and he always winds up ok. Iāve seen him much worse off than this, I tell myself. Heās already maxed out CPAP and we know that dropping an ET tube and placing him on a ventilator could be very difficult. He has a difficult airway, and even if we do get him intubated, weaning him off could be very difficult, if not impossible. My attending is talking to his family. Even though he is an adult, and they include him in all their decisions, they are still his medical power of attorney. They decide to go ahead with the intubation. My patient agrees that this is whatās best. If we donāt do it, heās going to die. We explain that thereās still that possibility even if we do intubate. I watch the mom talking to her first born, and only child, her only son. She strokes his hair away from his face, holds his hand and talks to him softly. I can see him start to relax as the medication starts to take effect. She backs away from the bed and we take over. The endotracheal tube slides into place, almost effortlessly. We all breathe a sigh of relief. The air in the room automatically goes from heavy and overbearing to light again. Weāve saved him we think. I silently say a prayer of thanks that I was right, heās going to be ok. His mom stands at the head of the bed stroking his forehead while we prepare to take him to the Cardiac ICU. I decide to walk up with them when they go. Heās doing well as we leave the ER, his oxygen levels are doing much better than we expected. I tell myself he was just tired, breathing that hard for that amount of time isnāt easy and the body canāt keep up that kind of work for long on its own. We took over the breathing for him, and now he can rest and get better. In the elevator, on the way up to the ICU, his mother thanks us again for the work we do. Itās a much appreciated thank you, because itās not often that people are appreciative of our work. As we round the corner to the ICU, his oxygen levels start to drop. I check the probe on his finger, thinking it may have come loose. Itās still firmly attached. My respiratory therapist checks her connections, I listen to his lung sounds, they are much more diminished than when we left the ED. He hasnāt moved a muscle, thanks to the paralytics, but itās possible the tube could have come dislodged during transit. I grab the suction and the other nurse does a couple quick passes down the tube to check for obstruction. His oxygen levels begin to drop. By this time we are in the ICU and calling for the attending to come to the bedside. Heās now in the low 50ās and his heart rate is starting to drop. We quickly move him from our cart to the other, and the cardiac ICU takes over. Theyāre doing everything we just did, checking the tube over and over. They decide to pull the tube and re-intubate. His heart rate continues to drop and now heās below 40. They start chest compressions. His mother and father are standing at the bedside speechlessā¦ I donāt even realize it until several seconds later, but his mother is holding my hand. Theyāre pushing drugs and placing tubes and even after they get him re-intubated, they canāt get his oxygen levels to come up. They canāt get his heart to start beating again. For a moment, they think he may be in V-Fib. They shock him, his mother squeezes my hand when his body jumps on the cart. Asystole. They start compressions again. Theyāre pushing Epi every 3 minutes. Thereās nothing they can do and we all know it, but we continue to go through the motions. At some point, searing hot tears start to run down my cheeks, as much as I donāt want them to, they still come. I donāt know how long it went on, but at some point, the CTICU attending asks if thereās anything else anyone would like to try. His mother drops to her knees, praying and crying, and begging God for it to not be true. I help her into a chair. Theyāre cleaning up so the family can spend some time with him. I feel like my feet weigh a thousand pounds and I canāt seem to pick them up to move out of the room. I want to console the family, but at the same time, I feel like crawling under the bed into the fetal position because I told him he was going to be ok. His mother looks up at me, our eyes meet and she says, āYou couldnāt have known.ā At that instant, Iām not a nurse anymore, Iām not the charge nurse in a Level 1 Trauma Center. Iām a mom, and Iām crying, huge, gasping sobs, trying to tell her how sorry I am. Iām sorry those words came out of my mouth. I donāt want the parents to have to comfort me, so I catch my breath and wipe my eyes, and hug them one last time. I tell them to call us if they need anything. They promise they will. I turn to walk the long, lonely walk back down to the ER by myself, head hanging, sniffling, trying to compose myself before the doors open back to the chaos of the ER.
