End of Shift Codes

Ah, the joys of doing drugs. Fridays in the ER always seem to alternate between hell on earth, or something akin to being left behind after the rapture. No rhyme or reason as to why some days you get killed, and others you are bored to tears. This particular Friday was one of those bored to tears nights. You clean and stock the rooms in expectation you’re going to suffer for the lull later. Sometimes you suffer, and sometimes the night passes and you go home on time. There is however, the “End-of Shift” code you always worry about. The End-of-Shift code is a phenomenon that can happen on any floor of the hospital. It is a patient in whom breathing or a heartbeat ceases, fifteen minutes prior to the end of your shift.

This is the worst possible time for a patient to code. Why? Well, not because of what you might think. Yes, most of the staff has been there twelve hours already, we’re tired, and we want to go home. The reason it’s a bad time to code is totally selfish. Once a nurse gets involved in a code, he is going to have to stick it out until the patient is pronounced, or until the patient is stable and he can report off. It’s actually worse when the patient lives because you have to care for the patient as well as get the paperwork up to snuff. It takes twice as long to get everything done and get out the door and home when the patient lives. I have been involved in many End-of-Shift codes that started at 6:45 AM, and I did not get out of the hospital until 10:30 AM.

One dead Friday night in rural Alaska, the doctor and I spent hours outside admiring the Northern Lights. I won’t even try to describe them to you. If you have never seen a high power plasma light storm, there is nothing I could put into words that would adequately describe it. I have forgotten if I have mentioned the doctor I was working with in another post. Her physical appearance was anything but intimidating. Her mastery of emergency medicine was nothing less than unbelievable. At just under five feet tall, with flaming red Irish hair, she (Dr Red) was the picture of stubborn confidence. She alternated between flying to Stanford to teach emergency medicine, and working and living in rural Alaska. I loved working with her because you always knew she was in control, and wouldn’t let anything bad happen to your patients.

Along about 2300 we received a call from the EMT’s that we would soon receive a 28 year old male actively seizing. Since the ambulance service was run by jolly volleys (volunteers) no paramedics were working that night. The EMT’s arrived shortly with the patient and we got to work.

While I started a line the doctor went and pulled some valium from the drug drawer. The other nurse was at dinner and had no clue we had received a patient. I got a 16 gauge started in the right forearm and hung a bag of saline. On most floors IV lines run at a particular rate. In ER’s we joke that there are two rates the IV runs at, wide open, and plugged. I opened the IV up to TLAR rate (that looks about right, an engineering term) and went about checking the monitor and O2 set up. The EMT’s had the monitor and SPO2 attached and had a non-rebreather mask over his mouth and nose.

The doctor pushed some valium while I set up to insert a foley catheter. The first 10 milligrams of valium had no effect and the patient continued to seize. I ran to the drug drawer and pulled another 10 milligrams of valium. I ran back to the patient and pushed the needle into the IV port and injected the drug.

We waited a short time and the patient continued to seize. Dr Red ordered another 10 milligrams of valium, and started to pull the intubation equipment out of the trauma cart. As she set up to intubate, I made another dash to the drug drawer and pulled out another 10 milligrams of valium. I made it back to the bedside and pushed the valium into the IV, and waited. While waiting for it to take effect I pulled two sets of soft restraints out of the trauma cart and began to tie down the patients arms. Tossing the other pack to the EMT’s they began to work on the patients legs.

As predicted, the patient finally stopped seizing, but was barely breathing after the massive load of valium. Dr. Red quickly intubated the patient and I secured the ET tube. I hooked up the silent night vent and called RT to come bring a regular vent.

My next task was to insert a foley catheter into the patient. I prepped the foley kit and tested the balloon. Yes, I have had foley caths that I was able to instill the saline into the balloon, but was unable to deflate it. I used the fenestrated drape and readied the patient’s penis. Here is where the nursing instructor in me comes out. Just grab the damn thing. Wrap your palm around it and get a good grip. Pretend it’s a handlebar on your bike and you’re going for a ride. Well maybe that’s a bad analogy, just grab the damn thing, and not with two dainty fingers. Three betadine swabs later I was stuffing the end of the 16 French foley into the end of this young man’s penis.

Want to wake the dead? Just put a foley catheter into them. The guy was suddenly wide-awake and pulling with all his might at the soft restraints. He was trying to wiggle his hips and get me to stop pushing the foley into his penis. I stopped and looked him in the eyes.

Do you understand me, I asked?

He slowly nodded his head up and down.

I need urine from you to test. Do you understand this?

Again the head nodded slowly up and down.

I explained he had been seizing and he was safe in the local hospital. He nodded again. Dr. Red was now at the bedside and amazed the guy was awake.

Do you want the breathing tube removed, she asked?

Again the slow nod.

Ok, I’ll take it out. She turned off the vent and deflated the ET tube cuff, and pulled it free of the patient.

YOU FUCKING BITCH!

That’s Dr. Fucking Bitch to you, she responded in a measured tone, as she turned to me and suggested I keep the four point restraints in place for the time being. I whole-heartedly agreed.

Look, I told him. I need urine from you to test, are you able to piss into a bottle?

YOU ASSHOLE, LET ME GO!!!

Is that a yes or a no, I responded.

Untie me god-dammit, I have to leave.

I don’t think so, you have been seizing and I’m not sure you’re not going to start seizing again. Have you been doing any drugs?

NO!!!!

Are you allergic to anything?

No.

Ok, as soon as I get some urine I will untie your feet. You are going to have to earn your release a little at a time.

FUCK YOU.

Ok, I’ll take that as a no. Look, I’ll give you 15 minutes to give me a urine sample. To help you I will open this IV up to help you pee.

Hum the theme from concentration…

Ok can you pee for me?

FUCK YOU!

I’ll take that as a no. Ok then plan B, I’ll just pop a catheter in and get some urine the easy way.

After a string of expletives I began the process of inserting the catheter. It went fairly smoothly with the patient thrashing about like a fish out of water. Funny thing, when you have a man by the penis, the thrashing subsides to some degree. The tighter the grip, the less thrashing you have to put up with.

Twenty minutes later, we had the reason for his seizures, cocaine, lots of cocaine.

Every time Dr. Red walked past the trauma room, the patient would holler BITCH. After about three rounds of this, Dr. Red was extremely angry. She whisked into the room and heard the familiar BITCH. She quietly told the patient she was DR. Bitch, but he was not to use the word BITCH in her presence again.

Or what, he asked?

I’ll tape a kotex over your mouth to shut you up if I have too, she responded. Why can’t you just relax, we’ll untie your arms and legs and you’ll spend the night in the hospital. We’re not the police and we have no intention of calling them.

YOU FUCKING BITCH, GET THE FUCK OUT OF HERE.

 At this point I went to lunch and left Nancy (the other nurse) to watch the patients dilantin IVPB.

When I returned, I was met by a 52-year old male identical twin complaining of chest pain. (I noticed as I walked by the trauma room the seizure patient had a kotex taped across his mouth.) His identical twin had died of a massive MI 6 months earlier. It was about 6:45 AM and I was due to go home at 7 AM, or so I hoped. I did a quick EKG on the man and confirmed that there were ST elevations in II, III, and avf. Great, an inferior MI. I started two more IV lines and prepared to give TPA (a blood clot busting drug). About this time, a trauma arrived and it really got hectic. The doctor looked at the EKG, examined the patient, and ordered TPA, then ran into the trauma room to care for the level I MVA patient.

I got the TPA bolus administered and started the TPA drip, then went in to care for the MVA patient. He was a mess. A fractured C2 and no movement below the neck. He was intubated and flown out to the tertiary care center. This took about 1 hour and I had not checked on the TPA patient. This worried me because I have had patients getting TPA code on me, as they experienced reperfusion dysrhythmias.

I went to the nurse’s station, actually a counter outside the patient’s room where three of us could cram together and chart. This was, after all, a six bed ER in rural Alaska. I turned and watched the cardiac monitor. Ok, a nice sinus rhythm, good, wait, now its v-fib. Nancy was watching the same display. We jumped up and ran into the room. On the way in, we dragged the day doc with us. Dr. Red had gone home and left us with this mess. The day doc walked over to the patient and felt for a pulse while Nancy and I checked the EKG leads. Not finding one, she punched the patient in the chest.

Ow, was the reply. Why did you hit me, the patient asked. I don’t have time to explain, the doctor responded.

The bed was sidewise in the room. Something I had failed to notice when I put the patient on the gurney. We had the cardiac monitor, IV poles on both sides of the bed, one TPA, one heparin, a nitro drip, and a pulse ox all connected to the patient. Because the bed was sidewise in the room, the O2 cannula would not reach the O2 outlet on the wall. I had used the O2 tank under the bed, which had since run out of oxygen.

The patient’s rhythm returned briefly to a sinus rhythm and then went back to v-fib. The doctor punched him in the chest again.

Ow, why are you hitting me? Through all this the patient never lost consciousness. Please don’t let her hit me again, he said, as he looked up into my eyes.

Nancy was struggling to get the paddles close enough to the patient so we could use them if needed. The battery in the monitor was dead so the monitor needed to be plugged into a wall socket. The bed was just far enough away from the nearest plug that the paddles couldn’t reach to the patient.

I was trying to get a BVM set up in case the patient went sour. The tube on the BVM was too short to reach the patient, so these problems heightened the stress of the situation.

The patient again went briefly into a sinus rhythm, then back into v-fib. I pushed the bed and all the associated equipment toward the paddles and finally was able to get him close enough to defibrillate him.

As the doctor leaned over the bed with the paddles, the patient looked up at the doctor and said, “this is gonna hurt, isn’t it.”

Ow! Damn, that hurt like a bitch, he said

After one defibrillation, he maintained a sinus rhythm. I transported the patient into the tertiary care center for a cardiac cath. He had several stints placed and came by several months later with his wife and thanked me for insisting to the doctor we transport him for cardiac consultation. The doctor wanted to keep him at our hospital, where we did not have a cardiologist.

The following Friday the seizing drug addict was again transported to the ER. He did not believe he had a seizure disorder, and had refused to take his dilantin. This visit however, when he woke up, he was very polite, even when he learned Dr. Red was not on duty. He asked me to apologize to her the next time I saw her.

I got home about noon that day after working since 7 PM the previous evening.

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