Mr. Spaghetti

On my first or second day in the ED, a nurse asked me to get a set of vital signs from a patient across the room- let’s call him Mr. Spaghetti. As I approached, he told me he was in excrutiating pain and demanded to know when his doctor would show up. I felt badly for him and really wished there was something I could do for his back and leg pain. I really didn’t know what to do though, so I told him I was sorry, I was just here to do his vitals. LAME answer.

At that point, I was still pretty clueless as to the appropriate responses to patients in an Emergency Room.

My first week, I would walk down the hall from the Nurses’ Lounge to the Cardiac and Trauma rooms (maybe 25 feet) and I would be stopped at least 7 times.

Family members:”Excuse me, my grandmother has been here for 6 hours.6 hours!!When will they see a doctor!?” or “There’s blood in my mother’s IV!!! HELP!!!” or, “My father’s IV bag is empty – Help her!”

Patients: “Where is the bathroom?” or the ever popular, “I’ve been here for 12 hours. 12 hours!!! When will I be seen!” or “Take this damn thing off,” as they wrestle with their C-collar. And finally, “I’m in a lot of pain.”

Alcoholics: “Nurse, I’m hungry. (5 minutes later) I’m hungry. (5 minutes later) I’m hungry.”

Patients having psychotic events: “Excuse me, I have an implantable device in my nose and JFK is talking to me. I’m going to have to remove my nose now.” (true story last week)

Random people dressed in street clothes, lurking around by triage, whispering: “Mira, mira, es que no tengo dinero. Solo llevo 2 meses en este pais pero tengo un dolor de cabeza fuertisimo. Pero no tengo dinero. Me van a cobrar?” Translated: “I don’t have any money. I’ve been here in the U.S. for 2 months and I have a really bad headache but I just don’t have any money. Do I have to pay to see a doctor?”

Each one of these encounters would fluster me more and more – accounting for my near comatose state by the end of the day. I just had no idea how to respond to people and wanted to give everyone my complete and full effort and attention. The problems here were many: My first week, I had no idea who the doctors were, I had no idea how to check where a patient was on the “To be seen” list, I had no idea if patients were even allowed to go to the bathroom, let alone showing them where it was. I didn’t know where to get food for the drunks and when someone showed me an IV backed up with blood, it would freak me out as much as it did the patient and family member.

Most importantly, I had NO IDEA how to triage whose complaint/request was most important. I’m not a full nurse yet, not a doctor, I wasn’t saving any lives. But there is a lot of prioritizing to be done, even for a student nurse. It took me 8 weeks to feel comfortable walking through the hall, deflecting some patients and answering others’ questions with some degree of confidence.

Now.

Family members: Grandma has been here for 6 hours!

“I know you’ve been here for 6 hours with Grandma and I understand that you are frustrated. I checked the board and she is third in line to be seen by the doctor. I don’t want to tell you how long that will take because it all depends on what kind of patients come in. The nurse knows you are here so you can ask her if you need anything.”

or

“That’s allright that theres blood in her IV. I’ll just clamp it. And we can undo her IV from the medlock because she is done getting fluids for now.”

and if the blood really freaks them out,

“Ok, I can flush her IV, but really, it’s Ok if there is a little blood in the tubing; it’s not an emergency.”

I realize how impossibly elementery all of this sounds, especially to anyone who is actually a nurse or doctor – but maybe it is also a reminder of what it is like starting out at the bottom again.

Patients:“Where is the bathroom?”

“What are you here in the ER for? (vomited blood this morning) How much blood did you vomit up? (There was just a little bit mixed in) Do you feel dizzy at all? (No.) Ok. (I note the patient is not pale, in their 20′s, and looks otherwise healthy) So do me a favor: sit up, dangle your feet over the side of the bed. Still Ok? (Yes.) Ok. Stand up slowly. Still ok? Dizzy? (No, I’m fine). Ok. Put on your shoes. The bathroom is around the corner.”

or

“What are you here in the ER for? (I had a seizure this morning) Ok. Do you have to pee or move your bowels? (Just pee). Allright, I am going to give you a urinal/bedpan and close the curtain to give you privacy. Since you had a seizure this morning, I don’t want to take the risk that you are going to seize again on the way to the bathroom. Ok? Just give a yell when you are done. (Frowning – Ok.)”

My first day, I thought I had to ask the nurse before I gave any patient permission to get out of bed to use the bathroom. Boy did the nurses hate me that first day. But look at how such a simple question lets me use my pathetic little assessment skills. Small things, small things.

Alcoholics: “Nurse, I’m hungry.

Give them a time frame.

“The trays don’t come until 9:00AM (Thinking: You know that because you are here every day and eat three meals a day here). I will get you a tray before 9:30, I promise. But you have to stay in bed until then. Here is some water to tide you over.”

Then, put them in bed, wait until they are done with their water, put up both of the siderails, and put them just slightly in Trendelenburg position (head tilted down). This is for no medical reason other than it makes it harder for them to get out of bed and they will generally fall asleep again soon. Whatever you do, get them a tray before 9:30 or you will find them in the storage room, ransacking the the entirety of the meal cart, eating everyone else’s breakfast.

Just for fun. I typed in Trendelenburg position into google and got this:

And finally back to Mr. Spaghetti. Over my 8 weeks, I saw Mr. Spaghetti at least 20 times. I didn’t know that first day, but Mr. Spaghetti is a homeless, drug addicted fellow who spends a great deal of his time harrassing doctors and nurses in the ED. He’s not particularly nice, making any last shred of sympathy hard to find.

Had my observation skills been better that first week, I would have noticed his filthy clothing, stained skin, and black fingernails. I would have noticed that he always rates his pain a 10 on a 1-10 scale, and he gets increasingly irate as time goes by without him getting a prescription.

I almost wish I didn’t notice these things now. Becuase they are not supposed to change the way you would treat a patient. That first day, I empathized with him as a man in pain and in need of help. It’s very hard, after seeing these guys 100 times to treat them the same way you would the first time you meet them.

So, upon leaving the ED after my internship ended, I now have a whole new slew of questions. I know the basics. I know what my job will be for a patient in cardiac arrest. I’m getting better at prioritizing patient requests, knowing that the pale guy silently suffering in the corner is closer to the top of my list than the red-faced woman screaming and marching around saying she can’t breathe. I can start an IV, draw the right labs, and usually can do it all on the first try. I’ve seen patients intubated, both in the stomach and in the airway. I’ve seen a newly dead man’s cell phone on the nursing station’s desk, hoping it doesn’t ring.

But now for my new mysteries. How do I avoid getting old and jaded? How do I maintain enough professionalism as to treat all my patients nicely? Hopefully my desire to avoid a jaded future will be enough to pull me through, unscathed. Is a desire to be compassionate enough protection?

I don’t know how to help Mr. Spaghetti and Mr. Homeless Alcoholic other than feeding them and putting them back out on the street before they get too sober that they go into withdrawl. Every nurse and doctor says the patient has gone through rehab 12 times this year and I don’t know yet if that means that I shouldn’t suggest a 13th try.

I don’t know how to express to my collegues that the whole “ER nurses eat their young, so new nurses beware!” saying is outdated and bullshit. Don’t eat your young. Be nice to people – Not being nice is a waste of everyone’s time. I’m not asking for flowers and puppies. Just a smile and the occassional “Good job” before ducking back under the chaos.