'Good morning, Sandy. How was work?”
How do I answer that in a normal way? Any given shift in any given ED is comprised of the gamut of emotions playing out behind the calm facade of physicians and nurses. Afterwards, we often don't articulate or even process the roller coaster of feelings. The story of a recent Monday overnight illustrates the wild ride of emotions most people don't realize that EPs experience in a single shift. I described it as crazy, but here's what that really means.
The night started with dread. I had one of those “oh, no” moments as I walked into my single-coverage ED. The waiting room was full at 9 p.m., and the tracker was clogged with holds waiting for beds. I put on my game face, but deep down was that nagging apprehension ever-present in the heart of EPs that the bedlam could get worse instead of better before the night was over.
I started in the waiting room because the ED was a parking lot. I apologized for the wait time as I brought each patient to the rudimentary exam room behind triage to hear their histories and start whatever preliminary workup or treatment could be done. Despite my frenetic pace, people quickly grew tired of waiting and began walking out AMA, leaving me with guilt that I couldn't be faster.
I cranked through the waiting room, and the nurses were frenetically trying to handle the usual Monday night volume on top of inpatient care for a department full of holds. Amid the pandemonium, no one had time to help the granny in bed eight or even realize she needed to use the bathroom until we heard the sickening loud crack of her skull on the linoleum. Surprise! She was OK, but a patient fall was a blaring warning that we needed to decompress our ED. I alerted the administration and got a response that couldn't have been farther from what I needed to hear: “No additional beds. No additional staff.”
I hung up the phone as a 50-something with a headache rolled in with EMS. Before I could review her records about her recent intracranial bleed, her nurse beckoned me to her bedside NOW for sudden unresponsiveness. A stat head CT confirmed recurrent bleeding. She had no IV access and soon stopped protecting her airway. I set up to intubate and place a central line as I registered the horror on her family's faces and paused for a moment of compassion. “I'm so sorry this is happening.” There wasn't time to say much else as she started to drop her sats.
Neurosurgery rushed her to the OR as we heard a code called in radiology around the corner. We hoped it was a false alarm but found another 50-something inpatient on the CT table with no pulse and no airway. I grabbed a MAC blade, tube, and suction as CPR commenced. Her oropharynx was a murky puddle of green chunky emesis. Partially digested broccoli or green beans or who knows what clogged the Yankauer. I made a face of disgust as vomit spewed at me. “I need another Yankauer.” With fresh suction, I finally visualized her chords through the slime, intubated her, and told the hospitalist taking over to remember to order antibiotics for aspiration if she made it.
I had a brief moment of sadness as I hustled back to the ED. Two ladies in their 50s would likely die with tubes still in place without speaking to their loved ones again. Too much work remained to think about it.
But Wait, There's More
An hour or so later, with my ED still a mess, the nursing supervisor called me upstairs to place an icy cath. This was a first because the EP isn't supposed to cover the floors. The audacity of summoning me upstairs instead of paging anesthesia on that night of all nights, after I'd been denied extra resources downstairs to decompress my own department, provoked anger.
I would have bluntly grumbled “no,” but the hospitalist trying to orchestrate the code chill is always wonderful to me. I went upstairs and helped in a gesture of caring for my colleague and his patient.
I returned to an elderly gentleman with an unflushable suprapubic catheter. Then I had another first: The on-call urologist instructed me to replace it. I was cautiously paranoid and filled with doubt the way all docs are their first time doing a new procedure. The plethora of patients still waiting allowed no time for hesitation, so I boldly thrust the catheter through his abdominal wall. He had immediate urine output and relief.
I was about to steal a moment for some much-needed urine output myself, or so I thought.
“Dr. Simons, this woman feels the head ‘right there.’ You need to check her cervix before we can take her to L&D.” Yes, a multiparous full-term mom was crowning. Fortunately, she hadn't delivered in the parking lot. Unfortunately, she wasn't going to make it to L&D. OB is supposed to come immediately in this scenario, but they didn't because it was that kind of night. “We've done everything else tonight. We might as well do this,” expounded our charge nurse. We felt frustration wondering where our backup was when we needed it.
The baby was coming even if OB wasn't, so I gloved up, reassured mom, and prepared to catch. There's no greater joy. “It's a boy!” He cried immediately, and for a second I cried, too — elated tears over the miracle of birth. Then I blinked them back and rushed back to my other patients because I had to keep going.
Dawn came soon after. As I drove to the gym, I could barely process the perfect storm and range of emotions I'd just quelled. All night we kept going because the next patient was waiting. We kept going because physicians and nurses aren't supposed to feel dread, disgust, or doubt. I suppressed an entire roller coaster of feelings in one night shift. As I broke into a run on the treadmill, it all came flooding out of me, and I started to cry. Tears for the joy, tears for the sadness, tears for everything I had kept bottled up all came gushing out in one big release. Then I took a big breath and kept going. And the next night I went back ready to do it all again.
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