What scares me as an emergency nurse?
These do not scare me: cardiac arrest, acute myocardial infarct, major multiple-system trauma, abdominal aortic aneurysms, status epilepticus, flash pulmonary edema, testicular torsion, perforated appendix, esophageal varices, cerebral vascular accident, acute pancreatitis, diabetic ketoacidosis, carbon monoxide poisoning, precipitous delivery, pneumothorax, pulmonary embolism, psychosis, acetominophen overdose, asthma exacerbation, cardiac tamponade, ectopic pregnancy, depressed fontanelles, femur fractures, atypical pneumonias, end-stage liver cancer, COPD exacerbation, rectal bleeding by the bucket, and chicken-pox.
I might be worried about you, that you’re about to go south, when the monitors are in constant alarm at your failing vital signs, or you start having runs of ventricular tachycardia or the inotropes are failing to boost up your blood pressure, or when your uncontrolled atrial fib isn’t responding to the diltiazem and it looks like you’re going into CHF. There might well be a sense of urgency, as I try to sort out your rescue catheterization/post-arrest hypothermia/emergency surgery/blood transfusion/transfer to a trauma centre. But I am not frightened, because I know what to do and I have done it all a thousand times before. VSAs: call a code. Stroke: thrombolyse. Pneumothorax: get the chest tube tray. Precipitous birth: call Labour and Delivery.* In the emergency department, it’s all routine and algorithms, remember? That calm focused expression is on the face which has seen everything.
“You can be scared,” I tell my patients, “when I look scared.” And I never look scared, but sometimes I’m quaking in my shoes.
This is what scares me. This is the terror laying in every nurses’ heart:
When I don’t know what’s wrong with you.
Because when we don’t know what’s wrong with you we can’t fix you. Because we end up giving you supportive care, which means we are treating the symptoms, not the cause, and treating the symptoms might make you sicker. When you come with new-onset confusion, fever, rigors, tachycardia; you have no recent travel (so no exotic bugs), you have a negative white cell count, negative CT and negative lumbar puncture. You appear, as we say euphemistically, in a miracle of understatement, unwell. This means you look like death. And then you start seizing, and we still don’t know what’s wrong with you, so we give you drugs to make the seizures stop — more supportive care — and we intubate because you’re comatose and it doesn’t seem like you’re going to protect your airway anymore. Funky arrhythmias start and your blood pressure drops like a train going over a cliff and then you —
Well, and then you die.
And you’re 29 years old, and your wife is still on her way to the hospital.
I was the primary nurse for this patient some years ago, not long after I graduated. I worried about his death afterwards, thinking I had missed some subtle sign in my initial assessment, some clue that might have saved his life, that I had given the wrong drug, or had set up the dopamine drip incorrectly, or didn’t clue in soon enough he was deteriorating. Or something. Some rationale or reason, to make sense of it. Because he was young and by rights, he should not have died.
After a couple of weeks or so of fretting, disquiet and misery, an older, more experience nurse looked at me critically, but kindly, and said, “He had the best emerg docs and the best internists at his bedside, and they couldn’t figure it out. So don’t you think you’re being a bit dramatic?”
The figurative bucket of cold water. Yep. I was.
Sometimes patients sicken and die and you don’t know why the hell they do. You can be the best nurse since Florence Nightingale pinned her hat, and patients will ignore all your wonderfully exact care. They sometimes will set sail for the yonder shore, oblivious to your best intentions.
Sometimes it has nothing to do with the nursing care at all. I know this in my head. Yet still, I think about this patient even now, and wonder.
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*Small inside joke. Actually, get out the Precip tray and pray L & D gets there before anything pops out.
