Authors: Elizabeth Nicholl
Memoirs of an Emergency Nurse
Copyright © 2012 Elizabeth Nicholl
All Rights Reserved
Published by Elizabeth Nicholl
Cover designed by Scarlet Trugers Design
Editing by FirstEditing.com
To my family
Thank you for
your support and encouragement
listening to all my stories
About the Author
Elizabeth Nicholl qualified as a
nurse at the age of 21 and has worked in a variety of settings such as vascular surgery, trauma orthopaedics, hyperbaric nursing, community nursing and the emergency department. Liz has worked in emergency departments in both the UK and Australia and has many dramatic and interesting stories to tell. Liz has always had a love of writing and after a time working in nurse education, she decided that it was time to share her experiences of working as an emergency nurse in order to educate others about the realities of emergency
nursing and also to share the highs and lows of such a role. Memoirs of an Emergency Nurse is her first book.
These are true stories taken from my memory, reflecting upon my experience as an emergency nurse through my own eyes. The reality of working in such a volatile and unpredictable place brings with it excitement, suspense, highs and lows. This book is not for the easily squeamish and does contain medical language, which has been simplified as best as possible into layman’s terminology. A glossary has been added at the end of the book.
For reasons of respect and patient confidentiality, certain names and details have been changed to give anonymity to the people involved; however, these are real people and real events that I have had the privilege to be involved in. This book gives a behind-the-scenes look at what really goes on behind the waiting room doors. It has some confrontational stories about the realities of ill health and unfortunate accidents. It describes the highs and lows of a nursing career in the emergency department. I hope you enjoy my collection of short stories and that it gives you a better appreciation of what may be keeping you waiting in the emergency department waiting room.
The emergency room has taught me the hard way to expect the unexpected. Anyone can walk through our doors twenty-four hours a day, whether we are short staffed, equipment hasn’t been restocked or have three cardiac arrests one after the other. On the whole, I believe emergency nurses perform their work with an innate calm and a stomach of steel.
On this particular occasion, I clearly remember coming into the area around the nurse’s station at handover time. About ten nurses at the desk were either waiting to be told about the patients they were taking over the care of or eagerly waiting to go home after a tiring shift. This day the waiting room security door was open, giving a full view of the waiting room and check in desk, down a long corridor ending in the paramedic bay and entrance to the emergency department.
All the nurses were looking intently at the white board, discussing the progress of the morning patients, and handing over information to the afternoon staff. Suddenly, there was a commotion behind us coming from the main entrance, and we all looked to see what was happening. A large woman with dishevelled hair and clothes hanging off her shoulder ran towards us, stumbling and gasping for breath and clutching a mound of blankets. She was red-faced with hair stuck to part of her face. She wore a look of sheer panic as she stumbled awkwardly through the waiting room. A man, also out of breath and panicked followed, behind her as the women continued her determined path towards the nursing station.
The woman continued to clumsily run straight through the waiting area, a distance of 10 meters, still gasping for breath and clutching her blankets. We all turned to face her but couldn’t see what was wrong in the seconds it took her to get through the waiting room corridor. I felt she was moving in slow motion. Finally, she barged her way through the half open security door and shouted, “Help me! My baby’s stopped breathing!”
Swaddled in the baby pastel blue blanket was a limp baby hanging in his mother’s arms. The baby was the colour of the blanket, blue and motionless.
Her panic passed over to me for a second and thankfully a male nurse immediately grabbed the baby out of the mother’s arms and ran in the direction of the resuscitation room. With the lifeless baby in his arms, he kicked open the doors and hurried inside with a stream of followers.
The resuscitation room has three trolleys for patients and one was specifically for paediatrics. Unfortunately there was an elderly patient in it, having her broken arm repositioned. We all cursed under our breath as we ran past this bed and to the last bed in the resuscitation room.
The nurse lay the baby on the bed, grabbed a bag valve mask off the wall, putting it over the baby’s mouth and nose and switched on the high flow oxygen. There was only adult equipment in this trolley area and consequently, the mask seeped oxygen over the whole of the baby’s face.
I swiftly followed him and pulled the emergency alarm to get the doctor’s attention. We already had a crowd of nurses assist as they had seen the baby come in. Another nurse called the paediatrician to assist in the baby’s resuscitation while another nurse talked with the mother and father and gained information about what had happened to the baby.
The baby looked tiny on the adult size trolley and the male nurse’s hands covered most of his head as he administered oxygen. I began snapping the popper studs on the baby’s jump suit, to gain information on colour, movement, temperature; I touched and felt for a pulse, looked for a vein and assessed the need to start CPR. Other nurses brought over the paediatric trolley with all the equipment in it and like a team of worker bees; we continued our assessment in silence, quickly and efficiently with everyone taking a role.
The adult oxygen mask was quickly swapped for a paediatric one, which fit snugly around the nose and mouth, with the male nurse keeping the baby’s head at the correct angle for best airway patency. The baby was blue and cold and still as a calm lake; it was unsettling to be in control of saving this baby. I couldn’t locate any pulses but my own throbbing pink fingers touching this cold baby, hoping and wishing to find some sign of life. I began CPR with one hand and two fingers, lightly depressing the baby’s small chest.
The paediatric equipment trolley was brought nearer and the circulation draw was opened. Now that the baby’s jumpsuit had been removed, a doctor was feeling for veins to site a cannula into a vein. He was poking the stubby cold arms of the baby to locate any vein that wasn’t hidden deep under his baby fat; he applied a tourniquet to the baby’s upper arm and laid the blood taking equipment on the spacious trolley between him and the baby.
Nurses began attaching electrocardiograph dots and leads. The 12 leads were placed strategically around his small chest, two on his arms and two on his legs. In the calm hub of activity, worry was relieved with a beep, beep, as a pulse had been found by the cardiac machine. I stopped CPR. The mother, who was being comforted by a nurse, gasped a huge sigh of relief. She was still getting her breath back from her rush into emergency and now had a fresh sense of hope that he would be okay.
His parents stood at the bottom of the trolley absolutely flooded with emotion, hugging and holding hands. Their precious baby had stopped breathing for no reason and they struggled to comprehend what had happened to their child that he would need help in this foreign antiseptic environment. The parents talked about the events preceding admission through brave sobs, concluding that the baby seemed to start shaking and then stopped breathing; it was their first child and it had never happened before.
The baby had a pulse, which was a good sign and his skin was gradually gaining colour from light blue to mottled white and pink. It was all happening so fast. I remember the tourniquet was around the baby’s wrist and the doctor had the needle poised at a vein on the tiny soft chubby arm, when a small kick from his legs caught the doctor’s hand, followed by a soft cry. The baby was breathing on its own and had a pulse; it was everything we could wish.
It seems that with that single cry, pink continued to return to the baby’s skin and what had been a rag doll started gently moving around under the medical team’s hands. Both parents gasped in relief and could see the dramatic difference in their child from only a moment ago.
The baby didn’t like all our attention but we weren’t stopping our treatment just because he was now breathing. We ended up taking blood samples to rule out any metabolic cause of apnoea and continued giving it oxygen. The child stabilised, he continued to have a strong pulse and was breathing on his own. He became warm and pink and responded like a normal baby.
A full history was gained from his relieved parents but we were still none the wiser as to why the baby had stopped breathing. The majority of the resuscitation team was stood down and the resuscitation equipment not needed.
There was no immediate cause to be found as to why this baby stopped breathing. He had no fever, was not unwell and was developing as normal. Once the baby had had all his tests and could be cuddled by his parents, I called the children’s ward and referred the baby to them.
As quickly as the baby boy had stopped breathing, he was back to his normal self, not even sleepy or confused. He knew who Mum and Dad were and was curious about the nurses around him. He was trying to grab anything that was within his reach and he remained an acceptable shade of pink. He continued intermittently to let out the odd loud cry, presumably protesting at what happened to him, but other than that, the drama was
over. The baby had an uneventful transfer to the paediatric ward and mum and dad were very relieved and thankful.
Surprisingly, many people ignore pains in their chest. They brush it aside as if it is only indigestion or will go away shortly. The events leading up to a heart attack such as crushing pressure on the chest, shortness of breath and pins and needles in arms usually indicate an unexpected problem; however, people often turn up at the last minute to the emergency department when irreversible damage has occurred.
It's an amazing thing to watch an emergency team attempting to save someone's life and even more to be a part of that team. Knowing what to do without panic is a quality emergency staff rely on. It’s not like ER or Casualty, the TV programmes, when the person’s heart has stopped beating and the patient isn’t breathing. In the real world, the likelihood of survival is minimal unless early resuscitation has taken place. This experience has taught me to keep my eye on what goes on outside the emergency department.
A standby call from the paramedics warned us that a patient in cardiac arrest was arriving by ambulance. We were pretty quiet that day. The estimated arrival time of the patient was four minutes so I went to set up the resuscitation room with the necessary equipment. Oxygen and suction were turned on, the defibrillation machine was on, drugs at the ready and the trauma team were called. I placed a pair of gloves on my hands and looked out of the resuscitation room windows. I caught a glimpse of a green car pulling up outside and parking in the ambulance drop-off bay, and then a fast response paramedic car pulled in behind him. The paramedic car usually stayed at the scene until ambulances arrived that could transport the patient, so I was intrigued to see it outside emergency. Also, people often park illegally outside emergency to collect relatives and block the ambulance bay, so I was keen to investigate as I was due a new patient any minute through those doors.
I walked outside into the cold air and saw the paramedic was out of his car, so were the drivers of the green car and the passenger door was open at the back. I could see a man in the back and I asked the paramedic if I could help. It appeared that the paramedics had got the call over chest pains; however, the patient had managed to get into the back of the car and his family drove him to hospital. The paramedic was on route and followed the car here to the emergency department.
I got closer and looked at a large man in the back seat. He had his left arm clutching his chest and his skin colour was mottled purple and red. He let out a moan and slipped sideways in his seat, the arm clutching his chest had fallen onto his lap and he hung there by his seatbelt. I immediately shouted at the man to gain a response. Nothing.
He had stopped breathing and was already gaining going pale. The other nursing staff must have seen me going out of the paramedic doors and they followed to see what I was doing. I
d told the staff he had just arrested and asked for a trolley so we could bring the patient inside. I managed to undo the patient’s seatbelt but had no chance of getting him out of his car, or doing a sternal thump due to his awkward position and being so heavy. The male paramedic was able to pull the man out of his car and onto the floor outside emergency. I was wearing my thin scrubs and a long waterproof apron and as I knelt on the tarmac, I could feel the cold seeping through my scrubs.
A trolley was brought out and I grabbed the bag off the bottom of the trolley that had airway equipment in it. I swiftly measured a Guedel airway for the patient while I was kneeling over him. I put it in his mouth so that he didn’t swallow his tongue and began to give him oxygen from the portable cylinder on the trolley. The fast response paramedic commenced CPR. There was no point continuing resuscitation when we were so close to all our equipment and rather than undress the man in front of his family outside, we knew we could work more efficiently if we moved him inside.
By this time, the other staff nurses and doctors had got a scoop board at the ready to scoop the patient up from the floor and put him onto the trolley. The family stood and watched every move we made on the cold damp tarmac outside emergency, with their hands over their mouths. Nurses were assessing the patient on the floor and our scrubs had dirty patches on our knees.
The trauma team had arrived from different departments within the hospital and about eight people assisted in lifting the patient into the scoop and onto the trolley so we could continue treating the patient inside. Once on the trolley, the patient was pushed in through the paramedic doors straight into the resuscitation room while his relatives were taken by another nurse into a quiet room. This was to gain medical history and the preceding event information.
The man wasn’t breathing on his own and nor was his heart pumping; we could see on the monitors that he had no pulse and none could be felt either. No blood pressure was recordable and his skin colour was changing to a mottled white and purple. The clock was started and we busily continued strenuous chest compressions, standing on the steps next to the trolley. Each nurse could only efficiently administer about three minutes of effective cardiac compressions at one hundred compressions a minute before getting too tired, so we rotated often. His clothes were cut off him while nurses compressed his chest and access to his veins was gained so we could give him drugs. The anaesthetist had intubated the patient with an endotracheal tube so his airway was now protected and he was given automatic breaths from the noisy ventilator that was connected, while we worked on and around him. Fluids were administrated via the new intravenous line; the doctor gave adrenalin through the patient’s IV line and atropine to try to raise a heart rate. However, with the patient being in asystole or flat line, defibrillation of the heart was ineffective. There are only two heart rhythms that can be shocked; ventricular tachycardia (VT) and ventricular fibrillation (VF). All other cardiac rhythms have to be treated with reversal drugs and cardiac compressions.
When the time on the clock beeped and it indicated nine minutes had gone by, a sudden green blip occurred on the defibrillator machine. A layperson would understand the thin green line had changed to a continuous hopeful green squiggle. The monitor showed a window of opportunity to defibrillate this man as his heart had flipped his asystole rhythm to ventricular tachycardia. Ventricular tachycardia was a rhythm that we could shock and hopefully jolt the heart back into a normal rhythm. The defibrillator pads were placed on his chest and the machine had been charged to 360 joules, ready to go. Someone shouted, “Clear.” Staff moved away from the trolley and the oxygen was removed, as it can ignite from the shock of the electric current. The patient jerked violently and threw his arms involuntarily into the air as his whole body jolted and rocked the trolley in a loud thud as the joules were administered.
All eyes focused on the green monitor and his rhythm was still in VT; his heart needed shocking again. We all moved away from the trolley for a second time and a further shock was given. The patient’s daughter had wanted to watch the resuscitation process and she stayed to one side, watching the many people doing essential jobs to help her father’s lifeless body. She was so brave, she stood tall and strong and just watched us do our best; a nurse had offered her a chair but she had refused and continued to watch without tears or panic.
This second defibrillation attempt jumped his heart in a stable rhythm and a palpable pulse was felt by one of the doctors. He now had a readable blood pressure and the monitors also confirmed he had a pulse. The drugs and defibrillation must have stimulated his heart enough to start beating again in normal sinus rhythm.
The ventilator controlled the patient’s respiratory rate and monitors were in place to closely observe his vital signs post cardiac arrest. His heartbeat had returned, his cardiac output was now strong and his rhythm was normal. He was motionless due to being anaesthetised, but the monitor beeped reassuringly and confirmed
effective resuscitation had occurred. His daughter breathed a sigh of relief as she understood the transformed readings on the cardiac monitor.
His colour was returning to a normal pink and after observation and documenting the event, the Intensive Care Unit was informed and a bed made ready for the patient. A phone call made the next day to inquire about the patient’s progress revealed that he was breathing on his own without the ventilation tube and was stable. He had been referred to the cardiologist for further investigation.