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Have you ever arrived at the hospital for your shift with the sinking feeling that the odds were stacked against you? Sometimes it’s a quick look at the ambulances lined up waiting to drop off patients. If I walk by the waiting room I can sometimes get the feeling of whether people are waiting patiently or whether there is a sense of anger and frustration. But you know you are in trouble when you see the ‘to be seen’ rack and it’s double and triple stacked. This was one of those nights.

“What’s he been doing?” I mouthed to the grim faced charge nurse as I pointed with a sideways head nod at the evening shift doc. She waved for me to step away from the nursing station.

“It’s not his fault,” she explained, shaking her head sadly. “The floor nurses must be sittin’ on their asses, because they are refusing to take anybody. He’s been arguing with everyone from the floors, the surgeons, even administration to get some of these people out of here. But nobody is helping us. He’s got everyone so pissed off now, he’s better off leaving.”

I looked at his blank expression as he slowly filled out his last chart. I couldn’t tell if it was anger, resignation, or just exhaustion. I knew that I desperately needed him to stay and help, but...

“I’m really sorry to leave you like this, but...” I could tell he meant it. I was only a locums doc filling in while they were trying to make up for a staffing shortage. But I had been coming and going to this hospital for almost a year. I knew the staff. They were working very hard under difficult circumstances.

“That’s OK,” I said, stopping him. “I’m fresh. Go home, put your feet up, and have a glass of...you fill in the blank.” I knew that I was cutting my own throat, but I didn’t see any other way.

“OK,” I said with resignation to the charge nurse. “Let’s get started.” I picked up an armful of charts and charged into the first room.

“Hi I’m Dr. Pla...”

“What the hell took you so long?” the patient interrupted. He was a middle aged business man who was clearly not accustomed to waiting for anything or anybody.

All I could manage was a grimace. I didn’t want to start like this. “We’ve been pretty busy tonight. Now that I’m here, what can I help you with this evening?”

“Are you the only doctor on tonight? For crying out loud, can’t you call in some more doctors?”

He was a fix-it kind of guy who expected answers. We usually had a back-up schedule, but with the weather, the holidays, and being short handed . . . anyway, I was in no mood to work through this with him or any other patient.

“Let’s talk about your problems,” I said, emphasizing ‘your’ in an attempt to get back on track. It turned out he really was sick and required admission. So he got into the cue to go upstairs and continued to try to grab me every time I passed.

At one point I thought I was starting to see the tide turn in this shift from hell. Maybe the folks in the waiting room finally had enough and left. My PG scores probably tanked for the night, but

I was thankful for what appeared to be the light at the end of the tunnel. But alas, the light turned out to be the proverbial freight train.

“I need for you to see the little old lady in room two,” the charge nurse said in passing while handing me the chart. “It looks like she’s septic and we can’t get a line in her.”

“That’s OK,” I responded, reassuring her. “Get the ultrasound out and I’ll put in an IJ.”

“No can do,” she said firmly. “You’ll have to put in a subclavian. And from the looks of her chest, she’s had a bunch of them.”

“I’ve put in hundreds of ultrasound guided lines. What’s the problem?”

“The department never bothered to do the paperwork to get you credentialed to do ultrasound-guided procedures. I saw the list the other day. Now radiology is cracking down and they’ve laid down the law.”

I knew she was right. I had seen the list too. It was sort of a catch 22. I had done plenty of ultrasound-guided lines, just not at this hospital. I had been too lazy to chase down my previous directors to get the proper documentation. So I wasn’t approved. Fooey! I did a slow burn while

I drummed my hands on the counter in frustration. “Get out the subclavian kit,” I said with a sigh. “We’ll just have to do it the old fashioned way.”

I took the consent form in with me to examine the patient since there were family members with her. “There is a risk, albeit small,” I said with confidence, “that in putting in the line, I could nick the lung causing it to collapse.”

“Has that ever happened to you?” the middle aged daughter asked with some suspicion.

“No. I’ve probably put thousands of these lines in without a complication.” My exaggeration was well meaning, but proved to only set up the eventual fall. Sure enough, as I probed to find her scar distorted subclavian I nicked a tiny edge of the apical lung. My heart sank as I withdrew air in the syringe. I finally got the line in, but follow-up filmed showed a 20% pneumothorax.

“Get out the chest tube tray,” I told the charge nurse in frustration.

“You better call her attending,” she counseled.

“I can take care of this.”

“I know you can, but you better call her attending first.”

“Dr. Who?” he said sleepily. “Well, you better call the surgeon on call to put in the chest tube.”

“I can take care of this,” I almost pleaded.

“Who did you say you were? No, call the surgeon.” That burned, but not as much as when the surgeon asked “Have you put in many subclavian lines before?” Then, “I’m sure you can put in a chest tube, but I better come in.” His implication was clear.

All the hard work of the entire night seemed to go up in smoke as the surgeon arrived and demanded most of the staff to assist him in putting in the chest tube while I took care of woman with a sore throat.

I longed to get out of that place as I saw the beginnings of dawn start to shine through the ambulance bay. Then a car came squealing to an abrupt stop in front of the doors. A man jumped out and ran in yelling that his wife was delivering a baby. One of the nurses raced to the door with a wheelchair. Deliveries were supposed to bypass the ED and go directly to L & D.

“I could see the baby’s head,” the man said breathlessly. “My other kids are in the car.”

“Maybe we should check her first,” I said stopping the nurse.

“Are you sure? The policy is that they go up upstairs.”

“Let’s just check,” I said with some frustration. Then, “Whoa, ma’am, don’t push,” as we got her onto the gurney, lifted her skirt, and saw the crowning head. A pair of gloves was all I had time for. I ironed the perineum as best I could and slid my finger down the baby’s neck to find and release a nuchal cord. Then before we could say more, I delivered a chubby pink little girl.

Cradling her to my chest like a fullback I suctioned, wiped and soothed her as she wailed like a siren. I looked up to see that the mother was likewise crying uncontrollably.

“She’s beautiful,” I reassured. “And perfectly healthy.” Then I saw the reason for her exuberant joy. Her husband appeared in the door of the room with four little boys.

“Looks like you got your little girl,” I said to the dad, just as he too burst into tears. “Do you have a name for her?”

“Grace,” they all said in unison. All but the littlest boy.

“Grath,” he said in a solemn lisp. “She’tha a gift from God.”

As I walked out later at the end of my ordeal I was confronted by the full blaze of the sunrise. Had I done a good job? Had I done my best? Was it good enough? I don’t know. I just know that every once in a while we all need a little grace.

Mark Plaster is the founder and executive editor of Emergency Physicians Monthly

 

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