Night Shift
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I’m proud of the fact that I’m self sufficient in the emergency department. And it irritates the fire out of me to see prima donnas (read surgeons) come into the department and require the entire staff to follow them around to do little things they could do for themselves. I guess you could say that I was trained well by a charge nurse by the name of Beatrix where I did my residency.

Miss Bea, as she called herself,  or Miss Behemoth as the interns called her under their breath, was a heavy set matronly type with a ruddy complexion. Her upper arms had extra fat that sagged and waved when she pointed to something. Though long out of style, she still wore her nursing school cap that said St. Francis over her hair that was tightly pinned and covered with a net. She once came out to the nurses’ station to confront me where I was writing a note after suturing up a wound. Having seen the litter of bloody gauze and needles I had left in the room after the procedure, she brought out a whole roll of plaster casting material, a bucket of water, and a sling and put it on the counter. Deep in thought, I didn’t notice her at first. But I soon heard her foot tapping and looked up to see her glaring at me. “What’s all this stuff for?” I asked.

“Well, I saw the mess you left,” she said. “And I just assumed that both your arms were broken.”

“Yes, ma’am,” I said instinctively, reaching back into my childhood of groveling. “I’ll clean it up, ma’am,” I said as I walked briskly to the room.

“You’re damn right you’ll clean it up,” she lectured, following me into the room. “Or you WILL have two broken arms.”

“Yes, ma’am,” I repeated several more times. The scene was reminiscent of a childhood memory where my mother made me select the branch with which she was planning to thrash me. Needless to say, the lesson in self-sufficiency took root. While the younger nurses I now work with are not as intimidating as Miss Bea, they can be just as stubborn.

I have learned how to do everything on my own. In the operating room a nurse holds up the surgical gown for the surgeon to put his arms into without contaminating his hands. Then she holds the gloves for him to dive his hands into for the same reason. Then she ties his gown behind his back. But in the ER it is very different. I don’t usually have any help. Of course, my wife has never believed this. She thinks that every time I forget to take out the trash it’s because I have gotten used to an entourage of nurses following me around at work picking up after me. If I ask her to hand me something she just glares at me with a look that is meant to say, “You aren’t at work, Buster.” Or she’ll hand me the object and say “Yes doctor” sarcastically adding “Would you like me to mop your brow?” She’s seen too many medical shows and thinks it is her duty to lower my expectations of stardom. The reality is that when I have a minor procedure to do that makes a mess, I set up and clean up, for the most part, by myself. I’ve even learned a neat little trick where I have one hand wearing a sterile glove to do clean things and the other hand ungloved to touch the non-sterile objects. It works pretty well. Sometimes, however, trying to fly solo can get me into trouble.

I knew as soon as I arrived that I would be on my own. The waiting room was full and the racks were jammed with charts. Everyone had their own list of tasks.

After several hours I picked up a chart with a name I recognized. Ethel Barnes was an elderly patient from a nursing home that I had seen many times before. She was morbidly obese with thinning snow white hair and skin to match. Unable to walk any more, she was confined to a wheel chair. And despite suffering from severe dementia, she seemed to have a jolly disposition. She just sat in her chair all day smiling and drooling. Every now and then she would make this bellowing noise, a sort of “arrrrrrgh” that sounded like Chewbacca from the movie Star Wars. The clinical picture was always the same. Having had multiple abdominal surgeries over the years, her adhesions precipitated multiple episodes of mechanical bowel obstructions, aka constipation. But because of her sunny disposition, no one could tell she was in trouble until her abdomen became severely distended and uncomfortable. That’s when the bellowing became louder and more frequent.

It was the same story tonight. The nursing home sheet just said “No stool for one week.” And I’m sure they just kept on feeding her, I thought to myself.

There was no other history. The exam was predictable. The vitals were normal as was everything else except for her massive, distended, silent abdomen. She seemed oblivious to her condition. I ordered the basic labs and an abdominal series of xrays to rule out another obstruction and dashed off to the next patient.

About an hour later her chart re-surfaced. The labs were all normal. The xrays, too, were unremarkable, except for the huge amount of stool present in her colon. I went back to the room to make a final check before sending her back to the nursing home. They can clean out her gut just as easily as we can, I mused. But when I opened the door I found Ethel still sitting beside her bed in a wheel chair, where the tech had left her. She was surrounded by a huge pool of diarrhea. Apparently she only had a stool plug in her rectum. Everything behind it was liquid.

Once the plug had dislodged, she had emptied her entire bowel. It had overflowed her Depends, filled her seat, run down her legs and formed a large brown lake around her wheelchair. She just sat there grinning.

“Ethel, Ethel, what am I going to do with you?” I asked out loud to no one in the room but her. “Well, first we have to get you out of that soiled hospital gown.”

By stretching my legs as far as they would go I was able to straddle the puddle and reach her neck to untie the soiled gown. Pitching it to the side, I then unwisely decided to attempt the “one-man move the fat lady to the stretcher maneuver.” While facing her I reached under her arm pits embracing her in a giant bear hug and lifted with all my might. Once I had her massive hips lifted from the chair I quickly lifted one leg and kicked the wheel chair out of the way. My plan was to make one large step over the puddle and muscle her onto the clean bed. And it worked until her sagging buttocks hit the unlocked bed, sending it rolling across the room. Now I was stuck with her suspended over the muck.

I studied the problem for a brief moment, but noticed that one foot was beginning to slide ever so slowly. It turned out that when my chair kicking foot landed, it was right in the edge of the puddle of liquid stool. I tried several times to regain my footing without stepping into the middle of the puddle, but without success. Nothing would stop our relentless slide to the floor. Wishing to save my hands from complete contamination, I finally pulled out my hands and rested them on her shoulders. When we finally came to rest, I was spread-eagled over an obese, senile naked lady in a lake of diarrhea.

“Help,” I called out softly, not wishing to draw too much attention to my predicament. “Help,” again somewhat louder. Finally in full voice,

“I need some help in here!”

“Doctor Plaster is calling for help in room 12,” I heard someone shout in a panicked voice.

Oh no, I thought. They think it’s a code.

The door flew open and Jo Ann the charge nurse just stood there frozen. “What are you doing?” she deadpanned incredulously after a long pause.

“I was sailing on the $#!+ Sea and got marooned on Blubber Island!” I yelled. “What do you think I was doing? Help me get off of her.” Ethel just smiled, drooled, and gave out a loud “Arrgggh!”

As expected everyone came running up with the crash cart, stopped, saw what was going on, and then began snickering. With help I was able to climb off of Ethel, but I had to change clothes to a set of scrubs and bag my clothing. Housekeeping cleaned up the mess in the room and a nurse’s aide got tagged to clean up Ethel. Afterward the nurses kept a relentless banter sailing jokes. I couldn’t wait to head home.

“How was your night?” my wife asked in her usual fashion as I returned from laundry room after dumping my clothes in the wash.

“You don’t even want to know,” I said with a look that warned her not to pursue the issue.

“OK,” she said slowly. “Well, then, on another note. The toilet’s not working again,” she said taking the lead to move on.

“Oh, I can fix that,” I said reflexively. “The plumber always charges an arm and a leg. I’ll do it.”

“You are going to fix the toilet by yourself?” she said incredulously. “You …,” she repeated slowly.

Our eyes met in a long question. “You know,” I finally said. “On second thought, I think I’ll let him handle it. He has a helper.”

Mark Plaster, MD is Founder and Executive Editor of Emergency Physicians Monthly

 

Comments   

# Supprt in EDsandy kuehl 2013-11-27 08:31
Just as there are no longer nurses in most ORs, there is no reason why lower level technians(we use a lot of basic EMTs) cannot prepare the patients and clean up afterwards. For that matter mid level(physician extenders) PAs and NPs can care for the vast majority of ED patients. ED Docs are the expensive and rare resource. The average 30,000 patient ED could function just fine with one doc , a PA or two , a charge nurse, a couple of LPNs and plenty of support help.
The problem is 12 hour shifts...and the fact the docs, PAs and RNs do a lot of things they shouldn't.
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# Physician Assistant _CertifiedJesse Belville, PA-C 2013-12-01 21:26
Sometimes kind sir you need to call for HELP.. Lesson Learned I am sure. LOL
In ER I often set up for minor procedures and cleaned off the Sharp Pointy things to protect myself and my Nurses. If they are busy I do it all. If not I leave some for them taking care of sharps. Now I just do Urgent care/walk In. After 37 years as an ER/Family Practice PA-C in rural area's that is much better and No Call better hours.
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# ED RN (Emeritus)Tricia 2014-03-29 00:37
I know I'm late to the party - I just found you and I'm catching up. Thank you, thank you, thank you for the visual and the belly laugh.

(And the nurse in me says thank you for trying.) TCG
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