Wednesday, May 16, 2007
The hospital where I volunteer isn't a trauma center, but sometimes we get trauma cases anyway if patients have been transported by car rather than ambulance. (This is one of many reasons to call an ambulance if someone's seriously injured: the paramedics will know the best place to take the patient.) During my volunteer shift this week, we had one of those cases. The patient and a family member wound up on a medevac flight to a hospital in another state, but they were in our ED for two or three hours.
I was in the room for at least an hour, first to comfort the family member -- mainly by offering tissues -- and then just to watch, since I'd never seen a case like this before and it was interesting. I know that sounds ghoulish, but everybody in the ED I've talked to about this feels the same way. There's a universal oh, COOL! reaction when a challenging or unusual case comes in, even though everyone also feels terrible for the patient and family.
What impressed me most was the teamwork among the medical staff, most of whom weren't used to this level of care and were clearly anxious about it. There was a lot of checking and doublechecking protocols: how do we handle this? A nurse who wasn't assigned to that room, but who'd worked trauma recently at another hospital, got called in to help evaluate the patient.
The nurses were worried about the patient's airway, which was fine but which they feared might become compromised by developing symptoms. At one point, I was at the bedside standing next to the relative; a nurse was on the other side of the bed monitoring the heavily sedated patient, who began to breathe with a soft rattling sound.
The nurse paled. "That sounds like stridor." She asked me to go get the trauma nurse, and asked her, "Does that sound like stridor to you? Do you think we need to intubate?"
While this was happening, the nurse explained clearly and compassionately to the relative what was going on. "We're just being over-cautious right now. We want to make sure we head off any problems."
The patient wound up surrounded by three nurses with stethoscopes, who listened to the breathing. "We need to go get the doctor. We need to intubate."
This doctor's one of my favorites, an easy-going and unflappable person who wears his status lightly. He came in, listened to the patient, listened to the nurses, looked at the monitor, and said, "We don't need to intubate. Come on, guys; we're looking at 100% oxygen saturation on room air. Why would we need to intubate?"
"But I heard stridor!" the first nurse said. (I'd heard it too, and I'm not even trained.)
"That's probably from oversedation," the doctor said, and the nurse -- who'd been pushing small amounts of Fentanyl whenever the patient started to come to -- looked stricken. "No, no," the doctor said, "the sedation's the right thing to do, to keep the pain levels down, but look, we don't need to intubate right now. The medevac crew can intubate during the flight if they need to: they're really good at that. Right now, the risks of intubation outweigh the benefits. But you were right to be concerned: this is really hard stuff."
The doctor thanked the nurses for calling him in; the nurses, in turn, thanked him for listening to them and explaining his rationale clearly. I got the feeling that they don't always feel listened to by doctors.
And everyone kept thanking me for being there, although most of the time, all I was doing was watching. I think my presence meant more to the medical staff than to the relative. The main nurse told me, "Because you're here, I can concentrate completely on the patient, since I know someone else is taking care of the family member." She took care of the family member more than I did, with those clear and reassuring explanations, but if having me there made her feel better, I was glad to keep standing and watching.
The doctor responded to my presence, too. "It's good you're here tonight. This is when we really need you." He grinned and said, "Most of the time you're just talking to schizophrenics in the hallway."
"They need me too! Those patients know how people look at them. They feel horrible about it." (Frankly, I think I've done far more for some of our mentally ill patients than I did for the trauma patient's family member.)
"Okay, okay, schizophrenia's a tough disease, you're right; what I should have said was, most of the time you're just talking to the alcoholics in the hallway." Another grin. "The alcoholics who are here every day. But what's happening now, this is important."
"Everybody's important." And alcoholism isn't a tough disease? I'd talked to this doctor before about how much alcoholism there is in my family, but he must have forgotten.
The nurses needed him then, so we broke off the conversation, but we continued it later. "Look," I told him, "there's nobody in this department who didn't feel for that trauma patient. Everybody was on that patient's side. The alcoholics and mental patients need somebody who's on their side, too; that's my job. They need me even more than this family did, because fewer people are rooting for them."
"Okay, you're right," the doctor said, and then explained his own frustrations with those populations: feeling as if the ED becomes their safety net because no one else is providing services for them. "I'm mad at the system, not really at them."
I think it was a good conversation for both of us. He got to vent about the difficulties of his job, and I got to explain my own priorities. Chaplains practice a kind of triage, too, and sometimes the patients at the top of our list are the ones the medical staff considers least in need of care. (All together, now: "Whatever you have done for the least of these who are members of my family, you have done for me.")
And I learned a lot from watching the trauma case, which really was fascinating from a purely medical standpoint. I've always thought working in a trauma center would be too hard, but now I think maybe I could do it after all.