A Nurse with a Gun

Wednesday, December 16, 2009

Playing Lead Guitar

"What are you doing now-a-days, Xavier?" one of my old nursing instructors, now gray but still intimidating, asked me. I was dressed in my finest duds for the pinning of a new crop of students nurses, all fresh and eager in their starched whites, capes and caps. We were at the reception, the new nurses having recited the Nightingale Pledge by candlelight. Back home, blood soaked scrubs lay in a laundry basket in my bedroom.

"Oh, I'm the lead guitarist in a Southern rock band," I lied.

"I bet you are," she replied, peering over her reading glasses at my soul.
"If I leave here tomorrow
Would you still remember me?
For I must be travelling on, now,
'cause there's too many places I've got to see."

Esophageal varices are blood filled devils at the base of the esophagus, that arise from the azygos vein, and the superior vena cava. Usually the result of portal hypertension from liver damage, whether caused by alcoholism or hepatitis, they can become the cause of a dramatic blood spewing demise in a matter of minutes.

When the first strains of "Free Bird" begin to sound from my iPod, a metamorphosis takes place with my team. Some suddenly realize they missed their smoke break. Others realize that they are being summoned, and they enter my suite with trepidation in their hearts, but willing.
"But, if I stayed here with you, girl,
Things just couldn't be the same.
'cause I'm as free as a bird now,
And this bird you can not change.
Lord knows, I can't change."

When Big Joe rolled the gurney containing the young black man in, there were already splatters of crimson on his sneakers and blood on his pillow. I went through my recital of preparations with the chirping at the beginning of "Free Bird" filling the air. "Do you drink? Smoke? Illegal drugs?" Negative. "Hepatitis, HIV, AIDS, Tuberculosis, Sickle Cell?" No.

Realizing that Lynyrd Skynyrd may be the last thing this young man wanted to hear, I switched the playlist to Motown.
"You can't hurry love
No, you just have to wait
She said love don't come easy
It's a game of give and take......."

"False teeth, false eyes, hearing aid, hairpiece?" I asked as though reciting a poem long memorized. The young man removed a partial plate with several gold teeth. "Tounge ring or lip ring?" No. I looked over his history, searching for an idiology. He had been banded on five previous occasions. That was not good. Each previous banding had likely resulted in scar tissue right where we needed to work. I got my goggles out of the drawer and tightened the cinch securing them to my head.

The team assembled, consent obtained, we began the sedation. He did not fight much as we entered his esophagus with the gastroscope. For a man of his age, that was not a good sign. The base of his esophagus was a fearsome mass of lavender scar tissue and one violent purple bulging clot. "Bander," I ordered.

A band ligator was being loaded on an alternate scope. It is a device that can deploy seven rubber bands, one at a time. Seven chances, seven little rubber life preservers to stop a varicele bleed. Just yesterday, we had saved a life by working with two scopes, the first applying direct pressure against a hemorrhaging varicele while the equipment was loaded on another. "Hurry."

"Ligator." As the first scope was ripped from the young man's esophagus, a great rush of bubbling blood spewed from his mouth and nostrils. I quickly inserted the Yankauer to the back of his oropharynx to keep us from being sprayed in a volcanic gush of hematemesis. The banding scope went down into the torrent of blood, the monitor screen an unfocused blur of red. My physician was relying on memory, working blind. I continued to manage the flow of frothy crimson as best I could when at last the cup to the bander reached it's mark and sucked the tissue inside.

"Although I might be laughing loud and hearty
Deep inside I'm blue
So take a good look at my face
You'll see my smile looks out of place
If you look closer, it's easy to trace
The tracks of my tears."

Through the ligation cup, we were looking directly into the azygos vein, at it's opposite wall. Pop! The first band was deployed. Suction released. The tide of blood blew the precarious band off the scar tissue, washing it right up and out of the young man's mouth. Quickly the physician reapplied pressure to the area with the gastroscope itself.

"Get me blood!" I ordered.

Pop!

"They are still type and matching."

"Emergency O positive!" I ordered again as I looked towards the monitors.

Pop!
"Outside I'm masquerading
Inside my hope is fading"

37/12...... SpO2-0. Damn. "He's not moving air Doc," I called for the crash cart. Big Joe rolled it in. Laryngoscope. ET tube. Bag. No carotid pulse. "Start CPR." Big Joe found his mark and as I bagged, he brought up the pressure with his compressions. "Have we got that blood yet?!!"

"Morrhuate Sodium," Doc ordered. "Epi!" More blood gushed from the young man's mouth and nostrils, dribbling across his dead eyes. "Epi."

Emergency O positive blood was spiked and shoved in. A femoral line was inserted and secured.

"Stop compressions." No pulse. "Resume CPR." I switched positions with Joe and he bagged as I compressed the chest. When the respiratory therapist arrived, she relieved Joe and he left the room. With each compression, more blood was being blown from the patient's mouth. The respiratory therapist cupped her hand over the patient's mouth to keep the cataclysmic flow off of us.

"Bicarb."

"Dopamine."

Another unit of blood. Bagging and compressions. Nothing. Finally, CPR was stopped. He was dead. Bled out. My paper scrub cap was stuck to my forehead with sweat and blood. I found Joe crouched outside the door. He had grown up with the young man. They were team mates on their high school football team. Friends. "I'm sorry," I said. Joe just nodded. Dried tears streaked his face.
"Bye, bye, its been a sweet love.
Though this feeling I can't change.
But please don't take it badly,
'Cause Lord knows I'm to blame."


Labels:

18 Comments:

Anonymous Alex said...

I'm sorry to hear that.

6:05 PM  
Blogger Talie said...

Sounds like this guy had no chance at all. :(
I have no doubt that you and your crew did the best you all could.

No matter how hard we try, we can't save them all.

Taliesin MacAran E.M.T.
Phoenix, Az.

6:29 PM  
Anonymous Steve R said...

Damn Xavier.

Try your best and you still lose some that really ought to be alive.

Truly sorry for what that does to you for having tried and lost.

7:15 PM  
Blogger JAFO said...

and that kind of day right there is why I could never do your job, Z...
thanks for the video- I've been re-discovering Skynyrd of late, myself

8:40 PM  
Blogger Fenris said...

You guys gave it a hell of a fight. Sorry he didn't make it.

11:48 PM  
Anonymous Shwiggie said...

As an x-ray student in clinicals, I've seen a number of similarly tough cases in the ED. It's a tough lesson to learn, that sometimes your best just isn't enough. But, regardless of the result, people like you have my utmost respect, if for no other reason than the effort itself.

Just keep on keeping on.

~ Scott

12:36 AM  
Blogger Cargosquid said...

I could not do what you do. Thank you. I'm sorry that he did not make it.

God Bless.

9:51 AM  
Anonymous Anonymous said...

1. Powerful.
2. RIP, young man.
V/R JWest

10:06 AM  
Blogger stbaguley said...

Whether that was your 1st person experience as a nurse or you as a writer drawing out and crafting what must have befallen more than one other practitioner, it was a well written and emotionally involving pulse pounder (literally). String a few of those together and there's your novel right there. You have ALL the tools to commence a fully realized and acurately drawn medico/action adventure. I know I will buy one and you haven't written it yet! (or have you?)

1:43 PM  
Blogger Ed Skinner said...

My Dad was a surgeon. On rare occasions he'd come home to quietly sit at the dinner table. We learned not to comment on the flecks of blood on his tie.

I couldn't do what you do, Xav. You're a saint for it.

3:54 PM  
Blogger Jarubla said...

Excellent writing like this will always elicit an emotional response. Whether fact or simply an amalgam of your experiences it was very well written.

Freebird is one of my faves. I wouldn't mind passing on from this world while listening to that song.

-Jay

7:53 PM  
Anonymous Anonymous said...

Sorry

8:29 PM  
Blogger James said...

Had to assist in the field on something like that.
Some left to puke, some helped. Pisses you off when it does'nt work.
All of our numbers are waiting to be punched.
The only redeeming part is knowing in your heart that you helped.
Not so long ago, a man could die from measles.
You are a good man X.

2:31 AM  
Blogger Ric in RIchmond said...

Hit me like a ton of bricks today Xavier!!!...one of our friends, a dad from our sons baseball team, was transported yesterday, coded, revived and the family told to expect the worse all before lunch.

Now they are saying it is looking better. still in an induced coma.

Bleeding from the esophagus.

I had no idea.

Ii don't how you do it....but thank you!

5:24 AM  
Blogger Sankey Photography said...

Wow. Just... Wow.

3:22 PM  
Blogger Tom said...

This one hits close to home as I nearly lost my dad to those bloated veins back in the spring. He's had eight banding procedures since then.

Sorry your patient didn't make it, I know you and your team fought hard to save him.

10:15 PM  
Blogger Rainbowbob said...

That was a very well-written and moving account, X.

More so because my wife of 34 years acquired Hep C 30+ years ago - before anyone knew what it was.

Since she was never an IV drug user, we suspect it was from the transfusions needed during the two c-sections that delivered our two children.

She is now one of those patients described in your narrative. I've seen what burst esophogeal varices
can produce, and we nearly lost her a few months ago.

Fortunately, courageous and thoroughly professional people like you were doing everything they could to keep her alive - and were successful.

Thank you for what you do.

1:42 PM  
Blogger Mose Jefferson said...

Back when I was first starting my x-ray tech clinicals, I would sit at the city bus stop after my shift, waiting to go home, and occasionaly I'd look up to the sound of the helicopters bringing in a trauma patient. Back then, it was still a struggle for me to avoid the embarrasment of tearing up at the thought of the poor individual on board, right in front of a bunch of seasoned health care professionals, so I would quickly put on my headphones and crank them, and Freebird was my song. Nowadays, my skin is thicker, but I still do the little ritual. It's my way of saying a prayer for the poor patient.

I once told a friend about this, and he told me to think of the sound of the helicopter as the sound of that patients salvation. It reminded me of how the Vietnam vets used to say the Hueys coming in to pick up the injured soldiers would sound just like angel's wings.

Thanks for the story, Xavier.

1:28 PM  

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