We did chest compressions, pushed another amp of epinephrine, bagged, watched. Idioventricular rhythm, nonperfusing. Pulseless electrical activity in a woman who was already cold, grey, the ash-blue of death on her lips and tongue. Her hands were soft, unresisting as I reached for one, carotids flexing without a beat beneath my gloved hands. He listened: Good breath sounds. No need to replace the Combitube, and in an aside to me, too bad. Not "too bad" for her - she had the best chance with a properly placed tube - but too bad for me, the resident, because there was no reason to let me try an intubation. There was no reason to ventilate her.
The monitor moved relentlessly on, the tick and twitch of a dying heart, sustaining itself on the last stores of energy, arcs of electricity causing ineffectual shivers within her chest. It almost looks like a bradycardia, but there was no oxygen moving through her, not now. Code called. I helped to draw a sheet over her face, eyes slit open slightly, black pupils glinting at me as if her body was watching me, as if she knew that I had curiously palpated the crushed wreck of her chest where CPR compressions had most certainly broken ribs, as if she knew that I had fingered her watch with a need to know whether its metal was warmer than her unresisting flesh. I drew it up, and I wrapped it carefully around the Combitube, and I left to watch the background of her name on the electronic board turn a strangely tranquil blue. Acuity: dead.
Next door, head trauma had finally grown quiet. He wrecked his lawnmower, from what I heard, hit his head, now with a basilar skull fracture. Go see it, staff urged. He's pretty tranquil now. And he was, as I crept into the darkened room, introduced myself, asked to look in his ears. He was quiet and complaisant, and when I asked how he was feeling he only whimpered that his head hurt. I peered. Right hemotympanum, blood staining the right eardrum a dark clotted red. CT confirmed it, and no wonder he had a headache. It was a welcome change from his presentation - swearing, screaming, moaning loudly enough to make the doors close on the other bays.
It was all right; the habitual drunks were coming in. They scream and swear enough for ten head traumas. I escaped, though, shift done.
Thursday I checked on my baby from the crash section. Off the vent, feeding tube out, taking PO intake and starting to gain weight. Head CT and EEG are normal. All responses are normal. I didn't wake him, small and sleeping and so delightfully pink; I watched over him until I felt my eyes stinging with tears and I seared him into my mind as he was there, ten days old, perfect and whole and a miracle, the survival rate is 44% for children of undiagnosed vasa previa, less when ruptured - more like 10-20%.
Girl in the ER, sixteen, looks twelve, syncopal episodes. Instinct made me send her parents away. She talked to me about a history of suicidal feelings, none now, but now she'd been planning to run away and changed her mind. Sister moving back home. Nobody at school she liked. Alone. I listened. I asked a few questions. I got her Kleenex. I asked if she wanted to have a professional to talk to, and she declined. I asked if there was anything else she wanted to talk about, and she looked up at me, shook her head. "Do you want a few minutes to yourself?" Another shake. A long pause. Thank you.
I let the peds resident she was being admitted to know what we'd talked about, let her pursue it further. Still wondering what the "thank you" was for, but I suppose maybe it was for being interested in her. A lonely girl.
Lots of minor problems. Poison ivy. Stomach pains. Pelvic pain. I have had a week of ER shifts and no lacerations to sew up, I will perhaps have to cry. But I have diagnosed gastroenteritis and ovarian cysts, delivered the news of a miscarriage to a woman no more than a few weeks pregnant, offered tissues and been accepted and rebuffed, met a band director who could not play his trumpet (Bell's palsy, no I think you'll need a sub for "Hello, Dolly" this weekend) and an elderly glass doll of a woman who was living alone and now may not again.
"GLF" means ground-level fall. It can mean that you stumbled and landed on your knees, or it can mean that you are eighty-nine years old, rolled out of bed, and broke three ribs on the vanity table, a finding that I almost missed, so focused on her scapular pain was I. She had been living in an apartment with her husband until this; now it will be hospital to rehab to nursing home for long-term rehab, and most likely assisted living after that. They were so proud of their independence. So proud, so fragile; bones that were nothing more than a threadwork of calcification on X-ray.
Ninety years old, they are all hard of hearing, the men. I shout at them: How long have you had trouble breathing? and I get back spunk and spice. It turns out he's not having trouble breathing, his left nostril burns and he's running out of Vick's Vapo-Rub to put under it to make it stop stuffing up. And across the hall, his counterpart at ninety-six refuses to wear Depends and is tired of his overflow incontinence. We can't fix you in the ER. Off to a urologist, at ninety-six. Fancy that.
I am pulled away from charts: What's broken? There is a leg X-ray on the screen, tib-fib top and bottom, ankle and knee. The first two fractures are easy to find: great jagged rends crossing both bones, sharp splintery things that leap off the screen. The third is more subtle; I squint slightly. What about that lucency at the lateral malleolus? A little smile crosses staff's face. "Try the other view." Still there. I point. He nods. "There's swelling there." Point tenderness? "Absolutely. Good call." He approves. Thus far, they all approve, except the ones who don't like residents. I don't talk to them and they leave me alone.
I meet a new doctor, introduce myself. I know, he says. I've heard about you. I'll sign anything you want to do. Night doc was raving about me. Evening doc wants me to moonlight now if I could get my license. I feel clumsy and slow and unconfident, but they approve of me and they approve of my skills and that is not a small thing.
Tomorrow morning clinic. Wednesday 2-midnight. Thursday afternoon I am double-booked with follow-ups so that I can see the girl with the falling beta-HcG. I asked OB about it. They think she should get another ultrasound; there is a chance still despite the grim look of things. She is clinging to that chance, despite my calls to tell her the level keeps falling. I will not dissuade her, not yet.
I am tired but happy; I went rafting this weekend and got a sunburn on my nose. The sunlight and fresh air are good for me. Angel is finishing up Order of the Phoenix so soon he will be reading Half-Blood Prince and I can talk about it with him because I had time to read it this past week. I was complimented manyfold on my presentation on Friday; fifteen minutes of case conference on vasa previa has now set a standard for me to continue to live up to. It has been a busy week - I did not arrive home until 9:30 AM last Monday and I hit the ground running - but I am starting at last to catch up to needed sleep, and I will perhaps be able to lose myself in coding for a while tomorrow afternoon. After all, from 1300 Tuesday until 1100 Wednesday is my time.