Tuesday, April 12, 2005

The Real ER

I don't really like the T.V. Show E.R. , but I love the IMAGE it presents.

On T.V. ERs are populated by a half dozen, bright, young, dedicated doctors; mentored by some experienced specialists, and supported by a professional, caring, and compassionate nursing staff, and competent administrators.

On T.V. ER doctors’ job is to save your life, and make you feel better, and nurses are there to help you deal with your pain.

On T.V. ERs have competent administrators, technicians, and orderlies to handle the beaurocracy, the paperwork etc...

On T.V. when you walk into the ER with a problem, you are surrounded by all of these bright dedicate professionals, who's sole concern is your health and welfare, and the work quickly and efficiently to GET YOU HEALTHY.

Let me tell you what the real world is like. This is going to be another one of those personal, and very painful postings, so if you're just here for the gun stuff stop reading now.


My mom called me at just after 5 yesterday evening, in very severe pain. She could barely talk. Unfortunately my mother has what I can only call an irrational hatred and fear of Ambulances, Doctors, and hospitals. She wasn't really coherent but she ABSOLUTELY REFUSED to call an ambulance. She screamed at me that if I called an ambulance she wouldn't let them treat her; and that she would only go to the hospital with me.

Understand, at 5pm, it's usually over an hour from my place to my mothers (about 25 minutes otherwise; its 27 miles - and we live in neighboring cities).

I asked her how much pain she was in, pretty much already knowing the answer - 10. See she refuses to even consider treatment unless she's in 10.

I should explain what this means: There's a pain scale that the medical profession has taken to using in the past few years, and it goes from 1-10, but I won't bother explaining the lower levels.
You see my mother has spent the last 5 years in the kind of pain that most people would commit suicide to escape. She is so opiate tolerant that morphine sulphate basically has no effect on her at levels that don't endanger her respiration. Her day to day pain is at about 5-6, with all her meds.

When I say all her meds, I mean 3 times daily 40mg Oxycontin, 3 times daily 15/125 percoset plus for breakthrough pain, and 4800mg daily neurontin. That’s just the pain meds, she also takes a muscle relaxant, and a nausea suppressant who's names I cant remember, 2000 mg of naprosyn (an anti inflammatory), and something that's supposed to prevent bone loss, and something to boost her red blood cell count, who's names escape me. Oh and she takes calcium and iron supplements.

Yes, most of these meds are to treat the side effects of the other meds; but if she didn’t have them, she'd be vomiting all the time, unable to move, anemic, and her joints would swell up, causing nerve impingement, which would cause her to have seizures then break her bones.

She's gone off all her meds before, out of stubbornness and pride mostly; I know this is what happens to her, because it already did.

Anyway, back to the pain scale.

Pain at 5 or 6 will cause severe insomnia, leading to sleep dementia; nausea and loss of appetite; and reduced co-ordination. Long term pain at 5 or 6 will cause your body to slowly degenerate, because when you are in constant pain, your body can't heal itself properly.

Pain at 7 and above will cause the above plus, dizziness, blurred vision, and muscle control problems.

Pain at 8 will cause all of these things, as well as vomiting, twitching, and light and noise sensitivity.

Pain at 9 will cause all of these things, along with loss of bladder control, and convulsions

Pain at 10 is so severe that it can cause loss of vision, loss of hearing, loss of consciousness, dementia, hallucinations, and significant loss of muscle control. People in pain 10 are generally only able to gasp, cry, scream, and speak for very short periods.

Spending prolonged periods in 9 or 10 can cause you to stroke out, or have a heart attack.

There's another level over 10, generally only used by pain specialist, and trauma specialists. It’s called 10+. People in 10+ generally have little or no voluntary control. They convulse and have seizures, the vomit uncontrollably, they twitch constantly. Their pupils don't dilate properly, and their eyes won’t follow you. They may lose vision entirely.

People in 10+ have massive spikes and dips in blood pressure, heart rate, and respiration rate. They may stroke out, or have a cardiac event.

People in 10+ would be screaming, but they can't get the breath to scream so they gasp, and sometimes moan, or bark. They pass out, and then come back into consciousness screaming, gasping, convulsing. They can't really see, they hear things, they don't know where they are, or what’s happening. They only know they are in pain, and they are afraid.

When people are in 10+, the only voluntary sound they are likely to make, is "please god, kill me. Kill me please"

That's how I found my mother.

When I walked in, she was on the floor, in her bathroom, convulsing, vomiting, gasping for breath, and saying over and over again whenever she could force words out "help me, someone please help, someone kill me, please kill me, god please kill me" over and over again, whenever she could breathe.

I said I was calling an ambulance, and she started trying to scream, "No, no I won’t go with them" but it came out like a wheeze because she had no air.

I picked her up, and carried her to my car. On the way over I had called the FD, and the nearest hospital to warn them we were coming in, and I called the ER now and told them that I had a severe neuro patient coming in, with a history of aneurysms, in 10+ radial in the head, blown out and non-responsive.

I was the equivalent of an EMT/Paramedic (they are certifying us as paramedics now) in the Air Force for two years; and I've been living with my mothers illness for longer than that; I know my shit here.

My mother is a multi-neuro trauma patient. She had a spinal injury a few years ago, and has had brain and spinal cancer. She has had uncontrolled growths in her spine, and along major nerve junctions, which causes her to live in just bearable pain, all the time.

In the last few months, she's had 5 aneurysms. 2 have been repaired (one coil, one clip), but the other three are very large (over 5), and in very sensitive areas, so they want to let the others heal more before they work on the next few.

They aren't really sure they can operate on these things, and still have her survive. They give her about a 20% chance, on the outside.

As a side effect of all this, she's lost most of the feeling in her lower body... it comes and it goes, and she has enough feeling and control to walk (sometimes yes, sometimes no, and never very far), but the only thing she can really feel is pain shooting up and down her legs and back.

It was about a five minute ride to the ER, but when we arrived, there were no staff present. There were about 40 people there, all but two of them (what looked like a lesbian couple) hispanic, almost all of them speaking spanish, most of them pregnant women.

This is in a very nice neighborhood, in far north Phoenix BTW.

I rang the buzzer a couple of times and no-one showed up, finally I started yelling "Hey I've got a neuro trauma coming in, and I need a chair.

I’m a very large and very loud man. I was yelling for about 30 seconds before a nurse showed up. From behind a buzzed and locked security door.

I tried to give the nurse the details, but she just shoved a clipboard with the admission paperwork and went away, back behind the locked security door.

My mother had recovered slightly by this point, and she staggered through the ER door, and almost collapsed just as the nurse came back out the security door; without the chair. I was holding her up, and the nurse saw this and said "Does she need a chair?"

Yes, yes she does.

So the nurse turned around, and went back behind the security door, for 3 MINUTES (I timed her), before she came back with the chair, as I'm standing there holding up my mother.

I tried to tell her again what was happening, but she REFUSED to speak with me before I filled out the paperwork. So I filled out the paperwork, but she had gone back behind the security door.

Another person came in, bleeding from a bad hand cut, and the nurse came back out. They asked, "how long we wait" in broken spanish accented English. The nurses’ response "About two hours"...

Before she could disappear again I went over to her and put the paper in her hand and I stood in between her and the door, and told her the exact same thing I said before. "I have a woman here, history of aneurysm, multiple neuro traumas, she’s at 9-10 radial in the head, spiking over it, constant vomiting, her right pupil is blown out, and she’s intermittently non responsive"

She said she'd be right back to take care of her, then SHE FUCKING DISAPPEARED AGAIN FOR 10 MINUTES.

When she came back again, I was fuming. I told her "I'm an EMT, I've given you clear indications of a life threatening emergency, WHAT THE HELL ARE YOU DOING"

"Well why didn't she call an ambulance?"

"I told you, she refused to call an ambulance, she said she would refuse treatment so she called me, I called it in on the phone, I told you the situation"

"Well you didn't call ME..."

"What the HELL ARE YOU DOING, you need to treat this woman RIGHT NOW"

She sighed and said "Fine, wheel her in here by my desk, and I'll be right back"

20 MINUTES WENT BY. I grabbed every person that went by and tried to get them to get someone to treat my mother, but most of them wouldn't even acknowledge me.

The nurse came back, and started going through the normal admitting paperwork, sitting there with my mother vomiting and convulsing, kicking herself out of a wheelchair.

"Do you NOT understand how serious this is? She's spiking above 10, and she's had 5 aneurysms, she's probably got a cranial bleed right now"

"I'm sorry sir, we can't treat her without this. You should have just called an ambulance"

The entire time, my mother is gasping, and choking out over and over again "Please help me, someone please help me, oh god help me"; while the nurse just sits there, writing away, and trying to ask her the standard admittance questions.

By the time we finished with the paperwork, my mother had become non-responsive again, and was convulsing out of the chair. When she WAS responsive, she was semi delirious, vomiting, and crying.

"Why have you made us wait this long?"

"Well if you had just called in ambulance this would have been much easier on us, and on you"

I was VERY angry at this point and said "Oh that's great, way to blame the patient"

"I'm not blaming the patient, she should have called an ambulance, it's not my fault she didn't"

I'm not a violent man, but I can't tell you how much I wanted to hit her at that moment.

They put us in a trauma room, and it was about 20 minutes before we saw anyone again. It was someone looking for her insurance information.

I asked for a doctor over and over again, but I kept being told, "he's not on the floor right now, he'll be here shortly", and "I’m sorry I can't help until the doctor sees her.

Another 10 minutes went by and a couple of med techs came in to get her into a gown. Her pain had gone down to a 9 by now, so she was able to partially assist, but she went non-responsive a couple times.

Every time someone came in, or came by I gave them my spiel, and every time, "Oh someone will be right here".

Finally a paramedic came in, and I gave him my spiel. I also said "she’s stopped vomiting and she has no saliva, I'm pretty sure she's dehydrated now". He said "Ok, were going to put a line in, and get some blood".

The entire time my mother was asking for help with the pain.

He said the doctor would be "right there", and he headed out. It was another 15 minutes before the Dr. came in, I gave the spiel, he got a few semi-responsive answers of my mother, and I told him what her normal pain meds were, and that she hadn’t been able to keep them down that day, and that she hadn’t had any water. He said "Ok, we'll get some pain meds in you", and he turned around and walked out.

After about 15 minutes, the paramedic came back in, and he did the stick, quick, clean, and talking with my mother the whole time. He took two samples, and hung the bag on an open drip for hydration.

I'll tell you right now, this is the only person who actually did his job the entire time we were there.

Again, the entire time my mother is asking for some pain control. He said, "I'll see what I can do". and I followed him out the door. Behind glass, through more security doors I could see maybe eight nurses, and three doctors, including the one who had just come in.

They were doing paperwork. All of them.

There were no other nurses on the floor, although they had 12 bays, with a patient in each one (two elderly women, the rest mexicans). The paramedic was going from bay to bay with a list. The only time I saw a nurse step out of their little glassed in staff area was to walk to another area, or to come ask the paramedic why he hadn’t got to something else yet.

I asked the guy later, and he said he was the only one on the floor doing sticks right now, but he wouldn't say why, just saying "well we're really busy". Of the three doctors on the floor, only one of them was taking cases, same reason.

While the doctors and nurses were doing paperwork.

About 20 minutes later, after a couple of conferences with the doctor, he came back in, with 2mg of Morphine, some Atavan, and some compozine (and anti-emetic). We told him right then, 2mg isn’t going to do a damn thing, and she's had composine before, it doesn’t work for her.

But that’s what the Dr. ordered.

He pushed the meds, stuck around for a couple minutes and saw there was no response (morphine acts fast, if it doesn’t work in a few seconds, it isn’t going to work); and went back to the dr.

About 45 minutes later, after I repeatedly asked them to help, the Dr. ordered 4mg of morphine, and a different anti-emetic (I don't remember which one).

No effect.

20 minutes later the paramedic came back with Diluadid, and fentanyl (another anti emetic/anti-nausea, with psychoactive side effects, but it's very effective). The dilaudid finally eased her breathing, and after about 10 minutes stopped her twitching, brought her down to an 8-9, and the fentanyl got her to stop vomiting.

I spent the next 30 minutes trying to get the Dr. and nurses to understand that she was still at 8-9, and that she was still nauseous, but that it had helped some, she was just highly tolerant, and needed another dosage. Finally, an hour after the first dose, the paramedic came back and gave her the same again, and changed the bag (she'd taken the whole liter, and when she could she was also drinking orally. She was VERY dehydrated).

She finally went down to about a 7, and she stabilized there. Her pupils went back to, if not normal (she had a lot of pain killers in her), at least responsive. She was able to focus, and to breathe properly, she wasn’t vomiting, and she was talking normally, when she wasn’t faded out.

At this point I was finally able to talk to her for a bit, and she told me that rather than this whole thing starting this morning, as she had said before, it had actually started three days ago, and that it had been getting progressively worse.

Realize, we walked in the door at 6pm, and this was at like 10. I had kind of lost track of time at this point. In that 4 hours, she had seen the Dr. a total of maybe two minutes, and there had as of yet NO DIAGNOSTIC ACTION TAKEN.

Oh I forgot to mention, the two blood samples just sat on the tray. The Dr. never ordered the blood tests.

I actually went and knocked on the glass until the Dr. came out to me, and I told him, she's stabilized, her pain is about 7, she's intermittently responsive again, and that the pain appears to be progressive, possibly indicative of a cranial bleed. He agreed with me, came in and examined my mother and said "Ok, we don’t have a lot of options here, but I'm going to get her in to CT"

"Ok, do you have a timeline for me", he turned around as he was walking out the door and said "bout two hours" over his shoulder as he walked out.

My mom kind of flipped out a bit at that, and I spent the next few minutes calming her down.

I went out to the Dr., and I re-emphasized how serious this was, and how agitated she was, and asked if there was anything we could do to make this go faster. I also mentioned that she was still in severe pain, just less than she was. The Dr. said he would bump her to the top of the list, and amazingly enough, about 10 minutes later a tech came in to wheel her up to CT. As she was on the way, a FUCKING FIREDRILL HAPPENED.

No, Literally, a fire drill.

There were four more fire alarms in the time we were there, because they reset them incorrectly after the drill.

So, she comes back from CT, and about 30 minutes later the Dr. comes back in and say, "I cant see a bleed, but this doesn’t look quite right... unfortunately there’s nothing I can do tonight. We'll admit you now for pain control and observation, and we'll transfer you to Barrows in the morning" ... Barrows is one of the best neurological institutes in the country, and it's where my mothers neurologist, pain control specialist, and neurosurgeon are.

Almost two hours went by, with us waiting for her to be admitted.

Still, all the Drs and nurses are in the glassed in area, doing paperwork.

I finally got a nurse to talk to me again, and she said "We can’t find her a bed, were short tonight and we're waiting for the shift to change so we can make up a room for her and get her into a bed.

I went back and told my mother this, and she FLIPPED OUT.

She tried to get out of bed and nearly ripped her IV out. She said she wanted to refuse treatment, she was going home right now.

Well, she and I had a HUGE fight over this, which culminated with me forcibly restraining her from ripper her IV out, literally velcroing her down, and getting the nurse in there.

The reason I got the nurse in? Because the ER doctor wouldn’t see her because they had admitted her, and the CR assigned her care wasn’t in, and wouldn’t respond to a page.

I had to spend the next 20 minutes trying to convince my mother not to leave. I finally told her I wasn’t taking her home...

It wasn’t good. She was VERY upset and angry with me, and I with her.

I still am; she would quite literally rather die than subject herself to the indignities of hospital care. I was honestly worried that if I took her home she would deliberately overdose just to end the pain.

This entire time, they refused to giver her enough medication to get her below 7.

My mother finally agreed to continue care, described ho much pain she was in (back over 8, into 9), and asked for more pain control.

The Dr. left orders that she receive 2mg of morphine every 4 hours, and no more. We told the nurse that this wouldn’t be effective, but she refused to call another Dr. to change it.

"I can try paging him again, but I know he's not going to come in just for you".

You see those caring, expert, dedicated Drs and nurses you see on TV? They don't exist.

Oh they used to; every one of those Drs and nurses in that little glass box doing paperwork USED to care. They used to give a damn. They used to be competent.

They don’t care anymore.

They have seen everything, and been abused, and are so used to dealing with all the bullshit, and the pain, and the suffering...

And they just don’t care anymore.

In the real world most ERs have ONE single Dr. who’s there because he has to be, not because he wants to be, and maybe three or four nurses for the 10-20 trauma bays they might have. They want to get your out of their area as fast as they can, to clear more space for the next piece of scum that walks in the door, because that who they deal with most of the time, and they know it, but they can't treat them any differently.

They just don't care anymore; and they get angry if you try to make them care. They get angry if you disturb their routine, and their system.

They are just trying to get through this next shift, and you're in the way.

They try to care, they try to do a good job, but they can't. There’s soo much paperwork, and so much bullshit, and so many lawyers and insurance companies. They are abused and lied to so much. Their funding, their hours, their shifts, their jobs are fucked with so much...

They just CAN'T care anymore, and they CAN'T do the job right anymore because the system won't let them

So they shut it out, and fill in their paperwork, and treat you like an inconvenient object in their way, because if they did anything else they would go insane. You'll be gone in a few hours anyway.

They just get through their shift, while the people around them scream, because they can't do anything else.