During the full ten years I flew with CALSTAR, I also spent time on the ground at Seton Medical Center in Daly City, where I worked in the emergency department. The day-to-day work wasn’t quite as exciting as life in the helicopter—ninety-five percent of what we see in the ER is more or less clinic work. But that other five-percent can include some bizarre, pathetic and downright horrifying incidents.
One night I was working the evening shift, and I was feeling pretty low. The CALSTAR annual hangar party had been the previous night, with the theme “Life’s a Beach.” We all wore bad Hawaiian shirts or obnoxious surfin’ dude outfits and swilled rum punch till the early hours of the morning. I had tried to call in sick, but a lack of staffing made that impossible. For the safety of the patients, I was relegated to the triage room, where my major responsibility was to take vital signs. Anyone remotely sick would be sent to the back immediately, and I wouldn’t manage any critical care patients.
The shift had been a long one. I had triaged twenty shrill, screaming children, innumerable coughs and colds, and several obnoxious drunks, whose stench only reminded me of my own foolishness from the previous night. Overall, most of the patients were in better shape than I was.
At 11:30, I lay down on the couch in the “quiet room,” which was usually reserved for counseling or grieving families. The waiting room had finally been cleared out, and I was impatiently watching the clock, praying for this hellish day to be over. Just when it seemed I might have made it, a car came careening into the ER parking lot and squealed to a stop—half on the sidewalk—right outside the window of the triage office. I ran out and found, to my horror, a white pickup truck with a man’s head hanging out of the passenger window at an unnatural angle. Blood and brain tissue were smeared down the side of the truck.
The driver jumped out screaming, “You gotta help us! He’s been shot! He’s been shot!”
I turned to the security guard who had followed me out the door. “Quick,” I told him, “go get a gurney and some help. Now. And tell them to bring an Ambubag.”
“Got it,” he said, and ran back into the department. I pulled on a pair of gloves and did a quick assessment of the patient. He had sustained several gunshot wounds to his head and had obvious gray matter oozing out of the jagged holes. He had only agonal respirations, very slow and irregular. He gazed forward out of unseeing eyes, and his pupils were fixed and dilated. He had a pulse, but it was very slow, probably in the thirties. I couldn’t see any other bullet wounds to his torso or limbs, and I climbed into the driver’s side and pulled him upright to initiate spinal precautions. I attempted to maneuver his jaw to open his airway, which was quickly filling with blood.
I found no radial or brachial pulses—meaning his blood pressure was less than sixty systolic. Reaching down to his groin, I tried to find a femoral pulse, but there was none. A woman sitting behind the seats was hysterical.
“They shot him! They shot him! Oh, my God, you have to help him,” she screamed. By that time the entire ER staff had come running out, including the doc. We got the patient out of the car, placing him on a backboard, then onto the gurney. As we laid him flat, the blood that had been running out of his mouth began to pool in his airway, causing him to sputter and choke with each slow breath. We turned him on his side so the blood would trickle out rather than drown him. Then we ran into the trauma room, attempting to bag him manually.
He stopped breathing altogether as soon as we got into the room. The doc had him intubated right away, but it was too late. We knew this man wasn’t going to live from the start, but we tried to get something back so at least he might be an organ donor.
According to the man and woman in the car, they had made a wrong turn as they left San Francisco and had ended up in a seedy part of town. A man had approached the car, demanding money. When they didn’t comply, he took out a gun and shot the passenger several times at point blank range.
When the police arrived, however, another story emerged. These people hadn’t mistakenly wandered into the wrong part of town; they had been told they could buy crack cocaine off the street in this area. The trio went into this dangerous area for the sole purpose of scoring drugs. They came across the wrong dealer, or maybe they couldn’t agree on the terms of the deal. Either way, for this man it was the same outcome.
Like a neighborhood coffee shop, every ER has its regulars—or frequent fliers, as they are known—and Sylvia was one of ours. The ambulance radio report always went something like this:
“Seton, this is Medic 21 with Code 2 traffic. How do you copy?”
“This is Seton. Copy you 10-2. Go ahead with your traffic.”
“Seton, we have a five-minute ETA to your facility with a seventy-year-old female with a chief complaint of altered level of consciousness. She was found lying on the floor of her apartment after a neighbor called in a welfare check to the police today. She had not been seen for three days. We found her with six empty vodka bottles, responsive to shaking only. She has extremely slurred speech, is unable to ambulate, and there is a strong odor of ETOH. She has been incontinent of both urine and feces, which is now dried to her skin. Her vital signs are stable. We are unable to elicit any past medical history from her due to her altered state, but she is well known to us. We believe you are quite familiar with her, too. Do you require any further?”
Nope. It could only be Sylvia.
All the nurses at the station tried to duck out the door, but Amber, the charge nurse, collared us. We suspiciously eyed one another, trying to come up with some excuse why we should not be the chosen one.
Regina was the first to speak up. “I got stuck with her last week. She hit me, bit me, and then slung shit at me. She was incontinent of stool five times. She pulled out her IV twice before we gave up. I’ve paid my dues for this month.” With that she quickly ran into another room. I tried to be very small in the corner, just a piece of furniture against the wall. It didn’t work. My number was up.
Amber turned to me. “How long has it been for you?”
“Uh, about a month,” I mumbled, realizing it was useless to protest.
The ambulance doors opened, and the breeze heralded the arrival of the great unwashed one. The paramedic, Karen, was wearing a mask and gloves and turning her head away from the smell. Sylvia’s K-Mart nylon nightgown, soaked with unmentionable fluids, was dried to her skin.
“Hello, Sylvia,” I managed. “How are you doing today?” Sylvia’s only answer was a well-timed belch. We pulled her into the Rose Room, the ER’s unofficial drunk tank. Out at the station, I could hear Edita, our unit clerk, setting up the obligatory pool so we could place bets on just how high Sylvia’s blood alcohol was today. Edita had no formal medical training but somehow she always seemed to win these pools. I idly wondered how she got her inside line to the lab.
While struggling to get Sylvia undressed, I noted her slurred speech and the pervasive odor of stale vodka. Karen was cleaning up her gurney. “Hey, Karen, how many bottles did you find?”
“Six.”
“Quarts or liters?”
“Liters, I think. Safeway house brand.”
Quickly calculating this data, Sylvia’s current condition, and my extensive knowledge of her drinking habits, I leaned my head out the door and yelled. “Edita, put me down for five bucks on 0.42.” In California, legally drunk is 0.08; personally, I’d be staggering at 0.15.
Once we got the BA wagering set up and the money collected, my job was to clean up Sylvia. I hated this part. The human body produces any number of unpleasant byproducts, but my personal nemesis is feces. I can easily handle anything else—sputum, emesis, blood, urine, bile, the works. But the sight and smell of shit makes me gag. Frequently I would bribe other nurses if there were a bedpan involved with my patient.
Turning back to the task of making Sylvia presentable, I grabbed a mask and shook several drops of wintergreen oil near the nose. It wouldn’t totally cover the stench, but it made it a bit more bearable. Decked out in battle gear of gown, double gloves and scented mask, I plunged into the first order of business: getting her undressed. It wasn’t going to be easy. Her cheap nightgown, cemented to her skin by the dried feces and urine, stripped away her fragile skin as I tried to peel it off. Her perineum and buttocks were a mass of suppurating ulcers. She had really done it this time. She was a mess.
Sighing, I prepared the banana bag—an IV of folic acid, thiamine, magnesium and other choice ingredients that replace what the body has depleted from alcohol and poor diet. I hesitantly approached her with a basin of warm soapy water and prepared for the battle to come.
The way Sylvia saw it, she was sleeping peacefully when her nosy neighbor summoned the police. From her comfy alcoholic cocoon, she was grappled onto a gurney, dragged out into the frigid night, and dumped in the ER. Now there was this nurse sticking needles in her and trying to pull off her clothes. It was no wonder she did not take kindly to the bedbath. She made a credible attempt to punch me, but was unable to reach that far—her last drinking binge resulted in a broken shoulder from some unremembered fall, and it remained hugely swollen and purple. Thwarted, she tried to bite me but I was too quick. Besides, she’d lost her dentures months ago.
After forty-five minutes of struggling, I was able to breathe again. Sylvia glared at me, but was too spent to put up much of a fight. After setting her IV at 200 cc’s per hour and restraining her hands, I placed a warming blanket over her and turned down the lights. Sylvia would be with us all night, taking up one room out of only twelve in the department. The most depressing part of all, I realized, is that this scene would be played out over and over again until one night, Sylvia would die, probably at home and alone.
Sylvia, when sober, was a delightful lady. Late one night, after hours of sobering her up, we sat down and had a long talk. She shared some of the happier moments of her life, and I came to realize she was a sweet, educated woman. For years she had worked as an accountant at a local firm, but was now retired and lived alone, barely surviving on social security and a minimal pension. Widowed and with no surviving family, her only companion was vodka, which was slowly destroying her body and mind. We had referred her to all the social services, including Alcoholics Anonymous and several self-help agencies, but she had thwarted all our efforts. The problem was that when she was sober she was quite capable of caring for herself, and she resented interference from the outside. She felt it was her own choice to drown herself in vodka, and it was nobody’s business but her own.
Sylvia died at Seton Medical Center on May 16, 1994. The cause of death was a subdural hematoma, thought to be secondary to head trauma sustained in a fall while drinking, and complicated by multiple organ failure, exacerbated by chronic alcoholism.
No services were held.
I am always amazed by some people’s inability to gauge the seriousness of a medical condition. On several occasions, we were summoned to the parking lot to “help get Grandma” out of the car. This was often followed by, “And she doesn’t look so good.” Occasionally, Grandma was a full arrest, and it’s difficult to do chest compressions in the back seat of a two-door Honda. The family’s reaction was often, “We thought she was sleeping.” Oh, she’s sleeping all right. And she’s not going to wake up.
Then there are the macho men—the guys who are in disastrous denial. The story goes something like this: They start having chest pain, but ignore it. Initially, it’s relatively mild, and rest usually relieves it. This goes on for several weeks or months. Then one day the pain won’t go away, and it becomes so severe it is unbearable. Then the secondary stuff starts: They become pale and sweaty, then start vomiting. They realize they are having trouble breathing. About this time they can no longer hide it from their wives, who immediately insist on a trip to the emergency room. Of course, they want no part of doctors and hospitals, due to an intense suspicion that all things medical are some sort of scam. I think they see being sick as a sign of weakness.
So I’d be sitting in the triage room and a man would come stumbling in, clutching his chest, diaphoretic and retching—and clearly having a large heart attack. When I tried to get him into a wheelchair he would always protest, between labored breaths, “It’s just a bad flu bug. You guys are overreacting. Really, just give me some antibiotics and I’ll be fine.” It isn’t until he loses blood pressure and is in frank cardiogenic shock that he’ll admit that this has been going on for a while, and yes, it does feel like a mule is sitting on his chest. The tragedy is if he had come in with the mild chest pain, he could have been treated easily, but now there’s major, permanent damage. If he survives this event, only a percentage of his heart muscle will still be functioning, and he’s become a cardiac cripple.
There is also a breed of patient in the ER who is incapable of understanding that someone else might need care more urgently than they do. Patience has never been one of my virtues, but sometimes it was all I could do to restrain myself.
One busy Saturday night, I found myself in charge of the ER. The wait to be seen was about two hours, and the mood in the waiting room was getting ugly. Patients who had managed to be placed in a room were now stalking the hallways, demanding attention. We were working as fast as we could, but the numbers were simply overwhelming our resources.
In the middle of this, we got an urgent call on the radio. “Seton, this is Medic 21 with Code 3 traffic, how do you copy?”
I reached for the radio. “This is Seton. Go ahead, Medic 21.” I knew the caller well—Randy and his partner Dave had worked with us for many years. I trusted his judgment and his skills. He wasn’t some hotshot Ricky Ranger who got a thrill running minor patients in Code 3. We could be assured this patient was critical.
“Seton, we have a four-minute ETA to your facility. On board we have an eighteen-year-old female, currently sixteen weeks pregnant with a chief complaint of severe abdominal pain and significant vaginal bleeding. She is a gravida five, para zero.” That’s four prior pregnancies, no live births. “She admits to alcohol and cocaine ingestion today,” Randy continued, “and was involved with an altercation with her boyfriend, who assaulted her and kicked her repeatedly in the abdomen. She has heavy, bright red blood from her vagina, and we estimate blood loss in excess of two liters. How do you copy so far?”
I leaned over to Joan, one of my fellow nurses. “Get the OB/GYN room cleared out. And get one of the OB guys down here now. I don’t care who. This lady is sick.” Joan nodded and lifted the other phone. Over the radio transmission I could hear the patient yelling obscenities in the background. Her speech was slurred. “Medic 21, this is Seton. Copy you 10-2. Continue.”
“Seton, continuing. Her last blood pressure is 70/38, and her heart rate is 160. She is pale, cool and diaphoretic. We have two large-bore IVs in place, wide open, and we believe delivery of the fetus is imminent. Do you require any further?”
“Medic 21, no. You’re going into room five. Seton is clear.”
I ran into the OB/GYN room to clear it for our patient’s arrival. A sullen woman who was complaining about losing her place in line met me at the door. I tried to explain that we had a life-threatening emergency that needed to be in the room, but she was uninterested. “I’ve been waiting for two hours in this goddamn place,” she fumed. “My sinuses are killing me. You people just don’t care, do you?” She then hurled that cutting phrase we had all heard so many times before. “And you call yourselves an emergency room.” She stamped out of the room, vowing to call the administration and let them know what a shoddy operation this was. Joan was at my elbow, watching this woman stalk away.
“What a selfish bitch,” she muttered under her breath. “Anyway, Dr. Bates is on her way down, and I have the OR and lab coming over to help. I’ll take her if you can help me get her started. OK?”
As usual, she had it all together. We watched as the doors opened and Randy and Dave pushed the gurney in at a run. Rivers of blood splashed onto the floor. Randy had not exaggerated in his report. We transferred her over to our gurney, and Dr. Bates headed south to try and stop the bright red blood gushing out between her legs. Her skin was a greenish gray, and she was barely conscious. Our ER doc got a central line started, while I placed another IV, got blood for labs, and prepared to run her over to the OR.
Dave helped as I hooked up the monitors. “She just delivered outside your door,” he said. Randy had disappeared, I assumed, to start cleaning up the mess in the ambulance.
Dr. Bates looked up. “How many weeks was she?” she asked.
“Sixteen, according to dates. Not much chance for viability, huh?”
Dr. Bates shook her head and returned her attention to the bleeding. “Come on, we have to go to the OR for an emergency hysterectomy. Looks like a probable uterine rupture. She’ll bleed to death if we don’t get her over there pretty quick. Let’s go.”
Joan and the team pushed the gurney out the door toward the OR, leaving me in a room that only minutes earlier had been clean. Now blood was spattered over the floor and walls. I walked to the nursing station to call housekeeping, and I heard loud angry voices coming from the registrar’s desk.
“Whaddya mean I can’t go to the operating room to see her? I’d like to see you motherfuckers stop me.” This was followed by a crash of furniture. I peered out the door to see security trying to wrestle a burly man to the floor. It was the boyfriend, obviously drunk and out of control. I didn’t even try to get involved. I picked up the hotline to the Daly City Police to have them come and haul off this drunken oaf.
Returning to the OB/GYN room, I surveyed the mess. Randy hesitantly walked up to me carrying a small bloody bundle. He was shaking. “Uh, I don’t know what to do with this,” he said, depositing the bundle in my arm. “I just don’t know what to do with this,” he repeated and wiped a tear from his cheek. He turned abruptly and walked away.
I looked down at the bundle, knowing what it must be. I unwrapped it, expecting to see a cold, blue, and very dead baby. What I saw shocked me. Lying there was a tiny infant, about six inches long, still moving. It was so young that the skin was translucent, and the hands and feet were webbed. His eyes were still fused shut. I could clearly see all the internal organs, including lungs and a slowly beating heart. He was moving his arms and legs, attempting to gulp air. It was a little baby boy, otherwise perfectly formed with five little toes and fingers. I stood there, stunned. For the first time in my professional life, I had no idea what to do. This child had no chance of survival. And I couldn’t stand the idea of the trauma involved in resuscitation.
Down the hall, the sinus woman caught sight of me. “Hey nurse,” she screeched. “Hey bitch, I’m talking to you. When am I gonna get seen? Can’t you people get anything right?”
Without responding to her, I turned and shut the door, laying the baby carefully down on the counter, which was covered with his mother’s blood. I drew a basin of warm water and gently bathed him, taking care not to tear the paper-thin skin, then bundled him in warm blankets. I picked him up, and went and sat in the corner, gently rocking and singing to him while he struggled, clinging to life.
He finally died about ten minutes later. Joan had returned from the OR and hesitantly opened the door, surveying the scene. “He’s gone,” I said, and broke into tears. Together we rocked the baby.
“You take a few more minutes,” she said as she got up and went to the door. “I’ll take care of things out there.”
I held the baby a while longer, then straightened my shoulders and headed back to deal with the woman with the sinus problems.