For one particular young man, only 21 years of age, who crashed his car on a quiet country road, I could almost understand why he didn’t bother putting on his seatbelt: it was five in the morning, he was on his way to milk his cows, and the milking sheds were only one kilometre down the road. The last thing he expected was to encounter another car. But one morning he did, and a miracle occurred: he survived going headfirst through the windscreen.
‘I think I need some fresh air,’ Amber said, racing for the door.
Like myself, Amber was a young nurse, new to the emergency room; this was her first trauma. I kept my face expressionless, a sign of a truly hardened emergency room nurse – at least that was how I hoped I looked. The patient in front of me certainly did not look his best. His skull was intact, but his face was a mass of lacerations; loose flesh dangled from his cheeks, chin and forehead. It was as if someone high on speed had taken a cheese grater and gone to work. The worst thing of all was that his forehead was missing. The skin had been peeled back like an onion, and sat in a line of ridges across the centre of his head, running from ear to ear. It was no surprise that Amber needed some fresh air.
‘What’s your name?’ I asked the young man.
All I got back were some incomprehensible sounds – bubbling and gurgling noises.
‘Sorry, can you say it again?’ I repeated as I leant closer to hear more clearly.
Every time he opened his mouth or tried to breathe through his nose, the blood kept on forming bubbles, but I finally deciphered a name: Darren. He spat out two of his teeth as he said this. I calmly picked them up and put them in a clean urine specimen bottle and then put them in a property bag. I didn’t bother getting him to sign the property form.
Despite not wearing his seatbelt, Darren was thankfully alive and by the looks of things he had no life threatening injuries. Okay, his face was rearranged, but he was breathing fine, although his broken teeth were proving to be a bit of a nuisance. He had no broken bones and no sign of organ damage or haemorrhaging, and the most unbelievable thing of all was that Darren insisted that he had been conscious the whole time.
Darren went from the emergency room straight to the operating theatre. He was operated on for three hours, until eventually being admitted into a general surgical ward. I came to work the next day, a Monday which was also a public holiday. It was eerily quiet in the emergency room, which was strange – Monday was usually one of our busiest days. (It’s amazing how people don’t get sick on public holidays.) It was so quiet, I was asked to lend a hand in the general surgical ward and it was here that I bumped into Darren again.
What a sight he was; he had over two dozen different suture lines zigzagging all over his face but my eyes were drawn to the massive zip that was tattooed across his forehead just above his eyebrows. He looked like something out of a Frankenstein movie; his face was literally being held together by a thread. There was still a lot of dried crusty blood and bits of glass in his hair and on his face. He looked miserable, but when he saw me walk in the door he gave me a big gap-toothed smile. I felt sure that his smile would fade once he saw himself in the mirror.
I really wanted to do something to clean him up a bit. I started with some of the small fragments of glass that were still peppered over his face and in his hair, and then moved on to the dried blood.
As I carefully and gently began to remove the dried blood from his face, his cheerful demeanour began to slip away.
‘Shit that hurts. Is there an easier way to do this?’ asked Darren as I began pulling at a particularly sticky globule of dried blood. ‘Are you sure you know what you are doing?’
‘Of course, don’t worry, you will feel much better once I’ve finished,’ I reassured him.
I became totally engrossed in the job – I might even go so far as to describe it as quite enjoyable, relaxing work – and soon I began looking for other ways to clean things up.
There were lots of long pieces of suture material all over his face. Some were dangling in front of his eyes, and he kept on having to brush them away, and some were stuck to his face in thick globules of dried blood. I trimmed some of the longer bits of spare suture material, and tried pulling some of the strings of suture free from the lumps of blood they were stuck in. I pulled too hard…
‘Oops… bugger… No nothing, Darren. I didn’t swear. No seriously, everything is okay.’
I couldn’t believe how dumb I had just been. In my eagerness to clean him up, the right cheek had been pulled very slightly downwards; his right cheek was the tiniest bit lower than the left. I was in big trouble and the surgeon wouldn’t be happy, if he found out.
Sometimes the stupidest things are done with the best of intentions – I pictured the right side of Darren’s face peeling off. I kept a smile on my face and my breathing even. I did not want Darren to worry. I felt sure I could fix it. The only thing I could think of was to give it a pull the other way. I took the other end of the suture and gently pulled. To my immense relief his right cheek moved up and back into alignment.
‘I think that’s enough cleaning for today, Darren.’
The next day I woke and during breakfast managed to have a quick glance at the paper. Staring at me from the front page was a picture of Darren with that gap-toothed smile. I felt like I had been hit in the chest – Darren must have complained about me, or told a friend or family member that I had been messing with his face.
I began to read the article with trepidation, certain that my nursing days were over, but I soon realised with relief that I wasn’t in trouble. Darren was being used as a promotion for the land transport safety authority. His mangled face was a warning for all of us to buckle up. Darren was actually happy having his image on the front page. The article stated that Darren hadn’t been wearing his seatbelt, but now he had learnt his lesson and would always wear it from now on.
I thought I had seen the last of Darren, but that was not to be.
Two months later, Darren appeared in the newspaper again. He had been pulled over and given a fine by a police officer for not wearing his seatbelt. He was on his way to milk his cows, on the very same stretch of road where he’d had the accident.
Don’t believe all you read
I sometimes wonder if the shocking picture of Darren’s face on the front page of the newspaper saved any lives. Even if it didn’t, it was a nice gesture. Unfortunately, from my experience, newspapers are rarely nice to hospitals, or the people that work in them. I can only assume that papers print what people want to read, which is something shocking, something to really make people get emotional about. It doesn’t seem to necessarily matter what emotion that is, but anger and shock always seem to draw people in.
I remember very clearly one story where the newspaper got it utterly wrong. It wasn’t a big fat lie, just a slight error in reporting all the facts. But it only takes a slight error, or a failure to present all the information, to make a big impact.
One of the most challenging aspects of emergency medicine is triage. Triage simply means deciding what needs to be seen first. The most life threatening will get seen immediately, while the less urgent will have to wait. It may sound simple, but it’s not. A typical example of where it gets difficult is someone presenting with a simple fever. By itself, this is pretty harmless, but what if it’s the early stages of a serious illness; an illness that can kill in a matter of hours?
When Mr and Mrs Goodwin presented to the front desk, I was the one doing the triaging. Cradled in Mrs Goodwin’s arms was a young boy, naked, except for a nappy, and covered in a blanket. He looked about 18 months old. As soon as I saw the baby, alarm bells immediately began to ring.
‘He was okay this morning. He only became really sick at dinnertime. I’ve never seen him like this.’
As Mrs Goodwin gave a history, I began checking the baby’s temperature, respiration rate, and body for signs of a rash. He had a high fever, but what was more worrying was how quiet the child was.
‘Has he h
ad a cough, blocked nose or any other symptoms?’ Both parents said that their son had previously been well.
‘He was a bit off colour this morning, off his food, a bit flushed. I just thought it was a normal virus, but he’s so hot, and so quiet. He was fine yesterday, running around playing happily,’ explained Mrs Goodwin.
It’s not unusual to have unexplained fever in children. It’s easy to blame it on some passing virus. But when you can’t find the cause, you can’t rule out something more serious. Even if you can find a probable cause, like a common cold, you still can’t rule out something more dangerous.
From my brief encounters with children in hospital, I had learnt that, even when sick, they are often still full of energy. It’s when they stop playing, stop even crying, that you know you need to worry. This is because they may have reached a critical stage of their illness. I spent only five minutes examining the Goodwins’ child, before taking him straight through to the emergency room to see the doctor.
Dr Munroe was the junior doctor working that day, and when I explained my concerns, he saw the child straight away. After a quick examination, blood and urine samples were taken and an intravenous line inserted.
The urine test took two minutes, and came back clear; but the initial blood test, which came back shortly after, indicated an infection. The problem was, no one knew what sort of infection. It was at this stage that Dr Munroe sought the advice of his senior, Dr Jackson.
The fear we all had was that the child might have meningitis. This infamous disease can present as a simple viral illness, but then kill within 24 hours. The only way to confirm the infection is to insert a needle between the vertebrae and take a sample of the spinal fluid. This takes time. The decision that needed to be made was whether to commence the child on antibiotics straight away.
Dr Jackson had dealt with many cases like this, and he took the prudent course of action, and commenced intravenous antibiotics immediately. He explained to the family that their child would still need a spinal tap, or lumbar puncture, at some stage, but that this wasn’t so urgent now that treatment was started.
‘Why does he still need a spinal tap, if you’re treating him for meningitis anyway?’ Mrs Goodwin asked. She understandably wasn’t keen on her child having the procedure. It’s unpleasant, particularly for a child, as you have to have several staff members holding the child still while the doctor inserts the needle. The child screams, and tries to wriggle free, but you just have to hold them firm, and not let them move.
‘We have to know for sure what is making your child so sick,’ explained Dr Jackson. ‘We’re treating him for the worst case scenario, but we don’t know for sure. We can’t base our treatment on assumptions. We don’t want to miss anything else.’ Dr Jackson also explained that if it was bacterial meningitis, the rest of the family would need a course of antibiotics as well.
‘I don’t want to be there when they do it.’ Mrs Goodwin turned to her husband. ‘You’ll have to be there for me. I won’t be able to bear it.’ Mr Goodwin held his wife for a moment, before turning to Dr Jackson.
Fortunately the spinal tap was going to be done in the children’s ward. Less fortunately, there were no beds free at that time. Mr and Mrs Goodwin had a three-hour wait in the emergency room before a bed became available and they were transferred to the care of a specialist paediatric doctor.
Once in the children’s ward, a spinal tap confirmed the diagnosis of bacterial meningitis. We’d done the right thing by starting treatment straight away. We’d saved another life.
It was several days after my dealings with the Goodwin family that I saw them again. They were on the front page of the local newspaper. It reported that a young child with meningitis had to wait three hours to see a doctor. Sure, there had been a wait to see a specialist doctor, and be admitted to the ward. But there was no mention made of me or the two doctors who initially treated their child.
I can only guess that the parents wanted something more from the hospital, but what more did they want than us saving their child’s life?
I no longer believe any medical story I read in the newspaper, no matter how realistic it may seem, as I’ve seen them get it very wrong on several occasions. It’s frustrating that the hospital often doesn’t respond, as they can’t break patient confidentiality. It seems a double standard to me – the patient or family are often only too happy for the world to hear of their time in hospital, so why can’t we return the favour? I wonder if that would cut the number of complaints.
Unfortunately, nurses and doctors can’t afford to make mistakes as we’re meant to be immaculate, but in reality we’re simply human. With the numbers of people coming to emergency rooms increasing, along with the variety of treatments on offer, statistically, there will be errors.
Confidential dilemmas
Most people will have heard of the Hippocratic Oath at some time or another. Issues of ethics and medicine are pretty tightly bound together, wherever you are. I have encountered similar moral dilemmas in both New Zealand and the UK, particularly when it comes down to the right to confidentiality. Sometimes it can be rather riling that medical staff cannot discuss patients, but they are free to discuss us. But then again, everyone needs to have someone they can turn to in complete privacy, when they may have no one else, and I’m happy to be able to be that person.
Things are rarely black and white, take these occasions for example:
1. I remember one woman who had tripped over some steps as she left the pub, and needed sutures for a cut on her face. She had driven herself, drunk, to the emergency room. Once she’d been treated, I offered to ring for a taxi to take her home. She refused. I even offered for the hospital to pay for the transport. She refused. Instead, she got into her car, still drunk. My colleagues claim that technically I broke the law when I phoned the police. Thankfully, the woman didn’t make it out of the hospital driveway because she crashed into the barrier at the hospital entrance. She wasn’t hurt, though I was more worried about others she may have hurt. She was arrested.
2. Another time, a 15-year-old girl came in following an accidental drug overdose. She was about one month pregnant and had tried to abort the foetus using a combination of emergency contraceptive tablets, ibuprofen and alcohol. She had not gone to a medical professional because she feared they’d tell her parents. The law in New Zealand states we cannot divulge sexual health to parents without the child’s consent. As much as I think it’s generally a good idea to involve a minor’s parents, and might encourage it, there are exceptions, and I’m grateful for this rule: often kids need someone and somewhere safe they can turn to – especially if this prevents them from taking matters into their own hands.
3. Probably the most unusual instance occurred at my local pub, when I lived in New Zealand. I was out with some friends when a very attractive woman approached us, and offered to buy me a drink. It took me a moment to recognise her. The last time I’d seen her she looked pretty terrible. I politely refused. My friends then wanted me to introduce them to her.
The woman in question had been a psychiatric patient in my care. She was a very unstable schizophrenic and spent the majority of her life in and out of the psychiatric unit. This was a real tough one for me. I strongly believed in her right to be treated like a normal person, and in this respect, I should have let my friends chat her up. But at the same time, she was a genuinely troubled soul and I couldn’t let a friend walk blind into a complicated situation. In some of her lucid moments, I’d heard her refer to her psychiatric medications as rape drugs. Ultimately, I refused, and my friends were pissed. But I left the pub and my friends followed me, none of them any the wiser.
The perfect match
Nursing boards in both New Zealand and the UK insist that we spend so many hours each year updating our skills. This generally includes things like basic CPR and correct lifting practice, as well as anything else that a nurse is particularly interested in. These hours can be fulfilled on an individual basi
s, or sometimes hospitals put on special conferences where guest speakers come to speak to the assembled nurses.
I hate to say it, but as a rule these mass education sessions can be a bit boring, particularly when you’re learning about things you already know. But for me there is one major exception, which is when we’re discussing ethical issues like confidentiality. As challenging and complex as these sorts of issues can be to deal with in real life, in the classroom, I enjoy them. I’ve always enjoyed a good debate – although my wife would say ‘argument’.
On one particular occasion, as part of our ongoing education, I was one of about a hundred nurses receiving a lecture on patient care ethics. The union rep caused quite a stir. She said that ‘Nurses should be discouraged from marrying their patients.’ There was a loud murmur of disapproval around the room, which surprised me. I didn’t think this was such a big deal. In fact, I assumed that most nurses would realise this, but I guessed from comments I overheard – which ranged from ‘That’s bullshit’ to ‘Who the fuck do they think they are?’ – that more of my colleagues than I’d imagined had married people they’d looked after.
The speaker also seemed surprised by the hum of displeasure, and although she didn’t back-pedal, she did become slightly more conciliatory: ‘Well, of course, we can’t stop you, and, of course, nothing would happen regarding your registration, but we do recommend that you do not enter into relationships with your patients.’
The rep then asked for a show of hands of nurses who had married patients. I got quite a surprise when I saw that nearly a third of nurses put up their hands.
To be honest, I think this is fine. Hell, most male patients, of all ages, flirt with the nurses. So I’ve seen many of them make the first tentative moves.
On the other hand, things are a little different when the nurse is a male. Friendly as I endeavour to be, I would not want to be seen to be genuinely flirting with a patient. Nor have I often experienced female patients making the first moves on me.
Confessions of a Male Nurse Page 17
