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Triage 

by Kimberly Goodman

Disclaimer: All patient stories are purely fictional, if there are any similarities, it is purely coincidental. 

Why does Starbucks always run out of those crunchy caramel topping thingies around the holidays, when they know everyone wants them in their coffee? Ugh…I’m so mad. They were out yesterday and now they are out today. Oh well, I guess I will have to survive this long 12 hour shift without them…I hope I can. Its sad when one of the things you really look forward to before a long work day is your caramel crunchy sprinkle thingies. What exactly are they called anyway? They always seem to know what I’m talking about when I ask for them. 

I pull into the parking garage and find a spot right away! This is going to be a great day, I can tell already. The only thing that worries me is that tonight is a full moon, one of those super moons or blood moons or something like that. There’s only one thing a full moon means in the ER…it’s gonna be a long day. I get out of my car and grab my no-sprinkle coffee and a ladybug lands right on the top of my cup. WOW! I love ladybugs and they tend to fly on me in times of trouble or stress. Weird, I think…it’s 6 am, dark, and here’s a random ladybug. I love them so much I tattooed a few of them on my left ankle. The first time I started really liking these fragile little insects was my very first day of nursing school. We were all in a huge auditorium and the instructors were going over what to expect, I was feeling pretty overwhelmed and wondering if I could really do this, could I really finish Nursing school with a 3 year old?? Just then a cute little dark red lady bug flew right onto my paper, indoors, in the middle of the lecture. I smiled and knew that it was all going to be okay.

I’m waiting to get report from the charge nurse, half asleep, dreaming of my non-existent caramel crunchies when in comes this “gung-ho” brand new nurse. He’s smiling and talking to everyone and super excited about his first day in the ER. Us old nurses are all just staring at him with the “sit down and shut up” expression. Ah, to be a young, excited, new nurse again. No thank you—been there, done that, bought the t-shirt. So, my assignment is triage today, awesome. Triage is the front window, the entrance to the ER. You decide who gets back first and how sick someone is by just looking and listening to them. Only seasoned nurses do triage because it requires superb critical thinking skills. 

I walk up into the “fishbowl” and see Tony, the game warden that does overtime in our ER. We call it the fish bowl because we are surrounded by glass in the round shape of a bowl with controlled entry doors. Not sure what I would do without Tony, he has literally saved me more times then I can remember. We still joke about the Thanksgiving morning I got punched in the face by a drunk guy. Man, I’ve never seen Tony take someone down so fast. We joke about it because I looked like a unicorn with a big knot in the middle of my forehead. People see the words “Police” on Tony’s hat and jacket and tend to simmer down when he stands up. “What up, dawg” I say, sleepily. “Hey girl, how you doing today?” Tony is from New York so he has this really cute accent that all of us girls like, not too bad to look at either. “I’m good, but why do they always run out of those caramel crunchy topping sprinkle thingies around the holidays? Why don’t they order extra if they know they are going to run out? They run out all the time and I just don’t understand it. Part of the reason I get this drink is because I love the crunchy caramel sprinkles…Ugh….Just frustrating”. Tony is laughing at me and says, “Girl if that is your one big problem today, thank your lucky stars”. He’s right. I’m sure I will probably end up having much bigger problems then no sprinkles. And in walks my first customer…

“Yeah, um, how long is the wait?” He looks to be in his early 20’s, about 6 gold chains around his neck, pants barely hanging on with a huge belt. He’s sporting a wide-rimmed hat with a marijuana leaf on it. I say, in my most pleasant customer service voice, “What brings you to the ER today sir?”, ignoring the question that was asked of me. “How long am I gonna have to wait to be seen?” “We aren’t too busy right now, what’s going on?” “I’m here for a STD check”.  Of course you are. “Okay, fill out Part A on the top and I’ll be right with you”. Tony rolls his eyes, I do too, but only inside my head. After all, we are measured by our customer service scores so every patient is treated with kindness and respect, no matter what. He brings back the clipboard, I put him in the system…14 visits in the last 3 months, of course. Isn’t it crazy how we tend to make our own assumptions by what someone is wearing, how they look, how they speak, how many visits they’ve had in the ER. I really think it is human nature though, we all do it. You know you do. If you say you don’t, you’re not being honest with yourself. Sometimes we rely on this judgement and it tends to prove itself correct, sometimes it doesn’t, but we still do it. I find that I am an excellent judge of character because I have to rely on my judgement every day. I don’t judge this young man in a bad way, it just is what it is. I call one of the nurses up to come get Mr. Chains and he goes back. 

Next we have a man running in to ask for a wheelchair. I grab one and follow him out to his car, where his pregnant wife looks panicked and is breathing heavily. “Hi, ma’am, first baby?” I already know the answer…”Yes, please hurry" she pants. The man looks pale and completely freaked out. “Has your water broken?” “NO!” “How far apart are your contractions?” The man says, “about 10 minutes”. This baby ain’t coming any time soon, but of course there’s no telling them that. To them, they are scared to death and the baby could just pop out any minute. I get her to the window and call for a tech to take her upstairs. I call the L&D charge nurse who answers the phone, “YES??” See, the ER and L&D have a love/hate relationship. We try to send them every single patient that has a child inside of them, regardless of any other symptoms, and in turn they send us pregnant patients that have complaints that have nothing to do with the baby. It’s almost like a competition of where the patient will go, weird, not sure where this started, or how, but it’s been this way since I was a baby nurse. We don’t like birthin no babies down here in the ER, that’s for sure.  “Good morning” I say in my most cheerful voice, “This is Cam from the ER and I’m sending you a 38 week-er, water intact, contractions 10 minutes apart, no bleeding, 1st baby, any questions?” “Nope, send her up” she says and hangs up the phone. Tony glances up from his newspaper and says, “Were they happy you called?” and snickers. “Ha, ha” I sneer.

I turn on some music, which is the cool thing about working triage. We can actually put on Pandora and listen to some music in between patients. I’m glad Tony is working because we are both obsessed with 80’s music. Do you ever hear a song come on and it immediately takes you to period of time in your life? First song on deck is “Dreams” by Fleetwood Mac, which is ironically my favorite song. My mom played the Rumors album over and over and over when we were little. Me and my sisters had every single song memorized. She cleaned to it, cooked to it, I knew every song by heart. And now my kids do too, which makes me proud. Tony puts the paper down, and says, “Don’t look now but your friend is coming in…” He’s talking about Henry. We all know Henry. Henry is our “resident drunk, homeless guy”. Every ER has one. Henry stumbles up to the window with only one shoe on, smelling like a mixture of stale alcohol and gym socks that have been in my son’s backpack for 4 days. “Hey Henry, where’s your other shoe?” I ask, loudly. Henry is hard of hearing, diabetic, has congestive heart failure, liver failure, smokes, and is an alcoholic. Of course he doesn’t take care of himself and is usually pretty sick when he comes in. We all wonder how he is still alive. “I got in a fight last night and took it off and threw it at the guy," he stammers. Tony says, “Didya hit ‘em?” Henry says, “I sure as hell did," and starts laughing, which turns into a wheezing, coughing fit. I get a wheelchair and ask “Well, what can we do for you today, Henry?” “I need something to eat, I am feeling dizzy and sick”. Knowing Henry his blood sugar is probably 43 and liver enzymes are up. “Okay, let’s get you back”. I put him in the computer without asking him for a thing, surprisingly I even have his date of birth and allergies memorized. One of the nurses comes up and says, “Hey, Henry, it’s been a little while, where’s your other shoe?” and wheels him to the back. 

“Thunder always happens when it’s raining, players only love you when they’re playing” ain’t that the truth, I think to myself. Song ends and the next one comes on, it’s Bruce Springsteen, “I’m on Fire”. This song always makes me think of 10th grade, when I lived in Illinois. Not the fondest of memories, for sure….abusive stepdad, alcoholic mom, struggling to survive as a 15 year old kid. “Hey little girl is your daddy home, did he go and leave you all alone?” I couldn’t take it anymore. I ran away from home at 15 years old, in the middle of the night with nothing but the clothes on my back. Kissed my three little sisters goodbye and hoped to God they would be okay. I felt like a failure for leaving them, but I had to get out. Only so much abuse one could take as a kid. Yet here I am, a home-owner, nice car, three degrees that I funded all by myself, successful career, and two kiddos I raised by myself, that are amazing-- I made it. And everything ended up being okay in the end. “Ma’am, excuse me, ma’am” I look up and see a man with his hand wrapped up in a towel. “What happened?”, I ask. “I was working on my car and the hood smashed my hand”. “I need to look at it and see how bad it is, okay? The man closes his eyes and holds out his hand. I slowly unwrap it and realize that yes, he will need a few stitches, but the bleeding is controlled and he will live. “Looks like you will  need a few stitches, but you will be okay, let me get your name and date of birth.” 

Tony gets up and says he is going to check and make sure Henry isn’t giving anyone a hard time.  I hear EMS encoding in the back “We have a 23 year old female patient with a GCS of 3, possible OD, Narcan given in the field. Patient is intubated BP 80/42, HR 154, RR 12, will see you in 5” Another overdose, third one this week. I wish these young people who decide to try to kill themselves could understand that they have their whole life ahead of them and it really does get better, I promise. You just have to keep climbing that mountain, through the storm. “When your day is long, and the night, the night is yours alone. When you’re sure you’ve had enough of this life, well hang on…don’t let yourself go ‘cause everybody cries, and everybody hurts sometimes….How fitting for today. I wonder if REM knew what a big hit this would be and how many people could relate to the lyrics. Why couldn’t she understand that everybody hurts and it WILL get better? Why?

In walks a timid looking young girl with an older lady behind her. She is carrying a blanket and tells me she just had a baby but its sick and pushes the blanket towards me, like “no big deal”.  I take the blanket, look in it, and it’s a full term baby that is blue and not breathing. I radio back to my charge nurse and tell him I’m running a baby up to crash that’s not breathing and ask him to get a doc now. Tony walks back up front, sees me running with the blanket and walks the mom and grandma up to the crash room behind me. The doc rushes up and we start to code the baby. We ask the mom what happened and she calmly states she gave birth a few hours ago and didn’t know what to do so she held the baby and decided to bring it in. We all realize that this baby has been dead for a while but we still work as hard as we possibly can to get this baby back. There’s a nurse on either side of the baby starting IV’s and pumping drugs, the doc is intubating and one of the preceptors tells the brand new nurse to start compressions. “Come on, come on little one” the doc states. The crash room is like a dance. Everyone knows their place and their routine. It’s a perfectly orchestrated dance. No one is out of place and everyone knows exactly what they are supposed to do. Charge starts to record every move on the code sheet and hollers to the clerk to page the chaplain. X-ray walks in, we move aside quickly as they put the board behind the baby, they shout  “X-ray” and shoot the film. We all jump right back in place and keep going. The mom is staring at the baby, motionless, lifeless, speechless. I look over and notice she has bruises on both arms and a scratch above her left eye and I wonder what happened...why did she wait so long to bring the baby in? The grandmother starts to sob. The chaplain arrives and takes them to the family room right as the doctor asks if anyone has any other suggestions before he calls it ...everyone silently shakes their heads and he says, “Time of death 1438”. I slowly walk back to my post, back to triage, so I can take care of the next patient. Tony calls APD to come in since it is a suspicious death.  No one ever has a good day when we have an infant or child die. We all become pretty gloomy after that but know we have a job to do and have to keep smiling for the next patient that needs us. I pass by Henry’s room on my way back to the front. He is sitting up in bed with 2 drips going into each arm, eating a turkey sandwich, watching Ellen. I guess he will spend a few days in the hospital again and get his blood sugars regulated and a few breathing treatments, as usual.  At least he is off the streets for a few nights. Our angel of a social worker has found him a pair of sneakers and he shouts to me “Hey, look at my new shoes!” with a huge smile on his face. The tech has come into the room to give him a shave and he seems to be on top of the world. “Wow!I see, Henry!  Try not to lose one this time!” I get back up front and Tony is sitting at the window gazing outside. “You okay, hun?” “Sure” I lie, as I slump down in my chair. “That sucked, I wonder what happened to that baby?” “I’m sure the police will find out, Cam, y’all did everything you could” “yep, and it wasn’t enough”. I sigh. 

“We need security to Bed 8 STAT, Security to Bed 8” blares over the loudspeaker. Tony jumps up and runs to the back while I help the next patient at the window. “How can I help you, ma’am?” I say, reminding myself to smile. “I am still waiting to get my stitches out!!” My GOD how long does it take you people to take out some damn stitches?? How come they took that other old lady back before me? Is it because of the color of my skin? It is isn’t it? “No, ma’am, we take people back in order of acuity” “What the hell does that mean?” We take the sickest people back first ma’am” “Oh, so I’m not important??” “Yes ma’am you are very important, we will get you back as soon as I have an open room” This is one of those moments where you wish you could explain why she didn’t get back right away…..that there is a 23 year old dying in Crash 1, who probably succeeded on her suicide attempt, the other “old lady” we took back before her is septic and getting a breathing treatment, not to mention the dead baby….and you’re yelling at me, calling me a racist because we haven’t had a chance to take out the 3 stitches in your thumb? OMG lady!! But, none of this can happen. “I can feel it coming in the air tonight, oh Lord. Well, I’ve been waiting for this moment for all my life, oh Lord…Yep, Phil, I can definitely feel it coming in the air tonight. And it’s exhausting. 3 more hours. Never say or think “what else could possibly happen” because, trust me, things could always be worse. You just have to hope the rest of the shift is decent. I radio back for the tech to come watch the window while I pee.  I walk to the break room and the new “gung-ho” nurse is sitting on the couch in tears with his preceptor rubbing his back telling him that you will eventually “start getting used to it”. Is this really true, I think to myself? I’ve been a nurse for 18 years and I’m still not “used to it”. I mean I’ve learned how to hold back the tears until I open the door to my car, and how to deal with death, but I wouldn’t say,  “I’m used to it”. I walk back up front,  I pass Crash 1 and hear the internal medicine doc consulting with the ER doc to put her on life support. UGH! You’re kidding me. Why? Over what? Was it a boy this time? What could be that bad that you want to die? I look on the counter and see her ripped jeans, Def Leppard t-shirt, and her dirty, white, Converse sneakers on the floor. I think of my own daughter and hope to God she would never think life is too tough to go on. I walk back to the window and grab my phone and search for “Brooklyn," my baby girl, and type three words….”I love you” and put my phone down. I hear the automatic doors open and look up. The parents have arrived. I know exactly who they are before I even ask. They are the parents of the 23 year old. The mom is frantic and has black mascara dripping down both cheeks, the dad is ashen white. They come up to me, I slide the window open, and ask, “Can I help you?” already knowing why they are here. I radio for the chaplain to come up and take them to the family room so the doc can talk with them. I say a little prayer for them.  I say a little prayer for the girl. I say a little prayer to let me get through the rest of this shift without anyone else dying. Before I could say Amen, a man rushes in and needs a wheelchair, I grab one and follow him to his truck. I open the door and there is an elderly man that is holding his chest and moaning. He looks very pale and sick. His son states he is having chest pain and says they were playing golf and he collapsed. I tell the charge nurse I’m bringing back a chest pain and radio for a doc and an EKG stat, possible MI (which means Myocardial Infarction, which means heart attack). I get him in bed and attach the leads and start putting him on Oxygen. The crash nurse and a few others take over and I walk back to the window, passing “the parents” who are sobbing in bed by their daughter. I get back to my triage throne and sigh. A big long sigh. I look down at my phone and notice Brookie texted back, “luvvvvv you too”  I smile, so proud that she used the right form of “too”. I have another text from my son, it says, “What's for dinner?” I silently thank God for both of them and stare out the window. Tony walks up and tells me that Henry just went upstairs to his room and that my Crash 3 patient was having a massive heart attack and is now in the cath lab having surgery.  That’s what keeps people like us going. The good stories….The good outcomes. The man ended up getting two stents in his left coronary artery and is going to be okay. Henry looks like a whole different person after a turkey sandwich, shave, and a bath. I open the window to get some fresh air coming in from the automatic doors, and the next song starts to play….it’s Annie….Whhhhhhyyyy? Whhhhyyyyyyyy?  I may be mad, I may be blind, I may be viciously unkind, But I can still read what you’re thinking….Why can’t you see this boat is sinking, this boat is sinking, this boat is sinking…..I don't know, Annie, Why?  I guess because life is life. It has its ups and downs. Some people die, some don’t. It is what it is.  We all just have to keep on going and realize how very precious it is…and how fast it can change. Sometimes I feel like my boat is sinking, too. But I know it will get better. It always does. And it can always be worse. Tony says, “Man I hate this song…too sad, change it!”   I reach down to change it and Don is belting out “In a New York Minute, everything can change, In a New York minute things can get pretty strange” Me and Tony look at each other and smile. “That’s our theme song today, hun” and pats me on the back. The night nurse walks up and I turn the watch over to her for the night and wish her good luck. She looks at me and rolls her eyes and says “Did you know it’s a full moon?” Me and Tony laugh. Boy, do we. May the force be with you! I grab my half drunk, no-sprinkle coffee and walk out. Tony shouts, “Same time, same place?” and I say, “but, of course!” Maybe tomorrow there will be a fresh supply of caramel sprinkle, crunchy thingies…

PO Box 1162 | Buda, TX 78610

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