Can’t Breathe Through the Foley

At five-thirty in the morning, any laughter you might hear in the Emergency Department is the laughter of the damned: damned by in-and-out sheets that refuse to add up, damned by orders signed off but not actually done, damned by having to herd exhausted physicians to needy patients, and damned by lack of sleep and general befuddlement and lack of coffee. Five-thirty in the morning is crap. Five-thirty in the morning is not the best time to get critically ill patients in the emerg.

Of course, the nature of the beast is that critically ill patients frequently and alarmingly roll in at the hour we’re least able to take care of them, psychologically at least. But I was in the resus room the other night, working with Brad, who is cool, friendly and fazed by nothing at all, actually having for once a happy-smiley night, a couple of nothing chest pains and a CHFer who got bipaped, foley’d and Lasix’d and up to the ICU before we could even finish the MARs.

Life in the emergency department, I fear, is all about the fulfillment of karma. Cause and effect, the accumulation of past deeds and actions resulting in present consequences, operating in the micro and macro-levels of existence: do you need to tell you what happened next?

At 0517 EMS brought us a violently sick, obtunded, Kussmaul-respiring, ketones-emitting 24 year-old non-compliant insulin dependent diabetic in DKA, who also happened to have a seizure disorder.

Kids, don’t try this at home. It’s very bad joss, and will really, really fuck you up.

How sick? Glad you asked. For you health care types, her pH was 6.97. For the rest of you, that’s a number not compatible with life.

And since the patient hadn’t taken her carbamazepine in nine months, continuous seizures started almost immediately.

Secretly, this is what we live for. Remember: airway, breathing, circulation. Always ABCs. Life and death with a nasty twist. Bring it on! Roll out the adrenalin, pump it out, baby, we’re goin’ in.

But not at 0530.

So after three IVs, fluid boluses, two blood draws, an ECGs, a central line, an arterial line, and insulin drip, status epilepticus, intubation, sedation, a dose of Dilantin, it was 0647. It was nearly shift change. But we were missing something — and my eye caught sight of the foley catheter set-up on the bedside table.

“We need to put in the foley,” I said to Brad. He was sorting out the multiple IV lines, labelling them to make sure we didn’t, say, push lorazepam in the insulin drip line. He shrugged. He looked — worn out.

“Screw it,” he said. “They can do it on Days. I’d like to get out of here sometime before sunset.” I glanced over to the Resus desk, saw our replacements for Days, and my heart quailed, just a little.

I need to explain there are two types of Emergency nurses. The first kind view Emergency nursing as a continuous and continuing process: what isn’t completed during one shift can be picked up by the next, because in the Emergency Department, sometimes it isn’t humanly possible to finish everything before shift change. The second type of ED nurse may publicly endorse the first, but believe deeply and firmly that all patients must be presented to the oncoming shift all fluffed and buffed and tidied, with a ribbon on top. If they aren’t, well, let the snark begin.

Unfortunately,  our replacements were Beth and Judy. Beth is a superb nurse, but she’s irritable and has little patience for foolishness. Certainly she is far more knowledgeable and cleverer than me; but also, she’s clearly in the second camp. Her partner, Judy, is also a good nurse, but tends to get a little flustered, especially when asked to do too many things at once.

Beth doesn’t like Judy, much.

Beth thinks Judy is an incompetent boob.

So Beth was already pissed off when I started report, Brad sitting beside me, head in hands.

“EF,” I said, ” 24 year old female brought in by EMS obtunded, smelling strongly of ketones, history of insulin dependent diabetes and seizure disorder. . .” and so on, detailing every diagnostic, treatment and intervention, the seizures, the status epilepticus, the intubution —

“You got a foley?” Beth interrupted. Brad’s head had sunk to the desk. I was quite sure he was sleeping.

Uh, no. We were going to but. . .

“I can’t believe you didn’t put in a foley. . .” Beth shook her head. Clearly she was disappointed, whether in us, personally, or in the nursing profession or the declining standards of the world at large, I don’t know. She made her discontent plain by her expression and a baleful sigh summarizing her indignation.

And so on. I continued with report, punctuated every 30 seconds by the repeating complaint  — “I can’t believe you didn’t put in the foley.”

And then a deep, annoyed rumble from Brad, head down, assumed to be in the attitude of sleep:

“ABC before pee pee pee, so can you please shut up about the fucking catheter, Beth?”

Brad told me later Beth’s face was a picture. But I was too busy jamming my fist in my mouth to keep from laughing hysterically to notice.

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  1. #1 by JennJilks on Wednesday 07 April 2010 - 1214

    You are brilliant! There has to be a book in this. Keep on posting. And I bow in honour for you in your profession.

    My favourite Nurse Practitioner, in our Family Health Team, told me she was a nurse, then elementary teacher, then loved nursing so much she went back to it! All of you can do so much good, if you keep your sense of humour.

    You, personally, TERN, know how to laugh when fatigued, pissed off, slapped silly by the powersthatbe or those who think they know more than you do.

    BTW
    Thank you for the hyperlinks to the acronyms, et al!

  2. #2 by DreamingTree on Wednesday 07 April 2010 - 1509

    Oh, I would have LOVED to have witnessed that! Brad is too cool for words!!

  3. #3 by D on Wednesday 07 April 2010 - 2141

    Best. Comment. EVER. I would have loved to see this as well!

  4. #4 by Maha on Thursday 08 April 2010 - 2101

    Brad is my hero! I just came off a string of horrible nights and I got atrociously chewed out for not putting in an effin Foley in a guy who was pretty much able to keep track of his own urine output. Never mind EVERYTHING was done. I’m stealing that line and probably adding a few more profanities to it.

  5. #5 by L on Thursday 08 April 2010 - 2137

    This is just what I needed to hear today. People are always going to find a reason to criticize. You delivered a living, breathing human from a wreck of a patient (pH of 6.97 ?!?!?!) but no matter what, it was never going to be good enough. Even if you had put the foley in, you would have got, “why isn’t it empty” or something else just as boneheaded. And I love the line – totally stealing it !

  6. #6 by Warm Southern Breeze on Saturday 17 April 2010 - 2330

    “ABC before pee pee pee, so can you please shut up about the fucking catheter, Beth?”

    What a freakin’ hoot!

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