Saturday, December 9, 2017

Stream Of Subconciousness



welcome to Hell I'll be your tour guide I love the sound of a waiting room full of screaming babies at the beginning of the shift because at least you know it has to get better everything's done on all your patients but the entire hospital's full so let me make sure everything's really all done oh look, a few details missing hey we're just waiting for beds and waiting for beds and waiting for beds and I don't know how long it's going to take another call light ma'am the alarm goes off because you keep bending your arm and playing with the pulse ox why haven't I sent my patients up maybe because you gave us bed assignments that still have the old patients in them oh hey they moved all their patients out now so all your beds are ready simultaneously but you'll have to transport them all yourself because we have no tech and there's no transport are you ready for report see you in five minutes are you ready for report see you in ten minutes are you ready for report see you in twenty minutes are you ready for report see you in about half an hour tell triage all my beds are empty clean and ready for the next batch ready for your lunch break see ya so we loaded up all your beds but one full arrest found down doing cpr eta five minutes out they're here PEA stop compressions vfib CLEAR we've got a pulse vfib CLEAR PEA resume compressions pulse check vfib CLEAR we've got a pulse get me an ekg right away doc vfib f**K! CLEAR we've got a pulse vfib CLEAR PEA resume compression pulse check we've got a pulse here's the EKG if that pulse holds we can get them to cath lab vfib F**K! CLEAR pulse is holding cath lab is here yes sir you can go with her there's a waiting area the surgeon will come find you right afterwards ICU is still full so cath lab is bringing the patient back here after they're done surprise the cardiac stuff wasn't the reason at all but your patient isn't going to make it and there's nothing else we can do great I'll just tell dad to explain to the four young kids that mommy's never coming home again with only two weeks from Christmas that should really cheer them all up but the chaplain's here Holy Father, we ask you to please ICU is sending a nurse to monitor your patient until something opens up in the unit, so you can just take care of the other patients you have while the twelve family members are sobbing their hearts out across the hall from the crazy patient we just gave you who decided he's fine and wants to elope because he's crazy whatever and hey look the docs ordered food for everyone and thank god it's two hours until day shift and the waiting room is finally empty and now I only have twelve patients in that room and the one the ICU nurse is taking care of is the only one in there with nothing to worry about if I hear one more heart-wrenching sob I'm going to completely lose it myself and then I'm no good to anyone and why isn't it shift change yet my knees were over tonight five hours ago free at last free at last and how come the shittiest nights ever in recorded history are always the first of three in a row instead of the last one, every single time, forever and Dear God, WHY? WHY? Just WHY...? hug your kids and WTH? how am I ever going to see to drive home when it's so damned dusty inside my eyeballs

So, how was your night?


Some days, I actually get home with enough energy to go do a couple of miles of jogging, have a nice shower, and go to bed.
Other nights, I get home with enough energy for a short bike ride, then have a shower, and go to bed.
And then, thank a merciful heaven not too damned often, are days like today: when I'm putting on the gloves, and beating on the heavy bag until my arms are too numb to hold up, and my soul stops hurting, so I can stumble to sleep from exhaustion, and hope I don't wake up until it's time to get up again for the next shift.



Monday, November 20, 2017

Level I Drama Center




There are precious few things you can control as a nurse.
As a nurse in the E.D., that number dwindles even more.

because whatever comes in the front door, or gets delivered on a platter at the ambulance bay, you're getting. 
An entire basketball team of DKA patients, all with blood sugars of over 900, and the highest at 1300.
Back to back to back to back STEMIs, all going to cath lab.

Train wreck stroke, who gets an ICU bed, followed by another train wreck stroke.
Four hot appys in a row, the night the whiniest surgeon/OR charge nurse is on call.
Ten psych patients, half before lunch, whom you get placed, followed by five more.

Tag, you're it!

And, truth be told, that can actually be the fun part, when you dig in and get it done, because you get an oak leaf cluster on your Badass Recertification Ribbon.

But there are things you can control.
Write them on your hand in sharpie in case you forget.

1) Don't make your workplace a Level I Drama Center.
I'm working travel and registry, and I promise you, I'm all out of f***ks to give about whatever bitchy little internal squabbles you want to unpack and play with in the middle of a code, or a biblical level of ambulance bay shitstorm.
Do that to me in the middle of a code, and I will wait for you to go into the med room, I will bring a #11 scalpel, and I will cut your carotids, and leave your carcass there for the next luckless sumbitch to find and deal with, I swear to you.
Do it because you have nothing better to do on an average busy night and I'll tie every monitor cable in all your rooms into square knots, I'll triage you every crying puking kid with a fever, and I'll pay the lab tech to tell you all your blood draws were hemolyzed and need to be re-drawn. Better than 50/50 odds they don't like you either, and will do it for free. Ask me how I know.

2) When a co-worker is drowning, you throw lifelines, not boat anchors
I'm not talking about the one who's never around when you need help; letting them drown is karma in action. But FFS, when you're caught up, and you see someone else getting beat down, pitch the f*** in. And when somebody does it for you, you say "Thank you", and you owe them a solid, which you pay back the next time it's their turn getting fed into the Giant Woodchipper of Karma, feet-first.
Sometimes just doing one thing for them can take the last straw off the camel's breaking back, and turn their night around. I've been on both ends of that deal, and it's really a thing.
If you don't have that work ethic, you should die of crotch cancer.
Slowly.

3) There's no "Fuck you" in "Team".
If I have to remind you of this, you've already fucked up, and you're not on the team.
I am middle-aged, devious, under-handed, and I have a memory like an elephant, and I will pay you back, with interest, when you've forgotten why you're getting the 30-foot-long party sub sh*t sandwich.
And then I'll make sure you get seconds.

I generally enjoy my job, I appreciate everyone I work with from janitors to surgical chiefs, and I tell them when they're getting it right. It costs me nothing.

But I have passed the point in life where I care if your feelings are hurt because I had to tell you to stop being a wand-waving crap-stirring drama queen, and in fact, if I see it pushes your buttons, I'll make sure to do it in front of God and everybody at the main station, during shift change, and leave you with a big pie-face of fail to wear around as a trophy.

The patients bring enough crap in the door, some of them because their having a serious problem.

If you aren't getting enough drama in your life without bringing yours to work, quit your hospital job and watch soap operas.
As an old master sergeant explained to me way back in the day,
"You play my game, and I'll play yours. You work with me, and I'll work with you. But if you try to screw with me, I'll screw you over twice as hard, and then again, and again, until you cry for your momma. Do not test me on this."

Tuesday, November 14, 2017

These Are My People

h/t Peter @ Bayou Renaissance Man
Vegas shooting ER team
Ironman, Captain America, Superman, and Batman 

From this month's Emergency Physician's Monthly (the trade paper for ER docs):

I’m a night shift doc. My work week is Friday to Monday, 8 p.m. to 6 a.m. Most people don’t want to work those shifts. But that’s when most of the action comes in, so that’s when I work. It was a Sunday night when the EMS telemetry call came in to alert Sunrise Hospital of a mass casualty incident. All hospitals in Las Vegas are notified in a MCI to prepare for incoming patients.
As I listened to the tele, there happened to be a police officer who was there for an unrelated incident. I saw him looking at his radio. I asked him, “Hey. Is this real?” and he said, “Yeah, man.” I ran down to my car and grabbed my police radio. The first thing that I heard when I turned it on to the area command was officers yelling, “Automatic fire…country music concert.” Ten o’clock at night at an open air concert, automatic fire into 10-20 thousand people or more in an open field—that’s a lot of people who could get hurt.
At that point, I put into action a plan that I had thought of beforehand. It might sound odd, but I had thought about these problems well ahead of time because of the way I always approached resuscitations:
  1. Preplan ahead
  2. Ask hard questions
  3. Figure out solutions
  4. Mentally rehearse plans so that when the problem arrives, you don’t have to jump over a mental hurdle since the solution is already worked out
It’s an open secret that Las Vegas is a big target because of its large crowds. For years I had been planning how I would handle a MCI, but I rarely shared it because people might think I was crazy.

It's written by the senior ER doc on duty, and so from his perspective. Taking not one thing from him, but the reality is, while his plan helped, it was a team effort.

For instance, they had 6 ER docs working that night, including a Trauma surgeon and Trauma resident.
We also initiated our hospital’s “code triage,” in which staff from upstairs would come down to help by bringing down gurneys and spare manpower. We took all of our empty ED beds and wheelchairs out into the ambulance bay. Anybody who could push a patient, from environmental services to EKG techs to CNAs, came out to the ambulance bay. I said to the staff, “I’ll call it out. I’ll tell you guys where to go, and you guys bring these people in.”
Unstated were how many RNs on hand, but in a 36-bed main ER, they had 10+, which swelled to probably 20-50.
What were they doing?

 At that point, one of the nurses came running out into the ambulance bay and just yelled, “Menes! You need to get inside! They’re getting behind!” I turned to Deb Bowerman, the RN who had been with me triaging and said, “You saw what I’ve been doing. Put these people in the right places.” She said, “I got it.”
And so I turned triage over to a nurse. The textbook says that triage should be run by the most experienced doctor, but at that point what else could we do?
Better late than never, doc. Nurses run Triage 24/7/365 everywhere. Should've seen that coming and made the call a lot faster.
We were in the hallway of Station 1 with the beds side by side. We were butt to butt intubating these three people. “I need etomidate! I need sux!”
Up until then, the nurses would go over to the Pyxis, put their finger on the scanner, and we would wait. Right then, I realized a flow issue. I needed these medications now. I turned to our ED pharmacist and asked for every vial of etomidate and succinylcholine in the hospital. I told one of the trauma nurses that we need every unit of O negative up here now. The blood bank gave us every unit they had. In order to increase the flow through the resuscitation process, nurses had Etomidate, Succinylcholine, and units of O-negative blood in their pockets or nearby.
Another good call. But "Duh".
By this time, all the patients had bilateral IVs. As the orange tags and yellow tags would become red tags, it became very apparent that those early IVs, put in while patients still had decent veins, were lifesaving. As the patients decompensated, we had adequate access to rapidly transfuse and stabilize patients. If we didn’t have that early IV access, we would have spent valuable time trying to cannulate flat veins.
Putting in IVs: nursing skill. Twenty-forty/night. That's why all those patients magically had bilateral IVs.
Cannulating flat veins: what ER docs do when patients don't have anything better.
So again, "Duh."
Throughout the night, I would look up from what I was doing and scan the room to see if anyone was crumping. I noticed a choke point forming for CT. We were now left with stable yellow tags. These patients needed CAT Scans. Typically, the CT Tech picks up the patient, transfers them onto the scanner, and then they bring the patient back. These yellow tag patients were shot in the torso, but for some reason were stable even after 2 or 3 hours. I told the CT Tech, go over to the CAT scan machine, and sit behind the controls. “I don’t want you to move. You’re just going to press buttons for the rest of the night.” Then I took every nurse that was free—at that point we had a lot of extra staff—and told them that all the people who needed CAT scans needed to be lined up in the ambulance hallway outside of CAT scan. We placed monitors on them, and nurses watched them. Then the nurses assisted getting each patient on and off the CT, and then back over to Stations 2 and 4. I called it the CT Conga Line.
And yet again: Good improvisation, excellent use of resources, poor foresight.
But how many hospitals deal with 250 GSWs in 6 hours? So far, just this one.
I identified another choke point with the green tag patients. Many were shot in the extremities. They had potential fractures or open fractures and needed X-rays. The standard way of doing things is taking the patient for an X-Ray, then sending it off to the radiologist so they can read it in their reading room. That was just going to take too long. So I told our CEO, Todd Sklamberg, “I need a radiologist here in the ER. I’m going to attach him to an X-Ray tech because our machines have little screens on them.” They X-Rayed patients, the radiologist read off the screen, and we would decide on disposition right there.
Another genius move. Put the people where the work is, and roll the patients past them.
Create flow; eliminate the bottlenecks, choke points, and single-points-of-failure.
IOW, destroy almost everything we do now, to do what you have to do then.
In the end, we officially had 215 penetrating gunshot wounds, but the actual number is much higher. As I would circle the ER “looking for blood,” I would hear the green tags say, “You know what? I’m not that bad—I’ll be fine.” Over time, they would walk out without getting registered. Our true number was well over 250.
The surgery team performed an unprecedented feat that night. The numbers speak for themselves. In six hours, they did 28 damage control surgeries and 67 surgeries in the first 24 hours. We had dispositioned almost all 215 patients by about 5 o’clock in the morning, just a little more than seven hours after the ordeal began. That’s about 30 GSWs per hour. I couldn’t believe that we saved that many people in that short amount of time. It’s a testament to how amazingly well the hospital team worked together that night. We did everything we could.

Improvisation: 10
Pre-planning: 5
Success: 9.9

Takeaway: Plans fail. So does planning. People - who can improvise on the spot - save your ass. And in this case, 200+ patients too.
Top to bottom, these folks were rockstars, when it counted.

Hopefully some of the two dozen nurses and hordes of other staff members will be telling their stories from that night, especially for lessons learned from all the other perspectives.

Superpowers, bitchez.
F**k a cape and tights; superheroes wear scrubs and stethoscopes.
And they kick Death's ass.

 

Friday, September 1, 2017

Consequences, SLCPD

 
 


 
 
 
I've got all day to do this, Officer Jackboots.
See if I know how to leave a mark.

Dear Jackbooted Thugs: You're Officially Dead To Me



How about this one from Salt Lake City:
ER nurse refuses (per policy agreed upon by hospital and SLC PD) that she's not allowed to draw blood from an unconscious patient unless he gives consent (impossible), or the officer arrests him, or they get a warrant for the draw.

So, instead of making the arrest, or obtaining the requisite warrant, Officer Jackboots arrests the nurse in the ER!
For refusing to break the law, violate hospital policy, do something unethical, and commit both a civil rights violation and an act of battery on the patient.

Story link

God help you jackbooted thugs if you get shot or injured.
I won't. You're why.

I'll relent on one condition, and it's a package deal:

Drop all charges against this nurse.

Fire the officer(s) who arrested her, for cause, without benefits or pension.

Refer them for prosecution for false arrest, kidnapping, and violation of civil rights.

Demote his/her/their supervisors.

Make your entire department go through mandatory re-training on why this is recockulous.

Revoke all sovereign immunity, so the nurse, hospital, and all patients affected can sue the officer(s) in question, the city, and the SLPD, for whatever exorbitant civil damages multiple juries think are justified and fair. Something in the mid nine figure range looks appropriate based on the video.

Require your mayor, your police chief, the watch commander, and the supervising sergeant(s) of the officer(s) in question make a full, forthright, rapid, and public apology, on air and in writing, to that nurse, her co-workers, the patients, hospital, staff, and citizens of SLC for this egregious violation and badge-happy horseshit.

Otherwise, you're worse than the criminals you claim to protect us against.

And never, ever, ever, ever, EVER let this happen again.


Barring that response, PDQ, let me be the first to say that when someone shoots you, I'm giving out candy.
When you die, I'll send a note saying I heartily approve.
And I hope you suffer on the way.

You maybe think you have a big team? Wait until you see what a wall of scrubs looks like.
There are 2,000,000 nurses in this country, and that's before we get to doctors, PAs, techs, etc. You're not even in the same league.
You're about to be shat upon, from a great height.


UPDATE: From Comments:
"officer A$$H*le can be contacted @ 801-799-3100
and his supervisor can be contacted at 801-799-6397 "

Wednesday, August 30, 2017

Shameless Product Plug Alert



One of the reasons I love travelling is because I get to see how different places do things.

Today's case in point:
the Purewick External Female Catheter, pictured above.
Which Shoestring General is using (and of which the last umpteen places hadn't yet heard).

In a nutshell:
1) Grandma (or any female patient) is incontinent, or non-ambulatory, a frequent pee-er, or any combination of the three.
2) She's gotta pee, which means sliding a bedpan in under her 400# backside, or broken hip, or moving her bony, cachectic bones, or needs 15 minutes per potty trip to bedside commode or bathroom, twice every hour, or any one of 27 other reasons.
3) Indwelling catheters are on the hospital sh*t list, because they provide UTIs with some regularity, which the hospital now gets to eat the cost for treating.

Enter the Purewick EFC.

As you can see above, it's 10" or so by 1" diameter soft plastic hot dog, with a central wicking tampon-ish core.
You put the white cotton side on your female pt.'s outgoing waste evacuation region, as seen below,
 
inside a diaper or underpants if possible, hook the other end of the magic peesucker to wall (or portable) suction tubing, set it and forget it, and you're done. When it works as advertised (which, anecdotally from me is about 95% of cases), it does exactly what is promised. And even when it's only partially successful it cuts way down on catheters, bedpans, diaper changes, and stinky undies.

It collects the urine in a standard suction canister.
Which can be counted for I+O purposes, sent/withdrawn for standard lab and POCT UA, urine Hcg and drug screens, as necessary. (Urine Cx, not so much).

My no-BS rating: Farking GENIUS! Twenty stars!!!

Eliminates 90% of your female caths as wholly unnecessary.
Which cuts way down on UTIs, and skin breakdown.
And keeps patient and bed less wet and stinky.
Which keeps pt. (and family) happier.

You've just made the day for all CNAs, clinical nurses, risk management, infection control, administration, Press-Ganey, and the CFO, all of whom will wet their pants with joy because 50% of your patients no longer will.

I wish I'd thought of this. I could retire on the royalties.
For that matter, I wish anyone had thought of this 25 years ago, just to save me a few hundred catheterizations. (Plus the ones I missed.)

Seriously, this thing is fantastic. If your hospital isn't using it, clamor for it yesterday, and don't take no for an answer.

Full disclosure: I'm getting zero bucks, nor any other consideration for saying it.
If you're the company marketing it, and you want a testimonial from an experienced clinical practitioner, I'm your pigeon - in return for one steak dinner. Really.
And if you're the Real American Genius who invented it, your steak dinner is on me.
Really.

The first shift you don't have to change 7 diapers, or help tiny frail grandma to the bathroom 10 times, and she can sleep peacefully all night long and stay dry as a bone while you get the ordered UA, and strict I+O tally, you'll want to buy that inventor a steak dinner too.

But if I had invented it, it would have rolled out as the Purewick External Elimination Device, and abbreviated as the P.E.E. Device.
Because I'd totally have gone there.

If your hospital doesn't adopt these, you're living in the 19th century.
Neener neener.



Monday, July 24, 2017

Clipboard Commandos


                                 Almost actual size, but it's not this new and shiny here.

New gig at Shoestring Hospital, in Teeny Weeny ER.

Small, hella-busy, still same old fun.

Except for (wait for it) all the ancillary BS hoops to jump through to start.
Wait, it gets better.

So busy and short-handed, your contract started yesterday. (What's that? You never signed one? Don't worry, we'll get around to that...in a coupla months. Maybe.)
But here's your log-in to complete the same 42 online modules (on my time and nickel, apparently) before you start.
Because the ones you just did for our sister hospital in the same system don't count, because the left hand and the right hand in this fucktarded corporate lash-up don't talk to each other.

How...special.

So, after pounding my head against the monitor for three weeks trying to follow their instructions, it turns out they assigned me no account, so couldn't log-in to the education site, which helpdesk line is so secret, no one in the entire hospital knows it or has ever heard of it, until we reach the threats-of-suspension stage, and it will suddenly leave them exactly as short-staffed as they were before I started, and suddenly shit gets real for them.

Whereupon they "suddenly" discover the secret helpdesk number, and I then find out all the courses they assigned to me in the first place three weeks ago were the wrong ones, and not the ones they've been telling me that I haven't completed, because I couldn't log in, and they never assigned the right ones in the first place.

Because they're all a bunch of chronically and blisteringly incompetent fuckups.

This is my shocked face. I didn't name this place Shoestring Hospital and Teeny Weeny ER for nothing, and Incompetence is one of the core values here.

If I did nursing like they do administration, the dead bodies would be piled up around here like firewood. (And, in all likelihood, they soon will be anyways. But that's another ten stories.)

This will be a short contract. If they ever give me one to sign before I finish it.

And they wonder why they can't find anyone besides brand new grads desperate for a job to become full-time staff? And why they all leave after 366 days?




Monday, July 17, 2017

$#!^ Happens. And You Brought...?





Summer in SoCal is everything you've heard about. Really.
I'm off for the weekend. Cruising down the street listening to my own song mix. The birds are singing. Not a cloud in the sky. And over there is a white haired woman face down in the street. Not a care in...

WTF? Why is grandma doing the dead fish impression off the edge of the curb?

So I pull over smartly, hop out with my first aid kit from behind the seat, and step over to where she lies.
She is, happily for both of us, conscious and breathing, so we chat.

Turns out moments ago (Why in front of me? Just lucky like that...) she negotiated a tall curb badly coming out of the jewelry store, tripped, with both feet on the curb, and fell to the street. As she's telling me this, and giving the okay for help, I tenderly pull her out of the traffic lane in which she was laying, noting her bilateral ankle pain and tenderness.

(And nota bene, total number of helpful bystanders who come over to assist, in front of three open business...zero, start to finish. Plan on that and you'll never be disappointed.)

I'm in town, and can call 9-1-1 while simultaneously cracking a couple of ice packs, after assuring myself that her feet have good pulses, are warm, and she can wiggle her toes. While also noticing she's probably broken both her ankles, at the tender age of 70-something.

So rather than having to splint both of her lower legs, I can wait the 110 seconds it takes for the city's red-engine pride to arrive, while I gather a quick history and baseline vitals, less BP, because I can hear the truck coming before I could deploy the cuff.

She is gently loaded on a gurney, to be whisked to the local ER, in little more than the time it took to write this, and other than handing the lead paramedic all the meat and potatoes of his run report, I'm done, and ready to depart. It also helps that he and the captain both recognize me from multiple contacts in that same ER, even though I'm not in scrubs at the moment.

The point, gentle reader, is that $#!^ happens anywhere. Are you prepared for that? You'll use a first aid kit in your lifetime one helluva lot more often than a gun, so whether or not you have a CCW and a weapon, where's your aid kits?
D'ya know what to do after you grab it?
Note I said kits, not kit. If you have a weapon, you should have an IFAK/blow-out kit on your body, as well as a mini-kit, and a disasterpiece theatre SHTF kit in the car, 24/7/365.
Mayhem doesn't send warning notices. He just shows up.


Can you quickly assess, evaluate, and treat someone you come across who needs medical attention? How about when you go shooting? (Of course, we know you'll never have an accident, because infallibility, but what about all those other jackasses waving guns around? Haven't you seen the bullet holes everywhere but downrange??)

Everybody carries one of these:
Okay, nice, provided you've got contact bars.
Some of you carry one of these:
Cool. Now, use it to stop bleeding. Can't do that?
Maybe it's time for one of these:
And one of these is even better.
For some problems, there's no other work around. You simply must have the proper tool, or you can't do the job. And waving your gun, or your arms, (or some other worthless anatomy) at the problem won't fix things.

Please, don't be that guy.
Naked and Afraid isn't even much good as a reality show, but it's orders of magnitude worse as a plan for coping with emergencies.

As a wiser man teaching field medical care once pithily explained,
"If you ain't got a kit, you ain't got $#!^."

Not the happiest ending in this case, but better than it could have ended.
Life happens. Tag, you're it...

Friday, April 14, 2017

Free At Last, Free At Last



Triple contract is over!
Loved the people. Loved the days. HATED the drive time.

I'll probably go back in a few months, if they need me.
(But definitely asking for the housing deal next time.)

39 weeks. 110 or so shifts.
So about 1000 to 1500 more hands-on patients.
And they trusted me enough to put me in triage for three weeks straight at the end.
Helluva ride there, and I'll miss all the familiar faces. It's going to be interesting to see how many of them are still there, if and when I go back down the road.

But eight whole days in a row off work??

LUXURY!

Later, taters. Happy Easter.

Wednesday, December 28, 2016

Expecto Patronum




It sucks coming in to the shift after the Christmas weekend, with the ER jammed, and the overflowing lobby looking like the tiger cage at the circus, at feeding time, and the triage nurse feeling like a staked lamb. It's even worse when every time you get a critical patient out of the ER, you get rewarded with another sick patient, even before you get back from passing along the last admit.

It starts getting better when you get everyone out, either discharged home or admitted, and it's really turned the corner when all your beds are empty, and the lobby has been cleaned out too.

Even when it doesn't happen until 6 AM.

Now all you have to do is make that last hour, hoping that nothing will go sidewa

"TWEEEEEEEEEEEEEEE...Medic Six...three minutes out...witnessed full arrest...CPR in progress...intubating..."

Leaving just enough time to clear the decks for action stations and grab the crash cart, because as the one with no patients, guess who's getting the run...?

And everyone shows up, just ahead of The Guy, the purpose of the exercise.
Including the uninvited party crasher.


I really hate that guy.

He tries his best, too. We get a pulse back, lose it, get it back, lose it, get it back, lose it.
The ET tube gets dislodged; the doc re-places it. We go through code drugs like Charlie Sheen at a cocaine lab. Everyone is on their game though. The guy comes in a deathly shade of purple, and we manage to turn him pink and warm with compressions and bagging. Lines go in like clockwork, IV, IO, central line, NG tube, foley cath. A pile of debris and detritus forms around the perimeter of the room, in inverse proportion to how our guy is doing. Apparently you need to fill a garbage bag to save a life, and we're doing our bit in spades on both counts.

Finally, the efforts start paying off, the pulse comes back for good, blood pressure and oxygen sats stabilize, and we start thinning out the garbage piles just ahead of the arrival of the family that last saw their husband/father/brother/uncle being loaded into an ambulance in the dark half an hour ago.

Sometimes, with some patients, the end is a welcome release from terminal pathology, but not this time.

And with an extra little push from timing, a short transport time, and rockstars on arrival, this guy got the A-Team.
And I love it when a plan comes together.


Oh, and f**k you, Death.
Not on my shift.
Not this time.