Train Wreck

The clerk sticks her head through the door and clears her throat to get my attention.

“You want me to entertain him?” the clerk asks, nodding at the toddler on my lap.

The clerk raised one eyebrow dubiously.

“She needs to beat his little ass,” the clerk whispers, sotto voce.

I wink at the clerk and lead Tyler by the hand back to his Mom’s room. Actually, I think Tyler is his middle name. From listening to his Mom, his first name must be Stoppit.

She holds one finger up and turns away from me, pressing her cell phone to her ear. Apparently, I’m interrupting an important conversation. For a woman with the Mother of All Migraines, she looks pretty fucking chipper.

She catches up to me in the hall. “Wait a minute! I was on the phone,” she says angrily.

“Well, where are we going?” she demands, trying to coax Tyler from my arms. He slaps at her hands.

“Why not any of these other rooms? I’m the only one in here! What’s so special that somebody else gets my room?

But I don’t say it.

“Why does he like you so much?” she wonders. “I’m his mother.”

Instead, I just shrug and walk away. Behind me, I can hear Tyler screaming as she once again calls him by both his names; Stoppit Tyler, STOP It Tyler, STOP. IT. TYLER!

“Hey!” I snap, and both of them jerk their heads up in surprise. “Stop. Drawing. On. The. Table.” Instantly, Tyler drops the crayon and his lower lip quivers. I turn to Malingering Mom. “Less threatening, and more making. Give it a try some time.”

1715 hours

I can hear the cops coming down the hall before I see them. Duster is growling like an animal, and the cops are grunting with the effort it takes to control him. They have him sitting in a wheelchair, and surprisingly, he’s fully clothed. When the excited delirium gets hold of Angel Duster, we normally get him buck naked and sweaty. His wrists are cuffed behind his back, and his ankles are hobbled. One cop is pushing the wheelchair, while another walks alongside and slightly behind, with his Taser firmly pressed to Duster’s right trapezius muscle. I heard it arcing from around the corner. Two other cops take up flanking positions, each walking alongside with one hand on a wheelchair arm and the other on Duster’s thigh.

We have a procedure for securing guys like Angel Duster. First one ankle goes in the leather restraint. Then the handcuff comes off that ankle and the person tasked with restraining that extremity moves to the other side of the bed and helps with securing the other ankle.

He has bloody divots worn in his ankles from the stainless steel cuffs. He has been restrained like this so many times he actually has handcuff scars. By the time Methuselah and I have Duster’s feet secured, the front of my gown is liberally smeared with his blood and sweat.

While I move to the head of the bed, Methuselah cranks up the foot end, effectively tightening the ankle straps and spreading Duster’s legs.

Then Methuselah and I grab him by the hips while the cops, taking care to avoid his snapping jaws, grab him under the arms and stretch him out, pulling him to the head of the bed.

One cop grabs Duster’s head so he can’t bite, while four of us bear hug him and roll him onto one side, just far enough for the sixth person to unlock the cuff on one wrist.

Once that wrist is free, it gets dangerous. Duster has both arms loose, one of which has a half pound of pointed metal projectile still attached. If he breaks loose, he’s going to maim people.

Working together, with much grunting and swearing and more than a couple pops of the Taser, we manage to get his arms secured and the handcuffs removed. He’s far from totally secured, though. He can still hurt himself if we let him. I add anot
her strap across his hips, and one across his chest, running under each arm. Once I assure that he has enough slack in the torso strap to breathe adequately, I raise the head of the bed a few degrees and strap an oxygen mask firmly to Duster’s face. It’ll keep him oxygenated, and it also serves as a dandy spit shield.

I cut off his sweat-soaked clothes and toss them in a rancid, soggy heap in the corner. I insert a Foley catheter through his urethra into his bladder, and I am not particularly gentle. Foley catheters hurt, even when inserted gently.

Serves you fucking right, I think spitefully. I don’t like hurting people, and I like even less what people like Angel Duster bring out in me.

1745 hours

“Got him squared away?” Doc asks sympathetically when I finally walk back into the ER nurse’s station.

“He needs sedation. Now.” I am tired, sweaty and frustrated, and in no mood to fight this battle. I tend to be blunt.

“You’ve got him adequately restrained, and he’s in a room by himself,” Favorite Doc argues. “I don’t like sedating people for the sake of convenience.”

“Right now he has a heart rate of 170, and he’s breathing 50 times a minute. He’s sweating so much I had to use liquid adhesive to get the monitor electrodes to stick. He’s so violent we don’t even have a hope of getting a decent blood pressure or 12 lead EKG on him right now. If I know Duster, he’ll hit every Goddamned drug on the tox screen. He’s in excited delirium, Doc. People die in his condition.”

“Okay,” he relents, “but don’t give him the full B52. Just go with 25 mg of Benadryl and 1 mg of Ativan for right now. We can always give him more later.”

I suppress the urge to roll my eyes, and go retrieve 25 mg of Benadryl, 5 mg of Haldol and 1 mg of Ativan from the med dispenser. Mixing them all into one big cocktail, I walk into the Quiet Room, swab Angel Duster’s thigh with an alcohol prep and plunge the needle into his quadriceps.

He doesn’t even react. He has managed to get the rim of the oxygen mask between his teeth and is busily chewing off a piece of it. It takes me a minute to extract the oxygen mask without losing a piece of it, or a couple of my fingers, down his throat. I replace the mask with a new one, and strap it a bit tighter this time. There is dried blood on his lips, likely from where he has managed to bite himself.

Both of his pupils are dilated, and his eyes roll wildly, unfocused. Who knows if he’s even capable of seeing anything at this point. I switch on the x-ray viewing panel on the wall and turn off the overhead lights, effectively darkening the room but leaving just enough light for us to see clearly on the video monitor. The less stimulus Duster gets, the better.

Outside in the hall, one of the cops taps me on the shoulder. “You think the Doc’s gonna commit him, AD? Do we need to detail someone to stay here with him?”

I look over his shoulder to see Favorite Doc shaking his head, no.

“I doubt it,” I answer. “He’s not suicidal, just stupid. We’ll let him sleep it off and release him in the morning.”

“Fair enough,” the cop allows, following me back to the nurse’s station. He grabs a bottled water from the fridge, takes a swig, squints at the image of Duster’s writhing body on the video monitor. “You know,” he muses, “I know his family. Good people, for the most part. None of them want anything to do with him. They used to try, but look at him in there. He’s an animal. He loved those damned drugs more than he loved his own family.”

Favorite Doc and I say nothing. What is there to say?

After the cop leaves, Favorite Doc clears his throat. “We need an IV and blood drawn,” he reminds me gently. “Still need that EKG and blood pressure, too.”

“I’m not getting anywhere near him with a needle right now,” I state flatly, “and neither will anyone else. I’ll keep an eye on the video and his telemetry, and we’ll see if he’s calm enough in twenty minutes or so. I’ve already sent his urine to lab for the tox screen. That’ll have to do for now.”

1815 hours

Shit, still tachy and flopping like a fish. He hasn’t slowed down a bit.

I get up and walk into the Quiet Room. Angel Duster is still writhing on the bed like a man possessed, which I suppose he is, in a manner of speaking. His oxygen saturation is 100%, but he’s still breathing 44 times a minute, huffing in a feral, bestial pant; Whooff. Whooff. Whooff. I turn around and walk back to the nurse’s station and knock on the desk. Favorite Doc raises his head questioningly.

“Come see,” I tell him, crooking a finger. Bewildered, he gets up and follows me back to the Quiet Room. I step aside and let him gaze upon Duster in all his demonic fervor.

“Jesus Christ,” he whispers. “He’s wild.”

“And he’ll stay that way, right up to the point he goes into cardiac arrest,” I inform him. “Unless you get serious about sedating him. Right now, we’re at a stalemate. We’ve done all we can do until he calms down.”

“His tox screen was positive for benzodiazepines and barbiturates,” he muses. “I’d really rather not give him anything that will interact – “

“Doc, he’s a walking Goddamned pharmacy of illicit drugs. Whatever sedatives he has on board ain’t enough to, you know, sedate him to any degree.”

“Okay,” FD nods, finally deciding. “Give him another B52, the full dose this time.”

“Gladly,” I breathe thankfully.

1845 hours

“Okay Doc, I’ve got two good IVs in him, and I’ve sent blood to the lab. Got a 12-Lead EKG, and it shows some anterolateral ischemia. But the real problem is, his heart rate is still 160 and his BP is only 94/50. And he has put out zero urine in the past ninety minutes.”

“Shit.”

“Fluid boluses?”

“He’s probably sweated off a couple of liters, at least. Yeah, give him a two liter bolus and check a BP every ten minutes.”

1915 hours

I bump into Favorite Doc as I’m walking out of the Quiet Room. “We’ve got problems,” he tells me, his face grim.

“No kidding,” I reply. “Let’s hear your bad news first.”

“His troponin is elevated. It’s only .2, but with the ischemia on the EKG…”

“He needs to be out of here,” I agree, walking toward our med room. “We’re beyond letting him sleep it off here in the ER. He needs an ICU somewhere.”

“Why don’t you get the ER Doc at Big City Memorial on the phone?” he asks. “Let’s get a transfer arranged.”

“Well, that leads me to my bad news,” I reply, keying my password into the med dispenser. “Right now, he’s actively seizing and I was just about to give him 2 mg of Ativan. He’s had two liters of fluids and his heart rate is down to 130, but his BP hasn’t improved, and what little urine there is in his Foley is pink.

“Shit,” Doc mutters. “Was it a traumatic insertion?” he asks hopefully. “Maybe a little blood?”

“I’m thinking it looks
a lot like myoglobinuria,” I tell him. “Is it possible he struggled so long and so violently that he’s got rhabdomyolysis?”

“It’s certainly plausible,” Doc agrees. “All the more reason to keep pouring in the fluids and get him shipped out of here.”

“Right now, he needs 1:1 care. Can Native Nurse fill out the transfer paperwork and make the phone calls while I take care of him?”

“I’ll get her right on it,” he sighs. “Jesus, this guy is turning into a train wreck.”

1945 hours

“Hey Methuselah?” I ask mildly. “Why don’t you go fetch Favorite Doc for me, and while you’re at it, roll the crash cart in here.”

Ten seconds later, Favorite Doc pokes his head in the room.

“He’s snoring,” I tell him. “I’m worried about his airway.”

“Well, we have given him enough sedatives to tranquilize a horse. Maybe a nasal trumpet will do him some good.”

“His tongue is swollen, a lot. I’m thinking he must have bitten it at some point. I suctioned him about five minutes ago, and there wasn’t much in there. He’s had some dried blood on his lips since he’s been here, but in the past few minutes he’s showed some fresh bleeding. I don’t like it.”

“Neither do I. Let’s knock him down and tube him. The ambulance will be here in ten minutes.”

As if in reply, Methuselah clears his throat. Doc looks back at him in surprise. “Need to get by you, Doc,” Methuselah apologizes.

Doc watches him wheel the crash cart to the bedside, turns on his heel and walks back out of the the room. Thirty seconds later, he’s back, trailed by Native Nurse. Doc is wearing a paper gown and a mask, and he’s putting goggles on.

“Okay, let’s get it done,” he orders.

By way of answer, I hold up one finger and hustle to the med room. I quickly draw our paralytics and sedatives from the med dispenser and hustle back to the room. Favorite Doc already has a laryngoscope assembled and Native Nurse is handing him a tube.

“Wait, wait, wait a damned minute,” I snap. “We may have only one shot to do this right. His saturation is still 100%. We have time to get everything ready, for Chrissakes. We get in a hurry, we’re gonna fuck this up for sure.”

Native Nurse looks a bit offended, but Favorite Doc nods agreement. I quickly set up two more endotracheal tubes and lay a Combitube on the procedure tray. I hear a knock on the door and Paramedic With Potential sticks his head in.

Thank God. Someone with some common sense to handle the transfer.

“Just the man I wanted to see,” I greet him with a grin. “You mind giving us some help?”

1955 hours

“Okay, we ready to go now?” Favorite Doc asks impatiently. I scan the procedure tray and the wall.

Suction running? Check.

Back up tubes? Check.

Patent IV line? Paralytics and sedatives ready? Check check.

Backup airway device? Check.

CO2 detector and tube restraint? Check.

Cricothyrotomy kit? God forbid, but check.

“As ready as we’re gonna get, Doc,” I shrug. “One suggestion, though? Give him a quick peek with the scope before we paralyze him. I’d hate to stop his breathing for ten minutes before we realize there’s no way we can get a tube.”

“Good idea,” Doc grunts, inserting the laryngoscope into Angel Duster’s bloody mouth. He peers around, squinting behind his goggles. “Suction,” he orders tersely. Native Nurse sticks a suction catheter into Duster’s mouth, pulling out a large, ropy string of bloody saliva. Doc grunts with effort, holding the scope in place and bobbing his head like a prizefighter, trying in vain to get a decent look at Angel Duster’s vocal chords.

“He’s fighting too much,” he mutters, “and there’s a lot of blood back there. I think I can get it once he’s flaccid, though.”

2000 hours

“I can’t see a damned thing,” Doc mutters. “Too much blood, and two much swelling.”

“Want some cricoid pressure, Doc?” PWP offers. Doc shrugs as if to say, couldn’t hurt.

“Saturation is down to 85%,” reports Native Nurse.

“More to the right,” Doc orders, and PWP obliges, pressing on Angel Duster’s larynx, shifting it to the right.

“Saturation is down to 80%,” reports Native nurse, this time with some urgency to her voice. “We need to back out and bag him a while.”

“Still can’t see a damned thing, damn it!” Doc curses softly, withdrawing the laryngoscope and straightening with a pained grunt. He massages his lower back with one hand and wipes the condensation from his goggles with the other.

Native Nurse squeezes the bag, but Angel Duster’s chest does not rise.

“Saturation is down to 70%,” I tell her. “You’re not getting a mask seal.”

She mutters something I can’t hear and shifts her hands. Still no mask seal.

“Hey, NN,” I say pointedly. “Two hands are better than one. Do some two-man BVM ventilation.”

“Saturation is 60%,” PWP reports tersely, his hands already reaching for the bag mask resuscitator.

Native Nurse snaps out of her trance and hands the bag to Favorite Doc while she struggles to maintain a mask seal with both hands.

Right idea, wrong execution. We need Doc holding the mask seal, not the 100 pound nurse with tiny hands.

“Saturation is 44%,” PWP reminds us. “He’s gonna code.”

“Y’all clear the head of the bed,” I order. “Let me up there.”

Favorite Doc and Native Nurse don’t hesitate, dropping the BVM on Angel Duster’s chest and stepping out of the way. I hardly ever use my I will be obeyed tone in the ER, because that’s not my role. Nice to know I still know how, though.

I negotiate the tangle of wires and tubing at the head of the bed and take my place behind Angel Duster’s head. I hold the mask with my thumbs, wedging my fingers under Duster’s jaw and cranking upward. I tilt his head back as Paramedic With Potential starts squeezing the bag for me.

“Call off the heart rate and the saturation,” I order, still using The Voice.

“Heart rate 74, saturation 35%,” NN obliges.

“Check a pulse,” I order.

“He’s got a good femoral pulse,” Favorite Doc informs me. I meet his eyes, and he winks.

That’s one reason he’s Favorite Doc. He has his blind spots, as do I. He’s reluctant to let me intubate patients, but not because he doesn’t trust my sk
ills. I don’t even think he considers his airway skills superior to my own. He just thinks of some things in the ER as his responsibility, and he aims to give it a try before he hands it off to someone else. He’s not afraid to ask for help and advice, however, and that makes him a pretty damned rare surgeon, in my estimation.

Plus, he knows what the I will be obeyed voice means. I’m sure he’s practiced it extensively himself.

“Heart rate 100, saturation 60%,” NN reports, relief evident in her voice. “Looks like it’s coming up.”

“Let’s get him back into the nineties before we try that again,” I reply. “Doc, why don’t I give it a look this next time?”

“Let the paramedics give it a try,” Doc assents, waving his hand at PWP and I. “Maybe you’ll have better luck than I did.”

We bag in silence for a few minutes more, and NN calls off his steadily rising heart rate and oxygen saturation. Angel Duster is improving, at least for now, but I look around the room and the tension is evident in everyone’s face but Favorite Doc’s.

“Hey guys?” I say brightly, and everyone looks at me expectantly. “That’s why I’m such an unreasonable, hypercritical horse’s ass in CPR class. And y’all thought it was just because I’m an arrogant bastard.”

And they all chuckle.

2010 hours

Damn, there’s nothing back here but hamburger.

I withdraw the scope slightly and motion for PWP to release cricoid pressure. Wielding the suction catheter with my right hand, my left forearm braced on Duster’s forehead, I walk the laryngoscope down his grossly swollen tongue, a half inch at a time.

Find the epiglottis. Find the epiglottis, and we’re home free. Just a little further now and we should be right about…damn. Too much blood, too much tissue.

I see a glimpse of a flap hanging down, and gently advance the tube to the cavity beyond it. I have a nasty suspicion that I’ve tubed the esophagus before I even hook up the bag resuscitator.

“Check epigastric sounds,” I order, and PWP listens to the stomach as I bag. Disappointment registers on his face and he shakes his head.

“You’re in the stomach,” he says. Native nurse, trying to be helpful, starts to pull the tube.

“Not yet,” I tell her, staying her hand. “Give me the other tube.”

“Saturation still 93%,” PWP informs me, knowing what I intend to do. “Plenty of time.”

I insert the laryngoscope yet again, walking it slowly down Angel Duster’s mangled, swollen tongue. I’ve tried sweeping it to the left like I was taught way back when, I’ve tried having PWP grasp it with Magill forceps. None of that works when you’re dealing with profuse bleeding and deformed landmarks. The initial dose of paralytic has worn off, and we’ve had to administer another.

Okay, so we have the esophagus marked. Just a simple matter of finding his trachea, the hole that doesn’t already have a tube in it. Piece of cake, AD.

Ten seconds later, we’re hooking up the bag resuscitator to the second tube, and a shake of PWP’s head tells me the bad news.

Well, fuck. Two tubes in the esophagus. That’s a career first.

“Give him a look, PWP,” I sigh in defeat as I pull the tubes and resume bag mask ventilation. “I’m gonna go for a Combitube if you don’t get it.”

“We need an airway,” Favorite Doc reminds us from the corner of the room. “however you manage to get one. PWP can’t bag this guy by himself for the next forty minutes, and I’d rather not resort to a surgical airway unless I have to.”

“When was the last time you did a tracheotomy on someone, Doc?” PWP asks as he butts me aside and inserts the laryngoscope for a look.

“An emergency trach? Twenty years,” Doc says wryly, rolling his eyes. “And I’d rather not break my streak now, if you don’t mind.”

“Well, technology has come a long way in twenty years, Doc,” I retort. “We’ve got some user-friendly little kits in the crash cart, but I’ve never used one on anything but a manikin. Might be a good idea to break one out and start reading the instructions.”

“Yep, that’d be a damned good idea,” PWP says as he withdraws the laryngoscope from Duster’s mouth, “because I can’t get it either.”

“Gimme the scope, and call out the saturation,” I tell him taking the bloody scope from his hand.

Normally, a Combitube is inserted blindly, but with all the blood, trauma and tongue swelling, I’m leery of doing further damage by forcing down a Combitube. Get a little overzealous, and you can jam it right through the back of the throat.

“88%, heart rate 112,” he answers. “Better make it fast.”

I insert the scope and lift, not really trying to visualize anything. I just want that swollen, mangled tongue out of my way. I gently advance the tube down to the depth marker, thankfully meeting little resistance along the way. I inflate both cuffs, hook up the bag and squeeze a few times.

PWP, stethoscope pressed to Duster’s abdomen, looks up and grins. “We be in bidness, AD! That’s an airway I can live with.”

Hopefully, Angel Duster can live with it, too.

“Yeah,” I grin. “Let’s just get that tube secured, get him on your stretcher, and get him out of here.”

“As close to twenty minutes ago as possible,” chimes in Favorite Doc. “Good job, gentlemen.”

2100 hours

“That could have gone bad, you know,” Favorite Doc reminds me. “Hell, it did go bad.”

“Yeah, but what else could we have done?” I counter. “He shouldn’t have been here in the first place. Then again, he made it pretty damned difficult to do anything for him. Once we figured out he was going bad, we got him out of here.”

“It took some sweet talking to get acceptance, too,” Favorite Doc says. “Nobody wanted to take responsibility for the transfer until he was stabilized…”

“And if we could stabilize him here, we wouldn’t be transferring him,” I finish. “Catch 22.”

“In a way, that worked the way it was supposed to, even as ugly as it was,” I point out as the phone starts to ring. “If we had waited another twenty minutes, you would have been using that scalpel. We tried our best airway, and when it didn’t work, we used our backup. We got it done.”

Favorite Doc nods thoughtfully as I press the speaker button on the phone. “Podunk General Hospital, Nail Salon, Tire Repair and Crawfish Hut. This is the Emergency Department. How may we alleviate your pain and suffering today?”

“Hey AD, it’s PWP,” a voice answers over a bad cellular connection. “We made it to Big City okay, but by the time we got here, our boy was crashing. The Docs don’t think he’s gonna make it. Can’t keep his pressure up, and he’s in heart failure now. Doesn’t look good.”

“They give you any shit about the Combitube?”

“Yup,” he chuckles, “but I blamed it all on you. They rolled their eyes and badmouthed all us small town hicks, right up to the point they pulled the Combitube and couldn’t get him intubated themselves. They had to resort to a tracheotomy.”

“I saw that coming,” Favorite Doc offers. “He was going to need one
sooner than later. Better he got it there than here, though.”

“I suppose,” PWP chuckles. “But in any case, I think old Angel Duster has partaken of his last batch of recreational pharmaceuticals. Y’all try not to need us for anything for the rest of the night, okay?”

“Same to you, PWP,” I chuckle as I hang up the phone.

And good riddance, Angel Duster. You shall not be missed.

Of all the times I had dealt with Angel Duster, I had never seen him when he wasn’t crazy out of his mind on drugs. Hell, I had never even heard him speak. By the time we sobered him up and kicked him to the curb, my shifts had long since ended. I never saw him as anything more than a nuisance, a particularly dangerous animal.

I’ll bet his wife and kids didn’t think of him as an animal, though, despite what PCP did to him.

When you do what I do for a living, that’s part of the risk you take. To excel in emergency care, you subvert a little bit of your humanity to do it. You put your emotions and compassion in a safe little box while you deal with the problem at hand, and sometimes you fail to see that problem has a human face.

The ER nurses, doctors and paramedics know what I’m talking about.

I’ve been at that career stage before, where I mistook indifference for professional detachment.

That’s when the abyss starts staring back.