I have a patient who went on hospice care a few days ago. She appears fine. She is not fine. And she knows it. She is just waiting in a small hospital room watching reruns of CSI and whatever junk they have on TV these days, making herself happy in small ways with the food she can tolerate, complaining about things that she can control when she feels overwhelmed by the things she can’t.

Oh my God, how humbling. What would I do in that position?
What would you do?

Imagine this. You are sick but trying so very hard to beat it. You go to the hospital for a stomach ache. You are told that you have an intestinal blockage and it’s a tumor recurrence. Furthermore, there is nothing more they can do.”I’m sorry, there is nothing more I can do. I can make you comfortable, and keep your pain to a minimum…but there is nothing medically I can do to stop the progression of your disease. You most likely have about 2 weeks left.”

Oh my god. What if that were you? What if you only had two freaking weeks left and you are too sick to go home, too sick to do much, but well enough to be aware and to understand. Well enough to realize “Damn. The writer’s strike doesn’t matter to me because I am not going to be around to see the new episodes of The Office. Christmas ads mean nothing to me because I won’t be home for Christmas this year. I won’t see my cat or dog again. Ever.” It just goes on. No more summer corn on the cob. No more Valentine’s day candy. No more fireworks. You don’t need to worry about taking next year’s summer clothes out of storage and trying them on to see if they still fit.You can cancel your dental checkup and your next haircut. Any appointments you have…you aren’t keeping them.All of life’s special things, and all of life’s mundane things will continue on, but they will continue on without you. You won’t be there.

How would you feel? How would you handle it? You can talk, eat, drink, and have minimal pain. You are tired but not exhausted. You are alert, you are in your right mind, but within 2 weeks - FOURTEEN DAYS - You will become progressively more and more ill. Then you will die.Nothing we can do about it…. Would you cry? Complain? Retreat inward? Would you change anything? Would you mend relationships? Would you rebuild bridges knowing that your particular bridge is going into the great beyond? Would you confess your love for someone whom you’ve never told? Would you confess your hate for someone whom you’ve never told?

Put yourself there. It’s a scary place.

Yesterday, the ED was on Red which means there were no beds available. My side wasn’t quite slammed yet but with the acute side of the ED full, it was only a matter of time until our side got full not only from our own designated patients, but also with patients who may better have been on the acute side, were there any room. Basically, a relatively normal day.

I got to work prepared for a busy 12 hour shift. I asked the charge nurse, who is one of our Nurse Leaders, what my room assignment was and she smiled. handing me the charge phone, she said “We’re training you today for charge.” Now, I have asked for this opportunity several times and I feel ready for it. But the minute that phone was in my hot little hands, I felt a surge of panic.

Me? In Charge of the whole Urgent Care section of the biggest ED in my city?? ME???

I swallowed hard, my mouth gone dry. “Cool!” I managed to say, telling myself that I want this.

The Nurse Leader took pity on me. “You’ll only have two beds to care for all day, and I’ll be here,” she said. “Until 4″. Which meant that from 4pm until I was scheduled to leave at 10pm, she wouldn’t be there.
I smiled weakly. This is something I can do, I thought. I hope.
The phone started ringing almost immediately. Calls were coming from Triage..can I take this or that patient, do we have a bed for one patient, can the attending come to triage and evaluate another patient….I just kept answering calls and doing my best. Using critical thinking and my nursing judgement, (which apparently I do have!), I fielded each call and cared for my two beds.
I did my best to assign beds fairly, alternating between the different zones so that no nurse was unfairly overloaded. I asked lots of questions, and helped the other nurses as much as possible.
Before I knew it, it was 4pm and the Nurse Leader was leaving. She told me not to worry and told me I could page her at home if I had to. “But really,” she said. “You are doing fine. You won’t have any trouble.”
So I kept on going and the night was going very smoothly.
Until we ran out of beds again.

Around 9pm, we start to taper the patients we take on the urgent side, since staffing goes down for the overnight shift. Concurrently, at 9pm not only did we get five more patients to be seen, the rest of the ED had gone red again and there were 10 acute patients who had been waiting for hours in the lobby. The charge nurse from the acute side called me, begging for me to take some of their patients into the urgent side.

I sat and thought.

I had five patients waiting who were appropriate for my side of the ED, and I had to take them first. The urgent patients become my priority. Not because they are sicker than the acute patients, but because after midnight, we would go down to one nurse and one provider and if I took patients with heavier needs, the nurse/provider team would become overwhelmed and the patient care could be compromised.
I reviewed some of the charts for the acute patients, and found a few that could conceivably come over to our side if necessary.
I helped the rest of our nurses with their discharges, opening beds and filling them just as quickly.

All the while, I kept the attending physician aware of the plans, as well as the other providers and nurses.

When I left, all of our waiting urgent patients were roomed, we had one room reserved for patients coming in via ambulance/EMS, and there was a working plan for dealing with the overflow of patients from the acute waiting room.

When I walked out, my legs were sore and my brain was tired. It had felt good to give report and hand that ever-ringing phone to the next nurse. But I felt invigorated as well.

I did it. I ran the show for 12 hours. Everyone survived, no one complained.

Me in charge? Oh, yeah. I showed myself I can do it, and I can’t wait to do it again!

“A Dios mio! Pain! Pain!” I heard the woman’s cries all the way down the hall as she was led by the ED tech to my last empty bed. I sighed and took the chart from the tech. 60 year old woman with a three day history of left flank pain. “OK” I thought, this should be easy.

I went in to see her, and introduced myself. She was tiny, barely 5 feet tall, her graying hair held back in a bun. She told me her name was Sonya and that her doctor had diagnosed her with kidney stones at one of the other local hospitals. She’d decided to come here because “they don’t give me any help.” I had her put on a gown, started an IV and drew labs, and instructed her to give me a urine sample. “Thank you thank you,” she said in breathless, broken English. “The pain is very much worse.” I smiled and pointed her to her bathroom. She patted my hand before heading that way. I am always a sucker for the older patients.

In the meantime I checked on my other patient in the same room. David was a 30 year old “frequent flyer” who came in via EMS writhing in lower abdominal pain; he was going to be worked up for possible appendicitis, even though he’d presented five times this month already with similar symptoms. His tests had come back negative each time, and the doctors were starting to suspect he might be a drug seeker. David was resting comfortably, having received a morphine and phenergan IV cocktail.

I could tell when Sonya was back to the room by the progressive moans and groaning she made as she ambled back from the bathroom. I helped her into her bed and assured her we would make her as comfortable as possible. I told the ED resident that Sonya was in a lot of pain, and that she was ready to be seen.

Next I saw David’s call light go on and when I went in to check, he told me that the pain was back again, and he asked for more morphine. The pain was rated a 10/10 and he curled up on the bed holding his abdomen. I remembered his last visits, which were the exact same presentation but nothing was ever found on CT. I looked at the clock; it had only been 45 minutes since he’d received the morphine. I tried repositioning David to find a more comfortable position but it was useless. He was in pain no matter what position he was in. I asked the resident for another order of morphine and she wrote it with a sigh, mentioning that it seems David had increased his visits lately and maybe it was time for a psych consult.

The resident saw Sonya while I prepped David’s morphine.

When I took the medication back in for David, Sonya saw me and started moaning again. “Is that medication for me?” she asked. I told her I was sorry, it wasn’t, but that I’d have some as soon as the doctor ordered it. She looked so small and alone in the bed. I brought her an extra blanket. I quickly obtained the order and administered Sonya some morphine. She lay back happily.

Shortly, both patients were transported to CT. I went about my shift caring for my other patients.

A half hour later, after both of the patients had returned, “Look at this” the Dr said, indicating her computer screen. Sonya’s CT was perfectly normal, no evidence of kidney stones.

“And this too,” the resident said, changing computer screens. Sonya’s history came up on the screen; she’d had 15 visits in the last 2 months, all with pain. Futhermore, her history indicated a continuous use of street drugs.

The resident sighed and was about to get up and go see Sonya when her pager went off. She returned the call and turned to me. “David’s got a hot appendix. He’ll be going to the OR within the next half hour.”

As I sat filling out the pre-op paperwork for David and listened to the resident as she attempted to explain to Sonya that there was no evidence of kidney stone and that she would not receive any more morphine, I sighed. In this business, it’s so easy to gain preconceived notions and ideas. This was a good night to remember that nothing is ever necessarily just what it seems.

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Hello and happy St. Patrick’s Day!

May the luck of the Irish be with you today.