by Robert Lanz, LCSW
sometimes think we should institute some new, unwritten rules in the ER. One example might be the rule that states if anyone younger than me dies on my shift, we all get to go home. The doctors, nurses, techs, me, everybody. But if that were the case, we’d all be going home early most nights and there wouldn’t be anyone to staff the ER. Bad idea.
It’s also a bad idea (and probably bad karma too) to go up against a group of nurses — ER night shift nurses in particular. They tend to be a tough group and they stick together, which is a good thing. Most of the time I stick with them. As a team, we’re hard to beat, and the night shift docs know that, so they put up with things they probably wouldn’t have to if they worked during daylight hours.
There are fewer patients in the ER at 2 a.m. (although over the years that has changed, so that the most crowded time is closer to “always.”) Therefore there aren’t as many doctors on duty. The same is true with nurses. For my first twenty years in the ER, I was on my own as a social worker from four in the afternoon until whatever time after midnight I decided to go home. Midnight was when I stopped getting paid.
When I first started at the hospital, it was assumed that there wasn’t enough work to keep a full-time social worker past midnight, so when I left, the nurses were on their own as far as social work business went. As the years went by, and the need increased, working after midnight became the norm for me, and everyone got used to me being there late. That was all right with me, since it wasn’t as if I had much else to do. I suppose I could have gone home to sleep, but if sleeping at night is high on your list of necessities, then maybe you should be working the day shift.
Nurses can hand-off their patients to other nurses when they take a break or go for a meal. The docs never work alone so they can take a quick break if the patient load isn’t too heavy. But the social worker has to have Power Bars and fruit juice available at all times, otherwise he or she might not get anything else to eat. (Unless the social worker can survive on the graham crackers and milk we are supposed to save for the patients.) We are given a dinner break, but it is usually eliminated by the buzzing of our beepers or cell phones. Dinner is that thing sitting on my desk getting cold if it is supposed to be warm and getting warm if it is supposed to be cold. Patients come before food. With any luck, the night shift social worker will manage to ingest some nourishment. But a night-shift social worker’s luck can be like that of the famous bluesman who once sang, “if it wasn’t for bad luck I wouldn’t have no luck at all.”
This particular night, I had been, in fact, ready to go home when the paramedic radio sounded to warn us they were bringing a college kid who had “crumped” in the dorm of a local university. The young man was brought into the ER and dying, but no one could figure out why. It was final exams time, a really busy season for this competitive college and we wondered if the kid had finished his finals and perhaps celebrated too hard, not an uncommon presentation. Perhaps he had been studying and had too much caffeine or cocaine or some other substance that would cause an over-amp crump. He was young enough that if my idea for a new rule were in effect, we could have closed the ER and gone home.
A “crump” is a loose medical term that means a person went down, reason not obvious, but to be determined by us through clinical findings or lab work, a scan of some kind or a combination of these elements. If he wakes up, sometimes the patient himself is forthcoming enough to tell us why he crumped. Sometimes his friends will tell us, if they understand the seriousness of the crump.
This night, we were on our own, because the patient’s friends described him as a highly-functioning, straight-thinking guy who didn’t take drugs or even drink alcohol. They had all been studying together in one of the student lounges and were just about to take a break when the patient took a step toward the water cooler and dropped to the floor. No sound. No twisting no contorting and looking to his friends for help. No exclamation of “oh sh-t” or grabbing at a body part that could give us a hint. He just crumped.
This presentation in and of itself is medically significant, since there are very few things that will render an otherwise healthy young man unconscious for an extended period of time. All of those things are serious: pulmonary embolism, stroke, intracranial bleeding and undiagnosed heart problems all have acute onset and lead to sudden and sometime irreversible consequences. Being young holds no advantage when one of these events happens. Not even being healthy does.
Knowing this, I unpacked my briefcase, went back into my office, turned on the lights and fired up computer. I went over to the refrigerator and got some cold juice. I knew it would be the only pleasant sensation I would experience until I finally got home, had a beer, took a sleeping pill and hoped for slumber.
When a young person is dying, the ER docs really do make extra efforts, and resuscitation procedures can go on for extended periods, even without positive feedback from the interventions. These procedures include drugs that can stimulate the heart, but if there isn’t a heart problem, the drugs don’t do any good. Different drugs can raise the blood pressure, but if the heart isn’t moving the blood to the lungs where it will get oxygenated, these drugs won’t do much good, either. Chest compressions can squeeze a little blood out of the heart and into circulation but you can’t do that for very long.
We put a breathing tube down into the young man’s trachea and hooked him the to a ventilator. A nurse dialed up the oxygen to pump the maximum amount of air to the minimally circulating blood. The ventilator doesn’t work very well either if the brain – for whatever reason – has broken. When everything fails in the ER and the patient is, or was, a young and healthy guy, the assumption is usually that he had a brain aneurysm. Quick. Deadly. Painless. But that’s just a good guess. This particular patient was never stable enough to get him to the CT scan, so we didn’t get a chance to look at his brain for confirmation. The ER docs were pretty sure that the scan would have shown massive bleeding in the brain but an autopsy would be done later in some other place and those performing it would make the final pronouncement on that, a pronouncement that we in the ER would probably never hear. For us, the next step was to call the time of death and to get ready to inform the young man’s family and friends of his untimely passing.
The police were there, that’s protocol. The student’s friends from the dorm were there, as were a few professors from the college. Naturally, after a patient dies, the doctors and nurses go back to their other patients and try to catch up on their treatments. Only the social worker remains on the scene to explain our intervention attempts and the medical probabilities to the police. No traces of drugs in the patient’s blood or urine were found, and no signs of trauma. Since nothing illegal appeared to be involved, the cops called the coroner’s office and executed some simple paperwork before returning to the station.
It was up to me to explain to the friends and faculty what had happened, what our best guess was and what they could expect next. It was up to me to try to make sense of a senseless death. It was my job to try and make sure that the survivors were going to survive, to make sure that they had a friend or staff member to talk to. When one of your friends crumps right in front of you it brings up issues that most folks won’t have to face until later in life, hopefully much later. Working in the ER, you are used to death. When you are a kid in college, you aren’t.
A lot of the night shift nurses are young, many just out of college themselves. Maybe that’s why they started to lean on me to call the student’s family, who happened to live in South Carolina. They wanted to get over this event. They wanted to move away from it, to wrap it up and look back at it over their shoulders instead of having it slapping them in the face.
Over the next few hours, the nurses asked several times if I had contacted the family yet, but I hadn’t. They got angry because they thought I was stalling, but I wasn’t. I had clocked out hours earlier and I wanted to go home too. I was going through some of my own emotional pain with this one and I wanted it over my shoulder and not slapping my face, the same as everyone else.
But it wasn’t about my feelings and it wasn’t about the nurses’ feelings. It was about the family’s feelings and at that hour, the sun had yet to rise where they lived. They were probably sleeping peacefully. As far as they knew, they still had a healthy and loving son. As far as I knew once I gave them the bad news, it might be the last peaceful sleep they would ever get. So you can understand why I wasn’t in a big hurry to ruin the rest of their lives, at least not while it was still dark. It simply felt too cruel. I went into my office and got on the internet to see what time dawn broke in South Carolina, then I waited in the dark until I knew it was morning where the family lived. Only then did I make the call.
We had all done our best, but we couldn’t make things better. Of course, only we knew that. Everyone else only knew that a healthy young man had died and life would never be the same for the survivors.
I was right about the juice—it was the last pleasant sensation I felt until I got home and had a beer, and two sleeping pills. Because tonight, I really needed to make sleep possible.