Trouble in Triplicate

A big part of my job in the ER revolves around the mindless paperwork, everyone's does actually. Every i dotted and t crossed, dosages and labwork, scans and all. Everything is documented endlessly, every god damn thing. This is all part of the larger bureaucracy that is the American medical system. Everything has a protocol, everything must be regimented. There is a form for absolutely everything, right? Well tonight I learned that despite the checks and balances in place meant to protect us, the healthcare workers, and the patients things can fall apart.

It started like every other shift I suppose. I walked in through the ambulance bay and stopped at the main ER nurses station to sign in when I was told they were overstaffed on accident. A clerical oversight, ironically, started my night. I wound up getting sent to the Pediatric ER which is a separate area altogether. It's not my first choice but I was there and I wanted to get paid, so I grumbled and walked over.

As I walked down the hall, it was lined with overflow stretchers. Non-critical patients and ones with one to one sits. I was dragging my feet, looking around from behind my aviators, searching my bag with one hand for a redbull when I stopped dead in my tracks. To my right was a man, thirty or so, thrashing about in his restraints with a PCA sitting next to him nonchalantly reading US weekly. What stopped me was what he was rambling about.

-Fucking TWAT! She's USING HIM! She uses them all! SHEEP I SAY SHEEP! She's not hurt! She's the wolf leading them to the slaughter! She HAS TO BE STOPPED!

I dropped my bag and picked up the chart. I laughed to myself as I read his psyche work up, it was God's awful sense of humor. Apparently his wife was sneaking around his back with his friend, he found out and kicked her out. According to him she then began to tell his friends, office mates, and who ever would listen that he was, in the patient's own words, "An abusive prick."
He then after a month proceeded to try and stab both her and his old buddy, and failed when the buddy knocked him out with a good left hook. I shook my head and smirked as I read and when I was finished I put the chart down and looked the guy in the eyes.

-I understand dude, really I do.

I looked at this guy who would be going to jail once the doctors said it wasn't a schizoid break and looked up to the ceiling, imagining God up there laughing his ass off at his own joke. I knew it was the start of a good day.

I moved on down the hall and dropped my bag at the desk in the Ped's ER. I took off my glasses and took in the scene, only five patients. It was a beautiful sight. So I sat down and drank my redbull and bullshit with the nurses and attendings there, waiting for bloodwork to come back and admission orders. It was laid back, a serious change of pace. I started to think that the night might not be too bad. Fool, I'm always such a fool.

Eight O'clock at night was about the time things went south, way south. The loudspeakers overhead roared to life suddenly.

-Two Adult Level One Trauma's in the Main ED. Two Level Two Pediatric Trauma's in the Pediatric ER.

I blinked, looked around, and in a second we were on our feet getting the trauma beds ready. Code carts, surgeons, a team, intubation boxes, drugs, kits of all sorts, making sure CT scan was open and OR's were cleared, getting blood ready and setting up rapid transfusers, this is what we scramble to do when trauma's are rolling.

I finished up doing the code cart checklist and walked out to the ambulance bay, watching the adult trauma team doing the same. I grabbed a few pairs of gloves and a gown on my way out. I walked through the doors and felt the muggy night hit me like a bag of bricks, checked my watch, five minutes out now according to the charge nurse. I fired up a Marlboro and watched the street, waiting to see the lights, hear the tires squeal and the wail of ambulance sirens. All I saw were streetlights, a few drunks, and all I heard myself sucking on my cigarette. By the time I finished a few more people had joined me awaiting the arrival of our customers, out blood pumping, anticipation and fear fueling us.

Then our hearts jumped as we saw the red and white lights in the distance. They grew and the wail started getting louder, we could see two, no three, no now four of them barreling down the road like bats out of hell. They all came tear assing through the small roads in the hospital complex in single file and came backing up so fast into the bay one after the other I was sure one of them would pop the curb and hit us.

I'd have been so lucky.

Then the doors swung open and out jumped paramedics, like infantry from an APC they hit the ground and pulled their patient's out, us listening to their reports as they did and tunning with the gurneys through the ambulance bay. The adults were husband and wife, car accident, ugly. I'm not sure what their faces looked like before hitting a telephone pole at a great rate of velocity, but right now they looked like red misshapen puddles with eyes and a mouth, glass, debris, and intubation tubes sticking out of them. They were dead on arrival but the teams tried for the sake of the other two patients we had.

The pediatric patients I was following looked good. A few cuts, the older boy seemed to possibly have a broken arm, but they were intact, in one piece, alive. We got them in and people ran around them like a swarm of bees. Drawing bloods, ordering scans, external examinations, asking questions, seeing if anyone was home. No one was it seemed. They're external injuries were minor compared to the apparent mental ones. They were shell shocked, white as ghosts, flinching, eyes wide with terror. The smaller one was a four year old girl, blond hair, light complexion, big scared green eyes. I walked over to her after sending the vials of blood to the lab to be tested for the usual trauma panel and touched her hand. She flinched and looked up at me in horror. I tried to smile, and moved my hand to hers again, and spoke in the softest voice I could muster.

-Hey there. Are you ok? Can you tell me your name? My name is Joe, and I'm here to help you. I want to make sure you're ok, and thats what all these people are here for too.

Her eyes were still wide as saucers as she looked at me, her mouth open but no words coming out. Almost like a silent scream no one but you can hear. I just kept holding her small, cold hand. I kept looking at her and smiling as the people around me tended to her small lacerations. One required a few stitches and when they went to anesthetize the area she flinched and squeezed my hand, screaming she looked up and said her name. She begged for me to tell them to stop touching her booboo, to just leave her alone. I kept smiling and squeezed her hand tight as I tried to distract her, asking her name, what day it was, what her favorite color was. Before she knew it the stitches were done and by this time the boy behind me, her fifteen year old brother, was X-Rayed, splinted and cast for a small break in his radius. They both began to talk to us and the little girl said something I was not prepared for, something that totally would change my mission for the night once more.

-Where's my brother?

I blinked. I smiled. I replied.

-Right next to us, kiddo. Right behind me. You see him, right?

She shook her head with a curious look in her eyes.

-Thats my OLDER brother. I mean MY brother.

I blinked again. I didn't get it till her older brother chimed in.

-She has a twin, he was in the car too. Do you know where he is? Is he here? Is he ok?

I spun around and tried to keep smiling. His face was pained and confused, I didn't want to give up the ghost, the worst answer was the truth. I had no idea, and the faces of the doctors and nurses around me told me they were in the same boat as me.

This was bad. So what was I to do? Paperwork, there had to be paper work. I calmly walked out of the room and went to the nurses station, picked up the chart for the little girl, and shuffled through the pages desperately. All I found that was useful was the ambulance PCR. It was all I needed though. There was a fifth ambulance on scene, it was a private paramedic company from a nearby hospital. Sure enough I called that ER and found that the kid was brought there since that hospital was about the same distance from the accident as us. There was a miscommunication on the scene and he wound up there, alone. I called the main ER and spoke to the charge nurse, the parents were dead. Now the problem got worse.

Here's the issue. When a patient comes in as a certified and leveled trauma after they are stable they are admitted to the trauma surgeon on call's service and becomes his patient. Coming in as a trauma requires a battery of expensive tests and physician's consults. So with the other kid over there, after this much time, being admitted there really is no medically pertinent reason to transfer him here. So began the barrage of phone calls.

I sat there for three hours, and with the help of the pediatric ER attending I spoke to and reasoned with every hospital administrator there and in my hospital. My argument? These kids' aunt and uncle were the closest relatives they had and wouldn't be there for a day as they had to fly in. For the time being, all they had were eachother. So I fought. I fought for hours, tooth and nail on the phone. I kept trying to figure out the combination of existing protocol and policy that could deal with this situation that had never even been fathomed.

Finally at midnight I struck paydirt and the transfer was approved. By now the kids knew what had happened and it had been arranged for them to be put in the only three bed room on the entire pediatric floor. Finally at one in the morning the ambulance came in, I took the wheelchair and the copy of the chart and hurried him inside. The pediatric hospitalist had already accepted the third kid to his service, the only thing wrong with him was a concussion that had already been cleared by neurology in the other hospital.

After going through the preliminary admission process I wheeled him upstairs, and quietly into the room. It was dark, only light coming from the muted TV. I could see the older brother lying on his side, tear soaked pillow, he had been staring at his little sister who was sleeping soundly. Just looking at the way he watched her, you could tell he felt the weight of responsibility being the oldest. He laid there and kept watch over her, he'd die before he let something else happen to her. I quietly picked up the four year old and sat him on the bed with his brother, they both smiled and hugged eachother. The little sister woke up and smiled too having seen her brother again. The room itself was littered with coloring books, crayons, and kiddie books. The little ones really wouldn't understand that their parents were gone till it dawns on them in the next few days. It's hard for a four year old to grasp that.

I backed out of the room slowly as they reunited and was looking at the nurses outside start to cry as I stopped again, dead in my tracks. My blood ran cold as ice and a tear welled in my eye as I heard the girls little voice say something in the softest tone.

-If mommy and daddy can't read us to sleep who can?

-I can guys, get into your beds and I'll read the Dr.Seuss one the nurses got you.

I turned around to watch this fifteen year old kid, who a few hours ago lost his whole life, regain his composure and read a bed time story. He swallowed his pain, he dried his tears and steadied his voice, and he read in a soothing tone, glancing at them and giving a reassuring smile as he did. He knew himself it was a lie, but he was lying to protect them. From now on he'd be the one that had to protect them and in that moment I believe I saw a child grow into a man of sorts.

It broke my heart.

I walked down to the ER quietly and packed my bag. I got a few pats on the back from the nurses and doctors, but none of us smiled. Today was a draw, no one won, everyone lost.

"I've lost more sleep than I can say
And blurred the lines between the days
Pour myself another cup
Put one out light another up
My mind's stopped making any sense
I've lost track of the present tense
Don't wanna leave, don't wanna stay
I'd kill to bring back yesterday
Folded up and left for dead
The things I wish I would've said
The times I should've turned and run
But the damage was already done
And I dug myself a deeper hole
Raked myself over the coals
Reason brings redemption
But redemption won't be mind

Suppressed my frustation
But it returned
Lost in the translation
I'm not concerned
Smoke 'em if you got 'em
'Cause we're never gonna learn
And dance upon the ashes of this world

Got hours more and miles to go
I feel the clock begin to slow
Play the hand that I was dealt
By the enemy that is myself
If I don't get out from under this
I might never know what I fucking missed
I'm at the breaking point
But don't know where to draw the line

I'm ticking like a fucking bomb
Had the best of intentions
My resolve outlasts my apprehensions
Won't be the first time
Not gonna be the last
I looked ahead through bleary eyes
And wondered what was left
Wondered will I pass the test

I've lost myself and found myself
And then I lost it all again

It comes down to me in the end
The more I know
The less I comprehend
It comes down to me in the end"

-Dillinger Four