Service And Boundaries

One of the more difficult tasks for healthcare providers is to know where to draw the line.

All good nurses want to help people. We hate seeing people in pain or watching as our patient’s life drains from their eyes. Even with patients that are difficult, nurses want to see them get better and we try our best to make their time in the hospital comfortable. On the other hand, we have to prioritize care because some patients are critical while others are merely needy.

One night, an elderly gentleman came in complaining of vague symptoms. It turned out that he had been involved in a recreational accident and was in far worse shape than he realized. The sharp-eyed triage nurse thought something was wrong and requested that he be taken to one of our trauma rooms. We didn't know it at this point, but in addition to broken ribs and an injured arm, he had severe internal bleeding, a collapsed lung, and was going into shock. Even though he had walked in, he was fading fast.

I work in a rural hospital that is not a trauma center. Sure, traumas come in, but it is our job to stabilize patients and send them to a facility with trauma teams and surgeons. We call the cavalry, which is usually a helicopter, while we stabilize. While we wait, we are starting IVs, intubating, catheterizing, medicating, and dumping fluid into their body as needed.

Anyway, this patient is dying. His heart stops. Compressions are started. We’re calling down to the blood bank to get O-neg blood, using pressure bags for dumping fluids in, trying to bring his pressures up. His torso is spider-webbed with multiple IV lines and cardiac leads. The blood finally arrives, going quickly through the checklist, repeating vitals, noting that blood is not going in because a line is kinked, fixing it. Plasma arrives. His heart has started again.

The transport helicopter arrives, but his heart stops before they are able to get him out onto the helipad. Compressions are started again. Is the chest tube draining? His color changes from pink to gray, with bluish lips. Compressions are fast and strong. The techs are used to this, they switch out with each other like they are in a relay race. His color improves again.

If we believe that a patient needs immediate specialty care, we usually call a helicopter. Sometimes flight nurses can feel like a bit of a pain to ER nurses. They want the patient to be stable, while we want the patient to be elsewhere. We understand logically that flight nurses have no room to work in the small choppers they use, but emotionally it feels like time wasted on the ground would be better spent in the air, getting a patient to a trauma surgeon. Luckily, this flight nurse is willing to work with us: we just need to get his heart beating and she’ll take him immediately.

His heart is beating and we have him on the helicopter pad. One of the flight nurses is untangling lines to make sure their pump is organized while we prepare to move the patient into this sardine can of a helicopter. “Do you feel a pulse?”, someone asks. I can see his color change, even in the dim lighting around the helipad. He is in PEA*.

So close, yet too far. His family is watching from a safe distance, but see as their loved one is straddled and compressions started again as we head back down the ramp into the strongly lit room we had just left. You can see in their faces that they know he isn’t going to make it. We don’t want to quit, but we can only do so much. After more compressions and more medications, the doctor finally calls it.

Odd as it may seem, we give each other exhausted smiles. We did our best.

Even though we are completely exhausted, we quickly clean the room of all the extra tubes and wires, blood-soaked sheets and leftover bits of IV start kits. We clean him up the best we can, so the family can see something less traumatic than it really is. The chaplain ushers the large group of family members into the room as I head out to check on my other patients.

Wiping the sweat from my face, I feel my hands are shaking ever so slightly as the adrenaline does its thing. I force a smile as I squirt some alcohol hand cleanser on my hands and step into a living patient’s room. This patient has been waiting for “hours” and isn’t happy. After listening to a tirade about how I need to get the doctor because I obviously wasn’t doing my job, I excuse myself as I feel my smile turn to plastic.

Yes, I will seek to help this patient. Maybe their needs seem small in relation to those I’d just seen, but this is my job. I am supposed to help people. I know I am only seeing them when they are feeling their worst. I understand how it can feel like an eternity, waiting for answers or relief. I also know that this isn’t my only patient, and their needs are not critical. I check on my next patient.

* PEA, or Pulseless Electrical Activity, is when the heart's electrical signal looks like it is beating, on the monitor, but the heart isn't actually pumping.