It’s Not Always Like This

Once Upon a Time I was a new nurse. No. It’s true. I had the uncommon good fortune to start right out in the ER for my first job. That’s not the case for everyone and I’m thankful it worked out that way for me. I’m still in the ER and sometimes I have the honor and privilege to shepherd a new nurse into our group.

Not too long ago I was chosen to orient a nurse who I had often heard mentioned outside the context of the hospital. She is an acupuncturist and has worked with my wife for several years in the birth community. In the ER we do just about anything we can to avoid delivering a baby in the department. We really will muster a sudden burst of energy and drop whatever we’re doing to redirect that imminent labor upstairs where that is what they do…what they expect to do and what they are trained for. Sometimes though it does happen that a delivery in the ER cannot be avoided and having a nurse who has attended births and is comfortable with the the perinatal milieu is a great asset.

This nurse is not just new to the ER.   She is a new grad as well, just out of nursing school like I had been. One of the benefits of working with students and new orientees is that it brings me back to the beginning.  It forces me to think about why we’re doing what we’re doing…why one thing is prioritized over another. During twenty years in the ER one develops shortcuts and workarounds to keep up with the pace of things. But this is a time to go back to basics and model correct methods, doing everything exactly as it is meant to be done, remembering pitfalls and pointing them out to someone who hasn’t yet been exposed to them… maybe keep her from stumbling.

Reflecting on where I started and where I have come I realize there is a lot to keep track of.  Luckily starting out you don’t know what you don’t know so it’s not too intimidating. Her whole career is ahead of her and now is the time to establish strong habits that will serve her as time goes on. Am I really the right person for this? My mind is kind of like a corkscrew. Not linear and methodical. Not by nature anyway, but I can squeeze myself into that mold when it becomes necessary. May I tell you a secret I have discovered? I think a too linear, methodical mind may be a liability in the ER. The way a day descends into barely controlled chaos lends itself to the person with the corkscrew mind. (I tell myself that).

You never know what to expect going in to work in the ER. I have probably said in the past that that is one of the things I really like about my job. It is one of the first things I stress with my orientee. Some days are Sunshine and Roses. Other days are … Not. Some days you have time to talk to the 75 year old children of the 98 year old woman you are taking care of. You can learn about where she grew up, what she did as a child and as a young woman living in a time so different than our own. You can hear about how it was on the family farm in South Dakota… how her husband had a farm accident and a suture was improvised from the E String of a violin by a neighbor who had the ingenuity and the nerve to close the wound with it.

You can learn about the soul damage of a Viet Nam Vet still broken and tormented by events that took place when he was just a kid of 18, now 50 years ago. That’s almost three quarters of his entire life defined by that time and place. The shock of the experience has chiseled deep and disturbing graffiti into the bedrock of his existence that he will never heal. It’s something he carries as a sort of sign saying “Keep Out”, and it works, because, to a large extent people don’t come near him…for better or worse. Guilt and pride for one’s service can be so fatally conjoined for some men I have spoken to that they can’t separate them and remembering either is a minefield they will not enter.

Having time with people brings gifts wrapped in lifetimes of emotion that you must open carefully. If you open them at all.

Some days there is no time for talk. No time to get to know the human side of the person you are caring for. The relationship can be so thin it is frustrating. You can feel like you are running full speed just to stay several steps behind and still lose more ground while doing the bare minimum… so much less than you know you are capable of, so much less than you know the person deserves. You would happily give so much more…but there’s no time. You just hope you don’t miss something important in times like that. Consequences are real and the weight pulls at you.

When I started the first day with this new nurse, as her guide and resource person, I never imagined that what had happened to me would happen to her. On my first day here we had a patient who died. It hadn’t occurred to me we would be dealing with the many tiers of issues that come with a death in the ER. The vast majority of shifts go by without a loss of life. But we heard the voice of the paramedic over the radio. It was a Code-3 ambulance… a cardiac arrest at home. Resuscitation was well under way, CPR was in progress. A tube had been placed for ventilation. Epinephrine and Amiodarone (Potent Cardiac Drugs) had been given through the IV. They had defibrillated the patient. (Delivered powerful electric shocks through the chest) to try to trigger an intrinsic heartbeat. They had repeated the process again…


Was the patient alive when he got to us? Legally yes. Physiologically? I believe not. We heard the report of what had happened at the house…what the paramedics had done and what response there had been, how long the man had been without a pulse. We asked the questions about past medical history while assuming responsibility for chest compressions. My orientee did them. It was her first time. We asked about medications the man takes while we started a second IV and drew blood. Respiratory therapy took over manual ventilation. Between cycles of compressions the heart rhythm was analyzed on the monitor. Asystole (No activity). Pupillary responsiveness was assessed. (Non-reactive and Dilated). Compressions were continued. Another round of Epinephrine was given…

This procedure…following ACLS (Advanced Cardiac Life Support) protocols for pulseless cardiac arrest can bring a person back. When you hear a person say they were dead for 2 minutes, or what have you, but they were brought back, this is what they are talking about. They were successfully resuscitated after their heart had ceased to beat. That is actually the miraculous success story of a friend of mine who was brought back after sudden cardiac arrest. But that is the exception. That is not what happened this time.

This time the patient died. He had a large family. Several people were on their way to be with him in the hospital. Thankfully we were not too busy at the time and we were able to give the family time to grieve …time for the people on their way to arrive and be together with the others. Time for it to sink in that he was gone. It is a small mercy, but can mean a lot.

It was sinking in for our new nurse too. She had never done CPR, had never felt the sensation travel up through her hands and arms to her own heart of how violent an act a cardiac resuscitation is. It is physically, mentally and emotionally demanding. A hell of an introduction to ER Nursing, having to figure out on the fly how to master your emotions in a hectic situation and keep your focus where it needs to be so you can do your job. And it’s all new. The team chemistry where everyone has isolated tasks and a practiced way of communicating and performing their role so the person you’re working on can have a chance at life. She had never been a part of any of that.

It’s interesting to be made aware that the person you are helping learn about her new workplace has just been closer to a dead body than she has ever been before. She has never touched the lifeless body of another human being. Thinking about it, most of us probably have not. I have. Many times. It is not easy, but there is a certain getting used to it in the context of the medical setting. It is a fact that one must be ready for. We weren’t.

She had lots of questions. Naturally. We have a checklist to help us remember all the important steps to be taken when you have a death in the ER. I guided her through all the things we do. We didn’t yet speak of what was going on below the level of our brains. What was rattling around untended in our hearts would just have to rattle there for a bit. We went down the list: Call the California Transplant/ Tissue Donor Network. This is required for every death in the ER. They have trained staff who take the calls, gather information on the person: age, sex, prior medical conditions, “Is the patient on a ventilator, or had they been during their treatment?”, is there family with them?, are we able to provide contact information of the next of kin?, will this patient be a coroner’s case?. The Donor network contacts every family at some point to see if there is any interest in donating any organs or tissues for transplantation to give hope to another person. That is a job that must take some finesse.

Contact Next of Kin (If that hasn’t already been done). Call the Coroner and give them information so they can determine if the Coroner’s Office will require an autopsy… Any time there is a suspicion of foul play, or if the death is unexpected and the person has not been under the care of a physician within a set time period an autopsy will be ordered by the Coroner and they will dispatch an officer to pick up the body.

Find out if the patient or their family have a prior agreement with any local mortuary for their funeral services. If so we will contact them on behalf of the family if that is their wish. Notify the Nursing Supervisor of the death. Make an inventory of any valuables or personal effects on or with the body. Offer for the family to take any effects with them at this time, or they can collect them later according to their preference. Contact Security. Any effects not taken by the family will go with security for safekeeping. Also at this time we will enshroud the body in a post mortem bag. Security often helps with this. Then the body will go to the hospital morgue awaiting disposition, either to a mortuary, to the coroner or with donor services.

File an event report on-line. This is something that goes to the corporate Risk Management Department for follow up, just as a matter of protocol. I’m sure deaths can easily turn into a potential for litigation. Crazy world. That about does it for the checklist. Quite a few tasks and contacts most of us will never have to give a thought to , but my orientee did. On day one. I should say she was strong and professional. That is how you have to be. I was impressed.

Things got busy in the ER. We had a group of other patients to take care of, though none of them stand out in my memory now. You just keep working. Especially when it’s all a new experience for you, you have a tendency to try to find something to hold onto, that will steady and balance the surreality of what you have been part of. At the end of the day I told her she had done well and asked if she needed to talk about any of it. We did have a conversation about what was coming up for her. She said it wasn’t as hard as it might have been because she felt no life in the gentleman when he came in. She said she just felt his spirit had already departed his body before he ever even got to us. So she didn’t have the feeling that we might have been able to have saved him but didn’t, or that he died in our presence…he was already gone. That helped her somehow.

She has a supportive husband who she will be able to talk things through with. Each of us has to find our own way with this part of the job. We all come from different traditions, religions or spiritual practices that may help us have perspective on death. Maybe we don’t have any such thing. To give her hope and minimize the dread of facing another day like this tomorrow, I told her, “It’s not always like this”. “In fact it’s rare”.

We had a little chuckle over that and went our own ways, to come back tomorrow.

The next day started out slowly, as they thankfully often do. A lot of mornings feel like we’re running a pediatric clinic. Babies and toddlers who have fevered in the night, or coughed or vomited keeping their parents awake are brought in to be checked out. Most of the time these are reassurance visits for the parents more than medical visits for the children. We meet a lot of beautiful little ones this way. It’s one of the sweet parts of the job. It was a nice way to begin again and put the darkness of the day before out of our minds.

It wasn’t long before the course of the day veered hard away from sweetness and accelerated us back again to our post on the portal between life and death. On this, her second day in the ER, this new nurse had to face the very situation she had said would have been harder than what she had done the day before. (And is maybe the hardest situation we do face). We had a patient who was alive when she came in. She was very ill though. A child with terminal illness. She was very weak and her degenerative condition had worsened to the point she could no longer carry on. Her parents knew she was dying. Their faces and posture were like stone. This day, which they had known for so long was coming had arrived.

When our efforts to sustain her proved futile and she ceased her struggle, her little body relaxed. Who knows if she had ever, in her brief time on Earth, known comfort and ease? Her parents were so quiet. Sometimes there is wailing and an angry defiance that death has come, a sharp and bitter refusal. But here, there was resignation and letting go. We were witness to a stoic acceptance of fate borne with dignity and grace by this silent couple saying goodbye to someone they had loved so dearly and who had needed them so completely. I wonder how much they needed her too, how much their lives had become about the dailiness of her care, how would they move on?

What can it mean that your first two days as a nurse are like this? Your training is definitely focused on the interventions you do to keep people alive and to make their lives as full and functional as possible. Very little Nursing School instruction addresses how you cope with death or how you’re supposed to help others with their loss. So this? Sure it’s got to be part of the Nursing experience, but maybe you could ease into it over time? This is sort of an assault to be greeted by your profession in such a way. I wish I had some stabilizing and comforting wisdom to share with her at the end of day two. She called me out on having told her, “It’s not always like this”. She asked if I meant it, if I really meant it, or if it really was going to be like this every day. “Hardly ever”, I tried to assure her. Tomorrow would be better. She would see.

So much comes at you in a day, and so much more in a week, that even if you try to remember everything, you just can’t. I should say I can’t. Some things I remember in detail, others not at all. By the end of a day I couldn’t recount every patient I had cared for that day. So when I’m trying to piece together the events of this first part of working with this new nurse a lot is lost. Mostly what I remember is the overall feeling of the days. By the third day I was ready to show her how a normal day in the ER plays out… a day where you take care of your garden variety patients without wishing them bon voyage over the River Styx. She was ready for that too. That’s what we had in mind as we started our third day together.

Oh how I wish we had been able to end that day as we had envisioned it. Maybe a bloody. nose, some sutures, someone falling off a bike or a horse but not much worse for the wear. Maybe a bunch of kids with fevers or asthma or ear infections. Maybe an abscess from skin popping – oh I mean from a spider bite- . Maybe poison oak or passed out drunk or closed their finger in the door. I’m talking about people who come in, you work with them and they walk out the door. That is the day we wanted (and which I had tacitly promised). Not the day we had.

We’re given to a few superstitions in the ER. One is that you are Never to say the “Q” word. SShh. (It rhymes with “Riot”). Say that and your co-workers will be all over you in an instant. And if something bad rolls in, or if it gets really busy you are to blame. You opened Pandora’ Box. As for myself, I’m not given to that particular superstition. I think that when it is not horrendously busy you ought to be able to gratefully acknowledge that. But I’m an outlier on that point. Another superstition (and I am an adherent to this one) is that things come in threes. It has just happened too many times for me to say it’s nonsense. So it was for us. We had our third.

Code-3 ambulance…respiratory distress…Paramedics were giving nebulized Albuterol and had put the patient on CPAP. You know those forced air machines heavy snorers use when they sleep to prevent sleep apnea? They’re used for respiratory distress too. When a person has been working really hard to breathe for a long time they can become fatigued and the work of breathing can tire them to the point of respiratory failure…they just can’t keep working that hard any longer. So the positive pressure of the machine does the work. When they arrived the patient was sitting straight up, restless with the CPAP blowing oxygen into his face. His fingers and toes were becoming bluish. His blood pressure was very high also. There was some obstructive airway process, Air wasn’t getting deeply into his lungs where the Oxygen can trade places on the hemoglobin with the CO2 he needed to get rid of.

The patient needed to be intubated. A breathing tube would have to be inserted and the patient put on a ventilator so he could continue to breathe and stay alive. Since he was awake and alert we would have to use RSI (Rapid Sequence Induction). This is a procedure to rapidly induce anesthesia and paralysis so the patient can be emergently intubated. This is a stressful thing to do. You have a person who is awake and breathing on his own, thought not adequately. And what you have to do is knock him out and paralyze him so he will relax his muscles and you can insert the EndoTracheal Tube. It is a moment of truth when you push that paralytic. It is derived from Curare, the Amazonian blowdart poison that paralyzes the prey so the hunters can bring home food. The only thing is, if you can’t sink the tube once the person is paralyzed you’ve got big problems.

Once the person is paralyzed you have got to be able to provide ventilation, since their diaphragm is immobile. If you fail to insert the ET Tube you can still fall back on forcing air through the nose and mouth with an Ambu-Bag to get oxygen to the lungs, But this doesn’t protect the airway and puts you in a worse position than when the guy just couldn’t breathe for himself. You 100% have to get the tube in place or your patient is going to suffocate right in front of you and you will be, to no small extent, responsible.

The intubation went fine. A portable chest x-ray showed the tube was about a half centimeter too deep, so Respiratory Therapy backed it out and re-secured it. Breath sounds could be heard in both lungs but his oxygenation was still not good. The ventilator was set up, but the patient started to fight it as the meds wore off. This is normal. He needed sedation. So we got out the Propofol and started an infusion, advancing the dose to try to get him relaxed again. He was a large man, so it took a lot to begin to work. We got his Blood Gas results and he was still not getting enough O2 and getting rid of enough CO2 and he was severely acidotic. The ventilator settings were revised to compensate. The other blood tests revealed a dangerous excess of potassium. His blood glucose was sky high, his lungs were full of fluid and his kidney function was failing.

It’s a high adrenaline scenario with a lot to do immediately and no wiggle room in getting it done. Even when all goes well and you’re accomplishing all your treatment goals, to counteract the list of emergency conditions you are aware of, there may still be others you don’t know about and the patient may still deteriorate. Maybe he has massive pulmonary emboli (blood clots in the lungs), occluded coronary arteries, DKA, MI, ringworm. (Alright we’re not going to sweat the ringworm). So even though we were doing everything we could he was getting worse.

Maybe if he had gotten to us sooner? It was her second time doing CPR. But harder this time because this person had been alive for her. She had known him to be a living human being and we had swum against the current to try to rescue him as he went down, but we lost him.

1-2-3 days, beginning to wonder if this career move was such a good idea. “I don’t know if I can take it if it’s going to be this way every day”. “You said it isn’t always like this. But it is. Why did you say that?”. I knew it was true, what I had said. It isn’t always like this. Thankfully I knew that. She had yet to see anything else. What was she to believe? I couldn’t fix it by talking. She would just have to experience better days. We had a few days off after that to try to shake some of it off.

When I first started working as a nurse I had three pairs of scrubs, all Forest Green. A rotation of three pairs is a decent start. My orientee started out with a few pairs, all of them black. After this day she questioned that choice. Was wearing all black inviting trouble? Before we came together again after our days off, she got some colored scrubs and has never worn all black again.

When we started off our fourth day I went out on a limb with her, because I figured,”Why should she believe me”, when I said it, but I told her again, “It isn’t always like that”. (It was probably beginning to sound like a worn out joke) “Most of the time it is nothing like that. It is going to get better and your patients are going to walk out that door like they’re supposed to”. She gave me a hard look. She had seen my quirky side, but she had seen me solemn as well. I believe I am a pretty transparent person and with that penetrating stare I think she could see it in my heart, I meant it. So she trusted me as we began another day.

Nearly a year has passed and she has never seen a stretch of consecutive days like those first three. She made it past that and has it as a foundation in her practice. Trial by fire has formed her and branded an indelible mark that speaks about Life and Death and ER Nursing. With that as a frame of reference, I should think the rest of the job looks pretty good.

6 thoughts on “It’s Not Always Like This

  1. Wow. That piece was both over powering and amazing. You have a gift of writing, Miguel. And such a gift I received from reading your piece. Love from Mary Lu

    Sent from my iPhone


    Liked by 1 person

  2. What a remarkable mentor and mentee relationship, thank you for writing this. When I was a new RN is was trail by fire with little to no support from co-workers and certainly no mentor. That was 1982, so happy to know that things have changed for the better!

    Liked by 1 person

  3. Michael I thoroughly, thoroughly enjoyed ““ it’s not always like this “. As a new nurse myself I found it to be therapeutic really, because some days are just beyond words but you gave some of those days words for me. Thank you Michael. I would like to add that in your very creative, yet solemn way you have given voice to the terror and delight , to the joy and the grief, the height and the depth of being an emergency room nurse thank you again ! Alma

    Liked by 1 person

    1. Thanks Alma. I surely appreciate hearing back about what I say and how I’m saying it. Your generous response doesn’t surprise me because you are a giving person. It pleases me to know you were able to find yourself in the writing. Who knows how many of us share these same extraordinary experiences and just file the emotions away, or never air them out?


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