Heart of EM

Room 16 Right

The emergency department can be filled with frustration at times. During the first wave of COVID-19 illnesses, that frustration reached a boiling point.

There are 4 things especially frustrating in the ED.

The first is the alarms.

They're too frequent and too constant to keep up with on a normal day; throw in a pandemic and you can just imagine. It often seems silly to turn them off, to be honest – give it a few minutes and they'll go right back on, I promise. But every now and then we'll still stop whatever it is we're doing to home in on an alarming monitor and turn it off.

I did this the other day.

The monitor was in room 16R. The patient was a frail older woman with long, white dreadlocks sitting upright in a reclined bed with better posture than my 28-year-old spine has probably ever experienced. She was breathing 40 times a minute, plus or minus; it’s probably why the monitor was going off. She had a mask on her face, strapped to her head like a helmet. From the front of the mask dangled a short, thick tube like an elephant trunk with a smaller tube connecting it to the oxygen port on the wall. The wall port measures 0-15 liters per minute, and the indicator was currently higher than the 15. "Flush rate" we call it, a.k.a. "the patient needs a lot of help breathing."

The second frustrating thing about the ED is the interruptions.

Constant, almost continuous interruptions, for anything, no matter how miniscule. From patients, nurses, clerks to attendings, if you have a plan to do anything at all, expect to be interrupted by someone while you do it. 16R, however, didn’t interrupt me. Instead, she just sat there silently with perfect posture and a freckled, light brown face the same shade as mine.

Her eyes were wide, almost fearful, but focused. I asked her, ironically, if everything was OK, and her brown eyes glanced up at me while her head gave a careful, subtle nod. I quickly understood why. The elephant trunk hanging from her mask was a makeshift CPAP device, designed to keep her lungs from collapsing by giving her added pressure when she exhaled – but really, it was a motley mix of pieced-together tubing and valves that had been constructed in a last-ditch effort to prevent her from being intubated (probably a day ago, I’d say). It worked. Here she was a day later, focused on nothing else but retaining her ability to breathe on her own. The tape holding her mask together must’ve loosened over the hours, to the point that even slight movement caused a leak, and now I had a pretty good explanation for her posture.

I threw on some gloves, adjusted my N95, grabbed new tape, and started retightening every piece of it. Small bursts of air sporadically blew into my face shield with each tweak, and her wide eyes watched the entire time, hopeful this was the last time it would need fixing. I knew it wouldn’t be, but it was the best we could do. 

The third frustration is the phones.

Between them and the monitor alarms, it’s a constant cacophony of beeps and rings doing their absolute best to prevent any sort of concentration. “Dr. Watson, radiology on line 20, Dr. Watson, radiology on line 20." But it wasn’t radiology. Instead it was a small voice saying she’s the daughter a patient who had been there for a few days now, and she just wanted to know if her mother was all right. Obviously, I had pressed the wrong button; line 20 was still on hold and blinking at me.

The small voice asked again for any information, explaining she had been calling all day because she wasn’t allowed to visit, but she hadn’t received any updates. I looked up the patient’s name on the EMR and explained that her mom was admitted 2 days ago and was now in the care of the inpatient team, whereas I was just the ER doc. She couldn’t hear me, of course, so I took off my N95 and offered to page her mother’s team. She said they’d been paged a few times, but they hadn’t called her back. I didn’t doubt her, but I also didn’t know what else to say. I was sifting through her mother’s EMR, looking for any information I could offer, when I noticed next to the patient’s name was her location: 16R.

I still didn't really know this patient, but I felt like I did. She was technically an "upstairs" patient, and on a normal day I probably never would have met her. But on this day I had a face in mind. A freckled, light-skinned face that was fighting to breathe a few minutes ago. I told the small voice on the phone that I was just in her mother’s room, and mom seemed to be breathing OK with her breathing mask – doing my best to imbue positivity into an intrinsically negative statement. I told this worried daughter I didn’t know all of the details of her mother’s care, but offered to ask her mom any questions. Her small voice became momentarily larger and thankful as she began to speak – “Dr. Watson, radiology on line 20, Dr. Watson, radiology on line 20." I didn’t hear what the daughter said. I wrote down her number on the back of an opened gauze wrapper, weaved back toward room 16R, ignoring the repeat calls to answer radiology on line 20. Multifocal pneumonia, likely viral – I'm sure.

I dialed *67 on my iPhone before her daughter’s number as I walked into 16R and held the phone next to her sweaty, freckled face. Those same wide, brown eyes stared at me, now confused, as her mask whistled with each breath. Her daughter answered the phone, and I watched as the confusion in her eyes transformed into a mixture of joy and longing, then dripped down the sides of her cheeks. It was the first familiar voice she'd heard in days.

And that was the fourth frustrating thing in the ED that day.

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