Harborview Moments: A montage..

Harborview Medical Center is the WAMI region Level 1 Trauma center, meaning Washington, Alaska, Montana and Idaho all send their critically ill and injured to HMC in downtown Seattle. This is where I have been for all of my clinical rotations as a nursing student, except for my peds rotation at Children's Regional Medical Hospital where I battled with toddlers to listen to their tummies and give them goopy sickeningly sweet smelling medications. One of my highlights at Children's was the "patient teaching" I did for my eight year old with an infected broken bone, I taught him how to play Battleship, we played for hours, it was awesome.

Anyway, Harborview is an incredible place. Let me give you a little run down of the past 9 months...

Key Words: ED = Emergency Department, TICU = Trauma Intensive Care Unit, BICU = Burn ICU, sedated = medication induced depressed central nervous system state in which a person is asleep and possibly without memory of experience, intubated = tube down a patient's throat to provide on airway, ventilator = machine that is hooked up to intubation device to manually or mechanically breathe for someone who is otherwise unable to breathe on their own e.g. a sedated individual, KCJ = King County Jail, CT = computed tomography, referred to sometimes as a CAT scan, FEMA = Federal Emergency Management Agency, divert = not enough beds or staff at the hospital to take any more non-critical patients--must be dispatched to other hospitals, IV = intravenous, BP = blood pressure, stridor = abnormal high-pitched breathing sound usually caused by throat blockage. Please let me know if I missed any!


One of my first weeks on the medical unit I had a patient who had a septic abdominal and pelvic infection and he needed a femur traction to stabilize the leg bone in place of the acetabulum in his pelvis. A surgical resident arrived bedside to perform the procedure, and asked if I'd be willing to help. As I'm donning sterile gloves, my first time practicing sterile field technique, he warns me that he recently had an army medic assist him in the ED and the guy passed out from the blood. The surgeon tells me it's a pretty barbaric procedure, "Ortho always is," he says. So far I think I'll be fine. I position myself to hold my patient's thigh with one hand and his knee with the other, to stabilize the femur. Andrew (as the surgeon had introduced himself) was giving lidocaine injections to the pin sites, the spots where the traction pin was to be inserted and then exit the leg on the other side. He begins to hand drill directly into the first lidocaine mark on the inside of the leg. My patient is psyching himself out to be royally in pain, I tell him to hold onto my elbow, and he grips it for dear life. Moments later, Andrew says, "Did you feel that? That vibration means we're in the bone now." After more manual drilling of this rather serious looking hardware the pin begins pushing its way out the other side. Andrew says, "Hmm, I think I missed the lidocaine wheel, but we're almost done here." As the pin emerges the skin around the site has become twisted with the manual turning, and Andrew very simply takes a scalpel and quickly slices from the pin outward about a centimeter to "unscrew" the tighly coiled skin. Now he attaches the device that will connect to the end of the bed and the rope that will be connected to each pin on the traction piece and the 15 lbs of weight that is hanging from this rope and dangling off the side of the bed, ya know to stabilize the leg.

Fast forward  a few months (to just a few weeks ago)  in the TICU where my nurse tells me to go watch a "Halo" placement on a newly admitted patient with a spine injury from a high speed motor vehicle collision. I stand in the back as a Neuro surgeon proceeds to inject lidocaine wheels into several key targets on this man's head. Then the halo contraption is placed and the pins are being screwed in. There were two of them working on either side with another surgeon holding his head, the patient here was sedated and ventilated. Once the whole procedure was finished the main surgeon turns to me and says, "Well, what did you think of that?" and I said, "Not as barbaric as a femur traction..." and he replies, "Ortho always is more barbaric..."

The day that I first shadowed in the ED was a day that folks in the community were not taking care of themselves as a general rule. I was immediately ushered into a curtained section where a man was sitting perfectly calmly as people buzzed all around him. His left hand was wrapped in gauze. He had been working in a steel cutting factory and had sliced off his fingers. The digits were in the cooler next to him. This became the main focus. The cooler was opened, the ice was dug through, a plastic biohazard bag was found and opened, rollls and rolls of gauze were unraveled and four separate dirty, but very cleanly severed fingers were revealed. You could see a creamy white round disc at the base of each finger, and when the hand was simultaneously unraveled from the gauze it also had four matching white discs of bone where his fingers had recently been. The patient was peering over the side of the bed and sneaking peaks at his own flesh. The doc said he's do his best, and that he was about to be wheeled in for a day of fine tuned surgery. The patient, very calmly, says "I just need one, just save at least one..."

The first bed in the ED is typically saved for a big trauma. So that's who showed up next. A KCJ man of 25 had jumped, he was later affectionately called the "jumper," from a two-story building and landed on his head... and never lost consciousness. He was immediately stapled and whisked into CT to scan for skull fractures and anything else. I peaked in on an x-ray and saw a couple of teeth in his stomach on the image they were collecting. When he was back out on the floor he needed to have his staples removed and proper sutchuring done to keep the swelling in check. I had been blotting his dry and cracked lips with a wet paper towel because he desparately wanted something to drink and wasn't able. As the doc was sutchuring two observing amry medics gathered and offered to help, he was obliging. First he asked for saline. The first medic grabbed a vial and handed it to the doc, and as the doc said, "that's lidocaine" I handed the assistant medic the saline flush. After a moment of trying his hardest to push the plunger on the syringe I reached over and unscrewed the cap for him. With the patients eyes covered he asked which one of these guys was helping him out with the wet paper towel... I did it one more time and then moved on to something else.

A classmate of mine also spent a day in the ED, and during report at the end of the day she says, "Jane, I thought of you down there today... we had a woman come in with contractions after dosing up with heroin that morning. This was her 8th baby and there wasn't time to take her to the UWMC where they have a Labor & Delivery unit, so we called in an on-call OBGYN doc and took her a semi-private room in the holding zone where she started pushing." This classmate says she's terrified of birth, and did not want to be there, but tried to at least slip into the background when her precepting nurse said they needed her help. She ended up holding a leg and saw very first hand her first birth. Unfortunately the baby (one of probably very few born at HMC) was born addicted to heroin.

I also had the amazing opportunity of riding with the paramedics on the Medic One rig for a day. I rode in the back of the ambulance while two paramedics were in the front (there were no medic students that day, just me). These two had impressive resumes that came up throughout the day; Carl had been with the fire department for over 30 years, and here at Harborview for 27, previously he had worked with FEMA as well--he said he quit after Katrina. Patty had also been doing this for decades and had previously worked as the medic for the swat team, she told me a story about her friend shooting a perfect shot, and that she could still save the guy.

Our first call was to 3rd avenue where a guy was having chest pain. After we assessed we called the EMTs to take him to Providence as Harborview was on divert. Next call took us across the street to the shelter where a woman was having shortness of breath, same deal happened to her. After we joked about hanging out on this block all day we got a call to hop on the freeway and out to a guy who seized and then fell and had a head injury or fell then seized, etc. CPR was on-going at the scene. When we arrived the fire department had revived him, but his blood pressure was dropping. In the back of the rig I watched as IV lines were started as the rig swerved through the streets and the equipement barely stayed put. One of the fire men came with us and helped manually bag the patient after the paramedic intubated him. The fireman was fumbling with the attachments and seemed to always have the wrong one ready. Back at Harborview the patient was taken away and the paramedics split up to do paperwork and re-stock the rig. I was given a pager and told to run to the rig if it went off. Rather soon after that, the pager went off and I found my way back to "my crew," I jumped in the back and we sped off to an address near to where I lived. The medic called back to me, "It's an assualt, we're being called along with the police." All I could think was, should I have a bullet proof vest on for this? At a local Vietnamese restaurant there was a man down on the ground, mumbling, but otherwise conscious. The medics waved the police away, if he had been assaulted, there was no one else there now. We put him in the truck, and the medic asks if I want to put in the IV, absolutely! I tried (we had just had our IV lab the week before) but I swear that 16 gauge needle was bigger than this guys' veins. The medic got it in no problem, and the patient was quicly sedated, intubated and ventilated. This time there was no extra person in the back, so I took on the role of manual ventialtor, and because I had just seen this done, I was much better at it than the fireman. Back at the ED I ran into my classmate who was down there that day, he'd been on the rigs the day before and nothing had really happened that day, he said he stuck around till about 10 pm when he finally went home. Again my two paramedics dispersed and I stayed there with the patient as he began his assessment by the ED Docs. People were shouting out questions, so I thought I would shout out answers; What was his glucose at scene? 138! What was his last BP? Systolic: 130s! What's his name? Last name: L...! Does he have a trauma number? 8....! That was fun. Next page was for a 3 year old boy/allergic reaction. We rushed down to a bus stop nearby. After barely touching a pistachio to his lips this little guy started having trouble breathing. The firemen set him down on the back of the firetruck and tried to tell him how brave he was, one of the medics brought out a teddybear from our rig which this kiddo clung to. He was showing signs of stridor, so we put him in our truck and headed off to Children's Emergency. Here was my big moment... everyone was vying for a distraction, trying to place and IV, give him a shot of epinephrine and benadryl, keep him calm, and all along he's been non-verbal, not making eye-contact and absolutely pertrified, and he looks up at me and mouths, "Wha-what's your name?"

After dropping this little guy off, the medics tell me it's time for lunch. They drive up to Capitol Hill and we all pop out to our respective meals. As I'm waiting for the guy to finish toasting my bagel the pager goes off. I tell the guy I'm actually going to need that bagel now, and I run out the door. I'm about two blocks away from the truck and hear the sirens. They bust down the road and swing into on-coming traffic blocking the street and slam on the brakes. I run around the rig and jump in the back doors. Off we go, and Patty shouts, "Did you get your bagel Jane?"

***

I've had countless experiences like this during my shifts at Harborview, an incredible place to learn, I love it. To my knowledge every one of the above stories proceeded well, with various degrees of recovery and health and survival. I may play a very small role right now, but it seems to be important nonetheless.