About six o’clock in the morning, we got a call from an ambulance that they were bringing in a pediatric gunshot victim. I asked myself, “A little kid shot this early in the morning? What the heck?”

In our trauma system, “pediatric” means up to age 18, so I immediately started picturing a seventeen-year-old gang banger shot in the line of duty. This thought was disturbed by a clarification from the nurse: a nine-year-old shot in both legs. That is really strange and left me wondering what the story would be behind this one.

As the trauma team began to assemble in the trauma room in preparation for the arrival of the little gunshot victim, an overhead announcement was heard: “Minor trauma in the department now.” That is said when a trauma patient comes in by private car, rather then by ambulance, and presents to the triage desk in the front of the emergency department.

This patient was also a gunshot victim and the coincidence made me think, immediately, that these two events had to be somehow associated with each other. I assumed we had two victims from the same firefight.

I met the man just as they were going to move him from the wheelchair onto the hospital bed. There was a hole in the top of his athletic shoe with a bit of blood oozing out. He was middle-aged and of slight build. He was in a lot of pain and was very upset. He told me he was getting ready to go to work when his gun accidentally went off. I was unable to get him to explain why he had the gun while getting ready to go to work or why there was a bullet in the chamber. “It was an accident, I swear!” he hollered over and over again.

I tried to reassure him as we started in on all of the treatment he needed: get him undressed and get his shoes off; start an IV for fluids, pain medicine and antibiotics; get an x-ray of the foot; get some more information about just what happened; find if he had any medical history and if he needed a tetanus shot.

As all of this was getting started, the boy came in. He had been shot with a single bullet as he lay on his side in his bed. The bullet entered one of his legs just below the knee, tore off a huge hunk of flesh, shattered the shinbone and passed into the other leg, breaking that shinbone, as well, and lodging just under the skin. We entered into the same plan of care for this gunshot victim.

When I went back to the bedside of the man, I learned that he shot himself through the foot with a high-powered rifle. There was a nasty hole through the middle of his foot leaving one of his toes almost detached. I also learned from the police that, after going through his shoe and foot, the bullet had also gone through his floor and come out of the ceiling in the apartment below, striking the nine-year-old boy as he slept in his bed.

To clarify, I went back to the bedside of the little boy and greeted the mother who was just arriving in the room. She spoke only Spanish so I served as her greeter, translator and explainer. She corroborated the story that a bullet had come down out of the ceiling, striking the boy as he slept in bed.

Both patients were admitted to the hospital. They both needed to go to the operating room to have their injuries surgically repaired. Both would probably end up with some sort of disability because of the accident. Both may well be emotionally scarred as well.

As I was finishing things up, word came back through the police that the wife of the man who was shot in the foot reported he had written a suicide note and had his rifle out with intentions of killing himself when it accidentally went off into his foot. If he was depressed before, how much more depressed will he be now?

Norm was a “regular” in our emergency department for many years. He was recently found down on the sidewalk in front of a liquor store and couldn’t be resuscitated.

Hearing he was dead reminded me of an interaction I had with him years ago.

Before our kids were in school, Shari volunteered for the local food bank. Every Wednesday, she and the kids delivered bags of donated groceries to shut-in elderly people in need. When my schedule allowed, I went with them. One day, as we made our deliveries, we ran into Norm. He provided my young children with an insight into life that they never would have had in our home.

We pulled our Camry up in front of the next house on our delivery route. It was in an older area of town with rundown businesses next to old houses inhabited by a less fortunate swath of society.

Following their normal pattern, Shari and the kids grabbed the bag of groceries and went to the door. While I waited for them, I looked over and was somewhat surprised to see Norm sitting on the ground leaning up against the building. He was drinking with another man I didn’t recognize.

We happened to have an extra bag of groceries so I called out to Norm, addressing him by name. He got up and staggered over to the car. He stuck his head through my open window and leaned his forearms on the door. He was not at all threatening, but he pressed a bit too far into my personal space and forced me to lean back farther in my seat.

It was about then that Shari and the kids returned from making their delivery.  Their conversation stopped and they, somewhat warily, climbed back in the car. The kids listened quietly and watched closely as their dad had a conversation with a dirty, scroungy, drunk man.

I offered Norm the bag of free groceries. He declined it. Then hit me up for money. I told him I was really glad to give him food but that I would not give him money because I knew he would use it to buy booze. That irritated him, so I started the car and told him we were leaving.

As we pulled away, the silence in the car broke. My kids were amazed that I knew Norm and could even call him by name. They wanted to know what he and his companion were doing there on the street. They were surprised he had no interest in food. Our son asked why his hands were so swollen.

I was able to explain that Norm drank too much alcohol. I pointed out other ways he looked and acted differently than people they were used to seeing. It painted a pretty graphic picture that I think was a good lesson for my kids.

The other night, the paramedics brought in a patient that was nervous and paranoid. He was a schizophrenic and admitted to being off of his psychiatric medications for some time. He said he was hearing voices and having thoughts of suicide. I explained someone would soon take him over to the emergency psychiatric ward for help. He agreed to wait. I did his paper work and went to see my next patient just around the corner.

She, too, was a schizophrenic, off her medicines and talking of suicide. Unlike the first gentleman, however, she had behaved so aggressively towards the police and paramedics that they had to restrain her. They did this by putting leather straps on her wrists and ankles and tying her to the gurney. We call this “four points,” meaning four points of restraint, one on each extremity.

By the time I went to see her, she was a lot calmer. I asked if she would behave if we took her restraints off. She assured me she would. As I started to release the restraints, one of the paramedics gave me a look like, “You’ll be sorry!” I released her restraints, reminded her or her agreement to cooperate and left while staff took her vital signs and got her registered.

Very soon, I heard screaming and detected agitation coming from her room. When I got there, she was face down on the floor. The nurse said she had refused to stay in bed and, as soon as she stood up, purposely went to the floor without hurting herself.

Let me help you picture what I saw as I looked down at her on the floor. She was a large woman. She had no clothes on under her hospital gown so her entire backside was visible as she lay sprawled out on the floor at the entrance to the exam room.

She pretended to be unconscious but I knew she could hear me as I told her she had violated our agreement and would now have to be put back in restraints. Hearing this, she immediately jerked herself onto her back. At the same time, she pulled the hospital gown away so her entire naked front side was now visible for the world to see. It appeared she tried to use her nakedness as some sort of a weapon when she was not happy with what was going on.

By this time, at least eight people were at the bedside including two police officers that happened to be in the department. Since the patient refused to get up, I instructed everyone to grab an arm or leg so we could safely get her back on the bed and into restraints.

That is when she really went off. She screamed at the top of her lungs and swung and kicked at us. Unable to get her arm loose from me, she grabbed my pants and tried to pinch my leg. As she flopped on the floor, she tried to pull her gown completely off.

When everyone had a secure hold of her, I called out, “One, two, three…” to coordinate lifting her back on the bed. We maintained our grip while someone went to get the restraints.

Suddenly, I looked over my shoulder to see that the first patient I told you about was now in the room. He was hollering as loudly as the lady was. Having heard her distress, he decided she was in trouble and needed his help. “I’m Federal! I’m Federal!” he repeatedly hollered as he grabbed some of those still trying to restrain the lady. “Let go of her! I’m Federal!”

Unfortunately for him, one of the people he grabbed was a police officer. In a flash, the officer released his hold on the female patient, turned, took the man down, and pinned him face down to the floor.

“Why are you doing this to me? Get your knee out of my back! Let go of me! I’m Federal!” the patient loudly protested. The police officer hollered back at him to shut up.

All of a sudden, I started to laugh. I couldn’t help it. It was too bizarre to even believe. One naked woman screaming and fighting in front of me on the gurney. One man screaming and fighting on the floor right behind me. It was just too crazy.

The woman, who now had her feet in restraints, turned to me and asked, “Why are you laughing?”

“I’m sorry, but it’s just funny,” I said.

“You are the shittiest doctor I ever had in my life,” she said as I was finally able to release her arm, which was now restrained at the wrist.

Soon, both patients were in four point leather restraints and sedated. I hope they were able to get the help they needed when they got to psychiatry.

We don’t have a social worker available to us on the night shift. When we have a patient who is ready for discharge but really needs the help a social worker could provide, I recommend that he or she wait until morning when the social worker gets in.

One night last week, I went home at the end of my shift leaving three patients waiting for the social worker. That was unusual and prompts me to tell you about them.

Lady from Seattle

The paramedics brought us a lady in her seventies. A Good Samaritan found her wandering around, confused, at the bus station. The police were called. They then called paramedics who brought her to the emergency department. The medics told me she had come on the Greyhound from Seattle looking for her son. She had been reported as a missing person, having left her nursing home in Seattle without telling anyone where she was going. The medics suspected her son didn’t even live in our fair city.

The patient said she had no medical complaints. She was a bit strange and had a speech impediment, but knew she was in a hospital in California. She said she had come looking for her son, though she didn’t have any contact information for him. I had no ability, in the middle of the night, to find her a place to go. So, we made her comfortable and she slept until the social worker got there in the morning.

The social worker found out her son did live here. Though he was not expecting his mother, he was glad to come to the hospital and take her to his home.

Open Heart Surgery Man

This guy was in his sixties. Two weeks earlier, he had open-heart surgery to replace a heart valve. On discharge from the hospital, it was arranged for him to go to a nursing home to recover. He came to the emergency department after leaving his skilled nursing facility earlier in the day. He told me he left because “a nurse and I didn’t see eye to eye.”  He said he was not recovered from his surgery and wanted to be readmitted to the hospital until he was able to fully care for himself. When I asked him just what problems he was having, he pulled up his shirt and indignantly said, “Well, you can see this is not healed yet.” The scar he showed me running up the center of his chest was healing perfectly well. There was no sign of infection or any other complication. So, I told him there was no reason to be readmitted. However, I also told him the social worker might help him find a different option for getting the care he felt he needed. I suggested he sit in the waiting room until she arrived. As I watched him leave, I wondered what the real story was. Had he gotten upset with the nursing home and chosen to leave? Or, had he done something to get kicked out? He was irritating enough that I figured either of these could easily have been true.

As it turned out, his doctor at the nursing home had decided he didn’t need to be there any longer and had discharged him with plans to go stay with his brother. The patient didn’t want to do that so he came to the hospital to be readmitted. The social worker made arrangements for him to get to his brother’s house and off he went.

Mary Kay Man

The third patient was a man about seventy-years-old. He came in complaining of various problems and wanting to be admitted to a nursing home. He was a homeless alcoholic and nearly blind. He had an irritating, unpleasant personality and was dirty, unkept, scraggly and smelly. Then he told me he sold Mary Kay cosmetics. When he told me that, I found it hard to believe anything he said. “Who the heck would buy Mary Kay from this guy?” I asked myself. The nurse pointed out he had a whole bag of new Mary Kay products among his personal belongs, which certainly left me wondering.

When it was clear he needed no medical care, he, too, went back to the waiting room to wait for the arrival of the social worker in the morning.

As it turned out, the social worker knew this guy well from many similar previous encounters. She learned he lost his housing when he was put in jail. He came to the emergency department that night because, recently released from jail, he had nowhere to go and thought being put in a nursing home would be the easiest way to get off the streets.

The social worker give him some direction to find housing. She also clarified that he had a legit, online Mary Kay business. That helped me understand how he could sell Mary Kay without completely wrecking their brand image.

A middle-aged woman was discharged from the hospital after a three-day stay for treatment of injuries suffered in a car crash. Less than twelve hours later, she was back in our emergency room.

She told me her son took her to a motel room and told her they would spend three days watching TV there until they could get into “the condo.” After settling into the motel, the son left to go out for something and did not return. In trying to get to the toilet alone, she ended up on the floor and was unable to get up. So, she called the ambulance, which brought her back to the hospital.

I clarified she was there only because of not being able to care for herself and not for any new medical problem. I told her we would make her comfortable on a gurney in the hallway until morning when someone from social services could see what might be done to help her.

Feeling comfortable with that plan, I placed her at the bottom of my priority list. Normally, I would have given her little attention for the rest of the shift.

Some time later, I went into a room and smelled cigarette smoke. I asked the people on one side of the room if they had been smoking, which they credibly denied. The other lady in the room was a severely demented nursing home patient who would not be able to smoke if she wanted to. Where was that smoke coming from?

As I walked back into the hall, I noticed an orange Bic lighter on the sheet next to the lady from the motel. I approached her and asked if she had been smoking. Slowly and dramatically, she pulled her hand out from where it had been hiding between the bed and the wall. In it was a lit cigarette. Mind you, this is in California where you basically can’t smoke in any public building. On top of that, this is a hospital! And right in the center of the emergency department! We occasionally catch someone smoking in the restroom, but I have never seen anyone brazen enough to smoke right in front of us.

Anger and indignation welled up inside me. I have never been good at hiding my feelings and in this case, I did not even try. I felt it important that the lady know I was completely disgusted. I said something snotty as I took the cigarette away from her, doused it with water and threw it into the trash.

A couple of hours later, I heard heated voices coming from the area where her gurney was parked. I looked up and saw a young man in conversation with her. I assumed, correctly, that he was her son. Before I could get over to talk with them, I overheard some of their loud conversation including sentences like, “Get me the fuck out of here!” and “Just shut up!”

I wish there were some way for me to paint an adequate picture of the interpersonal pathology displayed between these two people. She showed clear signs of having a personality disorder. Everything was about her. All she could do was be indignant and nasty because she didn’t have everything exactly how she wanted it. She even lit up another cigarette and sat puffing away while her son berated her for behaving worse than his three-year-old.

I tried to intervene but soon realized I was not going to have any positive impact on the way they were dealing with each other. All I could do was give them their options: leave or wait quietly until social services could see her in the morning.

She demanded he take her to the hotel. He insisted she try to get some help. In the end, he took her away, cursing and complaining. I hate to think of how things went when they got back to the motel.

A 67-year-old man was brought in by ambulance after being found unconscious with empty alcohol and pill bottles nearby. A review of his old emergency department visits showed he had a long history of drug and alcohol abuse.

He was so intoxicated there was concern he would stop breathing. So, he was intubated, which means a tube was placed into his windpipe and he was placed on a ventilator. However, other than a high alcohol level and Valium in his urine toxicology screen, nothing else turned up on his emergency department evaluation to explain his altered level of consciousness.

The intensive care consultant who came to see him wanted a CT scan of his brain. Even though there was no evidence the patient had suffered any trauma, the consultant wanted to make sure he didn’t have bleeding in his brain that would explain why he was so out of it.

Everyone was totally surprised when this picture showed up on the scan:

Here is a close up:

Let me help you understand what you are looking at here. This is a side view of the patient’s head. Only the bones show clearly. It can be seen that a nail entered his head from the front, in the middle of his forehead. As it passed back (from right to left on the image,) it went through the skin of the forehead, into the skull and through the frontal sinus, which is an air-filled space in the skull right above the eyes. The nail went in with enough force that it continued through the frontal sinus and stopped with the head of the nail pressed against the back of that same sinus. At the same time, the tip of the nail broke into the space where the brain sits. As it went in, it apparently missed injuring any important structures, sliding right under the bottom of the brain. The tip of the nail then continued out of the brain compartment and ended up in the sphenoid sinus, another air-filled cavity in the skull, back behind the nose.

A recheck of the patient’s forehead, where the nail would have entered, showed no open wound. A recheck of his old visits showed no mention of a nail in the brain. In fact, when the patient was seen two months earlier for a similar spell of intoxication, he had also had his head scanned and there was no nail there then. Because the nail did not seem to have injured his brain, it was felt that the patient’s unconsciousness was due to alcohol and Valium.

The next day, the patient woke up. He said he didn’t know he had a nail in his head and had no memory of any event that might have left him with one. He also denied any headaches or other symptoms that might be caused by having a nail in his head.

The patient was seen by a neurosurgeon who felt that, if having a nail in his skull did not bother the patient, there was no reason to remove it. The patient was discharged with referral for drug and alcohol counseling.

I am sure no one will ever understand exactly what happened. However, the best guess is that some time in the previous two months, the patient was shot in the head with a nail gun. It had been long enough for the puncture wound on the forehead to completely heal over so there was no sign left on the outside.

Beyond that, we have only more puzzling questions. Was he shot on accident at a construction work site? Did someone shoot him on purpose trying, unsuccessfully, to kill him? Did he shoot himself with a nail gun, trying to kill himself? Was he so drunk he really didn’t remember the event or was he lying when claiming to have no knowledge of what happened?

How could you get a huge nail shot into your head, have it penetrate your skin, frontal sinus, inside of the skull around the brain and out into your sphenoid sinus and never develop headaches or an infection? A truly amazing story that is hard to even believe.

Pediatric Pancreatitis

The pancreas is an organ that lies across the upper abdomen. It has two functions. First, it is where insulin is made. Children who develop diabetes usually do so because their pancreas quits making insulin.

The other function of the pancreas is to make digestive juices, including several enzymes. These are secreted into the gut and help break down the food you eat so it can be absorbed into your body. When the pancreas gets inflamed, these digestive enzymes escape from the pancreas and end up in the blood. The diagnosis of pancreatitis, or inflammation of the pancreas, is made if these enzyme blood levels are elevated.

The most common cause of the pancreatitis we see in the emergency department is caused by drinking an excess of alcohol. If an alcoholic comes in with upper abdominal pain, nausea and vomiting, we measure the level of lipase, one of those digestive enzymes. If it is elevated, the diagnosis is pancreatitis, and we treat the patient with IV fluids and medications for pain and nausea. The patient gets nothing to eat or drink until the symptoms have resolved.

There are many other, less common causes of pancreatitis and it can also occur in children.

One night, I was taking care of a ten-year-old boy who presented with upper abdominal pain and vomiting. We see lots of kids with abdominal pain and vomiting, usually caused by food poisoning or an intestinal virus. There was something different about this boy. He seemed sicker and his abdomen was more tender than we usually see. I ordered laboratory tests that surprisingly suggested the patient had pancreatitis. The pediatrician was called to admit the patient for treatment and further testing to determine the cause of this unusual condition.

While we were waiting for the pediatrician to come see him, I heard a commotion in the patient’s room and went to see what was going on. When I walked in, a nurse and a couple of family members were talking excitedly and hustling around the room. Sitting on the gurney was the chubby patient with a miserable, embarrassed look on his face and tears running down his red cheeks. In his lap, sat a plastic basin holding a mass of squirming, waxy-colored worms he had just vomited up.

I asked him if he had vomited worms at home. He slowly nodded his head and admitted he had flushed them down the toilet before anyone could see them.

Now, there was no reason to wonder why this boy had pancreatitis. He had recently gone on vacation to Mexico and eaten food contaminated with fertilized worm eggs. The eggs hatched into larvae, which moved through the lining of his small intestine. The larvae entered his veins and floated in the blood until they got to his lungs. They then crawled up out of his lungs into the back of his throat and were swallowed. The larvae matured and filled my patient’s guts with worms, some of which he vomited up. Others crawled up into and plugged the duct that carries the pancreatic fluids from the pancreas into his intestine. When the duct was plugged with worms, the pancreatic fluids backed up and made him sick.

The worms were mating inside him and the fertilized eggs were being passed in his stool. In unsanitary conditions, the eggs might have ended up on food that another person would eat and the lifecycle of the ascaris worms would have started over again.

Due to our first-world sanitation, we almost never see such an infection, but up to a quarter of the people in the world are affected with intestinal roundworms.

Fortunately, they are easily killed with anti-parasite medications and, most likely, the boy was going to be fine. Had he lived in a part of the world with no medical care, however, his outlook would not have been so hopeful.

Here are a couple of references if you just have to read more about intestinal worms. Enjoy!

https://en.wikipedia.org/wiki/Ascaris

http://www.medscape.com/viewarticle/410709_3

Quincy is an outdated name for a peritonsillar abscess.* This is an infection with a pocket of pus in the back of the throat, under one of the tonsils. People with a peritonsillar abscess have a very bad sore throat, fever and difficulty swallowing. It is really a miserable thing to endure.

When such patients come into our emergency department, we start an IV, through which we give them fluids, pain medicine and antibiotics. We then drain the pus out of the abscess, either by sucking it out with a big needle or cutting it open with a scalpel.

I had never really thought, before, about what might happen to a patient with a peritonsillar abscess if there were no one like me around to provide any care. I got insight into that when I was reading an account in a life history written by my great-grandfather, George Arthur Hurst. The event happened when he was twelve years old. I offer it not as a testimony that God answers prayers. Rather, I share it to offer insight into what illness was like when people had no access to medical care.

“In the summer of 1883, my mother was very ill with Quinsy. She had not eaten a morsel of food for fourteen days, as her throat was so badly swollen that she could not swallow. Father was away on a business trip. My older sister, Luell, had gone on a visit. I was the oldest child at home and was trying to do something to relieve Mother’s suffering.

“I felt I needed help. I went out in the orchard where I knew I was alone and kneeled down and poured out my heart to my Heavenly Father and asked him to come to our assistance and relieve Mother’s suffering, if it was his will.

“I arose, feeling much lighter hearted, knowing that my prayer had been heard and would be answered.

“I had no sooner reached the house when the baseness in Mother’s throat broke with such a gush that it nearly strangled her. I grabbed a small wash bowel and handed it to her. There was half a bowl full of puss and blood ran from her mouth and nostrils. As soon as she could clear her throat enough to talk, she told me to make a fire and cook a bowel of cornmeal gruel for her, which I did, then added a little new milk and gave her to drink. With some difficulty she drank the gruel and in about ten minutes she dropped off to sleep and did not awake until late morning.

“Can you make me think this was not a direct answer to my fervent and humble prayer!”

From George Arthur’s description, it is obvious that the abscess finally grew so large that it burst, allowing the pus to escape. Only then was his mother able to swallow. Thank goodness we have access to medical care so we don’t have to suffer like this.

* https://en.wikipedia.org/wiki/Peritonsillar_abscess

At 6:45 am, just when things should be tied together for the end of my shift, medics brought in a ten-year-old girl having a seizure. Her mother and the paramedics had both given her emergency medication but she was still seizing, though not violently.

Before I could even evaluate the patient, the mother approached me to say her daughter had a long history of seizures. She said she had with her a letter from their pediatric neurologist saying the patient should be given 20 milligrams per kilogram of phenobarbital in situations like this. Information from family is always helpful. It helps guide, but never overrides, my best judgment on how to care for patients. In this case, I reassured mom we would give her daughter that medication as soon as we had an IV line in place. Mom told me she was going up to the inpatient pediatric unit to “get help.” “Oh well,” I thought as she disappeared.

Our excellent nurses quickly placed two IV lines so, without delay, we were able to give the child 2 milligrams of lorazepam intravenously. This fast-acting medication stopped the seizure. Once that was controlled, we discovered the child also had a high fever, so I ordered all the tests we normally do on someone with uncontrolled seizures as well as those to find out why she had a fever.

By this time, the mother returned, apparently frustrated in her efforts to rally help from the people on the pediatric unit. She immediately tried to take control of the situation in the emergency department. She refused to let us put in a urinary catheter so we could collect and check her daughter’s urine for a urinary track infection. She demanded that one of the two IVs be removed. She refused to let one specific nurse provide care, etc. Her understandable concern for her daughter was disrupting the care her daughter needed.

I took mom aside and made her look directly at me. Then, in a calm voice, I pointed out her daughter stopped seizing after the medicine we gave her and I explained what else we were doing to take care of her. Mom argued that the lorazepam would not last for long. In reply, I pointed out the nurse who, at that very moment, was giving the longer-lasting phenobarbital she had told me the patient needed. With that, Mom seemed to relax somewhat.

I updated the day shift doctor on the case and went to finish up my charting. From the nurses’ station, I heard the mother get so out of hand my partner threatened to remove her from the emergency department if she didn’t calm down. In response, mom called the police on him.

Records showed that this mother had done similar things during previous hospital stays including calling the police to report nurses and doctors. People had spent time helping her see the effect her behavior might have on care providers. It obviously didn’t work because the mother resorted to the same behavior the morning I was in charge of her daughter’s care.

It is hard to imagine how difficult it is for parents to deal with stressful, long-term situations like this. You learn by experience what works for your child. And because you would do anything necessary, you can’t stand someone doing things different than what you would do. Your love and frustration drive you to take control of situations even when that causes problems for those caring for your loved one. You just want your child to be safe and normal, and you would do anything to make that happen. (In this situation, we later found out the child had been taken to China for experimental stem cell injections in an effort to cure her seizures.)

As I walked through the emergency department on my way out, the mother approached me in the hall and took time to thank me. She told me I was the first doctor to ever listen to her. I found that amusing and it made me feel good though I doubted it was true.

The medics brought in a twenty-three-year-old woman unconscious with an overdose. They reported she had texted family members telling them she wanted to die. Then she took some pills, washed down with alcohol.

It was obvious she was really intoxicated. As we watched her, it became clear she was not breathing well, which worried me, so I performed an intubation. This means that I passed a tube into her windpipe. She was then put on a ventilator and I arranged to have her admitted to intensive care.

During this time, I asked multiple times if we had been able to reach any family. I was told no one had called us about the patient and we had no contact information for her.

My shift ends at 7:00 am. Just as I was ready to leave, Mom walked in. She said she got the suicide text from her daughter, called 911, and then, went back to bed.

As it turned out, Mom was a nurse at our hospital. At 7:00 am, she reported to work and got her assignment of patients for the day. She then decided to see how her daughter was doing. By looking on the computer system, she saw her daughter was headed to the ICU. Only then did she come down to the emergency department.

I don’t understand this. Maybe Mom had so many problems with her daughter in the past she was not up to mounting a serious concern about her that morning. Maybe she didn’t even consider that her daughter might be seriously ill. Maybe she really didn’t care. I don’t know, but it is amazing to think she had a good night’s sleep, then got up and reported to work before checking to see if her daughter was alive or dead.

As a side note, I faced an interesting medical dilemma in caring for this patient. I intubated her because she was so intoxicated she was not breathing well. Yet, as soon as I got her intubated, the irritation from the intubation caused her to wake up! She got agitated and began to bite on the tube and fight the ventilator. She would buck, eyes open widely but blindly, and bolt nearly upright in the bed. In order for her to relax and tolerate the ventilator, I needed to sedate her even more. It was like giving her more of the disease for which I was treating her! Still, I had to medicate her so she could be comfortable as she went upstairs.