Highs and Lows

 

cropped-image.jpegThe “patient nurse” I want to be is getting tested to my upper limits tonight. First, I am working nights with only four hours of sleep on board. Second, it’s not any night, it’s Monday night – the worst night of the week in terms of illness levels, patient volume and available inpatient beds. Third, I’m facing one my least favorite patient types – the overdosed heroin junkie.

This guy (old enough to be admitted to the geriatric service) was found unresponsive and apneic an hour ago by his wife; this isn’t the first time for her. She calls 911 and one of our city’s best paramedic teams responds. They spend 30 minutes coaxing this belligerent old man into their rig. He rouses like a Rock ’em Sock ’em Robot each time his name is called but can’t stay awake more than 30 seconds. He slurs things like — “I’m not going”, “You’re not gonna kill my buzz”, “I know my body, I’m fine.”. His speech is vulgar and crass. He calls these lifesavers undeserved and horrible things. Adding to the challenge, the medics deal with the emotional wife who is screaming and trying to slap her man into submission.enlight40

The medics finally get him into their truck. He’s breathing on his own and maintaining his oxygen saturation > 95% without supplemental need. They collectively decide not to administer naloxone (Narcan) unless he stops breathing. Neither wants to wake a raging bull in the tight, moving confines of a city ambulance.

He arrives safely at our door and, like I mentioned, I pick the short straw – I’ve got an open room that’s close to the nurse’s station with the necessary resuscitation equipment ready to go. I immediately get the same caustic vulgarity with added racist and homophobic slurs. He immediately attempts to leap from the bed but is restrained by a security guard (a much younger, bigger bull!) I give him my “easy way/hard way” speech. My impatience is easy to read and exacerbates the situation. Fortunately, the ED tech assigned to help me is a pro. His calm, steady and reassuring voice gets the results we need. He explains everything he is doing while placing the patient on continuous Oxygen/Respiratory monitoring.

An ED physician immediately responds to the bedside. He likes the call by the medics to hold the naloxone; this becomes our plan as well. He discusses the “monitor to sobriety” plan with the patient and wife. The patient initially balks on staying but, quickly acquiesces to his spouse’s insistence (smart man!). She becomes my focus once the patient falls back to sleep.

This woman provides me with a glimpse into the struggle of living with addiction. She describes the heart-wrenching yet, maddening experience of finding the person you love nearly dead. She is exasperated by constant worry of what feels like an imminent outcome; it hangs like the blade of a guillotine. I screen her for domestic violence as we talk. She tells me she is safe and not being physically abused. “I just feel helpless and scared. This is just messing with my head”.  Her experience softens my callous veneer.

We recently launched a program in our emergency department that enables us to discharge opioid-addicted patients with a two-dose supply of intranasal naloxone. My feelings (biases) on this program are apathetic at best – “this is a no-win epidemic”, “they’re just going to shoot more”, “he’s bent on killing himself over a high” and on my thoughts go. Tonight though, I’m getting schooled to the bigger picture — This is an issue effecting/affecting more than one person. From those closest to, and to

enlight43those of us on the periphery, this opioid epidemic is killing more than those using. The tool I’ve been resisting is one that might give control to the passive victims feeling totally out of it.

Three hours pass and the patient is cleared for discharge. I spend the remainder of our time reviewing the naloxone administration directions. Tears are now dried and replaced by laughter over a corny joke I tell the wife. She gives me a “thank you so much!” as she shakes my hand and walks out of the room. The patient goes to follow her then he turns and squares up to me. He grasps my hand and looks with intensity into my eyes. We look like boxers before the bell. He mutters, “Thanks, dude”. The stare-off breaks as a tear forms in the corner of his eye.

 

A tear more likely for her, then his hope-starved self.

enlight39

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