What did I learn? I learnt to keep my mouth shut, which is quite different to what Id do in an emergency room. When youve got a forty-year-old man with chest pain, you question their symptoms because it helps define the problem, and may just save their life. Questions like Does the pain go down your left arm? or Do you have pain in the jaw? are absolutely vital.
But at the school, I didnt want to ask them if they had any visual disturbance, nausea, vomiting, aura, pins and needles, as the moment I gave them some symptoms to choose from, they usually chose the lot. Without fail, those who have real migraines know their symptoms and do not hesitate to let me know.
Basketball
I like Sunday nights at the school, because theyre usually pretty quiet nights to be on call. There are no activities, no drinking (that we know of) and usually little chance of the kids getting into trouble because theyre back in their dorm preparing for the week.
But when the phone rang at 8pm one Sunday I received a rude awakening.
You have to come quickly, theres blood everywhere. Come now, quick!
The line went dead. I was about to press redial when the phone rang again. Sorry, its me, Brian. Im in the gym; you have to come quickly, Steves real bad.
Brian was the coach of the school basketball team. He was normally a level-headed guy, but like many people involved in nasty looking accidents, when the adrenaline kicks in, theyre not the most coherent. I told him to slow down, take a couple of deep breaths, and tell me what happened.
After a pause: We were playing basketball, practising for the tournament next weekend. Steve took a fall. Its his arm. Theres blood everywhere. I dont know what happened; its real bad. An arm injury with lots of blood didnt sound good at all. The worst-case scenario I could think of involving bones and blood was a compound fracture, that is, a broken bone that is also poking through the skin.
I could hear screaming in the background and grabbed my first-aid kit and car keys and headed out the door.
I walked into chaos. There were two adults with Steve, and a horde of boys surrounding them all offering advice at the same time. Yet through all this noise I could hear Steve screaming in agony.
I was the only medic on the scene and it was up to me to do the right thing.
Dont move him. As I pushed my way through the crowd, the kids were yelling their diagnoses.
Its his back, hes broke his back.
Oh shit, theres blood everywhere, I think Im gonna puke.
As I reached Steve and knelt beside him, I grabbed the shoulder of James, the assistant coach, and ordered him to remove all the boys from the gym. Some resisted, determined to help, others were happy to be led into the foyer, speechless, helpless, but grateful for some direction.
In any situation where theres a crowd, the best thing you can do is to have someone remove the onlookers. Ive seen a lot of people with what initially appears to be a serious injury calm down and walk away without any problem once the jittery, frenzied bystanders have been removed. Its also impossible to do an assessment with a screaming horde of onlookers.
Steve was sitting on his backside, clutching his right arm, the front of his shirt covered in blood. I breathed a sigh of relief when I realised the blood wasnt coming from an open wound on his arm but from his nose.
I imagined myself back in the triage room. One of the basic rules of triage is the ABC:
A his airway was clear, although his nose still had a trickle of blood coming from it.
B judging by the groans of pain his breathing was fine.
And as for his C well, he hadnt passed out and he was able to sit so he had an adequate circulation.
Clearly something was wrong and causing a lot of pain, but it was probably not life threatening just yet. I asked him what had happened.
Please just do something its killing me.
I promised Steve I would do something shortly, but stressed that I did need to know what happened.
Steve had been jumping for a shot when he received an elbow to the nose and came down on his right shoulder. He said he hadnt hit his head or lost consciousness.
Its tempting to tackle the most obvious injury first, and while I could see him clutching his arm, I wanted to be doubly sure to rule out any possible head injury and anything more substantial than a bleeding nose. Alongside the A, B, C is an often unknown little addition, another C, for C-spine.
C-spine, in other words, the bones that make up your neck, should always be checked for injury before moving a patient. The problem is, Ive only ever assisted the doctors when they do such things. Im the one who leads the log-roll when turning patients with possible back injuries. Im the one who holds the neck still while the doctor gently prods his finger around the back of the neck. If I stuff up and make a sudden move, it can mean a patient is paralysed for life. But now it was up to me to decide the best course of action.
Is your neck sore? I asked.
Its my arm, please just fix the bloody arm, please do something, he begged. But I didnt get a definitive yes or no, and I had to be sure.
Im sorry mate, Ill get to the arm next, but I have to know for sure. Were you knocked out at all, and is the back of your head or neck sore?
Geez, theyre fine, the arm, please
To be 100 per cent confident, I placed my fingers on the back of his neck and he denied feeling any pain when I gently pushed. I moved on to the arm.
I asked Steve to sit up straight and he tried, but he wouldnt let go of his right arm. Its too painful, I just cant. He had straightened enough for me to see that his right shoulder was not the same as the left. It was obviously dislocated. I checked the pulse on his right wrist and felt his hands. His pulse was strong and his hand warm. No circulation problems there yet.
Not all shoulder dislocations are obvious, especially in the hospital setting where we see people of all ages and sizes. The size of a person can make it difficult to tell. Often frail people dont even need to have an accident or any overt force involved to dislocate a joint, and their statures make it hard to see if somethings out of sorts. But a seventeen-year-old boy on the basketball team is likely to be tall and skinny. The poor lad didnt have enough flesh on him to hide anything.
My clinic was only 100 metres away and with the help of Brian and James we managed to get Steve lying on the examination table. I tried calling Dr Fritz but got no answer. I remembered that this was one of the few weekends he had off; we were alone.
Fuck! Steve was trying to find a comfortable position but not succeeding. Just fucking do something, fuck, fuck, fuck He carried on screaming, pleading, while I didnt have the courage to tell him that there was no doctor.
Steve had found the best position to ease the pain a little. He was lying face down on the examination table with his right arm hanging down off the side. Please do something soon. I cant take this anymore.
In such instances the emergency call was directed to the next village over, usually a thirty-minute drive away. The next option was the ambulance, but the nearest ambulance was forty minutes away, which would mean at least an hour and a half before he got to hospital. My other option was to take him by car, screaming all the way. With such limited and unappealing choices, I opted for driving.
Steve had found the best position to ease the pain a little. He was lying face down on the examination table with his right arm hanging down off the side. Please do something soon. I cant take this anymore.
In such instances the emergency call was directed to the next village over, usually a thirty-minute drive away. The next option was the ambulance, but the nearest ambulance was forty minutes away, which would mean at least an hour and a half before he got to hospital. My other option was to take him by car, screaming all the way. With such limited and unappealing choices, I opted for driving.
Please, I cant move. Dont touch me. I cant move. We couldnt get Steve to move off the bed let alone into a car. Hed found himself in a slightly less agonising position and was not going to budge. I needed some advice.
I try to avoid calling my colleagues, Justine and Michaela, when theyre off duty because time off is supposed to be just that, and like all nurses, I know, when you ask someone for help, they will never say no. Michaela was no different and was happy to help out. In fact, Michaela relished the challenge of a decent trauma. I instantly felt reassured by her upbeat tone when she arrived.
Dont worry about a thing, Michaela said and quickly began examining Steves shoulder. Ive put dozens of shoulders back in place. What the hell was she talking about? Nurses dont relocate limbs. At least, not nurses in Britain or New Zealand. I knew Michaela was extremely experienced and supremely confident; perhaps this is what nurses did in the States.
What do you mean youve put in dozens of shoulders? I whispered, thinking I was out of earshot of our patient. You cant do that. Youre not allowed. I know my limits, and I know what is within the scope of my practice, and what is not. Relocating the shoulder myself had never occurred to me. Steve chose that moment to scream in pain.
Let her bloody fix it. I cant take this anymore. Just do it, he managed to shout.
Watching someone in agony never gets any easier, and its a whole lot worse when you dont have an IV line to insert with a whole lot of morphine or midazolam.
I was trying to think of what could go wrong if Michaela went ahead and fixed his shoulder. She could worsen any possible fracture or nerve damage, although there was no way to judge how much damage we could do by leaving him as he was there were possible circulation problems to worry about and this was without even considering the possibility of the relocation not working.
We cant leave him like this for the next hour and we cant take him to the hospital. We have no choice. Michaela was in total control, and not in the slightest bit fazed by the chaos. Honestly, dont worry, Ive done this lots of times with the docs at work. It really does look like an uncomplicated dislocation. I know what Im doing.
I stood back and watched.
She rolled up a sheet, wrapped it around her waist and Steves shoulder, and gently began to pull. Fuck-fuck-fuck-fuck-fuck Steves screams reached new heights. I was just about to stop Michaela when Thank fuck for that. Oh, thank you, thank you, thank you so much. The relief was instant and the whole procedure over in less than ten seconds. After checking Steves circulation and sensation in his hand, Michaela placed him in a sling and gave him some analgesia. I cant thank you enough, he said repeatedly.
Part of me felt more than a little envious, the childish part that wanted to be the hero. But that was nothing to the relief I felt knowing that he was feeling so much better.
Steve was taken to the doctor the following day where an x-ray showed no fracture, and the doctor congratulated Michaela on a job well done. Youre OK with us doing that? I asked. I had been prepared for him to be angry with us for doing something that was a doctors job. Why would I be angry? You did a good job.
His words were not helping me to figure out what was right or wrong (if there really was any such thing), or what my exact role was. I was doing more than the average nurse, a bit of diagnosing, and administering treatments and medicines like a doctor, as well as playing detective but nothing as practical as what Michaela had done.
Michaelas brave actions on that surprising Sunday night taught me a few lessons that Ill never forget. To act or not to act? Indeed, that is the question.
Checklist
Generally, dealing with big issues is easier, because you know its bad, and you know youre going to need outside help. Perhaps that sounds odd, but theres no uncertainty. So much of what I see is subjective, and while kids arent necessarily dishonest, no one is immune to playing the system.
It doesnt matter that 95 per cent of our students are either very wealthy or ridiculously wealthy, because theyre all the same. Theyre young, impressionable, tricky, manipulative, cocky, embarrassing, awkward, fun, scared, compassionate, and clever. Theyre capable of anything, even fooling their favourite nurse, although I do try to catch them out when I can.
Skipping class or PE is built into their DNA, and theres no better way to achieve this goal than to pull a sickie. After my first year on the job, Id learned, adapted, and implemented various techniques and tactics to spot the genuine from the fakes.
1. The Positive Make-Up Test.
2. Do they have a test in class? You need to be specific with your question: kids will say No but get in trouble for not handing in their assignment or presentation, and when confronted with this say, But you asked if I had a test, not an assignment. I always ask the full spectrum: Do you have a test, assignment, homework, presentation, or anything else in class that needs to be done today, at this moment in time?
3. How do they answer question 2? If they start the conversation with I dont have anything important in class today I know where this is going. It sounds planned and sick people are usually feeling too miserable to plan their escape.
4. Check with their dorm parent to see if they really were sick the night before.
5. Check the records to see if theyre regularly missing a particular class, PE and Maths are particularly common.
6. Obtain as much physical data as possible. Temperature, pulse, blood pressure, bowel sounds, pallor, obvious nasal congestion, lung sounds and document it all. By tomorrow you wont remember if theyve had a cold for one day or one week, because youve seen so many students, and kids arent the best historians, especially when theyre lying.
Reading this back, it looks like Im more of a detective than a nurse, but if that is so, then Im the most lenient one around. Its hard to say no to a desperate kid, although I can and will when required. And thats the problem with medical assessments often the symptoms are subjective. Its much easier with injuries; give me a simple break, cut or bruise anytime.
Chapter Two