Television gives a false impression of life in the ER. Judging by ER and Chicago Hope you’d think it was one trauma after another. STAT! STAT! gunshots, car bombs, school buses slamming into puppies on parade. We get emergencies, and yes, some are life and death, and yes we have to hustle now and then, but most of the time it’s no more active than your average doctor’s office.
But when we do hustle, we hustle with a capital H. Which is why in the emergency room at US Naval Hospital Okinawa Japan, slackers and newbies weren’t assigned to the trauma beds. When we had a gsw (gunshot wound) or mva (motor vehicle accident) or MI (myocardical infarcation) come in, we didn’t have time to waste while HM Freshley tried for ten minutes to start an IV or draw blood. The regular beds where you honed your skills.
Once upon a time I was HM Freshley, but now I was HM3 Byrd, Corpsman Extraordinaire. I could start IVs and draw blood in my sleep. With most patients it took seconds. Sometimes it took longer, maybe up to a minute for a particularly hard stick, but as the Mounties said, I always got my man.
The ER was the training hospital for a local medical school. Japanese interns who passed an English language proficiency test did their clinical rotation at USNH Okinawa, rotating thru the various departments, ER, Labor and Delivery, med/surg wards, etc. Many times, I wanted to meet the person who certified these med students as proficient in English. Some of them could barely say hello.
Rika’s first day with us was more typical of the TV show ER than it was typical of the hospital ER. Dr. Riggert had barely finished introducing her when an ambulance screeched into the bay with a fourteen-year-old who’d fallen off of the concrete seawall four blocks away. I was working the trauma beds that day. Dr. Rigger told Rika, a twenty something Japanese woman with shoulder length hair, wearing a pristine lab coat over her brand-new scrubs, to stand off to the side and observe, jotting down any questions she had. “If there’s an opportunity to put you to work, I will,” Dr. Riggert promised. Rika, too nervous to speak, nodded.
I helped Lt. Johnson, Dr. Riggert and the ambulance crew transport the patient from the gurney to the treatment bed. I grabbed a bag of normal saline, tubing, and an IV needle. In less time than it takes to type, I inserted the IV needle into the patient’s right hand, filled several tubes with blood, ready for whatever labs Dr. Riggert ordered, and hooked the IV tubing to the catheter. I hung the saline bag on the hook over the bed and connected EKG leads to his chest.
That gave Rika the wrong impression. Many patients that came through the ER needed to have IVs. We had a lot of drunk marines come in on the weekends. They needed IVs. We had a lot of people with stomach viruses, who’d been battling diarrhea and were at risk of dehydration; they needed IVs. But they didn’t need to have them inserted in half a minute.
We couldn’t convince Rika of that. It was imprinted on her brain during her first ten minutes in the ER that IVs had to be done in thirty seconds, no fooling. Inserting IVs are like any skill. It takes practice. When Rika couldn’t do it in thirty seconds she gave up and found a corpsman. “I sorry, I tried,” she said, bowing. She was apologetic to the point of remorse, if not shame. She asked us if we’d put the IV in for her.
The first few times I said, “Sure,” and invited her to follow me and watch how I did it. I made it a point to slow down, talking as I did it, A couple of times I intentionally made it look more difficult than it was, missing the vein the first time. Once the patient winced and Rika said, “Oh, stop! You are hurting him!”
I said, “I know. But it’s not hurting me.” And I kept on going until I hit the vein. When the IV bag was hung and Rika and I had left the treatment room I said, “If I’d stopped and pulled the needle out, I would have had to stick another one in, which would have still hurt him. In the long run we are helping him, so the pain is necessary. And remember, it doesn’t hurt you, so don’t stop. Keep digging till you find that vein. It’s in there somewhere,”
Eventually when Rika came up to me when I was treating a patient, softly clearing her throat and said, “I sorry. I tried. Will you put in the IV?” I said no.
“You can do it. You’re giving up too soon.” Her eyes opened so wide I almost laughed at her. She assured me that she couldn’t do it. “Show me,” I said, and followed her to the treatment room. She prepped the patient’s left arm. A Band-Aid was already on his right arm. She applied the tourniquet to his forearm, swabbed some betadine on the back of his hand and inserted the needle. Five seconds later she grunted in frustration and withdrew it.
“What the hell!” I said. “Slow down! Try it again!”
“I don’t think so,” the patient said. “I’ve given her two chances.” I grabbed a new IV needle, reswabbed his hand and inserted the fresh needle. Ten seconds later the job was done.
“Come with me,” I said to Rika. When I saw the look on her face I felt bad. “You’re not in trouble,” I said. I led her to the trauma beds and grabbed one of the wheeled chairs. I sat down and rolled up my sleeve. “Start an IV in me,” I said.
She shook her head.
Dr. Riggert stuck her head around the corner. “Do it Rika.”
Rika sighed and grabbed the Phlebotomy tray. She put the tourniquet on my arm, swabbed my hand and opened an IV needle. “Not yet,” I said. “Don’t be in such a hurry. Don’t stick unless you know you’re going to hit the vein. Slap me around and find the vein first.” The tourniquet was a little too tight, but I didn’t say anything. She slapped the back of my hand a few times and palpated it, looking for a vein. “Feel it?” She nodded. I was glad because I was no longer feeling anything. “Okay, poke that puppy.”
She inserted the needle, but it didn’t fill with blood. I could see the frustration on her face. I knew what was coming. I said, “Rika if you pull that needle out of my hand I’ll piss on the graves of your ancestors.”
“But I’m hurting you!” she protested.
Truer words were never spoken. “But you’re not hurting you,” I reminded her. “Take a breath, slow down, and dig around until you find that vein!”
It took her nearly two minutes, but when the needle filled with blood, the look of triumph on her face made the gangrene worthwhile. “I did it!” she shouted. Dr. Riggert, the nurses, and the other corpsmen all clapped.
“Yes, you did!” I said, smiling. “Please untie the tourniquet now.” She did, and as feeling returned to my hand I had her hook up a bag of normal saline to the IV and let a few ccs drip into my vein before having her dc the IV. She applied a Band-Aid and went to brag to her friends.
“That was a good thing you did, HM3,” Dr. Riggert said.
“Meh, I was getting tired of starting all her IVs for her.”
I would like to end this by reporting that Rika was soon an expert at starting IVs. In time she was. But the real ending of this exercise is that no good deed goes unpunished. When I got back from lunch an hour later. There were fourteen Japanese interns from different areas of the hospital, standing in line, waiting to start IVs on me.