You're in the bay. Once you get over to the bed,
we'll give you the story. Everything's going
to happen super fast. Welcome to the emergency
room. I wanted to get on here. I wanted to touch
on something. that I believe that most of us
nursing students, if you are a nursing student,
kind of feel frustrated about whenever you're
in nursing school. And this kind of came up yesterday
after we had a really rough exam in the mom baby
section of our program. And so it is anticipatory
stuff, not anticipatory guidance, like in pediatrics,
but just like the questions of the nurse will
anticipate this or the nurse will anticipate
that you know so i want to kind of talk on that
a little bit so i would like to kind of talk
about that just a little bit so um it's a trauma
story and it was a very interesting story so
um in our particular trauma center we or emergency
room trauma center. We have our E .R. kind of
segmented into different sections. And so you
will have a critical medicine side. You will
have just a you're not dying medical side. And
then we have a pediatric emergency center. And
then we have our trauma center. And even within
those categories, we have it broken into little
subcategories like we have like big rooms. And
then we have just kind of like rooms. And so
let's just say on the trauma side, the way we
have it set up is our trauma rooms wanted to
those Yes, are typically going to be used for
kind of like holes in waiting to get sent upstairs
to some type of trauma floor. And then we have
Like our big trauma rooms which are going to
consist of three four and then five is our pediatric
trauma room like OB traumas and pediatric traumas
under the age of like 16 17 Go into the pediatric
trauma room and that's where we have like all
the pediatric stuff the bras low chart You know
the crash cards dose for pediatrics and obstetrics
We have a little Wormer thing for the for the
neonates That way if they come out and we need
to resuscitate them we can do that or if they
have trauma we can Work the trauma angle that
way And so like that right there is all in room
five. And then you have six, seven, eight, six,
seven and eight are going to kind of be like
holds areas. Again, just waiting to kind of go
up to the floor. And then trauma room nine is
going to be like a geriatric trauma room, but
it's getting more and more used. Four different
things now, too. And then we have 10 and 11 and
12. Those are specifically for geriatric traumas.
And then 1314, those are going to be your mental
health people. So they have no trauma whatsoever.
They're just looking for attention and probably
just hot and hungry or cold and hungry. And then
15, 16, 17 and 18 are also your big trauma rooms.
And so this story takes place in trauma room
nine, which is traditionally a geriatric trauma
room, but it's slowly shifting out of that range.
And so and this particular story, it is not a
trauma story. I mean, it is not a geriatric story.
It's it's a fucked up story. So we It's probably
nine, 10 o 'clock at night and EMS, HFD, because
here in my particular county in the state of
Texas, it's Harris County. The fire department
doubles up as paramedics before they can even
go and put the wet stuff on the hot stuff. Right.
So. And I think if you if you like to watch like
Chicago fire or something like that, I believe
like maybe more counties are kind of going this
way because yes, you know, you need your guys
putting the water on the fire. But you also have
like this need for faster response times when
it comes to like 911 calls and stuff like that.
And so it just. seems to be a better use of taxpayer
dollars. I know that firefighters will probably
sit there and push back on that. But guess what,
dude, like there aren't that many fires happening.
So. So HFD, at least in our particular area of
town, it can be hit or miss with performance.
And so this one was not the best. And when I
tell you this story, you're going to be like,
how did you miss this? And everyone like in the
trauma bay thought the exact same thing after
the x -ray showed. So HFD brings the guy am auto
pad. And if you're not familiar with ER terminology,
auto pad is auto versus pedestrian. And so the
guy was riding his bicycle. And He was crossing
the street. And then I guess the guy either ran
a stop sign or ran a red light or something and
get ready for it. Hit the dude going 30 miles
an hour. OK. He hit the guy going 30 miles an
hour. Now, if you get hit in a car doing 30 miles
an hour, it's not a big deal. You know, you might
get a sore neck if you really, you know, top
heavy. You might you might have like a severe
neck injury. But the just regular basis. It's
just going to be a sore neck, maybe a sore back,
nothing crazy going on. Even if you get T -boned
at 30 miles an hour, it's not going to be detrimental.
It shouldn't be. But this guy was riding a bicycle
and crossing the street and he got hit doing
30 miles an hour. Now. He got hit and drug. OK,
so he got hit doing 30 miles an hour. and then
drug 100 feet. OK, now to give you an idea of
how far 100 feet is on the road, whenever you're
driving down the road and you see the hash line.
You see the hash lines in the middle of the road.
Each of those hash lines is about 10 feet long.
All right. And you're in your car. It doesn't
seem like it, but each of those hash lines in
between the road or in between the lanes. About
10 feet long and so he got drug 10 of those Okay
So That's the story His pressures were stupid
soft, okay And so when you get hit by a car I've
never been hit by a car before but I would imagine
that if I got hit by a car I would To be pretty
fucked up and so this guy was his pressures were
super soft and for you guys who are not Trauma
or er or maybe not even wanting to go trauma
or er or listening to this and thinking if you
do a pelvic fracture is the one of the worst
injuries that you can sustain It is a big bone
it's like a pretzel so When you think of like
a pretzel, like a rolled gold pretzel or something,
you can't just break one side of it. Right. Like
if you're trying to break it down the middle,
you can't just break one side of it, because
if you do, you'll break another side of it. And
the pelvis is exactly the same way. And so when
you start twisting it and moving it like one
side is going to break and the other side won't.
Right. And so one of the worst pelvic fractures
is what they call an open book pelvic fracture.
And that's when the center of the pelvis is broken
and flayed out like a book. Now, the significant
of this flayed out like a book kind of picture
is that your body is going to dump leaders and
leaders and leaders of look a minute into this
cavity now. And so it is a very very life -threatening
condition and it will it will kill you within
minutes. Okay, and so Like the guy comes in hit
30 miles an hour drug a hundred feet and just
on the surface the this the dermatology the dermatology
is just fucked because he's got gravel and And
rocks and stuff embedded into his to his skin
probably already tattooed if you are familiar
with the term like usually tattooing doesn't
occur until after Something's left in the skin
and it kind of heals over Or if it gets embedded
deep enough, you know, like it it'll like instantly
get tattooed So some of this stuff was already
kind of embedded really really deep and so me
and a nurse This is like one of the most beautiful
things that I love about you know working in
like the trauma setting is We work super super
super well together like when we just flow amazingly
well and It's funny because when you look at
the political stance of both of us of both of
us like we are completely opposite of what we
believe politically and probably a lot of other
things. But when we come together, together to
work, we work very, very, very well together.
And so we're sitting there and we're providing
care to this dude and we get them over to the
to the stretcher. And it got paged out as a level
two. So there was no one in the room but me and
her in EMS. And so in, of course, the trauma
resident that was in the room. And so we call
for the chest for the pelvic x ray because there
was no pelvic binder applied. We call for a pelvic
x ray. Shoot the x ray. We see a pelvis fracture,
a pelvic fracture that was so wide that you can
literally stick a textbook through it. Right.
That's how wide it was. And so when we saw that.
This is where that anticipatory stuff starts
coming in to play, okay? So we see that and all
of us in the room are like, oh fuck Like it wasn't
oh shit. It was oh fuck like this dude. No wonder
his pressures are like 60 over 40 and Like he's
not able to breathe. Well, he looks pale cool
diaphoretic and this dude was a black American
Like like this shit literally just hit the fan
as soon as that image came up on the screen And
we knew like we are now running against the clock
so knowing this What are you anticipating as
a nurse, right? Like this is where that annoying
shit on these nursing exams comes up What are
you going to anticipate right? And so Like I'm
like I look over at the nurse. I'm not gonna
say your name. I was like yo like Like I'm going
to probably start these two large bore IVs or
do you want me to put a makeshift pelvic binder
on? She said I'm gonna grab the IVs. I want you
to go ahead and place a makeshift pelvic binder
on So I literally just kind of like take the
sheet and kind of pull it down from under him
Like because we put like a fitted sheet on and
then we put like a white sheet on under them
to act as a draw sheet EMS was still in the room
They didn't bother bother to help. So thank you
HFD So I take the sheet from the top of the stretcher
pull it down to the waist and then I take the
bottom of the sheet From nearest feet and then
I shove it up towards now They eat like a lot
of times in EMS like I'm not a paramedic So I
try not to rag on you guys too much because I
don't know like the situation on my When and
how the like the patient was positioned when
you put the pelvic binder on? Because when we
put it on it's in a controlled environment on
a flat stretcher but You shouldn't put a pelvic
binder on by the knees. It's not a knee binder.
It's a pelvic binder So the easiest way for me
to think of a pelvic binder is you either want
your? Your closure to go around like over top
of the genitalia So if you got a guy, you're
going to sit there and you're going to make sure
that the securing mechanism is over, you know,
his penis and his scrotum area. And then like
for the for the females, it's going to be over
the vagina. Like, that's kind of like a good
a good landmark to aim for your pelvic binder
that the securing mechanism to land. Okay. And
so I grabbed the sheet I kind of like fold it
fold it fold it fold it like all the way down
you know without moving this guy too much and
Like I like tie it over his dick and then I kind
of keep moving right and like I'm really I really
sensed it down to where Whereas his legs were
kind of like flayed out like a like a rotisserie
chicken like it was just an unnatural position
and so like When I tied it, I kind of brought
them back up to an alignment situation, tied
it real quick. Everyone starts pouring in wanting
to know the story. We tell the story when everyone
starts coming in and we start repeating the story.
Guess what? EMS just kind of floats on out the
room, you know, because they knew they fucked
up. because again who the hell gets hit at 30
miles an hour and drug a hundred feet and you
don't think like you don't think that you're
gonna have some sort of pelvic injury you know
like because you don't see a broken bone out
of his leg that you just think like oh it was
just a clip and then he was good no man like
you fucked up and so everyone starts coming in
and then the uh the trauma attending was like
Why was this paged out as a level two and he
had the same exact thought that everyone in the
room had, which was why was this not paged out
as a level one when you got hit doing 30 miles
an hour? Now, I'm not a physicist by any means,
but I'm assuming that. If you get hit doing 30
miles an hour the energy is not at 30 miles an
hour I'm assuming that energy is going to be
closer to 60 miles an hour so Sure, but We I
get the pelvic binder tied on we secure it and
me and The nurse like we're sitting there. We're
running our stuff. We get blood. We get blood
pressure like she's getting another IV. I'm getting
a blood pressure on the other arm. You know,
the the trauma residents calling for a rock and
a Tomadei. They tube the guy and we start empty
ping blood immediately. Now a little side note,
like at our hospital right now, we have a little
debate going on amongst practitioners. including
nursing is, you know, whenever you're empty paying
blood, like, do you use the J loop? Or do you
just go straight to the IV hub? And the consensus
is like all over the place, because you have
the argument of it's the catheter link that is
going to determine how much blood you can push
through it. And then you have people that are
like, well, it's going to be the J loop. you
know, thickness that's going to determine how
much blood that you can push through it. Me,
I'm at the point where it's like, as long as
you get the damn blood in, I don't care how fast
it's going. Because we use Belmont, massive transfusers.
And like you can like deliver like a crazy amount
of blood in like a short amount of time. We're
talking about like, you know, don't let me lie
to you. If I'm not mistaken, it was like five
liters of fluid in like a few minutes or something
like that. If that's how you have it set up.
I don't know, don't let me lie to you. But it's
a crazy amount of fluid in a short amount of
time. And so but that there's kind of like an
inner debate at our hospitals, like, is it the
J loops fault that we can't get get any faster?
Or is it the catheters fault? And then a good
argument is when you look at the IV catheters
up in their packaging, the longer ultrasound
guided, you know, catheters, it'll tell you like
it's like 60, it might be like 60 80 mls a minute,
you know, for an 18 gauge and then on the 18
gauges, like on a normal IV, it's like 120, you
know, something like that, don't like it's something
crazy like that. Okay. So we start empty peeing
this dude with blood we get the blood pressure
his blood pressure on auscultation Was like it
was still mimicking what the monitor was saying
it was like 60 over 40 60 over 20 something stupid
low and so like we run it and then By the time
that everyone gets into the room to kind of help
us out me and the nurse For the RN Me and the
nurse that were in the room. We had already done
everything So the only thing that needed to be
done was rock and a tomodate and then like kind
of get the monitor set up that way we can go
to scanner and The pelvic fracture was so bad
that the trauma attending like walks in as we
have the monitor The brain on the monitor ready
to go to scanner. He was like you guys are going
straight to the OR Shit, okay, so Like if you
work in the OR go to hell, okay And that's all
I'm gonna say about that because the story kind
of continues this that that mentality So we got
this dude like he's literally bleeding everywhere
at this point, you know, he's not in DIC But
he just has open holes everywhere bloods just
kind of pouring onto the stretcher, you know,
and like we got blood going and we got fluids
going and like we're hitting them all different
types of liquid stuff to kind of prop up that
volume. And so we get up the ORs for us are like
one or two floors up and we have a special elevator
dead designated for those types of events where
we could just hit it hit a button and it goes
straight to the ORs and that's where we're at.
so We get we get on the elevator we get to the
OR and They see they see you guys at work in
the OR you see us Walk in with this dude that
has all this stuff, you know, cuz it's like an
entourage of us coming into the OR and You guys
want to sit there try to hold us up because we
don't have a little hat thing on a little bouffant
and we don't have little booties on. And we're
walking into your O .R. like, dude, we are literally
keeping this dude alive with. All right, we have
literally lactate ringers and blood keeping this
dude alive. And you're going to sit there and
tell us you need to grab a bouffant. Get the
fuck out of my way, dude. So we we get in there
the whole or team is trying to throw a fit and
the surgeons like yo We need to get him over
and we need to get going quit worrying about
what they're wearing We'll worry about that with
some vancomycin and I'm like, thank you Thank
you, you know, like you're gonna throw antibiotics
at this dude. Anyways, so just throw some more
antibiotics at him Don't worry about what the
hell we got going on because he's laying in rocks
and grass You know the stretcher has literal
rocks and grass on the sheet so So that right
there is the story right and The anticipatory
stuff of hey when you have something like that
that shows up it shows up in in whatever you
got going on That's where the nurse anticipates
this I was anticipating Two large bore IVs. I
was anticipating fluids. I was anticipating blood
and I was anticipating on Closing this pelvic
this pelvis long enough for us to get to the
OR those were the anticipatory things that The
doc didn't need to say now that right there is
where that stuff comes into play in real life
It's not you know A stupid question always like
the nurse is going to anticipate, you know, ambulating
the patient to the bathroom, like it's not it's
not always going to be stupid shit like that.
You know, it's going to be, you know, it can
be not going to be, but it can be. Hey, you know,
you got this patient, they got hit by a car going
30 miles an hour and he was drug 100 feet. What
are you anticipating? It's going to be stuff
like that. You know, so I just wanted to hop
on and kind of talk about that real quick, you
know, because yesterday, like our our cohort,
we had a really rough pediatric pediatric OB
exam with a really rough OB exam. And we all
kind of like walked out of there mad as hell.
So it just brought up like, man, this anticipatory
stuff like I know it's applicable, but the way
that they're using it is not. So I just wanted
to talk about that as a story and there's like
a meaning behind it. So there you go. All right,
guys. Thank you for listening and keep enjoying
the educational material.