Why Is Everything So Bad All The Time and What Can Be Done About It?

Tuesday was a shit day, from start to finish. 

It was bitterly cold, 16 below zero when I left for work. The roadways were frozen solid. I almost hit a car that spun out on the highway and came back heading directly at me. I dodged that bullet and made it in and I KNEW this did not bode well. 

We had something like 17 car crashes in the first two hours as well as a pretty horrific trauma unrelated to the weather. The biocom (radio that EMS calls to notify us of incoming patients) was barking nonstop. This is medic so and so coming to you with two patients, rollover at highway speed, airbag deployment, no seatbelts, heavy damage. And on and on. 

Thankfully no one died, and most had minor injuries, but they just kept coming. And coming. And coming. 

The day never stopped. By the end of my shift I was just done in. The night shift charge came in and I said “I gotta get out of here. Now. I’m DONE.” 

I could give you a list of reasons if I could remember what happened, but it was a bunch of minor things going wrong that just stacked up on each other. 

Driving home the roads were still fucked. It was snowing again. And I had to go pick up my daughter and I was so fucking tired. I pictured siding off the road. Would it really be that bad? What if I just broke a femur? Wouldn’t it be nice to have some time off? Or what if I died? I mean, was that really so bad? 

Yes, I know these are not normal thoughts. Yes, I know they’re teetering on the edge of Really Bad Thoughts. I’m in therapy, so know that I am trying to address the stress and loneliness and hopelessness that fall over me sometimes. 

Obviously I made it home, with my seven year old who has not been outside in a week because the world is frozen. Had no water as the pipes were frozen so took a bottled water shower to rid myself of COVID germs. Then I had to parent a very bored and restless child for two hours who was in a MOOD. 

Bedtime was a relief.

 I think that’s was so attractive about Bad Thoughts. That even if it’s a terrible end, it’s an END. Everything is so bad all the time and it never stops. Sometimes I snap at my child. Sometimes I bark at my coworkers. Sometimes I don’t text back and sometimes I forget to pay bills and sometimes on my day off I do absolutely nothing and feel awful about it. The problem isn’t another day like Tuesday. It’s all the days after that. If I think of it like that, life seems insurmountable. It’s so hard to find a way through this when it’s been like this for so long. Ending COVID isn’t going to end all the stress and trauma. 

Wednesday I woke up on my day off and got on social media. Many of my Facebook friends had changed their profile pictures to a local fire department and EMS logo, with a black line through the middle. 

That means someone, one of ours, died. Sometimes it’s COVID. Sometimes it’s natural causes, or cancer, or an accident. It’s paying tribute to a fallen comrade, in a small way. So I knew something horrible had happened. 

The department shared the news someone had passed. And a few words about suicide awareness. It was pretty easy to figure out we’d lost yet another of us to this manner of death. 

I found out who it was pretty quickly. I knew him. Not well, but many of my friends did, and they were devastated. A lot of pleas about reaching out. We’re always here. Which is how we always respond to trauma in our areas—we pull together. When my son passed away suddenly, someone from my department was at my house EVERY day for a month, at least. I was never alone. They didn’t leave my side. That’s the kind of people I work with and the kind of bond we have. 

I was saddened. I read firsthand accounts of people who loved him. Saw pictures of friends and family. I didn’t have the firsthand grief, which is maybe why I felt so much anger. No—not anger. Rage.

I’m so goddamn angry another one of us has died by suicide. I’m not angry at the people who chose this as their way out. I’m angry at the system that continues to fail the people that sacrifice to see the worst of the worst. Like veterans, many healthcare workers, particularly those in EMS, ERs, and first responders, experience trauma on a daily basis and suffer from a form of PTSD that is commonly called Complex-PTSD or secondary stress syndrome. 

Symptoms of C-PTSD include 

·         difficulty controlling your emotions

·         feeling very angry or distrustful towards the world

·         constant feelings of emptiness or hopelessness

·         feeling as if you are permanently damaged or worthless

·         feeling as if you are completely different to other people

·         feeling like nobody can understand what happened to you

·         avoiding friendships and relationships, or finding them very difficult

·         often experiencing dissociative symptoms, such as depersonalization or derealization

·         physical symptoms such as headaches, dizziness, chest pains and stomach aches

·         Suicidal thoughts

I want to stress something that I think is very important but is only my opinion—people who commit suicide don’t want to die. They want their pain to end. I think that is an extremely powerful statement—that their suffering had become so great they saw death as their only way out. Suicide, and suicidal thoughts/ideation, in my experience, is about escape. 

Working in the ER is a huge part of my identity. Most people who work in emergency services and emergency medicine are following a calling. It’s definitely not for the money—sure I make decent money but paramedics don’t. And I only make the money I do because I’ve hung in there for a long time and am going on twenty years of experience. If I was a new grad, I wouldn’t be making anywhere near what I do now. 

This may be a difficult read, because I’m going to talk about some pretty traumatic things. I have a whole lot of stories and a lot of them are terrible. 

But I want to start by telling you about one shift that I remember well, from years ago, when I was a staff nurse, that I hope illustrates where some of the stress and trauma came from. If I gave it a title, it would probably be “The Day the Highways Flash Froze.”

I started my shift in the “fast track” area. Minor complaint and injuries—cuts and ankle sprains and wrist fractures. In and out. Around ten am, EMS called in a post cardiac arrest. A woman in her sixties was barely clinging to life after several rounds of CPR and minutes out. I was pulled from my assignment and took this patient. 

The patient arrived with CPR in progress. We quickly replaced the temporary airway EMS had placed with an endotracheal tube, began transfusing emergency blood products. We managed to get ROSC (return of spontaneous circulation—the patients heart has begun beating effectively enough to circulate their blood without chest compressions), but she was bleeding heavily. The tube we placed in her throat kept filling with bloody, frothy sputum. Respiratory kept suctioning. We started multiple continuous infusions to raise the blood pressure, placed a large introducer sheath into her femoral artery to slam as much blood and fluid in to keep her circulating volume up enough to perfume her vital organs. We do this using a rapid infuser—a large machine that warms the fluid and delivers up to 575 ml of blood or fluid per minute. (Yes. We can give two liters of fluid or blood in two minutes if we have a big enough sheath in a large vessel like the femoral artery.)

 The patient arrested again. Her husband was in the room watching. Crying. Begging her to live. We started CPR again using a LUCAS, an artificial device that delivers CPR. The circuit that delivered oxygen to the patient filled with blood and RT disconnected it to switch it out—spraying me directly in the face with a significant amount of blood and sputum—mucous from the lungs. 

Here I am, my face covered in a stranger’s blood and mucous, while her husband begs her to live, and I’m the only person in the room who knows how to run the rapid infuser, which is probably her only chance of survival. Do I step out to wipe the blood out of my eyes? 

Of course not. What actually happened is the ICU intensivist patted blood from my face (I tried but he said I was smearing it everywhere) and we continued to try to save the patients life. 

We were not successful. 

This left the patient’s husband to deal with her death. The shock of trying to process the death, giving information on funeral homes, trying to give comfort.

Rain was falling now and the temperature was rapidly dropping. Which meant it was about to be trauma central. 

As I was performing postmortem care, cleaning the body, removing medical devices, I was notified I’d be receiving a trauma activation patient, found at the bottom of a flight of stairs, unresponsive. 

Hurry to finish the postmortem care.

Receive the trauma patient. Establish an airway. The patient is not responsive to painful stimuli and has significant trauma to the face, indicating a high probability of severe brain injury. The patients blood alcohol is also extremely elevated, making it difficult to assess what the actual neurological function is. The CT shows a significant bleed near the brain stem. The patient’s children arrive. They want to know if he will make it. What level of function he will have. But we don’t know. Right now, his vital signs are stable. The bleed isn’t operable due to the area it’s in. All we can do is  provide supportive care and hope for the best. But it doesn’t look good. 

Meanwhile, the temperature has gone from low thirties to less than fifteen degrees and the roadways have frozen. Motor vehicle accidents are rolling in, and my coworkers are running their asses off.

Another patient is activated as a full trauma, a highway speed wreck. The patient is a female my age who has significant neck and back pain and numbness in her extremities, with significant weakness, indicating a spinal cord injury. She is now also my patient. Her vital signs are stable, no internal bleeding, but her back is fractured and there is compression of her spinal cord. These injuries can go either way—the swelling and trauma to the spinal cord can resolve and the patient may be fine. Or the injury can worsen, resulting in paralysis and may even be lethal. 

I manage to get my brain bleed transferred to the ICU. My second trauma to MRI. 

I get another trauma patient, another high speed wreck into the guardrail. This patient has a left side flail chest, meaning his ribs are shattered on the left side, from blunt force trauma, placing him at significant risk for a hemothorax or pneumothorax-a lung full of blood or that is totally collapsed. They’re having difficulty keeping his oxygen levels up. 

He arrives and we place a chest tube, discuss intubating him to keep his sats up. But once the chest tube is in, he holds his own oxygenating on a non rebreather mask—a mask that delivers 100% oxygen. For reference, room air is around 21% oxygen. But he’s really straddling the line on that. And he is in a LOT of pain. Pain medicine often makes patients drowsy and slows their respiratory rate and effort, meaning we have to dance a fine line between medications for pain and keeping the patient breathing on their own. After a battle, we have to intubate him as well.

My other patient comes back from MRI and is assigned a room upstairs. The nurse accepting her is kind enough to come fetch her so I can focus on my frail chest patient. We stabilize him as well and he receives a bed upstairs.

He received a bed in the ICU and I package him to go upstairs. I’ve lost one patient and admitted three now. Of those three, I’d characterize the spinal cord injury as being in “guarded” condition, meaning things that could go either way, and my other two as critical and unstable, with high risk for further deterioration. 

I’m on the elevator. It’s 5:45, I have one hour and fifteen minutes left. I’m physically and emotionally exhausted. My step tracker says I’ve walked over eight miles since arrival. 

My charge nurse radios me. She has another patient. A stroke activation but they’re stable, she says. She knows I’m running on fumes. Hurry back, though, she says, so I get my patient into the ICU room, we transfer beds, and I apologize but tell them I’ve gotta run. Call if you have questions. 

I hurry back and drop the empty stretcher off and ask environmental services to clean it really well—there’s blood everywhere. I come back out and EMS is radioing in with an update in the stroke. I take the call and they notify me the patient has gone into cardiac arrest and CPR is in progress. 

I don’t remember exactly what I thought but I am sure it was along the lines of, “are you fucking shitting me?”

The patient arrives and we obtain ROSC quickly. His next of kin arrives. The patient is decerebrate posturing—extending his extremities and stiffening to painful stimuli. This is the worst type of posturing and it indicates that the injury to the brain is so severe that there will be minimal function even if we are able to reverse whatever has happened. There is no obvious bleeding, but a large portion of the brain on CT shows an infarct—a stroke. Ischemic strokes—where blood flow is interrupted by a clot in one of the cerebral arteries—generally do not show up on CT for a period of time, meaning this is a huge infarct and most likely not survivable. Even if survivable, there will be minimal brain function. 

After discussing the results with the next of kin, the decision is made to withdraw care. He passes away just before my shift ends.

One shift. Two deaths. Three that have significant injuries and one that will most likely pass away. 

It is hard for me to explain how I function through these days. There’s no time to “process” or panic or cry or step away. These are the days you just have to keep going. And going. When I left that day, I felt so numb and drained and disheartened. Was this a bad day? Yes. Does it happen every shift? No. But there are plenty of shifts like this. I could tell you about so many other days just like this. 

Imagine—a pregnant woman goes into cardiac arrest. EMS arrives and they know the patient most likely will not survive. 90% of out of hospital cardiac arrests die. The woman is obviously full term. They know that the baby’s only chance is high quality CPR to the mother and getting the baby out as soon as possible. Imagine rolling your stretcher into the ER and there’s someone dumping a bottle of betadine on the stomach and an OB/GYN cutting that baby out on your stretcher in less than a minute. 

Do you know how traumatic that is? 

I remember the first time I waited for a pregnant patient in cardiac arrest from a car accident to come in. Bystanders told EMS they thought she was pregnant. No one knew how far along she was. If the baby was viable. I was standing there waiting for them to arrive with the ultrasound machine and I kept thinking please don’t let her be pregnant. Please don’t make me do this. Please don’t make me see this. I can’t do this. 

But I was going to do it. Because I had to. 

The patient was not pregnant. They were mistaken. She did not survive. A month later, there was a similar situation and the baby was delivered, alive, in that same room. The mother didn’t make it. 

These things are horrifying. They hurt. They hurt a lot. They injure us, they truly do. If scars showed on the outside, I’d be unrecognizable. 

The baby beaten and thrown in a dumpster.

The domestic violence that codes on the table because her liver was lacerated. 

The overdose death brought in a car with rigor mortis that had a broken leg because her “friends” broke it getting her in the car. 

The child with gunshot wound whose chest was sawed through and cracked open on the table. 

The paramedic that was attacked on scene.

The nurse that was stabbed in triage. 

Bodies torn and mangled. 

Families crying and screaming.

Death, amputations, intestines, brains, blood, gore. 

My friend who was burned in a fire because on arrival a woman was screaming her babies were in there. 

He went into that smoke filled building and searched for children. He was caught inside and almost didn’t make it out. 

She meant her cats. 

Yes, I understand pets are like our children. 

He was looking for human babies, lost in a smoke filled building, separated from his teammates, listening for crying children, and he thought he was going to die, and he has never recovered from that. 

I wish I knew what to do about this. I wish I had an answer. Therapy. Support groups. Something. But I don’t know, because I’m in the thick of it, and the only way I know how to function is to keep going. I need help, we need help, to find the answers in how to manage and cope with these things, because our attitude it “shit happens. Yeah. I’m Ok. You good?”

So many of us drink. I don’t, anymore. I have a high risk of alcoholism. I don’t make good decisions where alcohol and drugs are concerned. Writing about it feels okay, though I’m always reviewing endlessly—did I say too much? Am I sure no one can identify any private information? Am I allowed to say this, does this seem too cold, is it too much, not enough, will someone say I’m a shitty nurse? 

It’s so hard to explain to others. It does feel lonely out here, it does feel like no one understand what’s happening to us EXCEPT us, and how can we lay our pain down at the feet of another who is suffering from the same?

I had an existential crisis last week, over a very frustrating thing that happened. What am I doing here? Is this my purpose? Am I doing the thing I am supposed to be doing? Am I the best I can be? 

And fuck, I DON’T KNOW. 

I’m sad a lot. I’m angry a lot. I need a break but I feel useless and restless and frightened when I take time off. 

I have the Bad Thoughts. I’m able to keep them at bay, with therapy and writing and plain old stubbornness, but we gotta do something. With the increased stress of COVID on healthcare, we are failing our healthcare workers and emergency services workers. We’re losing them to suicide and depression and substance abuse.

Something MUST be done. I’m asking, as an ER nurse who has no idea how to fix this, for help. We need help, we need it now, and we need someone to help us figure out how we can carry this load without carving pieces of ourselves off to do it. 

This is reaching out. Someone, anyone, please help us figure out how to fix this, because our system is broken and I don’t know what to do. 

— The Midwestern One