Expanding Your Scope of Practice

It was a normal night in the ER. Busy, crazy, and fast paced. I was assigned to 7 rooms, 3 of which we reserve for our most medical sick patients. Those three rooms are set up with more capabilities to treat sick patients in the most efficient way possible. Typically, it’s our stroke, septic, respiratory, and cardiac patients that come here. The patients are normally strictly medical, since our trauma patients go to our designated trauma room. We usually know ahead of time when a seriously sick person is on the way to one of the rooms. That gives us a chance to be waiting and prepared by the time the patient gets there.

On this particular night, we get a call that a respiratory distress patient is being brought by ambulance. One of my rooms was open so I knew the patient would be brought there. I started prepping for the patient’s arrival. Got the EKG machine ready, turned on the O2 in the room, called the respiratory tech, called x-ray, made sure the room had supplies for any scenario, got an IV kit ready with tubes to draw blood, and etc. The ER doors opened and without even looking up I knew the patient was here.

The sound of high flow O2 was the dead giveaway. Number two, was the sound of someone working very hard to move air in and out of their lungs. Number three, was the sound of yelling in between breaths in a language I didn’t understand. I looked up as the ambulance stretcher was coming into my room and I saw an overweight Haitian woman being wheeled in. She was yelling in Creole as best she could while struggling to breathe at the same time. Her arms were moving around frantically. None of us spoke Creole and the language barrier made things difficult.

We moved her over to our hospital bed and I noticed purple goo everywhere on the sheets and around the patient’s head. The ambulance paramedic saw my puzzled look and said, “Oh yeah. By the way, she was dying her hair when this all started so we just brought her here with it.” The dye was everywhere. Thick and everywhere. All in a chaotic symphony (the term I use to describe actual efficient team work done in the ER) chest x-ray, EKG, blood draw, and assessments were done. Respiratory put the patient on BIPAP. That did not go over well.

Creole is not like Spanish where you can catch a few words here and there and figure out what someone is generally saying. Creole is also definitely less common where I worked. We didn’t have anyone who could translate and trying to get our translator phone service in a time critical scenarios was usually impossible. As you can imagine, putting a BIPAP mask on someone who has no idea what we were saying or doing, is no easy feat. It’s like a medical Darth Vader mask that forces hair into the patient’s lungs at different pressures. The mask covers most of the patient’s face and straps wrap around the head to secure and seal it. It’s uncomfortable, loud, and probably overwhelmingly scary to someone who has no idea what it’s for.

The patient was not happy. She was yelling in Creole against the air that was being forced in her mouth and kept pulling the mask off in order to continue to yell in Creole. We finally get her to settle down and leave the mask on. She wasn’t happy but she wasn’t shouting anymore. Content that we may have made a breakthrough in calming down the situation, I left the room to attend to other tasks for my other patients. My nurse did the same. Every so often I’d walk by, peak in, check vitals, and move on. I thought the hard part was over. I was wrong.

I’m not sure how long the silence lasted. At some point the patient started shouting in Creole again. The nurse and I went into the room to find that the patient had ripped the BIPAP mask off and was trying to say something to us. I called for someone to grab the translation phone. Out of nowhere the patient said in broken English, “Head. Hurts. Fire. Help.” I looked at the nurse who was as confused as I was. After a few more minutes of trying to figure it out, the nurse figured it out. The patient still had all that dye in her hair. The dye was irritating her scalp and was making it feel like it was burning. Being a guy, I would have never thought of that.

The nurse says, “We’ve got to wash out her hair. But we can’t take the BIPAP off. I’ve got to go do something in the other room. Could you go get everything we need to wash her hair out?” Before I could answer, she walked out. I’m a guy. What do we need to wash dye out of someone’s hair? I’ve never done this before in my life and now I’ve got to do it without removing a BIPAP mask, without standing the patient up, and without making a huge mess everywhere. I went to the supply closet and stood there for a good five minutes just thinking. Co-workers came in and out as I’m just standing there staring at the wall.

A few minutes later, I came back out with 5 basins, a handful of hand towels, a stack of large towels, small bottle of shampoo/body soap, some 60cc syringes, 2 protective gowns, and one idea. I went into the patient’s room with the nurse. I wrapped the patient in the big towels. I put a bunch around her shoulders and neck. It was a cross between a spa and mummified look. I filled one basin with soap water. I filled another with regular water. I put both on the table at the bedside. The nurse decided she was going to be the one who held the BIPAP mask on the patient’s head since we had to take the straps off. That left me with the job of hair washing. I got a hand towel and soaked it in the soap water. I brought it up over the patient’s head. I paused for a second with uncertainty. I wrung out all the water from the towel onto the patients head. Purple hair dye and water began streaking down the patients face and head. It had begun.

One big flaw in my plan was using cold water instead of warm water. The thought never even occurred to me. I wasn’t sure what the patient hated the most. The burning sensation from the hair dye, or the cold water now being wrung out on her head. The facial expressions and the tone in her Creole told me it was probably the cold water. For 10 minutes straight I would wring out soap water on her head and let the water wash down into either the towels or the basin I held by her head. Then I soaked hand towels in the regular water and wrung those out. I would take my gloved hands and try and pull the dye out of her short hair without pulling her hair itself. It was almost like using my hand as a comb. It was not very effective but it was all I could come up with. I felt like we were getting no where. My overall idea was to saturate her head with the soapy water to break up the dye. Then I would “wash” it out with regular water. The goal was to do it without making a mess. I wasn’t anywhere close to achieving that.

The nurse was watching the whole process as it drug on and was slow. She’d give little ideas here and there and try and comfort the patient. She came up with an idea and thought it might work better. So I took over holding the BIPAP mask and she took the 60cc syringes and drew up the regular water. She then aimed it at the patients head and pushed the plunger full blast. Water shot out of the syringe at 100 mph and went straight through the hair, to the scalp, then was ricocheting off the scalp covering everything and everyone in purple water. Shocked at what she had done, the nurse looked over at me in silence. I lost it and started laughing. The nurse started laughing. Even the patient started laughing. It was such a mess. Everything in the room had purple on it. The syringe trick had done nothing to help rinse the dye out. There was still a lot of dye in the patient’s hair and we had been at this for what felt like an hour.

Finally, we got enough out where we felt comfortable that we had done enough. I was covered in purple dye. The patient’s bed sheets were soaked. All of us were a mess. We cleaned up everything and got the patient dry with new sheets. The patient seemed a lot more comfortable and was not as agitated anymore. We finally left the room and the whole staff was smiling at us. I grabbed water for the nurse and myself and sat down next to her. People would walk by and laugh. I wondered if I still had purple on my face. Then the nurse got up to go do something and her chair turned. On the back of the chair, now facing me, was a sign that read, “RN and Head of ER Beauty Salon.” I looked at my chair and it had a sign that read, “Tech and Beauty Specialist.” Cute, I thought, very cute.

Looking back on this event, the whole mess was a miserable experience. Definitely a learning experience I never expected to have. But, the more I think about it, the funnier it was. I was still new to the ER and would soon find out that there would be a lot of situations that I wouldn’t be prepared for.

-The Witch Doctor