Authors Note: A missing scene from the episode "The Bottom Line." In the episode a boy named Randy came into the ER with his coach. The child had been hit on the head with a baseball. After a few cursory questions by the intake nurse, the child was consigned to remain in admitting "until a Doctor was available.' While the wait time progressed, so did Randy's symptoms. Finally as the child's lethargy became alarming to the coach Dixie was accosted with a demand for immediate assistance. The child Randy later died in surgery; the implication suggested being he died because of a delay in getting treatment.
I always like to offer credit where credit is due. This little one shot is in response to an idea offered by pigletfan65.
My challenge was to come up with a story about what might have happened when Dr. Brackett and Dixie found out that the admission's nurse had been Ms. Barnette. I have to tell you, someone was obviously paying better attention that I was. I hadn't caught a good look at the Nurse's name badge. So, for the purposes of this story I'm going to use the surname suggested by pigletfan65, and add Sharon as the woman's first name.
When considering an angle for the story, I did a bit of research. The practice of triage is one that came from as far back as the days of Napoleon. But in its earliest form, triage was simple what today we would call "grab and go." Though the practice became more refined with every war, still the aim was in getting wounded men off the battle field as fast as possible. It has only been with advances in medical care that sorting patients by priority has become important because survivability of injuries has increased. In the 1970's emergency medicine was in its infancy. I approached this challenge with the timeline of the show in mind, as well as mitigating factors that might have been present on other fronts. This story indirectly deals with the death of a child.
Music, she heard music. Why were their melodies? And it wasn't even good music. Somehow there was static running through the melody. What the heck?
Sharon opened her eyes to a bedroom where morning light spilled through partially open drapes. Her eyes widened in horror! It was daylight, and she was still in bed.
"OH MY GOSH!" She screamed, jumping out of bed.
Hastily she glanced at the clock on her bedside table. The music from the clock radio had been what she heard. Apparently the clock attempted to waken her, and she'd slept through the radio's sounds. It was 6:30! She had to report to work by 7:00!
A flurry of activity followed the alarming discovery. Sharon ran a comb through short blond locks, slid into a fresh white uniform dress, stuffed herself into some white stockings and planted her feet into white shoes. A hasty brush of her teeth and swipe of a washcloth completed the morning's rapid cleansing ritual. Sharon snatched up her hand bag and car keys heading for her front door by 6:40. If she hurried, she'd only be a little late for morning report.
Rushing into Rampart's emergency room, Sharon headed for her locker where she hastily donned her nursing cap. Tossing her purse inside, she slammed the locker door and dashed from the area. While swiftly walking to the lounge where the nurses customarily gathered for report a quick glance at her watch told Sharon she'd indeed made good time getting to work. It was only 6:50. 'Phew!'
Scooting into the lounge Sharon found all the nurses from her shift were already seated around the room. Charts were spread out on the table and discussion about ongoing cases was in progress. Sharon found herself a mug, and served a blessed portion of steaming hot coffee for herself before finding a seat on the sofa.
"Well, good morning Sharon." Dixie McCall glanced up from the chart she'd been reviewing to address the late arriving nurse. "Late night?"
"Uh…. No, not really Ms. McCall. I uh…well, I over slept. I am sorry for being late." Sharon's fair complexion tinted pink with a blush as she spoke.
Dixie smiled knowingly. "Well, try not to let it happen again. We wouldn't want you to get a reputation for tardiness, now would we?"
Sharon nodded in agreement while verbalizing a reply. "Oh yes ma'am, I'll do better. Again, I'm sorry."
Dixie nodded, and resumed the meeting. As a supervisor, Dixie truly cared for her staff. Sharon was a good nurse, though quite young and inexperienced. Dixie could afford to cut the younger woman some slack once in a while.
For her part, Sharon was relieved her supervisor had gone easier on her than she'd expected. It could have gotten ugly if the head nurse had wanted it to. Sharon silently vowed not to let Ms. McCall down again. She would try extra hard to make sure everything ran smoothly today!
When the nurse's meeting ended, assignments for the day were handed out. Sharon found herself chosen to man the admitting desk for the morning half her shift. The afternoon she would spend in the observation ward. With a heavy sigh she resigned herself to a day filled with stressed grumpy people and too much paper work. Sharon much preferred the adrenaline high of working in one of the treatment rooms or on the floor of the ER. The admitting desk was in her opinion a monotonous way to spend a day. At least the observation area afforded her a chance to do some actual patient care.
As it turned out, the day would be rich and full with monotony only a wishful dream. Early that morning a woman came in with a coughing ten year old. The mother of the sick kid was loud and overbearing, and not particularly good with her own child. While leaning over Sharon's desk, the woman would spend a few seconds filling out paperwork, and stop to noisily chastise the whining child. The incessant whimpering from the kid and griping by the parent quickly had Sharon wanting to scream at the lady to just shut up and go away.
Next there was an obviously entitled women wearing expensive clothing. Her complaint was a minor laceration on the tip of her pinky finger. By the fuss the woman made, anyone listening would think she was in imminent danger of exsanguination! Sharon had difficulty getting the woman calmed enough to fill out the admitting forms. In desperation, eventually she'd called for a candy striper to come and help the distraught lady complete the forms by writing the information in the blanks so that Ms. Wounded Pinky wouldn't have to strain the digit, even though the hurt finger was NOT located on the ladies dominant hand.
While she'd been dealing with the injured finger patient, two more patients entered the admitting area. One was a man with an obviously broken wrist, and the other another fellow who was clearly in physical distress if his pallid and diaphoretic appearance were true indicators of condition. Sharon quickly dispatched the sweaty pale man to an orderly who delivered him to a treatment room promptly. The man with the fracture was placed on the top of the "see next." list.
The melee continued unabated. There were a set of puking twin girls who Sharon promptly dispatched to pediatrics for treatment, and a pregnant woman who'd just gone into labor arriving with a frantic husband and mother-in-law in tow. These fine folks were turfed to OB/GYN. While Sharon was attempting to get the OB case transferred, Ms. Wounded Pinky came and interrupted the phone conversation with a demand for immediate service. Sharon offered her most patient smile and assured the woman she would have someone treat her wound shortly.
The words of assurance had barely left Sharon's mouth when a police officer hauled a badly bleeding, and violently struggling handcuffed man through the Emergency Room entry. Blood was gushing from the man's head and lip, and dribbling rapidly from a wound on the man's left deltoid. Hastily dismissing demanding pinky lady with a nod, Sharon dispatched the policeman and his charge directly to a treatment room and then promptly called housekeeping for a biohazard cleanup of the blood that speckled the floor in a trail behind the wounded prisoner.
Even before an orderly with a bucket and mop appeared, Sharon was faced with a new patient who appeared at her desk. This time she looked into the greenish gray face of a disheveled woman who complained she was feeling sick. Before Sharon could get specifics about exactly what "sick" meant, the woman projectile vomited onto the counter of the admissions desk. Emesis spewed in every direction, though it had managed to miss the agile nurse because she'd hastily jumped back away just before the spewing began.
Yet another call was placed to housekeeping, and Sharon personally escorted the vomiting woman to the last empty treatment room. When Sharon returned to the admitting desk, she donned a pair of disposable gloves and began to sort out the fowl smelling damp paperwork. She discarded tainted papers and folders replacing them with dry materials. Eventually a woman from housekeeping appeared, and together the two workers cleaned and disinfected the admission's area.
The morning continued much as it began. A seemingly endless line of people with varying degrees of injury or illness appeared at Sharon's desk. Most of the patients who came through the admitting door could likely have gone to a physician's office given their complaints were generally minor. But sighing heavily, Sharon had to admit that it was likely the level of poverty apparent with some of these folks would have caused them to need to visit the emergency room of the county hospital where treatment would be inexpensive or free. It wasn't a perfect system, but at least the public hospital afforded even the least among the citizens of Los Angeles some sort of access to health care.
Memorably in the ongoing parade of entries into the ER came a man with white phosphorous imbedded in his arm. The man had staggered into the admitting area where he'd been met by Dixie McCall. Quite a ruckus ensued after the man whose arm was actively smoldering collapsed in a hysterical heap in the middle of the hallway. Sharon attempted to see what was happening while the man was surrounded by health care workers, but unfortunately got distracted as again Ms. Wounded Pinky had come forward to whine about the lack of attention being paid to her injury.
As time marched forward, while she worked the nurse couldn't help but wonder if the level of illness or injury incoming patients actually possessed bore any correlation to the amount of angst and outcry displayed. Her observations of most of the people she encountered took on an abject quality. She supposed it was some sort of internal mechanism that kicked in to allow a health care provider to distance their own psyche from the misery of those around them.
Finally, in a rare momentary lull, Sharon glanced hopefully at the clock on the wall. It was 10:20. In ten short minutes someone would be coming to relieve her so she could have a coffee break. Sharon quietly mused to herself that the timing of her break should be perfect. She'd managed to gulp down the better part of two cups of coffee during the morning meeting, and was now finding all the caffeinated liquid catching up to her. Her first order of business when reinforcements arrived would be to beat a path for the ladies room!
Sharon took a few moments to organize the plethora of papers collected in the rush of morning admissions. A folder was secured for each set of documents, and the young nurse precisely labeled each file before neatly stowing it. When she'd finished tidying the area, Sharon again glanced hopefully up at the clock. 10:26. 'Oh yes, four minutes! Just four more minutes! I can hold it four more minutes.' She discretely danced behind the counter in anticipation of impending relief.
Tic, tic tic…..the minute hand of the clock grudgingly crawled. "Three more minutes…." Sharon looked up from her carefully organized stack of paperwork to see a thirtyish dark headed man and a blond haired boy of about ten standing at the counter.
Cordially Sharon addressed the man. The gentleman indicated he was the boy's baseball coach, and the child had been hit on the head with a baseball. Sharon quickly gave the lad a visual once over. Seeing no obvious signs of distress, she began a cursory conversation with the child. After ascertaining that the patient was oriented, knew his name and what day it was, Sharon asked the young man if he'd passed out at all during the incident. A negative shake of a blond head, and a vocal assurance from the boy cinched things for Sharon. Obviously the youth was in no immediate danger.
Sharon glanced up at the clock on the wall again. Her relief person should be coming along any second. She'd get this newest patient started with the admitting forms, and likely get her break. Passing the forms across the counter to the boy's coach Sharon was disappointed, and yes a little annoyed when the man expressed distinct displeasure at receiving the news he and the boy would need to wait for a physician to become available. He uttered some angry words about having to wait just because he hadn't called an ambulance.
Sharon sighed heavily. "Why is it people think that coming to the hospital in an ambulance gets faster service?" She thought.
"Sir, we triage all patients." She replied trying to keep the irritation she felt from leaking into her voice.
After receiving a medical emergency parental authorization letter from the unpleasant coach, Sharon filed everything and looked up from her work to discover Gail Noble coming toward her. "Finally! Break time. I hope I can make it to the ladies room without leaving a trail!"
Approaching the reception desk Gail smiled at Sharon. The young blond nurse looked somewhat frazzled. "How's it going?" She politely asked while stepping behind the counter.
Sharon exhaled heavily, her breath causing her bangs to levitate briefly in the breeze. "It's been one heck of a morning! You just wouldn't believe!"
Gail smiled at the younger woman. "Well, run catch your fifteen minutes. I'll take care of things here while you are gone."
Sharon offered a relieved smile. "Thanks Gail! I've been dying for a restroom break for like forty-five minutes now." Her voice was a whisper. Then the perky blond nurse rapidly retreated from the admissions desk.
When Sharon's coffee break was over, a much calmer and more relaxed nurse reported back to her post. Gail indicated all had been calm while Sharon was gone, and with a smile and wave the other nurse left Sharon Barnette to finish out the morning in reception.
The influx of patients to Rampart Emergency Room slowed a bit in the remaining part of the morning. Gradually the admitting area began to empty as patients were received into a treatment area. By lunch time for Sharon, only a few patients remained in the waiting room. Ms. Wounded Pinky was still present and periodically shot angry glances Sharon's way. There were two more patients with minor lacerations waiting to be seen as well as the boy and his coach. After the coach's initial outburst, he had seemed to settle down, and the man and boy were currently sitting quietly flipping through magazines.
Sharon left her morning post with all paperwork completed and neatly organized. She said farewell to Ginger Hemmingway, her replacement at the reception desk while hastily heading off for lunch. After lunch the afternoon in the observation ward was much calmer. By the time Sharon's shift ended at seven, she was tired and ready to go home.
Entering the locker room with a sigh of relief, Sharon walked toward her locker. She had just reached down to open the handle of her locker when a voice behind her yanked her back to the present moment.
"Sharon?" The voice was that of Dixie McCall.
Sharon quickly turned on her heel. "Uh, yes Ms. McCall?" Sharon searched her brain for a reason the head nurse would seek her out in the locker room.
"You were on the admitting desk this morning weren't you?" Dixie questioned in a noncommittal tone.
Sharon mutely nodded affirmatively.
Dixie sighed, and slowly walked over to seat herself on the bench stationed in front of the row of lockers.
Looking upward from her seated position, Dixie met Sharon Barnette's questioning gaze. "Sharon, do you happen to remember young man coming in who had been hit by a baseball?"
Sharon opened her locker and began to unpin her cap while she answered Dixie. "Yes Ms. McCall. They came in at a little past ten this morning. Did that coach give you problems? " Sharon figured the man must have made some sort of spectacle of himself after she'd moved on to her afternoon assignment.
Dixie sighed heavily. Randy had been seen by her and Dr. Brackett at two-thirty in the afternoon. They had been waiting to be seen for a little over four hours.
"Sharon." Dixie began in a gentle and noncommittal voice. "Why did they wait so long? They were sitting in the waiting area for over four hours."
Sharon stowed her nursing cap, and reached for her hand bag. "When I spoke with the child, he said he hadn't lost consciousness, remembered what had happened to him, and was oriented. He didn't seem to be in any immediate danger, and there were several patients who needed to be seen immediately. This morning was very busy."
Dixie closed her eyes while slowly shaking her head with a gesture of sad displeasure. The young nurse had performed as she'd been trained. Obviously the procedure Rampart was using to triage patients for care needed to be refined. An injured kid who had been less than forthcoming, a very hectic morning in an urban Emergency Room, and a personnel change in mid day made it likely Randy had simply slipped through the cracks in Rampart's intake process. The unfortunate combination of circumstances had cost the boy his life.
Sharon watched the look of sadness cross the older woman's face, and slowly sank to sit on the bench beside Dixie. "Did something happen Ms. McCall? You must be talking to me about this because there was some problem. The boy is all right, isn't he?"
Dixie shook her head again sadly. "No Sharon, he isn't. He died in surgery."
Sharon sat with jaws agape staring at Dixie in stunned silence. Tears formed in the corners of her eyes and began to slide down her cheeks.
Dixie placed a consoling hand on the distraught woman's shoulder. "There was a subdural hematoma."
The young nurse was sniffling now. "It was so hectic….. He said he hadn't passed out. There were so many patients this morning. I thought he would be all right." Sharon began to openly sob. "He would have made it if he'd seen a doctor sooner, wouldn't he."
Dixie reached up to rub soothing circles on the younger woman's bowed shoulder. "We don't know that Sharon. Maybe, but it's hard to say."
Sharon knew. If she'd been concentrating more on what she'd been doing rather than watching the clock, that boy would probably still be alive. If only she had been able to ignore the pushiness of the boy's coach. If only she had looked more closely at the child. If she had just realized the head injury was that serious.
Carefully observing the younger woman Dixie could almost imagine what thoughts and recriminations must be going through the novice nurse's mind. "Now Sharon, even if there was something else you could have done, the time for that is past. It will do no good for you to dwell on the 'what if's'. Did you ask the appropriate questions?"
Sharon sniffed and fished for a tissue in her purse. "Yes Ms. McCall. I followed the protocol we've been taught to use. But….I should have looked at that kid closer. Maybe I could have seen something. Maybe I could have…."
Dixie raised her hand in a halting motion. "Stop Sharon. Look, even when we got the boy into a treatment room, he told Dr. Brackett he had never lost consciousness. But likely he had, based on the lack of a consistent story time line he reported. You are not a mind reader. None of us are. If he told you he didn't pass out, believing him was natural. The best thing we can do here is use this as a way to grow. Next time, we'll all know to pay closer attention. Experience is a harsh teacher, but an effective one."
Sharon dabbed at her eyes. "But a boy died!"
"Yeah, I know." Dixie replied softly. "It's tragic. It really is. But in our line of work, we deal with life and death and because of that we have to do our work with every bit of care and concentration we can every single day."
Sharon sniffed loudly. She felt so horrible.
Dixie wrapped a caring arm around Sharon's shoulder. "I know you feel terrible right now Sharon." Dixie gave the woman a gentle squeeze. "But I'll talk to Dr. Brackett. We'll put together some better procedures for triage at Rampart Emergency. We'll improve our methods so we can hopefully avoid another situation like this."
Sharon wiped her eyes. "I am so sorry Ms. McCall."
Dixie offered a sad smile. "Me too Sharon, me too. Now come on, let's get out of here for the day. Tomorrow I'll get together with Dr. Brackett, and we will put together a better system for sorting out our patients."
Extra Bits & Pieces
Triage: Derivedfrom French (root word: trier) meaning to sort, cull or select. The concept of triage was based on the greatest good for the greatest number of wounded. The process of triage is first known to exist as early as the times of the French Revolution and the Napoleonic Wars.
Triage - "A process for sorting injured people into groups based on their need for or likely benefit from immediate medical treatment. Triage is used in hospital emergency rooms, on battlefields, and at disaster sites when limited medical resources must be allocated." Definition taken from free dictionary dot com.
Research indicated that during the 1970's development of the concept and practice of triage was refined greatly for the purposes of domestic hospital use. After discussing the idea for this story with a practicing ER nurse, I learned that triage in our modern hospitals consists of verbal interactions with the patient, procurement of vital sighs, and some cursory physical exploration of specific complaints and issues. Also, as knowledge about age specific issues and trauma has deepened in the profession, greater priority for a child with such an injury would have been given today as opposed to the hospitals of the 1970's. Back in the era of Emergency, children's susceptibility to complications from illness and trauma likely would not have been as widely recognized in the burgeoning field of emergency medicine.
Significant study and standardization for triage processes was accomplished through any number of legal and research documents including but not limited to the following works.
1973 Emergency Medical Services Act
1976: Optimal Hospital Resources for Care of the Injured Patient (ACS)
1979 Orange County Study
1992: The Model Trauma Care System Plan (HRSA, 2006))
Notice that much of the work advancing triage occurred during the 1970's. Even in today's hospitals, the triage process is in a constant state of flux while emergency care providers search for ever improving tools for streamlining the process for the benefit of patient care.
I can't help but think the Emergency episode "The Bottom Line" was the show producer's method for calling attention to deficits in triage as it existed in emergency medicine of the 1970's. Perhaps the episode was designed to explore issues thereby increasing awareness of what would have been 1970's current day problems.