Analisa Traba has a job that is somewhat like performing triage in wartime. Only she does it in 12-hour shifts three or four times a week, and the war never ends.
A trauma nurse in the emergency room at Cedars-Sinai Medical Center, she has only seconds to determine what the problem is, whether the situation is critical, what kind of care, drugs and treatment the patient needs, and where the patient needs to go next home, to another hospital or admitted upstairs.
Traba arrives at 7 a.m., to take over as one of only two trauma nurses on duty. Moments after getting to work, she takes her first paramedic radio call of the day. The paramedics estimate an ETA of 10 minutes for the arrival of a 58-year old man with facial trauma, under the influence of alcohol, who has been "combative" with them.
The 33-year-old Traba is petite and trim, with short black hair and a wide smile. Everything she does is at triple-speed she walks fast, she types fast and she diagnoses patients fast. She arrives on duty wearing a dark teal set of scrubs. Like a majority of nurses, she wears clogs on her feet.
When she started out as a hospital bedside nurse at Tarzana Hospital six years ago, Traba had to wear the traditional white shoes and hose, and white dress. She screws up her face when she describes the outfit. "It's one reason why I went into E.R.," she laughs.
A lot has changed in health care dress in the past few years. Indeed, walking into the Cedars emergency department, it's hard to tell who does what. Unlike on the TV shows, dress is based on personal style not on job description, so nurses may wear lab coats and doctors may wear scrubs. Patients learn to look at the nametag to see who's treating them.
On this Monday morning, Traba will cover a variety of assignments, such as discharging patients and performing inventory on equipment carts. Most of all, she'll go over mountains of paperwork for each patient.
She will constantly enter and update information on the patient flow computer terminals. She'll check on her patients in trauma rooms or other E.R. rooms. She also takes a number of incoming calls on the paramedic radio.
At 8:30, Traba takes a half-hour break. She bounds up and down the staff-only stairs leading to the hospital cafeteria.
"I hate elevators," she says. This is her first cup of coffee of the day and it is the only time during the day she will have any fluids. "I may drink one glass of water a day, but I tell my patients to drink eight a day. We can't drink water because we don't have time to go to the bathroom. Our kidneys look like beef jerky," she says.
Traba wanted to be a nurse since she was a little girl and started out as a clinical bedside nurse at Tarzana Hospital in the early '90s.
That job, in its own way, was harder than being a trauma nurse it involved turning over a lot of heavy people, changing them, getting emotionally attached. Traba says trauma is more suited to her, with the running around and the adrenaline rush when a new patient comes in, and making split-second decisions that could save or lose a patient's life.
A lot of nurses burn out after a couple of years, and Traba says she's one of the old-timers on the ward, with one and a half years. She worked at Holy Cross (or "Holy Hell" as many call it) before coming to Cedars. Recently she was ready to take a break, but the hospital made changes that encouraged her to stick around.
"Three months ago, I felt like I was burning out. Now we've got more staff and we're not closing every day," she says.
No body fluids, please
Cedars is considered the cr & #269;me de la cr & #269;me of the emergency rooms in L.A. by hospital staffers. The nurses generally don't need to deal with body fluids there are less-trained staffers on hand to take care of cleanups. At the same time, the environment is low key, affectionate and jovial. "We don't have much attitude here. If we get a nurse in here who says, 'I don't do fecal or urine,' then they have to leave," Traba says.
After her break, Traba sees a number of patients complaining of chest pains, the most common complaint in the emergency room. Traba says most patients really think they're having a heart attack, though they seldom are. She adds that some of them also know that any patient who complains of chest pain at triage is more likely to be seen right away.
One of her chest pain patients tells Traba that she is having a bad pain in her leg, something she hadn't told her doctor. Traba says that happens often because she is able to take the time to ask probing questions, and the patients feel more comfortable with her. "I'll stay an extra few minutes you pick up on little things," she says.
Traba talks the whole time she is taking the woman's blood, to keep her mind off the pain. "You'll feel a little poke now. Do you want your head up? Do you want a warmer blanket? Hopefully the doctor will find out what's wrong with your leg, OK?"
Traba runs to gets a pillow. "I have a feeling she bonked her leg while she was switched from the paramedic gurney to the exam-room gurney," she says. "I don't think it's anything serious."
The older woman's doctor wears a cartoon-character tie but has an imposing manner, so it's understandable why the patient might have been more comfortable telling Traba something she didn't tell the doctor.
Between now and the afternoon rush, Traba will admit an increasing number of patients with varying complaints from repetitive lifting pain to a bloody nose. She will advise paramedics about a 7-month-old baby having a seizure. She will change a urine bag and replace a urine catheter yanked out by the elderly alcoholic admitted earlier. (No mean feat, since catheters balloon out in the bladder.)
She will also constantly update the flow charts on the banks of computers circling the nursing station. She will dispense drugs from the automatic Pixis machine, a computerized device that helps prevent nurses from making mistakes. To use the machine, Traba enters a patient's symptoms and her recommended drug choice. If the computer agrees that drug is appropriate for the symptoms described, a drawer containing that drug will open; if the computer disagrees, the nurse won't get any drugs.
Her one-hour lunch break will be her last break of the day. She and the other nurses drink nothing, demonstrating their devotion to avoid bathroom breaks.
Treating a TV star
At 2:45 p.m., an elderly man is admitted to the E.R. by two Beverly Hills paramedics. The man complains of hip pain after a fall and is recognized by trauma nurse Mike Richer as an old-time, very well-known TV comedian. The man's face is sallow and ashen, and he's very thin. He is wheeled into room No. 4, and Traba takes down all his vital statistics, stabilizes him, takes his blood and enters the information on the computer.
Moments later, a severely burned man is wheeled in amid a strong smell of chemicals and burned flesh. His face is many shades darker than the rest of his body. His mustache and hair has been singed off, he is in shock and shaking. The skin on his arms, torso and lips is shedding like a snake's.
A doctor yells out, "Get a pain scale." Traba speaks Spanish to the patient, asking how much pain he's in on a scale from one to 10. The man croaks, "ocho" (eight). He's given morphine.
While the doctors and nurses stabilize him with compresses, ointments and oxygen mask, the paramedics give their report. The man was cleaning an elevator shaft with acetone. He tried to chip some paint off with a hammer, the spark from the hammer ignited the acetone and the flames shot up the elevator shaft. The nurses joke with him that he got a nice haircut. They start singing. All of this is an effort to normalize the situation, and hopefully to calm the man.
Richer calls the man's wife and tells her to come to the emergency room. Then he asks the patient whether he wants more morphine. "OK," the man says. He gets another dose.
There is a short lull at 4:10 p.m. As Traba walks back from checking on a patient who wants to be discharged, Richer says, "We're gonna' get a big trauma here in a second." He's been on the phone with paramedics who are bringing in two car crash victims, one of whom had to be extricated from the vehicle.
The passenger comes in groaning loudly. About 10 doctors and nurses surround his bed and cut off his clothes, insert a catheter for urination and "intubate" him (insert an oxygen tube down his throat and into his lungs). The doctor shines a light in his eyes to check for concussion and other damage. After picking glass off his body, Traba wipes blood off him and makes notes on such factors as alertness, pupil size, blood pressure, respiration, medication and verbal response, entering the information on a three-page flow chart, and on the computer.
By the time all this has been done, the next crash victim, the driver, is taken into room No. 1. Only four attendants are free to deal with him, though he turns out to have the more extensive injuries and will need plastic surgery on his mangled face.
While Traba is still dealing with the passenger in the car accident, the comedian next door wants more painkiller. Traba jumps away from the crash victim and talks to the celebrity, then gets written approval from the overseeing doctor to give the star more than the 19 mg of morphine he's already had.
After the car crash victims, the burn victim and the TV star are groggy and stabilized, one of the E.R. nurses asks Traba for help with an elderly woman who had come in earlier with chest pains. Now she is near death and her entire family is there, crying outside of her small room.
They are having a DNR (do not resuscitate) conversation. The women in the family go off to another room to talk. The husband does not want to leave his wife's side. He walks in and out of his wife's room, then sits in a chair outside the room sobbing.
Richer talks to the man for a while, asking him what he would like. The man would like to speak to a Rabbi. Richer walks around the nurses' station yelling, "Is there no man of God here? Even the county hospitals have chaplains and Rabbis."
Traba, meanwhile, is in the dying patient's room helping to insert an IV into the woman, which will deliver three different medications. "I already told my mom, sign the paperwork now. You do not want to have to go through this in the hospital," Traba says.
Traba kneels down to talk to the husband with her arm around him. She explains to him that the doctor has said he will need to call security to escort him out if he doesn't stay out of the room.
Later, the family decides to keep the woman on a respirator, though there is little hope of recovery. Traba administers Pavillon, a paralytic anesthetizer that will shut her entire system down before she is ventilated (put on a respirator).
When Traba leaves for the night at 7:30 p.m., there are 40 patients in the emergency department, some of them on gurneys lining the halls. Before her shift is over, Traba will enter the inventory into the Pixis drug dispenser machine and report to the oncoming trauma nurse on all the patients she is handing over to him.
"It's been a slow day," she tells him.
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