by Tilda Shalof
Robyn stays a while longer, then tiptoes out, thinking I’m asleep and not wanting to disturb me. She’s flying home in the morning, but between us there’s no need for hellos, goodbyes, or any formalities, for that matter.
The lights have been dimmed in the hallway. I’ve dozed off and on all day, but I’m still tired. Nurse Ray left his stethoscope hanging on my IV pole. Slowly, I ease myself up and manage to pull it down. Sitting on the edge of my bed, I place it on my chest and listen to my heart and silently thank God for each lub-dub, every tick-tock. For the first time in my life, my heart sounds strong and healthy. It sounds like a normal heart. Wow.
Up till now, I haven’t had many rational thoughts, but one occurs to me now – and as grand and over-the-top as it sounds – it makes perfect sense: if every human being could be cared for so lovingly, if we could ensure that every human being’s needs were met so completely – world peace would be possible. How hard could it be? Maybe we could even nurse our planet back to health.
11
TRUSTING STRANGERS
Day four post-op. I’m on the mend, may have even turned a corner, but the morning got off to an unsettling start. I awoke to whispering voices outside my room. “The wrong patient,” it sounded like one nurse was saying to another. “He wasn’t supposed to get it, but he says he feels better than ever.”
Mmm … There are harmless errors, I thought to myself, but here’s something new: a beneficial one.
I tried to get back to sleep but couldn’t and I lay there, uneasy. Moments later, I hear them again, now chatting about another nurse’s engagement – “The party’s now, but the wedding’s more than a year away.…” which somehow leads to a discussion of Indian cooking. One nurse advises the other to fry onions, garlic, and ginger in ghee and the other politely insists that coconut is the essential ingredient. One of these nurses comes into my room, introduces herself, checks my armband, hangs a bag of antibiotic on my IV pole, and plugs it into the saline line running into my arm. I look up and examined it. Yup, that’s the drug I’m supposed to be getting, the right dose, right time, right route of administration, and right patient – me – but it got me thinking …
It’s a good thing that the nurse identified herself and checked my name band because I haven’t met her before and she doesn’t know me. It’s incredibly easy to mix up patients’ names and faces. Once, in the ICU, there were two patients, side by side, a Mr. Scotland and a Mr. London. (This sounds like a joke, but it’s true.) One’s the country, the other, the city, I kept telling myself to keep them straight, but a few times over the day, I caught myself addressing them with the wrong name. Luckily, they didn’t care or were too sick to even notice, but I had another patient who did. He was angry, but I couldn’t figure out why. He couldn’t tell me because he was intubated and too weak to write me a note. “His name is Roger,” his wife told me coldly when she came in the afternoon to visit and heard me calling him Richard. I felt terrible and apologized profusely. How upsetting for him! He must have felt I’d been taking care of someone else, maybe even worried I was giving him the other patient’s meds.
During this hospital stay, I’ve been given many tablets, capsules, and IV meds. Despite my woozy haze, I know what they’re for, their colours and shapes, possible side-effects, drug interactions, and what I’m supposed to be getting, but what if I didn’t?
“These aren’t my pills,” a patient once said to me, handing them back. I checked and double-checked and indeed they were the correct meds, but she was right to ask me to verify. But what if you don’t know what questions to ask, or you feel intimidated, or aren’t well enough to ask them? Luckily, a friend of mine was. “Hey, what’s that for?” he asked his nurse, stopping her as she was just about to give him an injection. “It’s your insulin,” she told him. He reminded her that he did not have diabetes, though his roommate in the bed next to him did. “Oops,” was all she said. He probably didn’t find it as amusing at the time as he did months later, when he recounted it to me with a chuckle.
Computerized doctors’ orders and medication dispensing systems will likely reduce errors, but it’s going to take more than that to keep patients safe. Some of the other factors that cause errors – stress, fatigue, distractions, interruptions, time constraints – are common features of nurses’ work, and let’s face it, when it comes to medications, it is nurses administering them to patients. Yet, as a patient, you want – no, need – to trust the people caring for you.
I’ll never forget the friendly-fire interrogation I received years ago from Dr. Arnie Aberman, who was the dean of medicine at the University of Toronto and a staff ICU physician at the time. He was known for his exacting standards and his habit of interrogating doctors and nurses – everyone, in fact – to make sure we knew exactly what we were doing in our care of patients. He himself was such a conscientious and caring doctor that he would show up in the ICU, at any time, day or night, weekend or holiday, to see a patient. “I’ll always come in,” he would say. “If I’m giving testimony in a court of law, I can’t just tell the judge how the patient was described to me over the phone. I have to see with my own eyes.” He always claimed that was the reason for coming in, but I knew he also did it because he was genuinely concerned and wanted to ensure everything was done properly.
One morning on rounds, he began to grill me about my patient, her diagnosis, medical history, tests she’d undergone, and treatment planned for that day. Then he started in on a line of questioning that felt like a cross-examination, but I knew him well enough not to take it personally. It was an intellectual exercise, meant to teach me something, though at the time, I wasn’t sure what.
“What medications is your patient receiving?” he started off.
I told him, along with the doses and the reasons for each one.
“Did you change your patient’s abdominal dressing today?”
“Yes, I did it earlier this morning.” I spent over an hour on it, so please don’t tell me you want me to take it down again so you can have a look at it, I thought, but he had something else in mind.
“How do I know that you changed the dressing?”
“Besides the fact that I’ve just told you and charted it, too? And that I signed and dated the wound care assessment sheet?” But these answers weren’t what he was looking for. I tried again. “The wound is healing well with a moderate amount of serous sanguinous drainage but no purulent discharge. There is pink granulation tissue around the circumference and the edges are beginning to approximate.”
“Now we’re getting somewhere. An eyewitness account.” He continued his questioning. “Okay, tell me, what’s running in her IV?”
“Normal saline at TKVO – To Keep the Vein Open,” I added, in case he wasn’t familiar with our nurse lingo, “piggybacked with an antibiotic. Ampicillin.”
“How do I know there is ampicillin in that bag?”
“Because I just told you I put it in there.” Where was he going with this?
“How could someone else know what was in that IV bag?”
“They could read the label I stuck on the bag. ‘Ampicillin, one gram.’ I dated and signed it, too.” What more was required?
He looked at me askance, eyebrow cocked. “Do you believe everything you read?”
“We’re professionals. We trust one another.”
“That’s a dangerous habit. If you were on a witness stand, and this was all the evidence you could come up with it wouldn’t hold up in court. It would be hearsay.”
Thankfully, I’ve never had to testify in court, but how could we do this work if we didn’t rely on one another? Yes, it’s true you can’t be sure something was done correctly unless you do it yourself, but what about teamwork and trust? Both are essential to do this work. And you need enormous amounts of trust to be a patient. (How stressful to be cared for by people you don’t trust!) Yet, a healthy dose of circumspection on both sides is needed to keep patients safe. You can have all the computers, patient i
dentification mechanisms, and safety checklists in place, but if don’t have true partnership, no one feels safe.
Years ago, I worked with a very experienced nurse. She had lived in different countries and had many specialties – obstetrics, pediatrics, orthopedics, and, when I knew her, critical care. Victoria was knowledgeable and capable and I had no reason not to trust her until one day I found a large syringe filled with fentanyl hidden behind the sharps container on her side of the counter. Noting the concentration, I calculated that there was 1,000 mcg of narcotic in that syringe. I was shocked. That amount is given to a patient in divided doses over hours, with close monitoring, during general anesthesia for surgery. In the ICU, we never give more than 25 mcg IV in a push dose, and then only if the patient is intubated and on a ventilator. When I asked her about it she didn’t seem at all perturbed by my question, casually saying she’d withdrawn that amount by accident and was planning to put it back in the narcotic cabinet later. We both knew it was impossible to return liquid to the original glass vials that had already been broken open. Then she came up with a different answer. She said she had been planning to inject that large dose of fentanyl into a bag of saline and use it for a continuous infusion for her patient. That was a more plausible explanation, but still, it was a huge red flag. Besides, for me it was too late: I had already gone from trust to mistrust.
I suggested we go to the med room to dispose of the narcotic. She said she would do it herself later, but I insisted we go together to “waste” the medication and I would witness its disposal, a practice we do whenever there is unused narcotic. Thinking back now, I should have notified our manager, but luckily, other nurses had their own concerns, too, and they reported her.
Soon after that incident, she was off on extended sick leave and I heard that Victoria was in the process of becoming Travis and was suffering severe pain following gender-reassignment surgery. That provided a possible explanation if she had been “diverting” medication for her own use, but I never found out for sure if she/he was a drug user.
I am a trusting person. Trust is where I begin, unless I have reason to think otherwise. But it seems like old-fashioned trust is becoming scarce. Over the last few years, with the increase in security measures and the tightening of practices to protect privacy in all areas of society, it feels like there’s more of a culture of fear and suspicion than ever, even in the hospital, where trust is needed more than almost anywhere else.
For the nurses, one of the first signs of a loss of trust happened when Corinne, our fearless union rep, political activist, and superb nurse, found what she believed to be a surveillance device installed in the medication room, on the ceiling. “It’s a spy cam!” Corinne said, appalled. She went straight to our manager in indignation. The administration said it was an “air quality monitor,” but we didn’t buy that. Someone else told us it was an “inventory control device,” but if so, shouldn’t we have been informed that we were being watched? Corinne took matters into her own hands and dismantled the contraption herself, with the rest of us standing by, cheering her on.
That incident happened a number of years ago, and looking back on it now, while I still admire Corinne’s daring and initiative, by today’s standards our outrage seems outdated. Nowadays, surveillance is everywhere; it’s the new normal. We recently learned that “undercover” watchers from Infection Control have been covertly observing staff to evaluate compliance with hand hygiene – of course, justified for quality control purposes, but nonetheless, it took us aback. Cameras are now everywhere, certainly in all public places in the big city from parking lots and banks, to schools and day cares, so why not hospitals, too? Increased “security measures” are supposed to make us safer, but why doesn’t it feel that way? In the hospital, there are more rules and policies designed to protect privacy, more transparency and accountability, and full disclosure about “adverse events.” There are public forums and town hall meetings; reports about a hospital’s performance, full financial disclosure of the hospital’s budget, the surgeons’ rate of infection or incidences of complications for various procedures, even the annual salaries of the hospital’s senior administrators (probably to their chagrin) are easily accessible to all. Yet with all of these measures in place, it feels like the public’s trust is at an all-time low.
But when you’re a patient what choice do you have but to trust the institution and the people caring for you? You’re in their hands – literally. Oh, there’s been an attempt to rename patients “clients,” perhaps to create an illusion that we’re “consumers” making independent and rational health care choices. For hospital nurses, clients as a term has never caught on. Patient refers to a person you care about, a client is someone to be dealt with. To nurses, patient can be almost a term of endearment because it has the connotation of protection and watching over, of tending to. Admittedly, it also carries the meaning of being subdued and obedient, passive and helpless. However, take it from me, when you’re the one in the hospital bed – you’re a patient!
Why should we trust the people taking care of us? Some of us have our own reasons not to. Trust can’t be promised, guaranteed, or legislated; you can’t be convinced or persuaded to trust, and there are no policies, mission statements, or corporate philosophies that will ensure it. Yet you know when it’s there and when it’s not. But for trust to be effective, it’s got to be mutual and reciprocal. It’s a relationship.
The ultimate sign of one family’s distrust was a bright yellow Frisbee. It was hung in a patient’s window by her husband, who was dissatisfied with our nursing care of his wife. His hotel room was across the street and we could see him aiming a telescope on the room identified by the yellow Frisbee, spying on us while we took care of her. We joked that the stuffed dog he left on her bed was probably bugged. When he wasn’t there, we talked into its plush fur and said silly things. He didn’t trust us and we learned not to trust him. All in all, it wasn’t a very therapeutic atmosphere for the patient, his wife. Nor was the time that a family brought in a herbal tea for us to give to their mother. We had no idea what was in the strange-smelling concoction and they weren’t able to tell us, so we refused to administer it to her. That didn’t stop them from sneaking it into their mother’s feeding tube when they thought we weren’t looking. All in all, it’s better for everyone, but especially the patient, if there is mutual trust.
I try to fall back to sleep to escape my unsettling thoughts, but I can’t relax. Worse, to my horror, I get a whiff of my body. I stink. My last bath was that luxurious one two days ago in the ICU. I lie in my unwashed condition, too scared to get up and walk to the shower by myself. My nurse left soap and towels out for me and there’s a shower right in my room, just a few steps away. There’s no reason why I can’t get up. I have been given the green-light with AAT—Activity as Tolerated – on my chart, but with the slightest exertion, I feel short of breath and light-headed. How am I going to get to the shower and wash my body myself? It seems monumental.
Still, I can’t sleep. My heart is beating rapidly. Breathing is difficult. I try to sit up but feel sore all over and fall back against the pillow. I’ve never felt worse.
It makes me think of morning rounds in the ICU when we were discussing a patient whose condition had shown no improvement after surgery. He had been critically ill, septic, and unconscious before surgery and was still now, afterward.
An eager resident pointed out to Dr. Hawryluck, “At least we didn’t make him worse.”
“No, we didn’t make him worse,” I remember her saying, then adding dryly, “but we set a much higher standard than that.”
Here I am, worse than ever. I’m even considering using the call bell or maybe trying to get up out of bed to hunt down a nurse when one appears at the door, but it’s a nurse I haven’t had before.
“Here are your pain pills, Tilda” she says cheerfully, “and these are your iron tablets and beta blocker, but first let me take your blood sugar and vital signs.”
> She knows me, but I don’t know her and I can’t seem to summon the energy to ask her name. It is so important for nurses to introduce themselves and spend a few minutes to listen to their patients’ concerns right from the beginning of a shift. It’s absolutely necessary if you want to establish trust.
The nurse tells me that my blood sugar is normal. Next, I hold out my arm for the blood pressure cuff. She starts pumping. She pumps and pumps until she’s squeezed me up to over 300 mmHg and holds it there.
“That’s too tight!” I snap at her. “You don’t have to go so high.”
She releases the valve, but for some reason the cuff doesn’t deflate. I sit with my arm in a clench. I’m fuming, waiting for her to release it. She doesn’t. I can’t take it. I rip it off my arm. Nonplussed, she flattens it out and is about to try again, but I stop her.
“There’s something wrong with that cuff. It’s broken. Try a different one,” I tell her, but she resumes pumping up my arm.
Why don’t you just forget about it? Oh I know, I know, numbers have to be filled in for my blood pressure. Just make something up, I want to tell her. I was tempted to do that, once, when I was a young nurse. I was scared to wake up a patient who was peacefully napping when I came into the room to take his blood pressure. Let sleeping dogs lie, I thought. On the other hand, what if his heartbeat is irregular or his blood pressure abnormal? I took a look in his chart. The last reading was 128 over 76. I eyeballed him. He looked fine, but you never know … so I woke him up and of course he was annoyed and sure enough, his blood pressure was stable at 134 over 74, perfectly normal. I backed off and skedaddled out of there as quickly as possible.
My nurse pumps up my arm again. The room is hot and I break into a sweat. Then a fuse blows. “That’s it!” I yell. “Stop! You don’t know what you’re doing!”
“Your pressure is 118 over 68. Very good.”
Oh, I guess she managed to get it to work.
