by Tilda Shalof
“What made you think something was wrong?” Janet’s observations are never vague or ambiguous, but her ability to recognize subtle clues – some would call it intuition but it’s much more than that – is unerring, absolutely bankable. This quality is priceless in a nurse.
“I couldn’t put my finger on it, but she did not look right. No sir-ee, Bob! The operation went well. Her numbers were hunky-dory. On paper, she was a rose, but in person, not so much. I gave her IV fluids and took some blood work, but then I had to check out the lay of the land in the rest of the hospital. Meanwhile, other fish were being fried and I didn’t get back to her until five in the afternoon when she was right on the edge.”
“So what did you do?”
“I always ask myself, How can I fix or improve the situation? I have to do something and I’d rather do it before a patient arrests. She was chugging along at over forty resps per minute, her heart rate was one hundred and thirty. I drew an arterial blood sample and it was absolute garbage – dark cherry red. The respiratory therapist put her on 100 per cent oxygen. She was pre-arrest and I needed help, so I called a Code Blue. I wished I could have prevented it, but in this case, I couldn’t.”
“How is she now?”
“I just visited her in the ICU. She’s hanging in there. The family was grateful I made things move along faster. ‘You told us to trust you and we did. We took you at your word. You were the only one who saw there was something going wrong.’ They appreciated that I hadn’t walked away. On the floor, some nurses are reluctant to engage. We’re not used to that in the ICU. If we see a problem, we have to do something. We don’t walk away. ‘You saved her life,’ the family said. Isn’t it the best feeling in the world?”
We sit on the couch for a while, thinking about this, the best feeling in the world, until it’s time for Janet to walk me back to my room and for her to get back to work.
A man in a dark green uniform carrying a toolbox arrives at my door. He’s here to fix the heater in my room. We chat briefly and I hear his Farsi accent. “What did you do back in Iran?”
“Mechanical engineer,” he said with a wry grin. “No work here.”
It’s a reminder of other people’s concerns and the world outside of the hospital – something I’d completely forgotten about – and countries where many people have a lot more to worry about than the temperature of their rooms. Sheepishly, I thank him for fixing my problem.
A pizza delivery guy has arrived. The nurses have ordered in food. Believe me, you don’t want a hungry nurse! There’s a nurse I know who brings a bag of celery for lunch and drinks coffee all day. How much energy does that provide? Would you want her caring for you? On the other hand, one hungry nurse went down to the food court late at night, just before it closed, to buy a Subway sandwich. She returned in a state of shock, visibly shaken.
“What happened?” we gasped when we saw her, rushing over to her with a chair.
“I was buying a sub and suddenly I hear weird sounds from the back of the dining area, you know, where the Coke machine is? I went over to check it out and there was this guy moaning, his pants down around his ankles, jerking himself off. Where’s a security guard when you need one?”
She was still carrying the plastic bag with her submarine sandwich, so I couldn’t resist:
“Was it a six inch or a twelve?”
How we howled with laughter!
Yes, such juvenile jokes and sophomoric pranks help to get us through the night. Call it nurse bonding. Sometimes our work makes us as needy as our patients. There’s the heavy-duty labour that results in neck, back, and muscle injuries – as much as construction workers – and the hazards of night shift. Sometimes even more draining is the emotional labour. All in all, it’s a risky career we’ve chosen and hospitals aren’t usually very healthy environments for nurses. We have to work extra hard to stay healthy, but I know many who don’t.
“We’re parents, nurturers, caregivers,” Janet was saying one evening in the staff room. “Between home and work, we’re holding down two jobs and not taking care of ourselves because we’re too busy taking care of everyone else, patients, their families, and our own families, too.”
She would know, I thought, because she does all of those things.
“Yeah, tell me about it, girlfriend,” chimed in Nina. “They say, ‘God can’t be everywhere, so he created mothers.’ I say mothers can’t be everyone so that’s why there are nurses. We give, give, give, but it’s never enough.”
Nina would know, too, because she was none of those things. She was one of those nurses who always feels hard done by. We all have moments like that, but she never seemed to rise above it as most of us do. That night Nina was particularly bitter in the wake of a heated encounter with her patient’s wife.
“Her husband isn’t getting better, so what does she do? Blame the nurse! I feel burned. I gave so much and next thing I know, she reports to our manager, saying that I had crossed the line, that I was ‘unprofessional,’ too emotional. I swear I’ll never get involved with families again.”
Ah, being professional – contained, businesslike, definite of your boundaries. If only expertise, skill, and knowledge were all that was required, it would still be a tall order. On top of that we’re also supposed to be mindreaders, purveyors of cheer, hope, comfort, kindness, and inspiration. Most of us start out idealistic and enthusiastic, trying hard to provide all these qualities to our patients, but many of us fall short at times along the way. There’s so much in a hospital that can break your spirit.
There’s one aspect about being “professional” that’s still a challenge for me. It’s the distance you’re expected to keep, that stance of formality that is required. I’ve always treasured the more human moments when I’ve ditched the “professional stance” and allowed myself to be real, when I’ve chatted one on one with patients and their families, joked around, shared a laugh or something of myself. Boundaries can be hard to establish because of the intimate, familiar quality of nurses’ interactions with patients. For example, at the end of that unintended group conversation with the roomful of people on the speaker phone, just before hanging up, the daughter said, “Give Dad a kiss from all of us.” Would they say that to any other “professional”? I admire nurses who use their individual flair, personality, and humour in their interactions with patients. They put their very selves into their toolbox. I love what my friend Rosemary once said, “When I go into my patient’s room, they get me. I’m the treatment.”
It’s good to be real and human, but in balance. Some people can’t see beyond initial impressions. We don’t always do a great job of managing our image. I learned this lesson long ago, on one of my first shifts as a new graduate. I was working with Hannah, an excellent nurse whom I looked up to as a role model. At one point, she checked her watch and said, “C’mon, let’s go. It’s time to flip the steaks.” I was offended by her crude, off-the-cuff words, so callous and at odds with her otherwise professional demeanour, but then I figured, so what? Did it matter if Hannah was a bit rough around the edges? She was kind to patients and clearly knew the importance of repositioning immobilized patients to reduce the incidence of pressure sores. Who cared if she talked like this, nurse to nurse? It didn’t change my opinion of her and I’ve long since learned to see beyond the brash talk or seemingly “unprofessional” behaviour of some wonderful nurses.
Being professional – that’s the easy part – but patients expect so much more! In addition to all of the above expectations, at various times we’re supposed to play the roles of mother/father, brother/sister, enforcer, confident, teacher, friend, coach, and mentor – not to mention ordinary angels and everyday heroes. Unlike most patients, my expectations of my nurses are more modest. With all they have to deal with, if they give me the correct meds and stay alert to problems, I’m satisfied. Most patients want their nurses to make them feel safe and comforted. Some even want a relationship. They like it when their nurses show emotions, but o
nly if they are in synch with what they are feeling; nurses who don’t show their emotions are deemed hard-hearted and cold. Can you imagine a profession where emotional expression is a job requirement? Welcome to nursing.
But I’ll admit, at times we can be too real, too human. Oh, I’ve seen some inappropriate things in my day. A nurse who wore outlandish earrings that dangled to her shoulders. Another nurse with a habit of resting his feet up on the desk at the nursing station in full view of the public. One time, I saw a nurse chowing down on a full-course dinner – chicken wings, French fries, corn on the cob while sitting right outside her patient’s door. The family was gathered around the critically ill patient’s bed, and the nurse was contentedly eating her dinner in front of them. She was either oblivious to their crisis or at least wasn’t going to let it ruin her appetite.
Then there are inadvertent faux pas and bloopers, like the nurse who was leaning on the dialysis machine when her long hair got caught in the wheels. It sounds painful, but her extensions snapped right off and she wasn’t the least bit hurt, though her braids gummed up the circuit and brought the machine to a standstill. She was laughing so hysterically – along with her patient – she could barely call for help.
Nurses aren’t the only ones who blunder. Once, a staff doctor arrived for a family meeting. He sat down with the distraught family and proceeded to tell them bad news. The complicated operation he’d just performed on their mother had been unsuccessful and her condition was very grave. I watched the family’s expression move from shocked to puzzled to bemused and relieved. I realized what was wrong. I tapped the surgeon on the shoulder and informed him he was talking to the wrong family. Wow, that was an awkward moment.
Then there was a small, silly mishap that still makes me chuckle. During rounds one day, a staff hematologist was speaking to the team, outlining a patient’s rocky course of chemotherapy protocols. For some reason, he happened to look down at his leg. I watched him slowly peel off a sock from his pants, stuck there from dryer static. He merely stuffed it into his white lab coat pocket and continued on without missing a beat. I admired his aplomb.
I’ve had my own cringe-worthy moments. Not the worst indiscretion, but one of the most embarrassing happened years ago when I was still working with Laura’s Line. An enthusiastic foodie, and onto a new health kick, I had bought a jar of Loblaw’s Savoury Seven-Bean soup and ate it for lunch. Delicious and nutritious, full of fibre and especially beans, later that afternoon, I began to experience its explosive side-effects. I had to beg various nurses to cover for me as I kept madly dashing out to the bathroom, each time trying to make it to a different location, so as not to be identified with the trail of stink bombs. It didn’t take long for Justine to “sniff” me out. “It’s you who’s going around here spreading the love!” she said in her booming voice. Busted! “This one you can’t blame on your patient.” Yes, we had been known to occasionally blame our own gaseous emissions on our innocent, unsuspecting patients.
I tiptoe out of my room and look down the long, deserted hallway. Not a soul around. I feel like I’m playing hooky – but remind myself, I’m a patient; I’m off-duty.
How short the night seems at home in your bed sleeping and how long it drags in the hospital when you’re working! There’ve been times when I’ve had to remind myself to keep the faith, that the night would eventually come to an end. There have been moments, though, of such intense fatigue that I managed to muster only the minimal wakefulness required to do my job safely, and not a drop more. Often I recall a quote by F. Scott Fitzgerald that I like: “In the real dark night of the soul it is always three o’clock in the morning.” Sure enough, even now, I look at my watch. It’s ten to three. Once, in the middle of a long night shift, I asked Maureen, a hardworking, seemingly tireless nurse, “What do you do when you feel tired?” I sat down out of my own fatigue to hear her response. “I don’t allow myself to think about myself,” she answered still in motion, in the midst of mixing a medication for her patient. “I just keep going.”
For me it’s more of a challenge to stay so focused, especially at night when I’m tired. Sometimes my imagination can get carried away, and I’m not the only nurse who’s like this. One night in the ICU, I stood at the window in my patient’s room, staring out at the downtown deserted streets, the traffic lights changing needlessly, unused parking lots, and empty, lit-up skyscrapers. A crime could easily be committed, I thought. There would be no witnesses and the corpse won’t be found until morning. I felt someone creeping up behind me. There was a breath at the back of my neck. A whisper blew into my ear and a velvet voice purred, “Perfect conditions for a murder, don’t you think?” I twirled around to see Valerie, a nurse who wrote true crime stories in her spare time. “Wouldn’t those icicles make the perfect murder weapon?” She pointed out long, sharp ones hanging from the ledge of the floor above. “When they melt – poof! – there goes the evidence. Something to think about, isn’t it?” She turned and went back to her patient.
I come out of my room, bleary-eyed, but still can’t sleep. The nurses at the nursing station look tired. I wonder if they’ve taken breaks or had a chance to rest. I hope so. If they do, they will be more alert and safer. Believe me, you don’t want a tired nurse giving you your meds or taking your vital signs.
Yolanda sees me and gets up. “Are you having pain?”
No, I feel fine, but I ask if they mind if I sit out here for a while with them.
“Feel like you’re missing out on the convo?” another nurse asks.
“Sort of,” I admit and then, on an impulse, ask, “Hey, could I read my chart?”
“Go ahead,” he says with a nod and hands it to me. Either I’ve caught them in an unguarded moment or they’ve allow me access because of my insider status.
I leaf through the pages, reading the story of me, told in point form, graphs, and numbers. Medical history, lab results, medication orders, consults, reports, consent forms, test results, progress notes, even my discharge summary, all ready for me to leave in the morning – it’s all here. The handwritten notes of the doctors of various specialties, nurses, respiratory therapists, physios, chaplain, etc., get intermingled, so your eye always gets drawn to the most legible entries, which often belong to nurses. I know one doctor who says he never reads nurses’ notes, only doctors’. That’s a shame. He’ll miss out on important information. On the other hand, I’ve seen ICU residents write their daily progress summary on their patients based entirely on information cribbed from nurses’ notes.
“Progress notes” are a log of events, sometimes organized in “SOAP” format, starting with Subjective data of what the patient says, then Objective observation. Assessment is what is gleaned from your actual examination, and then there’s the Plan of care. Every few years, a new charting style is rolled out, along with a team hired to teach and implement it, then evaluate its effectiveness. I’ve heard that in some places “narrative charting” is coming into vogue. It allows patients to record their experience, to tell their stories in their own words. It reminds me of an Israeli newspaper that for one day invited poets and writers, instead of journalists, to report the news. “The clothes flapping in the breeze, warmed by the sun,” conveyed the weather as vividly as a meteorological report.
Reading my chart is an unsettling experience. I kind of wish I hadn’t. It’s yet another case of TMI – Too Much Information. I saw in black and white that from 1230 hours to 1355 hours my heart was stopped: ischemic time. Then, later, in the ICU, I was restless and delirious. I read the nurses’ assessment of my condition, how they washed me, handled my bodily fluids, and cleaned me. It’s all here, my overuse of the narcotic pain pump and my extreme anxiety. There’s even a note dating back a few years about my cantankerous behaviour in the ER: “Hostile, demanding to be seen immediately.” How embarrassing! As for reading your own chart? I wouldn’t recommend it. What good can come of it? And it feels like I’ve intruded on the staff’s territory, infringed on their rig
hts. Caregivers deserve privacy, too, from us. We should let them do their work in peace.
It didn’t take me long to read through my fairly thin chart, but some patients have charts so extensive they are piled high in tall stacked volumes. Once, I had a patient who had a droopy eyelid and I mentioned it on rounds. To the team, it seemed like a new and ominous finding, possibly indicating a neurological problem. An MRI was ordered, along with other tests. Later, ploughing through the voluminous chart, I read that twelve years ago, the patient had brain surgery for a seizure disorder, leaving her with a weak eyelid. Upshot was, the MRI was cancelled and we returned to focusing on the patient’s current problem.
Peoples’ health histories can be so complex and charts are invaluable records, but the challenges to organize all that material, get it online, have it easily accessible to all the professionals caring for the patient and yet protect patient privacy is a huge and complex undertaking; a single, comprehensive, integrated electronic chart still eludes us, but we’re well on our way and I’m sure it will happen one day soon. Until it does, it’s also up to us to be responsible for our own information, keep track of records, tests, results, reports, lists of medications, and so on as best as we can. Maybe in the future our record will be so accessible and interactive that we could monitor our medical conditions and take on even more responsibility for our own health care.
But while the move to electronic charting and computerized medication dispensing machines are improvements, they have changed the way we work. For example, to chart a patient’s vital signs, I have to physically leave the patient altogether or merely look away, log on, go through screens, and enter the data. Likewise, to retrieve a medication, someone has to cover my patient so that I can leave the bedside to go to the medication station, log on to the computer, flip through a few screens to open the door of the cupboard or refrigerator to select each drug I need. Back in the days of yore, our nurse manager used dollar-store tin muffin trays that had a cup for diuretics, sedation, inotropes, antiarrythmics, and so on. Medications were kept at patients’ bedsides, with narcotics the only drugs under lock and key. In some ways, life was simpler back then. Though I do remember one time, I arrived home from work, reached for my house key, and discovered it was the narcotics key. I had to go all the way back to the hospital to return it. That wouldn’t happen anymore. Now there are no keys to worry about with the high-tech security measures in place. We access medications with our individual “biometric profiles.” A scan of our fingerprints opens the locked door. Only time will tell if these measure will improve patient safety.
