I graduated with a BSN in Nursing in 1973. My four year degree was the exception, not the rule, at the time. I received no extra pay or recognition. As with so many careers, training really began my first day on the job.

I learned about the demands of the relatively new hospital concept called “intensive care.” There was no internship, no syllabus, just flying by the seat of my support hose and white down-to-the-knee uniform. I pulled my hair into a bun and stuck my pens there, a sort of nurse’s kanzashi, to keep them handy. Charting consisted of half a page of lines and dots for vital signs and no more than eight lines for patient notes. Back then I documented drug infusions by flow rates, drops per minute, not dosages. I can’t remember how we documented medications. Self-edification drove my critical care learning. I enrolled in EKG classes, had the privilege of spending two days listening to Dr. Marriott explain the most complex arrhythmias, attended respiratory care seminars, and took advanced physiology to have the academics to support my practice.

Along the way I mastered how to finesse shaving a man with a heavy beard, how to navigate delicate family matters like a wife bumping into a girlfriend at the bedside. I learned a farmer rested better if I read him the bean futures or told him what I’d paid for a dozen eggs. I watched a learned professor die from his addiction to alcohol. I worked in a small unit where the patient was barely an arm’s length away. What happened to my patients I carried home, tucked in a portfolio of images, smells, and sounds. No escape, no mercy. I took every day personally.

Looking back on a forty-three year career, I evaluate myself and my profession. I ask, as Dr. Paul Kalanithi posited to himself in his book When Breath Becomes Air, did my life, my work, matter? I grew up in the Golden Age of Nursing. Before JCOH. Before computers. Before order bundles, protocols, and health care framed itself, first in a corporate model, now in a hotel management model. Before what was documented became more important than what actually happened.

I mourn its passing.

The Language of Touch

A piece of paper taped to one cabinet in the break room asked for items staff nurses would like to see in an admission package. I suggested a nice razor, one with more than one blade, one worth more than 29 cents and less likely to ravage the skin of someone sick enough to be in ICU, but well enough to feel better after a shave.

Later the same day, I walked by the break room and overheard two nurses, both who happened to be around thirty, ridicule two “seasoned nurses,” meaning over sixty, for making a big deal about shaving male patients. “I won’t do it. I just won’t do it.” One said.

I can’t imagine refusing to do any kind of patient care. I have been threatened, scratched, kicked, thrown up on, and sprayed with all sorts of body fluid. To me it’s part of the job. But I know times have changed. Maybe I AM out of step. So I looked up hygiene in a textbook called Fundamentals of Nursing. Shaving still appeared under the classification of personal hygiene and earned its own section with a “how to” discourse.

Two weeks prior to this I shaved a man days after an open heart surgery complicated by multiple co-morbidities. I asked his wife to bring in his shaving kit. It contained a nice four blade razor with Edge shaving cream, a brand I like to use on tough beards. I softened the whiskers with a warm cloth, slathered on gel that blossomed into an abundance of white foam, and shaved one side of the man’s face, then the other. When I finished, his family literally gasped with delight. The man they knew was beginning to look more like himself.

I sought out another experienced nurse. We discussed a scene from Out of Africa in which Robert Redford washed Meryl Streep’s hair. It didn’t overwhelm the audience with dialogue or sex. The mere act of washing hair epitomized the relationship between the senses and intimacy. To me it symbolized the universal language of touch. In the hospital setting, touch facilitates communication. It engenders a bond of trust that needs to be established between patient and professional, a bond that eases the distress caused by loss of control not only of the decisions of daily life, but also bodily functions. How do you make a person not feel ashamed when he knows he’s drooling because he’s had a facial reconstruction or when he loses control of his bowels and doesn’t realize it? It’s through a degree of intimacy and trust.

The senses connect us. They speak more articulately than words. It is not just a shave. It is a conduit that builds trust, creates a sense of safety, and makes a patient feel like he’s not just a room number, a diagnosis, and a daily weight.

Yesterday my patient’s skin peeled and pulled away from her fingers and toes. In the past week she had gained twenty pounds from water retention. The swelling stretched her skin until it radiated a watery sheen. As the swelling began to go down, the skin rebounded, dried, and flaked. I took off her anti-embolism hose and her sequential compression devices and released the smell of dirty gym socks. She was depressed, withdrawn, un-communicative, because a surgery she expected to earn her a brief hospitalization had incurred Murphy’s Law. She entered her fifth week in ICU with a tracheostomy and a surgically inserted feeding tube. I understood her frustration.

After trach care, catheter care, blood sugar checks, and adjusting IV drugs to a prescribed blood pressure parameter, I wanted to do something for her, not to her. I warmed up lotion and lavished her hands with it. Every finger got special attention. I remembered how pressure to my fingers during stress reducing massages seemed to release the tension in every muscle of my body.

I dialogued in an effort to break her silence. “You know why I’m doing this don’t you? If my mother were in your place, I would want to come in for a visit and know someone had cared enough to do it.” I moved to her legs and feet. I washed them warm wipes, slipped the disposable cloths between each toe. I slathered lotion on legs where lines of dryness mapped her skin in white. She grimaced when I rubbed lotion into her right ankle. “That really hurts.” No response. “What about the left one?” She actually nodded in response to my question.

Then for a dignified, mature woman, whose best friend told me she was meticulous about her appearance, disaster struck. She passed an enormous bowel movement, something the general surgeon would celebrate. It added to the patient’s humiliation and loss of her sense of self. How could I convince this stoic, regal woman that just this once, normal human bodily function meant she was one step closer to getting well.

I gathered cleaning supplies, linens, and another set of hands. “Now I’m going to bore you with some stories.” I warned. Stool puddled between the woman’s legs and housed itself in any crevice it could find. I had used stories before with a young male patient to pass the time when he found himself in a similar situation.

I talked about my grandmother, widowed after World War I, she raised four children on her own. “My grandmother worked to provide for her girls. When I knew her, she never was in anything but a skirt, her strawberry white hair in a chignon, and her nails long and perfectly polished.”  I think grandmother resonated with my patient. I could tell she was listening. My helper and I started to mop and wipe and clean and contain the flood of excrement.

“For supper one night, the family enjoyed a roast, probably a rarity in that day. The oldest sister cut and served while the others ate. Before she could sit down to eat, one sister was back for seconds. The eldest picked up the roast and threw it at the offender.  All my grand-mother could say was: ‘Girls. Girls.’” What I was trying to tell her was that we are all human, subject to human frailties and that this moment would pass. She smiled.

A week before that I cared for an octogenarian who lived alone. He began to hallucinate and provided intricate details of what he saw. He realized he was seeing things. The anxiety left him restless. He hollered for someone to come and kept punching the call light. I knew his daughter was coming. I pulled up a stool and sat beside him. “Tell me what you see.”

“Right now I see you encased in a sheet of water. It’s all around you.”

“I believe that’s what you see.” I held out my hand, not to deny him, but to share what I saw.

“I know there’s no rain, but I see it.”

“What else do you see?”

For the next forty minutes he created what I interpreted as his view of Heaven. He detailed with the precision of an engineer, a lift. It had a broad platform and inched upward toward Infinity. He talked about pulleys and cogs and people. “You were there too.”

He looked straight at me when he said this.

I shuddered like I had has a child, when other children who noticed me shake, said: “A rabbit just ran over your grave.”

In all the time he spoke his visions, I just listened and wondered what it all meant. Then the man uttered the words that explained it all.

“I think I’m dying.”

I sat with the man until his daughter arrived.

It is a cliché to refer to long standing definitions, but Florence Nightingale defined nursing as “the act of utilizing the environment of the patient to assist him in his recovery.” (1860) I added the italics. Our patients come to inhabit bland, functional rooms, filled with outlets, equipment, monitors, electric beds, television, climate control, negative pressure, and, if they are lucky, a window. But they also come with an inner environment which constructs the essence of who they are. The greatest privilege in nursing is being allowed into that most private place. Entering there may be one of the most important parts of a patient’s survival. The ability to gain entry is one element of the unquantifiable art of nursing.

After many years of nursing I celebrate every day I go to work and learn something new that improves my practice: a new drug, a new procedure, or some new machine. Recently nothing has taught me more than just being the patient’s wife. My husband, Dalt, injured his wrist cutting low hanging branches from a hackberry tree. When the chain saw broke through the branch, it dropped, yanked his wrist to an awkward angle, and triggered an autoimmune response that knocked my husband off his feet. The joints in his wrists and fingers looked like they had been hit with a baseball bat. His knuckles had not one wrinkle in them. The skin on his fingers, pulled tight from the swelling, turned his fingers bone white from the poor circulation. His usually active days became waking hours of agony. And I transformed from a competent health care provider into a worried, decompensating wreck.

Dalt went to see a hand specialist, had some x-rays, and got a prescription for pain pills. A few days after the “incident,” Dalt woke up in so much pain he couldn’t walk. I maneuvered him to the car and rushed to the ER. I happened to slip his pain pills into my purse. Because of his marked weakness, the doctor ran tests to see if Dalt had stroked. I knew he hadn’t, but didn’t want to be a “bad” family member. You know what I mean. The kind of person who micromanages the doctors, the nurses, the lab techs, even housekeeping. So I sat and waited and watched my husband moan with pain. I confess. I gave him one of his pain pills. In an hour he was 100% better. When the doctor came in to tell him she had scheduled an MRI of his head, Dalt declined. “I’m not having a stroke, I was just in so much pain.” I took him home.

Prior to this I assessed the silent symptoms of pain the way I learned in school: rapid heart rate, shallow breathing, a furrowed brow, even nausea. When Dalt was in pain, he aged ten years. Wrinkles impressed his usually smooth cheeks. He exhaled long, deep, gasping sighs when he slept. He wasn’t nauseated; he had no interest in eating. When he walked around the house, he held both arms close to his body, guarding his hands from anything that might accidentally hit them. I didn’t know how to help.

It took over a month to get scheduled for surgery to fuse Dalt’s wrist bone. The doctor promised pain relief with the procedure. We would have opted for the next day, but pre-op testing, booking an operating room, and allowing for the doctor’s schedule took time. Waiting. Something I never learned to do with grace, especially when someone I loved suffered. Watching him struggle through a day of pain wore me down as much as it did him. A man with strong faith, I sometimes worried about going to work and leaving him alone. That’s how much the pain changed him.

Dalt is a young 73, but not without health issues. I viewed the surgery as a panacea, a game changer, a pain ender. But on the day of surgery, the nurse in me kicked in and the “what-ifs” took over. Count on an experienced nurse to anticipate the worst case scenario. This was a post-Joan Rivers day where an out-patient procedure turned into a tragedy. I followed Dalt’s gurney down the hall to the operating room, then detoured to the waiting room. I let him see the tears, my fear, and told him to hurry back.

I knew this procedure was considered relatively minor, no intrusion on the heart, the abdomen, or the lungs. But this was my husband. It required general anesthesia. What may have been the most minor surgery on the schedule that day was most major to me. I checked the information board where computer graphics symbolized when the surgery started, with a knife, when the surgeon was closing, with cross stitches, and when the patient went to recovery, with a Band-Aid. Every time the phone rang in the waiting room, I strained to hear. The volunteer called a name I didn’t recognize. It was my married name; for most things I still use my maiden name. It finally dawned on me that it was my turn to rush to the desk and pick up the phone. Another hour to go a young woman’s voice told me.

It’s been done in movies and on television, the every five minute look at the clock. That’s how it happens. Every five minutes I sighed with a sound reminiscent of his pain and asked myself “Are we there yet? When would it be over?” Overhead I heard one Code Blue called, heard the room number, and recognized which ICU it was. Not in the OR. Thank God. One Code Red. Fire in the lab. I didn’t care. One Adult Rapid Response. Well I knew that wasn’t Dalt, and I was upright. We were both safe.

I didn’t want to go to the bathroom for fear of missing the precious few minutes I knew the doctor would grant me after surgery. The door where I watched different doctors emerge, doctors with whom I had worked for years, opened and Dalt’s surgeon, young enough to be my daughter, came out. I liked her no-nonsense provision of information, post-procedure x-rays included.

It required more waiting before I saw Dalt. A bed assignment had to be made, report called to the receiving nurse. I wandered up to a room that looked haunted by emptiness. Then his bed rolled in and he was there talking, thirsty, complaining of pain, but okay. I helped him with his first sip of water and watched him fumble with the PCA button to give himself some medication. I didn’t think hand surgery would be so painful. Dalt measured time in hours between pain pills and minutes between pushing the PCA. I measured it in the days it would be until I felt I could help him feel better.

The days of the call light are gone. Now patients call their nurses on hospital cell phones. “I’m in the middle of something. I’ll be there when I’m through.” The wife simmered; the nurse boiled. The first time it took twenty minutes for the nurse to come. One time she was an hour late with pain medication. I wanted insta-care for my husband. And all I could do was sit and feel totally useless.

Dalt is home now. For the next ten days he has to keep his hand above his elbow. When he’s up and about, he maintains this position wearing a sling. A new lesson begins. I never appreciated how many things I do that require two hands. Slicing a banana, peeling open a yogurt container, buttoning shorts, tying shoes, unscrewing a bottle, using the computer. I no longer take these things for granted. I get to do them for Dalt. Finally I am useful! He’s getting cabin fever from his confinement, not just because he’s stuck inside, but because when he’s healthy, he’s always busy.

Better days are coming. Because of Dalt I’ll go back to work a better nurse. I’ll remember that if you’re the patient’s wife, lover, son, daughter, father, whoever, there is only one patient. That from your point of view any surgery is the most major surgery. That pain is real and urgent and needs to be addressed quickly. That demanding families are a product of stress, love, disruption of everyday living, and fear of an unknown future. I promise I’ll remember what it feels like to be “just the patient’s wife.”
 

Why does ED happen

In forty years of nursing, I fought for respect and autonomy in my profession. I pursued a graduate degree and believed a higher level of education would not only enhance my clinical practice, but would also earn colleague status with doctors wherever I worked. For the most part, this has been true.

In the critical care setting, my specialty, adaptation to change, continuing education, and the ability to make sound clinical decisions has been instrumental in the practice of nursing. A four year degree has become the expected entry level education. Certification in this specialty and the pursuit of a higher degree is becoming more commonplace. Both are encouraged and economically supported by health care institutions. This sounds like nursing is advancing as a profession.

Enter the new ad campaign by a large health care conglomerate that praises the “servant” who cleans up messes and changes the sheets. The ads devalue the educational requirements, both basic and ongoing, the responsibilities assumed, and the commitment to best patient outcomes manifested by consummate professionals. The portrayal of health care providers as servants discomfited me.

As a nurse, I have been a witness to and caregiver in the most deadly epidemic in modern times. I have watched women infiltrate medicine and men infiltrate nursing. I have lived a history in which critical care grew from the MASH units on the front lines of war into the technology driven units in tertiary care facilities. I have watched drugs come and go, so-called best practices be replaced by better practices, and health care become a right. I recognize my profession is one of service. I know that without the patient I am nothing. Without the trust of someone who allows me into his or her life at a most vulnerable time, I cannot do what I am trained to do. But I am not a servant.

Conversely, when I come into the hospital, I want an educated professional familiar with the latest technology, the newest drugs, the best treatments, and the dedication of someone who is prepared for his job. I neither want, nor expect a servant.

I am a professional nurse. I empty trash, clean the floor, clean up excrement, and turnover a room. I have successfully resuscitated a patient before the doctor could arrive. I started an IV when a patient was bleeding to death as the doctor stood over me and told me I had to find a vein. I have made countless decisions in treatment plans, made critical notifications, participate in interdisciplinary collaboration to devise the best plan of care, wept with families, attended funerals, and shared the pain and joy of loss and recovery. I am and will always be in service to my patients. However I am not a servant.

Why does ED happen