Delmarva Review: Nursing 101 by Margaret Adams

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It was getting easier, touching strangers. Still, I hovered for a moment in the doorway of the hospital room, pausing before jumping into the pool of their personal space.

It continued to amaze me, after two months, how willing the sick were to let themselves be touched. Their abdomens palpated, their gums examined; the undersides of their feet inspected, repositioned, unwrapped and rewrapped in socks. I’m just going to check your capillary refill, you said, and then they let you pinch and prod them, quiet, supplicant. It felt so intrusive to even ask, and then shocking to gain such easy entry. May I take your blood pressure now? If it’s alright with you, I’d like to listen to your lungs.

The navy blue school uniform scrubs, embroidered at the shoulder with the name and seal of my nursing school, were the same shade as those the nurses wore at this hospi- tal. Between that and the stethoscope draped proprietarily around my neck, it was hard for the patients to know that I was a student. When I’d purchased those scrubs, their pressed and professional folds had impressed me with their aura of importance; I had tried them on at home in the eve- ning, turning and admiring my reflection. Once inside the hospital, though, on my first clinical rotation, I wished for something less assuming. Colorful cartoon scrubs, the kind of thing that patients automatically took less seriously. Too often patients asked me questions, trustingly, as if I would know the correct answers for them right away.

The hospital has its own noisy, constant cadence. The rhythm is marked by beeping IVs, thrumming respirators, shouted questions to the hard of hearing and hollered announcements across the nurses’ station. It’s constantly in the nurses neither sit, nor eat, nor step out to use the bathroom. It’s not a place where a nursing student, uncertain of herself, can wait, poised at a doorway, for too long.

I walked into the room. “Hello, Mrs. Douglas,” I said. “How are you feeling? Can I get you anything?” And, with her open eye contact and assent, I laid my hands on her wrist, carefully curving my fingers around the line of her pulse. She turned her head towards my shoulder and sighed as I counted the surges of blood beating through her fragile, small-boned arm, watching the movement of her breath in her chest. One, two, three, four…

A first-semester nursing student knows few things. We cannot administer medication, or yet be counted upon to make assessments on our own. What we can do is give bed baths, change beds, hold hands and steady elbows; we can listen, take vitals, and we can try not to get in the way. I was learning, slowly, to get beyond my own self-absorption and my preoccupation with what these ill people, the patients I was here to help, thought of me. The constant worry and consideration—Can they tell how uncomfortable, how new I am? Am I irritating them? None of it really mattered. No one cared who I was, whether or not I looked or acted like what they expected, if my hand shook or fumbled with the washcloths. They just cared about getting clean, about feeling better. A task I would have thought myself incapable of—brushing an old woman’s teeth—was accomplished when the reality of her need surmounted my awkwardness. It was humbling to do it, and horrifying to realize how such actions were carried out every day, roughly, by people hardened to it by routine.

I was halfway through administering my second bed bath ever when my patient, a woman whose body was swollen beyond recognition and covered with open sores, began to cry. “Have I hurt you?” I asked, horrified. “Are you okay?”

“No, sweetheart,” she said. “It’s just that no one has taken the time to give me this thorough of a bath in weeks.”

On our breaks, we students talk about what we’ve been allowed to do, or what interesting procedures we’ve seen. We mark our time here by how tough our stomachs get, by how many IVs we’ve been permitted to change. We talk a little about the people, about the fact that now, as students, we have the time to do things for patients that we will never
have time to do as professionals, but not that much.

“How was your clinical?” classmates assigned to other hospitals asked me. “Did you get to see anything cool?”

I talked to a senile woman’s stuffed animal for her, I thought. I put water in a dish for it so it wouldn’t get thirsty. She was grateful. “Fine,” I said instead. “I saw a stage 4wound…you could see the bone.”

On mornings when I have clinical I get up at 4:30, giving me a full hour to drink my coffee before going in to the hospital. I need that time to wake up, to get on my A-game before walking into this other world where the macabre is embraced intellectually and where the iron gates of intimacy are as malleable as tinfoil. I meet my carpool on the pre- dawn corner of my city street and arrive at the hospital just in time for morning report.

“Who has bed 142? Find me when you’re ready for the hand-off. Jane? I’ve got bed 147. Is that my coffee?”

The night shift briefs the day shift RNs on how things have gone during the night. Bed 143 is refusing to eat anything…bed 145 is overdue for her medication, I didn’t get to it in time. They speak of the patients by number, rather than name, identifying them in the corners of their notes with abbreviations: J.D., 87 y/o WF.

I was assigned Mr. Jones that day. An easy, interesting patient, my instructor told me, an elderly man with heart problems who didn’t throw things or swear. I read the front pages of his chart through twice, quickly, before going to introduce myself.

He was missing a large piece of his face, from the left side of his upper lip towards his nose, disappearing under a large, frayed bandage that covered a four-inch swath below his eyes. The bandage was old and ratty-looking; dried blood crusted around its edges. He held a napkin spotted with fresh blood up to it thoughtfully, dabbing at it. I smiled my brightest, most winning smile and made a hasty retreat.

“What? His face is half gone? She didn’t tell us that during the morning report. Oh, the skin cancer surgery he had done before the angina started. Well, let’s go in and have a look.” My preceptor Jen, a tall, sturdy woman with intri- cate braids woven around her head, gave a low whistle as she examined his bandages. “What happened here?” she asked.

“I’ve been picking at it,” he said, matter-of-factly.

“You really shouldn’t do that. We’re going to have to put you in mittens,” she said.

“Yes. I know.”

“How long ago was your surgery?” she asked, scanning his chart.

“Last week,” he said.

“It says here you had this surgery over the summer,” she said. “Can you tell me what month it is, Mr. Jones?”

“July.” “Do you remember Thanksgiving?”

“No…maybe…why?”

“It’s December, Mr. Jones.” She snapped a pair of gloves on and began inspecting his bandage with careful fingers. “Can you tell me how long this has been bleeding?” she asked.

“Um…no…an hour? I’m not sure,” he said.

“Okay. I’m going to go get some new gauze to help fix this up a little. I’ll be right back.”

Alone in the room with him, I felt that familiar sense of being at a loss. He held up the blood spotted napkin, looking at it with a perplexed expression on his face. “Is this a
clock?” he asked me.

“No,” I said. “It’s a napkin.”

“Oh. I was hoping it would have the time on it so I could tell her how long I had been bleeding.”

Jen came back in with the gauze, putting on a fresh pair of gloves, and I busied myself with my own pair. “Here, Meg,” she said. “Hold this.” I handed her supplies and stead- ied his chin for her as she reworked his bandage. “I’m going to put mittens on you if you can’t stop picking at this,” she said.

“You’d better,” he said, placidly. “I like picking at it.”

A young man in a transport team polo shirt with thin wrists and a spotty face stuck his head in the door. “Almost ready, Jen?” he asked.

“Yep, he’ll be ready to go in a minute.”

“Is that my dad?” Mr. Jones asked. “My father is coming to see me today.”

“No,” the nurse said. “That’s the transport team, getting ready to take you down the hall for that test today. Do you remember?”

“Oh,” he said. “Well, if my parents come in while I’m gone, please tell them I’ll be back soon. They’re coming to visit me today.”

“How old are your parents?” she asked, giving him a considering look. I glanced at his birth date again on the chart and read May 24, 1925.

“He’s 80, I think…and she’s 82,” he replied.

“Well. Breakfast should be here when you come back,” she told him. “We’ll see you soon.”

I stripped off of my gloves the way I’d been taught to, balling the first one up into the second one like a package, and washed my hands for the full 30 seconds before sweep- ing the extra gauze off of the counter and stuffing it into my pockets.

This wasn’t the work that I had decided to go to nursing school to do. I wanted to be abroad, helping with the International Red Cross, Doctors without Borders, tending to refugees in desert field camps. I wanted to be in the rural recesses of the U.S., delivering primary care to migrant workers in the fields and to children in the mountains of Appalachia. I was on track to become a Nurse Practitioner, a job granted a greater measure of autonomy and respect than the RNs who run the hospital ever received for their pains. Still, I knew I needed to learn this: needed to spend my time in the trenches, in the blue-collar, work-a-day world of medications, IVs, of calling doctors by their last names and nurses by their firsts. I had wanted a trade, the capability of learned hands, and this was the apprenticeship, the oil-changing days that come before craftsmanship. But I hated the hospital, hated the disease we spread and the discord we encouraged, the assembly-line feel of being part of a big-box health dispensary.

Our preceptors made a production of granting us a lunch break, refusing our offers to bring food back from the cafeteria for them. “I’ll eat something in an hour or two,” they insisted, making sure that we knew that they were lying.

I step out of the smells of latex and iodine and into the cold December air to call my mother.

“How’s it going?” she asks.

“Okay,” I say.

“Yeah?”

“One of my patients thinks that his parents are coming to visit him today. He’s really looking forward to it. He’s in his 80s and there’s no way they’re still alive.”

“Oh….”

“He keeps saying that they’re coming to see him soon.” “Maybe they are…just, from the other side.”

“Wow. Thanks, Mom, for making this even grimmer than it already is.”

“It’s not grim. It’s…I mean, everyone wants their parents at the end of their lives.”

“Yeah. I just don’t know what to say. The nurse is just avoiding engaging with it. I don’t want to tell him that they’re dead, but I don’t want to lie to him, either.”

“Does it matter?”

“I don’t know. Would it matter to you?”

“I don’t know.”

The names of illnesses, the rounds of medication, are still a foreign world to me: GERD, synthroid, albuminemia. Diverticulitis. It sounds like the Spanish verb for enjoying oneself, divertir, a relic of the world of my previous degree in Hispanic language and culture. Divierto, diviertes, diver- timos, diverticulitis. Except that all I do know about diverticulitis is that it isn’t fun.

The patients are subject and object, listened to and talked at. Compassion sits on one side of a perfectly balanced scale, with sleep, coffee, food, and workload on the other—the needs of the nurses, stretched to the limits by an institution which is necessarily economically driven, not the needs of their patients, define the extent of care.

“I feel like a waitress,” one nurse confessed to me.

“I feel like Atlas,” says another. “With a whole hospital on my shoulders.”

I’m a half-hour from the end of my shift when an alarm breaks through the usual cacophony of bells and shouts. Someone has called a Code Blue. I freeze, panicking, and then remember my instructor’s words about what I should do in an emergency and flatten myself against the wall. More nurses and doctors than I have seen all day boil out and into the hall. “Grab the crash cart,” one yells. “Bed 143, no pulse, no respirations.” Security runs past me, open- ing the elevator doors and holding them open so that the pa- tient, if resuscitated, can be rushed immediately to intensive care. The madness coalesces around the patient’s room and I hear the unmistakable sounds of two-person CPR, accompanied by the inevitable crack of breaking ribs.

It’s over quickly—the patient is packed neatly into the metal square of the elevator, accompanied by three sweaty but otherwise calm-looking RNs. I feel like the sudden reminder of what is happening here has swept my feet out from under me. We’re serving medicine, not burgers. We’re trafficking in lives. The cause of pit stains under my arms, a brief adrenaline rush, was someone else’s everything. Knowing that can’t be thrown in the laundry and washed away. It can’t be comprehended. I hope that I don’t get used to it, but I can’t deny that getting used to it might be the only way I will get by here.

I go into see Mr. Jones one last time before I leave the unit for the day. Fresh bandages cover the hole in the middle of his face, still bloody on the edges but less frayed. “Can I get you anything?” I ask.

“Could you bring me some water?”

“Sure.” I grab a fresh cup and a straw, open the tap, and watch as the clear liquid fills the Styrofoam container. I place it on the tray by his hand and he brings it to his mouth. Just enough of his lip is missing that the suction of mouth around straw is incomplete, and the straw rattles with each suck.

Here,” I say, taking the cup and cutting out part of the lid to make it an improvised sippy-cup instead. He nods with approval, drinking deeply before leaning back against his pillows.

“My parents are coming to see me this afternoon,” he says.

I pause, and then smile. “They must love you an awful lot,” I say simply.

“Yes…they do.”

I closed the door behind me.

Margaret Adams’s “Nursing 101” was published in Volume 4 of the Delmarva Review when she was a student in the Johns Hopkins University nursing and public health program. She is now a family nurse practitioner in Seattle, WA. A former columnist for The Bangor Daily News and a Pushcart Prize nominee, her essays and fiction have also appeared in The Portland Review, Baltimore Review, Bellingham Review, and Pinch.

The Delmarva Review is a nonprofit literary journal in partnership with the Spy that publishes compelling new poetry, fiction and nonfiction from writers within the region and beyond. It will celebrate its Tenth Anniversary edition in November. The Review is supported by individual contributions, the Eastern Shore Writers Association, and a grant from the Talbot County Arts Council with funds from the Maryland State Arts Council. For more information, please visit: www.delmarvareview.com

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