Another Clinical Day (of RN Refresher Course)
Written by Charlotte E. McCall, September 2014 (published here for safekeeping)
Working all day standing up is hard when you haven’t done it for a while. Over the last fourteen years, I’ve become rather doughy as I spend most of my time in a recliner or car, and manage my time as I see fit with plenty of breaks between errands or cooking or visiting with friends. What a shock to the system of loose tender muscles. Many years ago I was working three twelve hour shifts a week, but then, I was many years younger. Then, I wasn’t wearing orthotic shoe inserts to prevent plantar fasciitis, and I didn’t have to carry my reading glasses with me to see an IV site or the name of a drug (when did they start printing the names of drugs so TINY??). By eleven or so, I have to lie down in the locker room and put my feet into the air one at a time and do stretching exercises like they taught me last year when I had physical therapy after that herniated disk. In the afternoon, sometimes I have to sit down and breathe deeply several times because there are little silver shiny things, shimmering just at the edges of my vision. During the drive home, I often stop and get a large iced tea because I have been used to drinking ice water all day, and at this hospital they don’t allow any water at the nursing stations. After a shift, when I get home I generally have a float in the pool while I allow my husband to cook dinner, then after dinner I fall asleep in my chair around 7:30 or so. During the night, everything hurts. I talk myself out of taking the leftover Vicodin from my shoulder last spring. Maybe it will make me too groggy in the morning.
I took care of two patients for each of the last three shifts. The patients aren’t all the same of course, they all have their own stories. But on my floor, typically each patient has a long midline incision, several other smaller incisions or punctures somewhere in the abdomen or chest, staples up and down or across their bodies, and at least two drains coming from them with various colors and odors of fluids emanating from them. Usually two to five lumens of fluids going into them, maybe oxygen going into their noses, and probably things wrapped around their legs like big sheets of bubble wrap inflating and deflating, attached to the bed with tubes. Plastic bracelets around their wrist and bandages covering spots of blood in the inside of their elbows where they’ve been awakened each morning at four a.m. to have a bright light shown on them and blood taken from them. And five super-sticky squares of tape on their chests attached to gray wires, and a red light taped to one of their fingers, with a heavy box monitoring their heart rate that hangs off the pocket in the fashionable hospital gown (no underwear provided).
They get to ‘recover’ in a single bed with a plastic mattress and institutional sheets and a synthetic plastic pillow. They have one to six family members in their rooms, most of whom will get to see them naked at least once. They’ll ‘save’ their urine and stool for everyone to view, until someone comes to empty it. Their door will open and close 3 or 4 times at least every hour, usually with someone coming to poke at them or rip tape off them or take a fluid out of them or put something into them, or show a group of other people their incision or dressing or skin condition. There are other things you can’t see. Inside the abdomen, where the doctors have cut out their organs or their intestines and sewed up the remnants, and that hurts. And their spirit has been delivered a punch in the gut, too. Many times, they’ll have the dull throbbing knowledge that this is only the beginning, they still have chemotherapy or radiation or something else leading to death, to look forward to. They hurt inside.
So, I’m taking care of a lady last week who was a typical patient as described above. She was dealing with all the things I mentioned, plus a five-day impaction of stool in her colon. She was so uncomfortable. Five times up and down to sit on the pot, with no results. She can’t strain. She can’t move it. I give her a suppository and tell her we’ll check back within the hour and see how that does. But she has had no luck. I tell her that drinking more fluids, and moving about more might help her. And I suggest an enema which has been ordered for her if she needs it. ‘No,’ she says. ‘I had an enema before the operation, and it was just horrible.’ So I bring her some coffee. Up and down she goes, without any results. I go back to charting and taking care of my other patient who is just like her but without the impaction.
An hour later, I check on her again. She has two family members with her now and wants to get up again to the bathroom. She is almost crying in frustration as she sits on the bed after another poopless toilet experience. I tell her ‘It’s just a small enema.’ I show her the length with my hands. ‘I have had them myself, after surgery. It’s not that bad, really. And such a relief when you finally go.’ She hesitates. I can see her considering it. Then she says, ‘I have to rest for awhile. Just help me back in bed, ok?’ I settle her back in with her son and daughter waiting patiently beside her. The room is so tiny and there are two large chairs, a wastebin, a laundry basket, a sink and sharps container and the IV pole with its three channels and multiple bags hanging, and drains hanging off her and at the end of the bed, a sequential pressure device machine. Her walker leans against the wall. With me and the WOW (Workstation on Wheels) and the dynamap (vital signs machine) in the room, there isn’t enough space to spit. I tell her I’ll check on her again soon.
I go to lunch and come back, and it’s almost shift change and I try to wrap up some charting. I can’t figure out what I’m supposed to do with the intake and output. I must remember to ask my preceptor how to clear out the pumps. Am I supposed to be charting on these Plans of Care? Why is it asking for a co-signature on the chart check? I need to hang that tube feed on the other patient down the hall and do some teaching about incision care. He might be going home later. Maybe I should be getting ready to take out his IV. My preceptor told me the doctor has written some new orders. Where the heck would I find them in the computer system?
The lady calls me. She wants to try walking in the hall. We put another gown on her back to hide her butt. She is holding her walker. I am holding on to her. Her daughter is rolling the IV pole. Her son is bringing up the rear, with his walking cane. I feel proud of her and tell her so. She isn’t shuffling, she is standing up straight, she is using the walker correctly. She doesn’t look dizzy. People are going past in all directions: The RN’s with their Workstations-on-Wheels, respiratory therapists in their gray scrubs, care technicians in their forest green scrubs, environmental service people in their blue and black, medical students in their little pods, in the light blue. This is the time that her bowels begin to awaken. It starts with a series of long resonant, aromatic farts, for which the patient apologizes. I praise her and tell her it’s a good thing that she is passing gas. If I had a gold star, I’d paste it on her. ‘I’m pooping!’ she suddenly exclaims, and I suggest we head back the other way. We’ve gotten halfway down the hall despite the unwieldiness of our little group. Among the current of people streaming down the hall, we start to turn around. It’s like turning the Titanic to avoid the iceberg. And like the Titanic, it’s too late.
It seems to take forever to get back to the room. My mind goes in all directions exploring any other option than to be here, with this very large, sweet, elderly lady who is pooping brown streams down her legs and onto her rubber-soled socks and leaving dots of brown liquid along the waxed hall floor. Could I pick her up and run with her, like I would a puppy that isn’t yet housebroken? Could we teleport into the bathroom? But since this isn’t an episode of Bewitched, I have to settle for moving slowly and safely down the hall into her bedroom and through the narrow opening of the door with her son and daughter and the walker and on to the waiting toilet.
My heart goes out to her as I clean up all the surfaces of her legs and the major expanse of her behind and all around her thighs and yet, she still has not had success at emptying her colon. The impaction is still there. This was just leakage around it. We change sheets and put her back into the bed, and her daughter rubs lotion on her mother’s legs. I close the door and leave her to recover for a little while until I can somehow convince her to accept the enema.
My preceptor pops in while I am wrapping up my charting. I offer her the yellow folder which has been already dated for her convenience. She glances at the sheet, quickly scribbles that I need to maintain my focus and manage my time better, and circles a 6 on the evaluation scale. A SIX.
This failure had me down for several days as I wallowed in the despair of being so incompetent. Then I would vacillate between feelings of angry indignance (my preceptor doesn’t understand me) to reflections on who really cares anyway, what number she circled? It’s not going to be projected onto a screen in some courtroom! Nobody is going to know at my potential, God Willing, place of employment. The Texas Board of Nursing isn’t going to sit around their board table and say ‘We can’t give this woman back her RN license! For heaven’s sake! She has a 6 on one of her evaluation sheets! WHY, indeed, was I even doing this?? A SIX!
On my next clinical day I made the hour drive in to the hospital in the dark. It was Labor Day, and traffic was light. My shift started at 6:30. I had been awake since 3 a.m., unable to go back to sleep. I practiced smiling as I drove along. ‘I am going to make a difference in someone’s life today,’ I stated into the dark car. My cheeks felt stiff. I took two deep breaths. ‘My patients are in the most stressful time of their lives,’ I reminded myself. ‘I have much to be thankful for. My day will be spent doing the best I can to help them be comfortable and well.’ Two more breaths. ‘No matter what kind of day I have, my patients are having a worse day.’ The lights of downtown Dallas shown. ‘Only two more weeks, and I’ll be done with this class.’
And then what? said my little voice inside. But I’ll figure that out later.