I woke up early, before my alarm clock went off and shocked me out of bed. I put water on for coffee and showered quickly. Fifteen minutes after rolling off the edge of the mattress, I was pulling out of my driveway, with a travel mug between my legs, clean scrubs on my body and the rosy glow of anticipation warming me up for another day of something new. Part of me was still asleep, kidnapped by the movements of habit. If I had to think about waking up, I never would.
Unit nurses worked 12-hour shifts. Labor law required that the last four hours were paid at a rate of time and a half. We were scheduled to work 36 hours each two-week pay period, but most of us worked more. When we worked 16-hours, a double shift, the last 8-hours were paid at double time. Most of my overtime was double time – it made the most sense to the bang-for-the-buck part of me.
When I arrived at work, I cut through the ER, to check out new possibilities, just in case, and then took the elevator to the forth floor. I said my hello’s to everyone, poured a cup of coffee then joined the rest of the oncoming shift in the nursing conference room for the mornings general report on all the patients.
At the start of each shift, the nightshift charge nurse would meet with all of us fresh-faced nurses and give an overview of each patient, all of the scheduled surgeries, and the expected activities that might come up during our shift. After this, assignments were made my the oncoming charge nurse, and then we’d break up to get a more detailed report from the individual nurses taking care of the patients we were assigned to.
As we got report, the night shift watched the patients, praying that nothing bad happened in the last 30 minutes of their shift. Sometimes they prayed that they didn’t embarrass themselves by falling asleep and tipping off their chairs as they waited for us to come out and relieve them.
I took over my assignment from the day before, Mr. Posey. I was intense enough about it; the questions of whether I would, or would not, have him, as my patient never came up. I left the conference room and went to the nursing station to get report.
Old bat #2, Mary Louise, was waiting for me. Her report was, mostly, a list of complaints: I’d left the room a mess, the toilet was backed up, I should have never allowed the patients wife to stay in the room, and I that I’d left a smell of manliness on the linens.
I acknowledged the truths of what she said, but held drew the line with her about the toilet thing. I asked if Dr. Q had called back after I’d left. She said yes, then snapped at me for not calling him earlier in my shift, accusing me of shirking my responsibilities by dumping on her work that I should have done. I mumbled something about the meaning of the word shift in shift work, and how come she was so fat. Satisfied that I’d been humbled, she left without actually telling me anything important.
Nursing is a profession where the older members eat parts of the younger members to make their shapes more pleasing to them. It’s based on critical feedback – every day the work that you do is weighed and measured by the person who follows you. The feedback is professional in the sense that it’s a practiced tradition, but not in the sense of it being useful. Few nurses ever learned the rules of praising the good, as they featured the bad.
I picked up the chart to see that Dr. Q had ordered:
Inderal p.o. 10mg now, and daily
Persantine p.o. 75mg now, and daily
Trazadone, p.o. hs, prn.
Inderal was a beta-blocker and his choice of ordering it for Mr. Posey was interesting to me. Though its use is common enough today, beta-blockers were controversial back then, and I thought it in using it now, Dr. Q was making a progressive statement that might raise a few hackles in the cardiology frat boy meetings.
Inderal acts as a brake on the speedy impulses of the heart – it blocks the chemicals that allowed the heart to reve up and roar like an out of control Toyota being driven by an elderly Parkinson patient. The price paid for this was lethargy – a heart that just sat there and said, “Don’t bother me, I’m on a break.” It took from the heart the highs of excitement, and left it only with the lows a union worker lives daily when their job is located safely outside the boundaries of a right to work state.
Those with social phobias can overcome their fear of public speaking by taking Inderal before they get up to the dais. It removes the fear, slows the speech and limits the panic. It doesn’t make for a happy time, but it does dull the excitement by inducing a form of stupor that’s helpful when dealing with the public. It’s like that.
There were two schools of thought about the use of beta-blockers in fresh heart attack patients:
One school said, don’t make it worse. After a heart attack, the heart becomes a damaged pump that can no longer function as it’s intended to. By giving beta-blockers, you were making a bad pump even worse – you were chemically limiting the pumping action, just when it was needed to pump even more with what was left of it. Without a functioning heart, the blood couldn’t get pumped out to the body and keep it alive. Organs would fail, brain function would cease, and the patient would die.
The other school said, don’t beat a dead horse. After a heart attack, the heart muscle that was bruised, but not dead, needed to rest. It said that working a damaged muscle just made it fail sooner, and that this made the damage worse in the long run. It said that heart muscle forced to work harder when it was damaged was put under too much pressure, that it would warp and remodel into something dangerous – thin walled areas and inappropriate bulges, that would fail before the patient could get out of the hospital.
Both schools were right, but one was looking at the short term, and the other at the long term. The body needed the pump harder to work after a heart attack, but flogging it when it was damaged made it explode in various unpleasant ways. Choices had to be made, and both wasn’t a choice at the time.
Persantine was an anti-inflammatory drug that was thought to help with inflammation in general, and the specific inflammation that happened around the heart and the sack that surrounded it. Dr. Q ordered it for the rub I had reported the night before.
Trazadone was ordered for sleep. Night shift nurses liked their patient to sleep, if only to allow more time for them to investigate my shortcomings.
After reviewing the chart, I went to see Mr. Posey. I was surprised to see him sitting straight up in bed with an oxygen mask on. The mask was new to me, and something that old bat #2 had not mentioned to me in her report. Called a non-re-breather, it was a few steps more serious than the simple nasal cannula I had left him with the night before. A non-rebreather consisted of two parts: a mask and a small reservoir that was attached to the base of it. About the size of a kid’s lunch bag, it was connected to the oxygen supply built into the wall unit of each room. The bag was filled with 100% oxygen, and with each breath through the mask part, it refilled with more oxygen. Because it limited the mix of oxygen with air, it delivered a higher percentage of oxygen to the patient.
Seeing Mr. Posey sitting upright in bed with a non-rebreather mask strapped to his face told me as much about his condition as the full assessment I would do with him later that morning.
One of the tools I used as a nurse came from different discipline. I’d learned in college, from the doing of assigned essays in history class, about the use of compare and contrast as a methodology. I applied the concept to nursing – On my first examination of a patient, I took a “snapshot,” of what they looked like, and the obvious things I could see of their condition. After this initial snapshot, all became compare and contrast to me. Like video compression, I’d compare what I was seeing with what I had seen, and then subtract the things that had not changed and focus my attention on the rest. What I got from this was speed and direction; I could see where they were going, and how fast they were going to get there. I made this a part of my physical assessment, and along with the history the patient gave me, and the actual hands on physical examination, I had everything I needed to know to make good decisions about their care. All of this from paying attention in history class.
Mr. Posey was breathing about 24 to 26 times a minute and was huffing and puffing. The monitor showed his heart rate at 110 beats per minute. The normal heart rate—at rest—was about 70-90, and the normal breathing rate 14-18.
Posey’s breathing was faster because the body was trying to get more oxygen into his system, it was starving for it. The heart was beating faster to get more of this oxygenated blood out and into the body.
The heart was starting to lose the pumping battle --it was falling behind and trying to make up for it with volume. Each contraction (pump) the heart made was becoming weaker, and because the damaged area of the heart couldn’t help with the contractions, and because the damaged area of the heart was getting bigger, less blood was being forced out into the arteries with each beat of the pump.
The body lives on oxygen, our cells need it to survive – it’s both food and energy that food provides. Oxygenated blood is pumped from the heart, under pressure, though the arterial system until, at the very end, at the place blood cells are forced, one at a time, into the capillary beds, where they give up their oxygen to the tissues of the body. From this end point, they, mostly by the low pressure of gravity, head back to the heart by the venous system. The veins take their red blood cells, without oxygen now, to the right side of the heart, where, with a low-pressure pump of the heart, it’s pumped into the lungs. At the far tips of the veins that penetrate into the lungs, at the single point where a single blood cell stops, oxygen is diffused back into the blood cell, which is then sucked back into the left side of the heart for another trip around the body.
The heart consists of 2 separate pumps, each attached by a common wall, like a condo joined by its builder for both reasons of efficiency and reductions in the costs of upkeep.
The right side of the heart is a low-pressure pump, and its walls about as third as thick as the left side. It continues the gravity action started in the veins, and needs just enough of a contraction to get the blood into the lungs to be oxygenated.
The left side of the heart is thick and powerful. It takes blood from the lungs and pumps it under high pressure to every place in the body.
Each side of the heart also has two valves. On the left side, blood comes from the lungs via a sort of sucking action, and is held in a waiting room (Left Atrium), like people are held in the haunted house at Disneyland until a floating car shows up for them. The blood is waiting for the main chamber (Left Ventricle) to push out its load of blood to the body. The valve that holds back the blood (Mitral valve) feels the loss of pressure when the ventricle ejects its blood, and then falls open to allow the ventricle to refill again. When the chamber (Left ventricle) is full again, the pressure closes the mitral valve and allows the waiting room to refill. The left ventricle contracts and pushes the aortic valve outwards and pushes out the blood. Blood goes up and out to the aorta (ascending aorta) --- the biggest part of the artery system, then it goes down (descending aorta) into big and little branches that look much like the branches of trees as they poke out all over the place.
There is no spirit to be found in the heart, it’s a pump. Though intricate, complicated and full of nerves designed to feel pain of responding to the rhythms of life, it’s a simple pump and little more. As an oncologist once told me, “it’s just a way to get the poisons of chemotherapy to places I want to kill.”
But it’s a pretty pump, and like nothing that can be made by man. The fact that it beats 70 times every minute, for every day you are alive, doesn’t make it a thing of spirit, love or dream, it makes it the god of strength and consistency -- the god of methodical time and life itself. It's the way that spirit gets measured and allotted to you. Life, simply, is the sum of all the contractions your heart makes before it dies. It’s the container for the things of life, a personal stake driven deeply into the pale that marks the limits of time and its passing. It's where all of thought, action and feeling are housed, fed and given perspective.
It’s not spirit, it’s the place where spirit lives.
I started my checking of things. I compared the IV’s, lines, tubing and other measurements to make sure the things the night shift nurse had told me were the same thins I was seeing with my eyes. I checked that the IV controllers were set at the right dosage and plugged in, that the oxygen was turned on and that the patient I was seeing in front of me roughly matched the verbal description I’d been given earlier. Learned harshly from the lessons of experience, I methodically went through everything in the room. When I finished, I set up a basin of warm water with soap to give Posey a bath. I asked Mrs. Posey to take a break, and suggested breakfast in the cafeteria. She left and I began my initial assessment. I started another day.