Wednesday, April 28, 2010

Deadman, Chapter 4

Chapter 4

It occurs to me as this tale is told; that “I” seemed to have been the one making all of the decisions, and that “I” was the only one doing any work. Since this is a first person account, it’s probably appropriate for me to leave other people out, unless they interacted in some way and add to the story--- but an explanation is in order. I worked in crowded rooms alone, and other people were not a net I felt I could drop into when things went bad.
 Becoming a Coronary Care Nurse, and then developing any sort of a mastery of it was a long process. I received extensive “book” learning, provided by the hospital, as well as six months of hand holding by a nurse preceptor (babysitter.) Then I went to the night shift for a year, for both seasoning and experience.
My night shift experience involved working with two old bats that had been nurses for longer than I had been alive. One of them would yell at me continually – usually as just a background roar of noise that they she used to establish the beat, while the other one lashed me verbally, and randomly, with specific, targeted sarcasm. They coordinated – this was not amateur hour, they worked together well, and their criticisms were not without merit.
This tag team approach worked, it came out of the long established eating-of-their-young tradition that nurses learned early in schoolyards from other girls and vicious men.
Motivated by the strangeness of inappropriate anger, and a fierce hatred of those with blue-haired, I eventually learned the physical “How” of nursing. I think the whole experience might have been something like the hazing football rookies get before their first practice camp, only as done by devil women.
I spent a year on nights and it was a long year.
What I was given while doing this time, besides bitterness and a general understanding of the shortcomings of men, was practice. I learned by doing, all of the routine parts of nursing. I learned this by doing the same things for all patients, every time. I practiced over and over, on every night. I learned how to assess a patient in a methodical way. This repetition brought a sense of order and routine to the fundamentals of my nursing. I learned to really see the things I was looking at, though it was only later that I began to know what those things meant.
My time on nights, and this practice of routines, made me a functional nurse. Once I had been “seasoned” (parboiled) enough on nights, they moved me to the swing shift.
 Swing Shift brought a different approach to polishing of me, less of the cleaving and more of a rougher grit for the grinding. It was the fun shift, the doctors had just gone home, and we were alone with the patients.
(Normally, the doctors would do rounds in both the mornings, before office hours, and at night, prior to driving home. Like the captain of an oil tanker- they would set the course out of the harbor, then go to their cabin and drink themselves to sleep. We were the 1st mates left on deck to look out for icebergs. As with icebergs, we looked for tips of trouble, shark fins of trouble, and any trouble heading generally in our direction.)
The thing about trouble in a Coronary care was, to paraphrase the patron saint of ICU nurses, Calvin Coolidge, “It’s like a truck coming down the road at you -- 9 out of 10 times it runs into a ditch before it gets to you.”
When you act and make an intervention on a patient, and in the acting do a thing that doesn’t need to be done, it’s almost always a bad thing – at least for the patient, although you might learn something useful in it for later. Using this as a rule, most of the actions I learned involved doing nothing. I learned to actively, passionately and aggressively do nothing. Not the sitting on my ass kind of nothing, more the life and death holding a trigger in my hand kind of nothing. I learned that more times than not, courage is found by standing still and allowing events to unfold in the way they are supposed to, no matter how much the Sturm und Drang bustles around you and begs for an action.
 New nurses in coronary care tend to do a thing called “roller coasting.” They over react to what they see, and then over correct what they over reacted to. It’s a learning process that develops over time, and with experience. It’s a learning that allows you to wait for things to come to you. It’s a form of active surrender, or lessons in patience under the stress of impending doom.
When I was new, the treatment for a heart attack was to support the heart muscle when it was failing, with intravenous medicine that increased the force of contraction (dopamine). At the same time, you would give medicine that would dilate the arteries that the heart was pumping blood into (Nipride). This was known as ‘afterload’ reduction; by increasing the size of the “pipe” coming out of the heart, you could decrease the amount of resistance that the pump had to work against.
The dopamine would increase the blood pressure, while the nipride would decrease the blood pressure. What you wanted was a little of both--- a little more contraction into a little bigger tube. What you got, if you were not careful, was a roller coaster of ups and downs as you played with the amounts you titrated into the patient. Because the concentration of the drugs you were giving were so potent, tiny changes caused big fluctuations. You could increase the concentration if you mixed the drug in a greater volume, but this would have just cause other problems, like fluid overloading and bigger bags of stuff taking up the space around you. Besides – we had both our pride to consider and long standing traditions, passed on by generations of scary nurses, to uphold.
Old nurses tended to “ride out” the ups and downs when they made changes to the IV dosage, but since the new nurses tended to chase the numbers, the ups and downs became a roller coaster—quick highs, and quick lows, with lots of wasted energy. You had to be there, you had to have put in the time before you understood, that by chasing the numbers you were doing more harm than good. What the nurse needed to learn by doing was to develop the ability to give firm short taps in a gentle way. All in sober reflection, with a steady hand and mind, and under the stress of fucking up big time.
This standing, watching, and waiting had to be learned by doing, and not just the active doing of movement – it had to be learned by the active doing of nothing. This wasn’t a thing that they taught you from a book, this wasn’t a thing they taught you at all – it was a thing that got rubbed into you, until you smelled it in your sleep, and knew it by the movement of your bones.  

1 comment:

Mary said...

it's late but i want to read this again tomorrow, i feel as though i am there entangled in the story and information you are providing