Wednesday, November 26, 2014

Trench Warfare




 Trench Warfare



Emergency nursing is a battle, and the enemy is illness and injury: automobiles, motorcycles, guns, cancer, obesity, suicidality, violence, heroin, amphetamines, and narcotics.  The enemy never sleeps – and neither do the nurses in the trenches.

Each shift we see unspeakable harms; babies, children, men and women, preyed upon by our own species, serious injuries incurred by the technologies of man, and predation by unseen viruses – mutating, hiding, eating. Our academic training falls far short of the reality of it all. It dwells in the archaic principles of a bygone age of nursing; an age of divine care and heroic selflessness - an age before antibiotics, before MRI, before genome sequencing, before daVinci surgical robotics, cost centers, ICD coding, case management, and the cats cradle of legal bondage.  Academically, we do not produce nurses for this kind of battle – they are seasoned in the field, in the trenches with the enemy – and they either fail after only a few years, or become ED veterans, legends of tenacity, inkwells of black humor.

Your only allies are your comrades. You are part of a crazy dysfunctional family of misfits, somehow brought together by adventure, a sound background in herding cats, and the unwavering ability to withstand the abuses of mental and physical pressure. There is no personal space, and sometimes you are cheek-to-cheek to complete a task. Through human sickness, you are all bound together by touch, and smell, and sight. You know your friends by the scent of their shampoo or the boniness of their elbows. We engage in bizarre sudden games of Twister, putting our arms and legs all this way and that, often times holding down flailing screaming nakedness, or cleaning diarrhea from an anguished soul, their minds murky with Alzheimer’s. We cry over a dead baby, and then bring a demanding meth addict his pain medicine, apologizing profusely for the delay, hoping they won’t file a complaint over their slow service. We can sense the seriousness of a patient’s condition by the eyes of our coworkers - no words needed - only that look. These trench warfare nurses are more than just office mates – they are deeply bound together from being elbow-deep in atrocities.

There is also a sixth sense that develops over time – one where you see dead people - although they don’t know it yet. It’s an unnerving feeling, to know the future of certain patients, to see the walking dead - and its even more unnerving to know that, short of a miracle, you will soon be pumping their bodies full of semi-toxic drugs, pumping their chests with battery operated machines, covering their brains with gauze. This sense grows more powerful with time – and as it grows, you accept it as a grace, for with it comes the ability to prepare for the worse, to stay a step ahead of the downward spiral, perhaps even to alter the course of fate.

Experiences are drawn from an endless pool of suffering and the complex machinery of the human frame that is its host. Terminal injury aside, your shift in the trench is made up of a relentless flow of strangers - strangers who want something. Some are legitimate in their request – to repair their fractured femur, to breathe, to once again speak and move the right side of their bodies so that they can tell their family how much they love them – but many are not, and it is this complex set of customers that bring theater to the Emergency Department.  We, the nurses, are on stage – and we are the primary actors. It’s an art really, to be able to go from room to room and change your performance to fit the scene, to get the job done, to be so convincing. This constant play, however, requires a tremendous amount of emotion, and only with great effort can it be played out for the entire twelve hours.

Compassion is a finite emotion. You can run out of it – and once it’s gone, you hope the shift has ended.  Strangely enough, it seems to regenerate. Once your car leaves the parking lot and is pointed toward home, the day starts to fade. The images, scenarios, little victories and disappointments, things that no one outside the theater would ever understand – they all just wither as you drive home to your family, a friend, a dog, or a good glass of wine. By the next shift, your compassion meter seems to be back within operating range. ER trench nurses dole out compassion carefully; it is a need-based commodity, and a very valuable one at that. Once the words fucker or cunt are directed at you a few times in as many hours, you know very quickly who gets the compassion, and who might not. Empathy – we have loads of that, its part of becoming a great actor on the Emergency stage, to step into the shoes of our patients, to know what they feel and want, and to change our language and bodies to deal with their needs. Compassion though – that is precious.

Human interaction is a complex thing - even more so when you, the nurse, are guided in your speech by the haunting cloud of legal gloom that hangs over each of your words. Some patients have a known future, a certain future that you can predict from your thousands of previous experiences. However, you are compelled to avoid the truth, to keep your thoughts and knowledge at bay, you skirt the fact that no matter how much money is consumed by the institution, their loved one is going to die. Instead, you lie – or, better yet, remain silent. Oh yes, a miracle might be conjured, but probably not. You remain silent because people don’t want to hear it – that their weight is the cause of their medical problems, that their smoking caused their chronic back pain, that their addiction was the reason they pulled their own eyes out. Truth is clean, but brutal - and we know it could result in an unsatisfied customer, reduced reimbursement, a chain of migraines for the managers, and possible termination. The truth could leave you without a job. It’s frustrating for sure – but these harsh realities will also wither on the drive home, slowly shaping a shell of invulnerability - every so slowly.

Dealing with these concerns is not taught in school – it comes from experience, from thousands of mistakes made, and the learned ability to repair a mistake. It comes from stories told by your comrades in the trench – both of success and failure. You drink in the wisdom and knowledge of their startling tales, add them to your own, slowly building an empire of knowledge. Emergency nursing is both science and art, and from science comes known facts – kidney functions, ejection fractions, clotting cascades, neural pathways, and ligament insertions – but from art comes the soul of nursing. The ER is a sweeping pallet of colors, and with time, you begin to mix the colors together, blending, learning, discovering, sometimes having to start over, but in the end, hopefully leaving each shift with numerous finished paintings. None will be masterpieces – but perhaps one will be worth framing.


Nursing theory, nursing statistics, research, history, models of care, concepts of nursing, community nursing (collectively known as jumping through hoops, by some) – these are great course for those yearning for work as directors and educators, but for those who desire direct patient care in austere venues, all encompassing hard science and live preceptorship seems the most logical path. Experience is understood as knowledge gained by repeated trials, and without a series of supervised trials, experience will be slow to foster, frustrating, overwhelming, and potentially dangerous. Under real world conditions, we perform tasks over and over, perfecting each step, understanding the reason for each move, until the task is performed efficiently, and with an elegance of purpose. We work closely with each other, double-checking our work, transferring our knowledge up and down a mental conduit, a hierarchy of skills and experiences. ER nurses work on common sense, street smarts, evidence-based science, protocols, and past knowledge – not a modified Roy model.

No theoretical lecture will present you with the truth of the battle – that at any moment you could have your gloved fingers in a struggling vagina, and ten minutes later you would be eating a slice of pizza; that you will become a master of urine concentration, that the nauseating need for diarrhea will pass, and that the three meals a day of peanut butter and graham crackers are all you really need anyway. Some of your patients will hate you, and tell you so every time you give them a meal tray. Some of your patients will love you, want to touch your hair, ask about your family. Everyone you see driving a car will be a potential murderer, high on crack, to be watched and avoided, the children in your car more valuable than anything in your life. The constant coughing of aerosolized infection will drift into your open mouth – and your immune system will strengthen, becoming impenetrable, like the amour plating of a panzer tank – and you’ll wish that just once in a while you could get sick.  

The fellowship of nurses in the Emergency department is a coalition of shared sorrows and triumphs, of near death experiences and close calls, of comedic interactions, violent brawls, blood, urine, and vomit. It’s a place of chaos; old men dying and babies being born, of wailing and sobbing, and of laughter.  We crave the ability to produce a lasting contribution, but are often times tethered by the very profession we live. We work in the muck, on the front line – feeling quite alone, standing apart from the greater architecture that is the hospital, nervous, but so alive. Every day we see the insides of people, splayed open or draining, but always in awe of a creation that is beyond one’s understanding. Goodness and evil live in curious harmony within the ED, fighting it out as we try our best to feed the goodness, starve the evil, and not be taken down in the process.

And yet, every once in a while, when it’s dark and the beds are strangely empty, the trench nurses creep outside and lean against the wintery walls of the building, each feeling the heat from the others shoulders – and silently watch the snow come down - like swirling stars, trapped within invisible cones under the lights of the parking lot.


My friends who work at normal jobs always ask me why I stay. And always, after a pause, I say,  “How could I leave now?”

Rob Hart
www.hartimages.com

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