Touching Base

I was recently shadowed by a high school senior during a couple of shifts. She was considering becoming a nurse and had an interest in Emergency Nursing. She followed me as I provided care for patients with a broad spectrum of problems- from a known narcotic seeker who demanded (read: screamed) that we address his pain, to a homeless patient with a peritonsilar abscess and no access to continuity of care, to a nonagenarian woman who suffered cardiac arrest and whose family had kept her on "full code" (all measures to maintain life) status because they could not let her go. My young shadow saw everything from the mundane to the life-shattering. She didn't understand sometimes why we try so hard. She didn't understand sometimes why we gave up so quickly. She asked a lot of questions. Sometimes the only answer she got was "I don't know." But she certainly left with a stronger awareness of emergency nursing than when she came in. And in the end, she expressed a stronger desire to pursue nursing than when her two long nights with me began.

It was a good experience for me because it served to reaffirm the reasons I became an emergency nurse in the first place. While those initial guiding altruisms have been purified through the crucible of hard experience, the fact that they remain essentially unchanged reinforces my conviction that I have followed this calling for all the right reasons. It is good to "touch base" once in awhile- to step back and look at the big picture as it applies to this craft and my place in it.

And it really is a craft: it is more than mere science, more than mere art, and more than mere aesthetics. It is a dynamic entity comprised of all of these things and more; it is fluid, malleable, and flexible. The careful practice of the craft enables the experienced nurse to bring the fullness of his or her skill and expertise to bear in a manner that is custom-tailored to the unique needs of each and every patient. The craft thrives in an environment of constant purposeful increase of knowledge and experience; The diligent nurse carefully nurtures and grows his or her craft as if it was the rarest of flowers in a garden. The nurse who neglects this ultimately does so to the great peril of the patient.

There is a Great Abyss that nurses talk about but seldom recognize in themselves. I have known nurses from many disciplines who perhaps should have stepped away but continued to work. It is a danger faced by anyone who suffers daily exposure to the darker, meaner side of humanity, or to the pressures that accompany rigorous, demanding routine. And it is a soul-wrenching thing indeed to watch a nurse walk blindly, as most who go there do, into that abyss. Psychiatrists call it "Caregiver Role Strain." We nurses call it "Burnout."

There have been times in my own comparatively brief career when I have had to pull myself up short, step back, and coldly correct myself when I was too quick to judge or when a case rattled me- or if I got too emotionally enmeshed in an intense case. It happens to every nurse from time to time- more often in the high-stress specialties, but no nurse is immune. I don't think a nurse can avoid burnout by simply avoiding the situation; rather, he or she must develop the ability to maintain clinical objectivity. And sometimes, my friends, that is a hell of a hard thing to do. Because while a nurse may be simply maintaining objectivity, it can be misconstrued by the patient or family as being "cold," "uncaring," "rude," or "judgmental," even when a nurse has also expressed genuine concern for the patient.

So then, we nurses must not only carefully practice clinical objectivity; we must also show that we genuinely care. This is a tricky business. It's damned hard to do sometimes. Yet both are equally necessary all the time. It is a devil of a thing, a delicate balance. If one loses sight of the guiding altruism of nursing, certain disaster awaits- if not for the nurse on a personal level, then for the patient. For we practice upon living human beings, for whose benefit we live by the principle of First, Do No Harm. Thus, if altruism is sacrificed for the sake of pure objectivity, we also lose the ability to empathize. Yet at the same time, if we become too emotionally enmeshed in our patients' situations, we lose clinical objectivity and thus cannot see the thing that, while hard for them, will ultimately do the greatest good.

As an Emergency nurse, I perform some noxious- and sometimes brutally harsh- interventions in order to save a patient's life. Many times, the patient is fully awake when I perform them because they must be. It bothers me to do painful things to another human being who trusts me to do the right thing for him or her because I know that it hurts. I often find myself apologizing during the process because I know how much pain I am causing- and yet for the greater good of the patient, I continue. I do not apologize about having to do it; I apologize for the pain it causes. And not all procedures can be preceded by local anesthetics.

Yet if I explain the procedure beforehand to the patient according to his or her ability to understand, then he or she is generally better-equipped to endure these things. They understand that I am doing what must be done, that it may cause quite a bit of discomfort, and that while their discomfort may not necessarily be lessened, their active participation in the process is likely to shorten the duration of their discomfort. And I try every trick in the book to make things as easy for the patient as possible. Clinical objectivity is thus married with the altruism of compassion.

It's great when time permits gentleness. Sometimes, it does not. When a patient came in after a Tylenol and Benadryl overdose and I had to unceremoniously slam a nasogastric tube into her without fanfare or time-consuming preparation, it had to be done right frigging now. I am fine with that. But I talked to her while I was doing it- sometimes barking a command to swallow, and then at the end, just putting a hand on her forehead and telling her, "You did a great job, kiddo. I know that hurt, and you were wonderful." It's funny: she looked me right in the eye, gave me a nod, and smiled at me. In spite of the hundred Benadryl that raised black hell on her nervous system, I connected with her.

And that is the marriage of clinical objectivity and compassion: As horrible as a procedure may be, there is always time enough for a little gentleness afterward.

"Do you ever cry?" My shadow asked at one point.

I answered that I did cry sometimes for my patients. It's heartbreaking to see some of the cases that come through the door. But God is my healer, and so I am not afraid to care. I am thus free to be clinically objective and to genuinely care about my patients. I am convinced that if it was not for God, I would have fallen apart long ago. But because of God's grace, I do not merely endure; I thrive.

My astute young friend closed her experience with a question: "If you could tell me one thing that could guide me as a nurse, what would it be?"

After a few moments of thought, I answered: "Never forget that the person in that bed is somebody to somebody else- and even if the patient doesn't have a friend in the world, he is still somebody to God. The patient is not there to serve you; you are there to serve the patient. Sometimes that means telling them something they don't want to hear. When you care for someone, it means that you also care enough to warn them that their choices put them at risk for imminent harm or illness."

The young lady looked down, sighed, and nodded.

These are the things I told the young lady who shadowed me throughout two long and often brutal nights. And that wide-eyed young lady who shadowed me and plied me with questions (which begat more questions) had in her own way served to reignite my own passion for this craft. In reflecting on my experiences with her I came to realize that, if such is possible, I am more passionate about the craft now than when I first felt the call to become a nurse and to focus on emergency nursing. I found, to my delight, that it had never gone away- had not even paled from its original blush. And that, I think, is a most gratifying thing.