The gift of Rose

The phone call woke me at 2am.  Being the hospice nurse on-call, it was my duty to be present for any patient’s death if I was needed by the family.  The daughter who called was hysterical on the phone, and even though “I’m sure she is dead…but maybe she isn’t…I think she is still in pain…please come.”  I dressed quickly, grabbed my nursing bag and drove to the tiny town 28 miles away. 

The odor of death met me at the entrance to the upstairs bedroom.  I had been prepared and spread a thin line of mint balm under my nostrils~~ but the odor seeped through it and entered my nostrils anyway.  That’s the way with death…its particles are alive and they cling to the tiny hairs in your nose to preserve some tangible element to remind you that there was once life there.

As I cracked the door open I closed my eyes and silently prayed for calm.  I desperately tried to breath as shallow as possible to quell the waves of nausea that began to roll in my stomach.  Smells of urine, feces and bed sores hung in the heavy, stale air.  One tiny night light sent out translucent beams of light toward the small twin bed in the center of the room.

Her daughter wept behind me.  “She’s gone isn’t she?” she whispered.

I didn’t answer her just yet.  I moved to the bed and sat my bag down with my right hand as my left hand turned on the bedside lamp.  Light broke the darkness and illuminated the tiny elderly woman’s frame lying on her back in the center of the bed.  Her skin was pure white and melted into her hair line. Her mouth was open, baring gums and blackness.  Her eyes were open, but unseeing….blankly staring at the far wall.  The multicolored quilt that covered her looked oddly out of place in the darkly painted room.

Her daughter sat in the oversized blue chair in the far left hand corner of the tiny bedroom. She rocked back and forth while mumbling an unintelligible prayer of sorts.  I took out my stethoscope and gently placed it over Rose’s heart and waited…nothing…only stillness.  I checked her carotid for a pulse and placed my face next to her open mouth to feel for any breath…nothing~ again only stillness.  I knew she was gone, but often times the family needs these tangible, observable assessments of life to assure them of the truth.

After the exploding grief of pain that accompanied the confirmation of death that I delivered to her daughter… I asked her if she wanted me to clean her mother up and ready her for the funeral home.  She told me she wanted to help me… “She was once so proud.  She hated the way she smelled and the way that our family stopped coming by.  She prayed that God would deliver her from her torture for 6 months.” 

As her daughter left the room to get a new nightgown and some towels, I took rose and spearmint essential oils from my nursing bag and put several drops in a basin of warm water.  I lit a clean linen candle that I kept in my bag and placed it on the bed side stand.  When she returned we slowly bathed her mother.  We started at her face and worked our way to her feet.  Several moments were spent in silence, and some were spent in the sound of her grown daughter’s tears.  We placed clean lines underneath her and covered her with a clean white sheet and the multicolored quilt.

While we bathed her, I learned that this patient was a ballerina and the she taught classes until she was 70.  She was married at age 18 and widowed at 30.  She had a master’s in music and played classical music every day as therapy for her sadness.  She never remarried.  Her daughter was an only child and her best friend.  She never ate meat and only drank once a year on her husband’s death anniversary.  She had 2 sisters that she adored, but then resented as they stayed away.  She never ate at fast food restaurants but she loved the smell of Pizza Hut.  She loved flowers but once she got sick she couldn’t stomach their smell.  As she grew sicker she never wanted to talk about dancing or listen to classical music.  She didn’t accept chemotherapy or radiation and she lived with her cancer for 4 years.  She was only in pain at the end. 

I wish I had known her in life.

That couple hours of time was one of the richest experiences I had in my years of doing hospice nursing.  Rose was not my patient so I had not met her before that night.  Her daughter needed me and I was so glad that I answered that early morning call in April.  Bathing her mother and readying her for the “last part of the journey” was such “a gift.”  I was honored to help and be present for this moment in their lives.  I have never seen the daughter again, but the memory surfaces during April every year…

What are your most treasured memories from your career???? 

Always listen to the heart

I slowly walked past the patient room and caught a glimpse of her.  She was gazing out the window with a fixed expression.  She wasn't my patient, but something about her gaze stopped me from moving on.  I leaned against the door frame and took in the sight of her.  The neatly made hospital bed swallowed her frail, aged frame.  Her long white hair was in a low loose braid, and the tail end of it draped her left shoulder.  Elegant crooked hands were clasped and cupped the bulk of a black rosary. 

My eyes swept the room.  Her monitor registered stable vital signs.  Sun spilled in from the large window and blanketed the floor, the bed table, and the end of her hospital bed.  Books were stacked neatly on the bed table. A large, half-filled water bottle sat in the center of the table. Evian. The T.V. was off. 

A movement from the woman drew my eyes back to her.  She slowly and deliberately brought her rosary filled hands to her mouth and kissed the cross.  As she did this my heart tightened.  I didn't know what her mind was thinking, but the sight of this simple gesture caused me to enter her room.  She looked at me with large blue eyes but with no change of expression.  I went to her.

“Hello, I’m Bobbi.  I am on this floor today as a Nursing Instructor for UMA, and I was passing by your room and just felt the need to come in.  Is it okay if I sit with you for a moment?”

I watched my words register and a small smile tugged at the corners of her mouth.  “Yes dear, that would be nice.” 

She continued to hold the black rosary between both of her hands and rubbed the beads with her right thumb.  “The sunlight coming through this window is amazing,” I remarked.

“This new hospital is pretty fancy,” She offered.

“Yes it is,” I said with a smile.  She watched my face but didn’t speak.  I probed, “How are you feeling today?”

“Better.”

I wasn't sure if I should stay…I didn't feel unwelcome, but I got the feeling I was intruding somehow.

I stood to go, “Well, I just wanted to stop in and say hello…something about the way you were staring out the window just caught my attention and I felt drawn to you.  I will leave you to your thoughts.  It was so nice to meet you.” 

I watched her blue eyes fill with tears, “stay.”

I sat.  I watched her gather her emotion and stuff it back inside.  My heart was beating rather fast and I couldn't shake the feeling she needed me.  My eyes watched the monitor register her pulse speed up and I waited.

She slowly began speaking in a soft, but strong voice, as she stared past me out the window, “I am alone in this world.  I live alone.  I eat alone.  I pray alone. Oh I know that I am technically not alone because I have my faith and it does comfort me…but I am physically alone.  I came to the hospital because I felt terribly afraid that I might die…today, at this very moment as we are speaking my husband and my only daughter died in a car accident 10 years ago.”

She let that hang in the air as she continued to stare out the window.  One tear escaped her right eye and weaved down her lined face.  Time seemed to stop as I watched that tear and silently prayed for guidance.  The tear got trapped in a wrinkle and stopped by the corner of her mouth. She didn't wipe it.  She sat there enveloped in the bed and just stared out the window. 

I fought tears.  I fought the urge to talk.  I normally talk…I normally try to comfort people with words…But I felt God’s hand over my mouth.  I just prayed for her pain.  I waited, it seemed like hours passed by in that 2 minutes of silence. 

She pulled herself out of the memory she was lost in and looked at me.  “Do you have a family?”

As I told her of my family I watched her smile.  We talked about family and some of her memories for quite some time.  As I stood to go and check on my students, she reached her right hand out to me.  I walked to her and took her hand.  “You will never know how God used you today,” she tearfully whispered. 

I smiled as tears of my own formed.

“I was silently begging God to send me someone to just sit with me as the moment I heard of the car accident approached.  I didn't want to be alone…just this once as the memories crashed my soul.”

I couldn't hold the tears…they burst from my eyes and dumped from my cheeks.  I couldn't speak.

I moved to her and sat on the bed, and then I hugged her.  She hugged me back. 

It’s a beautiful thing to know that you were used by God.  Being a nurse has so many responsibilities attached to it.  Let us not forget that we are first and foremost gifted with the responsibility to be human…to be a vessel of healing in ALL ways.  I will never forget that woman nor will I forget those moments in time every year from now on as I will lift her up in prayer so she will NOT be alone.  What a gift to be a nurse~ To be able to be present with a patient… 

Exactly what does a nurse do anyway???

There we were, a bunch of people that I love, sitting around the table discussing our week, and the subject turned to jobs...then somehow it turned to college and why education was or was not important.  The subject then turned to nursing education and just how much was truly needed in order to "become a nurse." 

One of those people that I love (and of course still do) gave the opinion that "nursing education has turned into something so ridiculous and hard...mostly you just need to know how to follow doctor orders...it truly would only take half the time to educate someone to be a nurse"...and on and on it went. I will spare you all the "in depth" conversation that followed~~ BUT what this conversation did do for me was cause me to reflect on a lay person's idea of what the job of nursing entails...

Educating people to become a nurse entails so much more than teaching the technical skills required to be a nurse. 

Yes we teach them how to wash their hands properly (to not spread infection) take vitals signs (Blood pressure, pulse, temperature, count respirations, oxygen saturation and assess pain), insert foley cathetors, IV lines, nasogastric tubes, and trachs, give a bed bath and change linens, safely move people in bed and safely ambulate someone or move them to a wheelchair etc, to "wipe butts" and empty bedpans, hang IV drips and give medications in many forms...and on and on and on.

AND YES we could teach just about anyone to do these things.

BUT we also teach them anatomy, physiology, pathophysiology, biology, microbiology, immunology, algebra, chemistry, English grammar, sociology, psychology, developmental psychology, abnormal psychology, pharmacology, health and wellness/assessment across the life span, science of nursing, alterations in health/ illness, nutrition, nursing theory, research, informatics, clinical decision making, transcultural diversity and relations, ethics, professional behaviors, spirituality, death and dying processes, nursing management, leadership, community health, interpretation of lab values....and on and on. 

We also teach all of the above through concepts of human caring, basic human needs and teach the nursing process. 

We teach them all of these things in order to prepare the nursing student for the art and science of nursing. We educate them properly so once they are in the work setting and "following doctors orders" while performing their technical skills, that they will do so safely. The subjects that are taught give the nurse the ability to use the technical skills as a compass to asses the true health status of the patient. Without the knowledge base~~the technical skills would have no meaning.  

So~~ while the nurse is talking to their patient they are studying them and assessing their neurological status and assessing their oxygenation. During the communication with their client they are also assessing the patient for knowledge level, home safety, patient advocacy, illness insite, inside information to shed light on present situations and to develop a relationship of caring so that healing can occur. 

While the nurse is checking the patient's vital signs they are learning about their cardiovascular, respiratory and thermo-regulatory states.  

When the nurse is giving their patient a bed bath they are assessing their skin integrity, their ability to assist (their strength), fluid balance, nutritional state and infection/ skin breakdown risk. 

While assisting someone to a wheelchair the nurse is providing safety while assessing their patient's strength, cognitive ability, safety risk and spatial awareness. 

When inquiring about their patient's med list the nurse is assessing the patient's knowledge around their disease processes as well as their safety regarding how, when and why they take the medications. 

During the process of changing a patient's dressing the nurse is assessing the wound healing stage, the surrounding tissue state, as well as checking for odor/infection...they are also assessing whether that type of dressing that was "ordered by the doctor" is actually working.  

While "wiping butts" the nurse is assessing skin integrity, assessing the color, odor and consistency of the stool to detect disease states or healing. 

When a nurse is "following a doctors order" and medicating their patient, that nurse does 6 checks in order to ensure the patient is receiving that medication correctly~~ but more importantly the nurse has to know why that med was ordered, and they need to know if it is the right dose for that patient, and they need to know what side effects to watch for...and on and on and on.  

I could go on!!  The bottom line is that the nurse is with the patient far more than the doctor is. The nurse is the front line (bringing their thoughts, assessments, interpretations and communications to the doctor in order for the proper care to be given to the patient) and safety net for their patient (ensuring that the doctor's orders are indeed safe for the patient and not given if they are not!). If the nurse isn't educated but merely taught technical skills, then that nurse would not be able to do the above I just mentioned and the health of the patient would be in jeopardy. 

How educated do you want your nurse to be???? 

The wisdom of reflection

He sat on his mother’s lap clinging to her for dear life as he screamed in fear.  The hospital bed seemed to hug them as they sat in the center of it, leaning against the head of the bed that was at a 75 degree angle. His little body was shaking and his large dark eyes darted from one nurse to the other as they prepared to take out his existing IV and replace it with a new one. “No, No,” he cried. “Mom, mom,” he pleaded between screams and sobs.  His young mother was desperately trying to sooth his fear while suppressing her own.  She was tired, and her eyes betrayed her calm exterior as they were filled with sadness and protective instincts for her child. 

I watched them.  I prayed for them.  I desperately wanted to take this experience away from them.  This young patient is only 21 months old.  He is my grandson.  She is my daughter.  I was not there to be his nurse but to be their protector and guide through this experience and I felt like a failure.  I wanted to grab him and run away.  I wanted to cry. 

The nurses approached them cheerfully and tried very hard to sooth him by explaining things and by quickly and skillfully doing their job.  He would have none of it!  While he was a good trooper he was scared.  Fear is hard thing to watch your grandson and son struggle with.  The doctors were very good at providing us with timely updates and filled us in often of their concerns and thoughts as treatment progressed.  Added to the current fear of being in the hospital with a sick 21 month old, was the knowledge that the doctors were concerned that possibly our amazing little man “might possibly have lymphoma” because of his lab values…something they were looking into…

He was hospitalized after a week of strept throat that wasn’t treated or diagnosed by his pediatrician despite my daughter visiting the office 2x that week with her child who had a fever of 101 every day, consecutively all week.  As a result, he developed a large abscess posterior to his parotid gland that was drained of 15cc of bacteria after the second admit day.  He had to receive IV Vancomycin until they knew what the cultured drainage was growing.  He was sick of being sick and sick of being trapped in a small room with people accosting him! 

My daughter is a wonderful mother, she gets her protective instincts from me…anyone who knows me will know that I take protecting those in my care very seriously…as does she.  I watched her with awe and admiration as she loved, protected and cared for her son.  I watched in awe at my grandson who could still show curiosity, kindness and have fun during the times he wasn’t in pain or fearful.  The ability of being able to adapt to his situation was inspiring.  My son-in-law was equally strong as he provided his own brand of presence to the situation.  Watching them together parent their child in this very stressful situation gave me peace as I saw the strength and love they have for their child and one another.

Being an ER nurse I of course understood why all the medical interventions were needed.  As his grandmother, and my daughter’s mother, I was scared, angry and protective.  My husband and our family that was home in Maine were also sitting on pins and needles as they waited and worried about this precious little boy of ours. The experience reinforced a few things for me.  As a nurse it is our job to skillfully and compassionately provide our patients and their families with the treatment and care they are prescribed.  It is our responsibility to bring them accurate and knowledgeable information in a timely and routine fashion; giving them time to ask questions and to answer those questions without impatience or judgment.  It is our duty to care about the situation they are in and to convey that with a kind presence, a caring touch and to give them moments of our uninterrupted time to show them they are not alone. It is our calling to see the patient and the family as human beings in a scary situation.  There is also a piece that hit home for me…those family members and friends that continually come in to see their loved one are coming out of concern and they offer hope and distraction from fear for the patient and family. I challenge anyone reading this who is a nurse to reflect on your practice and be sure that you are truly the nurse you were meant to be.  Your presence is vital to the mental and physical wellbeing of your patients and their families. 

Lynchburg General Hospital in Lynchburg Virginia has an amazing pediatric unit filled with compassionate and truly skilled nurses who did all of the above with grace and humility.  The doctors were equally skilled at their job and also did it with much compassion.  My grandson fully recovered and is now running around at breakneck speed as usual!  He does not have lymphoma! Thank you Jesus.

 

An exercise of compassion

The ER is in total chaos today.  All 23 rooms are full, the behavioral health suite is full, the waiting room is full and even the hallway is full. Full of sick patients.  The nurses are frazzled, working as hard as they can delivering treatments, hanging IV medications, soothing fears, charting and carrying out each order on every patient. There are 23 rooms in our ER.  The waiting room has 12 triaged patients waiting for a room, the hallway holds 5 stretchers with sick patients on them and the behavioral suite has 5 patients in there (3 counted for in the room number).  We are currently in a crisis situation~ we have 2 doctors, a PA and 6 nurses.  Its only 9am. 

At this point another behavioral health patient is brought into our ER by the state police.  He is psychotic and half-dressed and screaming at unseen people.  He was found in the park yelling at a tree.  As the charge nurse I go out to assess him (the triage nurse is busy).  I find him to be completely in need of psychiatric help and not suitable to be allowed to stay in the waiting room, (as you can imagine the other patients and their families were getting an eye full!!) BUT where can I put him to him safe and to keep the staff and other patients safe???  Shuffling of patients begins…

Our ER, like every ER across the country is facing these situations every day.  The budget cuts to the mental health programs have resulted in catastrophic cuts in the community resources that our patients need to stay healthy and out of crisis situations.  The ER has become the place to send all of these patients. Once with us, the truly ill might be kept in our ER for days while waiting for a bed to open up in a psych hospital. 

Behavioral health/mental health patients are especially frustrating for us ER nurses for a few reasons.  We are not psych nurses, so many times we feel overwhelmed with how to help them, they are hard to manage both medically and emotionally and at times they have multiple outbursts that are unsafe and scary, they take up many of our limited resources (staff and beds) so we again feel overwhelmed, and the frustration level rises every time we present their situation to another hospital hoping they can be seen and helped in the fashion they need~~~ and they get declined due to “that patient just doesn’t fit our milieu.” 

With all of that said~~ how can we as nurses see these patients through a new lense??? Since we have no control over the red tape of the Psych world maybe there is something we can do to see the patient as we do the chest pain, the trauma and the septic patient; we might have less frustration and feel less overwhelmed.  I decided to try something~~ and it was an exercise in compassion. 

I decided to be a mental health patient to walk a mile in their shoes~~ to see how it feels on some small level.  With the ok from my supervisor and the help of the staff, I came into the ER and “signed in.”  At first it was silly and giggles erupted from myself and the triage nurse…but then as I was asked the multiple intrusive questions, and brought to a room to change out of my clothes and given the blue paper scrubs to change into, things were not so funny.  Out of respect for me the nurse didn’t stay in the room and watch me change~ BUT if I were truly in crisis she would have had to do that… once changed, all of my belongings were taken from me, bagged and locked up.  I had to be without my bra and undies…NOT COOL…and I couldn’t keep my cell phone either.  I was then moved into the behavioral health suite~ scary……….  I wanted the full experience so I was then put into 4 point restraints for “an unsafe outburst that put myself and the staff at risk of harm.”  At that point I was scared… something happened. 

I always knew that putting someone in restraints made me sick to my stomach…I knew on some guttural level how awful it must feel for that person.  Now, I know why we do it and I’m not saying we do anything wrong, I am just saying that it is WORSE than I ever imagined it to be.  I stayed in them for 15 minutes, and I was with people I trust… and at one point I had to tell myself to not freak out!  My nose itched and I couldn’t scratch it.  I didn’t like the way the shirt was slipping up off of my stomach… I felt so out of control… when I was released from the restraints I felt like crying.  I had the luxury of saying, “ok this little experiment is OVER!! I honestly can tell you that it was a good experience, in the fact that I got just a little taste of how the patient must feel…and it opened my heart as well as my eyes. 

There may not be anything I can do to get the mental health patient to a psych bed any quicker…BUT I can have a better understanding of their situation and a bit more compassion.