After completing my final year of nursing school,
after taking my nursing boards and receiving the envelope
that held my license, proof of my expertise, I became
a real nurse in a real job, working night shift in
intensive care.

My nursing program had been a rigorous combination
of clinical and academic work. By graduation, I’d run
a floor, taken care of ventilator patients, started
intravenous lines, passed meds, participated in codes
and, in general, was ready to hit the ground running.
And so, after an eight-week heart monitoring course,
I found myself in charge of a seven-bed ICU, the only
registered
nurse on the night shift. I had a nurse’s
aide to help me, a woman in her fifties with
30 years of experience, and I had the support of the
night
supervisor who floated about from floor to floor,
pushing the 3am snack cart, holder of the keys to the
pharmacy and the morgue and, in general, the one to
call in case of any emergency. But despite the aide
and the supervisor, in that small unit of desperately
ill patients, the buck stopped with me.

My first night as charge nurse, I walked in to find
two fresh myocardial infarctions, an elderly post-op,
and four ventilator patients, one of them a 10-year-old
girl who had been hit by a car and was dying.

Was I scared? I was terrified.

*   *   *   *   *

But first, some background facts: Everything was different
then. The intensive care beds, separated by glass half-walls
and long curtains, fanned out around a central nurse’s
station, a long desk where seven monitors beeped and
pinged, echoing, a second behind, the rhythms of the
seven monitors at the patients’ bedsides, an odd, syncopated
song that never stopped. There was an absence of computers
and an absence of paperwork. An intake and output sheet
hung by each patient’s bedside; a nursing cardex held
one page for each patient, and on that card was written
a succinct nursing care plan and any important information
about allergies, code status, and next of kin. Nurses’
and doctors’ notes were handwritten in the chart, available
for all to read with a minimum of effort. And the change-of-shift
report was given to the incoming nurses face-to-face,
not taped or typed into a computer to be printed out
and passed along like a secret note. In other words,
we had a lot less aggravation and a lot more time to
spend with our patients.

And spend time with patients we did. In intensive
care, there was no such thing as “rounds” – in
our small unit, we were with our patients constantly.
During the day, when most of the activity took place,
there was a low patient-to-nurse ratio. Since we had
no interns or residents, we nurses started and restarted
IVs, placed or replaced nasogastric tubes, pushed curare
to keep our ventilator patients sedated and, because
respiratory techs were not yet a common part of the
team, we adjusted ventilator settings, ordered blood
gasses, and then readjusted the vents to maintain doctor-ordered
parameters.

Every patient was bathed once a day and “sponge bathed”
in the evening, not with pre-packaged and pre-soaped
disposable cloths, but with real soap and water. Each
immobile patient was turned regularly, some even every
15 minutes. We gave back rubs three times a day, soaked
and washed feet, got patients out of bed and hounded
them to take deep breaths, to cough, to move.

Standing at the central nurses’ station, I could see
all my patients and, at the same time, watch their
heart lines leap across the monitor screens in front
of me. I could tell by a slight disturbance in the
pattern when a patient was restless or having pain,
and I knew that my duty was to go to that patient and
help him. Sometimes help meant sitting by
the bedside and talking; other times help meant recognizing
an impending disaster, calling the attending and positioning
the code cart right outside the curtain, out of the
patient’s sight.

*   *   *   *   *

I’d done all these things and more as a student, always
with an experienced nurse somewhere nearby. Even so,
that first night in charge, as I walked in to that
scene of agony and grief, I trembled as the evening
charge nurse gave me report. I wasn’t at all sure I
would survive. I wasn’t sure that I could help these
patients survive and, more than that, I was afraid
I might harm them. I’d never felt more alone.

“Little Jenny over there in cubicle three was hit
by a car while riding her bike today,” the evening
nurse told me. “She has massive internal and neurological
injuries, her blood pressure is dropping, they’ve got
her paralyzed on a vent, and we can’t control her heart
rate. The docs expect her to die within the hour, and
her dad won’t leave her side.”

I looked over at cubicle three. A thin girl, dark
haired, was barely visible in the bed. The respirator
huffed beside her, and a spider web of tubes and catheters
seem to hold her captive. Hovering over her was a man
with tousled brown hair, glasses, and a baseball jacket.
He looked as if he had run from his house without money
or comb, without anything in the world but his daughter,
who now was in what we rightly call the agony of death.
The father held his daughter’s hand, and I could hear
him, his words muffled, as he pleaded with her to live.
How could I, a new graduate – a well-trained
one to be sure, but also one who didn’t yet have the
years of experience – handle all this?

The evening nurses and aides and ward clerk left,
one by one, looking back over their shoulders at Jenny
and her dad. As the automatic door whooshed closed,
an eerie silence fell over the unit, interrupted only
by the out-of-synch music of the respirators, each
of them hissing their own tune, and the repeating voices
of the seven monitors. The nurse’s aide and I looked
at each other.

“I’ll do vital signs and make sure the IVs are OK,”
she said. She was probably just as frightened as I
was, wondering if this new grad in her crisp white
uniform was going to kill anyone that night.

I think maybe I did. I think I might have killed Jenny.

*   *   *   *   *

After all these years, I can’t remember the exact
sequence of events. In the middle of the night, when
memory plays its tricks and dredges up the worst scenarios,
the most awful implications, I think that I went first
to Jenny’s bedside, before I checked any other patients.
I introduced myself to her father. I remember tears
in my eyes as I watched them, father and daughter.
I recall reading the medication cardex, the order for
the intravenous medication to be given if Jenny’s pulse
exceeded a certain rate. I remember her wildly racing
heart, suddenly shooting up to well over 200 beats
per minute, and I remember drawing up the medication
and administering it. Then, shortly after this administration,
I remember her dying.

It wasn’t then, that night, that I wondered
if I’d hastened Jenny’s death. I didn’t wonder this
until years later, after I’d learned how human error
and imperfect knowledge walk beside us nurses and doctors
every minute of every shift. It wasn’t until I’d had
years of experience that I became familiar with how
we caregivers can sometimes second-guess ourselves,
especially when something suddenly goes wrong and we
have to act instantly. That is when I thought of Jenny.

When I’m awake, feeling sure of myself and my skills,
I recall a different memory. She didn’t die within
minutes of receiving the medication, but hours later.
I remember that the night supervisor, a friendly, gray-haired
woman, came to the unit to sit in the waiting room
with Jenny’s mother, who couldn’t bear to be with her
dying child. I remember Jenny’s mother sobbing so violently
she was retching, a grief sound I’ll never forget.

I remember that after Jenny died, her father insisted
on helping me prepare his daughter’s body for the morgue.
As I began to wash Jenny, and her father climbed into
the bed and took the washcloth from my hands. I started
to remove her IVs and her father stopped me. “I want
to do everything,” he said, his eyes dry and dark,
his voice firm. I stood back and watched as Jenny’s
father gently removed the tubes, the catheters. I helped
as he wrapped her body in the plastic morgue bag, and
I handed him the tags to tie on her toe and on the
outside of the at-last-zippered-shut black shroud.

*   *   *   *   *

Did I kill Jenny? No, I tell myself. In my
heart I know she was going to die, no matter what anyone
did or didn’t do. Instead I tell myself that I learned
a lot that night. And one thing I learned was that
sorrow comes when we least expect it, right in the
middle of happiness. I learned most of all, perhaps,
about grieving, about letting the survivors crawl into
bed with their loved ones and take part, if
that’s what they need to do, or to let them, like Jenny’s
mother, get as far away as they can and not
take part. I learned that we nurses, we caregivers,
can be well trained and efficient, and yet there will
always be times when we doubt our actions: Did I, who
thought she’d done it all by graduation, give that
medication too quickly, bringing Jenny’s heart to a
crashing halt? Did I give it too slowly, and so not
bring her heart rate down in time?

The rest of that first night in charge is now mostly
a blur. I know that the other patients lived through
the night, and so did the nurse’s aide and I. The post-op
patient voided, coughed, and sat in a chair. The other
ventilator patients were suctioned, turned, medicated,
bathed, rubbed, and talked to. The fresh MIs had no
arrhythmias and received their medications on time.
No IVs infiltrated or went dry. As dawn came to the
unit, the sun arriving as a pale yellow line beneath
the closed window shades, I sat with one man and talked
to him, balanced on the edge of his bed, about his
family and his business. I watched as his heart rhythm
slowed, steadied, helped by 15 minutes of casual and
reassuring conversation.

I can’t tell you how many times in the years since
that night that I’ve looked up the medication I gave
Jenny, its properties, its side effects, its benefits,
and its dangers. I can’t tell you how many times since
then I’ve stopped myself before giving a medication
or a treatment to check and make sure that what the
doctor ordered was correct – doctors make mistakes
too. I’ve learned that we caregivers are not infallible,
but only as human and sometimes as frightened as our
patients. We’re rarely as “in charge” as we may want
to believe.

That long-ago night made me a better nurse; it taught
me the need for abiding caution mixed with confidence.
Such caution has made me a safer nurse, especially
today when everything has changed and everything has
become more complex – how we do things, how we
record things, how we interact with our patients and
treat their diseases.

Still, I think about the small and mostly insignificant
mistakes we make, because we are human, every day that
we care for patients – all of us, from the most
famous and proficient doctor to the least experienced
nurse’s aide. No matter the reality of what actually
happens, we caregivers always carry, along with our
many responsibilities, the heavy and inevitable burden
of doubt.

If I’ve ever done anything wrong, I pray that my patients
might forgive me. If there is nothing to forgive, then
I wonder if I can ever stop believing that there might
be, and forgive myself.

 

First Night in Charge imageFirst Night in Charge imageFirst Night in Charge imageFirst Night in Charge imageFirst Night in Charge image(No Ratings Yet)
Guide tagged: