If it Looks Like a Duck…
As I sit here drinking my favorite Murchies tea, and digest my homemade banana bread, I am pondering the emotional roller coaster patients can be over a stretch of shifts. In fact, despite the physical challenge presented by bedside patient care, I find that I often come home more mentally and emotionally exhausted than anything else.
My evenings after work often look like this: Get home at 20:15, make my lunch, put together my uniform for the next day, find my bed, and pass out the moment my head hits my pillow. I haven’t figured out how all those young nurses go out after their shift, drink and dance the night away, and show up for their shift the next day, bright and cheery (and often still manage to do a much better job than me).
But I digress, I’m supposed to be talking about the emotional ride bestowed upon us by patients. And I must say, I think this plays an even bigger part of my working life in the ICU than on “the floor.” This is likely because we have only one patient that we are with for every second of the day. That’s twelve hours experiencing every intimate detail of the patient’s current health crisis. There’s never a break while we chart at the front desk, or care for another patient.
Frankly, I’m not that great at the “emotional” stuff that goes along with being a nurse. I struggle to be the warm, friendly type that has a soft, sympathetic touch on the shoulder, or a shared tear in the time of difficulty. No, instead, I tend to get more frustrated and impatient in these times. At best, I’m completely awkward. I am certainly aware of this flaw in myself. And it’s a flaw that spills over into real life; I’ve never been good at communicating emotions, or dealing with them in any capacity.
My patient was Mr. Panicky-anxiety-attack. If you walked near him, he would flail about in his bed, eyes wide open, screaming (around his trach even) shaking the bed, and banging the side rails. All the while I would be desperately holding his head trying to stop him from tearing apart the delicate sutures all along his neck and face. Of course, trying to hold his head still would make him even more ridiculously agitated and he would flail and bang even more–clearly mouthing very distinct swear words. We had to tightly restrain him so that he wouldn’t pull out his tubes, IVs, and airway during his “episodes.”
Pain control was his main issue. He had scheduled tylenol and dilaudid, and a large fentanyl infusion that we could titrate to effect, and bolus him with. Nothing helped, and the pain became more and more of a concern. CTs, x-rays, cultures were done in an attempt to find the source of his inappropriate pain, and when no reason could be found, our hospital’s pain team was consulted to try and help. Nothing would.
I went home completely drained. I was exhausted and nearly in tears with frustration because my patient was so incredibly uncontrollable. I even contemplated asking for a new assignment the next day, but had heard that three other nurses already asked, and I figured somebody had to “bight the bullet.”
The next day really wasn’t all that different. In fact, it was possibly worse. And it all came to a climax when Mr. Panicky-anxiety-attack had his biggest temper tantrum to date. By this time he was writing notes for us, and in a desperate attempt to find out what was wrong, I gave him a pen and paper. He wrote, with me continually prompting him for more details:
Help Me! Help Me!
What are you doing to me!?
Call 911!!! Something’s wrong, I need help!
I don’t trust you! Call 911
Fuck you Fuck You FUCK YOU ASSHOLE!!!
In his frustration, he threw the paper, clipboard and pen at me, one at a time, just missing, and began flailing about and banging his bed, screaming (as loud as he could around his trach).
After two days of dealing with his temper-tantrums, I was MAD. My ability to stay calm had been completely worn out.
“Listen Mr. Panicky-Anxiety-Attack” I yelled, “I’m not going to put up with this kind of shit anymore! You’re acting completely inappropriately, you’re like a two-year old here with your temper-tantrums, so stop all of this shit!”
Yes, I swore and yelled at him much more than I’m proud of. Then I took a deep breath and calmed myself down. I did the whole, “Close your eyes, breath, and count to ten” thing.
When I opened my eyes, I said, “Sir, do you remember where you are?” He shook his head to say no, “Do you remember that you’re in the hospital? You had that big surgery on your neck. I’m your nurse, we’re all nurses and doctors. We’re trying to help you.”
He shook his head no, looking confused. And then after a few moments, you could see the memories rushing back. He remembered everything. He wanted to write something, so I gave him the pad of paper.
I’m sorry, I’m sorry, I’m so sorry!
And then he burst into tears. I sat in a chair beside his bed.
“Sir, you’ve had one of the hardest surgeries to recover from, this is HARD, you’re in pain and have a million tubes going into your body. We get why you’re having trouble. And to top it all off, your wife hasn’t been able to come visit for days.”
He nodded, still crying
“Do you sometimes wake up and not remember where you are? is that why you get panicked and scared.”
He nodded again, crying harder.
“Would it help if I spent more time reminding you where you were and why you’re here”
He nodded and grabbed my hand, mouthing “sorry.”
And I’m almost in tears now, completely ashamed at myself and the way I acted. For the rest of the day, he was a delight. And I kept up my end of the bargain. If he started looking scared, I would reorient him, explain everything that was going on, and make sure he was calm before I continued.
So many lessons could be taken from this, but here are a few that I found for myself. Firstly, I realized that I am only human. I have serious flaws and weaknesses. I am not perfect, I can only tolerate so much emotional stress, and I too have the capacity to behave inappropriately.
Secondly, I learned that I can and do deal well with patient’s emotional issues. Perhaps I was slow on the draw, but I assessed the problem, provided emotional support, and found effective solutions. And, I did so in a caring manner–eventually.
Thirdly, I learned again (and this lesson will smack any nurse in the face over and over again), that you can’t always take a patient’s behavior at face value. When a patient is behaving strangely, look for reason for this behavior. And don’t forget that it isn’t always just an emotional issue. It could be a stroke, hypoxemia, withdrawal symptoms etc. And never EVER be afraid to ask family, “Is this behavior normal for your loved-one?”
After giving report to the oncoming nurse, we were discussing possible causes for his outbursts and confusion. She had a student nurse following here that day. The student theorized that it was the large amounts of narcotics, or perhaps ICU delirium. All valid theories.
The oncoming RN and I looked at each other and made drinky-drinky hand motions. You know, where you mime that you’re taking a drink from an imaginary beer bottle.
“But the chart says he never drinks” Argued the student nurse.
“If it looks like a duck…” I respond.
September 3rd, 2009 at 12:28
“But the chart says he never drinks.” HA HA HA HA HA!