A Tale of Two Night Shifts

The time is 2:57 am

I am struggling to keep my eyes open in the darkened nurses station. My next medication round doesn’t start for close to an hour and I have completed my documentation. The feeling overcoming me is unsettling, there is seemingly nothing to do on my busy medical ward and that is always inviting trouble. Do not think the ‘Q word’, even thinking that it’s quiet is asking for it. I yawn and right on cue a patient’s son comes out of his room, his eyes filled with tears.

“Sister I think he’s gone,” he says.

I have been looking after his father, a palliative patient in his final hours since I began shift. I have written up several doses of dilaudid for him over the shift and moved him into a comfortable position. He has looked peaceful all shift, his son wiping at his mouth and whispering “come on Dad, you’re too stubborn – you can go. Mum’s waiting”. I relate, I tell him my Nanna was the same – held on right until we all went for cake, then she decided that there ain’t no party without her, and rightly so. He smiles and tells me his Dad is the same.

My night started at 10:45pm.

I go in to see my patient. He has no respiratory rate, his pupils do not react when I shine light into them, and there are no pulses. Despite all obvious evidence that he has died, I have to wait for the doctor to declare him. At this time of night that’s medical ward call, and I know he is slammed. He’s run past on his way to a code three times already. Three of the other nurses have pages into him for patient reviews. I know it may be some time. I leave his son to say goodbye, and page the doctor. He is gone, but I have seven other patients who are still here, and I have to keep looking after them.

I spike fluids, draw up antibiotics, turn bed bound patients, and have an interesting conversation with a very confused patient. An entire shift happens in the time it takes for medical ward call to come. A son grieves, and it isn’t until I handover that my patient leaves his room for the last time and the porters take him to the mortuary. His son gives me a long hug and whispers thank you.

 

It’s 12:10 am.

“Hello sister,” the nurse whispers. “How are you feeling? Are the walls melting?”

I laugh and tell him no, but that my pain has mercifully become a background noise instead of an unrelenting torrent of abuse to my lower abdomen. It’s freezing and he gets me another blanket and a heat pack, because there’s very little that a heat pack won’t make better. When my infusion finishes he removes the IV cannula smoothly so that it won’t leave the same bruise as the last time I ended up in emergency, where the resident practically ripped it out of my hand.

“Should I get the doctor? Do you want to go home and be a nurse again?”

“That would be nice,” I murmur, thinking about the shift I can no longer go to that starts in six hours.

His night started at 6:45pm.

He had many patients before me, and by the end of twelve hours he will have had many more after I am gone, but while I was there he looked after me the best he could – the way I would my patients. I started my night in triage, then fast track, sitting when all I wanted to do was lie down. The nurse that did my vitals in triage looked like she wanted to give me a hug when she found me curled over in my chair, pain 9/10 – because as a nurse I feel like there’s always room to grow. Then she told the triage nurse to re-think my category, because I needed to move up. Then there was the night nurse in fast track who I overheard tell the doctor, in no uncertain terms, that he was not to ultrasound me in this condition unless he actually suspected ovarian pathology – well,  I wanted to hug her. There was the doctor I was assigned – overrun with his own patients, as well as signing off on the work of his residents – who apologised every time he left me for more than five minutes, murmuring “sorry my dear” each time he sat back down, and wouldn’t accept my unrelenting pain as reality until he had done everything he could to stop it; even in the face of “normal” results.

I know they were tired, I know they were busy – because I am all of these things on night duty, and yet their care did not diminish. Their touch remained gentle, and their resolve remained strong.

In these dark hours we do some of our best, our most vital, and, yes, at times some of our saddest work. Night duty is an underrated shift, in my opinion. On nights I have had some of my worst moments – patient deaths, big codes, falls, body fluids all over my uniform, but I’ve had some of my best too. There is a special kind of camaraderie and friendship on nightshift – perhaps because management has gone and it’s just us floor nurses. We have strange conversations between pad changes, and sometimes even serious ones that wouldn’t have slipped out any other time. Those special, privileged moments where we bring in new life, save lives, or help someone come to the end of theirs with dignity and comfort all seem to happen so often in the midnight hour. The hospital changes. Sometimes, on meal break, I walk its quiet halls in a fatigued, slightly delirious stupor, enjoying the quiet and stillness – so different from the day time. Often it’s the only true quiet I find all shift.

It’s hard work, we are tired, and the problems are often big and emergent, but there is a poetry in it. For me nights have a rhythm and a flow, and it can change so quickly, but I think that’s what I love even more. Nights call for a type of bravery, for courage – sometimes you realise in any given situation that it’s just you and you alone must be enough. Resources are scarcer, hand holding is out of the question, and advocacy is perhaps your most important skill alongside a good chest compression.

It’s not often one sees their profession from the other side, but when I do I am reminded of just how important the small and everyday things we do as nurses are. I don’t keep track of how many times I touch a patent’s shoulder when I talk to them, or call a sweet elderly lady honey, or tell someone in pain how well they’re doing – but it matters. It matters when our colleagues in medicine do too – no matter how busy or burnt out, your small mannerisms loom large in the minds of patients. My surgeon likely barely notices when he tells us, “chin up, hey?” and holds our hand, in holding bay before we go in, but I know we as patients do. A patient often doesn’t see the bigger picture, they don’t see our patient load and politics, our policies and procedures, they see themselves – sick, scared or in a place they’ve never been, and so they need us. They need our little gestures, and our advocacy, and our care. We must not forget the privilege that is caring for people, even alongside its many challenges.

Goodnight patients, goodnight sisters, goodnight ward call, goodnight wardies and cleaners, goodnight day shift, and goodnight management. At dawn we return to our beds for much needed rest, we’ll see you again tonight.

 

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That’s How I Got To Memphis

Dear Grad Nurse….

 You possibly feel as though you know a great deal, but simultaneously nothing at all, at night, in a hospital, while you’re responsible for eight people. I know you’ve studied so hard that you’ve feared your head will actually combust, only to step onto a ward as a student – the anatomical landmarks of the kidney firm in your mind – only to find that you in fact know nothing about showering, or making beds the right way. You might feel both accomplished and useless at the same time. 

 That’s okay…I have too. 

 The graduate nurse role is such that one is constantly in a state of haze, wondering if one even knows what one is doing – hint, you do. This is the moment you’ve been training for, you’ve trained hard, and made it through years of soul crushing academia, plenty of practical experience, and a series of often deadening job interviews to get where you are, right now. You made it through having to narrate what you were doing every time you gave a panadol, and smiling and nodding when a patient asked if you had done this procedure before; you have arrived. Your first day without a preceptor feels like you’re a child left at home alone, as though someone is forgetting something very important – that you’re unsupervised and clearly shouldn’t be left alone with real patients. You’ll get over it, you’ll find that somehow, like muscle memory, you just fit. The feeling of being a child in a candy store will only increase when you realise you can go in the medication room unsupervised, make up the IV meds yourself, and, good grief, administer them to the patient without someone eyeballing your every move. You’ll feel like a real nurse when someone else, without thinking twice because there you are in that RN uniform, comes up to you and asks you to check their meds. At the end of the shift, when you write your note, you’ll feel a little heady and ridiculously happy when you sign them off and the signature line reads RN. It’s all you now baby.

Know this newbie, there will be a moment, a moment where you feel wise and sage, like you made it to the promised land. For me it came one late shift in my fifth month as a pool nurse. I was sent to cardiology for the shift, a third year student nurse following close behind. I was tired, it was my fifth shift that week and eight hours stood between me and four days off. Little did I know, that shift I would put on my grown up nurse pants and prove to myself that I was leaving grad behind, and that no matter what I had thought as a final year student – I was a damn good nurse. First, I had a patient outlied from the upper GI ward, one of my favourite surgical wards, she hadn’t eaten in days and the treating team had charted her for parenteral nutrition – food in a drip basically. The team leader came to me and said that she would try to get the TPN nurse in to help me, but that it was likely she had already gone home. I was confused, and asked her why I couldn’t do it. She looked suddenly overjoyed.

 “Oh, you’ve done TPN before? Sorry, I haven’t in years, we don’t usually have these patients here,” she said.

 “It’s fine,” I told her. “I’ve worked on the gastro wards where we do this all the time.” 

 When I went to the medication room to prepare the TPN, done by rolling a giant plastic bag filled with fluids until the inner chambers break and they all mix together, three of the cardiology nurses asked if they could watch. I laughed a little to myself, did they seriously want to watch the grad nurse break a bag? But I did it, I told them my secret that Donna on UGI  had taught me as a student to make sure the bag didn’t just explode, leaving hundreds of dollars worth of medications on oneself and the floor. It was all me.

 Later on when they analysed telemetry for the end of shift, I asked if I could watch, because there’s always something to learn in each specialty. 

 Later in the shift I received a train wreck of a patient from emergency, and the handover had failed to reveal the code criteria vital signs the patient had been sporting for the last hour. I told the team leader and said that I was calling a code, because our doctors were gone and medical ward call would be swamped. This would get everyone in a room and swift action would be taken. I didn’t want my patient sitting tight with a blood pressure of 240. My favourite med reg attended the code, I told him what was going on and that I thought she was fluid overloaded, he examined and agreed, telling me he would write me an order for a frusemide infusion. The team leader came over to me and smiled, raising her eyebrows knowingly.

“Grad nurse kills it again, God I love pool.”

 The med reg looked surprised and asked if I was really a grad. I said I really was. I had the moment, the one my nurse manager had promised I would have when I started. I hadn’t wanted to believe him, thinking it would take me years to feel as though I was in fact a valuable member of the team, an asset and not just a bandaid solution to save the shift from being short staffed. The moment happened though, sooner than I thought it would, and it felt good.

 Trust me when I tell you then, that there will be a day when you look behind you and realise that you made it. There is still a long way to go, such is the beauty of this profession, but you will come so far so quickly that it will be nearly incomprehensible how you have grown from student to practitioner, and even to teacher. Nothing demonstrates to you how much you know quite like having a student nurse ask you questions, because they don’t usually know just yet that half the time you have no idea either.

 It’s a privilege to do what we do, you will come to realise, poop and all. That pad change at 2am may kill you a little inside, but it means everything to the person you did it for – the person who is no longer lying in their own waste, the person who is now positioned comfortably on clean sheets. You know the feeling when you climb into bed after night shift, the bed yielding beneath you, hugging you, welcoming you? Your pad change and reposition just got someone closer to that feeling. For every seemingly small task, there will be bigger ones that you will face and being part of them is the honour of this job we call nursing. The night shift where you watch a palliative patient take their last breath; the code where you pound a chest because when someone’s time is up you want to be able to say you did everything you could to save them; the diagnosis you help a patient through after the doctor is long gone; the hand you hold of a terrified patient before the midazolam kicks in before theatre – these intimate moments are ones you will be thankful for being a part of, because you are good nurse. Whether grad or seasoned veteran, you have the power to change patients for the better, to be of comfort when there is fear, so never forget it. When things get tough and you doubt yourself, because you will – you will spend a lunch time crying in the bathroom at least once, this is what you must remember.

 You know more than you think, so long as you’re willing to learn. You’re stronger than you think, so long as you’re willing to listen to your patients and your team. You will keep getting better at your job, even if you feel like you’re getting nowhere – trust me on this. Nursing is s team sport, use your team, learn from them, and use them to help you do your job better, to better serve your patients. Find out which specialty makes you happy, and remember that it’s okay to completely hate some. It does not make you a bad nurse, it does not make you unappreciative of your work when an area isn’t your cup of tea. One can be so many different people in the world of nursing, there’s no reason you should have to love being all of them. You’ll find your tribe. 

 Today I am no longer a grad, but I am still learning and always will be. I am no longer a grad, but I still doubt myself sometimes, as do we all, and as will you. Today, new grad nurse, you are where I was and one day you will be where I am, just as I will be in the shoes of my senior colleagues. It’s a hellride and a joyride, so get in there and enjoy it. 

 That’s how I got here. 

 

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She Used To Be Mine

She is funny, because there is no other way, in her opinion, to face each day. She is shy, introversion has always been her default and she is perfectly comfortable to be lost in the world on the page rather than the world around her. She dreams big, ambitious dreams, years too soon, always planning what will be when she tires of what is now, imagining that one day her life will be a certain way – just the way she likes it. She is kind and a loyal friend, but stand between her and the chance of a top grade and you’d be better off dead. There is an unrelenting fire inside that pushes her to do more, be better, and not accept good enough from herself, sometimes too much. She is all of these things and more, she is young and probably pretty naive, but that’s okay because there is still time to learn all of the things that make us older and wiser.

She is gone, but she used to be mine.

I was fifteen years old when I started to feel the pain that I have come to recognise as my endometriosis pain, just beginning to figure out who the hell I was and wanted to be. I know that endo changed me, before I even knew I had it, because it was inevitable – it was always going to be that way. When my first thought about my pain was that it was normal, and not something I needed to worry about, it was inevitable that the experience would change me as a person. When I couldn’t cope with the pain, I blamed myself, told myself to be stronger, to suck it up. Doing that burdened parts of my mind that I hadn’t dealt with before. As I got older and I began to question the pain more, I started to listen to other people who told me it wasn’t as normal as I had convinced myself it was. Questioning became worry, and worry lead me to my specialist for the first time. Then I spent another year and a half, battling with myself, about whether I had endo or if it was just me as I had always thought.

Who at fifteen years old is equipped to deal with the burden of a crippling pain of unknown origins, hoping that it’s just your period, but deep down worrying that it is something more? After “she” got involved, and I began to deal with my pain and confusion in maladaptive ways, I knew it was time to grow up. The real world awaited, because I had just been thrust into it, big time. Of course I clung to the safety of fifteen and sixteen, a place where one was expected to think about growing up and the future, but it was more than permissible to be lost in the present, being a stereotype of the typical teenage archetype. I lost track of the amount of times I told myself, “it’s just period pain, suck it up”. There would be times where I was not convinced of this fact at all, where the pain became consuming and I thought – this isn’t the way it’s supposed to be. Just as quickly the pain was gone, and I would forget how awful it was, thus assuring myself it was okay. Other people seemed to agree – other girls in my class said they had pain too, I should just wait until sixteen came around, then I could go on the pill and everything would be better. When going on the pill didn’t make things that much better, I again assumed it was my coping skills that needed work. This is the way it was, until I had my first surgery and Graham Tronc told me once and for all, this is not in your head, this is not just period pain, this is endometriosis.

After I was diagnosed I began to think about fifteen year old me.

I still think about her now, what she would have become if she didn’t have endo, if she would have been almost the same, or fundamentally different. I like to think I still have her sense of humour, her loyalty to friends, and maybe even a bit of her “give me perfection or give me death” approach to academia. I have rediscovered her ambition, and I still plan things to take a break from reality, just like she did, but I am much happier in the present than she was. Sometimes I wish I could re-write parts of her story, to take away the pain she felt and the sadness it brought. When I think about this, I am reminded of a surprisingly sage quote from my boss after my first patient death. He said to me, “part of me wishes I could take this feeling from you, so you wouldn’t have to feel the angst, but another part of me doesn’t want to because I want you to learn from it”. Endo changed me, but I can’t say it never gave me anything I could use either.

It’s normal to grieve for the person or the life you had before endometriosis, especially if your endo journey has taken a lot of what you once had. Endo brings so many challenges – pain, fatigue, sickness, infertility, social isolation; but it can bring other things too. Take a moment to think of some of the things that endo has given you. They may not be obvious at first, but I’m sure amongst all the disappointments (and there are so many, I know), there are parts of you that are the way they are because of endo, for the better. When I see women with endo, I see strength, because how else would we have survived all of this? I see women who are strong enough not only to do battle with their illness every day, but to help others deal with theirs through education and awareness. I see women smart enough to cope with multidisciplinary issues, to keep track of multiple medications, appointments and treatments, all while dealing with exhaustion and fatigue. I see women who are tenacious enough to keep trying, even when they face barriers, to seek another opinion, try another treatment, or speak up when they were told to be quiet. By all means, take the time to grieve the woman that you used to be if you feel that she was lost along the way. Give her the respect she deserves, leave her in the life that was before, honour her. But do not forget to celebrate the woman that you became, because there are so many great things about her too, you just have to see it. I see it.

Endometriosis may have brought me pain I didn’t realise existed, confusion, loneliness, and, at times, the questioning of my sanity, but when I look within myself and the people around me, I see how much it gave me. It gave me a voice with which to advocate, to educate and to help, where before I was quiet and believed what I was told. It gave me strength, when I was sure that I had none, because I had no other choice; I realised all of the things I was capable of doing despite horrific pain. It gave me a purpose, where before I had a drive to care, and to help, the same drive that lead me to become a nurse; but now I have focus, I see clearly the people whom I want to make things better for, my endo sisters. Most importantly, endo gave me a second family, full of exceptional women who look to the skies with the same hopeful and determined ambition as me, where before I was satisfied with my own company and the conversation in my mind. The most important thing to learn from your experience with endo is that you are never alone, not really, because one in ten of us know exactly what it is to be thrust into a new life and a new world with no idea what to do next. We roam the world that is endometriosis like travellers in a foreign country without a map, but others help us to reach each place, even if they’ve only just figured it out themselves. We walk hand in hand, because we go far when we go together.

As for fifteen year old me, I hope she’s happy back there in 2010, before all of this, when her biggest problem was the B she got on a paper instead an A, or whether she would get the good biology teacher next year {don’t worry girl, you so did). I hope that if she knew who she would become, that she would be happy that she became me, despite the path she has to take to get here. It’s pretty okay here in 2018, enjoy the ride.

 

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