First Night in Charge
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15 First Night in Charge 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: night shift in Intensive Care. Mynursingprogramhadbeenarigorouscombinationofclinicalandacademic 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 thirty years of experience, and I had the support of the night supervisor who floated about from floor to floor, pushing the 3 a.m. snack cart, holder of the keys to the pharmacy and the morgue and 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. On my first night as charge nurse, I walked in to two fresh myocardial infarctions , an elderly post-op, and four ventilator patients, one of them a ten-year-old girl who had been hit by a car and was now 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 even more curious 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 Davis text.indb 15 11/12/08 10:00:28 AM 16  the heart’s truth 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 nasogastic 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 prepackaged and presoaped disposable cloths but with real soap and water. Each immobile patient was turned regularly, some every fifteen 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, to mend. 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 illness and grief, I trembled as the evening charge nurse gave me report. I wasn’t...