Back to Basics

Some nurses recently said to me that nursing has changed so much and we do so much more, that we might as well be doctors. The two nurses who said this to me were both nurse anesthetists. They then went on to say that there a so many unskilled jobs that anyone could do, and that nurses should not have to do. In particular, they were referring to jobs such as showering/bed sponging, feeding, and dressing wounds. I found this rather sad. It seems that the fundamentals of nursing are being forgotten.

Confused? Well I'm referring to the days when RN's took care of the whole patient. Meeting hygiene needs, dressing wounds, and feeding patients eg stroke patients are not for the unskilled.

To me this feels wrong? It's these tasks which keep us in touch with the patient. For example, when we wash a patient we assess so much. When we log roll them onto their side we check their pressure areas, feel their skin under our hands: Are they hot, dry, cold and clammy. When we move them do they cough, does their chest rattle. When we feed a stroke victim we assess their ability to swallow. This is rather important as aspirating food into the lungs is never good. When we dress a wound, we observe each day its progress, it's shape, size, colour, odor, discharge. Is it pale red or angry red? There is so much that an experienced nurse automatically assesses when they look after the basic needs of a patient and it is not for the unskilled.

I realize that we do so much more, in some cases diagnose, treat/prescribe, or maybe we're nurse anaesthetists, but I feel that the absolute basics should always be a part of nursing. I am happy to delegate some basic jobs, but it should never be delegated because we feel it is a simple unskilled job for the unskilled health worker.

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No Chance

"I'm always scratching my head. Do you think it could be dandruff?" asked Louise. At twelve years old Louise was the youngest girl in the school. The high school sometimes took students a year early, they were called pre-nine's, referring of course to the ninth grade. Until I met Louise, I had never figured out why the high school sometimes took children one year earlier than normal.

"Well, I'd better have a closer look, it could be something else" I said as I put on some latex gloves. "Why are you putting gloves on? What could it be?" Louise asked nervously. "It's nothing to worry about, but you might have nits?" I explained. "Yuk, that's disgusting. That's so gross" Louise then pretended to vomit. I then began to search through her hair. I didn't have to search very hard as the nits were so big and there were so many, I could see them without having to sift through her hair.

"Yep, you've got nits" I said, "I'll get some treatment from the pharmacy today. Who's you're room mate? I'll have to get her checked as well" Louise again pretended to vomit, a big smile one her face the whole time. "How did I get them? Can I share them with my friends?" She really didn't seem too upset about the whole deal. She almost seemed to be enjoying the attention. "You could have caught them by direct contact from someone who already has them. You can even get them from using someone else's brush, or from their clothing" I explained "So it's really important I see you room mate." Louise went to her dorm and returned with her room mate, Nicole.

Nicole did have nits, although not as bad as Louise. Nicole acted the same as Louise, by expressing her disgust at having "creatures" in her hair, but she had a smile on her face and seeming to enjoy the attention. "Come back at lunch time and I'll have some medicine for you both. Oh, and I"ll call you parents, just so they know what's going on." Nicole nodded her head while Louise reacted differently. "They don't need to know" she said "Don't bother calling them" she said. "Why not? They need to know what's going on. It's part of my job" I explained. "There's no need, they won't care anyway. They'll say it was my fault" Louise pleaded. "Well, let's get the treatment started and we'll talk about this later" I suggested. As for the parents, I sent an email to both sets. Nicole's parents wrote back thanking the health center for helping their child, while I heard nothing from Louise's.

Nicole and Louise both received the treatment and after ten days were nit free, or in Nicole's words "creature free." Each day both girls came in laughing and joking about the "creatures" in their hair. They didn't need to come every day, but they enjoyed being in the health center. Between myself and the other two nurses who worked here, the girls probably received more positive attention than they were used to. At least in Louise's case, it was most likely the most positive attention she had received.

Over the next month Louise was involved in some rather serious incidents, all involving alcohol and boys. In fact she was even hospitalized because she had drunk so much and her 'friends' couldn't wake her. I had to pick her up from the hospital and had to call the mother. "She couldn't have drunk much, she's such a small thing. One tequila would be enough to make her very ill" said Louise's mum over the phone. "Well, she drunk enough to be unconscious. Her friends said she had a lot more than one shot of tequila" I said. "That can't be right. She's so small, she'd only need a few shots to be in such a state. Someone must have spiked her drunk. Can you do some blood test to check for that? I insist you do some blood tests."

During the drive back to the school campus I informed Louise that I had spoken to her parents. "She doesn't care. Mum's an alcoholic anyway. I'm just following in her footsteps." It's hard to know what to believe when kids talk about their parents, plus this wasn't the time to have a serious talk with her about her problems. I'd leave that up to the counselors. "What about your dad? He must be pretty upset" Louise kept silent.

Louise eventually left the school and was sent home. As I stated earlier, it was for an ongoing serious of problems. But I found out something so shocking that it made me worry just what sort of home she was returning to. It goes like this:

Two weeks before school was to begin for the school year, Louise's father had phoned the school and asked if he could drop his daughter off early, one whole week early. It was then explained to him that this was not possible as there were no staff at the school. The father then asked exactly what date school started, and he was told September twelve.

On the night of September 11th, at 2355hrs, Louise's father dropped his daughter off outside a dorm, unloaded her bags and drove off. No one knew she was here, she was left alone in a foreign speaking country, in the middle of the night.

By pure chance two staff members were walking home from a night out and found Louise and took care of her.

I got to say goodbye to Louise. "I don't want to go" she said to me. "I'm sorry, but it's not up to me. But you can't go on breaking the rules and doing so many dangerous things?" She nodded her head. "But you guys in the health center are the only people who've ever been nice to me, who've ever cared"

Five minutes later the driver arrived and took Louise to the airport.

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I don't mean to sound cruel but...

"What are you boys' doing?" I asked the boys' in front of me. "Ah, nothing" there was a pause as they thought of a suitable answer. They were standing in the dorm foyer dressed in ski jacket and pants. "Ah... just going for a hike. That's all." They must think I'm stupid. "Don't lie. If you lie to me, I'll just have to report this to the Dean." I was referring to Jim, the school Dean of discipline. "Well, we were just going up for a quick look. The snow looks so good. We were going to be back before lunch" said Justin.

Normally I encourage the kids to ski, but school exams began tomorrow (Sunday) and the headmaster specifically said no one can ski. He didn't want to risk anyone getting injured, in particular a broken bone, just before they were to start exams.

"Well, guys, I'm sorry but you know the rules" I tried to be sympathetic to their cause, but then I had a sudden thought. "Hey Justin, you're only a beginner skier. What the hell do you think you're doing going up? Do you want to break a bone?" Justin didn't even look guilty "I'm a natural athlete. I skied ten times last season. I am in the advanced ski lessons now." As a ski instructor of ten years, I knew that this was utter rubbish, but Justin probably genuinely believes he is good. "Well, whatever, but you can't go up today, the headmaster specifically said so. Is that clear?" Everyone nodded their head and headed back upstairs to their room to get changed out of their ski clothes.

As the nurse on call it was turning out to be a quiet Saturday morning and I was relieved that I had stopped a potential disaster from happening. Every weekend someone broke a bone. Ninety percent of the breaks were from kids going too fast and jumping. At this school any kid who could make it down a intermediate ski run thought they were good and could be found in the jump park. Some were even good at jumping, but rubbish at skiing. With the snow dumping down outside, I settled myself by the fire with a good book, expecting a quiet day.

At two o'clock the nurse mobile phone rang. "Hello, nurse on call" I answered. "It is doctor Munroe. We have one of your students here" he said. "Ah, you do?" I sounded surprised. Kids were supposed to call the nurse first, and then we took them to the doctor. Kids are not to go directly to a doctor. "We have a skier who has broken his collar bone. Can you come and pick him up?" said doctor Munroe. "Ah, the kids aren't supposed to be skiing doc, what's the kid's name?" "Justin. Do you know him?" said Dr Munroe. "I know him very well. I'll come and pick him up" I offered. "You don't need to worry, he just left in a taxi. It looks like he's trying to avoid someone" he said.

Justin isn't the first kid to try and hide an injury by sneaking to the doctor or even the hospital without contacting the school nurse. There was even one girl who, with two friends, sneaked out of the dorm at midnight and took a taxi to the hospital down in the valley. We never found out until the hospital sent us the bill. No matter how hard the kids try, we always catch them.

At two thirty I received a phone call from Justin. A very sombre Justin was asking for stronger pain relief. "Come to the health center and I'll see what I have for you" I instructed him. Ten minutes later we met in the health center. I couldn't help myself from saying "I told you so." Justin was still defiant "I'm a good skier, a natural athlete. I'm good at all sport" he said. It amazed me how Justin could still say this while his face was contorted with pain. Perhaps it's just as well he is in pain, maybe he'll learn a lesson. But that's just cruel of me...isn't it?

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Choosing to be blind

Before I begin, no names or places are real, but the situation is. It happened a couple of years ago, and the only reason it came to memory was that I have recently been giving some talks to the kids of drugs. I've also been recently dealing with some rather difficult parents. If the parent concerned in my next story did ever identify themselves, then it will be a mixed blessing. On one hand, the parent may be angry at me, but on the other hand it may just open their eyes, and by doing so, may just save a life.

"Do you think I should say something?" I asked the Sarah. Sarah was one of the other nurses whom I worked with. She had twenty years nursing experience behind her, twelve of those spent in boarding schools. "I don't see why not. It is a health issue. A very serious health issue. It would be wrong if we didn't say something" she said. "Yeah, but am I the right person to say something. The kid's already in trouble with Jim (dean of discipline) and he has already talked to the boy's parents. And you heard what Jim said, dad doesn't believe his kids would do such a thing."

Sarah was shaking her head in frustration, not at me, but at the father who wouldn't listen to what the school had to say. "Well maybe someone else needs to say something. Maybe he needs to hear it from someone else. We have to try." With that said I made the call to Mr Smith, father of Ian Smith.

"I've already talked about this with Jim, and the matter is settled. I don't appreciate you calling accusing my son of taking drugs" said Mr Smith. "I'm not calling to accuse anyone. I'm calling because I'm worried about Ian..." Mr Smith interrupted me before I could say anymore "Listen, I trust my kids. I know they wouldn't do anything. You cannot prove anything. They are good kids..." I decided it was my turn to interrupt him "I know they're good kids..." He interrupted me again. "Don't patronize me. You don't know my kids. I know they're good kids. Leave my kids alone or I'll sue you for harassment." I decided to give it one more try "Ok, but will you listen to me this once. If you don't agree with me, or want to speak to me after I've said my piece, then we'll leave it at that and the matter will be dealt with by Jim (Dean of discipline)." Mr Smith grudgingly agreed to listen.

I then explained the situation from our point of view, which was as follows:
Ian was found in his bathroom, with two other boys. They had a plastic bag filled with a dozen small, opened tins of varnish. A teacher walked in and found Ian sitting on the toilet, staring at the wall in a semi-conscious state. When spoken to he didn't respond. He was completely uncommunicative. The teacher hurried to get another teacher to come and help, and when he returned, Ian was still sitting there staring at the wall, looking pale, sickly, and still uncommunicative. The teacher's helped walk Ian to his bed where they lay him down and called the nurse. By the time the nurse got there (approx 15 minutes later) Ian was talking and almost back to normal.

"You've got no evidence. There were other children there. Ian was in the wrong place at the wrong time. This isn't the first time you've singled out Ian. You're out to get him. You have not right to accuse him of anything. Stay away or else."

I thought it best to end the conversation. Maybe with time he'll calm down and see reason. I wasn't accusing Ian, although I felt I had a justifiable right to. It's not politically correct or legally wise to go accusing, even when things are so damn obvious. I do wonder if anything I said would have made any difference. Jim, the dean of discipline didn't fare any better. It would be great if Mr Smith is right, but why can't Mr Smith at least accept that there is a remote chance he could be wrong. It's his son's life he is dealing with.

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Parents, Priorities and Kids

"I expect her to get better now" said the man on the end of the phone. I almost thought I could hear a hint of menace in his voice. The voice belonged Mr Smith, a naturally worried parent living thousands of miles away somewhere in South America. His daughter, Jennifer, was a student at the boarding school where I was working. "Well, we're doing the best we can. She's seen the doctor and is on her second course of antibiotics, so she should be fine" I replied, trying hard to keep my voice calm and neutral. "That's not good enough" he said "I want a real doctor. She needs a specialist. I want her to see a specialist today. Or do I have to come over there myself" when he said this, there was no doubt about the menacing tone in his voice.

I've heard it all before. Caring parents thousands of miles away accusing me of not taking care of their son/daughter. I've learned to have as little contact with parents as possible, as no matter what I do it will never be good enough, but sometimes I feel the urge to bite back.

"You're welcome to come over. I'm sure Jennifer will love it" I replied. "Shall I tell her that you're coming over then?" I added. "That won't...ah be necessary" my reply had caught Mr Smith off guard. Of course he wouldn't come over. He's just like many of the parents I deal with, too busy looking after their business instead of their children. "I'm sure you'll do what is needed." With that the phone went dead.

The problem was that one week ago Jennifer was diagnosed with a bad throat infection, commonly called Strep Throat. She had become sick one monday evening, about nine o'clock, whereupon I was called to see her. Her throat did look bad. It was an angry red and had a couple of small yellow spots. Her temperature was high and she looked dry. She was given the usual pain relievers, was given fluids and I instructed the dorm staff on how to care for her.

The following morning she was taken to the doctor where a Strep Throat test was performed, and following the positive result, she was commenced on the appropriate antibiotics.

After two days of antibiotics and analgesia, Jennifer felt much improved. So much improved that she wanted to go to class, which we allowed her to do. I did explain to her that even though she felt better, she still needed to take her antibiotics. It was a wednesday morning and everyone felt confident that Jennifer's illness would soon be cured.

Later that same day, around sixish, I caught up with Jennifer in her dorm because she hadn't come in to take her breakfast or lunchtime dose of antibiotics. "I feel so much better" she said when I asked her why she hadn't taken them. "Well, if you don't finish them you could get a lot worse. Do you understand?" She nodded her head. I then gave her a dinner time dose plus another to take around 10pm when she went to bed, that way she would only have missed one dose for the day. "Can I trust you to take them, or do I have to come and give them to you?" I asked. Jennifer promised to take the antibiotic. "You also need to rest this weekend. No going out. I want you resting in the dorm, staying warm, dry, no restaurants, no alcohol, and no partying." Jennifer again promised to do as asked.

I never saw Jennifer the next day (friday) or saturday. I saw her 6pm sunday evening after a phone call from the dorm staff which went like this: "She looks terrible. She's lying there not moving, please come quick." I made my way pretty quickly to the dorm.

As I walked into Jennifer's room I was almost knocked over by the smell of rot and bacteria. Jennifer was lying on her bed, staring at the ceiling, her lips parched, her breathing rapid and shallow and her bed soaked through with sweat.

It turns out that on Friday afternoon Jennifer's auntie had come and taken her away for the weekend. In that time, Jennifer said she had nothing to eat or drink because her throat was too painful, and she never took her antibiotics. On the sunday morning the auntie had taken her to hospital. She was discharged several hours later after being given a further course of antibiotics. The auntie never contacted any of us nursing staff or anyone else at the school. The auntie just dropped her off niece and left.

"Why was she so dehydrated? How could you let her get like that?" Mr Smith said accusingly. The phone conversation wasn't going well again. "Ah, Jennifer was under the care of her auntie. Jennifer never even told us she was going away. How can we look after someone when they are not here? Also, Jennifer insists she never had any food or fluids, and her friend who was with her confirms this. I don't want to blame anyone, but this is how she presented to us" As I said this I felt my ire rising. "You're calling my sister a liar?" Mr Smith fumed. "Ah, all I'm saying is she was away, when she was not supposed to be, and when she came back she was in this state. She came back at six pm, I was called at 1805hrs, and was with her by 1815hrs. We have done all we could for her, when she has been with us" I barely kept my voice calm. "Well your best is obviously not good enough" said Mr Smith. "Well, you did say you would come out here if you weren't happy with our care. Perhaps it would be best if you did, that way you can be assured your daughter is getting proper care." There was a brief pause on the line "Well, she's getting the care she needs now. So let's just leave it at that. I want a update every day on her progress. I want her to see the doctor every day and I want you to make sure she takes her antibiotics." I never got a chance to say goodbye as the phone went dead.

It is parents like Mr Smith that make me have as little contact with them as possible. Nothing we do is good enough. They rant and rave about specialists and threats of coming out here to deal with the matter personally, but generally they don't. Generally their board meeting is too important, or they send the family secretary out as they can't make some time for their own children.

Not all parents are like this, but many of these wealthy ones are. They have the money, the small or big fortune, but they don't have their priorities right. Their priorities are their business and making more money. It's a different sort of wealth from the one I'm used to.

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I'm not perfect. I'm far too human.

"I'm sorry" said the young man lying in front of me. "So you should be" I said and turned and walked away. The relatives of the man gave me hostile looks, but kept quiet. They may lay a complaint later, but I doubt it. Their son, brother, cousin, nephew, has caused enough grief already.

You're not going to like me for saying this. In fact it's the opposite of how nurses should be, but I can't be nice to that patient. I'm struggling to be civil, and for the most part, am managing it. How unprofessional of me, but he just killed his best friend. Fortunately the passengers of the car they crashed into survived.

He's not even a teenager anymore, so he can't use that as an excuse. He's twenty one and knows that drinking and driving kills. The guys weren't just a little drunk, they were roaringly drunk when they got into the car. His friend wasn't even wearing a seatbelt, but he, the driver, was. But it could just as easily have been the other way around, with the friend in the driver's seat and wearing the seatbelt.

My colleagues are treating him so gently, but I can't be gentle. My mum and dad were on the same stretch of road of the fatal crash only twenty minutes earlier. I keep thinking how easily it could have been them that they crashed into. The more I think the more angry it is making me, but I'll do my job, and give him the best medical care we can offer. Well, the best physical medical care, I'm not in the mood for the touchy feely stuff.

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The Sex Talk

"Hey, don't worry man. This is Switzerland" said Jason. I just hoped Jason was trying to be the 'Big man' in front of his friends and wasn't serious. I was having a discussion with a group of twelve 16-18yr old boys about sexually transmitted diseases. "What exactly do you mean by 'Hey, it's Switzerland?" I asked Jason. "You know, we're in the mountains man. It's not like a big city. No diseases here man." I stared hard at Jason for a moment. He sunk into his chair, a guilty smile on his face. "You really don't mean that do you?" I asked. "C'mon man, it's safe here. I'll be fine." I soon formed a plan on how to tackle this new found ignorance.

"Just for the record, this small village, used to be one of the biggest party places in Switzerland. It was also a hot-spot for intravenous drug users" I said. There was a chorus of protests at that statement. "You're bullshitting us. You're just trying to scare us...aren't you?" said Jason. I shrugged my shoulders, "Believe what you want. You seem to know this village better than me."

My plan wasn't to scare them, but to open their eyes, so I brought out my secret weapon. It was a chart that a teacher at another school had put together. This chart was a visual demonstration of all the students at a particular school of who had slept with whom. It linked all the people together ie If student A slept with student B, and student B had slept with student C, then in effect student A has slept with student C. The graph pretty quickly got way out of hand and in no time at all, every single sexually active kid was connected in some way to every other sexually active kid at the school.

The kids were horrified. If it wasn't such a serious subject, it would almost have been humorous to see the stunned expressions. I than made the matter even worse by suggesting that if student A visits another school for whatever reason, eg a sporting event, then student A is now connected with a whole new chart of every sexually active person from that other school. There were more gasps of horror. Even Jason was speechless.

Within one hour of that class, the health center was inundated with students requesting a STD check. It wasn't just from kids who had attended my little presentation. Word had spread throughout the school and everyone was worried. There was even a couple that were not sexually active, but just wanted a check, just to be sure. I did explain to this couple that they don't need to be tested, if they are not and never have been sexually active.

I never expected my talk to be so effective. Kids these days seem to think they know it all, but now I realize that I'm probably guilty of thinking they know it all. If I'm asked to have another talk with the kids, I suppose I could share with them some stories from my days working in a London walk in STD clinic. I can picture the kids faces now, and I can't help myself from smiling.

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