Diaries Magazine

Clinical Days: A Short History

By Torontoemerg

Some random reflections on my clinical progress as a nursing student. 1990s.

First rotation: Medicine. A “heavy” floor. Mostly strokes, CHFers, Unstable Anginas. It was here I decided I did not want ever to work on a med-surg floor. The distress and despair among the nurses was palpable. Lots of encrusted, bitter old nurses, and equally nasty physicians engaged in a kind of ritual war of attrition; it reminded me of my parents’ soured marriage. Here I witnessed a physician publicly denounce a nurse* for holding an antibiotic causing an allergic reaction, her passive-aggressive response, and the utterly disheartening silence of her colleagues. And also: RN collecting a urine cultures by wringing out an adult brief; another RN packing a wound with her bare fingers; an RPN “punishing” a stroke patient by leaving him sitting in a stool-filled adult brief. His crime? Failing to use the call bell to call her for the bedpan. It’s a wonder I didn’t run away screaming.

Rotten unit filled with the worst representatives of the nursing profession. Happily is now closed.

Second rotation: Surgery. No specific memories, except for a shave prep of a vast inguinal hernia the size of a very large cantaloupe. Also the hallway was carpeted. On a surgical floor! Think various dripping body fluids. (When the carpet was finally taken up years later, it had to be treated as bio-hazardous waste.) Lots of suture and staple removal. Post-op baths. Sterile fields and aseptic technique.

Third rotation: Medicine. Here I got into trouble. I failed to document the necrosis on a right great toe. (No other nurse had either, though clearly it didn’t happen overnight.) Big fuss, got written up, warned and made to write a long essay to expiate my sins. Altogether a lot of to-do over what I would now consider a fairly minor documentation error. The reason for the fuss? The attending physician noticed the lack of documentation, and suitable scapegoat was needed. Actually some good lessons learned. One, take responsibility for your own documentation, and by extension your own practice, and never mind what everyone else is doing. Second, nurses eat their young if given the chance.

Fourth Rotation: Paediatrics. Superb instructor, but was known for failing one student every rotation. We all breathed again when the unlucky student departed the second week.

Fifth rotation: Psychiatry. Good instructor. I was told, rather disturbingly, I would make an excellent psych nurse. Long pointless conversations with non-disclosing schizophrenics and BDs. Otherwise, zzzzzzzzz. . . .

Sixth rotation: Surgery. Urology floor. TURPs, CBIs. Placed my first foley catheter and learned how to calculate true urine, a skill which in my ED career I have never actually used. This rotation was in the middle of some Harris government health care cuts. “Why would you ever want to be a nurse?” More than one staff member asked me. I was beginning to wonder.

Seventh Rotation: Surgery again, different floor. Rigid, unhappy nurses. The surgeons here deemed the nurses too stupid to find extremity pulses and decreed with the acquiescence of the manager  all pulses — even bounding radials! — had to be verified using a doppler. No one thought this demeaning. Nurses lived in fear of her, and the surgeons. Not a happy floor, and was very glad to finish.

Eighth rotation: Labour and Delivery/Post-partum. Great instructor. Lots of breast cupping, boggy fundi and lochia rubra. (Too much, if you ask me. Sorry, AtYourCervix.) Learned the archaic langauge of childbirth. GPA. Primip. EDC. Apgar. Presentation. Pre-eclampsia. Pit drips. The placenta freezer — the hospital sold them off to cosmetic companies. More than one mother utterly disgusted with the idea of breastfeeding, one of them telling me, “They’re for my husband.”  Helped to birth one baby.

Ninth Rotation: Medicine. Different hospital than the rest. Great instructor, tremendous advocate for nursing who taught me, I think, about the potentiality of nursing, not its limitations. Physicians were respectful, the nurses generally enormously competent and more importantly (for me) welcoming to students.

Pregrad, first half: Telemetry. Awful. My preceptor  had the blunted affect of a chronic oxycodone user. Flat, uninterested, incurious, dull. She later went into nursing informatics. She disliked me, and franklyI wasn’t much fond of her either. When I insisted on doing full assessments, including chest assessments, she told me it wasn’t necessary because “that’s what the doctors do.” Telemetry floor apparently only in name. The only time I ever was close to quitting. It was that bad.

Pregrad, second half: Emergency. Amazing preceptor. When I witnessed my first trauma, all the intense orchestrated confusion, I confessed to her I thought I would never learn how to do it. “Oh you will,” she said cheerfully. Also she taught me the trick of placing the body bag under the sheets for incoming VSAs.* Except for the time the patient arrived VSA but survived long enough to go to ICU — after we discreetly removed the body bag. I have never done it since.

So, a mixed bag, and for better or worse making me into the nurse I am today. I suppose I did learn something, if by osmotic process — the mechanics of nursing, anyway. How to give subcutaneous injections. How to change sheets with the patient still in them. How to make mitred corners while making beds. (A skill which never leaves you, and then finishing by tucking in the pillow cases just so, exposed edge facing away from the door.) One of the things that strikes me is that how much of my real clinical education was by reverse example , if only because the exemplars — the nurses on the units — were often so terrible. I learned how not to treat patients,  how not to eat our young, how not to pack a wound, how not to deal with physicians. To say the gap between gold-standard or even just normal good practice, and actual practice was significant and large would be an understatement.

Another thing: how few are the positive memories, how very scarce were the good instructors, how the two or three great ones shone. Education ought to be for challenge and growth — until the dead hand of educators comes along! Yet I can honestly say the two or three great teachers I had influenced my present practice in ways I can’t begin to express.

I’m curious: was everyone else’s clinical experience as ambivalent as mine?

__________

*It still amazes me, even now, to see physicians speak to nurses in ways they wouldn’t speak to their mothers, spouses, daughters, patients, the girl behind the Tim Horton’s counter, grocery store clerks, bank tellers. . .


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