Part of nursing is quiet. Part of the nurse's job is simply to be there, to be available to respond to patient needs and emergencies. During the quiet moments, the best nurses take the opportunity to sit, to observe and assess, to think and reflect.
As a young nurse starting out in a newborn intensive care unit (NICU), I disliked the quiet. I preferred the constant bustle of routine activities, believing the good nurse should always look busy and harried. The act of sitting made me very uncomfortable.
With experience, though, I came to learn the value of quiet moments. They allow me time to gain a truer sense about my tiny patients. I look for what they cannot tell me, watching them breathe and move, seeing their color and posture. I smell their dirty diapers and infected discharge. I feel their warmth, their strength and strain, I palpate, pat and caress. I hear their cries and grunts, their gurgling bowels, the rhythm of their heartbeats. When their parents visit, I listen to the joy and anxiety, the tension, the hopes and fears.
During the quiet times I get a taste of my patients' lives. It is an acquired taste.
One quiet morning I was there, in the NICU, taking care of a premature baby boy sleeping in an incubator. His name was Robert, and his twin brother lay in a separate incubator only a few feet away.
I looked over Robert and was pleased. Although born almost 2 1/2 months early and weighing a mere two pounds, he was now five days old and seemed to be doing well. His heart rate, respirations and temperature were stable. He required a little extra oxygen for comfort, but could breathe on his own without the aid of a respirator. He received intravenous fluids for nutrition, but plans were to test him soon on milk feedings. When I moved him to do my physical assessment and change his diaper, he awoke, and his opened eyes gazed all around in baby wonderment. When I finished my care, he fell back asleep, peaceful and still. For such a tiny infant, he seemed a routine case.
I was there later that morning when his mother visited. She stopped first at the other twin's bedside, then came over to Robert's. After greeting her, I gave her my update on his condition, expecting her to be happy. Instead, her brow furrowed.
"Could he be coming down with a staph infection?" she asked. Her question threw me, so I asked what made her concerned.
"He used to squirm all over his bed, even when sleeping. Now he's so still, he just lays there. That's what his brother did before he got sick and they started antibiotics."
I assured her that her twins were separate individuals with separate temperaments, and they would not always share the same problems. Still, I marked her words. I am there with a patient for only a shift at a time. I see at best a brief snippet of their lives, and rarely get the full view. Robert's mother had seen him every day and had a more complete picture.
Premature infants such as Robert have very immature immune systems and thus are susceptible to infections. However, their response to an infection can be very subtle. Older children and adults typically develop a fever, but preemies lack the metabolic reserves and neurologic control to maintain a fever. They may show other symptoms such as coolness, labored breathing, paleness or lethargy, but often the only early sign of trouble is a change in behavior. According to his mother, Robert's stillness showed a change in behavior.
Later, I was there as Robert had a couple of spells of apnea. These are episodes of slowed breathing that cause a drop in heart rate. Premature infants are prone to such spells because of their poorly developed respiratory drive and the energy these small, frail beings expend just to breathe. Still, for Robert these spells represented another change in behavior.
Growing concerned, I conferred with the attending doctor about Robert. We decided to send a blood count to screen for any problems. After the test showed an increased white cell count--an early sign of infection--we did a further work-up and started Robert on antibiotics.
When I saw him again days later, he was squirming all over his incubator in his sleep, just as his mother had described.
This is a simple story of the everyday nursing experience of being there. Consider, though, what happens when the nurse is not there.
With no nurse at the bedside, no one assesses Robert's change in behavior, and no one listens to his mother's concerns. No one recognizes or responds to his subtle changes. His symptoms progress and he becomes seriously ill.
Then, of course, many nurses come running to be there for the crisis, along with doctors and therapists and everyone else available. It becomes more difficult and expensive to help this baby.
As a new nurse, I found such crises very active and exciting. There was no time to reflect as frenzied people flashed about frantically in a fervent fight for life. But with more experience, I have come to see that some of these encounters are preventable, if someone can respond to the early signs.
In the present-day atmosphere of health cost restraints and hospital cutbacks, I often wonder if we know what we are doing. Hospitals have fewer nurses to be there, and those nurses have less time to think or reflect. The patient load is bigger, the patients sicker. When a patient deteriorates and requires emergency treatment, I often wonder, "What if someone had been there at the right time to catch the problems early?" Part of nursing is the art of what doesn't happen.
I was there with Robert once more, weeks later. The antibiotics had defeated his infection, allowing for a rapid recovery. He had overcome a few other minor setbacks to start growing and developing. He looked pink and active and happy. He smelled clean and fresh in his bassinet. His warm skin felt smooth and soft. His lungs and heart sounded strong. Now, he was ready to leave the hospital, earlier than expected.
His mother came in, accompanied by his grandmother. As the two women approached Robert's bedside to prepare to take him home, his mother smiled and introduced me. "Mom, this is Ray. He's the guy who was here that day, the nurse who listened to me when Robert was getting sick."
Raymond Bingham is a registered nurse and writer living in Gaithersburg.