1. Pellico, Linda H. PhD, ACNS-BC


Where did she learn to diagnose by reading the air?


Article Content

Al is weak, frail, and most important, scared. At 55 years of age, after 34 years providing care, she finds herself in a major medical center- on her back, staring at ceiling tiles. The woman who's always had skin as pure as a china doll now ironically has a porcelain hip. She's just 36 hours out from a total hip replacement, and she knows something is wrong. She feels her heart pounding, she can hear the beating in her ears, feel the pulsing on her pillow. She rings the call bell to ask for the nurse to check her. An hour comes and goes, and no one comes to her room.

Figure. Illustration... - Click to enlarge in new windowFigure. Illustration by Annelisa Ochoa.

I'm sitting at home, nestled in my den for the night, when the phone rings. It's 9:15, and Al is on the line. "I'm scared. Something's wrong." I tell her I'm on my way and to ring her call bell again and ask the nurse to come take her vital signs.


The nurse, who is orienting, responds to the call. She says, "The doctor changed the vitals to once a shift, and they were already done today."


Al says weakly, "Even if my blood pressure has been in the eighties all day?"


Miss Orienting Nurse responds with a simple "yes" and leaves.


I arrive at Al's bedside and hear that vitals are now ordered by MDs. I tell her to hit the call bell again and ask for her vitals to be checked now. Al is a strong woman, but surgery has weakened her resolve. She needs to be buoyed over this wave of terror. She does as I ask.


This time when Miss Orienting Nurse walks into the room, she's cool and efficient, and clearly annoyed. Although she's far too professional to say anything, there's a chill in the air. She takes Al's pulse and declares that it's 122. She asks, "Are you angry?"


"Angry?" Al says. "Why no, I feel like I'm burning up."


The nurse is silent. Very professionally, she takes Al's temperature: 102.4.


I can tell that Al is somewhat pleased she's actually sick, so she can prove to this angry nurse that she's not "on the bell," "needy," or "special." Al knows her body. She knows fever. She has wiped countless sweaty brows, felt many times the weak rapid pulse of fever. She can put all the signs together-and in her case they say that she's in trouble and needs a nurse, a nurse who will assess her not because of a physician's orders but because it's what she was taught to do.


And I know she was taught to do it-because I taught Miss Orienting Nurse three years ago. I can see that she's done much over the past three years-but also that she's lost so much more.


I want to say to Miss Orienting Nurse, "How dare you? How dare you ask Al if she's angry?" I wonder whether she was always this detached. I feel responsible for not noticing it when she was in school, and honestly I'm embarrassed. More important, though, I've seen that she's not good for patients. Miss Orienting Nurse obviously prides herself on her ability to draw blood, give pills, and start an IV, but she didn't even check Al's wound. Or put ice on her incision. Or check her calves for tenderness. Or assess her skin turgor. And somehow, over the years, she's become a nurse who needs orders to check vital signs.


I ask for the resident to come assess Al. But he comes in and stares at the IV instead of Al. He announces to the room, "Post-op fevers in the first day are very common." No assessment, just a pronouncement, and he's out the door before any questions can be asked. I think to myself, My God we're failing patients on all fronts. I failed with my nursing student, and the medical school failed with this resident. Where did these two learn to walk into a room and diagnose by reading the air?


Finally, we call the attending, and Al receives a unit of blood and some saline. In a few days, she's discharged home.


That wasn't a good night. But my friend survived because we rallied around her and demanded care. Today her porcelain hip carries her about flawlessly, but I'm left thinking about those two providers. They're so young and new and yet so distant. Change will require work. Seeing themselves as their patients do will require reflection. Yet I fear they lack the honesty for self-appraisal. I fear we've already lost them.