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, working night shift in intensive care.

My nursing program had been a rigorous combination of clinical and academic 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 30 years of experience, and I had the support of the night supervisor who floated about from floor to floor, pushing the 3am snack cart, holder of the keys to the pharmacy and the morgue and, in general, 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.

My first night as charge nurse, I walked in to find two fresh myocardial infarctions, an elderly post-op, and four ventilator patients, one of them a 10-year-old girl who had been hit by a car and was dying.

Was I scared? I was terrified.

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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 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 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 nasogastric 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 pre-packaged and pre-soaped disposable cloths, but with real soap and water. Each immobile patient was turned regularly, some even every 15 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.

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.

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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 agony and grief, I trembled as the evening charge nurse gave me report. I wasn't at all sure I would survive. I wasn't sure that I could help these patients survive and, more than that, I was afraid I might harm them. I'd never felt more alone.

"Little Jenny over there in cubicle three was hit by a car while riding her bike today," the evening nurse told me. "She has massive internal and neurological injuries, her blood pressure is dropping, they've got her paralyzed on a vent, and we can't control her heart rate. The docs expect her to die within the hour, and her dad won't leave her side."

I looked over at cubicle three. A thin girl, dark haired, was barely visible in the bed. The respirator huffed beside her, and a spider web of tubes and catheters seem to hold her captive. Hovering over her was a man with tousled brown hair, glasses, and a baseball jacket. He looked as if he had run from his house without money or comb, without anything in the world but his daughter, who now was in what we rightly call the agony of death. The father held his daughter's hand, and I could hear him, his words muffled, as he pleaded with her to live. How could I, a new graduate – a well-trained one to be sure, but also one who didn't yet have the years of experience – handle all this?

The evening nurses and aides and ward clerk left, one by one, looking back over their shoulders at Jenny and her dad. As the automatic door whooshed closed, an eerie silence fell over the unit, interrupted only by the out-of-synch music of the respirators, each of them hissing their own tune, and the repeating voices of the seven monitors. The nurse's aide and I looked at each other.

"I'll do vital signs and make sure the IVs are OK," she said. She was probably just as frightened as I was, wondering if this new grad in her crisp white uniform was going to kill anyone that night.

I think maybe I did. I think I might have killed Jenny.

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After all these years, I can't remember the exact sequence of events. In the middle of the night, when memory plays its tricks and dredges up the worst scenarios, the most awful implications, I think that I went first to Jenny's bedside, before I checked any other patients. I introduced myself to her father. I remember tears in my eyes as I watched them, father and daughter. I recall reading the medication cardex, the order for the intravenous medication to be given if Jenny's pulse exceeded a certain rate. I remember her wildly racing heart, suddenly shooting up to well over 200 beats per minute, and I remember drawing up the medication and administering it. Then, shortly after this administration, I remember her dying.

It wasn't then, that night, that I wondered if I'd hastened Jenny's death. I didn't wonder this until years later, after I'd learned how human error and imperfect knowledge walk beside us nurses and doctors every minute of every shift. It wasn't until I'd had years of experience that I became familiar with how we caregivers can sometimes second-guess ourselves, especially when something suddenly goes wrong and we have to act instantly. That is when I thought of Jenny.

When I'm awake, feeling sure of myself and my skills, I recall a different memory. She didn't die within minutes of receiving the medication, but hours later. I remember that the night supervisor, a friendly, gray-haired woman, came to the unit to sit in the waiting room with Jenny's mother, who couldn't bear to be with her dying child. I remember Jenny's mother sobbing so violently she was retching, a grief sound I'll never forget.

I remember that after Jenny died, her father insisted on helping me prepare his daughter's body for the morgue. As I began to wash Jenny, and her father climbed into the bed and took the washcloth from my hands. I started to remove her IVs and her father stopped me. "I want to do everything," he said, his eyes dry and dark, his voice firm. I stood back and watched as Jenny's father gently removed the tubes, the catheters. I helped as he wrapped her body in the plastic morgue bag, and I handed him the tags to tie on her toe and on the outside of the at-last-zippered-shut black shroud.

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Did I kill Jenny? No, I tell myself. In my heart I know she was going to die, no matter what anyone did or didn't do. Instead I tell myself that I learned a lot that night. And one thing I learned was that sorrow comes when we least expect it, right in the middle of happiness. I learned most of all, perhaps, about grieving, about letting the survivors crawl into bed with their loved ones and take part, if that's what they need to do, or to let them, like Jenny's mother, get as far away as they can and not take part. I learned that we nurses, we caregivers, can be well trained and efficient, and yet there will always be times when we doubt our actions: Did I, who thought she'd done it all by graduation, give that medication too quickly, bringing Jenny's heart to a crashing halt? Did I give it too slowly, and so not bring her heart rate down in time?

The rest of that first night in charge is now mostly a blur. I know that the other patients lived through the night, and so did the nurse's aide and I. The post-op patient voided, coughed, and sat in a chair. The other ventilator patients were suctioned, turned, medicated, bathed, rubbed, and talked to. The fresh MIs had no arrhythmias and received their medications on time. No IVs infiltrated or went dry. As dawn came to the unit, the sun arriving as a pale yellow line beneath the closed window shades, I sat with one man and talked to him, balanced on the edge of his bed, about his family and his business. I watched as his heart rhythm slowed, steadied, helped by 15 minutes of casual and reassuring conversation.

I can't tell you how many times in the years since that night that I've looked up the medication I gave Jenny, its properties, its side effects, its benefits, and its dangers. I can't tell you how many times since then I've stopped myself before giving a medication or a treatment to check and make sure that what the doctor ordered was correct – doctors make mistakes too. I've learned that we caregivers are not infallible, but only as human and sometimes as frightened as our patients. We're rarely as "in charge" as we may want to believe.

That long-ago night made me a better nurse; it taught me the need for abiding caution mixed with confidence. Such caution has made me a safer nurse, especially today when everything has changed and everything has become more complex – how we do things, how we record things, how we interact with our patients and treat their diseases.

Still, I think about the small and mostly insignificant mistakes we make, because we are human, every day that we care for patients – all of us, from the most famous and proficient doctor to the least experienced nurse's aide. No matter the reality of what actually happens, we caregivers always carry, along with our many responsibilities, the heavy and inevitable burden of doubt.

If I've ever done anything wrong, I pray that my patients might forgive me. If there is nothing to forgive, then I wonder if I can ever stop believing that there might be, and forgive myself.

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