Sarah Heming: Medical Improv
How do you provide care for someone without knowing what ails them? Typically, a patient’s diagnosis acts like a map. It gives you hints as to what interventions should be priorities and what could happen during an exacerbation. It also provides the entire basis for a focused assessment (a nurse’s first assessment of the affected body system). For example, if you have a patient with heart failure you will check for tissue swelling, listen for abnormal heart rhythms and fluid in the lungs, and administer diuretics to get rid of excess fluid. Since diagnosis plays a crucial role in outlining the care of each patient, I was exceptionally challenged one day this summer when I took care of a 13-year-old boy whose condition has no name. The only information I had when I stepped into the trailer was the brief report my preceptor had given me, on the car-ride to the patient’s home. Without a seed of exaggeration, she told me, “His lungs are the size of a cow’s.”
It was easy to see that these were kind people, a mother and three children, living in a trailer half the size of my home. In the living room, cardboard boxes towered to the ceiling. They made the area seem even smaller and darker than it already had. A wave of despondency swallowed me whole when I realized that these boxes were filled with medical equipment. It was like a library of ventilation materials, old medication containers, and latex gloves. From the living room, I walked along a narrow hallway to the patient’s room. I immediately noticed that the boy was cognitively aware, an avid conversationalist, and surprisingly optimistic for a teenager who was confined to a bed all day, every day. It dawned on me just what a vulnerable and dependent position he was in, at a time in life when most people are yearning so strongly for autonomy and freedom.
I recognize that it may not seem obvious why enlarged lungs mean that an otherwise healthy boy can’t even get out of bed to use the bathroom, so allow me to explain. The lungs and heart are inside of the body’s thoracic cavity. Inside of this cavity there’s enough room for the lungs to expand when breathing, but that is it. Lungs as large as this boy’s take up all of the space in the thoracic cavity, causing the lungs to push against the heart. This makes each beat a laborious endeavor, especially during inhalation. Anything that could cause the boy’s heart rate to increase is an extreme danger to him because his heart could likely not meet that level of bodily demand. Further, his heart was enlarged because the muscle was working so hard to beat against the resistance of his lungs. When the heart muscle becomes too big there is little room for the ventricles to fill with blood, and so the body receives less and less oxygenated blood as the condition worsens.
Having no previous experience with this type of condition, I entered his room unsure of what the visit had in store. I was hesitant at first, scared that any simple action could set off a horrific chain of events for the boy. I was slowly eased by his bubbly laugh and approachable demeanor. Once I had talked to him for a while and adjusted to his environment, I abandoned my doubts and focused all of my energies on giving this patient what he needed. Our assessment was primarily based on the cardiac and respiratory systems. We used a stethoscope to listen to the boy, checked his nail beds for blood return, assessed the pulses in his hands and feet, and then provided maintenance care. This included changing him, repositioning him, and administering his medications.
Providing care for this patient was uncharted territory. We were doing what RN Beth Boynton refers to as “medical improv”. This was a stark contrast for me, since most of what I have learned from my curriculum has essentially been a variety of protocols, all varying based on diagnosis. Despite the uncertainty and confusion that surrounded this patient’s condition, I knew that I had given him the best care that I possibly could. It was the type of care that I imagine my mother would want someone else to provide me with under those same circumstances. My preceptor and I had successfully developed and executed an original plan of care for this remarkable young man. At the end of that visit, I left the patient’s house elated. As we pulled out of the driveway, the radio poured gospel music into my ears and I thought to myself, “I’m so happy I could dance!”
That day was not only successful, but also personally rewarding for me. I have since come to think that this unique circumstance was a perfect example to embody the contrast between hospital-based and home-based nursing environments. This summer I was incredibly fortunate to experience a healthcare setting that was the polar opposite of what I have been exposed to so far in my career. One of the ways this manifested to me was through the rare art of “rolling with the punches.” Many people, myself included, tend to avoid unexpected or imperfect conditions because we are scared of having to improvise. When things don’t go as planned, I see red flags all over the place and bold text is written across all of them saying, “what if you fail?” It isn’t comfortable or easy to improvise, but it is a skill that I drastically improved at this summer since I quickly recognized that in home health adaptation is not only beneficial, it is necessary.
In most homes, there are no supply closets with walls of latex gloves, and there are never any computers with the patient’s comprehensive health history or Pyxis systems to dispense any possible medications. I have been pampered in my clinical environments to have consistent access to these types of resources. Most intimidating of all, in private residences there is no backup. You can’t ask another nurse to double check anything, a charge nurse isn’t readily available to answer your questions, and there’s no doctor stopping by to see how things are going. As the only caregivers in our patients’ homes, my preceptor and I were solely responsible for ensuring each clients well-being while we were with them. While this never caused any problems, it is an intimidating realization that if a patient’s condition worsens, there is no one to turn to for assistance other than the family. Outside of the worst case-scenario, it is not uncommon to walk into a patient’s home and find that they are out of a medication, have no more urinary catheters, and their equipment is malfunctioning. What is the best thing to do in these circumstances? I think it’s simply to meet the patient where they are, help them progress by providing the best quality of care possible, and continue to serve as an empathetic advocate for them.
Tammy Mcclellan (RN) explains the difference in environmental resources well in her article, “Improvising in Home Healthcare.” She says, “I can think of many humorous experiences I have had in my nursing career when either my patients or I had to improvise. I have seen everything from patients washing latex gloves and hanging them on the line for reuse to carrying multiple outlets in my car to plug in an electrocardiogram machine.” This level of adaptability is an integral part of Home-Health culture, that I previously hadn’t been able to fully appreciate. I am not saying that this is merely a string of actions specific to one nursing specialty, rather that it is a cultural manifestation of the skill, logic, and priorities of the nursing profession as a whole, with specific environmental context. Though these manifest differently in patient homes than they do in the hospital, the core values of dedicated nurses are uniform across each specialty. At the end of the day, a nurse’s job is to provide quality care, preserve patients’ quality of life, and advocate for patients’ rights above all else.
Sarah Heming is a Senior nursing student who is expected to graduate in May of 2022. She worked as a personal care aide (PCA) with Nightingale’s Nursing and Attendants, a prominent in-home care provider for the state of South Carolina, over the summers of 2019 and 2020. During the summer of 2021, Sarah worked as a PCA and an extern within Nightingales. After graduation, Sarah plans to move to the upstate and establish her nursing career in Greenville.