In this chapter, we return to one of my themes—that we can understand more about handling stress in a hospital by looking at how stress is handled in other situations, including mountain climbing and firefighting.
Although I’ve forgotten the specifics, the scene is one of my favorites. Long ago—probably in Africa—a patch of newly exposed clay is rendered soft by a rain that fell in the night and has not yet been baked hard by the mid-day sun. Perhaps it was 100,000 years ago, perhaps more. That mud, baked rock-like, remains to this day.
In that drying mud we see three sets of footprints of differing sizes. The largest are almost certainly that of a man and the smaller of a woman. Between them are the tiny footprints of a child. Think of a father and mother, with the child walking between them and holding on to a hand of each. The child, who in my retelling is a little girl, senses the danger her parents feel and grips all the more tightly.
In my imagination, I see that long-ago family traveling a bit further and crossing a meadow with grass so high that it reaches to the woman’s shoulders. Suddenly out of the grass perhaps 20 yards in front of them, an adult male lion rears up. It’s hungry and sees them as prey. Their only chance is a tall tree over a hundred yards away through a dense thicket of briers and brambles.
What happens next matters immensely because I believe represents the essence of what it means to be truly human. What those two parents do is what we as humans should do.
We notice the mother first. Without hesitation, she grabs up her daughter and plunges headlong into those briers and brambles, shielding the child as best she can and heedless of the thorns ripping her skin.
We turn our attention to the father. He’s not moved an inch. He stands all the taller, communicating to that lion, “Before you get to my family, you must deal with me.” Perhaps by sheer force of will he can intimidate that lion into moving away—perhaps not. To prepare for the latter, he raises high his stone-tipped club and focuses on the danger he faces. If the lion attacks, he has but one hope. He must bring that club down with every ounce of his strength and with perfect timing and placement. The tip of the stone must come down in the center of the lion’s forehead in a killing blow. No other strike will succeed.
That long-ago scene fades away. The point I wanted to make has been made. It has revealed two of the traits that define our humanity. They are loyalty, which we might also call love, and focus.
The father and mother demonstrate loyalty to one another and to the child they love. The mother knows the father will stand and fight the lion even at the cost of his life. The father knows the mother will do her best to get their child to safety. Even the child, young as she is, knows she can depend on them. That’s why she gripped their hands so tightly.
At this point, we shouldn’t become shrill or ideological. It’s pointless to claim that the father or the mother is braver. The mother risks her life fleeing with her daughter rather than without. The father risks his life by standing up to the lion. The difference does not lie in their bravery, but how they demonstrate love. Each does what he or she can do best. The stronger fights the lion, the other tends the child. That may be why under stress men tend toward a fight-or-flight response, while women lean toward tend-or-befriend.
The other trait you see is focus. In the presence of so much danger, both the mother and father must focus on what matters and ignore all else. The mother must run with every ounce of her strength and ignore the thorns ripping at her skin. The father must set aside any fear he feels, project more confidence than he possesses, and stand fast when the lion attacks. Flight at that point would be folly. His only hope rests in well-struck blow. On that he must focus his all.
That story matters today because it illustrates the deeply held attitudes that people often display in a crisis. And yes, I am aware that not everyone responds that way. Some are cowards and blame-shifters. I write about them here too.
An experience I had while mountain climbing illustrates those same attitudes in a modern context. If you’re ever in Seattle, look west across Puget Sound toward the Olympic mountains. The largest mountain you see is Mount Constance, rising almost 7,800 feet above the water. Starting at a low elevation, it takes a many hours to summit and return. In the case of myself and my climbing partner that was about 16 hours on the move without a break. That came on top of having almost no sleep the night before.
We took one of the standard routes. On the mountain’s upper slopes we came to snowfield called the Terrible Traverse. That’s it pictured at the start of this chapter. Notice the two tiny climbers. Scary isn’t it? Mountain climbing can be like that.
Why is the crossing so terrible? Because many snow fields on mountains are gentle. They level out at the bottom, so those who slide down come to a gradual stop. This one is a killer. It’s not only steep, it ends in giant boulders. A climber who slips may be killed outright or die before help arrives. In the picture, those boulders are hidden by a part of the mountain in the foreground.
We reached the Terrible Traverse in early afternoon. We roped up and began putting on our crampons. That’s a steel frame with sharp spikes that clamps to shoes and is used for climbing on snow and ice.
The guy I was with finished first and started across. He’d only taken a single step when I heard a yell and saw him began to plummet down that steep slope. In a little over two seconds, the 50-foot rope that linked us together would snap taunt. A series of pictures flashed though my mind too quickly for words.
First, I saw myself on that bare rock with no hand holds to grab. When that rope ran out, I saw myself snatched away, sending both of us to our deaths.
Second came an answer. I saw myself grabbing the remaining rope still coiled on the rock and exerting as much drag on it with my hands as possible. That might save our lives.
Third, came a disturbing picture. It showed what might happen as that rope burned through my hands. I saw them ripped apart, with bones and muscles exposed. I grabbed anyway.
Whether my hands offered enough resistance or not, I’ll never know, but the rope snapped taunt, and I remained on the rock. My friend twisted around and slammed into the rocks on the side of the snowfield, but was otherwise unhurt. I looked down at my hands and was surprised to see them merely reddened from friction.
Our lesson learned, we abandoned the Terrible Traverse, climbed down the rocks on one side, crossed at the bottom, and climbed back up to the route on the other side. We reached the summit and returned by a different route.
You see in my climbing incident precisely the same traits as in that long-ago tale. Both loyalty and focus were present. Displaying loyalty, I didn’t release that rope, which I could have done in a split-second, even though I might have been snatched to my death. Displaying focus I was willing to see my hands ripped apart.
Traits like those are not just for life-threatening situations. They appear in stressful situations in a hospital as easily as on a mountainside. But they come with a downside. In some situations, that instinctive stress on loyalty and focus can keep us from thinking clearly or seeing all we should see.
No, I’m not arguing that loyalty and focus meant I decided badly in the crises I faced at the hospital. I believe I did well. No child died because of a mistake I made, nor did any child suffered harmful consequences from a bad choice I made. I also did not betray the nurses I was working with even under pressure. I did what really mattered.
On Hem-Onc, I was right to give those children my first loyalty and to avoid, as much as possible, the growing clash between nurses. Those ill-tempered day nurses could have crippled my ability to care for kids.
Perhaps I was also right, given what little I knew, not to raise a fuss about training. That I will never know. There were too many unknowns in how the administration might respond, particularly given that what I’d be saying was an implicit criticism of their decisions. Again, I couldn’t put at risk my ability to care for those children.
No, as I look back, what frustrates me aren’t the choices I made. Given what I knew at the time, I did the best I could. The problem rests how my loyalty and focus limited my ability to imagine other solutions that might have reconciled the conflicts I felt. Perhaps the choices I felt were necessary really weren’t.
Recall those illustrations and you’ll see what I mean. The long-ago father had only two choices. He could stand up to the lion or he could run away. Loyalty meant he stayed. Focus gave him the best chance of coming out alive. That was good.
In my climbing experience, there were again two options. I could disconnect the rope that joined me to my friend, or I could do my best to arrest his plunge downward. Those were the only solutions. Again, loyalty and focus drove my actions and were necessary. I couldn’t waste time looking for other alternatives because there were none.
In the hospital, although my life was never in danger, the lives of the children I was caring for were. The choices I made mattered for them. That created stresses not that different from those in a wilderness.
Look at the choices I faced. Should I focus on children or on training policies? I was responsible for those children and owed them my loyalty. I wasn’t responsible for training. But notice how complex my choices were. This wasn’t run or stand. This was taking a stand in two areas that seemed to conflict.
Again, should my focus lie with my young patients or with those much put-upon nurses? Again, I chose the children. The dangers they faced were far greater. But might I have been able to help both?
Later, I saw that I had other options. I did not have to take on those day nurses and risk the ire of the day nurses and head nurse. I could suggest to the night nurses that they complain as a group to the head of nursing. That would not have involved me directly.
Central line training had an equally imaginative solution, although it only came as I wrote this book. I knew that approaching the head nurse was futile, while approaching the nursing administration was risky. But there was someone who not only had a strong interest in seeing that central lines were safe, he had the authority to say, “This will be taught.” That was the line’s inventor, one of our most respected physicians. My working in Hem-Onc was enough to get his attention. Why didn’t I think of that?
Remember when I told you that engineer’s adage, “When you’re up to your neck in alligators, it’s hard to remember that your original goal was to drain the swamp.” What I’ve described here is like that, but rather than forget our goals under pressure, we lose our ability to come up with solutions. That’s why, when we recall the problem later, we often ask ourselves, “Why didn’t I think of that?” During my time at the hospital, there were dozens of situations I faced caring for patients whose solution only came later. That’s frustrating.
Under stress, our minds may become less imaginative because in many dangerous situations having to debate and choose can be deadly. Remember what I said about the Incident Command System and the importance of someone making decisions quickly? Within our minds is an ICS. It knows that an obvious decision made quickly may be better than a less obvious one made too late.
Yes, most of those hospital situations did not require the split-second response times. But the solutions also demanded far more complicated responses. That made them harder. Here’s an example where only seeming luck saved me.
One night we were finishing up chemotherapy on a two-year-old girl—the Wendy of My Nights. We hadn’t been able to give her chemotherapy in the alloted 24-hours, so the resident ordered a two-hour extension. That often happened. Then he and the nurse left and the girl’s mother took a coffee break. I was left holding a little girl who was oblivious to all that was happening.
Within seconds, a nagging thought came. On an earlier visit, Wendy screamed when anyone but her mother approached. Now she was unaware that her mother had left and I was holding her. “Not good,” I thought, “something is wrong.” I hit the call light. The nurse, knowing it was me, would come quickly. Then I realized I faced a complication. Other that my gut-level feeling about Wendy, I could give no reason for ending her chemotherapy. What was I going to say to persuade the nurse and resident?
A few seconds later one of Wendy’s feet twitched. I knew what that meant. I had her on her side in bed and was gently restraining her when a grand mal seizure hit. From then, no further explanations were needed. Her chemotherapy was stopped, and shortly after she was transferred to the ICU.
But notice the complications I faced. This wasn’t me reacting to a hungry lion or a falling climber. I could not act alone. I needed reasons to persuade others. That made the situation more complicated. But for that fortuitous seizure, I don’t know what I would have done.
That’s a major problem. Stresses in a hospital can make it harder for us to think clearly and creatively precisely when we most need to do so. That can be frustrating. What’s are the answers?
Training is a common answer. Those whose work is dangerous, train constantly. That’s why on the teen unit, I knew how to handle that girl’s air embolism and why the nurse didn’t. In an emergency, hesitation can be fatal. You need to be taught what to do. Emergency workers often refer to situations where “their training kicked in.”
Even when training fails, it can provide the confidence to look find an answer. When you’ve trained well, the presence of an unexpected situation is less likely to cause you to freeze up. Before my Mount Constance climb, I’d practiced arrests on glaciers, where the proper respond to a partner slipping was to go into an arrest position, lying face down in the snow and holding tightly to an ice ax thrust deeply into the glacier. I couldn’t do that on bare rock, but my mind remained calm and found an alternative. Even where training doesn’t have a programed answer, it can give you enough confidence to find one.
When a problem is outside the scope of any training, broader knowledge can make a critical difference. The account of “Oblivious Brian” in My Nights is an example. At that time, no amount of training could prepare me for dealing with his situation and yet I did.
About two a.m., as Brian was finishing up his initial chemotherapy, I became worried. He’d been admitted with a platelet count lower than most newly diagnosed leukemia patients. That led to a nose bleed that the usual remedies did not fix, so a resident was packing the boy’s nose with gauze. As he did, a nagging question popped into my mind. “This has to be painful,” I thought, “and yet he’s showing no reaction.” He seemed oblivious to everything around him.
I began to search through all I knew. Low platelets wouldn’t cause that oblivion nor would our chemotherapy on its own. There had to be something wrong connected to his treatment. But what was it?
I knew the resident had ordered a CBC, a complete blood count, to monitor the boy’s platelets. Because leukemia is a cancer of the blood, I also knew that one more test, a blood chemistry, would provide a good look at Brian’s total situation. Perhaps the answer lay there.
I intercepted the resident as he was about to leave and suggested that, since the boy hand been vomiting due to his chemotherapy, it might be a good idea to run a blood chemistry. Yes, I knew that was bosh, that his vomiting wasn’t enough for that. But I felt that Brian’s problem might show up in his blood chemistry and any reason, however dubious, that would give the resident a reason order the test was worth mentioning. He agreed and added an order for a blood chemistry, which we sent to the lab.
Just after I left work, that lab result came back with all alarms ringing. Brian’s blood chemistry was so far off, he was rushed to the ICU. Fortunately, his problem was caught early enough that he was back on Hem-Onc that evening.
That was early Monday morning. At report on Thursday, the evening nurse had news. The reason for Brian’s emergency had been discovered and the national treatment protocol altered to prevent it from happening again. He had what is called tumor lysis syndrome.
In a rough and ready sense, I’d come up with the answer to a problem who existence wasn’t even known at the time even by experts in the field. And no, I hadn’t found the cause of Brian’s troubles. Remember my limited training. I didn’t even know what the normal values for a blood chemistry are But I had patched together enough from my experience and knowledge to start a process going that did find answers. In short, you don’t have to know everything to know enough to act.
But every answer I’ve given thus far faces a serious problem. All hinge on the training and experience an individual nurse has had. Training requires being trained, as does the confidence to extend existing training into new areas. In much the same fashion, my response to Brian’s condition was dependent on my having spent perhaps two-thousand hours caring for children being treating for leukemia. I knew instinctively that something had gone wrong with him. If I had been recently hired, I would not have known that.
That’s why, when training and experience come up short, there is another answer. I’m sure you’ve guessed what that is. It’s the opportunity to consult with someone who may not only better trained and more experienced and is also removed from those stresses. Such a person has a broader perspective and often see answers that those closer to a problem may not be able to see.
Physicians already have such a person. It’s common practice in medicine to call in another physician when the patient is a member of their own family. Why? Because the profession know from bitter experience that, when physician’s own child is involved, his judgment can be seriously flawed. A physician’s much-loved daughter may be showing signs of leukemia. Yet, blinded by love, he may to fail to see that. They need another doctor to see what they may not be able to see.
Nurses are no different. They can grow so attached to their patients, that a blindness creeps. As you might guess, the answer lies the nursing equivalent of a physician calling on a colleague for assistance. It is the senior nurse mentor we’ve been discussing.