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Swimming in fear
Not…enough…air. I felt it, like an electric current going from the tips of my fingers all the way to my toes, as my legs kicked, my arms moved in concert. Thank God I was wearing flippers—no way I would have made it otherwise. Got to the wall, stuck my head above water, breathed in, desperate, panicked. I was swimming laps at the pool at my gym, but it felt like I was going to die.
Breathlessness. The first time I witnessed it I was a nursing student. My patient’s breathing rate was severely suppressed, a side effect of the opioids she was getting for pain. Some narcan—the reversal agent for narcotic pain meds—brought her out of respiratory depression, but even fully conscious her O2 sats were dangerously low. Her primary nurse called a code and they intubated her at the bedside. The thing I remember most, before they sedated her in order to stick the tube down her throat, was the look of terror on her face. Help me, her eyes said, I can’t get enough air.
I recently turned 47, and looking toward that birthday decided to do something that would provide a mental breather from work while solidifying my commitment to regular exercise. I signed up for individual swimming lessons with a coach at my gym. The lessons were cheaper than I expected, and I told myself I would save money on healthcare in the future because I’d be making myself more fit.
Once I started, the lessons turned out to be anything but easy—or mentally freeing. It wasn’t the physical work of the lessons—improving my freestyle stroke, mastering flip turns—but what the lessons brought up for me emotionally. The overwhelming feeling I took away from swimming was fear.
The fear started when Jordan, my coach, had me do a drill called “The Ladder.” In the ladder you swim double the length of the pool, allowing yourself first five breaths, then four, then three, two, one and none. It’s great for expanding breathing capacity and promoting efficient gas exchange, but the feeling it created of being desperate for air triggered a primal fear that lingered in my mind, sometimes for days.
Because they made me scared, the lessons started to seem like an odd choice of gift for myself. Pulling into the gym parking lot one day I wondered why I continued if they frightened me so. Eventually I understood: The fear was part of the point because I was really experiencing two interconnected fears. My fear of not getting enough air was instinctive and came from some primitive part of my brain that panicked when it sensed that the level of oxygen in my blood was too low. The companion to that fear was much more abstract. I worried about underperforming, of somehow failing at swim lessons. No matter how hard I tried, I feared I would never quite measure up.
I wish I could blame that particular reaction on a tyrannical coach, but Jordan is a spiky-haired exuberant African-American in his early 20s who has talked me through flip turns and my fledgling attempts at butterfly just by flashing his winning smile and saying, “You can do this.” His manner is upbeat, positive, never domineering.
So if Jordan wasn’t making me afraid in the water, the person responsible had to be…me. I was a middle-aged woman trying to get better at swimming and feeling like a failure because I didn’t have the Olympic stamina and flawless technique of Michael Phelps. That is, I was pressuring myself to exhibit the highest possible level of skill in an impossibly short period of time. Hard as that feeling is, and ridiculous as it is, I realized it’s very familiar because it’s how I often feel when I’m working as a nurse.
The crushing professional expectations begin when we’re nursing students. Too often, clinical instruction takes the form of scolding. The regular staff nurses can be quite mean to students—probably because that’s how they were treated—and patients can also be unwelcoming. Exactly what we’re supposed to accomplish in clinical isn’t always clear, and we’re admonished to keep busy even though a lot of standing around is inevitable when one instructor supervises four to six students.
It can be a hard introduction, and the stresses only increase once students graduate and start jobs. On a hospital floor, instead of having time to burn, there’s never enough time to get the work done. What we need to accomplish on any given day pretty much always feels unachievable. Some nurses will be mean, and some doctors will bully nurses. Hospitals tend to be chaotic, so something as simple as tracking down the right phone number can become a frustrating, time-devouring ordeal.
But the most affecting difference between being a student nurse and a working clinical nurse is that once a nurse is on the floor, his patients are his responsibility. There’s no longer a preceptor to turn to for help, and this is where the most potent fear on the job arises. Difficult clinical situations pose troubling puzzles to new nurses. Is a patient in excruciating pain because the chest tube she just had inserted is misplaced? Does a sudden increase in confusion mean a brain bleed? What do you do when a newly admitted patient goes to the bathroom and afterward calls you in because the toilet is full of blood?
These are all situations I’ve encountered, and having been through them once I’ll be less startled, and yes, less frightened, the next time. Other unforeseen situations will come my way, though. Maybe after a decade of nursing I will honestly be able to say I’ve seen it all, but I doubt it. The human body can be infinitely surprising, and the technologies and drugs we use keep increasing in complexity and potential severity of effect.
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Because of the challenges I’ve faced on the job, I’m aware of just how bad things can get in the hospital, and resilient enough to be able to act when the worst happens. Nurses are at the patient’s bedside to take action if something goes very wrong very quickly. But that need for an immediate and correct response also creates fear. Will I know how to react? What if I make a mistake and hurt a patient by doing either too much or too little? Seeing a patient sitting in bed, eyes wide, neck muscles standing out like gills while they struggle to breathe, we all want to do the right thing. The messages of inadequacy that begin in nursing school give us even less confidence about the clinical choices we make.
As a new nurse I had a patient bleed out and die in seconds in front of my eyes and I reacted in all the right ways: I called the code, did CPR. This sudden and unexpected death (the patient was set to be discharged later that day) generated the same kind of physical fear that breathlessness can, but also left me worried that I had screwed up. Could I have somehow prevented her death? The thought haunted me for months afterwards, but she’d had a primary artery burst, probably because a piece of tumor broke free of her lung. There wasn’t anything anyone could have done to save her life.
No one told me that, though. My unit manager asked, wasn’t I glad it happened in the hospital rather than in the patient’s home. The charge nurse, noting I was no longer carrying a full load, gave me an admission right away. Other nurses said I handled myself well, but no one sat me down and said it wasn’t my fault the patient died.
It’s not our way, as nurses or physicians, to speak up about our own pain and worries, or to acknowledge the pain of others. There’s an emphasis on being tough. I’ve heard nurses confess to feeling such stress about work that they vomit on their way to the hospital. A really horrible day has led nurses to uncork a bottle of wine or crack open a beer, and drink into the night. Many of us swear too much and make horribly callous jokes. A nurse may begin a shift with a murmured, “You never know what to expect…” and then grit her teeth and get to work. All of these methods of coping with stress will get a nurse through his day, but they’re all ways of avoiding difficult feelings rather than owning up to them. I know, because I dealt with my fear on the job in many of these ways.
Then I decided to take swimming lessons and the fear I had submerged on the hospital floor came to the surface as I struggled, breathless, through my strokes. The swimming lessons ended up being a great controlled fear experience because they made me scared, but why? Really, what’s frightening about swimming lessons? If I’d been rock climbing, skydiving, swimming with sharks, it would be obvious why I was afraid.
Swimming taught me that fear, like breathing, can be managed, but it also showed me that fear, like compassion, is inseparable from being a good nurse.
Nursing is a job, but a unique profession because we stand with our patients on the edge between well and unwell, stable and dangerously unstable. “Do one thing every day that scares you,” Eleanor Roosevelt said famously. I would respond to this maxim by saying, “I do: I go to work as a nurse.”