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Jennifer Culkin: Nurses on Television Miss the Mark

Today's post is from Jennifer Culkin, author of A Final Arc of Sky: A Memoir of Critical Care. Culkin, winner of a 2008 Rona Jaffe Foundation Award, is a writer and longtime neonatal, pediatric, and adult critical care nurse. Her work has appeared in many literary magazines, including the Georgia Review and Utne Reader, and in the anthologies Stories with Grace and The Jack Straw Writers Anthology 2006.

Book Cover for A Final Arc of SkyI'm so confused. To judge by two current television series about nurses, TNT’s HawthoRNe and Showtime's Nurse Jackie, are we nurses angels or 'hos? Self-righteous, micromanaging do-gooders in lab coats, or adulterous, vigilante prescription-drug addicts in scrubs? Granted, Jackie comes off as intelligent and realistic. Her black humor feels right. But how does she find time for lunch at a restaurant, let alone the sort of restaurant that has wine glasses on the table? And how, during the course of her shift, does she manage a roll in the hay with a hospital pharmacist? There are days I don't have time for a drink of water. I want to work where she works!

Except I'm not into narcotics, and certainly wouldn't use (Snort! Now there's a nice touch... and it's so lovingly filmed) them at work. Thirty years ago, when I was young and clueless, I sometimes had a glass of wine with lunch at noon before a shift that began at 3 PM. Now I'd never do that, and neither would the vast majority of nurses I know. My patients, like other consumers, have a right to expect that I'll save the wine for my time off. That I'll care for them unimpaired.

And then there is Christina HawthoRNe. I suppose it's a good thing that the public sees there IS such a thing as a chief nursing officer, that nursing is an independent profession with its own management hierarchy and that the CNO is a high-level administrator with her share of clout in the organization. But despite 30 years as a critical-care nurse, I have yet to see one charging around so ostentatiously, setting everyone straight: other hospital administrators, the Emergency Department nurses, her own daughter, a patient and his MD father. The disappointing bottom line is, Christina isn't any more realistic than... a TV doctor.

The public perception of nurses is littered with media depictions, from the impotent nurses who wallpapered the set of E.R. and Chicago Hope, to the systematic cruelty of Nurse Ratched in One Flew Over the Cuckoo’s Nest, to smoky-voiced Dixie on the radio in Emergency (I loved that show, but I wanted to grow up to be paramedics Johnny and Roy, not Dixie), all the way back to the Nancy Drew of nursing, cherubic little Cherry Ames in her white cap, throughout 27 novels written by two different authors. And there is one constant common to all these depictions, a constant they share with any drama about any profession. They're fiction.

Fiction. Not reality. And fiction is fine, as far as it goes, but reality, especially when you're a nurse, is almost always more complicated. More interesting.

So what is the reality for nurses? There are as many realities as there are specialties, as many realities as there are people, or days. I can only speak for my own. I'm a critical-care "float" in a busy, urban, public hospital; every day I go where the staffing needs are greatest, to any of five different ICUs, occasionally to the Emergency Department, occasionally to the angiography suite. Sometimes I'm a stat nurse, one of three nurses per shift who roam the house; we're the first to respond when patients decompensate outside the ICU or ED.

All these roles require a large medical, technical and scientific knowledge base, an extensive skill set, and the experience to pull it all together. Nurses are often portrayed as purveyors of empathy and not much else. If all a patient needs is a compassionate ear, he doesn't need me. A friend, a volunteer or a chaplain will do. If you're my patient and your heart stops, I will be the first to step in with ventilation, defibrillation, CPR, drugs and problem-solving in the attempt to restart it. I should already have used all my knowledge and expertise to prevent a cardiac arrest from happening in the first place.

But I do spend twelve hours with one or two patients. I am right there minute-to-minute, and that intense, in-the-present involvement requires human engagement as well as medical and nursing expertise.

On one recent day, I cared for two ICU patients. The first was a young man in his twenties, a few years older than one of my sons. He closed down the bars at 2:00 AM, missed a curve at high speed, and jettisoned his car 25 feet into the air and down into the belly of a wooded ravine. His friend was in the passenger seat; neither of them wore seatbelts. At some point in the car's crash trajectory, my patient's head rammed into his friend's torso. The friend suffered bilateral fractured ribs, a ruptured spleen and kidney, and some extremity fractures. My patient's injuries were all from the neck up. Thousands of fragile neuronal connections were severed as his brain slammed back and forth against his skull, mirroring the forces of the accident within the confines of his cranium. A diffuse axonal injury.

His mother kept watch. Her world had shrunk to 24 square feet: his bed-space. As I operated at a canter, trying to do twelve technical things at once, she wanted to know: do I understand? And the answer was--still is--yes, I do. As I told her, my two sons are out in cars with their friends, too. I know exactly what awful price her boy paid for one poor decision. About every fifteen minutes over the course of the twelve-hour day, she asked me if her son looked better to me. The truth was, he didn't. He hadn't changed one iota. Every fifteen minutes, no matter what else I was doing, I struggled to find yet another gentle way to explain what happened, another way to say it'll be weeks before the extent of the damage is assessable, months before you’ll know how much recovery he'll attain.

My second patient was also in her twenties, a victim of a domestic shooting. When she arrived in my unit at noon, there were curds of grayish brain visibly oozing from her right ear and nostril. During the afternoon we spent together, I provided plenty of science-based, technical care. But my main job was to help her father, mother and sisters understand through their anger and horror that her injury wasn't survivable, and even though our acquaintanceship was only hours old, to love them a little while we discontinued life support measures. We held hands around her bed as she paled, then cooled. As her life force, whatever that is, seeped away.

Every day is different. Yesterday, a shooting. Today, two burst aneurysms, with bloody fluid draining from a patient's brain into a bag at the head of the bed. Tomorrow I might care for someone with an overwhelming, life-threatening infection complicated by heart failure. My 78-year old patient won't speak to me at all. I'll be immersed in the struggle to keep her alive with a ventilator, antibiotics, fluids, and medications to support both her heart function and her blood pressure. Not long ago, I cared for a confused non-English speaker who cooed sweet nothings to me in a Slavic language when I held his hand. But as soon as I turned away, he lashed out with a foot to the base of my unsuspecting skull. My personal transformation from angel to 'ho was complete in 1.2 seconds, possibly a record. He was one of a succession of work-hardened, rambunctious brain-injured guys who needed constant reorientation, an artful hand with sedation, and wrist/ankle/waist restraints to keep their drains in their brains and their bodies in the beds. They weighed more than 100 muscular kilos each. They could probably leap tall buildings with a single bound, if only they could remember who they are.

In my thirty years as a nurse, if I do the math, I see that I've cared for at least 5,000 and probably closer to 10,000 people. The figure doubles when you include their "significant others," the loved ones at their sides. These numbers seem somewhat unreal, even to me. But for at least the span of a twelve-hour day, and often for a succession of twelve-hour days, I came to know something real about each of those people. We were thrown together in extreme circumstances, facing situations that are outside the bounds of the social paradigm. Situations that called for all the knowledge, skill and experience I could summon, yet reduced all of us--me included--to our common denominator as human beings. Over the course of 11,000 days, people from a profusion of cultures, people of every age and from every race and social stratum have shared some of their seminal, ultimate and sometimes their last moments with me. And I learned in a visceral, almost a cellular way that our lives--the lives of every single one of us, no matter who we are--hold inherent fascination. Each life thumps with some idiosyncratic form of blood and vitality; each life pulses with both white and black magic.

And some lives are itching to dropkick your head, given the tiniest opportunity. But that's reality for you.