"You need to write more." This simple sentence is about to alter the course of my life. Let me place the directive in context.
It's Thursday night in the largest emergency department in Brisbane. Around 200 people have been assessed today for a range of health problems from not-particularly-scary gastro to full blown respiratory failure and everything in between. As you may imagine there's a lot of paperwork and bureacracy to accompany the diagnosis and treatment of that many people. So it's a blessing when a girl around the age of twenty arrives with a typed triage sheet explaining that she has tonsilitis and is unable to keep down the antibiotics her GP started her on a few days ago because she's been vomiting all day. She's relaxed and cooperative - like all our customers...
I write down how many times she's vomited today (6), what antibiotic she's been prescribed (erythromycin), her allergies (none) and medical history (nothing other than several episodes of tonsilitis recently). I check a box to note that her airway is clear and breathing is normal. Her throat looks a little inflamed but nothing to write home about. This is a pretty straightforward presentation and mercifully brief to document. If only it were so easy all the time. I put an arm band on and start a basic physical examination. She doesn't have a fever (temp 37.0 degrees), her blood pressure is normal and oxygen levels are 100%. Her heart rate is a little high (110bpm). All of this information goes into her hand written medical record.
It goes without saying that this human being is more than just a sore throat. From a clinical perspective the list of questions which could be asked to rule out various pathologies is virtually endless:
- Is she suffering from a dangerous cardiac rhythm? Does she need an ECG?
- Is her airway at risk? Time to auscultate her chest? Could she have a clot in her lungs?
- Is there some undisclosed abdominal pain presaging a ruptured appendix, ischaemic bowel or ectopic pregnancy? Should I palpate her abdomen, ask about bowel habits or test her urine?
- Perhaps there's some IV drug use she's hiding? Is this endocarditis?
- Thyroid problems, lymphoma, Ludwig's angina?
Instead of asking these questions and endlessly documenting problems she doesn't have I greet the middle aged Asian woman accompanying her. I introduce myself again and ask her name. It's Yuki. This is a good chance to speak a language which I usually only use at home. "Doko no shushin desu ka?" I enquire. She compliments my Japanese which is far from fantastic but sufficient for most daily conversation. She's from Fukuoka. It turns out the patient is her daughter. When I ask about her work in Australia she explains that she's a registered nurse. She actually works on the 6th floor of the hospital we're standing in. I'm looking for a vein in her daughter's arm now. She's a little deydrated and would benefit from some IV antibiotics and fluid. The patient explains that like the good daughter of an oncology nurse she used to be a regular blood donor but had to stop because the phlebotomists had so much trouble finding her veins. She's a bit dry so I explain that if I can canulate her on my first attempt she owes me a beer - standard conditions. I hit the bulls eye and she offers me one of her brother's beers because she doesn't drink. By this time her mother is inviting me to a party she's having next week - she'd like to meet my wife who is also a nurse from Japan. I send off a basic set of bloods to make the bureaucrats happy.
The doctor arrives and gets a quick story then asks if there's a tongue depressor around. I get her one and she explains that there's no sign of the quinsy abscess on the tonsil the patient had worried she might have. The doctor, whose name is Megan, charts some soluble paracetamol and starts to leave. I remind the physician of the vomiting and suggest she order some anti nausea medication which she promptly charts. I give the patient the antiemetics and promise to return in a few minutes when they've had a chance to work. This interaction lasts somewhere from 10 to 15 minutes. By the time I return 10 minutes later one of my colleagues has hung a bag of fluid and given her the paracetamol. She gets a dose of IV penicillin and transfer her to the short stay unit to continue her antibiotics. Thirty minutes is not a bad turnaround time but it's a pretty straightforward case.
My colleague sends me on a tea break and as I'm heading off I her a phone ringing in front of the elevators. It's an odd spot to hear a phone ring because there's nobody there - just a couple of big skips full of dirty linen. Turns out the phone is actully inside the linen skip. I fish it out and answer. The caller is looking for Prue and the phone has a label on the back marked "Short stay unit team leader." I walk the 30 metres to the short stay unit and ask Linley if she has seen Prue. We can't find her so Linley takes the call I have a cup of tea and head back to work.
Later in the shift a young lady approaches me and introduces herself as Prue. "I think we've met before." I can't recall but agree, "Perhaps briefly." She explains that she's concerned by my documentation for the tonsilitis presentation. "You need to write more." That's her complaint. Verbatim.
When I offer the rationale that it was a relatively uncomplicated situation she protests that I have failed to record any assessment of the patients airway. I agree that the ability to breathe is important and point out that I have clearly checked the box to indicate a patent airway. "Oh it's all there," she agrees, "but you should write more."
Apparently my concise assessment has failed to please. Coming, as it did, at the end of a long day cleaning up piss and vomit this complaint is the proverbial straw breaking the hypothetical camel's metaphorical back. I go home and get drunk, wallowing in the sorrow caused by the slightest of slights. A few days later my sense of perspective is returning. To be honest I'm feeling a little jaded about this whole nursing gig. I'm ready to spend a year not getting out of bed at 0530hrs for a 7am start. I've had enough evenings getting home after midnight - my wife and children already asleep hours ago. There's barely been a month in the past decade I have't felt like a zombie for a week because of a run of night shifts.
So I'm going to modify my work life balance. While I'm not nursing I'm going to take Prue's advice and write more. A short story every week. Fifty two of them over the next twelve months. This is the first one.