By Susie Branagan, BSN, RN
One of my aides got called the worst word in this country’s vocabulary by a patient on a Tuesday. She finished her shift. She came back the next morning and went back into that room, and I have never stopped thinking about what that cost her.
So on a Wednesday afternoon, I walked down there and told the aide to go take her lunch, a real one, off the unit, and that I had the room for a while.
She looked at me like I had offered her money. Then she asked if I was sure, which is the thing nurses do when somebody finally offers to take something off them, and I said go, and she went.
That is what leaders do. You do not send your people into a room you will not walk into yourself. If I have her for a couple of hours, four other people get to do their jobs and one of them gets to eat sitting down.
“Ohhh, here comes Strawberry Shortcake to the rescue.”
Then, before I got to the chair, “Oooo, I’m shaking in my bones. What’s the problem now, b****?”
I told her the problem was that she had frightened and disrespected several people on my staff, that we have behavioral standards here that apply to patients the same way they apply to me, and that I had come to talk with her about both.
She laughed at me. She laughed at most things, and I let her, because humor was the only door she left open and I was not going to close it on my way in.
Naming it is not a reprimand. A patient has the right to be told, plainly and without heat, that what she is doing to the people caring for her is abusive. Saying it out loud is part of the care. Leaving it unsaid teaches her that the rules bend for her, which is the same lesson that put her in that bed at thirty-four with nobody left who would take her calls.
I was there because my staff had reached the end of what they could carry. Not the escalations, though there were plenty. It was what she said while she escalated.
She had called one of my male nurses a slur for gay men, loudly, in a hallway, more than once. She had called an aide the worst word in this country’s vocabulary, and that aide finished her shift and came back the next day and went back into that room, and I have never stopped thinking about what that cost her.
She had thrown trays. Several, over several days.
And she urinated in the bed, over and over, with a commode within arm’s reach. I asked her once whether she was having trouble getting to it. She said no. She said she just wanted somebody to come clean her up. She said, “That’s your job, isn’t it?”
So I took the assignment, because that is what leaders do. You do not send people into a room you are not willing to walk into. If I take her for a few hours, four other people get to keep doing their jobs, and one of them gets to eat.
She carried a diagnosis of borderline personality disorder. Somewhere behind her was a childhood I never saw the file on, because people do not arrive at thirty-four experiencing every closing door as a threat to their life without something having taught them that.
Abandonment was not a feeling for her. It was an emergency, and her nervous system responded to it the way anyone responds to a fire. Every behavior in the last four paragraphs is a person making certain she would not be left alone in that room. The trays brought people. The slurs brought people. Lying in her own urine brought somebody to her bedside to touch her and talk to her, and if the only way she had ever learned to be cared for was to be disgusting enough that somebody had to, then that is a sentence about her life and not about her character.
And my nurse still got called that word in a hallway, and my aide still went home carrying it, and came back the next day and went back in that room. Understanding why a person does something has never once removed it from the person it happened to. Both are true at the same time and I have not found a way to make them cancel.
We talked for a while. Some of it was almost decent.
Then she wanted a Coke. Not diet. She said, “Get me some realllll Coke, Shortcake.”
I told her she had an order against it because she was diabetic, and that I was not going to be the one who broke it.
She did what she did every time somebody told her no, which was to reach for the biggest thing on the shelf.
Fine. When I get out of here I am going to go kill myself in the woods.
I said, “How is your wheelchair going to roll out there?”
She laughed. She said, “This is why I like you, Shortcake.”
I want to be careful with that exchange, because on paper it looks like I made light of a woman saying she was going to die.
She said that sentence every time. Not sometimes. Every single time anyone held a line with her, out it came, because it worked. It was the one thing that could make an entire unit stop what it was doing and turn around. Her illness had been running that search for years and had found the answer long before it found me. She had said it to three other people that same week. Every evaluation came back the same. No plan, no intent, and she told the evaluator herself that she said it to see who would jump.
None of that let me off. You cannot be the nurse who guessed right, and there is no version of my license where I hear that sentence and decide this is the one she does not mean. It got asked about properly, every time, by me and by people above me.
But meeting her with alarm was the one response that taught her to say it again. Meeting her sideways, in the register she had already told me she trusted, was the thing that kept her talking to me instead of performing at me. That is a judgment call you make in about a second and a half with a person you have spent a lot of days with, and I would make it the same way again.
A person who has learned that the only reliable way to be taken seriously is to say she is going to die is telling you something true about her life, even when the plan is not real. That is not a trick. That is somebody using the one thing that has ever worked.
She let it go. The air came out of it, the way it usually did.
Then she told me she was going to wet the bed. And that she was going to have a bowel movement in it too, and somebody could come deal with that.
I said, “No, ma’am, we are getting into that commode. Come on, girl. We can do it.”
She looked at me for a second. Then she said, “Fine. Only because I like you.”
I said, “Oh, you do, do you?”
And she laughed, and I laughed, and for about four seconds there were two women in that room instead of a patient and a manager.
That happens more than people outside this work would believe. Somewhere under all of it was a child who had been small once and had something done to her that I never saw the record of, and every so often that person surfaced for a second and said something almost tender and then went back under.
I got her to the edge of the bed and I got her up.
Standing a person is a specific thing. My feet were outside of hers, my hands were under her arms, and my whole weight was committed forward, because that is how you get somebody off a mattress without either of you going down.
She waited until I was all the way in it. Then she put her leg behind mine and pulled.
I went. Not all the way. I got a hand onto the mattress and my knee caught the bed frame and I stayed up, and above me she was laughing, and it was not the laugh from four seconds ago. She was pleased.
That is when I understood I was by myself in that room with somebody who had just found out she could put me on the floor.
The call bell was on the bed where my hand landed.
That is where they live. Clipped to the sheet, the cord running up over the rail to the box on the wall, because the whole point of a call bell is that a patient can reach it without getting up. Which meant the thing I needed was six inches from her hand and it was hers.
The wall alarm was worse. It was behind her, next to the light switch, and getting to it meant letting go of a woman I had just barely kept off the floor, walking past her, turning my back, and pressing a box on a wall while she watched me do it.
So I kept one hand on her and I pressed the bell with the other.
She heard it. Of course she heard it. It is a sound she had been making all week to bring people to her, and she knew what it was for and she knew I had not pressed it for a blanket.
“What did you just do?”
I told her I was asking for another nurse to come help us get her up.
She did not believe me and she should not have. She started asking over and over. “What did you do? Who is coming?” and each time she asked it she was further forward, and I still had a hand on her because putting her down on that floor was not an option either.
A call bell is not a duress alarm. It rings at the desk, and somebody at the desk hears it and comes back through the speaker over the patient’s head and asks what you need.
That is the whole system. It is her bell. It is her speaker. It hangs over her bed. There is no version of pressing it where she does not know.
Nothing came back. No voice, no question, nothing.
The station was empty. Every person on that unit, the coordinator included, was in another room with another patient, and my bell was ringing out to a desk with nobody at it. I had no way to know that. All I knew was that I had pressed it and the room stayed quiet.
So I stood there holding a woman who now knew I had called for help, with no idea whether anyone had heard, and no way to press it again that would mean anything more than the first time.
Then I started yelling.
That is how a nurse manager and a duress system consisting of one call bell asks for help. I turned my head toward the open door and I yelled for somebody to come, and I did it with her watching me do it, and whatever was left of Shortcake and the wheelchair joke went out of that room.
Somebody came. I got what I needed. The whole thing resolved the way most of them resolve, which is to say it stopped being an emergency and became a very long afternoon.
Everything I did in that room was right. I stayed. I told her the truth. I did not lie about who was coming or why. I used the only thing within reach, and when the only thing within reach did not work, I used my voice.
And every one of those right decisions confirmed the thing she was most afraid of, which was that the person sitting with her was going to bring other people in and then leave.
We train nurses to de-escalate and then we hand them a system where asking for backup is itself an escalating event. The bell announces itself through a speaker over her head. The wall box requires me to cross behind her. Walking out to find a person means leaving her alone, which for this patient specifically is the thing her whole illness is organized around avoiding. Yelling tells everyone within forty feet, including her, including the other patients, including anyone’s family standing in the hall.
There was no quiet option in that room. There was a menu of loud ones and I worked it down in order.
The seconds right after somebody realizes you called for help are the most dangerous seconds in the whole event. That is not a theory I read. That is what her face did when I said it out loud.
A nurse should be able to ask for help without the person she is afraid of finding out she asked. That is the whole request. No sound, no light, no crossing the room, no explaining yourself into a speaker over somebody’s bed, no standing in a doorway shouting into a hallway. Just a way to say I need somebody, and then have somebody come through the door like they were coming anyway.
I came in the next day and checked on her.
“Oh hello, Shortcake, who did I offend now?” she said with a grin.
“Oh, no one. I just came to see how your night was.”
“Well, let me tell you, the food was terrible… nobody helps me clean up…”
“OK,” I stated. “Tell me alllll about it.”
This is healthcare.