Nursing: Looking back...
My career in nursing came an end in December 2020 and on this page I look back over the last 36 years that I have spent working in a public hospital as a Registered Nurse, with 32 years of that time spent in the strangest of worlds, the world of Intensive Care. I am attempting to not only look back at this time but also to see what I have to take away from such a career into the (hopefully) long years of retirement.
It is a page that I have been writing for several months now, mostly because I have a certain dislike for looking back when my goal in retirement has always been to look forward. Nevertheless I have completed this page now and I sincerely hope that it ties off some of my past for me and perhaps also is useful page for other nurses who are coming to the end of their careers...
A nursing timeline...
I was not entirely sure how to structure this examination of a long nursing career but when I was interviewed in my workplace about 'nursing in the old days' I could see a few naturally occurring divisions in my career that might help you, Gentle Reader, in making sense of this long page. And, dare I say it, perhaps this division will also help me to see the structure in my own nursing career; a career that was neither particularly well organised nor particularly well structured!
My training to become a Registered Nurse began back in 1984 when in Australia the last groups of nurses were being put through Hospital based training. Subsequent to this of course the training of Registered Nurses moved to University degree programs. But for me, the somewhat callow young man of the times, this was an opportunity to be paid for three years and I put no more thought than that into this decision!
The training back then consisted of periods of lectures in a school type setting on the grounds of the Hospital interspersed with substantial periods of hands on 'on the job' training. Working in the Hospital we were given somewhat desultory supervision while providing basic and then increasingly more complex nursing care for patients. The entire training took three years and at the end there was a State exam to be passed with various practical skills asssessed in the Hospital before this final exam was attempted.
I have often heard people claim that the training of Registered Nurses should return to this system but as one who went through this training I would disagree. It was an entrenched system that reeked of military training with power held by some pretty scary women who did not tolerate questioning and did not tolerate change; believe me when I assure you that it was long past time for change in that system! I went through the whole system and came out the other end well qualified to be a Registered Nurse but it was a bruising and many times unsympathetic system that was ready for the major changes coming.
As this section of the page is not meant to be an encyclodaedic account of my early experiences as a very, very junior nurse I have chosen instead to highlight about half a dozen or more experiences from that time that still live in my mind. I will add to these memories as they come back to me over time:
Three Day Fecal Fat
There is some heavy material coming so I thought I would start with a lighter memory! As a 'PTS' nurse (Preliminary Training School) the older nurses would go out of their way to gift you with all the best that nursing has to offer. And with nursing it is always about the poo! I am not sure if this is still done but all those years ago there was a test for fat absorption where a patient was fed a diet with a set amount of fat and their poo was analysed for the fat content.
So in the pan room was a very large tin coffee tin, Pablo coffee actually, and the most junior nurse on the ward got to scrape the poo from the bed pan into this tin using a wooden tongue depressor. Day one was ok but trust me by day three a strong stomach was required. And I never, ever drank Pablo coffee after that experience and in fact I believe that Pablo coffee no longer exists...
It was odd that for a man who would eventually be a Clinical Nurse Educator in a busy Intensive Care Unit that my stay in ICU as a junior nurse did not make that much of an impression on me. I remember seeing all of the Bird ventilators and being a little impressed with this amazing technology, also impressed with central lines and the early arterial lines. The arterial lines were connected to a transducer known as a 'Bentley Dome' and I remember learning the skill of carefully filling the dome with sterile fluid until a small meniscus formed before screwing the dome firmly down. And, Gentle Reader, I was taught the skill of reading both Tidal Volume and Minute Volume from the Bird ventilators by disconnecting the circuit and placing a Wright's Spirometer in place. With the PEEP turned off of course!
Many other small memories, I remember assembling the additives for the TPN and adding them to the bag on the ward, I remember the director of the ICU bringing his special Cardiac Output computer out while we all stood in a circle, astounded at this raw technology. And I remember as well those unfortunate patients in the side rooms that nobody really wanted to look after, so awful was their prognosis...
The Milperra Massacre
I was the very greenest of PTS nurses in 1984 when close to the Hospital there was a fight between two gangs of bikies that become known as the Milperra Massacre. Senseless loss of life and a great deal of violence with firearms, baseball bats, knives as well as fists and feet. I will never forget that evening shift on the Orthopaedic Ward when I heard somebody walking up the corridor and when I looked there was a police officer in full body armour, carrying a shotgun and walking up towards me. Not what I ever expected on this ward where the standard action was broken hips, Hamilton-Russel traction and Steinmann Pins.
I admitted one of the bikies that night who had been hit across the face with a baseball bat and had one knee shout out with a shotgun. I introduced myself and explained that I would be completing his admission form. First question from me was 'What is your name?' and I will never forget the way he looked at me and said: 'My name is Pig'! Almost too much for this little PTS nurse. Over the years I have toughened up but at the beginning there was not much toughness there...
First cardiac arrest
I was in my first year (as a PTS nurse) when I was involved in my first big Medical Emergency, and it was a great demonstration of how completely without a clue I was back then. For reasons that escape me there were three nurses and a wardsman assisting moving a very old and sick man up the bed. He landed on the bed with a bit of a bump and then looked a bit funny, although this was the end of my perception of what was going on. The wardsman however looked at the old man and said 'He's arrested' and of course this was exactly what had happened. One of the other nurses started chest compressions and I started mouth to mouth. Remember, Gentle Reader, that this was early in 1988 and that is what we did back then
I remember the feeling of his unshaved face against mine, I remember the feeling through my mouth of the rattle of sputum in his chest and I remember the sour taste of his mouth. And as happens for the most part when your heart stops the old man died, it shames me that I not remember any more details about him or did not even look a little deeper into his presentation to hospital or his life before then but as I have mentioned before I was a very young and callow man at this time.
The Falling Man
I remember the falling man vividly in part because I have a photographic memory and in part because I still feel a sort of unbelief that the whole thing actually occurred. The Hospital that I was training in had long verandahs lining the wards and it was a convention that we would sun any pressure areas on these balconies. I was outside doing something inconsequential with one of these patients when I saw that a couple of metres away from me an old man had walked out the rail of the balcony. I knew him but not well and what I remember mostly now is that he had a Polish name and one artificial leg. He stood there for a second and then he hoisted his artificial leg up on top of the railing and before I could even think of reacting he threw himself off the balcony onto the pavement below.
The feeling of unbelief that I had at the time remains with me even now, almost 40 years after his death. I looked over the rail and saw a nurse had rushed out to him where he lay and she told me later that he had obviously died on impact from at least massive trauma to the back of his head. Now Gentle Reader there was no debriefing back in those days so that story has remained with me to deal with by myself as I saw fit. Times have changed in that regard for the better. I think the man's name was Eddie but much more than that I do not know and as a callow and thoughtless man at the time I made no further investigations...
I have left out here my darkest memory from those early years, a memory of a baby who died in the ED; this was a truly traumatic incident for me and after all of these long years I still have unresolved feelings about that baby and that evening shift in the ED. Perhaps one day I will include this story but not right now...
And so I completed my training, passed the required registration exam and thus became a Registered Nurse. I was completely unaware that this would be my career, my work, for the next couple of decades but then in those days I did not look ahead too far or think about anything too deeply. I easily found a job in another Hospital and after the obligatory year in the trenches there I found my way yet again to the Intensive Care Unit.
Intensive Care, the long years...
Gentle Reader, I then spent 25 long years working 'on the floor' in the Intensive Care Unit and this is a course that I would strongly advise against for anybody reading this page! It was an extremely important time for me as an Intensive Care nurse as this 25 years is where I slowly and painfully assembled my ICU skills.
I learnt to care for patients undergoing conventional ventilation, HFOV (it was a bit thing in its time Gentle Reader!), iNO, dialysis in all of its myriad forms, SB Tubes (also big in their time), Pulmonary Artery Catheters and all of the assemblage of ICU technology. But 25 years is too much for even the most level headed ICU nurse and I now know that the work for a bed side nurse in the ICU will eventually consume anybody that stays for too long.
And in this 25 years on the floor I have a few memories that still remain as high points in my career despite the long passage of time that separates me from from most of these memories. I place them here, in no particular order, and I suspect I will add to these memories over time as I attempt to sort out my thoughts and memories:
First organ donation
In my first few years I confess that I was a little like a kid in a candy shop: swept away with the technology of the ICU, lost in the adrenaline rush of caring for critically ill patients. It was a good experience to have as later in my career I could be a little less judgemental of those who responded only to the mind of ICU and not the heart. But everybody must change after this initial period of excitement and for me this came with a 16 year old girl who came to the ICU late in 1990 following a combination of electrocution, drowning and cardiac arrest at her home. I was not used to looking after such a young person but I was used to using the technology of the ICU by now.
But something changed in me when I saw the eventual diagnosis of brain death and I saw the mechanisms of organ donation swing into action. I saw the grief and lack of comprehension of the family, I saw their tears and eventually saw the young girl wheeled off to OT for the removal of her organs. Finding the heart of ICU rather than living in its head comes to all ICU nurses eventually and I am grateful that it happened for me early in my ICU career. And I have not forgotten Felicity after all of these long years.
During my long years on the floor in the ICU I cared for a small but significant number of patients with severe Guillain-Barré Syndrome. The valuable lesson that I learned with these people is that their initial requirements for high levels of technological care (plasma exchange, intubation, tracheostomy etc) are almost always outweighed, especially in the later stages, by their requirements for extraordinarily high levels of nursing care.
And it was always imperative to form a close connection with people who were almost always frightened and fearful. Without fail these patients were extraordinary people and it was a privilege to care for them and at least for a time become such an important part of their lives.
And just to move away a little from the drama of ICU! I had been creating web sites since the late 1990s as a hobby and I decided in the early 2000s to create a web site for the ICU that I worked in. This was well before the days of corporate control, corporate templates and web sites created by committee, all things Gentle Reader that I loathe intensely. After a degree of success I managed to wangle myself a day away from the floor per week and a nice laptop to write the site with. I am very, very happy that this web site continues to this day although in a vastly altered look and format from my very early amateurish dabblings
Still, I was grateful for the support from the ICU Director and enjoyed having time at work to dive a bit deeper into web design. Odd that this web site, that hosts this page, has actually become simpler, not more complex: hand written HTML and CSS driven layout with all static pages. Perhaps everybody looks for clarity and simplicity as they get older, certainly I am...
This is a truly frightening disease that I met relatively early in my ICU career, towards the end of 1996. I had then been working in the ICU for about eight years and I thought that I was pretty comfortable with most patients and their conditions. This feeling of comfort was challenged many times over the next two decades that I spent nursing 'on the floor' but this was perhaps my first major shake up of confidence. A young school girl contracted the disease and for a long, long time was critically ill in the ICU with not only multi-organ failure but also with the loss of huge areas of skin and muscle.
The disease moved so fast in the very early stages that I was almost left behind in both tasks that I had to perform and in understanding of what was happening so quickly to this unfortunate young lady. A formative moment in my early ICU career. And for those ignorant of the nature of ICU, those who feel that ICU nurses only look after machines, I can tell you that I came into contact with this young lady many times over the next 20 years or so and I grieved when she eventually died in her late 30s.
End of beside nursing
Doubtless there will be more memories to place on this list as I look back over my long career 'on the floor' but here at least is a starting point for my recollections. I enjoyed it all hugely and for the most part I lived up to all of the challenges thrown my way. I met some incredible nurses and was part of a team that was as good as any Critical Care team in the world. But at the end of this 25 years I could tell that my time as a 'hands on' nurse was coming to an end. I was becoming angry, a little bitter even, and I could see small mistakes creeping into my work particularly during and following night shifts. By good fortune a change then came my way...
After some life changing experiences in a Yoga ashram I finally looked up from a quarter of a century working on 'the floor' in ICU to seek other things. I applied for a position as Clinical Nurse Educator (CNE) in the Intensive Care Unit and I was not only accepted in this position but I worked as a part of the Education team for the next 8 years until my eventual retirement at the end of 2020.
In many ways for me it represented the pinnacle of my career in Critical Care and I remember this time with enormous affection, in part for the many obstacles surmounted by myself and others in the Education team and in part for the many fine Critical Care nurses the Education team produced over that eight year period.
I have many, many memories of this time but I can perhaps isolate a few memories and achievements from this time, which I give below, again in no particular order:
New Graduate Nurses
Work with Registered Nurses new to the world of ICU was one of the most satisfying aspects of work as a Clinical Nurse Educator. As part of the Education Team I worked with completely raw University Graduates and in so many cases managed to produce some really skilled, caring and beautiful nurses.
I would often see one of these nurses, when fully trained, accomplishing some amazing work in ICU and I would always think: 'There goes one of my New Graduate Nurses!'. My best wishes to all of these fantastic nurses that now are perfectly capable of finding their own way in the world of Critical Care.
Advanced Life Support
During my long years on the floor in ICU I would eagerly find my way to the forefront whenever Advanced Life Support (ALS) was required: exsanguinating haemorrhage, cardiac arrest, emergency intubation etc. But I learnt when I became a CNE in the ICU that although performing ALS in 'real life' is a vital and necessary part of the Critical Care world equally important is developing the skill set required to effectively teach and mentor junior and senior members of the ICU team in ALS.
It was immensely satisfying to gain credentialling as an ALS instructor and teach / assess ALS programs both internally for the ICU and also externally for other hospitals in the area. And again there is great satisfaction when retiring from ICU to see that this teaching has taken root with many realy, really skilled staff members in the frontline of Medical Emergencies, performing their roles with skill and in depth knowledge. Very, very satisfying!
Certainly I will never forget my involvement with the first wave of Covid-19 patients in the Intensive Care Unit. We were very, very lucky in that first wave as there were not that many patients with this terrible disease that came through the door of our ICU; nothing like the experience of many other ICUs throughout the world.
To see the disease at first hand in the ICU was both an illustration of how powerless we can all be in the face of disease as well as an opportunity to experience first hand a piece of history that will be analysed and endlessly discussed for a long time to come.
I confess, Gentle Reader, that I am a great lover of technology and sometimes the Intensive Care Unit seemed like a playground stocked with the most incredible technology. I have always enjoyed working with modern ventilators, Balloon Pumps (IABP), inhaled Nitric Oxide (iNO), dialysis machines and the like. The technology and the machines themselves always came easily to me and the opportunity to get in at the cutting edge and not only use but instruct the usage of the newest ICU machinery was a gift on most days!
One great example for me was being part of the team that rolled out Citrate / Calcium regional anticoagulation using the amazing Fresenius Multi-Filtrate Pro. This involved not only a new dialysis machine but also a huge change to the concepts of dialysis that the ICU was accustomed to. Incredibly difficult education work but again very, very satisfying to see the work complete and the new approach to dialysis now part of ICU culture.
One very personal benefit to myself from my eight years as CNE was that I slowly matured as a public speaker. Before this time I was absolutely petrified of any form of public speaking and would deliberately avoid any gathering where I knew that I would be required to speak. Working as a CNE certainly beat that fear out of me!
As CNE there is a requirement to be able to communicate with small groups by the bedside, larger groups in more formal inservices for ICU as well external groups of people in much for formal settings. For me it was not an easy process but eventually I was able to speak confidently to all of these groups and this is one skill that I take away from this job now that I have retired!
And then on Friday December 4th 2020 I chose to leave my nursing life behind and start a new life in retirement. It is not often in life that you will get an opportunity to start again and it is my plan to grasp this opportunity firmly with both hands. To not only build a new life but to also build a life that has grown out of the lessons that I have learned in the old one. And writing this page and editing it again and again over the coming years will help me to both clarify and learn from these lessons.
And still I am working at the meaning of my long career in ICU, trying to find out if I was a good nurse and was useful and kind to patients and their families as well as colleagues that I have worked with over the years; trying to work out if during all of this time I was a good man, if I have made a difference?
And in conclusion...
I have spent many months writing up this small page with the expectation that I will return to it from time to time to edit and re-edit as I continue to examine my former nursing career. The page has hopefully a dual function of allowing me to organise my thoughts as well as to hopefully provide material of interest to others who are perhaps treading the same path. Please feel free to contact me with any errors of fact that you have found on this page, any errors of opinion will probably remain uncorrected. In the meantime I am having a great time in my retirement, what about you?