Strangulated

The grueling week of nursing orientation consisted of five days of station after station of nursing procedures and demonstrations. As I went from one nursing skills station to the next and then on to the different departments, my excitement grew. This was going to be different from nursing school. I would finally get a chance to actually use the equipment and practice my nursing skills.

In those five days I’d become vaguely familiar with policies and procedures, learned how to work medical equipment such as IV pumps, Patient Controlled Anesthesia pumps, heart monitoring equipment, blood glucose machines, and feeding pumps. In addition, every department that worked with nursing in one form or another had a station with a representative there – physical therapy, occupational therapy, cardiac rehab, infectious disease, laboratory, radiology, respiratory, special procedures, cardiac catheterization lab, Electrophysiology, pharmacy, social work, chaplain, and volunteers.

As if all of this wasn’t enough to remember, I learned that all of the equipment and departments were referred to in code or had a nickname that was either an acronym or reference to a manufacturer. I kept repeating them over and over in my head as not to forget. Patient controlled anesthesia pumps – PCAs, blood glucose machines -Accu checks, feeding pumps – Kangaroo pumps, cardiac catheterization lab – cath lab, radiology – rad, physical therapy – PT, occupational therapy – OT, infectious diseased – ID. The list seemed to go on forever – lab, EP, RT, Endo…

Walking in through the parking lot I tried to run everything I learned the previous week through my head. It was going to be my first day on the floor, my stomach rumbled and I felt a bit nauseous. I hoped I wasn’t expected to remember everything that I learned the previous week. The parking lot was on the west side of the hospital and the sun, just peering over the horizon, left a dark shadow looming over me that filled with me with dread. I heard the swishing sound of a chopper before I saw it and could feel the vibrations run through me as the helicopter came into sight. Looking up at the hospital, which stood nine stories high, I could barely see the red flashing light at the top that signaled the helicopter to the helipad. I wondered who lie in the chopper and felt a sense of pride knowing I was working for a hospital that cared for specialized patient populations.

The telemetry floor was on the ninth floor. I could hear the helicopter take off from the helipad above me as I exited the elevator. I took a deep breath and entered the conference room with a false sense of confidence. The day was starting in full swing. Both day and night shift nurses were in the room. Several different conversations were going on at the same time making the room loud and seemingly small. The night shift charge nurse took control of the room and read off the nursing assignments.

“Hope, you will be with Michelle,” she announced.

Michelle, pronounced Mik-el-lay, addressed me, “Don’t worry doll, I’ll teach you more in one week than you ever learned in school.” Michelle was short, Italian, and girthy but ran around the telemetry floor like a small bulldozer. She had a nasal voice with thick south-side Chicago accent and spoke in a no-nonsense manner. Everything about her said move out of my way here I come.

As soon as we got report on our six patients Michelle took off running. I wasn’t sure I was going to be able to keep up. “Hope, tell me what experience you have,” she said.

“Uh, none really. Just nursing school.” I replied following her like a puppy dog.

“Oh Boy, we have our work cut out for us don’t we?” She said. “I think this week

we’ll just focus on getting some nursing skills down.”

As she showed me around and introduced me to the other nurses, she told each of them, “Any IVs or foleys come get us. Hope needs practice.”
“Oh! I just got an admit into room twelve. He needs a foley,” Stacey replied after we were introduced. Stacey was young and hip. She had a bit of an Angelina Jolie look with a short pixie-like haircut, full lips, and an eyebrow pierced.

“Great,” Michelle said. “Hope, why don’t you go into room twelve, explain to the patient what you are going to do, and prepare the catheter setup. Meanwhile, I’ll peak into our rooms and check in on our patients and meet you in there.”

“Okay,” I said. I was a bit relieved not to have someone breathing down my neck like in school and I knew that inserting a catheter was something I could do with minimal assistance.

Upon entering the room, I could hear the patient’s breathing and a rattling in his chest. He had congestive heart failure, also known as CHF and his lungs were filled with fluid making him short of breath. He needed lasix, a diuretic that would pull the fluid from his lungs and make him pee.

I walked up to the bed where the older man was sitting up at almost 90 degrees.

“Mr. Henrich, my name is Hope. I’m a stu…” I stopped mid-sentence when I realized I wasn’t a student anymore. “I’m a nurse,” I paused again. Holy shit, I thought to myself, I am a nurse. Oh my gosh, what if I insert the foley and it perforates something. A bit of panic went through me as I thought of all the possible things that could go wrong. I could feel Miss. Annsack breathing down my neck and heard her piercing voice, “Remember, if it can happen it will!” I took a deep breath to calm myself and focused on the patient again. “Your nurse, Stacey, asked me to insert a foley catheter,” I said.

“Okay, Sweetheart, if it must be, it will be.”

“Have you ever had a foley catheter before?” I asked.

“Yes, I think I have.”
“A foley catheter is inserted through your pen… urethra and sits in your bladder. Stacey will be giving you lasix which will make you pee but the foley will drain your urine so you won’t have to get up frequently to empty your bladder.” I explained.

“Sounds wonderful, sweetheart.”

Carefully I opened the foley catheter insertion kit. It was imperative that it remained sterile. I took out the sterile gloves first and put them on. Then I prepared my supplies. First I needed to check the balloon at the end of the catheter to make sure it inflated evenly and didn’t leak. I connected the 10cc syringe to the balloon port and slowly pushed the 10cc’s in to inflate the balloon. As I let it passively deflate, I opened the betadine package and poured the betadine over the cotton balls in the kit. Lastly I pulled the cap off of the syringe of lubricating jelly and squirted the lubricant into the sterile kit. Perfect, I thought to myself proudly. Then I turned to the patient, still sitting 90 degrees and tucked under his covers, he smiled at me. Oh crap! I should have put is head down and uncovered him before I prepared the kit. There was no way to get the head of his bed down and turn his covers down without contaminating my sterile gloves. I would have to get a new pair.

“Oh sorry, Mr. Henrich. I need to get a new pair of sterile gloves,” I said.

“No problem, I ain’t goin’ anywhere,” he said.

I was so thankful that my first catheter insertion was with a patient that was nice and understanding. I cleared the bedside table and carefully placed my sterile supplies on it so it would remain sterile. Then I ran to get a new set of sterile gloves.

I returned to the room several minutes later. “Okay Mr. Henrich. I got my new gloves and we’re ready to insert that foley.”

“Okay, sweetheart.” He mumbled with a mouth full of eggs. Mr. Henrich’s bedside table had been moved and his breakfast tray was on top of it in front of him. I searched the room and found my contaminated sterile catheter field lying on the countertop. “Oh, man,” I thought to myself. “I have to get a new kit and start all over again. Michelle is going to think I am a complete idiot.”

Bringing the second kit in for preparation, my mind was in turmoil for several moments. I wanted to prepare the catheter, not only to cover up my error before Michelle came in but I also felt this one task was beginning to take up my whole morning. How was I ever going to take care of six to seven patients if it took me all morning just to insert a foley catheter? I looked over at Mr. Henrich, smiling as he spread jam over his toast he glanced at me and gave me a wink. I decided to wait to put the foley in and let Mr. Henrich finish his breakfast. As he ate, I busied myself in the room and discarded the contaminated kit. Just then Michelle popped.

“Hope, how’s that foley coming along?” she asked searching for my prepared foley kit.

“Well, I prepared the catheter but it got contaminated. So I have my new kit here but was waiting for Mr. Henrich to finish his breakfast first.”

Michelle took me to the side. “Hope, when deciding which task to do first, such as inserting a foley or allowing the patient to eat you must first do a quick visual assessment of the patient and then decide how to prioritize.”

“Okay,” I said.

“Now one of the things I learned early on and you’ll find it very helpful is always assess ABCs – airway, breathing, and circulation, first. If any of your tasks can improve A, B, or C, then you probably want to do those tasks first and in that order. You can assess your ABCs visually without any stethoscope if you want to do a brief assessment on a patient. So, let’s take a look at Mr. Henrich and using ABCs tell me what you see.”

I walked up to Mr. Henrich and looked at him closely. “Mr. Henrich’s airway is open but he does look like he is struggling to breath and eat at the same time.”

“Good,” Michelle replied. “Now tell me more about his respirations.”

“Well his breaths are short and shallow and rapid,” I said as I counted them with the second hand of the clock. “38 per minute and I can hear crackles with each breath.”

“So if we wanted to see if his respirations were effective how would you do that?” Michelle asked.

“Well since his respirations are fast I can assume that he is compensating for something,” I said.

“Yes, but how else could you measure if his respirations are effective in oxygenating him?” Michelle asked patiently.

“Oh! I could check his oxygenation with a pulse oximeter.”

“Great,” Michelle grabbed the oximeter probe and placed it on Mr. Henrich’s finger. “Now tell me about his circulation.”

I placed my finger on Mr. Henrich’s wrist and felt for a pulse. “His pulse is quick, 120 beats per minute.” I said.

“Tell me more,” Michelle said prompting me. “How does it feel?”

“It’s a bit weak and thready. His skin is cool and dry but his finger tips look a bit dusky.” Mr. Henrich’s oximeter displayed, 89%. I continued, “His oxygen level is 89%. He needs more oxygen.”

“Yes, Hope, you are right,” Michelle said. “He is already on 2 Liters via nasal cannula. You can increase that to 4 Liters and see if that helps. Now, the best way to do an ABC assessment is to start by taking vital signs. While you take vital signs you can check multiple things at the same time. Pull down the blanket and expose the patient’s chest. This could give you more information on the patient’s breathing. Look for accessory or abdominal muscle use. While taking the pulse you can also feel the skin like you did and whether it is cool and clammy. In addition to how the pulse feels, you want to see if it is regular or irregular. If the heart rate is irregular and fast the heart may not be emptying fully and can contribute to fluid overload. You also want to look at the color of the skin and if the patient has any swelling. You did an excellent job of noticing the crackle sounds with his breathing and that his fingertips are dusky but look at the swelling in his feet and ankles. This gives you more information as to how overloaded he is. Do you see Hope, how this basic assessment can give us important information about how the patient is doing?”

“Yes,” I said feeling really stupid.

“Now based on what we talked about. How would you prioritize your tasks of inserting a foley catheter or allowing the patient to eat?” Michelle asked.

“I think he really needs the foley catheter so when the lasix kicks in the fluid can come off faster,” I replied.

“Excellent!” Michelle answered. “Now let’s get that thing in.”

After explaining to Mr. Henrich again, I put the head of his bed down, pulled his covers down to his knees and lifted his gown to his abdomen exposing his midsection. Trying not to notice his penis, I prepared the foley catheter just as I had done before. With one sterile glove, I went to grab his penis but stopped when I saw it.“Oh gosh, he’s not circumcised! My first catheter insertion and the patient is not circumcised. I never even thought about that. Shit, what do I do?” I asked myself as I felt the heat in my face flush my cheeks.

Michelle noticed my hesitation and guided me through. “Hope, just pull the foreskin back and expose the tip of the penis. Then, holding it firmly, clean the tip with the cotton balls.”

I pulled the foreskin back and was amazed that once it was back it looked like a normal penis. I started to relax, gripped the penis firmly and cleaned the tip with the betadine cotton balls. After dipping the tip of the catheter into the lubricant, I went in for the dive (the sound of an airplane landing went through my head) and pushed the tip of the catheter into the hole. It went in smoothly and advanced further and further until clear yellow urine came back through the catheter. I advanced it an inch further and slowly pushed the 10cc into the balloon that sat in his bladder. I finished by giving the catheter a slight tug to make sure it was in place and hung the bag at the side of the bed. Urine flowed quickly and before I left the room there was already half a liter in the bag.

Michelle met me in the hallway. “Hope you did a great job in there. We have another catheter to insert in room twenty. Go get your supplies and I will assist you. It is a female patient this time.”

I went to the supply room and got another catheter set. This time I remembered to put the head of the bed down and pull the covers down first. I put on the sterile gloves and prepared the kit while Michelle also put sterile gloves on. “Mrs. Harper, go ahead and bend your knees for us. Then spread your legs.” Michelle said. “Just let your knees fall to the side. We are going to put a catheter in you.”

Mrs. Harper was an elderly woman. Her pubic hairs thinned and turned gray. As her knees fell to the side a strong smell of old urine and fish wafted up my nostrils. I tried to hold my breath as I spread her labia apart with one hand and using my free hand cleaned the area in a downward motion with the betadine cotton balls.

Unable to see the urethra I brought my face in closer for a better look. I could only imagine what this looked like. I thought I saw a hole and although it seemed a bit high I went for it. I tried to insert the lubricated catheter but when it didn’t go into the hole I tried again. I poked several times but each time the tip of the catheter bent to the right or to the left. When the catheter veered down I decided to go for it. The catheter seemed to be advancing. It went in further and further and I was focused so intently on advancing the catheter and maintaining my sterile field that I failed to noticed that the catheter had coiled within her. In fact, I thought just the opposite and was becoming a bit excited thinking the catheter was on it’s way to the bladder. Reality, snapped back, when the coiled catheter looped back and nearly poked me in the eye. I couldn’t help but giggle and Michelle trying to hold back also found herself chuckling.

“Mrs. Harper. I am so sorry, apparently I missed the hole,” I said. “I didn’t mean to laugh. I will try one more time.”

“Ahh. That’s okay.” Mrs. Harper replied. “We’ll see who’s laughing when I have an orgasm!”

I looked at Michelle wide eyed and holding in my laugh, realized that I was trying to catheterize Mrs. Harper’s clitoris. I spread her labia open again, this time trying to get it as far apart as I could. Michelle pulled out her flashlight and shed some light for me. Peering in, I saw a faint small dot that looked like it might be a hole. I decided to go for it and pushed the catheter through it and was amazed when it went in further and further until a flash of urine came back.

“Mrs. Harper I got it,” I said with much enthusiasm.

“Great,” Mrs. Harper replied. “I haven’t had that much excitement in years.” Mrs. Harper started to laugh and Michelle and I laughed with her.

The rest of the morning went quickly and at noon Michelle had me go to lunch. I headed down the hall when the call light in room twelve went on. Since I was walking by anyway, I popped my head in.

“Hey Mr. Henrich. How can I help you?” I asked. He was worse than he had been earlier that morning. He was confused and disoriented and had one hand on the call light while his other hand gripped the foley catheter. “Oh, don’t pull on that!” I said as I released his grip on the foley.

I lifted his gown to make sure he hadn’t pulled on his catheter too hard and let in a sharp gasp as I saw his penis and realized that I forgot to pull his foreskin back over his penis after I inserted the catheter. The foreskin still pulled back to the shaft had acted as a rubberband and decreased circulation to his penis. The tip of his penis was purple and swollen like a balloon. Frantically, I grasped his foreskin and tried to pull it back over his penis. Alternating hands, I tried over and over again to stretch the skin but each time I pulled on it, it just went back to the shaft.

Stacey walked in to see if I needed assistance. “Oh, Stacey. I didn’t put his foreskin back over his penis after I inserted his foley! Look at his penis,” I cried.

Stacey walked over and stood next me to have a look. I continued, “Look, now the skin won’t stay.” I pulled the skin again over his penis to demonstrate, it slowly slithered back to his shaft.

“It’s okay, Hope.” Stacey said as she covered him up. “The family just got here. They are going to sit with him. We just made him a DNR.” She came closer to me and whispered; “He probably won’t be with us but a few more hours. I will give him some pain medicine for his penis.”

“Oh my gosh, do you think I caused him pain?” I cried exasperated.

“I don’t know but I’ll give him something just in case. Don’t worry about it.”

I left the room feeling horrible. I couldn’t stop thinking how awful it was that not only was he dying but he was dying with a strangulated penis and all because of me. Most men would choose death over a strangulated penis but this poor man would have to endure both.

I made my way to the cafeteria but deep in thought I made a wrong turn and ended up in the radiology department which was a maze in itself. I tried to follow the aroma of the cafeteria and ended up making one large loop. I looked for signs and nearly 15 minutes had gone by before I found the cafeteria. Once in the cafeteria, I quickly grabbed a sandwich and then stood in line. By the time I could sit down to eat my sandwich I only had 5 minutes left of my 30-minute lunch break. I decided to eat the sandwich on my way back to floor just in case I got lost again.

Coming out of the elevator, the last bite of my sandwich shoved in my mouth, I was headed to the bathroom when Michelle caught me.

“Oh Hope, you are back. The patient in room fifteen is going to have a colonoscopy. Why don’t you go with her? That would be a great experience for you.”

Unable to respond with my mouth full, the patient rolled by with transport and Michelle pointed in the direction for me to follow. We went to endoscopy also known as endo. The physician, Dr. Glide, was performing the procedure. He showed me all of his equipment while the nurse prepped the patient and sedated her with some Versed. Once the patient was sedated adequately, Dr. Glide, lubricated his probe and inserted it into the patient’s rectum.

“Hope, stand over here so you can see the screen.” Looking up, the probe with a camera on the end transmitted the patient’s colon onto the screen. Dr. Glide was eager to teach me. “The pinkish color is normal colon tissue. I will keep advancing the scope until I see an area that looks suspicious to me,” he explained.

I watched the monitor as the scope zigzagged its way through the colon. It almost felt like a roller coaster until the scope stopped. I felt a rush go through my head.

Unexpectedly, my back felt cold. I felt a cold hard surface against it. I heard my name being called in the distance. “Hope, Hope. Are you okay?”

“I’m just going to the bathroom.” I tried to say but nothing came out. I could feel the urine trickling between my legs.

“Hope, Hope. Open your eyes,” I heard the voices again.

“I’m in the bathroom,” I said but it came out as nothing more than a mumble.

I heard voices talking, “What did she say,” One said.

The other replied, “I’m not sure. Hurry, grab some smelling salts.”

Suddenly, the strong smell of ammonia stung my nose and brain and forced my eyes open. Through the tears that had formed from the strong odor, I saw three blue-capped heads staring down at me.

“What the,” I said confused as I sat up and looked around.

“Hope, you are in endoscopy. You fainted while watching the procedure,” Dr. Glide reoriented me.

“Oh my gosh. How embarrassing,” I replied. I started to get up but slipped in something wet. I looked down and saw my pants were all wet at the crotch and I was sitting in a puddle of warm liquid. “Please tell me someone spilled water and that I am not sitting in my own urine,” I said.

The endo nurse looked down at me with pity and said, “No Hope. It’s yours. You seem to have wet yourself when you fainted.” She spoke in an English accent that was a bit soothing in the position I was in. She helped me up and handed me a spare set of scrubs to change into.

Humiliated I went to the locker room, cleaned myself up and put on the clean set of hospital scrubs. I sat on a bench and thought about how disastrous my first day was. The door opened and Michelle came in. “I came down to check on you and the nurse told me what happened,” she said as she approached me.

“Oh Michelle. This day has been horrible! I am such an idiot. I just don’t know if I am cut out to be a nurse.” I said leaning forward with my head in my hands. “I let Mr. Henrich eat when he could barely breath, I strangulated his penis, I tried to catheterize Mrs. Harpor’s clitoris and nearly gave her an orgasm, and then, not only did I pass out but I peed my pants.”

Michelle placed her hand on my back. “Well Hope, you have a point. Your first day on the job was probably worse than some. But look at the positive. For one, you didn’t kill anyone.”

“Oh my God! I peed my pants!” I repeated shaking my head.

“And think of what you learned today. I would bet my life that when faced with prioritizing tasks you will always use your ABCs. And I know for sure that you will never strangulate a penis or catheterize a clitoris again.” Michelle looked at me and smiled

“That’s true,” I said smiling back.

“You see, Hope. That’s what nursing is all about. Sometimes you will make mistakes. We all do. We just have to make sure that the mistakes we make, for one, are not deadly and, for two, that we learn from them. That is what makes a good nurse great.”

“I guess your right, Michelle, but how can I be sure that my next mistake won’t be deadly?” I asked.

“Hope, I’ve only known you for a day but I can tell from just today that you are conscientious about what you do and although I can’t make any guarantees, I am pretty positive you wouldn’t make that kind of mistake.”

“Thanks for the encouragement, Michelle.”

“Look, it’s almost three,” Michelle said looking at her watch. “Why don’t you go home and I’ll see you tomorrow morning.”

“Thanks, I think I have had enough for today.”

When I left the hospital I was thankful for Michelle. She was an exceptional preceptor and never let me quit. She encouraged and motivated me to come back to work day after day and it turned out she was right; I did learn more in one week with her than I did in two years of nursing school.