In Praise of Osmosis

Critical care nurse Crystal Diggs can’t help but think of Jello when she looks at her patient’s chart. The kidneys of the patient in room D 210 are rebelling because they are trying to do the equivalent of sieving Jello through a coffee filter. But instead of cherry-red or lime-green gelatin, his kidneys are straining to filter myoglobins, large molecules released into the bloodstream when muscle fibers begin to break down— a process called rhabdomyolysis. The common course of treatment is a cycle of fluids and a diuretic, Lasix, but the patient’s blood urea nitrogen and creatinine levels have continued to rise, which means his kidneys are not filtering these protein-metabolizing by-products effectively, even with the Lasix treatment. If the levels don’t stabilize and the rhabdomyolysis goes unchecked, his kidneys will be damaged irreversibly and he could die. Someone has to figure out what to do next. Whatever that is, it must happen soon.

 Repeated bloodwork for the patient we’ll call Mr. Rhabdo indicates that the diuresis treatment still isn’t working. Crystal knows that forced diuresis can also be harmful if continued when ineffective. She believes that the next step in his treatment should be continuous renal replacement therapy (CRRT). Unlike the intermittent or episodic forms of dialysis, CRRT takes over the patient’s kidney functions for an uninterrupted period of time, and the metabolic waste products are removed from the bloodstream without straining the already damaged kidneys. The good news is, because the kidney’s tubular cells regenerate, the damage can be temporary and sometimes can be resolved, with appropriate and timely treatment.

Selling the idea to Mrs. Rhabdo is a snap. She has only to look at her feverish husband hooked up to a ventilator, fluttering in and out of consciousness, to grasp the wisdom of a new treatment plan. He has developed a malignantly high fever in reaction to medication he was given during surgery, which resulted in the muscle damage that then caused rhabdomyolysis. Mrs. Rhabdo is also a nurse, employed at another hospital, and she looks too young to be the wife of a man so ravaged and worn-looking. None of her training has prepared her for this. She isn’t a critical care specialist, so she’s only generally acquainted with the continuous dialysis therapy that Crystal describes. But she knows enough to understand the danger her husband is in.

Crystal watches the two of them together, sensing the pain of that moment of white-hot realization that everyday life has been placed on a high shelf, out of reach. The husband and wife in that room are bound by a membrane forged out of the unspoken details of their before life. Our lives are shaped by small moments: the morning paper, a glass of wine before dinner, the cat crawling on your head at first light. During the hours she waits beside him, the wife wills the silence to be healing, like the busy silence of seeds gestating underground.

Crystal has been a wife. She knows that in this woman’s place, she would focus on hope, a spark of momentum created by the sense of doing something to bring her husband back relatively whole, back to something like their routine “before” life. She’d choose that over waiting and over caution. Yes, Crystal decides, Mr. Rhabdo needs CRRT therapy immediately.

The unit where so many patients die or linger near death for weeks and months is womb-colored. Double-doors grant access to the Trauma / Surgical Intensive Care Unit at this Tampa hospital. Walking into the Unit, with its low ceilings, salmon-pink walls, red kidney bean-colored trim, cream and mauve tile floors, is like finding a sensory mute button. The colors, the quiet, the sanitized air—all of it as deliberately subdued as a holy space—cushion the healthy against their encounters with the critically ill.

If you ignore the locked drug cabinet, the large flat-screened monitor tracking patients’ vital signs, the Xeroxed flyers posted outside every patient room advocating strict hygienic precautions—if you ignore those, the place seems like a typical office. In the hallways or nurses’ station, staff members chat about the Tampa Bucs game airing on a TV set in an unoccupied room. A torn, coverless phone book is left out on the counter. Stamped on the outer edges of the phone book pages like obscene graffiti is an attorney’s ad in navy ink: INJURED? Call 1-800-Ask-Dave. A resident scoops up the last piece of pumpkin pie left on a small worktable before going back to his charts. The hub of the Unit, the nurses’ station bordered by hallways on three sides, is the point of entry between the living and the gravely sick. It’s a clear threshold. It’s also one that the ICU nurses traverse easily, several dozen times over a twelve-hour shift. Inside a patient’s room, nurses move efficiently among the machines, tubes, and wound dressings, clear in their mission of diligent care.

Patients here are the sickest anywhere. If you are gravely ill anywhere from Tallahassee to Naples, chances are excellent you’ll wind up here, at one of the major trauma centers in a state of nearly 18 million residents. Nurses like Crystal Diggs, who spend twelve hours a day facing all the endless ways the human body can break down, make this ICU the place you would want to be brought to if you were facing the possibility of death.

Crystal whisks across the hall to the nurses’ station to phone the chief resident. She stares absently at a posterboard cutout of a cornucopia and a turkey another nurse has taped on the patient’s door, trying to figure out the best way to discuss her request with the chief resident, Dr. Gee. In her experience, straight to the point is best. She relates Mr. Rhabdo’s latest lab results and her opinion about discontinuing the current course. Dr. Gee knows that Crystal is a “Super-User,” a highly trained specialist in CRRT. He agrees with her recommendation and asks her to consult with Dr. Eff, an attending nephrologist who could order the treatment.

This is part of a critical care nurse’s job, the sometimes tricky negotiation of the hospital hierarchy. A primary attending physician usually has a team of primary care resident physicians working under his guidance, and a chief resident like Dr. Gee is highly regarded and experienced. In this case, there’s also an attending nephrologist, Dr. Eff, who oversees the work of a nephrology Fellow (similar to a resident), whom we’ll call Dr. Fellow. Typically the residents and Fellows have more interaction with patients and nurses than the attending physicians, though the latter are ultimately responsible for the decisions their residents or Fellows make while under their supervision. Crystal must follow the consultation hierarchy among hospital physicians and request the CRRT treatment from Dr. Fellow.

She watches for Dr. Fellow’s arrival as she checks on other patients. She doesn’t know him well, and she wonders if he is one of those doctors who tunes out any advice issued from the lips of a nurse, despite their knowledge and experience.

Crystal often tells her own trainees, “If you keep trying to filter the Jello after the filter is clogged, eventually you will not be able to push any more Jello—or water—through the filter.” Sensible food analogies work fine with trainees, but she isn’t willing to bet that Jello will persuade a nephrologist. So she gets busy looking for the file she keeps of studies that support CRRT treatment in rhabdo patients. Just in case, she thinks, as she clips a copy of the statistics to the patient’s chart. There’s a chance the doctor will see this as anything but helpful—that he will be upset because he perceives Crystal as being presumptuous or provocative—but it’s a chance Crystal is willing to take. Bruised toes and egos are nothing compared to what Mr. Rhabdo is facing.

Crystal is the conduit through which the team of doctors coordinates a patient’s care. She speaks for patients and their loved ones, silenced by trauma and illnesses that can at times overwhelm even the most carefully structured systems.

Crystal knows Mr. Rhabdo is at risk of losing all kidney function, even dying, from Acute Tubular Necrosis (ATN). The mortality rate in acute renal failure can run as high as 70 percent, depending upon the underlying causes and the presence of other health problems. ATN is a common cause of kidney failure because it is a deterioration of the renal system’s tubular cells, the microscopic pipes in the kidney’s filtering apparatus. Tubular cells are normally in a continuous process of death and regeneration. When the cellular renewal cycle is interrupted by disease or injury, however, the system quickly goes into overload.

Crystal is convinced that this breakdown in the Mr. Rhabdo’s kidneys will eventually trigger a chain reaction in his body, leading to systemic failure. Without her intervention and a change in treatment, he could drown internally.

When Dr. Fellow pauses to look over the charts in an alcove near the nurses’ station, Crystal approaches him with the chief resident’s orders for CRRT treatment.

He listens to her explanation and then decides. “There’s no indication for what you want.” He doesn’t look up from what he’s reading. Crystal is certain that she has miscommunicated her request. The air conditioning bailed a few months ago, and they are standing near the proxy air handler that sprouts white flexi-coil tubing and feeds air into the ceiling ductwork. Perhaps he hasn’t heard her.

            “But I have all of this research that does indicate this treatment. Right here.” Crystal leans over his shoulder, pointing at some of the statistics she has highlighted. He shakes his head while she talks and shrugs his shoulder impatiently, like a horse flicking its tail at a fly.

            Crystal repeats, “But the treatment is indicated.”

Other nurses pause or slow down in their tasks, ears cocked in alert toward the intense exchange happening just outside Room D210. Over Dr. Fellow’s shoulder, Crystal sees the patient’s wife standing in the doorway of her husband’s room. Her eyebrows are drawn up into sharp V’s of disbelief. Crystal taps the report again, standing up to her full five-feet, one-inch height, and willing calm into her voice. It’s hard for her to resist the reflex to adopt a “put up your dukes” kind of stance when protecting someone under her care.

Dr. Fellow keeps writing in the patient’s chart. Crystal lets a long silence pass, hoping that he is reconsidering.

“We will not be starting dialysis,” he repeats. “Period!” he adds, slamming the chart shut. Crystal watches the back of his neck, noticing the scarlet flush of anger contrasting so deeply against his white coat collar as he walks away.

Mr. Rhabdo is few minutes longer without the treatment Crystal is convinced he must have. In her mind’s eye she can see the coffee filter clogged with Jello.

As it turns out, Crystal’s patient’s condition is an apt metaphor for the problem that many well-informed people believe is the number one threat to our healthcare system. It’s also a strong analogy for the situation Crystal faced with Dr. Fellow in late 2004. Silence is a membrane. Its thickness, and thus its permeability, is dictated by the kinds of silence the medical community can unwittingly enforce: the silence of unassailable authority, the silence of fear, or the silence of “not my problem.” Fortunately, as the demand for increased medical accountability (and the number of lawsuits against hospitals) has increased, that membrane is thinning, raising pressure to create change. In osmosis, water molecules move from areas of high concentration to low concentration through a semi-permeable membrane, such as a cell wall. Effective communication is an isotonic state, where flow occurs in equal force in both directions through a semi-permeable membrane. Balance—whether pyschological or physiological—is good.

In 2005 an organizational-performance consulting company, Vital Smarts, released a report called Silence Kills: The Seven Crucial Conversations for Healthcare, which soundly concluded that communication breakdown is at the root of most medical errors. Vital Smarts co-founders Kerry Patterson, Joseph Grenny, Ron McMillan, and Al Switzler authored two best-selling books, Crucial Conversations: Tools for Talking When Stakes are High (2002) and Crucial Confrontations: Tools for Resolving Broken Promises, Violated Expectations, and Bad Behavior (2005), that address communication problems in personal and professional situations. Vital Smarts’ awareness of communication breakdown as a major culprit in medical errors has grown over the last two decades, as they have studied organizational behavior. After nearly twenty years of witnessing and analyzing problems within healthcare systems, they committed to quantifiying the issue through thorough research. One of the study’s authors, David Maxfield, describes the problem in this way: “Hospitals are the epitome of a knowledge organization, where the name of the game is how to get the right information from the right person to the right person—at the right time and in the right form. Whenever that breaks down, healthcare breaks down. Communication is the lifeblood of the healthcare process.”

Vital Smarts’ observations of organizational behavior proved over and over again that “The most pervasive and pernicious problem that keeps other problems from being solved is people’s inability to speak up about them,” according to Joseph Grenny, a co-author of the Crucial books and Silence Kills study. Researchers interviewed over 1700 nurses, doctors, and healthcare administrators and confirmed the systemic nature of communication pathologies in healthcare. The authors examined issues they feel are the most difficult and yet the most crucial for healthcare workers to safely and effectively address: broken rules, mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement. They concluded that “Eighty-eight percent of physicians and 48 percent of nurses and other providers work with people who show poor clinical judgment.” Perhaps even more alarming: “Fewer than ten percent of physicians, nurses and other clinical staff directly confront their colleagues about their concerns, and one in five physicians said they have seen harm come to patients as a result.” This study also found that the ability to hold crucial conversations—“emotionally and politically risky discussions”—is key to creating safety and accountability in the healthcare environment.

Silence Kills was released in conjunction with the American Association of Critical-Care Nurses (AACN) Standards for Establishing and Sustaining Healthy Work Environments, which is, in part, an imperative call to action for increased communication skills. Vital Smarts also conducts two-day Crucial Conversations seminars for members of the over 240 AACN chapters in the United States. The focus in improving healthcare is shifting to creating skilled communicators, because, according to the Silence Kills study, three in four medical errors are caused by mistakes in interpersonal communication. The study concludes that “With 195,000 people dying each year in U.S. hospitals because of medical mistakes, this study suggests that creating a culture where healthcare workers speak up before problems occur is a vital part of the solution.”

The AACN spent a year and a half studying healthcare environments and writing their own report on sustaining safe and healthy work environments, which addressed six issues: skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership. One of the directors of AACN, Dana Woods, says that these six issues are “seemingly simple, intuitive things that need to happen in the work environment, and we all know it, the same way we all know that if we exercise more and eat less, we’re going to lose weight. But it’s really hard to do.” That they are simple and intuitive is perhaps the reason why, up until the study and the AACN standards were released, communication and collaboration were considered “soft issues” or “soft skills.”

Mr. Rhabdo is fortunate. He has a nurse who is not only a highly trained clinician but also a tenacious advocate of healthy communication.

 When Dr. Eff, the attending nephrologist, appears on the unit later that day, Crystal again pulls out her folder of supporting research. “Here are Mr. Rhabdo’s results. You can see that his kidney function is declining. Dr. Fellow didn’t think so, but this patient needs CRRT.” Crystal keeps the growing frustration out of her tone as she sees the doctor’s expression shift into a frown. Research and diplomacy aren’t enough to make her point.

“No,” Dr. Eff says. That’s all. He’s confident the matter is closed. He scribbles his signature on the nephrology Fellow’s progress notes and leaves the unit without another word.

“It was like a brick wall,” Crystal remembered later. “ I just didn’t understand.”

Crystal had never met Dr. Eff before, which made trying to understand his refusal even more difficult. She would learn later that he wasn’t one of the regular attendings, that he was covering for another attending nephrologist. This means that his experience with hemodialysis was based on seeing outpatients, not hospital ICU patients. And hemodialysis is different from continuous dialysis, often used for different reasons. Part of his unfamiliarity with the treatment was likely one of the reasons he didn’t want to initiate CRRT. And yet, given the situation, why wouldn’t the subbing nephrologist defer to someone with clear knowledge and experience? Looking back, Crystal thinks that it could have been a bit of medical chauvinism as well. “I think some physicians—and I don’t know if this was the case with him, I didn’t know this nephrologist, I’d never met him, and I usually do know them, and they know which nurses are knowledgeable about this—but I think some are like, ‘Who are YOU to tell me how to run my practice?’”

Stalled by a doctor’s firm and authoritative refusal, maybe it’s easiest to drop the issue. Many nurses would, Crystal knows. No matter how dedicated a nurse is to patient care, there are just some issues that seem impossible to confront. But Crystal also knows she is right. Her reputation for being outspoken is something she’s proud of. She isn’t ready to give up fighting for her patient. “It’s my personal responsibility. If I don’t speak up and say something, it may mean the patient doesn’t get the treatment they need. If I don’t speak up and say something about the treatment they need, it may mean the patient’s demise.”

Crystal believes that part of the difficulty in training nurses to speak up is the result of larger social issues. “It hasn’t always been a culture where the nurses can do that. Historically, it’s been almost a subservient type of profession where you follow orders. Yours is not to question, yours is just to carry out orders. We have to break that culture and that way of thinking. It’s not the easiest thing, because it’s also part of a personal culture. As women, we’re taught not to question men, not to question authority, or we’re taught not to question people older than us. So these are a part of the barrier that needs to be broken down.”

Crystal has some experience with barriers. “As a kid, I was always the person to ask why we did certain things. I grew up Southern Baptist in Stone Mountain, Georgia. Part of our religion is to not ask ‘Why?’ It’s to just have faith. But I always asked why.” Ten-year-old Crystal asked why God would only allow Baptists into heaven, which would place everyone else, after death, squarely in Hell. “I just couldn’t understand why the loving God that I believed in would allow other religious people who believed in God, not necessarily Christ, to go to hell.” The answer she usually got was some version of “Just because,” and that rankled. Twenty-five years later, that answer, though given in a different context, still provokes Crystal. “I don’t think in the healthcare field we should settle for the status quo, or with the answer that ‘this is what we have always done and that’s why we do it.’ If you can’t answer why we do it, then you need to look into it and find out why we do it.”

“Crystal kept going back to her research and didn’t back down, ” recalls Caryl, another ICU nurse who walked in on the tail end of the conversation between Crystal and Dr. Eff. The deadlock was simple: the attending nephrologist wanted to wait until the patient didn’t have any kidney function left before considering a change in the current treatment, and Crystal wanted to start the treatment immediately. With improved dialysis intervention methods, the frequency of death due to uremia, hyperkalemia, and other kinds of electrolyte and metabolic imbalances has decreased. CRRT extracts the obstructive myoglobin molecule from the blood, which alleviates additional strain on already overtaxed kidneys: “If you remove the Jello and just filter water, eventually the water will help flush through the remaining Jello and begin to filter the water more rapidly,” Crystal explains.

Mrs. Rhabdo cries while Crystal explains that the attending nephrologist refused to order the treatment. She has sat beside her husband all afternoon, and she knows without being told that he is getting worse. After Dr. Eff leaves without speaking to anyone else, Crystal gives the wife a hug and reassures her, “We’re not done yet. Give us some time. This isn’t over.”

Critically ill patients often cannot speak for themselves, nor can family members always successfully negotiate through layers of medical jargon and emotional overload. Doctors juggle heavy caseloads and often have little time to spare for second-guessing, diplomacy, or more than a cursory bedside nod. Nurses spend twelve-hour shifts several days a week with their patients, and their understanding of a patient’s needs must be respected too. Crystal explains that “a large part of nursing is being a patient advocate. Part of our profession, part of what nurses do, is being a voice for patients and their families. We’re with patients 24/7, and the doctors are getting a snapshot view of the patient when they do their rounds. They normally have eighty patients or so, and it’s up to us to convey that information to the doctors.”

Being educated and knowing the literature creates a kind of respect. If the respect level is higher, people—doctors—will listen to nurses. Chief Trauma Resident Dr. Laurie Norcross has worked with most of these nurses for “seventy-five percent of the last five years,” and she attests to their high level of skill and knowledge. “They really pay attention to what’s going on,” she says. “They’re always on top of things. I trust them emphatically.”

The stand-in nephrologist, Dr. Eff, is neither familiar with nor trusting of the Trauma / ICU nurses at this facility. He is, thanks to Crystal, getting a whiplash-quick orientation. Earlier in the day, Crystal had asked him to phone Dr. Gee, to create what is called a “mutual purpose” for the patient’s care, a request Dr. Eff ignored. Running high on emotion as well as the certainty that she is right, Crystal phones the chief primary care resident. Dr. Gee backs her up again, “You tell them that they will start it or we will find someone who will.” This sounds a lot like an ultimatum, and Crystal’s mind races for a diplomatic way to phrase the order as she dials Dr. Eff’s pager number.

When Dr. Eff calls back, Crystal relays the message. “The primary team really wants CRRT started for this patient. That’s why they consulted you, and they’d like you to reconsider.”

When Crystal was eight years old, her mother got a job working as a crime scene investigator for the DeKalb County Police Department, “before it was cool, before CSI and all those other shows.” Crystal, now thirty-five, isn’t sure whether her mother’s unusual profession influenced her own highly developed drive for clarity and accountability. “Ma-a-a-ybe. Maybe that is true,” she says, carefully weighing her words. “I’ve never thought about it that way. Could be.”

And how much of what happened to her father when she was young influenced Crystal’s chosen path? Her thirty-year-old father had a cerebral hemorrhage and was in the hospital for a year. Hospital policies were different then, and they tried to shield children from illness and injury. That kind of subterfuge must have been frustrating for an inquisitive child, the same child who would grow up and become committed to fostering clear and open dialogue.

Her mother had two children and a seriously debilitated husband to look after. And she never questioned that responsibility, Crystal remembers; “She just did what had to be done.” Crystal’s father also taught her important lessons in facing tough challenges. The doctors said he would never walk, talk, or see again. “I remember sitting down with him and his speech books. He had to learn everything all over again. How to walk, talk, how to process everything.” With the exception of a vision problem, he made a complete recovery.

Shannon, one of Crystal’s co-workers, confesses that she had a pretty hard time with Crystal’s head-on, persistent style. “I thought she was just aggressive, condescending, and overly ambitious. I walked into a meeting one day, and Crystal had all of this stuff she brought in about Crucial Conversations that seemed like a huge waste of time, and I thought, ‘Oh, she’s really done it now.’” But one day, Shannon saw Crystal comfort a new nurse who was distraught about a patient who had died. The way Crystal supported the nurse made Shannon re-think her assessment. It wasn’t overnight, but she admits that over time she began to see two things: Crystal was able to talk about problems without talking about people, and other nurses supported Crystal because her methods work. Another ICU nurse, Caryl, adds, “When Crystal steps in, people don’t get offended because they know she’s stepping in to help. She’s about empowering instead of blaming.” Penny, who has worked with Crystal for six years, says that Crystal used to come off as more aggressive, but that when she softened her approach, a lot more nurses started to listen. But she also believes that Crystal had to be aggressive at first, in order to get people to start looking at the problem. Shannon, the coworker who admits to having been against Crystal’s methods in the beginning, says now that, “Crystal has given us all permission to speak out, and she has showed us how by example.”

Nurses at this hospital are outspoken when they need to be, and they are encouraged to have open discussions and journal-sharing sessions, and to publish their stories in nursing journals and newsletters. Crystal wrote an account of Mr. Rhabdo’s story for a Vital Smarts personal story contest, and won. After winning the contest, she attended a Crucial Conversations/AACN seminar in Washington, DC. Obviously, Crystal has an innate sense of the importance of speaking out, but some of what Crystal learned about softening her approach with co-workers came from what she learned at the seminar. She frequently uses Crucial Conversations training materials in staff meetings, and she recently submitted a proposal to bring Crucial Conversations training to Tampa. The issues raised by the Vital Smarts study and the Crucial Conversations training aid her work in ways similar to how medical research helps her to successfully challenge a doctor’s decision. The Silence Kills study is pretty compelling research, and Vital Smarts’ books and methods back up what she’s trying to make happen in the medical environment.

Since the publication of her essay on the Vital Smarts Web site and after Crystal attended the conference in DC, Crystal’s peers have come to her with questions like, “I need to have this conversation, but how do you think I should approach so-and-so?’ or ‘My babysitter isn’t doing what I think she should, so how can I correct her without hurting her feelings?” or “Help! I need to have a Crucial Conversation!” It’s routine for the nurses in this Unit to question each other or give advice, especially from more to less experienced nurses. They communicate “fluidly,” as Crystal describes it. “We can hold each other accountable. We can be responsible for change.”

It’s clear that Crystal embraces change and has been forging ahead on a challenging path for a long time. After more than a decade of being a wife and mother, the shock of a difficult divorce several years ago prompted an intense period of self-discovery. “Because of my medical background, I knew that behaviors were cyclical. And I knew that if I didn’t get myself on a different path, that I would repeat it.” She started going to yoga every night. She read self-help and religious books, everything from Christianity to Buddhism. Then she went back to school. Four years later, she has nearly completed two degrees, an MBA and an MSN. Crystal’s drive to move forward in her life is like what happens in osmosis. A cell in a hypertonic solution (of higher concentration than within the cell) will swell because of osmotic pressure, which means the “environment” solution moves into the cell. Crystal targets an area of low concentration in her environment, and rushes headlong into equalizing the situation.

Crystal is generous with examples of how supportive and empowering the hospital is of its nursing staff. But she does recall one incident where she felt punished for being so vocal. “Recently I didn’t get a promotion, even though I was probably the most qualified person for the position. I was given the impression that I might not be the right fit, that they wanted someone who wouldn’t be so likely to speak up as much as I do. You know, someone who doesn’t speak up, who doesn’t cause ‘problems’ in the way that I do. They didn’t really say that. But it was made clear to me that they chose someone who never encountered ‘problems.’”

The Fellow and attending nephrology physician are back in the Trauma / ICU unit. They finish writing the orders for CRRT treatment without speaking to Crystal. Her shift is nearly done. “Thank you for coming back. I know you didn’t want to do this,” Crystal says. The two doctors ignore her thanks. Crystal shrugs it off. This is what she calls “a ‘silence instead of a violence’ kind of response.”

Within twenty-four hours after the CRRT treatment begins, Mr. Rhabdo starts to improve. He has several weeks yet in the ICU / Trauma unit, but he and Mrs. Rhabdo will celebrate Christmas and welcome 2005 on another floor of the hospital, not in an Intensive Care Unit. They are profuse in expressing their gratitude for Crystal’s intervention. “The wife, being a nurse, understood that it’s not always easy to speak up, and that there are these kinds of conflicts. She doesn’t feel like he would have gotten the care if I hadn’t spoken up.” When Crystal’s essay about his case comes out in Vital Smarts a few months later, she goes up to Mr. Rhabdo’s floor and gives them a copy. It is a celebration of so much more than winning a writing contest.

The patients are key in helping Crystal maintain her strong sense of being right in the face of almost daily instances of being told she’s wrong. Recently Crystal spoke up to a resident she always has worked well with, on behalf of a newer nurse who needed help with a patient. Her patient’s heartbeat was pausing for longer and longer durations throughout the shift. Crystal noticed the lengthening pauses. Concerned, she asked what was being done for the patient. The nurse said cardiology had been consulted. When the patient was nearing code status and no one had shown up to look at the patient, Crystal decided to find the resident and ask him to do something. She found him in a room on the other side of the unit, obviously busy and stressed out. The resident exploded, “Mind your own business! He’s not your patient, and it’s not your concern!”

“Every patient is my concern. This one needs something done now.” She showed him the cardiac readings from the morning and from a few moments prior.

“I’m the doctor, and I’m telling you it’s not your problem.”

They argued in circles for several minutes. Finally Crystal said, “Don’t worry about it. I’ll call the attending and figure it out.” The resident followed her out of the room, down the hall, and to the nurses’ station, still yelling at her to mind her own business. The emotional exchange continued, and another nurse interrupted, pointing out the startled family members’ faces peering out of patient’s rooms.

Crystal tried to end the conversation. “Don’t you tell me what to do!” he yelled, and the dialogue deteriorated from there.

He kept ranting and yelling until one of the other nurses finally called the attending. Someone needed to take care of the patient, whose cardiac activity was declining.

The patient did receive the needed attention and his cardiac event was corrected before declining further. It took a little longer for the bad feelings between Crystal and the resident to mend. Crystal lives by the knowledge that, “We’re not always going to have perfect days, make the right decision, or even say the right thing. The most important thing is that we correct or make the situation right in the end. Most of the time, that means we have to admit we are not perfect, and then talk about what happened.” They sat down together in the conference room to talk three days later and patched things up. “I know he was really stressed out. We understand that happens.” Sometimes the filter is just full, and emotions release in a flood. “He admitted that he went off the deep end, that it shouldn’t have happened, and that it was a learning experience for him too.”

Sometimes critical conversations work. Sometimes they don’t. The effort continues even when supporters—for the most part, the doctors and nurses she works with—occasionally bail. “It is lonely sometimes,” Crystal admits. “But I ask myself two questions, ‘Am I doing the right thing?’ and ‘Am I doing it the right way?’ If the answers are yes, then I go forward.”

About the Author

Jill Drumm

Jill Drumm is a poet and writer living in Fort Myers, Florida. She received her MFA in Creative Writing from Florida International University (Miami) and teaches writing at Florida Gulf Coast University.

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