"Something bad happened. We're pretty shook up," Larry said. "We saw an accident on the way in. We must've been one of the first cars by because it looked pretty fresh. A car hit a moose. A guy was lying on the side of the road with a blanket over him. I don't think he was dead. The car was a wreck. The moose was badly hurt but still alive. It lifted its head and looked as we went by." FIGURE
Jason broke in, his dark eyes shining. "The moose looked at us as we went by." They nodded gravely. "We offered to help, but the people there said they had it under control and waved us on." He paused for a moment, his body tensing. "If we'd started out 10 minutes sooner it could've been us under a blanket lying on the side of the road."
"The bigger they are, the harder they fall," I thought to myself as I watched the two huge, quaking nursing students before me. Jason's concern was valid. Moose abound in the woods, and our early-morning travel hours coincide with common moose commute times; collisions between moose and cars are often fatal to both human and animal.
Of my two students, I would have expected Jason, the experienced paramedic, to be the less shaken, but Larry had worked all over the United States in the rough, nomadic world of heavy construction and had undoubtedly seen his share of injuries. Both senior nursing students were novices in home nursing care; in fact, it was only their second day at the agency, the day of their first independent home visit.
But while they were concerned about the moose and the accident, I was concerned about one of their patients. Ellen was an obese woman in her 60s who lived alone in a run-down apartment and had little family support. A list of her problems, both medical and social, could fill a book, and the outlandish stories associated with them would make a wonderful film. Ellen's legs were covered with large, draining ulcers requiring daily dressing changes. Because of concurrent medical problems, the wounds were not expected to heal. Larry and Jason were using the buddy system for a few weeks, to help them adjust to the differences between institutional nursing and home visiting. Both men certainly appreciated the serious responsibilities associated with visiting patients at home without an RN, but they were clearly preoccupied with the road accident.
As they kept talking about the moose, I wondered if they were manifesting "home visit anxiety." I've worked with many students and have known even experienced RNs to be anxious about going into a patient's home alone. Years of hospital experience do little to prepare a nurse for the unique situations encountered in home care. In an institutional setting, the patient is on the nurse's turf. To the nurse, it's the equivalent of home field advantage in sports. Home care is a different ball game.
"How do you both feel about seeing Ellen today on your own?" I asked. "No problem," they replied, although body language suggested otherwise. "Besides," added Larry, "what else could possibly go wrong today? Nothing could be as bad as that moose." Out the door they went, with bags full of dressing supplies.
Peace reigned for about an hour. Then I heard my name being paged. Apprehensively, I answered the call. It was Jason.
"Something bad happened. We're pretty shook up."
I assumed my calmest voice, a trick I learned in the ICU. "Can you tell me what happened?"
"When we opened Ellen's dressing we found maggots," he replied. "Some fell out of the wound and onto the floor."
I've seen a lot in the years I've been in home care, but I've never seen that. "Where are you?" I asked, hoping they weren't calling from the house, within earshot of the patient.
"We're calling from Larry's car phone," he said. Jason described the visit: dressing removal, discovery of maggots, reaction of patient (and of students), reassurance of patient, and finally, actions taken-the flushing of the wound to remove all larvae, redressing according to prescribed procedure.
I was impressed. "You did a terrific job," I said. "You've done everything you could in a difficult situation. Can you continue on to the second visit?" Jason surprised me by saying yes.
We discussed the situation at length when they returned, the appropriate people were notified, procedures were followed, and paperwork was completed.
I dreamt that night that the phone rang and a voice said, "Something bad happened. We're pretty shook up." I recalled the morning and my two hulking, quaking students, and I realized I'd been completely wrong about them. They had not fallen hard at all but had stood tall and strong when faced with what would have been by anyone's standards a most trying second day.