Off the Charts

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

By Ctd 2005, via Flickr

I’ve begun volunteering at a local free clinic. While it’s been rewarding and satisfying, it’s also been fraught with challenges I didn’t expect; I’ve only worked in an ICU, and the assessment skills specific to critical care don’t translate smoothly to the clinic setting. I’m out of my professional comfort zone, and I feel so inexperienced.

Here’s what I’m used to: By the time a patient is admitted to the ICU, they’ve already been “worked up” in the emergency room. Physicians have been assigned and a preliminary diagnosis is in place. The patients are connected to equipment that displays their vital data continuously, on monitors I can see from almost anywhere, and alarms are triggered by any alterations. I’ve got easy access to radiology reports and films, laboratory values, and microbiology reports. The nursing physical assessment is thorough and paramount; I know what I’m looking for, what I’m listening and feeling for, what certain smells indicate, and I trust my instincts. I’m accustomed to not only the forced intimacy that comes with the in-depth physical assessments of critical care, but the technology and data that supplement my assessments, as well.

At the clinic my nursing role is quite different. I sit at a desk. I am to determine the reason for each patient’s visit and take their vital signs. I ask how they’ve been and what’s changed since their last visit.

One gentleman, when I ask what medications he takes at home, fishes in his pocket and drops pills wrapped in toilet paper on the desk that separates us. I sit across from him, considering how to proceed, itching to take his hand and slide my fingers along his wrist to feel the pulse of his radial artery. I wonder about his breath sounds, what his feet look like, whether I’d be able start an IV on him, and what I’m missing. There are no same-day diagnostic reports to refer to and no dictated medical histories. All I have is the snapshot capture of his vital signs and what he wants me to know.

I’m used to knowing my patients from the inside, out. Here in the clinic, I hardly even touch anyone. I feel blind.

These are the challenges I’ve found: to create a picture of my patient with limited information and subtle clues;  to listen to what someone tells me, hear what they don’t say, and know what to ask; and finally, to not lose my vision because I miss my familiar tools, but instead find a different way to see.