The Puzzle of Snowflakes: Treatments May Be Uniform, But Patients Are Not

Julianna Paradisi blogs at JParadisi RN; her artwork appeared on the cover of the October 2009 issue of AJN, and her essay, “The Wisdom of Nursery Rhymes,” is upcoming in the February issue.

My patient sits in a chair, watching a DVD presentation about caring for his new, surgically inserted, tunneled catheter. In a few weeks, this catheter will be used for his stem cell transplant. I am teaching him how to flush it and change the dressing. He’s from out in the sticks, too far away from the clinic for our nursing staff to provide the care for him. He doesn’t have family or friends for support. After the DVD, I bring out a chest manikin and dressing kit to demonstrate the sterile dressing change. As I explain the technique of donning sterile gloves, he stops me with a challenging glare.

“I can’t do sterile.”

I stop what I’m doing to explain the dangers of infection if the dressing isn’t sterile. Like a car stuck in a snowdrift, he remains unbudged. “I can’t do sterile,” he insists. I puzzle over what to say next. My coworkers flurry by in their white lab coats. I’m wearing a white lab coat, too. My patient is lost in a health care blizzard. He doesn’t see snowflakes. He only sees snow.  

Many nurses enjoy puzzles. I’ve never worked on a nursing unit that doesn’t have a least one copy of the New York Times crossword puzzle floating around the desk. It’s not surprising, because developing an individualized care plan for each patient is a puzzle nurses are expected to solve every shift. Nurses want to see patients as individuals, like snowflakes, but when there are too many patients and not enough nurses, it feels like we are the ones lost in a snowstorm. It becomes easier to treat all patients the same. We can no longer see the individual snowflake, for all of the snow.

In contrast, medical treatment is often based on the assumption  that human bodies are all the same. The treatment is chosen according to the cancer’s pathology. Dosages are tailored for body mass and lab values, but treatment is based on cancer type, not specific patients. True, oncology researchers are looking for ways to individualize treatment, rather than using a one-size-fits-all model, because our DNA makes us like snowflakes. But even if we are unique, physically and psychologically, certain conditions are required for people, and snowflakes, to survive. Medical and nursing sciences grapple with this puzzle 24/7.

In my patient’s room, I sit down on the rolly-stool and look at him. “This must be very hard for you. You are an independent man and you have always taken care of yourself. You have never asked for anyone’s help, and until now, you have never been sick. Now, you have a disease you can’t see, and a bunch of people in white jackets are telling you where you have to be, and when to get there.” 

His face softens, and he says, “How’d you know that? You should be one of those psychologists or something.” I tell him I know because I’m a cancer survivor. Cancer sucks.

He decides to learn sterile. He practices putting on the sterile gloves, and works very hard to change the manikin’s dressing using proper technique. I send him home with the necessary supplies, and never see him again.

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Senior editor/social media strategy, American Journal of Nursing, and editor of AJN Off the Charts.


  1. […] if you want to read my other January post, follow this link: The Puzzle of Snowflakes (January 4, […]

  2. JParadisiRN January 5, 2011 at 10:18 am

    Thank you. And @ Ashley: Sounds like you have an inspiring story yourself. It’s kinda like a dual citizenship, huh?

  3. Ashley January 4, 2011 at 4:38 pm

    I am recoving from breast cancer and in my first year of nursing school. That is the insight I hope to be able to bring to my patients. You are inspiring!

  4. Peggy January 4, 2011 at 2:18 pm

    Love the snowflake analogy… thanks for a great post.

  5. Duncan Mcgonagle January 4, 2011 at 1:50 pm

    You looked into his soul and not his eyes.

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