Universal Table

Most nurses wanted nothing to do with the burn unit. It was a messy, smelly, hot place and had all kinds of infection control garb that had to be donned. After every shift, not only were you sweaty and exhausted, but you had gold medal class "bad hair day"hair. In addition, the protocols for caring for burn patients were intense and took a long time to master. Recruits were hard to come by and nurses from other intensive care areas would not agree to "float"there. They were usually scared of the enormity of the technical and emotional challenges. Working there was not for the faint of heart or the vain. We were constantly looking for, no - actually begging, nurses to stay overtime or to come in early or on their days off to help with the patient load. For some reason, though, I was drawn to the challenge the burn unit offered.

When I think back to those early years I recall my focus on efficiency. I was quite determined to learn all there was to learn about burn patients, every aspect of treatment, every pathophysiological process, and every sharp edge of intensive care technology. When I left the patient's bedside at the end of a shift having finished everything - the monitoring, the IVs, the meds, the tube feedings, the bath, the debridement, the clean sheets, clean bandages, the splints, the messy creams, the respiratory care, the team planning, the charting and more - I felt I had a pretty good day. Even though most of those complex days were generally accompanied by missed lunches and the paucity of potty breaks, I felt accomplished. My chest swelled with pride. when one of the doctors commented to me, "Oh good. You are here today. I am glad to have one of the best nurses taking care of this patient. He's really sick."The standards there were high but I was reaching them.

The emotional toll of working in a situation where most of the patients eventually died after many weeks or months of care, though, was more difficult to evaluate. To deal with the burden of many of the horrors we both witnessed and administered, many of us coped by distancing ourselves from our patients. We delivered care that was technically expert, we tried not to get too emotionally entangled, and we laughed, partied and jived each other all the time. We sought a release at the end of the day that often meant gathering at the local bar, frequently until the wee hours. It was at that time, in the wee hours, when I would finally get to sleep that the dreams usually started. Although I have never been able to discern with any degree of certainty whether my nighttime "visions"were actually dreams or nightmares, they were nonetheless very real and extremely vivid. Some were recurring. Some focused on the care I delivered to my patients or on my forgetting to give them some vital treatment or medication that could have saved their lives. Some focused on the patients themselves and their disfigurement and gruesome existence without a hand or a nose or eyelids. All of the dreams were disturbing, woke me up with a start, and left a lingering unsettled sensation the next morning.

It was on one of these mornings during this time of mixed sentiments, a strong sense of achieving technical excellence mixed with disturbing personal nighttime occurrences, that I had my first encounter with Stevie. Surprisingly, at 7 years of age, he was the sage who helped me understand myself more deeply and in doing so, changed not only my nursing practice but my perspective about life in general. On the day we met, I was the "charge"nurse and running around the unit trying to keep a lid on the controlled chaos that was the burn unit norm.

Everything was in check until I heard it: rrrrnnnggg, rrrnnnggg,rrrnnnggg. The RED PHONE! Before even answering, I knew what it meant - we were getting an admission. I picked up the phone and learned a seven year old from a housefire was arriving in 20 minutes. I started to scramble. Move a patient from bed 20 to bed 4 so the seven year old could have a private room for the first day or two. Page the resident on call and do the impossible, find a nurse to take care of the admission. I started down the list of names and numbers as I had done so many times before, and once I had a live person on the other end of the phone line began my plea, "Hi, how are you? This is Mary Ann."As if a line in a practiced script, I received a premature "No, I don't want to come in!"before I could even ask, "We really need some help today, can you - " "No." Click. Occasionally, the more polite staff would make up a lame excuse to cover the fact that they just didn't want to work overtime. "Oh, I am so sorry. If I had known I would have certainly come in but I just made an appointment to have my nails done. Maybe next time." In rare cases, someone needed money for a trip she had been planning or some piece of furniture she wanted for her apartment and I would hear the golden words, "OK. I'll come in."The relief brought by those four simple words was immense. On this morning, though, no one was planning a vacation or needing a new sofa. No one was coming.

Before I could regroup, Stevie's stretcher came barreling through the doors with the EMTs at his side. By default, I would have to be his nurse and manage all my other duties that day. "Oh boy!"I thought to myself. "No lunch today."Little did I know what was in store for me and how my life would be changed by this staffing situation.

The first hours with Stevie were hectic and centered around assessing his degree of injury, getting him stabilized, and hooking him up to the many tubes and monitors required to care for him. Having worked there for several years, I knew that his chances of surviving the serious burn injury he had sustained were mixed. He had a large amount of his body surface area covered in third degree burns but he had neither facial involvement nor smoke inhalation injury, two factors in his favor. He was also a child; and, children had the remarkable capacity to recover in ways that adults could not. He could actually get better and go home even if he couldn't walk out under his own steam. He had a chance to "make it"and I knew that I would do all that I could to help him become a survivor. Yet, I also knew too well that the future of his recovery was uncertain so I couldn't get too attached.

Stevie didn't communicate anything to us; but, there was so much going on that most likely we wouldn't have noticed him trying to get our attention. We were all too focused on his body and its needs. However, once the initial surge of activity at Stevie's bedside waned and the doctors, respiratory therapists, x-ray technicians and physical therapists were gone, I had some quiet time with Stevie. Standing by his bedside, he looked into my eyes directly and with them said, "I'm scared." I looked down at him ans saw a fragile little boy with a round moon face and beautiful eyes. I can still feel his eyes. I can still see them and see into them. They were a cross between Carolina blue and cerulean, a translucent Caribbean shade unusual for eye color. And BIG! His eyes were wide as he searched my eyes, perhaps because my eyes were the only human part of me that allowed connection. My hair was enclosed in a blue shower-cap like covering, my face covering by an isolation mask, my body covered in a blue gown over my scrubs, hands in latex gloves, and even blue covers hiding my shoes. The eye to eye contact may have been Stevie's only conduit to me. His eyes captured me. I stared straight back into them, connecting with him on a level that was unfamiliar to me. I could tell he really needed me.

He told me his needs with his piercing eyes and expressions that day when he couldn't speak because a tube was helping him breath. He needed me to connect with him, not just administer to him. He needed me to stay with him, keep him calm, allay his fears, and hold his hand. I can't explain why or how, but I believed I knew what he was telling me. I found myself answering his unspoken questions. "My name is Mary Ann. I am going to stay with you and take care of you. I will not leave you. You are going to be alright. I will help you get better."I held his hand. I took of my latex glove so he could feel my skin. He seemed calmed by my voice and my assurances. Soon, the morphine kicked in and Stevie fell into a restful sleep, his breaths paced by the cyclical paced puffs of the ventilator.

Over the next few days, Stevie and I became an item. Stevie did not allow "business as usual"nursing care from me. After the breathing tube came out and he was able to speak, he had lots of questions. "What is going to happen to me?" I reassured him that he was getting better every day (and he was). I joked with him, "You are so strong for a little boy. Do you lift weights? Eat Wheaties?"He would sometimes break into a big grin that seemed to make his eyes twinkle even more. Yet, the trials of the burn injury always interfered with those tender moments. Pain accompanied every treatment and sometimes worse were the  temperature swings that occured because his skin was gone. Shivering with his teeth chattering, he tried to let me know, "III'm sooo cccc -old."The warm blankets and heaters didn't seem to warm him. I was out of options having tried all my regular warming tricks. What I wanted to do was get in the bed next to him and hold him tight so my body heat would melt the cold he felt so intensely. But, I knew I couldn't do that for a host of reasons. Suddenly, I remembered a self hypnosis class I had taken a few years before where I learned to feed myself positive messages instead of the negative subconscious dispatches that somehow seep into our minds. These techniques had helped me improve my running stamina in the past. I wondered if a similar strategy could help Stevie. "We're taking a trip!"I announced. His eyes said, "Are you crazy? I can't get out of this bed. And I'm freezing!"I explained to him that I wanted to take him on a journey in our minds; a journey that we would take together. We embarked on our first adventure right there and then. We went to the beach in the summer, a Florida beach. Through still chattering teeth, he proclaimed, "I don't know what Florida is."So, I took his hand, and we connected eye to eye and I showed him Florida. We experienced the hot, so very hot, weather. We looked at palm trees that were perfectly still since there was absolutely no breeze in that hot climate. We burrowed our cold feet into the sand that had been warmed so thoroughly by the ever shining sun. We stared at the blue water that happened to be the color of Stevie's eyes. Slowly, the shivering stopped and Stevie's teeth became still. He closed his eyes and basked in the sun. "I like Florida."He said dreamily. He faded off to sleep.

We took similar trips to other places - Alaska when it was really hot in the tub room, carnivals when Stevie needed to have some fun, and the mountains when we needed to block out all the activity and noise in the unit. These trips, more than any traditional burn therapies, seemed to help that little boy cope with the hard reality of his life at that time.

As Stevie's nurse and friend, I started to experience nursing care as a soulful and holistic art. Technical competence would never have been enough to nurse and nurture Stevie. Almost in a role reversal, he instructed me about what he needed. "Why do you have to do that now?"he would ask when it was time for some procedure or other. I realized that the answer too often was that I needed to do it so my job would be easier, not necessarily because the timing was right for him. We started to alter the routines that, once examined, seemed very arbitrarily set. Together, we customized his care and even let a few things slide. We developed a shared understanding that allowed comfort to settle in for both of us, for Stevie in his bed and me in mine, surprisingly without burn unit nightmares disturbing me.

Stevie died suddenly one night, probably from a blood clot traveling in his small but suddenly septic body. I wasn't there. When I arrived the next morning to find his bed empty, tears welled up in my eyes and my throat began to tighten. For the first time, I cried because a patient had died. Yet he had become more than a patient. He was a friend and a mentor and I would miss that little boy who was so brave and scared at the same time. I mourned his fate and the unfairness of life.

Stevie hadn't quite finished his work in this world, though. He had a place to take me just as I had taken him on imagery trips every day. After he was gone, Stevie rejoined me on the quest that we had begun together in the weeks I cared for him - a journey of the soul. I felt myself searching for the essence of nursing that I sought distance from in order to safeguard my own feelings. I learned through Stevie how to bring genuine comfort to my patients, not merely by injecting morphine or providing nutrition, but by really being with my patients when often they had no other source of comfort. Slowly, over the weeks that followed Stevie's death, I understood more and more how I could provide my patients with something they needed, maybe even more than my clinical skills - a human to human connection that took each of us, both nurse and patient, to a place with a soul where a different source of comfort could be found.

Months later while caring for an elderly woman named Angela, I realized that my time with her that night might be her last. Her death seemed imminent. She had no family, no visitors. Only me. Before Stevie finished with me I might have frantically tended to all the equipment and processes that we employ in intensive areas when death is near. I would have been satisfied to document every part of that endeavor and with technical aplomb maneuver the code that marked the end. Yet, I knew that something much more important was expected from me. Angela needed me to comfort her in her last hours. She needed me to wash her hair, to powder her so she smelled nice, to put lotion on her charred body for no reason other than gentle human touch, and to hold her hand so she wasn't alone. I was able to do these things for Angela because I wasn't alone either. Stevie was there urging me on.

Over the many years that have passed since Stevie looked into my soul, I have dreamed of him often in those nighttime burn unit visions. These messages, though, have become dreams rather than nightmares and are more settled and comfortable for me than in those early years. But Stevie did change more than the nature of those dreams, he altered my life and my perspective by changing my connections with others. For me, finding places of comfort through communion with others has become a way of interacting. The peace emanating from these encounters has greatly enriched my daily life and emphasized my many blessings. I have traveled with many friends and strangers over the years to find places of comfort and I lovingly thank Stevie for being my guide. After thirty years, those eyes, long since gone from all but my memory, still speak to me.

Why was Stevie able to get through to the nurse-narrator when other patients didn't?

If you were dying, would you like a nurse to stop busying herself with trying to keep you alive another few minutes and just sit with you?

Would you be able to work in a burn unit? What coping strategies do you think you would use to handle the stress and the sheer suffering experienced there? Are the techniques you would use good for your psyche? Your soul?