Scope of Practice

Public Health Emergency

Branden Boyer-White

Day 1-  Finally here. Haven’t been “in camp” yet, what they call the medical zone, but we saw it from the bus window driving in—three football fields of tents and cots and mobile hospital trucks. Only one hospital still operational within a hundred miles, all others destroyed by the storm

and flooding. Think we’re near Virginia Beach but I don’t know the area, and everything’s utterly altered anyway. New satellite images yesterday—Delaware practically gone. Atlantis. What happens when you raise an ocean.

How to explain what it’s like? A bombing. Everything in pieces, shattered by wind or waves, or vanished. Garbage bulldozed into heaps, the smell of mud, rot, sewer in the hundred degree heat. People sit and lie and stand in masses wherever it’s driest. We passed lines two miles long for food, water, blankets, to file missing person reports. The bodies are evident only as mounds of plastic bags and white sheets, you can tell what they are because everyone stays so far away from them.

Half the coast was swallowed by the storm—does it all look like this? No wonder they’re so desperate for volunteers.
My tent is small, shared with two other volunteer nurses, enough room for the cots and that’s it. Writing this by the light through the tent flap, we don’t have a lantern. If we’re not sleeping we’re supposed to be out there. Of course.

Nervous but I’m more—excited not the right word. No happiness. Feel a sense of purpose, in-charge, ready. I became a nurse to help people. Why I’ve volunteered, when it was so needed. Too restless to sleep because I want to get out there and help.

Day Two-  Checked in with a man with a clipboard who had my name and license info and that’s all. “How long have you been a nurse?” he asked.
Was surprised—had given all that information when I signed up but it didn’t get here? Told him I was seven months out of school.
“Then we need to pair you,” he said. Made a note and waved me past. “Next.”
     Was paired to assist an experienced RN named Trish, from Nashville. She’s been a nurse for fifteen years, been in camp for twelve days.  
Impossible to work—people grabbing your elbows, shouting questions, insisting to be seen first. Bugs everywhere, in your mouth with every breath. So humid. Trish calm, demanding lines formed, picking who should be seen and isolating them.
Things went wrong. We saw a girl, 16, sweating pale. Trish examined and pronounced poisoning, spoiled food. Asked me to start an IV, antibiotics. I pulled Trish aside. “Shouldn’t we wait for a doctor to run diagnostic?”  

She laughed. “How many doctors you think ran into this burning building? The ones who are here aren’t sleeping.”
Looked around. People swarming, one volunteer to every fifty coughing, bleeding, or fainting humans. Trish said, “No one will tell you to break the rules but everyone knows you will. This is the end of the world, and you’re all that stands between that patient and the edge.”  

    Did everything she ordered rest of the day. It isn’t right, her diagnosing, me taking orders from her. She’s taken the physician role, turns out that’s expected, it’s the norm here.

Nurses are skilled but there’s so much we aren’t trained for and jumping in on the fly, in this chaos—we could hurt someone. There are ethics. The oath we took at graduation: I will devote myself to the welfare of those committed to my care… I will endeavor to aid the physician…
But there is no physician. And if Trish has been substituted, the patient’s welfare is dependent on her. So I must endeavor to help her?
The storm has washed away even what’s right and what’s wrong.

Day 4-  Water shortage causing mass dehydration. Lost count of IV’s started. Man 42 y.o. presented with wound to forehead. Trish examined, said, “Alright, get that clean and closed.” Tossed me a suture kit.  

    Froze up. I mumbled something about out of scope of my practice—not supposed to do invasive procedures, physician’s role.
Trish said, “Your practice is to help that patient,” moved to the next cot.

So I did it. Cleaned the wound, gave anesthetic, willed my hands not to shake. Had seen this done while assisting doctors, ran over the steps. Thought, ridiculously, how I also wanted it to heal beautifully, how could I leave the cleanest scar?  
Halfway through the man asked, “Have you done a lot of this before?” Could see his hands shaking. I will devote myself to the welfare of those in my care. “Oh yeah,” I lied. “You’re in the hands of a champ.”  
His hands stilled. He smiled when I was done. Said thank you.   
I did it. I can do it.    

Day 7-  Alone today. A birth, couldn’t get an airlift for the mother to hospital, Trish busy assisting for hours. Had to do diagnostic on new patients myself. Creepy awful feeling over my shoulder at first but soon fine—everything fell away but the patients in front of me. Diagnosed and treated dehydration, infection. Man 62 y.o. with chest pain, sent to mobile truck for EKG, hope he’s okay. Children with diarrhea, can’t help worry it’s cholera. All we need, an outbreak.       

Day — Losing track of days. Sleep in two or four hour bursts. Working alone a lot now, Trish and I dividing and conquering, fewer volunteers every day because moved to other regions, or getting sick, quitting. Quitting! Heard rumor there’s malaria in Chesapeake. Has to be BS. Right?  

— Trish feverish today. Worried. Worked alone. Saw dehydration, some new flu starting. 47 y.o. man with tattoo of a yellow bird on his neck, deep laceration on calf, a little swelling. Diagnosed nothing broken—just suture and icing, tetanus shot for good measure. Wonder if bird was a pet?

— Trish gone, into camp as patient. Never heard diagnoses. Dream of quitting, my shower at home, my bed, would drink water for days without stopping. Can’t quit.

— Paired with a new nurse, Billy, just licensed. Looks terrified. Can’t remember ever being clean as he is. “You’re all so thin,” he told me. A compliment in my other lifetime.  

— Swamped, children dehydrated, 2 seizures in 4 hours, needed Billy to do suture and he wouldn’t, “not supposed to,” scope of practice didn’t, couldn’t wouldn’t. I screamed, “Your practice is to help that patient!”  

— Man rushed to surgery. Leg below knee blackening, could smell it over general reek. Attending doctor screaming, “Misdiagnosed! Who did this?”
Compartment syndrome. Leg needed amputated 2 days ago, now possibly fatal. Saw patient wheeled away—yellow bird on his neck.
How many more have I messed up? How many? Want to go home.   
Someone calling my name. Don’t want to leave tent. Don’t wa—

— Bus wreck. Transporting refugees, road collapsed in mud, bus rolled downhill. Rounded up into Jeep, sped to scene, no siren. Bodies everywhere, half moving crying, half not. We ran, EMT kit in hand, Billy and I slid to our knees near a woman, 20-25 y.o., face stark white, eyelids fluttering. Bloody hole in her back wheezing and bubbling with air sucking in, some idiot pulled the glass out. Put ear to her back and tuned out everything else: no sound, no air moving on that side.
Said to Billy: “Pneumothorax.”  
“You’re sure? The lung is collapsed?”
Doctors all busy, everyone busy. “I don’t know what to do.”
Billy said, “We have to get the air out of her chest cavity, have to—”
“We have to find someone,” I said. Memory from a school lecture like a nightmare: a long needle is crucial. Insert through the ribs at the side into the chest cavity. There is a nerve, vein and artery there, don’t puncture them. But you’ll never have to do this. Out of scope of practice.  
“There is no one!” Billy yanking through the kit. “She’ll go into cardiopulmonary—”
“I know, Billy!” She’ll die, shut up, I know. We could kill her too, I could.

But Billy already drenching her side in betadine, swabbing, saying please please I can’t, you’re more skilled, please, and handing me the needle.