NURSES ARE LIKE COPS

Note: while all these clinical examples mirror actual clinical experience, details have been changed to protect patient privacy.

As an experienced Labor and Delivery Nurse, I’ve witnessed unthinkably traumatic things happen to people during the process of giving birth. Though I hesitate to describe them here, I do believe it’s necessary. Reading my words may be traumatic for some people, especially like me, if they struggle with their own or vicarious trauma.

Vicarious trauma occurs from repeated exposure to other people’s trauma. Over time, workers begin to mirror the bio-psychosocial effects shown by the victims of trauma (Tabor 2011; The Lookout 2017). Vicarious trauma can be described as a cumulative ‘negative transformation’ that impacts the physical and mental health of a healthcare worker, permeating all aspects of work and home life. It builds up over time, intruding on everyday life, and has the potential to drastically alter an individual’s character and belief systems. ~ from Identify Stress and Vicarious, Secondary, Indirect Trauma in Nurses (April 2020).

Please read carefully, and take care of yourselves.

It’s me, the nurse, in the room holding a woman’s hand, when a doctor first discovers she has incurable metastatic cervical cancer. This cancer has literally eaten her body from the inside out. Parts of her body fall away into the doctor’s hands, are collected into specimen containers, and wiped onto the disposable paper padding under her hips. We collect shreds of tissue; cells that months or years ago, used to form her reproductive organs. Today, they are just bloody clumps crumbling between the doctor’s gloved fingers.

I help a woman labor for hours. She tells me the name of her dog, the position she likes to sleep in at night, the food she craved while pregnant. Though I’ve just met her, I consider our relationship sacred. I am her nurse, and I vow to do everything in my power to keep her and her baby safe.

I give her sips of water and spoon ice chips, wipe her sweaty hair away from her forehead and back of her neck. I become familiar with parts of her body that she rarely shows anyone, that she may have never herself seen. During her cervical exam, I touch her baby’s head inside of her body with gloved fingers.

When her baby is close to being born, their heart rate slows again and again. In forty seconds, I page three physicians, my charge nurse, and anesthesia. My mind races with what might happen 60 seconds from now, five minutes from now, and in fifteen minutes if we don’t move fast enough. From experience, I know how many minutes I have before oxygen deprivation in utero may cause a baby permanent brain damage or death. It is 10 minutes, far less time than it takes us to wheel her back to the OR, drape her belly and cut into her skin to save her baby’s life.

The team decides to attempt a vacuum delivery. They place the plastic suction cup atop the baby’s head, pump up the pressure, and begin to pull. With gentle pressure, the baby’s head makes no movement at all. Together we helplessly listen to the tha-thump …. tha-thump, the baby’s heart rate even slower now. They have three attempts before they abandon their effort. They pull harder, harder; so they pull so hard that they have to leverage their foot against the bottom of the bed, but the baby won’t budge.

So I yank tangled cords out of machines and the wall, and we thrust our patient in her heavy labor bed down the hallway to the OR. My fellow nurse pours brown Betadine all over the woman’s belly. In less than a minute, an anesthesiologist places a tube down the woman’s throat. He puts her to sleep under general anesthesia and tapes her eyelids shut. She doesn’t even hear the first time her baby cries.

Or maybe her baby doesn’t cry. Maybe the baby is born what we call “floppy,” with very little tone. They are limp, with no respiratory drive. Maybe the baby’s heartbeat is very slow. The NICU team arrives, performing intervention after intervention to get this little heart to beat more than 100 times per minute, so the baby’s lungs and brain can oxygenate.

Sometimes, the baby will die. Or they may experience permanent brain damage, and never live a normal life without intense, long-term medical care.

I’ve witnessed babies die during birth with absolutely no warning. One minute that heart rate thumping like a band of wild horses, the next moment, they are born, limp and lifeless. Sometimes we save a birthing person’s life, by doing things like giving them a C-Section before their placenta detaches from the wall of their uterus (placental abruption.) If we don’t get their baby out of their body quickly, the baby will die. If we cannot stop the bleeding from the uterus, which is sometimes pouring from them with the force and momentum of a garden hose, the birthing parent may die, too. Sometimes a postpartum person loses liters of blood, poured onto the floor under our feet, and her team intervenes to save her. We quickly start an IV, give medications (cytotec, hemabate, methergine, TXA). We call the blood bank. As the blood infuses into her body, I watch the life energy flow back into her. Sometimes, a person bleeds so much that the surgeons have no choice but to remove their uterus.

I’ve seen severe physical trauma both to babies and to parents during the birth process. Sometimes it’s out of the blue, like an act of God. Sometimes it happens because of something that we as healthcare providers did, which is called IATROGENIC. Sometimes this trauma happens because we did something we shouldn’t have done. The worst part is that there is no reconciliation, no apology — because it was an act or reaction or intervention that’s become so common for us that has been NORMALIZED over time. We don’t even have an emotional reaction to it anymore.

And — there have been times when I have done something that will haunt me for the rest of my life. I lied: I told a person that everything would be ok - that she and her baby would be fine. Then, one or the both of them are not fine. I deceived that person, or that person’s partner. I broke my promise to them in the worst possible way. Even if there’s nothing I personally did, no action I took, that caused those horrific things to happen, I still feel responsible. Perhaps that is a harm that can never be repaired.

Those are images that flash through my mind, not regularly, but consistently. I am haunted by them.

THE CODE OF SILENCE

As birth and its traumas remain vastly behind closed doors, there is a wall between what the average public understands and what we as healthcare providers face. Through HIPPA (Health Insurance Portability and Accountability Act) we are severely curtailed in the narratives we can publicly, or even personally share. Rightfully so — privacy is a constitutional right that we must protect for every patient. However, in shielding our patients’ privacy in many ways we lose the ability to process our traumas. Per HIPPA and our code of ethics, we are prohibited from sharing patients’ stories, and events we’ve witnessed, even with our closest loved ones. In a cooperative work environment we may debrief with our team members, making our emotional processing of these witnessed traumas an insular event. An unintended, accidental or even iatrogenic outcome can lead to even more complex grief, with the sharing between team members hindered by a shadow of mutual blame and/or feelings of guilt.

The workings of patient care, due to patient privacy as well as institutional liability, are largely hidden from public view. Recently, private birth photography has illuminated aspects of hospital birth in ways rarely seen. However, many facilities restrict or prohibit photography, let alone video. As soon as complications arise, providers often request visitors or family members to cease filming. Thus many obstetric complications, either spontaneous or provider-driven, to the point of obstetric abuse, manipulation, coercion or assault, are kept from public view. Stress and trauma warp memory, shifting events. Without care or a quest for the truth, the culture of medicine and / or nursing will coach us to minimize what we’ve witnessed, so that we can continue working.

Some of the most traumatic events I’ve witnessed, including death or severe harm caused to the baby or birthing parent, happened in the middle of my shift. This meant that after relinquishing care of my patient post-traumatization, I would likely get a new admission and have to carry on with my work day AS IF LITERALLY NOTHING HAD HAPPENED.

Sometimes the only processing of this vicarious trauma happens on the brief drive from the employee parking lot to home, where I briefly, heavily sob before wiping my eyes so I can walk in the door and proceed with greeting, dressing, feeding children and the other busyness of co-parenting and managing a household.

THIS SILENCE, suppression of feeling, and secret-keeping within the culture of the medical team creates a trauma bond between both co-workers/colleagues as well as between nurse and provider.

We cannot process ANY trauma effectively since we are essentially told not to feel it and given no space nor resources to do so, thus we cannot intellectually differentiate between a so-called “natural disaster”/unpreventable and/or spontaneous traumatic event versus a event caused iatrogenically, via misstep, oversight, or even malicious provider intent.

TRAUMA BONDS

Traumatic bonding occurs as the result of ongoing cycles of abuse in which the intermittent reinforcement of reward and punishment creates powerful emotional bonds that are resistant to change. Wikipedia

I would argue that traumatic bonding exists wherever two or more people are being repetitively traumatized, together, over and over again. I.e. in an abusive relationship, a toxic living or working environment, or for us, a professional situation where we routinely find ourselves helpless in the face of extreme duress while caring for human beings experiencing physical (gunshot wound, violent childbirth, untreatable pain), emotional or psychological trauma.

Birth doesn’t have to be traumatic, but it often is. ⅓ of American births end in Cesarean Sections, which is major abdominal surgery. Most birth in the U.S. takes place inside of hospitals, and is highly medicalized. True, legally sound informed consent in many geographic locations and birth settings is non-existent. Pregnant people feel bullied and scared by their care providers. They are not informed of the side effects of birth interventions like epidurals, Pitocin, vacuum extraction, forceps or Cesarean birth, and things happen to people during birth that they are in no way prepared for, because they weren’t warned or informed.

Since healthcare institutions themselves do not protect us from the effects of this vicarious trauma (but instead asks us to pretend that nothing ever happened) and we cannot discuss details of the trauma beyond the care team members involved, we effectively create a code of silence amongst ourselves, or a siblinghood of vicarious trauma. Without professional guidance, watch how carefully this sister/brotherhood turns into a dysfunctional family, where hierarchies are maintained, coercive bullies remain in charge, we “do what we’ve always done” and otherwise well-intentioned individuals are too exhausted/beat-down to stop it.

NOW IMAGINE THAT THE VICARIOUS OR IATROGENIC TRAUMA IS OF A VERY SPECIFIC NATURE, AND THAT NATURE IS RACISM.

Implicit bias and the culture of old school, overbearing elder white nurses (“Karens”) have instructed me over the years, that the following are “facts” and not racist assumptions (content warning: hatred and racism.)

“Black people are more likely to live below the poverty line,” to “smoke cigarettes,” to “eat fast food,” to “shop at Walmart,” to “use food stamps/welfare,” to “buy expensive cell phones they can’t pay for,” to “smoke marijana,” to “smoke crack,” to “have too many children,” to “have children too young,” to “have children they can’t raise,” to “let young children run around late at night in the hospital without adult supervision,” to be “wild,” to be “promiscuous”, to be “irresponsible,” to BE AT FAULT FOR WHATEVER HARM COMES THEIR WAY.

RACISM moves our mouths to tell a Black pregnant mother that nothing is wrong with her although she feels something is off, though her blood pressure was elevated at home, though her face and hands look swollen, though she’s nauseous and has indigestion, though she hasn’t felt the baby move in a while.

RACISM tells us that we don’t need to do a BPP (biophysical profile) before we send her home.

RACISM tells us that while she states her pain is a 10 out of 10, she is not actually in pain, she is just drug seeking.

RACISM tells us that her baby’s non-reassuring NST (non-stress test) is because her placenta is calcified, because of her smoking/fast food/late-to-prenatal-care habit. It’s her own fault. What are you gonna do? Racism tells us to watch and wait instead of intervening.

RACISM keeps us outside a laboring Black patient’s room, instead of sitting at her bedside and providing her with more continuous labor support — coaching her to breathe, massaging her back (with her consent) or getting her into the tub for pain relief, the way we might do for our affluent, white patient.

RACISM is us waiting an extra 15 minutes while watching her baby’s heart rate slow down after each contraction, before calling the doctor.

RACISM is the extra minutes we waste getting her ready to go back to the OR when her baby is showing signs of distress.

RACISM is a physician pulling out clots from her uterus post birth, then rubbing her stomach and walking away without checking again, calling over his shoulder to the nurse, “I’m going home. Page me if you need anything.”

RACISM is reassuring family members that everything is ok with their daughter/sister/wife/friend, instead of assessing to make sure that everything is in fact, ok.

RACISM is five extra minutes, two extra hours, a little more distance, a little less patience.

RACISM is not looking into a Black father’s eyes to congratulate him on the safe birth of his baby.

RACISM is not doing everything in our power to ensure that birth is safe.

MEDICAL RACISM

Mainstream researchers are beginning to examine the concept of medical racism, particularly in relation to care of birthing people. “Our medical system is structured to individually and systemically favor white physicians (and nurses) and patients in ways that white people are trained to ignore. Most white doctors (and nurses) do not think race affects them or their clinical decisions and are taught to ignore their own racial privilege in favor of a meritocratic social myth. However, multiple studies reinforce the existence of racial bias among physicians (and nurses) and its negative implications for patient care.” ~ from White Privilege in a White Coat: How Racism Shaped my Medical Education (May 2018).

Human beings are courageously coming forward in increasing numbers to discuss their and their loved ones’ experiences being victimized by medical racism. But it is uncommon that we as a culture “look behind the curtain” to discuss the actual lived experience of a healthcare professional, addressing the problem of medical racism from the inside-out.

The concept I present here is that as healthcare workers, we cannot address our implicit bias and its impact of medical racism until we cope with our vicarious trauma. We must heal our vicarious trauma in order to break the TRAUMA BONDS we share as front-line healthcare workers that allow us to perpetuate a culture of white supremacy and the code of silence.

As a labor and delivery nurse, I have certain unconscious assumptions about people based on their race, their spoken language, their socioeconomic status, their marriage status, their age, their gender or sexuality, or any other aspect of their identity. One of the most lethal ways we wield implicit bias as nurses is against Black birthing people. The proof is that Black birthing people are 3–4x more likely to die (and in some areas like New York City, 12x as likely to die) in our care than white birthing people. This is true REGARDLESS of age, socioeconomic status, education. A Black person with a master’s degree receiving ‘excellent’ prenatal care is more likely to die during birth than a white person with less than a high school degree who doesn’t go to their prenatal appointments. Black people die during birth at atrociously high rates, and the cause is our racism.

I am not a sociologist, PhD or a researcher. But as an L&D nurse, I have seen implicit bias in action. I have personally had the quality of my care-giving affected by my own biases. That’s a fact.

IF YOU’RE A NURSE, DOCTOR, MIDWIFE OR DOULA, YOU WILL TOO, until you actively, urgently and diligently take substantive action to address your biases.

IMPLICIT BIAS AND MEDICAL RACISM may be more insidious than we think. As members of the healthcare team, we may not call each other out on it, because we are exhausted, because we are friends, because we have each other’s backs when no one else does, because the work itself is causing US harm, because our trauma is numbing us out until we can’t feel anything, so much so we can hardly remember horrific things we’ve seen, because we’ve been burned one too many times, because we’re burned out.

And that, my friends, is how nurses are just like cops.