Trigger warning:  All posts labeled “SANE Nursing” make references to patients who are survivors of sexual assault.

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Part One.

She declined to have the advocate from the county Sexual Assault Response Team stay with her during her exam and treatment, so it was just me and her in the room by ourselves.

I moved through the steps of the exam methodically, following the same path I use for all my survivors of rape and sexual assault.  The only differences in this case were that my survivor was Native/First Nations, and that she was markedly older than most of my other patients.

Native American women in North America suffer the highest rate of sexual assault of any demographic.  The statistics are horrifying – one out of every four Native women will be raped in her lifetime.  By some studies, that number is as high as one in three.

And as we talked about what happened that night, she quietly told me that this was the fourth time she had been raped.  The first time, she was nine years old.

I did a head-to-toe physical exam.  I swabbed her mouth, her fingernails, her bruises, the bite marks.  We bagged up her clothing for law enforcement.  And then it was time for the genital exam.

A genital exam is uncomfortable for many women, even when it is requested as part of a routine checkup and performed respectfully by a skilled medical professional.  But for a survivor of sexual assault, this exam is enough to re-traumatize them instantly, to fling them back into the very situation they just recently survived.

And to ask them if I can use a speculum – one of the best ways to get strong DNA evidence from the vaginal vault and cervix – feels like a question of unimaginable cruelty.

She granted me permission.  As I started, she began to wince in pain, to cry out from her injuries.  I moved quickly and efficiently, torn between wanting to stop her suffering and wanting to collect the swab that might send her assailant to prison.  She pulled the blanket over her head, hiding beneath the covers, unconsciously regressing to a universal act of childhood, a desperate attempt to find a safe haven from the monsters of the outside world.

More than half of my rape survivors do the very same thing during the genital exam.

They hide.

I quietly talked her through it, explaining every touch, every movement, every swab.  “I’m almost done,” I murmured, clicking two more swabs into the drying rack, reaching for another pair of gloves.

Muffled sobs came from beneath the blanket.  We were no longer in this together.  She was alone with the depths of her suffering, her grief, and her shame.

And then came a thin, eerie, high-pitched cry, one that made the hairs on my neck stand up on end.  It was the voice of a nine-year-old, lost and afraid.

“I want my mother.”

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Part Two.

A different year, a different ED.

The young woman on the bed in front of me is critically ill.  Her organs are starting to fail.  The bacterial infection raging throughout her exhausted body is so overwhelming that I cannot physically keep up with her needs.

More IV fluids, more volume.  Guard her IV as she writhes in pain, twisting like a corkscrew in her tangled mass of blankets.  More dilaudid.  A third antibiotic; I have to check compatibility with LR as I don’t know it off the top of my head.  Compatible.  More zofran.  Hold her arm down as I run the BP again.  We need a second line; a second nurse holds my patient down as I thread a tiny needle into her hand.  Now I’m guarding two lines from the terrible, agonizing pain she’s trying to escape.  Her heartrate is skyrocketing.  She’s breathing nearly fifty times a minute.

The house supervisor of this tiny, rural hospital sticks her head in the door.  “Critical care transport will be here in 45 minutes.”

I nod, and glance at the woman on the other side of the cot who has helped me the most that day.  My patient’s mother sits there, calm and collected as she has been for the past four hours, holding her daughter’s hand, murmuring reassurances, gently keeping the myriad of lines and cords from tangling, promising her terrified, delirious child that she’ll be all right.

“Do you want to run home and grab anything before the ambulance gets here?” I ask. She had promised her daughter, repeatedly, that she would stay with her during the long ride to the closest hospital with an Intensive Care Unit.

A strange look crossed the mother’s face, one I’d never seen there before.  She looked down at her daughter.

The alarm on the monitor flashed red and sounded again; my patients’ heart rate was nearly 160.  Her mother glanced up at it, and blanched.

And then the mother nodded, and stood up.  “Yes.  I’ll run home and shower and grab a change of clothes.”

“Great,” I replied, already tinkering with the IVs again.  More fluids.  Another dose of ativan.  “I’ll see you in 45 minutes.”

She didn’t respond, and as I glanced over she leaned down, kissed her daughter’s flushed and feverish face, and walked quickly from the room.


The ambulance arrived 40 minutes later.  My patient was wild with terror.

“Where is my mommy?” she yelled.

“She’s coming back, she’s coming, she ran home to get some clothes.”

“WHERE IS MY MOMMY?  I NEED MY MOMMY!” she screamed, and began to cry.  Her temperature had climbed to almost 103 degrees Fahrenheit, and acetaminophen was no longer working.  She was delirious with pain, fever, encephalopathic from her illness.

Her only anchor to reality was that her mother was not there.

“Calm down, calm down, you’re making yourself sicker!  She’ll be here.  She’s coming with you in the ambulance, I promise.”

But every time I glanced up at the door, her mother wasn’t there.

In the twenty minutes it took for the critical care team to transfer over her IVs and prepare to move her from the ED, my patient deteriorated further.  Her heart was racing at unsustainable levels.  She was gasping for air, and when she wasn’t gasping, she was crying, her eyes rolling wildly around the chaos of that tiny ED room, looking for her mother.

“I need my mommy!” she wailed, and her head thrashed against her pillow.  She reached for her IVs.  We jumped on her, grabbing her arms.

“Godfuckingdammit, we need to knock her out!” I yelled.

“No shit?” replied the transport RN, his dry sarcasm making me smile just a little.

And we called for the doctor, and I jogged to the Pyxis and grabbed the ESI kit, and jogged back to the room as the RT arrived, and I pulled and pushed meds and the GlideScope showed her vocal cords and the ETT sliding past them, and we secured the tube to her face and hung sedation and more IV fluids and slid her to the ambulance gurney and her mother still hadn’t arrived.

She had promised to be here.  I had promised my patient her mother would be here.  I’d been lying to my patient and hadn’t known it.

Ninety minutes after her mother promised to be back in forty-five, the medic slammed the back door of the ambulance closed, climbed in the driver’s seat, gunned the engine, and took off, lights and sirens, for the freeway and the remarkable ICU that would eventually, through sheer determination, save this young woman’s life.

But I didn’t know that then.  I fully expected her to die by morning.  I halfway expected her to die in the ambulance.

And as I stood in the hot summer air in an empty ambulance bay, hollow and exhausted, I suddenly recognized the look I’d seen on that mother’s face before she left the ED for good.

She had left and hadn’t returned because she could not bear to watch her daughter die.

She’d been saying goodbye.

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Part Three.

This woman, lying in the ED gurney in front of me, grinned at me with the impish smile of a small child.

“Have you gone to the meadow with her?  She’s seen the stardust trail.”

And she laughed, and the wrinkles around her mouth and nose lifted as the ones around her eyes closed in.  She had a shock of the whitest hair haloed around her face, and her dressing gown was a bright electric pink with small, colorful flowers embroidered around the neckline.

Her daughter, gentle and tired, sitting in the chair next to the bed, took her mother’s hand and smiled.  “I’m not sure this nice nurse has seen the stardust trail, mom.”

Now I grinned.  “I haven’t yet, but I’d like to!  Do you know where it is?”

“To the meadow, do you know where it is?”

And even without reading the chart I knew that this bright, smiling, healthy-appearing elderly woman was deeply enmeshed in the middle stages of Alzheimer’s disease.  The disjoint sentences, the nonsense words, the echolalia.  The childlike affect, the thousand-yard stare.

Her middle-aged daughter, who was her primary caregiver, spoke up, still holding her mother’s hand.  “I think she has another urinary tract infection.”

“Which is easier, for her to sit on the toilet, or for me to do a quick straight cath and get a pee sample?”

The daughter looked faintly apologetic, but determined.  “It’s much easier if you cath her.”

I nodded, agreeing entirely.  “No problem.  Should I get one of my techs to help me?”

The daughter shook her head.  “No, I’m used to taking care of her.  I’ll help you.”


As I moved through the routine of opening the cath kit, I quietly assessed my patient.  Her hair was clean, her teeth were brushed.  Her skin was soft and intact.  Her lips weren’t cracked, and her nails were nicely trimmed.  She was a good weight, hydrated and nourished.  Her clothes, though simple, were clean and neat.

She was one of the best-cared-for Alzheimer’s patients I had seen in a long time.

I glanced up at her daughter.  “She looks wonderful.  You’re doing an amazing job with her.”

The daughter smiled, and made a gesture somewhere between a nod and a shrug.  “She’s my mom.”


I turned to my patient.  “Are you ready?”

And her daughter suddenly spoke up.  “We’re almost ready.”  She reached into her bag and brought out her iPhone and a small packet of McDonald’s french fries.

She placed the french fries on her mother’s chest, and her mother’s eyes lit up like a Christmas tree.  “Oh, happy best taste!” she said, and grabbed one.

Her daughter nodded.  “Happy best taste indeed,” she said, and tapped the screen of the iPhone.  Music suddenly filled our little ED room.

Hey, hey, good lookin’,
Whatcha got cookin’?
How’s about cookin’ somethin’ up with me?

I smiled.  “Hank Williams.”

Her daughter nodded again.  “Her favorite.  She loved that man almost as much as she loved my father.”

Hey, sweet baby
Don’t you think maybe
We could find us a brand new recipe?

The daughter looked at me as her mother started to sing along between bites of french fries.  “All right.  Now we’re ready.”

I’m gonna throw my date-book over the fence
And find me one for five or ten cents.
I’ll keep it ’til it’s covered with age
Cause I’m writin’ your name down on every page….

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