The New York Times By THERESA BROWN, R.N.
In hospitals, there is a special kind of communication among doctors and nurses, an essential skill not easily learned. I’ve come to call it the Rattle.
In the Rattle, speed matters far more than style. It tends to be filled with jargon incomprehensible to an outsider — medical gobbledygook carefully arranged to present a patient’s story.
You have to rattle it off in a hurry, hence the name, but there is a lot of pressure to get it right. If you don’t, important information can be missed and — not to put too fine a point on it — the patient may die.
The lesson was driven home to me early in my nursing career. One day a patient of mine let out a sudden animal moan, and her head swung loosely down to her chest. After a few seconds she came out of it, but complained that her right arm was numb.
It happened just as shifts were changing, so another nurse was in the room with me to witness the event. Startled by the patient’s strange condition, we decided to call a code, which brings a rapid-response team to the bedside.
When the team arrived, an intensive-care nurse asked if the patient had lost consciousness. Drawing on my past as an English professor, I gave myself a little time to think about what happened so I could describe it precisely.
Had the patient passed out? Was it a seizure? Could she have had a stroke? And then I realized that my effort to give a thoughtful response was annoying the nurse from the I.C.U.
She looked at me with exasperation. The clock was ticking. She didn’t need the perfect answer, just an answer.
Julie, the nurse who had been in the room with me, stepped in. “It looked like she passed out,” she blurted. It was then that I discovered that hospital narratives are more E. E. Cummings than Tolstoy.
Another patient of mine needed a transfer to intensive care. The resident had planned to brief the I.C.U. doctor about the need for the transfer, but then she had to step away, and it fell to me to do the Rattle.
Intensive care doctors don’t readily give up beds in their units, so it was my job to convince him that this patient needed to be there. I knew the doctor, but I didn’t know what kind of pressures he was facing that might counterbalance my need to get my patient down there.
So I did the Rattle: “IL-2 patient, hypotensive, B.P. hovering between 70 over 40 to 60 over 30, occasionally tachy, bolused once this morning for a pressure of 80 over 50, getting another bolus right now, already fluid overloaded, crackles at the bases.”
I took a breath, then added, “Anything else you need to know?” which was pure bluff. I had just told the doctor that as a result of the chemotherapy the patient had received, he had severely low blood pressure, his heart rate was too fast, and we had already given him more IV fluid than his body could handle.
I had nothing else to include, no other pressing medical problems to add, but I thought it sounded good to suggest his problems were serious enough that there was still more to say.
“No,” the doctor replied. But he was quiet for just a minute and then, in his own way, called my bluff.
“These usually turn out to be therapeutic elevator rides,” he said knowingly, suggesting that this crisis could be resolved by the time the patient got to the I.C.U. “But, yeah, he can have a room.”
“Really?!” I said, abandoning my persona of determined, tough-talking professional, and instead exulting like a 5-year-old who has just been promised a puppy. I was relieved and happy — the Rattle had worked.
My relief was short-lived. Just as we were preparing to take the patient to the I.C.U., a code was called on another floor, meaning my patient could lose the bed he’d been promised.
I felt physically sick. From time to time, floor nurses have to manage patients who should be in intensive care because a bed isn’t available. It’s hard and scary work.
A long five minutes later, I got the green light from my charge nurse. Whatever had happened in that code, the I.C.U. bed was still open for my patient. We took the elevator ride — not, unfortunately, as therapeutic as the doctor had predicted. The patient’s blood pressure remained dangerously low.
Finally we arrived in the I.C.U., and although I had given them a tape-recorded patient report, the nurse wanted to know more.
I took a breath, and started my Rattle.