Island Nurses

by Howie, Leonie; Robertson, Adele;

  Sure enough, the fax came to life and a document on North Health letterhead slowly emerged. It was a written guarantee. Crisis averted, and lesson learned: inspect every version of a contract with a fine-tooth comb! When we compared notes on the whole experience later, we also agreed that we needed to have a backup plan in place in future, to say nothing of strategies by which to navigate tortuous health-funding hierarchies that didn’t know us.

  That experience was a one-off, but that is not to say that the funding rounds were plain sailing. There were endless bureaucratic changes between 1993 and 1999 that posed challenges. With each new structural change, it seemed a new set of managers came aboard who had little understanding of island health service issues. Fortunately, the RHA senior echelon remained very supportive, and this consolidated our position.

  One funding round we were summoned to Auckland to attend a meeting. We had not budgeted for trips to Auckland and the expense that this would put us to. It so happened that for Aotea Health the management staff were also the clinical staff. We would need to hire a locum doctor and nurses—at our own considerable expense.

  Still, we made the trip, and on our way it occurred to us that this was the first time we three had all been off the island at the same time. It was quite exciting, especially since it gave us an opportunity to do nothing but focus on the business.

  Two hours before we were supposed to leave the place where we were staying for the drive to the meeting, a call came on Adele’s cell phone. She fumbled with it—this was all new to her—and answered.

  ‘They want to postpone,’ she said.

  ‘What? Why? Until when?’

  ‘They didn’t say. There was no explanation.’

  We were in a tricky position. The longer we stayed in Auckland, the more it would cost us all to stay there and to pay for locums to minimise the disruption to the operation of our business. Should we stay or should we go?

  Adele phoned anyone she could think of who might have influence over the funding organisation, and eventually managed to get a commitment that the meeting would take place the next day.

  So the following morning we parked directly outside the offices of the funder. A receptionist looked up from her desk as we entered.

  ‘You can’t park there,’ she said briskly. ‘You’ll be towed.’

  We reshuffled the rental car into a safe park. Then, after a wait, we were admitted to the meeting room. We were all expecting the assembled managers to be conciliatory, or at least apologetic for the unexplained delay and the inconvenience to which it had put us.

  ‘First, Ms Robertson, I’d like to say that I didn’t appreciate being rung when I was on sick leave to be pressured about this meeting,’ the funding manager said tartly.

  ‘Well, we have expended a considerable amount of time and money to come to this meeting,’ Ivan replied hotly. ‘And we did not appreciate being left adrift in Auckland, not knowing whether to return to the island or not. I would also like to say that your receptionist was rude.’

  ‘Ivan,’ Leonie soothed, but Adele was agreeing with him. He was saying exactly what she was feeling.

  ‘No, this is outrageous,’ Ivan said. ‘This whole experience isn’t what we would have expected from an organisation responsible for health.’

  There was silence. Everyone stared at everyone else.

  ‘I think we should start again,’ Leonie suggested. ‘We’ll go out and come back in and we’ll try again.’

  So that is what we did. It was another valuable learning experience for us—in future, we would try to hold all funding meetings on the island so that the funders could experience for themselves the cost of travel, the vagaries of plane and ferry schedules disrupted by weather, and the time it cost you when that happened. It would also let them see us in our own professional environment, where the spirit of Aotea seems to get in the room so that meetings are run in a warm and constructive manner.

  One sobering fact we learned during the business course we attended in 1992 was that many small businesses fail in their first few years. We decided that, from the outset, we needed to be very hands-on, especially with finances. After the fiasco with the missing $20,000, we never again fully trusted that the promised funds would come through until they actually arrived in our bank account so, like most small business owners when the going is tough, we reduced our salaries so we would always have a float for a rainy day.

  To this day, staff salaries are our biggest expense. Our vision was to employ rural nurses and experienced GPs to provide a wide range of services to a defined population for a fixed price. We felt we had sold this concept to the RHA senior echelon, but then it was handed over to the managers, who wanted us to divide the money into separate contracts for seven different speciality areas of healthcare. In the end, we randomly assigned figures to each of the contracts so that it all added up to the total amount agreed upon. As a result, we hold multiple contracts but, given the nature of the work on Great Barrier, we can be working across all of them on any given day.

  Teething troubles and the occasional glitch aside, the system has worked. In 2014, the Auckland District Health Board (as it is now termed) conducted a series of community meetings to solicit community input into the services that Aotea Health provide. The feedback was overwhelmingly that the community has an excellent service and that the ADHB should do all that they can to support it—which they have done.

  Adele was at one of these meetings when the Auckland DHB organisers asked if there were any problems with alcohol abuse in the community. Around the table were several faces bearing the sadness of those who grow up in families affected by alcohol.

  This will be interesting, she thought.

  ‘No,’ someone said at length. ‘No. We don’t have alcohol issues.’

  Adele suppressed a smile. Afterwards, as they were washing the dishes from the meeting in the kitchen attached to the hall, she found herself alongside the spokesperson on the issue.

  ‘So,’ she said, ‘what’s the story with no alcohol issues?’

  ‘No way was I going to air our dirty laundry in front of a bunch of strangers, Adele,’ came the answer.

  Adele nodded and thought that the reply got to the heart of rural nursing: the ‘insider’ relationship built over time on trust was important.

  Chapter 8

  ANSWERING THE CALL

  Among the many and various qualities you need as a rural nurse is versatility: the ability to have the knowledge and skills to answer any call. This also involves having the ability to understand your patients’ needs because of your knowledge of their community, of their context. We are obliged to be generalists in order to perform within what is technically called our broad scope of practice. In our role, we therefore have a little knowledge about the wide spectrum of illness and trauma pathology that we may encounter during our day-to-day practice. But, every now and again, we are reminded that the inverse is also true. There is a lot we don’t know about some of the more specialist nursing skills. Nurse generalism versus specialism expresses the tension between the breadth of knowledge and the depth of knowledge a rural nurse needs to have.

  There is a knock, quiet but urgent, on the back door of the nurse’s station at the health centre. Leonie opens it and is surprised to find a young woman whom she knows well—usually of warm and smiling disposition, and totally in control of situations—looking pale, shocked and plainly on the verge of tears.

  ‘It’s Hemi,’ she says. ‘He’s had an accident.’

  Hemi* is bundled into the relative warmth of the clinic with a bloody towel pressed to the left side of his face. He is dressed in a wetsuit.

  Leonie and Hemi’s partner help him on to the examination couch.

  ‘What have you done?’ Leonie asks.

  ‘Wiped out. The sharp point of my surfboard slammed into my eye socket,’ he says, his voice tight with pain. Tears are welling within his partner’s eyes, although Leonie can see she is desperately trying to be staunch for H
emi’s sake.

  Leonie takes a brief history, and checks his vital signs. Hemi is 26 and otherwise very fit and healthy. On examination, she finds him hypothermic (cold), bradycardic (slow pulse) and hypotensive (low blood pressure). He seems to have normal vision in his right eye on cursory examination, and when she checks him for possible brain injuries she finds him conscious with no other obvious signs of an internal head injury.

  ‘I’m going to need to quickly have a look at the eye so that we can see what we are dealing with,’ she tells him. ‘Then we can give you something for the pain.’

  She scrubs up and pulls on a pair of gloves, and then he removes the towel he is still holding clamped to his face. There is a puncture wound on his cheek a little below his left eye, and there are a couple of obvious minor lacerations closer to the eye itself. When she gently raises the lid of the eye itself, she finds the eye socket filled with a thrombus (a blood clot) masking any internal structures.

  This is all clearly major, and well outside Leonie’s expertise. She hastily applies a light dressing comprising a saline-soaked gauze pad to the eye, and then calls Ivan to discuss a plan.

  He listens to her description of the injury

  ‘I’ll get there as quick as I can,’ he says. ‘But, in the meantime, you will need to get his pain under control.’

  He offers specific instructions on the analgesia to administer. Between herself and his partner, they wrestle Hemi out of his wetsuit. As soon as she has access to his arm, Leonie gives him some pain relief intravenously and an anti-emetic to prevent nausea: the last thing a damaged eye needs is the pressure that vomiting causes. They bundle him up in woollen blankets—enough to warm him, but not so much that he will overheat.

  Ivan arrives. He wastes no time in scrubbing up so that he can perform a detailed examination. As he removes the thrombus, he remarks that, contrary to popular belief, the eye wall is strong and will often survive a blow administered with great force.

  But as soon as he begins his inspection any optimism he might have felt leaves him.

  ‘It’s not good, I’m afraid,’ he says. ‘I can see most of the very inner structures of the eye.’

  Now that the pain relief is working, Hemi seems more curious about his injury than anything else.

  ‘What can you see?’ he asks.

  ‘Well, I can see some of your inner eye soggily clinging to your lower eyelid. The sclera has been badly damaged . . .’

  Hemi continues to ask questions while Leonie phones the Auckland Hospital Eye Registrar to discuss Hemi’s pending admission and then to request the despatch of the Auckland Rescue Helicopter. Hemi naturally wants to know what his chances of being able to see out of that eye are. Ivan deflects those questions. It is not until after he gets to the Eye Department at Auckland Hospital an hour later, and undergoes an examination under general anaesthetic that Hemi is told his chances of regaining sight in his left eye are pretty much nil.

  Hemi has always loved surfing. He has described it to Leonie as ‘riding on God’s energy’. He was surfing a break at a remote Aotea beach that beautiful spring day when the wave broke and pitched him, board and all, into the water. The nose of his board struck him directly in his left eye and the weight of the water pressed him down into the sand. It took all his reserves, as he will tell Leonie later, to stay conscious and to fight his way back to the surface. He remembers that first gasp of air as the sweetest of his life.

  He doesn’t remember much about the struggle up the track from the beach, or the 40-minute drive to the health centre. It all has the quality of a nightmare from which he has been unable to wake.

  The hospital performs a basic repair soon after admission. Later, one of the specialist eye nurses explains to Leonie that it is standard procedure in cases of major trauma to the eye: as the swelling subsides over the course of the next few days, the patient can come to terms with their loss before actual enucleation (the removal of the eye) is performed.

  The CT scan shows that there are blowout fractures in the eye socket floor with soft tissue prolapsing into the adjacent sinus. It seems that the nose of the surfboard entered his eye socket directly and destroyed the eye; another millimetre or so and it would likely have entered his brain.

  While he is resting in his hospital bed with both eyes bandaged, Hemi is in a dream-like state, a place where, as he tells Leonie, time both stands still and moves at a million miles per hour. It is hard to get a grasp on what is real and what is imaginary. The eye nurses indicated to Leonie the importance of voice and touch in providing comfort and reassurance when one’s world is tipped on its axis. They are an anchor in the confusion. It is a reassurance that he is still alive, and this is something that he clings to.

  Ten days after admission, the eye is removed and the socket reconstructed, the preliminary step before fitting Hemi with an ocular prosthesis (a false eye) down the track.

  Hemi’s whakapapa is Ngāti Kikopiri, a hapū of the Ngāti Raukawa iwi. His cultural heritage is rich with Māori and Pākehā kinship ties, and he moves easily between both cultures—but, as he recovers from his injury, he tells Leonie that perhaps because of his bushman grandfather, who was a big influence upon him as he was growing up, it is from his Māori heritage that he draws strength and the necessary perspective to deal with grief and loss.

  Eventually he, his partner and their child can return to Aotea to continue his rehabilitation. Leonie has followed his progress every step of the way. The eye nurses hand over to her to supervise the ongoing process. She has admired their specialised skills, and appreciates their advice in how to support Hemi in his recovery. He is still experiencing throbbing pain in the eye socket. Sometimes it is in the background; other times it is severe. He is also bothered by dizziness. The eye nurses assure Leonie that this is typical. The loss of depth perception is profoundly disorienting, and it takes a while for the brain to adjust to monocular vision. But perhaps the more significant hurdle to his recovery is the psychological struggle he may have. Leonie will have to observe for signs that he is failing to cope with the adaptation to his new, altered reality.

  Leonie gets to know Hemi well over this period. She admires his attitude, how he remains articulate about the emotions he is experiencing. He is determined to heal, both physically and spiritually. When the time comes, he plans to bury his enucleated eye at his marae.

  ‘How are you feeling?’ Leonie asks him.

  ‘I’m OK,’ he says. ‘Funny, but I feel like I’ve learned from all this,’ he says. ‘It has been really enlightening. I’ve tried to throw all my resources into healing. Having a positive life philosophy and my tikanga Māori has really helped. This hasn’t necessarily been a tragedy,’ he adds.

  Leonie has learned, too, and far more than just some of the techniques of caring for those who have suffered eye trauma. She has learned much about resilience, and about how and where we look within ourselves for healing.

  He pō, he pō

  He ao, he ao

  Tākiri mai te ata

  Korihi te manu

  Ka ao, ka ao

  Ka ao te rā

  Darkness, darkness

  Light, light

  Day has dawned

  The birds are singing

  It is light, it is light

  The sun is shining

  This is not the first serious eye injury Leonie has dealt with on the island. Several years earlier, a patient had presented unremarkably to the front desk of the health centre with his fist clamped over his left eye. Leonie ambled over to his side as she passed through the waiting room, and was immediately struck by how pale he was.

  ‘You’d better come with me,’ she said, and led him into the nurse’s station. ‘What happened?’

  ‘I was at home putting a window into my excavator. Slowly, as I fed the rubber weather strip around, I needed to lever it in tighter with one of the two screwdrivers I had. I just needed to put a bit more pressure on . . . then it slipped. Ping! Straight in my eye. Oh hell
, I think. Thirty seconds later I’m thinking, Well, I can think. That must mean I’m not dead. Praise God I’m still alive and the screwdriver didn’t get to my brain. I knew I needed help, so I put the dogs away in their pen then drove here.’

  ‘You drove yourself?’

  ‘Yes. First gear all the way. What else could I do?’ He grinned. ‘Not sure how I made it, but here I am.’

  Leonie was horrified. She peered to see if she could see the offending screwdriver protruding from his eye. All she could see was his hand. She settled him on the examination couch and dashed off to locate Ivan.

  As Leonie organised the intravenous pain relief and anti-emetic, Ivan scrubbed up and peered closely into the left eye.

  ‘You have a disrupted orbit,’ Ivan pronounced.

  ‘What’s that in English?’ the digger driver asked with a grin.

  ‘I can’t tell exactly what you’ve done to the inner structures, but I can see the wound involves your cornea and I can see bits of your iris protruding. There’s a large blood clot beyond that, so I can’t see what’s happening at the back.’

  The eye specialists at Auckland Hospital would likely inspect it all under a general anaesthetic, he added.

  The patient needed no persuasion to be evacuated immediately to the mainland. Leonie made the arrangements, and then rang around until she located the patient’s son.

  Minutes later, he was there.

  ‘Dad! What have you done to yourself?’ he asked.

  His dad explained, and then calmly issued instructions on what needed doing around home. By now, Leonie had dressed his eye, and the pain relief was working well. His vital signs were stable. Soon the helicopter arrived to whisk him off to Auckland Hospital, still in his work clothes and hefty boots.

  Nor is Hemi the last to lose his vision in Leonie’s time, although the third case is not the result of trauma. One day, a local woman—a farmer—presents complaining of a loss of vision in her right eye.