Clinical Narrative – Catherine Holley, BSN RN

Main Operating Room, Massachusetts General Hospital

My name is Catherine Holley and I am an operating room nurse on the Surgical Oncology/Trauma team. Each shift, I’m assigned to a specific operating room (OR). On this particular morning, I had the role of circulat­ing nurse, responsible for managing all nursing care within the OR. As the circulating nurse, I have du­ties outside the sterile field, affording me a ‘big-picture’ view of the surgical process while assessing, observing, and assisting the team in creating and maintaining a safe environment for the patient. The first scheduled surgery that day was ‘Betty,’ a breast-biopsy patient.

A critical part of the circulating nurse’s role, in addition to quality care and safety, is a comprehen­sive review of the patient’s medical history. This helps inform a broader perspective of the patient’s overall health, including emotional concerns, do­mestic issues, coping mechanisms, and makes me better equipped to anticipate patients’ needs and advocate for them while they’re anesthetized.   Relationship-based care is deeply woven into my practice. Engaging with patients on a personal level and identifying common areas of interest help build respect and trust in the nurse-patient relationship. In the perioperative setting, there’s precious little time to get to know patients prior to surgery, so es­tablishing trust is a kind of art form.

Betty arrived in the OR area tearful; she was concerned about the results of the breast biopsy. Impending surgery often causes anxiety; I knew I needed to support and validate her concerns. Offering those words that seem so obvious, I assured her that her surgeon was excellent and the OR team was prepared for her procedure.  As I completed her pre-surgical assessment, I had one more question. It’s a simple question, but in my more than 35-year nursing career, it has be­come an essential part of my pre-surgical practice.

I asked, “Is there anything else you’d like me to know; anything else I should be aware of?”

Nodding, she motioned to her right leg.

“I have a problem with my leg,” she said. “It’s very swollen.”

I lifted the blanket and saw that her leg was indeed edematous from thigh to ankle. I asked if she had a history of DVTs (deep vein thrombosis). I palpated her leg, inquiring if there was any pain or if she had any limitations with movement. She said it wasn’t painful, but it was ‘heavy.’ She explained that it had developed after a prior surgery on that leg a few years before.  Betty had seen doctors about the swelling. She’d been told it was lymphedema, but no one had ever offered suggestions on how to care for or treat it.

At that point, I reached down and pulled up the leg of my scrub pants, exposing my own swollen leg. I explained to Betty that I, too, had lymphedema. I’d had it for 30 years, also a result of surgery back when I was in nursing school.

Lymphedema occurs when the lymphatic system is unable to perform one of its basic functions — re­moving water and protein from tissues in a portion of the body. It can be caused by developmental ab­normalities of the lymphatic system (primary lymphedema) or damage to the lymphatic system (secondary lymphedema) from surgery, infection, radiation, or trauma.

Betty had never met anyone with this condition before, and we even had it on ‘the same leg.’ She asked many questions about my experience with lymphedema, if there was anything that could help relieve the swelling, where I received treatment, and where to find compression stockings. I felt a genuine connection with Betty. This was an oppor­tunity to share my knowledge with her as well as my personal efforts to find a specialist and some key points about lymphedema therapy.   I began to educate Betty about the chronicity of lymphedema and how it can be managed with posi­tive outcomes with the help of physical therapy and customized compression stockings. This conversa­tion brought our nurse-patient relationship to a new level. We were two people who shared an un­usual medical condition. She was thirsty for knowl­edge, and her interest in learning more was palpa­ble.  But I was surprised by how our conversation seemed to transform me, as well. I stepped into ad­vocate mode, sharing websites, nationally recog­nized organizations, and other resources. Betty could become her own advocate and through her own research realize the tremendous resources available for those of us with lymphedema. Betty couldn’t wait to tell her husband about our discus­sion; that she’d found someone who understood what she was dealing with on a daily basis.

Betty held my hand and thanked me, saying, ‘fate’ had brought us together. Her gratitude was so heartfelt, it brought tears to my eyes. It was obvious this was a special moment for me, too.

As the circulating nurse, my responsibility is to ensure a safe and protective environment for pa­tients while they’re anesthetized. By identifying Betty’s lymphedema, and along with my own per­sonal knowledge of the condition, I was truly able to be her advocate as we moved forward with her procedure. My input was well received by the team, and as Betty’s caregivers, we all took care to optimize her surgical experience.

Betty’s procedure proceeded without incident or complication. The surgeon excised the breast tissue and the specimen was sent to Pathology. 

Due to the nature of the perioperative setting, we seldom hear the final pathology results or learn the patient’s condition once they leave the OR. But the following week, I sought out Betty’s surgeon and learned that her biopsy had been negative for malig­nancy. She didn’t have breast cancer and would continue to have mammograms every six months. I don’t know what, if any, follow-up Betty received regard­ing her lymphedema. But I believe our honest and very personal conversation would have motivated her to take a greater role in her care, to advocate for herself, and to seek out the appropriate treatment.

When I later reflected on my encounter with Betty, I realized that an unexpected outcome of our meeting was the impact it had had on me. The brief moments I spent with Betty prompted me to re-evalu­ate my journey with lymphedema. I realized that I, too, had a voice, and I should be sharing my knowl­edge to help educate others. I was energized and em­powered to reach out to my colleagues to educate them and raise awareness about the risk factors of lymphedema that can potentially affect all surgical patients.

As a nurse, there’s no greater feeling than know­ing you made a difference in a patient’s experience or had an impact beyond the few moments you spent with them in the OR. I know that meeting Betty certainly made a difference in my life.

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Originally published in the August 4, 2016 issue of Caring Headlines, published by Nursing and Patient Care Services, Massachusetts General Hospital.