A Nurse's Story

by Tilda Shalof

  I watched Laura’s pretty face, its indignant expression and fine, delicate features. Her attractive appearance was so at odds with the harshness of this story. It seemed that none of this shocking information stopped Laura from enjoying her coffee and toasted English muffin with peanut butter. But then, I asked myself, why should it? She has to eat breakfast. Who would want a hungry nurse?

  I had passed Mrs. Wong’s room earlier that morning and guessed now that the two teenagers I had noticed standing outside her door must be her children. The boy wearing a denim jacket and an absent expression must be around sixteen or so. The girl in a school uniform with a tiny knapsack on her back looked about twelve.

  “One day they have a mother, and the next day they don’t?” I said.

  “Well, it’s not over yet. She might make it, if the bleed is localized, but it’s a slim chance,” said Laura with a grim expression.

  She sounded like she was the patient’s doctor, not nurse. But what was a doctor? What was a nurse? These roles all seemed to be changing, especially in the ICU.

  So, Mrs. Wong is hovering, I thought, suspended, neither here nor there, in such an uncertain place: neither dead nor alive. No wonder the children’s bewildered eyes.

  “What really got to me,” Laura went on, “was when I opened the locker where we stored her personal belongings. I pulled out plastic shopping bags full of grapes and rice and bok choy and gave them to the kids to take home. Imagine, a mother’s last actions, buying food for her family.”

  “Was Mrs. Wong previously healthy, no past medical history?” Tracy asked as she munched on her signature bacon, cream cheese, jam, and ketchup sandwich – salty, creamy, sweet, and sour.

  By her wry smile I knew a joke was coming.

  “Yeah, aren’t they all?” retorted Laura. “They’re all healthy before they get sick.”

  “Then something must have gone tewibbly wong,” said Tracy.

  As we were going up in the elevator, we stood in front of two surgical residents and we couldn’t help but overhear their conversation.

  “… What a trip that was, harvesting the heart! But by the time I scrubbed and got in there, it was too late, they’d lost perfusion. They opened her up after things got really bad, but by then they couldn’t get control…. Man, when things go wrong, they go really wrong.”

  “Weally, weally wong,” Tracy whispered and we burst out of the elevator laughing our heads off.

  How long could I remain sad about everything? I asked myself. I relished the relief that laughing brought. Besides, I couldn’t be part of this group and always be standing off to the side, always the sober, observing one, could I? These nurses found laughs in everything. Even if something wasn’t funny, they made it so. I was trying to hold in my mind simultaneously all the contradictions of my new work – respect and irreverence, humour and sadness, hope and despair, compassion and detachment.

  “What’s so funny?” Ivan asked me when I told him about some of the amusing things that happened at work. “I can’t understand how you guys can laugh so much. It sounds pretty sad to me.”

  I did have a lot of fun at work. What was stranger still was that the sicker the patients – the more unstable they were, the worse their conditions – the more fun we had, and the more we laughed – always behind closed doors. How could that be possible and at the same time be true that we were kind and caring nurses? We had all chosen nursing as our life’s work, and our specialty, critical care, was the business of suffering and sorrow. Even if the outcome was good, there was still a great deal of suffering along the way.

  I had to laugh. Laughing with the nurses assuaged a despair that had lodged tenaciously in me for many years. It was a despair that I tried to keep secret, yet friends told me they saw it ingrained in my face, in the slope of my shoulders, in the droopiness of my eyes.

  GRADUALLY, ROSEMARY BEGAN to assign me more challenging patients. For the most part, I coped with whatever came up, but I noticed an uncanny phenomenon that I never figured out. Whenever I was getting out of my depth, or not sure about something, one of them – Laura, Frances, Nicole, Tracy, or Justine – suddenly appeared. They seemed to know just what was needed, usually without asking me. They each had their own patients and were busy too; how did they know I needed help?

  A lot of patients died in the ICU, but so far since my orientation with Frances, no one directly under my care had died.

  My introduction to death came from one of my favourite night nurses. Valerie was a dark black woman from St. Lucia who had lived in England for many years. She could be intimidating because, while she carried herself with the air of sophistication and elegance like the royalty of her adopted country, she was at the same time blunt in her way of communicating. She came to work with a briefcase that she gripped in a hand that was always beautifully manicured with scarlet or fuchsia fingernail polish. In that briefcase she kept handwritten manuscripts of Victorian mysteries that she worked on downstairs in the dimly lit cafeteria during her break.

  “Your patient is dead,” she said by way of greeting as I walked in to start my shift. She ripped off a strip of heavy-duty cloth tape from her table, rolled it up into a ball, and tossed it into the waste-basket. On it she had jotted her “nag list.” This was what she called her list of point-form notes of concerns she had about her patient and issues she had wanted to raise with the doctor during the night. They were obviously no longer relevant.

  “What ventilator settings is he on?” I asked.

  “I told you, Tilda, he’s dead.”

  “Meds? IVS?”

  “No meds. He’s dead. Got that?”

  But there was a person in the bed and the equipment was running; green lines marched across the cardiac monitor. From where I sat with Valerie, I could see that the patient, a young man, was in a normal sinus heart rhythm, which meant that his heart was functioning properly. The ventilator was pumping air into his lungs, which were rising and falling, and a steady drip of urine flowed into the urometer. These were all the vital signs of life, as I had learned them.

  “I’m not too sure what you mean by dead,” I ventured.

  “Two staff doctors have declared him brain dead, legally and medically. The family just left and they have refused organ donation. All you have to do now is disconnect everything, wrap him up, and send the body to the morgue. If you don’t get another admission, you’ll have an easy day. You can float around and help the others.”

  “Please, Valerie, I don’t understand. Surely he’s not dead.” He looks great. “I want to get this right. I can’t disconnect life support on a man like this.”

  “I know, it’s very sad. He’s a young man, only thirty-six. Seems he was having sexual intercourse with his wife and suddenly, in the middle, had a heart attack. Tragic. But don’t worry, Tilda, you can’t do anything wrong, because he’s dead.”

  “But …”

  “Read the doctor’s report of brain death yourself. Pupils fixed and dilated, absent reflexes, and a failed apnea test. It’s all there. You’ll be out of a job now,” she said.

  For a moment, I thought she meant I would lose my licence.

  “Need a hand?” asked Tracy, her tall, lanky form suddenly appearing at the doorway.

  AS I BEGAN to be assigned to more and more complicated cases I could see the others trusted me and so I began to trust myself. But then, one day, something happened that made me think of giving up. If it hadn’t been for the support of my group – Laura’s Line – I might have.

  “How was your night, Casey?” I asked as I came into the room one morning.

  She was a heavy-set, grey-haired older nurse who worked her fair share of nights. She always complained that she was tired, but it was hard to believe her because she spoke with such verve, rarely went on a break, and never took shortcuts with patient care. She always gave a colourful and entertaining report, and I got ready to listen to it.

  “A-OK. I’ve been flying on cruise control, but I’m glad you’re here
, Tilda. I’m really beat.”

  Casey had already changed out of her uniform and into her street clothes. This was clearly going to be a straightforward report. A cut to the chase.

  “She looks good, Casey,” I said, glancing over at a tiny white-haired lady in the bed. She had an oxygen mask on her face and it was on maximum flow. Her breathing was rapid and shallow, but she looked well taken care of and perfectly aligned in the bed. The covers were smooth and the room orderly.

  “Grab a chair, darling, and I’ll give you the scoop. Mrs. Templeton is an eighty-six-year-old woman who lives at home with her grown-up son. Congestive heart failure, emphysema, and now pneumonia. She’s been trying to die for a few days, but he won’t let her. He wants her intubated and ventilated, the whole nine yards. We’re treating him, not her. Anyway, she was stable during most of the night. At one point she was trying to climb out of bed and pulling at her tubes, so I had to restrain her and give her a whiff of sedation. Anyway, I’ve got her all buffed, puffed, and fluffed for you. Make sure you grab a coffee before the charming son comes in. He’s been here all night and apparently stays all the livelong day, too, if you let him. He’ll be in here soon, breathing down your neck, asking you a million questions. Doesn’t believe that visiting hours apply to him. Well, that’s the story, that’s the glory.”

  “Maybe someone should have talked to Mrs. Templeton before she got so sick, when she could still express her wishes,” I said, thinking out loud.

  “Woulda, shoulda, coulda – do you ever watch Judge Judy? – oh well, it’s too late now.”

  She pulled her knitted poncho on over her head. “I’m outta here.”

  “Thanks, Casey. Good night. Sleep well. See you tonight.”

  I began to go through the chart for a more comprehensive medical history. When I looked up, I saw a tall man glaring down at me through thick glasses. For someone who had likely slept overnight on a couch in the hospital waiting room, he was immaculately groomed and dressed. His plaid shirt was tucked tightly into dark trousers that rode up high on his waist, cinched tightly with a leather belt.

  “Who is my mother’s nurse today? Is it you?”

  “Yes,” I said and introduced myself.

  “Are you aware of Mother’s condition?”

  “To be honest, I’ve just started my shift. I’m about to start my initial assessment.”

  “I’ll just wait here while you do that and then you can tell me what’s what.”

  I wasn’t used to having an audience, much less a likely critic of my work. It made me uncomfortable to perform my head-to-toe assessment under his watch. Some nurses made family members wait outside until they were finished their work, but I was afraid to ask him to leave.

  “She’s struggling with her breathing and very weak, but her blood pressure is good,” I told him afterwards. “She has a fever, but we hope that the antibiotics will take effect soon and she won’t need to be intubated and go on the ventilator.”

  “Well, whatever she needs, she should have. She’s a fighter. We want everything done to save her life.”

  “You know, Mr. Templeton, the doctors and nurses – plus the rest of the team – would like to have a meeting to talk with you about the situation,” I said gently. “In the event of –”

  He cut me off with a scowl. “I know what you’re getting at, and there is nothing to talk about.”

  By then, a crowd had gathered in my patient’s room. Dr. David Bristol, one of the staff physicians, and Dr. Jessica Leung, the senior ICU fellow, accompanied by the residents under her supervision, along with Rosemary, the pharmacist, and respiratory therapists and other nurses who were able to attend, arrived for morning rounds.

  “Mr. Templeton,” I said to him, “the team is here to discuss your mother’s case. She’s stable and in no immediate danger. Would you like to go to the waiting room?”

  He scrutinized me with hostile eyes and folded his coat over his arm. “I want Mother looked after immediately. I’ll wait just outside the room. I’m not going anywhere. I have a number of questions for the doctor.” He didn’t leave right away, however, but fussed with his mother’s pillows and blankets for a few minutes more before going out the door to stand in the hallway.

  Justine had just finished transferring her patient to the ward and came over to join us on rounds. Short and pretty with flaming red hair pulled back in a ponytail, she was oblivious of her attractiveness, yet always highly aware of her intelligence and sharp wit, which she could use like a weapon at times. Justine was our union representative, and we knew that our concerns were well taken care of. Over her loose-fitting ICU scrubs, she wore a baggy white sweatshirt emblazoned with “Nurses Care But It’s Not in the Budget” in red letters. Purple socks, running shoes, and earrings in the shape of tiny flowerpots, finished off her get-up. She stood with her hands on her hips, watching the son tend to his mother before he left.

  “What’s with this guy? He needs to get a life. Is he still on the breast?” She tried to whisper, but I think Justine was constitutionally incapable of lowering her voice. Her sotto voce was heard by other members of the team, who tittered at her comments.

  “Shh,” I hissed at her, but couldn’t help but laugh a little, too.

  “In the absence of advance directives from the patient herself, and given the inability of the patient to speak on her own behalf, due to her decreased level of consciousness,” Dr. Bristol was saying, “we will be advised of the patient’s wishes by proxy. The son is her substitute decision maker and will represent her wishes. Has he been spoken to?”

  He had been, by me, and I volunteered what I knew.

  “He wants everything done. She is to be a full code – inotropes, intubation, cardiac compressions, and defibrillation – in the event of an arrest. Whether those are his or his mother’s wishes, I can’t be sure.”

  “Well, continue then we must. It would be a shame to intubate her as she’ll be difficult to wean off the ventilator, but it doesn’t look like we can hold off much longer,” Dr. Bristol added, as he glanced at the deteriorating numbers and failing lab values recorded on the flow sheet. “Her work of breathing is considerable.” He paused. “Sometimes it’s easier not to start things at all than to withdraw them later,” he mused.

  Mr. Templeton confronted us in the hall as we came out of the room. “I want to understand.” The team moved on with Dr. Bristol at the head, but Dr. Leung stayed behind to answer Mr. Templeton’s questions.

  “The problem is her lungs,” he said. “What if I sit with her and remind her to breathe, won’t that help? What about the pneumonia? Is it just in her lungs or is it anywhere else, too?”

  “Yes, her respiratory status is the primary system affected.” Dr. Leung spoke slowly and carefully, to avoid misinterpretation. “But she is frail and debilitated and eighty-six years old, with a chronic, irreversible disease. She doesn’t have the recuperative powers of –”

  “She’s eighty-five. Who said she was eighty-six? I want that corrected.”

  I came forward and assured him it would be.

  Later that day, during the shorter early evening team rounds, Dr. Leung got right to the point.

  “The nurse and I spoke again with the son about withdrawing care and he was –”

  Dr. Bristol interrupted her. “We never withdraw care. In certain circumstances we may withdraw treatment, but never care.”

  “You’re right,” she agreed.

  I looked at him with huge respect. I loved working in a place where words mattered.

  “WHAT ARE YOU giving her?” Mr. Templeton jumped when he saw me drawing up medication in a syringe.

  “A small dose of morphine. Your mother’s breathing is laboured and she’s in respiratory distress. It will make her more comfortable.”

  “No, I don’t want her to have it. She won’t be able to fight. It will make her too groggy and she won’t recognize me. No, I don’t want her to have morphine or any sedation. Nurse, why are there bubbles in the
IV tubing? What about that moisture in her oxygen mask?”

  I flicked the bubbles out of the tubing and wiped out the condensation from his mother’s breathing mask.

  One of the junior residents came to tell Mr. Templeton that she was going to put in a special intravenous line called a pulmonary artery catheter. Its purpose was to measure the various pressures in the chambers of the heart. The son looked pleased with this plan, even after hearing that there were risks involved, such as blood clots, air emboli, and infection. He glanced over at me, as if vindicated.

  MRS. TEMPLETON WAS restless, flailing her arms about in the bed as the doctor tried to insert the line into a deep vein in her neck.

  “You’re going to have to tie her arms down,” the resident said in frustration. “I can’t get this line in with her moving all over the place.”

  Maybe she’s trying to tell us something.

  “Maybe she’s trying to …” I started to say, and then stopped myself.

  Soon there was blood all over the bed and clots hanging off the doctor’s gloved fingers. The patient will need a blood transfusion after this, I thought. The doctor carelessly squirted blood from a syringe in the general direction of the wastebasket, spraying it out in all directions, dangerously close to me, where I stood at the side of the bed.

  “Hey, watch out,” I said, stepping back.

  “Sorry. Did I get you?”

  “Have you done this procedure before?”

  “Once.”

  “What are we trying to accomplish here?” I asked, knowing I might be getting on her nerves. She had a job to do and I was distracting her with my questions.

  “We need more information about her right and left chambers so that we can differentiate between pulmonary edema and possible cardiac failure. Fluid management will be guided –”

  “I know what the textbook says, but do you think we should be doing it? It seems kind of, well … cruel. She clearly doesn’t want it.” I hated having to hold down Mrs. Templeton’s frail arms as she struggled to get away from what must have felt like an assault.