by Tilda Shalof
“David Bristol came into my room today,” said Laura, gearing up for a tirade rather than a confession. “And he says to me, why are your urine totals always listed in multiples of 5? Doesn’t your patient ever put out 33 cc or 46 cc? How persnickety can you get? He tells me it’s inaccurate to round them off! I told him I’m not a 3 cc nurse.”
Morty’s story was about someone else’s misconduct. “I couldn’t believe the nurse who brought down a patient from the floor this morning. The patient had arrested up there, but she stands there and tells me that she hadn’t done his vital signs because she had gone on her coffee break. ‘What did you say?’ I asked her. I’m thinking, I’ll give you another opportunity to change your story, sister. Let’s just pretend I didn’t hear that. But she said it again. ‘Yeah, I never do my vitals until after my coffee break.’ By then they’re not vital any more, are they? I said to her. She was scary.”
“Was she black?” asked Belinda, who was.
“What’s the difference?”
“You said ‘sister.’”
“As a matter of fact she wasn’t, but what’s your point?”
“You white chicks don’t believe me, but black people are stereotyped. Everyone thinks we’re lazy. I’ll be sitting at the nursing station with a white nurse and someone needs help with their patient. Who are they going to ask? Me, because they assume I’m sitting around doing nothing anyway.”
The gauntlet had been thrown down to the right person, and Morty rose to the challenge.
“Belinda, the population of Toronto is now more than 50 per cent immigrants. Our profession is well represented by women and men of colour. Maybe at one time nursing had a conservative, white-bread image, but no more. Don’t you think you’ve got a bit of a chip on your shoulder?”
“A chocolate chip, I’d say,” said Laura with a snort.
“Is that so?” shot back Belinda. “And how many black nurse managers do you know of at this hospital? Sure, there may be a few token black doctors and lots of cleaning staff, but how many black middle management or nursing leaders do you see? Racism is everywhere. It always will be. Haven’t you ever noticed on a news report they don’t mention that it’s a white guy who commits a crime, but they do mention if he’s black.”
“What if it’s a girl? They’ll be sure to mention that!” I said. “What was your scariest thing, Bruno?” I wanted to bring the discussion back to my topic. I had meant his scariest thing with patients, but Bruno blurted out what was obviously on his mind.
“Waiting for the results of my AIDS test,” he said. “Those twenty-four hours were the worst, the scariest.” He looked off into the distance.
“Even scarier than the answer?” someone asked.
“Yup.”
Nicole jumped in to deflect the uncomfortable spotlight away from Bruno.
“My worst mistake happened at the last hospital I worked at with a multiple myeloma patient I brought to the ICU from the floor. She had excruciating pain throughout her entire body. She was thrashing around and crying out to Jesus for mercy. The pain had turned her into a raving animal. Her iv bag was empty so I changed her morphine over to one of our bags from the narcotic cupboard. I got busy taking blood work, an X-ray, an ECG, drawing blood cultures, and all the time her family was breathing down my neck. The patient kept on screaming. But then, over a few minutes, she settled down and even fell asleep. Then I realized she wasn’t sleeping; she was right out of it. I called her name, tried to get a response, we almost had to call a code. Then I noticed that the concentration of the pre-mixed morphine bag was twice what she’d been receiving on the floor, yet I had been running it at the same rate. Double the dose should have been running at half the rate! I should have cut the rate! Shit, I thought, and ran to get some Narcan! You know what? In seconds, she went from almost being in a coma to rearing up like a horse. Her eyes wide-open, wild. Man, that stuff works! Then I calmed her down, gave her Tylenol for her fever and she said she felt better and was so grateful to me. Should I have mentioned, ‘Well, that’s nice, because I almost killed you’?”
We all nodded. It was time to go back to work. We threw away our litter in the wastebasket, folded the bedspread, and walked back into the hospital together.
We were solid citizens, weren’t we?
IT MADE ME recall a party I had gone to once. When people heard I was a nurse, everyone asked me about the case of a young girl who had died in hospital and the two nurses who had been charged in connection with her death.
“I just know what I read in the newspaper, like everyone else,” I said, my palms up to show they were empty. “I don’t have any inside information.”
“How could it have happened?” everyone asked me. “How could a young girl die like that?”
“She had intractable pain. They were running high doses of morphine because she was continually complaining of pain. Maybe she needed closer monitoring or maybe it was a freak reaction, but for some reason, she had a respiratory arrest. She was young and fairly healthy, but they weren’t able to resuscitate her. It’s tragic, but I can imagine how it could happen. Morphine can be a dangerous drug.”
“The nurses wrote her off as a hypochondriac and thought she was trying to get attention,” someone said. “The mother was getting on their nerves so they ignored her. That’s what it said in the newspaper.”
“I can see both sides,” I said.
“Why do you always sit on the fence?” Ivan asked, impatient with me. “Surely you have an opinion.”
“My opinion is that it is tragic. A young life was needlessly lost. Maybe there were staffing problems. There was probably carelessness, a lack of vigilance; both are human mistakes. There are possible explanations, but no excuses. I doubt it was intentional. I don’t think those nurses deserve the same treatment as someone who is accused of assault or murder. I’ve seen nurses rushed or disorganized or overworked, but I’ve never seen intention to harm.”
Maybe I did sit on the fence, but that was the only vantage point from which I could see both sides and possibly begin to understand the complexity of it all. And it was only from understanding it that there was a chance to find ways of prevention and correction.
I recalled what Laura often said, “It’s like when doctors say the cause of some problem is ‘multi-factorial.’ What they mean is, we haven’t a clue.”
I HAD BEEN trying to help a nurse who had recently joined our ICU.
“You make me feel like I’m in kindergarten,” Vicky said in exasperation. “Do you think I don’t know anything? I’ve been a nurse for nine years. I’ve worked in palliative care, in obstetrics, psychiatry.”
“Yes, but you’ve only worked in critical care for two weeks,” I said.
Not only that, but you have a lot to learn, I refrained from adding, when I saw the embarrassment I was causing her. Vicky was a recent graduate from the critical care course and had been buddied with me to help ease her into the ICU.
“You hung a drug without a label on it. How would anyone else know what’s in that IV bag? You stuck a needle in the patient’s pillow –”
“I meant to remove it,” she explained.
“But you forgot and it’s a dangerous habit. You didn’t transcribe the doctor’s orders and see, now the patient has missed her 1400 hours dose of ampicillin.”
Frances walked by to see what was going on. My face flooded red with shame. Frances, who had been so patient with me when I was new, had caught me with the tables turned.
“It’s time for your break, Tilda,” she told me with a wink and a shove in the direction of the door. “I’ll work with Vicky.”
ON ANOTHER OCCASION, just as I was getting ready to leave at the end of a shift, my patient, who had been extubated and had improved over the course of the day with me, called out.
“Nurse, I’m dying. You gave me the wrong pills. Are you trying to poison me?”
I pulled up short. There had been a time in my career when a comment like that would have made
me defensive, but not any more. I looked over the medication record, reviewed the drugs I’d given, matched them against the doctor’s original orders. I kept in mind that the patient was still confused from his chronic liver failure and also claimed he was making a tea party for his friends on the ceiling of the antique shop in his kitchen. I looked at the bottles and vials I’d used that day. I recalculated the dosages of drugs I’d given. Mentally, I went through all the motions of my day.
“Good night,” I said to him. “Sleep well.”
When I was driving home or just as I was dropping off to sleep at night, of all the many good, helpful things I had done in any given shift, the one thing that always would pop up in my mind was a medication I forgot to sign off; a volume of bodily fluid I had neglected to add to the tally; the blood work I’d sent off in a green-top test tube that should have gone in a red top.
“It happens to me, too,” said Frances, “all the time.”
MARIANNE SORENSEN WAS one of the sickest patients I’d ever taken care of. She had undergone a lung transplant for pulmonary fibrosis, a serious condition that in her case had no known cause and was likely terminal. Both during and after her surgery, Marianne experienced many complications: bleeding, pneumonia, an acute rejection reaction, and poor oxygenation. A drastic measure had to be implemented on the day that I was taking care of her. It was called ECMO – extra corporeal membrane oxygenation. It was an advanced, highly technological procedure, usually performed only in the operating room during open-heart surgery, to bypass the heart and lungs and take over the work of these essential organs. In Marianne’s case, it would be used until her own heart and her new, but fragile lungs recovered.
That afternoon, Team Canada was in the final game of a hockey tournament against Team USA in the Olympics in Nagano, Japan. The broadcast was playing softly on the radio at the nursing station and in a number of patient rooms throughout the ICU. On and off throughout the day there were ripples of cheers or groans.
All the while, in Marianne’s room, we were participating in a far more fateful Olympics. We kept our eyes on the numbers, waveforms, and oscillator screens that helped us navigate through her body. I didn’t dare look at Marianne’s face because I didn’t want to see a certain expression that I’ve seen on some patient’s faces. When I see it, it sometimes makes me lose faith that we will be able to turn things around. I didn’t even have a moment to glance at Marianne herself, her exposed, stretched-out body, much less her grey, ashen face, so busy was I fighting to get oxygen into her blood cells, working with the medications to increase her circulation, balancing her fluids so that enough was going in, and coaxing more to come out.
Out of the corner of my eye, I glimpsed the anxious faces of her husband, mother, father, and sister, who were hovering in the background, but I had no time to answer any of their questions or offer any words of reassurance.
Toward the end of the day, Team Canada lost and we were afraid we were going to lose Marianne’s life, too.
“We’ll try ECMO,” Daniel Huizinga told the family. “It’s a last resort. Some centres have modest success with it. It may help, it may not. The next twenty-four hours will be crucial.”
In one hand I held a thick tube of the bright cherry-red blood that was being returned to Marianne’s body, saturated with oxygen molecules. In my other hand, I held a slightly cooler, darker tubing of blood that was flowing out of her body. It was the spent, venous blood that had been used by her body to sustain life, moment to moment. There had never been a time when I felt more literally that a patient’s life was in my hands.
“I suggest you get some rest,” I told the family, whom I knew had been up all night and all day. I offered them blankets and towels. “You can lie down in the waiting room. Take care of yourselves. Whatever happens with Marianne, it will be a long haul for everybody.”
“Will she make it?” The mother clutched my arm, my hand – at straws.
“I don’t know. We’re doing our best … she’s hanging in there.” They needed more from me than that. “She’s critically ill and we’re fighting for her life. Right now, it’s all about heartbeats, oxygen, blood pressure.” Then I thought of something useful to say. “I have seen other young people who were this sick get better.” That gave them some hope, I could see.
“Do you think it’s safe to leave her for a little while to get some rest?” they asked.
If I said yes and something happened, they would never forgive me. If I said no, they would exhaust themselves and be of no use to themselves or Marianne. They saw my hesitation and didn’t press.
For the rest of that day, I worked nonstop. Frances, Laura, Tracy, Justine, Nicole, and many others were also there, helping.
Frances tried to pull me away to take a break, even ten minutes.
“No, I can’t,” I insisted.
I was high on this powerful drug. It was the most thrilling thing in the world to be working so hard to save a person’s life.
When my shift came to an end, it was time to hand Marianne over to the night nurse who was coming in to replace me. My heart sank when Pamela walked into the room. She was a competent nurse, but I didn’t trust her to give the extra vigilance required, the extra tender touch, the kind words I wanted for the family. I toyed with the idea of staying for an overtime shift. It would be twenty-four hours and I’d be on my feet constantly, but I was pumped for action. Maybe I could do it.
“You can’t do that, Tilda. It’s crazy,” said Frances. “You’ll be exhausted. It’s not safe for the patient or healthy for you. No way. Go home.”
So, reluctantly, I handed over my baby to another mother, Pamela. She didn’t look happy about it.
“I didn’t want a busy patient,” she grumbled. “I’m tired. This is my fifth night in a row. I should have called in to ask for an easier assignment.”
“Why are you working so many shifts?”
“We just bought a new house and want to take the kids on vacation this winter, and I’ve gotten way behind on my bills. Man, I’m beat and the night hasn’t even started.” She took a sip from her cup of coffee.
“Maybe you’d like to switch with another nurse. Marianne is very sick. You’ll definitely have a busy night. She’s on ECMO.”
“Shit! I’ve never had an ECMO patient before. It’s a lot of work, isn’t it?” She surveyed the huge complicated machinery and the thick tubes of blood going in and out of the patient’s arteries and veins. The perfusionists were responsible for the machines, but Marianne was very unstable and would need constant, unrelenting, unwavering nursing care every minute of the night.
The next day, I couldn’t wait to get back in there with Marianne and her family.
“I got her through the night, but I didn’t get a break,” said Pamela when she saw me. She yawned widely. “Thanks for coming in early. I can’t wait to get out of here.”
My worries were for nothing. Marianne had improved during the night under Pamela’s care. All the work was neatly done. All the blood work drawn, vital signs recorded accurately.
“How about the family? How are they holding up?”
“What family? They called in to come see her, but I don’t let families in at night. She doesn’t need visitors now. The patient has to rest. The nurse too.”
Marianne spent many difficult weeks in the ICU and experienced even more complications – a bowel obstruction, internal bleeding, blood infections, and briefly, kidney failure that required dialysis. Each time, we thought it was the last thing, but she made it, over and over again.
Her mother spoke to me during one of the crises. “For months now, we’ve had to keep preparing ourselves for the possibility that she’s going to die and, at the same time, pray that she’ll make it.”
Marianne’s body and mind made it intact, but her spirits were very low.
A photograph on the wall in Marianne’s room of her beloved golden retriever, Hugo, gave me an idea. I conspired with her husband, got our nurse manager’s approva
l, and obtained clearance from the infectious disease specialists. (I had brought a patient’s dog in once before and it had definitely cheered up the patient. Unfortunately, it was the only time I ever saw a dog cry. I am certain that the dog was crying.) Some nurses were wary of my plan, but most supported me. Marianne’s mother was unsure. Marianne’s husband, Rick, was excited and believed wholeheartedly that bringing Hugo in would delight Marianne and lift her mood. But Pamela happened to come up in the elevator with Marianne’s mom and they discussed the dog’s upcoming visit.
“I wouldn’t let a dog in if I were sick,” Pamela said to the mother. “Dogs have germs. Their mouths are full of bacteria. You can get all kinds of diseases from animals and Marianne is already immunosuppressed. That’s all she needs.”
The mother forbade the dog to visit.
THE WORST MISTAKE I ever made is one that still fills me with regret. I saw it over and over again and didn’t do anything about it. No one did. My biggest mistake was Pamela. Pamela was not lazy or stupid or disorganized. She was not bad or evil. Pamela was indifferent. Pamela was completely cut off from her patients’ suffering. Perhaps that degree of apathy and disconnection from human beings – the quality that is the exact opposite of empathy – in a nurse, is a form of incompetence.
On a day when the hospital’s hot water was turned off for plumbing repairs, most nurses boiled water in kettles to heat up their patients’ baths. Some decided to skip the bath for that day altogether. Not Pamela. She gave her patient a bath with tepid water.
Once Pamela called a Code White – violent patient. Her patient was recovering from a drug overdose and was frightened and violent as the chemicals in his body were wearing off. He was kicking and lashing out and security guards had to be called to the ICU to help us restrain him.
“I’ll tie your arms and legs down if you’re not careful!” I heard her shout at him in exasperation. Later, even after he was securely restrained and sedated, it seemed to me that she was just a bit rougher with him than was necessary for her own protection. I should have reported her. We all should have. I should have taken her aside and talked to her, nurse to nurse. I should have tried to reach out to her and make her see how hardened she had become. Perhaps I should have documented some of the things she did. We all knew it was going on and looked away, not wanting to report one of our own.
