The Making of a Nurse

by Tilda Shalof

  The ICU was dark and cramped with two patients in each room. In fact, one room was located so far from the nurses’ station and was so poorly lit that it was called the Cave. Needless to say, no one wanted to work there. There was a hushed, tense atmosphere in the icu, punctuated by the frequent beeping, buzzing, and ringing of machines in each room. Attached to the equipment, the patients were unconscious, lying stretched out on huge beds. The nurses all wore green scrubs, the walls and countertops were pale green, and in my imagination, there was a ghoulish green hue on some of the patients’ faces. The place made me queasy. I jumped up a few times during the nights before work, always afraid I would sleep in. The ICU environment scared me, and the prospect of taking care of critically ill patients terrified me, yet I think that’s why I chose it. I wanted to face what I was most afraid of and master it. I’ll never forget my first day and how Laura, the charge nurse, greeted me. “Welcome to the House of Horrors,” she said with a grim laugh. She was pretty, but I could tell that her good looks didn’t matter to her. In spite of my fear, I couldn’t help but feel thrilled to be part of the ICU team, facing the incredible challenges of bringing people who were on the brink of death, back to life.

  I immersed myself into my work – caring for patients with the most catastrophic, life-threatening illnesses imaginable. There were people recovering from massive surgery to their chest or abdomen and the doctors there were even starting to perform liver and lung transplants. There were cases of cardiogenic shock, septic shock, and multi-system failure, where more than one of the major organs was malfunctioning or had shut down altogether. Doctors were on-call at all times, but each nurse was assigned one or two patients at most and assumed complete responsibility for all of the nursing care that patient needed. Doctors came and went, but the nurses always stayed close to the patients and their families.

  There was so much to learn, so many numbers and formulas to memorize and complex concepts to grasp, that for the first few weeks, I operated on a strictly need-to-know basis. I couldn’t absorb anything extra. Everything seemed urgent and top priority and I wasn’t always efficient enough to get technical jobs done fast enough. For example, I often spent an inordinate amount of time sorting out the tubes, wires, and lines that always bunched up around the patient. The nurses called it “spaghetti” and invariably one of them would sense my frustration and arrive on the scene to help me out. (It was a task akin to disentangling necklaces that become inexplicably and impossibly intertwined from merely lying in a jewellery box.) Those experienced nurses knew lots of tricks with their hands, like how to use gravity or negative pressure to get fluids to flow in or out of the body and how to apply traction or leverage to position patients more comfortably in bed. They often jerry-rigged various pieces of equipment to get them to work the way they liked and some even kept a screwdriver and a surgical clamp (which they used as a wrench when needed) in their pockets.

  Within the larger team of nurses, there were six of us whom I ended up working with closely for many years. We were dubbed “Laura’s Line,” but if we had been the “Spice Girls,” Laura would have been pungent Garlic; Frances, heart-warming Cinnamon; Tracy, elemental, essential Salt; Justine, spicy Cayenne Pepper; Nicky, sweet Maple Sugar; and I, Coriander, an acquired taste that grows on you over time, or so I’ve been told.

  Even back then, Laura was a paradox. Brusque and sarcastic toward doctors, demanding and critical of other nurses, irreverent and dismissive toward administrators and politicians, Laura was at all times exquisitely kind and exceedingly gentle with her patients. She was intelligent and very well read, yet she had little respect for formal education. Patients loved her, but Laura prided herself on never getting too attached to them.

  “One thing, I can tell you,” Laura said to me early on. We were sitting in the staff lounge during a coffee break, and she stretched out on the couch, her arms behind her head. “The personal stuff is highly overrated. I never get emotionally involved with my patients.”

  “How can you care for people and not have a relationship with them?” I asked in dismay.

  “I’ve taken care of a lot of patients over the years and never felt I had to get to know them,” she shot back. “Give me a break, Tilda! There are too many of them and they’re too sick and there isn’t enough time or enough of us.”

  “Haven’t you noticed how it means so much to patients when nurses get emotionally involved with them?”

  “Patients also tend to favour nurses who give them the right medications on time, too!”

  Laura showed little deference to doctors. She addressed them all by their first names and when a weekend was coming up, she not-too subtly suggested that they treat the team to bagels and cream cheese or pastries. And if a resident wanted to perform a procedure on her patient and asked her to bring him sterile drapes, an angiocath, a scalpel, and a pair of forceps, Laura didn’t miss a beat. “Do you want fries with that?” she’d ask. When the doctor finished the procedure and if he should turn to walk out of the room, she would call him right back to clean up the mess of bloody towels, used swabs, and especially “sharps” – the needles, wires, and blades – he’d left behind. “Why should she clean up his mess or risk her safety handling things he had used?” she’d ask him. And just before she released him, if he had written a slew of orders in the chart, she stopped him. “Whoa, there. You can’t split without discussing those with me. I’m in charge of this patient’s care.” Eventually, she set him free and he would scurry off.

  She spoke in the same way to senior staff doctors. If one of the specialists asked Laura about her patient, she might say, “That depends,” not looking up from whatever she was doing. “Tell me who you are first. If you’re from Neurology, then he’s improving. If you’re from Cardiology, he’s stable, but if you’re from the liver team, he’s in a bad way.”

  Once I asked Laura about my patient’s Central Venous Pressure. “Where do the doctors want the CVP to be?” I asked her. By then I understood the various manipulations that we could make with fluids and medications to affect the heart’s functioning. “Where do they want it?” she shot back. “Where do you think it should be? Don’t just follow orders. Think it through yourself.”

  Frances was the softie in our group, and I don’t know how I would have survived those first few scary weeks in the ICU if she hadn’t been there. She always made herself available to me and was at my side the first time I had to suction a patient, something we had to do to remove secretions from the lungs. He was on a ventilator and had a breathing tube. “This will make you cough,” I told him timidly, and he nodded his assent for me to proceed. “I know it’s uncomfortable, but afterwards you’ll feel better,” I explained unconvincingly. I hesitated and tried to steel myself to perform this procedure that I knew would be unpleasant for him. “Here,” said Frances, “let me show you.” She did it smoothly and the patient nodded his appreciation of her more confident style.

  “Smile,” Frances said to me afterwards, and I did, broadly, falsely. “That’s better. At least try to look like you’re having fun, then maybe you will.”

  I don’t know exactly how she did it, but Frances made patients feel she was doing things for them and with them, not to them. She saw the patients’ room as their personal space that she entered with their permission. And although Frances could perform advanced and high-tech skills as well as anyone, it was providing care and comfort measures that she most prided herself on. “Never neglect the basics,” she explained to me on many occasions. “You have to keep the mouth clean and the skin moisturized.” She also meant the turning and the lifting, the rubbing and the massaging, keeping patients’ hair washed and tidy, trimming beards, cutting toenails, removing wax from ears, rubbing mineral oil onto the soles of scaly feet, and at all times, keeping patients clean and comfortable on smooth, fresh sheets. These were the dreary, menial jobs, the “custodial care” that many university-educated nurses assumed a degree would exempt them from. Yet, Frances perform
ed them like they were almost sacred tasks and regarded them at times as having even greater importance than sophisticated procedures. “It’s when you are doing these things that you can assess the condition of your patient’s skin, their oxygenation, and pain and so on. Some nurses think doing these things is beneath them, but I don’t and never will,” she said.

  One day, to my surprise, Frances called upon me to help her. She was caring for an elderly Chinese man who was dying. With the family’s consent, I joined the intimate circle around his bed. Frances instructed me to place warm towels all over the patient, with a few extra around his neck, as this was part of the Chinese custom of keeping the body warm. And when she noticed that the family was ill at ease and unsure of what to say or do, she guided them. “Tell him you are here,” Frances said, motioning them to move in closer around the bed. “Say the names of each person here today with him. Let him hear the sounds of your voices.”

  “Can he hear us?” they asked.

  Frances nodded. “You may not get a response, but talk to him anyway.”

  “We don’t want to disturb him.” They were afraid and drew back.

  “This is hard for you, but he is peaceful. He’s comfortable.” Frances let down the side rails so they could be even closer if they wanted. “It’s okay. Hold his hand. That will make him feel loved and secure.” She gave them a cloth to wipe his brow, a moist swab for his mouth, and I could see their fear lessen as they did these small actions. When he began to take his last breaths, Frances put her arms across their backs. She stayed with them until the last heartbeat, the last breath.

  For me, it was fascinating to watch how a person died, organ by organ. The technology of the ICU exposed everything. All the body’s secrets were revealed. I watched the kidneys shut down, the blood pressure diminish, the heart slow down to a wavy, then horizontal green line, the irregular breathing pattern of the lungs mapped out on the ventilator screen, the incremental diminishment of oxygen to the tissues, and all the while, the gradual loss of consciousness. I watched death happen and saw how it could be measured, charted, documented – even manipulated. It was no wonder, in fact, that when Frances shut off the cardiac monitor, the family took that flip of a switch to be the moment of death. “Is he gone?” they asked and her “yes” was as gentle as possible. They asked her to please open the windows so that their father’s spirit could escape into the afterworld, but Frances explained that that was not possible because the hospital windows could not be opened. That distressed them, but there was nothing that could be done. Then the family left and I helped Frances wash the body and remove all the tubes, lines, and machines. All the while that we worked, she kept a quiet, almost reverential silence. Then she brought the family back in so that they could spend time with the body, pay their last respects, and chant prayers.

  “Salt-of-the-earth” Tracy was tall, skinny, utterly unflappable, and at times, inscrutable. She had an uncanny – almost spooky – way of appearing just when you needed her the most, without your even asking. And she had a respectful way of helping, so that you felt she was assisting you, not coming to your rescue because you were freaking out and not coping with the crisis yourself. Tracy said little and in fact was so quiet and serious that occasionally when she cracked a joke, it snuck up on me. I was sitting with her in the staff lounge one day and she was telling me about a patient of hers who had lung cancer. “I was giving her a bath,” Tracy said. “She seemed fine, but all of a sudden, out of the blue, she burst into tears.”

  “What happened?” I gasped.

  “She told me she was afraid the surgeons didn’t get it all and that she might die.”

  “What did you say?” I asked, wondering what I would have said.

  “I said, ‘C’mon, knock it off, don’t be such a crybaby. Put on a happy face.’”

  “You said that to her?!”

  “No, you doofus. There was nothing to say. I just sat with her and held her hand while she cried.”

  She said it as if it were nothing, but it seemed to me something fairly important.

  In contrast to Tracy and her subtle manner, Justine was known to be a spicy chili pepper and not just because of her flaming red hair. She had a fiery tongue and could be brutally honest, but most people took it from her – even patients’ families – without question, because she was totally fair-minded and completely without malice. She enjoyed working in the ICU but saw its limitations. She believed we often went too far with some patients and decried the fact that we didn’t know most of our patients’ wishes. She was convinced that if they could speak for themselves, many would refuse the extreme measures we were offering them. Even though these were delicate situations, Justine’s humour could be outrageous. Once, I went over to chat with her and she casually mentioned with a wicked grin that her patient was about to be transferred out. I looked at the number of pumps and machines in the room and the ominous numbers and abnormal waveforms on the monitor screens. “Transferred out? You mean he’s going home? How?”

  “Yeah, he’s going home all right – in a jar. He’ll be transferred out to the Eternal Care Centre. You know, the Celestial Discharge Unit.”

  It was a horrible joke, but what a relief it was to laugh. Justine provided that opportunity for all of us on many occasions and sometimes for patients as well. “You’re a Scorpio?” she said to one young man she was caring for, noting the date of birth on his chart. “Hey, me too! Scorpios rock!” As anxious and worried about their loved one as a family might be, Justine always managed to get a laugh out of them. Walking past her patient’s room one day, I was shocked to hear her say to a family who was barraging her with questions and demands, “Stop it, you guys! You’re driving me crazy!” Rather than being affronted by her, I saw how she put them at ease. After all, they must have figured, how bad could it be if the nurse was joking around?

  As for Nicky (pure maple sugar), it was probably not a good idea for us to work together because we chatted far too much. We gossiped about boyfriends, travel plans, and forbidden liaisons and rendezvous between certain doctors and nurses that only we knew about. We talked as we bathed our patients. Nicky would wash one leg, and I, the other. She soaped up one armpit while I rinsed off the other. She took temperatures and I recorded the blood pressures. One patient moved his head from side to side watching our routine and as ill as he was, couldn’t help but laugh at our antics.

  As for me, I thought of myself as coriander, a herb my father used liberally in his cooking. It has a flavour that most either love or decidedly, not. My father claimed it was a delicate yet hardy plant with both a sweet and bitter flavour, and in the proper growing conditions, it would flourish. Coriander, he explained, had special properties because it was neither exclusively wild nor domestic; it was a “cultivated weed.” I was coriander in those days in the ICU where I felt I was finally flourishing in the proper environment. It was a place where I also had the opportunity to explore many different ways of being a nurse.

  I studied all of the nurses I worked with, adopting the traits I liked. I was in awe of Laura, who engendered such affection and confidence in her patients. There were others like her who were no less caring even as they kept their emotions intact. I admired Frances and Nicky and other nurses like them who did connect personally with patients, yet I often saw, in private moments, how it took its toll on them. I longed to be as calm and focused as Tracy. As for Justine – what a pistol! I hoped one day to have the courage she had to stand up for what she believed was right – whether it was advocating for patients or for nurses – and to find a way, as she did, to use humour to make people feel better.

  I wonder if any of the nurses suspected that I was “spying” on them, listening in to their conversations with patients and watching how they handled difficult situations. I admired how some always managed to find something hopeful or positive to say, even when the patient was getting worse or dying. Some nurses took such care with seemingly small things, for example, ensuring to cover up part
s of the body they weren’t washing to keep the person warm and unexposed or warming up a metal bedpan before putting it in place underneath the patient – and how others didn’t take or make the time to do these things. Some noticed even minute things, such as the discomfort caused by a bit of plastic jutting out from the iv tubing. They would fold up a pillowcase and place that softness between the plastic and the patient’s skin. They would ensure the urinary catheter was anchored so that it wouldn’t pull and they would gently ask a family’s permission to remove jewellery, especially a wedding ring, with soap or Vaseline, knowing very well that soon the fingers would swell, making it impossible to remove without cutting it off. I watched nurses who accompanied families into the ICU for their first visit and how they caught them when they drew away, fell back, or even fainted, shocked at the sight of their loved one’s condition. Some nurses knew how to actually help the family befriend those scary machines. This is what we do in the icu, they explained to them. It’s what’s normal here. Once those machines have served their purpose, they will be removed, but for now, they are needed.

  They could make the most extreme situations seem ordinary in a way that calmed the patient. “There’s blood pouring out of your rectum,” I heard a nurse say to his patient as if that was an everyday occurrence. Later he told him, “Your heart is going in and out of a wacky rhythm, but I’m giving you a medication in your iv and we’ll get it settled down.” I went over afterward to tell him that I liked the way he’d handled the crisis, but he brushed the compliment aside and waved me away.