by Tilda Shalof
And I don’t think any nurse ever forgets the first time they participated in a “code,” a cardiac or respiratory arrest. That’s when you truly feel you are an essential member of the team. Finally, in the icu, I wasn’t just standing by while the rest of the team sprang into action, everyone knowing what to do. I became one of the ones who ran in to help. Undeniably, we were having an adrenalin rush as we came together, our hands swarming over the patient, doing chest compressions, giving electric shocks, drawing blood, and pushing medications. Often we didn’t even know if we were keeping someone alive or staving off death, but in those moments it didn’t matter. (Perhaps it amounted to the same thing, but it implied a different mindset.) We were united in our efforts and if there were times that we were even grooving on that high and feeling so heroic and powerful, who of us would admit it?
Soon, I, too, could read the subtle clues and speak the insider language. If I started a shift and saw the crash cart wasn’t in its storage corner, I searched for the room where there was a “busy” or “sick” patient, a patient in trouble who was “crashing.” Coming into a patient’s room and seeing ECG strips spewed out of the monitor, trailing all over the floor, curling up like party streamers, meant the patient had likely been having irregular heartbeats, called “arrhythmias.” If the patient was on “bug drugs,” I knew that antibiotics had been instituted and likely “tropes,” too, which were inotropes, drugs, like Dopamine or Levophed, used to raise the blood pressure when it had dropped dangerously low. “Going travelling” meant transporting your patient to a test in another part of the hospital – no simple matter, considering how unstable they were and all the equipment they were attached to, including the portable “zapper,” which was the defibrillator and all the “Christmas trees,” the ringing, dinging, flashing IV pumps on either side of a patient.
But there were moments, after I got over my awe at it all, that I wondered, was I nursing the patient or the machines? Was I caring for the body in the bed or an electrophysiological representation of bodily functions on a monitor screen? There were many hours when my attention was entirely given over to the gadgets and gizmos of chrome, metal, glass, and plastic, as much as, if not more than, to the patient. I couldn’t always bring the two together. It was Laura who got me thinking about these things. She fixed her level gaze on the patient first and the machines second. “That’s where the truth is,” she told me, nodding at a patient in the bed. “Don’t believe everything you see up there,” she waved at the cardiac monitor. “Hey, Tilda, watch this.” She jumped up and down beside the monitor to create “artifact,” making the screen imitate ventricular fibrillation, a lethal heart rhythm. We’d all seen her occasionally give a little kick or punch to a malfunctioning IV pump and get it started up again, buzzing happily back at work. “Oh, I believe in the sanctity of life, all right,” Laura said one day after morning rounds, “but I don’t worship technology. Take temperatures, for example. We measure them by mouth, under the arm, in the tympanic membrane of the ear, or in the rectum. We use mercury, water pressure, electronic pulsation, or a thermodilution catheter in a patient’s pulmonary artery. But most nurses can feel their patient’s forehead and tell if there’s a fever.”
Frances agreed. “It’s true. Sometimes I touch the patient, take a guess at his temperature, and then measure it. I’m always accurate within a few tenths of a degree.” Nicky and I looked over at Tracy, who didn’t say anything. We had both seen Tracy predict a fever before the temperature even began to rise. She had a preternatural ability to know exactly what was going on with her patients long before the machines proved her right.
They were incredible nurses and the ICU provided perfect conditions in which to do our work.
“If only the nurses on the floor were as good as you ICU nurses,” a doctor said to me one day with a huge sigh of exasperation. It was late afternoon and we were sitting at the nurses’ station catching up on our charting. He was a third-year resident who was enjoying his ICU rotation. “The nurses on the floor don’t know as much as you ICU nurses.”
“It’s not fair to compare them to us in our ideal conditions,” I explained. “There aren’t enough nurses on the floor and their workloads are impossible.”
“But they don’t even look at lab results. They don’t know what’s going on with their patients.”
“They have no time, they’re just trying to keep up.” It hadn’t been that long ago that I had worked on the floor myself and I well remembered how many times I’d left at the end of a shift feeling frustrated and discouraged. My work had fallen so short of my ideals that my ideals began to seem impossible. I had felt at the mercy of others, at everyone’s beck and call, and powerless against whatever might be thrown at me. Nurses were often pitted against each other, even sabotaged one another, and were stressed and unhappy. But here in the icu, nurses had a feeling of empowerment and a sense of their capacity to take action. We expressed our opinions vocally, sometimes even vociferously. None of us hesitated to do whatever was required to make things better. All nurses had a right to work like this and every patient had a right to receive care in a respectful, healthy environment, didn’t they? Yet, that wasn’t always the case. It was only when I got to the ICU that I finally experienced the possibility of mastery. Mastery was within my grasp.
COFFEE BREAKS WERE a respected and inviolable tradition in the ICU. The nurses all took turns covering for each other so that we could get away for even a few minutes. At first, I refused to leave, saying I needed to stay behind to catch up. “No matter how busy it is, you have to take a break,” said Justine, that first day, herding me out the door. “The work here is never done,” said Frances pulling me along by my arm. “You have to pace yourself.” By then, Laura had already left for her break, taking a longer, circuitous route down the back stairs so she could avoid walking past the room where the worried families waited.
In the cafeteria, we sat and watched Justine over at the menu board, removing the decimal places so that the price of the lunch special shot up from $5.95 to $595. We could hear her griping to the head cook: “Does the World Health Organization know what prices you’re charging for this slop?” He pointed to a posted notice that the cafeteria would soon be closed to make way for the more profitable Subway, Burger King, and Pizza Hut chains. “The forces of globalization strike again,” Justine said, shaking her head. “Retrenchment is in the works, too, I bet. What’s your union say about all this?”
“The hospital management promised us jobs,” the cook said, stirring a huge vat of soup.
“Ahh, I get it.” She came back to explain to us. “They’ll get the pastry chefs to bathe patients so they can get rid of us ‘expensive’ nurses. You’ll see. That’s the plan in the works.”
Her worry was not unfounded. We knew from experience that the hospital management didn’t always value the work of skilled, educated nurses, but at least we had Justine on our side, fighting for our rights – and our jobs – if they became threatened once again.
EVERY MORNING THE ENTIRE TEAM – the staff doctor, the residents, the nurse manager, the charge nurse, the patient’s nurse, and a whole range of other professionals, including the dietician and pharmacist, the physiotherapist, and respiratory therapist – gathered outside each patient’s room to discuss the plan of treatment. The resident presented a summary of the patient’s medical history and current condition and then the nurse highlighted particular problems identified in his or her morning assessment. Then the interesting part ensued – the debates. We looked at X-rays together and discussed the patient’s fluid balance and whether or not the patient was in overload or in fact needed extra fluid. We might review the reasons for performing a lumbar puncture, weigh the risks and benefits of transporting an unstable patient for a CT scan, or consider the merits of various antibiotics. And always, there were complex dilemmas that we faced, such as whether to perform resuscitations on patients with multiple organ dysfunction even with the documented low success rat
e. Is this a futile practice? someone might ask, and we would all get an opportunity to express and explore our views. Morning rounds were like the Town Hall gatherings of philosophers in Ancient Greece. Questions were posed and discussions raged about great mysteries of the universe. Everyone had a say and all voices were heard and valued.
At the end of each twelve-hour shift, it was time to hand over our patients, and all the information we knew about them, to the oncoming nurse. Handover was a form of storytelling and some nurses were known for their engaging, even entertaining delivery, all the while still giving a comprehensive and organized report.* One nurse even had the hockey game on the radio and stopped to cheer when her team scored. I learned to give a decent, organized report and luxuriated afterward in the feeling of release of a weight of tension so palpable I was certain I had to be a few pounds lighter. When I got home, I was exhausted but elated, too, from a day intense with thinking, doing, feeling, and seeing so much.
ONE MORNING after I’d been working in the ICU for almost a year, the nurse in charge came over to tell me she’d assigned me the sickest patient. He had been admitted the night before into the room we called the Cave. She was paying me two compliments: I was being entrusted with the most unstable patient, and therefore the most challenging one, and I was expected to work independently. The rest of the team would not be as readily available, but of course would come running in an emergency. I went in and got to work. My patient was a sixty-five-year-old man, two days post abdominal surgery, who had developed subsequent complications of bleeding and infections. He had so many tubes, drains, ivs, and incisions that one nurse had drawn a map and labelled everything to help others navigate around the patient’s body. Another nurse had thought to demarcate the area of bleeding around his incision with a permanent marker so that we could all keep an eye on its possible spread. I started off by searching for a flicker of the person, beginning with the neurological part of my head-to-toe nursing assessment. He was unconscious, but I spoke to him anyway. I listened to his heart and lungs and suctioned him efficiently. Justine came by to see how I was doing. She handed me a blood culture result on my patient and updated me on the latest tiff she’d had with the laboratory technicians. It seems she had told them her name was “Chi Chi” so they wouldn’t be able to find her, that nurse with the attitude, and when they asked for her first name, she said, of course, “It’s Chi.” I saw that I could take care of everything for my patient and also laugh at her silly joke, too. Justine suddenly recalled the reason she’d come down to visit me in the Cave. “Oh, by the way, your patient is growing filamentos fungus in his blood,” she chuckled. “I think I ordered that once in a Mexican restaurant.” On the basis of that report, I spoke with the doctor and we changed the antibiotic to one that was sensitive to the particular organism growing in the blood culture.
“Your family is here,” I told my patient as I beckoned them to come in. His wife and two grown-up children were shocked at the sight of their father, intubated, unresponsive, his face swollen, his entire body bloated. They couldn’t bear to look at him and instead stared up at the monitor. I had the feeling the children almost envied me that I could do things for their father that they wished they knew how to do. I knew things about their father that they did not, such as his lab values and what they meant, how much urine he was producing and if he had called out for them during a moment of need. When he suddenly started coughing and his oxygen saturation plummeted from 99 per cent to 70 per cent, they jumped up and looked to me to fix the problem. I acted quickly and smoothly to extract a tenacious mucous plug lodged deep in his bronchus, all the while reassuring them and the patient, too.
“Good work, Tilda,” one of the ICU doctors said as he passed by the room, and the family looked pleased I was their father’s nurse.
“I’ll take good care of him and you can call anytime,” I reassured them as they were leaving.
By the end of the day his blood pressure had stabilized, his fever was down, and he was beginning to wake up. Even the reddened area on his toes was beginning to recede. I stood there taking it all in, feeling triumphant, even heroic, claiming a lot of the credit. Frances came over to see how I was doing and I told her I thought we could probably start weaning down the settings on the ventilator and how I planned to get my patient up in the chair the next day.
“That’s thinking like a nurse,” she said.
“How does a nurse think?”
“Like the way you considered all the aspects of the situation and set goals, planned ahead. How you supported the family, explained everything to them. That kind of thing.”
MY FIRST YEAR working in the ICU with Laura’s Line was unforgettable. I learned so much, and made wonderful friends. It was also the year my mother died after so many years of being so ill and the year in which I got married to Ivan, a South African man I’d met during my trip to Israel. He came to live with me in Toronto, we bought a house, and together made it a home. It was a surprising year. As I worked through the fresh grief over my mother’s death and the residual grief over my father’s, I found tremendous gratification at work and in my friendships with my colleagues, and enormous happiness in my private life. Unexpectedly, joyfulness overtook me. So, that year, the juxtaposition of mourning and celebration made perfect sense to me. I had always known that sadness and happiness could coexist. And along with all of that, there was so much fun! Laura’s Line made sure of that. No holiday, milestone, or birthday ever went uncelebrated. After work or on days off, we’d get together. Once, at a late-night karaoke bar, I got up on stage and belted out a mean version of “Hit Me With Your Best Shot,” then Justine did her raunchy rendition of “Love Shack,” which brought the house down. (Also memorable was the cake with green icing on St. Patrick’s Day and the chocolate bars Laura brought in on Halloween that were shaped like skeletons and sarcophagi. And Justine was the first person I had ever heard use the word party as a verb.) We got about an hour or two of sleep those nights, even when we had to work the next morning. We were tired but we knew we could get through anything together. They were colleagues, soon became friends, and will always be my sisters.
* I’ll never forget the nurse who had a most disconcerting habit of repeatedly gesturing or pointing to the parts on my body that she was referring to on the patient’s body such as the internal jugular IV site on my neck or the bowel obstruction on my abdomen. I didn’t like it one bit.
7
HOCKEY MOM, RN
Many decisions in my life have been fraught with ambivalence and anxiety. But when it came time to ask my true love to marry me, I plucked up the courage. Luckily, he had no such hesitations.
“Yes, of course” was Ivan’s immediate answer.
Eighteen years of marriage have been pretty good, mostly wonderful, in fact. Even during the first few years when Ivan, originally from South Africa, had to leave his thriving business and close family in Israel, the country he loves most, uproot himself, and join me in Canada, he never once complained or expressed any doubts about his choice. And over the years when inevitable misunderstandings and conflicts have arisen between us, he remains steadfast. “You make the decision to love someone and that’s it. You don’t stop” is how he puts it. And any doubts I might have had were completely banished one romantic evening about twelve years ago as we took a leisurely stroll in our new neighbourhood. I was nine months pregnant with our first child and I had a feeling it would be the last of such serene moments. Since Ivan was still fairly new to Canadian ways at that time, I felt it my duty to inform him about an essential requirement for our new citizen-to-be. “You know,” I said as we strolled hand in hand. “If it’s a boy, you will have to get up very early in the morning and take him to hockey practice.”
Without missing a beat he answered, “And if it’s a girl, I’ll get up early and take her, too.”
I don’t think he knew how his comment made me love him more, if that was possible, and even more, since.
AT WORK THE O
THER DAY, I shared a laugh with the other nurses. It was right before starting our shift and we were gathered at the nursing station, checking our patient assignments. A few of us were chatting about our kids. “Can you believe it?” I asked them. “Me. A hockey mom!”
Because of our two hockey-playing sons, I have learned about hat tricks, drop passes, and one-timers. I have even begun to understand breakouts, offsides, and penalty kills. I am intimately familiar with the exact location of every hockey arena in Toronto. Yes, I have become a bona fide, albeit at times reluctant, hockey mom. But the nurses had reason to laugh because many of them still recall how I faced the prospect of motherhood: with a mix of excitement and dread, anticipation and fear. They tried hard to encourage me during my pregnancy.
About labour, Casey offered scary, yet reassuring, advice. “It feels like there’s a train blasting through you and all you can do is hold on for dear life and pray you don’t split in two. But you’ll get through it.”
I called George at home. He was on parental leave with his second child and had given me helpful information about epidurals during labour and now I had questions I wanted to ask him about episiotomies, but in the midst of our discussion he broke off: “Gotta go. There’s diarrhea streaming out of Amelia’s diaper.”
Noreen noticed me reading a novel during my break. “Enjoy it now,” she said grimly, “there’ll be no time to read once the baby comes.” I could have cried. I knew that everything was about to change and the problem was, I loved things just the way they were. But then I thought about so many nurses I had known who struggled with infertility problems and how they longed for a baby. For example, I knew just how badly Jenna yearned for one once when I covered for her so she could take a break and happened to come across her hopeful list jotted on the back of a lab report. “Corey, Colin, Cathleen, Candice.” I just knew they were potential baby names. For Ivan and me, everything was going smoothly. Perhaps it was time to be grateful.
