by Tilda Shalof
Up until now, nothing has cheered me, except this, a little.
* Other celebrity heart valve patients include actor Robin Williams, former First Lady of the United States Barbara Bush, and journalist Barbara Walters. I’m in good company.
3
FEARLESS NURSES
Night shift.
I have to be a nurse again, one last time before going off to camp, and then who knows when I’ll be back at work?
“Should you be doing this?” Ivan asks as he watches me getting ready. He seems worried about me – or maybe about the patients who will be in my care – but, as I tell him, I need to do this. I leave the house around 6:30 in the evening – or 1830 hours – and drive downtown for my shift, which starts at precisely 1915 hours. On the way, I turn on the Saturday Evening Golden Oldies and listen to the Four Seasons sing “Big Girls Don’t Cry” and Elvis croon “It’s Now or Never.”
Welcome to Toronto General Hospital, my world. Affectionately called “The Big House” by insiders, this huge, venerable medical centre is a mecca of world-class research, academic teaching, and exemplary patient care (according to the corporate mission statement) that specializes in cardiac surgery, organ transplantation, the treatment of eating disorders, and stem cell research (among other things). It has also been my place of work for eons and I have always felt proud to work here. But now, entering the revolving front door and standing for a moment in the main lobby, I see it with new eyes and am reminded that most people don’t like hospitals. (I guess I forgot.) Not too much hospital-ity around here or many friendly faces or smiles, especially this late in the day when everyone who doesn’t have to be here is scurrying off in the opposite direction, heading home. People coming in are reluctant and frightened; those leaving are eager and relieved. No one wants to be here!
In the hospital, everything and anything can happen – and frequently does. Nothing that goes on here surprises me. I’ve seen it all – birth, life, and death – in all its variations – not to mention sex, drugs, and rock ‘n’ roll. Every human emotion and activity takes place here: fainting, yelling, joking, sobbing, laughing, doctors crying, nurses dancing; gentle folk raise their fists, the cheerful become melancholy, and the timid learn to be outspoken. A patient gets married moments before dying. A son donates a lobe of his liver that saves his mother’s life. A woman swallows the contents of her medicine bottles and we race to rescue the life she’s tried to escape. A man breathes easy for the first time, now with new healthy lungs, a gift from an unknown family. No, it’s not an episode from a television show, it’s any day – or night – in a big-city hospital.
If you walk these halls and take a peek into the rooms you will see grim, ghastly sights. You’ll smell the pungent mix of bodily fluids and industrial-strength chemicals. You’ll hear people calling out in distress or confusion, and sometimes their cries go unanswered. Like a prison or a battlefield, the hospital is every bit as raw and extreme. You will be reminded that human suffering is close at hand; you don’t have to travel to faraway places to find it.
I feel right at home here. It’s my comfort zone. Hospitals are my second home; they’re in my blood. As a child, I accompanied my parents to their numerous doctors’ appointments. As a teenager, I spent my summers as a volunteer “candy striper.” Years later, I resurfaced as a student nurse, and for the past twenty-eight years, I’ve been showing up, taking care of patients, and still trying to figure out the mysteries of this world, as a nurse.
I have stayed the course, working during the profligate 1980s, laid off suddenly in the me an, restructuring 1990s, when there was no “job security” and the joke was, “Don’t bring a lunch.” Eventually, I was rehired to do the same job and have remained employed here throughout these sober, downsizing times. Because I’ve been in it so long, I’m often asked the question: What has changed?
A lot.
Back when I was a teenager spending summer vacations in hospitals, strolling the wards, pushing a blue cart filled with books and magazines that I handed out to patients, I would stop to sit on the edge of their beds to chat and joke around. It’s a different reality now. There’s a huge shift. These days, hospital patients are not reading novels. They’re too sick. Patients who are deemed “stable” or sometimes merely partially recovered are sent home to be cared for there – or not. The ones who remain in hospital have complicated, chronic medical issues, are unstable, often older, and need a great deal of complex nursing care. They have multiple IVS, are on oxygen, many have wounds and are receiving invasive treatments. (I have heard of hospitals in the United States that offer gourmet meals and spa treatments in order to improve “patient satisfaction.” Want my advice? If you are well enough to enjoy such things, stay home.)
People are in the hospital because they need nursing care, and too often there aren’t enough nurses to do the job properly. We all know of cases of patients who needed more nursing care than they received. “I rang the call bell and no one came.” “I didn’t see a nurse all day or night.” Then there are worse tales of insufficient monitoring or inattention to serious problems.
All true, but there is one relatively new innovation that offers me a great deal of comfort as a soon-to-be patient. It’s the ICU Rapid Response Team, now a standard feature in most hospitals. On-call twenty-four hours a day, this mobile “SWAT team” covers the entire hospital, scouting out high-risk or deteriorating patients. If they are alerted quickly to a patient in need and can get there during the crucial “golden hour,” as it is called in the scientific literature, treatment is most effective. An ICU nurse is the first responder to arrive and assess the situation. Then, in consultation with a physician and other members of the team, the nurse administers oxygen, fluids, takes blood work, arranges for X-rays, and starts medications. My friend Stephanie, who’s on the team, jokingly calls it the “ICU Roadshow.” Another friend who’s on the team, Janet, says, “it allows us to light a fire under the situation to get things moving along faster.” What it does is bring the ICU to patients so that they might not need to come to the ICU. In a way, the Rapid Response Team is like a “virtual ICU” because it’s about the people and their expertise, not the place or its equipment. The ICU is a way of doing things.
I have seen the results of the Rapid Response Team and have read the reports: they are catching problems early, preventing mishaps, saving lives, and reducing ICU admissions. What’s comforting to me to know as a patient is that anyone – doctor, nurse, patient, family member – can call on them. I plan to keep their phone number close at hand in case I get into trouble post-operatively.
Something else has changed and it’s not just at Toronto General Hospital, though TGH has been leading the way. It’s the adoption of a corporate philosophy called “patient-centred care” that espouses “respect for patients and their values, beliefs, and concerns … and the promotion of physical comfort and emotional and spiritual health …” These ideas seemed a “no-brainer” to us nurses when it was first introduced a few years ago. Wasn’t our care already all about the patient? We were there to meet patients’ needs – it’s could be the definition of nursing. That’s why we chose this profession in the first place – to serve patients. Nursing care is patient care. To us, these terms are interchangeable. “Patients R Us” is like “Toys R Us.” Would you ask a dentist to be more “teethcentred?” Yet, the reality was that we often fell short, and we knew it. We’ve been pulled in too many other directions as we’ve tried to meet doctors’ demands, perform housekeeping, secretarial, and administrative duties, and, of course, all the “hunting and gathering” of equipment and supplies, tending to machines, completing paperwork, and charting on computers – all activities that dragoon us away from patients. Not to mention our own personal failings in trying to meet patient needs.
I will never forget the horrific experience of one nurse who was a patient. Her book, Bed Number Ten, had a huge impact on me as a young nurse. Nurse Sue Baier’s harrowing account of the cruel and i
ndifferent treatment she received at the hands of hospital staff made me vow to never become one of those callous nurses like the ones who cared for her. Rendered paralyzed by Guillain-Barré syndrome, a rare neurological disorder, Nurse Baier was in the ICU for months and endured unspeakably insensitive, at times cruel, treatment by the staff. I hate to think that there might still be places where patients experience such inhumane treatment, but it’s possible.
However, I sense a sea change taking place in the delivery of patient care. Sincere and real efforts are being made to transform the hospital culture into a kinder, friendlier place. These days, patients themselves have a much greater awareness of their right to courteous and respectful care and I hope they will not tolerate any less. Patient affairs departments are there to listen to families’ concerns and to step in to mediate conflicts when necessary. Hospitals are making efforts to raise awareness among all staff to improve our communication skills and to be more attuned to patients’ needs. We may still fall short at times, but progress is definitely being made. Well, I guess I’ll soon find out for myself, won’t I?
It’s a long and circuitous route to get to the Medical-Surgical ICU where I work, high up on the tenth floor. After the stark, ground-floor entrance hall with its hand-sanitizing stations and the lobby with its potted plastic plants, vinyl chairs and benches bolted to the floor, and rows of philanthropists’ bronze busts and donor plaques, you go past a bank of fast-food outlets (communal cafeterias long gone) and commercial gift shops (Volunteer Ladies’ Auxiliary Gift Shops vanished) and enter a twisty labyrinth of corridors (where patients are sometimes cared for, when the ER is overflowing, thus the moniker “hallway nursing”). You pass gleaming laboratories and procedure rooms and whiz by “quiet” rooms (a misnomer if there ever was one as they’re more like “disquiet” rooms, where patients go to wait and worry) and multifaith worship spaces. Down a sloping hallway past the ICU Reception Area (name changed from “Waiting Room,” presumably to take peoples’ minds off what they’re really doing there; it’s more of a “Limbo Lounge”), then enter the heavy steel doors and, voilà, the Medical-Surgical ICU, my home away from home.
But tonight I’ve chosen a different route: I’m taking the stairs. I have to see if I can do it. Maybe I don’t need this surgery after all …
One … two … three steps … A crushing tightness clamps down on my chest. Stopped in my tracks, crouched down on the bottom step, I try to catch my breath.
Out of the corner of my eye, I see inside-out vinyl gloves flung on the stairwell floor right next to what looks like a dried pool of blood but I’m hoping is an old coffee spill. This place is disgusting! I’ve seen cleaners swish the filth around in buckets of grey water, push it from one side of the room to the other … splattered cardiac electrodes, the stinky, soggy blood pressure cuff’s …
I take the elevator to the tenth floor.
Progress is probably being made in the way nurses work on the wards these days, but years ago, when I was starting out as a new nurse, I was on a general medicine floor and it felt like a brutal reality shock after my protected life as a student. My initiation period was rough. The staff were unfriendly and the workload gruelling. I was constantly thrown into situations I couldn’t cope with. There was no one to ask questions about things I was unsure of. I was always running, trying to catch up, constantly frustrated and plagued with the feeling that I was supposed to be somewhere other than where I was, doing something other than what I was doing. It was lonely because there was no teamwork whatsoever, nor any of that “multidisciplinary collaboration” that they promised in school. It was the doctors’ world, and nurses were either subordinate, peripheral, or invisible altogether. We were expected to be quiet and just follow orders. Empowered by my enlightened, progressive university education, I had a different vision of how things should be. Though I believed I had more to contribute, I didn’t have the courage to speak up and be a maverick. I had no choice but to stick it out because I needed the salary. It was either “sink or swim,” so I dogpaddled frantically for almost two years.
Then, when an opportunity came up to study critical care, I didn’t know what the ICU entailed, or if I had the right stuff to take it on, or even if the working conditions would be any better, but I took a chance. I did and they were.
I found a lot to love in the ICU. Here, my ideals about nursing could actually be put into practice; the conditions were in place to actually provide patient-centred care – it wasn’t a distant dream. Here, my contribution was respected and I could work as equals with the other members of the care team. In fact, our slogan is “Every voice is valued.” In the ICU, teamwork is essential because you have to depend on one another; you couldn’t do this work alone and you have to be able to count on knowing that whatever comes through the door, we’ll deal with it together.
For me personally, the best part was my good fortune to fall in with a group of nurses dubbed “Laura’s Line.” They soon became mentors and colleagues and now, even though most of them have moved on from the ICU, remain close friends.
For almost thirty years, the ICU has been my home. I know the place, its routines, and all the players. Even so, I try never to lose sight of how unsettling, disturbing – at times terrifying – it is to patients and families, especially when encountering it for the first time. When I bring visitors to their loved one, they stare in disbelief, hardly recognizing the person, unconscious, entangled in wires and tubes, attached to hulking, noisy machines. One mother insisted I’d brought her to the wrong patient. “This is not my daughter.” She stared at the pale, puffy stranger in the bed. I stood at her side while she absorbed the fact that it was.
The ICU is hard-core even for nurses. When it suddenly dawns on you what you’re taking on, it’s daunting – or should be. I’ll never forget the look of utter amazement and discombobulation on one newbie’s face as she looked around and pronounced the place “phantasmagorical.” She was a Trekkie and nailed it: “They say space is the final frontier, but I think it’s here.” She was trembling with excitement and fear at the prospect of working here. Laura, the eponymous leader of “Laura’s Line,” and a buddy of mine, came over to help bring down her stress level a notch or two.
“Relax. It’s only machines.” Laura gave the ventilator a little kick. “Just keep in mind that that’s a person in the bed and it’s all about hands-on care, you’ll be okay.” At that moment, a high-pitched alarm went off. Laura glanced at the monitor and smoothed the patient’s covers. “See, it’s just an artifact. When an alarm goes off it doesn’t necessarily mean something is wrong, only that something could be wrong. Your job is to know the difference.”
Laura herself could detect a problem long before any machine. To her, the truth was with the patient.
In the ICU, “vital signs” has a different meaning. On the floor, they are taken once a shift; here, they are noted moment by moment. You have to have a solid grasp of normal before you can recognize abnormal. Further, you have to know what normal is for your patient, like a “personal best.” Take blood pressure, for example. Before I came to the ICU, I thought of BP as a routine task or something measured once a year at an annual checkup (for those who had them). Very quickly you realize that in the ICU, blood pressure is a big deal. Your patient’s blood pressure is always on your mind. We monitor it continuously by a line in the patient’s artery and are concerned not only about the systolic and diastolic pressures but a calculated ratio of the two, called the mean arterial pressure (MAP). It reflects the perfusion of the vital organs, but I tend to think of MAP as the force that propels life forward. To me, MAP is that poetic.
Heartbeats are given equally close attention as we examine them in second intervals, measure parts of them in milliseconds. We are constantly sizing up whether the hearth rhythm is regularly regular, regularly irregular, irregularly regular. The same close attention is given to breathing. Second by second, breath by breath, each is counted and measured, as well as the intervals i
n between breaths.
Then there’s urine! We note the colour, if there is sediment, and the amount, millilitre by millilitre, we tally it hourly, not just allow it to accumulate to the end of the shift. In the ICU, all the elements of life – cells, enzymes, minerals, electrolytes, and microbes – are under scrutiny. Moment by moment, bodies are in the balance – beating, dripping, dropping, ticking, pulsing, and pumping.
Another thing I love about the ICU is that everything about my patient is my business: heartbeats my responsibility to safeguard, each drop of urine my concern. I’ll never forget the first time I heard an ICU nurse say, “My pressure’s low,” and realized she meant her patient’s blood pressure. “It’s like when your child coughs, it’s your cough, too,” she explained.
A nurse has to earn the privilege to work here – and stay. You have to study hard and keep on top of your game, proving yourself over and over again. The learning curve is steep, especially at first. For me, the technical skills came slowly and acquiring the mandatory knowledge and critical thinking took even longer. As for the emotional fortitude – well, I’m still working on that.
“Why are you still there?” friends often ask. “Isn’t it time to move on to bigger and better things?”
Like what? I wonder. What could top this? I’ve found my place. To me, what happens at the bedside is the most interesting and important thing – and in the ICU, I couldn’t get any closer to the bedside. Besides, why would I leave when I haven’t mastered it? I’m still trying to get it right.
“You’re just here for the stories,” some nurses tease me.
I’ll admit it – I’m an adrenalin junkie, getting high on the drama and action and grappling with the various complicated ethical dilemmas, but my real fix is stories. I never tire of being let into my patients’ lives. I’m insatiably curious about the multitude of challenges that people face and the infinite ways they respond to them.
