by Tilda Shalof
As fascinating as it all is, I rarely let outsiders into my world. I don’t tell my friends or family much. When I do, they either don’t get it or it makes them worry about themselves – or me. Then I have to reassure them that I’m okay. This is what I’ve chosen, what I love to do. I have never nursed sick children, worked in disaster zones in the aftermath of earthquakes or floods. I’ve never taken care of trauma victims, women in labour, or babies, only critically ill adults. Violence, cruelty, trauma, abuse are harder for me to compute, but illness, disease, and existential suffering make more sense to me.
Our patients have complicated metabolic diseases, overwhelming infections, or rare auto-immune disorders; many have undergone major thoracic (chest) or abdominal surgeries or organ transplants. Some have multiple organ failure; few have only one thing wrong with them. Many, but by no means all, are elderly. In all cases, outcomes are uncertain. But there is one thing there’s no getting around: our patients suffer. We do our best to ameliorate their discomfort, but there’s no denying it. At times, it’s hard to tell the difference between the suffering caused by the illness and that caused by the treatments. More than anything, there are always more questions than answers, way more problems than solutions. “We’re like CSI detectives,” one nurse said, “always gathering evidence, building a case, trying to solve puzzles.”
After the mystery is “solved,” more or less, our patients move on to a step-down unit or a medical or surgical floor. When they eventually go home, they don’t usually stay in touch, but a few do. One grateful patient took the time to write to us recently:
You first met me as a very sick patient on the verge of death. Tomorrow I will be transferred to the rehab centre. You kept me alive to make this possible. I am so grateful for your skills and care. My two grandchildren will now see much more of grandma. Bill and I will continue to grow old together and enjoy ourselves. Thank you from the bottom of my heart …
It’s lovely to hear from them, but those aren’t the ones we get to know as we do the ones that end up with complications, whose paths are rocky and turbulent. They loom larger in our psyches. In other parts of the hospital there are faster turnarounds, even “miraculous” recoveries, but here, triumphs are hard-won and tenuous; progress more fragile, usually partial and imperfect. It’s more of a slogging away, a day at a time, two steps forward, one back, or one step forward and two back. Down seven, up eight.
And yes, over the years, I have seen many deaths. I once had an argument with an administrator who designed a poster to represent our ICU. She chose a photograph of a sunset and a tree, the light glinting through the leaves at sunset. It sends the wrong image, I insisted. People come here to fight. The pastoral beauty of nature is not what inspires them here; they want cutting-edge science and sophisticated technology. This is not a hospice or a place to die – at least not at first. We admit a patient to the ICU because we believe we can make them better – at least it starts off that way.
But not everything can be fixed and death can’t always be “cheated,” as we like to believe. Those of us who’ve worked here for any length of time have seen too much of the other side of things – or maybe that’s just what we remember best.
“Do the math,” said a friend, another old-timer who’s worked here twenty-five-plus years like me. “We’ve witnessed the equivalent of the death of an entire town.”
True, but it’s not the numbers that stay with you, it’s the stories. For most of us, it’s not the death, but the way many people die, spending their last days cared for by strangers, in this alien environment, tethered to machines, chrome, and plastic.
Most of our patients do get better – we do have many success stories, for example, organ transplants. Rarely an easy course, but when all goes well, it is thrilling to meet the recipients, walking and talking, weeks later. Through the selflessness of a family who has just received the worst news of their lives, or the generosity of a family member or friend, the gift of lungs, kidney, pancreas, heart, or liver can save lives. No one who does this work can fail to be in awe when that happens.
Tonight, the hustle and bustle at change of shift is at a fever-pitch. There are some sick people. I catch fragments of conversations as I pass by the rooms.
“… forty-two-year-old female, idiopathic pulmonary hypertension … satting only 71 per cent on 100 per cent oxygen … awaiting lung transplant … top of the organ list.”
“… twenty-eight-year-old male, found at a bar … overdosed on Ecstacy … unconscious, tachycardic … no urine output … kidneys shut down – not even bladder sweat … dialysis to be started shortly … can’t locate family.”
“… Rapid Response Team bringing patient from the floor … eighty-two-year-old, unconscious, in respiratory failure … needs intubation … family is too distraught right now for a discussion, but we need to make some decisions about the plan of care …”
I adjust my ears to the ICU background music, a playlist of dings, dongs, chirps, buzzes, and beeps going off at random intervals from patient rooms. I never noticed it before but this place is noisy. Heavy doors bang open and close, rushed footsteps, loud voices – even peels of laughter and excited chatter at the nursing station. As for tonight’s vintage bouquet? I sniff the air and catch a whiff of a fresh upper gastro-intestinal bleed, the sweet-sour undertones of a brewing pseudomonas infection, and do I detect a frisson of melena – the distinctive smell of the end result of that GI blood passing through the “lower” end?
The housekeeping staff are cleaning rooms and restocking cupboards as they finish their shifts. Cindy, Comfort, and Eunice speak in a mélange of Chinese-, African-, and Jamaican-inflected English. They wave or call out hey as I make my way to the nursing station. There, David, a tall, elegant man, a patient care assistant, greets me in his courtly manner.
“Good evening, young lady.” He makes a deep bow. “I’m pleased to see you’ve decided to grace us with your presence on this lovely evening.”
The twenty-four ICU beds are full, I see, as I make my way around the spacious, rectangular-shaped unit to check the assignment board to find out the name of my patient. Most of our patients are so ill and unstable that they require one-to-one nursing care. In some cases, two nurses are needed to care for one patient.
For years, I’ve had a mystical belief that I always get the patient I need. (Whether my patients get the nurse they need is another story, and whether as a patient I’ll get the nurses I need remains to be seen.) For example, if my energy is flagging and I’m assigned a very sick patient, it’s a sign to dig down deep and rise to the occasion. A “quiet,” or stable, patient is a cue to make myself available to other nurses who need my assistance. I become the nurse I need to be. Tonight, with my own worries on my mind, all I’m hoping is to be a Good-Enough Nurse who can get my patient safely through the night. One bed full of suffering is all I can cope with right now.
Ramona, the day nurse, is standing outside the patient’s room waiting for me. She’s been here all day and is eager to hand over so she can go home. She launches straight into her report on our patient, a sixty-six-year-old First Nations man admitted to the hospital three weeks ago for abdominal surgery for a bowel obstruction who then developed pneumonia and respiratory failure.
“Mr. Beausoleil – he likes to be called George – awake and alert, oriented to person, place, and time. Restless and confused at times. I gave him Haldol 2.5 milligrams IV twice today. Tolerated well, but we’re trying to minimize sedation because we’re hoping to extubate him in the morning. On pressure support of five, oxygen at 35 per cent … if he doesn’t fly he’ll need a trach. Gets tachypneic with anxiety – his resp. rate goes up to fifty or so. Cardiac status stable … normal sinus rhythm with no ectopics; blood pressure stable. Line-wise, he’s got a subclavian triple lumen catheter – site was changed two days ago – with normal saline to keep the vein open … magnesium was low so I topped him up with two grams. On insulin nomogram … last blood sugar 10.2 millimoles.
”
I’m used to this barrage of rat-tat-tat facts coming at me in rapid-fire bullets. I let it wash over me as I mentally highlight key points, what needs clarification, and what questions remain, like this one:
“Any family?” What I need to know is anyone hovering out in the waiting room, anxious to come in. I want to know who cares about this man in his life outside the hospital, other than me, tonight for twelve hours, for whom it is my job to do so?
“Oops, forgot about that. No one came to visit. His wife died a few years ago. There’s a daughter in Vancouver, but she didn’t call today.”
A sad but all-too-common situation.
But what’s uppermost on my mind is this question: Would I have Ramona as my nurse? Yes. She’s a just-the-facts-ma’am kind of nurse, but I probably wouldn’t die on her watch.
Before going in, I glance through the window at a frail, elderly man, his arms tied down in restraints. The sedation Ramona gave him has kicked in so I wonder if he still needs them. Most of us do all we can to avoid physical restraints, but if patients are at risk for pulling out their lines or endotracheal tubes (breathing tubes), we have no choice. Some patients can’t be soothed with words, touch, or even drugs. A restless patient can be more challenging to care for than a combative or even violent one; it’s a persistent, gnawing need that’s never quelled or satisfied. You do your best to keep your cool, but we’ve all had moments of impatience. One time I was so rattled by a patient’s agitated state that I caught myself shouting, “Calm down!” as if calmness could be commanded. Justine, my pal from Laura’s Line, used to call it “going nurse!” instead of “going postal!”
Doctors don’t get this. If they pass by a patient’s room and happen to see the patient in a moment of rest, that’s their snapshot impression. Even if the patient is agitated, it doesn’t affect them like it does us. They aren’t required to be as up close and personal for such extended periods of time as we are. They can keep a remove of time, space, and often emotion, too. One thing that helps me is keeping in mind the motto of the “Dog Whisperer.” Cesar Millan advises people to stay “calm and assertive” when dealing with unruly canines. (Though I don’t have a dog, I watch the show and aspire to be a “Patient Whisperer” by putting into practice Cesar’s advice about “fulfilling the other’s needs” and helping them attain “balanced energy.”)
After introducing myself to my patient, I loosen the restraints on his arms and then begin my head-to-toe assessment, starting with his level of consciousness. Though he’s awake and alert, he can’t speak because of the breathing tube in his mouth, which, by necessity, passes through his vocal cords.
“How are you doing tonight?” I ask and he motions for a clipboard to write on.
“Anything in particular bothering you?”
He shakes his head and sets aside the clipboard beside him on the bed.
“Just being here, huh?” He nods. “Do you know what day is it?” I ask and he shrugs his shoulder to indicate he hasn’t a clue, so I tell him. It’s easy to lose track of time here, cut off from the world. When I wake up in the morning or especially in the middle of the night, the first thing I do is check my watch or clock.
When I tell George it’s Saturday night, June 30, he moves his legs and arms like he’s out dancing on the town. He reaches for the clipboard again.
“Love to.” I strip off a vinyl glove so that I can touch his hand, skin to skin. This can be a hazardous practice, possibly exposing me to infectious bodily fluids, but sometimes I take the risk. George points to the eagle tattoo on his shoulders and tries to tell me something but falls back against the pillow, too weak to get the words out clearly.
“Maybe later you’ll be able to tell me?” I ask and he nods.
The night wears on. As I monitor his heart, record his hourly vital signs, suction his lungs, give him his meds, and change his chest tube dressing, I can’t help but think about my own heart, vital signs, lungs, the meds that will be given to me, and the wound I’ll have. I’ll be in the hands of strangers, just like George.
Tonight, some of my buddies are on duty. There’s Jasna, who is in charge of the ICU this shift, making her rounds, checking on the patients and the nurses, too. Stephanie is in her patient’s room, the curtains closed. I don’t expect to see much of Janet. It’s her turn on the Rapid Response Team. She’ll be making her rounds, following up on patients who’ve recently been discharged from the ICU to the step-down unit or answering calls for help from the floor, always on the alert for patients in trouble or, as Janet puts it, “people making mischief in the night.”
She’s explained to me how it works. “Anyone can page us, a nurse, doctor, or even a family member. We go there, size up the situation, figure out if it’s a hot A – a patient who needs to come to the ICU ASAP! A B is a worrisome or iffy patient. It’s a ‘heads-up’ that this patient needs to be followed closely. We try to fix them on the floor so they won’t have to come to the ICU. A good save like that is an amazing feeling! Then there’s a C, which is a consult about someone who’s stable but not looking good. It’s someone that someone is worried about. You’ve got to trust your gut and use your noggin. Sometimes we just offer advice or teaching, nurse to nurse, say, about pain management or symptom control. Some of those nurses on the floor are very experienced. But they don’t have time to help the rookies – so that’s what we’re there for.”
To me, this advanced role sounds daunting, but Janet is quick to explain that they don’t do anything without running it by the doctor first and getting an order, and that all decisions are made together. “We’re the eyes and ears, right at the scene, telling them what we see and what we think.” She’s serious and emphatic about that, but in a moment the old twinkle in her eye reappears. “But what usually happens is we’ve figured out the problem and have a pretty good idea what needs to be done by the time we’ve called the doctor.”
To be chosen to become a member of the Rapid Response Team, you have to be an experienced nurse, undergo additional education, and have proven yourself capable of this advancement. I haven’t taken it on myself but hope to one day.
I look over at my partner for the night, Simone. She has been an ICU nurse only a few months, a nurse less than a year. There aren’t many nurses who are capable of working in the ICU so soon after graduating from nursing school, but Simone might be one who is. What she lacks in experience, she more than makes up for in book smarts and an eagerness to learn. At first glance it would seem unwise, even unsafe, to pair an inexperienced nurse with a complex and unstable lung transplant patient, but new nurses will never come into their own if they aren’t given challenges, especially under the watchful eye of a well-seasoned (sounds like a roast turkey) veteran. That’s where I come in. It’s how I learned.
I’d been hoping to coast tonight, but I’ll need to keep my radar out to help Simone if she needs it. So far, she doesn’t seem worried, not the least bit daunted, but I have a feeling she should be.
It’s less than an hour into the shift and Simone is in over her head. I go over to help, staying mere steps from my own patient and well within earshot of him and his monitor alarms. At first Simone balks at what she sees as my interference, saying she can manage on her own, but quickly softens when she realizes that I’m here to help, not to criticize. She’s clearly overwhelmed, glancing from the monitor, to her patient, to the countertop cluttered with meds due to be administered, not sure where to start first. Her patient’s ventilator alarm keeps going off and she silences it without checking the reason. The family has been calling in repeatedly from the waiting room, asking to come in, and she is flustered, snapping at them over the phone, Not now. I go over and suction her patient’s lungs and give him an extra boost of oxygen. I change the chest tube drainage system that has filled up with bloody drainage and then start sorting out the “spaghetti,” the tangled-up, intertwined IV lines. Her patient has a fever and a high white count and needs blood cultures, so I do that. Together, we check
and doublecheck, then co-sign for two units of blood, and I prime blood tubing, then prepare extra drips of IV Levophed and epinephrine. These powerful meds are running in each of the IV ports and cannot be put on hold while the blood runs in.
“After the antibiotic runs in, a port will be freed up to hang the blood,” she reasons.
“But you have other meds due and your hemoglobin is only sixty. Your patient needs the blood now. It can’t wait. You’ll have to start a peripheral IV and let the doctor know we need a new central line. This one may be a source of infection.”
“I’m not good at them,” she admits, eyeballing her patient’s arm.
Veins are one of my specialties. The plump ones look juicy, but I don’t fall for that easy temptation. I prefer the ones you can feel rather than see. First, I send her on a scavenger hunt to collect what’s needed. It’s like a mis en place before preparing a complicated French recipe: if you assemble the angiocath, tourniquet, alcohol wipes, and prime the IV tubing before starting to “cook,” you won’t be scrambling and will calmly nab that vein. It doesn’t seem that long ago that I was bumbling around, coming into a patient’s room, forgetting to bring something, going out to get it, coming back in again, running around in circles. “Have you started many IVS before?” I ask Simone when everything is ready.
“Yeah, but only on the simulator models at university.”
Ahh, this is the new nursing education, a more in vitro process than in vivo. What Simone means is that she learned to take a pulse, auscultate lungs, and perform other skills on high-fidelity dummies made of plastic, rubber, silicone, and computer chips. They even mimic human responses like crying out in pain or expressing distress. What they don’t mimic is the disruptions, distractions, interruptions, fatigue, and simultaneous multitasking of real-life nursing.
