by Tilda Shalof
Way back in the day when I was a nursing student, we practised our skills on one another before working with patients under the close supervision of an experienced nurse. It was the old-fashioned training or apprentice system. We took blood pressures, drew blood, and once, we even inserted naso-gastic tubes into one another. (This is a catheter that goes into the nose, down the throat, and into the stomach, used to drain fluids, deflate air, or give medications.) It was unpleasant, but every single time I’ve done that procedure to a patient, I remember how it feels. You can’t get that from an electronic dummy, just as you can’t pilot a plane after playing a flight simulation game. Something is lost. It fosters the kind of detachment I saw in one young nurse. She sat outside the room, staring at a computer screen, glancing now and then at the patient’s cardiac monitor and ventilator screen. Later, standing at the bedside, she pushed buttons and recorded data from the machines. She didn’t touch or speak to the patient, nor make eye contact. It was nursing by numbers with no connection to the person in the bed.
But how to teach empathy? Compassion may be innate in some, but not in most of us. The skills of face-to-face interaction may be challenging to the “net generation,” or “millenials,” since many are more familiar with online relationships, electronic connections, and virtual realities than one-on-one, real-life ones. But the new nurses teach me a lot, too, and I love being around them with their verve, idealism, and self-confidence. Their ease in learning new things and their refusal to compromise their personal lives for their careers is inspiring. They’ve all had a chuckle at our old-school ways, like our resistance to new computer programs or when the automated medication dispensing machines were introduced. They were patient with us, holding our hands until we were up to speed. They want to learn from us, but unfortunately not enough of us are willing to work closely with them and impart what we know, thus the need for laboratory models to practise on. Paradoxically, you have to be young to do this work but old enough to do it right (though “old” or “young” in this context has nothing to do with age).
Under my guidance, Simone gets the IV in and looks pleased with herself. Everything is under control for now, so I suggest it’s time to bring the family in, but she doesn’t feel ready because the room is still messy and she wants to tidy it up.
“None of that matters,” I tell her. “They’ve waited long enough. Bring them in.”
I’m not always so helpful – or bossy – but I feel a new urgency to pass the torch.
Nathan, our ward clerk, dims the hallway lights, an encouraging sign that nudges the night along.
My patient appears to be sleeping, but it can be hard to tell; I’ve cared for patients who looked like they were in a deep sleep but tell me in the morning they didn’t have a moment of rest. His vital signs are stable and I make sure his monitor alarms are on. “Listen out for a minute, would you?” I call out to Simone to let her know I’ll be stepping away from the bedside for a moment. It means Stay tuned to my patient’s alarms, extend your radar to cover my patient, too. You are responsible for both of them. There isn’t a crisis every minute, but in the ICU, there’s a constant expectation of close observation and quick response should a problem arise and so our patients can’t be left alone, not even for a minute to step out to for supplies or a bathroom run. I alert Jasna, too, so there’ll be a nurse for the nurse as well as one for the patient.
I take a stroll around the ICU, pausing outside each patient’s door to peer inside, to watch not the patients but the nurses.
There’s Wendy, who brings a sense of order and peace as she chats quietly with her patient and at the same time checks his chest tube drainage and urine output. He’s a nineteen-year-old boy with cystic fibrosis, two days post-op lung transplant, just extubated and experiencing what it feels like to breathe easily for the first time in his life.
Diana has her arm protectively around her patient’s wife as she explains something about her husband’s condition, in her excitable yet comforting way, as they stand outside his door.
Holly is caring for her patient behind a closed curtain, talking to him softly.
Kelly is on the phone calling all over the hospital, hunting down a drug her patient needs right away. There’s no time to waste; waiting until the morning might be too late.
I can hear Jason (who’s Chinese) speaking Tamil to his Sri Lankan patient. (Welcome to Toronto!) He reads from a “cheat sheet” prepared by the family for us to use. “Naan ippoothu unkalai marupakkam thiruppa paakiren. Iruma seiya paakum,” he says to let her know he’s going to turn her and that it might make her cough.
And anyone who is still under the misconception that men aren’t as nurturing as women should hear “Big John,” a manly, strapping, huntin’ and fishin’ kinda guy, speaking to his patient, a thirty-nine-year-old woman with breast cancer and now pneumonia: “It’s 11:30 at night. David is here to help me to turn you to the other side and I’ll give your sore back a rub. You’re doing great, darlin’. I’ll suction the secretions out of your lungs first. Easy does it. You’re safe. I’m right here with you – not going anywhere.”
I move on to Stephanie’s room and I can see in an instant that her patient is sick – the sickest patient in the ICU tonight. I don’t know if Stephanie got the patient she needed, but her patient – a twenty-three-year-old woman in septic shock – surely got the nurse she needed. If it’s possible to do so, Stephanie will pull her through.
There are many such A-listers who work here, including Edna, Allyson, Grace, Connie, Murry, Kate, Lesley, Marcia. From whatever angle you observe them, whatever moment you chose, they are reliably doing something that makes the situation better and safer. Oh, there are a few D-listers, too, but we keep them in check. It’s always like that: some extraordinary professionals, a tiny group of stragglers, and the majority of us in the satisfactory middle. But nurses are the wild card. You don’t know what you are going to get. I remember how one patient put it. “How’s it going?” I asked at the start of my shift.
“Depends on the day.”
“How about this day?”
“Depends on the nurse.”
I get this. The nurse can make all the difference for good or bad.
The wife of one of my patients was fond of me, at least at first. I think it was because of my optimism. Well, in the morning I felt that way, but by the late afternoon her husband’s condition had worsened dramatically and we were working hard to keep him alive. I felt less certain that he would make it, and had not as much time and energy to devote to reassuring and comforting her because I had to stay focused on his care. I watched her mood plummet. “I’m not feeling as good about things as I felt this morning,” she said, searching my eyes for my faith so that she could be buoyed up again. But frankly, I didn’t have as much to give. I tried to fake it but I could see I’d lost her trust. The next day, she requested a different nurse.
Privately, we ask ourselves, “Would you want this nurse to take care of you?” (The more telling question is, which nurse wouldn’t you want?) Yes, I’d have Simone, as long as an experienced nurse is also there to back her up and watch my back at the same time. Problem is, not enough of us “golden oldies” are willing to light the way for the newbies. We say we’re busy or too burnt out. I’m nursing the patient, do I have to nurse the nurse, too? they ask. I say, Yes, you do. How else will we pass on the collective wisdom of this profession and sustain it? Too many of us are complaining and acting dissatisfied but not expressing what we treasure or why we’ve stayed, other than it pays the bills.
I see I’ve gone from worrying which patient I’ll get to which nurse I’ll get. Does my karmic theory have a corollary – will I get the nurse I need? I’ll soon find out.
It’s two o’clock in the morning and Simone comes over to sit beside me at the desk outside our patients’ room, a post from where we can still observe them and their machines. She looks tired. Because we always work in pairs, on a buddy system, when it is safe to do so we cov
er each other’s patients and spell each other off so we can take breaks during the night, sometimes even naps.
“If you need to lie down for a while, I can cover your patient for you,” I offer, but she says she’s too keyed up to take a break.
“I don’t feel well. I should have called in sick,” she says, looking more stressed and fatigued than ill. “Nights suck, don’t they?” she says with a sigh. “Do you ever get used to them?”
“Not really. I still find them hard.” There’s no getting around it – night shift is hard. On the upside, it allows you to escape the hubbub and politics that goes on during the day, but you feel cut off from the rest of the team, not to mention your family, friends, and normal life, which, for most people takes place during the day. Working all night is unfathomable to non-nurse friends. You feel embarrassed to admit you’re working Saturday night. They pity you, and you feel a bit sorry for yourself, too.
I don’t work nearly as many nights now as I used to, but there was a time when I worked so many nights that three o’clock in the morning felt exactly the same as three o’clock in the afternoon. I used to dread coming in, having to tear myself away from friends or family. For years I worked my share of nights (the union decreeing that we split our shifts equally between nights and days), always fighting off an exaggerated feeling of loneliness and isolation from the rest of the world during those dark hours. Most nights I managed to attain the minimal wakefulness required to be safe. Over the years, I’ve learned to make peace with working the night shift, which isn’t to say that at the age of almost-fifty it isn’t difficult, but then again, it was back in my twenties, too. It’s never felt normal or healthy to work at night and sleep all day. But patients need nursing care around the clock, so the night shift is here to stay.
George is now awake and indicates that he’s uncomfortable, so I call for David to help me reposition him. Then I draw the curtains and give my patient a bath, not as much for hygiene as for relaxation. Washing him as I do, soaping his armpits, rubbing his back, massaging his fingers one by one, cleaning his legs, pulling back the foreskin, wiping the folds around the scrotum, actions that in any other context would be sexual. These professional intimacies are decidedly not, but they aren’t strictly clinical either. We each find our own ways to deal with any discomfiting thoughts that come up in these situations of vulnerability, shame, or embarrassment – at times, our own.
Some nurses seem disinterested or disappointed by these seemingly mundane aspects of patient care. “I like everything about nursing,” one told me, “except actual patient care.” Perhaps they believe that their university education qualifies them to do “better” things and that such “menial” work is beneath them. It’s a class, even a caste, prejudice. Their academic, theoretical education does not adequately prepare them for the shocking realities of the hospital. Patient care seems to have a low priority on the nursing curricula in universities, not accorded the importance it deserves. Knowledge workers is the new phrase to describe our role, and while it’s a true description, there is also body work and, for many of us, a spiritual component, too. But many new nurses tell me they don’t plan to stay at the bedside for long. For many, patient care is merely a stepping stone in their career path before moving on to teaching, research, administration, management, or graduate school. Years ago, I felt as they do, and wanted to move on to “better things,” but that was before I saw how nurses heal people with their hands and minds, with their actions and their words. Soon, I discovered that for me, there is no work more meaningful and satisfying than patient care.
George is still uncomfortable. I ask if he’s in pain. He nods but can’t say where or how much, but I don’t need evidence. He has plenty of reasons to have physical pain, and mental anguish, too. We know a lot now about ICU delirium, a syndrome that can exhibit as confusion, hallucinations, delusions, nightmares, and an altered sleep-awake cycle. It affects up to 80 per cent of ICU patients and a large number of hospitalized patients, particularly the elderly. It can even cause post-traumatic stress syndrome, with long-term flashbacks, bad memories, and nightmares, all from an ICU stay. We use sedation and antipsychotic medications to treat this problem, which, as a nurse, you have to be on the lookout for its signs and symptoms at all times.
I draw up a dose of sedation and inject it into his IV, a central line that goes into a large vein that leads directly into his heart. What a leap of faith it takes to allow someone to inject a drug into your veins! Just before nodding off, he mouths, “Thank you” around the ETT tube, a message that’s easy to decipher. Most of us have learned to read lips – eyebrows, foreheads, shoulders, fingers, and toes, too.
If my patient gets a good sleep, in the morning when he’s extubated, he’ll do better. But so far, he’s not having a restful night, sleeping on and off, mostly off.
I stand outside my doorway for a moment and call out to Stephanie as she flies past my room, but she’s so focused on what she’s doing she doesn’t even stop to say hello. “Busy patient?” I call out, but I can hear and see the answer for myself by peeking into her patient’s room. The overhead lights are on. The noisy high-speed oscillator ventilator is going full blast, pounding hundreds of tiny breaths into her patient’s lungs per minute. The counter is lined with syringes of medications and there’s a stack of IV pumps attached to her patient. Classic signs of a busy patient. That phrase is so ICU. Once, I told a friend I had a busy patient and he thought I meant a “workaholic,” talking on a cellphone, using a computer, doing business from his hospital bed! No, busy patient means a busy nurse.
I return to my patient’s room and see that he is wide awake, and restless, pulling at his ventilator tubing and trying to tell me something. He motions for the clipboard.
I know what lies behind that question. He’s come to trust me and now he’s going to have to trust someone new. Patients often ask why they get a different nurse every day. They’ve gotten used to the quirks of Nurses Dawn, Mercedes, and Hasmina and now it’s May-Ling, Trey, and Scott? Each nurse is so different in personality, style, tone, tempo, and energy – and I know patients feel it.
The way we make up the patient assignment must seem so random and arbitrary to them, but there’s actually logic to it, but it’s hard to crack the code. Though we want to provide consistency of staff to achieve a “continuity of care,” the reality is that with the vagaries of hundreds of work, family, and school schedules, along with nurses’ varying skill sets and all the complicated personality alchemies, it is difficult to do so.
On top of that, we try to take into consideration certain sensitive situations, like not assigning a nurse who’s had a recent death in the family to care for a dying patient. Nurses themselves sometimes request assignment changes because, as one exasperated nurse put it, “my patient was driving me friggin’ crazy” or as another said, visibly disappointed in herself, “I tried my best, but I just wasn’t gelling with the family.” We keep a secret* book, not officially acknowledged by management, stashed in a drawer at the front desk in which we record the challenging or “difficult,” long-term patients so as to not overburden any individuals. We would like to be above such personal failings, but most of us aren’t – though that’s no excuse. It would be nice to offer bespoke care; nursing is neither a one-size-fits-all enterprise nor a one-way interaction. But the expectation that we will be able to care for any and every patient at any time doesn’t jibe with reality.
“No, I won’t be back,” I tell my patient gently. “This is my last shift for a while.”
His disappointment is a compliment. He wants me back. He motions for the clipboard:
Desperation, so politely put.
There’s something else he wants to tell me. Through gestures, mouthing words, and pantomime, he manages to tell me the story of the eagle tattoo on his shoulder … why the wings face backward. “The eagle has my back,” he tells me and gives a toothless grin around the plastic tube in his mouth.
That’s what he w
as trying to tell me earlier. I nod in understanding.
“You are doing so well,” I tell him. “We’ll get that breathing tube out this morning. You’ll be able to talk.” I squeeze his hand and he squeezes mine in return.
It’s 0500 hours, time to record another set of vital signs and perform my hourly checks.
There’s somewhere I need to go, something I need to do. I promise Simone I won’t be gone for long and ask Jasna to cover our patients as well. I leave the ICU and take the elevator down to the Cardiovascular ICU. I am looking for Meera, a friend who left Med-Surg for CV because, as she puts it, “it’s cleaner” – meaning fewer infections – “and most people get better” – meaning they have (usually) one fixable problem.
“Meera isn’t on tonight,” the nurse-in-charge tells me but doesn’t seem to mind my hanging around at the nursing station. She has no idea I’m here on a reconnaissance mission, spying and checking out the place, wondering which bed I’ll be in and which nurses will be taking care of me.
A caravan is making its way down the hall. The patient on the stretcher is motionless, eyes taped shut, flanked on all sides by people pushing poles of IV pumps with green and red lights flashing (the reason we call them “Christmas trees”).
“Quadruple bypass,” the in-charge says as they pass the nursing station. “We took him back to the OR. Bleeding.”
“What’s going on in there?” I point to a room so crowded I can’t even see the patient in the bed.
“Two days post-op heart transplant. They’re evacuating a tamponade.”
Here’s yet another post-op complication. Cardiac tamponade is fluid in the pericardial sac surrounding the heart that impedes blood flow. The ultrasound technologist is guiding the surgeon to place the needle to relieve the pressure.
There’s a different vibe here. Even with this crisis, all is calm. In my ICU, it’s more chaotic, the rhythm more erratic. We either go full-tilt, non-stop or ride out a steady, slow burn with uneasy lulls. We do more guesswork, try this or that, see what works. We manage problems, but here they fix them.
