by Tilda Shalof
I try it for a few minutes but lose patience.
“Perhaps there’s a book you could recommend about meditation?” One day I’ll meditate, I promise, but not now! I don’t have time for this.
Note to self: Google mindfulness, meditation, serenity, etc.
We’re meeting again tomorrow. It’s a lot of work, this breathing.
It’s Day Two in Mindfulness lessons with John and I bring my lists to show him what we’re dealing with here, including last night’s entry:
Intubation. That tube down my throat, in my lungs, breathing for me, the sensation of choking. Many patients say it’s the worst part. What if I pull out the tube by accident as some agitated patients do and wreck my vocal cords?
Dying on the table. The surgeon comes out, slowly makes his way over to Ivan and the kids, and solemnly says, “We did everything we could … I’m sorry … but she’s gone.” Boo-hoo.
Death Part III – Death is bad, but dying can be worse.
The scar. An ugly, permanent souvenir running down the length of my chest.
Loss of privacy. When pesky Kevin asked me questions about another camper’s meds I explained about privacy and the “circle of care,” meaning that only the people caring for that child have the right to know this information. I love my privacy, too, but it’s likely I’ll be a patient in the hospital where I’ve worked as a nurse for twenty-five years! I know everyone and everyone knows me. My secret insides will be exposed. Others will see parts of my body that I’ll never get to see. They’ll see me naked! They’ll see my urine – even worse – they’ll know my weight!
John gives my notebook a glance and sets it aside on the picnic table, which makes me realize that the particulars of my situation are not what this exercise is about; it’s about fear itself. We return to the work of breathing. I take a desperate gulp of air like it’s my last.
“Let it out, too,” John reminds me. “With each feeling that arises, surrender to it. Identify each fear, then let it go. Meet it with compassion for yourself.”
My mind is full of scary thoughts. “Bad stuff keeps coming up.”
“Escort each unwelcome guest to the door. Note the thought and the feelings it creates, then let them go.”
I sit with that for a minute or two. My eyes pop open. “Just to recap, what’s the purpose of all of this?”
“To bring us back to the present, to an awareness of this moment, which is all we have.”
I look up at the sunlight shining down through the trees making them so bright and green. The blue lake peeks through the leafy branches, sparkling in the breeze. I understand that what I’m looking at is beautiful, but I can’t connect with it – I barely see it. It’s as if I’m not even here. I’m already on the operating table, the surgeon’s scalpel poised above my chest, about to cut into me.
“Should I keep my eyes open? Closed? Assume the lotus position?”
“It doesn’t matter. Just sit and be aware of what is right here now.”
“Hey, John. I’m sorry. I can’t do this. I don’t want to waste any more of your time. Meditation is not for me.”
“Just breathe,” he encourages me, “in and out.”
I can’t still my chattering mind. I strain to hear him over the static in my head.
“What are you feeling?”
“Terrified!”
“Pay attention to how your thoughts create your feelings.”
I close my eyes. “Am I meditating yet?” I ask after a few more minutes.
“We’re not there yet. It may take a lifetime to master.”
Who has time for this?
I open my eyes. “This isn’t working.” He doesn’t get it. He’s not the one who has to go under the knife, have his chest cracked open, his heart stopped. I look at his kind face, his fit, athletic body. Every morning, he goes for a ride in the countryside on his mountain bike. What does he know about physical limitations? I shake my head. “I have to get back to work. Keeping busy is the only thing that helps me.”
The next morning I am practising my own brand of meditation as I treat the kids’ various ailments. I put a bandage on a kid’s arm and breathe in deeply. I give an antihistamine for a case of hives. A wave of panic washes over me and I wait and watch it subside. The kids push to the front of the line, each wanting to be seen first. I treat them and momentarily they’re satisfied. But there is one child whose need is endless.
“I have a question,” Kevin starts up again. I try to ignore him.
“Can I try your stethoscope?” he asks.
“No,” I snap at him, all serenity vanished.
“Why do the pills come in different colours? What do they taste like? Are there flavours? What’s the strongest one?”
“In the wrong dose, they all can kill you.” I shoot him a menacing glare. Scram, kid.
“I have a question.”
“Just one?”
“Yes.”
“What is it?”
“Can I ask you privately?”
“Of course.”
“Do I have to make an appointment?”
“No. How about right now?” I have a question, too. Does this kid do anything but ask questions?
We go outside and sit on the grass and I wait for the question.
“I don’t know what’s wrong with me, but I’m not having a good time at camp. What can I do to help myself feel better?”
I look at him, his freckled face focused on mine. This is a good question! Now we’re getting somewhere! We talk for an hour and plan strategies. He will focus more on the activities he enjoys, cross off days on the calendar, and come for daily talks with me. I will arrange with his counsellor for him to have downtime, some quiet and privacy that there is so little of at camp. My advice is practical, but maybe John’s approach could also help him to feel better. I will arrange for them to meet tomorrow. Kevin returns to his cabin in better spirits, as I do to mine.
My stint at camp is finished. My kids are staying for another week and a half, but it’s time for me to go home and face the music – Open-Heart Surgery: The Musical.
Alice and I go to our cars and she asks as she always does at the end of our time at camp, just as we are saying goodbye, “Will you come back next year?”
“Yeah, if I’m still alive.”
She laughs, assuming it’s a joke. She doesn’t for a minute think I’m going to die. Probably not, but there are many other possibilities.
“You’re strong. You’ll make it,” Alice says, echoing Mary.
“We’ll see about that.” I hug her and try to commit her embrace to memory.
A few days after I’m home from camp, I go to the hospital to visit Steven. Outside his door stands Albie, his elderly father, who looks like he should be the patient. Stooped over and breathing heavily with chronic lung disease, he’s had congestive heart failure, diabetes, and lots of aches and pains for years yet keeps on keeping on. “They’re going to have to shoot me,” he always says.
He brightens when he sees me. “Pssst …” he says, waving me over. “Here’s a hot tip. D’you wanna sell more books? Put in a centrefold. I’ll even pose for it. How ’bout it?”
I’m so familiar with this old-man Jewish humour that it doesn’t bother me, even at a time like this. It comes from a long cultural tradition of laughing through the pain.
“How’re you doing, Albie?”
“Steven is sick, but he’ll be just fine, don’t you worry. As for me, I’ve never felt better! I have a bowel movement every morning at 7:00. Problem is, I wake up at 7:30.”
I can’t help but laugh, but then remember something. “You had a bypass, didn’t you, Albie? When was that?”
“Take a guess.”
“2000?”
“Close. 1986. Quadruple. Yup, I’m a charter member of the Zipper Club.” He lifts up his shirt to show me the long scar on his chest.
“What was it like?”
“A piece of cake! A walk in the park! My problem is I’m ha
ving too much sex.”
“Shhh …!” Carol, Albie’s wife, admonishes him.
Albie may be in high spirits, but Vanessa knows the score and she’s worried. “Steven looks terrible,” she says. “Please go in there and tell me what’s happening.”
As soon as I go in I understand. What’s happening is that Steven is crashing. His systolic blood pressure is hovering in the seventies, with his mean arterial pressure in the fifties. (In the ICU, we usually aim for at least a MAP of sixty millimetres of mercury (mmHg), the absolute minimum necessary to provide blood flow to the coronary arteries, brain, and kidneys.) Steven is gasping, hungry for air. Even worse is that his heart has slowed down to around fifty-five beats per minute. A healthy heart responds to stress by speeding up to maintain cardiac output. The nurses sit, chatting. When they get up and move, their feet are in cement. This man has a very poor prognosis, but at this point he is a full code.
“Hey, listen up!” I clap my hands to get their attention. “This man is in trouble. He needs central IV access, an arterial line, fluids, intubation!”
“Are you family?” one nurse asks.
“Yes,” I say, after a nod from Vanessa. “This is an impending arrest,” I say, stating the obvious. From the nurses, there’s no response. Why aren’t they doing anything? “Where’s the doctor?” I ask.
“I have no idea.” Steven’s nurse bends down to empty the urine bag for 1600 hours and dutifully charts the two drops she manages to squeeze out of the urometer.
Steven’s kidneys are shutting down, but even more pressing is that his oxygen saturation has plummeted to 74 per cent. “Turn up his oxygen!”
The nurse says she doesn’t know how and even if she did, they aren’t allowed to adjust oxygen flow. Steven’s blood pressure is dropping farther. He needs fluids and probably an inotrope to constrict his vessels and boost his pressure. I don’t trust the blood pressure reading on the cardiac monitor because the wave form is dampened, so I go over to take his blood pressure myself the old-fashioned way, with a cuff and stethoscope that’s hanging on the IV pole. It’s barely detectable. But the systolic is around sixty, lower than what it shows on the monitor screen. Steven’s heart is dying before our very eyes.
His nurse sits at a desk, busy with her charting, probably writing something like, Difficult visitor. Will call Security to remove visitor if disruptive behaviour continues. The other nurse pretends to be very busy, tucking the covers around an elderly patient, settling him in for a nap. How to wake them up, galvanize them into action? I don’t care if I’m out of line. People die because of this kind of indifference, this antiquated view some nurses have of themselves that they are helpless or powerless.
But I rein myself in and soften my tone to be more diplomatic.
“You might want to call the doctor,” I say gently.
“He’s busy,” the nurse answers.
“Tell him the patient is crashing. He’s about to arrest.”
She glares at me. From across the room, the other nurse stares at me. Their expressions seem to say, We’re just nurses. There’s nothing we can do. What if the doctor gets angry at us? They’ve given up. If I wasn’t so caught up in the situation and my feelings for Steven, I could actually muster some sympathy for them. I was a nurse like this, once. I remember feeling so constrained and afraid. I know the frustration of seeing problems but not having the means to fix them.
And it’s not all that unusual that big, obvious signs of trouble like this get wildly missed. Unfortunately, it’s been known to happen and it’s one of the reasons that the Rapid Response Teams were created in hospitals. There’s even a name for this kind of situation: failure to rescue. Sometimes it occurs when doctors don’t listen to nurses, but here, the nurses aren’t even speaking up to the doctor on behalf of their patient.
“Page the Rapid Response Team!” I demand.
“We don’t have one yet, we’re still developing it.”
Precious minutes go by, but at last the nurse tells Vanessa the doctor is coming and they’ve called the respiratory therapist to assist with intubation. Steven’s blood pressure is still low, but he’s responding to a bolus of saline that the nurse finally started. They’ve gotten the ball rolling. It may be too little, too late, but Steven’s condition seems stable for now. It’s time for me to go home.
“Is he going to make it?” Albie asks when I come out of the room.
“I think so,” I say wearily, “for now, anyway.”
I get home, turn on Dr. Phil, open a bottle of wine, and start dinner. It’s romantic, having the house to ourselves, like old times.
Soon, I hear Ivan’s car in the garage, then his key in the door, and I get that familiar flutter. Did I happen to mention how handsome Ivan is, in a rogue-ish, pirate-y sort of way? Short, strong, swarthy, and rough-looking, he’s completely my type. Would I be able to have sex, one last time? I greet him as the phone rings. It’s Sue, Vanessa’s neighbour from across the street. She had arrived at the hospital just as I was leaving, less than an hour ago.
“Steven died. He went into cardiac arrest just after you left. They called a Code Blue and worked on him for almost an hour, but he didn’t make it.”
Now I know what my biggest fear is. It’s the best-kept hospital secret. Nurses are capable of the greatest good and also the greatest harm. They will cure or kill me – or worse. They will protect or neglect me, save or sabotage me. The worst thing to have if you’re a patient is a scared, cowardly nurse, one who sees a problem but looks away and does nothing, a timid nurse who’s afraid to go out on a limb or an indifferent one who doesn’t care enough and gives up.
To survive this experience, I will need nurses caring for me who have guts and grit; smart, staunch, stubborn, protective, feisty, fierce nurses, savvy nurses with moxie, pluck, and chutzpah. I’ll take a brave nurse over a nice one any day! Patients always say they want the best doctor, the most qualified, the top of the class. Fair enough, but they rarely give a thought to the quality or qualifications of the nurses who will be caring for them. This is a dangerous oversight because nurses are the ones who will keep you safe – or not. They are in charge of seeing that you get better. The problem is they are the salvation and the danger, both the rescue and the risk – and possibly the weakest link.
5
TICKING TIME BOMB
Chocolate doughnuts, double-cheese pizzas, Rocky Road ice cream, and other sugary and trans-fat-laden delights – I’m on the phone confessing all my dietary transgressions to Mary and am coming to the realization that my carbohydrate foodprint is more damning than my carbon footprint.
“But what about the olives!” Mary reminds me, in my defence.
She’s got a point. In my refrigerator right now, there’s a jar of dry, wrinkled black olives from Morocco, containers of green, Spanish ones stuffed with chipotle peppers, and smooth-skinned, dark Kalamata from Greece, chock full of vitamins, omega 3s, and antioxidants. Also on my kitchen shelves are walnuts, blueberries, and bran. Does it balance out? Risk factors and lifestyle choices – each only half of the picture.
I didn’t completely come clean with Dr. Drobac: I do have a significant cardiac family history. My father had coronary artery disease, which caused him frequent bouts of crushing chest pain (angina) for which he popped nitroglycerin pills like candy. He ignored his doctor’s advice to lose weight, even when he eventually developed diabetes and had to go on insulin. At sixty-two, he had a massive heart attack that caused cardiac arrest and he died. My eating habits are also bad and I’m always carrying around an extra twenty (more like thirty) pounds. I guess I’ve been in denial about that, too, because I seem to have the opposite problem than most women, always thinking I’m thinner and fitter than I really am.
Inexplicably and undeservedly, my test results came back perfect. My blood sugar is normal, my good cholesterol is high, and the bad is low. But tomorrow is the big reveal: a cardiac angiogram is the ultimate report card. If there are blockages in my coronar
y arteries, that’s a failing grade. It means I will need a bypass as well as a valve replacement and will require an even longer, more difficult surgery with greater risks and potential for complications.
“Tilda, if you had stayed, could you have saved Steven?” Albie asks me.
“I’m sorry. I wish I could have, but … no.”
Steven had massive irreversible heart and brain damage. He couldn’t be saved, but the nurses and doctors didn’t even try. But what about patients who do need rescuing – a patient like me, for example? Will they give up on me, too? Will important things be missed? Will my nurses fight for me?
Albie is looking for answers, trying to fathom the death of his son. As hard as it if for her, Vanessa seems more accepting of the situation. She knew how sick Steven was and, given his underlying medical problems coupled with such extensive brain damage, how unlikely was the chance of any significant recovery. She knows Steven wouldn’t have wanted to live under those circumstances, but what disturbs her is that he died in such a violent and undignified way. A Code Blue involves pounding on the chest, possible cracking of ribs, often electric shocks, and possibly other extreme measures but, in this case, futile efforts.
It’s the day after, and according to Jewish law, the burial must take place as soon as possible. I’m helping Vanessa with funeral arrangements, the shiva, and keeping it all together.
At the cemetery, Albie gets out of the hearse slowly. When he sees me, he says sadly, “You spend your life stopping at red lights, but when you’re dead they let you go right through them.” Together, we follow the ancient custom of tossing a shovel-full of earth onto the casket. I put my arm around his back that sags with grief. “No matter how you work and strive, you don’t get out of life alive,” he says.
“You’re a poet, Albie.”
“And don’t even know it.”
One day, these corny, old jokes will be gone, too.
We stand at the graveside, each of us with a damaged heart: Albie’s is failing, Vanessa’s is broken, Steven’s is dead, and mine, defective.
