by Tilda Shalof
A “code” can go on for many minutes, even an hour. When it’s successful – what satisfaction and jubilation we all feel! When it is unsuccessful and is finally called off, there is a sudden and unsettling calm. The time of death is pronounced. Everyone strips off their vinyl gloves and turns away from the exposed, worked-upon corpse. One by one, they walk away from the messy room, strewn with empty syringes and assorted debris, and return to doing whatever they were doing before they dropped everything and ran in to try to save a person’s life. Everyone leaves – except the nurses. We stay behind with the body, wash it, sponge blood out of the hair, and do all the things that nurses do to bestow dignity upon the body of someone’s loved one. We tidy the room, dim the lights as if to soften the blow, then go out to bring the family in, offering our arms for support and our words for comfort.
But tonight I’m not on duty. I can relax and not concern myself with all the matters an ICU nurse has to consider upon hearing “Code Blue”: Is a bed available in the ICU if the patient survives the arrest? If not, is there a stable patient who could be transferred to the floor? Is there a nurse for the patient? Is a room clean and equipped? Where is the family? Are they at home and need to be informed ever so gently over the phone that their loved one is in a crisis and may not make it? Or are they in a waiting room somewhere, frantic and distraught, needing someone to throw them a lifeline of hope? Since I’m not a nurse right now, I have the luxury of thinking only what an ordinary person would think: I hope that poor soul makes it.
* Instituting cardiopulmonary resuscitation (CPR) or using an automated electronic defibrillator (AED) out in the community have much higher rates of success. Everyone should know how to do these things.
12
NURSES EATING CAKE, DRINKING COFFEE
Saturday night. Everyone is either out on the town with friends, having a good time, or else at home, sipping wine and snuggling in for the night. No one wants to be here in the hospital – not the nurses or doctors – or us patients, either.
Shift change. It’s 1915 hours and the night nurses, peppy and fresh, rush in to relieve the droopy and spent ones who are moving slower, tallying up fluid balances, and finishing their charting by writing the words – a tad prematurely – that will release them from the responsibilities they’ve shouldered for the past twelve hours: Report given to night RN.
Those going and those coming take up places around the nursing station, ready to give and receive report.
It’s still unbearably hot in my room so I’m sitting in my blue hospital gown, in the hallway, on a chair that I’ve dragged out here. Positioned near the nursing station, I can eavesdrop, watch the action, and vicariously enjoy the familiar activity and aura of intimacy of shift change. I’m smack-dab in between my two worlds.
The nursing station is the usual setup. There’s a long table in the centre, counters around the perimeter lined with phones and computers, and, at the back, a rack of charts in dark green plastic binders. (We are still in the process of weaning ourselves off paper.) I listen in on the amusing banter going on at our “water cooler.”
“… I’m switching over to nights, but my body is not happy about it.”
“Tell me about it. When I’m on nights, I have no social life.”
“… spent the day cleaning the house … my three sons, a husband, and a father-in-law, but not one person in my household who can pee in the toilet.”
How I love this chatter! In my ICU, I work with hundreds of people. I know them all by name, am on friendly terms with most, close friends with many, and Facebook friends with quite a few. Recently, a patient asked to “friend” me. Would it be crossing a line to be on Facebook with a patient? It feels that way to me. I couldn’t be friends – neither Facebook nor the flesh-and-blood type – with anyone who is currently my patient. The Internet is shaking up old notions of privacy; there’s a lot more sharing going on, but some boundaries are still necessary, especially in the hospital. (By the way, on the hospital computers we can’t do any social networking, but it’s not for lack of trying. There’s an impenetrable firewall.)
There’s always a commotion at change of shift, and I know one nurse who prepares herself for what’s ahead by finding a quiet spot and meditating. She says it helps her get centred before diving into the unknown fray. My friend Mary, in North Carolina, passes a church as she drives to work. “I say a blessing and ask God if He could do rounds with me again this shift, and give me an extra dose of wisdom and patience,” she told me once. Then there’s the rest of us, who merely plunge right in, hoping for the best.
Soon, the nurses settle down to the business of giving report. Don’t worry – we patients aren’t left on our own – they are a few steps and a call bell away. They’ve gone into a tight huddle so I take my chair and return to my room to give them space to exchange confidential information about patients.
There’s an art to giving “good report.” There’s a lot of important – often crucial – information and instructions that must be conveyed in the midst of noise, distractions, and interruptions. You have to be focused and organized in your presentation of your patients’ history, plan of care, and remember to mention any pressing work you’ve left undone that needs immediate attention. You can’t just relay facts: a good report also conveys interpretations, opinions, and impressions but manages to avoid biasing or swaying the oncoming nurse. You try to sneak in a helpful hint of how the previous shift was for you and what sort of scene the oncoming nurse is facing. A few “heads-ups” are always welcome! Receiving a good report is the best way to start your shift.
Unavoidably, individual styles come out in our report-giving. I once knew a nurse with amazing panache. She used handover to showcase her own accomplishments as much as the patient’s progress. Phaedra’s reports were perfect – thorough, to the point, and delivered concisely. “I weaned him off the Levophed and got the blood pressure stabilized. I improved his creatinine, normalized his lactate, treated his potassium, and brought the hemoglobin up to eighty-five from seventy after transfusing two units of blood.” She beamed with pride, taking full credit for any and all improvements in her patient, as if she was a one-woman show. Phaedra was a superb nurse – and made sure you knew it!
One of the most memorable reports I ever gave was about a patient whom I’ll call Violet. It was a very sad situation. Violet lived a hardscrabble life on the streets of downtown Toronto, working as a prostitute and in the drug underworld. In addition to mental illness, Violet had cardiac damage as a result of cocaine abuse, respiratory issues, and acute kidney disease requiring dialysis. She also suffered a side-effect from one of the drugs she was on. It caused poor circulation to her extremities and her fingers became necrotic – blackened and shrivelled. They were hanging on by mere threads of mummified skin. (Think Tales of the Crypt.) That was one of many shocking details that had to be included in my report. In order to give a complete and accurate picture to the oncoming nurse, I also had to describe Violet’s bizarre behaviour, like her attempts to rip into her rectal drainage bag to eat her feces; the multiple genital piercings that necessitated delicate perineal care; Violet’s unusual “relationship” to a stuffed Winnie-the-Pooh she placed between her legs and “made love to” (there’s a more accurate word but this book is rated PG). I tried to keep my composure as I hurried through my report, then rushed away to escape the sheer gnarliness of it all. I was desperate to get home and into a hot shower.
But in the car on the way, I suddenly realized I had forgotten to inform the oncoming nurse about the loose fingers. What if she came across one of those desiccated, dangling digits – a flying phalange that had come dislodged among the bedsheets? She’d get a fright and be scarred for life. I pulled over to call the hospital.
“Don’t worry. Of course you told me about the fingers,” the nurse reassured me.
As I mentioned, a good report prepares you for what’s ahead.
The nurses are interrupted from handover by the patien
t in the room next to mine. He has started moaning, “Take me home, man,” “Help me, sir,” and “Help me, ma’am,” over and over. The nurses haven’t finished their reports, but one of them gets up and goes to his room, first putting on a gown, gloves, and a mask because he’s still in isolation. Another nurse goes to help her. Then, about a half-hour later, when they come out and as they are finishing washing their hands, a family member approaches and asks them to please go back in because the man is still not comfortable. The nurses glance at each other, yet show no sign of impatience, and gown up again and go back in.
“Do you want the radio?” I hear one of them ask twenty minutes later, as she’s about to leave again. No answer. “AM or FM?” Muffled response. “AM or FM?” she repeats. It’s not long before they’re all laughing with the instant familiarity of old, easy friends.
His nurse is my nurse, too, and after a reassuring squirt of antibacterial hand sanitizer, she comes into my room, introduces herself as Yolanda, and takes my vital signs. In her crisp, white uniform she stands out from the rest in their pastel or patterned ones. You don’t see many people wearing white uniforms these days, but it’s a sure sign of a nurse. As she takes my temperature, I see on the lanyard around her neck that holds her name tag and hospital ID, the phrase “I Jesus.” Many patients find that comforting. I do, too.
Good times! It’s someone’s birthday and cake and coffee are being served at the nursing station. A green bedspread is the tablecloth and wooden tongue depressors, forks. Nurses are the designated celebrators, party planners, and potluck dinner/baby shower organizers – and the ones who stay afterward to clean up the mess.
Raucous peels of laughter. How rebellious it feels to be cheerful around here! It’s not seemly for a nurse to be eating, resting, chatting, or laughing. Sometimes it’s even uncomfortable to tell patients or family that I’m taking a break. It surprises them, maybe because nurses are expected to be constantly available, there to meet others’ needs, not have any of their own.
(It’s always best not to take too long on a break. A nurse once told me that she’d been gone for more than an hour and during that time, her patient got married. She missed the wedding ceremony, but luckily they saved her a slice of cake!)
“They’re busy doing nothing,” I’ve heard visitors complain when they see nurses sitting around the nursing station, joking around or in high spirits. I see how it seems that way, but if only they knew how necessary it is for nurses to regroup, think, study, collaborate, socialize, and commune with one another. These things usually take place in off-hours or stolen moments in equipment rooms, hallways, or waiting for elevators. However, the need to debrief and de-stress can be every bit as urgent for nurses as it is for combat soldiers, firefighters, and police officers.
How can nurses offer comfort when they don’t feel it themselves? We go to great lengths to keep our feelings hidden from patients, to not let on if we’re worried, scared, or quietly freaking out. Then, afterward, we escape – usually off-stage – and let loose. We all know stories of nurses who “lost it” on the job or later, after-hours. Most hospitals make psychological counselling available to employees dealing with job-related – or otherwise – stress.
Sometimes pent-up emotions get the better of us and we need a reminder to rein it in. In fact, we have a discreet sign, a plastic flower that we hang outside a patient’s door at times when there is a particularly sensitive situation, like a crisis or a grieving family. It’s a visual alert to everyone to show more decorum.
At night, we tend to loosen even more. Laura always used to say she behaved better on days, only swearing on nights. One thing is for sure. Whatever petty conflicts or grievances we have on days, we usually manage to put them aside on nights. We try to come together and help each other. Night shift is hard and it never feels normal or natural to work all night, but what’s the answer? Nursing presents unique challenges to staying healthy.
But some of our harmless shenanigans don’t help our image. Once, I was sitting in the staff lounge with colleagues, eating cake someone had brought in celebration of something or other. Suddenly, we noticed family members peeking in at us through the window in the door. Nurses aren’t supposed to be enjoying themselves. “Nurses just want to have fun!” was our anthem, but “Let them eat cake!” the onlookers must have thought.
In another cake-related debacle, we were gathered and just about to partake of a birthday cake in the “fishbowl” behind the nursing station. Stephanie went off to the pantry in search of a knife, but all she could find was a rather large cleaver, more suited to pumpkin-carving. On her way back, still holding it, she heard an alarm going off in a patient’s room. Seeing that the patient’s nurse was busy with another patient, Stephanie stopped to remedy the problem. “I hope you’re not going to use that on me,” the patient said in terror at seeing a knife-wielding nurse at his bedside!
In another weapon-related incident, none of us will forget the stir Nurse Gina created the day she called over the loudspeaker, “Who has the gun? Whoever has the gun, please bring it to the nursing station immediately!” She was referring to an instrument used to staple chest tubes to the suction apparatus, which we called the “gun.” You can see how that could create alarm, but it was also pretty funny, too.
FYI to the public at large: if your nurses are noisy or having too much fun and it bothers you, speak up and say so. Know that all you have to do is say, “Please help” or “I need you” and we’ll drop our forks, knives, or “weapons” to come to your aid.
–
It’s 2130 hours. A nurse is writing in a chart, the telephone cradled next to her ear, reading a bedtime story to her child over the phone. “I’ll be there in the morning, sweetie, before Daddy takes you to day care,” she says before hanging up.
Another nurse sits beside her, text-messaging her boyfriend.
Beside a bank of cardiac monitors a telemetry nurse oversees thirty-six patients’ heart rhythms. An alarm goes off, she looks up, studies the screen for a moment before deeming it a “normal abnormality” (there are such things), and silences the alarm.
I listen to a nurse on the phone speaking to a family member. “I’m just calling to put your mind at ease,” she is saying. “I knew you would sleep better if you talked with me before you go to bed. Feel free to call whenever you like and I’ll let you know how he’s doing. It’s our job to worry, not yours.”
You have to be extra cautious on the phone. Once, I gave information to a patient’s husband and later learned the couple was separated. He was only calling to make sure she was still alive so he could continue to collect her pension cheques. Another time, while talking on the phone to one patient’s daughter, all of a sudden I clued into the fact that the background echo I was hearing meant I was on a speaker phone. I had just broadcasted personal information about my patient to unknown people who were also present in the room. Privacy is not only getting tricky to define, it’s getting harder and harder to guarantee.
The night is moving along. I hum a few bars from “Strangers in the Night” – shooby-dooby-doo – an old Frank Sinatra song. These pain meds are great! Feelin’ groovy! Whoa-oa-oa! I feel good, I knew that I would, now … sugar and spice … Thank you, James Brown! Here in the cardiac ward, most of us are getting better – like me: I’m going home tomorrow.
It seems like the nurses are running the show around here. Haven’t seen any doctors tonight, but there must be at least two because I heard one nurse ask another which doctor wrote an order for her patient because she needed to clarify something about it. She asked, “Was it the resident with the blue hair or the one with the purple tattoo?”
(I swear, I don’t make this stuff up.)
The din has died down. The hallway lights are lowered. Beddybye time for us patients, but the nurses’ night is just getting underway. Janet, of Bagel Club renown, pops in for a visit. “Just making my rounds, checking on my babies, and thought I’d see you, too, Tillie.” But the wave of heat i
n my room hits her too and we don’t stay in there for long.
“It’s freakin’ hot in here.” Janet fans herself with her clipboard of papers, notes on her patients. “Stick a fork in me – I’m done. Let’s get out of here.”
We walk to the visitors’ lounge and she slows down her brisk steps to match mine.
Janet gives me a once-over. “Jeepers, you’re looking a heck of a lot better,” she says. “You were in rough shape down in the ICU. Not a healthy-looking specimen at all.”
“Were you there?” I have no recollection of visitors.
“You don’t remember, do you? We were all there and saw you, stewed, blued, and tattooed. It figures you’d hemorrhage – nurses are always the ones to get complications.”
Satisfied with my progress, Janet turns to her real patients. “Did you hear that Code Blue yesterday? She was my patient. I’d been following her all day. Vital signs were normal and I didn’t have specific concerns – just a bad feeling. I talked to one of the vascular surgeons about her, a guy who was an intern on a floor I worked on many moons ago. Back then, he wouldn’t even talk to me, but now that I’m an ICU nurse, he does – go figure. He’s one of those jerks who’s always complaining about nurses, how useless and incompetent they are or how many times he got woken up at night, etcetera, etcetera. ‘Go easy on them,’ I told him. They’re young and have no one else to call. Anyhoo, I told him I was worried about this patient. He said, ‘What’s the problem? She’s doing fine,’ but I had a bad feeling about her. Sure enough …”
