by Tilda Shalof
lives
in the
balance
Nurses’ Stories from the ICU
Tilda Shalof RN, BScN, CNCC(c)
EDITOR
Publishing
New York
Contents
Introduction
Chapter 1 Intensive Care
Echo Heron, RN
Chapter 2 Those ICU Nurses
Madeleine Mysko, RN, MA
Chapter 3 What I Can’t Hear
Judy Boychuk-Duchscher, RN, BScN, MN, PhD
Chapter 4 My First Code Blue
Chris Kebbel, RN, BScN
Chapter 5 Stranger in a Strange Land
Rosemary Kohr, RN, BScN, MScN, CNP, PhD
Chapter 6 Discernible Markings
Claire Thomas, RN, BScN
Chapter 7 Visiting Hours
Mary Malone-Ryan, RN, BN
Chapter 8 Sick Kids
Linda L. Lindeke, PhD, RN, CNP
Chapter 9 Ray Can’t Get No Satisfaction
Lisa Huntington, RN
Chapter 10 Almost
Bella Madeiros Manos, RN
Chapter 11 Three A.M.
Sarah Burns, RN, BScN
Chapter 12 O, Holy Night!
Bob Hicks, RN, BScN, BHSc
Chapter 13 Power and Voice
Sharon Reynolds, RN, BScN, MHsc
Chapter 14 Nursing the Machines
Cecilia Fulton, RN, BScN
Chapter 15 Why I Stay
Karen Higgins, RN
Chapter 16 That Deep Place Within
Elizabeth DiLuciano, RN
Chapter 17 Rescue Work
Tilda Shalof, RN, BScN, CNCC(C)
Chapter 18 Conducting an Orchestra
Sherrill Toldy Collings, RN, BScN
Chapter 19 Tipping the Balance
Matt Nathan Castens, RN, BA, CCRN
Chapter 20 Tennis, Anyone?
Karen Klein, RN, BScN
Chapter 21 Not Just the Patient
Gina Rybolt, RN, BScN
Chapter 22 Making Mischief in the Night
Janet Hale, RN
Chapter 23 An Uneasy Feeling
Kathy Haley, RN
Chapter 24 Bridge to Transplant
Linda McCaughey, RN, BScN, CNCC(C)
Chapter 25 Open Heart
Meera Rampersad Kissondath, RN, BA, BScN, MN
Acknowledgment of Permissions
About the Editor
About the Contributors
Also Available in The Kaplan Voices: Nurses Series
Introduction
IN THESE 25 ESSAYS, critical care nurses reveal the fascinating world of the intensive care unit (ICU). Moment by moment, by day and by night, ICU nurses care for patients who have life-threatening illnesses or injuries. The stakes couldn’t be higher.
In these pages, you will find stories of healing and recovery, along with others about decline and, ultimately, death. Some stories are about the period in between when, quite literally, lives hang in the balance. As they reflect on their experiences, these ICU nurse writers share their knowledge and expertise, as well as their thoughts and feelings, stresses, joys, and even moments of mirth. While their stories are all true, all contributors have taken great care to protect patient and family confidentiality. All names and identifying characteristics have been changed.
When it comes to writing about the ICU, Echo Heron was a trailblazer in her bestseller, Intensive Care: The Story of a Nurse. It is an honor to publish an excerpt from this classic, which inspired many nurses to choose to specialize in critical care.
The nurses in Lives in the Balance possess years of clinical experience in pediatric and adult care and a wealth of expertise in medical, surgical, cardiac, cardiovascular, trauma, and neurosurgical units. However, it’s neither the population they serve, nor the medical specialty, that defines them. Critical care nurses share a readiness to take on challenges, a preference for fast-paced, action-packed work, and the courage to find ways to cope with tough, raw emotions that come with the territory.
Karen Higgins’s enthusiasm for the ICU bursts from the page as she takes us step by step through the thinking process she uses to solve uniquely ICU problems. Mastering the ICU involves a steep learning curve, but Chris Kebbel took it on as a student nurse and then new graduate, eventually shaping a career that combines critical care with information technology. He recalls his early days in the ICU, as does Madeleine Mysko, who shares her first impressions of ICU nurses. Linda Lindeke recalls her career in pediatric critical care and the influence of a significant mentor.
Dropping down into Planet ICU as an outsider, Rosemary Kohr provides an objective impression of this rarified world, which she visits as a wound care consultant. And while the ICU is a place, it is also a way of delivering care to critically ill patients.
Sherrill Collings has to move fast from the ICU out to other parts of the hospital, and back again as she takes readers step by step through one extraordinary-ordinary ICU day. Kathy Haley and Janet Hale tell about the exciting development of Critical Care Rapid Response Teams. A cutting-edge technology to assist prospective lung transplant patients is reported on by Linda McCaughey. And if there was any doubt about the breadth and depth of nursing knowledge, coupled with the emotional maturity and communication skills that ICU nursing requires, read Meera Rampersad Kissondath’s story. It is a picture of consummate ICU nursing.
ICU nurses know that our patients are not just the person in the bed. Families are often nearby, in need of information, comfort, reassurance, and above all, hope. Gina Rybolt shows this in her compact but telling story. Mary Malone-Ryan tells how she met the needs of one family as their father was dying. When patients are too ill to speak for themselves, families are often called upon to articulate their wishes. This situation presents Matt Castens with an unusual dilemma in his role as patient advocate.
In the ICU, death is an ever-present possibility. Sarah Burns tells an unsentimental but moving story of the end of one man’s life. After Cecilia Fulton witnessed too many distressing end-of-life situations where her patients suffered deaths that were undignified and overly technologized, she made the decision to leave the ICU. As a community nurse, she helps patients articulate their advance directives and wishes for their end-of-life care.
The extreme suffering that ICU nurses witness takes its toll at times. As Claire Thomas and Elizabeth DiLuciano care for trauma victims, they show remarkable self-mastery in order to provide the best care possible to their patients. Bella Madeiros Manos bravely recalls an earlier stage in her career when the emotions her work evoked were just too great to handle.
The ICU presents particular challenges in getting to know our patients. Many are unconscious or intubated, thus hampering communication. When her patient becomes extubated and regains his voice, Sharon Reynolds discovers the person who had been temporarily hidden. Karen Klein learns about her patient through his wife’s recollections. This essence of “patient-centered” care—of seeing the patient’s perspective and attending to mind, body, and spirit—is conveyed succinctly in Judy Boychuk-Duchscher’s ICU moment. Lisa Huntington and Bob Hicks offer surprising twists to “getting to know the patient” and the results are equally holistic—and humorous, too.
Entertaining, informative, uplifting, and moving, these stories show nurses who have found work to which they feel dedicated. Indeed, anyone who spends any time in the ICU, as either a patient or family member treated there, or as a professional who works there, knows that what is most intensive and caring about the ICU is the nursing care. Here are voices of ICU nurses.
Tilda Shalof, RN, BScN,
CNCC(c)
Editor
Intensive Care
Echo Heron, RN
THE LARGE INSTITUTIONAL CLOCK read 2:50 P.M., and somewhere in the middle of the eight flights of stairs, I wondered what I would have to do for the next nine hours of my life.
What would they need? Would it be simply a matter of controlling the pain with a little morphine and oxygen, or would I constantly be on the run, checking vital signs every five minutes, suctioning secretions to keep an airway clear, calculating drug dosages, calibrating machines, and listening to my sixth sense—all while keeping one step ahead. And, of course, a portion of my attention was reserved for the one fear that loomed larger than the rest, the one always present: Would I make a fatal mistake?
I reached the last step and had to juggle my brown paper lunch bag, oversized purse, and umbrella to open the door to the green waiting room. As I walked under the ACUTE CORONARY CARE sign, I noticed a woman with white hair sitting on the couch, crying. A younger woman with red hair leaned over her, touching the woman’s shoulder, saying nothing.
It could mean something critical; it could be over-reaction. But there wasn’t the usual hysteria that came with overreaction. This was the kind of sorrow and fear that came from something tragic.
I opened the door leading into the world of the four fishbowl rooms, each holding a single blue bed for the critically ill. The monitor banks stood directly in front of me. Only one scope was lighted and running: bed two.
Before taking another step, I named the rhythm and knew what was wrong with the heart that generated it. Glancing at the assignment board, I saw bed two was mine.
I walked to my locker and took the blue cotton uniform from its hanger. As I slipped it over my head, I noticed an old bloodstain on the waistband that repeated laundering had not removed. I tried to remember the name of the patient who had contributed the small piece of color and felt guilty when I could not.
Next, my badge. I pinned the insignia of authority on the left shoulder seam of my uniform. RN, MICN, CCU, ER: Registered Nurse, Mobile Intensive Care Nurse, Coronary Care Unit, Emergency Room. How many years of school and hard work did those initials stand for? Ten?
Lacing the white shoes, I allowed my mind to drift toward work. Bed two. How old? Man? Woman? How bad was it? The grieving white-haired woman in a green waiting room hinted at the answer.
Glancing at myself in the mirror, I hastily repinned several wild strands of my chestnut hair back into the knot at the top of my head and picked up my tools: stethoscope, packaged ointments, germ-killing swabs, and blunted bandage scissors. I was ready to face the evening.
The familiar subtle thrill began to well up inside me as I walked to the nurses’ station. I compared the feeling to what it must be like walking on stage. Even though I had memorized my lines for the scene, no one ever really knew what was going to happen.
The report from Kelly, the on-duty nurse, was tedious and uninformative. That was unusual. Kelly was one of the coronary unit’s better nurses, but tonight she lacked her normal enthusiastic energy.
“The patient is a sixty-eight-year-old male, admitted in the wee hours this morning. The diagnosis: possible cerebral hemorrhage. He had a head scan this morning, and I haven’t heard results as yet,” said Kelly. She sighed and leaned forward. “I just couldn’t get into doing the job today, I’m sorry. I didn’t bathe him, and I turned him only a few times and …” She took in a deep breath, then hunched her shoulders even more. Exhaling, she looked directly at me. “Jesus, it just seems so pointless. I don’t like taking care of corpses. I just want to get out of here and go home to my kids.”
I wrote down the clinical information about the patient without changing my expression or responding to Kelly’s comment. We all knew the feeling of being forced to keep a patient alive long after it was determined the situation was hopeless. It was a futile battle that was more emotionally draining than almost any other nursing situation.
After arranging the facts by body systems, I looked them over once again and walked quietly into the glass-walled acute care room.
The rhythm of the respirator was in tune with the continuous hum of the building. The man’s arms and legs were twitching, disturbing the plastic tubes that lay twisted across his naked chest and thighs.
I came close to the bed, which was cranked to the level of my waist, and looked at him carefully. With his slightly overweight, large-boned body, he filled the bed head to foot. A mist of sweat covered his balding head, and his skin was that particular gray color I knew well. The once-white adhesive tape, tightly wrapped in a thin strip around his mouth and cheeks, held a red-striped tube that invaded his airway and carried the warmed, moistened air from the respirator into his lungs.
I crossed the room again and pulled the solid blue curtain all the way around the glass, blocking the view of outsiders interested in watching.
Where to start? The mechanical assessment of the man’s body was so like taking apart a dysfunctioning engine piece by piece. Neurological focal seizures; all signs absent; no responses—no one home. Kelly had termed it “vegetable soufflé.” Cardiovascular: heart rate, 150; blood pressure, 80 palpable. Skin: cool, wet, and mottled. Color: bluish gray, dusky. Drugs: procainamide, dopamine, and lidocaine. Pushed through his veins by more pieces of mechanical apparatus, they did their job to keep his heart pumping smoothly.
I replayed Kelly’s report in my head. He had been alive and laughing yesterday. There had been a special gathering of the family to honor him: Grandpa, Dad. I could see images of the silly predinner joking and the fumbling backyard football, then the after-dinner Grandpa stories he told, keeping the younger children entranced. It all had taken place fewer than 24 hours ago.
I saw the small, dried crystals of blood clinging to his nostril hairs and pictured the paramedics, their adrenaline running rampant, trying to push the tubes in without success. The man’s broken ribs gave evidence of the prolonged cardiopulmonary resuscitation; so much effort without reward.
Spontaneously the seizures stopped, and I allowed the family in to be with him, one at a time.
His sister walked in first. Like him, she was large-boned. Seeing him, she made a half-waving sort of movement with her hand and laughed lightly while tears fell on her brother’s arm. She stared at the place they had fallen but made no attempt to wipe them away. Without looking into his face, she shook her head and said in a very low voice, “Oh Colonel, Colonel, good-bye now, dear, bye-bye.”
She noticed me moving about on the other side of the bed and started to explain. “I called him Colonel all his life. He liked it. It was his nickname.”
The woman stole a quick glance at her brother’s face and walked away from the bed as if to leave. With a jerky motion she turned back and started to say something to him, but her mouth moved without the sounds. Putting her hand to her lips, she backed out of the room, still speaking silent words to her brother.
I stood motionless until I heard the waiting room door shut. Coming close to him again, I put my hand on his and held it. It was moist and warm. With the digital thermometer I quickly took his temperature; the bright red numbers stopped at 105.2. From my training I recalled having read somewhere: “Anything over 105 is incompatible with life.” Incompatible with life. Simple. To the point.
Ten minutes later a grandchild, a thin boy in his late teens, walked stiffly into the room. He stared straight ahead as if prepared to fight the enemy which held his grandfather. The boy reached out to touch the older man’s face and caught himself. He would not make this real. This was his grandfather, a man he had loved all his life. He would not give him up to the world of these ugly tubes and sterile smells. His grandpa was the smell of pipe tobacco and apples. He was the tall, balding man always telling stories. Gramps was the wisest man he’d ever known; he would not let him go.
Suddenly his shoulders began to shake, and his angular face distorted with the shape of his pain. He turned away quickly and left the room without say
ing a word or making any sound.
I went to the bed again and looked at the man’s face. As I leaned close to him, my hand moved to his forehead and slowly wiped away the sweat. I pulled the bloody tape away from his upper lip and was surprised to see the full white mustache. For a time I looked carefully at his face and decided it was a kind one.
Pulling back the lids of his eyes, I found large and unresponsive pupils surrounded by a ring of light blue. I moved close to his ear and whispered. “Colonel, I’m here, do you know that? I am right here.”
Down at the end of the bed I massaged his purple feet as they lay still and ice-cold. I thought about his life, his work, and wondered if he’d ever gone fishing. “What kind of man were you really?” I asked aloud. While listening to the answers of silence, I noticed the monitor: heart rate 70; blood pressure 74. He was slowing down despite the drugs.
Twenty minutes passed, and the soft, whooshing noise from the respirator lulled me into a kind of trance as I did my charting and prepared the paperwork. A male voice startled me. Looking up, I saw a tall man with a middle-aged woman standing close to him. They looked worried and anxious.
“How’s he doing?” the man asked, hope hanging on every word of the question.
“Not well,” I answered. “He’s very critical at this point.”
The woman moved toward me slightly, wringing her hands. “Do you think he’ll pull out of this? We’ve been his friends for so long. How long will he be in the hospital?”
I paused, staring directly at the woman. “He’s not going to make it. His body is dying now … as we speak.”
The man stepped toward me with a look that said he did not believe me; he wanted to bargain. “Look, if we go to San Francisco and hire the best specialists, that would help, wouldn’t it?”
I stood up and approached them. “No. His brain is dead. He, the man, the person, really died last night; only his heart is beating and a machine is breathing for him. Not much else is functioning.”
