by Tilda Shalof
As Ray walked out of the ICU door and made his way to the elevator with his brother, I couldn’t resist asking him the question that had been on my mind.
“How were the Rolling Stones?”
Ray turned back to me with a big, semi-toothless grin, gave me a thumbs-up, and rasped out a classic, Canadian-style answer, “They were fuckin’ eh!”
Almost
Bella Medeiros Manos, RN
WHEN I FIRST STARTED in the ICU I was terrified. I always worried: What will the next shift bring? Will I be able to handle what’s thrown at me? Do I have the right stuff to be an ICU nurse? Before the start of each shift, there would be a tight knot in my stomach that just wouldn’t go away. I would walk into the ICU, glance at the assignment board posted near the nursing station, read the name of the patient listed beside my name, and think, This is the name of the person whose life will be entrusted into my care for the next 12 hours. I would walk slowly to my patient’s room. “It’s good to feel fear,” the older nurses would say so confidently. “That’s the way you should feel when you start out in the ICU.
“It builds character,” they would tell me, as they went about their work.
It was easy for them to say that. They had years of experience under their belts, just like I do now. Nurses can be harsh with their young. For a long time, I always felt I had to prove myself to them. But the real reason I felt such fear working in the ICU was that despite all my new ICU skills, acquired in a six-week crash course on critical care, along with my new knowledge base and repertoire of advanced skills such as mechanical ventilation and CVVHD (a form of hemodialysis), hemodynamic monitoring (which involves pulmonary artery catheters, cardiac outputs, titrating inotropes, and cardiac rhythm interpretation), I grasped pretty quickly how enormous are the responsibilities of the ICU. Patients’ lives are literally in our hands.
Another challenge of the ICU has to do with working as part of the larger multidisciplinary team. In the ICU, nurses are expected to present our findings and recommendations about our patients to everyone on rounds. “Everyone” includes staff doctors; residents from specialists such as anesthesiology, general surgery, or cardiology, pharmacists; social workers; respiratory therapists; dietitians; physiotherapists; and others. It was new for me to communicate my nursing knowledge with all of those other professionals. I prayed to not sound like a babbling fool when my turn came to present my patient! In those early days, when everything was so daunting and scary, I kept thinking, What have I got myself into? Couldn’t I have chosen an easier path?
I have cared for many patients in my twenty years of ICU practice. Not every patient grabs you and leaves you with a lasting impression, but some do. There is one patient I will never forget. I was on a night shift and still very new to critical care. I can still feel a flicker of the fear I felt as I entered her room and still recall a particular stale, sour odor and the feeling that I wanted to run and never come back.
I was assigned to care for Sabrina Sanchez, a young woman with breast cancer. When I looked at her chart, I saw she was exactly the same age as I was—24. When I saw her colorful head scarf of yellow and green daisies, I knew it was to cover her bald head. She’d lost her hair from chemotherapy. I saw how pale she was and checked her lab results. Sure enough, her hemoglobin was very low. I wondered if I would be giving her a blood transfusion that night. She was very thin, with deep-sunk eyes and no eyelashes. Her lashes had fallen out, too, like the rest of her hair, from the chemotherapy. Her exposed eyes, bony frame, and pale skin made her look so vulnerable. I didn’t know if I was up to the challenge of caring for someone who looked so sad and needy. A part of me wanted to run away. My first thought was to ask for a different patient assignment. The prospect of caring for this patient felt emotionally overwhelming. But the day nurse had already started giving her handover report to me and I felt I couldn’t interrupt her. Besides, I didn’t want to show my fear. There was no way out. To cope, I focused on her disease.
Sabrina’s cancer must be very aggressive, I reasoned, because although she had been recently diagnosed, she already had metastases to her brain and bones. She was in the ICU because of sepsis—overwhelming infection—and pneumonia, too, both of which she’d gotten because of the immunosuppressive effects of the chemotherapy. She was on a ventilator and needed close monitoring, aggressive fluid replacement, and IV antibiotics.
At the end of her report, the day nurse told me a very important piece of information. That very day, Sabrina, our patient, had made a decision. She had requested that all treatment be stopped. She wanted to be allowed to die. Because it was a big decision, and one that couldn’t be rushed, nothing was going to be done that night. My job was to keep everything going until the morning. If Sabrina still felt the same way the next day, everything would be stopped and treatment would be withdrawn.
Thoughts came rushing at me as I listened to the day nurse tell me this information. I looked at our patient. Why are you giving up? I wanted to say. You can’t do this. Don’t make this choice. I looked at the day nurse, who was still giving me her report, but I could barely listen because thoughts were swirling in my head: She can’t make this choice! She’s my age exactly. She must be depressed and not thinking right. She’s in no state of mind to make this fateful decision. We can’t give up on her, even if she wants to give up on herself. Someone stop this! This is a mistake. Have you all lost your minds?
But I kept my thoughts to myself. I couldn’t say those things out loud. I couldn’t tell anyone how upset I felt over her decision. I had to find a way to deal with my feelings. I was the one with the problem.
I began that shift as I began every shift, with a methodical head-to-toe assessment of my patient. I took refuge in my critical thinking skills and rational, logical mind. They helped me to stay focused and keep my emotions in check, but my private thoughts kept intruding: We’re the same age. I’m healthy and happy. Today, while I’ve been planning my upcoming wedding, you’ve been spending the day planning your good-bye to your family and friends.
I felt overcome with sadness and despair at this woman’s situation and her decision. I’d wanted to be an ICU nurse to help people and make things better. I wanted to save lives. What this young woman was doing made no sense to me. I could barely look her in the eye as I took care of her.
I stayed focused on her body. I saw how the endotracheal tube was cutting into her dry, cracked lips. I saw how the skin on her left breast was still burned from recent radiation therapy. Her abdomen was concave from not being able to eat any of the foods she probably, just like me, enjoyed—ice cream, good greasy fries, café latte loaded with whipped cream. Sabrina no longer wanted these things. She only wanted her suffering to stop. I was about to ask her why, but stopped myself. I suppose I could figure out the answer, but I could not accept it. I guess I didn’t ask her because I didn’t want to hear her say it. She wasn’t able to speak because she was intubated, but I didn’t hand her a clipboard and ask her to write me a note, because I didn’t want to face what she might write there.
As the night wore on, I continued to do my best to hide my feelings. I gave Sabrina her medications and took hourly vital signs. I made adjustments on the ventilator. I even took blood work and sent it off to the laboratory. I washed my patient’s hair and glossed her lips. I went about doing everything I could to keep my patient pain free, comfortable, warm, washed, and well groomed. I cared for her as if she were a patient who we had every reason to believe was going to get better.
All the while, I kept thinking, How do you plan that today will be “that day”? What if she changes her mind? Can I help her change her mind? Maybe I could help her choose to live. I counted the minutes until the end of my shift.
As morning approached, I began my end-of-shift routines: tallying fluid balances, emptying drains, tidying the room, and doing last-minute turns and comfort measures. As I worked, Sabrina woke fully. She began to bite on her breathing tube as if to cut off her oxygen supply.
Each time she did that, her airway was occluded, the alarm on the ventilator went off, and I silenced it. I begged her to stop, but she was determined. I tried to force her jaw to stay open. I attempted to insert a plastic oral airway but was unsuccessful. I was about to give her some light sedation to make her stop fighting the ventilator, but she shook her head furiously when I suggested that. Is this how she’ll go? I thought. I can’t let this happen! I can’t have someone die right in front of me by her own hand when I’m the nurse on duty! Sabrina continued to struggle against the ventilator, clamping off the tube in her mouth with her teeth so that no air could enter her lungs. She pulled at the tube, trying to rip it out of her lungs. In panic, I pulled the call bell and screamed for help.
Sabrina was starting to turn blue from lack of oxygen. Her mouth was clamped down so tight that no air was getting into her lungs. The ventilator alarm kept going off. I knew what she was doing. She was determined to die, ready to go then and there, in this brutal way, right before my eyes. Again I tried to pry her teeth apart, but they were clenched down on the tube. Her actions were louder than any words. She was furious at me for trying to stop her. She grabbed the scarf from her head and threw it across the room. I held on tight to keep the endotracheal tube in place so that she would continue to receive oxygen. I held down her arms to prevent her from violently pulling out the endotracheal tube and damaging her airway and vocal cords. Soon, others came to help and we managed to keep the tube in place. I was shaking by the time everyone arrived.
When my shift ended, an hour or so later, I left Sabrina looking out the window, her bald head exposed. Tears were running down her face. It was a beautiful spring morning. Trees outside her room were in full bloom. A new day was beginning for me, but this young woman’s life was about to end…. Today will be her last day. There was nothing I could do but accept her decision.
As I gave my report to the day nurse coming on, I knew I had failed this patient. I was there to support patients in their choices, even if their choices were not the ones I would make. I walked out of the hospital that day a different person, a different nurse. And to this very day I remember Sabrina Sanchez. I wasn’t there for her death—the other nurses told me it occurred later that day—but almost.
Three A.M.
Sarah Burns, RN, BScN
THE STRETCHER WITH THE CARDIAC monitor was parked outside Mr. McGovern’s room. The bottom shelf of the stretcher was full, packed with IV tubing, bags of fluid, a portable blood pressure cuff, and all the emergency drugs. We call this stretcher the Cadillac.
“Going on a road trip?” I asked Alice. She was standing near the sink in Mr. McGovern’s room, mixing water with all the pills she’d crushed.
She looked over at Mr. McGovern and rolled her eyes. He lay there, mounds of pinky white flesh, arms sprawled out, filling the bed. “We’re going to head CT,” Alice said.
I looked down at the flow sheet. He weighed 359 pounds. “What’s the weight limit?” I mouthed.
“I guess the table can hold this much if he’s spread out,” Alice whispered. “Like if he were five foot two, they couldn’t do it.”
“When are you going?” I asked.
She looked up at the clock. “They want us down there in fifteen minutes.”
“Want me to page respiratory?”
“Rochelle’s on,” Alice said. “She’s going to finish her treatments and she’ll be over. Could you call CT though, and tell them to send two transport people? Look at all this junk.” She waved her hand toward the six IV pumps, the ventilator, all the tubes and wires.
I called CT, checked on Mr. Livingston, and returned to the room. Alice had the Cadillac lined up next to the bed, the IV pumps wheeled up to the head of the bed, out of the way. Drew was disconnecting the cables from the monitor, turning stopcocks, flushing lines.
“Maybe you should just take him in the bed,” I suggested. “That way you’ll only have to move him twice.”
Alice looked at the Cadillac, then at Mr. McGovern. “Yeah, if we have two transporters—yeah, that’s a better idea.”
I hooked Mr. McGovern up to the portable monitor and lifted it off the Cadillac.
“Just moving your leg over a little,” Drew said. He pushed the right leg over as far as he could and I set the monitor down on the bed. Alice put the box of emergency drugs by the left leg and we stuck the blood pressure cuff and the chart up near Mr. McGovern’s shoulders. Then Rochelle walked in with a new oxygen tank and an ambu bag. Drew wedged the oxygen tank between the side rail and the monitor. I took down the pressure bags and laid them on Mr. McGovern’s arms.
Now the bed was full. Rochelle had disconnected him from the ventilator and was bagging him with the ambu bag, but still no transport people.
“I can go down with you,” I said to Alice.
We hoisted the pumps up and hung them on the side rails, but that made the bed too wide and we kept bumping into things. One pump had a continuous blood pressure infusion, one was an antiarrhythmic, two were infusing antibiotics, another had a sedative, and the sixth line was the med-line, which I mentally took special note of: I knew it would be the line I’d use to push drugs in case of an emergency. So Alice hung three of the pumps from the headboard and I pushed the other three. Rochelle kept bagging and I steered the bed. We made it to the elevator but we had to take the pumps off the bed so the elevator doors could shut. Rochelle was squeezed in at the head of the bed, bagging Mr. McGovern; Alice was at the foot, watching the monitor and the pumps. “I’ll take the stairs,” I told them.
When we got downstairs we pulled the bed and all the equipment out of the elevator. I’m always afraid the wheel of the bed will fall into the gap between the hospital floor and the elevator doors. The space is exactly the width of the bed wheel. I’m good at imagining disasters. When I’m snow skiing, I imagine hitting one of those moguls and falling smack on my back, rupturing my kidney, bleeding internally. Water skiing is worse: I think the rope will accidentally get wrapped around my wrist and the boat will drag me that way. I know I’ll have to curb these paranoid thoughts if I ever have a child.
We traveled up and down the halls twice before we found the right CT room. Mr. McGovern was doing fine, his chest rising and falling with the breaths Rochelle gave him. I took over bagging while Rochelle ran back upstairs to get the ventilator.
The CT technician emerged from the other room. He was pale, dressed in a white uniform, sort of like a pant suit. His hair was sandy colored and his glasses were too big for his face. “How much does this gentleman weigh?” he asked.
“Three fifty-nine,” Alice said
“Pounds?”
“Yes, pounds.”
“Well, I don’t know why they even send these patients down here. Our weight limit is three hundred and twenty pounds.”
Alice quickly brought him up to speed on the height times weight, square mass of flesh rule and we moved him over to the CT table. He was heavy but at least he wasn’t fighting us. I hate bringing people down who are moving all over the place, trying to sit up. Usually the doctors don’t want to give them any sedatives because they don’t want to “cloud” the mental status. That makes sense, but then you have these CT technicians telling you they can’t do the study if the guy won’t hold still. So you’re caught in the middle, trying to please all parties and get the test done. It must be what middle management is like.
Alice found some Velcro straps in the cupboard and we swaddled Mr. McGovern’s IV tubing and his arms up against his body. One pump started to beep and I pulled the Velcro strap off, straightened the IV line, and wrapped the arm back up; then another pump beeped. The technician crossed his arms and sighed.
“The battery is low on this one,” Alice said. “Where can I plug it in?” She started toward the wall with the cord.
“Not there,” he said, still with his arms across his chest. “The scanner needs to move back and you’ll knock that pump right over.”
“This is a level one trauma cen
ter!” I wanted to yell at him. “Lots of people are going to come down here with lots of machines to plug in. You need to have a PLAN!”
“Can I use this?” Alice pulled a power strip with a long cord from the corner. I admired her persistence and unflappable style.
“That’s fine.” He opened the door and went into the adjoining room to start the scanner.
“What a worm,” Alice said. She handed me a pink lead apron and a little cellophane package.
“What’s this?” I asked.
“Fruit roll-up.” She wrapped the blue lead apron around herself and opened her own fruit roll-up. We leaned against the counter, three o’clock in the morning, eating our fruit roll-ups and watching Mr. McGovern get fed into the scanner. “What was everyone so worried about?” Alice laughed. “There’s at least two millimeters to spare.”
“Yeah, and we didn’t even have to grease his sides to get him in.” I popped the last of my fruit roll-up in my mouth and washed my hands.
“When did he come in?” I asked Alice.
“Three thirty. A neighbor found him in his apartment. But no drugs, no alcohol.” Alice always grilled the ambulance drivers for details. “Bobby said he had stacks of newspapers and magazines everywhere in his apartment, like a path. It was hard to get the stretcher out. ”
The worm pushed the door open. “We’re finished,” he reported.
“Did you see anything?” Alice asked him.
“I’m not at liberty to say.” Why was I not surprised? I turned away from him and rolled my eyes at Alice. Then a transporter arrived and we pulled Mr. McGovern back over to his bed.
Same thing on the way up: Rochelle bagging, Alice watching the monitor and the lines, the transporter and I pushing the bed and the pumps. I sealed them all in the elevator and I took the stairs.
