by Tilda Shalof
CONTENTS
Cover
Title Page
Dedication
Foreword
Author’s Note to the 10th Anniversary Edition
Preface
Acknowledgements
1 Treating the Numbers
2 First, Take Your Own Pulse
3 The Vein, the Artery, and Beyond
4 A Dagger in the Bed
5 Decompression
6 Sisters of the Air
7 Gifts and Donations
8 Gratitude
9 Celestial Housekeeping
10 Redecorating
11 Transfigured Words
12 The Difference Between a Foot and a Penis
13 Shh! It Happens
14 Tired, Hungry
15 Narrow Margins and Close Calls
16 A Dose of Photo-Realism
17 A Prisoner of War
18 Shift Change
Copyright
To nurses everywhere
FOREWORD
As a veteran emergency physician, I have worked alongside my nursing colleagues for more than thirty years. You can’t work in a big-city Emergency Department without learning how to get along with health professionals. You learn how to ask nicely for an internist to squeeze in a final consult at 6 a.m. – knowing they hand over in an hour – and how to get a reluctant respiratory therapist to give your patient with asthma a nebulizer of salbutamol instead of an inhaler.
In the same way, you figure out which nursing colleagues stand tall in a crisis. You learn that in the resuscitation room, where patients’ lives are on the line. It also helps if you get to know the nurses you work with on a personal level – their likes, their dislikes, what kind of sense of humour they have, and the tender no-go places in their hearts. After more than twenty years as an ED physician, I thought I knew well the nurses with whom I work. Then, I read Tilda Shalof’s extraordinary book A Nurse’s Story, which was first published in 2004. At that time, the only books about medicine that I had read were books that told stories from the point of view of physicians. A Nurse’s Story was the first book I read that told stories from their perspective. Through Shalof’s deft and soulful writing, I met the nurses who worked on “Laura’s Line” in the intensive care unit. Shalof created vivid portrayals of the members of the team – Justine, the union rep, Frances from Newfoundland, and Laura, who set the tone with her sharp remarks.
Not surprisingly, I immediately took to Shalof – the sensitive one. How many times had colleagues accused me of being too sensitive? Like me, Shalof probably came to realize that sensitivity is not a weakness but a strength. Sensitive health professionals are among the best observers of the culture of modern medicine, as ably demonstrated by Shalof in A Nurse’s Story.
The book gave me a close-up view of what it’s like to care for patients hovering on the brink of life and death. There’s a saying among critical care doctors: if you’re a patient in the ICU, and you’re not getting better, than by definition, you’re getting worse. The doctors who work in the ICU play a critical role in making the diagnosis. But make no mistake: it’s the nurses who keep you alive. Shalof made that clear with story after story of nurses who have an incomparable ability to think critically and multitask when a patient is crashing.
Since then, through my own book The Night Shift: Real Life in the Heart of the ER, I have discovered how to tell stories that get inside the heads and the hearts of my colleagues who work in emergency medicine. But I give kudos to Tilda Shalof for helping to lead the way. When I first read her book, I was envious of Shalof. Why hadn’t I written a book like that? The book also made me feel anxious and insecure. Where did Shalof find the time to write the book? More important, how did she develop her ability to master prodigious detail to tell those stories?
Two years after this ground-breaking book was published, my show, White Coat, Black Art, aired on CBC Radio. A Nurse’s Story was a template for the show, which was tagged as “medicine from my side of the gurney,” and it had a strong influence on my approach. In particular, I admired Shalof’s refusal not to candy-coat the experience of working as a frontline nurse in critical care. She presented working life in the ICU – warts and all. Her characters were real people – at times elated and at times difficult and grumpy to work with.
More important, her book exposed longstanding problems in health care that need to be discussed. Since my early days as a freelance medical reporter for the Toronto Star and the Globe and Mail, I have had a passionate interest in medical errors and patient safety. On White Coat, Black Art, I have explored patient safety many times. I have to tip my hat to Shalof for devoting an entire chapter to medical errors in the ICU. I have seen many authors point the finger at others; what I admired greatly was Shalof’s willingness to talk about her own errors – those that caused harm as well as near misses. Her brave confessional is a good example of using one’s own mistakes as a steppingstone to making health care safer. Talking about it is essential to removing the shame associated with human error in medicine that precludes discussing errors openly.
The book owed its success to several factors, including Shalof’s bracing honesty and her willingness to tackle edgy contemporary subjects. This book was firmly in my mind when I did my TEDtalk “Doctors Make Mistakes. Can We Talk About That?” Back in 2004 it was rare for health professionals to write openly about their jobs and specifically their all-too-human mistakes. The fact that my TED talk has been viewed close to a million times convinces me that talking about one’s own errors is both authentic and helpful in helping to create a culture of safety.
A Nurse’s Story is set during the time of Severe Acute Respiratory Syndrome (SARS), a coronavirus that appeared mysteriously in Guangdong province in China and then arrived (via ill passengers) at several hospitals in Toronto and Vancouver. As a frontline ER physician at Mount Sinai Hospital in Toronto, I remember all too well an outbreak that some feared would become an airborne pandemic and would wreak havoc on the community. Ultimately, as we know all too well, SARS caused a disproportionate amount of illness among health care professionals who provided intense respiratory care of ill patients. Many of the most urgently ill patients were respiratory therapists, anesthesiologists, and (not surprisingly) critical care nurses. It is in chronicling the impact of SARS on her nursing colleagues where Shalof’s book truly shines. A Nurse’s Story gave voice to nurses who were apprehensive about an illness with no cure and a potentially grave prognosis. Shalof validated the anger many nurses felt about being urged to come to work while uninformed about the risk to themselves and their families.
Many lessons were learned from the SARS outbreak. Just one example of a resulting change is in the ER where I work, which now has three rooms for isolating patients with airborne respiratory illnesses, instead of the one isolation room it used to have. Another is the willingness of nurses to speak up about shoddy care and decision-making that puts them at risk. With the emergence of a new coronavirus that has been dubbed Middle East respiratory syndrome (MERS), we will watch and see how good a job the authorities do to protect nurses on the frontlines.
A Nurse’s Story was well received in Canada and in the United States. The book’s literary success leads me to wonder what impact it has had on the culture of medicine. That is a hard thing to gauge. My own opinion is that books like A Nurse’s Story and The Night Shift don’t change culture so much as reflect a change in the culture towards more openness and self-reflection. I doubt that A Nurse’s Story or The Night Shift changed relations between nurses and doctors on a larger scale. Knowing the tendency of nurses in a hierarchical structure to bully one another, I suspect Shalof was rewarded for her courage with a little disdain and a lot of envy.
No matter. It has
n’t stopped her from exploring the nooks and crannies of modern medical culture. And it hasn’t stopped me either. My new book The Secret Language of Doctors is a deep exploration of the culture of medicine as evidenced by the pejorative slang health professionals use to talk about patients, clinical situations, and colleagues we don’t like.
For me, the best part of revisiting A Nurse’s Story was realizing just how fresh and relevant it still is. I suspect it will still be in the decade to come. Knowing that writers like Tilda Shalof are out there giving readers an inside look at the world of medicine buttresses my own determination to do the same.
Brian Goldman, M.D.,
author of The Night Shift and The Secret Language of Doctors
AUTHOR’S NOTE TO THE 10TH ANNIVERSARY EDITION
The best thing about writing a book is having readers and in this regard, I am very fortunate. Since the publication of A Nurse’s Story and its foreign language translations, I have heard from literally thousands of readers from around the globe – China, Korea, Sweden, Australia, England, Russia, Chile, and North America. It has been astonishing to discover that my personal story of being a nurse resonates with nurses from countless countries, working in a multiplicity of roles, specialties, and settings, and at the various stages of their careers. There is much about the nursing experience that is universal and timeless.
Equally astounding to me has been the enormous interest in the perspective of nurses and learning what they do from outside of nursing circles (other health care professionals and the public). Readers continually express how grateful they are to have this window into a nurse’s world. Many of them say they never knew, and feel reassured to learn, how knowledgeable and skilled today’s
nurses are. Some readers have a seemingly paradoxical response: the stories, which are at times disturbing, both frighten and comfort them. I get this. It is inspiring to witness the bravery of people and their families coping with catastrophic illness and disease; there is great comfort to be had in knowing that any hardship can be endured if there are professionals to keep you safe and meet your most essential needs with competence and compassion. This is at the heart of nursing.
Never could I have imagined that when I sat down to write my nursing story that it would get published, much less that it would become a national bestseller, be optioned for a television series, excerpted and anthologized, and used as a text of nursing narratives for schools of nursing. Student nurses have sent me their finished assignments and it is fascinating to discover the variety of interpretations and personal reflections that A Nurse’s Story has generated. Some of the students go so far as to share their grades with me! (One undergrad boldly asked for help with her paper on the book. “Please tell me what A Nurse’s Story is about,” she wrote. I told her, “You’re going to have to bite the bullet and actually read it.”)
For young nurses this book has been a personal GPS that allows them to locate their career destinations and map out the variety of routes to get there. Experienced nurses read A Nurse’s Story and find affirmation and inspiration during challenging times. Retired nurses write to tell me that A Nurse’s Story helps them to fondly reflect on their own storied career in nursing. I always write back with the purpose of urging them to record their own precious nursing memories.
There have been some truly touching responses to A Nurse’s Story. One reader wrote to tell me that learning about the extreme measures and invasive technological interventions that many families request as their loved one is dying, helped her decide against using these tools to prolong her mother’s suffering at the end of her life. Another reader told me that this book helped her and her father initiate a difficult discussion about his end-of-life wishes. “You explained what nursing really entails and showed the reality of the working world,” another reader wrote. Many readers asked for follow-ups about patients or nurses (especially Laura’s Line) from my book. Nurse readers often give a copy of A Nurse’s Story to their spouse and other family members, “so they’ll know what I do.”
New nurses tell me that A Nurse’s Story inspired them to choose a career in nursing; because of it, some even ventured into critical care. They want to know how they too can become extraordinary nurses. These young nurses’ commitment to excellence and excitement about nursing as a tool for positive change in the world – not to mention their exuberance, energy, and creativity – makes me feel confident in the future of nursing. (However, one young nurse recently gave me cause for concern. She wrote to thank me for information from A Nurse’s Story. It had helped her to pass her licensing exam – I wouldn’t recommend that.) And what greater tribute is there than the reader who got a tattoo of a quote from A Nurse’s Story on his forearm?
Indeed, our stories document the rich lore and legacy of the nursing tradition: the night-shift blues and the highjinks, the path towards becoming a capable and above all “safe” nurse, and the struggle to manage the strong emotions that our work inevitably provokes. I have never heard a nurse express surprise at any of my stories, only amazement that someone had the guts to put them in print. Indeed, it did take courage to broach difficult topics and share stories that I knew had never been told before. I wanted to smash the stereotypes of nurses as either “heroes” or “villains” and show the reality as I know it: nurses are hard-working professionals who do their best to meet the enormous challenges of this job on a daily and nightly basis.
With A Nurse’s Story, I knew I was writing dangerous stuff because as its words poured out of me I became increasingly tachycardie, tachypneic, and diaphoretic – all signs of a heightened state of excitement and anxiety. Why anxiety? It was hard to write about my mistakes and how I’ve learned from them. It was painful to relive some of the long periods of moral distress I’ve felt when seeing problems that I cannot solve. Not to mention the ongoing challenge of staying open to the suffering of others and protecting oneself from “compassion fatigue” or “burn-out.”
Another unexpected outcome of writing this book is that I began to receive invitations from the media to speak about nursing and health care. It was a daunting proposition at first, however, I quickly realized that a golden opportunity had been given to me to represent my profession and advocate for patients. I did my homework and prepared to enter the sometimes contentious world of public speaking. I knew that the best way to bolster my argument against existing inequities in health care delivery was to draw from my thirty years of experience. My stories served to illustrate the negative effects of nursing cutbacks on patients. By talking about real people and their experiences, I was able to clarify these otherwise abstract, ethical issues.
Since writing A Nurse’s Story, I have travelled around the world, sharing my nursing stories. Some of the nurses I met while travelling worried that I had been “too honest,” had disclosed too many “secrets” of our profession, and revealed nurses’ failings and frailties. They were concerned that my hard-core reality will discourage young nurses. But honesty is a writer’s first commitment and it was important to me not to perpetuate the mythology of “heroes” and “villains” in nursing, but rather to show that nurses are all too human. Even nurses who are idealistic and passionate about making a positive impact can become dispirited, disengaged, and disillusioned.
If A Nurse’s Story was the book I was meant to write, The Making of a Nurse is the book I wanted desperately to write for many years. It’s about how being a caregiver at home and in my family led me to choose nursing as a profession. It’s both a more personal and political book than A Nurse’s Story. It was fun to write Camp Nurse, which chronicles my seven years working at various summer camps that my children had attended. I wrote Opening My Heart to share my experience of being on the “other side” as a patient and how it informs my nursing practice today. My latest book, Bringing it Home, is about nursing outside of the hospital, an area I wasn’t interested in at first, but ended up loving.
Writing about nursing has been a joyful experience, which perhaps r
eflects my enthusiasm for the subject. A Nurse’s Story flew out of me, as if it wrote itself and I was merely taking dictation. But I couldn’t have written it – nor anything for that matter – without the guidance of my writing teacher, Barbara Turner-Vesselago (www.freefallwriting.com) and her book Writing Without a Parachute. But writing is nothing without editing and for that, I am grateful to Elizabeth Kribs at McClelland & Stewart. To each manuscript, Elizabeth has applied her expert skills, extensive knowledge, and wise judgement, caring for our “patient” during its fragile beginnings and nurturing it along to become a robust, healthy book.
Wherever I go in the world and whenever I meet nurses, I remember again and again the richness of our world and the privilege we have to inhabit it. Nurses carry volumes of stories inside of them, imprinted upon their brains and souls. My hope is that A Nurse’s Story has opened the door for more nurses to tell their stories. We are too quiet. We need to get louder when speaking up for our patients and more vocal about advocating health care for all. Any discussion of health care that does not include nurses’ voices is fundamentally flawed. As the largest providers of health care, we are health care. After all, nursing care is what people want, what they need the most.
Tilda Shalof
March 2014
PREFACE
This book is the story of my life as a nurse. In writing it, I have culled from my twenty years of professional experience, almost all of it caring for people who have catastrophic and life-threatening illnesses, in a number of hospitals in Toronto and other cities. Although the stories are true and based on first-hand experience (either my own or, in a few cases, that of my colleagues), I have changed the names and descriptions of all individuals in order to protect their privacy. A few of the characters portrayed are actually composites of two or more real people. The time frame of this book is the early eighties to the present; however, some chapters take place over days, others encompass years. I have expanded and telescoped time in order to describe trends in nursing and the health-care system, rather than to document specific political or historical occurrences.