by Tilda Shalof
“Why is his face so puffy?” asks Mrs. DeWitt.
Anasarca, massive edema, third-spacing, fluid shifting … how to explain it to her? It is so upsetting for her to see him like this! “When there is overwhelming infection throughout the body, the tissues don’t hold the fluids inside the cells and it leaks out and causes swelling, known as edema,” I explain.
“So why are you giving him more fluid?” She points at the bank of electronic machines pumping fluid into his veins.
“That fluid contains powerful medications to help his blood pressure.”
“Why is his blood pressure so low?”
“Because of the infection in his blood. The infection releases substances called endotoxins that cause the arteries to expand.”
“Why is there an infection in his blood?”
“Well, his diabetes put him at risk, and the surgery he had last week….” I reiterate explanations that we have all gone over many times before, but bear repeating. “The disease itself and the treatments, too, can cause all these problems.”
One thing leads to another….
“Why isn’t the infection getting any better? Isn’t he on antibiotics to fix that?”
“Yes, but the antibiotics don’t seem to be working.”
“Why aren’t the antibiotics working?”
“They don’t always work in these situations … of overwhelming sepsis. We may add a new one.”
“A stronger one?”
“Yes.”
“Is it a better one?”
“It may work better for him. In his case.”
“Is it better?”
“It may be, for him.”
“Well, then, why hasn’t he been on that better one all along?”
I fall silent. I have no more answers because these are not the real questions she wants to ask. For those questions there are no answers, certainly none that I have. She scowls at me and I return to the patient, to listen to his heart, his lungs, his stomach. I study his heartbeats on the cardiac monitor and make notes in the chart.
“Getting all this down, are you?” she asks. She is standing beside me, peering down over my shoulder, as I write in the chart. “Is my husband an interesting case for you?”
She doesn’t like that I am writing notes, but she kept notes, too, for a long time, especially in the beginning of her husband’s long stay in the ICU. One day she left her notebook behind on the bedside table, and a nurse found it. She had written comments about all of us and kept a list of the “good” nurses and the “bad” ones; the ones she wanted, the ones she didn’t. She recorded the names and dosages of the drugs we gave each day and what percentage oxygen he was receiving. How unnerving it was to all of us to be so closely scrutinized.
She has a hard, bony face and she is making it difficult for me to feel warm toward her, as I try to do under these circumstances. I stand up, face her, and find it in myself to put my arms around her and envelop her in a hug. With this hug, I am trying to offer an answer to Mrs. DeWitt’s questions. I am trying hard to like her, but even though I don’t, I have learned that I can still do my job well. I hold her in my arms and she sobs and I let her.
The unit is quiet now. Only a few, necessary lights are on now, the rest have been dimmed. The earlier swirl and turmoil of activity in a patient’s room across the hall where a fresh lung transplant was admitted a few hours ago has now settled; the room has cleared out and calm has been restored, so I know the patient has been stabilized. A few nurses are gathered at the nursing station sipping coffee and chatting quietly, their voices a familiar and pleasant murmur. In my room, I can feel the growing distress brewing in my patient’s wife and I remind myself to stay calm. For it is only if I remain calm and centred that I will be of any help to Mrs. DeWitt tonight. She stands at her husband’s bedside, telling him she’s there, knowing all too well by now not to expect any response from him. I see her legs in droopy stockings and faded sandals that were probably once jaunty and colourful, but at this hour, under these weary fluorescent lights and these dismal circumstances, they look pathetic. She wipes up the countertop with a dirty towel and dumps it into the laundry basket. She takes a clean face cloth, wets it under the tap, and presses it to her husband’s sweaty, bloated face. By now, after so many weeks of her husband’s illness, she makes herself at home here in her husband’s room. It’s her room as much as his, and certainly more hers than mine.
I busy myself with paperwork. It’s almost midnight – 2359 hours – and the new date involves a lot of extra documentation. It seems quite irrelevant, especially at a time like this, but it must get done.
Then a horrible stench fills the air and we know instantly what this is. Mr. DeWitt has lost control of his bowels in the bed and Mrs. DeWitt flees from the room.
Later, when she returns, he has been cleaned, his linen changed, and I have managed to make the room smell more pleasant with a floral spray and an air deodorizer. Fresh air is an impossibility as the windows are hermetically sealed throughout the entire hospital.
“If we were to let him go,” she asks me as if it’s a test question for which she knows the correct answer and wants to find out if I do, too, “what would the cause of death be?”
Each time she asks a question, it is as if she has never received any information, no one has told her anything. Even though we’ve spent weeks providing her with information, sitting with her every day to go over everything and answer her questions, she still feels as if she’s been kept in the dark.
I decide to go where she is leading me. She wants information.
“Multi-system organ failure.” I take a breath before the list of Mr. DeWitt’s medical problems: “Overwhelming sepsis, disseminated intravascular coagulation, pancreatitis, renal failure, and complications of diabetes.”
“Oh.”
I sense she’s looking for wrongdoing: there must be someone to blame for the condition her husband is in. Someone must have made a mistake. Surely there were things that could have been done that weren’t; things that were done that shouldn’t have been. Something must have been missed. I see accusation on her face. Perhaps she still finds some comfort in our conversation. For all the time we are talking, mortal decision making is delayed and her husband is, more or less, alive. Technically speaking, anyway. Legally alive. In biological terms, that is.
She holds herself in her two arms, close and tight, doing it for herself as if she already knows that her husband will not be doing this for her ever again.
IT’S 0100 HOURS and a new admission has just arrived. Without even going out of my room, I can feel the buzz, the energetic spring into action of the other nurses, a few doctors, and the respiratory technicians. Frances has gone in the room to help and another friend of mine, Tracy, steps forward to cover for me while I go check out who has arrived. Tracy has been reading my telepathic messages for years. She probably senses I need a short break from Mrs. DeWitt’s gaze and the hopes she has pinned on me to save her husband.
“It’s a pink hamburger lady,” says Laura, another nurse I’ve worked with for years, referring to her new admission. Laura looks concerned about her patient, a young woman, thrashing in the bed. One leg is right over the side rail. Her body looks healthy, an even tan all over, no bikini lines, and silver nail polish on her toes. She is babbling incoherently, calling out to people she sees, voices only she can hear.
“Only twenty-two years old. She’s been seizing, her eyes are bulging out from intracranial pressure, and, I think – she might be going” – Laura milks the urinary catheter tube for a few more drops of amber-coloured urine – “into kidney failure.”
“All from eating rare meat?”
“Yup, can you believe it?”
“She looks pretty sick. You must be busy.”
“It’s steady,” she admits. “But I’m glad to be busy. The night is flying by. So, how’s Mr. DeWitt doing?”
“I think he’s going to die tonight.”
“He’s been ci
rcling the drain for weeks.” Laura shakes her head. “Mrs. DeWitt can’t let go.”
The resident on call tonight rushes in, still chewing the last bite of her submarine sandwich. Meningitis has to be ruled out, so she’s preparing to perform a lumbar puncture on Laura’s patient. She pulls her long, dark hair back and tucks it into the collar of her white lab coat that is not so white any more. Her eyes sparkle in anticipation of this procedure. She told me earlier that she was looking forward to performing it and hoped for a “champagne tap.” That’s when you just get the clear cerebrospinal fluid, no red cells, and no white cells. It’s supposed to look like water. CSF comes straight from the brain and is the cleanest, purest bodily fluid, the hardest to come by.
“DO YOU REALLY think he’s going to die? Is there any chance at all that he might make it?” Mrs. DeWitt asks as I re-enter the room to resume my sentry post at her husband’s bedside.
I look at her long and hard. “I hope I’m wrong,” I say. I would like to remind her that it’s not up to me. We have failed you, I think, by encouraging you to believe that we can cure anything and everything.
The night grinds on. Most rooms are settled and there is a feeling of calm in the ICU. There is an unspoken understanding among all the nurses: we will get through this night together.
It is now almost five in the morning, well into the day of March 6. Mrs. DeWitt looks exhausted and I offer her a blanket and a pillow, but she refuses.
I have now added two more potent medications to boost Mr. DeWitt’s blood pressure, but his urine output has petered out. His body is shutting down, organ by organ, and even Mrs. DeWitt can see where we’re heading and that what we are doing no longer has any purpose. She is beginning to see, too, how it detracts from her husband’s dignity to have all this inflicted on him. She decides it is time to let him go. He is already so close to death that as soon as I cut off the flow of just one medication, his blood pressure drops and his heart goes into a slow, erratic pattern.
“What’s that called?” After all these months, she’s learned to recognize significant changes on the cardiac monitor screen and she knows that every configuration has a name.
“Do you mean the heart rhythm?” I ask.
“Yes.”
“It’s called the dying heart.”
That’s the truth. That’s the name of that particular configuration. Textbook.
The resident is having a busy night with other patients but comes into the room. She is obligated to make a difficult request and she approaches Mrs. DeWitt now to put it to her.
“Would you be in agreement for us to perform an autopsy?”
“Is there a question about the cause of death?” Mrs. DeWitt’s raised eyebrow conveys renewed suspicion as she makes one last rally to apportion blame. “What would you be trying to find out by doing an autopsy? Are there unanswered questions?”
“It is not an investigation,” I cut in to explain. “It will contribute to medical knowledge. Science. Even in cases like this, your husband” – and we pause to look over at him as I speak – “even in cases like this where the cause of death is known, the information that we will obtain from the autopsy and will pass on to you, may help you come to terms with … it.”
“Can he donate his organs? Ed signed his organ donor card.” She brightened visibly at the thought.
“Unfortunately, there is too much disease and infection for organ donation.”
I see she takes this as a personal rejection and is miffed. “Very well then, autopsy, with the remains to be returned to me for cremation.”
NOW THERE IS just an occasional blip and then long, smooth, green lines on the monitor screen. I turn off a button at the back of the ventilator and it stops pushing air into his lungs. I close the clamps on the intravenous fluids and shut off the pumps that are pushing those fluids into the body of Mr. DeWitt.
“How low could the numbers go?” she asks.
She keeps her eyes trained on the cardiac monitor.
“To zero,” I say. “It could go right down suddenly, or drift gradually. Why don’t I just turn off the monitor now, since we’re not treating the numbers any more, right?”
She nods. It seems that only when I push the “off” button on the cardiac monitor – the “TV screen” that played a constant movie of her husband’s heart for so many days – and the fluorescent green lights zap off and the screen goes black, only then does Mrs. DeWitt believe that her husband has died. To her, the heart monitor had been the proof of life, especially when there were no other signs, and only now, turned off, is she forced to face what it means.
“So, is he … he’s gone now?”
I think she needs time to tell herself the answer, so I keep quiet.
I close off all the IVS and turn off the other machines. Once, it all held such promise and now, in a moment, it has become useless paraphernalia. Junk. Much of it disposable.
Then I turn to her husband’s body and, like an old-fashioned country doctor, take out my stethoscope from my lab coat pocket. It comes down to this. How strangely reassuring and quaint it seems to use this basic piece of equipment. It’s based on a principle as simple as two pop cans connected by a string to carry the voices of kids across a backyard. I stand over my patient’s body and listen to his heart with my stethoscope for a long time so that there will be no doubt in anyone’s mind that his life has ended. The stethoscope has long since replaced a feather under the nostrils, or a mirror held up to see if there is moisture from a breath on the glass, or fingertips pressed to the neck. Yet it does the same thing. I keep on listening. There are no signs of life. Legally, this diagnosis will have to be confirmed by the doctor, but I am confident enough of my findings to tell her myself.
“Yes,” I say. “He’s dead. I’m very sorry.” For her, I really am.
Some of the other nurses who had gotten to know Mr. and Mrs. DeWitt over this long hospitalization come to offer comfort and say goodbye.
WHEN I WALK in the door in the morning after my shift and my husband, Ivan, who’s sitting at the breakfast table, looks up and asks, “How was work?” I say, “Fine, no problem.”
“Busy?”
“Yes,” and we leave it at that.
Should I tell him the truth? That I helped a man die, that I comforted his wife who sobbed in my arms, and that no, I am not upset about it. This is what I do for a living as a nurse in the intensive care unit.
When my husband asks about work I almost always answer the same way. I rarely go into too many details. He might regret he asked if I did. He would stare into the newspaper. His coffee would go cold. It might make him worry about me – or about himself – and I feel protective of him. Another reason that I don’t go into details about my work is for the sake of our children, who might be within earshot and become frightened. They are very young and beginning to wonder about the world. Sometimes they see a still, squished bug and other bugs that are alive, busy creatures, and that’s the closest thing they’ve ever seen that has anything whatsoever to do with the work I do. Not that everyone dies where I work, but some do, and there are a lot of close calls.
Now I will eat a bowl of Cheerios and go straight to bed, because even though it’s early morning, the sun is up, and most other people are starting their day, I need to sleep.
2
FIRST, TAKE YOUR OWN PULSE
The stopcock terrified me.
Before I became a critical care nurse, I worked on a variety of medical and surgical wards in many different hospitals and I had acquired a lot of experience with veins. Veins trickled, oozed, or dripped. One of the big differences of working in the ICU was that, for the first time, I was confronted with arteries. Arteries spurted and gushed. After all, they are the vessels that pump blood directly from the heart. The stopcock is the gateway to the world of the artery.
In my early days of working in the ICU, the arterial stopcock – that little nub of hardware – taunted and haunted me. It was a mere half-inch piece of white plasti
c, and its mechanism was simple, yet its implications were immense. Each and every ICU patient had an “art line” in place (inserted in the radial artery in the wrist or femoral artery in the groin) to give us easy and instant access to the patient’s circulation. The art line allowed the nurses to monitor patients’ blood pressure and procure the many blood samples – most importantly, the arterial blood gases, ABGS we call them – without disturbing the patient.
With the stopcock positioned in the upright direction, we could monitor the patient’s blood pressure. We made sure to set the alarms to upper and lower parameters for the systolic (contraction of the heart) and the diastolic (relaxation of the heart) measurements. As long as the numbers stayed “WNL” – within normal limits (something I was expected to be able to ascertain at a moment’s glance) – all was well.
Problems could occur. Sometimes, a stream of blood crept up backwards and went along the tubing in the wrong direction and I was supposed to troubleshoot the problem. It could be a loose connection somewhere in the system or insufficient counter-pressure. Sometimes, the waveform on the monitor was dampened or had an overly high amplitude. Then I would have to flush the system, re-calibrate the transducer, heighten the sensitivity, or merely check the module and cables.
In order to obtain a sample of arterial blood to send to the laboratory to test the oxygen, carbon dioxide, and bicarbonate levels (substances that had to stay within a narrow range or else the patient would be in life-threatening danger), I had to turn the stopcock to the left – which meant the artery was wide open – and then move swiftly to attach a special tube that withdrew a sample of bright red blood from the pulsating stream. Then I had to flush the line clear of blood, reset the stopcock to the upright position, and close it off, all the time keeping everything absolutely sterile.
For other procedures, I had to turn the stopcock to the right. In that position, a flat green line would suddenly appear on the cardiac monitor and an urgent, piercing alarm would sound. If family members were present, they would jump, especially when their loved one was being cared for by a novice nurse – something they seemed to sniff out moments after meeting me. However, the alarm could also go off if the patient rustled the sheets or moved in bed, in which case the alarm was caused by “artifact.” Most importantly, the alarm could signal the “real thing” if the heart went into a sudden lethal arrhythmia. It was my responsibility to know the difference.