by Tilda Shalof
“Yes, they are,” I insisted.
It was my last med round of the evening. I pushed the unwieldy metal wagon ahead of me like some pharmaceutical ice-cream vendor, dispensing a rainbow of pills, capsules, liquids, elixirs, and suppositories to thirty-six cardiac patients. I glanced at my watch. An hour to go and I still had ten more patients’ pills to give out. Call bells were ringing. A mountain of uncompleted charts was heaped up at the nursing station.
“What are these pills?” she demanded.
“The blue one is your water pill, the white ones are digoxin for your heart rhythm. The little yellow football is for your blood pressure and the tiny white one, that’s for your nerves.”
I was going to need one for my nerves too, if she kept this up.
“That’s not what my nerve pill looks like,” she said.
“But Mrs. Jones, that’s your Ativan. It’s 1 mg of Ativan.”
“Ativan is bigger than that. I know Ativan! Ativan is oval, not round. You’re giving me the wrong pill.”
“Here’s the bottle. You can see for yourself what Ativan looks like. Here, have a new one,” I offered.
“No, you’re not going to give me anything. I want a different nurse. I know what you’re up to. You want to knock me out so that I can’t report you.”
I was finished. My shift was almost over. I pushed the cart to the next bed.
WITHIN ONLY A few years, the trend in the nursing job market was completely reversed. The public’s need for nurses was just as great as always, but now a new provincial government had been elected with the promise to pay for them. Suddenly, nurses could choose which hospital they wanted to work in. Attractive signing bonuses and educational benefits were offered. Almost every department in each hospital was advertising nursing positions. The only problem was that now, there was a nursing shortage. Enrolment in nursing was down and the previous “surplus” of nurses had forced many nurses to move to the United States to find work. Splashy newspaper advertisements and job fairs proliferated to try to lure them back to Ontario hospitals.
I applied for a job at a big downtown hospital. It was the same hospital where I had been a candystriper as a teenager, where I had once worked in the patient lending library as a summer job, and where I used to accompany my mother to appointments with her specialists for her various, mysterious ailments.
“A degree from the University of Toronto? Mmm.” The nurse recruiter who reviewed my file looked pleased. Not many nurses had a university degree in 1986, and it was definitely the way of the future. In fact, nursing leaders were predicting that by the year 2000, all nurses at the bedside would have their degrees.
“Which specialty area do you prefer?” she asked. “We have openings everywhere.”
I was hard-pressed to choose. I didn’t have a particular loyalty to any specific organ, like the brain (neurology) or the heart (cardiology). At that moment, I happened to look out the window and saw a sign that had arrows pointing to the various departments in the hospital. There was Admitting, Radiology, and a sign that said Intensive Care Unit – the ICU – fourth floor. The reputation of ICU nurses was that they were the elite squad. To work there was an achievement many nurses aspired to attain. There, the patients were the sickest of the sick and the nurses wore serious green scrubs (which I thought might be more flattering to my fair complexion than the white or soft pastels I wore on the wards), stethoscopes slung around their necks, and got a lot of respect. As I stared at the letters, I sounded them out in my head and found myself hearing the words as “I see you,” beckoning me to take on this challenge.
“ICU,” I said. “I’d like to work in the intensive care unit.”9“Normally, we prefer a nurse to have acquired at least a year of experience in one specialty area of acute care before progressing to critical care,” the recruiter explained, noting my spotty employment history, “but we’re desperate for staff in every department. I have so many openings to fill.” She paused. “With your university degree, I’m sure you’d catch up in no time. You will have to go on a special course first, would you be agreeable to that? Tuition will be paid, plus your salary for eight weeks. In return, there will be a commitment from you to stay with us for at least a year and work in the Medical-Surgical ICU. The patients there have critical illnesses such as major surgeries or complicated medical problems – and we are now starting to perform lung and liver transplants. You will find it a very interesting place to work.”
“Good, no problem. Where do I sign up?”
ROSEMARY MCCARTHY WAS the nurse manager of the Med-Surg ICU. She was short, round, and serene. It was calming to be in her presence, something I tried to be, whenever possible. She wore the same green scrubs that the staff nurses wore, and over that, a white lab coat. On her bookshelf she kept a graduation picture of herself in a navy blue cape, wearing a nursing cap – a high, starched one with a black velvet ribbon. To me, it looked ridiculous. I had learned that the cap was an obsolete symbol of the subservient role of nursing and of nurses’ subordination to doctors – and practically everyone else. We had come a long way from those days.
For the first few weeks of my orientation to the intensive care unit, they buddied me with Frances. Only a year older than I, Frances was already an experienced ICU nurse who had acquired her “training” (as she called it), “back home” (as she referred to it), in a small town in New Brunswick. She had learned on-duty from nuns, who were nurses in the local Catholic hospital, but since there were no jobs available for nurses when she graduated, she left her hometown to seek work in Toronto.
Frances was patient and didn’t seem to mind taking me on. Orientation was a good word for what we did together, because disoriented was exactly what I was. Disoriented and discombobulated. The first thing she did was help me overcome my fear of the stopcock by giving me an unused arterial line set-up that I took home to practise with privately, in a strange-looking pantomime of drawing blood.
Frances watched me closely my first time drawing blood from a patient. I knew that if I didn’t do it exactly right, the person could lose a lot of blood very rapidly. Litres of blood would pump out in few moments and if I wasn’t fast enough, or didn’t pay proper attention, the patient could hemorrhage and slip into unconsciousness. That degree of blood loss could lead to iatrogenic anemia, exsanguination, and death!
“Probably not,” said Frances, “but it sure would make a mess.”
AT THE START of every day shift in the ICU, the overhead fluorescent lights were turned on, one by one, as if to simulate sunlight and daybreak. However, I quickly realized that this was truly an illusion as there was very little natural light, and for most of these patients, there was no real sense of differentiation between day and night; they were sick around the clock.
In each room, the weary night nurses moved around the beds, finishing up their work and preparing to give report to the fresh and well-rested incoming nurses who bounced into the room, energetic and eager to start their day. They would nod and listen to the night nurses’ report, wish them a “good night,” and then start their day with their own assessments of their patient. They would make their own interpretations, adjust the plastic tubing and wires the way they liked them, and take charge of the flow of fluids draining in and draining out.
We started work at precisely 0715 hours when we went to our assigned patient room and received report from the night nurse. Since all the patients were critically ill and unstable, we were rarely assigned more than one patient at a time. Each one required our complete and constant attention.
Frances decided that I should take full responsibility for my patient’s care, and she would be there as backup, only if I needed her. By then, I had completed the critical care course that the hospital had sent me on and was soon expected to be out on my own, to have my own patient assignment, and do everything myself. I was just about to start my initial assessment of my patient when Laura, one of the other nurses who always worked with Frances, came by to offer me advice.
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br /> “Don’t panic. If there are green lines moving along on the monitor and no alarms ringing, everything’s okay, for now. Sit down and have a coffee. Relax.”
My stomach was churning. “I think I’ll run to the washroom, first, before we start.”
“No. That’s not allowed,” Laura said sternly.
I was too stressed to notice the twinkle in her eye. “What? I can’t go?” I gasped.
“Of course, silly. Just kidding.”
We were never supposed to leave a patient in the ICU unattended.
“NURSING ISN’T FOR everyone, don’t you know,” said Frances to me as we sat in the staff lounge, eating our lunch. She said it kindly. “You remind me of this girl in our class back home. She had to run to the bathroom all the time, just like you, before she gave an injection, before she changed a dressing. She dropped out of nursing and became a nun. Some people can’t take the pressure, especially here in the ICU.”
“I might very well turn out to be one of those people,” I said grimly, “but I want the chance to find out.”
“That’s good on you!” she said.
I WORKED HARD to learn the routines, to stay on top of the hourly vital signs, to perform the ventilator checks, to give the medications on time, do the treatments, participate in team rounds, arrange for X-rays and ECGS, and assist with tests and procedures. There was something to do every minute. I noticed how Frances did not only the task at hand, but also two or three other things at the same time, all the while, preparing for upcoming tasks that she anticipated.
“Where did you do your training?” Frances asked me one day.
I was standing there, watching her draw a blood sample from my patient’s arterial line. She flipped the stopcock to the right, attached a test tube, and then flipped the stopcock open to the left. As she waited for each tube to fill, she smoothed her patient’s ruffled hair and checked his heart rhythm and blood pressure on the cardiac monitor. When the test tubes were full, she flushed the tubing, took a moment to hold up a tube of blood to the light to admire its bright redness – an indication of good oxygenation – and praised the patient for his progress. All the while, she was listening for my answer to her question.
“My training?” I was embarrassed by my university education, paid for by my parents. The other nurses in the ICU with their college diplomas were, in many cases, still paying back their student loans. Not only that, but they were the competent ones, and I was the disoriented and discombobulated one. I mumbled my answer.
“And where did you work before coming to the ICU?” Frances asked.
“Oh, here and there,” I said. “A little of this and a little of that.”
We started every shift by performing a head-to-toe assessment of our patient. “Head” meant to talk to the patient, but it felt awkward to talk to patients who couldn’t talk back because of the tubes they had in their mouths or because they were sedated or unconscious. But I did as Frances had shown me. I approached the bed and greeted my patient who, on that first day, was a sixty-eight-year-old man, two days post-op major surgery to repair a ruptured aortic aneurysm.
“Hello, Mr. Stavakis. My name is Tilda and I’m your nurse today. Can you squeeze my hand? Can you give that a try?” Then I started to go through, in a systematic fashion, the tests of a patient’s level of consciousness. First I checked his pupils with a flashlight to assess their reaction to light. I gave him simple commands, such as “Open your eyes” or “Wiggle your toes.” When he passed those tests, I proceeded to the higher cortical-level functioning tests to determine if he was oriented to person, place, and time. I checked his reflexes, handgrips, and his response to painful stimuli such as pressing on his nail beds and rubbing his sternum.
“When a patient is fully conscious, you don’t have to go through all the tests, Tilda.” Frances gave me a nudge and whispered in my ear. “Move on.”
Of course.
I turned my attention to auscultation of the patient’s heart and lungs with my stethoscope, and then assessed the condition of his skin and incision. I checked all the equipment and examined his heartbeats on the monitor and measured each one with my brand-new pair of calipers. I palpated his stomach, measured the amount of urine in the Foley catheter, and peeked under the sheets. No problems there. Well, I congratulated myself, so far, so good. I might make it here, after all!
After I finished my assessment, I decided to say something to my patient that I had heard Frances say to her patients. Sweet words that were the essence of nursing itself. I silently praised myself that here I was, ready to say them to a patient, and so soon in my career as a critical care nurse.
“Mr. Stavakis? I’m your nurse and I’ll take good care of you. You don’t have anything to worry about because I will be with you all day. I will take care of all your needs and make sure that you’re comfortable. Okay, Mr. Stavakis?” He squeezed my hand in agreement (what choice did he have?) and gave a weak smile around the tube in his mouth, a tube that went into his throat and down into his lungs.
Maybe if I said the words and went through the motions, that feeling of confidence, of being the capable ICU nurse that I dreamed of being, would follow? I had read somewhere that orthodox Jews advised skeptics to go through the actions of keeping kosher, lighting the candles and observing the Sabbath – even if they didn’t yet fully believe: do the deed and the faith would surely follow. But even as I performed the correct actions, so much of the complex information that I was learning in the ICU remained a bombardment of separate, concrete items. I still couldn’t put the whole picture together. I tried to imagine the complicated drugs I was giving and what each one was doing. This one is contracting the heart, this one is expanding the lungs, this one is carrying the oxygen molecule, I told myself. But the images were like cartoon pictures in my mind.
As we came to the end of the long twelve-hour shift, I emptied all my patient’s drains and measured their contents, changed the IV bags, tallied my fluid balance, made my final notes in the chart, smoothed the bedsheets and pillows, made sure Mr. Stavakis was comfortable, and prepared to give report to the night nurse. By then it was evening and so I dimmed the lights in my patient’s room to create a peaceful atmosphere at the end of the day.
Frances said, “You’re doing great, Tilda.”
I beamed. Yet I was exhausted from the heightened state of alertness I had been in all day, listening for and responding to the ringing of alarms. As I walked out the door, I felt the weight of responsibility unfurl from my shoulders, as physical a sensation as shedding a heavy winter coat on a spring day.
MR. STAVAKIS DETERIORATED during the night. The next morning when I came in I saw that his colour was dusky and he was sweaty and restless. He wasn’t responding to my questions; he didn’t squeeze my hand. I tried to ignore what I saw and pretend it wasn’t happening. I didn’t feel ready to cope with an unstable patient.
Frances came over. She took a look at my patient and her eyes went straight to his chest. She studied the rise and fall of each breath for a few moments and pointed out to me that the two sides were not symmetrical. “How long have his saturations been in the 80s?” She glanced at the monitor. “Look how fast he’s breathing.” She called for a bag of ice upon which to place the sample of arterial blood that she was busy drawing for testing of his gases. “He may have blown a pneumothorax.” I knew that meant a possible collapse of the lung. Frances cranked up the ventilator to deliver 100 per cent oxygen but the patient’s saturations kept falling – they were now down to 78 per cent – and then grabbed the oxygen bag off the wall and began ventilating him herself, with fast, strong pumps of the bag. She unwound her stethoscope from around her neck and listened to the patient’s chest. She suctioned his lungs, listened again to both sides of his chest, and then looked up to me. “There’s no air moving in there.”
She yelled out, “I need help in here!” and then told the ward clerk to page for a chest X-ray and call for the doctor and the respiratory technician to co
me immediately – “STAT.”
All these events took place in a matter of moments. I stood watching and wondering what it was that I was supposed to be doing.
“He needs another iv line. Start one in his antecubital space,” Frances said. “Use a large bore needle – at least an 18 gauge – and run it with normal saline at 50 cc an hour.”
Quickly, I found the equipment I needed. The old man’s veins looked so easy to get, but as soon as I stuck the needle in, the vein collapsed and I watched in horror as a big blue lump popped up like a plum under his skin.
“Elderly veins can be tricky,” Frances whispered from across the bed. She came over to my side and slid the needle into another vein on the patient’s arm, taped it up, and pushed the clamp open to let the fluid flow in, all in a matter of seconds. “We got it,” she said.
Frances went out to the waiting room to bring the patient’s wife to her husband’s bedside. “He’s hanging in there,” Frances assured her. Both Mrs. Stavakis and I breathed a sigh of relief.
But the patient worsened as the day went on. He became agitated and delirious. We put in a chest tube but his oxygenation still kept falling, and once again, Frances went back out to the waiting room to bring the wife in. Frances, together with Dr. Daniel Huizinga, one of the staff physicians of the ICU, explained that her husband’s condition had worsened and he was now very critical. We would have to give him medication that had a drastic side effect. It would render him unable to move.
“Paralyzed,” Dr. Huizinga explained, in his curt but not unkind manner. “It’s a temporary measure. We have to paralyze him so that we can get more oxygen into his cells. Pavulon is the neuromuscular blocking agent that we use to decrease his metabolic requirements.”
“What?” cried the wife in alarm. “Paralyzed?”
Mrs. Stavakis watched in horror as her husband gasped for air. She did not have to be convinced that something had to be done immediately, but this? A drug-induced paralysis? It must have sounded like a nightmare to her.