by Tilda Shalof
“We sometimes paralyze patients, Mrs. Stavakis, for a short time,” Frances said, putting her arm around her. She made paralysis sound like a desirable thing, perhaps even a pleasant experience. “It will probably be for only a few days, and then we will stop it and he will move again and wake up. It will make him more comfortable with the breathing tube. See how he’s fighting the ventilator? Right now he’s not getting the oxygen he needs. This drug will help him.”
Frances and I prepared the infusion of the paralyzing drug, and after the doctor administered the first dose, it was up to me to continue it and monitor the patient closely. Frances reminded the resident not to forget to order sedation, too.
“Sometimes the doctors overlook the fact that the patient might still be wide awake,” Frances explained to me. “Paralysis without sedation is cruel. Can you imagine you can’t move, but you’re mentally intact inside? It’s called ‘locked-in’ syndrome and it’s my biggest fear. Pavulon is a scary drug, but it really helps patients. Some nurses even call it Vitamin P.”
BEFORE SETTING ME loose on my own, Frances kept a close eye on me and made sure I had gone through all the important experiences – that I had transferred a patient to the floor, received a fresh post-op patient, cared for a lung transplant and a liver transplant. She made sure I had given and received report to and from the other nurses and that I knew how to make a concise presentation of my patient to the team during morning rounds.
“You need practice helping the doctors with procedures,” she said on one of my last few days of orientation to the ICU under her supervision. “Go give that new resident a hand putting in a pulmonary artery catheter. He doesn’t know his ass from his elbow.”
Frances came to check on us later and brought a few extra catheters and sterile green towels, because he was having difficulty cannulating the vein that led into the artery. “Give him these,” she said, tossing them on to the bed for me to hand to him. “Looks like he might need a few tries.” She adjusted the height of the table where he was working and lowered the bed to make our work more comfortable. “Body mechanics can make such a difference,” she said. “We have to protect our backs.”
Justine, another nurse who seemed to be a regular part of Frances and Laura’s group, showed up at the door to see how the procedure was coming along. She pretended to take aim with an imaginary dart and shot it into the room, ostensibly directly into the patient’s internal jugular vein.
“Bull’s eye!” she crowed. “I could get that line in from here.”
WORKING IN THE ICU reminded me of an animated short from the National Film Board I had seen as a child in school. It started with a boy rowing a boat on a lake. Then it zeroed in on a mosquito stinging the boy’s arm. Down the camera went from the skin, into the layers of epidermis, then into the blood cells, the nucleus of the atom, the electrons and protons. Then, zoom, the camera went back out to the boy, the boat, the lake, the country, the world, the galaxy, and the universe. That’s how I felt: tossed between the stopcock and the complicated world of the ICU; zooming in between drawing blood from an artery and helping to withdraw life support on someone’s dying mother.
“You’ll get the hang of it,” said Frances. “You’ll figure out what’s big and what’s small, what’s urgent and what can wait. There are some nurses whose main goal is to settle the patient, make them look nice, tidy up the room, so they can sit down and read a magazine. I have a feeling you’re not like one of those.”
IT WAS THE last morning that I would be buddied with Frances. My orientation was over.
“Are you okay?” she asked. “You look a little green.”
“Yeah, fine, thanks.” I peered down into my coffee cup to avoid her eyes.
The truth was, I was having problems sleeping, problems getting up in the morning, and still, the constant churning in my intestines.
“Are you sure nothing’s wrong?”
“Not a thing!”
“Well, that’s good, because we’re going to have a busy day today. A patient came in during the night and she’s really sick.”
I listened to report from the night nurse.
“Andrea … a twenty-three-year-old … just graduated from law school. She and her husband were scuba diving in Lake Simcoe and she was caught in a strong undertow. She panicked and rose to the surface too quickly. She dislodged her mask and oxygen tank and aspirated a lot of cold lake water. Too bad they weren’t in the ocean, seawater would have been a lot less damaging to her lungs, poor thing.”
The patient’s healthy, muscular arms were a startling sight against the white sheets, the cage-like bed with its metal rails, and the bottles and tubes attached to her body. I squinted at her and tried to imagine her in jeans, her wedding dress, or a wetsuit, anything but the faded blue hospital gown she had on over her naked body. As I recorded her vital signs, I noticed some occasional but worrisome beats on the cardiac monitor upon which a teddy bear presided as a sentinel. Around one side of her bed, machines and equipment huddled like a team of robotic consultants. A group of real consultants huddled on the other side.
On the patient’s bedside table was a clipboard. I knew how private and intimate were the notes that patients wrote and had no choice but to leave them out in public for all to see. I couldn’t help but read the shaky scrawl that trailed off the side of the page:
Don’t blame yourself. I came up too fast. You gave me your O2.
On another page, How sick am I? was followed by, Go easy on Mom and Dad. Edit a bit. I love you.
She must have written those notes during the night when she first came in and since then had deteriorated fast. Now she was unconscious, probably due to air bubbles, called emboli, in her brain.
“No eye opening, no following commands, no response to deep pain, no response to voice,” I reported to Frances.
No response to the Mozart symphony on the radio that her husband had placed beside her. No response to his touch, no awareness of his presence when he came in the room.
“She’ll probably need a CT scan of her head,” said Frances, planning the day ahead. “Make sure that all the alarms are on. She’s having some premature ventricular beats – see there goes one – but right now let’s wash her hair.”
I looked at her, surprised that the patient’s appearance would be a priority now.
“I know she’s sick,” Frances said. “But whether she makes it or not, I’m sure she’d want to look nice for her husband when he comes in.”
Frances prepared syringes of various emergency drugs and lined them up along the counter like ammunition. “Just in case,” she explained. “I don’t have a great feeling about her.”
As the day went on, I stayed focused on the tasks at hand, but all of a sudden, late in the afternoon, while Andrea’s husband was visiting, something made Frances glance up at the cardiac monitor, seconds before the alarm even had a chance to sound. “She’s gone into V-tach! Get the crash cart!” she shouted at me.
Ventricular tachycardia! Here it was, the real thing! If I didn’t act fast, it could lead to ventricular fibrillation!
Frances pulled the husband out of the way as the room quickly filled with people. He shrank back against the wall. I thought of reaching out to him, but didn’t. I didn’t know what to say, anyway.
Laura, Justine, and two other nurses, Tracy and Nicole, appeared out of nowhere and they helped Frances lift Andrea and place a hard board under her back. With that board now in place, Frances climbed up onto the bed and started doing vigorous chest compressions while Nicole hooked up the patient to the defibrillator to prepare for shocking her with electricity to get her heart going again.
Tracy injected an ampoule of epinephrine into an IV that went directly into Andrea’s heart.
Justine thrust her fingers into the patient’s groin to feel for a pulse. Nothing. She nodded at Frances to resume compressions.
Within a few moments, a doctor arrived on the scene and took over directing the resuscitation efforts
that the nurses had already begun.
I stood frozen to the spot. Unable to move. Unable to think. Unable to recall accurately even one of the resuscitation logarithms I thought I had memorized: If the victim is without a pulse and unresponsive, then shock with 200 joules. If patient does not convert to sinus rhythm, repeat shock with 300 joules. Or was it 360?
“Here,” said Tracy, shoving the arrest report at me. “Record the arrest.”
How could she have known? Paper and pen had always been my refuge.
THEY MANAGED TO bring Andrea back. Meanwhile, I went to the med room to prepare a drip of a powerful new drug called amiodarone, which we were going to use to try to stabilize Andrea’s still-erratic heart rhythm. It was taking me a long time to get the medication ready. Six glass vials were lined up on the counter and I was struggling to crack them open – already, I had a cut in my thumb from the first one, which had shattered in my hands.
“Leave that for a moment,” said Frances. “Do you want to know the first thing you do in an arrest? Take a deep breath. Then take the pulse. Your own, I mean. Then, take the patient’s. Do everything slowly. Don’t run for anything. Don’t let anything or anyone rush you. Ever.” She turned to go back to Andrea’s room. “By the way, there’s a trick to those vials. Let me show you. They break with light pressure. You can’t break them if you push too hard.”
Easy, not hard. Light, not heavy. Slow, not fast. Relaxed, not rushed. How was I going to learn all this?
Later that day, Andrea arrested again and that time, she didn’t make it, which was the way Frances put it gently to the husband. He knew, but needed to be told. He slumped into Frances’s arms and sobbed in the comfort and safety she offered. I wanted to enfold myself in there, too. Frances’s arms were wide and strong enough for a lot of sorrow and I knew she could handle his and mine, too, and still be intact herself.
Andrea’s death affected a lot of the nurses who identified with someone so young and newly married, someone so full of life and promise. Some stopped by to console the family, to take one last look at her lovely body lying in the bed, still attached to the machines that had now fallen silent and useless, disconnected from the electrical outlets, their screens gone blank. Some of the nurses even cried, and I could see that their tears touched the family. The family probably knew that the nurses couldn’t always cry over their patients, so that when they did, they were especially grateful that their grief was shared.
I pulled myself away. It was the end of my shift and the others would carry on. They would wash Andrea’s body and prepare it for the morgue. They would tidy up the room and soon it would look like no one had ever been there. It would be made ready for the next patient.
I hung up my lab coat and walked out the door. I was completely spent. I had nothing more to give. Many hours had gone by, but I had no sense of the passage of a day; it was just a jumble of events and experiences to be sorted out later. I wondered if I had enough steam to get myself home, take a shower, and fall into bed. When I stepped out into the cold, rainy evening, the cool mist felt good on my face. My boyfriend was waiting for me in his warm car with the engine running and I slid in beside him.
“So, how did it go?” Ivan asked, but I was at a loss how to answer.
We drove in silence, but when we got home, I pulled him into my bedroom. Suddenly, I was seized with the desire to have sex, to make love all night, to chase death out of my body.
3
THE VEIN, THE ARTERY, AND BEYOND
It got better.
Like an actress, I memorized my lines; like a dancer I learned the steps.
“How’s the patient doing?” the doctors would ask when they breezed into the room, and I could rattle off all the numbers they wanted to hear: “Pulmonary artery pressure 38 over 22; wedge pressure 16; mean arterial pressure 72 to 78; sinus rhythm 110; blood pressure 118 on 72; pressure support of 20 with a rate of 8 at 80 per cent; positive end expiratory pressure 7.5. Blood gases 7.34, 41, 88, and 22. Urine output 30 to 50 cc per hour.”
The more numbers, the better!
(I made sure to first find out the specialty of the consultant I was talking to, so that I would not uselessly go into details about the patient’s kidney function to the cardiologist, or start telling the thoracic surgeon about the liver enzymes. They weren’t interested, anyway.)
The chaotic noise of the ICU began to make sense to me. The ringing of the alarms was no longer a maddening cacophony, creating a constant state of expectation in my mind. I could differentiate between the ominous gongs of the ventilator, the melodious chimes of the iv pump, the insistent buzz of the cardiac monitor. Most importantly, when an alarm went off, I checked the patient, then the equipment.
It was a serious place, and I appreciated the atmosphere of scholarly inquiry and the dedication to erudition and research. Late one night we had to summon the security guard to unlock the library in order for a resident to retrieve a back issue of the Journal of Immunological Disorders that had an article about an obscure disease of one of our patients. It was exciting to work in a place where the pursuit of knowledge could be a 911 emergency. And yes, I mastered the arterial stopcock and was soon flipping it right and left, drawing blood, monitoring the blood pressure, and troubleshooting the equipment.
I started to relax and even began to look forward to going to work.
The ICU had twenty beds and each nurse was assigned to one patient. Sometimes we doubled up if a patient was stable enough to do so. Sometimes, even when the patient wasn’t stable enough, if staffing was short, we had no choice but to double up. At times, that was a concern.
On each shift there was a nurse in charge plus an assistant nurse, so there were always twenty-two nurses on any given shift, day or night. We all worked twelve-hour day or night shifts, starting in the morning at 0715 hours and finishing at 1915 hours, when the night shift nurses came in to relieve us. They would then work all night until 0715 hours the next morning.
A small group of us – Frances, Tracy, Nicole, Laura, Justine, and I – worked together and soon came to be dubbed “Laura’s Line.” Possibly it was because of the easy alliteration of the Ls, but more likely it was due to Laura’s commanding presence, formidable intelligence, and consummate skills. Her sassy attitude and high jinks became legendary, too.
Although each nurse was extraordinary in her own way, Laura was arguably the best nurse of all. She was the nurse you would want in any situation, good or bad. As rude and irreverent as she was privately, behind closed doors, she was equally respectful and kind, dedicated and compassionate to patients and their families in person.
She made everything she did seem effortless. I remember her running off one day to help with a patient who was arresting. When she came back an hour later, she looked not in the least bit flushed or exhilarated after saving someone’s life. She looked distant, even a little bored, as if she was in need of a coffee to perk her up.
On another occasion, Laura admitted a patient, examined him, and went ahead and wrote all the doctor’s orders, including medications, X-rays, and tests. Later, when the doctor came to admit the patient, he was taken aback that everything was already ordered, but he agreed with everything she had done. He even admitted that Laura had picked up on things that he hadn’t noticed himself. He co-signed the orders she had written.
We all wondered if one day she would go too far.
The schedule we worked, when I think of it today, was so gruelling, so unhealthy, and fundamentally insane, I wonder now how we managed to do it. On Monday, Tuesday, and Wednesday we worked three nights in a row. Then we came back on Saturday and Sunday for day shifts, then returned on Wednesday, Thursday, and Friday. Then we were off that weekend and back again on Monday and Tuesday for days. Then we worked four nights in a row, from Thursday to Sunday night. By Monday morning, the group of us planned to go out for breakfast, but more often than not, by the time that fourth morning came around, we felt too cranky and out of sorts and cancelled it. Each of u
s then staggered home to sleep the day away. We’d lounge around sluggishly for a few days, recovering from work and preparing to go back. We followed this schedule for years.
Some of us still do.
There was a lot of death in the ICU, but for the first few months, Rosemary, the nurse manager, took care not to assign me very sick or dying patients. She probably did this because of the reputation I was developing – Laura kept telling everyone that I was “too sensitive” and predicted I wouldn’t last long in the ICU. Perhaps Rosemary was also protecting the patients from a nurse who was still gaining clinical skills in caring for stable patients, but who didn’t yet have the ability to handle complex and delicate situations.
If we could arrange it, the group of us tried to take our morning break at the same time. We went to the cafeteria together in the elevator, except for Laura, who took a circuitous route around the back of the hospital and down the stairs. She avoided walking past the waiting room with its smell of tension and sweat, full of families waiting and worrying. She claimed the families begrudged us taking breaks.
“I never tell them I’m going for breakfast. I say that I’m going to a meeting. Their loved one’s life is in the balance, and they think all we care about is whether to have the pancakes or the French toast.”
But I believe she couldn’t bear to face their eyes, which scanned ours for scraps of hopeful news. She needed that separation.
We always said we wouldn’t talk about our patients – we told each other we needed a break from it all – but we always did, and it was usually Laura who started off.
“I have Mrs. Wong,” she said one morning. She was careful to keep her voice low to ensure confidentiality. “She’s a thirty-eight-year-old Chinese woman who was found collapsed in the supermarket yesterday evening. She’s unresponsive but the neuro-surgeons are in there now examining her to see if she’s operable or not. Anyway, Mrs. Wong had a massive cerebral bleed and is likely going to be declared brain dead soon. Then the vultures – I mean the surgeons – will flock down for her organs, if the family agrees.”