by Tilda Shalof
Our group, Laura’s Line, all worked the same schedule, so we were also off on the same days, too. Sometimes we met for lunch at Hannah’s Kitchen, Fran’s, or the Daily Planet. Each time we vowed that we wouldn’t talk about work, but inevitably and within minutes, our conversation drifted in that direction. Who else knew what we had seen, what we had experienced? To whom else could we unburden ourselves? Who would want to hear? Who would understand?
“The problem with you is you’re too sensitive,” Laura kept saying whenever I moaned about whatever tragedy was currently taking place in the ICU.
It was true. It was something I had struggled with all my life. Yet somehow, I wanted to believe that I could find a way to turn that liability into an asset, that I could find a way to use it to help people.
“Try not to think about it so much,” advised Frances. “I know it can get to you, but when you leave work, put it all out of your mind. Now, what are we having for dessert?”
“I know,” said Nicole. “Sometimes it gets to me, too. No one likes to think that terrible things could ever happen to you or to someone you love. That’s how you do this work. How about the chocolate cheesecake and a bunch of forks?”
But we all knew that something terrible had happened to Nicky. Her mother had died of cancer. My own mother had died, my father too, and I was estranged from most of my family. Coupled with my own problems, the sadness of my work felt like a lot to bear, especially because I did take it so seriously and personally. Yet I couldn’t leave now. I was six months into the yearlong commitment I’d made to Rosemary, our head nurse, to stay in the ICU. Even more important to me than keeping my promise, however, was the dread of leaving in failure and starting over somewhere else.
It wasn’t only the death and dying that made me wonder if I could be good at this work. It was the inadequacy I felt when I didn’t know what I could offer patients, other than my rapidly expanding repertoire of technical skills. I was still so far from possessing the critical thinking, the intuition, and the courage of so many nurses that I admired, and not only the ones within my tight circle.
There was Valerie, the night nurse with the beautiful fingernails and the British accent, who on more than one occasion stayed long past the end of her shift to hold the hand of her dying patient.
“No one should ever die alone,” she said as if enunciating an axiom.
There was Nell with her unreliable attendance and dubious, outlandish stories, who was always calling in sick at the last minute, just before the start of a shift. But when she did come to work, she gave exquisite care to her patients and they loved her. It didn’t bother her in the least, for instance, to create chaos in the room and to mess with the monitors and machinery in order to turn her patient’s bed around to face Mecca as he was dying.
It was Nell who stood up to Dr. York, a senior hospital administrator, when he asked to see the chart of a patient who was a prominent government official, recovering from an aortic aneurysm in our ICU.
“No,” said Nell, holding on to it. “You can’t have access to the chart. You are not his doctor.”
“I am a doctor.” He reached for the chart in her hands.
Nell held tight. “You are not this patient’s doctor.”
“Do you know who I am?”
She smiled, almost laughed. “Of course,” but didn’t deign to tell him who he was.
“He’s an asshole, that’s who he is,” she told us later, to our delight, in the lounge at lunchtime. It was fun to see that word come out of her pretty, lipsticked mouth. “When I wouldn’t give him the chart, he stormed off in a huff, saying he was going to report my insolence to Rosemary.”
It was a breach of patient privacy, something we were there to protect. We all knew what had happened to the curious nurse who had gone into the computer chart of a prominent journalist who was a patient in our hospital. It had sobered us to learn that she had been fired over her thoughtless invasion of patient privacy.
Murry was another nurse I admired. He was an artist, and his patients’ bodies, his canvas. They became his masterpieces. He took impeccable care of them, cleaning the wax from their ears and whatever dripped from their noses. He applied patients’ favourite creams and lotions and gave them massages. Once I watched him tenderly wipe away drips of menstrual blood from between a young woman’s legs and then made her feel clean and well-groomed with a perfumed bath and a manicure and pedicure before her boyfriend came to visit. Murry talked to her all the while, treating her like the lovely young woman that she was, despite the fact that she was completely unconscious from raging bacterial meningitis.
Murry’s nursing care was not merely cosmetic: he could read an electrocardiogram like a cardiologist.
Of course, it wasn’t all just nurses. The ICU was teeming with many other professionals and the doctors, too, from interns to residents, senior fellows and researchers, specialists of every organ of the body, consultants, students and visitors from other hospitals, and from countries as far away as Bahrain, Ecuador, and Norway, who came to share what they knew and to learn from us. But anyone who spent any amount of time in the ICU readily admitted that it was the nurses who ran the place. Sure, the doctors made the diagnosis and ordered the tests and treatments, but the nurses did just about everything else.
The residents were full-fledged doctors who had finished their internship and were specializing in internal medicine or general surgery or a sub-specialty, such as cardiology or urology. They came for a week or a month and then moved on. The Medical-Surgical ICU was one of many of their rotations throughout the hospital. A few of them went on to specialize in critical care medicine and they spent a longer time with us as “fellows.” Their next step would be vying for a staff position somewhere. A small group of permanent staff physicians, called “intensivists” and who had specialized in critical care medicine, were the medical directors of the ICU, and they rotated with each other on a weekly basis. We nurses always checked the board when we came in to find out who was the attending staff physician on that week. By the name on the board, we knew how things would be handled; whom we could count on in the middle of the night; who would pass the buck on making tough decisions; who respected what the nurses had to say and who didn’t.
Dr. Daniel Huizinga was a cowboy. He often told us about his travels with his wife and family to Third World or war-torn countries to volunteer his expertise. Daniel – we were familiar enough with him to call him Danny – wore a black leather jacket and black Reebok running shoes, which he needed, as he was always on the go. He smirked and guffawed at whatever anyone – nurses, patients, or families – said. He knew best. Yet everyone who could see beyond his gruff, rough manner grew to love him.
“Thank you for coming in,” I said to him gratefully at 0300 hours one morning. Laura was in charge, and she had called him at home to tell him that my patient was crashing and that the resident on call that night was out of his depth and not coping.
“I’ll always come in,” he said, “especially if the patient is young.”
“That’s very caring of you,” I murmured as I watched Justine sticking her finger down her throat to tell me to quit sucking up to him.
“Nonsense,” he said with a shrug. “In court when they ask me if I examined the patient, it won’t wash with the judge if I just say that my resident described him to me over the phone. That’s why I come in.”
I told him that my patient’s blood pressure was dropping, his urine output, low. “He was stable up until an hour or so, when –”
“You call that stable? He looks like crap, and why is this saline bag half closed?” he bellowed at Laura, who had come in to help me. He flipped open the clamp on the IVSo that the fluid would pour in, and when that wasn’t fast enough for his liking, he squeezed the IV bag with his whole fist. “I said on the phone to give him a bolus. When I say bolus, I mean give the fluid as fast as possible,” he muttered.
I had been the one who had set the rate too cautiously, bu
t Laura told him, “Relax! Look at it this way; it’s also half open. Look on the bright side!”
He grinned at her and at me, too.
“Send off a bunch of lytes, minerals, and a lactate, too,” he said, but Laura had already done that before he arrived and had the results ready to show him.
“I’ve seen guys like this go sour in a few minutes,” he said, pacing around the room, keeping his eyes on the patient.
“What do you mean?” I asked.
“I remember a guy just like this. He was sitting up in bed eating a hamburger and less than two hours later, I was draining pus out of his belly in the OR.”
“Yeah,” said Justine, who had come in to lend a hand. “It’s that cafeteria food.”
If I saw Dr. Huizinga in my patient’s room when I came on at the start of my shift, it meant the patient was sick. All the patients were sick, but if the nurses said a particular patient was “sick,” it was cause to worry. They were the ones that Daniel hovered over, anytime, day or night.
That night, while he was there working alongside me at my patient’s bedside, I got flustered and accidentally disconnected the “jet” ventilator, a high-powered breathing machine that delivered up to 150 breaths per minute. It was one of the things we brought in as a last resort for the sickest patients.
Laura stepped in and calmly began to hand-ventilate my patient with 100 per cent oxygen, while Dr. Huizinga plugged the machine back in and re-calibrated it.
Justine began to sing the song about leaving on a jet plane to tease me.
“Don’t worry, Tilda, he’s okay,” Nicole said when she saw my stricken face.
Laura came in to tell Daniel about a phone call she’d just received from a doctor at another hospital who was looking for an ICU bed for a very sick patient.
He wanted the details, quick and to the point. “What’s the story?”
“She’s a forty-one-year-old woman, two days postpartum, thirteen previous pregnancies –”
“Has she got rocks in her head?” he growled.
“Hold on.” Laura put up her hand to stop him. “She’s bleeding, unconscious, already lost about two litres of blood during the delivery. She’s intubated –”
“Bring her in,” he barked, “right away.”
“Bow-wow to you, too,” said Laura.
There they were, the two of them pretending to be Rottweilers, when everyone knew they were both spaniels.
It didn’t take me long to figure out there was nothing about Dr. Huizinga to be afraid of. Even though he could be intimidating and demanding and was a brilliant, world-renowned specialist in the complex relationship between oxygen and hemoglobin molecules in microcirculation and in the biochemical reactions involved in lactic acidosis, he was actually very approachable and enjoyed teaching us all that he knew. He could be preoccupied at times and disinterested in the minutiae of the daily management issues of the ICU. On morning rounds he often perched up on the counter in the patient’s room and became engrossed with his clipboard, upon which he tinkered with mathematical equations and scientific formulas. Once there was a lengthy discussion between two of the residents about which antibiotic to choose for a septic patient. Should it be one that protected against anaerobic microbes or a more broad-spectrum one that would cover a possible hospital-acquired pneumonia? Should we wait for the results of the cultures, or should we proceed with an antibiotic on spec?
“What do you think, Dr. Huizinga?” Dr. Leung asked.
“About what?” He looked at her blankly. “I wasn’t listening.”
One day Justine caught him perusing the Cosmopolitan magazine she had tucked under her patient’s chart.
“Are you checking out Hot Sex Tips on page 87?” she asked him in front of the team. “I’ve tried them all and my boyfriend likes number 32 the best.”
Later, when she was on lunch, I noticed him return to her patient’s room and open the magazine. He blushed, put down the magazine, and glanced around to make sure no one saw him. I didn’t let on that someone had.
Hot Sex Tip No. 32: Guaranteed to drive your man wild: Gently pull down on his balls as you are sucking on his cock.
“THIS UNFORTUNATE GENTLEMAN choked on a piece of filet mignon,” said Dr. Leung one morning as she began to review a patient’s history during team rounds. She was a senior fellow, just a year away from completing her specialization as an intensivist. She had confided in me that she hoped to be offered a staff position at our hospital, but believed her chances were slim. She was pregnant, early on so she was still able to hide it, but would soon be unable to actively engage in the research projects that the hospital expected.
We loved working with Jessica, whose soft voice and sweet words could make even choking sound elegant. She wore her long dark hair in a ponytail, pulled back. She told me that although she loved clothes, she always wore green scrubs – some families mistook her for a nurse – to bolster her credibility with the other doctors. She was entrancing to watch and listen to, because of her intelligent face and her articulate way of speaking. I once observed a large noisy family, overcome with shock over the death of their father, become momentarily distracted from their grief by Jessica’s beauty, which in itself seemed to offer comfort. If someone this angelic, smart, and kind couldn’t save their loved one, maybe it was God’s will, they seemed to reckon.
Once I heard Jessica deliver bad news, and even she sometimes stumbled over the words in these difficult situations.
“Despite all of our best efforts – and I want you to know that we did everything we could, the doctors – and the nurses too,” she added glancing at me, “did absolutely everything we could, but unfortunately, there has been a negative outcome for your mother.”
“Do you mean Ma is out of it? She’s comatoast?”
“Unfortunately, your mother has expired.”
So had a carton of milk in my refrigerator.
But surely that was better than Laura’s short form: DAD –Dead As a Doornail – not that she ever put it that way when a family member or patient was anywhere within earshot.
I had started accompanying doctors to family meetings during which they told upsetting news. The family members were often hunched over and tense, but I made sure to keep my pose and posture more in keeping with the doctor – straight-backed and in control. I always came equipped with a small box of tissues in my lab coat pocket to have at the ready. Although I wanted to contribute helpful comments, I usually couldn’t think of anything to add, so I kept quiet and listened.
It was in that tiny, airless, windowless, grey-walled room – the quiet room – that even those well-spoken, well-educated, and brilliant doctors ended up resorting to clichés. After they’d offered elaborate explanations of physiological and pathological processes, delivered in arcane medical terminology, after they had expounded on the complicated legal ramifications and temporized with lofty philosophical disquisitions about the patient’s condition, they all ended up saying things like the patient was “not out of the woods,” or “might not make it;” that we were “doing everything we could,” but that he had “taken a turn for the worse,” or that we had to let “nature take its course.”
The most disturbing cliché, the plainest and the most rarely uttered was “There is nothing more we can do.”
The families listened carefully and tried to follow the logical reasoning. They occasionally asked questions or wept softly. However, I knew that all they really wanted to know was, what does this mean? Will he make it? What are his chances?
After the meeting, the family and I would return to the patient’s room. It was there that the families pored over all the details of the quiet room discussions with us, the nurses. They felt more at ease with us to go over the details and ask questions that they had been afraid to put to the doctor.
THE SKILL AND confidence of the nurses impressed me, but how they occasionally covered for the doctors astounded me.
“Watch out for that one,” whispered Laura, poi
nting at one of the new surgical residents. “Make sure you go over every order she writes. Yesterday she ordered Dilantin 900 milligrams IV to be given as a loading dose. Can you imagine? She’s scary.”
Thankfully I knew that the usual loading dose was 300 milligrams, but what if I hadn’t known? What if I had given the amount that had been ordered, almost a gram of Dilantin? What would have happened was that the patient would have arrested and died.
“Adenosine,” I said to one of the foreign medical residents when my patient suddenly went into a rapid atrial arrhythmia. “I’ll go get it, draw it up for you, but you’ll have to give it.”
“What?” He started flipping through the spiral-bound ICU handbook he’d pulled from his lab coat pocket.
“You need to diagnose the underlying rhythm,” I explained. “Adenosine will slow down the heart rate in order to differentiate between a supraventricular –”
I scanned the unit for Frances or Laura to come and explain all this to him, but there was only me. Clearly he was struggling with English, with the ICU, but most of all, he was struggling with the basics of medicine.
“They don’t pay us enough for what we do,” said Laura, enjoying the role of the unsung hero.
DR. DAVID BRISTOL, in his well-tailored dark suits, with his intellectual, esoteric language, spoken in a strong British accent, droned on endlessly with abstract theoretical discussions and kept us all at a distance with his slender Mont Blanc fountain pen. He stood outside the patients’ rooms during morning rounds and talked to us from behind that silver pen, which he used as a pointer to highlight numbers and lab values on the patient’s flow sheet.
“I don’t touch patients,” he said when Laura hid his pen from him. He was at a loss without it.
“How about windows? Do you do windows?” Justine inquired, but it was very hard to get a laugh out of him.
Dr. Bristol liked to expound on the ethical arguments involved in each case and often gave spontaneous lectures about the deontological framework of Immanuel Kant and his Moral Imperative versus John Stuart Mill’s Utilitarian philosophy of the greatest good to the greatest number. Every patient became a jumping-off point for a discussion about the allocation of precious resources, withdrawal of life support, and his all-time favourite topic, the supremacy of the hallowed concept of “patient autonomy.”