by Tilda Shalof
He upbraided me one morning because I was not forthright in answering his question about whether the thoracic surgeons had been by to see my patient.
“What did they tell her about her prognosis?” he asked.
“Well, um, I, er … they were here, yes … and they did see the patient, yes, but …” I hesitated. “They didn’t really go into …”
The problem was that my patient was sitting up in a chair and fully conscious. I didn’t think she knew about the cancer that was rapidly spreading through her lungs, but was this the way to tell her?
“Come on now, Tilda, speak up! We don’t keep secrets around here. We give full disclosure and respect patients’ rights to all information pertaining to their condition. Good morning, Mrs. Lawson,” he called out to my patient from where he stood in the hallway. “Did the thoracic surgeons mention to you if your cancer had spread or not?”
Had she even been told she had cancer in the first place, much less that it had spread? The notes didn’t say. She was a frail woman, lovingly tended to by her husband, who had stepped out during rounds. I felt certain that she would want him by her side, if she were to be told such news. Fortunately, she hadn’t heard Dr. Bristol. She merely waved at him and didn’t answer.
“I’m not trying to hide information from my patient,” I said in my defence, “it’s just that I don’t know what she has been told. This doesn’t seem the kindest way to tell her.”
“Nonsense, Tilda,” he scoffed. “You’re being paternalistic. Your patient has the right to know the truth about everything. She is entitled to have all the information that we have about her condition.”
“All the information she can handle,” I answered back, thinking that my motive was more maternal than paternal.
“Which is everything,” he countered.
“But her emotional state is fragile, and sometimes news like that could cause a setback. It might make her feel less motivated. Maybe the truth is too much for her to handle right now, especially all at once.”
“And who are we to judge for her what she can handle?”
Later in the day he came back to see Mrs. Lawson to tell her himself that the cancer had spread and that it was inoperable, but she was in bed, sleeping.
“Why is she back on the ventilator?” he asked me. “I thought we were weaning her.”
“She was tired. She said she didn’t want to do any more weaning today and asked to be put back on the vent. Given her prognosis, I didn’t think that weaning her off the ventilator was top priority,” I explained.
“Since when does the patient make a medical decision?” He was kind enough, at least, not to wake her up then and there, but he was completely oblivious to his contradictory moral stance.
“Why didn’t you call him on that one?” demanded Justine, her hands on her hips.
“I only thought about it after he left” was my lame reply.
“MORAL COURAGE IS what’s needed in these situations,” Rosemary told me many times. “We’re here to do what’s right for the patient. That is your ultimate guide.”
From time to time Rosemary invited me in to her office to check on how I was doing and to give me a pep talk. She always had soft classical music playing. Her cubicle was a peaceful refuge, even though it was littered with Post-it notes, “to do” lists, and framed sentimental cross-stitched sayings such as The Serenity Prayer and Desiderata, that she hadn’t got around to hanging up on the wall. Messy piles of nursing journals, policy and procedure manuals, and memos spilled onto her desk.
“How is it going?” she asked with her serene smile.
Why not be honest with her? She knew the score.
“It’s still pretty stressful, Rosemary.” I drew a deep breath. “I keep having the feeling that there is so much to learn and that I don’t know enough. To the families, sometimes I just don’t know what to say. I want to make it to the end of my year here, but I’m not sure.”
“It’s the nurses who raise these questions that I never worry about, Tilda. It’s the ones who have all the answers that concern me. Let me tell you something that may help put your mind at ease. Do you remember when Harriet – one of our most senior nurses – her brother was in our unit for a liver transplant? You were one of the nurses she asked me to assign to his care.”
There was no greater praise than that, I knew. Perhaps I had arrived as a critical care nurse, after all.
Just then, Rosemary’s pager went off, but before she ran to attend to it, she reminded me that my turn to be in charge of the ICU would be coming up one day.
“It is an expectation of every nurse in the unit to take on this responsibility,” she said. I could tell from her tone that this point was non-negotiable. “You have to know what’s going on at the bedside, and beyond that, too.”
“I don’t think I could handle the responsibility of being in charge.”
“When the time comes, you will be ready.”
Okay, okay, I thought, but put it out of my mind for now.
I sat there for a few minutes after she left. On her desk was a journal article she had been reading. It was entitled “Hardiness: An Essential Attribute of the ICU Nurse.”
I almost started to cry, but instead, I composed myself and returned to the ICU, where I could hear Laura busy expounding out loud at the nursing station, on her latest “theory” about the personality profiles of various medical specialists.
“Haven’t you ever noticed that cardiologists are, by and large, musical and shy? They’re slim and have long, narrow feet, and are very conservative lovers.”
“How would you know that?” Nicole asked.
Laura ignored her. “Anesthesiologists are crass mercenaries, just in it for the money. They do lots of little procedures and make the big bucks. Patients get very attached to them because they put them to sleep or get rid of their pain. They’re usually womanizers who drive fast red sports cars, and they’re often drug addicts, too, because of their easy access to narcotics. Gastroenterologists are just grown-up kids who still like to dissect frogs and muck around with worms and mud pies. They love anything gooey or slimy. Surgeons are mechanics and technicians. All they care about is their little organ and only if they can fix it. If not, they move on. The patient could be having a heart attack, but the brain surgeon couldn’t care less. Know what I mean? As for psychiatrists –” Here, she stopped for dramatic effect and rolled her eyes. “Need I say more? You get my drift. Endocrinologists are the only nice ones because they actually talk to patients. They listen to them, too. That’s how they make their diagnosis. Neurologists are tight asses. So pedantic! They care way more about numbers and statistics than about people and pain. They care more about the diagnosis than the treatment. An exact identification of a rare, malignant astrocytoma in the subarachnoid space fascinates them so much that these nerds might just overlook the fact that there’s no treatment for the poor patient who has that terrible tumour in their brain. Neurologists can’t see the forest for the trees. In fact, they can’t even see the trees for the leaves. Yeah, neurologists are leaf men,” said Laura, ending her diatribe. “Strictly leaves.”
“Aren’t you generalizing, just a bit?” Nicole asked.
“No. I know what I’m talking about.”
“Why don’t you research all of this?” I asked Laura in mock seriousness to cajole her out of her crankiness. “You could do personality tests on the various groups of specialists, test out your hypothesis.”
She walked away, but I could hear her going on about another of her theories. It was something to the effect that people peaked at different times in their lives. Let’s say you were a rotten, miserable grown-up, she explained. You might have been a great baby. Maybe your peak was back then. Some people were great at being a teenager, but then went downhill in their twenties.
Perhaps my peak was yet to come?
By the time I had worked there almost a year – just two months short of my year-long commitment to the ICU – I finally felt
competent. Of course, I wanted to be more than competent. I wanted to be a nurse like Laura, for her intuition and skills, Tracy for her calm helpfulness, Nicole for her kindness and fairness, Frances for her compassion, and Justine for her chutzpah. How Justine could make us howl with laughter! Was it that she saw everything as funny or was it that funny things always happened when she was around?
“Will you look at that?” she said just then. We were still standing outside of Rosemary’s office. She pointed at Glenda, our housekeeper, who was just coming out of a patient’s room, holding her rainbow-coloured feather duster up high across her chest, brandishing it like a drum majorette, hoisting her baton to the tune of some marching band that only she could hear.
“Oom-paa-paa, oom-paa-paa!” said Justine to her. “You go, girl!”
EARLY ONE MORNING, on a day that I wasn’t scheduled to work, I got a phone call that woke me from a deep sleep.
“Could you come in for an overtime shift for us today, Tilda?” It was Cynthia, the night nurse in charge. “We’ve just had two sick calls – one of them Nell, of course, I should have predicted that – and we’re really short-staffed.”
The extra money would be great, but I was just coming off a stretch of nights and I was tired. I thought for a moment. It would be nice to help out, show them I was a team player. On the other hand, I didn’t feel like going in and I wouldn’t have the security of working with my gang. Cynthia needed my answer right away, so I stilled my chattering mind and decided to offer whatever answer came out of my mouth. Let my unconscious decide for me.
“Okay, I’ll come in,” I heard myself say.
As I drove to work, I listened to the local news on the radio: a gang murder, an abducted child, and a devastating house fire, at least two people confirmed dead. There would likely be enough sadness and tragedy awaiting me during the day ahead, so I turned the dial to music – a peppy Blue Rodeo song.
When I arrived in the ICU, there was the usual bustle of activity. By then I knew all the other nurses because of our overlapping schedules. I easily joined the group gathered at the nursing station, the buzz of their conversation now comforting and familiar. It felt as much like a social gathering as part of the daily work routine.
“There’s your assignment today, Tilda,” said Cynthia. She pointed to a room outside of which a policeman stood watching the passing parade of the slower-moving night nurses leaving one by one, and the perky day nurses taking their place.
“Did you hear about the terrible fire in the West End overnight?” Cynthia asked me. “Well, the wife, she’s one of the few survivors – she’s your patient. They got her out in time and her husband’s okay, too, but their baby died. Your patient has been in the hyperbaric chamber for decompression and just came out. She’s doing well. You’ll have a good day.”
“Hello,” I said to the policeman and stepped into the patient’s room.
The smell hit me first. It was a smell I’d never encountered there before and it seemed out of place in the ICU. It was the wild, elemental scent of smoke. It was a natural smell of the outdoors that was so different from the chemicals and antiseptics or the human smells of infection and bodily fluids. It was the lingering aftermath of a bonfire on the beach, the fire tamped out, the embers dying down, but the ash smouldering, alive and still dangerous. It was also the smell of happy, carefree times – a campfire – but in this setting it seemed ominous.
“The patient is improving and her husband survived, too – he didn’t even have to go in to the hyperbaric chamber, but – it’s so sad – her mother, father, sister, and her eight-month-old baby all perished, burned to death in the fire this morning,” said the night nurse. “No smoke detector, can you believe it? Anyway, so far only the husband, two brothers, and the wife have survived. The bodies of the parents, the sister, and the baby are still in the morgue, awaiting official identification.”
“I haven’t taken care of a smoke inhalation case before,” I said. “What goes on in the hyperbaric chamber?”
“It looks like a submarine and it’s based on the same concept. They put the patient in for a few hours. In the chamber they raise the atmospheric pressure so high that more hemoglobin and oxygen molecules bind together. Then they lower the pressure and decompress the patient slowly and gradually as they bring her out so that she doesn’t get the bends.”
“And what’s with the cop outside the door?” I asked. I had noticed him peeking in the room from time to time, trying to get a glimpse of this unfolding drama.
“He’s there to ensure that no one tampers with anything. He explained it to me, it’s called continuity of evidence.”
After she left, I proceeded to do my assessment. I could see the outline of a slight, still body under the yellow bedspread. Like all our patients, she was attached to the cardiac monitor. The breathing machine pumped oxygen into her lungs, and an assortment of other plastic, chrome, and wire attachments criss-crossed over and around her body. Her heartbeats moved across the black screen in green lines, and I noted that her rhythm was fast, but steady and regular. So far, so good.
I parted the tubings and made my way through the equipment and the stiff linen to get to her body and her hands. It still occasionally felt awkward to talk to intubated patients, but touching them was easier and more immediate. However, this time was different, because my patient opened her eyes a little and nodded her head in response to my voice.
Darryl Price, a visiting doctor from Ireland, specializing in critical care, came in to check on her. He reached under the covers for her hand, leaned down toward her and spoke softly, directly into her ear; his silk tie dragged across her chest. “You’re going to be just fine, m’dear. Coming along nicely. We’re hoping to get that breathing tube out, right away. You’ve got a great nurse taking care of ye.” He winked at me.
He spoke like he was crooning a song and I loved listening to him. Even more, I was moved at the startling phenomenon of this doctor, speaking so personally and personably to a patient whose eyes were closed and who was just barely able to respond.
“Isabella,” I said, afterwards, emboldened to show even more compassion by the example of this new doctor, “you’re in the hospital, the intensive care unit. There was a fire in your house, but you are okay. I’m your nurse. Do you understand what I’m saying?” She squeezed my hand in reply.
As the morning wore on, I could see marked improvement from hour to hour. Isabella opened her eyes and began to look around. She began to breathe more on her own and I started to wean her off the ventilator. I gave her a warm bath and scrubbed the soot stains from her face, hands, and body. I explained everything I was doing, as I monitored her lungs, her heart, her stomach, and her mind.
“Isabella, you’re doing really well,” I kept telling her.
It was true. I could see she was getting better under my very eyes. What I suddenly realized was that she was getting better, in part, because of the care I was giving her.
Throughout the morning I spoke to her constantly, so that she would have a voice to move toward. I did not mention the loss of her child; she did not ask and I did not feel it was the time to tell her. She was pretty and looked so young, a lot younger than her thirty-one years. She had a long thick braid of black hair that I tried to keep neat and tidy. Someone from the family came to the door and pressed a tiny plastic Madonna and a gold cross into my hand and asked me to put them next to her pillow, and I did.
Rosemary came to tell me that the husband had recovered sufficiently from smoke inhalation to visit his wife.
“Why don’t you go out to the waiting room to bring him in while I cover for you?” she asked.
The waiting room was full of visitors, but it was easy to spot which family was mine. Fernando Alvarez was the short, slight man, still greasy and grimy from the fire. He was covered in soot and looked like a shell-shocked soldier, just returned from battle. Aunts, uncles, and cousins accompanied him with me to the ICU to see Isabella for the first time since t
he fire.
“She’s doing well,” I reassured him, along the way. “She has been waking up slowly and is starting to move her limbs. Her blood pressure is very stable and soon we will have her off the ventilator. She’s going to be just fine.”
Once in the room, he approached the bed slowly. He could face her only in gradual increments, taking tentative, sideways glimpses, so his mind could catch up with his eyes. He looked at the bed, then at the floor, and then glanced back at the bed.
I guided him closer with my arm across his back, as I had seen Frances and Nicole do.
“She won’t be able to talk to you right now. She’s still not fully awake and she has a breathing tube in her mouth that goes down into her lungs. But she’s alive.”
I couldn’t tell if it was too much information or, perhaps, not enough.
Mr. Alvarez approached the bed and forced himself to look at his wife. He took a long, straight-on look at her and then suddenly reared backwards in horror.
“Jesus! Meu Deus! Ai, ai … não, não! Porque?” he cried and collapsed in a heap on the floor. The other family members rushed to him where he lay.
“But she’s improving!” I said. “She’ll be just fine. Look, she’s opening her eyes. There! Look. Isabella, look who’s here. It’s Fernando.”
The other members took a look at her, then they too reeled back.
A cousin came forward to explain to me, in gasps. “This is not Isabella! This is not her. It’s Isabella’s little sister, Alva. And if it’s Alva Machado in the bed … that means … that the body downstairs … oh, my God. Poor Fernando,” he sobbed into his hands.
That meant that the charred remains of a human being that lay awaiting identification in the morgue must be his wife, Isabella.