by Tilda Shalof
“Not busy or slow. Just steady, but I’m exhausted. Pull up a chair, darling, and I’ll give you report. First off, there’s a possible brain-dead donor. It’s Stuart Bradshaw, a twenty-seven-year-old man who was thrown and trampled by his horse in a show-jumping competition and suffered massive head injuries. The docs are in there now, doing the brain-death testing. Next to him there’s Nadia Kholodenko, a twenty-five-year-old with psychogenic polydypsia. You remember what that is.” She glanced at my face. I must have had a “systems failure” kind of blank expression. “It’s water poisoning. She’s a psych patient and voices of Satan told her to drink about six litres of water all at once. She’s managed to screw up her electrolytes, but good. Her sodium is only 115! I thought of sprinkling table salt all over her! Next is Mrs. Derczanski, who had carotid surgery today for removal of calcifications but there are complications and she’s not doing well. You need to arrange for her to be transferred out for a neurosurgical consult. In the next room is Mr. Joe Binder, a thirty-five-year-old, four-hundred-pound man with a history of alcohol and IV drug abuse, admitted with diabetic ketoacidosis and abdo pain. Came to us from jail – assaulted his mother. He is also in acute renal failure and on dialysis. Had a bowel obstruction that ruptured and was in the OR for eight hours today and now has a colostomy. Peter Hollander, forty-six-year-old, four days post-op for repair of an aortic aneurysm. I don’t have a good feeling about him. His numbers are great, but he looks terrible. Ha! They’ll put that on his gravestone: ‘This man had great numbers.’ Sarah Mitchell, thirty-three years old, previously healthy, went into acute liver failure after a week of flu-like symptoms, now decreased level of consciousness, liver enzymes rising, waiting for a liver to become available. Hey, if we can’t cure a previously healthy young person like that, who can we save? Then there’s a tourist from Greece, a fifty-two-year-old Elias Roussos, here in Canada visiting his lover, when he had a massive MI*. Came in with symptoms of SOB, but no CP, N. or V. Came in with HIV, HIT positive, and CMV. Oh, and PCP, to boot. No OHIP, of course. This is a freebie! We’re paying for it!”
“He’s got most of the letters of the alphabet,” I noted.
“And how! Anyway, we had to put him in isolation today for MRSA† – you know, it’s one of those new super-infections that are resistant to most antibiotics – plus he’s growing a new little bug, Cryptococcus malformans! Let’s see how the rest of the passengers – I mean patients – are doing here …”
Casey had once worked as a flight attendant for Air Canada, back in the days when she was young, thin, and beautiful, as she described herself, and I wondered if that slip was a joke or not.
“Okay, who else have we got on board tonight? Mr. Dwayne Pickup – yup, that’s really his name, believe it or not – who’s got necrotizing fasciitis, climbing up both legs. Started with an ingrown toenail that got infected. It crawled right up his legs and into his scrotum and buttocks within twenty-four hours. He was in the OR all day for debridement. You should take a look at it – it’s a complete anatomy lesson. My husband once worked in a fur barn and this patient’s leg looks like one of those skinned animals. It’s right down to the bone. Anyway, he’s got huge dressings. It takes two nurses over an hour to do it and he’s in septic shock and very unstable. Then there’s –”
A tall and imposing woman stared down at us through large glasses with shiny mother-of-pearl frames. “My husband, Dr. Laurence, needs to see the doctor right away.”
Casey sighed. “Is it urgent, Mrs. Laurence?”
“He’s coughing.”
She looked from one of us to the other, trying to decide which would be of more use to her. It was a toss-up: I was coming on and Casey was signing off.
“Yes, it’s urgent,” she said to Casey, whom she had seen all day, rather than me, who was unfamiliar.
“That is something his nurse at the bedside can take care of,” Casey said. “I’m in the middle of giving report to Tilda. She’s in charge tonight.”
“I need to speak with the doctor. A staff doctor.”
“Have you ever noticed how it never helps to tell families that there are nineteen other patients, most of them in a lot worse shape than their loved one?” Casey said quietly to me. “They only care about their loved one, of course, but neglect can be a good thing in this place.”
She turned back to the patient’s wife. “Mrs. Laurence, believe me, if it was an emergency, the doctor would be there, tout de suite.”
Mrs. Laurence stalked off, unsatisfied.
“Aren’t doctors and their families the worst patients? Always expecting special treatment. She tore a strip off Belinda, who was his nurse today, about something trivial and reduced her to tears. I was sweating bullets, but I went in there and told her off. I threatened to call Security and have her escorted out of the hospital if she ever talked to one of our nurses like that again! Imagine! Anyway, where were we? – Mrs. Wei Chong, seventy-nine years old, with end-stage everything, you name it – renal disease, coronary artery disease, and dementia. She doesn’t speak a word of English. Come to think of it, doesn’t speak a word of anything, since she’s unconscious. Family is gathered at her bedside. It’s going to be an all-night vigil, I can tell. Someone needs to have a chinwag with them and tell them the score.”
“Which is what?”
“That she’s dying. You know how the Chinese families have difficulty letting go. Pang-Mei was on today and she explained it to me. Chinese people are terrified of their ancestors, and they don’t want the ghosts to come back from the grave and accuse them of sending them off too soon. Anyway, Mrs. Chong came in with failure-to-thrive syndrome. Was living at home, stopped eating and drinking, and the family brought her in. She’s been tapped, scoped, scanned, prodded, and cultured and they still can’t find anything wrong with her. The daughter was force-feeding her some soup and she aspirated, then arrested, and was brought down from the floor. First thing she did was pull out her endotracheal tube and her IVS. We had to put them back in and tie down her arms. Did they ever stop to think that maybe she’s trying to tell us something? Oh, and last but not least – you met the wife – I think she’s the ex-wife – of Mr. Laurence – excuse me, Dr. Laurence. She insisted I put ‘Dr.’ on the patient name board. Geez, some people!”
“What’s he got?”
“Chronic lung disease. Congestive heart failure and cancer of the prostate, but doing well, for now, anyway. Blood gases are acidotic, so he’s here for monitoring. He’s a repeat offender.”
“What?”
“You know, he’s had multiple previous admissions here. Take a look at his mile-high chart. Anyway, he’s doing well, for now. If you need the bed for an admission, Dr. Laurence is the one who will have to be transferred out because, believe it or not, he’s the most stable one here tonight. But I’m sure the family will raise a stink if you do. Good luck. Just remember what Rosemary says: ‘You’re not here to win any popularity contests. You’re here to do what’s right for the patients.’ Oh, there were two Code Blues from the floors. The cardiac arrest didn’t make it – I don’t know where we would have put him if he did. We simply don’t have a bed or a nurse to spare – the other Code Blue, a respiratory arrest, did make it and belongs to us, but we didn’t have any beds, so he’s being bed-spaced in the Cardiovascular ICU. Be prepared in the morning for the chief of CV surgery to come roaring through here like a lion because he needs that bed for his own heart surgery patients. Well, as you can see, it’s been a pretty busy day, but hopefully you’ve got a horseshoe up your butt and you’ll have a quiet night. Oh, by the way, see if you can find out who’s been leaving these religious quotations all over the place.” She pointed at one stuck on the refrigerator door of the med room.
Those who hope in the Lord will renew their strength.
They will soar on wings like eagles
They will run and not grow weary.
They will walk and not be faint.
– Isaiah 40:31
“Probably
one of the bible thumper nurses,” Casey said. “Well, good luck. See ya in the morning. Tootle-loo. Ciao, baby.”
Mrs. Laurence peered down over the counter at me and she pressed her fingers into her temples. “Could you please give me two Tylenol.”
“Is it for your husband?”
“No, it’s for me. I have a headache, but my husband – in 618 – is a doctor.”
“I’m sorry, but I can’t give you medication. There is a drugstore –”
“I’ll pay for it, if you’ll just give it to me,” she said angrily. “I can’t. I don’t know you or your medical history,” I said. “I don’t like that nurse,” I heard her complain to another visitor. “She’s going to be trouble.”
ONE OF THE main differences of being in charge of the ICU is that you’re listening for phone calls, pagers, faxes, and call bells, instead of alarms, beeps, and the ringing of machines. All the while, you’re playing a big chess game, moving all the pieces around – and you have to know which way they each go – and at the same time, you’re planning your upcoming moves and preparing in your mind for various contingencies and likely scenarios. To play it well, it’s all in the strategy. Intuition helps a lot, too. There are twenty patients, twenty beds and, maybe, enough nurses to go around.
As it stood, there was enough staff for tomorrow, unless someone called in sick. But it was only a few minutes into the shift when the ward clerk came to tell me that Nell Mason had just called in sick for the next day.
“Quelle surprise!” said Laura, whose room was right next to the nursing station. She rolled her eyes. “What’s the excuse this time? Scurvy? The bubonic plague? Did she tell you that her mother died? If so, make sure you ask her if it’s the same mother who died last year!”
“Laura,” I said in a tone meant to remind her we knew that Nell had a serious problem.
IT WAS LESS than an hour into that shift when there was an announcement over the hospital public address system and we all paused to listen: “Code Blue, Code Blue.”
“It’s called change-of-shift syndrome,” said Laura. “Some nurse doing evening rounds came across a cold body in the bed.”
I went right away to prepare the room that had just been vacated by the organ donor, who had gone to the operating room. Everything had to be ready in case the arrest patient needed to come to the ICU.
“Please call housekeeping to come and clean this room,” I asked the ward clerk.
“Laura already called them for you,” she said and returned to her private phone call.
“Yup, let’s go up there,” said Mike, the resident on that night. “It may be business for us. We’ll have a look-see.”
It was our last empty bed and none of us nurses dared say it, of course, but it was our only napping bed, too.
THE ROOM ON the floor was chaotic with doctors, nurses, and respiratory therapists trying to save a life. A nurse was perched up high on the bed doing athletic-looking compressions on a patient’s chest, and I could hear the unavoidable crunching of ribs with each thrust. A large plastic tube had been inserted into the patient’s mouth and I noted by the rise and fall of the chest that it was in the lungs, where it should be. One nurse was starting a large needle IV in one arm and another nurse was injecting medication into the IV that was already in place in a vein in the arm that was flopped over the side of the bed. Yet another nurse was recording everything that was happening. She had filled the allotted page and was now scribbling on a long, torn piece of paper towel.
A nurse stepped forward out of the crowd to give me report. “Mr. Lilly is a 104-year-old gentleman, previously well, living independently at home. Came in with pneumonia. He had a respiratory arrest and then cardiac –”
“Did I hear you correctly?”
“I know.” She smiled. “But he looks good, doesn’t he? Just turned 104.”
Mike came to talk to me. “They’ve got him stabilized, but he obviously needs to come down to the ICU. Do we have a nurse and a bed?”
“Did you know that this patient is 104?” I asked.
“That’s his heart rate?” He peered at the portable cardiac monitor, attached to the bed.
“No, his age.”
“Wow,” he whistled. “He’s in pretty good shape for 104.”
“Not any more, he isn’t. Do you think it’s a wise idea to bring him to the ICU?”
“What do you suggest we do with him?”
“Well, get rid of all this equipment, give him morphine if he looks in distress, gather around, and hold his hand. Common sense dictates that this event signals the end of his life. He’s lived to a ripe old age with dignity and you know what we’re going to subject him to in the ICU. Do you really think we can buy him more time? And at what price to him?”
“But he was well before. Living on his own. You think we should just write him off ’cause he’s old? That’s called ageism.”
“All I’m asking is should we be doing all of this? Does he have any advance directives? We can’t just resuscitate by default, can we? Don’t forget, Mike, it’s our last bed. Anyone else who needs an ICU bed will have to go elsewhere.”
“Let’s not start playing God, here,” he said. “These are choices that are way out of our control.”
“But every choice has an impact on other choices and every choice we make affects people’s lives. Even no choice is a choice.”
Surely this was not the time to have such a conversation, regarding the life of a complete stranger, but that’s exactly what we were doing.
Mike flipped through the chart and went off to consult with the staff physician. When he came back he said, “Nothing is known about his wishes. We have to take him. Besides, we’ve started everything already, we can’t stop it all now.”
“You’re going to take him?”
People had cleared out of the room, and I was able to get closer now. The old man’s face was in a grimace and his papery, wrinkled skin strained against the breathing tube, like a horse bucking against the sharp bit of a bridle. “Can he have some sedation at least?” I asked.
“It would drop his blood pressure and it’s already too low.”
I took a reading myself and barely heard the systolic, hovering around 80.
“We have to take him,” Mike said. “You have a point, but we don’t have a choice.”
“What about his family? Where are they?” I suddenly felt desperate to spare this man the indignity of the ICU.
“There is none. He’s outlived them all. He had a son who died and there’s a seventy-year-old daughter who’s in a nursing home with Alzheimer’s. There’s a niece in England, but she hasn’t seen him in years. I spoke with the family doc, but he said he never spoke with him about it. You’d think the topic might have come up when he hit ninety, wouldn’t you? There was a girlfriend, but unfortunately –”
“A girlfriend?”
“It’s possible. Male sexuality can extend well into –”
“I’m not saying –”
“Anyway, the girlfriend died a few weeks ago.”
“Oh.” I gritted my teeth and pressed on with my campaign. “What if he arrests in the unit, what are we going to do then?”
“Do what you think is right. Tell me about it afterwards.”
I hated the cowardice and the artifice of that charade. I’d done it a number of times before.
“Then this exercise is nothing more than protecting your –” I stopped myself as a nurse handed me a plastic bag containing Mr. Lilly’s belongings, and Mike and I began to push the heavy bed down the hall.
It never failed to touch me when I saw the personal items that patients brought to the hospital. So hopeful they must have been when they packed them that they would use them once again. They seemed to me like souvenirs from a country to which they might, or might not, return. Over the years I had seen pink furry slippers, a knock-off Nascar racing jacket, a package of condoms, subway tokens, a three-hundred-page word-search book in which only the first few pages had b
een completed, a nibbled chocolate bar, rolled-up children’s crayoned pictures: “Gamps, Get beter soon, Love Meagan.”
Inside Mr. Lilly’s No Frills shopping bag were the following items: a plastic container of false teeth knocking about in blue liquid, a pair of reading glasses, a rosary, a plaid flannel robe, yesterday’s Globe and Mail and a Happy 100th Birthday! card signed, “Your Sweetie.”
“I thought you said he was 104,” said the resident as we got on the elevator.
“I imagine the demand for Happy 104th cards is rather limited,” I said dryly.
When we got back to the unit, I assigned Nicole, who was freed up from the brain-dead donor patient, to now take over Mr. Lilly’s care. When I told her the story, her face registered the same dismay that I had felt.
“I know we’re not supposed to have opinions about these situations,” she said, “but this is wrong.” She took his hand in hers. “It’s so cold and thin. It feels like it will break right off.”
Mike came over to where I sat at the nursing station, going over the staffing for the next day.
“I’m starving,” he said. “Is there anything around here to eat?”
“There’s a tuna sandwich in the pantry. It was Mrs. Daley’s.”
“Maybe she’ll want it?”
“She was the one who died this afternoon.”
He raked his hand through his hair. “Man, I’m beat. My girlfriend – she’s a resident too – says our jobs are a form of birth control.” He was catching up on his notes in the patients’ charts. “Hey, what’s the usual dose of cefotaxime? Is it one gram four times a day or three times?”
What if I tell him and I’m wrong?
“I don’t remember,” I said.
“Whatever,” he mumbled and scribbled something in the chart.
“What have you decided to specialize in?”
“Radiology or pathology most probably. Something without too much patient contact and a fairly decent lifestyle. Isn’t it funny how it’s the patient contact you think you want in the beginning and how that changes as you go through it?”