by Tilda Shalof
“Oh gee, hopefully a doctor will come around soon and explain it to me,” I said, hating my sarcasm. I turned away from him as I noticed him staring at my chest.
“What big tits,” I heard him comment.
Later, he hung his head and moaned that it had been an extra effort for him to come in today. It had been very difficult because he had a bad cold and maybe I could take his blood pressure and his temperature?
“Rectally, of course,” he said with a lewd smirk. “I’m not feeling well. I need some soup. You got any? Can I lie down in the extra bed over here and you can take care of me?”
I busied myself straightening out the tubing on the ventilator and emptying it of condensation that had collected in the coils. I prepared the flow sheet for the nurse coming on to the night shift. I went into the bathroom and flushed the toilet a few times.
Then he asked me to give him a back massage. When I refused that as well, he was visibly displeased.
“It’s making me pretty hot, coming in to this place, day after day, being surrounded by all you beautiful women,” he said. “Maybe I should bring in a stripper for Dad or one of the pretty, sexy nurses like Julia or Sharon – or – what’s the name of that tall, blond one?”
“I don’t know who you mean,” I said.
“You know, she was the nurse here the other day. The stunning one. The real knockout.”
“Karen?”
“That’s it! I’ll never forget what’s’ername! When’s Karen coming back?”
“I haven’t the faintest idea.”
“Bring Karen back. She’ll get a rise out of Dad. She’ll get him going, whatya think? Dad’s got quite the eye for the ladies!”
“I’m sure.”
“Maybe Karen could nurse him in the nude.”
The whole scene was an enactment of a burlesque melodrama. They were a troupe of travelling actors in a commedia dell’arte. The theatre was their father’s body. The principal actors were Irving, the aging Patriarch; Sidney, the snivelling, spoiled Son, Brenda, the Jewish Princess Ex-Wife and valiant rescuer; Howie, the embittered, put-upon, long-suffering Servant; and the grandchildren, in their bit part for comic relief, off-stage. I could see all this, but still couldn’t rise above it and keep to my role as the producer. I couldn’t even seem to stay put in the audience and avoid getting swept up into the dramatic action taking place on centre stage. They annoyed, insulted, and irritated me. They reminded me of my own family. It was all too close for comfort. Worst of all, because of the way they treated me, and because of the way they behaved, I felt, in their presence, ashamed to be a nurse and embarrassed to be a Jew.
I NEVER FIGURED out how they managed to coordinate their visits so that they rarely had to face one another, but once again, shortly after Sid left, Brenda arrived, this time with another grandchild, Sid’s daughter, Melissa, a teenager who spoke to her grandfather in baby talk. After a few minutes she said she was bored and wanted to leave.
“C’mon, honey bunch,” her grandmother said, “let’s go shopping. Melissa needs shoes for the wedding, Irv,” she yelled into his ear.
“Yeah, mention money, that should get him going,” said Sid who was back again. “Mother’s spending all your money, Dad. Wake up and stop her.” He walked to the other side of the bed, where Brenda had been standing, the side toward which Dr. Laurence’s head was turned, but as soon as Sid came into his father’s line of vision, he turned his face away.
“My mother’s nuts,” Sid said to me when she left. “Always has been. All she cares about is his money. They’ve been separated for years, but they still have joint bank accounts. She tries to control everything, but she doesn’t love him as much as I do.”
I looked over at the father who lay in bed, unmoving, his eyes closed, oblivious to his family, oblivious to everything, really. To me, his big, shaggy face was handsome, despite the baggy skin under his eyes, his bulbous, hairy nose, and sagging features, even despite the endotracheal tube and the heavy-duty plastic tape we used on his face to secure the tube. But his expression was vacant, vacated almost, expressing only the desire to sink deeper within himself and away from us all.
The next day I sat with my friends in the lounge eating lunch, and we all seemed to need to let off steam about difficult families, of which the Laurence family currently topped the list.
“They’re driving me crazy,” I complained. “They told Sydney they don’t want me taking care of him and I can’t say I’m too disappointed about it. They have given me an easy out.”
“I also had a difficult family last week,” said Tracy. “They went to Sydney to complain that I didn’t give good ‘service.’ You know how demeaning that felt?”
“Tell them they should ask for a different waitress, next time,” Morty suggested.
“I’m having a hellish day, too,” said Nicole. “I’ve got the twenty-eight-year-old woman who had a baby three days ago and has now gone into acute renal and hepatic failure – it’s a rare autoimmune syndrome.”
“Did the baby make it?” Frances asked.
“Yes, but it doesn’t look very good for the mother. She’s septic and that’s led to problems with her blood-clotting function. She’s dangerously acidotic – her pH is only 6.79 and her lactate is over 12 – so we had to sedate her, paralyze her, the works. Anyway, I’m working my butt off – it’s been nonstop in there all day – and the patient’s mother, sister, husband are all there, crying at the bedside, asking me a million questions and telling me she’s hot, she’s cold, she needs a blanket, rub her feet, put Vaseline on her lips. The husband looks at me and says, ‘It’s our anniversary tomorrow.’ What could I say? I didn’t want to hear that. I’m getting married next month. I’m planning my wedding. I want to be happy. I feel for them – of course, I do – but I’m tired and want to go home and they’re crying their eyes out. I know it doesn’t make any sense, but I felt like saying, ‘Why such long faces? Come on, it’s depressing being around you guys.’”
Morty recalled a funny story. “Remember that patient whose husband kept speaking into a tape recorder? I was taking care of the wife whose name was Louise and he was going, ‘I’m talking to … what’s your name?’ he asked me and I said, ‘I’m Thelma.’ So he goes, ‘I’m talking to Thelma, Louise’s nurse. Not a bad nurse, but not a great one, either.’ He gave everyone a grade. I think I got a B minus.”
“We get no appreciation,” said Nicole, joining in to this self-pity fest, “and I know we shouldn’t expect it, but, remember that hockey coach we had as a patient who gave out gold playoff tickets to the doctors and left a box of stale candy for the nurses?”
“Sometimes you give and give and then get to a point where you feel you can’t give any more,” sighed Frances. We were taken aback to hear a comment like that from her. She looked guilty at letting us down.
“I don’t understand you guys.” Laura sat up from where she had been curled up on the couch like a cat, pretending to be having a power nap, pretending she hadn’t been listening to any of this conversation. “I never have problems with families. I don’t get personal with them and I don’t expect anything from them. Don’t get so emotionally involved. Especially you, Tilda, you’re the worst for that. You’re sooo sssensssitive.”
Morty broke into a few twangy bars of Jann Arden’s hit song, “In sensitive,” to bait me.
“Another problem with you,” said Laura, surveying me as if she were going to do a complete makeover of me, or at least give me a new hairstyle, “is that you think too much. Stop it.”
“I suppose you’re right,” I agreed.
Families never complained about Laura, but Laura also never attempted to forge a relationship with them. She had mastered the art of compassion without losing herself in the process. Families loved her because they knew she gave exquisite care to their loved one, but they also knew to contain themselves in her presence.
“I never have trouble with families, either,” mused Nell, who wasn’t boasting. In he
r case it was simply true.
Some nurses had a natural wisdom or an acquired maturity that allowed them to give in such a way that they didn’t lose themselves. More than once, I had seen Nell, Frances, Bruno, Ellen, Valerie, or Suman cry with a family over a patient’s deterioration. They had been known to occasionally give out their home telephone number to a family member who wanted to speak to them privately. Karen sometimes went to the funerals, visitations, wakes, or shivas of some of her patients and had even made home visits on her own time. For those nurses, none of these gifts they offered seem to either extract or detract from their personal resources.
There were others like that: Julia, Juliet, Murry, Ann, Lisa, Linda, Judith, Richard, Sharon, Anita – and others. The good nurses. The ones who made every patient family’s request list, those families who compiled such lists. Then there were all the rest of us. The vast majority of us who struggled to maintain our emotional equilibrium in the presence of so much suffering and despair. All the rest of us who tried to stay open to the pain of others and not be overwhelmed by it.
In school, they’d taught us how important it was to offer empathy to our patients. Sympathy was wishy-washy, sentimental. Empathy was the ability to perceive and feel another’s pain. One was supposed to share the patient’s “lived experience of illness.” One was supposed to get inside the patient, see things from the patient and family’s point of view, think and feel like the patient, take on what that person was experiencing. All of this was in order to know them intimately and only by knowing them in this way could the nurse give the greatest gift: empathy, the hallmark of the professional nurse.
What profession other than nursing was defined by this degree of emotional involvement? Certainly not my husband’s work selling life insurance, even though it required him to have serious discussions with young, healthy people and convince them of their mortality. Even social workers could keep their distance with words and paperwork. Teachers could choose to get involved in students’ personal problems, listen, empathize, and draw them out, but they could also choose not to do so and stick to their subject matter and still be excellent teachers.
However, a nurse who was not sensitive to a patient’s emotions, who did not help to assuage bad feelings, who did not offer the ultimate gift of feeling for them – empathy – was simply not meeting a basic requirement of the job.
Did those who taught us ever realize what a demand it was on young (mostly) women (by far the vast majority of nurses) whose boundaries were often so permeable and pliable? Had anyone ever considered the toll such emotional receptiveness took on most of us, both male and female? Why wasn’t it covered in the lectures and textbooks of nursing – how one could stay sensitive to the patient’s experience, see things from their point of view, be compassionate, and still manage not to get pulled down with them into despair and sadness, or be affected by their anger and frustration? Otherwise, who could do this work effectively for any length of time? Who could sustain it into a lifelong career?
AS MY SECOND day caring for Irving Laurence progressed, he seemed to go deeper and deeper into his detachment from the world. When we turned him in bed, he lay there helplessly and let us do all the work. As the day wore on, he seemed feverish, and sure enough, by the afternoon, he’d spiked a temp.
“He was perfect this morning! What have you done to him?” asked Brenda, throwing off her coat and flying to his side. “He came into this hospital just fine, and look at him now!”
She stayed only a short while and right afterwards, predictably, Sidney showed up. (Was he hiding outside in the bushes, watching her come and go?)
“Before he got sick, Pop was never sick a day in his life,” Sid moaned. “He didn’t even know what a hospital was.”
I tried not to glance over at the stack of old charts piled up on the counter; they spoke volumes. I merely nodded at Sidney as he spoke. His cellphone rang.
Sid had been told frequently to turn off his cellphone while in the hospital, as it could interfere with the electronic equipment, but he kept it on anyway, because, as he explained, he was expecting an urgent call. He was always working on a “million-dollar deal that was about to be put to bed.” However, most of the calls I overheard him making seemed to be to his lawyer, to find out the exact details of his father’s will, how the estate would be shared between him and his mother, and how quickly the disbursements would take place – would it be days or weeks?
I wasn’t assigned to Dr. Laurence’s care again, but the questions the experience provoked in me were still very much on my mind a few days later. I had just returned to the ICU from transferring a patient to the floor, so I was free to cruise around the unit, visit patients, and help the other nurses. I happened to walk by the room of a patient who was calling out for help.
I had heard about this patient on rounds. She was a forty-two-year-old woman, a mother of three, who was newly diagnosed with aggressively spreading breast cancer. She wound up in the ICU with a perilous respiratory infection. I knew from having gone over her X-rays with the team that she was deteriorating rapidly and it was only a matter of time until she would need to be intubated.
When she saw my face at the doorway, she reached out toward me. “I’m flailing all around the bed and I can’t seem to stop,” she said. “My nurses think I’m crazy. Tell them I’m not.”
Her nurse, Esmeralda, a petite Philippina nurse with long shiny black hair and a preference for candy-pink scrubs, went over to her. “You’re upset, that’s what you are, dear,” she said with calm authority. “Would you like me to give you medication in your iv to help you calm down?”
As Esmeralda was asking this question, I saw that she was already injecting 5 mg of Valium into the patient’s iv line.
“My family were here and now they’re gone and I’m scared. I don’t know what to do,” the woman said. Her breathing was fast and shallow. “Help me! Help me, someone. I’m all swollen up.” She held up a puffy, bruised arm to show us where IVS, and attempted IVS, had been.
“Moderate peripheral edema and scattered superficial hematomas,” I saw Esmeralda jot down in the chart for her nursing assessment under the category of “Integumentary System,” commonly known as “skin.”
She was giving good care and getting her paperwork done, too. That’s efficiency, I thought. That’s a nurse who’ll rest easy tonight. She’s in it for the long haul.
“I’m scared,” the patient said, her eyes beseeching me, Esmeralda, and then Ruth, the other nurse in the room who was caring for another patient.
“What’s scaring you?” asked Esmeralda, even though we could think of about a million things.
I noticed that in the few minutes I had been in the room, uninvolved and merely observing, even I was becoming uncomfortable. The patient was so anxious, was moaning so much, and was so inconsolable, despite the competent efforts that Esmeralda was making, that it was putting me into a heightened state of alertness and unease. Reassurance wasn’t working, the Valium hadn’t kicked in, and this woman’s need seemed to fill the room. I could feel myself getting tense and my own breathing felt a little constricted. I was tempted to shut out the patient’s pleading voice and busy myself with tasks. I could move on to another room, as I really had no obligation to stay there. There were other nurses who could use my help.
“I’m upset, I’m so upset, I really am. I hate this place. Get me out of heerre!” the woman cried out.
Esmeralda patted her arm, a gesture that reminded her at the same time that it was a good opportunity to stretch out the patient’s other, less swollen arm and take her blood pressure and then compare it with the electronic read-out of the arterial line transducer on the monitor. (We considered the high-tech method more reliable than the hands-on method but we still checked it the old-fashioned way from time to time to make sure the two readings more or less correlated.)
“How do you do it?” I asked Esmeralda. I saw how emotionally secure and stable she was as she gave good, kind care. S
he was compassionate, yet contained within herself. She cared, but she wasn’t particularly emotionally involved.
“I come here, give what I can and then I say, bye-bye, time to go home,” she said in a chirpy voice.
Ruth, the other nurse, was moody. She had her good days and her bad days. I had seen her give nursing care with incredible skill and compassion and, at other times, be distant and perfunctory with patients. “If you ask me, that patient is a PITA,” she said quietly, from her side of the room.
“Not an abbreviation I’m familiar with,” I said.
“Pain in the Ass. I know she’s dying, but does she have to be such a bitch about it?”
“Ruth, how can you say that?” I asked, acting appalled and self-righteous, with my hands on my hips. But then I stopped myself – hadn’t I just had my own unempathetic thoughts? Was I any better? I had been in this patient’s room for about two minutes and already I wanted to escape. I felt drained of the empathy that I was there to give.
Was this a sign of the “burned-out syndrome” that we had been warned about in school? I had been a nurse for fifteen years, ten of them in critical care. I had read about this phenomenon, studied it in school, and had seen other nurses with severe cases of it. I had always promised myself I would never get that way, but here I was, dragged down by a patient’s despair, on edge from her anxiety. I had caught it from this patient as easily as one contracted an infectious disease.
At times, certain people, certain patients had that effect on me: the young ones, the awake ones, the insatiable ones, and the tragic ones. For as sad as some of the deaths were that I helped and witnessed in the ICU, most were not tragic. I felt relieved for the old or very sick people who died; they had managed to slip away and escape. It was sad for those left behind, the family and friends, but those cases were not the ones that caused me to lose my composure. They were not the ones who broke my heart.
A few days later, Laura and Frances returned from a nursing conference that Sydney had sent them on. They reported back to us about the latest products for preventing pressure sores, new techniques for postural drainage of lung secretions, and the latest nursing theory that the hospital seemed eager to adopt, called “patient-centred care.”