by Tilda Shalof
But it was a frightening, chaotic time and many nurses were angry. Every day the information changed as the experts were learning about this new disease. It seemed as if almost every day that we came to work there was a new set of rules about the appropriate gear needed to protect ourselves. The lengthy screening process of every patient, staff member, and visitor was oppressive, but unavoidable. The stringent precautions we had to take for all patients slowed us down. There were many troubling questions that were left unanswered. Infectious disease experts and public health officials did their best to keep us informed, but nonetheless, new and contradictory information surfaced on a daily, sometimes hourly, basis.
Our work felt overwhelming and we were afraid. When I mentioned where I worked to a neighbour, he jumped ten feet away and continued our conversation at that distance. Some people I met during that period praised me for my work, yet refused to shake my hand or come near me. Even though only a few of us were actually exposed and had to be quarantined, we all knew of many nurses and other professionals who were quarantined, and a few who did in fact contract SARS.
Many nurses and other staff continue to feel angry and resentful about the dangers our work exposes us to. Yet I believe that during the crisis of SARS, we received the most up-to-date information that was available under the circumstances. There were problems and inefficiencies due to the sudden, excessive strain on the health-care system, but within my limited experience, I don’t believe anyone is to blame.
Others feel differently. I heard one nurse preparing to go into a SARS patient’s room and while she was undergoing the time-consuming suiting-up process, assisted by another nurse, I could hear her from where I sat at the nursing station.
“I haven’t seen a doctor all day,” she said. “I heard one resident tell another, ‘Minimize how much you go in. Let the nurse go in.’ They’re basing their treatment solely on my assessment and my observations of the patient.” Her tirade continued when she came out of the patient’s room, after she stripped off all the gear. I saw her flushed face and the sweat dripping off her arms and darkening the back of her uniform. “They should pay us danger pay,” she grumbled as she scrubbed her hands at the sink.
“This isn’t the time to be asking for more money! The public’s health and safety are at stake. We all knew there were risks in this line of work when we went into it,” Laura said.
“Don’t we have the right to refuse unsafe work?” she shot back.
“Come on,” said Laura. “Dealing with infection is nothing new for any of us. We’ve all had needle stick injuries, splashes in our eyes with all kinds of fluids and we’ve all cared for patients with AIDS and hepatitis. Don’t you remember when Tracy got that scare with the tuberculosis patient and had to go on medication when she was pregnant?”
“Remember that time we were giving that experimental drug and you had to sign a waiver that you weren’t pregnant, allergic, wearing contact lenses, or on steroids before you went in there? Now that was scary!” Nicole said.
“How about last year with that ’flu epidemic and we all had to be vaccinated before coming back to work here? This is a hazardous place. Enter at your own risk,” Tracy said.
“Yeah, but this is different. SARS can be fatal,” she reminded us and that gave us a moment’s pause. “Don’t you think we should be compensated for this new danger?” She continued, “The managers all got vouchers for fancy hotels and a night on the town. They got bonuses. What did we get? A movie coupon and a T-shirt! Oh, and a certificate of ‘thank you very much, for risking your lives’ from the management.”
“At least be glad we’re spared the exposure to the real dangers: flowers and ferns,” I said and at long last, one of my jokes got a rise out of them.
“IN CONCLUSION,” I said looking around from the podium, “we need to find ways to support nurses in the emotionally dangerous work we do. Many nurses found these photographs upsetting. This finding attests to the emotional price our work exacts of us. We know a lot about the looming nursing shortage, workload issues, burnout, the hazards in our working environment, and the moral distress in our institutions. However, this research documents another kind of stress that is equally infectious, risky to our health, and difficult to treat. We have to recognize that nurses are affected by the sadness of our work. The constant proximity to this degree of suffering is eroding our emotional health. Nurses are suffering. We need to find ways to assist nurses to cope with these perils of our work.”
The audience clapped politely. What I was saying wasn’t new. It was well known that nurses’ work is difficult and stressful. Sometimes even depressing and now, more than ever, dangerous. But nurses have always taken on the sorrow and suffering of the world. Most of us are proud to be nurses, but reluctant to speak publicly about these challenges, since those in helping professions aren’t supposed to complain.
The audience turned their attention to the next speaker, who would speak about a topic with which everyone was more familiar and comfortable: Guidelines for Nursing Care of the Patient in Fulminant Hepatic Failure.
17
A PRISONER OF WAR
Tracy bounded over to me as I was starting my day and she was coming to the end of her night shift. We didn’t work together as much any more because she’d had to change her schedule in order to accommodate the early-morning university classes she was taking.
“How can you possibly listen to a lecture now?” I asked, scanning her face for signs of fatigue. “You must be exhausted.”
“No, I’m not at all.” Her eyes were lively, but something was troubling her. “This course I’m taking has got me thinking. Do you remember Mr. Kerr’s death? I wanted to talk to you about how we could have done it differently.”
We all remembered the details about our patients, especially their deaths. Even when a patient died when we weren’t at work, we sought out the nurse who had been there, to tell us what had happened so that we could put it to rest in our minds.
“His death was terrible. The son was so upset with us. Remember how we left the tube in because we thought it would be too upsetting for the family to hear the sounds of his last breaths? But that just made it go on longer. We gave him morphine to make him look better and make the family feel better. The narcotic was for the family! They couldn’t bear to see anything that looked like he was struggling. Who were we serving?”
“I know.” I remembered this and much more. We had increased the rate of the morphine drip as the father gasped his last breaths, but even with morphine, he’d opened his eyes and looked around. Perhaps it seemed to the son that his father wanted to say something, but couldn’t. The mother was sobbing, the daughters were clinging to the mother, and the son was furious. “You promised he wouldn’t suffer,” he had cried.
“Sometimes it feels like we are orchestrating the whole process to make the families feel better. It doesn’t feel honest. We didn’t want to hasten it or prolong it, but remember how the family kept asking how much longer it would take? They wanted it over quickly and they assumed we could arrange that,” said Tracy, who suddenly did look weary. “Which we can, of course. They were shocked when I turned off the monitor, but we weren’t using it any more.”
We had all seen this reaction time and time again. Families rely on the monitor. They become so glued to it, sometimes for weeks, and then when the time comes and we pushed the “off” button, it is as if that is the moment of death.
“I know. They looked like my kids look at me when I turn off the TV and tell them to go to bed. It’s like they can’t believe I’d do this to them!”
We laughed uneasily.
“Mr. Kerr’s death has been haunting me,” said Tracy. “We didn’t handle it very well.”
I agreed. “The way a patient dies in the ICU is the nurse’s responsibility. Decisions are made – or not – in the family meeting, but in the end, the care of the dying patient is left to the nurse.”
I thought for a moment. “Trace, how would
you have done that death differently?”
“I don’t know, but the son was so angry at us,” said Tracy. “I can’t stop thinking about it.”
“But the real reason the son was angry was that his father was dying.”
“I know,” she said and suddenly looked deflated. It was as if the fatigue, from having worked all night, suddenly occurred to her. I watched as she came to a halt, let down. But a second wind kicked in and she rallied to continue our debriefing.
“Then remember how afterwards we brought the family back in, as we always do, after we tidied him up, removed the IVS, tubes, and machines, and freshened the room. We made sure everything was nice and neat. We wanted to show them that he looked like himself again. Exactly how he would have looked if he’d died naturally. Sometimes, how we handle death feels dishonest.”
“I know,” I sighed.
“You know how sometimes we joke around afterwards?” Tracy continued. “I hate myself for it, but can’t seem to stop. Once I leaned over a corpse I was wrapping with another nurse to turn up the radio to catch a song I liked. I guess I had to make a disconnect with what I was really doing.”
“I know what you mean,” I said. “Just the other day, I was wrapping a body for the morgue and Morty was going on her tirade again about the shrouds and how they’re an occupational hazard. ‘Why do they make shrouds from this toxic plastic stuff?’ she was saying. You know how when we open them up they have that industrial chemical smell that we all try to avoid inhaling? ‘They’re going to make us sick,’ she says. ‘Why can’t they make biodegradable shrouds? You know, dust to dust. Eco-friendly shrouds! There’s a market for that!’ So, to the tune of ‘Born Free,’ she starts singing, ‘Die Green’!”
Oh, how we howled at things that were not the least bit funny, but the fleeting pleasure of the intoxication was rarely worth the queasy hangover of discomfort.
WE CLAIMED WE had seen everything, done everything. We were unshockable and unshakable. We boasted that nothing fazed us. We were seasoned veterans and felt confident that we could handle anything. After all, we’d dealt with the worst-case scenarios. We’d seen every drastic, catastrophic thing that could possibly happen to a human being. We were wrong. One day a patient rolled in that changed everything.
I received Mr. Bellissimo from the OR. He had cancer of the prostate that had spread to his bladder. But cancer was the least of his problems. He arrested on the floor and then developed a pulmonary embolism after a long cardiac resuscitation. Most troubling was the finding on the CT scan of his brain damage due to prolonged oxygen deprivation. However, nothing about any of that was unusual to us. We had seen other patients like him before; patients like him, and worse.
“We’ve managed to stabilize your father, right now,” I told his two grown-up daughters, Maria and Theresa, as I brought them into the ICU for the first time, “but he’s still critically ill.”
“Up on the floor, they worked on him for hours,” Maria, the older one, said. “But maybe, if they had gotten to him sooner, things would have been different?”
“I don’t know,” I said, “but sometimes it can be difficult to resuscitate a seventy-six-year-old heart.” WAIT, I wanted to warn them. Stop, for a minute. Don’t let us do all of this. If you let us, we’ll go too far and then it will be harder to stop than not to have started at all.
Mr. Bellissimo experienced no major crises or setbacks in the first few days, but even Dr. Huizinga and the surgeons looked uncharacteristically grim. They didn’t paint their usually optimistic picture to the family. I tried to be positive when I spoke to the daughters. After all, it was too soon to predict that a man this ill couldn’t get better, even though my intuition told me otherwise.
“We’re doing everything we can for him,” I assured his daughters, who were busy setting up camp in the waiting room, determined to stay for the duration.
For some reason, in case I might have thought otherwise, Maria said, “Dad’s a real fighter.”
“That’s good,” I said. “He will have a long road to recovery.”
“He loves to dance,” she said, and I was pleased she wanted me to know that about him.
“Bring in a picture of your dad, if you wish. We’ll put it up on the wall for everyone to see.”
“Unfortunately, he never danced with our mother,” I heard Theresa mutter.
“Mom died last year,” explained Maria, glaring at her sister to be quiet. “Dad lives with me.”
“How was he before he got sick?”
“Plays bocce ball every Saturday! Drinks a double espresso before bed every night.”
“Plus a grappa or two,” murmured Theresa.
“Dad has a great sense of humour,” Maria said and looked over at him with dutiful adoration. “Don’t you, Dad? Nurse, I’ll give you an example of just how funny he is.”
“When he’s sober,” interjected Theresa bitterly.
“If anyone ever asked Dad if he had any children, he used to say, no, but my wife has two.”
Maria shook her head in amazement at her father’s extraordinary wit.
A week later, Mr. Bellissimo developed an intestinal blockage and needed emergency surgery. Even Dr. Huizinga, famous for taking on challenges that no one else would touch, looked worried. When I came into the room to visit Morty, who was taking care of him that day, I found Daniel with his hands deep in the muck of the patient’s bleeding intestines. He took the patient back to the OR but when he returned he was still bleeding. We hung unit after unit of blood (we stopped counting at sixteen) and just as we pumped it into his veins, it oozed back out through his incision. Blood flowed onto the mattress, dripped down off the sides of the bed onto the floor. I went to get a mop.
“I’m going to bring the Red Cross in here so they can see where their precious resource is going!” Morty announced, looking down at her blood-splattered running shoes. “What a waste!”
Theresa was fidgety and tended to come and go while Maria was stalwart and sat in the room for most of the day, watching the cardiac monitor. I remembered Tracy’s comment and saw how Maria was watching the monitor exactly like it was a TV, with her eyes glued to her favourite program.
“I’m keeping an eye on Dad’s heart,” she explained when she noticed me watching her watching.
When I bent over him, to listen to his lungs and heart with my stethoscope, Maria regarded me as if I might, if I chose to do so, invoke the miracle they were praying for. The intensity of her gaze and the expectations it held, were unbearable because I had come to the realization that in her father’s case, I didn’t believe in what I was doing. Even worse, I had come to the conclusion that what we were doing was wrong, because it was causing suffering for no benefit.
“We’ve talked about it and decided we want to have everything done,” Theresa said when she joined her sister in the afternoon.
“Is it what your father would want?” I asked.
I decided not to wait for the family meeting to be called, arranged, and endured. I took the initiative to tell them what I knew. “It doesn’t look very good. The CT scan shows massive brain damage. He’s still critically ill. Have you thought at all about the possibility that he might not recover?”
“Yes, but that nice female doctor, you know, the pretty Chinese one? She said he might not recognize us. That he might get the words, but not know their meaning. That’s okay with us.” Maria spoke for them both. “We’ll take him like that.”
“Even before all this happened he sometimes thought it was 1950 and he was still in Italy,” said Theresa with a giggle.
Oh well, at least the war is over.
“She said it might be like he’ll be one of those people who see the golf club and the golf ball, but can’t bring the two together. That wouldn’t be so bad, would it?” Maria reasoned.
“That would describe a lot of beginning golfers,” said Theresa with a grin that looked to me, at that moment, positively goofy.
Two and a half weeks later Mr
. Bellissimo was still there and the daughters chose to interpret his “survival” as evidence of his innate fighting spirit. However, their father was now full of a raging blood infection and pneumonia, too. We had him on three different inotropes at maximum doses to maintain his blood pressure, the systolic hovering only around 85.
“His X-ray looks like a snowstorm,” Nicole told me when I went in to cover for her break. “It’s a total white-out. Take a look at it. The daughters haven’t a clue how to interpret what they’ve been told about the CT scan of his brain,” she said. “They say it’s like if he’ll see a coffee cup, he might put his hand into the coffee, rather than grasp the handle. He’s got global cerebral hypoxia, for goodness’ sakes. He’s going to be in a vegetative state, if he even recovers from everything else wrong with him. Why doesn’t someone spell it out for them in terms they can understand?”
“Go for lunch,” I urged her.
Since Mr. Bellissimo couldn’t move by himself, we repositioned his body every few hours to make him comfortable. I called for Lola, the hospital assistant, to help me. At first she wasn’t paying attention, but all of a sudden I saw her eyes fill with tears as she looked down at the patient’s swollen face, ballooned out and straining tightly around the breathing tube, his black fingers and toes, his skin, dripping with infected sores.