The Making of a Nurse

by Tilda Shalof

  “Don’t leave.” He held me with his eyes. “Don’t avoid me.”

  I hadn’t realized I was doing that. His face was thin and pale, but in his eyes I saw his vitality. Suddenly I realized what he did in the army. It was obvious. He was a spy. He could fool anybody he wasn’t going to die.

  “Sit down,” he said, “and be with me.”

  “Of course.” I sat next to him on his bed. “I’m here. I’m with you.”

  “Breathe,” he said, and we sat quietly for a few minutes. He handed me a pair of earphones and he put on his and plugged both into his tape recorder. “Listen to this.”

  “It’s magnificent,” I said, still breathing for him.

  “Of course it is.” He grinned. “It’s Bach’s Magnificat.” He lowered the volume. “Tilda, when two people listen to music together, it is an act more intimate than sex. Music is direct experience, the only one that two people can feel at the same time. Even during love making each person is inside their own orgasm, experiencing their private pleasure. Only music can be felt simultaneously.”

  I was loath to change the subject but I had to ask him something. “Shaul, are you afraid?”

  He thought a moment. “Not of death,” he said, “only of pain.” He had started to suffer terrible bone pain and could no longer be as stoic as he had been for the biopsy. Once, his pain was so bad that I gave him a large injection of morphine very quickly. His eyes rolled back and he went limp. I was afraid I’d given too much, too fast. “Shaul,” I shouted at him. “Are you there?”

  “Don’t worry, sweetheart,” he answered with his eyes closed. “I feel fantastic. I love you.”

  IN THOSE DAYS, I had the ability to block everything out of my mind on my days off. I had some mental switch that allowed me to disconnect from any thoughts of my patients and their problems. I put it all out of my mind and escaped into fabulous adventures with the new friends I was making. We went camping in the desert, scuba diving in the Red Sea, had mud packs in the Dead Sea, went skinny-dipping in the Sea of Galilee, and went horseback riding through the Golan Heights. We threw parties and sang, drank, and danced all night. On many occasions, I went up to Jerusalem with them and we visited the holy sites there. Once, while standing in the shuk, the outdoor market where vendors had overflowing displays of vegetables, fruits, nuts, seeds, and spices, all bursting with colour and flavour (I never knew there were so many varieties of olives, dates, pecans, and pomegranates), I thought about my father and burst into tears. He would have loved that panoply and to have tasted each item, so I did, as many as I could, in his stead.

  Every month, I called my mother and tried to have a conversation, but it was impossible to hear her and what I heard I could not understand. Just as my frustration was about to spill over into anger, Pearl came on at the right moment and helped me say goodbye and hang up.

  THERE WERE FIVE single-patient rooms in the bone marrow transplant unit; two nurses worked on days and one nurse at night when it was usually quieter. Since I was the most junior, I ended up being assigned to more night shifts than the others. At first I was worried about working alone, but Hannah assured me I could call her at home if I had any questions and the doctors and nurses in the main ward, Barrack Thirty-six, were always available to help if needed.

  One evening Ayelet, the day nurse, gave me her report as I came in to start my night shift. Shaul was now in remission and had gone home a few days ago. In his bed was Talia Bar-Lev, who was six days post-bone marrow transplant. She was doing well, except for persistent high fevers, which could indicate lingering infection, but tonight they had abated. Abdullah, a twelve-year-old boy from Gaza, was to be discharged the next day. His mother watched over him and nodded at me when I checked in on him. Yuri was there that night, too. He was to get a bone marrow transplant in a few days, but seemed relaxed, sitting up and watching TV when I peeked in on him. In the fourth bed was Samuel Abulafia with his wife sleeping in a chair beside his bed. He had been admitted that morning in pulmonary edema, a buildup of fluid in his lungs, but for now, he seemed comfortable and was breathing easily.

  “Only four patients?” I looked at the fifth room. An empty bed might not stay that way.

  “I haven’t heard about anyone who needs it.” Ayelet got up to leave. “I know it’s a nurse’s superstition, but I’ll say it, anyway. It’s been a slow day. I’m pretty sure you’ll have a quiet night.”

  After I got everyone settled for bed, I did a final check. The patients were comfortable and stable. Talia had been started on a new medication and her fever was now down. Yuri’s TV was on softly, but I knew he’d leave it on all night. He had told me once how he dreaded falling asleep, afraid he might not wake up. I stood in the doorway, chatting with him for a few moments and told him I was close by if he needed anything. Then I lowered the lights in the hall and at the nurses’ station. Abdullah’s mother had spread out a mat on the floor and was reciting her night prayers outside her son’s room. When she finished she came and stood observing me over the counter, smiling at me from behind her black veil. Each time I caught her watching me, she giggled and looked away. I was writing in my journal, where I recorded my private thoughts every day. I felt her watching my pen move across the page. She opened a picnic basket and offered me a banana. It was two in the morning. The long night stretched ahead of us. We both yawned at the same moment. I handed her a stack of lab reports and a rubber stamp, and she was pleased to help me while I prepared medications for the morning. Then she sat down on a chair beside me. There we were, the two of us, unable to speak to one another, but understanding each other perfectly. Soon we fell asleep, leaning heavily into each other, our heads resting on the tabletop. A sharp knock at the back door startled me awake. It was 3:00 a.m. Geula’s husband stood on the doorstep with his wife in his arms.

  “She’s vomiting blood,” he cried. I saw the trail behind him. “Bring her in,” I said. “Put her in the bed.” I pointed to the empty room.

  Although he hadn’t predicted this crisis would happen so soon, Ben Cassis had spoken about this very possibility yesterday on rounds. Geula had received a bone marrow transplant from an unknown donor. The match was good, but not perfect, and he’d seen ominous signs of “graft versus host” syndrome. It is the opposite of what occurs in organ transplants where the person, the “host,” may reject the organ, the “graft.” In GVH, the transplanted bone marrow is seen as a foreign body and is rejected by the recipient.

  Luckily, Ben Cassis had left explicit orders in the case of this eventuality and I got to work. I quickly inserted a naso-gastric tube down her nose and into her stomach to drain the blood. Then I started an IV for fluids, another for antibiotics and steroids, and another for blood and platelet transfusions. I hung the first unit of blood. As I waited until the tubing blushed, pinked up, became crimson, and then deepened to scarlet, I searched Geula’s face for signs of life being revived within her. I had seen blood have fast, almost magical effects, but Geula lay there, limp and pale, barely conscious. Her four daughters gathered around her bed, chanting prayers and a song with a haunting melody:

  The entire world is only a narrow bridge

  The main thing – the main thing – is never to be afraid.

  The youngest daughter, Sarah, who was only nine years old, nestled into the curve of her mother’s bent legs. The older girls dabbed at her forehead and lips with water that had been blessed by the Chief Rabbi of Israel. I recalled Geula’s last admission, just after her bone marrow transplant and how the family had moved into the same room she was in now. In no time it became full of puzzle books, homework notes and textbooks, and a row of their sandals lined up along the wall by the door. I had a feeling that during this admission there would be no time to set up camp as before.

  I recalled meeting Geula and her family in the out-patient clinic. I had asked Tikva, the eldest daughter, a question that opened the floodgates: “Tell me about your mother before she got sick.”

  “My mother is a succ
essful business woman. She owns a textile factory. She knew from the start how serious her situation was, yet she always said she would beat this thing. Even after each chemo treatment she got up and went to work. We aren’t close, but she’s my mother, you know?”

  I nodded. Yes, I knew about mothers.

  Tikva usually spoke for the family and approached me now. “Nurse Teelda, please don’t give my mom any sedation. We want her to be with us the whole time, even if tonight is the end.”

  “Even if she is in pain?” I asked.

  “Well, maybe then,” she conceded, “but we want her to know we are with her.”

  This was a matter for a longer discussion, but I had to check on Abdullah and Talia. Both were sleeping quietly. Suddenly, I heard Samuel start coughing violently. I ran to him and found him struggling to sit up in bed, spitting frothy blood into a linen handkerchief. He gasped for air. I raised the head of his bed, gave him an oxygen mask, and administered Lasix that had been ordered for him if this happened. It would increase his urine output and thereby reduce the excess fluid load on his heart and lungs.

  “I’m sorry it’s taking so long,” he whispered.

  What, to die? He’s sorry it’s taking so long?

  “I’m ready,” he said, gasping for air. “It’s my time.”

  I knew he had decided on no more treatment, but I had to make him more comfortable. I gave him a small injection of morphine and stood beside him waiting. Would the sparrows still come to him in the morning if he were too weak to sing for them, I wondered? That very morning, they had heard his calls and had flown right into his room in the barrack. His wife held his hand and I smoothed his brow and watched his breathing start to ease. Blessed morphine, I thought.

  “Am I in heaven?” Samuel asked.

  Why not let him think so, if that would comfort him? I guess I had learned a thing or two from Hannah by then. I nodded yes. Was it lying? If so, I didn’t care. I bent down and kissed his dear forehead. I had never done something that intimate to a patient before.

  I stood there and began to weep, for him, for Shaul, and for all of the patients that we’d lost and were going to lose.

  “Nurse Teelda?” Tikva stood at the door. “Come now, please! Mom needs you.”

  I hurried out of Samuel’s room and rushed past Yuri’s room where the TV was still on. It was 3:30 a.m. and despite himself, he’d fallen asleep, the remote control still in his hand. Abdullah’s mother watched me. I felt she wanted to help me but didn’t know what to do, so she stayed by her son’s side as if to indicate that she would tend to him if he needed anything and thus lighten my load by at least one patient. For the rest of that night, as I rushed from patient to patient, I felt the weight of each decision I made, of each action I took or did not take. Each one held a practical implication, but also a huge moral freight, too. If I ran to hang another unit of blood for Geula, I might not get to Samuel in time to suction him and he would suffer and be afraid. If I stopped to readjust Samuel’s oxygen mask and comfort his wife, Geula’s naso-gastric tube might clot off. Talia was sleeping peacefully, but she was due for medications and they would have to be given late. I kept running as fast as I could in all directions, doing as much as I could.

  Tikva was getting frantic. “When will Dr. Ben Cassis be here?” she asked.

  “In the morning,” I said. It was almost 5:00. I imagined him in bed lying beside his wife.

  “How could God do this to us?” the daughters cried, standing around their mother’s bed. The husband sat in a chair, sobbing. Geula’s breathing was raspy and heavy. They understood that her kidneys had stopped working. They saw the pools of blood all around her. “Do something!” Tikva shouted at me. “Do something!”

  It was 6:00 a.m. In an hour everyone would be there. “The doctor is on his way,” I said to them. I looked out the window, scanning the horizon for the sun. The night sky was giving way to a violet sky with streaks of orange that promised that day would come. I looked at the mess I’d made. Empty vials and used syringes were strewn all over the counter. I had thrown a drained bag of blood at a garbage can and missed and I watched the last few drops drip onto the floor.

  “You should have called us,” they all said when they arrived, but I could tell I had won their respect for having toughed out the night on my own. Aviva got straight to work tidying up, shaking her head at the disorder. Ben Cassis sat down and started grilling me about each patient. “What did you do then?” he asked. “Next? … What then?” He seemed satisfied with each answer I gave, but kept on going. Hannah went into the tiny on-call room, off of the nurses’ station and left the door open so that she could see and hear everything. She wanted to intervene and tell him to lighten up, but didn’t dare interrupt. Jamilla arrived with her friend Fredja and they were chattering and laughing as they started up their little finjan on the stove to brew Turkish coffee and then began the morning sponja. Aviva wiped off the countertops. “Whose medication is this?” she asked. She held up a syringe filled with clear yellow fluid. I stared at it in her hand.

  “How did Talia deal with the high dose of Amphotericin?” Dr. Ben Cassis continued his interrogation. “Did she have a reaction this time? Any chills or rigours? What’s her temperature?”

  “A reaction?” I asked slowly, stalling, thinking it through.

  “I hope you gave it slowly, with lots of fluid. Did you do that?”

  No, I hadn’t given it at all. I had prepared it and drawn it out of the vial, but I hadn’t given it to Talia. I gulped for air, but my throat closed up tight. “I forgot to give it,” I squeaked. Aviva ran off to tend to Geula as I stood stock-still, quaking in terror, staring at that syringe on the counter.

  “What? How could you be so stupid?” Ben Cassis pounded his fist on the tabletop. “Damn it!” he shouted. Hannah jumped up. I thought he might hit me, but words were his blows. “You could have killed her,” he screamed at me, switching to English, as if its foreignness might help him restrain himself from murdering me. Maybe he did it to even the playing field, otherwise it would be like crushing a bug. He was a powerful, intimidating man, but he was not a bully.

  “I know, I know,” I cried.

  “Surely you realize that a patient as immuno-compromised and vulnerable as Talia could quickly become septic!” he raged at me. “She could die from a fungal infection!”

  I stood there taking it. I deserved it. It was part of my punishment.

  “This is a matter of life and death here! Don’t you realize that?” I nodded and looked down at my blood-splattered running shoes. “If Talia dies, it is because of your carelessness.”

  “That’s enough.” Hannah stood in between us. “Go home,” she whispered to me. “Talia will live or die regardless of one missed dose.” I couldn’t move. Hannah took my face in her hands. “Go home, sweetie. You need sleep. See you tonight.” She pushed me toward the door. Dizzy and exhausted, I stumbled out and onto the dirt road at the back of Barrack Thirty-six Alef. As I began to make my way home, the wailing began. Geula’s daughters’ grief shook the old building.

  I reviewed the night. I must have reasoned that Talia, the youngest and the most curable, could likely withstand more temporary neglect than the others. Although the others had less chance of survival, I felt certain Talia would make it through the night. And even though we were not actively treating Samuel any more, I had to ensure he was comfortable and didn’t suffer. Geula’s fierce daughters intimidated me and I was afraid they would blame me if she died during the night, while I was alone on duty. So, even though Geula had been closest to death, I had worked the hardest on her. My thought process was flawed because it was motivated by fear.

  I made it home and didn’t even bother to shower before flopping onto my bed, still in my uniform. I tried to sleep. The phone rang and I jumped up. As I flew to it, I felt certain it was Ben Cassis calling to tell me that Talia had died. I answered the call and instead took a message for my roommate to call her mother. Finally, I fell asleep an
d when I woke up it was ten o’clock that night, barely time to rush back to work by eleven o’clock for another night shift.

  That night new patients were in Samuel’s and Geula’s beds, now freshly washed and made up, completely innocent of the suffering they had recently contained. Yuri was watching the TV show Top of the Pops, the weekly hit parade of tunes, and waved to me as I walked past. Abdullah had been discharged home that morning. Only his mother and I knew what had gone on that night.

  For months after that night, I avoided Ben Cassis. Of course, I worked with him and saw him every day, but I never made eye contact with him. I felt cowed in his presence and kept a low profile. I started getting headaches before going in to work and I checked and double-checked myself even more than ever. How could he ever trust me again? I asked Hannah for some time off, but she told me she didn’t have anyone to cover my shifts.

  A FEW MONTHS LATER, on another night shift, I had an opportunity to make peace with Ben Cassis. I took over from the day nurse and she gave me report about Dawud, a twenty-two-year-old man from Gaza, recently diagnosed with leukemia. He was coughing up blood and his blood pressure was low. Shortly after she left, I took my own reading and could barely detect it. His pulse was weak and thready. He was cool and clammy. I opened up his IV and let fluid pour in and called Ben Cassis at home and reported my findings.

  “He’s gone into septic shock,” he said to me. “Damn it,” he said to himself. He began to outline exactly what he wanted me to do: give lots of fluid, plus two units of packed red blood cells, ten units of platelets, start him on a different, stronger antibiotic and a drug I wasn’t familiar with called Dopamine. “What’s that?” I had to ask him because there was no time to look it up as I was taught to always do. “Dopamine is a powerful drug that will constrict the vasculature,” he explained, “and it will raise the blood pressure.” I hung up the phone and got to work.

  “Ya! Allah!” cried his young wife along with his mother and sisters, who gathered around his bed. “Ya! Allah!” they wailed and threw themselves upon his body. They had turned his bed around to face Mecca, in case he should die before the morning. As I hung the first unit of blood, I looked up to see Dr. Ben Cassis walking in the door. For the rest of that night we worked side by side. I gave the antibiotics and assisted him as he inserted a central line into the patient’s subclavian vein through which I could run the Dopamine faster and more safely. I took care of the other patients while he stayed with Dawud. At dawn, we took a break and sat down at the nurses’ station. I thought about Aviva and what she’d say when she arrived in the morning. She would look at the mess and exclaim, “You made all this effort for a guy who might go on to bomb us?”