The Making of a Nurse

by Tilda Shalof

  Meanwhile, as hospitals madly scrambled to care for patients, administrators once again came to the obvious realization that the so-called surplus of nurses was, in fact, quite the opposite – a shortage of nurses. I reapplied to my old job in the ICU and was able to return, this time in a part-time position. Going part-time was my choice back then, but many nurses didn’t have that luxury and had to patch together a number of jobs in various hospitals in order to bring in a full-time salary to support their families, now as casual workers, without benefits.

  Returning to work after a second long maternity leave, three years later, it didn’t take me long to regain my groove. And during that time, without fail, every week, Daphne and I continued to meet. Until one day, after six years of writing together, I realized the time had come to break away from her. There were stories I wanted to tell but felt I couldn’t in her presence for fear of upsetting her. By bowing out, I was protecting both of us, she from hearing my disturbing stories and myself from frustration at having to squelch, or at best, sugarcoat them. Daphne was angry when I ended our partnership that for such a long time had been so productive for both of us. In time, I think she forgave me. At any rate, she went on to publish two books of poetry, and years later, a third. But neither of us could have known or imagined in those days that within only a few years Daphne would be diagnosed with an illness herself and be forced to enter the world of the hospital. But back then, if she preferred not to think about such unpleasantness, who could blame her?

  8

  YOUR MOTHER, YOUR FATHER

  It takes a nurse to teach a nurse. There have been many teachers along the way for me and now I teach others. It’s relatively easy to show someone how to insert a naso-gastric tube to decompress a patient’s stomach. Adjusting the ventilator to improve a patient’s arterial blood gases is a more complex skill. It’s even more complicated to teach someone how to attend to the multitude of details required to manage a patient in multi-system organ failure. But I still haven’t figured out how to teach another nurse to manage the emotions this work can evoke. I know many experienced nurses who still struggle with this challenge. How do you care, but not so much that it hurts? How do you make your care patient-centred, yet still keep your personal boundaries intact? There are huge emotional risks in caring for critically ill people. This work can break your heart.

  I began to understand something about these boundaries one night a few years ago during a hockey game. It was the Stanley Cup playoffs, in a match between the Toronto Maple Leafs and the Detroit Red Wings. A Detroit player slammed into Maple Leafs goalie Curtis “Cujo” Joseph, who got angry and hit back. Well, the gloves came off and the punches started flying. The referees had to pry the players apart to end the brawl. Then, when they must have assumed the camera was off, Cujo lifted his goalie mask (that depicted a ferocious beast) and mouthed to his rival, “You okay?” The opponent nodded and pointed with his chin, “You?” Seeing that tender, sincere moment helped me understand something about nursing, the place to which for me, all roads lead. Not that I ever saw myself as an adversary with any of my patients – not at all – but it is so easy to imagine that the gap between them, the sick ones, and us, the healthy ones, is much vaster than it is. Sometimes I took off my mask, too, and went over to the other side. But in my need for intimacy and my desire to rescue others, I often took on patients’ emotions in ways that helped neither of us.

  For many years, I took off my mask and crossed over frequently and sloppily. Perhaps it was how I learned as a child to care for my mother by sharing her sadness. I showed her my love by feeling her pain. Growing up, my personal boundaries were always uncertain. So often, my own emotions blended and mixed with whatever others around me were experiencing. When I became a nurse, I continued on in that style of caring, even though it made things worse for me and sometimes for my patients, too. They needed to feel that I was steady and in control, but I couldn’t always offer them that security. I caught their emotions as if they were contagious. Sometimes, merely being in the presence of a patient, family member, or even another nurse, who was flustered, anxious, or angry would affect me, and I would respond in tandem. Patients may even have felt they had to take care of me. Too often, I was a gushing, emoting heart that rendered me less effective as a nurse. Nurses are supposed to keep their emotions under control, but it’s been a struggle for me.

  WHEN I THINK OF Mr. Salvatore, I think of his daughter, Yvette. Mr. Salvatore was a seventy-two-year-old with esophageal cancer who developed abscesses throughout his abdomen. The doctors were hopeful that they could drain them and that he would then be well enough to undergo surgery to remove the cancer. In the meantime, he went into respiratory failure and had to be admitted to the icu. Every day Yvette stayed at his side. She kept her eyes locked on me the whole time, watching every move I made. When I went to suction his lungs, she leaped out of her chair. “Should I panic?” she asked, searching my face for clues as to how she should react.

  “No need to panic,” I said extra calmly and slowly. “Your dad is doing just fine.”

  “Look, Daddy, your nurse is smiling. She wouldn’t smile if things weren’t looking good.”

  Yvette asked me if she could go home for a little rest. I knew she wanted my reassurance that nothing bad would happen while she was away from her father’s side. With her eyes she implored me, I need to rest, shower, see my kids. Please grant me permission to do so. I wanted to tell her to go home and take care of herself but I didn’t dare. If something did happen while she was gone, she would never forgive me. She left briefly only for a coffee and a phone call. “Take good care of him while I’m gone,” she pleaded, throwing kisses at her father as she left. “He’s special. He’s my dad.”

  Later that afternoon, when Mr. Salvatore’s heart suddenly went into an erratic rhythm, Yvette was right there at his side. When the alarm sounded, she grabbed my arm. “I’m panicking!” she shouted. I tried to calm her down and deal with the emergency at the same time. The doctor came in and ordered an intravenous beta-blocker to slow the heart rate. Shortly after I gave it, Mr. Salvatore’s cardiac problem was resolved, but no amount of reassurance I offered eased his daughter’s anxiety. Later that day, Mr. Salvatore had to be transported to another part of the hospital for the radiologist to drain the abscesses in his belly.

  “Is this reason to panic?” Yvette asked, clasping my hand. In answer, I put one arm around her and pushed the bed along with my other hand as we made our way down the hall to the procedure room. There, the radiologist met with her and told her that if the “collections” turned out not to be fluid-filled then he wouldn’t be able to drain them. “In that case, I can’t do anything,” he said as the technician spread out a green sterile drape over the patient’s abdomen in preparation for the procedure.

  “What does that mean?” she asked him. “Does that mean it’s serious?”

  “It means I can’t drain it,” the doctor said without further elaboration. Draining abscesses under fluoroscopy was his specialty, but for whatever reason he didn’t explain that if there wasn’t fluid to be drained, then it was probably a solid mass, such as a tumour, and in this case, likely malignant. But Yvette sensed the ominous implication. “Are you saying it would be bad?” The radiologist was preoccupied, already in the midst of the procedure, so she turned back to me, but I was busy giving her father sedation and assisting the doctor with the procedure. Out of the corner of my eye, I saw her terror-stricken face, her tiny, rigid body that looked like it might snap in two. She held on to her pale forehead. “I’m panicking,” she said in a tremulous voice. I looked around the room for a chair and luckily, just then, the technician caught her as she keeled over. Fullblown panic had finally done her in, but at least it allowed me to now focus my attention on taking care of her father. I exhaled. I hadn’t realized how shallow my breathing had become, how tight my chest was, how jittery I felt. I had caught a bad case of her panic.

  I’VE WORKED WITH Noreen for the pas
t ten years or so. She has a tough, abrasive personality and often has a sour look of disapproval on her face, but I have learned to ignore it because she’s really very kind-hearted and an excellent nurse. Noreen is someone who always seems to have her emotions under control, even the day she took care of a patient whose family pushed her to the limit.

  Loud and clear we all heard a terrible drama playing out in the corner room. A young man had been brought to the ICU in fulminant liver failure, a life-threatening consequence from the anabolic steroids he’d been taking for bodybuilding. The waiting room was jampacked with visitors, all wanting to see him, so many that they spilled out into the hall.

  “Are all those people family?” someone asked Noreen, who was his nurse that day. “There are cans of Coke and bags of potato chips everywhere and they reek of cigarettes and alcohol. You should inform them that only two visitors at a time are allowed and they have to call in first.”

  “To me, family is whoever they say they are,” Noreen said in her matter-of-fact manner. “As far as I’m concerned, they can come in whenever they want. The kid is going to die.”

  On one side of the bed, a slim teenaged girl wearing a doo rag and tattered jeans was doubled over, sobbing. On the other side, sat an older woman wearing a dress that draped her body like a tent. “That’s the girlfriend and that’s the mother,” Noreen whispered. I had heard vicious screaming going on and had come over to give Noreen a hand, but she didn’t seem to need my help.

  “You just want a piece of him,” the mother shouted at the girl, “you fuckin’ whore!”

  Noreen stood at the foot of the bed, a bit closer to the girlfriend. “Now, now,” she clucked. “Keasha loves him, too.”

  “Yeah, right,” the mother snarled. “Jerome has lots of chicks and this here bitch is only one of ’em. He’s my boy. I want her the hell out of here.” She lunged across the bed to take a swing at Keasha, but Noreen grabbed her arm and stopped her in time. “You better control yourself, or you’ll have to leave.” She pulled up a chair for Keasha, who smiled sweetly but then retaliated in an equally nasty manner. “I hate you,” she screamed at the mother, “and Jerome hates you, too. He told me so.”

  “That’s enough,” Noreen snapped, but then softened. “Easy does it, sweetie. Take a deep breath. Think before you speak.”

  “Alls I wanted to do was wipe his forehead, but she,” Keasha glared across the bed at the mother, “slapped my hand.” She turned to the safety of Noreen. “Something like this has never happened to me before.” She fell onto Noreen and cried into her shoulder. “I never had a sick boyfriend.”

  “Of course not, you’re still a baby,” Noreen put her arm around her, and held her close, comforting her the way a mother would her child. “You’re so young to have to go through this.”

  “It’s not her going through this, it’s Jerome,” the mother said, pointing at her son, who was completely unconscious and unaware of the storm taking place, literally, over his body. “A piece of work like her’ll get herself another boyfriend, but I’ll never get myself another son.” She caressed his arm.

  “Jerome’s going to make it,” Keasha said. “You’ve given up on him.”

  “You’re nothing but a fuckin’ ho!” shouted the mother, gripping the side rails of the bed and hauling herself to her feet. “You have no right to even be here.”

  “Yes, I do, you bitch!” The girlfriend lunged at her neck, but Noreen held her back. “We’re getting married,” she held up her hand to reveal a ring with a blue stone in it. “Jerome loves me. He told me how you abused him and screwed up his life.”

  Noreen stared at them over the top of her bifocals. “Both of you are disturbing my patient. Now, you better show respect for Jerome. He’s the focus here. Get a grip or get out!”

  “You can’t get rid of me. I’m his mother.” She settled back down into the chair and crossed her arms across her chest.

  The war continued all day. It was ugly and unrelenting, but it didn’t flap Noreen in the least. She focused on caring for her patient in her usual calm, methodical manner and on supporting all members of the family as best she could. Meanwhile, Jerome’s condition was deteriorating. He began to vomit blood and suddenly had a seizure that deepened his coma. His blood pressure was dropping and the Ph, oxygen, carbon dioxide, and bicarbonate levels in his arterial blood gases began to reach dangerously abnormal amounts, indicating that he was near death.

  “Jerome is dying,” the liver specialists told them. “There is nothing more we can do. His liver has been damaged beyond repair and unfortunately he is too sick to be listed for a transplant. We are very sorry.” Then they left.

  This news made the mother and girlfriend even more violent. They lunged at each other. The girl scratched the mother’s face and neck. The mother yanked the girl’s hair. Noreen sprang into action. “That’s it! Get out, the two of you! Take it outside. I’m calling security.” But before they could arrive, the mother stomped out of the ICU and Keasha fled to the waiting room. Noreen looked at me with the same exasperated expression I had seen on her face at the behaviour of her own teenaged kids. Otherwise, as far as I could tell, she remained unperturbed by the chaos swirling around her, steadfast in the face of the impending, inevitable tragedy. She was a calm centre around which the two of them could safely rage.

  The problem was, you weren’t supposed to speak like this to patients. The scripts we had been taught as students, the stock phrases and prescribed responses we were supposed to offer, such as “you seem angry,” “what are your concerns?” or “what is this situation like for you?” were inadequate for many of the extreme situations we encountered in the icu. Noreen spoke to this family in the same way I’d heard her speak to her own kids when they misbehaved. She tried to bring them into line. She scolded them. She took a stand and called them on their bad behaviour. She used her own pragmatic personality and no-nonsense, straight-talking manner to nurse this family, and it seemed the perfect way to handle the situation.

  Later that day, Jerome had a cardiac arrest and no further resuscitation efforts were attempted. His mother and his girlfriend had no more energy to expend on their anger, as they were forced to expend it on their grief. Noreen removed all of the tubes, IVs, machines, and pieces of equipment attached to Jerome and then she bathed his body thoroughly and put fresh sheets on the bed. Then she brought his mother and girlfriend back into the room, along with other members of the family, and allowed them to be with his body for as long as they wished. Noreen stayed strong and silent amidst the room full of mourners who were wailing and pulling at their hair and clothing in their anguish. Other nurses came over to offer their support, as well, but I had my patient to get back to and my own work to do. I got busy and didn’t think any more about them.

  At the end of the shift, I found Noreen sitting on the bench in the locker room, sobbing uncontrollably. She apologized for her emotions. “I guess I got too involved.” She wiped her face and stood up. “I don’t know what happened. I usually never let myself go there.” I waited while she slowly put on her coat. We were planning to meet up with a few other nurses for drinks, but Noreen bowed out. She said she was tired and was going home instead.

  YES, I’LL ADMIT IT: certain patients still crank me up, especially the angry, distrustful ones or the combative, hostile ones. I feel more comfortable around patients who are sad or depressed, perhaps because those emotions are more familiar to me. Expressions of emotion from the nurse mean a lot to families. When I cry with them, they appreciate that I share their grief. Sometimes it seems to matter more to families how sympathetic I am than how skilled I am. When they see how hard it is for us, too, somehow it lightens their burden.

  Patients expect nurses, and nurses expect themselves, to make every effort to see, feel, and understand a patient’s experiences. But all too often, when I did that, I became overwhelmed with someone else’s sorrows. I lost myself. I came to realize that I wasn’t going to be able to stay in this profession if
I didn’t change my ways. I had to learn how to safely enter a patient’s world and still keep mine intact.

  We once had a social worker who came up with the idea that the nurses should make more of an effort to attend patients’ memorial services, to stay in touch with grieving families, send them sympathy cards, and even pay them visits in their homes to help them find “closure.” I wasn’t the only nurse who felt uneasy with this plan.

  “Don’t include me in on that,” one nurse told her sharply. “Some of us need to make a separation. Most of us do.”

  The social worker looked even more dismayed when I expressed my opinion that some families might not wish to have any reminders of the ICU if their loved one had died there. She seemed to consider anything less than a full, emotional demonstration, replete with weeping and moaning, to be cold and callous. She would sit with families and commiserate with them about every setback. She told them about her own problems. She had such demonstrably personal reactions to patients, especially select ones who suffered from diseases her own friends and family members had lived through, such as HIV and psychiatric illnesses. But who was I to judge? I had my own weaknesses. I always broke down when children came into the ICU to say goodbye to grandparents, or even parents. When one little boy said to his mom, “It doesn’t look like Daddy on the outside, but it’s still Daddy on the inside, isn’t it?” well, I lost it altogether. Once, when I found a clipboard with the one word perché? which I knew was “why?” in Italian, scribbled by a dying old man, I burst into tears.

  For a time I thought that perhaps the way to counterbalance my emotional nature would be to hold myself back. What would happen, I asked myself, if I didn’t try to connect personally with each and every patient and family? I would give correct, safe care, of course, but maintain a dispassionate stance and keep my guard up. I would not take off my mask and go over to the other side. After all, didn’t Laura always say you didn’t have to get to know your patient in order to give good care? What about Frances, who always gave so much of herself but never let her emotions get out of control? “When you come to work,” she told me on many occasions, “leave yourself at the door.” She believed it was her function to ensure her patient’s well-being. “I treat all my patients as if they’re members of my family,” she explained to me. But still, how did she do it, I wondered?