by Tilda Shalof
Justine was a nurse who willingly took on emotional risks, but eventually it got the better of her, and I think it was the reason she ended up leaving the ICU. She once was furious at a family that never visited their grandmother, yet kept calling to insist that “everything be done” to resuscitate her. Justine hung up the phone on them and returned to her patient. She looked down at the frail old woman, pushed the machines aside, parted the tubes and lines with her hands, crawled right into the bed and lay down beside her. I can still see that lady’s soft white hair and Justine cradling her in her strong arms and rocking her like a baby.
My problem was that I got into too many patients’ beds! I felt their despair. I worried along with the family. At times, I even took their pain home with me. I decided to make that conscious effort to hold back, not let myself feel too much. I kept focused on numbers and facts and didn’t make myself as readily available for patients to tell me their stories. I lasted about a week. I had made such a complete disconnect from feelings that my actions began to feel empty and meaningless. Caring for patients became drudgery and every task a chore. Without emotions to fuel me there was only logic and reasoning to figure out what was needed and my sense of duty to carry it through. I couldn’t find a balance between my emotional nature and the rational thinking required to be a nurse. There had to be an alternative to losing myself or else keeping strictly within the confines of my nursing role, as if it were part of my uniform. I knew that only by bringing those two sides together could I be the nurse I wanted to be.
Many nurses struggle with the emotional stress of our work, yet rarely talk about it. I have long suspected that burn-out and the disproportionately high rates of smoking, drinking, substance abuse, and depression among nurses, and the high numbers of sick days that nurses are known to experience aren’t entirely due to the physical demands of our work, yet there are plenty of those. But I have always recovered from the sore backs caused by lifting heavy patients and the headaches after a stretch of night shifts. I’ve even had needlestick injuries that caused me worry for weeks, but that fortunately didn’t cause serious harm. Once, I was splashed in the face by spray from a ventilator accidentally disconnected from a patient with hepatitis C. Droplets of sputum melted in my eyes as I yelled, “Cover for me!” and ran out. Laura was there and she grabbed a bottle of sterile saline, clamped my eyelids open, and poured the whole bottle of fluid into my eyes, drenching me all over. I worried for weeks, but as it turned out, I didn’t get infected, after all.
It seems that almost every nurse has a war story or two.
Casey recently reported an ailment that was serious, but in her telling, at least, fairly amusing. We were sitting at the nurses’ station late one night when she launched into her latest drama. “I swear, I had the worst diarrhea of my life after taking care of that patient with C. diff.* This place is such a cesspool we should wash our hands before going to the bathroom. I was shitting myself, literally. There were no safe farts. I had only to hold the little specimen bottle over my butthole to give the doctor a sample, can you picture this?”
Unfortunately, I could, yet Casey felt it necessary to enact a pantomime with an empty Styrofoam cup before continuing on with her rant. “The manager called to challenge me about my sick time. The nerve of her to imply that I would take advantage of the system!”
It was lucky for her that Monica was not on that night, as she also would have taken her to task about her sick time. Monica was a nurse with keen ambitions and vowed when she was manager of an ICU, she would crack down on malingerers and abusers of the system. But how was she going to distinguish between those individuals (if there were such fraudulent claims) and all the legitimate complaints such as Casey’s? Every one of us had to some degree or another experienced the real hazards of our work. We knew that most nurses’ sick time was but a partial compensation for taking the brunt of only some of the very real risks of this work.
I SPENT MANY YEARS searching for my way of being a nurse. It’s only been in recent years that I’ve learned how to take off my mask and not strip off my entire uniform along with it. Because if becoming a nurse has taught me one thing, it was that there are a lot more helpful things to offer a person than feel their pain. As a nurse there is so much you can do for people.
I took care of Evelyn McDermott many times during her long stay with us and got to know her and her family well. I’d always noticed how some families adorn patients’ rooms with beautiful objects, messages, letters, signs, pictures, and photographs. Mrs. McDermott’s three sons and her daughter, Carly, went beyond mere decoration. They transformed the entire room into a celebration of their mother. They covered the walls with photographs and a huge sign that announced: “Thank you to all of my care-givers.” Through the stories the children told, and the ones revealed by the photographs, I got to know Evelyn McDermott as a woman and as their mother.
She was a single mom who’d raised her children on her own, a hockey mom, a master bridge teacher, superb baker, generous friend, and marathon runner – up until she got lung cancer. As a mother she had recognized and nurtured the talents and abilities of each of her children, especially the one son, a gifted athlete who became a professional baseball player.
“Too bad you didn’t know my mom,” her daughter, Carly, said. “I mean before she got sick.”
“I am getting to know her,” I said, “through you and your brothers.”
Carly smiled. It was true. They were a lovely family and everyone enjoyed taking care of them. We cut them a lot more slack than most other families, letting them come and go as they pleased, even letting them participate in daily rounds and view their mother’s X-rays and lab reports. One day, Carly went around the ICU and placed a small bar of Godiva chocolate beside each nurse’s computer. On the label was a picture of a Florentine-style angel. There was something about this family’s love for their mother that brought out the angelic in all of us who had the privilege of caring for them.
Around the clock, either Carly or one of her brothers was at their mother’s side, spelling off the others so that everyone could get some rest. They became skilled at interpreting medical information and knew exactly what each test result meant and what each waveform on the monitor signified. A tiny improvement in the numbers made them rejoice. They sank back down again with each and every setback, big or small. They wanted to help with their mother’s care and most nurses made that possible for them, but some had a harder time giving up control over the way things were done and handing over their responsibilities to the family.
When the time came to choose whether to opt for yet another surgery, the family did their homework. They went on the Internet and became thoroughly knowledgeable about the options. They deliberated for many days, weighing the pros and cons. It was a difficult decision because, as the surgeon explained, without this surgery she would die, but even with it, he admitted, she might die. During rounds, the eldest son said to the staff doctor. “We want to ask you something.”
“Sure, shoot,” said the doctor cheerfully.
I looked at the son’s face and knew what he was about to ask. No, please, not that question, I prayed silently. But I could see it coming and there was no way to stop it.
“What would you do if this were your mother?”
Your mother, your father. It’s the most telling, the most provocative, potentially the most truth-extracting question of all. I watched the sharp, jutting angle of the doctor’s Adam’s apple sink deep into his neck. He swallowed hard and looked down at his shoes. What the family couldn’t possibly know, but I knew, was that this doctor’s own mother had died from breast cancer, just a few weeks ago. He was mourning the loss of his own mother at the same time as he was being called upon to show empathy for the possibility of this family’s losing theirs. Of course he did not mention his private grief, nor reveal his own feelings in any way. “It’s completely your decision,” he said, putting the responsibility squarely back on their shoulders and launched
once again into the various choices before them.
“We need our mother to be well,” Carly implored him. “Help us make the right decision.”
His eyes showed concern. He swallowed again. He didn’t speak. I think he couldn’t.
“She must get better. She’s our mother,” Carly offered by way of explanation for her “demanding behaviour.” “Can you understand how we feel?”
He nodded and cleared his throat a few times, as if something was lodged there. He patted her gently on the arm and then moved to the next room, pushing along the portable computer that we use to display X-rays and lab reports during morning rounds.
The McDermott family chose to go ahead with the surgery and Evelyn improved rapidly, but became dependent on the ventilator for a long time afterward, now breathing through a tracheostomy – an opening in her neck. I was her nurse on the first day she was strong enough to take a few steps by herself. That day we also closed off her trach for a few minutes with a cork and that allowed her to finally speak. I was reminded once again how startlingly intimate and personal it is to hear a patient’s voice for the first time. At first it was raspy and hoarse, but later in the day, when we corked her trach again, she conversed more freely, even cracking a few jokes. She gave me her prized secret recipe for her signature cake that oddly enough called for a can of 7-Up. Carly and I found a lot in common and exchanged e-mail addresses so we could keep in touch once her mother went home.
How false it would have felt to stay within the limitations of my strictly professional role with this family. How much I would have missed! I was responding to them as personally as I was professionally. I was their nurse, but I was also interacting with them like their friend. I couldn’t help myself because I liked them and knew so well what it was like to be the daughter of a sick mother.
Later that day when I saw that Evelyn was tiring, but reluctant to rest and possibly disappoint Carly, I intervened. “Evelyn, you can close your eyes now and do your work while I do mine.”
She looked relieved, but asked, “What’s my work?”
“Breathing. Resting,” I said.
Later, Carly wanted to bathe her mother and give her a back rub and I set up a basin, towels, and everything they would need for her to do so and gave them privacy. The nurses had even taught Carly how to suction her mother and clean her tracheostomy site and she did that, too. I wanted to caution Carly to slow down and pace herself. There was still a long haul ahead and plenty of time to do more, but she told me that her mother was not a burden. “I love taking care of her,” she said. “I love her. I love her body. We’ll take her home in any condition.” Carly showed no signs of faltering. The more she did for her mother, the more she wanted to do. Every act was motivated by pure love and I was in awe of this mother and daughter, because to me that bond has always been a mystery. “Mom, you’ve just got to get better! I’m watching over you and I won’t let anything bad happen,” Carly promised. She covered her mother with a quilt she had made and sat beside her to watch a movie.
There was something else happening here and I knew it. Carly was the youngest, with three older brothers, just like me. She was the same age as me and had two young sons as I do. She loved the same books I did and also made quilts in her spare time, as I do. She did Sudoku puzzles to calm her mind; I did them too, for the same reason. She gave devoted, whole-hearted, loving care to her sick mother and I – well, there the similarities ended, but I enjoyed being in the presence of the two of them loving each other.
Complications set in. Evelyn spiked a high temperature. Infection developed and the surgeon came to take her back to the operating room. “She will die without this surgery,” he said, handing a pen and consent form to Carly to sign. This time she had no hesitation. “I always told Mom that if you want to live, I will help to enhance your life in every way I can. If you decide you want to die, we accept that and we’ll help ease your way out. So far, she keeps giving us the sign that she wants to fight.”
Once again, Evelyn recovered. Day by day she improved. One afternoon, I spent time talking with Carly, her mother too weak to do much more than nod at us from time to time and hold Carly’s hand. I put the radio close to her bed and she and her daughter sat there, listening to the baseball game and cheering for her son, Carly’s brother’s team. At the end of the day I got ready to leave and Carly came over to hug me. She told me that my strength that day had helped her to be strong. She whispered that she didn’t want me to go, but said it genuinely, not as some families did to cast aspersion on other nurses. I said goodbye and when I looked back, I saw them sitting together, absorbed in the game.
Sometimes it is only the clock that frees me at the end of my shift; it allows me to put a limit, or a boundary, around my caring. Without it, I might not know to stop. I gave my report to the night nurse. I walked out the door and began to release all that I had seen and felt from my mind and from my body. I fell into my reliable ritual that liberates me from Planet icu. I start by swinging my now-empty lunch bag as I call out goodbye to my friends. I trudge up the stairs to the locker room, always at a slower pace than when I started the shift and tripped down those same stairs long ago, that morning. I hang up my stethoscope and lab coat in my locker. Bundle up my dirty uniform and bang the locker door shut with my foot. Glance in the mirror over the sink as I sail past. Waiting for the elevator, I think about dinner, trying to decide if I will go through with the complicated mushroom risotto that I bought all the ingredients for (it has to be stirred and stirred over the heat until the moment it is served) or if I’m too impatient for that and will pop a frozen pizza in the oven. I push the revolving hospital door and inhale the city air as I step back out onto Planet Earth. By the time I’m on the subway, riding home, I have begun to re-acquaint myself with thoughts of my own family. By then I have put the McDermott family completely out of my mind. It’s what I have to do.
So I was completely unprepared for what happened a few days later. I was on a day off and was at home reading the morning newspaper. I rarely read the sports section, but something there caught my eye. It was a half-page article with a photograph. The mother of a baseball player had died suddenly, unexpectedly at a Toronto hospital. She had been the team mother and mascot and the players had been rooting for her recovery. It was Evelyn McDermott. How could it be? She was doing so well. What had I missed? I seized the phone and called the icu. I spoke with the nurse who had taken over from me that day. She told me about the arrest that occurred a few hours after I’d left. They’d worked on her until three o’clock in the morning. Everyone was there, the baseball star son arriving straight from his game.
“I’d never seen anything like it, Tilda. The family was right there and shouting at us the whole time. ‘Do more compressions! Shock her again! Go up on the inotropes! Don’t stop.’ It was as if they were calling the code. When we finally stopped, she died immediately and we didn’t even have to tell them. They knew. They knew in a way they wouldn’t have if we’d kept them out. They had to see for themselves that everything was being done and what everything being done looked like.”
Then the doctor came on the phone, the one who had been there that day and all that night, too. He also felt unsettled about such an unexpected death. The autopsy report had not provided any concrete answers, only that there was nothing obvious we had missed. I hung up the phone and sat back. What did I feel? Two things: very sorry for their loss and genuinely proud of the care I had given. I have come to accept that this is the emotional cost for the privilege of doing this work. The price is steep, but I am prepared to pay it. To me, it’s worth it.
The funeral, the nurse had told me, was that very day. A few of the nurses were going, and they asked if I wanted to join them. “No thanks,” I said. I rarely went to patients’ funerals, wakes, shivas, or visitations, even though there were times I was tempted and this was surely one of them. So, what did I do? I stayed home and wrote it all down. It’s my way of remembering, of honouring.
9
THE PROPER USE OF THE F-WORD
As one of the few Jewish nurses where I work, I am often called upon to explain the religious rituals and laws that affect the care of our Jewish patients. The others realize I’m not an Orthodox Jew (unorthodox is more like it) but they still turn to me to answer their questions. I am usually out of my depth and have to run off to consult with an authoritative source, but the questions keep coming at me: What is the significance of the number eighteen? What is a bar mitzvah? Why, when a Jewish patient dies, is it necessary for someone to stay with the body at all times?* In turn, I have asked Muslims about the Koran, their prayers, and their halal foods, and Buddhists about their rituals and philosophy, as well as Christians, Catholics, Hindus, Zoroastrians, about theirs. Nowhere do religious beliefs come up more than in situations of life and death – especially death.
In our morning rounds in the ICU we often discuss the many ethical dilemmas that arise from our work. We usually discuss these matters as if they were strictly based on science and ethical principles, but often I think they come down to religion and values: what people believe and what they hold dear. And when that’s the case, I’ve learned to back right off. If I do have an opinion, I keep it to myself. I have worked hard not to allow my personal values to affect the care I give my patients. Yet, other nurses find ways to use their religious beliefs in therapeutic ways.