The Making of a Nurse

by Tilda Shalof

  A NURSE CALLED from the floor one day and I happened to answer the phone. “There’s a patient here named Mr. Robichaud who wants you to pay him a visit,” she said. “He’s doing great after his liver transplant, but he says he has some concerns.”

  “Me? I didn’t take care of a Mr. Robichaud.”

  “He says any nurse will do. He has questions about his stay in the ICU.”

  I volunteered to go and another nurse took over my patient while I went to the seventh floor.

  “I hear they drugged me,” said a wan, worried-looking man in his forties, after I introduced myself. “I lost eight whole days of my life.”

  “Yes, it must feel like that,” I said. “Pain medication was given to you after the surgery. Some of those drugs make you lose your memory for those events, others can distort your thinking.”

  “Yeah, I can’t remember what happened there. I was terrified. All I could think of was if this is my life now, I want to end it. The clock moved so slowly. I couldn’t talk and always felt like I was choking because of the tube in my mouth. I panicked when I couldn’t see the nurse. Most were nice, but there were a few who were rough.”

  “I am sorry to hear that,” I said quietly.

  “But why did they dope me up so much?”

  “You were probably in discomfort or pain,” I explained, but then tried a different tack. “What do you feel you missed?”

  He thought for a moment. “My wife bought the kids a puppy and there was a hurricane in New Orleans …” He was incredulous that the world had gone on in his absence. “Wait, there’s more …”

  “Yes? Tell me.”

  “The morning of my transplant, before I even knew there was a liver for me, I sensed something. The nurses moved differently. They kept stepping out of my room to whisper to each other. The day before, I had been given a meal tray, but that morning, nothing, with no explanation. Hardly anyone spoke to me and when they did it was with these bright, overly cheerful expressions pasted on their faces as if they had a secret.” He gave a weak chuckle. “Oh, they had a secret all right. But I didn’t dare ask what it was. I had been carrying a pager for two years. One time it went off, but it was a wrong number and that sent me into a tailspin. I’m ashamed to admit how long I’d been praying for some young, healthy person to die. If it was going to happen anyway, why not for me? I was hoping for a car crash, headlong collision preferably, so that the vital internal organs would still be intact.” He paused and I sat there until he was ready to say more. “I’ve always been a light drinker, on social occasions only, or a glass of wine at dinner – doesn’t everyone? Haven’t done drugs for years, but how I got hepatitis – I have no idea. They say it’s idiopathic – no known cause.”

  “It seems like you are remembering a lot more.”

  “But not my eight days in the ICU. I’ve lost all of that.” We sat there together for a long while until he spoke again. “I am very grateful for this new chance at life, but it still bothers me what I missed. I’d like to know what happened in the ICU. I have nightmares about it.”

  “Would it help to visit the ICU?” He nodded eagerly and reached for his dressing gown. Since he was still too weak to walk, I found a wheelchair. As soon as I pressed the metal button to mechanically open the doors of the ICU, he recoiled and covered his eyes with his hands. What was it, I asked, the mere glimpse of the place? The noise? The smells? “Yes, all of those things,” he said. “I remember now – too much. Please take me back to my room.”

  WE SO SELDOM SEE the results of our efforts and no matter what we do to ameliorate the experience, no matter how hard we try to bring about some measure of comfort, the bottom line is that no one wants to be here. It’s perfectly understandable that most patients wouldn’t want to return to the scene of their pain and suffering. However, it is very sweet when patients do come to visit us, often looking so well that we hardly recognize them. I think of them like soldiers returning from the war, a little stunned and still shaken, but grateful to have survived a mighty battle. We gather around them, keeping a respectful distance and listening to their testimonies.

  SOME PATIENTS got better so fast! I had a patient who had a lung transplant and the next morning we extubated her and by that afternoon, she was sitting up in a chair taking sips of water. “You’re making amazing progress,” I told her.

  “It’s because I prayed so hard,” she explained. “That’s the reason I got the lungs so fast. I was only on the list for five days.” She put her feet up on the little stool I brought for her and rearranged the blanket over her knees.

  “Mmm,” I said, trying hard to keep my mind open to what she was saying.

  “My doctor said it was a perfect match and everything went smoothly in the operating room. It’s because we prayed so much. The whole church prayed for me.”

  “But what about patients who also pray, just as you did, but things don’t go as well for them?”

  “They must have lost their faith. They’ve slipped and wavered or maybe didn’t pray hard enough. That’s not to say my husband and I are perfect,” she admitted. “We’re sinners, too.”

  WE WERE ALMOST at the end of a shift when we got a call from the critical care dispatch centre saying that they were sending us a patient. We raced to prepare the room for someone about whom we knew very little. The mother arrived first, always a bad sign: the patient was likely someone young. She was a nineteen-year-old girl in shock, unconscious, and in fulminant liver failure. We moved her onto the bed, hooked her up to the monitors and the ventilator. Her blood pressure was dangerously low and her lungs were filled with fluid. She was in a coma and bleeding everywhere as her liver had completely stopped working and was unable to produce essential clotting factors. Her mother stood there, gripping a jug of her daughter’s urine. She told us her daughter had been out at an all-night rave, had come home that morning and seemed fine. She went to sleep, but didn’t get up for her job at the music store in the afternoon, and her mother couldn’t wake her. The doctor took her aside and explained that her daughter’s liver had inexplicably shut down and that if we could manage to stabilize her condition, we might be able to put her on the transplant list and wait for an organ. He could not tell at this time what caused the liver failure. As the doctor spoke, the mother kept her eyes on us, watching us work on her daughter. I saw her hand move to the place on her own body, feel for it and press in. I read her thoughts: she was ready, at that very moment, to offer up her own liver, if she could.

  I finished that shift and then was off work for the next few days. I made a point of not calling in to find out how she was doing, as I sometimes did. It’s enough, I told myself. I have to make that separation. There’s a limit to how much I can care – isn’t there? But on the next shift, I came in early. If she was still alive, I wanted to be her nurse. I looked to her room. There was a Korean man in her place. Had they moved her to another room? I flipped through the patient logbook. Ms. Celeste Alaya – Transferred to General Medicine. The floor? Impossible! How could she have progressed from being critically ill to going home in just three days? Perhaps she had been sent to the floor to die? Sometimes the floor nurses were more able to provide palliative care in a private room than we were in the icu. I saw the resident who had been on that evening. “What happened to that young girl in liver failure?” I pointed at the room where she had been.

  He thought for a moment. “Oh, her? She got better. We transferred her out.” His gaze returned to his computer and he scrolled down to something on the screen.

  “What was it? An overdose? Did she ingest something weird? Was it hepatitis or an infection from her body piercings? Was it a tropical disease from her trip to Jamaica?”

  “No … we never actually arrived at a definitive diagnosis.”

  “What made her better? Dialysis? Plasmapheresis? Antibiotics?”

  “Nothing in particular. None of that.” He shrugged a shoulder. “I guess it was Tincture of Time. You know, old Mother Nature.” He look
ed off into space. “And nursing care.”

  Everyone needed a diagnosis, didn’t they?

  I had to see for myself. I raced up to the floor. The curtain was closed around the bed and her mother was packing a suitcase. A pretty young woman pulled open the curtain. “Who’s there, Ma?” She was zipping up her jeans and jiving to a beat on her iPod.

  So, here was another mystery. Just as people could get inexplicably sick, they could also get inexplicably well. But did there have to be a miraculous recovery in order to have the heart uplifted and warmed? Some of the most tragic losses I have witnessed were inspiring for reasons other than recoveries. It’s easy to get excited about success.

  A fit young woman, a mother of two, was running a marathon when she dropped to her knees. She was brought to us, deeply unresponsive, her pupils barely reactive to light. We put her on a heart-lung machine* to oxygenate her blood outside of her body because her lungs couldn’t fulfill that function and her heart was so damaged it could not pump adequately. Her blood pressure plummeted despite the maximum dosages of the drugs we gave her. Then, two days later, when she was off ECMO, we took her for an MRI† scan and saw that her brain had become so swollen it bulged down into her spinal cord. She was irretrievable and the doctors deemed further medical treatment to be futile.

  As all that was happening, her mother, who lived in England, was flying on a plane to be with her daughter. She arrived during the night and I brought her directly into the icu, straight to her daughter’s bed. The mother took her hand and stood for a long time, taking in the sight of the swollen, motionless body attached to machines whose dancing lines and beeping alarms made it seem more alive than the patient. “Oh, Cat,” she moaned, as if her daughter were a little girl, merely misbehaving. Then she turned to me and said, “My Catherine is dead. I see that.” She did not want to speak to a doctor or be shown the results of the MRI to prove what she knew as a mother. “I thought it through all the way on the plane,” she said softly, “and I accept it. My Cat is gone.” We stood together and I felt the vast understanding between us that, although miraculous recoveries were possible, there was no miracle to be had here. I pulled up two chairs and we sat together. After a long while, she spoke. “I want everything turned off.” She waved away the machines around her daughter. “I want Cat released from all of this.”

  “It’s only been forty-eight hours,” I said. “The doctor wants to speak with you in the morning.”

  We’re doing this for the doctors?” She smiled as if she pitied them for their inadequate understanding of a mother. “Has a person in this condition ever recovered?”

  I didn’t answer her because I felt she had arrived at her own conclusions, but the thought of having to wait for what she saw as a formality disturbed this otherwise imperturbable mother. “What is the effect on her spirit to be kept in this state of suspension, this limbo between life and death, sustained on chemicals and machines?” Her voice choked and she paused to collect and contain herself. “Anyone can see she’s dead. I could hold on to her with my love. You could keep her here with your machines, but it’s beyond all of us now. It’s out of our hands and I accept it.” She, who had much more at stake, was more prepared to let go than we were. “I will cremate her body and scatter the ashes in Georgian Bay, where we spent every summer. Yes, I’m ready. You can turn everything off.”

  I was in awe of her, her love and her ability to let go. I thought about what I should do.

  “Are you telling me that a mother has to wait for a doctor to discharge his legal duty before her daughter can die?” she said in disbelief, trying to reconcile with a situation that confounded her. “What about organ donation? Can Cat donate her organs? She would have wanted that.”

  Her huge generosity of spirit at a time like this was astounding, but we were entering tricky and uncharted waters. Brain death was the criterion for organ donation, not cardiac death and technically speaking, Catherine’s brain was not completely dead. She still took the occasional breaths, there was a flicker of a primitive reflex in her limbs. Yes, Catherine was surely dead, if not for the life support she was on, but she was not legally or medically brain-dead. “You can donate her tissues and bones after the machines are turned off,” I explained, “but not her organs.”

  I called the staff doctor at home. Indeed, why should she have to wait if this was her belief in the face of incontrovertible medical facts that were documented and not in dispute? He agreed with me and regretted the fact that she did not qualify to be an organ donor. We could sympathize with how donating her daughter’s organs could bring some redemption to an otherwise inexplicable, tragic event, but it was legally unprecedented. I returned to the mother and sat with her as she meditated or perhaps prayed. When she indicated to me that she was ready, I got up and turned off each machine, pump, and monitor, one by one, until there was silence.

  AT HOME, in my spare time, I was busy making my own quilts. Lots of colourful, slapdash, mismatched, imperfect ones made from bits and pieces of flannel baby blankets (precious stains long washed out), bits of souvenir T-shirts and cut up pieces of my husband’s shirts* sewed into the mix. One night, I lay one of these quilts over my son Max as he was falling asleep. “How does that feel, sweetie?” I tucked it in all around him. “It feels like God,” he said.

  The nurses’ quilt squares started coming in. There were the four seasons depicted in sequins and paint; dolls with different-coloured skins dressed in scrubs; a ripped apart heart sewn back together and labelled “mender of broken hearts;” a cross with appliquéd hearts in each corner; a plastic syringe filled with rhinestones, beads, gold coins, flowers, a peace sign, rainbow-coloured bits of ribbon, and candy hearts flowing out of the tip; a heart as the red, muscular organ beside one drawn as a Valentine, the symbol of love; Chinese wishes for health and good fortune in gold braid and pearlized beads; a “giving tree” with red felt hearts; nurses’ hands joined to form a circle; a cat dressed up as a nurse; a cardiac rhythm strip marching across a dark night sky merging into a sunny day sky; a Hindi greeting of good wishes; curlicue Arabic script in gold glitter; embroidered words: hope, faith, spirit, love, healing; a caution in script: “Reckless words pierce like a sword, but the tongue of the wise brings healing. Proverbs 12:18;” Simba the Lion King and the “Circle of Life;” footprints across a starry sky; intertwined political ribbons of green, yellow, pink, and white symbolizing various causes; a plaid tartan heart from the “Maritime Nurses;” an embroidered white nursing cap with stripes on the wings; Hebrew letters inside a Star of David that spelled refuah shlemah, a wish for a renewal of body and spirit; a stethoscope over felt red hearts with music notes coming out of the bell, and a welcoming cottage with chimney and curtains at the windows.

  And hands were all over that quilt! Hands reaching out to each other against a blue sky, white clouds as in Michelangelo’s Creation of Adam from the Sistine Chapel; hands intertwined in a circle; a dark hand reaching out to comfort a light hand; interwoven red and purple hands, labelled “hope” and “faith,” covered with sequins. Only a few nurses signed their names; most did not.

  As I gazed at the quilt, I thought of all the patients who had been cared for by the hands of the nurses whose hands also created this work of art. Janet, an experienced nurse and an expert seamstress, pieced it together on her sewing machine. The quilt was finished and it was spectacular. A date was set to unveil it to the public during a dedication ceremony scheduled to take place during Nurses’ Week in May 2003. But suddenly, SARS* broke out and the hospital was closed, all patients and many staff put under quarantine. There was a spooky, eerie feeling in the hospital, as overnight it became a ghost town. SARS brought the hospital and the entire city of Toronto to a standstill. Only essential workers, meaning nurses and some doctors, came to work. Nurses’ Week was cancelled. The quilt was folded up and stored away.

  Many caregivers risked their lives, quite a few got sick, and a few tragically died in the service of caring for SARS patients.
Thankfully, most of us in our ICU survived intact. We learned some very hard-won, important lessons about infection control and developed a much greater appreciation of the enormity of the risks involved in caring for our patients.

  Recently, quietly one afternoon, the Nurses’ Comfort Quilt was mounted behind glass in the waiting room. It can be found hanging on the wall, in between the window and the fish tank.

  * I didn’t get a chance to tell them about Justine’s famous T-shirts, like the one that reads: “Nurses Call the Shots” imprinted over a scary-looking needle and syringe. Then there was a night she wore one that said, “Institute for the Sexually Gifted” and handed out fake “Virgin Restorer Pills” to the older nurses, who laughed about it until the morning.

  * Acute Respiratory Distress Syndrome, a life-threatening lung injury that requires a long and difficult course of treatment.

  * It is called ECMO for extra-corporeal membrane oxygenation.

  † Magnetic resonance imaging is another type of scan, particularly useful for visualizing the brain.

  * Thus, explaining the missing items from your closet, Ivan, should you happen to read this.

  * Severe Acute Respiratory Syndrome – a 2003 global epidemic during which thousands became ill and more than eight hundred people died.

  11

  A NIGHT IN THE LIFE

  Sleep, nature’s soft nurse.

  – William Shakespeare

  Even after all these years, I still work night shifts. I probably could find a day job or an excuse to get out of them, but I’m not yet ready to say goodbye to the nights. However, on my evening drive to work along the darkening city streets, I often think about the long night ahead of me (especially about three o’clock in the morning or so, when the jokes begin to run thin or have petered out altogether and fatigue threatens to take over), and I wonder how much longer I will be able to keep this up. As I contemplate the night ahead, I dread that desperate moment that comes at least once, when I’ll have to make a huge leap of faith to believe that the morning will really come.