by Tilda Shalof
When I go to work at night, most people I know are settling down for bedtime. I’m out of synch with my family’s schedule. My “weekend” might be in the middle of the week. Friends often complain that they never know when to call me. (Do they think a nurse would allow precious sleep to be interrupted by the telephone? We unplug it or turn off the ringer!) “What’s a typical shift like?” someone asked me recently and since a typical shift might just as likely be a night, I decided to keep a running log. Here goes.
Pre-Night Shift Jitters
My unease dissipates as soon as I arrive and realize once again the hospital at night is a different place. It’s more humble, no longer bustling with self-importance as it is during the day. There are no staff doctors and scientists in suits and white lab coats charging around. The flurry of retail activity has ground to a halt. You encounter far fewer lost and bewildered folks asking for directions to the Endoscopy Suite or Radiation department. We are workers, all of us, no managers or bosses around – all mice, no cats – and there’s a sense of solidarity in the understanding that we will take charge in ways we wouldn’t dare – nor be expected to – during the day. To be sure, some nights are quiet and even offer opportunities to relax. Unless, of course, someone suddenly gets really sick.
1900: At the Nurses’ Station
Roberta, the nurse in charge tonight, looks worried. We’re short-staffed, even with Beryl unexpectedly showing up, mistakenly thinking she was scheduled to work. As it turns out, we need her, “But even if we didn’t, I’d keep her here for her own safety,” Roberta mutters. We chuckle because although Beryl is a decent nurse, a journeyman, she’s not the brightest star in the sky. It’s Roberta’s third night in a row, an overtime shift, and no matter how tired she may be, or preoccupied with her personal problems being the family’s sole breadwinner (her husband died of a heart attack a year ago), I’ve never seen her fatigue show, except maybe a little bit, tonight.
(Well, at least it’s not one of those change-the-clock nights at the end of daylight saving time when we “fall back” and end up having to work an extra hour. The union finally managed to get the hospital to pay us for that extra hour. It was only an hour, but no one wanted to be forced to volunteer their services for free, especially for an extra hour of night duty.)
Noreen is pacing outside her patient’s door. She’s the day nurse and wants to get out in time to make it to her daughter’s soccer game. I hotfoot it over there a few minutes early to avoid her wrath. She thanks me and launches straight into the story of the patient we will share, back and forth, over the next few days and nights. I am listening to her as I glance across the room to Monica, my partner, who gives me a thumbs up to indicate that whatever happens, we’ll deal with it and have a sweet night. “This is Mr. Lee, a sixty-eight-year-old man who came in a week ago in respiratory distress and septic shock,” Noreen introduces the patient to me. “Got him off the Levophed and blood pressure remained stable … his temp stayed down. Extubated this afternoon … chest sounds clear and gases are good … saturations stayed in the nineties all day on forty per cent oxygen by facemask. His urine was about fifteen cc per hour, so I got an order for a diuretic.” She scans the flow sheet where we make our recordings to ensure she hasn’t missed any important details. “He’s a peach, so if there’s an admission during the night, he’ll have to be transferred out so that you can take an arrest from the floor or a new admission from emerge. You know how it is.” I do.
2000: Initial Assessment
I take the first hour of my shift to examine my patient and learn him organ by organ, from head to toe and inside out. He is uncommunicative, so I try to pick up his energy and sense his personality. I study his “machines” and memorize their numbers, modes, settings, and alarm limits. I lower the lights around his bed and have taken up my seat at the desk just outside the room to read the chart when Jenna, whom I had noticed earlier looking distraught, scoots out of her room, pulls up a chair beside me, and gets right to the point.
“My gynecologist – what a jerk!”
After three years of trying to get pregnant – not that she hasn’t enjoyed that part of it – Jenna now wonders if it’s worth it. The tests, hormone injections, the cost, and the emotional rollercoaster she’s been on – maybe it’s not meant to be? “At the last minute, he cancels my appointment and his secretary reschedules me for tomorrow at eleven o’clock, when I need to sleep after this night shift.”
A thought occurs to me. “Have you ever considered getting off of nights for a while?” I want to ask her, but she has to hurry back to her patient before she has a chance to answer.
I’ve learned how to cope with practically any situation that can arise in the icu, no matter how difficult or stressful, as long as I have a partner I can rely upon and Monica is certainly that. She is an excellent nurse, confident and competent, though bossy and judgmental at times. But Monica has a secret, wild side that not many know about. She was teased about her name during the Monica Lewinsky thing, but it didn’t bother her in the least. “I would have fallen for Clinton, too,” she said shamelessly. She often says she’s prepared to try anything once and thankfully what she tried one year after the ICU staff Christmas party happened only once. She came to work hungover and convinced someone to start an iv and give her a litre of fluid and Gravol. She hung the iv on a coat hook in the staff lounge and lay down to sleep it off. Despite her own antics she is quick to find fault with other nurses who behave in a manner of which she disapproves. “We’ve got to get the lazy and overweight nurses dragonboat rowing or start a hockey team,” she often says. She herself is petite, pretty, and keeps herself incredibly buff with a daily 6 a.m. spinning class at the gym. I’ve never seen her eat anything but carrot sticks and protein shakes and she’s always throwing out the boxes of candy that families bring in to thank us and replacing them with fruit. But I admire that as a divorced single mother with a deadbeat ex-husband, working overtime and extra shifts at other hospitals, Monica has raised and supported her daughter all by herself. On top of all that, she’s working toward a Master’s degree in nursing administration. We all predict she’ll go far.
I record my patient’s vital signs, listen to his lungs, give him iv medications, a bath, back rub, and change of linen. With the assistance of Stanislaw, one of our hospital assistants, I reposition him to make him more comfortable. When I wish him a good night, I swear I can see gratitude in his eyes. When I come out of his room, Roberta is making her rounds to see how the patients are and if anyone needs help. She looks a bit tense, so I play my little game with her. “Born to Be Wild,” I toss out and she calls back, “Mars Bonfire, the Steppenwolf album,” without missing a beat. Ten years of working with her and none of us has managed to stump her yet.
The phone is ringing at the nurses’ station. “Tilda, pick up line two,” I hear over the intercom. It’s my patient’s wife, asking how he’s doing. “He’s fine. I’ve just gotten him ready to sleep.” I’m pleased to tell her.
“Will he make it? Through the night, I mean?”
“Yes … I think so,” I say cautiously. “Anything can happen, as you know, but I think he’ll have a good night,” I add more reassuringly. There are no guarantees, which is what I suspect she wishes I would offer. I don’t mention the possibility that he may be transferred to the floor during the night if the need arises, but perhaps I should so it won’t come as a surprise if it happens?
“Give him my love,” she says, and I return to my patient and do just that.
2100: Time to Kick Them Out!
The overhead announcement system comes on. “Visiting hours are now over!”
“Remember that sweetie who used to be on the switchboard?” we recall fondly. “How he used to give the weather reports and advice?”
“Whatever happened to him?” someone asks, but no one knows.
Since everything is hunky-dory with my patient, I take up my post just outside his room, where I can keep an eye on everything. Ho
pefully, he senses I’m there and feels reassured so that he can feel safe and sleep. I sit back and sink into the quiet lull of the early night. When these interludes come, I ride their gentle wave like a dreamy lifeguard, fixing my gaze out at the ocean, scanning the horizon for trouble, always in a state of relaxed vigilance, and ready to spring into action and dive in at a moment’s notice.
“What’s new, Monica?” I ask when she joins me at the desk we share. She’s serious about her studies, but I am aware of certain extra-curricular activities that keep her fairly busy as well.
“I do have a meeting … later on,” she says, looking at my face to assess my reaction.
Ah, yes, I remember. “How’s it going with you-know-who?” I ask, knowing perfectly well the name of the very married surgeon she’s told me about.
“There’s a transplant scheduled, tonight.” She smiles and returns to her charting.
I connect the dots. Roberta had mentioned that an organ donor had been brought in this afternoon, brain-dead after a head-on collision. In the brief window between the harvesting of the organs and their reconnection to the recipient, there might be just enough time for a romantic tryst.
2200: To Stand or to Sit?
I wander over to the nurses’ station to joke around with Roberta, but she’s preoccupied. She’s going over the staffing for tomorrow morning and at the same time receiving updates about a patient in the operating room who is going sour and troubleshooting problems as they come at her from all directions. All twenty-two beds are full tonight with fully ventilated, sick patients, but she’s got the situation completely under control. She pauses to mention that the family of one of our patients has given us forty dollars to order pizza. “It’s really decent of them, considering he’s not doing very well,” she says wryly.
We often enjoy wonderful meals on night shifts. Occasionally we call for a potluck and everyone brings something. It used to be pasta salads, sausage rolls, and macaroni and cheese, but over time, we have become more diverse and sophisticated. We now have Philippino noodles called pansit, Greek dolmades with lemon sauce, Indian samosas with tamarind chutney, and Jamaican rotis. Tonight, I see only a dismal bag of stale jujubes on the desk, but Oscar, a nurse originally from Guyana, tells us he has brought in a big pot of “cook-up” – a rice dish. “It’s in the staff lounge, help yourselves,” he says. “But it may be too spicy for you Joneses and Smiths,” he warns with a grin.
We’ve celebrated many birthdays, weddings, and baby showers together. There are always notices plastered all around the walls of the ICU, and not just for these social events, but also for workshops, conferences, or information about new tools and technology. There are always a few posted on the inside of the door in each bathroom. Presumably, they are placed there because the majority of the readers are female and, therefore, face the door. I postulate that gender equality will have been achieved in nursing when there are an equal number of notices on the wall behind the toilet seat as there are facing the toilet!
2210: A Critical Call
Someone, somewhere is very sick and needs to come to us. “How are we for beds?” I assume the resident is asking Roberta on the phone because she answers, “Beds? Plenty of ’em! It’s nurses we’re short of.” She rolls her eyes and covers the receiver. “Why don’t people get this? We need more nurses, not furniture.” Roberta looks at the list of patients’ names and the list of nurses’ names and thinks out loud. “I’ll have to double up two patients, prepare the rooms for the liver and a lung transplant coming out of the OR, and move a few people around, but it sounds like this patient needs to come here.” She hangs up the phone and I follow after her to give her a hand preparing the room for the new admission. “At least you won’t have to be on standby to transfer your patient out after all, Tilda,” Roberta says.
“How so?” I had just been regretting that I hadn’t warned the wife that might happen.
“Casey’s patient just died, so she’s free to take this new patient.” Roberta flips on the overhead light and the cardiac monitor, which emits a humming, then a buzzing, as if it, too, is gearing up for the action ahead. She goes out into the hall to stop Tariq, the respiratory therapist, to let him know that a patient is on the way. “She’s a twenty-five-year-old, found unconscious at home, with an empty bottle of Tylenol beside her. She’ll be here in a few hours by helicopter from Sudbury,” she tells him so that he can get a ventilator ready. “Yes, Casey will admit her,” she explains to me, “as soon as she finishes her arts and crafts project, or whatever it is she’s doing.” Roberta waves at Casey, who’s sitting at the nurses’ station, busy with yards of bright pink fabric. I stop to ask Casey what she’s up to and pull out yards of silky fabric from her huge shopping bag. There’s a salami sandwich in there, too, I see. Until her patient arrives, she’s working on a bridesmaid’s dress she’s making for a friend’s wedding.
Around 2300, or So: A Messy Situation*
Trina needs our help. In preparation, we don gowns, masks, vinyl gloves and with Jenna and I on one side of the bed, we roll the patient toward us. Trina is on the other side with a pile of wet, warm washcloths ready to get to work. It started with a few dabs, then a smear. Now, it’s a slow ooze.
“That’s it! I’ll never be able to eat chocolate pudding again,” Jenna whispers and looks away.
Shhh, we say, suppressing our own equally unsavoury, naughty, uncharitable, unprofessional thoughts. Thank goodness the patient is unconscious!
Now it’s morphing from dark squirts to bubbly ribbons. It’s flowing, gathering speed. I hand Trina more wet washcloths and picture the little Dutch boy with his finger in the dyke to stem the flood. I cough a little to expel the smell. Stay focused on the patient, not the smell or the sight, Frances used to say to me. It’s advice that actually helps. “You’re doing fine,” I whisper into the patient’s ear, whether he can hear me or not.
Now it’s a river, pouring out faster than Trina can wipe it away. Rollin’, rollin’, rollin’, … We stand there, waiting it out while it streams down the patient’s legs, into the folds of his scrotum, around his catheter. Our gloves are slippery and there are now flecks and streaks on the front and sleeves of our gowns. It’s a force of nature, like lava pouring forth still smouldering from inside a human cave.
This experience is no longer what it was for me in the past, but I had to overcome my own shame before I could help patients deal with theirs. I do not consider this work demeaning or degrading. It is not humiliating, disgusting, or repulsive. It is not boring or tedious or anxiety-provoking. I accept it. It is what it is. It’s life itself. It’s an opportunity to help restore dignity and I do it with as much finesse as I can. I put my hand on the patient’s shoulder. “It’s okay,” I say.
It has taken me such a long time to get here.
We stay until the flow abates sufficiently for Trina to put the finishing touches on the job by herself and we hustle out of the room. We strip off our gowns and gloves and gather at the sinks and now that we are sufficiently out-of-range and “offstage,” we let loose, a little.
“That was a poo-nami!” Jenna says, laughing helplessly. “It reminds me of the time a patient shit on my head,” she says. “I’ll never forget it. It was purely accidental, of course, but I was leaning down to tuck in the sheets and out it came, spurt, spurt, spurt, all over me. Liquid poo was dripping down my bangs and forehead. I ran out and hosed myself down.”
“Why do so many of our patients have diarrhea?” I muse. “Is it from the antibiotics? The feeds? The stress?” (Note to self: Do an online search of diarrhea-related scientific literature.)
“What about my invention?” Theo comes over to tell us. “Before giving the patient a bedpan,” he explains, “first, line it with an incontinence pad. That makes it warm and cozy for the patient’s bum and afterward, voilà, you wrap up the entire bagatelle, that splendid little package, and dispose pronto. No rinsing or scraping. No spraying and having back splash comin’ at ya! Make sure y
ou prepare another one all ready for the next event!”
“That is life-changing advice, Theo,” I say solemnly, sincerely.
At 2359: Just Before Midnight
Monica’s gone on her break. I check on the patients and then dash out to get some supplies. On the way back I run into Jenna, who looks worried and I’m fairly certain it’s not about her ovulation cycle. “Take a look at this.” She hands me a clipboard upon which her patient has written a note to her. “Ever since I lightened his sedation he’s been frantically trying to tell me something.”
It’s a wobbly scrawl, but we make out “daughter” and “alone.” Jenna’s patient has pneumonia related to HIV he got from sharing needles. “I asked how old his daughter is and I’m pretty sure he held up six fingers.” Jenna looks worried. “Do you think he’s trying to tell me she’s been left alone?”
Roberta comes over, flipping through the chart for clues. “He was brought in by ambulance to emerge. No one came with him. There’s nothing in the chart.” She sighs. “They could look into it on the day shift,” she thinks aloud, “but on the other hand, it might be urgent. I’ll call the police and ask them to check into it,” she decides and hurries off.