by Tilda Shalof
Perhaps for some, the act of blaming others imparts a sense of relief. It may be that such a fight is a way for some people to honour the memory of a loved one, or is a part of their own healing process. For some people I even suspect it may be an attempt to avenge the bitter loss. But do explanations actually offer consolation? Does blame ever make anything better? I have experienced many losses, but never one that I attributed to someone else’s fault, so perhaps I don’t understand. I do believe that it is only by moving from anger and retribution to understanding and forgiveness that there is any hope of improving safety and building trusting relationships.
FINALLY, TIKKI RETURNED from her vacation. We arranged to meet on a day that we both had off work, away from the ICU but at the hospital Starbucks kiosk, rather than at the usual Tim Hortons (or “Timmie Ho’s,” as some call it) because they had more comfortable chairs. Most nurses drank Tim Hortons on the run and if they preferred the darker roasts at Starbucks, it was always “to go.” In between cases, doctors may be able to make time to meet for coffee and others do so in between meetings, but for nurses, our time is not our own and we can’t run off from our patients, sit and linger over café lattes at these blond wood tables, listening to piped-in jazz in the middle of the afternoon. Our work rarely allowed time for reflective pauses or discussions unless we arranged for it after hours, on our own time. As I waited for Tikki, I looked around. Sitting at the other tables were managers and administrators, wearing stylish suits and jackets of sophisticated hues. I overheard one telling the others that she had observed a nurse standing outside a patient’s door checking off a list of tasks. “Tick, tick, tick,” she said contemptuously. “Is that all nurses do nowadays?”
Tikki arrived and apologized for being late. She pulled her earphones out and sat down. “Wassup?” She seemed puzzled.
“Tikki,” I started. “You’ve been in the ICU five months. How do you like it?”
“It’s awesome. I love it. You’ve been a big help, Tilda. I really appreciate it.”
“How do you think you’re doing?” I saw she had no idea that there was a problem. I took a deep breath. “Tikki, I have serious concerns about your work.” She looked shocked at the suggestion that her practice was other than impeccable. I spread out my notes on the table so we could look at them together. Her bad-girl tattoos and cocky manner now seemed like so much bravado. She looked like a lost little girl. I steeled myself to present my long list of complaints. When I came to the end, Tikki was no longer surprised or bewildered. She was enraged. She stood up.
“Fuck you, Tilda! You’re trying to ruin my career! I’ve only worked in the ICU such a short time and you haven’t stopped picking on me. Give me a break! These are such little things you’re finding fault with. This is harassment! I’m going to take it to the union and file a grievance against you.” She spat out the words at me. I sat there in silence and accepted the venom. It was such a small price to pay for the satisfaction of doing the right thing.
* Serum potassium level must be within normal range before administering Digoxin to avoid arrhythmias.
† Anticoagulation therapy (blood thinners) is instituted for atrial fibrillation (a serious arrhythmia) to prevent clot formation, which can lead to a stroke.
13
CHESS MOVES
“Remember the days when we used to work in teams?” Noreen asked. We were sitting in the staff lounge and had a few more minutes before we had to get back to our patients. I looked at her over the top of my newspaper. “Do I remember? How could I ever forget? Those women are my sisters.”
Christmas had been the last time I’d seen them. Now it was February and my birthday was coming up, so I knew we’d be getting together soon.
“You were on Laura’s Line, weren’t you?” Noreen asked. “Did Laura become a doctor?”
“No, that didn’t pan out, but she acts like one and still bosses doctors around.”
“Tracy was part of your team, too, wasn’t she, but what about the others?”
“Frances works with Laura in an out-patient clinic, assisting with angiograms and biopsies. Nicky moved to the States with her husband. She’s still a scratch golfer and now has three kids and works part-time in a cardiovascular ICU.”
“What about Justine? Now, there was a real go-to kind of gal! I always thought she would become a lawyer or go into politics. What a great sense of humour she had. Once, I got on an elevator with her and she called out, ‘Let me off at the liposuction suite!’ Everyone was in stitches!”
“Justine also has three kids. She’s a hockey mom, plays baseball on a women’s team, and has her own business. She’s doing great and looks fantastic.”
ON THE SATURDAY closest to my birthday, we met for afternoon tea at a funky, bohemian place on Queen Street called the Red Tea Box.
“Who chose this joint?” Justine asked, rolling her eyes.
“Tilda, of course,” Laura gestured at me. “It’s artsy-fartsy.”
“Hey Tilda, are you and Tracy still torturing people in the ICU?” Justine asked. “D’you guys remember that patient’s son who called Tilda the Angel of Death? Say, isn’t it time to move on from the ICU? Haven’t you had enough?”
“Not yet. I still haven’t figured it all out,” I said.
“If that’s the case, then you’ll never leave.” Justine shook her head in amazement. “I can’t believe you two still work there. Do the families still call the shots and demand everything be done before their loved one croaks? If those patients could talk, they’d beg for a visit from Dr. Kevorkian!”
“Do you guys remember that patient’s wife with the weird hair that was all teased and matted?” I asked. “The one that Justine threatened, ‘I’m going to hold you upside down and use you for a mop!’ and instead of being insulted, she howled with laughter.”
We remembered that – and much more. I looked around the table at them and silently hoped there would be mentors like them for new nurses coming along. I told them about Tikki, how angry she was and how she was threatening to make trouble for me with the union.
Laura didn’t need a moment to think it over. “Get rid of her. Make sure she doesn’t come anywhere near patients. You have a responsibility to see she gets the boot.”
“She said I wasn’t giving her a chance and that I was trying to ruin her career.”
“Suck it up, princess. Get over it. The stakes are too high in the ICU to mess around.”
“I have to agree,” said Tracy quietly. “She’s a scary nurse.”
Only Frances felt differently. “Don’t give up on her, Tilda,” she advised. “Not just yet. Maybe she just needs more time buddied with you.” I suddenly remembered how hard Frances had worked with me and how patient she had been with me in my early ICU days. It was unthinkable to Frances to give up on someone. “Tell her you’re prepared to keep working with her and point out where she needs to improve. Oh, geez, I’m having a hot flash.” Frances pulled out a fan and flapped it madly at her face.
We were getting older, weren’t we?
“It used to be all you had to say was ‘panties’ to make Frances blush,” chortled Justine. “Hey, Frances, have you been following the case of the Recipe Robber? There’s this thief who goes around making demands for cash on the back of recipe cards. ‘Gimme $1,000,000’ on one side and ‘Mom’s Chocolate Cake’ on the other!”
Frances had a predilection for collecting recipes, following weird crimes in the news, and reading the obituary column in the newspaper too, word for word.
“Mmm … chocolate reminds me of Nell’s classic candy diagnosis,” Laura said with glee.
(I don’t think we’d ever gotten together and not exchanged tales of our colleague super-nurse Nell Mason, whose legend lives on, long after her untimely death.)
“That was one of my faves,” I chuckled, but Tracy didn’t remember it so Justine filled her in.
“That was when Nell was running an Emergency department single-handedly and a woman came in with
an unusual gynecological problem. Nell figured out she’d stuck a Mars Bar up there!”
“The tip-off must have been the nougat and caramel dripping down her legs,” said Laura dryly, with a snort of contempt for Nell’s outrageous confabulations, her brilliance as a nurse notwithstanding.
Justine remembered another tall tale. “How about when Nell was an outpost nurse on a native reserve, delivering babies and performing appendectomies – according to her – and this old Cree woman came in with a foul stench? Nell examined her and found a festering crow inside of her. She said she had to remove feathers and little bones.”
“What about her claim that she never went to the bathroom at the hospital in all her years working there? I suppose she adopted the water-retention ability of her pet camel,” Laura said, “the one she used to ride to school, dontcha remember? Imagine, riding a camel in Thunder Bay! Did she really think we believed those stories? Hey, did she ever tell you about her practice of scatomancy?”
“What the hell is that?” asked Justine.
“She claimed she could tell people’s fortunes by examining their feces.”
“Eeewww!” we all exclaimed, laughing helplessly.
“Well, I always said old Nell was full of shit,” scoffed Laura, but then looked a bit remorseful for making fun of Nell once again. I think we all regretted that we hadn’t recognized that Nell was seriously ill. In the end she died at home alone, after a long and private battle with alcoholism.
“None of us ever really knew the late, great Nell Mason,” I said.
“Yes,” said Justine sincerely. “Nell was Über-Nurse.”
“Let’s have cake,” said Frances. “It’s Tilda’s birthday.”
THE NEXT DAY AT WORK, Tikki was back and I found a moment to speak with her privately. “Listen, Tikki, if you are willing, we can continue to work together and if we review some of the …”
She shook her head. “At first I was upset with you, Tilda. I don’t usually let anyone push me around like that and I really took it hard but now I feel, whatever.” She gave a wave of indifference. “I’ve decided to go back to school for my Master’s in Nursing, so I can teach or do research.”
I was blown away. Did I look as astonished as I felt?
“Don’t worry, it’s no biggie,” she said with a shrug and worked her last shift without incident.
I wasn’t sorry to see Tikki go but we had been losing a lot of nurses lately. Chandra had left and Jenna was still off work for health reasons. Monica would soon complete her Master’s degree and was already looking for a position in management. Even Tracy had been thinking of moving on and trying something different, such as public health nursing, after nearly twenty years in the icu. The loss of experienced nurses had been putting a real stress on the icu. We were short-staffed on almost every shift and sick-time and overtime costs were cutting deeply into the budget. The ICU had been crazy-busy for more than a year and we’d been working non-stop. The moment one patient was discharged, another was right there. Nurses were complaining they were feeling like factory workers on an assembly line, trying to keep up with the pace that showed no signs of letting up.
It was easy to see why more patients needed to come to the icu. You only had to walk through the wards to see that the floor patients were sicker than ever. In today’s hospitals, patients who used to be treated on the floors are now being discharged home “sicker and quicker,” nurses on the floor always say. More and more, patients who are in the hospital need closer monitoring, quicker intervention, and the attention to detail that we are able to provide in the icu.
We had long since moved from both the original ten-bed ICU where I had started (memories of the Cave) and then a few years later, from a sixteen-bed ICU in another part of the hospital. About three years ago we moved into a bright, spacious new twenty-two-bed icu, up on the tenth floor, with a view of the city right down to the lakeshore. In this icu, there are large patient rooms, expansive hallways with turquoise and beige geometrical designs on the floors, and windows all around that let in not only light, but also a sense of space and grandeur, as well as glimpses of the outside world. It is a much more pleasant place than the original icu. Back then ten beds had been sufficient, but now we are always full to overflowing with twenty-two beds. More and more patients need to come to the ICU.
Is the ICU a physical place or a way of doing things? I got to thinking about this question after what happened to a patient named Carole Oxton. She was not my patient but was Xavier’s in the room next door to mine. However, as the day went on and I saw what was unfolding, I had no choice but to get involved. Noreen, Casey, and Monica were on that day, too, and Roberta was in charge. I had worked with Xavier a few times and I had no concerns about him. He was a new nurse, but very competent and caring and what I liked about him was that he asked a lot of questions and that’s always a good sign. He was assigned to care for Carole Oxton because she was a stable patient. In fact, she was deemed so stable she was to be transferred out of the ICU early that afternoon. She was a fifty-four-year-old woman with a long history of alcohol and drug abuse who had fallen down a flight of stairs at home and broken her arm. She had dark circles around her eyes (even textbooks labelled them “raccoon eyes”) and multiple purple bruises all over her body. Her electrolytes – the potassium, sodium, calcium, magnesium, and phosphate levels in her blood – were abnormal due to liver and kidney failure. They needed to be closely monitored and swiftly treated, in order to avoid serious complications. I saw that Xavier was very capably topping up the low phosphate and preparing to give a calcium supplement, so I returned to my patient in the room next door.
Mr. Drummond was a sixty-year-old man, three days post lung-transplant, weaning slowly off the ventilator, getting used to his new lungs and battling re-perfusion syndrome.* On rounds that morning, we tweaked his medications on the advice of the pharmacist. On the respiratory therapist’s recommendations, we adjusted the ventilator so as to allow him to gradually do more of the “work of breathing,” by himself. He was making progress, but still had a long way to go.
The team pushed the portable computer along to the next room, Mrs. Oxton’s.
“This lady is doing well,” said the resident. “She’s ready to be transferred to the floor.” Since no one had anything to add, they moved on to the next patient. Yet, after a mere glance at Mrs. Oxton, I felt uneasy and clearly, Xavier did too. “I don’t think she’s ready to be transferred out,” he said.
“She’s been off the ventilator for forty-eight hours,” the resident called back over his shoulder. “Her blood gases are good. She’s a rose. She could have gone out yesterday.”
“It’s true,” said Xavier, thinking out loud to me. “She’s on nasal prongs with just a few litres of oxygen, but the problem is, she’s not very alert. I don’t have a good feeling about her.”
“How’s her blood pressure?” I asked, trying to figure out what it was that disturbed me, too.
“Normal,” Xavier said, looking unhappy. “What do you think, Tilda?”
“Let’s go in and examine her together,” I suggested.
Xavier’s patient opened her eyes when she saw us. She made raspy gurgles of secretions at the back of her throat. I handed her a tissue. “Try to cough that out.”
“I’ve paid my bills,” she mumbled. She tried to cough, but only managed a feeble splutter. Even without listening with my stethoscope, I could hear her chest was noisy.
“Mrs. Oxton!” I shook her shoulder a little. “Would you like to get out of bed?” She didn’t answer or even appear to have heard me. I looked at Xavier.
“I already tried to sit her up at the side of the bed and dangle her legs,” he explained, “but she was too weak to stand.”
“Let’s hoist her up,” I said, “it’ll make it easier for her to breathe.” Xavier went on the other side of the bed and we lifted her as she lay there helplessly.
“If we had extra staff, we could keep her longer,” Roberta said
when I went to the nurses’ station to talk to her about it, “but as it is I am short two nurses and three short for the night shift.”
“We always have to move everyone along so fast,” I grumbled.
“I know how you feel, but we’re getting two transplants and someone just called in sick.” Roberta stared into the staffing book as if more nurses would suddenly materialize in there. “Hey, it’s still early. We’ll keep her a few more hours and reassess the situation in the afternoon.”
I’m convinced the best preparation for this role would be to study the moves of the grand chess masters, Kasparov, Fischer, and Spassky and so on. The nurse in charge has to control the board (the ICU) and plan moves (transfers, discharges, room swaps, etc.) in advance. You have to stay a few steps ahead and have a strategy for a possible arrest on the floor, or a surprise admission from the Emergency department. You have to be ready to move some “pieces” out quickly and hold others back and protect them. The King is your sickest patient, but you also have to protect your Queen – your last ICU bed. Roberta was a supreme chess master, and in her hands, the ICU could cope with any “attack.”
About an hour or so later, I wandered back to the nurses’ station to get a sense of how the game was playing out. Roberta looked stressed. “I see you’re ‘Takin’ Care of Business,’” I sang, trying to play our old game, but she wasn’t in the mood. I could see by her expression that it was time for push to come to shove, quite literally.
Roberta looked at me. “Mrs. Oxton has to go, Tilda. There’s a patient on the floor who is deteriorating fast and needs to come to the ICU. I want you to help Xavier get her ready to be transferred out.” She returned to the lists of nurses and patients and tried to massage the numbers to stretch the supply of staff to cover the demand of patients, all the while doing her utmost to ensure everyone would be safe. “Let’s see,” I heard her talking to herself, “if we transfer the patient in 1011 out, then Casey can take the liver transplant when he comes out of the OR and when Xavier’s patient goes out, we’ll admit the floor patient …”