The Making of a Nurse

by Tilda Shalof

  “Why did you agree to stay open to admissions if you’re so short of nurses?” asked Dr. Sandor, as he passed by the nurses’ station. He helped himself to a squirt of antibacterial lotion.

  “How could I say no?” Roberta asked in dismay.

  “But it’s a staffing issue. That’s your call. Take a stand.”

  Check.

  “And I suppose you’ll back me up when the newspaper headline tomorrow reads, ‘ICU Closes Doors due to Shortage of Nurses’?”

  She glared at him and he grinned back. “That’s what I thought,” she said.

  Checkmate.

  I COULD SEE THE PRESSURE Roberta was under, but still I stalled, trying to buy more time for Mrs. Oxton in the ICU. Xavier and I fussed around her and turned the radio on to stimulate her. We tried again to get her out of bed, but she became combative. We wondered if she might be starting to go through the DT’s,* the syndrome of agitated withdrawal from alcohol. I sat down to read her chart. She had been a widow for many years and had a teenaged son who was in jail. Three days ago a neighbour found her lying unconscious on the floor of her basement apartment. Empty liquor bottles were strewn about.

  “I heard you are planning to transfer Carole out,” said a thin, anxious woman who came up from behind me. She frowned and then introduced herself as Margaret, Mrs. Oxton’s sister.

  “She is ready to be transferred out,” I said uneasily.

  “Someone else needs the bed, is that it?” she asked.

  I squirmed, but by my silence, she knew the answer. Xavier stood by, listening in.

  “The nursing care is better here in the ICU. I know it and you do, too.”

  “She will be well taken care of by the nurses on the floor,” I said. Of course she would, she and another six equally needy patients that some nurse would be running back and forth between. I recalled a patient I transferred out of the ICU a few weeks ago. He was a renal patient on dialysis three times a week who was recovering from septic shock. He was confused and disoriented and on top of all of that, he spoke only Italian so I could not communicate with him properly. On the floor, I gave a report to a nurse who was listening but in a very distracted way. “The other thing,” I added at the end, loath to add to her burden, “you’ll need to get hold of an interpreter so you can explain his meds. Could you page one?” I asked the ward clerk who was listening in.

  “This isn’t the UN,“ she grumbled, then tried to be helpful. “How about, ‘Hey Paisano!’“

  “How many other patients do you have?” I asked the nurse.

  “Along with this one? Seven. No, wait a sec,” she reviewed her notes. “Six. One just died.” She crossed a name off her list.

  “Are all of them this sick?”

  She nodded. I noticed she was panting and looked as if she was ready to take off on a sprint.

  “Why are you so short of breath?” She worried me.

  “From running. A patient just yanked out his chest tube and then the patient in the other bed took out a knife and cut his own chest tubes off.”

  “Were they psychotic?”

  “No, just competing with one another.” I couldn’t tell if she was joking or not.

  “You look stressed,” I said. All of a sudden, she got up and ran into a patient’s room. My patient – the one she’d just inherited from me – was climbing out of bed. How did she even know? Together, we lugged his heavy, swollen legs back into bed, and I put the side rails back up.

  Good night, nurse! I thought, walking away from her, feeling guilty leaving her with such a mess. Good luck! I am ashamed to admit how fast I booted it out of there and raced back to the ICU. It was my home and while there was chaos there too, at times, we had the ways and means to tame it.

  Now I understood what was the biggest dilemma for nurses. We can no longer solely focus on doing good for patients. We are doing everything in our power to ensure we don’t cause them harm.

  “The nurses on the floor won’t have time for her,” Margaret, the sister, said.

  “Yes, they will,” I lied.

  “She is falling off a cliff,” she said. “Do something!”

  Xavier removed Carole’s arterial line, and I gathered up her personal belongings. There wasn’t much, only a dirty pair of jeans, old running shoes, a T-shirt, and a grimy jacket. I placed them in a plastic bag and tried to give it to her sister to take home, but she wouldn’t touch it.

  “I’ve spoken to my son who is a doctor, and he insists Carole stay in the ICU. This is a disgrace.”

  “I understand how you feel.” I felt the same way.

  “We have a terrible health-care system.”

  Just then, a teenaged boy bolted into the room. “I’m the son,” he said, slamming his jacket onto a coat hook so violently it ripped right off the wall.

  Margaret whispered, “I didn’t know whether to tell him to come. He’s out on probation.”

  “Is she even with it?” the son said, staring at his dishevelled mother, who was grinning and gurgling, sprawled in the bed, not appearing to recognize him one bit. “She’s a drunk,” he said in disgust, “plus she’s a junkie, so it’s no use trying to save her because she’ll just be back again in a few days.”

  “Don’t you think you should take her for a CT scan?” Margaret inquired politely. “When my husband got sick, they took him for a CT and it helped him get better.”

  Out in the hall, Noreen asked me, “Why do you let your patient’s sister boss you around?” Everyone was watching this drama play out.

  “She has to go,” Roberta came over to tell me. She had paged housekeeping to clean the room that hadn’t even been vacated yet. Roberta knew the bigger picture and this patient and her sister were the smaller picture. Just one little patient caught in the big scheme of a huge and mighty hospital.

  “Carole!” Xavier and I shouted at her, trying to make her more alert. If she was more alert, she might be able to protect her airway from aspiration. “Carole, wake up. Open your eyes.”

  “The fishing rod is too tight,” Carole muttered, pulling at her central line, the IV in the jugular vein in her neck. “I can’t reel it in.”

  The housekeeper arrived and started cleaning the floor around her bed, then stopped and leaned on her mop. “This patient is going to the floor? She don’t look too good.”

  “See, even she can see it,” exclaimed Margaret. “Have the courage to stand up for her! Where’s a doctor? Get a doctor!”

  I would gladly call the doctor if she wanted, but it was a nursing matter, pure and simple. Pure, perhaps, but not so simple.

  “Who changed the time for transportation?” I heard Roberta ask. Sneakily, behind her back, I had rebooked the porter in order to buy more time. Roberta was getting frustrated with me, as were other nurses. Word was getting around the unit that I was not supporting our charge nurse, that I was getting too emotional and not taking a firm enough hand with a demanding family member. Roberta came over and spoke to me sternly. “Tilda, we can’t keep Xavier’s patient here any longer.”

  Margaret, in turn, confronted Roberta. “You know very well she should stay, but you’re feeling pressure to move her along and bring someone else in. If she dies, it will be on your conscience. Please do the right thing and keep her here.”

  “I can’t,” Roberta said, throwing her hands up in the air.

  Margaret crossed her arms across her chest and looked away, fuming.

  “I suggest if you are concerned about your sister that you stay with her on the floor,” Roberta advised. “That’s what I would do if someone I loved was in the hospital. This is what we are dealing with right now in our health-care system. Choices have to be made.”

  Roberta and I stepped out into the hallway to discuss the matter further. “Look, Tilda, the nurses downstairs will be able to handle this patient. I know she has a lot of needs, but what can we do?”

  The resident came over. “I’ve written the transfer orders. She’s good to go.”

  Well, what
could we do in the meantime, but go for our lunch breaks? There had been a meeting of the managers that day, and there were sandwiches and éclairs. I had to chuckle at Casey, who was serving the Caesar salad, using tongue depressors as tongs.

  “I can’t stand the waste of money,” Monica said and looked at the fancy leftovers with disgust while we munched away. “Everyone knows our health-care system is in trouble.”

  “Oh, come on, Monica. There are lots worse excesses. A few platters of food is a drop in the bucket,” I snapped. She was ruining my appetite with her griping, and that on top of my real problem. “I’ve got bigger issues on my mind.”

  “Why are you being so difficult, Tilda?” she asked. “You know there’s another patient out there who is in worse shape.”

  “I realize that!” I could hear a hysterical edge to my voice. “But don’t we also have a responsibility to the patient already in our care?”

  “But that other patient deserves a chance at what the ICU has to offer, too,” Monica said. “It’s not like we’re sending her home. Don’t underestimate the nurses on the floor.”

  “You know as well as I do that a patient like this can easily fall between the cracks.”

  “Look, if the family is giving you a problem, call security.”

  And smash this tiny ant with a sledgehammer? Was that the solution? How easy it was for them all to weigh in on the matter. Why was it never so easy for me?

  “Xavier,” I said briskly when I came back, “I’m going to help you transfer this patient.”

  He looked surprised at my change of heart.

  “What!” shouted Margaret, who was sitting beside the bed.

  “Your sister cannot stay in the icu.”

  “You know what the right thing to do is, you are just not willing to do it.” Her eyes bored into me. “Look at her! She’s so frail. Imagine it was your sister. Please, keep her here,” Margaret pleaded.

  “Unfortunately, we can’t,” I said crisply as I disconnected the patient from the cardiac monitor.

  “I suppose you have someone sicker who you want to bring in her place,” Margaret sniffed.

  I didn’t dare tell her she was right, but Roberta came over and she dared. “Yes, that’s exactly what is happening. Someone is in worse shape than your sister.”

  Check.

  The porter arrived. Xavier released the brake on the bed. As we wheeled the bed out of the ICU, I fought back tears of rage at what we were forced to do.

  Checkmate.

  I HONESTLY CAN’T SAY I was shocked when I came back to work the next morning and heard that Carole Oxton had a respiratory arrest during the night and had to be brought back to the ICU, unconscious and re-intubated. I’m not even certain the wrong decision was made to transfer her out, given that our resources are not unlimited. We can’t always keep patients in the ICU because of the possibility that something could go wrong. But I did wish that it were possible for nurses all over the hospital to be in the position to give the kind of care that we give to our patients. The hospital is full of seriously ill people and don’t they all deserve intensive care? After all, what was most “intensive” and “caring” about the ICU was the nurses. It wasn’t merely a place with machines and equipment; it was a way of doing things. And since it wasn’t feasible to bring every patient to the ICU, perhaps there was some way that we could bring the ICU to patients?

  * This syndrome is a common, but complicated, risk post lung-transplant.

  * Delirium tremens.

  14

  INHOSPITABLE HOSPITALS

  Suddenly, my life became more complicated. After standing by helplessly and watching what happened to Carole Oxton, I felt terribly disheartened. We hadn’t been able to keep her safe. We couldn’t do the right thing for her. All around me, I began to see more and more things I could no longer ignore. Nurses on the floor were overloaded and distressed. There was no one they could turn to for support or to ask questions. Nurses were leaving nursing, and I was beginning to understand why. Jessica, a friend of mine, left nursing. She became a nurse when she was in her mid-thirties, after a successful career as a musician in the symphony. But after less than a year in the workplace, she decided to leave the profession. She looked miserable and defeated as she told me about it.

  “I felt I had no choice but to walk away. Can you understand, Tilda?” She felt she had to explain it to me, but I knew very well that hospitals could be very inhospitable places, not only for patients, but also for conscientious nurses like Jessica. “Patients were always dissatisfied with me because I wasn’t giving enough care to them, but I was always off somewhere else, giving not enough care to another patient.”

  “I guess you never had a chance to get to know your patients,” I murmured.

  “Know them? I was lucky if I knew their names. All I knew was their room numbers.”

  Why had I never walked away? I had been tempted long ago, when I worked on the floor and always felt so powerless and invisible. I had chalked it up to my personal problems at the time, but what if I went back to the floor now? I’m still not sure I could handle the conditions there. More than ever, I appreciated working in the icu. We could set goals, plan ahead, intervene early, and not always be scrambling to react to crises. As an ICU nurse you felt respected, that your voice was heard and that your contribution counted. I was beginning to realize that many nurses out there didn’t feel that way.

  These impossible situations made me worry about my profession, but even more, about patients who don’t have enough nursing care. I didn’t know what to do, but I knew I couldn’t look away any more. (Of course it wasn’t all up to me to rescue the patients, save the hospital, and fix the problems in the health-care system, but at times, I felt like it was!)

  I have never had a problem or a worry, either big or small, that couldn’t be made better by meeting with a girlfriend and talking about it over coffee. If only world leaders could do the same, I’m certain wars could be averted. I arranged to meet Monica at a café near her gym just before her spinning class. I knew she was finishing up her Master’s degree and I wanted to hear how that was going, but first, she was bursting to tell me about her thrilling love life that involved yet another married doctor.

  “But what happened with you and Nick?” I asked. I thought he was steady at the time, but it was hard to keep track as she always had a steady and one or two on the side.

  “Oh, Nick is strictly PG-13,” she said. “You won’t believe who I’m seeing now!”

  Suddenly, I was disgusted with myself. I’d been listening to her stories for years and here I was, listening once again, to the titillating details of her latest encounter, this one in the office of a prominent surgeon, while his waiting room filled up with patients. “He said to me, ‘For years, I’ve been dying to get my hands on you, Monica,’ and so you know what I said to him? ‘Well, then, do me.’ We had to stop when his secretary knocked on the door.”

  I felt queasy. By listening, I was drawn in. I became a part of her deception.

  “I’m having such fun.” Monica sighed and smiled to herself. She explained how she had to be unfettered by emotional commitment so she could focus on her career goals. I looked at her pretty face and her impossibly fit body with its perfect posture from years at Catholic school where nuns had tied a broomstick to her back to make her sit up straight. She was determined to have a fabulous career and fun on her own terms, but I wondered if she really could manage to “have it all.”

  “How’s work going?” I asked. “You haven’t been in the ICU for a while.”

  “I’ve been moonlighting at another hospital,” she said. “You wouldn’t believe what happened the other night. They sent me to a floor and I got a fresh post-op patient who wasn’t peeing. The doctor told me not to put a urinary catheter in, but after a few hours she still wasn’t peeing and I needed to get a better assessment of her fluid balance. So I decided to put one in anyway and …”

  “I hope you didn’t do it, Monic
a, not against a doctor’s order.”

  “It was political,” she said, avoiding my question. “The doctor said she’d be more alert by morning and wouldn’t need a catheter, but in the meanwhile she had zip urine output and I was worried. I was there with the patient. He was on his cell phone at home.”

  “Yeah, and if you had put one in and the patient had developed a urinary tract infection or blood in her urine, your licence would have been on the line.”

  “But he was digging his heels in and it was about power, not about what was best for the patient. I told him to get in here and see for himself. So, he came in and to be honest, he took one look at me and didn’t give me any further hassles about the patient. He invited me into his on-call room and, well …”

  “Don’t tell me!” I interrupted. “You didn’t!”

  “He said, ‘You’re so hot, Monica,’ and so I locked the door and we made out a bit on the couch and then I told him he was wrong about the catheter, and about a few other things, too, and he was pretty weakened at that point, and gave in to me. Anyway, the point is, I can’t stand it when a nurse sees a problem, knows what to do, but her hands are tied.”

  She may have meant that literally. She had a penchant for kinky things and did take pride in her claim that she’d try anything once. She looked pleased with herself, as much for having fought for what she believed was best for the patient, as for making another conquest along the way.

  I got up to leave. Monica looked surprised. “Why are you going so soon? We didn’t even get to what you wanted to talk about.” I had had enough. Monica was so completely at ease with her secret, lying life and relentless pursuit of pleasure that it brought her integrity into question – and mine, too. Who Monica was as a person tainted who she was as a nurse. I no longer respected her or valued her opinions.

  I WANTED TO SEE how Chandra was doing and we arranged to meet. She had been a fabulous critical care nurse, but never regained her confidence after making that terrible medication error. Her new job was in a five-bed ICU in a small community hospital in the suburbs. She said she chose it for the convenience of being closer to home, but I think she may also have been hoping it would be a less stressful environment. She soon discovered that even there the issues were just as big and the stakes just as high.