by Tilda Shalof
“What do you think, Tilda? Do you think I can beat this thing? Do you think I’ll make it?” She closed her eyes to take a deep breath, then opened them to receive my response.
I had never been asked a harder question. I couldn’t look her in the eye because if I did she would see that I thought she was going to die. Still, that question hung in the air between us. I wanted to give the best, kindest response, but also the truest. I looked at her expectant face. How cruel it would be to say anything that might dash her hopes.
To Daphne, giving up was the worst possible choice, but wasn’t there a peace to be found in surrender? I am committed to look at life as truthfully as I can, but I had to respect her way. As a nurse and as a friend I try to treat others as they wish to be treated, not how I would wish to be treated. It’s like giving a present: you don’t give what you would like to receive; you try to imagine what the other person would want. I had to find a way to tell the truth, but which truth and how to tell it? I delved deep into the well of all that I have learned as a nurse and said, finally, “If there is anyone who can beat this, Daphne, it would be you.”
She leaned back against the couch, pleased to receive the gift I’d offered.
A FEW WEEKS LATER, the hospital sent her home and the doctors told her they had nothing more to offer her except palliative care, but she was angry at the very suggestion. I went to visit her and her husband, Ken, told me that the tumours were wrapped around her entire intestinal tract, cutting off the circulation. She was receiving nutrition at night through an intravenous line called TPN* that he managed quite capably. Their living room had been transformed into a mini hospital suite.
“I wrote only one line today,” Daphne said when she saw me. “Nothing feels like a poem.”
Ken asked about the drain in her abdomen. “Sometimes it flows well, but other times it seems blocked.” He was an engineer and needed to visualize the internal structures in order to understand their function. I drew a diagram of the anatomy of the organs and how the tumours obstructed the outflow of fluid. By positioning Daphne on her side, gravity would ease the pressure. We talked about the laws of motion and the impedance of flow, until he said he understood. I sat down on the bed beside Daphne, feeling proud of my small but useful contribution.
She rocked herself back and forth. Suddenly, she lurched forward for the plastic basin into which she vomited in an almost graceful way. Ken rubbed her shoulders as she heaved into the basin and then hurried off to empty it and rinse it out. I wondered if he felt any of that resentment that used to sweep over me when I had been home alone taking care of my mother, but he seemed wholehearted in his new role as his wife’s caregiver. He had a few more questions and for those, he took me aside.
“They won’t admit Daphne to the palliative care unit, because she wants to have the night time nutrition. I see their point of view,” he said. “Why feed someone who is only going to …”
“Hospitals can’t tolerate too much ambiguity or contradiction,” I explained. “They can’t work at cross-purposes. If Daphne wants to be fed, she doesn’t by their definition qualify for palliative care.”
“To her, palliative care means it’s the end.”
“Yes, and it also means comfort.”
“What should I do if I can’t manage with her at home?”
“Has she expressed a wish to die at home?”
He shook his head. “She doesn’t believe she is going to die.”
“Bring her to the hospital when she is ready or when you are.”
I went back to sit beside Daphne.
“It’s hard, Tilda,” she said, shuddering as she reached for the plastic kidney basin. “My poems are from my old self and I am still giving voice to my new being.”
I was leaving the next day for a family vacation and I wanted to say goodbye to her, but she wouldn’t have accepted it. I believed it would be the last time I’d see her, but when I got up to leave, she smiled and said she’d see me soon. I saw that she was not afraid of dying because she did not think it possible. It was her ingenious way of keeping fear at bay. But it was only a few days later, during that vacation, that a mutual friend called to tell me that Daphne had been admitted to the hospital and had died there, that morning.
It’s the Jewish custom to rush to burial in the belief that mourning cannot properly begin until the person is in the ground. I was too far away to attend the funeral, but I wanted to know the end.
“I went to see her yesterday,” the friend said. “I asked her how she felt. She said ‘grand,’ and then a minute later she died. That was Daphne, elegant to the end.”
EVERYONE HAS SOMEONE they are worried about. Everyone needs a nurse, or will at some time. And once you become a nurse, or choose to act like one, you’ve signed on for life. Can you ever be off-duty? Once you know what you know and once you have chosen to care, can you ever look away and not respond when needed? Is it possible to turn off that awareness of others’ needs, especially if you have the skills or knowledge to mitigate another person’s suffering? It is, but you don’t. For most nurses, their profession defines who they are. They are nurses everywhere, all the time. There’s no turning back. Nurse is noun, verb, and adjective. It’s a job, but it’s also a way of being in the world, on-duty and off, at work and away.
* TPN is Total Parenteral Nutrition.
17
DANGEROUS ASSIGNMENTS
My day was not getting off to a good start. Usually, I leave myself enough time so that I can sit for a few minutes before work in the underground mall opposite the hospital. I like to take the time to pause and locate my calm centre that I vow to maintain in the face of the possible things in the day ahead that might threaten to disrupt it. That morning, I guess I hit the alarm clock snooze button a few too many times, and had to scramble to get dressed and then rush off to work.
Outside the front doors of the hospital, there was the daily gathering of die-hard smokers clutching their IV poles (urine bags dangling off the bottom) with one hand, their lit cigarettes in the other. (It’s the only place they can go because smoking is banned inside.) As I was about to get onto the elevator, two men, their fat bellies pushing out under their flapping hospital gowns elbowed their way forward, cigarette packs in hand, eager to get outside for their smoke. “I’m on thinners,” one was saying to the other. “How ’bout you?”
“Me too,” his partner said. “Man, they do a number on your heart.”
Riding up in the elevator, I was subjected to more snippets of dreary conversations.
“Our health-care system is falling apart … gone to rack and ruin.”
“Forecast calls for rain,” a voice said.
“What a dull morning,” someone else said. “Not a bit of sunshine.”
Maybe it’s time to look for a new job. Why do I still work in this depressing place?
It takes effort to be positive. It doesn’t come naturally to me. At times, it requires courage and imagination, neither of which I could muster during a recent period of disenchantment with my hospital world. I wasn’t burnt out as much as tuned out. Coasting along, floating mindlessly, going through the motions, I gave safe and satisfactory care, but my thoughts were elsewhere, my heart empty; the zing was gone. I worked to pay my bills, no more, no less. Then a patient startled me awake. He was a nameless, homeless man in his forties who came in with a terrible diagnosis. It’s the condition that causes the greatest suffering, requires the most painful treatment, and has the bleakest prognosis. To me, it’s the worst possible diagnosis because it’s the one I once had. I knew this man’s problem so personally that I never believed a time would come when someone like me could offer anything to a person like him, much less the other way around.
“YOU LOOK TIRED, Tilda. Coming off nights?” someone asked in the locker room as I changed into my scrubs.
“I’m coming on now.” I glared back at her. “Day shift.” Do I look that bad?
“Ouch. Excuse me.”
Sin
ce I was running late, I hustled off to the ICU, checked my assignment at the nurses’ station, and headed straight to my patient’s room. “How was your night, George?”
He leaned back in his swivel chair. “I worked all night to save this guy, even though I’m not sure we’re doing him a favour. But he’s finally coming around. Say, how are your muscles?” He playfully squeezed my biceps. “This dude’s rambunctious. You may have to call a Code White for the security guards or else snow him with sedation.” Then George dropped down to the more serious story of our patient. A street nurse found him collapsed in an alley, cold, emaciated, and hardly breathing. She brought him in her van to our hospital where he was intubated and ventilated. During the night, he kicked and punched everyone who came near him. He had pneumonia, but the medical notes stated the more dire diagnosis: Failure to Thrive.
The physical causes of failure to thrive, such as poor nutrition and dehydration, are easy to treat, but when failure to thrive is due to a loss of will or lack of hope, that’s a case of pure despair, and what’s the cure for that? I had a feeling that’s what we were dealing with here. In the place of “Name” read “John Doe.” “Home address” was blank. He was an alcoholic, iv drug abuser, and out on bail for assault. He had been attending a methadone clinic but had lapsed back onto heroin, cocaine, and crystal meth use – in short, whatever he could lay his hands on. Then he’d developed an untreated upper respiratory infection that in his debilitated state quickly led to pneumonia and brought him to us in the icu.
I looked into the room. He was sitting up in bed, peering out to see who would be his nurse just as I was peering in to see who would be my patient. I didn’t like what I saw. He was thrashing about and had a nasty look in his bleary eyes. His ribs stuck out as he leaned forward, tugging his hands against the restraints pinning him down. He whipped his head from side to side, as if trying to escape the tube that was sticking straight out of his mouth. He was trying to kick his legs, but they were held down tight. Despite the restraints, he was managing to create quite a commotion. George finished giving me report and stood up to leave.
“Good night,” I said with a fake smile.
“Good luck,” he said with a sympathetic one.
I paused to consider my options. No one would want to switch patients with me and it was far too late to secretly pencil in a different nurse’s name beside this patient. If I had gotten to work earlier, I could have made the change and no one would have been the wiser. Another more energetic and motivated nurse could deal better with this patient than I. I’ve done my time with difficult patients and the younger ones need this experience, I reasoned. Since I could see on the monitor that his vital signs were stable, I didn’t go to him immediately. I sat outside his room, perusing the chart, and wasting time before I had to go in. Carmel, a nurse I’d worked with occasionally, came by with a guilty look on her face. “Hey, Tilda.” She touched my arm. “I have a confession.” She took up the seat beside me. “I got here early and saw they’d put me with this patient and I made a switch. I put you here instead. Have you noticed how they usually give the dangerous assignments to the black nurses?”
No, I hadn’t noticed, but other nurses have told me this. Perhaps it’s true, but what makes one assignment more unpalatable or difficult, or even more hazardous, than another? Caring for this patient was frightening for me for reasons no one could possibly know. It was my secret. The dangers here weren’t only that this man was filthy, infected, and violent. I felt confident I could capably protect myself from those risks. I was far more susceptible to catching a lethal dose of his despair. I swallowed hard. “Carmel, if you feel you’re being discriminated against, why don’t you say something to the nurse who made up the assignment?”
She nodded but she seemed content to complain. “Tilda, are you okay with this patient?”
“Yes. No problem,” I said, not letting on what I really felt, which was a sinking sense of dread. I got up. It was time to go in. I donned a mask, gown, and gloves to add yet another barrier to all the others that already stood between us. As soon as I opened the door of his room, I reeled back from the stench. I couldn’t do my head-to-toe assessment, or check his heart rhythm, or listen to his lungs: hygiene was top priority. It would have to come first, admittedly, more for me than him.
He’d managed to wriggle out of all of his sheets, leaving himself exposed. Standing at the door, I could see the long red dotted lines of scabies along his legs and arms. His inner arms had raw, oozing purple-blue track lines along his veins. Whatever I felt or thought didn’t matter. I filled a metal basin with hot soapy water. I got two more and filled them as well. More than ever did I wish I had that portable shower I had been dreaming up for years.
I stood at the foot of his bed. “I’m Tilda, your nurse,” I said dully. Lucky me. Lucky you.
It’s usually hard to make out the words of intubated patients but there was no mistaking this message. “Fuck off!” he mouthed, his eyes filled with rage.
I told him I was going to give him a bath, and he neither consented nor refused so I pulled the curtains closed and got to work. He was tall, maybe six feet, but all skin and bones. As I worked on him, he continued to thrash around, his fists clenched, still straining at the tube. Gradually, the water calmed him down a bit, but he kept shaking his fists at me. I was tempted to sedate him, but that might delay extubation. I wondered if loosening the restraints would calm him down but I was afraid to get hurt. I have received punches and kicks from patients and I realize that it is delirium that makes them combative, but still, it’s not easy. I looked down the hall for help, but everyone was busy. I had to take a chance. As I untied one hand, he grabbed my arm in a tight grip. I shook it off. “Let go of me,” I shouted, jumping back. “Don’t touch me!” I threw the washcloth into the basin, splashing water all over the bed. “Are you going to let me take care of you or not?” He nodded and I released his legs. He kicked them around, perhaps just to feel them again after being tied down. I began to wash his face and neck with the warm, soapy water, maybe a bit roughly at first to show him who was boss, and then more gently. I shaved around his beard and then soaped up his arms and legs and chest and splashed lots of hot water all over him. I washed and combed his hair. He lay there, indifferent to what I was doing. Then I attacked the streaks of dried shit and urine that stained his genitals and legs. I have cleaned excrement from patients who were unconscious or who for other reasons had lost control, but this man had relinquished his continence. It didn’t matter to him. It was the shit of not giving a shit any more.
I have never read much of the New Testament, despite the many copies that have been pressed upon me over the years by sincere and well-meaning Christians. But I knew that Jesus had washed the disciples’ feet and that was a very impressive act indeed, although they probably weren’t as dirty as this patient’s. I thought about that as I washed his stinking feet, as I parted each toe and scrubbed away and tried not to look too closely at what I was pretty sure were bugs in there. I changed his sheets and put a fresh hospital gown on him. I pulled opened the curtains and didn’t say another word or give him a backwards glance. I peeled off my gown and gloves, washed my hands, and hurried out.
PREJUDICE IS A TERRIBLE THING, but in a nurse it is unconscionable and dangerous. We hold ourselves to a high moral standard. Every professional does, but few are challenged in the way that nurses are to confront what most repels us. I once asked Tracy if there were patients she had difficulty caring for and she admitted, “I can’t stand the way men in some cultures treat their women.” She told me about a female patient who had tribal slashes all over her face and who had been circumcised. “I realize it’s their culture, but it’s too alien to me. I couldn’t get past it and definitely couldn’t get close.” And when Laura had judgments about patients who made suicide attempts, she never showed it, at least not to them or their families. Noreen certainly hadn’t recoiled from the hostile, angry family of Jerome, the young man who died of
liver failure. Funny how Carmel, the one who complained that others discriminated against her, once complained to me about a patient. She told me about a new immigrant to Canada from Pakistan who was not yet a citizen but nonetheless was put on the list to receive a lung transplant. “Don’t you think a real Canadian should get one before her? Not only that, but our tax dollars are paying for her health care! Don’t you think it’s wrong?” No, I didn’t, but I had my own prejudices to contend with. Mine were against people who gave in to despair, just like I had.
It was when I returned home from travelling to Israel. I was twenty-four. My father had died, my mother was dying, I was estranged from my brothers, our house was sold, and I felt so bereft of family and comfort and all alone in the world. Friends offered me places to stay, but in my condition it felt like too much of an imposition. I was just as angry, just as homeless as this man. I had resources and supports but I chose not to turn to them. Instead, I went underground and hid. This man was me. I was him. I had been that lost, that close to the edge.
IN MORNING ROUNDS the team gathered to discuss his case. The staff doctor peered in through the glass. “He looks familiar,” she said. “I’ve seen him before.”
How could that be? He looked like any of them. He could be any of many derelicts loitering on Carlton Street on Sunday morning after a Saturday night binge or even that greasy bum near the University of Toronto who I used to rush past whenever he begged for a bus ticket.
“Where?” I asked her. “In emerge? The nurses there said he’s a ‘frequent flyer.’” I had obtained his old charts from medical records where it stated his name was Zbigniew Zwiezynskow, but there was no home address and no family, next of kin, or friends listed. He was all alone.