by Tilda Shalof
Both the man and the woman looked away from me, but not at each other. For a second I was afraid I’d said too much, too bluntly.
After a moment the man said, “Oh, dear God, I feel so bad.” His eyes filled with tears, and the woman put her hand on his arm without looking at his face.
“He was very special, wasn’t he?” I asked quietly.
There was a brief silence. Then the tall man answered me in a torrent of words that gained momentum as he spoke. “He was a wonderful man, the best of men. So intelligent, and boy, talk about a sense of humor!” The man threw his head back and laughed at the ceiling, though tears still dripped from his face. “He made everyone laugh. He tried to teach people how to feel good about their lives. He was a professor at Stanford, you know—very quick mind and yet always so gentle.” He paused, then: “Special? Yes, he was definitely special.”
The woman spoke up with a shaking voice. “Thank you, thank you so much for telling us the truth.”
A lump came to my throat, and I could only respond with a smile. And with that they left me alone with my patient.
The thermometer now read less than 98.8 degrees. I felt the clamminess of his skin and had a half-formed thought of primitive things from the sea. I shuddered and walked to the outer door. Through the waiting room window I saw the white-haired woman still sitting on the couch. I opened the door and asked her to come in. It was her time to be with him.
She approached the bed very slowly, then touched his face and kissed him. “Papa? Papa, I love you so much. I always have, darling. Don’t forget I love you so. I love you.”
I pretended to rearrange the plastic tubes and gray monitor leads that were no longer of use. I was torn between curiosity and feeling intrusive, witnessing the years of love.
“During the night,” the white-haired woman said, not taking her eyes off her husband, “he woke up several times, you know, the way we older people do, but the last time, when he walked back toward the bed, he called my name out. Just once. He looked so strange, lost really. Then he fell down, and I didn’t know what to do. I was scared, and he wouldn’t answer me, so I just kept talking to him, holding him, but he didn’t say another word.”
His wife opened her purse and took out an embroidered pink handkerchief and wet a tip of it with her saliva. With that she wiped away a smear of orange germicide from his chin. She picked up his cool, limp hand and put it softly to her cheek. “We were married forty-two years and loved each other every single day. He was my gift from God.”
She stared down at him and kissed the palm of his hand. “I love you, my darling. Good-bye for now.”
She put his hand down, closed her purse, and walked out of the room without saying another word. Forty-two years of loving and in one instant it was history.
Thirty minutes later, as I was turning him onto his side, I felt another presence in the room. Looking up, I saw Dr. Skinner staring at us from the door.
“The head scan showed massive hemorrhage. The largest I’ve ever seen. Stop all the drugs. The family wants it that way.”
“Okay,” I said, but didn’t move toward the intravenous lines. He felt like an intruder, and I wanted him to leave.
After a second he said, “He was dead before he even hit the floor.” It was his explanation, his excuse. He shrugged and walked away.
Carefully letting down the side rails, I gently put my hands under the Colonel’s shoulders and spoke to him in a slow, measured whisper.
“Did you feel all this love here today? You can leave this behind you now. It’s all right, I promise.”
My face touched his. “I’ll stay with you. I’ll be right here.”
A soft buzzing drifted through the room, demanding attention, as a small red light flashed in harmony to the sound. Blood pressure 40, heart rate 32. I squeezed his hands and felt a pressure rise in my throat. The blurring image of his face was changed and molded through my tears.
I turned to the pole holding the blue intravenous fluid, the one that kept his blood pressure up, and turned the plastic stopcock to the “off” position; then the yellow fluid, the one that kept his heart beating smoothly … off.
“All the pain is over for you now. Let it go. Let go.”
His skin was almost white, and the ring of blue surrounding his pupils had disappeared, leaving only the gray-black window open to finality.
Again the monitor flashed and buzzed as the agonal rhythm, the rhythm of death, slowly snaked its way across the screen…right to left. Blood pressure…zero.
The respirator seemed suddenly loud and obnoxious, diminishing the dignity of death. With one smooth, swift movement, I pulled the plug from the wall, creating silence.
For just one moment I knew all the warmth and joy his spirit had ever given.
I removed all the tubes and tape from his body and washed him with the warm, soapy water reserved for the living. And as I bathed him, I softly hummed a lullaby, covered him with a clean, soft blanket, and said, “Goodbye, Colonel.”
Just after midnight I walked through the empty waiting room, feeling drained. Yet, as I descended the eight flights of stairs and walked out of the hospital into to the crisp night air, I carried something with me. He had never spoken to me, there had been no gestures, I’d won no visible battles, but I had touched him, and his spirit…lingered.
Those ICU Nurses
Madeleine Mysko, RN, MA
IT WAS 1969, and I was 23, a newly commissioned second lieutenant in the United States Army Nurse Corps. My orders were to report to the Institute of Surgical Research (ISR), Brooke Army Medical Center, in Fort Sam Houston, Texas. And I was filled with dread.
The war in Vietnam was going on and I was serving in the Army Nurse Corps. I was proud of my commission and had just emerged from six weeks of basic training. I was prepared to go to the battle zone, if that was where the army needed me to go.
The feeling of dread didn’t arrive immediately. When I opened the orders and saw the words “Institute of Surgical Research,” I had a vaguely pleasant picture in my head of a place gleaming with stainless steel, where one might don an immaculate white lab coat and take precise notes on a clipboard. Rather, the dread arrived when I learned that the other name for ISR was “The Burn Ward”—the unit to which the seriously wounded from all branches of the military were flown directly.
It wasn’t that I was afraid of caring for burned patients. For that matter, I wasn’t afraid of caring for any sort of trauma patients. I had completed my training in an urban Catholic hospital nursing school, where the Sisters of Mercy still held fast to the tradition that student nurses learned best by doing—and by doing a lot. Thanks to them, I’d had plenty of experience caring for really sick people, for the dying, and for the bodies of the dead. Moreover, after graduating, I’d held my own for a year on the evening shift in a busy emergency room.
It’s hard to put my finger on the source of that dread. But looking back at the young woman I was then, and at the era I’d been trained in—a time when the nursing profession was undergoing rapid and dramatic change—I wonder if the dread had to do with the concept of intensive care nursing itself. To my way of thinking back then, an ICU was a closed-off space, crammed with scary machines and suffocating responsibilities. And the nurses whirling about at the center of those units were steely, a breed apart from the rest of us. I was only 23, but already I saw myself as belonging to an earlier era, to the breed of nurses comfortable putting their hands on the suffering patients, but not so comfortable with their hands on the ever-evolving, complicated machines that were used to keep those patients alive.
But orders being orders, there was nothing to do but report for duty. And so I climbed the steps of Brooke Army Medical Center in my crisp uniform and my spit-shined (literally) shoes.
The ornate facade of Brooke gave it a grand, old-world air—not at all how I imagined a modern “medical center” or a research “institute” would look. I walked through a cool, dark lobby with high ceiling
s and elaborate moldings. The polished floor squeaked underfoot, like the floors in the lobby of the old Mercy Hospital in old Baltimore, where I had trained, and where my aunts had trained, too. For a moment, it was like walking backward in time, not forward into the scary unknown. The dread lifted—but then I rode the elevator three floors up, to the Burn Ward.
My first impression of the Burn Ward is captured best in the incongruity I saw: the worn features of that old ward—the multipaned windows, the iron beds, the swabbed linoleum floors, the wooden wheelchairs lined up in the corridor, the antiquated bed-scale, the dark and cramped nurses’ station—juxtaposed against the advanced level of critical care that the patients were so obviously receiving. Nurses and corpsmen hurried about that small space in their surgical gowns and masks, their mouths hidden, but not their eyes, which expressed absolute confidence.
The chief nurse, Colonel Katherine Galloway, gave me the tour. She must have sized me up immediately. She put her hand on my shoulder and said, “You’ll be fine, dear. Don’t be afraid to ask questions.” The other nurses greeted me kindly, taking their masks off to smile and welcome me. The dread began to diminish. I saw that these good nurses would support me and teach me, and that I’d never be left to flail alone in a panic. And so I put on the gown and the mask and went to work beside them.
Blessedly, out on the main ward, there weren’t a whole lot of machines to deal with. The everyday work was that of debridements in the Hubbard tanks, dressing changes, post-op care of skin grafts, OT, PT, and the continual stress of managing the pain. I learned how to care for burns. I was comfortable on the Burn Ward.
But at the heart of the Burn Ward there beat the vital sanctum—a space off the main ward that was further separated into two smaller chambers and closed off by solid doors. Beyond those doors lay the burned patients whose lives hung the most precariously in the balance. They called it the Cube (short for “cubicle”). In truth it was the real ICU within the intensive burn care unit. Every time one of those doors was propped open to allow a stretcher to go in or out, or to admit a long parade of doctors and visiting researchers on rounds, I would force myself to look in. All those respirators and monitors, intravenous lines, suction machines: I dreaded the day I’d be assigned to work in there.
As it turned out, I never did get assigned to the Cube, either because Colonel Galloway saw I wasn’t ready, or because she never really needed me. ISR was blessed with a full staff of experienced nurses—more captains and majors than second lieutenants like me, a number of whom had served a tour in Vietnam, and a few who had additional training as flight nurses.
Still, every now and then I’d be asked to go into the Cube and assist. Looking back, I imagine this was Colonel Galloway’s way of providing me with opportunities to learn at my own pace. I confess I didn’t really take advantage of those opportunities, but rather became even more resistant to “intensive care.” I didn’t want to join the ones whose hands were always flying around in webs of intravenous lines, whose attentions were always riveted on readings, printouts, lab results, and the proper functioning of those respirators. I didn’t want to cross over into what seemed to me a realm that was all about the intensiveness, and less and less about really caring. I had no ambition to assume the weighty responsibilities of “the steely ones.”
One day I was in the Cube, helping Colonel Galloway and another nurse to care for a soldier who’d been burned over most of his body. He had just been returned to us from the tank room, and we were in the process of slathering Sulfamylon all over his entirely naked body. I remember that the soldier’s face was so swollen it was nearly featureless. I don’t remember all the details but with such devastating trauma, there must have been all sorts of things to manage for this patient: a tracheostomy, a ventilator, intravenous lines, gastric tube, Foley catheter. What I do remember—my heart squeezing in my chest even as I write this—is the enormous pity I felt for that poor young soldier, as I carefully applied the Sulfamylon. I also remember being relieved that that was all I had to do.
But there was Colonel Galloway—very much the nurse in charge, handling it all. She was explaining to the soldier what we were doing, acknowledging his need to know—whether or not there was the slightest indication he heard. Her voice was low and at the same time so beautifully powerful that even I was not afraid. I remember she reached down to the bottom of the linen cart to retrieve a single white facecloth. I remember that she placed it gravely over the soldier’s burned and swollen privates. “There,” she said, so kindly, leaning in to speak directly to her patient. “All done for now, Private Jones.”
I remember it still, 40 years later: watching Colonel Galloway, learning that they are a great deal more than steely, the best of those ICU nurses.
What I Can’t Hear
Judy Boychuk-Duchscher, RN, BScN, MN, PhD
AS CRAZY AS IT SOUNDS, this story is not an unusual representation of my daily life as a critical care nurse and clinical nursing educator in the cardiothoracic ICU at the Walter C. Mackenzie Health Sciences Centre in Edmonton, Alberta, Canada. In fact, as I think over the countless care situations I’ve experienced, which range from the absurdly humorous (“black humor”) to the tragically heartbreaking, this one fits right in the middle.
Our unit routinely handles some of the most precarious of medical situations: instability of the heart, lungs, and vascular system. It is not uncommon to have VADs (Ventricular Assist Devices), balloon pumps, hemofiltration or dialysis machines, electrocardiographic monitoring, IV medication pumps, and various artificial ventilators providing a symphony of sounds, which only a highly qualified nursing ear can interpret.
On this fairly usual day, the crisis came early in the afternoon, which is when patients often are returned from the operating room to our recovery unit. The OR had called to update us on the progress of a pediatric case, a nine-year-old boy who was not doing well. The surgeons had performed a rather complex array of congenital repairs and the patient was expected to require fairly extensive support in the form of multiple inotropic, vasoactive, and volume-balancing intravenous medications that we used to regulate blood pressure, heart rate (and rhythm); high-frequency ventilation to maintain the patency of, and maximize the function of, his underdeveloped and now chronically damaged lungs; and ECMO (extra-corporeal membrane oxygenation) to ensure he had adequate levels of oxygen to sustain his life.
We had prepared the corner bed of our 12-bed unit for him, in an attempt to minimize the sounds of traffic around other patients’ bedsides and to reduce the noise level his own medical interventions were producing. I can’t say we were that successful—it was loud in that corner: transferring this patient from the operating room took at least 10 people including several pump technicians, 2 anesthesiologists, 1 operating room and 1 critical care nurse, 2 respiratory therapists, and the attending pediatric surgeon and her entourage of residents and fellows. As often happens during such situations, everyone was talking at once and several people had to yell their requests for medications or particular interventions so that they could be heard above the roar of the equipment and voices. One really has to marvel at the poetry of “nursing in action” that is evident in what we would call the “uneventful” transfer of an unstable patient.
And thus the “tipping point” that is the always-dangerous transfer of a critically ill patient was eventually replaced by the ordered chaos of an “admission.” Those personnel not directly involved in the patient’s care or in the ongoing monitoring of his assistive devices left, and those of us who remained were the ones charged with helping this vulnerable child on his long road of recovery. I had pulled slightly away from the bedside of this patient, returning to the nurses’ station to get a different perspective of our progress … when I heard the voice. I couldn’t figure out the exact location of the whisper, but realized it was becoming increasingly persistent.
Before a patient is transferred into our unit, it is common practice for us to ask the family members of all
patients to leave the unit; we also close the curtains surrounding the other patients’ beds to spare them any secondary anxiety. So the area was less crowded than it ordinarily is. I gingerly scoped out the area, trying to locate the source of this insistent voice. Then I located which curtain was hiding my anonymous whisperer. I poked my head through the drawn curtains to see a quite-elderly gentleman smiling at me, motioning with his hand for me to come closer and “shouting” in a whisper, “Nurse, nurse, come here, nurse.” I smiled gently and entered his area, anticipating a need to debrief and reassure him about the new patient in the bed next to his. I took his wrinkled hand and leaned toward him. “Yes, Mr. C, what is it I can do for you?” I asked, fully expecting that he would need to be consoled and that I would likely be required to explain that what had happened to the patient next to him was not going to happen to him. But what he said (now shouting so that he could hear what he was saying) was, “Nurse, I just wanted to thank you.” He patted my hand appreciatively and continued, “It is so quiet in here—I am having the best sleep I’ve had in years!”
I smiled, encouraged him to go right back to sleep, thought for a moment how rich my life was as a nurse, and went back to work.
My First Code Blue
Chris Kebbel, RN, BScN
MY HEART WAS RACING. What do I do? Do I remember? Everything was a blur. All I knew was that the patient flatlined. Asystole. Vital signs absent. I climbed up onto the bed and planted my shaking knees right next to my patient’s limp arm. I thrust my hand into the carotid, felt for a pulse … waited … The only pulse I could feel was my own. I positioned my hands over the patient’s chest. Have I landmarked correctly? I tentatively pressed down. The laboratory dummies I practiced on seem so inadequate now! The patient’s chest barely moved. Rob Fuerté, my ICU preceptor, came up beside me. He urged me to press harder. My heart pounded faster and my body felt electrified by the adrenaline racing through it. I pressed down harder. This time the patient’s chest moved, but I felt it cracking under my hands. They’d taught us in school that you can break ribs, but I never imagined how unpleasant, how unsettling that would feel. I relaxed my muscles but definitely not my mind. I continued compressions.