Lives in the Balance: Nurses' Stories from the ICU

by Tilda Shalof

  Then it was time. The decision had been made: everyone was in agreement that to continue life support would have no benefit for Mr. Chu. It would only forestall his inevitable death. To continue with these futile measures would not, in this case, be the compassionate or dignified thing to do.

  The first thing I had to do was pull out the endotracheal tube that was keeping oxygen flowing into his lungs. This wasn’t like so many other times when I had extubated patients because they had been successfully weaned off the ventilator. This time there would be no success.

  God, please guide me with my words and actions.

  As I explained to the family what I was going to do, I slid my hand behind the ventilator and switched it off. A wave of silence fell across the room. I positioned myself at the head of the bed and extubated Mr. Chu. He started to make snoring sounds with each fast, shallow breath. The snoring sounded eerie to the family. In distress, they looked to me for explanation, reassurance. I felt unsettled too, because although I knew I had not caused this, I was the one that allowed it to happen. I offered to give my patient an analgesic that might decrease the snoring, but the family refused. I then offered a comparison to him snoring while asleep at home. This notion seemed to give them some peace.

  Within moments after extubation, the cardiac monitor showed that Mr. Chu’s heart rate was increasing to a sinus tachycardia of 148 beats per minute. I adjusted the alarm settings and repeated my assessment. There was no change. I tried patiently to answer the family’s questions. But it was the question one of the younger sons put to me that was the most difficult to answer: “He is breathing on his own now and the monitor shows his heart is still working. Is it possible he could survive this?”

  His words saddened me, because I knew he was looking for hope and I wasn’t certain what I could offer. I had cared for many dying patients and their families before and I knew what I had to say and, most importantly, what to not say. I felt grateful at that moment for having my many years of experience to draw upon. “Your father has suffered a major bleed in his head. All of the tests—the MRIs, the CT scans, and the EEGs—have shown that there has been so much damage to his brain that he will not survive. His shallow breathing shows that his brain is not working to keep him alive. I am so sorry; but your father is dying with dignity. He is so blessed to have such a loving family.”

  I scanned the room. They all seemed to be processing what I’d just said. Without waiting for any more questions or comments, I excused myself to check on my other patient.

  I returned to Room 286 frequently over the course of the night, bringing extra chairs, boxes of tissues, and cold drinks for the family. I continued to assess my patient’s condition, jotting down vital signs and suctioning from his mouth the oral secretions that he was unable to swallow.

  For the family, the wait was on.

  Seven hours passed; the family continued to hold their vigil. By 3 A.M., the physical and emotional exhaustion was visible on their faces. Suddenly, as I stood outside the door, charting the hourly vital signs, I heard screams from the room. I rushed in. Mr. Chu’s breathing pattern had dramatically changed. He was gasping. It sounded like a struggle, but I knew it was the normal sound of the breaths of a dying person. His respirations were only about four or five a minute. I looked at the monitor. Mr. Chu’s blood pressure was 54/36 and falling; the heart rhythm showed a wide, complex bradycardia. I rushed to the monitor to turn off all the alarms; they were no longer needed. All the family was looking at the monitor.

  I knew my role. I had been here before.

  I gently directed the family to focus on Mr. Chu and told them that the end was now very near. The family wailed, dropping their heads on his body; his wife frantically kissed his face, professing her love for him. I could feel a knot grow in my throat, tears forming in my eyes. I knew what was happening to me: I felt a measure of their sorrow. Twenty-two years as a nurse and it still happens to me. We nurses do our work, perform our important tasks, but we feel it, too.

  I turned back to the monitor. Asystole. There were no more heartbeats. I discreetly turned off the monitor and, as the family watched, I auscultated his lungs and heart. There were no breath sounds, no heart sounds. “He is gone now,” I told them. I hugged each family member in turn and allowed them to stay with their loved one’s body as long as they wished.

  The patient’s and family’s wishes had been carried out, and I had helped to make that happen. Very sad, but very satisfying to me, in my life as an ICU nurse: I could help make it possible for all the family members to be present at the patient’s bedside in his last hours and moments, and to find some measure of peace.

  Sick Kids

  Linda L. Lindeke, PhD, RN, CNP

  I WAS 23 YEARS OLD and had moved 3,000 miles to work at Toronto’s The Hospital for Sick Children (Sick Kids’), the most famous children’s hospital in the country. It was 1971. Wanting to challenge myself as much as I could, I asked to work in the ICU. This hospital was world renowned because it had pioneered some innovative procedures and was well-known as a world-class center for performing many experimental, cutting-edge open-heart surgeries for children. I remember hearing stories about the miracles performed for “blue babies” and about the surgical procedures that saved children’s lives. When I was in third grade, I had known a little boy named Eddy, who was in my class and had to come to school in a wagon. He died that year. Eddy could have benefited from the particular kind of open-heart surgery that was only done at that time at Sick Kids’ Hospital. It was from these experiences that I developed an interest in children’s heart surgery from a very early age.

  It was amazing to work in that hospital’s ICU. Children arrived at the hospital from many continents. We cared for many patients from very wealthy families in the impoverished but oil-rich countries of Central and South America. We also cared for native children from the reserves of northern Canada whose parents were not able to fly down to be with them and thus, we, the nurses, became their proxy families. Daily I would look up from the bedside of a sick child and see a group of visiting doctors and nurses from other parts of the world who were touring our unit and learning about the care we gave and the techniques we used.

  My experience working at this hospital, decades ago, has shaped my life and career. Teamwork is one of the most powerful lessons I learned. Children died daily in the ICU because the children who were the most severely ill were the ones who were transferred to this facility from near and far. We dealt with incredibly intense and heartbreaking situations, and because of the flat structure (meaning, there was little hierarchy; we all worked closely together) of the professional and support staff—our teamwork—we also saved countless lives. Staff turnover was low because we supported one another and gained tremendous satisfaction from caring for the children and families in the best possible way.

  We were all on a first-name basis in the unit. Staff nurses were valued and their skills and responsibilities appreciated. The custodial staff was known by name and often formed relationships with the children and families, some of whom remained on our unit for months. Teamwork was wordless at times, and very verbally expressed at other times. Of the many powerful situations I remember, here is one I still learn from.

  As I gained nursing skills, both intellectual and manual, the level of complexity of my daily assignments gradually increased. I had to know when a subtle change in a child’s breathing indicated a post-surgical complication of pneumonia or internal bleeding. I had to be able to manage ventilators, tubes, lines, medications, and various procedures unthinkingly, automatically, so that I could be simultaneously comforting the child and communicating with the family during the daily care.

  As the level of my responsibilities advanced, I was under the close supervision of experienced nurses. After a while, they deemed me ready to be the nurse who cared for a child directly out of the operating room after open-heart surgery. Children did not go to a recovery room after surgery because our ICU was equipped to
care for them in the post-anesthetic phase; that way they would not need to be moved a second time. The sickest children and those undergoing the most complex surgeries were the first on the daily operating room schedule. The ICU routine for post-op care was that the assigned nurse spent the time prior to the patient’s return from surgery setting up the room and doing as many things in advance as possible, so that she or he could immediately care for the patient returning from the OR. That meant preparing all the medications, intravenous solutions, bandages, charting forms, and other equipment. I had done all those things many times in my supervised orientation and knew the drill. I was ready. Because I was ready ahead of time, I spent my spare time relieving other nurses as they went on breaks and helping nurses who needed an extra hand with their patients.

  Then the call came that my patient was coming out of the OR. The bed was wheeled into the room. The child’s small body was barely visible beneath the tubes, machines, and dressings of the entire chest. My heart was racing and my adrenaline surging as I put my training into practice, providing immediate care for this child and family during the critical post-operative phase. I was moving at top speed and thinking as fast as I could to be sure I was doing everything in the right order and with correct procedure.

  Suddenly I looked up and saw Marion, the calmest and most understated nurse I believe I have ever met. She gave a small smile and went to the other side of the child’s bed. Without a word she reached over and took off the blood pressure cuff that I had just put on the little arm. Carefully and slowly she repositioned and connected the cuff to the wall-mounted equipment. She then gave me a penetrating glance and a small smile, and walked away.

  What was Marion doing at that moment? Why can I re-create that scene in crystal-clear detail? Because in my rush to remember all the tasks I needed to do to give this small, sick child the best care I could provide, I failed to pay attention to detail. Marion slowed me down; I had to look at my own behavior. In fact, in this high-stress situation, I wasn’t being effective overall. A reading from a misapplied blood pressure cuff is worse than no reading at all. Blood pressure is a key indicator of post-operative bleeding, septic shock, and other serious complications. One of the first things I had learned in nursing school was how to take a blood pressure reading, and now, at a time of critical importance, I had made a mistake in a simple task, and that mistake could have jeopardized my patient.

  I learned from Marion that being a mentor and role model is subtle work, and profoundly significant work: powerful mentoring can occur in a brief moment, if the mentor is a wise and internally grounded, caring person. Marion was head nurse for a reason. She possessed qualities that were not apparent on first meeting. She was not outgoing or flashy in her communication. She didn’t take center stage and demonstrate her deep understanding of pathophysiology, quality improvement, or the latest administrative process, though she had all those areas of expertise. She knew how to be in the moment and how to connect to a person’s inner core.

  I continued to work in the ICU for a year and a half and have countless other moments of deep learning that stay with me to this day. I left to become a nursing educator when an enticing opportunity came my way. I still tend to rush when I’m in a new or stressful situation; I tend to respond too quickly, in ways that are less precise or thoughtful than if I had been more deliberate in my actions. I continue to struggle with that tendency and tell myself to slow down and make sure that small but essential details are attended to.

  There are many, many more stories that I could write about this ICU era of my life. Perhaps I will write more. But the story of Marion’s wisdom and mentoring needs to be told. Thank you, Marion.

  Ray Can’t Get No Satisfaction

  Lisa Huntington, RN

  AFTER OVERDOSING on crack cocaine and alcohol at a Rolling Stones concert, Ray, a 42-year-old unemployed truck driver, ended up in our ICU to dry out overnight. He was unconscious, barely responsive to deep pain stimulus, and not breathing at all, so we had to fully ventilate him. As he began to wake up, he got restless and needed close monitoring. He kept making yanking motions to indicate that he wanted the breathing tube out, but he wasn’t awake enough or breathing on his own enough to have the uncomfortable apparatus removed yet. As with most overdose patients he began to wake up in fits and starts, at times thrashing around on the bed. We couldn’t sedate him because we wanted him to wake up so that we could extubate him, yet we were all at risk of him causing injury to us caring for him with one of his kicks or jabs, so we had to put him in four-point restraints: both arms and both legs had to be tied down.

  Ray finally woke up and, like Hospital Houdini, managed to slip his right hand out of its restraint. The first thing he did was pull out his breathing tube, setting off various bedside alarms. My partner for the day, Shilpa, a very petite middle-aged Pakistani nurse, got to him first, but she was no match for his 220 pounds of drunken fury. She tried to calm him down, suction his lungs, and assess his breathing. He had a strong cough and was able to get out a few words (swearing and threats, mostly). “Listen, lady, I gotta record as long as my arm, so call the cops if you wanna!” He then promptly passed out.

  “I think I will let sleeping dogs remain lying down, so to speak,” Shilpa said. She enjoyed trying out various English idioms and using them in her own way.

  I tried to settle Ray and managed to convince him that if he’d sit up, do the deep breathing and coughing exercises I had instructed him in, using an incentive spirometer device designed to inflate his lungs, and go along with other chest physio exercises, we might be able to spare him an unpleasant re-intubation. In his semi-stuporous, semi-lucid state, he managed to convince me that he’d cooperate. By then, it was time for my lunch break and the ICU finally seemed quiet enough for me to take it. Shilpa would be able to manage on her own, I figured.

  I had no sooner walked down the hallway, away from the ICU, when I heard Shilpa cry out, “Lisa-girl! Come back! Help me! All of hell is breaking loose!”

  I ran back to find Shilpa cowering in the corner. Ray had managed to spring loose from all four of his restraints. He’d jumped out of bed and ripped out his IV. Blood was dripping all over the bed and the floor. Even worse, he had ripped out his arterial line and bright red blood was gushing out of his radial artery. He’d even pulled out his Foley catheter; there was blood dripping from his penis due to that rough method of removal. Ouch, I thought, wincing at the sight. There he stood beside the bed, naked now, having torn off his hospital gown, ECG electrodes hanging from his chest but disconnected from the monitor, teetering on one leg, the other still tethered to the footboard. He was still confused but had cleverly managed to grab a pair of suture scissors and was madly trying to cut the last flannel restraint binding his foot.

  I tried reasoning with Ray, but he was just getting more agitated. I had no choice but to call a Code White over the public announcement system. The security squad would help with our violent patient. I managed to get close enough to Ray so that I could clamp some pressure on that bleeding artery, while Shilpa tried to cover up Ray’s private parts, but he didn’t care about that and waved her away.

  “I just want to get the fuck outta here!”

  Two security guards finally turned up with the nursing supervisor. They donned disposable gloves, crossed their arms, and stood just outside the door, looking bored. They couldn’t do much more than we were doing.

  We all tried negotiating with Ray, trying to calm him down and make him behave, to no avail. He was staggering around, mumbling and getting wobbly on his feet. Finally, he dropped the scissors and fell back onto his bed. I untied the last restraint and covered him back up. Shilpa promised him that he could have a drink as soon as she checked his blood pressure and oxygen level and put a bandage where his IV had been and a pressure dressing over his arterial line site.

  Ray no longer needed to be in the ICU. He certainly needed something; I wasn’t sure what, but it wasn’t the ICU. The guards said we could
call them back if we needed them. I was about to find the resident to write transfer orders and have Ray sent to a medical floor. But Ray would have none of that. He wanted to go home.

  “I want out of here, now! Where’re my clothes?” He was getting restless again and there was no reasoning with him. The decision was made that he could be safely discharged home if a responsible adult came to pick him up. We managed to track down a brother who lived about an hour away who said he’d come around to pick up Ray … eventually. Until then, Ray remained in our care. He scowled at that. “Well, if I have to stay here, I’m gonna need a drink,” he mumbled.

  Shilpa, always helpful, brought him a paper cup of apple juice.

  “Not the drink I had in mind,” Ray said.

  “You can lead horse to juice but cannot force him to take the drink,” she said, with a giggle.

  Ray drank the juice, then immediately announced, “I need to take a piss.” I offered him a urinal, explaining that he was still too shaky to walk to the bathroom. I just hoped he wouldn’t throw it. Shilpa grabbed the full bottle just before Ray passed out again on the bed. “The cup is running over,” she said, and we both tried to hold back our laughter, but no matter, as Ray had dozed off to sleep.

  Suddenly, he woke up with a start. “Where are my pants?” I gingerly handed the booze-stained, cigarette smoke–infused garment to him. As he shakily pulled on the pants, about ten dollars in change and three guitar picks fell out onto the floor. I helped him get dressed and then brought him a sandwich.

  “Thanks, ma’am,” he whispered.

  An hour before the end of my shift, Dave, Ray’s brother, finally arrived. Unfortunately, he seemed even drunker than Ray. I prayed he wasn’t driving. It was unusual to discharge a patient from the ICU directly home. Most of our patients go to a step-down unit and then to the floor before going home, but Ray had gone from a critical condition to his normal, sober but chronic, alcoholic state in less than 24 hours and was ready to resume his “normal” life straight from the ICU.