Lives in the Balance: Nurses' Stories from the ICU

by Tilda Shalof

  “Call the surgeon!”

  “Call blood bank—we need blood!”

  “How many units?”

  “Lots!”

  “Where’s the RT?! We need to intubate, right now!”

  “Open all the lines!”

  We pushed epi again and again and again, to try to kick-start her heart. There was still no rhythm.

  “Continue chest compressions!”

  “Call The Team!” In a CV-ICU there is the ICU team and then there is The Team. The latter comprises the individuals who work in the OR with the cardiovascular surgeon: cardiac OR nurses, perfusionists, and many others. They came, bringing with them the equipment they would need to perform cardiac surgery right in the room. I figured this was likely a precipitous tamponade, which is a compression of the heart due to a collection of blood in the pericerdium, most probably due to a ruptured graft. There was no time to get the patient to the OR; the OR would have to be brought to the patient. Her chest would be opened right there in the room.

  Within minutes, everyone arrived. The patient was prepped and the chest sutures were cut. The chest wall was peeled back and held open by large steel clamps called retractors, to reveal a quivering heart bathed in a sea of blood. Someone reached in and gently squeezed the heart, waited for its own intrinsic electrical conduction system to take over … but nothing. The blood was quickly suctioned away and the area was washed and kept reasonably free of blood by a constant flow of fluid so that the surgeon could identify the rupture and re-suture the graft. While all this was going on, powerful medications were being prepared and IV drips were hung. I was drawing up drugs and sending off blood work. By this time, the activity in the room reverberated like a low hum: in these situations, the urgency is palpable but it is tempered by steely determination and purpose.

  All hands were on board—this was a team, and despite the crisis and seeming pandemonium, there was order to this chaos. No one needs to be told to tie up a gown, open a sterile package, pour the chlorhexidine: things get done. Everyone knows what to do. A code or an emergency surgery like this is an exquisitely choreographed dance among many skilled professionals who know and respect one another’s roles and who depend on every other dancer to get it right. Everyone knows that the life of this patient hangs in the balance.

  Finally the rupture was sutured and sterile internal defibrillation paddles were applied to the ominously still heart.

  “All clear?” Once. Nothing.

  “All clear?” Twice. Still nothing.

  The heart was squeezed gently again and this time there was no blood flow from the coronary vessels. We needed to get the heart going on its own—immediately.

  Suddenly, there was a little movement. More drugs were pushed. I stood off to the side and watched and prayed for her heart to respond.

  “We’ve got a heartbeat!”

  Yup, and a blood pressure, too, although it required support from a slew of drugs, including epinephrine, Levophed, vasopressin, dopamine, and others. Blood and plasma were being pumped into the patient; the lines were wide open. Someone was shooting cardiac outputs, sending off blood work, analyzing arterial blood gases, and making adjustments on the ventilator. She was still unconscious, but I did what I always do with my patients, regardless of their state of awareness: I talked to her, encouraged her, told her to hang on.

  She was still so critically ill, we didn’t know if she’d make it. Would the chest be closed? What’s her lactate? Where’s the family? Have they been notified?

  Then came the hard part: getting this patient through the next 12 hours. There were so many immediate tasks to do that I couldn’t even allow myself to think of the possible complications that might result from this catastrophe. Due to such prolonged and profound hypotension, her kidneys might not have received adequate perfusion, so she might develop something called “acute tubular necrosis.” That might mean dialysis, either temporarily or permanently. Depending on the condition of her heart, a balloon pump might be added, to assist perfusion. My goal for the next few hours and the next day, when I returned to care for her again, was to help her become stabilized.

  Surprisingly enough, this patient survived—that in itself is a miracle. Open-heart procedures in the ICU setting are uncommon, and when you consider the uncontrolled environment, the length of time without a heartbeat, and the patient’s age, among other variables, you realize that this patient’s resilience—the human body’s resilience—is truly a marvel.

  IT WAS A YEAR OR TWO LATER, a Monday, around 9:00 in the morning. Everyone had descended on Hospital Row, as this stretch of University Avenue in downtown Toronto is called, as the workweek began. I had gone to the first floor for a cup of Tim Horton’s coffee and stepped into the crowded elevator to find that the button for each floor had been pressed, lighting up the panel like a veritable Christmas tree. The doors closed, and lulled by the muted sound of conversation, I retreated into my own thoughts. My day had started almost two hours earlier, when a real hospital day starts. The elevator door opened and closed.

  “There you are! I knew one day I would see you again,” a voice said.

  A tiny woman stood in front of me, looking at me; I looked behind me to see who she was talking to. I didn’t know this woman.

  “You may not remember me, but you were my nurse when I had my surgery.”

  I opened my mouth to say something, but what could I say? I didn’t remember her, and I was embarrassed at being singled out. The crowded elevator had fallen silent, as all eyes turned onto this unfolding tableau.

  “I had heart surgery,” she said, as if she were telling me she’d had mango ice cream, and it tasted good.

  “Oh, yes …” I said uncertainly.

  “And I had another attack and they opened me up right in the room. I almost died.”

  Now I remembered, and along with everyone else in the elevator, I became caught up in the story this little dynamo of a woman was spinning. I was so entranced by her obvious delight at being alive and her lack of constraint in the telling of this tale.

  “And as I was going in and out of consciousness, at one point you said to me, ‘Hang on, sweetheart, I’ve got you.’ Your face was the last thing I saw just before I blacked out.”

  By then, I was so choked up I could barely speak. She reached into her bag.

  “When I left the hospital, I bought this because it reminded me of you; I always keep it with me.” She pulled out this blond, blue-eyed angel from her bag and took my face between her hands, pressing the pale doll onto my dark-skinned cheek. I had to chuckle at that image, but I was very grateful for her sincere intention.

  “I will always remember you,” she said and stepped from the elevator.

  The elevator doors closed.

  How can you beat that feeling? I was on top of the world!

  “That would make my day,” I heard someone say from the back of the elevator.

  I stepped from the elevator, tears rolling down my cheeks. I felt so touched and humbled, and so appreciative of my profession. Nursing reminds me, each day, to care—in the midst of chaos and imminent death.

  I have been blessed in my choice of career.

  Acknowledgment of Permissions

  “Intensive Care” is excerpted from Intensive Care: The Story of a Nurse, copyright © 1987 by Echo Heron. Published by Ballantine Books.

  About the Editor

  TILDA SHALOF is a staff nurse in the Medical-Surgical Intensive Care Unit at Toronto General Hospital of the University Health Network and has been there since 1987. She graduated from the University of Toronto, Faculty of Nursing back in 1983 and has worked in hospitals in New York City, Tel Aviv, and for the past 23 years in Toronto. In 1990, she achieved certification as a specialist in Critical Care Nursing from the Canadian Nurses’ Association.

  In 2004, Tilda published A Nurse’s Story, a memoir of her career as a critical care nurse. It received wide critical acclaim, became a national bestseller, and has been translated into C
hinese, French, Japanese, and Vietnamese. In 2007, Tilda released The Making of a Nurse, in which she charts the educational, intellectual, emotional, and spiritual steps in her journey of becoming a nurse. In it, she shares some of the professional and personal challenges she’s faced in becoming the nurse she aspired to be. Her latest book, Camp Nurse—My Adventures at Summer Camp is a fond remembrance of six summers working at a variety of residential summer camps for children in Ontario, Canada. Written from the perspective of both parent and professional, it describes the joys of camp, its many benefits to children, and the ways that a camp nurse helps keep campers—and their counselors—safe and healthy.

  In addition to being a critical care nurse and bestselling author, Tilda is also a frequent media commentator, a nurse and patient advocate (she believes the two roles go hand-in-hand), and an inspiring and dynamic public speaker. Her presentations include insider stories from her long career as a critical care nurse and observations about the realities of clinical practice in today’s healthcare environment. Tilda addresses a broad range of audiences, but her messages resonate most strongly with frontline caregivers, both professional and lay, nurses and doctors and all other healthcare roles, specialties, levels of experience, and practice settings. She is passionate about helping caregivers re-connect with their ideals, to inspiring them to excellence in their practice, and to reminding us all about the privilege it is to do this work. Tilda is dedicated to explaining nursing and healthcare to the public and to raising the awareness of the central role of nurses in ensuring the public’s health and safety.

  Tilda lives with her husband, Ivan Lewis, and their sons, Harry and Max, in Toronto, Canada, and can be reached through her website www.NurseTilda.com.

  About the Contributors

  DR. JUDY BOYCHUK DUCHSCHER RN, BScN, MN, PhD, became a nurse in 1979 and went on to achieve a Post-Graduate Diploma in Intensive Care Nursing from the University of Manitoba, a diploma in Cardiovascular Nursing from Stanford University in California, and Critical Care certification (CCRN) from the American Association of Critical Care Nursing. Boychuk Duchscher helped initiate the heart and heart-lung transplant program at the University of Alberta Hospital, developed the multi-organ donor referral program at Toronto General Hospital, and managed the lung transplant program at Barnes Hospital in St. Louis, Missouri. She has taught at the University of Saskatchewan and holds academic positions with universities in Alberta, Calgary, and Western Sydney in Australia. In 2006, Boychuk Duchscher launched a non-profit organization called “Nursing the Future,” an initiative that serves as a bridge between the ideals of nursing education and the realities of professional practice. As a scholar, Boychuk Duchscher has published widely on the topic of new graduate transition in peer-reviewed articles and book chapters. Boychuk Duchscher is a much-sought-after speaker on the topic of the contemporary climate of acute-care nursing, new graduate transition to professional practice, and multi-generational nurses in the workplace.

  SARAH BURNS, RN, BScN, is a graduate of Northern Michigan University’s Nursing Program. She has worked at hospitals in Massachusetts, Michigan, and Texas. Currently she works in a medical intensive care unit at the University of Michigan Hospital.

  MATT NATHAN CASTENS, RN, BA, CCRN, discovered that nursing was more fulfilling than his previous career as an actor when he started working as a nursing assistant in critical care. Matthew has since worked as a staff nurse in a cardiovascular ICU, in a trauma-neuro ICU, and as a flight nurse. He now enjoys nursing staff development as the Resource Educator for Critical Care at North Memorial Medical Center, a Level I Trauma Center in Robbinsdale, Minnesota.

  ELIZABETH DILUCIANO, RN, lives in Virginia Beach, Virginia, with her husband, Gregory. She’s worked in a Level 1 Trauma Hospital as a bedside nurse in a Neuro Intensive Care Unit since 1990.

  CECILIA FULTON, RN, BScN. A graduate of George Brown College, Ontario, Canada, Cecilia went on to complete a Bachelor of Science in Nursing from Ryerson University, graduating as class Valedictorian. She began a master’s degree at the University of Toronto but “found the disconnect between the curriculum and clinical practice to be too large an abyss to bridge.” Fulton has worked as a community nurse and vows never to relinquish her nursing license. “I worked too hard to get it,” she says, though in 2004, she took her real estate license. “Nursing is no longer my primary profession these days. Living in Toronto with my husband, Larry, and raising our three children is now my priority. At times, I miss the excitement of the ICU, but get discouraged when I hear that my colleagues are still battling some of the same issues we faced years ago. I am proud of them for having the energy, skill, and compassion to continue doing one of the most demanding jobs in the world.”

  JANET HALE, RN, graduated from Seneca School of Nursing in 1975. She worked in General Surgery, then became a critical care nurse and has worked in the Medical-Surgical ICU at Toronto General Hospital for over 24 years. “I am married to Dan and we have two wonderful daughters, Karen and Julie, but I am owned by a Scottish Terrier and three West Highland Terriers. I love to sew, quilt, knit, read the classics, such as the works of Thomas Hardy and Jane Austen. I volunteer with Team Captain of the Medical Team for the Annual Weekend to End Breast Cancer and the Ride to Conquer Cancer…. Life is never dull.”

  KATHY HALEY, RN, has worked at Toronto General for 24 years, most of them in the Medical-Surgical ICU. She has been a member of the Critical Care Outreach Team since it began in 2005. Kathy is married to Bob and they have two sons, Christopher and Connor.

  ECHO HERON, RN, worked in ER and Coronary Care in the San Francisco Bay Area for 18 years. She is the author of the bestselling Intensive Care: the Story of a Nurse, Condition Critical: the Story of a Nurse Continues, Tending Lives: Nurses on the Medical Front, Mercy, and the Adele Monsarrat R.N. medical mystery series, Pulse, Panic, Paradox, and Fatal Diagnosis. Ms. Heron continues to champion nurses and pursue her literary career. Find out more about Ms. Heron’s work at www.echoheron.com.

  BOB HICKS, RN, BScN, BHSc, has studied at the University of Western Ontario (2002) and the University of Toronto. He co-authored the Preceptorship Resource Kit, published by the Registered Nurses’ Association of Ontario. Bob currently works at New York-Presbyterian Hospital in the Surgical ICU.

  KAREN HIGGINS, RN, has more than 33 years nursing experience as a front-line caregiver and staff nurse. She is also past-President of the Massachusetts Nurses’ Association. During her tenure Higgins led MNA’s fight to improve the quality and safety of patient care in Massachusetts’ healthcare facilities, worked to increase access to healthcare for all citizens, and chaired a task force to address the nursing shortage. Higgins is a leading figure in the American Association of Registered Nurses. She currently works as a staff nurse in the Cardiac Care Intensive Care Unit at Boston Medical Center.

  LISA HUNTINGTON, RN, graduated from St. Rita Hospital School of Nursing in Sydney, Nova Scotia, in 1983. She began her nursing career in Moose Factory, Ontario, a tiny Cree community in James Bay. She has worked in the ICUs at Northwestern Hospital in Toronto, Toronto General Hospital, and in Townsville, Australia. Presently, Lisa works in Medical Imaging, where her critical care skills are invaluable.

  CHRIS KEBBEL, RN, BScN, is a critical care nurse with over ten years of bedside experience in the Medical/Surgical ICU at Toronto General Hospital. He now divides his time between clinical practice and his own healthcare informatics consulting firm, Cecktor Limited, which provides clinical information systems and web solutions to healthcare clients. He can be reached at his company’s website, http://www.cecktor.com.

  KAREN KLEIN, RN, BScN, obtained her nursing degree from Adelphi University, graduating magna cum laude. Her varied experience includes ER/Trauma, Pediatrics, Interventional Radiology, Telemetry, ICU, Home Infusion, and Occupational Health. She is a certified Emergency Nurse, an American Heart Association CPR/First Aid Instructor and has been published by Nursing Spectrum Magazine.

  DR. ROSEMARY KOHR is
an Advanced Practice Nurse in Acute Care Medicine, London Health Sciences Centre, London, Ontario, where she has worked for 15 years. She is a wound care consultant and educator in acute, community, and long-term care settings. Rosemary completed a BA in Visual Arts from the University of Ottawa, BScN from Laurentian University, a MScN from the University of Western Ontario, and a PHD from the University of Alberta. She holds a post-Masters’ Acute Care Nurse Practitioner (ACNP) certificate (University of Western Ontario) and has academic appointments in the Faculty of Health Sciences at UWO and Athabasca University in Alberta, Canada.

  DR. LINDA L. LINDEKE, PhD, RN, CNP, graduated from the University of Alberta, Canada, and received master’s and PhD degrees from the University of Minnesota. She is a pediatric nurse practitioner, working in educational settings as well as with infants born prematurely and their families. Her interests include health policy, children with special healthcare needs, and barriers to nursing practice. She is the national president of NAPNAP, the 7,000-member National Association of Pediatric Nurse Practitioners.

  MARY MALONE-RYAN, RN, BN, studied nursing at Dalhousie University of Halifax, Nova Scotia, in 1987. She worked in General Medicine and the Medical ICU at Toronto General Hospital until moving to Hickory, North Carolina, where she works at the Frye Regional Medical Center in the cardiovascular ICU. Mary is married to Frank and they have Molly, Caileigh, and Luke Malone.

  LINDA MCCAUGHEY, RN, BScN, CNCC(C), has worked in the ICU for the past 24 years and has achieveds certification as a critical care nurse from the Canadian Nurses’ Association. Linda has helped initiate and develop the Critical Care Rapid Response Team. “Of all that I have done in the hospital, I am most proud of being a bedside nurse, caring for patients. It’s not always given enough credit, nor is it the most popular choice for newer nurses, but it’s what gives me the greatest satisfaction.” Linda has been married to Dan for the past wonderful 25 years and they have three children, Kirsten, Shannon, and Alison. Kirsten and Shannon are in their second year studying nursing and Alison is in grade school.