A Nurses Story | Chapter 10 of 27

Author: Tilda Shalof | Submitted by: Maria Garcia | 1443 Views | Add a Review

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FIRST, TAKE YOUR OWN PULSE

The stopcock terrified me.

Before I became a critical care nurse, I worked on a variety of medical and surgical wards in many different hospitals and I had acquired a lot of experience with veins. Veins trickled, oozed, or dripped. One of the big differences of working in the ICU was that, for the first time, I was confronted with arteries. Arteries spurted and gushed. After all, they are the vessels that pump blood directly from the heart. The stopcock is the gateway to the world of the artery.

In my early days of working in the ICU, the arterial stopcock – that little nub of hardware – taunted and haunted me. It was a mere half-inch piece of white plastic, and its mechanism was simple, yet its implications were immense. Each and every ICU patient had an “art line” in place (inserted in the radial artery in the wrist or femoral artery in the groin) to give us easy and instant access to the patient’s circulation. The art line allowed the nurses to monitor patients’ blood pressure and procure the many blood samples – most importantly, the arterial blood gases, ABGS we call them – without disturbing the patient.

With the stopcock positioned in the upright direction, we could monitor the patient’s blood pressure. We made sure to set the alarms to upper and lower parameters for the systolic (contraction of the heart) and the diastolic (relaxation of the heart) measurements. As long as the numbers stayed “WNL” – within normal limits (something I was expected to be able to ascertain at a moment’s glance) – all was well.

Problems could occur. Sometimes, a stream of blood crept up backwards and went along the tubing in the wrong direction and I was supposed to troubleshoot the problem. It could be a loose connection somewhere in the system or insufficient counter-pressure. Sometimes, the waveform on the monitor was dampened or had an overly high amplitude. Then I would have to flush the system, re-calibrate the transducer, heighten the sensitivity, or merely check the module and cables.

In order to obtain a sample of arterial blood to send to the laboratory to test the oxygen, carbon dioxide, and bicarbonate levels (substances that had to stay within a narrow range or else the patient would be in life-threatening danger), I had to turn the stopcock to the left – which meant the artery was wide open – and then move swiftly to attach a special tube that withdrew a sample of bright red blood from the pulsating stream. Then I had to flush the line clear of blood, reset the stopcock to the upright position, and close it off, all the time keeping everything absolutely sterile.

For other procedures, I had to turn the stopcock to the right. In that position, a flat green line would suddenly appear on the cardiac monitor and an urgent, piercing alarm would sound. If family members were present, they would jump, especially when their loved one was being cared for by a novice nurse – something they seemed to sniff out moments after meeting me. However, the alarm could also go off if the patient rustled the sheets or moved in bed, in which case the alarm was caused by “artifact.” Most importantly, the alarm could signal the “real thing” if the heart went into a sudden lethal arrhythmia. It was my responsibility to know the difference.

As if the stopcock wasn’t daunting enough, I also had to deal with the transducer, which connected to the monitor, cables, computer module, and the oscilloscope. Those, together with the electrodes, waveforms, and amplitudes, were just some of the vocabulary of a brand-new language in which I had to become fluent. In addition to all that, I had to add on the lexicon of critical illness, such as multi-system organ failure, congestive heart failure, and hepatic or renal failure. Then there were the shocks: anaphylactic, hypovolemic, cardiogenic, and the worst shock of all: septic shock. All failures and shocks.

I HAVE ALWAYS been a big reader, and as a child I devoured the Cherry Ames stories – Cherry Ames, Cruise Nurse; Cherry Ames, Dude Ranch Nurse; Cherry Ames, Ski Patrol Nurse; and Cherry Ames, Department Store Nurse. I had dreamed of being like her, one of those compassionate, selfless people who did generous things for people in need. The glamour and exotic adventures that nursing seemed to offer were appealing, too. All in all, nursing seemed like a good way to do all that and make a living at it, too.

In some ways, my career choice of nursing felt like a fallback onto something familiar. In my family, I had always been the caregiver. I was one of those little girls who could spot the one person in a crowd who wasn’t feeling well, the one who needed a chair or an arm to lean on. Early on, I figured out that to help someone who is unsteady on their feet, you offer your arm, rather than take theirs in yours. Without anyone telling me, I would run off to fetch an aspirin and a glass of water if someone had a headache or a pain somewhere.

I often wonder if other nurses come from homes where they learned to be the caregiver, where that was the role handed to them or the one they took upon themselves. It was at home, where my parents were older than most, and where there was so much illness, that I first honed my nursing skills. My mother had Parkinson’s disease and manic depression; my father had diabetes and heart disease; and one of my brothers, schizophrenia. Doling out my mother’s pills, monitoring my father’s blood sugar, and coping with my brother’s paranoia and verbal outbursts occupied my free time as a child. To the best of my ability I took care of them all until my parents died and my brother and I lost contact. My two other brothers left home to escape the madness, and who could blame them?

Nursing was a logical, if ironic, choice for me: those very skills that I had developed at home in my family provided the vehicle that transported me away from that house of sadness. They provided my means of escape and became the tools of my trade. However, when I first told my self-educated, working-class father and my uneducated, yet cultured mother my choice of career, it took them aback.

“Jewish girls don’t go into nursing,” my father said when I told him what I was thinking of studying. It was the early eighties and I had just finished high school and was casting about for something to do. There would always be sick people and nurses would always be needed to take care of them, I reasoned. Surely I could do that; I had been doing it for years.

“I never heard of a Jewish nurse, have you, Ellie?” He turned to the couch where my mother lay. My mother knew a lot about opera, but very little about anything else.

“She’ll be Florence Nightingstein,” my mother said in a voice muffled by a giggle and her arm, flung back across her face.

“I wonder why there aren’t many Jewish nurses,” my father mused. The question seemed to interest him, as did most everything. “It is one of the oldest professions, although by no means the oldest one, mind you. We all know what that is, of course, heh, heh. Perhaps it is because the noble vocation of ministering to the sick is, somewhat – how shall I put this?”

“Icky,” offered my mother.

“Well, Ellie, now that you mention it … but it’s not just the menial work, it’s also that nursing is not very, well, it’s not the most –”

“High class and refined. Not at all,” my mother said, with a melodramatic shudder of disapproval behind her arm and her now-closed eyes.

“Surely, Tilda, you could choose a profession that doesn’t involve such selfless, back-breaking labour and long hours for such meagre remuneration. What are your girlfriends going into?”

It was true that none of my friends had even considered nursing. Natalie was off to study social work in New York. Allison was going to do a liberal arts degree at the University of Toronto, but first a year of backpacking through Europe. Stephanie was an aspiring actress.

“Your mother and I always hoped you would go to university,” my father said wistfully. I knew he regretted that he had not had that opportunity when he was my age.

“Maybe I could study nursing at university,” I said, wondering if I’d even be accepted with my ho-hum academic performance in high school.

“I see,” he said slowly. I knew he was trying to come around to supporting me, as he did in most everything else. “Whatever you decide,” he said finally. “In life, it’s not about doing the work you love, it’s about loving the work you do.”

I had no idea what my mother thought. At any rate, she had no further comment, as she had risen from the couch and was busy being Madame Butterfly in the kitchen.

FOR THE NEXT four years I stumbled, bumbled, and fumbled my way through university lectures and clinical assignments in hospitals throughout the city. Somehow I got through it all but I began to have qualms about my choice. There was something about my personality that seemed unsuited to being a nurse. Nurses were by and large practical, sensible people, oozing with confidence and common sense. I was nothing like this. There was also something about my temperament (too mercurial) and my constitution (too sensitive) that made me ill suited to be a nurse. Yet, at the same time, I still felt passionately committed to the noble idea of service to human beings in need. I longed to be a bona fide member of the “helping profession.”

I drifted along in my first two years of university in a state of dreamy distraction. Then, during my third year, my father died suddenly. I barely had time to register the shock, so busy was I caring for my mother, who was in the advanced stages of her disease and overcome with grief and depression. It was just before my final exams and my professors advised me to drop out and defer my studies for a year, until things settled down. But I was in so much of a hurry to get out and be free that I didn’t take their advice. Somehow I managed to finish that year and then the next, all the while counting the days until I could escape my home and family, and most of all, myself. Somehow I got through it all. I managed to graduate with a Bachelor’s degree of Science in Nursing and a Certificate of Competence to practise nursing. I was familiar with abstract theories and had read lots of research studies, but the rigorous discipline and practical skills of basic nursing practice eluded me.

The dean of the Faculty of Nursing shook her head sadly at me on graduation day. Prim and starched as Florence Nightingale herself, she wore a dove-grey suit with a white blouse and the requisite coral cameo at her throat. I had scraped by with a 66 per cent average. Who would want a nurse who knew only 66 per cent of the material? I knew I was a liability out there, but I promised myself I would be very careful, double-check everything, and try to stay out of the way of patients.

“You do have potential, dear. If only you had applied yourself, you could have made the Dean’s List,” said the dean herself. “Maybe you should go into research or administration. If you repeat courses and improve your marks, you could apply to graduate school. Have you considered that?”

I had thought about it, briefly, then quickly put the idea out of my mind. I was too impatient to get away from home – and to work, to travel, and to have fun and adventures – to pay much attention to her suggestion.

“She’s a good nurse,” I heard the dean telling the other professors afterwards at the graduation party. “Competent, but a bit scatter-brained.”

UPON MY GRADUATION, full-time nursing positions were scarce. That didn’t particularly perturb me, as I was not ready to settle down in one job, anyway. I joined a nursing agency and took on a variety of placements, such as private-duty nursing for imperious, rich old ladies recovering from hip replacements in their homes. Over the next few years, I did freelance medical writing for a pharmaceutical company; computer work for a doctor; and lots of part-time gigs in hospitals around town, never going more than a few times to the same place. I thought of myself as a “freelance” nurse.

In my travels, I discovered that many nurses were suspicious of degree nurses. Sure, they know lots of theories and research, they said, but can they cope with the demands of the job? In my case, they had reason to be concerned.

I recall one of my first days on a general medical ward. The doctor ordered a naso-gastric tube to be inserted into my patient’s stomach after surgery.

“There’s the clean utility room,” said the nurse in charge, waving in one direction and running in another to receive a fresh post-op patient who was coming off the elevator on a stretcher. Over her shoulder she called out instructions. “Get a size 10 or 12 tube, a large syringe, and a basin of ice. Make sure you auscultate the gastric bubble to check for proper placement. Once you get it started, connect it straight drainage – no, better make that low Gomco – and replace the hourly losses with saline. While you’re at it, his potassium is low, so you’d better change the IV to 20 millequivalents of KCl per litre and run it at 100 cc per hour. When you’re done that, insert a Foley catheter and measure his hourly urine output. If this is your first time, you lucked out, ’cause males are a lot easier to catheterize than females. Got all that?”

I had read about these things, even seen one or two, but had never actually done any of them before.

“Oh, you university grads!” she said when she saw me floundering. “We need real nurses around here.”

The littlest things could trip me up. One day, on a postpartum ward, I was assigned to take care of five new mothers and their babies. One new mother, exhausted and in discomfort after a Caesarian delivery, needed my assistance with a bed bath, but something was wrong with the curtains around her bed. I tugged and pulled, but they were stuck and didn’t slide along the rails on the ceiling. I yanked at the curtains but they wouldn’t budge. I went off to find the nurse in charge to report the curtain problem. I advocated for the client’s right to privacy. Patients needed personal space within the vast public territory of the institution that they can call their own, I argued, recalling a lecture I had once heard on the subject. Patients have an inalienable right to autonomy, and with their permission, we may enter their domain.

“Call housekeeping,” the nurse said, pushing the laundry cart into a patient’s room. “Probably just needs some more rods and hooks. That and a spritz of WD-40 should do the trick.”

“You’re right,” I conceded. A few rods and hooks, not a paradigm shift. I went back to work.

Even though the agency sent me to different hospitals around the city, and I rarely returned to the same ward twice, after just a few months, wherever I went, they considered me “senior staff” on the team. But “team nursing” was beginning to be considered old-fashioned and on the way out. Nursing theorists were promoting the virtues of “primary nursing.” In primary nursing, nurses were responsible for all aspects of the care of a small group of patients to whom they were assigned. Whereas in team nursing, the work was divided and each nurse focused on a few tasks – say, vital signs or dressing changes – and did those tasks for all the patients in that ward, sometimes up to as many as forty patients.

From the patients’ point of view, team nursing was “off-the-rack” shopping and primary nursing was personalized service; it was assembly-line production versus a made-to-measure, custom job. As so-called “senior staff,” working with a team, I might be the one to administer the meds for all the patients in the ward or pair up with an orderly and make rounds turning patients in bed, giving baths, changing the iv bags. It was a big responsibility, but my role was clear and straightforward.

I loved making beds, especially an “occupied bed,” when we turned the patient from side to side and did everything for the person who lay there helpless. As we went from room to room, I worked with a nursing assistant and we moved together wordlessly in concert with the sheets and blankets, making corners and pulling up the linen, folding it down, and making it smooth all over. Presto: the finished product, so crisp and inviting. Those beds we made would be a gift to any feverish patient.

Team nursing also gave me a fleeting sense of belonging to a group, even though I never stayed anywhere for long. Team nursing assuaged my loneliness and gave me a sense of family, something I craved, but then wanted to escape from. From the nurses’ point of view, team nursing was an efficient way to work. It even occasionally allowed for time at the end of the shift to sit and drink coffee together at the nursing station while we finished up our charting. Although team nursing was convenient for nurses, I could see that for patients it fragmented the care they received into separate tasks performed by different people coming and going at various times. However, at that stage in my career, patients were the least of my concerns.

In those days of adjusting to the realities of my profession, one of the hardest things for me was waking up each morning for work. The luminous green numbers on the face of my alarm clock glowed in the darkness when I woke up long before it rang, after a night of broken, restless sleep. During those nights before work, I couldn’t afford to abandon myself to the deep sleep that allowed for dreaming. The hours of the night were a countdown. My alarm clock was set for 5:00, but bells were ringing in my head at midnight, around 1:30, at 2:00, again at 3:14, around 4:00, at 4:33, until I finally shut it off at 5:00, before it had its chance to do its job. I lay there in disbelief that it was so early and that there was so much ahead of me that day. Would this be the day that would break me? I wanted to go back to sleep, not because I was tired, but because I was afraid. Duty propelled me forward. I put on a tape of Glenn Gould performing the Bach Concerto in E Major. His deliberate and forthright interpretation helped drown out my apprehension. The music fortified me to go on.

At 6:00 I left the house and rushed through the deserted streets to the subway. At that time of the morning, the moon is still out, as well as the bright headlights on the few cars in the city streets. When I reached the hospital, I entered the chrome-walled elevator and rode it to whatever floor I was assigned to that day. I strode through dark, disinfectant-smelling corridors, opened the heavy door of the ward or department du jour and reported for duty like a soldier.

The work was hard and I was busy every minute of each twelve-hour shift. Mostly I was running, fetching, pushing, hauling, lifting, carrying, and pulling. There were lots of opportunities to use my mind, but there was little time for it; the work required a Trojan’s stamina and stopping to think only deterred me from completing all the tasks that were required. I was beginning to realize that the best way I could excel as a nurse would be to invest in a good pair of running shoes and a gym membership. I had to get in top physical shape for this line of work.

Nursing also required close attention to detail, quicksilver problem-solving abilities, and strict time management. Often, I fell short. Once, I increased the rate of a patient’s IV, not even noticing that it was not properly connected, and fluid and medication had dripped into her slippers. On another occasion, on an ophthalmology floor, I reported that my patient’s pupils were wide and unresponsive to light. Could he be having a stroke? Should I call for a neurology consult? When the nurses gathered at the nursing station stopped laughing, they told me that the patient’s widened pupils were due to the drops the doctors instilled to dilate the pupils, a standard procedure prior to an eye examination.

At least I always tried to be empathetic. I had been taught that empathy was the most important quality a nurse had to offer. In fact, it was the hallmark of the professional nurse. However, in my case, some common sense and maturity would have helped, too.

One evening on an Oncology floor, a man with advanced stages of cancer silently ate his dinner. The news was on the TV, but he paid it no notice. The room was filled with flowers and boxes of unopened candy, but there was no family at his side. His disease was progressing rapidly, and at times he endured excruciating pain.

He pushed away his half-eaten dinner, leaned back against the pillows, and sighed deeply. I noted his “flat affect” and reminded myself to document that later in his chart in the “emotional/psychosocial” category. “Oh,” he let out a long sigh. “What will be?” He shook his head and covered his face with his hands. “What will be?”

Finally, my chance to be empathetic had arrived. I pulled up a chair to his bedside.

“Tell me how you are feeling, sir. Are you perhaps worried that the cancer has spread?”

He looked up and noticed me. “No, my dear.” He patted my arm. “This Mulroney government is ruining everything. Oh, for the Trudeau days. Now there was a leader!”

I HAD A tendency to take patients’ reactions too personally. Toward the end of a busy evening on a Cardiology ward, I brought a plastic med cup of pills to a patient. I gave her the pills along with a glass of water with a bent straw in it.

“Which pills are these?” She sat up in bed to examine them.

“Please don’t sit up yet, Mrs. Jones.” I put my hand gently on her shoulder. “You have to lie down and keep that sand bag on your groin. You’re at risk for bleeding after your angiogram.”

“These aren’t my pills.” She took her glasses from the bedside table, shook them out, and put them on to examine what I was offering.

“Yes, they are,” I insisted.

It was my last med round of the evening. I pushed the unwieldy metal wagon ahead of me like some pharmaceutical ice-cream vendor, dispensing a rainbow of pills, capsules, liquids, elixirs, and suppositories to thirty-six cardiac patients. I glanced at my watch. An hour to go and I still had ten more patients’ pills to give out. Call bells were ringing. A mountain of uncompleted charts was heaped up at the nursing station.

“What are these pills?” she demanded.

“The blue one is your water pill, the white ones are digoxin for your heart rhythm. The little yellow football is for your blood pressure and the tiny white one, that’s for your nerves.”

I was going to need one for my nerves too, if she kept this up.

“That’s not what my nerve pill looks like,” she said.

“But Mrs. Jones, that’s your Ativan. It’s 1 mg of Ativan.”

“Ativan is bigger than that. I know Ativan! Ativan is oval, not round. You’re giving me the wrong pill.”

“Here’s the bottle. You can see for yourself what Ativan looks like. Here, have a new one,” I offered.

“No, you’re not going to give me anything. I want a different nurse. I know what you’re up to. You want to knock me out so that I can’t report you.”

I was finished. My shift was almost over. I pushed the cart to the next bed.

WITHIN ONLY A few years, the trend in the nursing job market was completely reversed. The public’s need for nurses was just as great as always, but now a new provincial government had been elected with the promise to pay for them. Suddenly, nurses could choose which hospital they wanted to work in. Attractive signing bonuses and educational benefits were offered. Almost every department in each hospital was advertising nursing positions. The only problem was that now, there was a nursing shortage. Enrolment in nursing was down and the previous “surplus” of nurses had forced many nurses to move to the United States to find work. Splashy newspaper advertisements and job fairs proliferated to try to lure them back to Ontario hospitals.

I applied for a job at a big downtown hospital. It was the same hospital where I had been a candystriper as a teenager, where I had once worked in the patient lending library as a summer job, and where I used to accompany my mother to appointments with her specialists for her various, mysterious ailments.

“A degree from the University of Toronto? Mmm.” The nurse recruiter who reviewed my file looked pleased. Not many nurses had a university degree in 1986, and it was definitely the way of the future. In fact, nursing leaders were predicting that by the year 2000, all nurses at the bedside would have their degrees.

“Which specialty area do you prefer?” she asked. “We have openings everywhere.”

I was hard-pressed to choose. I didn’t have a particular loyalty to any specific organ, like the brain (neurology) or the heart (cardiology). At that moment, I happened to look out the window and saw a sign that had arrows pointing to the various departments in the hospital. There was Admitting, Radiology, and a sign that said Intensive Care Unit – the ICU – fourth floor. The reputation of ICU nurses was that they were the elite squad. To work there was an achievement many nurses aspired to attain. There, the patients were the sickest of the sick and the nurses wore serious green scrubs (which I thought might be more flattering to my fair complexion than the white or soft pastels I wore on the wards), stethoscopes slung around their necks, and got a lot of respect. As I stared at the letters, I sounded them out in my head and found myself hearing the words as “I see you,” beckoning me to take on this challenge.

ICU,” I said. “I’d like to work in the intensive care unit.”9“Normally, we prefer a nurse to have acquired at least a year of experience in one specialty area of acute care before progressing to critical care,” the recruiter explained, noting my spotty employment history, “but we’re desperate for staff in every department. I have so many openings to fill.” She paused. “With your university degree, I’m sure you’d catch up in no time. You will have to go on a special course first, would you be agreeable to that? Tuition will be paid, plus your salary for eight weeks. In return, there will be a commitment from you to stay with us for at least a year and work in the Medical-Surgical ICU. The patients there have critical illnesses such as major surgeries or complicated medical problems – and we are now starting to perform lung and liver transplants. You will find it a very interesting place to work.”

“Good, no problem. Where do I sign up?”

ROSEMARY MCCARTHY WAS the nurse manager of the Med-Surg ICU. She was short, round, and serene. It was calming to be in her presence, something I tried to be, whenever possible. She wore the same green scrubs that the staff nurses wore, and over that, a white lab coat. On her bookshelf she kept a graduation picture of herself in a navy blue cape, wearing a nursing cap – a high, starched one with a black velvet ribbon. To me, it looked ridiculous. I had learned that the cap was an obsolete symbol of the subservient role of nursing and of nurses’ subordination to doctors – and practically everyone else. We had come a long way from those days.

For the first few weeks of my orientation to the intensive care unit, they buddied me with Frances. Only a year older than I, Frances was already an experienced ICU nurse who had acquired her “training” (as she called it), “back home” (as she referred to it), in a small town in New Brunswick. She had learned on-duty from nuns, who were nurses in the local Catholic hospital, but since there were no jobs available for nurses when she graduated, she left her hometown to seek work in Toronto.

Frances was patient and didn’t seem to mind taking me on. Orientation was a good word for what we did together, because disoriented was exactly what I was. Disoriented and discombobulated. The first thing she did was help me overcome my fear of the stopcock by giving me an unused arterial line set-up that I took home to practise with privately, in a strange-looking pantomime of drawing blood.

Frances watched me closely my first time drawing blood from a patient. I knew that if I didn’t do it exactly right, the person could lose a lot of blood very rapidly. Litres of blood would pump out in few moments and if I wasn’t fast enough, or didn’t pay proper attention, the patient could hemorrhage and slip into unconsciousness. That degree of blood loss could lead to iatrogenic anemia, exsanguination, and death!

“Probably not,” said Frances, “but it sure would make a mess.”

AT THE START of every day shift in the ICU, the overhead fluorescent lights were turned on, one by one, as if to simulate sunlight and daybreak. However, I quickly realized that this was truly an illusion as there was very little natural light, and for most of these patients, there was no real sense of differentiation between day and night; they were sick around the clock.

In each room, the weary night nurses moved around the beds, finishing up their work and preparing to give report to the fresh and well-rested incoming nurses who bounced into the room, energetic and eager to start their day. They would nod and listen to the night nurses’ report, wish them a “good night,” and then start their day with their own assessments of their patient. They would make their own interpretations, adjust the plastic tubing and wires the way they liked them, and take charge of the flow of fluids draining in and draining out.

We started work at precisely 0715 hours when we went to our assigned patient room and received report from the night nurse. Since all the patients were critically ill and unstable, we were rarely assigned more than one patient at a time. Each one required our complete and constant attention.

Frances decided that I should take full responsibility for my patient’s care, and she would be there as backup, only if I needed her. By then, I had completed the critical care course that the hospital had sent me on and was soon expected to be out on my own, to have my own patient assignment, and do everything myself. I was just about to start my initial assessment of my patient when Laura, one of the other nurses who always worked with Frances, came by to offer me advice.

“Don’t panic. If there are green lines moving along on the monitor and no alarms ringing, everything’s okay, for now. Sit down and have a coffee. Relax.”

My stomach was churning. “I think I’ll run to the washroom, first, before we start.”

“No. That’s not allowed,” Laura said sternly.

I was too stressed to notice the twinkle in her eye. “What? I can’t go?” I gasped.

“Of course, silly. Just kidding.”

We were never supposed to leave a patient in the ICU unattended.

NURSING ISN’T FOR everyone, don’t you know,” said Frances to me as we sat in the staff lounge, eating our lunch. She said it kindly. “You remind me of this girl in our class back home. She had to run to the bathroom all the time, just like you, before she gave an injection, before she changed a dressing. She dropped out of nursing and became a nun. Some people can’t take the pressure, especially here in the ICU.”

“I might very well turn out to be one of those people,” I said grimly, “but I want the chance to find out.”

“That’s good on you!” she said.

I WORKED HARD to learn the routines, to stay on top of the hourly vital signs, to perform the ventilator checks, to give the medications on time, do the treatments, participate in team rounds, arrange for X-rays and ECGS, and assist with tests and procedures. There was something to do every minute. I noticed how Frances did not only the task at hand, but also two or three other things at the same time, all the while, preparing for upcoming tasks that she anticipated.

“Where did you do your training?” Frances asked me one day.

I was standing there, watching her draw a blood sample from my patient’s arterial line. She flipped the stopcock to the right, attached a test tube, and then flipped the stopcock open to the left. As she waited for each tube to fill, she smoothed her patient’s ruffled hair and checked his heart rhythm and blood pressure on the cardiac monitor. When the test tubes were full, she flushed the tubing, took a moment to hold up a tube of blood to the light to admire its bright redness – an indication of good oxygenation – and praised the patient for his progress. All the while, she was listening for my answer to her question.

“My training?” I was embarrassed by my university education, paid for by my parents. The other nurses in the ICU with their college diplomas were, in many cases, still paying back their student loans. Not only that, but they were the competent ones, and I was the disoriented and discombobulated one. I mumbled my answer.

“And where did you work before coming to the ICU?” Frances asked.

“Oh, here and there,” I said. “A little of this and a little of that.”

We started every shift by performing a head-to-toe assessment of our patient. “Head” meant to talk to the patient, but it felt awkward to talk to patients who couldn’t talk back because of the tubes they had in their mouths or because they were sedated or unconscious. But I did as Frances had shown me. I approached the bed and greeted my patient who, on that first day, was a sixty-eight-year-old man, two days post-op major surgery to repair a ruptured aortic aneurysm.

“Hello, Mr. Stavakis. My name is Tilda and I’m your nurse today. Can you squeeze my hand? Can you give that a try?” Then I started to go through, in a systematic fashion, the tests of a patient’s level of consciousness. First I checked his pupils with a flashlight to assess their reaction to light. I gave him simple commands, such as “Open your eyes” or “Wiggle your toes.” When he passed those tests, I proceeded to the higher cortical-level functioning tests to determine if he was oriented to person, place, and time. I checked his reflexes, handgrips, and his response to painful stimuli such as pressing on his nail beds and rubbing his sternum.

“When a patient is fully conscious, you don’t have to go through all the tests, Tilda.” Frances gave me a nudge and whispered in my ear. “Move on.”

Of course.

I turned my attention to auscultation of the patient’s heart and lungs with my stethoscope, and then assessed the condition of his skin and incision. I checked all the equipment and examined his heartbeats on the monitor and measured each one with my brand-new pair of calipers. I palpated his stomach, measured the amount of urine in the Foley catheter, and peeked under the sheets. No problems there. Well, I congratulated myself, so far, so good. I might make it here, after all!

After I finished my assessment, I decided to say something to my patient that I had heard Frances say to her patients. Sweet words that were the essence of nursing itself. I silently praised myself that here I was, ready to say them to a patient, and so soon in my career as a critical care nurse.

“Mr. Stavakis? I’m your nurse and I’ll take good care of you. You don’t have anything to worry about because I will be with you all day. I will take care of all your needs and make sure that you’re comfortable. Okay, Mr. Stavakis?” He squeezed my hand in agreement (what choice did he have?) and gave a weak smile around the tube in his mouth, a tube that went into his throat and down into his lungs.

Maybe if I said the words and went through the motions, that feeling of confidence, of being the capable ICU nurse that I dreamed of being, would follow? I had read somewhere that orthodox Jews advised skeptics to go through the actions of keeping kosher, lighting the candles and observing the Sabbath – even if they didn’t yet fully believe: do the deed and the faith would surely follow. But even as I performed the correct actions, so much of the complex information that I was learning in the ICU remained a bombardment of separate, concrete items. I still couldn’t put the whole picture together. I tried to imagine the complicated drugs I was giving and what each one was doing. This one is contracting the heart, this one is expanding the lungs, this one is carrying the oxygen molecule, I told myself. But the images were like cartoon pictures in my mind.

As we came to the end of the long twelve-hour shift, I emptied all my patient’s drains and measured their contents, changed the IV bags, tallied my fluid balance, made my final notes in the chart, smoothed the bedsheets and pillows, made sure Mr. Stavakis was comfortable, and prepared to give report to the night nurse. By then it was evening and so I dimmed the lights in my patient’s room to create a peaceful atmosphere at the end of the day.

Frances said, “You’re doing great, Tilda.”

I beamed. Yet I was exhausted from the heightened state of alertness I had been in all day, listening for and responding to the ringing of alarms. As I walked out the door, I felt the weight of responsibility unfurl from my shoulders, as physical a sensation as shedding a heavy winter coat on a spring day.

MR. STAVAKIS DETERIORATED during the night. The next morning when I came in I saw that his colour was dusky and he was sweaty and restless. He wasn’t responding to my questions; he didn’t squeeze my hand. I tried to ignore what I saw and pretend it wasn’t happening. I didn’t feel ready to cope with an unstable patient.

Frances came over. She took a look at my patient and her eyes went straight to his chest. She studied the rise and fall of each breath for a few moments and pointed out to me that the two sides were not symmetrical. “How long have his saturations been in the 80s?” She glanced at the monitor. “Look how fast he’s breathing.” She called for a bag of ice upon which to place the sample of arterial blood that she was busy drawing for testing of his gases. “He may have blown a pneumothorax.” I knew that meant a possible collapse of the lung. Frances cranked up the ventilator to deliver 100 per cent oxygen but the patient’s saturations kept falling – they were now down to 78 per cent – and then grabbed the oxygen bag off the wall and began ventilating him herself, with fast, strong pumps of the bag. She unwound her stethoscope from around her neck and listened to the patient’s chest. She suctioned his lungs, listened again to both sides of his chest, and then looked up to me. “There’s no air moving in there.”

She yelled out, “I need help in here!” and then told the ward clerk to page for a chest X-ray and call for the doctor and the respiratory technician to come immediately – “STAT.”

All these events took place in a matter of moments. I stood watching and wondering what it was that I was supposed to be doing.

“He needs another iv line. Start one in his antecubital space,” Frances said. “Use a large bore needle – at least an 18 gauge – and run it with normal saline at 50 cc an hour.”

Quickly, I found the equipment I needed. The old man’s veins looked so easy to get, but as soon as I stuck the needle in, the vein collapsed and I watched in horror as a big blue lump popped up like a plum under his skin.

“Elderly veins can be tricky,” Frances whispered from across the bed. She came over to my side and slid the needle into another vein on the patient’s arm, taped it up, and pushed the clamp open to let the fluid flow in, all in a matter of seconds. “We got it,” she said.

Frances went out to the waiting room to bring the patient’s wife to her husband’s bedside. “He’s hanging in there,” Frances assured her. Both Mrs. Stavakis and I breathed a sigh of relief.

But the patient worsened as the day went on. He became agitated and delirious. We put in a chest tube but his oxygenation still kept falling, and once again, Frances went back out to the waiting room to bring the wife in. Frances, together with Dr. Daniel Huizinga, one of the staff physicians of the ICU, explained that her husband’s condition had worsened and he was now very critical. We would have to give him medication that had a drastic side effect. It would render him unable to move.

“Paralyzed,” Dr. Huizinga explained, in his curt but not unkind manner. “It’s a temporary measure. We have to paralyze him so that we can get more oxygen into his cells. Pavulon is the neuromuscular blocking agent that we use to decrease his metabolic requirements.”

“What?” cried the wife in alarm. “Paralyzed?”

Mrs. Stavakis watched in horror as her husband gasped for air. She did not have to be convinced that something had to be done immediately, but this? A drug-induced paralysis? It must have sounded like a nightmare to her.

“We sometimes paralyze patients, Mrs. Stavakis, for a short time,” Frances said, putting her arm around her. She made paralysis sound like a desirable thing, perhaps even a pleasant experience. “It will probably be for only a few days, and then we will stop it and he will move again and wake up. It will make him more comfortable with the breathing tube. See how he’s fighting the ventilator? Right now he’s not getting the oxygen he needs. This drug will help him.”

Frances and I prepared the infusion of the paralyzing drug, and after the doctor administered the first dose, it was up to me to continue it and monitor the patient closely. Frances reminded the resident not to forget to order sedation, too.

“Sometimes the doctors overlook the fact that the patient might still be wide awake,” Frances explained to me. “Paralysis without sedation is cruel. Can you imagine you can’t move, but you’re mentally intact inside? It’s called ‘locked-in’ syndrome and it’s my biggest fear. Pavulon is a scary drug, but it really helps patients. Some nurses even call it Vitamin P.”

BEFORE SETTING ME loose on my own, Frances kept a close eye on me and made sure I had gone through all the important experiences – that I had transferred a patient to the floor, received a fresh post-op patient, cared for a lung transplant and a liver transplant. She made sure I had given and received report to and from the other nurses and that I knew how to make a concise presentation of my patient to the team during morning rounds.

“You need practice helping the doctors with procedures,” she said on one of my last few days of orientation to the ICU under her supervision. “Go give that new resident a hand putting in a pulmonary artery catheter. He doesn’t know his ass from his elbow.”

Frances came to check on us later and brought a few extra catheters and sterile green towels, because he was having difficulty cannulating the vein that led into the artery. “Give him these,” she said, tossing them on to the bed for me to hand to him. “Looks like he might need a few tries.” She adjusted the height of the table where he was working and lowered the bed to make our work more comfortable. “Body mechanics can make such a difference,” she said. “We have to protect our backs.”

Justine, another nurse who seemed to be a regular part of Frances and Laura’s group, showed up at the door to see how the procedure was coming along. She pretended to take aim with an imaginary dart and shot it into the room, ostensibly directly into the patient’s internal jugular vein.

“Bull’s eye!” she crowed. “I could get that line in from here.”

WORKING IN THE ICU reminded me of an animated short from the National Film Board I had seen as a child in school. It started with a boy rowing a boat on a lake. Then it zeroed in on a mosquito stinging the boy’s arm. Down the camera went from the skin, into the layers of epidermis, then into the blood cells, the nucleus of the atom, the electrons and protons. Then, zoom, the camera went back out to the boy, the boat, the lake, the country, the world, the galaxy, and the universe. That’s how I felt: tossed between the stopcock and the complicated world of the ICU; zooming in between drawing blood from an artery and helping to withdraw life support on someone’s dying mother.

“You’ll get the hang of it,” said Frances. “You’ll figure out what’s big and what’s small, what’s urgent and what can wait. There are some nurses whose main goal is to settle the patient, make them look nice, tidy up the room, so they can sit down and read a magazine. I have a feeling you’re not like one of those.”

IT WAS THE last morning that I would be buddied with Frances. My orientation was over.

“Are you okay?” she asked. “You look a little green.”

“Yeah, fine, thanks.” I peered down into my coffee cup to avoid her eyes.

The truth was, I was having problems sleeping, problems getting up in the morning, and still, the constant churning in my intestines.

“Are you sure nothing’s wrong?”

“Not a thing!”

“Well, that’s good, because we’re going to have a busy day today. A patient came in during the night and she’s really sick.”

I listened to report from the night nurse.

“Andrea … a twenty-three-year-old … just graduated from law school. She and her husband were scuba diving in Lake Simcoe and she was caught in a strong undertow. She panicked and rose to the surface too quickly. She dislodged her mask and oxygen tank and aspirated a lot of cold lake water. Too bad they weren’t in the ocean, seawater would have been a lot less damaging to her lungs, poor thing.”

The patient’s healthy, muscular arms were a startling sight against the white sheets, the cage-like bed with its metal rails, and the bottles and tubes attached to her body. I squinted at her and tried to imagine her in jeans, her wedding dress, or a wetsuit, anything but the faded blue hospital gown she had on over her naked body. As I recorded her vital signs, I noticed some occasional but worrisome beats on the cardiac monitor upon which a teddy bear presided as a sentinel. Around one side of her bed, machines and equipment huddled like a team of robotic consultants. A group of real consultants huddled on the other side.

On the patient’s bedside table was a clipboard. I knew how private and intimate were the notes that patients wrote and had no choice but to leave them out in public for all to see. I couldn’t help but read the shaky scrawl that trailed off the side of the page:

Don’t blame yourself. I came up too fast. You gave me your O2.

On another page, How sick am I? was followed by, Go easy on Mom and Dad. Edit a bit. I love you.

She must have written those notes during the night when she first came in and since then had deteriorated fast. Now she was unconscious, probably due to air bubbles, called emboli, in her brain.

“No eye opening, no following commands, no response to deep pain, no response to voice,” I reported to Frances.

No response to the Mozart symphony on the radio that her husband had placed beside her. No response to his touch, no awareness of his presence when he came in the room.

“She’ll probably need a CT scan of her head,” said Frances, planning the day ahead. “Make sure that all the alarms are on. She’s having some premature ventricular beats – see there goes one – but right now let’s wash her hair.”

I looked at her, surprised that the patient’s appearance would be a priority now.

“I know she’s sick,” Frances said. “But whether she makes it or not, I’m sure she’d want to look nice for her husband when he comes in.”

Frances prepared syringes of various emergency drugs and lined them up along the counter like ammunition. “Just in case,” she explained. “I don’t have a great feeling about her.”

As the day went on, I stayed focused on the tasks at hand, but all of a sudden, late in the afternoon, while Andrea’s husband was visiting, something made Frances glance up at the cardiac monitor, seconds before the alarm even had a chance to sound. “She’s gone into V-tach! Get the crash cart!” she shouted at me.

Ventricular tachycardia! Here it was, the real thing! If I didn’t act fast, it could lead to ventricular fibrillation!

Frances pulled the husband out of the way as the room quickly filled with people. He shrank back against the wall. I thought of reaching out to him, but didn’t. I didn’t know what to say, anyway.

Laura, Justine, and two other nurses, Tracy and Nicole, appeared out of nowhere and they helped Frances lift Andrea and place a hard board under her back. With that board now in place, Frances climbed up onto the bed and started doing vigorous chest compressions while Nicole hooked up the patient to the defibrillator to prepare for shocking her with electricity to get her heart going again.

Tracy injected an ampoule of epinephrine into an IV that went directly into Andrea’s heart.

Justine thrust her fingers into the patient’s groin to feel for a pulse. Nothing. She nodded at Frances to resume compressions.

Within a few moments, a doctor arrived on the scene and took over directing the resuscitation efforts that the nurses had already begun.

I stood frozen to the spot. Unable to move. Unable to think. Unable to recall accurately even one of the resuscitation logarithms I thought I had memorized: If the victim is without a pulse and unresponsive, then shock with 200 joules. If patient does not convert to sinus rhythm, repeat shock with 300 joules. Or was it 360?

“Here,” said Tracy, shoving the arrest report at me. “Record the arrest.”

How could she have known? Paper and pen had always been my refuge.

THEY MANAGED TO bring Andrea back. Meanwhile, I went to the med room to prepare a drip of a powerful new drug called amiodarone, which we were going to use to try to stabilize Andrea’s still-erratic heart rhythm. It was taking me a long time to get the medication ready. Six glass vials were lined up on the counter and I was struggling to crack them open – already, I had a cut in my thumb from the first one, which had shattered in my hands.

“Leave that for a moment,” said Frances. “Do you want to know the first thing you do in an arrest? Take a deep breath. Then take the pulse. Your own, I mean. Then, take the patient’s. Do everything slowly. Don’t run for anything. Don’t let anything or anyone rush you. Ever.” She turned to go back to Andrea’s room. “By the way, there’s a trick to those vials. Let me show you. They break with light pressure. You can’t break them if you push too hard.”

Easy, not hard. Light, not heavy. Slow, not fast. Relaxed, not rushed. How was I going to learn all this?

Later that day, Andrea arrested again and that time, she didn’t make it, which was the way Frances put it gently to the husband. He knew, but needed to be told. He slumped into Frances’s arms and sobbed in the comfort and safety she offered. I wanted to enfold myself in there, too. Frances’s arms were wide and strong enough for a lot of sorrow and I knew she could handle his and mine, too, and still be intact herself.

Andrea’s death affected a lot of the nurses who identified with someone so young and newly married, someone so full of life and promise. Some stopped by to console the family, to take one last look at her lovely body lying in the bed, still attached to the machines that had now fallen silent and useless, disconnected from the electrical outlets, their screens gone blank. Some of the nurses even cried, and I could see that their tears touched the family. The family probably knew that the nurses couldn’t always cry over their patients, so that when they did, they were especially grateful that their grief was shared.

I pulled myself away. It was the end of my shift and the others would carry on. They would wash Andrea’s body and prepare it for the morgue. They would tidy up the room and soon it would look like no one had ever been there. It would be made ready for the next patient.

I hung up my lab coat and walked out the door. I was completely spent. I had nothing more to give. Many hours had gone by, but I had no sense of the passage of a day; it was just a jumble of events and experiences to be sorted out later. I wondered if I had enough steam to get myself home, take a shower, and fall into bed. When I stepped out into the cold, rainy evening, the cool mist felt good on my face. My boyfriend was waiting for me in his warm car with the engine running and I slid in beside him.

“So, how did it go?” Ivan asked, but I was at a loss how to answer.

We drove in silence, but when we got home, I pulled him into my bedroom. Suddenly, I was seized with the desire to have sex, to make love all night, to chase death out of my body.

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Alice
Great book, nicely written and thank you BooksVooks for uploading

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