The Making of a Nurse (24 page)

“You mean the one right before?” I asked, and Louise nodded.

“She looked right at me and asked, ‘How will I know when I’m dead?’ Tilda, it was extraordinary. It had been an overcast day, but at that moment, the sun broke out of the clouds and Alice’s bed was filled with sunlight. She looked like an angel lying there and I knew exactly what to say: ‘Alice, you’ll know you’re dead when you’re looking down at us.’”

We were in a frieze of reposes, still and quiet, listening with our entire bodies.

“Alice looked me in the eye and said, ‘I’m dying, aren’t I?’ I said, ‘Yes, Alice, you are.’ It was the most amazing thing to see someone completely aware, experiencing her own death. She was saying goodbye and beginning the journey of leaving us behind. She was excited. She believed she was going on to something else and she was not afraid. I had promised her I’d keep her pain-free and comfortable and I did that. She was aware right up until the moment when she wasn’t aware any more. I thank my lucky stars I had the skills to be able to help her.

“Then she started Cheyne-Stoking, with gasps and long pauses and then another gasp and a pause. The family was distressed at her breathing, but I explained that this was natural and expected.”

I’ve seen how the “death rattle” unnerves many people, even some nurses. It is raw, animal-like, and different from any other sound on earth. Many interpret it as a cry of distress, but when experienced nurses hear it, they feel a sense of peace and relief. They know the person is unconscious, feels no pain, and that the end is near. The families are grieving, so nurses turn their attention to them. I’ve seen families become desperate to have a fast transition from life to death, like what they’ve seen on hospital
TV
shows. They can’t handle the lingering passage in between. They want it over with quickly.

“The pauses got longer and then stopped. I put my ear to her chest and told them she was gone.”

“Wow,” everyone murmured. We’d seen many deaths but never one like that. In the
ICU
we are so reliant on machines to tell us when the moment has arrived. Most of us had not seen a death unmediated by technology.

Louise smiled. “At the funeral, the minister came over to me. ‘Ah, so you were the nurse who helped Alice in her last hours,’ he said. It was the proudest moment of my life.”

I DON’T THINK
you could work in the
ICU
for any length of time and not think about your own death. Recently, I told Dr. Sandor my wishes in the event that I become critically ill.

“What about organ donation?” he asked.

“Yes, I want to donate my organs.”

“Tissues, too?”

Consistency and clarity decrease confusion, he’s always said. I hesitated momentarily, fleetingly recalling what Casey once told me. She said she would donate everything except her corneas. “I know it sounds weird,” she chuckled, “but I don’t want to be blind on the journey, wherever it is that I am going.”

But I felt differently. “Yes, all of my organs and tissues, too.”

“What about burial of the remains?”

“No, no burial.”
He doesn’t mess around!

“Cremation, then?”

No, I told him about biodegradable internments I’d been reading about, about the body disintegrating, becoming fertilizer and rejoining the ecosystem.

“But isn’t that against your religion?”

Good question. I am still trying to figure out what I believe, but I am Jewish and Jews have been doing eco-friendly burials for years. Yom Kippur, the holiest day in the Jewish calendar, is supposed to be a
death rehearsal
when Jews fast and wear white just like the plain cotton shrouds that they are to be buried in. But even if one doesn’t have a religion, doesn’t everyone have something they believe in? Last spring, when it seemed like just about everyone was celebrating something, a feast, a festival, or a fast of Ramadan, Easter, Passover, or Diwali, I asked Boris, a hospital assistant who immigrated to Canada from secular, Communist Russia what he celebrated.

“Nothing,” he answered in his serious, but sweet way.

“Do you celebrate May Day, International Workers’ Day?” I tried.

“No, not any more.”

“What, then?”

“March 8 is the only day I celebrate,” he said with an impish grin.

“What’s that?”

“International Women’s Day.”

How could I forget?

But it finally all made sense to me last December 25 when I arrived for a day shift just as Ibrahim, another of our hospital assistants, was heading home after his night shift.

“Merry Christmas,” he called out to me with a wave.

“Merry Christmas to you, too.”

After all, isn’t the
true
spirit of Christmas what we all share? Perhaps it will be through the universal bond of values – justice, forgiveness, goodwill, and compassion – which all the great religions have in common, that Muslims like him and Jews like me can find the way to greet each other in peace.

T
oday, twenty years after starting in the
ICU
, I call it home. To me, the work is just as challenging, exciting, fascinating, and at times, fun. But there are still situations that continue to puzzle and perplex me. Take what happened just the other week.

After nearly three hours of non-stop activity, I finally emerged from my patient’s room. Mr. Rodriguez was a middle-aged father of two who had had a liver transplant two days prior. After a rocky forty-eight hours, there were now hopeful signs that his new liver was working. However, he was still on maximum ventilator support and unconscious. I had given him a bath, a shave, shampoo, back rub, and changed his bed linen. I made adjustments to his medications, gave him an antibiotic, observed his respirations, checked the ventilator, measured his central venous pressure, pulmonary artery pressures, and cardiac output, and compared all of these numbers against previous readings, and made additional adjustments to his medications. I went into the tiny anteroom outside the patient’s and stripped off my gown, gloves, mask, and goggles that we all had to wear to curtail dissemination of the bacterial infection he’d
acquired while in hospital. I washed my hands, sat down at my computer to begin my charting, all the while keeping my eyes on my patient and the cardiac monitor. I was just about to take a sip of the coffee I’d bought earlier when several visitors happened to walk past and I overheard one say to the other, “See how the nurses sit outside the room? That way they don’t have to go to the patients as much.”

“Yeah,
right
. All we do is sit here,” I grumbled under my breath, but apparently not softly enough, because she heard me and turned back.

“Oh, I’m sorry, dear. I’m sure you are all working very hard.”

“No,
I’m
sorry,” I said, and we both fell over each other apologizing again, she for her offhand comment and me for my sarcastic retort. But it’s easy to see how she could get the impression we were doing nothing. Much of nursing care is invisible, especially to the casual observer. So many things we do are private and extremely intimate and take place behind closed doors or drawn curtains. And those “comfort measures,” the repositioning, those gentle, reassuring touches, the hugs, the understanding of things unsaid, the back rubs – and more – seem simple and trivial, especially when compared to the big-ticket items doctors offer, such as tests and prescriptions.

“Why do you bathe patients so much?” a student nurse once asked me. “It’s not like they’re dirty.”

“It feels good to patients,” I explained to her. “Water is relaxing and it makes a person feel fresh and clean.” The hospital had been trying to get us to use new antibacterial “bath in a bag” chemical wipes, but nothing was better than water. In fact, I had been working on an invention for a portable shower contraption that could be placed over the bed and would rain down warm water all over the patient. The water will drip off all the sides, into troughs, but I hadn’t got around to building the prototype just yet.

Researchers measure, quantify, document, describe, evaluate, in order to validate nursing and prove its effectiveness, but something seems to get lost in the process. Data is generated and numbers are crunched but the essence, beyond the tasks and skills, continues to elude scientists. Cardiac monitoring is one of those
particularly invisible activities. It looks like nothing more than blank staring, or casual gazing, but it is actually a studied vigilance that requires a deep understanding of the heart’s electrical system, the skill to identify a potentially lethal problem, and the knowledge to intervene. While the attention required looks incidental and easy, the thinking behind it is anything but:
why has the heart rate jumped from 80 to 110? Is he in pain? Is he “dry” and needs a fluid bolus? I better take his temperature … fever can cause the heart to race. What’s his hemoglobin? What about those premature atrial contractions? Are they causing a compromise in blood pressure? And those ventricular contractions, are they unifocal or multifocal? I’ll check his potassium level because if it’s low, that’s what could be causing an arrhythmia
.

Those aspects of nursing that are elusive, indefinable, and ambiguous contribute to a debate that rages not only within the insular walls of the institutes of education, but also in the real-life places where nursing is practised: What is a nurse? That is, what are the roles, responsibilities, and actions that define a nurse? Who is a nurse? That is, what does a nurse look like and how can you tell one apart from the doctor or other professionals? More worrisome is that patients have been known to ask, “How can I tell who is my nurse?” given that gender and clothing alone are not definitive. Most nurses say they wish to be known by the relationships they have with patients, not by their clothes. I’ve seen many nurses individualize their uniforms by wearing scrubs in ice-cream colours of raspberry, lemon, and grape. There are those who wear lab coats decorated with teddy bears, angels, or lollipops.

Later that day after the incident with the visitor passing by, I decided to ask some of the other nurses sitting in the lounge about clothes. “Do you remember Carrie? The one who tied her scrubs with a gold lamé belt and always wore a string of pearls? What a
fashionista
she was!”

“I remember her,” someone recalled with a chuckle. “That girl really knew how to pimp her uniform. She wore those white shoes with the kitten heels that went clickety-clack down the hall. You could always hear her coming. And what about her nail art? She had those long, curved acrylic ones and when she was dating that
sailor she decorated them with nautical symbols! I always meant to ask how she managed to insert a catheter.
Ouch!”
*

“Why do we even have to wear uniforms?” someone else asked. “We’re individuals, aren’t we?”

“In the old days,” reminisced Phyllis, a senior nurse, still going strong in our physically taxing work, “we worked hard for our caps and white uniforms and when you put them on, you felt like a real nurse. It was like you were preparing for your role in a play. It meant something.”

Monica kept quiet, but I felt certain she had a strong opinion on the matter. I knew her ambitions. Even with a young daughter who she supports on her own and after going through a messy divorce, Monica has returned to school for her Master’s degree in management and is a stellar student. Finally, she spoke up. “Appearance matters. How would you feel if the pilot of the plane you’re on showed up wearing track pants and a T-shirt? What kind of impression would that make? And what about all the bling nurses are wearing these days? It doesn’t look professional and surely they know jewellery harbours bacteria that we can bring in or take home with us.” A chorus of dissent flared up, but Monica continued above the din. “Besides, the hospital has a dress code and we’re supposed to adhere to it.”

“That’s just a way for management to control us. It takes away our individuality!”

“What’s a nurse supposed to look like?”

Someone sarcastically offered the suggestion, “Try the ‘Naughty Nurse’ website. You can get some wild ideas there!”

“My kids want to dress up as nurses for Halloween. What can they wear to look like a nurse?”

“Have you seen that nurse in Dialysis who still wears a cap? What a dinosaur!”

“Did you see that doctor who came to see my patient this morning? He looked like a geeky high school student, no lab coat, no name tag, nothing. He went into my patient’s chart. Who are you, I asked him? He looked like he’d walked in off the street. He could have been a visitor or a patient from the Psych ward!”

Nurses’ uniforms seem to be yet another issue in the ongoing debate about what and who a nurse is. Uniforms did have a way of obliterating individuality. They could turn people into a service to such a degree that ease of recognition or the speed with which they responded to a call bell became the measure of their worth. Even I, who always preferred the generic, unisex, and equalizing qualities of my green or blue scrubs, recently purchased a pair of shiny, candy-apple red shoes for work, as much for the vibrant colour as for the comfort. Is individual expression really such a threat? Can’t beauty and function coexist? What if nurses could find ways to use Beauty and Art as capably as they use Science?

I was pondering all of this one day at the grocery store. While I realize most people start at the produce sections, move on to refrigerated items and frozen foods last, I head straight to the jumbled bin of remaindered or damaged books. I was digging in there and happened to dredge out a book of unexpected possibility:
Transitions: Unlocking the Creative Quilter Within
, by Andrea Balosky, a Californian quilter. I stood there, entranced. Wow, I thought, looking at photographs of her quilts. The juxtapositions of shapes and colours thrilled me! The mix of vintage and modern! The artistic and the functional! That book sparked my exploration of quilt history and lore. Even the names of traditional blocks intrigued me: Flying Geese, Log Cabin, Broken Dishes, Hidden Windows, Jacob’s Ladder, Card Trick, and Courthouse Steps. I loved the “crazy quilts” that didn’t use uniform shapes and instead had a distinctive haphazard look. There were equally lovable scrap quilts with mismatched, chaotic colours and glaring, but appealing, flaws. Other quilts, such as in the Amish style, were balanced, symmetrical, and in muted colours. Many quilters used whatever was on hand; their intention was not perfection. Quilts have even found a place in museums as examples of both simple folk art and sophisticated craftwork.