The Making of a Nurse (33 page)

We had long since moved from both the original ten-bed
ICU
where I had started (memories of the Cave) and then a few years later, from a sixteen-bed
ICU
in another part of the hospital. About three years ago we moved into a bright, spacious new twenty-two-bed icu, up on the tenth floor, with a view of the city right down to the lakeshore. In this icu, there are large patient rooms, expansive hallways with turquoise and beige geometrical designs on the floors, and windows all around that let in not only light, but also a sense of space and grandeur, as well as glimpses of the outside world. It is a much more pleasant place than the original icu. Back then ten beds had been sufficient, but now we are always full to overflowing with twenty-two beds. More and more patients need to come to the
ICU
.

Is the
ICU
a physical place or a way of doing things? I got to thinking about this question after what happened to a patient named Carole Oxton. She was not my patient but was Xavier’s in the room next door to mine. However, as the day went on and I saw what was unfolding, I had no choice but to get involved. Noreen, Casey, and Monica were on that day, too, and Roberta was in charge. I had worked with Xavier a few times and I had no concerns about him. He was a new nurse, but very competent and caring and what I liked about him was that he asked a lot of questions and that’s always a good sign. He was assigned to care for Carole Oxton because she was a stable patient. In fact, she was deemed so stable she was to be transferred out of the
ICU
early that afternoon. She was a fifty-four-year-old woman with a long history of alcohol and drug abuse who had fallen down a flight of stairs at home and broken her arm. She had dark circles around her eyes (even textbooks labelled them “raccoon eyes”) and multiple purple bruises all over her body. Her electrolytes – the potassium, sodium, calcium, magnesium, and phosphate levels in her blood – were abnormal due to liver and kidney failure. They needed to be closely monitored and swiftly treated, in order to avoid serious complications. I saw that Xavier was very capably topping up the low phosphate and preparing to give a calcium supplement, so I returned to my patient in the room next door.

Mr. Drummond was a sixty-year-old man, three days post lung-transplant, weaning slowly off the ventilator, getting used to his new lungs and battling re-perfusion syndrome.
*
On rounds that morning, we tweaked his medications on the advice of the pharmacist. On the respiratory therapist’s recommendations, we adjusted the ventilator so as to allow him to gradually do more of the “work of breathing,” by himself. He was making progress, but still had a long way to go.

The team pushed the portable computer along to the next room, Mrs. Oxton’s.

“This lady is doing well,” said the resident. “She’s ready to be transferred to the floor.” Since no one had anything to add, they
moved on to the next patient. Yet, after a mere glance at Mrs. Oxton, I felt uneasy and clearly, Xavier did too. “I don’t think she’s ready to be transferred out,” he said.

“She’s been off the ventilator for forty-eight hours,” the resident called back over his shoulder. “Her blood gases are good. She’s a rose. She could have gone out yesterday.”

“It’s true,” said Xavier, thinking out loud to me. “She’s on nasal prongs with just a few litres of oxygen, but the problem is, she’s not very alert. I don’t have a good feeling about her.”

“How’s her blood pressure?” I asked, trying to figure out what it was that disturbed me, too.

“Normal,” Xavier said, looking unhappy. “What do you think, Tilda?”

“Let’s go in and examine her together,” I suggested.

Xavier’s patient opened her eyes when she saw us. She made raspy gurgles of secretions at the back of her throat. I handed her a tissue. “Try to cough that out.”

“I’ve paid my bills,” she mumbled. She tried to cough, but only managed a feeble splutter. Even without listening with my stethoscope, I could hear her chest was noisy.

“Mrs. Oxton!” I shook her shoulder a little. “Would you like to get out of bed?” She didn’t answer or even appear to have heard me. I looked at Xavier.

“I already tried to sit her up at the side of the bed and dangle her legs,” he explained, “but she was too weak to stand.”

“Let’s hoist her up,” I said, “it’ll make it easier for her to breathe.” Xavier went on the other side of the bed and we lifted her as she lay there helplessly.

“If we had extra staff, we could keep her longer,” Roberta said when I went to the nurses’ station to talk to her about it, “but as it is I am short two nurses and three short for the night shift.”

“We always have to move everyone along so fast,” I grumbled.

“I know how you feel, but we’re getting two transplants and someone just called in sick.” Roberta stared into the staffing book as if more nurses would suddenly materialize in there. “Hey, it’s still early. We’ll keep her a few more hours and reassess the situation in the afternoon.”

I’m convinced the best preparation for this role would be to study the moves of the grand chess masters, Kasparov, Fischer, and Spassky and so on. The nurse in charge has to control the board (the
ICU
) and plan moves (transfers, discharges, room swaps, etc.) in advance. You have to stay a few steps ahead and have a strategy for a possible arrest on the floor, or a surprise admission from the Emergency department. You have to be ready to move some “pieces” out quickly and hold others back and protect them. The King is your sickest patient, but you also have to protect your Queen – your last
ICU
bed. Roberta was a supreme chess master, and in her hands, the
ICU
could cope with any “attack.”

About an hour or so later, I wandered back to the nurses’ station to get a sense of how the game was playing out. Roberta looked stressed. “I see you’re ‘Takin’ Care of Business,’” I sang, trying to play our old game, but she wasn’t in the mood. I could see by her expression that it was time for push to come to shove, quite literally.

Roberta looked at me. “Mrs. Oxton has to go, Tilda. There’s a patient on the floor who is deteriorating fast and needs to come to the
ICU
. I want you to help Xavier get her ready to be transferred out.” She returned to the lists of nurses and patients and tried to massage the numbers to stretch the supply of staff to cover the demand of patients, all the while doing her utmost to ensure everyone would be safe. “Let’s see,” I heard her talking to herself, “if we transfer the patient in 1011 out, then Casey can take the liver transplant when he comes out of the
OR
and when Xavier’s patient goes out, we’ll admit the floor patient …”

“Why did you agree to stay open to admissions if you’re so short of nurses?” asked Dr. Sandor, as he passed by the nurses’ station. He helped himself to a squirt of antibacterial lotion.

“How could I say no?” Roberta asked in dismay.

“But it’s a staffing issue. That’s your call. Take a stand.”

Check
.

“And I suppose you’ll back me up when the newspaper headline tomorrow reads, ‘
ICU
Closes Doors due to Shortage of Nurses’?”

She glared at him and he grinned back. “That’s what I thought,” she said.

Checkmate
.

I COULD SEE THE PRESSURE
Roberta was under, but still I stalled, trying to buy more time for Mrs. Oxton in the
ICU
. Xavier and I fussed around her and turned the radio on to stimulate her. We tried again to get her out of bed, but she became combative. We wondered if she might be starting to go through the DT’s,
*
the syndrome of agitated withdrawal from alcohol. I sat down to read her chart. She had been a widow for many years and had a teenaged son who was in jail. Three days ago a neighbour found her lying unconscious on the floor of her basement apartment. Empty liquor bottles were strewn about.

“I heard you are planning to transfer Carole out,” said a thin, anxious woman who came up from behind me. She frowned and then introduced herself as Margaret, Mrs. Oxton’s sister.

“She is ready to be transferred out,” I said uneasily.

“Someone else needs the bed, is that it?” she asked.

I squirmed, but by my silence, she knew the answer. Xavier stood by, listening in.

“The nursing care is better here in the
ICU
. I know it and you do, too.”

“She will be well taken care of by the nurses on the floor,” I said.
Of course she would, she and another six equally needy patients that some nurse would be running back and forth between
. I recalled a patient I transferred out of the
ICU
a few weeks ago. He was a renal patient on dialysis three times a week who was recovering from septic shock. He was confused and disoriented and on top of all of that, he spoke only Italian so I could not communicate with him properly. On the floor, I gave a report to a nurse who was listening but in a very distracted way. “The other thing,” I added at the end, loath to add to her burden, “you’ll need to get hold of
an interpreter so you can explain his meds. Could you page one?” I asked the ward clerk who was listening in.

“This isn’t the
UN
,“ she grumbled, then tried to be helpful. “How about, ‘Hey
Paisano
!’
“

“How many other patients do you have?” I asked the nurse.

“Along with this one? Seven. No, wait a sec,” she reviewed her notes. “Six. One just died.” She crossed a name off her list.

“Are all of them this sick?”

She nodded. I noticed she was panting and looked as if she was ready to take off on a sprint.

“Why are you so short of breath?” She worried me.

“From running. A patient just yanked out his chest tube and then the patient in the other bed took out a knife and cut his own chest tubes off.”

“Were they psychotic?”

“No, just competing with one another.” I couldn’t tell if she was joking or not.

“You look stressed,” I said. All of a sudden, she got up and ran into a patient’s room. My patient – the one she’d just inherited from me – was climbing out of bed. How did she even know? Together, we lugged his heavy, swollen legs back into bed, and I put the side rails back up.

Good night, nurse!
I thought, walking away from her, feeling guilty leaving her with such a mess.
Good luck!
I am ashamed to admit how fast I booted it out of there and raced back to the
ICU
. It was my home and while there was chaos there too, at times, we had the ways and means to tame it.

Now I understood what was the biggest dilemma for nurses. We can no longer solely focus on doing good for patients. We are doing everything in our power to ensure we don’t cause them harm.

“The nurses on the floor won’t have time for her,” Margaret, the sister, said.

“Yes, they will,” I lied.

“She is falling off a cliff,” she said. “Do something!”

Xavier removed Carole’s arterial line, and I gathered up her personal belongings. There wasn’t much, only a dirty pair of jeans,
old running shoes, a T-shirt, and a grimy jacket. I placed them in a plastic bag and tried to give it to her sister to take home, but she wouldn’t touch it.

“I’ve spoken to my son who is a doctor, and he insists Carole stay in the
ICU
. This is a disgrace.”

“I understand how you feel.” I felt the same way.

“We have a terrible health-care system.”

Just then, a teenaged boy bolted into the room. “I’m the son,” he said, slamming his jacket onto a coat hook so violently it ripped right off the wall.

Margaret whispered, “I didn’t know whether to tell him to come. He’s out on probation.”

“Is she even with it?” the son said, staring at his dishevelled mother, who was grinning and gurgling, sprawled in the bed, not appearing to recognize him one bit. “She’s a drunk,” he said in disgust, “plus she’s a junkie, so it’s no use trying to save her because she’ll just be back again in a few days.”

“Don’t you think you should take her for a
CT
scan?” Margaret inquired politely. “When my husband got sick, they took him for a
CT
and it helped him get better.”

Out in the hall, Noreen asked me, “Why do you let your patient’s sister boss you around?” Everyone was watching this drama play out.

“She has to go,” Roberta came over to tell me. She had paged housekeeping to clean the room that hadn’t even been vacated yet. Roberta knew the bigger picture and this patient and her sister were the smaller picture. Just one little patient caught in the big scheme of a huge and mighty hospital.

“Carole!” Xavier and I shouted at her, trying to make her more alert. If she was more alert, she might be able to protect her airway from aspiration. “Carole, wake up. Open your eyes.”

“The fishing rod is too tight,” Carole muttered, pulling at her central line, the
IV
in the jugular vein in her neck. “I can’t reel it in.”

The housekeeper arrived and started cleaning the floor around her bed, then stopped and leaned on her mop. “This patient is going to the floor? She don’t look too good.”

“See, even
she
can see it,” exclaimed Margaret. “Have the courage to stand up for her! Where’s a doctor? Get a doctor!”

I would gladly call the doctor if she wanted, but it was a nursing matter, pure and simple. Pure, perhaps, but not so simple.

“Who changed the time for transportation?” I heard Roberta ask. Sneakily, behind her back, I had rebooked the porter in order to buy more time. Roberta was getting frustrated with me, as were other nurses. Word was getting around the unit that I was not supporting our charge nurse, that I was getting too emotional and not taking a firm enough hand with a demanding family member. Roberta came over and spoke to me sternly. “Tilda, we can’t keep Xavier’s patient here any longer.”

Margaret, in turn, confronted Roberta. “You know very well she should stay, but you’re feeling pressure to move her along and bring someone else in. If she dies, it will be on your conscience. Please do the right thing and keep her here.”