Opening My Heart (8 page)

“… Rapid Response Team bringing patient from the floor … eighty-two-year-old, unconscious, in respiratory failure … needs intubation … family is too distraught right now for a discussion, but we need to make some decisions about the plan of care …”

I adjust my ears to the
ICU
background music, a playlist of dings, dongs, chirps, buzzes, and beeps going off at random intervals from patient rooms. I never noticed it before but this place is noisy. Heavy doors bang open and close, rushed footsteps, loud voices
– even peels of laughter and excited chatter at the nursing station. As for tonight’s vintage bouquet? I sniff the air and catch a whiff of a fresh upper gastro-intestinal bleed, the sweet-sour undertones of a brewing pseudomonas infection, and do I detect a frisson of melena – the distinctive smell of the end result of that
GI
blood passing through the “lower” end?

The housekeeping staff are cleaning rooms and restocking cupboards as they finish their shifts. Cindy, Comfort, and Eunice speak in a mélange of Chinese-, African-, and Jamaican-inflected English. They wave or call out
hey
as I make my way to the nursing station. There, David, a tall, elegant man, a patient care assistant, greets me in his courtly manner.

“Good evening, young lady.” He makes a deep bow. “I’m pleased to see you’ve decided to grace us with your presence on this lovely evening.”

The twenty-four
ICU
beds are full, I see, as I make my way around the spacious, rectangular-shaped unit to check the assignment board to find out the name of my patient. Most of our patients are so ill and unstable that they require one-to-one nursing care. In some cases, two nurses are needed to care for one patient.

For years, I’ve had a mystical belief that I always get the patient I need. (Whether my patients get the nurse they need is another story, and whether as a patient I’ll get the nurses I need remains to be seen.) For example, if my energy is flagging and I’m assigned a very sick patient, it’s a sign to dig down deep and rise to the occasion. A “quiet,” or stable, patient is a cue to make myself available to other nurses who need my assistance. I become the nurse I need to be. Tonight, with my own worries on my mind, all I’m hoping is to be a Good-Enough Nurse who can get my patient safely through the night. One bed full of suffering is all I can cope with right now.

Ramona, the day nurse, is standing outside the patient’s room waiting for me. She’s been here all day and is eager to hand over so she can go home. She launches straight into her report on our patient, a sixty-six-year-old First Nations man admitted to the hospital three weeks ago for abdominal surgery for a bowel obstruction who then developed pneumonia and respiratory failure.

“Mr. Beausoleil – he likes to be called George – awake and alert, oriented to person, place, and time. Restless and confused at times. I gave him Haldol 2.5 milligrams
IV
twice today. Tolerated well, but we’re trying to minimize sedation because we’re hoping to extubate him in the morning. On pressure support of five, oxygen at 35 per cent … if he doesn’t fly he’ll need a trach. Gets tachypneic with anxiety – his resp. rate goes up to fifty or so. Cardiac status stable … normal sinus rhythm with no ectopics; blood pressure stable. Line-wise, he’s got a subclavian triple lumen catheter – site was changed two days ago – with normal saline to keep the vein open … magnesium was low so I topped him up with two grams. On insulin nomogram … last blood sugar 10.2 millimoles.”

I’m used to this barrage of rat-tat-tat facts coming at me in rapid-fire bullets. I let it wash over me as I mentally highlight key points, what needs clarification, and what questions remain, like this one:

“Any family?” What I need to know is anyone hovering out in the waiting room, anxious to come in. I want to know who cares about this man in his life outside the hospital, other than me, tonight for twelve hours, for whom it is my job to do so?

“Oops, forgot about that. No one came to visit. His wife died a few years ago. There’s a daughter in Vancouver, but she didn’t call today.”

A sad but all-too-common situation.

But what’s uppermost on my mind is this question: Would I have Ramona as my nurse? Yes. She’s a just-the-facts-ma’am kind of nurse, but I probably wouldn’t die on her watch.

Before going in, I glance through the window at a frail, elderly man, his arms tied down in restraints. The sedation Ramona gave him has kicked in so I wonder if he still needs them. Most of us do all we can to avoid physical restraints, but if patients are at risk for pulling out their lines or endotracheal tubes (breathing tubes), we have no choice. Some patients can’t be soothed with words, touch, or even drugs. A restless patient can be more challenging to care for than a combative or even violent one; it’s a persistent, gnawing need that’s never quelled or satisfied. You do your best to keep your cool, but we’ve all had moments of impatience. One time I was so rattled by a patient’s agitated state that I caught myself shouting, “Calm down!” as if calmness could be commanded. Justine, my pal from Laura’s Line, used to call it “going nurse!” instead of “going postal!”

Doctors don’t get this. If they pass by a patient’s room and happen to see the patient in a moment of rest, that’s their snapshot impression. Even if the patient is agitated, it doesn’t affect them like it does us. They aren’t required to be as up close and personal for such extended periods of time as we are. They can keep a remove of time, space, and often emotion, too. One thing that helps me is keeping in mind the motto of the “Dog Whisperer.” Cesar Millan advises people to stay “calm and assertive” when dealing with unruly canines. (Though I don’t have a dog, I watch the show and aspire to be a “Patient Whisperer” by putting into practice Cesar’s advice about “fulfilling the other’s needs” and helping them attain “balanced energy.”)

After introducing myself to my patient, I loosen the restraints on his arms and then begin my head-to-toe assessment, starting
with his level of consciousness. Though he’s awake and alert, he can’t speak because of the breathing tube in his mouth, which, by necessity, passes through his vocal cords.

“How are you doing tonight?” I ask and he motions for a clipboard to write on.

“Anything in particular bothering you?”

He shakes his head and sets aside the clipboard beside him on the bed.

“Just being here, huh?” He nods. “Do you know what day is it?” I ask and he shrugs his shoulder to indicate he hasn’t a clue, so I tell him. It’s easy to lose track of time here, cut off from the world. When I wake up in the morning or especially in the middle of the night, the first thing I do is check my watch or clock.

When I tell George it’s Saturday night, June 30, he moves his legs and arms like he’s out dancing on the town. He reaches for the clipboard again.

“Love to.” I strip off a vinyl glove so that I can touch his hand, skin to skin. This can be a hazardous practice, possibly exposing me to infectious bodily fluids, but sometimes I take the risk. George points to the eagle tattoo on his shoulders and tries to tell me something but falls back against the pillow, too weak to get the words out clearly.

“Maybe later you’ll be able to tell me?” I ask and he nods.

The night wears on. As I monitor his heart, record his hourly vital signs, suction his lungs, give him his meds, and change his
chest tube dressing, I can’t help but think about my own heart, vital signs, lungs, the meds that will be given to me, and the wound I’ll have.
I’ll be in the hands of strangers, just like George
.

Tonight, some of my buddies are on duty. There’s Jasna, who is in charge of the
ICU
this shift, making her rounds, checking on the patients and the nurses, too. Stephanie is in her patient’s room, the curtains closed. I don’t expect to see much of Janet. It’s her turn on the Rapid Response Team. She’ll be making her rounds, following up on patients who’ve recently been discharged from the
ICU
to the step-down unit or answering calls for help from the floor, always on the alert for patients in trouble or, as Janet puts it, “people making mischief in the night.”

She’s explained to me how it works. “Anyone can page us, a nurse, doctor, or even a family member. We go there, size up the situation, figure out if it’s a hot
A
– a patient who needs to come to the
ICU ASAP!
A
B
is a worrisome or iffy patient. It’s a ‘heads-up’ that this patient needs to be followed closely. We try to fix them on the floor so they won’t have to come to the
ICU
. A good save like that is an amazing feeling! Then there’s a
C
, which is a consult about someone who’s stable but not looking good. It’s someone that someone is worried about. You’ve got to trust your gut and use your noggin. Sometimes we just offer advice or teaching, nurse to nurse, say, about pain management or symptom control. Some of those nurses on the floor are very experienced. But they don’t have time to help the rookies – so that’s what we’re there for.”

To me, this advanced role sounds daunting, but Janet is quick to explain that they don’t do anything without running it by the doctor first and getting an order, and that all decisions are made together. “We’re the eyes and ears, right at the scene, telling them what we see and what we think.” She’s serious and emphatic about that, but in a moment the old twinkle in her eye reappears. “But
what usually happens is we’ve figured out the problem and have a pretty good idea what needs to be done by the time we’ve called the doctor.”

To be chosen to become a member of the Rapid Response Team, you have to be an experienced nurse, undergo additional education, and have proven yourself capable of this advancement. I haven’t taken it on myself but hope to one day.

I look over at my partner for the night, Simone. She has been an
ICU
nurse only a few months, a nurse less than a year. There aren’t many nurses who are capable of working in the
ICU
so soon after graduating from nursing school, but Simone might be one who is. What she lacks in experience, she more than makes up for in book smarts and an eagerness to learn. At first glance it would seem unwise, even unsafe, to pair an inexperienced nurse with a complex and unstable lung transplant patient, but new nurses will never come into their own if they aren’t given challenges, especially under the watchful eye of a well-seasoned (sounds like a roast turkey) veteran. That’s where I come in. It’s how I learned.

I’d been hoping to coast tonight, but I’ll need to keep my radar out to help Simone if she needs it. So far, she doesn’t seem worried, not the least bit daunted, but I have a feeling she should be.

It’s less than an hour into the shift and Simone is in over her head. I go over to help, staying mere steps from my own patient and well within earshot of him and his monitor alarms. At first Simone balks at what she sees as my interference, saying she can manage on her own, but quickly softens when she realizes that I’m here to help, not to criticize. She’s clearly overwhelmed, glancing from the monitor, to her patient, to the countertop cluttered with meds due to be administered, not sure where to start first. Her patient’s ventilator alarm keeps going off and she silences it without
checking the reason. The family has been calling in repeatedly from the waiting room, asking to come in, and she is flustered, snapping at them over the phone,
Not now
. I go over and suction her patient’s lungs and give him an extra boost of oxygen. I change the chest tube drainage system that has filled up with bloody drainage and then start sorting out the “spaghetti,” the tangled-up, intertwined
IV
lines. Her patient has a fever and a high white count and needs blood cultures, so I do that. Together, we check and doublecheck, then co-sign for two units of blood, and I prime blood tubing, then prepare extra drips of
IV
Levophed and epinephrine. These powerful meds are running in each of the
IV
ports and cannot be put on hold while the blood runs in.

“After the antibiotic runs in, a port will be freed up to hang the blood,” she reasons.