Life Support

Three Nurses on the Front Lines

Suzanne Gordon

• Publisher: ILR Press
• Year: 2012
• eBook ISBN: 9780801464997
• Topic: Medicine
• Subtopic: Nursing

In this book, Suzanne Gordon describes the everyday work of three RNs in Boston—a nurse practitioner, an oncology nurse, and a clinical nurse specialist on a medical unit. At a time when nursing is often undervalued and nurses themselves in short supply, Life Support provides a vivid, engaging, and intimate portrait of health care's largest profession and the important role it plays in patients' lives.

Life Support is essential reading for working nurses, nursing students, and anyone considering a career in nursing as well as for physicians and health policy makers seeking a better understanding of what nurses do and why we need them. For the Cornell edition of this landmark work, Gordon has written a new introduction that describes the current nursing crisis and its impact on bedside nurses like those she profiled in the book.

Chapter 1

The Tapestry of Care

It is four o’clock on a Friday afternoon. The Hematology / Oncology Clinic at Boston’s Beth Israel Hospital is quiet, almost becalmed. Paddy Connelly and Frances Kiel, two of the eleven nurses who work in the unit, sit at the nurses’ station, an island comprising two long desks equipped with computers and constantly ringing phones. They are encircled by thirteen reclining blue leather chairs in which patients may spend only a few minutes for a short chemotherapy infusion, or an entire afternoon when they receive more complicated chemotherapy or blood products. The two nurses write the results of their day’s work in various patient charts. Across from where they sit, Nancy Rumplik is starting to administer chemotherapy to a man in his mid-fifties who has colon cancer.

Nancy is forty-two and has been a nurse on the unit for the past seven years. Her brown, straight hair is cut in a short bob. Her eyes are a pale, almost indistinguishable hazel, the bridge of her nose a wide track that crooks slightly to the left at its tip. Her soft voice is muted by the weariness of a long day.

She stands next to the wan-looking man and begins to hang the intravenous chemotherapy that will treat his cancer. Dressed in black jeans and a black T-shirt that accentuates his pallor, he seems apprehensive about the treatment but does not verbalize his concerns. Nancy, who wears a white lab coat with a stethoscope dangling around her neck, reminds him of the purpose of every drug that is going into his system. As the solution drips through the tubing and into his vein, she sits by his side, watching to make sure that he has no adverse reaction.

Although she is primarily responsible for this particular patient, today she is acting as triage nurse. Each week, one of the clinic’s eleven nurses serves as the person responsible for any patients who walk in without an appointment, for any patients who call with a problem but can’t reach their primary nurse, for the flow of the unit, and, of course, for emergencies. Even though she concentrates on her own patient, Nancy’s eyes thus constandy sweep the room to check on the remaining patients. She focuses for a moment on a heavy-set African American woman who is sitting in the opposite corner. The woman, in her mid-forties, is dressed in navy slacks and a brightly colored shirt. Her sister, who is notably younger and heavier, is by her side. The patient seems fine, so Nancy returns her attention to the man next to her. Several minutes later, she looks up again, checks the woman, and stiffens. There is a look of anxiety on the woman’s face she did not see before. Leaning forward in her chair, she stares at the woman.

“What’s she getting?” she mouths to Kiel.

Looking at the patient’s chart, Frances Kiel names a drug that has caused a number of severe allergic reactions. In just that brief moment, as the two nurses confer, the woman suddenly clasps her chest and her look of anxiety turns to terror. Her mouth opens and shuts in silent panic. Nancy leaps up from her chair, as do Kiel and Connelly, and sprints across the room.

“I can’t breathe,” the woman sputters when Nancy is at her side. Her eyes bulge and she grabs for Nancy’s hand; she tightens her grip and her eyes roll back as her head slips to the side. Realizing that the patient is having an anaphylactic reaction—her airway swelling and closing shut—Nancy immediately turns a small spigot on the IV tubing to shut off the drip. At the same instant, Kiel calls a physician and the team responsible for responding to medical emergencies in the hospital. By this time, the woman is struggling for breath.

Kiel next slips an oxygen mask over the woman’s head and places a blood pressure cuff around her arm. Connelly administers an antihistamine and cortisone to stop the allergic reaction and to decrease the inflammation blocking her airway. An oncology fellow arrives within minutes. He assesses the situation and then notices the woman’s sister standing, paralyzed, watching the scene. “Get out of here!” he furiously commands.

The woman moves away as if she has been slapped. Then, with practiced synchronicity, no one leading or following, Nancy continues to work with the nurses and physician to stop the reaction and stabilize the patient.

Just as the emergency team arrives, the woman’s breathing returns to normal and the look of abject terror fades from her face. Grasping Nancy’s hand, she looks up and repeats, “I couldn’t breathe. I just couldn’t breathe.” Nancy gently explains that she has had an allergic reaction to a drug and reassures her that it has stopped.

After a few minutes, when he knows the patient is stable, the physician and emergency team walk out of the treatment area, but the nurses continue to comfort the terrified woman. Nancy then crosses the room to talk with her male patient who is ashen-faced at this reminder of the potentially lethal effects of the medication he and others are receiving. Responding to his unspoken fears, Nancy says quietly, “It’s frightening to see something like that. But it’s under control.”

He nods silently, closes his eyes, and leans his head back against the chair. Nancy goes over to the desk where Connelly and Kiel are breathing a collective sigh of relief. One of the nurses comments about the physician’s treatment of the patient’s sister. “Did you hear him? He just told her to get out.”

Wincing with distress, Nancy looks around the room to try to locate the patient’s sister. She goes into the waiting room, where the woman is sitting in a corner, looking bereft and frightened. Nancy sits down next to her. She explains what happened and suggests that the patient could probably benefit from some overnight company. Then she adds, “I’m sorry the doctor talked to you like that. You know, it’s a very anxious time for all of us.”

At this gesture of respect and recognition, the woman, who has every strike—race, class, and gender—against her when dealing with elite, white professionals in this downtown hospital, smiles solemnly. “I understand. Thank you.”

Nancy Rumplik returns to her patient.

* * *

2:00 P.M.

Ellen Kitchen, a nurse in Beth Israel’s Home Care Department and a geriatric nurse practitioner for the past seven years, spends her workday in some of Boston’s most ramshackle neighborhoods visiting poor and elderly patients. There is the crotchety old African American man who lives alone in a tattered one-bedroom apartment. He is trapped in those two rooms because his ancient lungs have been damaged by emphysema. Then she visits an elderly woman with diabetes and congestive heart failure who tries, despite her many ailments, to care for the grandchildren her daughter has abandoned. Next comes the ninety-two-year-old woman with coronary artery disease and arthritis who lives with her yelping dogs and is at constant risk for falls and other serious medical problems.

The forty-year-old nurse is slender and of medium height. Her blunt-cut brown hair is going gradually gray. A self-described optimist, her demeanor is so friendly as to be at times almost perky. She generally rides her bike to work and home visits. To make her last visit of the day, Ellen, who dresses casually in slacks and a wind-breaker, parks her bike in a lot of an apartment building. As she passes the staff in their offices, they wave her in. An apartment door on the third floor has been left ajar so she can enter.

The tall black man who lives here is dressed nattily in slacks and a navy-blue-and-white plaid cardigan. At age eighty-eight, however, his legs are weak and he must grasp the end of a table to haul up his lanky frame and greet Ellen. He smiles and welcomes her with a barrage of personal questions about her upcoming move to another apartment, her husband’s work, and the health of her two-year-old son. Then he settles back into his chair.

For the past five years, Ellen Kitchen has been a constant in the life of Theodore Cousins.* She originally cared for his wife, who after a stroke was wheelchair-bound until she died three years ago. On weekly, sometimes even biweekly, visits, Ellen has traveled the short distance from the Longwood Avenue medical area—home to many of Boston’s major teaching hospitals, Harvard Medical School, and the Harvard School of Public Health—to this neat, compact apartment. Here she watched with increasing respect as Cousins devoted himself to his wife’s care. His children had long ago left home, and it was the former waiter who cooked, cleaned, and shopped and bathed, dressed, and fed his wife during her long illness.

When Cousins himself grew increasingly frail and ill, Ellen began taking care of both husband and wife. Since the death of his wife, Ellen has been the primary-care provider and coordinator of the services “Mr. C.” receives from the homemaker who cleans his house, the neighbor who cooks his meals, and his social worker and physical therapist.

Unloading the backpack that contains her medical paraphernalia—rubber gloves, blood pressure cuff, syringes, tourniquets, prescription blanks, and medical charts—she appraises her patient. “How are you, Mr. C.?” she asks. Then, without once being prompted by his medical chart, she inquires about the arthritis in his right shoulder, the injured tendon in his leg, and mentions, in passing, the aortic aneurysm he suffered from—and to everyone’s surprise survived—many years ago.

“How’s the cold you had last week?” she continues. “Did you have any more pains in your chest? Have you needed to take your nitroglycerin?” She checks a plastic pillbox stationed under a sign she has posted—Take Your Heart Pills!—and frowns as she scans the contents.

“It looks like you’ve missed one pill,” she observes and then checks more carefully. “No, two. Let’s see. You didn’t take a pill Tuesday and Wednesday.” Patiently, without condescension, she reviews each medication. “Remember, Mr. C, there’s the nitroglycerin—that’s a vasodilator for your heart—the digoxin for your congestive heart failure and atrial fibrillation, and the enteric-coated aspirin to thin your blood since you had the stroke last summer.”

Mr. C. points a wrinkled hand at his crotch and complains about vague urinary symptoms. So she asks him to give her a urine specimen “just to see if anything’s cooking.” She wants to prevent a repeat of an undetected urinary tract infection that put him in the hospital last fall. He lurches up out of his chair, goes into the bathroom, and comes out with a vial full of urine to offer her.

Then Ellen takes his blood pressure while he’s sitting and standing and escorts him into the bathroom to weigh him, all the while continuing to chat about his week. The conversation inevitably turns to a major concern—monitoring the prostate cancer that was diagnosed a year ago. “Before all this, I never even knew what a prostate was,” Mr. C. jokes.

The cancer is slow-growing and appears to be stable. But Mr. C. brings up the subject of his refusal to have the operation—the orchiectomy, or removal of the testicles—his doctors had originally recommended. Instead, Mr. C. received monthly injections that lower testosterone to treat his prostate cancer. As they chat about his decision, the old gendleman suddenly slaps his thigh and reveals a powerful boyhood memory.

When he was a boy, he lived on a farm in the South. There he was a spectator to a horrifying ritual. Although it took place decades ago, the memory is still vivid. He would stand outside the large pen and watch as farmers corralled their hogs. With the animals squealing and wriggling, they took their huge knives, grabbed a hog, and with a swift motion sliced off its testicles. The animals spurted blood and bellowed in agony as the farmers smeared tar over the bleeding wounds before setting them loose.

“You know, I can’t get that out of my mind. I remember those hogs, cut and tarred, running off squealing and bleeding.”

Ellen flinches at the description. “Mr. C., that would never happen to you,” she assures him. Although she makes no attempt to persuade him to have an operation he clearly does not want, she does express surprise that he has never before confided this story. “Why didn’t you tell me this when we talked about the operation a year ago?” she inquires.

Looking sheepish, he confesses. “I guess I didn’t want to tell that to a woman.”

Then he smiles slyly and winks. “But I found out women know a damn sight more than I thought they did.”

6:00 P.M.

Today, clinical nurse specialist Jeannie Chaisson arrived on her general medical unit at seven in the morning and cared for patients until 3:30 in the afternoon. Before leaving at 4:30, she wrote notes in their charts and reported on their condition to the nurses who would replace her. Then she made the forty-five-minute commute from Boston to her home in suburban Auburndale. As soon as she enters her home, she makes herself a pot of coffee and, cradling a fresh cup, sits down in her living room. She has only a few moments to relax before her kids return home from their after-school activities. Jeannie takes off her burnished copper wire-rimmed glasses and rubs her opalescent blue eyes. Her brown hair, lightly filamented with gray, is cut in a hairdo that varies only slightly—a modified bob that falls either just below her ears or somewhere above her shoulders.

Just as she is shedding the strain of the day, the phone rings.

It’s the husband of one of Jeannie’s patients—a sixty-three-year-old woman suffering from terminal cancer. She has metastases in her bones. When she left the hospital, Jeannie knew the family was in crisis. After having the cancer for several years, the woman was exhausted from the pain, the effects of the disease and failed treatments, and the pain medication upon which she had become increasingly dependent for any peace. Jeannie knew she was ready, willing to let death take her. But her husband and daughter were not.

Now, the crisis that was brewing has exploded. The caller is breathless, frantic with anxiety. “She says she wants to die, that she is prepared to die,” explains the husband, relaying his wife’s pleas. “She says the pain is too much. This isn’t her,” he insists. “It can’t be. She’s such a fighter. It’s not like her to give up, to abandon us like this.” He insists that it’s the disease talking, or maybe the pain, or the pain-killing drugs.

“You’ve got to do something,” he implores Jeannie. “Keep her going, stop her from doing this.”

Jeannie knows that it is indeed time for her to do something—but, sadly, not what this anguished husband wishes.

“Be calm,” she tells him, “please hold on. We’ll all talk together. I’m coming right in.”

Leaving a note for her family, she gets into her car and drives back to the hospital.

When Jeannie arrives on the floor and walks into the patient’s room, what she finds does not surprise her. Seated by the bed is the visibly distraught husband. Behind him, the patient’s twenty-five-year-old daughter paces in front of the large picture window that looks across Boston. The patient herself is lying in a state somewhere between consciousness and coma, shrunken by pain and devoured by the cancer’s progress. Jeannie has seen scenes like this many times before in her fifteen-year career as a nurse. A patient who has tried to fight his or her disease for months, perhaps years, is reconciled with death. But the family and / or medical team are unable to let go.

As she looks at the woman, she can understand why her family is so resistant. Her child and husband remember her as she first appeared to Jeannie three years ago. Then she was a bright, feisty, sixty-year-old woman—nails tapered and polished, hair sleekly sculpted into a perfect silver pouf. Jeannie remembers the day, on that first of many subsequent admissions to a medical unit on the sixth floor of the Feldberg Building—a building of the hospital named after a wealthy donor—when she asked the woman if she wanted her hair washed.

“Wash my hair?” the woman replied in astonishment. Then she announced in a clearly enunciated staccato, “I do not wash my hair. I have it done. Once a week.”

Now that hair is unkempt, glued to her face with sweat. Her nails are no longer polished. Their main work these days is to dig into her flesh when the pain becomes too acute. That immaculately tailored frame has crumbled under her. The disease—like the dirt and stones that pit and burrow into winter snow, eroding its pristine surface—has slowly bored through her bones. Simply to stand evokes pain and could even be an invitation to a fracture. The doctors have done everything to try to shore her up and beat back the disease—operated and pinned disintegrating bones, treated every infection, given her narcotics to try to offset the excruciating pain.

To no avail. Her pelvis is disintegrating. The nurses have inserted an indwelling catheter because the simple act of slipping a bedpan underneath her causes agony. But she has developed a urinary tract infection. Because removing the catheter will make the infection easier to treat, doctors suggest this course of action. Yet, if the catheter is removed, the pain will be intolerable each time she has to urinate.

When the residents and interns argued that to fail to treat the infection could mean the patient might die, Jeannie responded, “She’s dying anyway. It’s her disease that is killing her, not a urinary tract infection,” and they relented.

Now, it is the family’s moment to confront reality.

Jeannie goes up to the woman’s bed and gently wakens her. Smiling at her nurse, the woman tries to muster the energy to explain to her daughter and husband that the pain is too great, she can no longer attain that delicate balance between fighting o...

Table of contents

• Foreword to the Cornell Edition
• Preface
• CHAPTER 1 The Tapestry of Care
• CHAPTER 2 The Care of Strangers
• CHAPTER 3 Not on the Charts
• CHAPTER 4 A Special Visitor
• CHAPTER 5 The Meaning of Illness
• CHAPTER 6 A Mentor of Their Own
• CHAPTER 7 Collaborative Care
• CHAPTER 8 A Good Enough Death
• CHAPTER 9 Final Checkups
• CHAPTER 10 A Good Enough Death II
• CHAPTER 11 Unraveling the Tapestry of Care
• CONCLUSION Preserving the Tapestry of Care
• Afterword to the Cornell Edition
• Notes
• Selected Bibliography