Opening My Heart (3 page)

He looks perplexed, perhaps wondering how to reassure someone so anxious and somewhat irrational-sounding.

“If that’s how you feel,” he says, taking me at my word, “you should document your wishes and make sure to tell your family doctor.”

“I don’t have one.”

“Get a lawyer and write a living will. Spell out your advance directives. Let your family know your wishes for your end-of-life care. Inform the surgeon.” He shakes his head. “I don’t want to disappoint you, but you’re actually going to do very well. I wouldn’t send you for surgery if I didn’t think you were going to make it. This is a routine case.”

Surely he’s had patients who’ve died from “routine” surgery. And yes, I know, it is a good thing to be an ordinary patient with a common problem, but, see, I don’t want to be a patient at all!

Walking slowly out of his office into the bright, hot summer afternoon, I’m scared out of my mind. Admittedly, there’s a tiny bit of relief, too, to be set free from this heavy secret buried inside of me all of these years. In my heart of hearts, I knew this day would come. I’ve always felt I was getting away with something, continually dodging a bullet. Up until now, I’ve managed to stay on
this
side of the bed, a nurse in charge of others’ care. Now I’ll be the one
in
the bed, nurses bending over my body, tending to me.

I’ve always been such a big champion of our health care system, here in Canada, but will I remain a loyal fan when I’m on the receiving end?

I’m also a writer of stories that have been described as “heartwarming” and “heart-wrenching.” The only thing I know for certain about the story ahead of me is that it will be heart-
stopping
.

This is so not happening!

Oh yes it is.

I make my way out to the parking lot after seeing the cardiologist, my heart pounding, stomach churning, legs shaking. No “flight or fight” – I’m all
fright
. And I know, I know, I shouldn’t drive, but I do, and worse, I call Ivan on my cellphone as I’m weaving in and out of traffic.

“We’ll deal with it, Til,” he says in his strong, confident way.

My news seems to come as no surprise to him. Ivan is an insurance broker and it always seemed odd that he never applied for a policy for me, but maybe he knew all along that I was too high risk to qualify for life insurance. Though we rarely talked about my heart condition, he must have realized it was serious.

At home, I drop my purse and keys and race to the phone.
I have to call Mary
. Mary Malone-Ryan. You can’t get more Irish Catholic than that. But it’s not her religion I need, it’s her intellect – and her
support. Originally from New Brunswick, Mary and I have been friends for years. We worked together in the
ICU
until she moved with her family to North Carolina, where she now works in a cardiovascular
ICU
.

“Til – eee!” Mary is ecstatic whenever I call, but in a split second she senses the worry in my voice and hers drops down. “Tilmeister, what’s wrong?”

She’s shocked when I tell her. I’d kept this secret from everyone, especially nurse friends who would have insisted I see a doctor. Mary quickly changes gears, shifting straight into clinical mode, asking about my symptoms, blood pressure, electrocardiogram findings, and ejection fraction from my left ventricle. Once the data is out there between us, we both know there’s no way around it: open-heart surgery is the only way to fix my problem.

“You can do this,” she says calmly.

“No, I can’t,” I wail hysterically.

“You’re strong, Tillie. Stronger than you think.”

“No, weaker,” I insist. I’m none of the noble things said about brave patients and their indomitable spirit, their courage. No one is going to call me a “fighter” or a “trooper”! I’m ready to run for the hills! I blubber on to Mary about putting my affairs in order, writing in-case-I-don’t-make-it letters to my kids, and music for my funeral.

“Don’t go there,” Mary interrupts.

“Maybe I should delay the surgery. I feel perfectly fine.”

“You’re going to feel better afterward. You’ll have so much more energy.”

“If I make it.”

“It’s scary, but you’re not going to die, Til.”

“I’m just saying. It’s possible. You know it is.”

“Most valve replacements do very well.”

Yes, most do, it’s true, but some don’t and those are the only ones I can think of. When I get off the phone with Mary, my mind turns to all the bad things that can happen. Patients who “don’t do well” are the very ones I’ve dedicated my career to taking care of in the
ICU
. We’re nurses. We know every possible Worst Case Scenario.
WCSS
are my specialty! Maybe I’ve gravitated toward caring for catastrophically ill people so that my problem would seem mild by comparison. Now my whole career seems like a preparation, a dress rehearsal – maybe even a death rehearsal? – for this. Waiting in the wings, I’ve played a supporting role, never the star. Now I’ll be centre-stage. Or maybe it’s more like I’ve been a loyal fan, a spectator at the game, always cheering the players from the bleachers. Now I’m going to be in the action, taking one for the team.

I can picture it all! The images come forth, unbidden, in fullblown technicolour, high-def, surround-sound: the whine of the pneumatic saw cutting into my chest, the crack of ribs, the whirr of the bypass machine, the bloody heart beating, slowing down, then still. When the heart is stopped there’s a hush in the room while the surgeon works in silence.

Some things are better left unknown
. It’s scary enough even when it goes well. It’s probably easier going through this as a civilian, but I don’t have that luxury. We all fear the unknown, but it’s what I know that scares me. I can’t find comfort in “There’s nothing to fear but fear itself” because there are real reasons to be afraid.

First, there are all the known, usual risks along with the unexpected, rare, or oddball events that end up as someone’s presentation at a medical conference. Common complications are infection,
ICU
stress ulcers, deep vein thrombosis, which could lead to a pulmonary embolus (blood clot in the lung), burst blood vessels, uncontrolled bleeding, a blood clot or air bubble in the brain or in the heart itself, collapse of the lung (pneumothorax), or
the dreaded acute respiratory distress syndrome, a devastating condition that causes massive lung inflammation, affects every organ, and carries a high mortality rate. There are iatrogenic problems (ones we cause) like unintended injuries or nosocomial (hospital-acquired) infections from inadequate hand-washing practices, contaminated surfaces, or even improperly sterilized instruments. We’ve all heard of such cases. Hospitals are dirty places. I know a patient who caught a Norwalk virus after a brief visit to the emergency department for a throat infection. (Why he went to the
ER
for a relatively minor problem is another story.) Hospitals are hotbeds of super-bugs such as methicillin-resistant staphylococcus aureus
(MRSA)
or Clostridium difficile (C difficile) floating all over the place. There are even infections specific to the
ICU
known by the Dr. Seuss – like mantra of “Zap the
HAP, VAP
, and
DAP”
– hospital-, ventilator-, and donor-acquired pneumonias.

More common than human error is the myriad ways your own body can let you down. Even if everyone does everything correctly, complications can happen. The immune system weakens and an opportunistic infection sets in. A bizarre reaction to an ordinary drug leads to the kidneys shutting down, boils all over the body, and the skin sloughing off. An unknown allergic reaction causes anaphylaxis, then cardiac arrest. I’ve seen all of these things happen.
For starters. That’s on a good day
.

One day I was transferring a patient from the
ICU
to a step-down ward. She’d recovered from septic shock, pneumonia, and kidney failure. As I pushed the bed out of her room, I was chatting with her when suddenly she said, “My chest is exploding.” On the monitor, I saw her heart rate go into an erratic rhythm and she quickly became unresponsive. Ventricular fibrillation! We did cardiac compressions in the doorway. We worked on her for more than an hour but couldn’t save her. There were no indications this might
happen and no one was at fault. Even an autopsy didn’t reveal the cause of the cardiac arrest. Bodies break down. Not every problem can be prevented or fixed. Many times no one is to blame.

There are many unsolved puzzles like these, but there is also a logical cascade of events I’ve seen time and again. I call it “One Thing Leads to Another.” A patient walks into the hospital with one problem and new problems are discovered – or caused. You start off with a straight-forward heart problem, then a respiratory infection sets in. An electrolyte disruption causes a heart arrhythmia. A “suspicious shadow” seen on the liver during a scan necessitates “further investigations,” upon which another problem is revealed. A brief dip in blood pressure intra-operatively and next thing you know, the patient’s gone into kidney failure and needs dialysis … and so on. What did I tell you?
OTLTA
.

I’ll never forget a healthy, vibrant eighty-one-year-old grandmother who jogged five miles every day. At an annual checkup, her family doctor found hematuria, a trace of blood in her urine. A
CT
scan of her kidney showed a small mass. “It may cause a problem in ten years or so,” a surgeon said, but the patient wanted to get it over with now when she was feeling well. A reasonable choice, yet, during the surgery, her intestine was accidentally nicked. In a few days, her peritoneal cavity was filled with fecal contents and her blood became contaminated. Meanwhile, the pathology report came back stating that the original kidney tumour was benign. She hadn’t needed surgery in the first place, but now she needed multiple surgeries to drain the infection and to create an opening for feces to drain out. She got pneumonia, a hospital-acquired infection, then kidney failure.

A doctor’s note in her chart read:
This patient is not a well woman
.

She was, once!

She walked into the hospital in perfect health and by the time
she left, she’d lost a kidney, most of her large and small intestine, had a chronic infection, and was bed ridden. After a year-long hospital stay, she was brought home and died there. Yes, I’ve seen too many times when it would have been best to leave well enough alone. Beware of
OTLTA!

And we’ve all heard of the alarming incidence in hospitals of adverse events, sometimes called
medical errors
, which is actually a misleading term because it sounds like only doctors are capable of negligence or incompetence, but nurses can cause just as much harm – or healing, too. After all, nurses are the front-line care-givers, the ones actually doing most of the things that are being done to patients.

Every single day and night that we go to work, nurses live with the knowledge that our actions can hurt – even kill – a patient. Any nurse who forgets this reality should leave the profession. Immediately. Keeping the awareness of risk uppermost in my mind helps me practise safely. Most nurses have not made serious medication errors, but those who have will live with it all their lives. Yes, I have made a few medication errors. Thankfully, all were minor, didn’t cause harm, and after full disclosure and an apology, I learned from them, but they haunt me still. However, I know some excellent professionals who couldn’t come to terms with an error they’d made. They lost their confidence and ended up leaving the profession, all because of one moment of inattention.

Paradoxically, my own “near-misses” have made me a better, more careful, and safer nurse. One trick I’ve learned is to constantly remind myself of all the things that
could
go wrong. For example, when I prepare and administer an infusion of heparin, a powerful blood thinner, I think how easily I could grab the black-topped bottle of 1,000 units per millilitre instead of the similar-sized, same-shaped, red-topped 10,000 units per millilitre. If I
choose the black when it should be the red, the patient could receive too little heparin, possibly leading to a blood clot; if I draw from the red vial when the black is required, the patient will receive too much heparin, possibly causing bleeding.

Another mindset I use to stay safe is to read doctors’ orders with a measure of caution and reserve, regarding each one as a
suggestion
or
recommendation
until I’m in complete agreement that what is ordered is the right course of action. Of course, in most cases it is, but if not, or if I have queries or concerns, I don’t hesitate to speak up. When it comes to patient care, I’m not afraid to question authority or express my opinions, but it’s taken me a long time to become like this. Am I going to feel as confident when I’m a patient as I do as a nurse?

Now right back at’cha! Payback time!

Yes, I know all the problems and potential for danger, but I calm myself down with the knowledge I have of all the hospital-wide efforts underway to fix them. Pre-mixed pharmacy medications, automated dispensing machines, computerized doctors’ orders, a new culture of hand-hygiene awareness, and additional safety checks that are all in place are reassuring. However, nothing is foolproof, and none of these measures gives you an exemption from constantly thinking about safety.

For me, the best environment in which to be a patient or a nurse is one where there is a culture of safety and “no-blame.” Not every nurse is as fortunate as I am to practise in such a “healthy” workplace, one that is as egalitarian and hierarchy-free as mine. It’s a place where most people feel they can turn to a colleague and say, “Please double-check this dose for me” or “Hey, I think you forgot to …” or “I’m not sure about this, what do you think?” No technology or inventions are going to prevent all mistakes because nothing can replace teamwork and old-fashioned vigilance. Safety is an
attitude, a way of doing things every bit as much as merely carrying out the correct actions.