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M.J. watched carefully as Julia continued preparing Helen to travel, an oddly cheery nursing term, considering where the patient was about to go: Doctors wanted a CT scan of the advanced ovarian cancer that surgeons had discovered as they battled the infection. Helen hadnt been told yet, but she was in danger of dying from two diseases at once.
As with many intensive care patients, Helens problems were a devastating mix of bad luck and bad choices. The reclusive woman had noticed a lump in her groin months earlier, but had not sought medical help until the infection was rampant. She also had stopped chemotherapy for ovarian cancer against her oncologists advice. Surgeons at a suburban hospital discovered the consequences of both decisions, and promptly put her in an ambulance bound for Boston.
Now she was in the hands of Julia and M.J. in the surgical intensive care unit, or SICU. Nurses in the cluster of 20 small, starkly lit rooms on the fourth floor of Mass. Generals Ellison Building jokingly call the ambience cavelike, because most of the windows look out on a brick wall a few feet away. But they pride themselves on caring for the most difficult caseload among the six intensive care units in this 875-bed teaching hospital of Harvard Medical School. Its patients run the gamut from gunshot victims to some of the most severely burned patients from the 2003 fire at the Station night club in Rhode Island.
The SICU is a place of inescapable intensity, where staff members converse in a clipped shorthand that is both urgent and sometimes vulgar; where the loudspeaker can summon a stampede of white coats and blue scrubs to the bedside of a crashing patient; and where, lest anyone for a moment forget how fragile their patients are, electronic bulletin boards in the halls flash a stream of warnings in red 434 APNEA ..... 406 TACHY ..... 428 VNT ALARM whenever a patients vital signs drift beyond safe levels.
Youre at Mass. General now; do you know that? M.J. loudly asked Helen about an hour after she arrived on a frigid January afternoon, nervous and disoriented. The patient shook her head. M.J. told Helen that she had taken care of her two years earlier, when she was in for cancer surgery, but Helen didnt seem to comprehend that, either.
You might want to see if shes anxious, M.J. said, turning to Julia. Youve got that order for Ativan. Minutes later, Julia injected a clear syringe of the fast-acting sedative into a tube that drained into Helens central vein. Soon, the patient closed her eyes, looking almost serene.
For Julia, who only a few months earlier had been a nursing student at the University of Massachusetts at Lowell, Helen would be the first highly unstable patient she would transport out of her room, a carefully orchestrated undertaking that requires a nurse to leave behind the built-in monitors, breathing equipment, and racks of medicine in a patients room for portable versions of the same. Every ICU nurse has a healthy respect for the challenge of what sounds like a simple chore pushing a very sick patients bed down the hall. You dont want to be stuck in the elevator with a dead [oxygen] tank, M.J. said.
Julia set about moving Helen with single-minded zeal, stretching on tiptoes to the farthest corner of the bed to disconnect tubes and unplug wires, laughing when M.J. compared her to an octopus. She got the monitoring line out of Helens artery and held gauze over the wound, just the way M.J. had suggested. She attached Helens IV medicines and fluids to a tram, a rack that hooks to the bed. She put a green canister of oxygen on the bed and connected it to a purple ambu bag with a facemask to manually inflate and deflate Helens lungs. She placed a portable vital-sign monitor in its rack at the foot of the bed, plugged Helen in, and headed off for the scan.
Youre remembering everything today. Youre getting an A-plus, exclaimed M.J.
Julias very presence in an ICU at New Englands largest hospital is a measure of the upheaval in nursing, one of the most demanding but least glamorized professions in medicine. Although television shows such as ER make it seem as if doctors do just about everything in hospitals, nurses actually provide nearly 90 percent of intensive care, usually with no doctors in sight. Nurses sometimes feel like second-class citizens, but they are the backbone of the ICU, and hospitals struggle to recruit and train enough of them.
Until four years ago, Mass. General required nurses to have one to three years of hospital experience before they could work in the ICU, giving them more on-the-job training than
most residents, the recent medical school graduates who are the frontline doctors in teaching hospitals.
As residents rotate through, seasoned nurses provide continuity of care and a practiced eye for the telltale blood pressure drop, raspy breathing, or other signs that a patient is failing.
But the nationwide shortage of nurses 6.7 percent of nursing positions in Massachusetts are vacant has forced even prestigious hospitals to take once unthinkable steps to recruit the next generation, including signing bonuses of up to $5,000.
In 2001, Mass. General began its intensive care program for new nurses willing and able to work under near-constant stress. A patient in the SICU typically requires 20 hours of nursing care daily, 13 percent more than in 1999, as medicine gets better at keeping the sickest of the sick alive. Patients here routinely require a dozen or more intravenous medicines and up to six feeding and monitoring tubes.
The patients that ICU nurses are taking care of would have died 30 years ago, said Jeanette Ives Erickson, Mass. Generals nursing chief.
Some senior nurses are uneasy about the growing number of first-year nurses in the ICU, believing they lack the judgment to make life-and-death decisions. But the idea is catching on: Nearly one-fifth of Julias graduating class went directly into intensive care or emergency room positions.
For Julia and the other fledgling nurses, the months of training would be exhausting. In short order they had to master how to administer scores of drugs; carry out complex procedures; help families cope in their darkest hour; and, most important, head off crises that can take a patient swiftly from critical care to the morgue. There were times when I would come home and couldnt keep my eyes open past 8 p.m., recalled one former ICU trainee less than fondly. Senior nurses like M.J. decide whether trainees have the aptitude and grit for this work. And while the teachers are supportive, they pounce quickly on mistakes, especially those that may jeopardize patient safety.
Some days youre going to get hammered, M.J. said one day, summarizing what she expects of trainees. But you know what? Take it to heart, learn from it, and tomorrows another day.
Not everyone makes it: Four of the 17 nurses in Julias class would not graduate, a higher dropout rate than basic training for the Marines. For those who survive, the prize is considerable: a job with lots of autonomy at a world-famous teaching hospital, where senior nurses make more than $100,000 a year. For Julia, whose training was observed firsthand by a Globe reporter and photographer (click here to hear reporter Scott Allen and photographer Michele McDonald discuss their experiences at Mass. General), graduating from the ICU program would mean something more: regaining her sense of direction after tragedy knocked her life off course.