As a patient's needs multiply, the lessons become intense

Second of four parts

Julia Zelixon had just gathered the dozen or more drugs she would need for her new patient when four nurses and doctors in blue surgical scrubs, caps, and masks wheeled the tiny, gaunt woman into room 402.

Unconscious in the big hospital bed, Kathleen looked almost childlike, but she was perilously close to death following emergency abdominal surgery. One nurse hand-pumped oxygen into her lungs while an anesthesiologist warned Julia and the other nurses in the surgical intensive care unit that a key oxygen sensor had fallen off Kathleen's finger.

''We lost the SAT on the elevator," the anesthesiologist said, referring to the clip-on device.

For Julia, this would be a critical test. A ''sick admit" like Kathleen arrives on short notice from an accident scene or emergency surgery, often ailing in so many ways at once that it can test the judgment of even an experienced nurse -- and Julia was only months out of nursing school.

From the moment she laid eyes on Kathleen, she felt uncertain what to do.

Julia knew that the woman, who had nearly ''flat-lined" that morning, had a host of problems -- damaged lungs, a weak heart, and a potentially fatal intestinal condition. Plus, there were so many tubes that needed connecting -- to IV drugs, to IV fluids, to monitoring lines inside Kathleen's arteries, to the ventilator that would help her breathe. Which should she worry about first?

There was nothing to do but dive in. She moved to disconnect Kathleen from her portable vital-signs monitor so that she could link her to the larger machines in the room.

For the moment, she did nothing about the missing oxygen sensor.

Standing at Julia's side, her teacher, M.J. Pender, noticed the lapse immediately: Without a SAT reading, there was no way to be sure oxygen was reaching Kathleen's vital organs. The first thing Julia should have done was make sure the patient wasn't dying right in front of them.

''The first issue is breathing," said M.J. in a voice that left no room for discussion. ''If your airway is shot, then you're screwed. Nothing else matters."

Maybe Julia should have expected a bad day. The 35-year-old mother of two woke up an hour later than her usual 4:50 a.m., putting her in a mad rush to catch the train to Massachusetts General Hospital for a 12-hour shift in the Ellison 4 surgical ICU. She flew out of the house bleary-eyed, her curly hair unwashed, and without her nametag and ID badge. All day, a strip of masking tape on her scrubs told patients who she was, and she had to borrow M.J.'s badge whenever she needed to get into the locked medications room.

''I hate it when the days start like that," she said.

Still, the morning went smoothly enough, as M.J. praised Julia's easy, compassionate manner with an 83-year-old man who had just undergone surgery for pancreatic cancer. Julia was feeling pretty good, too, about her progress in the hospital's grueling eight-month training regime for ICU nurses. One appreciative patient had even sent her a card that read: ''You will make it. Never doubt that. In our minds, you already have."

As Julia grew comfortable in the ICU, her teachers, M.J. and Jeanne Rufo-Huckins, were letting her handle more tasks on her own. But M.J. knew that Julia's testing time lay ahead. She respected Julia's intelligence and her speedy mastery of complicated procedures. But she was less certain about how steady her student would be under pressure, and she wanted -- needed -- to find out. So M.J. was delighted when the ''charge" nurse who administers the ICU told her she was expecting Kathleen, an 85-pound, chronically ill woman, to soon arrive on the floor.

''We haven't had a sick admit in a long time," M.J. said. ''We need this."

The smile on Julia's face vanished when M.J. called her away from the elderly man's bedside at 11:45 a.m. to brief her on the new patient. ''She's pretty much a disaster," M.J. told her. Julia remained outwardly calm, listening with arms folded, but her anxiety was mounting at the thought of caring for such a fragile patient. ''If you make a mistake in a situation like that, you remember it forever," Julia remembers thinking.

Kathleen, 56, had been admitted earlier in the week to one of the regular floors at Mass. General with ''toxic megacolon," a life-threatening intestinal condition that causes severe bloating, excruciating pain, and dehydration. Weakened by her other ailments, she had ''crashed and burned," M.J. told Julia, and had to be transferred to another of the hospital's ICUs. There, Kathleen became nauseated and vomited so violently that her heart nearly stopped, prompting emergency surgery to find the cause. Now the OR team was sending word to expect her in Ellison 4 within two hours.

''We don't have a lot of time," M.J. said.

Julia had cared for ''sick admits" before. But Kathleen's condition was more dire, and Julia knew that much more was expected of her now that she was six months into her training. It was no longer enough to dutifully do as M.J. said. Julia had to show she could play a leading role in admitting an unstable patient and getting her settled.

To prepare, Julia reviewed Kathleen's medical records on a computer screen. She was taking 13 medications for everything from low hormone levels to high anxiety. Julia hurried to assemble the drugs and supplies she felt she'd need in the hours ahead.

Initially, M.J. left Julia to set up the room on her own. But when the senior nurse checked in just before Kathleen's arrival, she saw problems. Julia needed to fetch more machines to deliver intravenous medications and to prepare injections to control Kathleen's heart rate. ''You're going to need a second Harvard pump," said M.J., with the certainty of a 20-year veteran. ''Set up levo and some vasopressin in syringes. It will make your life easier."

Minutes later, during the controlled chaos of Kathleen's arrival just after 2 p.m., M.J. again let Julia take the lead. But the senior nurse took charge when she saw that Julia hadn't immediately checked Kathleen's breathing. She worried that the oxygen levels in Kathleen's blood could have dropped dangerously during the several minutes since her monitor fell off on the ride to the ICU.

''Could someone bring albuterol and adjuvant MDI to 402 please?" she ordered over the public address system, calling for emergency medicines that could further open Kathleen's airway and lungs. She asked another nurse to get a respiratory therapist who could quickly connect Kathleen to a ventilator so that nurses would not have to continue hand-pumping oxygen.

Julia, meanwhile, tackled the spaghetti of IV and monitoring lines on Kathleen's bed. ''Pick one thing and back out" the line from the tangle, said M.J., urging Julia to first fish out the two lines that measure heart function. Because Kathleen was dehydrated, they needed to know -- immediately -- whether she was in imminent danger of heart failure. Not waiting for Julia, M.J. grabbed one of the lines only to discover that there was no electrical cable in the room to attach it to the monitor.

''Did you have three cables when you set up the room?" M.J. asked. Julia said she did, but M.J. shook her head, replying coolly, ''Actually, there was probably only one." Julia started to respond, but held her tongue. She turned back to her patient, then went to fetch more cables.

When she returned, Julia connected the line from Kathleen's pulmonary artery to the monitor, but M.J. was immediately puzzled by the heart rhythm that appeared on the screen. The peaks and valleys didn't seem to match the racing heart of the woman in the bed. Then M.J. figured it out: They were looking at the heart rhythm of the last patient in the room. Julia had forgotten to erase the ''brick," the memory bank in the monitor that holds each patient's information. The mistake was small and correctable, but irritating to M.J. because it showed a lack of planning.

''If you don't do things before, it's just one more thing you have to do when you're really, really busy," she reminded her student.

Still, M.J. was sympathetic, knowing that lots of people make mistakes in an emergency: The operating room team, for example, hadn't kept track of how much blood Kathleen had received during surgery.

Forty-five minutes had passed since Kathleen's arrival, and the nurses were finally getting a clearer picture of her heart's performance. The information on the screen above her bed suggested dangerous dehydration: Her heart was beating fast, 134 beats per minute, but producing only about two-thirds the normal volume of blood. There wasn't enough fluid to pump.

''Damn," said Dr. Jose Ramos, the resident directing Kathleen's care. ''Let a whole liter [of fluid] flow in." He had been reluctant to give too much fluid to Kathleen, fearing that it could accumulate and compress her weak lungs.

M.J. was frustrated, too, realizing that Kathleen had been growing more dehydrated the whole time she was in the room, and, in part, she faulted Julia. She tried to turn frustration into a teaching moment, asking Julia what she should have done first for Kathleen's heart. But when Julia suggested a drug to strengthen Kathleen's heartbeats, M.J. cut her off: ''If there's no volume to pump, it's not enough. Always check the stroke volume before prescribing."

Any pretense that Julia was in charge of Kathleen's care had given way to the reality that M.J. was calling the shots -- and not just among the nurses. She told Ramos that Kathleen would need a nasogastric tube inserted up her nose, both for feeding and for draining fluid from her stomach, and she sent the resident to get it. When Ramos sheepishly returned empty-handed, M.J. chided him good-naturedly -- ''Oh, give me a break" -- and sent a nurse to get the tube.

Julia remained stoic -- and busy -- through the afternoon as Kathleen's vital signs gradually stabilized, but she was disappointed in herself. ''I wasn't happy with how I handled the first 40 minutes," she admitted later. ''I didn't have a good grasp of my patient."

Still, her basic self-confidence was undiminished. ''Smart people learn from their own mistakes," she said. And, she knew, ICU nurses and doctors inevitably make mistakes, given the frailty of the patients and the complexity of care. Even at a top hospital like Mass. General, the goal isn't perfection, but to prevent errors from harming patients.

So, with her first solo shift as an ICU nurse tentatively slated for April 4, Julia felt she was ready. ''There will be people to help me," she said. ''I think I'm pretty realistic about myself. I know I don't know a lot of things."

Tensions between teacher and student were probably inevitable as graduation approached and M.J. systematically reviewed the black ''competency book" that listed the skills Julia would need to succeed. Ericka Coutts, one of the first to complete Mass. General's ICU training for first-year nurses, said she came to despise the book so much that, when she graduated, she used the book for kindling.

But there was also a clash of wills going on between two proud women. M.J., one of the most senior nurses in the ICU, was forceful in correcting even small mistakes, like an insufficiently clear ''6" in the patient's record. And she wanted Julia to do something that came hard to her -- acknowledge her errors so they wouldn't be repeated. ''Doesn't she know I'm putting my heart out on the floor, because I'm getting nothing from that girl?" she asked irritably one day when she felt Julia was disregarding her advice.

Julia was quieter than her teacher, but equally self-assured. She was by no means convinced that M.J. was right every time she corrected her. In nursing, Julia explained, there are often conflicting goals -- like relieving pain without stifling the patient's will to breathe -- and good nurses can make different choices.

Julia didn't openly disobey M.J., but her cheerful expression could turn to a scowl as she carried out her instructions. As a long winter gave way to spring, Julia was growing tired of being a student. ''It works much better for me knowing that there's no backup," she said. ''Whatever happens, it's my responsibility."

One March morning, Julia could no longer contain her frustration at the relentlessness of M.J.'s critiques. M.J. had been worried that their patient, a 66-year-old man, was endangered by poor blood circulation, and she was irritated when Julia paused to listen to his abdomen through a stethoscope before going for a doctor. ''Julia is a really smart girl, and she has a lot of book knowledge," M.J. said within earshot of her student, ''but . . . it's not her job to make a diagnosis."

''Sometimes it's like, OK, OK, I get it already," Julia snapped back, flipping the stethoscope behind her neck and heading off to look for a resident.

However, both M.J. and Jeanne, Julia's second instructor, agreed that there was more than a personality conflict at work. Maybe, the two nurses thought, Julia, who brought less experience to the ICU than most other trainees, just needed a little more time.

Still, M.J. worried. Even after their testy exchange, she had tried to leave the care of the 66-year-old patient to Julia. But M.J. didn't stand back for long.

She chided Julia for not paying enough attention to the doctors' instructions during morning rounds about the patient's ventilator setting. (''You should really be able to spit back what they told you.") M.J. didn't like it that Julia hadn't seemed to notice that the semiconscious patient was slowly raising his hand toward his breathing tube, a device so uncomfortable that patients will often try to remove it. (''OK, I'm just going to butt in here . . .") Finally, M.J. criticized Julia for trying to wrestle the big man into a johnny before she administered a potent sedative.

''Oy, vey," said M.J. at how far off-track the day had gone.

Two days later, Julia's teachers met and concluded that she needed at least two extra weeks of training, meaning that she could graduate with her class on March 28 but would not be allowed to work on her own until at least mid-April. The next day, Julia sat across a conference table from Jeanne, M.J., and Susan Tully, the SICU's chief nurse, to get the bad news officially.

Julia argued that she couldn't be expected to be as accomplished as veteran nurses and that she would always ask for help in situations where she had doubts. But M.J. and Jeanne made it clear that they wanted to see improvement in the way Julia planned for her patients' care. ''It's very hard to get back on your plan if you don't have a plan," said M.J.

In addition, the two teachers felt that Julia wasn't listening critically enough when the doctors came by on rounds, and that she seemed reluctant to go back to the residents for clarification or help. In fact, M.J. said, Julia seemed to want to do most things herself. During the extra two weeks of training, they would have Julia work from a checklist of priorities for each patient.

''It doesn't mean you're not going to graduate, but these things are serious enough that you're not going to be ready to be on your own in two weeks," M.J. reassured her.

At first, Julia was discouraged: Had she worked for four years to become an ICU nurse only to find out she wasn't very good at it? ''I was thinking, probably I didn't do well," she recalled, ''but then I thought, no, I don't think so. I think I'm able to be realistic about myself."

Julia agreed that she could use more practice in some areas, such as handling new patients who are rapidly going downhill. ''It's a luxury, actually, to get all this training," Julia concluded.

By the time graduation day rolled around, Julia was chatting cheerfully with other new ICU nurses about her situation.

When she saw Jeanne, they embraced warmly, and Jeanne pressed a pastel bouquet of daisies and snapdragons into Julia's arms. ''You deserve it," Jeanne said.

Julia was content, for the moment, but she had also made a promise to herself. If her teachers tried to add still more time to her apprenticeship, she would resist: ''I would say, 'You know what, guys? I'm getting out of here.' "

Scott Allen can be reached at allen@globe.com.