Time comes to perform on her own

Last of four parts

Julia Zelixon stood at the center of a scrum of white-coated doctors, blue stethoscope around her neck, taking notes and fielding questions about Phyllis, her patient.

The slender white-haired woman suffered from inoperable bladder cancer, and her breathing had become so labored that the doctors feared she would need a mechanical ventilator. Julia had a suggestion: decrease the fluids in Phyllis's system to give her lungs more room to expand.

''What are your goals on i's and o's?" she then asked confidently, using nurse shorthand for the patient's IV fluid ''input" and urine ''output."

While Julia, a first-year nurse in the surgical intensive care unit at Massachusetts General Hospital, consulted on the case, her teacher sat in the hall, drinking coffee and talking about taking her two children to see ''The Lion King" during school vacation. There wasn't much for M. J. Pender to do, and that was as it should be.

For today, if nothing went wrong, was to be the last day of Julia's eight-month apprenticeship -- a crash course in the most challenging brand of nursing at a hospital that cares for some of New England's sickest patients. M. J. had deliberately skipped the beginning of morning rounds to give her student more independence. Julia, she said, ''is definitely ready to be on her own, especially for this kind of assignment."

Yet Julia did not feel as if she was on her own. Not at all. After 20 years in nursing, M. J.'s ability to rapidly size up a patient's care and condition bordered on a sixth sense, and every time she popped into Phyllis's room to check on Julia that morning, she rattled off a litany of concerns: The IV blood isn't dripping fast enough. . . . Did you ask her pain level? . . . Empty your urine bag, or you're going to have a flood.

''I'm so ready to be out of orientation," Julia grumbled to herself.

Julia knew that, with each critique, her freedom hung in the balance. The head nurse had instructed M. J. not to let Julia out of training unless she could safely care for the full range of patients in the everyday workload of the ICU. M. J. and Julia's other teacher, Jeanne Rufo-Huckins, had already extended her training by two weeks because they felt she wasn't ready. If they extended her time again, Julia said, she'd be furious, ''and they would know it."

But by noon M. J. was feeling less confident about her student's progress. Phyllis wasn't doing well, clutching her stomach in agony and complaining that she was freezing. When M. J. checked in, Phyllis's blood pressure had dropped so low it set off a flashing red alarm on the vital-sign monitor, and M. J. was puzzled that Julia didn't recognize the obvious: The treatment plan she had discussed with the doctors at morning rounds wasn't working.

M. J. had stressed time and again the importance of getting a doctor when the patient takes a serious turn for the worse. Yet after all these months, M. J. felt that Julia was still stubbornly inclined to rely on her own judgment.

''She's fully off your plan, basically," M. J. said. ''What should you do?"

''Get the resident," Julia answered, giving the response she knew her teacher wanted.

''Absolutely," M. J. replied. ''You've got to do something. You can't just look at it."

After so many shifts working side by side, Julia and M. J. had grown increasingly blunt and testy with each other. The two women considered themselves friends with much in common, but in some ways they may have had too much in common. Smart, opinionated, and strong-willed, both are accustomed to being in charge at home and at work, and neither finds it easy to hold back if she sees a better way.

And Julia's self-confidence had grown tremendously since she reported for ICU training straight out of nursing school the previous August. She had believed from the start that she would be a very good intensive care nurse. Now she had come to believe something else: that her teacher wasn't always right.

In fact, she knew it. Ten days earlier, Julia had prevailed when M. J. questioned her judgment. The patient, a diabetic, had come to the hospital for what he thought would be a routine checkup and ended up with a diagnosis of advanced gangrene in his right leg, which required amputation at the knee. Julia wanted to turn off the blood-thinning drug the patient was receiving to prevent dangerous blood clots. M. J. thought otherwise, but the doctor assigned to the case agreed with Julia that the drug was causing internal bleeding and damaging the patient's liver. ''I'm happy," she beamed afterward.

But the glow from such moments didn't last. M. J.'s running commentary was a constant, grating reminder to Julia that she was still a student.

''I've had it up to here," Julia said, holding her right hand to her eyebrows.

M. J. was tiring of the tension, too. Of all the nurses M. J. had trained, Julia was among the brightest and, at 35, brought the most life experience to the job. But she had comparatively little hospital experience, the practical bedside seasoning that could temper her textbook smarts and instinctive self-reliance.

Sometimes, M. J. said, she felt Julia was trying to win a debate that experience -- M.J.'s experience -- should decide. ''Everybody else I've [taught], when you say, 'There's a better way to do something,' they would listen to me, and they may not do it exactly, but they will incorporate it into their practice."

Julia, M. J. complained, always had to be convinced, and even then, ''she would do things her way."

When the doctors returned to Phyllis's room during afternoon rounds, they were discouraged by what they found. Her breathing -- ragged from pneumonia -- and her low blood pressure had not improved. ''She's slipping a little bit," said Dr. Bill Benedetto, an anesthesiologist, bringing tears to the eyes of Phyllis's son, who was sitting nearby.

Julia told the doctors that Phyllis was in a lot of pain and receiving little pain medication. But the patient was quiet while the doctors were on hand, and attending physician Ed Bittner was focused on avoiding the need for a breathing tube for the frail woman. If Phyllis were too sedated, he worried, it might weaken her will to breathe.

''I really dread the idea of her [breathing] continuing to worsen," he said. Bittner suggested that Julia sit Phyllis up in bed, so that she might be able to clear her lungs, and the doctors moved on.

''OK, dear, we're just going to sit you up," Julia said, as she started to adjust the bed to a more upright position. Phyllis began to moan.

''Oh, it hurts so bad," she cried out, and complained again that she was cold.

Just then, M. J. walked in.

''Did you tell them that she's on no pain control at all?" M. J. demanded, looking toward Phyllis, her gasping mouth wide open beneath a breathing mask. Julia said she had told the doctors, but M. J. was unimpressed.

''You've got to bring them in the room, because this is unacceptable," M. J. said. ''You have to go back to them and say their plan isn't working."

''Again, I raised it several times," insisted Julia, her back straightening.

As M. J. looked at the medication record, she got even angrier. Though Phyllis's heart was beating slightly faster than the target set by the doctors, Julia was not giving Phyllis the full dose of Lopressor that could slow it. ''I brought this up at 11," M. J. said. ''Now it's 4:30, and she's still over 90 [beats per minute]. . . . She actually is somebody who, at that heart rate, could be vulnerable."

As Phyllis continued to moan, a red-faced M. J. finally exploded, letting loose frustrations that had been mounting for weeks.

''If this was my grandmother, I'd be ballistic," she said, in a voice so loud that other nurses on the floor could hear. ''You have to appreciate that I'm a little bit aggravated. . . . I left it up to you to decide what to do. . . . It's not pain control to do nothing while she's lying there. . . . You have a brain, and you are not just supposed to follow orders."

Julia didn't say a word, and she did what M. J. asked, retrieving a vial of Dilaudid from the medication room. Still, she did not believe that she had done anything wrong in caring for Phyllis. Like the doctors, Julia had been worried that any sedative would further weaken Phyllis's already-shallow breathing. And wasn't it M. J. herself who preached that protecting the patient's breathing comes before everything else?

''Sometimes you have to admit that there's nothing you can do," Julia said later. ''This isn't magic. It's medicine. I saw her in a week, and she was still moaning. This woman was in chronic pain. It was her cancer."

Julia did, however, agree deeply with the principle behind M. J.'s criticisms: A nurse must champion her patient's needs, even if she has to stand up to the doctors. Early in her training, Julia and her other teacher, Jeanne, had gone over the head of a young doctor when he tried to stop the sedation for a girl who had suffered severe head injuries in a car accident. Julia believed that the first priority for the girl was rest. The supervising physician agreed, and reversed the order.

''It was a great lesson for me," Julia later wrote for a class that was part of her ICU training. ''It demonstrated the meaning of being the patient's advocate. We are here at the bedside every minute. . . . We should speak up."

Rattled by her student's decisions and demeanor -- ''It scares me that she's not more scared" -- M. J. briefly considered extending Julia's training once again. But Jeanne argued that Julia was getting more restless as the weeks dragged on.

''She's not 100 percent there, but she's safe enough to be on her own," she said.

Susan Tully, head nurse of the surgical ICU, agreed that M. J. was justified to be upset about Phyllis's suffering, but she concluded that Julia had not done anything that harmed the patient, just made a different judgment call.

M. J. reluctantly admitted that, like a ''mother duck," it was time to let go, and she returned to Phyllis's room to tell Julia.

''We think it's time for you to basically sink or swim," said M. J., practically spitting out the words as the two stood in the hall. ''I've taught you everything I can teach you. If you don't feel fine, speak now or forever hold your peace."

''I'm ready," Julia replied simply and unsmilingly, arms folded in front of her.

By 8 p.m., when the two nurses finished their last 13-hour day together, the anger of the afternoon had passed. But it was an awkward ending, hardly what Julia had imagined a few days earlier, when she bought a silk scarf at a tony shop on Newbury Street to thank M. J. Before becoming a nurse, Julia had trained new employees herself at an electronics plant in Israel. She knew how hard M. J. had worked, and she was grateful.

Julia also knew that she had tested M. J.'s patience, and that, more than once, M. J. had saved her from serious errors. But M. J.'s outburst had been humiliating, and Julia had to summon all her self-control as she pulled the bag with the scarf in it from behind her back.

M. J. was genuinely touched by the offering, and, mortified by her ''unprofessional" outburst, she apologized for being so hard on her student.

''I hope I didn't seem like a bitch," M. J. said.

No, Julia said, although she agreed it was a rough way to finish their time together. ''That's all the more reason to give [the scarf] to you," she said. The two women smiled and hugged. One day, Julia acknowledged, she might look back on all this and laugh.

''But not for a few years," she said.

The next Monday, Julia reported at 7 a.m. for her first solo shift as an ICU nurse. She quickly discovered that M. J. wasn't kidding when she warned that there would be no special treatment.

The patient waiting for her was one of the toughest cases in the unit that day: an immense, schizophrenic man who apparently had steered his wheelchair into the path of an oncoming car. Now, Julia realized, it really was time for her to ''sink or swim."

The man, 42, had come up painfully short of suicide, winding up in a coma with head injuries, a fractured pelvis, a ruptured bladder, possible kidney failure, a broken leg, pneumonia, and a drug-resistant staph infection. He lay motionless, covered only in a loincloth, his breathing so shaky that it was unsafe even to X-ray his injuries. ''He's a do-not-move right now," said night nurse Deborah Simonetti.

But there was plenty of work for Julia: To start with, her patient needed 20 different medications, from pain relievers to antipsychotic drugs to laxatives.

Julia was surprised that she had such an unstable patient on her very first day, but she was game, peppering Simonetti with questions -- What's the blood pressure goal? What kind of IV fluids? Does he have bowel sounds? -- and writing questions for the doctors on a piece of white adhesive tape that she stuck to a small table. After a half-hour briefing from Simonetti, Julia did her own assessment of the patient, taking his temperature, flashing light in his eyes to test his responsiveness, checking his respirator for leaks, leaving nothing to chance. ''I'm starting to figure out what I'm doing," she said.

But there was still so much to learn. Julia gave a puzzled look when nurse Suzanne Francis handed her a small black box with two electrodes to test her unconscious patient's reflexes. Francis asked if she could show Julia how to use the Innervator, but Julia demurred, preferring to figure it out for herself.

She attached one electrode to the man's left wrist and the other to his thumb, then turned on the electrical current. The patient's left thumb jumped ever so slightly, showing that there was lingering nerve function; her patient was not completely comatose.

''Yes!" said Julia. She had solved her first puzzle as a full-fledged ICU nurse.

And she had done it without asking for help.

In the weeks that followed, M. J. waited for the rumor mill to pass word of how her former student was working out. M. J. knew that, as the teacher, she, too, would be judged by Julia's work, and that other veteran nurses would be quick to let her know if things had gone awry.

But all the reports were excellent. One nurse did have a conflict with Julia, but when M. J. investigated, she took Julia's side. By early June, M. J. said: ''I've had nothing but good feedback the last two to three weeks. Somebody came up to me and said, 'You guys did such a good job. She's very focused.' " The favorable reports have continued into the fall.

For M. J., the final proof of Julia's growth came one day in May, when she was tending a patient across the hall from her. Julia needed to get an unstable patient ready to leave the room for an MRI, a time-consuming test that requires more preparation than the usual movement of patients between rooms. Because Julia had never done it before, she crossed the hall to ask M. J. for advice.

''At times," M. J. reflected on their long months together, ''I thought she was acting more like a medical student or a resident rather than a nurse. . . . Now that she's on her own, she realizes that she has to be a nurse. . . . I think she's going to be a great nurse."

Julia, too, felt she had come a long way from the day she showed up at Mass. General, cocksure but also intimidated. There was no one moment of enlightenment, she said. ''At some point, I just got it." Julia now understood that she would never ''know it all," and that she would always draw strength from those working with her.

''Nurses who have been here for 20 years have situations where it's not obvious what to do," she said one summer evening. ''In that kind of situation, you are supposed to work together. I don't mind going and asking people questions. I'm more willing now, because I'm on my own."

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