[ Page 2 ]  /  [ Previous page ]

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 nauseous 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.