Jillian Horton is a physician and the author of We Are All Perfectly Fine: A Memoir of Love, Medicine and Healing.
In the late fall of 2021, just before the height of the first Omicron wave, I found a lump in one of my breasts.
Tests were booked, cancelled and rebooked several times. Finally, one day in January, I sat in a candy-pink gown in a breast imaging clinic, a sick feeling in the pit of my stomach as I waited for a nurse to call my name. Listening to the sighs and coughs of the anxious strangers around me, I couldn’t shake one thought: All our tests had been delayed because of the pandemic, and if one of us had cancer, that woman would have a more advanced breast cancer as a result. Whoever that woman was, her life would change.
After a few harrowing weeks of waiting, I learned I was one of the lucky ones – my investigations and follow-up tests were normal. But my friend Vanessa’s weren’t. Unbeknownst to me, she had been going through the same tests. She would turn out to be that other woman.
I first encountered Vanessa Davis in 2004, on a busy internal medicine ward at the Health Sciences Centre, the largest tertiary care hospital in Manitoba. I’d just moved to Winnipeg from Toronto, and was still adjusting to the local culture. Vanessa was around my age; since she’d been a ward charge nurse for seven years, she was the perfect person to show me the ropes. She was tall with blue eyes and a thick braid of hair that hung down to her waist. She was also funny and smart and passionate about her work, and we soon became good friends.
When you work with a person in a hospital for 18 years, you are privy to the full breadth of their gifts. I have seen Vanessa get blood from veins that would stump a vampire. I’ve watched her tenderly clean and bandage rotting, dinner-plate sized wounds that would make a hospital chief executive faint. I’ve seen her cry with countless families as their loved ones died of brutal, cruel diseases, seen her hold hands and stroke temples at the end of life and remain calm as she was called unprintable words by patients who were delirious or throwing blood-soaked bandages and bedpans in the throes of psychosis. And I’ve seen her braid those same patients’ hair when they were no longer delirious, and sneak them coffee and muffins from Tim’s. She brings a lightness to her work, a joy that begets more joy.
But I’ve also seen the things she manages on the side – the problems she copes with outside of work. One of her sons has Type 1 diabetes, and he spent years on an Omnipod insulin pump and continuous glucose monitor, both of which Vanessa and her husband paid for out-of-pocket at a cost of more than $10,000 a year. Occasionally, when we were rounding and discussing a patient’s critical blood sugar levels, she had to quietly excuse herself to help her son manage the very same emergency. She’d also had a bout with her own serious autoimmune condition, leading to a short stay in the ICU. Her stepfather died of a terminal leukemia as a patient under my care; we’d cried together silently on a ward a few steps away and hugged as he took his last breaths. And now Vanessa faced the big challenge nobody wants: that lump, that little cluster of impudent rogue cells that does not defer to the authority of any charge nurse, not even one like Vanessa.
There is a saying in medicine I have found to be universally true: A ward is only as good as its charge nurses. The “charge” is the ward’s commander-in-chief, and they orchestrate how care will be delivered by all the nurses on that ward for the next 12 hours. But they are also HR – they deal with complaints from patients and families – and allied health logisticians, creating daily patient plans with therapists and social workers for every patient on the ward. They do this while supervising junior nurses, assessing and reassessing sick patients whose conditions are changing constantly, and trying to boost morale. Meanwhile, they are reviewing an infinite stream of incoming lab results, imaging reports and non-clinical data, and charting almost endlessly. And this was before COVID. For the past two years, they have done all of this in full personal protective equipment, under the threat of acquiring an infectious disease for which there was initially no treatment or vaccine.
In Manitoba, after working for five years without a raise or contract, a nurse at the top of the pay scale under the new Manitoba Nurse’s Union Agreement earns $48.12 an hour. If they have Bachelor of Nursing training, they receive an extra 59 cents an hour. For the added stresses of being the charge, nurses are entitled to the additional compensation of exactly one dollar per hour, and a clinical resource nurse like Vanessa – the most senior of them all – is entitled to an additional two dollars an hour.
Put another way, for every 12-hour period as charge, Vanessa goes home with a little more than an extra 20-dollar bill.
It took a lot of 20-dollar bills to pay for that insulin pump.
When the pandemic hit, emergency departments and intensive-care units were the focus of headlines about the health care systems. But a forgotten space between those two destinations is the internal medicine ward, like the one where Vanessa works. Internal medicine wards are home to patients with non-surgical problems who are so sick they require admission to hospital. Those problems are typically complex and multisystem, and in a hospital like ours, they are often even more complex, because we serve populations who bear the brunt of social inequity. On those wards, we do a lot with far too little. And patients sick with COVID in Canadian hospitals are generally admitted to internal medicine wards, or wards that have been assembled from shuffled internal medicine staff. As a result, those stretched wards have been pushed right to the breaking point, in ways that are often impossible for the general public to understand.
“COVID necessitated changes that impacted care at every level,” Vanessa told me recently, as she recovered from an infection that was delaying her next course of chemotherapy. It impacted how a room was cleaned, how a patient was taken to a test. Something like arranging for a family to see the COVID-positive body of a loved one became a logistical nightmare, one she and her colleagues would try to solve, staying well after their shifts were over.
On a ward where few patients are uncomplicated, Vanessa pointed out that it is difficult for the average person to understand how much COVID muddied her already challenging work. “It just complicated things beyond measure,” she said. “It caused patients to worry more, nurses to worry more about their patients and the quality of care, and – at the end of the shift – about their own safety and the safety of their families.” In those early months, she frequently experienced the same thing patients sometimes report just before they end up on a ventilator: a deep and persistent feeling of impending doom.
In November, 2021, Vanessa was at work, getting changed out of her hospital greens, when she felt an odd pulling sensation in one of her armpits, adjacent to her breast. She’d just had her COVID booster shot, and there had been numerous reports in the media about associated minor lymph node enlargement causing some women to think they had breast cancer. She couldn’t feel a lump; she’d had a normal mammogram less than two years previously. She spoke to a few colleagues, and everyone reassured her the timing favoured a mild lymph node reaction. But over the next several weeks, that odd feeling persisted, and Vanessa began to worry.
Between her 12-hour shifts, she tried to schedule an appointment with the replacement for her family doctor, who was on leave. She secured an appointment for December, but Omicron was barrelling down on the health care system, and her appointment was cancelled. Then it was Christmas and most medical offices were closed. She made another appointment in early January, which was cancelled because the doctor had COVID; then another one in mid-January which was supposed to be a phone appointment because her doctor was still sick. When that appointment was cancelled, she ended up going to a walk-in clinic.
She had been a nurse for long enough to read any doctor’s face, and as she watched the change in the walk-in doctor’s expression as his fingers probed the thickened tissues under her arm, she knew with absolute certainty she had cancer.
By this point in the pandemic, Vanessa had been working at breakneck speed for almost two years. She and her colleagues were exhausted. She was especially worried about her younger peers, those who were still in the process of forming their professional identities, consolidating their skills and gaining confidence. Those nurses often told her they felt at the end of their ropes. They didn’t want more shifts; they wanted to rest and recuperate at home. They felt anxious, sad and stressed at work – they’d never earned their “sea legs” before being assigned to the Titanic. As their mentor, coach and den mother, Vanessa despaired.
“There’s nothing to fill their tank,” she lamented. “And as charge, what can I do about it?” The nurses around her were burning out at a spectacular rate. What saddened her the most were the things that were getting left by the wayside – the things that “fill your soul back up.” Vanessa calls them extra, little “bonus” moments, such as braiding a patient’s hair or taking them for a walk. It’s difficult, she told me, to make those small differences in a patient’s life when you only have time to try to keep everyone alive.
But the most difficult part was limiting visits for those who were in the final days of their lives. Nurses were tasked with sharing the complex and ever-changing institutional policies with families, dealing with the inevitable anger and outpouring of grief from patients, and trying to navigate exceptions. “It was horrific for me,” Vanessa said. “All I did on my breaks – when I got them – was send e-mails advocating for patients and their families.” She asked me to emphasize one thing in my writing – not the delays in her diagnosis, not her two-dollar-an-hour charge top-up, not anything about her own experience. She wanted me to stress that since COVID, nurses have almost no chance to rest and reset, no matter what type of work they are doing.
That same lack of an opportunity to recuperate, the frantic pace at work, the sheer number of shifts and the lack of breaks, made it hard to tend to her own health, or schedule her own medical appointments, or to swap a shift so she could go to a walk-in clinic. Everyone was just spread so thin. Vanessa, like her colleagues, excels at putting other people first, and our system excels at exploiting that very good instinct.
Vanessa had her mammogram in early February, 2022; it showed multiple areas that were suspicious for cancer. She waited three more weeks for an urgent biopsy. The results were disclosed to her over the phone by the kindly doctor at the walk-in clinic, the one who had sent her for the mammogram when he felt the hardness under her armpit. She had breast cancer, in all the biopsy sites. She would be put in the queue to see a breast surgeon in a few weeks, then another queue for all her imaging, and then, once all of that was completed, she would see a medical oncologist to determine her course of treatment.
Days continue to pass, days when she kept looking after the sickest patients with COVID, earning that extra two dollars an hour as a charge nurse, keeping her situation from her family and friends until she absolutely had to disclose it. She didn’t even tell her sister, also a nurse at Health Sciences Centre, because her sister was in the hospital with a flare of a rare autoimmune disease that had been triggered by a COVID infection.
But telling her two boys – that was the hardest part of anything she had been through over the previous two years. She and her husband told her older son first. Her youngest son was away playing hockey in Thunder Bay and Vanessa didn’t want to tell him until he was back home, because she didn’t want him to be distracted from his game. At those two awful moments she cried, and all the pent-up tears of the past two years flowed.
Vanessa is now almost four months into her year-long course of treatment. We text virtually every day. We check in before and after her chemo, on the weekends, at night before we go to bed. We exchange silly pics of our dogs; she sends me tons of selfies. Her long rope of blonde hair is gone. She is bald, and absolutely gorgeous. No matter what hellish thing is going on with her she always, always asks me how I am doing, usually before I can ask her. She is a crafting fiend, a person who cannot sit still, who throughout her chemotherapy weeks continues to make and create and do things for others. I worry about her, and I also marvel. I do believe she is one of the toughest and most resilient people I have ever known.
Vanessa’s disease stage is unclear, and thus, she has not yet been given a prognosis. Her cell type is triple-negative, an aggressive form of breast cancer that tends to be difficult to treat. Her scans show abnormalities in her lungs, which may or may not be metastatic disease. This is a critical distinction, since lung involvement would make her disease Stage 4, and, by definition, incurable. She is scheduled for another CT scan in the coming weeks which will make the next steps clearer. There may be surgery, and a switch to other chemotherapeutic agents. Her treatments will carry on for many, many months. She is on long-term disability; it took until July to kick in. Even knowing how to navigate the system couldn’t blunt the difficulties associated with the mountains of impossibly complicated paperwork, or the huge financial hit of suddenly having cancer in the prime of your life.
One might expect that a person in Vanessa’s shoes would be angry, resentful of the fact that she exhausted herself for others on the front line, only to become one of the legions of immunosuppressed Canadians who are now told to look after themselves because their provincial government’s work is done. This is the root of the vicarious anger I feel on her behalf. Some weeks after chemotherapy she has almost no infection-fighting white blood cells, and thus, COVID poses an extreme threat to her. She is a woman who would change a sick adult’s diaper in a heartbeat, but some of those same adults refuse to wear a mask to make it safer for a person like her to go into a drugstore to pick up her cancer medication.
There have been many times over the past several months when I have thought back to my moment last winter in the breast clinic waiting room, when I could just as easily have been the “other” woman, the one whose life was about to change. Doctors and nurses know how quickly we can be reassigned from the legions of the healthy to the ranks of the seriously unwell. It only takes one slip on the ice, one lump, one abnormal blood test result. This knowledge often breeds humility, a heightened awareness of the fluid nature of health.
But it is one thing when fate deals you the difficult blow of a serious disease; it is another when the community you have served with your whole heart sees no need to do anything to shield you from that blow, because they don’t consider your bad luck to be their problem.
And yet, when I asked Vanessa if this upset her, she texted back, late at night, that it did not. She told me there was no way she could have survived for 27 years as a nurse if she were always jaded and angry. Yes, she’d been angry more often in the past two years, but she’d tried to reserve her anger for the times it was truly necessary. She said couldn’t have kept going during the pandemic if she hadn’t become adept at moving on. She just tried to teach the younger nurses and her colleagues who were struggling to figure out what filled their tank so they would have the strength to come back and nurse tomorrow. And then she added:
“I know how broken the system is; I am so grateful for the care I receive. I waited for my diagnosis, sure, but I could have waited even longer and I have been so lucky to get some pretty awesome care.
Sorry, I know that’s not what you really wanna hear but that’s how I feel, lucky.”
Lucky. That’s how I felt, the day I learned I wasn’t the woman with cancer. It’s how I felt all those years working alongside Vanessa. It’s what her patients were, to have a nurse like her in their corner, throughout the pandemic and, before that, year after year.
But as a society in deep denial about COVID and what it has asked, and continues to ask, of people like Vanessa, it’s also the very thing we seem to be exploiting – how lucky we are to have them, and just how far we can continue to push them before everyone’s luck runs out.
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