The Shift: One Nurse, Twelve Hours, Four Patients' Lives (13 page)

Abraham Verghese, the physician and writer, speaks eloquently about the value of touch in health care. During a lecture here in Pittsburgh he explained that when doctors examine patients by physically touching them the patients feel more thoroughly cared for than if they had only been asked questions and observed. That reaction makes sense since when we’re ill it’s usually our bodies that are sick and hold the details of our affliction; a doctor intuitive enough to diagnose from touch is not just appealing, but reassuring.

Nurses touch patients all the time, typically not to make diagnoses, since that’s not what we officially do, but to gather information and to help—with going to the bathroom, bathing, walking, eating, managing pain, figuring out if someone’s taking a turn for the worse. Touch connects the essential humanness of nurse and patient, reminding me that we are two people with a shared mission: healing, if we can. The image of a mother placing the back of her hand on a child’s feverish forehead is indelible because it communicates, “I can feel how you feel when you are ill.”

I take the ends of the stethoscope out of my ears. “You’re healthy,” I tell Candace.

“Except for my cancer!”

“Right. Except for your cancer. It’s not fair, is it?”

I point to her right side just below the tail of black hair covering her clavicle. Three plastic tubes dangle from a holder inserted in her chest. “That’s the line that isn’t working?”

“Um-huh.”

“Let me call IR, see if I can get a time for when they’ll be ready for you.”

“Oh thanks.” Turning away, she swings her legs around and gets up on the other side of the bed, starts rummaging in one of her suitcases, but her “thanks” seemed sincere.

“You’re—” The door bursts open and the fellow, Yong Sun, walks into the room looking slightly lost. I was just about to say, “You’re welcome,” when his entrance interrupted me.

Whirling around, Candace looks him up and down through narrowed eyes, “Who are you?” she demands. She’s got a point. People in white coats go in and out of hospital rooms all the time, often without knocking or even saying their names. No one would like that and, unlike a lot of patients, Candace doesn’t hide her discomfiture.

I should stay and help out the fellow but I don’t have time. There are too many other priorities: call IR, start the pre-op checklist, confirm the timing of the Rituxan with pharmacy, repage the pastor, look in on Mr. Hampton and see whether he has finally woken up.

I do this all day long: run through a mental checklist that changes unpredictably. Of course I have things written down, but nurses spend the shift recalibrating the tasks we have and their urgency. Doing an assessment on Candace right when she gets here? Not that pressing. Monitoring Sheila’s blood pressure more than ordered—very important.

An old animated sketch on
Sesame Street
shows a little girl being instructed by her mother to bring home some basic groceries: a loaf of bread, a container of milk, and a stick of butter. The mother offers to write down the list, but the little girl is sure she can remember. She walks to the store repeating, “A loaf of bread, a container of milk, and a stick of butter,” over and over, and she does remember once she’s there, but only by bringing her mother’s exact words to mind. In the hospital I’m like that little girl on my way to the store, except the trip lasts twelve hours and the items I have to remember are much more varied and potentially consequential.

The computer tells me that Dorothy’s discharge paperwork is ready to complete; she can leave after I’ve done my part. I push Candace and the well-intentioned but awkward and difficult-to-understand fellow to the back of my mind along with all my other to-dos and head up to the nurses’ station. Let me see how quickly I can get Dorothy out of here. Leaving the hospital to go home always makes people glad.

CHAPTER 7

No Time for Lunch

Suddenly I’m dizzy. I look at my watch: 1:45 p.m. I usually don’t feel this way until after 2:00, but I haven’t had a morning snack except for those few saltines and Dorothy’s candy. The dizziness will pass, but then simple things will start to make less sense. I’m not unsafe when I’m hungry, just slow, and I’ll get slower the longer I wait to eat.

I’ll have lunch. Dorothy’s discharge can wait a few more minutes and the pastor usually lets us know when she gets here so I won’t miss her if I’m off the floor.

Lunch is touchy for a lot of nurses. We don’t get paid for the thirty minutes when we supposedly eat, but there’s rarely staff to cover our patients, so most of us work through lunch without being paid for that time. Class-action lawsuits have been filed on behalf of nurses not getting paid for a lunch break we never take, but the practice, at least from what I hear, is common.

Even when there’s an official way for nurses to note that we didn’t get a lunch break and should be paid for the time, the hospital may subtly dissuade nurses from putting in a claim for every non-lunch. I worked a year at my first job before I even learned I should be paid for that time. Labor laws say that lunch is thirty minutes of uninterrupted time, but on my floor that’s an uncommon abundance of time to eat, so legally pretty much every nurse I work with should be paid for lunch for every shift. Three million nurses in America. How much money do hospitals save by not paying nurses for the thirty-minute lunch break we more often than not work through?

Not to mention the physical toll of hunger. Glucose is the only form of food energy our brains can use, so if I don’t eat my brain is deprived of fuel. I spend the shift going from room to room, lifting patients, pushing carriers, moving beds, raising IV poles up and down. All that uses energy. If I don’t eat, the tank gets low—simple physiology.

To be clear: I’m not a martyr. I would love to pass my patients off to a lunch-nurse for a full thirty minutes and really get a break. But no lunch nurse exists on my floor and I don’t like taking on another nurse’s four patients while managing my own, then asking that same nurse to take on my four patients so that I can eat. Another four patients, even for half an hour, could be overwhelming or, worst of all, unsafe.

Now, though, my patients are stable and I need to eat. No one else is in the break room, so I turn off the wide-screen TV. After all the pings and beeps and buzzes and alarms on the floor I want silence.

Grabbing my lunch out of the refrigerator, I sit down and feel the physical effort of the day. I’d like to make a cradle of my arms, lay my head down on the table, close my eyes. But food comes first. I eat my turkey sandwich quickly, reminding myself to chew and take deep breaths between bites. I wash it down with ice water, sipped through a straw.

Swallow. Drink. Breathe. Bite. Chew. Breathe. Swallow.

I start to feel it: my blood sugar rising. My head clears and I blink a few times. There’s nothing like food when you’re hungry.

There’s a knock on the door and Maya, an aide, pokes her head in.

“Hey, I know you’re eating.”

“No. It’s OK,” I gesture at the empty plastic bag and crumbs on the table. “I’m done.”

“Well, it’s Candace Moore.”

“Uh-hunh?”

She starts counting on her fingers, holding up her index finger first: “She wants to know where she can get extra hangers and,” now her middle finger, “if the water pressure in the shower can be increased.”

“The water pressure?”

The aide nods. She raises her ring finger. “And she says to thank you for the new shower curtain.”

“Oh, they replaced it.” I smile, even though it’s only a shower curtain. “Soooo, did she take a shower?”

Maya shrugs in a casual I’ve-got-no-idea way. “Her cousin said the water pressure wasn’t good.” She moves into the break room and lets the door close behind her, rests her back on it. “I said I would come tell you because I wanted to get out of the room. She is intense!”

We burst out laughing. This is absurd and yet also not. “Well, Candace is keeping us honest. By the time she leaves, the hospital will be perfect.”

“Right.” The aide is not convinced. “But what do I tell her now?”

I don’t want to leave the break room. “Tell the secretary that Candace needs more hangers.” She nods. “Ask her also to call maintenance and pass on the message about the water pressure.”

“Will do.” She heads back out the door when her phone rings. “You’re kidding. He pooped again?!” I hear her say before the door closes.

I stay sitting for a few minutes more. It would be so nice to float. But I don’t float; I take the lid off my yogurt and stir it up with a spoon.

I start to think about armchairs. A grateful patient donated money to the floor to buy some comfortable armchairs for the patient rooms. It was a very nice gesture, except there was only enough money to buy six. Enough of our patients are long-term that they now know there are a few A+ armchairs in a few of the rooms, and the chairs in the rest are B- at best. The A+ armchairs are big enough, comfortable enough, and recline enough that family members who stay over can sleep in them. They say the smooth imitation leather covering feels good on your skin, or at least much better than the thick vinyl of the B- armchairs, which barely recline at all.

I’m sure that Candace would like an A+ armchair. Can I get her one proactively? Sick people, stuck in the hospital, already operating in an environment of scarcity since they’re worried their time on earth is dwindling, are especially sensitive to deprivation and comfort. Candace would be happier with a good chair in her room.

Does Dorothy have one? I mentally run my mind around Dorothy’s decorated room and realize there isn’t space for one. Sheila has one of the superior armchairs, though; her brother-in-law’s been sitting in it all day. After Sheila goes to the OR I can offer Candace the good armchair with its built-in pillow and puffy armrests that feel like they’re giving you a hug. That will work because Sheila won’t come back to the floor after her operation—they’ll put her in the Surgical ICU.

I take a spoonful of yogurt with my plastic hospital spoon and slide it into my mouth. This will work.
Ping-ping-ping.

Lucy the nurse practitioner is on the phone. Very nicely, she tells me that Dorothy’s husband has arrived and wants to leave as soon as possible since it’s a long ride and he hates driving at night. She knows the discharge form is in the computer. Could I just finish up the paperwork and get Dorothy out of here? I sigh. But of course.

“Yup,” I tell her.

“Are you eating?”

“It’s OK. I’m just finishing my yogurt.”

“Theresa, it can wait five minutes. Finish eating, then do the discharge.”

“You’re sure?”

“It’s five minutes.”

“Hey thanks. I’ll be out in five minutes.” I look at my watch. It’s 1:58 p.m.

I slowly swirl my spoon around the sides of the yogurt container. “Chocolate Underground,” it’s called and the bittersweet of the chocolate sets off the tang of the yogurt. I turn the spoon over in my mouth to lick off the back of it and taste a burst of liquid chocolate.

“You gonna marry that spoon?” It’s my friend Gloria, with spiky hair and sass she brings from her native Tennessee.

I laugh. “I’m just enjoying my yogurt before my next five and a half hours.”

“Uh-huh. That’s not what I saw.” Now she laughs, too, goes to her locker, and starts spinning the lock.

“Hey, where are you? I haven’t seen you at all today.”

“Got pulled across the hall,” she tilts her head. “Just came to get money so I can eat,” she takes her billfold out of her locker and holds it up. “They had two call-offs so it’s busy, but I only have four patients; they didn’t saddle me with the extras.” Gloria was sent to another oncology floor for her shift. When one unit doesn’t have enough staff they sometimes request a nurse from a sister-unit that may have a nurse to spare: the oncology floors draw from one another, the ICUs share staff, etc. No nurse really likes working on a different floor, hence the negative connotations of “being pulled.” Even worse, sometimes the regular staff dump an extra patient, or the more difficult patients, onto the nurse who’s come to help, but our sister oncology floor didn’t do that to Gloria today.

“It’s good they kept you at four patients. But two call-offs?” A call-off is what we say when a nurse doesn’t show up for a scheduled shift. “Call” because we use the phone to notify the floor that we won’t be there. No matter the reason—death in the family or an emergency appendectomy—there are nurses who always resent call-offs, because a nurse not showing up means more work for everyone else who’s there. It’s telling that we don’t call them sick days, only call-offs.

“Someone’s car wouldn’t start, and Tony’s wife went into labor.”

“Nice! But who’s Tony? I don’t know him.”

“I don’t think he’s been there that long. We renewed CPR together—that’s where I met him.”

“It’s a nice reason for a call-off.”

“Yeah. And the charge nurse is taking patients to pick up the slack.”

“Really? How’s that going?”

She shuts her locker with a metallic scrape, clicks the lock closed. “She’s storming around in a terrible mood, complaining about her chart audits.” She laughs.

“Patients before paperwork,” I say, mock-piously holding up my index finger for emphasis.

A mischievous look returns to her face. “Hey—I’ll let you get back to your spoon.”

I smile. “Me and the spoon are done. I’ve got to discharge Dorothy.” I toss the plastic spoon and the yogurt container in the trash.

“She’s finally going home? That’s great! You back tomorrow?”

I have to think about it. “Yes. You?”

“Where else would I be? Picked up an extra shift, so I’m working four twelves this week. And for that they pull me.”

“Ugh. Four twelves—you’re a better person than I am.”

She shakes her head. “See you tomorrow. Coffee at ten? You know, if it’s not crazy?” she laughs.

“Yes! I didn’t have time today.” She raises an eyebrow, but I don’t feel like explaining. “I’ll tell you tomorrow. Short version: Rituxan, a perf, and Candace Moore.”

“Now, an assignment like that is just not right.”

“I think everyone’s a little crazy.” I drop the timbre of my voice. “Did you hear about Mr. King?”

She nods somberly and I’m surprised to feel tears at the edges of my eyes. I blink them back. “Maybe being pulled is better than being here today.”

“Could be,” she sighs as we both move out the door. She goes to the right to take the elevator to the cafeteria while I turn to the left to get back to the floor, stopping when I remember my apple. Didn’t I bring in an apple today? I’ll leave it for now; maybe I can eat it later.

At the nurses’ station Lucy waits for me. She puts her hand on my shoulder and gives me a small hug. Some of the nurses don’t like it when she’s physical, but I find it soothing—the power of touch. “Sorry I interrupted your lunch.” Her manner is always distracted, as if she’s half-thinking of something else, but she explains herself clearly.

“No. It’s fine,” I say. “She’s been here for six weeks, of course they want to get home.”

I sit down in front of a computer and pull up Dorothy’s chart. Double-checking the list of medications Dorothy will take at home, I smile to myself when I see Omeprazole: the generic for Prilosec. Once Dorothy’s home she can take her Prilosec whenever she wants.

I need a checker for the discharge instructions, so I print them out and flag down Susie, the new nurse, as she walks by. “Have time to check discharge instructions?”

She breathes out and in heavily. “Not really.” In addition to the friendly couple I met this morning she’s also got one of the completes, the patients who need us to bathe, dress, and feed them, and keep them clean when they go to the bathroom. That patient’s wife, living in her own personal hell of guilt, anxiety, and fear, finds fault with almost everything we do. “Today, his lunch was cold and she’s annoyed because the Internet connection isn’t working so she can’t email the family. I get it; she’s the one keeping everything together, but I’ve called the computer HELP desk twice now and they can’t fix the problem.” She holds up a covered plate of food, “And I’m just now going to warm up his lunch!”

“Hey, have you eaten?”

“There’s no time, Theresa.”

“Go eat. You’ll feel better.”

She looks down at the place. “I’ll just do this—”

“No. I’ll do it. Give me the plate and go eat now.”

“I can’t.”

“You can. Go. It’ll be all right. I know how to use the microwave.”

She nods slowly, looks at her watch again. “Fuck it.” she says, handing me the plate and heading back to our break room.

Beth sidles up to me. “It’s hard for the new ones. The floor’s tough right now.”

“I guess you’re right.” I watch Susie as she walks away, her curls bobbing as she moves. Does it have to be quite this hard? One in five nurses quits a first job within a year. Susie’s a good nurse. I don’t want her to be part of the 20 percent who leave.

Beth looks at the discharge instructions in my hand. “It looks like you need another checker, so I’m here.”

I smile at her, surprised. “Thank you. I—”

“Hand ’em over,” she says, reaching out. “It’s Dorothy’s time to go home.”

“I’ve got to heat this up and drop it off, first—” I say, but Amy, her long blond hair down for the day, interrupts me.

“I’ll do it. I like them.”

“Where did you come from? I haven’t seen you all day.”

“I was in the conference room. I heard everything. I’m in front today, but I know that family pretty well. I’ll take care of his lunch.”

“It’s all yours!” I tell her, handing over the plate. “I thank you and so does Susie.” She shrugs and heads into our kitchen.

Turning to Beth I read from the list of drugs entered by the nurse practitioner and Beth checks it against the official list in the chart. The oncology attending will have looked over the medication record, but it’s the NPs and PAs who, like the residents, do the actual work of carefully putting these lists together with correct doses and times. For Dorothy there are fifteen medications and we verify the drug, the dose, the number of doses per day, and any special instructions such as “Synthroid: Take on an empty stomach.” Sometimes the prescribing practitioner who’s typing up the list checks a box in error, writes down the wrong dose, or forgets to write down a dose at all. Then we page that person to get the right information, but it can take a while to pin down the correct answer. Unfortunately, the waiting patient gets angrier every minute with the—in her view—obstacle-creating nurse.