The Shift: One Nurse, Twelve Hours, Four Patients' Lives (14 page)

Dorothy’s nurse practitioner is careful and there are no discrepancies between the different lists of prescribed meds. Beth and I take turns signing both copies of the discharge instructions and then I take one of the special discharge envelopes out of the drawer at the secretary’s station and slide in Dorothy’s paperwork. Dorothy will sign a separate copy and that one goes in her chart. It takes many pieces of paper to send one person home and even then the array of pills, with different doses and times, can be overwhelming. Lab tests, office visits, and scans may need to be scheduled, along with transportation to and from our outpatient cancer center. Cancer patients tend to be savvier than most. Because they often get treatment for so long, they have a lot of time to learn about their disease and how the system works, but even they sometimes feel that what they’re tasked with is unmanageable. For patients who are rarely hospitalized, who have little understanding of how the human body works, who lack money, or simply don’t read or speak English very well, our high expectations of them as outpatients may make any outcome but failure unlikely. All of us who work in health care put our shoulder to that huge rock every day trying to get the system to work. But sometimes shift after shift it feels like the same damn rock.

I’m closing Dorothy’s envelope when Nancy, the charge nurse, lays her hand on my shoulder. “I hate to do this,” she says, “But you’ll be getting another admission.”

“I just got Candace Moore. And I have Rituxan and a perf.”

“I know, but when Dorothy leaves you’ll be down to three and everyone else has four and I have to leave early,” she says, looking at her clipboard.

She has to leave early.
Has to?
This nurse often leaves early while the rest of us scramble. Or maybe I just notice it, and mind, on the days I’m especially busy. The position she has is half regular nursing, half management and she’s salaried, not paid by the hour, so no overtime when she exceeds forty hours per week. If the idea behind getting a salary is to elevate the staff to a new level of professionalism it hasn’t worked for this particular RN.

Truth is, she’s older, has some longstanding problem with her back, and never calls-off no matter how much her back hurts. Her straight brown hair is cut in a severe line at shoulder-level and her half-glasses hover halfway down her nose. She’s put in her time pushing the rock and now she’s tired. I understand. Of course I understand because I’m also tired and I’ve been a nurse a lot fewer years than she has.

“You know him,” she says, “It’s Irving Mooney.” She tries to make it better: “Besides, he shouldn’t be here for a while. He has to wait for an ambulance at his group home and then he’s over an hour away. And they said the ambulances were all backed up.”

I take the piece of paper she holds out. Worried about dropping an important ball, or worse, making a serious mistake, but also not wanting to appear a whiner I don’t handle these situations well. I withdraw; suck it up.

Pride’s at work here. I’m too proud to tell her the assignment feels potentially overwhelming, that I’m afraid I can’t do it. I will not make myself vulnerable in front of someone who has power over me because I want to show I can do it all, that I’m that good: Theresa Brown, super nurse. If I spoke up it might make a difference—it might—but now I’ll never know.

I look down at the printout. It just says ‘infection’ under reason for admission. “What’s wrong with him?”

“I don’t know.” She looks down at her clipboard again. “Just call the group home,” she says, “the number’s right there.” She points with her index finger, then walks away, making ticks with her pencil on the new paperwork she’s moved on to.

I walk back to my medcart. I want to slam the admission paper down on top of it, but don’t. One of the key factors in burnout, though, is employees feeling like they have little control over their work environment. That’s pretty much status quo in hospitals for nurses and doctors.

Dorothy’s call light comes on, its chime sounding like a reproach. “Dammit.” I left her discharge papers—special envelope and all—back at the nurses’ station. I should stick my head in and tell her everything’s ready. But all I want is to sit down, tell the charge nurse to stay until she’s scheduled just for today, and then have five minutes to eat the shiny red apple I left in the fridge.

The call light goes out and I sigh. Relief. And then my phone rings. It’s Maya, the aide. “Theresa, Dorothy wants to know where her discharge papers are.”

“I’ve got them. I’ll tell her.” My voice goes low.

“Are you OK?”

“I just got another admission.”

And suddenly she’s there, standing next to me. “Who is it?”

“Irving Mooney.”

“Irving.” She thinks. “He’s always late; comes by ambulance.”

“Yes?”

“Yes.”

“Really late?”

“Hours and hours.”

I smile at her. “You’re lying.”

“Yeah, but you’re not frowning anymore.” She smiles back at me.

“Hey, can you tell Dorothy I’ve got her paperwork ready, that I just have to get it from the nurses’ station. Do you have time?”

She hesitates, then nods yes.

“Thank you!” I sing it out, smile big. A small dose of help can give me the same jolt as an afternoon coffee.

Back at the nurses’ station Dorothy’s papers are right where I left them. “I knew you’d be back for those, T.” The secretary says. Then she lowers her voice and bends her head toward me as if she’s sharing a secret. “Did Candace Moore really complain about the water pressure in her shower?”

“So I hear.”

“Oh, T.” she laughs. “Now that is just too much. She needs to get a little perspective.”

“True that.” I say. Our secretary’s husband has been ill for several years with a degenerative muscular disorder. When she misses work it’s usually because he’s in the hospital again. She can be scatterbrained but is almost always good humored, and today I really appreciate that.

I turn and see Ray on a stretcher coming back from his test. I remember all that’s at stake here: Mr. Hampton and his sometimes killer drug, Sheila and her possibly killer perf, Candace trying to save herself from what is always a killer disease. Dorothy’s husband wanting to get his wife safely back home.

Nurses sometimes joke at change of shift that it was a good day if “everyone was still breathing when I left.” That may sound like we set the bar way too low, but illnesses can be unconquerable. I tuck Dorothy’s paperwork under my arm. It’s time for her to leave this clean, well-lighted place. The armchairs in her house, I’m guessing, are not vinyl but nubby cotton and lovingly worn. There are probably shelves filled with picture frames. The candy dish . . . she always kept out and full in her hospital room . . . can be put away until next time, if there is a next time. I’m hoping Dorothy never graces our floor again. In all the hurly-burly, I’d forgotten, but now I remember: The most important thing of all is that everyone’s alive at the end of the day.

CHAPTER 8

Duo Damsel

I dial the number of Irving’s group home and a woman answers with a pleasant murmur. “Shady Oasis Center.” Her words come out slowly and easily and the time she takes reminds me of how relatively unhurried people’s lives seemed in southern Missouri where I grew up. “Let’s see . . . Irving Mooney is going to the hospital for . . . Well, it says here—oh my goodness—it says he has an abscess . . . Oh, that must hurt.” She clucks her tongue. “Poor man. He’s such a nice man, too.” There’s silence and I realize I’m nodding my head sympathetically as she talks.

“We’ll take care of him,” I tell her. “Do you have any idea when he might be leaving?”

“Now, honey, I don’t. All we know is they said it would be a while for the ambulance, and Irving’s so patient. He doesn’t mind.”

“Can you call me when he leaves so I have some idea when he’ll arrive?”

“I sure can. Let me just get your number . . .” She promises to call and I hang up, hoping she remembers.

Irving is a soft-voiced African American schizophrenic in his late fifties. He lives in a facility he describes as the most agreeable place he could have imagined as a home for himself. The large front porch has rocking chairs he sits in while watching the world go by, or so he’s told me. I’m never sure which of Irving’s memories are real since he once reported a conversation he had with an IV pump. According to him, the machine started it: “I know I’m not supposed to talk to IVs, but the pump talked to me first.” So the rocking chair may not actually exist, but the idea of sitting in it makes him feel good.

You’d think schizophrenia and homelessness would be enough of a load that some sort of cosmic force of justice would keep leukemia from being added onto it, but one thing I’ve learned in the hospital is that life is not fair. Ill health, and especially cancer, takes all comers.

Irving’s done very well with his treatment so far. We’ve been able to put his cancer into remission and keep it there with consolidation. Immune suppression from the chemo probably explains the abscess. A small scratch got irritated, then infected, and now needs to be treated. But there won’t be a room for Irving until Dorothy is gone and housekeeping has thoroughly cleaned, so I need to get her out of here.

Sometimes that feeling of a revolving door at the hospital is exhausting. Patient flow equals income in hospitals, what I’ve heard administrators call “heads in beds.” I wish we could occasionally slow down, but the pace won’t change unless caring becomes as lucrative for hospitals as tests and procedures.

Now my phone rings and Dorothy’s call light comes on at the same time. I grit my teeth and swear that giving Dorothy her paperwork will be the next thing I do even if I have to sit on the phone to quiet it, but first I do have to answer it: “Medical Oncology, this is Theresa.”

It’s pharmacy wanting to know if I can start the Rituxan soon because it has to go in slowly. They prepare the drug for us, so the timing of a medication depends on when they are able to mix it. “Right. I’m just waiting for the patient’s son to arrive and that should be . . .” I hold the phone between my ear and shoulder and glance at my watch, “any minute now.” It’s almost three o’clock.

Nora, who’d teased me earlier about Candace Moore, walks by and points silently at Dorothy’s call light. She holds up a bag of blood for me to see and shrugs her shoulders in a sorry-I-can’t-help-you way as she moves down the hall. I hold up the special discharge envelope, showing her that I’m on top of it, and walk over to Dorothy’s room, continuing to listen to Bobby in pharmacy.

I open the door to Dorothy’s room with my right elbow and stand in the open doorway, finishing up my call, showing Dorothy and her husband that I have papers in my hand. “Right. Yes. I’ll call you when he gets here,” I confirm, punching off the phone and shoving it back in my pocket.

Quick change. I smile at them, her sitting on the bed, fully dressed, him squeezed in to one of our lesser armchairs. Dorothy’s husband intrigues me. He visited her almost every day, but rarely talks, and unlike Sheila’s brother-in-law, who seems to be silent because he’s angry and scared, Dorothy’s husband comes across as simply not in the habit of talking. Maybe she does the talking for both of them. He’s short and big-bellied and his hips bulge out slightly under the chair’s stiff wooden arms. Maybe that’s why he’s so quiet. Maybe he doesn’t want to complain about his uncomfortable chair.

“I’m sorry about the wait. A little too much going on at once today, but now I’m ready, so let’s get you out of here. You’ve got how long of a drive home?” I’m talking too fast, trying to drown out any irritation they have.

“It’s two hours,” Dorothy says. “But he—” she gestures toward her husband, “he hates driving after dark so he wants to leave as soon as we can.” Her eyes shift from him back to me and I see that she’s frustrated with him, not with me, which is unfortunate, but I’m just relieved I won’t have to apologize for eating lunch.

“This is for you.” I hand her the special envelope. “And we can go through everything together, because I’ve got a copy also.” I brandish it as proof.

She looks at the envelope, peers inside, then pulls out the stapled set of papers. “Mmm—umhmm—” she nods, “and there’s my Prilosec,” she says, looking up to quickly meet my eyes before she continues reading.

“The next two pages tell you when to take each medication, morning, noon, or night, and what the dose is.”

“Uh-huh,” she’s not really listening, but I keep talking anyway.

“And—” my phone rings.

Dorothy keeps reading. “Oh, you can get that.”

I click my phone to answer it and hear: “This is escort. I’m here for Moore. Um, could you come out in the hallway for a minute? We have a problem.”

Only a door separates me from the caller, but the distance feels huge. Staying in the room will allow me to discharge Dorothy, and that will be the only thing I have to focus on for as long as it takes to get her out of the hospital. Leaving the room will cause more delay since who knows what I’m needed for or how long whatever it is may take.

“I actually need you, her nurse, I think,” the escort says into the phone and I hear Candace’s voice in the background: “I’m not doing that. I’m not doing that without an explanation!”

“I’ll be right out.” Clicking off the phone I look up at Dorothy. “Hey, I’ll be right back. Just need to sort out something in the hallway.”

“Oh, it’s fine,” Dorothy says, carefully reading through the packet of papers I gave her. I see her husband slightly roll his eyes and quietly sigh. He wants to drive home in daylight, but I have to do my job for Dorothy and Candace. Let’s see if I can satisfy everyone.

Passing through the doorway I step into an argument. Candace confronts me. “She,” she gestures toward the escort worker, “says I have to go on the stretcher, but no one told me that before.”

“No one told you that on other visits to the hospital?”

“No. No one told me that
now
, this time, about this test.”

I’m not understanding. “Is there something wrong with the stretcher?” I ask her.

“No. But no one told me I have to sit on it and now she’s telling me I have to.” The escort, who is turned away from Candace, holds up her hands in a gesture of helplessness. I look at her inquiringly, when suddenly I get it.

“I’m sorry no one told you about the stretcher.” I keep my voice even. After all, this is about control. “They insist on it at CT, even for healthy patients like you.” I use air quotes around “healthy” so it won’t offend her. “Even for something as straightforward”—I stop myself from saying “simple”—“as checking a line. Do you mind going on the stretcher?”

“I don’t mind at all,” she’s suddenly much calmer. “It’s just that no one told me.”

“Right. Well, thanks for being accommodating. You know, you could even walk to CT next to the stretcher if I say it’s OK. They just want a stretcher there with you.”

“No, I can go on the stretcher. See?” She stands with her back to it and with a hop settles herself onto it, then gracefully swivels her legs to lie down. “Wait. I need my phone,” she hops back off the stretcher and walks back into her room to get it.

Score another one for empathy.
Th
ank you
, I mouth to the escort. “I’ll see you when she’s done.”

I can tell that stubborn wrinkle is there between my eyebrows. I just want to finish with Dorothy—it shouldn’t be so hard.

One time I created a time-free bubble for myself to focus exclusively on a discharge. I could call it a gift to my young patient, but it was a gift for me as well. Work had felt high pressure and scattered for weeks. I wanted to experience really doing something right.

The patient, Jenn, was in her early twenties. She deserved to have things done right, too. Her diagnosis of leukemia came out of the blue, as it does for everyone, but she’d only recently moved to Pittsburgh after getting married. Except for her new husband she was alone in the city.

She was one of those rare people who was filled with goodwill. In a fairy tale, flowers would have bloomed behind her as she walked. Her newly bald head covered with a cheap bandanna, she never betrayed any bitterness about the poor timing of her disease. I sometimes wondered if all that generosity of spirit was real, if anyone could be so consistently nice. She must have had selfish, lonely moments, but we never saw them in the hospital.

The day I discharged her Lucy was her nurse practitioner. Jenn didn’t have a lot of money and there were insurance issues, so the supplies she needed at home wouldn’t show up on time. Lucy asked me to load Jenn up with saline flushes and latex gloves and to show her how to care for her central line since, like Candace, she would go home with it remaining in place on her chest.

In our supply room I grabbed wrapped saline syringes, a box of alcohol wipes, and gloves in her size. Technically I was stealing from the hospital, but nurses do it when it’s either pilfer or leave the patient without proper care at home. The real cost of the supplies was negligible.

I brought my phone into Jenn’s room, but told myself I wouldn’t answer it if it rang while I was discharging her. I also moved the usual set of concerns—an antibiotic to be hung, a phone call to return, a tube of blood to draw and send to the lab—to the back of my mind.
For as long as it takes
, I thought,
I’m talking to her
.

The paperwork was quick. She had learned well during her six-week crash course in leukemia. The hard part would be taking care of her central line. It makes people understandably nervous to go home with a piece of medical hardware hanging out of their body. Jenn had the typical Hickman catheter with three separate tubes, or lumens, hanging down from the insertion site on her upper chest. Each of those tubes needed to be injected with saline every day and each day Jenn also needed to verify that blood could be pulled from each one. To me it’s mindless work because I’ve done it so many times, but I might be worried if I had to care for my own line myself. Jenn had learned about her IV line amid the flurry of treatment and the doldrums of count recovery.

Sitting in a chair across from her while she sat on the bed, I explained the process and that it had to be done every day. The lumens are color-coded red, white, and blue, and I advised her to do them in that order so she wouldn’t skip one accidentally. I picked up the red lumen, scrubbed the top of it for fifteen seconds with an alcohol wipe, then screwed a syringe of saline onto the red lumen and pushed the plunger in. It slid in easily. “This is the flush,” I told her, “and then you stop, pull back on the plunger like this.” I held the syringe with my left hand and drew back with my right until the expected thin stream of blood swirled into the saline. “That’s your blood return. That lets you know the line is working and in the right place.”

She watched me carefully. I did the white lumen and had her do the blue to show me that she knew how. She hesitated when twisting on the saline flush and pushing in the plunger, but when she pulled back, drawing a rush of blood into the syringe, she smiled without reservation. Then, like I’d shown her, she pushed in the whole 10 ml of saline, unscrewed the syringe, and re-closed the clamp lock on the line.

“See. Piece of cake.” She laughed.

“I wrote the steps down here,” I handed her a piece of paper. “Read them and see if they make sense.”

She read through the instructions, keeping her head very still, and when she was done, nodded solemnly.

“You’ve got this!” I said, and we hugged, teacher and student, very pleased with her success. Last, I showed her the items I’d packed up and put all of them into a bigger plastic bag.

And maybe there is some cosmic force for justice, at least in small things, because my phone didn’t ring and I didn’t think about anything but her discharge during the twenty-five minutes I stayed in her room.

Man was made for Joy and Woe

And when this we rightly know

Thro’ the World we safely go

William Blake’s poem again finds wisdom in a simple truth: “Some to Misery are born” while others “are Born to sweet delight.” Jenn embodied both possibilities. She was a joy of a human being who’d been struck with a woeful disease; the sustaining love she felt from her husband offered delight amid her misery. I like to think that by giving her so much focused attention on the day of her discharge I contributed to her ability to travel safely through the world.

Remembering my time with Jenn, I close my ears and eyes to any other needs when I return to Dorothy’s room. It looks as if neither she nor her husband has moved, but there are now two suitcases resting against the bed and I see that all the photographs are gone from her walls. “We’re ready to go,” she says, a funny kind of Mary Poppins hat on her head and a dark wool coat lying next to her.

“Great. I just need you to sign here,” I tell her, flipping to the correct page and pointing at the signature line.

“Looks like you’ll need a wheelchair for yourself and one for everything you brought,” I say, looking at the two suitcases, the purple comforter folded on the bed, the jigsaw puzzle on the table in its box.