The Shift: One Nurse, Twelve Hours, Four Patients' Lives (15 page)

“That’s right. And he can push one of them.” She gestures again toward her husband. “I’ll hold the comforter. The puzzle can go in this bag and hang off a handle on the wheelchair.” This is how Dorothy likes it to be, I realize. Despite how agreeable she usually was at the hospital, she wants to be in charge, and that includes packing.

“I’ll call escort for the wheelchairs—” but before I even press any numbers on the phone, it rings.

I hear the polite and quiet voice of the escort, “Could you come out here one more time?”

“Right
now
?” I ask. Can’t I just finish this? Can’t I just get Dorothy out of here?

I hear Candace’s sharp voice over the phone.

“I’m coming.”

“Calling for the wheelchairs
right now
,” I tell Dorothy, holding up the phone and dialing ostentatiously while I open the door to her room and go out.

Candace starts to talk, then sees me on the phone. Her eyes get small and the skin around her mouth pinches at her lips. Smiling, I hold up a hand, hoping it communicates “please wait, I’ll be right with you,” rather than, “dear God, what is it now?”

I put in my order for two wheelchairs, then hang up and look at Candace.

“I’m ready. I just thought you’d be here when I left. After I got my phone from my room, you were gone.” Her voice is acid; it stings. But underneath I hear something else—hurt. And then Candace’s full history comes back to me. I first met Candace a few months ago and she told me about her serious surgery from a few years earlier where everything went horribly wrong. It wasn’t our hospital and I didn’t know the docs. She was scarred, literally, with a jagged criss-cross on her lower abdomen. She showed it to me. It took months before the pain completely went away and though she hadn’t wanted children, she would no longer be able to have them after that operation.

I had forgotten all of that, and remembering now, I look at her, try to really see her, all of her, not just the upward jerk of her chin, the accusatory voice. “I’m so sorry. Got caught up.”

“I just thought you’d be here. That’s all. It doesn’t matter,” she says, turning away from me and hopping up on the stretcher again.

“You’re right; I didn’t explain. I’ll see you when you get back.” She ignores me and the escort looks at me, grimaces sympathetically, then starts to push the carriage down the hall. I feel bereft, for a second, but then I hear the chime of a call bell and see that Sheila’s light is on. Dammit! She must need more pain medicine and Dorothy isn’t yet out of here.

I turn toward Dorothy’s room and my phone rings. What now? I’m drowning in details, moving as fast as I can, but in truth not moving at all. Giving Dorothy that final push home depends on me. Getting Sheila to the OR, safely, depends on me. Hooking Mr. Hampton up to his drug depends on me, as does making sure it doesn’t kill him. And Candace; caring for her without saying something I regret, or in my distraction missing a detail that makes all the difference, also depends on me.

My hands feel tingly, my throat tight. It’s the beginning of panic. I only have four patients. Four. How can taking care of them feel so impossible?

I USED TO LOVE A
comic book series called the
Legion of Super Heroes.
One of the super heroes, named Duo Damsel, often comes to mind when I’m at work. She could divide into two fully intact versions of herself just by concentrating. Maybe I could do that, too, if I tried really hard. Maybe just today—just this one time. If I really wanted it.

My phone keeps ringing. No matter how hard I concentrate, it’ll only be me here. I hit the talk button. “Medical Oncology, Theresa.” It’s the OR scheduler. Sheila’s set for 7 p.m. at the earliest. They couldn’t get her in any sooner. “We need the pre-op checklist done
before
she gets here,” the guy tells me.

Love the emphasis on
before
, as if I don’t understand that “pre-op” indicates “prior to the operation.” I want to respond with something clever or sarcastic, but I just say yes and hang up. What’s the point? He may be a rude SOB, or maybe he’s overworked like the rest of us, or both. I write down the OR time and then banish him from my memory.

Jesus! Call lights escalate in volume and frequency as time goes by and Sheila’s now achieves the pitch of a warning in a bad action movie. Warning: the perimeter has been compromised!

I push hard on her door. “Sorry, sorry, sorry. Too much to do.” Her face is a mask of deep lines and she’s bent over in bed, her breath coming short and fast.

I reach behind her to turn off the chiming light. “Pain?” She nods and gulps. “I’ll be right back with more medicine. And, hey,” I move my eyes around the room, connect with her sister and brother-in-law, “the OR has you scheduled for seven tonight so that’s our ballpark.” Her sister sits next to Sheila, holding her hand. The husband is standing up beside her, his hands stuck tight in his front jeans pockets.

“Seven,” he says, and nods, just once.

“I’ll be right back.” Down the hall, into the locked drug room, pulling up Sheila’s record on the locked narcotics machine, picking the drug, double-checking the dose, counting the number of syringes already in the drawer, and entering that number into the computer. It says my count is wrong. I recount and get the same number. Again it says my count is wrong. “Fuck it.” I hit the button to go ahead and pull out one pre-filled syringe. So there’ll be a discrepancy. I’m not fixing it now.

Around the corner and up the hall I go as fast as I can without running. Screw a needle onto an empty syringe, alcohol the top of the narcotic tube, then pull out the Dilaudid and squirt it into 10 ml of saline. Sheila’s lined face is all I see; I hear her stabbing breath. The pain got ahead of her.

Back into her room and I pivot so fast from my medcart that my shoes squeak on the floor. I hold up the syringe, show it to her, then pick up her running IV and inject the drug into the line after first wiping it with alcohol. Then I wipe it again and push in another 10 ml of saline, to make sure the narcotic gets into her bloodstream fast.

She sighs and closes her eyes, then leans back against the pillow at the head of the bed. “Thank you,” her sister says, and her voice, quiet in the dark room, quavers. The husband nods again then sits back down in the embracing armchair.

“I paged a minister for you. I don’t—I don’t know when she’ll get here.” Then I leave them; I don’t even look to make sure they heard.

I should also re-check Sheila’s blood pressure, but I’ll give the Dilaudid fifteen minutes or so and then go back in.

While I chart Sheila’s drug on the computer along with the multi-step “pain assessment,” I look at Candace’s open door and, somewhat unkindly, hope she has a very long wait once she gets to interventional radiology.

Suddenly our other clinician, the half-bedside nurse/half-management partner to Nancy the charge-nurse, finds me at my medcart. “I just got back from my meetings. Sounds like you’re having a day.” Her name is Marilyn and she’s got the most beautiful green eyes as well as a preternatural calm. “What can I do for you?”

“Can you give Mr. Hampton his pre-meds for Rituxan? We need to get that started ASAP.”

“Sure!” she says.

I pop into Dorothy’s room. “The wheelchairs are coming. Do you need any help getting ready to go?”

“No. We’re all ready. It’s just—” she inclines her head to me, hinting there’s something she wants to conspire about. I bend down and she starts to speak quietly. “Now, I took my candy dish, but I left you the candy. It’s all here.” She pulls out the top drawer of her nightstand and I see bags full of brightly colored paper, all in patterns familiar to me from my own childhood: mini Snickers, tiny Reese’s Peanut Butter Cups, and Hershey’s Kisses. “I don’t want it to be forgotten.”

“We don’t want it to be forgotten, either, Dorothy. I’ll put it in the break room right now.” I pick up the plastic bags and cradle them like a baby. Turning, I see her husband smile. His mouth forms a slim rectangle, but the outer edges turn up just enough that it has to be a smile. “Thanks for this! The wheelchairs should be here soon!” I say, heading off to our conference room with my spoils.

I dump the bags of candy on the conference table and the silver and gold foil wrappers twinkle at me. Just one. I slip a Snickers in my pocket, hover over a Hershey’s Kiss, leave it. Sheila’s blood pressure!

I run into Marilyn on my way back to my medcart. She whispers to me. “Theresa, when you asked me to pre-med your guy for Rituxan you didn’t tell me he was already half-dead.”

“Yeah, I told them that. We’re all a little concerned.” I say, shaking my head.

“Well, he’s ready to go and I charted the meds.” She smiles at me.

“You so rock! Thank you!”

“You’ll get my bill. Gotta go help Susie now.”

She walks up the hall, passing a tall attractive man who stops when he approaches me and extends his hand. “Hi!” he says, “I’m Trace Hampton, Richard Hampton’s son. Are you Theresa?”

“Yes. Hi!” I say, surprised at how movie-star handsome he is, with high cheekbones and thick brushed-back hair.

“I’m a little bit late,” he says easily.

I check my watch: 3:30 pm. “Oh no, it’s fine. He just got his pre-meds. I’ve, um, had a busy day.”

“Well, then we’re both on time.” His smile is welcoming, his voice relaxed. I look for a resemblance to his frail father, but except for the height, see none. “A friend of mine’s coming, too,” he says, “Stephen. If you can direct him in . . .” He gestures toward his dad’s room.

“Sure,” I tell him. “Stephen.” He keeps standing next to me, as if he wants to say more, when two escorts arrive with their two wheelchairs for Dorothy and her paraphernalia. “Sorry. I’ve got to get a patient out of here.”

“Oh, of course,” He’s so gracious. The tightness in my throat, the tension in my arms that came when I so much wanted to split in two, releases just a little.

There’s a bustle outside Dorothy’s room as the escort moves in both wheelchairs. I’m going to help, when I see Peter coming down the hall toward Sheila’s room. I’m surprised by the look on his face. He’s angry. I’ve never seen him angry. He’s holding papers in his hands. He must be here to have Sheila sign the consent forms for her surgery.

What a mess this whole thing was from the start, I realize. They should have scanned her abdomen last night at 3 a.m. when she first showed up in the emergency department. Then the Argatroban might never have been started and she might have already been operated on.

Now, though, Peter will operate into the night, even though a tired doc, or nurse, is just as impaired as a tired truck driver or airline pilot. Work hours are limited for resident physicians, but why the workload for all MDs isn’t regulated as carefully as some other professions is unclear. Is it because doctors’ mistakes due to exhaustion only have the potential to kill one person, not many? Or perhaps as a culture we want to believe that physicians are superhuman, and some docs want to believe that of themselves.

Problem is they’re not; no one is. Peter at least is smart enough to know he has limits, but on the other hand, time is working against us here. In the hospital we say “Time is muscle” for heart attack victims and “Time is brain” for stroke patients, indicating that the sooner those patients get the care they need the less heart or brain damage they will have. In Sheila’s case, the bacteria will reproduce exponentially in her abdomen as time passes, and more of her intestine may die. The longer we wait the sicker she potentially becomes.

I want to go into Sheila’s room, be there when she signs the consent, make sure she understands, check her blood pressure, but Dorothy’s on her way out of the hospital.

“Are you her nurse? I’m gonna need some help stacking these belongings.” The escort is new, learning the job. Helping with discharge is one of the things we get evaluated on when patients answer surveys about the quality of their care.

Dorothy’s room is right next to Sheila’s, but I walk into Dorothy’s and Peter walks into Sheila’s and we don’t even say hello.

“OK, let’s get you out of here, Dorothy.”

We get the suitcases on one wheelchair, Dorothy in the other. She insists on loading everything in a precise way, but eventually it gets done and her belongings appear well-arranged. As she settles herself down I check the closet and the bathroom one last time, peak at the space under the bed. The card table was ours, not hers. It will need to be scrubbed down with antibacterial wipes, but I can leave that to housekeeping, I think. The rules about who cleans up what after a discharge occasionally change.

The husband raises himself from his confining chair, gives his large glasses a slight adjustment, and walks to the wheelchair holding Dorothy. He grasps the handles and looks straight ahead, out the door of Dorothy’s room.

“You make sure to share that candy,” Dorothy bends around to tell me, arms encircling the purple comforter on her lap.

“I don’t know, Dorothy. Maybe after I pick out the Hershey’s Kisses for myself.”

She laughs at the same time as Peter comes out of Sheila’s room. He doesn’t stop, just keeps walking up the hall. My throat feels tight again. How long has it been since I checked Sheila’s blood pressure? I don’t look at my watch; the time itself doesn’t matter, but I need to do it soon and make sure that last shot of Dilaudid helped.

“Good-bye everyone,” Dorothy calls out as she rolls down the hall. She waves with her right hand cupped, fingers together like a queen. Then she giggles as she blows kisses. No matter what happens today, I will make sure to remember this moment. When we’ve made you better, there’s nothing as satisfying as leaving the hospital.

CHAPTER 9

Judgment Calls

Hey, sorry I couldn’t be in here when the surgeon got your consent for the operation.” I head right to Sheila, wrap the blood pressure cuff around her left arm, and pump up the balloon. The whole family looks as if the last bit of life energy they had just got wrung out of them. I need to know what Peter said.

The IV pump beeps as the cuff tightens, cutting off the flow of fluid up Sheila’s arm. I silence it, then listen through my stethoscope for the tell-tale clicks that register her pressure: 152 is the first click and silence comes after 90. It’s the sound of blood flowing through thousands of miles of arteries and veins pumped by a heart that never rests.

I let the pressure in the cuff fully run out and hear the Velcro rip as I take the cuff off Sheila’s arm. I’ve done this so many times, yet it always feels like insight gained from a look inside a patient’s body. Two numbers tell me if all is well or if something is starting to go very wrong.

The first few times those numbers were wrong came as a shock. Not shock from concern over my patient, though I felt that, too, but steeped as I was in the study of literature, I wasn’t used to the idea that events in books, even if they’re textbooks, can become real.

“Can you double-check a pressure for me?” I asked Gloria, the friend who teased me today about my yogurt spoon. She was about to say no, that she didn’t have time, but there must have been something about the look on my face that made her change her mind.

She took the patient’s pressure, looked up at me, eyes narrowed and firm. “Sixty over thirty.”

“I got seventy over forty.” We spoke quietly, looking right at each other. I’d read about severe hypotension, seen it before, but I was still a new enough nurse that the reality of detecting it surprised me. The patient had grown increasingly confused during the day and now was only semi-conscious. Those symptoms probably arose from the drug he was on, called Interleukin-2, but his drop in blood pressure would only make them worse.

“You OK?” Gloria asked me, using our shorthand for “Do you need help?” and if so, what should she do?

“No. I think I’m OK. I’ll page the resident.”

She called back right away. Everyone is on high alert when patients get IL-2. “I’ll be right there. At that level I’m worried his organs won’t be fully perfused.”

She spelled it out like that, as if she, like me, was remembering her textbook. Perfusion: the nub of life is red blood cells oxygenating every part of our bodies.

The patient went to the ICU and they put him on vasopressors, drugs that raise blood pressure and keep it at a healthy level. He came back to us the next day, restored fully to himself, though with very little memory of the last twenty-four hours.

“You lived to tell the tale,” I said, which seemed to make him feel better, even courageous. At least he knew there was a story to be told.

But Sheila’s blood pressure is holding steady now. “One fifty-two over ninety. Like usual, you’re a little high, which for now is good.” I tell Sheila, looking at the IV tubing and eyeing the amount of fluid left in the bag. Then I realize Sheila and her family aren’t hearing a word I say; what did Peter say when I couldn’t be in the room?

Sheila’s sister purses her lips, gestures at the door. “He said,” she pauses and blinks a few times, “he said they might wait until tomorrow to operate.”

“What?” I blurt out.

Sheila, sunk back once again under a pile of blankets, seems to be melting like a lump of wax into an amalgamation of pain, confusion, and hopelessness.

“Let me talk to him. I’ll go now and try to catch him.” Hurry. Out the door, up the hallway. I must ask Peter why and then tell him that the idea of waiting another day for surgery seems inexplicable and terrifying to Sheila.

I’m lucky. He’s heading out the door, toward the elevators, when I call out.

“Theresa, you just can’t stop bothering Dr. Coyne, can you?” our secretary calls out, loud enough for anyone standing nearby to hear. This is a moment when I find her effusiveness difficult.

I try to ignore her, but then I feel it: upset. The secretary’s comment suggests I’m not adhering to the expected MD-RN relationship. I feel exposed, and it’s not the first time, as an opinionated, even a pushy nurse. But why is that? Shouldn’t I feel assertive and responsible, instead? Aren’t those core values for all health-care professionals?

The two best articles I’ve read on how physicians and nurses work together are called “The Doctor-Nurse Game” and “The Doctor-Nurse Game Revisited,” both by Leonard I. Stein, a psychiatrist. The first article came out in 1967, the second in 1990. There is no data in these articles, no carefully tabulated results from original research, but the sting of painful truths comes through.

The word “game” itself refers not to child’s play, but to psychologically intricate interactions governed by rules, even if the rules are not consciously acknowledged. The MD-RN relationship is historically rooted in gender differences and the condescension and imperiousness that marked men’s relationships with women a century ago. Many women have now become doctors and men are increasingly becoming nurses, but vestiges of the history remain.

In the sixties Dr. Stein wrote that if a nurse had an idea about patient care, the unwritten rules of the Doctor-Nurse game dictated that her recommendations appear to be the doctor’s ideas all along. The nurse might say, when discussing a patient with insomnia: “Pentobarbital mg 100 was quite effective night before last,” and the doctor would relay back to her, “Pentobarbital mg 100 before bedtime as needed for sleep, got it?” The drug and dose are the nurse’s ideas, but the MD is allowed to rephrase them as his own.

Dr. Stein revisited the doctor-nurse game in 1990, and this time he described the nurse as a “stubborn rebel.” Rather than giving the doctor a clinical script, the nurse cast herself as a corrective agent to the doctor’s potential incompetence. The pentobarbital scenario becomes a confrontation instead of a polite, carefully calibrated exchange: “Mrs. Jones can’t sleep. She needs pentobarbital.” The nurse would probably be figured standing with her hands on her hips, head thrust forward, and implicit in her tone would be the unspoken challenge, “Your patient’s in need; what are you gonna do about it?”

There are nurses who hate these articles and I understand why—neither image of our profession is flattering. But I know I have played both these games and all possible permutations in between. Hospital nurses get hired and fired independent of MDs, but from what I see and hear, at a fair number of hospitals no nurse would be protected if an important doctor really wanted her gone. Doctors are our shadow bosses, the people whose orders we put into action, whose patients we share the care of, even though the MDs don’t explicitly supervise us. No wonder we both end up playing games when we communicate at work.

But Peter’s not like that. Now he stops immediately, ready to listen. I put the secretary’s words out of my mind, try not to think about whether anyone is watching me with a critical eye. “Sheila said you may wait until tomorrow to operate.” He nods. He doesn’t look angry anymore, just as if he also resents the impossibility of being two places at once.

“If you could operate tonight, that would be so much better for her. I know anesthesia needs to prep her and that regardless, you could get that out of the way tonight, but with the amount of pain she’s in I hate for her to go down, meet with anesthesia, come back up to the floor, and then go back down to the OR again tomorrow morning.”

“It may be better to wait until tomorrow.” He hears me, but he’s looking out the door toward the elevators.

I’m not sure what to say. He’s the surgeon; the decision about whether to operate has to be his. It won’t be my hand holding the knife. There must be a weighing of how dire Sheila’s situation is and how tired he and the rest of his team will be. I know from experience that fatigue is a thief of concentration and memory because I lived it when my twins were babies. Peter, I’m sure, also knows how dangerous fatigue is.

When doctors and nurses train, the idea is to push through exhaustion, ignore it, transcend it, but only the rarest of us can really do that without drugs to help, and no one, even with chemical stimulants, can do it forever. Humans need sleep as much as we need food and water, and when we don’t get enough our minds fray at the edges. Sleep is said to clean our brains; tired people can make mistakes without even realizing what they’re doing. Shakespeare knew it: “Sleep knits up the raveled sleeve of care.” This is poetry and truth. It may be better to wait until tomorrow, Peter said. He could be right. A decision like this is all about weighing the risks and benefits. Only he knows how tired he is, how much the week has already worn on him, what else he has to accomplish this day.

But what about Sheila? Overnight the bacteria will proliferate inside her abdomen and parts of her colon that aren’t now dead may begin to die, or will finish dying. That is also truth. Tissue damage at that level can’t be repaired; it has to be cut out by the, perhaps exhausted, surgeon. The multiplying bacteria will have to be killed by large doses of intravenous antibiotics. The longer Sheila waits with her gut oozing inside her own body, the closer she gets to a point of no return.

No surgical protocol or clinical algorithm will make clear in advance what the best timing is for her specific case. For one patient the wait won’t matter. For another it could be the difference between living and dying. For one surgeon the fatigue won’t overcome years of training and professional discipline. For another it could be the moment when he hits the wall of his own vulnerability. No crystal ball exists to reveal which patient and surgeon we have today.

I, the nurse, am here for Sheila, who’s worried and in pain. Peter’s my friend and colleague, but Sheila’s my responsibility, so I make my request one more time. “If tonight works.” Pushy or patient advocate? He nods his head just slightly then turns to the elevators he’s been eyeing and before I can say “Thanks for thinking about it,” he’s gone.

Dave the pharmacy tech walks up behind me with the Rituxan for Mr. Hampton. He’s got a low deep voice, almost a growl, but he’s often quite funny and his eyes crinkle up when he laughs. “Rituxan for Richard Hampton.” He hands me the bag full of clear liquid.

This is the next-to-last step of chemotherapy administration. The process started when Mr. Hampton’s attending physician decided to give him Rituxan. Then the pregnant oncology fellow wrote the order and brought it over to me so that I could double-check it with another nurse. Afterwards I left the verified order for pharmacy and they took the order and mixed the drug according to specifications. Finally Dave delivered the drug to me and all I have to do now is set it up to intravenously infuse into Mr. Hampton.

It’s a complicated and well-rehearsed protocol because chemotherapy, like surgery, almost always comes with Faustian trade-offs. We kill your cancer but your hair falls out, you have unrelenting diarrhea, permanent nerve pain and/or mouth sores so bad you can’t eat. Rituxan is different in that it mobilizes the patient’s own immune system to attack the disease. Since the rare person can die from a bee sting or eating a peanut—the result of an extreme overreaction of the immune system—it’s difficult to predict what will happen when a patient receives a drug like Rituxan, and the trouble it brings usually happens during the infusion: a precipitous drop in blood pressure, shaking that can’t be controlled, a racing heart, severe shortness of breath.

I check my watch. How did it get to be 4:30 p.m.? Well, at least the passing of time ensures the pre-meds that Marilyn gave are definitely active in Mr. Hampton’s body so I can connect the Rituxan to his IV.

“Theresa!” It’s Nora and Amy, who helped me by taking lunch to Susie’s patient. “Want some?” says Amy, holding up a gift card to the coffee shop across the street.

“Oh my God, you are lifesavers! Where did you get that? And how do you have time?”

“We-ell,” Amy says, “Remember the Vaughans?”

I nod. “Oh gosh, they were so-o-o-o nice.”

“Yeah, well, he had an outpatient appointment in the clinic and they came and dropped this off.” There’s probably some rule about how we’re not supposed to accept gifts from patients if they are connected to a cash amount, but I’ve never heard of it being enforced.

“So how do you have time to do this?”

“We don’t,” Amy says, “but we both really need some caffeine and it’s free!”

I lower my voice and look at Nora, “How’s Mr. King in the ICU?”

She shrugs one shoulder, looks away, then shakes her head.

“Medium skim latte?” Amy asks me brightly. She’s writing down orders on a notecard.

“You know me well. Thanks.” I’m suddenly overjoyed. Is this how addicts feel before getting a fix? Oh, who cares—even if I am a junkie, it’s only espresso and milk.

Back at my medcart I think of Sheila and her family. I feel the weight of the Rituxan—it’s almost a half-liter and has some heft—in my hand then set it down on my medcart. I need to tell Sheila and her family what Peter said, but I’m so tired of hurry up and wait for this kind and fragile woman and I dread confirming the uncertainty about when the operation will be.

Remember. I make myself remember that she could be my sister, my mother, me. I would want to know what the surgeon said. I would want a nurse who told me what was up as soon as she knew. I try to summon courage, fortitude from wherever they are in my body, pull it up to my brain from my toes.

It’s quiet where I stand. I turn back to my medcart, pick up the Rituxan. I could hang it and then talk to Sheila and her family. It would take fifteen, twenty minutes to check the drug, grab some vitals, hook it up, and record all that on the computer. Dorothy’s gone, Candace is off the floor, and Irving’s yet to arrive. I could get the Rituxan going—making things a little easier for night shift since the sooner the drug starts the sooner it, and all the checks it requires, are done—then tell Sheila what’s going on.

But I don’t.

I go into the dark room. Sheila and her family have never raised the blinds. Perhaps the sunlight would have been another unwelcome sensory experience, or maybe they just never thought of opening them. I could have offered, except that right now evening is coming and the sun will soon set anyway.