The Shift: One Nurse, Twelve Hours, Four Patients' Lives (16 page)

They all look up expectantly as soon as I walk in and I know then it was right to come in here before hanging the Rituxan. “Hey, I just talked to Peter Coyne. He’s going to try for tonight.” The sister raises her head to me and her shoulders, tight and hunched forward, relax back into her chair as Sheila closes her eyes and the lines on her face, just for a moment, disappear, making her skin appear smooth. “It may not work, though. It may have to be tomorrow”—I improvise a little here—“depending on how your blood is clotting and what the schedule in the operating room is. I’ll tell you as soon as I know anything.”

I thought this information would deflate them all over again—I haven’t told them much new—but it doesn’t. They seem to understand that many factors influence when Peter will operate, not just timing or his own personal preference. They may have just wanted an acknowledgment that not knowing is hard, because when I finish talking they all nod, the brother-in-law’s chin doing one slow up and down.

“I’ve got to start chemo in another room.” I point my thumb backward at the door. “Can I get you anything?” Sheila’s brother-in-law gives a shake of the head no and her sister breathes out and settles back into her chair. Ambiguity is anxiety-producing, but the appearance of indifference combined with a lack of control may be what mattered the most here.

John Keats, the nineteenth-century poet, recognized the challenges posed by lack of hard knowledge and the strength it takes to endure in such situations by coining the term “Negative Capability,” which he defined as: “when a man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason.” Keats spent his adult life fighting tuberculosis and died at age twenty-five, so for him the “irritable reaching after fact” was not merely poetic or theoretical. He knew what would kill him, and soon—“for many a time / I have been half in love with easeful Death”—and yet his art triumphed over his affliction.

Out in the hallway I close my eyes briefly to clear my head and Marilyn, like an apparition of helpfulness, appears at my shoulder. “Thought you might need a checker for the Rituxan.”

“Thank you.”

“Brought you this, too,” she says, handing me a thick blue plastic gown.

“You are the greatest.”

“And this.” She holds up Mr. Hampton’s chart.

“I could kiss you.”

“Please don’t.”

“Here we go.” Inside, Mr. Hampton’s room is a different world from Sheila’s. He’s using the oxygen of course and he looks awfully pale, but no one in this room is at all worried. His son Trace and Trace’s friend are in the room and all three of them look as relaxed as if this is just an ordinary day.

Trace waves to Marilyn and me, an easy, friendly movement of his hand, then gestures to the man sitting beside him. “This is Stephen,” he says, like a seasoned host introducing friends at a cocktail party.

Mr. Hampton even waves at us and I reach forward to pick up his wrist, read off his wrist band. Name. Birth date. Medical record number. Marilyn checks them against the same information on the chemotherapy order in his chart. Then I lay his wrist back down on the bed, but not before patting the back of his hand. When possible, touch in the hospital should come with a dose of kindness.

Marilyn holds up the Rituxan and reads off the information on the bag of drug. Patient name. Birth date. Medical Record Number. Drug. Dose. Rate of Administration. I double-check everything she reads against the chemotherapy order. It all checks. His base rate is 25 ml/hour and after one hour I’ll turn it up to 50 ml/hour and leave it there. Jeez Louise. This bag will take all night to go in.

Marilyn pulls up Mr. Hampton’s chart on the computer in the room and together we initial our double-check of the patient and the drug, referring back to the paper chart, too, but officially confirming everything in the computer.

Marilyn winks at me as she leaves, taking the chart with her. “I’m here if you need me,” she says.

“This is when I get in costume,” I tell them, pulling on a pair of chemo-protective gloves, then putting on the blue plastic gown that Marilyn brought me. I leave it open to the back with the tie doubled-around and knotted in front and pull on another set of gloves, making sure the glove ends cover the soft white cuffs on the chemo gown, protecting the skin on my wrists.

I hook up a liter bag of saline as a “just in case,” as in, just in case his blood pressure severely drops I can turn off the Rituxan and load him up with fluid quickly from the big bag of normal saline. Giving lots of liquid fast is the standard first-line response to hypotension.

I pick up one lumen of Mr. Hampton’s PICC line from his upper arm and connect the saline to it, checking first for the flash of blood in the line. Then I connect the Rituxan to the line of saline. “This is the drug,” I point to the Rituxan, “and this is just saline. He’s only getting the one smaller bag.”

This is modern medicine: a plastic bag of what looks like water contains one of the best drugs we have against lymphoma.

I now insert the clamp on the Rituxan tubing and the section of tubing immediately after it into the IV pump. I unclamp the tubing, unroll the roller clamp farther down the line, and start the pump, which makes a soft purring noise as I look at the drip chamber just below the bag and see one clear drop form and fall.

My orders say I need to take vital signs every fifteen minutes for the first hour and it’s a good idea since Mr. Hampton is so fragile. I will be in and out of his room for the next hour, checking and watching.

I pull off my first layer of gloves and gown, then the second layer, wad them up together, and throw them away in the hard yellow plastic chemo waste bin in Mr. Hampton’s room. It’s not that coming in contact with Rituxan by itself is so toxic, but for nurses who give chemotherapy, repeat “unintentional exposure” to biohazards from spills, accidental contact, or drugs that aerosolize, could threaten our health. When working with chemo we take a “better safe than sorry” approach. Pregnant nurses never even hang chemo. Why take the risk?

“I think you’ve already heard about this drug, but let me tell you about it one more time.” Trace and his friend Stephen incline their torsos forward just a little bit, listening. “Rituxan can be a tough drug. A lot of people get it and do just fine. Some people, though, have a really bad reaction to it: hives, itching, shortness of breath, rigors—uncontrollable shaking—fever, sudden sweats, an overall feeling of yuck!” They laugh. They like the description “yuck!” “So, if he feels in any way unusual, put on the call light immediately and get me in here, OK?” I point to the nurse button on the TV remote and behind the bed. “I’d rather you call me in for nothing than wait and have things get pretty bad.”

The two of them nod energetically. “I’ll be back in . . .” I look at my watch, “ten minutes.” Before I go out the door I give Mr. Hampton a quick look. He remains supine in bed but his eyes are wide open and bright. Well, the drug’s started. I’ll monitor him and keep on my toes.

Outside in the hallway my phone rings. It’s the interventional radiologist; the doc who did the dye study on Candace’s central line. “Her line’s completely fine,” he announces. “In fact, she couldn’t even tell me what was wrong with it.” I’m not sure what I can say since I didn’t order the study and received no extra information about it beyond what Candace told me and what the order itself said: “Consult Interventional Radiology: STAT dye study of central line.”

The IR physician keeps talking. “We put off other patients who really needed scans and stayed around later than usual to do this today all because of a STAT dye study. It’s not really appropriate to put in a dye study STAT for a line that doesn’t have an obvious problem.”

Now I get it. He’s annoyed with the oncologist who ordered the scan for STAT—NOW—making him do this job when sicker patients possibly more in need could have gone first. I want to say, “Am I a doctor? Did I enter that order?” but I don’t. It won’t help. Nurses sometimes serve as intermediaries in this way: physicians take their frustrations with each other out on the bedside nurse because we’re safer.

“This is . . . a very insistent patient,” I say, trying to be diplomatic.

“Yeah, I got that,” he sighs. “But this study didn’t need to be done. The line was absolutely fine and her X-ray last week showed that.”

“She had an X-ray last week that showed the line works fine?”

“Uh-huh.”

“I didn’t know that.” Silence. Again, I’m not sure what to say.

“So it didn’t need to be done, or at least not today ahead of other people with real problems.”

“I hear you,” I say, and then I drop my professionalism and just talk, human to human. “Hey. I’m sorry you had to stay late, I’m sorry other patients got put off. It’s one of those situations . . .” My voice trails off. I can’t explain Candace with a few bland, ameliorative phrases.

“It’s not your fault,” he says, the hard edge suddenly gone from his voice. “We just, we had to postpone a test that was a lot more important for someone else. I don’t like making people wait for nothing.”

“Right. Well, thanks for doing her study first. She does need the transplant to save her life, if that gives the dye study any more urgency.”

And then he laughs. Maybe he appreciates irony. “Good luck with her. I think you’re gonna need it.”

“Indeed.” I hang up and check my watch. Time to get Mr. Hampton’s vital signs, make sure he’s not in his room gasping for breath, though with his son sitting next to him that’s unlikely.

Suddenly Amy’s back, holding a paper tray of coffee drinks in matching white cups. “Your latte,” she says, setting it down on the medcart before moving on, her blond hair shiny in the hospital’s bright lights.

I pick up the cup and take a careful sip. It’s hot but not scalding, and the frothiness of the milk, the bitterness of the coffee, hit my mouth like a pleasure bomb. It’s just past 5 p.m. Two and a half more hours and then I go home.

CHAPTER 10

Faith

I have ten minutes before my next set of vitals is due and I again cycle mentally through my list of preoccupations: Sheila shouldn’t need pain meds, Candace is off the floor, and Irving isn’t here yet. I head up the hall. I need to look at a different set of ecru walls and maybe Beth has heard from her daughter.

Rounding the corner to her medcart, I almost run into her. I’m distracted, but she’s ecstatic. “My daughter emailed me and then I just talked to her on the phone,” she says, holding up her cell phone in her right hand like it’s a prize she’s won. “I know we’re not supposed to talk on our cell phones at work, but I thought this would be OK.” She’s smiling and that tightness in her face is gone.

My mental image of a crashing helicopter, of black smoke and ripping screams is, thank goodness, replaced by a woman in fatigues running through the dust churned up by helicopter blades. The dust dries out her mouth, stings her eyes, settles like a mist in her hair, but she’s on the ground and no one shoots at her as she runs. She’s safe.

“Right now I’m having a very good day,” Beth says. “Yes, a very good day.”

“That is so great.” I’m smiling so hard my face starts to feel stiff. This is excellent news. Because Beth’s daughters are twins, like mine, the loss of one might be irrecoverable for the other. That person has been with you, literally, since the very beginning of both your lives.

Having twins is what got me into nursing, so I think about the connection between twins and being a nurse a lot. I never expected twins. Never. But because I was bigger than normal and very nauseated at the start of my pregnancy I had an early ultrasound, at eight weeks. When the ultrasound tech showed me those two glowing white blobs on her screen, their nascent hearts beating, I felt reverent and afraid. Could I do this? Handle two new lives at once?

Thirty-four weeks later they arrived, babies fully formed: Miranda and Sophia, wonder and wisdom. Labor had started at four in the morning. After I got to the hospital and changed into a gown I stood in the bathroom, arms bent, palms against the wall, having a contraction that felt like it would rip my belly apart.
Oh my God, how will I survive this
, I wondered, but the labor was quick. After just three hours, out they came, four minutes apart: two little bald heads, four eyes and ears, two brains ready to learn about the world, two beating hearts.

I fell in love with the mess of it all: hugs and crying and baskets of laundry and early smiles and sleeplessness and the joys of motherhood, in stereo. Midwives managed my pregnancy and after Miranda and Sophia were born I decided I wanted to be a midwife, to trade the books and classrooms of a university for the controlled chaos of the maternity ward. Midwifery got me into nursing and once I learned more about being a bedside RN, I knew I had found my professional home. Bringing two lives into the world in one day is not a small thing. It gave me a taste for the life-and-death struggles that are our daily bread in the hospital.

Consider my friend Beth. She has two daughters, twins, and one grew up to be a soldier, risking her life in a foreign land for an unsure goal and little glory. The mom works as a nurse, keeping the home fires burning, and this afternoon she hears that daughter’s voice at the other end of a cell phone connection, on the other side of the earth, and knows her little girl, her daughter’s twin, is safe. A ripple of joy goes through the universe. It’s what we live for.

“What will you do tonight?”

“You know, Theresa, I’m just happy right now, just very happy. So I’ll finish the day and go home and just be . . . happy.” I give her a hug. There’s nothing I can add to that.

“Do you need any help? I suddenly feel like I have all the time in the world,” Beth says.

“No, I’m good. I may end up calling a rapid response on this guy, and then I’ll need your help.”

She raises her eyebrows. “Well, you know where to find me,” she says.

Back at my medcart I see Doris, the minister I paged for Sheila and her family. She’s wearing a blue-patterned cotton cardigan over her gray shirt with white clerical collar and her middle-aged belly makes her look pleasingly soft and huggable. Her short wavy brown hair halos her round face, setting off a wide smile. Presbyterian? I think she’s Presbyterian. Denomination doesn’t usually come up in the hospital.

“Sorry it took me so long. Had a meeting. Places to go, people to see.”

I tell her about Sheila, the sister and brother-in-law, her perforated bowel, and the twenty percent chance of death statistic. She breathes in. “They asked for me?”

I nod, “Uh-huh.”

“OK.” She nods back firmly and I realize that I trust her. If I thought I might be dead tomorrow I’m not sure whom I would want to talk to, but I don’t think I’d turn Doris away.

She knocks gently on the door to Sheila’s room and I step into Mr. Hampton’s. “How’s he doing?” Trace and Stephen both nod enthusiastically. I get his vital signs: the blood pressure cuff, the stethoscope, the pulse ox monitor, and the thermometer. He’s stable. By these measures he’s even fine. I look at him, scrunching my eyebrows together and tilting my head to the side. “How’re you feeling?” Mr. Hampton shrugs. “Any shortness of breath? Feel like your heart is racing? Dizziness?” He shakes his head, no. “Itching?” he shakes his head again. I tilt my head the other way, studying him.

“You haven’t seen any problems?” I ask Trace and Stephen. They shake their heads no. I purse my lips, shrug. “That’s good! Let me know if anything changes.”

One more set of fifteen-minute vitals to get, then it switches to every half hour. I could ask an aide to get them for me, but with this drug and this patient I want to take the vital signs and observe him myself. If I know exactly what’s going on it gives me the illusion of control.

I start a note on the computer about beginning the Rituxan infusion, how Mr. Hampton is doing, that his son is in the room with him. In my note I write VSS: vital signs stable. Then I enter the vitals I have so far into the computer, listing the precise times I took them. I’ve been lucky today—I was able to take them on time. Otherwise I battle with my conscience about what to write down: the actual times I got the vitals, or when I was
supposed
to take them. It’s another nursing no-win. We shouldn’t lie when documenting, but there’s the not-able-to-be-two-places-at-once problem, which can make accurate charting ethically complicated. If I falsify records in small ways I worry I will end up being too comfortable with the idea of little, victimless lies. I don’t want to get used to fudging records even for something as relatively trivial as this.

I check the orders tab—nothing new—go to the task list and see . . . I forgot to fill out the computer form that says Dorothy is gone.

I already put the discharge paperwork in her chart, but with electronic charting completing paperwork only on actual paper is not enough. I type a short missive into the computer verifying that Dorothy left the hospital in a wheelchair and that she “communicated understanding” of her discharge instructions. Then I fill out the discharge/transfer form on the computer, certifying that she planned to leave in a private vehicle (versus an ambulance) accompanied by her husband and went to her own home. It feels like the apotheosis of CYA charting.

My phone rings. Nancy, the charge nurse, has an update on Irving. The ambulance already left, but she doesn’t know when. I look at my watch. It’s almost 5:30. Most likely I’ll be settling in Irving while sending Sheila off to her surgery. We hold the infinity of our patients’ lives in our hands and yet I cannot hold Irving and Sheila—one coming the other going—in my two hands at the same time, although I may have to.

“Does he have a fever, pain?”

“I don’t know. That’s all they told me. But, you know, there’s a lot of construction out that way and it’s rush hour. They’ll be at least an hour.” She hangs up. I look at the phone. It doesn’t seem necessary to be quite so abrupt but the traffic information is helpful.

Hey, wait a minute. Nancy was going to leave early, right? Maybe she got delayed and is trying to rush out of here, which has to be frustrating. She’s not easy to work with as charge nurse, but I feel a pinch of empathy for her.

Irving has an abscess on his backside; a “boil on his butt.” If I weren’t focused on the timing with Sheila I might laugh. It’s not funny and I’m sure it hurts, but that’s the kind of Missouri-Ozarks phrase my dad would use. He was also fond of the vivid “Don’t get your bowels in an uproar” and the vulgar, “Just hold on to your pecker” if he thought someone was being impatient.

“This is fine. I’m fine! You can just stop right here.” It’s Candace, come back from the dye study of her Hickman catheter. She wants to get off her carrier in the hallway rather than immediately outside her room. The escort is older than I am, with thick glasses and gray hair. He argues with her in a monotone.

“This is policy. I take you back to your room. No getting off in the corridor.”

“Stop. Stop!” Candace glides off the right side of the stretcher, making a little hop to get both feet solidly on the ground. “There’s my room.” She points to it. “I’m close enough and I’m getting off.”

The escort looks up at the door to her room. “That’s your room?”

“That’s my room.” He frowns, makes a
tshcck
noise with his mouth.

“OK. Here’s the chart.” He hands it to me. “You’re back at your room.” He looks at Candace, then he turns the carrier around and slowly pushes it up the hallway.

“They weren’t at all nice down there. Not at all, but at least now I know my line is working.”

“That’s good. I’m glad.” I try to smile but feel sure I look insincere.

“My cousin had to take her son to pick up his car from the shop but she’ll be back soon. I’m going to give the room one more going over
now
.” I don’t argue. I can call Candace paranoid and a germ-o-phobe, but she’s not necessarily wrong to want to sanitize her room. The truth probably is that I just wish she weren’t so public about it

Another fifteen minutes, another set of vitals. This time Mr. Hampton is sitting upright in bed instead of curled up on top of it. He’s also got color in his cheeks and it’s not a flush, like a medication reaction, but a gentle pink that looks like health. I ask Trace if he and Stephen propped up Mr. Hampton themselves.

“No, he just sat up a few minutes ago by himself.”

Hmmmm. I’m not sure what to make of that. His oxygen saturation is also staying at 100 percent without any fluctuations, which suggests he may not need supplemental oxygen and can breathe room air and be fine. “Let’s take off the oxygen and see how he does.” Mr. Hampton himself nods in agreement. I turn the oxygen flow down to zero, then take the plastic prongs of the nasal cannula out of Mr. Hampton’s nostrils and remove the rest of the cannula from behind his ears. His eyes focus on what I’m doing with my hands, following along as I hang the now-discarded tubing off the oxygen flow meter on the wall.

Stephen is telling a story about a trip the three of them took and Mr. Hampton listens attentively.

I re-check his oxygen saturation level to see how he’s doing on room air. The pulse-ox machines are addicting because of their speed: good news and bad are quickly revealed with a two-digit number. Now off supplemental oxygen, Mr. Hampton fluctuates between 97 and 99 percent. Wow. That would be normal for anyone. I look back on the computer to check his previous oxygen levels, but he was only here for half a day yesterday and got put on O2 right away so they’re not helpful.

“Was he on oxygen at home?” I ask Trace.

“Oh no. Never.”

I pucker my eyebrows. “Do you know why they started the oxygen here?”

“He was short of breath.” Trace tells me. “Just felt like he couldn’t get enough air.” Now he takes over the story of their vacation, talking about having to portage a canoe: emptying it out and then carrying it and its contents overland. He gestures with both hands and makes sure to include me by catching my eye as he talks.

“That was hard work,” Mr. Hampton says, chuckling. I’m so surprised I flinch. He understands. He speaks! He laughs!

Trace and Stephen laugh along with him and I realize that Mr. Hampton’s not a frail old man at the beginning of a tragic decline. He’s a lively septuagenarian whose manner for the past few days has been anomalous.

I can’t explain to myself what’s happening. Rituxan cannot work this fast, or if it does, it tends to cause serious problems. Could it have been the drugs he got beforehand? His Tylenol, Benadryl, and an intravenous steroid? Maybe, but I’ve given that drug combination to lots of people without it miraculously restoring their health.

I take his vital signs again and his numbers are perfect. He holds out his arm for the blood pressure cuff, smiles as I slide the thermometer under his tongue. I don’t understand it, and I can’t explain it, but it’s good.

“I’ll be back,” I tell them. Trace mouths, “Thank you.” Stephen bends forward in his chair, “. . . I only have to outrun the bear,” he says, and Trace laughs at the old joke. Mr. Hampton leans back on the bed, his breath coming without effort. I quietly close the door on my way out.

I myself don’t believe in miracles, but being pleasantly surprised, in the hospital or out, is always welcome. It feels good to think that the love of family or friends can bring on a turnaround that science can’t explain. Liz Tilberis, the editor-in-chief of
Harper’s Bazaar
, had ovarian cancer and in her memoir
No Time to Die
, she tells us that a phone call from Princess Diana raised her platelet count, making it possible for her to leave the hospital and spend the weekend in the Hamptons near the beach. “I believe the princess was single-handedly responsible for getting me home, and no one will ever convince me otherwise,” she writes. Princess Diana called and Liz Tilberis’s platelet count went up. Mr. Hampton needed oxygen and was confused until his son visited and they traded memories and jokes about past travels. My rational mind doesn’t believe getting better can be that easy, but hospitals are full of stories just like Tilberis’s, and whether it’s coincidence or the power of connection, the positive effects are real.