The Shift: One Nurse, Twelve Hours, Four Patients' Lives (17 page)

In the hallway Doris, the minister, is waiting for me at my medcart. “We said a prayer in case she doesn’t make it.”

I frown. It sounds so sad.

“No, it was nice,” she says, like someone at a different kind of job might say, “I just finished the meeting with Thompson. It went well.” That’s why I like her; she’s both spiritual and down-to-earth. Doris seems to adapt her faith to the occasion while keeping her belief just as strong. I find that flexibility comforting.

“It’s lucky they have a nurse who’s concerned about their spiritual welfare as well as their physical,” she tells me before she leaves.

I never thought about it that way before and it’s a nice compliment. However, truth is, they wanted a minister, so I got a minister; any other nurse would have done the same. It’s what we do. I once bought a newspaper for a patient because she was bored and wanted one. On a different shift, in the evening, I almost cried with frustration because I couldn’t get jam for a dying patient nibbling on dry toast. Another nurse on the floor regularly brought in Fruity Pebbles cereal for a patient who wouldn’t eat anything else.

“I gotta go,” Doris says, heading up the hall to minister to someone else. I watch her springy walk and wonder if I should have asked her to say a prayer for me before she left.

As I watch her leave I see one of our phlebotomists come down the hall. “I’m here to draw blood for Fields,” she says, pulling her metal cart filled with tubes, tourniquets, needles, and labels to a stop.

“What do you have?”

She hands me three labels for three tubes of blood to match Sheila’s blood type with our existing stocks of red blood cells in case she needs a transfusion. Two of those tubes are supposed to be drawn now and the third one thirty minutes later. If the tubes and the blood types match there’s no question it’s the same blood from the same person.

I’m guessing that someone (phlebotomist? nurse?) at some time made a mistake: The wrong patient’s name was put on a tube of blood that was sent to be typed and screened. As a result of this mistake, a patient’s blood was “typed”—labeled A+ or O-—incorrectly, which is a serious error because transfusing someone with the wrong type blood could make her very sick.

The problem is, although drawing and sending an extra “third tube” of blood may be an excellent safeguard against errors in blood typing it’s completely impractical. The phlebotomists cover the entire hospital and don’t have time to take blood from a specific patient and then return in half an hour to repeat the process. So, all three tubes of blood get drawn at the same time and one gets held back and sent down later. That tube of blood becomes the “third tube” even though it was drawn at the same time as all the others and thus in no way ensures the safety of blood typing in the hospital.

True to form, the phlebotomist looks at me guiltily and explains, “Um, I’m just gonna draw all three of these type and screens now. No way I can be back here in thirty minutes.”

I look at the metal clipboard on her cart and see that the lined top sheet of paper is entirely filled with patient names and the blood work they need.

“Just send that third tube a few minutes later. It’s what we always do.”

I nod. This is how the new rule plays and it’s a classic hospital work-around. Besides, we already have procedures in place to ensure 100 percent accuracy in labeling of blood tubes and if everyone followed those rules, mistakes wouldn’t be an issue. A type and screen requires that two staff members check the patient’s name and ID number against the preprinted labels from the lab. We’re also supposed to physically attach those verified labels to the filled tubes of blood in the patient’s room. These two steps make mislabeling a tube of blood impossible. Adding in a new rule is unlikely to encourage stringency in staff members who are either careless or too busy to carry out the required checks, but layering on protocols is a standard way hospitals respond to mistakes.

The phlebotomist goes into Sheila’s room to draw her blood and I follow her. She turns on the light and Sheila, her sister, and brother-in-law all blink at the sudden illumination.

“I’m here to draw your blood,” she says, all business. “Let’s see what you’ve got.” She bends down to Sheila’s right arm, then runs her fingers expertly up and down it. “Here’s a good one.” She snatches a tourniquet off her cart and ties it tightly around Sheila’s upper arm. I see a vein to the right of her elbow crease pop out.

I pick up Sheila’s left wrist so that I can read off her ID bracelet. “Sorry about this,” I say quietly. “How’s your pain?” She shakes her head and closes her eyes.

“Go ahead,” the phlebotomist says. She’s holding up the label for Sheila’s type and screen and peers at it closely while I read Sheila’s name and medical record number off the ID band on her wrist.

“Yeah. They match.” She quickly writes her initials and the time and date on the labels, then hands them to me to do the same.

“We need to check her blood type before the surgery,” I explain as the phlebotomist lines up her tubes for blood and unwraps a needle. Sheila’s sister nods, accepting.

“I’m gonna let you work,” I tell the phlebotomist, giving a wan smile as she slides the needle into Sheila’s vein. Sheila shuts her eyes shut tight, then lets out a loud breath.

“Hold on, Ms. Fields, I need three tubes,” the phlebotomist says as I leave.

In the hallway I check the time on my computer screen: 6:10 p.m. Ninety more minutes to two hours or less in the shift, depending on how late I have to stay tying up loose ends. I can do this. There’s a fair amount of research suggesting that twelve-hour shifts for nurses are dangerous for patients and lead to burnout for nurses. I like the continuity of twelves—knowing I have someone for a whole day—but these days are very long and I don’t know if I can sustain this pace year after year. I also wonder if my patients benefit from having the same nurse over twelve hours—what we call “continuity of care”—or if they would be better off with a nurse who’s fresh every eight hours.

The metal dietary cart comes into my pod and I catch an aroma of food. It’s bland enough that I don’t end up feeling hungry myself. As the meal delivery woman slides out the dinner trays and delivers them to Mr. Hampton and Candace I click on my computer tabs, looking for new orders. Thirty separate items pop up for Candace. The oncology fellow, Yong Sun, must have put them in; everything she needs before the transplant. I close my eyes.

The phone rings and I let it go. Once. Twice. Three times. A fourth ring. “T., what are you so busy doing that you’re not answering your phone?”

It’s the secretary and for the second time that day her friendly pestering irritates me. At this moment I find her irrepressible cheerfulness annoying.

“T., tell the truth. Were you in the bathroom?”

“Yep. I dropped the phone in and it took me a minute to fish it out.”

She snorts into the phone. “Is the room ready for Irving? I’m supposed to call and check.”

I glance through the door to Dorothy’s old room. “It looks ready.”

“
Looks
ready? T., after Candace Moore and her crazy shower curtain you need to get in there and make
sure
it’s clean.”

So now we’re doing housekeeping’s job. I step into the room, wipe my finger across the aluminum brackets on the wall that hold oxygen and suction. No dust comes off. I look under the bed and the floor is shiny—no bacteria balls. “It’s clean.”

“Great.”

What I wouldn’t give for a moment where nothing in my world rings, dings, or alarms.

Then Sheila’s call light turns on and I check my record of when she last got pain medicine. She’s overdue. I wonder if she was hurting when I was in the room with the phlebotomist and didn’t tell me. She’s also worried she’s going to die, if not tonight, then soon, and she’s being stuck with a needle.

And like that I’m back. I turn myself around, go to her room, open her door and reach in to turn off the call light. “Do you need more Dilaudid?” I ask her, my voice steady and clear.

This is what I’m here for.

CHAPTER 11

Revolving Door

After going through the usual procedure—pass code, accu-dose code, count, and confirm—I’ve got the Dilaudid. I check the concentration on the vial one more time, draw up the drug, and dilute it in 10 ml of saline. Check the volume. Drop the glass vial into the sharps’ container attached to my medcart. In nursing school they told us that addicts have been known to dig empty vials out of the trash to get whatever drops of narcotic are left inside clinging to the walls of the empty syringes. I have no idea if that’s true but I treat empty narcotic vials as if they’re contraband.

I go into Sheila’s room. The phlebotomist is finishing up and surreptitiously hands me the “third tube” for Sheila’s type and screen. “I’ll send these to the lab right now,” she says overly loudly, holding up the other tubes.

Sheila’s sister looks up briefly when I come in, then returns her gaze to the floor. Sheila’s eyes are closed, her lips held tight together from the pain. I pick up her left arm and shoot the Dilaudid into her IV, follow it up with a saline flush.

“Did the pain get away from you?” I ask.

“It was OK,” she says, closing her eyes tightly, “and then it”—she gasps—“wasn’t.”

She looks up at me now, apologetically. “I need to pee.”

“Of course. Can you roll toward me on this side? It’s less walking then.” She nods, then slowly rolls to her left. Her eyes flitter open, then close again. She pants.

I didn’t ask her to rate her pain with ten being “the worst pain ever.” Some people, and Sheila is probably one of them, could have an arm half cut off and would cry out “six,” covered in sweat, straining to make their voices sound normal. Patients like that also rarely ask for pain medicine before they’re in agony because they believe their pain never rises to the level of deserving to be treated. Although I explained the physiological reasons for staying ahead of her pain to Sheila, I should have realized she might not follow my suggestion. The trick with a patient such as her is to watch her face, see how she moves, or doesn’t. Faces rarely lie about pain, but sometimes you have to look closely and today I haven’t done that. I was persuaded by Sheila’s stoicism, fooled into thinking she needed less pain medication than she probably did. Trouble is, the joke’s not on me—she’s the one who has suffered.

Pain is awful. It hurts. But narcotics, the drugs that best treat pain, come with their own patina of shame, even here in the hospital. There are health care workers who reserve a special kind of scorn for drug abusers, probably because we’ve all heard stories about being burned by an addict: a patient someone went the extra mile for only to discover the patient wasn’t actually in pain, she just wanted to get high. Patients with chronic pain are often labeled “drug-seeking.” Sickle-cell patients, who live lives filled with pain and during disease crises can get relief only from large doses of opioids, sometimes get dismissed as junkies. Do we in health care hate the need for narcotics due to their high potential for abuse or is it the pain itself we find outrageous? We can’t see it, can’t test for it objectively. We’re taught “Pain is whatever the patient says it is,” but then we don’t believe our patients, and in that lack of belief we miss the message of pain. People born without a sense of pain—a rare affliction called congenital insensitivity to pain—are in constant danger. Pain is a neural explosion telling us that something is very wrong. Today I missed the full import of Sheila’s pain.

“Do you think you can stand up to go to the bathroom? Let me help you.” I reach down for Sheila’s arm when my phone rings.

“This is the OR. We’re ready for your patient Fields.”

“Oh.” I look at my watch. “You’re early.” I don’t intend to sound accusing but I do.

“We had a cancellation. And they wanted to get this one down ASAP.”

This is good news for Sheila, but my work for her isn’t done yet. She needs to pee and there’s paperwork to finish.

“That’s the OR,” I tell her and her family, hanging up my phone. “They’re ready for her.”

“Ready? But it’s early,” her sister says.

“They were able to make room for her. So I just need to complete her paperwork, after she goes to the bathroom, that is.” I smile at Sheila, whose eyes are slits.

“No. We’ll get her to the bathroom,” her sister says. “You go and get her ready.” She stands up and her husband stands up, too.

“Are you sure? Can you manage?”

“We’ll be fine. We’re fine. She has to get down to that operating room.”

I nod. “Call if you need me.” Back at my medcart I pull up Sheila’s pre-op form. More boxes to check and click.

What are her vital signs? Does she have allergies? Was there a history and physical done within three days and is it on the chart? Have her belongings been safely stowed? That last question doesn’t seem so important. Sheila could die on the table. Does it matter where her clothes end up? But of course it does. Even in the midst of calamity ordinary details must be attended to. It reminds us that life goes on.

One of the odder experiences I had in the hospital also revolved around a patient’s property, though property of a more personal nature. I walked into a patient’s room at 8 a.m., start of shift, having never met her or any member of her family before. A tall thin woman with a very short haircut held out a denture cup to me, with the plastic lid on, and said, “These are not her teeth!”

I try to always be patient in the hospital but sometimes I get my hackles up when people are rude, and this was one of those times. I arched my eyebrows. “These are not her teeth!” the woman said again, thrusting the denture cup toward me.

“Excuse me?”

“She went down to a CT scan, returned to this room, and these are not her teeth!”

She’d said it three times now. “And you are?”

“Her daughter.”

The woman standing next to her, heavier and shorter, spoke up. “I’m her daughter, too, and these are definitely not her teeth!” Just then the rounding medical team came in, all six of them. I hadn’t gotten much information in report, but as the medical team started talking it became clear that the patient, a woman in her eighties, did not have long to live. She was also barely conscious.

So I put the dentures out of my mind. The patient would not be needing them. And then I got busy, just like any normal day, except a little busier than usual: phone ringing constantly, a string of time-consuming miscommunications, hands in need of holding, medications to be given, and, if I’m totally honest, lives with more promise to be tended.

At some later point in the day the daughter found me to relay a precise description of how the dentures in the cup differed from her mother’s. The canines were too long, the incisors too short, or maybe it was the other way around. I took a minute, called CT, asked if they had any misplaced dentures forgotten on a counter. They reacted as if I was insane. Plus, the scan had been done the day before, when the staff at CT had been completely different. No one there now had seen the patient the day before. Learning this and thinking about it made me wonder why the night-shift nurse had not been asked about the mixed-up dentures. Maybe by the time the patient returned to the floor following the test, the family had already left for the night.

Finally at the end of the shift I had time to talk to that day’s charge nurse, who made a point of being involved. She talked to the nurse-in-charge, who oversees the whole hospital. Her explanation didn’t help with locating the teeth, but it was reasonable. “I don’t understand,” she said. “Does CT just have sets of teeth lined up waiting to be returned to patients and sometimes there’s a mix-up?” The imaging center had no idea how a patient could come down for a scan and return to the floor with the wrong teeth. Why would a patient even need to have her dentures removed for a CT scan? And most important of all, why was a patient so near death having a CT scan anyway?

I punted. I gave up. I left. My shift was over, but thinking back on it now I feel ashamed of myself for walking out without having solved the problem. There was, however, nothing I could tell those daughters about their mother’s teeth. I wonder if our carelessness with the dentures made the daughters think we had generally been careless with their mother, including the grim prognosis she received. Dentures are irrelevant to a hospital staff when a patient’s very survival is unlikely, but relatives may look at such scenes through the other end of the telescope: If we can’t keep track of someone’s dentures how can we be trusted to care for her whole body?

The dentures could also have been a proxy for the mother’s life. It’s a not uncommon reaction to getting very bad news about someone you love. All the pain and anger of grief focuses, like light concentrated through a magnifying glass, on some small item that absolutely does not matter. “These are not her teeth!” Two daughters’ lives condensed into the contents of one cheap plastic denture cup. A mother’s death is a deep, some would say irreparable, loss.

I attentively fill out the form for Sheila. No, she does not have dentures. Yes she has glasses and will leave them with her sister. No, she has nothing of value that needs to be locked up. Yes, her sister will take care of her clothes.

Our patients become like refugees, hustled from floor to floor, bed to bed, with the minimum of belongings. I finish the form and save it, look at my watch: Vital signs! I forgot. Into Mr. Hampton’s room, the blood pressure cuff, the thermometer, the pulse-ox monitor. He’s normal, fully and completely normal, and he, Trace, and Stephen continue to talk excitedly, this time about fly-fishing. To me there is nothing more boring than fishing, but they have so much enthusiasm it feels like fun. Their energy draws me in the same way it seems to have pumped up Mr. Hampton.

I check the time against the computer and realize I’m ten minutes late with these vitals. I go through the usual debate with myself about writing down the correct time or the actual time and then write down the actual time.

“He’s good,” I say, after eyeing the IV pump and tubing. The three of them stop talking long enough to absorb what I say and then return to their stories. They are self-sufficient in a way that comforts me as well as them. When a patient does so much better than expected I enjoy not being needed.

Candace’s door is open and she calls out as soon as I step into the hall. “There you are! I have some questions.”

Oh my goodness. Well, there’s no avoiding her, so I go in, shutting the door behind me.

“So who was that doctor who came in here earlier? Yong—somebody.”

She’s referring to Yong Sun, the oncology fellow. I explain that he’s an oncologist in training and that he’ll work with the oncology attending in the hospital to manage her transplant.

“So even though I’m finally getting my transplant my regular doctor won’t be here?”

“No-oo,” I tell her, reluctantly. Even though our outpatient cancer center is literally across the street from the hospital, whichever physician the patient has been seeing there—sometimes for months or years—will not necessarily be involved in that patient’s care once she is admitted to the hospital. The inpatient attending is supposed to check in with the patient’s regular oncologist, but if that MD is not scheduled to round on that patient in the hospital then it is rare for that doc to see the patient during her stay.

This tends to be how care is managed in teaching hospitals and the idea is to use physician time efficiently, but patients dislike it for obvious reasons. They want to be seen and supervised by the MD who knows their case better than anyone else. In
How Doctors
Th
ink
Jerome Groopman writes that the individual doctor makes all the difference in how an oncology patient fares. That may or may not be true, but if it is, then why are teaching hospitals structured in this way: separating patients from their usual doctors when patients are most vulnerable? If having patients managed by a specific doctor matters, then why are secondhand reports from residents, fellows, or other attendings, considered good enough when the patient is arguably the sickest she will be?

Candace knows the usual arrangements for rounding; she’s venting by pretending to be uninformed. I don’t mind, though. It’s very hard when patients see “their” doctor on rounds in the hallways and that MD fails to stop at their room or even say hello. I also don’t have what I consider a good enough explanation for why we do things this way. The system’s teaching efficiency doesn’t matter to the people who are sick; all they want is for the person they know and trust to be taking care of them.

“That guy barely knew my history. I won’t have a physician who doesn’t know my plan for transplant taking care of me.”

“And you shouldn’t have to, Candace.” Yong Sun is here to learn, but for Candace, getting a stem cell transplant is scary enough. We shouldn’t add in worries that knowledge of patients is piecemeal. “I’ll pass along the message. It may be possible to switch with an oncology fellow who’s more familiar with your case. I’ll try.”

“Fine,” she says, nodding her head definitively. “I appreciate that.”

“You’re welcome.” In this moment I admire her. She’s willing to complain about things that so many other patients mind but don’t speak up about. I add this request to my mental grocery list, written in bold and underlined.

As I step out of Candace’s room the escort is holding up Sheila’s chart to get my attention. It’s a different one this time, the young woman who pulls her long brown hair up into a pouffy ponytail and wears a lot of eye makeup. I like her because she’s friendly and patient, which is rarely true of the escorts who come from the OR. Their schedules are usually too tight for that.

“Can she walk?” She inclines her head toward Sheila’s door.

“Yes, but slowly.”

“Should I take the stretcher into the room?”

“No, it’s OK. I’ll go and get her.” I’m not sure what’s motivating me here. It’s easier not to bring the stretcher into the room, but leaving it outside will make the transfer harder for Sheila. However, if she walks out of the room under her own steam she has set a tone of strength and determination that will, I’m hoping, endure. The operation she’s being taken to will save her life and it’s my belief that walking to the stretcher tonight will lead to her walking out of the hospital a few weeks later when our work is done.