The Shift: One Nurse, Twelve Hours, Four Patients' Lives (8 page)

She reaches the stretcher and I see with relief that it’s one of the newer ones that actually goes low enough for patients to sit down on like a normal chair. The escort and I help Sheila lie down on it. She looks more comfortable flat on her back, but the lines around her eyes stay tight.

“Hold on,” I say, going back into her room to grab her pillow. “I’ll be here when you get back.”

The stretcher takes her away and I look at my watch: 10:10 a.m. I want to check in with my friend Beth about giving Mr. Hampton Rituxan. She’s got more experience than I have and maybe she can help me feel less concerned about his ability to tolerate the drug, or have some advice about how best to monitor him when I give it. I remind myself that a rapid response team is always only a phone call away in an emergency and that whether Mr. Hampton lives or dies while getting his Rituxan is not solely on me, though I am the canary in his particular coal mine.

I would also love to get a coffee and something to eat, since my morning hunger is kicking in, but first Mr. Hampton needs to take the pills I left in his room. “Think you can take these now?” He’s awake, but lying flat in bed, so I rattle the pill cup and try to look encouraging. He slowly moves his head up and down.

I raise the bed and help him situate himself so he can swallow safely. He needs my guidance to figure out where to move his torso, but not my strength to lift him.

I hand him water and he swallows the pills one by one with no trouble. “Great!” I say. “Want to lie back down?” He nods and I lower the bed, but something’s off. He seems only vaguely aware of me and makes no sounds at all.

I peer at him, thinking, making the worry wrinkle, that vertical crease I get between my eyes. “I’ll leave the room dark if that’s what you want.” But he’s already curling back under the thin hospital blankets. Maybe he’s just tired and doesn’t feel like talking, but now I feel even more concerned about the Rituxan. It’s an unpredictable drug. Most people who get it have no problems at all, others have mild reactions, some become quite ill, and a small percentage of those who become very ill die. It stands to reason that already being frail would translate into increased vulnerability to this hard-to-tolerate drug, but I don’t know that for sure—I only have my worries.

Back out in the hallway I go to find Beth. Like me, Beth has twin daughters. Hers are all grown up, but she and I stand out among the mostly twenty-somethings on the floor and being moms of twins is a bond between us. Beth says our sick sense of humor is really what connects us. Like that time I asked her to witness me rinsing leftover narcotic down the sink: we have to give a reason for wasting opioids, but “patient died” is not one of the choices on the drug dispenser’s computer menu, even though that was why I had a lot of morphine left over. Beth and I focused in on “patient refused” as a reason for wasting the narcotic, and the idea of it struck us both as so funny we laughed loud enough for people in the hall to hear us. The laughter was an acknowledgment of my grief, because I was actually quite sad about the patient’s death and Beth knew that. I’ll always remember the sadness of that shift, but because of Beth I’ll remember the laughter, too.

Today, though, Beth doesn’t seem up for humor. There’s a grimness about her mouth that goes beyond the usual for work. She’s preoccupied by something else.

“My daughter’s flying to Kandahar today,” she says, not looking away from her computer when I walk up.

“Your daughter, the one who’s in the army?” Stupid question, but she nods.

“She left this morning, or whenever morning is over there.” Now she looks at me. “I can’t call. I can’t email.”

Hearing about a flight in a war zone, I picture brief clips from the movie
Black Hawk Down
: bullets, cornered soldiers yelling “RPG,” the yellow dust of Somalia, and one stunning crash of a Black Hawk helicopter, propellers cutting sideways in slow motion as they hit hard-packed earth, black smoke funneling up and out of the wreck.

It will not be helpful to bring up any of this.

“Will you be able to work?”

“Well, being busy is good—it takes my mind off things.”

That I understand. I don’t call home because it feels too soft, too real, a threat to the game face I need to get through my day. For Beth, today, home is scarier than work.

She starts to add something else when my phone rings. “Sorry,” I say to her and she turns back to her computer.

“You’re getting a fourth patient and she’ll be here soon.” It’s Nancy, the charge nurse, who is also one of our floor’s two clinicians: she still works at the bedside, but also has set managerial tasks that take her away from patients. When Nancy’s in charge her decisions tend to be whatever makes her day easiest. Some charge nurses will settle in the first admissions themselves to give the rest of us a break but others, like Nancy, never pick up patients.

“Admission for transplant; she got put on tomorrow’s list by accident. You know her, it’s Candace Moore.”

Candace Moore. Shit. We
all
know Candace Moore. She’s a PITA: Pain In The Ass. One Candace Moore can keep me as busy as two normal patients.

“You know I’m giving Rituxan later,” I say.

“It’s your turn to get a patient,” she says. “The sheet’s here at the nurse’s station.” I click off my phone. She’s right that it is my turn, but Candace Moore . . . .

Candace brings her own supply of Clorox wipes to the hospital and has a rotating set of family and friends who help sanitize her room. She also writes down everything that happens and reads back over her notes with the intensity of an IRS agent studying tax returns, searching for damning discrepancies. Of course, with the very real danger of hospital-acquired infections and the large number of mistakes made in hospitals every year, I understand her obsessiveness. The problem is, she doesn’t trust any of us. She wants our care but deep down, she’s convinced we’re here to hurt her, accidentally, or maybe even with malice, so she vacillates between aggressive suspicion and perky ingratiation. She lures all of us in with what looks like friendliness, only to turn against us when something, anything, triggers her paranoia. Being her nurse is the worst kind of no-win situation, which, if I’m honest, may be exactly how she feels about being a patient.

Early forties, Candace is youthful-looking, athletic and strong, but none of that matters much. She’s coming in for an autologous transplant—an intravenous infusion of her own (cancer-free) cells—unlike an allogeneic transplant, in which a patient receives cells from someone else, called a “donor.” Autologous transplants, or “autos,” pose much less risk than allogeneic transplants, or “allos.” The outcomes are also generally good for people with Candace’s type of cancer, so objectively she has much less reason for anxiety than many of our other patients.

“An admission,” I tell Beth, hanging up the phone. “I gotta go. Keep me posted,” I say, sounding banal, but Beth waves as I walk away. At least I didn’t complain about Candace; I also didn’t get to ask her about Mr. Hampton. There’s time, though.

At the nurse’s station I pick up the patient printout the charge nurse left for me. “Candace Moore,” the secretary says in a teasing voice, “Oh, T., you’re gonna need some extra love today.”

I frown. “Yes, well . . .”

The secretary laughs, then lowers her voice to a stage whisper. “Maybe she’ll get here late. We can only hope.”

Back at my medcart I’m wondering what time Candace will arrive, when
ping-ping-ping
my phone rings again.

“Medical Oncology. Theresa.”

“Do you have Fields? This is radiology. What’s she here for?”

His tone is urgent, his voice strained, and it throws me a little because I don’t understand. I fall back on what I know: “She’s got antiphospholipid antibody syndrome, we’ve started her on an Argatroban drip—”

“There’s a lot of free air in her abdomen,” he insists, cutting me off. We’re back to her belly again. I’m not understanding. “That’s a classic sign of a perforation.”

A perf? Sheila’s got a perf? No way—she’s here with a clotting problem. A perforation is an emergency; she’s got a hole in her gut that’s leaking bowel contents into her abdomen. I can’t comprehend what he’s saying or connect with the urgency in his voice because Sheila is my “interesting medical” patient. My expectation is that we will manage her blood-clotting problem by monitoring laboratory values, making careful observations, and finding the right combination of drugs to control her disease. A perf is a surgical problem, as in only a scalpel can heal her, if even then.

Surgeons and nurses who work in OR inhabit a different world in the hospital from us medical folk. We work on floors with drugs; they use scalpels in sterile, well-lit rooms. We collect data and consider, while they cut out patients’ problems with alacrity and skill.

There’s an old joke about physicians going duck-hunting. The medical doc sees a bird flying in the sky and says, “It looks like a duck, and flies like a duck, and quacks like a duck, so therefore it must be a duck.” He takes so long to determine that the duck is indeed a duck that it’s flown away by the time he’s ready to aim. Another bird flies into the sky and a different MD, this time a surgeon, takes out his gun and shoots the bird repeatedly. It falls to earth with a thud and he walks over to look at it. “Yup,” the surgeon says, “that’s a duck.”

We don’t usually have surgical patients up here on the heme/onc floor—we collect data and consider while they cut—but today it seems like I will. Absorbing this diagnosis is like moving a train through switches to get it on the right track. Sheila has a clotting problem, not a perf. But she has a perf, too. Click, click, click—my brain tries to adjust.

“Can you call the resident?” the radiologist asks, and his voice sounds very far away. I’m stunned, but now I get it. Sheila has a perforated, which is to say torn, intestine. There’s a final click of the train track, then, “Yes, yes,” I tell him. “I’ll call.” I hang up the phone.

This is bad. “A perf” is a phrase we learned to fear in nursing school because it is difficult to detect and deadly. I look on my paper for the intern’s number and send a page with my phone number as the callback. I feel terrible that I had no inkling Sheila was so seriously hurt inside, but the truth is, diagnosing what’s called an “acute abdomen” is complicated, and a scan is the only way to know for sure that a patient has perfed.

It’s not the perforation itself that’s so dangerous, though it will have to be surgically repaired; the gravest danger comes from the intestinal contents oozing from Sheila’s GI tract into her open abdominal cavity. The insides of our bodies are sterile except for the parts open to the outside world, and while the human digestive tract is filled with bacteria that are essential for healthy digestion, those bacteria can become deadly if they proliferate in parts of our bodies that are supposed to be germ-free. In Sheila’s warm, wet abdomen intestinal bacteria will multiply with little control, becoming an infection called peritonitis, which can become an even deadlier condition: sepsis.

Sepsis stimulates a catastrophic response from the immune system called SIRS for Systemic Inflammatory Response Syndrome. The acronym sounds polite but the reality of SIRS is not. At the late stages of sepsis, fluid from the blood stream moves into the body’s tissues, leaving a reduced volume of blood in the arteries and veins. Due to this decrease in volume, the patient’s blood pressure drops, and can keep dropping until there isn’t enough pressure to send blood to every part of the body. When that happens, organs begin to shut down and die.

To picture what happens during the late stages of sepsis, imagine a garden hose with small holes placed throughout to turn it into a sprinkler. When a normal amount of water goes through the hose, the sprinkling effect is constant. If the flow decreases, the sprinkler effect becomes more erratic, and if the volume of water in the hose lessens even further, the sprinkler will turn into a leaky mess that waters only the strip of garden it rests on.

The tissues of our bodies are like that garden. Humans need constant watering with oxygenated blood—this is called perfusion—to keep our tissues healthy and alive. Human cells can become as parched for oxygen as carrots and zucchini in a garden become for lack of water, and if the flow of blood is too diminished the cells of our bodies will die, just like the vegetables in a drought-stricken garden.

Sepsis is a medical problem, but we can’t treat only that—a surgeon must fix the hole in Sheila’s gut to give her a chance of surviving this crisis. She’s a medical patient on a medical oncology floor with a serious surgical problem and we have little experience with such cross-disciplinary cases in bone-marrow transplant. Sheila’s perf puts me clinically out of my element, just like her attending physician, Dr. Martin, was out of his.

And then the guilt comes on full bore. Why didn’t I see this coming? Why didn’t I
know
? A good nurse has intuition; I believe that. I listened to Sheila’s belly, but obviously I should have listened harder, better, thought more about what I was doing. My intellect was certainly piqued by antiphospholipid antibody syndrome. Was I not thinking about Sheila’s abdominal pain because I was hoping that taking care of her would increase my knowledge of the clotting cascade and rare blood disorders? And is that why I didn’t listen to her belly sooner?

Well, I’m learning a lot, but not what I hoped. Some years ago I had a different patient in the same room as Sheila, writhing and moaning with abdominal pain. Her husband was a yeller, one of those guys who’s used to getting his way by being louder than everyone else. In the age of reimbursement based on patient satisfaction scores, nurses are discouraged from asking people to “please stop yelling because it makes it impossible for me to think.”

I paged the oncology fellow because the husband insisted on what he called a “real doctor.” The fellow came over, did a physical exam, and even though there was nothing indicating the need for a CT scan, there was a feeling of inevitability in the room. No matter what the fellow found, the wife would get that CT of her abdomen; and she did. There was no blockage of her intestine, not even a partial obstruction, and certainly no perforation. Cancer itself can cause extreme pain and pain medication was all she needed, though she did require a lot.