The Shift: One Nurse, Twelve Hours, Four Patients' Lives (9 page)

I realize now that the memory stayed with me as an example of sound and fury signifying nothing. I made the mistake of equating loudness of suffering, including the belligerent husband’s, with clinical severity. His yelling intensified my concern for the wife, as it should have, but when we confirmed the wife’s bowels were working fine, at least as far as the CT could show, I made that experience my baseline without thinking it through. In that situation there was lots of yelling and no perf. Therefore, a real perf would evince more moaning and writhing and even louder yelling.

A psychologist would call that a reaction formation: my outsize anxiety about a non-existent abdominal perforation led me to believe that if an actual perf occurs the patient will have a lot of pain and be very agitated. This, I now know, is wrong.

If there’s one thing I should have learned in the hospital, it’s how little control—of the good or the bad—we really have. Dorothy is cured and going home. Mr. Hampton is getting Rituxan and I am worried that it will hurt him more than help, or at the very least land him in intensive care. Candace is a hard patient to manage, but of course I want her transplant to go well. And now Sheila, my learning opportunity, turns out to be a slow-motion medical emergency.

My phone rings. “Medical Oncology. Theresa.”

It’s the intern. She’s already heard from the anxious radiologist. “Stop the Argatroban,” she tells me. She sounds scared or maybe, like me, she feels guilty for having no premonition about the perf. It’s not rational that some of us who work in health care expect ourselves to be omniscient.

“If we stop the Argatroban now it will take several hours to clear her body. They can’t operate until then.” She hangs up.

I slide my phone back into my pocket and wonder who’s going to tell Sheila this terrible news? Me? I would, but without any kind of plan in place I’d unnerve her without being able to list her options. I know very little about the surgery she will need.

My phone rings again. “Hey, it’s Peter. Are you taking care of Sheila Fields?”

“Yes,” I tell him. Click, another switch goes through; my mind is now mostly on track with Sheila’s perf. Peter is Peter Coyne, an attending surgeon who is also a friend. The most common thing people say about Peter is, “I love Peter Coyne.” He puts the lie to the common stereotype of surgeons as arrogant. He’s sweet and a huge fan of bad puns and even worse jokes that I always laugh at despite myself. Whoever put in the consult for Peter to become Sheila’s surgeon did a good thing for her.

We met a couple of years ago over the phone. He’d surgically placed a permanent intravenous line, a triple lumen Hickman catheter, in one of my patients and I needed to know if the line could be used. I was a new nurse and not as clued into the hospital hierarchy as I would eventually become. I called around to find out about my patient’s IV line and someone told me to just page Dr. Coyne so I did.

My straightforward question, crisply delivered, “Is this newly-placed Hickman OK to use?” somehow devolved into a joke that made no sense but struck me as very funny.

“Well, I don’t know,” Peter said, “Are we placing Hickman catheters today or pumpkin catheters? If no one told you whether that line is safe to use I may just have to start handing out demerits.”

The unexpectedness of his answer surprised me and I couldn’t stop laughing. Then Peter got serious and told me the line was good and he would put an order to that effect in the computer.

“We’ll be up soon, but I need to talk to her doctor,” Peter tells me now. “Do you have the name?”

“I have the intern’s name.”

He laughs, but it’s strained. “This isn’t a case for the intern; I need to talk to the attending.”

This is unusual. Attendings may talk to each other at meetings, or socially, I suppose, but on the floors they seem to only talk to each other through go-betweens such as interns or nurses or through scribbled notes that often don’t even get read.

Attending to attending confirms my worries about Sheila. But Peter is on the case, so soon we will have a plan and it will be a good one. I think of the frustrated heme/onc attending, Dr. Martin. He was upset about having a patient with a blood disorder. Sheila’s situation will only make him feel less capable of taking care of her.

“Nicholas Martin is the oncology attending.”

“Oh, I know him,” Peter says. There’s something in his voice, not neutral, but I can’t fix on it. “I’ll call him.” He hangs up.

I look down at the admission paper on my medcart. I need Candace Moore to take her time getting here because I’m short on patience, even though Sheila can’t be operated on for hours because the Argatroban would make a complicated abdominal surgery even more dangerous than it already is. Because Argatroban slows clotting times, any cut would bleed much longer than usual and fixing a perf requires a large incision. Sheila’s also overweight enough that she has thicker-than-normal layers of tissue to cut through for the surgery. The risks of excessive bleeding are obvious.

“You have no idea how much blood the human body holds,” Matt, the ICU doctor from this morning’s emergency, told me once, recalling what it was like to watch that precious fluid run out of a patient’s body and cover the hospital floor when he had no ability to stop it.

But Sheila’s stuck. The bacteria in her abdomen will multiply and spread while we wait for the Argatroban to clear her system. As time passes we swap one potential for death with another, but it’s what we do here. The cutting edge of health care sometimes nestles just next to the razor’s edge of survival. I check my watch. It’s 11:00 a.m.: we’ll have several hours of watch and wait.

I log into the computer, checking for any new orders on Dorothy, Mr. Hampton, or Sheila. All orders get recorded electronically and the computer is where newly placed orders pop up for nurses. While I think of it, I enter the verbal order the intern gave me to stop the Argatroban on Sheila and I write a note to myself to disconnect the drug once she’s back on the floor. That should be soon.

But why wait? I call radiology and ask a nurse there to disconnect the Argatroban and ask her to tell Sheila there’s been a change in the plan, which is true, even if my banal phrasing doesn’t reflect how dire her situation is.

Ping-ping-ping
. “Your admission is here!” the secretary says in her chirpy voice. Ugh. This timing is so bad. Not that I’m rushed right at this moment, but I’m worried about Sheila and preoccupied with my own useless feelings of guilt. Well, both of those will have to wait.

I quickly glance into the empty room between Mr. Hampton and Dorothy. Candace will start in on us right away if it’s not, in her view, perfect. I repress my impatience as I see her push through the double doors toward me. She’s pulling two designer suitcases behind her; she’ll be here for at least a month. Her straight black hair is beautifully blown out. Is that a wig? I can never tell.

She smiles a big smile and I smile back, but I know the warmth she’s offering probably won’t last. Taking care of her usually feels like an emotional chess game.

“Candace. So it’s really time for transplant.”

She hugs me, giving my back a soft pat. She smells of citrus and expensive shampoo. “Well, first my dye study,” she says and I squint at her because I don’t understand.

“Dye study?”

“My Hickman’s not working right,” she says. She’s had it for several months now and they do malfunction. If we suspect a defect in the line, the patient goes to interventional radiology where they run dye through it while taking X-rays. It’s a fairly precise way to show where the Hickman ends in the body and if each of the three lumens works correctly. “I told them I’m not having my transplant with this line until I have a dye study and that it’s going to be today, right now.”

I know I should just agree with her, but my curiosity gets the better of me. “What’s wrong with it? Do you want me to flush it, check whether it’s OK?” The lines are fairly simple mechanically and there are only a few things that can go wrong with them.

“No, I don’t want you to check it; it’s not working!” she bursts out, her voice almost shrill. “Would you want a transplant through an IV line that wasn’t working? Or someone messing with it?”

“No,” I say, shaking my head. Why did I ask her? “So that’s today?”

“Yes, I’m just dropping my bags off and going down there.”

“They’re expecting you?”

“They’d better be,” she says. I nod, smile again.

“Let me call transport. Since you’re here as a patient, we’ll want you to go down with an escort.” I think for a minute, then explain hesitantly. “We’ll need to send you with your chart, too, so there will probably be a little bit of a wait while we get that together.” I try to sound pleasant, but firm, not like she’s been here for five minutes and I’m already apologizing.

“Oh, that’s fine,” she says brightly, her mood once again friendly, talkative. “No rush—my cousin’s on her way in and we can clean the room while we wait.” She holds up a grocery bag defiantly and through the thin plastic I see that it contains two large containers of Clorox wipes.

We go in the room and she puts one of her suitcases on the bed and tells me, without turning around, “I know you’re busy—you just go do your work and I’ll get settled in here.”

In the hall, Nora, Mr. King’s nurse, puts her hand up to her mouth and loudly whispers as she walks past, “Candace Moore.”

“Good news travels fast, huh?” I say.

Breathe,
I tell myself.
Just breathe.
Our bodies can’t make energy without oxygen.

CHAPTER 5

Surgical Team C

Needing to clear my head I walk up to the nurses’ station. When people ask why I left teaching English to become a nurse, it must be moments like this that puzzle them. Instead of being here at the hospital, concerned about madly proliferating bacteria and killer drugs, I could be discussing a novel with a group of interested college students. There’s a lot more control in a classroom than in the hospital and no one’s life was on the line as a result of my work in the Tufts University department of English.

I look up and there’s Peter Coyne at the nurses’ station, his white coat emphasizing the straightness with which he holds himself. He’s tall and athletic-looking, with short-cut gray hair, and immediately he starts joking around with our secretary: “Someone said they tried to page me, but they didn’t have a
Coyne
for the phone.” His smile is irresistible even though the pun is terrible. The secretary laughs and he keeps going: “To
Coyne
a phrase, did someone page me?” At the same time escort arrives back on the floor with Sheila.

Two of them have brought her, the blond guy from before and a short African-American woman with high cheekbones and long braided hair. They both have lives, hopes, and dreams, but the boundary between their world and mine is another that rarely gets crossed.

The stretcher is angled away so Sheila doesn’t see me. I look in her direction quickly and see the Argatroban, unhooked on the IV pole, its tubing looped up neatly on one of the pole’s metal hooks. The nurse in radiology hung a bag of normal saline in place of the Argatroban and I see that it’s infusing—I’ll check the orders and make sure the intern put that order in.

I should go over to Sheila and explain what’s happening, but instead I gesture discreetly toward her room. I want the two escorts to get Sheila into bed without my help because I’d rather talk to her after I’ve checked in with Peter and have solid information to deliver.

The whole system should probably put more of a premium on giving patients disturbing news quickly. If it were me I would not want to discover that someone else had secret information about whether I might live or die and didn’t tell me. But then again, I also wouldn’t want them to frighten me with bad news if they weren’t
sure.

Peter keeps joking and I feel my impatience, so I interrupt him, “Let’s go. I’m worried about my patient.”

He stops joking and looks at me, suddenly earnest. “Does she need to be in the ICU?”

I think about it. “No. Her pressure’s been good—she’s stable.” Since the bacteria multiplying in Sheila’s belly will make her sicker over time and the overarching fear is sepsis, paying attention to her blood pressure is critical. Having Sheila’s blood pressure remain normal or high is good right now. If she starts to drop—like the water pressure failing in the garden hose—we’ll know she’s getting sicker fast.

Peter and I head down the hall to Sheila’s room. I’m ready to go in with him but the medical student who’s been trailing us gestures at me in front of the computer in the hallway. He has a question.

These poor medical students. They worked so hard to get into med school and then in the hospital no one gives them the time of day, in part because they have no real purpose, at least on our floor. They’re supposed to be learning and I’m sure they are, but as far as we nurses know they can’t
do
anything. Plus, the white jackets they wear, deliberately shorter than the long white coats of the interns, residents, and attendings, make the male students resemble those little boys in old photographs wearing short pants.

I don’t know why the medical student thinks it’s my job to explain our software to him and I don’t mind, usually, but his timing sucks. I squeeze my lips together, holding in frustration, then arrange my face to look neutrally helpful. Clueless now, he’ll be a full-fledged doctor someday and I want him to see that nurses can be collegial.

He wants two small things explained: how to look up laboratory results and where to find the radiology report on Sheila. Geez, don’t they teach the students anything before they start in the hospital? In a couple of years they’ll be residents practicing medicine on real patients, but until then it’s like no one even tells them where the bathrooms are.

This guy is nice despite his nervousness. Questions answered, he heads toward Sheila’s room and I’m right behind him when my phone rings. It’s Lucy, the nurse practitioner, wanting to update me on Dorothy’s discharge. There will be dose adjustments in a few of her meds, so it’s going to take a little longer.

“OK.” I hang up and reach for Sheila’s door when the phone rings again. “This is Trace Hampton. Richard Hampton’s son.” His voice is pleasant and direct and he asks me not to start the Rituxan until he can be there, around three in the afternoon. I look at my watch. It’s 11:00 a.m. Considering I don’t have orders yet that should be fine. “No problem,” I tell him.

Then the phone rings again. It’s Sheila’s intern, the one with the long hair parted in the middle who smiled at me to show we were on the same team. “What’s going on? No one’s told me anything.”

“The surgical service is already here,” I tell her. “And I’ve stopped the Argatroban. Beyond that I have no information except we probably won’t be moving her to the ICU.”

“Can you call me when you find out anything?”

“Sure.” I remember my question for her. “Did you order fluids?” I haven’t had time to look it up on the computer yet.

“Yes. Normal saline at seventy-five.”

“Great. I’ll page you when I know what’s up.” I push the off button and see Peter and the medical student heading back up the hallway. I missed Peter’s entire conversation with Sheila.

He turns around and flashes me that irresistibly friendly smile. “See ya later,” he calls out, giving an exaggerated wave.

“What?!?” I say, playing along with what I think is a joke. It has to be a joke—how could he leave without filling me in? But my phone rings again so I can’t quick-step after him to make sure.

“We have a Candace Moore down for a dye study and imaging today. It’s not clear what exactly the problem is, though . . .”

It’s interventional radiology and I don’t have an answer for them beyond her telling me her line wasn’t working. “Um.”

“ ’Cause we just got two emergencies, so we’re gonna have to push her back a few hours, OK? We’ll call you when we’re ready for her—it’ll be a while.” He hangs up.

I absolutely should go in to see Sheila, but first I run my eyes down my papers. Dorothy has a med due and I need to find out if Mr. Hampton is any more with-it than he was. I should also tell him about his son’s phone call and that we won’t start the Rituxan until at least three p.m. And now I have to tell Candace that her trip to IR has been delayed and hope she takes it well.

Prioritizing: The problem is, Dorothy will want to chat, and while I enjoy chatting with her I don’t have time right now. I get out her pill and steel myself for a quick getaway only to discover that my planning was unnecessary. She’s once again on the phone to her daughter (or maybe she never hung up?) discussing her discharge. I set down the pill in its little plastic cup and wave. She waves back by wriggling her fingers in her usual way while talking. “Now when I get home we’ll have to wash all the drapes. And maybe we should have the carpets cleaned. Also . . .” I leave. I can only imagine the domestic whirlwind Dorothy is going to be after being away from her home for more than a month. As I head out the door she’s saying, “No, of course I won’t be doing the cleaning myself!” I smile. Her daughter will make sure Dorothy takes it easy, whether she wants to or not.

Mr. Hampton is sleeping again when I go into his room, but he’s more alert when I wake him up than he was before. I give him the message from his son and he nods. He seems to know where he is, but his breathing is not easy.

Now to inform Candace about the delay. If my life were a play, this would be the moment of French farce—going in and out of adjoining rooms never knowing what I’m going to find on the other side.

I knock on her door and walk in. “Thank goodness,” she says, raising her face to me, her eyes squinty with anger. “That shower curtain is moldy and look at this—look!” She holds out her hand, protected with a latex glove, and I glance down at it, seeing in her palm a quarter-sized ball of tangled hair and lint.

“That’s, um . . .”

“Dirt! We found it behind the bed.
On the floor
!
”

I swallow. We clean constantly in the hospital because residual dirt is never just mess. Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococcus (VRE), Clostridium difficile—these are the bacteria that live in hospitals and even sometimes in rooms that have been thoroughly scrubbed. A microscope might reveal Candace’s dust bunny as a deadly disease vector. That is not a joke. She will be severely immuno-compromised after transplant, making her susceptible to infections that wouldn’t ever trouble a healthy person.

I swallow again. Hospital administration recently laid off some housekeepers to save money and the ones left on the job now have too much to do. As with nursing and doctoring, mopping and wiping can only be speeded up so much before efficiency degenerates into missed spots.

“That’s why
we’re
cleaning the room,” she says, and her cousin nods aggressively, keeping her back to me as she carefully rubs the windowsill with a Clorox wipe.

There’s nothing to do but make things better from here on out. “You’re right about the room.”

“I know that!” she says, but her eyes are more relaxed. She’s probably used to people treating her as though she’s annoying rather than correct. Score one for empathy.

“You may not like this, either,” I say, “but IR just called and they have to push back your dye study. They got two emergencies back to back.”

“Oh, that’s OK,” she says, wiping down the stainless-steel bed rails. “Tell me when they’re ready for me, but don’t forget the new shower curtain! That shower curtain is disgusting!”

“She could die from that shower curtain,” the cousin throws in.

“Right. New shower curtain.” I slink out of the room without even checking to see if it really is moldy. It’s a five-dollar shower curtain. After the hair-and-bacteria ball under the bed I’m not going to argue.

Out in the hallway I call maintenance before I forget. “OK,” the guy says, and I hang up, relieved that for once I could tell someone about something needing to be fixed and they would agree to do it without my having to explain.

Ping-ping-ping
my phone rings again and this time it’s Peter calling me; he’s back on the floor. I look at Sheila’s door. I should go in, see how she’s doing. But it’s easier to ignore a closed door than a live person on the telephone. “I’m coming right now,” I tell him, putting my phone in my pocket and walking to the nurses’ station.

He sits in front of a computer surrounded by a flock of surgical interns and residents, bright in their long white coats. One is on the short side with red hair and freckles on his plump cheeks, another is tall with a long face. And then I see my real-life next-door neighbor, Akash Patel. Young, handsome, from an Indian family, he grew up in the South and now lives in the house adjacent to mine. Akash is very smart and very nice. His wife is sure he works too hard, which I think is a common feeling among doctors’ spouses—women and men.

A surgical team encamping on our medical oncology floor in the middle of the day is unusual. Dot, the veteran nurse with a bottomless reservoir of common sense and a sly smoky laugh, sidles up next to me. “What’s going on?” she whispers.

“My patient, Fields, has a perf.”

“Oh shit,” she says, scrunching up her face. “When?”

“They just found it on CT. She came in last night from an outside hospital.”

“Are you OK?” This is a hospital question that asks about much more than it seems to: Is your patient stable or could she spiral down at anytime? How’s the rest of your load? Are you calm or panicked at this emergency?

“Right now I’m good, but I’ve got Candace Moore.”

“Oh . . . shit.” Her great laugh comes low and deep.

“And I’m giving Rituxan later to a seventy-five-year-old on oxygen.”

“Who thought up that assignment? Oh wait, let me guess.” Her eyes slide over to the charge nurse.

“You got that right,” I say.

“Hey,” she says, serious now. “You can only do what you can do, and you know where to find me if you need help.”

“Thanks,” I squeeze her arm and turn back to the flock of surgeons.

“Hey,” I say to Akash, who nods his head back at me. I jerk my thumb toward him and ask Peter, “Did you remember that he’s my next-door neighbor?” Peter and I had talked about Akash before.

“Oh, that’s right,” he says, not taking his eyes off the computer screen.

“So, are you being nice to him?” I ask.

Peter looks up. The air feels electric. I may have crossed a line, just like Dorothy’s attending did this morning when he teased me about getting him coffee. This line isn’t doctor-nurse, though; it’s resident-attending. Peter
is
nice, but at the moment he is also my neighbor’s boss and it’s not my place to pester him about that no matter how many bad jokes he makes with our secretary or how good my intentions.

He turns back to the computer screen unperturbed, though, and begins planning out loud. “Stopped the Argatroban around 10:00 a.m.—let’s say 11:00 a.m. just to be safe; so we probably can’t operate until five at the earliest depending on her clotting factors.” He stops to think for a moment. “Have to call the oncology attending, see if we can give her anything to speed that up. What’s her pressure?”

“It’s been high,” I say while he scans the computer, “160 over 100. Though I haven’t checked it for at least an hour.”

Akash says, “That’s fine. And better too high than too low,” while the other residents nod.

“She’ll have to see anesthesia,” Peter continues. “They’ll talk to her—for a really long time—plump her pillows, get her ready.”

“Will they give her tea?” I ask, playing along with his joke.