Matt has signed off on the rapid-response sheet that Susie filled out and starts to walk back up the hall when I flag him down. I lean in closer to him and keep my voice low. “What do you think his chances are?”
“Slim to none,” he says, like he’s swearing, and I hear in his voice that note of concern masked by resignation that made me like him the first time we met.
“That bad?”
He grabs my arm. “Theresa, we’re all gonna die.”
“Right. I know. But I like him,” I say, trying not to sound childish.
“If you really like him, then wish for the family to put him on hospice so we don’t have to keep all this up in the ICU.”
“No chance that he’ll make it?”
He stops and looks at me for a minute without speaking. We’re about the same height and our eyes meet. “His lungs are junk, we can’t stop him from bleeding, and he’s got an opportunistic infection that’s barely under control.”
“I’d forgotten about the infection,” I say in a low voice, mostly talking to myself.
“Wish for hospice,” he tells me, firmly, and we both start walking again.
At my pod we wave good-bye to each other. “Thanks for looking on the bright side.”
He gives me a pained smile, then, “That’s what I’m here for.”
The ICU nurses start to roll Mr. King down the hall. A housekeeper will clean the room, making it ready for a new patient. Nora will give report to the nurse in the ICU, just like the day-shift nurses all got report this morning, then come back upstairs and record everything that happened on the computer. Susie documented during the code, but that was on paper. Half an hour, forty-five minutes, and the emergency is over, except it feels like Mr. King took a piece of my heart with him, and he wasn’t even my patient today.
I stand at my medcart and close my eyes. I try to mentally pack away Mr. King and the blood running down his chin while scanning my notes. Dorothy. Dorothy needs patient-belonging bags, too, especially since she’s brought so many items from home into her room.
I go to the supply room and grab a bunch of them. Dorothy’s going home, not to the ICU, I remind myself. Remembering that doesn’t make me feel better about Mr. King, but it makes me less sad overall.
Back in her room, Dorothy’s talking on her cell phone. “Well, now I don’t know what time, if you can just help Dad get ready.” It must be her adult daughter.
I hold up the bags and she gives me a half-smile and a loose finger wave with her right hand. She’s put on lipstick and it gives color to her whole face. The beginning of her transition to home.
“Just tell Dad to get here as quick as he can.” Trying not to interrupt, I put the belonging bags on her bed, wave back, and turn to the door.
“Wait!” She snaps her fingers. “No, not you!” she says sharply into the phone. Covering the receiver with her right hand and pointing at the candy dish, she says, “Take some chocolate. Today’s my last day.”
I pick up the glass lid, see the silver glint of Hershey’s kisses, and pull them out from among the gold-wrapped Reese’s and green and red Jolly Ranchers.
“Thank you,” I mouth, dropping them into my pocket. My phone rings as I’m on my way out the door.
“It’s radiology, CT scan. Can your patient Sheila Field come down now?”
CT: Computated Tomography—X-ray on steroids. I look at my watch. It’s not even 10:00 a.m. “Sure. That was quick.”
“We had a cancellation. Want me to put it in for transport?”
“If you have time, that’s great. Thanks. I’ll get her ready.”
As I leave Dorothy’s room she continues to talk on the phone, distractedly kneading the plastic bags I gave her. “Forget about that old carpet right now,” I hear as I shut the door.
Now I will listen to Sheila’s belly before she goes to CT. Sloppiness seems like a slippery slope, so being thorough, even if I’m late, is a form of mental discipline for me. I enter her room as quietly as possible. It’s completely dark and she remains a lump under the blankets. I reach out for her shoulder and gently squeeze it. “Sheila? It’s Theresa again. Did the Dilaudid help?”
The blanket goes up and down—a nod. I kneel so that my mouth is at the level of her buried ear. “Sheila, they’ve ordered a CT scan of your abdomen, to make sure everything is all right.” The lump moves up and down again.
“Before you go to CT, I need to listen to your belly. Do you think you can roll onto your back?”
“Ungh,” she says, with a grunt, and the lump rises and turns. The top edge of the blanket slips down and I see a pleasant-faced woman, in her late thirties, with thin reddish-blond hair that flows wispily away from a plump face. Her pale blue eyes are gentle, but lined, and her mouth has that frozen expression pain creates. The fingers holding onto the blanket are thick and there’s a trustingness about her that makes her seem younger than she is, and vulnerable. She’s all alone here, I think. I’ll have to take care of her.
“This will be quick,” I tell her.
I pick up the Fisher-Price stethoscope, rub alcohol on the ends, and stick them in my ears. I put the bell of the stethoscope down on the four quadrants of her abdomen—like two, five, seven, and ten on the face of a clock—and press lightly. Instead of the gurgling that’s typical, I hear nothing, which is unexpected.
Why is Sheila’s bowel quiet? It could be the cheap stethoscope. Or her having just woken up. Or my phone ringing right now as I listen, drowning out her abdominal burbles: “Escort. I’m on my way for Fields.”
Or the rounding team returning, even though it’s only Dr. Martin and the intern. “Now, Ms. Fields,” the attending says peremptorily even though I’m bent over her with the stethoscope in my ears, “you’ve got a clotting disorder and your stomach hurts.” Sheila nods, the fingers of both hands curled over the blanket’s edge so that she looks like a child, trying to hide.
“We’re giving you argatroban. We’ll get a CT of your belly and look at your blood work. It’ll all get sorted out eventually. You should be home in a couple of days.” He gives her a tight smile and she nods, but it’s unclear how much she understands. I don’t fully understand what’s going on, so how could she?
He pulls back the blankets and pushes firmly on her belly. She gasps and her eyes open wide, then squeeze shut as she quickly pulls in her breath. “That’s why we’re getting the CT scan,” he says, covering her back up with the blankets. “Anything else?” Dr. Martin looks questioningly at the intern, who shakes her head.
“They’ve already called her for CT,” I say, wanting them to know what’s happening.
“That’s good,” the attending says, but his tone doesn’t change from that bland professionalism he used with Sheila. However, the intern gives me a weak smile. She and I are in this together.
I hear the electronic ping-ping-ping of my phone. “Transport. Here for Fields.”
“I’m in the room—we’re coming out.” Dr. Martin signals for me to go out first. A little old-fashioned chivalry. Maybe he’s not completely indifferent to the people around him. It could be he copes with clinical curve balls by withdrawing, or it could be he was taught to always let women go out doors first and that habit has never died.
The escort guy waits in the hall with an empty stretcher. He barely makes eye contact, but he’s smooth with the carrier, like all of them. When I have to push a bed I’m an embarrassingly bad driver. The escorts make it look easy.
“Hey,” I say, trying to be friendly. “You’re here to take her to CT?”
“Fields,” he says, half a question. I nod. “Can she walk?”
“She’s in pain, but she should be able to walk.” A piece of straight blond hair falls over the left side of his face. He’s got a long-on-top haircut and that, combined with his funky thick-rimmed glasses make his burgundy uniform look almost cool. I can’t recall ever, ever, having a real conversation with an escort. Never. Maybe that’s why they often seem surly with us nurses.
> It strikes me that my behavior with the escorts is not that different from the attending’s behavior toward me. Maybe that means the attending, like me, is just trying to do his job as best he can. Or maybe it means we should all try a little harder to see each other as human beings.
I go back into the room and wake up Sheila. She’s groggy but willing to move, if very slowly, and starts by sitting up in bed, grimacing.
“Can you stand up on your own or do you need my help?”
“I can do it.” She breathes, starts to rise, then grips each of my arms as if they’re chair rests. “Sorry.” Her breath comes heavily.
“That’s what I’m here for. You’re fine.”
She makes it all the way up. She’s shorter than I am, heavy but not obese, and her hair is longer than I realized. It covers her shoulders like soft down.
She shuffles one foot forward. “You sure you can make it?” She nods, her mouth pulled tight, and shuffles the other foot forward. I feel for her and also feel fretful about how much time her slow walk is taking. Viewing time as the enemy has become a bad habit.
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.”
The Shift Page 7