The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital (11 page)

To get there, healthcare organizations are going to have to force stakeholders to agree on the most effective role for a twenty-first-century nurse. As a Canadian ER nurse posted on
KevinMD.com
, “The issue boils down to whether the healthcare industry can tolerate highly educated, vocal, critically thinking, engaged nurse-collaborators who, in the interest of their patients, will constructively work with—and challenge, if necessary— physicians and established treatment plans. Or does the industry just want robots with limited analytical skills, who blindly and unthinkingly collect vital signs and carry out physician orders? More importantly, which model presents the best opportunity for excellent patient care?”

Before Sam’s first night shift, she guzzled a grande nonfat mocha from the hospital’s twenty-four-hour coffee shop. As a morning person, she wasn’t sure how to handle her sleep logistics to remain alert for a 7:00 p.m. to 7:00 a.m. shift. She had awakened at ten that morning, unable to sleep later. She was scheduled to work three night shifts in a row.

Sam arrived early, wiped down her glasses, tied her long hair back in its usual ponytail, then went to the outgoing day-shift nurse for report. She had heard that the beginning of night shifts were the craziest part of the twelve-hour period. She expected to have several patients initially, and then taper down to two or three. She didn’t expect the outgoing nurse to list six patients immediately, more than a full load. Sam rushed around the department, taking each patient’s vitals. Her ER cell phone buzzed. “Your drip is here,” the secretary said.

“What drip?” Sam asked.

When she got to the nurses station, she looked at the patient’s name on the bag of Cardizem, a heart and blood pressure medication that the pharmacy had premixed. It was unfamiliar. She looked at the computer, and there he was, a seventh patient—and the sickest one—whom the other nurse had forgotten to mention. Sam rushed to the room. The patient, who had come into the ER with an irregular heart rhythm, was in danger of a blood clot traveling to his lungs or brain. Sam hung the drip and prepared the patient for the Cardiac Care Unit, where he would be monitored closely.

By 2:00 a.m., the ER was quieter, but Sam felt like she was going to keel over. She was distracted from her vaguely unsettled stomach only by the piercing headache behind her gray eyes. All she wanted to do was lie down on a stretcher to nap. As she slugged down the hallway, her eyelids drooping, the charge nurse called out to her. “You just gotta keep moving, sweetheart, you just gotta keep moving.” Sam revisited the coffee shop and drank another mocha.

Still, she did not regret her decision to work nights. During the following weeks, she learned that the night staff was more laid back, less harried. By day, the ER was loud; it was hard for Sam to hear herself think. At night, under the fluorescent glow of emptier hallways, it was more peaceful. Only the people who truly needed to be at the hospital were present at night. If a chief resident came down to the ER during the day, he would be accompanied by a fellow and four medical students. At night, the resident visited the patients alone. The ER felt like more of a team that had to pull together to get things done. The night shift was better for introverts, too. In this smaller community, it was easier for Sam to get what she needed for her patients. Gradually she began to learn how and when she needed to be assertive to get something done.

The only drawback to night shifts was that they wreaked havoc on Sam’s social life. As a new nurse, she was given the least desirable schedules, which rendered her entire week useless for nonwork matters because she slept until 5:00 p.m. She wasn’t a party girl to begin with; she spent much of her free time babysitting her brother’s young daughters. But when she did date, she found that people outside the field of medicine usually didn’t understand her. She would tell a guy about seeing a rare disorder or amputation, and his response would be, “That’s nice, but did you see the basketball game?”

A week after a date that seemed to go well, Sam hadn’t heard from the guy and was debating whether to text him. Working a slow night, Sam ran into William, her attractive former preceptor. “Hey, how’s it going?” he asked.

Sam unleashed on him. “Guys suck!” she growled. “I had a date last week. I had a good time and he didn’t seem like he was having a terrible time, either. But I haven’t heard a word. If you say you’re going to call, call. If you don’t want to call, tell me.”

William smiled, his kind eyes crinkling. “Yeah, I’ve never understood that. That’s not my M.O.,” he said. “But most girls aren’t like you, so guys might not be used to someone with no pretense. You’re not one of those girls who acts dumb or creates drama. You’re quiet, but if someone says something stupid, you let them know.”

“I just wish guys would be straightforward.”

“Some guys are nervous, I guess,” William said, shrugging his broad shoulders. “They don’t want to hurt your feelings. But, Sam, you’re a great girl. You’re like the opposite of a damsel in distress.”

Another nurse came over to talk to William and Sam scurried away. She realized that William was usually surrounded by nurses because he was a good listener who made people feel better about themselves. He seemed to know everything that was going on in the department but he didn’t spill secrets.

Sam was just getting settled into the hospital when a new ER director came on board. The staff despised Victoria almost immediately. She would sit in her office or go out for meals when her nurses were struggling with excessive patient numbers. She sent annoying mass emails announcing the ways nurses and other staffers were “
really
supposed to” do their tasks or they would be written up, but she wasn’t willing to expend the resources needed to execute those policies. When a trauma came in, for example, nurses were “
really
supposed to” don plastic gowns to protect from blood spatter, which sounded fine on paper, but usually there was no time to waste, there weren’t any gowns in the ER, or there were only size XLs, too large for most of the nurses to use safely.

On multiple occasions, nurses went into Victoria’s office to ask a question or to voice a concern, and exited the office either fuming or sobbing. One nurse quit within minutes of leaving Victoria’s office. She had gone in to tell the director that the nurses were short-staffed and needed help, and Victoria had answered, “Pull yourself together, put your big-girl panties on, and do your fucking job.” Within four weeks of Victoria’s arrival, twenty of the fifty-eight full-time nurses at Citycenter had reportedly quit because of her. The ER was nearly always extremely short-staffed now, which meant higher patient-nurse ratios and longer wait times.

With fewer nurses, it became impossible to dodge CeeCee. She was everywhere, chatting, flirting, bubbling, high-kicking. CeeCee seemed to take a particular liking to William. Any chance she got, she sat next to him, at meetings, at the nurses station: “Oh, William! I need your help.” “Oh, William! Listen to this.” She would sashay to the busy nurses station and toss passive-aggressive barbs at Sam, like, “Oh my God, I have so much work to do. Sam, you’re sitting down; what have
you
been doing?” as if Sam were relaxing. Sam bit her tongue.

One night, a young woman came in with severe pain from endometriosis and repeatedly falling blood pressure. She was potentially septic from pelvic inflammatory disease, which meant she was in danger of a systemic infection. Sam monitored her, noting that her blood pressure would drop significantly over a couple of hours, then rise slightly in response to the saline that the resident kept ordering to replace the volume in the blood vessels. In fuller veins, the blood pressure was supposed to go up. In sepsis, however, other factors could cause the blood vessels to dilate; flooding the patient with saline would not fix the problem.

After a few hours, per the resident’s orders, Sam had given four liters of fluid (the body has room for approximately four to five liters), but the pressure was still low.

Sam sought out the resident, a first-year. “Um, something is obviously going on here. Her B.P. is low and I’ve just given her four liters of saline,” she told him. “I think we need to do something about this blood pressure instead of overloading her with fluid.”

“Let’s get a CT scan and see what’s going on,” he said.

The results revealed that the woman had fluid in her lungs.
That’s probably from the fluid that I already gave her
, Sam thought. But the attending physician insisted that because the blood pressure was still low, Sam had to administer two more liters.

Sam was getting frustrated. The woman’s heart rate was still elevated, indicating that she was either in pain or experiencing another type of physiological distress. Meanwhile, the attending physician was relaxing at his desk, surfing the Web. He had not spent five minutes with the patient.

Sam found William at the nurses station and relayed the scenario. “The attending said the patient probably lives low [normally has low blood pressure]. So we’re not giving her any pressors.” Pressors would constrict the woman’s blood flow, thereby raising the pressure. “But I’m not comfortable with these orders.”

“Your thought process is right,” he said. “Document everything.”

When Sam talked to the resident about the attending’s orders, he also seemed uneasy. But he was new, and seemed to trust that the attending knew what he was doing.

At dawn, the woman spoke. “I feel puffy,” she said. Her eyes were extremely swollen, and she was pale and lethargic. The fluid bags had emptied. Sam took her blood pressure. 85/50. That was low.

Sam approached the resident again. “At what point do we want to start getting concerned about this?”

The resident paused for several moments. “Eighty systolic.” (Systolic refers to the top number of a blood pressure reading.)

Twenty minutes later, the woman’s blood pressure had dropped further. “She’s at eighty over forty,” Sam told the resident.

“Okay, I’m worried now.” He went to talk to the attending.

When the resident returned, he pulled Sam into the hallway and told her that the attending didn’t want to do anything about the blood pressure and had given no explanation why. The doctor had ordered them to give the woman another liter of fluid, for a total of seven, and then hopefully a bed would open up in the ICU.

“Are you kidding me? We have to do something!” Sam said, gesturing to the patient.

“He’s my boss; I can’t do anything about it,” the first-year said. Sam would eventually come to know the attending as a doctor who didn’t excel in situations in which a patient had no clear diagnosis. But for now, the resident was too green to question a superior, and Sam was too new to tell an attending that she thought he was doing something wrong. Sam updated the notes in the patient’s chart, making sure to add, “No new orders per MD.” After leaving for the change of shift, she never found out what happened to the patient.

That was typical for ER nurses: Each patient’s story continued, at home or on another hospital floor, but the nurses were left with only a caption of the patient rather than the whole of the person, a full narrative life shrunken down to a room or a diagnosis: “Remember that patient in Twelve?”

Medicine asked something extraordinary of nurses: to forge intimate connections with another person for hours, weeks, or months, to care thoroughly and holistically—and then to let that individual suddenly go, often never to be heard from again.

That was just life in the hospital.

Lara sprinted on a treadmill at the gym, sweat dripping off of her chiseled abs.
I want my mom
, Lara thought, pushing herself to run faster.
I do not want the drugs
.

Since the day at South General when she’d nearly taken the vial of Dilaudid, Lara had attended more than her usual thrice-weekly NA meetings to bolster her support. She had increased her interactions with her sponsor and sponsees, all of whom were looking out for her. And she went to the gym as often as she could. She knew full well that she had replaced her painkiller addiction with an exercise addiction. She went to the gym every day for boot camp and spin classes. At home, she religiously exercised to Beachbody Insanity DVDs, a hard-core cardio workout.

She rationalized that exercise was an acceptable outlet which, unlike the drugs, wouldn’t kill her. Besides, it helped. “I think too much about the bad stuff I see: children who have died, a teenager who died in a motorcycle accident. I can’t help thinking about their parents’ faces,” Lara said. Exercising “helps me release some of that negative energy. It allows me to think about it without breaking down and becoming incapacitated. Before, I wasn’t facing things going on. Drugs helped me to stuff it down more. Exercise helps me process it.”

She had been able to put down the Dilaudid in August because she reminded herself how painful withdrawal had been. She had suffered through weeks of sleeplessness, night sweats, diarrhea, vomiting, and terrible nausea. “The withdrawal from narcotics is a living hell. I felt like my skin was crawling. All you want to do is sleep and you can’t. That’s why you hear about heroin addicts who can’t get clean. It’s because they’re like, ‘I know what will make this go away for just a little bit,’ ” Lara said. “I do not ever want to go through that again. Could you imagine feeling like that and having to take care of your kids?”

When she got to work after the gym, a loud drunk woman came into the ER shouting vulgarities. “That motherfucker!” she screamed. “My brother’s going to cut his dick off and shove it up his ass!” She was so out of control that the nurses couldn’t calm her down.

Lara took report from the medics. The woman claimed that someone followed her home from a party and raped and sodomized her. Unfortunately, she had showered afterward, which likely washed away much of the evidence for her case. While she waited for South General’s designated sexual assault nurse to arrive, Lara had nowhere to put the woman but the lobby.