The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital (38 page)

“No.”

“Any cardiac history?”

“No.”

“Shortness of breath?”

“No.”

Erin took the man to the adjacent lab room while Juliette began triaging the next patient. “Are you doing okay?” Juliette heard Erin say.

“I’m okay,” the patient said.

“Do you feel weak?” Erin asked as she began to place the IV.

“No,” the man said. “But . . . I think I need to lay my head back.”

“Juliette!” Erin shouted. “You need to come in here!”

Juliette rushed to the room. The man looked unconscious. “Do you have a pulse?” Juliette asked.

Erin already had her hand on his neck. “No, I don’t have a pulse.”

Juliette quickly checked the man’s neck. She couldn’t find a pulse, either. He was barely breathing. “Agonal respirations,” Juliette said. “I’m starting CPR.” Juliette pushed the Code Blue button behind the chair and began doing chest compressions. Erin began airway management with the ambu bag.

They wheeled the chair toward patient rooms while continuing CPR. “We need a bed!” Juliette announced as they dashed through the double doors.

Juliette had performed solo CPR twice (as opposed to working a code with a hospital team). Once, she and her daughter were going out to dinner when a businessman collapsed on the sidewalk. Juliette did chest compressions until, finally, he came to.

That time, Juliette had been scared because she was outside of the hospital setting, without equipment and staff that could support her. She had not been afraid recently when a 50-year-old woman came into the ER for bradycardia, a slow heart rate. Juliette had asked a new tech to put in an IV, but when she returned to the patient’s room, she discovered that the tech instead had gone to triage. Juliette was hooking the woman up to the cardiac monitor when the patient took her hand and said breathily, “I just want to say good-bye.”

“What are you talking about?” Juliette said. The words sounded strange.

“I’m just going to say good-bye,” the woman repeated. Her eyes went vapid. The monitor showed the woman’s heart rate plummeting to zero. There was no time to press a code button. There was no IV to utilize.

Juliette didn’t even think. She did the precordial thump, a method of resuscitating a patient in cardiac arrest: She raised her forearm to her nose and brought it down hard on the woman’s chest. The woman opened her eyes and burst into tears. She seemed to know exactly what had happened. “Thank you,” she whispered, grasping Juliette’s hand. “Thank you.”

When Juliette yelled at the tech, he blamed the new zoning rules, another Westnorth policy. “They set up our priorities so we’re supposed to help with triaging,” he complained.

“If I ask you to put a line in somebody who has a heart rate below forty, you need to put the line in,” Juliette said.

Shortly after the tech placed the IV, the woman’s heart rate rose. Later, Juliette learned that the woman received a pacemaker.

Juliette wasn’t going to lose this cardiac patient, either. Her arms ached but she continued the compressions. About a minute later, his eyes flickered. He looked around in a daze. “What happened?” he asked. Juliette savored the adrenaline rush.

Erin turned to her. “He was totally gone! His eyes were rolled back, he was shaking all over before he went still!” Agonal convulsions sometimes preceded clinical death.

Carla, a nurse in the clique, walked by. “Way to save a life!” she told Juliette, who smiled.

Once the man was in a room, the cardiologist came downstairs to evaluate him. “It turns out he also passed out at the pulmonologist’s office when he got some bad news, so it might have just been a vasovagal reaction,” the doctor told Juliette. A vasovagal reaction is a nervous system reflex that causes a sudden drop in heart rate, resulting in less blood pressure to the brain and leading some patients to lose consciousness. The doctor nevertheless admitted the man to the hospital’s cardiac unit.

When asked later what it felt like to save a life, Juliette said, “It’s amazing. That’s what we’re supposed to be doing but it doesn’t happen every day. Most days are about cleaning up poop or addressing abdominal pain or nasty family members.”

At the start of her shift the next morning, Juliette looked over the charts for Mr. Morse, a 77-year-old who had come in overnight. She noticed that the night shift had made a mistake. The man had blood in his urine and low blood pressure, but the nurses hadn’t done a three-way bladder irrigation. These irrigations weren’t pretty, but they usually worked. If a man had a large clot in his bladder, treatment involved inserting a catheter into his penis to flush out the clot.

Juliette caught the night nurse before she left.

“The doctor didn’t order it,” the nurse said.

“But if he has blood in his urine, you need to make sure there aren’t any clots.”

“Well, I would have needed an order and it wasn’t ordered.”

Juliette stared at the night nurse long enough to convey that she knew the nurse had been lazy; she should have requested the order from the doctor. Juliette called urology, then explained to Mr. Morse what she was going to do.

“Mr. Morse, I have to flush your catheter with saline to get rid of the blood clots that are in your bladder,” she said. After a tech inserted a Foley catheter, Juliette rolled up her sleeves. With one hand, Juliette held the man’s penis, and with the other, she pushed saline from a 60-cubic centimeter syringe through the catheter until the output was no longer cranberry-colored. Periodically, she also dialed a clamp on a tube to transfuse the patient’s blood. The skinny old man resisted. “What are you doing?!” he yelled. “What are you
doing
down there?!”

Juliette looked up. Mr. Morse was feebly trying to bat her hands away from his penis. Finally, he gave up. He put his hands behind his head and, with a look of bemusement, said, “Young lady, you ought to be ashamed of yourself.”

Juliette laughed and again explained what she was doing. Throughout the morning, she kept returning to the room to irrigate, but sometimes she didn’t get to Mr. Morse quickly enough. When his catheter got blocked, his sheets would saturate with fluid. Mr. Morse would try to escape the wet sheets. The staff would find the man naked and halfway out of bed while undergoing both a blood transfusion and a three-way irrigation.

Her coworkers were annoyed with Mr. Morse, but Juliette liked him. He was funny, sweet, and slightly senile. “I wanted to make him better,” Juliette said later. “He required so much work, but I didn’t mind because he was sick and he needed help.”

She was checking on another patient when out of the corner of her eye, she saw Priscilla treading cautiously down the hallway.
Uh-oh
, Juliette thought. She left the patient’s room to investigate. There was Mr. Morse, naked in the hall, a bag of blood hanging from his arm, and a catheter hanging from his penis.

“That’s it, Juliette, you have to put him in restraints,” Priscilla said.

Juliette escorted him back to his room. She wasn’t going to put the poor man in restraints. Juliette stayed past the end of her shift to take Mr. Morse upstairs to the cardiac unit. He would undergo surgery the following day to find the source of his bleeding.

The next afternoon, Juliette called the urologist from home to ask what had happened to Mr. Morse. “He made it,” the doctor said. “We were able to close off the bleed.”

Nursing involved deaths and inevitable disappointments, hostile visitors and slacking coworkers. But just often enough, something wonderful happened to remind a nurse why she loved the field.

During her next shift, Juliette was meticulously sanitizing her cell phone when someone from the hospital’s professional development committee found her. He handed Juliette a certificate and her clinical ladder portfolio. “Congratulations! You got the promotion! You’re a clinical level four!”

Juliette grinned with pride. A step up on the clinical ladder was almost comparable to an extra degree after her name, and clinical level 4 was considered a major accomplishment. She had put in time and effort to develop her expertise and prove her work ethic. A $2,000 bonus and a raise accompanied the promotion but, to Juliette, the promotion wasn’t about the money. It was about recognition of a job well done.

“Nurses are frequently put in situations of conflict arising from competing loyalties in the workplace, including situations of conflicting expectations from patients, families, physicians, colleagues, and in many cases, healthcare organizations and health plans.”

—
Code of Ethics for Nurses
, Provision 2.2

“Somewhere along the line, when we lost the long white skirts, pleated blouses, and nursing caps of yesteryear, we also seemed to have lost the public’s respect. I would gladly go back to the nursing days of Florence Nightingale and Clara Barton to have the respect they had from society. I wish I could start a revolution for ER nurses specifically; we are the rock stars of nursing, but are treated like the red-headed bastard stepchild.”

—a North Carolina ER nurse

“So many things are just simply bullshit. I don’t know why I was surprised. I guess I always thought that when it came down to
people’s lives
, things like making money no matter what wouldn’t be so important.”

—a Texas ER nurse

A divorced South General nurse in her late forties was trying to get pregnant through IVF. Afraid to give herself the injections, she asked Lara if she could come to her house and inject the daily shots. Lara agreed without hesitation. The nurse repeatedly tried to pay her for her time. “I’m not taking your money,” Lara told her. “Just tell me, how did you talk to your first husband when you guys were separating? What did you tell him? What did you wish you didn’t say? Help me with advice.”

Friends called Lara all the time to ask medical questions or to have her look at their injuries. Before she had kids, Lara slept over at her friend’s father’s house for two weeks because the family couldn’t afford a twenty-four-hour nurse and the man had painful bone cancer. “I’d never accept money for stuff like that,” Lara explained. “I do that in a heartbeat.”

She loved that people felt they could ask her opinion and that she could almost always help them. Being a nurse was more than a job. “It’s kind of who I am,” she said. “Nurses can truly make a difference in someone’s life. In the ER, even if it’s not a true emergency, an accident is something a person will never forget. That ER visit for stitches could be one of the worst times for people, and a nurse can make it a little better for them, putting them at ease, alleviating some of their fear. Even a pillow or blanket for someone’s grandma can make a difference. It may sound silly, but that makes nursing special.”

Now that the bills had started to come in and she was paying them, Lara had begun to grasp how well she could manage life as a single mom. She could support her family. She couldn’t spend as much time at home with her children as she wanted to, but she was doing her best, and she knew that her kids were safe when she left them with John. She had started to emerge from her funk, though she was still disappointed that she wouldn’t be able to go to PA school. She put her bachelor’s degree classes on hold, unsure of when she’d be able to continue them.

At work, she was able to focus more on her patients. One morning, Lara was working trauma and precepting a nursing student when an ambulance brought in a heavyset woman in her forties. While driving, the woman had told her spouse she didn’t feel well, then pulled over and went into cardiac arrest. The medics had briefly brought her back to life twice by the time she arrived at South General with no pulse. She was blue from midchest up.

Dr. Alisa Hawkins, a well-respected ER doctor, ran the code. While the team performed CPR, she reviewed several possible algorithms that could have caused the heart attack. Dr. Hawkins stuck a needle in the patient’s chest in case fluid had pooled around the heart.

“It’s not fluid,” Dr. Hawkins said. “Did we cover our Hs and Ts?” (“Hs and Ts” was a mnemonic device to help medical professionals run through possible causes for a cardiac arrest.)

“We did,” Lara said.

“Could be a blood clot in the lung,” said the doctor. “Does anyone have any ideas?”

“What do you think about t-PA?” Lara asked. Tissue plasminogen activator could save a patient by dissolving a clot or it could cause a patient to bleed out and die. Typically, the procedure required the patient’s or family’s written permission. In this case, the patient was technically dead anyway.

“Yeah, let’s do it,” Dr. Hawkins agreed.

The other nurses backed away from the bedside, suddenly busying themselves with other things. Lara looked around. She hadn’t given t-PA in more than a year. “Wow, really, guys?” Lara said. “Okay, I’ll do it.”

As the others continued CPR, Lara explained to her student what she was doing. “Usually you give a bolus [a single dose] of t-PA first intravenously, and if the patient is still alive, you do the second half over thirty minutes. But we don’t have that kind of time, so we’re doing a straight push over three minutes,” she said. She encouraged her student to take a turn performing CPR, which she had never done before. “It can be creepy to do CPR because you often break ribs even when you’re doing it right, so I want you to know what that feels like,” Lara told the student. Lara stood by the intravenous drip, slowly depressing the plunger of the syringe of t-PA while instructing the student how to set up the remaining medication. Afterward, the student thanked her effusively.

The patient, as expected, didn’t make it, but Lara found that she had completely regained her medical confidence. “I felt like it came back and flowed,” Lara explained to a friend, relieved that she was back on her game. “I didn’t feel like I was struggling to think through anything. That was nice, because my fear at work was missing something on a patient. As a team, we didn’t miss anything. T-PA might have helped, so I was glad I thought of it. Even though the patient died—really, she came in already dead—I walked out of there knowing I did every single thing I could possibly do to try to save her.”