The Shift: One Nurse, Twelve Hours, Four Patients' Lives (11 page)

I sit down in the chair next to Sheila’s bed and take hold of her hand. It’s soft and warm and she gives me a sad smile. Her sister reaches over and uses her own hand to wipe Sheila’s tears. Then she, the sister, takes hold of Sheila’s other hand. “Here’s what will happen,” I tell them. “We’ll allow six hours minimum for the Argatroban to clear, then we’ll draw labs to check Sheila’s clotting time and see where we are. Surgery tonight, but it’s impossible to say what time even approximately; there are too many unknowns.” I tell them Peter is a good doctor and will do an excellent job. I tell them I’ll be with Sheila, and the two of them, until she leaves the floor and afterwards she’ll go to the ICU because she’ll need the close attention intensive care provides.

I hold infinity in the palm of my hand, and eternity in the next few crucial hours.

CHAPTER 6

Paperwork

The time I spent with Sheila, her sister, and brother-in-law feels like one of the most important things I will do today, but it doesn’t show up on any of my electronic to-do lists. We need a menu that includes the option: spent time comforting patient with life-threatening diagnosis. But nothing that empathy-intense gets included in our required paperwork.

A lot of what nurses document is strictly CYA, as in Cover Your Ass. We record most of what we do on paper, or more typically, in the computer, including proof that we’re complying with all the regulatory requirements for hospitals. The morning assessment on every patient—what I heard when I listened to their lungs and heart, how their skin looked and whether they are moving their bowels—must be charted in addition to all medications given. Pain medicine, like the Dilaudid I gave Sheila, gets charted on a series of menus that specify where she feels pain, rate her pain from one to ten (based on me asking her, with ten being the ‘worst pain ever’), and say whether the pain is aching, burning, cramping, stabbing, shooting, or another of the fifteen different descriptive options. Patient care—looking after Sheila, Dorothy, Richard Hampton, and Candace—is heart and soul, but these days, charting pulls nurses away from the bedside more and more.

Now’s a good time to catch up on my charting, though, because lunch is being delivered. The woman taking in trays catches my eye. “Fields is NPO now. Is that right?”

“Yes. Thank you.” NPO: short for
nil per os
, which is Latin for “nothing by mouth.”

I try to chart my meds on the computer as I go along since that makes it less likely I’ll forget something. Charting my morning assessments before the morning is actually over is a goal every shift and I did Mr. Hampton’s and Dorothy’s, except, I realize, shaking my head, I never even did an assessment on Candace, much less charted it. She just got here and she’s energetically cleaning her room so it’s likely she’s fine, but I need to listen to her heart and lungs, formally ask how she’s doing, and then record all that on the computer.

Before Candace, though, I need to finish my notes on Sheila, particularly since my morning assessment was wrong in crucial ways. I put in a note about her perf, including when and how I found out about it. Then I go to a different screen and I pull up the spreadsheet where we document our daily clinical observations. Bowel sounds? I didn’t hear them, but didn’t think that silence through. The documentation seems pointless in light of what her real problem is. Neither I nor the medical staff nor the nurses and doctors in the emergency department, paid the right kind of attention to what was happening in Sheila’s bowel, but our mistaken observations have to be checked off on multiple drop-down menus so that the record is complete. I do understand why such thoroughness matters legally, but I sometimes wonder if sadists designed our software. It should not be easier to order a sweater from Lands End than to chart on my patients, but it is. Click, scroll, type, enter. Here’s the menu with twenty choices, none of them the one I need. Here’s the point where I need information from two different screens, but there’s no way to toggle between them. Here’s the screen with thirty discrete options to check, but the window it opens up only shows me five at a time. New lab results, X-rays, CT scans, MRIs: none of those generate an alert and the screen is full of minute icons, some of which represent functions I don’t use or even understand.

Finally I finish up Sheila’s assessment and check it off on my papers. Then I look for new orders and see that Dorothy’s discharge paperwork isn’t yet in the system. I look at my watch: 1:00 p.m. Not bad, except that I need to chart on Candace. It’s frustrating to end a shift and then stay late doing the day’s charting. “If it isn’t charted it isn’t done” is the mantra we hear over and over again in school.

Another one of the oncology fellows is suddenly next to my medcart, holding the written order for Mr. Hampton’s Rituxan. Since the fellows are learning to be oncologists they write the chemo orders, but with more or less supervision from the attendings depending on how long they’ve been around. This fellow is visibly pregnant. She continues to wear heels to work, and I admire her commitment to style even though I would wear flats myself. I take the order and stare at it. “We’re really doing this?”

“I know—he doesn’t look so good. We are keeping it at a steady rate—not increasing the dose over time. That’ll make it easier for him to tolerate.”

I nod, ignoring that fluttery feeling in my stomach.

“And we got permission to give it inpatient?” Rituxan falls under one of the odder billing rules in the U.S. health care system. Reimbursement for the drug is much smaller if patients receive it in the hospital, rather than in an outpatient clinic, and it’s an expensive drug. I’ve had patients transferred from their inpatient room to our outpatient clinic simply to receive a dose of Rituxan, but it can be given to admitted patients if the medical director of the oncology division approves that decision, and Mr. Hampton’s frailty is a good argument for infusing the drug in the hospital. If he reacts badly to it we have the ability to respond more fully than a clinic could.

She gives a dry laugh that sounds like a snort. “If he’s going to get this drug it has to be here. He’s too sick to get it outside a hospital.”

We look at each other and both raise our eyebrows, frowning. “Hey, thanks for bringing it over so quickly—I know you’re in clinic and,” I wave my hand toward her belly, “pregnant.”

“Yeah, well, it was slow today,” she says, “Can you believe it?”

“Maybe we’re curing cancer!”

“Wouldn’t that be great.” She turns to go and then turns back to me. “I’m on call this afternoon and then it’s Bruce this evening, so if anything goes wrong . . .”

“I’ll call you.”

She lowers her voice and leans in to me. “I’ll explain to Bruce in sign-out. And just call us; don’t call the house staff. The intern wouldn’t know what to do.”

“Got it. Fingers crossed,” I say, holding up my left hand with the first two fingers twined around each other. It may be dumb, but it makes me feel better.

Mr. Hampton’s weakness, his difficulty breathing, his confusion are all on my mind. Will we save him or push him closer to death? You can only know what you know, a wise friend told me, but so much is on the line here in the hospital I sometimes want to know more than I can.

I pick up the chemo form and really look at it. Chemotherapy orders continue to come on paper. The thinking is that the drugs are so strong, the regimens so specific, that a physical copy of the entire order needs to be in the patient’s chart as well as entered into the computer. I like the tactility of paper, feeling it between my fingers, hearing it snap and crinkle when bent, running the tip of my finger over the slight indentations left by the fellow’s careful printing.

Sheila’s call light goes on. The clock’s running on getting this chemo order to pharmacy, but I’ve got a little time since Mr. Hampton’s son won’t be here before three.

Sheila’s room is so still it seems airless. I peer into the dimness and consciously relax my face before I speak. Sheila looks defeated, exhausted from crying. “Is your belly hurting you?”

She shakes her head. Her sister sits next to her, holding her hand. “We’d like to see a minister,” she says, and her voice catches, “just in case.”

“Right.” This is an easy request. I call the hospital operator and ask her to page the pastor on call.

“I’ll check your pressure while I’m here.” I feel a flash of guilt that I hadn’t checked it earlier, then suppress that feeling as I grab the cuff from its plastic holder on the wall and take the stethoscope down from the hook behind the bed. As I stick the ends of the stethoscope in my ears Sheila and her sister watch me trustingly. The trace of tears on Sheila’s face makes her look like a child. “We need to know that her blood pressure is staying up. I’ll be quick.” I wrap the cuff around her arm, pump up the bulb, and slide the bell of the yellow disposable stethoscope under the cuff. Up the arrow goes on the dial and I see the cuff tighten around Sheila’s arm. As quickly as I can I let it out and hear the first click—her systolic pressure—then the count down of five quieter clicks, the Karatkoff sounds, and the louder final click. I let the rest of the air out with a shoosh and take the stethoscope out of my ears, unwrap the Velcro cuff from her arm.

“Is it OK?” her sister asks me.

“Yes.” I purse my lips. “One sixty over one hundred.”

“But that’s high, right?”

“Yes, but high is good right now considering the operation she’ll be having. With a perforation and major abdominal surgery coming up, a blood pressure that’s abnormally low would be more troubling.” I’m ready to explain more, but I see that tears hover in her eyes. She blinks them away and her features become fluid as she struggles to hold in her grief. Hearing more medical details from me right now will probably not help.

I bend down beside the bed and take hold of Sheila’s sister’s free hand. “I’ll send in the pastor as soon as she gets here.”

The brother-in-law surprises me with a question as I’m going out the door. “Do you think it was the ambulance ride that did this? All that bouncing around? She said it was rough.”

I stop to consider that. “I don’t think so.” Lots of people ride in ambulances without having their intestines perforate. “It more likely has to do with her clotting problem and the trouble she was having with her medication.” He nods, then leans back into the chair and I lose him to the corner’s darkness.

I look at Sheila and her sister. “I’ll be back. Call me if you need anything for pain or . . . anything else.”

People react so differently to distress. Sheila and her family could be furious, focusing on our failure to do a CT scan right away, to start the anti-clotting drug without understanding why her belly hurt. They’re not being like that, though; they’re mostly suffering in silence. That’s their portion and it makes my life easier, but I wonder if it serves them. Those who bear up, demanding little, are the reverse version of patients such as Candace Moore. Candace is a wounded Fury—hurt and wanting help but focused also on justice and some desire for revenge. It’s impossible for Candace to simply endure. She lashes out at everything and everyone, unsure whom to trust since it’s really her disease holding most of the cards in the hospital. I wish I had more time to sit and hold every patient’s hand. To really listen. I think it would make a difference for Candace as well as Sheila. I really do.

There was an afternoon when I had time. My patient, a married man in his sixties, healthy and fit except for having leukemia, had received a cord blood transplant and it hadn’t taken. That is, he’d gotten an infusion of stem cells from a stranger’s — a baby’s—umbilical cord, but the graft of cells failed. The day eventually arrived when we knew, without a doubt, that the treatment was unsuccessful and we also knew that his cancer would recur and he would die of it. He’d fought cancer and lost, and the inevitability of it all was making him bitter. He had a lot of living he still wanted to do.

The afternoon all this became undeniably clear to us and to him, I was his nurse and I was very lucky that it was one of those rare afternoons when I wasn’t all that busy, although I can’t remember why. Maybe my other patients were off the floor at tests. Maybe they were on the upside of treatment and weren’t that sick. Maybe they were all taking long restorative naps.

I spent a lot of the middle part of that day in Joe’s room. I didn’t do much, and then again I did all I could: I listened. Sometimes people just need to talk, to say the same things over and over and over. I listened while Joe did that.

“It’s not that I’m angry the treatment failed, just disappointed.

“I wish I’d had a better idea this might not work.

“It’s no one’s fault, but I hoped for a better result.”

He would stop, then start up again where he’d left off: “What if we hadn’t had that two-week delay at the start—could that have made the difference?”

I said almost nothing. He needed only a witness to his suffering. He was in the impossible position of standing on a train track waiting for the train he knew would eventually run him down, and no one he knew could be with him that day—not his wife or a neighbor or friend—but I was there silently listening as he tried, by talking, to turn his pain into a story he could accept.

At the end of the shift I told Helen, the same night-shift nurse I’d talked to this morning about Ray Mason, that I’d spent a lot of time in Joe’s room listening. I felt as if I’d had it too easy, but at the same time I was exhausted. There’s nothing easy about helping someone start the journey from life to death. “They also serve who only stand and wait,” the poet Milton said. It’s a line I often hear in my head at work, where standing and waiting can be the best service we offer.

Today is not that day, though.

My phone rings. “Theresa, just wondering when you’re going to have that Rituxan order?” It’s pharmacy. “We want to get it going ASAP since they’re not increasing the rate. The docs would rather it didn’t run all night long.”

The chemo order is lying on my medcart where I left it and I and another nurse have to verify it before the paper goes to pharmacy. “Yeah. Sorry. I just got it; I’ll start my check now.”

“It’s fine. We’ve got a lot of chemo to do for the other oncology floor and wanted to make sure we finished your Rituxan first.”

“Right. Thanks, Bobby.” So many needs; I’d better get this done.

Focus: the fellow’s calculation of the BSA or body surface area is the first thing to check. We calculate from a verified height and weight, which requires two nurses to weigh and measure Mr. Hampton together. That must have been done yesterday. I double-check by looking it up on the computer—it’s there—and then double-check the math, multiplying Mr. Hampton’s height in centimeters by his weight in kilograms, dividing by 3,600, and taking the square root of that number. The answer comes out in meters squared, which makes no sense and yet it’s what we do.

All of this is just arithmetic, but mistakes slip in. Fellows round down instead of up, use an old weight, plug the numbers into the non-customary formula—these kinds of errors and others have been detected by nurses reviewing chemotherapy orders. The drugs are biohazards, so the dose has to be precise: more than enough to cure the patient’s disease might be too much for the patient’s body to tolerate since many of these drugs are toxic enough at the predetermined safe doses.