The Shift: One Nurse, Twelve Hours, Four Patients' Lives (20 page)

Eva looks up at me. She mouths, “Sorry,” but I shake my head. “Is Opal here? His wife?”

“I think she went out to get something to eat.” Eva shrugs, giving me a slight frown.

“This Xray was
STAT
,” the technician says, walking into the room trailed by an assistant holding a flat sheet of film. “I need it
now
.”

“Got it,” I say. I squeeze Frank’s hand one last time. “See you.”

In the hallway I pull Eva aside. “What’s the plan for him?”

She lowers her voice. “Family meeting tomorrow. His son can’t get here until then and they want to make the decision about hospice together.”

“Right. Well, thanks. He’s a nice guy. We’ve taken care of him for a long time.”

An alarm sounds in another room. “Eva, that’s you,” a voice calls out.

“Gotta go,” she says, swirling around, her pale hair shining like light behind her.

I grab my bag from the floor and retrace my steps back to the stairwell.
It’s over for Mr. King
, I think, and feel a lump forming in my throat. I shake my head, cough—it’s not time to grieve; it’s time to go home.

A few more flights down and at the first floor I open the heavy door slowly and walk out into an almost empty hallway. A couple of nurses are also leaving and a few visitors come and go. The cafeteria barely buzzes; they’ll soon be closing up for the night. I can see why Opal would want to get food somewhere else.

The double glass doors whoosh open for me and, buttressed by a wall of indoor heated air, the evening’s cold doesn’t hit me until I take a few steps into it. After I’ve spent twelve hours in a hermetically sealed world, including a brief stop in the ICU, fresh air is enlivening. I breathe in, then feel the sting on my cheeks and pull my neck scarf up and over most of my face.

I unlock my bike, put on my helmet, snap the strap of my bag across my chest, and pull on my gloves. By the time I get home I’ll be sweating, but right now I want to be comfortable, so I start out completely covered up. My bike lights are on and I zip straight out of the parking lot, happy that riding my bike makes parking free for me.

I push into traffic and the first real turn of the pedals is a release. The streets are dark and it’s a weeknight, so there’s very little traffic. My mind wanders to Dorothy. A few weeks before, she told me about her love of the Girl Scouts. It came up because she was trying to order a special Girl Scout hat and they kept messing up the order. I wonder how hard it would be to order one of those hats. How much might it cost? Could I surprise her with it? Pie in the sky—it’ll never happen. For one thing, I can’t afford to buy my patients gifts. But I’d like to get Dorothy the hat she wants if I could. Does that matter? My mother loves to say that the road to hell is paved with good intentions, but sometimes that’s all we have in the hospital.

Pedal, breathe. I go slowly because I’m tired. I think about the owlish intern and his comment that knowing the future would make our jobs a lot easier.

Before I started this work I thought I would never be able to leave a patient at the hospital at the end of shift, never walk out when this trying chapter in someone’s life story wasn’t yet fully told. In nursing school, though, they teach us how to leave.

Clinical groups meet on the floor together at the start of shift and leave together at the end. We don’t call the hospital after we’ve left to ask how so-and-so did. We give our all while we’re there and then we go. This isn’t indifference but practicality. Nurses are the hospital’s mechanics, its sprockets and gears. The idea is, from one shift to another, a seamless blanket of nursing care is provided to every patient. For that model to work we have to make what happened that day—the good and the bad—as separate from ourselves as the uniforms we take off at shift’s end.

And sometimes we don’t know how a patient’s story ends. People are “lost to follow up,” move, get treatment elsewhere, never again come to the hospital because they’re transferred to outpatient care. I often don’t know what happens to patients I’ve laughed with, cried with, gone toe-to-toe with a doc for, or talked at length with family members about.

Pedal, breathe. I’m going uphill now over a short stretch of road paved with stones. Bumpity, bumpity. My hands shake on the handlebars but I go this way to avoid the smoothly paved but very steep road one block over.

Now Mr. Hampton’s surprising, inexplicable recovery comes back to me. What if it continued? What if, after his dose of Rituxan is complete, he is completely healthy?

What if Mr. Hampton, his son Trace, and Trace’s friend, Stephen, decide to begin a new life somewhere else? Where would that be? Spin the globe. Find some place warm, cheap. Could be an island, but the important thing is to be safe, hidden from disease and out of reach of modern medicine because he won’t be needing it. It’s my fantasy, creating for Mr. Hampton a new clean, well-lighted place.

The paving stones give way to asphalt and I turn right onto the last long climb to my house. The hill doesn’t look that tough but it’s a deceptively steady rise. This is where I start to sweat despite the winter’s cold, give up on the idea of cadence, and just push slowly, breathing hard.

I let myself imagine Mr. Hampton and his family in the rain forest. They would build a house on a raised platform, fish for food, watch butterflies, listen to multi-colored birds squawk and scold, and laugh together. It will be warm but not too humid. If rain comes, it will be gentle. Time will stop.

And then I’m home. I go in through the basement so I can put away my bike. The dog comes down to greet me, sniffing and wagging her tail. Her dark coat shines in the basement’s bare bulb lights. Upstairs I hear the clink of silverware, some news program on the radio. My husband will be finishing cooking dinner as he mulls current events or thinks about physics. The days I work, they wait on dinner so we all eat together.

I take off my helmet, gloves, unzip my Gore-tex. Home. I’m home again. The steps feel steeper than they did this morning, or maybe there are more of them. Finally at the top I reach up, pulling on the basement door, the old metal knob that’s loose and rattly the way basement doorknobs should be.

Light hits me first and then more sounds. Not the bright fluorescent light of the hospital, but the soft incandescent lights of home. And not the beeps and rings and dings of the floor, but “Mom’s home! Let’s eat!” and the sound of my son practicing his violin.

“Do we need knives?” My daughters are setting the table.

“You made it,” my husband says, looking up from the stove, as if I have come a long way just to get home for dinner. And maybe I have.

I turn off the radio and we eat: black beans, white rice, orange cheddar cheese, green broccoli, a glass of red wine. The meal is good and the wine gives me a start on feeling peaceful, but I’m not quite there yet.

The kids talk about school and I have no idea what they’re saying. I’m thinking about Sheila. Sheila meeting with anesthesia. Sheila heading into the OR.

My husband plops a clear plastic container of mini peanut-butter cups on the table when we’re done and I think of Dorothy’s glass candy dish. I love that William Carlos Williams poem “So much depends / upon / a red wheel / barrow / glazed with rain / water / beside the white / chickens.” A few of my fellow PhD students in graduate school derided that poem as a minimalist pretension to art written by a doctor pretending he was a poet. But those people never knew Dorothy or her candy dish, the pull it exerted on the staff, the way it told us something important about who she really was: a mother, generous, kind, with a determination to get what she wanted out of life.

After dinner I wash away memories in the shower, throw my dirty scrubs down the laundry chute, put on my pajamas. The shift is over. I settle into the threadbare couch in our family room and do the
New York Times
crossword puzzle in pen. Using ink is not about pride but aesthetics. Pencils scratch on newsprint and it’s hard to see the traces of lead against the gray of the paper. The pen, in contrast, feels smooth and the strong capital letters I make stand out in the grid of squares.

The puzzle soothes me. I read a clue, “How knights roam,” then fill in “ERRANTLY.” Clever. Ordered. I may not be able to finish the whole thing, but that’s only because some tricky logic, an extravagant pun, or the name of a European river or a small Oklahoma town eludes me. There is no fundamental deficiency in me that leads to failure to complete the grid, no lack of vigilance, or empathy, or efficiency, or ability to know that someone’s belly hurts because part of her gut is torn, ripped open. No one will suffer if I never finish another crossword puzzle, if I Google all the answers and then lie about it, if I toss it into the recycling half done, without a backward glance.

I look up from the puzzle and my daughters are standing in front of me. Freshly showered themselves, with wet hair they refuse to brush, they call out to me, “Good night, Mom.”

“Wait! Wait!” I say, startled out of my preoccupation with the puzzle and the day. “I have to hug you.” It’s almost exactly what I said to Sheila and I’m relieved that here with my own children there’s so much less at stake.

One daughter extends her index finger and touches it to mine—the only version of a hug she allows me. The other, with only slight resistance, lets me slide an arm around her waist and squeeze. “Goodnight!” they chorus.

“Do you want me to come up and tuck you in?”

“No.” Sometimes they say yes and I follow them up to their lair on the third floor of our house and then they tell me stories: the plot of a book one of them is reading, or what’s up with Ultimate Frisbee, or this inexplicable thing Mr. So-and-So did in such-and-such class, or how funny Mrs. X is. Sometimes we even have girl talk about a lesson from health class or their surprisingly detailed middle-school sex education program.

Not tonight, though, and I don’t fight it. Much as I hate to admit it I am pretty close to all used up.

My son, at fourteen an official teenager and biologically driven to stay up late, hauls his backpack into the family room. Then he roots around in it like a squirrel trying to find just the right nut from his store.

“Found it!” he says, extracting the piece of paper he needs.

“What is that?”

“Questions for U.S. History.” I don’t know if they’re learning about the Revolutionary War, the Industrial Revolution, or the Underground Railroad.

“What are you studying now?”

“Stuff,” he says, taking the piece of paper over to the computer and logging on to the course website.

“You know you need to sleep, right?”

“Uh-huh.” He’s reading online now.

“Well, OK.” I walk over and give his shoulder a pat. “Good night. Don’t stay up too late.”

“Good night.” he says, eagerly reading. Whatever he’s studying, it has captured his imagination.

I go to brush my teeth and something about the ordinariness of that, the habit of it makes me think of Ray, Irving, and Candace, all pulled out of their regular lives and forced to confront the potentially deadly realities that accompany cancer.

“You going to bed?” It’s my husband, come to check on me.

“Yuppers.”

“You OK?”

I incline my head. “Why?”

“I don’t know—you seem more out of it than you usually are after a shift.”

I breathe in and let it out. “Today made no sense. My one patient I thought was fine wasn’t at all, and my other patient, who I thought would maybe die from his treatment, did fantastically well.”

“Aren’t a lot of days like that? Isn’t that why it’s a hard job?”

“Are they?” Do I always live with this level of uncertainty and have never realized it? “I guess you’re right.” I tell him.

He places his index finger between my eyebrows and barely touches the worry wrinkle that I know has appeared. “Can you sleep?”

“I’ll see,” I tell him.

“ ’Cause I’m gonna stay up for a while . . .”

“That’s fine. I’ll try to sleep.” He nods and leaves, turning out the light. I place my head on the pillow and then get up to look at the clock. It’s 10:30 p.m. and I need to get up at 6:00 a.m. tomorrow. Sheila is God-knows-where in the hospital.

Sheila, Sheila, Sheila.

I rarely fall asleep easily after a shift, especially if I’m working the next one, but now quiescence comes, pushing at the edges of my mind. My breath deepens and I feel the calm of oblivion begin to cover me. I will do this all again tomorrow and then there will be another shift and another and another. To be in the eternal present of illness and unease, never knowing the future. It’s where my patients live so I, ever hopeful, live there with them.

AFTERWORD

Knowing the Future

Peter didn’t finish operating on Sheila until 2 a.m. and he told me her abdomen was full of stool. Shit. She had a belly full of shit. Peter and his team cut out the part of her colon that was dead and connected up the end of her living bowel to an outlet—a hole—in the wall of her abdomen. For the near future, and maybe for the rest of her life, she will defecate into a bag that attaches to the outside of her belly. It’s called a colostomy and while it may sound distasteful or embarrassing, patients adapt. Even more important, they live.

I went down to the surgical ICU a couple times after Sheila’s operation. Once I talked to her sister, the second time her nurse, but never to Sheila, who wasn’t doing well. And then I got sick myself with a sinus infection and bronchitis. When I went back to work I was weak and had a hacking cough you could hear up and down the entire floor.

After a few weeks of dragging through my shifts I finally felt more or less like myself and sought out Sheila. She was on our inpatient surgery floor and I found time late one afternoon to stop by. But she was gone. The nurse said she’d left just a couple hours before—finally discharged after a month in the hospital.

I kept saying “What? She’s gone?”

And Sheila’s nurse kept saying, “It’s really great you came down to see her. Really really great.”

It didn’t feel great but it didn’t feel bad, either. In the end she did all right.

Beth’s daughter made it home from Afghanistan OK, too. Apparently she took the world’s longest shower once she arrived in the U.S. and then cut off her hair, so penetrating had been the Afghani dust. She visited Pittsburgh and went shopping with Beth, sat and talked outside while warding off fall’s chill with their fire pit, got a chance to live without being under threat. “I never thought my daughter would end up a soldier,” Beth told me one day at work, “but that’s who she is.”

Ray, Candace, and Irving all made it out of the hospital cancer-free. Their lives will continue to spool out as they each weave the fabric of their own unique existence.

Irving’s story is the simplest. Whether by nature or as the result of his many troubles, Irving asked little of life and in that he was adequately answered. The group home kept him safe. The rocking chairs on the front porch were comfortable and the voices in his head weren’t too intrusive or demanding. From him I learned that sometimes when we strive less we end up with more of what we actually need.

Ray’s brother’s transplanted stem cells brought Ray back from the underworld. His journey was not as bad as it is for some though certainly rough enough. His skin didn’t slough off, he wasn’t cursed with voluminous black diarrhea, and despite a lifetime of enjoyably heavy drinking, his liver after treatment was none the worse for wear. He did succumb to infections, high fevers, breathing trouble, blood in his urine, but he came out whole.

His goal now, his mantra, is to stay out of the hospital unless he’s critically ill, as defined by him. It’s worked so far. He’s returned to fighting fires. He plays in his band, loves his wife, is an involved father. The basics of life seem ordinary only if you’ve never faced losing them. His youth and health gave him only a slim advantage against his disease. He bet on his life and won.

And Candace. Unkind people might say that Candace sailed through her treatment because she was too mean for even cancer to hurt her. If only it were that easy. If only the right kind of personality could keep cells from duplicating out of control and clogging up veins and arteries and organs, forming tumors that grow their own blood supply and steal food from healthy tissue. If an optimist’s cancer goes into remission we say that’s the power of positive thinking. If it’s someone like Candace we credit her survival to sheer cussedness.

There may be psychology involved, but it’s never just that, and luck plays a big role, too. There’s genetic luck always, sometimes at a level of biochemical processes that science does not yet understand. There’s dumb luck, referring to when the cancer is detected, when treatment begins, and whether there’s a match for transplant if a matched transplant (like Ray’s) is what’s needed. There’s economic luck, too. Does the patient have good insurance that will pay for the best treatment available? Is she wealthy enough to cover a multitude of out-of-pocket costs without breaking the bank? And there’s geographic luck as well. New Yorkers with cancer have more options than do South Dakotans or patients from Wyoming simply because they have a wider pool of nearby doctors and hospitals to choose from.

Candace may have saved her own life with her Clorox wipes and her obsessive hand washing. Evidence tells us that such attention to hygienic detail is relevant to what we euphemistically call “good outcomes,” so it should not be described as pain-in-the-ass behavior but important work done by an “empowered patient,” even though it’s the kind of patient contribution that can make people who work in hospitals uncomfortable.

Despite all our good wishes Dorothy came back to the hospital several months later to die. Do we need the details? In the end she didn’t even know herself much less anyone else. Her husband was there, taciturn, uncomfortably wedged into a too-small chair. Their daughter, whom I’d never met, but who had fielded many an annoyed and anguished phone call from Dorothy, was there, too. She looked like Dorothy with the same squat build except pale where Dorothy was dark. She talked to me about how Dorothy could be stubborn and demanding, and then her voice would start to shake and her eyes would fill with tears and she couldn’t speak at all.

Dorothy didn’t make it but her husband lived on, her daughter, too, and her granddaughter. Like it or not, this is the way life works; these are the terms we’re all given, whether we accept them philosophically or resist with everything we’ve got.

I am sorry to report that after his treatment finished, Mr. Hampton did not go to the rain forest, he did not end his days listening to brightly colored birds and watching delicately winged butterflies. A few weeks after I was last his nurse I got to the hospital and learned he was checked in, too. I didn’t see him—just his son, who had that irresistible smile, even though lines had crept onto his face. Around his eyes small creases gave away his stress and his look had an intensity that wasn’t there before. Mr. Hampton’s room was in the front part of the floor and my patients were in the very back.

“I thought you left,” I called wishfully to Trace as I passed him in the hallway.

“We did, but then we came back,” he told me, keeping his mouth straight and flat. And then I knew. His father had not had a miraculous recovery during his last hospital admission. Whatever happened to make him so much better while he slowly got Rituxan didn’t last, which, sadly, was the more likely course of events for someone his age with his particular disease.

Trace was walking quickly, so I couldn’t get more details then, but later on when I had the chance, I didn’t ask Mr. Hampton’s nurse how he was doing. I finished my shift in ignorance of his real fate and kept myself that way on purpose. In my mind he was living in a tropical paradise, eating freshly caught fish cooked just enough over an open flame. While that shift lasted I let myself believe that once I pushed Mr. Hampton’s rock to the top of the health care hill it stayed there. Not true, I knew, but for those twelve hours I chose hope over hard reality.

Finally, a solid two years later at least, I ran into the owlish intern in my local coffee shop. I didn’t remember his name and I’m pretty sure he didn’t remember mine, and yet we knew each other right away. It turns out that we’re neighbors.

He had become a fellow, not in oncology, and I debated with myself whether to speak up, to tell him about this book, and then I did. I told him he had said something so wise to me, something that shaped my thinking about the entire project: “If we could know the future our jobs would be a lot easier.”

“That was probably something I said half asleep,” he told me, not acting embarrassed or falsely modest, but being scrupulously honest, the way he had been so careful as an intern. He doesn’t remember saying something that changed my life, but I do, and seeing him I felt the import of the entire shift again, for Mr. Hampton and for Sheila, for Candace, Dorothy, and Irving. I felt infinity in the palm of my hand and eternity over the next twelve very busy hours.