The Shift: One Nurse, Twelve Hours, Four Patients' Lives (4 page)

Looking up from my computer, I see Ray Mason’s wife, Liz, farther down the hall, taking clean linens out of the cupboard. We’re not supposed to let family members do this. It’s considered an infection risk, which matters since so many of our patients are immune-suppressed, but some people can’t tolerate feeling useless—they like to do for themselves—so I don’t act as an enforcer. I’m here to care for people, not make them follow the rules, especially considering how often the rules around here change.

I walk over to Liz and we hug silently. I want to say something helpful, comforting, but she and I both know there’s nothing good to say.

“It sucks, huh?” She nods and her eyes look wet. “How are you doing?”

She shrugs. “He’s fine,” she says, her voice lifting up at the end, implying that she’s not. She hugs the sheets, blankets, and pillowcases to her chest and shakes her head. “He needs these,” she says.

“Are you here today?” I ask.

“No, I . . . ” she stops and her eyes squinch up. “My office says if I don’t come in I could lose my job.”

“But . . . they were so supportive before.”

“Yeah,” she inclines her head, compresses her lips. “I’m sure it will work out eventually.” I think about her clients. She’s a therapist who specializes in obsessive behaviors, so the people in her care are in need, too. But can she help them if she’s focused on her husband, back in the hospital, once again fighting cancer? That’s the hard thing about empathy—even people with an abundance of it can run out.

I grab her arm, wishing I weren’t so powerless to help. Relapse typically leads to a stem cell transplant—Ray will need cells donated by someone else—and the choice is pretty much transplant or death, so almost everyone who can chooses transplant, but it’s not an easy road. “In the midst of life we are in death,” the Episcopal
Book of Common Prayer
says, reminding us that life is a continuum and we’re all mortal. In my work with cancer patients I have found that the specter of death powerfully connects us to life. Maybe if I had Ray today I would have felt newly enlightened about my work as an oncology nurse, but it wasn’t meant to be. “I’ll come by,” I say. She nods and we each head back to our own corner of the floor.

I check my watch: 8:20. I have time to look up antiphospholipid antibody syndrome. Google is where I would normally start and I can do that if I don’t run into trouble with the filters on the computers. Nurses’ access to online material is restricted, typically without notice. So one day I was denied admission to our online medical library. Another time I was blocked from chemoregimens.com, a website we use to double-check treatment protocols. It’s frustrating to be restricted from knowledge, but it’s humiliating to be trusted with the daily care of people who have life-threatening conditions and not be trusted with the level of Internet access required to learn about their problems. I can push doxorubicin, a drug that will burn skin and can damage hearts, into a patient’s vein through an IV, but I’m not mature enough to use Google without filters designed for children?

We’re told the filters were put in place to keep nurses from using social websites at work and in general to keep nurses from surfing the Web when we should be working. I don’t honestly know if that’s an issue. Maybe it is. All I can say is that no nurse I know wastes time on the Internet when there’s work to be done.

Today, though, I’m allowed access to the information I need: antiphospholipid antibody syndrome is an autoimmune disease, like Lupus. It can occur secondary to an existing autoimmune disorder, but for other people (and my patient Sheila Field seems to be one of them) it arises on its own. Patients with this syndrome generate a mistaken immune response to crucial components of what’s called the clotting cascade. Short version: their blood clots too easily.

It’s essential to have blood clot when we’re cut, saving our lives, but a blood clot inside the body, in an artery or vein where we need it to flow continuously, is damaging and potentially deadly. During a heart attack a clot blocks the blood supply to the heart muscle itself, causing part of the heart to die due to an absence of blood. Because cell death hurts, patients having heart attacks complain of crushing chest pain. The pain is the scream of all those cardiac cells dying.

I don’t know if Sheila’s heart or any other part of her body is at risk from her illness. I only learned about her stomach pain from Andie, so if that’s part of the complete clinical picture, I’m not sure how it fits in. Judging by the paucity of the notes on her case it seems as though no one else has a clear picture of her situation either. I frown. It looks as if I’ll have to wait until rounds to learn more.

I am clicking around more computer screens, writing down what I need, when the door to Richard Hampton’s room opens and the intern (I think) walks out. His round glasses with thick frames make him appear owlish and though he’s young, his hair is already thinning on top, adding to the impression that he’s old before his time.

“Hey,” I say quietly, giving a small wave.

“Are you his nurse?” he asks. His voice is soft and low and he bends in toward me. He looks so serious I can’t imagine him smiling, but I like the intensity since I can be intense at work myself.

I nod at him, say my name.

He nods back, and then speaks again, very quietly and calmly. “So, it looks like we’re going to give him Rituxan today,” he says.

“Rituxan?” I ask, raising my eyebrows.

His features collapse and his face goes blank, a mask. “We’ll discuss it on rounds, but the attending wants him to get Rituxan.”

He grimaces, then walks away, but I feel my stomach tightening. Rituxan is a first-line treatment for certain lymphomas. It’s not chemotherapy per se, but a biological response modifier, a drug that activates the patient’s own immune system to kill cancer cells. For many people it’s safe, but it has killed patients while being used correctly. Too much of an immune response can make a person very, very sick rather than well. In fact, that’s often how influenza kills—it’s not the virus itself that’s deadly, but the overwhelming immune response it provokes.

Because of its potential dangers, Rituxan comes with a label reserved for particularly toxic drugs called a Black Box warning. That is, in addition to listing all possible side effects of the drug the information with Rituxan includes the most serious reactions inside a literal box drawn with thick, black lines. The Black Box warning for Rituxan includes death.

Bad diseases seem to require bad drugs and Rituxan is hardly the scariest of the treatments we use against cancer. Doctors even consider it “well-tolerated” and comparatively benign, because once it has been infused there are no long-term side effects. That allows it to be safely prescribed to seventy- and eighty-year-old patients who likely wouldn’t survive the toxicities of more standard chemotherapies. If anyone asked me I would recommend Rituxan because it works for lymphoma patients, but nurses dislike giving it because infusing the drug doesn’t always go well and we’re responsible for keeping patients safe.

I watch the intern walk down the hall, slightly stooped, as if he bears the weight of the world on his shoulders. But it is I who will give Mr. Hampton his Rituxan, who will monitor him for serious changes in blood pressure, heart rate, and breathing, who will need to call this intern, or his replacement, if the treatment intended to heal ends up hurting instead. The intern doesn’t know this drug as well as I do. The intern won’t be the person hooking it up to Mr. Hampton’s IV, watching it run down the plastic tubing directly into his vein, knowing that if things go badly it will be a result of the work of my own hands. And now I’m nervous. From what I’ve heard about Mr. Hampton’s frailty, I’m worried he’ll be particularly vulnerable to the rigors of Rituxan, that giving him this drug is a really bad idea. Before I become too committed to this line of thought, though, I decide to see Mr. Hampton for myself.

His room is dark, with just a hint of sun lightening the edges of the window blinds. He’s on three liters of oxygen and it makes a subtle whistling sound that’s not unpleasant.

“Mr. Hampton.” I gently shake his shoulder to check for myself how responsive he is when awake. I would rather not wake him up, but there’s no other way to find out and it’s important. “I’m Theresa. I’m your nurse today.”

He opens his eyes and looks at me blankly. “Do you know where you are?” It’s a standard question for the confused. He blinks, but says nothing, then lies back on the bed while his eyes slowly shut.

Being awakened from a deep sleep would only make any confusion worse, but I’ve been told he’s slept most of the time he’s been in the hospital. That’s not normal. He’s thin and his face is lined and his white hair stands up in a peak over his brow. It is a shock of hair.

I decide to let him sleep and leave, shutting the door quietly behind me.

Then, worried about what the Rituxan might do to this old man, I start to blame the doctor for clinical myopia, for focusing on the need to treat without also considering the possibility of harm. Mr. Hampton is weak and breathing with difficulty. Can he tolerate this toxic drug?

The attending physician on this case is one of those docs who never discusses his decisions with anyone; he decides and the rest of us—interns and nurses both—do as he says. He could be right in ordering Rituxan for Mr. Hampton; that’s not my call. For some patients it is a killing drug, but it’s much better at getting rid of cancer cells than hurting people. All I want is a minute, maybe two, to confirm that the treatment isn’t more harmful than curative, or if it is, that the patient or someone who can speak for him deems the risk worth it.

“Work is love made visible. And what is it to work with love?” the poet Khalil Gibran wrote. In the hospital, working with love sometimes requires putting people in danger. For Richard Hampton, my patient now destined for Rituxan, old, frail, and short of breath, we will try to save him by administering a drug that could end his life. That’s a surprising kind of love, but in here it’s very real.

For myself I wonder, will I kill this patient today or heal him? I’d like to have an idea of the specific degree of risk involved instead of relying on this queasy feeling in my gut. I look at my watch. It’s 8:35. Even without talking it over, I’ll find out soon enough if my gut is right.

CHAPTER 3

Hitting the Floor

Susie, the newbie, walks by me holding up a clear plastic bag filled with a thick, orangey fluid. “Have time to check platelets?” She’s bright-eyed, overtly friendly, and those characteristics, combined with her blond curls, give her a Shirley Temple vibe. But the hospital is not the good ship
Lollipop
, not even close.

I nod. “Platelets so early in the morning?” Blood products usually don’t get ordered until after the doctors’ finish rounds.

We start to walk down the hall, toward her pod. “He’s getting a line placed and they want him above fifty.”

“Listen to you,” I say, “slingin’ the lingo.” She smiles. Her patient needs an intravenous line surgically inserted and the surgeon putting in the line wants the patient’s platelet count—platelets are the cells that cause blood to clot—to be 50,000 or greater. Otherwise there’s a risk of bleeding. A normal number of platelets is 150,000 to 300,000, but in the hospital people will do OK with just 10,000, which is kind of unbelievable to me, but 10,000 platelets isn’t enough if we’re deliberately cutting into someone.

Susie’s patient has the opposite problem from my patient Sheila. Sheila’s blood clots when it shouldn’t; because this patient’s platelet count has been greatly reduced by chemotherapy, he probably won’t clot when he needs to. Imagine a garden hose with no shut-off valve, except it’s not water that can’t be stopped from flowing out; it’s human blood trickling from a vein. That’s what life is like for hemophiliacs, and it is one of the dangers of cancer treatment. The platelet count will return to normal once treatment stops, but until that happens, giving patients platelets intravenously is the only way to replenish their supply. When we transfuse platelets two nurses first verify that the identification codes on the blood product and the patient match. That’s what’s required when “checking platelets.”

We get to Susie’s medcart and an older woman with short gray hair and a friendly face peers out of the partially opened door to one of the rooms. “Susie, do you mind coming to disconnect him? You know how he is about getting his morning shower.”

Susie bites her lip. She needs to get the platelets in before her patient getting the IV line is called to surgery.

“I’ll do that,” I tell her. “You type in the numbers for the platelets and we’ll check them after I’ve disconnected him from his IV.”

“Really?”

“Sure.”

“OK, thanks.” She pulls up the right screen on our electronic record system and I head into the first patient’s room, pulling out a wrapped saline syringe while I go.

“Hi, I’m Theresa. I’m helping Susie out.” I squirt Purell from the dispenser on the wall into my hands and rub them together until it evaporates. Then I grab a pair of latex gloves and pull them on. Purell then gloves is the procedure we’re supposed to follow and it’s a rule I try to obey.

The gray-haired woman nods to me. “You girls are so busy I hate to ask for anything, but he’s just a bear without his morning shower.” This last bit she says in a mock whisper, hiding her mouth behind an exaggeratedly raised hand.

The gray-haired man in the bed speaks up now. “I’m a bear, am I? Well, you’re a tiger without your morning coffee.”

The woman laughs. “That’s true, honey, but I can go and get my coffee myself. I don’t have to be unhooked from this stupid machine.”

“Ain’t that the truth,” he says. He’s moved to the edge of the bed and I bend over his chest to follow his IV line to the red-tipped channel of his Hickman catheter, which protrudes from his right upper chest. The Hickman has three separate tube-like openings called lumens that hang down, so we call this a triple-lumen catheter. I stop his pump and then unscrew the IV from the Hickman, carefully putting a sterile red plastic cap that I have already taken out of my pocket and unwrapped on the end of the IV. Then I rub an alcohol wipe across the top of the lumen and push in the entire contents of the saline flush I also just took out of its wrapper. This is standard procedure to keep the line free of germs and flowing smoothly.

“Do you need me to tape that up for you?” I ask. Our IV lines are covered with bandages, and we protect them with water-repellant plastic covers when patients take showers. A wet dressing offers a prime breeding ground for unwanted bacteria.

“Oh, no,” the woman says. “We’ve developed our own system using Press ’n Seal.”

“It’s amazing I have any hair left on my chest!” the husband calls out to me as I turn to leave, but he’s laughing as his wife approaches him with the plastic wrap.

Welcome to twenty-four-hour visiting. Family members sleep over, share meals, tease, bicker, joke, and sometimes evolve their own ways of doing things that make their lives, and ours, easier.

Susie’s not in the hallway, but I see her in the other patient’s room, helping him onto a stretcher that a technician from the operating room is steering. The technician’s dressed in that blue-gray the OR staff wear, her hair protected by a filmy cover.

I poke my head in. “What’s going on?”

“They’re ready for him,” Susie says, “Said to send the platelets down with the tech,” she nods toward the woman holding the stretcher, “and they’ll hang them.” That is, the OR nurses will begin and monitor the platelet transfusion. “He got two bags already overnight so he should be good.” She says “good” definitively and gives her patient an encouraging smile.

“Works for me. See ya.”

I get back to my pod and the light above Sheila’s doorway turns on. I also hear the chime that goes with it. At this point in the shift it sounds soothing, melodic. By the end of the day I will be desperate to silence that ringing. Now, though, it’s a gentle calling and I feel fresh, ready to be needed.

Sheila’s my puzzle and I want to understand her disease better. The human clotting mechanism is an impressively complex series of chemical processes appropriately called a cascade. Something as simple as a paper cut activates two unique pathways of proteins called factors, which trigger a chemical called prothrombin, which becomes thrombin, and then activates fibrinogen, which turns into fibrin. Fibrin threads form the physical structure of a blood clot by giving platelets something to adhere to and thereby stop active bleeding. An error along any of these pathways can cause poor clotting or, as with Sheila, blood that clots too easily. It’s one of those proverbial “for want of a nail” situations, where the lack of a nail for a horse’s shoe leads to an undelivered message, a lost battle, and a vanquished kingdom. Every step of the human clotting cascade has to work correctly for the patient’s blood to coagulate the way it should.

I’m sure Sheila’s exhausted from her middle-of-the-night ambulance ride, so if she’s turned on the call light this early in the morning it must be important.

Each pod on the floor has four rooms and the door to every room is usually kept shut to maintain a positive air pressure that stops any hallway germs from accidentally drifting inside and making one of our immune-suppressed patients sick; if the doors stay open for too long they trigger an alarm that penetrates like an aural jackhammer. The closed doors keep my patients safe from foreign contaminants, but at the same time keep me from quickly looking in and physically seeing how they’re doing.

I push on Sheila’s heavy door, trying to be quiet with the metal latch even though I know she couldn’t have put on the call light if she weren’t already awake. Her room is dark and she’s buried—head and all—under a double layer of blankets. “Sheila? I’m Theresa, your nurse today.” A hand edges out from beneath the blankets and I walk up to the bed after once again disinfecting my hands with Purell and grabbing a pair of gloves.

“Hurts.” she says, in a high-pitched voice, pinched at the end, the volume muffled by her blankets.

“Your belly?”

“Hurts,” she says again, and I see a nodding motion under the covers.

“I’ll get you something for the pain,” I tell her. That is one of my favorite hospital euphemisms: I’ll get you
something
for the pain. Perhaps a mug of hot cocoa, a plush toy bunny with floppy ears, a warm compress delivered with a cool and gentle hand. No,
something
in this case refers to narcotics: Vicodin, oxycodone, Dilaudid, morphine. We give out these drugs like candy on Halloween; our patients need them.

Outside Sheila’s room I run into the oncology fellow—an MD specializing in cancer, on his way to becoming an oncology attending—who’s getting ready to go in himself. This fellow is kind and quite smart but hesitates over even the smallest decisions. I’m never sure if that’s because he lacks confidence, or because his English is poor, or because he is genuinely interested in having a nurse’s input. Let’s hope it’s reason number three.

“Yong Sun,” I say, and get his wide friendly smile that makes his eyes crinkle up. “She’s having abdominal pain—”

“Ahh, right,” he interrupts. “Hmmmmm.” He purses his lips. “What you think?”

“Not sure. But she doesn’t have anything ordered for pain. You OK with Dilaudid IV?”

“Ah. Hmmm. Yes. One-time dose of Dilaudid, 1 mg—you will put it in?”

“Yes!” I say, glad because now Sheila won’t have to wait for the fellow to enter the order into the computer himself. I head down the hallway to the locked narcotics room, where I punch in the code, then key in my individual password to our Pyxis machine: the multi-drawer device that dispenses opioids and other pain medications. Rushing back, I stop and take the time to type the drug order into the computer. Paperwork delayed can end up forgotten and this is a narc. I need to do it right so it doesn’t look like I’m stealing drugs. I record that an MD ordered the drug and that Sheila got the correct dose on time.

Done, I grab the plastic vial that contains the Dilaudid and twist off the top. Next I slide out the glass vial of drug and flip off the plastic cover. I tear open an alcohol wipe and smear it across the top of the vial, then stick in a needled syringe, turn the vial upside down, and pull out the ordered dose of Dilaudid: 1 mg/1 ml. Good. Then I slide the plastic off one of my 10 ml syringes of saline, enjoying the satisfying “pop” sound it makes, and inject it into the 1 ml of narcotic. Most patients aren’t chronic users of opioids and they don’t like the heady, dizzy feeling that comes from getting the drug straight, so I always dilute it in saline for their comfort.

In the room I notice that the fellow is already gone. Maybe he couldn’t get Sheila to talk much. She seemed in so much pain. I unwrap another syringe of saline and rub alcohol over the lowest hub—or opening—on Sheila’s IV tubing. She’s getting the blood thinner Argatroban and it’s safer not to push the Dilaudid through that drug, so I pause her pump, pinch the tubing above the Y-site, and push in 10 ml of normal saline to clear Argatroban out of the stretch of IV line immediately below the hub. Then I clean the connector with alcohol again and push in the diluted Dilaudid. After that I use another alcohol wipe and push in another 10 ml syringe of saline. Finally I release the tubing, smooth it out, and restart the pump. Sheila’s Argatroban returns to its slow drip.

I lower my face to where her head is below the blankets. “That should work pretty quickly,” I tell her. “So let me know if it doesn’t.”

I pull back just a little of the blanket and put the stethoscope on her back so I can listen to her lungs. “I’m giving you a little bit of a check,” I tell her, measuring her heart rate at her wrist. I look at her feet for any swelling (which is a way to evaluate kidney and heart function), then cover her back up. I need to listen to her gut, but don’t want to ask her to move until the Dilaudid’s had time to work.

“I’ll be back,” I tell her, making a mental note to remember.

I don’t linger. This is the part of the day when it’s easiest to get behind. I’ll check these systems on every patient, plus verify the change-the-date sticker on the IV tubing and check dates on the dressings that cover central lines. We want to keep patients from getting infections in the hospital, and that’s why I’m obsessive about Purell and wearing gloves and always using alcohol wipes for IVs, too.

I gather together Mr. Hampton’s morning pills and go into his room. He’s lying in bed blinking himself awake, trying to rise to a sitting position, but he can’t quite do it.

“Hi! I’m Theresa, your nurse today. I’ve got your morning pills,” I tell him, holding up the individual pill packets with my right hand.

He bobs his head, sort of like a nod. “Do you want to sit up in bed?” I ask him. “I can help you.”

He shakes his head: no. “Want to get some more sleep?” He nods again. I guess he decided that sitting up was too much effort.

“OK, let me just get in a listen,” I tell him. I don’t hear anything obvious in his lungs and the chart isn’t clear about why he needs oxygen, just that he does. I hope he sounds all right. In the interests of infection control every patient gets his own disposable stethoscope and they don’t work too well. We call them Fisher-Price stethoscopes. Not only are they bright yellow and hard plastic, making them look like a toy from a child’s doctor kit, the sound quality is also similar.

I go through the rest of my routine, evaluating his heartbeat, belly, and feet. Then I check his IV line, a Peripherally Inserted Central Catheter or PICC, in his left upper arm, by rubbing alcohol pads on the end of each his two lumens, then attaching a 10 ml syringe of saline to each, injecting just a bit before I pull back on the stopper of the syringe, looking for the flash of blood that tells me the line is in the right place.

It’s hard to imagine that the tip of a thin intravenous line could get dislodged inside a person’s body, but it happens. I even had one patient who accidentally pulled his own PICC line out from his arm in the middle of the night without realizing it. Mr. Hampton’s flushes smoothly and the flash of blood comes with little effort from me. I’ll need to see that blood in the line immediately before he gets the Rituxan so it’s efficient to verify that right now at least the line is working fine.

As force from the syringe makes blood swirl into the saline I stop and watch it billow like silk. Red. Beautiful. I never gave blood too much thought before I took this job, but now I revere it. Blood is the liquid of life. Red cells give oxygen, platelets form clots, and white cells protect us from infection. Without healthy blood humans cannot live. Seems obvious, I know, but working with cancer patients has made me unexpectedly respectful of this life force. I quickly take Mr. Hampton’s pills out of their individual packages and leave them by the side of his bed in a pill cup. I’m not supposed to do that, but he’s fallen back asleep already and I’m not sure I can get him awake enough to swallow them. In school they call this nursing judgment, just like my decision to wait to listen to Sheila’s belly. At this moment neither of these things seems crucial. Of course, later either one might turn out to be.