The Shift: One Nurse, Twelve Hours, Four Patients' Lives (6 page)

I’ve been discreetly charting my morning assessment on Dorothy on my medcart computer while listening to Lucy, and now I click to the screen with lab results to check if Dorothy’s ANC—her absolute neutrophil count—has been posted by the lab. An ANC reliably above 500 indicates that Dorothy has enough of an immune system to go home and it’s important to learn that number right now. Once again Sheila has to wait.

“. . . ANC wasn’t back yet . . . ,” Lucy is saying, but after seeing that the lab has just posted the ANC. I interrupt.

“It’s here!” I say, “And it’s . . . Whoa, it’s 850!”

“It’s 850?” the attending says, “Well, let’s go tell her!” He swings his arm holding his papers in an arc toward Dorothy’s door, as if he’s sweeping us all into the room. We happily follow en masse. Moments like this are why we’re all here.

“Your ANC is 850!” the attending announces and Dorothy claps her hands in her bed. If she had heartburn this morning it seems to be OK now. Or maybe she’s so excited about returning home that she doesn’t care.

“So that means,” the attending says, “that someone has to do the neutrophil dance.” He looks at me, “Theresa! Do the neutrophil dance.”

Startled, I look around the room. I’ve heard of the neutrophil dance, but I thought it was a joke, hospital legend, not an actual thing that real people actually perform. Is the attending physician trying to make me look foolish?

Everyone’s looking at me, including Dorothy, and I realize there are worse things than embarrassing myself for her sake, a lot worse. Recalling movements from ballet classes of years past I wave my arms around above my head, more or less fluidly, and shimmy my hips, feeling pretty ridiculous, but the whole room cheers, and Dorothy once again claps her hands like a child. This is the Dorothy I’m used to—pleasant and forbearing. I’m glad this news came when it did; once Dorothy is home she can take her Prilosec whenever she wants.

She looks at me and laughs and I smile back.

“So you get to go home,” the attending says. “Today, if you like.” He gets a sly look on his face, “Or you can stay another day if you’d rather.”

“Oh, no,” she answers back, her knit cap shaking emphatically “Today is just fine. I’ll call my husband and start packing.”

A chuckle goes around the room. The attending points at her now, leaning his body forward. “Lucy and Theresa will get you out of here,” he says, slicing his right palm across his left in a quick motion. “Lickety-split.”

“Well, not too fast. My husband has to get here.”

“Don’t worry, Dorothy,” I reassure her, “Nothing happens too fast in the hospital if it involves paperwork.”

“Oh, that’s right. Well, I’ll get started anyway,” she says. “As soon as you all leave.” We laugh again and then troop out and that’s it, an ordinary day shot through with the crystalline illumination of earned success, a gem-like moment. There’s paperwork to do and it will all take longer than it should, but I’m contented. Dorothy’s month and a half on the floor accomplished what we hoped, and she is finally going home.

Her team moves down the hall to its next patient, and I see the owlish intern for Mr. Hampton trailing behind his own attending physician and the rest of that group, heading in the opposite direction up the hall. Damn! I missed rounds on Mr. Hampton while I was in with Dorothy and her team. I wish the medical staff would call the nurses for rounds, include us, but they never do, and because I wasn’t part of rounds I lost my chance to understand why the benefits of giving Mr. Hampton Rituxan are worth the possible risks. The intern looks preoccupied; he’s probably already thinking about his next case. I won’t be able to check in with him until later.

The woman from dietary shows up at my pod with her large warming cart full of trays. Breakfast is late today, but that’s probably good for Dorothy’s heartburn. The woman takes a tray in to Mr. Hampton, whom I’m guessing won’t eat it. Sheila probably won’t either. It’s odd how little attention I pay to what my patients eat. I notice
if
they eat and if they don’t, especially if that lasts for several days, but the food itself barely registers. If I think about it I know why that is, too. I’m not responsible for the food, so I wall it off in my mind, make sure it never goes on my mental list. What I do notice is patients feeling bad about, in their words, wasting food, because either cancer, or chemo has taken away their appetite. It’s amazing how deep those messages about eating go. I tell them they’ve got cancer, so they have enough on their plate and don’t need to fret about whatever they don’t eat. Now I realize I’m comforting them with a metaphor that is itself about food.

Sheila’s medical team gets to my pod—all the rounding groups are coming at almost the same time, unfortunately. I don’t recognize anyone except for Yong Sun, the fellow, who gave me the Dilaudid order this morning. He gives me a discreet wave as the intern, a very tall woman with straight brown hair she wears long and parted in the middle, says “Sheila Field” and starts to talk in that breathless way most interns have, trying to get all the words out before being interrupted.

This is how rounds work. The person on the team with real-time responsibility for the patient that particular day—an intern, resident, NP, or PA—verbally delivers the relevant clinical information about that patient to the entire rounding team. Called “presenting the patient,” the idea is that everyone on the team learns while listening. The attending physician responds by grilling the presenter into silence, or more ideally, by asking the presenter questions designed to make him or her think. A good attending physician instructs the entire team by explaining his or her thought process and treatment decisions, but the behavior and teaching style of all of them vary widely, as might be expected.

The residents—also called “house staff”—switch their clinical placement every month and the attendings sometimes change even more frequently than that, so the composition of the teams is always in flux. The NPs and PAs make up a permanent team, without interns or residents. The fellow, who stands in the hierarchy between the residents, NPs, PAs, and the attendings, can throw a life preserver or a wrench into the works. Most everyone has good intentions, but chemistry can be bad between members of the team, speaking styles can vary, even expectations won’t always be the same.

I don’t know Sheila’s attending well. Balding, with the beginning of middle-aged spread and his lab coat pockets drooping from too many stuffed-in papers, he listens distractedly. I read his name, Nicholas Martin, on the tag clipped to his white coat.

“Came in from an outside hospital,” the intern says, “. . . coagulation disorder . . . abdominal pain.”

I stand in their circle, concentrating. Dr. Martin grimaces and says, to no one in particular, “I’m an oncologist, not a hematologist.” He’s complaining that he’s trained to treat cancer patients, not people with unusual clotting problems. Sheila doesn’t have cancer, but her disease is rare enough that despite being a teaching hospital we don’t have an MD onsite 24/7 who specializes in her particular illness. An oncologist who’s also trained in hematology is the best we can do, but throw in Sheila’s mysterious abdominal pain and Dr. Martin is out of his element clinically, which annoys him, probably because it makes him insecure. He may feel he’s not expert enough to care for her.

Regardless, the interns and resident look at him expectantly. They may get his point—that he’s not the ideal physician for Sheila—but they have their own pressures to contend with. They’re on the floor to learn how to be doctors and the attending is there to teach them. He will not help them juggle their many responsibilities by doing some of the day-to-day work that keeps them busy, and they will be equally as abstemious with their empathy for the clinical predicament in which he finds himself. It’s the way the hierarchy works.

“Could be HIT” he says, half to himself. He’s talking about heparin-induced thrombocytopenia. People pronounce HIT like the word “hit,” but I always think it should be “H-I-T” because that makes it sound a lot more serious. “Hit” is kids squabbling, but H-I-T, like HIV, is a disease.

Doctors like to tell stories about the rare but tragic case they will always remember, but we nurses have our stories, too, and mine involves a patient with HIT. I met this man when I was a nursing student. He’d come into the hospital for what was supposed to be a routine cardiac test and ended up with a new heart, the lower half of his right leg amputated, and toes dying on his still-intact left foot. An emergency heart transplant had saved his life after a routine cardiac procedure went very wrong, but the heparin he received to prevent blood clots after the open-heart surgery gave him HIT: a rare but very serious allergic reaction to the drug. Heparin is supposed to extend the clotting time of blood, but with HIT the reverse happens and blood clots when it shouldn’t.

For this patient clots formed in both of his legs, leading to massive tissue death and the amputation, and he was facing the possible loss of his left foot, too. At one point he half woke up and wanted only to die. Then a few days later he really woke up and his wife was there, his sons. He changed his mind. Whatever it took he wanted to live as fully as he could.

That was the first time I really saw that our attempts at healing can do harm. Everything that happened to this patient fell into the range of rare-but-acknowledged-risk, and the guy was lucky he wasn’t dead. His life was forever changed after receiving our “care.” He would need anti-rejection medicines for his new heart and have to learn to walk all over again with a prosthesis in place of the leg he’d lost. Changing the bandages on his dying toes caused a shadow of pain to fall over his face, like the moon covering the sun during an eclipse.

Outside Sheila’s room the intern suggests a few blood tests to run. I hope they show that Sheila does not have HIT. Dr. Martin nods. “Order a scan of her belly, too,” he says. That’s routine, a good idea, I think. They’re getting ready to go into the room when the other intern gets a call on his cell phone. He looks startled as he relays the message, but his voice is steady. “Chardash, that patient on five north, is decompensating.” A different patient somewhere else in the hospital, maybe a cancer patient we didn’t have room for on one of the oncology floors, is spiraling down.

“Well, then we need to go there,” the attending says. “We’ll come back here. But get everything we talked about started,” he says, with a flick of his wrist to indicate that the tall, thin intern should enter her orders.

“Tell me more about Chardash,” I hear him say as the team quickly moves up the hall to get to the fifth floor.

The intern hurries up to the nurses’ station to put in the orders she suggested on rounds and I’m left alone and disappointed and, I realize as my stomach growls, hungry. I grab two packs of Saltines from the small patient kitchen across the hall and eat the plain crackers meditatively while standing in front of my medcart re-reading the notes I have on Sheila. It seems like no one on the team was very interested in figuring out what was up with her. They probably just didn’t have the time, but this is when I miss being in a university, a place where people could stand around and talk exhaustively about all sorts of arcane concerns for hours. I wanted a mini-seminar on antiphospholipid antibody syndrome, a fuller explanation of why Sheila had to come here at three in the morning, but instead I got the silence left in the wake of an emergency.

“Hey, can you help me with a transfer? My patient came back pretty sedated; I’m gonna need some help moving him.” It’s Susie again.

I swallow the last bite of Saltine. Mr. Hampton needs to take his pills and Sheila’s belly has not been listened to by me, but Susie needs help now. The escorts who move patients to and from different places in the hospital are blamed if they fall behind schedule. Patients dislike waiting on the hard carriers since their beds are a lot more comfortable. And Susie’s new—she’s learning about nurses having each other’s backs, or not.

“Let’s go.” I tell her.

“You sure?”

“I’ve only got three patients.”

“Three? You’re so lucky. My four are keeping me jumping.” We’re walking down the hallway, back to her pod.

“It’s a busy time on the floor,” I tell her.

In the room Randy, another fairly new nurse, is also waiting. The guys often get called in for transfers and Randy was an EMT so he’s good at moving people.

“I’ll come on the other side of the bed with you, Susie,” he says, “Theresa, you grab the feet.”

We take our positions. The patient doesn’t look that heavy, but bodies can be deceiving.

“Can you get that IV line up and out of the way?” I gesture at the escort, who’s ready to push from her side of the carrier. She lifts up the plastic tubing and lays it on the patient’s chest.

“He’s too out of it to help,” Susie says. “So, one, two, three!” We each pick up our section of the patient, slide it to the right, and lay it down with a gentle thud. It was a smooth transfer. The patient briefly opens his eyes, then closes them again.

“Very nice!” Randy says. He looks at the patient, who seems sound asleep. “Jeez, what’d they give him down there?”

Susie scrunches her eyes together, then remembers. “Conscious sedation, but he barely slept last night—he got platelets and his pump kept beeping. He was really tired.” Randy gives a quick nod. That makes sense.

“You good in here?” I look at Susie and the escort while sliding between the carrier and the bed to raise the bed rail up and next to the patient. We don’t want him falling out.

“Yup. Thanks!” Susie confirms.

“I’ll get this carrier out of here,” Randy offers, and pushes it into the hall, stripping off the dirty linens after he gets it there.

I see the patient’s physical chart in his room. “I’ll take this up to the nurses’ station,” I call out to Susie.

As I head up the hall I dial down my impatience about Sheila. She’s getting a drug that will make her blood clot more slowly and we’re drawing the appropriate labs and getting a scan of her belly. It’s not dazzling clinical work, not the Sherlock Holmes of medicine in action, but then again most of modern health care doesn’t consist of intense deduction followed by “Aha!” moments. Smart, hard-working people gather data, ponder for however long they’ve got, and then act. Time is always of the essence.