The Shift: One Nurse, Twelve Hours, Four Patients' Lives (7 page)

Speaking of time, I look at my watch. How did it get to be 9:30 a.m. already? And I didn’t call home. I used to make a point of always calling home in the morning before the kids left for school. I loved hearing their little soft voices, imagining the bustle of lunches being prepared, backpacks being loaded and zipped up. They usually didn’t have much to say to me, but I wanted to let them know I was thinking about them. It seemed important.

Paradoxically, once I got more experience under my belt I stopped calling home in the morning. If I think about it I have to admit that not calling is actually easier. A call makes home, my actual home, too real and thinking too much about home might make me vulnerable in ways the job doesn’t really accommodate. It’s the patients who get to be emotional and unpredictable, not the staff, or at least that’s the ideal. I need to be in control at work, so I don’t call home unless I have to. I stick the chart for Susie’s patient back in the circular rack and one of our social workers pulls it out immediately. “Is he your patient?” she asks, hopefully.

“No—Susie, down the hall,” I point. Many hands make light work and that’s good, because the sickest patients need a team of people to look after them.

Sheila’s thin intern is talking on the phone and I overhear her. “Chardash was fine? Oh, that’s good. Just a problem with his oxygen?” Sheila continues to wait for a full consideration of her health status, but I feel relieved that Chardash, a patient I’ve never heard of and know nothing about, has been rescued from whatever trouble seemed to be heading his way.

CHAPTER 4

Worries

R
apid response team
” comes over the PA system and I wait, holding my breath, to find out where. “
Medical Oncology.
”

Shit! Our floor? Which room? “It’s here! It’s Mr. King!” I hear Nora. She’s in the pod next to mine.

I walk back to her, fast, and see Susie coming down the hall, fast, too, with Randy behind her. Nora has already pulled the crash cart into the room and I see, quickly, Mr. King, a patient most of us have known for over two years, lying in bed not moving with a thin stream of blood running from his mouth down his chin onto his chest.

My focus narrows to what’s right in front of me: the portable defibrillator is on the bed next to Mr. King. I grab the small plastic instrument we use to measure oxygen saturation and stick his finger into it.

“What’s his pulse-ox?” asks Nora.

“Waiting.” The machine registers a horizontal line as it calculates Mr. King’s oxygen level. “Seventy-five percent.”

“I’m cracking the cart, getting out a non-rebreather.” That’s Randy.

I hear Susie say, “What happened to him?” as I wrap the blood pressure cuff around his arm and start the machine so we can get his pressure.

Nora says, “I dunno. I walked in and found him like this. Here—you can record.” She shoves a clipboard at Susie. “Write down everything that happens on this form.”

Susie’s eyes widen, but she takes the clipboard and clicks her pen open.

Suddenly the room floods with people: an ICU doc, nurses from the ICU, a respiratory therapist, an anesthesiologist. The code team has arrived.

This intensivist, Matt, is a friend. Despite not being any older than I am he’s world-weary, but also whip smart with a well of compassion hidden beneath his hard edge. He stands by the opposite side of the bed, across from me, and our eyes briefly meet. Then he raises his voice above the loud buzz in the room. “What’s up with this patient? Who’s the nurse?”

Nora’s good in codes. She rolls the information out like she’d memorized it. “Day one hundred – plus of a mud transplant, patient has GVH of the lungs and a fungal pneumonia, with increasing needs for oxygen. Alert and oriented with occasional moments of confusion, bed-bound due to weakness. Walked in this morning and saw him . . . like that, non-responsive. O2 sats 75 percent, so we put him on a non-rebreather.” She points to the breathing apparatus now covering Mr. King’s nose and mouth.

“His sats now?”

“Eighty-eight percent on twelve liters.” Twelve liters is the maximum amount of oxygen that device can give and 88 percent is far below normal, which hovers between ninety-five and one hundred percent.

“Heart rate?”

“Fifty,” someone calls out as Matt flips through Mr. King’s chart.

“Pressure?”

“One hundred over eighty,” I say.

“Let’s get some blood gases,” he tells the respiratory therapist.

“What’s his pressure? And what’s his platelet count?”

“One hundred over eighty,” I say again, louder this time, but I’m not sure Matt hears me over the ICU nurse calling out, “We have a bed! He can go to A222.”

Nora also calls out at the same time, “Platelets are ten—he’s refractory. No HLAs available.” With a platelet count of ten, people can bleed spontaneously, and although we’ve been transfusing him regularly, his platelet count barely rises each time. (HLAs are platelets matched to Mr. King’s blood, but we don’t have any on hand. They can be hard to get.)

“Do I get to hear a blood pressure or not?” Matt demands.

I look at him and raise my voice. “It’s one hundred over eighty,” I say very loudly and he nods to himself. “OK, we’ll take that bed. Pack him up and move him out. He’s stable enough to transfer—we’ll intubate him downstairs if we need to.”

“Can we take him down in your bed?” the ICU nurse asks Nora. “We’ve got time—we can do it for you.”

“You’ll return our defibrillator? And the bed?”

“Uh . . . no. But you’ll have to bring down his meds and give report. You can take them back with you then.”

I have a sick taste in my mouth. Mr. King was my patient when he was first diagnosed over two years ago. He’s gone up and down, but I thought he was in an up-phase. I haven’t taken care of him for a while, though, so he must have gotten worse without my hearing about it. Having blood drip from his mouth and pool on his chest is unsettling since it suggests he didn’t notice enough to spit or even turn his head to let it dribble out.

“Aspirated.”

“He aspirated.” It’s a low murmur, passed person to person. Some of the blood from Mr. King’s mouth went down the wrong tube, into his lungs.

“Has anyone called Opal?” I say. His wife. She’s tough and resilient, but not prepared for this turn of events, at least not the last time I talked to her.

“I called her,” says the nurse practitioner who’s permanently on the stem cell transplant team. Mr. King is one of their patients. “She can’t come right away, but as soon as possible.” They live more than an hour’s drive away and he’s been in and out of the hospital for two years. God knows how she’s keeping the rest of her life going in between times.

Nora, Randy, and the ICU nurses gather Mr. King’s things—framed pictures, extra pairs of pajamas—and put them in some of our “patient-belonging bags.” He’ll have a lot less room in the ICU. Opal will have to take some of it home, I guess.

Matt has signed off on the rapid-response sheet that Susie filled out and starts to walk back up the hall when I flag him down. I lean in closer to him and keep my voice low. “What do you think his chances are?”

“Slim to none,” he says, like he’s swearing, and I hear in his voice that note of concern masked by resignation that made me like him the first time we met.

“That bad?”

He grabs my arm. “Theresa, we’re all gonna die.”

“Right. I know. But I like him,” I say, trying not to sound childish.

“If you really like him, then wish for the family to put him on hospice so we don’t have to keep all this up in the ICU.”

“No chance that he’ll make it?”

He stops and looks at me for a minute without speaking. We’re about the same height and our eyes meet. “His lungs are junk, we can’t stop him from bleeding, and he’s got an opportunistic infection that’s barely under control.”

“I’d forgotten about the infection,” I say in a low voice, mostly talking to myself.

“Wish for hospice,” he tells me, firmly, and we both start walking again.

At my pod we wave good-bye to each other. “Thanks for looking on the bright side.”

He gives me a pained smile, then, “That’s what I’m here for.”

The ICU nurses start to roll Mr. King down the hall. A housekeeper will clean the room, making it ready for a new patient. Nora will give report to the nurse in the ICU, just like the day-shift nurses all got report this morning, then come back upstairs and record everything that happened on the computer. Susie documented during the code, but that was on paper. Half an hour, forty-five minutes, and the emergency is over, except it feels like Mr. King took a piece of my heart with him, and he wasn’t even my patient today.

I stand at my medcart and close my eyes. I try to mentally pack away Mr. King and the blood running down his chin while scanning my notes. Dorothy. Dorothy needs patient-belonging bags, too, especially since she’s brought so many items from home into her room.

I go to the supply room and grab a bunch of them. Dorothy’s going home, not to the ICU, I remind myself. Remembering that doesn’t make me feel better about Mr. King, but it makes me less sad overall.

Back in her room, Dorothy’s talking on her cell phone. “Well, now I don’t know what time, if you can just help Dad get ready.” It must be her adult daughter.

I hold up the bags and she gives me a half-smile and a loose finger wave with her right hand. She’s put on lipstick and it gives color to her whole face. The beginning of her transition to home.

“Just tell Dad to get here as quick as he can.” Trying not to interrupt, I put the belonging bags on her bed, wave back, and turn to the door.

“Wait!” She snaps her fingers. “No, not you!” she says sharply into the phone. Covering the receiver with her right hand and pointing at the candy dish, she says, “Take some chocolate. Today’s my last day.”

I pick up the glass lid, see the silver glint of Hershey’s kisses, and pull them out from among the gold-wrapped Reese’s and green and red Jolly Ranchers.

“Thank you,” I mouth, dropping them into my pocket. My phone rings as I’m on my way out the door.

“It’s radiology, CT scan. Can your patient Sheila Field come down now?”

CT: Computated Tomography—X-ray on steroids. I look at my watch. It’s not even 10:00 a.m. “Sure. That was quick.”

“We had a cancellation. Want me to put it in for transport?”

“If you have time, that’s great. Thanks. I’ll get her ready.”

As I leave Dorothy’s room she continues to talk on the phone, distractedly kneading the plastic bags I gave her. “Forget about that old carpet right now,” I hear as I shut the door.

Now I will listen to Sheila’s belly before she goes to CT. Sloppiness seems like a slippery slope, so being thorough, even if I’m late, is a form of mental discipline for me. I enter her room as quietly as possible. It’s completely dark and she remains a lump under the blankets. I reach out for her shoulder and gently squeeze it. “Sheila? It’s Theresa again. Did the Dilaudid help?”

The blanket goes up and down—a nod. I kneel so that my mouth is at the level of her buried ear. “Sheila, they’ve ordered a CT scan of your abdomen, to make sure everything is all right.” The lump moves up and down again.

“Before you go to CT, I need to listen to your belly. Do you think you can roll onto your back?”

“Ungh,” she says, with a grunt, and the lump rises and turns. The top edge of the blanket slips down and I see a pleasant-faced woman, in her late thirties, with thin reddish-blond hair that flows wispily away from a plump face. Her pale blue eyes are gentle, but lined, and her mouth has that frozen expression pain creates. The fingers holding onto the blanket are thick and there’s a trustingness about her that makes her seem younger than she is, and vulnerable. She’s all alone here, I think. I’ll have to take care of her.

“This will be quick,” I tell her.

I pick up the Fisher-Price stethoscope, rub alcohol on the ends, and stick them in my ears. I put the bell of the stethoscope down on the four quadrants of her abdomen—like two, five, seven, and ten on the face of a clock—and press lightly. Instead of the gurgling that’s typical, I hear nothing, which is unexpected.

Why is Sheila’s bowel quiet? It could be the cheap stethoscope. Or her having just woken up. Or my phone ringing right now as I listen, drowning out her abdominal burbles: “Escort. I’m on my way for Fields.”

Or the rounding team returning, even though it’s only Dr. Martin and the intern. “Now, Ms. Fields,” the attending says peremptorily even though I’m bent over her with the stethoscope in my ears, “you’ve got a clotting disorder and your stomach hurts.” Sheila nods, the fingers of both hands curled over the blanket’s edge so that she looks like a child, trying to hide.

“We’re giving you argatroban. We’ll get a CT of your belly and look at your blood work. It’ll all get sorted out eventually. You should be home in a couple of days.” He gives her a tight smile and she nods, but it’s unclear how much she understands. I don’t fully understand what’s going on, so how could she?

He pulls back the blankets and pushes firmly on her belly. She gasps and her eyes open wide, then squeeze shut as she quickly pulls in her breath. “That’s why we’re getting the CT scan,” he says, covering her back up with the blankets. “Anything else?” Dr. Martin looks questioningly at the intern, who shakes her head.

“They’ve already called her for CT,” I say, wanting them to know what’s happening.

“That’s good,” the attending says, but his tone doesn’t change from that bland professionalism he used with Sheila. However, the intern gives me a weak smile. She and I are in this together.

I hear the electronic
ping-ping-ping
of my phone. “Transport. Here for Fields.”

“I’m in the room—we’re coming out.” Dr. Martin signals for me to go out first
.
A little old-fashioned chivalry. Maybe he’s not completely indifferent to the people around him. It could be he copes with clinical curve balls by withdrawing, or it could be he was taught to always let women go out doors first and that habit has never died.

The escort guy waits in the hall with an empty stretcher. He barely makes eye contact, but he’s smooth with the carrier, like all of them. When I have to push a bed I’m an embarrassingly bad driver. The escorts make it look easy.

“Hey,” I say, trying to be friendly. “You’re here to take her to CT?”

“Fields,” he says, half a question. I nod. “Can she walk?”

“She’s in pain, but she should be able to walk.” A piece of straight blond hair falls over the left side of his face. He’s got a long-on-top haircut and that, combined with his funky thick-rimmed glasses make his burgundy uniform look almost cool. I can’t recall ever,
ever
, having a real conversation with an escort. Never. Maybe that’s why they often seem surly with us nurses.

It strikes me that my behavior with the escorts is not that different from the attending’s behavior toward me. Maybe that means the attending, like me, is just trying to do his job as best he can. Or maybe it means we should all try a little harder to see each other as human beings.

I go back into the room and wake up Sheila. She’s groggy but willing to move, if very slowly, and starts by sitting up in bed, grimacing.

“Can you stand up on your own or do you need my help?”

“I can do it.” She breathes, starts to rise, then grips each of my arms as if they’re chair rests. “Sorry.” Her breath comes heavily.

“That’s what I’m here for. You’re fine.”

She makes it all the way up. She’s shorter than I am, heavy but not obese, and her hair is longer than I realized. It covers her shoulders like soft down.

She shuffles one foot forward. “You sure you can make it?” She nods, her mouth pulled tight, and shuffles the other foot forward. I feel for her and also feel fretful about how much time her slow walk is taking. Viewing time as the enemy has become a bad habit.