At the nurses’ station the night-shift RNs cluster on chairs, looking like birds wanting to shove their tired heads under a free wing. Their lined faces and heavy-lidded eyes show how hard it is to stay awake and alert for an entire night. I don’t work a lot of nights, but when I do I feel it. I hit a wall at 2:00 a.m., then again at 4:00. The hospital’s strong tea, bad coffee, Diet Coke from the vending machine—they all help, but nothing non-pharmaceutical will really make me feel awake for the entire night, and I’m not going down the pharmacologic road. The day after, even if I sleep all morning and afternoon, it feels as though I’m seeing the world through gauze.
And yet there are compensations at night. It’s calmer than daylight and watching over people as they sleep can be peaceful. Night is also when some patients plumb their deepest fears and talk about death, and paradoxically, in the darkness, the possibility of dying becomes less scary for some.
“How was the night?” I ask Linda, the nurse sitting closest to me at the nurses’ station.
“Quiet,” she says.
“Yeah, for you!” Melanie calls out, her eyes fixed on her computer.
I raise my eyebrows. “ICU transfer,” Linda says.
“Who?” Not one of our familiar faces, I hope. We all get attached to certain patients and families. If one of them ends up in intenstive care in the middle of the night that is not good news.
“New admission. We don’t know him. Visiting family from Ohio.”
“Ugh. That sucks. Talk about ruining your vacation.”
“Yeah, the family was freakin’ out, the guy’s pressure was, like, seventy over forty and he was just lying there drooling on himself.” Melanie’s turned toward me now. She raises her hands in a gesture of frustration.
“Is he OK?” I ask.
“Let me see—” she turns back to the computer and types something in, looking for him on the list of ICU patients. Some nurses believe that using the computer to follow patients in the hospital violates patient confidentiality laws, but I’ve never officially heard that, and so far no nurse I know has gotten reprimanded for it.
Melanie skims his electronic file. “Heart rate . . . blood pressure—Yes!—one hundred over sixty.” She turns around to face me again.
I frown, thinking. “Sepsis?”
“No. He wasn’t an onc. patient; they just didn’t have a family practice bed.”
“Whaddya think? Could he have just been dehydrated?”
“Well, probably not with that drooling!” She returns to the computer, intent on the paperwork—charting—she has to complete. The paperwork demands have steadily increased over time and the busier a nurse is with a very sick patient the more charting is required, even though she has less time to do it in. Computers should make the process faster, easier, but instead of efficiency, they enforce thoroughness. We’re expected to chart almost everything, preferably in real time. Real time charting is impossible, though, if a patient needs a lot of immediate care.
I reach out for the printed papers I get for each of my patients and overhear another patient’s name—Ray Mason—from a nearby conversation.
“What’s Ray doing here?”
“Relapse,” Helen, another night shift nurse who’s walked over, says. Her mouth looks sour and she lets the single word hang in the air.
Dammit, I think, and then, “What?” Maybe if I pretend I don’t understand what Helen has said it will make the fact of Ray’s relapse untrue.
“Uh-huh,” Helen says.
“When?” I ask.
She inclines her head. “Few days ago.” She shrugs. Does it really matter? Nurses work a couple days on, a few days off, so we don’t always hear the news. For me, ignorance helps maintain a border between home and the hospital.
“But I had coffee with him last month, him and Liz.”
“I did the same,” she says, “Except it was a beer.”
Having coffee with a patient is unusual. Normally I would never meet a patient outside the hospital, but Ray was different. A firefighter who sings and plays guitar in a punk rock band is obviously an unusual combination. Ray’s appeal, though, came from his easy way of being in the world and his unaffected bravery. We also had the same birthday, and when you work with cancer patients, that kind of coincidence ends up feeling significant.
Ray is young: twenty-five when he developed leukemia. He’d noticed himself growing daily more and more tired, and then he had a bruise that blossomed into a deep purple bulge under the skin of his lower abdomen. Something about its intensity and spread seemed unnatural. Next he caught a cold that, no matter what he did, just wouldn’t go away.
The tiredness was what sent him to the doctor. Firefighters can’t be chronically exhausted and Ray played hard, too: kids, the band, parties. The fatigue was making his job hard and cramping his style.
I see the coffee shop where we met in my mind’s eye, at the bottom of one of the narrow slanted streets in Pittsburgh’s Polish Hill neighborhood. Sunlight streamed in through big plate-glass windows. We’d cured his cancer and I asked Ray how he felt now that his disease was in remission. “The future looks brighter than bright,” he told me. As he held up his hands, gesticulating, he seemed to hold the light between them. “Life,” he said, “is better than it ever has been,” and Liz, his wife, who was also there, agreed.
Time passed like liquid honey pouring out of a jar, slow and just sweet enough. People came and went from the coffee shop, wearing their own multi-zippered black leather jackets and worn T-shirts with combative slogans. Everyone knew Ray. “Hey, how you feeling?” was the most common question, with casual talk about music, where Ray’s band was playing next. Around noon Ray ordered a sandwich and I got another latte. Liz stretched out her legs and asked what else I wanted to know, because they knew I was a writer and that their story captivated me.
I remember the creamy taste of my latte, the electric connection between the two of them, the crumbs of bright green spinach wrap left on Ray’s plate, the future hanging pendulous, infinite. In this moment I thought that Ray would stay healthy forever. He would work, raise his children, grow old, and die when the time was right, but not before. He would fight fires and save lives and he and Liz would keep looking toward the future, drawn in by its promise.
I believed it. I believed that meeting outside the hospital and talking only of a rosy what-would-be could conjure a permanent remission. I believed it, when I knew that, for better and for worse, time never stops for long.
Relapse—the return of disease—is not unlikely for patients with Ray’s kind of leukemia, but I’m shocked that he’s back on the floor. I’m also angry, really angry. And then I pull myself back to my work.
“Do I have Ray?” I ask Helen, the night-shift nurse. She was officially in charge overnight, making her the “charge nurse”: a bedside RN who functions as a manager for that particular shift. Charge nurses—also called resource nurses at some hospitals—assign patients to staff, troubleshoot, and perform set administrative tasks, such as making sure the crash cart (a toolbox of equipment and drugs we need in an emergency) is ready to go. Some RNs bowdlerize “charge nurse” to “charge bitch” because for the wrong kind of person it becomes a power trip, but Helen’s not like that.
She shakes her head—Ray will not be mine today—and I am relieved. I prefer to be Ray’s nurse later, not right now when cancer once again has the early advantage, before we’ve put our own treatment plan into motion
I pick up the papers for my patients, fingering them with the contained apprehension of a poker player gathering in a hand on which she’s already bet more than she can afford. The patients are the key to the entire shift: they can make a day intolerably frustrating or unbelievably rewarding, or occasionally both. For each patient there are two pages of information stapled together and those pages tell me their names, birth dates, medications, diet orders, trends in lab values, and a brief medical history, which oddly enough is not always correct. For the moment I ignore all tha
t detail and start by learning who these people are.
Tense, but also curious, I read the names to myself: Richard Hampton, Dorothy Webb, and Sheila Field. Dorothy I know, the other two I don’t. Skimming the papers I pull out the most basic information. Richard Hampton is a lymphoma patient in his late seventies. Dorothy Webb, a cheerful woman who keeps a well-stocked candy dish in her room, is in her late fifties and was hospitalized for the initial treatment of her leukemia. Everyone knows Dorothy, who is getting to the end of her six-week stay. My third patient, Sheila Field, in her midforties, came in with a blood clotting disorder called antiphospholipid antibody syndrome. It sounds intriguing.
I look at Helen, eyebrows raised, “Three?” I ask, with a half-smile.
“Well, yeah,” she says. “You’ve got that empty room between A15 and A17, but there’re no scheduled admissions today.”
“Sweet.”
“Of course, if someone comes in . . .”
“Right—they’ll be mine. I’ll enjoy it while it lasts,” I tell her.
The difference between three and four patients is huge. Three to four is supposed to be a standard load and that usually ends up being four, but there are no official rules about how many patients we can have. If we’re working short-staffed four patients will jump to five and night shift occasionally has six each.
There are stem cell transplant units where each nurse covers only two patients—the ideal level of care for our sickest people. With four patients they sometimes become human to-do lists and I could get a fourth anytime: a transfer from intensive care, an admission from the Emergency Department, someone with a new diagnosis of leukemia jerked out of his normal life and pulled, unwilling, into the world of the hospital. This unknown fourth patient feels like a vulture perching on my shoulder, hungry to scavenge my peace of mind, so I try not to think about it.
Three allows me to treat my patients as people. Instead of rushing from room to room I can move at a human pace and also be on top of everything going on with them: talking to worried family members who call, knowing the results of recent scans and tests so that I can answer questions knowledgeably, tuning in to iffy vital signs, or pushing a physician to come up with an anti-nausea regimen for a patient who’s spent two solid days vomiting.
Hospital administrators with their eyes on the bottom line seem to think that nurses can stretch infinitely, like rubber bands. The fewer the number of nurses the lower the labor costs for the hospital. But if I give care a numerical value, represented by TLC, while P stands for number of patients and RN for each individual nurse, then:
RN/p = TLC
The more patients an individual nurse cares for, the smaller the amount of TLC per patient. More significantly, research on staffing levels has made it pretty clear that the more patients a nurse has above a certain number (the number itself depends on the patient population and how sick the patients are), the larger the likelihood a patient will die who wouldn’t have otherwise. In other words, nurse-to-patient ratios aren’t just about patients feeling cared for; they’re also about fragile people staying alive.
Of course administrators have their own different formula with KVIs—Key Volume Indicators—and FTEs—full-time employees. My eyes glaze over when I try to understand health care economics from a manager’s point of view. I say, put the patient at the center and figure out the money from there.
I pick up the portable phone that night-shift left out for me and idly clean it with one of the packaged alcohol wipes I keep in my scrub pockets. Every floor has its own supply of phones and each nurse is assigned one for the day. There aren’t enough for each of us to have our own permanent one. They are expensive, but often don’t work well, probably because they are accidentally dropped over and over during the day. They all also have identical ring tones, so when one phone goes off we all have to pull out our own to discover whose it actually is. By the end of shift there’s a ringing in my head that only time away from work can dim the sound of.
The phone is a mercurial presence on the job. The calls always have a claim of urgency, so I’ll answer if I’m eating or even if I’m changing a dressing on a wound. I could have just buttonholed a doctor who’s notoriously hard to pin down only to have him scurry off when my phone rings. Wherever I am, if my phone rings I will probably answer it because, more often than seems possible, I really do need to know what the person calling has to say.
Every nurse I know has at one time or another wanted to throw her phone against a wall or casually, as if by accident, drop it out a window. If I did that, though, the charge nurse would just get me another one, so I slide it into a pocket of my scrubs.
Once when I was a new nurse I got an aide’s phone by accident. It was the only phone left in the drawer and looked just like one of ours. The problem was, it couldn’t receive calls from outside the hospital and no one told me, so the doctor I’d been paging about a patient’s chest pain never called me back, or rather, did call me back from his own off-site clinic, but couldn’t reach me. We called in a rapid response team—the people who come when a patient seems to be taking a serious turn for the worse—and that patient spent the night in intensive care, “just in case.” All of that drama and activity might have been avoided if I’d had the right phone.
I check my watch. It’s 7:15 and I’m already behind. This half hour, from 7:00 to 7:30, is when I organize my day. I put my papers in order based on room number and pull a blank sheet out of the computer printer tray and staple it on top for notes. Electronic health records are ubiquitous in health care, but in the hospital we remain dependent on our physical “papers.”
I fold the blank sheet of paper into fourths. Then I take my pen and outline the four squares I just made by drawing along the fold. Each patient gets one square and I have a blank square for the fourth patient if she or he shows up. I number each square at the top with the patient’s room number and write in each patient’s name. Then I draw the grids we use to write down laboratory values and add in the abbreviations for intravenous lines. So strange to me as a new nurse, these now come easily. TLHC is a triple lumen Hickman catheter, a permanent IV line that protrudes from the upper chest. A PICC—peripherally inserted central catheter—is a different type of permanent IV line that gets inserted in the patient’s upper arm. Temporary IVs I notate as “per,” because they go into a peripheral vein: the kind you can see when you look at your own arm or hand.
I used to need a full sheet of paper for each patient, but now it’s one 4.25" x 5.5" square of white each. I’ve got my printed papers, too, of course, that come from the computer, but this one-sheet documentation of the day is uniquely mine. It’s just enough space, I hope, to record all the variables of the shift, including the new information I cannot forget: an MD called to consult when a patient will go off the floor for a scan, a cell phone number from a distraught husband or wife, the specific bacteria found growing in culture, test results whether good or bad, and new orders from the nurse practitioners, physician assistants, or MDs.
If it’s a bad day, I’ll know because that small quarter of a page of white paper won’t be big enough for everything I need to write down.
CHAPTER 2
Report
The other day-shift nurses, like me in white scrubs, are already in the conference room. I see Amy, with her long blond hair, and Katherine, one of our veteran nurses who actually works two jobs. Their form of rebellion is wearing colored long-sleeve shirts under their white scrub tops.
Susie, one of our newer nurses, is there and her tight curls bob as she nods her head and writes. I know Randy, also a newer nurse, is on today, but he likes to go somewhere quiet for report. Quiet can be good, but today I want the social connection.
There’s Nora, who can be a great coworker, but has a catty side I don’t much like, and Dot, whose throaty smoker’s laugh inexplicably comforts me; not much throws Dot.
And last I see my friend Beth, who’s maybe ten years older than I am and stopped throwing up on h
er way to work a long time ago. Her hair is cut just above her shoulders in a tidy, middle-aged bob. Her wire-rimmed glasses flash up at me as she offers me a wave and a smile, but she doesn’t stop listening and writing.
This is what we call “report.” The nurses all sit, intent, portable phones up to their ears, writing down histories, numbers of white blood cells, chemotherapy regimens, problems we’ve yet to solve. It’s an internal room, windowless. A half-full two-liter bottle of Diet Coke, a leftover from night shift, or who knows when, sits out on the table along with some stacked Styrofoam cups. The soda’s probably flat, but I bet at some point today someone will drink it anyway.
Listening to voice care can be a little like attending a spoken-word poetry slam. Near the end of every shift each nurse uses the phone to tape a verbal report on each of her or his patients. Report always begins with the same information: name, age, diagnosis, but after that every nurse has her own style, her own points of emphasis. We’re people after all and some nurses will discuss the most pressing issues first, while other nurses describe all the normals before getting into what’s really up. With cancer patients, in general, something is always up. Plus, some nurses like to know everything about a patient, others the bare minimum, and the report we give reflects our own inclinations. Katherine is notorious for reports that come across like haikus. Beth tends toward the epic. I try to be concise, then catch myself rambling; later I’ll worry that some important detail got left out because of my self-editing.
Report is also always in our unique hospital lingo, which includes acronyms and diagnoses, but explains events in terms of well-known clinical narratives:
“Lisa Smith, you know her, day ten of a MUD, intractable nausea and vomiting. We’re trying Ativan and it seems to be working, but knocks her out.” Translation: the tenth day after her matched unrelated donor transplant.
The Shift Page 2
