The Shift

by Theresa Brown

  “Bob Jones has a fungal pneumonia. He just couldn’t stop smoking and we can’t give ampho because he’s allergic to it.” Amphotericin B is a potent but toxic antifungal medication.

  “Diane Doe, day twenty-four of an Auto and . . . let me look it up . . . her ANC is, oh my God, her ANC is already back and it’s eight hundred. She’s going home.” ANC is absolute neutrophil count, a measure of immune system function.

  Voice care is efficient. In the old days report was given from nurse to nurse face-to-face, which took all the nurses off the floor at the same time. With voice care the shift going off duty covers while the shift coming on duty listens, but nuances get lost on the tape. A grimace, raised eyebrows, a frown communicate the feel of taking care of someone. Voice care passes on the details of a patient’s stay, but it doesn’t always capture who the patient is.

  Some hospitals are starting to do change of shift with both nurses in the room talking to each other and the patient. The idea is to make the patient a partner in care and to smooth out the transition between nurses. I like the sound of it, just as I agree with letting patients read their own medical records, but what about the patients who consciously choose to know only the broad outlines of their care because hearing all the details makes them anxious? Treatment for cancer is not like having your gallbladder removed; some patients want to know everything, while others prefer to remain as ignorant as possible. And sometimes we keep secrets from patients, usually when the news is bad and we want to be 100 percent sure before confirming it. Will a face-to-face report lead to all patients learning new medical information in real time, or will we sometimes deliberately hide what we know, institutionalizing a layer of deception? Knowledge is power, but how much and when for each individual patient?

  Then there are the petty secrets nurses want to keep among ourselves: that we find a patient whiny, that his wife is suspicious of everything we do, that the relatives who visit expect us to chat with them, making it impossible to get any work done. Should complaints be part of report? Underneath the fog of irritation, venting can reveal the human being. But maybe being in the room with the real patient would be an even better reminder of her humanity.

  I dial up voice care and punch in my access code, pen ready. I have to go fast.

  I hear Andie, the night-shift nurse, telling me about my patients. When one nurse’s patients get transferred as a group to another, as happened this morning for me, report is easier. That kind of easy pass isn’t always possible, though, since the number of staff and patients can vary. Richard Hampton, the seventy-five-year-old with lymphoma, is having some difficulty breathing and is off and on confused. In other words, he’s elderly, has cancer, and is not doing so well. I scribble down how his night was. No alarming highs or lows in his daily lab reports—also called lab values or just labs, for short—that we need to address, but I’m not sure what, if anything, we’ll be able to do for him. The printout I got lists his meds, but Andie doesn’t mention a treatment plan. Seems like, except for his cancer, the fact that he can’t breathe without oxygen, and doesn’t always know where he is, he’s doing great. I sigh inwardly—cancer sucks, it really does—and punch in the number for my second patient.

  Next up is Dorothy Webb, beloved by everyone because she’s very friendly and because of that candy dish in her room, located right next to the door. Dorothy, fifty-seven, came in with leukemia, went into remission after chemo, and now we’re keeping her until her immune system returns close enough to normal that it’s safe for her to go home. For the next several months she’ll come back to the hospital every few weeks for what we call consolidation chemo: high-dose chemotherapy to help maintain her remission. None of that’s on the table today, though; today she’s mostly waiting, stir-crazy, I learn, but from an illness point of view doesn’t have a lot going on.

  Sheila Field, my third patient, is a wild card. She arrived at three this morning from an outside hospital and I learn that she’s got a history of a blood clotting disorder—ah, that’s the “antiphospholipid antibody syndrome.”

  Sheila puts the “heme” in hematology/oncology, which is what our floor specializes in. Blood disorders like hers and blood cancers such as leukemia and lymphoma are both considered problems of hematology, the study of how blood is produced and what its diseases are. Blood cancers are also categorized under “oncology,” the same as solid-tumor cancers (such as lung, breast, liver), and some clinicians even describe leukemia and lymphoma as “liquid tumors.” For me, Sheila provides a break from cancer and a chance to learn. I, too, forget that “heme/onc,” as we describe ourselves, includes blood disorders of all stripes. Blood seems so simple—a cut bleeds and then clots, red blood cells carry oxygen—but there are people whose blood itself is dangerously flawed and Sheila may be one of them.

  I click the phone off and glance over my notes; everything looks OK. The clock on the wall says 7:30. I need to find Andie; she’ll be wanting to go home to sleep.

  She’s waiting at the nurses’ station. Young and pretty, her thick black hair piled up on her head, her delicate neck bent with fatigue, she looks like a drooping flower.

  “Any updates?”

  “Naaw,” she says, trying to stifle a yawn. “Dorothy’s ANC isn’t back yet.” That’s her Absolute Neutrophil Count: a specific type of white blood cell crucial for fighting infections. It’s Dorothy’s neutrophils that have to regrow enough for her to go home. “This guy, Richard Hampton, I don’t know what they’re gonna do with him.”

  “Is there a plan?”

  “Not that I’ve heard,” she says.

  “Anything else on Sheila?”

  “God, you know, did they really have to bring her here in the middle of the night? They couldn’t just let her sleep?” she asks. I used to underestimate Andie because of her looks. Stupid. She’s a damn good nurse.

  “Well, it’s the old ‘Send ’em to Pittsburgh; they’ll know what to do,’ ” I say.

  She frowns. “Yeah, right.”

  “Go home,” I tell her.

  She nods, looks down at her notes one last time. “Oh, wait, she’s also having some belly pain.”

  “Abdominal pain?”

  “Yep. Not too too bad, but it hurts.”

  I purse my lips, wrinkle my eyebrows. Could be any number of things.

  I nod. “See ya,” I say, as she slowly walks away, yawning again, this time not trying to hide it.

  In the hospital, this is friendship. We take a “just the facts, ma’am” approach, and add in an ineffable bit more. “Only connect,” the novelist E. M. Forster famously wrote. “Go home,” I tell Andie, in place of saying how much I admire her and wish her well. No time for any of that right now.

  I look up at the whiteboard across the nurses’ station from me. It’s got twenty-eight rows delineating our twenty-eight rooms and they’re all numbered and divided into sections. The first three letters of each patient’s last name go in the blank space following the room number—laws about patient confidentiality forbid us from writing more. The next space lists the attending physician. This is the doctor who has ultimate responsibility for the patient and supervises morning rounds but will not be physically in the hospital during the day to address problems. That work—daily medical care—is done by interns and residents, nurse practitioners, and physician assistants, and their names go in the empty space following the attending physician’s.

  In any teaching hospital, interns and residents are completing the intense clinical training that follows their four years of medical school. They are technically already doctors, but residency is when they really learn how to be doctors. Internship is the first year of residency and so first-years are called “interns.” After that they become “residents.” For them, this is the time of no sleep and being “pimped”: asked questions so persistently by attending physicians on rounds that even the most prepared intern eventually runs out of answers. In the end she may feel foolish and exposed, but also by butting up against her own
ignorance she will have learned something important—that’s the idea at least. Most of the residents are nice, but some aren’t; many understand how to work well with other people while others don’t. They are trying awfully hard and many, especially in the first few months of each training year, seem anxious to do well.

  First-year interns are supervised by residents, who in turn are supervised by older residents and fellows—MDs specializing in a field. The residents on my floor will become a variety of doctors, but the fellows are all “heme/onc.” Nurse practitioners (NPs) and physician assistants (PAs) have many of the privileges and responsibilities of physicians, but most don’t get paid close to a physician’s salary. From what I’ve seen, inpatient care would collapse without them. They, similar to the interns and residents, do a lot of the daily medical work in the hospital.

  True to tradition, the NPs and PAs are listed on the board by their first names, as nurses are, and the interns and residents by last names only. Any good history of medicine would have to examine how important the title “Dr.” is to many MDs and how certain types of docs don’t allow anyone but another doc to call them by their first name. That kind of attitude is changing in the newer generation; they tend to introduce themselves as “Lisa” or “John.” But there are even now nurses who call every physician—whether an attending physician or intern—“Doctor” because that’s how they were trained and what they believe is right.

  I bring my informality to work as well as my background in a university. When I taught at Tufts I was Theresa and my husband is Arthur at the University of Pittsburgh physics department. Hierarchies in naming reinforce hierarchies of power and I guess that explains the rigidity about who’s called what in hospitals, but health care might run more smoothly if those of us who work together used first names, identifying ourselves to each other at least as more equal than not.

  The last two rows on the white board show the nurse’s name and phone number. I pull out my phone and check the number taped to the back of it. Yes, they wrote it down correctly. Occasionally the numbers get mixed up and it’s very confusing until someone figures out what happened and fixes it on the board.

  I write down the pager numbers for my patients’ clinicians (intern, NP, or PA), which I get from the other big white board we have. That board, hanging on a wall perpendicular to the first, includes key phone numbers: the blood bank, our satellite pharmacy, the lab, escort, MDs whose clinics are separate from the hospital, and so on.

  Report done and all needed contact information written down, we nurses scatter to our pods and medcarts, compact wheeled sets of drawers that hold supplies and patients’ medications and have a computer and work space on top. The top surface is higher than a normal desk so our chairs feel like barstools. If only.

  I’m in the back part of the floor today, behind a set of double doors that keep the hallway pretty quiet, although they serve a practical purpose: protecting our stem cell transplant patients, who are particularly vulnerable to infections. The doors keep random visitors out and remind the patients not to mingle.

  I sit down to do computer work and every nurse on the floor is doing essentially the same thing: looking up each patient’s lab values, medication times, vital signs, and new orders. Then browsing the patient’s history, checking test results, and confirming conclusions from scans. This is in some ways the most important part of the entire shift because it’s when we prepare for the next eleven hours.

  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 situati
on 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.