I’ve got time, so I document on Mr. Hampton now. Nurses used to “chart by exception”; we would note anything going on with the patient that deviated from normal and assume the rest was OK. Fear of lawsuits, combined with electronic health systems loaded with regulatory bells and whistles, has made charting more and more about recording everything possible about the patient, whether abnormal or not. Do the lungs sound clear? That’s normal—chart it. Is the patient urinating? Normal—chart it. Having bowel movements? Chart that, but also specify the consistency, color, and frequency. Is the pulse steady and regular? That’s normal, too, so make sure to chart it. Is the patient in pain? Pain gets charted if it’s present or absent, even though lack of pain is also normal.
My concern is that over time charting has become a simulacrum of good care, rather than a record of it. A simple example: hospitals worry tremendously about patients falling down since falls can lead to regulatory hand slaps, additional costs of care that may not be reimbursed, and lawsuits, as well as, most important of all, patients getting hurt. The managerial response to this risk is to require more charting on whether a patient could fall. Every shift, I complete a full fall assessment on every patient, noting age, whether he’s on narcotics, if he’s incontinent and unsteady on his feet, and if there have been falls recently. The electronic health record then gives the patient a fall risk ranking of low, medium, or high. Each level of risk comes with a set of necessary precautions and I have to chart which ones I’ve done. Ideally I would do all of them.
The recommended safeguards are all excellent: make sure the call light is nearby, check on all high-risk patients regularly, tell them to ask for help before getting out of bed. Physicians such as Atul Gawande and Peter Provonost persuasively argue that checklists in hospitals save lives. Their work focuses on procedures and protocols, not assessments, but I also agree that carefully analyzing a patient’s risk of falling is probably a good idea. It needs to be quicker, though, because the irony right now is, the time I spend on the computer carefully documenting a patient’s fall risk is time I could physically spend in the patient’s room talking about how we can work together to keep him upright and on his feet. Designers of electronic charting systems don’t seem to understand that checklists themselves are not the innovation, because checklists are not substitutes for care. The real innovation is having staff use lists to consistently create the safest and highest-quality clinical environment possible.
Mr. Hampton is a true fall risk. He’s older, on oxygen, and appears confused. He’s been asleep so far this shift, but he could wake up needing to go to the bathroom at any time, feel uncertain about where he is, get tangled up in his sheets or oxygen tubing, and fall simply getting out of bed.
Thinking of that I feel a sudden sense of urgency and go and knock softly on Mr. Hampton’s door. He’s asleep again and I step over to the bed and tap his shoulder.
He opens his eyes and I pick up the plastic urinal on the shelf next to his bed. “Mr. Hampton,” I say quietly, holding up the urinal with a gloved hand so that he can see it. “Do you need to go to the bathroom?” He nods and I help him sit up in bed by sliding one arm behind his back. Then I disentangle his legs from his heap of covers until he can dangle them over the edge of the bed, ultimately resting his feet on the floor. He is very tall.
“Do you need my help?”
He shakes his head no and reaches out for the urinal. With his other hand he reaches under the edge of his hospital gown and prepares to urinate. I turn sideways so that my back is to him, but I keep my right hand on his shoulder to prop him up and so that I’ll feel it if he starts to lean forward precipitously.
I hear the sound of a urine stream and then it stops. I wait a few seconds, then ask if he’s done.
“Hunh,” he says. It’s the first sound I’ve heard him make! I turn around to face him, pleased that he’s verbalizing something, and with my other gloved hand take the urinal from him and set it aside. I grab a wet wipe from the packet in his room and hand it to him. He takes it and slowly and carefully wipes both hands, afterward handing the used wipe to me.
I look at the urinal. He really needed to pee. I bend down to put myself at eye level with him. “Better?”
“Better,” he says, almost as if he’s talking to himself, but his voice is strong with none of the quaverings of old age. I look at him, wrinkling my eyebrows together as I adjust the two plastic prongs that send oxygen into his nose. Already he’s trying to get back under the covers and I help him slide his legs in and fall back on the bed.
His eyes start to close. I use the pulse-oxygen machine to check his oxygen saturation and heart rate. All normal. Guess he’s tired, I think, frowning to myself. All this sleeping is somewhat unusual but, of course, he’s also sick with lymphoma.
In his bathroom I empty the urinal, measuring the amount so that I can record it later. All fluid that goes into and out of a patient gets charted, too.
I’ve now helped to keep Mr. Hampton safe, but the scary thing is that patients will fall no matter what hospitals do. They fall because they lunge for cell phones. They fall because their blood pressure drops too quickly too soon after they stand up. They fall because cancer is clouding their brain and messing with their cerebellum. They fall because they don’t want to ask for help in the bathroom.
Humans are bipeds—it’s easy for us to fall. My husband and I have both had bad falls walking the dog in sketchy weather. I would like to be encouraged to physically observe my patients rather than simply record that I have observed them. Today at least I documented that I kept Mr. Hampton safe from falling and I also had time to actually do it.
Suddenly I remember. I have to listen to Sheila’s bowel sounds and I don’t want to forget. Is this the small something I might easily neglect that could make all the difference for Sheila, similar to the many small but vital steps in the clotting cascade? Watching Mr. Hampton as he falls back asleep, head nested in the pillow, I think it through. Oh, that’s right, I wanted to spare her pain. To have listened right then, when I was in the room, was the correct clinical choice, but it was not the best choice for Sheila overall. No harm, no foul, though; I can fix this.
I decide to hurry into Sheila’s room, check her abdomen and see if the Dilaudid is working, then give Dorothy her pills. Except Dorothy’s call light comes on and I hear it chime. Rock and a hard place. I’ll see what Dorothy needs; I’ve already gathered her morning meds. I’ll review them with her quickly, then see Sheila, and come back to Dorothy’s room later for a chat.
I saved Dorothy for last because she always enjoys talking and she’s made her hospital room as much like home as possible, so it’s nice to go in there. Her glass candy dish is on the bedside table, she’s covered one wall with taped-up family photos, and a card table in the corner offers visitors a perpetually half-finished jigsaw puzzle. A thick, purple comforter overlies the bed and Dorothy herself always wears loose gray sweat pants, pastel sweatshirts, and a series of floppy caps that disguise her lack of hair.
I go in, say hi, reach behind the bed to turn off the call bell. Dorothy looks preoccupied and I’m guessing she wants to know what her neutrophil count is, to know if she can go home. But she surprises me.
“Do you have my Prilosec?” she asks, her voice high, tremulous.
“Sure. It’s right here,” I say, tearing off the paper wrapper and dropping the pill into the plastic cup I’ve brought into the room.
“I need that Prilosec!” she says, and she has tears in her eyes. “Breakfast will be here soon and I get such horrible indigestion.” She shakes her bald head and her pink and white knit cap shakes with it. “Every day I ask to have my Prilosec earlier and I never get it when I want it.”
I’ve never seen her like this. I wonder selfishly what happened to my sweet, motherly patient. And then, because I want to be kind and feel effective, I make a promise that most likely I cannot keep.
“I’ll fix it for you, Dorothy,” I tell her.
&nb
sp; There are certain drugs that have to be given on time—insulin, chemotherapy, opioids for pain—but Prilosec, a drug that prevents heartburn, doesn’t qualify for that list. I’ve never had a patient feel strongly about it.
“I’m awake at six a.m. and I could get my Prilosec anytime after that. It’s already past eight right now.” Her voice cracks—she’s very upset about the Prilosec.
“I’ll fix it for you,” I say again, pained by her high, strained voice. I want to help her, but honestly, I can’t guarantee Dorothy will get her Prilosec any sooner than she did today. It’s scheduled for 7:30 and pills are rarely given earlier since most patients are asleep and there’s typically no urgency. We’re treating cancer here; no one worries about Prilosec . . . except for Dorothy.
I take her other pills out of their wrappers, announcing the name of each one as I go: voriconazole, Acyclovir, ciprofloxacin. I drop them into the pill cup and the light blue, pink, yellow, and white pills mix together like Easter eggs in a basket.
I do all my checks, which she just tolerates because she’s annoyed, and I ask the usual questions: “Besides the heartburn, any other issues with eating? Nausea, vomiting, diarrhea, constipation?”
She shakes her head. I take out alcohol wipes and pop some saline flushes out of their wrappers, checking each lumen of her central line while she obligingly pulls down the upper right edge of her shirt to show me the dressing where the line goes in just below her right clavicle.
“Your line’s working great,” I murmur, satisfied with the flash of blood I see in all three lines.
Now I bend toward her, looking her right in the eye. Her fleshy face interrupted with a hard frown, she gives me a firm look. I couldn’t have known about the Prilosec, but I feel I should have.
“I will try to make sure you get your Prilosec earlier, Dorothy,” I tell her, gently shaking the cup of pills so that they rattle—a reminder to her to take them even though she knows the routine after being in the hospital for almost six weeks.
She nods, still irritated, and reaches for the pill cup, her water at the bedside.
“I’ll be back.” I give her a small frown, hoping it conveys empathy with her frustration. She’s busy swallowing her pills and doesn’t notice, but her shoulders have relaxed.
On my way out the door I grab a couple of Hershey’s kisses from the candy bowl and eat them in the hallway without much noticing the taste. Breakfast?
Dorothy had AML—acute myelogenous leukemia—the deadliest and most pernicious of the adult leukemias. The initial treatment requires an extended hospital stay and that’s what she’s mostly done with. In the first week the patient receives a seven-day blast of chemotherapy. The next five weeks are spent recovering from the chemo’s side effects: mouth sores, diarrhea, vomiting, and pancytopenia, or a severe reduction in the numbers of white blood cells, red cells, and platelets.
We draw blood every day to track the fall and rise of patients’ blood counts and when needed we give transfusions of red cells to control anemia and platelets to reduce the risk of spontaneous bleeding. White cells, unfortunately, can’t be transfused like blood or platelets and not too much can be done to make them grow back faster, so the patients get sick easily and fast when the white count, and especially the neutrophil count, is at the nadir or low point, which is typically zero. Having a fast-moving infection raging through a body with very few defenses of its own is dangerous, and a large part of why AML patients like Dorothy usually stay in the hospital for so long. We nurses keep an eye on them—checking temperature, heart rate, blood pressure, and oxygen level every four hours—so that if there is a problem we can respond right away.
Truth is, having heartburn be her biggest worry is a welcome change for Dorothy, though I wouldn’t put it that way to her.
Sheila. I should see Sheila, but first I go to the computer on my medcart and reschedule Dorothy’s Prilosec for 6:30 a.m. I attach a note in the computer about how important it is to give Dorothy the drug at that time. Maybe it will work for the day or two before she gets discharged.
Now Sheila—“Hey, Democrat,” I hear, and turn around, half-smiling, shaking my head. It’s Dorothy’s rounding team and the attending physician is giving me a hard time. “Are you actually doing some work?” He’s on the youngish side, for an oncologist, but he teases me the way my older brother would. Except it’s not quite brother and sister. He’s flirting, mildly, and I’m flirting back.
“You’re not just freeloading, right? Like most Democrats?” This is our usual joke, that our politics reveal me as lazy and him ridiculous. My being a Democrat and his being a Republican aside, our sparring is fun and I have no idea where his real political loyalties lie. He steps up to me now and puts his arm around my shoulders. He’s my height, with short blond hair and thick cool-nerdy glasses. He smells vaguely of not-cheap cologne and I see a streak of razor burn above his crisp white collar. “Hey, Theresa,” he says. “If I asked you to get me a cup of coffee would you do it?”
Hmmmm. This is a new wrinkle. When joking with attending physicians there’s always a risk of crossing the line between teasing and impertinence, but this doc is skating very near the line between banter and insult. I can’t let him get away with treating me like a servant, or a nurse from forty years ago. Plus, I feel on firm ground with this MD, who doesn’t take himself too seriously.
“Sure,” I say, “As long as I could bring it back here and pour it over your head.”
We’re being flirty, yes, but there’s aggression here, too, some old-school doctor/nurse nonsense.
“Well, just as long as you bring it to me,” he says, being boyishly charming. “That’s what matters.”
And then he drops his arm from around my shoulders and switches back to work mode. “OK,” he says, “Dorothy Webb,” and points at Lucy, the nurse practitioner, or NP, while we cluster around her in the hallway. Lucy’s short and today has tamed her thick black hair with a bright red headband. She reviews Dorothy’s history and updates the team—the attending physician, a clinical pharmacist, another NP, and a physician assistant, or PA—on Dorothy’s status.
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 Shift Page 5
