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 sche
dule. 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.
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
Rapid 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.
The Shift Page 6
