We don’t usually have surgical patients up here on the heme/onc floor, but today it seems like I will. Absorbing this diagnosis is like moving a train through switches to get it on the right track. Sheila has a clotting problem, not a perf. But she has a perf, too. Click, click, click—my brain tries to adjust.
“Can you call the resident?” the radiologist asks, and his voice sounds very far away. I’m stunned, but now I get it. Sheila has a perforated, which is to say torn, intestine. There’s a final click of the train track, then, “Yes, yes,” I tell him. “I’ll call.” I hang up the phone.
This is bad. “A perf” is a phrase we learned to fear in nursing school because it is difficult to detect and deadly. I look on my paper for the intern’s number and send a page with my phone number as the callback. I feel terrible that I had no inkling Sheila was so seriously hurt inside, but the truth is, diagnosing what’s called an “acute abdomen” is complicated, and a scan is the only way to know for sure that a patient has perfed.
It’s not the perforation itself that’s so dangerous, though it will have to be surgically repaired; the gravest danger comes from the intestinal contents oozing from Sheila’s GI tract into her open abdominal cavity. The insides of our bodies are sterile except for the parts open to the outside world, and while the human digestive tract is filled with bacteria that are essential for healthy digestion, those bacteria can become deadly if they proliferate in parts of our bodies that are supposed to be germ-free. In Sheila’s warm, wet abdomen intestinal bacteria will multiply with little control, becoming an infection called peritonitis, which can become an even deadlier condition: sepsis.
Sepsis stimulates a catastrophic response from the immune system called SIRS for Systemic Inflammatory Response Syndrome. The acronym sounds polite but the reality of SIRS is not. At the late stages of sepsis, fluid from the blood stream moves into the body’s tissues, leaving a reduced volume of blood in the arteries and veins. Due to this decrease in volume, the patient’s blood pressure drops, and can keep dropping until there isn’t enough pressure to send blood to every part of the body. When that happens, organs begin to shut down and die.
To picture what happens during the late stages of sepsis, imagine a garden hose with small holes placed throughout to turn it into a sprinkler. When a normal amount of water goes through the hose, the sprinkling effect is constant. If the flow decreases, the sprinkler effect becomes more erratic, and if the volume of water in the hose lessens even further, the sprinkler will turn into a leaky mess that waters only the strip of garden it rests on.
The tissues of our bodies are like that garden. Humans need constant watering with oxygenated blood—this is called perfusion—to keep our tissues healthy and alive. Human cells can become as parched for oxygen as carrots and zucchini in a garden become for lack of water, and if the flow of blood is too diminished the cells of our bodies will die, just like the vegetables in a drought-stricken garden.
Sepsis is a medical problem, but we can’t treat only that—a surgeon must fix the hole in Sheila’s gut to give her a chance of surviving this crisis. She’s a medical patient on a medical oncology floor with a serious surgical problem and we have little experience with such cross-disciplinary cases in bone-marrow transplant. Sheila’s perf puts me clinically out of my element, just like her attending physician, Dr. Martin, was out of his.
And then the guilt comes on full bore. Why didn’t I see this coming? Why didn’t I know? A good nurse has intuition; I believe that. I listened to Sheila’s belly, but obviously I should have listened harder, better, thought more about what I was doing. My intellect was certainly piqued by antiphospholipid antibody syndrome. Was I not thinking about Sheila’s abdominal pain because I was hoping that taking care of her would increase my knowledge of the clotting cascade and rare blood disorders? And is that why I didn’t listen to her belly sooner?
Well, I’m learning a lot, but not what I hoped. Some years ago I had a different patient in the same room as Sheila, writhing and moaning with abdominal pain. Her husband was a yeller, one of those guys who’s used to getting his way by being louder than everyone else. In the age of reimbursement based on patient satisfaction scores, nurses are discouraged from asking people to “please stop yelling because it makes it impossible for me to think.”
I paged the oncology fellow because the husband insisted on what he called a “real doctor.” The fellow came over, did a physical exam, and even though there was nothing indicating the need for a CT scan, there was a feeling of inevitability in the room. No matter what the fellow found, the wife would get that CT of her abdomen; and she did. There was no blockage of her intestine, not even a partial obstruction, and certainly no perforation. Cancer itself can cause extreme pain and pain medication was all she needed, though she did require a lot.
I realize now that the memory stayed with me as an example of sound and fury signifying nothing. I made the mistake of equating loudness of suffering, including the belligerent husband’s, with clinical severity. His yelling intensified my concern for the wife, as it should have, but when we confirmed the wife’s bowels were working fine, at least as far as the CT could show, I made that experience my baseline without thinking it through. In that situation there was lots of yelling and no perf. Therefore, a real perf would evince more moaning and writhing and even louder yelling.
A psychologist would call that a reaction formation: my outsize anxiety about a non-existent abdominal perforation led me to believe that if an actual perf occurs the patient will have a lot of pain and be very agitated. This, I now know, is wrong.
If there’s one thing I should have learned in the hospital, it’s how little control—of the good or the bad—we really have. Dorothy is cured and going home. Mr. Hampton is getting Rituxan and I am worried that it will hurt him more than help, or at the very least land him in intensive care. Candace is a hard patient to manage, but of course I want her transplant to go well. And now Sheila, my learning opportunity, turns out to be a slow-motion medical emergency.
My phone rings. “Medical Oncology. Theresa.”
It’s the intern. She’s already heard from the anxious radiologist. “Stop the Argatroban,” she tells me. She sounds scared or maybe, like me, she feels guilty for having no premonition about the perf. It’s not rational that some of us who work in health care expect ourselves to be omniscient.
“If we stop the Argatroban now it will take several hours to clear her body. They can’t operate until then.” She hangs up.
I slide my phone back into my pocket and wonder who’s going to tell Sheila this terrible news? Me? I would, but without any kind of plan in place I’d unnerve her without being able to list her options. I know very little about the surgery she will need.
My phone rings again. “Hey, it’s Peter. Are you taking care of Sheila Fields?”
“Yes,” I tell him. Click, another switch goes through; my mind is now mostly on track with Sheila’s perf. Peter is Peter Coyne, an attending surgeon who is also a friend. The most common thing people say about Peter is, “I love Peter Coyne.” He puts the lie to the common stereotype of surgeons as arrogant. He’s sweet and a huge fan of bad puns and even worse jokes that I always laugh at despite myself. Whoever put in the consult for Peter to become Sheila’s surgeon did a good thing for her.
We met a couple of years ago over the phone. He’d surgically placed a permanent intravenous line, a triple lumen Hickman catheter, in one of my patients and I needed to know if the line could be used. I was a new nurse and not as clued into the hospital hierarchy as I would eventually become. I called around to find out about my patient’s IV line and someone told me to just page Dr. Coyne so I did.
My straightforward question, crisply delivered, “Is this newly-placed Hickman OK to use?” somehow devolved into a joke that made no sense but struck me as very funny.
“Well, I don’t know,” Peter said, “Are we placing Hickman catheters today or pumpkin catheters? If no one told you whether th
at line is safe to use I may just have to start handing out demerits.”
The unexpectedness of his answer surprised me and I couldn’t stop laughing. Then Peter got serious and told me the line was good and he would put an order to that effect in the computer.
“We’ll be up soon, but I need to talk to her doctor,” Peter tells me now. “Do you have the name?”
“I have the intern’s name.”
He laughs, but it’s strained. “This isn’t a case for the intern; I need to talk to the attending.”
This is unusual. Attendings may talk to each other at meetings, or socially, I suppose, but on the floors they seem to only talk to each other through go-betweens such as interns or nurses or through scribbled notes that often don’t even get read.
Attending to attending confirms my worries about Sheila. But Peter is on the case, so soon we will have a plan and it will be a good one. I think of the frustrated heme/onc attending, Dr. Martin. He was upset about having a patient with a blood disorder. Sheila’s situation will only make him feel less capable of taking care of her.
“Nicholas Martin is the oncology attending.”
“Oh, I know him,” Peter says. There’s something in his voice, not neutral, but I can’t fix on it. “I’ll call him.” He hangs up.
I look down at the admission paper on my medcart. I need Candace Moore to take her time getting here because I’m short on patience, even though Sheila can’t be operated on for hours because the Argatroban would make a complicated abdominal surgery even more dangerous than it already is. Because Argatroban slows clotting times, any cut would bleed much longer than usual and fixing a perf requires a large incision. Sheila’s also overweight enough that she has thicker-than-normal layers of tissue to cut through for the surgery. The risks of excessive bleeding are obvious.
“You have no idea how much blood the human body holds,” Matt, the ICU doctor from this morning’s emergency, told me once, recalling what it was like to watch that precious fluid run out of a patient’s body and cover the hospital floor when he had no ability to stop it.
But Sheila’s stuck. The bacteria in her abdomen will multiply and spread while we wait for the Argatroban to clear her system. As time passes we swap one potential for death with another, but it’s what we do here. The cutting edge of health care sometimes nestles just next to the razor’s edge of survival. I check my watch. It’s 11:00 a.m.: we’ll have several hours of watch and wait.
I log into the computer, checking for any new orders on Dorothy, Mr. Hampton, or Sheila. All orders get recorded electronically and the computer is where newly placed orders pop up for nurses. While I think of it, I enter the verbal order the intern gave me to stop the Argatroban on Sheila and I write a note to myself to disconnect the drug once she’s back on the floor. That should be soon.
But why wait? I call radiology and ask a nurse there to disconnect the Argatroban and ask her to tell Sheila there’s been a change in the plan, which is true, even if my banal phrasing doesn’t reflect how dire her situation is.
Ping-ping-ping. “Your admission is here!” the secretary says in her chirpy voice. Ugh. This timing is so bad. Not that I’m rushed right at this moment, but I’m worried about Sheila and preoccupied with my own useless feelings of guilt. Well, both of those will have to wait.
I quickly glance into the empty room between Mr. Hampton and Dorothy. Candace will start in on us right away if it’s not, in her view, perfect. I repress my impatience as I see her push through the double doors toward me. She’s pulling two designer suitcases behind her; she’ll be here for at least a month. Her straight black hair is beautifully blown out. Is that a wig? I can never tell.
She smiles a big smile and I smile back, but I know the warmth she’s offering probably won’t last. Taking care of her usually feels like an emotional chess game.
“Candace. So it’s really time for transplant.”
She hugs me, giving my back a soft pat. She smells of citrus and expensive shampoo. “Well, first my dye study,” she says and I squint at her because I don’t understand.
“Dye study?”
“My Hickman’s not working right,” she says. She’s had it for several months now and they do malfunction. If we suspect a defect in the line, the patient goes to interventional radiology where they run dye through it while taking X-rays. It’s a fairly precise way to show where the Hickman ends in the body and if each of the three lumens works correctly. “I told them I’m not having my transplant with this line until I have a dye study and that it’s going to be today, right now.”
I know I should just agree with her, but my curiosity gets the better of me. “What’s wrong with it? Do you want me to flush it, check whether it’s OK?” The lines are fairly simple mechanically and there are only a few things that can go wrong with them.
“No, I don’t want you to check it; it’s not working!” she bursts out, her voice almost shrill. “Would you want a transplant through an IV line that wasn’t working? Or someone messing with it?”
“No,” I say, shaking my head. Why did I ask her? “So that’s today?”
“Yes, I’m just dropping my bags off and going down there.”
“They’re expecting you?”
“They’d better be,” she says. I nod, smile again.
“Let me call transport. Since you’re here as a patient, we’ll want you to go down with an escort.” I think for a minute, then explain hesitantly. “We’ll need to send you with your chart, too, so there will probably be a little bit of a wait while we get that together.” I try to sound pleasant, but firm, not like she’s been here for five minutes and I’m already apologizing.
“Oh, that’s fine,” she says brightly, her mood once again friendly, talkative. “No rush—my cousin’s on her way in and we can clean the room while we wait.” She holds up a grocery bag defiantly and through the thin plastic I see that it contains two large containers of Clorox wipes.
We go in the room and she puts one of her suitcases on the bed and tells me, without turning around, “I know you’re busy—you just go do your work and I’ll get settled in here.”
In the hall, Nora, Mr. King’s nurse, puts her hand up to her mouth and loudly whispers as she walks past, “Candace Moore.”
“Good news travels fast, huh?” I say.
Breathe, I tell myself. Just breathe. Our bodies can’t make energy without oxygen.
CHAPTER 5
Surgical Team C
Needing to clear my head I walk up to the nurses’ station. When people ask why I left teaching English to become a nurse, it must be moments like this that puzzle them. Instead of being here at the hospital, concerned about madly proliferating bacteria and killer drugs, I could be discussing a novel with a group of interested college students. There’s a lot more control in a classroom than in the hospital and no one’s life was on the line as a result of my work in the Tufts University department of English.
I look up and there’s Peter Coyne at the nurses’ station, his white coat emphasizing the straightness with which he holds himself. He’s tall and athletic-looking, with short-cut gray hair, and immediately he starts joking around with our secretary: “Someone said they tried to page me, but they didn’t have a Coyne for the phone.” His smile is irresistible even though the pun is terrible. The secretary laughs and he keeps going: “To Coyne a phrase, did someone page me?” At the same time escort arrives back on the floor with Sheila.
Two of them have brought her, the blond guy from before and a short African-American woman with high cheekbones and long braided hair. They both have lives, hopes, and dreams, but the boundary between their world and mine is another that rarely gets crossed.
The stretcher is angled away so Sheila doesn’t see me. I look in her direction quickly and see the Argatroban, unhooked on the IV pole, its tubing looped up neatly on one of the pole’s metal hooks. The nurse in radiology hung a bag of normal saline in place of the Argatroban and I see that it’s infusing—I’ll check
the orders and make sure the intern put that order in.
I should go over to Sheila and explain what’s happening, but instead I gesture discreetly toward her room. I want the two escorts to get Sheila into bed without my help because I’d rather talk to her after I’ve checked in with Peter and have solid information to deliver.
The whole system should probably put more of a premium on giving patients disturbing news quickly. If it were me I would not want to discover that someone else had secret information about whether I might live or die and didn’t tell me. But then again, I also wouldn’t want them to frighten me with bad news if they weren’t sure.
Peter keeps joking and I feel my impatience, so I interrupt him, “Let’s go. I’m worried about my patient.”
He stops joking and looks at me, suddenly earnest. “Does she need to be in the ICU?”
I think about it. “No. Her pressure’s been good—she’s stable.” Since the bacteria multiplying in Sheila’s belly will make her sicker over time and the overarching fear is sepsis, paying attention to her blood pressure is critical. Having Sheila’s blood pressure remain normal or high is good right now. If she starts to drop—like the water pressure failing in the garden hose—we’ll know she’s getting sicker fast.
Peter and I head down the hall to Sheila’s room. I’m ready to go in with him but the medical student who’s been trailing us gestures at me in front of the computer in the hallway. He has a question.
These poor medical students. They worked so hard to get into med school and then in the hospital no one gives them the time of day, in part because they have no real purpose, at least on our floor. They’re supposed to be learning and I’m sure they are, but as far as we nurses know they can’t do anything. Plus, the white jackets they wear, deliberately shorter than the long white coats of the interns, residents, and attendings, make the male students resemble those little boys in old photographs wearing short pants.
The Shift Page 8
