The Shift

by Theresa Brown

  I don’t know why the medical student thinks it’s my job to explain our software to him and I don’t mind, usually, but his timing sucks. I squeeze my lips together, holding in frustration, then arrange my face to look neutrally helpful. Clueless now, he’ll be a full-fledged doctor someday and I want him to see that nurses can be collegial.

  He wants two small things explained: how to look up laboratory results and where to find the radiology report on Sheila. Geez, don’t they teach the students anything before they start in the hospital? In a couple of years they’ll be residents practicing medicine on real patients, but until then it’s like no one even tells them where the bathrooms are.

  This guy is nice despite his nervousness. Questions answered, he heads toward Sheila’s room and I’m right behind him when my phone rings. It’s Lucy, the nurse practitioner, wanting to update me on Dorothy’s discharge. There will be dose adjustments in a few of her meds, so it’s going to take a little longer.

  “OK.” I hang up and reach for Sheila’s door when the phone rings again. “This is Trace Hampton. Richard Hampton’s son.” His voice is pleasant and direct and he asks me not to start the Rituxan until he can be there, around three in the afternoon. I look at my watch. It’s 11:00 a.m. Considering I don’t have orders yet that should be fine. “No problem,” I tell him.

  Then the phone rings again. It’s Sheila’s intern, the one with the long hair parted in the middle who smiled at me to show we were on the same team. “What’s going on? No one’s told me anything.”

  “The surgical service is already here,” I tell her. “And I’ve stopped the Argatroban. Beyond that I have no information except we probably won’t be moving her to the ICU.”

  “Can you call me when you find out anything?”

  “Sure.” I remember my question for her. “Did you order fluids?” I haven’t had time to look it up on the computer yet.

  “Yes. Normal saline at seventy-five.”

  “Great. I’ll page you when I know what’s up.” I push the off button and see Peter and the medical student heading back up the hallway. I missed Peter’s entire conversation with Sheila.

  He turns around and flashes me that irresistibly friendly smile. “See ya later,” he calls out, giving an exaggerated wave.

  “What?!?” I say, playing along with what I think is a joke. It has to be a joke—how could he leave without filling me in? But my phone rings again so I can’t quick-step after him to make sure.

  “We have a Candace Moore down for a dye study and imaging today. It’s not clear what exactly the problem is, though . . .”

  It’s interventional radiology and I don’t have an answer for them beyond her telling me her line wasn’t working. “Um.”

  “ ’Cause we just got two emergencies, so we’re gonna have to push her back a few hours, OK? We’ll call you when we’re ready for her—it’ll be a while.” He hangs up.

  I absolutely should go in to see Sheila, but first I run my eyes down my papers. Dorothy has a med due and I need to find out if Mr. Hampton is any more with-it than he was. I should also tell him about his son’s phone call and that we won’t start the Rituxan until at least three p.m. And now I have to tell Candace that her trip to IR has been delayed and hope she takes it well.

  Prioritizing: The problem is, Dorothy will want to chat, and while I enjoy chatting with her I don’t have time right now. I get out her pill and steel myself for a quick getaway only to discover that my planning was unnecessary. She’s once again on the phone to her daughter (or maybe she never hung up?) discussing her discharge. I set down the pill in its little plastic cup and wave. She waves back by wriggling her fingers in her usual way while talking. “Now when I get home we’ll have to wash all the drapes. And maybe we should have the carpets cleaned. Also . . .” I leave. I can only imagine the domestic whirlwind Dorothy is going to be after being away from her home for more than a month. As I head out the door she’s saying, “No, of course I won’t be doing the cleaning myself!” I smile. Her daughter will make sure Dorothy takes it easy, whether she wants to or not.

  Mr. Hampton is sleeping again when I go into his room, but he’s more alert when I wake him up than he was before. I give him the message from his son and he nods. He seems to know where he is, but his breathing is not easy.

  Now to inform Candace about the delay. If my life were a play, this would be the moment of French farce—going in and out of adjoining rooms never knowing what I’m going to find on the other side.

  I knock on her door and walk in. “Thank goodness,” she says, raising her face to me, her eyes squinty with anger. “That shower curtain is moldy and look at this—look!” She holds out her hand, protected with a latex glove, and I glance down at it, seeing in her palm a quarter-sized ball of tangled hair and lint.

  “That’s, um . . .”

  “Dirt! We found it behind the bed. On the floor!”

  I swallow. We clean constantly in the hospital because residual dirt is never just mess. Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococcus (VRE), Clostridium difficile—these are the bacteria that live in hospitals and even sometimes in rooms that have been thoroughly scrubbed. A microscope might reveal Candace’s dust bunny as a deadly disease vector. That is not a joke. She will be severely immuno-compromised after transplant, making her susceptible to infections that wouldn’t ever trouble a healthy person.

  I swallow again. Hospital administration recently laid off some housekeepers to save money and the ones left on the job now have too much to do. As with nursing and doctoring, mopping and wiping can only be speeded up so much before efficiency degenerates into missed spots.

  “That’s why we’re cleaning the room,” she says, and her cousin nods aggressively, keeping her back to me as she carefully rubs the windowsill with a Clorox wipe.

  There’s nothing to do but make things better from here on out. “You’re right about the room.”

  “I know that!” she says, but her eyes are more relaxed. She’s probably used to people treating her as though she’s annoying rather than correct. Score one for empathy.

  “You may not like this, either,” I say, “but IR just called and they have to push back your dye study. They got two emergencies back to back.”

  “Oh, that’s OK,” she says, wiping down the stainless-steel bed rails. “Tell me when they’re ready for me, but don’t forget the new shower curtain! That shower curtain is disgusting!”

  “She could die from that shower curtain,” the cousin throws in.

  “Right. New shower curtain.” I slink out of the room without even checking to see if it really is moldy. It’s a five-dollar shower curtain. After the hair-and-bacteria ball under the bed I’m not going to argue.

  Out in the hallway I call maintenance before I forget. “OK,” the guy says, and I hang up, relieved that for once I could tell someone about something needing to be fixed and they would agree to do it without my having to explain.

  Ping-ping-ping my phone rings again and this time it’s Peter calling me; he’s back on the floor. I look at Sheila’s door. I should go in, see how she’s doing. But it’s easier to ignore a closed door than a live person on the telephone. “I’m coming right now,” I tell him, putting my phone in my pocket and walking to the nurses’ station.

  He sits in front of a computer surrounded by a flock of surgical interns and residents, bright in their long white coats. One is on the short side with red hair and freckles on his plump cheeks, another is tall with a long face. And then I see my real-life next-door neighbor, Akash Patel. Young, handsome, from an Indian family, he grew up in the South and now lives in the house adjacent to mine. Akash is very smart and very nice. His wife is sure he works too hard, which I think is a common feeling among doctors’ spouses—women and men.

  A surgical team encamping on our medical oncology floor in the middle of the day is unusual. Dot, the veteran nurse with a bottomless reservoir of common sense and a sly smoky laugh, si
dles up next to me. “What’s going on?” she whispers.

  “My patient, Fields, has a perf.”

  “Oh shit,” she says, scrunching up her face. “When?”

  “They just found it on CT. She came in last night from an outside hospital.”

  “Are you OK?” This is a hospital question that asks about much more than it seems to: Is your patient stable or could she spiral down at anytime? How’s the rest of your load? Are you calm or panicked at this emergency?

  “Right now I’m good, but I’ve got Candace Moore.”

  “Oh . . . shit.” Her great laugh comes low and deep.

  “And I’m giving Rituxan later to a seventy-five-year-old on oxygen.”

  “Who thought up that assignment? Oh wait, let me guess.” Her eyes slide over to the charge nurse.

  “You got that right,” I say.

  “Hey,” she says, serious now. “You can only do what you can do, and you know where to find me if you need help.”

  “Thanks,” I squeeze her arm and turn back to the flock of surgeons.

  “Hey,” I say to Akash, who nods his head back at me. I jerk my thumb toward him and ask Peter, “Did you remember that he’s my next-door neighbor?” Peter and I had talked about Akash before.

  “Oh, that’s right,” he says, not taking his eyes off the computer screen.

  “So, are you being nice to him?” I ask.

  Peter looks up. The air feels electric. I may have crossed a line, just like Dorothy’s attending did this morning when he teased me about getting him coffee. This line isn’t doctor-nurse, though; it’s resident-attending. Peter is nice, but at the moment he is also my neighbor’s boss and it’s not my place to pester him about that no matter how many bad jokes he makes with our secretary or how good my intentions.

  He turns back to the computer screen unperturbed, though, and begins planning out loud. “Stopped the Argatroban around 10:00 a.m.—let’s say 11:00 a.m. just to be safe; so we probably can’t operate until five at the earliest depending on her clotting factors.” He stops to think for a moment. “Have to call the oncology attending, see if we can give her anything to speed that up. What’s her pressure?”

  “It’s been high,” I say while he scans the computer, “160 over 100. Though I haven’t checked it for at least an hour.”

  Akash says, “That’s fine. And better too high than too low,” while the other residents nod.

  “She’ll have to see anesthesia,” Peter continues. “They’ll talk to her—for a really long time—plump her pillows, get her ready.”

  “Will they give her tea?” I ask, playing along with his joke.

  Peter glances at me and says, “With cookies,” then turns back to the computer screen.

  Finally looking up from the computer screen, he announces, “I’m giving her to Akash. You’ll be the resident in charge of her case.”

  This is excellent news for me. It’s much easier to work with someone you know than someone you don’t and even better if you know you like them.

  Peter’s pager buzzes and he pulls it off his waist, checks the number, and nimbly reaches for the phone next to the computer. Akash walks over to me. “What’s her IV access?”

  “She’s got a twenty-two gauge in her left arm.”

  “Do you think it will hold?” He’s asking me if her IV will stay functional. The non-permanent intravenous lines can go bad at any time, though they usually work well enough for at least a couple days.

  I raise my hands in an “I don’t know” gesture: “It’s working.”

  “Fluids?”

  “Normal saline at seventy-five.”

  “Let’s increase that to one fifty. We want to keep her plenty hydrated.”

  I nod. “I’ll put it in as a verbal.”

  He looks at his watch. “You’ll be home late tonight,” I say. “Tell Monique that it’s all my fault.”

  He laughs, then asks me to write down his cell number. “Can you call me when she’s on her way to the OR? It just makes it easier.” He sounds apologetic and I’m surprised that he’s asking me to call him directly rather than paging and waiting for a call back. That we carry phones, which have to be answered when they ring, whereas doctors have pagers that they can, at least briefly, ignore, sometimes feels unequal to me. But I also know that a page can be just as disruptive and annoying as a phone call. Docs aren’t as immediately on the hook as we nurses are with our phones, but the pressure to call back ASAP must be fierce.

  I spent a day shadowing in the emergency department when I was in nursing school. An elderly woman who’d fallen needed a hole drilled in her skull to relieve the pressure from a bleed in her brain.

  A neurosurgery resident was called in to do the job and a more tired-looking human being I hadn’t seen in a long time. His face was ashen and being unshaven only emphasized the lack of color on his cheeks. His scrub pants were too big and too long and his scrub top was so wrinkled it looked as though he’d slept in it.

  He held the drill up to the back of the patient’s head with a narrowing of his eyes, hoping focus would keep his hands steady. As the drill went in small pieces of bloody tissue and bone spattered out behind the unconscious patient.

  His pager kept beeping. Every time it beeped he would stop the drill, put his right forearm up to his forehead, pick up the pager and look at the number, then go back to the drill until the pager beeped again.

  I thought that if I were having a hole drilled in my head I would not want the person doing it to be constantly interrupted, or interrupted at all. I picked the pager up from where he’d left it on the stretcher and mimed that I would be responsible for it until he was done.

  He shifted his eyes over to me quickly and gave one shallow nod. Then he returned to the patient’s head, the application of the drill. It can’t take that long to make a hole in someone’s head and thread in a drain for the accumulating blood, but it felt like we stood there for hours, me holding the pager and writing down numbers when it beeped, him blinking to keep his exhaustion away.

  When he was finally done he put his right forearm up to his forehead one last time. He set down the drill and without even looking at me took the pager along with the numbers I’d written down. He turned around to the phone on the wall behind the patient and started dialing.

  Peter hangs up the phone now and our attention turns back to him. “I’m going to go back and talk to the family. Akash, you prepare.” The surgical residents nod and start to leave in a group, including Akash. “I’ll call you,” I mouth to him, holding up the paper where his number is written down. Then I follow Peter and his medical student back down the hall to Sheila’s room.

  “How’s Arthur’s leg?” Peter asks. My husband badly broke his left tibia and fibula a couple winters before.

  “It’s good, hurts occasionally.”

  “Really?” he looks puzzled, but we’ve reached Sheila’s room, so I can’t ask him why Arthur’s continuing leg soreness seems confusing. He gives the door a quick rap before opening it. I pretend the medical student isn’t standing right behind me. If I ignore him he can’t keep me out of the room with questions.

  Sheila is half-sitting up in bed and two more people, a man and a woman, roughly Sheila’s age, are also in the room. I’m guessing they’re relatives.

  “Does anyone else in your family have this clotting disorder?” Peter asks. It seems abrupt, but then I remember he’s talked to them already. I was the one who missed that conversation.

  “Well, we think our mom probably had it,” the woman in the room says, “and our brother maybe, too.” She glances at Sheila. “We don’t hear a lot from him, though.” She shakes her head. “But the rest of us are close.”

  The man, sitting in a lounge chair in the room’s back corner and wearing a baseball cap, is half in shadow and has a thick black beard. Peering, I see that his wedding ring looks like it matches the one Sheila’s sister is wearing. The brother-in-law. His baseball cap has a wrench printed on it and I
can just make out the writing in the dark, FIELDS’ PLUMBING. I remember a note about a family business. Maybe the three of them all work together.

  Peter describes the operation Sheila will have in detail, how they’ll remove part of her colon and most likely leave her with a colostomy. A colostomy is a diversion of the bowel to the wall of the abdomen. The end of Sheila’s colon will be relocated to the skin of her belly and her large intestine will drain into a bag that attaches there. When I first learned about colostomies I found them unsettling, even repellant, but a nursing instructor reminded me, “Life is precious.” All it does is change where the shit comes out; that is not worth dying for.

  Peter explains that some colostomies are reversible and some aren’t. Sheila’s probably will be, but doing any surgery on her is risky because of the antiphospholipid antibody syndrome. In the end he would probably advise against restoring her bowel to its natural configuration: the potential risks of bleeding or clotting seem to permanently outweigh the benefits of returning to normal.

  Then the conversation turns darker. Nothing changes in Peter’s demeanor, but the things he says come across as almost cruel. “You’re a smoker and you’re overweight,” he tells her. Both things will cause Sheila to heal more slowly than normal and she’s going to have a big incision.

  Then he drops the other shoe and it’s a big one: “There’s a twenty percent chance you won’t survive this operation.”

  I look over at him. He’s wearing a dark suit, holding a sheaf of papers in his hand. His expression hasn’t changed. There’s maybe a little more intensity around the eyes, but he’s very clear and not impersonal. He could be a lawyer, an accountant, a corporate vice-president—anyone but a surgeon. Except that he is a surgeon.

  I would not want to give Sheila such news, but he does it without flinching; he just says it. He is a kind man, a good doctor. I know both those things. How does it feel to tell someone there’s a one in five chance the operation she is preparing for will kill her?