I could ask him, probably will ask him at some point, but I already know he won’t tell me the truth. Instead he’ll say he was thinking about what’s for lunch, or remembering some joke one of the nurses in ICU told him earlier, or that he’d kill for a cup of bad coffee.
Myself, I feel charged up. I guess it’s an adrenaline rush, the same one that started when I heard we would give Mr. Hampton Rituxan, and that ramped up even more when the radiologist called me about Sheila. What if we kill him and can’t save her?
Peter finishes talking and Sheila starts to cry quietly. He’s already on his way out, trailed by the medical student. We’re all too damn busy. I’m sure this emergency has been shoved into a completely packed schedule. He has no time to be gentle.
Sheila looks as if she’s having an internal struggle. She is afraid, but is also telling herself not to be a baby, to stop crying. I want to validate her more vulnerable feelings.
“This is big,” I say, hoping that doesn’t just increase her anxiety and wishing I could stay in the room with her and her family. Instead I hand her the Kleenex box and rush out after Peter. “I’ll be back,” I announce, “I want to ask him a few more questions out in the hall.”
At the nurse’s station Peter is on the phone with Dr. Martin, Sheila’s physician who felt out of his element on morning rounds. “Can we give FFP? Platelets?” He wants to use a blood product that promotes clotting—fresh frozen plasma, a transfusion of platelets—to make surgery safer and faster. But when Peter gets off the phone he reports, with just a touch of irritation in his voice, that according to Martin transfusions will not speed up Sheila’s clotting time; we all just have to wait.
Peter’s too polite to say anything like this directly, but I suspect he feels blown off, as if the cancer doc, already bothered by having a patient with an unusual blood disorder, is even less inclined to be thoughtful now that she’s been found to have a surgical problem. He could also just be frustrated there is no quicker fix than waiting.
We don’t talk about Dr. Martin, but we do talk about what will most likely happen to Sheila and when. I need the process to be clear so that I can explain it to Sheila and her family.
Before I return to Sheila’s room I ask the secretary to call maintenance and make sure they got the new shower curtain for Candace. I haven’t seen anyone on the floor but I might have missed him.
“Shower curtain? They were brand-new a month ago. These are the new ones that, um, you know, keep off germs.”
“I gotta go,” I tell her, frowning just enough to look hang dog without being pathetic. “Can you just call for me?”
“If you stop making that awful face,” she says.
I laugh out loud. “Deal!” Then I head back down the hall and see Sheila’s intern in our secondary computer room off the hallway.
“Hey,” I say, and she nods at me. “Surgery’s been here. Peter Coyne, do you know him? We’re increasing her fluids to 175, normal saline—”
She interrupts me. “It’s not my case anymore.”
“What?”
“She’s switched over to surgical. She’s not my patient.”
“Oh.” I wonder why no one told me. It’s the kind of change that should go on our whiteboard, too, but often gets forgotten.
“I like hearing how she’s doing, so thanks.”
“Sure. No problem.”
I go back into Sheila’s room. She’s quietly crying and her shoulders gently shake as one tear after another slides down her face. She looks at me with that same guilelessness I noticed this morning. Her sister, however, won’t look at me at all.
“She thinks it’s wrong for doctors to give odds like that,” the husband says, indicating his wife. He’s leaned forward out of the shadow so that I can see his face. Above his bushy black beard his eyes look pained. His thick fingers are spread out straight on his solid thighs and he holds his torso stiffly. “She thinks it does more harm than good.”
Sheila’s sister is right, of course she’s right, but she’s wrong, too. If the worst happens isn’t it better to have some forewarning, to know before surgery that her sister may not come out of the OR alive? Wouldn’t we all want to know that? Or is that just me, stubbornly wedded to the truth no matter how painful it is or how remote? The odds are in Sheila’s favor, but it’s not my sister who’s going under the knife; maybe if it were I wouldn’t want to know the risks, either.
“Yes,” I say. There’s no need to convince her that Peter’s honesty was ethically correct or even essential for informed consent. Sheila will get the operation and she will probably survive it. Why argue about the right or wrong thing to say? Fixing Sheila’s perforated bowel will threaten her life but if we do not fix it she will die.
I say nothing else and Sheila’s sister turns around to look at me. Her face is drawn and she’s dark where Sheila is pale, but their features are very similar: the same round eyes, the same cute button nose. Right now, more than anything, the entire family needs someone to trust.
One summer when I was a kid a group of us were playing outside—me, my brother, the Allen boys, my best friend Erica—and it started to lightly rain, but only in small, separated patches. In southern Missouri, where I grew up, summers are hot and the rain felt good, but it was unusual, startling, how it fell in one spot for just a minute, then stopped, moved a couple of yards and started up again.
We ran after the rain, chased it, wanted to always be under it as sunlight glinted through the drops, making a lattice of light out of the bursts of gently falling water. “It’s over here,” one of us would call out, running to the rain. “No, now it’s here,” someone else would say, heading off in the opposite direction: “I’ve got it! I’ve got it!”
There were no interruptions to this summer idyll, no adults asking what we were doing, just us kids, breathless, moving fast. Did it last for five minutes? Ten? It wasn’t any longer than that, but I can recall the joy I felt. How rare—the chance to catch a rainstorm.
To see a World in a Grain of Sand
And a Heaven in a Wild Flower
Hold Infinity in the palm of your hand
And Eternity in an hour
William Blake wrote those lines more than a century ago and he was on to something. It’s not exaggerating to say that Sheila could be dead tomorrow. Today this is the storm we chase: the infinite potential of Sheila’s continuing life, held in the hand of the hospital. As a child I experienced only wonder while running after flashes of rain; I saw a world, a heaven. Now, grown-up, I try to draw on my child’s sense of awe and commitment as I help Sheila confront, perhaps, the end of her time on earth.
She will have pain, her blood pressure will need watching, and her blood itself has already been revealed as untrustworthy. Getting the timing right is critical, so I’ll be following the rain, but looking for the light. I believe there will be light if only I can find it in the storm.
I sit down in the chair next to Sheila’s bed and take hold of her hand. It’s soft and warm and she gives me a sad smile. Her sister reaches over and uses her own hand to wipe Sheila’s tears. Then she, the sister, takes hold of Sheila’s other hand. “Here’s what will happen,” I tell them. “We’ll allow six hours minimum for the Argatroban to clear, then we’ll draw labs to check Sheila’s clotting time and see where we are. Surgery tonight, but it’s impossible to say what time even approximately; there are too many unknowns.” I tell them Peter is a good doctor and will do an excellent job. I tell them I’ll be with Sheila, and the two of them, until she leaves the floor and afterwards she’ll go to the ICU because she’ll need the close attention intensive care provides.
I hold infinity in the palm of my hand, and eternity in the next few crucial hours.
CHAPTER 6
Paperwork
The time I spent with Sheila, her sister, and brother-in-law feels like one of the most important things I will do today, but it doesn’t show up on any of my electronic to-do lists. We need a menu that includes the option: s
pent time comforting patient with life-threatening diagnosis. But nothing that empathy-intense gets included in our required paperwork.
A lot of what nurses document is strictly CYA, as in Cover Your Ass. We record most of what we do on paper, or more typically, in the computer, including proof that we’re complying with all the regulatory requirements for hospitals. The morning assessment on every patient—what I heard when I listened to their lungs and heart, how their skin looked and whether they are moving their bowels—must be charted in addition to all medications given. Pain medicine, like the Dilaudid I gave Sheila, gets charted on a series of menus that specify where she feels pain, rate her pain from one to ten (based on me asking her, with ten being the ‘worst pain ever’), and say whether the pain is aching, burning, cramping, stabbing, shooting, or another of the fifteen different descriptive options. Patient care—looking after Sheila, Dorothy, Richard Hampton, and Candace—is heart and soul, but these days, charting pulls nurses away from the bedside more and more.
Now’s a good time to catch up on my charting, though, because lunch is being delivered. The woman taking in trays catches my eye. “Fields is NPO now. Is that right?”
“Yes. Thank you.” NPO: short for nil per os, which is Latin for “nothing by mouth.”
I try to chart my meds on the computer as I go along since that makes it less likely I’ll forget something. Charting my morning assessments before the morning is actually over is a goal every shift and I did Mr. Hampton’s and Dorothy’s, except, I realize, shaking my head, I never even did an assessment on Candace, much less charted it. She just got here and she’s energetically cleaning her room so it’s likely she’s fine, but I need to listen to her heart and lungs, formally ask how she’s doing, and then record all that on the computer.
Before Candace, though, I need to finish my notes on Sheila, particularly since my morning assessment was wrong in crucial ways. I put in a note about her perf, including when and how I found out about it. Then I go to a different screen and I pull up the spreadsheet where we document our daily clinical observations. Bowel sounds? I didn’t hear them, but didn’t think that silence through. The documentation seems pointless in light of what her real problem is. Neither I nor the medical staff nor the nurses and doctors in the emergency department, paid the right kind of attention to what was happening in Sheila’s bowel, but our mistaken observations have to be checked off on multiple drop-down menus so that the record is complete. I do understand why such thoroughness matters legally, but I sometimes wonder if sadists designed our software. It should not be easier to order a sweater from Lands End than to chart on my patients, but it is. Click, scroll, type, enter. Here’s the menu with twenty choices, none of them the one I need. Here’s the point where I need information from two different screens, but there’s no way to toggle between them. Here’s the screen with thirty discrete options to check, but the window it opens up only shows me five at a time. New lab results, X-rays, CT scans, MRIs: none of those generate an alert and the screen is full of minute icons, some of which represent functions I don’t use or even understand.
Finally I finish up Sheila’s assessment and check it off on my papers. Then I look for new orders and see that Dorothy’s discharge paperwork isn’t yet in the system. I look at my watch: 1:00 p.m. Not bad, except that I need to chart on Candace. It’s frustrating to end a shift and then stay late doing the day’s charting. “If it isn’t charted it isn’t done” is the mantra we hear over and over again in school.
Another one of the oncology fellows is suddenly next to my medcart, holding the written order for Mr. Hampton’s Rituxan. Since the fellows are learning to be oncologists they write the chemo orders, but with more or less supervision from the attendings depending on how long they’ve been around. This fellow is visibly pregnant. She continues to wear heels to work, and I admire her commitment to style even though I would wear flats myself. I take the order and stare at it. “We’re really doing this?”
“I know—he doesn’t look so good. We are keeping it at a steady rate—not increasing the dose over time. That’ll make it easier for him to tolerate.”
I nod, ignoring that fluttery feeling in my stomach.
“And we got permission to give it inpatient?” Rituxan falls under one of the odder billing rules in the U.S. health care system. Reimbursement for the drug is much smaller if patients receive it in the hospital, rather than in an outpatient clinic, and it’s an expensive drug. I’ve had patients transferred from their inpatient room to our outpatient clinic simply to receive a dose of Rituxan, but it can be given to admitted patients if the medical director of the oncology division approves that decision, and Mr. Hampton’s frailty is a good argument for infusing the drug in the hospital. If he reacts badly to it we have the ability to respond more fully than a clinic could.
She gives a dry laugh that sounds like a snort. “If he’s going to get this drug it has to be here. He’s too sick to get it outside a hospital.”
We look at each other and both raise our eyebrows, frowning. “Hey, thanks for bringing it over so quickly—I know you’re in clinic and,” I wave my hand toward her belly, “pregnant.”
“Yeah, well, it was slow today,” she says, “Can you believe it?”
“Maybe we’re curing cancer!”
“Wouldn’t that be great.” She turns to go and then turns back to me. “I’m on call this afternoon and then it’s Bruce this evening, so if anything goes wrong . . .”
“I’ll call you.”
She lowers her voice and leans in to me. “I’ll explain to Bruce in sign-out. And just call us; don’t call the house staff. The intern wouldn’t know what to do.”
“Got it. Fingers crossed,” I say, holding up my left hand with the first two fingers twined around each other. It may be dumb, but it makes me feel better.
Mr. Hampton’s weakness, his difficulty breathing, his confusion are all on my mind. Will we save him or push him closer to death? You can only know what you know, a wise friend told me, but so much is on the line here in the hospital I sometimes want to know more than I can.
I pick up the chemo form and really look at it. Chemotherapy orders continue to come on paper. The thinking is that the drugs are so strong, the regimens so specific, that a physical copy of the entire order needs to be in the patient’s chart as well as entered into the computer. I like the tactility of paper, feeling it between my fingers, hearing it snap and crinkle when bent, running the tip of my finger over the slight indentations left by the fellow’s careful printing.
Sheila’s call light goes on. The clock’s running on getting this chemo order to pharmacy, but I’ve got a little time since Mr. Hampton’s son won’t be here before three.
Sheila’s room is so still it seems airless. I peer into the dimness and consciously relax my face before I speak. Sheila looks defeated, exhausted from crying. “Is your belly hurting you?”
She shakes her head. Her sister sits next to her, holding her hand. “We’d like to see a minister,” she says, and her voice catches, “just in case.”
“Right.” This is an easy request. I call the hospital operator and ask her to page the pastor on call.
“I’ll check your pressure while I’m here.” I feel a flash of guilt that I hadn’t checked it earlier, then suppress that feeling as I grab the cuff from its plastic holder on the wall and take the stethoscope down from the hook behind the bed. As I stick the ends of the stethoscope in my ears Sheila and her sister watch me trustingly. The trace of tears on Sheila’s face makes her look like a child. “We need to know that her blood pressure is staying up. I’ll be quick.” I wrap the cuff around her arm, pump up the bulb, and slide the bell of the yellow disposable stethoscope under the cuff. Up the arrow goes on the dial and I see the cuff tighten around Sheila’s arm. As quickly as I can I let it out and hear the first click—her systolic pressure—then the count down of five quieter clicks, the Karatkoff sounds, and the louder final click. I let the rest of the air out wi
th a shoosh and take the stethoscope out of my ears, unwrap the Velcro cuff from her arm.
“Is it OK?” her sister asks me.
“Yes.” I purse my lips. “One sixty over one hundred.”
“But that’s high, right?”
“Yes, but high is good right now considering the operation she’ll be having. With a perforation and major abdominal surgery coming up, a blood pressure that’s abnormally low would be more troubling.” I’m ready to explain more, but I see that tears hover in her eyes. She blinks them away and her features become fluid as she struggles to hold in her grief. Hearing more medical details from me right now will probably not help.
I bend down beside the bed and take hold of Sheila’s sister’s free hand. “I’ll send in the pastor as soon as she gets here.”
The brother-in-law surprises me with a question as I’m going out the door. “Do you think it was the ambulance ride that did this? All that bouncing around? She said it was rough.”
I stop to consider that. “I don’t think so.” Lots of people ride in ambulances without having their intestines perforate. “It more likely has to do with her clotting problem and the trouble she was having with her medication.” He nods, then leans back into the chair and I lose him to the corner’s darkness.
I look at Sheila and her sister. “I’ll be back. Call me if you need anything for pain or . . . anything else.”
People react so differently to distress. Sheila and her family could be furious, focusing on our failure to do a CT scan right away, to start the anti-clotting drug without understanding why her belly hurt. They’re not being like that, though; they’re mostly suffering in silence. That’s their portion and it makes my life easier, but I wonder if it serves them. Those who bear up, demanding little, are the reverse version of patients such as Candace Moore. Candace is a wounded Fury—hurt and wanting help but focused also on justice and some desire for revenge. It’s impossible for Candace to simply endure. She lashes out at everything and everyone, unsure whom to trust since it’s really her disease holding most of the cards in the hospital. I wish I had more time to sit and hold every patient’s hand. To really listen. I think it would make a difference for Candace as well as Sheila. I really do.
The Shift Page 10
