There was an afternoon when I had time. My patient, a married man in his sixties, healthy and fit except for having leukemia, had received a cord blood transplant and it hadn’t taken. That is, he’d gotten an infusion of stem cells from a stranger’s — a baby’s—umbilical cord, but the graft of cells failed. The day eventually arrived when we knew, without a doubt, that the treatment was unsuccessful and we also knew that his cancer would recur and he would die of it. He’d fought cancer and lost, and the inevitability of it all was making him bitter. He had a lot of living he still wanted to do.
The afternoon all this became undeniably clear to us and to him, I was his nurse and I was very lucky that it was one of those rare afternoons when I wasn’t all that busy, although I can’t remember why. Maybe my other patients were off the floor at tests. Maybe they were on the upside of treatment and weren’t that sick. Maybe they were all taking long restorative naps.
I spent a lot of the middle part of that day in Joe’s room. I didn’t do much, and then again I did all I could: I listened. Sometimes people just need to talk, to say the same things over and over and over. I listened while Joe did that.
“It’s not that I’m angry the treatment failed, just disappointed.
“I wish I’d had a better idea this might not work.
“It’s no one’s fault, but I hoped for a better result.”
He would stop, then start up again where he’d left off: “What if we hadn’t had that two-week delay at the start—could that have made the difference?”
I said almost nothing. He needed only a witness to his suffering. He was in the impossible position of standing on a train track waiting for the train he knew would eventually run him down, and no one he knew could be with him that day—not his wife or a neighbor or friend—but I was there silently listening as he tried, by talking, to turn his pain into a story he could accept.
At the end of the shift I told Helen, the same night-shift nurse I’d talked to this morning about Ray Mason, that I’d spent a lot of time in Joe’s room listening. I felt as if I’d had it too easy, but at the same time I was exhausted. There’s nothing easy about helping someone start the journey from life to death. “They also serve who only stand and wait,” the poet Milton said. It’s a line I often hear in my head at work, where standing and waiting can be the best service we offer.
Today is not that day, though.
My phone rings. “Theresa, just wondering when you’re going to have that Rituxan order?” It’s pharmacy. “We want to get it going ASAP since they’re not increasing the rate. The docs would rather it didn’t run all night long.”
The chemo order is lying on my medcart where I left it and I and another nurse have to verify it before the paper goes to pharmacy. “Yeah. Sorry. I just got it; I’ll start my check now.”
“It’s fine. We’ve got a lot of chemo to do for the other oncology floor and wanted to make sure we finished your Rituxan first.”
“Right. Thanks, Bobby.” So many needs; I’d better get this done.
Focus: the fellow’s calculation of the BSA or body surface area is the first thing to check. We calculate from a verified height and weight, which requires two nurses to weigh and measure Mr. Hampton together. That must have been done yesterday. I double-check by looking it up on the computer—it’s there—and then double-check the math, multiplying Mr. Hampton’s height in centimeters by his weight in kilograms, dividing by 3,600, and taking the square root of that number. The answer comes out in meters squared, which makes no sense and yet it’s what we do.
All of this is just arithmetic, but mistakes slip in. Fellows round down instead of up, use an old weight, plug the numbers into the non-customary formula—these kinds of errors and others have been detected by nurses reviewing chemotherapy orders. The drugs are biohazards, so the dose has to be precise: more than enough to cure the patient’s disease might be too much for the patient’s body to tolerate since many of these drugs are toxic enough at the predetermined safe doses.
I use the calculator on my computer desktop and this time the numbers for the BSA and the ordered dose of Rituxan are correct. Good. Now I need to make sure the ordered dose and timing of Mr. Hampton’s Rituxan match the treatment plan specific to his disease. Pulling up chemoregimens.com on my computer (luckily the website is not blocked today) I go to lymphoma and easily find Mr. Hampton’s regimen. Harder are the moments when I can’t find the correct doses listed and a call to the fellow yields the information that they’re using a novel protocol taken from brand-new research. “The article’s in the front of the chart,” the fellow will say, helpfully, but why didn’t she or he just tell me at the start? Often the docs are too busy to think of that detail, but it may also be because MDs have little idea what nurses actually do when we check chemo orders. Do they know that we perform our own independent verification of the math and the ordered regimen? Nurses and doctors—our work is often invisible to each other.
I’m at the final step: I need another nurse to redo my verification. I walk up the hall and there’s Beth at the nurses’ station. I feel uncertain about asking her to help me since I know her daughter’s trip to Kandahar is on her mind, but she sees the order sheet in my hand and says, “You need a checker?”
“Do you have time?”
“Being busy is good,” she says. And then she laughs, “But then you may have to double-check my math. I’m a little preoccupied.” She’s joking; I know how careful she is.
“Any word?” I ask quietly.
“No,” she says, not looking up. She’s pulled a small calculator out of her pocket and is already punching in numbers. “And I’ve decided it’s just too early to worry!” she says, briefly glancing up, but she presses her lips together in a hard line as she compares the calculations.
I see Ray Mason sitting up on a stretcher on the opposite side of the nurses’ station, near the main door to the floor. He must be on his way to a test. I realize it’s past noon and even though I talked to his wife, Liz, in the hall I haven’t yet gone by to say hi to him. Leaving Beth to her work I walk over.
“Hey,” he says. He’s taken out his nose and ear piercings and looks vulnerable without them. I bend down to the stretcher to hug him.
Something in my face must give away my concern for him, because he says, “It’s cool. What will be will be.” He says it in a rush, with little feeling, almost like a mantra. Well, why not invoke karma? There’s nothing else he can do.
“What happened?”
“Just started feeling more and more tired. Got a blood test. Have to do a marrow, but . . .” he shrugs. The relapse isn’t 100 percent confirmed until leukemia cells are detected in a sample of his bone marrow, but he’s resigned to it.
“The thing is, my brother, the super-conservative, will be my donor. I’m worried I’ll end up being like him.” I look at Ray; I can’t tell if he’s kidding or not and decide to go with “not kidding.”
“No!” I tell him, “That’s ridiculous!”
“I don’t know,” he says, “I’ll be getting his entire immune system.”
“Nah,” I tell him. “Your personality won’t change—just your blood cells.”
The escort who’s taking Ray to whatever test he’s having steps up to the stretcher. He’s ready to roll.
“Hey,” I say, “I’m sorry.” They take off toward the elevator and Ray, with his back to me on the stretcher, raises one hand in the air and waves it at me without turning around, friendly, but dismissive. He doesn’t want my pity.
I met Ray for the first time during the follow-up chemotherapy to his initial treatment—what we call consolidation. He’d brought a guitar to the hospital and the live music on the floor seemed to free time from its usually strict moorings. Ray’s signature line was “It’s cool” and one evening I volunteered to hang his dose of chemo because Nora, his nurse, was busy with another patient’s emergency.
My taking Nora’s place didn’t faze Ray at all. He sat on the bed, bald, ca
lm, looking like a young Buddha. He seemed to have a deep belief in fate, the idea that life works out the way it should. It makes sense that if you crossed the heedlessness of a firefighter with the anarchism of a punk rocker the result would be a person acutely aware of life’s randomness.
I can’t remember what Ray and I talked about, but I remember the feeling that I could breathe in his room, really breathe, as if I’d already pushed his particular rock to the top of the hill and had nothing more to do than look around.
The next summer, after Ray finished consolidation, he went back to work as a firefighter. I know this because he came to visit one day on the floor. We knew him as a patient, bald, stuck in the hospital, weak, coping. The day he stopped by it felt as though Odysseus from Homer’s Odyssey, that most well-known of lost travellers, was visiting the underworld of his own volition. Well-muscled, trim, with a full head of thick brown hair and a lingering smell of summertime sweat, he explained that he’d spent the afternoon at the firefighter training grounds crawling around in tunnels.
He knew, he said, that some of the guys he worked with thought he wouldn’t be able to come back to the job, that he would have to prove he could do it. So he did: lifting weights, navigating dark tunnels with only a flashlight and his wits, carrying the heavy equipment he would need to save lives.
Odysseus visited Hades seeking knowledge of the future from the prophet Tiresias. Ray came to us as a bearer of the rarest and most precious knowledge to be had on an oncology floor: that people make it. The miracle of oncology is that patients confront their own possible death, and move on.
To keep Ray and Candace moving, they both will receive stem cell transplants. Candace will have her own cells infused. Ray will take donated cells from his brother the Republican. Different diseases require different treatments. Ray has the harder road, since receiving another person’s stem cells can cause a lot more problems afterwards than getting one’s own back. For both of them, transplant day will arrive with a sense of anticipation and a bit of low-key fanfare.
Candace’s cells, harvested earlier and then frozen solid, will be thawed in a water bath by the cell technician who attends every transplant. The numbers on each bag will be checked and double-checked to make sure she receives only her own cells. As each bag is thawed the nurse will hook it up to Candace’s central line and let it flow in just like any other blood product. The preservative used on the cells, called DMSO, could be dangerous, though. A few unlucky patients have a potentially fatal allergic reaction to it and we have no way of knowing in advance who those patients may be. Because of the risk posed by DMSO we put all patients receiving an autologous stem cell transplant on a heart monitor, make sure to have oxygen tubing and suction equipment in the room, take vital signs every five minutes, and stay with them at all times. I even give my phone up to the charge nurse.
This is nurses’ work and it’s a privilege to do it. It’s not every day you get to give someone her life back by hanging an IV, checking some vitals, and making sure she continues to breathe deeply since the body eliminates DMSO through respiration.
The DMSO also produces a distinct odor. Some people smell garlic, others tomato soup. For me it’s creamed corn. It’s not a nice scent, but it is a joyful one. Yeast proofing in water smells like nothing anyone would want to eat, but, with proper mixing and baking, turns flour, sugar, and water into bread. Similarly, an aroma of DMSO, even days after an auto, will make me recoil and, on reflection, smile because it tells me another patient is on the road to survival.
When Ray gets his transplant he won’t have any worries about DMSO, because the cells from his brother will be fresh. He’ll be carefully monitored, but the transplant itself is relatively risk-free; the trouble for him, if it comes, will begin later when his body may attack the “graft,” or infusion of his brother’s cells. The really nice thing will be if his brother can be in the room during the transplant. I had this happen once. The patient’s brother finished donating cells in the morning and the transplant took place in the afternoon, so he got to see his cells infused; got to see a new shot at life, donated by him, flow into his own brother’s veins. It’s trendy in some restaurants now to serve beef marrow and people say it’s delicious. I wouldn’t know. Having given the stem cell portion of this precious substance to patients as a lifesaver I can’t imagine eating it, but I can attest to its beauty: deep red, iridescent with flashes of white and pinks.
We say “Happy Birthday” to all transplant patients. The stem cells they receive—whether their own or someone else’s—are needed because we use very high doses of chemotherapy to wipe out their own marrow’s ability to produce stem cells. The transplant is technically a rescue therapy after they’ve gotten enough chemo to kill their disease, but I like the rebirth analogy better. If donated cells differ in blood type from the patient’s own, that person’s blood type will actually change after transplant and engraftment. I used to think blood type was as fixed as eye color or having dimples, but it isn’t. It can change, does change, as a side-effect of the treatment given to save someone’s life.
Beth gives me back the Rituxan order. “That’s my call light,” she says, hearing the insistent beep and checking the screen at the nurses’ station for a room number. “Mr. Parrish probably needs help to the bathroom.”
I check that we both signed the form in the right place, dated it, wrote down the time: 13:45. I like that we use military time in the hospital; it avoids confusion. I glance over the order sheet one more time, then leave it in the bin for pharmacy. There’s a pre-operation assessment that I need to fill out for Sheila and I’ll do that back at my medcart.
Before I start the pre-op form, I check on her. I open the door slowly and peer into the dark. “Pain?” I ask her. She nods, just barely.
“I’ll get you some more Dilaudid.”
Inside the locked room where we keep our narcotics I punch my code into the Pyxis machine, just as I did this morning, look up Sheila’s name and get the dose of Dilaudid I need. Back at my medcart I draw it up and dilute it as usual.
I chart the med, guessing at the number on the one-to-ten pain scale since it’s subjective and I know she needs it. The few times I’ve been asked to rate my own pain from one to ten I’ve found it inaccurate and unhelpful. Hurts some, hurts a lot, and oh-my-God give me relief now seems like a more appropriately human scale.
In the room I hold up the syringe, saying nothing. I prepare the IV port and slowly push the drug in while I explain how to best manage pain. “If you can, call me in before it gets so bad; we call that ‘staying ahead of the pain.’ Pain is not physiologically neutral. It stresses the immune system, interrupts sleep, can delay healing. I can also get your dose increased if you need more relief.”
Sheila grimaces, then nods while closing her eyes, taking a sharp breath in. I unscrew the used syringe and attach another filled syringe. “This is saline,” I say. “If I push this in in fast it will make sure the drug gets into your system as quickly as possible.” I probably don’t need to do that since she’s got IV fluids running in at such a fast rate, but why not? It makes me feel like I’m doing everything possible for her. I look at the one-quarter full bag of saline that’s running now; she’ll need a new one soon. That’s a small something I can do as well.
“I paged a minister,” I say. “It seems like it’s taking her a while to get here so I’ll page again. Sometimes it’s good to be the squeaky wheel.”
The sister actually smiles, but Sheila catches a sound in her throat. The brother-in-law is sitting closer to the two of them than he had been, but he has his head down and is staring intently into his lap. He’s unreadable.
When I leave a patient’s room I try to always ask, “Is there anything I can get for any of you?” We have soda, ice water, crackers, bread for toast, peanut butter. This time, though, I don’t ask. I throw the empty syringes away, pull off my latex gloves, and drop them in the trash.
The door quietly latches shut behind me and
I want to leave, to walk off the floor. I want five minutes to collect my thoughts, go get some tea, maybe, not feel responsible, when—
“There you are!”
It’s Candace. She’s put a hospital gown over her sleek black yoga pants and has another gown on backward, ensuring that her back is completely covered.
“Aren’t you supposed to listen to my lungs and ask me how I’m doing? Isn’t that part of being in the hospital?”
I swallow. Transitioning from Sheila to Candace feels like turning inside out: Umgekehrt, a German word for “upside down,” “confused.” It fits. “Right.” I offer a weak smile, like a cup of half-brewed tea, the one I don’t have time for. “I wanted to let you get settled in first.”
“Or maybe you just forgot,” she says. Her words are accusing, but her tone is neutral and her face looks pleasant enough.
“Well, how about now?” I hold out my hands, palms up, like a used car salesman ready to make a deal.
“My cousin just left, so now’s good. She’s coming back but I needed a few things. And we used up almost all of the Clorox wipes.”
I follow her back into the room and pull the disposable stethoscope down from her IV pole. The overlapping gowns billow around her like a cape. Only Candace could make a hospital gown look that stylish.
She sits lightly on the edge of the bed, collects her long hair and, looking down, pulls it around behind her neck and over her right shoulder so that a tuft of thick black hair rests on her right chest. Suddenly I see the person she probably is outside the hospital—energetic, aggressive, but personable. Here, inside, all that gets channeled into an unstinting wariness.
The Shift Page 11
