The day I discharged her Lucy was her nurse practitioner. Jenn didn’t have a lot of money and there were insurance issues, so the supplies she needed at home wouldn’t show up on time. Lucy asked me to load Jenn up with saline flushes and latex gloves and to show her how to care for her central line since, like Candace, she would go home with it remaining in place on her chest.
In our supply room I grabbed wrapped saline syringes, a box of alcohol wipes, and gloves in her size. Technically I was stealing from the hospital, but nurses do it when it’s either pilfer or leave the patient without proper care at home. The real cost of the supplies was negligible.
I brought my phone into Jenn’s room, but told myself I wouldn’t answer it if it rang while I was discharging her. I also moved the usual set of concerns—an antibiotic to be hung, a phone call to return, a tube of blood to draw and send to the lab—to the back of my mind. For as long as it takes, I thought, I’m talking to her.
The paperwork was quick. She had learned well during her six-week crash course in leukemia. The hard part would be taking care of her central line. It makes people understandably nervous to go home with a piece of medical hardware hanging out of their body. Jenn had the typical Hickman catheter with three separate tubes, or lumens, hanging down from the insertion site on her upper chest. Each of those tubes needed to be injected with saline every day and each day Jenn also needed to verify that blood could be pulled from each one. To me it’s mindless work because I’ve done it so many times, but I might be worried if I had to care for my own line myself. Jenn had learned about her IV line amid the flurry of treatment and the doldrums of count recovery.
Sitting in a chair across from her while she sat on the bed, I explained the process and that it had to be done every day. The lumens are color-coded red, white, and blue, and I advised her to do them in that order so she wouldn’t skip one accidentally. I picked up the red lumen, scrubbed the top of it for fifteen seconds with an alcohol wipe, then screwed a syringe of saline onto the red lumen and pushed the plunger in. It slid in easily. “This is the flush,” I told her, “and then you stop, pull back on the plunger like this.” I held the syringe with my left hand and drew back with my right until the expected thin stream of blood swirled into the saline. “That’s your blood return. That lets you know the line is working and in the right place.”
She watched me carefully. I did the white lumen and had her do the blue to show me that she knew how. She hesitated when twisting on the saline flush and pushing in the plunger, but when she pulled back, drawing a rush of blood into the syringe, she smiled without reservation. Then, like I’d shown her, she pushed in the whole 10 ml of saline, unscrewed the syringe, and re-closed the clamp lock on the line.
“See. Piece of cake.” She laughed.
“I wrote the steps down here,” I handed her a piece of paper. “Read them and see if they make sense.”
She read through the instructions, keeping her head very still, and when she was done, nodded solemnly.
“You’ve got this!” I said, and we hugged, teacher and student, very pleased with her success. Last, I showed her the items I’d packed up and put all of them into a bigger plastic bag.
And maybe there is some cosmic force for justice, at least in small things, because my phone didn’t ring and I didn’t think about anything but her discharge during the twenty-five minutes I stayed in her room.
Man was made for Joy and Woe
And when this we rightly know
Thro’ the World we safely go
William Blake’s poem again finds wisdom in a simple truth: “Some to Misery are born” while others “are Born to sweet delight.” Jenn embodied both possibilities. She was a joy of a human being who’d been struck with a woeful disease; the sustaining love she felt from her husband offered delight amid her misery. I like to think that by giving her so much focused attention on the day of her discharge I contributed to her ability to travel safely through the world.
Remembering my time with Jenn, I close my ears and eyes to any other needs when I return to Dorothy’s room. It looks as if neither she nor her husband has moved, but there are now two suitcases resting against the bed and I see that all the photographs are gone from her walls. “We’re ready to go,” she says, a funny kind of Mary Poppins hat on her head and a dark wool coat lying next to her.
“Great. I just need you to sign here,” I tell her, flipping to the correct page and pointing at the signature line.
“Looks like you’ll need a wheelchair for yourself and one for everything you brought,” I say, looking at the two suitcases, the purple comforter folded on the bed, the jigsaw puzzle on the table in its box.
“That’s right. And he can push one of them.” She gestures again toward her husband. “I’ll hold the comforter. The puzzle can go in this bag and hang off a handle on the wheelchair.” This is how Dorothy likes it to be, I realize. Despite how agreeable she usually was at the hospital, she wants to be in charge, and that includes packing.
“I’ll call escort for the wheelchairs—” but before I even press any numbers on the phone, it rings.
I hear the polite and quiet voice of the escort, “Could you come out here one more time?”
“Right now?” I ask. Can’t I just finish this? Can’t I just get Dorothy out of here?
I hear Candace’s sharp voice over the phone.
“I’m coming.”
“Calling for the wheelchairs right now,” I tell Dorothy, holding up the phone and dialing ostentatiously while I open the door to her room and go out.
Candace starts to talk, then sees me on the phone. Her eyes get small and the skin around her mouth pinches at her lips. Smiling, I hold up a hand, hoping it communicates “please wait, I’ll be right with you,” rather than, “dear God, what is it now?”
I put in my order for two wheelchairs, then hang up and look at Candace.
“I’m ready. I just thought you’d be here when I left. After I got my phone from my room, you were gone.” Her voice is acid; it stings. But underneath I hear something else—hurt. And then Candace’s full history comes back to me. I first met Candace a few months ago and she told me about her serious surgery from a few years earlier where everything went horribly wrong. It wasn’t our hospital and I didn’t know the docs. She was scarred, literally, with a jagged criss-cross on her lower abdomen. She showed it to me. It took months before the pain completely went away and though she hadn’t wanted children, she would no longer be able to have them after that operation.
I had forgotten all of that, and remembering now, I look at her, try to really see her, all of her, not just the upward jerk of her chin, the accusatory voice. “I’m so sorry. Got caught up.”
“I just thought you’d be here. That’s all. It doesn’t matter,” she says, turning away from me and hopping up on the stretcher again.
“You’re right; I didn’t explain. I’ll see you when you get back.” She ignores me and the escort looks at me, grimaces sympathetically, then starts to push the carriage down the hall. I feel bereft, for a second, but then I hear the chime of a call bell and see that Sheila’s light is on. Dammit! She must need more pain medicine and Dorothy isn’t yet out of here.
I turn toward Dorothy’s room and my phone rings. What now? I’m drowning in details, moving as fast as I can, but in truth not moving at all. Giving Dorothy that final push home depends on me. Getting Sheila to the OR, safely, depends on me. Hooking Mr. Hampton up to his drug depends on me, as does making sure it doesn’t kill him. And Candace; caring for her without saying something I regret, or in my distraction missing a detail that makes all the difference, also depends on me.
My hands feel tingly, my throat tight. It’s the beginning of panic. I only have four patients. Four. How can taking care of them feel so impossible?
I USED TO LOVE A comic book series called the Legion of Super Heroes. One of the super heroes, named Duo Damsel, often comes to mind when I’m at work. She could divide into two fully
intact versions of herself just by concentrating. Maybe I could do that, too, if I tried really hard. Maybe just today—just this one time. If I really wanted it.
My phone keeps ringing. No matter how hard I concentrate, it’ll only be me here. I hit the talk button. “Medical Oncology, Theresa.” It’s the OR scheduler. Sheila’s set for 7 p.m. at the earliest. They couldn’t get her in any sooner. “We need the pre-op checklist done before she gets here,” the guy tells me.
Love the emphasis on before, as if I don’t understand that “pre-op” indicates “prior to the operation.” I want to respond with something clever or sarcastic, but I just say yes and hang up. What’s the point? He may be a rude SOB, or maybe he’s overworked like the rest of us, or both. I write down the OR time and then banish him from my memory.
Jesus! Call lights escalate in volume and frequency as time goes by and Sheila’s now achieves the pitch of a warning in a bad action movie. Warning: the perimeter has been compromised!
I push hard on her door. “Sorry, sorry, sorry. Too much to do.” Her face is a mask of deep lines and she’s bent over in bed, her breath coming short and fast.
I reach behind her to turn off the chiming light. “Pain?” She nods and gulps. “I’ll be right back with more medicine. And, hey,” I move my eyes around the room, connect with her sister and brother-in-law, “the OR has you scheduled for seven tonight so that’s our ballpark.” Her sister sits next to Sheila, holding her hand. The husband is standing up beside her, his hands stuck tight in his front jeans pockets.
“Seven,” he says, and nods, just once.
“I’ll be right back.” Down the hall, into the locked drug room, pulling up Sheila’s record on the locked narcotics machine, picking the drug, double-checking the dose, counting the number of syringes already in the drawer, and entering that number into the computer. It says my count is wrong. I recount and get the same number. Again it says my count is wrong. “Fuck it.” I hit the button to go ahead and pull out one pre-filled syringe. So there’ll be a discrepancy. I’m not fixing it now.
Around the corner and up the hall I go as fast as I can without running. Screw a needle onto an empty syringe, alcohol the top of the narcotic tube, then pull out the Dilaudid and squirt it into 10 ml of saline. Sheila’s lined face is all I see; I hear her stabbing breath. The pain got ahead of her.
Back into her room and I pivot so fast from my medcart that my shoes squeak on the floor. I hold up the syringe, show it to her, then pick up her running IV and inject the drug into the line after first wiping it with alcohol. Then I wipe it again and push in another 10 ml of saline, to make sure the narcotic gets into her bloodstream fast.
She sighs and closes her eyes, then leans back against the pillow at the head of the bed. “Thank you,” her sister says, and her voice, quiet in the dark room, quavers. The husband nods again then sits back down in the embracing armchair.
“I paged a minister for you. I don’t—I don’t know when she’ll get here.” Then I leave them; I don’t even look to make sure they heard.
I should also re-check Sheila’s blood pressure, but I’ll give the Dilaudid fifteen minutes or so and then go back in.
While I chart Sheila’s drug on the computer along with the multi-step “pain assessment,” I look at Candace’s open door and, somewhat unkindly, hope she has a very long wait once she gets to interventional radiology.
Suddenly our other clinician, the half-bedside nurse/half-management partner to Nancy the charge-nurse, finds me at my medcart. “I just got back from my meetings. Sounds like you’re having a day.” Her name is Marilyn and she’s got the most beautiful green eyes as well as a preternatural calm. “What can I do for you?”
“Can you give Mr. Hampton his pre-meds for Rituxan? We need to get that started ASAP.”
“Sure!” she says.
I pop into Dorothy’s room. “The wheelchairs are coming. Do you need any help getting ready to go?”
“No. We’re all ready. It’s just—” she inclines her head to me, hinting there’s something she wants to conspire about. I bend down and she starts to speak quietly. “Now, I took my candy dish, but I left you the candy. It’s all here.” She pulls out the top drawer of her nightstand and I see bags full of brightly colored paper, all in patterns familiar to me from my own childhood: mini Snickers, tiny Reese’s Peanut Butter Cups, and Hershey’s Kisses. “I don’t want it to be forgotten.”
“We don’t want it to be forgotten, either, Dorothy. I’ll put it in the break room right now.” I pick up the plastic bags and cradle them like a baby. Turning, I see her husband smile. His mouth forms a slim rectangle, but the outer edges turn up just enough that it has to be a smile. “Thanks for this! The wheelchairs should be here soon!” I say, heading off to our conference room with my spoils.
I dump the bags of candy on the conference table and the silver and gold foil wrappers twinkle at me. Just one. I slip a Snickers in my pocket, hover over a Hershey’s Kiss, leave it. Sheila’s blood pressure!
I run into Marilyn on my way back to my medcart. She whispers to me. “Theresa, when you asked me to pre-med your guy for Rituxan you didn’t tell me he was already half-dead.”
“Yeah, I told them that. We’re all a little concerned.” I say, shaking my head.
“Well, he’s ready to go and I charted the meds.” She smiles at me.
“You so rock! Thank you!”
“You’ll get my bill. Gotta go help Susie now.”
She walks up the hall, passing a tall attractive man who stops when he approaches me and extends his hand. “Hi!” he says, “I’m Trace Hampton, Richard Hampton’s son. Are you Theresa?”
“Yes. Hi!” I say, surprised at how movie-star handsome he is, with high cheekbones and thick brushed-back hair.
“I’m a little bit late,” he says easily.
I check my watch: 3:30 pm. “Oh no, it’s fine. He just got his pre-meds. I’ve, um, had a busy day.”
“Well, then we’re both on time.” His smile is welcoming, his voice relaxed. I look for a resemblance to his frail father, but except for the height, see none. “A friend of mine’s coming, too,” he says, “Stephen. If you can direct him in . . .” He gestures toward his dad’s room.
“Sure,” I tell him. “Stephen.” He keeps standing next to me, as if he wants to say more, when two escorts arrive with their two wheelchairs for Dorothy and her paraphernalia. “Sorry. I’ve got to get a patient out of here.”
“Oh, of course,” He’s so gracious. The tightness in my throat, the tension in my arms that came when I so much wanted to split in two, releases just a little.
There’s a bustle outside Dorothy’s room as the escort moves in both wheelchairs. I’m going to help, when I see Peter coming down the hall toward Sheila’s room. I’m surprised by the look on his face. He’s angry. I’ve never seen him angry. He’s holding papers in his hands. He must be here to have Sheila sign the consent forms for her surgery.
What a mess this whole thing was from the start, I realize. They should have scanned her abdomen last night at 3 a.m. when she first showed up in the emergency department. Then the Argatroban might never have been started and she might have already been operated on.
Now, though, Peter will operate into the night, even though a tired doc, or nurse, is just as impaired as a tired truck driver or airline pilot. Work hours are limited for resident physicians, but why the workload for all MDs isn’t regulated as carefully as some other professions is unclear. Is it because doctors’ mistakes due to exhaustion only have the potential to kill one person, not many? Or perhaps as a culture we want to believe that physicians are superhuman, and some docs want to believe that of themselves.
Problem is they’re not; no one is. Peter at least is smart enough to know he has limits, but on the other hand, time is working against us here. In the hospital we say “Time is muscle” for heart attack victims and “Time is brain” for stroke patients, indicating that the sooner those patients get the care they need
the less heart or brain damage they will have. In Sheila’s case, the bacteria will reproduce exponentially in her abdomen as time passes, and more of her intestine may die. The longer we wait the sicker she potentially becomes.
I want to go into Sheila’s room, be there when she signs the consent, make sure she understands, check her blood pressure, but Dorothy’s on her way out of the hospital.
“Are you her nurse? I’m gonna need some help stacking these belongings.” The escort is new, learning the job. Helping with discharge is one of the things we get evaluated on when patients answer surveys about the quality of their care.
Dorothy’s room is right next to Sheila’s, but I walk into Dorothy’s and Peter walks into Sheila’s and we don’t even say hello.
“OK, let’s get you out of here, Dorothy.”
We get the suitcases on one wheelchair, Dorothy in the other. She insists on loading everything in a precise way, but eventually it gets done and her belongings appear well-arranged. As she settles herself down I check the closet and the bathroom one last time, peak at the space under the bed. The card table was ours, not hers. It will need to be scrubbed down with antibacterial wipes, but I can leave that to housekeeping, I think. The rules about who cleans up what after a discharge occasionally change.
The husband raises himself from his confining chair, gives his large glasses a slight adjustment, and walks to the wheelchair holding Dorothy. He grasps the handles and looks straight ahead, out the door of Dorothy’s room.
“You make sure to share that candy,” Dorothy bends around to tell me, arms encircling the purple comforter on her lap.
“I don’t know, Dorothy. Maybe after I pick out the Hershey’s Kisses for myself.”
She laughs at the same time as Peter comes out of Sheila’s room. He doesn’t stop, just keeps walking up the hall. My throat feels tight again. How long has it been since I checked Sheila’s blood pressure? I don’t look at my watch; the time itself doesn’t matter, but I need to do it soon and make sure that last shot of Dilaudid helped.
The Shift Page 14
