“Good-bye everyone,” Dorothy calls out as she rolls down the hall. She waves with her right hand cupped, fingers together like a queen. Then she giggles as she blows kisses. No matter what happens today, I will make sure to remember this moment. When we’ve made you better, there’s nothing as satisfying as leaving the hospital.
CHAPTER 9
Judgment Calls
Hey, sorry I couldn’t be in here when the surgeon got your consent for the operation.” I head right to Sheila, wrap the blood pressure cuff around her left arm, and pump up the balloon. The whole family looks as if the last bit of life energy they had just got wrung out of them. I need to know what Peter said.
The IV pump beeps as the cuff tightens, cutting off the flow of fluid up Sheila’s arm. I silence it, then listen through my stethoscope for the tell-tale clicks that register her pressure: 152 is the first click and silence comes after 90. It’s the sound of blood flowing through thousands of miles of arteries and veins pumped by a heart that never rests.
I let the pressure in the cuff fully run out and hear the Velcro rip as I take the cuff off Sheila’s arm. I’ve done this so many times, yet it always feels like insight gained from a look inside a patient’s body. Two numbers tell me if all is well or if something is starting to go very wrong.
The first few times those numbers were wrong came as a shock. Not shock from concern over my patient, though I felt that, too, but steeped as I was in the study of literature, I wasn’t used to the idea that events in books, even if they’re textbooks, can become real.
“Can you double-check a pressure for me?” I asked Gloria, the friend who teased me today about my yogurt spoon. She was about to say no, that she didn’t have time, but there must have been something about the look on my face that made her change her mind.
She took the patient’s pressure, looked up at me, eyes narrowed and firm. “Sixty over thirty.”
“I got seventy over forty.” We spoke quietly, looking right at each other. I’d read about severe hypotension, seen it before, but I was still a new enough nurse that the reality of detecting it surprised me. The patient had grown increasingly confused during the day and now was only semi-conscious. Those symptoms probably arose from the drug he was on, called Interleukin-2, but his drop in blood pressure would only make them worse.
“You OK?” Gloria asked me, using our shorthand for “Do you need help?” and if so, what should she do?
“No. I think I’m OK. I’ll page the resident.”
She called back right away. Everyone is on high alert when patients get IL-2. “I’ll be right there. At that level I’m worried his organs won’t be fully perfused.”
She spelled it out like that, as if she, like me, was remembering her textbook. Perfusion: the nub of life is red blood cells oxygenating every part of our bodies.
The patient went to the ICU and they put him on vasopressors, drugs that raise blood pressure and keep it at a healthy level. He came back to us the next day, restored fully to himself, though with very little memory of the last twenty-four hours.
“You lived to tell the tale,” I said, which seemed to make him feel better, even courageous. At least he knew there was a story to be told.
But Sheila’s blood pressure is holding steady now. “One fifty-two over ninety. Like usual, you’re a little high, which for now is good.” I tell Sheila, looking at the IV tubing and eyeing the amount of fluid left in the bag. Then I realize Sheila and her family aren’t hearing a word I say; what did Peter say when I couldn’t be in the room?
Sheila’s sister purses her lips, gestures at the door. “He said,” she pauses and blinks a few times, “he said they might wait until tomorrow to operate.”
“What?” I blurt out.
Sheila, sunk back once again under a pile of blankets, seems to be melting like a lump of wax into an amalgamation of pain, confusion, and hopelessness.
“Let me talk to him. I’ll go now and try to catch him.” Hurry. Out the door, up the hallway. I must ask Peter why and then tell him that the idea of waiting another day for surgery seems inexplicable and terrifying to Sheila.
I’m lucky. He’s heading out the door, toward the elevators, when I call out.
“Theresa, you just can’t stop bothering Dr. Coyne, can you?” our secretary calls out, loud enough for anyone standing nearby to hear. This is a moment when I find her effusiveness difficult.
I try to ignore her, but then I feel it: upset. The secretary’s comment suggests I’m not adhering to the expected MD-RN relationship. I feel exposed, and it’s not the first time, as an opinionated, even a pushy nurse. But why is that? Shouldn’t I feel assertive and responsible, instead? Aren’t those core values for all health-care professionals?
The two best articles I’ve read on how physicians and nurses work together are called “The Doctor-Nurse Game” and “The Doctor-Nurse Game Revisited,” both by Leonard I. Stein, a psychiatrist. The first article came out in 1967, the second in 1990. There is no data in these articles, no carefully tabulated results from original research, but the sting of painful truths comes through.
The word “game” itself refers not to child’s play, but to psychologically intricate interactions governed by rules, even if the rules are not consciously acknowledged. The MD-RN relationship is historically rooted in gender differences and the condescension and imperiousness that marked men’s relationships with women a century ago. Many women have now become doctors and men are increasingly becoming nurses, but vestiges of the history remain.
In the sixties Dr. Stein wrote that if a nurse had an idea about patient care, the unwritten rules of the Doctor-Nurse game dictated that her recommendations appear to be the doctor’s ideas all along. The nurse might say, when discussing a patient with insomnia: “Pentobarbital mg 100 was quite effective night before last,” and the doctor would relay back to her, “Pentobarbital mg 100 before bedtime as needed for sleep, got it?” The drug and dose are the nurse’s ideas, but the MD is allowed to rephrase them as his own.
Dr. Stein revisited the doctor-nurse game in 1990, and this time he described the nurse as a “stubborn rebel.” Rather than giving the doctor a clinical script, the nurse cast herself as a corrective agent to the doctor’s potential incompetence. The pentobarbital scenario becomes a confrontation instead of a polite, carefully calibrated exchange: “Mrs. Jones can’t sleep. She needs pentobarbital.” The nurse would probably be figured standing with her hands on her hips, head thrust forward, and implicit in her tone would be the unspoken challenge, “Your patient’s in need; what are you gonna do about it?”
There are nurses who hate these articles and I understand why—neither image of our profession is flattering. But I know I have played both these games and all possible permutations in between. Hospital nurses get hired and fired independent of MDs, but from what I see and hear, at a fair number of hospitals no nurse would be protected if an important doctor really wanted her gone. Doctors are our shadow bosses, the people whose orders we put into action, whose patients we share the care of, even though the MDs don’t explicitly supervise us. No wonder we both end up playing games when we communicate at work.
But Peter’s not like that. Now he stops immediately, ready to listen. I put the secretary’s words out of my mind, try not to think about whether anyone is watching me with a critical eye. “Sheila said you may wait until tomorrow to operate.” He nods. He doesn’t look angry anymore, just as if he also resents the impossibility of being two places at once.
“If you could operate tonight, that would be so much better for her. I know anesthesia needs to prep her and that regardless, you could get that out of the way tonight, but with the amount of pain she’s in I hate for her to go down, meet with anesthesia, come back up to the floor, and then go back down to the OR again tomorrow morning.”
“It may be better to wait until tomorrow.” He hears me, but he’s looking out the door toward the elevators.
I’m not sure what to say. He’s the sur
geon; the decision about whether to operate has to be his. It won’t be my hand holding the knife. There must be a weighing of how dire Sheila’s situation is and how tired he and the rest of his team will be. I know from experience that fatigue is a thief of concentration and memory because I lived it when my twins were babies. Peter, I’m sure, also knows how dangerous fatigue is.
When doctors and nurses train, the idea is to push through exhaustion, ignore it, transcend it, but only the rarest of us can really do that without drugs to help, and no one, even with chemical stimulants, can do it forever. Humans need sleep as much as we need food and water, and when we don’t get enough our minds fray at the edges. Sleep is said to clean our brains; tired people can make mistakes without even realizing what they’re doing. Shakespeare knew it: “Sleep knits up the raveled sleeve of care.” This is poetry and truth. It may be better to wait until tomorrow, Peter said. He could be right. A decision like this is all about weighing the risks and benefits. Only he knows how tired he is, how much the week has already worn on him, what else he has to accomplish this day.
But what about Sheila? Overnight the bacteria will proliferate inside her abdomen and parts of her colon that aren’t now dead may begin to die, or will finish dying. That is also truth. Tissue damage at that level can’t be repaired; it has to be cut out by the, perhaps exhausted, surgeon. The multiplying bacteria will have to be killed by large doses of intravenous antibiotics. The longer Sheila waits with her gut oozing inside her own body, the closer she gets to a point of no return.
No surgical protocol or clinical algorithm will make clear in advance what the best timing is for her specific case. For one patient the wait won’t matter. For another it could be the difference between living and dying. For one surgeon the fatigue won’t overcome years of training and professional discipline. For another it could be the moment when he hits the wall of his own vulnerability. No crystal ball exists to reveal which patient and surgeon we have today.
I, the nurse, am here for Sheila, who’s worried and in pain. Peter’s my friend and colleague, but Sheila’s my responsibility, so I make my request one more time. “If tonight works.” Pushy or patient advocate? He nods his head just slightly then turns to the elevators he’s been eyeing and before I can say “Thanks for thinking about it,” he’s gone.
Dave the pharmacy tech walks up behind me with the Rituxan for Mr. Hampton. He’s got a low deep voice, almost a growl, but he’s often quite funny and his eyes crinkle up when he laughs. “Rituxan for Richard Hampton.” He hands me the bag full of clear liquid.
This is the next-to-last step of chemotherapy administration. The process started when Mr. Hampton’s attending physician decided to give him Rituxan. Then the pregnant oncology fellow wrote the order and brought it over to me so that I could double-check it with another nurse. Afterwards I left the verified order for pharmacy and they took the order and mixed the drug according to specifications. Finally Dave delivered the drug to me and all I have to do now is set it up to intravenously infuse into Mr. Hampton.
It’s a complicated and well-rehearsed protocol because chemotherapy, like surgery, almost always comes with Faustian trade-offs. We kill your cancer but your hair falls out, you have unrelenting diarrhea, permanent nerve pain and/or mouth sores so bad you can’t eat. Rituxan is different in that it mobilizes the patient’s own immune system to attack the disease. Since the rare person can die from a bee sting or eating a peanut—the result of an extreme overreaction of the immune system—it’s difficult to predict what will happen when a patient receives a drug like Rituxan, and the trouble it brings usually happens during the infusion: a precipitous drop in blood pressure, shaking that can’t be controlled, a racing heart, severe shortness of breath.
I check my watch. How did it get to be 4:30 p.m.? Well, at least the passing of time ensures the pre-meds that Marilyn gave are definitely active in Mr. Hampton’s body so I can connect the Rituxan to his IV.
“Theresa!” It’s Nora and Amy, who helped me by taking lunch to Susie’s patient. “Want some?” says Amy, holding up a gift card to the coffee shop across the street.
“Oh my God, you are lifesavers! Where did you get that? And how do you have time?”
“We-ell,” Amy says, “Remember the Vaughans?”
I nod. “Oh gosh, they were so-o-o-o nice.”
“Yeah, well, he had an outpatient appointment in the clinic and they came and dropped this off.” There’s probably some rule about how we’re not supposed to accept gifts from patients if they are connected to a cash amount, but I’ve never heard of it being enforced.
“So how do you have time to do this?”
“We don’t,” Amy says, “but we both really need some caffeine and it’s free!”
I lower my voice and look at Nora, “How’s Mr. King in the ICU?”
She shrugs one shoulder, looks away, then shakes her head.
“Medium skim latte?” Amy asks me brightly. She’s writing down orders on a notecard.
“You know me well. Thanks.” I’m suddenly overjoyed. Is this how addicts feel before getting a fix? Oh, who cares—even if I am a junkie, it’s only espresso and milk.
Back at my medcart I think of Sheila and her family. I feel the weight of the Rituxan—it’s almost a half-liter and has some heft—in my hand then set it down on my medcart. I need to tell Sheila and her family what Peter said, but I’m so tired of hurry up and wait for this kind and fragile woman and I dread confirming the uncertainty about when the operation will be.
Remember. I make myself remember that she could be my sister, my mother, me. I would want to know what the surgeon said. I would want a nurse who told me what was up as soon as she knew. I try to summon courage, fortitude from wherever they are in my body, pull it up to my brain from my toes.
It’s quiet where I stand. I turn back to my medcart, pick up the Rituxan. I could hang it and then talk to Sheila and her family. It would take fifteen, twenty minutes to check the drug, grab some vitals, hook it up, and record all that on the computer. Dorothy’s gone, Candace is off the floor, and Irving’s yet to arrive. I could get the Rituxan going—making things a little easier for night shift since the sooner the drug starts the sooner it, and all the checks it requires, are done—then tell Sheila what’s going on.
But I don’t.
I go into the dark room. Sheila and her family have never raised the blinds. Perhaps the sunlight would have been another unwelcome sensory experience, or maybe they just never thought of opening them. I could have offered, except that right now evening is coming and the sun will soon set anyway.
They all look up expectantly as soon as I walk in and I know then it was right to come in here before hanging the Rituxan. “Hey, I just talked to Peter Coyne. He’s going to try for tonight.” The sister raises her head to me and her shoulders, tight and hunched forward, relax back into her chair as Sheila closes her eyes and the lines on her face, just for a moment, disappear, making her skin appear smooth. “It may not work, though. It may have to be tomorrow”—I improvise a little here—“depending on how your blood is clotting and what the schedule in the operating room is. I’ll tell you as soon as I know anything.”
I thought this information would deflate them all over again—I haven’t told them much new—but it doesn’t. They seem to understand that many factors influence when Peter will operate, not just timing or his own personal preference. They may have just wanted an acknowledgment that not knowing is hard, because when I finish talking they all nod, the brother-in-law’s chin doing one slow up and down.
“I’ve got to start chemo in another room.” I point my thumb backward at the door. “Can I get you anything?” Sheila’s brother-in-law gives a shake of the head no and her sister breathes out and settles back into her chair. Ambiguity is anxiety-producing, but the appearance of indifference combined with a lack of control may be what mattered the most here.
John Keats, the nineteenth-century poet, recognized the challenges posed by
lack of hard knowledge and the strength it takes to endure in such situations by coining the term “Negative Capability,” which he defined as: “when a man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason.” Keats spent his adult life fighting tuberculosis and died at age twenty-five, so for him the “irritable reaching after fact” was not merely poetic or theoretical. He knew what would kill him, and soon—“for many a time / I have been half in love with easeful Death”—and yet his art triumphed over his affliction.
Out in the hallway I close my eyes briefly to clear my head and Marilyn, like an apparition of helpfulness, appears at my shoulder. “Thought you might need a checker for the Rituxan.”
“Thank you.”
“Brought you this, too,” she says, handing me a thick blue plastic gown.
“You are the greatest.”
“And this.” She holds up Mr. Hampton’s chart.
“I could kiss you.”
“Please don’t.”
“Here we go.” Inside, Mr. Hampton’s room is a different world from Sheila’s. He’s using the oxygen of course and he looks awfully pale, but no one in this room is at all worried. His son Trace and Trace’s friend are in the room and all three of them look as relaxed as if this is just an ordinary day.
Trace waves to Marilyn and me, an easy, friendly movement of his hand, then gestures to the man sitting beside him. “This is Stephen,” he says, like a seasoned host introducing friends at a cocktail party.
Mr. Hampton even waves at us and I reach forward to pick up his wrist, read off his wrist band. Name. Birth date. Medical record number. Marilyn checks them against the same information on the chemotherapy order in his chart. Then I lay his wrist back down on the bed, but not before patting the back of his hand. When possible, touch in the hospital should come with a dose of kindness.
Marilyn holds up the Rituxan and reads off the information on the bag of drug. Patient name. Birth date. Medical Record Number. Drug. Dose. Rate of Administration. I double-check everything she reads against the chemotherapy order. It all checks. His base rate is 25 ml/hour and after one hour I’ll turn it up to 50 ml/hour and leave it there. Jeez Louise. This bag will take all night to go in.
The Shift Page 15
