Finally at the end of the shift I had time to talk to that day’s charge nurse, who made a point of being involved. She talked to the nurse-in-charge, who oversees the whole hospital. Her explanation didn’t help with locating the teeth, but it was reasonable. “I don’t understand,” she said. “Does CT just have sets of teeth lined up waiting to be returned to patients and sometimes there’s a mix-up?” The imaging center had no idea how a patient could come down for a scan and return to the floor with the wrong teeth. Why would a patient even need to have her dentures removed for a CT scan? And most important of all, why was a patient so near death having a CT scan anyway?
I punted. I gave up. I left. My shift was over, but thinking back on it now I feel ashamed of myself for walking out without having solved the problem. There was, however, nothing I could tell those daughters about their mother’s teeth. I wonder if our carelessness with the dentures made the daughters think we had generally been careless with their mother, including the grim prognosis she received. Dentures are irrelevant to a hospital staff when a patient’s very survival is unlikely, but relatives may look at such scenes through the other end of the telescope: If we can’t keep track of someone’s dentures how can we be trusted to care for her whole body?
The dentures could also have been a proxy for the mother’s life. It’s a not uncommon reaction to getting very bad news about someone you love. All the pain and anger of grief focuses, like light concentrated through a magnifying glass, on some small item that absolutely does not matter. “These are not her teeth!” Two daughters’ lives condensed into the contents of one cheap plastic denture cup. A mother’s death is a deep, some would say irreparable, loss.
I attentively fill out the form for Sheila. No, she does not have dentures. Yes she has glasses and will leave them with her sister. No, she has nothing of value that needs to be locked up. Yes, her sister will take care of her clothes.
Our patients become like refugees, hustled from floor to floor, bed to bed, with the minimum of belongings. I finish the form and save it, look at my watch: Vital signs! I forgot. Into Mr. Hampton’s room, the blood pressure cuff, the thermometer, the pulse-ox monitor. He’s normal, fully and completely normal, and he, Trace, and Stephen continue to talk excitedly, this time about fly-fishing. To me there is nothing more boring than fishing, but they have so much enthusiasm it feels like fun. Their energy draws me in the same way it seems to have pumped up Mr. Hampton.
I check the time against the computer and realize I’m ten minutes late with these vitals. I go through the usual debate with myself about writing down the correct time or the actual time and then write down the actual time.
“He’s good,” I say, after eyeing the IV pump and tubing. The three of them stop talking long enough to absorb what I say and then return to their stories. They are self-sufficient in a way that comforts me as well as them. When a patient does so much better than expected I enjoy not being needed.
Candace’s door is open and she calls out as soon as I step into the hall. “There you are! I have some questions.”
Oh my goodness. Well, there’s no avoiding her, so I go in, shutting the door behind me.
“So who was that doctor who came in here earlier? Yong—somebody.”
She’s referring to Yong Sun, the oncology fellow. I explain that he’s an oncologist in training and that he’ll work with the oncology attending in the hospital to manage her transplant.
“So even though I’m finally getting my transplant my regular doctor won’t be here?”
“No-oo,” I tell her, reluctantly. Even though our outpatient cancer center is literally across the street from the hospital, whichever physician the patient has been seeing there—sometimes for months or years—will not necessarily be involved in that patient’s care once she is admitted to the hospital. The inpatient attending is supposed to check in with the patient’s regular oncologist, but if that MD is not scheduled to round on that patient in the hospital then it is rare for that doc to see the patient during her stay.
This tends to be how care is managed in teaching hospitals and the idea is to use physician time efficiently, but patients dislike it for obvious reasons. They want to be seen and supervised by the MD who knows their case better than anyone else. In How Doctors Think Jerome Groopman writes that the individual doctor makes all the difference in how an oncology patient fares. That may or may not be true, but if it is, then why are teaching hospitals structured in this way: separating patients from their usual doctors when patients are most vulnerable? If having patients managed by a specific doctor matters, then why are secondhand reports from residents, fellows, or other attendings, considered good enough when the patient is arguably the sickest she will be?
Candace knows the usual arrangements for rounding; she’s venting by pretending to be uninformed. I don’t mind, though. It’s very hard when patients see “their” doctor on rounds in the hallways and that MD fails to stop at their room or even say hello. I also don’t have what I consider a good enough explanation for why we do things this way. The system’s teaching efficiency doesn’t matter to the people who are sick; all they want is for the person they know and trust to be taking care of them.
“That guy barely knew my history. I won’t have a physician who doesn’t know my plan for transplant taking care of me.”
“And you shouldn’t have to, Candace.” Yong Sun is here to learn, but for Candace, getting a stem cell transplant is scary enough. We shouldn’t add in worries that knowledge of patients is piecemeal. “I’ll pass along the message. It may be possible to switch with an oncology fellow who’s more familiar with your case. I’ll try.”
“Fine,” she says, nodding her head definitively. “I appreciate that.”
“You’re welcome.” In this moment I admire her. She’s willing to complain about things that so many other patients mind but don’t speak up about. I add this request to my mental grocery list, written in bold and underlined.
As I step out of Candace’s room the escort is holding up Sheila’s chart to get my attention. It’s a different one this time, the young woman who pulls her long brown hair up into a pouffy ponytail and wears a lot of eye makeup. I like her because she’s friendly and patient, which is rarely true of the escorts who come from the OR. Their schedules are usually too tight for that.
“Can she walk?” She inclines her head toward Sheila’s door.
“Yes, but slowly.”
“Should I take the stretcher into the room?”
“No, it’s OK. I’ll go and get her.” I’m not sure what’s motivating me here. It’s easier not to bring the stretcher into the room, but leaving it outside will make the transfer harder for Sheila. However, if she walks out of the room under her own steam she has set a tone of strength and determination that will, I’m hoping, endure. The operation she’s being taken to will save her life and it’s my belief that walking to the stretcher tonight will lead to her walking out of the hospital a few weeks later when our work is done.
There’s a word for this kind of thinking: crazy. I’m not being rational. “If wishes were horses, beggars would ride,” my mother often says. Well, fine. This is one wish I’m going to take out of the stable and see how far I can go on it. Once Sheila leaves here she’s out of my hands. I won’t be there to explain the diagnostic mistake, hold her hand and wipe her brow, or say, Please, please be careful with her. I trust the people I work with in the hospital, but they’re not me.
I open the door to Sheila’s room. This is the moment when I have to let go. “They’ll take good care of you. You’re in good hands now.” I must say good-bye with confidence, wish her all the best.
Her sister and brother-in-law flank her as she sits on the bed. Her breaths come deep and rough and she’s squinting as if to block out the pain. The last dose of Dilaudid hasn’t helped much. “We can move the stretcher in here if it hurts too much to walk.” I offer.
But Sheila herself shakes her head no at the idea of the str
etcher being brought to her and instead slowly rises from the bed. Eyes closed, she bends forward just slightly and then straightens up. Her sister takes one arm, her brother-in-law the other. I walk in front of them, pulling the IV pump and holding out one arm toward Sheila as if to catch her should she slip and fall.
We move slowly. It’s maybe four feet from the bed to the door, four feet from the door to the stretcher. The time feels infinite. With every step Sheila lets out a contained “Hummph.”
Another nurse would call for the stretcher now, insist she shouldn’t walk. Not me. And maybe it’s not magical thinking. Maybe I believe in the power of normalcy.
At no time was this principle clearer to me than when the Twin Towers fell in New York on September 11, 2001. We were living in Princeton, New Jersey, close enough that what happened felt very real. Our daughters were just two and a half, our son five years old. I’d been doing research in the Princeton Public Library for the microbiology class I was taking as a prerequisite for nursing school. We had to write a short paper about West Nile virus.
I was reading articles, taking notes when I noticed a cluster of people in the library’s lobby all watching TV. Curious, I went over. “A plane flew into one of the towers,” one of the librarians told me, her voice low and tight, nervous in a way that seemed out of proportion. I didn’t understand. A small prop plane went wildly off course. Odd. Dangerous for the people involved, of course, but no more.
And then the first tower fell, on the TV screen right in front of me, all one hundred and ten stories of it collapsing into a giant pile of cement and fire and toxic dust. The second tower fell soon after. In my memory, the collapses are separated by only a few minutes, although the south tower fell at 9:58 a.m. and the north tower at 10:28 a.m., thirty minutes later. Afterwards I went back to my research and methodically finished up my notes, thinking, Things aren’t going to feel normal for a long time; I want one more dose of normal before that begins.
But of course there’s no way to be sure that Sheila herself preferred a dose of normal over having the stretcher brought to her. She’s such a stoic she would never say she couldn’t walk, especially since I presented walking to the stretcher as the first choice option. Hmmm. In my need to help her feel indomitable, have I inadvertently caused her pointless pain? I’ll never know.
Once Sheila makes it to the stretcher it’s almost too high for her to get up on and this one doesn’t adjust. What genius designed these stretchers? Sheila’s not tall but she’s not that short, either. “I’ll go grab a step,” the escort says, hurrying off as Sheila stands with her back to the stretcher, pulling in long, shallow breaths and letting them out with a raggedy exhale. She’s not sweating, so the walk didn’t completely tax her.
The escort returns quickly—“Here you go!”—putting a one-step footstool behind Sheila’s feet, then maneuvering the carrier just slightly backward to give her a little more room. The brake locks back in place with a loud ka-thunk. It takes the four of us to get her on. Sheila’s sister has one arm, her brother-in-law the other. I’m reaching in, my head close to hers, my arms under her armpits and the escort is standing on the other side of the stretcher waiting to help. I count out loud “one-two-three,” just like on TV, and we lift, except in real life it requires actual exertion, not just looking cool.
It works and we get Sheila onto the stretcher. She gives out a low moan, her eyes tightly shut.
“We’re going to lay you down now,” I tell her, making sure the IV tubing is out and away from her body. She doesn’t need that to be pulling on her arm.
I ease her back on one side, her brother-in-law on the other, while her sister picks up her legs. We get her flat and she sighs and opens her eyes. “Better?” She shrugs.
I look at her. This is the moment when she will leave my care for good. Mine may be the last familiar hospital face she sees before she goes under and I want her to remember it as calm and present.
“I have to give you a hug,” I say.
“And a kiss,” she says in return, surprising me. What kind of a kiss, I wonder, is this?
Kisses in the hospital, real kisses, are as the six pomegranate seeds must have been to Persephone in the underworld: rare, enticing, a taste of life impossible to resist when you’re stuck in hell.
A few years ago the wife of a patient who had just died stood in the hallway and kissed me on the lips over and over again. “You’re an angel,” she murmured.
Well, no, but I had made sure he could die in the hospital on our floor, which had been his home and hers for the last few months. Reimbursement rules said he should go to hospice, which would involve a bumpy ride in an ambulance to deliver him and his wife to an unfamiliar place with nurses and doctors they didn’t know. He’d had tubes inserted so that his urine drained into bags outside his body and they never worked right. The end of his life was pain.
I made my case for not moving him with the nurse practitioner in palliative care. I don’t remember what I said. There was no medical reason for keeping him in the hospital—the guy was dying and people can and do die anywhere. The argument for moving him came down to money. Hospitals get reimbursed at a lower rate for hospice patients than those who are expected to live. He’d be using a bed the hospital could get more cash for.
I, however, didn’t give a damn about that. Either I persuaded the nurse practitioner of the wisdom of his staying or she was colluding with me, but we got the patient switched over to hospice in the hospital. It was our biggest room, too, supposedly for VIPs, with extra space for a sitting area, sort of like a suite room in a hotel, with a couch. The hospital bed was hidden behind enclosing curtains. What that wife had done for her husband over months as he fought the inevitable—she deserved at least a sofa and maybe a medal, too, for extreme selflessness without complaint. I know. I was there. She was the real angel.
I look at Sheila, put my arms around her neck as she lies on the stretcher, and go to kiss her on the cheek, but she moves and we kiss on the lips. Sealed with a kiss. Kiss and tell. A Judas kiss. The kiss of life.
The escort takes hold of the carrier and pushes her up the hall with her sister and brother-in-law following behind carrying her few belongings even though we could have transported them later. Away and away with nothing of her left in the room. Good luck, I think to myself, but I don’t say it out loud. Instead I swallow, and my phone rings.
“T., your admission is here.”
“Who?”
“Your admission. Irving. You’ve been waiting half the day for him! Wake up,” she laughs over the phone.
“Oh. Right.” My mind feels like a battleship trying to turn in shallow water. Irving. “Send him back once he’s checked in.”
And then I remember the final thing I need to do for Sheila. I call Akash, Peter’s surgical resident, my neighbor. “She’s on her way,” I tell him, just as he had asked me to do.
I don’t ask if they’ll take her tonight or if she’s just going down to be prepped by anesthesia. I had put in my pitch to Peter already and now all I can do is hope the surgery happens as soon as it’s safe for Sheila and not any later. Besides, it’s not Akash’s decision and he may not know right now anyway. Even Peter may not know, since doing the surgery depends on Sheila’s clotting time, which is tricky to evaluate because of her disease and the Argatroban.
I check the last box on her pre-op form—the one that records when she left the floor—and stick my hand in my pocket, feeling the “third tube” of Sheila’s blood that the phlebotomist gave me for her type and screen. Right. I had forgotten. I walk up to our pneumatic tube station and send the tube to the lab, more or less thirty minutes after the other two tubes went.
I’m back at my medcart when two burly EMTs push a loaded stretcher through the double doors that separate my part of the floor from the front section. Then I hear Irving’s whispery voice: “OK now. We’re here at the hospital now. OK.”
“Hi, Irving. It’s Theresa, but you may not remember me.”
He’s strapped down, but he looks up toward me. “I might remember,” he says, as the EMT hands me an envelope filled with paperwork and they wheel him into Dorothy’s old room.
CHAPTER 12
End of Shift
You guys OK in here?” The EMTs are lowering Irving’s stretcher, unstrapping him, putting the side rails down.
“Oh yeah, we know Irving.” EMTs have a reputation for being adrenaline junkies, hardened to the job, and they see a lot: people dead from sudden heart attacks, gunshot victims with clothing covered in blood, accidental overdoses by the young. The adrenaline rush is good, I imagine, and the ability to stay calm when all external signals are screaming “panic!” must be gratifying, too. The pulseless body, the crying wife, could become intoxicating; called in daily to traverse the border between life and death. Licensed to save. But that kind of grind could wear on a person because there would be many times when the patient couldn’t be rescued.
It’s probably a relief to ferry around someone like Irving, and they seem to really know him. They may have taken him to his outpatient chemo appointments and his doctor visits, becoming part of the family he doesn’t have. EMTs’ talk can be rough, their manner brusque, but it seems obvious they care about the people they’re responsible for. After all, why else would they do the job?
My daughter Sophia, when she was seven, swallowed a nickel. She’d put it in her mouth the way kids do, maybe to explore the impressions on its smooth surfaces, trace the roundness of its edges with her tongue. It was in her mouth and then down her throat when she called out. I had just started nursing school, but knew that if she could talk she could breathe. Her airway wasn’t blocked. I also knew to call 911 and soon enough the ambulance came, bringing two EMTs. One, a woman, strikingly pretty with dark skin and hair in small tight braids, fit the tough EMT stereotype. But the other one, a guy, youngish with sandy blond hair, had a gentleness that surprised me.
The Shift Page 18
