“I just wish guys would be straightforward.”
“Some guys are nervous, I guess,” William said, shrugging his broad shoulders. “They don’t want to hurt your feelings. But, Sam, you’re a great girl. You’re like the opposite of a damsel in distress.”
Another nurse came over to talk to William and Sam scurried away. She realized that William was usually surrounded by nurses because he was a good listener who made people feel better about themselves. He seemed to know everything that was going on in the department but he didn’t spill secrets.
Sam was just getting settled into the hospital when a new ER director came on board. The staff despised Victoria almost immediately. She would sit in her office or go out for meals when her nurses were struggling with excessive patient numbers. She sent annoying mass emails announcing the ways nurses and other staffers were “really supposed to” do their tasks or they would be written up, but she wasn’t willing to expend the resources needed to execute those policies. When a trauma came in, for example, nurses were “really supposed to” don plastic gowns to protect from blood spatter, which sounded fine on paper, but usually there was no time to waste, there weren’t any gowns in the ER, or there were only size XLs, too large for most of the nurses to use safely.
On multiple occasions, nurses went into Victoria’s office to ask a question or to voice a concern, and exited the office either fuming or sobbing. One nurse quit within minutes of leaving Victoria’s office. She had gone in to tell the director that the nurses were short-staffed and needed help, and Victoria had answered, “Pull yourself together, put your big-girl panties on, and do your fucking job.” Within four weeks of Victoria’s arrival, twenty of the fifty-eight full-time nurses at Citycenter had reportedly quit because of her. The ER was nearly always extremely short-staffed now, which meant higher patient-nurse ratios and longer wait times.
With fewer nurses, it became impossible to dodge CeeCee. She was everywhere, chatting, flirting, bubbling, high-kicking. CeeCee seemed to take a particular liking to William. Any chance she got, she sat next to him, at meetings, at the nurses station: “Oh, William! I need your help.” “Oh, William! Listen to this.” She would sashay to the busy nurses station and toss passive-aggressive barbs at Sam, like, “Oh my God, I have so much work to do. Sam, you’re sitting down; what have you been doing?” as if Sam were relaxing. Sam bit her tongue.
One night, a young woman came in with severe pain from endometriosis and repeatedly falling blood pressure. She was potentially septic from pelvic inflammatory disease, which meant she was in danger of a systemic infection. Sam monitored her, noting that her blood pressure would drop significantly over a couple of hours, then rise slightly in response to the saline that the resident kept ordering to replace the volume in the blood vessels. In fuller veins, the blood pressure was supposed to go up. In sepsis, however, other factors could cause the blood vessels to dilate; flooding the patient with saline would not fix the problem.
After a few hours, per the resident’s orders, Sam had given four liters of fluid (the body has room for approximately four to five liters), but the pressure was still low.
Sam sought out the resident, a first-year. “Um, something is obviously going on here. Her B.P. is low and I’ve just given her four liters of saline,” she told him. “I think we need to do something about this blood pressure instead of overloading her with fluid.”
“Let’s get a CT scan and see what’s going on,” he said.
The results revealed that the woman had fluid in her lungs. That’s probably from the fluid that I already gave her, Sam thought. But the attending physician insisted that because the blood pressure was still low, Sam had to administer two more liters.
Sam was getting frustrated. The woman’s heart rate was still elevated, indicating that she was either in pain or experiencing another type of physiological distress. Meanwhile, the attending physician was relaxing at his desk, surfing the Web. He had not spent five minutes with the patient.
Sam found William at the nurses station and relayed the scenario. “The attending said the patient probably lives low [normally has low blood pressure]. So we’re not giving her any pressors.” Pressors would constrict the woman’s blood flow, thereby raising the pressure. “But I’m not comfortable with these orders.”
“Your thought process is right,” he said. “Document everything.”
When Sam talked to the resident about the attending’s orders, he also seemed uneasy. But he was new, and seemed to trust that the attending knew what he was doing.
At dawn, the woman spoke. “I feel puffy,” she said. Her eyes were extremely swollen, and she was pale and lethargic. The fluid bags had emptied. Sam took her blood pressure. 85/50. That was low.
Sam approached the resident again. “At what point do we want to start getting concerned about this?”
The resident paused for several moments. “Eighty systolic.” (Systolic refers to the top number of a blood pressure reading.)
Twenty minutes later, the woman’s blood pressure had dropped further. “She’s at eighty over forty,” Sam told the resident.
“Okay, I’m worried now.” He went to talk to the attending.
When the resident returned, he pulled Sam into the hallway and told her that the attending didn’t want to do anything about the blood pressure and had given no explanation why. The doctor had ordered them to give the woman another liter of fluid, for a total of seven, and then hopefully a bed would open up in the ICU.
“Are you kidding me? We have to do something!” Sam said, gesturing to the patient.
“He’s my boss; I can’t do anything about it,” the first-year said. Sam would eventually come to know the attending as a doctor who didn’t excel in situations in which a patient had no clear diagnosis. But for now, the resident was too green to question a superior, and Sam was too new to tell an attending that she thought he was doing something wrong. Sam updated the notes in the patient’s chart, making sure to add, “No new orders per MD.” After leaving for the change of shift, she never found out what happened to the patient.
That was typical for ER nurses: Each patient’s story continued, at home or on another hospital floor, but the nurses were left with only a caption of the patient rather than the whole of the person, a full narrative life shrunken down to a room or a diagnosis: “Remember that patient in Twelve?”
Medicine asked something extraordinary of nurses: to forge intimate connections with another person for hours, weeks, or months, to care thoroughly and holistically—and then to let that individual suddenly go, often never to be heard from again.
That was just life in the hospital.
LARA SOUTH GENERAL HOSPITAL, September
Lara sprinted on a treadmill at the gym, sweat dripping off of her chiseled abs. I want my mom, Lara thought, pushing herself to run faster. I do not want the drugs.
Since the day at South General when she’d nearly taken the vial of Dilaudid, Lara had attended more than her usual thrice-weekly NA meetings to bolster her support. She had increased her interactions with her sponsor and sponsees, all of whom were looking out for her. And she went to the gym as often as she could. She knew full well that she had replaced her painkiller addiction with an exercise addiction. She went to the gym every day for boot camp and spin classes. At home, she religiously exercised to Beachbody Insanity DVDs, a hard-core cardio workout.
She rationalized that exercise was an acceptable outlet which, unlike the drugs, wouldn’t kill her. Besides, it helped. “I think too much about the bad stuff I see: children who have died, a teenager who died in a motorcycle accident. I can’t help thinking about their parents’ faces,” Lara said. Exercising “helps me release some of that negative energy. It allows me to think about it without breaking down and becoming incapacitated. Before, I wasn’t facing things going on. Drugs helped me to stuff it down more. Exercise helps me process it.�
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She had been able to put down the Dilaudid in August because she reminded herself how painful withdrawal had been. She had suffered through weeks of sleeplessness, night sweats, diarrhea, vomiting, and terrible nausea. “The withdrawal from narcotics is a living hell. I felt like my skin was crawling. All you want to do is sleep and you can’t. That’s why you hear about heroin addicts who can’t get clean. It’s because they’re like, ‘I know what will make this go away for just a little bit,’ ” Lara said. “I do not ever want to go through that again. Could you imagine feeling like that and having to take care of your kids?”
When she got to work after the gym, a loud drunk woman came into the ER shouting vulgarities. “That motherfucker!” she screamed. “My brother’s going to cut his dick off and shove it up his ass!” She was so out of control that the nurses couldn’t calm her down.
Lara took report from the medics. The woman claimed that someone followed her home from a party and raped and sodomized her. Unfortunately, she had showered afterward, which likely washed away much of the evidence for her case. While she waited for South General’s designated sexual assault nurse to arrive, Lara had nowhere to put the woman but the lobby.
Patients in the waiting room were loudly gossiping about the woman, whom they assumed was a typical ER drunk. “What’s her problem?” they complained. “Just let her go home,” a security guard muttered. Gradually, patients yelled back at her directly: “Shut the fuck up!”
Lara couldn’t tell them not to judge. And she didn’t want the woman to go home; she wanted her to get the help she needed. She brought the woman back to triage with her, depositing her in a room where nurses did blood work and EKGs. The waiting patients were angry at Lara for not sending the still-ranting woman home and the woman was angry because she said it hurt too much to sit down. Lara tried to ignore the glares coming at her from all directions, reminding herself repeatedly, This is not about me. She didn’t know why, but she believed the woman.
At first, Lara had been slightly nervous to work at South General, where violence, including murder and rape, touched many patients’ lives. Now, South General was her favorite hospital. While some patients had been initially leery of the curly-haired blonde nurse assigned to them, they soon changed their minds. “Once they lose their attitude against me, they see I’m there to help them and we build a rapport,” Lara said. “I respect them, I’m taking care of them, I’m not judging them. I can give them a pillow or blanket or five minutes of my time to really listen, and they’re grateful. Sometimes I’ll even get a hug from a patient after they’re discharged.” That didn’t happen elsewhere.
Lara also liked working with her colleagues, despite racial tensions that separated the black nurses from the few white nurses. She was the only white nurse whom many of the black nurses treated the same way they treated each other. A veteran ER nurse named Rose, in particular, had gone out of her way to welcome Lara since she had first arrived at South General. Rose was a sweet woman with no edges. If any nurse needed help of any kind, Rose was there for her without hesitation. She kept an eye on her coworkers so that if one of them was struggling with her patient load, Rose would step in, offering to take a patient for a CT scan or an admitted patient upstairs. She was a true team player.
When the sexual assault nurse finally arrived to evaluate the still-ranting patient, she spent more than an hour examining the woman. Afterward, she told Lara she was right to keep her in the ER. The woman’s injuries corroborated her story.
Lara was a self-assured nurse, skilled and experienced. She’d been confident ever since she had made the correct call on her own child. When Lindsey was four months old, Lara happened to be taking a pediatric advanced life-support class. She was reviewing her textbook in bed and decided to quiz her husband. “Hey, John, what would you do if one of our kids was choking and I wasn’t home?” she asked.
He answered correctly. “And where would you take a pulse on a baby?”
John didn’t know that one.
Lara went to Lindsey in her crib and pressed her fingers on her upper arm. She counted. “Sixty?” she said. “That can’t be right.” She did it again. “Oh my God, her heart rate is sixty and it should be one-forty!” She ran to the book to show John the page. “It shouldn’t be sixty! Something’s wrong!”
“You’re overreacting. Lindsey’s fine,” her husband said.
The next day, she took her daughter to the pediatrician, who said that Lindsey’s heart rate was normal. “Umm, maybe she has a cold,” the doctor said.
“What does having a cold have to do with her heart?” Lara asked. There was no reply.
Unsatisfied, Lara made an appointment with a cardiologist. The morning of the appointment, Lara weighed whether to cancel it. “I feel like the freaky know-it-all mom. I don’t want to go there and have them look at me like I’m crazy,” she told her husband.
“You might as well keep the appointment since you made it.”
At the cardiologist’s office, even before Lindsey’s EKG results had finished printing, the doctor told Lara, “Your daughter is in heart block and needs a pacemaker this week.” Heart block referred to a dangerously slow heart rate because the electrical signals that caused the heart to contract were partially or totally blocked. Lindsey had a pacemaker inserted during open heart surgery. Two months later, she went into complete heart block, saved only by the pacemaker. The cardiologist told Lara that if she hadn’t detected the problem, Lindsey “would have been one of those babies who was put to bed one night and didn’t wake up.”
Lindsey, who still had the pacemaker, was now a healthy 5-year-old. The experience bolstered Lara’s faith that she was “supposed” to be a nurse. Between the pacemaker and Lara’s addiction recovery, “Weird things have happened to me. I look at them as ways to grow,” Lara explained. “I am a stronger, more confident woman now. I tell my patients all the time to listen to their gut. I tell parents who seem self-conscious or unsure, ‘You know your kid better than we do.’ ”
She wished she were as confident in her marriage, but John was making that difficult. His own addictive personality led him to relate to and help her with hers, but dealing with his gambling and cheating—he said he had a sex addiction—added to her stress. He loved her, she knew, but he said he couldn’t curb his behavior. She stayed with him because Lindsey and her 6-year-old brother, Sebastian, were young. Lara and John made a good living together; at least, they had, until he got laid off from the heating and air conditioning company. They led separate lives anyway, with their own interests and friends. “I have a beautiful home, beautiful babies, and a good life, just a ridiculous husband,” she said. “When my mom got sick, I didn’t have time to focus on his stupidity.”
She remembered during her mother’s illness, she was working full-time, taking care of her children, and shuttling back and forth to her mother’s home twice a day. The week she put her mother in hospice care, her husband was cheating on her in Vegas. When Angie, Lara’s former coworker and roommate, asked Lara why she put up with it, Lara had replied, “I don’t have time to focus on John right now. My mom is dying and she is my focus.”
Lara still wasn’t ready to address her marriage. For now, she had plenty of other distractions. She was taking college classes toward her bachelor’s degree, and she was hoping to volunteer once a week as an elementary school nurse to spend more time around her children and their friends. Volunteering was also an outlet to express her gratitude. She said, “I’ve messed up so much in my life, and this is a way to give back. I made a lot of mistakes and God kind of let me off.”
JULIETTE PINES MEMORIAL, September
While Priscilla, Charlene, and Erica managed the ER nursing staff, in that order, rarely did all three work the same shift. The day’s supervisor directly affected Juliette’s workload: Priscilla and Erica were fair, Charlene was not. Juliette wished her work life weren’t so tied up in her
feelings about her coworkers, but nursing was a deeply interpersonal profession in which people had to depend on others—doctors, techs, fellow nurses—to do their job well.
Erica made Juliette want to be a better nurse. As senior charge nurse, she advocated for fellow nurses: If a doctor talked down to a nurse, Erica would march up to him or her and announce, “You can’t talk to my nurse that way.” She was a good charge nurse, a good manager, and a good teacher; she had taught Juliette how to be a good charge nurse, too.
Juliette was eager to please her supervisors because positive reinforcement inspired her to work harder, perform better, learn more. At Avenue Hospital, the ER director had made clear that she appreciated Juliette. Every few months, she emailed Juliette a positive message: “The charge nurse told me what a great job you did last night” or “We’re so happy you’re part of our staff.”
At Pines, Juliette had been dismayed to learn that Priscilla, the nursing director, was a member of the exclusive nurse clique (and that Charlene thought she was part of it, too). Juliette cared so much what her manager thought of her that she shared personal secrets with Priscilla, wanting her to understand everything she could possibly need to know about her. That way, like the Avenue director, Priscilla could encourage her to be the best nurse she could be. Priscilla appeared supportive of Juliette and had a good rapport with several of the nurses. Juliette had made an extra effort to show Priscilla that she was a hard worker, hoping to get the same positive reinforcement that she had received at Avenue. She was still waiting for it.
On a warm September morning, Juliette walked into the building thinking, as usual, Please don’t be Charlene, please don’t be Charlene.
The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital Page 9
