The Shift: One Nurse, Twelve Hours, Four Patients' Lives (3 page)

I fold the blank sheet of paper into fourths. Then I take my pen and outline the four squares I just made by drawing along the fold. Each patient gets one square and I have a blank square for the fourth patient if she or he shows up. I number each square at the top with the patient’s room number and write in each patient’s name. Then I draw the grids we use to write down laboratory values and add in the abbreviations for intravenous lines. So strange to me as a new nurse, these now come easily. TLHC is a triple lumen Hickman catheter, a permanent IV line that protrudes from the upper chest. A PICC—peripherally inserted central catheter—is a different type of permanent IV line that gets inserted in the patient’s upper arm. Temporary IVs I notate as “per,” because they go into a peripheral vein: the kind you can see when you look at your own arm or hand.

I used to need a full sheet of paper for each patient, but now it’s one 4.25" x 5.5" square of white each. I’ve got my printed papers, too, of course, that come from the computer, but this one-sheet documentation of the day is uniquely mine. It’s just enough space, I hope, to record all the variables of the shift, including the new information I cannot forget: an MD called to consult when a patient will go off the floor for a scan, a cell phone number from a distraught husband or wife, the specific bacteria found growing in culture, test results whether good or bad, and new orders from the nurse practitioners, physician assistants, or MDs.

If it’s a bad day, I’ll know because that small quarter of a page of white paper won’t be big enough for everything I need to write down.

CHAPTER 2

Report

The other day-shift nurses, like me in white scrubs, are already in the conference room. I see Amy, with her long blond hair, and Katherine, one of our veteran nurses who actually works two jobs. Their form of rebellion is wearing colored long-sleeve shirts under their white scrub tops.

Susie, one of our newer nurses, is there and her tight curls bob as she nods her head and writes. I know Randy, also a newer nurse, is on today, but he likes to go somewhere quiet for report. Quiet can be good, but today I want the social connection.

There’s Nora, who can be a great coworker, but has a catty side I don’t much like, and Dot, whose throaty smoker’s laugh inexplicably comforts me; not much throws Dot.

And last I see my friend Beth, who’s maybe ten years older than I am and stopped throwing up on her way to work a long time ago. Her hair is cut just above her shoulders in a tidy, middle-aged bob. Her wire-rimmed glasses flash up at me as she offers me a wave and a smile, but she doesn’t stop listening and writing.

This is what we call “report.” The nurses all sit, intent, portable phones up to their ears, writing down histories, numbers of white blood cells, chemotherapy regimens, problems we’ve yet to solve. It’s an internal room, windowless. A half-f two-liter bottle of Diet Coke, a leftover from night shift, or who knows when, sits out on the table along with some stacked Styrofoam cups. The soda’s probably flat, but I bet at some point today someone will drink it anyway.

Listening to voice care can be a little like attending a spoken-word poetry slam. Near the end of every shift each nurse uses the phone to tape a verbal report on each of her or his patients. Report always begins with the same information: name, age, diagnosis, but after that every nurse has her own style, her own points of emphasis. We’re people after all and some nurses will discuss the most pressing issues first, while other nurses describe all the normals before getting into what’s really up. With cancer patients, in general, something is always up. Plus, some nurses like to know everything about a patient, others the bare minimum, and the report we give reflects our own inclinations. Katherine is notorious for reports that come across like haikus. Beth tends toward the epic. I try to be concise, then catch myself rambling; later I’ll worry that some important detail got left out because of my self-editing.

Report is also always in our unique hospital lingo, which includes acronyms and diagnoses, but explains events in terms of well-known clinical narratives:

“Lisa Smith, you know her, day ten of a MUD, intractable nausea and vomiting. We’re trying Ativan and it seems to be working, but knocks her out.” Translation: the tenth day after her matched unrelated donor transplant.

“Bob Jones has a fungal pneumonia. He just couldn’t stop smoking and we can’t give ampho because he’s allergic to it.” Amphotericin B is a potent but toxic antifungal medication.

“Diane Doe, day twenty-four of an Auto and . . . let me look it up . . . her ANC is, oh my God, her ANC is already back and it’s eight hundred. She’s going home.” ANC is absolute neutrophil count, a measure of immune system function.

Voice care is efficient. In the old days report was given from nurse to nurse face-to-face, which took all the nurses off the floor at the same time. With voice care the shift going off duty covers while the shift coming on duty listens, but nuances get lost on the tape. A grimace, raised eyebrows, a frown communicate the feel of taking care of someone. Voice care passes on the details of a patient’s stay, but it doesn’t always capture who the patient is.

Some hospitals are starting to do change of shift with both nurses in the room talking to each other and the patient. The idea is to make the patient a partner in care and to smooth out the transition between nurses. I like the sound of it, just as I agree with letting patients read their own medical records, but what about the patients who consciously choose to know only the broad outlines of their care because hearing all the details makes them anxious? Treatment for cancer is not like having your gallbladder removed; some patients want to know everything, while others prefer to remain as ignorant as possible. And sometimes we keep secrets from patients, usually when the news is bad and we want to be 100 percent sure before confirming it. Will a face-to-face report lead to all patients learning new medical information in real time, or will we sometimes deliberately hide what we know, institutionalizing a layer of deception? Knowledge is power, but how much and when for each individual patient?

Then there are the petty secrets nurses want to keep among ourselves: that we find a patient whiny, that his wife is suspicious of everything we do, that the relatives who visit expect us to chat with them, making it impossible to get any work done. Should complaints be part of report? Underneath the fog of irritation, venting can reveal the human being. But maybe being in the room with the real patient would be an even better reminder of her humanity.

I dial up voice care and punch in my access code, pen ready. I have to go fast.

I hear Andie, the night-shift nurse, telling me about my patients. When one nurse’s patients get transferred as a group to another, as happened this morning for me, report is easier. That kind of easy pass isn’t always possible, though, since the number of staff and patients can vary. Richard Hampton, the seventy-five-year-old with lymphoma, is having some difficulty breathing and is off and on confused. In other words, he’s elderly, has cancer, and is not doing so well. I scribble down how his night was. No alarming highs or lows in his daily lab reports—also called lab values or just labs, for short—that we need to address, but I’m not sure what, if anything, we’ll be able to do for him. The printout I got lists his meds, but Andie doesn’t mention a treatment plan. Seems like, except for his cancer, the fact that he can’t breathe without oxygen, and doesn’t always know where he is, he’s doing great. I sigh inwardly—cancer sucks, it really does—and punch in the number for my second patient.

Next up is Dorothy Webb, beloved by everyone because she’s very friendly and because of that candy dish in her room, located right next to the door. Dorothy, fifty-seven, came in with leukemia, went into remission after chemo, and now we’re keeping her until her immune system returns close enough to normal that it’s safe for her to go home. For the next several months she’ll come back to the hospital every few weeks for what we call consolidation chemo: high-dose chemotherapy to help maintain her remission. None of that’s on the table today, though; today she’s mostly waiting, stir-crazy, I learn, but from an illness point of view doesn’t have a lot going on.

Sheila Field, my third patient, is a wild card. She arrived at three this morning from an outside hospital and I learn that she’s got a history of a blood clotting disorder—ah, that’s the “antiphospholipid antibody syndrome.”

Sheila puts the “heme” in hematology/oncology, which is what our floor specializes in. Blood disorders like hers and blood cancers such as leukemia and lymphoma are both considered problems of hematology, the study of how blood is produced and what its diseases are. Blood cancers are also categorized under “oncology,” the same as solid-tumor cancers (such as lung, breast, liver), and some clinicians even describe leukemia and lymphoma as “liquid tumors.” For me, Sheila provides a break from cancer and a chance to learn. I, too, forget that “heme/onc,” as we describe ourselves, includes blood disorders of all stripes. Blood seems so simple—a cut bleeds and then clots, red blood cells carry oxygen—but there are people whose blood itself is dangerously flawed and Sheila may be one of them.

I click the phone off and glance over my notes; everything looks OK. The clock on the wall says 7:30. I need to find Andie; she’ll be wanting to go home to sleep.

She’s waiting at the nurses’ station. Young and pretty, her thick black hair piled up on her head, her delicate neck bent with fatigue, she looks like a drooping flower.

“Any updates?”

“Naaw,” she says, trying to stifle a yawn. “Dorothy’s ANC isn’t back yet.” That’s her Absolute Neutrophil Count: a specific type of white blood cell crucial for fighting infections. It’s Dorothy’s neutrophils that have to regrow enough for her to go home. “This guy, Richard Hampton, I don’t know what they’re gonna do with him.”

“Is there a plan?”

“Not that I’ve heard,” she says.

“Anything else on Sheila?”

“God, you know, did they really have to bring her here in the middle of the night? They couldn’t just let her sleep?” she asks. I used to underestimate Andie because of her looks. Stupid. She’s a damn good nurse.

“Well, it’s the old ‘Send ’em to Pittsburgh; they’ll know what to do,’ ” I say.

She frowns. “Yeah, right.”

“Go home,” I tell her.

She nods, looks down at her notes one last time. “Oh, wait, she’s also having some belly pain.”

“Abdominal pain?”

“Yep. Not too too bad, but it hurts.”

I purse my lips, wrinkle my eyebrows. Could be any number of things.

I nod. “See ya,” I say, as she slowly walks away, yawning again, this time not trying to hide it.

In the hospital, this is friendship. We take a “just the facts, ma’am” approach, and add in an ineffable bit more. “Only connect,” the novelist E. M. Forster famously wrote. “Go home,” I tell Andie, in place of saying how much I admire her and wish her well. No time for any of that right now.

I look up at the whiteboard across the nurses’ station from me. It’s got twenty-eight rows delineating our twenty-eight rooms and they’re all numbered and divided into sections. The first three letters of each patient’s last name go in the blank space following the room number—laws about patient confidentiality forbid us from writing more. The next space lists the attending physician. This is the doctor who has ultimate responsibility for the patient and supervises morning rounds but will not be physically in the hospital during the day to address problems. That work—daily medical care—is done by interns and residents, nurse practitioners, and physician assistants, and their names go in the empty space following the attending physician’s.

In any teaching hospital, interns and residents are completing the intense clinical training that follows their four years of medical school. They are technically already doctors, but residency is when they really learn how to be doctors. Internship is the first year of residency and so first-years are called “interns.” After that they become “residents.” For them, this is the time of no sleep and being “pimped”: asked questions so persistently by attending physicians on rounds that even the most prepared intern eventually runs out of answers. In the end she may feel foolish and exposed, but also by butting up against her own ignorance she will have learned something important—that’s the idea at least. Most of the residents are nice, but some aren’t; many understand how to work well with other people while others don’t. They are trying awfully hard and many, especially in the first few months of each training year, seem anxious to do well.

First-year interns are supervised by residents, who in turn are supervised by older residents and fellows—MDs specializing in a field. The residents on my floor will become a variety of doctors, but the fellows are all “heme/onc.” Nurse practitioners (NPs) and physician assistants (PAs) have many of the privileges and responsibilities of physicians, but most don’t get paid close to a physician’s salary. From what I’ve seen, inpatient care would collapse without them. They, similar to the interns and residents, do a lot of the daily medical work in the hospital.

True to tradition, the NPs and PAs are listed on the board by their first names, as nurses are, and the interns and residents by last names only. Any good history of medicine would have to examine how important the title “Dr.” is to many MDs and how certain types of docs don’t allow anyone but another doc to call them by their first name. That kind of attitude is changing in the newer generation; they tend to introduce themselves as “Lisa” or “John.” But there are even now nurses who call every physician—whether an attending physician or intern—“Doctor” because that’s how they were trained and what they believe is right.

I bring my informality to work as well as my background in a university. When I taught at Tufts I was Theresa and my husband is Arthur at the University of Pittsburgh physics department. Hierarchies in naming reinforce hierarchies of power and I guess that explains the rigidity about who’s called what in hospitals, but health care might run more smoothly if those of us who work together used first names, identifying ourselves to each other at least as more equal than not.

The last two rows on the white board show the nurse’s name and phone number. I pull out my phone and check the number taped to the back of it. Yes, they wrote it down correctly. Occasionally the numbers get mixed up and it’s very confusing until someone figures out what happened and fixes it on the board.

I write down the pager numbers for my patients’ clinicians (intern, NP, or PA), which I get from the other big white board we have. That board, hanging on a wall perpendicular to the first, includes key phone numbers: the blood bank, our satellite pharmacy, the lab, escort, MDs whose clinics are separate from the hospital, and so on.

Report done and all needed contact information written down, we nurses scatter to our pods and medcarts, compact wheeled sets of drawers that hold supplies and patients’ medications and have a computer and work space on top. The top surface is higher than a normal desk so our chairs feel like barstools. If only.

I’m in the back part of the floor today, behind a set of double doors that keep the hallway pretty quiet, although they serve a practical purpose: protecting our stem cell transplant patients, who are particularly vulnerable to infections. The doors keep random visitors out and remind the patients not to mingle.

I sit down to do computer work and every nurse on the floor is doing essentially the same thing: looking up each patient’s lab values, medication times, vital signs, and new orders. Then browsing the patient’s history, checking test results, and confirming conclusions from scans. This is in some ways the most important part of the entire shift because it’s when we prepare for the next eleven hours.