Текст книги "The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital"

Автор книги: Alexandra Robbins

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Текущая страница: 18 (всего у книги 33 страниц)

JULIETTE

  PINES MEMORIAL, February

On a relatively slow afternoon, Juliette was documenting at the nurses station. While she relished the adrenaline rush of busy workdays in the ER, she also treasured the occasional quiet spell that allowed her to chat with her coworkers or in the back office with Clark Preston.

Molly had been trying to convince Juliette to leave Pines because the clique bothered her so much. “Why don’t you work agency? There’s no reason not to,” Molly had told her. “You can work anywhere you want, you don’t have to do holidays or weekends, and the pay is higher.”

Juliette had resisted because the devil she knew was better than the devil she didn’t. She had anxiety about putting herself in new work situations. And while the clique overshadowed her job, she was still able to find positive connections with patients and some of her coworkers.

Ruby, the recently divorced nurse, stopped by the nurses station to say hello. “So what’s the deal with him?” she asked, pointing to a good-looking murse who was an incorrigible flirt. “I know he’s young for me, but what’s the deal?”

“If my daughter were in her twenties, I would not let her date him,” Juliette replied. “He cheats on his girlfriend every six months.”

“I gotta get laid. My little toy isn’t doing it for me anymore,” Ruby said.

Juliette was both surprised and pleased by the confession. She liked Ruby and respected her as a nurse, but they had not spent time together outside of work. How refreshing it was to gab with a coworker about something personal. “I know someone who’s more than willing,” she said. On a scrap of paper, she scribbled the name of the womanizer whose dalliances with several nurses had caused his secretary girlfriend to have a panic attack. She handed it to Ruby.

“Hmm, Dr. Fontaine. Isn’t he a little short? Cute, though,” Ruby said.

“He’s always down here. But apparently he’s been around the block a number of times.”

“Well, I’d just have to wrap his thing up twice then,” Ruby said, pondering the piece of paper.

Juliette cracked up. “Are you going to triage? I’ll walk you there.”

The women walked past the waiting area and stopped abruptly. Erin, a likeable young nurse, was heading toward the back wall with a large pair of forceps. “Uh, what are you doing, Erin?” Juliette asked.

“I have to get some candy out of the vending machine,” Erin said.

“Why, does a diabetic patient need some sugar?” Juliette joked, and followed her.

Two techs were kneeling in front of the machine. A dozen snacks were caught between the glass and the shelves. In front of an audience of patients and families in the waiting room, Erin tried using the forceps to reach the bags. No dice.

A few minutes later, Gabriel, the secretary, came over, rolling up his sleeves to reach inside the machine. “I can do it!” he announced. He couldn’t do it.

A murse brought a splint instrument that he had manipulated into the shape of a hook. The techs tried to grab the candy with the hook. “What if I get a lacerated finger?” one of them asked.

“That’s workman’s comp!” Juliette answered. The group laughed.

Soon, Dr. Preston came by. “Come on, Dr. Preston, you can do it!” someone shouted.

Ruby elbowed Juliette. “I bet those fingers can do anything.”

The staff and the patients watched as Dr. Preston reached his exceptionally long arm far into the machine and jarred loose a bag of Doritos. Finally, the chips and sweets tumbled from the machine. A cheer went up from the waiting room. Dr. Preston bowed and left.

Back at the nurses station, Juliette saw Dr. Fontaine flirting with a nurse. Ruby sidled by and bent toward Juliette’s ear. “Really?” Ruby whispered. Juliette grinned, raised her eyebrows, and nodded.

When Juliette got home that evening, she was still on a high from a fun day at work. As usual, she stripped off her dirty scrubs in her garage so as not to bring the germs into her house, painstakingly washed her hands and arms up to her shoulders, and pecked Tim on the cheek. She found 7-year-old Michelle on the couch.

She hugged her daughter tightly in greeting, but Michelle didn’t smile.

“Mommy, do you work tomorrow?” she asked.

“Yes, honey. It’s Tuesday.”

Michelle’s shoulders slumped. “It seems like you never have a day off. I want you home in the mornings to help me get ready. I wish you could work just in the afternoons.”

Juliette’s cheerfulness dissipated beneath her guilt. If she took shorter shifts, she’d lose not only wages but also opportunities to bond with her coworkers, as she had today. She decided then and there to apply for a clinical ladder promotion.

In the past, nurses who wanted to advance their career could study for extra degrees or apply for jobs in management. Juliette had no interest in applying for Erica’s vacant senior charge nurse position, or for any other administrative role, because she preferred to care directly for patients rather than supervise her peers.

Juliette loved bedside nursing because she cherished the direct interactions with patients. “I love being around them, being able to make all types of patients feel better,” she explained. “I love the moments of connection with the patient and with the family.”

Clinical ladders offered nurses like Juliette opportunities for a raise and recognition without having to leave the bedside. While the stages could vary by the hospital, Pines’ ladder offered four rungs of recognition: clinician level 1 (entry level), clinician level 2 (proficient), clinician level 3 (advanced), and clinical level 4 (expert). Each level required research, initiative, and a demonstrated level of clinical knowledge and advanced practice work. Juliette had reached advanced clinician level 3 a while ago. She didn’t have too much left to do to finish her application for clinical 4. She resolved to complete the requisite research project (which she had started and set aside last year) to reach the top level as a validation of her skills and a rationalization for keeping a demanding job that took time away from her daughter.

To achieve a clinical ladder promotion, nurses had to be in good standing at the hospital. Pines had a policy prohibiting nurses who made one patient identification error from applying for any type of promotion that year. Two mistakes in a twelve-month period and the nurse would be fired. Juliette knew she hadn’t made any notable mistakes, but she wanted to make sure she qualified before she put in the work.

“There’s nothing specific that I know of,” Priscilla told her. As the nursing director, she would have heard if Juliette had committed an infraction or received complaints about her work. “But you have six tardies and you need to watch it.”

“I will, I’ll be careful. But I’m okay to apply?” Juliette asked.

“Absolutely.”

Juliette punched a fist into the air. She was so exuberant that she went to tell Charlene. “Charlene, guess what! I’m applying for clinical four and I’m going to make a really strong effort.”

“I’m not sure you can,” Charlene said. “I’ve got everyone’s tardies and stay-lates printed out. I’m highlighting all of them. It’s a pet project of mine.” Charlene didn’t want nurses to stay later than their shift because she didn’t want to pay them unnecessary overtime. She smiled. “So we’ll see.”

Juliette deflated.

SAM

  CITYCENTER MEDICAL, February

Everyone at Citycenter was talking about the surprise inspection. The nurses were ecstatic and relieved that The Joint Commission had stepped in. One nurse told Sam that during an interview, she had admitted to the TJC investigator that she was uncomfortable sharing what she really wanted to say. The investigator held up a thick stack of papers to indicate how many others had spoken freely and replied, “You have nothing to worry about.”

The day after the inspection, Victoria sent a mass email to say she was transferring to another department to pursue other opportunities. A nursing administrator would take over as interim ER director. Victoria’s words didn’t fool the nurses. Everyone knew the real reason she had been transferred. A nurse who was friendly with Sam included her in a Facebook message to several coworkers that said only, “Ding dong, the witch is dead.”

Once Victoria left, the changes came quickly. The hospital immediately hired more than a dozen new nurses and instituted a bonus policy for nurses who worked extra shifts. The ER now would have mandatory daily checklists that monitored code carts and supplies. Maintenance workers deep-cleaned every room, waxed the floors, and painted the walls. Reportedly during the inspection, one of the surveyors had asked to see a room considered to be clean. A nurse led him to an empty room that was ready to receive an incoming ambulance patient. The surveyor saw blood splattered on the wall, empty bags hanging from IV poles, used blood culture bottles, capped IV needles on the floor, and trash on the counter. When administrators later dispatched multiple housekeepers to that room, it took ten hours to clean it to infection control standards.

Sam was pleasantly surprised by the interim ER director, who seemed willing to listen to the staff. On her first day, she changed Sam’s status to “weekend alternative”: For $10 more per hour, Sam would work weekends plus one weeknight per week, with one weekend off per month. She had been trying to get weekend alternative for ages, because, she rationalized, “if I’m going to be working in hell I’d at least have a regular schedule doing it.” Her previous discussions with HR and her supervisors had gone nowhere. The new director made it happen in one day.

The director quickly gained respect from the ER staff because she was willing to do whatever was necessary to help the department. She came in on weekends and cleaned stretchers. She put on scrubs and transported patients. “She is terrific,” Sam said. “It’s great to have someone in an authority position supporting us like she does. It makes a tremendous difference.”

Sam was sitting at the nurses station with William when Dr. Spiros stopped five feet away from them to talk to another nurse. William waggled his eyebrows toward Dr. Spiros, whose back was turned, then mouthed at Sam, “Your boyfriend’s here.”

Sam’s gray eyes narrowed behind her glasses. Angrily blushing, she whispered, “You can be done with the comments and the looks because there’s nothing going on.”

By now, Sam could discuss patient care with Dr. Spiros, but she still felt too awkward to say anything more to him than was professionally necessary. It was weird enough that she knew what he looked like when he wasn’t in scrubs and that she had been inside his home, let alone that they’d had an almost-but-didn’t relationship. At work, rather than waver between calling him Dr. Spiros or Dimitri, she tried not to use his name at all.

Sam didn’t mind being single, though it would have been helpful to have an extra ally in the hospital. She could admit to herself that she had a crush on William, but knowing he had a girlfriend, she would never act on her feelings. She was content to appreciate their growing friendship. Despite his teasing, Sam enjoyed working with William, and not only because he was an excellent, sure-handed nurse. He respected her and he made her feel appreciated. Sometimes he called her hospital cell phone just to say hi or to ask if she needed help.

One night, the charge nurse was doling out assignments and put William on Zone 1. In front of the staff, she asked him who he wanted to work with that night.

“Sam,” he said.

As Sam smiled to herself, proud and touched that William had chosen her out of all of the other nurses, she looked up and saw CeeCee glaring at her.

It was obvious that CeeCee assumed that she and William were close. Certainly, he was nice to her. CeeCee was always badgering him with social requests: “William, let’s do a group bike trip!” “William, come on the ferry with us this weekend!” Sam knew that William was warm to everybody. He had told Sam that he joined the young nurses’ social outings so that they would continue to feel comfortable seeking his help at work. He didn’t want them to think that because he was often the charge nurse, he was unapproachable.

Sam remembered when, as a nursing student, nearly everyone her senior seemed unapproachable to her. That had changed as she had gained experience treating patients and become accustomed to her colleagues. Without a doubt, William had played a major role in her growth, as a teacher and as a friend. He felt like a safety net, especially, as Sam put it, “when the place is so unsafe that I could lose my license.”

Now Sam was growing more confident day by day. She had a good general sense of the ER, knowing where the sick patients were even if they weren’t hers. She had learned how to get other people to work more efficiently with her; for example, if she needed lab results urgently, instead of inputting a lab request into the computer, she wrote it on a paper lab form, brought it down to the lab herself, and said, “We’ve done these labs. I need you to run them, please.”

One night medics brought in a 58-year-old trauma patient who had driven his car into a tree. He was awake and alert, though he didn’t remember the accident. While two residents examined the patient, Sam, as the recording nurse, stood in the back of the room taking notes. Shirley, the ER nurse practitioner, stood next to her.

As Sam watched the heart monitor, she noticed that the patient was having several premature ventricular contractions, extra heartbeats that disrupt the regular heart rhythm. While some PVCs are normal, the patient had many more than the average person. The patient’s nurse was busy drawing blood and the residents were engrossed in their assessment.

“Hey, Shirley, our buddy here is throwing a lot of PVCs,” Sam told the NP.

Shirley watched the monitor. “You’re absolutely right,” she said, then addressed the other nurse. “Let’s add magnesium levels to the labs and get a cardiology consult.”

The next night, Shirley approached her at the nurses station. “Sam, nice catch last night. The trauma patient turned out to be a cardio patient.” She explained that the cardiology team believed the man had had a heart attack or another massive cardiac event that had stopped his heart from functioning efficiently. The force of the air bag hitting his chest had probably restarted his heart, albeit at an irregular rhythm. The man had received a pacemaker that morning.

“Sam, you have good situation awareness and a good sense of what’s going on with your patients,” Shirley said. “I think you’d be a fantastic NP.”

Sam’s confidence soared.

MOLLY

  March

Academy Hospital

Molly’s first patient of the morning was an unemployed, heavily tattooed gang member with a cocaine habit. He had a small bowel obstruction because he had been shot in the stomach a decade ago. Molly tried not to judge her patients. (She’d had several tattooed dudes come in and say, “I hate needles.” You just never knew.) Recently at Citycenter, Molly had treated a trauma patient who had been shot three times and killed the other guy. Molly was creeped out by the man, but pleased with her ability to treat a murderer by separating the man’s crime from the medical treatment he needed.

When Molly entered the room, the gang member was telling Maxine, a medical student, that he was in severe pain. “Can y’all please talk to the surgery resident and get an order for pain medication?” Molly asked the student.

“Okay,” Maxine said. “I already ordered a Foley.”

“I’m not putting a Foley in a patient who is able to urinate on his own,” Molly said. She explained to Maxine that Foley catheters commonly caused hospital-acquired infections. If a patient developed an infection in the hospital, Medicare and Medicaid could refuse to pay for the visit. Hospitals had strict policies about which patients could get a Foley. Patients able to walk to the bathroom, like this man, were not supposed to have one.

“But we need to accurately measure urine output,” Maxine argued.

Molly held up a plastic urinal jug. “This has very accurate markings for measurement. The way we measure urine output in patients with Foleys is to empty the urine into the same urinal the patient would use to pee in, anyway. So I’m not putting the Foley in.”

The patient watched the back-and-forth with interest.

“But the resident wants it.” Maxine looked confused: If a doctor said it, it must be gospel.

“It’s not going to happen. Just because a surgery resident said it doesn’t change the policy,” Molly replied.

An hour later, the patient still hadn’t received pain medication. By now, he was technically no longer an ER patient; he was an ICU patient boarding in the ER because no ICU beds were available. His orders would come from the admitting team of ICU doctors rather than the ER. Although Molly was slammed with other work, as usual, she wanted to make sure that the patient was looked after. He was in obvious pain, but boarder patients were often the last patients the attendings would visit.

Molly found the ER doctor in the hall. As she was about to ask Dr. Ward for the meds, Maxine came out of the patient’s room, held up her hand, and said, “We’re taking care of it.”

“You told me that an hour ago and he still has no orders,” Molly said.

“I texted the surgery resident and she said she’d take care of it,” Maxine replied.

“When?”

Maxine paused. “I’m not sure.”

“That’s why I’m asking the ER doctor. He’s been in severe pain and vomiting since he came in here.”

Maxine tilted her chin condescendingly. “Don’t you think you should let us take care of it?”

“I’ve given you an hour to take care of it.”

Dr. Ward finally chimed in. “Imagine that’s your dad in the room. Would you sit there for an hour with him in severe pain and just wait around for someone to do something? How about you text that to your resident?”

Maxine looked sheepish. “Yes, sir.”

Five minutes later, the surgery resident was in the room. Molly followed her in and asked for the order, which the resident wrote immediately.

When the room emptied, the patient turned to Molly. “You’re the best nurse I ever had. Thanks for looking out for me.”

Molly considered patient advocacy the most important role for a nurse. She was surprised at how often she had to push hard for patients because doctors weren’t doing the right thing. She spent a great deal of time hounding doctors for pain medications for cancer patients and elderly patients. When Pines had offered to ban Daryl, Molly’s assaulter, from the hospital, Molly had declined because he could be a patient someday: “If he had a legit medical reason to seek treatment, I didn’t want his options limited.”

Similarly, she wanted to ensure that her patient was cared for as an ailing human being, not as a gang member. “I felt for this guy,” she said. “I’m sure he had received substandard care in his life because of his appearance and past. I treated him the way I’d like to be treated. To him, that was the best nursing care he’d ever had. That made me happy, but at the same time, it’s pretty sad.”

Pines Memorial

One day in late March, Molly took a shift at Pines on a day she knew the hospital could use the help. Because she was already established in the ER as a talented nurse with a strong work ethic, the ER office manager gave her hours whenever she wanted them.

Two hours into her morning, she decided to take a urine pregnancy test. It was more than two weeks after her IUI and she couldn’t let her hopes teeter for another day. She took a test and specimen cup from the lab room and went to the staff bathroom. With a pipette, she drew a few drops of urine from the cup and dripped it onto the test. Then she waited. Please.

This cycle had been Molly’s last chance to get treatment covered by insurance. After more than eight months of fertility tests, treatments, and appointments, besides wanting to conceive a baby, she yearned to be finished with the uncertainty in her life and back on track to work reliably for her employers. While the stakes increased with every cycle, these results seemed a great deal more important than the others. If the IUI didn’t work, she would have to undergo IVF, which would cost nearly $25,000 out of pocket for only a 30 percent chance of success. Molly and Trey would have to charge it on their credit cards.

Molly consulted her watch. Three minutes had passed. She looked at the pregnancy test. No color change. Negative. Molly stared sadly at it. Her stomach dropped.

But Molly had to return to work; there were no breaks at Pines. Nurses had no room for their own personal struggles in the hospital. She tried to brush off her emotions. Oh well, at least I’ll earn lots of credit card points toward cash back, she told herself. And now I need to get back to my patients. She trashed the pregnancy test and returned to the ER.

That afternoon, Bethany—the nurse whom Juliette had assumed was part of the clique—sought Molly out to talk. Priscilla had given the senior charge nurse title to three of the four nurses who had applied for the job that Erica had vacated. (Charlene had complained about this, but made sure to tell everyone, “They’ll all be equal, but I’ll still be over them.”) Bethany was the only rejected applicant. When Bethany asked Priscilla about it, Priscilla said she had heard the only reason Bethany applied was to prevent Juliette from getting the job.

“That’s not true at all. Why would I do that?” Bethany told Molly.

“Juliette didn’t even apply,” Molly said. “She didn’t want a new job; she’s working really hard for clinical level four.”

“Right,” Bethany continued, “and then Priscilla said, ‘Between you and me, I would never hire Juliette for that position.’ A manager should never talk to employees about other employees!”

Molly was floored. Priscilla gave Juliette the impression that she loved her. Juliette was a hardworking nurse who always tried to do right by her patients, and she was assembling a strong portfolio for her clinical ladder application. “If she feels this way about Juliette, she should tell her, and her performance evaluations should reflect it,” Molly said. She struggled with whether to tell Juliette because she knew it would hurt her feelings. But Juliette needed to know that the private information she shared with Priscilla might not be remaining confidential.

Staff politics were only one of many reasons that Molly was glad she had left Pines. Pines had the best educated and best insured patients that Molly had seen; they were probably among the smartest and wealthiest in the area. They were also the most demanding patients Molly had ever met.

Recently, the Westnorth Corporation announced to staff that care should be tailored to the patient surveys that were administered randomly after discharge. Thanks to the Affordable Care Act (also known as “Obamacare”), hospitals took their patient satisfaction surveys very seriously because their scores affected the amount of federal money they received. Since Westnorth had taken over the hospital, patient satisfaction scores had dropped. Administrators now were scripting nurses’ discussions with patients and ordering them to use memorized key words in what the hospital called “guided conversations.” For example, the survey asked, “Did your nurse educate you on your condition?” Patients tended to answer no, despite receiving discharge instructions about their diagnosis and treatment. Therefore, Westnorth now instructed nurses to say, specifically, “I am going to educate you on your diagnosis.”

At Pines, the patients could be difficult to please. “You can come in with appendicitis and we fix you but your room was cold, so you’re pissed off and give us a poor rating,” Molly said. “I don’t care whether the patients are ‘satisfied.’ I care that they get the treatment they need.” A patient once found Molly in a room performing CPR and yelled, “I ASKED YOU FOR A PILLOW FIFTEEN MINUTES AGO!” During CPR!

Too often, Pines patients demanded specific procedures, after speaking with doctor friends or searching for ideas on the Internet. If the patient’s orders didn’t match the doctor’s orders, the patient might leave the hospital dissatisfied, even if he was cured, simply because he didn’t receive the treatment he demanded.

One of the worst patients Molly could remember was an annoying woman who pressed her nurse’s call light every few minutes. “I’m cold,” she’d say, so Molly would cover her with a blanket. Molly would just be sitting down at the nurses station when the woman rang again. “I want some water.” Molly brought her the water. Five minutes later: “I don’t like it with ice.” Molly brought her water without ice. Another few minutes, then: “It’s too warm. I want one piece of ice.”

Thinking the woman should have to “work a little harder” to contact her nurse, Molly moved the call light out of reach. The woman called her on the room phone, asking for another blanket. Molly complied. Three minutes later, the patient rang her again. Molly was wise enough to know that some patients were difficult because they were lonely and scared. But she had four other patients just as lonely and scared as this woman, who was taking up way too much of her time. Nurses flipped coins to avoid patients like her.

Those were the kinds of people who answered the patient satisfaction surveys. Not the man to whom Molly gave her own meal because he missed putting in his dinner order and hadn’t eaten all day. Not the little old lady who had taken her first-ever airplane flight, fallen at the airport, and needed a CT scan that messed up her intricately braided cornrows. She’d had her hair done because she was meeting her great-granddaughter for the first time. Molly spent 45 minutes rebraiding the woman’s hair into its updo. As an out-of-town resident, the grateful woman wouldn’t receive a survey. Instead, Molly got in trouble with the charge nurse for braiding hair.

And no one would hear from the 30-year-old man who was dying of AIDS. He had been estranged from his family, and had just reconciled with his mother when his condition deteriorated. While Molly was triaging him, he begged his mother, “Please don’t leave me. I don’t want to die alone.” Soon afterward, he became unresponsive.

At 2:00 a.m., the patient was admitted to a medical floor for end-of-life care. When Molly wheeled him upstairs, his mother turned to her in tears. “I can’t stay here and watch my child die.”

“I understand this is very painful, but he specifically said he didn’t want to die alone,” Molly said.

When Molly left the man’s room to return to the ER, the mother left, too. At 7:00 a.m., when Molly’s shift ended, she called the floor to ask if the man was still alive. “Yes, but barely,” came the answer.

“Is anyone with him?” Molly asked.

“No. His mother never came back.”

Molly had just finished an exhausting twelve-hour night shift, but she wanted to honor the man’s last wish. She clocked out, took her things to his room, and sat next to him, holding his hand for two hours until he passed away.

“Of course,” Molly said later, “since he was an admitted patient—and dead—he couldn’t be polled about his hospital experience.”