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: 21 (всего у книги 33 страниц)

SAM

  CITYCENTER MEDICAL, April

At 3:00 a.m., Sam was documenting at the nurses station when she received a text from William. She hadn’t seen him much since her schedule had shifted. She’d been surprised how much she had missed him. She glanced at her phone. He had texted, “Didn’t know you went on a date w/ McCrary.”

“What?” Sam yelped, and slammed down the phone. From Citycenter, Sam had gone out only with Dr. Spiros. Certainly not McCrary, an intern. Where do people come up with this stuff? she wondered. Rumors of promiscuity had followed her at Pines Memorial, too. How did people not see that she was too awkward to be a slut?

She texted him back. “I didn’t! Where is this coming from?”

When he replied, she learned that he was at a bar with several people from work, including CeeCee and Dr. Spiros.

She did not have time to stew about it. Medics brought in a trauma patient who had been shot in the leg. With no pulse in his foot, the staff assumed that the bullet had severed an artery. When the OR called down to say that the team was ready, the ER doctor told Sam to hurry the patient upstairs for surgery. Once Sam wheeled the patient upstairs, however, the OR nurse refused to take her report. “I don’t know anything about this patient,” the nurse huffed. “Just go in there. They’ll take report.” The nurse pointed toward the operating theater, the area bordering the operating rooms.

The patient, a young man in his twenties, was whimpering in pain. His bleeding was well controlled and his family was on the way. There was little that Sam could do for him because he was in a limbo between the ER and OR. Sam found two anesthesiologists in the operating theater. “Do you know who I can give report to?” Sam asked. She had to thoroughly update a nurse from the admitting department on the patient’s condition before she left.

“No,” said the more senior doctor. The doctor turned to the patient. “Have you ever had surgery? Did you have any problems with it? Okay, open your mouth.” Anesthesiologists checked patients’ mouths before surgery because if the patient had a large tongue or the roof of the mouth hung low over the throat, then intubation would be more challenging.

Sam wasn’t allowed to return to her other patients until she gave report on this one. After several minutes of waiting around, she asked the male anesthesiologist about the delay.

“We’re still waiting for the on-call vascular attending to get here,” he answered.

“Can I get fentanyl for him while you’re figuring this out?” she asked. Her patient desperately needed pain medication.

“No,” the doctor said, and resumed doing paperwork.

Sam, exponentially more confident than she had been in August, stared down the more senior anesthesiologist. “Really? You want him to sit here in pain when you guys were the ones who wanted him to come upstairs and I could have gotten him pain medicine downstairs, so he’s up here in pain because of you?”

The doctor sighed. “Fine,” she said, and wrote the orders.

By the time Sam retrieved the fentanyl and administered it to the patient, there was still no news on the surgery status. Sam was frustrated: She had nowhere else to take him, and she had five other patients downstairs who needed her, including a woman in bad shape and bound for the ICU.

Typically, taking a patient to the OR was a quick and easy trip. If Sam had known this visit would have been so complicated, she would have asked a less busy nurse to escort the patient. Sam circled the floor, asking the anesthesiologists and the PACU nurses for the name of the person who had given the okay for the patient to come upstairs, so she could finally give report.

“Here,” the senior anesthesiologist said, handing her a piece of paper. “Call this number. It’s the senior surgical resident.”

Sam had a feeling the doctor was giving her a task just to shut her up. Reluctantly, she dialed. “Who gave you this number?” the surgeon barked when Sam reached him.

Sam realized that the anesthesiologist had given her the doctor’s personal cell phone number rather than his hospital cell. (“That was completely inappropriate! It was a doctors’ pissing match,” she said later.)

The surgeon ranted to her about the anesthesiologist. “Anesthesia had no right to give you this number,” he fumed. “No one is on their game tonight. The OR has had problems all week.”

Sam fidgeted with her glasses. The ultimate goal is taking care of the patient, not seeing whose stethoscope is longer, she thought. She didn’t care about interdepartmental politics; and she had heard that tension between surgeons and anesthesiologists was common. Sam just wanted to get back to her patients.

“I need to go. I’ll just leave the patient in the PACU with the nurses.”

“That’s fine,” the surgeon said.

When Sam wheeled the patient to the PACU, she found a nurse surfing the Internet. “The surgeon says to leave the patient here. I have five other patients to get back to.”

The annoyed nurse took Sam’s report. Later, Sam learned that after seventeen hours of surgery, the patient would make a full recovery.

When he left the bar, William called Sam. He explained that someone had blurted out that she had dated the intern and a few of the residents, making her sound like the hospital tramp.

“Funny, I didn’t realize I was going on these dates,” Sam retorted. “Who said this?”

William sighed. “Okay, so what happened between you and CeeCee?”

“Oh. Well. CeeCee and I don’t make beautiful music together,” Sam said, and recounted when CeeCee had discovered that Sam said she drove her crazy.

William told her that the group had been drinking. Out of nowhere, CeeCee had declared that Sam had been hostile to her. She launched a diatribe about what a horrible person Sam was, and then claimed that Sam had dated four guys who worked at the hospital (none of whom Sam had dated). Dr. Spiros had chimed in, “Oh yeah, she went out with me, too,” as if something had happened between them. Dr. Spiros was now dating another tech.

CeeCee then burst into loud drunken tears. “Why do you even like her? She’s so mean!” she wailed to William. Surrounding bar patrons turned to watch her drama.

Eventually, CeeCee’s friends had dragged her out of the bar before she could make more of a scene. Later that night, CeeCee texted William: “I hope you and I are okay.”

Once again, Sam was beset by unfounded rumors of promiscuity at her workplace when she tried hard to avoid drama, let alone extraneous personal interaction in general. And self-absorbed girls like CeeCee didn’t even get embarrassed by their own ridiculous behavior.

People had done this to Sam since high school: Because she was quiet, they projected onto her a superficial image of the character they assumed she was. Because she was opinionated and did not mince words, that character was often negative, and because she was chesty and men found her attractive, that character was presumed to be a slut. Sam tried not to get caught up in what other people thought about her. But these types of rumors motivated her to work even harder. “I need to be really good at what I do if people are going to think ill of me without even knowing me,” Sam explained.

Sam didn’t claim innocence; she shouldn’t have said CeeCee drove her crazy when they were interns. But at least she had respected CeeCee as a nurse. Confronting CeeCee would only exacerbate the hostilities. “I feel like I should wear a plaid skirt and carry a backpack to work,” Sam told a friend. “It’s like high school, except for the dying people.”

MOLLY

  May

Citycenter Medical

Carl, one of Molly’s Citycenter patients, weighed more than 300 pounds and was missing a leg. He complained of chest pain but wouldn’t let anybody treat him. When Molly told Carl, who was homeless, that his discharge orders had come through, he crossed his arms. “I’m not going anywhere because I want to kill myself,” he said, smug.

Molly was unfazed. This was a popular game among homeless people so that they could score “three hots and a cot.” They would come to the ER, try to gain admission to the psych ward, refuse treatment, and get a warm bed and meals. Many hospitals automatically admitted any patients who mentioned depression or suicide, even if the staff knew they were bluffing. But here was one thing Citycenter did right: Molly called the crisis counselor, who spent three minutes with Carl, then told Molly to resume discharging him.

“But I’m going to kill myself!” Carl insisted.

“The crisis team thought there was a low likelihood of that, so here are your discharge instructions,” Molly replied.

“Just set them on my chest because when I go outside and kill myself, I want everyone to see them and know you don’t give a shit about me.” The man leaned back in his chair, splayed his arms dramatically, closed his eyes, and pretended to be dead.

Molly shrugged. “Okay.” She set the instructions on his chest and walked away. “I’ll call security to come help you,” she said while leaving. Carl wheeled himself out of the building.

Later that week, the hospital’s CEO sent an email to the ER staff. The Joint Commission had performed a follow-up investigation and had determined that the ER could keep its accreditation. Molly was stunned. “I can’t believe they found nothing!” she said.

The department had improved slightly; Molly didn’t get sick to her stomach on the way to work anymore. For her, the biggest difference at Citycenter was that the ER created a dedicated trauma nurse position. Because Molly was always assigned to the sickest patients, she was now able to concentrate on Zone 1 patients without having to abandon them immediately whenever a trauma came in.

The rooms still weren’t as clean as they should have been, however. Nurses were supposed to call housekeeping as soon as they discharged each patient, a practice that had quickly fallen by the wayside. And now that TJC had come and gone, Citycenter was trying to control the budget by creeping the nurse-patient ratios back up again.

Undercover observation conducted for this book during this time revealed multiple violations of TJC standards. At one visit, floors, supply drawers, carts, tubes, and equipment were spattered with dried blood; urine samples had spilled across a counter in a lab room; and bloody gauze was strewn over a sharps container. In the utility room where nurses brought pregnancy tests, a urine-soaked absorbent pad lay on the counter beneath a hospital binder.

Elsewhere, the ER didn’t use proper TJC notification systems, and a tech blatantly flirted with a visitor as he held down a patient who was being catheterized and moaning in pain. And when a pregnant woman came in with vaginal bleeding, worried that she had miscarried, the ER doctor discharged her without bothering to tell her that her fetus was fine.

Molly would continue to take shifts at Citycenter, but she knew that it wasn’t the hospital she was looking for. She didn’t like that Citycenter and Academy hired new grads directly into the ER and that she was considered one of the most senior nurses, with only ten years of experience. “There’s no one for me to learn from,” she said. And while Academy was easy, it was too easy for her to consider working there permanently: “There aren’t enough sick people there for me to help.”

Academy Hospital

Molly took a few extra shifts at Academy so that Jan, the grateful young nurse, could spend time with her long-distance boyfriend. Molly was in triage when she heard a familiar voice in the lobby. “How long have you been waiting?” a man asked other patients. “What’re you in for? I’m suicidal.” It had been only six days since Carl had visited Citycenter, at least when Molly was working.

Molly finished assessing her patient. When she finally called Carl back, he was sweet as pie. “I’m suicidal,” he repeated, giving her puppy eyes.

“Uh-huh,” Molly said.

“Are you a nurse?” he asked her.

“Yes, I am. I’ve also been your nurse at Citycenter.”

“Really? How’d you know it was me?”

Nurses called patients like Carl “frequent flyers” or “hospital hoppers.” One man called an ambulance at least once a day to visit the Pines, Academy, Avenue, or Citycenter ERs, complaining of “uncontrollable farting.” Molly was incredulous that EMS was required to transport him and that ERs gave him IV fluids, food, drinks, clean clothes from the hospital’s donation closet (collected mostly from staff), and a bed. Several drug-seeking frequent flyers claimed to have sickle cell disease and asked for Dilaudid. This was a shrewd tactic; nursing schools taught students not to treat sickle cell patients as drug seekers because they had legitimate pain. Many doctors went ahead and gave these patients six Percocets, then discharged them.

“Why do y’all give in?” Molly asked one of the Academy doctors about a drug seeker. “He goes to a different hospital every day of the week. I would bet my last dime he sells the pills.”

The doctor shrugged. “I sometimes find it easier to give drug seekers what they want than deal with them raising hell.”

Molly knew of one drug seeker who had gone to an ER every day that Molly had worked for the past six years. “I want to know how he still has Medicaid,” Molly said. “That’s a minimum of $600 to $800 per visit. Conservatively, that’s $1.3 million to support a drug dealer and addict. I worry about what will happen to healthcare costs if we can’t get our act together.” When he became her patient, she used a larger needle than necessary on purpose to draw his blood; it was the only time she had ever practiced punitive medicine. Less than an hour after he left Citycenter, he showed up at another ER to get more drugs.

The ER abusers who most infuriated Molly were the homeless people who claimed they had a problem—chest pain, abdominal pain—so that the ER, as required, started a full workup. Then they would ask for a sandwich. “Some will even admit that the only reason they came in was for a sandwich,” Molly said. “Are you effing kidding me? You think taxpayers should pay six hundred dollars so y’all can get a sandwich?!”

Another abuse of the system routinely occurred on weekends at Citycenter, which wasn’t far from a jail. Come morning, people incarcerated for drunk driving or drunk and disorderly conduct looked for any excuse to leave their cell. Police escorted a 22-year-old college student from jail to the ER because he had slept in his contact lenses and claimed he needed eye drops. “To avoid doing paperwork, sometimes the police ask patients if they want to go to jail for being drunk and disorderly in public or to the hospital. Of course they choose the hospital!” Molly said.

ERs were packed with nonemergencies. One patient came into the ER complaining of acne. Another man showed up because his barber told him he was going bald. And then there were the patients who visited the ER simply because it fit best with their schedules. Several patients checked in because their doctor couldn’t see them until the afternoon. One of Molly’s Academy patients had an outpatient prescription for an ultrasound, but said, “The line was too long, so I came here.” Instead of paying $200 for the exam, the patient’s insurance company would now pay the minimum of $600 for an ER visit plus approximately $500 for an “emergency” ultrasound.

Molly decided to emulate another triage nurse, who greeted patients by asking, “And what’s your emergency today?” While the phrasing wouldn’t embarrass patients enough to leave, perhaps it would discourage them from coming to the ER the next time they had a nonemergency complaint.

JULIETTE

  PINES MEMORIAL, May

Juliette was working triage with Erin when a thin man in his late fifties came in. He had pulmonary problems and his doctor sent him to the ER because of an irregular EKG. His vitals were fine. “Do you have any chest pain?” Juliette asked him.

“No.”

“Any cardiac history?”

“No.”

“Shortness of breath?”

“No.”

Erin took the man to the adjacent lab room while Juliette began triaging the next patient. “Are you doing okay?” Juliette heard Erin say.

“I’m okay,” the patient said.

“Do you feel weak?” Erin asked as she began to place the IV.

“No,” the man said. “But . . . I think I need to lay my head back.”

“Juliette!” Erin shouted. “You need to come in here!”

Juliette rushed to the room. The man looked unconscious. “Do you have a pulse?” Juliette asked.

Erin already had her hand on his neck. “No, I don’t have a pulse.”

Juliette quickly checked the man’s neck. She couldn’t find a pulse, either. He was barely breathing. “Agonal respirations,” Juliette said. “I’m starting CPR.” Juliette pushed the Code Blue button behind the chair and began doing chest compressions. Erin began airway management with the ambu bag.

They wheeled the chair toward patient rooms while continuing CPR. “We need a bed!” Juliette announced as they dashed through the double doors.

Juliette had performed solo CPR twice (as opposed to working a code with a hospital team). Once, she and her daughter were going out to dinner when a businessman collapsed on the sidewalk. Juliette did chest compressions until, finally, he came to.

That time, Juliette had been scared because she was outside of the hospital setting, without equipment and staff that could support her. She had not been afraid recently when a 50-year-old woman came into the ER for bradycardia, a slow heart rate. Juliette had asked a new tech to put in an IV, but when she returned to the patient’s room, she discovered that the tech instead had gone to triage. Juliette was hooking the woman up to the cardiac monitor when the patient took her hand and said breathily, “I just want to say good-bye.”

“What are you talking about?” Juliette said. The words sounded strange.

“I’m just going to say good-bye,” the woman repeated. Her eyes went vapid. The monitor showed the woman’s heart rate plummeting to zero. There was no time to press a code button. There was no IV to utilize.

Juliette didn’t even think. She did the precordial thump, a method of resuscitating a patient in cardiac arrest: She raised her forearm to her nose and brought it down hard on the woman’s chest. The woman opened her eyes and burst into tears. She seemed to know exactly what had happened. “Thank you,” she whispered, grasping Juliette’s hand. “Thank you.”

When Juliette yelled at the tech, he blamed the new zoning rules, another Westnorth policy. “They set up our priorities so we’re supposed to help with triaging,” he complained.

“If I ask you to put a line in somebody who has a heart rate below forty, you need to put the line in,” Juliette said.

Shortly after the tech placed the IV, the woman’s heart rate rose. Later, Juliette learned that the woman received a pacemaker.

Juliette wasn’t going to lose this cardiac patient, either. Her arms ached but she continued the compressions. About a minute later, his eyes flickered. He looked around in a daze. “What happened?” he asked. Juliette savored the adrenaline rush.

Erin turned to her. “He was totally gone! His eyes were rolled back, he was shaking all over before he went still!” Agonal convulsions sometimes preceded clinical death.

Carla, a nurse in the clique, walked by. “Way to save a life!” she told Juliette, who smiled.

Once the man was in a room, the cardiologist came downstairs to evaluate him. “It turns out he also passed out at the pulmonologist’s office when he got some bad news, so it might have just been a vasovagal reaction,” the doctor told Juliette. A vasovagal reaction is a nervous system reflex that causes a sudden drop in heart rate, resulting in less blood pressure to the brain and leading some patients to lose consciousness. The doctor nevertheless admitted the man to the hospital’s cardiac unit.

When asked later what it felt like to save a life, Juliette said, “It’s amazing. That’s what we’re supposed to be doing but it doesn’t happen every day. Most days are about cleaning up poop or addressing abdominal pain or nasty family members.”

At the start of her shift the next morning, Juliette looked over the charts for Mr. Morse, a 77-year-old who had come in overnight. She noticed that the night shift had made a mistake. The man had blood in his urine and low blood pressure, but the nurses hadn’t done a three-way bladder irrigation. These irrigations weren’t pretty, but they usually worked. If a man had a large clot in his bladder, treatment involved inserting a catheter into his penis to flush out the clot.

Juliette caught the night nurse before she left.

“The doctor didn’t order it,” the nurse said.

“But if he has blood in his urine, you need to make sure there aren’t any clots.”

“Well, I would have needed an order and it wasn’t ordered.”

Juliette stared at the night nurse long enough to convey that she knew the nurse had been lazy; she should have requested the order from the doctor. Juliette called urology, then explained to Mr. Morse what she was going to do.

“Mr. Morse, I have to flush your catheter with saline to get rid of the blood clots that are in your bladder,” she said. After a tech inserted a Foley catheter, Juliette rolled up her sleeves. With one hand, Juliette held the man’s penis, and with the other, she pushed saline from a 60-cubic centimeter syringe through the catheter until the output was no longer cranberry-colored. Periodically, she also dialed a clamp on a tube to transfuse the patient’s blood. The skinny old man resisted. “What are you doing?!” he yelled. “What are you doing down there?!”

Juliette looked up. Mr. Morse was feebly trying to bat her hands away from his penis. Finally, he gave up. He put his hands behind his head and, with a look of bemusement, said, “Young lady, you ought to be ashamed of yourself.”

Juliette laughed and again explained what she was doing. Throughout the morning, she kept returning to the room to irrigate, but sometimes she didn’t get to Mr. Morse quickly enough. When his catheter got blocked, his sheets would saturate with fluid. Mr. Morse would try to escape the wet sheets. The staff would find the man naked and halfway out of bed while undergoing both a blood transfusion and a three-way irrigation.

Her coworkers were annoyed with Mr. Morse, but Juliette liked him. He was funny, sweet, and slightly senile. “I wanted to make him better,” Juliette said later. “He required so much work, but I didn’t mind because he was sick and he needed help.”

She was checking on another patient when out of the corner of her eye, she saw Priscilla treading cautiously down the hallway. Uh-oh, Juliette thought. She left the patient’s room to investigate. There was Mr. Morse, naked in the hall, a bag of blood hanging from his arm, and a catheter hanging from his penis.

“That’s it, Juliette, you have to put him in restraints,” Priscilla said.

Juliette escorted him back to his room. She wasn’t going to put the poor man in restraints. Juliette stayed past the end of her shift to take Mr. Morse upstairs to the cardiac unit. He would undergo surgery the following day to find the source of his bleeding.

The next afternoon, Juliette called the urologist from home to ask what had happened to Mr. Morse. “He made it,” the doctor said. “We were able to close off the bleed.”

Nursing involved deaths and inevitable disappointments, hostile visitors and slacking coworkers. But just often enough, something wonderful happened to remind a nurse why she loved the field.

During her next shift, Juliette was meticulously sanitizing her cell phone when someone from the hospital’s professional development committee found her. He handed Juliette a certificate and her clinical ladder portfolio. “Congratulations! You got the promotion! You’re a clinical level four!”

Juliette grinned with pride. A step up on the clinical ladder was almost comparable to an extra degree after her name, and clinical level 4 was considered a major accomplishment. She had put in time and effort to develop her expertise and prove her work ethic. A $2,000 bonus and a raise accompanied the promotion but, to Juliette, the promotion wasn’t about the money. It was about recognition of a job well done.