“Compelling and compassionate human drama. If you want to understand how modern medicine ticks, fasten your seat belt and spend a day in the hospital with Theresa Brown on The Shift.” —Danielle Ofri, MD, PhD, author of What Doctors Feel A gripping story unfolds in real time as practicing nurse and New York Times columnist Theresa Brown reveals the individual struggles as well as the larger truths about medicine in this country. She lets us experience all the life that happens in just one day in a busy teaching hospital’s oncology ward. In the span of twelve hours, lives can be lost, life-altering treatment decisions made, and dreams fulfilled or irrevocably stolen. Every day, Theresa Brown holds these lives in her hands. On this day there are four. There is Mr. Hampton, a patient with lymphoma to whom Brown is charged with administering a powerful drug that could cure him--or kill him; Sheila, who may have been dangerously misdiagnosed; Candace, a returning patient who arrives (perhaps advisedly) with her own disinfectant wipes, cleansing rituals, and demands; and Dorothy, who after six weeks in the hospital may finally go home. Prioritizing and ministering to their needs takes the kind of skill, sensitivity, and, yes, humor that enable a nurse to be a patient’s most ardent advocate in a medical system marked by heartbreaking dysfunction as well as miraculous successes. This remarkable book does for nurses what writers such as Atul Gawande and Abraham Verghese have done for doctors, and at shift’s end, we have learned something profound about hope and healing.
About the Author
Theresa Brown, RN, works as a clinical nurse. Her regular column appears on the New York Times opinion pages as well as on the Times Opinionator blog. She has also been a contributor to the popular “Well” section of that paper and writes for CNN.com and other national media. Brown received her BSN from the University of Pittsburgh and, during what she calls her past life, a PhD in English from the University of Chicago. Before becoming a nurse she taught English at Tufts University. Today, her focus is medical oncology and end-of-life issues. She lectures nationally, is a board member of the Center for Health Media and Policy at the Bellevue School of Nursing at Hunter College. Brown was a panelist for the TEDMED's Great Challenges of Health and Medicine initiative and is also involved in the Robert Wood Johnson Foundation's "Flip the Clinic" initiative and an advisory board member for Scrubs Magazine. She lives with her husband and three children in Pennsylvania.
Read an Excerpt
PROLOGUE A Clean, Well-Lighted Place The buzz of the alarm surprises me, as it always does. Six a.m. comes too soon. I’ve been off for a few days and never go to bed early enough before a first shift back. That’s the problem with being a night owl at heart. I lie in bed and think, What if I just don’t go in today at all? I consider it, then realize how much the nurses I work with would hate me if I didn’t show up. I close my eyes one last time, though. It feels good to float in the warm darkness, Arthur, my husband, asleep next to me. There won’t be any floating once I hit the hospital floor. I’ll have drugs to deliver, intravenous lines to tend, symptoms to assess, patients in need of comfort, doctors who will be interested in what I have to say and others who won’t, and my fellow RNs, who with a combination of snark, humor, technical skill, and clinical smarts, work, like me, to put our shoulders to the rock that is modern health care and every day push it up the hill. The memory of that effort comes back to me, keeping me in bed, but there’s something else, too, some feeling I don’t want to own up to. It’s why I’m hiding under the covers: I’m afraid. Afraid of that moment when the rock slips and all hell breaks loose. For me it was the patient who started coughing up blood and within five minutes was dead, just like that. I’ve told the story many times, written about it, thought about it. Seven years later it has gotten easier. But remembering it I feel a flutter in my stomach, a tightening of my jaw. That day the rock wrenched itself free, and until then I hadn’t fully understood that we could completely lose control of a body in our care. It wasn’t for lack of exertion; it was destiny, or fate if you prefer, that tore the rock away from me. I had run after it hard and fast, doing CPR in scrubs splattered with blood and calling in the code teamthose professionals, usually from the ICU, trained for “rapid responses,” who try to rescue patients when they crash. The nurses and doctors did their best for this patient, but they couldn’t save her, and in the end a person who’d been alive and talking and laughing was living no more. I put that memory away, get out of bed. It’s early November and dark out and I prepare for Pittsburgh’s late-autumn weather by pulling on riding tights and my wool sweater that proclaims “Ride Like a Girl.” The sweater makes me feel young. Brushing my hair, I almost forget to put on my necklacea small silver heart charm surrounded by the words “I” and “Y-O-U.” The heart has the tiniest of rubies stuck in the center, so that when it catches the light it seems to glow with life, like a human heart. Arthur gave me the necklace for our anniversary a few years back. I reach behind my neck with both hands and secure the clasp, comforted by having a reminder of love in the hospital. As I move down the stairs, the house is hushed. Arthur remains asleep, as do our three children. I think about the sleeping kids, and a smile crosses my face: our son is fourteen, our twin daughters, eleven, all with variations on their dad’s curly hair, the girls blond, as I used to be, too. None of them will get up for school until long after I’m gone. The dog doesn’t even wake up with me in the morning, but the truth is, I like it quiet like this. The warm blue of our cabinets and our pot rack in front of the kitchen window make me happy. In the silence of the morning I take a mental snapshot of the kitchen as a dose of home. Home is a vaccine against the stresses of nursing. Oh, food! I pick up a banana from our fruit bowl, peel it fast, and then eat it while drinking a glass of water. I should scramble eggs, toast bread, or even pour a bowl of cereal, but I don’t get up early enough to do any of that, and anyway I’m not hungry first thing in the morning. My mother tells me my eating habits around work are unhealthy. Uh-huh. She’s right, and the irony is not lost on me, but the shift starts at 7:00 a.m. and I’m never hungry until 9:00. I can’t change that. Lunch? I grab a yogurt, an apple, slap together a turkey sandwich, light on the mayo, and stow it all in my bike bag. The cafeteria food all tastes the same to me so I try not to buy my lunch. I see my reflection in the glass sliding door. Don’t have my game face on yet: my blue eyes look wary, waiting. The house remains silent as I sit on the stairs and tie my biking shoes. Then I put my bright yellow Gore-Tex jacket on, wrap my neck for warmth, and slide my bag over my shoulder. I head down into what a friend calls our Norman Bates basement. It’s where I keep my bike. There’s no dead mother down here preserved with taxidermy, although you could find more than a few cobwebs and the sparse lighting makes the corners impenetrable. As a child I was terrified of the basement in our house and my best friend loved to tell stories about horrors befalling innocent young girls in creepy basements. I wonder why I listened to her. I must have enjoyed the thrill, that frisson of fear that came from transforming our very ordinary cellar into a place of the macabre. My bike is stacked up against our family’s four other bikes. The basement is limbo, a portal between the ordinary joys and struggles of home and the high-stakes world of the hospital. I put on my helmet and lock the basement door behind me as I leave, awkwardly carrying my bike out the low door and up the few steps. As usual, I’m running late. I turn on my bike lights, saddle up, and push off. It’s two miles to the hospital and the ride starts with a downhill. I enjoy the feeling of moving without work, having the world shoot past as I pick up speed, my front light illuminating a slim strip of road. I barely brake at the first stop sign, making a quick left down an even steeper hill that makes me go even faster. The rush is fun. The next bit, mostly flat, gives me time to think. Like many nurses, the thing I’m always worried about is doing either too much or too little. If I sound an alarm and the patient is OK, then I over-reacted and have untrustworthy clinical judgment. If I don’t call in the cavalry when it’s needed, then I’m negligent and unsafe for patients. You don’t always know because what goes on inside human bodies can be hidden and subtle. This job would be easier if there weren’t such a narrow divide between being the canary in the coal mine and Chicken Little. I push hard during the one small uphill on my way to the hospital, neck scarf up and over my mouth. The cold makes the passageways in my lungs constrict when they shouldn’t, giving me that scary feeling of not being able to fully draw in a deep breath: bronchospasm. Covering my mouth and nose with a fleece wrap warms the air enough that I breathe just fine. I could carry an asthma inhaler, too, the medication that reopens those passageways, but that feels like overkill. At work I’ll pump medicine costing $10,000 a bag into patients’ veins, but use an inhaler? Me? That’s for people who are sick. There’s not a hint of sunrise at the hospital parking lot, but cars scoot in and out of the gated entrance: the start of change of shift even though the day hasn’t yet officially broken. I glide in around the barricade to the metal bike rack just inside the parking garage on my right. In the parking lot nurses, doctors, patients, family, friends drive in expectant, worried, excited, hurting. They grip glowing cell phones, hard-to-read pagers, pieces of paper, extra clothing, all while waiting impatiently, anxiously, expectantly for the elevator. The hospital itself is a paradox. Despite its occasional terrors, it is undeniably an oasis for the ill and infirm, a clean, well-lighted place. Sick people come, bringing their hopes and fears and we minister to them with our, mostly, good intentions. That phrase “a clean, well-lighted place” comes from a Hemingway story. It’s a short short story, about five pages long, in which, really, not much happens. The main character is a middle-aged waiter who works in a late-night café. He says some people require “a clean, well-lighted café” and late at night especially. Because of his own insomnia he understands why in the wee hours someone might need somewhere to go that’s not home and not a bar. But the young waiter he works with doesn’t agree that the café needs to stay open so late. “Hombre, there are bodegas open all night long,” he complains, eager to close up, go home, be with his wife. “You do not understand,” the older waiter says, “This is a clean and pleasant café. It is well lighted. The light is very good.” It’s two thirty in the morning and their one customer is an elderly man, a drunk who, the week before, tried to kill himself. If necessary, the older waiter will keep the café open all night to give sanctuary to this one forlorn soul. However, his generosity to the patrons of the café stems not from compassion only, but his own hopelessness as well: “It was not fear or dread. It was a nothing that he knew too well. It was only that and light was all it needed and a certain cleanness and order.” A feeling of dark disorder has overtaken him and he keeps the café open in part to keep his own nihilism at bay. But he also knows something the eager young waiter does not. There will come a time when each of us will need a clean, well-lighted place that stays open all day and night, offering shelter from life’s storms. This is a hospital. I work on a cancer ward, and while “cancer” used to always imply “death,” more often than not that’s not true anymore. Now, cancer involves treatment and its accompaniments: chemotherapy, radiation, surgery, scans, clinic visits, and hospital stays. People survive, often. We cure themput their cancer into remission, forever one hopesand they go home. Indeed, an oncology nurse’s favorite words to a patient are, “I hope I never see you here again,” and we’re telling the truth. The older waiter and I both come to work with the hope of doing good, and we share the same wish: for our customers, or patients, not to need us. But until that moment comes we will remain at our posts, ready.
Table of Contents
CONTENTS Prologue: A Clean, Well-Lighted Place Chapter 1: 7:03 a.m. Chapter 2: Report Chapter 3: Hitting the Floor Chapter 4: Worries Chapter 5: Surgical Team C Chapter 6: Paperwork Chapter 7: No Time for Lunch Chapter 8: Duo Damsel Chapter 9: Judgment Calls Chapter 10: Faith Chapter 11: Revolving Door Chapter 12: End of Shift Afterword: Knowing the FutureAcknowledgments