Threshold

I visited a patient in mid-August who was being transitioned to comfort care. He was lying quietly in bed, eyes open just a little. I spoke to him out loud, offering good wishes. He looked terrible, which I discovered later was because he had died 20 minutes before I arrived. (Not all dead people look terrible. It varies tremendously. Some look serene and lovely.)

One of my colleagues mentioned that it was his habit to take a look at the list of patients near the nursing station for his unit each morning to see which ones were being discharged that day, and then not to visit any of those patients unless he absolutely ran out of every other kind of patient. This is a very good idea I wish I’d encountered about 12 months earlier. As he accurately said, all such patients say, “I’m happy! I’m going home today!” None of them says, “I’m going home today! I feel horrible. Can you sit down and talk to me?”

Sometimes a patient’s name is replaced in the electronic health record system with a row of asterisks. This might be because the patient is a celebrity (I encountered one this year), or a forensic patient, with armed guards outside his room (so far these have all been men). Or the patient might be a victim of partner violence who doesn’t want the hospital operator to tell callers she is in the hospital. I have also discovered that it can indicate someone who was formerly in the psychiatric institute. The names of all patients currently at the psychiatric institute are so obscured, but even after the patient has left there and is on some other unit for an unrelated reason, his or her name may be concealed. I’ll bet that’s because they make that change when someone becomes a psychiatric patient and then forget to unmake it. The asterisks are also used when an employee of the hospital becomes a patient.

At the very end of the month, the person who had been on call the night before was fried, so I took the pagers and got slammed—page after page after page, including a request for a chaplain to facilitate a viewing, which can take an hour or two, and, for the first time in my experience, a Code Blue at the campus where they do day surgeries. Naturally that happened on a day when we were down to four people. Fortunately, Jodie took over and determined that the crisis had passed and that no one needed to take a cab over there.

On top of all of that, there was a request for a chaplain to attend a family meeting. By then, it was 2 p.m. and I had turned the pagers over to a peer, so I volunteered to go. Just as I approached the conference room, the door swung open and two physicians said, “Perfect timing,” as they walked past me and vanished. (“That was not very good interpersonal team communication,” Jodie said later.)

I went into the conference room and discovered I was the only care team member present, with 19 family members and friends of a patient who had gotten several pieces of bad news. I recalled watching another supervisor lead a debriefing and drew upon what she had done. I asked people to share their thoughts and feelings, and I observed that there was a lot of sorrow in the room. After a few people spoke and it fell silent, I asked about the hopes they had had for the patient, and people said a few things about that. One woman said she felt guilty for leaving the patient too soon one recent day. Another comforted her, saying it would have come out the same whether she stayed or left. A young family member wasn’t so sure: “How can we know?”

Then a family member politely said they would like to be by themselves, and that they had their pastor with them. I said I would be happy to go, and asked them to point out their pastor. I thanked him for being there, and said one thing that made me happy was that they were all there together.

After that, I went to see one of my current favorite patients, a homeless man, and to say goodbye to my other favorite, finally off to rehab after two serious injuries and several weeks in the hospital. Days earlier, I had given the latter a piece of polished rose quartz “with the hope that all of you will always be seen and cared for.” That day, a nurse asked, “Did you give my patient a stone?” I admitted it, and he said, “Very cool!”
 
I also saw a man who had gotten in a life-changing accident; he was described by his nurse as being despondent. I didn’t find him to be despondent at all. He seemed quite angry, but also was admirably philosophical, saying that the accident had put things in perspective for him, and that it could have been worse, and that he was now thinking about how he actually wants to spend his time. People are remarkable.

Late in the month, I had my second-to-last on-call shift, starting on a Saturday afternoon. One thing that happened during that shift, besides my getting 10 hours of sleep—I’m pretty much convinced now that the same people who can’t or don’t get enough sleep when they’re not on call tend to not get enough sleep when they are on call, and that those who get enough sleep when they’re not on call can usually find a way to do the same while on call—was that I was sitting in front of a computer charting when there was a flash and all the computers froze, the phones went dead, and my badge suddenly no longer worked.

A nurse came onto the unit and reported that she had just been on an elevator that had gone into freefall, though it didn’t fall very far. Another nurse said he had had the same experience in the past, but, far worse, that a few years ago, a doctor was standing in the doorway of an elevator chatting when the elevator suddenly lurched and crushed him to death. One of my peers said it’s a good thing we didn’t find that out earlier in the year. I agreed: “We would all have thighs like tree trunks by now,” from taking the stairs. The lesson I took from that is to be either in the elevator or not in the elevator, but not to linger at the threshold.