By 3:00 p.m., Sam, usually cool under pressure, was uncharacteristically shaken because she didn’t know the plans for her patients. Kathleen wasn’t telling her which patients were being discharged and which were being admitted. Disgruntled patients had been waiting for procedures, test results, or discharge papers, and they were taking out their frustrations on Sam, who couldn’t answer their questions.

Embarrassed, Sam talked them down. “We’re still waiting for the test results,” she bluffed. Or, “The CT scan isn’t ready yet.”

Sam was too daunted to confront Kathleen directly. She just wanted to get through her first day. Then a patient yelled, “I’ve been here for six hours! I don’t know what’s going on! You don’t know what’s going on, no one knows what’s going on, and I’m going to leave!”

Nobody wanted that to happen. “I’ll-I’ll go find out,” Sam said, feeling smaller than her five-foot-one-inch frame. “We’re still waiting for your test results.”

Sam couldn’t find Kathleen anywhere. In the hall, she saw Dr. Spiros heading toward the break room. Naturally he was working today, of all days. She was expected to go up the chain of command and he was the next person in line. He was also the only familiar face she saw.

“Umm, I’m having a bit of a problem,” she said. Remembering her previous encounter with Dr. Spiros made Sam even more flustered.

“What’s wrong?” Dr. Spiros asked, gazing into her eyes.

Sam was surprised that he seemed sincerely concerned. She spoke quickly, ignoring the deepening flush of her cheeks. “I don’t know what’s going on with my patients. Kathleen’s not talking to me, everyone’s getting mad, and I don’t know what else to do.”

Dr. Spiros patted her on the back. “It’s okay.” He walked her to Dr. Shannon, another senior resident, whom Sam hadn’t noticed. Dr. Spiros’s shift was over, Sam thought, wanting to disappear. “Brad, this is Sam. She needs some help.” He patted Sam again and left for the night.

“The foot lady wants more Dilaudid, the guy in six needs his discharge—he’s been ready for an hour—the guy in sixteen is still puking and he’s already had two rounds of Zofran, and I have no idea what’s going on with the fourth patient,” Sam said, her voice rising.

Dr. Shannon’s voice was soothing, as if he had plenty of time to help her. It was no secret that Kathleen was a difficult PA to work with. “Okay, I can tell you what’s going on with that first patient. I will find out about the second and third patients. And discharge papers are being written up for the fourth patient.”

As she followed him down the hall, Sam wondered whether she had made a mistake: Maybe nursing was not the right career for an introvert. She decided to try the night shift instead.

MOLLY

  September

South General Hospital

After quitting her staff job at Pines, Molly immediately signed with a nursing agency. The scheduler, whom she would interact with only over the phone, assigned her to rotate among three different hospitals. Molly chose to work twelve-hour shifts, three to four days per week.

Academy Hospital was a brand-name hospital with first-class doctors and pretentious medical students. Most of the nurses, young and cliquish, were just out of school; Molly dubbed them “baby nurses.” Citycenter Hospital was a teaching hospital with a poorly run ER. And South General was a Level-1 trauma center in an impoverished neighborhood. Molly had to leave her house at 4:30 a.m. to get to South General in time for her 6:00 a.m. shift. South General was in such need of experienced nurses like Molly that administrators put her to work after only an hour of orientation, rather than the usual four to twenty-four hours.

During her first week at South General, Molly ran into Dr. Lee, a wonderful trauma doctor who also worked at Pines. Dr. Lee was prone to self-deprecating humor, which was relatively rare among surgeons and a good way for physicians to get nurses to appreciate them. “Molly! Welcome to The South,” he said. “I heard you left Pines because of the uniform.”

Molly laughed. “You’ve got to be kidding me. Do you think I’m that big of an idiot?”

Dr. Lee nodded. “I thought that was a little weird. So you left because I’m based at Pines, then?” he joked.

“Ha. The uniform policy was just the last thing I was willing to tolerate,” Molly said. “I wanted something different.”

“Well, this is different!” he replied cheerfully, and left to check on a patient.

Over the next few weeks, as the agency circulated Molly among hospitals, she came to understand what he meant. South General nurses had nerves of steel. In this particularly disadvantaged part of the state, they saw extreme cases of medical and psychological distress. By contrast, on Molly’s first day at Academy, a college-aged patient had a psychotic break. She sat on her bed laughing and talking to an emesis basin that she held to her ear like a telephone. Molly could hear the “baby nurses” whispering, “Can you believe how crazy she is?” “They thought she was the most psychotic person they’d ever seen,” Molly said. “My thought was ‘That’s a big deal to y’all? That’s crazy?’”

At South General, medics once brought in a homeless guy high on PCP. When they tried to move him from the gurney to a stretcher, he jumped up, ripped off his clothes, ran naked into the full waiting room, and “helicoptered,” gyrating so that his noticeably long penis spun like a propeller. “To impress a chick, HELICOPTER DICK!” he shouted. While one nurse called security and gathered staff—it usually took several people to hold down patients on PCP because they had herculean strength—other nurses calmly ushered people to the other side of the large lobby, far from the now naked man.

“The South General nurses were like, ‘Hmm, naked man helicoptering in the lobby. Security was called, no big deal.’ That’s why I like South General,” Molly explained. “When he started screaming—‘Waaaa!’—and dove out the plate glass window, then he became a trauma.”

Citycenter Medical

On Molly’s first day at Citycenter, she felt sick to her stomach. She was not the nervous type, and certainly had never been anxious about a job before, even as a new grad. But she could see that Citycenter’s ER was extremely unsafe. First, the entire department was filthy: Blood spattered the walls, full urinals sat on counters in rooms that were supposedly ready for a new patient, and dried urine covered a utility room counter. Second, patient wait times were inordinately high. And because there was no dedicated trauma nurse, a nurse in Zone 1 was expected to drop all of her patients—the sickest bunch in the ER—when a trauma patient came in. Trauma patients could require one-to-one care for several hours, leaving the sickest patients neglected and in danger.

Molly’s anxiety was justified. That morning, she was assigned at least seven patients at a time, sometimes nine, which was more than she’d ever had at Pines, and too many for her to care for adequately. “How do you handle this kind of patient load?” she asked the other nurse in her zone.

“We can’t,” the nurse replied. “People are quitting left and right, which means an even bigger workload for the rest of us.”

One of Molly’s patients was a 400-pound drug addict who had been running around the city without pants. It had taken nine police officers to bring the man in. The ER staff had shackled him in four-point leather restraints and left him alone in an empty room. When Molly saw the patient, her jaw dropped. As Molly understood it, The Joint Commission instructed that patients in four-point restraints should have a one-to-one staffer who was supposed to document the patient’s behavior, note medical interventions, and offer nourishment and toileting every fifteen minutes. If the patient became cooperative, the staff was supposed to release him from the restraints. The patient’s chart said that since he had been in the ER, he had been quiet and cooperative, but tied down for hours.