“Let’s get a CT scan and see what’s going on,” he said.

The results revealed that the woman had fluid in her lungs. That’s probably from the fluid that I already gave her, Sam thought. But the attending physician insisted that because the blood pressure was still low, Sam had to administer two more liters.

Sam was getting frustrated. The woman’s heart rate was still elevated, indicating that she was either in pain or experiencing another type of physiological distress. Meanwhile, the attending physician was relaxing at his desk, surfing the Web. He had not spent five minutes with the patient.

Sam found William at the nurses station and relayed the scenario. “The attending said the patient probably lives low [normally has low blood pressure]. So we’re not giving her any pressors.” Pressors would constrict the woman’s blood flow, thereby raising the pressure. “But I’m not comfortable with these orders.”

“Your thought process is right,” he said. “Document everything.”

When Sam talked to the resident about the attending’s orders, he also seemed uneasy. But he was new, and seemed to trust that the attending knew what he was doing.

At dawn, the woman spoke. “I feel puffy,” she said. Her eyes were extremely swollen, and she was pale and lethargic. The fluid bags had emptied. Sam took her blood pressure. 85/50. That was low.

Sam approached the resident again. “At what point do we want to start getting concerned about this?”

The resident paused for several moments. “Eighty systolic.” (Systolic refers to the top number of a blood pressure reading.)

Twenty minutes later, the woman’s blood pressure had dropped further. “She’s at eighty over forty,” Sam told the resident.

“Okay, I’m worried now.” He went to talk to the attending.

When the resident returned, he pulled Sam into the hallway and told her that the attending didn’t want to do anything about the blood pressure and had given no explanation why. The doctor had ordered them to give the woman another liter of fluid, for a total of seven, and then hopefully a bed would open up in the ICU.

“Are you kidding me? We have to do something!” Sam said, gesturing to the patient.

“He’s my boss; I can’t do anything about it,” the first-year said. Sam would eventually come to know the attending as a doctor who didn’t excel in situations in which a patient had no clear diagnosis. But for now, the resident was too green to question a superior, and Sam was too new to tell an attending that she thought he was doing something wrong. Sam updated the notes in the patient’s chart, making sure to add, “No new orders per MD.” After leaving for the change of shift, she never found out what happened to the patient.

That was typical for ER nurses: Each patient’s story continued, at home or on another hospital floor, but the nurses were left with only a caption of the patient rather than the whole of the person, a full narrative life shrunken down to a room or a diagnosis: “Remember that patient in Twelve?”

Medicine asked something extraordinary of nurses: to forge intimate connections with another person for hours, weeks, or months, to care thoroughly and holistically—and then to let that individual suddenly go, often never to be heard from again.

That was just life in the hospital.

LARA

  SOUTH GENERAL HOSPITAL, September

Lara sprinted on a treadmill at the gym, sweat dripping off of her chiseled abs. I want my mom, Lara thought, pushing herself to run faster. I do not want the drugs.

Since the day at South General when she’d nearly taken the vial of Dilaudid, Lara had attended more than her usual thrice-weekly NA meetings to bolster her support. She had increased her interactions with her sponsor and sponsees, all of whom were looking out for her. And she went to the gym as often as she could. She knew full well that she had replaced her painkiller addiction with an exercise addiction. She went to the gym every day for boot camp and spin classes. At home, she religiously exercised to Beachbody Insanity DVDs, a hard-core cardio workout.

She rationalized that exercise was an acceptable outlet which, unlike the drugs, wouldn’t kill her. Besides, it helped. “I think too much about the bad stuff I see: children who have died, a teenager who died in a motorcycle accident. I can’t help thinking about their parents’ faces,” Lara said. Exercising “helps me release some of that negative energy. It allows me to think about it without breaking down and becoming incapacitated. Before, I wasn’t facing things going on. Drugs helped me to stuff it down more. Exercise helps me process it.”

She had been able to put down the Dilaudid in August because she reminded herself how painful withdrawal had been. She had suffered through weeks of sleeplessness, night sweats, diarrhea, vomiting, and terrible nausea. “The withdrawal from narcotics is a living hell. I felt like my skin was crawling. All you want to do is sleep and you can’t. That’s why you hear about heroin addicts who can’t get clean. It’s because they’re like, ‘I know what will make this go away for just a little bit,’ ” Lara said. “I do not ever want to go through that again. Could you imagine feeling like that and having to take care of your kids?”

When she got to work after the gym, a loud drunk woman came into the ER shouting vulgarities. “That motherfucker!” she screamed. “My brother’s going to cut his dick off and shove it up his ass!” She was so out of control that the nurses couldn’t calm her down.

Lara took report from the medics. The woman claimed that someone followed her home from a party and raped and sodomized her. Unfortunately, she had showered afterward, which likely washed away much of the evidence for her case. While she waited for South General’s designated sexual assault nurse to arrive, Lara had nowhere to put the woman but the lobby.

Patients in the waiting room were loudly gossiping about the woman, whom they assumed was a typical ER drunk. “What’s her problem?” they complained. “Just let her go home,” a security guard muttered. Gradually, patients yelled back at her directly: “Shut the fuck up!”

Lara couldn’t tell them not to judge. And she didn’t want the woman to go home; she wanted her to get the help she needed. She brought the woman back to triage with her, depositing her in a room where nurses did blood work and EKGs. The waiting patients were angry at Lara for not sending the still-ranting woman home and the woman was angry because she said it hurt too much to sit down. Lara tried to ignore the glares coming at her from all directions, reminding herself repeatedly, This is not about me. She didn’t know why, but she believed the woman.

At first, Lara had been slightly nervous to work at South General, where violence, including murder and rape, touched many patients’ lives. Now, South General was her favorite hospital. While some patients had been initially leery of the curly-haired blonde nurse assigned to them, they soon changed their minds. “Once they lose their attitude against me, they see I’m there to help them and we build a rapport,” Lara said. “I respect them, I’m taking care of them, I’m not judging them. I can give them a pillow or blanket or five minutes of my time to really listen, and they’re grateful. Sometimes I’ll even get a hug from a patient after they’re discharged.” That didn’t happen elsewhere.

Lara also liked working with her colleagues, despite racial tensions that separated the black nurses from the few white nurses. She was the only white nurse whom many of the black nurses treated the same way they treated each other. A veteran ER nurse named Rose, in particular, had gone out of her way to welcome Lara since she had first arrived at South General. Rose was a sweet woman with no edges. If any nurse needed help of any kind, Rose was there for her without hesitation. She kept an eye on her coworkers so that if one of them was struggling with her patient load, Rose would step in, offering to take a patient for a CT scan or an admitted patient upstairs. She was a true team player.