It would also behoove administrators to decrease staff turnover, and not only because hospitals must expend resources to train and hire new employees. Inadequate nursing staffing has been called a national emergency. When nurses resign from a hospital, they create a cycle in which the remaining nurses are left short-staffed and more stressed. A Drexel University study found that when nurse turnover rates increase, so do the odds of nurse injury and patients’ risk for pulmonary embolism/deep vein thrombosis.

Meanwhile, it is up to nurses to bolster each other, and to appreciate when hospitals get the system right. Nurses at a midwestern NICU rely on a particularly effective chaplain and each other’s strong support. After a tragedy, the team discusses the case to talk about the plan of care and what could have been done differently. They often follow up with parents whose children died in the hospital.

“One of the worst parts of coping with traumas and tragedies is when the family is present,” said a pediatric ICU nurse in New York. Parents might watch CPR breaking their child’s ribs, alarming bedside procedures, the monitor numbers dropping, or their children in an altered mental state. “Believe me, it’s shocking what we do to these children; the brutality of a [cardiac] arrest can be very intense. We are trained to be the eye in the storm, to stay calm. But in the periphery of the storm, that’s where some of the worst damage can be done; parents suffer PTSD, they have nightmares. So do we, though.”

Recently, as the New York nurse gave compressions to a baby in cardiac arrest, the child’s parents were on their knees sobbing and praying in the corner of the room. After the team had lost the pulse twice more, a doctor escorted the parents out of the room so they would not be present for emergency surgery. “The surgeon got there and the baby’s chest was opened at the bedside so he could do manual heart massage and his fellow could rewire the pacer wires. The child ended up being fine. That is the miracle of medicine,” the nurse said. “This baby left three weeks later in his parents’ arms with a Superman cape tied around his little neck. No residual neurological damage, no cracked ribs. Nothing. That’s what you have to remind yourself of the next time a kid codes and things don’t go so well.”

In the University of Akron study on burnout, 99.9 percent of the nurses surveyed nevertheless reported feeling happiness or pride during the previous week at work. “Sure, there can be an overall feeling of being burnt out at work, but things happen that give you that sense of worth, pride, and happiness,” a Kansas ER nurse told me. “I’ve been completely beaten down after three twelve-hour shifts in a row, then gotten a compliment from a patient that turned my feelings around. Helping a particularly sick patient can be physically and emotionally draining, especially when you’re feeling burned out, but if the patient opens their eyes and gives you a smile, or you get a sincere hug from the wife, that can make it all seem worthwhile.”

This fortitude is part of what makes nurses so incredible, and is one of many reasons that should convince administrators to consider nurses valuable contributors rather than replaceable employees. “I work where kids die,” an Arizona pediatric oncology nurse said. “What words can be used to describe that? If I allowed myself to, I would cry every day. Instead, I try to focus on the time that that sweet little life was a part of mine. I try to keep things as fun as possible for the child. Kids who are dying know they are dying. If I can elicit one little chuckle from them, then I’ve had a really blessed day.”

Nurses know to take solace and joy in the moments they are able to comfort a patient. Among the tragedies, miracles shine—wondrous flashes, whether flickers of hope or impossible resurrections—in which nurses played a part. These triumphs add up, and experienced nurses learn to clasp them close, to draw on them when they need a lift above the darkness. Instead of dwelling on lives lost, nurses can hold fast to remembrances of those they have rescued. Perhaps that’s also how Seattle Children’s should have considered Kimberly Hiatt. As Georgia nurse Brittney Wilson, who runs The Nerdy Nurse blog, said, “She made a mistake . . . but how many lives over those twenty-seven years did she save?”

JULIETTE

  PINES MEMORIAL, January

The ER was still overcrowded. Pines already had closed to ambulances twice the week before and turned the ER’s minor care room into a medical surgery unit. For this particular holiday season, out of twenty-three rooms in the ER, eighteen were occupied by “boarders,” patients who had been admitted to a hospital floor that didn’t have a bed ready. How could a hospital run an ER with only five rooms? As far as the nurses knew, eighteen boarders was a record.

Some nurses surmised that the patient overload was a result of some of Westnorth’s new policies and agendas; understaffing led to less frequent bed turnover and longer ER waits. Others guessed that because of the recession, more people had lost their health insurance, causing them to come to the ER instead of a doctor’s office. Sometimes, too, Juliette wondered if life spans were increasing. It seemed like fewer people were dying, and fewer patients had Do Not Resuscitate orders. “There are so many old people we shouldn’t be doing all these interventions on to keep them alive. Just let them be,” Juliette said.

Juliette had a 90-year-old patient who was nonresponsive, shaking, and exhibiting a sodium level of 171 milliequivalents per liter (normal range is 135 to 145), which indicated severe dehydration and/or kidney disease. Juliette readied herself for end-of-life comfort care.

Dr. Preston found Juliette at the nurses station. “Her daughter wants her treated,” he said.

“But she has an active DNR,” Juliette said.

Dr. Preston shrugged. “It’s not worth the cost of what the lawsuit would be to go against the family.”

Juliette’s jaw clenched. This was absurd and she was comfortable enough with Dr. Preston to tell him so. “Clark, you’re telling me, if I’m ninety and I have a DNR and I’m dying, but my daughter or husband says, ‘I want you to do everything you can to save her,’ that you would go ahead and try to save me?”

“Yes, we would. That’s what Pines wants us to do,” said the doctor as he scribbled orders for an IV, antibiotics, a catheter, and blood draws. “Pines wants us to go with the family’s wishes if the person isn’t awake or able to say anything.”

Juliette had seen this before at Pines. If the family was present and wanted the hospital to override the DNR, the staff would first try to convince the family that the patient’s wishes were clear. If the family insisted that the doctor keep the patient alive, he would usually do that.

“What is the purpose of having a DNR if we ignore it?” Juliette asked.

“Juliette,” Dr. Preston said, patting her on the back as he left the room, “take off your cape.”

This year, Juliette was scheduled as the charge nurse on Christmas Eve and New Year’s Day. Because Molly wasn’t flying home for the holidays, she had graciously volunteered to work eight hours of Juliette’s twelve-hour Christmas shift so that Juliette could spend most of the day with her family.

On New Year’s Day, when Juliette arrived for her shift as charge nurse, the waiting room was packed with drunks. This was the worst holiday to work because ERs were beset by hordes of intoxicated patients. There was a three-hour wait for patients to be seen. The trauma doctor was busy with the unusually high number of traumas that had come in overnight, including three teens whose car had crashed into a tree and a man whose wife had run over him on purpose. The charge nurse wasn’t supposed to have any patients at all, but every other nurse had several boarders already. Juliette assigned herself eleven patients.