Socially, Pines Memorial hadn’t panned out as Juliette had hoped. At Avenue, the hospital where Juliette, Molly, and Lara had worked together before, the nurses had formed a lasting bond. They were together constantly, at and outside of work. When the Avenue nurse manager, whom Juliette had adored, left, and a disorganized, inexperienced manager took over, the nurses scattered to various hospitals across the region. But they had grown so close that three years after leaving Avenue Hospital, they still gathered a few times a year for parties and called each other for advice or comfort. Juliette and Molly were particularly tight. Neither woman was afraid to speak her mind.

When they left Avenue, Juliette and Molly had worked briefly for an agency that had sent them to Pines, where they eventually signed on to work full-time. At Pines, they had joined an ER that was dominated by a clique of beautiful nurses. Pines was known for its attractive nurses and dreamy doctors, but the ER nursing clique outshone the rest. They were a group of nine women who lived in the same town and scheduled frequent social events, including playdates for their children. They invited Molly, who did not have children. They did not invite Juliette, who did. For years, Juliette had tried to gain entry. She often complimented various members of the clique and she frequently mentioned her 7-year-old daughter.

It didn’t work. They chatted about their get-togethers at the nurses station, right in front of Juliette. They posted on Facebook, arranging outings and rehashing them afterward, even though Juliette could see every exchange, every ebulliently posed photo. They were pleasant enough in the ER, but they never made her feel included. They acted, and looked, like a sorority.

The clique loved Molly—everyone did—but she didn’t hang out with them. Instead, she was a loyal friend to Juliette. Juliette was 42 years old, and it still hurt to be left out. She wondered if they rejected her because she was six feet two inches tall and overweight. Between her size and her bright auburn bob, she couldn’t have looked more different from the clique. Juliette wasn’t looking for best friends. She just wanted to feel like part of a team. And the fact that Priscilla, the nursing director, was part of the clique made Juliette feel even more excluded.

Didn’t they already have something in common, something that could supersede the bonds of colleagues in other professions? They were healers, all of them, whose job was to reach people, to connect with them, to make them whole. Why couldn’t they be as compassionate to each other as they were to their patients?

“You don’t need them. You have me!” Molly would say.

But not anymore. Molly’s resignation was a blow to Juliette and to the ER in general. Dr. Preston, himself a large personality, had told Juliette that Molly’s leaving was a major loss to the department. Clark, who had light blue eyes and curly white-blond hair, was loud and hilarious, livening up the ER. He was one of the few doctors to insist that nurses call him by his first name, which seemed to soften the medical hierarchy. He could often be found joking around with the nurses, particularly the cute ones. Although he was a risk-taker with his patients, he was also straight- forward, which patients and nurses appreciated.

Once, a successful high school sprinter had come to the ER with a badly fractured ankle. “He can’t race tomorrow,” Dr. Preston told the boy’s parents, who were obviously overbearing and competitive.

“What will happen if he races?” the boy’s father asked, prioritizing the sport over his son’s health.

Dr. Preston smiled. “He’ll lose.”

Right now there wasn’t time to dwell. In addition to four other patients, Juliette had two rapid heart rate patients who needed constant monitoring. She was also precepting—training—a new nurse, which meant having someone at her heels and explaining everything she did throughout her shift. Juliette enjoyed precepting because she liked teaching and working closely with another nurse, but it did add to the busyness of the day.

Juliette and her precept, a freckled girl named Noelle, had just transported a complicated stroke patient to the Intensive Care Unit, when Charlene assigned them another extremely critical patient, a 60-year-old man who had fallen in the shower and hit his head. As Juliette and Noelle worked him up, Charlene told her, “We have another LOC [loss of consciousness]. Room 18. Brain injury.”

Hurrying down the hall, Juliette saw that Room 8, which was directly in front of the nurses station, was empty. Andrea, the nurse assigned to that zone, was idly surfing the Web. Why is Charlene giving me so many critical patients when Andrea has none? she thought. Suddenly, the monitors started beeping from Room 18. The new patient was crashing, unable to maintain his vitals.

When Juliette entered the room, she saw a neurological physician’s assistant frantically attempting to insert an IV into the brain injury patient. “I can’t get IV access,” the PA said. She had to prepare the patient for a central line, an IV line going into the major vein near the groin. Sometimes central lines could be difficult to place.

Charlene had overloaded Juliette with critically ill patients as if the preceptee were an assistant, rather than extra work for Juliette. Trainees were supposed to be learning directly from a preceptor, not thrown into the deep end as full-fledged nurses. Quickly but gently, Juliette instructed Noelle how to help. “Go check on the patient with the cardiac drip. Ask him if he’s having any further chest pains, and then check to see if the cardiac drip needs to be titrated based on his chest pain. Check on Room 16’s level of abdominal pain. Then come back here to see what else we can do for this brain injury patient before we assess him again.”

The PA tried again to insert the IV, but couldn’t. The pressure was getting to her. “Get me an ICU nurse! We need more people in here,” she hollered.

Juliette rushed to the hall to ask Charlene to check on Noelle and Juliette’s other critical patients. Charlene was nowhere to be found.

Scatterbrained and prone to favoritism, Charlene spent much of her day gossiping in her office, rather than making sure that patients received proper attention. She was hard on Juliette for coming into work five or ten minutes late when traffic was particularly bad, but said nothing to clique nurses who arrived half an hour late without explanation. She was overly focused on getting patients out the door as quickly as possible, so she could bring in more patients and increase hospital profits. And she certainly didn’t prioritize the overall safety of the ER. Recently, when a loud bang sounding like a gunshot occurred near the nurses station, Charlene shoved another nurse out of the way and bolted out the front door. For weeks, the nurses made fun of her for abandoning staff and patients to save herself, especially because the noise turned out to be a harmless equipment malfunction.

Charlene thought she was part of the clique. The nine nurses kissed up to her so that she would give them the plum assignments, and the ploy worked: Charlene blatantly favored Andrea and the other dominant clique members when it came to scheduling. But Juliette had heard them laugh about Charlene behind her back. The childishness of this behavior exhausted Juliette, who did not want juvenile social maneuverings taking up brain space that she hoped to devote to patient care.

Juliette’s patient was now completely unresponsive. His Glasgow Coma Scale, a range from 3 to 15 used to measure consciousness, was a 3: He was not opening his eyes to painful stimuli, talking, or moving any extremities. Without the central line dispensing medication, he couldn’t be intubated.

Finally, the tech got the line in. Juliette immediately started the medications to prepare the patient for intubation.