Chapter 1 1
He arrived in a wheelchair. Paramedics hustled him in from the ambulance bay, steering him into the sharp light. His face was serious. His eyes jumped left and right, taking in the unfamiliar setting. There was a steadfast procession of such arrivals swerving into the hospital, thickening as the day lengthened. With this man, something was wrong, but it wasn’t clear how wrong. All visits to this fast-motion environment were stories with yet unknown endings.
Nurses were coming and going. Doctors were coming and going. Noise was high: the staccato of beeping heart monitors; alarms ringing; phones chirping; the clank of wheeled beds being moved. The grumble and moaning of people and murmurs of misery were catapulting off the walls. And that vivid smell. The pungent disinfectant hospital smell, day in and day out, always the same.
Few places stir up as much drama as rooms like this. Walking in, you feel an electric nervousness that never passes, the nervous flutter of sickness. Patients, with their omnivorous needs, seek its alchemy. The emergency room.
A woman came over to inspect the man in the wheelchair. Her name was Hadassah Lampert. She was thirty-three and a registered nurse, and this was Lenox Hill Hospital, New York City. Every day, Lampert met strangers in pain, and their pain became her concern. Now this man’s breathing, his oxygen level, his blood pressure, his heartbeat, the sensation in his face and his limbs, whether he was agreeable or surly, hungry or full, whether, in fact, he lived or died—they were her concern.
He had a trimmed beard on an angular face. Short, dusky hair. Hound dog eyes. Sinewy. He was forty-nine. He wore a baseball cap and had his sunglasses perched on the brim. While she took his vitals, Lampert noticed that he was listing to the left. He told her he had been on the way to work—a blue-collar job—when he felt dizzy and collapsed on the subway.
“Okay, you’re going to come over here and lie on the stretcher,” she told him.
Helping him transfer over, she noticed that his gait was uneven. She focused hard on him and considered her options. She called a stroke code.
A stroke code was a speeded-up regimen, an auto racing pit stop. A retinue—two nurses, a technician, an ER doctor, a neurologist, a nurse practitioner from neurology, someone from pharmacy—quickly assembled. Lampert economically filled in one of the doctors on the particulars.
The doctor asked the man, “Were you having difficulty walking?”
“What does it feel like?”
“Like things are moving.”
The doctor asked him to touch his fingers together.
“Can you go with your finger and touch your nose.” A little off.
“Can you touch the tip of your nose?”
“Look at my nose. How many fingers do you see?”
The patient held up two.
“How many fingers?” the doctor asked.
“What month are we in?”
“How old are you?”
Lampert escorted him to get a CAT scan of his brain. She and a male nurse hoisted him onto the exam table.
After the table slid into the big doughnut hole, Lampert and the others positioned themselves around the screen in the control room, the space limited, and stared stonily at the interior of the man’s head. No discernable issues. Puzzled looks were swapped. “Weird,” the neurologist said, jutting a finger at the image. “This didn’t happen overnight. I’m thinking seizure. Maybe he had a tooth issue.”
Lampert mentioned that he had had sinusitis, inflamed sinuses. They decided to do an MRI.
While Lampert tended to the man, a young woman awaiting her discharge instructions loped past in her chilly gown, wailing, “I’m telling you, I need to get a life.”
In the gathering day, beds were filling up, patients squeezing into the maximized space. A maintenance person was mopping up a dusting of blood from a dripping patient, doing it casually as if cleaning up after a mixer at a reunion, guiding visitors around the freckled area. A “patient experience” volunteer toured the room cradling a highly sociable toy poodle. She whisked it from bed to bed for occupants to pet. “Hi, this is Twitter,” she announced. “He weighs three pounds. I put him on a diet if he gains weight.” The nurses fussed over him too, appreciating his calming effect.
Among its patchery of cases that morning, the ER had a fall, flank pain, chest pain, suicidal ideation, shortness of breath, rectal bleeding, foreign bodies in the eye, altered medical state, weakness—the various betrayals of the body. There was a fidgety, caterwauling man who couldn’t keep his feet still and glanced over his right shoulder about every nanosecond. At one point, he appeared to be having a conversation with an IV pole. A whimpering woman roughed up by her husband was being interviewed at her bedside by two cops.
The clock on the wall put the time at 9:05 a.m. Lampert’s lengthy shift had barely begun.
She accompanied the man to the resuscitation room. A doctor felt his arms. “Do they feel the same?”
“More on the right side.”
“If that’s one hundred, what is the left side?”
“Sixty or seventy.”
Doctor: “There’s no stroke. But I think you may be having an infection. Or something going on with your sinuses.”
“I was feeling pain in my neck.”
The doctor pushed on his neck. “Does this hurt?”
“Did you have any teeth taken out?”
“You may have had a seizure this morning. Very subtle. So we’ll give you some seizure medication. If it improves, that’s it.”
The attending doctor departed. Lampert saw the troubling-over of the man’s eyes and told him, “It’s okay, we’re going to take care of you. I’m going to give you a medication called Keppra. It’s for seizures. If you had a seizure, this will protect you.”
The man nodded. He had gone quiet. He was shivering.
“You cold?” Lampert asked.
“We’ll get you a blanket.”
Lampert turned to a computer terminal near the bed and, clear of mind, began documenting what had been done. She looked over and asked him, “How are you feeling?”
Much of nursing is asking questions. Listening. Looking.
“Tired,” he said.
“Well, this medicine makes you a little drowsy. Take a little snooze.”
He drank in the scene, one he hadn’t anticipated when he rose this morning, this dutiful young woman trying to make him better. He said, “Sorry that I don’t speak English that well.”
She gave him a warm, open smile. “You speak English beautifully. I have no problem with how you speak English.”
Lampert habitually kept these conversations upbeat, which served her well. Emergent nurses are taught about emotional contagion. Getting drawn into the despair of patients makes it harder to do your job. You can catch fear almost like an airborne illness. And if you show it, patients will pick it up. Project joy and calm and your patients may well absorb those feelings. Nurses chase illness with medicine but they also witness patients who, through cheerfulness, think their way to health.
“Do you smoke?” she asked.
“I know I should quit. Don’t tell my wife.”
“We’re not going to talk about it now. Right now, we’re waiting for the rest of your results to come in. So far, your blood work is good. They’re concerned there is some sort of infection. You’re going to be admitted. It’s annoying to be admitted, but it’s the best thing.”
“You only have one life.”
“Exactly. I like that attitude. We each get one life.”
She went out and returned with a cup of water. “I’m going to make sure you can swallow properly. Take a small sip… Swallow good… Now take a big gulp… Swallow… Good, you pass.”
By 10:15, after considering further results, the doctors readjusted their judgment. They believed the man did in fact have a stroke. A stroke can manifest itself either as bleeding in the brain or as a clot. They thought he had a clot. He was now lodged in bed 7, and the plan was to give him a blood thinner. It was called tPA, tissue plasminogen activator. Administered intravenously, it dissolves the clot, improving blood flow to the brain. Time is essential; studies show that if not given within three to four hours, it becomes ineffective. Lampert said, “Time is brain,” a common hospital expression for stroke patients, meaning that the sooner a person is treated, the less brain damage they will suffer. (For heart attack patients, the saying goes, “Time is muscle.”) The drug can also have the side effect of causing bleeding. Everything in medicine involves risks. The important thing is to weigh the benefits against the risks.
Lampert gave the drug over the course of an hour, keeping vigil at his bedside and checking his vital signs every fifteen minutes. For the first hour, she needed to test his sensation and hand strength. His wife was there now, camped out at the foot of the bed solving word puzzles.
Lampert told him, “This medication is hopefully going to bring your symptoms back. While we give it to you, we’re going to be taking your blood pressure very often. We’re going to monitor your symptoms. If you have any major change—major headache, major dizziness—you have to tell me.”
She took his hands. “Close your eyes and hold your hands out like you’re giving a present.”
She said, “A little better already.”
She told a tech to put him on a portable monitor.
Ritually, she asked him, “You good?”
“We’re just hanging out.”
A young man appeared with a backpack slung over his shoulder, and Lampert asked, “This your son?”
“You have a great dad,” she said to him.
The boy said, “When he wants to be.”
With watchful patience, she did a neurological assessment. Ran her hands lightly over the man’s cheeks. Over his temples. She had him squeeze her hands. Lift each leg. Raise his hands with his eyes closed.
“Better. Much better. Not a hundred percent, but better.”
The treatment continued to reanimate his former self. A little later, as part of the halting steps to full recovery, he was sent upstairs to a room on one of the floors. Lampert went along, telling him, “You’re in good hands. You’ve responded well. I’m so glad.” She hugged his wife and son. Her work was finished, the outcome good. Taking a deep breath, she wove her way back to the babble of the ER. You keep moving. Someone else in pain is always waiting.