The Night Shift

The Night Shift

BY: Larry Barlow

Nick is a student in a respiratory care program. He is in his last year but has not graduated yet. His family does not have much money. Nick has learned to live with pressure, and at nineteen, in his final year of a respiratory care program, pressure is simply part of the deal. Nick is paying his own way through school, and this means long days at classes and clinical sites, followed by working at his new job.

 Nick is able to get a job in a local community hospital, St Ann, a small. Underfunded facility tucked into one of Chicago’s struggling neighborhoods. The 200-bed hospital can handle the basics required by the local community, but lacks the expertise found at larger facilities or the major university hospitals in the City. Nick is 19 years old. He is a good student; he studies hard but is not fully confident in his ability. The Respiratory department at St Ann is not very busy, and 90% of the time Nick can show up for work and read a book or study. Nick works part-time on the evening shift and weekends because he has to attend classes and clinical sites during the day. St Ann usually tries to staff at least two therapists on a shift, but sometimes it cannot, and on this Saturday evening Nick is working alone in the respiratory care department. He does not mind this because the workload is light, as usual, and he has just opened a book on oxygen therapy to study.

Today, like most nights, St. Ann was quiet. The Respiratory department rarely saw much action, and most nights Nick could study in peace. Tonight was one of those nights. He sat alone in the department, a book on oxygen therapy in front of him. He was reading about how oxygen affects blood gases and how the amount of oxygen in the blood affects the circulatory system as a whole. Nick felt like he was on the verge of understanding how the complex relationship between oxygen and carbon dioxide helped to describe what was happening in the body when he received a STAT call from the emergency room.

The emergency room at St Ann has one attending and two nurses covering this Saturday evening, which is usually enough to adequately cover the shift in this quiet local area. Most days there might be a stab wound, a drunkard who injured themselves, or a COPD or asthma patient who was having difficulty breathing. On this day, the ER was staffed by a registered nurse, Jennifer, the Charge nurse, and Leeann, an LPN. Jennifer was a middle-aged woman who had worked at St Ann for 15 years and was familiar with most situations that might occur.Nick was in the ER on a fairly regular basis, and he remembered hearing Jennifer, a seasoned nurse, comment that new medical interns were clueless and that it was the nurses who really got them started on the right track in their medical careers.  Jennifer was demanding, but she always seemed to be fair in her decisions. She was OK with Nick. Leeann was an LPN who had been working at St. Ann for about 15 years.On the few occasions Nick had the opportunity to work with Leeann, he found her a bit talkative and easily annoyed when she felt the job was keeping her too busy. Leeann claimed that   she was going back to school to get her RN, but somehow, life always seemed to get in the way, and she had not done it yet.

Dr Andrews was the Attending, on call, a graduate of Northern University, in his early forties, with a specialty in general practice. More often than not, Dr. Andrews would make rounds on every ward and end up in the ER, where he would assess any patients who required urgent care and sit at the nurses' station to write or update orders for the patients in the hospital.

It was 9 pm on that Saturday, and the evening shift would be ending at 11 pm. Nick in Respiratory was hoping to make the 1130 pm bus to get home on time. It had been a good night for Nick so far; he had given a couple of bronchodilator treatments to two asthmatic patients and performed chest physical therapy on Mr. Jefferson, a patient with chronic obstructive pulmonary disease on the third floor. It was a good shift, with not much activity, almost like getting money for nothing.

Unbeknownst to Nick, at 920pm a car drove up to the ER, and the calm ended.

A car screeched up to the entrance of the emergency room. James, a young man burst through the doors, shouting for help. His wife, Millie, seven months pregnant, was in the back seat – and the baby was coming. Too soon. 

James looked at Leeann and told her, “Millie, my wife was not expected to deliver for another 8 weeks, but something was wrong”. James was at a loss and doing the only thing that he could think of, and that was to get her to the nearest hospital. Millie said the baby was coming, and he had no idea what to do. So here they were, but it was too early for the baby to be delivered now, wasn’t it? Leeann, along with James's help, was able to get Millie into a wheelchair and into a bed in the ER. Dr Andrews was called to the ER, STAT. Millie was pale and sweating.

Nick had passed Dr. Andrews a few times in the hospital hallways. To Nick, the Doctor always seemed a bit intimidating, wearing his starched white coat, with a neat bow tie, owl-like glasses, and a stethoscope in his coat pocket. Doc Andrews, as Nick thought of him, seemed to be well respected throughout the hospital. He was an inspiration to Nick, who saw himself as being an accepted member of the medical community one day.

Dr Andrews was in the ER within 10 minutes of being paged, and during this entire time Millie was groaning and saying, “The baby is coming, the baby is coming!”

On his way to the ER, Dr. Andrews passed through the waiting room where he saw James sitting nervously on the edge of his seat. He smiled at James as he went into the ER, but did not stop to talk; he needed to know what the emergency was before he did anything else.

Upon arriving in the ER, Dr. Andrews proceeded to perform the Physical examination of Millie, and what he found was that the baby was crowning much too early and would be premature. It would be an understatement to say that Dr. Andrews was not happy about this situation. This could be a serious problem. St Ann did not have a neonatal facility; the baby would require oxygen and probably mechanical ventilation to keep it alive. The hospital did not have the ability to adequately support a premature child for an extended period. Dr Andrews knew that as soon as the baby was safely delivered, it would require an incubator, oxygen, and ventilation. This was a life-threatening situation waiting to happen.

Dr Andrews' voice tightened, and he directed Jennifer to contact the University of Illinois immediately and tell them that they needed an emergency neonatal transport from St. Ann to the Neonatal facility at the University. All of a sudden, it seemed that all hell was breaking loose, and Leeann could be heard quietly complaining in the background and saying, “ We don’t have time for this.” Jennifer yelled back that the University ambulance would be there in about 90 minutes, and the countdown was on. They would have to keep Millie and her baby alive and cared for until the University ambulance arrived. Ninety minutes. That was the soonest they could arrive. Ninety minutes was an eternity. Dr. Andrews told Leeann to call respiratory; we need oxygen and get an infant intubation setup now.

At 9:50 pm Nick’s pager went off as Nick was in the RT department, counting down the minutes until his shift ended at 11 pm. If the rest of the evening stayed as quiet as it was so far, he could finish his shift at eleven, walk to the bus stop, and catch the 1130 home. He had an early class the next morning, and still needed to finish the chapter on oxygen and blood gases before he went to bed.

It was a STAT call from the Emergency Room. Probably just an asthmatic who needs bronchodilator treatment, he thought. So he grabbed a nebulizer and an oxygen mask and headed to the ER. When Nick arrived in the ER, it was a chaotic scene. Both Jennifer and Leeann were dashing around the ER looking for supplies. Dr. Andrews looked over his shoulder and yelled, “Nick, get over here and help. Dr. Andrews watched Nick approach and wondered to himself, “Will this young kid really be able to help?” When Nick got over to where Dr. Andrews was bent over the bed, he saw a tiny human baby, no larger than the palm of a large man's hand. It was a baby boy, the smallest baby Nick had ever seen. Dr. Andrews had an adult breathing bag and a small pediatric mask over the baby's mouth and nose. He said, “The University transport will not be here for at least another hour. Time is running out. If I'm going to be able to keep this baby alive, I need a ventilator now! Whatever you have that we can use, get it. I will keep bagging the baby until you get back. And Nick, Please Hurry”.

All Nick could say was, “OK, Doctor Andrews,” and he nearly ran out of the ER. What was he going to do.The baby's life was in Jeopardy. Dr. Andrews was depending on him. There was no time to call in a more experienced therapist; he had to come up with a solution fast. The ER was on the 1st floor; Nick couldn’t be bothered to wait for the elevator, so he ran up the stairs to the third floor. He swung open the door to the equipment room.He saw oxygen equipment, nebulizers, catheters, and vaporizers, none of which was what he needed right now. Nothing that was designed to keep a premature infant alive. As he looked around the room, Nick said out loud, “Geez, what am I going to do?” He stood in the middle of the equipment room, breathing hard. His eyes moved across the shelves again.

Then, out of the corner of his eye, Nick saw a gray machine sitting on a pole. It was a device called an IPPB machine, designed to help deliver air to the lungs of an adult with emphysema or asthma. It was not a mechanical ventilator, which he had read about and seen at a clinical site, and it was not remotely designed for neonatal care, but it was the only possibility. It would have to do. There were no good choices; this was the only choice he had, and time was running out.

Nick tried to remember what he knew: a baby's lungs were extremely small; the machine was designed to push air into a patient by creating increased pressure to push the air in. But the small, underdeveloped lungs of a premature infant would not be able to take a lot of pressure, because a baby is not just a small adult; they are much more fragile. Nick knew that, for better or worse, his decision was made; if this is what he had , this is what he would have to use. Dr. Andrews, the nurses, the mom, the man he had seen nervously pacing in the waiting room, and, most importantly, the baby, were depending on him. Yeah, maybe a little pressure when you thought about it that way.

Nick grabbed the IPPB machine and connected the necessary tubing to make it usable. With the understanding that he would have to ensure that oxygen would be delivered and the pressures would have to be as low as possible, so as not to overexpand the baby's lungs and possibly create a pneumothorax. The clock was ticking. Nick made his final adjustments and hurried back to the ER, with the potentially life-saving machine in tow.

As Nick came into the ER, he saw Dr. Andrews give him a hopeful look. He said, “I think this can work as our ventilator, Doctor.” Nick wasn’t sure if he was telling the doctor or himself, but he proceeded to connect the oxygen and air hoses to the wall outlets.

The nurses had not been able to find an intubation tube that was small enough to use for a newborn, so it had been necessary to hold a pediatric mask over the baby's mouth and nose. Nick quickly attached the pressure machine's hosing to the mask that was being used to ensure the baby was able to breathe. The machine came alive, and for a moment, nobody spoke. Nick took over holding the mask. “Pressure as low as possible,” he said. Dr. Andrews nodded. Nick looked down. The baby's chest moved, barely, but it moved, and that was enough.

Once that was done, Nick was able to relieve Dr. Andrews and hold the mask on the baby. He assured Dr. Andrews and the nurses that he could maintain ventilation until Transport arrived. The entire world seemed to shrink to that tiny chest. Nick kept his hands steady, not putting too much pressure on the baby's face. He watched the dials on the machine, , every sound seemed magnified.

Half an hour later, at 11:20 pm, the University Transport arrived. 

Their team intubated the baby, placed him on a neonatal ventilator, assured that the appropriate intravenous lines and monitors were in place, and transported Mom and baby to the University of Illinois Neonatal Unit. There was a pleasant glow that seemed to surround the ER as everyone ended their shift that night.

 The baby's name, he learned later, was Bob.

Just Bob.

A simple name for a little boy who arrived eight weeks too soon and managed to make an entire hospital hold its breath.

Nick smiled when he heard it. Then he went home.

Finis