The Night Shift Warning

Chapter 2 The Notebook

The next week passed slowly, the way hospital weeks do, measured in shifts rather than days. I worked Tuesday, Wednesday, and Thursday nights, and each night I did what Marcus had told me to do: I kept my head down. I gave my patients the care they needed. I charted what I saw. I did not say anything to anyone.

But I watched.

I watched Marlene more carefully than I ever had before. I noticed the way she timed her medication passes, the way she was always in the medication room at 2 a.m., when the night shift was quiet and the day shift had not yet arrived. I noticed the way she kept a separate key to the locked drawer where the controlled substances were stored, a key that was not supposed to exist. I noticed the way Dr. Patel came to the unit on Wednesday night at 11:30 p.m., which was not a normal time for a physician to round, and how he and Marlene had a conversation in the supply closet that lasted twelve minutes.

I did not know what they were talking about. But I had my suspicions, and my suspicions were getting harder to ignore.

On Thursday night, I was assigned to room 412, the heart failure patient whose daughter had been sleeping in the chair beside his bed. His name was Harold Brennan. He was 78 years old. He had been on the unit for three weeks, and his condition had been stable, declining slowly, the way heart failure does, but not dangerously. His daughter's name was Angela. She was a high school teacher from a town two hours away, and she had taken a leave of absence to be with her father, and she slept in the chair and she ate in the cafeteria and she did not leave the unit, even when we told her she should go home and rest.

I had grown attached to Harold in a way that I was not supposed to grow attached to patients. He reminded me of my grandfather, who had died when I was sixteen, in a hospital far less nice than this one, in a room that did not have a chair for anyone to sleep in.

On Thursday night, at 1:15 a.m., Harold's heart monitor began to show an arrhythmia. I looked at the strip. It was a run of ventricular tachycardia, sixteen beats, self-limiting, not sustained, but significant. I went to the medication room to get the amiodarone, the d**g that would stabilize his rhythm, and I noticed that the dose was higher than the standard dose. It was higher than his previous dose. It was higher than what was listed in his chart.

I stood in the medication room with the vial in my hand and I thought about July 14, the code blue that should not have happened.

I went back to Harold's room. I checked his chart again. The order was there, signed by Dr. Patel, dated that morning. The dose was not standard. The dose was dangerous.

I did not give him that dose. I called the on-call resident, the second-year who still needed supervision, and I told him what I saw. He came to the unit and he looked at the order and he looked at the chart and he said, "That's not right."

He changed the order. He gave Harold the correct dose. Harold stabilized.

At 3 a.m., Marlene came back to the unit. She had been off since 7 p.m. She was supposed to be off until Friday morning. But she walked in at 3 a.m. wearing her scrubs and she went straight to the medication room and she did not come out for fifteen minutes.

I was charting at the station when she came out. She walked over to me. Her face was calm. Her voice was quiet.

"Jordan," she said. "Did you change an order tonight?"

"I followed protocol," I said.

She looked at me for a long moment. Then she smiled. It was not a nice smile.

"You know," she said, "I tried to help you. When you came back from your leave, I was the one who told administration that you were ready. I was the one who said you were not a risk. I vouched for you."

I did not say anything.

"But I can't vouch for you if you go around making changes without consulting the attending. You know that, right? That's not how we do things here."

I looked at her. I thought about the notebook in my bag, the sixteen pages of notes, the dates and times and room numbers and names. I thought about Marcus Cole and his calm voice and his promise that it would take time. I thought about Harold Brennan and his daughter sleeping in the chair and the dose that would have stopped his heart.

"I know how we do things here," I said.

Marlene's smile did not change. "Good," she said. "Then we understand each other."

She walked away.

On Friday morning, I went to Marcus Cole's office again. I told him what had happened with Harold Brennan. I gave him the name of the on-call resident and the time and the order number. I told him about Marlene coming in at 3 a.m. and going to the medication room and staying there for fifteen minutes.

Marcus listened. He wrote it down. He did not say what he was thinking.

"This is enough," he said finally. "This is enough to open a formal investigation. But I need to ask you something, Jordan. Are you prepared for what comes next?"

I thought about what came next. I thought about human resources and interviews and the way that everyone on North 4 would know that I was the one who had done this. I thought about Marlene, who had been my friend, and the way that friendship would curdle into something else, something that did not have a name but that I had seen before, in other units, in other people's lives.

"Yes," I said.

Marcus nodded. "Then I'm going to do this by the book. I'm going to do it carefully. But you should know that these things have a way of getting out. People talk. And once it's out, there's no going back."

"I know."

He looked at me for a long moment. "Then I'll start today," he said.