The Shift

Theresa Brown is an oncology nurse with a PhD in English who works 12-hour shifts at a teaching hospital in Pittsburgh. Her memoir follows a single November day shift, weaving together the stories of her patients to illuminate the realities of bedside nursing.

Brown woke at 6 a.m., reluctant to leave bed. She recalled a patient who coughed up blood and died within five minutes, an experience that left her fearing she might one day lose control of a patient in her care. She biked two miles to the hospital, reflecting on the tension nurses face between overreacting to a patient's condition and failing to intervene when needed. She frames the hospital as "a clean, well-lighted place," borrowing from a Hemingway story about a café that shelters the vulnerable, and describes her cancer ward as a place where patients are increasingly cured and sent home.

She arrived on the floor at 7:03 a.m. and learned that Ray Mason, a young firefighter and punk rock musician she had met for coffee a month earlier when his leukemia was in remission, had been readmitted with a relapse. Brown received three patient assignments: Richard Hampton, a 75-year-old lymphoma patient who was confused and on supplemental oxygen; Dorothy Webb, a 57-year-old leukemia patient nearing the end of a six-week stay and waiting for her immune system to recover; and Sheila Field, a woman in her mid-forties admitted at 3 a.m. with antiphospholipid antibody syndrome, a rare autoimmune disorder that causes blood to clot too easily. With three patients instead of the usual four, Brown felt a temporary reprieve, though a fourth could arrive at any time. Brown reflects on research linking higher nurse-to-patient ratios to preventable deaths, a recurring theme.

After researching Sheila's condition, Brown learned that Hampton's attending had ordered Rituxan, a biological response modifier carrying a Black Box warning, the FDA's most serious label, which includes death as a possible outcome. She visited Hampton and found him barely responsive, deepening her concern about giving this drug to such a frail patient.

During morning rounds, Brown administered Dilaudid, a narcotic painkiller, to Sheila for abdominal pain but decided to wait on checking her bowel sounds until the medication took effect. Dorothy's team then delivered the day's best news: Her absolute neutrophil count (ANC), a measure of immune function, had reached 850, high enough for discharge. The attending asked Brown to perform "the neutrophil dance," and she improvised a shimmy that made the room cheer. Brown missed rounds on Hampton, however, losing her chance to question the Rituxan order.

Sheila's attending, Dr. Nicholas Martin, grumbled that he was an oncologist rather than a hematologist and seemed uncomfortable managing her rare disorder. He ordered tests and a CT scan but was called away before examining Sheila, leaving Brown without the clinical discussion she needed. A rapid response was then called for Mr. King, a long-term patient in the adjacent pod found unresponsive with blood running from his mouth. The code team transferred King to intensive care, where the ICU doctor privately told Brown his chances were "slim to none."

Nancy, the charge nurse, assigned Brown a fourth patient: Candace Moore, a woman in her early forties arriving for an autologous stem cell transplant, in which her own previously harvested cells would be reinfused. Known on the floor as extremely difficult, Candace brought her own Clorox wipes, oscillated between suspicion and forced friendliness, and immediately demanded that her central IV line be tested before proceeding, insisting it was malfunctioning.

A radiologist called with devastating news: Sheila's CT scan showed free air in her abdomen, indicating a bowel perforation. The intern instructed Brown to stop the Argatroban, the blood thinner Sheila had been receiving, but it would take hours for the drug to clear before surgery could proceed. Brown felt intense guilt for not detecting the perforation sooner, reflecting on how a previous patient's loud complaints had turned out to be nothing, possibly biasing her into underestimating Sheila's quiet suffering. She explains the danger: Bacteria leaking through the perforated intestine into the sterile abdominal cavity would cause peritonitis, an infection that can progress to sepsis and death.

Peter Coyne, an attending surgeon, took Sheila's case and told her there was a 20 percent chance she would not survive the operation, citing her smoking and weight as risk factors. Brown sat beside Sheila's bed, took her hand, and outlined the plan: at least six hours for the Argatroban to clear, then surgery that evening. She told the family Peter was a good doctor and promised to stay with them until Sheila left the floor.

The hours that followed were a blur of competing demands. Brown double-checked the Rituxan order with Beth, a fellow nurse, and briefly visited Ray, who joked that his conservative brother would be his stem cell donor. She tried repeatedly to discharge Dorothy but was pulled away by Sheila's escalating pain, Candace's complaints, and constant phone calls.

Dorothy finally signed her paperwork. Her husband grasped the wheelchair handles, and Dorothy rolled down the hallway waving and blowing kisses. Brown resolved to remember this moment no matter what else happened.

Brown caught Peter before he left the floor and advocated for operating on Sheila that night rather than waiting until morning. Peter acknowledged her concern but said waiting might be safer, weighing surgeon fatigue against the risk of delay.

Brown started Hampton's Rituxan infusion, donning protective gear and monitoring vital signs every 15 minutes. Hampton not only tolerated the drug but improved dramatically: He sat up, came off supplemental oxygen, spoke clearly, and laughed during animated conversation with his son, Trace Hampton. Brown reflects on the possible healing power of family presence.

The OR called unexpectedly early for Sheila due to a cancellation. Rather than bringing the stretcher into the room, Brown had Sheila walk to it, believing a dose of normalcy would serve her spirit before a life-threatening operation. At the stretcher, Brown told Sheila she had to give her a hug. Sheila replied, "And a kiss." They kissed on the lips, and Brown watched the escort push Sheila away.

Irving Mooney, a man in his late fifties with leukemia who has schizophrenia, arrived by ambulance from a group home. Brown recorded her end-of-shift reports and visited Ray, who preferred to discuss Cormac McCarthy's novels rather than his cancer. Peter called to confirm he would operate that night; fresh frozen plasma, a blood product that aids clotting, would add time, but surgery would proceed. Brown visited Mr. King in the ICU, squeezed his hand, and told him everyone upstairs missed him. She biked home in the cold, ate dinner with her family, and fell asleep thinking about Sheila.

In the afterword, Brown reveals outcomes. Peter finished operating at 2 a.m., performing a colostomy, a procedure that diverts waste through a surgically created opening; Sheila spent a month in the hospital but recovered. Beth's daughter returned safely from Afghanistan. Ray received a transplant from his brother and recovered fully, returning to firefighting, his band, and his family. Candace completed her transplant successfully; Brown notes that her vigilance should be recognized as empowered behavior rather than dismissed as difficult. Irving returned to his group home cancer-free. Dorothy, however, came back months later and died, her husband and daughter at her bedside. Hampton was readmitted; his improvement during the Rituxan did not last. Two years later, Brown ran into the owlish intern at a coffee shop and told him his remark, "If we could know the future our jobs would be a lot easier" (236), had shaped her thinking about the book. He replied it was probably something he said half asleep, but for Brown the encounter brought back the full weight of the shift and its patients.