‘The 4th Floor’

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Prologue


The twelve-bed Palliative Care Unit (PCU) at San Francisco General occupies the fourth floor of the busy downtown hospital. In the simplest of terms, palliative care is 'care without cure.' The task of the unit is to provide relief from the unrelenting pain that often comes with terminal illness, allowing patients to pass with dignity. Palliative care is not doctor-assisted suicide. 
It's understood that patients checking on to the ward will die. No one ever gets well. There are no miraculous recoveries, no homecomings to plan. The stark reality of life and the inevitable end we all will face some day plays out daily on the PCU.
The unit is staffed 24/7 by two specially trained nurses who work twelve-hour shifts, four on three off. In addition to the nursing staff, there are nine physicians from across the hospital who rotate through the ward visiting patients twice daily. It's during these visits that they regularly administer a variety of opioids: Hydrocodone, Morphine, Fentanyl, Oxycodone, and Hydromorphone. Each of the physicians has received advanced training in pain management.
Propofol is another medication widely used in palliative care primarily as a sleep agent. Nearly all patients on the PCU are in advanced respiratory failure and require constant intubation. To better accommodate the procedure, they're kept asleep. The milky-white drug gained notoriety with the general public after the death of the pop star, Michael Jackson, who succumbed to an accidental overdose of the medicine administered by his physician.
The time was 12:07 a.m. when Dr. Lee Kirby stepped onto the PCU accompanied by another man who's badge read Eric Clanton, MD. Kirby, a cardiologist by training, has served as an attending on the PCU for the last two years. Tonight marked Clanton's first appearance on the floor.
 Karen Hunt, the on duty charge nurse, welcomed the physicians.
"Good evening Dr. Kirby, you're right on time," Hunt said peeking down at her watch.
"Hi, Karen. This is Dr. Clanton from St. Luke's. He'll be making rounds with me tonight," Kirby said. 
"Good to meet you, Dr. Clanton," Hunt said with a knowing look on her face. Had Kirby been paying attention, he might have noticed her odd reaction to the visiting physician's presence.
"So what's the caseload look like tonight?" Kirby said.
"There are only four patients on the unit at the moment. Mrs. Raymond passed a few hours ago. The transport team from Sullivan's left with her about twenty minutes ago," Hunt reported. Sullivan's is a nearby funeral home that regularly retrieves deceased patients directly from the unit.
"Did she have an advanced directive?" Kirby said.
"No, but the family sat with Dr. Rogers this morning. Her daughter signed all the necessary paperwork. We made all the usual notifications when she passed," Hunt said just as Kirby turned to face Clanton, who hadn't spoken.
 "Ok, thanks, Karen. This way, Doctor," Kirby said to the younger Clanton before walking from the nurse's station to the first stop on their rounds. Hunt turned her attention back to the narcotic medication inventory control documents laid out on the desk in front of her.

Copyright 2016 DBE

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