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Missing Piece

Ray Bingham

I entered the hospital by a back door. It was evening. As I walked down the quiet corridors, their cinder-block walls, green paint, tiled floors and soft fluorescent lighting granted me a superficial sense of familiarity: I’d walked these halls countless times over the last five years.

Now, however, I also felt a bit apprehensive. I was not supposed to be here. 

Two weeks before, I’d been laid off. It had been the second round of staffing cuts in six months–due, the administrators said, to declining revenues. They made this claim despite the continued high numbers of patients in my unit, the newborn intensive-care unit, or NICU. 

As a veteran nurse, I’d spoken up. The cuts, I’d said, were leading to understaffing, to increased stress among the nurses and to declining care for our fragile patients. Soon after, they’d canned me. 

Not risking the elevators, I climbed the stairs to the third-floor landing outside the NICU. I had a flimsy pretext for visiting: I wanted some of my former colleagues’ phone numbers to use as job references. Mostly, though, I just missed the place. I’d started in the unit as a neophyte, fresh out of nursing school. Through hard work, and skilled and dedicated mentoring, I had grown into an experienced clinician, board-certified in neonatal intensive-care nursing. Now, after years of holding and handling and caring for the sickest of infants, my hands felt empty and useless. 

Shannon, a fellow nurse and long-time friend, burst through the NICU’s outer doors. Seeing me, she came and gave me a quick hug. She worked in a different unit, but she always knew all the NICU goings-on. 

“You don’t want to go in there–it’s a complete madhouse,” she said. “They just got two babies in, pre-ECMO. And guess what? No one is there to take care of them. What a surprise, huh?”

Then she bustled off. I walked through the inner doors. 

Shannon hadn’t exaggerated. Right away, I sensed the tension in the room. It radiated from the nurses’ faces; they were too busy even to acknowledge me. 

“Hi, Ray,” said Margaret, the unit secretary. 

“Hi,” I answered. “I was hoping to have a look at the staff notebook for references. I’m job-hunting.” 

Without a word, she handed it over. I flipped through its pages. No one else acknowledged my presence.

I glanced toward the ECMO bay in back. Sure enough, there were two babies there. By the amount of equipment by their beds, I could tell that both babies were very sick. There was no nurse at either bedside.





Right away, I sense the tension in the room.




It radiated from the nurses’ faces…







Now, all babies in a NICU are sick, but “pre-ECMO” babies are about the sickest. Most are full-term infants who, for various reasons, haven’t been able to make the transition from the womb to the outside world. Their lungs need help breathing, and their hearts need help pumping. 

To do this, we place them on ventilators and give them heart medications. Sometimes, though, those measures aren’t sufficient. In extreme cases, we turn to a last-ditch intervention–placing them on a heart-lung bypass machine called an ECMO (extracorporeal membrane oxygenator).

Putting an infant on ECMO means piercing the baby’s major blood vessels to divert the bloodstream through yards of tubing and an artificial lung before returning it to the baby’s circulatory system.

ECMO can be life-saving, but not every infant survives, and those who do have a high rate of developmental impairment and/or physical disabilities. It’s an intervention to be avoided if at all possible. 

Ironically, if you want to avert ECMO, a nurse is your best tool. A vigilant, highly trained NICU nurse can instantly note any changes in a baby’s behavior or vital signs and respond by adjusting the ventilator or medication as needed. The catch, though, is that the nurse actually has to be there, minute by minute.

Felicia, the charge nurse, rushed by. I half expected her to tell me to leave; I would have complied. 

Instead, she murmured, “I wish you could work.”

Then she hurried to the phone. She called the hospital supervisor, then other nurses, trying to get someone to come in to help. It appeared that no one was responding.

After jotting down some names and phone numbers, I returned the notebook to Margaret. I found a quiet spot to stand and observe, my gaze glued on the babies in back.

More minutes passed. No nurses appeared. 

A missing piece of care.

I felt knotted, paralyzed. 

I’m not going to leave until I see someone come to care for those babies, I thought.

But what could I do about it? 

Well, I still know where the locker room is. I could change into scrubs and go to the ECMO bay…I could take over for those babies. 

I didn’t give a damn that I wasn’t on the payroll anymore. I didn’t really have any other plans for the evening, anyhow. 

But what would that accomplish? My inner voice went on. No doctor would talk to me. The other nurses would avoid getting involved…I’d only be a distraction. There’s no way anyone will let me do what I know how to do. And think of the liability issues!

My anger bubbled over. Why should I put my ass on the line for the hospital that put my ass in the can?

Joan, a former nurse manager turned staff nurse, approached. “What are you doing here?” she said tersely.

“Someone needs to take care of those babies,” I replied, glaring into her eyes.

“We’ll handle it. You have no business here.”

“I’ve been watching. Nobody’s been back there. It’s been half an hour.” I struggled to rein in my frustration and anger.

“We’re doing the best we can. It’s not your concern anymore.”

She was right. There was nothing more I could do. 

I turned and walked out.

In the hallway, I put my hand on the wall. The cinder blocks felt cold under my palm. The paint was sickly green. The floor was worn linoleum, stained in some places. I saw it so much more clearly now.

The hospital was only a building. It didn’t care. 

I walked back down the stairs and left it.

About the author:

Ray Bingham, RNC, MSN, lives in Gaithersburg, MD, with his wife, three kids, three cats and one dog. He worked as a neonatal nurse for more than ten years before turning his attention to science writing and editing. His essays and stories have appeared in a wide range of publications, including The Washington PostHealth AffairsAmerican Journal of Nursing and Journal of Nursing Jocularity. He is an avid, if not particularly fast, runner.

Story editor:

Diane Guernsey


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