Notes from 8 years of adrenaline chasing

The first time I saw a patient try to die, I was hooked on adrenaline. This was years before our hospital started running mock codes. I was a few months out of nursing school and almost completely clueless, staring wide eyed at the travel nurse doing compressions and calling for help. I think I might have run to the phone to page the code team. I don’t remember. But I do remember afterward running the scenario through my head; if the patient is unresponsive, check for breathing, check a pulse. Call for help, start CPR. And every day after that, when I clocked in on the post-op floor that was my first real job, I hope that if a patient were to arrest, they’d do it while I was nearby.

As a new (clueless) nurse, I wasn’t taken very seriously. I watched the swat nurses, whose job it was to round on every floor and assess patients the nurses were concerned about, to respond to code and to sit with ICU level patients until they had a bed on the unit. They argued with the doctors. They knew their shit, they got things done. I’d gone to nursing school with the intention of becoming a midwife, but I was drawn to the adrenaline rush of Saving Lives.

After a very short stint in med-surg, I got a job in the MICU. When I started there, we were only a 16 bed unit, in a hospital that usually had more than 16 micu patients. The sickest of the sick came to us and as soon as they were remotely stable, got shipped out so we could take more sick patients. I learned fast. After less than a year, I was adept at deciding from report who was the most likely to crash, and I’d request them. Those patients became my speciality; the ones with low blood pressure who didn’t have access; with a bad ph but weren’t intubated and we were talking about dialysis, the ones with uncertain code statuses.

I got respect from the residents. “Her ph is 7.11, she’s a little altered and she’s on pressors. She’s satting ok on a 90% facemask, do we want to intubate her before she gets worse?” They listened to me. I was the fulcrum in the patient’s room, the locus. I’d update the consulting physicians, the family, the charge nurse. I learned to advocate for my patients, to argue for them, to listen to them. I’d rush to get supplies, asssist with procedures, titrate multiple drips, chase lab results. I knew when patients were getting worse. I could brief a fellow while doing CPR.

And when patients died, as the inevitably did, I’d wait for the family to be done, bag up the body and bring it to the morgue, and wait for a new patient, hoping it wasn’t something lame like DKA.

People would ask me, how do you do it? And I’d shrug. Because the enormity of the tragedy I witnessed didn’t bother me that much. It was my job. Not that it didn’t make me sad; it did.  But it didn’t keep me up at night; I did it well because it was my job.

So here’s the dirty little secret, and I think it’s endemic in most new ICU nurses, and probably extends to the ER and to paramedics. We like sick patients. We like it when people are actively spiraling. The layman’s worse nightmare is when we can flex our muscles and show off our skills. If we spend more time tending to impressive machinery than an actual human, we are pretty badass.

To a certain extent, there is a time and a place for this, because if your husband is in multi-system organ failure, don’t you want a nurse who’s going to hyper-analyze every lab value, critique the vent settings and re-adjust the pressors manically? But seen through another window, we are very strange human beings, we adrenaline junkies. Most of us will never get a chance to do roadside CPR or pull puppies out of a burning building but in this controlled setting, we are lifesaving rockstars. And no matter how exhausting it is, it’s fulfilling as hell.

So here’s my theory. We start off like that, but it wears on us. Eventually, we start to see the humanity in all of it. We begin to mature. I started seeing wives a the bedside as widows-to-be. Started wishing that my end stage pulmonary patients were home enjoying morphine and ice cream instead of pitting their lungs against a ventilator. I cringed when I had to help put central lines in old women. The families ceased being annoying and became desperate or unfortunate. I didn’t seek out the crashing patients anymore; to my horror I found myself enjoying getting people out of bed, washing their hair, getting to know their families.

Recently we’ve had a couple of younger patients come in with no brainstem reflexes and we’ve made an incredible effort to stabilize them, because no one is dead until they’re warm and dead, or oxygenated and dead. I’ve found myself wishing we could just tell the family, look. It’s pointless. It’s an exercise in futility, because it is.

And the chronically critically ill! This is the result of so much of our heroic lifesaving treatment; the dialysis and/or vent dependent, depressed, pressure sore laden souls. They do not live, or die, but linger. Burdened by heavy choices, their families cannot let them go, and so they circle from the ICU to the floor to rehab and back again, maybe to a vent facility. Sometimes they are confused and they beg us to let them die, but they’ve lost their voice to delerium and I must pretend to be deaf to their pleas. This crushes me.

Many of our patients do live to tell the tale. But they are not the thrilling ones. Unpopular opinion; if you only want to take care of the sick sick and actively spiraling, if you’re only happy at the bedside when tending to complicated machinery, you need to grow up. If you’re annoyed when your patient isn’t fully sedated, or irate when you don’t get the sick patients, look at the humans who have entrusted you with their care. Through everything, that is the most important thing. It is what separates a technically competent nurse from a truly good nurse.

I think it’s clear from this that it’s time for me to leave the ICU. Each time I have a very sick patient I think, “Tending to technology manifests commitment,” from nurse anthropologist Helen Stanton Chapple. She’s right; by our attention to the machines, we show families that we are Doing Something, when all too often, nothing should be done. And they cling to hope, that demon from the bottom of Pandora’s box. And hope disappoints. This isn’t fulfilling anymore.

I’ll be going to primary care soon, a novice once more. I am grateful for all that I have learned, both from the ICU and from the patients. I’m not leaving because I’m burned out, it’s just clearly time for me to leave the adrenaline chasing to other people.

Nurses’ Rights

The hospital I work in used to have posters hanging up, describing patients’ rights. The right to have their medical care explained to them, the right to refuse treatment, the right to be treated courteously, the right emergency care regardless of the circumstances.

These posters are no longer displayed, but the concept hasn’t gone away. The healthcare team I work with makes every effort to treat people fairly and humanely. If a person refuses a test or treatment, that’s fine. If someone wants to leave against medical advice, they are free to go.

Health care professionals actually have very few rights. What other profession is not allowed to drink water while they do computer work, or sip on coffee throughout the day? Or to work twelve hours without a break to eat? In what other profession is it part of the job to be cursed at, spit at and threatened?

And what if I’m a bedside nurse, and I very strongly disagree with the course of treatment? Where is my right to refuse? What about when it becomes my job to torture someone?

Charlie Guard, the English child whose parents wanted to fly him into the US for experimental treatment, because an unfortunate poster child for Republicans campaign against state sponsored healthcare. Out of all the garbage written about that, I read one good article. A nurse wrote about working in a PICU and watching patients suffer. Think of the nurses, she wrote, who know a patient is suffering and are forced to be part of that suffering, knowing the outcome.

We had this patient, George in our ICU a few years ago. George was 95 and he had cancer. He was never able to speak for himself, so his son spoke for him. George was with us for close to two months. In that time, he suffered unspeakably. Anyone with any medical experience knows that people with bony metastasis require a lot of pain medications. The patient’s son insisted, repeatedly, that we only medicate him with tylenol, because he didn’t want him given narcotics. (We gave them anyway, when the son wasn’t there.)  He insisted his father undergo radiation, wanted him to have chemo and if he wasn’t weaning from the vent, why couldn’t he get a trach?

He got the radiation. Chemo and a trach were out of the question. But according to our current healthcare structure, the patient has a right to autonomy, to make their own decisions. In lieu of the patient, the surrogate decision maker calls the shots. He or she is supposed to speak to what is in the patient’s best interest but too often, they are thinking of themselves. Or they’re irrational. Who bears the consequences of these decisions? The patient, the physicians and the nursing staff. Especially the nursing staff. The things we do to patients in the ICU are horrible, but they’re in the name of preserving life. When death is imminent no matter what, these needles and tubes become instruments of torture. When George’s heart stopped, we were required by law to do CPR, with the knowledge that we would only break his ribs.

I took care of George about two weeks into his stay, on a day when we trialed him off the ventilator. He lasted about twenty minutes. In those minutes, his eyes closed. His pulse and respiratory rate increased as his oxygen levels dropped, but he rested. He was 95 and terminally ill. We had to re-intubate him, of course, because his son was dictating his care and I believe it was the first time I’ve cried during an intubation.

Where are the nurse’s rights in that situation? Why am I forced to torture when I am in this profession to comfort and cure? Consider a patient with advanced parkinson’s getting chemo, or the patient who said she wanted to be left in peace, but since she cannot speak for herself, now has a feeding tube. The 88 year old with no family that wants CPR but no breathing tube and so we code her until two physicians agree that we have tried long enough.  My fellow nurses and I become part of the conspiracy, a gang of brutes, preying on the helpless, with no choice but to comply, with the knowledge that we are causing pain, wasting resources and the end result is death. Beyond outright quitting, we have absolutely no choice in the matter. Unlike our patients, we don’t have the right to refuse.

Being Lucy

(I wrote this a few years ago. It has been published in the Healing Muse and a shortened version in Scrubs magazine)


He knows it has been a bad day when he gets home and she is talking to the dog.

  He slams the door and sets the grocery bags down on the counter.“I’m home,” he says, unnecessarily. He hears her rise and come out into the kitchen. She has already changed out of her scrubs. She kisses him quickly, and in the fading winter light, she looks older than her age, worn out.

“How was your day?”

She looks at him. “It was fine.”

He takes a deep breath, takes a plunge. “Why don’t you work somewhere else?”

The fine lines furrow, the eyes narrow. “I said it was fine. Why would I want to change jobs?”

“You don’t seem fine. You were talking to the dog.”

“Those damn windows. If we had neighbors, they’d know everything about us.”

“We don’t have neighbors and I like the windows.”

“I know.” She bumps by him and gets the Advil out of the cupboard.

“You could try working out or something to let off steam,” he tells her.

“Are you crazy? Do you know how hard I work already?”

“Or you could quit. I make enough,” he says mildly.

“Don’t tell me what to do.”

“I wasn’t. It was a suggestion.”

“Don’t suggest. It was a terrible idea.”

He puts the groceries away, eggs and milk in the fridge, rice in the pantry. “Should I throw these steaks on?”

“How much did you pay for those?” She is glaring at him. “Never mind. I should know by now not to ask.”

He doesn’t say anything. He wants to be thanked for good meat, for offering to cook, to grill in the cold, for goodness sake, and for getting everything on the list. He isn’t sure what he has done wrong, but he knows by now not to ask.

She pulls a platter out of the cupboard and hands it to him. “How was your day?”

The question hangs, and he sees the office crowded paper and programs. In his mind, above the mess chaos, there are buildings not yet realized. “Lots and lots of drafts,” he says. “One of the drafters is out sick and I have to do his work, and this client is really pushy. They can afford to be, with what they’re paying us” He cracks open a beer. “Stress, but I like it. It doesn’t push me to come home and spill my guts to Lucy.”

He immediately regrets his words, and sees the disdain flash across her face, nearly, but not quite, concealed.

They stand facing each other for a moment, a gulf of unsaid words between them.

Then she says, “Don’t forget the lighter. The grill’s been acting up again.”


During dinner, she says, “Did you take Lucy out with you while you were cooking?”

“Yeah. Didn’t you see?”

“I don’t pay attention to you all the time.” She plays with her food.  “It’s undercooked.”

“I forgot you don’t like it that way.”

She is about to say something, but bites her tongue. He waits. Then she says, “It’s not about you, OK?”

For a while, she is silent. He thinks about windows on a sunny day, great sheets of glass that he’ll draw into his draft of his new building tomorrow. Windows that look clear, but when you stood back a little, you could only see reflections. Her eyes are like that. Her whole being is like that and there is something beneath that he can’t touch. If he does, he’ll have to share it, and he feels like he can only offer pity. Is this love?

She mutters something about needing the bathroom, and gets up. She doesn’t return. They have a long standing agreement that one of them cooks and the other cleans up. He puts his plate in the sink and goes to his office.


He works on drafts. He wants to work from home all of the time, but there is  a clause in the company’s insurance that won’t allow it. He loves his house with its huge windows, open spaces and all of its good sense. He designed it, created it around himself and his wife. It is on a hill, a half hour from the city, isolating them from the world and sometimes from each other.

Outside the wind blows. The house creaks. He knows exactly what joint it creaking and where it needs to be fixed. If spring ever comes, he’ll fix it. He thinks about taking down the drywall, exposing the faulty joints, setting them right, repainting. The corners would be sharper and cleaner. Actually, that whole side of the house could be set straight. If he gets the next commission, they could have a screen porch on the south side.

His pencil draws straight, clean lines, and in his mind, a building rises.

Suddenly it is eleven pm. He sits up sharply, and stands. She will be in bed already. He feels a sudden need for her, for her physical presence. He can’t plumb her depths, can’t reach her, and he is suddenly afraid that one day their little spats will create a rift that neither of them can bridge.

Or perhaps she’ll wither away, her body, already small, worn down by the nature of her work, will finally crumple under the strain. He’ll be left alone, strong and ropey as he was at twenty, to tend to her empty shell. She should exercise, he thinks, eat right. Stop the diet of chocolate, coffee, lettuce and Advil. She’d feel better.

The dishes are where he left them. He shakes his head.

He brushes his teeth. The bedroom is dark with moonlight and silence. He climbs in bed next to her.

She is curled up facing away from him. He touches her neck gently, reassuring himself that she is indeed still there. She stirs. “Sorry to wake you,” he says.

“I haven’t slept yet.”

She does not move towards him, nor does she move away. Finally, he pulls her closer and kisses her neck. She shudders and he reaches a hand down her leg. Then he realizes she is crying.

He fends of his irritation. What am I, your counselor? He doesn’t know what to say. Who ever does?  

“The worst thing about today was that the patient’s sister just kept saying, we were supposed to go to Florida together. And that was the worst thing. I could just see it. When she first got to us, she looked good, like a cancer survivor… the time she died she looked terrible.” She sniffs. “The fucking magic of sepsis. It’ll fucking transform you from a human into a fucking corpse in less time than a bullet.”

It is quiet. In the long dark silence between words, the clock ticks and time moves on.

“I’ve been thinking that all day. And I could see them in a hotel or on some post-card beach down there. She would be bald and not care. And they would do all the stupid things tourists do sometimes, like do the YMCA when it plays in a restaurant or Kareoke to horrible songs and wear funny shirts and fat sandals, but to them… would mean more. The whole time….they’d be thinking, we survived non-Hodgkin lymphoma. They probably fucking already had their plane tickets. And here she was, with pneumonia.”

She stops talking and starts crying, big dirty sobs, like a little kid, he thinks. He still says nothing just holds her. He is trying to think of the last time he’s heard her say fuck. Two years? Three years ago?

“She was only on levo when we got her, but we maxed on neo pretty fast and gave her five boluses. And of course we couldn’t ventilate her, and her pressure still sucked even after the vaso went up, and they would want to run bicarb. Why? By the time you start bicarb, its too late. It never works. It’s sort of like admitting that you’re desperate.” She is crying, sobbing between her words. He doesn’t know really, what she is talking about, but like Lucy, he listens.

She sits up, and he watches her get out of bed. “I need some tissues,” she says. She goes into the bathroom in the dark. “If I turn on the light,” she says, “I won’t be able to tell you any more. It will be like…I don’t know.”  She fumbles around, and when she comes back, he can see by the dim light of the clock and the moon that she has a roll of toilet paper. Her eyes are black holes in her pale face. “I’m sorry I’m such a wreck. I shouldn’t dump on you like this. You don’t deserve it.” She slouches on the side of the bed, back facing him.

He says something then, something quiet and stumbling, pulling her back towards him, wiping her tears, cradling her, and she is quiet for a while.

Then she begins to speak in that language nurses have, a language of abbreviations, diseases and curses. She tells him, or maybe she is not telling him at all, she is just reliving her day.

“And the resident wouldn’t call his fellow. And I think that’s…that’s because he realized before I did that this woman was just going to die.” She shudders silently. “And she did die.”

“People die there all the time, right?”

She makes a funny noise.“People die all the fucking time in the ICU, but this woman was supposed to live. She was in rehab when she got sick. She was in remission. And her dad was there, sitting in the corner, and he just looked so lost, and her sister was walking up and down in the hallway muttering fuck fuck fuck fuck. And then I realized what Wasim realized. Everything we were doing was pointless. And I said, Wasim, we need to talk to the family. And he just kept looking at the monitor and at the patient and didn’t answer me. I had to say it like five times. So we went and talked to the family, and at that point, he decided a chest tube might help her, and we were playing that game, you know, where there is an elephant in the room that no one will say anything about it. The elephant’s name is death.”

She laughs, a terrible sound. “Wasim and I both knew she would die, but we couldn’t say that to the ‘ family. Why? Why couldn’t we say, we know she is going to die no matter what we do? She laughs again, but he can hear that she is not smiling.

“Don’t answer that question. No one knows the answer. So they decided to put in a chest tube, but the surgeon that comes just dicks around for the longest time, she can’t decide whether it will hurt or harm the patient. And I sort of took the sister out of the room, explained what was happening, and if she knew what she wanted to do if the patient coded, and she finally started crying and said, ‘We were supposed to go to Florida together.’ ”

In his mind’s eye, he sees a 40-something woman sitting on the beach. The sun is bright and hollow. The chair next to her is empty. Below it is a pair of unworn flip-flops. She couldn’t leave them at home.

“I just wonder how we bear it. All this death. It has to happen. With some people, it’s almost a blessing that they die and with others it is a tragedy. And we code them or let them go, but they all die in the end. And we send the family home and bag up the body and strip the room for the next patient. And usually I don’t take it home. But this one was bad.”

“I think…I usually don’t get like this with families. I usually see a patient in the bed, disconnected from everything, and that is OK….But we were working so hard, and we knew it was pointless and when I looked at her sister….and I saw that unbelief…”

There was silence. He holds her tighter, thinking of what he could lose. Outside, the wind blows through empty branches and the moon watches the world silently, dispassionately. Outside of the room, there are dirty dishes and unpaid bills. There is a snow blower that needs to be serviced and a mother-in-law who hasn’t been visited in weeks. There are drafts unfinished, unhappy clients and traffic jams waiting to happen. There are wars and famines and plagues and droughts, but in here, in this room, in this bed, there is her, alive and sobbing.

“I love you,”  he says, and realizing that he means it, kisses her hair. She cries some more, her body wracked, and he lets her, thinking about non-Hodgkin’s lymphoma.

After a few minutes, she quiets. “Do you feel better now?”

“Kind of snotty, but better.” She sniffs. “If you let that stuff build up inside, you rot, I think. It just sits there, and you rot.” She gets up again and goes into the bathroom. This time, she turns on the light.” I’m a freaking mess.” The door shuts and he hears water running and after a small eternity, she comes out again.

“Sorry I had to put you through all that,” she says. He is temporarily blinded and also rendered  mute by her outpouring. But to her, it must be in the past. She is crawling across the bed, to kiss him, to lay her body, beneath the blankets, on his.

Emily A Weston

dammit, you should have listened to me

Saturday I accept a patient from the ER; stage 4 breast cancer with mets to bone and lymph, needs an emergent pericardial window, but her platelets are too low for surgery. Somewhat confused, anxious, in enormous amounts of pain and on a moderate amount of O2. We talk about options. She doesn’t want to think about end of life, doesn’t want to talk about it. Doesn’t want a procedure done today, wants to wait until the morning. CT surgery says now or never. We need to intubate her and bring her to the OR or she will die within the next few days. He husband wants to know, if we put her on the vent, what are the odds of her coming off? Not good, we tell him. On the other hand, should they choose to forgo the procedure, she’s gonna die.  

I spend a while with both of them. The odds of coming off the vent aren’t good, I tell them. But if the procedure isn’t done, at some point her heart will stop and we will have to do CPR and it isn’t going to bring her back. So you should choose either to withdraw and stop or to go all out. Don’t leave us hanging, forced to break her ribs for nothing. She is pretty lucid while we talked about this, and the husband started bawling and asking her if she wanted to just go home. Should I just bring you home, he keeps asking her. Michelle, should I just bring you home?

I give them some time, and meanwhile wait to correct the platelets and all the other urgent things that need to be done. These things take time. The poor woman is up the wall anxious, and I finally have to take her catheter out because she keeps trying to climb out of bed to go to the bathroom. I’m pretty sure we are going with comfort care at that point, so I take the initiative and oops, it comes out.

One way or another, I tell them, we are looking at the end. It isn’t easy for me to talk about this stuff and I’m always worried that I’m going beyond my scope of practice and that a doctor’s going to contradict me, but I tell them anyway. Whether we stop care, I say, continue without the procedure or do the procedure, it is probably going to end. Many people don’t get a chance to decide how they want their last days to go, but you do. It is in your hands now.

We’ve never talked about this before, the husband tells me, because we didn’t want to admit that the end could come. I just thought we’d have more time. I didn’t expect it to happen so soon.

There is a lot of discussion, time passes, and finally they choose to stop. I witness the DNR, put up a pain drip (continuous of 10, morphine!), dope her up with ativan and leave her alone. She sleeps, at last, and her husband is so thankful. I could have reversed her clotting time, replaced her iv’s, done a hundred heoric nursing things and he would not have been half so impressed as he was that I was able to make her sleep. It’s the little things.

I leave that evening and feel as though I’ve done something worthwhile. I listened. I got two people to talk about things they never would have. I helped a woman sleep.

When I come back on Monday, the patient has come back to MICU from the floor. The oncologist convinced them to pursue full care. He’s told them that it isn’t the cancer that is killing her right now, it is her heart and she needs the procedure.

I’d like to strangle the oncologist, but that is outside my scope of practice.

I think the family may be a little perturbed to see me, who had so advocated for comfort care, at the bedside, but if a family has made a decision, I try to support them with all I have. I know that some decisions are agonizing, and families have enough trouble convincing themselves they’ve made the right choice, let alone standing up to a nurse who doesn’t agree with them.

She is again anxious and in pain and confused. She goes to the OR, has the drain placed without complication, and then begins to decompensate when she’s back with me. I up her oxygen and it helps a little. An hour later she is moaning and anxious again, oxygen levels dropping. We give her as much oxygen as we can and I send a blood gas. It isn’t good. I bring it to the doctors. I’ve done my bit, and now they need to decide what to do. The problem isn’t that we can’t do more; we can, it just that she’s going to die no matter what.

At 1800, with the patient getting worse, I demand an answer of Wasim. What are we going to do, stop care or intubate her? If we wait any longer, I’m going to break her ribs with chest compressions. Family doesn’t know which way is up, they keep trying to understand what she was saying even though it doesn’t make sense. (At this point, I start to feel like I’m the only one who actually understands what’s going on; the family thinks she’s lucid, the surgeons are asking questions and not waiting for answers, my doctors are trying to look the other way and pretend the patient doesn’t exist.) So Wasim talks to the husband, gets an answer and we do what we do best. Intervention. A tube is placed and she is on the ventilator, easy breezy beautiful. And then it all goes to hell.

I could relate in technical terms what happens after that, but it doesn’t matter. What matters is that she slides very quickly towards death and despite our best efforts, we cannot stabilize her once she begins her quick decline.  We’ve got three doctors and five nurses in the room. The monitor won’t shut up. Meds are everywhere, xray is at the bedside, we’ve got a code cart out. And the husband pushes his way in and says stop. Just stop.

I wish I would have hugged him.

So what I told him the beginning comes true. She does go on the vent, and she can’t come off. And this is how he has to remember her last day; tumultuous and awful. Full of clinging to hope and finding only despair. The resident keeps running through possible diagnosis; he is torn up that we couldn’t figure it out. I am torn up that we had a bad death. We told them in the beginning (well, I did) she is going to die no matter what we do. And she does die. And it is a bad death and no one is happy.

What I learned from death

What I learned from death

I am an ICU nurse. I work with a team of professionals who are fantastic life savers. But our medical system can incredibly dysfunctional when it comes to death. Like most people, some health care professionals don’t like to discuss death and may view it as a failure. Or perhaps their patients view it as a failure and not an inevitability. It’s a part of life that most people don’t encounter on a weekly basis, a thing from which we distance ourselves and it’s something everyone needs to know more about. After all, everyone will die someday. There is no formula or remedy for death, and there is no preparation on earth that could have prepared me for taking care of someone who was actively dying. Death changed my view on life.

I’m going to call him Mr. Wolf. He taught me what nursing school never could.

He was my patient when I was new to the world of medicine, still trying to put it all together and figure out what it was that I was supposed to be doing. Nursing school does not and cannot prepare new nurses for the reality they face upon graduation; the call lights they don’t have time to answer, the medications they give without having time to look up, dealing with a schizophrenic off of her meds, caring for a prisoner who’s chained to the bed. The floor where I started was busy to a point where nurses ran from it; a typical nurse lasted a year there. As a consequence, my co-workers and I were all new to the world of illness and surgery, life and death. Taking the time to speak to a patient about end of life issues was a luxury I never had.

Mr. Wolf had a cancer in his abdomen for which he’d just undergone a surgery. From what I understood, it was not a curable cancer. I took care of him for two or three days and spared some time to talk to him. I learned he was illiterate, and I got the feeling that he would pretend to understand what doctors told him, nod and scribble on the dotted line.

He lay in his bed, doped up on oxycodone. He had a tube running from his nose emptying his belly contents into a container on the wall. His incision was still fresh. He would not be able to drink even clear liquids for another few days and eating was far away. He needed help to even sit on the side of the bed. In the course of my caring for him, he told me something I don’t think he told anyone else. “I know I’m going to die,” he said,  “I just don’t want it to hurt.”

Why did he tell me this? Why not his daughters who were talking (outside of his hearing and in the conference room) about his poor prognosis, about palliative care at home? He probably thought, and he was right, that they believed they were running the whole show, that what he knew and wanted wasn’t quite as important to them as getting things done. He probably thought I could do something to help him with his wishes.

I flipped through his chart. There was no paperwork about an advance directive or code status, which meant by default, that if he were to arrest, we would have to do everything in our power to save him, going against his wishes. I told the doctor, a first year surgical intern, and she said she’d speak to her chief about filling out DNR paperwork. Nothing was done.

The next day, I saw the team caring for Mr. Wolf leaving the floor. His surgery had been done by the chief of trauma, and I was more than a little intimidated by him. I should have ran down the hall after him. I was 22 and six months a nurse. Surely a trauma surgeon wouldn’t care for my opinion (Years later, said trauma surgeon still knows my name and says hi to me on occasion. He would have listened to me). And Mr. Wolf wasn’t that sick. He was just three days post-operative.  It could wait. So I didn’t pursue the matter, at least not hard enough.

Later that evening, I went into my patent’s room and woke him up to get his vitals. He looked at me. Something was different; he was paler, quieter. “Don’t I know you?” he asked. I’d only been taking care of him for three consecutive 12 hour shifts. I wanted to cry. He was acutely confused and I knew something was wrong. He was going to go bad and now he wouldn’t be able to make his own decisions. He’d lost his say in his care.  I bit my lip and paged the resident.

I don’t know what killed him in the end; if he was bleeding out or septic or if he stroked. What I do know is that the resident came out of the room shaking his head. Something wasn’t right. Mr. Wolf went from OK to bad to worse and in the night was taken up to the ICU and placed on a ventilator, which was exactly what he did not want to happen. What I do know is that I could have prevented this.

His daughters chose to withdraw care a few days later.  If anyone had listened to him or if I’d made anyone listen to me, he could have had a good death. He could have gone home and been in his own bed, said good bye to his daughters and had enough morphine to make him comfortable.

I betrayed my patient. A person only gets one death and not many people get a say in their death. Mr. Wolf told me what he wanted and I failed to help him. It profoundly affected me, that all of those unnecessary interventions were performed on a man who did not want them because I was too shy to advocate for my patient. But I learned. I learned that I care about providing a good death. I learned to be the squeaky wheel. I learned to go against the grain. Because taking care of patients isn’t about following a formula and adhering to a medication regimen and staying on the pathway. It is about doing what is important for a person. Sometimes it’s teaching, or getting them home or setting limits or giving them chemo or pain meds or washing their face. Sometimes it’s being their voice when they can’t or won’t say what they want.  

Happy Nurses’ Week

July 10 will mark my 10th year as a nurse. When I began, I was shy and naive. Now I am already an old nurse, surprised by nothing and filled with battle stories. I’ve spent the last seven years working in a medical ICU, and I’ve seen and done so much. I counseled a bewildered husband on withdrawing care on his cancer stricken wife. I got in a fight with a hematologist who insisted we transfuse a man who kept going into pulmonary edema. I’m convinced my antagonism prevented an intubation. I’ve pushed morphine, and through tears, told a widow-to-be to hold her husband’s hand while he breathed his last. They were both 28.

A few years ago, probably to appease satisfaction scores, my hospital mandated a class in empathy training. We were instructed on how our own empathy fell short, on how we needed to learn to feel what the patient feels.

I can’t possibly feel what the patient feels. If I did, I’d be crippled with grief.

It hurts to be a nurse, especially in ICU or oncology. I remember a woman I cared for years ago who had a head and neck cancer. She was dying and before they withdrew the husband asked for a second opinion. After we took her off the ventilator,  I watched her sons, 6’5” men, weeping at her bedside. Her husband, a diminutive quiet guy, never shed a tear. When I was leaving later that night, I saw the husband standing in the hallway, hunched, expectant, holding a lunch pail, looking for all the world as if her were waiting for a third opinion. I went home, ate dinner and was watching something brainless when suddenly I began to cry. I kept seeing the husband in the hallway, so bereft he couldn’t yet process it. What happens to us, I thought, after we bag the body, clean the room and admit another patient? The wheels of the hospital move on.

Yet through all of these years, I’ve been stoic. I’ve understood that there is a time to live and a time to die, and I’ve considered it a privilege to provide a person with a good death. And  there is a rush to saving a life, an edge to being to intimate with death and so far, I’ve been willing to give up neither of these things.

I may have come to the end of my capacity. A trifecta of patients pushed me to my limits one Sunday.  Number one was a boy with cancer. He was 26. Last year he was healthy and normal and when I met him his lungs were so bad that he had to be pharmaceutically paralyzed to allow the ventilator to do its work. On that Sunday, on my walk in, the hallway was filled with red eyed nurses from the oncology floor who’d come down to check on him. The nurse that had taken care of him yesterday was crying in the breakroom and asking if she could have a different assignment. Lisa never cries, she runs marathons and shrugs things off. The patient’s father paced the hallways.

Patient number two was a middle aged woman with a tumor on her carotid artery. She was demanding and cantankerous and I liked her. She wanted everything done as fast as possible, but I could see through her tough demeanor. She was scared out of her mind. She and her family were given options. Hospice care or a procedure that would cause complications but buy her a few weeks. She chose no more interventions.

I went in to unhook the monitor and disconnect her IV. While I was touching her, she heaved herself upright. I held her while her severed carotid bled. She lost at least a liter of blood in my arms. This is the end I thought. I called for help, but there was nothing to do. I told her family to come in, even though it was horrifying. What if it was her last moment on earth and they were waiting outside the curtain? She stopped bleeding and didn’t die that day.

Patient three was a man in alcohol withdrawal with pneumonia. He ripped off his oxygen and screamed for air. He tried to jump out of bed on unsteady legs. He was verbally abusive and if we hadn’t pinned him down, would have been physically abusive. It isn’t unusual for nurses to deal with physically violent patients; and our administration is very supportive to make sure we don’t get hurt. However. this particular man got to me, with his unpredictable outbursts and I found myself wanting to hit him back. Together with the bloodbath in patient two’s room and the knowledge that patient one was dying, I was a frazzled mess. By the time I got home, I was worn out to the core.

My sister works on the oncology floor. She texted to ask me what was going on with the young boy. The whole floor is a wreck, she said.

When I went to bed that night, I couldn’t sleep. I was nauseated, shaking and crying. I kept thinking about all of the nurses on the oncology floor, trying to take care of other patients through their grief. I kept thinking about the blood spurting out of my patient’s mouth, the sure knowledge that nothing modern medicine had cooked up could save her life. I couldn’t face the thought of going back. I called in and spent the next day on the couch, letting my mind drift.

What about all the other nurses? What about the oncology nurses who couldn’t function? What about Lisa? There’s no acknowledgement that we suffer, that we witness tragedy. We are expected to keeping passing meds, charting and being helpful and positive when we interact with our patients. No taint of another patient’s suffering should mar our demeanor. We are not given a day off to recoup, or even an hour’s break with a cup of coffee. Instead, we are told to be empathetic. To commit to being more involved with our patients so that when they fill out their surveys, they remember the nurses as caring. We are given more charting, more alarms and more demands on our already tightly managed time.

What is the end of all of this? Burnout. Our compassion tanks run dry. We either leave the profession or we become lazy and embittered. This week, while to celebrate nurses’ week, my hospital is giving us badge holders and inviting us to walk the Monday Mile, thank a nurse. If you are in administration, ask yourself if your nurses are burned out. Ask yourself if you could witness death, day in and day out and stay sane. We need to change the expectation that being a part of agonizing loss is normal and give nurses space to grieve.


the truth is the saddest part

The desert’s vastness defies imagination. The screaming blue white sky above, the sharp hills of crunching rock. The distances are illusions. The mountainous horizon taunts him with its seeming proximity, yet it defies him. He cannot reach the end. In dark robes, he bakes.


“Did you hear me?”

“What,” Cody says. He crosses out the last sentence. Sorcerers don’t overheat.

“I said get me my glasses. The nurse left ‘em in my drawer when she got me my dentures.”

Cody moves. In the wan light of a winter sunset, he shuffles away from the curtain, careful not to bump into it. The lady on the other side has something wrong that causes her to cry in pain in a way that Cody can’t forget. He clicks on the light and finds the glasses and watches his mother fumble to put them on. In the harsh fluorescent, her already pale face looks sickly. He sits back down, deliberately, on the notebook. He doesn’t want Mom to ask what he’s writing. He could say a grocery list. She might buy that.

“I think I’m gonna go, Mom,” he says. He rolls up the notebook, shoves it in his cargo pocket.  

Darlene says nothing. She’s flipping through the channels.

He feels the urge to justify himself. “Chris says he’s gonna help me fix the headlight on the truck,” he says, jamming his hands down into the pockets of his jeans. “I’ll be able to visit you in the evening. Like when it’s dark.” He feels the track phone in his pocket, rolls it over and over.

“I should be outta this place soon,” Darlene says. “The food is terrible.”

“Just keep gettin stronger like Dr. Carson said,” Cody says. “Maybe day after tomorrow.” He gives her a hug and gets a faceful of that weird hospital smell.

“This iv bugs me an awful lot,” she says. “Ask them nurses to do something about it.” It’s her way of saying good-bye.

He walks by the lady in pain, careful not to look, and into the hallway. He ambles towards the nurses’ desk.

“Uhh.” He knows they’re not going to take the iv out. Darlene is what they call a hard stick, and he and the nurses know she likes to find something to complain about. She’s just passing the time. “My mom is in 23 and she says her iv hurts.” As soon as he says it, he feels their disdain. Their annoyance is palpable. But Charity, who was working here when he was born, winks at him. “I’ll look into it. You get  home before it gets dark. And get that headlight fixed.”

“Yeah,” he says. “Night.” He turns down the familiar bright hallways toward the doors.

The air is still and cold. He kicks some snow from the wheel flaps before he gets into the truck.


The sun is setting earlier each day and he’s forgotten about that. He crosses his fingers that no tight ass cop is gonna see him and fine him money he doesn’t have for driving with  a headlight out. He trolls. He goes 50 in the 55 zone.

The snow is luminous as the light disappears. Across an empty field to his left, through the tangle of leafless trees, there is an opening. It glows orange. A brush fire, burning down. The last of the sun, reflecting off a cloud near the horizon. A portal into another world.

He fights a sudden strong urge to go see for himself. His own Narnia, maybe. Possibilities open before him.  He sees himself jumping out of the truck and bounding across the field, reaching the portal seconds before it closes, throwing himself through…

He keeps driving, thinking about how wet his feet would get.


Chris, with a pocket knife in his mouth and half his ass hanging out his pants asks him, “What’s wrong with Darlene?”

Cody shrugs. “Her heart’s acting up and she hadda infection in her bladder.” He could say her congestive heart failure was getting worse, but he didn’t want to confuse Jason, who would equate heart failure with heart attack.

“I had one of those UTI’s,” Chris says. “Burned like a son of a bitch.” He squats, considers the light socket in the light of Cody’s flashlight. His breath fogs like a dragon. “You’re a good kid, watching out for her. See now, this isn’t supposed to fit her, but if you wire her like this? See?”

Cody nods, trying to follow. His feet are freezing. He’s thinking about dinner. His stomach rumbles.


In the mobile home, he hangs up his sodden sweatshirt and microwaves a Hungry Man. He considers, and warms up a can of ravioli. He didn’t get lunch today. When Darlene gets home, he’ll go to the store and get some vegetables and stuff and they’ll cook for each other. When he’s alone, he doesn’t really have the heart for it.


Between the elaborate iron scrollwork of the doorframe, the portal glowed orange. He waited, body humming with tension and anticipation. He was ready, but the scars he bore reminded him, told him to wait just one more minute. His arms were folded beneath black robes, pretending placidity, but it was a facade. Everything in him yearned to leave this hell called the dessert.

Then the portal was gold, the yellow gold of sun falling through leafy trees, and he strode through. The dragons awaited him.


It’s exactly 2 am when the phone rings. He only knows this because he’s staring at the phone, trying to remember who set an alarm. What is it he is supposed to do?

He grabs his mental faculties (they’re trying to escape, he thinks) and answers the phone.  


“Cody? It’s Dr. Carson.”

Dr. Carson sounds about as fuzzy as Cody feels. “We need to transfer your mother to a higher level of care.”

“Darlene? Ok. Where is she going?” He rubs his forehead, then sits up on the couch and turns on the light. “Wait, what?”

There follows a technical discussion beyond his 2 am comprehension. Dr. Carson is talking about her lungs and heart and did he say kidneys?  There was never anything wrong with Darlene’s kidneys. Or was there? His mind is with swirling with the tattered remnants of his dream, and his stomach is starting to knot up. He regrets the ravioli.

“Uh, should I come in?” he says when there is silence on the line.

“Mmm, you should probably just go to Upstate. Know where that is?”

His memory traces a foggy line down a map, towards the city. “I can probably find it.”

“Ok then,” Dr. Carson says. He sounds oddly chipper. “I’m sorry about all this. I really hope everything goes well for both of you.”

“Yeah, thanks, good bye.” Cody clicks the little phone shut and sits on the edge of the couch. He tries to get in touch with reality and all its friends; gravity, light and the speed of shock. He tries and fails. He finds himself on his laptop, asking google, please, how do I get to Upstate, and scribbling the directions down in his notebook. His heart is pounding and his hands are sweaty. He remembers to put on pants, frayed jeans still wet around the cuffs and he finds a new sweatshirt, a dryer one than the night before. He kicks off the space heater. Something else, there was something else. He spins around in the trailer, clenching and unclenching his fists. Finally he grabs a granola bar and shoves it in his pocket. In the cupboard, he sees Darlene’s emergency money, and grabs a handful of crumpled ones. Armed with keys, his wallet and his notebook, he sets off into the brave unknown.


Samir stood straight, staring off into the dark rustling trees full of dying leaves. His breath clouded in the air and his piss steamed in the moonlight. He fastened his trousers, gaze still intent on the unknown depths of the Deepning Forest. What watched him from within? What had he avoided, escaping the grasping clutches of its devil trees? More importantly, what had he missed? Was there yet treasure untold therein?

No matter now. He had the relics to save his people. He turned on his heel, away from the trees, into the clear, towards his destiny.


He shivers uncontrollably as he drives south, headlights rolling over empty fields. After ten minutes, he’s finally warmer. His hands are still and white on the steering wheel.


Upstate is cradled in the armpit of two intersecting freeways and thank God there is no traffic at 3 am.  His stomach does a flip when he sees the posted parking rates in the garage; $14 for a day? That’s all of Darlene’s emergency fund. After long consideration, he parks there anyway and wanders towards the bright lights until he finds the main entrance to the hospital. The desk guy gives him a sticker that ABSOLUTELY MUST WEAR AT ALL TIMES, makes a phone call and rattles off directions. Cody clenches his fists in his pockets, relaxes them. Samir is not afraid of the Deepning woods and Kliar fears no dragons. He finds himself in an elevator. He rises.


He finds the right ICU mostly by accident. He’s not sure how he got there. 3 am is an unholy time, full of deception and uncertainty and it should never ever be lit up in this ungodly way. He needs sunglasses. The nurse at the desk is younger than he is and wearing more makeup  than anyone he’s ever seen. Her id tag is clipped at the V in her top and he is disgusted and entranced by the white line of cleavage he can see, even without looking.

“Darlene Prowski?” To Cody’s dismay and delight, she bends over a computer monitor, showing him everything she owns. “Yeah, she’s in 30. Let me see if they’re finished.” She comes out from behind the desk and gestures for Cody to follow. Finished? With what? His apprehension is inseparable from his thrill at walking a few paces behind this extraordinary young woman.

All the rooms have glass walls with curtains. None of them are closed. He sees horrible things; machines invading body orifices, humans caught in silent screams. Darlene won’t be that bad. She couldn’t be.

The hot nurse opens the curtain to room 30. Darlene is bad. She is very very bad.


“You must fight them! This must not come to pass!” The young warrior is so full of passion that his eyes brim with tears, but Samir places a staying hand on his shoulder.

“There is a time for swords and a time for words, my friend.” He rubs the pommel of his longsword, his old friend. This pains him. It pains him for than the others will ever know. “We will make peace with our enemy.”

“They have decimated our homes and burned our crops! They have torn down our wall and taken our children! And you would make peace!” The outcry is tumultuous. He waits for a moment, head bowed in silence, black hair long in need of barbering draping his weary face.

“The cost of war is great,” he says. “It is too great for us to bear. Our people will be extinguished. Therefore, let us take counsel from each other and sit and parley with our enemy.”


They’ve turned down the lights. After a hundred questions he couldn’t really answer, they’ve left him alone. He sits in the corner. Darlene breathes. There are machines at either side of the bed. One he knows is an IV pole, but this one’s bigger and beastlier than he’s ever seen. The other has a bright computer screen and a tube that snakes into Darlene’s mouth. He can’t think right now. He can’t anything. Darlene’s arms are tied down. Every once and awhile she tries to lift one and them seems to find it too great of an effort and drops it. He wants to touch her but he’s afraid the machines will beep and the sharp cool nurses will waltz in and stare at him while they fuss with Darlene. He shivers. His fingers play with the tracphone.


He must have slept, because he dreams. He dreams he’s outside of his body, sort of drifting, unanchored by his dorky glasses and pale awkward belly. He sees his sleeping form, slumped in the chair. Charity and Dr. Carson regard him from the doorway.

“You must be very careful with him,” Dr. Carson says. “There’s no telling what he’ll do. It’s as if someone has literally taken a rug from under him.”

Charity nods sagely, says nothing.

“He might go around the bend. Who knows, he might go off the deep end. He might go bananas.” Dr Carson smiles whistfully as if this prospect excites him somewhat.

Cody awakens with his head propped awkwardly against the wall. There is a blanket over his shoulders and two nurses are in the room. Gray daylight leaks through the blinds.

One of the nurses turns, and smiles at him. She’s not the hot one from last night, but that one sort of made him uncomfortable. “I’m Marlowe,” she says. “I’ll be your Mom’s nurse until seven tonight.”

He nods. He hasn’t thought as far as seven tonight. His tongue is gummy and stuck to the roof of his mouth.

Marlowe smiles at him gently. In her ill-fitting scrubs and with her hair cut too short, she is the most beautiful thing he’s ever seen. “I’m really sorry about all this,” she says. “I know it’s a lot to handle.”

He’s filled with sudden, overwhelming gratitude. It overflows and drips out of his eyes. His head weighs a ton and it falls in his lap. Oh shit. Oh poor Darlene. His shoulders shake. Marlowe touches him gently. He hears her feet leave the room and return. She drops a box of tissues in his lap. “Maybe you should call somebody,” she says. “She have any other family besides you?”


He calls Chris.

“Cheyanne wants to come up too,” Jason says. “But uh, are kids allowed? We got no sitter for them.”

Cody looks at the tubes and machines. He thinks about Gage and Chevy. They love Darlene.

“No,” he says. “No kids allowed.”

“Ok,” says Jason. “Cheyanne! We’ll hafta take turns.” Then he says, “I’ll be up in bit. You need anything?”

Cody knows that no matter what he says, Cheyanne will send up 3 sandwiches and a six pack of pepsi and one of the cousins will send money for parking and someone else will scrounge up gas money. He knows they’ve got nothing and yet when country people are hardest up is when they are the most generous.


Chris stands at the bedside for a long time. He holds Darlene’s hand and says nothing. When he looks at Cody, Cody sees himself from above, like in his dream, sees himself sitting fat and useless, and stupid too. He bites his lip.

“Christ,” Jason says. “I think she did it this time.” He sighs. “What’d the doctors say?”

“I uhh I don’t really know.”

“They talk to you yet?”

Cody shakes his head. If they did, he can’t remember.

Jason punches the call button and after a few minutes, Marlowe comes in.

“Yeah, we need a doctor,” Chris says. “She’s this kid’s mom and we have no idea what in hell is going on. Can you get on that?” Cody dies of embarrassment. He can see the irritation radiating from his new favorite nurse.

Marlowe’s mouth pinches together. She starts to speak and then stops herself. “I’ll work something out for you,” she says.


Sometimes to wait is the most difficult thing. Samir is tense but his body betrays no sign. He alternately leans against the cool stone wall or squats by the fire. The moon is a waxing gibbous, casting cold shadows on the world around him. He has canted the message. The sorcerer will come this night.


The doctor is a short paunchy Indian woman who ends all her sentences with “I think” and never looks Cody in the eye. She uses words like “idiopathic encephalopathy” and “permanent kidney damage”, which she tries to explain, but Chris cuts her off.

“Cody’s not stupid.”

Cody tries to soften it. “I understand what you mean,” he says.

“You have been helping your mother for a long time, I think,” says the doctor. “In this case, she can no longer make decisions for herself, I think. So it is going to be you. I would advise, I think, seeing if there is any improvement in the next three days, but if there is not, then you need to think about would your mother want to be on a ventilator for a long time and would she be ok with being in a nursing home.”  She stares at the wall for a minute. “We will tell you if there is any improvement, but in the meantime, you have to start thinking about what your mother would want. Ok?”

Cody stuffs his hands into his pockets. “Ok,” he says. He hears the doctor’s clicky shoes go out. The ventilator wheezes, clicks and something adjusts.  Chris is studying the whiteboard on the other side of the room intently.

“I gotta go,” he says. “Cheyanne’s gotta go to work.”

“Ask for a parking sticker,” Cody says. “Then you pay less.”

“You want me to come up later?”

Cody shakes his head. He is thinking about the trailer without the funk of Darlene’s cigarettes. He is thinking about silent evenings after work without her weird dating advice, the way she could make food out of nothing. He thinks about funerals and gravestones and the way that words flow into his notebook if he writes while she watches tv.  


Samir waits patiently in the moonlight, still as a stone. The fire has burned to embers, and still he waits.

And then it happens. Reality shimmers. The dark wood before him suddenly seems a mirror, a facade. It ripples. It shatters. And for a moment he sees the truth, he sees what lies beneath. With his own eyes, he beholds black horrors not meant for human vision. He averts, he covers his face, but it is too late; he has already seen.

The dark woods come together again, and before him stands the one for whom he waited. Kliar, the sorcerer.

“Your boots have crossed mountains and deserts, your sword has slain many, and yet you cower at the sight of my homeland.” Kliar’s face is hidden, but Samir can hear the smile in his voice.

Samir holds his head in his hands until the nausea subsides, willing himself to unsee what he saw, and then he unfolds, stands slowly, looks directly at the hooded figure “Your homeland, sorcerer, is not for the eyes of man.”

“Am I not merely a man?” Kliar says.

“Let us not banter,” answers the warrior. “You know what I seek and I fear time is short.”

“Ah, your people.” Kliar speaks as in mockery, but Samir hears true compassion. Or perhaps that is only what he wants to hear.“You would have from me my healing elixir,” murmurs Kliar.

“The moonshadow potion,” Samir says. “To protect the remnants and preserve us.”

“Then there is aught you must do. This one is not easy, and when it is finished, so also is my debt to you.” Kliar looks up at the moon with sightless eyes. “Three days long will be this ritual, and then you will have your elixir.” He tells Samir what he must do.

Cody goes home. He goes to work. He returns. Marlowe isn’t there. Darlene lays beneath the bright lights. They’ve untied her hands. She doesn’t reach up.

There are a few things we can try, the doctor tells him. He signs consent forms, waits in the waiting room while blue sterile drapes and masked doctors surround his mother.

Marlowe comes in on the evening shift. One day at a time, she says, but Cody sees only pity in her eyes. She adds more IV bags and monitors. She is busy and Cody feels bad taking her time away so she can pity him.

He holds Darlene’s hand. It’s so cold, even though Marlowe says she has a fever. Get better, Mom, he thinks. Don’t leave me. Get better.


Beneath cold and glittering stars, Samir is defeated. The horizon glows, but it is not the sunset. The armies and walls have failed. The spells have come to naught. The might of war machines and warriors, of sorcerer and spellbooks have all been useless against his enemy. The city burns. He is alone, an orphan without a people. He drops to his knees, unable to to believe that all that is left is a smited ruin. Stones and embers. All is lost. He holds his head in his hands and at last, he weeps.


A true story

It starts with an uneasy feeling. A flutter, but not in his heart. No anywhere he can put his finger on. The shrapnel in his shoulder migrating, he thinks. He knows this isn’t true. The ache is the same as it’s always been. He bounces up on the balls of his feet, lifts his arms up straight and relaxes. There, again, a flutter. He puts it away in a box in his mind, along with some of his memories from Nam, and goes outside to mow the lawn.

Dale sleeps soundly that night. In the morning, the coffee doesn’t wake him up. He can’t shake the sleepiness. Getting old, he thinks.

By the next day, the sleepiness has progressed to lethargy. He has to stop moving frequently and catch his breath, like he’s just run a 5K. His wife does not notice this because he remains still much of the day, pretending to read. In the afternoon, he tells himself,iIt will be better in the morning. He hates summer afternoons. Something about the harsh angle of the light, the loss of the day’s promise. Summer days are meant to filled and by afternoon, intentions never line up with reality. Tomorrow is already bright with promise, with projects and ideas.

In the morning, he wakes up sharply and sits on the side of the bed. A coughing fit assails him, and by the time he’s done, he’s panting like he’s run a marathon. A serious 26.2. He’s utterly depleted and as he grips the edge of the bed, he’s nearly felled by a wave of dizziness. He waits for the questions and concern from his wife, but he’s forgotten. It’s her day to go in early.

He spends most of the day drowsing uneasily in a recliner. He sends her a text, tells her he’s got a cold. It’s much much worse than that and he knows it. Fear eats away at him, but he needs to get to know this fear, the shape and manner of it, before she meets it. Has to know how he’s going to deal with his own fear before he deals with hers. Because everything is shared. He is unaccountably grateful that she’s kept a little late at work and can go to bed early before she gets home. He feels her settle in beside him and does not think of the blankness he is going to leave her with on his side of the bed.

That night, he tosses and turns with fitful unease, not asleep and yet not awake. he awakens in the black hours of the morning with sharp belly pain. He can’t breathe. God has taken away all the oxygen in the world and they will all suffocate. His bowels spasm and cramp. He stumbles to the bathroom and crouches on the toilet, gasping for air.

When he finally manages to stand up, he sees that the stool in the toilet is black. His vision is black. He’s holding onto the sink for support. “Brenda!” he cries out hoarsely. “Brenda!”

In the emergency room, they have him on oxygen, and he feels unspeakably better. Chipper, in fact. He manages a smile at Brenda. These tired Indian men with unpronounseable last names and assuring intelligence will figure him out and fix him up.  A nurse without a name badge draws blood and puts in two IVs and frowns at the monitor, all without talking to them.

They send him to the ICU, and tell him he’s got a GI bleed, a slow leak in his bowels making his stool black. He’s uneasy again, there’s the flutter. And The Plan keeps changing; a CT scan, no an endoscopy , no just monitor and medicate. If he keeps bleeding, they’ll scope Monday. Why am I bleeding, he wants to know? He’s cold and sweaty and suddenly he can’t breathe. The nurse gives him a mask and he feels better, but he still can’t even sit on the side of the bed to pee without feeling, well, like he just ran a marathon. Or walked the breadth of the Hoh valley. He didn’t know it was possible to be this tired.

His blood counts are all off. Where did his blood go? He didn’t have enough black stool to account for it, and it’s not a dietary deficiency. They give him blood and he’s supposed to feel stronger, but he can’t breathe. They have to keep giving him more air. A nurse frowns at the monitor, smiles at him, and changes out his mask. Each time the flow increases, he knows he’s got less options for when he gets worse.  Brenda smiles and jokes with the nurses and Dale can see how nervous she is. She learning it too, the shape of this fear.

A hematologist comes in, because of the anemia. She is Vietnamese, and Dale has to fight to keep his expression neutral. He can’t put his finger on any particular way he feels about her; it isn’t hate or fear or pity, it just makes him remember things about Vietnam. He hears her voice as if through static, from a mile and a half away. After she leaves, he asks Brenda what she said.

TTP. Thrombotic thrombocytpenic perpura. Could be caused by a hundred and twenty things. He sighs. He is so weary. Only two weeks ago he was weeding the garden, mowing the lawn and remembering what sort of bulbs he already has planted. Now he has a terrible premonition he won’t see spring time. He wonders if Brenda feels this way too but he doesn’t want to ask her.

They treat him for TTP. When will things get better, he asks? No one knows. A week, a month. Hopefully. But why can’t he breathe? If he could just breathe.

In the middle of the night, he wakes up to an elephant on his chest. His breath is short and whistling. He grips the siderails of the bed. His vision is a tunnel, and at the end of the tunnel is the VietCong, and the hematologist. He’s a tunnel rat and the walls are closing in, the ceiling is falling down and the alarms are going off. The tunnel is lit with gaudy daylight suddenly and filled with the sound of voices. He’s been found out. He struggles. He tries to cry out but he can’t even breath. The alarm is shrill and and he gasps and gasps.

Oxygen. There’s a tight mask over his face and blessed cool oxygen pumping into his lungs. If he lays still, he can just about get a breath. His watery vision starts to clarify. Nurses and doctors are gathered around, looking at him, looking at the monitor above his head. He shuts his eyes. He can breathe.

It’s called facial bipap. It’s a tight facemask with a windy airflow that makes him feel like he’s sticking his head out of a car window. It’s his lover and his curse. They are together, he and the bipap, til death do us part. He breathes with it, but woe unto him should he try to part with it! Not for food, conversation or even a sip of water. He’ll pay for this infidelity with paralyzing breathlessness.

This can’t be explained by TTP, so he’s sent off to CT scan.

In the end, it’s cancer. Some silent lung cancer has metastasized to three other places before he even felt that twinge. He rages and cries, but there is nothing to be done against death. He danced and evaded this old enemy during the war, beating the odds, and now it’s come back to claim him. He can’t reconcile with this darkness, this final ending. He grips Brenda’s hand, re-memorizing the familiar lines of her face, the muted light in her eyes. I’m so tired, he tries to tell her. I’m so sorry, he wants to say, that this happened. That I can’t be a cancer survivor for you. That you’ll have to hire someone to mow the lawn and maybe start sleeping on the couch. I’m so sorry to leave you alone.

Brenda holds his hand and sobs as if the world were ending (it is) while he rages and fights even as the morphine eases his tortured breathing and ushers him away from this life.


The Social Worker’s Story

On Tuesday, the social worker is late to work and has to park on the top level of the garage. Instead of the elevator, she takes the stairs down to the bridge which crosses into the hospital and regrets it. She’s feeling fat and old, neither of which are true, but her knees and ankles are already telling her that the heels are a mistake. She has flats in her office, but before she even goes down there, she has to see a few people. The tearful drug addict who needs rehab. The man with no family who needs help at home (that should really be a case management issue). And Manuel.. She’s not thinking about Manuel, not until she has to see him. She has to talk to Manuel’s wife, Alicia. She hasn’t been in yet. Does she even know?

Two hours later, she needs a cigarette and a few excedrin. And a nap. She needs to go boxing. In addition to everything else, she’s had to council two patients trying to leave against medical advice and one of them threatened to hit her. Again sir, she said, I’m just doing my job. I’m required to talk to you, just to make sure you understand the ramifications of leaving.

I’ll give you ramifications, the man yelled, and the social worker left the room. Ostensibly she’s not paid to be abused, but some days, really, she is. And she’s not paid enough, either.

“Am I a terrible person if I hate him for that?” she asks one of the nurses. “Don’t answer that.” She’s still got to see Manuel, but she calls Fiona and they walk across the street to get coffee.

She leans against a warm brick wall in the sunshine. She doesn’t smoke, not offically, but every once in a blue moon, a patient twists her kindness into shrapnel and cuts her and she needs a drag. She thinks about Manuel.

“Jesus, Fiona,” she says. “Some people have all the luck. I mean, this kid left his country, fought in Libya, and he came home alive. Fine. He got married, he’s going to school and now he’s got cancer.”

Fiona drops her cigarette and looks at her watch. In their line of work, exceptional tragedies are everyday realities. “What kind of cancer?” she says.

“I don’t know. I don’t think the docs know,” the social worker says. “The nurses say he screamed when he found out. I mean here is this kid, so tough and so composed and he’s screaming.”

“Why isn’t he on the oncology floor?”

“I don’t know. I’m going to try to move him there today.” She looks up at the sky. “Time to go.”

But when she gets to Manuel’s floor, he’s not there. The bad news is that he’s been moved to the ICU. The even worse news is that it’s her ICU. Somebody hates me, she thinks. Somebody really hates me.

She goes in to meet Alicia.

The social worker is good at what she does. She’s not afraid of verbal abuse, of tense family meetings, of emotional catharsis. She’s probably too good, because she carries these things with her wherever she goes. She once went hiking (that was a bad date) to a place where the ground was all smooth rock, but filled with thin, deep, fissures, and it seemed to her, if one was strong enough, canny enough, one could wrench open those fissure and the earth’s secrets would spill out. People are like that to her. She can find their fissures, open them up. She knows denial, anticipatory grieving, dysfunctional coping, and when she opens a person, like a book, like a crack in the earth, she can help them. She helps them more than they’ll admit and more than she knows. But she can’t crack Alicia.

Manuel’s wife is standing at his bedside, staring down impassively. Manuel himself is beyond caring. A ventilator regulates his breathing and a sedative drips into his veins. Metastatic carcinoma of unknown origin. It’s not testicular and probably not from the colon. An exposure in the military? Or something he’s been keeping, like a dirty secret, a remnant of his impoverished childhood in the slums of San Salvador. Radon-rich groundwater or contaminated air breathed in 15 years ago, manifesting itself today as an orphan maker.

In the stroller, the baby kicks and smiles at the social worker. The social worker cannot help herself. She is delighted. She smiles back. She introduces herself to the baby, whose name by all rights, should be Sunny. She talks to Alicia.

She does all the right things. Introduction, open ended questions, non-judgmental attitude. Leading statements. Alicia answers only yes or no and sometimes she does not answer at all. She’s a well dressed, good looking young woman and she keeps staring at the social worker, as if she’s wondering why the profession exists. As if she’s saying, this is my tragedy. What right to do you have to lay claim to it? Finally, Jessica picks up the baby and turns her back. The interview is over.


Alicia watches the social worker close the door and then rub alcohol gel on her hands. What the hell does she know about Manuel? She allows herself to scowl at the woman’s back. That perfectly thin woman with her life together and her good job, coming to work every day to dissect human agony. Probably eats sorrow for dinner and grief for dessert. When she’s done, crumbs of hopelessness remain on her plate.

Sunny giggles at one of her toys, and chews thoughtfully on her hands. Jessica touches Manuel’s arm. It’s already not the arm, not the body of the man she married. He feels unstable and unanchored, like a strong wind could whisk him off to heaven any moment now. This is what she’ll do. See him as a different person. As the twin he never had.

She won’t see him as the veteran who cried about the children in Soyapango, or the shy boy who proposed to her by whispering in her ear during a late night, half-drunk slow dance when they’d only been dating for two months. She won’t think of him as a frustrated student, struggling with some of the English words, and laughing at himself when he said (his words, not hers) that he sounded like an immigrant.

This man laying in bed, this sick and bloated remnant of a person is not her husband. He’s a brother. She’s looking in on him while Manuel is visiting his mother.


Manuel is 26. He’s getting chemo, but he’s already critically ill. He’s going to die and Alicia is going to lose her husband and the father of her beautiful baby. She sets her face like a flint. She is not going to crack.

Over the next few days, Manuel gets worse. The social worker has a lot of other patients to see, but she always checks in with Alicia. She’s persistent, if not effective. I’m here for you, she says. Alicia smiles that tight little smile. Sunny smiles with her whole body, kicking her legs and laughing.

“My god,” she tells Fiona. “That boy is going to die. He’s going to die and the baby isn’t going to have a father and is Alicia even going to cry? This woman is like made of steel or something. I can’t imagine. I just don’t get it.”

But she does imagine. She imagines Sunny without a father and she feels tears prick the corners of her eyes. It isn’t fair. She gives up smoking again, and goes to boxing. She punches cancer in the face, again and again, but cancer won’t die. Cancer won’t be defeated. It roars back.


In the waiting room, Sunny charms. Other families smile at her and talk to her. They use her as a buffer for their own sorrow, looking into her eyes forgetting for a moment that the world has teeth and it can bite. Alicia doesn’t mind. She’s glad to share. Glad for the distraction. It means she can avoid the pity.

It’s more than the social worker. She’s seeing pity in the eyes of the nurses, the oncologists and she swears the parking garage guy is in the know. All these people wanting to reach out and comfort, so they can forget their own snarled lives and smelly entanglements. She’s just a convenience for them; her tragedy is the gristle of their dinnertime conversation and the meat of their self-avoidance. They can feel bad for her, reach out to her, but she’s not going to help them.

Down the hall, Manuel has taken a turn for the worse. The nurses have asked her to leave for a little bit. There’s blood coming out of his lungs. Alicia stands in the warmth of a sunny window and pushes the stroller back and forth. She needs to find a baby-sitter.


Two weeks after he has been admitted to the ICU and five weeks after he has been diagnosed with cancer, after 25 blood product transfusions, four thousand dollars worth of chemo and several hundred hours of nursing care, Manuel dies. The social worker watches the doctor talk to Alicia and hears the words between them, even though she’s not close enough. She sees Alicia nod, sees her eyes close for a minute and sees the grief etched on her face. For a moment, Alicia cracks.

At the bedside, in a room full of machines and beeps, the nurse sets down a syringe of morphine. This is to help him, she tells Alicia. He’s going to feel like he can’t breathe, and the morphine will help.

Alicia stands in the corner. She knows there’s nothing more they can do, she’s known it for a few days now and she’s not ready for this, but what’s the point in waiting. She’s trying to stay out of the way, but really, she’s scared out of her mind. She tries to put the fear in a box, push it away as the respiratory therapist removes the breathing tube and the nurse turns off the IV pumps and gives the morphine. They seem to certain. How can you be so sure, Alicia screams inside her head. She’s on thin ice, barely intact over a dark and chilly river of doubt.  

Manuel jerks. He coughs and his face turns a horrible color. The nurse turns. She is crying.

“Come hold his hand,” she says. “Come be with him.”

Alicia does. She does not think, does not feel. She takes her mind away to a cold gray place where no smiles or tears exist. She stands biting her lips so hard they bleed while the life slips out of her husband. Manuel coughs and then his breathing slows. There are no last words, no final gaze. This is not how it is on TV.

The social worker sees the nurse come out of the room and close the door. They stand at the desk and watch the monitor as Manuel’s heart slows and stops. She has never seen this nurse cry before, but they are both thinking about Sunny. Who will teach her to ride a bike or walk her down the aisle?

“Why do we do this?” the social worker asks. She does not expect an answer.

The nurse wipes her eyes and blows her nose. “Who else should?” she says. “We did everything. I mean, we couldn’t have done more.”

The social worker nods. She’s going to take this one home; they both will. But they’ve done everything they can. There’s nothing more.

“We all failed,” the social worker says. She thinks of all the failures, and Alicia, standing, cold and remote at her husband’s bedside.  

The nurse wants to tell the social worker that she didn’t fail, helping Alicia get childcare and locating Manuel’s long lost mother. But the nurse’s voice is full of tears and she says nothing.

Alicia leaves. She pulls out of the parking garage and gets on the highway. She makes it to the first exit before the first spasm wrack her body. By the time she reaches an empty parking lot, she barely has control of the car. She jams it into park and curls up in a ball of anguish. She wails. It’s like being possessed by a hurricane. There isn’t enough space in her body for the volume of grief trying to fill it, and yet it grows and grows, this loss this desolation, this utter agony. How can the human heart hold so much pain and go on beating? This is why the Sioux women cut themselves, to bleed out the pain. She wants to slip into a hole and never be seen again. She wants to drive  for hours until she reaches the ocean and drive in. She wants to be alone forever. She grips the steering wheel, beats it, rests her head on it, and grieves.

Sometimes there are no good answers. There aren’t any lights at the end of the tunnel, or happy endings to smile at. Fate is capricious and tragedy is real and cruel and I can testify to this. I was that nurse who stopped the drips and pushed the morphine and told Alicia to hold his hand. I sat in the back room afterward and cried. In telling Alicia’s story, I want a moral to it, something good to hang onto, but there is nothing. This is what happened. It was not an everyday tragedy; it was extraordinary, and yet Alicia, the social worker and I, we bear no scars. Maybe I am feeding off her grief, thanking God that it is not my own. The social worker and the doctors and I see so many cases where illness and tragedy could have been forestalled if a person had been more careful or come to follow up appointments, but here, nothing could have been changed. It happened and its ending was foretold as soon as it began.