The homeless alcoholic with withdrawal seizures

You don’t know what they can do to you. You don’t know until you’ve been on the outs, in the cold weary weather where even the other bums turn the shoulder and the salvation army bed starts reeking of piss and self-righteousness so bad you think you’re gonna get religion if you stay there. The religious ones are the worst, I mean the absolute shits. The crazy crazy bums who got religion and who moon around talking about God and the stars and the prophecies they come to fulfill, and then the religious helpers. They do it all in Jesus’ name. Ask in My Name, He said, well then then why the hell didn’t I get a beer when I asked? And a nice house and a hot wife? Or even a spot under the bridge out of the rain? And they show up on Thanksgiving and Christmas, these meek fat white people, ladling out soup and pity, well they smell so goddam good because they got showers in their houses and if I didn’t have to wear everything just to stay warm, I’d wash my clothes every once in awhile too.

Then there’s that other thing he said. Jesus. The poor you will have with you always. Ain’t that the truth. As long as there’s shitheels, there’s gotta be people to be the turds. And won’t nobody turn their head and look twice if you’re cold and hungry or need smoke, but they get you in the hospital and its all you can do to get away. We have to make sure you’re stable, they say. I ain’t been stable for 14 years, and you’re gonna fix that with IVs and a heart monitor? Like hell.

You don’t even know what they can do. They can tie you down and shoot you up and not even read your Miranda. You say one thing about leaving the goddam hospital and that little nurse so tiny you could break her in half says, well, I’ll call the cops. She will too. Cops’ll hold you down and it’s all good with the law. I don’t even think they make laws about the hospital.

Three times I woke up with a tube in my mouth and almost choked to death. That 19 year old doctor told me I had seizures. Bullshit. I never had no seizures. Not me, not never. They just wanted to clear me offa the street and when I said no, I’m good on the street they beat me up. Got the scars to prove it. Course it’s my word against theirs, those blue shirts. Those tough guys with their big bellies and their scissors, ruining all my clothes, shooting me up and putting me to sleep. Then I wake up and they tell me I had seizures.

It’s a warm place to sleep, though. There’s food. But they don’t give you no choice, that’s what gets me. And when I’m done sitting inside, laying in bed like a lazy bones, I gotta be out on my own terms. Back to my turf. Back to my place. Cuz you don’t know the things they can do to you.

I know it’s cold outside. I know the places where the rain falls sideways and the snow’ll be your blanket when you wake up in the morning, if you wake up, and I know the reek of desperation. It’s inhospitable. Ain’t that a two dollar word. But at least it’s not hospital. The hospital’s warm and dry and the meals come regular but when I gets to feeling restless, start to missing the love of my life and my constant mistress, the bottle of Grants I left in the pile of gravel at the corner of State Street, I can’t get out. It ain’t a hospital, it’s a goddam prison. I can’t help it that I said f- you to the nurse and I dumped everything offa the table onto the floor and it made such a noise, I needed out, and then the guards came and yelled at me, and I heard the little nurse bitching about next time he has a seizure, he should make sure he has it where no one will find him. You’re welcome for saving your life! Well the problem is I didn’t have no goddam seizure, I got beat up by the cops what didn’t want me on the street. Cleaning up for some operation, something they didn’t want no witness to.

I’m back outside now. Frozen and free. I gotta hot date with a lady who warms me up like no other. Left her hidden on the corner of State Street.

Shirley

(This is a true story. Details that would reveal patient identity have been changed,  to protect patients and to comply with HIPPAA.)

Inside the hospital walls,we still have the lights off, as night pales to gray dawn. In the outside world, alarms clocks go off and normal people start their morning. The day shift will be leaving their houses, and soon I can go home. Salvation is at hand. It’s been a busy night, but not a memorable one in the medical ICU. Not one of those nights that it occurs to you at 3 am that you haven’t peed in more than eight hours and you probably can’t slow down and go now. But it’s been busy enough and we’re ready to go home in an hour. Until there’s a rapid response down the hall and the swat nurse asks if he can just bring the patient right now because she looks really bad. Ok, I say, bring her up.

I log into the computer to see what’s coming our way. “Oh no. Avery, Mrs. Rivers is coming back.”

Avery looks puzzled for a moment and then his face opens up. “Shirley!” he says. “Oh God, what’s wrong with Shirley this time?”

I shrug. Mrs. Rivers’ name is not Shirley, but Avery has a particular way of getting close to patients, close enough that he can do things like call them by the wrong name, and they think it’s funny. He helped me out with Shirley last week when her frail heart was racing and her blood pressure was dropping. “She’s back for more of the same,” I say. “Her blood pressure is 50/20, o2 sats are low and they want to try bipap.”

“She’s a DNI,” I tell Teresa, the nurse who’ll be taking Shirley. “She did it herself. Said no vent, but want compressions. She said she’s had them before and they work.”

Teresa rolls her eyes. She’s hanging IV tubing in the patient’s room. “Well, we won’t be doing compressions. We got 1 hour til day shift gets here.”

When Shirley comes, she’s lost in white blankets in the bed. She’s frail, she weighs all of 90 pounds. We put her on our monitor, put her on bipap. Her blood pressure reads 45 over nothing, and she’s completely unresponsive.  Teresa touches her neck. “Do you feel a pulse? I don’t feel a pulse.” A few others reach down, touch the tiny old woman’s neck, wrist, groin. Heads shake. We look at each other.

Shirley, before she was unresponsive, made two things very clear. She never wanted to be on a ventilator, and, if her heart stopped, she wanted chest compressions to restart it. Unfortunately, the doctor who signed this paper work with her did not explain that it is extraordinarily difficult, sometimes impossible to bring back a stopped heart without the presence of an artificial airway and mechanical ventilation. If Shirley had wanted neither, we would have held her hand and let her die in peace. If she had wanted both, we would have called anesthesia, put in an airway, and done everything to stabilize her. But as it was, as we stood there looking at each other, and  in that moment of silence, we knew we were going to break her ribs and we knew she was going to die.

“Start compressions,” the doctor says. One of the nurses goes for the code cart. I delegate; you’re going to push meds, you’re going to draw them up, you’re going to record. In the middle of it all, Teresa is pushing on Shirley’s emaciated thorax, tears running down her face. I know with every compression she can feel the ribs pop as they break and then the chest feels all wobbly because the rib cage is falling apart. “This is criminal,” she says. But she keeps going.

After a few rounds of epinephrine, we get a pulse back. But there’s no question of bringing Shirley back. She’s too far gone. The resident, for some asinine reason, orders fluid boluses, blood cultures, a stat echo-cardiogram and an chest xray on a woman who is virtually dead. Poor Shirley. None of it will help her. Of her six children, none of them has a working phone number. Her husband must have passed years ago and she has no friends or siblings that we’ve been able to reach. In the clear light of day, two attending physicians make the case for futility (this almost never happens) and do not escalate care. Shirley dies.

But Shirley does not die alone. There is a nurse there. We were with her to change her name and make her laugh, to tempt her with food when she wouldn’t eat, to help her out of bed. We were there to try to save her life and we were there when it ended. This then, is nursing. It is science, paperwork, and heavy lifting but as Peggy Anderson wrote in 1978, it is about caring for other humans. This is the place where I never thought I’d be, never wanted to be, but now I can’t imagine being anywhere else.  Nursing is not glamorous. It is messy and sad and awful, and it is uplifting and renewing and amazing. It is the science of disease management and prevention and the art of intervening in the human response to suffering. It is being able to give the right medications at the right time and knowing their purpose and side effects, but it is also how to approach the patient getting the meds, and how to teach him what he doesn’t know and how to make him smile. The profession is difficult to define; nurses write volumes trying. No other discipline so skillfully blends compassion and science, or mixes so well rigid policies with creativity. On the job, we hold lives in our hands and at the end of the day, we clock out like everyone else. We work with high stakes and drama, with monotone reality and with the heartbreaking agony of everyday pain and sorrow. I never thought I’d be here and today I can’t imagine myself anywhere else.

The Hero

David is 38 years old. He has been a nurse long enough that almost nothing makes him gag anymore, but not long enough that he is annoyed if he misses lunch because of a cardiac arrest. In his mind, full of logic and order and straight lines, this is a not very precise measurement, but he understands that if he reaches the point where he’s doing CPR and wishing the patient could have waited until after he ate, then he’s been a nurse for a very long time.

On an average day doing charge on A6, David  answers 32 phone calls, starts seven IVs and corrects four mistakes made by new nurses. He hangs eight new bags of IV fluid, questions fifteen new md orders, discharges four patients and admits five new ones. He helps eight people to the bathroom, cleans up six dirty beds and helps other nurses and tech to lift or reposition a total of one ton of human flesh. He clocks between three and seven miles on his fitbit. When he gets home at night, he lays on the couch and stares at the ceiling. Some days A6 is more work than the Air Force.

He likes it, though. Likes that he knows the answers, he can assist and correct, likes the way illness and disability don’t faze him anymore, because there’s something he can do. And he likes the way he moves. In a place where walking down the hall is a feat and so many are hampered by stiff knees, disease and extra weight, he walks easily, for hours, his body still lean and strong from years in the service, a lodestone of order and sanity in his cluttered and chaotic environment.

On Tuesday morning, after switching the assignment twice (the pregnant nurse can’t take the chemo patient and the patient in 20 door is suddenly refusing male RNs) David illegally eats a cliff bar in the med room.

Three call lights are going off. One will be 20 door, asking to page the doctor about her change in morphine dose. 16 door is probably ready to come off the bedpan and other, well, it could be anybody. He swallows his cliff bar and thinks he’ll make a break for his water bottle in the break room but as soon as he steps out of the med room, he is confronted by middle-aged man in a Vietnam hat.

“You know what’s going on with my wife?” he says.

“Who is your wife, sir?” His mouth is dry. 15 steps and he can grab his water.

“I’m Howie. My wife is Beatrice.” The man gestures towards 18. “She’s been here for a week and can’t nobody tell me what’s wrong. You doctors just sit around with your thumbs up your ass all day or something?”

David is thinking about Beatrice. He’s been hearing her rattling cough and raspy voice much longer than a week, and he’s pretty sure she’s dying. Then he realizes the man’s mistake. “Howie, I’m not a doctor, but I can page one for you.”

Howie peers at David’s name tag. “Oh,” he says. “What’d you become a male nurse for?” He looks David up and down. “You a homo?”

At the desk, the phone is ringing. There is no secretary today. The nursing tech hurries by, laden with linens. David bites back three ridiculous answers. “I’m not a homo.”

“Hmph,” says Howie. He looks at David’s ringless fingers. “You ever been married?”

David is puzzled now. “I was.”

“Ha! Wish I could say was. Damn woman is a pain in the ass.” He scratches his head beneath his hat. “Nevva mind callin a doc for me. They’re just gonna tell me the same stuff.” He glances towards his wife’s room. “I just thought you was a doctor and maybe…” His sentence hangs, fractured.

David lays a quick hand on the man’s shoulder goes for the phone. It is his manager, reminding him that the staff have mandatory empathy training over the next two days.  Ok, he says, while scrolling through Beatrice’s chart. Chronic diastolic heart failure, non-resectable lung tumor, unstaged, history of smoking, DNR. He was willing to bet Howie knew all that stuff, and Beatrice did too. Sometimes people want a different answer.

 

At 3pm, staffing changes. He’s down a nurse and the supervisor is sympathetic, but sympathetic doesn’t help do discharge paperwork and turn total care patients. She sends him an LPN and he feels obligated to thank her even though that means he’ll have to look out for the LPN’s patients. At 330, the girl in 20 door has screaming meltdown because she’s in horrible pain and the pills aren’t cutting it. 16 window was all set to go home and then his discharge got cancelled because his insurance wouldn’t pay for a critical medication. A new patient arrives in 8 in from ED and when she arrives, her blood pressure is 65/40, confirmed, thank you and and it takes an hour to get her transferred to the ICU.

At 530, he finally checks on his patients. The LPN (who would think about lunch while doing CPR) gives him an update, he thanks her, and says hi to all of them. This is a little hazardous because there’s a pretty high chance that one of them will want something that will either be impossible or take a half an hour. But the LPN is good, she knows her stuff, and his patients are well cared for. He checks on Beatrice last.

As soon as he opens the door, he knows his mistake. There’s no rattling cough or raspy voice, and the room feels empty. He steps around the curtain. She lays alone in a quiet room. The light above her head is like a halo. He gets that queer dizzy feeling like the world is shaking a little beneath him. He knows what he will find, but he touches her anyway. There is no pulse at her wrist, her skin is waxy and cooling and the DNR bracelet confirms that his work with her is finished. If I checked on her earlier, he thinks, this might be different. But would it have? Was there anything else he could have done?

He hears a shuffle step behind him. Shit. He turns, and imagines how he must look to Howie. The male nurse, the potential homo, holding Howie’s wife’s dead hand, confirming her non-existence.

The man sits down heavily in a chair at the foot of the bed.

“Howie,” David says.

Howie grunts. His knuckles are tight, squeezing and releasing his legs. Men of that generation do not  cry, nor do they show emotion. David slowly places the dead woman’s hand on her chest and walks to Howie. He squats next to the chair and touches Howie. The man stiffens and then grips the nurse’s hand tightly. They both look at Beatrice, beatific beneath the lone fluorescent light. Howie shudders and his head drops to his chest.

In a few moments, David will step out of this sacred moment and into the bright chaos. He will call the supervisor to let her know 18 window has passed. He will help bag the body and send her to the morgue. He will answer more phone calls and call lights, manage the assignment for the night shift. But right now, there is nothing more he can do. He is thinking about Howie, and that both of them will, tonight, be home alone. He is thinking about how, because he is a nurse, it is ok for him to hold hands with a complete stranger, and share sorrow.  He is thinking about how it is not that he is a nurse and Howie a client, but that they are two human beings, grieving together for the beautiful temporary blink that is human existence.

An RN, unintentionally

“You take your material where you can find it, which is in your life, at the intersection of past and present. The memory traffic feeds into a rotary up on your head where is goes in circles for a while, then pretty soon imagination flows in and the traffic merges and shoots off in down a thousand different streets. As a writer, all you can do is pick a street and go for the ride, putting down things as they come at you. That’s the real obsession. All those stories.”

-Tim O’Brien, The Things They Carried

What I have found in nursing, is that there are stories everywhere and I can’t not write them down. Medicine is drama unscripted and I, at the bedside in the hospital, am the unprepared audience or an unrehearsed player. I never know when a normal day, a normal situation can spiral towards disaster or evolve into a miracle. I often feel like a voyeur, knowing the intimate details of my patients’ bodies and maladies, their family secrets and tragedies, and also the function and dysfunction the world’s most expensive health care system. Miracles, tragedies, extraordinary people, extraordinary odds, even the mundanities. Each time I’m certain I’ve seen it all, something new happens. I’ll never have seen it all.

I don’t understand why more nurses don’t write. The professions lends itself to the telling of tales but it usually stops with gossip in the back room, or those stories that start with “This one time…”. For myself, I can’t comprehend how the extremes we undergo become normal to us. That’s really what I’m trying to work through. It doesn’t matter how my times we try to resuscitate a man who will die despite our trying, I rage against the trying. Each time I take away life support or roll a patient to the morgue, I’m struck by the brazenness of I’m doing.  How can I counsel and comfort an anguished husband who is going to stop treatment on his wife? Since when am I, a human being, qualified to prolong a life or aid in a peaceful death? When I help a family navigate a difficult situation, I think, this is my job, and this is their life. How can I walk into this drama, partake, and go home? The moment that will scar this patient forever is merely what I’m getting paid to do.