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Life and death on an eight-hour shift

Nurse's log

I start taking vital signs on all my patients, which sounds simple enough, except when you’re dealing with a patient like Mrs. Nidy, who is uncooperative, or Mr. Ustoy, who can’t hold a thermometer in his mouth.
  • I start taking vital signs on all my patients, which sounds simple enough, except when you’re dealing with a patient like Mrs. Nidy, who is uncooperative, or Mr. Ustoy, who can’t hold a thermometer in his mouth.
  • Image by Tom Voss

1500

I am sitting in the nurses’ conference room, about to take my assignment for the evening. This afternoon we are short one R.N., and the remaining five of us have to absorb the extra workload, since we’ve not been guaranteed replacement. While I wait, I scan the bulletin board for messages and hospital news. The only significant bit of information is an announcement that because of hospital budget cuts, we have to empty trashcans in the patients’ rooms at the end of the shift. Great! Do I look like a bag lady?

I have inherited Mrs. Trager in Room 552, over and above the six patients I normally care for. She is eighty-nine and has been comatose for some weeks. She is a “no code,” which means that her family has stipulated there will be no CPR when her heart stops. She has a diagnosis a paragraph long, and we have kept up a level of life support based strictly on what is humane: we turn her in order to prevent bed sores; we keep up her nutritional and fluid levels by way of nasogastric tube feeding and intravenous therapy; we support her breathing with oxygen. Just now, while I am adjusting Mr. Ellington’s I.V., the day nurse announces that Mrs. Trager has stopped breathing and that there is no heartbeat. Do I detect a sense of relief in her voice, or am I projecting my own ambiguous feelings? Relief because Mrs. Trager no longer has to suffer the humiliation of a disinherited body from which (philosophically speaking) the spirit must have fled a long time ago. Relief also because caring for her has become such a routine that I have to remind myself that she is, after all, still a person.

The nursing coordinator tells me I must inform Mrs. Trager’s next of kin, as well as Dr. North, our house physician, whose duty it is to pronounce her dead. What to do first? I still haven’t had report on the other six patients, three of whom are critically ill. Postponing their treatments, some of which are due within the hour, is going to put me behind for the rest of the evening. On the other hand, calling Mrs. Trager’s next of kin might mean that one of them may come before then. She hasn’t been pronounced dead yet; the physician is currently tied up in the emergency room. The problem is, I can’t touch her, move her, or clean her up until he comes.

All right, leave her tubes intact, oxygen still wheezing into a system no longer responsive. Shut off the feeding pump. Any fluid pumped into her stomach at this point is counterproductive, even if her vital functions should, by some miracle, be restored. Close the door. Put up a No Visitors sign so no one will accidentally enter. Call the next of kin.

Mrs. Trager’s next of kin is a niece; she accepts the news calmly and says she’ll come by after work. Good. I have an hour to get started on my chores.

My patients today are on the lower half of the right corridor of the fifth floor; the upper half of the hall is Natalie’s. When it comes to lifting and turning the patients, we band together. We also relieve each other for dinner breaks.

Letitia, the day nurse, finally gives me report: Room 546. Mr. Ellington, pneumonia and asthma-related breathing problems. He’s a cocaine addict and smokes two packs of cigarettes a day. When I was in his room earlier, he demanded that I take out the I.V. He is verbally abusive and bad-tempered.

Room 547: Mrs. Williams, age ninety-four, has a long history of diabetes mellitus. She is currently in for anemia and is scheduled for a barium swallow tomorrow to determine if she has a bleeding ulcer. She is scheduled to receive one more unit of blood tonight.

Room 548: Mrs. Jones, who is eighty-four, suffers from recent weight loss, anorexia, and hypothermia.

Room 549: Mr. Johnson, age forty-one, cirrhosis of the liver, kidney failure related to alcohol abuse. Since admission, he has developed a tolerance for Demerol. His condition has deteriorated since yesterday, and his physician is aware of it.

Room 550: Aurelius Ustoy, age eight-six, right-sided paralysis since his stroke a year ago, dehydration, diabetes mellitus, and weakness.

Room 551: Mrs. Nidy, electrolyte imbalance, contractures, recent change in mental status. She was transferred here from a local nursing home. Her bedsores speak for themselves.

Room 552: Mrs. Trager.

Assessing the acuity of my patients, all but two of whom have I.V.s, I calculate that at least one or two of the I.V.s will malfunction in the course of the evening and have to be restarted.

Don’t be so negative, maybe you ’ll get lucky.

1600

I start taking vital signs on all my patients, which sounds simple enough, except when you’re dealing with a patient like Mrs. Nidy, who is uncooperative, or Mr. Ustoy, who can’t hold a thermometer in his mouth and you need help to turn him and take his temperature rectally.

1630

Dr. North arrives to pronounce Mrs. Trager dead. I’m glad I got a head start on the other patients; now I have to get on with cleaning her up. The most frustrating thing is to receive a call through the intercom saying that so-and-so needs a bedpan, while you’re trying to give a patient your undivided attention.

Please, let them be quiet for a half-hour.

While Dr. North is in the room, I am calm and disinterested. After all, Mrs. Trager has been “dead” long enough that this procedure is only a kind of formality, right? But then Dr. North leaves and closes the door behind him. All right. This is the moment.

We rush toward our deaths as surely as rivers to the sea, evolving inevitably toward the fearful disintegration of all mortal flesh. It consumes us in the end and paints our skin a macabre green. It is merely the color of skin not oxygenated. Why can’t I be objective? I have put pets to sleep and taught my children that death is not angry or vengeful. Birds, particularly the sea gulls, doves, and sparrows found dying on the beach near our house, have never elicited a sense of horror in me. They close their eyes and give up their spirits. By no accident do they symbolize the soul. But you just put them in a shoe box and bury them.

Mrs. Trager, you are different.

Why haven’t I thought of your first name before?

I pick up her left wrist and read the ID bracelet.

Your name is Aimee. The Beloved.

I study her features. She is very small, almost birdlike: a sharp nose; small, close-set eyes; a tiny round mouth; and tufts of gray hair that give her head the appearance of a fledgling bird’s before adult feathers grow in.

I try to remember my prayers from catechism, but nothing comes. Was it so long ago that I was a fearful child reciting memorized prayers?

Our Heavenly Father, take this soul.... No.

Dear Lord, accept this sinner.... Try again.

Dear Aimee, I hope you walk in a green place where there are flowers and music and laughter. I hope that you have a crown of roses in your hair and that your hair will be the color of dark honey.

Our belief in an afterlife is most likely tied to a wish — the wish to be eternally young.

Just then the floor secretary walks in.

Bless you, Cindy, and please don’t leave. I need you to be here.

Cindy is wonderful; she is slightly acid-tongued and can start an I.V. when no one else can. She is an L.V.N. who occasionally agrees to be our desk clerk when the regular is off-duty.

The procedure for post mortem care is to wrap the body into a shroud. Cindy has the shroud, acquired from central supply. We take it out of the plastic wrap — only to find that it is just another plastic wrap. Cindy gives voice to my sentiment: “What a way to step off this planet, in Saran Wrap.”

Aimee, your funerary trousseau consists of a frayed pink bathrobe and tattered slippers — and a ring on your finger. I will leave the ring there. Perhaps your love from long ago will recognize it.

1700

Back to the living. Mr. Ellington is making a loud noise. He has decided he is going to sign himself out, against doctor’s advice. I have barely managed to pass out all the medications, and when I walk into his room, he grins and holds his I.V. tubes, disconnected, in his hand. I guess I lost that round, and I don’t even argue with his insistence that it was “an accident.” But he has also cut himself off from the medication that counteracts his wheezing, and I can hear it across the room! Oxygen is running, although he is not using it, and I can smell the odor of a recently smoked cigarette. I’ll have to call security and have them deal with the cigarette problem. Ellington is potentially combative.

So. Turn off the oxygen for the time being, call security and his doctor for further orders. I really don’t like you, Mr. Ellington.

At the nurses’ station, I ask Cindy to call Dr. Lopez, who responds immediately and substitutes medication that can be taken by mouth. I also call security and the lab (results are now in on two of my other patients), as well as the pharmacy for Mr. Ellington’s new order. I might as well pick up enough linen and supplies to change a few sheets; he has dribbled blood all over the floor, on the bed, and on his gown.

1800

Dinner trays are brought up on a metal cart, and the nurses are expected to pass them out. Do I look like a waitress? At this time, I’m grateful for family members to visit. All of Mr. Ustoy’s relatives show up, as usual. I have counted as many as sixteen members and four generations crowding around his bed and spilling into the hallway. It’s hard to administer treatment while sixteen pairs of eyes are watching, but on a certain level, I want them to witness the sputtering and coughing fits that accompany passing a suctioning tube into his throat. Better to do it with them there than to face his quiet resignation alone.

I leave the feeding of Mr. Ustoy to his daughters. Lately he has refused food; swallowing is simply too tiring. They manage to get a spoonful of applesauce into his mouth after much prodding, and he’ll swallow it to be polite. Then he will start to choke again, and I have to suction the food out of his throat.

You’re fine, Aurelius Ustoy. Don’t feed him for a while, Amanda. He’s old and tired. I know you want to do something; love is supposed to have deeds. But please don’t do anything right now. Just sit there and knit.

I check in on Eugene Johnson. As I walk into his room, I see him in a knee-chest position, rocking back and forth in order to get relief from his cirrhotic liver. He shifts to his side and asks if his Demerol is due.

Right away, Eugene, even though I know it isn’t due for another fifteen minutes. How do you argue with a man in this much pain?

Lately he has taken to curling his lips back and exposing his gums. Then he will grind his teeth and let out sonorous moans. It makes me think of the expression a wild animal might have that had caught its foot in a trap.

His tray is untouched. He has lost interest in food. When he first came here, he looked like one of those Masai warriors I’ve seen in National Geographic: lean, almost gaunt, and tall, with an elegant neck and aquiline profile. Only his hollow eyes and protruding abdomen gave him away. He must know he is dying because he never asks for anything except Demerol.

I go in search of his medication and see Mrs. Williams ambling down the hall with her hospital gown gaping open in the back. She is sweet but gets confused after her daughter’s visits. I walk her back to her room and strap her into bed.

When I return to Mr. Johnson, a curious thing happens. He places my hand on his forearm, where a previous I.V. had infiltrated because he thrashes around so much. The site is ugly and swollen. And then, his moaning stops. So now I know what it is to heal by the positioning of hands; it has to do with the belief that those hands can heal. Mine are unnaturally cold.

Mrs. Nidy still needs to be fed. She is no trouble and eats voraciously and noisily, and as long as you fill her mouth, she’ll swallow. Her tray is polished clean in seven minutes. Time to clear all the other trays as well.

1900

Natalie, my companion nurse, asks if I’m going on my break, which on this floor is a joke. To my knowledge, no nurse here takes her allotted half-hour to sit down. I heat up my soup, but just then, the coordinator nurse corners me to discuss a specimen-collection technique. I bite into an apple, being deliberately noisy. Maybe she has gotten the message; at least her talk is brief.

Two other nurses join me; they are both Filipino, and their husbands have delivered dinners of steamed rice and fish. I accept a few bites when they offer. Dinner is not a time for heavy talk. One of them wonders if I have an accent. “No,” I answer, “I don’t. All the time, I thought you had an accent.” We laugh, and it occurs to me that I am the minority in this hospital. I am surrounded by Hispanics, blacks, and Filipinos. I love it.

1920

Time to take vital signs and get the next round of medications set up. Mrs. Williams’s blood is ready to be picked up from the blood bank, too.

I haven’t checked on Mrs. Jones yet. She is here because concerned neighbors were worried about her. Old people who live alone tend to neglect themselves, especially after a spouse has died. They forget to eat. She is sweet and very fragile, and she is the least trouble tonight — all the more reason to spend ten minutes with her, adjusting the pillows, straightening out the bed, encouraging her to have a late-night snack.

Mr. Ellington is furious. He’s just been talked to about the dangers of smoking in the presence of running oxygen. Fortunately, he’s out of cigarettes, but he’s demanding more and is ready to “blow this joint up.” His room, too, is a mess: remnants of food, spilled ashes, cigarette butts on the sheets.

I have developed a smoldering resentment for this man.

2030

For the next hour and a half, I pass out medications, write notes on the patients’ charts, tally up I.V. fluid intakes, empty urine bags, document the medications that have been administered. I turn Mrs. Nidy and Mr. Ustoy, who has required more throat suctioning. Mrs. Williams’s blood transfusion isn’t running as quickly as it should because she has taken several trips to the bathroom.

2100

I am trying not to hear Eugene Johnson’s moans. The doctor is in his room. Eugene has not put out any urine in two shifts, and I will have to catheterize him and give him an enema. He tolerates the former but absolutely refuses the enema. There was a time when doctor’s orders were law, but things have changed, and I respect Eugene’s refusal. He is due for another Demerol injection, and I hope it will calm him down so I can finish my charts.

2310

Joyce, the night nurse who will relieve me, is ready to report, and we walk from door to door, the patients’ profiles on a rolling cart in front of us: Room 546, Mr. Ellington, I.V.s discontinued, tolerating oral medications, still wheezing.

Room 547: Mrs. Williams. The blood is not yet infused, and Louise acts as if I left her the unfinished transfusion on purpose.

Room 548: Mrs. Jones is sleeping soundly.

Room 549: Eugene Johnson — by far the sickest person on this shift. We check his I.V., which has again infiltrated. Since even 11:00, his condition has deteriorated markedly. He is barely breathing, and his blood pressure has dropped to 60/30. The random thrashing of his arms and legs has stopped. A scream is frozen on his mouth, but there is no sound. We wonder why the doctor hasn’t transferred him to ICU; and we can’t transfer him without a written order. Joyce calls the doctor, who orders the transfer, and I try to restart the I.V. and roll a crash cart to his door. We’re ready to perform CPR but hope he’ll survive the trip to Intensive Care.

2340

By now, Mr. Ustoy’s visitors number only five, and they have something to tell me. The daughters want their father to die naturally, another “no code.” I call the doctor for consent, and when it is given, they head out toward the elevator.

Bless their hearts. We have a right to die with dignity. If relatives could witness the violence and trauma that accompanies CPR, especially on an old and fragile body — and what for? To prolong life for another day or week.

Two people, separated by a wall between two rooms, live out their lives, yet they are light years apart. Aurelius Ustoy, the patriarch surrounded by loving, crying women, belongs to another century. Eugene Johnson belongs to our age. As far as I know, he hasn’t had a single visitor, and his loneliness is the counterpoint to Mr. Ustoy’s large family. Yet there is something ennobling about him facing a death that is not dressed up as an event.

Is there a proper way to die?

The night nurse returns from ICU. A final check. Mr. Ustoy: status quo, no code. Mrs. Nidy: asleep, no problem. Mrs. Trager: her room is empty.

2345

The thirty-minute drive home is the necessary transition between two worlds: the hospital and my cozy house at the beach. Along the way, I think of the things left undone. I forgot to sign off the death document on Mrs. Trager. I forgot to chart the last blood pressure on Mrs. Williams. I forgot to empty the trashcans....

The house is an oasis of silence and darkness. Above is a sky like a huge cathedral dome studded with stars. Our cat jumps over the gate when she hears the key turn in the lock; she weaves past me up the stairs. This is our nightly ritual.

And I have only one thought, to curl around my husband’s body and stay still for a long time.

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