“Patient assignments are on the charge board,” my preceptor chirped, “and you got a tough one!”
Dread. There were only two days of clinical left and I couldn’t wait to tick each one off the calendar. One obligation over. Final exams were looming, and I just needed to get through the next six hours so I could study. The dread deepened as I scrolled through pages and pages of notes. He was here for another amputation on his leg after a long history with uncontrolled diabetes. A visiting nurse had reported that his apartment revealed “possible hoarding.” I imagined a dark place full of old newspapers and cigarette smoke. He had come in to the hospital at 324 pounds. He had lost 78. I wondered how much legs weigh.
His nurse blew into the charting room. “Hey, kid. You got Mr. W? He needs his vitals and we’re in a fight. He won’t let me in the room anymore. Let’s send in the fresh meat, shall we?” I knew which room it was already. There were loud, beefy groans emanating from room 116. I tried to muster my best cheery nursing student facade, but it was a weak try.
A messy shock of white hair greeted me as I entered. He was a big man, but it wasn’t just flesh. His features were large, his head was large, his hands were large. His skin was pale and freckled with age spots. All of the fluorescent lights were on and the room was hot and stuffy and smelled of unwash. Two full urinals stood alert on his bedside table and one more, a little more than half-filled, lay on its side on his bed, with the lid on. The urine sloshed back and forth as he heaved himself closer to the edge to get a look at me. His sheets had brown stains and there were bits of yellow flaky skin in the pockets and folds of the blankets.
“Are you gonna tell me I have to bathe too? It’s not happening.” He was perched on his right side to avoid any weight on his left side, his bed raised higher than usual so his body was at the level of my elbows. Both of his hands grasped the right side rail and the bandaged stubs of his legs rested, one on top of the other.
“They washed me up yesterday. People don’t need to shower every day. Your skin dries out and then you itch and bleed and then that becomes another medical problem.”
He had a point. I tried to remember the last time I had showered. It was the post-clinical shower that was sacred. Peeling out of your scrubs and throwing them directly into the washing machine. Pulling the hair tie out and releasing a headache you didn’t know you had. Cranking the faucet with a screech and waiting for the room to fill with steam, then stepping in and letting the heat and pressure wash off the sweat, the who-knows-what, the sadness. A far cry from a tub of tepid water and washcloth.
“Well I’ll talk to your nurse about that. What about breakfast?”
“You have to check my sugar first, with the machine thing.” He looked down at me from his perch like a bird of prey.
I pricked his finger with the lancet and watched the small strip on the meter suck in the blood, digesting it and spitting out a number. 186. We’ll need some insulin. I wiped off his finger with a small square of gauze and held it in place for a second.
“I’ll be right back with the insulin. Can I get you anything else while I’m out there?”
“No.” He was looking at the ceiling, his neck arched and his eyes pointed upward as if praying.
After finding my preceptor, we headed to the machine where the medications were kept to check his orders and draw up the insulin. For a sugar of 186….2 units. My preceptor tapped the computer screen with her long, pink fingernail. Click, click. I found the two-unit measure on the syringe and drew an exact amount of air into the barrel before injecting it into the small bottle of insulin. I flipped the contraption over and pulled out the liquid, flicking the needle to get rid of air bubbles. For a second I felt like a real nurse.
Later, after he had polished the last dry crumb of French toast off his plate with his finger, I presented the idea of a bath again. His sheets clearly needed changing. The room needed fresh air and natural light. He refused my offer, loudly, forcefully. The PCA appeared in the doorway and reminded him that if he doesn’t move onto that left side his might get a sore, and sores can lead to infections, and infections can lead to surgeries. That there are consequences to these actions.
That seems to be the lesson up here on cardiovascular floor. I wondered how much of it is true. Do we blame these patients for their heart conditions and their diabetes because they are overweight and they don’t go running three times a week and eat more vegetables? But what of poverty, forcing people to make choices between vegetables and electricity? What of anxiety, depression, tragedy? What about waking up and realizing that you are a widower who no longer has a job because the economy tanked, and to numb that realization there are Oreos. And suddenly you have to give up your toe, and then your foot, and then both your legs. You are seventy-six years old and two small women in their twenties are telling you to roll over. You can feel their impatience. You can imagine their judgment. So you cling to the side rail, you assert you last small shred of authority and you refuse your bed bath.
His daughter came after breakfast, a middle-aged woman in a baggy sweatshirt and short curly hair. She put on the gown and the gloves with a practiced ease and stepped into her father’s room. Before pulling back the curtain, she turned back and smiled at me, apology in her eyes.
“You’re the nursing student? I hope he hasn’t given you too much trouble. He…changed a lot in the last few years.” She hesitated for a minute and then nodded, quickly, and to herself before she entered the room.
After an hour or so had passed she came out of the room. As she removed her gown and washed her hands, she started speaking, without looking at me.
“He took me prom dress shopping for five hours once in high school. We went to five different stores and I couldn’t find anything. He hated shopping and he sat there, looking miserable, but he never said anything about leaving. He just sat there, telling me I looked great.” She pulled a dry, coarse paper towel from the dispenser and the wet from her hands made a dark stain on the grey-brown paper. “He was a great dad.”
“I’m sure he was, is…” I smiled at her, but she was still wiping her hands, carefully examining her rings, and in between her fingers.
What had he looked like on that day in the department stores, surrounded by great swathes of pink and yellow tulle, bows and strappy heels? What had he looked like when he walked his daughter down the aisle? What kind of clothes did he wear? What had he loved?
He was whistling when I went back in, the practiced whistle of someone who knows music. The whistle of someone playing an instrument in his head.
“Are you a musician?” I asked as I straightened up his bedside table.
“I used to play. The saxophone. I was in the Navy band. We traveled all over, the Pacific, mostly, and the west coast. We were trouble.” He smiled. “The ladies knew to watch out when we were on leave. I was handsome then.”
“Do you still play?”
I pictured him in his apartment. It wasn’t such a lonely place in my mind this time. Maybe it had a few plants. A cat. Stacks of sheet music. Some neighbors who stopped by to chat. I pictured him at home, his wounds healed and smooth, the stumps of his legs bobbing to the rhythm as he played his saxophone, his wild white hair swaying to the beat.
BIO: Gillian Graham graduated with an English degree from the University of New Hampshire in 2009. Fascinated by the intersection of medicine and the humanities, she went on to earn a degree at Columbia University in Narrative Medicine. Here at Yale, she is a co-founder of the YSN Narrative Nursing group with Rebecca Theise. She will graduate in 2015 as a Psychiatric Nurse Practitioner.
On paper, you are: “87 yo Caucasian M; Parkinson’s, dementia, UTI; BIB family s/p unwittnessed fall at home; VSS. Obs unit for change in LOC. Strict I’s/O’s. ?Renal impairment. HD: 5, Post-op day: N/A. D/C: TBD”
In person: I don’t yet know.
You are wearing a mostly-clean gown and socks that are too small. Your hair is short, pure white, and disheveled atop your age-spotted scalp, which smells of seborrhea dermatitis and sweat. Draped around your body – a thin, faded, blue blanket. Your posture is heavy and lop-sided as if Time’s thin fingers and Gravity’s great force have teamed to pull your body toward them, holding tight to this earth your frame, which looks as though it used to defy them both. These are the only aspects of your presence that I am sure of right now. The rest – your awareness of person and time, where and why we’ve met – is unclear.
This morning, after I’d woken you, recorded numerous descriptions of your body’s sights, sounds, temperature and turgor, and scouted for signs of illness digging deeper or mental status falling looser, I helped you eat. Together, we brought a sandwich of bread and cheese to your mouth. Again. Again. And again. Then a straw for water, a crumble of coffee cake, and back to the straw for a bit more moisture. I washed your glasses, your face, and your urine soaked parts. Only after all this, and then some, did we share our first moment together. Briefly, your stare became un-fixed, as if vision had returned to your eyes bringing with it a bout of confusion.
“Are you in the navy?” you asked. “No, I’m not,” I replied gently, trying not to furrow your brow further. “I’m a nursing student, here to work with you today.” You seemed unsatisfied, perhaps more perplexed by this statement of my role; all you wanted to know, I quickly realized, was why this stranger at your side. I knelt and you scanned my face. Carefully, I smiled. “Were you in the navy?” I asked. You nodded. At least, I think it was kind of a nod. Then you were still again.
I wanted to hear more of you, to talk with you, to see you come alive. Your eyes stayed oriented toward me, but I did not see you in them anymore. You had slipped away again. Without indication whether you were speaking to me, to yourself, or to no one at all, you uttered, “Two tours.” Then your head turned away ever so slowly and your gaze landed on a bare patch of wall a few feet from the open door of your hospital room. As if you were headed there, to the door, but overshot it a tad. You stayed outside of your eyes the rest of the morning. ———————————————————————————————————————————-
On paper: I am 30 and in my first year of nursing school.
In person: I am 30 and in my first year of nursing school, and don’t yet know what I’m doing and who I am in this place.
A novice to this career, my past work included cancer research and child psychology. It is week eleven for me in my hospital rotations, and I have all but given up the search for solid footing. Academically and emotionally, I have surrendered to the humility of how little is known – and smaller yet, how much I will ever understand – about our bodies and the souls that live through them. Last week, my first patient died. He had been sick for so long that he spoke of his experiences in textbook terms: debridement, radiation, nectar-thick fluids. What really got me though, was how scared he was to die and how sad he was to be leaving his wife. Moments this true don’t happen at the lab bench, hidden from the grit and raw emotions. Nicely packaged case studies and diagnostics might as well be Hamlet or hopscotch when it comes to one-on-one with a patient in step-down. I often wonder what it is I’m even trying to do.
Just then, a team of neurologists comes in to see you. You do turn and attend to them – a fact that almost startles me – but they are more focused on the beeps and bumps and flashing numbers of the machines on the walls around you. A quick hello, and they’re off. Question after question, they ask of you: Do you remember who they are? Do you know why they are here? Where are you right now? And so on. For the first couple, you nod, kind of. But the last one – where are you? – furrows your brow again. You slowly scan the room, look up at the physician standing by the wall, and say, “Church.” He smiles, tells you “Try again.” After pause you guess, “A basement.” He looks at the rest of his team and chuckles in a way that tells me he’s either feeling light-hearted or self-conscious. “You think we’re in a church basement,” he proclaims and looks down to straighten his sleeve, “Look around.” He points to clues – the IV pole, the monitors. “Who is she?” he says gesturing to a colleague in a starched white coat, “You can do it. Look what she is wearing.” After the longest pause yet, you say, “A psychiatrist.” This brings more chuckles, “Well. Good. She’s a neurologist, but you’re on the right track.” They have plenty more questions: Where is the window? The door? The TV? Where is your right ear? Can you touch it with your left hand? Once they leave you appear more at ease, though still unsettled and awkwardly slumped on a pillow you won’t let anyone fix. I give you time to collect your thoughts, or at least I hope that for you, then get a wet rag for your face. I say to you, in my own attempt at filling silence, “Bet you didn’t know you’d have a pop quiz today, huh?”
Then you surprise me. You turn to me. Your eyes seem different as they meet mine; it’s not a dramatic shift, but it’s something. “Have they asked you those before?” I wonder aloud. And then – again nearly startling me in the best of ways – you answer. “Every day.” “Really? Huh,” I speak only a few soft words in hopes you will keep talking. It’s quiet for a minute, then you nod, kind of. I venture another question, “Which is the hardest?” I’m not sure why I chose this one, and quickly think it’s a silly thing to have asked. Slowly and cautiously though, you respond, “Where are you.” “Mm, that one did seem to slip you up a bit,” I say and kneel to be nearer to you in your chair, “What’s their best question?” You say nothing, but you look like you are still behind your eyes. I wait. I stop myself from moving too quickly, eager as I am to hold steady to whatever ground we’ve found. “I know. Tell me, what’s a better question? One you think they should ask?”
With that, and with extreme slowness but steady follow-through, an astounding thing happens. A subtle smile begins on your face. Time and Gravity have loosened their grips, and the corners of your mouth are thinking of the sky. You answer, “Where do you want to be?” Then, the beginnings of a smirk. Your sudden moment of clarity causes my brows to rise! The corners of my mouth mirror yours. There you are. ———————————————————————————————————————————-
You are man of 87 and I am novice of 30 and right now we are together in this room. I have exams next week, which will conclude my course in medical and surgical nursing, the course that brought me to your room in first place. And you? You will die soon, I know. But tonight we are both still here. Your wife and two sons join us shortly, and I greet them, but you do not. This stands out painfully sharp. I do not know where you’ve gone, but I can at least answer their questions about the day and the numbers and beeps of the machines around you. They are sure to ask if you have caused me any trouble; the worry on their faces makes my heart ache. “Not at all,” I assure them, “He’s been pretty quiet.” They nod solemnly and look onto you, and we share a silence. Then I tell them of the questions – the same questions you get everyday – and your suggestion of a better one. I tell them of your smirk. Their eyes meet mine, then swell with tears. They smile and laugh and cry all at the same time; your half-dozen words mean the world to them, as you lay there in front of us, without indication of where you might be.
At the end of my shift, I say goodnight and wish them the best. Your wife stops me and reaches out her hand. “Thank you,” she says, her eyes holding my own, “Thank you for being here.” As her hand squeezes tight, the lump in my throat burns. I also want to smile and laugh and cry all at the same time. She speaks softly but with confidence, as if she’s telling me a lovely secret I don’t yet know: “You are going to be a great nurse.”
BIO: Jaime E. Biava received a Bachelor of Science in psychology from the University of Washington, supplementing the degree with specialized study in genetics and biological sciences. Between his undergraduate years and beginning at Yale, he worked as a mental health specialist in acute care psychiatry and as a consultant in youth suicide prevention. He is a first-generation college student who calls single variable calculus and the ever-green chlorophyll of the Pacific Northwest home. Jaime is currently studying to be a Psychiatric-Mental Health Nurse Practitioner and will graduate from the Yale School of Nursing in May of 2015.
His body overlapped the hospital chair, with only the arm rest big enough to hold his arms. He was to be my patient for the day, to assess, to learn from. And did I say he was dying? He wasn’t happy about being here, the VA hospice unit, but at home he was falling and his wife couldn’t catch him- literally and figuratively.
You never realize when they say PTSD what that truly means to the person experiencing it. That day I found out: I went where my WWII veteran took me-without knowing why, we went there together. Our conversation started off innocently: I asked him about coming back to the VA, how he was coping. “Well, I hate that music across the hall! I like country”. “You’re a man after my own heart” I said to him. “You like Hank Williams?” He barely smiled, nodding his head. I was thinking how do you question someone about their impeding death, the final failing of their body? My question about pain took us down that road: I wanted to know if his pain was being managed, were we addressing his needs and if not what could we do about it. So, the pain scale gave me the “in” to a kind of pain him and I shared: the pain of a past we could not undo, but relived in a vicious cycle. Remember, forget, remember, forget.
“On a scale from 1 to 10, with 10 being the worst pain you ever experienced what would you say your pain is today?” Silence. He stared at me, but he was gone, gone, gone. “You really want to know?”
“Yeah, I do. I want to make sure we’re helping you”.
His 93 year old eyes, barely visible beneath drooped eyelids, answered my question. Tears welled up, flowed over with a purpose like rocks in a mud slide, going down, down his body, with his chest absorbing every blow. His lips moved and words flowed as if he were in a silent movie: no sound, but emotion that ripped my heart out. I leaned in, held his hand and did all I could to hear every word.
“I wanted my mother” he whispered, “I called out to her”.
“I was lying there, bombs exploding all around me. I reached and grabbed my buddy’s leg. That’s all I got, his leg….I w-a-n-t-e-d my m-o-t-h-e-r.” The pitch of his voice peaked at wanted and fell with mother. He said it over and over and over. I squeezed his hand harder, pulled myself to him, and finally gave in and placed my head on his shoulders. What words could bring him back to me? What could I do to save him? It wouldn’t help to tell him I wanted my mother, too.
“Did she come?”
“She did. She stood there beside me, put her hand on my leg. I don’t know why, but I crawled away from my buddies. I should have stayed. I should have stayed.”
He stopped talking and I became more afraid of his past and mine. But I wanted him to know there’s no shame in surviving. “You did what anyone would do. You survived for a reason.” He went on to tell me the gruesome facts of war: How death constantly seeks you out and somehow someway, you beat it down. His friends died, he died, but this body, this shell that held his heart lived on. Now, at the end of this life, he wanted someone to know, he wanted me to know his pain. I touched his shoulders, feeling underneath a man who carried the weight of a war and the guilt of a survivor. We all think we could have done better, we all question those split second decisions we make to survive. Back then he wanted to save his friends and today he wants to save himself. After our hour and half together, I didn’t go back the next week. He might be dead or he might still be sitting in his chair
Hating the music across the hall and himself.
BIO: Sylvia Parker graduated from Yale School of Nursing in 2008 within the Gerontological specialty track. Currently working at Masonicare Health Center in Wallingford, CT since 2008 as an GNP-BC, Sylvia oversees the care of 150 residents within long term care and dementia.
“Hi there, sweetheart,” the patient said in a soft, raspy, whisper of a voice, as I entered the room cautiously. She sat upright in bed, her thin hands with long fingers folded delicately in her lap. “I know they say my name’s William, but I like to be called Jane,” she offered. I nodded nervously, clutching a list of very intimate questions in my perspiring hands.
“Hi Jane, it’s nice to meet you,” I said. I introduced myself as a student nurse and inquired if I could ask her some questions. My assigned patient had been discharged early in the morning. In a rush to help me complete the interview requirement for my care plan, my preceptor had sent me in to see Jane without allowing me so much as a glance at her chart.
“She’s HIV positive, has been for twenty-five years. Oh, and she’s a man. But she wants to be a woman—goes by Jane, she’ll really like you if you call her Jane.” My preceptor had briefed me outside the patient’s room and hurried off to help another student give meds. Now I sat, feeling the full effect of my lack of nursing experience as I faced Jane, unsure of what to say. She appeared about forty-five, sitting tall with a regal posture, her dark skin and shriveled body clearly tormented by HIV over the past few decades. There were so many questions that begged asking, for the purposes of both completing the interview and satisfying my growing curiosities, but they were all very private questions I felt I simply didn’t have the right to ask.
“So, um, why don’t you just tell me a little bit about yourself,” I started. I looked at the list in my hands. It was littered with questions I wouldn’t dare ask my family or closest friends. Where I come from, we don’t speak about such things. My upbringing in a small and safe New England town that is full of gossip, where there is strength in holding in all your hurt and secrets, had not prepared me for the story I was about to hear.
Jane began to talk, offering little glimpses of her life. I began with seemingly unobtrusive topics. I asked about her relatives. She told me stories of her family—how her parents had died of substance abuse, how her siblings had met similar fates at the hands of addiction or infections, and how her remaining brothers had disowned her because they disapproved of her lifestyle and were embarrassed of her disease.
As she opened up more and more, I began to ask about her illness and how she contracted the virus.
“Ya’ know, I can’t tell when I gots it. But it was a long, long time ago. I just got sick. I dropped out of high school ‘cause I was doin’ drugs. Heroin an’ then crack, I was always usin’. I started sellin’ myself to pay for it. An’ I always liked pleasin’ men and I liked dressin’ up real pretty like a girl to do it. I was just walkin’ the streets. I don’t know if the AIDS came from the needles or from the prostitutin’, but it got me.” She paused. I exhaled. Her sharing the plain and honest truth with me had broken the tension in the room. We went on to discuss her apartment and finances, her sexuality and relationships, her long history of sexual and physical abuse, her struggles with drug addiction, and her chronic loneliness. The tragedies of her life continued to shock me and I felt myself hurting in the deepest depths of my soul. I came to the last question on my list, now irreparably crumpled by my nervous hand-wringing.
“What hopes and plans do you have for the future?” I immediately wanted to swallow my words. This person in front of me was frail and dying of AIDS. What a blatantly insensitive question to ask someone who may not live much longer. And then I realized that my fear and avoidance of the topic was much greater than hers.
“Well, I know I ain’t done a whole lot a’ good in this world,” she said, “but I hope that when I go, I go home to meet my Lord. I hope and pray He’s forgiven me for the wrong I done. An’ if He takes me soon, I’ll be ready,” she answered, “but, if He blesses me here on earth, I hope I won’t be lonely for the rest of my life. I don’t need a lover, I just need a partner in this world—someone to share the rest of my days with.” And in this moment, I found that despite the class, race, sexuality, gender, religion, education level, disease state, and seemingly endless number of issues that separated Jane’s life from my own—and even though my limited experiences and the safety and naivety of my sheltered life had caused me to comprehend only on a very superficial level the extent of her pain and suffering—our hopes and dreams were exactly the same. I said a silent prayer that God might grant her this request and put an end to her sorrow.
When I had ended the conversation, I stood up to leave the room. I promised to be back with my preceptor to do a physical exam and thanked her for her time and her openness. I put my hand on the door knob and she answered, “Honey, I want to thank you, too. It’s been a long time since I spoke these words out loud. I ain’t had someone to tell this to in a long time. I been holdin’ it all in and it helps to have someone listen.”
As I closed the door, I said a second prayer: a thank you to God for the opportunity to meet Jane, who had proven herself an unparalleled teacher. I knew now that a good nurse must always listen with an open heart and an open mind. She had taught me that in order to care for a patient, one may need to gather the courage to reach across a great social schism to feel the pain and suffering of another human being. But most importantly, she had shown me that the things that bind us are stronger than those that divide.
Anne Marie Kearing graduated from Villanova University in 2011 with a degree in biology before coming to Yale as a GEPN. She is currently studying to be a Family Nurse Practitioner and hopes to graduate in 2014.
The snow is falling here and a chill has encapsulated my body. It is during these times that I conjure up memories of warmer days—of sand in my toes, freshly cut lawns, and dribbling ice cream cones—and I am reminded of the last time I saw you. I was driving back to the office with the radio blaring, my moon roof open, the sun scorching my leather seats, and your hospital bed getting smaller and smaller in my rear view mirror. Another visit was complete. I came to your house, I read your morphine levels, I stroked your straw-like hair, I petted your dog, and I held your tiny hand. But in an unintentional way, I held my breath, too. I prayed that you wouldn’t scream, that you wouldn’t fuss and that you wouldn’t die. At least, not while I was there. Could you sense my fear? Hear my silent prayers.
The last time I saw you, your emaciated legs and your cracked lips were upon that bed and your sunken deep blue eyes gave the only color to your skeleton. Your glances told me that you could hear me, that you could understand. Your vision was compromised by the tumor that would eventually strangulate the life out of you. But you could feel. And you would reach for my hand. You would give me “five”, turn it around, touch the lines and trace my fingers. You would play with my faux-wooden bracelet. And grab your toys—the plush Mickey Mouse, the cotton-candy textured hair of the trolls, and the plastic stress ball. You would grunt for your mother but real words were mostly beyond you at this point. I sat dutifully at your bedside and wondered what you were thinking. Wondered what was happening in your body. Sure, I could look up the physiologic processes and graph them and make trends of them, but I didn’t know what you were experiencing.
I remember seeing the book “When I Leave This Place” next to your bed. Did you want people to read that to you? To tell you how you were going to hop on a star or become an angel or did you want to hear that you were destined to just rot unceremoniously in the ground? Did you learn the great secret that no one has come back to tell us? Or did you hear the story and cry inside? Cry for all that you were losing—your mother, father, sister, brothers, friends, your future—or were you content? The only time that I was confident that I knew what you were experiencing was when you yelled out in agony. Your cries to “not hurt my head” were ear piercing and soul crushing. My hands worked nimbly to patch up the oozing, purulent abscess behind your ear, but the fibrous gauze and crusting edge of your wound snagged my mission. My feeble attempts at care and healing resulted in pain that no number of morphine pushes could take away. When I saw your long, raw spaghetti-like fingers reach to your head as a tear coursed down your cheek, I knew that you were still living. Your hours of sleep, lack of color, and utterly wasted appearance did not dissuade me in those moments of your humanity. I was relieved by your emotion. I needed to see that you were still there—that you weren’t a piece of flesh, left to decompose in the middle of a living room in the heat of the summer. I did not doubt the love of your family, but I wondered about their stamina. Your long illness, your steady state of being on the edge of life and death took a toll on them. You could hear it in your sister’s voice as she protested another afternoon at home. It wasn’t that they resented you. It was the illness that they hated. They wanted their little brother back and if they couldn’t have that, they wanted to purge themselves of you. The goodbyes had been said, the casket picked out. We were just waiting on you.
But you persisted. You couldn’t quite let go. I wondered what you were waiting for. 52 days of not eating. Over 60 without getting out of bed. Were you waiting for a Red Sox victory? Was someone going to help you to the “other side”? I needed to know. You see, I’m going to do this for a living—I need to know what is happening so that I can feel at ease and help those poor kids struggling with what you went through. I have so many questions for you, C. I’m not done learning from you. I’m not done asking you questions. What’s it like? Are you on that star? Are you watching down on your family? Do you ever glance my way? Isn’t it funny how after all of these months it’s still me I’m worried about. Perhaps I should just tell you what I’ve thought so many times, but never really got up the nerve to meaningfully articulate. Thank you. Thank you for forcing me to look at myself, to see my selfishness, to see my insecurities, to recognize my generosity, to admit to my compassion and to my strength, to ask the questions that aren’t polite, and to pride myself on coming to terms with all of these emotions. Some of this may seem egocentric, or reflective, depending on your point of view. But they are me. They are who I am, and they represent the nurse that I will one day become. So, C, thank you for letting me feel.
a, your visiting nurse student
Allison Grady, MSN, PNP-BC, APNP, RN, is a pediatric oncology nurse practitioner at Children’s Hospital of Wisconsin in Milwaukee, WI. She is a 2011 graduate of Yale School of Nursing where she specialized in pediatrics.
It was all a mess. I didn’t know what had happened. Somewhere between promising forever and now, it had all fell apart. As I drove in my car to work, I cried for the thousandth time. I was six months pregnant and my husband had decided that he didn’t want to be married any more. Each time I packed my bags and found the courage to leave, at the door I would find some reason to stay; some excuse, some doubt, some hope that things would be exactly as I planned. And then, I would find myself crying in my car with my brain telling my heart the truth.
My heartache was so raw and so deep I had thought several times about quitting my job as a nurse. Night after night, working in the intensive care unit I thought my heart would burst. How can people trust me to take care of their loved ones? I couldn’t even keep my family together; and here I was in the business of trust. People would leave their loved ones with me, their nurse, and expect that I would keep everything together, that when they came back in the morning or the next day, that everything would be as it should. My hands were the ones they expected to heal their families, when my family was broken and falling apart.
I walked on the floor taking a deep breath and putting on the usual mask. “Are you ok?” people would ask. “Yes, yes, I’m fine…just the hormones” I would answer with a weak smile. Their concern would be there in their eyes but it would fade because they wanted to go home to their families and they would begin giving me report.
Tonight was a special night. I was caring for a patient who was a live organ donor. His story was sad, as with most patients who end up being live organ donors. The patient was a prescription drug abuser who had an alcohol addiction, but a family who loved him and protected him. If he were high, they would care for him so he was safe; if he went to get drunk, they would search the bars until they found him and brought him home. Between his wife and his daughters, they had managed to orchestrate their love for him despite his addictions. Ironically, he fell asleep in his lounge chair while watching a movie with his daughter and he silently cardiac arrested. By the time the daughter realized he was really unconscious, he already had irreversible anoxic brain injury. He was my only patient that night.
The first time I walked into the room I was amazed. His wife sat faithfully at his bedside and their youngest daughter, the one who had been present at his arrest, sat on the other with a pile of paper in her lap, intently focused on folding origami birds. There were already hundreds of little origami birds present in the room on the bed and the tables. They were beautiful. I introduced myself to the wife and the daughter and then carefully picked up one of the birds. I gently questioned the daughter. She looked up with pain and loss clearly present in her eyes and told me that there is a Japanese legend that states that the person who folds a thousand origami birds may be granted one wish. I didn’t need her to elaborate as to what that wish was. As I looked at her father lying still in the bed, I knew what she would wish for. The ventilator pumped breaths rhythmically and the I.V. pumps sang their repetitive song, and right then and there I realized that all of us in that room had the same wish: that our families had been perfect and exactly how we had wanted them to be.
I worked more passionately then I had in months. The baby in my belly rolled and kicked throughout the whole night. I felt as if I were alive and awake for the first time in a long time. I loved his family and spent the entire night in their room. They recalled the good times and the bad times. We laughed and we cried together that night in the intensive care unit. They shared with me and I shared a small portion of my pain with them. “Sometimes no matter how hard you try, things will never be the way you want. But there comes a time when you have to make a wish and let go…” his wife said to me. I watched as she glanced over at her daughter and then stroked her husband’s hand.
In the morning, I brought the patient and his family to the OR for the organ recovery. I watched his family say a tearful goodbye to him as he went into the operating room with a thousand origami birds covering him. As I turned to leave the wife touched my shoulder. She hugged me and thanked me. And then in my hand she placed one of the tiny origami birds, she patted my belly and walked away.
That morning when I drove home I stared at my hands at a stoplight. These hands were not devoid of healing and love. I had cared and loved a patient and their family through one of the toughest times of their lives. These hands would carry me through, and there were thousands of patients who needed my healing touch, and most importantly, one tiny baby. I had learned so much from this family. As I looked over at the origami bird on the passenger seat I smiled, for me, it was time to make a wish.
Kassandra August-Marcucio, RN, APRN started her nursing career at Quinnipiac University where she received her bachelor’s degree in 2007. During her time there, she fell in love with acute care nursing and with the encouragement of her boss and nursing professors, decided to apply to Yale University’s Acute Care Nurse Practitioner program. She graduated from Yale University in May of 2012. While attending Yale, Kassandra faced some of the toughest challenges in her life; she became a single mother, struggled to balance work and school and even came close to giving up on her nursing career. But through the tough times and tears, she was reminded time and time again when caring for her patient’s that there was hope. Kassandra is now happily employed as a Urology Nurse Practitioner at the West Haven CT Veteran’s Affairs Hospital. She has also given love a second chance and got remarried last July. Her, her husband, and her son are anxiously awaiting the birth of their baby girl in October. Kassandra is looking forward to a long life full of happiness, healing and nursing.
A Strange Kind of Birth
Up until the time I started to smell burning tissue, like the smell at the dentist when they’re drilling on a tooth, my observation in the operating room resembled a program on the Discovery Channel. For the last two hours, I had been watching a laparoscopic hysterectomy on a video screen above the surgeon. The surgeon wasn’t touching the patient; he was operating the controls of the Da Vinci – a multi-armed robot that was doing the dirty work. The patient, a 46-year old woman, had been unresponsive to various treatments for her fibroids and was now having her uterus removed.
Three short months had passed since I attended my last birth as a doula in cool, temperate, San Francisco. There, I met with clients, explored their feelings and offered validation, my vocabulary peppered with words like energy, chakras and breath. I came to mothers in the middle of the night, embraced them, whispered words of encouragement in their ears as they moaned their way through contractions. Now, as a student nurse, in hot, humid New Haven, I studied scientific fact and lab values, and communicated in the language of anatomy, disease and interventions. Any attempt at intimacy was hampered by the sheer terror of not knowing what the hell I was doing. I was amazed by how recently I traded in the raw, messy warmth of labor and delivery to the precise, chilly sterility of the operating room.
Prior to surgery, the surgical team spent two hours prepping, an activity that I hoped would be educational, but left me feeling awkward and misplaced — dodging cords, equipment and staff, trying not to touch anything sterile, attempting to be helpful, but failing at everything. At some point, I did strike up a hushed conversation with one of the nurses. We were discussing my former college when she asked, “That’s a pretty left school, isn’t it? Do you feel that it prepared you for grad school?” My mind began to race. What did she mean, “left” school? Left like West Coast? Or left like liberal? Either way, I resisted the urge to point to my ID badge. “Yes, my small, West Coast, ambivalent on shoes, but very much pro-ultimate frisbee, liberal arts college got me accepted into Yale,” I wanted to say. Instead, I gave some canned response about how a liberal arts education prepares you for a variety of experiences after college. Does it, though? I wondered. Does it prepare you to stand in a room with a patient you’ve never met and look at her most intimate parts inside and out? Does it prepare you for this?
My thoughts were interrupted by the surgeon announcing that he was done. All that remained was to slice the uterus into smaller pieces and then pull the uterus and the cervix through the vagina. What had previously been an intellectual experience suddenly became a visceral one, my own uterus cramping the way it does at a birth when a mother begins to push. After three hours of watching, waiting, holding space, the time had come: I held my breath as the surgeon made two or three longitudinal cuts, turning the uterus into some sort of soft-bodied sea creature. Then, he instructed the resident to pull.
“Slowly,” he said, “You don’t want it to tear.”
I watched on the video as the uterus made its exit, the cut pieces overlapping, just as a baby’s skull bones fold over one another to ease its passage down the birth canal. At some point, the resident had to start over and the uterus tried to reclaim its former home, the way a baby slides back into its mother between pushes. Pull, pull. Hand over hand. Keep pulling. And then it was out.
“Did you get it?” the surgeon asked.
“I did!” the resident exclaimed.
The focus in the room then shifted to the uterus, the prize in all of this. The surgeon joined the residents in examining the pale, lifeless piece of flesh. “Look at how big it is!” they cooed. Reflexively, I turned my attention to the patient, half expecting to make eye contact, to place a hand on her and send her unspoken words of love, gratitude and affirmation. As I looked over, I remembered that she was asleep — bundled in pads and sterile sheets, cords hanging off and out of her. The ten feet between us may as well have been a continent. I thought about how she would feel when she woke up — tired, sore, happy to be done and glad it went well. My eyes shifted from the patient to the video screen, to the image of the space that once contained her womb — the space that was once so full, now empty.
Audrey Muto will graduate from YSN’s nurse-midwifery program in 2014. After completing her undergraduate degree in Biology, with a minor in Japanese, at Lewis & Clark College in Portland, Oregon, she spent two years teaching English to elementary and junior high school students on a rural island in Japan through the JET (Japan Exchange and Teaching) Programme. Prior to her acceptance at Yale, she worked as a doula, childbirth educator and prenatal yoga instructor near her hometown in the San Francisco Bay Area, California. In addition to her studies, she continues to teach yoga and prenatal yoga here in New Haven.