12 Hours

I'm tired.

We had two codes in two days. One Saturday and the other on Sunday. We have an almost entirely new staff and no one, apparently, can think very well.

I am normally a pretty scattered, ditsy person. I can never find my keys. My house is a mess, and I always seem to be a day late and a dollar short, but at work, I am weirdly competent. Maybe it's the fact that the environment is so controlled? And when things get really hairy and bad, I hate to say this about myself, because it sounds like bragging (I think it's okay because I'm so miserable about so many other aspects of myself--my hair I can't seem to do anything about, my unfulfilled potential, my flat violin playing. my sloppy mothering), but when things get really hairy and bad, I'm a fucking machine. I am really good at thinking very clearly and taking action when everyone else is freaking out. It's like my competency is inversely proportional to that of the people around me.

Maybe that's how ADD is an adaptation?

But normal situations--like grocery shopping--take me 5 times as long as anyone else.

Well, that's enought about me.

Both patients lived. And one's survival was kind of funny. We had coded this guy for 25 minutes. No pulse. Nothing. We'd gone through three drug boxes. The wife had been in the room during the code, crying, but not interfering.

Mac, who was the code physician, turned to her. "I don't know what else to do." He told her, helplessly. She stood by the bedside, sobbing, stroking her husband's hands.

The little medical students in the room continued to practice chest compressions on the guy, rotating through, so they could get their check-off.

Mac turned to us--"Can you guys think of anything else to do? Is there anything we haven't done?"

I was the recording nurse. In a code, everyone is assigned a role. There's a drug nurse, a code nurse, a recording nurse, and a code physician. Then there are 37 other people who just show up, criticize and generally get in the way.

I looked down at my form, which has a list of all the meds you can give during a code.

"The only thing we haven't given is bicarb."

"He's not acidotic." Mac says.

"You asked."

"Okay. Give him some bicarb. What the hell."

2 meQ of bicarb.

"It's in," says Kim. Kim's one of our new disasters. Here's a sample: Last week she was a no call, no show for her shift. She called in at 10am and blithely explained, "I'm so sorry--I went out drinking the night before and was still too drunk at 6:30 to come to work!" Laughing. Like we would all laugh with her and think this was just fun little shenanigans. Why she's still on our staff is beyond me. That's the nursing shortage, folks.

"Stop compressions. Check pulse."

We wait. Then: beep beep beep beep. P...qrs...t...p...qrs...t. Regular rate and rhythm.

Giovanni, our new fellow--I've talked about him before, right?--"and that, my lovelies is a pulse."

After these, though, I can't do anything. All my meds are late, I seem to move through jello. Two days of this. No wonder I have now been diagnosed with adrenal insufficiency. I have a dim suspicion this is connnected to Adderall.

Oh, well. You gotta have something. Didn't JFK have Addison's?

It's amazing how much the world outside does in 12 hours. Last Thursday, I was on the river.
Jay's organization, River Rescue, held a formal party on one of the sand bars. It was wonderful. 120 people, the environmental aristrocracy of the state, were transported by boat to the island, which had been transformed into paradise--sort of a hippy paradise--but paradise nonetheless. We ate jambalaya and caramel cake on white tablecloths. We wrote our dreams for the river and hung them on a tree constructed out of driftwood on the edge of the island. We sat by the fire afterwards singing John Prine songs and launching fouchees (these are fire balloons made of ingeniously folded newspaper--they look like willow-the-wisps). A generator had been lugged out to the island and the tables and tents were strung with tiny blue lights. Made silent, silent laughing love in the tent. Got miraculously called off the next morning, so I was able to wake up and see the mist coming up off the river in the sunrise.

Good times.

That's my 1/2 hour.

A letter from Home

I continue reading Raise High the Roof Beam Carpenters and Seymour: an Introduction.

Did you catch the pun on his name?

Seymour. See More. Seymour the mystic. Seymour the prophet.

I read this book last when I was probably Lilly's age. I parcel out Salinger's stories because he hasn't written that many, and I want them to last me my whole life. This is an idea I got from my ex, Charles. Another poet/saint. We lived together my first year at Dartmouth in a little two-hundred year-old house that had been rebuilt and rebuilt, near the velvet rocks. It was painted state park restroom chalk blue, was freezing cold, and had an unhappy and hostile, if ineffective ghost in the attic. When I realize that I was Lilly's age when I was doing this, throwing away my life, I freeze with fear. Oh, well.

The reasons you make the choices you make.

J.D. Salinger is/was my favorite author. Then came Dostoyevsky. And then Murakami. But from 12-16, when I was making all the important life decisions, it was JD. I was a crackerjack 16 year-old. I have to say, in terms of the world, I really peaked at that age. I mean, I've done other things since, good secret things, things that I'm happy with. I like myself better now. But you and I both know I haven't exactly burned a trail to greatness. But at 16, I was a baton twirling, singing, tap-dancing, poetry spouting, national merit finalist. I got into both Duke and Dartmouth. Which should I choose? J.D. Salinger lived near Hanover. I decided that I was going to Dartmouth.

So I'm reading this again at 40-something. And I love him so much more. And dislike him, too. Which I didn't the first time around. But I know more about him, of course. There's so much in it that you miss. That's kind of a wonderful thing, isn't it, about getting older? Finding what you missed? I didn't have a lot of real compassion when I was 16. Compassion has been a long time coming. The lotus is a good image for that. So is the rose. Rose of sharon, abide with me. It unfolds, just like that, when you finally get silent. Many petaled, infinite, fragrant.

Ok. So I went to Dartmouth to seek out JD Salinger. And I wanted to sit down with him and talk to him. But then I read Seymour--the part in which he talks about the students who beat their way to his door. And I realized (surprise!) that I was not the first person who had had this idea. I put my little idea away, ashamed. And, although I did indeed meet J.D. Salinger, twice, it was purely by magical accident. And I didn't talk to him about anything. I said "good morning" the first time, and the next time I showed him where a book on the New Yorker was in the bookstore. And the only things he said to me were, "Good morning" back, early on a sunny October day, and "Wallace Shawn was the ONLY editor the New Yorker has ever had. The magazine doesn't even exist any more."

Back to Seymour. Buddy outlines the types that visit him. But he misses one. He misses the reader, who, reading feels the writer is writing a letter specifically to her, putting into words all the things she suspected but could never really articulate, and that no one around her ever expressed. He misses the one who (crazily?) feels that at last she has always been an orphan, and has now heard from her family. Now that I'm writing and thinking about it, it was my mother who first read me For Esme with Love and Squalor. I think she was giving it to me so I would know her heart.

Call no man Raca. We don't get to know anyone here, do we?

That's my 1/2 hour.

Capitulations

It's hard to think on Monday mornings, after three days on the floor. I can't even type my password in correctly to log on. Then I forget my username. Or, I don't exactly forget it, I remember it but my fingers type the wrong thing.

I had two old men. One had a traumatic brain injury. One had Parkinson's and dementia. His bright black eyes, fringed with beautiful long lashes peered out at me, knowingly. He bristled with white hair. Neither would do anything I asked. At all. The one with Parkinson's couldn't enunciate. "OOOOHAAAAY!" he'd say. "OOOOHHHAAAAAY" He could only hold his head at a 45 degree angle back, staring at the ceiling with his gleaming black eyes. He held his hands close-in, stiff. I couldn't bend them. I wasn't about to force him. His daughter was one of those women who have never been able to be young and is a little put-out about it. Pretty, but burdened. No true laughter. I know just how she feels. Now. I asked her for her contact information. She gave it to me saying, "I'm the only one who didn't run away. You'll always be able to reach me." His wife was like a child. A little lost. She wore the same clothes the entire weekend--all three days--visibly dirty and torn. Grimy. You could see how pretty she'd been. Short buzz cut hair that was falling out. She smelled like the street--like piss and booze and smoke. The daughter kept rolling her eyes when she referred to her. The "wife" she called her. "Oh," I asked, "Is she not your mother?" Exasperated, exhausted sigh. "Yes. She's my mother." At one time, apropos of nothing, the daughter says to me, "I'll say this for our family, we come together in a crisis."
It was true. You could pick up the tension between everyone. But they weren't playing it out too much. They were all focused on the father, on his well-being. Even "the wife"
"We're very dysfunctional." The daughter informed me.
"You're behaving like champs here."
"You have no idea." She and her husband both start to giggle.

At lunch I reread Raise High the Roof Beam Carpenters. I bought it for Lilly, but she wasn't interested. They had fried chicken. Second weekend in a row (it's usually every other Sunday). Our hospital makes some of the best fried chicken I've ever had. I sat on the little cement patio in the sunshine and ate. I have to get outside at least once a shift. Wiz never takes lunch, never goes outside. I used to follow his example--but then I decided that it wasn't a moral failing to take a 1/2 hour break in a 12 hour shift. I know he secretly sees this as a betrayal of the order, but I think a little sanity is called for. I make everyone else take lunch, too. He makes fun of me. "I think I'll go take a break now," he mimics.
"Go. You need one."
He grunts, waves me off.

Back in the room, I discovered that the OR had just absolutely botched my old man's arterial line dressing. They'd used non-sterile skin tape--the catheter was about half out--wonderful. Which meant that changing the dressing would pull the cathether out. The family had left the room. I've gotten into the bad habit of talking to myself in front of my patients--who are mostly gorked--I was working over his art line, the god damn tape sticking to my gloves, trying to save the line. Muttering to myself. "the god damn OR. What the hell. I mean, what the hell." And my patient, who'd been fighting me all day, looks at me and says, "wahheyoo?"
So I told him. "Well, look at this dressing on your arm." He lifted his wrist up and looked at it. "See? It's covered with sticky tape--right on the catheter that's going into your wrist. It's sloppy. It drives me crazy."
"I-orry."
"It's not your fault."
"I-orry." And, for the first time in three days, he relaxes his arm and turns his palm up so I can get to the dressing.
That's my 1/2 hour.

City of New Orleans

Went to see District 9. It was really good. At least I think it's good. It held my attention from the first frame. And I liked that the creatures were made to be so repulsive, so that there was a real emotional journey the audience had to make in order to find them sympathetic. Much the same thing happens with my patients. At first they're overwhelmingly horrific, but then I get to know them, and their humanity pokes through--or rather, mine does. I seem to lack a heart. What I mean by this, is that my empathy does not kick in automatically. I am almost always repulsed initially. I have to talk to myself, to make my patients into stories. I describe them to myself as if I were reading about them in a book..."He lay there--the ET tube had twisted and was pulling at his mouth which was covered in herpetic blisters brought on by the stress of his condition" and then I think--"Jesus, I'd better fix the ET tube." This is a constant practice. I "write" every inch of my patients to myself this way--and then I nurse them. But I don't do it automatically, which shames me. Wiz does it automatically. The great nurses do. I have to break it down...I want to be nice, but I'm not nice. I always have to think, "what would a nice person do in this situation?" And then I do it. But I'd mostly rather be reading a book. Lilly and Nick have both told me they feel this way, too. Does everybody, I wonder? I think maybe a lot of people do. Religious practice is exactly that--practice. Church services held once a week, mass every morning. We need to be reminded. We need to renew our vows to each other, every day.

I dropped Nick off at Loyola a week and a half ago. New Orleans. A strangely empty city. But it feels like she's growing. She doesn't feel dead. Loyola is in the Garden District, and I liked its noble, underdog feel. Its gingerbread peeling red brick ramparts next to solid, rich old grey Tulane. The Jesuit ideals of Social Justice embedded in the paving stones outside the library...the flowering trees, Audubon park with its shady live oaks (I guess?) and ibis. Girls in blue plaid skirts and long straight gleaming hair. And the streetcars! I really loved the streetcars. Walked around, thought about my old lost friend Barry Gifford. He was right, it felt a lot like the Grove. I sent him a letter before we went, but it was returned "unable to forward" Probably for the best. Nick and I took the train--the City of New Orleans. Coach. From Carbondale, Il. We sat in a bar waiting for 1:30am, watching two men in french cuffs and a very drunk, plump, red haired girl in an expensive black dress.
"Never trust anyone in french cuffs." I told Nick. "There is no need for any normal American male to ever, ever wear them unless they are planning to take advantage of you." The bar-owner, a man named Tip, dressed entirely in a carhart jumpsuit, first distrusted us (we were carrying all our things, including pillows, in a cart,like homeless people), then liked us (I ordered Bauchant), even walking us down the tracks to the Amtrak station once the bar closed--we knew where it was, but, as my grandmother always said, it is wise to let people be kind to you when they want to. Never know when you'll have to hang out in Carbondale.

Home, I discovered that I suddenly wanted every thing clean. With a toothbrush.

Saturday, Wiz calls me over. He was clerking. We are short staffed, and doing more with less. So the nurses are clerking. Dangerous.

"Sit."
I sat.
He looks at me with his blue-yellow lizard eyes. "Patton, you need to find a way to deal with your children growing up that does not involve disinfectant, a toothbrush, and a green scrubby. You're taking the wax off the floors. Look."
The floor is polka-dotted with white spots. Hundreds. Where I've cleaned, I've left the floor cleaner than the surrounding tiles. And I cleaned the chairs, and the rubber areas around the sink. And the venetian blinds in the patient's rooms. And the computers. And I took care of my patients--exquisitely, I might add.
"No one trusts medical care in a hospital with dirty floors."
"True."
We're silent.
"Ahh, the deafening silence of reality." He says.
"It's not about Nick. I just want every thing clean."
"Passages by Gail Sheehy. That would be a good book for you." He muses.
"Don't go all soft on me."
"I am nothing like you think I am." He tells me.
"Neither am I." I reply.
That's my 1/2 hour.

The Insayne roote

Well, I have officially entered the land of the insane.

I am finishing up both my health assessment final projects and my research proposal. I am doing this all by the 21st. I think. I hope. I haven't left the house. I'm living off armour thyroid, b vitamins, cafe con leches and grape nuts. When I sit zazen, all I do is cry. Then I get up and memorize cranial nerves (along with some other stuff, like heart murmurs). I've had three classes prior to this where I had to memorize cranial nerves--I have to rememorize them every time. I wonder if I've actually learned anything. I always have to run through in my mind--"On Old Olympus' Towering Tops" Sometimes however, at work, someone will ask me an academic question, and the answer will just weirdly pop out. Blurp. Like a knowledge lugie. (sp?) And I think: "I didn't even know I knew that!"

So, while I was sitting zazen this morning, feeling guilty for not using the 1/2 hour to study, I started thinking about Joaquin Phoenix.

There's this great line in this Julio Cortazar story The Pursuer, where all the sudden the main character (pretty much exactly based on Bird) is in a recording session and he freaks out and stops the session saying, "I'm playing tomorrow!" or something like that. And I think this has something to do with what Mr. Phoenix is trying to do. What happens when you drop the spin and the plan and just sit there?

It's even worse now. We are never where we are. Our culture is about smoke and mirrors. People don't even get to die. We think we have created immediacy with the internet, etc., but we have just made more shadows. Everything is up for grabs, everything is open for comment. This is why the families in the ICU are so awful. We have nothing that coaches us for finality, because everything now has the illusion of living on and on. As Wiz says, "Hello, Mr. Reality." We are lost in dreams--and mostly, oddly, dreams of being known. We want to be loved and known. And known in our world = recorded and broadcast. Our phrases are canned. We spout movie lines to each other instead of coming up with conversation. All communication is heuristic. Secret handshakes. Are you red or blue.

Well, best of luck, Mr. Phoenix. Remember there are other places, other lives. It's a big world. You can truly step out of your frame, if you want to. What about nursing school?

That's my 1/2 hour.

Surfacing

There is a drowned boy in the unit.

He's from Tibet. He's a physics student.

We have this beautiful recreational center at the university--I mean--you've never seen anything like it. It's the most beautiful, uplifting, marvelous gym you can imagine. It has a climbing wall and lounge chairs and computers and lattes and great exercise equipment. It has three pools--an olympic size one with a diving tower, a meandering "water park" sort of pool indoors, and a pool outside. It has fake banyon trees, a teeth whitening salon and tanning beds. All paid for with state tax dollars! (and then we can't get the new cancer center built, or a new nursing school--but that's a different story). So the drowned boy came from freezing Tibet, got into the physics doctoral program here in sunny Little Dixie, and, enticed by our beautiful swimming facility, decided to take swimming lessons--something not routinely offered in Tibetan mountain villages.

He lived in a local apartment complex with a lot of other foreign students, mostly Chinese, and he did something not too terribly crazy. One evening, he and another girl who had also been taking swimming lessons, decided to swim in the pool.

Only he hadn't yet progressed to the deep end, but he decided, since he was with the girl, and he knew in principle how to swim, that he would go ahead and try it.

Then he panicked. And sank. In 8 feet of water.

His friend couldn't get him up. She ran from door to door, rousing the other students. She collected 30 people, but no one could swim! Someone called 911. The paramedics pulled him out, but he'd been under for 10 minutes.

I drowned once, when I was 3. I did the same thing this boy did. I thought I could swim and I went into the deep end. I remember staying afloat for a little bit, feeling proud, but then, somehow the water became bigger--and staying on top of it became harder and harder. I don't remember panicking, in fact, I remember being far below and looking at the sun coming through the blue water and thinking, "I'll get back up," and paddling harder. I was right near the smooth white wall of the pool and I tried grabbing on to that, but I couldn't get a grip. And I remember the bottom of the pool and breathing water in.

I guess what happened after that was that my mother jumped in (she'd been writing a letter and hadn't noticed me go down), pulled me out and gave me CPR. I revived right away. I don't think I even went to the doctor. I remember staying in bed a few days. But you know, come to think of it--I had pneumonia all through my childhood--almost once a year. So maybe it damaged my lungs. I never made the connection until just this moment--but of course, that's probably it. I'm not afraid of water at all.

So the drowned boy came to our unit. And MacLean redeemed himself after the incident in October. Because he may be a materialistic fucker, but he's a genius with ventilator. He understands lungs and trauma like no one else. And the boy, after lying there for weeks, is finally waking up and responding. His physics advisor (academics, man...what planet are they from) asked--as he was laying there, vented, seizing, eyes rolling back in his head, shitting himself, "Do you think he will be able to regain cognitive function?"
"I don't know." I told him. "Maybe, after a few years. He's had a severe anoxic injury."
"Okay, I understand that," the man says impatiently, "But do you think he'll be able to finish his dissertation?"
I just looked at him. I wanted to say,'you know, really, at this point we just want him to be able to breathe by himself and wipe his own ass-that'll be success in this arena."
No clue what they were dealing with.
The parents were brought over from Tibet. I'll say this--the Chinese government got them over here fast.
They are lovely, they stand next to him and pat him and stroke him and murmur to him. When the nurses come in to tend him, they pat and stroke us, too.
Yesterday, we were able to put him into a wheelchair and wheel him into the courtyard. We parked him under the crabapple trees. I think I've written about the courtyard.
There are swallows there, they swooped and dived. The boy lifted his head and watched them...and smiled.
The professor, who, despite his annoying qualities, has been at the boy's side almost constantly, started crying.
Me, too.

a B

Did you know that naproxen and glyburide are highly protein bound? This can result in increased glyburide levels, as the Aleve competes with protein binding sites, causing hypoglycemia. I didn't know that. It wasn't anywhere in the reading, class notes, lexicomp, or epocrates--but it was on the clinical pharmacology EXAM!!!! And I got it wrong. 88%. I haven't gotten a B on a test in 6 years and I'm pissed off.

Arghhhh.

It's been an almost perfect storm at work the last two weeks, equal elemental forces converging consisting of responsibility--I charged--3 level one trauma admits, short staffed, inexperienced staff (but great attitudes--what a group)--severed limbs, unredeemable patients, severed limbs, constant diarrhea, crazy family members, and leaking rectal tubes (between my two patients I had 17 linen changes on Saturday).

I had weird dreams involving that surgeon I kind of like. I had to insert a rectal tube. He wanted to kiss me, moved a strand of hair out of my eyes. He'd also grown his hair out and looked a little bit like Brad Pitt in Legends of the Fall (a really stupid, hokey movie). "I don't have time for that," I snapped (in the dream). "We've got to get a new Zassi in you right now.!"
I'll never forget the look of disappointment and betrayal in his eyes... Then I woke up next to Jay and felt all guilty.

I told Marcy about the dream.

"He deserves a rectal tube." She said. "Maybe it would get that stick out of his ass. And it wasn't like you were having sex with him. I don't think Jay would be jealous of that kind of interaction. Unless he's weirder than you know."

He might be. I caught him lying last week. Maybe that's why I'm having dreams about putting rectal tubes in my coworkers! He did go visit the 28 year old bartender in Summerville when he was on his shoot. He had told me that he didn't even go into town. We went down to visit his son in Summerville last week. "Haley's (her name's Haley, too--can you believe it? another one!) going to think I live down here, now," he said, musingly, as we were driving. "I've been in that bar almost once a week lately."

"I thought you said you didn't get into town."

Silence. Whoops.

"I never said that."

"Yes, you did."

"No, I didn't. You're just looking for trouble."

I let a few minutes pass. Then I said, "You know, you need to accept that, now you're 53, and with the head injury and all, you're probably not cognitively intact enough lie anymore."

We choose our poison, don't we?

I had a patient who had taken to his bed. He'd just decided...that was it. Not getting up anymore. Young guy. Lay in bed. Watched MTV. Those horrible reality shows--the one with that girl with all the tattoos...oh my god, what a waste of a life. Curled up in bed. Smoked two packs of cigarrettes a day. He developed contractures. He could only turn to the right. His organs became compressed, he couldn't breathe. He developed osteopenia. His bones fractured--hips and ribs. Wore a diaper. We couldn't do anything for him. And he chose this. One day at a time. Our bodies and our lives form the shape of our minds and hearts.

Dear Reader. Life is imperfect. Stand in the sunshine. Stand and stretch and move as much as you are able. Move through your pain. Breathe deeply. Love those around you impeccably. Learn as much as you can. Serve and love your world. Forgive yourself and others. I will try if you will.

Love,
Haley