Peter Hannan

Nurses pass through your lives largely unseen. But we see you. We are there when you’re born and we’re there when you die.

Mrs. Silva had gone into the hospital for an exploratory lung biopsy. The procedure was routine and considered low-risk, but it did necessitate a general anesthetic. Once trussed out on the operating table, attached to a breathing machine and hooked up to electrodes that relayed vital information on the state of her union — heart rate, respirations, and blood pressure — she had been given Pavulon, a short-acting paralytic (purported to have been extracted initially from the poison with which Amazonian Indians paint their darts for the big kill) to keep her motionless.

Doctors, it is true, are more intensively trained: four years of college, four years of medical school, several years of internship and residency — a kind of indentured servitude in a hospital setting.

Maybe her anesthesiologist had a rough night. There are, after all, rumors about anesthesiologists. In any case, this particular doctor had been too spaced out to monitor her neurological responses properly. For a brief time in the operating room, Mrs. Silva’s heart stopped; the surgical team kick-started her back to life.

Aspersions are cast on an anesthesiologist’s skill when a patient dies during an operation, or, immediately after an operation, in the recovery room. You want to wait the decent interval so that the death doesn’t call anyone’s competence into question. Deaths in the operating room frequently trigger a review by a hospital administrator. Surgeons don’t like this. Costly and embarrassing.

A burnt-out nurse hates her patients. The patients who constantly complain; the patients who are constantly hitting the call-button for no other reason than to make her jump;

After the operation, Mrs. Silva had been brought back not to her anonymous cubicle on the hospital’s medical surgical ward, but to the intensive care unit where all the big mojo takes place.

Perhaps the patient’s IV bag has run empty. The patient waits for many minutes for the nurse to reappear with a new bag of solution.

Now at three o’clock in the morning, Mrs. Silva was suspended in the zen of Deep Coma. Her pupils were fully dilated; you could grind brass knuckles into her chest without eliciting a sign of outrage. IVs dripped dextrose flavored with vasopressins into the bruised, discolored flesh of her antecubitals; an arterial line snaked out of her groin; a catheter drained urine from her bladder, while another larger catheter, pushed up her rectum, poured liquid stool; a thin plastic tube hooked to a suction pump sucked bile from her stomach; an endotracheal tube fed into a ventilator, a complicated piece of machinery with flashing lights and incessant alarms, bells and whistles that made the frail body lying attached to them seem somehow insignificant.

A tube for every orifice.

Her ventilator made a very soothing noise: a long hiss up, a sudden shove down. A millisecond of absolute silence. Very rhythmic. Very meditative.

It had been a clear case of medical negligence. If Mrs. Silva had had anybody who cared whether she lived or died, these loved ones might have been enriched immeasurably by Mrs. Silva’s demise. But the next-of-kin on the hospital admission form was some anonymous self-described “other” at an address several states distant from Mrs. Silva’s convalescent home.

Around four o’clock in the morning, Mrs. Silva began having seizures. These were not the all-throttles-out quaking and shaking you might expect from Mr. Rochester’s deranged wife in the attic; no, these were demure, even fastidious tremors. Her heart rate plummeted: the pips kept getting farther and farther apart, a jagged line like a kid’s Etch-A-Sketch scribble played on the telemetry broadcasting her heartbeat out to the nursing station.

“Oh, Jesus,” I sang out when her heart rate hit 50. “Here we go-”

Code Blue is what we call these mercy missions, designed to jump-start flagging cardiac muscles.

When the Code Blue electronic alert system failed to detonate, I phoned the emergency down to the hospital switchboard.

“Blue?” the telephone operator kept asking. “Blue?” as though I had just hit upon an exciting new color scheme for redecorating the intensive care unit. “Blue?”

I wheeled the crash cart down. Back in her room, one of the other nurses had straddled the old lady and begun doing chest compressions, breaking a few of her ribs in the process. We all seemed to share the unspoken knowledge that what we were doing was protocol, etiquette, the proper thing to do; it had very little to do with actually saving the lady’s life.

Eventually, the emergency room doctor came strolling on up. He stood there and watched.

The nurse broke one of her fingernails on Mrs. Silva’s chest.

“That’s it,” the doctor said abruptly. He lifted his hands and held them briefly in midair — a gesture originally copyrighted by Pontius Pilate. “What time is it?”

“Four twenty-four.”

“Angela Silva died at 4:24 a.m.”

And that was that.

I stood there for a second, not so much stunned as disoriented. I felt terrible. I had violated the great unspoken law of medical practice: never let them die on your shift.

After a second, matter-of-factly, I began switching off the intravenous pumps, removing the electrodes.

Business as usual in a large metropolitan hospital.

Dying alone in a hospital bed: everyone’s worst nightmare.

My first day in nursing school, my nursing instructor — a robust young woman whose ardent idealism took the form of referring to her students as “her little novitiates” — posed a sample real-life situation to the nursing class: suppose you and a doctor were standing on either side of a patient and that patient vomited.

What do you do?

One of the more enterprising members of the class raised her hand: “You turn the patient’s head to the side.”

Ah! Well and good. But which side do you turn the patient’s head to?

“Your side,” our instructor told us. “You don’t want the patient vomiting on the doctor.”

Doctors make decisions; nurses carry them out. Doctors, it is true, are more intensively trained: four years of college, four years of medical school, several years of internship and residency — a kind of indentured servitude in a hospital setting during which sleep deprivation and overwork are used to teach physicians the fine art of medical intervention. After this, depending upon how specialized a physician wants to become, there are a wide option of fellowships and more intensive training to choose from.

A staff nurse’s training is far less extensive. Although the trend these days is towards baccalaureate nurses with four years of college behind them, there are still nurses who practice competently after two years of training in a clinical setting.

Still, you have to ask yourself: why does a person have to have a rigorous course of medical education that lasts over ten years to prescribe Tylenol for a hospitalized patient with a headache?

Because that’s the line of command.

Nurses are legally prohibited from making any kinds of diagnoses or intervening directly. They are not allowed to exercise their knowledge or judgment independently. They function invisibly behind the physician’s mandate. The vigilant nurse in the nonteaching hospital is forever faced with a daunting prospect: at three o’clock in the morning, when Mr. Plunkett complains of unusual chest pain from his cardiac care unit bed, does she shoot him up with another three milligrams of morphine or does she brave the wrath of the on-call doc, pick up the telephone, and beg for a 12-lead EKG and a CPK with isoenzymes?

Nine times out of ten, of course, nothing will be wrong: the tenth time, however, Mr. Plunkett will have a dissecting aneurysm. Nine out of ten times, as well, the doctor on the other end of the line will be resentful, sarcastic, and feel justified in taking out upon the hapless nurse the frustrations of his job — an extremely well-paying job, of course, but at three o’clock in the morning, who’s counting?

The choice of pronoun — “his” — in the sentence above is deliberate. While the number of women in the medical profession has increased dramatically in the last 20 years, the culture of the profession remains predominantly male. You can see it most clearly in MDs’ lamentable tendency to refer to their patients by diagnoses and room number — “the hepatic cancer in 301” — objectification on a mass scale. Distance. Physicians display, too, an arrogance that is characteristic of anyone who sits at the top of the gender hegemony: I have seen doctors plunge their unwashed hands straight into gaping abdominal wounds; I have watched them stride into immunosuppressed patients’ rooms, ignoring the Protective Isolation signs on the door that caution all visitors to mask and gown, as though exempt from the microorganismal colonizations that infest lower humans.

People are almost always afraid of anyone who sees them naked. For that reason, they often deliberately choose not to recognize these people, to defocus, to render them — for all intents and purposes — invisible. In a hospital setting, patients do this either by ignoring their caretakers as individuals or by projecting upon them — the beneficent godlike doctor, the officious Nurse Ratched — stereotypes that do not strictly belong.

Hospitals are large, anonymous places where individuals are stripped of everything that is not essential to their disease. Personality is irrelevant. You are stripped of the clothing that you’ve carefully chosen to provide the world with clues to who you really are and issued a backless blue hospital gown. You are assigned to a room with a bed, a call-button, and, if you’re lucky, a television — a decor that is impossible to personalize. You are trapped in an institution where you know neither the rules nor the language, but where any of the staff members have access to your most intimate secrets merely by flipping open your medical chart or peering at the contents of your bedpan.

The myth of medical confidentiality, of course, would like you to assume that none of your secrets ever get talked about. But of course they do. It’s the favorite chat in nurses’ break rooms next to gas mileage and family vacations.

Confronted by this relentless dehumanization, patients usually pick one of two options — denial or regression. Denial is easy; one smiles and never looks at a face or a name tag. Regression is more complicated.

Mr. Jackson had a problem. There were the obvious facts of his incontinence, his aphasia, his paraplegia, and the impending nature of his slow and ghastly painful death: cancer cells were methodically turning his spine into one big snap, crackle, and pop. But more serious than that, there was his roommate. The roommate was a man in his 70s who was suffering through a mild bout of congestive heart failure. His roommate was regressing. “Oh, Mama. Oh, Mama. Come and help me make caca. Caca now. The doctor wants me to make caca. The Virgin Mary wants me to make caca. You,” fixing me with a baleful eye, “make me make caca right now.”

“I’d love to, Mr. Macris,” I sang out sweetly. “But unfortunately, £j you’re not my patient.”

I hovered over Mr. Jackson with the suction tubing in my sterile gloved hand. Mr. Jackson’s chest sounded like a sink that was having trouble draining. Mr. Jackson’s chest was brimful of a. gunk. The gunk was described in the nurses’ notes from the night before as “thick green foul-smelling sputum with grey and maroon 3 flecks,” but I had to take the night nurse’s word for it, because Mr. Jackson had interpreted my air of generalized anxiety as a sign of incompetence and gritted his teeth every time I waved the suction 5° under his nose.

Mr. Jackson was probably right....

“Open, open, open,” I crooned.

“I can’t open,” yelled Mr. Macris. “Caca won’t come. Caca won’t come! You!” he hissed. “I’ve got your number! You better pray to the Virgin Mary you never end up like this!”

(I do, Mr. Macris. Every night. Believe me.)

Mr. Jackson glared malevolently at me and then in an act of supreme passive aggressiveness, produced the biggest bowel movement I had ever seen.

All over his sheets.

I looked at him lying there, at his fierce but frightened glance. Insight comes at the oddest moments: for one split moment, I was seeing through his eyes. All these huge women in white, scowling at him, scolding him, shaking their fingers at him. You make caca? Bad boy. It’s total regression. It swings him right back to those earliest, pre-rational days when his life and his psyche were totally run by enormous, domineering females.

How can a hospital setting possibly be therapeutic in the least for an elderly person?

Regression occasionally verges on genuine craziness.

One morning, I walked into a patient’s room and the patient handed me what looked like two dried mushrooms on a grimy paper plate. She looked at me expectantly, a child waiting for help with its construction-paper project.

Alma Peterkin had been hospitalized with terminal breast cancer. A cheerful, wizened little lady, Alma had lived her entire life in the same decaying Victorian mansion in which she had been born, with three equally batty sisters and their 14 cats. Once an upscale address, the construction of a freeway and the subsequent invention of billboards and boom boxes had turned their grand thoroughfare into the heart of the inner city. Alma and her sisters never left the house. Alma’s sisters had finally carted her off to a doctor when the brown lizard scaling on her chest grew so pronounced that they became afraid one of the cats would catch it.

There was a large patch of what looked like green and brown lichen where Alma’s breasts used to be. The smell that issued from it was sweet but nauseating, the musty scent of decomposing human flesh. The metastases were far advanced into her bone and lungs. But Alma was not in any pain.

“Can you put these back on for me?” Alma asked.

I smiled, uncomprehending.

“I’d put them back on myself but I don’t know how,” she said. “But you’re a nurse, you know about these things, can you...?”

I blinked. Wait a minute. The peyote buttons. They were her...nipples.

Alma continued to stare at me, her eyes wide with the moist and childlike entreaty of the truly insane.

Hospitals are sensory-deprivation environments. To successfully occupy them as a nurse, you must sustain one of two mental attitudes.

Either you must become totally, exhaustively absorbed in the tasks at hand: every drop of urine that trickles through the catheter tubing must be counted, must be reported back to the physician in charge with full expectation that it is somehow significant; every transient rise and fall in blood pressure must be recorded on a piece of paper especially designed for that purpose and monitored intently, fluctuations in the stock-and-bond market of the corpus. Or you become the perfect codependent: your patients become your family; you stay long after your shift is over to remain by their side; you have no family of your own. Nurses see it all but physicians get to decide what to do about it. Often a physician’s reading of vital information is lax; nine-tenths of any nurse’s job consists of ingratiating herself (or in those few rare cases, himself) with the physician sufficiently so that the doctor will pay attention to what the nurse tells him.

And frequently a nurse’s job is to tell the physician that any further fact-gathering missions are irrelevant to a patient’s care.

The doctors don’t often listen.

Raymond Arroyo was a 21 -year-old boy with acute lymphocytic leukemia. He was dying, although medical technology was doing everything it could to conceal this fact from his simple, superstitious, impoverished Chicano mother. Steroids, antibiotics, twice-daily blood counts, weekly lumbar punctures — you name it, your tax dollars paid for it. He had relapsed after treatment for the third time in less than five years.

I overheard a doctor talking up a new cisplatin regimen to his mother. Chemotherapy mimics chemical warfare — British soldiers at Ypres in 1917, exposed to mustard gas, showed a marked regression of tumors before they died in intractable agony.

The physician presented the options to Raymond’s mother. What she heard him say: “He has relapsed, but we think there is a 20 percent chance that we can get him into remission with an aggressive course of treatment.”

What she did not hear him say: “There is an 80 percent chance that your son will die — in a month or a week or a day.”

Death came, as it turned out, three days after the new chemotherapy was started.

Raymond developed a pain in his chest.

“I think it’s very important that we figure out what’s going on with Raymond, where the actual source of his pain resides,” the doctor told us during rounds in a firm voice and scheduled Raymond to be transported several floors down for a computerized axial tomography scan. Raymond, by this time, looked like a human x-ray himself, pale, cachectic; except for a rare moan, unresponsive.

“He’s much too unstable to transport,” I objected.

The doctor stared at me icily. ‘‘I see the nurses are getting hysterical,” he said. “Let me tell you something — you’re not paid to have opinions.”

Raymond died in the elevator on the way down.

The word “nurse” itself, of course, superimposes the solicitude of the loving mother onto the grim experience of blood draws, IVs, catheters, and strange pharmaceutical reactions that are the reality of most patients’ hospital stay; as though the default experience is one of pampering, chicken soup, and a get-well kiss upon the forehead. Of course, nothing could be farther from the truth. Still, many nurses do grow to love their patients, in a manner of speaking. It is not always what pop psychologists might call a healthy relationship; in fact, it often borders on obsessive attachment. Ego boundaries blur. It is often hard to distinguish whether it is the patient or the disease process that the nurse is more devoted to.

At coffee break time, a nurse’s fancy turns to pathology — patients’ illnesses, of course, but more significantly, her own.

“My ulcer has really been acting up lately,” remarks one nurse, hoisting up her support hose. “But I’m already on the highest dose of Tagamet I can take.”

“My back is killing me,” sighs another. “My doctor tells me to find some other line of work. He’s ready to write up the forms for permanent disability any time. But we couldn’t live off that. How’s your migraine, dear?” turning solicitously to a nurse stretched prostrate on the stained and lumpy couch.

In any occupation that deals intimately with people in extremis, it stands to reason that some of the pain will be internalized by caretakers. Ill people are often abusive people: intense experiences of any sort retract consciousness; illness in particular shrinks the human attention-span to the dimensions of a sickly, malfunctioning body. Not much is left over for niceties of discourse.

Among your duties as a healing professional is a ceaseless, relentless cheeriness. With your palms upraised and open, your head tilted to one side, the right side, you participate in therapeutic discussions with your patient designed to reflect back to them the realities of their own frustration. You make yourself invisible.

Patient to angel of mercy: “I hate this zoo! I hate you!”

“I hear you experiencing emotional stress, Mr. Jones!”

Every nursing journal contains at least two stories about the crusty patient who adds insult to injury with a verbal attack while the nurse attempts to take a blood pressure or pass a medication; the selflessly compassionate way the nurse straegizes, via lengthy written care plan, to redirect that patient’s anger; the subsequent revelation: Mr. Jones really isn’t that bad.

Putting up with abuse is part of your job, you are told. Just as staying hours past the end of your shift to catch up on your charting is part of your job. (And you never enter these hours upon your timecard.)

You’re a bad nurse if you set limits.

Sometimes the abuse isn’t verbal.

One day, seven-year-old Rashaad Green got an idea: what a blast it would be to go back to that abandoned house where he had found that half-empty can of gasoline. Only this time, they’d take a book of matches.

And a blast it was....

Rashaad got 3 of his Andy Warhol-guaranteed 15 minutes of fame on the local newscast that night. As fate would have it, the father who abandoned Rashaad and his mother when Rashaad was three months old was watching that channel in a neighborhood bar. Hours later, Melvin Green showed up in the pediatric intensive care unit where all the burn patients were interned. “That’s my boy you got there,” he informed the doctors and nurses. “You do right by my boy— ” finger jab to stethoscope — “I be watching very carefully to see that you do right by my boy.”

The hospital had very liberal visiting policies for distraught parents. They hardly ever had to leave the bedside if they didn’t want to. This proved convenient for Melvin Green who, as it turned out, had just been kicked out of his most recent living arrangement and had no place else to go. Rashaad’s mother clearly feared the menacing presence of the man who had fathered her child; once he moved into Rashaad’s isolation room, she stopped visiting. “Mommy, Mommy,” the child would whimper, looking around only to meet the eyes of a man he didn’t know, telling him harshly, “I’m here now, little man.”

The child continued in intractable pain. He had sustained deep tissue burns over more than 70 percent of his body, arms, thighs, chest, lungs, and face. He lay enswathed in bandages. They were white when they were first put on but quickly grew discolored as blood and pus and serous fluid seeped through them. Twice each day, the bandages were changed — once after Rashaad’s whirlpool bath, and once during my shift. Rashaad screamed: no matter how much morphine was shot into the boy’s precarious deep-line IV access, it wasn’t enough.

Melvin Green watched the morphine injections with particular interest. Several times the used syringes were missing from the room afterwards.

From the start, he didn’t like the way I changed the bandages. “You do it too slow,” he told me. “You gotta rip them off fast.”

“Mr. Green, I’m the nurse here. Rashaad’s wounds get debrided when they take him down to the whirlpool every day. I don’t want to cause him unnecessary discomfort.”

And Melvin Green would glare at me with little, red-rimmed eyes.

This went on for weeks and weeks.

One night, Melvin Green was asleep on an easy chair, his feet on a cassock, when I walked into the and his mouth half open, each snore propelling the smell of stale alcohol into the boy’s world. The room was dark. Without turning on the light, I laid out supplies for the dressing change on the portable bedside table: sterile gloves, white gauze 4x4s, betadyne, half-strength normal saline, jars of thick white silver sulfadiazine cream, mummy shroud bandages. I glanced at the clock: almost time to draw an arterial blood gas. Might as well get that one out of the way too.

Syringe in hand, I approached the bed.

“What the hell do you think you’re doing?” Melvin Green had woken up. And he looked even meaner than usual. “I’m doing what I usually do this time of the night, Mr. Green. I’m drawing an ABG. And then I’m going to change your son’s bandages.”

Melvin Green was shaking his head. “Oh, no, you ain’t. You ain’t doing nothing. I ain’t going to have you people sneaking in here when I’m asleep.”

“I see. So you’d prefer it if I woke you up next time?”

He narrowed his eyes. “Don’t you go smarting off at me, girl.” His clothing rustled and I saw that he had pulled something from his pocket.

A gun.

A flat, silver-barreled, plastic-gripped gun.

It looked ridiculously small lying in his lap.

He was grinning at me. It was the first time I had ever seen him smile.

I turned and left the room. Except for the isolation rooms, the pediatric intensive care unit was an open ward: the glare and hum of a busy hospital ward was all around me. The gun in Rashaad’s darkened isolation room — had it really happened? Had I imagined it?

One thing I knew: I didn’t want to go back into that room.

Seconds later, Melvin Green came out of the isolation room, hands in pockets, head down, walking fast. He stumbled once and kept going.

When the locked doors of the unit had closed behind him, I paged the nursing supervisor.

She listened to my story with her head cocked to the right side and her palms upraised. “You have to look at it from Mr. Green’s point of view, dear,” she said. “You have to realize...”

Realize what? That a man had threatened to kill me? That fielding death threats were apparently part of a nurse’s job?

The incident happened nine years ago. Security has improved since then in the wake of hospital shootouts and hostage situations and more than a few emergency room raids by disgruntled patients. Nursing supervisors have not.

The first years spent in the medical environment are adrenaline-charged, filled with the excitement of the front lines. Everyone gets addicted to the constant state of crisis. But few provisions are made for R and R; it’s difficult to decompress.

In hospital lingo, this is called “burnout.”

A burnt-out nurse hates her patients. The patients who constantly complain; the patients who are constantly hitting the call-button for no other reason than to make her jump; the profane, loud, or boorish patients whose favorite movie is apparently Night Nurses in Bondage. The 250-pound female patient who wedged two tampons up her vagina sometime during the last month or so (she’s a bit vague about dates) and now needs help. Or the constipated patient who requires a little manual disempaction.

Burnt-out nurses hate doctors too.

Burnt-out nurses seek revenge.

Burnt-out nurses move slowly and resentfully through the hospital halls when a patient’s call light flickers on. Perhaps the patient’s IV bag has run empty. The patient waits for many minutes for the nurse to reappear with a new bag of solution. Only by the time the nurse shows up, something has happened to the IV access site. The solution won’t drip in anymore. “Whoops!” says the nurse. “Guess that one is dead.” It takes her three times with an 18-gauge needle before she can start another IV. It takes her another hour and a half before she gets around to changing the bloodied sheets.

There are special tricks to use on doctors. A favorite one is to wait until four in the morning to phone in that request for a glycerin suppository. Another favorite: dial the doctor’s beeper number and code in a number so he’ll call himself back. Some doctors catch on quick; with others, the beeper routine provides hours of entertainment, something like a cat chasing its tale or a hamster in its wheel. Perpetual motion.

Most nurses choose their occupation because they feel compassion for people in pain. They want to help. And most nurses remain committed to quality care even after many years on the job.

Nurses pass through your lives largely unseen. But we see you. We are there when you’re born and we’re there when you die.

Got an operation coming up? Be afraid. Or better yet: be polite.