I picked up Mitch Albom’s The Little Liar wondering if I needed to read another story about the Holocaust. I almost didn’t check it out. We live in a world at war. We live in a world where starvation, strife, and civilian casualties are collateral damage of those wars. Yet war continues to be waged. I am glad I checked the book out. I read it in less than twenty-four hours. A unique voice serves as narrator in The Little Liar. It is Truth. Albom masterfully uses that narrator to explore the meaning of truth and to illustrate the horror of man’s inhumanity to man. Four characters, Nico, his brother Sebastian, Fannie, and Udo pull the reader into the story and demand the reader’s attention from start to finish. In a way, their stories have been told before, but as written, they seem startlingly fresh and compelling. In the context of what’s happening in the world, their stories are more than relevant. Rather than mar the story by retelling it, I want to share what I call the wisdom of Albom. “Never be ashamed of a scar. In the end, scars tell the stories of our lives, everything that hurt us, and everything that healed us.” “But questioning a madman is like interrogating a spider. They both go on spinning their webs until someone squashes them out of existence.” “How could fishing boats keep rolling so innocently? How could the world eat when all those prisoners were starving? How could things look so terrifyingly normal here…?” Why do world leaders create scenarios where these questions still are relevant today? Read this story. Keep asking the question. Why do we still wage war?
Quiet Horror
I am not a sommelier, but I do know what wines I like. I am not a movie critic. I have friends who critically analyze movies, their production, stories, costumes, and acting. Not me. Having said that, I do not take lightly writing about The Zone of Interest. It still haunts me. I read the novel by Martin Amis before watching the movie. Usually, books satisfy me more than the movie productions of them. Not so in this case. The opening scene portrayed a family outing. Men wore swimsuits like the one my dad wore when he took me to the local pool and taught me to swim. Women and children sat on blankets spread across the grass. A river lazed in the background. What it didn’t show, but what I knew from reading the book, was this all took place in the shadow of a death camp. It registered for me as quiet horror. No audible dialogue, just the establishment of an atmosphere that was down to earth while being obscene for someone who knew the secret of the setting. Throughout the movie, ordinary people did their jobs, followed orders, created innovative machines, even fought to remain in the penumbra of Auschwitz, with little reference to the people who suffered and died. In one scene, women quibbled over who would take what from a collection of garments confiscated from prisoners. I couldn’t help but see vultures picking over the flesh of dead animals. What gut-punched me the most was a scene, not from the 1940s, but a modern scene in which uniformed workers cleaned the floors of a what seemed to be a Holocaust Museum. Again, no dialogue, just people doing their jobs as if they either did not know or had become immune to the context. Encased in glass, a mountain of shoes stood in the background. Another quiet horror. I remember my shock and grief when I saw a similar display at the museum in Washington, D.C. It made visible and real the number of lives taken during the Holocaust. I often think of The Zone of Interest in a world at war in so many places. I must wonder if, because of our responsibility for mundane tasks and day to day survival, do we become immune to the quiet horror of man’s inhumanity to man? The Zone of Interest helps keep me from becoming so.
Has Medical Specialization and the Business Model in Health Care Given Rise to Google, MD?
As a nurse, my family sought my advice over the years. I never practiced medicine without a license and stuck mainly to my specialty, Cardiovascular Nursing. If people asked me about pregnancy, I used the line “I don’t know nothing ‘bout birthin’ no babies.” I learned more about labor and delivery from Call the Midwives than I did from a clinical rotation forty some years ago.
With time, my advice took second chair to a new pundit, the internet. My mom asked me things, I advised, she argued. She would quote something she “Googled.” When a close relative developed cancer, she prepared for long distance care at a Cancer Treatment Center she read about until I reassured her that for her type of cancer, therapy at home would be more than satisfactory.
I agreed with the doctors at work who disdained Dr. Google or Google, MD. But then I had easy access to talented professionals amenable to “curbside consults.” I felt light-headed at work one day. I mentioned it to a colleague, a cardiologist. I had a stress test within a week.
Now that I have retired, I experience patienthood in an entirely new way. It started with a little light-headedness. No. Not a little. A lot. Bad enough to call 911. The red ambulance rolled up with lights flashing. I never felt so relieved as I did when the gurney rolled into the foyer of the fitness center. By the time they did a blood pressure, a blood sugar, an O2 sat, and looked at my EKG, I felt better, well enough to go to the bathroom and drive myself home.
I did what I would have told anyone. I went to my PCP the next day. He drew labs and did an EKG. My heart rate was, hold it, take it in, thirty-six. My heart had been bradycardic for years, but a rate below forty scared me. I’d been to a cardiologist before, so I called his office to schedule an appointment. When you imagine your heart might slow to a stop, you don’t want to wait around.
This is where the fun began. Despite the fact that I had seen this doctor and had a near “syncopal” episode, I hadn’t seen him often enough, so I was considered a new patient and couldn’t get an appointment for a month. Imagine me going to sleep at night with my index finger palpating my carotid artery to make sure my heart was still beating. Yup. That was me.
Thanks to Facebook and a few good friends and the fact that health care professionals treat each other like family, my appointment got moved up. I only had to wait a few days. My heart had to behave for a little while longer. However, I was warned that the doctor was extremely busy and that sixty patients were scheduled in the office that day. Whether you’re a nurse or a lay person, when it is your heart that is thinking about quitting, retiring from the rat race, going on hiatus, you don’t give a damn about anyone else’s problems whether it’s a cold sore or an office trying to make a buck.
When the doctor with whom I had worked for years walked in, I knew he recognized me, although he wasn’t sure from where. Yeah doc, I was the one who took care of all your very sick, high risk patients who agreed to participate in the trial of the procedure that revolutionized aortic valve repair. I worked hard with the unknowns and celebrated successes that changed the horizon for cardiac interventions. Guess what? I don’t give a damn about all that. I want you to NOT diagnose me in a five-minute office visit and exam. I want you to let me know you know all of my history, my MS, my anti-phospholipid syndrome, my meningioma, my very bad reflux, my hiatal hernia, the fact I have engaged in some sort of physical training since I was six years old. not just my heart history. But he chose the five-minute route. So, I went home and chatted with Google, MD.
Dr. Google mentioned sometimes a hiatal hernia can cause the exact same symptoms I was having, which was a relief, except it made me wonder if I should visit my GI doctor. I wondered if my meningioma was getting bigger and causing increased intracranial pressure and bradycardia. See my neurosurgeon? I wondered if I had thrown a clot to my lung again. Oh, did you not know about that? It’s on the paperwork, initially labeled incorrectly with someone else’s name. Call the pulmonologist. I had already done that.
You get my drift. In a perfect world, maybe all involved in my care could conference call and coordinate a plan. Since all my health care problems reside in one body, mine, maybe it would be helpful to consider them all before proceeding. Thanks to medical specialization and the business model of medicine, that will never happen. To be the best advocate for myself, I will draw from my experience, consult Dr. Google, and hope I make the right decisions.
The Second Amendment Blues
The month of June from any old calendar in a spider webbed, abandoned garage. A picture of a woman whose breasts spill around two tiny triangles of diaphanous fabric. You know the one I mean. Her nipples punctuate the centers of each. She straddles a Harley-Davidson and ogles the barrel of a gun, its size distorted by the photographer.
In Starbucks a man fumbles for his wallet, pulls back his jacket, and exposes a carved mahogany gun handle. A man in low-riding jeans shops at Walmart, bends over to grab a fifty-pound bag of dog food. His t-shirt pulls up. The handle of a Smith and Wesson beckons from his butt crack.
Mine’s bigger than yours.
Some people see guns as phallic symbols, some merely as weapons of defense. I carry my own weapon of defense, a silent partner, a barrier that protects me from encroachment by the intolerable. Depression. Religion promises the Savior walks a path with the faithful. My intimate friend, depression, rides within. I slide back the panel to the hidden compartment in my bed’s headboard and sequester my gun there. I want easy access to the tool of my exit strategy.
Although I don’t remember it, I suspect I experienced depression the first year of my life, the year I learned I wasn’t worthy. My mother told me a story. “You learned to swim in urine because I was too tired to change your diaper. You never cried.”
Not worthy of a clean diaper. Praised for holding back my tears. Learning to survive.
My Mom in post-partum depression, I diagnosed in fifty or so years of retrospect and after forty years a nurse. A gene passed on to a daughter? A mother’s gift?
Days on my bike. Hours away from home. I found a steep hill at the middle school and pushed off. My feet hovered above the brake pedals. I imagined my metallic midnight-blue bike a flying unicorn. With my stringy blond hair whipping in the wind, I sped down the bumpy, stone encrusted hill. My gaping mouth shrieked in glee and fear. I didn’t want to die. I wanted to fly and land in a place where if my mother looked at me, she really saw me, and maybe even liked me. A place where I liked me.
A diary of lasts and leasts. The last girl in my class to get her period. The girl with the flattest chest. The girl with the fewest choices for dress shoes to wear to the sixth-grade dance because of her shoe size. Adolescence ravaged my face. Loneliness gutted me, either with, or because of, the distorted world view of an introvert, a label I didn’t understand at the time. I zeroed in on every dead bird in a storm drain after a heavy rain, every daffodil flattened by tornadic winds.
A taste of love. My first true love I lost to miles and time and adversarial politics. I learned people break-up for reasons more powerful than the comfortable familiarity of a friend who fumbles through a first kiss and heated pleasure with no shame. The next love, an insecure adolescent, lost on some now-well-named spectrum, who dropped out of his collegiate rat race, showed up on my doorstep, the date of his last bath unknown, his face familiar through the thick lenses of Lennon-like wire-framed glasses. After I encouraged him to shower, we explored each other. His mouth left a purple bruise on my breast, and he took off. He wrote an acerbic good-bye, rife with blame, on pieces of toilet paper. Thankfully unused.
Then the university. Miles away from home. People with whom I had no connection. I drank until I cried in chest-heaving sobs. My sorrow, so powerful, convinced my roommate I had been raped. Not my body, just my heart. I didn’t sleep. Studied all night. Took a Spanish final exam, answered all the questions in French. Hungover in two foreign tongues. I need a gun.
My career grounded me, then ground me down. A caretaker, a professional nurse. A person in control challenged by the exponential changes occurring in technology and in the role designated as the “handmaiden of the physicians.” Responsibility without rights. Accolades for successes and the demonstration of newly acquired knowledge; blame for failures that meant loss of life. Sleepless nights. What did I do wrong? Could I have done more? Retracing every drug administered, every vital sign documented, every word spoken to the patients, to the families, to the doctors, to the bleary-eyed face in the mirror. I need a gun.
A son. The greatest joy. I promised I would never make him feel unworthy. Even when I went to visit him in jail. On Mother’s Day. On his birthday. I failed. On that day I left before our time was up. I made another promise, loud and honest and unwavering. “If this happens again, I won’t be visiting you in jail when I’m fifty.” I need a gun. My feet burn constantly. I know I am not walking on hot coals, but occasionally I look down, hoping I am. Because if I am, I can step off them and the pain will stop. One day I touched the outside of my slow cooker. A blister erupted where my skin brushed against the stainless steel. My hands feel like that every day. I worry about pissing myself. When I awaken, vision blurry from sleep, I fear I am going blind. My body attacks itself. I need a gun.
Today I have had enough.
Sitting on the edge of my bed, I considered the pills I collected over the years from various therapists. They half-filled the plastic, amber container with the child-proof cap. It opened with a push and a twist. I re-engaged the cap. It snapped into place. I rolled the container between my palms as if I were shaping clay. The pills skittered, no tickety-ticked, against the plastic and sounded like mice playing, unseen, behind wallboard. I saw myself drifting away dreaming of the perfect life I should have, but not sure what it should be. I knew my heart would slow and become erratic, would struggle to thrust every drop of blood out toward the ends of my body. I knew my breathing would stop, a task forgotten. Then I saw rescuers and intubation and hospitalization and questions and anti-depressants and the guilt-laden faces of my family.
I think of the garage where my pink Peugeot mountain bike hangs on hooks, unused. A battered filing cabinet organizes instruction manuals for the coffee pot, the generator, and the robotic vacuum I named Frisbee. Hand-made Mother’s Day cards with a childish scrawl, pictures from innumerable seasons of sports, and vet records of a favorite cat, long dead, crowd the top of one drawer. How easy it would be to leave surrounded by these bits of history. A bottle of wine, my favorite pillow, the made-in-China blanket with the Grand Canyon on it, iPhone, and ear buds. So easy to start the car, listen to music, take one final trip.
My first job I cared for a girl the EMS brought to the ICU. Cherry red lips, in a perfect application of color, belied the displacement of oxygen by carbon monoxide on the blood. It starved her brain of oxygen and left a robust, young body without a command center. I didn’t know what happened to her after she left ICU, but I knew the consequences of complete immobility.
I thought about a gun. Any gun. I wouldn’t put it in my mouth and pseudo-fellate it. I understood recoil and the chance for a misfire. A bullet pushing through my palate, exploding an eye, ripping through my cheek, or, worst of all, trashing my sanctuary of words. No. I would press the muzzle under my chin just above my Adam’s Apple and I wouldn’t give myself time to think. The move would be swift and smooth and sure and my finger would be poised to pull the trigger. A blast to the brain stem. No more worries about being worthy. The perfect exit strategy.
Thank God I don’t own a gun.
The month of June from any old calendar in a spider webbed, abandoned garage. A picture of a woman whose breasts spill around two tiny triangles of diaphanous fabric. You know the one I mean. Her nipples punctuate the centers of each. She straddles a Harley-Davidson and ogles the barrel of a gun, its size distorted by the photographer.
In Starbucks a man fumbles for his wallet, pulls back his jacket, and exposes a carved mahogany gun handle. A man in low-riding jeans shops at Walmart, bends over to grab a fifty-pound bag of dog food. His t-shirt pulls up. The handle of a Smith and Wesson beckons from his butt crack.
Mine’s bigger than yours.
Some people see guns as phallic symbols, some merely as weapons of defense. I carry my own weapon of defense, a silent partner, a barrier that protects me from encroachment by the intolerable. Depression. Religion promises the Savior walks a path with the faithful. My intimate friend, depression, rides within. I slide back the panel to the hidden compartment in my bed’s headboard and sequester my gun there. I want easy access to the tool of my exit strategy.
Although I don’t remember it, I suspect I experienced depression the first year of my life, the year I learned I wasn’t worthy. My mother told me a story. “You learned to swim in urine because I was too tired to change your diaper. You never cried.”
Not worthy of a clean diaper. Praised for holding back my tears. Learning to survive.
My Mom in post-partum depression, I diagnosed in fifty or so years of retrospect and after forty years a nurse. A gene passed on to a daughter? A mother’s gift?
Days on my bike. Hours away from home. I found a steep hill at the middle school and pushed off. My feet hovered above the brake pedals. I imagined my metallic midnight-blue bike a flying unicorn. With my stringy blond hair whipping in the wind, I sped down the bumpy, stone encrusted hill. My gaping mouth shrieked in glee and fear. I didn’t want to die. I wanted to fly and land in a place where if my mother looked at me, she really saw me, and maybe even liked me. A place where I liked me.
A diary of lasts and leasts. The last girl in my class to get her period. The girl with the flattest chest. The girl with the fewest choices for dress shoes to wear to the sixth-grade dance because of her shoe size. Adolescence ravaged my face. Loneliness gutted me, either with, or because of, the distorted world view of an introvert, a label I didn’t understand at the time. I zeroed in on every dead bird in a storm drain after a heavy rain, every daffodil flattened by tornadic winds.
A taste of love. My first true love I lost to miles and time and adversarial politics. I learned people break-up for reasons more powerful than the comfortable familiarity of a friend who fumbles through a first kiss and heated pleasure with no shame. The next love, an insecure adolescent, lost on some now-well-named spectrum, who dropped out of his collegiate rat race, showed up on my doorstep, the date of his last bath unknown, his face familiar through the thick lenses of Lennon-like wire-framed glasses. After I encouraged him to shower, we explored each other. His mouth left a purple bruise on my breast, and he took off. He wrote an acerbic good-bye, rife with blame, on pieces of toilet paper. Thankfully unused.
Then the university. Miles away from home. People with whom I had no connection. I drank until I cried in chest-heaving sobs. My sorrow, so powerful, convinced my roommate I had been raped. Not my body, just my heart. I didn’t sleep. Studied all night. Took a Spanish final exam, answered all the questions in French. Hungover in two foreign tongues. I need a gun.
My career grounded me, then ground me down. A caretaker, a professional nurse. A person in control challenged by the exponential changes occurring in technology and in the role designated as the “handmaiden of the physicians.” Responsibility without rights. Accolades for successes and the demonstration of newly acquired knowledge; blame for failures that meant loss of life. Sleepless nights. What did I do wrong? Could I have done more? Retracing every drug administered, every vital sign documented, every word spoken to the patients, to the families, to the doctors, to the bleary-eyed face in the mirror. I need a gun.
A son. The greatest joy. I promised I would never make him feel unworthy. Even when I went to visit him in jail. On Mother’s Day. On his birthday. I failed. On that day I left before our time was up. I made another promise, loud and honest and unwavering. “If this happens again, I won’t be visiting you in jail when I’m fifty.” I need a gun. My feet burn constantly. I know I am not walking on hot coals, but occasionally I look down, hoping I am. Because if I am, I can step off them and the pain will stop. One day I touched the outside of my slow cooker. A blister erupted where my skin brushed against the stainless steel. My hands feel like that every day. I worry about pissing myself. When I awaken, vision blurry from sleep, I fear I am going blind. My body attacks itself. I need a gun.
Today I have had enough.
Sitting on the edge of my bed, I considered the pills I collected over the years from various therapists. They half-filled the plastic, amber container with the child-proof cap. It opened with a push and a twist. I re-engaged the cap. It snapped into place. I rolled the container between my palms as if I were shaping clay. The pills skittered, no tickety-ticked, against the plastic and sounded like mice playing, unseen, behind wallboard. I saw myself drifting away dreaming of the perfect life I should have, but not sure what it should be. I knew my heart would slow and become erratic, would struggle to thrust every drop of blood out toward the ends of my body. I knew my breathing would stop, a task forgotten. Then I saw rescuers and intubation and hospitalization and questions and anti-depressants and the guilt-laden faces of my family.
I think of the garage where my pink Peugeot mountain bike hangs on hooks, unused. A battered filing cabinet organizes instruction manuals for the coffee pot, the generator, and the robotic vacuum I named Frisbee. Hand-made Mother’s Day cards with a childish scrawl, pictures from innumerable seasons of sports, and vet records of a favorite cat, long dead, crowd the top of one drawer. How easy it would be to leave surrounded by these bits of history. A bottle of wine, my favorite pillow, the made-in-China blanket with the Grand Canyon on it, iPhone, and ear buds. So easy to start the car, listen to music, take one final trip.
My first job I cared for a girl the EMS brought to the ICU. Cherry red lips, in a perfect application of color, belied the displacement of oxygen by carbon monoxide on the blood. It starved her brain of oxygen and left a robust, young body without a command center. I didn’t know what happened to her after she left ICU, but I knew the consequences of complete immobility.
I thought about a gun. Any gun. I wouldn’t put it in my mouth and pseudo-fellate it. I understood recoil and the chance for a misfire. A bullet pushing through my palate, exploding an eye, ripping through my cheek, or, worst of all, trashing my sanctuary of words. No. I would press the muzzle under my chin just above my Adam’s Apple and I wouldn’t give myself time to think. The move would be swift and smooth and sure and my finger would be poised to pull the trigger. A blast to the brain stem. No more worries about being worthy. The perfect exit strategy.
Thank God I don’t own a gun.
The month of June from any old calendar in a spider webbed, abandoned garage. A picture of a woman whose breasts spill around two tiny triangles of diaphanous fabric. You know the one I mean. Her nipples punctuate the centers of each. She straddles a Harley-Davidson and ogles the barrel of a gun, its size distorted by the photographer.
In Starbucks a man fumbles for his wallet, pulls back his jacket, and exposes a carved mahogany gun handle. A man in low-riding jeans shops at Walmart, bends over to grab a fifty-pound bag of dog food. His t-shirt pulls up. The handle of a Smith and Wesson beckons from his butt crack.
Mine’s bigger than yours.
Some people see guns as phallic symbols, some merely as weapons of defense. I carry my own weapon of defense, a silent partner, a barrier that protects me from encroachment by the intolerable. Depression. Religion promises the Savior walks a path with the faithful. My intimate friend, depression, rides within. I slide back the panel to the hidden compartment in my bed’s headboard and sequester my gun there. I want easy access to the tool of my exit strategy.
Although I don’t remember it, I suspect I experienced depression the first year of my life, the year I learned I wasn’t worthy. My mother told me a story. “You learned to swim in urine because I was too tired to change your diaper. You never cried.”
Not worthy of a clean diaper. Praised for holding back my tears. Learning to survive.
My Mom in post-partum depression, I diagnosed in fifty or so years of retrospect and after forty years a nurse. A gene passed on to a daughter? A mother’s gift?
Days on my bike. Hours away from home. I found a steep hill at the middle school and pushed off. My feet hovered above the brake pedals. I imagined my metallic midnight-blue bike a flying unicorn. With my stringy blond hair whipping in the wind, I sped down the bumpy, stone encrusted hill. My gaping mouth shrieked in glee and fear. I didn’t want to die. I wanted to fly and land in a place where if my mother looked at me, she really saw me, and maybe even liked me. A place where I liked me.
A diary of lasts and leasts. The last girl in my class to get her period. The girl with the flattest chest. The girl with the fewest choices for dress shoes to wear to the sixth-grade dance because of her shoe size. Adolescence ravaged my face. Loneliness gutted me, either with, or because of, the distorted world view of an introvert, a label I didn’t understand at the time. I zeroed in on every dead bird in a storm drain after a heavy rain, every daffodil flattened by tornadic winds.
A taste of love. My first true love I lost to miles and time and adversarial politics. I learned people break-up for reasons more powerful than the comfortable familiarity of a friend who fumbles through a first kiss and heated pleasure with no shame. The next love, an insecure adolescent, lost on some now-well-named spectrum, who dropped out of his collegiate rat race, showed up on my doorstep, the date of his last bath unknown, his face familiar through the thick lenses of Lennon-like wire-framed glasses. After I encouraged him to shower, we explored each other. His mouth left a purple bruise on my breast, and he took off. He wrote an acerbic good-bye, rife with blame, on pieces of toilet paper. Thankfully unused.
Then the university. Miles away from home. People with whom I had no connection. I drank until I cried in chest-heaving sobs. My sorrow, so powerful, convinced my roommate I had been raped. Not my body, just my heart. I didn’t sleep. Studied all night. Took a Spanish final exam, answered all the questions in French. Hungover in two foreign tongues. I need a gun.
My career grounded me, then ground me down. A caretaker, a professional nurse. A person in control challenged by the exponential changes occurring in technology and in the role designated as the “handmaiden of the physicians.” Responsibility without rights. Accolades for successes and the demonstration of newly acquired knowledge; blame for failures that meant loss of life. Sleepless nights. What did I do wrong? Could I have done more? Retracing every drug administered, every vital sign documented, every word spoken to the patients, to the families, to the doctors, to the bleary-eyed face in the mirror. I need a gun.
A son. The greatest joy. I promised I would never make him feel unworthy. Even when I went to visit him in jail. On Mother’s Day. On his birthday. I failed. On that day I left before our time was up. I made another promise, loud and honest and unwavering. “If this happens again, I won’t be visiting you in jail when I’m fifty.” I need a gun. My feet burn constantly. I know I am not walking on hot coals, but occasionally I look down, hoping I am. Because if I am, I can step off them and the pain will stop. One day I touched the outside of my slow cooker. A blister erupted where my skin brushed against the stainless steel. My hands feel like that every day. I worry about pissing myself. When I awaken, vision blurry from sleep, I fear I am going blind. My body attacks itself. I need a gun.
Today I have had enough.
Sitting on the edge of my bed, I considered the pills I collected over the years from various therapists. They half-filled the plastic, amber container with the child-proof cap. It opened with a push and a twist. I re-engaged the cap. It snapped into place. I rolled the container between my palms as if I were shaping clay. The pills skittered, no tickety-ticked, against the plastic and sounded like mice playing, unseen, behind wallboard. I saw myself drifting away dreaming of the perfect life I should have, but not sure what it should be. I knew my heart would slow and become erratic, would struggle to thrust every drop of blood out toward the ends of my body. I knew my breathing would stop, a task forgotten. Then I saw rescuers and intubation and hospitalization and questions and anti-depressants and the guilt-laden faces of my family.
I think of the garage where my pink Peugeot mountain bike hangs on hooks, unused. A battered filing cabinet organizes instruction manuals for the coffee pot, the generator, and the robotic vacuum I named Frisbee. Hand-made Mother’s Day cards with a childish scrawl, pictures from innumerable seasons of sports, and vet records of a favorite cat, long dead, crowd the top of one drawer. How easy it would be to leave surrounded by these bits of history. A bottle of wine, my favorite pillow, the made-in-China blanket with the Grand Canyon on it, iPhone, and ear buds. So easy to start the car, listen to music, take one final trip.
My first job I cared for a girl the EMS brought to the ICU. Cherry red lips, in a perfect application of color, belied the displacement of oxygen by carbon monoxide on the blood. It starved her brain of oxygen and left a robust, young body without a command center. I didn’t know what happened to her after she left ICU, but I knew the consequences of complete immobility.
I thought about a gun. Any gun. I wouldn’t put it in my mouth and pseudo-fellate it. I understood recoil and the chance for a misfire. A bullet pushing through my palate, exploding an eye, ripping through my cheek, or, worst of all, trashing my sanctuary of words. No. I would press the muzzle under my chin just above my Adam’s Apple and I wouldn’t give myself time to think. The move would be swift and smooth and sure and my finger would be poised to pull the trigger. A blast to the brain stem. No more worries about being worthy. The perfect exit strategy.
Thank God I don’t own a gun.
The month of June from any old calendar in a spider webbed, abandoned garage. A picture of a woman whose breasts spill around two tiny triangles of diaphanous fabric. You know the one I mean. Her nipples punctuate the centers of each. She straddles a Harley-Davidson and ogles the barrel of a gun, its size distorted by the photographer.
In Starbucks a man fumbles for his wallet, pulls back his jacket, and exposes a carved mahogany gun handle. A man in low-riding jeans shops at Walmart, bends over to grab a fifty-pound bag of dog food. His t-shirt pulls up. The handle of a Smith and Wesson beckons from his butt crack.
Mine’s bigger than yours.
Some people see guns as phallic symbols, some merely as weapons of defense. I carry my own weapon of defense, a silent partner, a barrier that protects me from encroachment by the intolerable. Depression. Religion promises the Savior walks a path with the faithful. My intimate friend, depression, rides within. I slide back the panel to the hidden compartment in my bed’s headboard and sequester my gun there. I want easy access to the tool of my exit strategy.
Although I don’t remember it, I suspect I experienced depression the first year of my life, the year I learned I wasn’t worthy. My mother told me a story. “You learned to swim in urine because I was too tired to change your diaper. You never cried.”
Not worthy of a clean diaper. Praised for holding back my tears. Learning to survive.
My Mom in post-partum depression, I diagnosed in fifty or so years of retrospect and after forty years a nurse. A gene passed on to a daughter? A mother’s gift?
Days on my bike. Hours away from home. I found a steep hill at the middle school and pushed off. My feet hovered above the brake pedals. I imagined my metallic midnight-blue bike a flying unicorn. With my stringy blond hair whipping in the wind, I sped down the bumpy, stone encrusted hill. My gaping mouth shrieked in glee and fear. I didn’t want to die. I wanted to fly and land in a place where if my mother looked at me, she really saw me, and maybe even liked me. A place where I liked me.
A diary of lasts and leasts. The last girl in my class to get her period. The girl with the flattest chest. The girl with the fewest choices for dress shoes to wear to the sixth-grade dance because of her shoe size. Adolescence ravaged my face. Loneliness gutted me, either with, or because of, the distorted world view of an introvert, a label I didn’t understand at the time. I zeroed in on every dead bird in a storm drain after a heavy rain, every daffodil flattened by tornadic winds.
A taste of love. My first true love I lost to miles and time and adversarial politics. I learned people break-up for reasons more powerful than the comfortable familiarity of a friend who fumbles through a first kiss and heated pleasure with no shame. The next love, an insecure adolescent, lost on some now-well-named spectrum, who dropped out of his collegiate rat race, showed up on my doorstep, the date of his last bath unknown, his face familiar through the thick lenses of Lennon-like wire-framed glasses. After I encouraged him to shower, we explored each other. His mouth left a purple bruise on my breast, and he took off. He wrote an acerbic good-bye, rife with blame, on pieces of toilet paper. Thankfully unused.
Then the university. Miles away from home. People with whom I had no connection. I drank until I cried in chest-heaving sobs. My sorrow, so powerful, convinced my roommate I had been raped. Not my body, just my heart. I didn’t sleep. Studied all night. Took a Spanish final exam, answered all the questions in French. Hungover in two foreign tongues. I need a gun.
My career grounded me, then ground me down. A caretaker, a professional nurse. A person in control challenged by the exponential changes occurring in technology and in the role designated as the “handmaiden of the physicians.” Responsibility without rights. Accolades for successes and the demonstration of newly acquired knowledge; blame for failures that meant loss of life. Sleepless nights. What did I do wrong? Could I have done more? Retracing every drug administered, every vital sign documented, every word spoken to the patients, to the families, to the doctors, to the bleary-eyed face in the mirror. I need a gun.
A son. The greatest joy. I promised I would never make him feel unworthy. Even when I went to visit him in jail. On Mother’s Day. On his birthday. I failed. On that day I left before our time was up. I made another promise, loud and honest and unwavering. “If this happens again, I won’t be visiting you in jail when I’m fifty.” I need a gun. My feet burn constantly. I know I am not walking on hot coals, but occasionally I look down, hoping I am. Because if I am, I can step off them and the pain will stop. One day I touched the outside of my slow cooker. A blister erupted where my skin brushed against the stainless steel. My hands feel like that every day. I worry about pissing myself. When I awaken, vision blurry from sleep, I fear I am going blind. My body attacks itself. I need a gun.
Today I have had enough.
Sitting on the edge of my bed, I considered the pills I collected over the years from various therapists. They half-filled the plastic, amber container with the child-proof cap. It opened with a push and a twist. I re-engaged the cap. It snapped into place. I rolled the container between my palms as if I were shaping clay. The pills skittered, no tickety-ticked, against the plastic and sounded like mice playing, unseen, behind wallboard. I saw myself drifting away dreaming of the perfect life I should have, but not sure what it should be. I knew my heart would slow and become erratic, would struggle to thrust every drop of blood out toward the ends of my body. I knew my breathing would stop, a task forgotten. Then I saw rescuers and intubation and hospitalization and questions and anti-depressants and the guilt-laden faces of my family.
I think of the garage where my pink Peugeot mountain bike hangs on hooks, unused. A battered filing cabinet organizes instruction manuals for the coffee pot, the generator, and the robotic vacuum I named Frisbee. Hand-made Mother’s Day cards with a childish scrawl, pictures from innumerable seasons of sports, and vet records of a favorite cat, long dead, crowd the top of one drawer. How easy it would be to leave surrounded by these bits of history. A bottle of wine, my favorite pillow, the made-in-China blanket with the Grand Canyon on it, iPhone, and ear buds. So easy to start the car, listen to music, take one final trip.
My first job I cared for a girl the EMS brought to the ICU. Cherry red lips, in a perfect application of color, belied the displacement of oxygen by carbon monoxide on the blood. It starved her brain of oxygen and left a robust, young body without a command center. I didn’t know what happened to her after she left ICU, but I knew the consequences of complete immobility.
I thought about a gun. Any gun. I wouldn’t put it in my mouth and pseudo-fellate it. I understood recoil and the chance for a misfire. A bullet pushing through my palate, exploding an eye, ripping through my cheek, or, worst of all, trashing my sanctuary of words. No. I would press the muzzle under my chin just above my Adam’s Apple and I wouldn’t give myself time to think. The move would be swift and smooth and sure and my finger would be poised to pull the trigger. A blast to the brain stem. No more worries about being worthy. The perfect exit strategy.
Thank God I don’t own a gun.
The month of June from any old calendar in a spider webbed, abandoned garage. A picture of a woman whose breasts spill around two tiny triangles of diaphanous fabric. You know the one I mean. Her nipples punctuate the centers of each. She straddles a Harley-Davidson and ogles the barrel of a gun, its size distorted by the photographer.
In Starbucks a man fumbles for his wallet, pulls back his jacket, and exposes a carved mahogany gun handle. A man in low-riding jeans shops at Walmart, bends over to grab a fifty-pound bag of dog food. His t-shirt pulls up. The handle of a Smith and Wesson beckons from his butt crack.
Mine’s bigger than yours.
Some people see guns as phallic symbols, some merely as weapons of defense. I carry my own weapon of defense, a silent partner, a barrier that protects me from encroachment by the intolerable. Depression. Religion promises the Savior walks a path with the faithful. My intimate friend, depression, rides within. I slide back the panel to the hidden compartment in my bed’s headboard and sequester my gun there. I want easy access to the tool of my exit strategy.
Although I don’t remember it, I suspect I experienced depression the first year of my life, the year I learned I wasn’t worthy. My mother told me a story. “You learned to swim in urine because I was too tired to change your diaper. You never cried.”
Not worthy of a clean diaper. Praised for holding back my tears. Learning to survive.
My Mom in post-partum depression, I diagnosed in fifty or so years of retrospect and after forty years a nurse. A gene passed on to a daughter? A mother’s gift?
Days on my bike. Hours away from home. I found a steep hill at the middle school and pushed off. My feet hovered above the brake pedals. I imagined my metallic midnight-blue bike a flying unicorn. With my stringy blond hair whipping in the wind, I sped down the bumpy, stone encrusted hill. My gaping mouth shrieked in glee and fear. I didn’t want to die. I wanted to fly and land in a place where if my mother looked at me, she really saw me, and maybe even liked me. A place where I liked me.
A diary of lasts and leasts. The last girl in my class to get her period. The girl with the flattest chest. The girl with the fewest choices for dress shoes to wear to the sixth-grade dance because of her shoe size. Adolescence ravaged my face. Loneliness gutted me, either with, or because of, the distorted world view of an introvert, a label I didn’t understand at the time. I zeroed in on every dead bird in a storm drain after a heavy rain, every daffodil flattened by tornadic winds.
A taste of love. My first true love I lost to miles and time and adversarial politics. I learned people break-up for reasons more powerful than the comfortable familiarity of a friend who fumbles through a first kiss and heated pleasure with no shame. The next love, an insecure adolescent, lost on some now-well-named spectrum, who dropped out of his collegiate rat race, showed up on my doorstep, the date of his last bath unknown, his face familiar through the thick lenses of Lennon-like wire-framed glasses. After I encouraged him to shower, we explored each other. His mouth left a purple bruise on my breast, and he took off. He wrote an acerbic good-bye, rife with blame, on pieces of toilet paper. Thankfully unused.
Then the university. Miles away from home. People with whom I had no connection. I drank until I cried in chest-heaving sobs. My sorrow, so powerful, convinced my roommate I had been raped. Not my body, just my heart. I didn’t sleep. Studied all night. Took a Spanish final exam, answered all the questions in French. Hungover in two foreign tongues. I need a gun.
My career grounded me, then ground me down. A caretaker, a professional nurse. A person in control challenged by the exponential changes occurring in technology and in the role designated as the “handmaiden of the physicians.” Responsibility without rights. Accolades for successes and the demonstration of newly acquired knowledge; blame for failures that meant loss of life. Sleepless nights. What did I do wrong? Could I have done more? Retracing every drug administered, every vital sign documented, every word spoken to the patients, to the families, to the doctors, to the bleary-eyed face in the mirror. I need a gun.
A son. The greatest joy. I promised I would never make him feel unworthy. Even when I went to visit him in jail. On Mother’s Day. On his birthday. I failed. On that day I left before our time was up. I made another promise, loud and honest and unwavering. “If this happens again, I won’t be visiting you in jail when I’m fifty.” I need a gun. My feet burn constantly. I know I am not walking on hot coals, but occasionally I look down, hoping I am. Because if I am, I can step off them and the pain will stop. One day I touched the outside of my slow cooker. A blister erupted where my skin brushed against the stainless steel. My hands feel like that every day. I worry about pissing myself. When I awaken, vision blurry from sleep, I fear I am going blind. My body attacks itself. I need a gun.
Today I have had enough.
Sitting on the edge of my bed, I considered the pills I collected over the years from various therapists. They half-filled the plastic, amber container with the child-proof cap. It opened with a push and a twist. I re-engaged the cap. It snapped into place. I rolled the container between my palms as if I were shaping clay. The pills skittered, no tickety-ticked, against the plastic and sounded like mice playing, unseen, behind wallboard. I saw myself drifting away dreaming of the perfect life I should have, but not sure what it should be. I knew my heart would slow and become erratic, would struggle to thrust every drop of blood out toward the ends of my body. I knew my breathing would stop, a task forgotten. Then I saw rescuers and intubation and hospitalization and questions and anti-depressants and the guilt-laden faces of my family.
I think of the garage where my pink Peugeot mountain bike hangs on hooks, unused. A battered filing cabinet organizes instruction manuals for the coffee pot, the generator, and the robotic vacuum I named Frisbee. Hand-made Mother’s Day cards with a childish scrawl, pictures from innumerable seasons of sports, and vet records of a favorite cat, long dead, crowd the top of one drawer. How easy it would be to leave surrounded by these bits of history. A bottle of wine, my favorite pillow, the made-in-China blanket with the Grand Canyon on it, iPhone, and ear buds. So easy to start the car, listen to music, take one final trip.
My first job I cared for a girl the EMS brought to the ICU. Cherry red lips, in a perfect application of color, belied the displacement of oxygen by carbon monoxide on the blood. It starved her brain of oxygen and left a robust, young body without a command center. I didn’t know what happened to her after she left ICU, but I knew the consequences of complete immobility.
I thought about a gun. Any gun. I wouldn’t put it in my mouth and pseudo-fellate it. I understood recoil and the chance for a misfire. A bullet pushing through my palate, exploding an eye, ripping through my cheek, or, worst of all, trashing my sanctuary of words. No. I would press the muzzle under my chin just above my Adam’s Apple and I wouldn’t give myself time to think. The move would be swift and smooth and sure and my finger would be poised to pull the trigger. A blast to the brain stem. No more worries about being worthy. The perfect exit strategy.
Thank God I don’t own a gun.
The month of June from any old calendar in a spider webbed, abandoned garage. A picture of a woman whose breasts spill around two tiny triangles of diaphanous fabric. You know the one I mean. Her nipples punctuate the centers of each. She straddles a Harley-Davidson and ogles the barrel of a gun, its size distorted by the photographer.
In Starbucks a man fumbles for his wallet, pulls back his jacket, and exposes a carved mahogany gun handle. A man in low-riding jeans shops at Walmart, bends over to grab a fifty-pound bag of dog food. His t-shirt pulls up. The handle of a Smith and Wesson beckons from his butt crack.
Mine’s bigger than yours.
Some people see guns as phallic symbols, some merely as weapons of defense. I carry my own weapon of defense, a silent partner, a barrier that protects me from encroachment by the intolerable. Depression. Religion promises the Savior walks a path with the faithful. My intimate friend, depression, rides within. I slide back the panel to the hidden compartment in my bed’s headboard and sequester my gun there. I want easy access to the tool of my exit strategy.
Although I don’t remember it, I suspect I experienced depression the first year of my life, the year I learned I wasn’t worthy. My mother told me a story. “You learned to swim in urine because I was too tired to change your diaper. You never cried.”
Not worthy of a clean diaper. Praised for holding back my tears. Learning to survive.
My Mom in post-partum depression, I diagnosed in fifty or so years of retrospect and after forty years a nurse. A gene passed on to a daughter? A mother’s gift?
Days on my bike. Hours away from home. I found a steep hill at the middle school and pushed off. My feet hovered above the brake pedals. I imagined my metallic midnight-blue bike a flying unicorn. With my stringy blond hair whipping in the wind, I sped down the bumpy, stone encrusted hill. My gaping mouth shrieked in glee and fear. I didn’t want to die. I wanted to fly and land in a place where if my mother looked at me, she really saw me, and maybe even liked me. A place where I liked me.
A diary of lasts and leasts. The last girl in my class to get her period. The girl with the flattest chest. The girl with the fewest choices for dress shoes to wear to the sixth-grade dance because of her shoe size. Adolescence ravaged my face. Loneliness gutted me, either with, or because of, the distorted world view of an introvert, a label I didn’t understand at the time. I zeroed in on every dead bird in a storm drain after a heavy rain, every daffodil flattened by tornadic winds.
A taste of love. My first true love I lost to miles and time and adversarial politics. I learned people break-up for reasons more powerful than the comfortable familiarity of a friend who fumbles through a first kiss and heated pleasure with no shame. The next love, an insecure adolescent, lost on some now-well-named spectrum, who dropped out of his collegiate rat race, showed up on my doorstep, the date of his last bath unknown, his face familiar through the thick lenses of Lennon-like wire-framed glasses. After I encouraged him to shower, we explored each other. His mouth left a purple bruise on my breast, and he took off. He wrote an acerbic good-bye, rife with blame, on pieces of toilet paper. Thankfully unused.
Then the university. Miles away from home. People with whom I had no connection. I drank until I cried in chest-heaving sobs. My sorrow, so powerful, convinced my roommate I had been raped. Not my body, just my heart. I didn’t sleep. Studied all night. Took a Spanish final exam, answered all the questions in French. Hungover in two foreign tongues. I need a gun.
My career grounded me, then ground me down. A caretaker, a professional nurse. A person in control challenged by the exponential changes occurring in technology and in the role designated as the “handmaiden of the physicians.” Responsibility without rights. Accolades for successes and the demonstration of newly acquired knowledge; blame for failures that meant loss of life. Sleepless nights. What did I do wrong? Could I have done more? Retracing every drug administered, every vital sign documented, every word spoken to the patients, to the families, to the doctors, to the bleary-eyed face in the mirror. I need a gun.
A son. The greatest joy. I promised I would never make him feel unworthy. Even when I went to visit him in jail. On Mother’s Day. On his birthday. I failed. On that day I left before our time was up. I made another promise, loud and honest and unwavering. “If this happens again, I won’t be visiting you in jail when I’m fifty.” I need a gun. My feet burn constantly. I know I am not walking on hot coals, but occasionally I look down, hoping I am. Because if I am, I can step off them and the pain will stop. One day I touched the outside of my slow cooker. A blister erupted where my skin brushed against the stainless steel. My hands feel like that every day. I worry about pissing myself. When I awaken, vision blurry from sleep, I fear I am going blind. My body attacks itself. I need a gun.
Today I have had enough.
Sitting on the edge of my bed, I considered the pills I collected over the years from various therapists. They half-filled the plastic, amber container with the child-proof cap. It opened with a push and a twist. I re-engaged the cap. It snapped into place. I rolled the container between my palms as if I were shaping clay. The pills skittered, no tickety-ticked, against the plastic and sounded like mice playing, unseen, behind wallboard. I saw myself drifting away dreaming of the perfect life I should have, but not sure what it should be. I knew my heart would slow and become erratic, would struggle to thrust every drop of blood out toward the ends of my body. I knew my breathing would stop, a task forgotten. Then I saw rescuers and intubation and hospitalization and questions and anti-depressants and the guilt-laden faces of my family.
I think of the garage where my pink Peugeot mountain bike hangs on hooks, unused. A battered filing cabinet organizes instruction manuals for the coffee pot, the generator, and the robotic vacuum I named Frisbee. Hand-made Mother’s Day cards with a childish scrawl, pictures from innumerable seasons of sports, and vet records of a favorite cat, long dead, crowd the top of one drawer. How easy it would be to leave surrounded by these bits of history. A bottle of wine, my favorite pillow, the made-in-China blanket with the Grand Canyon on it, iPhone, and ear buds. So easy to start the car, listen to music, take one final trip.
My first job I cared for a girl the EMS brought to the ICU. Cherry red lips, in a perfect application of color, belied the displacement of oxygen by carbon monoxide on the blood. It starved her brain of oxygen and left a robust, young body without a command center. I didn’t know what happened to her after she left ICU, but I knew the consequences of complete immobility.
I thought about a gun. Any gun. I wouldn’t put it in my mouth and pseudo-fellate it. I understood recoil and the chance for a misfire. A bullet pushing through my palate, exploding an eye, ripping through my cheek, or, worst of all, trashing my sanctuary of words. No. I would press the muzzle under my chin just above my Adam’s Apple and I wouldn’t give myself time to think. The move would be swift and smooth and sure and my finger would be poised to pull the trigger. A blast to the brain stem. No more worries about being worthy. The perfect exit strategy.
Thank God I don’t own a gun.
A Ghost of Christmas Past: Dec. 1973
The year I graduated from nursing school I knew very little about nursing except what to wear.
My white uniform, designed with a bib of crisp pleats across the bust, tented into an A-line skirt. The hem fell exactly to the middle of my knees. White stockings and utilitarian shoes worthy of a convent exemplified my look of a novitiate. Infection control and the influx of men into the profession eventually rendered the winged-white caps obsolete. I pulled my long blonde hair into a pony tail, stuffed it into a crocheted “snood’” and secured it with bobby-pins. For convenience I always stuck a few pens in my mound of hair, Geisha hair sticks by Bic. I never wasted time looking for a writing tool. My favorite offered three colors of ink, red, blue, and green, to accommodate each of the eight hour shifts in a day.
Three hospitals provided services to my small college town in the Midwest. A five bed surgical intensive care unit became my basic training camp. Monitoring EKGs and frequent vital sign checks were considered state of the art. On days when less than three patients required this vigilance, I functioned by myself in this new, specialized area of the hospital. I documented changes in EKGs, electrolytes, vital signs, and pain control, and established standards of care. I initiated calls rather than depending on a “head nurse” or supervisor to speak for me. Intensive care necessitated eliminating time delays and the middle man; I answered directly to doctors and the demand for accountability fell on and appealed to me.
Of course I worked my first Christmas on the job. Christmas 1973 gifted me with insight into my career choice and the ever-present threat to ICU patients known as death.
My patient looked like Alan Bates, the actor. Roguish, with curlicues of black hair slick with sweat and oil, the man reclined in a rickety framed gurney. He angled his elbows on the metal frame like a king holding court He strained the cloth restraints that secured his hands to the side rail. With each effort, his biceps bulged and trembled. Shaking his head side-to-side, he uttered incomprehensible sounds and marked his territory with a circle of spittle. My immaculate uniform meant nothing to a man wallowing in a reality fragmented by the effects of alcohol withdrawal and hypotension.
I fantasized about Alan Bates ever since the movie Women in Love, where I watched Mr. Bates and a young, though semi-portly Oliver Reed romp in the first nude male wrestling scene to appear in a mainstream film. The full frontal male anatomy fascinated me. How could I imagine in five years that career experience would reveal every variant of the mysterious penis and turn it into nothing more than a delivery conduit for the precious measure of renal perfusion, urine?
I nicknamed him The Professor. I can’t remember his real name. Today HIPPA would demand I protect it. He epitomized my ideal of an English professor complete with perfect, albeit, slurred diction and a penchant for whiskey. I imagined him fully functional, both cavalier and cerebral in a tweed sports coat with leather patches on the elbows. College girls flocked to his classes, his office, even his apartment. And I, fresh enough, inexperienced enough, thought like all novices with addiction, that a little love and attention could cure alcoholism and all the underlying problems that caused it. I’d say the right things, and The Professor would quit smoking, quit drinking, eat right, and publish a book dedicated to me. I also thought medicine could save him from the massive gastro-intestinal bleed channeling life from his body. In one day I learned what little power altruism, innocence and science wielded.
It was just he and I. The day nurse dashed away as soon as she finished report. Short and to the point: “ 34 year old white male. Bloody emesis with clots in his stool. Found unconscious at home by a neighbor. Two units of blood given in the ER. No family. Sinus tach on the monitor.”
There it was. The security of what I then believed was the pinnacle of technology. In just a few years to merely monitor the EKG would be comparable to using a squirt gun against a light saber.
“Dr. Reisman said there is nothing more to do.” Today it seems there is nothing we can’t do. There are no rules about when to stop.
I picked up my stethoscope to start my assessment and stopped a moment to shift gears. Looking around it disappointed me to see no one had decorated the unit for Christmas. Through an expansive fifth floor window, low hanging clouds rolled over the trees and houses. Smokey mist covered every building and obscured the lights and decorations heralding the season. Loneliness accompanied the focus required for my work.
I approached The Professor with caution. His gown gathered in folds across his abdomen and groin. The monitor electrodes glared white against a thicket of chest hair. Small halos surrounded each electrode where the hair had been shaved. A small slash of dried blood marked a path down his chin. He sat in a smear of maroon with a clot the size of a plum mashed against one rail of the gurney. His writhing agitation caused his blood pressure cuff to slip down his arm to the restraint. I could see his pulse on the monitor and count his respirations. I needed to check The Professor’s blood pressure.
There is nothing more gag-inducing than stool from someone bleeding in the gut. It blends the smell of fresh blood, rotting meat, and swamp gas.
When I started to examine The Professor, I didn’t know this. The odor surrounding him forced me to breathe through my mouth. I stepped closer and started a standard script. “I’m Cindi and I’m going to be your nurse today. I need to listen to your chest, heart, and abdomen.” I said abdomen because he was a professor. A whiff of his body odor reassured me I could have said “gut.” After holding my stethoscope between both hands to warm it, I placed the diaphragm on his chest. I heard the familiar squeaks and crackles of smoker.
“I need…I need…”
I heard his voice drone as the sound traveled through his chest and the diaphragm of the stethoscope, up the slick black tubing, and through the ear pieces into my head. I pulled back. “What is it that you need?” Pompous satisfaction. I was making progress with the man. He trusted me enough to ask for something.
“I need…” A blast of red erupted from his mouth and landed in an abstract design of spatter on my uniform. I looked at the chrome paper towel dispenser and saw nothing on my face, but from mid chest down I easily could have been mistaken for a gunshot victim or a Pollack. I washed and dried my forearms and returned to The Professor. Before AIDS and public awareness of the dangers of hepatitis, it never dawned on me to be afraid of exposure to body fluids.
The Professor’s head dropped against his shoulder. His heart beat twenty beats per minute faster to compensate for the loss of blood from his system thus maintaining his blood pressure. I sped up his IV fluids and paged Dr. Reisman.
When waiting for a physician to return a call, when it feels like all the responsibility is on you, time shows no mercy. My heart pulsed in my temples. Sound amplified. The Professor’s sonorous breathing seemed to roar through the unit.
The monitor warned of irregular heartbeats. Unable to hear a blood pressure, I palpated one with the systolic throb recognizable at 45. The phone rang. I reported the events of the past ten minutes and hoped some new medical development had evolved in that time.
Dr. Reisman was as new to his medical practice as I was to my nursing practice. When we worked with patients and each other, two pairs of fresh eyes explored changing professional roles, planning care with new knowledge and inspiration, reshaping old traditions. I represented a new breed of nurses with my four year degree. Just starting his practice, he seemed to approach me differently than the older, well-weathered MDs. Or perhaps he simply heard the uncertainty, the disbelief, and, yes, the desperation in my voice. “I’m on my way.”
The Professor rallied and resumed thrashing about the gurney. His heart rate remained high. A pallor circled his mouth. With a violent twist of his head, he resisted the green plastic prongs for supplemental oxygen. He repeated the move when I tried to wipe his mouth and wash the blood from his chin.
A small man with thick, pre-maturely silver tipped hair and an earnest demeanor, Dr. Reisman arrived. I noticed the five o’clock shadow of his beard. He noticed my uniform. “Did this just happen?”
I nodded.
“There really is nothing more we can do.” Dr. Reisman stroked his chin and walked over to The Professor.
“Can you hear me? You are really sick. At this point we can’t get you better. Is there anyone we can call? Is there anything I can do for you?” He rested his hand on The Professor’s forearm.
The Professor stared across the room and said nothing. Guttural sounds rumbled in the back of his throat. Watching a man’s demise, tethered to a bed in my ICU, gobsmacked me.
“Call me when something happens. I’ll be in the ER.”
I admired tailored slacks and polished shoes as Dr. Reisman stood at the elevator. In a time when patriarchal practice dominated medicine, Dr. Reisman showed me a glimmer of the collaborative practice of the future. That day I sensed something about the potential of my profession that would come to fruition many years, many patients, and many challenges later.
“Doc.” The Professor sputtered in a coarse whisper. “Doc, can I just have a cigarette?” His head lolled to one side. The monitor warned of disaster.
When I looked up at the small black screen, three to four beats of wide amorphous conduction, the kind that drop cardiac output and blood flow to the brain, interrupted the rapid, but regular white P-QRS pattern of tachycardia. The Professor lost consciousness. The irregular rhythm looked like a child’s drawing where a tiny hand zig-zagged a crayon across a piece of paper. More and more clusters of chaos appeared. Finally chaos reigned.
Without a regular heart rhythm, the heart failed to perfuse. Within minutes The Professor stopped breathing. A white line, as clear and sure as a jet stream, crossed the monitor screen. The monitor screamed its proclamation of death with a continuous high-pitched alarm.
What happened after The Professor died, I don’t remember. I knew the mandatory procedural rituals performed after a patient’s death. In 1973 plastic body bags didn’t exist. I assume I wrapped The Professor in a sheet. Today I sing Native American chants to patients as I prepare their bodies to be taken away. There was no singing for The Professor. I had much to learn about what was right and proper and comforting to me when working with the dead.
Nor do I remember what I did that Christmas night when I got home. Until I owned a house with a fireplace, I made one out of construction paper and corrugated cardboard painted like bricks. The felt Christmas stocking my mother made me hung by the faux-fireplace on a tiny nail. Mom decorated the stocking with symbolic cut-outs. Beads and sequins sparkled on a candle, a train, a ball, and other various mementos of childhood. There was no nursing cap; that identity had not entered my being when Mom created the stocking.
For many years, the memory of The Professor’s last words, the loneliness of his death, and my feeling of inadequacy stayed with me. I saw myself, like a candle in an infinity box, as a myriad of nurses expanding in many directions, burdened with the responsibility for another person’s life, alone to experience the loss of a man who, at first glance, seemed a person of looks and intelligence and potential, but who was simply a man I tried to help and failed.
I could have changed jobs, gone to work in the newborn nursery or a doctor’s office. I could have quit nursing altogether. The Professor would have no second chance, but I continued nursing in search of my mine.
Just a Nurse
One Christmas Eve Day I extubated a patient who had open heart surgery the previous day. A few hours after removing the breathing tube, he went into a pulseless ventricular tachycardia. I was at the bedside, called a Code Blue, and shocked him back into a regular rhythm before his surgeon arrived on scene. His family thanked me for giving them such a gift. I am just a nurse.
Another day our shift received a patient from the operating room who started to bleed faster than we could replace the blood. Without hesitation all but one nurse (and she was unaware of the crisis) stayed over to run to the ER to get the rapid infuser, to run to the blood bank, to support the family, to call in the OR team to take the patient back to surgery, to coordinate care until transport, and to help the next shift cover the rest of the patients. We are just nurses.
A woman came in to speak with the doctor, who had to tell her that her husband had just died. She did not collapse until she looked at me and asked me if it was true. I nodded, hugged her and lowered her to the floor. I am just a nurse.
A patient sat in a chair in distress. While I spoke by phone to the doctor, the patient had a respiratory arrest. Six people lifted the patient back to bed and started CPR. Before the end of my shift, although intubated, the patient woke up and was neurologically intact. A few weeks later the patient visited and said: “I didn’t understand about the job you do until now.”
We are just nurses. Proud is an understatement.
The Last Resort: A Fascinating Look at the Future
The current health care model mandates that discharge planning begins the day a person enters the hospital. On a grander scale, life follows this model; from the day of birth, a person moves toward his demise. Maureen Holtz’s novel The Last Resort explores a future in which a small country in Africa bases its economic survival on providing a place where self-determination at the end-of-life is legal, thus generating a unique sort of medical tourism. Using an American “everyman,” Holtz intertwines the lives of Livvy and Simon Harper, who reside in Illinois, with the politics and health care of both America and Mkanda, Africa. She explores a not-too-distant future (2020) in which an aging population burdens not only family, but also the finite resources of health care.
The questions raised by this novel are not pretty, not easy to discuss, nor are there any quick fixes or ready answers. This is what makes it must reading for anyone: health care providers who offer extreme options without assessing post-procedure quality of life, family members who pursue what’s radical and new without considering outcome, the young who will be responsible for a portion of the costs through taxation, the aging who will leave a legacy of health care debt with the coming generation.
Ms. Holtz complicates the overall picture by introducing the conflict between faith and medical ethics. When a family faces health care decisions, what role does faith play in making medical choices? Quite simply the novel poses two important questions: Who decides? And who should decide?
Livvy and Simon Harper know tragedy. They have lost a child. Simon’s parents have died. Livvy’s mother succumbed to cancer. Now Livvy’s father, Hank, a successful journalist with an inquisitive, brilliant mind, has been diagnosed with ALS and early Alzheimer’s.
As these family problems unfold, President Adebayo, of Mkanda, must live up to his campaign promises and revitalize his country’s economy. He proposes the Euthanasia Legalization Act. In Mkanda access to health care is negligible. Adebayo watches a worker dies by the roadside in agony because of the impoverished country’s lack of resources. As a doctor, Adebayo wrestles with his pledge to “do no harm” and the harm caused by allowing suffering to continue. He and his aide Kwesi come up with the idea for The Last Resort, a place where those who wish to end their lives can come to a pristine setting, plan their last days, and exercise control over their final moments.
Ms. Holtz illustrates the subtle mental and obvious physical decline of Hank with accuracy. She allows the reader to see these changes from different points of view. Hank shares his perception through an inner dialogue filled with candor and doubt. Livvy frets over what’s next and how she and her husband will manage Hank’s care. Hank’s friends surround him with support and the therapy of good memories. Hank, ever the investigator, hears about Mkanda and begins to talk about choosing how he wants to die.
Hank’s decline occurs as President Adebayo’s plans come to fruition. The Last Resort opens. Gradually the number of clients increases. As people experience a different way of dying and Mkanda’s economy flourishes, a modicum of acceptance comes to the country and its people.
This book has many strengths. In Livvy Ms. Holtz creates a character who draws the reader into the horror of a family member wasting away not just physically, but mentally as well. Livvy struggles with suicide as a sin in the context of her religion. As she watches Hank deteriorate, she questions her faith. The reader can’t help but join in vicarious debate about life, faith, and final days. Hank speaks for all who perceive nursing homes as warehouses for the frail and elderly who are managed by drugs rather than any sort of individualized care. Even the family dog, Sherlock, introduces a thematic element and allows the reader to establish the contrast between the humane therapies given a dying pet versus the options given a human being.
One sub-plot of this unsettling novel is the role of pharmaceutical companies in medical care. Before The Last Resort can open, a price of the drug used to end life must be negotiated. The usual dickering over cost and profit occurs. After The Last Resort opens, a plant that produces a drug which causes a rapid, pain free death is discovered in Mkanda. A taste of white collar espionage and greed ensues. The novel alludes to the complex process of FDA drug approval in this country. This element flows well in a story laced with multiple medical-moral issues.
As someone with a health care background, I wish Ms. Holtz had created scenes that addressed some missing pieces. I asked myself why there was no scene where Livvy sought serious counsel from the clergy. When faith was so important to her, it would seem a logical step in the process of finding out how best to support Hank. I also think to show the potential benefit of such a discussion would add much to what this novel has already taught about living and dying.
Ms. Holtz skims over the use of Advance Directives and Durable Power of Attorney for Health Care in end-of-life situations. These legal concepts represent strong, albeit not absolute, tools in self-determination. She also fails to address the role of palliative care and hospice in the lives of the terminally ill. In some institutions, a palliative care consultation is required when a patient is considered for certain therapies. Comfort and quality of life represent top priorities. In the overall context of this thought-provoking and controversial novel, these are minor omissions.
The Last Resort is an imaginative novel that forces the reader into the tempest of human truth: from the day of birth, a person moves toward his demise. Ms. Holtz offers a means by which a person can direct his course.
Beware: Death Panel Paranoia on the Horizon
I predict a resurgence in “death panel” panic thanks to an article first appearing in The New York Times and picked up by The Dallas Morning News. Beginning next year, end-of-life-decision discussions may be covered by Medicare. Without thinking it through, the euphemistic question will arise: “Will the medical community arbitrarily ‘pull the plug’ to cut costs and conserve resources regardless of what the patient and/or the patient’s family wants?”
During my career, I have been involved with many families forced and unprepared to make decisions about a dying relative. Tears, anger, guilt, and regret overwhelm those involved in the process. The time for such discussion and choices is not when death is imminent, but when rationale thought balances conflicting emotions.
If Medicare were to cover the cost of time spent for these discussions, choices bound by reason and compassion as opposed to fear, fatigue, and stress, could be made. As a nurse at the bedside for forty years, I see this as proactive, an activity that advocates self-determination for the patient.
Who should represent medicine in this decision making process? The cardio-thoracic surgical specialist who knows the specifics of the patient’s cardiac problems, who has seen what some believe is the site of the soul, the heart, while the chest is open? The anesthesiologist who does a cursory history by phone to assess the essentials of a national risk scale for patients receiving anesthesia? The nephrologist who tinkers with meds, fluids, and diet to keep the kidneys functioning at acceptable levels? Each specialist focuses on a slice of the human pie. The surgeon is invested in the heart, surgical statistics, and hospital length of stay. The anesthesiologist is like one of the tea cups at Disneyland. He spins through the patient’s life with a brief interface when the patient is awake, administers anesthesia, and then is gone. The nephrologist looks at the BUN, creatinine, and daily weights. Who looks at the total patient? Who looks at, talks to, and delves into the history of the bio-psycho-social being who makes up the whole pie?
I think of my Mom who just lost her extraordinary PCP. He spent almost an hour with her each time she visited. He knew not just her physical history, but her social history. He supported her desire to maintain the highest level of wellness so she could continue to live independently. He asked per permission to pray with her. He LISTENED to her. And when she self-diagnosed an acute myocardial infarction, he personally drove her to the hospital in her car, because she wouldn’t leave it at his office. This physician extended himself in what I perceive as a gesture of love and respect and grace, not just as a doctor dealing with a patient. If my Mom needed someone with whom she could discuss how she wanted to die, I would want it to be with someone who knew how she lived. And that would be her PCP.
Any discussion of end-of-life/death meets several obstacles.
Thanks to technology things considered impossible before have become possible. AIDS transformed from being a death sentence to a chronic disease. Organ transplantation evolved from being a great experiment to a process that extends the life of organ recipients and is limited only by organ availability. Minimally invasive surgeries have allowed procedures to be successfully performed on people who previously would have been turned away because of their co-morbidities. The blessing of technology is the extension of meaningful human life. The curse of exponential growth and change in medicine is two-fold.
First, medical therapy can extend life without factoring in risks of potential outcomes and the quality of the life extended. How often I have seen patients survive perfectly executed surgeries while failing to recover their previous level of functioning. The surgery succeeds; the patient fails and endures an emotionally draining and physically tortuous life.
Second, death is seen as a weakness or a failure. America is a country that evolved through ingenuity, innovation, and hard work. Many people think these qualities and access to health care empower them to elude death. Of course this isn’t possible. Nor is it a failure to succumb to the natural, end result of having lived. Death is the “elephant in the room.” It is something we don’t want to believe happens, especially to those we love, admire, and draw strength from. Quite simply it is much easier to talk about life than about death.
Television has further complicated real understanding of disease and death. Just as Law and Order or CSI has generated an unrealistic expectation of crime-solving and justice to occur within an hour, so House and ER have created a false sense of rapid diagnosis, treatment, and recovery, leaving little room for death and the discussions surrounding it.
Advertising inundates viewers with quick pharmaceutical fixes for everything from depression to fibromyalgia, from diabetes to Crohn’s disease. Bariatric surgery is touted as the be-all-end-all solution for weight control. Just as the drug ads list a plethora of warnings and exceptions, every surgical consent has fine print. Success with bariatric surgery requires a life style change, not just a surgical intervention.
How do families open the necessary discussion about death? From the time I was old enough to participate in adult conversation, my parents discussed quality of life. When my father developed a brain tumor, there was no question in my mind what he would want done, or not done. My courageous mother asserted my Father’s wishes against a medical construct that in the mid-1970s still leaned toward patriarchy. My sister and I fully supported her. We were three of the lucky few who discussed such things before they happened.
When my husband and I prepared wills, we also prepared Living Wills/Advanced Directives. What better time to think about end-of-life as when documenting your history by distributing what you leave behind, no matter how insignificant those things may be? Our daughter became involved as she has Medical Power of Attorney if something happens to both of us together. Hopefully this role opened a discussion between her and her husband. Experience has surprised me when I count the number of patients I have taken care of who don’t have a basic will.
Perhaps when families are together, enjoying the grace engendered by love and connection, when relatives are savoring all that has come before and all that has yet to come, a discussion of how each family member hopes to leave this world can be part of the experience. I don’t find this macabre; it is part of the human experience. I have things I will leave behind and have a hope about how I will be remembered. I want people to remember the love I had for them, how I loved to read and write, how I could never sit still, how I flew with white knuckles and fled an MRI because of my loathing for small spaces, how I loved my cats, attended patients’ funerals, and balked at mastery of the cell phone. I don’t want to be remembered inert, unthinking, in a swamp of my body’s own making. In the warmth of a gathering of friends or family, what better place to share these thoughts, these concerns?
Politicians seeking a photo-op will misrepresent this subject. They will suggest, without hands on experience, that the decision to stop or withdraw extraordinary care equals stopping care. To the contrary, I explain to families that the plan of care merely changes from one of aggressive, often traumatic therapy, to care, support, and comfort. Death may be imminent, but time is not a certainty and death may not be immediate. To the health care team, the caring never stops.
I hope Medicare begins to cover time spent with patients and families discussing these matters. The American Association of Critical Care Nurses has reported that families in crisis situations involving a dying patient need 1:1 care as much as any patient in an acute physical crisis. Addressing these needs in all patients can’t help but improve quality of care for both patients and families. Rather than “pulling the plug,” these discussions will give patients a voice and a choice in the direction of their care. And so it should be.
Where are the cell phones?
Finally the media is addressing the silence of over two hundred passengers and their cell phones. A CNN expert suggested that the plane was too high for the towers to reach the phones. If that’s true, then why is the FAA considering the issue of allowing use of cell phones in flight? In response to people recalling the plane that went down in Pa. and last minute communications, he stated that those calls were made via “air phones” on the back of the seats that required the caller to swipe a credit card before calling. Really? Wasn’t that plane low enough for cell phones to pick up tower signals? And yesterday another expert stated the plane was flying low in an attempt to avoid being detected by radar. If just one of the passengers were alive, wouldn’t he have called someone? To the untrained ear, the inconsistency in reporting smacks of cover-up and subverts any confidence in the media. To date, there are far more questions than answers, more doubts than reassurances.
A Matter of Life, Death, and Miracles
In the weeks since the cardiac arrest and the declaration of death for Jahi McMath and brain death for Marlise Munoz, the media has conducted a discourse with ethicists, an elementary school class, the grieving family, and medical professionals. Maybe I missed it, but nowhere have I heard anyone speak with health care professionals, specifically nurses, assigned to care for either of these patients. In this group of care providers, a continuum of emotions and opinions about what is ethical and humane would abound.
After forty years of nursing, I still find most disturbing the provision of care to those who have no chance of a meaningful recovery. I have cared for a patient who was declared dead. The Harvard criteria for brain death includes: unresponsiveness, apnea (no respiratory effort), absence of movement, no reflexes, a flat electroencephalogram, no central nervous depressants in the body, and a core body temperature greater than 32 degrees. The beside nurse observes more subtleties. There is a vacancy in the eyes, an emptiness, and a lack of recognition of the outer world. Many times I have sensed an absence well before the body declared itself done with this life. No one can verify if the spirit transcends the body, but in my experience it seems that way. And it feels that way. Does this change the type of care I, or any professional, provides? No. I still talk to the person as if I’ll get a response, and I handle the body with the upmost tenderness and respect. This doesn’t change the lack of reciprocity in the human connection between this nurse and the specific patient.
Part of the conundrum with end-of-life decisions stems from the failure to differentiate life from living. In the cases of Ms. McMath and Ms. Munoz, a heartbeat defines life. But when she was alive, Ms. Munoz defined living by her ability to do certain things. She did not want life maintained by mechanical means. Each individual defines living differently. For many people, work and certain activities define who they are. For me, I am a nurse, a fitness nut, a reader, a writer, a wife, a homebody, a thinker. I am not sure which roles I could give up, which things I could stop doing, and still feel life had enough value for me to want to live. For me a heartbeat is not enough of an existence to justify the consumption of finite resources that would better serve another human being. These things I have discussed with my husband, my attorney, and have set down in an Advance Directive.
“What about miracles?” you might ask. Have I seen them? Yes. I still cry when I remember walking down the hall with a patient who suffered a catastrophic brain injury. When I saw his father’s face morph with the recognition it was his son coming down the hall, I knew I had been privy to something divine. I can give you all the scientific rationale for why the boy got better: his youth, perfect timing, a tenacious, committed doctor and team of nurses. I can only speculate about a force present, not prescribed by any medical practice. My question to you is this: “If it truly was a miracle, would it have happened had we done nothing?”
When Jahi McMath’s family prays and talks about God’s miracles, I wonder if they could surrender to their faith, remove all life support, and wait for God’s intervention? At a time when they were most vulnerable, experiencing the worst grief parents can endure, the media spotlighted decisions of the most delicate, private nature. I wonder where the reporters will be six months from now. And I wonder if the family will rethink their decision once they have begun to deal with, not only what they have lost, but also with what they have begun.
You may say: “It’s easy for you to say, you haven’t ever been there.” But then you don’t know me or the kind of nurse I am. I remember the first patient I “lost” on my first Christmas Day on the job. I remember my father, my husband’s son, my neighbor, saying they were ready to go when the quality of their lives became intolerable, all for very different reasons. My mouth went dry and I felt embarrassed and sad when I read an article in the newspaper about my own challenged grand-daughter who suffered a brain injury at age six weeks. She is seventeen years old, requires total care, and has never uttered a word. She receives tube feedings, never to enjoy the delightful taste of chocolate or grapes or a well-cooked steak. She passes urine, stool, and has gone through adolescence. Someone must attend to all of her bodily functions. I believe all of us have “been there” at some time and bear the wound of loss deep within us.
Perhaps that is the point of this discussion. These situations are so personal, so private, that people calling the hospital to get information must have a security code. Then how has it come to pass that the law, bureaucrats, and outsiders, who have no knowledge of the people involved, impose decisions on virtual strangers about life and death.
Each person’s definition of living or quality of life determines the path he chooses to its end. I demand this as a sanctified, inviolate right for myself and exclude input from all other external sources. Life, death, and miracles, all very private concerns.