So Many Good Things

Three months old, she has never left the hospital.  There is a hole in her heart and that is the least of her problems.  Her kidneys look like Swiss cheese and her esophagus has scarred from the surgery to close the hole that connected it to her trachea.  So they cut a tiny incision in her belly and snake a gastrostomy tube into her stomach and feed her from the outside.  She is three months old, she has just learned to smile but will only really do it for her mom, and when she cries, she makes no noise.  Her tracheostomy  is hooked up to oxygen twenty-four hours a day, it bypasses her larynx and so when she wails, all that comes out is a breathy wheeze and the insistent beep-beep-beep of her monitors that tick out her escalating heart rate - 148, 162, 210.  All she does is fight.  She doesn't know how to do anything else, and so I change her diapers and learn how to suction, and research her condition.

He is 85 years old, and his health is failing quickly.  He still speaks clearly and articulately, though he takes a breath every few words.  He has lived long and well and he tells me that his trusty body is giving out and that that's okay.  I sit by him and I'm supposed to be asking questions but all I can do is listen, rapt, while he tells me that this is the greatest country there is and that I should never forget that and that I should use my skills and be an achiever and a lone tear slides down his cheek as he tells me that his wife of sixty years, who died one year ago, was a magnificent woman, and a woman of great wisdom.  He tells me his children are the best thing that ever happened to him and he tells me that I should have a plan, but that I should always remember, there are so many good things.  I shake his son's hand when he comes to visit and I bring him more ice water and a new stack of paper cups.

I bounce my neighbor's baby on my hip tonight, in the seventy degree evening air.  We're chatting and laughing, there are four of us on the porch and there are families walking down the sidewalk and I have soup on the stove in my little yellow house across the street and the baby is drooling and so unremarkably healthy that I feel as if the world is splintering in my hands when he blows a bubble.  The horizon slides away and then springs back against my eyes as they fill with tears and I want to lay down in the street and sob because there are so many good things and even though things are so good they can still be so hard and what is hard for a baby who can't make noise or eat or breathe on her own?  And what is hard for a man who is dying with his mind fully intact?

I lay in my bed, the window is cracked and the spring air comes in and I soak my pillow with tears for them all, and still in my head I can hear him saying, There are so many good things.

Quotables

The room is 105 degrees Fahrenheit.  Yes.  I'm serious.  A hundred and five.  And I - voluntarily, mind you - continue to go back, day after day now, and subject myself not only to the room itself, but to what goes on in there.  It's like the worst parts of yoga, for ninety minutes straight.  It's the parts of yoga where you start to tremble at the end of a pose, and your knee twitches or your hip twinges and you impatiently wait for the instructor to release you to something else.  It's those few moments in a regular yoga class but it's constant and it's so much worse.  It's Bikram yoga, and it's an instructor telling you, "This is supposed to hurt.  Be brave."  Or, "In twenty-five minutes, we'll all take a water break."  Or, "Your body is a folded box, your hands are under your feet, your stomach is GLUED to your thighs, your chest is GLUED to your knees, your face is flush with your shins, EYES OPEN, and there is no room for light or air between your halves, now pull up on your heels, straighten your legs and lock your knees - do it, do it now - LOCK YOUR KNEES and breathe normally, through your nose, don't give up on this pose..."  And in my head, I am like, "WHY AM I HERE?" and also, "I'M GOING TO DIE, I'M GOING TO BE A DEAD FOLDED BOX," but also, and best of all, and the reason I keep going back -

If it doesn't challenge you, it doesn't change you. 
-Fred DeVito

* * *

The patient's team of physicians gather around the foot of his bed and I can't even tell if they are just discussing the case with each other, or if they're under the impression that anything they're saying is making sense to the patient.  He struggles to shift his head up so he can look at their faces as they tower over him, but I cannot raise the head of his bed more than 20 degrees, or it will put too much weight and pressure on the rapidly deconditioning skin of his coccyx and sacrum.  The doctors ignore me, and I listen intently to what they're saying about his renal biopsy results because I know that as soon as they leave, I'm going to have to explain all of this again to the man whose colostomy bag I am attempting to empty.  I look up and see one med student fling a sidelong and disgusted glance at the bag that I am attempting to empty efficiently, with some modicum of dignity, but it's hard because no one has emptied it in the four hours that he's been off the floor and down in dialysis.  He's so uncomfortable and  he's so hungry and I'm so mad at these doctors for knowing so much and still not being able to fix him and cure him of this terrible condition that came on so suddenly and I feel the wave of helplessness starting inside me as I think to myself, If you knew more, maybe you would know what to do for him, maybe there's more tests they can do or answers to be found... but I stop.  I look at his hands, lying clenched in fists on the bed below me and I remember the words that are like a song in my heart, the number of times I have repeated them to myself, over these last ten weeks:

Not all of us can do great things.  But we can do small things with great love.
-Mother Teresa

I finish emptying his bag, clean up, and wash my hands.  I ignore the doctors.  I say, "Excuse me," firmly and with conviction and they scoot away from his tray table.  I maneuver it over his legs, adjust it to the perfect height for him so he can eat even though he is almost flat in bed.  I open his food, and his cup of apple juice, put in a fresh straw, and tilt the straw way down so he can get it in his mouth.  I stir up his pasta and comment softly to him that his spaghetti looks delicious, that I know he waited so long for this dinner, and now he can relax and enjoy.  I tell him, here's your call bell, I'll be right outside if you need me, I hand him his fork and touch his shoulder.  He smiles at me, starts to eat, and I blaze past the doctors on my way out the door.  They might know more than me.  They might do big things, like diagnose, and order meds, and perform surgery.  But I do small things.  And I do them with love.

30 Days Hath November
Day 01: A place I'd like to travel.
Day 02: A favourite movie.
Day 03: Something I never leave the house without.
Day 04: A friend I adore.
Day 05: My hometown.
Day 06: A book I'm reading.
Day 07: A song for the day.
Day 08: Three inspirational quotes (I only did two).

A Song for the Day

I know there's California, Oklahoma

It is a danger of being busy, of being swamped with studying, the danger of inflating your own importance.  

And all of the places I ain't ever been to but

How will I ever learn the difference between the five different types of hepatitis, know what immunoglobulins indicate latent infection or chronic disease, and what the heck is hepatic encephalopathy anyway?  Is that the one that causes asterixis?

Down in the valley

With whiskey rivers

And then, every Wednesday, I walk into the hospital and take a deep breath of the Purell-scented air on the renal unit where I spend my days now.

These are the places you will find me hidin'

And I remember.  I remember that I get to walk away at 7 PM.  That I can comment on the weather with some knowledge of what that air feels like outside, because I was in it that morning and will be in it again that night, cold or rainy as it is.  I remember that yes, I have a lot of studying, and it feels overwhelming, but - I can go to the bathroom when I want to, and I don't need anyone to help me.  I can eat what I want to, and my kidneys work, and my blood is not slowing to sludge in my veins because it's so loaded with toxins that I should be able to pee out but can't.  I remember that I can walk more than three feet without getting out of breath, and I remember that when I dream about being on a beach, or being home with my Mom and Dad, or even just being asleep in my own bed...those things are possible for me.  Some are more likely to happen than others, but they're still possible.

These are the places I will always go

People in end stage renal disease can dream of leaving the hospital, but most of them never will.  The places they go in their dozes and daydreams, after I dim the lights and pull up their blankets, are places they will probably never see again.  The inside of their bedroom, the slope of their front steps, the sky outside their kitchen window.

These are the places I will always go

A document entitled "Discharge Plan."  It's blank inside.

I am on my way

I pull up the order list, updated this morning after the patient met with his physician team.

I am on my way

Comfort measures only.  Morphine, PRN.

I am on my way back to where I started

I catch my breath again and say a prayer that the sky is beautiful there.  He's on his way.

Lyrics from: Down in the Valley, by The Head and the Heart.

30 Days Hath November
Day 01: A place I'd like to travel.
Day 02: A favourite movie.
Day 03: Something I never leave the house without.
Day 04: A friend I adore.
Day 05: My hometown.
Day 06: A book I'm reading.
Day 07: A song for the day.

Another Fall

Lub-dub. Lub-dub. Lub-dub.

My heart beat pounds in my ears, and I rest my forehead against the cooler porcelain that edges the tub, closing my eyes against the bright overhead light.  The water rushing into the tub is drowned out by the blood rushing in my head.  Subconsciously, I begin to count my pulse, opening my eyelids to slits to glance at the second hand of my watch that lies on the floor, partially buried under the heap of my discarded scrubs.  Eighty-eight beats per minute.  My normal resting heart rate is around sixty-two.

Slow down, I implore the weary organ.  Please slow down.

Bon Iver plays faintly from the stereo, and I want to stay in the bathtub forever.  The water cools around me, my skin begins to wrinkle, and still I sit, wrapping my arms around and behind my knees to try to stay warm.

I blink back tears and wonder idly why I'm crying.  Why oh why can I not make it through these seasonal transitions without falling apart, I say in my head, I mean come on Cait it's fall, it's not the fucking end of the world.  It's fall, it's school, it's raining outside, it's we haven't been grocery shopping in three weeks, it's I can't see my bedroom floor for the mess everywhere, it's everything and nothing and who even knows.

The leaves have begun to blow in the streets.  In the predawn darkness of 5 AM, I can nearly see my breath.  It's fall again, and I panic.

They chose wrong.  They have no idea how wrong they were to pick me.  I don't belong here.  I will be in the 2% of my entering class that doesn't graduate.  How could they have been so stupid as to choose me?

My first patient, he's on contact precautions.  He has MRSA.  It takes me five minutes to gown up to go into his room, my preceptor nearly twitching with impatience at my ineptitude.  I find his pulse, and press down to start to count.  His hand jerks, his face grimaces in pain, and I realize that I've found his pulse on the wrist of the hand that has a fresh IV.  I want to cry, I feel so bad.  He offers me his other arm, and I take the pulse on his left wrist, awkwardly leaning over the bed.  I dig for my watch underneath my disposable protective gown, start to count, and give myself a talking-to.

This isn't about you right now.  You are going to fuck up.  You are going to fuck up a lot.  You need to get over it.  Look, he's already over it.  Get ahold of yourself.

And it's true, he is.  I take his vitals, and we talk about the operation he's scheduled for the next day.  He tells me about his fifteen-year-old grandson that called him just minutes ago to ask him to tell Nana, his wife, to make sure to drive safely home from the hospital because it was storming.  I ask him if he needs anything, make sure his call bell is within reach, and I tell him to get a good sleep because he has a big day tomorrow.  I fumble taking off my gown and gloves before I leave his room, and I idly wonder if I'll come down with MRSA from my first real patient.  I wipe my stethoscope extra carefully with the caustic bleach wipes provided outside his room.

It's 11 PM.  I feel like I've been awake for a month.

I go home, and climb in the bath.

Clinical is over.  Until next week.