Grandma

I'm sitting at the kitchen table, the sun setting in the West out the window, a new hybrid of iris that blooms twice unfolding in front of me, and Grandma cozy in her bed for her after-supper nap. Tonight at dinner she had a hard time getting food from her plate to her mouth. Her hands shake so much that a fork and a knife just seem like foolish tools from another lifetime. Grandma is diligent, though, and fought her way through the meal until the third bite in a row landed in her lap. She turned her blue eyes to me at that moment, shrugged, and sighed with a half-smile of resignation. I picked up her spoon, filled it with casserole, and fed her a bite, and another, and another.

Somehow, six weeks ago, Grandma became a much-older 91. Everything is difficult. Eating is difficult. Digesting is difficult. Her hip hurts. Her knee and its monumental arthritis are a constant. She needs to be reminded to pick up her feet when she walks, and any distance greater than about 20 feet is exhausting. Last Sunday she nearly fell when she missed a grab bar in her bathroom and came out with a bloody nose, a black eye, and the whole right side of her face and neck an artist's palate of browns, maroons, and yellows. This was the last straw, and she declared to me on the phone, "Suzanne, my spirit is broken. My world is coming to a crashing end."

When Grandma's new state of vulnerability hit my radar last week, I could not stop crying about it. I started to write a piece several times, trying to work out my feelings, but became so upset I couldn't finish. Here is some of what I wrote:

"I see clearly, as does the rest of my family, that Grandma's interest in coping with the stresses of daily life, and her body's capacity to do so, are quickly waning. This I understand. But I cannot stand the thought that her beautiful story is coming to a close. I cannot bear it."

Grandma and I sat across from each other at the table this afternoon, each sipping coffee and she munching here and there on a chocolate chip cookie. "You know, Suzanny," she said, looking at the cookie the way we all do, wondering if the cookie-to-chip-ratio is to our liking, "I wish there were just a string I could pull or a bell I could ring so I could go and be with my Lord Jesus. But it's not like that, is it?"

She took another bite while I thought about it for a minute. I remembered the little snapping turtle my Mom and I had encountered on our walk earlier today. We were with my Mom's best friend, Esther, who picked up the little creature, no bigger than a 50-cent piece, and analyzed his condition. We noted he was dry, a couple of his legs not moving, parked in a dangerous place on the path, and quite a distance from the creek. Still, there was no clear way down the banks of the creek, so getting him to the water would take some effort. We three peered over the bridge, our new friend getting squirmier with each passing moment and diminishing Esther's desire to hold him.

"S'pose we could just toss him down there?" one of us suggested.
"Oh I don't like that idea; seems cruel."
"Can he swim?"
"I don't know, do turtles swim?"
"Is he a turtle?"
"Well, how do you tell?"
"What's the difference between a turtle and a tortoise anyway?"
"I think I see a way to get down to the edge."
"Oh, Suzy, now don't end up with a broken ankle."
"Do you want to go down there, Mom?"
"Here, take him - I'm not holding him anymore. He's too snappy."

I took his little-ness gingerly in my left fingers and worked my way down the bank of the creek, sliding a bit with each step, testing the boulders at the creek's edge for sturdiness. I kept glancing at him, his head practically wagging out of his shell and his teeny legs dancing to and fro, wondering if any of this would do him any good in the end, especially if I did break an ankle. My Mom and Esther watched me as I went, sending words of care and occasional direction. I made it to the bottom and wandered under the bridge, looking for the perfect muddy spot at the water's edge for him to be, racking my brain for any knowledge about the lives of turtles and what he probably needed most. Access to water? Food? What food? Out of sight of the other two, I squatted down and placed him on the mud, six inches or so from the water's edge. He waited a beat and then jetted into the water, diving under and then surfacing, his body wiggling around with what I interpreted as glee. I watched for a moment as he gracefully made his way among the creek's rocks, and turned to climb back up.

Back at the table, I looked at Grandma and replied, "I guess we don't get to ring a bell when we're ready to go, Gram. We don't get to pick where or when for many of the big things in life, do we?"

"We sure don't, Suzanny. I feel just awful for all the things I forget to do and troubles I have doing the things I remember to do. I wouldn't know even how to make it easier anymore."

"Then, Grandma, you have to let us try to make it easier for you."

She smiled, and I heard her take a long, deep breath.

She had asked me earlier in the day if I'd do her nails "just the way I like it, Suzanny." I squeezed her hands and stood up to go to the sink, filling a bowl with warm salt water. I lay a towel in front of her on the table, put the bowl on it, and placed her left hand into the water to soak. I organized the clippers and files, took her left hand out of the water, patted it dry, and started to trim and file each nail, giving the edges a slight curve the way she'd done to mine so many times.

In truth, I don't know if a manicure is what Grandma needs. I don't even really know what will make this lonely, autumnal stage of her life any easier. But now Grandma is like our little turtle. If we can be with her as she makes her way to the River, one day she, too, may find the grace to cross.

Nights

After a weekend at home celebrating the 4th of July, I am back to work, and for the most part happy about it. Or content. Or perchance resigned. I believe in the training I am receiving, which appears to be in critical care nursing, but in my opinion is really just further exploration into the human condition.

Today my patient has vast metastases of what started as colon cancer five years ago. Surgery this afternoon removed part of his liver. In the midst of all this, he is also bright eyed, 44, and a married father of four.

When I meet him and his tragic story, what keeps me from sorrow is the long list of duties I have to accomplish throughout the night as his nurse. Here and there he gives me a look that communicates a total understanding of his plight. I pause and take in his gaze, and try to look back in kind. What an honor to be the person receiving these communications at this point in his life.

I keep eying his monitor, and eying him, and he seems at rest. Nothing makes me happier, since sleeping is an unfortunate rarity in the ICU. He even seems to sleep through the hourly finger-sticks I am forced to do, one of my most unsavory tasks. I know that pain inevitably exists on many levels for my patients, but for some reason the idea of poking their finger every hour seems like adding insult to injury. I for one think that finger-sticks hurt like hell, but tonight, my man snores right through, bless his heart.

Since moving to nights, many friends and family have asked me what it's like, and how I handle the schedule. I say the same thing to everyone: the actual work and shift is not a problem. The stress comes on my days off, when I sleep all day and wake up with only a couple hours of daylight in which to re-connect with people on conventional schedules. Then I am reminded of how "off" my schedule makes me to the rest of the world, and then I am reminded of how few people I even know in this new city of mine. Here enter the blues, and I find myself on my couch, doomed to looming infomercials and replays of daytime baseball games.

I go back into my patient's room to hang a new medication, to do another finger-stick, to adjust his insulin pump, to make sure his reflexes are intact, to check on the rate of his epidural anesthesia, to listen to his breath sounds, to flush his arterial line, to empty the urine from the collection bag of his catheter, and he wakes and watches me. He has big, brown eyes and they are full of questions. I try to be quiet, hoping he'll close said eyes and go back to sleep to get much needed rest, but I know he is awake and wants to say something. "How am I?" he asks. I stop working with the pump and look at him. "How are you?" I say, unsure of his question. "Yes," he replies. "You know more than I do about how I am doing. How am I doing?"

And here's where the time equilibrium betrays me; where my knowledge of his prognosis and probable outcome haunt me; where I have to be conscious about how much I say, but yet hold myself to some modicum of truth. So I talk about now, this shift, this immediate period of time we're sharing. I tell him his vital signs are stable, the surgery he had that day went well, that he is not bleeding, and that together we are managing his pain. I comment that he's been resting so well that I can hear him snoring from the nurse's desk. He smirks.

I crouch down to empty the catheter bag, and he again watches me, peering over the edge of the bed.

"Miss Suzanne?" he asks, "What if I have to pee?"

I smile from my squatted position and explain to him that he has a catheter, and that if he feels he has to pee, he should just go ahead.

"You sure?"

I hold up the bag, saying, "See all this urine here?"

"Yeah," he replies.

I point at him and nod.

"That's mine?!" he exclaims.

"Well, it's not MINE!" I quickly reply with raised eyebrows. He gifts me with a chuckle and turns his head in mild embarrassment.

I go over to the toilet and dump what's been collected, take off my gloves, wash my hands, put on a new pair of gloves, and set about my final task (which I've put off until last), the finger-stick.

I approach his bed and take his big, calloused hand, picking a new finger and noting the tan lines from his rings.

He's watching me.

"Suzanne, do you believe in God?"

I jab the tip of his middle left finger.

"Sure," I say as I squeeze the drop of blood onto the test strip and put gauze and pressure onto the little wound I just inflicted. "Why do you ask?"

Without a flinch he tells me, "Because I have been praying for you tonight. I've been praying for God to grant you wisdom, and intelligence, and courage. I pray that through your wisdom, and your intelligence, and courage, that God will be able to cure me. And I know already that God has blessed you with these things. And I thank you."

The glucometer beeps out a reading, I take the gauze off his finger and give it a quick, soft rub to make sure there is no bleeding, and take his hand in mine for a moment.

"Thank you for praying for me," I say. "You are a blessing."

He smiles at me and squeezes my hand. "God bless you, Suzanne."

"And God bless you. Now get some sleep."

I take off my gloves, wash my hands, adjust the insulin infusion, and leave his room in order to document his blood sugar and carry on with the next task. Later I document in my nurse's notes, "Patient rousable, alert, conversational, oriented to person, place, time."

Nurse's notes are painfully dry. Such documentation communicates little of the greater narrative at work. And so, from the bleary-eyed perspective of a somewhat reticent night nurse, I'll continue to tell the story.

Yellow People

I am writing today about people with ESLD, a medical acronym for End Stage Liver Disease. I have met more of these people, the Yellow People, in the last 2 months, than ever before in my life. My work in the ICU at Methodist Specialty and Transplant Hospital here in San Antonio has brought me this opportunity, and I am changed.

ESLD is unforgiving and vast in its reach. It affects skin, eyes, kidneys, bowels, brain, heart, lungs, esophagus, blood, platelets, hemoglobin - it is a macro and micro villain to all those who suffer its invasion.

I say Yellow People because of the jaundice, caused by the liver's inability to properly excrete bilirubin through the gall bladder into bile. All of my ESLD patients have come to me in varying colors of yellow. One today referred to herself as Homer Simpson. She was not exaggerating.

My heart broke several weeks ago when Jimmy died. He'd been on our unit for over a month, his liver finished, his body in the throes of its demise. He was bright yellow, his eyes nearly glowing, and spent most of the day in and out of another one of ESLD's greatest challenges: hepatic encephalopathy. That simply means that ammonia, which is normally broken down by the liver and excreted by the kidneys afterward, builds up in the body, crosses the blood-brain-barrier, and causes a person to exhibit various levels of psychosis.

Jimmy, with his East Coast accent and history, was a bittersweet and often funny picture of encephalopathy. At least I thought he was funny. And so did his wife. I'd come in the room to give him some medication or change out some of his IV fluids, and he'd glance in my direction and shout "OH GOD HERE COMES THE JUMPER!!!" or "YOU'RE NEVER GONNA GET IT IN, DOLL!"

"Get what in, Jimmy?"

(beat)

"JUMPER!!!!"

I admit I was thrown the first couple of times, but the more twelve hour days I spent with Buddy, the more his essence was expressed and the wittier and more poignant he became.

He didn't always shout, either. Sometimes he spoke to me in an urgent whisper.

"Hey," he'd say, looking both ways and nodding me to come in close,"Hey, babe, you gotta get me the fuck outta here, yeah?"

I'd laugh and say, "Jimmy, where do you want to go?"

He'd tsk, roll his eyes, shake his head, and usually respond, "Aw, hell, if you don't know, we ain't goin'."

I'd pat his shoulder, make sure all his monitors were in place, IV's running well, and walk back out onto the unit. Just as I'd cross the door's threshold, I could hear him mutter to himself, "Damn JUMPER," as his wife giggled and chastised him.

She was another piece of Jimmy's captivating picture. Married for 20 years, she was doting, present, concerned, involved, grieving, candid, caring. She fed him every meal we brought into the room. If he was being difficult, she found the way to bring him back to himself. In the worst peaks of encephalopathy, she never lost track of Jimmy, and always gave him ways to pull out of it.

I walked in the room on what would be my last day with him, a dose of medication in my hand.

"I AIN'T TAKIN' SHIT!!!" he shouted as I put on my gloves and gathered the syringes and flushes.

"Jimmy!" his wife exclaimed, "This is Suzanne! Your favorite! Be nice to her! She's the only one here who knows how funny you are!"

I laughed and smiled at her.

"Sorry, sorry," Jimmy muttered as he tsked at himself.

"Jimmy, no need to apologize. I know who you are and even when you yell I'm happy to see you."

He nodded, searching for words, another struggle due to the ammonia levels.

"See,"

(beat)

"See, ...I'm just, I'm just not the same dude, you know?"

He looked up at me from his bed with his glowing yellow eyes, handsomely set behind his wire-rimmed glasses, an item I always put on when I worked with him. I think it kept him feeling just one step above gravely-ill, and he looked pretty dapper in them as well.

"I know, Jimmy. But so much of the dude is still just right here, and as soon as we get you that liver, we won't have to worry about this other JUMPER anymore."

He looked at his wife with a furrowed brow and whispered in that same, urgent voice, "What the hell is she talking about?"

She and I guffawed.

Jimmy was a big sports fan, and on that same last day I learned he loved the Yankees. I am so grateful for this discovery, because it lead to a conversation about Yankee Stadium, and the concert I'd seen there last summer in which Paul McCartney made a surprise appearance. Twice.

I was again at Jimmy's bedside, trying to get him to take some medicine or something, when the topic came up. Jimmy's entire demeanor shifted when I mentioned McCartney, and his wife chimed in from her chair, "Oh Jimmy! You hear that? Paul McCartney! Suzanne, he LOVES the Beatles."

Jimmy gazed up at me again and asked, "What'd he sing?"

I reached back into my memory and replied, "First, he came out and sang 'I Saw Her Standing There," Jimmy nodding his approval, "and then he surprised us AGAIN and came out for the very last song of the show and sang, "Let It Be."

Jimmy sank back into his pillows, closed his eyes, and exhaled, "Ah man....that's a good one; a real good one."

I couldn't believe how much of Jimmy I felt like I was finally seeing in those moments. We all know how unlike ourselves we feel when we're sick, even with a measly rhinovirus. Imagine how hard it is to maintain some version of integrity when every system in your body is failing? Suddenly, at the mention of one song, I saw Jimmy re-integrate right there in his bed. He lay there, eyes still closed, and began at a whisper, "When I find myself in trouble, Mother Mary comes to me..."

At this point he squinted his eyes open just a twitch and reached his right hand over to touch my hand resting on the side rail of his bed. His voice came in more fully and he continued, "...whisper words of wisdom, let it be."

He opened his eyes fully, gave a half smile, and said "Ah, yeah. A real good one."

Moments like these are risky as I learn to be a nurse. Emotion could keep me from the perspective I need to maintain in order to monitor all the things happening with Jimmy, and more importantly, all the things on the cusp of going very wrong with Jimmy.

ESLD makes it hard for the body to clot, so patients bleed very easily.

It also creates lots of potential for bleeding throughout the entire digestive tract, because a failed liver builds up pressure in the whole vasculature of the digestive, renal, pulmonary, and cardiovascular systems. Pressure on vessels makes it easier for them to burst. And with a hindered ability to clot, burst vessels can be deadly, and deadly very quickly.

I stood with Jimmy for a few moments after he finished singing, exchanged looks of understanding and admiration with his wife, and went on to give him his medication. I then took off my gloves and washed my hands, all of us still in silence. Before I left the room, I stopped at the foot of the bed and said, quietly, "Thanks for the song, Jumper."

The rest of our day was upbeat. Jimmy's wife and I laughed at little things he'd say, and he had more moments of clarity than not. During the last medication administration, I asked him if he wanted me to sing him anything, since the day was coming to a close and I didn't know if he'd be my patient tomorrow. He blinked a couple of times and said, "Sure, why not?"

I had about a two minute window while I had to do the tedious job of pushing dissolved pills through the tube in his nose, (Jimmy wasn't so good at swallowing pills anymore, and the risk of aspiration into the lungs was too high), something he tolerated very well for me, and so I figured I'd pick a Beatles song.

"Ready, Jimmy?"

"Yeah, babe."

He paused, then grumbled, "Hit it."

I began to infuse the medication into the tube, took a deep breath, and sang, "In the town where I was born, lived a man who sailed the sea. And he told us of his life in a yellow submarine ---"

At this moment, right during those three beats before the chorus, Jimmy's hand shot up and he started conducting, shouting "TWO! THREE! FOUR!"

Not missing a beat of our impromptu duet, I chimed in, along with Jimmy and his conducting, "WE ALL LIVE IN A YELLOW SUBMARINE! A YELLOW SUBMARINE! A YELLOW SUBMARINE! WE ALL LIVE IN A YELLOW SUBMARINE! A YELLOW SUBMARINE! A YELLOW SUBMARINE!"

His wife clapped along, I finished giving the meds, and Jimmy looked at me out of the corner of his bespectacled, yellow eyes, and winked.

His wife left later on that day, coming by the computer where I was working to say good-bye and that she'd be back in couple of days, as she had to go back down to the coast where they lived to tie up some things with their house and her job. We hugged, and thanked each other for a great day.

I worked the following day, but wasn't assigned to be with Jimmy. I stopped in during a break and his nurse gave me an update - said he was more out-of-it than cogent, but relatively stable considering the extent of his illness. One of his doctors came by as we spoke, all of us concerned that he hadn't yet gotten a liver, and joked in a marked, macabre tone, "If only we could suspend speed limits for one weekend in the state of Texas. Then our friend would get the liver he needs."

Jimmy died the next day, in the afternoon The lab called his nurse at 2pm to say that the most recent blood work results "were not compatible with life." His blood pressure dropped to an alarmingly low level, and by 3pm, after coding and a good hour of earnest attempts to save his life, Jimmy bled to death internally.

I heard Garrison Keillor say that he writes because he feels that if it doesn't get written, it didn't happen. I can't bear the thought that my brief time with Jimmy didn't happen, and so, now, it is written.

Let It Be
Paul McCartney

"When I find myself in times of trouble, mother Mary comes to me,
speaking words of wisdom, let it be.
And in my hour of darkness she is standing right in front of me,
speaking words of wisdom, let it be.

Let it be, let it be, let it be, let it be.
Whisper words of wisdom, let it be.

And when the broken hearted people living in the world agree,
there will be an answer, let it be.
For though they may be parted there is still a chance that they will see,
there will be an answer. let it be.

Let it be, let it be, .....

And when the night is cloudy, there is still a light, that shines on me,
shine until tomorrow, let it be.
I wake up to the sound of music, mother Mary comes to me,
speaking words of wisdom, let it be.

Let it be, let it be, ..... "

Welcome to Texas

During my early and mid twenties I spent a lot of time setting goals. I had a the one year, two year, five year, and ten year plan. Goals could be as vague as “international travel” or “keep performing” or as specific as “save $5k by June, 2001” or “learn to speak conversational Italian.” I can promise you that “become a nurse and move to Texas” never made the list. And yet here I am, a nurse who has now lived in Texas for 18 days.

I loved living in New York, and still can’t believe that I left. Moments arise, however, to cleanse me of any such confusion. Just the other day I went to the DMV to get a Texas driver’s license. Though I’m sure I knew it at some point, it came as a surprise to me as I filled out the paperwork that I would be expected to turn in my New York license. Not only that, but the wording was something like “state from which current license will be surrendered.” Surrendered? Does the acting of giving back one’s driver’s license really deserve such dramatic wording? It’s not like I was giving up a weapon, or a battle, or a painting I stole from the Louvre. It was merely a driver’s license from the state of New York. I stood there in the sardine-like quarters of the Texas Department of Safety (are all DMVs the same? Why is there never enough space? Do the people who design these places never go to them and thus never understand how poorly they are able to handle the sheer volume of humanity who pass through their doors on any given day?) and found myself crying as I filled in line after line on my form. I became suddenly aware that I felt like I had given up on New York, or worse, that New York had given up on me, and now I was being punished by having to surrender my driver’s license; my only official document and claim to having lived there, driven there, thrived there.

A woman with voluminous 80’s rock band hair in a thick pink sweater stood at the microphone and kindly called me out of my sorrow.

“Number 58, Number 59, Number 60, 61, and 62,” she shouted, seeming to forget she was using a microphone. I glanced up, she caught my eye, and I affirmed that I was indeed Number 59.

“Okay honey, “ she nodded, half-smiling with her hand over the mike, “you go on ahead to line number 1.”

Something about her made me feel better. Maybe it was her hair, or her coarse, direct communication style, or the fact that really, she could have been from Weehawken. She was familiar, and she was nice to me, and I knew if I told her how sad I was about surrendering my license, she would have understood and given me a nice pat on the back with her big hands and pink sunburst acrylic nails.

Soon I was giving my finger prints, taking a vision test, and listening to the lady next to me going on and on about how disappointing it was for her to have to take a new photo for her new license, since her last license was the "best ID photo of her life.” She spoke with a warm, honeyed South Texas accent and somehow got the agent to let her pose three times for three different shots.

“Oh honey, now, would you just be a sugar and let me take just another one? I think that last one just looked so glossy, you know?”

She lined up again against the blue wall. The agent snapped the photo. My agent and I exchanged knowing smiles.

“Oh sugar pie, I think we need to do just one more now, don’t you? Just to be sure it’s the very best? I mean, I wore this nice black v-neck with the lace around the neck and I just don’t think that lace is showing up on these shots like it should. I mean I really want this to look good, honey.”

When I realized she was on photo op number three, I let discretion go by the wayside and turned around to watch. There I found another big-haired blond beauty, hovering somewhere around age 50, with vast amounts of black mascara, blue eye shadow, and rouge. I say rouge rather than blush because I really think that’s what she used, or certainly imagine that is how she would refer to it. She was dressed in black jeans with a silver-studded Western belt, black boots, and yes, that black v-neck shirt edged in lace, a lovely frame for the 4-plus inches of cleavage she was sporting.

For her final shot, she smiled and unabashedly pushed her arms up and into the sides of her chest, thrusting the lace-bound Cleveland into the camera’s viewfinder. Her agent’s eyebrows were raised as high as mine as we watched this final bold gesture. The picture taken, our subject relaxed her stance, winked at me, and shimmied up to the desk to analyze her final pose.

“Ah, Sweet Jesus, sugar, that’s the one! We did it! Oh my, it looks so GOOOOOD!”

My eyebrows still in the “in shock” position, I turned back to my agent who shook her bowed head and exhaled audibly, her hands braced on the counter. After a beat, she brought her head up, looked me straight in the eye, and said, “Welcome to Texas, Sugar.”