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, ..... "