“One Hundred Days” by Andrea Eberly

BLAST, TMR’s online-only prose anthology, features fiction and nonfiction too lively to be confined between the covers of a print journal. In her 2021 Perkoff Prize finalist story “One Hundred Days,” Andrea Eberly gives us an oncologist and new mother whose past rock-star crush comes crashing into her present professional life in the form of a dying patient.

 

One Hundred Days

Andrea Eberly

 

Earlier in my career as an assistant professor of medicine, I would lose myself in charting, reading, writing. I’d imagined myself all mind, just a big brain hitching a ride in a body-machine that I kept running with protein bars, premade cafeteria sandwiches, cup noodles, all washed down with cup after cup of coffee. Now my mammal-body called me back every few hours as my breasts filled with milk, two biological hourglasses that got flipped over after twenty minutes of pumping.

Wichita wichita. The breast pump’s cicada-like chorus filled the clinic’s break room. Today was Thursday, my clinic day. Since I was working as the attending physician at the hospital this month, I spent the rest of the week I was at my research lab. I willed my oxytocin-fogged head to be up to the task of skimming over two years’ worth of chart notes during a single pumping session. I stuffed salmon salad into my mouth while flipping through the electronic chart on my laptop, reviewing chemo regimens, cell counts, CT-scan images. A couple of quinoa kernels fell onto the keyboard, and I brushed them off. I was now responsible for nourishing two bodies, so I’d given up the cup noodles. This next case was new to me; he was coming in for a pretransplant workup.

Wichita wichita wichita. Drip, drip, drip.

When the medical assistant walked in to tell me the patient had arrived, I turned around to his voice. He backed out of the room, hands held up in a Hey, don’t shoot sort of gesture. Strangely bodiless, my swollen nipples pulsed with the suction of the machine, sticking out from the cone-shaped flanges strapped onto me with an elasticized corset. Larry was filling in for Sonya. Sonya was used to the pumping.

I unscrewed the bottles and pulled off the bra, losing a few drops of milk on my pants, and wrapped up the gear before chucking it all into the fridge. I rinsed out my mouth with tap water to conceal stank coffee breath before walking into the exam room. I rubbed some alcohol gel onto my hands.

A man sat on the edge of the paper-covered exam table. Slim dark jeans and a nubby sweater covered a slim body. He appeared closer to my age than his calendar age of fifty-one. But that’s how it is with cancer—the puffiness from IV fluids and steroids can make you look unnaturally young, or the disease can eat away at you and turn you old overnight.

I introduced myself, Dr. Sydney Weaver, and he reached out to shake my hand. A tattoo covered his wrist and half the back of his hand. I’d seen the image before. A blue serpent circled his wrist, scaly body looping on itself with the head eating its own tail. I recognized the ouroboros from the album art of The Invisible City. The poster was still up at my parents’ house, in my old bedroom.

Cool tattoo, I thought, very cool. I was about to say so, when I really looked at the prednisone-puffed face and the postchemo hair fuzz. The cleft in his chin cinched it.

It was him. Mr. Polo.

***

One night in eleventh grade, my friends and I had gone cruising. It was the late ’80s, Phoenix. Tan desert dotted with stuccoed tract houses and green lawns. All the roads at right angles to each other.

Beth, Angela, and I piled into my Ford Escort—stick shift, plastic dash cracked from endless sun, fabric-wrapped visor disintegrating into a swirl of fine powder. We’d just taken the practice SAT and were giddy with having made the first concrete move toward getting into college, which was to say, getting the hell out of Phoenix. I pushed a Mr. Polo tape into the deck, twisted the volume nob, and felt the bass shake the air, even as the warping speakers were all rattle and static. We stopped at Denny’s and ate cheese fries and drank bottomless cherry cokes. Angela smoked some cigarettes she’d stolen from her mother. Menthols. After driving past Jim Delver’s place and launching a couple of eggs at his window, we drove over to the elementary school with the big speed bumps out front. The city had painted HUMP to warn drivers to slow down. We chalked in the word KIDS underneath. After midnight, we stationed the car in the parking lot of the Ross Dress for Less where Beth worked. It was next to the Taco Bell with the late-night drive thru. We stuffed ourselves with fifty-nine-cent tacos, witnessed petty drug deals, and ripped jokes about the creepy guy in fifth period who was always drawing pictures of wolves in trench coats. Beth and I bet on which one of us he’d ask out first. Definitely Angela. We laughed our throats raw, and then we laughed more. All the while, Mr. Polo blasted from the cassette deck and we swore to each other that even when we went to college, we’d never lose touch and would be friends forever.

Back then, I just thought Mr. Polo’s music was the best thing I’d ever heard. If anyone had asked me why I loved it, I would’ve said it was because of the way he wove together the beats and sounds, how he pushed and pulled the tempos. What a dumb and technical answer, but I cared a lot about sounding smart back then. Really, I just I loved how it made me feel, how he made me feel, like he had crawled into my skull and made sense of everything. I could listen and think, Yeah, it’s just like that. Just like that.

***     

Not long after Marco’s first appointment, I dug around in some old boxes and found my Mr. Polo CDs. I hadn’t listened to his stuff in years. With my windows down, the volume up, and my baby Maddie in the back seat, I drove around. Maddie goo goo gah gah’d and bounced her feet to the electronic drums, the synthesizer click, and Mr. Polo’s machine-gun lyrics. The baby seemed to like Mr. Polo’s middle work best, before he returned to real drums and guitar shreds. In the delicious anticipation of the next beat, the next musical structure, feelings poured through me that were both familiar and strange.

Of course, in medical school I’d learned about dopamine and the pleasure and reward centers in the brain, so I figured music was like drugs, food, and sex—big fat dopamine hits in the deepest parts of the brain. I once shared this theory with Ben, my best buddy from med school, when we were studying neurotransmission, and he joked that I had a pretty mechanical view of the best parts of being alive.

Ben and I had ended up living together in San Francisco for our internal medicine residencies. We shared a one-bedroom—I paid more rent to get the bedroom and Ben slept on the couch-bed. We often went to the laundromat together, the nicer one a little farther away called the Lost Sock. When we washed clothes, Ben always came up one sock short. He had an old shoe box filled with the singletons taking up valuable real estate on our bookshelf at the apartment. I guess he was an optimist, believing that someday all the socks would be reunited. Me, I used to put all my socks in a mesh bag, so it was impossible to lose one. I believed in planning, not luck.

We’d watch our clothes spin around in the dryer while dreaming out loud about the next stages of our careers. Classic overachievers, both of us planned on doing fellowships following residency. I told Ben I wanted to go into hematology/oncology. Ben said he couldn’t understand why anyone would want to go into oncology, because so many of those patients were not fixable. That was the appeal of infectious disease, he said. Match the drug to the bug and cure the patient.

I told him that I didn’t want to stop just at regular oncology. I would push further. Hematopoietic stem-cell transplantation. Every patient on a research protocol as investigators trialed new combinations of medications, new methods of harvesting cells. The fucking Wild West of medicine. In transplant, the goal wasn’t just a feeble extension of life. It was cure.

I wanted to be a goddam cowboy.

***

On the days Mr. Polo, whose given name was Marco Schellenbach, was on my schedule, a fluttery feeling filled my chest. I wore mascara and was careful not to leave the house with a white blob of dried spit-up on my blouse, even as I was less careful about fastening up all that blouse’s buttons. My husband would sometimes even tell me I looked nice as I dashed out of the house.

On one of those days, as I waited for Marco to arrive for his appointment, I massaged the kinks out of a grant application that was due the following day. My grad student, technician, and two postdocs didn’t deserve to end up unemployed because I couldn’t get my act together and secure funding. I yawned. My kid’s first teeth were coming in, so I was getting little to no sleep, even by new parent standards. The only thing that kept Maddie from screaming was constant attachment to my breast. All. Night. Long.

Marco came in and sat down in a chair—not the exam bench—next to the office computer and stared at his hands. I started with the results of his last bone marrow biopsy.

“Your leukemia is no longer detectable.”

“So that means I can get the transplant?”

I nodded.

His lips pulled into a smile that gripped my heart as we hashed out some of the other details—which conditioning regimen he’d get, the brother who was a match, the sister who could come out from Waco to shepherd him through recovery.

“Do you have any more questions?”

Marco picked up one of the two photos on my desk. Since I shared the exam room, I always had to remember to take my photos home at the end of the day.

“Your baby is cute. How old is she?”

“That’s Maddie. She’s six months old.”

“Who’s the guy in the other photo? Your brother?”

He was asking about the one with the blonde in a tux standing next to the redheaded bride. A lot of patients send their doctors cards with family photos, and we put them up in our offices. I knew it blurred the lines of patient confidentiality, but I couldn’t help myself and answered Marco’s question knowing the hope that the photo could inspire.

One of my first patients.

“Did he live?”

“Yeah.”

My fellowship had just started when Jason, the guy in the photo, was diagnosed with acute myelogenous leukemia—same diagnosis as Marco. I remember the spring in my step in those days; I’d been driven by my belief that the initial induction and consolidation treatments would work, and even if they didn’t, there was always another step, another treatment, so many different chemotherapy cocktails. I’d prescribed the clotrimazole troches for his thrush during salvage treatment. I’d optimized his antirejection meds. He survived, grew back his hair, got married, and sent me that wedding announcement—the photo on my desk. He’d been the first patient I ushered through the whole process. The first patient I cured.

Marco nodded and pursed his lips as he looked at the photo. His brow twitched. I wondered if he was imagining himself in a similar photo, hair grown back, muscles rounded out. A future without cancer. A posttreatment world.

What was I thinking, leaving the neck of my blouse undone?

***

During our appointments, I kept thinking that Marco would eventually mention music, like Hey, last weekend I was messing around on my Roland 808 drum machine . . .

But he never did. It became a bit like when you’ve been talking to someone at a party all night long and realize you don’t know their name. You can’t ask anymore. In this case, I wanted to tell Marco that I loved his work, but it seemed deceptive to not have said anything for so long. Maybe he valued what he’d believed was a certain anonymity in our interactions. I mean, I’d now seen him naked under a backless hospital gown, taken blood, knew his whole medical history. So intimate, and yet.

It became a secret I watered like a houseplant. But not any houseplant. Maybe an orchid, where the pleasure was married to the toil of keeping it alive.

***

While I waited for Marco to arrive—that patient before him had canceled—I caught up on emails. My grad student almost had enough data to write a paper, but her figures were awful, and I didn’t have the time to really get into it, so I closed the email and opened up Amazon to buy some new clothes for my daughter. No one told me it would be so sad to retire Maddie’s six-month footed pajamas, the ones with the hedgehogs.

Earlier that week, I’d replaced Maddie’s photo with a new one. My husband was holding her, and you could just see his hands. Maddie had two tiny bottom teeth. Marco noticed the new photo immediately when he sat down. He said she looked like me. That was when I asked him about his daughter and immediately felt my face grow three sizes too big, hot and red.

My leukemia patient had never told me about his daughter.

In high school and college, I’d read every article about Mr. Polo in Spin or Rolling Stone or whatever other music rag. My high school binder was covered in a collage of magazine cutouts, and the one taking up the most space was a black-and-white photo of Mr. Polo in sunglasses screaming into a mic. I still had a pair of the same aviators.

“I’m actually a huge fan,” I mumbled and swallowed and drummed my fingers against my leg, and the air in the room was jelly. What would he say?

“My daughter just finished art school,” he said. “Hard to believe she was ever that little.” He motioned toward the photo of Maddie.

“Yeah. It goes by fast,” I said. After a moment, I got my nerve up to meet his eye and asked, “What kind of art does she do?”

“She wants to open a tattoo shop.”

He paused and took a deep breath, almost like he was tired from the talking. He lifted his arm, the one with the ouroboros, and said, “She always liked my tattoos. She likes the idea of living art.”

We went over his lab results before he got onto the exam table. I placed my stethoscope over the jaguar tattoo on his back, and the tip of my finger brushed his ink. My heart skipped into my throat as I listened to his breaths go in and out.

***

Right after graduating college, my roommates and I took a road trip to a big open-air concert near Jackson Hole. Mr. Polo was the headliner. On the stage, Mr. Polo unbuttoned his starched white shirt. Under the stage lights, his muscles rippled, creating the illusion that the stylized jaguar tattooed on his back was alive.

Masses of sweaty bodies, moving to the beat. The violence, the raw physicality of the crowd, edged on sexy. With disassociation from caring and really letting loose, I was for the tiniest moment living life without my mind—I was just a body swimming in thereness, if there even is such a word—synched up with Mr. Polo and his music.

After the concert, we camped for a few nights off a dirt road that lay in the border region between Yellowstone and Grand Teton Park. One night in the tent, my roommate dug out a piece of paper from her bag and wrote the letters MASH on top. It had been ages since any of us had played that schoolgirl game. Mansion, Apartment, Shack, House. A game to predict our futures. The game foretold that I would end up in an apartment with five kids, working as a movie star and married to Dr. Richards, our lech biochemistry professor, whom we always saw working out at the campus gym in such short shorts I swear you could see his nut sack. My roommate got a mansion and was married to Mr. Polo. Lucky her.

Our campsite was near a stream. From our tent we heard something splashing in the water, and then it would stop before starting up again. Was it bison charging through the water? A massive grizzly bear catching fish? We’d been hitting the hash pipe, and paranoia tickled the napes of our necks. That fall I would be heading off to medical school—my roommate, too. My other roommate had been accepted to a PhD program in chemical engineering. We snort-laughed as we imagined the headline. “Young talent cut short. Eaten by bears.”

I unzipped the tent, and my bare feet felt as though they were floating over the chalky dirt as I padded toward the stream. I parted the willow branches like a curtain just in time to see a cloud of white pelicans landing in an explosion of water. They floated with the current of the creek a stretch before flying upstream to land and float downstream again. Paranoia melted into awe as I stumbled back to the tent.

Safely zipped inside the tent, we listened to the sounds of pelicans taking off and landing in splashes of creek water, and we fell asleep to the rhythm of living things.

***

As usual after working at the lab, I had to get Maddie from day care. The day care teacher told me Maddie had started to point.

Earlier that day I’d reviewed Marco’s chart to see how he was doing. He was two weeks out from his transplant and still admitted to the hospital. His liver enzymes were through the roof, and he was suffering watery diarrhea—graft versus host disease or maybe side effects from the conditioning regimen. We’d know more when the pathology report came back.

My stomach filled with ash.

I strapped Maddie into her car seat. Mostly I was ignoring the stream of garbling sounds emerging from her mouth, when I jammed my finger into one of the buckles. The fingernail of my left middle finger bent back, and pain seared through my hand. It was all I could do to not yell “Fuck!” to not plow my fist into my thigh. I sucked on the finger to dull the ache and inhaled a couple of times. Maddie’s long toes wriggled, taunting me. Goddammit, her sock was off again. What was it with children’s feet and socks? I leaned over, the waistband of my jeans cutting into my belly fat, and picked up the pink-and-white knit thing. Maddie stuck her thumb in her mouth and gave me the stink eye as I pulled the sock over her foot for the eight hundredth time before cinching the straps of her car seat.

***

One Thursday in clinic, after Marco had been discharged from the hospital, he talked to me about his garden.

“Sydney, what is your favorite apple?”

“I’ve never thought about it.”

“Well, a few years back I planted a Gravenstein tree. This year it has two apples, so next year it should really start producing. Maybe enough for a pie. Gravensteins make the best pies. My grandma had a big tree in her yard, and she baked with nothing else.”

During another visit he told me about a novel he was trying to complete. He said this in between body-wracking coughs that he tried to cover with trembling hands.

“I’m about halfway through revising it.”

“I didn’t know you wrote.”

“My head is filled with all these people—my characters. It will be weird to say goodbye when I’m done with the book.”

I kept hoping he’d talk to me about the music, especially now that he knew I was a fan. I wanted to learn about his process for writing songs, choosing samples, what it was like to stand on the stage above a sea of dancing bodies.

Somewhere inside these conversations lurked his real question: Will I get be able to get my book done?

No, deeper.

Am I going to die?

No, deeper still.

When will I die?

***

One hundred days after I had birthed my daughter, my mom watched her while Craig and I went to a café for a glass of wine to celebrate having kept our baby alive for this milestone. As we walked home, the clouds cracked open with a fountain of rain. We ran the last blocks back to the house, and something warm happened between my legs. I knew what it was, but still hoped I was wrong.

My body had fallen apart to bring new life into the world.

I wanted control of my bladder back.

I’ve always wanted control.

***

On day eighty-seven posttransplant, it was confirmed that Marco’s leukemia was back. He didn’t get to one hundred days.

***

Marco paced in the office. Not the violent lunging steps of a healthy man, not the vigorous movements of that man I’d seen so many years before at that festival in Wyoming, but the nervous shuffle of a sick man. A scared man. I explained that the prognosis for people whose leukemias relapsed within one hundred days of transplant was grim.

“What does that mean, Doctor?”

He usually called me Sydney.

I met his question with silence, and that was when he started to cry.

***

The lights in our living room were on a timer. They clicked off at ten thirty. So did the heat. I had already put Maddie to bed. and Craig was upstairs playing on his computer. The baby cried, and I didn’t think it could be that she was hungry; she had just eaten. I hollered at Craig to go in and get her back down.

Ghost-like light from my laptop filled the room as I flipped through the PubMed database, sifting the medical literature for any option that could go after Marco’s leukemia. There had to be something there if you looked hard enough.

My breasts filled with milk.

I saved links, skimmed abstracts, printed a couple of articles, made notes. Normally I would have fed Maddie around midnight, but I kept working until the sky lightened and birds chirped outside the window. My breasts felt like they had become bags filled with stones. Finally, Craig came downstairs and asked why I hadn’t ever come to bed. I couldn’t say much more than that I was trying to help a patient. I couldn’t tell Craig I was treating Mr. Polo. You know, HIPAA and all that.

Craig went back upstairs and returned a few minutes later with the baby.

“Syd, Maddie’s hungry.”

He said it like “hawngree.” It was our joke.

I held Maddie to my breast. The flood of milk made her cough, and pain shot through me as she clamped down on my nipple.

Goddamit, Baby.

She now had four teeth. Two top and two bottom.

Maddie’s swallows made little “kah” sounds. A recent paper outlined how something called a FLT-3 inhibitor could attack the leukemia cells, but the drug was still in clinical trials. Could I procure it for Marco? Sometimes drug companies let you use experimental therapies for what they called “compassionate use.” I had to try. I’d contact the medical science liaison at Novo Nordisk. They’d give me the drug. They had to.

The baby dozed off at my breast. A flutter of guilt rushed through me for ignoring her. I remembered the advice my mother had given me—sleep when the baby sleeps. Don’t fight nature. So I picked up her sleep-limp body and carried her into bed with me. I held her to my chest and breathed in the scent of her hair. My own restlessness seemed so abrupt and harsh next to her sleeping form. Her eyelashes were so long. I had no idea that a baby could have such long eyelashes. Underneath the paper-thin lids, her eyes twitched. What was she dreaming about? What would her dreams be? My body was tired, but my mind resisted sleep, and my thoughts wove in and out and kept coming back to the same place. Physicians were just body mechanics. Why could some bodies be fixed, while others failed? What if I couldn’t patch it up and get it back on the road? A package of bones and tissues and vessels and blood—was that all we were?

***

How many hours did I spend on the phone or drafting emails to the drug company? But inside Marco, his cancer had a schedule of its own.

There hadn’t been time to work through the regulatory hurdle for the experimental drug, so he’d elected to try another transplant. I told him it was a long shot, that it was off protocol and that there was no way his insurance would cover it. Marco didn’t care that his insurance wouldn’t pay. After all, he’d quipped, what else was a gold album for? I tried to be clear and upfront about the risks, about how we were going into unknown territory, that his body hadn’t recovered from the first transplant. But the truth was I never suggested he shouldn’t do it. Not really.

I wasn’t attending the month he got the second transplant, so it wasn’t as a physician that I visited Marco at the hospital. He had a scarf wrapped around his head. He’d been in the room long enough that his family had decorated. A huge line drawing of Marco holding a toddler girl—I had to assume his daughter—was taped to the bathroom door. I had to blink for a moment to control myself. The image so keenly evoked how it felt to hold your child. Marco said his daughter had drawn it and was planning to have it tattooed on her calf.

“Are you able to eat?” I asked.

“Yeah, when I don’t feel too sick.”

“I brought you some pie. The farmer’s market didn’t have Gravensteins, so I got some other kind the guy recommended.” I pulled a Pyrex out of my bag and put a small piece of pie on a paper plate I’d nabbed from the unit’s nourishment room.

“And don’t worry, Marco, it meets criteria for neutropenic precautions.”

Marco smiled and took a small bite.

“I didn’t expect you’d be so good at baking.”

I wasn’t his doctor today. I also wasn’t his friend; that would be presumptuous. There was some sort of blurry relationship between us. I finally asked if we could talk about the music.

***

Marco had been in the hospital for over a month when it was once again my month to attend on the inpatient unit. His head glistened, totally bald from the treatment. Yellow complexion and sunken eyes, knobby hands, jutting collarbones. His skin like a loose suit over his frame. Diarrhea came next, neutropenic fever, a rectal tube, blood-pressure support. He was altered and could no longer hold a conversation. And then came the breathing tube.

His body was still there, however tenuously, but where had he gone?

Marco’s daughter came every day to visit and sometimes asked questions during rounds. Sometimes they weren’t really questions.

“Is he going to wake up?”

“Why aren’t the treatments working?”

“Isn’t there anything you can do?”

***

I was home in bed with my baby and my husband the night Marco coded. I found out the next day that the team had worked on him for over an hour, getting his pulse back a couple times before they called it. I was glad I wasn’t there. I didn’t want my last memory of him to be of his body getting smashed by chest compressions while blood frothed around the breathing tube and his eyes became fixed and dilated. The eyes of the dead aren’t like in the movies. They don’t stay closed when you brush your hands over them. The lids spring back open.

***

That last conversation, the one we had over pie, I’d literally taken notes as Marco talked about his influences. And it wasn’t just other music, but visual artists and novels too. I did mean to look it all up. But as I sat in my office and held the wrinkled piece of notebook paper trying to figure out why I’d scrawled the half sentence, most people like rubbers, I realized I was already remembering it wrong. The notes were meaningless. Sure, I had asked him some questions, but mostly I’d just gushed about how much his music meant to me and how much fun it had been to dance at his shows. Suddenly, a thousand questions leaped into my brain, things I hadn’t asked him. Would never be able to ask him.

Had it been about me all along?

***

Marco had been gone for two weeks when I received a letter in my office mailbox. It was from Marco’s daughter. I held the small blue card for several minutes before I had the courage to open it.

Thanks for taking such good care of my father. He said you were a fan, and I know that shouldn’t make a difference, but it did. 

***

Later that week, on a sunny Saturday morning, I decided to take Maddie to the park. I buckled my seatbelt, turned the ignition, and stuck in a Mr. Polo CD. Maddie yelled, and I craned around. Her staccato laugh filled the car, and she wiggled her legs and feet. One of her socks hung from her toes.

At the next red light, I turned back to Maddie. Her foot was now bare. I didn’t pick up the sock. Instead, I pulled off the other one and released her beautiful baby foot. She kicked and giggled as I tickled her feet. I was laughing so hard that I didn’t notice the light had turned green until the car behind me laid on its horn.

I was laughing so hard, I peed.

And now? When I listen to Mr. Polo, it is like drinking a memory, taking a hit of the way it felt to be seventeen, parked outside of Ross and laughing with my best friends, how it felt to lie in a tent listening to pelicans splash, how it felt to sit in the car tickling the feet of my beautiful daughter, always on the jagged edge of the rest of my life.

***

 

Andrea Eberly works as a clinical pharmacist in emergency medicine. Her stories have appeared in Witness, Southwest Review, Carve, Bellevue Literary Review and elsewhere. She is currently working on a novel-length work.

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“Intro to Nursing” by Jessica Watson

BLAST, TMR’s online-only prose anthology, features fiction and nonfiction too vibrant to be confined between the covers of a print journal. “Intro to Nursing” by Jessica Watson was the runner-up in TMR‘s 2021 Perkoff Prize competition. In this reflective essay, part confession, part elucidation of process, Watson gives the reader an inside view of the challenges faced by an early career nurse.

 

Intro to Nursing

 

Author note: All reports included in this essay are recreations; in the interest of protecting identity, they are not actual patient reports.

 

The first rule of diagnosis I learned in nursing school: a diagnosis must be stated in terms of a problem, not a need. In our simulation labs on the third floor of the School of Nursing and Health Studies at the University of Miami, we’re clad in hunter green scrubs, our school color, representing the leaves of the Florida orange tree. Our school’s mascot is the ibis: elegant, white, gangly wading bird—the last animal to take cover before a hurricane and the first to reappear afterward. We live in the most hurricane-prone state in the country: hurricane alley lies just offshore on a path that ends in our living rooms. Green amid swarms of white lab coats and blue scrubs, we nursing students are easily recognizable in the local hospitals: Jackson Memorial, the University of Miami Hospital, and Holtz Children’s Hospital.

As students, we learn to identify problems while thinking on our feet through encounters with simulated patients like the SimMan® 3G. Laerdal, a medical supply company, makes several lines of manikins for emergency, trauma, military, and nursing scenarios. There’s Crash Kelly, MegaCode Kelly™, and Extri Kelly, who I can only imagine needs to be extricated somehow. For peds, PICU, NICU, neonatal, and labor and delivery nurses: Premature Anne™, SimBaby™, and MegaCode Kid. Patient-care manikins like Nursing Anne, Nursing Kelly, and Next Generation Harvey®-the Cardiopulmonary Patient Simulator, prepare student nurses for the fundamentals. For complete disasters, there’s The Ultimate Hurt.

In crews of three or four nursing students, we enter the bay to greet our manikin reclining on a gurney. The sim lab educational team debriefs us with a few sparse details about Harvey Sims in advance: thirty-five-year-old man, came in with shortness of breath, history of peripheral vascular disease. The rest of the scenario plays out during our visit. Our visits are called encounters, and this distinction ups the ante. We’re not just visiting the manikin; we’re encountering him; we’re unexpectedly faced with something difficult or hostile. In the first few simulations, I’m paralyzed by the sight of Mr. Sims. He’s stiff as the diaphragm of my stethoscope, rubber skin pulled taut on his plastic frame, eyes and mouth in perpetual surprise. His face unnerves me, and the metal springs inside his ribcage squeak with every chest compression during CPR.

In sim lab, we fail the simulation if we don’t fake sanitize our hands. I train myself over and over to remember to reach for the pretend sanitizer pump on the pretend wall, mimic rubbing my hands together with sanitizer made of air. I exaggerate the performance, exclaiming how clean my hands feel. “I’m rubbing a golf-ball sized dollop of sanitizer for no less than twenty seconds until my hands are dry. I’m rubbing my palms, back of hands, fingers, and wrists. Now I’m letting it air-dry completely before moving on,” I say to the instructors observing us.

We rehearse the moves with our manikin Harvey before we use them on real people. “Hello, Mr. Sims. My name is Jessica, and I’ll be your nurse today.” I put my stethoscope on his stiff chest to listen for lung sounds. I take his pulse by putting my fingers on his wrist, where his thumb juts out rigidly. I shine the penlight in his eyes and pretend that his pupils have reacted. My encounter with Harvey involves so much playacting that I’m not sure where to look or what to think. Do I pretend he has a pulse? Do I maintain direct eye contact with his painted-on, permanently surprised eyes? Do I wait for the voice on the overhead speaker to shout out that his lung sounds are diminished?

***

The first step to solving a problem is being able to describe the human body as succinctly as possible. We distill the myriad components of what keeps everyone alive and healthy into systems, hemispheres, quadrants, markers, and metrics, which are compared to a baseline or “normal” standard—a mountainous task made more attainable through the use of shorthand.

The first time I see a nurse’s patient report in its entirety, I’m overtaken by anxiety. If I was the type to faint or hyperventilate into a full-blown panic attack, this would be the moment. Instead, I’m the type to hold the spring of boiling, frothing water in my throat so that my own volatility blisters my insides. I spend several months learning to decipher these reports. My anxiety is made more severe by the realization that soon my job will involve assuming responsibility for the safety, health, and well-being of each person under my care.

Even so, I can’t help but marvel at the ingenuity of the nurse’s report.

 

Patient 1 Report

Patient Hx: HIV, ESRD w/ HD, pericardial effusions
Neuro: opens eyes, – commands, pupils sluggish
Cardiac: SR 80’s-90’s
Respiratory: desats to 70’s during suction; CPAP* 5/5/40% (*vent setting)
GU: HD Tu, Th, Sa; anuric
GI: 1 liquid brown BM; OG @ 50 – osmolite 1.5 @ 35 ml/hr
Peripheral: RUA fistula +/+, R foot amput.; RLQ blake drain; 4 lap sites
Labs: BG 168/185; Na+ 134; all else WNL
Lines: L SC CVC, L fem a-line, L AC #20
Drips: vaso @ 0.04, neo/levo standby; precedex @ 0.4
To Do: CT Head; Check CXR; T&S
Meds: see back
Ask MD: Na+ 134
Notes: rec’d 1 unit PRBC’s à Tmax 100.2

 

So much of what we learn is passed down from nurse to nurse, and this is also true of shorthand, which for the most part I learn on the unit. I study the way more senior nurses write their own reports and orders on the order sheets. Sometimes I’m given someone’s report in its entirety at shift change. RUA is right upper arm and RLQ is right lower quadrant. The shorthand for lines tells us whether it’s in a vein or artery and where on the body. The first time we lay eyes on a patient, even before, during report, we begin a critical thought process.

Peripheral refers to extremities, or limbs, as well as peripheral vascular findings. Peripheral is where I document assessment findings such as surgical drains, dressings, and wounds, fistulas for hemodialysis, and amputations. Peripheral also means skin. Skin tells a story. Patient 1’s Report tells us about hemodialysis three times a week and a fistula on the right upper arm where machine lines connect with blood vessels for cleaning. I put my finger on the fistula and feel a buzz like the throat of a purring cat. My fingers tickle. Using the small diaphragm of my stethoscope, I listen for a woosh, a bruit. If both are present, it’s patent, +/+ on the patient report. If neither are present, I have a problem.

The doctor diagnoses Patient 1 with HIV, End Stage Renal Disease, and pericardial effusions. The nurse might diagnose the patient with something related to fluid volume or risk for infection, given that the patient receives hemodialysis. A nursing diagnosis can change minute by minute, depending on the patient’s vitals and response to treatments. In practice, a nurse responds to the patient’s needs faster than the time it takes to formulate a nursing diagnosis, but nursing school emphasizes these diagnoses and care plans in an effort to train the student nurse to adopt a certain critical thought process. As a nurse gains more experience, nursing care begins to arise from something more akin to instinct. Like the night I leaned in the doorway of my patient’s room, number two on the liver transplant list, watching him try to sleep, sensing that something was off. First a simple question: “Do you know where you are?” Then drawing a blood gas, alerting the team, rolling a ventilator to his doorway to keep on standby.

***

My first job taking care of real patients is critical care nurse in a multisystem intensive care unit in Orlando. The streets here don’t flood like they do in the city of my alma mater, but we find ourselves inside the cone of probability enough to adopt the ritual of annual hurricane prep. I’m on the hurricane team my first two years on the unit. Team A for Hurricane Michael, which means I sleep over and work the two day shifts on either side of my sleepover. Team B for Hurricane Irma, which means I work the day after the hurricane, when the power is out across most of the city and downed trees still line the roads.

The nurses on the unit range from fresh out of nursing school to veterans of twenty or thirty years. Every new nurse goes through a rigorous sixteen-week training program with an assigned mentor, which includes additional study outside of work. Our patients are the sickest of the sick, except for some in CVICU or lung transplant. We get our share of liver and kidney failure, transplants fresh from surgery, end-stage diseases, respiratory failure, sepsis, complicated GI surgeries, and chronic care patients. We wrap our code cool patients in Arctic Suns, affix pads to their skin which circulate cold water that drops core temps to 32-34°C: therapeutic hypothermia. We have a fair number of transfers to hospice or palliative care, plus withdrawal of life. Sometimes we get laterals from neuro or a patient with heart failure awaiting transfer to CVICU.

I’m assigned the color royal blue for my unit. My scrubs are Cherokee, Grey’s Anatomy, and Healing Hands. I buy a pair of New Balance memory foam sneakers and compression socks with rainbow stripes and polka dots. The socks compress at 15-20 mmHg and imprint ridges on my calves. It’s a 10-percent discount if I show my hospital badge.

I buy scrub pants with as many pockets as possible: two on the seat, two in front, with a pocket or two nested inside each, and the occasional added thigh pocket. On the loop of my thigh pocket, I clip a hemostat, ready to go. Hemostats resemble scissors but grip like needle-nose pliers. Of all my tools, this tool has most often bailed me out of a bedside situation, elbow deep in a “clean” procedure I can’t step away from. The grippers on the nose loosen any tubing wrenched too tight, needed in a pinch when changing and troubleshooting lines.

My EKG calipers ride my pockets next to the pens, ready to measure the distances on a heart-rhythm strip. Each patient has a unique heart rate and rhythm. The peaks, troughs, and distances between them, each accentuation, tells us where in the heart the beat originates and how long it takes the chambers to fill with blood and squeeze. All the heart songs are printed on scrolls every four hours and glued to paper. I unclamp each patient’s three-ring binder, put the strips in their rightful place. Scanning morning labs, I rub the critical labs bright with yellow highlighter, make them pop with alarm. Orders must be written with a black pen, so I carry several.

***

Before I enter the patient’s room to assess them and determine problems, I sanitize my hands. Then again after I touch anything in the room, again before touching the patient, and again after touching the patient, and once more outside the room. In nursing lingo, this is known as “the five moments of hand hygiene.” I’ve abbreviated “the moments” because they specify “after body fluid exposure/risk, and before clean/aseptic procedures,” as well.

Usually, I think of a “moment” as being a more intimate occasion. Perhaps even a momentous one. That might be the intention of calling them “moments”: to transform hand hygiene into an inviting self-care experience—a sort of rebranding of infection prevention as a self-indulgence. At the least it’s a helpful mnemonic device. Here, take a moment for yourself while pausing in the hall just outside your patient’s room. Drop a glob of sanitizer in your palm and rub your palms together as you breathe in and out. Take this moment, and every other moment of hand hygiene, just for you.

A single piece of paper determines my plan of care for the day. It’s the nurse’s patient report, given at 0650 then again at 1850, plus any notes, labs, meds, or other details I’ve scribbled onto the sheet. Sometimes I forget the sheets in my pocket when I wash my scrubs. In the drum of the washer, the paper disintegrates into a million pieces that coat my pant legs and sleeves like a light dusting of snow. I wash and rewash the scrubs, then pick the remainders of white pulp off the valleys of my pocket seams. By the end of day, the paper will be softened like butter by folding and unfolding, moved in and out of my scrub pockets a hundred times. Sometimes I check my pockets just to make sure it’s still there.

 

Patient 2 Report

Patient Hx: DM, substance abuse
Neuro: agitated/combative
Cardiac: SR 70’s-80’s
Respiratory: Room air
GU: voids
GI: NPO
Peripheral: Ø
Labs: BG 600’s on admit
Lines: L AC #18
Drips: insulin
To Do: BG checks Q1H
Meds: see back
Ask MD: Pt requests morphine

 

On a bad day, bed management sends us the difficult patients: according to report from the emergency department, a patient with a history of substance abuse who let his blood sugar go to get access to opiates. He claws at his hospital gown in bed and flails his arms and legs, disheveled locks of dirty blond hair partly covering his face. After I receive the Patient 2 Report from the outgoing nurse and respond to his first several call bells, the nurse manager of our unit tells me that in a previous admission, he was caught rubbing his central line on the toilet to get an infection in order to lengthen his stay. Technically, he’ll need to be on an insulin drip, which requires blood-sugar checks every half to one-hour. Technically, that falls under ICU jurisdiction. He’ll be on the call bell every ten minutes asking for morphine. As soon as I administer the morphine, he asks for more.

The secretary, the one answering his calls with her push-button speaker, will ask me for a plan, as in, “How are we going to handle this?”

The way I handle this problem, which is also the secretary’s problem, creates more problems. In addition to answering my patient’s call bell every ten minutes, I have to figure out how to get the patient to stop using it every ten minutes.

Nursing Diagnosis: Powerlessness related to institutional environment and unsatisfactory interpersonal interaction as evidenced by secretary asking, “How are we going to handle this?” and reports of frustration over inability to perform previous activities.

Here, the problem is powerlessness.

In response to the secretary, I stop at her desk on my way to the med room and stare at her a minute before responding. I’m tired. It’s around 7:00 in the morning, and I am not yet ready to be bombarded with call bells and needs and problems. “What can I do?” I say, then get back to work.

My response makes her cry. I only find out because the charge nurse that day, there to offer assistance and supervise the nursing staff, pulls me into the break room. She wants to ask me my version of what transpired with the secretary. She emphasizes that the secretary is a tough lady, and it’s extremely rare for her to cry.

A new problem arises, one I didn’t intend to create, one with origins I don’t entirely understand.

***

A nursing diagnosis is different from a doctor’s diagnosis. Because of the differences between doctor and nurse in scope of training and treatment, nursing diagnoses can focus on spiritual and psychosocial concerns. It wasn’t until 1980 that the American Nurses Association defined nursing as “the diagnosis and treatment of human responses to actual or potential health problems.” Emphasis here is on human, while medicine (what doctors practice) is thought of as prevention and treatment of disease. In essence, nursing treats the human, and medicine treats the disease. The spiritual realm is one area that nurses are permitted to diagnose and treat. For instance, we don’t need an order to call a rabbi to bedside. We don’t need to ask a doctor if the chaplain can pay a visit or if we can hold hands at the bedside and bow our heads in prayer.

As a nurse, I can diagnose patients with impaired religiosity, impaired individual resilience, disturbed personal identity, spiritual distress, powerlessness, situational low self-esteem, risk for compromised human dignity, risk for loneliness, risk for chronic low self-esteem. My favorite diagnosis of all is perhaps the “imbalanced energy field” because of the way it flirts with the metaphysical and territories wholly unknown.

For care of the patient with an imbalanced energy field, nurses ‘evaluate energy fields’ and perform ‘therapeutic touch.’ In a step called “the unruffling process,” therapeutic touch resembles Reiki as an intervention, wherein nurses lay hands two to six inches away from the patient’s body to “dissipate impediments to free flow of energy within the system and between the nurse and client.” The last part always gives me pause—the exchange of energy between nurse and patient. Suffering is painful to observe and engage, but there’s no avoiding it at the bedside. I believe empathy works in part by absorption of another person’s energy when in close proximity, and this can be an overwhelming and painful sensation felt within the body.  How does the story our body tells change through that exchange?

 

Patient 3 Report

Patient Hx: Liver transplant, Etoh
Neuro: opens eyes, + commands, agitated/paranoid
Cardiac: SR 90’s-100’s
Respiratory: Room air
GU: voids
GI: Regular diet
Peripheral: Ø
Labs: ammonia
Lines: R FA #20
Drips: precedex
To Do: lactulose
Meds: see back
Ask MD: Pt delusions

 

I remember well most of those encounters with patients when a powerful energy was exchanged. One of my youngest patients with liver failure was a twenty-something with stringy black hair and piercing, mistrustful eyes. On the second day I cared for her, she became convinced I was trying to kill her. Most nurses learn how to develop a sense of humor when it comes to these things, but I couldn’t help but feel uncomfortable. My patient scrutinized my every move and action. A self-consciousness overtook me, and guilt bloomed within me like an open wound. I started to feel raw and vulnerable, my emotions just at the surface of my skin so that an air current might set them off. All my efforts to convince her that I was here to ensure her protection and safety failed.

She watched me unwrap syringes and draw up medications. As I explained to her what the medications were and reached for her IV, I knew she was thinking about what she might do to my hands and how to turn the medicines on me.

 

Patient 3 Diagnosis

Nursing Diagnosis: Patient has risk for other-directed violence related to paranoid delusions. 

Subjective Data: The patient states, “The nurse is trying to kill me.”

Objective Data: The patient has clenched fists and jaw. The patient eyes me suspiciously.

Plan for Care: Continue reassuring the patient. Continue reorienting the patient to time and place. Continue to explain the purpose of the liver failure medications. Continue to reassure that you’re administering medications for liver failure and not a lethal dose. Ask the patient if she wants family present. Ask the patient if she wants to speak to the chaplain. Continue to pretend that you’re not deeply, irrevocably uncomfortable, that you won’t remember this for the rest of your life, that you don’t begin to wonder if you are trying to kill the patient, because the patient is so convincing, because there is one reality outside the patient’s room and another reality inside the patient’s room. Pretend that when the hepatologist visits the patient, that you and the patient aren’t both crying for help with every sinew and muscle in your bodies.

Originally, ‘imbalanced energy field’ was called ‘disturbed energy field.’ The diagnosis of “disturbed energy field” was removed from the tenth edition of Nursing Diagnoses: Definitions & Classification 2015-2017. The editors explained their decision thus: “all literature support currently provided for this diagnosis is regarding intervention rather than for the nursing diagnosis itself.” The diagnosis returned in the eleventh edition of Nursing Diagnoses: Definitions & Classification 2018-2020 as “imbalanced energy field.” The difference between the two diagnoses, although a difference of one word (imbalanced rather than disturbed), embodies one of the goals of nursing: to be nonjudgmental. The word disturbed itself casts judgment on the diagnosis (and person); it tinges the diagnosis (and person) with something undesirable.

The ideal nurse is first and foremost nonjudgmental, perhaps so much so that they have one foot in the realm of the kind of implicit acceptance of anything human we’ve come to expect from our spiritual and religious communities. The ideal nurse wouldn’t use the word disturbed to describe anything about their patients. The ideal nurse legitimizes their patients through acceptance and listening. Imbalance within the body connotes more legitimacy than if something in the body is disturbed. An imbalance can be restored through care and attention, while a disturbance, like a colony of wasps getting knocked out of their nest, is not likely to be put back together into anything resembling its former self.

What is the difference between a problem and a need? For some reason, I often think of needs as being unmet, and problems as getting solved. You solve a problem; you have needs. When needs aren’t met, do they create problems? Are problems needs that can be met? Can a person have needs that aren’t problems requiring correction? The more I think about it, the cycle between need and problem seems like a hungry beast that can never be content. Do we feed it? Does medicine feed it?

Then again, why must our needs be problematized? Why can’t we state our needs – loudly, declaratively. Why can’t we make grandiose proclamations of need to the person next to us in the cafeteria sandwich line?

A problem can be physical, psychosocial, spiritual—so why is nursing tasked with the job of addressing all of them?

I need to breathe versus “patient has impaired gas exchange” or “ineffective airway clearance” or “anxiety.” I need to be closer to God versus “patient has impaired religiosity” or “spiritual distress” or “moral distress.” Outside the hospital, we have needs. Inside the hospital, our needs are transformed into entities with actionable plans and interventions executed by nurses for measurable outcomes.

***

“A nursing diagnosis is defined by NANDA International (2013) as a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response, by an individual, family, group, or community.” It’s interesting that the diagnosis concerns the “human response.” Why human? Is there any other type of response? It’s interesting too that the diagnosis doesn’t just pertain to the patient, the “individual,” but can also extend outward to family or even an entire community. And it’s interesting that nurses’ responses can extend to ”vulnerabilities” as well as health conditions.

As nurses, we know that when the patient has experienced brain death and there’s nothing that can be done to reverse this condition, that sometimes the most vulnerable person is the closest family member. My first brain-dead patient was a woman who attempted suicide by an overdose of blood pressure medicine when five weeks pregnant. She starved her body of oxygen long enough that only a ventilator and continuous medication could keep her alive. Her husband was adamant that she was going to make a miraculous recovery and “walk right out of this hospital.” The family of my patient viewed me with suspicion whenever I entered the room to change a bag of medication or reposition her. The health care team was keeping her indefinitely in a steady state that couldn’t last forever, while the family pushed back and fought about prognosis.

Taking care of the husband was as important as taking care of his wife:

 

Patient 4 Diagnosis

Patient Hx: wife admit s/p suicide attempt, anoxic brain injury, five weeks pregnant

Nursing Diagnosis 1: Husband has complicated grieving related to his wife’s brain death as evidenced by lack of acceptance of the death, persistent painful memories, self-blame, distressful feelings about the deceased, and mistrust of the health care team and translife representatives.

Nursing Diagnosis 2: Husband has ineffective denial related to his wife’s brain death as evidenced by husband states, “a miracle is going to happen, and she will walk out of this hospital” and husband also states, “they just want her to die so they can harvest her organs.”

 

There are five stages of grief, more or less. We don’t necessarily move through all of them in sequential order. The husband embodied the first two: denial and anger. Sometimes he transitioned into bargaining, when I could hear him begging God for help. I felt stinging anger in his eyes when he looked at me; it was my natural instinct to look away. Before acceptance, the grieving might lapse into a depression—what the body does when it feels powerless.

 

Patient 5 Report

Patient Hx  lung CA w/ mets, malignant pleural effusions; pt RRT to ICU for respiratory distress
Neuro opens eyes, – commands
Cardiac ST 110’s; systolic 90’s
Respiratory Bipap 12/4/80%; sats low 90’s, tachypnic; use of accessory muscles
Code Status Ltd to Bipap

 

Because I can’t remember anything about the weather, or time of year, I don’t know when exactly this patient came to me. I know it wasn’t long after I got off my sixteen-week orientation with my preceptors sometime in February. Less than a year earlier, I’d passed my nursing license exam. Let’s say that it was late spring in central Florida, when the heat was beginning to build by midday and you could feel it pressing down on your face like a wet xanthosoma leaf.

I remember her as having long white hair that flowed over her pillow. Inside our perfectly climate-controlled hospital, there still wasn’t enough oxygen in the air for her. There would never be enough oxygen. The Rapid Response Team rolled her into my empty room on a BiPap, bilevel positive airway pressure, accompanied by her husband and daughter, who reminded me of New England, my home: modest in manners and appearance, forthright in speech, and stoic in their grief.

Since her code status was Limited to Bipap and she was already on Bipap, I had the sinking realization that there was nothing else we could do. No intubation, no CPR, no medications to restart her heart. Unless she miraculously recovered from her respiratory distress, she was going to die. I knew what it was like to try to assuage a family member begging for a miracle, but her husband looked to me for guidance. I had never had a patient in this state who was Limited to Bipap, had never gone through the motions before of caring for someone this way.

Her face was engulfed in the machine, a transparent breathing mask with a flexible cushion sealant that molds to the contours of the face. Straps go around the head and the mouthpiece connects by accordion tubing to a machine on wheels that houses the oxygen supply and control panel. The triangular shape fits over the nose and mouth for maximum gas exchange, but she looked so uncomfortable, head tilted away as if repulsed, back arched reflexively, that the BiPap appeared to be parasitizing her.

Her husband, a mild-mannered man in trousers and a button-down, sat dutifully in the bedside chair as if awaiting instruction from me. As his wife labored to breathe through the BiPap, he turned toward me, outside the room, and asked, “Is this it?”

Before instinct comes paralysis. But this wasn’t simulation paralysis; this was the real world.

There was an innocence and bravery in his voice, but what really unnerved me was how much faith he placed in my ability to answer this question. As though I knew exactly what was happening and what to do:

 

Patient 5 Diagnosis

Nursing diagnosis: Ineffective role performance related to despair as evidenced by me sitting in my chair looking despondent while her husband turns his head toward me and asks, “Is this it?”

Related Factors: Inadequate role preparation, skill rehearsal, and validation; unrealistic role expectations as evidenced by the fact that I never knew what it would feel like to let my patients die; inadequate support system because at the end of the day I couldn’t tell anyone what I did at work, I moved to a new city for this job and didn’t know anyone; stress; lack of role model

Subjective Data: Altered role perceptions; change in self-perception of role; change in usual patterns of responsibility or capacity to resume role; role overload; powerlessness

Objective Data: Inadequate adaptation to change; inadequate confidence; ineffective role performance; inadequate external support for role enactment; role strain, confusion, or ambivalence; uncertainty; anxiety; depression

 

The problem: I had never rehearsed this scenario before, didn’t know the protocols. I never thought of nursing before as the absence of action, as the opposite of saving a life.

The need: I needed support, backup from one of my colleagues. I needed to feel less alone.

Protocols exist as a way to continue the choreography of care despite any emotions. They tell the body what to do.

A senior nurse working the rooms next to me stepped in. I had met her in the lunchroom before. She was the nicest of the nice. Management often paired green nurses with senior nurses for these occasions.

She spoke in a hushed tone: “Your patient’s dying, right. Let’s make sure this is what they want, then write the orders.”

I followed her into the room to speak with the family. She answered the husband for me, “Yes, this is it. Is this what you want?”

 

***

Jessica Watson is a writer from New England who calls Florida home. She recently finished an MFA in nonfiction and became a nurse after dropping out of a PhD program in oceanography at the Rosenstiel School of Marine and Atmospheric Science. She’s currently at work on a collection of essays blending research, personal narrative, embodiment, and cultural criticism. “Intro to Nursing” is her second essay published from that work in progress. Growing up, she never wanted to become a nurse, but now she considers nursing one of the most profound professions.