by Robert J. Lanz, LCSW
RJ and I worked together for fifteen years on the night shift, and she only yelled at me once when I didn’t deserve it. The times I did deserve it were so seldom that it never took anything away from our deep friendship, and on those occasions when I really had it coming, the yelling was actually instructive. A guy with more pride might have gotten angry and fought back, but it’s hardly ever a good idea to fight with the charge nurse on the night shift.
Three to midnight is when the most patients come to the emergency room. That’s as many as drag themselves in or are dragged in by a family or professional service during the other sixteen hours combined. The worst things seem to happen at night. Darkness brings out the ugliness that seems to shun the daylight. When it’s dark, many people get a little braver, a little stupider, drunker, weaker, lonlier or angrier. We see a lot of guys who don’t have any other reason to act badly—it’s just that it’s dark, and that’s all the excuse they need.
The charge nurse runs the ER itself, is responsible for the staff, the movement of patients, the assignment of rooms and duties. With the exception of telling them how to care for patients, she rides herd on the doctors, too. They get “adjusted” to it more than they like it, because the big egos needed to get through the rigorous training required to become a phsyician often carry over into working as one. Everyone needs to be shown from time to time that we’re all in the big picture together regardless of status, and it’s the charge nurse that reminds us of this. She will seldom be the star of the never ending drama, but she can help to elevate other players to star status. By the same token, she can send an overcompensating, rude intern to the library for an all night study session, if necessary.
Tough. For that job you have to be tough. That means tough enough to always do what is right for the patient, even one who shows up with a fresh load of poop in his pants and a bad attitude for the third time in a week. Even if they puke on your fresh scrubs, your last clean pair after some other patient jumped on you after he shit and puked on himself—again.
Anyone who can put up with that on a regular basis has to be tough. Many people called RJ the ultimate ER survivor, thought she was the toughest there was and that nothing could ever get to her. But then, when no one expected it, it turned out she wasn’t tough enough. She developed a cough that wouldn’t go away. At first we thought it was another one of those things that we get exposed to all the time just because we show up for work, but the cough didn’t get better. Our best doctors tried for a month to get rid of that little white patch that kept showing up on her chest X-rays. It looked so much like pnuemonia, everyone was sure it would clear up with the right antibiotic, and several were tried, but even the strongest ones didn’t do the job.
“Let’s biopsy it on Monday, I’m a little worried about that last X-ray” Dr. M. said with a worried look, a look usually reserved for patients he didn’t expect to live. We all knew the look. After working with intensive care patients for years, habits develop. Mannerisms are revelations if you know the code. And most of us had worked with Dr. M. long enough to be just as worried as his body language implied he was.
But RJ was hard core. She was ER all the way. And if you were ER all the way, you could always find a way to put aside those things you could not change. If you don’t develop this valuable skill in the ER, the pain will overwhelm you and you won’t last long. If that dead baby is going to be hanging around while you’re tending to that burn patient, treatment will be compromised and the psychological burden will become too great. Just because that crushed traffic accident victim reminds you of someone you love doesn’t mean you get the luxury of dragging that useless feeling around with you all day. You have to stash it someplace where it doesn’t hurt, maybe to retrieve it later if it can be of some value.
We all need to hide from the ugliness of life when it shows itself so frequently in the course of our daily work. To pay attention to the ugliness after it has left the immediate vicinity, however, is to waste valuable energy that may be needed to save someone later. That someone may even be yourself.
Like a lot of ER nurses, RJ swore when she turned fifty she was getting NO CODE tattooed on her chest, because she knew that sometimes, many times, things just happen the way they happen. She knew that bad guys can get shot ten times and survive and minister’s wives with lovely children can get raped and executed in broad daylight. She knew it because she’d seen it happen and she knew it could happen to anyone at any time. But like most of us, she didn’t think she would be on the list, so she made plans to go dancing over the weekend with some other nurses. She needed to blow off a little of the stress and fear that lurked in all of us—the fear that anything can happen to anyone, any time. You can sit around and fret about the inequities of life and the illness and injuries that come with them, or you can go out dancing and believe they won’t happen to you, at least that night, on that dance floor. An ER nurse would always choose dancing.
RJ never made it to the party. The cancer they were about to find with their biopsy on Monday had already traveled to her brain, and the tumor that grew there put her down. Down on the bathroom floor with such devastation, she would never walk again. Down to the point she couldn’t even move enough to call for help. The tumor in her brain, the one they would have found in a few days, killed half of her body and had started the slow process of killing her mind.
Many years before, on a night when we had an unusual number of gorks—patients with wasted brains and wasted bodies—patients fed through tubes or only able to eat baby food, droolers who had so much brain damage they didn’t even know they had lost their dignity—we talked about such situations. We all concluded that these patients would be better off dead, and most of them, if only slightly aware of their condition, would have been among the first to agree.
So, we started the Pillow Club—a brotherhood and sisterhood founded on the ultimate promise: Do whatever it takes to spare me from not caring anymore where and when my bodily fluids leave my body. Our motto became one of the sick ways in which we came to deal with the living dead we were forced to take care of.
“Here, let me make you more comfortable. I’ll adjust your pillow for you. It’s on the wrong side of your head.”
No one reacted with horror when we said this about a patient. The most common reaction was, “Really. Overdue. Welcome to the club.” Never with anger at the patient, but with pity for someone who should have been long gone. Any anger we had was reserved for the technology and the system that allowed life to linger too long.
RJ was treated with brain surgery, chemotherapy and enough radiation that, if she survived, she could probably use her own body as a night light. None of it worked. The chemo left her bald and skinny as an IV pole. Then the steroids puffed her up like a sad old sleeping bag. We all knew she was going south soon, and so did she. But no one spoke of it aloud, hiding again, if only for a moment, in that safe space of denial we had developed to protect ourselves. The treatments were, at best, going to slow the pace a little, perhaps to grind out another month or so—a little extra time for more than a brief goodbye to her old friends who were with her around the clock. A little extra time to break the rules and have a full blown Margarita party in her hospital room, where all you had to do to get invited was to complain about the noise. A lot of people ended up at those Friday night farewells, so many that the parties became more like college keggers than solemn events which, of course, led to more noise and more invitations.
The pallor in RJ’s face grew worse and her arms began to sag. The tombstones were there in her eyes, but she wouldn’t give in to them and she could still laugh and smile. At least the part of her face that still worked could. It was both a terrible and inspirational thing to see, and even the people who knew her best and loved her the most could no longer deny that it was getting to be time for her to leave us.
At the last big party (by this time, there had been so may complaints, the guest list numbered about sixty and we were finally forced to move to a large conference room), we had a full sound system, a rather large cooler full of margaritas and several cases of beer. When I thought the moment was right, I lifted my dying friend from her wheel chair and we danced, her feet well off the ground, her tired, lifeless head resting on my shoulder, the memories of fifteen years of friendship spilling from my eyes. As I did the spins and dips I could only have done with a seventy pounder, I could feel her saliva soaking through my shirt and running down my back. She could feel it too just as she could feel my tears dripping down my cheek onto her own shoulder.
“This is the last dance Bob. By the end of the week I’ll need to have my pillow adjusted.”
I didn’t answer then. I couldn’t answer now.
My favorite nurse died in her sleep a few days later. A natural death, they said.
She was always good to me, even when she didn’t have to be. I owed her a lot for showing me how to grow up in the ER and for helping me be a good friend. A guy who could always be counted on to take the best of care of his patients. A guy who would always keep his word.