Chapter 1: IN THE BEGINNING

“If you give me 5 minutes, I can give you something that took me 20 years to learn.” Elisha Cummings

Long before donning new scrubs as a nurse in a major medical center and taking the Hippocratic Oath to first “do no harm,” an incident occurred that helped steer me in the direction of my career and transform me from naïve civilian to trusted, professional caregiver. I was living with my wife and three children in an A-frame I had helped build about twenty-five miles from the hospital, where I had just taken a job as a patient transporter. It was a quaint little house with original wooden beams in the ceiling and hard wood floors throughout. It also had a very steep stairway to a bedroom upstairs.

When June heralded the first spring in our new home, my brother Joey and his family of six children came to visit from Illinois, arriving one night while I was working the evening shift. Upon descending the stairway, Joey slipped and aggravated an old injury to his back. He was lying on the couch in my living room in a lot of pain, when I arrived home late that night.

By the following morning, Joey was still miserable, and I convinced him to seek the advice of a neurosurgeon friend of mine. Joey is about an inch taller than I, and I enlisted the help of the older children to move him onto a piece of plywood I had. After tying him to the board, we slid him into the bed of my old but reliable 1947 Dodge truck and closed the door to the cap of the bed. I gingerly drove the twenty-four miles to the doctor’s office, trying my best to avoid the potholes for which Maine roads are famous in the springtime. It was a far cry from my present insistence that patients be evaluated for proper Swan-Ganz catheter placement prior to being released for ambulance transport, but again, I had no training in the finer art of patient care at this point. After parking the truck at the back of the doctor’s place, I went in to see my friend.

“Where is the son of a beech?” he asked in his typical broken English, following me outside and peering into the cab.

I walked to the back of the truck and opened the cap door, and Dr. B. peered into the dark interior. Joey looked up from the backboard to which he was strapped and moaned. We were perhaps fifty feet from the door of the doctor’s office.

“If he’s that bad, just take him to the hospital, and we’ll do a CT scan,” Dr. B. said. “No sense risking further injury and pain by moving him to my office.”

The CT (computerized tomography) scan revealed enough damage that Dr. B. admitted Joey to the hospital and performed a laminectomy and fusion of his vertebrae that same day. Post-operatively, I stayed with my brother and noticed that Joey’s nurse kept asking him if he had urinated yet. She explained that the atropine that he had been given to help dry his secretions during his surgery was also preventing him from voiding. When visiting hours ended at 8:00 pm, I picked up my jacket and prepared to say good night.

Joey’s nurse stuck her head into his room at that moment, looked at Joey’s empty urinal, and before retreating cheerfully announced, “If you don’t pee by midnight, we’ll have to put a Foley catheter in your bladder.”

Joey looked at me in horror. He’d heard of catheters before and knew that that meant inserting a tube through his ureter and into his bladder.

“Please don’t let that happen, Ray. What can I do?”

I put down my jacket and walked to the bathroom, where I ran the water so that he could hear it, a trick I had used for my children before bedtime. When that didn’t produce the desired urge, I stepped into the storeroom a few doors down the hall and rummaged through the supplies until I found some spirits of peppermint, which I added to his urinal upon my return to his room. I wasn’t sure what the medical staff used it for, but my grandmother had always used it on her grandchildren before bedtime. Joey found himself still unable to urinate and begged me to help him. Being a brother with a keen sense of loyalty, as well as a “medical professional” rookie with an IQ of a monkey, and rationalizing that I was not on-duty but in civilian mode, I did what now seems to me the unthinkable: I peed in his urinal. With a sigh of relief, he set the now full urinal between his legs and bid me a grateful good night. I went home feeling very relieved, confident that Joey had avoided a “major” invasive procedure and glad that it wasn’t an enema that had been needed.

The next morning when I went in to visit Joey, the first thing I saw when I walked into his room was a Foley bag hanging on the side of his bed.

“How did this happen?” I asked in astonishment. “I left you with a lot of urine.”

What I hadn’t banked on was the perceptiveness and intelligence of a seasoned nurse, a professional who would not only follow up but follow through as well. After I had left, Joey had fallen asleep with the urinal between his legs. When he turned slightly, he spilled all the urine into his bed sheets. Aware of Joey’s fear of the catheter and his inability to urinate due to the atropine, the nurse’s suspicions were aroused when she saw the unexpectedly pale drops left in the urinal. She didn’t know exactly what this was that Joey had placed in his urinal (a little ginger ale from his supper that night, perhaps?), but she knew that it couldn’t be his urine, which should have been a very concentrated, dark color.

“I laid in your urine for twenty minutes before the nurse could come in to change my sheets,” Joey whined.

After that early experience in a hospital setting, I vowed that under no circumstances would I ever again pee in anybody else’s urinal, ever fill anybody else’s bedpan, and especially ever again try to fool a nurse. But something else bothered me about that experience. Although the nurse was astute, her presence in that room was not reassuring to Joey. On the contrary, there was no direct eye contact, no touch, no one who would stop and address Joey’s fears. Indeed, the nurse seemed to him rather to have morphed into another artificial limb of a healthcare system that seemed overwhelming and mechanical. He needed to be educated about what was happening in terms he could understand; he needed to be encouraged rather than frightened; and he needed to know that he was not alone. The whole thing was more complicated than just trying to fix the problem, which I had also focused on. I had gained a new respect for the profession of nursing, a respect which eventually called me to try on for myself the various hats of a truly challenging and rewarding career, and to insert my very ordinary existence into a multitude of extraordinary situations.

“It’s probably better to have him inside the tent pissing out than outside the tent pissing in.” LBJ

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As part of graduation exercises for RN school, an awards ceremony was being planned in the chapel of the Catholic hospital from which I had received my instruction. Thirty minutes prior to the ceremony, the director of the nursing program, Sister Laetitia, called me into her small office. I took a seat next to the door and glanced around the room while I waited for her to take her seat. It was not as lavishly furnished as I had anticipated for someone in such a position. There was no large oak desk, no color photographs of loved ones lining the walls. The austerity of the space--- plain walls with crumbling white paint and an old, scarred, student-sized desk---was rivaled only by the dominance of the great crucifix, which hung behind her. On the desk was a ruler, and I was reminded of an incident in first grade, when Sister Roberta had slapped my hand for chewing gum.

“Ray, are you coming to the awards ceremony?”

“I wasn’t planning on it.”

“Why not?’ she asked.

“Well, Sister,” the rebel in me pressed, “There are two reasons. Number one is that my classmates wanted a song by Bob Dylan that is not going to be allowed. And number two is that we were expected to buy a brand-new white uniform for the graduation exercises. It’s like a wedding dress, Sister. I couldn’t see buying one if I was going to wear it only one time.”

It was only after my pent-up words had been vented that I was able to see the object of my rebellion in a clearer light. At eighty-five years and five feet two inches, she hardly cast the formidable presence I had anticipated. Maybe it was her long white habit, complete with the starched white wimple and bib, or the wooden rosary beads that circled her waist and terminated in a dangling crucifix, which had seemed so threatening. No, they looked harmless enough, too. A pair of old-fashioned, round wire-rim spectacles surrounded her tired eyes, and her hands lay delicately folded upon the top of her desk. I studied her face, which despite its softness, was crisscrossed with a myriad of lines undoubtedly carved there by all the snot-nosed, self-serving greenhorns like me who she’d helped mold into full-fledged, compassionate nurses. I was surprised to see tears welling up in Sister’s eyes, as she removed a thin tissue from a generic box on her desk.

“I wish you’d reconsider,” she said softly.

In the quiet recesses of my mind, a reassessment had already started to emerge. I had not predicted that my boycott would cause a little old nun to cry--- a little old nun who had after all been there in the beginning to hold our hands through the hesitations, doubts, and fears that had accompanied our decisions to become nurses. Hadn’t she been there to take me from codeine to codes, from dopamine to death, from aspiration to applause? Hadn’t she sacrificed a whole lot more in her entire lifetime than a song? Besides, I’d made my point, and I knew that things weren’t going to change overnight.

“Maybe I will,” I simply said upon retreating, knowing that I surely would and that I’d better shake a leg.

I quickly shed my Levis and pulled on the white uniform pants that I had used during training. I put my old white uniform top over the t-shirt I had on and ran out of the locker room and into the chapel. Slinking into the now mostly full pews, I took a seat near the back. My heart was pounding, not because I had just run in, but because I was nervous that I might be asked to get up in front of this crowd.

The evening went by quickly, as student after student rose and walked to the podium on stage to receive his or her award. Glancing at my program, I knew there was only one more award left to be handed out. Phew, I thought to myself. Maybe I’ll get out of this easy.

The speaker looked out into the audience and around the formally decorated chapel. White balloons packed the ceiling overhead, while white crepe paper and satin ribbons adorned the aisles and speaker seats. Filling the air and mixing with the scent of the dozen white roses and baby’s breath in a crystal vase beside the podium was the aroma of fresh carnation corsages. Mother Mary and Saint Joseph, in all their beneficence, smiled down upon the audience from a stained-glass window behind the stage.

“We have saved the most prestigious award for last,” she began.

I was again relieved, remembering some of my less-than-genius moments, like the time I had proudly challenged my nutrition instructor’s grading of a test question by bringing in a box of raisin bran. The question had been whether or not cereals are fortified with vitamins and minerals, and my box explicitly stated that the product contained reduced iron. Though I found out later that “reduced” meant a non-elemental form of iron that could be used by the body, my instructor did give me credit for trying.

“This award is for best academic performance. I’d like to call Nurse Carol to the podium.”

A state of relief enveloped me, and I was finally able to relax and enjoy watching my friends and classmates enjoy the fruits of their hard labor. Carol was a very smart nurse. Even though she hadn’t studied as long and as hard as I had, she deserved the award. She had always been the first one out of the room during an exam, whereas I had always been the last.

I also thought that Pam might have gotten this award. I had first realized how smart she was as the eighteen-month program was just wrapping up and we were cleaning out our areas and preparing for the final exams...

After removing six notebooks full of notes from my desk, I noticed that Pam’s pile of notebooks was considerably smaller. In fact, there was only one notebook in her hand.

“Pam” I asked, “What’s that?”

“It’s my notes,” she calmly said.

“Can I see them?” I asked in disbelief, concluding—or maybe hoping--- that she had left her other notebooks at home or that she knew short hand.

She handed me the notebook. At the top of the first page was written “June 1977,” the date of our first class. Three quarters of a page down was a tidbit of information I recognized as coming from our last class just a week ago. This was the first time I wondered if Pam might have a photographic memory, and...

I was suddenly rocketed out of my daydreaming by a resumption of the speaker’s voice.

“I’d also like to call Nurse Ray. These two students were tied for the highest grade-point average.”

I was stunned. Nurse Carol was already graciously accepting her award, shaking the moderator’s hand, and I floated past her in a fog as she happily took her seat. I felt as though I were watching myself from outside my body, and though my feet propelled me forward, they did not seem to touch the floor. As I stepped up onto the stage, my back to the audience, a peal of laughter started to grow behind me. Had they appreciated and remembered the humor I had brought to the class? By the time I walked back past a smiling Sister Laetitia and sat back down, I felt pretty well appreciated, as the laughter had risen to a roar.

Preparing for bed that evening, I recalled how appreciated I had felt. I removed my t-shirt (a souvenir from a company whose services I had once needed), and upon folding it noticed the design and bold writing on the back, which had surely shown through my white uniform top at the ceremony. It read, “Ray’s Porta-Potty Service.”

Entering into your patient’s Hell requires almost super human courage, strength and stamina. It would be difficult to imagine being able to achieve any vision of a deep level of patient involvement without the support of co-workers and mentors, the best parts of whom over the next several years I would weave into my own personhood. I would take their warmth, honesty, and compassion and make it my own, would mold them into my wholeness and beauty. Upon receiving the first Nurse of the Year Award granted at EMMC (Eastern Maine Medical Center) some years after my graduation, I gave credit to the human forces that surrounded and sustained me: co-workers, to whom I could in confidence release the stopcock of emotions that were threatening to overflow; family and friends who cheered me on; people who believed in what I was doing when I was in doubt; partners who were with me every step of the way, no matter what; friends who cared enough to tell me perhaps what I didn’t want to hear but what I needed to hear for my own good; and visionary guides like Sister Laetitia, who could see where the end of the road would take us, but who gave us our own space and time to process trivial matters.

“We are not here merely to make a living. We are here to enrich the world.” Woodrow Wilson

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Newly graduated nurses often come equipped with the desire to help but a lack of experience in administering all the necessary skills they have learned. The translation from classroom to actual practice in the trenches is not always seamless. As a rookie myself shortly after graduation, I shared care of a patient with Nurse Linda and was surprised one morning to find the patient with what looked from a distance like white spots all over his face. Approaching his bed, I reviewed the chart, looking for a history of fungal infections or of allergies to medications, but there were none recorded. I knew it wasn’t snow, frostbite or hail, as it was the middle of July. Could it be chicken pox, or had he traveled to some third world country and been stung by a swarm of killer African bees? At the bedside now, I discovered that the spots were actually about 25 little pieces of toilet paper plastered on his skin, a result of Linda’s inexperience with shaving a man’s face and her attempt at stopping the bleeding from where she had accidentally nicked him.

Linda and Nurse Pam and I had all started our careers together. Eventually, I ended up on the evening shift from 3:00 to 11:00, and Pam and Linda worked nights from 11:00 to 7:00. When Pam relieved me one night, I told her that my patient in Room 140 was very sick and probably would not make it through her shift without getting into trouble. Those were the days when mouth-to-mouth was standard, as ambu-bags had not yet come into standard use in all rooms for patients who had gone into a deadly rhythm requiring cardio-pulmonary resuscitation.

“You were right,” she said to me the next afternoon. “He coded at 2:00 am, and I had to do mouth-to-mouth on him.”

“Gee, Pam,” I said. “If I’d known that, I would have given him better mouth care.”

Pam forgave me for that, but it seems she often ended up on the wrong end of the stick. Like the time she was attempting to move a 300-pound patient in his bed, trying carefully to hold onto his endotracheal tube (breathing tube inserted into the distal trachea) and keep him from being extubated in the process. Department Head Sue heard her scream and went running into the room to find the patient on the floor in her lap----but she was still holding that tube secure.

Pam, in fact, always seemed to have her patients’ best interests in mind. One patient, George, came in from the ER (emergency room) and had not eaten for almost ten hours. Pam, who was working replacement on the evening shift, had tried to call the admitting doctor to get orders but had not yet heard back. Meanwhile, the patient was threatening to leave against medical advice, because he was so hungry. Rather than see him suffer, she noticed on the dietary cart a tray of food, which had been refused by one of my patients, and she asked me if she could have it for her patient. He gobbled this up in short order and asked for more.

“Are there any desserts left over?” she asked us an hour later. “He seems to have an insatiable appetite.”

“Pam,” I said. “I just got a call from the lab with a critical result. Seems your patient has a glucose of 800.”

Since the normal range for glucose is 70-120 mg/dl, Pam’s eyes widened in a look of horror. It was a joke, of course, but it made enough of an impression in the immediate aftermath that she decided next time she’d just let her patient starve.

These experiences demonstrate our inexperience, but they pale in comparison to my very first day caring for a patient. That was while I was still in nursing school. While our initial failures to perform certain rudimentary tasks independently were embarrassing, I was dealing with a potentially more dangerous issue. And while the term cockiness has its roots in the male gender, those of the female persuasion are certainly not immune.

I was assigned to care for an elderly woman, who had come into a Catholic hospital across town after suffering a mild heart attack. As I prepared to enter Julia’s room, I was filled with confidence that I had researched everything there was to know about myocardial infarction and that I had familiarized myself thoroughly with the woman’s background.

Darkness greeted me when I opened the door and strutted into her room. The blinds had been closed, and I could barely make out the tiny figure of a woman sitting up in bed. In the absence of light, I felt disoriented, and my confidence quickly waned, swallowed up by a twilight-zonish fear that I was not cut out to be a nurse after all. This is crazy, I thought.

Gradually, my eyes adjusted to the darkness, and I could make out a set of dentures soaking on the bedside table and a Bible in the woman’s lap, illuminated by a small light near the bed. With her long hair drawn up into a bun on the top of her head, she reminded me of my grandmother “Babba.” (I was perhaps anticipating that, as she had reported in her demographics that she was Czechoslovakian.) Remembering that Czechoslovakian women like Babba never cut their hair—Babba’s trailed two feet on the floor--- I hoped that I was not going to have to wash and comb Julia’s.

“Good morning,” I said cheerfully. “My name is Ray, and I’ll be your nursing student for the day.”

She said nothing but pointed toward a door on the same side of the room from which I had just come. Disoriented in the darkness, I thought she wanted me to leave.

Oh, no, I thought. She doesn’t want a man nurse. Though I had worried about this before deciding to become a nurse, my mother had given me the confidence to continue. She had told me that she liked having nurses who were men, because she felt confident in their strength to support her when she needed help walking and in their typical no-nonsense honesty. As I neared the door to obediently leave, I noticed the other door beside it.

Maybe she wants something from the closet.

I opened the door and found that it was the bathroom. Of course, my inner voice continued, the bounce returning to my step.

Returning to her bedside, my foot stepped on what felt like a power cord, and I kicked it farther under the bed. This is a tripping hazard, I thought, patting myself on the back for averting an accident. As I helped Julia out of bed, she began talking a mile a minute in Czechoslovakian. I had grown up in a Czechoslovakian household, and the words fell sweetly on my ears. But I remembered very little of the language. Every now and then I recognized the word dobrze (pronounced dobzheh), which means “good.” I smiled, thinking she had appreciated my talent at recognizing the bathroom. The faster she talked, the more urgent I thought was her need to get there.

As I helped her up onto her feet, I noticed a downward pull, as if the floor were playing a game of tug and war with us. Nothing in my reading had prepared me for this. Her foot and hand seemed heavy, as if drawn to a magnet under the bed, and I pulled more forcefully to get her away. All the while, she had not stopped talking.

Finally, I said with a smile, “Dobrze,” hoping that this would put us on the same team.

I dragged her into the bathroom as fast as I could manage, sensing by her still relentless talking that the need was urgent. After she finished on the toilet, I interrupted her rambling to interject some encouragement.

“Dobrze,” I said. “Dobrze.”

As we made our way back from the bathroom, I marveled at how fluent I had become in Czechoslovakian. Think of all the possibilities. “Dobrze” could be used in speaking with anyone, whether they’re Portuguese, Japanese, or Indian. It’s a universal word. I could use it to say “Dobrze morning,” or “Dobrze night.” If someone doesn’t like the food, I could use it to ask, “Not dobrze?”

My musing thoughts were interrupted when we reached the bedside and she again started kicking and falling toward the floor.

This is odd, but she’s not going to fall on my watch.

And I heroically scooped her up, placed her in the bed, and raised the bed rails. Whatever the force under the bed was, it now appeared to pull on her face and hands, which started reaching past the rails.

What the heck am I doing here? A lapse of confidence began to color my thoughts. I didn’t sign up for this crap. All the while, Julia never stopped talking. In Czechoslovakian.

Right about then, my nursing instructor, Nurse Eva, walked in. I looked at her. I looked at the patient. Nurse Eva flipped on the light and opened the blinds. It was then that I noticed on the floor sticking out from under the bed a small picture of Jesus. It was attached by two cords to another picture, and I recognized it immediately as a scapular. I knew from my Catholic upbringing that scapulars are believed to allow a person into Heaven, if they are worn at the time of death, and realized that she had been reaching for the floor (not the other way around—Huh!). I picked it up and placed it gently around her neck.

“Dobrze,” she said, settling back into her pillow and finally becoming silent and compliant.

Nurse Eva was not aware of all that I had already accomplished that morning. I felt proud to have mastered a very difficult language and in so doing helped Julia in her time of need. She announced that it was time to give Julia her meds.

This is where I will shine, I thought, feeling my confidence rise. I had watched many senior nurses give intramuscular injections and had done all my reading. I knew all of this drug’s side effects and could describe its pathway and target organ. I knew what to do to avoid hitting the bone and nerve. Piece of cake. Piece of cake.

Confidently, I filled the syringe with the medication and recapped the needle (which was acceptable back then). I knew the landmarks and put the index finger of my left hand on the iliac crest and my thumb on the greater trochanter. Proudly, I swabbed the “V” that fell within these landmarks, grasped the syringe and cap between my teeth, pulled the syringe out of the cap, and proceeded to give the injection. Glancing at my instructor for approval, I was surprised to see her mouth and eyes open wide in a look I had long associated with shock.

“Dobrze?” I asked weakly. I would learn that uncapping a needle using your teeth is not at all good technique.

Despite getting off to a shaky start with Julia, I grew to like her and spent the following week as her nursing student. The first encounter had been a good lesson in humility, and it would be one of the last reminders I would need to make me realize that making of myself a virtuous hero or a suffering victim served only to hinder the higher purpose of my vocation. I realized that I couldn’t communicate effectively with a patient unless I was focused entirely on her. On our last day together, I waved good bye in the fashion customarily used by Westerners, my hand up, palm side toward her, and fingers moving downward. She smiled and waved in the Czechoslovakian custom, her hand up, palm facing herself, and fingers moving downward, which meant, “Come back sometime.”

“They don’t care how much you know until they know how much you care.” Common advice given to new graduates