After putting the Foley in, I went to the waiting room and found Mr. Posey’s wife reading a magazine and finishing a cup of coffee. She followed me back to the desk to the nurse’s station, and asked to talk with me before she went into his room.
Mrs. Posey appeared to be about 10 years younger than Mr. Posey. When she spoke, her speech was syrupy slow; it made me think of white people rolling their R’s. The pattern of speech – the cadence – featured exaggerated syllables with mushy vowels, as if each word she articulated came from a different place, and from a different time zone –and that all of the words just barely managed to get to me in the same sentence by a freak of an accident.
Mrs. Posey was the kind of woman that I would pay to sit in front of me and talk. Listening to her was like being in a room with John Gardner as he read from a book, getting lost in the simplicity of words well said, until BANG, you wake up surrounded by a clean idea, given to you in soft cupped hands. I liked her and she was pretty.
She had not been eating lunch in the cafeteria earlier; she’d been calling in favors and making arrangements. She had visited other hospitals, and doc shopped the best of them to get opinions and suggestions. She had managed to get copies of all his ER documents and spread them around to newly interested parties. She knew as much as I did about what was going on.
Arrangements had been made for the family to come out. Bosses had been contacted and excuses given. Money had been freed up from scattered retirement accounts, and a small apartment had been rented next to the hospital.
Clearly, she was an iron fist in a velvet glove kind of girl -- a non-squeaky wheel that still managed to roll over everything in her path. She was a load-bearing wall of a woman, with attractive wallpaper.
She asked me where we stood today, and what we were going to do about it, right now, and then, tomorrow. She had a nice clarity about her questions; they were direct and presented with a sharp focus. She wanted a plan, or process, from me, and though it was clear that she didn’t need an outcome, it was also clear I’d better come up with one at some point.
I talked to her of process and progression, and gave her timetables for events to come. I was specific with each of the points on the path as I saw it, but rough on the timing. I explained what the maximum therapy would look like, and what I had seen in the past with patients like him. I tried to be as direct with her as she was with me.
I kept thinking the whole time I was with her: I would want my wife to care for me like this; that she was the mold the models should be cast from when looking for a second wife, the wife you should have gotten the first time if life was fair, or rats were chickens and just as delicious
After I finished, she talked to me of hope, grace and god, and of wanting to walk the process of whatever this was, with her husband. She told me you can’t win a lottery without buying a ticket, and that God could only save people who were available for saving. She said that grace was the time god gave you while waiting for salvation.
I took her into her husband’s room, and then dragged a comfortable recliner in from the hall. I told her she could stay with him in the room as long as she wanted to. I left them alone and returned to the nurse’s station to get some new medications organized.
Mr. Posey complained of some mild chest pain when I returned to the room. He described it as being “mild” and a “pressure” type pain centered in his chest. I started a new IV in his forearm, and then started the nitroglycerin infusion I’d mixed up a few minutes before.
Back then, giving nitroglycerin by IV was a new thing. It had a lot of rules and procedures that had to be followed in order to use it safely. It needed a dedicated line for administration, and had to be mixed in a glass bottle and connected with special, thick plastic tubing. It looked oily in the bottle, and didn’t play well with other drugs or solutions. It acted by relaxing all smooth muscle in general, and the coronary arteries specifically.
Chest pain happens when the nerves attached to the coronary arteries recognized they were not getting enough oxygen. When you relaxed the arteries by dilating them, more blood could flow through the now bigger tube, and more oxygen could get to the heart muscle and it stop its complaining.
I also signed out some morphine from the narcotic cabinet at the nurse’s station and gave him 4 milligrams intravenously. In a short minute, I saw him visibly relax.
Morphine is a painkiller. It kills both emotional and physical pain, and nothing works as well as morphine for most people – except for those poor sad people who violently vomit and retch when they get a taste of it.
Morphine is a problem solver, and in the short run, I have never seen anything better at solving emotional or physical pain. The Buddha’s wait beneath the Bodhi tree would have been much longer if he’d taken morphine – Suffering would no longer have been his linchpin for universal awareness and he would have had to find something else to blame – the path would have ended up with one less fold.
In the long run, everything that the experts say about opiate drug abuse is right, but again, in the short run-- morphine’s the best solution to almost any problem you can think of. It’s the duct tape of drugs. It doesn’t take away pain so much as make the pain indolent. With long-term abuse, it makes people pretty indolent as well.
When the body is under stress it releases a flood of amphetamine like drugs (catecholamine). It’s old behavior that’s been hardwired into our brains. Called the “fight or flight syndrome”, it’s automatic. When a mugger asks for your money on a dark street; your eyes dilate to improve your vision, your heart beats faster to allow you to fight, (or run away) and your kidneys start to hold on to fluid—just in case! It’s like not using a mask in a meth lab- with all the different pluses and minuses.
On the plus side- you feel like a god. On the minus side- you’re doing a lot of work.
One of the effects of morphine on this kind body induced drug abuse is to kick it down a notch, to allow the heart to work a little less hard. Think indolent.
Morphine makes people more reflective, and gives distance to problems. It allows a person to see their problems as a complex whole, while disconnecting the normal emotional turmoil that complex problems usually have attached to them. It takes away crisis, importance, and priorities, as well as bills, grooming and moral standards.
You can see how this would be a problem when used for long-term problem solving, yet also see the blessing of it for short term upsets and woes. Morphine makes your life flash by you in short video segments, with no one segment given more weight than any other. You feel the pain, but from a distance, and with this distance the pain seems like just another interesting process you are going through on this wacky field trip called life -- without the emotional cuts and physicals stops that seem to want to be played out in the daily activity of real time living. Morphine provides this distance, in fact, it insists on it.
With his pain relieved by the morphine, and now high as a kite, Mr. Posey started reflecting on things, as I made myself busy putting other, more physical things, in order in his room. He talked about his time in Korea during the war.
Posey was assigned to an Army anti-aircraft tank like vehicle. He said that during WWII it had been used against German aircraft, but in Korea it was used against people. He told me that when waves of North Koreans attacked, they moved the guns from vertical gun to horizontal, and “blasted away”. The projectiles they used were larger than the biggest machine gun bullets that the army had and, they were “real effective against people”. He told me at the time it was hard for him to see the North Korean soldiers as people, that they were more like blobs of green things --a dangerous horde of people that never ended, rushing to overwhelm him. He said that he had lost the comfort of these comic book emotions over the years that had passed since then, that he had been changed emotionally by the death he had been responsible for. He said that this change had come to him gradually over the years. He had done what he had done, and it had been “the right thing to do at the time,” but it had caused him great grief and bad dreams for much of his life since then.
He told me he had dreams of going to North Korea on vacation and seeing all the names of the people he had killed on a large stone memorial. He dreamed that as he read aloud each name, a family would step foreword and talk about the person he had killed, while ghosts of the unborn they would have had whispered like bees in the background. The families all talked in various sorts of common English, and all told tales about the people he had killed, tales that sounded the same to him as tales his friends had told him about themselves. It was like he was no longer a soldier at war, but the largest mass murderer in history. He told me he woke up startled some nights, with serious pangs of old regrets.
I sat Mr. Posey up for dinner of clear liquids from which he drank next to nothing. He asked me why I even bothered trying to feed him; he could barely breathe, let alone eat. I told him that it was state law- I was required to offer him food three times a day, but that it would be considered battery if I actually forced to eat it.
I said this to him as a joke, as part of my, “I’m a competent nurse show.” It was a piece of my ritualized routine of wit and fearlessness, and a way to show me laughing at danger from the edge of the abyss. It was also a moment of humor that connected us in the universal guy thing, so not completely selfish.
He told me to stop being a smart ass and to help him out of bed to take a crap.
Posey was very short of breath, and I almost had to lift and carry him to the bedside commode that was parked right next to his bed. I stayed in the room with him as he had a bowel movement; a loose and gassy expulsion that took only seconds. I help him wipe himself, and quickly lifted him back into bed. I then emptied the bucket into the hopper on the other side of the room, and sprayed a disinfectant from an aerosol can around the room with short quick waves with my hand.
It was getting towards the end of my shift, so I did a final assessment on him so I could give an update to the next nurse that was to follow me.
His lungs continued to sound wet and crackly when I listened to his back. He continued to be short of breath with any exertion and his oxygen continued at 4 liters by nasal cannula. His urine output had picked up a little -- it was 45-50cc’s every hour and it was slightly clearer, but still nothing to beat a circus monkey with. His heart monitor had slowed slightly, but was still much faster than normal for just sitting around. His blood pressure was low- but low stable, at this time. When I listened to his heart sounds they were distant but I heard a rubbing kind of squeak whenever he took in a deep breath. The squeak was new, so I planned to let the doctor know about it prior to going home.
I mentioned to Posey that he was squeaking. I explained to him that the squeak came because the heart sits in a sack in the middle of the chest, under the breastbone (sternum,) and was inflamed and irritated from the injury of the heart attack, and that it was now rubbing on the against the sack from the inside.
As I said goodnight to Posey, and let him know that I’d be back in the morning, I took pillows and blankets from the closet and handed them to his wife. I reminded myself to tell the next nurse that she had permission to stay overnight if she wanted to.
I left the room and went to the nursing station to finish up my charting, and to give a report to the nurse that was following me. I called Dr. Q to let him know about the squeaking, and got connected to his paging service. I asked for a call back, and let the new nurse know to expect it I had worked a double – a 16-hour day, and had also made myself available to work another the next day with the charge nurse. As I took a last look at Posey’s monitor, a nurse standing next to me said to me, “Resting tachycardia in a fresh anterior MI is an ominous sign.”
I smiled at her as I left, and went home to get a few hours of sleep.