Dix, Hamm, and Pulmonary Fibrosis

I mentioned pulmonary fibrosis in my last post. We had three big cases on our ICU in April, all three of them pretty difficult.

Pulmonary fibrosis is essentially scar tissue-- the formation of thick, tough, fibrous tissue that grows through and fucks with your lungs until you die of not being able to breathe. Imagine a transporter accident like in The Fly, but between a pile of wet cardboard and your dick, and you’ve got a little of the idea.

The treatments for pulmonary fibrosis include nebulizers to help open the parts that aren’t scarred up; steroids to reduce the growth of scar tissue (not always effective); and a host of other last-chance drugs that might have been helpful, maybe once, to some other pt whose pulmonary fibrosis took a little longer than usual to kill them. It might have been another drug, or luck, or fucking homeopathy for all the proof we have, but if it might have worked, we’re probably gonna try it.

The cure for pulmonary fibrosis is a lung transplant.

So when our first pulm fibrosis pt turned up eligible for an eventual transplant, we transferred them to the hospital where they would live until they either died or went on the table. We don’t do lung transplants here. They’re complicated.

Our second decompensated so quickly that there was no time to talk about transfers or transplants or last-chance drugs. I admitted him; his wife was in a panic, and I spent the whole shift managing her anxiety and anger while trying to keep him breathing; when I came back the next morning, he was intubated and chemically paralyzed to minimize his oxygen consumption. He circled the drain for a full week after that, his wife growing thinner and grayer as she paced the hallways, and then one day I came back and he wasn’t there.

The third had been living with a degree of pulmonary fibrosis for years, slowly losing his lungs, trying to raise his teenage daughter on a disability paycheck, increasingly depressed and immobile as his body failed. He was an immigrant who had worked most of his young life in a series of factories in Mexico, moved to America with a visa to work, had a successful career and helped build a factory, and then become a living, gasping advertisement for the importance of the EPA.

Our pulm doc rounding that day, the dignified and gentle fellow who consistently fails to chew me out for my terrible paging and who generally looks handsome enough to set the angriest little old lady at ease, went into an absolute froth during grand rounds. (This is a process in which the charge nurse, intensivist/pulmonologist, pharmacist, nutritionist, social worker, and a host of others all make a loop around the unit every morning, checking to make sure everyone’s crucial dots are connected and boxes checked.) We stood outside the man’s room while Dr Cooper* shouted about how factories that expose their workers to asbestos and other toxic chemicals should be burned to the ground, how the great failure of unrestrained capitalism was the human cost of suffering and the burden of that suffering on society, how the pursuit of profit turns good men into bitter men and wicked men into monsters, etc etc.

Dr Cooper is also known for dropping the fatherly, professional air during very tense situations, and cursing like a sailor as he runs difficult codes. He also likes to sit in the break room and heckle Fox News. Most importantly, one time he had the opportunity to absolutely nail me to the wall for failing to get a procedure set up properly, and instead he took a deep breath and declared that some days just don’t go smoothly and that he would be back in thirty minutes with the RT, no need to worry about it.

For the record, I love Dr Pug, but if I pulled that shit with him he would still be screaming up chunks of his vocal cords at me. (We get snippy every time we discuss my paging him to the unit phone instead of the closest wall phone.) He’d be right, too. I’ve been working here long enough that I should know enough to get a chest tube kit, a procedure cart, an RT, and a couple vials of Versed when I’m asked to. So Dr Cooper won my absolutely eternal loyalty by keeping it professional even though I wasn’t being professional.

That said, you can only listen to so much ranting during grand rounds, and by the time that pt died I had learned to give rounds report at top speed and volume to avoid the explosion.

Sometimes the only way you can cope in the ICU is to let yourself fall into that guilty, cowardly gratitude that at least it isn’t you. Pulmonary fibrosis? Horrible way to die, hope a stroke gets me first, glad it’s not me begging for air. Inhumane working conditions? Miserable way to ruin your body for a dollar, thank goodness we have a nursing union and material data safety sheets, glad it’s not me. Immigrant, disability, child to leave behind? Glad it’s not me, glad it’s not me.

Glad there are people like Dr Cooper who can still get mad about it.

The fourth really critical respiratory pt in April was ruled out quickly for pulmonary fibrosis. Nah, Mr Dix just had good old-fashioned pneumonia, and lots of it, and hadn’t come in until he was literally blue in the face and his wife and daughter called an ambulance. He was right down the hall from the room where Ellen Hamm wheedled and screamed, and he made her seem pretty chill.

Hamm was no longer hurting. Ketamine had given her some spectacular hallucinations, but had completely knocked her pain out. Unfortunately, this brought her fucked-up personality to the forefront, and she exhausted everyone who came within earshot with an endless litany of petty demands, attempts at manipulation, lies about other staff, and belittling complaints about her husband.

Our manager recently put his picture up in every room with his personal phone number and an invitation for any pts or family to call anytime if they needed, because he is some kind of freaky manager superhero. Hamm made him sorry for it. He started avoiding the clinical educator’s office because Lydia’s* door was directly across from Hamm’s door, and Hamm screamed at him like a teakettle full of witches on sight.

At the front nurses’ station is a clipboard with a list of nurse requests: Maycee wants room 22 back, Tara would like a neuro pt soon, no more bariatric pts for Krissy this month because her shoulder is acting up. This week, the clipboard looked like a vegan petition full of signatures: NO HAMM. NO HAMM. NO HAMM.

But Dix… well, to start with, his anxiety was also out of control. It manifested in an unwillingness to go through with any plan, no matter how banal. Would he like a glass of water? Sure, of course, yeah. Here’s your water, sir. Actually no, no I don’t want water, it’s probably got contaminants in it, you’re trying to make me sicker, I’m not drinking any of your chemical water.

He refused literally all care. All of it. He refused to lie in the bed, preferring to sit in the recliner. He refused turns; he refused medication; he splashed piss on his leg and refused to let us wipe it up, batting us away as we opened the wet wipes and announcing that he’d “changed his mind” and “the wipes would just irritate his skin.” We were lucky to sneak one dose of antibiotics into his IV per shift.

Okay, not all of it. The IV, of course, was fine. You can give dilaudid through an IV. Dilaudid was also fine. Ativan was not fine, nor diuretics, nor tablets of aspirin or antibiotics, nor oxygen.

Mind you, on room air he desaturated into the 60% range pretty quick. Your oxygen saturation is, barring COPD, generally between 92% and 100%; with COPD you lose your ability to tell when to breathe, and your oxygen stays much lower, between 88% and 92% usually. At 80% you start to feel like you can’t breathe. At 70% your body is struggling and hypoxic brain fog renders you loopy. At 60% you’re turning blue and possibly losing consciousness, depending on whether you’re able to tolerate hypoxia.

At 62% Mr Dix tried to refuse his oxygen mask. Yeah, no. I bribed him liberally with the promise of dilaudid when I could, and clamped the mask back over his face once he was too hypoxic to fight me.

Still, every few minutes he would rip off his mask and press his face to the hand-held fan he kept on his tray table, blowing average-oxygen air across his face in the full belief that it would do him more good than the fifteen liters per minute of extra oxygen it took to keep him above 90% saturation. I would have to bribe him, bully him, or beg him to wear it, and he would always refuse until he hit the mid-70s. By the time I got the mask back on him he would be in the 60s, blue in the face and panicking.

The fan, by the way, is one of the methods we use to relieve shortness of breath for the dying. Air blowing on your face feels fresher than still air, and sometimes you can convince your body that it’s getting enough air even while your heart is slowing to a halt from hypoxia. Combine that with a few doses of opioid to depress the respiratory drive, and you can get someone comfortable while they literally smother to death.

We weren’t trying to gently shuffle Mr Dix off this mortal coil, however, much as he tempted fate. So I would be in my other pt’s room, assisting a cute little old lady from bed to the commode as she worked through the residual diarrhea after a GI bleed, and I would hear his oxygen alarm start dinging and hammer my Vocera walkie-talkie in desperation.

I can only imagine what the CNA on the other end of those calls was hearing. On my end, it mostly sounded like me pleading for someone to check on Mr Dix and put his mask back on, plus a rolling thunderstorm of old lady grunts and farts. Fortunately, the CNA that day had my back. Rhea is tiny, young, innocent, and filled with the kind of Gryffindor fury that puts the fear of god in old shitty white guys who think it’s funny to slap the nurse’s ass. She would march into the room and I’d hear this ear-splitting staccato outburst and Dix’s oxygen would climb to 92% and stay there without a peep of protest.

I’m mean as hell but I ain’t got chops like that.

Of course, she had the element of surprise on her side. To him, Rhea was a mysterious stranger who appeared in his room unpredictably, snarling and staring daggers, whereas I was in there constantly. My scare factor wore off completely by 0900. The pulm that day, none other than our medical director, came in to talk with Dix and ended up so frustrated and disgruntled that he stomped out and called for a psych consult to have the guy declared incompetent to direct his own care. Dix shouted after him that he refused to see the psych doctor.

The psych doctor came by anyway, but somehow walked away with the impression that Dix was competent to make life-and-death decisions despite being too anxious to accept a glass of water. The rest of the shift was a blur of bribery, frustration, and dinging oxygen saturation alarms.

That evening, word came down from on high: Ellen Hamm would be transferred off the ICU in the morning.

Her nurse June*, one of the unit’s top contenders for sainthood, gently prepared her for the transfer, talking up the new floor (“It has sit-down showers!”) and slinging opioids with a free hand. Near bedtime, Hamm made a strange request: for her last night on the ICU, she planned to have a date night with her husband, who would be here in half an hour to paint her nails and spend some quality time at her bedside. “I don’t want to be disturbed,” she said. “I want the door closed and the curtains pulled, and nobody can come in or out until he’s gone.”

“I don’t know if we can do that,” said June, “just because it’s a hospital and if something bad happens we need to rescue you, but if you want privacy… sure, we can knock on the door, give you plenty of warning, whatever.” I think the idea of a few hours without a peep from Hamm made us all giddy with delight. It wasn’t like they could get up to anything saucy-- even looking at her the wrong way could make her wail with agony.

At any rate, her husband showed up that evening with a bouquet of flowers and a bag of cheap candy, and we closed their room as if we were sealing Nosferatu into his tomb. Apparently they made not a peep for the rest of the evening, and when her husband went home she settled into a ketamine-addled mumbling doze that lasted until they transferred her out in the morning. Not so bad, for an anxious woman who started her ICU visit screaming.

First thing the next morning, Dix started telling me that the government had implanted a hearing aid in his chest so that he could record all our conversations, and that he would have us convicted for rape and torture when the FBI reviewed the tapes. He also started demanding that we let him leave against medical advice (AMA).

The pulm allowed that, perhaps, maybe this afternoon, we could have the psych doc come back and look at him again. You know, later. Just see if you can talk him into cooperating first.

I took to bribing him with little jaunts in the hallway, pushing his rolling recliner twenty feet down the hall and back in return for letting me give him his antibiotics.

During one of these outings, the pulm had a great idea: what if I took him outside to get some fresh air?

Now, I’ve taken pts outside more than a few times. Usually, I wheel them down in a transport chair and we sit in the jasmine garden and talk about our pets for a good fifteen minutes, then I bring them up. Once I was part of a massive group effort to take a dying man outside to see the stars, after which we took him to the chapel for last rites, still in his hospital bed with his ventilator and IV pumps in tow. Then we unhooked him and let him go. One of the prouder moments of my career.

In this case, Mr Dix was totally inappropriate for an out-of-hospital stroll. The pulm insisted, though, and finally I figured that with the help of a CNA-- not Rhea, but another person from a different floor who had floated to ours, since Rhea was about to clock out and go home-- I could get him out the front doors of the ER lobby, give him ten minutes sitting on the sidewalk, and then roll him back upstairs.

This was my first big mistake.

No, my first big mistake was not throwing an unmitigated shit-fit at the pulmonologist and the psychiatrist simultaneously. The second big mistake was taking a huge, anxious, unpredictable, gasping man downstairs and outside in a recliner.

The third big mistake happened a few minutes later, after I got my guard down. Outside, there was a lovely breeze and a sky full of sailing white clouds, and Mr Dix relaxed and didn’t even fight the oxygen mask as he wiggled his toes in the sunlight. The float-pool CNA helped me brake the chair in place, then kicked back and checked her texts. The air smelled like mown grass and mulch. I started to think the pulm might have had a really good idea.

Rhea caught up with us a few minutes later, having clocked out and stuffed all her textbooks into her backpack, which made her look like a tiny but furious grade-schooler. She was waiting for her mother to pick her up, and for the space of two minutes we chatted about her nursing classes, her mother’s health, and the employee evaluation survey we were supposed to have done a week ago.

Conversations between on-duty health care workers are the most awkward things to watch. At least one participant is usually staring a hole in something else and can’t be bothered to look at their chatterin’ buddy lest their pt’s blood pressure crash. If the other participant isn’t staring at their own personal project with their back turned to the conversation, they’re usually typing, texting, or scrubbing something. At least a third of the words are either profanity or gibberish. If you’re just watching from a distance, it probably looks like we hate each other.

Anyway, as I talked to Rhea and stared at Mr Dix like a serial killer outside his window, the float pool RN sized up the situation, decided that Rhea must have arrived to tap her out, and headed back inside. I was watching Mr Dix so closely that I missed her departure, so when Rhea hopped in her mom’s car and zoomed away, I was exceedingly surprised to find myself alone with Mr Dix on the sidewalk outside the ER lobby.

My walkie-talkie was out of range. I waited for a minute or two, craning my neck for other hospital staff, but the only other person in earshot was a tiny old lady waiting in the foyer for a pickup. Worse, Mr Dix started to pick up on my concern, and all the peace and comfort of the breeze and the sunlight vanished into spiraling anxiety.

I started rolling him back inside immediately, hammering my walkie-talkie every few paces, still out of range. As we passed through the foyer, Mr Dix spotted the old lady in her wheelchair, watched her wave to her ride and stand up to go outside, and decided he wanted to ride in the wheelchair instead.

The wheelchair in question had been chosen specifically for a tiny old lady: I’m a narrow type myself, but my hips would have scraped sitting down. No way was Mr Dix’s enormous bulk squelching into that little basket. “Let’s go get you a larger one that will fit you,” I said, hoping he would distract himself on the way back to the ICU.

“No I want THAT one right THERE,” shouted Mr Dix, ripping off his oxygen. He wrenched the footrest on the recliner down with a jerk and leaned forward as if to stand, then fell back into his seat. “Actually I think that wheelchair is broken,” he said, “it’s a death trap, if I sat in it I would fall and hurt myself, I’d get tetanus.”

I breathed a sigh of relief, promised him a better wheelchair once we reached the wheelchair storage (a place I completely made up but which would conveniently be located just beyond his room if he asked), replaced his mask, and put his feet back up.

Too late, though. His anxiety was raging. As we passed into the ER lobby, he started bellowing and ripping at his clothing. The lobby attendant was busy with a young family, and I made my fourth mistake: instead of shouting for her to call security, I figured I could get him upstairs-- within range of the walkie-talkie, with trained staff at hand to help me manage him-- before things got really bad. After all, the elevators were right there, and he hadn’t been able to get out of his chair before…

Turns out, he just wasn’t motivated enough. The elevator doors closed, and some claustrophobic fuse in his head burned out. Ripping the mask off, Mr Dix kicked himself upright, screamed at the top of his lungs, and shoved the chair backwards as hard as he could.

Right into me. It took me a second to process what was happening, and by then he had managed to drag the chair forward again for another blow. The recliner was a big bariatric model with a metal bar across the back, and it hit like a bull, especially with Mr Dix’s full weight behind it. I pushed back, smacking my walkie-talkie, trying to free myself in the tiny elevator-- the next hit knocked the wind out of me.

I know I belched something into the walkie-talkie, because eventually the charge nurse answered and I was able to croak for help. I’m not sure how many times he hit me, although at one point I felt my knees give out and I realized that if I fell I would be helpless and he would still keep hitting me, and even realizing that I couldn’t make my knees straighten up.

The elevator ride from the ER to the ICU is a little under thirty seconds, which seems in retrospect like barely enough time for a decent yawn, but in my memory it lasts approximately seventeen hours and is divided into millions of vivid frames that tell me absolutely nothing about what happened. Mr Dix yelled and turned blue-gray and rammed the chair back into me; I flopped around uselessly like an unhappy amoeba; the elevator doors opened and the charge nurse was there with backup.

The chair got stuck as it passed over the threshold-- Mr Dix kept yanking on it and got the wheels sideways enough to slip between the elevator and the doorsill. Fortunately, we got the chair dislodged just as he lost consciousness, more-or-less shoved his body onto the recliner, and raced him down the hallway to his room.

He wasn’t breathing. The charge nurse, a woman who looks like the star of an 80s barbarian sci-fi film in scrubs instead of a chainmail bikini, shouted for a code cart and an ambu mask. She had been in the middle of a shift change, and her relief clamped the oxygen mask over Mr Dix’s face, then gave him a sternal rub so merciless that I heard the pop of her knuckles scraping his sternum as I pushed my side of the chair.

Somehow, in the rush, my body switched modes seamlessly from “being beaten” to “preparing for a Code Blue.” Adrenaline is a multipurpose drug. By the time we got him back in his room, he was breathing again, his oxygen percentage was above 70%, and he was starting to fight us again.

Psych doc be damned. We held him down, shot him full of ativan, gave him the antibiotics he’d refused three hours before, clamped the oxygen mask over his face, pushed the diuretics he’d refused earlier that would help reduce lung swelling, restrained his arms and legs to stop him from hitting, and pumped him with even more ativan just to make sure. By the time we were finished, his eyes rolled back in his head every time he tried to open them, his oxygen was at 94%, his color looked fantastic, and we had even seized the moment to bathe him a little so he smelled less like stale pee.

“You all right?” asked the charge once we had a moment to breathe.

“Yeah,” I said. “Thanks for showing up.”

“You wanna talk to the doc or should I?”

“I’ll talk to him. Do you have any ibuprofen? I’m out.”

400mg of Motrin later, I cornered the pulm and gave him a brief update on the situation. The mention of Mr Dix’s name made his nostrils flare. “That man is a lost cause,” he said, the harshest thing I’d ever heard from him. “I don’t know why he’s here if he’s going to refuse everything.”

“Okay, I hear you, but we need psych to come back and sign off on him, and I need orders for restraints, and I want you to come see him--”

“Come see him? Can’t you just… talk him down? He just needs a little finesse.”

I made myself stare at the ceiling for a minute and just breathe. “Sir, he nearly coded and he hit me with a chair. He needs compulsory care and possibly sedation.”

“I’ll come see him in a little bit,” replied the doctor. “Can you talk to him until then, keep him calm? You can put in the verbal orders you need until then.”

In my head, I reminded myself of all the reasons not to fly into a screaming rage. The doc was working on a tricky admit; I didn’t look like I’d been hit with a chair, and have been known for dramatic hyperbole in the past; Mr Dix was astoundingly unpleasant and it was just human nature to want to avoid him; the doc knows if anybody on the floor can finesse an anxious pt, it’s me. None of these things worked. My vision dissolved into a red haze.

I saw two futures branching from this moment: a future in which I walked away, put in about four milligrams of IV ativan and four-point restraints as verbal orders in the computer, and called psych myself-- and a future in which I lost my shit, choked out a doctor, and went to jail.

I write this from one of those futures, and I can tell you that the psych doc declared him incompetent to manage care. Also that I had several more conversations with the pulm about Mr Dix after that, most of them very diplomatic and one of them exceedingly tart, and that the doctor in question has apologized profusely and admitted his fault. Beats the fuck out of jail, so I’m glad I walked.

While Mr Dix snored into his mask from an ativan swoon, I checked on the little lady next door, the one with the GI bleed. Sure enough, it was time for another trek to the commode. I helped her, as usual, but as the adrenaline wore off I started to shake and my joints felt floppy. My left arm, which had taken the brunt of the first few hits, was weak at certain angles. Worse, I had the sudden, humiliating urge to cry for an hour, and I found myself swallowing continually while I supported my pt on the commode.

It wasn’t like I felt sad, or scared, or really much of anything besides shaky and annoyed. It was a reaction as unthinking as the weird red blotches that show up on my chest when I’m drunk or angry. I was so checked out that I felt like a robot as I smiled and made pleasant small talk with my pt, comforted her and explained that the diarrhea wouldn’t last forever, pivoted her back to bed and tucked her in, made the usual unfunny joke about the call bell wandering away as I put it back in her hand. My face did all the normal things and my body performed all its duties well.

When I left the room, Mr Dix was still snoring, and I suddenly couldn’t stand the thought of being anywhere near him. I pulled up a rolling chair, logged into the computer outside the next room (which had been empty since that morning’s transfer) and started catching up on my charting.

Well, trying to catch up on my charting. I was exhausted. At nearly 1700, I was ten hours into my shift, and my attention splintered every time I blinked. Weird un-sad cry-noises kept coming out of my mouth. I wanted to sleep for a week and then eat four cakes.

A full minute into staring at the spot where the linoleum vanished under the empty room’s door, I realized that I was actually seeing something there: a fleck of brown plastic, the corner of a small object. Poking it with my toe revealed that it was actually, impossibly, a fun-sized chocolate bar.

Every synapse in my brain went off at once. I think my hands actually made claws. I said aloud: “This is a gift to me from Jesus.” Then, because I might have been malfunctioning but I wasn’t completely stupid, I washed the thing repeatedly in the sink-- it was the plastic-wrapped kind, not the foil-wrapped kind-- and scrubbed it with sani-wipes and then washed it again. Once I was satisfied that it was clean, I took a pair of clean scissors and dissected the wrapper, revealing a one-ounce rectangle of chocolate so cheap I could feel the crayon residue on my teeth just looking at it. Waxy white bloom covered the corner; it had spent a while sitting on a shelf.

Listen, okay, I could have got other candy. I could have begged somebody to cover my pts while I dashed to the cafeteria or the pharmacy. I could have wheedled one of my coworkers for their sugar stash. It wasn’t about making rational decisions: I needed something, anything, to restore my soul, and somehow chocolate had appeared right in front of me.

I ate the chocolate. I wept as I ate the chocolate. I still remember how it felt, dissolving into sandy sweetness on my tongue, leaving dry sticky corners in my throat as I swallowed. I remember the sour taste afterward as the residue settled and my mouth reminded me that oral hygiene is a thing. I remember feeling like the whole world was settling back into place. I finished my charting.

In a fit of returning humor, I sent a chocolate-eating selfie to Leah and to June, who was enjoying her hard-earned day off. “I’m so demoralized I just ate a piece of chocolate I found outside of Hamm’s old room,” I texted them.

“That was the chocolate Hamm’s husband brought her for sexytimes,” replied June.

JUNE NO.

NOOOOOO.

JUNE NOOOOOOOOOOOO.

“They couldn’t have sex,” I reasoned back. “She screams every time you touch her.”

Gently she explained to me that after Hamm’s husband went home, the night nurse had given her the requisite per-shift foley catheter care, and found the area completely shaven. I mean, they probably didn’t have penetrative sex, but they definitely had some sort of downstairs fun. And she ate almost all of the candy.

All the candy that I didn’t find later and eat, I guess.

Because I definitely ate Ellen Hamm’s weird sex chocolate. Those molecules are part of me now. However that single candy bar got launched across the room and jammed under the door, whatever activity was distracting enough to cover its escape… these are things I will never know, and at that point I was beyond caring, because the damn thing was plastic-wrapped and I washed it. And who gives a fuck if Ellen Hamm’s shaved snatch led directly to me finding and eating the candy? What matters is that, when I needed it, candy was there.

Later that evening, on the way home, the candy and the numbness both wore off, and I gripped the steering wheel and listened to my clutch pedal squeak and worried myself sick. I had endangered Mr Dix by agreeing to take him downstairs. I had failed to advocate for him aggressively enough, and he had nearly died because I shied from conflict and didn’t stress to the pulm that he needed a psych consult now. I had lost control of the situation, failed to keep track of the float CNA, failed to get help in the lobby, failed to keep him calm. If I had been smart about it, I would have had ativan in my pocket, ready to give him even against his will if it would keep him safe and alive.

I knew I would have to write up the incident report the next day at work, and probably talk to my manager about it. I suspected I would have to talk to the pulm, and probably the psych; I feared that I would have to explain my incompetence to multiple people, and dreaded it. But I was grateful at least for that clipboard with its NO HAMM registry, because at the bottom I had written: ELISE – NO DIX.

It wasn’t until I got home and pulled into the parking garage that something else occurred to me. I stood at the elevator that would take me up to my front door, where my husband awaited me with Thai takeout and Netflix, and felt the oddest reluctance, a hesitation in my brain that kept me still for a few extra moments before I stepped on.

It wasn’t just failure and incompetence and worry that had my teeth on edge. I had been beaten up in an elevator that day.

Just putting words to it, even inside my head, was like flipping a switch. That fucking motherfucker! That ASSHOLE! Mr Dix had beaten the shit out of me in the elevator, had just about put me on the ground, even though I was trying to save his fucking life! What a fucking shitfuck, fuck, I did save his life, we all saved his life, right the fuck after he beat the shit out of me! Fuck, my arms and my back and my sides and my legs all hurt like fury, I was actually hurting right now, and instead of eating pad thai and watching cartoons I was standing in a parking garage worrying and hoping I didn’t get in trouble at work and, and having feelings, all because that dickblister of a shitty human being beat me up! And the fucking pulm, I was going to strangle him, and god, when I saw that psych doc next I was going to--

And I got on the elevator without skipping a beat, and I went home.

________

Lucita, the woman with the swollen leg and the cancer that had rearranged her downstairs, finally chose comfort care and died in her sleep, high as balls, pain-free.

Jelena remains on the medical-surgical floor where she's been this whole time. She is beginning, against all odds, to recover some function, and has recently been able to say a few words in her own language and perform coarse voluntary motor movements. She has some contracture in her hands, but overall her prognosis looks better than we could ever have imagined.

Maycee, my preceptee, has preceptees of her own now. I am an ICU grandmother. It feels pretty good. 

The bruises from the elevator were all gone within two weeks.