Chapter 1 Listening to Trauma

from The Comfort Garden: Tales from the Trauma Unit by Laurie Barkin

The names of all patients and their family members have been changed.

© Copyright Laurie Barkin. All rights reserved.

ISBN 13: 978-0-9844965-4-9

First Edition, February 2011

 

Chapter 1 Listening to trauma

“They are dressed in bright orange jumpsuits. Seven prisoners — four African-American and two Latino men, and one very pregnant African-American woman, all handcuffed and shackled to­­gether at the ankle — shuffling through the entrance to the hospital emergency room. Three sheriff’s deputies — two white, one Filipino — joke with the prisoners while herding them through the doors, past the ER waiting area, and down the hallway toward the back of the hospital. The sight of seven people, mostly black, handcuffed, and shackled together, raises my hackles. I keep expecting to see German Shepherds and billy clubs as if it were the sixties in Birmingham and not the nineties in San Francisco. Each clink of chain rattles in my ears. Seventeen years ago, I worked on a surgical intensive care unit where inmates from the local prison were chained to their beds. I never got used to that either.

Upon my arrival to 4D, the surgical unit where I have been assigned, a loud male voice blasts, “Don’t touch me! Get the fuck out of my face!”

4D, also called The Trauma Unit, pulses with adrenaline. Nurses dash from doorway to doorway as flocks of medical residents and their students swoop through the halls, poking in and out of patients’ rooms. Lab techs dart around them, grabbing opportunities to draw blood. No one looks particularly concerned.

Don’t screaming patients warrant attention around here? At Presbyterian, the hospital where I used to work, security would have been paged the moment someone raised a voice, let alone hurled obscenities at a caregiver.

Another blast from the agitated patient: “I said get the fuck out of my face!”

This time the voice sounds more panicky than angry. I’m halfway down the hall looking for the source of trouble when Trudy, the day-shift charge nurse, intercepts me.

“He’s OK for now,” she says before ducking into the head nurse’s office.

Just ahead, a transport aide from the recovery room angles an empty gurney out of a patient’s room. He pushes it past four rooms to the double doors at the entrance to 4D and slams the gurney through metal doors where it crashes into a portable X-ray machine that a tech is pushing into 4D.

“What the hell?” he sputters.

Trudy emerges from the head nurse’s office to help the transporter and the X-ray tech do-si-do through the doors. On her way back to the nurses’ station, Trudy stops when another scream pierces the din.

“Owwwww! Sonofabitch! Leave me the fuck alone!”

“Uh oh,” mutters Trudy. “Here we go again.” She looks my way and says, “It’s the IVDU in 14-1.”

In nurse-speak she is telling me the troubled patient is an intravenous drug user (IVDU) in room 14, bed 1.

As the new psych nurse consultant, I should be doing something to help but I’m not sure what. While I hesitate, Victoria, the trauma unit’s humorless head nurse, opens the door to her tiny cubicle, a former janitor’s closet that is opposite the nurses’ station. She makes eye contact with Trudy and shakes her head. With hands on considerable hips and jaw jutting below thin lips, Victoria strides through the ward where she has reigned for eighteen years. Trudy, a head shorter, older but energetic, quickens her pace to keep up. A few minutes later Trudy returns to the nurses’ station and puts her arm around me, saying, “This is why we need you psych nurses! Give James time to calm down before you check in with him. This was not his fault.”

Victoria marches into the nurses’ station shortly after Trudy and waits until a tall blond surgical resident accompanied by a Chinese-American medical student reach the Formica counter that frames two sides of the nurses’ station. The two stop and talk, seemingly oblivious to Victoria’s relentless gaze.

“So what just happened there?” Victoria demands.

The surgical resident scratches his forehead as if newly bitten by a mosquito.

Victoria raises her voice slightly. “I am speaking to you, Dr. Murdock. I want to know what set that patient off.”

Dr. Murdock’s jaw muscles bulge. Without making eye contact, he replies in over-articulated speech, “The dressing was dry, so, in removing the old packing some of the healthy tissue must have been pulled out as well. Sometimes it’s unavoidable.”

“Hell it is,” Victoria growls.

“What did you say?” This time the resident makes direct eye contact.

“You heard me.” Victoria locks her eyes with his and doesn’t let go. “That kind of pain is totally avoidable. My nurses give their patients pain medication before taking down dressings. If the packing is dry, they soak it in saline so they can remove it easily without ripping out healthy tissue. That’s why you don’t hear patients screaming when the nurses remove the packing.”

“We did it the way we’ve always done it,” counters the resident.

“Here, you mean,” says Victoria. “I bet you don’t do it that way to the private patients at University Hospital, do you? Let me be clear, Dr. Murdock. When a patient, any patient, tells you to stop, it means you do not have consent to continue. Do you read me?”

“You’re out of line,” retorts the resident straightening his body. “I’ll be discussing this with Dr. Steinfeldt.”

He opens the patient’s chart, scribbles a note, slams it shut, and exits the ward.

Victoria rolls her eyes. “I get so tired of these baby doctors,” she says to no one in particular before heading back to her office.

I pick up the chart that the resident left on the counter and turn to the last entry. His note reads, “Patient uncooperative with care.”

A hand lightly squeezes my shoulder. “Now that you’re off hospital orientation, are you ready to start seeing patients?”

Everything about Janice is soft. Her creamy voice, her honey-colored hair, her luminous smile, and her round body all remind me of being curled up in an overstuffed chair, drinking hot-spiced cider next to a fire and talking with an old friend.

“I am, but I have to confess I’m a little nervous. I haven’t worked at the bedside with medical-surgical patients since graduate school and that was ten years ago.”

“Should we interview a patient together?”

“Sure.”

I look at my list and choose a young paraplegic woman hospitalized for treatment of a urinary tract infection and a pressure ulcer on her buttocks, both common complications of paraplegia. According to her chart, Shalimar Banks became paraplegic after she was stabbed in 1983. The nurses say she’s been withdrawn and tearful for the last two days.

Janice and I scan her chart. Then Janice shows me the filing cabinet where old charts are kept. Five thick volumes of Shalimar’s old charts dominate the drawer. “I know it’s a good idea to begin a consultation by reading the old chart, but that will take more time than we have. Let’s see her first.”

The patient rooms at SFGH differ little from most I’ve seen. All of them look monotonous. Paint, porcelain, laminate, and linoleum span the color spectrum from ivory to ash gray. The dull blue of both the bed curtain and the patient’s standard gown offer the room’s only hint of color.

Shalimar lies on her left side facing cartoons on TV. Long ringlets of thick black hair cascade down her shoulders. Over-tweezed eyebrows sit high above a wide but tiny nose and full, Kewpie-doll lips. Shalimar is a mixture of Caucasian, African-American, and Filipino.

“Hi, Ms. Banks,” says Janice, extending her hand to Shalimar. “Laurie and I are mental health nurses who talk to patients on the medical and surgical units. Your nurses asked us to check in with you because they’re concerned about your mood. How have you been feeling?”

Shalimar switches the TV off and turns her head toward us. “Not so good,” she replies while gesturing toward the dull-gray plastic chair in the corner of the room. Janice moves it closer to the bed while I pull a chair from the corridor.

“My butt keeps breaking down because MediCal won’t pay for a KinnAir bed in my hotel room.”

“What’s a KinnAir bed?” I ask.

Janice motions Shalimar to explain.

“A bed that’s made to shift air around in the mattress so people like me don’t get pressure sores. They say it’s too expensive — but then they pay to hospitalize me when my skin breaks down. Does that make any sense?”

Shalimar reaches for a tissue and wipes her eyes.

“None whatsoever,” Janice replies. “That sounds so frustrating. I can’t do much about MediCal but maybe I can help you improve your mood. Have you been crying a lot lately?”

Shalimar nods. Janice asks her questions that comprise the standard depression inventory, suicide assessment, and mental status exam. Does she have any problems sleeping or eating? Does she sometimes think that life is not worth living? Does she hear voices telling her to hurt herself or others? Seamlessly, Janice weaves the questions into the conversation. A picture of chronic, untreated depression begins to emerge. Shalimar often thinks about suicide but has no active plan to carry it out. Janice zeros in on the trauma that severed her life into before and after.

“May I ask about your injury?”

“It’s OK. It happened nine years ago.”

She looks out the window and launches into her story. “I grew up in the valley. When I was eleven, I ran away to the city with my friend. She was thirteen. She said she knew someone there we could stay with. Prince seemed OK at first. He gave us some weed, took care of us. Then he shot us with dope. It felt so good at first. Like the best hug you could have. I would say to him, ‘Where’s my hug, honey?’”

My mind struggles to comprehend Shalimar’s story. I force my breath deep into my lungs and grip the seat of my chair. I need to be able to listen to the rest of it.

Shalimar runs her fingers through her long hair. “Then Prince made us be with older guys. By that time, we were hooked. You know. We give him money; he gives us hugs. No money, no hugs. It went on like that until I was sixteen.”

Five years! Where were her parents? Were the authorities notified? Did anyone notice this child was missing?

“Then, I met a really nice guy who asked me to marry him. When I told Prince I was leaving to marry this guy, he said I couldn’t, that I belonged to him. When I turned to go, he stabbed me in the back.”

While I struggle to push down the jagged-edged outrage rising in my throat, Janice continues the interview, her voice steady and smooth.

“That’s a lot to cope with,” says Janice. “But right now I want to focus on the present. Have you been having difficulty sleeping?”

Shalimar whispers, “I’m afraid to sleep. Sometimes I have the worst nightmares.”

“How about during the day?” asks Janice. “How would you describe your general mood?

Shalimar curls a long strand of hair around her finger. “Most of the time I’m real bitchy because I’m not sleeping. And, I’m still afraid to go out. They never got him, you know, so I’m always looking over my shoulder thinking I see the flash of a knife.”

Shalimar shudders and claps her hand over her mouth. She grabs another hunk of hair and winds it tightly around her fist. “Sometimes I see someone who looks like him and I start to feel like I’m having a heart attack, you know? I can’t breathe and I feel like I’m going to faint. It’s real freaky, so I just try to stay in most of the time.”

“It sounds like it’s been a living hell for you,” says Janice. “Do you have any family or close friends you can count on for help?”

Shalimar shakes her head. “No, not really. I’m pretty much alone.”

The sound of clanking metal outside Shalimar’s room startles us. The porter has arrived to transport her to the radiation department.

Janice tells Shalimar she will see her again tomorrow. In the meantime, she will ask a psychiatrist to consider prescribing an antidepressant to improve her mood. We return to our office on the seventh floor. Antionette looks up from a journal as we fall into our chairs.

“Whew,” says Janice. “That was rough. I haven’t heard a story like that for a while. How are you doing, Laurie?”

“I felt like I was going to lose it. How did you stay so calm and controlled?”

“I felt the same as you,” Janice says. “I guess I’ve learned to fake it pretty well. Fooled you, I see!”

Antionette swivels around to face us. She is dressed in an elegant wool suit, stockings, and stylish shoes. We’re both in our late thirties but that’s as far as our similarities go. Antionette is an African-American from Savannah, sleek and stunning as a model, single, and a major in the California Army National Guard. She is as controlled and private as I am spontaneous and open. She can’t hide her love for clothes shopping. If I had Antionette’s body, I might enjoy it too.

We met several years ago when we both attended regular meetings of Bay Area psych nurse consultants who, like us, work on medical/surgical units rather than psychiatric units. There were only fifteen of us working in Bay Area hospitals then. After hospital mergers and reorganizations, we are even fewer today.

Antionette looks stricken after we tell her Shalimar’s story. “Prostituting at eleven? That poor child. No wonder you two look ragged.” Antionette shakes her head and sighs. “Whenever I hear a story like that I say to myself, ‘There but for the grace of God go I.’”

Janice smiles at Antionette and points a finger at me. “I think exactly the same thing. Take good care of yourself, Laurie. I know you’ve been a nurse for a long time but listening to some of our patients’ stories can suck the life out of you.”

“I’ll be OK,” I say, a little too quickly.

To get my hospital ID, I walk across campus to an old brick building, which used to be part of the original hospital and now houses the Department of Human Resources. Outside, San Fran-

cisco’s famous summer fog has lifted its veil to reveal a sky of startling blue. A soft glow of light warms my face. We’ve been enveloped in fog for days and it’s no wonder that all of us who have just stepped outside are lifting our faces for a smooch of sunshine.

After I leave Human Resources with my laminated ID, I exit the wrong way and find myself facing a garden wall covered in psychedelic orange flowers. I walk through the entrance to the garden and catch my breath. Across from me, in front of an old red brick building that houses the HIV and methadone clinics, stands an enormous Atlas cedar. Its lowermost branch sweeps the ground like the arm of a ballerina bowing at the end of her performance — bent at the elbow and curling softly up at the wrist. To my left, a twenty-foot wide swath of garden sweeps downhill a hundred fifty feet or so until it reaches the busy city street bordering the hospital campus. Five mature Monterey pines line the length of garden like colossal warriors ready to defend the young and innocent plants that lie at their feet. I recognize many of them — roses, camellias, princess plant, hebe, and dahlias — but there are many more I can’t identify and some I’ve never seen before. If Shalimar’s story knocked the wind out of me, this garden — enthusiastic and bursting with life — revives me.

Since the few benches in the middle of this mass of flora are occupied, I stroll the length of the garden. Half way, a wooden post with a brass placard rises from a circle of pink geraniums and blue forget-me-nots. The placard reads, “The Comfort Garden: This garden was created in June 1990 as a living memorial to those employees of SFGH who have died. It is meant to be a place of solace where nature’s beauty can bring you comfort.” The garden is only two years old.

“What do you think about the garden?” asks a compact, sandy-haired man about my age. His cheeks are sunburned and he’s leaning on a shovel.

“I’m in awe especially of the pines and the cedar. That’s what’s missing in my garden — a big tree for my kids to climb. How old are these?”

“Oh, probably sixty or seventy years. If you plant a sapling now your kids could climb it in about ten years.”

His name is Antoine and he has been a gardener at SFGH for twelve years. “I have the best job in the city,” he says. “I’m outside all day; I can ride my bicycle to work and wear shorts most of the year. For me, it doesn’t get better than that.”

Antoine wipes his brow and checks his watch. “Gotta run, but I’ll see you around.”

A young couple, previously entwined on one of the benches, pulls apart and walks toward the clinics. I sit down on the vacated bench and watch the people walking by. They are a mix of body types, colors, and ages. Some move with determination; others seem lost in their thoughts. A young mother drags her unhappy two-year-old son. An emaciated young man, perhaps with AIDS, inches along with a walker. A much older man with a cane passes him by.

Until now, I wasn’t aware of the tension in my body. But thinking about the morning, it’s understandable. First, it was seeing people, mostly black people, in shackles. Then as if a rock were thrown through a window, my usual calm was shattered by the knowledge of the violence done to Shalimar. I feel a murderous rage toward her pimp.

How many others has he terrorized? Is he still walking free among us? No wonder Shalimar can’t sleep at night. I’m not so sure I’m going to be able to sleep tonight.

While massaging the muscles in the back of my neck, I muse about how I’ve come full circle. Just out of school, I began my nursing career on a surgical, intensive care unit at a county hospital much like SFGH. It was in Phoenix that I learned how to be a “real nurse” — one who could maneuver a butterfly catheter into the scarred veins of a junkie, one who could slip a nasal gastric tube into the esophagus instead of the trachea, one who could suction thick phlegm from a tracheostomy without gagging.

In Arizona, my first ICU patient was a husky, twenty-four-year-old Latino male with a head injury. Tubes penetrated his nose, mouth, arms, and penis — draining, ventilating, and hydrating a body that offered no resistance. Pointing to his nearly flat EEG, Betty, the nurse assigned to orient me, declared him a good patient on whom to practice invasive procedures. She showed me how to insert a Foley catheter through his penis and into his bladder and how to inflate the balloon that kept it from sliding out. She watched my technique as I pierced his impressive veins with twenty-gauge needles and connected them to intravenous solutions. Throughout the lesson, she called my attention to such things as the color of his urine, the condition of the skin under the thick adhesive tape anchoring the catheter to his thigh, and the spongy puffiness of the area around an infiltrated I.V., one that is no longer positioned in the vein.

To her credit, Betty never told me that the patient had been hit over the head with a metal pipe by a man who had witnessed him raping a young woman in an alley near Arizona State University. I learned that later from a newspaper article.

After a few months of close supervision on the day shift, I was moved to the night shift where I became the low person in the unit hierarchy. While day-shift workers thrived on precision teamwork at a fast pace, night shift attracted a less gregarious and more independent worker.

I never quite got the polyrhythm of life on the night shift. Beginning with a 7 p.m. wake up call, I struggled to adjust. After eating “breakfast” in the evening, I could catch the first set at the El Bandito jazz club and still manage to arrive on the unit by eleven p.m. Fresh from the soothing swish of brushes on the snare drum and long, sonorous, saxophone solos, I entered a world of hissing ventilators and angry alarms in the ICU.

County Hospital was the area’s trauma center. Many of our patients arrived after being stabbed, shot, beaten, or mashed in car accidents. One night, the recovery room nurse called to let us know we would be receiving a young man who had barely survived a motorcycle accident. Watching us settle the patient in, the surgical resident shook his head and worked his jaw.

“We shouldn’t have saved him,” he said in a monotone.

I’ve forgotten the patient’s name but can still see his eyes and droopy eyelids. The unfocused daze of Post-Op Day One gave way to a look of utter bewilderment, then fear as his clouded consciousness cleared. Each of us oriented the patient to his surroundings: “You’ve had an accident. You are in the hospital. It’s Friday, September 19, 1975. You can’t talk because there’s a tube in your mouth to help you breathe.”

I remember how his eyes darted, desperate to find something familiar, something comprehensible, something acceptable.

It happened sometime before night shift on Post-Op Day Three. His gaze turned hard as a drill bit, boring into the faces of the doctors and nurses who gathered around his bedside speaking over him in the language of laboratory values and neurological signs. When they left, his eyes blazed with anger, the anger of a man who has just realized he would never again be able to move or even breathe on his own.

I averted his stare. I was twenty-one years old and without a clue as to what to say to the first quadriplegic I had ever met. I felt overwhelmed just trying to figure out how to turn him and his tubes safely on the Stryker frame, a bed that allowed us to invert him quickly onto his stomach in order to relieve pressure on his backside.

The patient’s care became routine after a few more shifts and I relaxed enough to feel his eyes following me. When he had been turned and suctioned and his blood work drawn and sent to the lab, I sat down and forced myself to acknowledge the person inhabiting the body.

He regarded me without expression. He did not glare, implore, or narrow his eyes. Nor did he look away. His face was rough and ruddy, wide with high cheekbones, a fleshy nose, and full lower lip. Wisps of chestnut hair hung past his shoulders. Feeling unveiled and inept, I looked down. Wasn’t there another nursing task I needed to do for him? Shouldn’t I offer to help one of the other nurses with her patients? When our eyes again met like headlights approaching each other too close and too fast, I panicked. To avoid a collision, I imagined reversing direction and driving parallel to him, looking out on the same terrain. Then, after calming myself, I jumped into the seat along side him.

“You must feel lonely,” I began. “Everything must be so strange for you. I’ve only been working as an RN for a few months and this place still freaks me out sometimes.”

I chuckled before I could censor myself. “Oh, God, I’m so sorry. I didn’t mean to laugh. I’m just kind of nervous right now.”

Idiot! This is about the patient’s feelings, not yours. Try again.

“I guess you’re probably having a lot of feelings about what’s happened to you. It must be horrible not being able to talk about it. It’s just not fair. This shouldn’t happen to anyone.”

Finally, I just said it: “I’m so sorry this happened to you.”

I don’t know who started to cry first. It was an awful moment for us both. I reached for the tissue box and started to hand it to him before realizing I had salted his wound again. Jesus, he can’t even wipe his own nose. I watched frustration foam out of every pore as I did it for him.

Returning to the present but with my head still full of memories, I walk past the Atlas cedar on my way back to the main hospital. A part of me would love to climb that majestic tree, to be above the world, oblivious to the pain of others. But, I’ve never been able to stay in a place like that, alone and unengaged with the world.

At the entrance to the trauma unit, Janice’s warning echoes in my mind. “Take good care of yourself, Laurie. Our patients’ stories can suck the life out of you.”

Being out of practice, I can now imagine how listening to stories like Shalimar’s, day after day can warp a person’s view of the world. But, as an experienced psych nurse who has heard lots of horrible stories, I know I will soon recover my ability to focus on the things I can do to help my patients instead of being dragged down by their tragedies. I will revive my skills of listening to their traumas with my head and my heart in equal measure — at the same time analytic and empathic. Symmetry doesn’t always come easily but surviving this job will depend on finding and maintaining that balance.

 

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