patient stories, pop culture, spirituality

The Need for Poetry

Margins of my high school senior English notebook are covered in beloved teacher Father Gordon Gilsdorf’s studied one-liners. Some were jokes about how his classroom was not “Gordy’s diner” or how we seniors should not be lemmings and all jump off the school’s roof after our first thesis paper. Others were serious and wise.

His one-liner that I think about frequently in my career as a nurse is, “The world does not need more doctors. It needs more doctors that understand poetry.”

Fr. Gilsdorf told us this as senioritis kicked in, and we all began slacking off as our poetry unit began. A high school senior in a college-level English course accepted to multiple highly ranked colleges around the region, I balked. I needed English class like I needed Spanish classes in college. I took them for a good grade, for credit, for a warm deviance from the cold, hard facts of my science coursework. After hours of staring at stained slides of bacteria cell walls, studying chemical reactions, or memorizing psychologic loops, Don Quixote was a much needed mental anomaly.

Such was the case with Gilsdorf’s class for me. Oedipus Rex was a pleasant deviance from college applications. Daisy Miller was a welcome distraction from choosing between colleges. Even my final research paper was a happy divergence from the stress of deciding my future.

But even then, my science-minded brain took over.  I wrote 14 pages on the proposed physiological theories of how crucifixion killed its victims. Most people wrote 10 pages with adjusted margins and a slightly larger font size on the history of the sonnet or something equally boring. Clearly, I earned my “Senior Who Wouldn’t Slide” superlative.

Yet, as the repetition of graduate school has settled in, as my work has become increasingly rote and automatic, I find myself once again craving something more, something different, something more humane than the cold, hard facts of science. I find myself craving the humanity of literature.

In summer of 2015, I walked through a thrift store’s book section, and my eyes caught sight of a very thick book. Norton Anthology of Poetry, I thought with a smile. Norton served as our 2nd semester textbook where we studied the English sonnets of Shakespeare to Donne’s The Holy Sonnets teeming with hidden sexual innuendoes. My memories of Norton, just like high school senior English class, are mostly fond.

I picked up of the book and almost laughed as I saw the cover. It was a painting of Don Quixote. I smiled as I thought of my upper level Spanish literature classes in college and how much they reminded me of my senior English class. This Norton was a different anthology than my beloved Norton. Instead of poetry, it was the 5th edition of World Masterpieces. Yet, no matter how many times I picked it up and put it down, I couldn’t leave without it. $3 seemed like a small price to pay for nostalgia anyway.

Like my old Norton, my 5th edition Norton Anthology of World Masterpieces sat in the same spot and collected dust. I read shorter books on my bookshelf, but after a particularly difficult couple weeks at work, I cracked it open. I was pleasantly surprised to find Leo Tolstoy’s classic novella, The Death of Ivan Ilyich.

The Death of Ivan Ilyich recounts the carefree life of St. Peterburg lawyer Ivan Ilyich who dies at 45 years old. The story opens at his funeral and then tells the story of his life. Ivan Ilyich lived a normal life, seeking to build his career, his social circle, and his home with prized possessions. One day, he falls off a step ladder, and the pain never leaves. It grows, nagging at him, torturing him, and no one can explain it. His wife, daughter, friends, even doctors do not treat Ilyich as he wishes. They treat his disease, not his fears. They offer false hope as Ilyich knows he is dying.

As Tolstoy wrote:

“What tormented Ivan Ilyich most was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and he only need keep quiet and undergo a treatment and then something very good would result.”

– Leo Tolstoy, The Death of Ivan Ilyich

I had first heard of Tolstoy’s short story while reading another book, Being Mortal, by Atul Gawande. Gawande, MD, MPH, is a general and endocrine surgeon at Brigham and Women’s Hospital, Professor in the Department of Health Policy and Management at Harvard, Professor of Surgery at Harvard Medical School, and a public health researcher (and Executive Director) at Ariadne Labs. In his ample spare time after saving lives and raising 3 children, he writes. He started writing as a junior surgical resident and has written several books on modern medicine. His most recent book, Being Mortal, explores death and dying in the United States, written after Gawande experienced the death of his own father who died after battling cancer.

I again heard of Tolstoy’s novella while reading When Breath Becomes Air, the Pulitzer Prize winning memoir of a neurosurgery resident named Paul Kalanithi who was diagnosed with lung cancer in his final year of residency and discusses his newfound understanding of mortality. A former English major, Kalanithi writes:

Lost in a featureless wasteland of my own mortality, and finding no traction in the reams of scientific studies, intercellular molecular pathways, and endless curves of survival statistics, I began reading literature again: Solzhenitsyn’s Cancer Ward, B. S. Johnson’s The Unfortunates, Tolstoy’s Ivan Ilyich, Nagel’s Mind and Cosmos, Woolf, Kafka, Montaigne, Frost, Greville, memoirs of cancer patients—anything by anyone who had ever written about mortality. I was searching for a vocabulary with which to make sense of death…

– Paul Kalanithi, When Breath Becomes Air

(And I could not escape an author’s thoughts about mortality once again as I read the lighthearted autobiographical journey to faith Something other than God: How I Passionately Sought Happiness and Accidentally Found It by Jennifer Fulwiler last month. It’s like this discussion of mortality is following me or something.)

In the opening lines of the introduction Being Mortal, Gawande discusses Ivan Ilyich, the titular character of Tolstoy’s The Death of Ivan Ilyich as he explains his journey to try to make sense of death. Gawande read the story for a seminar on the doctor-patient relationship at Havard’s medical school. Gawande recounts the hour discussing the novella to be the only time in his years of medical training discussing mortality. As Gawande writes,

“As we medical student saw it, the failure of those around Ivan Ilyich to offer comfort or to acknowledge what is happening to him was a failure of character and culture. The late-nineteenth-century Russia of Tolstoy’s story seemed harsh and most primitive to us. Just as we believed that modern medicine could probably have cured Ivan Ilyich of whatever disease he had, so too we took for granted that honest and kindness were basic responsibilities of a modern doctor. We were confident that in such a situation we would act compassionately.”

– Atul Gawande, Being Mortal

Part of me is searching literature desperately for some way of understanding death. Ever since my friends’ child was diagnosed with mitochondrial depletion syndrome, I’ve been searching for something to help me understand this sweet child’s unfair early death and overall human mortality.

But nothing has quite answered the question for me.

Even my beloved Henri Nouwen’s answer in Our Greatest Gift: A Meditation on Dying and Caring left me with unsettled questions of: but why him? But why so early? But why my friends? But why this? Why do any of us need to go through this?

I still need to read Nouwen’s last book before his death, Can You Drink the Cup? Maybe that’ll clear it up…Too, I’m reading Peter Kreeft’s Love is Stronger than Death which my friend says is one of the most incredible books he’s read… But I don’t think my unsettled questions about death with be solved in a book.

I think mortality is something we need to live, not something we try to understand intellectually.

As a nursing student, I cannot recall honestly discussing mortality, aside from one lecture in my geriatrics class discussing the signs and symptoms of active dying. So, too, as a nursing student, I recall naively thinking death could be prevented  or it would be painless.

But my experience has taught me it is anything but.

It took me years to realize my first DNR patient Frank had a “good death” in this hospital. He was not in pain. His wife was at his side. No one forcefully tried to pump life back into his broken body. Eventually, I could live with his death.

But some patient’s death I cannot live with.

Seeing the page broke my heart before seeing my patient’s face ever did. “96 yo M, ROSC, 103/65, 60, 16, ETCO2 low, intubated.” Emergency medical services was alerting my Emergency Department that they were bringing in an elderly man who survived CPR.

I was assigned to the trauma room that day. Our trauma room was a 4-bed section of the ED, a room where beds were only separated by curtains and the most emergent of medical emergencies from victims of severe car accidents, gunshot wounds, and motorcycle accidents to pulseless persons or patients who needed medical assistance to breathe were brought in. I liked being assigned there. I flourished under pressure and found an odd delight in resuscitating a good trauma, stabilizing a good bleed, or even seeing a good page.

John was not that page.

I finished assisting my co-worker in the arena and walked over to trauma. Bed A was already full of staff: my fellow trauma nurses, a respiratory therapist, a social worker, an ED technician and her orientee, a pharmacist and her intern, an attending and his resident. The resident was one day away from finishing her residency, and she was calmly reviewing his pre-hospital EKG as we waited for EMS to roll in. I took up my station to scribe, jokingly kicking the attending off my computer.

Minutes later, we heard the tell-tell wheels rolling down the hallway from the ambulance bay to the trauma room. John arrived intubated and comatose. As my co-workers furiously began getting him on the monitor, checking and starting IV lines, verifying ETT placement, and otherwise settling the patient, we were told the rest of the story.

John lived in the independent living portion of a skilled nursing facility. He had woken up, gotten dressed, and walked with his cane to breakfast. At breakfast, he suddenly became unresponsive, and when staff checked for a pulse, they found none. John was a known DNR, had paperwork on file at the facility and at his primary care doctor’s office, and was known to always wear his bracelet.

Emergency Medical Services (EMS) was called. Why they were called was unclear, but someone fatefully dialed 9-1-1.

When EMS arrived, John did not have a DNR bracelet on. His paperwork could not be found. Per protocol, EMS started cardiopulmonary resuscitation (CPR). After 5 rounds of epinephrine and 18 minutes of chest compressions, ROSC (return of spontaneous circulation) was achieved.

“Positive femoral pulse,” the resident called out. That pulse was still present for us.

Despite the flurry of activity around him, John was not moving. Not even as the resident dug into the middle of his chest with her knuckles for a sternal rub to wake him up. “Did you give any meds?” the attending asked.

“Just the epi,” the paramedic replied.

I grimaced internally. Not moving despite a foreign endotracheal tube (ETT) in the throat, sticks in the arms for IVs, and other painful stimuli was not a good sign. When the brain goes without its vital blood supply, every second contributes to anoxic brain injury, the term for the brain damage from lack of oxygen (hypoxia). It was obvious to all of us that John had suffered a massive anoxic brain injury. It was also obvious to us that John would not survive his hospital stay.

“How long between him going down and CPR getting started?” I asked.

The paramedic shrugged. “Less than 5 minutes, I think. We got there pretty fast.”

I signed my name that I had received his report, trying to smile at the firefighter despite completely disagreeing with his decision to administer CPR. I knew it probably bothered him too. EMS is required by law to administer CPR.

“18 gauge, right AC” my fellow nurse called out.

“Unable to get an axillary temperature,” called out his preceptor.

Poor John, I thought as I typed the flurry of activity before my eyes. John knew he was going to die someday, and he was dying in the way he never wanted: with everything possible.

The social worker called out from the corner, “I’ve got his daughter on the phone.” John was obviously acutely sick, but for the moment, he was stable. The resident left his bedside to talk with her on the phone. She explained the story as best she could before asking the words no one wants to hear and the decision no one wants to make, “if his heart stops again, do you want us to attempt to re-start it?”

His daughter did not want us to do CPR again. We hung medications, hung fluids, monitored his oxygen levels, stuck a needle in his wrist for an arterial blood gas (ABG), put a tube in his urethra (Foley). The social worker came by again, announcing the son was here. The resident said to bring him in.

As the social worker left to get John’s son, I furiously double checked the bedside to hide as many tubes as possible. The ED tech flurried about his bedside too, cleaning up any signs of blood and trauma.

His son Peter was shaken when he arrived. I talked him through the most important lines and tubes that were on him. “I’m just not used to seeing him like this,” he said. His facial expression was a horrific blend of absolute fear, worry, brokenness, and disgust.  It was burned into my head and brought me to tears on my ride home.

John quickly received a bed in the medical ICU, and I gave his son instructions on getting to the family center, a waiting area for all family members of ICU patients. My co-worker whisked John upstairs after I called report. I felt a heavy sense of pain and emptiness as I cleaned up the mess we made an re-stocked supplies. Surely he deserved better, I thought.

But really, what do we deserve when it comes to death? What do we deserve when it comes to life? Do we deserve anything or is our attitude that life owes us something preciously the attitude that causes us so much anguish?

As Henry David Thoreau famously wrote: “Most men lead lives of quiet desperation and go to the grave with the song still in them.”

What are we desperate for? Why is death a cause of so much anguish? If I really lived every day well and trust that God can create good out of anything, would I be so tormented by death? What is it that we demand of life that makes what we are given seem so unfair?

Fr. Gilsdorf was over 80 when he taught me. I remember my sister having him and loving him, and I prayed desperately that he would be well long enough for me to learn from him. I did, but my brother’s year, he suffered a massive stroke during class. He had long-term weakness and memory loss after recovering from his hospital stay. He could never return to the classroom he loved, but instead moved into a nursing home for elderly religious.

My mother told me where he was staying, and one trip back to my hometown, I visited him. I held back tears all the way in and could not hold them in any longer when I saw his sweet face. It pained me to see such a physically and mentally able man who I deeply admired chained to a wheelchair and weak.

Fr. Gilsdorf asked me why I was crying as he put in hand in mine. I said it was just so good to see him, because despite the pain, it truly was. I was so used to my weak patients getting sicker, even in my limited nursing experience.  Though he was not able to return to his previous work, he was quite well. We talked literature, and even when discussing James Joyce’s Dubliners. I had a trip coming up in Ireland, so Joyce and Dublin was naturally brought up.

Fr. Gilsdorf seemed unsatisfied with Joyce’s his conceptions of death and loss. He voiced dissatisfaction with any of the conceptions of death and loss he once taught during our conversation. He was even unsatisfied with his own poems when I showed him a book of poems he once published that I had won in class. But his memory would fade after a moment of clarity. We’d return to the same stories again and again. It pained me that he re-told the same story about my classmate’s younger brother, the last thing he remembered before his stroke, before his life changed.

As I promised, I came back after my trip. Something about him seemed unhappy and unsettled, and though I had no idea how little 22-year-old me was going to help, I felt a need to return. Too, I had bought him a little angel ornament in Ireland that I wanted to give him.

But Fr. Gilsdorf was not in his room.

I walked around the facility and found him sitting in his wheelchair in the chapel. I had inadvertently come during Mass. He was sitting in the front row, hands folded, in clear view of the simple cross as a priest said Mass. Something about his posture was different. His shoulder were relaxed, not tense as they were. He face was had a sense of tranquility about it. He was at peace at the foot of the cross.

He had once said in another famous one-liner, “We are born in another’s pain and die in our own.” But seeing him at peace, sitting in his wheelchair at the foot of the cross, I saw he was not in pain. I saw he was with Christ, the only Person who could really share in his pain and suffer with him. I smiled softly, returned to his room to write a small note, and left.

Despite my intentions to do so, I never returned to visit him. Fr. Gilsdorf died about two years later. I was living in California when he died and was not able to go to the funeral. Many of my friends and classmates grieved the loss. They shared memories of this sweet man and expressed their regret never seeing him after graduation, . I too grieved. Yet even though I never made it back to see him, I knew he was taken care of. I knew he was at peace at the foot of the cross.

Maybe we lead lives of quiet desperation because we think we are alone in our desperate hour. Maybe we are tormented by the lies that we need to keep quiet because we crave to express our pains to Someone. Maybe we think our simple and ordinary lives are terrible because if we had allowed ourselves to really dive into our human mortality we would find the cross but instead we’ve run from it.

My questions surrounding mortality will not likely be answered this side of heaven. Stories like  The Death of Ivan Ilyich remind me of the humanity of my patients, that their questions about test results are a scratch on the surface of their questions about God, life, death, and human mortality. But people like Fr. Gordon Gilsdorf have taught me that God is with us, even when we feel tormented and alone, and in Him alone will we find the inner peace we seek.

Thank you, Fr. Gilsdorf, for your holy example. You’ve taught this nurse the importance of literature, and I hope I’m the kind of provider who understands poetry as you once said. But even if I’m not there yet, I know I’m getting there in part because of you. Thank you, for your wisdom, your example, and your courage in showing me your suffering.

Forgive me, body before me, for this. Forgive me for my bumbling hands, unschooled in how to touch: I meant to understand what fever was, not love. Forgive me for my stare, but when I look at you, I see myself laid bare. Forgive me, body, for what seems like calculation when I take a breath before I cut you with my knife, because the cancer has to be removed. Forgive me for not telling you, but I’m no poet. Please forgive me, please. Forgive my gloves, my callous greeting, my unease— you must not realize I just met death again. Forgive me if I say he looked impatient. Please, forgive me my despair, which once seemed more like recompense. Forgive my greed, forgive me for not having more to give you than this bitter pill. Forgive: for this apology, too late, for those like me whose crimes might seem innocuous and yet whose cruelty was obvious. Forgive us for these sins. Forgive me, please, for my confusing heart that sounds so much like yours. Forgive me for the night, when I sleep too, beside you under the same moon. Forgive me for my dreams, for my rough knees, for giving up too soon. Forgive me, please, for losing you, unable to forgive.

Morbidity and Mortality Rounds by Rafael Campo

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