CHOICES| David Howard


I met RN Jennie last fall in the Emergency Department Meds Room. I’d chat with her while I stocked catheters and flushes or got sandwiches and juice for patients. Jennie would prepare IV fluids or pull up meds from the PYXIS dispensing machine – dilaudid, zofran, cipro.

Mostly we talked about her son Chris who was graduating high school and making college plans. He’s Jennie’s only child and a terrific student. She’s been ambivalent about Chris leaving home, but by springtime the family is celebrating. Chris has been accepted to a prestigious university.

My daughter Ana, on the other hand, is a heroin addict.  She never applied to college because during her senior year in high school she was using meth and hearing a steady stream of punitive voices in her head. She cut herself a lot that year, but the psychiatrist said he wasn’t very worried about suicide. My wife and I worried plenty. I joined Al-Anon and learned that worrying is not a virtue.

I cannot imagine what it would be like to be proud of Ana’s academic or career accomplishments. I get by on being proud she has survived. Several of her friends didn’t. One, Tommy, with whom she shared a campsite at the River Bottom, was murdered and dismembered. Everyone knew who killed him, but no one would snitch. The police never made an arrest.

Al-Anon taught me to focus on gratitude. I’m grateful that Ana is my daughter and that we love each other.

On August 15th survival was not a certainty for Ana. She came to our ER to be treated for an abscess she got from injecting heroin.  It would have to be lanced and drained. The Physician Assistant was Nicole, who has since moved to Afghanistan. The RN was Jennie.

Nicole did the procedure. Jennie cleaned and packed the wound. I watched as my daughter’s arm was sliced open, and Jennie asked how I was holding up.

“Me? Fine.”

The next time I saw Jennie I thanked her for being so kind to Ana. “Sometimes kids make bad choices,” she told me. Ana is almost 30, no kid. And “choices?” I’m never sure how much free will Ana has exerted in her addictions. I’m open to both sides of the argument.

I’m happy that we made the choice to adopt Ana. She weighed 4 pounds at birth. Her birth mother received zero pre-natal care and was only 17. We had just adopted Rebecca who was three months old, and we had to decide overnight if we’d take Ana as well. “Yes.”


Mysteriously, something shifted for Ana that day in the ER.  She broke up with her gangbanger boyfriend, she moved out of her apartment where heroin was as handy as toilet paper, and she has now been clean for 333 days. And counting.

Now she has a new therapist and a new boyfriend. Good choices?


My next memorable interaction with Jennie was when we both encountered Jane Doe.  I wrote about it for the hospital’s Patient Engagement Team.

“Jane Doe is a beautiful young woman found unconscious near the railroad tracks. She is transported by ambulance. Her age is estimated at 20. A drug overdose, perhaps intentional, is suspected. Her blood work comes back negative for opioids, but she still isn’t waking up.

Jane has only one tattoo. It’s on her forearm and says, “Paint it black.”

I look inside myself and see my heart is black
I see my red door, I must have it painted black
Maybe then I'll fade away and not have to face the facts
It's not easy facing up when your whole world is black.*

I put red hospital socks on Jane’s bare feet. She pushes her toes and ankles into the socks like a half-asleep child. How deep is her coma? Does Jane remember, somewhere in deep slumber, being dressed by a loving parent?”


Jennie and I worry about Jane Doe. What if she never wakes up or wakes up with a mushy brain? What if she awakens and marches out the door only to overdose again tomorrow? What if she has no one in her life who cares?

Jennie and I don’t share these worries verbally. They seem too obvious to mention.

I also worry about Jennie as my fellow-worrier. If she worries about Jane Doe too much – if she is too empathetic – she’ll never make it through the 12-hour ED shift, much less a career. If she worries about Jane too little –- if she is not empathetic enough -- she may come to question or sabotage her calling in life. Nursing could just become an exhausting job. I remind myself: worrying is not a virtue.

Jane Doe is intubated and wheeled to the ICU. What will become of her? “She has a bad prognosis,” Jennie said. Did she choose this outcome when she swallowed her bottle of pills?

I see a red door and I want it painted black
No colors anymore, I want them to turn black
I see the girls walk by dressed in their summer clothes
I have to turn my head until my darkness goes*


A few days later I ask Jennie if she remembers “Paint it Black.” We see hundreds of patients. Sometimes, after the ED “disposition” they quickly vanish from memory. Transfer, discharge, admit; admit, discharge, transfer.

“I think about her every day,” she answers. Jennie, I learn, prays for her patients and co-workers. She prays for me.

“I’ve thought about her a lot too.” But I don’t pray.

“I have a book for you to read.”


Dear Jennie,

“No Greater Love” by Mother Teresa is not a book I would ordinarily read, but it is a beautiful gift that you have inscribed to me, and I want to read it for you, for our relationship, to understand you better.

I think the truth and light we seek in the ER (and everywhere else) is to be found in one-to-one relationships. So here we are. In touch.

On page 27 I find a clue to a mystery that profoundly interests me. The topic is self-awareness among caregivers.

Mother Teresa describes the death of a man in Calcutta who was found in the gutter, covered with worms. As the man dies he has a radiant expression on his face, which Mother Teresa ascribes to the love of a nurse who cleaned him and cared for him in his final hours.

“See what love can do! It is possible that young sister did not know it at the moment…”

It is the question of love’s knowing or not-knowing “at the moment” that intrigues me.

It seems to me that the loving work performed by nurses is often beyond their own mortal comprehension.

The ER, like a medieval cathedral, is always open. Virtue is performed around-the-clock, and the agents of virtue, the caregivers, are virtuous people; but they may remain experientially detached from their virtue.  Are they stunned to distraction by their own light? Or perhaps each little light that shines is too subtle, just off the perceptible grid: infrared, ultraviolet, divine.

If there were a God, God would see the nobility at the heart of this enterprise and rejoice.

We touch the sacred here, but how much sense do we make of it? Do welive and feel the light or just see through a glass darkly?

If such holiness exists and shines, how can there not be a God? But if God, how could God permit the misery? The decay and dying of the light, the demonic injustice of disease, the failure of Jane Doe to awaken.

I conclude that God is not an interventionist God who watches over you and me, Jennie, over Jane Doe and the sparrows. The holiness we know here is merely tantamount to God.

In any case, you and I don’t have to agree about God. We agree about love, which is more important. “Three things will last forever--faith, hope, and love—and the greatest of these is love.”




I thought when I first came to the ER that I might understand the love of caregivers, not despite but perhaps because of my fathomless medical ignorance. As a volunteer who cleans the gurneys, stocks shelves, runs errands and commiserates with one and all, I had nothing cerebrally significant to do at work, so maybe I would have a privileged position from which to focus, bear witness and ultimately understand the intimacy among us, the love in the ER. Perhaps I could articulate it.

Now I realize that there is nothing to articulate beyond the witnessing. The very witnessing — if I awaken from my coma — evokes the love, always available, always new. Mother Teresa’s “young sister who did not know in that moment” (and we are all that young sister) cannot make a conscious choice to awaken to love. If we do awaken in any given moment, it’s gratuitous grace. A kind of miracle.

* * *

This story is based on real incidents. Names and identifying details have been changed to protect privacy.

*”Paint it Black,” lyrics by Mick Jagger and Keith Richards

David Howard is an educator, translator and writer. His novel “The Last Gospel” was published in 2000.  He currently volunteers as a Patient and Family Advisor at a hospital in Southern California. His hospital work includes training and mentoring Emergency Department volunteers and teaching Spanish to nurses. Influenced by the philosopher Martin Buber, Howard believes every healthcare encounter provides a unique opportunity for intimacy and reciprocal healing.