MOVING DAY | Christine Nguyen
It was moving day, and even the quietest residents seemed to stir. Behind a glass door, Carol, Dad's nurse, prepared him for his 2:30 PM departure. She pushed his last scheduled morphine dose through a syringe into his IV. Although my ICU service days were long behind me, as a doctor, I knew that good nurses like Carol would run through the basics–the A-B-Cs–to systematically prioritize a critically-ill patient's needs.
A-Airway. Dad's tracheostomy tube emerged just below his Adam's apple and was firmly secured with Velcro ties. Carol checked the blue collar around his neck. White gauze cushioned his skin from the plastic flange. It was a small, silly thing, but the way the gauze ruffled out from each side of the trach made it look like he wore a bowtie. At a glance, it looked whimsical, like a child's costume, not a medical intervention. In case of dislodgement, an extra tube rested by the bedside.
B-Breathing. A Yankauer was ready next to the sterile suction kit. On the hour, a respiratory therapist threaded a catheter through the hole in his neck and noodled it deep to his carina. Dad hated being suctioned. Wet foam bubbled up. He grimaced and coughed. His chest heaved and collapsed and sometimes his heart rate dipped and lit the alarms when his vagus nerve protested. That brought Carol to C.
C-Circulation. His skin did not appear mottled. Not yet. With gloves, she removed the dressing for the PICC, the intravenous line that threaded to the door of his heart. First, she cleaned the exit site. Then she used a gauze to apply pressure with one hand to the hole on his cobblestoned skin. With her other hand, she pulled the thin purple and white tube. It was slightly elastic, and she was careful not to tug too quickly and tear his skin. Still, the recoil of the line made a subtle snap. She threw the catheter into the garbage.
D-I graduated from medical school years before they added D for disability, an assessment of a patient's level of consciousness, but his Glasgow Coma Scale, by my guess, was 8. I wasn't sure if the scale was relevant to Dad, who had dementia. His mind's unsteady flicker had faded well before his most recent crisis. Still, he wasn't just about to die any more. He was just inevitably going to die. We were living with the consequence of his technically successful resuscitation.
Carol covered him with new warm blankets. His eyes tracked her. She documented everything. So much documentation! She dutifully filled his data into her COW, her Computer on Wheels. Vital signs. Oxygen requirement. She recorded his physical exam. All the data sets needed to be complete in order to close his file.
At Kindred, we had been in purgatory for two months. I thought the name for places like Kindred, long-term acute-care hospitals, was deceptive. The MediCare website stated long-term care hospitals were not, in fact, for long-term care. I wondered who wrote that explanation, who blandly decided 1 + 1 = 3. MediCare said the routines of feeding, dressing, cleaning and frequent turning to prevent bedsores was supposed to happen at home or in an assisted living facility.
Like any hospital, Kindred was designed for intervention, not acquiescence. Before I signed the hospice paperwork, I asked if we could remove Dad's tracheostomy, but no one answered my question. I did not ask again because I did not want to sound like a murderer. So the tracheostomy remained in place. The staff continued to suction the mucus to prevent suffocation. Each shift, the nurses recorded the effluent from his gastrostomy in a careful ledger of fluid in and fluid out. They
peered at the dark Foley bag looking for any trace of urine. Measurement and quantification was part of hospital protocol.
Finding an assisted living facility or nursing home willing to take him was no small task. He needed too much care. If the tube in his neck dislodged, he might die, and the risk of death was a liability. The tracheostomy required constant vigilance. Nursing homes marketed pictures of cheerfully aging residents. Hale elders seemed ready to spring unassisted from their walkers. No oxygen tanks or medical clutter in sight.
I wished we could take him home, but Dad did not have a home any longer. He was in Pasadena, Texas, far from my home in California, and I didn't think I could check my father into an Airbnb to die. It probably violated the terms of service.
Finally, the case manager found a nursing home that would take Dad. I felt we found deliverance. The hospice doctor signed the transfer order. I never met or spoke to this man, the one who signed all the orders. The one who would, in a few days, officially declare Dad dead. I quietly noticed the doctor's absence like I imagine many other families had done. I had no energy to make a fuss.
As we waited for Dad's ride to the new nursing home, I washed his face with a warm washcloth. Wiped the protein crust from the corners of his eyes and the white film that clung like a wet web on his gums. I rubbed moisturizer onto his skin from his elbows to his fingers. I massaged his heels and interlaced my fingers through his toes.
When the EMTs arrived, an hour late, they wore navy polos with the Star of Life and the Staff of Aesculapius on their sleeves.
“How ya doin’ Mr. Duck?” The EMT's name tag said Andrew. He had close cropped sandy hair and strode confidently in tactical pants. Trauma shears swung casually from his pockets. His partner, a short man with broad shoulders and a name tag that said Doug, followed into the room. He pulled a yellow X-frame gurney. Doug kicked his boots on a pedal and clicked the wheels to lock. Then he pumped another pedal to raise Dad's bed so the mattress and gurney were level. Andrew handed me an electronic tablet.
“Can I get your signature just saying we’ve got permission to transport him?”
I scanned the illuminated touch screen, confused and unsure where to focus.
“Just type your name in here for me,” said Andrew.
“Oh, you're just like UPS."
I tapped the letters for my name, signed with my forefinger, and handed back the tablet.
"Yeah," Andrew said. We both laughed.
"Actually, it will tell our boss where you signed it and at what time," said Doug.
"Oh yeah?"
"Yes, so that we can't drive off and sign later."
"Yep," agreed Andrew.
The three of us fixed expectantly on the screen as an hourglass spun two, three, four times.
"It's taking some time, just like UPS." A small chuckle. Yep, just like UPS.
I turned back to Dad. He did not know these men. I gently pried his hands from his accordion humidification tubing and brought my face close to his ear.
“You okay Daddy? Don’t worry, these men are helping you get out of here." I smoothed the long white hairs along his eyebrow ridge. His skin felt like wax. Ever so slightly, he shifted his eyes. "We’re getting out of here, okay? I’m here. Don't worry, Daddy."
“What’s he satting at, usually?” Andrew asked.
Carol cleared her throat.
“Ninety, ninety-three." She hesitated. Her voice was hoarse. "I’ve just come back from Colorado and my voice, I don’t know what happened.”
Everyone began to move by muscle memory. Lower the guard rails. Place a sheet over the slider board.
“Oh, wow, doing fun things? Hiking? Family?” I asked Carol.
Roll the patient to face away from the board. Scoot the slider board underneath him.
“No. Elk hunting.”
Roll the patient to his back on the board. Shift the legs to follow.
“Elk hunting, oh my God!”
“I’m looking at doing a twenty-one day trip for my fiftieth birthday,” said Andrew. "You fly into Alaska and you pay like six thousand dollars for twenty-one days. They provide the cabin, you provide the meals.”
Doug nodded, held the side of the sheet by the gurney.
“Well, we didn’t see the elk,” continued Carol.
"You didn't?"
"No."
Andrew approached the head of the bed.
“Go grab his feet.”
“A lot of mule deer. But that’s okay, I don’t hunt.”
Carol helped with the other end of the sheet.
“Your family does?”
“My son. My husband, he doesn’t hunt either, he was just gonna go along. But we didn’t see any elk.”
One. Two. Three. Dad rolled like a log.
“Just mule deer.”
Push the patient on one side, pull the patient on the other. Pull the sheet, slide it over the board. Slide the board over to the gurney. Remove the board. Straighten him out. Cover him back up with blankets.
“That was good," Carol said.
“We try,” said Doug.
"Here's the oxygen." I tried to be useful and passed Doug the tubing.
Carol gave me a clear plastic bag with a handle. Inside were no-rinse body wipes, lotion, pink mouth swabs and wound care ointment.
“Well thank you.” I was grateful.
“Good luck.” Carol said, and then she hugged me and gently rubbed my back. I clung to her. It was the first and only hug I had received during Dad's illness.
“Thank you.”
“He sounds like he’s been around the world.”
“He has.”
“He was really cool.” She tucked tissues into my jacket pocket. “Here’s some Kleenex.”
Doug lowered the gurney, and its pneumatic engine made a high-pitched hum. Dad was ready to go.
We left the room quickly. The men passed the nursing station with brisk steps as staff called their goodbyes. Stay warm. See y’all next time. Y’all have a good day. Oh we try.
My right hand dragged my rolling luggage and Carol's goodie bag while my left hand lightly gripped Dad's bed rail. I kept pace with the EMTs, my boots rapping purposefully on the floor. We took a wide turn to the double doors and then broke out of the hospital seal.
The sound of the nearby freeway was immediate. Wind and rubber rolling on pavement and the stun of winter sun. Woodsmoke. Fall leaves. Instead of overhead lights, the sky surrounded us. Dad stiffened, trembled, and I felt I could hear his thoughts. He wondered where I was, he was suddenly very cold.
When we got to the van ambulance, Doug raised the stretcher on the hydraulic lift and locked it into the bay. Dad was alone, staring at the ceiling of the ambulance van, and I wanted to jump inside to be with him.
"Am I going to be sitting…"
"You're going to be in the front," said Doug, "Yes ma'am." It was disappointing to leave Dad alone in an ambulance bay with a stranger, but of course, I was Dad's daughter, not his doctor.
"Can I just tell him, can I just say it's going to be okay? He's looking a little freaked out. Let me just let him know first." I felt I could hear Dad's thoughts. Cars. Wind. Air. Fear. What. Is happening?
“Daddy, I’m going to be right in the front, okay. I’m coming.”
I turned back to Doug. I still had the luggage and all our other crap, and I was embarrassed to look like a tourist boarding a plane.
"I’ve got so much stuff."
"I got you. Yes ma'am."
"My mom brought a lot of bags."
"No, I understand that." Doug took the bags and suitcase and tucked them under the bench seat cushion. He closed the back doors.
"You’ll have to ride up in the front with me." Andrew called.
I met Andrew by the passenger side door. He held out his hand, and I briefly stared at it in confusion. I had forgotten all about Southern chivalry. He was offering to help me up. I took Andrew's hand and climbed up the step to the passenger side seat. We buckled up.
Andrew called in to dispatch. “Hey this is Medic twenty-six, we’re transporting.” He waited while Doug performed his safety checks in the back.
“I’m more cautious with the trach collar. Cuz things can go south," Doug said.
“Watch his hands, he’s really strong,” I warned.
“Really?”
“He, he, he tries to rip it out.”
“Oh really? Ooh that’s not good. That’s why I...”
“Just watch his hands.”
Doug nodded, secured the back door with a thud. “You, you’re good! Let’s go!”
“Flight time should be about five minutes. It’s reading ten, but we’ll see," said Andrew, "I’m gonna take it a little slow, no bouncing around too much," he explained to me. "These van ambulances are a lot better than the box ones, just because they're actually made as an automobile for the smoother ride."
"Not like the really squared off ones?"
"Right, the box ambulances, they're really pretty bad. I work 911 my other job, and it's pretty rough. You get one little bump, and you can be flying out the back." We turned out of the driveway to the freeway feeder road. "So how long you been at Kindred?"
"He's been six weeks at Kindred, and then two weeks before, he was at the ICU at Memorial Southeast, " I answered. "So, he's been, he's been two months."
"Wow. And he started with the respiratory failure?"
"Yeah. He was in shock. He had all the blood pressure medications. He needed everything." I didn't mention the year before. I didn't mention Dad's previous ICU stay. I didn't mention his years of slow decline. None of it seemed to matter anymore.
Hasta la vista, baby. We fixed our eyes forward. It felt like a fresh start.
Christine Nguyen has performed her work live in San Francisco with Back Pocket Media and at LitCrawl Sebastopol. She won journalism awards from the Asian American Journalists Association, the Society of Professional Journalists-NorCal, and the San Francisco Press Club. She was born in Vietnam and practices medicine in San José, California.