I still remember the teenager but not his name or how long he had been getting peritoneal dialysis (PD). I recall him walking between his parents down the long hospital corridor. He was going home to die. A father with small children had preempted the teenager’s spot on the dialysis unit. Restricting patients was necessary because supplies and personnel were in short supply at the time. Dr. Norman Lasker, head of the Renal Division made that decision unilaterally.
I had taken care of the teen when he came in for twice weekly treatments. His mother and father came with him bringing magazines with pictures of sweaty wrestlers, which I found repulsive. Not having any brothers, what did I know about teenage boys? However, we did have something in common: the new TV show, Batman. I would watch the show each week (no binge watching then) so when the teen came on the unit, we would have something to talk about.
What happened to him after he was sent home? Hospice or palliative care hadn’t evolved, as yet. How did his parents manage? Did he wind up in a hospital at the end of his life?
I called Carol Passarotti-Novembre. She and I worked on the same research floor: a 15-bed unit at Pollak Hospital in Jersey City. Carol was the first renal nurse in New Jersey, working alongside of Dr. Lasker in one of the first Dialysis Centers in the US in 1961. Only three other major Dialysis Centers existed then: Boston, Seattle and New York City. Dialysis nurses received on-the-job-training.
Carol didn’t remember the teenager.
Of course, she wouldn’t since she had so many other patients. Some were on chronic PD, like the teenager. Patients came twice or three times a week, interspersed with emergency dialysis for acute problems like drug overdose, end stage renal failure, and post-surgical renal shutdown. For eight years, Carol was on call 24/7. Only once did she miss an on-call emergency. Another staff nurse from the research unit stepped in. The patient survived.
Later on, Dr. Lasker was no longer the lone decider. Carol told me that a “board consisting of physicians, administrators, clergy and others reviewed potential patients to receive dialysis treatments.” She sat on this board.
Carol ran the show at the Dialysis Center. The “Dialysis Center” was in reality four beds devoted to renal patients on the 15-bed unit.
The procedure for PD was as follows:
After warming two-liter glass bottles of dialysis solution in the sink, Carol hung them from an IV pole. The fluid flowed into the peritoneal cavity and remained in the patient for 30 to 40 minutes. The bottles were taken down from the IV pole, inverted and placed on the floor so the fluid would drain back into the bottles, which took another 10 minutes. Repeat. The patients stayed overnight since each treatment lasted 36 hours.
Carol managed up to four patients on Monday, Wednesday and Friday or Tuesday and Thursday. The day shift helped when we could. Evening and night nursing staff managed the PD during their shift. Carol discontinued the PD the following morning only to see the same patients come back the next day.
Not surprisingly, Carol got to know her patients and their families well, as did all us nurses, since each patient came to the unit so frequently.
One patient, Ellen, a slight Italian women with a large family, stopped breathing and became pulseless when I was in her room. I did what we were taught to do at that time. I slipped her on to the floor, struck her sternum with the side of my hand, breathed into her mouth and started chest compressions. The doctors on the unit came to assist me. We revived her. When she awoke, she told us she didn’t want to be resuscitated. We didn’t ask these questions in 1965. Happily, for me, when Ellen stopped breathing next, I wasn’t in the room.
Carol had an uplifting story to share:
“One of our patients was on PD for four years. Her local internist came to her home for each treatment, inserted the trocath [to make the pathway into the peritoneal cavity], and left. Her husband carried out each treatment. Even her little children helped with warming the bottles of dialysate. She switched to home hemodialysis for five years, then continued In-Center Hemodialysis for ten more years. At that point she received a cadaver kidney transplant, which lasted for a good number of years after.“
The following is from a speech Carol gave to nephrology nurses and technicians of North Jersey at Marriott Newark Hotel, Newark, NJ, May 6, 2011:
“The role of the nurse has changed along with each modality of treatment, the changing needs of the patients and families, the advances in technology and the increasing demands for specialized education in nephrology.
. . . My knowledge of nephrology was ‘on the job’ everyday type of learning. I depended upon the physicians I worked with. . . .Working for the medical school had its advantages. The most important being able to be involved in research projects. e. g., vitamin studies, various solute clearance studies, cardiac output studies in the chronic PD patient and also, in developing the original cycler and starting home training programs for PD and hemodialysis.
(Carol was the first nurse to be included in a research study citation in the Annals of Internal Medicine.)
Today’s nephrology nurse is involved in direct patient care, teaching in all the fields: PD, hemodialysis, transplantation to the patients and their families as well as research and development. National and local organizations, such as American Association of Nephrology Nurses and Technicians were formed in order to ensure a high standard of education on both a local and national level and making nephrology nursing an accredited and recognized area of nursing.
For me, the rapid growth and development in this area of medicine over the past 49 years, has been totally mind blowing, awesome, most exhilarating. The potential for future development is limitless!”
Carol married in 1968 and remained with the renal unit of the New Jersey College of Medicine and Dentistry Renal Division until mid 1969 when she left to have her first child. In 1971, she worked as a staff nurse in hemodialysis unit and later in the Hemodialysis Home Training unit at Saint Barnabas Medical Center in Livingston, NJ. In 1976, she joined a Renal and Hypertension practice as both an office nurse and researcher in many drug studies. Carol worked full-time, sometimes 50 hour weeks, before she retired in 2010 at the age of 70.
After reflecting on Carol Passarotti-Novembre’s long career in nephrology, I ask the obvious question. How could the development of peritoneal and hemodialysis have progressed without the collegial partnership between nurses and physicians?
I almost forgot about Dennis. That’s what Carol Novembre thinks his name was. Carol and I worked together in the early 60s at Pollack Hospital in Jersey City. It was a county-run hospital. Dennis was head of maintenance. I learned a lot from him about the political corruption that went on behind the scenes. Not that I had any doubts about the kickbacks and abuse of power. I had seen the cases of liquor at the loading docks that were to be delivered to the administration suite (aka “the penthouse”). One time when I answered the phone on our nursing unit, a voice at the other end reminded me that my “donation” of five dollars was due in order to keep my job. When I identified myself as a nurse, the male voice apologized profusely.
Dennis, a tall, lanky guy with a pocked marked face and disheveled clothes, made rounds in the hospital when he wasn’t off-site, overseeing the unofficial work of prisoners. He would bus the prisoners from the county jail to work on the administrator’s suburban house—building a fence, painting the siding, tending to the gardens in the summer. He seemed especially fond of the nurses. If he learned one of us had missed lunch, he would run down to the kitchen and reappear with a bacon sandwich.
Reminiscing about Dennis was only one of the memories that resurfaced as I spoke to Carol last week. I had asked her if I could write about the fact that she was one of the first dialysis nurses in the country. I worry that as nurses age and die off, stories of nursing history will be lost. My stories included.
You will read more about Carol Novembre in a future post. In the meantime, here is a story I had published about one of the patients I cared for while I worked at Pollack Hospital in the mid-60s.
CLOSING THE DOOR
I screwed off the cap of the Black and White Scotch bottle and I carefully measured out sixty milliliters, two ounces, into a medicine glass. The alcohol fumes gagged me every time. Then I grabbed a pack of Lucky Strikes from the carton on the shelf next to an aspirin bottle. Cigarettes and Scotch balanced precariously on a small tray. I locked the door to the tiny medication room and went in search of Charlie Hobbs.
The tobacco smoke clouded the air in the patients’ lounge. The drab room was empty except for a middle-aged man in blue pajamas staring at pieces of a jigsaw puzzle on the card table in front of him. A cigarette clung to his lower lip.
At times, I imagined myself the airline stewardess I had always wanted to be. Coffee, tea, or me? This day I was a Playboy Bunny as I bent at the knees, stretching to place the drink in front of Charlie, while his blue eyes riveted on my imagined cleavage. But Charlie’s eyes fixed solely on the amber liquid. Not once in the past four weeks had he acknowledged me, the young nurse in a starched white uniform with thick support hose and practical shoes. An unlikely dispenser of booze and butts.
Charlie had arrived with no suitcase, only the clothes he wore. The faded blue hospital pajamas and robe comprised his daily wardrobe. One of the other nurses had donated slippers. I looked down at the top of Charlie’s wild red hair. “I got to get me another puzzle,” Charlie said without looking up at me. “This here one is almost done.” He snuffed the cigarette butt into an overflowing ashtray and reached for the drink. I was glad Charlie had decided to shower that morning or else his pungent body odor would have added to the foul air.
Charlie shuffled the jigsaw pieces about by day, and watched television by night, all a maneuver, I thought, to keep human interaction at bay. No one ever visited him. Did he even have a home to go back to?
Dr. Clark’s research money supported Charlie’s hospital stay. Dr. Clark needed recruits who would agree to have a cardiac catheterization in order to see the effects, if any, that alcohol had on their hearts. Cardiac catheterization was the latest tool of the sixties. It measured heart function but carried the risk of injury and even death.
Dr. Clark scoured the downtown bars searching for men who drank excessively. On a warm summer night about a month ago, Dr. Clark had gotten lucky. Charlie seized the carrot: a roof over his head, three squares a day, free liquor and cigarettes. He agreed to live on the third floor of the county hospital for four weeks and then undergo a cardiac catheterization.
I carried the empty medicine glass on the tray back to the nursing station. How could Charlie drink alcohol at nine in the morning? Or all day long, for that matter? What would make a man so desperate that he would consent to have a procedure that might kill him?
Even though I didn’t particularly like Charlie, there were times as I placed the Scotch in front of him that I wanted to nudge him and jerk my head towards the exit sign down the hallway. Get out, Charlie. The catheterization isn’t worth all the free alcohol and cigarettes that Dr. Clark’s giving you. Get out. Now. But I didn’t have the audacity to undermine Dr. Clark’s research, no matter how conflicted I felt.
At twenty-three and a nurse for just two years, I vacillated between professionalism and irreverence. I struggled with knowing when to step back and when to dig deeper into my patients’ psyche. How to be empathic and not sympathetic. How to balance cool detachment with overbearing involvement. Charlie needed someone on his side to help him understand what he was getting into.
Nellie Mineo interrupted my thoughts as she waved to me from the doorway of her husband’s room. She looked like the Italian housewife that she was: salt and pepper hair piled in a bun on the top of her head. A well-worn cardigan sweater covered the simple cotton dress she wore. Behind her thin frame I could just make out her husband’s outline under the starched white sheets.
The Mineo’s had known the chances weren’t in their favor when they first met with Dr. Clark to discuss replacing Joe’s diseased heart valve with an artificial one. At that time Joe was so short of breath that he could hardly talk, much less continue to work in the family grocery store. Joe had been my patient during the week Dr. Clark evaluated him for surgery. The Mineo’s large, gregarious family resembled my own extended Italian family. Joe could’ve been my Uncle Tony with olive skin, dark eyes and soft smile.
An artificial valve, which clicked audibly, replaced Joe’s faulty one. I had worked overtime on the surgical unit as Joe’s private nurse the first night after surgery. At first things looked great, but soon Joe developed a cough, and then his legs swelled. Diuretics only worked for a while, and the antibiotics failed to prevent the infection from ravaging his body. Although the valve was being rejected, it continued to click on.
Joe had the first room near the nursing station. The floor was dedicated to research and held only fifteen patients. The patients stayed for a long time or returned frequently for evaluation. Not surprisingly a strong bond developed between the professional staff and the patients and their family.
Joe’s family and friends usually came and went at all hours, but this day only Nellie stood guard. When I ambled towards her, she grabbed my hand. “He looks worse,” she said, rubbing my hand in absent-minded distraction. “Promise me you’ll stop in before you go off duty today.”
Nellie and I both knew that there would be no miracle for Joe. His once muscular body shriveled into sagging skin covering a bony frame. He didn’t open his eyes to Nellie’s voice. Even a sharp pinch to his face couldn’t get a reaction. “Stop and see me before you go off duty,” Nellie repeated. I nodded. Only then did she loosen her grip on my hand.
At the end of the day, as I flung my coat over my arm, I heard a racket from the patients’ lounge. Charlie stomped past me, head down and fists clenched. “I’m outta here.”
“What happened?” I asked the nurse who jogged after Charlie.
“Charlie kicked over the card table. No reason I could see for this.” She shrugged her shoulders and continued down the hall.
Nellie watched the commotion from the other side of the hall. I walked towards her. She pulled me into her husband’s room, grabbed my coat and purse and held them tight against her body. She stared at me for a long while without speaking. From behind her I could hear Joe’s wet bubbly breaths. Even in my short stint as a nurse I recognized the rancid smell of impending death.
Nellie moved her face closer to mine and whispered, “He’s dying.” She caught a sob and swallowed hard. “I don’t want him resuscitated. Stay with us, please stay with us. Don’t let them resuscitate him. Please don’t.” She wept quietly, clutching my coat and purse closer to her body.
What was I to do? I had never faced this dilemma before. I knew Nellie had witnessed plenty of resuscitation attempts as she lingered outside her husband’s hospital room day after day. Cardiopulmonary resuscitation was so new that all patients were candidates. At the first moment a patient stopped breathing, we leaped into action. We flung him to the floor and straddled him. With the side of our hand we walloped the sternum to get the heart started, then breathed frantically into his mouth. Pumped on his chest. We worked until we were exhausted. In most cases the patient died anyway with fractured ribs and a lacerated liver. Nellie didn’t want this for Joe.
Thoughts flew in and out of my mind. If the staff saw Joe turning blue, they wouldn’t give a second thought to trying to revive him. A resuscitation attempt might bring Joe “back to life,” but only briefly. Then there would be more pain and agony before his heart gave out and he died—again.
What would I want for Uncle Tony? A quiet death, or zealots in white coats beating on his chest? What should I do? Was there a choice? I looked at Nellie, her dark eyes pleading.
I heard Charlie’s voice from down the hall spewing curses. Perfect timing. Charlie would leave the hospital AMA—against medical advice—right before his scheduled catheterization. I hoped whatever he was up to would distract the staff just long enough for Joe to die.
My heartbeats kicked up a notch as I reached over and slowly shut the door. Nellie’s hold on my coat and purse relaxed and they slid to the floor. Wordlessly, she settled down in the chair next to Joe’s bed, lifted his limp hand into her lap and clutched it. I commandeered the chair by the door: the sentry blocking the enemy from entering.
I sat knotted tight while Joe’s breaths became more erratic. The lapses between his gasps for air stretched farther apart. Just when I thought he had quit breathing, he gulped for air.
Finally, the mechanical valve stopped clicking and the room became silent. I walked to the bed and placed my hand over Joe’s clammy hospital gown. I didn’t feel any movement in his chest. I didn’t feel a heartbeat. Joe’s open eyes stared at nothing. I stood there for a long minute before I smoothed down his lids.
Nellie gripped her husband’s hand to her breast and sobbed softly.
I stood over her, my hand lightly on her shoulder. While I felt relief that Joe died peacefully with his wife by his side, each footfall by the door made my heart flip. What if one of the staff would walk in and find I had made a decision that wasn’t mine to make. “ I really need to leave, Nellie,” I whispered, taking Joe’s lifeless hand from hers and placing it by his side.
Tears slid down Nellie’s cheeks. She rose from the chair and embraced me. “Thank you,” she said, her voice cracking. I felt Nellie’s tears soaking into my shoulder as my own tears fell. Then Nellie pulled away and sat back down next to Joe, taking his hand again into her lap. I wiped the moisture off my face with the back of my hand, grabbed my things from the floor, cracked open the door, and glanced up and down the hallway. No one was around. Retrieving my coat and purse, I walked leisurely toward the exit leaving Nellie waiting for the evening nurse to discover Joe dead in the bed.
The floor was unusually quiet. The medication door was ajar in the nursing station. I had no intention of poking my head inside and saying so long to the evening nurse. Just a few more steps and I would be in the clear. As I turned the corner of the white tiled hallway, Charlie Hobbs’ presence blocked me. “Hi,” he said as if we were old friends. “I’m leaving. Can ya spare a buck for bus fare?”
Charlie had on a bright green jacket I was sure wasn’t his. Noticing my eyes on the jacket, he said, “Borrowed this from the guy in the next room. I’ll return it.” I nodded even though I knew the coat would never make it back to its owner. He shifted his feet nervously as he waited for my answer.
I wasn’t anxious to break any more rules but I was glad he was leaving. Why even try to entice him to stay? That would be hypocritical. I reached into my purse guessing he would head for the nearest tavern rather than the bus stop.
“Thanks,” he mumbled. Shoving the dollar bill into the pocket of the purloined jacket, he turned abruptly. In two long strides he disappeared though the doorway under the red exit sign and raced down the steps. I followed. A cold wind chilled my stocking legs as Charlie opened the door at the bottom of the stairs to the outside world. In his haste to escape he let the heavy door slam shut behind him.
I pushed the heavy door open with my shoulder. Unlike Charlie, I had no desire to announce my departure from the hospital by slamming the door. Leaving my covert actions behind me, I griped the handle with both hands and eased it closed.
The Closing the Door was a winner of the TulipTree’s Stories that Needto be Told Contest and is featured in their 2016 anthology: Stories that Need to be Told.