The Good Nurse

2

June 1987¹

Saint Barnabas Medical Center had the only certified burn unit in the State of New Jersey, so it took everyone—the horrible husks of humans, people burned in car accidents, house fires, industrial spills; men and women and, most often, children, some burned to stubs, without hair or eyelids, their body surfaces cooked beyond repair. Charlie's job was to clean these burn victims on a metal gurney—to scrape and wash away the charred, necrotic skin with antibacterial soap and a brush. Even within the field of critical care medicine, this is an almost unimaginably gruesome procedure; as a first job straight out of nursing school, it's something close to hell.

All burns start with a story. A mother in a nightgown reaching for the teakettle,² a paraplegic with a dropped cigarette, a drunk feeding a flagging campfire, the punctured gas tank of the crumpled car. Fire is the punch line. The body reacts predictably to the trauma. Third-degree burns are more deadly—complex layers of the skin, nerves, veins, arteries, and muscle cooked and dead—but second-degree burns are more painful because the nerves are still alive. Even in the 1980s, burn wards were scream wards. The drug of consolation was morphine. Some patients will recover; others are kept on the ward only to suffer and die. The nurses know which is which. Fate in the burn unit is a statistic written on skin. Sooner or later, all nurses can read it.

It's always the same drawing on the burn sheet, a human figure, bald and naked. It's ageless, sexless, hairless. Its toes point toward an unseen ground. Its arms stretch palms up in the universal expression of supplication and surrender. The figure's eyes are open and lidless, its lips full but without expression. You can tally damage in the figure precisely, marking the drawing for pieces of thigh, a half a leg, a piece of the head. The damage corresponds to a point system: One point for the genitals, 1.25 for each palm, etc. But there is an easier way.

The nurses call it the rule of 9s. Each big piece—a leg, the back, the head—counts as 9. Add up the total, then add that to the patient's age; the sum is the mortality rate. By this rule, a fifty-year-old patient burned over half his body is 100 percent dead. If not now, soon. The rule helps soften the blow of the inevitable, indicate where on the burn ward the meager rations of hope are best invested. Every burn nurse knows the rule, there's no point talking about it; you use the formula, then try to forget it. The impending death is like a black car you see in the rearview mirror, always there if you look. So why look?

Meanwhile the pain on the burn ward is unbearable, and the nurses have no options for treatment except to hit their patients with more and more morphine. When these patients die, it isn't always clear whether they've overdosed or simply died of unsustainable wounds. All anyone knows is they aren't in pain anymore.

The burn victims arrive at all hours. They may arrive in surprising ways, on stretchers or walking, alone or in packs. Sometimes they are lucid, talking, worried about their watch or a missed hair appointment. That's shock. Reality follows soon enough.

Burn victims are connected to machines, lines snaked into wrists and femoral arteries, plastic tubes shoehorned into holes top and bottom. Saline, electrolytes, pain meds, anxiety meds, liquefied food; the body swells with the fluids, sometimes doubling in size. The scrotum inflates like a beach ball, the eyes puff to slits, lips balloon and break like overcooked sausages. The body swells against the skin until the patient is as hard as carved marble. The blood vessels are squeezed shut. The core begins to die. And so they cut. It is simple surgeon's work. A blade runs the length of the arms and legs, front and back. Even the hands, puffed fat as udders, get cut. The knife runs tendon deep, five whisker-flicks beneath the knuckles like vents on a leather glove. The cuts³ allow space for the insides to expand, like pleats on pants, pressure sighing open along a sudden fault line, exposing canyon walls of yellow fat, a valley welling blood. The smell can be terrible, but the bleeding is a good thing. If it bleeds it is alive. But bleeding makes more work.

The pleated skin is loose, a greased shirtsleeve of leather, shocking to the touch. It takes time for nurses to acclimate to the point where they can effortlessly handle these tactile details of damage. When these details become too much, they leave. Some nurses leave the burn Intensive Care Unit right away, switch to something—anything—less brutal. Others stay only until they encounter the burn patient who reminds them, too much, of a loved one—or of themselves.

Nearly a third of the patients on the unit were children. Sometimes their burns were delivered as punishments, for peeing on a mattress or forgetting a chore. Nurses recognize the signs of abuse. There are burns from radiators and cigarettes, lighters and stove tops, red-hot water scalds and blackened electrical scorches. Each has its unique signature of pain. Charlie saw them all.

Some pain blossomed across skin in crenulated carnations of tissue, some blistered or knifed in thin white stalks. The nurses did their best to hide the pain beneath neat rows of gauze and tape, behind the mask of drugs. But Charlie knew that pain could be held in secret. Pain could be a banked ember, burning from the inside, endured without expression. Especially by children. Unlike adults, children didn't scream when he cleaned them, they didn't whimper in their beds. Children tolerated the pain and held their secrets to avoid being punished again. Charlie's mother had never used a stove top or a hot pan to punish him, but he'd been punished, pushed around, hit by his sister's boyfriends, big guys with rings and Camaros and bulging jeans. He'd felt their adult power, and he had never forgotten what it was to be a child abnegated in its shadow. One of his sisters had a live-in boyfriend, who had beaten her ruthlessly through her pregnancy. She had run away, but the boyfriend would not leave. And Charlie had known that man's relentless attentions, too.

He'd known pain in the military. Burns and punishment, too, for "damaging Navy property," as they put it, after he had woken up from a drunken shore leave with his bare feet sunburned red and as swollen as kickballs. They'd forced him into his dress shoes and gave him only aspirin. As he worked, he reminded himself that, yes, he knew a hurt far beyond what anyone could understand. Charlie dwelled on these kids in the ward in tremendous pain that no one could understand or properly address. At the time, nurses weren't allowed to give children any pain medications more powerful than Tylenol 3.⁴ It wasn't nearly enough. Many nurses wanted to give more. Some did.

The kids came in hot and rising, hurting and reminding Charlie of his own hurt, too. He would pick them up, these screaming, melted little people, knowing that later the surgeons would open each like a baked potato, a Y-cut to keep them from exploding, only the first of many operations to come. In time, their melted skin would heal into scars, vinelike ropes that the surgeons would cut again and again to prevent the neck from locking into an unbendable trunk, to keep the arms flexible. Without these operations, the children would remain stunted within their baked bodies. Their hard scar casings were too inflexible to accommodate growth spurts and normal movements. Their only hope was the knife and the pressure suit, a wetsuitlike garment that squeezes a child in a painful hug. The pressure suit presses against the scars, thinning them, like a constant rolling pin against the hard rising tissue. Maybe, with enough work, after time and pain and pressure, the scarred cocoon might thin enough. The child might one day move and grow. One day, maybe, they might even forget their pain. Charlie knew that the children might live, they might age in years, but not in body; without a nurse's intervention, they would be forever trapped within the groaning cocoon of their childhood. Charlie considered it one of the neater equations in life: the world pushed, and the pressure suit pushed back.

Charlie liked the Saint Barnabas job. He knew he was helpful there, needed. He enjoyed caring for the infirm, bathing and feeding and dressing the dependent. He appreciated the one-on-one of the night shift and the professionalism of his veteran coworkers. He even liked the name of the hospital; raised Catholic, Charlie was familiar with Saint Barnabas, an apostle. He had a personal connection with this particular saint. The church celebrates Barnabas's feast day every year on June 11. It was the day Charlie Cullen started working at Saint Barnabas Medical Center.⁵

In church on Sunday, Saint Barnabas was suspended in the archway of the stained glass window—bearded Barnabas, the handsome young companion to Luke and Paul, the Aramis⁶ of the early Christian Three Musketeers. As a Jew he had been Joseph, a landowner who sold his fields and gave cash to the apostles;⁷ as a convert, Saint Barnabas was an inspiration: Grant, O God, that we may follow the example of your faithful servant Barnabas, who, seeking not his own renown but the well-being of your church, gave generously of his life and substance…

But Charlie had no use for those sorts of prayers. In preparing to marry Adrianne he had formally renounced the religion of his upbringing and converted to Judaism. Charlie felt like he was living the life of the saint in reverse.

It never ends well for saints, no matter how good they are. Castration, defenestration, hot pincers, prison—the saint is a scapegoat, a martyr, a patsy. Barnabas was stoned to death,⁸ but his story lived beyond him. Every Catholic knew his name. It was the paradox of the saints, one thing Charlie held on to from his childhood: remembered well, remembered forever, but only after being hated to death.

3

October 1987

Adrianne and Charlie Cullen took a mortgage on a small one-story in the steel suburbs of Phillipsburg, New Jersey. The house was cramped and dark and in need of paint. One side faced a billboardlike supporting wall, and the backyard bordered a weedy lot, but the price was within the range of their combined incomes. Adrianne had a new job as a computer programmer—entry level, but at least in a business office rather than a fast-food chain. Their reversed schedules, with her on long days and Charlie working long nights, surely contributed to Adrianne's sense of isolation, but that was only a piece of it. Increasingly, she felt alone, with or without Charlie.

Self-deprecating vulnerability had been part of the charm package Charlie had presented as a suitor. He was so forthright and often funny about his personal problems—particularly his history of depression and alcoholism—that Adrianne had quickly come to believe that she knew this man and, more important, that he knew himself. His perspective on himself made him seem not so much damaged as experienced, mature even. It gave Adrianne the illusion that Charlie was in full control of his demons; in fact, he was only now coming to know them. Adrianne sensed that a strange new chill had set into her life, an early autumn in their emotional life together. She chalked it up to the heart-rending nature of her husband's work and decided this was simply the lesson every medical spouse learns: love can't compete with death. She didn't imagine that her husband was drinking again.

Drinking had been the one aspect of naval tradition at which Charlie excelled. He drank to get drunk. He liked red wine, or tropical drinks—even Listerine, in a pinch—which had landed him repeatedly in the military's infirmary and psychiatric hospital, and introduced him to Antabuse and Alcoholics Anonymous. Adrianne had no experience with this side of her husband. She had never once seen him have a drink. When they were dating, he'd always said that he simply "couldn't." Adrianne considered his abstinence a sign of his conviction rather than a warning of his appetites. When Charlie had moved in to her apartment in Union, she even threw away the dusty bottle of Baileys Irish Cream she'd kept for fancy guests.

In Phillipsburg, Charlie kept his booze in his Navy footlocker, kept the footlocker in the boiler room, and kept a lock on the boiler room door. He drank alone in the basement, avoiding his wife. He liked it there. There was only one way in, nobody below, bedrock all around, always dark. The boiler room was a place to drink and think and watch the pilot light dance within its metal prison.

That first year of married life was a whirlwind. Charlie had been exceptionally busy. He'd received his New Jersey RN license a month after starting at Saint Barnabas, and a month later he started on another degree program at Kean College. Between school, work, and the commute, Charlie was seldom at home. Adrianne watched Dick Clark rock in the year 1988 alone with a minibottle of Chardonnay. By February she was pregnant. This was family life, the real thing, the point. But she felt her husband becoming increasingly cool with her, almost professional, as if she was one of his patients. Adrianne felt him cool down another click that fall, when their daughter Shauna¹ was born. Now any attention Charlie had previously given his wife was shunted exclusively to the baby. Adrianne didn't understand the reaction—it was as if her husband had to choose between his wife and his child, as if he couldn't broaden the focus of his affections to cover them both. Charlie was overly enthusiastic about new things—their relationship, their house, their life—but as the novelty faded, so did his affect. She had seen him lose interest in a similar way with her dogs, first with her Yorkie, Lady. Adrianne adored Lady, and had believed at first that Charlie did, too. He petted her mechanically, groomed her little ears, watched intently as she gobbled her food. Then he seemed to change the channel, and the dog no longer interested him.

He was, however, interested in the new puppy—at least, Adrianne had thought so when they'd picked it out. This was her second Yorkie terrier, a companion for Lady. She had left for work Tuesday morning, leaving Charlie with the baby and the puppy, their usual changing of the guard on his day off. When Adrianne returned from work that evening, the puppy was gone. Charlie didn't seem to care, and he didn't want to help her look for it.