December 2009

Saving Grace

Unflinching and tireless, the ER nurses of Cedars-Sinai are disaster’s first line of defense

Elaine
Kagan

“I heard a guttural scream,” Rich says, “and a man was handing me his lifeless son.”

“How old?” I ask.

“Nine months. We worked on him for over an hour.”

Rich moves his chair, coughs. It’s freezing in the conference room. [Note: For privacy, nurses are mentioned only by first name.] The muffled din of the emergency room is audible through closed metal doors. It’s 7 a.m., and Rich’s 12-hour shift has just ended. “I flashed to something I heard once about how a casket doesn’t weigh very much—just enough to break a father’s heart,” he says, “and I lost it. I’m standing there, between beds one and two holding that dead baby, and I’m sobbing. I am in charge, and I’m crying.”

As an 11-year volunteer in Cedars-Sinai Medical Center’s emergency room, I’ve seen close up what ER nurses deal with. It takes rare emotional courage not to burn out when you know that every time those doors open—whether you are working triage in front, where a guy may stumble in with a heart attack, or in back, where paramedics may race in with a girl who has been knifed or shot—it’s bad news. Then there’s the physical strength required to survive 12-hour shifts with two half-hour breaks and 45 minutes for lunch. ER nurses never sit. But it’s the children—every ER nurse will tell you—who take the biggest toll.

“For a very long time,” Rich says, “I viewed it as a badge of honor—How much crap can I take? How much horror can I see and not show emotion?” He clears his throat. “But you can’t keep stuffing it down; you have to deal with the emotion.”

Rich has been a nurse for 22 years. He has a 12-year-old son. There are 98 nurses in Cedars’ ER. Their ages range from 24 to 67, and they are as different as heavy metal is to polka. What they share are guts and a desire to give. “I was an operating-room tech in the army. My CO said, ‘Nursing?’ And I thought, Maybe,” Rich says.

He is big and bulky, with soulful eyes and a wild sense of humor. When I ask why he really became a nurse, he jokes, “I liked the cute little hats, the white nylons and the sensible shoes.”

Rich was diagnosed with leukemia last year in his very own ER, when he showed a doctor some large bruises on his body. The doc ran tests while Rich was on shift and returned with the diagnosis. The story goes that he asked the doc if he could finish his shift so he wouldn’t get docked pay. After eight months off, five rounds of intravenous and oral chemo and too many bone-marrow biopsies, Rich is back working nights. I don’t know how he does it. I don’t know how any of them do it.

“It affects your soul,” Melissa says. She could be called the queen of trauma, having done 20 years in what she terms “the knife and gun club” at St. Luke’s Roosevelt Hospital in Harlem and five years in Newark, New Jersey, before coming to L.A. “Newark made New York look like kindergarten,” she says.

Hearing Melissa’s accent is like flying to N.Y. and walking into Original Ray’s. She recalls a guy “who was having a big heart attack in room nine...In the middle of his pain, he heard me, looked up and said, ‘What part of the Island are you from?’ ”

“Why nursing?” I ask.

“I had a scholarship to the American Ballet Theatre, and I was good, but I wasn’t brilliant...and my dad said, ‘You need an education—go be a nurse.’ ”

I can’t imagine Melissa in ballet shoes, but 29 years ago, she traded them for a stethoscope. We’re at Orso, across the street from Cedars, having dinner after Melissa’s 7 a.m.–to–7 p.m. shift. She’s wearing a chic black jacket over blue scrubs, but there are smudges under her eyes. “Where do you find joy in the job?” I ask.

Without blinking, she says, “Using my knowledge to participate in stopping bad things that happen to people.”

Of course, they can’t always be stopped. You can’t stop a mother’s pain when her 18-month-old drowns. “The mom was still wet,” she says, “making a puddle by room three. When she knew her baby was gone, she wailed...just melted to the floor.” She pauses. “I swaddled her in warm blankets. It was all I could do for her.”

“What do you do for you?”

“I compartmentalize,” she says, finally smiling. “And I buy very expensive shoes.” She must have a closet full of Manolos.

Shari runs to cope with the stress. She did the 2007 Boston Marathon. “I’ve also run after psych patients who escaped the ER and took off down Gracie Allen toward 3rd Street.” She works mostly as a charge nurse, overseeing patient flow. If paramedics bring you in on a gurney, you’ll see the charge nurse first. That’s who decides whether the man in room four gets kicked into the hall because the room is needed for the woman the LAFD just scooped up off the pavement.

Some ER nurses charge, but all work triage and patient care. There are approximately 15 nurses on each shift, and shifts change all day. There are 41 beds in the ER—58 if they fill the halls. Cedars is a number one trauma center—the wait can be 10 minutes or four hours. Think of all the L.A. hospitals that have closed.

Shari, who was raised on a farm in Racine, Wisconsin, has been a nurse for 21 years. The only other job she considered was a baker...and that was when she was five. “How come you didn’t do that?”

“They have to get up really early,” she says, taking a bite from her perfectly wrapped homemade sandwich. She expertly cuts her peach with a paring knife.

Shari came on at 11 a.m. and will work until 11 p.m. We’re in the cafeteria on her dinner break, but she looks like she has just showered—blond curls escaping a perfect ponytail—a Goldilocks nurse who behaves like a general. I have seen her hustle a parade of bloody, broken patients through the door with the cool calm of an air-traffic controller moving jets through a bank of thunderstorms.

Abby and Sylvia carpool from Santa Clarita. They call the drive back and forth to Cedars their “psychotherapy hour.” Abby, fast and funny, was born in the Philippines. She has been a nurse 27 years—Hoboken and then L.A. “Why nursing?” I ask.

“I got into the short line,” Abby says, and she and Sylvia fall into a fit of laughter. “I’m Chinese, and when you’re Chinese, you’re supposed to study math—go into accounting, banking. So I went with my girlfriends to apply to school. All of the lines were really long, but there was this one short line, so I got into that one.”

“It was the premed, premed tech and nursing line,” Sylvia adds, smiling widely.

“I passed the test,” Abby says, “and I said to my friends, ‘Nursing?! My mom is going to kill me.’ ”

The ER can bring out the worst in people—not just the patients but the people bringing in the patients. Week after week, I see fear breed anger and despicable manners. I ask Abby how she deals with that. “You can’t take it personally,” she says. “You have to get over it and move on.”

“What’s the joy in this job?” I ask Sylvia, who has three children and has been a Cedars nurse for 19 years—not long enough to dim her radiant smile.

“You get to help people,” she says. “You make a difference.”

The nurses remind me about the funny stuff: the toddler whose potty got stuck on her head when she tried to put it on like a hat; the four-year-old who shoved an aspirin up his nose. “Did you have a headache?” Rich asked the kid.

Some of the nurses are on their second careers. Paul, one of the calmest in the ER, was a Navy SEAL. Jerry, who could find a vein in a stone, was a fashion designer. Joe was in marketing at Anheuser Busch. “And then came 9-11,” he recalls, “and I was watching those firefighters on TV, and I just knew I had to change my life. I had to do something honorable.”

Clean-cut, in pressed scrubs and Clark Kent glasses, Joe is the one you’d want to marry your daughter. “Can you have the same compassion for a drug addict as you do for a cardiac arrest or the patient back for the third time with terminal cancer?” I ask.

“You have to. What about the guy booked on a double vehicular manslaughter, still drunk, spewing ef-yous and showing no remorse? He’d kept driving after he hit them,” Joe says, eyes narrowing. “You have to give him the same care.”

Lots of people are brought into the ER in cuffs—think of gang shootings, car wrecks, domestic violence. Bad guys get hurt just like good guys, and they’re all brought to the same ER.

Kelly wanted to be a cop. “First an actress, second a cop,” she says. Raised in Tennessee and Arkansas, she calls herself a hillbilly but looks like a movie star. She hunts, motorcycles, parachutes and has an 11-year-old son. A nurse for 10 years, she once did CPR on a woman in the ER driveway.

“I was triaging, the doors opened, and someone was yelling for help. It was the sound of the help; the hairs on the back of my neck stood up,” Kelly recalls. “Female, mid seventies, cold as a cucumber, not breathing, in the passenger seat. I pulled her down onto the cement. There wasn’t any time; her feet were still in the car.”

Flor nods. She, Kelly and I are at Du-par’s on their day off. “I did CPR on a doctor once,” she says. “We were moving him to the OR, and he went into cardiac arrest. I jumped up on the gurney, straddled him and did CPR—in the elevator. It probably didn’t look good,” she says, brown eyes wide.

Flor is a “good Catholic girl” from Manila—nuns and rosary beads to Kelly’s bikes and rifles. “My aunt was a nurse in the U.S., and when she’d come home, it was like she was a celebrity. People gathered around—they made a fiesta: We have to kill a pig,” she says, grinning. “They respected her, and I thought, I want to be like that.” She has been a nurse for 31 years. She has three kids in college and looks like she’s their age. “I’m a caregiver,” she says. “That’s what I took the oath for.”

Triage is the hardest, most ER nurses agree. It’s not just the patients’ vitals. What are the skin signs, the alertness, the level of consciousness? Sweaty, pale, faint, red? It’s not just their pain.

“Triage is the most dangerous,” Nili says.

“You use your clinical judgment to assess the patient. You can’t let anyone slip past you, and you can’t make a mistake.” Tall and impressive, if Nili walked into your room with a needle, you’d extend your arm. “Why did you go into nursing?” I ask.

“Oh,” she says shyly, “I was out of control at Cal State Northridge, and my parents said, ‘It’s either nursing school or leave home.’ ” She has been on the job for 16 years. “Not everyone can do it.”

Well, that’s for damn sure. I’ve seen Nili on the trauma team, suited up in blue plastic, waiting for the paramedics to arrive, like a solider about to take a hill. I’ve sat next to her at the radio when the LAFD calls. The silent blue lights in the corners of the ER flash and spin, and a nurse on the blue team hotfoots it to the radio room. “Cedars base, copy,” and the line crackles: “This is Rescue 41. I have a 57-year-old male, altered LOC, in moderate distress; this is Rescue 27, I have a 16-year-old female...” And on it goes.

“Every day is a crisis,” Nili says.

ER nurses don’t give long-term care. They don’t get to know you, and they don’t even know what happens to you after you leave the ER. They are a platoon of adrenaline junkies with invisible capes and angel wings, there to take care of you at your worst moments. And it never ends. “Patients are like waves of ocean hitting the beach,” Shari says. “New ones just replace the old ones.”

“If I have to cry, I cry,” Mark says. “You can’t carry it to the next shift.” Blond and lanky, he has the mischievous air of a reformed bad boy. He did 10 years as a paramedic before his 10 as a nurse, so he has seen his share. “I wanted to be that person who knew what to do, how to run a code—perfectly.” A code, even laypeople know, is when the heart stops.

Mark thinks about the process for a moment and flashes one of his rare smiles. “It can be a miracle,” he says.

“Does it scare you anymore?”

“No,” he says. “I’m either enlightened or f--ked up.”