Ernesto Barbieri is a registered nurse in the Boston area whose writing has appeared in The Believer, Iowa Review, Midway Journal, Fourteen Hills, Berkeley Fiction Review, and elsewhere. A graduate of Hunter College’s MFA fiction program, he is at work on a novel and a graphic memoir.
Jess Ruliffson is a graphic journalist based in Boston. She teaches at Boston University and The Sequential Artists Workshop. See her work and connect at https://www.patreon.com/jessruliffson and www.jessruliffson.com.
Editors: Jim Dao, Marjorie Pritchard,
Amy MacKinnon, and Heather Hopp-Bruce
Animation and project management: Heather Hopp-Bruce
Digital editor: Rami Abou-Sabe
Audience engagement editor: Karissa Korman
Developer: Andrew Nguyen
Copy editor: Jessie Tremmel
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Written by
Ernesto Barbieri
Illustrated by
Jess Ruliffson
True stories from an ICU
THE SISTERS
Recovery
and decline
Recovery and decline
ICU stories 3:
When accidents happen
ICU stories 2:
Tenderness and brutality
ICU stories 1:
Recovery and decline
ICU stories 3:
When accidents happen
ICU stories 2:
Tenderness and brutality
ICU stories 1:
Recovery
and decline
ICU stories 3:
When accidents happen
ICU stories 2:
Tenderness
and brutality
ICU stories 1:
Editors: Jim Dao, Marjorie Pritchard,
Amy MacKinnon, and Heather Hopp-Bruce
Animation and project management: Heather Hopp-Bruce
Digital editor: Rami Abou-Sabe
Audience engagement editor: Karissa Korman
Developer: Andrew Nguyen
Copy editor: Jessie Tremmel
Ernesto Barbieri is a registered nurse in the Boston area whose writing has appeared in The Believer, Iowa Review, Midway Journal, Fourteen Hills, Berkeley Fiction Review, and elsewhere. A graduate of Hunter College’s MFA fiction program, he is at work on a novel and a graphic memoir.
Jess Ruliffson is a graphic journalist based in Boston. She teaches at Boston University and The Sequential Artists Workshop. See her work and connect at https://www.patreon.com/jessruliffson and www.jessruliffson.com.
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Although the events in this story are real, names have been changed to protect identities.
Recovery and decline
ICU stories 3:
When accidents happen
ICU stories 2:
Tenderness and brutality
ICU stories 1:
NEXT PANEL NARRATION: Sometimes you want to shake people. You want to scream in their faces: “Look at her! She’s dying!” But you can’t do that. The words don’t get through. The picture doesn’t cohere. The gasses won’t exchange. LABEL: Day 45 The doctor speaks to the sisters. The doctor: “We can continue to treat what’s treatable.” ROSE: “Yes, let’s do that.” NEXT PANEL NARRATION: What the sisters kept hearing was a promise. NEXT PANEL The ICU—Shift change. Ernesto takes a report from the day-charge nurse, Ann. NARRATION: Then one night I came to work and Helen wasn’t there. In her bed, a 31-year-old man who’d ingested some kind of poison. ERNESTO: “What happened to Helen?” ANN: “Shipped to Boston.” ERNESTO: “You’re kidding.” NEXT PANEL In the break room. Ernesto dumps the rest of the COOKIES in the trash. NARRATION: I wondered what would become of her. Would they keep resuscitating her body? Keep bringing her for more surgeries, opening and closing her like a suitcase? We could’ve offered her something better: a good death. It didn’t have to be unseemly. It could be lovely. Flowers, morphine. A quiet room. A quilted blanket. Things that cost almost nothing. NEXT PANEL FINAL SCENE—Church. NARRATION: In the pews my mind kept drifting. The priest was saying something about grace. Grace and mercy — I didn’t quite catch it. NEXT PANEL Closer on PRIEST. NARRATION: He was saying grace hinged on suffering . . . and without suffering, we could never know God. NARRATION: They were yoked together — mercy and grace. Twinned somehow. They were in dialogue with each other — connected in ways that didn’t always make sense. NEXT PANEL Closer on Ernesto. NARRATION: I leaned in closer. I was trying to understand.
NEXT PANEL Ernesto at home. On the couch, in his scrubs. The cat rubs up against his leg. NARRATION: Sometimes I’d come home from work and just space out. I would stare at the wall. I needed perfect silence, perfect stillness. NEXT PANEL Ernesto rummaging through the medicine cabinet. Jess appears at the doorway. She’s wearing an apron dusted with flour. JESS: “What’s wrong?” ERNESTO: “The cat bit me.” JESS: “Well, you didn’t say hi to her.” ERNESTO: “Say hi to who? The cat?” JESS: “Forget it.” NEXT PANEL {A dark room. Ernesto lies awake on the couch.} NARRATION: At night I’d try to forget the things I’d seen and done in the wards over the years — the bandaging of necrotic limbs, the siphoning of blood from withered arms, all the elderly unpersoned from their bodies, penned into rooms with no windows, no music, and no flowers. They seemed less like acts of valor and more like human rights violations. NEXT PANEL Jess and Ernesto eating dinner, Ernesto looking tired, or angry. Cat is on the table, sniffing food. NARRATION: Every so often I’d decide to spontaneously rejoin my marriage, and we’d sit for a meal together, and there would be an honesty between us. ERNESTO: “I wouldn’t want to live like that.” JESS: “Like what?” NARRATION: I was talking about Helen. I was relaying what many nurses say in private – that we’d rather die on the street than in our own wards. NEXT PANEL Ernesto and Jess still at the table; Ernesto is propping his head up with his hand. JESS: “What if I find you on the floor, not breathing?” ERNESTO: “Don’t call an ambulance. Call a priest.” JESS: “Why not call both?” ERNESTO: “No. Let me die.” JESS: “That doesn’t sound very Catholic.” NEXT PANEL A series of meetings with the sisters. They’re dressed differently in each panel — suggesting many such meetings. NARRATION: The doctors did not lie. They didn’t try to mislead. They chose their words carefully. The doctor: “She’s clinically improving.” AMELIA: “Oh, that’s good news.” The doctor: “Not necessarily.”
NARRATION: In the spaces between the words was the truth. The doctor: “I mean to say her numbers look better.” AMELIA: “Great.” The doctor: “That doesn’t mean she’s getting better.”
NEXT PANEL LABEL: Day 27 New character — CHLOE. Tall, with a septum piercing. Different color scrubs than the rest of the crew. Fancier scrubs. NARRATION: In October, the hospital hired a travel nurse named Chloe. She made herself right at home on our unit. CHLOE: “Mind if I use this?” {She takes Ernesto’s FOOTSTOOL} ERNESTO: “Be my guest.” NEXT PANEL As the docs discuss Helen’s case, Chloe props her legs up on FOOTSTOOL, listening without writing anything down. RESIDENT: “Helen’s Albumin is low again . . .” the doctor: “Where are we on goals of care?” INTERN: “Still a full code.” CHLOE: “So, what — she just wants to rot on the vent?” NARRATION: Dead silence. You could hear a pin drop. NEXT PANEL The intern stops typing. The doctor views Chloe over his glasses. The doctor: “Yes. Those are her wishes.” CHLOE: “Those can’t be her wishes.” The doctor: “It’s my understanding of her wishes.” NEXT PANEL NARRATION: An hour later, Chloe hit the call light, summoning us into the room. Helen tipped to her side (facing us) as Chloe does something behind her. Presumably she’s probing the pressure ulcer on her sacrum. The doctors shimmy into their gowns and enter the room. CHLOE: “Look at this. This is disgusting, inhumane. Look at this sacral wound. It’s huge. It’s down to the bone. You could stick your fist in it.” The doctor: “Okay. Show them.” NARRATION: Meaning the sisters. Meaning Chloe should let them see the festering wound, the kind of wound that grows in bedfast patients despite our best care, our best efforts. NARRATION: Offer them visual proof of Helen’s dismal prognosis. NEXT PANEL The sisters visit. Rose carries a paper bag from Trader Joe’s. Amelia has a blue circular tin of COOKIES she’s brought for the staff. NARRATION: When they are buzzed into the ward, Chloe greeted them with a hug — that surprised us. CHLOE: “I’ve heard so much about you.” NEXT PANEL Chloe stands behind Amelia, tying her gown’s drawstring. CHLOE: “Let’s tie a nice ribbon.” AMELIA: “Thank you.” CHLOE: “I love your sweater. Is that lamb’s wool?” AMELIA: “Why, yes.” CHLOE: “I never buy synthetics.” NARRATION: And we listened as Chloe segued incredibly from fabrics to wound care — describing the erosion of muscle and bone, the layers of yellow sloughing — after which the sisters thanked Chloe, and told us to carry on with the plan.
NEXT PANEL {COLOR SHIFT—Time passes; perspective switches to first-person} LABEL: Day 21 NARRATION: I was charge nurse by then. I posted the assignments in dry-erase marker. I tried to be equitable with the assignments. But I never wrote my name in that last slot. Ernesto writes on a gridded white-board. He is hesitating filling in a line. NARRATION: I was afraid of Helen, for some reason. The way she stared at the ceiling, her mouth agape in unfed hunger, and she never seemed to sleep. NEXT PANEL The sisters fad in over an image of helen in her bed. It is night; stars twinkle in the sky through the window. NARRATION: And I was leery of the sisters, both sisters. I didn’t understand how they could look at Helen and possibly see any meaningful chance of recovery. NEXT PANEL A Catholic mass. A priest presides over a good turnout, a mix of all ages. No phones, no masks are present. In the pews we see Ernesto and his wife. NARRATION: In church with my wife, Jess, I get restless. The pageantry, the organ music. Ridiculous, all of it. But yet I enjoyed going. NEXT PANEL Ernesto and and Jess walk home on a crisp and clear afternoon. NARRATION: In the afterglow of mass, I felt healthy and cleansed in ways I can’t describe. JESS: “What’d you think of the sermon?” ERNESTO: “Something about a vineyard?” JESS: “You weren’t listening.” ERNESTO: “I was.” JESS: “He said whoever’s first will be last.” ERNESTO: “I couldn’t understand him.” NEXT PANEL In a monotone purple scene, Ernesto sits by himself in the dark, illuminated by the TV screen as he plays a video game. NARRATION: I was mired in a rut. Disconnected from the pulse of my life. NEXT PANEL Ernesto watches TV . . . an ad for a new, unnamed pharmaceutical comes on.} COMMERCIAL: “Side effects may include vomiting, intestinal torsion, blindness, and exploding head syndrome . . .” NARRATION: It seemed to me that the bond between medicine and healing had dissolved irreversibly, had mutated into something obscene. I couldn’t shake the feeling that we were foot soldiers in some vast criminal enterprise.
NEXT PANEL NARRATION: In all our time caring for Helen — bathing Helen, clipping her fingernails (with that grip, she could hurt you) suctioning mucus from her airway, and irrigating her fecal tube — in all that time, Helen spoke just one word: HELEN: “No.” Ernesto checks Helen’s vitals as clouds pass slowly in the window NEXT PANEL NARRATION: Logrolling Helen to stuff pillows under her deteriorating elbows and hips HELEN: “No.” Ernesto has rolled Helen onto her side and is fitting a bolster to support her as clouds, darker now, roll past out the window NEXT PANEL NARRATION: Packing her decubitus ulcer with moistened gauze, and then, once it dried, unraveling it in red ropy braids. HELEN: “No, no, no.” Ernesto and nurse Laura are attending to Helen, who is now on her back. Dark clouds form out the window and heavy rain begins. NEXT PANEL NARRATION: At some point, early in Helen’s stay, we noticed a gurgling sound coming from her feeding tube. When we clamped the tube, the sound shifted back up to her tracheostomy. The doctor and Laura look at Helen, concerned. LAURA: “Isn’t that weird?” The doctor: “Yes. Weird.” NEXT PANEL NARRATION: That air was escaping from the incision in Helen’s throat, and also from the one in her umbilicus, suggesting an unnatural connection — a fistula — between her esophagus and trachea. This sounded bad, and was in fact very bad. NEXT PANEL NARRATION: The surgeons came the following Tuesday. They examined Helen in a brief, perfunctory sort of way and then rendered a decision. A new doctor is talking to the staff doctor and Laura stands by, arms crossed. ENT DOC: “We’re not touching her without cardiothoracic on board.” NARRATION: Our hospital, poor as it was, did not employ any cardiothoracic surgeons. In order to fix this problem, Helen would need to be airlifted to a major hospital in Boston. This was impossible, lacking a helipad as we did, and anyway Helen was too unstable to be flown across the city. NEXT PANEL Laura hangs a bag of yellow fluid as the sisters look on. ROSE (to Amelia): “She’s looking better, isn’t she?” AMELIA: “She’s been through so much.” LAURA (unsmiling): “Yes, she has. A lot.” NEXT PANEL NARRATION: So it went for many weeks — us keeping Helen alive with increasing doses of oxygen, opioids, vasopressors, electricity, blood products, antibiotics, and steroids — and the sisters visiting religiously, asking the usual questions, and enlisting us in the torture of Helen.
NEXT PANEL It’s night now and the sisters are gone. Ernesto is watching the monitors behind Helen’s bed. NARRATION: It happened a lot. Too often. We’d get these patients and they’d languish. Held in stasis, hostages of medicine. Scanned, probed, drained. NEXT PANEL Wide view. The doctor, ERNESTO, an INTERN, and a RESIDENT hold a mini-conference with the SISTERS. They are discussing goals of care — i.e. how aggressively to treat Helen’s condition. ROSE: “Believe me, I wouldn’t want this. But I’m not her, you understand. I am not my sister. And Helen, she was very clear — she wants everything done.” NARRATION: We leaned in closer. We were trying to understand. NEXT PANEL MEDIUM VIEW. Tighter on just the doctor and the SISTERS. The doctor: “When did she say this?” ROSE: “Many times. Do everything — that’s what she said.” The doctor: “Recently she said this?” ROSE: “Recently enough.” The doctor: “How recently?” ROSE: “Oh, I don’t know. Weeks?” {Turns to check w/ her sister.} AMELIA: “That sounds about right.” NEXT PANEL Back to WIDE VIEW — the ICU team appearing skeptical. NARRATION: But it seems to us, from the size of her tracheostomy, that Helen hadn’t spoken in a very long time. ROSE: “Look, if she hadn’t told me, I’d sign the DNR right now.” the doctor: “No, you don’t have to sign anything tonight.” ROSE: “I’d say pull the plug. But that’s not what Helen wanted.” the doctor: “No, no, don’t pull any plugs.” NEXT PANEL {LONG SHOT: An ICU room with windows looking out on Boston’s skyline.} NARRATION: We moved Helen down to the end of the hall, a large room with spectacular views of the cloudscapes over Boston. LABEL: Day 7 NARRATION: We anticipated a long stay. NEXT PANEL The respiratory therapist, DENISE, explains the ventilator’s settings to the sisters. DENISE: “We’re maxed out. We can’t go any higher.” ROSE: “Yes, I see.” DENISE: “She’s not oxygenating. The gases won’t exchange.” AMELIA: “We understand.” NARRATION: But it was clear that they did not see, did not understand.
The Sisters True stories from an ICU Written by Ernesto Barbieri Illustrated by Jess Ruliffson {COLOR SCHEME—“winterberries”—merlot, mauve, seafoam green, olive, touch of bright yellow} Title image: Two women, standing on opposite sides of the screen looking toward one another. Robust-looking women, their hair in perms like steel wool. AMELIA is taller and wears a plastic face shield over her mask. Both wear loose-fitting, soft-colored wool sweaters that seem homemade. NEXT PANEL LABEL: Day 1 NARRATION: When Helen could no longer breathe, they brought her to the hospital. SCENE: An ICU at night. Paramedics deliver a woman, HELEN, to the waiting night crew. Helen is in her late 70s, gasping, malnourished, with a pre-existing tracheostomy and surgically-implanted feeding tube (via her abdomen). Her tracheostomy dressing is stained red. There’s a CROAKING sound coming from the trach–expressed in the comic as “gruh-gruh”. There’s a white scruff of beard on her chin. She’s been uncared for. NARRATION: Paramedics couldn’t tell us much. But she appeared unwell. ERNESTO: “What’s that sound?” In the background, the letters kssssssssss extend off the screen Doctor: “Helen, can you hear us? Helen. Helen!” NEXT PANEL NARRATION: She’d been living in a care home on the fringes of the city. LAURA: “OK, let’s check her skin.” NARRATION: A knee surgery, gone septic. NEXT PANEL NARRATION: Her sisters, Amelia and Rose, came later that night. They followed all our protocols, all our little rules. They kept their masks pinched tightly over their noses. SCENE: The two sisters approach Helen, in her bed, eyes closed and tube emerging from the base of her throat. NARRATION: We never saw their faces. NEXT PANEL Ernesto is tending to Helen as Rose sits bedside, watching. Amelia is inspecting the IV bag. NARRATION: Rose had been a nurse. She was Helen’s legal proxy, her decision maker. Amelia took great interest in the bags of fluid we hung from hooks above Helen’s bed. NEXT PANEL NARRATION: Whenever the doctor adjusted the vent settings, Amelia would listen and nod, silently transmitting her acquiescence. Amelia is talking to the doctor in the background as Ernesto checks Helen’s vitals. Rose leans in to watch, clutching her bag. NARRATION: Rose, though. Maybe Rose wasn’t so sure. She seemed dubious of the whole operation – the injections, the hourly reflex checks, the midnight trips to MRI, all the medical baubles and knickknacks we dragged into the room.
NEXT PANEL NARRATION: Sometimes you want to shake people. You want to scream in their faces: “Look at her! She’s dying!” But you can’t do that. The words don’t get through. The picture doesn’t cohere. The gasses won’t exchange. LABEL: Day 45 The doctor speaks to the sisters. The doctor: “We can continue to treat what’s treatable.” ROSE: “Yes, let’s do that.” NEXT PANEL NARRATION: What the sisters kept hearing was a promise. NEXT PANEL The ICU—Shift change. Ernesto takes a report from the day-charge nurse, Ann. NARRATION: Then one night I came to work and Helen wasn’t there. In her bed, a 31-year-old man who’d ingested some kind of poison. ERNESTO: “What happened to Helen?” ANN: “Shipped to Boston.” ERNESTO: “You’re kidding.” NEXT PANEL In the break room. Ernesto dumps the rest of the COOKIES in the trash. NARRATION: I wondered what would become of her. Would they keep resuscitating her body? Keep bringing her for more surgeries, opening and closing her like a suitcase? We could’ve offered her something better: a good death. It didn’t have to be unseemly. It could be lovely. Flowers, morphine. A quiet room. A quilted blanket. Things that cost almost nothing. NEXT PANEL FINAL SCENE—Church. NARRATION: In the pews my mind kept drifting. The priest was saying something about grace. Grace and mercy — I didn’t quite catch it. NEXT PANEL Closer on PRIEST. NARRATION: He was saying grace hinged on suffering . . . and without suffering, we could never know God. NARRATION: They were yoked together — mercy and grace. Twinned somehow. They were in dialogue with each other — connected in ways that didn’t always make sense. NEXT PANEL Closer on Ernesto. NARRATION: I leaned in closer. I was trying to understand.
NEXT PANEL Ernesto at home. On the couch, in his scrubs. The cat rubs up against his leg. NARRATION: Sometimes I’d come home from work and just space out. I would stare at the wall. I needed perfect silence, perfect stillness. NEXT PANEL Ernesto rummaging through the medicine cabinet. Jess appears at the doorway. She’s wearing an apron dusted with flour. JESS: “What’s wrong?” ERNESTO: “The cat bit me.” JESS: “Well, you didn’t say hi to her.” ERNESTO: “Say hi to who? The cat?” JESS: “Forget it.” NEXT PANEL {A dark room. Ernesto lies awake on the couch.} NARRATION: At night I’d try to forget the things I’d seen and done in the wards over the years — the bandaging of necrotic limbs, the siphoning of blood from withered arms, all the elderly unpersoned from their bodies, penned into rooms with no windows, no music, and no flowers. They seemed less like acts of valor and more like human rights violations. NEXT PANEL Jess and Ernesto eating dinner, Ernesto looking tired, or angry. Cat is on the table, sniffing food. NARRATION: Every so often I’d decide to spontaneously rejoin my marriage, and we’d sit for a meal together, and there would be an honesty between us. ERNESTO: “I wouldn’t want to live like that.” JESS: “Like what?” NARRATION: I was talking about Helen. I was relaying what many nurses say in private – that we’d rather die on the street than in our own wards. NEXT PANEL Ernesto and Jess still at the table; Ernesto is propping his head up with his hand. JESS: “What if I find you on the floor, not breathing?” ERNESTO: “Don’t call an ambulance. Call a priest.” JESS: “Why not call both?” ERNESTO: “No. Let me die.” JESS: “That doesn’t sound very Catholic.” NEXT PANEL A series of meetings with the sisters. They’re dressed differently in each panel — suggesting many such meetings. NARRATION: The doctors did not lie. They didn’t try to mislead. They chose their words carefully. The doctor: “She’s clinically improving.” AMELIA: “Oh, that’s good news.” The doctor: “Not necessarily.”
NARRATION: In the spaces between the words was the truth. The doctor: “I mean to say her numbers look better.” AMELIA: “Great.” The doctor: “That doesn’t mean she’s getting better.”
NEXT PANEL LABEL: Day 27 New character — CHLOE. Tall, with a septum piercing. Different color scrubs than the rest of the crew. Fancier scrubs. NARRATION: In October, the hospital hired a travel nurse named Chloe. She made herself right at home on our unit. CHLOE: “Mind if I use this?” {She takes Ernesto’s FOOTSTOOL} ERNESTO: “Be my guest.” NEXT PANEL As the docs discuss Helen’s case, Chloe props her legs up on FOOTSTOOL, listening without writing anything down. RESIDENT: “Helen’s Albumin is low again . . .” the doctor: “Where are we on goals of care?” INTERN: “Still a full code.” CHLOE: “So, what — she just wants to rot on the vent?” NARRATION: Dead silence. You could hear a pin drop. NEXT PANEL The intern stops typing. The doctor views Chloe over his glasses. The doctor: “Yes. Those are her wishes.” CHLOE: “Those can’t be her wishes.” The doctor: “It’s my understanding of her wishes.” NEXT PANEL NARRATION: An hour later, Chloe hit the call light, summoning us into the room. Helen tipped to her side (facing us) as Chloe does something behind her. Presumably she’s probing the pressure ulcer on her sacrum. The doctors shimmy into their gowns and enter the room. CHLOE: “Look at this. This is disgusting, inhumane. Look at this sacral wound. It’s huge. It’s down to the bone. You could stick your fist in it.” The doctor: “Okay. Show them.” NARRATION: Meaning the sisters. Meaning Chloe should let them see the festering wound, the kind of wound that grows in bedfast patients despite our best care, our best efforts. NARRATION: Offer them visual proof of Helen’s dismal prognosis. NEXT PANEL The sisters visit. Rose carries a paper bag from Trader Joe’s. Amelia has a blue circular tin of COOKIES she’s brought for the staff. NARRATION: When they are buzzed into the ward, Chloe greeted them with a hug — that surprised us. CHLOE: “I’ve heard so much about you.” NEXT PANEL Chloe stands behind Amelia, tying her gown’s drawstring. CHLOE: “Let’s tie a nice ribbon.” AMELIA: “Thank you.” CHLOE: “I love your sweater. Is that lamb’s wool?” AMELIA: “Why, yes.” CHLOE: “I never buy synthetics.” NARRATION: And we listened as Chloe segued incredibly from fabrics to wound care — describing the erosion of muscle and bone, the layers of yellow sloughing — after which the sisters thanked Chloe, and told us to carry on with the plan.
NEXT PANEL {COLOR SHIFT—Time passes; perspective switches to first-person} LABEL: Day 21 NARRATION: I was charge nurse by then. I posted the assignments in dry-erase marker. I tried to be equitable with the assignments. But I never wrote my name in that last slot. Ernesto writes on a gridded white-board. He is hesitating filling in a line. NARRATION: I was afraid of Helen, for some reason. The way she stared at the ceiling, her mouth agape in unfed hunger, and she never seemed to sleep. NEXT PANEL The sisters fad in over an image of helen in her bed. It is night; stars twinkle in the sky through the window. NARRATION: And I was leery of the sisters, both sisters. I didn’t understand how they could look at Helen and possibly see any meaningful chance of recovery. NEXT PANEL A Catholic mass. A priest presides over a good turnout, a mix of all ages. No phones, no masks are present. In the pews we see Ernesto and his wife. NARRATION: In church with my wife, Jess, I get restless. The pageantry, the organ music. Ridiculous, all of it. But yet I enjoyed going. NEXT PANEL Ernesto and and Jess walk home on a crisp and clear afternoon. NARRATION: In the afterglow of mass, I felt healthy and cleansed in ways I can’t describe. JESS: “What’d you think of the sermon?” ERNESTO: “Something about a vineyard?” JESS: “You weren’t listening.” ERNESTO: “I was.” JESS: “He said whoever’s first will be last.” ERNESTO: “I couldn’t understand him.” NEXT PANEL In a monotone purple scene, Ernesto sits by himself in the dark, illuminated by the TV screen as he plays a video game. NARRATION: I was mired in a rut. Disconnected from the pulse of my life. NEXT PANEL Ernesto watches TV . . . an ad for a new, unnamed pharmaceutical comes on.} COMMERCIAL: “Side effects may include vomiting, intestinal torsion, blindness, and exploding head syndrome . . .” NARRATION: It seemed to me that the bond between medicine and healing had dissolved irreversibly, had mutated into something obscene. I couldn’t shake the feeling that we were foot soldiers in some vast criminal enterprise.
NEXT PANEL NARRATION: In all our time caring for Helen — bathing Helen, clipping her fingernails (with that grip, she could hurt you) suctioning mucus from her airway, and irrigating her fecal tube — in all that time, Helen spoke just one word: HELEN: “No.” Ernesto checks Helen’s vitals as clouds pass slowly in the window NEXT PANEL NARRATION: Logrolling Helen to stuff pillows under her deteriorating elbows and hips HELEN: “No.” Ernesto has rolled Helen onto her side and is fitting a bolster to support her as clouds, darker now, roll past out the window NEXT PANEL NARRATION: Packing her decubitus ulcer with moistened gauze, and then, once it dried, unraveling it in red ropy braids. HELEN: “No, no, no.” Ernesto and nurse Laura are attending to Helen, who is now on her back. Dark clouds form out the window and heavy rain begins. NEXT PANEL NARRATION: At some point, early in Helen’s stay, we noticed a gurgling sound coming from her feeding tube. When we clamped the tube, the sound shifted back up to her tracheostomy. The doctor and Laura look at Helen, concerned. LAURA: “Isn’t that weird?” The doctor: “Yes. Weird.” NEXT PANEL NARRATION: That air was escaping from the incision in Helen’s throat, and also from the one in her umbilicus, suggesting an unnatural connection — a fistula — between her esophagus and trachea. This sounded bad, and was in fact very bad. NEXT PANEL NARRATION: The surgeons came the following Tuesday. They examined Helen in a brief, perfunctory sort of way and then rendered a decision. A new doctor is talking to the staff doctor and Laura stands by, arms crossed. ENT DOC: “We’re not touching her without cardiothoracic on board.” NARRATION: Our hospital, poor as it was, did not employ any cardiothoracic surgeons. In order to fix this problem, Helen would need to be airlifted to a major hospital in Boston. This was impossible, lacking a helipad as we did, and anyway Helen was too unstable to be flown across the city. NEXT PANEL Laura hangs a bag of yellow fluid as the sisters look on. ROSE (to Amelia): “She’s looking better, isn’t she?” AMELIA: “She’s been through so much.” LAURA (unsmiling): “Yes, she has. A lot.” NEXT PANEL NARRATION: So it went for many weeks — us keeping Helen alive with increasing doses of oxygen, opioids, vasopressors, electricity, blood products, antibiotics, and steroids — and the sisters visiting religiously, asking the usual questions, and enlisting us in the torture of Helen.
NEXT PANEL It’s night now and the sisters are gone. Ernesto is watching the monitors behind Helen’s bed. NARRATION: It happened a lot. Too often. We’d get these patients and they’d languish. Held in stasis, hostages of medicine. Scanned, probed, drained. NEXT PANEL Wide view. The doctor, ERNESTO, an INTERN, and a RESIDENT hold a mini-conference with the SISTERS. They are discussing goals of care — i.e. how aggressively to treat Helen’s condition. ROSE: “Believe me, I wouldn’t want this. But I’m not her, you understand. I am not my sister. And Helen, she was very clear — she wants everything done.” NARRATION: We leaned in closer. We were trying to understand. NEXT PANEL MEDIUM VIEW. Tighter on just the doctor and the SISTERS. The doctor: “When did she say this?” ROSE: “Many times. Do everything — that’s what she said.” The doctor: “Recently she said this?” ROSE: “Recently enough.” The doctor: “How recently?” ROSE: “Oh, I don’t know. Weeks?” {Turns to check w/ her sister.} AMELIA: “That sounds about right.” NEXT PANEL Back to WIDE VIEW — the ICU team appearing skeptical. NARRATION: But it seems to us, from the size of her tracheostomy, that Helen hadn’t spoken in a very long time. ROSE: “Look, if she hadn’t told me, I’d sign the DNR right now.” the doctor: “No, you don’t have to sign anything tonight.” ROSE: “I’d say pull the plug. But that’s not what Helen wanted.” the doctor: “No, no, don’t pull any plugs.” NEXT PANEL {LONG SHOT: An ICU room with windows looking out on Boston’s skyline.} NARRATION: We moved Helen down to the end of the hall, a large room with spectacular views of the cloudscapes over Boston. LABEL: Day 7 NARRATION: We anticipated a long stay. NEXT PANEL The respiratory therapist, DENISE, explains the ventilator’s settings to the sisters. DENISE: “We’re maxed out. We can’t go any higher.” ROSE: “Yes, I see.” DENISE: “She’s not oxygenating. The gases won’t exchange.” AMELIA: “We understand.” NARRATION: But it was clear that they did not see, did not understand.
The Sisters True stories from an ICU Written by Ernesto Barbieri Illustrated by Jess Ruliffson {COLOR SCHEME—“winterberries”—merlot, mauve, seafoam green, olive, touch of bright yellow} Title image: Two women, standing on opposite sides of the screen looking toward one another. Robust-looking women, their hair in perms like steel wool. AMELIA is taller and wears a plastic face shield over her mask. Both wear loose-fitting, soft-colored wool sweaters that seem homemade. NEXT PANEL LABEL: Day 1 NARRATION: When Helen could no longer breathe, they brought her to the hospital. SCENE: An ICU at night. Paramedics deliver a woman, HELEN, to the waiting night crew. Helen is in her late 70s, gasping, malnourished, with a pre-existing tracheostomy and surgically-implanted feeding tube (via her abdomen). Her tracheostomy dressing is stained red. There’s a CROAKING sound coming from the trach–expressed in the comic as “gruh-gruh”. There’s a white scruff of beard on her chin. She’s been uncared for. NARRATION: Paramedics couldn’t tell us much. But she appeared unwell. ERNESTO: “What’s that sound?” In the background, the letters kssssssssss extend off the screen Doctor: “Helen, can you hear us? Helen. Helen!” NEXT PANEL NARRATION: She’d been living in a care home on the fringes of the city. LAURA: “OK, let’s check her skin.” NARRATION: A knee surgery, gone septic. NEXT PANEL NARRATION: Her sisters, Amelia and Rose, came later that night. They followed all our protocols, all our little rules. They kept their masks pinched tightly over their noses. SCENE: The two sisters approach Helen, in her bed, eyes closed and tube emerging from the base of her throat. NARRATION: We never saw their faces. NEXT PANEL Ernesto is tending to Helen as Rose sits bedside, watching. Amelia is inspecting the IV bag. NARRATION: Rose had been a nurse. She was Helen’s legal proxy, her decision maker. Amelia took great interest in the bags of fluid we hung from hooks above Helen’s bed. NEXT PANEL NARRATION: Whenever the doctor adjusted the vent settings, Amelia would listen and nod, silently transmitting her acquiescence. Amelia is talking to the doctor in the background as Ernesto checks Helen’s vitals. Rose leans in to watch, clutching her bag. NARRATION: Rose, though. Maybe Rose wasn’t so sure. She seemed dubious of the whole operation – the injections, the hourly reflex checks, the midnight trips to MRI, all the medical baubles and knickknacks we dragged into the room.