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
Developer: Andrew Nguyen
Copy editor: Jessie Tremmel
Tenderness and brutality
Read ICU stories 1:
Series
When accidents happen
Read ICU stories 2:
RECOVERY
AND DECLINE
True stories
from an ICU
Written by
Ernesto Barbieri
Illustrated by
Jess Ruliffson
(SCENE: Gemma is at a computer near where the action is happening. Ernesto walks by.) ERNESTO: “Gemma, go home.” BETH: “You sure? I haven’t charted anything.” ERNESTO: “Your shuttle’s leaving.” ERNESTO: “Trust me. Leave. While you can.” CAPTION: It might double as career advice: Leave. While you can. SCENE: Gemma, wearing a plaid coat and scarf, walks out of the hospital. Fall leaves swirl at her feet. CAPTION: I feel sorry for these new nurses, who came through the crucible of the pandemic, and now there’s nothing left for them. SCENE: An empty hospital bed. CAPTION: Pete was flown to a hospital in Boston. I don’t know if he made it. But if he survived, I hope he’s free of pain — and that he remembers what I said, about how I got sober.
(SCENE: Gemma is tending to Pete; Ernesto walks into the room. Pete now looks gravely ill—pouring sweat, abdomen grossly distended. Beth fixes a blood pressure cuff to his leg. On both his arms are other, different-sized cuffs. Behind them the monitor reads: No Measurement. His heart rate is in the 200s.) TIME: 6:05 p.m. CAPTION: Pete is deteriorating. Gemma: “I can’t get a pressure.” ERNESTO: “Does he have a pulse?” CAPTION: He’s got that dead fish color. BETH: “Still no blood pressure.” ERNESTO: “I’ll grab a manual.” (SCENE: Ernesto stands next to Pete’s bed taking a manual blood pressure reading with a cuff. Sweat is dripping from Pete’s browline and his shirt is damp with sweat.) CAPTION: A lost art, the manual blood pressure. Requires nuance. Sensitivity. You need to be able to look, touch, listen, intuit — and guess. ERNESTO: “Hey, Pete, stay with me.” (pause) ERNESTO: “Something’s wrong.” (SCENE: Ernesto is how holding an IV bag.) ERNESTO: “I’m starting norepinephrine.” DEFINITION: A common vasoactive drug used in the ICU, norepinephrine increases cardiac output — and heart rate — by helping the heart “squeeze.” TEXT: It’s a poor choice. And I know it’s a poor choice. The drug he needs is phenylephrine — but we don’t have it stocked. DEFINITION: A pure vasoconstrictor, phenylephrine improves blood pressure — but without the consequent rise in heart rate. (SCENE: Coming back into the room, Ernesto hands Gemma a bag of norepinephrine.) ERNESTO: “Hang this. I’m calling pharmacy.”\ CAPTION: So here’s a scene for you. Three nurses, one brain-fried resident, and a kid who’s about to go into cardiac arrest. Thirty minutes to keep him alive. Go. (SCENE: A doctor and multiple nurses are trying to gain control of the situation. A blood pressure has finally resulted on the monitor. It’s not good: 60/20.) DOCTOR: Let’s get some blood cultures. NURSE 1: Is that really a priority? DOCTOR: If he’s septic, yes. GEMMA: You can’t treat an infection if he’s dead. DOCTOR: OK. Give us another bolus of ringer’s GEMMA: He doesn’t need more fluids. DOCTOR: How’s his urine look? GEMMA: Like Lipton tea ERNESTO: Guys, he doesn’t need more fluids. It’s all in his abdomen — look. DOCTOR: “We can diurese him later.” ERNESTO: “With that blood pressure??” DOCTOR: “I know. I’m buying time. ERNESTO: “Call Dr. Gaffney.” CAPTION: I feel like that’s all we’re doing, all this job’s become: buying time. Treading water. Trying not to drown. (SCENE) Three new nurses arrive on the scene and excitedly put on their gloves.) CAPTION: Night crew trundles in. They seem energized by the spectacle. ICU nurses are funny like that. (SCENE: Some of the nurses are talking.) NURSE 1: I hate to ask you this. NURSE 2: No. Absolutely not. NURSE 1: Just hear me out. NURSE 2: I’m not picking up a shift tomorrow. ERNESTO: Don’t look at me.
(SCENE: A blond male nurse gently washed the arm of an intubated woman.” CAPTION: Years ago, a nurse I worked with — call him Simon — overdosed in our ICU. He was a traveler — one of those mercenaries who helped us through the pandemic. He was a great nurse. (SCENE: The blond nurse stands with his arms in the arm, while Ernesto sits at the charge desk.) CAPTION: But I’d noticed him acting strangely, giggling, bursting into manic episodes of song ... SIMON: (singing) “I don’t wanna wait . . . for our li-i-ives to be over…” . . .” (SCENE: The blond nurse is slumped at a desk. His skin is a light greenish color. A nurse stands above him with her arms up, shouting.) CAPTION: We found him slumped in his chair at the nursing station. Cyanotic, brachycardic. NURSE: “I need Narcan!” CAPTION: There was an IV in his arm — self-inserted — and drops of blood at his feet.
(SCENE) Three nurses stand at the blond nurse’s desk. Ernesto, in the middle, is holding a small empty milk carton.) CAPTION: And there were all these little cartons of milk scattered about. It was the weirdest thing. NURSE 1: (to Ernesto) “Dude, what’s with the milk?” ERNESTO: “I don’t know.” NURSE 2: Is that … propofol? ERNESTO: I have no idea NURSE 2: He’s injecting propofol? DEFINITION: Propofol: A potent hypnotic and sedative, easily identified by its opaque white color. Often used in conjunction with fentanyl to induce deep sleep in ventilated patients. Jokingly referred to as “milk of amnesia” (although never in clinical practice). TEXT: We theorized he was filling the milk cartons with propofol for easy access. Searching the unit, we found other things that had somehow escaped our attention. A large syringe filled with fentanyl, stashed in one of the rooms. Blood on the rim of the toilet and streaks of blood on the wall, presumably from self injections. Scandalous things. Obvious things. Things no one was looking for, so no one had seen.
(SCENE: A man is curled up sleeping in a church pew as the warm light from a stained glass window falls gently upon him.) CAPTION: Cyanotic, bradycardic — that’s how we find them. Slumped at the wheel as the light turns green . . . breathless and blue in a Walgreens parking lot (it’s always Walgreens, for some reason) . . . in church pews covered in vomit . . . pressed against sewer grates with gangrenous limbs . . . (SCENE: Portrait grid of four young men in work clothes.) TEXT: Today it’s four HVAC guys who say they snorted a mysterious white powder they found in the ducts. Two were airlifted to Boston. Another woke up after a single dose of naloxone. The fourth is downstairs, waiting for an ICU bed. (SCENE: Ernesto is on the phone with Janice the E.R. emergency room director.) CAPTION: We’ve been hearing about him all morning. JANICE: “Heads up. He might get tubed. He keeps going apneic.” DEFINITION: Apneic: Defined as the absence of breathing. Can be transient, as in sleep apnea or holding one's breath, or severe, as in chest trauma. ERNESTO: (scribbling) “OK..” JANAICE: “He’s done it like 40 times.” ERNESTO: (scribbling) “Yikes.” JANAICE: “We’re going to run out of Narcan.” CAPTION: In his clinical note it’s written that he “insufflated a white substance, presumably fentanyl, for reasons unknown.” Well, I think I know the reason. DEFINITION: Insufflate: To blow or sweep something into a body cavity. A term used mostly in laparoscopic procedures, where CO2 gas is pumped into the abdomen to expand/enlarge the operative space. ERNESTO: (still on phone) “Weird question. Did you save the vials? I want to show him.” JANICE: “We did save the vials!” ERNESTO: “Can you put them in a biohazard bag for me?” (SCENE: The fourth HVAC guy —“BOB”—comes in on a gurney wearing a non-rebreather mask. Janice and another E.R. nurse steer him into a room: Time: 3:55 p.m. ERNESTO: (shaking patient awake) “Bob! Hey! Bob, can you hear me?” (SCENE: Ernesto holds up a clear bag filled with several dozen empty vials.) ERNESTO: “This is how much Narcan you’ve gotten.” BOB: “Is that a lot?” ERNESTO: “Yeah. It’s a lot.” CAPTION: It hasn’t set in yet — I can tell. He thinks it’s a joke. BOB: “Can I take a picture?” ERNESTO: “Sure. Take a picture.” BOB: “I’m posting it to Facebook.” Ernesto: “No, don’t do that.” CAPTION: It will hit him in the morning, when he finds out what happened to his friends.
(SCENE: Ernesto is back at the charge desk, talking on the phone.) TIME: 1:15 p.m. ERNESTO: “Hey, I need a sober coach.” INGRID, on the other line: “You do?” ERNESTO: “Not for me. For bed 8.” INGRID: “Try the bridge clinic. Or a church.” ERNESTO: “A church?” INGRID: “Sometimes they hang out in churches.” (SCENE: Ernesto sitting at the computer.) CAPTION: Poking around the kid’s notes, I see he’s had 13 E.R. visits in the last month alone. His M.O. is showing up in an hour of crisis and asking for Valium. And it’s sad because he knows he needs help with his addiction, and he’s coming to the one place he should be able to get it. But there’s nothing here for him. (SCENE: Ernesto is sitting at the charge desk. A woman in pigtails wearing a pink shirt that says “believe” has come in.) CAPTION: The sober coach breezes in. I’ve never seen her before. But she radiates serenity. She broadcasts good cheer. SOBER COACH: (at charge desk) “Sorry to interrupt. He looks super busy in there.” ERNESTO: “Don’t be sorry. We love recovery coaches here.” SOBER COACH: “They’re really draining him, huh?” ERNESTO: “Yes they are.” CAPTION: We get to talking. And she tells me her story. An alcoholic at 12, addicted to meth at 14. Tangled up in the legal system for the next twenty 20 years. SOBER COACH: “A judge saved my life. He’s still on the bench. And part of what I do, I go to the courthouse and advocate for the pill heads.” ERNESTO: “Wow.” SOBER COACH: “And I tell them: I spent half my life in this courtroom. My foot was shackled to that table. Recovery is possible. But you’ve got to want it.” ERNESTO: “Right.” SOBER COACH: “You’ve got to seek it out, you know?.” ERNESTO: “I do know.” SOBER COACH: “You can’t find what you’re not looking for.”
(SCENE: Ernesto encounters another nurse, who is very pregnant) CAPTION: In beds 2 and 3 are classic ICU patients — a woman with dementia whose family reversed her DNR; a man with emphysema who can’t get off the vent. ERNESTO (to another nurse): “You seen any recovery coaches?” NURSE: “We don’t have any.” ERNESTO: “Why not?” NURSE: “It’s Friday. There’s no one.” TEXT: We hear that all the time now: There’s no one. No one to sit with the dying, no one to feed the strokes, no one to set up the trays, no one to fetch blood products, no one to perform the essential functions of a hospital. Flashing text: “Rapid response, outpatient pharmacy.” (SCENE: Ernesto is rushing down a flight of stairs with a bright orange bag over one shoulder.) CAPTION: I grab a jar of Narcan and the Drill. DEFINITION: The intraosseous drill is a battery-powered device that deploys a hollow needle to a large bone, usually the shoulder or leg. Useful when IV access is limited or impossible. (SCENE: A crowd has gathered by the shuttered gift shop. A young man is on the floor, weeping and screaming. His body is strangely contorted, as if in the throes of a seizure. The man is screaming “AAAHHHH!”) (SCENE: Three women stand around the man on the floor: Janice the E.R. emergency room director; Cheryl from Respiratory; and Ingrid the house supervisor.) JANICE: “We just saw this guy.” ERNESTO: “What for?” JANICE: (shrugs) “What else? Pain.” (waves hand) “Pain, pain, pain, pain, pain.” Ingrid: “OK, let’s get him in a wheelchair.” (SCENE: Janice and Ingrid wheeling the man down the hall, toward the elevator. Ernesto and Cheryl watch as they go.) CHERYL: “You know what that is?” ERNESTO: “Drug-seeking behavior?” CHERYL: “No. That is heartbreaking.” TEXT: Our patients keep getting younger, sicker. More desperate, more complex. More addicted. Thirty-one years old. Endocarditis, polysubstance abuse, low platelets, H. pylori infection, hematemisis — this is all one patient — acute kidney injury, seizures. DEFINITIONS: Endocarditis: Caused by a build-up of “vegetation” (clotting proteins, bacteria, and other debris) on the valves of the heart. In IV drug users, the heart’s right side is more often affected; the telltale sign is swollen legs and ankles. Hematemesis: Vomiting blood. Usually caused by a gastric ulcer or swollen esophageal veins. Not to be confused with hemoptysis (coughing blood) as happens with active tuberculosis or pulmonary embolism. How do people get this sick, this soon? Is the food all poison? Is radium leaching into the groundwater? Or is there some metaphysical or supernatural influence at play? The doctors see it. The nurses certainly see it. You see it too, don’t you? Something has gone wrong here.
(SCENE: A patient is sitting on a hospital bed wearing a gown, his hands folded into his lap. Ernesto, the nurse, leans into a cabinet with his arms crossed.) TIME: 7:34 a.m. CAPTION: Pete is 24 years old, withdrawing badly from alcohol, with a nasty case of pancreatitis. Enzymes are tearing apart his insides — a process called autodigestion. ERNESTO: “What’s your drink?” PETE: “Whiskey.” ERNESTO: “I was a Vodka man” PETE: “Was?” ERNESTO: “I quit. In 2017.” PETE: “How?” CAPTION: But the finer points of recovery — mindfulness, gratitude — are best explored when one’s body isn’t cannibalizing itself. ERNESTO: “I had a lot of help.” (SCENE: Another nurse, Gemma, comes into the room holding IV bags.) CAPTION: He’s Gemma’s patient, not mine. ERNESTO: (to Gemma) “Need anything?” BETH: “I don’t know what I need.” (SCENE: Ernesto walks, alone, down a hallway) CAPTION: I’m trying to find him a sober coach. They used to be everywhere — roaming the wards in their scuffed-up sneakers. But lately I haven’t seen any. It feels like our hospital is dying, as a life form dies — one organ, one system at a time.
The sisters
ICU stories 4:
When accidents happen
ICU stories 2:
Tenderness and brutality
ICU stories 1:
The sisters
ICU stories 4:
When accidents happen
ICU stories 2:
Tenderness and brutality
ICU stories 1:
The sisters
ICU stories 4:
When accidents happen
ICU stories 2:
Tenderness
and brutality
ICU stories 1:
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Join the online discussion
Write a letter to the editor
Although the events in this story are real, names have been changed to protect identities.
Read published letters to the editor about this story
Join the online discussion
Write a letter to the editor
Although the events in this story are real, names have been changed to protect identities.