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Where Night Is Day

Where Night Is Day: The World of the ICU

James Kelly
Copyright Date: 2013
Published by: Cornell University Press,
Pages: 240
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  • Book Info
    Where Night Is Day
    Book Description:

    "There is no night in the ICU. There is day, lesser day, then day again. There are rhythms. Every twelve hours: shift change. Report: first all together in the big room, then at the bedside, nurse to nurse. Morning rounds. A group of doctors moves slowly through the unit like a harrow through a field. At each room, like a game, a different one rotates into the center. They leave behind a trail of new orders. Wean, extubate, titrate, start this, stop that, scan, film, scope. The steep hill the patient is asked to climb. Can you breathe on your own? Can you wake up? Can you live?"-from Where Night Is Day

    Where Night Is Day is a nonfiction narrative grounded in the day-by-day, hour-by-hour rhythms of an ICU in a teaching hospital in the heart of New Mexico. It takes place over a thirteen-week period, the time of the average rotation of residents through the ICU. It begins in September and ends at Christmas. It is the story of patients and families, suddenly faced with critical illness, who find themselves in the ICU. It describes how they navigate through it and find their way. James Kelly is a sensitive witness to the quiet courage and resourcefulness of ordinary people. Kelly leads the reader into a parallel world: the world of illness. This world, invisible but not hidden, not articulated by but known by the ill, does not readily offer itself to our understanding. In this context, Kelly reflects on the nature of medicine and nursing, on how doctors and nurses see themselves and how they see each other. Drawing on the words of medical historians, doctor-writers, and nursing scholars, as well as the works of James Agee and Michel de Certeau, Kelly examines the relationship of professional and lay observers to the meaning of illness, empathy, caring, and the silence of suffering. As Kelly reflects on the rise of medicine, the theory of nursing, the argument of care versus cure, he offers up an intimate portrait of the ICU and its inhabitants.

    eISBN: 978-0-8014-6765-3
    Subjects: History

Table of Contents

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  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
    (pp. ix-xiv)

    You may never get to Big Sur or drive the Going-to-the-Sun Road in Glacier National Park or see where Hemingway lived in Key West, but the odds are that, one day, you will lie in a bed in an ICU.

    I’ve been an ICU nurse for twelve years. I came to nursing late in life, after getting a BA in English just as the ten-year time limit was running out at UMass, having a little arts-and-crafts business, helping with the U-Pick at Hicks Orchard in Granville, New York, getting married, honeymooning at Sugarloaf campground in the White Mountains, studying theology...

    (pp. 1-23)

    . . . Cory Granger. Fifty-one-year-old patient of Critical Care and Neuro. Chest pain while up in the mountains, hiked out. One hundred percent occlusion of the right coronary artery. Stented in cath lab. Was on a heparin drip after and had an intracerebral bleed. He’s got a left hemiparesis. He’s been hot: 39.7 temp. He’s gone from 40 percent to 90 percent oxygen on a nonrebreather mask. He’s going for a CT this morning. He’ll get sick before he gets better.

    Bed Two. Dakota Yazzie. She’s Hopi. Forty-two. New admit. Occipital bleed. Probably nonoperative. She’s awake, alert. Moves everything....

    (pp. 24-41)

    The night nurse is a traveler I haven’t met before.

    “Cushman, James. Fifty-four. Past medical history, alcoholism, question of hep C, organic brain disease, whatever that means. Came in on the twenty-eighth vomiting bright-red blood. He was scoped. They banded five varices. Was getting blood but there was a problem with the transfusion. He went into DTs. He crashed on the sixth. They paralyzed him to help his oxygenation. We’re using Nimbex. He’s maxed on Levophed at twenty. They don’t want to go any higher, vasopressin .02. They want a systolic blood pressure greater than ninety-five. He’s on pressure control...

    (pp. 42-51)

    I have two young men today. Most of the young are traumas or ODs. Timothy Lawson is twenty-two. He was diagnosed with ALL, acute lymphocytic leukemia, in October last year. Had chemotherapy and radiation but still got metastasis to the hip, leg, pelvis. Was admitted first to Memorial down south in Las Cruces near his home. Then mets to the head. Air-flighted to us for a higher level of care. On the way he began to bleed—from his mouth, his rectum. When he got here, they did an endoscopy and it showed severe erosive esophagitis, radiation induced. I look...

    (pp. 52-66)

    You have to walk by the waiting room on the way to the unit. It’s never empty. There’s always somebody in it, day and night. Maybe a late admission but often either people who look Hispanic or Native American from Gallup or from a pueblo too poor for even Motel 6 or the Super 8. The couches are designed so you can’t lie down on them. They’re short, with a wooden arm in the middle. There are nine people in the room. All of them are sleeping. Two are sleeping on the floor in opposite directions, their heads on pillows...

    (pp. 67-81)

    You could hear him moaning in the unit, the sound like the wail of a fire alarm.

    “What’s the matter? Are you in pain?”


    “Why are you moaning?”

    “It makes me feel better. Sorry.”

    “No, it’s okay. Can you tell me your name?”

    “Bernard Fleischer.” He’s a small guy with patchy white hair, the red scabs on his scalp like burn patches in a forest.

    “Do you know where you are?”


    “No, you’re not home. You’re in the hospital. Do you know what month it is?”

    “September. October?”

    “Close enough. It’s October. If you’re having pain you need...

    (pp. 82-95)

    Bed Ten just died. She came over the U.S. border a month ago from Mexico, gave birth last week, and arrived last night in cardiac arrest. They coded her for almost two hours. They shocked her ten times. They’re trying to convince the family to autopsy. The room is dark. When there’s a dead person in a room, the room looks different, feels different, as though something has gone out, letters missing in a neon sign.

    There are three residents outside the room standing shoulder to shoulder, so close the sleeves of their white coats touch. Jacobs I know, two...

  10. 7 CARING
    (pp. 96-110)

    The night nurse is Linda. “This is Helen Bardwell. Seventy-six. I got her at eleven last night. She came down from the floor. She was admitted for COPD exacerbation. She gets here with a pH of 6.9 and a carbon dioxide of 111. She had been on a heparin drip for a clot in her left leg. She’s been bleeding all night. The first thing I did was turn off the heparin. I didn’t wait for an order. She was DNI but the resident on the floor talked her husband into intubating her. It was Miller I think. The intubation...

    (pp. 111-127)

    We walk out of report and there’s a commotion in Lawson’s room. His mother is standing outside, off to the side. She’s still wearing the yellow isolation gown over her clothes. Here every night. The room is crowded. Fowler. The residents. The night nurse, Amanda. His sat is blinking: sixty-eight. Systolic blood pressure seventy-four. It looks like they’re getting ready to intubate him. Every person is holding something in a hand—a tube, a needle, a syringe—like a dart they are about to throw at a board.

    He had come back to the unit the night before last. He’s...

  12. 9 DYING
    (pp. 128-145)

    One thing I was unprepared for was the dying. The first day of nursing school we learned how to make a bed. The second day we learned how to make a bed with someone in it, something that so impressed Hemingway that he wrote about it in A Farewell to Arms. We learned you should turn patients every two hours so they don’t get skin ulcers. We learned how to give medications. If you’re giving both Novolin and regular insulin, you draw them up clear to cloudy, the regular first. We never learned about death. We never talked about it....

    (pp. 146-163)

    The night nurse for Six is Dave. He’s juiced up, bristling. Some of the night nurses are so wiped out you worry how they drive home, but some are so stoked up on coffee that it’s like the beginning of the day for them. He’s in his late forties, I figure. He says, “Cool,” “Right on.” He’s a fist bumper.

    “You ready?” he asks. “Janine Sinclair. She’s thirty-nine. PCom hemorrhage. She was at work. Headache. Worst of her life, of course. Collapsed. Nine one one. She’s on twelve of dopamine. ICPs are running twenty to twenty-five. It’s a Codman; we’re...

    (pp. 164-182)

    Patty’s the night nurse. She gives report off the top of her head; no notes, she doesn’t look at the chart. “Paul Lucero. He’s a Do Not Announce. The cops are investigating. The mother chose the code name: Angel. He was at a party, took some drugs, but his tox screen was so loaded, they thought maybe someone had spiked something. It was a traumatic intu-bation. He got tons of fluid in the ER.”

    The team is four beds away. I look at the first-day progress notes:

    Corneal and gag reflex absent; no response to noxious stimuli. Pupils fixed, dilated...

  15. 12 CAN THEY HEAR?
    (pp. 183-195)

    “Joseph Martinez. Motor vehicle accident. Unrestrained. They found him in a ditch in Española. He’s like Hannibal Lecter. Let me show you.” Amanda leads me into the room. She means the bed. It’s a TriaDyne bed that rotates side to side. The patient is strapped on to it. It’s for spinal injuries.

    “To stop it, you have to take hold of the handles to disengage it. Like you were steering a big yacht. Push in this pin. This is how you get to his bottom.” She’s down on one knee, like a mechanic looking under a car. “It’s a true...

    (pp. 196-208)

    Maria Sandoval had been moved to a room with a window. There’s a study that actually says that a window in the room increases survival in the ICU. On the corkboard on the wall are pieces of paper stuck there with pushpins. One has the names of doctors: Dr. Fowler, Dr. Morgan, Dr. Cohen.

    The other is in Spanish:

    Para las semanas que entran

    1. Sacar el tubo de respiracíón

    2. Sentarla una silla

    3. Preguntas posibles cosas para preguntar a María

    Tiene dolor de cabeza?

    Le duele el tubo?

    Quiere dormir?

    Tiene calor? Tiene frio?

    Mama—todos sus hijos...

  17. 14 THE HORIZON
    (pp. 209-219)

    “David Chrisman. Fifty-eight. History of ankylosing spondylitis.” Amanda takes a deep breath. “Long night,” she says. She opens the chart to look for the green tab where the history would be. “Bizarre. He was admitted for neck pain from an MVA. He was on the floor. Going for an MRI. They had him in a soft collar and apparently his head flexed; he became apneic. They bagged him, brought him back, and brought him to the ICU. He’s in a soft collar attached to a traction bar with ten pounds of weights like . . . you’ll see. You can’t...

    (pp. 220-222)

    This morning I was still in bed when a storm came up from the south, from Albuquerque, a direction storms don’t usually come from. Not with the antiphon of lightning then thunder but a steady growling sound just like a train that grew and grew and when it arrived seemed to turn back time, turned the morning into night again. On the prairie, there were skirts of snow below the piñon on which the low sun cast shadows sharp as knives. The peaks of Baldy and Truchas were white.

    The residents had come by late last night just before the...

  19. NOTES
    (pp. 223-232)