The Nudge

“Alright, everyone, alright” Dr. Brandt said from the foot of a stretcher strewn with the bloody gauze and syringe-caps “Unless somebody has something else they’d like to try, something we may have missed, I going to call it.” 

It had been a horrible wreck. The best guess was the car had hydroplaned on the wet road, loosing control and sliding sideways into a four-foot diameter pine tree. The main point of impact had been the driver’s side door and he, the only passage in the vehicle, had his left side effectively crushed, breaking his femur and pelvis, 6 ribs, destroying his spleen and left kidney, puncturing multiple holes in his left lung, and fracturing his skull, sending shards of pulverized bone into the brain’s frontal, temporal and parietal lobes. A rapid deceleration injury doing its damnedest.  

“One last time, everybody” Dr. Brandt repeated. “Anyone with anything else? Anything at all?” 

Scanning the room, making eye contact with each member of the staff clustered around the bed, confirming that ideas really had run dry, she nodded and flipped the Lucas Device’s power switch to the ‘off’ position, stopping its silicon pad tipped piston from depressing the patient’s sternum two inches, compressing his heart against the back of his rib cage, his only source of circulation. The only thing keeping him, at least technically, alive. 

Continuing her run through the protocol the doctor said, “No cardiac tracing on the monitor. Any pulses? Radial? No. Carotid? No. I don’t feel a femoral. OK, then I mark official Time of Death as…20:43 hours. Thanks everybody. Thank you all. Good work tonight.”

-0-

Alex Durrell hadn’t planned on working tonight. More accurately, Alex Durrell, RRT hadn’t planned on working any night. “Night shifts and I get along kind of like two wet alley cats in a trash bag” being his familiar refrain whenever the subject arose. And, as senior member of the Respiratory Department staff with now north of twenty-five years at Reliant River Hospital, it very seldom did. Tonight, however, had turned into one of those rare exceptions. 

Joe Sullivan was scheduled for the shift but his three-year old son had developed a hot appendix late that afternoon. With Reliant River a 25-bed Critical Access Hospital in Cooper’s Falls, a hardscrabble town of barely 5,000 in Maine’s rural western mountains, the boy had to go by helicopter evac nearly 100 miles to the nearest available pediatric surgeon in Portland. 

The code that started the shift all guns blazing had ended hours before and with the patients on the Inpatient Unit now all attended to and the voluminous charting approaching being caught up Alex decided it was a good time for a mid-shift break.

Settling into a Respiratory Department office chair well past its sell-by date he propped his feet up on the sill of a window overlooking the ambulance bay. 

“This isn’t so bad. Not really. Not really so bad at all.” Alex muttered to himself giving the office clock his best death-stare, trying to increase the speed of the hands around the dial by sheer force of will. 

“Look at that. It’s 1 AM! I’m half-way home! Just got to stay positive, that’s all. Upbeat. Can-do attitude. Just…stay…positive.”

He’d only had time to throw a few odds and ends from a bachelor’s refrigerator into his back pack in the rush to get to work. Rummaging through the bag’s contents he didn’t hear his visitor until she stood next to him.

“Hey, Alex. Mind if I take a load off?” 

Brenda Cole, RN was the “Supe’ on tonight. Pronounced like ‘soup’ and short for Nursing Supervisor. The good one were usually a senior nurse with enough time in harness not to get rattled easily, and enough cool to settle others jittery nerves. The really good ones also had the kind of office politics savvy to “know where all the bodies were buried” and be able to parlay that knowledge into the odd favor from time to time. That was Brenda Cole.

“What ‘cha got that’s good?” she asked, pretending to look in his pack as she dropped with a sigh into the chair across the table from his.

“Not much I’m afraid, Brenda.” Alex replied, “Looks like there’s, ah…let’s see here…yup, one, no, wait, make that two jars of horse radish, but one is out of date. Then there’s a slice of what I’m pretty sure is baloney, and the piece de resistance for your dining pleasure, a mystery container from last week’s takeout order at the Happy Pagoda. Want some?”   

Alex had only been half-lying about the Happy Pagoda. There was a take out order, but it was from that afternoon and following a few minutes in the microwave the moo shu pork steamed on a couple of paper plates.

The pair made small talk as they ate. Both much the same vintage, they swapped war stories of traumas past, reminiscing as the shift shouldered off night and progressed, however reluctantly, toward dawn.

“So, Alex” Brenda said after he returned to his seat from dropping their paper plates in the trash, “I meant to ask. How do you think the code went tonight? I mean from a staff stand point. How’d we do?”

“God bless ‘em all, Brenda” Alex began, “I think everyone from the fire department and EMS to the team in Trauma One was on their A-game tonight but, honestly, it seems to me this poor guy’s ticket got punched on scene. I was surprised we worked the code as long as we did. What did it end up being?”

“Total between the trauma bay doors opening to TOD being called.” Brenda said, adjusting her reading glasses as she checked her notes, “Let’s see. Yeah…52 minutes.”

“Almost an hour with no spontaneous heart beat, not including on scene and transport time” Alex continued, “that’s one hell of an effort in anyones book. It just wasn’t meant to be.”

“Glad you see it that way, Alex.” Brenda responded. “Really glad…by the way, what do you remember about your arrival at the code?”

A quizzical look came to Alex’s face as he focused on Brenda.

“What do you mean my ‘arrival’? I got to Trauma One, went to the head of the bed, just like always.”

“Oh, I know, Alex. I know.” Brenda went on, “You were in Trauma One, you were at the head of the bed. But what do you remember about how you got there? Let’s start with this. How did you know there was a trauma happening?”

“This is silly, Brenda” Alex said, “but I’ll play along. OK, I knew there was a trauma because I heard the overhead Trauma Alert page.”

“You heard the page, Alex?” Brenda said. “You’re sure you heard the page.”

Alex’s answer caught in his throat as he realized he didn’t clearly remember actually hearing the page. 

“I must have” he thought, in an effort to banish doubt from his mind. “How else would I have known? But, still…”

“Well, I can’t say 100% for sure I definitely heard the page, but I can’t say I didn’t, either. Brenda, I’ve heard so many of those things over the years they all kind of run together. What difference does it make. I was there.”

“That’s true you were there. But you were almost late to the party. Got there just about the same time the ambulance bay doors opened.”

Alex wanted to deny what Brenda had said, but he knew she was right. He should have been there sooner, would have been there sooner, always was there sooner…except for tonight.

“I…I don’t know, Brenda” he half-stammered in reply, “I don’t know. Must have gotten tied up with something. Neb treatment on inpatient”. I don’t know. I’m not sure. I’m just not sure.”

“That must have been it though, right? I mean, what the hell else could it be?” Alex negotiated with himself but coming up less sure of his reasoning than he had been just a minute of two before.

“Stay with me for one last question, then” Brenda said, rolling her chair a bit closer to his, “What do you remember about the drive in tonight?”

Alex opened his mouth to speak, jabbing his right index finger at Brenda…then stopped, his mouth closing, hand dropping to his lap.

“What the hell do I remember?” he puzzled, struggling to order his thoughts, striving for clarity. 

“I got the call to come in late. Maybe 5:45. I was in a rush to get here for 6:30 shift report. Put on some scrubs, threw my stuff in the car and took off. Weather was junk. Might have been rain, might have been snow. Should have let the car warm up a little, defrosters didn’t do much good and those old wipers really do need replacing. Didn’t matter, I just kept going, maybe a little faster than I should’ve. Came off Hall Farm Road, took the left on route 4, and that’s when I saw it. A moose. A moose just standing there in the middle of the highway. Tried to steer around him, might have hit the brakes but…but, what? What in hell happened next?”

 “Brenda” he finally said, softly now, all bravado gone, “What’s going on here? Why can’t I remember anything?”

There was no immediate reply. Brenda just reached out, resting a hand on his forearm.

This was the point where Alex realized that something was going on. Something completely out of his control. Pinpricks of sweat burst out across his forehead. Color ran from his face like a frightened kitten.

“Brenda, I don’t get it.” Alex’s words gushing out like he was afraid it was his last chance, “I remember leaving my house, and the moose, then being in Trauma 1, then the code, and then I’m sitting here with you eating leftover moo shu pork! It doesn’t make any sense.”

Sitting back in her chair now, Brenda folded her hands, resting them on the table top.

“Alright, Alex, alright. Take a deep breath. It’s going to be OK. I’ll explain everything” she began, “First off: How long have you and I worked together?”

Feeling slightly more in control now Alex feigned counting on his fingers before saying, “Well, I’ve been here for right around twenty-six years, back to the days before we got bought out and it was still Cooper’s Falls Community Hospital. Good Old CFCH. You were here on my first day, so twenty-six years. Right?”

“You’re right, we did meet twenty-six years ago” Brenda said with a slight grin “but how long have we actually worked together?”

“Well, twenty-six years. Started right after Y2K..” Alex responded, although unable to muster the confidence he had hoped. 

“Alex, do you remember my retirement party?” Brenda asked.

“Remember it? That was a legendary blow out! Rocco’s Place never had a blast like that before or since! The x-ray tech’s dancing on the bar! The administrator getting caught with his secretary in the parking lot…by his wife! Who was it that started the conga line through the kitchen?….” 

And then the gas ran out. Alex realized Brenda had indeed retired, some seventeen years before.

“That’s right, Alex. I retired. Would have been back in ‘09. Moved to Arizona to be close to the grand kids. Got a place at Saguaro Valley Retirement Village near Prescott. Nice spot. But then, around 8 years ago..”

“I remember hearing” Alex said, tip-toeing around his words like a man with no shoes trying to walk across a dark room full of mouse traps. “I remember hearing you…”

“What you remember hearing, Alex, was I died.”

Brenda let the sentence hang for a moment before continuing,

“I was supposed to meet the other three girls in the Mahjong Mavens for our weekly game but I never showed. Nancy and Estelle tried calling me. When I didn’t answer after a couple of times they came to check. Ruth, the old bat, sheee didn’t bother. Figures. Anyway, they found me slumped over my desk. People say it was quick. Probably a triple A. All I really recall is sitting down to write out a check to the power company then, bam, waking up here dressed in my in scrubs.”

Alex fixed Brenda with an appraising stare. None of this made sense…yet…somehow…there was more truth to what the supe was saying than he wanted to believe.

“Let’s say I buy it I buy the whole thing, lock, stock and barrel.” Alex began, “Let’s say all of this is true and not some dream I’m having fueled by not enough sleep and bad moo she pork. If it’s all true and you’re actually dead and I’m talking with you then that would mean that I’m…”

“You’re dead, too.” Brenda said matter-of-factly. “That’s right.” 

“I want you to follow along with me, Alex.” Brenda continued, “First off, you’re never late, and by that I mean you’re never less than five minutes early, yet tonight you got to the code at the same time as the ambulance and you can’t explain why.”

“We’ve been over this” Alex interrupted, “I must have gotten tied up somewhere else. I’m working alone. If there’s a call to RT I have to go.” The answer, he knew, was half-hearted at best.

“Are you sure on that?” Brenda replied, “Really sure?”

He wanted to respond, but the words evaporated half-way out.

Pressing on, Brenda said “Next, what did you do during the code? You didn’t intubate, didn’t bag the patient, didn’t get a vent ready. You were there, but what did you do?”

Again, Alex’s brain scrambled for an answer he’d believe. He couldn’t find one.

“And last, and I really need you to think about this one” Brenda stressed, “During the entire code, all 52 minutes, who did you talk to?”

“Well, now wait a minute, I did talk to people.” Alex insisted. “Let’s see, I talked with you, and…”

“Yes?” said Brenda.

“Well, there was Dr. Brandt, Kelly the lab tech. Who were the other nurses, Desiree, Lilly, uh, let’s see…”

“They were all there Alex. But who did you talk to? Aside from me, who actually responded? It’s OK, Alex. This part is always the toughest, but let’s take it one step at a time. First, you got to trauma at the same time as the ambulance because you were in the ambulance. You were the patient. You saw the moose in the road, jammed on the brakes, spun out of control and hit the tree. Next, you didn’t do anything during the code except watch. Watch Sam Shelley as she stood at the head of the head and managed the airway, your airway.”

It was nearly 2:30 AM now. This time of year daylight wouldn’t smudge the eastern horizon for around 4 more hours. But, in the Respiratory Therapy Department office of Reliant River Hospital a personal dawn was starting to break in the mind of Alex Durrell.

“I still don’t get it. If I’m dead and you're dead, why are we here? No harps and halos. No devils and pitchforks just, ah…work?”

An involuntary laugh escaped Brenda’s lips before her answer. “Well, it took you a little longer to get there, but you’ve asking the same question I asked Eleanor Stanley, the old OB nurse who was here when this happened to me and I’m going to give you the same andwer.” 

‘Brenda, each one of us is here because we need to be. Not just for the mortals still working here, but for us, so that we can pass on that one special thing we have to give to one certain someone. We won’t ever be truly finished until that’s done. I don’t think we’ll ever know who that is, or what they need to know, but once that happens our time is complete.’

“So, what you’re saying is I’m here like a teacher, an instructor?” Alex asked.

“More like a mentor.” Brenda countered. “Remember the times you’ve told people you did things you couldn’t explain how you knew to do. That was someone helping. Someone giving what I call ‘the nudge’. Give them there head, let them make their own mistakes, but every once and a while it won’t hurt to…”

“Give them the nudge” Alex said, completing the sentence. 

“Well” Brenda said, slowly standing from her chair. “I know you have more questions than I’ve got answers and you’ll find the ones you truly need on your own. As for me, the clock's running and it’s time to move along.”

“What happens to you next” Alex asked, wondering if it was a sneak peek into his future.

“I’m not sure. Eleanor said she just wanted to move back to her family’s old home in Wichita Falls. Can’t swear to it, but I’m pretty sure that’s what happened. For me, I’ve always wanted to see Paris!”

“In that case, maybe living out my Ernest Hemingway fantasy in Key West is in the cards” Rising from his seat Alex took his old friend's hands in his, “Thanks, Brenda. Thanks for your help getting me through this.”

“Just remember, Alex, you’re here because you are the right person, right now.”

And with that the office door closed, Brenda disappearing.

“Watch out Champs Elysees.” Alex said with a half grin.

The clock on the office wall was edging toward 4. Shift change was in just a couple of hours. Time for a quick check on the patient census before the new shift came on for days. Looping his stethoscope around his neck Alex headed toward the back hall stairwell. It was new. It was different. But, in his heart it all felt right.