Spring 2012

Edited by BLAS FALCONER | BARRY KITTERMAN | AMY WRIGHT



Nonfiction

Lazarus

Diane Kraynak


 

The little brown baby lay on his back. Opal, a bedside nurse, stood behind his incubator. Its plastic blurred the Snoopy pattern on her scrubs. Blue lights lit the incubator’s Plexiglas roof and made his white eyeshades glow. It was my first day in the Neonatal Intensive Care Unit and his third day on earth. Opal opened his incubator door.
       “Watch this, Kimi,” she said to the nurse beside me and reached in. At her touch, the baby’s arms and legs stretched long. His fists clenched. His toes pointed. His head arched backwards. Opal slipped her hand underneath him, curled her thumb and fingers around his sides, and tilted him up and down. He lay rigid as a board while she seesawed him. He howled silently into his breathing tube.
       “I’m supposed to put a PICC line in him. How?” Opal said to Kimi.
       “Well, at least he’ll keep his arm still,” Kimi said.
       “Meet Lazarus. He came back from the dead,” Opal said to me, looking over the incubator roof.
       Kimi turned to me, her hand heavy on my shoulder. “He’ll be your patient today, Diane. You can’t hurt him.”
       I nodded, silent, my eyes fixed on the baby tilting up and down.
       Opal peered in and manipulated his stiff arm, looking for a vein. The blue lights turned her blond hair green. “I can’t believe Samantha resuscitated him,” Opal said to Kimi.
       “She had to. She saw him breathing.”
       “It was an agonal breath. He was already gone.”
       “I know. But Dr. Walker saw it, too. They couldn’t both watch a baby try to breathe and do nothing.”
       “Yes, they could. He was down more than twenty minutes. Let him go.” Opal snapped the incubator portholes closed and looked up at me and Kimi. “I’ll be back when you’re done with your vitals and assessment. I’ll get a PICC line in him yet.”
       “Thanks, O,” Kimi said. Turning to me, she continued, “Opal’s real good at putting in PICC lines. She’ll get it. You know what a PICC line is, don’t you?”
       “It’s a deep IV, right?” I croaked out, unable to take my eyes off the stiff brown baby.
       “More or less,” Kimi said. “It’s deeper than IV and the tip goes into the heart. It’s not a permanent central line, but we use it for long term IV use, especially if kids are difficult sticks. Like with him. We don’t want to keep losing IV’s and having to stick him.”
       I watched Kimi fiddle with the monitor above his bed. Everything around this kid was glowing. I looked around the unit. Harsh overhead lights beat down on incubators, quilts, warming tables, and various other scuffed plastic items. At eight a.m. my ears hurt with the chorus of sharp beeps, low bells, shrill rings, snaps, and clips. I caught half of what Kimi said, still stunned at the baby before me.
       I had been in nursing school for one year and this was my first specialty clinical placement. I had chosen the pediatric intensive care unit, but they gave me the neonatal intensive care unit. Kimi was my preceptor. Lazarus was my first patient. Kimi walked away from his bed and I trailed behind her.
       “Lazarus tried to arrive in a prison toilet,” she said. A tall, Rubenseque woman, she leaned up against a counter and told me the story.
       His sixteen-year-old mother was in Juvie. She was on her way upstate to finish her sentence for drug distribution when her placenta sheared itself off. Handcuffed, ready to board the bus, she doubled over and hemorrhaged. The detention guards thought she might be faking so they took their time. When they finally realized that the ocean of blood was real, Lazarus was almost here.
       The ambulance brought her, still handcuffed, to my hospital, where she delivered, still handcuffed, across the hall from the NICU. The baby emerged blue—the result of his sudden birth, the delay at Juvie, and the time-consuming trip to the hospital.
       The NICU team—doctors, nurses, and respiratory therapists— all worked to get this tiny life going. Everyone took a side of the bed and a task: one rubbed his limbs vigorously, one compressed his little chest, one gave him oxygen, one intubated him. Twenty-five minutes later, he hadn’t come through. They called the time of death.
       The room cleared. People went back to what they’d been doing. But twenty-six minutes out of the womb, he opened his mouth and gasped. Samantha, who’d been cleaning him, saw it. The obstetrician, filling out the paperwork nearby, saw her see it, which started the code all over: rubbing, oxygen, intubation. Forty minutes out, they named him Lazarus and wheeled him into the NICU. 
       “Wasn’t that in the newspaper the other day?” I said, finding my voice at last.
       “Maybe. I only get Sunday’s paper.”
       “It was buried on the second the page of the Metro section. A story about a teenager who gave birth handcuffed. They didn’t give a lot of other details. But how many of these kids are there?”
       “More than you’d think. We get a fair amount of transports from babies born in toilets and a few times a year it’s a prison baby.”
       My eyes widened. This is not what I signed up for.
       Oh, really? I thought. Easy for you to say.
       Kimi noticed my discomfort. “First time in an ICU?”
       “I did a semester in the Neuro ICU last year,” I said. “But yeah, first time in peds. I wanted the PICU but they gave me the NICU.” Crap. Should I have said that?
       “PICU’s good, but I’m a little biased towards the NICU. You’re an older student,” she said, sizing me up. “What were you doing before this?” Kimi’s back was turned from me. She was opening cabinet doors and drawers, gathering supplies.
       “I was an art therapist. Seven years.”
       “What made you change?”
       “I wanted something more concrete. More immediate gratification. I like psych, but I wanted more visible improvements.”
       Kimi laughed. “Medicine isn’t always so concrete.”
       “So I’m seeing.”
       “You’re pediatrics?”
       “Yes. I was a women’s studies major in college and I almost chose women’s health. But I’ve been working with children and families as a therapist, so I decided at the last minute to stay with kids. Thank God too. I wouldn’t want to look at that all day.”
       Kimi laughed again. “Well, you’ll see that in the labor and delivery, but it’s not all day. I know what you mean. I’ve always been in the NICU and now I’m working on my master’s to be an NNP.”
       “Neonatal Nurse Practitioner? That’s a different program, right?” “Yep. All right. Let’s get to work.”
       We were back at his bedside. I stared at Lazarus, dazed and intimidated. Grey beige cords snaked from his incubator and plugged into corresponding grey beige bricks above it. Thin green, white, and black wires curled and twisted around his body. His face was invisible. The white eyeshades protected his eyes from the bilirubin lights, the breathing tube covered his mouth, and a feeding tube lay in his nose, secured in place by white tape across his left cheek. Curly black ringlets and thin brown cheeks were what Lazarus showed to the world.
       I approached his bed, ready to take his vital signs. “I can do this,” I said to myself. Temperature, 98.9 Fahrenheit. Blood pressure next. I struggled to wrap the tiny cuff around his wrinkly ankle. He hadn’t grown into his skin. I couldn’t get it on straight. It kept gaping.
       “That’s the best it’ll fit,” Kimi said reassuringly. She plugged the cuff into a blue machine the size of a nightstand. “Try the Dyna-Map.” I hit the start button. The blood pressure monitor sang da-da- da-datdat, and 70/53 flashed in neon red.
       “Now for blood gases.” Kimi moved to the incubator’s other side. The baby’s leg vanished in her gloved hand. She pricked his heel with a lancet and applied a thin glass tube that sucked in blood. “We made a ventilator change thirty minutes ago. We need to assess how he’s doing with the change,” she explained.
       She nodded toward two white rubber caps at the baby’s feet. “Grab those and put one on each end of the tube,” she said. “Gently.” They rolled like rubber balls between my gloved fingers. I gingerly placed them on the tube. It looked like a tiny baton.
       “Now stick it in that bag and take it to the Gas Lab while I get his other labs,” she said, aiming her chin at the back of the unit. “He’ll need another gas in a few hours. You can do that one.” She kept hold of his leg and held a plastic tube at his heel. Blood dripped into it.
       Later Kimi walked me through programming the IV pump to give him phenobarbitol so he wouldn’t thrash around and get hurt. Later still, I watched Opal expertly demonstrate how to put in the deep IV known as a PICC line.
       The beeps and rings still echoed inside me as I shucked my tennis shoes and my polyester nursing-student uniform. My make-up had long since melted, and a hot shower beckoned. But my mind would not stop spinning, and I had to write my clinical log for class.
       My phone rang as the computer was booting up. “Hey. It’s Karen,” my friend said on the other end. “Hey. What’s going on?”
       “How was your first day today?”
       “Intense.” I told her the story.
       “Wait,” Karen said. “He was dead? And he came back?”
       “Pretty much. That’s what I understand, anyway.”
       “Can they do that?”
       “I guess. Hey, you’re Catholic. Do you know the story of Lazarus?”
       “You’re Catholic too.”
       “Yeah, but I don’t go to church like you do.”
       “Lazarus is who Jesus rose from the dead. ‘I am the resurrection and the life,’” she explained. “You know, the whole Easter spiel.”
       “I thought Easter was Jesus rising from the dead,” I said, confused.
       “It is, but Lazarus was one of Jesus’ last acts before they killed him.”
       “Whatever. The baby came back from the dead,” I said, trying get back on track with the conversation. “Listen, I gotta go. I’ve got to do my clinical log while I’m thinking of it, and I have to be there bright and early at seven a.m. tomorrow.”
       “Seven is early.”
       “Seven is inhuman. Are we going to that happy hour thing at the science museum Thursday?”
       We finished up the logistics of happy hour and I turned my attention back to Lazarus.
       Nursing school logs involved none of that. Patients appeared as cryptic initials and medical diagnoses. Nursing diagnoses, like “risk for skin breakdown,” were additional. Clinical placements didn’t just teach us about direct patient care, they taught us concrete measurable goals. Objective: prevent skin breakdown. Goal: turn patient every thirty minutes. I scanned my NICU placement sheet. The goals and objectives were all things I made up for myself to learn, like “assess” and “demonstrate technical proficiency in the clinical area selected.” Lazarus had no goals or objectives.
       I drifted uneasily asleep thinking of Lazarus. The Dyna-Map punctuated my dreams.
       “Diane? Lazarus’ mom is coming in,” Kimi said. I was struggling with the blood-pressure cuff again.
       I looked up and a saw a detention guard pushing a young woman in a wheelchair. He aimed her in my direction.
       “Hi, I’m Diane,” I said, when they reached me. “I’m helping take care of him today. I’m a nursing student. His real nurse, Kim, is over there.” I pointed to Kimi.
       “Hi. Lola,” she said, her smile tight across her face. Lola had the same brown skin, the same curly black hair as her son. The plaid flannel shirt draped over her hands hid the handcuffs. She looked just like my therapy patients had: young, pretty, and distracted. Probably a good kid, but one with bad role models pushing her into worse decisions.
       A guard uncuffed one hand and she stroked what she could reach through the incubator portholes. Lazarus stiffened at her touch.
       “Were you able to hold him at all?” I asked.
       “No. They wheeled him by me for a second so I could see him, but I haven’t held him yet,” Lola said.
       “That was four days ago,” I said, mentally calculating the days. “Yeah.”
       “Is this your first time here?”
       “Yeah. I’m being transferred tomorrow. They’re letting me see him before I leave.”
       My heart rate accelerated. I looked around for Kimi. She was talking to some burly guy by the gas lab. I’d been in the NICU one day. This mom had been here for ten minutes. I said nothing. I hoped Kimi would come back soon. I dripped formula into his tube and charted.
       She turned to me. “Will he play football?”
       I was thirty-two years old. I had been in nursing school one year. Her son was my first NICU patient. Even I knew he was never going to play football. He would never walk. I drew on seven years’ experience as a therapist, because as a nursing student I had only goals and objectives. “Well, first we’ll worry about getting him to breathe on his own. Eat, grow, things like that.”
       “Yeah,” she said, rubbing his clenched and wooden leg. “I hope he plays football.”
       She stayed for an hour, touching him and asking questions. She was concerned he didn’t move like normal newborns. No, he didn’t. She was worried he’d look retarded. I didn’t say I thought that should be the least of her worries. Lazarus remained stiff at her touch, but he stopped grimacing. She pointed to the breathing tube. “How long will he have that in?” she said.
       “I don’t know. What did the doctors tell you?”
       “Not much.”
       “Did they talk to you?” I assumed someone had talked to her. I hoped they had.
       “A little. After the delivery.”
       Sweat trickled down my back. I wondered if anyone had talked to her since then. During the whole hour, doctors came and went. No one came to our corner of the room. Kimi came by periodically to check in, but no doctor came to talk to her. I scanned the unit for one of the doctors. By then, her time was up, the guards returned, cuffed her again, and rolled her out.
       “This is my last day in here,” I said to Lola. “I’m glad I could take care of your son.”
       “It was nice to meet you,” she said.
       “Sure. Bye,” I said.
       “Bye.” Her curly black hair glinted in the overhead lights. She didn’t look back. I wondered if anyone would ever ask her how she felt.
       Except, the babies knew. They smelled my ineptitude. They recognized my novice hands, my trembling IV sticks. They heard my halting conversations with their parents. They knew medicine wasn’t about concrete results and visible improvements. But they were kind. They did not outwardly object. They were gifts, not just to their parents, but to me as well. They let me care for them. Let me practice, let me learn. It was not really my skills that saved them, but their presence and availability—they allowed themselves to be healed. Some families said thank you for saving their baby, but it was I who was grateful.
       Many years later, I was purging old nursing school papers when I found, clipped to my NICU project, my clinical log:

 

 

“All right,” Kimi said, pulling me back to earth. “Let’s get started. We start with our assessment. We try to cluster care—that is, do everything you need to do while you’re in the bed so you don’t have to keep disturbing the baby. Gather everything you need so it’s ready. That way, when you get into the bed, you do everything at once.”

 

 

Eight hours afterwards, I trudged up the stairs to my apartment. The setting summer sun lit up my few rooms. Eight p.m. My ears still rang from the NICU’s monitors, IV pumps, telephones, and ventilators. My answering machine had no new messages. My house had almost no food, which didn’t matter because I was too tired to eat. If I ate the lone cherry yogurt in the fridge, I’d have no breakfast. I’d worry about that later. I peeled back the foil and ate at the kitchen window. On the courts below, people played tennis. They laughed and ran. My legs hurt just looking at them. I had never worked like this before, and certainly had never stood for twelve straight hours.

 

 

Nursing school, like therapy school, involved reams of patient documentation—proof that we’d seen a patient and figured out what to do for the patient’s problem. Both fields called these clinical logs. But there the similarity ended. In art therapy, we spent a long time on emotions; not just our patients’ emotions, but our own. How did we react? How did this patient make us feel? How did the experience make us feel?

 

 

The next day, caring for Lazarus was more of the same—vital signs and medications. I got to make my own capillary gas baton. Kimi placed another thin plastic tube in his nose for feeding, demonstrated how to check for proper tube placement, then watched me check for placement. I trickled miniscule amounts of formula into the thin plastic tube.

 

 

No one ever asked me. I didn’t know, as I left the unit that night, that I would be back—that I would begin my nursing career in the unit that Lazarus began his life. I picked the NICU because the babies were small, didn’t talk, and the parents were rarely there. I could learn my craft and maybe no one would notice I was terrified out of my mind.

August 1999. First day in the NICU. My preceptor is Kim. My patient was Baby J, a 34-weeker. His APGARS at 1, 5, and 15 minutes were zero. He gave a gasp at 26 minutes of life and they resuscitated him. They call him Lazarus. If APGARS are zero at 15 minutes, isn’t that dead? Wasn’t he a stillborn? Mom is 16 and in jail. What kind of quality of life are we giving to them? Have we really benefited this kid?
       I got to do a lot on him: I hung fluids, got capillary gases, gave meds, and suctioned. Suctioning isn’t as bad as I thought, now that I’ve got the hang of it. I also got to go to the delivery room this afternoon.
       Hours: 12, Goals met: 1, 4, 9, 10, 13, 14. Objectives: 1, 2, 3, 4, 5, 6, 8, 9.
       I called Kimi. “Do you know whatever happened to Lazarus?” I asked.
       “Lazarus. Wow. No. Why?” she said.
       “Just wondering. He was my first patient, you know?”
       “I know. I remember.”
       “He was gone by the time I started working there.”
       “When was that?”
       “Twelve years ago.”
       “Wow.”
       “I know. I think he got transferred up some where around DC.” “That might be right.”
       “I wonder if he’s still alive.”
       “God, I hope not.”
       “I know.”
       But there was never another Lazarus, a three-pound flesh and bone reflex. He came to me as a gift—as practice—because I could not hurt him. I fed and changed him. I took his vital signs and blood gases. I met his mother. I asked the right questions, which had no answers. It would be years before I understood the real ways in which Lazarus was a gift: he showed me the hardest part of the path ahead. 

 

 

My breath caught in my throat. Baby J. Lazarus. What was his real name? Did I ever know it? His moniker had stuck quickly. Did anyone in the NICU ever know his real name?

 

 

I have cared for hundreds of children since Lazarus. Other children like him, personifications of purgatory, children who cannot live but are not allowed to die, forced to hover in the space between. There are children whose names I never knew, children whose names I can’t remember, and children whose names I can’t forget. 

 




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