When the walls listened.

I was my seventh consecutive night on duty, and it seemed by now that I could give the 11:00 p.m . report as well as the nurse who was going off. It was usually a busy intensive care unit, but for some time the patients had been fairly stable and the census low. So my interest was piqued when she said we had a new patient. Mark, 25 years old, had been thrown from his motorcycle earlier that evening. Respiratory arrest followed. He had a tracheostomy, a respirator, multiple fractures, possible in­ ternal injuries and brain damage, and a urinary output that was alarmingly low. So far, the evening nurse said, his pupils were normal, and although unconscious and dependent on the respirator, he did respond slightly to deep pain. “ I ’m sorry about all the dirt you'll find ,” she said. “ It’s imbedded an inch deep, and I just did not have time for that. H e’s a handful.” Her parting words echoed in my thoughts as I entered M ark’s room. The bright overhead examining light left no shadow to soften the destruction that he had sustained. I smiled grimly as I saw the dirt and remembered the nurse’s apology. I was not sure I’d be able to do much better myself. I introduced myself to the unconscious man and took his hand. Palpating his pulse and beginning to check the maze of tubes that hissed, dripped, and drained, I said: “ Mark, it looks like you got into a pretty nasty motorcycle accident. You have quite a few tubes here.” More to keep m yself company than anything else, I con­ tinued to ramble on as I worked: “ Mark, you are in the hospital and it’s midnight. The new day will be Sunday. I bet your plans for today didn’t include th is.” Using his name frequently helped transform the pallid figure into a human being. Reducing the glaring lights to a soft glow, I explained the care that would follow. The minutes slipped past, regimented by endless needs and observations. At some point I washed away the outer layers o f gravel and dirt gently; it would take more than one bath to remove the rest. My 7:00 a.m . vital signs sheet showed that Mark had held his own for the night, although blood was appearing in the still-scant urine. “ Good-bye M ark,” I said, “ I’m going home now . Another nurse will be with you during the day . ” I did not look back as I left the unit. I was sure he would die. Two days later it was a surprise to find him still there. His kidneys were functioning better, and now he triggered the respirator almost continuously. Perhaps there was a chance after all. Mark became my special patient. Caring for him grew into more than an exercise in skilled nursing; the seed of hope took cautious root and grew. Periodically, the odds seemed insurmountable. I was dis­ couraged by his lack o f response. The progress notes men­ tioned the possibility of brain damage, and I wondered if any mind existed in the shattered body we were trying so hard to salvage. Still I spoke to him as the person I wanted him to be: “ Mark, the tube in your throat makes it impossible to talk. But it will not be there perm anently.” One night the orderly was helping me change his bed. “ Mark, we are going to turn you on your right side n o w ," I said. “ I’m sorry my hands are so co ld .” My assistant looked at me curiously. “ W ho are you talk­ ing to, the walls?” The question touched my helplessness and futility. I could only reply sadly, “ I don’t know. Perhaps you are right — only the w alls.” Time inched by the rest o f the night. Mark seemed more like an inert lump than anything else. In an unreasonable way I felt angry, as though he had let me down. The next night I arrived full o f resolutions to do better with Mark. However, the report from the evening nurse made my attitude an issue of very low priority . During the day he had haemorrhaged internally and had been taken to surgery. Postoperatively he developed complete renal failure. A shunt had been inserted, and dialysis started. There was so much equipment in M ark’s room that it looked like a storage closet. Getting to the bed was a trick. The dialysis technician smiled at me from his perch near the kidney machine. Mark was lost under the web o f dressings, tubes, and coils. My heart was full and threatening to spill over. My best ICU intuition told me that the end could not be far away. The body could endure only so much. That night I spoke softly as I worked, explaining and reassuring as a mother sings a lullaby to soothe a child. I was aware of my touch; it must be gentle. None of this attention took any extra time. Caring is a state o f mind, not additional work.