Step-Down
Nitin K. Ahuja
2022 Winner, Goldenberg Prize for Fiction
***
I don’t mind the night shift. I’m still new here, granted, so it doesn’t really matter whether or not I mind it. I suspect I’d have a harder time on the general wards, where nights are really just a babysitting gig. But not in the step-down unit, where the patients are all sick in a steady but uncertain way, suspended between the floors and the ICU, waiting for the course of an illness to reveal itself. The lights are dimmed through the early morning hours, and the cardiac monitors keep softly beeping. I spend most of my time with a pleasant sense of calm and capability, holding in my haunches the energy of a weighted spring.
The best compliments I receive from my colleagues are in this spirit. “You’re so levelheaded, Russell,” or, “If I was ever in here, Russ, I’d want you to take care of me.” I try to accept this praise with an ample dose of self-deprecation, or else false swagger that serves the same basic purpose: “God help you, Marge,” or, “You should be so lucky, Marie.”
It isn’t lost on me that I stand out in other ways. Male nurses at this hospital are few and far between. They skew either young and effeminate or old and foreign. Visitors who stop me for directions in the lobby usually mistake me for a doctor. With my back half-turned toward a cabinet or computer, I sometimes feel my coworkers’ eyes on me, lingering with the sort of idle curiosity that I assume drives zoo patrons through the lesser exhibits, where the animals aren’t beautiful or dangerous, just rare enough to be interesting.
Mostly I try to ignore this difference of mine at work, but sometimes it’s inescapable—like last night, when I was assigned to Joe, a twenty-year-old frequent flier with cystic fibrosis, well-known for his recurrent, drug-resistant pneumonia and reliably inappropriate behavior with female staff. At the 7 p.m. handoff, his day nurse Megan gave me the highlights from her shift: the IV line that blew in the middle of Joe’s antibiotic infusion, the way his hand had lingered on her thigh while she replaced it, the steady improvement in his oxygen requirement, his repeated requests for a sponge bath.
I went to Joe’s room first, where I found him asleep with one arm and one leg hanging off his mattress past the bedrails. His oxygen tubing had gotten twisted around his neck, knocking the nasal prongs out of position, forcing me to wake him.
“Rise and shine, boss,” I said, then louder: “Hey, Joe.” He groaned into his pillow and started coughing. I helped him up, leaned him forward.
“Shit,” Joe said, when the fit had subsided. “Where’s Meg?”
“Done for the day,” I said. “I’m taking over.”
“Raw fucking deal. No offense.”
“None taken.” I hung a fresh bag of saline on the pole.
My other two patients were located in rooms on either side of him—Mrs. Wood, an old lady with heart failure, and Mrs. Vine, an old lady with cirrhosis. Last names down here seem to borrow often from common nouns—Aspen, Baker, Cotton, Dove. Maybe it’s a Southern thing, I’m not sure. If I asked around, I bet I could find some fellow Pennsylvania transplants with whom to compare notes. But I’m just as happy figuring things out on my own. In the step-down unit, the sliding doors are made entirely of glass, and walking past them at night, I sometimes imagine myself in a museum of natural history, looking into dioramas of representative specimens, their bodies twisted deliberately into postures of instruction.
What sort of specimen was Joe? A hybrid form, restless even in stupor, all tangled up in the linens. A lattice of bone and sinew that hinted at the vigor it might have held. I exchanged an empty bottle of bronchodilators for a full one, turned on the nebulizer, and gave Joe the mask. While he inhaled, I updated the dry-erase board hanging just below the television, replacing “RN: Megan” with “RN: Russell.”
“Meg used to draw smiley faces,” Joe said, his voice muffled by plastic.
“Don’t talk, just breathe,” I said. “You want a smiley face?”
“Not from you.” At the bottom of the board, I drew two stick figures wearing cowboy hats. Neither was smiling.
“What’s that supposed to be?” Joe asked.
“You and me.”
“Fuck off,” Joe said, and coughed some more.
Mrs. Wood was lying flat on her back in bed, staring at the ceiling, when I came in to introduce myself. “Evening, ma’am,” I said.
“Hello,” she said, turning her head. “I’m afraid I’ve made a mess.” The smell of it soon followed.
“Oh no,” I said. “Why didn’t you ask for help?”
“There wasn’t any time, sweetheart. I’m sorry.”
“Don’t be sorry.” I picked up the call button that was dangling nearby and pressed it. Eventually a voice came through the speaker.
“Can I help you?”
“Hey Maura, code brown—swing by?”
Maura arrived in an isolation gown and turned Mrs. Wood’s bloated body sideways while I gathered up the dirty sheet from underneath. I used its clean corners to wipe the stool still stuck to Mrs. Wood’s backside, where her skin was going a little pink.
“How about we get you to a chair after this, Mrs. Wood?” I asked.
“That’d be fine,” she said. Maura glared at me over her mask but helped with the transfer.
“You single, young man?” Mrs. Wood asked, once she was facing me again, sitting up in the bedside recliner.
“Unfortunately,” I replied.
“Handsome,” she said, looking me up and down from her new perch. “Very handsome.” She mulled it over a few seconds before offering, “I got a granddaughter you might like to meet.”
“Much obliged, Mrs. Wood.” I strapped a blood pressure cuff around the flab of her arm. “I’m sure she’s lovely.”
I moved down here about a year ago with Lily, a woman I’m no longer with. I’d met her back in Philadelphia, as volunteers at a crisis hotline, when I was still trying on the idea of healthcare to see how it fit. She was there after breaking up with a depressive grad student who had taught one of her senior seminars at Penn. The experience, she said, had left her sympathetic to mental illness but also terrified by the prospect of a life enclosed entirely by books. And then there was me: an idler, a meathead, a state college graduate who had cycled through six potential majors before winding up, somehow, with a bachelor’s in kinesiology. I had spent most of my senior year smoking weed and lifting weights, bulking up on the path of least resistance. Lily was smart, and I told her so. In reply, she told me I was beautiful.
I applied to nursing school while Lily applied for a master’s degree. When we both got in, she suggested we audit each other’s classes, getting a rise out of it the way other couples exchanged underwear. I sat in on a couple of her poetry workshops, the nakedness of which embarrassed me enough that I couldn’t go back. Lily made good on her end of the bargain, though, ransacking my syllabus of core requirements as if they were hers. Months later she could still trace the muscular landmarks of my limbs, naming them confidently, poking her finger into them like a pin.
We lived in separate apartments but slept over most nights. We cooked meals, told jokes, and met each other’s mothers. By the time she decided to get her PhD here in Charlottesville, I decided to come with her, thinking we might be in it for the long haul. Last fall, though, shortly after we’d settled in, she told me she was beginning to see her life as not necessarily enclosed by books, but more like a book itself, organized into chapters.
I’m impressed by how little I see of Lily anymore given the size of this town. We last ran into each other a few weeks ago at the farmers market, when the spring vegetables were just starting to come in. Her hair was longer than I’d ever seen it, tied up in a high ponytail. She wore leggings and had a yoga mat slung over her shoulder. The man with her was the sort I might have guessed, a graduate student studying Latin or maybe Greek, an inch or two shorter than me, and sporting a scruffy beard that hid the softness of his jaw. I told Lily that I’d extended the lease on my little guesthouse. I told her about the nearby bar I found, cheap and windowless, where the middle-aged bartenders greet me as a regular already. All this feels slightly beyond my control, but like the night shift, it suits me fine.
Around 10 p.m., Joe spiked a fever. I checked it twice to be sure, then sent a message to his covering resident. The doctors who staff this hospital overnight rotate so much that it’s never made sense to me to remember their names. She called back a few minutes later.
“Hey, it’s Nina,” she said. “I got your page.”
“Hey, thanks,” I said.
“Panculture, I guess, and some Tylenol. I put the orders in.”
“Panculture? He’s got a pneumonia.”
“Yeah, I know. Other vitals okay?”
“Yep.”
“Great.” Nina hung up. This crop of residents is due to graduate soon, and you can hear it in their voices, how ready they are to move on, how tired they are of the whole routine. I have to remind myself that this is the purpose of their education, to run the same track a thousand times, to build reflexes so natural they sound perfunctory.
I gathered my supplies and walked back to Joe’s room. He had sweat through his sheets and thrown them aside. He was sitting up in bed wearing a pair of orange gym shorts, his damp face glowing in the light of his phone.
“Need some more blood from you,” I said. He extended his arm without looking at me. I flicked his skin at various places with my middle finger, seeking a target.
“Right here, dumbass,” he said after the fourth or fifth flick, pointing to a faint blue line coursing along the crook of his right elbow. I followed his lead and sure enough got a flash of blood return.
“Pretty impressive,” I said. “Ever thought about nursing?”
“Fuck no,” Joe said.
“Why not? Phlebotomy’s like the hardest part. You have a knack.”
“I got better things to do.”
“Oh yeah, like what?”
He turned his phone toward me then, like he’d been waiting for the question. He was watching pornography on mute, a girl-on-girl scene going at full tilt. The camera panned slowly across the plush couch where the two women lay, then zoomed in and out, spotlighting each of their lipsticked mouths in turn. I kept my eyes on the screen while collecting the rest of Joe’s samples, playing it like a game of chicken. His smile faltered in my peripheral vision as he waited for a reaction that never came.
“Well?” Joe asked. “You got anything to say?”
“Whatever gets you through the day, bud.” I retracted the needle into its holster. “Me personally? I prefer the real thing.”
He stayed quiet, watching the video on his own again, and it occurred to me that I might have hurt his feelings. I held pressure with some gauze against the puncture site. A few seconds later, his crotch started to bulge. I pulled back abruptly.
“All done,” I said, and pointed to a specimen cup that I’d left on his bedside table. “They want some urine, too, by the way. Whenever you get a chance. No rush.”
“Christ,” Joe said. He stood up before I made it halfway to the door, which set off the high-pitched alarm that signaled a patient was out of bed. He pulled his shorts down and started pissing into the container. The oxygen tubing and telemetry wires still tethered him to the wall.
“Careful, Joe,” I said. I grabbed at the room’s pastel curtain to draw it shut behind the glass door. “Take it easy.”
The cup was almost full when Joe entered another violent coughing fit and splashed himself across the arm. “Fuck all,” he yelled, and hurled the cup to the floor, leaving a long trail of dark yellow across the linoleum. He braced himself against the mattress, catching his breath. His swollen penis was still hanging out over his waistband, all the more vulgar for how healthy it looked, how functional, while dangling from his emaciated frame. His intercostal muscles clenched visibly beneath his damp skin.
“Do me a favor, faggot,” Joe said finally, “and get me a goddamn ginger ale.”
I had a bout of vertigo in between sending his samples to microbiology and calling environmental services to see about a mop. What was I doing here, actually? My older sisters ask me as much whenever they get me on the phone. After running into Lily at the farmers market last month, I wondered if she was wondering the same thing. Why had I stayed? Because there’s a bullheaded part of me, I might have said, that bristles at the idea of retreat. A broken compass buried somewhere deep in my lizard brain that keeps me plowing forward on my current trajectory, with its sickly backdrop, its southward bend.
At 11:00, Mrs. Vine was ordered for a lab draw, a complete blood count that came back stable. At 11:30, Mrs. Wood had a ten-beat run of ventricular tachycardia that I paged the resident about, Nina, who told me there was nothing to do. A little after midnight, I checked on Joe again.
His temperature had normalized after the Tylenol, but his oxygen saturation had also dropped a bit. I turned up his flow rate, then looked through his active orders.
“Did you get your chest PT today?” I asked. “Did respiratory come by?”
“Who?” Joe said.
“Physical therapy, airway clearance. Did they come by?”
“No, not after yesterday.” He was smirking again. “Don’t think she liked me much.” Something was rattling in his throat, splitting his voice like a broken stereo. I could have paged whatever skeleton crew was managing the ventilators at that hour but wouldn’t expect a response. I stared at Joe’s bare back, split all the way down by a prominent line of vertebrae. I weighed my options, then took a long, steadying breath.
“Sit up for me,” I said.
“Why?”
“So I can help get that shit out of your lungs.”
“Pass. I’m good.”
“You’re not. Suffer if you want to, but I’m offering.”
“Offering what? You’re not respiratory. You don’t know what the fuck you’re doing.”
“In general I agree, Joe, but this isn’t rocket science.”
He thought about it for a while, wheezing. “Fine,” he said. “Where do you want me?”
“Kick your legs over the edge of the bed. I’ll stand here.”
“Switch sides,” Joe said, opting to face away from the glass door and the empty hallway outside it. I lowered the opposite bedrail and wheeled his table around, letting him rest on it with his elbows. I laid my gloved hands on his shoulder blades, which tensed immediately.
I started clapping against his upper back with cupped palms, as I had seen therapists do. It was maybe thirty seconds before Joe was coughing again, this time bringing up a small chunk of phlegm. I waited for him to settle, then grasped his deltoids and shook his thorax back and forth, which sent him into another spell. We went on this way, alternating between percussions and oscillations, pausing as needed for Joe to spit into the basin. After a few minutes, I moved my hands down his spine to mobilize mucus from his lower lobes.
I thought back to my practical exams and learning the rhythm of a full physical, a series of esoteric maneuvers that I never ended up needing in real life. I’d studied them with Steve, my only friend in nursing school. He was a few years older than me and hailed from a neighboring hometown. Especially in our class of mostly women, he felt like kin—another son of Chester County getting his act together for a steady paycheck, chuckling through the necessary absurdities and degradations. He took to calling the two of us murses, a clinical slur that I’d heard once or twice in passing on the wards and that Steve said he was trying to reclaim. The evening before a final, he and I sat shirtless in my living room, practicing our auscultation and palpation, while Lily stole glances at us from the kitchen table over the top of a paperback. After he left, she told me how much she enjoyed the spectacle of our preparation. “Half-man, half-nurse,” Lily whispered into my ear that night, lying on top of me, her legs straddling my waist.
I waited for Joe to change positions so I could attend to other lung segments, but he stayed seated, turned away from me, hacking periodically. After about fifteen minutes, he waved his hand in the air like a retiring wrestler. “Fuck,” he said, but softer now, his respirations audibly slower. I let my fingers rest at the edges of his neck, kneading his shoulders a little as a gesture of goodwill.
Around 2 a.m., I went down to the cafeteria, where a pretty woman stood next to the soda machine, holding a grilled cheese sandwich, talking on the phone. At least, I thought she was pretty—her eyes were darkly circled, the lower half of her face was covered by a mask, and her slim figure was hidden by baggy scrubs. The badge around her neck displayed her name. I idled, browsing the pre-packaged salads, until she hung up.
“Are you the resident covering step-down?” I asked.
“Unbelievable,” she said under her breath, slipping her phone into her back pocket, looking down briefly at her congealing cheddar before looking up at me. “Yeah, that’s me.”
“Sorry, I don’t need anything. Just, thanks for your help tonight.”
“Oh, no problem. Who are you?”
“One of the nurses. Russell.”
“Hi, Russell. Nina.”
“How’s your night going? You seem busy.”
“I’m being dramatic, it’s fine. Sort of quiet, actually.”
“Careful,” I said, calling up a bit of superstition that I’d only recently learned. “You’ll jinx yourself.”
“There was a study on that recently, did you hear? Some doctors in England who thought they were funny. They flipped a coin every day for two months and said ‘quiet’ every time it landed on heads. No difference either way. So relax—speak your truth.”
“What a relief,” I said. We were at the register. “Are you eating down here?”
“Oh,” Nina said, surprised. “No, I should probably get back. Are you?”
I looked out over the deserted seating area. “I think so,” I said. “I get a thirty-minute break and plan to milk it.”
“As you should. Y’all work so hard,” she said, turning toward the elevators. “Have a good one.” That y’all stuck out strangely. Who did she mean? Otherwise she had no trace of a local accent. What words might she presume would soothe a male nurse twice her size? I felt like a farm animal, penned in by its own mass, its brute understanding.
I sat down, dressed my salad, and pulled out my phone. My social networks were all quiet at that hour. I searched for Steve’s profile, which had long stopped appearing in my feed. He had posted a new photo of himself, standing in what looked like the trauma bay of an emergency room, wearing a plastic face shield lightly spattered with blood. His head was angled slightly away from the camera, smiling, almost bashful.
The last time I saw him was in Philly, at his place, for farewell drinks. He’d sprung for a bottle of scotch to celebrate the end of the road. He served it neat. I told him I had a theory that nice liquor gave you a different sort of hangover, muted and somehow enriching. The word I think I used was “twinkling.” He laughed and poured me another, and then another. We toasted each other as two newly minted murses. We toasted the various women in our graduating class Steve had tried and failed to date. We toasted our jobs and our loans.
We took his dog out for a walk and picked up hoagies for dinner on the way back. On my way back into his apartment, I tripped over the threshold, and he suggested that I spend the night. I texted Lily to say that things had gotten out of hand, that I’d see her in the morning. Steve queued up a big-budget movie with a complicated plot involving time-traveling secret agents. We talked each other through our shifting interpretations. When the credits finally started rolling and the bottle was almost empty, Steve asked if I’d spare him the trouble of making up the couch and just crash with him in his bed. I followed his lead and stumbled into the bedroom. I stripped down to my boxers and tucked myself in.
When I woke up, there was just enough pale light coming through the blinds to recognize the shape of him bent toward my midsection. I didn’t understand what was happening as he grasped my hips, didn’t register his intention until he had me fully in his mouth. His arms were bigger than mine, his belly rounder, his legs hairier. I had sized him up long before, or thought I had, in the usual chaste intimacy of dormitories and locker rooms, where if admiration ever flickered into curiosity, it did so privately, fleetingly. Waves of confusion and nausea bound me in place. Still, I could have put up more of a fight. Instead I just lay there, floating over my own body like an untethered astronaut, caught somewhere between stupidity and speech, tenderness and disgust.
I rolled over onto my stomach as soon as Steve was off me. Neither of us spoke. I must have fallen asleep again, because I remember dreaming myself into the time-travel movie, only a different and more explicit version, where the whole cast was intermittently undressed. I’d recently sworn off pornography, having learned in a psychiatry elective how it can distort your vision, ruin your appetite. I’d watched a lot of it as a teenager, though, sometimes over and over again, to the point of dwelling on particular characters and storylines, puzzling over how certain messy scenarios were supposed to resolve themselves after climax, what unwritten script the characters could possibly follow to get back to the original pretext of the job interview, the piano lesson, the pizza delivery.
My head was throbbing when I finally got out of bed. I put on my pants, reached into my pocket, and made a fist around my keys, wondering, not for the first time, if I could ever be capable of real violence. Steve was already up, leaning against his kitchen counter, drinking coffee. He’d pulled an extra mug out of the cupboard and left it sitting empty, expectant, next to a bottle of ibuprofen. I said I was heading out. He started to lean in for a hug, then thought better of it and shook my hand.
Mrs. Vine hadn’t slept all night. Around 4 a.m., she started pulling at her lines and climbing out of bed. Redirecting her proved futile, so I went into her room with soft restraints, ready to cuff her wrists and ankles to the rails for a few hours, hoping the delirium would pass by sunrise. “You got a girlfriend, baby?” Mrs. Vine asked as I guided her trembling hands through the Velcro straps and into the quilted mitts. I had one harness left to secure when the code bells went off overhead.
The room number announced over the hospital-wide intercom turned out to be right next door. Joe’s telemetry tracing had abruptly changed. I joined all the other nurses on the unit who were swarming to his bedside, where he lay blue at the lips, failing to rouse to a chorus of women calling his name. Maura dug her fingers above his clavicle and shouted that he had no pulse, that he wasn’t breathing.
We had him flat on a backboard with chest compressions started by the time Nina came running up the hall. She had another doctor with her, the lanky pulmonary fellow, his hair matted as if just awoken. He ordered defibrillator pads to be placed on Joe’s torso and then, watching the monitor, called out for shocks to be delivered or withheld. An audience of support staff swelled around us.
Nina pulled a folded bundle of papers from her white coat, found Joe’s name, and rattled through some potential causes for his arrest: acidosis, blood clots, pneumothorax, mucus plugs. The difficulty of knowing for sure meant acting on every hypothesis at once. An overnight pharmacist rummaged through the shelves of a nearby crash cart, pushing dextrose, then potassium, then bicarbonate. An on-call anesthesia resident wearing a bulky backpack pried Joe’s jaw open with an illuminated blade and guided a plastic tube into his trachea. On a nearby computer, Nina scrolled through a cloudy chest CT.
It was close to sixty minutes before they decided to call it quits. I hadn’t been part of many codes before, but Joe’s was the longest by far. The room got quieter as the hour wore on, as we kept working to recover a heartbeat long past when it would have done him any good. There was a line of people waiting to perform CPR, and I cycled through it several times. With each pass, I pressed all my weight onto Joe’s cold torso, feeling his ribs fracture under my palms into smaller and smaller pieces. The pulmonary fellow offered up some feedback on my form: slower, faster, better, good. During my last round of compressions, he observed without commentary. All I heard was the creaking of the bed.
I look backward more than I should. I’m trying to break the habit. After Joe’s body was wheeled off the unit under a fresh white sheet, I took the other night nurses at their word when they told me that there was nothing I could have done differently. Joe had been dealt a bad hand well before I met him.
“Time bomb,” Maura said, rubbing her hand between my shoulders. “Plain and simple.”
Nina called Joe’s parents to break the news, and I was glad I didn’t have to face them myself. Joe would have been a wildly different person to them, if not a long series of different people, stacked one on top of the other, like a flipbook—a vulnerable baby transforming into a vulnerable man, then back again, over and over. I imagined them praying, as everyone down here seems to pray, for miracles, hoping that the span of their son’s life wouldn’t end up fitting cleanly inside their own.
At 7 a.m. I handed Mrs. Wood and Mrs. Vine back over to Megan. She couldn’t believe what happened. Joe had been on the upswing just twelve hours earlier. He’d never coded before.
“Folks surprise you,” I said.
“Shit,” Megan said. “I guess.”
Activity was picking up on the first floor as it tends to at that hour, a steady stream of patients and employees trickling through the building’s various entrances. On my way out, a woman stopped me for help in front of a map on the wall. “Excuse me, doctor,” she said. “Which way to dermatology?” A sullen teenager stood next to her, looking at me through thick glasses, up from the painful, larval depths of puberty. There was acne spread across his cheeks, peach-fuzz growing under his nose, and an extra fold of fat slung around his neck. I pointed them in the right direction.
Before driving home, sometimes I take the elevator to the roof of the parking garage, where there’s a decent view of a brand-new surgical center being built just up the road. Police officers guide traffic around it while construction workers fit its external panels into place. I’ve been following their progress with interest, this pack of men whose jobs are woven into their uniforms, organizing the world with their whistles and cranes.
The best part of the night shift is at its end. I’ll be back there soon enough, eager again to be kind and useful. But for now, on this bright morning, in this friendly town where I don’t know anyone, I ease into my car, into my earned fatigue, into the sprawling freedom of the day. There’s a soreness to my arms that feels familiar and satisfying. I lower my window and rest my elbow on the frame. Disease and deformity, weakness and error recede in the rear-view. I permit myself the monstrous pleasure of not caring. I cast care off like a yoke.