Confession

The questions are unexpected.

“Have you ever robbed a bank?”

“No,” I say.

“Have you ever killed anyone?”

“No.”

“Okay then.” Father Tom lays his hands on my head, says a prayer, and absolves me of my sins.

I’m in confession, and the priest and I have been talking for two hours. I chose to take this sacrament face to face and avoid the anonymous dim, smelly confessional booth with the scowling Angry Jesus picture that I remember from my youth. It’s been over 30 years since my last confession and they call it “reconciliation” now. The luxury of this personal approach is the allowance of time. After reviewing my entire adult life Father Tom, a kindly septuagenarian, and I veered off into other philosophical topics. With nothing more to confess, he asked about robbery and murder. I assumed he was joking and I denied the claims.

“Thank you. I’m sorry I was here so long.”

“Oh, no problem. If you want to talk more, just give me a call.” With that, Father Tom escorts me out of the Jesuit parish rectory and into the late spring evening.

I drive home in silence. The sun slips behind the Smoky Mountains. I thought confession, an unburdening of the soul, would feel more cleansing. I don’t feel particularly lightened. My hospital identification badge is still clipped to my dress. It lies heavy on my chest.

Have you ever killed anyone? The question unnerves me. I’m a nurse. I’m a healer. I’m supposed to help people. Uncomfortable memories suddenly surface: patients, colleagues, and situations I haven’t thought about for years rush back.

I remember pushing my fingers into a baby’s chest for 20 minutes, but none of the pressure would bring him back to life. I remember standing next to a little girl with a Do Not Resuscitate order, watching lines on her monitors flatline. I remember the stunned grief of the mother who was told we weren’t going to start dialysis on her son because his overall condition was too grave and the dialysis would be futile. There were others: too many children we couldn’t save, too many parents we couldn’t console.

By the time I reach home I’ve tallied up my failures. My boyfriend Scott calls later that night. “How was it?”

“Fine. He asked me if I’ve killed anyone.”

“Well, you haven’t.”

“I’m a nurse. My patients die.”

“But you didn’t kill them.”

I grasp at images and feelings, feebly articulating what I’m thinking. But the pictures are gauzy and my words are clumsy. “I don’t know. How are we defining killing?”

Mirage dies a few weeks after my confession to Father Tom. Mirage is part of a herd of horses near my house. I ride one of his herdmates, Sundrop, and I consider Mirage to be one of my own. A majestic Tennessee walking horse, he is the alpha and at 29 years old is still going strong except for a little arthritis. On a Tuesday morning Mirage slips in the pasture and can’t get up. His leg is broken. The woman in charge of the horses that day brings the herd up late for their breakfast; she is busy with upcoming trail rides. The people running the barn don’t do a head count. No one notices he is missing.

Four hours later a kayaker spots a black horse alone in the field, struggling to rise. He calls the barn. The vet arrives first. Mirage is dehydrated. He has baked in 80-degree heat for four hours, suffering with a broken leg. He is put down immediately. His owner can’t get there in time. She couldn’t say goodbye.

Mirage’s former owner is my riding instructor, and she erects a shrine in his stall at the barn. We lesson students bring things for the altar: pictures, his halter, his bit and bridle. The black toy horse I bought him for his birthday joins the offerings. We huddle together under the barn lights and share Mirage stories.

The woman we accuse of killing him cries when she sees us. We’re silent in our grief and fury.

“I’m so sorry! I was so busy. It was an accident. I’m so sorry!” she wails repeatedly.

I’m uncomfortable watching her cry. Something in me stirs and I open my arms to her. She sags into them, sobbing harder. Hugging her, I feel like a traitor to Mirage, but the woman’s pain seems genuine. My riding friends remain immobile during this exchange. I hope these are not crocodile tears.

I’m back at the rectory entrance waiting for the solid oak door to open. I trace the outline of the slate patio with my shoe. The door hinges creak. Father Tom appears at the threshold and ushers me back into the same moss-green room as before.

“You said I could come back if I wanted to talk.” I resume my place on the cargo sofa.

Father Tom settles into his chair. “Of course. What’s on your mind?”

“You asked me if I killed anyone.”

He waits quietly.

“I’m not so sure I haven’t.”

“What do you mean?”

“It’s not really a fair question to ask a health care provider. I’m a nurse. People die on me all the time. One Christmas our NICU lost seven babies in 10 days, and five of those assignments were mine. I’ve turned off ventilators and unhooked IVs. I’ve done CPR on a baby but couldn’t get the heart beating again. As a nurse practitioner I’ve been part of discussions where we decided to discontinue care or not get things started. I put my cat down because she only had months to live and I wanted her to die on my schedule before she got worse. Does any of this make me culpable of killing?”

Father Tom puts his palms together and places them over his lips. I tell him about Amadeo.

My boss calls me at home on a January evening. He’s a physician but I call him Fred. He’s a kind, quiet man and one of few words. “We have a new consult. NICU.” “Okay. Do you need me to come in?”

“No, no. We can’t do anything tonight. Just come to NICU in the morning.”

“What is it?”

“Polycystic kidney. We don’t know how bad but if it is, we need to plan for PD catheter. I’m arranging with the surgeons.” He sighs.

“What’s the baby’s name?”
“Amadeo.”

Amadeo’s kidneys have cysts, bubbles of fluid that formed in his kidneys while he grew from an embryo to a baby. These fluid-filled cysts expanded, encroaching on the rest of the kidney, pushing the normal tissue out of the way and making the kidney bigger. Amadeo drew the unlucky straw of having cysts in both kidneys. His kidneys and lungs jockeyed for space in his tiny abdomen but the kidneys, being the heavyweight, won the fight and squished his lungs high into his upper chest. The lungs didn’t have room to grow and thus didn’t develop properly. Amadeo was born with kidneys too big and lungs too small.

There was a time in the not-so-distant past when these babies would die at birth because the lungs couldn’t breathe, the kidneys wouldn’t work, or both. Not breathing is an obvious cause of death, but without kidney function there is no way to urinate. Without urine, excess fluid and toxins build up in the body. Potassium goes up. Blood pressure goes up. The heart beats faster trying to rid the body of the extra fluid but to no avail. The heart floods and the body drowns in a sea of toxic fluid. Exhausted, the heart gives up. Death comes shortly after. But not now. Now we can take out Amadeo’s kidneys and start him on dialysis to give the lungs room to develop and do their job — breathe.

Since Fred is talking to the surgeons, I know the plan: dialysis. Through a combination of biology, chemistry, and physics, dialysis will work in place of his kidneys. First, a surgeon will place a flexible plastic tube in his abdomen. A nurse will infuse a special fluid of water, sugar, and electrolytes through that tube and into Amadeo’s belly. The fluid will mix with his blood and this mixture will pass back and forth across his peritoneum, which acts like a membrane. Good things like blood and protein will stay in the body while waste products and extra water go out. He’ll do this every day until he’s big enough to be transplanted with a kidney, at least two years from now. Until then infection, poor growth, and death are among some of his constant threats. Amadeo has a long, rough, uphill, twisting road ahead of him.

This newborn intensive care unit is my old territory. This unit molded me into the nurse practitioner that I am today. These white walls, scuffed linoleum, and overhead lights cradled me as a nursing student. I chose to work here after graduation and I learned how to be a nurse among the rows of incubators and monitors. This NICU is where I observed my first delivery, performed my first CPR, witnessed my first death, administered my first postmortem care. I no longer work as a unit nurse here but my friends are still around.

“DK. You here for Amadeo?” My friend Bobbie catches me in the hallway. She is one of the nurse practitioners. She was my preceptor when I was a student and is one of the reasons I chose to work in the NICU.

“Yeah. Fred been in?”

“I haven’t seen him. Baby’s cute.”

Bobbie leads me to Amadeo and we join Sue, another friend and Amadeo’s outgoing night shift nurse. “Hi honey,” she says, stifling a yawn.

“Hey.”

Amadeo looks up at us. He’s a tiny baby boy with chocolate eyes and raven curls. “You guys doing dialysis?” asks Sue.

“That’s the plan.”

“Glad I’m off for a few days.”

Dialysis stresses everyone. The mere suggestion of it causes much hand-wringing. I know why the nurses are anxious. Fred and I are a new team together, just over two years. His predecessor didn’t do much, if any, dialysis. With volume comes experience and with experience comes proficiency. We’re going to do dialysis on a baby in a unit where there’s been no volume, thus no experience and certainly no proficiency. I saw dialysis once when I worked in the unit, and it wasn’t with the equipment we’re going to use. This combination of a new modality and inexperience threatens everyone’s confidence. They’re fearful of failing; for if it doesn’t work, new procedures will be sought and the line between helping and meddling blur, and his care could segue into needlessly prolonging life. They are worried he’ll turn into a Science Project — the moniker for babies who languish on the altar of “because we can, we do.”

Fred and I talk to Amadeo’s mom. She’s from my hometown. She has the same dark hair as her son. Fred walks her through the upcoming steps. Dialysis. Growth. Discharge. Transplant. We discuss the many obstacles to overcome, the labyrinth of complications that can happen. Mom is hopeful. Deep dimples accentuate her smile.

I go to the operating room for Amadeo’s surgery. One surgeon, Dr. B, puts in the peritoneal dialysis catheter. Another surgeon, Dr. X, removes the kidneys. They are rust colored and lumpy and look like a bag of marbles. Both kidneys are 13 centimeters long, over 6 ½ inches. Normal newborn kidneys should be around 2 ½ inches. Amadeo’s evicted kidneys overfill the stainless-steel specimen bowl. We take turns staring at them, resisting the urge to pop the cysts like bubble wrap.

As surgery winds down Dr. F, the anesthesiologist, pulls back the sheet covering Amadeo’s face. Amadeo is white. Too white. There is sudden activity at the front of the bed. Labs are drawn. Blood pressure is retaken. His hematocrit, a measure of red blood cells that carries oxygen through the blood, is 4 — dangerously low. Without oxygen being able to get to his brain and organs, he will die. Everyone starts talking. The activity speeds up.
I call Fred from the OR. “His catheter is in. Kidneys are out. And his crit is 4.”

“No. That can’t be. His hemoglobin would be 1. That’s not possible.”

Dr. F is pushing blood into Amadeo, who is slowly pinking up.

“No, I think that’s right. His kidneys were 13 centimeters apiece. Apparently they had all his blood supply.”
Jamie is the nurse taking care of him after the OR. I fill her in on what happened. “Was his crit really 4?”

“Yep. The kidneys are huge. I think Dr. X took pictures.”

“When are we starting?” she says, referring to the dreaded dialysis. “Twenty-four to 72 hours. Hopefully 72. The longer we can wait and let the catheter incision heal, the better.” We discuss what will give him a successful prognosis. I put my hand on her shoulder. “We’ll be fine.”

Our hope for Amadeo is not misplaced. The dialysis works. He’s gaining weight. He’s eating. He’s doing well. By mid-February he’s cleared this hospital hurdle. He’s ready to go home. We will follow him in our outpatient clinic. I’m coordinating the last of his discharge plans when Bobbie calls from the NICU.

“Amadeo has a fever. We’ve already done a blood culture and the fluid culture is pending.”

“We’re on our way.”

In healthy people fevers are useful. The high temperature helps the body fight infections by denaturing the viral or bacterial proteins. In compromised patients fevers are concerning. Compromised patients are targets for opportunistic infections — viruses, bacteria, fungi, all lying in wait like a mugger ready to assault an unsuspecting victim. Amadeo’s age, his hospitalization, and his dialysis put him in the compromised category. His fever is worrisome.

Fred and I arrive at the bedside. Fred furrows his brow. Amadeo looks puny. His color is off and he’s not as alert as he usually is. The fluid coming out of his belly is cloudy. It should be crystal clear. None of these are good signs. We get the confirmation soon enough: fungus has infected Amadeo’s peritoneum. Fungal peritonitis can be fatal because we have to stop the peritoneal dialysis while we clear up the infection. We need an alternative treatment.

Amadeo’s medical team confer together. We decide to try another form of dialysis, hemodialysis. A different surgeon removes Amadeo’s belly catheter and places one in his neck. Through this catheter a hemodialysis machine will pump out his blood, push it through a filter to clean it, and then return it to him. This dialysis is most often used in adults, larger children, and teenagers. It’s a daunting and dicey plan with risky complications: blood loss, infection, death.

We feel Amadeo is worth the risk and we reconvene at his side. Amadeo’s fever has come down and he looks better. He stretches in his sleep. The hemodialysis nurses have arrived with the equipment, but they look worried. They are experienced dialysis nurses with adult patients, not kids, and certainly not newborns or infants. Through no fault of their own, no one here has dialyzed a baby with hemodialysis.

Fred sucks in his breath. The surgeon put in an Eight French catheter. It’s too small. Catheters are thin tubes like straws. The wider the tube, the faster the fluid can travel. If the tube is too narrow, incredible pressure is required to keep the fluid moving, much like drinking a milkshake through a cocktail straw. An Eight French catheter is insufficient for hemodialysis. We need at least a Ten French catheter.

The dialysis nurses shift nervously and fiddle with the machine. The narrow catheter will likely not work but we have no choice. We have to do something.

“Let’s get this going,” Fred says.

We give up on hemodialysis the next day. The nurses can’t keep the hemodialysis machine going. It needs to pump the blood fast but the catheter can’t handle the pressure. The force needed to move the blood is destroying red blood cells and making the machine stop. It’s straining Amadeo, the catheter, and the machine. We’re going to hurt him if we keep this up.

We try continuous renal replacement therapy, another form of hemodialysis but with a slower blood speed. The dialysis nurses run into the same issue. The catheter is just too small. They start, stop, and tinker with the machine for a shift. We can’t get this to work. Amadeo is getting sicker. His laboratory values are changing for the worse, he’s getting puffy, and his blood pressure is going up. Nursing is getting agitated. We’re on the precipice of hurting versus helping him. It’s starting to feel like an experiment. Someone mentions “Science Project.”

We give hemodialysis another try but the same problems persist. Dr. B is out of town and his colleagues refuse to attempt placement of a bigger catheter.

“Why?” I ask Fred.

“I don’t know.” He runs his hand through his hair. “They’re not comfortable. They’re worried it’ll be too big and tear his vein.”

“But if we don’t do a bigger one, what do we do?”

Fred doesn’t answer.

“If we don’t do dialysis, he’ll die. It can’t get worse than that, right?”

Fred stays silent, staring at Amadeo.

“Can we do two Five’s? We need a Ten French, right? A Five for venous and a Five for arterial? Will that work?”

“No. Not here. I suggested but they don’t do that here.”

Peritoneal dialysis isn’t available to us yet. His peritoneal dialysis catheter was removed and we’re still treating the fungus in his belly. Surgery won’t operate on his abdomen while he’s infected. We concur, as that would certainly make him sicker, but now we’re out of options. There are no more tricks, no more work-arounds.

“So what do we do?”

Fred closes his eyes, massaging his forehead with his hand. “Nothing.”

We stare at each other. We went from planning his discharge party to signing his death warrant. It’s not supposed to be like this.

Fred and I meet with Mom on a dishwater gray Friday morning. We’re at Amadeo’s bedside. He’s been moved to the back row, by the windows. White vinyl privacy screens surround him. Staff and nurses drift in and out to hold his hand and stroke his cheek. It’s déjà vu. When I was a nurse here, I had a “Science Project” one spot down.

Mom understands the technical quandary we are in. She doesn’t want him to suffer. She agrees to no further care. She is gracious as she accepts the plan.

The dialysis nurses pack up the machines. In the upcoming hours Amadeo’s blood pressure will go up. His potassium will go up. He will lose consciousness. His heart will stop beating. The nurse taking care of him has tears in her eyes. Fred holds Amadeo’s hand in his fingers. We can’t stay. We have patients to see across town in our outpatient clinic.

“I need to say goodbye to him,” I say. “I’ll meet you over there.”

“Okay.”

It is my turn to hold Amadeo’s fingers. He has plumped up since birth and inherited Mom’s dimples. I try not to cry. Mom gives me a hug.

“Thank you. Thank you for doing all this.”

“I’ve done nothing.”

“You gave me six weeks with him.”

“I’m so sorry. I’m just so sorry.”

“You did everything you could.”

Did I?

She squeezes my hand. Tears drip down my cheeks as I slip out of the unit doors. I sniff and weep my way across town. I’m late but I detour to 7–Eleven. I stagger into the convenience store, dazed among the familiar smells of linoleum, burnt coffee, hot dogs, and gas fumes. Coffee in hand, I queue in behind a dapper elderly black man chatting up the clerks.

He turns to me. “I’ll get that.”

“What?”

“I’ll take care of that.”

“Huh?”

“Your coffee’s on me.”

“Oh no, I couldn’t.”

“Really, no, it’s my pleasure. You look like you need it,” he says. “Please. It’s on me.”

I want to hug this old stranger with his gentle eyes, in his shiny brown suit, and smelling like Aqua Velva. I want to tell him we just said goodbye to a baby — that with all our tricks, tools, and toys, we couldn’t get a catheter or machine to work and keep him alive. I want to ask him why in 20th-century America, right outside of our nation’s capital, the power center of the world, we can’t save this baby.

I croak out a thank you and flee.

Fred meets my eyes when I arrive. We move through clinic in silence, trying to be present to those in front of us, hoping they don’t notice we’re distracted. Their problems are important to them. We can’t tell them about Amadeo and that today we think they have no problems.

Clinic is finally over and we’re alone. Snow flurries wisp outside.

“You staying?” Fred asks me.

“I’m going to finish these notes.”

He lingers in the doorway. “Okay. See you.”

“Bye. See you Monday.”

Years later Fred and I will be working in a large freestanding children’s hospital in the Midwest. A baby with the same disease will be born. A surgeon will take out her kidneys and put in a peritoneal dialysis catheter. She will get fungal peritonitis. She will get a hemodialysis catheter. She will get hemodialysis six times a week for three months until we can do peritoneal dialysis again. She will live. She will be transplanted. She will thrive. I will look at Fred and say, “This could have been Amadeo.” He will shake his head sadly. The remorse lingers.

Father Tom shifts in his chair. The afternoon light sparkles on his white hair. Before he can respond I continue.

“I looked at the board on Monday — just to see if he was still alive by some miracle. His name wasn’t there.”

I tell him about Mirage. “I’m hugging this woman and I’m thinking ‘you killed him’ and then I think of Amadeo and think that I did the same thing.

“I know it’s different but somehow, they remind me of each other. Mirage fell. He broke his leg. He would have been put down regardless of when they found him. But if that woman brought them up on time, maybe Mirage wouldn’t have fallen. And if he did fall, if they did a head count, they would have found him and maybe he wouldn’t have had to suffer for four hours. Mirage died because a woman failed to do her job. Amadeo died because we failed to do our job. When you asked if I had ever killed anyone, I thought of him. I know it’s different but it seems the same.”

Father Tom takes his time to answer. “It’s more of a team failure, don’t you think? You alone didn’t do this. For Amadeo, the mother agreed to no further care. Isn’t that what you said?”

“Yes. She did. On one hand it seems like we did all we could but on the other hand, it feels like giving up. I remember feeling like we worked hard, like we gave it a valiant effort. But we didn’t have what we needed so we just stopped.”

“Without any intervention, would he have died at birth?”

“Yes.”

“Those other babies, were they following the natural course of their illness?”

“Yes.”

“It’s not the same, you know that, right?”

I stare absently out the window. I try to sort out the guilt I’ve taken on. “I don’t know. We stopped care. We left him. I’m part of that ‘We.’”

Father Tom pauses again before he speaks.

“I’m very sorry about Mirage.”

“Thanks. I guess that’s a team failure too. Other people at the barn could have noticed he was missing.”

“Have you thought that you helped the family?”

“No. Not really.”

We are quiet, absorbed in my story. Father Tom says a prayer. I head to the door.

“You’re being too hard on yourself,” he says.

“Maybe. It’s still a provocative question to ask a health care provider. We all have blood on our hands.”

I go to the barn before it closes for the night. The herd grazes in the pasture. I wonder if they avoid the spot where Mirage fell. My chest tightens. The question unsettles me. Have I killed anyone?

I approach the fence. Sundrop is a few yards away, golden in the fading light.

“Hey, sweet girl.” I make kissy sounds to her. Sundrop lifts her head, pulling a weed up with her. Grass pokes out of the corners of her mouth. She locks her eyes with mine and swishes her tail.