Cover for Where Night is Day

Where Night Is Day will be of interest to doctors, nurses, medical and nursing students, patients, and those interested in the organization of health care delivery. This excellent and compelling book marries theory to observation. James Kelly has created an intriguing presentation of social science thought about the health professions and illness, the socialization process of medical and nursing students, a clinical ethnographic study of life in an ICU, and an auto-ethnography.”

Brian Hodges, MD, PhD, FRCPC, University of Toronto, coeditor of The Question of Competence: Reconsidering Medical Education in the Twenty-First Century

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“James Kelly’s ICU is a relentless and claustrophobic space where all the stories begin in the middle and only some have endings. His book is an exhilarating and humbling depiction of nursing in the twenty-first century.”

Arthur W. Frank, author ofThe Wounded Storyteller: Body, Illness, and Ethics and Letting Stories Breathe: A Socio-Narratology

“James Kelly provides an exceptionally thoughtful narrative of the modern intensive care unit.  He characterizes the rhythms of the ICU and captures odd juxtapositions of the deeply emotional and highly technical, while he explores the complex history and unspoken social hierarchy of American hospitals. Through the experience of caring for critically ill patients and their families, he ultimately delivers a moving meditation on life and death.”

Peter Clardy, MD, Director, Medical Intensive Care, Beth Israel Deaconess Medical Center/Harvard Medical School

Where Night is Day

The World of the ICU

Where Night Is Day is a nonfiction narrative grounded in the day-by-day, hour-by-hour rhythms of an ICU in a teaching hospital in the heart of New Mexico. It takes place over a thirteen-week period, the time of the average rotation of residents through the ICU. It begins in September and ends at Christmas. It is the story of patients and families, suddenly faced with critical illness, who find themselves in the ICU. It describes how they navigate through it and find their way. James Kelly is a sensitive witness to the quiet courage and resourcefulness of ordinary people.

Kelly leads the reader into a parallel world: the world of illness. This world, invisible but not hidden, not articulated by but known by the ill, does not readily offer itself to our understanding. In this context, Kelly reflects on the nature of medicine and nursing, on how doctors and nurses see themselves and how they see each other. Drawing on the words of medical historians, doctor-writers, and nursing scholars, Kelly examines the relationship of professional and lay observers to the meaning of illness, empathy, caring, and the silence of suffering. Kelly offers up an intimate portrait of the ICU and its inhabitants.

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End-of–shift. I walk the unit. Some of the rooms are dark, some lit, some with families, some with one person, some empty. The patient on a bed like an actor alone on a stage. The one thing you can see in all the rooms, above the blankets, resting on a pillow, is a face. Different odors. Feces, C. diff, renal. Like different temperate zones. TV voices flow out of the caves of the rooms and weave in the air. The Spanish station Univision. ESPN. CNN. Garcia like a bug on its back, arms and legs flailing. Still, a long, slow climb out of the depths. Three surgeries. A friend holding his leg and kneading his calf. His wife Lakota calls every day. “I don’t drive.” She sounds drunk. Says things like “I pray for all of you. Be patient with him. He didn’t finish high school.” A CD playing in his room. Mark Knopfler and Emmylou Harris. All the Roadrunning. Sanchez’s family talking to her. “Fruta. Fruta.” The loving daughter. Carson. Like he’s on fire. Heart rate 143. Pressure 188 over 104. They’ve tried everything. Rate of 35 on the vent. Reversed the I and E. A healthy guy who got the flu. He’s like one of those California wildfires they say is seventy percent contained or forty percent contained. Pneumonia. Then kidney failure. Billy Collins has a poem about sitting on a train and seeing speed lines on people. It’s like you can see the flames. He’s zero percent contained. Even the doctors, running out of ideas. They paralyze him, then stop the paralytic, then paralyze him again. I had him once. Early. His wife like a schoolteacher. Asking a lot of questions. A soft woman. Warm. Friendly. Trying to understand. “Life changes fast,” Joan Didion wrote. “Life changes in the instant. You sit down to dinner and life as you know it ends.” Every day now she seems harder or denser or more focused. Friendly still, but like a child losing her baby fat. She’s early fifties growing up before our eyes. They put a Vas-cath in for dialysis. Wallach is intubated. All the terror and work of breathing over. His wife sees me and smiles. I smile back. I think what Garcia and Carson have missed. Daylight savings time. The World Series. Halloween. The first snow in the Sangres.

In The Birth of the Clinic, Foucault writes about the origin of the teaching hospital, the change in disease theory, the rise of the medical profession. The first question, Foucault says, in looking at a profession, is, “Who is speaking? Who has the right to speak? Who is qualified to do so? Who derives from it his own special quality, his prestige?” In medicine, doctors speak. They speak mostly to each other. They have rounds, conferences, teaching sessions. They have their own jargon. They don’t speak to nurses. They don’t speak to patients very much. The first chapter of Jay Katz’s book The Silent world of Doctor and Patient, is “Physicians and Patients: A History of Silence.” When doctors do speak to the patient, we are there. We’re there when they speak to families. We’re sometimes there when they speak among themselves. We know what they say. But they don’t know what we say to the families. They don’t know what families say to us. If you asked a doctor what is the one thing almost every family asks us, they wouldn’t know. The one thing every family, at some point, will ask is: Can they hear?

Someone has been in the room all the time. A daughter. The husband. Whenever I do anything, suction, blood glucose, a turn, I say her name. “Mrs. Montoya,” I tell her softly, “bright light,” “little stick.” Every day I end my first note with “All procedures and interventions explained to patient and emotional support given throughout.” I am faithful to it. Now there is no one here. I think she feels the peace too. Like we’ve been at a wedding or a festival dancing to music for a long time and can now rest. The husband’s crossword puzzle book on the chair. The lettering jagged, coming out of the little boxes. He can hardly write. Fifty-six and a half years aren’t enough. He wants more. He doesn’t want it to end. Being here is everything. The clocks were turned back weeks ago and at five-thirty it is night. Out the windows, tall hooded lights illuminate the parking lot. Above them stars. Thanksgiving is in three days, the city quickening with visitors. Sons and daughters coming home. Maybe dying is like the effort in pulling back the string of a bow but the moment before the release is a kind of stillness. Once you’re back, you just hold it, everything taut, and all the runs of V-tach and breathing fast are the quivering of that holding, harbingers of release and then whoosh, you let go. Her eyes are closed. The room is as dark as the outside. I take her hand and rest it in mine. I do something I almost never do. I call her by her first name, “Jennie, it’s all right. You’re all right.” Because when they ask, what we tell them, the answer is: yes, they can hear.