icon caret-left icon caret-right instagram pinterest linkedin facebook twitter goodreads question-circle facebook circle twitter circle linkedin circle instagram circle goodreads circle pinterest circle

The Quality of Mercy

This article appeared in the April, 1998, edition of the Smithsonian Magazine. It won several national writing awards, including the American Society of Journalists and Authors June Roth Award for Medical Journalism and the Clarion Award. It takes readers through a single workday at a small hospital with two exceptional nurses and a physician.

Hour by hour, we see these medical professionals shoulder staggering responsibility for the well-being of others, and offer kindness to people who may be in no position to say "thank you." We learn something about the complexity of modern medicine. We glimpse the complexity within our own bodies. And we learn that for each of us, whether we think about it our not, the possibility of death is always with us.

A central character in this article, unnamed, is a woman undergoing treatment for acute myelogenous leukemia. That woman is one of the authors of this article--so the story becomes a kind of "thank you" to two nurses and an oncologist, who saved a life.


by Richard & Joyce Wolkomir

It is still dark outside her window. But she has been unable to sleep. Her fear is now a continual inner roar.

"I don't want to die," she thinks.

She cannot see the flag outside, drooping in the dark, but she knows it is inscribed "Central Vermont Hospital." She knows every detail of the view from her window and every item in her room--the blue pump, which has infused her blood with chemicals so toxic the nurses changing the bags must wear goggles and rubberized gowns; the bedside tray, where they put the food she does not eat; the pinned-up wall chart showing each day's blood-test results, as the chemotherapy eats away her bone marrow. She is losing her hair.

Two weeks ago, she thought she had a flu. Her husband persuaded her to see a doctor. That evening the doctor called.

"It's bad," he said. A chilling pause. "You have acute myelogenous leukemia--you have to go into the hospital tonight."

She had been healthy, an educated professional. A nonsmoker, a nondrinker. Fruits. Vegetables. Exercise. She looked a decade younger than her 54 years. But she had tumbled into this alternate universe, the planet of the sick.

"Debby will be here soon," she thinks. "And this evening, Alma will come." She comforts herself, thinking of her nurses.

Today Dr. Valentine will do a biopsy. It will show if the chemotherapy has put her into a complete remission. If it has, she will have a chance to continue living. Her chance will be 35 percent.

"I don't want to die at all," she thinks.

6:00 a.m.--"Good morning," the night nurse says. She rests a reassuring hand on the leukemic woman's thin shoulder. "I'm going to draw blood."

Headlights sweep into the parking lot as the day-shift nurses arrive at the hospital, a red-brick fortress atop a ridge. Fog fills the valley, hiding the little state capital, with its 8,000 souls.

It is a ritual, this drawing of blood, the night nurses' final chore. First the nurse pulls on sterile gloves, her naked fingers never touching the gloves' outside surfaces. Then she shakes a sterilized towel from its plastic bag and spreads it over the patient's blankets.

Implanted in the patient's chest is a white plastic tube, a Hickman catheter. Inside her body, the tube enters the subclavian vein, which leads into the superior vena cava, the main blood vessel into the right chamber of her heart. Outside, the tube dangles from her chest, forking into two ports. One port is attached, via plastic tubing, to the computerized bedside pump, now transfusing the patient with antibiotics. The other port, capped in red, is for drawing blood.

With latex-covered fingers, the nurse prepares to open the catheter. The patient's hazel eyes watch, knowing the tube leads to her heart: chemotherapy has shut down her immune system, leaving her defenseless against infection.

The nurse swabs the port's cap with Betadine, an iodinelike antibacterial, dabbing the red liquid into the tiniest crevices. Then she swabs away the Betadine with alcohol, so it cannot contaminate the blood sample she is about to draw. Next she unscrews the port's cap. She has not yet opened a passage into the patient's body, however, because a clamp still squeezes the catheter tube shut. The nurse screws an empty sterile 10 cc syringe to the port, unclamps the catheter with a quick press of her fingers, and pulls back on the syringe's plunger: cherry fluid wells up in the hypodermic.

"That's waste blood," the nurse says.

The patient knows this syringe of blood will be thrown away. It might be contaminated with heparin, the anti-coagulant nurses use to flush her catheter. Reclamp the catheter. Unscrew the waste-blood hypodermic for disposal. Screw a fresh hypodermic to the port. Unclamp. Pull back on the syringe's plunger. Once again the patient's blood fills the syringe, cherry red.

"I'll get this right down to the lab," says the nurse.

She injects the blood into a test tube. Its purple cap signals lab technicians to perform a Complete Blood Count, or CBC.

Flush the catheter with saline solution. Flush again with heparin. Reclamp the tube. Twist on a new red cap.

"Have a nice morning," the night nurse says.

Downstairs, a laboratory machine will count the cells in each cubic millimeter of the patient's blood. Then it will extrude a printout. When the patient's oncologist arrives on the floor, he will scrutinize the printout like a shaman examining cracks in a burned bone.

It worries the patient, what portents Dr. Valentine might see in the accounting of her blood's neutrophils, lymphocytes, hemoglobin, erythrocytes, platelets. But today she has a sharper worry.

Will Debby be here, she wonders, when Dr. Valentine does the biopsy?

He is her wizard. He fights the cancer in her blood with potions, which she calls "my dangerous chemical friends." He transfuses her with platelets, so she will not bleed. Infections flare. He douses them. But, mostly, it is the nurses she sees. They are the doctor's proxy eyes and ears and hands. She has come to depend on the kindness of nurses.

Night shift. Day shift. Evening shift. Two South--the Medical-Surgical Ward--has its own peculiar rhythms.

Nights are quiet, with muffled hacks and coughs. Sometimes she hears cries from patients who are old and unhappy. She arrived here an hour after her diagnosis. She was in shock, and so was her husband. Night nurses brought a cot so he could sleep in the room. And they were especially kind, she remembers: they even brought a mat for her pet corgi, so he could sleep here, too.

Days are Two South's busiest shift. Social workers visit patients. Nutritionists go from room to room. Physicians make their rounds. Respiratory technicians hook up oxygen masks. But nurses still find time to dispense more than medicine.

On her first day here, brawny Mickey McLaughlin, a former sheriff, with a blond walrus mustache, shook his bullet-bald head and told her, "If God exists, He must have a mean streak." Blaming God was reassuring. It meant she did not bring on her cancer with dietary malfeasance, or bad thoughts. Mickey had relinquished his pistol and badge to become a nurse, he said, because "you can make things a little easier for someone, on occasion, and that means a lot." And Emily Pastore, the intravenous or "IV" nurse, came especially to tell her about another of Dr. Valentine's leukemia patients--two years after treatment, he was playing college sports, almost surely cured. Her spirits lifted. And Sandy Durkee seemed a nursing paragon, radiating healing, entering her room like blonde sunshine. It was the nurses who told her how to guard against bleeding, after chemotherapy lowered her platelet counts. She must not rub her eyes. She must not scratch the red rash on her legs, which chemotherapy had induced. She must be careful blowing her nose.

Mostly her day shift nurse has been Debby. And on the evening shift, from 3 until 11, her nurse has been Alma.

6:45 a.m.--Day nurses, just arriving, have gathered around a conference table for Report. They listen to tapes recorded by the night nurses, updates on patients. They jot notes.

"In Room 238," says the voice on the tape, "the patient is 34, with spina bifida and draining wounds on his buttocks and thighs...."

Deborah Farnham, brushing aside curly dark hair, dons the glasses usually dangling from strings around her neck and peers, with brown eyes, at her notes on the man with spina bifida. He will be her patient today.

"In 234, a 96-year-old man, pre-op for surgery on an enlarged prostate impeding urination...."

"In 238, a woman with leukemia. Dr. Valentine will do a biopsy today...."

"A 79 year-old man, pneumonia...."

"In 239A, a 36-year-old woman with rhabdomyosarcoma, Dr. Valentine's patient. Receiving chemotherapy...."

Debby has one more chore before she can visit patients. She must check their charts.

Two-South's rooms run along the outside walls, offering views of the Green Mountains. At the ward's hub is an island of computer stations, workrooms, closets, a kitchenette. Here, too, is the desk where the charge nurse sits, like a ship's captain in the wheelhouse. But the ward's nexus is behind the charge nurse, a revolving circular cabinet. Stacked inside, like books, are metal-covered files, each a patient's "chart."

Debby stacks five charts on the desk in front of her. Once again she puts on her glasses.

Each chart tells the story of one of her patients. Each pill swallowed is noted in the chart, along with the time of swallowing. Injections go in, too. Intravenous feedings and infusions. Surgical procedures. Lab reports. Updates of the patient's "vitals"--blood pressure, temperature, pulse. Food and drink ingested. Sounds heard through a stethoscope applied to the patient's lungs or belly. Nurses also enter into the chart, via computer printouts, their observations: responses to treatment, coughs, fevers, vomiting, sweats, pains, color of sputum, erratic hearts.

It is through the charts, mostly, that physicians communicate with nurses. After reading nurses' comments, the physicians may scrawl into the chart changes in their patients' orders, for the nurses to execute. Debby is now scanning for new orders from doctors.

Dr. Valentine, she sees, has ordered a new IV antibiotic for the woman with leukemia. Debby is especially alert for such medication changes. "Meds" must be administered in precise doses, at particular times. Mistakes can be lethal. Nurses must sign off as they administer each dose, taking responsibility. Often, late at night, Debby lies awake, while her husband and children sleep, reviewing her patients. Did she forget anything? Sometimes she telephones the charge nurse, to make sure some detail of a patient's care is attended to.

In one of Debby's earliest memories, she is four years old, helping her mother--who wears a full face cast--drink through a straw. An auto crash has injured her head. After the accident, Debby and her mother lived in her grandparents' home, where Debby grew up. Her grandfather, a Yugoslavian emigrant, worked in a granite shed, a short walk from their house on the Vermont capital's outskirts. Her grandmother worked at the Montpelier Steam Laundry, but she had yearned to be a nurse. Nursing became Debby's goal.

Once, as Debby programmed the leukemic woman's chemotherapy pump, the patient asked what attracted her to nursing. "I love taking care of people," Debby had said. "I always have." And she does not mind that her work--despite the high-tech gear and the life-and-death responsibility--requires services as humble as Jesus's washing of his disciples' feet.

7:00 a.m.--Room 237's bathroom floor is smeared with feces. It is the work of one of Debby's patients, a 79-year-old man with Alzheimer's disease, recuperating from gall-bladder surgery. Nobody from the cleaning crew is around. And so Debby is on her knees, with towels.

Today will be hectic. Two South can handle a maximum of 39 patients, and the census is already 36, with more due up from the operating room. Debby can hear the charge nurse and the ward's supervisor talking about how to juggle rooms.

"Are you hungry this morning?" Debby asks her Alzheimer's patient as she takes his blood pressure. "I think so," he says.

He looks distinguished, sitting in his chair. He has white hair. He resembles Robert Frost.

Debby has donned her glasses to keypunch data into the room's computer terminal: Temperature--98.8; Blood Pressure--138/80; Incontinent....

The information enters the hospital's data bank. She types in that the patient has taken his morning Tylenol. Soon the updated printout will go into the patient's chart. Debby's keypunching also attracts the billing department's digital robot, eternally patrolling the computer network: automatically, a charge for one Tylenol tablet ticks onto the patient's record.

"Your son's coming to take you home later," Debby tells the distinguished-looking man. "Do you want to go home?"

"Okay," he says. "Okay. Okay."

7:30 a.m.--Debby is at the rolling medicine cart, parked in the corridor. Each patient on her side of Two-South has a drawer in this cart. In the pharmacy downstairs is a matching cart, its drawers empty. Technicians are filling the empty cart with each patient's prescriptions for the next 24 hours.

Technicians mix potent chemotherapy drugs in a sealed "safe" room, where the air pressure is low, so no toxic whiffs can escape. They prepare other IV infusions in a "clean" room, where the pressure is high, so that no contaminants can blow in.

Meanwhile, doctors' scrawled prescriptions rain down continuously from Two South, via fax. The pharmacy's computer screens them for erroneous dosages or harmful combinations.

This pharmacy stocks 1700 types of drugs, but sometimes a rare drug must be rushed in by courier. For instance, the hospital stocks no snake anti-venoms, Vermont having virtually no venomous snakes. But it does stock drugs for people who poison themselves drinking antifreeze.

Once a day, a technician rolls the newly filled cart up to Two South and returns with the emptied cart. The drawer filling begins again.

Debby is now leaning against the cart, her glasses back on, studying the Medication Administration Record, or "MAR." By comparing the MAR to her own records, she can decide if she and the pharmacists disagree. Should a drug be given three times a day? Or every eight hours?

Debby also checks to see who will need IV work. She sees the woman with leukemia will be getting a new antibiotic, and also IV nutrition. Good, she thinks. She has been noting in the chart that the patient is not eating, her appetite destroyed by chemotherapy. Debby is already planning when to set up the leukemic woman's IVs as she hurries to her next patient, a 96-year-old retired seafood merchant, awaiting prostate surgery .

"Let me brush your teeth," she tells him. He obligingly pops out his dentures into her hand.

She wants to be everywhere, taking care of each of her five patients. But some need her more.

7:45 a.m.--"It's me!" Debby says, walking into the room of the woman with leukemia.

"Debby!" the woman says. "I'm so glad you're here."

Debby is still knotting the strings of her breathing mask. Because chemotherapy has shut down the patient's immune system, visitors must wear masks to protect her from infection. Masked, Debby looks to the patient like a Muslim woman wearing a veil. It makes her eyes look even softer and browner.

"Let me wash your back and your feet," Debby says, after taking the patient's vitals.

Such washing, she believes, offers comfort. But it also enables her to examine the patient closely, the skin, the nails, the feel of the muscles.

"Your stomach is distended," Debby says. "How much of that anti-diarrhea stuff have you been taking?"

Because the patient's platelet counts are low, she could hemorrhage internally. And because her white cells are down, she is vulnerable to microorganisms. Diarrhea could induce hemorrhaging. Alarmed, she has been gulping ever larger amounts of an antidiarrheal medication. Debby suspects she is overdosing, and has plugged her digestive system.

"Stop taking it, Honey," Debby says. "I'll ask Dr. Valentine about it--your system is compromised and it could make you sick."

Two weeks ago, when they first met, Debby sensed that this patient was highly intelligent. But she has been stunned how little the woman knows about medicine. Nursing her, Debby has pondered how serious disease can bring anyone down. Intelligence, education, social level--nothing matters. You are too weak to wash yourself. You are terrified. Just being here, Debby believes, just showing the patient she cares, can be healing.

She hooks up the new IVs: "hang" the bags from the pump's metal pole; string plastic tubes from the bag, through the pump, into the patient's catheter ports, while maintaining scrupulous sterility; program the pump to deliver the two infusions. As she works, the patient speaks of her impending biopsy. Debby knows she is afraid.

"I'll be here for that," Debby promises. Then she tells a story about her husband, who has a business installing industrial scales. She can sense the woman relaxing.

The patient thinks: "I'm in good hands--at least, I'm in good hands."

7:50 a.m.--Dr. John Valentine has dropped off doughnuts at his office, a Friday morning ritual. He tells his two partners and the nurses and the office staff it is his duty as the boss. But he likes the doughnuts himself.

A lean marathoner, 48 years old, but looking 35, Dr. Valentine can afford the once-a-week doughnut binge. Otherwise, except for Wednesday afternoon drives to Boston with his wife, to watch the Celtics play--he is an ardent fan--his days focus on lung cancer, pancreatic cancer, breast cancer, the lymphomas, the sarcomas, prostate cancer, cancers of the blood, on malignancies of every organ and tissue.

From his mountainside home it is a 20-minute drive to his office adjacent to the hospital, four-wheel drive insuring he makes it through blizzards and March mud. He has worked at major medical centers. But he likes central Vermont's sparse population, where he might spend a Saturday afternoon chopping wood, with his beeper handy. He tells patients to call him whenever they are troubled by a symptom or a fear. He has mastered the knack of answering a wee-hours call about cancer, then dropping back to sleep.

Dr. Valentine is this region's sole oncologist. He likes making decisions himself, taking all the responsibility on his own shoulders. But he also consults with oncologists at larger hospitals. And he has National Institutes of Health research grants, so he can offer patients cutting-edge treatments.

At his office he pockets his stethoscope. In the hospital, just a few steps away, one elderly man is dying. It is the hard fact of cancer.

Chemical research was Dr. Valentine's original goal. He switched to oncology because he likes the unpredictability. "They'll never be able to write an algorithm describing a human, and run it through a computer, and it says what will happen," he thinks. He sees his work as defining the patient's problem, then choosing the correct solution from the chemical toolbox. But sometimes there is no solution. He tells himself: "You have to accept that."

8:00 a.m.--Dr. Valentine punches in a code at the hospital's staff entrance. He wears a blue-and-white checked shirt, charcoal slacks, and tan sandals, which coddle his running-injured heels. Inside, he pushes a button, alerting the staff that he in the building.

Today he has five patients on Two-South. He is pulling their charts from the revolving file when Mickey McLaughlin, looking sherifflike even in his nursing whites, tells him the dying man's family is gathering.

"He can't live too much longer--will you talk with them?" Mickey says.

Dr. Valentine nods. It is painful. He does not always successfully keep a professional distance. As he puts it, "You hate to see your friends die."

At the bedside, a middle-aged grandchild looks fondly at the old man. "But he's been a ball of fire," she protests.

"He'll die soon," Dr. Valentine says.

He gazes momentarily at his shoes. "I want you to know that I really like him," he says finally. "He's a great man to take care of, and I want to thank you for giving me the opportunity."

Back at the ward's central island, he studies his next patient's chart, half listening to the other physicians' banter. He asks his partner, Peter Dale, an infectious diseases specialist, about dosages for a new antibiotic. Dr. Dale theatrically announces, "He's helpless without me!" Somebody joins the teasing--"You've always said that, but I never really believed...." Dr. Dale turns up his eyes, in mock resignation. "I have to live with it every day of my life," he says.

But Dr. Valentine, the teasing's target, is already off to see a rugged-looking workman whose bladder cancer has spread to his prostate. Next he visits a tiny old woman, her head bald as a croquet ball. Lung-cancer surgery has left her coughing.

"Want some cough syrup?" he says. "Your roommate coughs, too. You make a great pair. Want to go home tomorrow?"

Next he visits the young mother. Uncomfortable sitting, she assumed she had hemorrhoids. It turned out to be a rare cancer, rhabdomyosarcoma. It is dangerous, Dr. Valentine has told her. She may die. And last month, before her first chemotherapy session, a surgeon performed the ultimate indignity, a colostomy. Mostly she wept.

But she has 10-year-old twins. Focusing on them has stopped her crying. Her second chemotherapy is nearly finished, and Dr. Valentine finds her sitting cross-legged on her bed, chatting with Debby Farnham.

"This sweetheart," the patient says, pointing at Debby. "She was so good to me this morning--she washed my feet."

He checks her groin, where the cancer had spread to lymph nodes. "That's really a lot better than it was," he says. "That's great."

Leaving, he allows himself a flash of optimism. After just two chemotherapies, the cancer has shrunk eighty percent. "And that growth in her lymph node is about gone," he tells Debby. The patient is responding unexpectedly well. "We'll be able to keep this under control for a good time, at least!" he says.

But he is already focusing on his leukemia patient. At the charts cabinet, he checks her blood counts for today. A normal white-cell count would be at least 4, meaning 4000 cells per cubic millimeter of blood. Her count is .1, virtually zero. Fine, he thinks. Her cancer is a white-cell malignancy, and chemotherapy is doing its work. She had a blood transfusion yesterday, raising her hemoglobin count to 8. Normal would be 14 or better. Her hematocrit, a measure of red cells, expressed as a percentage of total blood volume, is 25. Normal would be at least 37. Her platelets should be above 150,000, but they are just over 5,000. If they drop any lower, she will need a platelet transfusion to prevent bleeding. But her counts look typical for a leukemic at this stage of treatment.

He is trying a new antibiotic for her fevers. But the lab is still culturing her blood samples, to see what grows in the petri dishes. Once he knows exactly what bacteria have infected her blood, he will know which antibiotic will work best.

He decides to go ahead with the biopsy. He is anxious to know the results himself.

8:45 a.m.--Dr. Valentine detests wearing the mask, but the nurses have put a "visitors-must-wear-masks" sign on the leukemic woman's door. Debby is wearing her mask. The patient lies prone.

Dr. Valentine numbs a patch over her pelvic bone. The biopsy needle has a hollow core and a sharp cutting edge. He pushes it through the numbed skin and drills it into the posterior iliac crest, the top of the pelvic bone.

It is the patient's first biopsy and the instrument's grinding sensation is unnerving. Mostly, she fears what the biopsy might reveal. Debby is holding her hand.

When Dr. Valentine extracts the biopsy needle, it contains a sample of bone marrow the diameter of a pencil lead, an inch long. In the laboratory downstairs, technicians will place the sample in a solution to dissolve the calcium, then prepare stained slides for examination under a microscope. But that will take at least 24 hours. Dr. Valentine is too impatient to wait. And so he takes a second sample, an aspirate, using a thin needle to draw out soft bone tissues. He can examine the aspirate under the microscope immediately to get a snapshot of what the biopsy will show when the pathologist reports. "I'm going to look at this right away," Dr. Valentine says, mainly to himself. He packs his instruments and starts for the lab.

Debby is speaking to the patient soothingly. She is still holding her hand.

8:55 a.m.--Dr. Valentine, wearing sterile gloves, places a drop of aspirate on a glass slide and covers it with another slide. He fits it under a microscope, apprehensive about what he might see.

Leukemia is among Dr. Valentine's favorite cancers to treat. It is rare, and he sees only one or two a year. The patient almost always arrives in a crisis, needing life-saving transfusions. As chemotherapy drops the patient's platelet counts, internal bleeding threatens. Dangerous infections flare up. He must deal with the patient's emotions. He must deal with his own emotions. He finds it exciting, like climbing Mt. Everest.

He fixes the slides under the microscope. He is a scientist, but a bit of a shaman, too, acutely aware that many aspects of cancer are opaque to his science. Tissues surrounding cancer cells, for instance, may produce growth factors that enhance or impede chemotherapy drugs. To Dr. Valentine, understanding cancer, and treating it, is like a computer game. "You think you're set," he tells himself, "but you're only on level two, and there are 20 other levels, each more complex than the last, and you have to advance through them." He brings his eye to the microscope.

He hopes to see a menagerie of different cell species in the marrow. Cells of various sizes. Nuclei of various sizes in relation to the rest of the cell. Nuclei with various shapes. That will mean chemotherapy has cleared away the leukemia.

But he might see sheet after sheet of the same cells, immature blasts. Cancerous cells remain eternally infantile, immortal, their numbers ever rising. In this patient's case, if the chemotherapy has failed, he will see blasts of the white cells called neutrophils.

Dr. Valentine gazes intently into the microscope. Then he sits back.

"I'll tell her," he thinks.

2:40 p.m.--Debby is going from room to room, checking on her patients one last time, telling them the evening nurse will be here shortly. She changes some of the spina bifida patient's bandages. And she gives the rhabdomyosarcoma patient a steroid drug to reduce swelling. Yesterday, when another nurse gave her this drug, it burned terribly. But Debby dilutes it, and injects it infinitely slowly.

"That's not burning at all," the patient says.

"I have magic hands," Debby says.

2:45 p.m.--Alma Mueller has come onto the ward. She wears a white-linen shift that evokes Africa, or the Caribbean. Today she wears amethyst-colored earrings and a purple head scarf. She wears gold-rimmed glasses. Something in her chin's angle hints at her former life, as a Broadway dancer.

Alma joins the other evening nurses in Report, to listen to the day nurses' observations on their patients. She takes extensive notes.

She will have the woman with leukemia tonight. And the young mother with rhabdomyosarcoma. A 90-year-old woman, anemic, has just come in from a nursing home for a blood transfusion. An elderly man has pneumonia. There is the young man with spina bifida and draining wounds. And a new patient has arrived unexpectedly, about whom little is known.

"I'll be a busy girl tonight," Alma mutters. Debby Farnham, too late to tape, rushes in to report in person. No improvement in the wounds of the spina bifida patient, admitted for a ruptured appendix, she says. "The coccyx area is still very necrotic," she adds. "He's had no doctor at home, and no hygiene. There was a big blood clot on the bed, from one of his old wounds."

Alma is writing rapidly.

"Also, a man just came in, 56 years old, 85 pounds. He has only half a tongue, apparently from previous surgery for cancer," Debby says. "He's coughing up copious amounts of brown liquid, and his hygiene is extremely poor. Exactly why he's been admitted should be coming up shortly."

After Report, Debby resumes typing at a computer terminal, although her shift is over. Alma studies her patients' charts, brow knitted, looking like a medieval abbess in the scriptorium.

Ready, she gathers up a stethoscope and a digital thermometer. She knows exactly how they feel, her patients, lying in their hospital beds. Fifty years ago, as a toddler in the New York City borough of Queens, she began a lifetime of hospitalizations for sickle-cell anemia. She spent weeks at a time in the hospital. City streets claimed her four brothers and three sisters. But the hospital claimed her, and redirected her life.

Her stepfather was an alcoholic. Her mother especially watched out for her bright, sick little girl, whose smile dazzled.

At the hospital where little Alma spent so much time, the beds stood along the walls, separated only by curtains. Kids mingled with adults. It could be horrifying for a child. Once, all around her, people lay dying. Nurses and doctors ran from bed to bed with electric paddles to jolt hearts into beating.

Alma read in the hospital. She had learned to read at age three, going on to consume every book in her neighborhood library. One Christmas, when there was no money for presents, she found books in her house's attic, left by the previous owner. She decided which books should go to whom and wrapped them as presents.

Her hospital pastime, besides reading and schoolwork, was helping nurses. One project was collecting all the old ladies' false teeth and cleaning them.

Hospitalization was not Alma's sole refuge from the streets. Starting at age three, as a Fresh Air child, she spent summers on a chinchilla and dairy farm in Charlestown, New Hampshire. There was grass, clean air, wholesome food, cool nights. It seemed like heaven.

Doctors ordered her to avoid physical exertion. But, as a teenager, she turned defiant: she became a competitive runner. And she began to dance. Her mother urged her to learn a trade she could count on, like being a secretary. Alma set her jaw.

An eighth-grade classmate told her about a school for the performing arts, which sounded to her like the "High School of the Reforming Arts." She wanted to study ballet there. Her neighborhood school was dangerous for the girl she remembers as "a scared little fragile thing." But her guidance counselor, her doctors, and her mother argued against the "High School of the Reforming Arts." Alma badgered them.

She prepared for the audition by watching dancers on the Ed Sullivan television show. She wore gold-painted slippers and a cotton leotard her mother had sewn. Confidently, she handed the judges a recording of The Nutcracker Suite. As the music welled up, she began leaping around the room, smiling radiantly. The judges laughed. She assumed she must be doing really well, which inspired her to further leaps and grins.

"You can't dance," the judges told her. "But you have a beautiful smile--we'll give you a chance." She began on probation, one of only three black freshmen. By midyear she had worked her way into her class's top third. Because she was black, teachers discouraged her from ballet, steering her into modern dance.

After Alma graduated from the High School of Performing Arts, in 1963, she studied under a scholarship at the Martha Graham school. She toured with a children's theater troupe, danced in England, then returned to dance with an all-black group, the Tally Beatty Dance Company. She married. She danced in the Broadway musical, Hair, but quit when the production required nudity. She joined the Alvin Ailey dance company. She danced with the Negro Ensemble Company. She danced in Broadway's The Wiz. And she danced in the movie, The Wiz.

But her husband died, leaving Alma with a small daughter and son. Rethinking her life, she resolved "to be of use."

She earned a Bachelor's degree in psychology. She married a German immigrant, a social worker who decided he could earn more as an electrician. They studied a map and moved to Vermont.

Alma taught dance at a state college. But in 1982 she graduated from the University of Vermont with a second Bachelor's degree, this time in nursing. She was going "to be of use."

4:00 p.m.--Today is the twenty-third anniversary of her first husband's death, Alma thinks. Her daughter is working on a master's degree. Her son, just graduated from MIT, is at Harvard, earning simultaneous MD and PhD degrees. But she cannot reminisce. She has too many patients.

"I'm Alma," she says, her calm voice soothing. "I'll be your nurse this evening."

He has pneumonia, an 88-year-old farmer, with big bones and a massive jaw. His roomful of relatives, large older women, exude rosy-cheeked cheer. But he wheezes and hacks.

"All righty, I'm going to check you out!" Alma says, applying a blood pressure cuff. "How are you feeling today?"

"Been down to get my head X-rayed," he gasps. "They told me they didn't find anything in there--I mean, anything that's not supposed to be in there," Alma laughs, easing a thermometer into his mouth.

"I told them all they'd find in there is horse manure," he says.

She puts her stethoscope to the man's back and listens to his lungs, frowning. She takes his pulse, saying, "Let's see how you're doing in this department." He shows her a tissue into which he has spit. Alma grins. "Now, that's light yellow," she says, tapping the data into the room's computer.

Two patients occupy the next room. She leans over the bed of an ancient woman, gaunt, hardly breathing. She is anemic, brought in from a nearby nursing home for a blood transfusion. Afterwards, she will return to the nursing home.

"Do you remember me from last time?" Alma asks, leaning over the woman's bed. She brushes the woman's forehead with affectionate fingers. "So how are you feeling? A little tired?"

"My hands are cold," the woman says.

Alma rubs them gently. "Your blood will be up soon," she says.

In the next bed is the young mother with rhabdomyosarcoma, on the telephone with her fifth-grade twins. "I'm talking to Alma," the patient tells her daughter. "No, she's not a doctor, Honey. She's a nurse. Yeah, I know. She's really cool."

Alma listens to her lungs with a stethoscope as the patient talks to her son. "You're
having trouble with your independence? Do you mean your appendix? It hurt and you fell on the ground? Can I talk to your dad?"

Alma, at the computer, tells her what to check on the boy. "What more can go wrong?" the patient tells her husband. "Me, and then last week your mother has a heart attack, and now....If he runs a fever....That's right. Don't mess around."

She tells Alma her son is coping poorly with her illness. Their neighbor, in the apartment below, got cancer. He died. After her mother-in-law's heart attack, the boy asked: "Is Grandma going to die, like you?"

"I told him we're both too mean to die," the patient says. "I told him they'll take care of us."

Next, Alma visits the mystery patient, an emaciated 56-year-old with twiglike arms and a wild shock of gray hair. He was admitted through the Emergency Room, with half a tongue and an esophagus obstruction. He is ranting.

"....and they don't give me nothing to eat here, either!" he is saying, although a dinner tray is beside his bed.

"Oh, we've got to get you some food!" Alma says, with a big grin, as she takes his blood pressure. "That looks awfully low," she says, frowning.

"I do want codeine to take the damned sharp edge off this pain in my throat," he says.

In the hall, Alma tells a passing dietary technician to get the patient cream of mushroom soup. "He wants some choice, to have that much control," she says.

She is at the medicine cart, checking the MAR, when she sees the mystery patient has lit his call light. She rushes down.

"Where's my soup?" he demands.

Alma, however, is looking at the tissues heaped in his wastebasket.

"Where's this blood coming from?" she says.

"From my nose," he snaps. Abruptly, with a petulant flick of his hand, he knocks over his wastebasket, strewing the contents. Alma rights the basket and refills it. She puts a cloth to his nose.

"I want you to use a tissue," he says.

"That would be too rough," Alma says calmly. "Now I'll be right back, and let me find out where she went with your food."

But nurses from the operating room are wheeling in a new patient for Alma. Huge, bearded, he looks like a Harley rider. He is drugged, barely sentient. An OR nurse gives her the details--shoulder surgery, supposed to go home, too much post-operation pain. He is already snoring. Alma shrugs.

Now the woman with rhabdomyosarcoma has lit her light, worried that her two bags of chemotherapy are not pumping out equally. Using her wristwatch, Alma times them. She explains that one bag is puffed up with a little more air, making it seem fuller.

The spina bifida patient's back is hurting. She helps him adjust his position, and gives him his iron pill. Finally she hurries downstairs to the cafeteria, for a quick supper.

6:30 p.m.--Alma visits the woman with leukemia. She knows Dr. Valentine brought her biopsy results because nurses waylaid him, eager to hear if the patient was in remission.

"I've brought you a present," Alma says.

It is a scarf, purple like her own, fringed. It matches the woman's bathrobe. It will hide her baldness.

As usual, the patient's husband is spending the evening. Alma knows they are both frightened.

"Everything will change now," Alma tells them, her voice quiet, calming, as she takes the patient's temperature. "How you see yourself will change, and your relationship will change."

Sickle-cell has taught her that. But she has also become diabetic. In 1988, she developed an auto-immune lung disease, pulmonary sarcoidosis. And in 1992 she abruptly collapsed with thrombotic thrombocytopenic purpura: the blood's platelets cohere, causing the kidneys to fail, breathing to stop. She spent three weeks unconscious in intensive care, receiving transfusions, then three weeks recuperating in the medical-surgical ward, and three weeks more in the rehabilitation unit.

On one of Alma's sickle-cell hospitalizations, not long after she became a nurse, to save her coworkers from seeing her in so much pain, she struggled to the bathroom clinging to her rolling IV pole. Back in bed, she thought, "My God, how many of our patients do this?"

It taught her to answer patient's call lights promptly. Who knows what humiliation she can help avoid? Who knows what is happening in that room?

Her leukemia patient's temperature is 103 degrees. She soaks washcloths in cold water in the bathroom sink, then drapes them carefully across the woman's forehead and under her arms.

"Thank you, Alma, thank you so much," the woman says.

"I'll be back, Dear," Alma says.

7:15 p.m.--Alma, helped by a student nurse, is working on the young man with spina bifida. Both women wear yellow protective robes as they prepare to clean his open wounds.

A stench emanates from his fistulae, wounds that erupted from inside his body. Alma gently washes his back, while he talks about his model car kits, piled on his chairs.

Alma teaches the student nurse to extract bandages from their package without contaminating them, lest they infect the patient's wounds. She demonstrates how to peel off the old bandages, stained yellow and brown. The stench intensifies.

Working together, Alma and the student clean the patient's wounds. His backside looks as if it has been slashed repeatedly with a machete. One new wound is so deep that Alma can see down it to the leg muscle. Working in tandem, the two women in yellow gowns bend over the naked man on the bed, as if performing a rite.

9:00 p.m.--A stretcher crew is wheeling out the aged lady who received a blood transfusion for anemia, returning her to the nursing home. Alma stops them to lean over the stretcher and whisper in the patient's ear. She kisses the old woman's forehead.

10:30 p.m.--Alma, almost running from room to room, is tapping data into the rhabdomyosarcoma patient's computer. The woman is saying that, two weeks before she was diagnosed with cancer, she quit her job cleaning motel rooms. Meanwhile, her husband had just taken a new job, painting highway white lines. It was a pay raise, but they make under twenty-thousand dollars a year. They had decided to forgo health insurance.

"We figured that after we pay the rent and all the regular bills every week, and buy food, we have five dollars left," the woman shrugs, sitting up in bed. "I don't know what we're going to do about the medical bills--it was thirty-thousand dollars just for last month, and I suppose we could give them all a nickel a week each."

10:45 p.m.--Alma is tending a new patient, a retarded man, when she hears the night nurses arriving. Her shift is almost finished. She has time for one last round.

Her biker with the shoulder operation is snoring. His roommate, the man with half a tongue, seems asleep, too, although muttering. The woman with rhabdomyosarcoma is asleep. So is the spina bifida patient, his wounds newly bandaged. The 88-year-old farmer with pneumonia is gasping in his sleep. And the woman with leukemia lies still, her eyes closed. Her husband has gone home for the night.

Alma has no time to tape her observations. She hurries to Report in person, to brief the incoming night nurses. And now she has data entry to attend to, a chore she could not fit into her shift. It will be hours before she can actually leave

Lying in the dark, the woman with leukemia is not entirely asleep. She is thinking about the cancer in her blood, and remembering the day.

She sat today in the chair her husband uses. She looked at the bed. How terrible for him, she thought. To sit here, to see your wife hooked to tubes, no hair, 20 pounds gone, not eating. How awful for him.

Her thoughts shift to Debby Farnham, warning the doctor she was overdosing on antidiarrheal medication. She thinks: "Debby saved my life."

And she thinks of Alma's soothing hands, draping her in chilled washcloths, bringing down her fever. Alma was right, she thinks. Our life will change now. I wonder, will I be here?

Dr. Valentine brought her the biopsy results today: she is in remission. When he looked through his microscope, he saw no signs of leukemia.

She has more chemotherapies to go. Each will drive down her immune system. She could hemorrhage. Infections will flare. But now she has a chance to survive. It seems to her a window has opened, just a crack. If she can just get through that crack....

"At least I have a chance," she thinks. "I have a fighting chance."

She hears the night nurse walk quietly into the room and look down at her in the dim light. But the patient is too weary now to open her eyes, almost asleep.

She feels the nurse kiss her on the forehead.

"Good night," she hears the nurse say. "Good night, Sleeping Beauty."

1:00 a.m.--Alma has finally finished typing data into the computer. Her day has ended. Alma Mueller is leaving the hospital.