*The text comes from observations of the Medical Intensive Care Unit at Rhode Island Hospital during the summer of 2009. All names have been changed to protect privacy.
More poetry by Yael Shinar in this issue.
excerpt from the book-length poem
*AWAKE, ALERT, ORIENTED
a poetry documentary of
Rhode Island Hospital
Medical Intensive Care Unit
Get to a punch line. Try to understand whats relevant. It doesnt matter if shes unemployed, it matters whats the shape of the bacteria. The shape of the bacteria might tell us the source of infection.
Figure out what you dont know and try to get to know about that. Figure out what you can do without knowing the stuff you dont know about without making things worse. Its OK to write things down, OK? Keep your notes with you, OK? OK.
MICU rounds, AM
15 June 2009
Ms. Kendra Ness, 32 years old . . .
two weeks in the MICU as of 15 June 2009—
Whos the nurse?
—heart rate came down to low one-hundreds from one-thirty,
shes young, but shes stable—
pain gone, has nausea, vomiting. She lives at home, with her mom and her three kids—
Are the three kids hers?
Maybe theyre her moms?
Non-smoker, non-IV-drug user, confessed occasional alcohol use, doesnt have a primary care physician, not taking any meds—
Sounds like everything leads to vomiting.
Sounds, like everything, lead to vomiting.
Comfortable otherwise. Her chest exam is clear, shes making urine, shes able to pee in a urinal—
Shes able to pee in a bedpan!
Hemoglobin 12, platelets down to 130—
—Its usually: give cipro, obtain urine culture—
See! This happened the last time!
What are you giving her for nausea? Abby, what do you think?
Well, before—when he said her pains gone?—Well, she rated her pain 10 out of 10.
What do you rate her pain?
Its in her groin—
No, but what do you—
its . . . legitimate.
MICU rounds, PM
patient visit—Ms. Kendra Ness
18 June 2009
Kendra looks like a puddle.
They look like puddles because they are puddles.
Her skin has become the container for her bodily fluids—instead of her vessels. Her belly is swollen and round.
Kendras face is swollen and round, her right cheek deflates on her pillow. Eyes closed, eyelids crimson. Shes not looking anywhere—eyes closed in to all that fluid.
In the MICU, edema often occurs in patients who are being treated with large volumes of IV fluid. The sodium in the fluid disrupts the usual pressure dynamics between the cardiovascular system and the surrounding tissues. The sodium in the IV fluid moves out of the blood vessels and into the space between blood vessels (called interstitial space). Water molecules then also move out of the blood vessels and into the interstitial space, so that the proportion of water to sodium inside the blood vessels comes to equal that proportion outside the blood vessels.
Water may also move into the interstitial space if the plasma proteins in the blood are reduced—for example, from malnutrition. Usually, such compounds as plasma proteins pull fluid back into the capillaries, providing counter-balance osmotic pressure across the capillary walls. When these compounds are absent, water may move into the interstitial space.
As water builds up in the interstitial space, the tissues become puffy, and people swell within their skins. They are puddles. This is called edema.
Get to a punch line.
Kendra died before her doctors discerned a source of infection.
Gauze covered her skin ulcers—purple and yellow bulls-eyes below her navel.
In the waiting room, Kendras friend arrives and hugs Kendras sister. You know, when she had the kidney transplant eleven years ago, 32 seemed far away, like an advanced age. Now—32?
Tonight, morphine in Kendras blood, 32 seems as incomplete an age as any. It seems like 8 years old. Its like 12 years old. Its like other ages when Kendra was living and was living—like 3 hours and 3 months, 14 months, 3, 4, 9, 8 years
11, 15, 16 ½,
18, 22, 24, 27,
28, 29, 30, 31.
Before the morphine, pain—
Because of pain, morphine—
Masses—clotted-blood-&-pus masses, breaking—
bursting through thin skin—
If Kendra is a Polish name, it means long-haired woman. If Kendra is an Anglo-Saxon name, it means understanding or knowledge. If Kendra is an English name, it combines the names Ken and Sandra, or Ken and Andrea. Kendra may be a variation of the name Kenda. Kenda may be English for water baby (like Moses?), or it may be Dakota for magical power. Kendra could be a female form of Kendrick, which may originate from the Welsh for greatest champion (Cynwrig) or the Anglo-Saxon for family ruler (Cyneric). Kendra may refer to a beautiful woman, a goddess-like woman. Kendra may be a Curonian word meaning cedar. The Latvian for cedar is ciedra.
Curonian is a language with old and new forms, spoken in the Curonian Spit, by people who also speak Latvian. The Curonian Spit is an elongated sand dune peninsula, 98 km long and .4-4 km wide. It connects Lesnoj, in Russia, with Klaipeda, in Lithuania, like a hair anchored in saliva would connect the ear to the mouth and frame the cheek. The Curonian Spit frames a lagoon, The Curonian Lagoon. The Curonian Spit is a precarious formation. It has been threatened by winds and waves since prehistory. Its survives, though, through ceaseless human efforts.
A nurse cares for Kendra and one other patient. An attending physician, five residents, one fellow and a transplant surgeon care for her, as well. Two sisters, one mother, three nephews, a childhood friend. Some of the physicians examine her personally and some discuss, think, and consult regarding her case. I am here writing down her story, and here you are reading it.
The Curonian Spit survives the winds and waves because ceaseless human efforts combat erosion. For example, continuing stabilization and reforestation projects combat erosion.
Everything leads to vomiting, says one of Kendras doctors. We dont know the source of infection, says another. Ceaseless human efforts swirl around her without touching the source, like a whirlpool with a center that is merely imaginary, just effort near a dark opening.
It took Kendra longer to die than her physician had predicted it would take her, by about three hours. In the course of three hours, her mother and sisters encircled her, image of goslings reaching open mouths up to a mother bird, but inverted: the separate one below, her mouth slack and empty.
Kendras mother sang a lullaby into her right ear. Kendras sister caressed her temple with the back of her right hand—tan and clean.
The third sister, flown up from Florida that afternoon, smiled and talked about her son. She watched her mother and sisters and narrowed her brow. Kendra really loved Benjamin, she said. There, now Im thinking about Kendra now.
 Thursday, 18 June 2009, 5:47 PM.
 Information on the Curonian Spit, including the phrase ceaseless human efforts, comes from the UNESCO World Heritage Centre website: http://whc.unesco.org/en/list/994.
 Friday, 19 June 2009, 8:12 PM.