Sam, a patient on our stepdown unit, wasn't big to begin with, and now, three months after cardiac surgery, he's down to almost nothing. He eats little of the food on his tray, and only a spoonful or two of the soups and desserts his wife brings in daily. The tube feeding-induced diarrhea prevents his body from absorbing much of what he does eat.
We encourage, beg, cajole, and nag him-to feed himself, to sit in the chair, to roll over. Healing is work, we tell him.
But his body has turned on itself as a substitute for food. His long series of complications has left him discouraged and depressed. If staying comfortable impedes his progress, he's willing to live with the trade-off.
Sam opens his eyes when I walk into his room, then closes them again. While I assess him, I tell him the plans for the day.
He puts a finger over his trach. "Do I have to have a bath? I feel so tired." His voice is soft and slightly rasping.
"You were bathed during the night, so I'll just do your hands, face, and privates."
Soon he's ready for the chair. We lift him out of bed and carefully position him. Then I set up his breakfast tray: one and a half sugars on the oatmeal and in the coffee. A large splash of milk on the cereal and a small splash in the coffee. He eats slowly, the way the speech therapist taught him. He drinks a little coffee and announces he's finished. I carry the tray out, saying I'll be back shortly to get him back to bed.
Instead, I go next door to help bathe another patient. The aide finds me untangling a spaghetti of IV tubing. "Sam wants to go back to bed."
He's been in the chair for 15 minutes. He won't be accepted for rehabilitation if he can't sit out of bed for at least half an hour, so I say to tell him we'll be in soon.
Before his surgery, he'd been full of hope and plans. Though his ordeal has worn him down, we're determined to see him fulfill those plans.
When we lift Sam back into bed, he asks, "Do I have to go to PT? I'm so tired."
"Yes," I tell him. "You refused to go yesterday, and your doctor was mad at us. Rest now while I do your dressings."
The dressing changes are long and complicated. His bedsores, partly a result of malnutrition, aren't healing, despite the plastic surgery performed to close them. Sam is too weak to turn, so I push him up on his side.
"Are you done yet," he says. "I don't think I can hold myself in this position much longer."
Although changing Sam's position and keeping everything sterile is hard work, resisting his depression is even harder.
"I don't think I can stand today," Sam tells me on the way to PT.
"Just try." I explain, not for the first time, that his muscles are weak because he's not using them. "You have to build them up. Don't you want to go home and play with that beautiful new granddaughter?" He stares at the floor.
Am I pushing too hard? But he was so happy when his daughter visited last month and put the newborn baby on his lap.
Jim, the head therapist, greets Sam and asks him how long he'll stand today.
Sam doesn't reply. He knows it's useless to argue. If you show up, the therapists make you do their thing.
Jim sits on the stool in front of Sam, Sally and Jean grasp Sam's arms, and I hold the wheelchair. "Okay, now," urges Jim, "on three I want you to stand and straighten those knees and tighten your buttocks like you did Monday. One [horizontal ellipsis] two [horizontal ellipsis] three!" Sally and Jean pull, I move the chair back, and Jim puts pressure against Sam's knees. Sam is standing, semierect.
"Come on, Sam, you can do it," says Sally.
"Two minutes and 10 seconds last time," says Jean. "Let's make it two and a half minutes today."
"Straighten your knees," Jim orders.
"Come on, Sam, you're doing fine," I add.
"Can I sit down now?" he asks weakly.
"No way," says Jim, "we're going for a new world record!"
When he begins to sag, we quickly lower him into the chair.
"Two minutes and 25 seconds," announces Jim. "That's the longest you've stood. We'll have you walking out of here yet."
On the way back to the room we meet Sam's wife in the hall. "How was therapy today?" she asks.
Sam smiles. "I stood an extra 15 seconds."
It's in such small increments that progress is made.