First three chapters can be read here.

CHAPTER 4

Wiltwyck Hospital was a small community hospital. We didn't have a lot of sophisticated resources. We only had nine ventilators. We didn't have a negative pressure room or a single ECMO machine. We barely had enough reserve oxygen tanks for our regulars with chronic obstructive pulmonary disease.

There wasn't much we could do for COVID patients, but the COVID patients kept coming in anyway.

At first, we'd try to transfer the sickest patients to one of the bigger, better-equipped hospitals in Albany, Poughkeepsie, or Westchester County. But pretty soon, those hospitals were all filled up. And then we had to admit the patients.

There wasn't enough space for everyone pouring into the ER waiting room. Plus, even if there had been, the Wiltwyck management team had decreed the hospital a COVID-free zone—except for those patients diagnosed with COVID who required hospitalization. So far as I could tell, they all had COVID—there were no longer any other types of patients in the hospital—so this new directive was yet another example of the Cover Your Ass school of administrative strategy. CYA! Always best practices at Wiltwyck Hospital.

###

Once the pandemic got underway, they pitched a huge white open-air tent over the visitor parking lot where anyone who imagined they might have had the slightest contact with the virus was herded. To the side stood the original hospital building and a grove of old trees, sugar maples and white oaks, where birds sang, and squirrels frolicked. The effect was almost festive, like a demented lawn party in the Hamptons where the guests arrived in dirty bathrobes and ratty slippers.

The original building, erected in 1874, was a National Historic Landmark with prescriptive easement, designed by Calvert Vaux in the high Victorian Gothic style so beloved by remote country lunatic asylums. Pre-COVID, various street ministries had tabled on the sidewalk there, Jesus freaks, Chabadniks, yoga nuts, flying saucer cults. You could stagger out from the bedside of a dying relative and choose your own religious conversion experience. Only one of the apocalyptic Jesus cults was brave enough to stand up to the virus, though. The New Millennial Kingdom.

We had a protocol. First thing was a digital thermometer touch to the forehead.

Temperature over 100.4°? You were escorted to a VIP section, where long cotton swabs would be maneuvered up your nasal cavities, and the residue mixed with an extraction buffer. If, half an hour later, the solution made little pink lines appear on a test cassette, then tag, you had it.

Most of those people were sent home with instructions. You have tested positive for the SARS-CoV-2 virus, we told them. Take Tylenol. Stay hydrated. Most importantly: Do not come into contact with another living soul! Barricade yourself behind closed doors! Disinfect everything you touch with an alcohol-based disinfectant! Wear a mask at all times! More CYA verbiage! We printed it out as a discharge summary. We knew perfectly well these instructions did little to help control their symptoms and absolutely nothing to allay their desperate fear that a positive test meant they were going to die.

Some people we admitted. These were the ones with spiking fevers, or blue lips, or persistent chest pains, or who were so disoriented, they had no idea where they were.

These people, or more precisely, the flustered family members who'd carted them off to emergency services, had perfect faith that we were going to save them. They were not frightened at all.

That was okay because I was frightened enough for all of them. I no longer had access to the world behind the sliding doors, so I had no idea what happened to them once they were admitted to the hospital. I suspected, though, it was Not Good.

###

COVID was just a cold, right? Okay, a bad cold. But it wasn't the bubonic plague. It wasn't polio. You didn't die from it.

Your throat got sorer, you had a headache even if your sinuses were not stuffed, and then there was that cough, that eerily distinctive cough, that sounded like a car that had run out of fuel, only the driver keeps stamping down furiously on the gas pedal. Okay, some people died from it, true, but then, some people died from colds, too, if they were old, if something else was seriously wrong with them, if it traveled to their lungs and became pneumonia. I wasn't going to die from a cold.

No, the scariest thing about COVID was what happened to some people afterwards. A profound fatigue, an absolute inability to think, joint pains, heart palpitations, some inner battery draining that could never be recharged that cycled you into perpetual exhaustion, helplessness, disorientation. This was long COVID. Nobody knew what triggered it or why some people got it, and some people didn't.

I didn't want to get long COVID.

The hospital was responsible for providing us with personal protective equipment, or "PPE," they liked to call it, as if acronymizing masks, gloves, and paper isolation gowns imbued these items with supernatural powers of preservation. But they were useless. The virus survives on latex, and when your surgical mask slips under your nose and your gloved hand reaches to pull it back up—a thoughtless reflex, but you're too exhausted to remember the warnings—you contaminate yourself. Isolation gowns are open-backed; if you sit or squat, your back is exposed. A surgical mask might stop you from expectorating virus particles onto people you talked to, but it did nothing to protect against the aerosols those people shed when they talked to you.

The surgical masks bugged me the most.

N95 masks were the most effective. Everybody knew that. Even the CDC.

###

Hospital administrators were everywhere in the tent under the old-growth trees, standing apart from the conveyor lines of patients and practitioners. Watching the action, tapping furious notes on their POC tablets. To what end? More CYA directives? Who knew? Most of them wore N95 masks. Every shift, Noah, the ER Director, planted himself in a spot 10 feet away from the nose-swabbing station and stood there with his arms folded for half an hour or so. Noah wore an N95 mask.

One afternoon, I confronted him. "When will the hospital be providing us with N95 masks?"

A couple of patients turned around to gawk.

"We're not having that conversation here," he said.

"We're damn well going to have that conversation somewhere," I said.

He looked at me a couple of seconds too long, then exhaled loudly enough so that I could hear the sigh through his mask. Beckoned me: Follow.

We walked to the little patch of public-access lawn near where the New Millennial Kingdom table stood. Behind it stood a tall, stooped man and a plump woman with flaxen hair and a radiant smile. They were not wearing masks. Covid Is God's Down Payment, read the banner taped to the table.

Noah grimaced and moved a few steps farther away. "We've put in an order for N95 masks. It should be approved very soon. Till then, surgical masks are what we have to use. Back up, please. You're standing closer than six feet—"

"We are actually being told to reuse these masks—"

"It's perfectly safe. Do you know the protocol? It's on the website."

"The protocol tells us to put them in brown paper bags labeled for days of the week—"

"Right. The virus dies after 72 hours. So when you take your mask off on Monday, put it in the Friday brown paper bag, and on Friday, it will be safe to wear again!"

"Oh, right! And the brown paper bag will magically eliminate all the snot that dripped from your nose and the sweat that poured from your skin. You know I had underwear labeled with the days of the week when I was six. My mother still did the laundry."

"It is a temporary supply chain issue," Noah said. I could tell he was working hard to sound reasonable. "We're working as hard as we can to resolve it. But I'm glad we're having this opportunity to talk, just the two of us, because there's something else I need to discuss with you."

"What's that? You're writing me up because I prefer N95s to martyrdom?"

"We're floating you to the ICU."

"What? You can't do that!"

"We can," Noah said. "It's in your contract." He quoted from memory: "The Hospital reserves the right to require the Employee to float or be temporarily reassigned to other units or departments within the hospital as needed to meet patient care demands and operational requirements."

I was speechless. I was stunned. My heart began to beat fast.

The ICU is the place where failing organs are plugged into chargers, and quality of life is measured by the hiss of ventilators, the beeping of intravenous pumps, the drip of urine into catheter bags. Apart from the ER, I hated every ward in the hospital, but the ICU was the absolute worst.

In the ICU, nurses were handmaidens to biomedical equipment that needed constant calibration, monitoring, resetting; the patients' needs were really secondary to the needs of the machines. Patients remembered their ICU stays, if at all, as a bad acid trip, or a prolonged episode of sleep paralysis, or a sojourn in hell. Sure, it extended some patients' lives, but a significant percentage of them would be dead in six months anyway, and another sizeable fraction would wish they were, so what exactly was the upside?

"I won't work in the ICU," I said flatly.

Noah sighed again. "Grazia, you're being wasted here. A nurse with no skills whatsoever can stick a Q-tip up someone's nose. You are a skilled practitioner. You're valuable. You've worked with ventilators. You know how to read an EKG. We need nurses with your level of skills to work with actual patients on the inside."

"I am not an ICU nurse."

"You'll get the necessary training."

"You can't make me do it."

"I can't force you, true. But your job description will be changing. And it's not just my decision. It's the hospital administration's decision. You know as well as I do that an emergency room runs on the principle of triage. Now we are having to triage our nurses. Not a best case scenario, I agree. But we all have to make sacrifices. Look on the bright side: ICU nurses get N95 masks."

Noah's laugh had always had a strange quality, like a barking dog being slowly strangled. I'd always tried not to take it personally. That was hard to do right now.

"Fear is the real infection," the young woman with the flaxen hair called over to me pleasantly from the New Millennium Kingdom table.

###

That night, it was Neal's turn to call me.

Neal wasn't a frontline essential worker exactly, but even in times of pestilence, the wheels of justice must keep grinding, albeit more slowly, though not particularly more finely. He was still down at the city jail three times a week, visiting clients and prospective clients. He was conducting other work-related meetings by Zoom, though, and dealing with all required paperwork from the computer in his bedroom. Which left him with a lot of time on his hands.

He had endless hours to practice his fingering on Missy Quat. He'd joined a "Finnegan's Wake" discussion group over Zoom whose members included a psychiatrist in India and a librarian in Iceland. He was flirting heavily with the librarian in Iceland, though who knew if anything would come of that: “Mispronounce Eyjafjallajökull once and it's through, right?"

He was also gardening, listening to epidemiology podcasts, mediating a war between the finches and the bluejays over his birdfeeder, overdoing his treadmill, and smoking a lot of dope. Oh, and Mimi was staying with him—

"When does 'staying with you' become 'living with you'?" I asked.

"Staying with me never means living with me," Neal said. "I have sworn off cohabitation. But her house got foreclosed. She needs a safe place to regroup. And when your world falls apart, I'll do the same thing for you."

"Funny you should bring that up," I said and recounted my conversation with Noah.

"You didn't know your contract included a float clause?"

"I'm allergic to fine print."

"And that's why the world is full of lawyers. So, what are you gonna do?"

"I don't think there's anything I can do. I am totally powerless here."

"Well, that's not true. In any situation, you always have three choices. You can say, 'Yes'. You can say, 'No'. Or you can walk away."

I thought about that one for a moment. I was a grasshopper: I had a lot of debt and no savings. That's because, in the words of "Chicago's" Roxie, I was older than I ever intended to be.

"I mean, you could find a rich guy and marry him," Neal said.

"I don't dream about marrying a rich guy," I said. "I dream about divorcing one."

"Or I could pitch a tent behind the house if you quit your job and need a place to stay. You'll need to get rid of that great couch—it won't fit. And you'll have to fight Mimi for the shower. That's Mimi's favorite thing in the world, taking long, hot showers that steam up the mirror. I think she likes it even better than when I go down on her—"

"Too much information!" I said.

###

Sometimes I wondered what it was like to be a patient in a hospital. It was an exercise in powerlessness, I supposed. An exercise in acceptance of powerlessness. A good patient is one who suffers quietly, is always cheerful, always friendly. A good patient is one who keeps demonstrating how little they really need. Says, "Thank you!" often. Gratitude was the engine grease!

A bad patient, on the other hand, was one whose excessive demands threw you off schedule. If they were conscious, they were always riding the nurse's call button. They hurled invective and verbal abuse. They pulled out IVs, struggled to get out of bed when you told them not to. Threatened lawsuits. If they were unconscious, their various organ systems were always staging general strikes so that their monitors were perpetually alarming. They always tried to die at precisely the moment you had finally gotten to the break room for your first cup of coffee after a night when you'd only gotten three hours of sleep.

By that metric, the COVID victims in Wiltwyck Hospital's ICU were all bad patients.

"They code at four o'clock in the morning, regular as clockwork," Debbie Reynolds told me. "Just when you've finally gotten a chance to crank up that bedside recliner and put your feet up."

Debbie Reynolds was the nurse charged with orienting me to the ICU, a large-boned woman with full-sleeve tattoos and short platinum hair that she spiked with gel. She reminded me of a cowgirl, somehow.

"How many of them actually survive?"

"Oh, maybe 20%. The odds are not good. I wanted to start a betting pool. But the other nurses told me that was too morbid."

"Does it bother you to be named after Princess Leia's mother?" I asked.

"Hell, no," she said. "It's a good way to estimate somebody's demographic cred. Like now I know you're a Millennial. If you were a Boomer, you'd be asking me about Liz Taylor and Eddie Fisher. If you were GenX, you'd start humming 'Singing In the Rain' and trying to tap dance."

"How long have you worked here?"

"Oh, girl. A long time. Why I remember back to the days of heart attacks and septic shock, 'cause some girls couldn't remember to take out their tampons. BC in other words—Before COVID."

Wiltwyck Hospital's ICU was an open bay, all one big room. Seven beds and their attendant machines arranged in a semi-circle. An intimate space—but not in a good way: Every patient was on a ventilator, which meant all of them were paralyzed, all of them on heavy doses of fentanyl and morphine. Many of them were wrapped up like mummies, the better to flip them on to their stomachs, a procedure known as "proning."

"But nobody sleeps on their stomachs," I said.

"Well, we don't care about their comfort," said Debbie Reynolds. "We care about their O2 saturation. Which increases by 10% when they're proned, P/F ratio be damned!"

Mostly, though, Debbie Reynolds wanted to orient me to the personal protective equipment. There was a ceremonial aspect to putting it on, a kind of ritual Yoroi wo kiru as though we were medieval Samurai warriors girding for battle.

First, you pulled paper booties over your shoes. (Weekly staff meetings always included at least 15 minutes of heated debate as to whether or not we should also be removing our shoes.)

Next, you donned the isolation gown, a blue smock made from some kind of cheap, woven paper material that covered your torso from the neck to the knees and your arms to the wrists. The isolation gown would always slide from your shoulders at exactly the wrong time—when you were suctioning a patient, maybe, or when you were reaching down to dislodge a diarrhea-heavy Depends—because no matter how tightly you secured them, the ties on the back always came loose.

Then came the N95 mask, which wasn't a mask at all, really, but a respirator that was supposed to filter out airborne pathogens like viruses, bacteria, and dust. The N95 mask was heavy; it felt like what it did best was to filter out oxygen.

The hospital didn't supply eye protection. Each nurse was tasked with providing their own, so no two face shields or pairs of goggles looked alike, as though each was a helmet, denoting kinship in its own hereditary warrior clan.

"So, does this stuff actually protect nurses from getting COVID?" I asked Debbie Reynolds.
Debbie Reynolds shrugged. "Define 'protect.'"

"Do ICU nurses get COVID?"

"ICU nurses get COVID."

The rest of orientation consisted of trotting around in Debbie Reynolds's steps as she tended her two patients. They were both on ventilators.

"Wait," I said. "I thought the rules say you can only take care of one ventilated patient at a time."

Debbie Reynolds shrugged. "We're short-staffed. Can you believe that at a time when the healing profession needs martyrs on the ground the most, there are actually nurses who'd rather quit patient care and get cushy office jobs doing insurance utilization review?"

It was late afternoon by the time I finally left the hospital. The golden light made the white ER party tent look more festive than ever. When I walked by the New Millennium Kingdom table, I saw a new banner: Turn to Jesus While There's Still Time.

The flaxen-haired girl was standing behind it alone. "Hello! Good to see you again!" she called over.

I doubted very much she remembered seeing me before.

A stack of pamphlets lay near the banner. The pamphlet's cover displayed an illustration of a hearty-looking Savior using a massive wooden cross to batter what appeared to be a green balloon studded with red spikes. "Is that Jesus fighting COVID?" I asked. "Get a lot of takers for those?"

"Not a whole lot," the flaxen-haired girl admitted cheerfully.

"Can I ask you something that's always bothered me?"

"Sure!"

"Jesus knows everything, right? Knew everything. So why did he allow Judas to betray him?"

The girl's smile widened. "Jesus allowed it so the prophecy could be fulfilled. Judas was part of God's plan. God uses everything to help us ascend to redemption, even betrayal. Even COVID."

"Wait. You think this—" the wide arc I made with my hands encompassed both the white tent still crowded with potential COVID patients and the hospital where confirmed diagnoses were processed—"is all part of God's plan?"

The girl was positively beaming now. "Matthew 24:7: 'For nation shall rise against nation, and kingdom against kingdom: and there shall be famines, and pestilences, and earthquakes, in divers places.'"

Then she gasped, brought her hand to her mouth. "Your face," she said.

It wasn't until I had driven home and stood in front of my bathroom mirror that I figured out what she was talking about. The N95 mask had left its imprint in the form of huge blue bruises on my cheeks. Your very own stigmata. Neal's voice in my brain! Customized. 'Cause you're such a cheeky bitch.

###

The work itself was not tremendously challenging. In fact, it was boring. Rote. Monotonous. As though you were somehow trapped inside an algorithm. We plied patients with corticosteroids to reduce the edema in their inflamed lungs. We injected patients' IV bags proactively with antibiotics so they wouldn't succumb to secondary bacterial infections. You had to suction respiratory gunk out of the patients' ET tubes every two hours, or the gummy phlegm would occlude their ventilators. You had to pry their eyelids open and shine your flashlight in their eyes to make sure their pupils still dilated. You had to stay current on their Pavulon and morphine schedules so they'd be paralyzed and stupefied, wouldn't fight the ventilator.

Occasionally, patients started coming out of paralysis and began fighting the ventilator; this made a terrible racket as the high-pressure alarms, low-volume alarms, and apnea alarms began going off simultaneously.

We had to keep a close eye on oxygen sats, too, because if a patient's oxygen saturation dropped below 90, then it was all hands on deck for the proning maneuver. It generally took all five nurses on shift to prone a patient. That was the other thing about the ICU in the time of COVID. Until the shift ended, we were like astronauts marooned on a space station. No nurses aides, no respiratory therapists. We did everything ourselves.

Visitors were no longer allowed in the ICU, and the worst thing was talking to those families on the phone because, really, what was there to say? The best thing was to snow them with medical jargon they couldn't possibly understand: We have him on assist-control volume at a tidal volume of 400 milliliters and a respiratory rate of 20. Moderate to high PEEP but low pressure so his lungs don't get injured further—

But what does that mean? the agonized love one might ask. Is he going to make it?

"How the fuck would I know?" I complained to Debbie Reynolds as we stood outside smoking once the shift was through. We smoked defiantly, right in front of a large sign that said, Wiltwyck Hospital is a smoke-free premises.

"You don't bring your Tarot cards to work?" Debbie Reynolds asked.

"I assumed there was a Ouija board in the break room."

"Tsk, tsk. Next time, just tell her, 'God's not answering His pages."

"Too busy doing that sparrow count in Iceland."

Sometimes, we would stand there chain-smoking for an hour. We never took smoke breaks during shift; struggling in and out of that PPE was too much of a pain in the ass.

Gradually, I extracted Debbie Reynolds' story: After saddling her with a moniker in homage to her mother's favorite movie—not "Singing In the Rain," but "Tammy and the Bachelor"—her blue-collar family had kicked her out of the house at age 16 for being gay. Since then, though, her life had been peachy. "Plus, you know, my brothers are always trying to borrow money."

"Do you lend it to them?"

"Fuck, no. MAGA asswipes. Though sometimes I like to pretend that I will just to see how low they'll grovel."

I'd stopped answering my phone unless it was Neal. At first, I responded to texts, but then I stopped responding to those, too. Neal complained: "You're not updating your LiveJournal anymore. You know, I bookmarked it! I read it every day." But there was nothing I wanted to write about.

Debbie Reynolds and Neal were really my only social contacts—unless you wanted to count the flaxen-haired girl at the New Millennium Kingdom table with whom I'd gotten into the habit of stopping and chatting every day.

I'd say goodbye to Debbie Reynolds, recycle my cigarette butts into a napkin in my pocket—moral corruption begins with littering, after all—and trot on over to the New Millennium Kingdom table. Offer marketing advice on the day's banner. "The Blood of the Lamb Works Better Than Purell? That's not gonna go over too well in a healthcare environment."

The girl just laughed. I had the idea that I could say anything—Aliens have landed! A 9.0 earthquake just took out Australia! You are a piece of shit preying on hapless human fears and insecurities!—and she would just laugh.

One time, I asked her, "What did you do before you got into the saving souls biz?"

Right on cue, she laughed merrily. "I traded at Goldman Sachs."

"For real?"

"Buy the eternal, short the godless."

Another time, I asked, "If God loves humanity so much, then why is He ending the world?"

She shook her head in amused disbelief at the depth of my incomprehension. "If a building is collapsing, do you think about redecorating? No! You get your loved ones out. God isn't ending the world. The world is ending itself. God is building us a new world."

"Why didn't God plan the original world better so that it wouldn't collapse?"

She shrugged. "Free will turns out to be a dangerous illusion."

"Wait! You're saying free will is an illusion? So human suffering is—what? God watching an experiment go bad?"

"It's not an experiment going bad. It's a patient refusing treatment."

"I've had patients refuse treatment. I didn't phone a bomb threat into the hospital."

"That's because you just work there," she said.

"And I don't really care," I said. "I'm just covering my ass."

The flaxen-haired girl chuckled heartily at that one. "Didn't we already decide that?"