Oct/Nov 2007  •   Fiction

Nurse Miriam

by John Palcewski

The pipe organ up in the loft of Saints Peter and Paul played a gloomy requiem. Then came the eulogy intoned by the Reverend Martin Harrison. White hair, flared nostrils, bushy white eyebrows, crystalline blue eyes, granny glasses. His resonant baritone reminded everyone of Richard Burton.

"I'll always remember Miriam for her forthrightness," he said. "One time she showed me an application she had filled out for one job or another—I don't know which one, she had done so many different things in the course of her eclectic life. They'd asked her to put down a single word to best sum her up. She wrote, 'Authentic.' And that's exactly right. Miriam was no more—and certainly no less—than herself."

I heard footsteps behind me and turned in the pew to see them coming up the aisle. Gerrard, and Norma. Norma looking fabulous in a tight navy sheath dress. Her dark hair framing her face, falling down to her shoulders. As they passed, Norma pretended she hadn't seen me. Gerrard gave me a nod of recognition and quickly looked away. They sat two pews ahead.

The Reverend continued.

"My wife and I once saw Miriam at an outdoor music festival in Fairmont Park. We invited her to join us, and she said, no, she would rather wander about on her own, because it was too crowded there where we were sitting. And after a while I looked back over my shoulder and saw her dancing to the music, barefoot, all by herself. And I like to remember dear, sweet Miriam that way—dancing alone. Bare feet in the grass.

"Her dream was to build her own house. And her ex-husband—but still her good friend—suggested the best approach would be to build a small one, something within her financial means, and design it so over time it could be added to, expanded when she could afford it. But she said no, it had to be exactly as she wanted it, or not at all. She spent so much time with all the plans and sketches he made for her, and she finally got that house started. But then, unfortunately, she never saw her dream fulfilled."

Norma leaned, whispered in Gerrard's ear. She spoke several sentences, which I could not make out. Gerrard kept his head tilted, listening carefully to her. Then he nodded. Oh, yes, those two were tight. They'd long ago stopped trying to hide it at work.

"Many of us relate to others in different ways. That is to say, to one person we are a certain kind of person, and to another we are someone entirely different. We present different parts of ourselves, depending upon whom we're dealing with. But Miriam never changed. She was the same to everyone.

"Now, I can tell you Miriam had an epiphany in the last two weeks of her life, which she didn't bother to elaborate upon. But I believe it was she—after a long, painful and lonely struggle—had come to terms with her brain tumor, and her rapidly deteriorating awareness, and her inability to speak, and its awful finality. As a man of the cloth, of course, I like to think she at last saw the open beckoning arms of The Lord, inviting her to come home. There, in the loving protection of our Lord Jesus Christ, is where we all truly belong."


Norma arrives at the rehab looking like she's about to go out on a date. Skin-tight jeans. A clinging white or red silk blouse, which usually is open down to the third button. Brown loafers, which she casually slips out of as soon as she sits down for morning report. She likes to show off her pale, slender, perfectly formed feet.

"Morning sex," she announces to the assembled clinical team, "is something I'm really getting into lately. But there's a big downside. Do you know how awful a man's breath smells when he wakes up? Ugh."

Gerrard blinks rapidly in cognitive dissonance, then gets hold of himself. Norma smiles. She knows precisely what she's doing to the big goofus. I'm about to say something to change the subject, but Miriam, the senior psych nurse, speaks up.

"And what do you do when you wake up, dear?" she says. "Pop a mint?"

Laughter all around. Louder than it really needs to be.

Then Gerrard shuffles his papers, and says, "Okay, folks, let's get started."

Norma always brings along a bagel or a muffin and a container of coffee, and as evening shift supervisor Martha gives her report, Norma munches and sips casually. This gives her the appearance of being an old hand, someone who's seen and heard it all, even though she's been an addictions technician for what? Six months?

"Joey D. refused his meds," Martha says, reading from her notes. "Alice A. is hooking up with Mary Z. Yes, everyone's talking about it. Oh, and Harry T. went AMA around 2230. I called a community meeting and all the patients tried to talk him out of it, but he said he didn't need any more of this recovery bullshit because he had some important business to take care of."

"Yeah, like copping some crack," Norma says.

"And then," Martha continues, "a big coincidence! At 2300 there's another AMA. Guess who?"

"Harriet N.?" Gerrard asks.

"No way, big toad!" Norma says. "Harriet N. is more like a sister to him. It was Alice. Right?"

Gerrard blinks again. He is extraordinarily sensitive to demeaning nicknames. He's wounded by allegedly-good-humored allusions to his obesity, his powerlessness over eating—which, as every clinician knows, is as serious an addiction as alcohol or drugs. And Gerrard bristles at references to his general bumbling incompetence, his mismanagement. His blatant favoritism toward a certain inappropriate tech with big tits. Gerrard looks at Martha with big, sad, bloodhound eyes.

"Norma happens to be exactly right," Martha says. "After the community meeting, Alice just threw her stuff into a black plastic garbage bag and walked out the door. She didn't bother to sign the AMA form."

Norma smiles in triumph. I look at Nurse Miriam. I know exactly what she's thinking. Her term for what's going on between Gerrard and Norma and upper management is simple and on the mark: "institutionalized dysfunction."

Miriam says despite management propaganda, we are not in a meritocracy here at the Green Acres Recovery Center. Hard work and competence go only so far. To get ahead in this nut house's hierarchy, you have to do just one thing: bend over and kiss Gerrard's big, fat, hairy ass. Prop up his fragile ego, his almost non-existent self-esteem.

I admire Nurse Miriam, and I deeply respect how she takes care of her patients. She's a natural-born healer. Some of these addicts and alcoholics are permanently fucked up, but nevertheless they instinctively know who really wants to help them and who is just going through the motions.


Gerrard ordered another staff meeting in the cafeteria. Attendance was mandatory, no exceptions. He stood in the front of the room and waited for everyone to quiet down. Finally he said, "If you want to get right down to the nut of it, there's only one real, serious issue we have got to face around here."

"The lousy food?" someone in the back called out.

"It's REVENUE, folks. We've got to get more referrals, because we need to keep these beds filled. And we need to hold onto our patients as long as we possibly can."

Gerrard made a show of staring at Marty, one of the therapists, who last week discharged two patients—a middle-aged male and a 20-something female—who had been fucking in the janitor's supply closet. Fucking was absolutely forbidden between patients. Long-standing policy. They had to go.

"We also need to cut costs," Gerrard continued, "and that's exactly what I intend to do."

"Don't you even THINK about cutting nursing staff, buster!" Miriam said loudly. "We're barely getting by as it is."

Gerrard paused two beats. Then he said, "I hear you, Miriam."

Nurse Miriam knew this was just more of the spin and bullshit Gerrard felt obliged to throw at us. Did the tub of lard say he would NOT cut nursing staff? Oh, hell no. He just said he'd heard her. But she wasn't through. "If anything you should hire at least three more nurses," she said. "And you damned well know it."

"Yes, dear, we're keeping that in mind. But nevertheless we've GOT to save some money."

Dr. Leverett, the quiet red-bearded and pale gray-eyed resident psychiatrist, didn't look up from his rapidly clicking knitting needles. A bright red scarf was coming along nicely. "I've got an idea," he announced.

"Please, Doctor, let's hear it."

"The psychos who hear voices? Instead of turning them over to me, why not just issue them earplugs?"

Everyone laughed.

Gerrard's face flushed. "All right, now let's move on, shall we?"


It was inevitable. Norma and I were bound to butt heads. I called her into my office. She was calm, composed, self-assured. Well defended.

"Norma, I'm getting a lot of complaints about your spending too much time on personal calls," I said.

"What personal calls?" She affected a look of surprise.

"They also say you're inappropriately flirtatious with male patients."

"Whoa!" she said. "Where do you get flirtatious? And who are 'they?'"

"The other techs."

"Like who exactly?"

"Look, Norma. Extended personal calls are against policy. And your dress is inappropriate."

"You've got to be kidding me."

Norma's breasts bulged above the tight scoop of her green satin blouse, like Michelle Pfeiffer's in the movie Dangerous Laisons. Her skin was flawless, like the pale Carrara marble Michelangelo carved for his Pieta. Those breasts were firm, and they rode high on her chest. I imagined that without any support whatever, they'd still ride high. Now, had I met this raven-haired, narrow-waisted, long-legged crack whore in a bar back in my wild drinking days, well, it wouldn't have been long before I had my hands and mouth... But that was then, and this was now.

"No, Norma, I'm not kidding. Your dress is provocative."

"Excuse me. But that's just your twisted, sexist opinion."

"Let's make this simple. No more extended personal calls. No more flirting banter with male patients. And please reduce the amount of flesh you expose."

She looked at me intently, then rose.

"Fuck off, creep," she said. Then she walked out.

I typed out a summary of the conversation, along with the time and date, then put it in the file containing all the other complaints I was getting about Norma. As they say in the rehab, if it's not written down, it just didn't happen.

Despite our little chat, the complaints did not abate. Everyone kept telling me, Norma did this, Norma did that. And they asked me how come I'm letting her get away with it? I was the guy in charge, wasn't I? When we break the rules, we get our asses kicked. But not her.


A week or two later Nurse Miriam and I were sitting across from each other at the staff table in the dining room. She told me the latest outrage. At the beginning of the evening shift on Saturday, Norma had brought in her seven-year-old son, Jason, because she couldn't get a baby sitter. Miriam told her bluntly this was not a good idea, because we have a bunch of seriously disturbed patients, many of them with parental sexual abuse issues, and so on and so on. But Norma blew Miriam off.

Soon there was a loud commotion. Miriam ran upstairs and there's Norma, shouting at the top of her lungs at little Jason, who'd been running all over the place like a wild Indian and had knocked over one of the big potted plants by the window in the corner of the community room. Little Jason ran wailing into the bathroom in the tech office and slammed and locked the door. Norma pounded—boom-boom-boom-boom!—yelling and screaming like a banshee. A group of patients were standing outside, wide-eyed and totally freaked out. From the bathroom came the pitiful sound of little Jason bawling hysterically. "I hate you, I hate you. Fucking cunt bitch, I HATE YOU!"

Finally Miriam convinced Norma to take little Jason home. She did not return to complete her shift and did not amend her time sheet to reflect her absence. Apparently she expected to be paid even if she hadn't been there, because after all, it was Miriam's idea she take the kid home. "So, John. What's next? That's what everyone is wondering."


I sat in Gerrard's cluttered, chaotic office. Cute, adorable little fuzzy doggies and kitties were scattered all over his desk. Also a spinning magnetic top, three or four electronic games, a Rubic's cube, rattles, bells, and a big plastic doll speaking in a squeaky electronic voice: "Bite me! Bite me!" On the walls were pinned a large collection of calendars, photos, and Charles Addams cartoons. On the door was a sign. It said: "DO NOT REMOVE THIS SIGN!"

All this was not an accident. Rather it was part of Gerrard's theory of an effective therapeutic environment. Didn't most drug addicts and alcoholics have huge problems with authority figures? So look around, bud. Do you really believe this playpen of an office belongs to a cold, distant, abusive father? Huh?

Gerrard came in, huffing and puffing, as if he had just finished last on a 100-yard dash. "Sorry to keep you waiting," he said, "but I just couldn't break away." He sat down. The phone rang. He raised his forefinger apologetically and answered. Blah, blah, blah, blah, blah. Then he uttered a long string of single words. "Okay. Okay. Right. Yes, I know. Yes. Okay. Uh-huh. Sure. Right away. Bye. No, I will do it. Yes. Of course. You have my word."

He hung up. "It just never stops," he said, shaking his head. Then he pulled out four or five tissues from the faux-chrome-plated box on the coffee table, and honked. Then he clasped his pudgy hands over his massive belly, and looked downward. As if composing himself. Getting totally focused. Because, after all, he had something of tremendous importance to say to me. Finally he spoke, but he did not look up.

"I want to address an issue causing me a hell of a lot of grief," he said.

He paused. I waited expectantly.

"All right, I'll just come out and say it. I know perfectly well, a lot of people around here think I'm a fucking idiot."

He was dead serious. I had to suppress a laugh.

"So I'd appreciate it," he continued, "if you could tell me precisely what contributes to this mistaken perception."

"You really want my opinion?"

"Yes, I do."

"Well, Gerrard, you could start with Norma."

"What about Norma?"

"Your intimate involvement with her is no secret. And it has clouded your judgment. I've told you many times about her inappropriate behavior, but to date you've done absolutely nothing. Despite all the complaints, you keep looking other way. Staff deeply resents this."

"Staff? Which staff?"

His eyes were flashing.

"And how come they haven't come to me directly?" he said. "Why do I have to hear this shit second hand? If somebody has something to say, goddamnit, they ought to have the balls to come here and say it to ME."

"Gerrard, nobody feels comfortable confronting you. They know the deck is stacked against them."

He sat motionless and silent for half a minute. Those basset hound eyes of his. So mournful. The world was pressing heavily on his chubby shoulders.

"Well, the nurses are just jealous of Norma's good looks," he finally said.

"No, I'm sorry," I replied. "I just can't agree with that. You've got to do something. And you've got to do it soon."

Another long silence.

"I hear you," he finally said.


Lakota Sioux in the 19th century called the raven "Little Grandmother Who Scolds, But Not Unkindly." That's how Nurse Miriam handled the people in her care. She insisted on order and discipline because she knew chaos made people even more crazy than they already were. She made her patients line up single file for their meds, and to just wait calmly, one at a time please, and don't get excited, you'll get your turn. She told the terrified wretches who were hearing voices, it really was okay, don't worry, because once the Haloperidol kicks in, the chatter will magically go silent, but it may take a while. Meanwhile, she told them, if the voices are telling you to do something to harm either yourself or others, just say, "HELL NO! I'M NOT GONNA DO IT!"

The very last thing Miriam would do was to blindly follow the herd. She informed the resident psychiatrist she just didn't buy into that recovered memory craze sweeping the therapeutic community. Wholly ridiculous folderol about adults not remembering being sexually abused by their parents a long time ago, and forgetting as well the satanic rituals in which their crazed, incestuous daddy tortured little babies, cut them up, and ate them for supper. Shrinks are eager to bring all these bizarre events back to people's awareness. Gadually, of course. Victims spend $150 a session, three times a week, for two or three years to get the job done. The longer one stays in this absurd therapy, Miriam pointed out, the worse one gets.

She also had no use for what she described as the Three Faces of Eve Thing, a disorder the Diagnostic and Statistical Manual breathlessly called "Multiple Personality" before they renamed it "Dissociative Identity." Whenever a patient spoke in a voice not his or her own, Miriam replied—and not unkindly—"I'm sorry, dear, but I don't talk to alters." And that was that. Interesting, isn't it? How quickly these various personalities disappear into thin air when nobody pays attention to them?

Miriam was the protypical multi-tasker, always on the go. She scribbled progress notes in patients' charts rapidly, in a spidery scrawl full of exquisite detail. Even though she wasn't required to, she always attended the shift's group therapy sessions and was able to draw out the patients even more skillfully than the therapist facilitators. She noticed everything, missed nothing. She knew which patient was hooking up with whom. Who was serious about recovery, and who was just taking another spin through the revolving door.

Miriam was one of the most skillful, effective, and empathetic nurses I'd encountered in my seven-year tenure as weekend supervisor at the rehab. I liked, admired, and respected her. That is, until she began to change.

Nothing spectacular, just little things. Annoying things.


Miriam was screaming from the far end of the female wing, and I hurried down the hall. I expected to see a suicide, or bloodshed, or some broken window glass, but the room was empty. She was rummaging through a bureau drawer, throwing panties and bras and blouses and socks to the floor. She slammed the drawer closed, then pulled open the next.

"Suzie is using. I just know it," she said.


Miriam looked at me sharply. "What's the matter with you? Are you deaf? I said Suzie. And I'm going to find her stash. So go check the stuff hanging in the closet. Right now!"

I thought: What in hell is she getting excited about? This sort of thing happens all the time, no matter how carefully we strip search patients and inspect their bags during intake. Addicts will always find a way to get their shit. So why is Miriam making such a big deal of this? For Christ's sake, all we have to do is get a sample of Suzie's urine, send it over to the hospital. Case closed.

I didn't say that, of course.

In the community room, a few weeks later, Robert was escalating. He had just gotten word his wife had filed for divorce. Behind his back she was fucking a slick Philadelphia lawyer, and that meant she was guaranteed custody of the kids, and it meant she was going to get the house and car as well. There wasn't a damned thing he—a chronic DWI repeat offender who had been court-ordered to three months of rehab—could do about it. Miriam tried to bring him down, but the more Robert talked, the more manic he got. Oh, how could she do that to me? I can't believe it. I can't take this shit, honest to God. He threw his head back, opened his mouth wide, and issued a sustained and anguished howl freezing everyone in place.

Miriam ran to the janitor's closet, got a bucket. Filled it with cold water. She quickly carried that sloshing bucket to the community room, and ordered Robert to take off his shoes and socks.

"What?" he said.

"Just DO it, Bobby," Miriam said.

He slowly untied his shoes, slipped off his socks. Miriam directed him to put his feet in the bucket. He shook his head. She insisted. So he complied.

It was a rather unconventional therapeutic intervention of Miriam's, to say the least, and the fact that Robert quit howling didn't entirely put me at ease.

Before these relatively minor events, being around Miriam had been calming, reassuring. We all enjoy watching people who are on top of their game. But gradually her behavior became more annoying, more bizarre.


One Sunday evening she thrust her clipboard at me. "You have got to take a census." She looked grim. She wasn't kidding.

"Why? We have only six patients currently in residence. I saw four of them a minute ago in the recreation room. The other two are on the couch over there."

"John, I've been a psychiatric nurse at major Philadelphia hospitals for 25 years before I came here. Census must be taken regularly. By name."

"It's not necessary in this instance," I said.

"I'm telling you it IS necessary. Now are you going to do it, or not?"

"If you think it's that important, Miriam, go right ahead. Take a census."

"No," she hissed. "You're the shift supervisor. YOU have to do it."


Gerrard flipped through the typed pages of my report on Nurse Miriam. Yes, he had indeed read it. Very carefully. And what's more, as soon as he got it, he'd immediately forwarded a copy to Sally, the Director of Nursing, and just yesterday they had lunch and had a long, thoughtful discussion.

"It's all about perception," Gerrard said, leaning back in his chair, steepling his pudgy fingers. "It boils down to this. You see one thing, and we see another. You have a way with words, John. You're very convincing. But then Sally says there may be something else going on here."

"You mean besides my deep concern for Miriam, as well as the patients?"

"Listen, Sally and I went over the whole thing. Beginning with her searching for a patient's stash. Don't you think that was actually the most responsible thing she could have done? And that you, as supervisor, should have been supportive? And the census. Miriam asked you for help because she had a backlog of progress notes to write, but you refused. As for the bucket of cold water in the community room, well, it worked, didn't it?"

"Gerrard, it's not just one big thing, it's an accumulation of small ones. She's going through a personality change. She was never like this before."

"Well, it's common knowledge Miriam likes to do things her way. She's a powerful, formidable woman. Intimidating, you might say. So I have to agree with Sally, something else may be going on here."

"Like what?"

"She suggested you might be struggling with, uh... some unresolved mother issues. Which are affecting your perceptions."

I couldn't disguise the sudden, nearly overwhelming surge of contempt I felt for Gerrard. Once again this incompetent shit was avoiding his responsibility by changing the subject, thus ignoring it. Miriam's bizarre behavior? Whoa, Gerrard whines, I don't wanna talk about THAT, 'cause it's dangerous territory. I'd prefer to talk about something else.

"You've got to be kidding."

"No, John. I'm just passing along the input Sally gave me. And, after all, she's in a much better position to assess Miriam than either you or me. The bottom line here is it's Sally's call."

Okay, fine. There wasn't anything else I could do. Gerrard and Sally were in perfect self-serving synch. Nothing unusual was going on, therefore no action was required. Miriam, meanwhile, was gradually getting worse.


It wasn't just this ridiculous episode with Gerrard and Miriam and Sally that made me think seriously about quitting that writhing pit of snakes they called a recovery center. Trying to help addicts and crazies was stressful. Exhausting. Over time I gradually lost confidence that I could help people change their self-destructive behavior. Eventually I realized most addicts can never be helped, because they just don't want to be. And even many of those who genuinely desire recovery simply can't do it.

Like Anthony, a handsome, well-groomed, 22-year-old cocaine addict. I asked him to take a seat in my office and then quietly asked him why he never shared in group. He was wearing a blue Oxford shirt with a button-down collar, khaki trousers, and shiny brown docksiders. His dark hair was combed neatly, and his nails were manicured. He didn't look unkempt like most of the other addicts, rather more like a law-school graduate who'd just passed the bar.

"I don't feel like sharing," he said in a flat, expressionless voice.


"I've got nothing to say."

His chart indicated, before being admitted at Green Acres, he had seven previous treatments at facilities in Connecticut, Rhode Island, and upstate New York. He had an extremely wealthy and politically well-connected father who paid for treatment because he didn't want the health care insurance companies involved. Gerrard had no siblings. His intake evaluation suggested he was possibly obsessive/compulsive, and might have some anger management issues. No criminal record, however. And so on.

I went into a long speech about the absolute necessity of recovery, which means we have to get honest with ourselves and with others. The words just came rolling out of my mouth, one after another. For a while it looked like he was listening to my earnest, intense monologue. But Anthony's eyes, his facial expression, told me he'd become sick of this endless treatment bullshit. He turned, looked out the window.

At that moment I knew everything I was trying to do was futile. Useless. Stupid. Ineffective. A waste of time. This kid didn't want or need me. I had absolutely nothing of value to give him. So he'd just slammed the door in my face. Just like my own son had done, a long time ago.

I had to stop talking, to let the tightness in my throat subside. Anthony turned. "May I go now?"

I nodded, yes.

Anthony left AMA the next day. He caught a plane to Phoenix, checked into the airport Hilton. He somehow persuaded his ex-girlfriend to come and talk. He said he just wanted to say goodbye to her properly. He said he'd fully accepted her dumping him for a really nice guy who wasn't always jonesing for coke. He said he understood. So she agreed.

When she arrived, he closed the door, pulled out a flat-black Glock and blew her brains out. Then he put the gun into his mouth and pulled the trigger.

Anthony's murder/suicide gave me the idea that addiction is not really a medical or psychiatric problem, but rather the embodiment of Evil. Evil as an invisible but real entity. An enormously intelligent and sophisticated being, who waits patiently for us. Who knows us perfectly, and where we're most vulnerable. Making us miserable or dead is for Evil a sport, an amusement. Something to break the monotony of eternity.


Three months after I handed Gerrard my letter of resignation—which by the way he eagerly accepted—I heard Miriam had died. Massive brain tumor.

Mary, one of the techs, said the service would be at Saints Peter and Paul day after tomorrow. She told me, after I left the rehab for good, things with Miriam had gotten worse and worse. "It was awful," she said. "Miriam's face got round and swollen, she'd gained a lot of weight, you would never have recognized her. They'd given her steroids to ward off infection after the surgery to remove at least part of the huge tumor. Afterward most of her hair fell out, and what was left she'd dyed blonde. She couldn't speak coherently. She carried a tablet around and scrawled unintelligible words. Her gestures and facial expressions were violently exaggerated."

"At the Christmas party she accused Gerrard of giving her a Recovery Center employee telephone list with incorrect numbers, which she claimed he'd done deliberately, because obviously he didn't want her talking to her friends anymore. Why? Because he didn't want her spreading malicious gossip about him. Naturally, he denied it. Miriam went ballistic. She shrieked and screamed and pounded the table with her fists. Gerrard just stood there, paralyzed. He didn't know what to do."

"Oh, John, it was heartbreaking."


At the end of the eulogies at Saints Peter and Paul, we went down to the basement, where some of Miriam's artifacts were arranged on a long table covered by a linen cloth. At the end was one of her trademark, wide-brimmed straw hats, with a long flowing blue ribbon. There were a couple dozen silver and turquoise bracelets and necklaces from Santa Fe, a town she visited often because she loved the artworks of Georgia O'Keefe. A Papago Indian basket. An open notebook with her spidery, delicate writing.

Norma picked up a silver-framed, black and white picture of Miriam as a young girl. Her face was in profile, lit by a candle stuck in a wine bottle, taken by one of her lovers, a professional photographer. Hers were the clear skin and aristocratic features of a Philadelphia Main Line debutante. The sort of charismatic beauty who could have had any man she wanted.

"She looked great back then, didn't she?" Norma said to Gerrard.

Gerrard looked at the picture. He nodded. Then he said, "For a long time Miriam was very good at disguising her symptoms. We never had a clue what was going on with her."

"You're absolutely right," Norma said. "None of us ever saw it."

I could have said something. And almost did. But then, what good would it have done?

In the end, there's just not one single goddamned thing you can do.