Her shift ended at 7 p.m. She didn’t clock out until 4 a.m. The family she stayed for didn’t know her name until a year later.
The pediatric intensive care unit at Rainbow Babies & Children’s Hospital in Cleveland is on the fourth floor of a building that takes up most of an east-side city block. The unit has fourteen beds, arranged around a central nurses' station in the rough shape of a horseshoe. The lights, after eight in the evening, are turned down to the soft amber level that hospitals call night mode, which is engineered to keep the small humans in the beds from waking and the parents in the recliners from quite remembering, in the brief eddies of sleep they get, that they are still in a hospital.
Beth Karchner had been a pediatric ICU nurse for almost twelve years. She was thirty-six. She had grown up in a small town outside of Akron, in a family of teachers, and had come to pediatric nursing after a long thoughtful detour through anthropology in college and a year teaching English in Ho Chi Minh City after graduation. She lived in a one-bedroom apartment in Lakewood with a small gray cat named Cabbage. She did not, on the evening I am describing, have anyone waiting for her at home. She had not, in the careful private accounting of her life, had anyone waiting for her at home in almost three years.
Her shift on that particular Tuesday in February was a twelve-hour. It had started at seven in the morning. By the time the day-shift charge nurse handed off to the evening team at three, Beth had been on her feet for eight hours, had managed two intubations, had de-escalated one parent who had begun screaming in a hallway, and had eaten exactly half of a turkey sandwich at her station while charting a med change for a six-year-old with a complicated cardiac history. By five-thirty, she was in the third hour of a slow steady decline that, in pediatric ICU nursing, is the body’s way of asking you, in increasingly direct terms, to consider going home.
She was scheduled to clock out at seven.
She did not clock out until four in the morning.
II. Bed nine.
Bed nine that evening was occupied by a fifteen-month-old girl named Iris Marshall. She had been admitted four days earlier with a severe respiratory infection that had progressed, despite aggressive intervention, into the kind of pediatric ARDS that pediatric ICU nurses recognize, without saying it out loud, as the kind of pediatric ARDS that does not always end the way the family hopes it will end.
Her parents, Tomas and Renée Marshall, had not left the unit in three and a half days. They had taken turns sleeping in the recliner. They had taken turns eating in the small parents' kitchen on the third floor. They had taken turns making careful phone calls to the grandmothers in Toledo. They had not, by the Tuesday afternoon in question, slept more than perhaps two hours at a stretch since the previous Friday. They were thirty-three and thirty-one years old, respectively, and Iris was their first child.
The doctors had begun, that afternoon, the slow careful conversations that pediatric ICU teams have with parents when a child’s trajectory begins to bend in a particular direction. Beth had been in the room for parts of those conversations. She had stood, in the careful peripheral way nurses stand during family conferences, near the door, with her hands folded loosely in front of her, watching the parents' faces.
At six in the evening, the attending pulmonologist had gone home. The on-call attending, a woman Beth had worked with for almost a decade and trusted with her life, had come on. At six-thirty, Iris’s oxygen saturation had begun to soft-drift downward — not in an alarming way, not yet, but in the slow steady manner that, to an experienced pediatric ICU nurse, looks like a child trying to make up her mind.
At six forty-five, Beth had begun her end-of-shift handoff to the night nurse, a competent woman named Linda Park, who was a friend and a former mentee. Linda was a good nurse. Linda would have been a perfectly adequate nurse for bed nine on that Tuesday night.
At six fifty-three, Beth stopped mid-sentence in the handoff. She told Linda she would, instead, stay.
She did not, she told me when we spoke about that night fourteen months later, plan to stay. She did not, in fact, ever consciously decide to stay. She had been in the middle of telling Linda about a med change, and she had turned, in the way nurses turn, to glance through the doorway of bed nine, and she had seen Tomas Marshall’s hand resting on the bedrail. He was not holding his daughter’s hand. He was just resting his hand on the bedrail, the way an exhausted man rests his hand on whatever furniture is nearest to him. Renée was asleep in the recliner with her head against the wall.
Beth told Linda, I am going to take this one tonight. Linda did not argue. Linda, who has been doing this work for almost as long as Beth has, simply nodded. They reassigned the rest of Beth’s patients to Linda. Beth went back into the parents' kitchen, drank half a cup of bad coffee, washed her face, and went back to bed nine.
III. The shape of the night.
There is a particular kind of pediatric ICU shift that does not have a story in the usual sense. There is no dramatic crisis. There is no resuscitation. There is, instead, the long quiet work of watching a small body try, hour by hour, to choose. The work, on these nights, is not heroic in the way television shows hospital nursing to be. The work is the work of being present.
Beth sat, for most of the next nine hours, in a wheeled stool beside Iris’s bed. She did not, in any traditional medical sense, do anything that the night nurse would not have done. She charted. She adjusted the small ventilator settings according to the careful arrows of the night attending. She suctioned. She changed an IV bag at nine-thirty. She turned the small body, with Tomas’s help, at ten-fifteen, and then again at one in the morning. She watched the saturation monitor with the kind of careful attention that experienced pediatric ICU nurses pay to a number that is, by any reasonable medical standard, being adequately tracked by a machine.
The most important work a pediatric ICU nurse does at night is not measurable. It is the work of being a known calm presence in a room where the rest of the world has, temporarily, stopped existing.
Tomas slept in the second recliner from one in the morning until almost three. Renée woke at nine, slept again from eleven to one, then sat up and did not lie back down. She did not, that night, ask Beth’s name. Beth did not, that night, offer it. They had, by then, exchanged perhaps eleven sentences over the course of the four days Iris had been in the unit, all of them functional. Beth had become, in the household economy of the Marshall family’s worst week, a piece of the furniture of bed nine. The furniture does not have a name.
At two in the morning, Iris’s oxygen saturation dropped, briefly, into the low seventies. Beth adjusted the ventilator settings. The saturation came back up. Renée had been watching the monitor. She had not, until that moment, taken her eyes off it for almost an hour.
“Is she going to be okay?” she said.
Beth did not answer immediately. She finished the small adjustment she was making. She set down the chart.
“I don’t know,” she said. “But she is fighting tonight. She is fighting hard.”
Renée nodded. She did not cry. She had, in the four days, more or less stopped crying. She had been replaced, by the late-Tuesday version of herself, by a different kind of woman — quieter, sharper, more careful, more tired, more in love with her daughter than she had ever been with anyone else. She reached forward and rested her hand on Iris’s small ankle, on the side of the bed where the IV was.
“Is she going to know?” she said. “If — if she does not — is she going to know that we were here?”
Beth, who has answered this question hundreds of times in her career, did not give the brittle reassuring answer that pediatric ICU nurses sometimes give. She gave, instead, the careful honest answer she has come to believe.
“Yes,” she said. “She knows.”
IV. The morning.
By three in the morning, the saturation had stabilized. By three-thirty, Iris’s small breathing pattern had quieted. The night attending came in at three-forty, examined her, and stepped back into the hallway with a careful neutral face. Beth followed her out. They had, in the unit’s small private code, a brief conversation that Tomas and Renée could not hear. The attending told Beth that the next twelve hours were, in her professional judgment, the corner. If Iris held her current pattern through morning rounds, she would, probably, turn.
Beth went back into bed nine.
She did not, in the careful protocol of her training, tell Tomas and Renée what the attending had said. That was not her place. That was the attending’s conversation, at morning rounds, with the appropriate disclaimers and qualifications. What Beth did, instead, was the small thing that was hers to do.
She brought Renée a cup of weak tea from the parents' kitchen, in a small paper cup. She brought Tomas, who had woken up at three-thirty, a cup of bad coffee. She said, in her quiet conversational tone, she is holding. She did not, beyond that, characterize the situation. She let the parents have the small fact and nothing more.
At four in the morning, the night nurse who had taken Beth’s other patients came over to bed nine and asked, in her gentle nurse-to-nurse way, if Beth would consider going home. Beth had been on her feet, by then, for twenty-one hours. The new day shift was coming on at seven. She had a shift again at three the next afternoon.
Beth looked at the chart. She looked at the saturation monitor. She looked at Renée, who was now asleep in the recliner with her head against Tomas’s shoulder.
She nodded. She handed off, this time, to a different night nurse — a woman she trusted, a woman who had been on the unit for almost as long as she had. She wrote a careful note in the chart. She picked up her bag. She walked out of the unit at four-fourteen in the morning.
She did not say goodbye to the Marshalls. They were both asleep.
V. Iris.
Iris Marshall held her pattern through morning rounds. By Wednesday afternoon at three, she had begun to improve. By Friday she had been transferred out of the ICU to the step-down unit. By Monday the following week, she was on regular pediatric, and by the second Friday after the Tuesday I have been describing, she was home in the Marshalls' apartment in Cleveland Heights, breathing on her own and beginning, in the slow careful way of a recovered toddler, to walk again.
The Marshalls did not, in the discharge process, encounter Beth again. Beth was, that week, on her four days off. By the time she returned to her next set of shifts, the Marshalls were already on the step-down floor, and by the time her schedule rotated back to overlap with the family, they were home.
They did not, for almost a year, know her name.
VI. The letter.
Renée Marshall wrote the hospital eleven months later. She wrote a long careful letter, in the way exhausted mothers sometimes do when, almost a year after the worst week of their lives, they have at last begun to have the cognitive bandwidth to write a letter. The letter described the night her daughter had begun, in her phrase, to come back. The letter described a nurse — a woman in her thirties, with brown hair tied back and small wire-frame glasses, who had taken bed nine that Tuesday night and had stayed long past her shift, and who had not told the Marshalls her name. The letter asked the hospital, in careful and apologetic language, whether it would be possible to identify this nurse, because the Marshalls would, after a year of thinking about it, like very much to thank her.
The hospital’s family relations coordinator — a woman named Diana Bauer, who has been doing this work for eighteen years and has, in those eighteen years, received many letters of this kind — sat with the letter for a long time. She matched the date against the schedule. She matched the description against the staff. She identified, without much difficulty, Beth Karchner.
Beth did not, when Diana approached her, immediately remember the night. She remembered, when Diana described the case, the small things — the saturation drop at two, the cup of tea, the way Renée had asked whether her daughter would know. She did not remember staying late as an act of any particular kind. She remembered it as something she had done.
The Marshalls came to the hospital on a Saturday in late March, with Iris. Iris was two and a half by then. She had a small careful walk. She had her father’s eyes. She had a small pink stuffed rabbit she had been holding in her hand for the entire drive, which her parents had brought with her from home that Tuesday night and which had spent the four days of her ICU stay tucked into the corner of bed nine.
They met Beth in the small family conference room on the fourth floor. Renée had brought a card. Tomas had brought, at his wife’s careful instruction, a small bouquet of yellow roses. Iris had brought, on her mother’s lap, the pink rabbit.
The Marshalls did not, in the conference room, say very much. They thanked Beth. They cried. Iris, who did not understand any of what was happening, played with the rabbit on the floor at her mother’s feet. Beth, who has been in conference rooms like this many times in her career, did the small careful thing she has learned to do in these conversations. She did not deflect the thanks. She did not, in the false-modest way some nurses do, say I was just doing my job. She accepted the thanks. She accepted the roses. She held Iris’s small hand for a moment when Iris, having grown tired of the rabbit, reached up with the casual confidence of a healthy toddler.
She told Renée and Tomas, before they left: I am very glad to know how she is.
VII. What it means to stay.
I spoke with Beth at a coffee shop on Detroit Avenue in Lakewood about three months after the meeting in the conference room. I asked her, in the careful way I have learned to ask people who have done a quiet remarkable thing without believing they have done a quiet remarkable thing, what made her stay that night.
She thought about it for a long time. She did not, she told me, decide to stay. She said, with the careful precision of a nurse who has had twelve years to think about her own work, that she had not made a decision. She had, instead, noticed something — Tomas’s hand on the bedrail, the slow soft drift of the saturation number, the particular angle of Renée’s head against the wall — and she had, as a result of noticing those things, found that she was already walking back into the room with the chart.
The decision to stay, when staying matters, almost never feels like a decision at the time.
I asked her whether she had ever done it before. She said yes. She said she had done it perhaps fifteen times, in twelve years. She said she did not, in any of those fifteen times, do it as a policy. She said she did it when she noticed something. She said she had also, on many other nights, gone home on time. She said the discipline was not the staying. The discipline was the noticing.
VIII. Why it stays.
I have been writing for The Chapbook for almost nine years, and the stories of American pediatric ICU nurses are, on the whole, written in the language of heroism. They are written as if these women and men have made grand sacrifices, performed dramatic interventions, saved lives against impossible odds. Some of them have. But most of the meaningful work they do is the work I have been trying to describe in this piece — the work of staying when staying matters, of being a known calm presence in a room that has temporarily stopped being a room and has become, instead, the entire world a family is living in.
Beth Karchner is, the morning I am writing this, on the day shift at Rainbow Babies. She is taking, by the careful schedule of the pediatric ICU rotation, bed seven and bed eleven today. She will, in the slow careful way she has learned, notice the things that need to be noticed. She will, when her shift ends at seven, almost certainly go home. She will, on one of the next fifty nights, almost certainly stay.
Across the United States, in pediatric intensive care units in cities and small towns and rural medical centers, nurses are quietly performing this small careful discipline every day. They are noticing. They are staying when they need to stay. They are, in their own private way, holding the world open for families who have not yet recovered the bandwidth to know how to thank them. For broader context on the long history of American pediatric nursing, readers can spend time with the careful work at the National Library of Medicine or the long-form reporting at PBS NewsHour. The Chapbook keeps its narratives clean, human, and responsible — read more in the Editorial Policy.
Iris Marshall is three this year. She is, by her mother’s account, an unusually verbal child. She does not, of course, remember any of what happened. She does not know the name of the nurse who sat in a wheeled stool beside her bed for nine hours on a Tuesday in February. She is, in this respect, exactly the way she ought to be.
The work, when done well, is the kind of work the child does not have to remember.
