1. Forbes, V. Jude MSN, FNP

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My phone rings at 4:30 AM but stops before I can pick up. It's too early for anything but bad news. Caller ID displays the number and name of a local hospital. I try to convince myself that it was a wrong number and return to sleep. What are the odds? If Dave had been admitted to the hospital, the caller wouldn't have hung up. I phone the hospital and ask for Mr. Cameron's nurse. Yes, a voice confirms, a Mr. Cameron has been admitted with chest pain. Dave apparently tried to call me from triage.

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I drop to my knees to ask for strength. I prepare a pot of coffee. I hop into the shower. The routine has become all too familiar. In the car, I try to convince myself that it wasn't a heart attack. From what I've been told, the nerves on transplanted hearts have been removed, so transplantees don't experience the pain of ischemia.


When I arrive, Dave is hooked up to two IV drips, a telemeter, and oxygen as two technicians await his approval for a bedside chest X-ray and echocardiogram. He is angry and demanding to leave against medical advice. And I snap, telling him that since he called me from the ED at 4:30 AM, by God, he'd better stay until they rule out any problems. Then I ask the medical staff about enzymes, strips, troponin.


More than six years after Dave's transplantation, I still have to deal with the "let's withhold information" game, as physicians and nurses try to figure out the relationship between the old, bald white guy with the tattoos and goatee and this much younger, chunky black woman. Even though in Dave's wallet and on his paperwork I'm listed as his partner and his next of kin and given medical power of attorney, more than once I'm asked whether I'm his sitter or an LPN. Hell, my name is permanently etched on his body, along with the names of his mother, siblings, and our daughter. But I don't point this out. I simply inform them, again and again, it seems, that I'm his partner and I'm also in a postmaster's nurse practitioner program.


Dave undergoes his third angioplasty and second stent in a year. The diagnosis for the early-morning chest pain was 99% occlusion of the left anterior descending branch of the left coronary artery. But no heart attack. The cardiologist tells me that the surgery was successful, that perfusion to his heart is excellent. He says he wouldn't be surprised if Dave has five or more years in him.


Four days later the situation suddenly changes. His prognosis goes from five years to 12 hours. If that. Dave's cardiologist is visibly shaken. He says that Dave has experienced spontaneous stent closure. It sounds like he's talking to me through water. When he explains that this occurs in fewer than 3% of patients who've undergone percutaneous transluminal coronary angioplasty, the roar in my head grows louder. From his lips come the words "massive infarct." I can't take this. I interrupt him. I ask whether Dave is alive or dead. I can't integrate any of this information until I know whether we are talking about the living or the dead.


About four years after transplantation, Dave shared with me that he sometimes regretted it. This made me ashamed of him; I was offended, angry. How could someone regret life? Didn't he know how hard we all worked? Didn't he realize that he was a member of a very small group of miracle patients? How dare he regret the sacrifice the donor family made? How could he question the gift that allowed him to have more years with our daughter?


Years later, sitting in yet another coronary care unit, I finally understood that he hadn't been expressing a lack of gratitude. Instead, he realized that miracles come at a price. After transplantation, he was unable to return to work. Along with "post-pump syndrome" (a complication of being on the heart-lung machine, resulting, in Dave's case, in confusion, memory loss, and other cognitive deficits) and the adverse effects of the medications, he battled severe depression, developed significant physical debility, and had been forced to file for bankruptcy.


The heart attack was severe. Dave's on a dopamine drip and a balloon pump. I bring in a copy of his advance directives.


But Dave survives the first 12 hours. Then the next, and the next. Within 72 hours, his heart is beating on its own.


He awakens angry, confused, combative. He spits on the nurses and tries to pull out his tubes. He spews epithets and nearly breaks one nurse's hand. He's put in four-point restraints. My newest battle is to convince the staff that this isn't his mental baseline. This is not "my Dave." To anyone who will listen, I explain that even though he looks like an old Harley-riding wrestling star, Dave drives a Geo Prism, wears trifocals, has a lap cat named Daisy, and is the parent support for our daughter's after-school girls' empowerment group. I bring the nurses Krispy Kreme donuts.


I'm detaching. So is our daughter, Sloane. She doesn't ask about her dad. Her dad, when lucid, doesn't ask about her. And I'm sinking. Why didn't we ever marry? What joy have we had since the transplantation? What progress have we made as a couple? I walk into the room and say, "I know you hate everyone, but you still love me, right?" He looks up, lips slightly upturned, his pale blue eyes boring into me. "I really fucking hate you." Everyone on the unit stops as his words ring out. I'm as alone as I've ever been.


On the fifth day of hospitalization, Dave is taken out of restraints. He wakes up only to raise hell. But the man who is combative and confused shocks everyone when he sets up his medications flawlessly.


I'm torn between being a partner and being a nurse. Ultimately, I opt for being a nurse. I have more success when I treat Dave as a patient: the structure and familiarity of nursing practice are reliable. Now I side with the nurses; he is the "patient from hell."(How could I convince them otherwise after what he said to me?) In all honesty, I really hate him.


I keep thinking about the nerve it takes to have a heart attack with someone else's heart.


If they had asked me when Dave was admitted whether he would ever want aggressive measures to be taken-such as a balloon pump, a dopamine drip, and several days of conscious sedation, when the previous hours had featured emergency angio-plasty, insertion of a stent, closing of a stent, and a massive anterior wall infarct-I would have said no. Now he was alive because I had not been asked to make such a decision.


A week after discharge, Dave looks 10 years younger. He has dropped about 20 lbs., has more energy, and is clearer, mentally, than I've seen in years. He is driving. He spends almost every waking hour engaged in some activity. He has almost completely redecorated the house and dusted all of its bric-a-brac. He's performing acts of kindness unlike any I've seen him perform before. He donated an old computer to a neighbor and a television and PlayStation to a local teen recreation center. The man who has left Texas only once in the past decade has suddenly decided to visit his family in Wisconsin. Dave, Sloane, and I are planning our first trip-ever. He is happy.


But Dave's new life has left me without grounding, like an untethered kite.


Editor's postscript: V. Jude Forbes (under the name Vashti Forbes) first wrote about Dave in "The Dying Game," in the September 1998 issue of AJN, before he received his transplant. After a decade of partnership, she and Dave have separated but are still close. As she puts it, "we still have a connection that remains intact." When she told him this story would be published, he sent a return e-mail: "Now the whole world will know my powers, and fame is but a few months away." She passed on his words to AJN, saying, "I had to laugh because that's 'my Dave.'"