When you wind up in a hospital, you’re suddenly surrounded by – and often, dependent on – health care workers like nurses. Garth Greenwell explores the relationships between a patient and his medical team in his novel “Small Rain.” Mayo Clinic nursing administrator Melania Flores joins us to discuss the importance of nurses and the unique connection, humanity and support they can provide to patients.
When you wind up in a hospital, you’re suddenly surrounded by – and often, dependent on – health care workers like nurses. Garth Greenwell explores the relationships between a patient and his medical team in his novel “Small Rain.” Mayo Clinic nursing administrator Melania Flores joins us to discuss the importance of nurses and the unique connection, humanity and support they can provide to patients.
This episode was made possible by the generous support of Ken Stevens.
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Dr. Denise Millstine:Welcome to the “Read. Talk. Grow.” podcast, where we explore health topics through books. Our topic is critical illness with a focus on the importance of nursing care. And our book is “Small Rain” by Garth Greenwell. I'm your host, Dr. Denise Millstine. I'm an assistant professor of medicine at Mayo Clinic, where I practice women's health, internal medicine and integrative medicine.
My guests today are Garth Greenwell, who is the author of “What Belongs to You,” which won the British Book Award for debut of the year and was longlisted for the National Book Award, in addition to multiple other honors. His second book, “Cleanness,” was also met with great acclaim, including as a 2020 New York Times Notable Book. His cultural criticism has appeared widely, and he writes regularly about books, music and film for the Substack newsletter, “To a Green Thought.” He's a 2020 Guggenheim Fellow and a recipient of the 2021 Vursell Award for Prose Style from the American Academy of Arts and Letters. He is currently a Distinguished Writer in Residence at New York University. Garth, welcome to the show.
Garth Greenwell: Thanks so much for having me.
Dr. Denise Millstine: “Small Rain” is his latest novel, which is going to be the focus of our conversation today. Our expert guest is Melania Flores, who is a nursing leader and administrator at Mayo Clinic. Her clinical time has been in intensive care and progressive care cardiac units, in addition to multiple other settings, but this makes her an excellent expert guest for our discussion today. She's passionate about mentoring nurses and health care professionals and in her free time, loves to trail run. Melania, welcome to the show.
Melania Flores: Thank you so much for having me.
Dr. Denise Millstine: Okay, you both know how “Read. Talk. Grow.” works; we discuss books that portray health topics in an effort to better understand health experiences through story.
“Small Rain” is a modern novel set in the dark days of the 2020 Covid-19 epidemic, and follows an unnamed narrator after a sudden, life-threatening medical event called aortic dissection. Initially not realizing the seriousness of its condition, the narrator eventually seeks care and embarks on a journey that requires him to face his mortality. Through his story, we see the incredible importance of nurses, which is going to be our conversation today.
Garth, this book was recommended to me by a reader who's also a physician, Dr. Donald Abrams, who told me to read it right after he had finished it. And then I got back to him about a week later and said, I loved it. We're going to invite him to the show. And he said, “Is it autofiction? You have to find out.” And I was like, what are you talking about? It's a memoir. He's like, please reread the description of the book. And I realized that it is indeed a novel that truly reads like memoir. So tell us your inspiration and if you feel open to it, please reveal if it is autofiction.
Garth Greenwell: So autofiction is this term that's being used a lot now that I don't like because it pretends it sort of acts as though there's something new. You know, this is some new trend in what is really the oldest game in literature, which is, we write books to make sense of the world around us. And it has always been the case for me, that I feel moved to write a book when I feel bewildered by something that has either happened to me or that has happened sort of in my vicinity, in my immediate world. What is true, that I underwent a health crisis similar to what the narrator undergoes. The book is fiction, and it's full of stuff that I made up. You know, there's a lot of detailed stuff about medical care, and a question I've often gotten is, how did you remember all of this? And I say, remember it? I watched a lot of YouTube nursing videos, like, that's what I did in order to try to describe these things.
So it's full of invention. It's a novel, but I wrote it because I did suffer an aortic dissection. I had this experience, you know, totally out of the blue as someone sort of not in the demographic that this usually happens to. I had an experience of sort of confronting questions about my life and the meaning and value of my life and my mortality. You know, decades before I anticipated it. And that experience was so bewildering that I had to spend three or four years writing this book to try to make sense of it.
Dr. Denise Millstine: Well, you can tell from the way that it's written and is so authentic that you either are a world class researcher, which I'm sure you are, or had some personal insight into navigating something like this. And we're going to talk about what aortic dissection is in a minute.
But Melania, I wonder if you'll share your reaction to the book.
Melania Flores: I was drawn in from the first couple pages. And as I've stated, I've been a nurse for many years. But I was drawn into the room and I was walking through everything that nurse did, and I was like, that was correct. That was good. Oh, that wasn't good. And embarrassed of some of the actions that were portrayed and so I held on to every word. I really did.
Dr. Denise Millstine: I feel like this book is going to find its way into nursing education through Melania's hands, Garth.
Melania, you probably also had a similar reaction to me, where we see the narrator at home with this tearing abdominal pain. Of course, we know it turns into a book. So it's something terrible. But we're probably both like, go to the E.R., get care. You're about to die. And of course, he's quite stubborn.
Melania Flores: Yes. What not to do.
Dr. Denise Millstine: Exactly.
Garth Greenwell: I think that's so important. Like, that's what novels are. You know, novels are about people making bad decisions. If you always make the good decision, there's no story. You know? So it's true. He's very dumb. He waits five days from the onset of the pain to go in and be seen.
Dr. Denise Millstine: When we meet the narrator, he's having pain that defied description and demanded a different scale compared to our normal 0 to 10 scale to rate.
So we later learned that this is an aortic dissection, which in this condition is when the inner lining of the wall of the aorta, which is the largest blood vessel in the body, tears and then blood runs into that wall, creating what we often call a false lumen or a false opening. If it's not recognized and managed, most people will die from this condition. So, Garth, can you tell us what you want listeners to know about aortic dissection if they haven't already read the book?
Garth Greenwell: Oh gosh, you did a really great job. You know, it did seem from my research that it's actually pretty often the case that sort of the cause, the sort of etiology of it remains mysterious if there's not obvious trauma or sort of, you know, a kind of pattern of behavior.
I can't remember now, when did this happen that the reporter at the Russian Olympics, you know, this young man, sort of, I think in his 40s, in his early 40s and healthy, you know, running all the time and taking really good care of himself. And he suddenly died and it was of the same condition. And that was right when I was finishing the book. And it's interesting how I've also I've discovered since publishing the book, you know, people reach out to me and this is not something that happens all that often. And yet I've met a lot of people now who have suffered this condition. And it's fust, it's a really scary thing, in part because it does seem so random and mysterious.
Dr. Denise Millstine: Yeah, it's terrifying how it just can come out of the blue and be so extreme and so unfortunately fatal. Okay, Melania, we're going to jump into talking about the nurses in this novel. So the first nurse that the narrator meets is in urgent care, and she's described by the narrator as tired and kind, exceedingly professional. And because she cannot determine the diagnosis, she refers him to the hospital for advanced imaging, like a CAT scan. Do you think she saved his life?
Melania Flores: Yes, because he went. But I wished it would have been with more diligence and more: You have to go with this in an emergency. I'm concerned, using those words, because I think there's often times where they go home and take a left or, you know, instead of the right, and that's sometimes life or death. And so I think it's us as health care professionals to really relay the importance of it. And I didn't get that part out of it because I was like, you know, I hope he goes, he better go. He better realize that this, you know, is probably not appendicitis. This could be big. And so that was my little takeaway from that scenario.
Dr. Denise Millstine: That poor nurse, she did the right thing. And still she could have done it more emphatically.
Melania Flores: Now hindsight is always beneficial.
Dr. Denise Millstine: 100%. Okay, Garth, so the next nurse is the triage nurse at the emergency department. And just restating this is 2020. This is a pretty devastating time. Not pretty. This is a devastating time in health care.
So the character meets the triage nurse who's the person who starts the process once somebody arrives at the emergency department and has been registered to request care. So as she's taking his vital signs, she's humming. Which the character states “…seemed to less encouragement than skepticism. He disliked her even while realizing she was probably exhausted and worked day after day seeing people in pain at their worst moments.” So again, while this observation displays a wisdom and an empathy, it's really authentic. He's scared. He automatically dislikes her. Can you talk about that interaction?
Garth Greenwell: Yeah. So one of the things that was most fascinating to me writing the book, was these relationships between the narrator and the people who take care of him. Which are, I mean, more than anything, these are the nurses who really are taking care to take care of him moment to moment. And immediately just how sort of, unbalanced they are. You know, because here's this guy who's terrified something is happening to him that has never happened before. And that he senses possibly may change his life.
And then on the other side, there's someone who literally is processing. Who is doing a routine procedure again and again and again. And the narrator keeps looking to these people for this kind of recognition that almost this system, this routinization, which on one hand, you know, and I've said this often, like that routinization saves lives, you know, and I've often said, like, if someone looking at me like a machine and not a person allows them to save my life, then please, by all means consider me a machine.
But he's desperate for this kind of human recognition that he does realize is really unreasonable for him to expect. And yet it's still something he desperately needs. And that was interesting to me throughout the book, this sort of these asymmetrical relationships where these people are sort of in the same place and time, but they're also in radically different stories.
Dr. Denise Millstine: But I hope we'll talk about where as they come together at different points, they interact on that more sort of level, nonhierarchical realm. And then there is this, “No, I'm going to tell you what to do, because I recognize this as a professional and you maybe don't understand what's happening here.” So I feel like there's a juxtaposition about that throughout the novel.
Melania, Garth just said something that I think is really important when we think about nursing care in general, particularly in the hospital setting, that these are the people taking care of him moment to moment. And I think as physicians, we often think that we direct care. But the truth is the care is provided by the nurses and it takes a team of collaborators. But will you just respond to that comment of the people who are there moment to moment as a nurse?
Melania Flores: It has such great impact when you think about the career as a whole and what we can offer from day to day, from moment to moment. Just even looking back up my career through that one. It's the patients and the family members. And so, you know, the significant other that was in the book and the sister that came, it's holistic. And I think from a nursing perspective, that's a greatest gift in and of itself is, how do we tie all these pieces together and fill in the gaps?
But I do want to go back to talking about routine, because, yes, that routine that is there for safety, quality, perspective. But I think we as health care professionals always need to remind ourselves that there is an individual at the end of each of those lines, at the end of the lab draw, at the end of a blood pressure, checking in. And so that's one thing that I hope maybe readers can get, is to put themselves in the patient's shoes, to offer that perspective.
Because we are human, we try to come to work. I think, each and every day to do our best, but to really remind ourselves that how vulnerable patients are, especially in these critical moments and to really they're looking to us not just for that routine care, but also for that empathetic listening care as well. It's just as important.
Dr. Denise Millstine: Thank you for highlighting that. I think there is an element of that that allows us efficiency. But then there's a boundary where, like you said, Garth, it's almost like people feel like they're being treated as machines or as not human. And that's where we cross the line, often related to stress and burnout.
But let's talk about the next nurse. So Melania, the next nurse we see is a nurse practitioner. So she comes out and the narrator knows. Garth, I really wish you had given this guy a name.
Garth Greenwell: Ha ha. So many readers wish that. And yet for me, it is just essential that he is nameless. It is.
Dr. Denise Millstine: And you are the writer who gets to make this choice. But as I was preparing my questions, I can promise you I was slightly cursing your choice. Not you, just your choice.
Garth Greenwell: Yeah, I understand.
Dr. Denise Millstine: Let's go back to the nurse practitioner. So the narrator understands that he's meeting somebody who has more power to direct his care now and is wanting really to move his care forward, even sort of pulling him in when they don't have a bed for him yet, to start to get some of the work up processing. Can you tell us, Melania, what a nurse practitioner is, what that role is? Maybe particularly as somebody is being seen in the emergency department or in a hospital setting.
Melania Flores: The nurse practitioners advanced practice provider and they are master's prepared or doctor prepared nurses that are able to care for patients. Each state kind of navigates it differently, where they have to where they can practice independently. Or I would imagine in this case, if you're in the E.D., they're still, working with a physician colleague and of course, a team that goes through the process.
But they're trained in whether acute care or, you know, family practice and so trained for, of course, for this emergency room, which I'm sure was very busy, as you said, during Covid and can only imagine the stress, but still.
Dr. Denise Millstine: So this person has been trained to bring you into the diagnosis, to go through the diagnostic workup, to take you into treatment. All of those things. So, Garth, this nurse practitioner is the same person who delivers the diagnosis of aortic dissection and what she says is, “You’re a surprise. A lot of people want to talk to you.” She wheels him back to a room where he can be monitored and start treatment.
Meanwhile, he's been in the waiting room for hours, but he comes finally back to this room because there's an awareness that this is somebody that doesn't have appendicitis or a gastroenteritis but now has a very critical illness that the health care system needs to help to mitigate. So here we meet our first named nurse. So this is Frank. And he moves in methodically and with purpose. He even asks a young doctor to wait until he's been able to get the medications in and started and hung the fluids and connected the narrator to the monitor. Can you tell our listeners about Frank, and then especially about the moment where they really connect around music?
Garth Greenwell: I love Frank. He's one of my favorite sort of characters in the book. It's the first time that the narrator really attaches to somebody. You know, even though he's still in the E.R., it's clear they're going to process him and get him somewhere else. But he thinks, oh, here is someone I'm going to see again. Like, this is someone who is assigned to me who's taking care of me.
And that, I think, opens the narrator up in a certain way to sort of want to have a more human connection. And then what happens is that the narrator has an allergic reaction to one of the medicines. He goes, it's not a dangerous one. He starts scratching himself. And so Frank says he's just going to hang out and just make sure that the Benadryl works and that this doesn't become something serious. And this creates just this kind of empty time, you know, to add to this point, everybody has been so busy, but now, Frank, he just needs to sort of hang out for a minute. And so they start talking to each other. And this is really the first time, pretty much certainly in an extended way, that the narrator has a really human interaction with someone.
And he, Frank, sort of tells him about his life and growing up in a tiny town in Iowa and playing in his high school band and then having a musical talent, which is what brings him to Iowa City, where the big university, the University of Iowa, is. And he came to a point where he had to choose between a possible life in music that might have carried him really far away from the world he knew, or the path that he took. Which leads him to this job as a nurse in the E.R. But he still loves music, and it turns out that he and the narrator love some of the same music. The narrator has a background as a musician, and so just in this room, he pulls out his iPhone and they listen to a song together, and it becomes this moment, which the book is kind of full of these moments.
And art is so important in the book, in part because in some way it can seem so different from the kind of clinical world of the machines he's hooked up to. And blood draws and heparin shots and everything else. And so it's the first instance of a moment where art becomes an instance where meaning is made between people, like they are able together to make a kind of meaning that goes far beyond any routinized care. Any, you know, sense of being processed where they really connect as human beings for a moment. But it's a really important moment.
Dr. Denise Millstine: Melania, I'm sure you have thoughts about Frank as well.
Melania Flores: And you do, but I think that moment where if you listen, or if you pause and you're not routine, and you go in and you meet the individual where they're at, you can have that connection. It's that listening, that storytelling, in those small moments that really build, as you stated and showed in this build that relationship. And it's so important in the healing process.
And these are what nurses then translate to the physicians. Whether it's they're having home issues, you know, it's a strained relationship, whatever it may be, that's going to impact their care. It's that relationship and those conversations. It's going to really take that healing process to that next level when you have a connection like that. Unfortunately, sometimes it's missed, but that's why I can only really hope that our health care workers can relate to the importance of listening and really being in, in their in that moment with individuals, whenever possible.
Dr. Denise Millstine: Hey listeners, we hope you're enjoying this episode of “Read. Talk. Grow.” If you find our discussions helpful and insightful, please take a moment to subscribe to and rate “Read. Talk. Grow.” on your preferred podcast platform and don't forget to tell your friends to listen. Your support will help us reach more readers and those eager to learn about health through books. As always, feel free to drop us a line at readtalkgrow@mayo.edu with suggestions for books, topics or any comments. Thanks for listening.
Dr. Denise Millstine: I think another aspect of Frank that's so important is that he's clearly competent, and the narrator sees that and suddenly feels, I'm in good hands and I can relax to some degree because he isn't moving coldly with purpose, but he is clearly moving with purpose. And even when this reaction happens, he's not excessively worried about it. But he is recognizing, okay, I need to make sure that you're okay and that sense of being in good hands, in competent hands is really important when somebody is especially just being diagnosed or recognized as having a critical illness. So I think that was really important for the narrator, especially at that scary, terrifying moment.
Garth Greenwell: Something that people have often asked me about, talking about this book is the way that the narrator is just sort of hyper aware and watching and, you know, tracking these small little details and noticing how nurses move, etc. And, you know, one reason he's doing that is because, you know, he's in a world he doesn't understand at all. He doesn't know how these things work. He doesn't know the words they're using. He's completely bewildered. And yet he knows. I mean, he's watching these people this closely because he feels like his life depends on it. And so these gestures, just as you say, in the way they show their knowledge, in the way they navigate the room and the way they move their bodies, every single caregiver he meets, he's trying to evaluate, like is this person going to be able to take care of me? Or is this person going to be dangerous to me?
Dr. Denise Millstine: Yeah, and even without that background knowledge, he's able to assess that very clearly and very quickly. There's a small moment, Melania, where a group of surgeons come in and there's a nurse on their surgical team, and the narrator feels a touch on his foot, and it's for no reason other than what I think can be described as reassurance or connection. And he states that he feels tears spring to his eyes. She was the first person here who had touched me in a way that had no medical purpose. How important is touch in medical settings?
Melania Flores: I don't think he put enough emphasis on it, especially as we're moving into the AI generation and technology. You will never replace that healing touch and that bond and what that means to both sides of it as well. Because they did pick up again, I think it was in the latter part when he was being discharged, when the surgeon sat and touched the narrator in the same way. And it was an intimate moment where you felt that that connection and so extremely important.
Dr. Denise Millstine: And was particularly important in 2020 and during the Covid pandemic, when really we were told to stay away from each other. So very impactful for this narrator at this point.
All right, Garth, we're going to talk about the character that's my favorite. And I would think many readers favorite, which is Olivia. So can you tell us about Olivia?
Garth Greenwell: I love Olivia too. You know, if this book has a hero, the hero is Olivia. And this is one of the, when I tell people that know really a lot of the book is made up. You know, one of the things that's unrealistic about the book is how much time he spends with Olivia. You know, I mean, she spends just more.
I've been waiting for, like, a Goodreads review to be like, oh, he got this wrong. But I knew I was being unrealistic and having her just work so many days of the time that he's there. But I needed that. I needed a single character who could really dramatize what was interesting to me about these relationships and especially, I mean, she's well, I think I'll be so interested to hear Melania, what you think? I think she's a great nurse. And like, you know, he really does feel it's a kind of, he's vulnerable in a way he's never been in his entire life. And what he feels for Olivia, on one hand, it seems so outsized to his feelings to sort of this person who's just doing her job and they're going to spend very little time together in the context of a whole life.
But, I mean, on the other hand, his life is in her hands, and he knows that they're good hands. He feels really this intensity of gratitude. And the really love, I think, is the word for it, for her, I love her. It was so much fun to write her. Yeah, I think she's great.
And I will say actually, she is a tribute to the nurses of the cardiovascular intensive care unit at the University of Iowa Hospital. I had never really thought about the hospital as someone who had always basically been healthy. I had never really thought, is it a good hospital? Is it a bad hospital? And it was my incredible good fortune, that it's a very good hospital. And the nurses in the cardiovascular ICU were extraordinary. And so I did want to have a character who could sort of represent my gratitude to the multiple nurses I had who gave me such good care.
Melania Flores: She was my favorite.
Dr. Denise Millstine: Our listeners can't see Melania cheering her with both arms in the air. So tell us. Tell us your thoughts about Olivia.
Melania Flores: Fantastic. Holistic. The epitome of what you would want that nurse to be. Because not only did she provide you that safe care, I was walking through every step that you described and I was like, correct, perfect. Yes. I was giving her applause as I was reading the book. But from the little things, when she folded your underwear, when she always had the seat for your significant other. These little things are showing that she understands where you're at, where the family needs are, and the importance of that healing environment, that not only is it that care that we need to provide that medical care, that clinical care, but everything else that's involved in being in the hospital during Covid and you do you develop relationships. And I was kind of counting the days, as you said, could she really be working that many 12-hour shifts? But, it was Covid. We did a lot. We did a lot more than we normally would have, but it was impactful and really appreciated. So for you to say that it was that holistic care that you received, I thought you relayed it very well in the story. And I being an ICU nurse in the cardiac area, just, it was it was a nice tribute, very much so.
Dr. Denise Millstine: And I think what you said about the care being in the details, warning when something was going to hurt or warming up items before she placed them on the body. She wanted the character to know what she was watching for or even being ahead of it, saying how are those IV’s? Do those hurt? And the character not wanting to say that he had noticed that they were starting to get a little irritated. And then when she changed them and he could just breathe a sigh of relief because she didn't wait for him to say, this is probably going to happen, or, tell me when this happens. She just took it into her own hands. So she was really a beautiful depiction of world class, excellent, best-ever nursing. So thank you about that.
All right. Then we meet the new nurse, this poor ICU nurse who is coming in clearly out of her depth. She is bumbling, fumbling, dropping things. Compare her to Olivia, Garth.
Garth Greenwell: Like the character, I have such mixed conflicted feelings for her because she is a baby, you know? I mean, she's just sort of gotten her nursing degree. I mean, and really, she has no business being in charge of. I mean, I would say, I don't know, but I think she has no business being in charge, all by herself of a patient who really needs careful care.
And the narrator suspects that it is because of the pressures of Covid and nurses being out sick and just need being needed in other parts of the hospital that she has to take his care in hand, and she just really can't handle it.
And what happens is that over her shift, he actually becomes a lot sicker than he had been. He knows the numbers that his vascular surgeon wants for his blood pressure and his pulse, and he sees them shooting up and she doesn't respond to it in a way that reassures him. And, you know, by the end of her shift, you know, he has a fever. He's shaking with chills, his blood pressure has spiked, his pulse has spiked, and he's just terrified. He is just scared out of his mind.
And it is this moment where he realizes the most important people here are these nurses. Like they are the ones who are going to determine if I live or die. Then when Olivia gets back the next day, he just is so desperately glad to see her because he has a really harrowing 12 hours with this nurse who I'm sure she is doing the best she can, but she doesn't have the skill. And then because she's embarrassed that she doesn't have the skill, she's also not able to sort of ask for the help that she needs in a time appropriate way. You know, things have to get really bad before she's able to go and find another nurse and say, I need help.
Dr. Denise Millstine: And everybody starts somewhere. So this is a really difficult scene to portray. Melania, I can't wait to hear your thoughts.
Melania Flores: I think you said it good as everybody starts somewhere, I think where my concern or pause was, is that when to escalate? Because we know even from orientation and from graduation, from being out new on a unit, you know, they're not going to come across everything, but you hope that they you've instilled that critical thinking and that to when to ask for help, when to know when you're in over your head, or when to seek that senior nurse on that unit. And that's where I felt like, like you mentioned that there was that gap to where did she even know that she was in over her head at some of these moments?
And, you know, because I was like, go get someone or maybe you need help or is there anyone else on the unit that can come and get another test or look for different medications? I didn't know, you know, what the plan of care was for that day, and neither did the patient because she didn't articulate that, which was another issue. But I think that was the concern is that we at least hope that they can articulate when they need help, because there's a learning process in every role that you have. But that's important, especially in critical care.
Dr. Denise Millstine: And I think another important aspect is that being over your head, being intimidated by a situation can read as lots of different emotions, and in this case, it was defensiveness. And then the narrator's response to that is anger. And so it's very hard for the two of them then to come to a point where they're working together. Now they're just in conflict, which, it's a novel. So there has to be conflict, but it's very uncomfortable as a health care professionals reading this and just being like, wait, just take a breath and give her a minute, wait, go get your supervisor. Because it was a very uncomfortable exchange.
Garth Greenwell: Yeah.
Melania Flores: In addition, the anxiety that it was causing the patient, which triggers blood pressure. And so I was like, it was just one thing after another. And I was like, everybody has to calm down. And because I was like, if you could calm down, maybe the blood pressure could come down some and we could work together. But yeah, there is multifactorial moments there that day.
Garth Greenwell: I mean, the narrator is definitely not his best self in that moment. And, you know, one of the first readers said to me, I think you should tone this down because he really seems like a jerk. And I thought you know what? I think it's really important that he has a moment where he gets mad. His vascular surgeon, who I also think is kind of a pretty heroic figure, very competent and caring. She says at the very in their first meeting, she says, look, there's going to come a moment when you get really mad at us and that's okay.
And like, this is his moment. And on one hand, he doesn't act well. You know, he makes things worse. At the worst. There is this negative feedback loop. And on the other hand, he's so scared and he is so vulnerable, you know, and also because it's Covid. And so there are these, you know, there's just this tiny window when his partner can come, he's all alone.
There's no one to sort of advocate for him. And so he's trying to figure out a way to get her to escalate, to get her to go get help to navigate this bureaucracy, while he's also just terrified that his artery is going to erupt because his surgeon has told him, you know, keeping the blood pressure down, that's the way we're keeping you safe.
It's an interesting scene, but I remember how sort of fiercely I rejected that comment about sort of toning it down, making him a little better behaved. I think that's real. You know, I think that's sort of a real moment and that I should allow him that ugliness that comes up because it feels to me human.
Melania Flores: I would agree and glad that you kept it there, because I was also a charge nurse in the ICU for multiple years. And so walking into those situations, that's real and that's for all and that's reality. And so I think keeping it in there, was it very appropriate.
Garth Greenwell: I'm sure.
Dr. Denise Millstine: It's not as bad as it could have been. And what if we approached each other with compassion instead of our initial reaction, whether it's anger or defensiveness, it would all go so much more smoothly. But that's not reality. We aren't always our best selves, especially when we're sick and we're scared.
So we're going to finish with the most poignant and impactful nursing moment of the novel. But before we do, in reflecting about his care from Olivia, the narrator states that he meant to write a letter about her, how she deserved a place in the gallery of honor that he had been wheeled past. And Melania, he never wrote this letter. And I wonder if you'll share with our listeners how important that recognition and those letters are.
Melania Flores: I was so sad when he said I never wrote the letter. You don't often meet the patients ever again, especially from a critical care area. They go off and become well and you very rarely do they come back in a visit or do you get to reconnect with them again, except for that vulnerable moment when they are critically ill.
If ever anyone has a moment to write down a name or two or what that impact and meant for them, it goes very far. They read it, they hold on to it, and it's a recognition that is held in high regard and appreciated greatly. But that did that stuck with me. I was like, oh, she's not going to get her place on the wall. She deserves it.
Dr. Denise Millstine: So if you had an early nurse reader, that's the feedback you would have got for a change. But it is the reality that there's a lot of good intentions out there, and people often don't take that extra step and don't necessarily even know how much it impacts people who are doing their jobs.
Okay, so the final scene between the narrator and Olivia, So the narrator is transferred out of the ICU, transferred to the floor is how we would often refer to that. And he and Olivia are saying goodbye and he thinks something that you've already mentioned. Garth, I was struck again by the asymmetry between the patients and those who care for them. And I'm going to read directly from the book, “And then Olivia stepped back into the doorway and looked at me. Well, she said, I'll head on upstairs. It's been a pleasure. I hope you'll keep feeling better. Thank you, I said to her, which was inadequate, and I was struck again by the asymmetry between a patient and those who care for them. Olivia said goodbye to patients all the time after shepherding them through whatever crisis. She was used to it. But for me, she was singular. She had cared for me in a way no one ever had. I was attached to her, and what could I say now that she was passing me on?”
I want you both to comment on that scene.
Melania Flores: Where he just thinks that she does this all the time, and it's not impactful. It is, and patients and the relationships are real, and there's certain ones that we can recall at any moment in time. I can remember the room, I can remember the family, I can remember their illness. And so there are those relationships that are built and we carry them forever through our careers. And so I see it as Olivia with like, no, she will remember this relationship forever. It was one of those bonding moments where I felt that they had.
Garth Greenwell: I really can't say how moving it is to hear your response to the book. As someone who lives in the world of the book from the other side, I am very moved by what you just said. You know, I that scene was so important to me, and it's one of the things that the book I feel really proud of because I was trying to find a way to indicate how precious… you know, that something really real had happened between these people. Something that far exceeded the routine, the bureaucracy, that exceeded the skill with which she puts things in his body and, you know, takes care of him, that there was this human warmth between them.
And there's this moment, you know, the way that she brings him into the room and then she sort of looks around, you know, like she's checking out the room for him and making sure it's an okay room for him. I didn't know how that scene was going to go. I had been aware the book was basically written in order, and so this was one of the last parts I wrote, and I was aware as it approached, how am I going to do that? You know, how am I going to find a way for them to say goodbye to each other that conveys the sort of fullness of this relationship, even though it's a relationship that he knows is now ending.
And anyway, I feel happy with that scene. In part, I think I feel happy with it because I think you can feel reading it how much I, the narrator, love Olivia. I really fell in love with her as I wrote the book, and that's something in each of my books. There has been a character that I have just kind of desperately loved, and in some way, I think I need that to write a book that the book has to have at its center, someone that the author loves. And in this book, that's Olivia.
Dr. Denise Millstine: Well, that clearly comes through. And how important nursing care is, clearly comes through. So I would like to encourage our listeners to go out and read “Small Rain” by Garth Greenwell. I'd also encourage you to find the nurses in your life, and to say thank you to them, and tell them how important their care is to all of us.
Thank you both for being here with me and having this impactful conversation.
Garth Greenwell: Oh thank you. It has been really such a joy for me.
Melania Flores: The same. Thank you.
Dr. Denise Millstine: “Read. Talk. Grow.” is a product of the Women's Health Center at Mayo Clinic. This episode was made possible by the generous support of Ken Stevens. Our producer is Lisa Speckhard Pasque and our recording engineer is Rick Andresen.
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This podcast is for informational purposes only and is not designed to replace a physician's medical assessment and judgment. Information presented should not be relied on as medical advice. Please contact a health care professional for medical assistance if needed for questions pertaining to your own health. Keep reading everyone!