With the dying of my patient last week, the transfer of a time-consuming patient to a nursing home, and another patient discharged from the hospital today, there is a temporary lull in the proverbial storm. Thank you, Powers That Be!
Luckily, my work life has taken a turn towards quiet this week as things at home are in full swing. Our newly renovated basement apartment is now rented, a painting party last night (including the new tenants) finished a first coat on almost all of the walls, and that home-under-construction feeling is almost done, the operative word here being "almost". Until the new tenants have moved in, the small touches and fixes completed, and a sense of normalcy ensues, I won't feel completely able to rest at home. It's recently seemed like we're under seige, with the normal routines somewhat convoluted and the fabric of our daily lives slightly altered. When is life not altering in some unforgiving way, you ask? Rarely is it not, but the crispness and coolness of autumn will be welcome as the home-front settles down.
Four weeks into my third semester of teaching nursing, my prep-work from last year is now bearing fruit. Without having to study, take notes, prepare lectures, and create overheads every week, I am relieved of the constant preparation and now feel like I can more fully enjoy teaching, although those 13-hour Thursdays are wearing at times. Nonetheless, I love sharing my knowledge---such as it is---and trying to inspire yet another group of interested adults as they enter the nursing world. It's one thing to discuss pathophysiology and medications, but it's a completely different pursuit to actually explain what one does as a nurse, especially when speaking of the intangible, the ethereal, the energetic/intuitive aspects---this is the "art" of nursing. One must not forget the pathophys, but one must also bear in mind the humanity of the person behind that anatomy and that illness. Memorization can get one just so far, and then the emotional and spiritual aspects of one's self must emerge and connect with others meaningfully. Imparting this is a challenge, especially in a classroom setting. I hope that my colleagues on the clinical front can take time to address the real human needs of our students' patients. It is still humbling to teach, and even more humbling to know that my words are guiding and shaping human minds that will directly address the physical, emotional, and spiritual needs of the ill and dying.
May my words be effective in communicating what needs to be said clearly and efficiently. May these students go out into the world and touch others in a way which is always effective and occasionally transformational. May I also simply make it through each day and come out the other side.
Wednesday, September 28, 2005
Saturday, September 24, 2005
In The Neighborhood
The neighborhood where I work is a troubled area rife with poverty and its discontents: drugs, crime, and frequent violence. As I noted in a November post, my car was broken into prior to Thanksgiving and I lost my car stereo and a sense of safety and invulnerability.
Some other neighborly incidents:
One day last year, I was exiting the clinic with a doctor with whom I work. We came outside for a breath of fresh air around 3pm and immediately noticed something was wrong: his car, a 99 Honda Accord, was sitting on four plastic milk crates, all four wheels having been removed while the car sat in the clinic parking lot in broad daylight! Those 99 Hondas are a hot item!
Our noble medical director fought to have a small store included in the plan for the building in which the clinic has been housed for some years now. The little store caters to the Latino population in the neighborhood and supplies many elders with milk, avocados, and many Latino staples at decent prices, the store being a short walk from the nearby subsidized housing projects. There are often electric wheelachairs and scooters parked outside--the store is too small for even a small wheelchair, and only two school-age children are allowed in at a time to protect against shop-lifting. That said, the windows of the little store are broken with bricks and stones---and occasionally bullets---an average of four to six times a year. This Latino-run business serves the community well, but still suffers from vandalism, which could cause increased prices or possibly a permanently closed store.
Just outside the store, the landlord paid for some lovely shrubs to be planted a few years ago. The following week when we returned from a long weekend, the shrubs had been stolen, dug out from the ground with their root-systems still intact. Luckily, the replacement shrubs have escaped a similar fate.
Last week, one of my favorite docs was working late at the clinic, attending an HIV providers' meeting and finishing some notes. He left the building and began to back his car out of the lot, but remembered something on his desk and ran back inside, locking his car behind him. He was only in the building for ten minutes, but by the time he came out, his trunk was broken open, a window smashed, and all of the contents of his car had disappeared: stethoscope, brief case, car stereo, CD collection, and other flotsam and jetsam. This particular doctor works 50 hours per week, splitting his time between the clinic and the county jail, where he provides award-winning HIV-care for incarcerated men and women. His dedication to medically underpriviledged populations is an inspiration.
The same night as the theft from this doctor's car, a teenager was knifed to death just three blocks from our clinic on a street where many of our patients live. The son of one of our patients witnessed the murder---as did a dozen other people, it seems---but no one is talking and the perpetrator was never apprehended.
So, this is my work neighborhood, but this area is also graced by hundreds of lovely and giving people, a community garden worthy of a Puerto Rican "finca", the sounds of children and adults in the park on sunny afternoons. I am greeted daily with salutations of "hola", "buenos dias, doctor", and "Dios te bendiga" (God bless you). It is a microcosm of the wider world. I love it, I hate it, I long to leave it, and I cannot think of doing so. It is my neighborhood for more than forty hours each week, and it is in my blood. Although I generally feel safer in New York City than I do in the city in which I choose to work, I feel protected and blessed, knowing that my karma of service will shield me from harm and mistreatment.
May all beings be happy. May all beings be free from suffering, and may this neighborhood---and all places where people and animals make their homes---be blessed with freedom from violence, from Boise to Baghdad. This is my wish in this moment. May we all strive to make it so.
Some other neighborly incidents:
One day last year, I was exiting the clinic with a doctor with whom I work. We came outside for a breath of fresh air around 3pm and immediately noticed something was wrong: his car, a 99 Honda Accord, was sitting on four plastic milk crates, all four wheels having been removed while the car sat in the clinic parking lot in broad daylight! Those 99 Hondas are a hot item!
Our noble medical director fought to have a small store included in the plan for the building in which the clinic has been housed for some years now. The little store caters to the Latino population in the neighborhood and supplies many elders with milk, avocados, and many Latino staples at decent prices, the store being a short walk from the nearby subsidized housing projects. There are often electric wheelachairs and scooters parked outside--the store is too small for even a small wheelchair, and only two school-age children are allowed in at a time to protect against shop-lifting. That said, the windows of the little store are broken with bricks and stones---and occasionally bullets---an average of four to six times a year. This Latino-run business serves the community well, but still suffers from vandalism, which could cause increased prices or possibly a permanently closed store.
Just outside the store, the landlord paid for some lovely shrubs to be planted a few years ago. The following week when we returned from a long weekend, the shrubs had been stolen, dug out from the ground with their root-systems still intact. Luckily, the replacement shrubs have escaped a similar fate.
Last week, one of my favorite docs was working late at the clinic, attending an HIV providers' meeting and finishing some notes. He left the building and began to back his car out of the lot, but remembered something on his desk and ran back inside, locking his car behind him. He was only in the building for ten minutes, but by the time he came out, his trunk was broken open, a window smashed, and all of the contents of his car had disappeared: stethoscope, brief case, car stereo, CD collection, and other flotsam and jetsam. This particular doctor works 50 hours per week, splitting his time between the clinic and the county jail, where he provides award-winning HIV-care for incarcerated men and women. His dedication to medically underpriviledged populations is an inspiration.
The same night as the theft from this doctor's car, a teenager was knifed to death just three blocks from our clinic on a street where many of our patients live. The son of one of our patients witnessed the murder---as did a dozen other people, it seems---but no one is talking and the perpetrator was never apprehended.
So, this is my work neighborhood, but this area is also graced by hundreds of lovely and giving people, a community garden worthy of a Puerto Rican "finca", the sounds of children and adults in the park on sunny afternoons. I am greeted daily with salutations of "hola", "buenos dias, doctor", and "Dios te bendiga" (God bless you). It is a microcosm of the wider world. I love it, I hate it, I long to leave it, and I cannot think of doing so. It is my neighborhood for more than forty hours each week, and it is in my blood. Although I generally feel safer in New York City than I do in the city in which I choose to work, I feel protected and blessed, knowing that my karma of service will shield me from harm and mistreatment.
May all beings be happy. May all beings be free from suffering, and may this neighborhood---and all places where people and animals make their homes---be blessed with freedom from violence, from Boise to Baghdad. This is my wish in this moment. May we all strive to make it so.
Friday, September 23, 2005
Death Pays a Call
Yesterday morning, we were able to smoothly transfer my dying patient to his home for his final hours with family. The hospice nurses met me at the home, and we spent 90 minutes teaching the caregivers different techniques: how to move and reposition him to maintain comfort and decrease pressure on bony areas; how to administer extra IV morphine and Ativan for pain and agitation; how to provide oral, skin, and catheter care; what to do when his breathing changes and he slides into unconsciousness; what to do when he dies. The nuts and bolts of midwifing a death.
A call came late yesterday afternoon that the family was beginning to implode, verbally attacking the main non-family caregiver, creating a very stressful atmosphere. Although the dying gentleman was almost in a coma, hearing is always the last sense to be lost, and he reacted with grimacing and great agitation to the interpersonal melee unfolding around him. I was able to calm the situation somewhat over the phone, and hoped that all would be well enough for my dear patient to have a peaceful night, which would later prove to be his last night on earth.
I arrived to the home at noon today, and all was well and tranquil. My patient's respiratory rate had been decreasing and becoming more irregular, with longer and longer pauses between breaths, a sure sign of his steady decline toward death. His urine output was becoming darker and more scant, signaling that his kidneys were actively conserving fluids, producing as little urine as possible, trying their best to keep the body's fluid and blood volume at an acceptable capacity for the cancer-ravaged body. He was now completely unresponsive, the room's ambient sound being that of the pneumatic bed and oxygen tank whirring as white noise above the sounds of traffic through the window and voices from the kitchen and living room.
Saying that I knew this would be my last time with him, the family allowed me a few moments alone at the bedside. I communicated in Spanish that he was now free to leave, the family was together, friends gathered, everything in readiness for his departure. There was nothing more for him to be concerned about, all business had been taken care of, and nothing now stood in the way of him leaving his body. I encouraged him to thank his body for its service, and prepare to leave it behind for good. I kissed his forehead and left the room.
In the living room, I was generously offered a huge plate of traditional food which was impossible to turn down. We ate and chatted, and I shared with several people that the dying will often wait until all is quiet and no one is at the bedside to take their leave. It is a common phenomenon, perhaps because the dying person wishes to spare his or her loved ones from witnessing their departure, preferring to do it alone. After all, we are born alone and die alone, and no one can travel those passages for us. It is a singular event in life and one to be faced with aplomb and tranquility if at all possible, not to mention great courage and humility.
Not fifteen minutes had transpired between my goodbye soliloquy in the bedroom and finishing our meal in the living room when someone went to check on the dying man who was the central focus of everyone's attention for so many days now. I was abruptly called into the bedroom, and I immediately confirmed what was vividly apparent--he had died quietly after I left the room, leaving his body while we all ate our lunch together in the living room. Perhaps he really took to heart what I had said and realized it was time to go. Perhaps he would have died at that time whether I had been there or not, but being given permission to go, being blessed on one's way is a gift that can always be given to the dying, and I felt honored that I was given the gift of being present during this death, both for the dying and the living.
The scene that followed was classic: tears, hugs, weeping sons arriving afar receiving urgent cell-phone calls, neighbors coming to pay their respects. I, the professional, wandered from room to room, offering helpful words, concrete advice, fielding questions, and preparing the body. Not being a visiting nurse, per se, I am not licensed to pronounce a patient dead and sign the death certificate in Massachusetts, although I have been priviledged to perform this service in the past when I did have that legal right and responsibility. I called the hospice nurse and reported the time of death, requesting a nurse be dispatched as soon as convenient.
Exiting the building after warm goodbyes filled with kind words, a certain fullness pervaded my spirit, and a level of emotional exhaustion that cannot be described, along with a feeling of elation and freedom as well. Unfortunately, three more very busy hours of work would then ensue, robbing me of the opportunity to further explore this state of being. I was instead ruthlessly flung back into the maelstrom of the day, removed from the timelessness that seemed to pervade that apartment as we contemplated the death of a very noble man.
But now I can reflect on the experience, bless this soul on its journey, and enjoy the knowledge that my guidance played a small part in this soul's ultimate transition from the physical world to the spiritual realm.
Yes, Death paid a call, and I would say that the call was a sweet one.
A call came late yesterday afternoon that the family was beginning to implode, verbally attacking the main non-family caregiver, creating a very stressful atmosphere. Although the dying gentleman was almost in a coma, hearing is always the last sense to be lost, and he reacted with grimacing and great agitation to the interpersonal melee unfolding around him. I was able to calm the situation somewhat over the phone, and hoped that all would be well enough for my dear patient to have a peaceful night, which would later prove to be his last night on earth.
I arrived to the home at noon today, and all was well and tranquil. My patient's respiratory rate had been decreasing and becoming more irregular, with longer and longer pauses between breaths, a sure sign of his steady decline toward death. His urine output was becoming darker and more scant, signaling that his kidneys were actively conserving fluids, producing as little urine as possible, trying their best to keep the body's fluid and blood volume at an acceptable capacity for the cancer-ravaged body. He was now completely unresponsive, the room's ambient sound being that of the pneumatic bed and oxygen tank whirring as white noise above the sounds of traffic through the window and voices from the kitchen and living room.
Saying that I knew this would be my last time with him, the family allowed me a few moments alone at the bedside. I communicated in Spanish that he was now free to leave, the family was together, friends gathered, everything in readiness for his departure. There was nothing more for him to be concerned about, all business had been taken care of, and nothing now stood in the way of him leaving his body. I encouraged him to thank his body for its service, and prepare to leave it behind for good. I kissed his forehead and left the room.
In the living room, I was generously offered a huge plate of traditional food which was impossible to turn down. We ate and chatted, and I shared with several people that the dying will often wait until all is quiet and no one is at the bedside to take their leave. It is a common phenomenon, perhaps because the dying person wishes to spare his or her loved ones from witnessing their departure, preferring to do it alone. After all, we are born alone and die alone, and no one can travel those passages for us. It is a singular event in life and one to be faced with aplomb and tranquility if at all possible, not to mention great courage and humility.
Not fifteen minutes had transpired between my goodbye soliloquy in the bedroom and finishing our meal in the living room when someone went to check on the dying man who was the central focus of everyone's attention for so many days now. I was abruptly called into the bedroom, and I immediately confirmed what was vividly apparent--he had died quietly after I left the room, leaving his body while we all ate our lunch together in the living room. Perhaps he really took to heart what I had said and realized it was time to go. Perhaps he would have died at that time whether I had been there or not, but being given permission to go, being blessed on one's way is a gift that can always be given to the dying, and I felt honored that I was given the gift of being present during this death, both for the dying and the living.
The scene that followed was classic: tears, hugs, weeping sons arriving afar receiving urgent cell-phone calls, neighbors coming to pay their respects. I, the professional, wandered from room to room, offering helpful words, concrete advice, fielding questions, and preparing the body. Not being a visiting nurse, per se, I am not licensed to pronounce a patient dead and sign the death certificate in Massachusetts, although I have been priviledged to perform this service in the past when I did have that legal right and responsibility. I called the hospice nurse and reported the time of death, requesting a nurse be dispatched as soon as convenient.
Exiting the building after warm goodbyes filled with kind words, a certain fullness pervaded my spirit, and a level of emotional exhaustion that cannot be described, along with a feeling of elation and freedom as well. Unfortunately, three more very busy hours of work would then ensue, robbing me of the opportunity to further explore this state of being. I was instead ruthlessly flung back into the maelstrom of the day, removed from the timelessness that seemed to pervade that apartment as we contemplated the death of a very noble man.
But now I can reflect on the experience, bless this soul on its journey, and enjoy the knowledge that my guidance played a small part in this soul's ultimate transition from the physical world to the spiritual realm.
Yes, Death paid a call, and I would say that the call was a sweet one.
Wednesday, September 21, 2005
Comfort Measures
As the week progresses, my patient with stomach cancer declines. The progression of his illness over the past few days has necessitated conferences with the family and health care proxy, meetings and phone calls, and finally a decision yesterday to institute "CMO" status: Comfort Measures Only. This means we have withdrawn IV fluids and IV antibiotics, ceasing all discussion of how to stem the growth and ferocity of the cancer. He is now simply on morphine and oxygen, with a urinary catheter inserted. Death is certain, perhaps within 2-3 days.
The family took it well, although there are several members who were not present for our discussion yesterday afternoon and who will need some education. Hospice nurses are coming to the hospital this afternoon to meet with me and the patient's health care proxy/caregiver, and we will initiate a transfer to home for the late afternoon if all goes well. There he'll be surrounded by family and friends who will be encouraged to maintain a peaceful and quiet atmopshere. Hearing is said to be the final sense to be lost prior to death, so even if the dying person seems to be unconscious, it is a golden opportunity to say anything that has been left unsaid.
Things have moved along at a rapid pace for this lovely gentleman, but the care which he is receiving is motivated by love and a deep respect. I assume he will not survive the week. I too will say my good-byes......
The family took it well, although there are several members who were not present for our discussion yesterday afternoon and who will need some education. Hospice nurses are coming to the hospital this afternoon to meet with me and the patient's health care proxy/caregiver, and we will initiate a transfer to home for the late afternoon if all goes well. There he'll be surrounded by family and friends who will be encouraged to maintain a peaceful and quiet atmopshere. Hearing is said to be the final sense to be lost prior to death, so even if the dying person seems to be unconscious, it is a golden opportunity to say anything that has been left unsaid.
Things have moved along at a rapid pace for this lovely gentleman, but the care which he is receiving is motivated by love and a deep respect. I assume he will not survive the week. I too will say my good-byes......
Sunday, September 18, 2005
Cognitive Dissonance
Yesterday's post brought home to roost some cognitive dissonance which I've been experiencing as of late. If you read this blog regularly, you might guess that this dissonance revolves around work and identity.
In my full-time day job, I now have approximately 8o patients for whom I am responsible. A medical assistant follows about 25 of those patients, but I am still legally responsible for their care and carry them all under my license. The pace at which I live my 9 to 5 existence can be exasperatingly fast. Being a healthcare setting, everything I do must be properly documented, nursing notes being legal documents to which one affixes one's signature. I teach my students that any note which a nurse signs can later be used in a court to question your actions (or lack of action) in any circumstance in which the nurse was involved. Omission of information can sometimes be as damning as adding information. What you did not do can sometimes be the subject of inquiry. While I do not live my life worrying about potental law-suits, I always bear in mind that a prudent nurse will document well and completely, affixing a signature with as much confidence as possible.
With that in mind, I examine what a day can be like: planned home visits or office visits with patients; dozens of calls and voice-mails; spontaneous walk-in visits from unexpected patients; frequent crises which need immediate attention; interactions with other professionals; case conferences; documentation; internet research; symptom management; care plan reviews; and myriad other administrative and clinical tasks which cannot be listed here for lack of time and willingness to do so. Each call and each action necessitates documentation. The pile of unfinished notes grows throughout the day, and with my sieve-like brain under stress, doing notes the next day and remembering what transpired is a challenge. I sometimes feel like I need to explode or the information will begin to leak out of my ears in an unsightly manner.
The stress of my work is palpable. I serve a population which is poor, with low levels of education and sophistication (with a few exceptions), lives of crisis, strained relationships, financial hardship, and chronic illness. The level of dependence and need can be overwhelming and I often long to remove myself from the struggle. However, there is such life in what I do, such satisfaction in the positive aspects, that it keeps me coming back. My agency is also a pilot program providing cutting-edge care to underserved populations which is only equalled in two or three other programs in the country at this time. There is a political nature to our work which is enthralling, and while we're still figuring out how to do what we do (and convince others that it works and is worth replicating around the country), we struggle with the burdens under which we toil. Large caseloads, needy patients, and overseers who demand a great deal from us in order to justify our existence.
Looking objectively at my work, when I think of leaving for another position, I imagine how much easier it could be, how much more sane. But then I look at this team of people with whom I work, the heart and good-will at the center of our work family, coupled with the political and social ramifications of what we are doing, and I cannot find it in my heart to seriously examine other work opportunities. I've been offered a full-time position at a corporate visiting nurse agency which is begging me to work for them, but it is just that: a corporate for-profit national chain of nursing agencies which lacks a true vision other than profit and providing generally competent nursing care. While I am attracted by the small caseloads and change of pace, I'm not drawn to the people, the work environment, or the politics of the organization. I do per diem visits for this agency a few times a month, but involvement beyond that seems unlikely to me.
Healthcare in this country is in crisis. Services to the poor are consistently being cut. Disparities of race and socioeconomics are even more apparent as the aftermath of Hurricane Katrina shares its lessons. I struggle to stay afloat, to maintain my composure, but my dedication to serving these populations does not wane. The cognitive dissonance is born from concern for my own well-being, my own health, and the consequences of stress on my body and mind. For now, I stay put and make the best of it, looking for ways to maintain health, strike a balance, and save myself from long-term consequences of stress. Reading Tracy Kidder's book Mountains Beyond Mountains recently, I'm struck and awed by Dr. Paul Farmer's tireless worldwide struggle to bring healthcare to some of the most underpriviledged people in the world. It's people like him who inform my own career decisions and empower me to stay the course. It has been said that no one would want "I wish I had worked more" engraved on their tombstone. But perhaps "I'm glad to have helped so many" would be a worthy alternative epitaph. The secret lies in how to lengthen others' lives without consequently shortening one's own.
In my full-time day job, I now have approximately 8o patients for whom I am responsible. A medical assistant follows about 25 of those patients, but I am still legally responsible for their care and carry them all under my license. The pace at which I live my 9 to 5 existence can be exasperatingly fast. Being a healthcare setting, everything I do must be properly documented, nursing notes being legal documents to which one affixes one's signature. I teach my students that any note which a nurse signs can later be used in a court to question your actions (or lack of action) in any circumstance in which the nurse was involved. Omission of information can sometimes be as damning as adding information. What you did not do can sometimes be the subject of inquiry. While I do not live my life worrying about potental law-suits, I always bear in mind that a prudent nurse will document well and completely, affixing a signature with as much confidence as possible.
With that in mind, I examine what a day can be like: planned home visits or office visits with patients; dozens of calls and voice-mails; spontaneous walk-in visits from unexpected patients; frequent crises which need immediate attention; interactions with other professionals; case conferences; documentation; internet research; symptom management; care plan reviews; and myriad other administrative and clinical tasks which cannot be listed here for lack of time and willingness to do so. Each call and each action necessitates documentation. The pile of unfinished notes grows throughout the day, and with my sieve-like brain under stress, doing notes the next day and remembering what transpired is a challenge. I sometimes feel like I need to explode or the information will begin to leak out of my ears in an unsightly manner.
The stress of my work is palpable. I serve a population which is poor, with low levels of education and sophistication (with a few exceptions), lives of crisis, strained relationships, financial hardship, and chronic illness. The level of dependence and need can be overwhelming and I often long to remove myself from the struggle. However, there is such life in what I do, such satisfaction in the positive aspects, that it keeps me coming back. My agency is also a pilot program providing cutting-edge care to underserved populations which is only equalled in two or three other programs in the country at this time. There is a political nature to our work which is enthralling, and while we're still figuring out how to do what we do (and convince others that it works and is worth replicating around the country), we struggle with the burdens under which we toil. Large caseloads, needy patients, and overseers who demand a great deal from us in order to justify our existence.
Looking objectively at my work, when I think of leaving for another position, I imagine how much easier it could be, how much more sane. But then I look at this team of people with whom I work, the heart and good-will at the center of our work family, coupled with the political and social ramifications of what we are doing, and I cannot find it in my heart to seriously examine other work opportunities. I've been offered a full-time position at a corporate visiting nurse agency which is begging me to work for them, but it is just that: a corporate for-profit national chain of nursing agencies which lacks a true vision other than profit and providing generally competent nursing care. While I am attracted by the small caseloads and change of pace, I'm not drawn to the people, the work environment, or the politics of the organization. I do per diem visits for this agency a few times a month, but involvement beyond that seems unlikely to me.
Healthcare in this country is in crisis. Services to the poor are consistently being cut. Disparities of race and socioeconomics are even more apparent as the aftermath of Hurricane Katrina shares its lessons. I struggle to stay afloat, to maintain my composure, but my dedication to serving these populations does not wane. The cognitive dissonance is born from concern for my own well-being, my own health, and the consequences of stress on my body and mind. For now, I stay put and make the best of it, looking for ways to maintain health, strike a balance, and save myself from long-term consequences of stress. Reading Tracy Kidder's book Mountains Beyond Mountains recently, I'm struck and awed by Dr. Paul Farmer's tireless worldwide struggle to bring healthcare to some of the most underpriviledged people in the world. It's people like him who inform my own career decisions and empower me to stay the course. It has been said that no one would want "I wish I had worked more" engraved on their tombstone. But perhaps "I'm glad to have helped so many" would be a worthy alternative epitaph. The secret lies in how to lengthen others' lives without consequently shortening one's own.
Saturday, September 17, 2005
More Musings on Nursing
As a thunder storm roars through the area, I set aside my school-prep and reach for the laptop. The rain spatters on the transparent roof of the porch, the smell of ozone in the air....
What a week! I have a number of patients weighing on my mind, as well as my professional life and career in general.
First, the gentleman with gastric cancer grows worse, death somewhat closer every day. This weekend they'll be starting palliative radiation in an attempt to slow the bleeding in his stomach from the mass which has grown there. The cause of his intractable vomiting is now clear: the mass is completely blocking the outlet from his stomach to the small intestine. Anything that enters his stomach has nowhere to go but back up from whence it came. His oncologist broke the news to him that he will never eat or drink again. He stared into space at that moment, a tragic realization sinking in.
We also had the very difficult discussion of resuscitation status and whether or not he wanted to be DNR/DNI (Do Not Resuscitate/Do Not Intubate). I had to explain the reality of what would happen if his heart stopped: the "Code Team" would come running from all over the hospital, they would put an artificial airway down his throat, and they would commence CPR immediately. In his condition, many ribs would be broken in the process, and it would be a traumatic and potentially violent event for everyone present. What we call a "Code Blue" is not pretty, and it is rarely depicted realistically on television. He has chosen to be DNR/DNI. On Monday, I'll go straight to the hospital and ascertain whether or not they decided to place a tube in his small intestine through which he could receive feedings and fluids, bypassing his ravaged stomach. He clearly stated that he wanted us to do everything to keep him alive and comfortable as long as possible. He has been in my thoughts all weekend.
My sweetheart of a patient recently discussed in another entry, is still in the hospital, the mass in her chest still unidentifiable after four biopsies. A more invasive surgical biopsy was attempted but aborted when her oxygen level and blood pressure began to crap out during the induction of anesthesia. We sit together in her hospital room holding hands every day as she becomes thinner and more dejected, never failing to ask me about my wife, son, and dogs, and to send her blessings for their well-being. As her face grows thinner and more gaunt, her eyes become more prominent, orbs of love and faith tinged by the knowledge of her obvious mortality and shortening life. She also will not leave my mind this weekend.
Aside from work, I now have school and teaching added to the mix. I struggle to learn my students' names, try to correct mistakes I made last year as a novice professor, and make good use of the materials created through hours and hours of preparation last autumn. Today I was able to simply edit and slightly change an exam created last year, cutting the time for preparing the exam for printing from several hours to perhaps thirty minutes. Teaching is a pleasurable activity made burdensome by the preparation involved, but as I gain experience and make us of my materials from last year, the ratio of burden to pleasure should widen.
That said, teaching gives me a way to take the nuggets of knowledge which I glean from my direct work with patients, and distill them down into illustrative stories which I can then relate to my students in a way which brings our subjects of study to life. The correlation and relatedness of my clinical work and teaching helps me to see my work in a different light, as well as to use my relationships with patients as a teaching tool.
I find my identity as a nurse very strong right now, and while I yearn for a time in the not-too-distant future when my work is not so central to that identity, I accept for now that there's plenty to learn about myself in that milieu. My greatest hope is that I will intuitively know when I'm ready to make a change and create a simpler, less stressful worklife. Until then, I bounce from the frying pan to the fire and back again, yearning for the days when I can rest on the back burner.
What a week! I have a number of patients weighing on my mind, as well as my professional life and career in general.
First, the gentleman with gastric cancer grows worse, death somewhat closer every day. This weekend they'll be starting palliative radiation in an attempt to slow the bleeding in his stomach from the mass which has grown there. The cause of his intractable vomiting is now clear: the mass is completely blocking the outlet from his stomach to the small intestine. Anything that enters his stomach has nowhere to go but back up from whence it came. His oncologist broke the news to him that he will never eat or drink again. He stared into space at that moment, a tragic realization sinking in.
We also had the very difficult discussion of resuscitation status and whether or not he wanted to be DNR/DNI (Do Not Resuscitate/Do Not Intubate). I had to explain the reality of what would happen if his heart stopped: the "Code Team" would come running from all over the hospital, they would put an artificial airway down his throat, and they would commence CPR immediately. In his condition, many ribs would be broken in the process, and it would be a traumatic and potentially violent event for everyone present. What we call a "Code Blue" is not pretty, and it is rarely depicted realistically on television. He has chosen to be DNR/DNI. On Monday, I'll go straight to the hospital and ascertain whether or not they decided to place a tube in his small intestine through which he could receive feedings and fluids, bypassing his ravaged stomach. He clearly stated that he wanted us to do everything to keep him alive and comfortable as long as possible. He has been in my thoughts all weekend.
My sweetheart of a patient recently discussed in another entry, is still in the hospital, the mass in her chest still unidentifiable after four biopsies. A more invasive surgical biopsy was attempted but aborted when her oxygen level and blood pressure began to crap out during the induction of anesthesia. We sit together in her hospital room holding hands every day as she becomes thinner and more dejected, never failing to ask me about my wife, son, and dogs, and to send her blessings for their well-being. As her face grows thinner and more gaunt, her eyes become more prominent, orbs of love and faith tinged by the knowledge of her obvious mortality and shortening life. She also will not leave my mind this weekend.
Aside from work, I now have school and teaching added to the mix. I struggle to learn my students' names, try to correct mistakes I made last year as a novice professor, and make good use of the materials created through hours and hours of preparation last autumn. Today I was able to simply edit and slightly change an exam created last year, cutting the time for preparing the exam for printing from several hours to perhaps thirty minutes. Teaching is a pleasurable activity made burdensome by the preparation involved, but as I gain experience and make us of my materials from last year, the ratio of burden to pleasure should widen.
That said, teaching gives me a way to take the nuggets of knowledge which I glean from my direct work with patients, and distill them down into illustrative stories which I can then relate to my students in a way which brings our subjects of study to life. The correlation and relatedness of my clinical work and teaching helps me to see my work in a different light, as well as to use my relationships with patients as a teaching tool.
I find my identity as a nurse very strong right now, and while I yearn for a time in the not-too-distant future when my work is not so central to that identity, I accept for now that there's plenty to learn about myself in that milieu. My greatest hope is that I will intuitively know when I'm ready to make a change and create a simpler, less stressful worklife. Until then, I bounce from the frying pan to the fire and back again, yearning for the days when I can rest on the back burner.
Thursday, September 15, 2005
Among the Living
Yes, dear Readers, I am still among the living.....er, blogging, as it were. This last week has been a storm of busy-ness, my time to write completely precluded by...now, what was it called? Oh yes, life. Yes that's it, life got in the way of this other very important aspect of life which is near and dear to my heart. This blogging business is certainly addictive and tonight my "blogging jones" must be satisfied, at least desultorily.
Blessedly, last weekend was not overridden by work and chores. Rather, it was filled to overflowing with the celebration of Mary's birthday which happens to fall on September 11th. We have spent the last four years striving to reclaim her birthday which seemed to be usurped by the 2001 event which cast a long shadow over anyone wanting to use that day for celebratory purposes. Needless to say, we spent the better part of the weekend celebrating in the appropriate manner.
On the homefront, we are having our somewhat finished basmement almost completely finished, with a small kitchen and new floors and windows, in hopes of renting the space to a lucky grad student or young couple who do not mind living in a very dry basement with two windows. That process has taken a great deal of our time and energy. While we are not doing the construction ourselves, anyone who has had construction done in their home at any time understands the disruption that it can cause to one's accustomed living patterns, not to mention the process of seeking out, and interviewing, potential tenants. More on that, perhaps, at a later date.
School is back in session and I just completed evening #2 of lecture in the LPN course which I am teaching for the 2nd year in a row. One of my greatest challenges is learning my 24 students' names, as well as the fact that I teach from 5:30-9:30pm after working an intense 8-hour day. Having taught the class last year, my prep time is thankfully less taxing this time around, but I still spend a fair amount of time at home in preparation. Is it worth it? Maybe I could make better money elsewhere, but the act of teaching is an exciting process which I do sincerely enjoy.
My work soars along at sonic speeds. The gentleman with stomach cancer of whom I recently wrote is failing fast, and I helped to get him directly admitted into the hospital on Tuesday when I visited him at home and he was obviously dehydrated. I was sharing with my students this evening that, when visiting a patient at home as an autonomous nurse, there are many judgement calls which I must make which do give me pause. I have luckily never made a decision that ended in a premature death, but I always know that my license and my conscience are both on the line when a patient's life is at stake. It can be a scary thought which often informs our decisions as healthcare professionals.
Aside from that, my life has been a piece of cake with not much to blog home about. I just had to post something tonight and say hello to whomever has hung in there and checked in to see if I would surface after a week's pause.
Now for some quick prep for tomorrow and off to bed with my honey.
Bon nuit.
Blessedly, last weekend was not overridden by work and chores. Rather, it was filled to overflowing with the celebration of Mary's birthday which happens to fall on September 11th. We have spent the last four years striving to reclaim her birthday which seemed to be usurped by the 2001 event which cast a long shadow over anyone wanting to use that day for celebratory purposes. Needless to say, we spent the better part of the weekend celebrating in the appropriate manner.
On the homefront, we are having our somewhat finished basmement almost completely finished, with a small kitchen and new floors and windows, in hopes of renting the space to a lucky grad student or young couple who do not mind living in a very dry basement with two windows. That process has taken a great deal of our time and energy. While we are not doing the construction ourselves, anyone who has had construction done in their home at any time understands the disruption that it can cause to one's accustomed living patterns, not to mention the process of seeking out, and interviewing, potential tenants. More on that, perhaps, at a later date.
School is back in session and I just completed evening #2 of lecture in the LPN course which I am teaching for the 2nd year in a row. One of my greatest challenges is learning my 24 students' names, as well as the fact that I teach from 5:30-9:30pm after working an intense 8-hour day. Having taught the class last year, my prep time is thankfully less taxing this time around, but I still spend a fair amount of time at home in preparation. Is it worth it? Maybe I could make better money elsewhere, but the act of teaching is an exciting process which I do sincerely enjoy.
My work soars along at sonic speeds. The gentleman with stomach cancer of whom I recently wrote is failing fast, and I helped to get him directly admitted into the hospital on Tuesday when I visited him at home and he was obviously dehydrated. I was sharing with my students this evening that, when visiting a patient at home as an autonomous nurse, there are many judgement calls which I must make which do give me pause. I have luckily never made a decision that ended in a premature death, but I always know that my license and my conscience are both on the line when a patient's life is at stake. It can be a scary thought which often informs our decisions as healthcare professionals.
Aside from that, my life has been a piece of cake with not much to blog home about. I just had to post something tonight and say hello to whomever has hung in there and checked in to see if I would surface after a week's pause.
Now for some quick prep for tomorrow and off to bed with my honey.
Bon nuit.
Tuesday, September 06, 2005
Out of the Frying Pan
Today I was involved in a scene at a patient's home that was straight out of a movie. My patient, a middle-aged man not born in this country, has a history of polysubstance abuse, Hepatitis C, violence, a personality disorder, and a former life of foreign miltary service with a history of committing and witnessing violent acts of warfare. I will not disclose his city of residence, age, or his country of origin.
People involved in this gentleman's care are often afraid of him. He can cut an imposing figure until you look into his eyes and see the wounded child crouching in his heart. This man lives in fear and psychic pain, and his family member with whom he lives also lives in fear and pain. I was called to the home because it was apparent that my client had possibly taken way too many antipsychotics and benzodiazepines over the weekend, prescribed medications that he will frequently supplement with crack cocaine. The fact that he has recently been under threat from a local gang does not inspire confidence in his coping and interpersonal skills.
Based on an urgent request from the primary physician, my unannounced arrival to the home with a third-year medical student in tow did not meet with a warm welcome, although his family member was relieved that we had come. When the situation became somewhat threatening, I was sure to always keep myself between the patient and the medical student in my charge, and constantly de-escalated the conversation and redirected the patient to why I felt he should go to the hospital.
At one point, my patient was on his hands and knees in the kitchen, babbling incoherently in his native tongue mixed with English, crying like a baby. Shortly after, only semi-coherent and walking very unevenly with eyes at half-mast, he exited the home to smoke outside and I knew that there was no stopping him. From previous experience, I understood that physical touch of the most minimal kind could send him over the edge, so I simply followed him outside, leaving the medical student to chat calmly with the family member, who, when asked, reassured me that there were no weapons in the home. (Later, I would glean a great deal of information from the medical student, who truly got an "ear-ful" while I was outside.)
Once outside, speaking with the primary doctor on my cellphone, I asked her to call 911 and request a police cruiser and an ambulance. After fifteen minutes of following my patient up and down the hot street, the ambulance arrived and we coaxed him onto the stretcher as he whimpered and pleaded for mercy. The police arrived ten minutes later when we were getting ready to leave the scene and return to the clinic. Better late than never, I guess. They must have been at Dunkin Donuts.
This was simply a 60-minute scene at the end of a day filled with telephone calls of desperation, illness, another unfolding crisis, two lovely and uneventful home visits, and the odd prescription refill. A day in the life.
So here I sit on the porch, the frogs and cicadas beginning their evening chorus, and I prepare to officially document all that I did at work today before I forget the gory details. It was a rude awakening from a perfect weekend, and I'm pretty sure I missed the frying pan.
People involved in this gentleman's care are often afraid of him. He can cut an imposing figure until you look into his eyes and see the wounded child crouching in his heart. This man lives in fear and psychic pain, and his family member with whom he lives also lives in fear and pain. I was called to the home because it was apparent that my client had possibly taken way too many antipsychotics and benzodiazepines over the weekend, prescribed medications that he will frequently supplement with crack cocaine. The fact that he has recently been under threat from a local gang does not inspire confidence in his coping and interpersonal skills.
Based on an urgent request from the primary physician, my unannounced arrival to the home with a third-year medical student in tow did not meet with a warm welcome, although his family member was relieved that we had come. When the situation became somewhat threatening, I was sure to always keep myself between the patient and the medical student in my charge, and constantly de-escalated the conversation and redirected the patient to why I felt he should go to the hospital.
At one point, my patient was on his hands and knees in the kitchen, babbling incoherently in his native tongue mixed with English, crying like a baby. Shortly after, only semi-coherent and walking very unevenly with eyes at half-mast, he exited the home to smoke outside and I knew that there was no stopping him. From previous experience, I understood that physical touch of the most minimal kind could send him over the edge, so I simply followed him outside, leaving the medical student to chat calmly with the family member, who, when asked, reassured me that there were no weapons in the home. (Later, I would glean a great deal of information from the medical student, who truly got an "ear-ful" while I was outside.)
Once outside, speaking with the primary doctor on my cellphone, I asked her to call 911 and request a police cruiser and an ambulance. After fifteen minutes of following my patient up and down the hot street, the ambulance arrived and we coaxed him onto the stretcher as he whimpered and pleaded for mercy. The police arrived ten minutes later when we were getting ready to leave the scene and return to the clinic. Better late than never, I guess. They must have been at Dunkin Donuts.
This was simply a 60-minute scene at the end of a day filled with telephone calls of desperation, illness, another unfolding crisis, two lovely and uneventful home visits, and the odd prescription refill. A day in the life.
So here I sit on the porch, the frogs and cicadas beginning their evening chorus, and I prepare to officially document all that I did at work today before I forget the gory details. It was a rude awakening from a perfect weekend, and I'm pretty sure I missed the frying pan.
Friday, September 02, 2005
Take a Breath
Friday morning, a day off from work, elongating the Labor Day weekend to four days. Hallelujah.
What a week. The Gulf Coast disaster has engulfed the national consciousness as New Orleans seems to slide into absolute chaos. Mary has approximately fifty family members in the New Orleans area, thirty of whom are first cousins. We did not have word from any of them until last night and we're thankful that they're all safe, although several homes appear to have been lost. Another good friend escaped to Austin and thinks he'll remain there permanently.
Aside from the tragedy in New Orleans, Florida, and Mississippi, the stampede and scores of unnecessary deaths which resulted in Baghdad earlier this week is also fuel for despair and a desire for change in the world. One could see why certain segments of society might see this as the beginning of "the end times". I don't know about the end of the world, but I sure would like to see an end to needless suffering in the world.
Closer to home, the biopsy of my dear patient's chest mass was inconclusive other than to say that there is necrotic tissue in there, underscoring the notion that the spots on her lungs are very likely malignant. The next move is a trans-tracheal or trans-esophageal exploratory biopsy, basically a tube with a camera snaking through the trachea or esophagus into the chest to take a real-time peek at what's happening in there. I stopped by for a visit to my patient's hospital room yesterday, prior to leaving for my four-day weekend. Her depression and loneliness were palpable, and we sat on her bed holding hands. I noticed that she hadn't touched her lunch, and for the second day in a row I encouraged her to drink an unopened can of Boost to keep her energy up and receive at least some nutrition. She agreed to do so only if I shared it, so I poured the lion's share into a cup for her, and drank the remaining 1/4 can of thick vanilla liquid after a quick toast to her health. (I thought to myself, "If doctors I know have taken AIDS medications just to see how the side effects feel, I can stomach a bit of Diet Boost".) It wasn't bad really, though I bet the chocolote is better.
The gentleman with metastatic stomach cancer who I've recently written about is beginning to fail. Although he is still home, he's now taking almost nothing by mouth due to his almost constant nausea and vomiting. This does not bode well for him ever being able to tolerate chemotherapy, so I've begun the difficult conversation about end-of-life issues, such as resuscitation status, health care proxies, funeral arrangements, etcetera. Due to the family's insistence and my encouragement for them to explore every option, we're now researching putting in a "J-tube", a feeding tube which would bypass the stomach by going directly into the small intestine. It is an easy procedure in which a small incision is made in the central abdomen and a small tube is inserted into the jejunum, the first section of the small intestine which attaches to the outlet from the stomach. Specially prepared food is then injected through the tube directly into the intestine where the majority of nutrient absorption occurs. Many people don't realize that it is altogether possible to live without a stomach since very little happens there in terms of digestion, other than the breaking down of foodstuffs into what comes to be known as chyme. Granted, the stomach assists in the absorption of Vitamin B-12 and several other nutrients, but its lack of involvement in the digestive process can be replaced by other therapeutic means.
With both of these patients in tenuous situations, and one of them at home in need of daily checking in and symptom management, it was very difficult for me to let go and tell them I would be back in 5 days. There's a certain "ownership" of a patient's care that one can begin to feel, and one can often experience resistance to entrusting these tasks to others, no matter how trusted and skilled they are. There is also admittedly an ego-level attachment to not "missing out" on some turning point, something perhaps akin to what a parent might feel when their young child experiences a developmental milestone while at day-care. ("Oh, Mrs. Smith, little Sallie took her very first steps today! I wish you could have been there!"---I imagine many daycare providers are sensitive to this post-modern parenting conundrum and perhaps refrain from telling a parent everything a child does, for fear of the parent feeling utterly destroyed that they missed a child's first step....) But I digress.
Anyway, as you have surmised, attachments can hinder a healthcare provider's ability to "let go and let others". For now, though, I sign off from both work and blogging, preparing instead for a 48-hour trip to lovely Cape Ann, Massachussetts, where we will visit friends and frolic with my brother and his family who are vacationing there. Having lived in Gloucester, MA for several years as newlyweds, there's a nostalgic feeling to our visits to the other side of the state, and the weather looks promising. Our son and his girlfriend will also be there for the weekend, so we look forward to some needed family time. Even as we rest and recuperate, we'll of course bear in mind the suffering of others, and remember that there but for the grace of God(dess) go we.
Signing off til Sunday or Monday, giving thanks for the Labor Movement, the kind folks who brought us the weekend.....
What a week. The Gulf Coast disaster has engulfed the national consciousness as New Orleans seems to slide into absolute chaos. Mary has approximately fifty family members in the New Orleans area, thirty of whom are first cousins. We did not have word from any of them until last night and we're thankful that they're all safe, although several homes appear to have been lost. Another good friend escaped to Austin and thinks he'll remain there permanently.
Aside from the tragedy in New Orleans, Florida, and Mississippi, the stampede and scores of unnecessary deaths which resulted in Baghdad earlier this week is also fuel for despair and a desire for change in the world. One could see why certain segments of society might see this as the beginning of "the end times". I don't know about the end of the world, but I sure would like to see an end to needless suffering in the world.
Closer to home, the biopsy of my dear patient's chest mass was inconclusive other than to say that there is necrotic tissue in there, underscoring the notion that the spots on her lungs are very likely malignant. The next move is a trans-tracheal or trans-esophageal exploratory biopsy, basically a tube with a camera snaking through the trachea or esophagus into the chest to take a real-time peek at what's happening in there. I stopped by for a visit to my patient's hospital room yesterday, prior to leaving for my four-day weekend. Her depression and loneliness were palpable, and we sat on her bed holding hands. I noticed that she hadn't touched her lunch, and for the second day in a row I encouraged her to drink an unopened can of Boost to keep her energy up and receive at least some nutrition. She agreed to do so only if I shared it, so I poured the lion's share into a cup for her, and drank the remaining 1/4 can of thick vanilla liquid after a quick toast to her health. (I thought to myself, "If doctors I know have taken AIDS medications just to see how the side effects feel, I can stomach a bit of Diet Boost".) It wasn't bad really, though I bet the chocolote is better.
The gentleman with metastatic stomach cancer who I've recently written about is beginning to fail. Although he is still home, he's now taking almost nothing by mouth due to his almost constant nausea and vomiting. This does not bode well for him ever being able to tolerate chemotherapy, so I've begun the difficult conversation about end-of-life issues, such as resuscitation status, health care proxies, funeral arrangements, etcetera. Due to the family's insistence and my encouragement for them to explore every option, we're now researching putting in a "J-tube", a feeding tube which would bypass the stomach by going directly into the small intestine. It is an easy procedure in which a small incision is made in the central abdomen and a small tube is inserted into the jejunum, the first section of the small intestine which attaches to the outlet from the stomach. Specially prepared food is then injected through the tube directly into the intestine where the majority of nutrient absorption occurs. Many people don't realize that it is altogether possible to live without a stomach since very little happens there in terms of digestion, other than the breaking down of foodstuffs into what comes to be known as chyme. Granted, the stomach assists in the absorption of Vitamin B-12 and several other nutrients, but its lack of involvement in the digestive process can be replaced by other therapeutic means.
With both of these patients in tenuous situations, and one of them at home in need of daily checking in and symptom management, it was very difficult for me to let go and tell them I would be back in 5 days. There's a certain "ownership" of a patient's care that one can begin to feel, and one can often experience resistance to entrusting these tasks to others, no matter how trusted and skilled they are. There is also admittedly an ego-level attachment to not "missing out" on some turning point, something perhaps akin to what a parent might feel when their young child experiences a developmental milestone while at day-care. ("Oh, Mrs. Smith, little Sallie took her very first steps today! I wish you could have been there!"---I imagine many daycare providers are sensitive to this post-modern parenting conundrum and perhaps refrain from telling a parent everything a child does, for fear of the parent feeling utterly destroyed that they missed a child's first step....) But I digress.
Anyway, as you have surmised, attachments can hinder a healthcare provider's ability to "let go and let others". For now, though, I sign off from both work and blogging, preparing instead for a 48-hour trip to lovely Cape Ann, Massachussetts, where we will visit friends and frolic with my brother and his family who are vacationing there. Having lived in Gloucester, MA for several years as newlyweds, there's a nostalgic feeling to our visits to the other side of the state, and the weather looks promising. Our son and his girlfriend will also be there for the weekend, so we look forward to some needed family time. Even as we rest and recuperate, we'll of course bear in mind the suffering of others, and remember that there but for the grace of God(dess) go we.
Signing off til Sunday or Monday, giving thanks for the Labor Movement, the kind folks who brought us the weekend.....
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