Technology and Its (Dis)Contents

The issues around technology in our office are becoming more clear as the weeks since my last related post go by, although we all understand (don't we?) that technology that's supposed to make our work "easier" is not always so, or at least not in the beginning, anyway. Those post-modern learning curves are steep these days.

Anyway, our bosses have chosen to purchase Treo phones for us, which are basically "smart phones" which provide Palm Pilot capability, cell-phone service, alphanumeric paging, as well as the ability to wirelessly check email, write Word documents, alter spreadsheets, carry huge files of medical and pharmacological data, and a gamut of other functions. Contrary to popular belief, these small machines---with thousands of times more memory than the Lunar Module---will be insured, and we providers will not be financially responsible for their replacement if lost. We'll just be summarily fired, no questions asked. (Now that's an occupational hazard!)

The upside is that these devices will eventually allow us to have reams of information available to us in the field as we visit patients at home or accompany them to appointments. We will eventually be able to record vital signs and other data in the phone rather than relying on little slips of paper in our pockets. And when we eventually have laptops upon which we access EMRs (Electronic Medical Records---it's the future, folks!), we'll be able to "sync" the phone/PDA to the computer, share and back up data, and then some. The phone will also serve as a wireless connection to the Internet, allowing us to access patient medical records from remote locations. (So, I'm in a neurologist's office in another city with a patient for a consult, and I need her most recent lab results, and this doc is not privy to our hospital's database. I quickly access my info and---voila!---said information is in my hand.

The downside? A relatively expensive ($500) toy for which I am responsible will no doubt cause this obsessive-compulsive no small amount of checking and double-checking to see if I haven't lost it yet today. Hardware and/or software problems will cause loss of not just one function but many, including appointments and phone numbers, cellphone, and pager. Could be incredibly inconvenient when malfunctioning. Another downside? I get addicted to such a device and feel I just have to purchase one for myself when I eventually leave this workplace. Another? OK, why not? The entire technological infrastructure of the United States collapses overnight when Saudi Arabia and China decide to pull all investment in the American economy out from under our currency. The stock market crashes, the World Wide Web is reduced to a sputtering DSL line in Omaha, and we're reduced to scrawling lab results and vital signs on portable chalkboards. And my Palm crashes and I miss my haircut appointment. Devastating. I could think of others, but that's enough for now. I wouldn't want to look like a technological curmudgeon now, would I?

On the bright side, the on/off button on my (personally purchased) Palm Pilot is on the fritz and the "5" button on my (workplace-purchased) cellphone is pokey. Plus, my pager only receives a percentage of the messages sent to me from the support staff. Now why can't that Smart Phone take a set of vitals?

Adding to the digital fun, I'm now able to fax prescriptions to any pharmacy I choose directly from our hospital system's new on-line prescription function without even having to find the paper chart and record the prescription that I called in on a medication flowsheet. An electronic message is generated which ends up in the inbox of the prescribing doc whose name I used in vain to order said prescription. S/he then digitally "signs" the script after the fact (or comes to find me and wrings my neck for refilling that patient's Ultram again!) An added benefit: when one of my patients ends up hospitalized, all of their meds---refill history and all---are universally available to anyone in the system. Pretty nifty, at least until the system crashes with the economy and we have no paper record. (We may be forced to re-think the whole stone- and-chisel medical record practiced before the time of Hippocrates. I heard that the curved chisel revolutionized the recording of blood pressures. Imagine chiselling 146/80 in Roman numerals!)

So folks, until the digital economy collapses under its own weight, I will play with my new Smart Phone and report to you the vicissitudes and joys of its presence in my professional and personal life. (Do you think I don't use that work-subsidized cell-phone for all it's worth?) When the technological shit hits the fan, I may mourn its passing while simultaneously thinking, "Good riddance to all of that! Now where's my old hand-cranked phonograph? Oh no! I replaced all my old vinyl on CD!

From the technology desk here at Nursing Central, yours truly bids you bon nuit.

Grand Rounds per Medviews

Grand Rounds is up and running this week at Medviews. Cruise on over for a view.

Thinking Globally

Blogging about health and healthcare, it's easy to focus on the microcosm, the minutiae of the lives and struggles right here on the urban streets of America. But amidst our struggles for the lives of our patients, we also must occasionally expand our focus outward towards the global issues affecting health and healthcare. The worldwide movements to eradicate AIDS, malaria and tuberculosis are high-profile issues which garner the celebrity power of Bill Gates and Bono to trumpet their cause. This is all well and good, and that trio of diseases is well deserving of our attention.

Tonight, on the way home from work, I was lucky enough to be listening to Fresh Air with Terri Gross on NPR. On this particular segment, Dr. Paul Epstein of the Center for Health and the Global Environment at Harvard Medical School was discussing his research findings indicating that global warming and climate change are having a more profound effect on public health than previously suspected. (You can listen to the interview here.)

Dr. Epstein postulates that the explosion of asthma and allergies around the world are seen to be directly related to global warming, as is the rising number of mosquitoes and insect-borne illnesses. around the world. We already know that the power and frequency of storms such as Katrina are said to be directly caused by climate change, but do any of us realize that desertification in Africa causes dust storms which travel across the Atlantic and cause exponential increases in asthma in previously unaffected children in Trinidad, and that mold spores in said dust from Africa infects Caribbean coral reefs and causes their disintegation? Do we also understand that airborne diesel fuel particles can increase the power of pollen to enter the lungs of poor urban populations who live along truck routes in our cities?

Some of this information is, sadly, not terribly surprising and seems to make sense in the sorry scheme of things. Those of us who work in urban centers already know that poor urban populations suffer more greatly from the effects of pollution, ground-level ozone (smog) and other poisons which disproportionately contaminate the air where the poor and working class live. What we may not also realize is that even affluent areas and places long considered to have healthy air are now no longer the bastions of oxygen and clarity that we once enjoyed. The air in the Caribbean, once considered a place where the wealthy could travel for their health, is now seeing pollution and ozone rates like never before.

With the release of Al Gore's new documentary, An Inconvenient Truth, perhaps a quantum leap forward will be engendered worldwide, and massive lifestyle change and sociopolitical shifts of consciousness will begin to take place on a global scale, and the powers that be which hold the purse-strings of the world economy will step up to the plate and abandon the pursuit of profit which has, to a large extent, fueled (no pun intended) the imminent demise of our planet as we know it. Then again, perhaps not, and the voices in the wilderness will continue to cry out as the asthma rates sky-rocket and desertification drastically decreases our ability to feed the hungry with our ever-diminishing amount of viable topsoil.

So, is global warming a public health issue? What has the power to convince us? Is it increased rates of asthma and environmental allergies? Is it decreased food production due to net loss of topsoil, with millions suffering needlessly from malnutrition? Is it water shortages around the world and the dehydration that it engenders? Is it exponential increases in melanoma? Or is it pandemics of insect-borne diseases which will drive us into action?

I ask myself these questions as well, dear Reader. I am as guilty as the next, as unconscious as the others, and my car pollutes no less than my neighbors'. We are all complicity, we are all suspect, and if the health effects of global warming do not touch us now, there will eventually be no escape. So, from the barrios to the suburbs, we all must start thinking, acting, and actively changing, not just for the earth, but for our very health and that of our children. After all, the personal is political, the political is personal, and health---of the individual or the collective---can be very personal indeed.

A Viral High Five

My blogger friend Ian Miller over at ImpactED Nurse in Australia runs an excellent and well-designed site which is both instructional, moving, and amusing. This week, he chose to post a "Viral High Five" which highlights his five current favorite blogs. I am humbled and grateful for his having chosen Digital Doorway for this honor. He wrote:

• Digital Doorway: Keith is a nurse working with the Latino community of a New England city in the US. His writings are moving, astute and crafted. They demand a switch from surfing, to floating face down in wonder of the deep.

I was speechless after reading such a description of my writing, touched beyond words, and grateful for someone so erudite and talented to nod in my direction. At Ian's behest, I now present to you my current "Viral High Five" which will now infect five other bloggers to reciprocate and do the same. (Note: there is no assumption or desire on my part for Digital Doorway to be included on those subsequent lists. Having been on one, let's give others the limelight.) That said, I will also say that there is no way I can fit my favorite blogs and bloggers into a measly little list of five, so see this list as a taste rather than a meal---a morsel, if you will, with promises of further sumptuous courses to follow in good time. Enjoy, and may the infected go on to infect others equally as wonderful.

Genre Cookshop: a (mostly photographic) blog by my cousin Nancy Bea Miller, a talented fine artist and photographer, as well as a devoted mother of three boys, one of whom is autistic. Nancy Bea shares stories from her daily life, often taking seemingly mundane moments and transforming them into magic, either through her camera lens, her perceptive writing, or both. A touch of humor, irony, and plain old beauty all mix together to create a lovely site to visit again and again.

ImpactED Nurse: what can I say other than that Ian runs a lovely site riddled with gallows humor and real life stories from Down Under. "Departments" of the site include: Piss and Vinegar, Nurses' Desk, The Funny Bone, among others. Ian offers a treasure trove of commentary, medical stories, and humanity. Please pay him a visit.

The Happystance Project: Tony Plant, an award-winning facilitator providing Laughter Yoga and Stress Relief workshops to caregivers in the UK, runs a site which takes progressive views on caring, caregivers ("carers" in British English), mental health, and public health to new levels. Tony is an advocate for children, the mentally ill, and anyone who needs a helping hand. He also supports and advocates for "carers"---those individuals who provide aid and assistance, either in a professional or personal capacity. His service to the world is unique and laudable.

Graceful Presence: Bhuddist philosophy and inspiration permeate this site which is like a breath of fresh air on a mountain morning. Akilesh and Meredith take turns regaling us with quotes, anecdotes, poems, and meditative missives which offer not only soothing notions but deep mysteries and awe. There is a large Bhuddist presence on the web which I am only now discovering. Their thoughtful links will lead you further.....

Swamp Things: "Swamp4me" is a woman in North Carolina whose work seems to take her into the Carolinian swamps near her home on a daily basis. Although my phobia of snakes occasionally will cause me nausea when I come upon a serpentine photo which Swampy has happily posted after a day's fine work, I heartily recommend a cruise over to her corner of the Southeast via the World Wide Web when you need a dose of Nature's wonder. Her lovely photos of muskrats, birds, (ugh!) snakes, and other creatures of the swamps and woods are a sight to behold. Her regular commenters are also worth a read.

So, dear Readers, these are five sites worth visiting of an untold number for whom I do not have room at this time. Please see my links for other suggestions, and enjoy the creativity and talent of those who choose to wear their digital hearts on their sleeves.

No Exit

Her calls are consistent in their regularity and in their production of stress hormones in my body. They are consistent in other ways as well. Dramatic. Tearful. At times explosive with anger and frustration (on her part) and quiet frustration (on my part). She almost always calls on Friday afternoons as we are beginning to wind down the week. Inevitable and fruitless for us both.

She suffers from doubtlessly debilitating illness and pain. She's been abandoned by friends and family. She is utterly alone. With a history of addiction to pain medications, Borderline Personality Disorder, depression, social anxiety, and a host of other physical complaints, the mix is volatile. She has no car, hates to take public transit, but lives within walking distance of the Emergency Room where she's a very frequent flyer. Her isolation is devastatingly complete, yet she abhors psychotherapy and psychiatry and chronically skips medical appointments. It's my job to keep her from falling through the proverbial cracks. Yet fall she does. Those aren't cracks---they're caverns.

The calls are mostly identical:

"I'm in so much pain."

"I know. What would you like me to do for you?"

"I don't know." (Sobbing.)

"It's 4:30 on Friday afternoon. I can't get you seen here. Do you feel like hurting yourself?"

"No. I'm in so much pain." (More heart-wrenching sobs.)

"Do you want to call Emergency Psychiatric Services?"

"No! I need you to admit me to the hospital." (A hint of anger now.)

"For what?"

"For my pain. Admit me for my pain."

"I can't do that. They wouldn't admit you for that. Do you want to go to the ER?"

"No."

"What do you want me to do?"

"Nothing. Nothing. You don't understand my pain. Thanks alot." (Click.)

She'll often call back after hanging up on me, contrite and sweet, but still crying. The second call is mostly the same and we finally agree that she can go to the ER where she'll wait a few hours, get an injection of morphine and a Rx for 30 Percocet. The next night, around 2am, she'll call the on-call Nurse Practitioner who will have basically the same conversation with her that I did on Friday. The following week will be mostly the same.

This person is a failure of our system. I have failed her. We don't keep her out of the ER. Those visits cost thousands, not to mention her numerous calls to 911 and the dispatching of needless ambulances. Her pain and other symptoms are often precipitated by isolation, angry telephone calls from her hateful mother, and occasional visits from her estranged husband who asks her for money to buy cigarettes. We spin endless variations of the same conversations and go nowhere. Progress is nonexistent. Her doctor, of whom I am exceedingly fond, has no answers for us. It's a revolving door of frustrating calls, anger for her and frustration for me. My impotence in this arena is obvious and painful.

As I sit here in bed late on a Saturday night, my heart goes out to her in her suffering. There is nothing I can do to assuage her pain. Her past is a shadow to me which I have not explored and could never penetrate. I am not a psychotherapist and have not touched on those realms with her because I know I am too unskilled to handle what might be exposed to the light of day. Her suffering is her own and I acknowledge my helplessness in its powerful grasp upon her troubled psyche.

There are those who we can help, who we can lead to healing, to wholeness. There are others---and they are many---whose healing is beyond our ken, and whose shadows of past wrongs and abuses are beyond our capacity to understand or rectify.

Does compassion fatigue set in during interactions with this patient? Do I feel powerless and impotent in her care? Can I see no end to this merry-go-round of suffering, reaching out, and the failure to change anything which might be alterable in this woman's life? I chose the title for this piece by borrowing a title of a play by Jean-Paul Sartre, that cheery existentialist in early 20th century France who created such masterpieces of human drama and suffering alongside his comrade and lover Simone de Beauvoir. No Exit is a fitting title for this clinical conundrum in which I find myself, and the ambiguity of that title underscores the pain which the human beings on both side of this real-life drama must bear.

Emolument

emolument \ih-MOL-yuh-muhnt\, noun: The wages or perquisites arising from office, employment, or labor; gain; compensation.

Ah, the wonders of dictionary.com, which gives me food for thought and fodder for writing. Sometimes a simple definition can be the jumper-cables for a fatigued writing battery. Sometimes not.

Recently, emolument was the word of the day, and it informs the feeling that another work-week is over and a paycheck is in the bank, thankfully enough. Like many people in these post-modern times, however, payday now comes every two weeks rather than every Friday so that 50% of all weeks end without that gratifying sense of renumeration which concretely rewards one's labors of the previous five days. That paycheck, whether weekly, bi-weekly, or even monthly, is a physical manifestation of the consistent exercise of one's powers to move and produce in the world. Taking into consideration the fact that there are many people who lack the opportunity (or physical or mental health) to achieve such an accomplishment, the salaried among us must periodically count our blessings that we are granted the luxury and priviledge of earning a living. More than anyone else, I remind myself of this fact as I recover from a busy week and reflect on my Friday evening fatigue.

The gratification of being paid relatively well for work which feels honest and worthwhile is indeed a priviledge whose potential transcience is important to remain aware of. That paycheck deposited in my bank account is a manifestation of the energy which I expend in the world through service to others. While it is not the soul reason for being the professional that I am, it's a certainty that supporting my family has been a driving force behind my professional aspirations and accomplishments. I do not take for granted the opportunity which my relative health and ability have afforded me, and I am grateful for my work, my patients, and the dollars and cents which sustain my own financial solvency. As the saying goes, money isn't everything, but it sure helps.

Nurses and Bloggers and Carnivals, Oh My!

As an avid supporter of nurses and nurse bloggers, I'd like to draw your attention to a new nursing blog carnival known as Change of Shift, which has been lovingly created by Kim at Emergiblog. Kim works as an ER nurse in the San Fransisco Bay Area and uses humor and real life stories to entertain and educate. Change of Shift is not meant to compete with Grand Rounds, that most prestigious of medical blogging carnivals to which docs, residents, patients, nurses, EMTs, and other individuals contribute on a weekly basis, including yours truly. Rather, it is a blog carnival meant to showcase nurses, nursing, and others' experiences of such. Kim is inviting anyone with anyone to say about nurses or nursing to contribute, whether it be humor, stories, accolades, or constructive criticism. I fully intend to participate (and host occasionally) and thank Kim heartily for her efforts.

Wake

He lay there in the coffin, surrounded by flowers and loved ones, his features supple and natural. I've heard that funeral directors call this a "memory picture"---the last image of a loved one that many people see before a familiar body is cremated or interred. Tonight I understood more clearly the meaning of that euphemism, but also the importance in many cultures of the opportunity to see the body of a loved one without the tubes, tracheostomies and other indignities frequently visited upon a human body ravaged by disease. Everyone remarked how wonderful he looked, and this was the first time I could truly say that the deceased really did look great, and I will actually carry that image of him with me forthwith.

This burgeoning multigenerational and racially and ethnically diverse family was inspiring, complex, and a genogram-maker's dream. As I worked the crowd and met person after person, a map of the family took form in my brain, and I began to more fully appreciate the depth and breadth of the support and intimacy engendered by this clan. Many close friends who seemed like siblings filled the rooms of the funeral home, and I tried to chat with as many as I could, increasing my knowledge of the family and its interconnections. It's interesting to gain such insight as my work with this family has now actually come to an end, but this knowledge is a piece of the puzzle which helps to more fully inform my practice as a nurse and cement this experience in my mind and heart.

As I was introduced around---or introduced myself in some instances---people would say, "Oh, you're the Keith that we've been hearing about for the last two years!" Luckily, the reputation which preceded me was a positive one, and the feedback which I tried to take in with grace and humility was a very nice way to end my workday. So many times, one can be somewhat uncertain as to how one is perceived, and a clear reflection of one's impact on another human being is truly a gift.

Tomorrow, the funeral will see our final view of his body, handsomely clad in a dark green suit with lovely black mandarin-collar shirt and tasteful gold jewelry. The notes, children's drawings, and other mementos---along with his black fedora with jauntily-placed red feather---will all be sealed within the fancy coffin and lowered into the verdant earth.

It happens all over the world, this process of mourning the dead and placing their bodies in their culturally appropriate container, be that container wood, metal, fire, or water. In Tibet, bodies are sometimes left on mountaintops for vultures to devour, sending the body back to the Source in a visceral (and to some shocking) fashion. But the body is only a vehicle, a vessel from which we are eventually released, and its corporeal existence will deteriorate as it should according to the dictates and wishes of its loved ones who care for it in its final days. As for the spirit and the soul, some of us see its eternity and rejoice in its freedom from this mortal coil.

As the funeral card memorializing my patient reads:

"I shall lead you
through the loneliness,
the solitude,
you will not understand;

but it is My shortcut
to your soul."

Grand Rounds With Dr. Serani

Please visit the blog of Dr. Deborah Serani for the newest version of Grand Rounds, the wonderful weekly medical/nursing/allied health blog carnival.

So Glad We Said Goodbye

The call came at 3am on Saturday, less than 12 hours since my visit to the home (see previous post). A tearful sister-in-law was on the other line, apologizing for waking me. I thanked her heartfully for the call, asking if everyone was OK and if Hospice had been called. They were apparently called just before me and were on their way to the home. I offered condolences and some advice---drink water, stay close to his wife---and hung up the phone, informing my wife that my patient had died. Lighting a candle in the dark dining room, I offered this soul my blessings and encouragement to be on its way back to the Source. I smiled and went back to bed.

In the late morning, driving in the car with my wife and son towards my niece's graduation party in another state, I called my patient's wife to check in. She was composed, voice slightly shaky. I urged her to drink water, eat small frequent meals, and stay close to family, especially during the first day or two. Her response---"Oh, we never have any problem eating in this family"---was followed by genuine laughter from her and her sister in the background. She thoughtfully gave me the details for the wake and funeral, both of which I'll be sure to attend. I told her I loved her, a blessing which she promptly returned.

Another soul leaves the earth. Another family grieves while simultaneously experiencing the sweet relief that a long period of suffering and transition is now over.

May all beings be free from suffering.

Today We Said Goodbye

On my way home from work today, I stopped by the home of a patient who has been slowly withering away from invasive and incurable cancer for many months now. With care by the local VNA/Hospice organization in place, he receives excellent care which allows him to stay at home rather than to die in a nursing home. As I have mentioned in previous posts, this gentleman's wife works six days per week, and her tenacity and courage in the face of her husband's slow death has been nothing less than heroic. Her friends and family have all pulled together, taking shifts at the bedside, learning to suction his tracheostomy, administer medications through a gastric tube, and do all of the things required for the home-based care of a dying human being.

Usually, when I make my unannounced visits, one of the wonderful personal care attendants who the family has hired with funds from our organization is at the home, tending to my patient, or quietly watching TV in the living room, always attentive for the slightest hint that there is a need for suctioning or other assistance in the bedroom down the hall. Long gone are the days when he would ring a bell for help and then mouth the words he wished to communicate, always refusing to write down his requests, relying instead on his caregivers to read his lips, or failing that, his mind.

Today, I was very surprised to find his wife at home at 4pm, and we had a heartfelt hug and a long tete-a-tete on the living room couch. We discussed the funeral arrangements, the wake, the obituary, the high cost of funerals, and her sense of peace that all of these details are arranged and ready to be put into action at a moment's notice. I praised her for her courage and strength, and reaffirmed for the umpteenth time that she has given her husband a priceless gift: the chance to die at home, surrounded by the sounds, smells, and feelings of a house where he feels comfortable, safe, and at peace. I encouraged her to talk to him up until the final moments, since hearing is said to be the last sense to fail, and that her encouraging words and expressions of love will do wonders for him as these final hours go by.

Moving into the room where her husband has lay for months, I followed this steady and surprisingly peaceful woman into the room. I've been visiting weekly for months, the hospice nurse doing all the work, my role being more to sit back and observe, getting involved in decisions that need my input, as well as keeping the primary doctor apprised of the situation. He lay there on his back, as always, the trach bubbling with secretions, his chest rattling, all of his accessory muscles of respiration working away. As his body tries harder to capture as much air as possible, it has recruited the shoulder, neck, and abdominal muscles to expand the lungs as far as they can go, and this type of breathing pattern is very common at this stage of the dying process. Eventually, long periods of breathlessness---apnea---will begin, marking yet another transition as he heads towards respiratory arrest. The morphine has been administered every three hours up until now, and I quickly call the hospice nurse to inquire if we can increase the frequency to every hour in order to lessen any discomfort and air hunger which our mutual patient might be experiencing. We all know that narcotic analgesics depress the respiratory center in the brain and can ostensibly hasten death, but when weighed against the potential for unnecessary suffering as the patient begins to possibly feel like he's drowning inside his own lungs, it's a worthwhile endeavor. Her affirmative answer gives us the green light and I instruct the attendant and wife to start giving morphine hourly.

With each of my visits over the last month or so, I've always spent a few minutes telling this lovely gentleman that his wife will be OK, that he is loved and safe, and that he is free to go at the time of his choosing. I have consistently given him a kiss on the forehead and told him I loved him before taking my leave, and I do not take that ritual lightly. My love for him is genuine, as is my admiration for him and his family, especially his wife and sister-in-law. They are truly special in my eyes.

Being a creature of habit, I again took time to talk with him while his wife looked on. I kissed him on the forehead, telling him with certainty that this would be the last time that I would see him in this body, this vehicle of learning and loving. I told his wife that I could not see him lasting through the weekend, and that I would hazard a guess that he'd be gone within twenty-four hours. As always, she promised to call me when he dies---no matter the hour of day or night---so that I can light a candle for his spirit as soon after his passing as possible.

Not being a hospice nurse or visiting nurse, I cannot currently have the honor of pronouncing a patient dead, something which I did a number of times as a visiting nurse. Doing a pronouncement is a solemn yet beautiful mission: one arrives at the home after that long anticipated telephone call and does what one must do. I remember receiving that call one evening about six years ago. I had requested that I be the nurse to pronounce my patient, and the call came on my cell-phone when I was at the creek nearby my house with my dogs, having a late afternoon swim. I told the daughter who placed the call to simply keep everyone calm, that there was no rush to call the funeral director, and that they could have several hours to simply be in the presence of their loved one before we did anything at all. I reiterated that the death was not an emergency, and that I would be there within the hour. I ran home with the dogs, showered, and drove the thirty minutes to their home, arriving as the driveway was filling with the cars of friends and relatives who had received similar calls with the news. This scene is, I think, quite typical:

The family and friends are gathered. The deceased person lays quietly in bed. There is often low lighting and candles, hushed voices in the home. Sometimes children are playing and laughing, life naturally continuing even in the presence of its denouement. A thoughtful family member or friend washes dishes or prepares food, people chat, cry, laugh, tell stories. It's an unoffical wake for those in the closest circle. The hospice nurse or visiting nurse arrives. People gather around, the nurse going into the room to see the patient, check for vitals, and determine official lifelessness. The nurse checks the time, fills out the death certificate (at least in my state, anyway) and decides with the family how long to wait to call the funeral home and allow the body to be taken. That last time I did a pronouncement which I remembered in the preceding paragraph, we had some food, sat at the table, chatted about the patient/loved one, and called the funeral home about an hour after I'd arrived. The funeral directors were quite nice and efficient, and when the body of my patient was safely stowed in the hearse, I took my leave and went home.

Back in the present, I will not have the opportunity to render that service this time. That's for someone else to do. My work for this family as of late has been one of background support, and I'm fine with that role. Knowing he's in good hands, well medicated, relatively comfortable and held in the hearts of his friends and family, my stewardship of this scenario is basically at a close. I release this soul, send him lovingly on his way, and bless his family as they begin the process of walking the earth without him physically at their side.

May all beings be free from suffering. May all beings find peace in life, and in death.

Grand Rounds, Haversian Style

Please take some time to visit Grand Rounds, this week's carnival being held over at The Haversian Canal. Enjoy!

The No-Show Show

The urban community health center where I work has a 30-40% no-show rate for scheduled appointments. There are many theories about why this may be, including that if impoverished people feel undervalued in the healthcare setting, they will also learn not to value their health, healthcare or medical providers. This same theory has also been used to describe the reason for the amount of trash littering poor urban neighborhoods: if people do not feel valued and live in areas which are neglected by the powers that be, polluted with industrial waste, and suffering from infrastructural neglect, what would cause pride of place to be engendered? These are all good theories which, for me, hold a great deal of water.

That said, when a community health center's funding from its parent hospital organization is based upon productivity, and a 30% overall no-show rate plagues that facility, the patients will eventually suffer due to decreases in staffing, fewer available appointments, and a decreased standard of care delivered by overworked staff. The picture becomes more gloomy as the cycle expands.

This chronic lack of motivation or value effects many providers on a variety of levels. In terms of mental health, we refer our vulnerable populations to community mental health centers for management of mental illness and psychotropic medications. Due to the economic constraints placed upon the mental health agencies, their providers are generally paid on a fee-for-service basis. Thus, when our patients are referred and subsequently miss two or three appointments, they are automatically discharged from the practice and placed back on a waiting list which can be as long as six to eight months. Without a psychiatric provider, the patients decompensate, and return in crisis to the clinic, where the overworked staff and providers struggle to provide mental health care and psychotropic medication management which they are inadequately prepared and staffed to deliver. Suicidality and psychiatric crisis visits to the ER abound, but the local Psych Crisis unit is under pressure from the state, so the client is generally screened out of an inpatient stay and sent back out into the community, back to the six-month waiting list for mental health care and a primary doctor who would rather discuss their diabetes or HIV rather than their schizophrenia or bipolar disorder. You can see where this could lead.

For myself, today was a typical example. I had a tightly booked day, no home visits planned, but a number of clinic visits and a great deal of paperwork to do, let alone telephone calls, faxes, and a few urgent walk-ins who I attended promptly. I even squeezed in a 90-minute visit to the hospital to help organize a dying patient's discharge to home and a 75-minute lunchtime conference at a local restaurant. Amidst this controlled chaos, two of my patients no-show'd as I waited for them by filling my time with other tasks. While a no-show frees up time unexpectedly, it often wreaks havoc with a carefully planned schedule and precludes my ability to see a patient who would have gladly filled that spot. I did indeed turn down a few calls for visits today which I may have squeezed in without the patients who simply ignored (or forgot) their appointments with me.

But the piece de resistance today came with a 1pm telephone call from the surgical office. To explain, a patient called me last Thursday after an ER visit during which she had received a diagnosis of cholelithiasis and cholecystitis. After she pleaded for expedited attention, I pulled all of the strings at my disposal, landing her an appointment with one of the best surgeons in the area for the following day, Friday. She went to this appointment, and much to her pleasure (and my surprise) was scheduled for surgery today (Monday) at 11am with the same surgeon. I was extremely grateful to my colleagues for making this process so seamless, and I gave my patient explicit instructions for weekend symptom managment.

The 1pm call came from the surgical nurse, informing me that the patient did not show for surgery. The OR was prepped, the surgeon was ready, the team prepared for a cholecystectomy and simultaneous liver biopsy which we had requested at the last minute due to the patient's underlying untreated Hepatitis C. Understandably, the surgeon was peeved, having lost thousands of dollars of surgical income, and the incredibly busy OR whose schedule and waiting list are bursting at the seams was also negatively effected.

And the patient? MIA. I left a message on her machine, stern but not harsh. Is she OK? Did she have an emergency over the weekend? Did she realize the ramifications of not showing for the surgery? Did she realize that this surgeon may never agree to see her again, along with all of the surgeons in his practice? (And, I thought, is she dead? The best excuse for a no-show.)

So what do we make of this scenario and that which is described earlier in this post? How do we correct this insidious problem? How do we stem the tide and decrease the deleterious effects of such dynamics on both our patients and our medical practices and staff? Is there an answer to our dilemma when we actively choose to serve the poor, vulnerable and disenfranchised with quality medical care? There are no easy answers. This was not the first time one of our charges failed to arrive for a scheduled surgery, and it will not be the last. There are truly few answers, and each question or potential response only begs a host of other considerations. For all of our efforts, the show must go on, and the No-Show Show will no doubt be a popular attraction for many years to come.

The End Is (Always) Near

Every week, I check on my patient who has been battling cancer and living at home with the help of hospice care and the devotion of his family. At my last visit on Thursday, he was sixteen days without any nutrition, receiving morphine and a few essential medications with a cup of water via g-tube daily. Each visit, I put a hand on his forehead and one on his chest, whispering in his ear that he has been brave and strong, that his wife will be OK without him, and that his time to let go is near. His wife tells me that she gives him permission to go every day, and he has indicated in his obtunded state that he's beginning to see dead relatives in the room. Each visit seems like it may very well be the last, and I keep expecting that call which will tell me he has left this world for the next.

Similarly, my old dog was given two months to live a few months ago, and I pump him with IV fluids every night in an effort to support his slowly failing kidneys. This journey of living and moving towards death is being chronicled on my other blog, Latter Day Sparks. Even as his death seems always around the corner, his continued apparent joy of living is what shines through most clearly. Even as we commemorate his life and memorialize him while he is still with us, we've chosen his burial place and begun to make some plans. Our sweet time with him is so limited, but so cherished.

When I think about it, I can picture the faces of dozens of patients and friends and family members who have passed from this world. How was the quality of their living? What was the quality of their final days, their actual death? Was peace the final sum of their lives' rotations around the sun?

Even as death surrounds us and we prepare for the loss of loved ones near and far, even as death fills the news media and reminds us of the suffering in the world, we embrace each sunrise and live our days in awareness of their numbered reality. As my patient awaits his death, perhaps resisting its inevitable gravitational pull, I understand that each day, each breath, could also be my last, as well. When we know that someone is dying, we of course try to make our moments with that person meaningful, with the thought that we might never see that person again. Carrying that notion forward, each time we see a patient, a friend, a neighbor, a loved one, could also be the last time we lock eyes with that unique individual. May every interaction be informed with that reality, that potential for finality, for a desire for true and honest and authentic discourse.

The end of days is prophesied, but we have no idea what that really means. Global warming, nuclear disaster, pestilence or plague may rob us all of our full lives. A slight miscalculation can send our bicycle into traffic, our car off the road. A lifetime of dietary indiscretion or simple genetic predisposition can block our coronary arteries and send us into arrest at any moment. We may even be struck by lightning.

All of that said, it is only the present, the moment in which we live and breath, that anything real and authentic can occur. As we struggle to save for retirement (a recommended practice, to be sure), pay off debts (also recommended), raise our families and make a living, every moment is truly an opportunity. Working with the ill and disabled, I always try to remember that "there but for the grace of God(dess) go I."

Yes, the end is always near for us all, but each day is also a beginning. Armed with this knowledge, what more can one do but bring this awareness to our days, console the ill, support
the dying, offer succor to the impoverished, and give thanks for another chance to love.

As Mother Teresa said, "I have found the paradox that if I love until it hurts, there is no hurt, only more love."

Technology and Its Discontents

Healthcare and technology almost seem inseparable these days. Everywhere one turns, technology has improved (and often complicated) healthcare workers' and patients' lives. Where are the points where technology breaks down, where human interaction is negatively impacted, and where technology gets in the way? Where also are the places where the enhancements provided by technology are undeniable and documentable? And when are new technologies simply not worth the cost of their operation, both personal and financial?

I've never worked in a hospital, but I've spent enough time visiting hospital floors to understand that technology rules the roost, whether it's the documentation of vital signs or the administration of meds. The hospital with which my agency is affiliated uses laptops on wheels which the nurses roll through the corridors, entering meds and patient data, as well as retrieving orders and consults. Medications are dispensed from a robot in the nurses' station wherein the nurse enters an ID code and PIN with the corresponding patient data, and the med is then delivered on a tray, labeled with the medication strength, dose and frequency, as well as the patient's name and date of birth. It's like a pharmacological ATM but the currency ranges from atenolol to zithromax rather than in tens of dollars. It has apparently cut down on medication errors enormously, a benefit that cannot be denied

At the clinic where my agency is housed and with which we are even more intimately affiliated, the hospital system is piloting an electronic medical record. Our clinic "went live" last week---only one of three sites to do so at this juncture---and IT staff swarmed over the place for the first five days, providing technical support to the often frustrated doctors as they began using the system in real time. Will it improve patient care, productivity and job satisfaction? The jury is out, and we all understand that the learning curve is high, with the first six months a party of trial and error. The benefits of prescribing electronically with the computer system automatically faxing prescriptions to the chosen pharmacy was a great selling point to the docs, who will have less and less need to use hand-written prescriptions which can be lost (and illegally altered).

Within our agency, we have two programs. The one for which I endlessly toil uses an electronic database for tracking medications, some lab values, and demographics, but our visit notes are still hand-written in prehistoric fashion. We are all required to carry company-issued cell-phones and alpha-numeric pagers, and almost all of us carry Palm Pilots with our schedules, address books, and medical software which we download from the Internet. (I highly recommend ePocrates, a free program which allows one to carry the entire list of FDA-approved medications with dosages, side effects, interactions and costs, not to mention herbs and home remedies, insurance formularies, as well as additional software for diagnosis and treatment available for a fee. There is also a desktop version of ePocrates available for free.) Our other program uses an interactive electronic medical record which we occasionally envy, except when it crashes and we hear no end of complaints from the other side of the office. At times like those, I like my handwritten notes just fine, thank you.

On any given day, I carry my company-issued and mandated pager and cell-phone which we must have on and within reach from 8:30am until 5:00pm when the on-call nurse takes over. I also carry my aforementioned Palm Pilot, pens, business cards, sticky notes, and keys, and that's just the equipment that I actually have on my person all day. We each also have a networked desktop computer. That said, we all feel fairly content with our technological set-up, although we sometimes feel burdened by it at times.

Our manager has decided to purchase each of us a "Blackberry", a pocket device which performs the combined tasks of beeper, cell-phone, Palm Pilot, and wireless email access. We'll be expected to carry (and not lose) these $500 toys as we go about our daily work, hi-ho. But there is mutiny in the wind. Over the last few years, a number of us have lost our cell-phones and pagers and Palm Pilots from time to time. We all know pagers and phones are a dime a dozen, made with throw-away materials, easily and relatively inexpensively replaced. Those of us who choose to carry Palms do so at our own risk and expense since they're not essential to carry out our duties. I have argued---to no avail---that these Blackberries are too expensive, too risky, and bound to eventually be lost, stolen or broken. Our supervisor has informed us that we will need to be especially vigilant since we will be personally and financially responsible to replace a lost device. This is a point at which I say,"If it's not broke, don't fix it." Up until now, if someone loses a cellphone, they at least have a pager through which they can be reached, and vice-versa. Now, with an all-in-one device, a loss will mean the individual loses phone and paging capablilites along with Palm Pilot interfaces, and the cost of replacement is astronomical and born by the employee. This technological change has us up in digital arms.

Change---whether it be the development of the wheel, the advent of the cellular phone, or the invention of the outdoor gas grill---brings with it challenges and hopes for the future. Tired of charcoal and lighter fluid, the post-modern hunter-gatherer can simply buy a tank of propane and barbecue the night away with no muss, no fuss, and no gaseous fumes. That same hunter-gatherer can roll along the highway on rubber pneumatic tubes at 80mph, talking to far-flung friends and family as a way to avoid making tedious telephone calls at home (except where cell service is spotty, that is--"Damn you, T-Mobile!"). Now, the itinerant nurse, continually tethered to the office by an electronic umbilical cord, is forced to adapt to a new technology which may be super cool, but offers very little in terms of added value when measured against calculated risk and relative cost. This nurse, using the wheel and the cell-phone to offer individualized care to those in need, now faces the daunting task of protecting and obsessing over a device with which (s)he would rather not be encumbered, especially in light of the substantial financial cost of momentary forgetfulness or disorganization. At this moment, unnecessary change is maddening.

What then does this itinerant nurse do? Refuse to carry said device with risk of being told there is no other choice? Take the risk of carrying said device and spending several days' wages to replace it if lost? Or does the nurse band together with his or her coworkers and demand the right to be part of the decision to make such drastic and apparently useless change?

These are the questions I ponder this weekend, wondering how my coworkers and I will handle this dilemma. We all agree that technology is useful and convenient in many forms, and adapting to new technologies simply de rigeur in this digital world. But is such adaptation palatable when delivered with the force and finesse of an unwanted intubation? Stay tuned, dear Readers, as this battle of wills dramatically unfolds in an office not-quite-near you.

Desperation and Empowerment

The workdays flow by, often inundated with faxes, emails, patient visits, charts, labs, and other flotsam and jetsam. Sometimes it seems we're all simply buzzing with the energy of staying on top of our patients' care. I currently "care manage" 84 people, many of whom have extremely complex medical conditions and comorbidities. Their poverty and relative level of disempowerment only adds to frequent feelings of desperation (both on my part and theirs). That desperationis not always quiet, but it can be profound for both patient and provider.

Reading recently about the lack of infrastructure for the care of people with AIDS in Africa, I'm astounded by the lack of awareness our patients have of their relative fortune vis-a-vis their healthcare. We have access to every medication on the market for which our patients pay absolutely nothing. We have complete and unfettered access to the most cutting-edge blood tests, including genotyping which elucidates for us the exact mutations of virus replicating in our patients' bodies at any given time. Doctors in Africa probably only dream of testing genotypes, let alone having the vast armada of medications needed to work around such mutations once they're revealed.

However, even as we note that our patients are blessed with the availability of care and medications, we also must bear in mind that such blessings are indeed relative, and even here in Amerika---"the land of milk and honey"---poverty and powerlessness serve to undermine our patients' ability to fend for themselves and take their healthcare into their own hands. We must also examine our own patrician attitudes which may only serve to perpetuate their dependence and seeming lack of will, disempowering them even as we feel righteous in our work with the poor and disenfranchised.

That said, it's just that when I see those dying souls in Africa bereaved for lack of access to life-saving medications, I can feel justifiably disgusted that my patient may simply fail to call the pharmacy for a refill, or worse yet, simply not take his medications as they gather dust on his dresser. No one can live inside the mind of another. No one can know the processes which bring a person to a certain frame of mind, a certain way of being. Past traumas and indignities are suffered only by the individual, and my white, middle-class priviledged self can never truly understand the plight of another.

Luckily for us all, the dawn brings each of us a new opportunity. For my patients, it might be an opportunity for empowerment and self-actualization and self-care. For me, the provider, it might be a new perspective, or perhaps a newly discovered well of patience and humility. It is all so complex, this being human. And when one attempts to help others in this complex and multidimensional world, one's emotional, class, and cultural baggage also comes along for the ride.

May the dawn bring us all a new chance, and the ability to seize the day in unprecedented and life-affirming ways.

Fun Facts

These fun facts are courtesy of the website of Bodies: The Exhibition, which I plan to see as soon as I can manage to do so. For those of you not in the know, this exhibition present dozens of complete human bodies, preserved in toto, with the skin removed, in various poses. A polymer was injected into the bodies to perfectly preserve them: nerves, blood vessels, organs and all.

Did You Know?

• A human being loses an average of 40 to 100 strands of hair a day.

• A cough releases an explosive charge of air that moves at speeds up to 60 mph.

• Every time you lick a stamp, you consume 1/10 of a calorie.

• A fetus acquires fingerprints at the age of three months.

• A sneeze can exceed the speed of 100 mph.

• Every person has a unique tongue print.

• According to German researchers, the risk of heart attack is higher on Monday than any other day of the week.

• After spending hours working at a computer display, look at a blank piece of white paper. It will probably appear pink.

• An average human drinks about 16,000 gallons of water in a lifetime.

• A fingernail or toenail takes about 6 months to grow from base to tip.

• An average human scalp has 100,000 hairs.

• It takes 17 muscles to smile and 43 to frown.

• Babies are born with 300 bones, but by adulthood we have only 206 in our bodies.

• Beards are the fastest growing hairs on the human body. If the average man never trimmed his beard, it would grow to nearly 30 feet long in his lifetime.

• By age sixty, most people have lost half of their taste buds. By the time you turn 70, your heart will have beat some two-and-a-half billion times (figuring on an average of 70 beats per minute.)

• Each square inch of human skin consists of twenty feet of blood vessels.

• Every human spent about half an hour as a single cell.

• Every square inch of the human body has an average of 32 million bacteria on it.

• Fingernails grow faster than toenails.

• Humans shed about 600,000 particles of skin every hour - about 1.5 pounds a year. By 70 years of age, an average person will have lost 105 pounds of skin.

Amazing Lung Facts

• At rest, a person breathes about 14 to 16 times per minute. After exercise it could increase to over 60 times per minute.

• New babies at rest breathe between 40 and 50 times per minute. By age five it decreases to around 25 times per minute.

• The total surface area of the alveoli (tiny air sacs in the lungs) is the size of a tennis court.

• The lungs are the only organ in the body that can float on water.

• The lungs produce a detergent-like substance (surfactant) which reduces the surface tension of the fluid lining, allowing air in.

Amazing Heart Facts

• Your heart is about the same size as your fist.

• An average adult body contains about five quarts of blood.

• All the blood vessels in the body joined end to end would stretch 62,000 miles or two and a half times around the earth.

• The heart circulates the body's blood supply about 1,000 times each day.

• The heart pumps the equivalent of 5,000 to 6,000 quarts of blood each day.

A Big Issue

Obesity seems to be everywhere. An epidemic, they say. I think I believe them, whoever they are.

Driving through my city of employment yesterday, I was stunned as I saw what appeared to be a parade of obese individuals wherever I turned. Since I work in neighborhoods where a preponderance of poor people reside I am exposed to the lives (and dietary habits) of American's urban poor on a daily basis, and it seems that eating healthily may be beyond the grasp of many who subsist on welfare and food stamps. McDonalds appears to be stellar in its ability to ensconce itself in poor neighborhoods, as is Burger King, KFC, and other purveyors of fat-laden, carb-heavy, calorically-dense foods. Add to that the ubiquitous 99-cent fast-food sandwich enticements seen on billboards and signs across urban (and suburban) America, and you have the beginnings of the recipe for carbohydrate/fat addiction and rampant obesity, not to mention pre-diabetes and hypertension.

So, who's to blame?

Well, fingers can point in multiple directions simultaneously. Corporate Amerika does its best to super-size our populace by flooding the market with fast food. In the inner city, supermarkets and farmer's markets are often miles away and virtually inaccessible by public transportation, especially for the disabled, the elderly, and single moms with small children. If one does make it to the supermarket, more and more foods are packed with unnecessary extra carbohydrates through the ubiquitous use of high fructose corn syrup. Even as soy milk gains popularity as an alternative and "healthy" beverage, companies make their product more palatable by pumping it full of corn syrup or "evaporated cane juice", the new flavor enhancer du jour. Whether it's organic or not, evaporated cane juice is just another word for sugar, something the American public needs alot less of, especially children.

Public schools make financial deals with Coca Cola and other predatory companies who use the lure of "free" technology and computers to insinuate themselves into the educational environment, but the devil is in the details. In exchange for such faux largesse, schools deliver to their children carbo- and sugar-laden snacks and foods, often available ad lib through the venue of vending machines in the cafeteria. Interview any cohort of schoolchildren during lunchtime and many will be subsisting on Doritos and Coke as a main course and candy for dessert. Many groups in local districts seem to be fighting back, demanding the removal of vending machines from schools and the provision of healthy meals and snacks. It's an uphill battle.

Sadly, globalization has led not only to the sharing of technology and the opening of "call centers" for American companies in Bombay, it has also led to the globalization of the obesity epidemic to previously healthy societies. Asia is now seeing unprecendented obesity among all age groups, with fast food and Americanized high-sugar dietary choices becoming the norm, leaving traditional eating habits in the dust. Not only do we as Amerikans consume more energy per capita than any other society on earth, we also share our love of fattening foods, poor health, and gas-guzzling SUVs with the rest of the world as well. We tax the world economic and healthcare infrastructure with the weight of our addictions and the unsustainable habits which we so freely share with the world at large (pun intended).

Government can easily be implicated here, from poor public health planning, corporate hegemony, the influence of big business, and the Every Child Left Behind Act. Resources galore are wasted in preparing our students to pass rcailly biased standardized tests, while our children's nutrition is ignored and physical education funding cut in the interest of the bottom line.

So where from here? BigPharma is now rushing to create a "magic bullet" for obesity, pills that will curb appetite, burn more calories, or cause the consumer to retch violently when eating anything with high caloric value (I made that one up). Are pharmaceuticals the answer? Is gastric bypass the panacea for thousands of obese teenagers raised on X-Box, Doritos, and sugar-laden breakfast cereals? Is poor urban planning only going to increase our reliance on cars, erasing sidewalks and the idea of shopping on Main Street and walking to the store? As more and more entertainment is delivered to our homes without more than the click of a mouse or remote, Americans will be more than ever frozen in their recliners, the yard-sale exercise machine gathering dust in the garage. Eventually, robots will vacuum, wash our laundry, and pick up the mail, while we eat microwaved meals as we surf the InterTV-Net for infotainment.

Hyperbole aside, maps of obesity trends in the US show rapid growth in the obese population of our country, and the healthcare costs of such an epidemic are staggering. A study commissioned by the American Obesity Association (AOA) estimates the healthcare-related costs of obesity in the United States for 1994 was over $7 billion! And that was more than a decade ago. The AOA website states:


"The Lewin Group examined the costs of fifteen (15) conditions causally related to obesity. They included: arthritis, breast cancer, heart disease, colorectal cancer, type 2 diabetes, endometrial cancer, end-stage renal disease, gallbladder disease, hypertension, liver disease, low back pain, renal cell cancer, obstructive sleep apnea, stroke and urinary incontinence."

We obviously need to get this monster under control before it controls us, our economy, and our country's future. Public health experts believe that gains made vis-a-vis increased lifespans in the last 100 years may be eventually lost due to the health effects of obesity and its sequelae. It is an enormous problem of as-yet-unseen ramifications for the future, and if any of your children would like a career in medicine, let them know that the care of people with diabetes and heart disease and other complications of obesity is a sure bet for the future of medical careers and paychecks. That said, make sure your children are free of the epidemic, or they too will only serve to feed the medical machinery that devours the dollars needed to stem the tide of obesity-related morbidity and mortality.

Did I say it was a big issue? Big may be the understatement of the year.

Denial is a River....of Apathy

Visiting a patient today, his friend/assistant complained to me how my patient is not taking good care of himself, neglecting his medications at times, smoking, eating poorly, even in the midst of terminal cancer and other disease processes.

When I questioned my patient's friend about her own health, she shared with me an apathy so deep that I was shocked by her clear articulation of its breadth and depth. With blood sugars usually in the "300 to 400" range, she described for me how her apartment is often like a "candy store". Addicted to sugar and sweets, she now injects well over 200 units of insulin per day, barely convering her insulin needs. "Every time I see the doctor, they look at my numbers and raise the insulin again," she laughs, as if it were a game she were playing. And perhaps she is. When I ask her about the potential consequences of her actions, she laughs again. "I'm already old. In 20 years, I'll weigh 100 pounds more!" She gestures at her already obese body. She's 41---my age. We share the same birth year: 1964. She sees her life as almost over.

Flabbergasted, I paint a picture of dialysis, amputations, blindness, cardiac disease, nursing homes. She only laughs more. "Anyway, the Lord is coming, the world is ending, so I don't have to worry about it. I'll go to Heaven." When I ask her what will happen if the Lord does not return to Earth in her lifetime and she gets gravely ill, she looks thoughtful for a moment, then laughs again. I hold her hand and tell her that I care about her and want her to survive and be healthy.

"I'm not going to change. I'll just keep getting fat. I love sugar. There's just no reason to try."

No. Denial is NOT a river in Egypt. But it runs deep, and its waters are treacherous beyond belief.

Service

A framed poster of Marian Wright Edelman hangs in the hallway of our clinic alongside numerous similar posters of people of color who have changed the world. The quote on Ms. Edelman's poster stopped me in my tracks the other day:

"Service is the very purpose of life. It is the rent we pay for living on this planet."

Among many accomplishments, Ms. Edelman established the Children’s Defense Fund, "the most powerful voice ever created for the millions of poor children in the United States" (according to the National Women's History Project).

It seems that my life has become centered around the service of others, either through nursing, teaching, or various volunteer projects in which I've taken part. While it may be possible to lose one's way by ignoring one's own growth and needs in the interest of altruistic service, I've found that one can often find one's self through the medium of service. When I look at those who have endeavored to devote themselves to the welfare of others: Martin Luther King, Jr., Mother Theresa, Mahatma Gandhi, I don't see egoless waifs whose personalities were lost in the wake of their call to serve. What I see are dynamic individuals who brought their visions to fruition and silmultaneously achieved self-actualization and ersatz sainthood.

Ayn Rand professed that true altruism could not exist, because every human act---whether for the benefit of one person or a multitude---is essentially a selfish act, even when couched in altruistic desires. She felt that even the most seemingly selfless person gains from their actions in some way (if only by increased self-esteem), thus making selflessness essentially impossible.

We all might experience a feeling of accomplishment or well-being for a deed well done. Does this diminish our altruism? Does it demean our desire to serve? Does the benefit to one's ego preclude the benefit felt by the recipient of our largesse? I would say no to all three rhetorical questions, and will continue on my path of service and good will for as long as that path is aligned with my soul. Whether altruism is absolute seems to me to be beside the point. Any amount of ego boosting would seem a small price to pay if a small corner of the world is uplifted or bettered by one's actions on the ground.

Service with a smile? As often as possible. To paraphrase that ubiquitous McDonalds sign in front of that fast-food monolith of capitalism: "Billions and Billions Served".