Monday, July 31, 2006
Symptom management: swim at creek with dogs; relaxing computer time, blogging and emailing; fruit smoothie for dinner (frozen banana, blueberry-pomegranate juice, soy milk, watermelon); 15-minute sunset bike ride; gin and tonic with organic lime juice while sitting on screened-in porch listening to crickets and locusts; looking at the face of my love; cool shower; 7 or 8 hours of sleep in air-conditioned room after gin and tonic settles nicely; toothbrushing mandatory, flossing is elective procedure.
Diagnosis: Monday Evening Nurse Syndrome; alteration in weekend relaxation.
Prognosis: good, as long as the swims, gin and tonics, and air-conditioned sleeps are adhered to as rx'd.
Treatment Goal: happy nurse, without burnout or compassion fatigue, ready for the world tomorrow.
Likelihood of successful treatment: high.
Likelihood of similar symptoms in future: also high.
Likelihood of ability to cope with said symptoms in future: unquestionably high.
Overall prognosis: positive, with proper maintenance and adherence to treatment.
Additional rx: gin and tonics, ad lib. Adhere to Prozac rx. Add ice cream or chocolate prn.
Saturday, July 29, 2006
His liver is almost gone, and he just keeps pouring gasoline on the fire. We'll meet on Wednesday with my psychologist colleague and try to come up with a plan.
Another patient who I've been trying to find for six months also finally surfaced. His liver is also mostly shot, and he hasn't had a drink or used drugs in three months, or so he reports.
"Can't I have just a few beers a day?"
"Well, that's asking for trouble, really. We need to keep you clean. Plus, your diabetes is way out of control."
He regards me dubiously, then talks about liver functions, bilirubin, hepatitis viral load. Very impressive grasp of the issues, but still not sold on the sobriety part. Denial, I guess.
Some of our success stories are walking the streets today, while those who were not so successful (in our terms, anyway) are in the next world, hopefully learning some of the lessons they missed down here.
We all carry our pains and losses and traumas, and we all have deep-seated reasons for why we are who and what we are. It's hard to not judge another for how they choose to cope, but we might find their moccasins pretty damn uncomfortable if we tried them on for a day.
For every patient who manipulates us and pulls the wool over our eyes (or tries really hard to do so), there's another who's forthright, honest, authentic, and easy to read. The very sweet gentleman who I mentioned at the beginning of this missive is a troubled soul with a trauma history to which I am not yet privy. If I actually heard his story, his recidivism vis-a-vis drug use would make even more sense, but I can hear the plaintive note in his voice which calls desperately out for help, and we'll keep extending a compassionate hand. Whether he takes that hand remains to be seen, but for now we hope that our presence in his life can cause some small shift, some minor changes that could lead to major decisions about improved life and health.
We've seen some miracles, and I have no doubt that there are more to come. If he shows up to our appointment on Wednesday, that will be the first. If he comes to the next one, even better. If he goes on the wagon, gets with the program, stays clean, turns himself around and begins to help others do the same, then that's a miracle of the highest order (and we know several who have done just that), and I'll be the first to congratulate him on his recovery. Until then, that hand is extended, and the rest is up for grabs.
Friday, July 28, 2006
Said cat---"Timmy"---has been sneezing and anorexic for days, and only today began taking azithromycin. My patient was mostly concerned with ongoing anorexia on Timmy's part.
Being a nurse who likes to please, I performed a cursory exam of the surprisingly cooperative feline, felt his belly, palpated his nose and throat and sinuses, checked out his nose and mouth and ears, and concluded that he had no acute GI symptoms and was most likely not eating due to a combination of the antibiotics and a cold. I urged my patient to relax, keep plenty of fluids and cat food available to him at all times, and recommended she follow up with her vet if Tommy isn't better by Monday.
As for the finger, the wound culture has so far grown out gram-negative rods and we're waiting to see if the herpes culture is positive or negative. While my patient has already had one lung removed due to adenocarcinoma, I don't think the finger will be killing her any time soon. (Interestingly, she reports having had a colonoscopy recently and thinks that the finger with the lesion was the one that they had in a pulse oximeter. Could she have picked up an infection from poorly cleaned medical equipment? It wouldn't be the first time.)
As for Timmy, I expect a full recovery and give him a prognosis of a very long and happy life, along with the occasional URI.
Tuesday, July 25, 2006
Monday, July 24, 2006
I occasionally came up for air, especially when Mary arrived just before noon, knocking on the window behind my desk. I opened the office door to see her, a vision in a lovely summer dress, saying "Can you come out to play?" Smiling, she held our lunch in her hand for us to enjoy by the sprinkler park as children frolicked in the splashing water, some of which misted us as we ate watermelon and organic pistachios. I walked her halfway across the park back towards her sweet Senior Center and we kissed goodbye. She didn't know it, but I looked back three or four times to watch her cross the expanse of grass towards her workplace. I just couldn't stop watching her. It was like my soul was crossing that field. Then I headed to the office and plunged back into the melee, the simplicity of lunch in the park with my love giving way to the complexity of the endless needs of my patients.
It was uphill from there.
Saturday, July 22, 2006
Imagine that you had gone all your life without ever washing, and then one day you decide to take a shower. You start scrubbing away, but then watch in horror as the dirt begins to ooze out of the pores of your skin and stream down your body. Something must be wrong: You were supposed to be getting cleaner and all you can see is grime. You panic and fling yourself out of the shower, convinced that you should never have begun. But you only end up even more dirty than before. You have no way of knowing that the wisest thing to do is to be patient and to finish the shower. It may look for a while as if you are getting even dirtier, but if you keep on washing, you will emerge fresh and clean. It’s all a process, the process of purification.
Whenever doubt arises, see it simply as an obstacle, recognize it as an understanding that is calling out to be clarified or unblocked, and know that it is not a fundamental problem but simply a stage in the process of purification and learning. Allow the process to continue and complete itself, and never lose your trust or resolve. This is the way followed by all the great practitioners of the past, who used to say: “There is no armor like perseverance.”
---Sogyal Rinpoche, from the website Rigpa
You can have daily meditations on living and dying emailed to you from this page.
Friday, July 21, 2006
For all the troubles in this very troubled town, there are still good people making good things happen. Our health center, for example, hosts a Christmas party for the neighborhood children every year, complete with Santa, elves, a very impressive Santa's workshop, substantive gifts for every---and I mean every---child who shows up, free Polaroids of each kid with Santa, music, free food, and the promise of a very good time. The amount of hours put into this undertaking are astronomical and the planning and gift-gathering begin each summer.
All of the numerous social service agencies in our end of the city---serving an 83% Latino community---have banded together to form a committee to oversee and guide the overarching plans for knitting this community together and providing comprehensive services to families and individuals, taking into consideration health, healthcare, economics, elders, children, teens, families, addicts, sex workers, IV drug users, and newborns. The vision is astounding---the implementation will be a challenge. Nonetheless, a well-meaning and ethnically diverse team has assembled itself to transform and restore this community, and there are times when I feel that I could not work anywhere else. Even as the city collapses upon itself---or threatens to---the movers and shakers continue to plow ahead to bring their visions to fruition. To wit, my program of care management for the most vulnerable members of the community was born---and is sustained---by such tenacity of will and desire to serve. That underpinning of heart is what keeps me where I am.
As I watched the children frolic in the sprinkler park and the people chat under the trees, it became easy to overlook the trash, the violence, the corruption, the homelessness, the desperation that walks these streets. Even for a moment, frozen for a summertime pause of sun and water and laughter, the promise of community unfolded and placed a gently soft hand upon the faces of those gathered in such innocent joy and celebration of life. These are instants that cannot, and should not, be taken for granted, and they are truly miracles, conscious manifestations of the power of positive energy, the will to serve, and the desire for togetherness that I feel lives in us all.
Thursday, July 20, 2006
Aside from the accounts of the soldiers' misfortunes and incredibly painful treatment---some extensive burns require debridement of the charred skin down to a subterranean layer of viable and healthy tissue, exposing thousands of screaming nerve endings---I was extremely touched by the nurses and doctors who were interviewed. One must consider the fact that the staff are working with individuals who are horribly disfigured, often lacking recognizable faces and features. It was explained that pictures of the soldiers before their burns are always hung on the walls around their beds---posing with families and loved ones---to remind the burn unit staff that these are real people with real families, who used to have features that distinguished them and identified them. The supervisors want the staff to know what these men and women really look like, and to treat them from that perspective of wholeness and the recognition of their complete selves.
One nurse described how he has a place along the highway on the way home where he stops to cry, meditate, or scream, so that he can arrive home having released some of the emotions which were generated during the workday. Another describes "cramming" emotions away---a sure recipe for burnout and substance abuse, in my book. Coping mechanisms can sometimes be overwhelmed when such trauma is witnessed, and I can only imagine how a nurse or doctor must feel as he or she debrides an extensive burn, exposing raw nerve endings and tissue. The screams and tears and curses must be powerful and strong. (This is why I hate clinic evenings when I have to give three, four or even five vaccinations to a one-year-old child all at once. The terror and pain in that child's eyes---and the caterwauling screams---are enough to put me over the edge with guilt.)
Such suffering is witnessed by so many around the world---whether parents, children, soldiers, nurses, or the infirm themselves---and I sometimes wonder how we---humanity---carry the weight of such suffering on our collective conscience. Aside from the right or wrong of war, the good and bad things inflicted upon human beings by other humans beings, there are stories of heroism, compassion, and incredible kindness around every corner. This story which beamed to my car across the airwaves today was just one small reminder of one small corner of the drama experienced by a relatively tiny portion of this multicellular organism we call humanity.
Even as I write, at this moment, those burned soldiers dream morphine dreams of blissful forgetfulness while a mother in Beirut mourns her three-year-old killed by a bomb, or an Israeli settler bemoans the ruins of his home, or a homeless man in the city where I work drops his bottle of beer, clutching his chest as a heart attack commences to extinguish his unsung life. And at that same moment, hundreds---perhaps thousands---of children are born into this world as new parents weep with happiness despite the pain which they know their children may endure in the course of a lifetime on this spinning globe.
Those stories opened something in my heart today, and I'm grateful for the moment of reflection and connection to others. These are the moments when one can sometimes get in touch with that collective unconscious of which Carl Jung spoke, that undercurrent of connectivity which binds us all in our shared humanity. Perhaps this story opened my heart as I thought of an old friend undergoing surgery for cancer today, or another friend recently hospitalized with a dangerously high fever induced by a tick-bite, or the daughter of a former boss who suddenly died this week at 33. The drama is multifaceted, and I can choose to send all beings a wish for happiness and wholeness, recovery and hope. Stories can do this to us, and that ability to listen and recognize the suffering and tribulations of others may be the key to cultivating more compassion each day. Compassion for others---an important lesson worth learning again and again.
Wednesday, July 19, 2006
Our client has expressed determination and a fierce desire to pursue an education, overcome his disability, and enter the workforce. Eager to help others, he has grand plans for how he would actualize himself and bring his many gifts to others. Through many applications and beaureaucratic processes, my coworker enabled this gentleman to be approved for classes, training, and a free home computer to facilitate his academic success. Our pleasure at seeing his face light up when talking about his future is beyond measure, and his plans for the future only seem to expand.
This week, a huge monkey wrench was thrown into the works in the guise of The War on Drugs. It appears that, due to misdemeanor drug possession charges and mandatory minimum sentencing laws with prolonged probation, this gentleman---who is eager to make something of himself, give back to the world, and contribute to society---is thwarted in his desire by the fact that his past convictions and current probation preclude his ability to receive even one dollar in financial aid. With classes ready to be registered for, a computer ready for delivery, and training all set to commence, his dreams and aspirations are now dashed against the rocks of misguided government action.
While white collar criminals bilk retirees of millions, slum-lords charge outrageous rents for substandard housing, the Big Dig in Boston collapses under its own weight, and members of law enforcement (including the CIA and FBI) appear to profit from involvement in the international drug trade, this promising young man with so much to give cannot receive the education he needs to remove himself from the rolls of Social Security Disability and create a new life. For all the talk of the "rehabilitation" of criminals, the government's denial of financial aid for the education of those on probation for minor non-violent crimes flies in the face of all logic and ethics. If this society was to put into words its goals for the future of non-violent offenders, those words would certainly reflect a desire for such individuals to receive education and training which would make them productive, peaceful, tax-paying citizens contributing to the welfare of the larger society while simultaneously pursuing self-mastery and personal fulfillment.
So, in light of this maddeningly Kafkaesque outcome, our protagonist cannot pursue his dreams, better himself, or otherwise lift himself from poverty and economic reliance upon the state, because his previous actions preclude his receiving financial assistance for training and education. Rather, he should languish in uneducated disability, unable to obtain the skills training needed for advancement and gainful, tax-paying employment. It's just another great example which proves that the War on Drugs is really just a War on the Poor; and the war, my friends, is simply never over.
Tuesday, July 18, 2006
I often forget that many of my patients actually lease their furniture and large-screen TVs from local leasing companies. I'm genuinely shocked at the size of some of my patients' television screens and the excessively massive furniture (all black with fake gold and chrome plating) which crowds their apartments and homes. I was also shocked a few years ago when I realized the enormous amounts of money which is spent on the leasing of such home furnishings.
While perusing my patient's lease agreement, I could see that a mediocre dining-room set with four chairs, retailing at around $600, was going to cost this woman on a fixed income more than $1300 by the time she finished the payments over several years. Add to this mix the great risk which she runs of having the items reposessed if she happens to become ill, get hospitalized, or otherwise miss a monthly payment, thus forfeiting all of the money which she has already paid on said furnishings. This type of exploitation (and poor judgement) makes my blood boil.
After she left my office, I spent some time pondering the reasons behind such behavior and consumption. I had asked her why she leased under such horrible and exploitative terms rather than simply saving up money and purchasing a dining room set outright for much less money, and she could not necessarily answer me in a way that explained her actions. What I surmised from her answer is that "this is what is done" and she didn't necessarily have the skills to do anything differently. I was perplexed, but was (and am) undaunted in my determination to more fully understand.
From my solid middle-class perspective, it's relatively easy to not see the other side, to turn a blind eye to the eagerness of those less fortunate to rise up, or to at least have surroundings which make one feel more comfortable and on a par with others. Don't so many of us strive for more? I told myself to look deeply at the circumstance of a disabled person with multiple illnesses, perhaps a history of emotional trauma, and generations of poverty and struggle. That person watches TV, takes in thousands of commercials and advertisements enticing him or her towards a better life of conspicuous consumption, and numerous television shows and movies portray beautiful people in beautiful surroundings enjoying comfortable furniture, the latest technology, the most chic of homes, and the latest and greatest gadgets and toys. Cinderella stories---in the form of "American Idol" and "The Apprentice", for example---demonstrate that ordinary people can transform their lives and reap the benefits of fame and wealth almost overnight. The economically disadvantaged watch these shows with zeal, look around at their homes, and are determined to bring some semblance of that wealth into their own living rooms and bedrooms.
Is this a fair theory? Are they victims of the free market and the media's relentless presentation of the contentment which consumption might deliver? Do they, in their desire for a more comfortable life, miss an opportunity to reexamine how they wish to spend the little money with which they manage their lives? And when they complain that they don't have the $1 co-payment for their antihypertensive medication (and believe that they should not have a government-mandated co-payment in the first place), is it fair to remind them how much they pay for cable and their dining room set? Is it really my place to use that moment to instill a new way of looking at consumption, economics, and priorities? Am I right to suggest that they downgrade their cable to the $60 package so that they have $15 for medication co-pays each month? My jury is out.
Reflecting on these questions, I examine my own life and financial state and the choices which I make. Do these choices point towards a desire to have more, to live in a way which my income and level of education do not necessarily reflect? Do I also make choices which some would find suspect vis-a-vis the realities of my situation? Do I even have the right to question others' motivations in this regard?
We all strive for happiness and comfort, and in a consumer culture that happiness and comfort is often reflected in our purchasing habits. I feel strongly that I cannot properly address this issue with any substantive acumen in this post, as it would take a great deal of research, reading, and contemplation to get to the heart of this very complicated socioeconomic issue. The bottom line is that I see individuals with whom I interact on a regular basis make choices which may be deleterious to them economically, and which, in my opinion, are based on artificial desires created by suits on Wall Street who decide in boardrooms what the next gimmick may be which they will peddle to the poor masses as those mega-corporations behind these "objects of desire" seek ever-expanding profitability and market control.
Although this may seem far from healthcare-related, economic health and savvy financial planning are actually integrally entwined with health, healthcare, and self-care. An individual's priorities might dictate how often an individual refills prescriptions, how important they feel it is to spend a dollar on the bus ride to a doctor's appointment, or whether they choose between a cable upgrade or fresh vegetables. Consumerism drives our culture and economy (and our healthcare system), and our patients are often pawns in a game which they perhaps are unware even exists. Or perhaps they willingly play that game, openly acknowledging that they desperately want what the purveyors of consumer goods offer so willingly. It is a conundrum of a dizzying order, one with which I struggle, and one which certainly impacts my patients' health---and my sanity.
The next time a patient tells me that they can't afford a dollar for a medication prescribed by their doctor, my response will be colored by these thoughts which I have pondered here, unfortunately never having reached a satisfactory conclusion from which to draw a pearl of wisdom and insight.
The pursuit of happiness, did you say? Yes, and that pursuit may very well take some to Wal-Mart to buy cheap goods made in sweatshops, whether I like it or not. It may also make a woman who can barely afford her rent choose to lease a dining room set for $1000 which she does not have.
This is an exercise in tolerance, in understanding, of confronting internalized classism, and of coming to terms with aspects of our society which drive me to the brink.
May all beings be happy. May all beings be free from suffering. May I be more understanding and compassionate. And while we're at it, may all beings in need find an extra thousand dollars in their bank account on the day they need it most.
Friday, July 14, 2006
Whether one opposes or supports capital punishment, the myriad questions raised in its discussion are thought-provoking and quite worthy of consideration. The media has recently focused a fair amount of attention on the various court decisions which have ruled lethal injection as a flawed form of execution which is in dire need of readdressing. Many opponents have stated that the cocktails used for the euthanization of animals in the United States are far more effective in producing a soporific effect with no apparent experience of pain than those used in our prison system today. Horrific stories have been published of condemned prisoners complaining of pain while undergoing injection, one particularly gruesome account detailing that technicians needed 90 minutes to complete the execution of a man who kept raising his head from the gurney to say "It ain't workin'!" These stories send chills down my spine and underscore the next questions that I will raise.
In these times, we have come to understand that execution has become "medicalized", in that it no longer involves a firing squad or hangman---it now involves IV access, the administration of sedatives and narcotics, and the need for medical oversight of such an undertaking (no pun intended). During tonight's show on PBS, a nurse from Georgia who participates in executions was interviewed about her experience. In her descriptions of the executions in which she takes part, she carefully stated that she does not see herself---nor the anesthesiologists who actually push the plungers---as executioners. She sees the execution team as a group of professionals carrying out orders, the "executioner" actually being "The State". This Kafkaesque denial of responsibility was difficult for me to swallow, as was a doctor's statement that by solely overseeing the heart monitor and vitals of the "patient", he was not actually participating in the execution, rather, he was advocating for the prisoner and assuring that no undue suffering was occuring.
To wit, the AMA states clearly that a doctor "should not be a participant in a legally authorized execution. Physician participation in execution is defined generally as actions which would fall into one or more of the following categories: (1) an action which would directly cause the death of the condemned; (2) an action which would assist, supervise, or contribute to the ability of another individual to directly cause the death of the condemned; (3) an action which could automatically cause an execution to be carried out on a condemned prisoner." Additionally, the American Nurses Association states that "participation in executions is considered contrary to the fundamental goals and ethical traditions of the [nursing] profession."
Taking into consideration the Hippocratic Oath of "do no harm", as well as the many pledges taken by (and professional standards imposed upon) nurses, takng active part in the carrying out of executions seems to be a contradiction of any medical code of ethics with which I am even vaguely familiar. Reading the AMA position statement, even consulting with the administering personnel would be a violation of the physician's role as healer. That said, some doctors' defense of the practice---and continued participation in such---has led to proceedings and investigations, although whether licenses have actually been revoked is unknown to this writer.
This article by Atul Gawande, MD, is certainly worthy of perusal. Dr. Gawande is firmly against the participation of any medical professionals in state-sanctioned executions of any kind, and his article was published in the March 23rd edition of NEJM earlier this year.
When considering "non-traditional" roles for doctors and nurses and other medical professionals---whether it be participation and medical oversight of interrogations at Guantanamo Bay, oversight of medical experiments on those unable to defend themselves (remember the institutions for the mentally retarded in the 20th century?), or the doctors who colluded in the Nazi experiments in the 1940s---one must bear in mind the ethical and moral issues underscored when such acts are committed by said indivduals. While there are some stellar prison healthcare facilities which offer state of the art compassionate care to the incarcerated, there are those in the shadows who, rather than contributing to the health and recuperation of the imprisoned, actually are complicit in the extinguishing of those lives.
Whether we can truthfully say that "The State"---a faceless entity---is the true executioner or not, many of our brethren and colleagues are taking part in the ending of life for reasons other than the relieving of suffering. One might argue that execution provides "closure" and relief from suffering for the loved ones of the victims of violent crime. That said, it is still a stretch---in my mind---that there is any precedent for a medical professional to take part in such an act and still truly call him- or herself a healer.
Thursday, July 13, 2006
Tuesday, July 11, 2006
Next came the mailbox filled with papers to review, the email inbox to slog through, and the new technology in the form of a Treo smartphone which needed a great deal of attention and detail management. Juggling my old Palm Pilot, old pager, new Treo, old cell-phone (with all the numbers I need and no way to transfer them to the new phone)---it was a post-modern mess. See this post for the recent history of our office's techno-struggle.
I jokingly asked the administrative staff if they had sent out a notice to all of my patients that I would be back at 9am today because the phone began to ring and didn't really stop all day for the most part. Aside from the few prescriptions I called in and fax'd, my day did not feel very "nurse-like"---more administrative and desk-based. What is "nurse-like" really like, anyway? Probably however I feel at any point of the day is nurse-like enough, dammit.
As a "wellness and health broker"---a term (that I think I made up) which I have come to see as indicative of some aspects of my work---I felt today like there were so many threads which I again needed to find and pursue. My brain's problem was the fact that remembering the details of what comes next for approximately 80 people is a Herculean task (or is it more Sisyphean? You be the judge!) Who was it who needed a follow-up visit this week? Whose blood sugar is most uncontrolled? Who died? Who's in the hospital? Whose med box needed filling today? What about those narcotics? Did that patient I love really go to Puerto Rico to die? Sisyphus would surely let this rock go a-tumblin'.
The devil is certainly in the details, as the saying goes, and the devil of details is certainly the devil I know intimately. Does one become a nurse because one enjoys the micro-management of endless minutiae? Do all nurses make those little boxes next to the items on their t0-do lists and then garner a perverse pleasure from checking those boxes off? Again, you be the judge, folks, but my obsessive-compulsive side sure likes being a nurse.
So, as Zen Mind, Vacationer's Mind gives way to Worker-Bee Mind, I'll do my damndest to make the evenings and weekends their own little vacations, while still being the (watered down) productive-obsessive which I am to my core.
The circus-tent of work as a nurse never ceases to entertain, even if that entertainment sometimes carries a certain sadomasochistic aura. I re-enter the fray, rested and vacated, but still sadly longing for the briefly carefree days of vacation. Head down, nose already sharpening on grindstone, can that softening and loosening of the tightened mind which occurs on holiday still retain its afterglow? Stay tuned......