A Correspondence is Born

My niece, a newly minted college student somewhere in New England, referred a friend to me for advice on exploring the joys and vicissitudes of nursing as a career. This thoughtful young woman who is entering her senior year in high school is filled with questions which I most readily and joyfully answer. This is affording me a golden opportunity to examine my motives for being a nurse, my reasons for remaining a nurse, and why and how I would ever consider encouraging anyone else to enter this profession.

Yes, nurses may still sometimes "eat their young", and hospitals may still use mandatory overtime to heartlessly over-utilize their nurses, while some of us struggle with caseloads which burst our brains' ability to provide what we feel is the most thoughtful, thorough care possible.

Still, I see a noble and genuine love of people driving many individuals to enter the nursing milieu, and a career which, historically, is portrayed as one which is grounded in compassion and caring. Nurses have made great strides (alongside some misguided backwards motion at times), and I still feel enormous pride vis-a-vis my chosen vocation/profession.

This correspondence, which I hope to integrate and share here on Digital Doorway, may open for me some more doorways to explore, and I'll be sure to share them here so that you can experience them with me. Stay tuned.

Turning Corners, Connecting Dots

Recovery, healing, and a new life reality are always around the corner. In healthcare, watching someone make that shift is incredibly gratifying.

Two of my current patients are both making great strides in their recovery, accepting help and attempting to make positive choices. One's drug of choice is alcohol. The other has a predilection for cocaine and heroin. Each one has other health problems which only magnify the urgency of making better choices: cirrhosis, hypertension, diabetes, neuropathy, depression, anxiety. No matter the constellation of comorbidities, the potential outcome---disability and death---is certain.

I try to offer a clean slate with each visit. My role, while multifaceted, is also quite simple. I provide guidance, compassion, tough love when needed, and a steady hand through the rough patches. I tell them: when the cravings come, call me. When the pain is too much, call me. When you feel like you're so afraid you want to die, call me. When you need a pep talk, call me. And these two people really do call---as do some others---and now it's paying dividends.

One of the secrets to guiding our patients towards health is getting them to pay attention. If they don't focus on the fact that their liver is affected directly by every drink, every drug, every decision, they just don't connect the dots. If they forget how important it is to tightly control their blood sugars, they lose sight of the prize. If they can't connect their current symptoms with their lifestyle choices, they're lost. Health is a complex entity, and seeing the lightbulb go off in their head is a gratifying moment in itself. Watching them use that lightbulb to illuminate their darkest corners of pain and regret is pure magic.

When it all comes down to it, it is compassion which drives the vehicle. Even when they come in, sit down in the exam room, and say "I fucked up. I used again this weekend. My life is over," I try to keep my expression neutral, my voice calm. "OK. You made a poor choice. But today you're here. Let's talk about today and tomorrow. What next? What's the next step?" I maintain my equilibrium, look them in the eye, hand reasurringly on their arm, my gaze steady but soft, open and inviting of confidence.

One man has been clean of alcohol since January of 2005 and has turned his life around. He is still struggling with the fact that he can't hang out with his old friends anymore and feels isolated. "I don't have much fun since I quit drinking. Everyone else seems to be having such a good time. It's lonely." But he keeps on the straight and narrow, and though his liver is riddled with cirrhosis, it seems we caught it just in time. While he may not be agood candidate for a transplant, he's a good candidate for a paradigm shift. He's living and eating well and trying his best. He turned a corner and never looked back. That liver will eventually kill him, but we don't focus there, turning our gaze forever on the present.

Another patient relapses again and again but now may be on the right road. I finally got him into an outpatient addictions treatment program and he's doing the work, plus going to meetings every day. Frightened of death and disability, knowing that his liver is damaged (but not yet beyond repair like the gentleman in the previous paragraph), he wants to do it all. He sees the cardiologist, shows up for appointments, sees our psychologist, and continues to make the right choices. We treat him like the respectable human being he is, with dignity and respect. He responds by coming back again and again, ready for more. I cant promise him he'll live forever, but I can promise him improved health and quality of life if he pays attention. And his attention is currently riveted----eyes on the prize.

For each patient who I cannot reach, who is lost to their own devices, there are several who respond to the call and step up to the proverbial plate. Their stellar performance, their willingess to engage again and again, that can keep me going. The others? I keep sending out the bait and trying to reel them in. Some respond from time to time, some crash and burn, many die. The hand is always there if they want it----if they can even see it. One such gentleman is now institutionalized forever, having ruptured his esophagus from intractable vomiting. He admits that he should have listened, that he should have known this day would come. Regretful and sad, his body filled with tubes, unable to ever eat or drink again, he is a living example of what happens when one fails to pay attention and falls into the abyss again. It's dark in there, and he was saved only by a miracle. He's a living example, a sad reminder to many. I feel such compassion for him, such sadness.

Back to the present, there are many more willing to take the leap of faith, and we're ready for them every day. What a treat to watch as a person turns that corner, beaming a smile of pride, and seems to finally "get it" in a way that is irreversibly joyful. The dark moments still come, the corners in need of illumination still harboring silent watchful demons, but there's still room for recovery and growth, the light filling the room with hope. That light is what we try to point out, and many thankfully refuse to shade their eyes and step over that threshold. It is a wonder to behold.

Change of Shift, Vol. I, No. V

Please surf on over to Change of Shift, Volume 5. Change of Shift is a new blog carnival by and about nurses and nurse bloggers. Please show your support by reading this newest edition. No charge!

A Question and an Answer

QUESTION: Tired nurse seeking fuel for his train running low on soul coal. Where does one turn? Exercise? Vacation? Gin? Meditation? Sleep? Narcotics? Dear Abbie? Dr. Ruth? Judge Judy? Dr. Phil?

ANSWER: Don't just do something. Sit there.

Mid-Week Fatigue

Mid-week fatigue rolls in on this nurse who just finished a 12-hour day plus time at the gym early this morning. I have that boy-my-feet-and-brain-are-tired feeling. Bone tired. This chronic pain thing is draining. Part of my fatigue is the extra weight of pain and discomfort throughout the day, with lost sleep for extra spice.

Tired or not, the patients keep coming, each with their individual needs. So many interactions fill a day. Hours go by, with myriad details flying around my head like so many swarming flies.

Each interaction, each situation, calls for a certain level of awareness and presence. I try to bring to each patient a sense that I am fully there, fully listening, hearing their complaints and responding to them in a way which helps them to feel heard. Beyond hearing, I look for teaching moments, as well as ways in which my actions will benefit that individual in some way, assuage a pain, relieve a worry, mitigate an annoyance. There is so much to do, so many choices to make.

Sometimes the days are like being in an asteroid belt, dodging and sailing around so many obstacles, potential clashes and frictions always on the verge of manifesting themselves. At other times, it feels like a battlefield, and as the telephone calls and faxes and unannounced patients arrive, the support staff yell "incoming!" like infantry in a foxhole. Then again it can sometimes just feel like an office with alot of hubbub, while I coast atop the crest of the wave, few ruffles of my feathers even noticed as I breeze along. Still other days, it is a nauseating roller-coaster, the carnie on an extended break and the ride set on an endless loop. Then we reach for the barf-bag and pass the Dramamine.

No Dramamine today. Rather, a need for deep sleep uninterrupted by pain, muscles crying out, disturbing my needed rest. Pain can raise one's compassion---for one's self and for others. It can be a very human reminder of the mortal corporeal reality in which we are ensconced, the dangerous pull of gravity which wears down our resistance, pulling us to earth like the proverbial ball and chain.

This physical existence, this dragging around a body---it's enough to make one realize just how much work it takes to propel yourself along through life. As healthcare professionals, we try to remedy that weight as it is experienced by our patients, but we cannot carry their burdens for them. No. We use compassion, skillful listening, and our own life's truth to guide us in our guiding of others along these difficult earthly paths. I feel the weight of gravity today. May tomorrow its pull be less noticeable, the strain of physicality assuaged for all who need that sweet relief.

Barely Living

Her home feels like a tomb. Her paranoia causes her to barricade the front door with the couch and hide in her room upstairs. She's lost her Personal Care Attendant services, her family have abandoned her, and she spins relentless webs of paranoia as she cowers indoors on even the nicest summer days.

The level of trauma which she has experienced in her life is something which I cannot begin to fathom, and the chaos of her mind is also beyond my ken. I can tell that it's muddy in there, but the muddiness is not within my ability to clarify. What I am able to provide is concrete: an appointment with our psychologist for an assessment, prefilled psychotropic meds in an easy-to-use daily med box, the number for psychiatric emergency services, holding her hand as she cries.

I offer a hug when I get up to leave her barren apartment which once teemed with life---children, teens, neighbors, grandchildren, visitors. The house feels so lonely, there are barely echoes of its former life. I know her husband died in this house and his ghost must haunt her still, not to mention the horror of finding him in their bed, blue and lifeless.

She complains of voices constantly telling her "horrible, horrible things." She peers through the curtains into the bright sunlit street and demonstrates for me how her paranoia manifests in fear-based obsessive-compulsive behavior.

What can I offer? Empathy? Sympathy? Emergency phone numbers? An appointment? Medications? I feel like what's needed here is an all-out exorcism, and I leave the darkened home, sobered and sad.

"Barely living" is what I think as I walk towards the clinic. Can we really prescribe a return to life?

On Blogging and Connectivity

I realize that I spend a great deal of my time either thinking about blogging, talking about blogging, or actually writing on my blogs. I am a great proponent of the medium, have now appeared in at least one article about nurse bloggers, and participate in two ongoing and regular blog carnivals which gather together the "best" of the bloggers in the medical, nursing, and allied health fields.

In the mainstream media, "blogger" or "bloggers" are generally lumped into one category---the political blogger---that pesky nuisance (or brilliant iconoclast, depending upon your opinion on the matter, of course) who breaks a story faster than ABC and makes Dan Rather look like a dinosaur (an easy task, I know, but still laudable, in essence).

Aside from the political pundits who inhabit the blogsophere, there are countless categories of bloggers filling the Web with what some might call drivel, but which I consider a portal into the lives, loves, longings and interests of millions of souls staring at a screen, fingers typing with intention. While some blogs which detail the ins and outs of rechargeable batteries may not be my cup of tea, the fact that an individual feels strongly enough about those batteries to publish his or her thoughts about them and share them with the world is, by nature (at least in my mind) a worthwhile task. Whereas some might postulate that the "battery blogger" needs to get a life, perhaps his life includes time devoted to filling one small mini-hectare of cyberspace with his opinion on the merits of various batteries. Is this in itself bad or good, productive or not? The person shopping for the ultimate rechargeable battery would certainly be grateful for the information on offer.

Strolling through any blog search engine will reveal that there are many, many people with something to say. The worth of those words and pictures are completely subjective, but the sense of connection and community which these communications can foster is certainly worthy of exploration. I'm interested to see what scholarly and popular tomes are written (on real paper) in the near future, examining the effect of blogs on culture, social connectivity, and the dissemination of information and opinion on a global basis, be it about batteries or Babar.

To some, sitting in front of a computer to "connect"with others might seem somewhat of a conundrum. Why not meet like-minded others in a cafe? A bar? A local gym? A meeting or club? Yes, all of the these are distinct possibilities, yet meeting people these days and forming friendships can be a slow and painstaking process, especially as life has taken on a propulsive velocity that precludes the practice of sitting in the town square and watching the people go by as we chat with neighbors and friends, making new friends and acquaintances in the process. The fact of the matter is that meeting for lunch, then going out for drinks, then getting one's families together to meet one another, is often a prohibitive experience for many new friends. If one is a parent, the taxiing and ferrying of children to and fro---and the complicated social lives of children---make it even more difficult for working adults to simply spend time over coffee, chatting and deepening friendships the old-fashioned way. For better or for worse (probably for worse), our culture has changed, and this type of easy social discourse is much more difficult to achieve, perhaps even in smaller towns previously untouched by the speed of life in the 21st century.

With blogs can come community, connectivity, and a sense of belonging. Nurse bloggers "meet" on-line and form strong professional and personal bonds. Posting comments on one another's blogs leads to personal email transactions, then telephone conversations, even face-to-face meetings. After a year of blog and email communications, my wife and I actually visited a blog-friend of mine in her hometown and we have begun a friendship built upon the foundation of the multitudinous and deep sharing we have done in the digital realms. The friendship moved from the virtual to the physical plane, and we are richer for it.

Beyond blogs, on-line social networking communities have created even more cohesive groups where individuals find like-minded people and congregate to discuss topics or issues of interest. often leading to "real-time" meetings, even international conferences and the like. Tribe, MySpace, Zaadz, Care2---these sites all carry the promise of connectivity, community, a sense of belonging, and a way to find those who share your interests without standing at a bar, ordering a beer, and asking the person next to you if they happen to like Jean Paul Sartre and would be interested in discussing Nausea with you for an hour or so. Zaadz is where I put my attention, a place dedicated to bringing together people who want to change the world. I also concentrate on the relationships fostered between myself and other bloggers, and the sense of true connection is something only the initiated can truly understand and appreciate.

I am by no means covering all of the aspects of blogging and social connectivity which could be put forth in such a missive. These are simply the late-night ramblings of a dedicated blogger and admitted email addict who sees that much good can come of such predilections, as long as one maintains normal real-world social discourse, takes time to read real paper books, drink coffee unhurriedly with friends at outdoor cafes in dappled sunlight, and delight in the scampering of a puppy pursuing a stick thrown by its owner in the neighborhood park. There is room for connectivity of all kinds in this world, and we all know that too much of any good thing---blogging included---can only myopia make.

So now I will peel my eyes from the screen, pick up my book, pour some tea, and connect with myself through the magic of literature and the fire it lights in my imagination. Meanwhile, millions of bloggers fill the ethers as they share their lives and loves and inspirations, digital tendrils snaking around the world, connections made, severed, reconnected and strengthened. What a tangled web we weave......

Moonlightin' Nurse

Now that my teaching days at the community college are done, I'm stepping up my moonlighting at two other per diem gigs. This nurse and his blushing bride don't seem able to earn quite enough from 9 to 5, so some evening shifts are de rigeur in terms of financial survival and debt relief, at least for now.

This evening was four home visits for a local visiting nurse agency which had woo'ed me for more than a year to take a full time position. I've refused their offers time and again---including a managerial position---but have taken on the mantle of "Evening Per Diem Nurse" simply to increase deposits to my checking account.

Interestingly, both of my per diem gigs reflect the nature of two previously held jobs during my early career as a nurse. My current work as a per diem visiting nurse harkens back to my previous employment at a locally-owned visiting nurse association which afforded me the opportunity to work somewhat autonomously, visiting 8 homebound patients per day, but bound and gagged by the specific orders signed by the supervising physician. I found that role stifling and clinically limited and lasted only a few years before being swept off my feet to the job which I now hold.

My second per diem position is within the community health center where my full-time care management program is housed as a contracting agency. I primarily chose to work per diem at the clinic so that I could gain access to various employee benefits at the hospital of which the clinic is a part, namely the employee gym where I work out several times per week for $20 per month. Aside from that, it gives me an insider's view of the health center and some measure of an edge when it comes to facilitating care for the 80 patients on my roster during my day job.

Wearing several different hats as a nurse can be confusing at times if one loses sight of what the particular scope of practice is for the position of the moment. While I may occasionally experience "role confusion" (ie: wanting to make an autonomous decision in my clinic role as Pod Nurse before realizing that this autonomy belongs to my full-time job), I'm relatively capable of maintaining my differentiation depending upon the role in which I am presently embodied.

Examining my three distinct clinical roles and their defined scopes of practice, I am immeasurably grateful for the breadth and depth of the autonomy which is the cornerstone of my full-time job, a reason why I remain in such a stressful and demanding professional position. Overseeing and managing the care of 80 people whose clinical disposition, comorbidities and occasionally chaotic lives can be an enormous challenge, but the freedom of practice which is the central aspect of my role more than makes up for the frustrations and vicissitudes of the job.

As much as it's difficult to work in two other positions which place me in a more, shall we say, "subservient" nursing role (ie: simply carrying out doctor's orders with relatively little room for personal initiative), spending time in those other "hats" gives me time to pause and reflect on the singular nature of what I do from 9 to 5, the authority and trust placed in me by my bosses and the doctors with whom I co-manage patients, and the ability which I regularly exercise of making clinical judgments and enacting plans of action vis-a-vis those judgments.

All this is to simply say that my "other jobs" can often serve to reinvigorate my 9 to 5 experience rather than just exhaust me due to the extra hours of labor after the 5 o'clock whistle blows. Would I rather not feel the need to work more than just my full-time job? Sure. But when push comes to shove, the Man Who Would be Nurse does what he must do, and then comes home to reap the rewards of a day's work well done.

Eavesdropping

You are a fly on the wall of an exam room today, and I'm facing a patient whose choices are not always the best, but she shows great promise.....

"I'm so worried about my liver, I've been thinking of killing myself."

"Well, your liver really isn't that bad."

"Are you sure? I'm so nervous. I took one of my mother's Ativans this morning. I just couldn't take it. I'm gonna die."

"We're all gonna die someday. I could die when I leave work tonight. You may outlive me by thirty years. But here we are right now."

"I don't wanna die. I'm shittin' myself."

"Look at the computer screen with me for a second. Do you see those lab values compared with two years ago? That indicates inflammation and damage to the liver. You were much worse off at that time. We're making progress."

"But I just did crack recently and was in detox for days! I keep telling myself that I don't really drink, but I have this whole box full of nip bottles. I just guzzled one after another."

"Look, everybody makes mistakes. The fact is, you went to detox, now you're clean. You've got a fresh start, a chance to begin again. Every day you're clean is a victory. Every hour you're clean is a victory. Don't look at the bigger picture---it's too overwhelming. You can say to yourself, 'Wow, I didn't use today. I didn't have any cravings. That's great! I went an hour without thinking about drugs. Wow!' "

"But I'm so worried. I went to the methadone clinic today, and somebody said, 'Hey, you look all stressed out. Want some Xanax? I've got some rock [cocaine] you could have.' Jesus, don't these people get it? I just got out of detox and they're offering me rock! Shit!"

"Part of recovery is changing the people you hang out with. Seeing those same old people every day just triggers you to use, or at least to crave it."

"But that's the thing----the methadone clinic is crawling with druggies. And the staff don't want me to get off of methadone---they don't want to lose clients. I need to get off of that stuff and away from those assholes."

"There is a place where you can be detoxed off of methadone safely, but you have to go every day for at least a month and really get with the program. There's counseling, nurses, a doctor to oversee your care, and they'll communicate closely with me. We also need to get you into therapy and to see a psychiatrist. If we don't deal with the depression and anxiety, we're missing a big piece."

"I wanna do it all! I'm ready. You've been so good to me, all I want to do is get it together. I don't wanna die, not any time soon. Do you think I have a chance?"

"You have all the chances you need right here in front of you. Let's go one step at a time. You look good, your labs aren't that bad, and you're ready to roll. Let's get you referred to those programs, and then for a liver biopsy so we know exactly what we're working with, OK?"

"All right. I'm ready. I'm gonna take good care of myself this weekend, go to meetings every day, and come see you Monday."

"Great plan. I really think you can do this, and we're here to help you make the right choices. Call me Monday."

"OK. It's a deal."

And with a handshake, she's gone, swallowed by the world, and the streets that tempt her at every turn. May every force for good in the universe be with her........

Prima Facie

prima facie \PRY-muh-FAY-shee; -shuh\, adverb:
1. At first view; on the first appearance.

adjective:
1. True, valid, or adequate at first sight; as it seems at first sight; ostensible.
2. Self-evident; obvious.
3. (Law) Sufficient to establish a fact or a case unless disproved.

To many of us, the desire for healing, for health and wholeness is prima facie, or obvious, a self-evident goal and marker of life's quality. From our priviledged middle-class vantage point, we go to the dentist for prophylactic cleanings, make sure we see our doctor, read labels on the foods we buy, make informed decisions about our healthcare and diet, and see this as a responsibility and a wise decision.

As healthcare providers, we are often faced with individuals who don't seem to make the same choices, who appear to behave in ways which would lead some observers to decide that our patients don't really care about themselves and have blatant disregard for the tenuousess and preciousness of life. But this is never truly as it seems.

What does one say to the middle-aged man whose father lashed out in blind drunken rages and threatened to kill the child who next spoke a word? How do you help him to see past his own addiction, his predilection for the numbing qualities of cocaine and alcohol?

How do I impress upon the thirty-year-old with AIDS that this current regimen of antiretrovirals is his final chance, that if he blows this one by not taking his meds correctly and religiously, the virus will mutate in ways which will preclude any futher successful treatment, pending the invention of new drugs which he could tolerate?

What do I say to the woman whose history of trauma leads her to acts of desperation, to somatic complaints for which we have no remedy, to blind rages that no counseling can relieve?

When patients' state insurance cuts all dental care for four years, ceases to pay for eye glasses, and does not cover $50 pairs of compression stockings for peripheral vascular disease, how does one convince a patient that they are valued and should value themselves? Patients have said, "The government doesn't value my dental health, why should I?"

How does a citizenry feel valued when their taxes increase, their benefits shrink, and the government appears to consistently abandon its neediest members while pursuing questionable policies which only enrich the wealthy and well-connected?

So, prima facie, at first appearance, it is easy---too easy---to impose our own middle-class standards of self-care and conscientiousness on our patients. We see their plight through eyes which have never been denied glasses. We speak through mouths which have received the dental care which they needed. We leave for work, bellies filled with nutritious food which fuels our morning, an equally nutritious lunch packed in our bag or awaiting us at a local restaurant of our choosing. As tax-paying working citizens, we feel validated, our education and relative luxuries cushioning and softening our days and nights.

Sure, it's easy to be self-righteous, to preach the gospel of the priviledged. It's another to see the plight of the disadvantaged and forgotten, and see clearly with eyes stripped of their middle-class blinders. Can I always do it? Not a chance. I'm as guilty as the rest.

We must all be reminded time and again, and we healthcare providers must also remind ourselves that there is only so much we can say, so much begging we can do, so much pleading we can verbalize. There are those whose psychic spines seem to have been broken beyond repair. It's hard to not be discouraged, not to feel angry, to blame the patient, their families, the government, the world, "the system". Our perceived powerlessness can be maddening to the point of tears.

At first appearance, there is so much we just cannot fix. But in the end, we fix that which is fixable and we move on, letting compassion guide our steps and hearts, and allowing realism to remind us that we can only do so much, and even we must sometimes let go.

Prima facie.

Eskimolitos and The Economics of Poverty

The heat gripped the city tightly today. The children pranced in the sprinkler park, and the elders sat in the shade of the trees playing Bingo and dominos. The youth played basketball, oblivious to the heat and the dire warnings of poor air quality and smoggy humidity. I don't know how many times I warned people to be careful in the heat today, sounding like a broken sweaty record.

At my wife's senior center, popsicles from the Department of Elder Affairs made the rounds---the Puerto Ricans call them "Eskimolitos".

All of our patients receive checks from Social Security on the first of each month, making that a relatively quiet day for the medical providers. Unfortunately, today---the hottest day of the year---was "Check Day", and hundreds of our clients and patients rushed around the city to cash checks, pay bills, shop, and otherwise hurriedly rid themselves of the small amounts of money with which they subsist on a monthly basis. I spent some time today worrying about the many people in compromised health who, out of force of habit, spent the hottest part of the day on the simmering streets.

This line of thought led me to consider the economics of poverty and how our patients do---and don't---manage their funds. In previous posts, I've described the extortionate prices that our patients pay for leased household furnishings and the money that's squandered on such high interest rates and fees. Similarly, our clients generally do not have bank accounts, choosing simply to cash their checks at a check-cashing facility (which takes a cut, of course) and subsequently paying their bills from the same store (with additional fees paid for each money order written). Add to this the extraordinary amounts which people pay for premium cable television service, and it's no wonder that when push comes to shove, there's precious little money left for such things as prescription co-payments and extra fluids and popsicles for hot weather. It's enough to make a nurse steam with incomprehension.

So, there they all ran, the macadam soft under their shoes, their monthly stipend from the federal government dwindling at each stop. Some walk, some take the bus, some get rides from neighbors, friends, and family members. Their children hopefully learn to use banks, checks, debit cards, and on-line bill-paying, leaving the old-fashioned money orders and fees to the elders. Check Day is a monthly phenomenon, an orgy of consumption, a rush to fill the cabinets and stock the fridge, pay the rent, and flatten the bills. With poor planning, the final week of the month then becomes a time to scour the cabinets for that last can of beans, visit the free lunch program, or find a ride to the food pantry.

Today, the heat be damned, they criss-crossed the city in a mad dash of accomplishment and consumption (not to mention responsible bill-paying, a praiseworthy practice). One diabetic and asthmatic patient of mine arrived to the senior center sweaty and dizzy, with a blood sugar of 59 and a roaring headache, but it was nothing that a little Eskimolito couldn't cure.

And the temperatures will only rise tomorrow.