New Year's Eve Ruminations

A friend sent me this incredible link to an on-line video which I highly recommend. You can find it here. It is an inspirational, humbling, and provocative evocation of what it means to be a citizen of the Earth at this point in human history. A fitting moment of reflection at the turn of the year.

Concurrently, I also recommend visiting this site for a microscopic view, equally humbling in its representation of the complexity and beauty of the world in miniature.

Both of these experiences provide ways to get out of one's own way and see one's place in the world for what it is---an infinitesimal part of the wider web of life. In our peripatetic lives---wandering from person to person, place to place, experience to experience---our own lives become so big in our eyes, and we so easily lose sight of the bigger picture. When we curse our broken toaster and lament the money we will spend on a new one, we miss an opportunity to think of those who have never known such luxury and convenience, and perhaps haven't even been blessed with a piece of wholesome bread to eat for months. Sure, a broken toaster is a drag, but if you can just go ahead and buy a new one without so much as a second thought, you have precious little to grumble about. I say this to myself more than anyone else.

It is so easy to lose perspective. Sogyal Rinpoche writes about "cherishing" one's self to such an extent that one wears blinders towards the plight of others. I remind myself more than anyone that gratitude is the key---giving thanks for what I have, not focusing on loss and what-if scenarios. On her desk, one of my colleagues has a quote posted next to her computer monitor: "If the only prayer you said in your life was thank you, that would suffice" (Meister Eckhart).

So, in keeping with the tradition, here's to letting go of the old, ringing in the new, and accepting the past as done. Any new year, be it secular or religious, offers a fresh start. The fact is, every sunrise offers a fresh beginning. Taking that thought even further, every breath offers an opportunity to start again. Imagine that, a "new year" every moment. "With this breath, another year begins. With this breath, another year begins....." (Let's just agree that a glass of champagne does not need to accompany each breath. since precious little would ever be accomplished!)

Tonight, Mary and I will make New Year collages to visualize our goals and aspirations for 2007. We will listen to our favorite New Year's Eve song, "Sacrificial Bonfire" by XTC, and probably be sound asleep at midnight.

For all you revellers, dreamers, seekers, and beings great and small: Happy New Year and many happy returns.

Sacrificial Bonfire

Lyric by: Colin Moulding

Fire they cried
So evil must die
And yields are good
So men pull back hoods and smile
The scapegoat blood spilled
Spittled and grilled it crackled and spat
And children grew fat on the meat
Change must be earnt
Sacrificial bonfire must burn
Burn up the old
Ring in the new
Assembled on high
Silhouette against the sky
The smoke prayed and pranced
And sparks did their dance in the wind
Shadows wore thin with less and less skin
And the clothes that were draped
Was all that told man from ape
Change must be earnt
Sacrificial bonfire must reign
Reign over good
Banish the bad

© 1986

An Enlightened Vision of Death & Dying

It is crucial now that an enlightened vision of death and dying should be introduced throughout the world at all levels of education. Children should not be “protected” from death, but introduced, while young, to the true nature of death and what they can learn from it.

Why not introduce this vision, in its simplest forms, to all age groups? Knowledge about death, about how to help the dying, and about the spiritual nature of death and dying should be made available to all levels of society; it should be taught, in depth and with real imagination, in schools and colleges and universities of all kinds; and especially and most important, it should be available in teaching hospitals to nurses and doctors who will look after the dying and who have so much responsibility to them.

---Sogyal Rinpoche

It's a Wrap

At 4pm today we locked the office doors, popped the champagne and sparkling cider, toasted a year well done, and called it a day, or rather, a year. There is always something satisfying about handing in that last paperwork of the year, submitting the final time sheet and expense report, dashing off those last emails, and shutting that door. It has a comforting feeling, leaving the year of travail and sweat behind, readying oneself to receive the new. Whatever happened, whatever failed to happen, whoever lived, whoever died, it's all part of the stream now, and we can let it all just wash away.

"See you next year!" was the refrain as we began to file out the door, some lingering to put final touches to their work, as always. Yes, Bono did indeed sing "nothing changes on New Year's Day", but something does change, if at least internally.

This evening afforded me a massage and a haircut, then a return home for a shower and a shave. Clean, shorn, with pajamas and the warmth of home, 2006 begins its denouement, and I could not be more content.

The Late December Challenge

Here we are at the fulcrum of the holiday season, with Christmas and Hanukkah behind us, Kwaanza beginning, and the secular New Year on the verge. The challenge for me right now is to embrace and finesse the need to return to work and contnue walking the walk while my heart and soul cry out for long naps, luxurious time with my sweetheart, and the natural desire for semi-hibernation and focus at home.

Patients' needs do not decrease in the holiday season---why, they seem to inflate. Survivors of trauma and family dysfunction are triggered during this time of year, and physical and psychological symptoms come to bear. I am myself not immune from such manifestations. and my deepest desire is to hole up and nurture my own heart.

Suffice it to say, this time of warmth and family and togetherness has a flip side which can lead to introspection, memory, and the need to look within.

Finding the balance between the inner and the outer is certainly the challenge of the day.

Compassion Versus Pity

Compassion is a far greater and nobler thing than pity. Pity has its roots in fear and carries a sense of arrogance and condescension, sometimes even a smug feeling of “I’m glad it’s not me.” As Stephen Levine says: “When your fear touches someone’s pain it becomes pity; when your love touches someone’s pain, it becomes compassion.” To train in compassion is to know that all beings are the same and suffer in similar ways, to honor all those who suffer, and to know that you are neither separate from nor superior to anyone.

---Sogyal Rinpoche

Spiritual Identity in Middle Age

So, here I am, admiring our Christmas tree, a middle-aged man with nothing but Jewish roots traced back generations to the permeable borders of eastern Europe in the 1800's and early 1900's. Well, how did I get here, anyway?

Raised in a admantly secular, non-denominational home in suburban New Jersey, I grew up celebrating Christmas and Easter as the ubiquitously plastic-coated, gift-wrapped confections of post-WW II middle American culture that they generally are. My parents, both Jewish New Yorkers, left New York for the Jersey suburbs in 1951, assimilating into a predominantly white Christian culture, with a Christmas tree in the living room and chocolate bunnies in April. Occasionally visiting my observant Jewish cousins and extended family in New York and Long Island, I would get a fleeting taste of the alien Judaic world, returning to the safety and cultural anonymity of our assimilated existence.

Unlike some adult Jews who "rediscover" Judaism later in life, I continue to feel drawn in other spiritual directions, pagan and otherwise. Morphing from teenaged devout atheist to twenty-something agnostic seeker to middle-aged spiritual eclectic, I guess I'm just one who dares to not embrace the root culture, striking out for something uniquely my own. Some would call me confused, others would feel sorry for my loss of identity. Still others would simply see someone caught in a world he never made, making lemonades from so many lemons. However ill-defined, my spirituality and sense of self amidst the great Universality of Being is a constant work in progress, and while this is certainly not a dress rehearsal, I apparently still don't know my lines.

Some day, I'll exit stage left, and whether I meet St. Peter, Moses, the Buddha, Jesus, Paramahansa Yogananda or my old dog Sparkey, I know that ease and bliss await me in that Great Beyond. Will I know the script? Probably not. But just as I did while traipsing the Earth, I'm sure I'll just fake it 'til I make it.

Unnecessary Disparities

On holidays, I always seem to think about my patients, especially those without family who spend those special days alone. This year is no exception. It's not my intent to throw a wet blanket on holidays and family time, but it is so easy to simply forget those who sit alone when millions of people feast and frolic with family. Several of my patients of whom I am exceedingly fond are certainly going to be alone on Christmas, and my personal challenge is resisting any guilt I feel while celebrating with my family, as well as resisting the urge to rent a van, pick them all up, and go out for a big Christmas dinner.

When my son was fourteen or so, I was a visiting nurse and had to work on Christmas Day by necessity. So, when I went on my rounds that day, Mary and Rene accompanied me, waiting in the car during some visits, and coming in to spread holiday cheer on others. It was a learning experience for my son when we visited an elderly gentleman who literally lived in a shack in someone's back yard. With bilateral amputations from poorly controlled diabetes, he struggled to survive, going to dialysis three times a week and trying to avoid falling through the holes in the bathroom floor as he rolled in his filthy wheelchair. Sitting on his equally filthy bed, we presented him with several simple gifts and my son got an eyeful of how so many people live around the world, even here in the ersatz Land of Plenty.

I feel like I could spend one of these upcoming holidays in the streets, handing out gloves and hats and snacks, redistributing even a little wealth among those who have less than they need and deserve. Come to think of it, working with the poor day in and day out, I don't feel an overwhelming urge to join the well-meaning thousands who pack the country's soup kitchens on Thanksgiving and Christmas as their annual pilgrimage of community service. As many soup kitchens and food pantries will tell you, holiday time---when people are more apt to be generous---is usually the flush time of the year. It's the other eleven months when we all need to awaken from our collective stupor and think of others without the reminders of ubiquitous Salvation Army bell-ringers in front of our local grocery store.

Are these reminders wet blankets? I hope not, but it is the time of year when we naturally give thanks for what we have, observe those who are not so blessed, and possibly resolve to do more
to assuage that overwhelming and unnecessary disparity.

Tis the Season

Today at our health center, the annual Community Christmas Party is held. One of the doctors, dressed as Santa, sits in one of the nurses' stations in a big red chair, surrounded by medical assistants and nurses dressed as elves. Hundreds of neighborhood children line up with their parents to sit on Santa's lap and receive an age-appropriate gift which has been lovingly wrapped by clinic staff over the last few weeks. Donations of toys pour in, and the wrapping paper and preparations take over several rooms from December 1st until today. Music plays in the lobby, food and drink are for the asking, and the health center gives back to the community yet again, this time with cheer, gifts, Polaroids of each child, and a spirit of giving that permeates the air.

Across the park at the Senior Center yesterday, my wife was involved in a toy distribution project which gives age-appropriate gifts to local grandparents, ensuring that each elder has at least one toy for each of their grandchildren.

Privately, Mary and I are raising money for a Jamaican friend who is trying to finish building his humble home before the winter rainy season begins. This disabled gentleman, a talented artist with Post-Polio Syndrome, helped us to repaint and decorate the Children's Ward of a poor rural hospital in eastern Jamaica when we were doing community development work with Global Children back at the turn of the century. Although our project has since ended, we continue to support this one person in improving his life, and we may sponsor him for a three-month visa in 2008. If any of you would like to donate as little as $2, please email me privately.

One of my patients gave me and my wife gifts of perfumes, colognes and other scented products for Christmas. Since we both suffer from Multiple Chemical Senstivity, those gifts needed to be recycled elsewhere. Thus, I dropped them off at our local shelter for families in transition where they will be happily re-gifted.

As this season of open-heartedness comes to a close, the giving and openness to others must continue to be propagated and expanded upon throughout the year. While I will always applaud the acts of generosity engendered by the spirit of the season, I urge us all to continue that practice, even as the memories of the holidays fade.

The redistribution of wealth and prosperity certainly has a place at this time of year, as conspicuous consumption becomes the order of the day. Still, conspicuous consumption is part and parcel of the American Way, therefore conspicuous deconstruction of the consumer society must continue unabated.

To all who give to others, sincere thanks. To all who live their lives in love and compassion, my heartfelt solidarity. To all those who are yet to open their hearts just a little bit more, there is no better time than now.

A (New) Blog Is Born

The original purpose of this blog was to have a creative space to ponder my life, write about it, and have a place to go at the end of the day where I can be myself and process this life on earth. Although that end has been accomplished, the vicissitudes of my work as a front-line community nurse do indeed garner the lion's share of my attention herein.

Thus, I have created a tertiary blog (apart from Digital Doorway and Latter Day Sparks) where I will use my love of amateur digital photography with my Treo smart-phone (luckily provided by my work at no cost) as an extra key to creative expression. Please surf over to A Nurse and His Treo from time to time, if you please. You will find links to my two "side blogs" on the right of your screen.

Thanks, dear Readers, and many blessings of the season.

Will Atlas Shrug?

"You know you could die tonight if you don't go to the hospital," I tell him.

He lies on his messy bed, smelling of feces and vodka. A plastic bucket sits beside the bed as an ersatz spittoon. He misses more often than not, gobs of chewed tobacco caking the dirty wooden floor. I notice that the toilet seat is caked with feces. There are more than 20 empty vodka bottles piled behind his bed. He stares at the TV tuned to Spanish soap operas.

"I won't go to the hospital. I won't go." He stares intently at the TV.

"Look," I respond in Spanish. "Your blood pressure was more than 200/120 yesterday and today I can't even hear it. You have no pulse in your wrists, and I'm afraid your pressure may be dangerously low."

"I'll stay here in bed and take my medicine. I'm not going anywhere, and that's that."

He tells me he fell a few hours ago on his way to the bathroom. He was very dizzy.

I call the primary doctor. She advises me to write a letter for him to sign, stating that he understands he is going against medical advice by refusing to go to the hospital. She also says he shouldn't take any more meds until I can recheck his pressure and pulse. He readily signs the paper with his shaky signature.

"Are you sure you won't change your mind? I'll feel bad if you die, but that's not important. Your health is most important. Do you care that you could die?"

"I don't care. I'm staying here."

I leave messages on his brother's cell phone and land-line, saying that his life may be in danger but he refuses to go to the hospital. I know his brother is at his wits' end and doesn't know what else to do. This man, the oldest of six, is a helpless and hapless alcoholic, pouring vodka down his throat like gasoline on a fire. His end is written all over his face in pure and deep pain which I will never understand. I hide his medications in a kitchen cabinet so he won't take them by accident. I offer again to call an ambulance but he waves me away like a pesky fly.

I walk down the four flights of the fire escape, feeling somewhat dejected. It's cold. The wind whips through the sorry city. He could die tonight. Does he really not care? Is he that far gone? What about the others who can't pay attention long enough to take their AIDS meds? And the smokers with COPD and asthma? And the other alcoholics with cirrhosis? And what about the diabetics who gorge on sweets and leave their pancreas abandoned on its own road to self- destruction?

My shoulders hurt. Am I carrying the weight of the world? If I was Atlas, I'd probably shrug it off and take a long winter's nap.

A Short Break

Dear Readers,

Please pardon the brief period of silence. The holidays are upon us, and a weekend trip to visit family precluded my appearance here since last week. Please stay tuned and check back in the next several days.

Merry merry. Happy happy.

Area of Refuge

I came across this sign recently while visiting a medical office building. On the pragmatic side, I wanted know what the meaning of this sign was. Where was the area of refuge? The arrow simply pointed to a non-descript hallway. Was there some hidden meaning? Was this hallway earthquake-proof? Fire-resistant? Spiritually protected? It seemed so mysterious.

On the metaphoric side, I took the photo with my trusty little Treo smart phone solely in order to show other people that I actually saw this sign and felt that its metaphoric value far outweighed its practical and intended nature. We all need areas of refuge in our lives. Is it our living room? Our porch? Our workshop? Or perhaps a beach, or the mountains, the forest, a favorite city park. Some individuals find refuge in their own enlightened minds through meditation. Others find refuge in their bodies through exercise, yoga, dance, or painting. Still others find refuge in substances, both natural and synthetic, which disconnect them from their bodies for a while, or perhaps even make the body a playground of sensation and experience.

In her beautiful book Refuge, the author Terry Tempest Williams uses the Great Salt Lake---its risings and fallings, and the lives of the wild birds around it---as a metaphor for refuge, as well as a geographic touchstone for the actual peace she experiences on its shores as she struggles with a seeming epidemic of breast cancer in multiple generations of women in her family.

What is your refuge, dear Reader? Where does it lie? Is it within? Without? Have you not yet found it?Do you need a new one? Have you not tended your refuge for a while? Take a moment, if you like, and find that refuge---perhaps for the first time, or maybe for the thousandth---then give yourself the gift of visiting that sacred space soon.

Namaste.

Of Interns, Residents, and Sleep Deprivation---A Hippocratic Conundrum

The hospital with which my agency is affiliated is a teaching facility. I fully support teaching hospitals and the vital service which they provide as training grounds for almost-minted doctors, and I try my best to be friendly and helpful with med students, interns and residents with whom I come into contact. The second-year residents who actually take on a caseload at the clinic cause me no end of frustration, however. While they leave for two months at a time for rotations through the ICU and OR, I'm left holding the bag, trying to figure out how to move forward with a patient's care when these clinicians are otherwise engaged and en absentia.

Those interns and residents who choose to specialize in Community Medicine frequently cycle through our health center, and I am often asked to take some of those docs-to-be out into the wilds of the city for a realistic community experience. On one occasion, I brought a quite sheltered medical student on a home visit which turned ugly, the irate patient (with a history of violence towards medical providers) making threatening gestures and behaving in a very unstable manner. I wasn't sure if there was a firearm in the house or not, but my patient's alleged connections to drug dealers and a certain underworld element added to the sense of danger and excitement. That medical student sure got an eyeful, and he probably went on to specialize in something safe, far removed from drug-infested apartments and wild-eyed patients seeking Xanax. Luckily, no one was hurt, I kept myself between the student and the patient, and eventually talked my patient into an ambulance after dialing 911 as I followed him out into the street as he yelled and gesticulated, arms waving wildly. In retrospect, he was quite high and we were at great risk. Live and learn. Emphasis on "live".

Apropos of medical residents and interns, I heard a story today on NPR detailing the travails of medical interns as they negotiate the 30 to 36-hour shifts often thrust upon them. Even though regulations were put into place several years ago to limit interns to 80 hour work-weeks with mandatory 10-hour rest periods between shifts, these standards are not enforced and wannabe doctors log inhuman hours, their sleep-deprivation often putting patients---and other clinicians---at risk.

Numerous articles detail increased risks of medical errors, job-related injuries, increased incidence of car accidents, and most interns reporting having exceeded the limits put in place in 2003. A study at Harvard Medical School showed that "staying awake for 24 consecutive hours induces decrements in human performance similar to a blood alcohol level of 0.1 percent." The NPR story bandied about statistics that the risk of errors increases 700% when interns work 30-hour marathon shifts, and that the risk of fatal errors triples. One anonymous intern reported actually falling asleep while performing a cardiac exam, his head literally hitting the patient's chest. The Harvard study reported by NPR used instruments attached to the interns and residents to monitor their sleep/wake cycles, much like the instruments used to monitor astronauts' sleep cycles in space. The results are cold comfort.

As a nurse, not only am I concerned for my patients who are hospitalized, I am concerned for my medical colleagues who are undergoing such an "education", for the drivers on the road at risk of accidents caused by sleepy interns, and for other employees who may experience injuries---such as needle sticks---when working alongside a sleep-deprived resident. Even when residents are rested, I still occasionally need to correct small errors or point out discrepancies to the precepting doctors at the health center. How many errors could be avoided if the 2003 guidelines---or even stricter edicts---were actually enforced and obeyed?

Many sources state that a "culture of suffering" among generations of doctors keeps this practice alive. There is a sense that "if we could do it, they can do it" mentality, subsequent generations tormenting their juniors with the same long hours and deprivations which they survived during their own residencies. This smacks of fraternity-style initiation practices which fail to advance the cause---better doctors---without incurring great risk of harm. A conundrum of Hippocratic hypocrisy presents itself. That said, doctors used to smoke in exam rooms and nurses' stations---did we keep doing that just because it had always been so? Something needs to change, and when thousands of patient deaths are attributable to medical errors due to fatigue, a public health crisis looms before us with a horrendous human cost.

Although many residents and interns and student nurses perform their duties very well, I have reminded patients who were uncomfortable being seen by a student that they have a right to refuse such care, demanding a staff doctor. As a student nurse, I was once or twice in the position of being told that I could not provide care to a patient, a "real nurse" having been requested. We must all recognize that subsequent generations of doctors and nurses must learn patient care in the real world with hands-on experience at every turn, and only this will create the generation of providers which we will continue to need ad infinitum. Still, when avoidable death, injury and illness result from the poor management of such programs, patients and staff suffer the very real consequences.

Something must be done. Multiple studies have all yielded the same results: our medical interns and residents work too hard for too many hours, and provide hands-on care for our mothers, sisters, lovers, and children in debilitated physical and mental states . A 700% risk of unavoidable errors is unacceptable, and we will all continue to pray that it is not us---or our loved ones---suffering needlessly from medical bravado and hubris. Education is crucial, but human life trumps all.

A Lightning Flash

Life, as Buddha told us, is as brief as a lightning flash; yet, as Wordsworth said: “The world is too much with us: Getting and spending, we lay waste our powers.” It is that laying waste of our powers—that betrayal of our essence, that abandonment of the miraculous chance that this life, the natural bardo, gives us of knowing and embodying our enlightened nature—that is perhaps the most heartbreaking thing about human life. What the masters are essentially telling us is to stop fooling ourselves: What will we have learned, if at the moment of death we do not know who we really are?


---Sogyal Rinpoche

Illness as Metaphor

Browsing through an eclectic used bookstore recently, I came upon a copy of Susan Sontag's small but mighty "Illness as Metaphor", published in 1978. Sontag uses her wisdom and literary talent to expose and debunk the myths which blamed the victims of tuberculosis (in the 19th century) and cancer (in the 20th century) for their own conditions, often exacerbating their suffering by propagating myths which have the power to discourage rational thinking and the pursuit of the best treatments for disease. Although I fully embrace the idea of the mind-body connection, certain writers, thinkers, public institutions and media sources have often used fear, ignorance, and outright bigotry to hold sufferers of certain diseases at arm's length, rendered single-handedly responsible for their plight. Fear of death will turn humans away from their suffering brethren, and Sontag points out that TB and cancer were hallmark cases in such treatment and myth-making.

Making my way through the first few chapters, I immediately began to wonder how this idea has been treated by writers and thinkers vis-a-vis the AIDS epidemic. A quick Google search revealed that, lo and behold, Sontag had revisited the ideas of her original book in a follow-up treatise, "AIDS and its Metaphors", published in 2001, which I am now very keen to read.

Although I have yet to finish the former work of Ms. Sontag and am as yet uncertain if I will agree with 100% of her thesis, I can immediately agree that language has been frequently used as a weapon against the sufferers of myriad diseases. I am sure Ms. Sontag will address in her second work the notion that AIDS began in the early 1980's as a "gay" disease, with large numbers of gay men in urban centers falling prey to a strange "gay cancer" erupting on the skin like so many bruises. The long-esgtablished marginalization and social isolation of the gay community allowed mainstream America to ignore its importance, many claiming that AIDS was a punishment by God visited upon the "wicked" homosexuals and their "unnatural"ways. Photographs of early protests even show evangelicals holding signs using the word "gay" as an acronym for "Got AIDS Yet?" or "God Abhors You."

Words are powerful, and even those of us with the best intentions may at times use them to the detriment of others. In my position, it is all too easy to fall into blaming those affected by substance abuse, eschewing the disease model and embracing the notion that these individuals are wholly responsible for their actions and should know better. Life experience alone will convince most thinking individuals that substance abuse and the suffering it engenders goes well beyond a simple "personality flaw" of the sufferer. Similarly, depression---experienced by millions of people around the world---responds quite poorly to admonitions that one should simply "get over it" and "cheer up". Research bears out that substance abuse and mental illness have genetic, physiological, psychological, and chemical components over which we do not have complete control. Exasperation with a recalcitrant substance abuser is one thing---outright blame is another.

AIDS, cancer, substance abuse, disfigurement, disability---any and all of these conditions can cause the uninitiated or ignorant to turn their faces in disgust or denial, the common denominator being fear. Fear of death, fear of mortality, fear of the unknown, fear of the "other"---our fears will often prevent us from looking another in the eye and see their suffering as if it were our own.

Each day is an invitation to open ourselves to the suffering of others, and each time we embrace that opportunity, we further the causes of compassion and love. As Mother Teresa once said in one of my favorite quotes of all time, "I have found the paradox that if I love until it hurts, then there is no hurt, only more love."

Interstice

interstice \in-TUR-stuhs\, noun;
plural interstices \in-TUR-stuh-seez; -suhz\:
1. A space between things or parts, especially a space between things closely set; a narrow chink; a crack; a crevice; an interval.
2. An interval of time.

Today is a Friday at home. While the ostensible reason for not working is my dog's recovery from knee surgery yesterday, this is also a chance for me to take yet another breath amidst the maelstrom that can be the workweek.

Earlier this week, I described a patient with AIDS who has dementia of unknown origin. Luckily, he came to his appointment at the clinic with our Infectious Disease specialist after leaving the hospital "AMA" (against medical advice) twice in one day. Aided and abetted by his family, this demented man in need of an extensive workup was back in the community where he should not have been until we had made some treatment decisions. With great skill, the whole team managed to convince him to be readmitted to the hospital---where he is safely ensconced as I write. A collective sigh of relief can be heard, despite the fact that we still have no known cause for his symptoms.

Another patient has spun out of control again. I have taken her off of her AIDS medications since she just can't manage to take them correctly, if at all. She's living on a knife's edge and she knows it. Will her school-age children live through their teen years with or without their mother? What hope is there for them?

Still another patient will simply not even talk to me about why he isn't taking his meds. He knows that his options for HIV treatment are dwindling, yet he continues to throw it all out the window, even as his wife is a model patient and takes her meds like clockwork.

Yet another person has taken his recent hospitalization and illness as a sign from God that he now has a second chance. He has rededicated himself to his medications, his health, and his survival, especially in light of his granddaughter with whom he is totally enamoured.

It's hard to care so much. Some patients engender such concern, while others engender quiet indifference, or at least a feeling like indifference. I guess we all have patients whom we would rather avoid, those who drain our energy and come across like psychic vampires, bottomless pits of unmet need. This may seem harsh, but down in the trenches it's a fact of life. There are some patients for whom we will move Heaven and Earth, and some for whom we are simply not disposed to go above and beyond. Motivation and the assuming of responsibility on their part has an enormous impact on how we finesse that dance.

Anyway, it's time for some cuddle time with my little Tina, who moans in distress beneath the table. She's not the easiest of patients, but she makes up for it in so many ways. Her wish is my command.......

Scenes From a Day at Work

Bang Head Here

In yesterday's post, I wrote of a patient with dementia who is driving me to repeatedly connect my forehead with the nearest wall. Today, my bruised forehead is crying, "Uncle!"

As I described last night, my patient eventually arrived to the hospital after much hemming and hawing. He reportedly made it through the night---with some complaining--after undergoing some bloodwork, a chest x-ray and a CT-scan of the head. This morning, I arrived at the hospital with my Nurse Practitioner colleague and we read through the patient's chart. He was not in his bed, and we assumed that he was downstairs for his brain MRI and lumbar puncture. I noticed some discrepancies in the chart, left a note with my cell-phone number, and we were on our way.

Two hours later I receive a call that said patient actually left the hospital---without a word to anyone---in a cab this morning in the company of his son who had spent the night with his father in the room. That was the first strike of the ol' forehead against the wall. I was then informed that he would lose the bed entirely if he did not return immediately. They had not deemed him a "flight risk" and the examining doc found him "competent". "How could he be competent when he thinks he bought a plane in Puerto Rico yesterday?" I retorted. There was stunned silence on the other end of the line. I banged my forehead again. Harder.

I began to work the phones. No answer at the home phone but I managed to reach the patient himself on his nephew's cell. To wit:

"Where are you? You're supposed to be in the hospital."

"I had to come home. I was going to lose my apartment, and the plane that I bought in Puerto Rico."

"You aren't well, and you have to come back now. Put your wife on, please." I tried to be patient, I really did.

"Hello?" said his wife.

"Why isn't he in the hospital? He's not well. You can't let him make decisions like this."

"I don't know what to tell you," she replied.

"Well, I'll just tell you that he needs to be back at the hospital immediately."

"OK, we'll go now."

I continue with my day, paging the attending doctor that he is on his way back to the hospital and they should hold the room. I call the Infectious Disease doc who deemed him competent and I suggest a real psych evaluation for competency and a sitter in the room for the duration. I also point out discrepanices I noted on the inpatient med list.

An hour passes. And another. My forehead begins to feel better.

My cell phone rings. It's the Infectious Disease doc.

"Keith, I'm afraid I have bad news."

I prepare my forehead for further abuse.

"He came back to the floor, and we told him to settle in his room. He asked if he could go out to smoke, and the charge nurse told him he'd have to wait 30 minutes until everything was in order. When she returned to the room, he was gone. That was an hour ago."

I put the call on hold, brace my hands against the wall, and continue making a lovely dent in the sheetrock wall next to my desk. There's probably chips of paint stuck to my forehead by now. Should I switch to a filing cabinet?

I call the patient again, and the family is at a loss as to why he left again, who was with him, and why they allowed this demented person who thinks he owns a plane in San Juan to leave the hospital. I explain that his chest x-ray was abnormal, he needs a brain MRI, a CT scan of the chest, a lumbar puncture, and his serum ammonia level is high, dangerously so.

"We'll bring him to the clinic tomorrow" is all they say.

"OK, that will have to do." I finally give in. What more can I do?

"He must come in tomorrow to see our infectious disease specialist---no excuses." I hang up the phone.

Oh, my aching head. Maybe I should switch to meditation and abdominal breathing. But the feeling when my head hits that wall is just so satisfying........

Consternation and Potatoes

Things seemed to be improving. I wrote of his situation recently and was encouraged by some signs of improvement reported by his wife and the visiting nurse. Now, things just seem to be going downhill.

A call from the visiting nurse today informs me that he is increasingly unsafe in the home, the family not really coping as would be desired, and the patient's health at risk. Nightmares, violent dreams, wandering through the house at night, smoking in bed---not very good signs, I fear.

So, many telephone calls later, and we manage a direct admission to the hospital without a trip to the emergency room. Not an easy task. The primary doctor pulled some strings and I received a harried call at 1pm that a bed was ready and the patient needed to get down there as soon as possible. I reached his wife, and she agreed to get him there within the hour.

Five hours later, I'm washing potatoes for dinner and my cell phone rings. The Caller ID shows me that it's the hospital. "Oh good," I think, "the admitting doc is calling me for my input." Maddeningly, it's the Admissions Department. The patient never showed and the bed will be given to the next patient forthwith.

I call my patient's family. "Oh, he's out with his nephew," is the response I receive from a rather blase family member. "Do you want his cell phone number?" The potatoes need cutting but I'm steaming mad.

One call to the aforementioned cell-phone yields the information that the patient wants to go "tomorrow". The nephew says, "He's tired."

"First of all," I said, "do you realize how much work went into getting this bed for your uncle? Second," I continued, "just this morning, he insisted that he bought a plane in Puerto Rico yesterday. Are you giving him control over when he goes to the hospital when he can't even feed himself and thinks he's in San Juan? Aren't you all even a little worried?"

"I'll have him there in forty minutes," he responds.

I resume preparing the potatoes and Mary comes home to see the look of consternation on my face. In some ways, it's no different than my patient who just didn't show up for her cholecystectomy and liver biopsy. "I was busy," she said when I called her, incredulous that she would no-show for surgery.

Sometimes I wonder what it is we're doing. Sometimes I wonder what my patients and their families are thinking. Sometimes I would like my forehead to make repeated contact with a nearby wall. Sometimes I wonder what it would be like to wash potatoes from 9 to 5.

At any rate, my hope is that by the time I post this missive, my demented patient is happily or unhappily ensconced in a safe hospital bed, and the grand neurological work-up can commence. Meanwhile, I'll get some needed sleep and leave the forehead banging for another day.

Small potatoes in the bigger picture? Sure, but at times like these, there's nothing like a blog when one needs to kvetch.

The Winds of Compassion and Loss

Today, December 2nd, 2006, is the 5th anniversary of the killing of Woody---our closest family friend and honorary uncle to our son---at the hands of the police. I do not wish to discuss the details of the event, and feel no need to publicly admonish those who took my dear friend's life so needlessly. Any readers who want the larger story can email me privately.

This anniversary marks a closing of a chapter, our energies collectively focused on moving forward rather than being mired in the past. On the back of my car a bumper sticker states, "Love your enemies". Although this advice also applies to me, my ability to do so is still quite challenged in this regard. On some level, I still wish psychic suffering upon those who shot my friend, the final bullet penetrating his back as he lay handcuffed and bleeding on the ground. Love my enemies? Somehow, perhaps, I do love my enemies spiritually, but my all-too-human ego still cannot embrace them.

Not being a stranger to loss, being connected with others who are also bereft, allows the winds of compassion to blow between us. I understand the denial and disbelief when the news first arrives, the gut-wrenching grief as the truth sinks in, the anger that rips through the fabric of sadness like a knife, and the lingering loss that remains when all other emotions have faded. It's a club to which most every human eventually belongs, and its members are legion and growing.

This day also marks the three month anniversary of the death of our dear and loyal dog Sparkey. Sparkey and Woody were quite the pair, often barrelling together through the woods, returning to the house bleeding, limping, panting, and grinning from ear to ear. They seemed like brothers then, with matching red and golden fur, both unconditionally loving and loved. We miss them both so much, and hope they can frolic together in the grasses of some far-off heaven that is actually closer to us than it seems.

As the winds whip the trees outside our home, may the aforementioned winds of compassion also blow, stirring up love, understanding, and connection wherever they circulate. As far as loss is concerned, I could not agree more that it is still better to have loved and lost, than to never have loved at all. Death doesn't erase love, it only changes the pathway the energies of love must travel between the beloveds. Embracing loss, embracing change, embacing grief---what more can one do but continue on, powered by love and compassion?

On this day of remembrance, I choose to continue on, empowered and emboldened, with compassion as the fuel for living.

World AIDS Day

At the clinic today, a slide show depicting dozens of people who have died in the last twenty years of battling AIDS in our neighborhood was the close of the day's work. Patients and staff gathered together over snacks, pizza, and soda, acknowledging the day, what it represents, how far we've come, and how far we still have to go. The fact that someone is infected every eight seconds is no comfort.

Just this afternoon, one of my itinerant patients surfaced. I have been trying to keep her on antiretrovirals for several years. I took over her case from a nurse practitioner who left our practice for a new life in the Southwest. When we discussed this woman, my colleague said, "She's a lost cause." Perhaps she was, but I took her at face value and invested in the relationship.

Several years earlier, my former colleague and the patient's primary doctor had visited this woman at home and said goodbye, the patient's liver finally giving out from the effects of AIDS meds, a common occurence for meds that can burn up the liver. For some reason, that ravaged organ decided to have another go at life, and she bounced back from the brink of death.

So here I was today, faced with this woman who has been on and off of crack and heroin, her school-age kids in and out of protective service, and her young adult daughter trying to hold it together for the family even as she struggles with mental illness and drug-addicted parents.

The focus of the brief visit was explaining that we would stop the antiretrovirals. "Why?" she asked. "I need those meds more than anything else!" I have explained to her countless times that it's better to stop the meds altogether than to take them poorly. She looked at me and nodded, but I registered her discontent. I handed her a seven-day medication box prefilled with everything but her antiretrovirals, and sent her and her daughter on their way, admonishing them that I expect a phone call in six days to schedule the next med prefill. "Gracias, Keith!" they yell on the way out the door.

As I watched the slide show, I imagined that I saw this particular woman's face flash across the screen as the background music swelled, Sarah McLachlan crooning "I will remember you." She may not be up on that screen this year, but eventually she'll be added to that lengthening roster of losses. Tears will be shed, and her children will be alone without her.

How many more lives are also on the brink in a similar manner? We'll save quite a few, but there are always those who we just can't keep afloat. That said, our lifeboat has plenty of room, and I'll keep pulling on those oars until I no longer can sustain the effort.

I will remember you.