Tuesday, May 30, 2006

The Age of AIDS

I hope that some of you can watch the new Frontline special, The Age of AIDS on PBS tonight. I plan to watch it, especially in the knowledge that this is the 25-year anniversary of the beginning of the epidemic. FYI, it is actually a two-night special, and will certainly be repeated.

When I was a young art student in Philadelphia in the early 1980's, I came to personally know a number of gay men who began to exhibit symptoms of massive weight loss, strange pneumonia-like infections, and purplish splotches on their faces and arms. The idea of a "gay cancer" attacking the male homosexual community gained ground quickly in those early years, and due to my connection to the arts community and its large gay subculture, I was witness to the beginnings of the devastation that was to follow.

Looking back, I clearly remember a gay acquaintance of mine---a fellow painter---who made it very clear that he wanted me to be his lover. Never having had romantic feelings for men, I politely rejected his ardor, and our acquaintance never amounted to much, although we had a few mutual friends and would see one another at various art openings around the city. Several years later, before I left Philadelphia, he died a miserable death, riddled with Kaposi's Sarcoma and pneumonia, apparently having wasted away to a mere shadow of his former robust self. It's only now that I realize how profoundly life-altering a choice it would have been if I had entertained his offer of companionship. At that time, heterosexual infection was still relatively unrecognized, and although I had dodged an enormous bullet, the risks for young adults in the early and mid-80's would only grow.

A few years later, as a newly-trained massage therapist, I leapt at the opportunity to volunteer my services at a free holistic AIDS clinic in a relatively small New England city hit hard by the epidemic. Both gay men and IV drug users were affected most profoundly, although it was mostly only the gay men who flocked to the clinic for free medical advice, acupuncture, massage, support groups, and a place to feel at home. With my wife as a counselor, we both subsumed ourselves in this community which embraced everyone who walked through its doors. Free of the professional boundaries of a medical practice, we partied together, had meals together, raised money, created friendships, and developed a small network of interconnected lives who all worked tirelessly to improve (and possibly prolong) the lives of our affected brethren. Men dominated the clientele, but there were women as well, and the mix was enlivening and exciting. We were part of something great. I remember dinners, healing sessions, fund-raisers, Halloween parties with over-the-top drag shows, and funerals galore. Funerals. Memorial services. And more funerals. And more. Mary and I practiced Reiki on one of our dear friends as he lay on his deathbed. This kind soul, who had been at the top of his game in the publishing world in New York City, who would hum show tunes as I massaged his slowly wasting frame, died in the middle of the night with his beloved sister holding his hand, people chanting and praying around his bed. We were not there for his death, having gone home to tuck in our young son in the big haunted house where we lived at the top of the hill.

Now, in my current professional role as a nurse, clearly deeply affected by my earlier life experiences, I still marvel at the insidiousness of the virus, its ability to mutate and gain resistance to powerful medications, and its clear agenda to infiltrate every walk of life, nationality, race, and religion. What was once "the gay cancer" has become the most lethal epidemic in memory, and its grip on Africa and Asia tightens like a noose with each passing year. While I may not work exclusively with patients with HIV or AIDS, I currently carry fifteen people on my caseload who are infected, and have probably lost half a dozen in the last five years. For every victory, there's a dismal failure. For every stellar patient who takes his or her meds like a champion, another can't seem to stay focused long enough to follow through. The city where I work has been violently attacked by the virus, and politicians' fears of a needle exchange program have furthered the epidemic by tacitly allowing dirty syringes to pass from hand to hand.

As a Baccalaureate nursing student several years ago, I and a few classmates wandered the back streets of another devastated town under the guidance of a heroin addict in recovery, visiting the places where junkies shoot up, handing out condoms and bleach kits, preaching the gospel of clean needles and safe sex. Much to our professors' dismay, we held a health-fair at a local drop-in center for IV drug users, teaching them clean injection technique, how to sterilize needles, skills which could prevent infection with HIV, not to mention dangerous abscesses of the arm from poor injection technique. It's called harm reduction, and we did it well, if not a little clumsily. Did we save lives? No one can say. But one piece of information can go a long way, and I like to think that the effects of our work may live on in some child somewhere, whose parent used those techniques to avoid infection and thus give birth to an uninfected child. How I hope that that may be the case.

So, my friends, take a moment to acknowledge this anniversary, whether you have known someone infected with the virus or not, whether you work with infected individuals or not, whether your family has been touched or not. It is a passage in human history worth pausing for, and a time for even a brief reflection at this historic time.

May all beings be happy. May all beings be free from suffering.

Monday, May 29, 2006

Paradox Now

Ah, what magic a long weekend can work for the soul. Leisure, something which many people lack in their lives for a variety of reasons, is such a necessity for mental and physical health. I can see that many of my own physical symptoms in the last few months have been absolutely stress related. As summer begins to dawn on the horizon, I spend more and more time outdoors, exercising and soaking up the sun. It's a time for healing, but also for deeper questions.

Watching a film last night, Paradise Now, I was reminded how many people in the world live in environments of constant stress and trauma, with leisure and stress relief something of an unattainable panacea. In the film, two Palestinians in the West Bank are chosen for a suicide mission in Tel Aviv, and each one must grapple with his conscience. Aside from the socio- and geo-political implications of the film, what I took away from it was a sense of how people all over the world live in situations in which respite from stress---often a level of stress which is trauma-producing---is often not an option. In Darfur, Palestine, Congo, Iraq---life is interwoven with the constant and relentless threat of death or dismemberment. On many of the streets of rural and urban America, hunger and poverty rule the day. How many American children go to bed hungry each night?

I'm struck by the paradox of reveling in my long weekend, recovering from the stress of full-time, well-paid work, replete with comprehensive health insurance and relative job security. Of course, it's a given that stress is relative, and there's no question that I deserve rest and renewal within my middle-class bubble. However, in the larger scheme of things amidst the general tumult of the world, my struggles to lose a few pounds, decide if we can afford having someone clean our house twice a month, or how long we can go on vacation this summer take on a somewhat anemic pallor. Clearly, perspective is key in this moment, and one must not lose sight of one's place in the puzzle, playing with the deck that's been dealt. Middle-class guilt for one's luxuries serves no one, but at the same time blinders to others' plight serve no one as well.

The conclusion which I draw this morning is that awareness of one's relative priviledge is key, while mildly indulging one's needs is not evil or disingenuous, as long as one retains a view of the larger picture, using that position of relative priviledge to positively effect the lives of others.

Some rhetorical questions:

Does the quintessential "wounded activist" serve anyone through his or her self-denial of pleasure? Does not the blind purchase of goods at Wal-Mart made in Chinese sweatshops help to perpetuate the globalization (and Wal-Martization) of the world? Does simply doing one's work and living a balanced and non-ostentatious life improve the lives of others indirectly? Do political bumper-stickers with catchy slogans preclude the need for real political activism in one's life? How do my actions from day to day truly effect the lives of people in Darfur, Palestine, South Central LA, or Basra? Does my purchase of a new refrigerator negatively impact some individual life somewhere in the world? What do my purchasing habits say about me? How does the sum of my actions define me in the larger scheme of things? Am I doing enough? Am I walking my talk? Where is my energy best spent? Am I more blinded by my priviledge than I can truly see?

I realize as I write that these are not necessarily the words of a person embracing a national holiday and paid day off with complete equanimity. I'm choosing to not live my life like a blind and ignorant bull in the china shop of the world. I want to acknowledge the paradoxes inherent in being a middle-class white American with full-time work, health insurance, my own home, and the luxury of time and material well-being. One must accept where one is, change that which one chooses to change, and live life according to a chosen path. I simply find it necessary to periodically examine that path, take stock of my position in the wider world, and determine if I'm truly living the life that I desire. Blindess is an option, but I choose today to re-open my eyes.

Friday, May 26, 2006

Attrition and Addition

Working in the same place for any number of years (five in my case), changes of personnel are to be expected. During my tenure in my current place of employ, we've survived a number of "goodbyes" to beloved staff-members, several programmatic and funding changes, and various other challenges which small non-profits must face as they grow and evolve. Today saw one of my closest friends from work take her leave. In fact, she is the only person from my work-place who I regularly socialize with outside of work, and her loss only began to truly hit me today. This particular person and I often go out of our way to offer one another hugs, kisses, and warm fellowship that can truly make a difference in the trajectory of a day gone haywire. Her absence beginning next week will be difficult to overcome quickly. With her not at her desk, it'll be like a smile missing a shining front tooth.

Just as I'm beginning to digest this particular co-worker's departure, celebrating her new chapter of life with a group dinner out on Wednesday and a cake and gifts today, yet another colleague announced her imminent departure in 14 days, followed by yet another whose departure date is set distantly for September. Just as our office is undergoing a major shift of responsibilities and practice coordination, some of the cogs are removing themselves from the wheel, and we will soon all be reeling from the effects of such personnel loss. Of course, we have lost many others over the years as well, living to tell the tale each time. But each time a member of the team leaves, worries surface that the new replacements won't "gel" as well, that the sense of family and connectedness will be undermined, that what we have worked so hard to create will feel different, less intimate, less cohesive. While I am generally one who welcomes change, stability in a stressful workplace is key to success and satisfaction, and each change which threatens stability does not necessarily bode well for the future.

On the bright side, someone of whom I am exceedingly fond and with whom I worked within another agency some ten years ago was just hired to join our team in a somewhat administrative capacity. We will not be sharing patients, per se, and she will not be directly involved in my day to day practice, but her presence in the office is a "good fit" and brings some fresh energy and ideas to the fray.

So, attrition and addition were foremost on my mind today, even as the calls and pages, unannounced visits and constant multi-tasking pummeled my tired brain and body. Now a long three-day weekend awaits, Friday night relief seeping into my bones like a nectar.

Wednesday, May 24, 2006

Private Hell

It was 9am and she reeked of alcohol. As I passed through the waiting room, she cornered me and launched into an unstoppable diatribe. Ducking into an exam room, I allowed her to vent and share her pain with me. "I relapsed last night. I drank with my boss, then I pawned my car for $70 and bought some cocaine. I can't take this anymore. I'm so alone." Her affect and obvious self-loathing were painful to behold, and though I had appointments pending and my beeper would not stop vibrating, I grabbed a Nurse Practitioner familiar with her and the three of us hunkered down for some straight talk. In the end, we got nowhere. She left without agreeing to detox or other treatment and a vague promise to call us later when she had gotten her car out of hock. (Suprisingly, she would actually call us later to report that she was OK. Thank God for small miracles.)

After she left, the NP and I looked at each other and shrugged our shoulders, giving in to the notion that we were powerless to change her life, powerless to keep her with us when she didn't want to be kept, and frustrated that so many people live in such isolated and private purgatories.

Other personal purgatories revealed themselves to me today as well, as they do most every day. We are witnesses to suffering, as I have said before, and it is not our job to fix, to repair, to alter the course of others' lives by sheer power of will. There are forces at work much larger than us against which we have little transformative power. The best we can do is open doors and illuminate pathways, cajoling and teasing our patients towards different choices and better alternatives.

Coming back to my small town with good schools, excellent infrastructure, and tax dollars hard at work for the benefit of middle- and upper-middle class families, I realize that I can't change the dynamics and machinations of inner city life. There are slum lords, corrupt officials, drug dealers, gangs, organized crime, institutional racism and economic apartheid which all contribute to the plight of the poor. It is all of our responsibility to turn that tide, but in the course of a day slogging through the swamps of chronic illness, poverty, and lives of desperation---be that desperation quiet or not---I at times lose sight of the benefit which my therapeutic interventions may have.

At times, I wish that I was one of those movers and shakers who takes on the system, challenges the status quo, and creates a new society from the ashes of the old. Alas, I am not so much of a leader, opting instead to do my work in the quiet of one-to-one interaction and therapeutic relationship, in the hopes that my work will have some small impact while others with a larger grasp of the global issues work to undermine the foundations of the larger framework which only serves to further oppress the oppressed.

Please forgive this rant. It is just a tip of the iceberg of the rage and sadness felt while witnessing first-hand the misery of those living in the belly of the beast---urban America.

Saturday, May 20, 2006

Greetings From Atlanta

Well, here I am in the Deep South, visiting my sister, having a small partial family reunion with some other family members who have also flown in for the occasion. An interesting change of pace and scenery.

Scenes from the day:

-Anxious couples rushing to catch their flights, babies and strollers flying everywhere.

-Security agents joking with passengers and being playful, returning a confiscated nail-clipper with a smile and admonition that it is contraband.

-A man on the subway who took a pack of Camel Filters from his shirt pocket and proceeded to do that ritualistic tamping down of the cigarettes by hitting the pack repeatedly against his palm. The look of utter concentration on his face as he performed this well-practiced ritual was intense to behold. He then held a cigarette between his lips as the train came to a stop. Perhaps he felt some nicotine seeping into his mouth through osmosis. Perhaps the taste of the cigarette between his lips was enough to mollify his craving for the time-being. I noted his barrel chest and spider angioma on his nose (small, red, broken capillaries) which spoke to me of years of hard drinking and smoking. His was a story with many fascinating chapters.

-At the top of the long escalator up to baggage claim in the Atlanta airport, there is an enormous and awe-inspiring mural whose centerpiece is a beaming African-American child with arms stretched joyously overhead, welcoming the visitor to this racially diverse city which was the birthplace of Martin Luther King, Jr.

Apropos of Mr. King, on Monday we will visit the tomb of this amazing man, and see the home in which he was born.

The warm embrace of the South and of family is soothing to my spirit today.

Wednesday, May 17, 2006

MRI for I & I

I had an MRI this evening. It's always so interesting to be on the receiving end of medical care. The Southern-accented technician who did the intake was quite business-like but friendly in his own way, sort of military in his inquisition style and the way he called me "Sir" too many times. We sat in the "Interview Room" where he made sure I had no metal in my body and understood that if the doctor decided to give me a magnetic contrast dye---gadolinium---that they were fully prepared to revive me in case of anaphylaxis. I told him I had nothing against Ana Phil Laxis and would have no need of her services. (Actually, I thought of that just now and am so glad I didn't say it. Stupid Jewish punster humor can be so embarrassing.) The perfunctory interview complete, I locked my belongings in a locker, took off my earring in case the magnets of the massive machine ripped it from my unsuspecting ear lobe, and lay upon the table amidst the machinery which may have originally been designed for 2001: A Space Odyssey.

Ear plugs donned and padding stuffed around my head to cut down the noise, the table rose into the air and I was slid into the sarcophagus-like tube. The disembodied voice of the technician came over the intercom every so often to inform me how long the subsequent series of pictures would take. I guess this is supposed to be reassuring, but I found it annoying in terms of interrupting my meditation.

Each time the machine whirled into action, it would make a semi-rhythmic set of sounds---electronic, of course, but each one with a distinct tone. While it would be easy to be unnerved by the racket, my predilection for strange electronic and experimental music paid off in a big way. (If any of you've heard Matmos' CD, A Chance to Cut is a Chance to Cure, you know what I'm talking about. That CD is made almost completely from sounds recorded, sampled, and edited from various medical procedures such as liposuction surgery. Really. And it's still called music!) I approached each sound as an event, a sonic reality which presented itself for meditation and analysis. Each series of sounds and vibrations brought a new mental sensation and emotional timbre. As I listened intently, I even found myself hearing harmonics and other layers of sound which I was not sure were real or simply a part of my internal aural experience as the sensations entered my inner ear and traveled the cranial nerves into my brain. The permutations of sound were actually multitudinous amidst what could be experienced as a form of post-modern sensory torture. (Does the United States government employ MRI machines in its arsenal of interrogation techniques? They could consider it, but fans of electronic music and meditation would be strongly protected against ill effects. Attack dogs are so much more cost-effective, as is near-drowning and sexual abuse, but alas, that's for another blog....)

Anyway, despite what could be considered as infernal noise born of a Radio Shack in Hades, I experienced what turned out to be a quite peaceful time in that tube. Beyond simply learning a little more first-hand what patients experience in the maw of the MRI, I took advantage of this opportunity to have an interesting and thought-provoking aural adventure at the cost of many thousands of dollars by Blue Cross/Blue Shield. I should let them know how enjoyable it was and that I feel it was certainly money well spent, no matter the outcome of the actual exam. I'm sure they'd be thrilled (and subsequently increase my deductible).

Tuesday, May 16, 2006

Grand Rounds Comes Around----Again

Here's the current edition of Grand Rounds, up and running at Doc Around the Clock, featuring links to articles by yours truly and countless excellent healthcare bloggers from around the world. Again. Never a dull moment.

Sunday, May 14, 2006

Mother's Day

Contrary to popular belief, the American Mothers' Day was initially conceived by social activist and abolitionist Julia Ward Howe (who wrote The Battle Hymn of the Republic) as a call to women and mothers to rise up against the brutality and murder of The American Civil War. Her Mothers' Day Proclamation made its intentions clear:

Mother's Day Proclamation

"Arise, then, women of this day!
Arise, all women who have hearts,
Whether our baptism be of water or of tears!

"Say firmly:
"We will not have great questions decided by irrelevant agencies,
Our husbands will not come to us, reeking with carnage, for caresses and applause.
Our sons shall not be taken from us to unlearn
All that we have been able to teach them of charity, mercy and patience.
We, the women of one country, will be too tender of those of another country
To allow our sons to be trained to injure theirs."

"From the bosom of the devastated Earth a voice goes up with our own.
It says: "Disarm! Disarm! The sword of murder is not the balance of justice."
Blood does not wipe our dishonor, nor violence indicate possession.
As men have often forsaken the plough and the anvil at the summons of war,
Let women now leave all that may be left of home for a great and earnest day of counsel.

"Let them meet first, as women, to bewail and commemorate the dead.
Let them solemnly take counsel with each other as to the means
Whereby the great human family can live in peace,
Each bearing after his own time the sacred impress, not of Caesar,
But of God.

"In the name of womanhood and humanity, I earnestly ask
That a general congress of women without limit of nationality
May be appointed and held at someplace deemed most convenient
And at the earliest period consistent with its objects,
To promote the alliance of the different nationalities,
The amicable settlement of international questions,
The great and general interests of peace."



I enter this post in honor of Mothers everywhere, and in condolence to all Mothers who have lost children to war, famine, disease, brutality, slavery, and human frailty.

To paraphrase Robert Fripp, may our living honor our mothers and repay the debt of our existence.

Saturday, May 13, 2006

A Letter to My Students on the Occasion of Their Final Exam

To The Students of the 2005-2006 Evening LPN Program,

Well, folks, here we are at the end of our nine months together, and I am truly sad to see you go. You’ve been a great class, and I’ve learned a great deal from all of you. As was said by some famous person, the roles of student and teacher are often reversed.

I wish I could affirmatively say that I have sufficiently prepared you all for the NCLEX, covering every detail that might confront you when you sit in front of that dreaded computer screen, but alas, it’s not my place to say whether you’re prepared or not, nor can I affirm that we did all that we needed to do. The fact is, we covered a great deal of ground but could never do it all in nine months no matter how hard we tried. It will now be up to each of you to prepare for that last major hurdle before you can officially enter the nursing profession.

That said, I want to leave you here with a few pieces of advice.

Practice
Nursing is called a “practice” because, in my opinion, it takes constant practice to be the best nurse you can be from day to day. As your practice develops, you need to be continually willing to learn and grow---both professionally and personally---or you’ll stagnate. Continuing education credits are something that many of us dread fulfilling, but continuing education is crucial to staying abreast of what’s new and different out there in the world. Medicine is constantly changing and evolving, and we need to evolve with it if we want to be up to date and savvy in our work. So, to that end, be interested in learning. When something doesn’t make sense, look it up, ask someone, or try to discover more about it. Let your curiosity lead you to always learn just a little more. It’s the exceptional nurse who’s willing to ask why and then find the answer.

Technology
I can’t emphasize enough that you must continue to increase your comfort with technology. By this I mean computers, the Internet, search engines, email, chat rooms, blogs, databases, spreadsheets, on-line research, on-line journals, etcetera. Many hospitals (and maybe nursing homes, as well) now employ laptop computers on wheels that the nurses must use for orders, notes, and other documentation. Some facilities are moving in the direction of electronic medical records (EMRs) and you have to be ready to deal with this reality. If you’re already skilled and comfortable with some forms of technology, include this on your resume under the heading of “Skills”. Potential employers want to know who can sit down at a computer and need only a little coaching to get started. If you have the ability to take some computer classes at MCDI or another school, take advantage of that opportunity as soon as possible. You can mark my words that being conversant with technology will only increase your ability to find a job you like, the caveat (remember that one, Lindsay?) being that lack of understanding of such information can be a professional liability.

There are many places on the Internet for nurses to surf for information and I want to point you in the right direction. As I may have mentioned in class, if you need to find something out about anything, go to Google and simply type in what you’re looking for. I use it daily and have rarely been disappointed.

Medscape is a great free resource on the Web, and I recommend that each of you sign up. Just go to www.medscape.com/nurseshome. You can create an account and then come back as often as you like to look for articles, support, links to other sites, and updated information, as well as conferences and on-line CEUs. You can sign up for various Medscape email updates, or you can just check the site at your leisure.

Other sites of interest:

www.allnurses.com General nursing site
www.globeofblogs.com A blog registry site. Find blogs on nursing or anything
www.blogger.com A great way to start your own blog.
www.digitaldoorway.blogspot.com: my blog where I mostly write about my work, and link to many other medical and nursing blogs of great interest and variety.

Professionally-speaking
I recommend you collect letters of recommendation from anyone you work with that would be willing to write one for you. Keep a file of these, and also ask those individuals if they’ll serve as references for you when you apply for jobs down the road. Also, keep an updated resume on your computer at all times, changing it as necessary depending on the job you’re applying for. After you accumulate more experience, you can have several versions of your resume on hand and you can target them towards different types of facilities.

Once you have some experience under your belt, start to look around and find out what facilities and agencies are hiring LPNs. Dialysis units, doctors’ offices, schools, some VNAs---there are many places open to hiring LPNs. I know for a fact that ____________will hire skilled LPNs for their HIV/Mental Health, Pedi, and MedSurg teams. This is something to look forward to.

I know most of you would rather not think about it, but furthering your education is also something that you can consider. Being an LPN is great, but if you want to broaden the scope of your practice, consider eventually becoming an RN, if not a BSN. While it of course involves more loans, more studying, more sacrifice, and lots of work, it also involves greater ability to pick and choose your work environment, as well as larger paychecks. It is only food for thought, but definitely worth considering.

Nurses Eat Their Young
You may have all heard the phrase, “Nurses Eat Their Young”, and I have heard a few stories from some of you who already have experienced the callousness and rigidity of some of those nurses out there. No matter how poorly you might be treated by some of those seasoned nurses, be careful to not repeat history when it’s your turn to mentor someone new. I always try to be exceedingly kind and helpful to nursing students, because I remember that “there but for the grace of God go I”. It was not long ago that I was in the same boat, and it’s no fun when all you want to do is learn to do your job and someone seems to go out of their way to make you miserable while you try. If we each decide to break that cycle, many more novice nurses will stay in the profession and pass that kindness along to the next generation.

The Future
As your teacher, I feel a responsibility to be available to you if you do indeed need a letter, some advice, or another form of support over the next few years. Since I don’t plan to continue teaching at ________at this time, below is an email where you can reach me.

You have all done a courageous thing, and I am so impressed that you have done it. Between raising children, owning and renting homes, working 11-7, maintaining family obligations, getting ready to have a baby, or saying goodbye to your parents and loved ones, you have all undertaken a huge task and should be very proud of yourselves.

Congratulations, good luck, and please keep in touch as you enter the world of nursing. I look forward to hearing about your successes and challenges, and will entertain any questions you have along the way.


Respectfully,

Keith Carlson, RN, BS
nursekeith@gmail.com
http://www.digitaldoorway.blogspot.com

Friday, May 12, 2006

From ICU to Fishnet Stockings

Today I paid a nursing home visit to my morbidly obese patient with COPD and asthma who was only a month ago intubated in ICU with a recalcitrant asthma exacerbation. Obese, asthmatic, agoraphobic, diabetic, depressed and anxious, she is generally stuck in her dusty bedroom which reeks of urine, unable to summon the strength of will and body to do much else. Several of her children are now on the same self-limiting path, and she blames herself for not empowering them to take charge of their lives. She knows that she has clung to them too rabidly, just as her parents did to her in Puerto Rico. But alas, the cycle continues, and now several of her grandchildren are demonstrating the same pattern. Nature or nurture?

I had not seen her for nine days. The last time I came to this nursing home, she had just been transferred from the hospital to this facility for some reconditioning and rehabilitation. After four weeks in the hospital---one of which was in ICU---she needed some time to gain back some strength. Today, two days before Mother's Day, I find her in her room with three of her daughters. They have brought all of her jewelry for their mother to select from, and I see my patient---all 375 pounds of her---perched on the edge of her bed. She is smiling, bedecked in pointy brown leather shoes, fishnet stockings, a skirt, a low-cut blouse, several gaudy necklaces, earrings, and a hat on her head at a jaunty angle. She beams at me as her daughters argue over some jewelry.

"Girls, muchachas---I'm not dead yet! That's MY jewelry anyway!"

The women continue their good-natured dispute, one daughter pocketing a key-ring she'd been eyeing.

"I'm not getting involved in this family argument, " I say, taking my place near the window.

We chat, and when questioned, my patient tells me that there's a Friday afternoon concert at 2pm downstairs, and she wanted to look nice for the occasion. With most of the residents of this home 20-30 years her senior and confined to wheelchairs in the hallway, my patient looks like she's from another world. And indeed she is. An enormous Latina woman relegated to this facility of mostly white elders with various diseases of the aged, she is out of place, I must admit. There just don't seem to be any rehab facilities specifically for the younger set. Not much money in it, I guess.

As we talk some more, her daughter admonishes my patient for talking to me from under the visor of her hat with her eyes hidden from my view the whole time. She tips the hat back and smiles sheepishly.

I wish her a fun time at the concert, a lovely Mother's Day with family visiting her with homemade Puerto Rican food on Sunday, and I promise to stop by every week until she comes home. She thanks me, her daughters turn back to the jewelry, and I make my way back down the hall among the maze of dazed-looking residents parked along the walls in their wheelchairs. I picture my aging parents in such a place and cringe. The ubiquitous smell of urine and feces is a reminder of where I am.

Outside, the rain pours down, and I open my umbrella for the dash to the car. A few more home visits and then back to the office. Another day in the life.....

Thursday, May 11, 2006

GR, v. 2, n. 33

Yet another excellent edition of Grand Rounds is now up at Aetiology. Stop by for a perusal of this week's offerings......

Tuesday, May 09, 2006

Gems

Today I attended a workshop/conference on Spirituality and Healing with a very famous keynote speaker (who shall remain nameless in order to preserve the relative geographic anonymity of this site). Individual small-group workshops focused on mindfulness meditation, walking meditation, drumming, aromatherapy, acupuncture, and various other modalities and perspectives on healing.

That said, this conference fed my soul like no other has in some time. Aside from the keynote speaker (the main attraction for my attending in the first place), this experience renewed my sense that there are countless healthcare professionals out there who are willing to put time and energy into personal growth, as well as the spiritual needs of their patients. While the majority of the attendees were nurses, there was adequate representation by pastoral counselors and social workers, as well as a smattering of occupational and physical therapists, a recreation therapist for seniors, and a small cadre of open-minded and interesting physicians. The main speaker explored some very cogent ideas related to spirituality, care of the psyche of the patient and caregiver, as well as the more ancient underpinnings of the roots of some modern medical and psychiatric practices.

To wit, I learned that the etymological roots of the word psychotherapy lead us to understand that "psycho" means "psyche" which in the original Greek meant "soul", and "therapy" comes from the ancient Greek word "theros" meaning "nurse". Hence psychotherapy actually means literally "to nurse the soul".

I also learned that Heraclitus said that "you can never discover the limits of the soul, no matter how many roads you take, so deep is its mystery." This one is worthy of further exploration, perhaps in a future post. This led to a discussion centered around the notion that while "spirit" speaks of things of a higher nature, as in spirituality, the intellect, and connection to a higher source beyond the earth, "soul" traditionally refers more to things closer to earth---or actually in the depths. While spirit gives us our connection to the greater and larger, soul gives us our connection to the internal, the underworld, the underbelly of the self. They don't say "dark night of the soul" for nothing......

Other ideas which were floated:

How does it feel when we walk into a clinic or hospital? What are the textures and colors like? Is it inviting? Are the artistic depictions of humans normal and colorful and full of life, or are the exam rooms filled with pictures of diseased organs and flayed bodies showing everything that could be wrong with one's internal organs? Do we have flowers in the exam room or little plastic models of disembodied kidneys? Is the waiting room like a living room or a bus station? How do we make our healthcare facilities more healthy and inviting, more nurturing of the soul and spirit, more restful?

Finally, one of the best quotes of the day came from a participant who shared a story of a patient who approached the dying process with great humor, aplomb, and dignity. He had said one day, "I've never seen a hearse pulling a U-Haul." That one really gave me pause and perhaps will be fodder for a future post as well. Gives new meaning to the phrase, "you can't take it with you."

All in all, a nurturing day of reinvigoration and release. Gratitude all around.

Monday, May 08, 2006

Cities, Violence, and Loss

Yet another shock was delivered to us today, just several weeks after one of our colleagues at a neighboring agency was caught in the crossfire of a gang-related shooting. It seems an elderly patient of ours and her husband were murdered during a break-in at their apartment. Apparently, the intruder forced his way in as the husband was leaving the apartment. Our patient was killed as she lay in her hospital bed. I cannot elucidate any more, but it's another shocking reminder that we work in a city where random violence and senseless brutality are still rather commonplace. Many of my colleagues also live in this city, while I and several others escape each night and return to our homes in much more relatively sedate and characteristically quiet New England towns. "Escape" takes on a new meaning in this context.

There's a scene in My Dinner With Andre---one of my favorite films of all time---in which the main character describes for his dinner companion his vision of New York City. He describes a city which is in fact an ersatz prison in which the citizens were originally the inmates but eventually became their own guards, holding the keys to their own freedom but blindly perpetuating their own misery and isolation. Does the fate of such troubled cities indeed rest in its citizens' hands, and does the power to alter the fate of the inhabitants actually reside in the streets and homes and businesses which make up that urban conglomeration of people and lives?

This little city where I ply my trade is riddled with corruption, violence, cronyism and poor management on most every level. Drugs and gangs seem to rule the streets, the police and city hall fighting a losing battle against the perpetual tide. The saddest part of this brutal equation are the innocent lives which are shattered, literally caught in the crossfire, taken out in the heat of the moment, murdered for a pittance.

Where is the power to change? Where does it reside? In whom does the responsibility rest? Can cities such as ours turn themselves around, and if so, what will it take?

We grieve for the family of the murdered elderly couple, bereft of their parents and grandparents, who lived quiet and humble lives in a city they called home. May their souls rest in peace, and may their grieving family members eventually find healing and solace.

Sunday, May 07, 2006

Winding Up, Winding Down

The weekend winds down, and I begin to wind myself up for the week ahead. I accomplished a great deal this weekend, including having a nice nap each day in the hammock. Time well spent.

This week marks the end of my current teaching career. I must say, no matter how much I love my students---and I do---it will be a sweet relief to no longer have exams, lectures, overheads, power-points, and other detritus to deal with all year. I truly love the act of teaching---the moments of laughter, of watching a student "get" something crucial, the crystallizing ideas coalescing in understanding and synthesis---it is very gratifying. But on top of a full-time job that demands such energy and commitment, teaching has been a psychic burden which I am ready to shed.

Beyond the mechanics of teaching, and the preparation and responsibility involved, I have always found nursing school to be somewhat deadening. The rote memorization, the need to teach towards the licensing exam---it all makes the process less alive for me. Grading students on their performance on multiple-choice tests is a frustrating but necessary evil which sometimes precludes the desire to spend time delving deeper into issues which cannot be addressed on such standardized exams.

In my teaching, I try to impart my excitement, my fascination, my sense of justice and socioeconomic equality, my commitment. I try to use stories, scenarios, and anecdotes to illustrate the reality of patient-provider interactions and the mystery and subtlety of such relationships. Sadly, the reams of information needing to be reviewed and lectured upon often precludes such non-linear teaching, keeping us information-oriented, away from the realm of feelings and relationships. This is a hole in nursing education, and area which I think is often overlooked in the interest of the "harder" scientific aspects of nursing.

I will honestly miss teaching, but I'll be sure to find opportunities for teaching which do not necessitate my standing in a classroom and talking until my throat is hoarse. In my mind, there are many changes needed in nursing education which I will not address in this forum, but I recognize that there are areas sorely lacking and in need of attention, especially on the comunity college level. Some day, perhaps, as a retired nurse, I'll return to academia and give it my all, acting as a change agent to reinvigorate the education of nurses. For now, I will gracefully bow out of that world, and leave the teaching to others more comfortable with the process than me.

Saturday, May 06, 2006

Recovering and Recharging

The weekend brings recovery, a moment to step back from the obsessive-compulsive nurse-mind which envelops the psyche during the week. The trick is to somehow manage to tone down that drive for efficiency and allow the mind to rest. Being away from home 50 hours per week, the piles of papers and laundry and errands and tasks grow exponentially during the week, and the secret is how to remain able to accomplish those tasks while still unwinding the mind and body, regenerating the biological and spiritual batteries, and shedding the baggage and accumulated stresses.

This skill of recovery and recharge is a learned skill---it is not necessarily innate. At times it seems easier to remain on that track, following the ego's drive towards doing rather than being. My desire is to accomplish what needs to be done over the weekend, but rest my mind and heart from the week's ups and downs.

Balance is called for---the balance of doing and being, of mindful action and thoughtful repose. Recovery and recharge should not be just another task to accomplish and cross off the to-do list---it is a state of mind, and one which, unfortunately, I must consciously steer myself toward.

Wednesday, May 03, 2006

Home

She's going home. As her body is consumed by cancer, weight loss, advanced AIDS, and debilitating illness, her only desire is to return to Puerto Rico. With the cancer treatment done and no further hope of stemming the tide of rapidly reproducing cells to any helpful degree, there is nothing more to do but look for comfort, succor, spiritual nurturance, and the respite of the family's warm embrace.

Laying on her bed in a slowly emptying apartment---she's selling everything she owns in preparation for the journey---she looks more and more wasted and wan each time I visit. Although the visiting nurses come twice a day, I'm shocked that they haven't noticed the reddened areas on the iliac crests, a sure sign that skin breakdown and bed-sores are on the way without intervention. I also notice that the inside bony prominences of the knees are very red--she is laying on her side with knees together almost all day and night. I instruct her to put a pillow or folded towel between her knees at all times when in bed. I'm disappointed the VNA didn't catch these subtle but crucial changes.

She shares that she hasn't taken her antiretrovirals (the meds used to control HIV) for a week because she vomits whatever she puts in her stomach. I plan to order meds for these symptoms within the hour after a quick call to my NP colleague. We speak of other symptoms, I take notes, and the HIV case manager who I brought along probes more deeply for answers which I think may be more forthcoming in the presence of this other compassionate professional that she has known since first arriving here.

While she doesn't speak of depression per se, this is a spiritual crisis of huge proportions, and it is clear that faith and the power of the mind are hard at work. This individual may have only completed the fourth grade, but there is a depth of soul and spiritual wisdom that far outweighs any intellectual capacity which might be lacking.

We discuss more concrete issues and plans, medications, symptoms, egg-crate mattresses, bed-sores, diabetes, and the need for Ensure and vitamins. We make some decisions, look forward to some changes which may alleviate some discomfort, and prepare for a day in the near future when she will leave this lonely apartment behind and return to her hometown. The sirens, the jackhammers of the construction crews, the smell of exhaust through the open windows, the long winters, they will all be a thing of the past, a figment of memory. She will stay with her sister, her brother and father down the street, cousins and other extended family nearby. Perhaps these five years in New England will then seem like a dream, an extended journey which perhaps occurred on some other plane of existence. Perhaps when she hears those familiar tropical sounds---the birds, frogs, and insects of her beloved island---and smells the soil, air, ocean breeze and rich home cooking---it will be like returning to the womb, to the culture and land which cradled her from birth to adulthood.

I regret not setting more services in place sooner, but each week I add yet something more in order to assuage suffering or alleviate symptoms. Since she is too weak to go to the doctor lately, it feels like I'm running the show, bringing reports to the primary physician after each of my home visits, making recommendations, and getting a green light on most every suggestion I make. This is where my role is crucial. This is also where the stakes are higher and my errors of judgement or lack of action could have dire consequences.

My goal is to keep her healthy enough to make the trip, leave this odd New England world behind, and melt back into the comfort and familiarity of home and family. Gods, goddesses and angels of comfort and healing whose very existence I often question, bless these ensuing weeks and allow safe passage for this dear soul, and guide me well in my actions. If home is where the heart is, then bring this child where her heart longs to be.

Tuesday, May 02, 2006

Grand Rounds Again

Since you're here, I will direct you to the latest edition of Grand Rounds, the always entertaining and informative blog carnival dedicated to all things related to the worlds of medicine, health, nursing, healthcare, and all permutations therein.

Monday, May 01, 2006

What Price Efficiency?

As I went about my day today, I noticed the plethora of tasks and errands which I accomplished. While I marvelled in a way at what I had done, it led me to wonder what price one pays for such a high level of activity and obsessive-compulsive action.

In the course of my day, I checked email; answered calls; visited a dying patient at home and counseled his wife on the need to now decrease fluids and nutrition in the interest of comfort (more on that perhaps tomorrow); visited a patient in a nursing home; picked up flowers and coffee and chocolate for Mary on her first day of her new job, then picked up seven orders of falafel for Mary and coworkers at a downtown restaurant. After lunch, I sat in on a visit with a patient and a doc who was unfamiliar with her, sent some faxes, made calls, met with my boss, wrote my notes, and then tied up the loose ends of the workday in preparation for teaching from 6:30-9:30. Between 5 and 6pm, I sat at my desk and finished writing an exam for tomorrow's class, emailed it to the college for xeroxing and had a snack before driving up to the college to teach. The came a few hours of lecturing on HIV which I actually really enjoyed. Phew.

On the way home I called my mother from my cell phone, then debriefed with Mary about our days while giving Sparkey his meds, packing my bag for the gym tomorrow morning, loading Mary's car with some things for her new office, taking a bath with Mary, then giving Sparkey his IV fluids. Phew again.

Now I am finally in bed and letting my thoughts flow as I wonder indeed what price I pay for trying to do so much.

Living a full life? Agreed.

Enough leisure time? Almost never.

Chronic pain and fatigue? Often.

Does something have to change in this picture? The answer seems easy enough.