The Behavioral, The Physiological, and Everything In Between

This afternoon, my boss sent out an email asking us all to review our caseloads and identify which patients we interact with almost exclusively vis-a-vis mental illness, behavioral health, or substance abuse. He then asked us to also identify those patients for whom mental illness is a major factor which often leads to self-neglect on the patient's part, but who also carry multiple co-morbidities.

Well, as I reviewed my caseload and began to compose my email in response, the first list was rather short. There are perhaps half a dozen patients out of my 80 who have no other notable morbidities other than mental illness of some kind. The second list, which grew to considerable length quite quickly, numbered approximately fifty. Looking at the two, it once again became starkly clear how my work is, to a large extent, behavioral in the nature of its interventions. While I do indeed respond to many patients' physiological symptoms and complaints---listening to noisy lungs, palpating edematous limbs, evaluating strained backs, assessing abdominal pain---the lion's share of my work is often that of fielding calls of psychic distress, assuaging fears, and otherwise calming the minds and hearts of individuals in mental pain.

Yesterday, I recounted the tale of accompanying a patient to the gastroenterologist. I mentioned in that post that the patient's depression with psychotic features will often preclude her ability to grasp the situation at hand during medical appointments. Examining this very kind woman, one could not necessarily tease out whether her psychological issues trump the physical when measuring their importance or need for intervention, but it is strikingly obvious that her ability to cope with her various diseases is considerably challenged by her mental state. One might further argue that her mental/emotional state directly affects her physiological state on a moment to moment basis as well as in the long term. A mind which is almost exclusively focused on the negative---dwelling in fear and anxious worry with a powerful undercurrent of powerlessness---can only serve to poison the well, figuratively speaking, exacerbating illnesses and their processes, strengthening symptoms, weakening the immune system, and delaying recovery.

The lack of parity in health care when it comes to behavioral health goes a long way towards diminishing the amount of time and resources devoted to mental health. Insurance plans are skimpy with behavioral health allowances, awarding paltry numbers of psychotherapy sessions during each treatment year. While an insured patient can go to the doctor an unlimited number of times for physical complaints with no questions asked, insurers will often question a patient's need for weekly therapy, deny requests for extensions beyond short-term treatment, and make mental health clinicians leap through hoops of fire to win additional sessions for the suffering client. How can this be?

Here on the front lines, somewhat removed from the watchful eyes of bureaucrats who question our motives and actions, we struggle to treat the suffering sufficiently. But even our cutting-edge program is underfunded in terms of behavioral health, with only one full-time clinician to oversee and coordinate the care of over 800 patients. Relying on private and public mental health clinics in the city, we are often left holding the bag. Long waiting lists, incompetent clinicians, and flawed referral systems act as long-term deterrents to our patients' ability to receive the care they need. Frustration abounds. Sure, a CT-scan can be had under duress, but when a psychiatrist or psychotherapist is urgently needed, even moving a mountain will be in vain.

So, we limp along, the psychic band-aids applied, slowing the gushing river, but never stemming the tide. The imagery of life-boats and life-preservers comes to mind, but on the horizon---a tsunami.

At the Gastroenterologist

I met her at the gastroenterologist's office. With diabetes, emphysema, astronomically high triglycerides, reflux disease, and depression with psychotic features, her mental illness and confusion frequently preclude her ability to understand the goings on during crucial medical appointments. I felt it was important for me to be there.

"I'm so nervous about this" she says. "I'm always so nervous at appointments."

We sit in the exam room and wait for the doctor. We review her diet, making lists of foods she can buy at the grocery store that are low in fat, low in sodium, and sugar-free.

"This diet's no goddam fun," she grimaces. "But I'm trying so hard."

"Well, your triglycerides have come down from 1400 to 400. You're doing great!"

"It came down 1000 points? I'm so thrilled!" She smiles broadly.

She's still beaming when the doctor enters hurriedly, his arms filled with charts and radiographic films. He dumps it all onto the desk. We shake hands, and I remind him of our previous encounters. He shakes my patient's hand, sizing her up and opening her chart.

"Sorry I'm late," he says as he settles into his chair. "One of my partners fell out of bed and broke his arm this morning. I'm picking up the slack for him."

"Talk about getting up on the wrong side of the bed," I say. He smirks.

After a quick review of my patient's history and a cursory physical exam, he looks her in the eye. "Well, with diabetes, reflux, emphysema, and those triglycerides, we have to do some tests. Basically, we're going to scope you from one end to the other." He smiles.

"Are you kidding? Do you have to?" She's incredulous and looks to me for support or possible rescue. I smile and nod and will obviously be of no help to her in the rescue department.

"Look," he says. "You're sixty, have never had a colonoscopy, and have reflux disease and diabetes. We have to make sure your colon's healthy and your esophagus isn't damaged. It's simple, but the prep isn't, I know."

"You're tellin' me!" she retorts. She looks like a cornered rabbit. We both look back at her, silent.

"OK, OK, I'll shit my guts out, all right?" She smiles and puts her head in her hands.

"That's my girl!" the doctor exclaims as he rises from his chair and gathers the pile of charts and papers and films.

As we walk up the hallway towards the reception area, the doctor a few steps ahead, I put my arm around her shoulders. "You're doing great, and I'll help you through this, OK?"

"OK," she replies, hand patting my back.

We receive the appointment, the prescription for the powerful laxative that will purge her bowel, and other instructions, and we walk down the three flights of stairs to the building's entrance. (She's trying to get more exercise, as am I.) I call the taxi company to take her home where she can continue to stew about the impending colonoscopy and endoscopy.

"Thanks for everything, Keith. I know you're busy and have alot of patients. I appreciate you coming and everything." She gives me a quick hug.

"My pleasure. Sorry this isn't going to be so pleasurable for you."

"Oh well. Bringing my triglycerides down 1000 points sure is something to smile about! I'm really gonna keep trying hard." She smiles.

"You take care. I'll talk to you soon, and don't worry."

I wave and walk towards my car. The air is cold, but there's a warm glow in my heart.

Reconstitution

Arriving back for a quick half-day of work is an easy way to reintegrate. Smooth sailing and then back in the warmth and familiarity of home. Just a long weekend away and some inkling of internal reconstitution can be had. Laughter, rest, good food, the company of one's child, time out of the ordinary habitual patterns---food for the soul.

Sunday, Sunday

Vacation weekend continues apace, with a plethora of rest and relaxation and little "accomplished". I keep thinking I should blog about something meaningful as it crosses my mind or comes up in conversation. To wit:

--the privatization of the American prison system.
--the story I read of a blind woman who hates hybrid cars because she can't hear them coming

But, my vacated mind is simply that---vacated.

We will resume our regularly scheduled blog quite soon.

Bon nuit.

Friday, Glorious Friday

This morning, we packed up the car, Tina the Dog in tow, and left for a quick half-day at work. Luckily, Tina is welcome for brief visits to both Mary's senior center and my office. After those mercifully uneventful four hours, we left for the Big City to visit our boy. A dog-friendly hotel shields us from the 30-below wind-chill, and take-out from Whole Foods warms our bellies.

In the hot tub, my son and I got to talking about young men he's known who lost their lives to recklessness---abusing pharmaceuticals, mostly. Kids at college sell their Adderall as a "study drug", lace marijuana with crushed Oxycontin, or drink and drug and never wake up. One of my patients, in his thirties, is wandering the streets as I write, high on crack. Still others sleep under bridges on this frigid night.

Sometimes we just need to escape from all of that. Sometimes we just need to get away. Sometimes, the constant reminder of others' suffering is enough to send one over the edge. It's a deep need to rest and collect one's thoughts that's often more imperative than anything else. So here we are, and that's just where we need to be.

So Many Carnivals, So Little Time

Not only is Grand Rounds up and running this week (see last post), the new edition of Change of Shift, our favorite nursing carnival, also graces the blogosphere this evening. It's time to put down that newspaper and glue yourself to the computer!

Signing In and Signing Out

An interesting edition of Grand Rounds is up at Signout this week. In my perpetual ignorance, I didn't learn until after I had submitted my contribution that the theme was "the interface of scientific evidence with health and healthcare". My esteemed colleague stated that about 40% of bloggers submitting pieces to this current edition gave that theme the proverbial finger and were subsequently left on the cutting-room floor. Apparently, the talented and forgiving medical resident who writes and edits Signout felt my piece was sufficiently appropriate and featured it early on in the proceedings. Thanks to my colleague at Signout, and happy reading!

Aegis

aegis \EE-jis\, noun:
1. Protection; support.
2. Sponsorship; patronage.
3. Guidance, direction, or control.
4. A shield or protective armor; -- applied in mythology to the shield of Zeus.

Health insurance, like the shield of Zeus, is meant to be the aegis of the masses, not something available only to the priviledged few. Organizations around the country are galvanizing for a further push towards coverage for all citizens as healthcare costs skyrocket and preventive healthcare is superceded by use of emergency rooms for primary care issues. With costs escalating exponentially, more and more employers are shedding---or at least eviscerating---their employee coverage, with the working poor left out in the cold, as usual. As often happens, California and Massachusetts are leading the way, being watched as litmus tests for the rest of the nation, everyone on the edge of their seats to see if these efforts fail like all of their predecessors, either from lack of political will or economic fears fed by a jittery Wall Street.

What will it take for this country to insure everyone, when the numbers of uninsured Americans continues to climb? As of August of last year, The Center on Budget and Policy Priorities reported that the number of uninsured Americans stood at 46.6 million in 2005, a shocking 15.9% of the total population. Additionally, the 2006 CBPP report underscored the fact that "the number of children who are uninsured rose from 7.9 million in 2004 to 8.3 million in 2005."

What do those numbers say about our society and how can citizens force their legislators to tackle such a contentious issue? For those of us in the healthcare fields, seeing the effects of poor health coverage on the ground, the continued effects of this emergent situation will only exacerbate the overall poor health of the American citizenry. With no health insurance, low earning power, a frozen minimum wage, exorbitant rents, high gas prices and increasing food costs, the working poor are left to their own devices, often faced with devastating hospital bills and nowhere to turn. Cheap foods laden with sugar and fat feed the obesity epidemic, and the poor feel they have no other choice but to fill their children's bellies with such fare. And those children, developing diabetes in record numbers, will only further stress the healthcare infrastructure as they age and face complications from poorly controlled chronic illness. (And we thought the care of the Baby Boomers would break the bank.)

It is a stark and frightening picture, but just like global warming, there is a window of opportunity to turn the tide before the levees break and there is no turning back. Burying our heads in the proverbial health insurance sand will do little to assuage the coming calamity, and meanwhile millions of children go to sleep not only hungry, but with no means to have their basic health needs met. Something has to give, and it had better give soon. We will all bear responsibility for the outcome---just as we will vis-a-vis climate change---and the potential for success has to be our driving engine.

There must be an aegis, a shield, and that protection is long, long overdue. From where will it emerge?

You're a Nurse, Right?

Yesterday morning, Mary and I drove to our favorite cafe and used bookstore in the middle of nowhere where we like to spend Sundays eating warm brown rice salad, drinking decaf, and pretending to read. The view of the icy river was lovely, and we eventually repaired to an old moldy couch in the bookstore, Tina snuggled between us (she was kicked out of the previously dog-friendly cafe).

We ran into an acquaintance who we had not seen for some time, and he regaled us with stories of his international community development work and other adventures. His stories were intriguing, plus Tina got to eat the leftover butter from his bagel. What could be better than that?

After a while, he looked at me and said, "You're a nurse, right?" I responded affirmatively, and he immediately shifted his gaze to Mary and said, "So what are you doing now?" The conversation continued vis-a-vis Mary's work for a while and then circled back to him.

Now, I'm more than happy to talk about my work, and I'm also happy to not do so, as well. It is such a big part of my life (and identity) that it's fine to leave it behind once in a while. However, after he asked me that question and did not pursue it further, I drifted off into a reverie thinking about what that lack of follow-up signified. Of course, we are all sometimes guilty of asking a question in a social situation and then failing to follow up, allowing the conversation to drift on its course, some tangents left to dangle like so many orphaned participles.

Another very possible reason for this gentleman not following up his question is that after confirming my continued nurseness, he immediately assumed that I work in a hospital. With that assumption, his mental images of "nurse"---hanging IVs, making beds, comforting the ill and dying, assisting a doctor---allowed him to have a vision of what I do every day without needing to ask further questions. The authors of From Silence to Voice would probably add that, while many nurses erroneously think that the public knows what they do without being told, many members of the public also think they know what nurses do based on media stereotypes.

Contrary to that experience, Mary and I were at our favorite tapas bar tonight for beer and snacks (and no, we don't go out to eat every day!). The bartender (who we know from her previous place of employment) said, "So, what kind of a nurse are you?" having been told by Mary that I was a nurse prior to my arrival. Question thus asked, she planted her elbows on the bar, hands under chin, and listened closely to my response, her face lighting up as she responded with her own dream of helping others by volunteering to create delicious, healthful meals for the ill or infirm.

There are several interesting points here. First, one might say that this could be an illustration of classic male and female conversational style. The man (our acquaintance) asked a question to which he received an expected answer, made some assumptions based upon his own experience, and then proceeded to the next question, ne'er looking back. The woman bartender, on the other hand, asked a question, used her body language and eye contact to express her sincere interest, and then added to my response by building upon it in relation to herself. Classic differences in communication style with which Deborah Tannen would have a field day.

Needless to say, I can imagine you need no help figuring out in which scenario I felt more "seen". While the bartender will not necessarily remember exactly what I do, she will most likely carry around a mental image of "latinos, vulnerable populations, HIV, substance abuse" as it relates to her memory of me. Whereas, aforementioned acquaintance will remember only "nurse" with either a caricature of Nurse Ratched, or perhaps a Hallmark card image of me in a white uniform and funny hat, compartmentalized in his mind. (As for the hat, I flatly eschew them, along with the white stockings and orthopedic pumps, mind you.)

But I digress. Does the public know what nurses do? Maybe they think they do. Do nurses think the public knows what they do? Perhaps nurses in hospitals, doctors' offices and schools do, but those of us in slightly alternative roles are creating the public's image of us as we go along, educating people that nurses do many things not involving a hospital. I have never been a hospital nurse. In fact, I vowed prior to graduation that I would never work as a nurse in any setting where a uniform or scrubs were required. (What a non-comformist!)

So, the next time someone says to you, "So, what do you do?", be aware of how they follow up that question. Do they put you in a mental box and carry on, or do they probe to further understand you, your work, and its place in the world? Food for thought, and for conversation.

To Cudgel or Not to Cudgel

cudgel \KUH-juhl\, noun:
1. A short heavy stick used as a weapon; a club.

transitive verb:
1. To beat with or as if with a cudgel.

Good ol' dictionary.com. Almost always food for thought, grist for the mill, and fodder for blogging.

Apropos of yesterday's post, the concept of cudgeling is something worth consideration. When a patient refuses to take his or her medications, misses appointments either through avoidance, sabotage or outright self-neglect, how far does the earnest medical provider go to cudgel such an individual into action? As described yesterday, I managed to frighten my patient enough that she decided to restart her medications. Pummeled by visions of amputations, dialysis, blindness, and imminent myocardial infarction, she felt an impetus to take her metformin and pay a little closer attention.

The "scare-'em-to-death-technique" may be effective in the short-term, but I do ask myself if it actually engenders real change from within, or simply cudgel the patient into compliance out of fear or a simple desire to please the provider. Some patients respond well in the moment, but time has shown that change not necessarily coming from within may very well not remain fixed and strong.

Motivational interviewing is a non-confrontational technique of counseling aimed at assisting clients to recognize their potential problems, the potential consequences of those problems, and how those consequences might be avoided by way of self-directed change. There is a small voice in my head that this may be a way to increase one's skills to direct non-compliant or passive patients towards change while avoiding the techniques that simply use fear and warnings of dire consequences to alter behavior. How does one convince a very sick person that their illness simply cannot improve without their active participation? How does one help that patient decide whether or not to take proactive steps towards change? When does the earnest nurse just let go?

Of course, I have certainly found myself in situations where there was little to do but watch and wait. In yesterday's post, I mentioned the gentleman who I simply cannot protect from his own self-neglect as he heads down a path that will probably result in the most dire of consequences. Can I save him? Absolutely not. Does he want to be saved? Certainly not. Will I just watch him self-destruct? Seems that way.

To cudgel or not to cudgel? That does appear to be the question. The answer is apparently a double-edged sword.

Non-Compliance, Apples, and Surrender

She calls to say that her stomach hurts, her blood sugars are high, and she vomits every time she eats. I haven't heard from her in weeks. Since she's so bad at refilling her prescriptions, I keep her meds in my office and fill med boxes for her every few weeks. Her only responsibility is to bring in the empty boxes so I can fill them up again. I do this for about seven patients who can't manage it themselves.

I tell her I'll be over in an hour or so.

I arrive at her home. Her apartment, which I've been to before, is unchanged from last time except for the addition of a computer (and her adult son who is now living with her, surfing the Internet and ignoring my arrival). Her home is cluttered but nicely decorated with countless images of red apples: pot-holders, tiles, photos, towels, mugs, refrigerator magnets. It's a cornucopia filled only with apples. I find it oddly comforting today.

I ask to see the three med boxes that I filled in December. She drops them on the table. They seem to still be filled with pills and capsules.

"You haven't taken anything since I filled these last time?" I ask.

"Oh, I took a few here and there," she says.

I poke through the boxes and see that, yes, she's taken her Levothyroxine and Lipitor and nothing else. She must have a predilection for meds that begin with the letter "L", I think to myself.

"Now, why haven't you taken your meds?" I ask. "You're vomiting because you aren't taking what we prescribed for your stomach, and your blood sugars are high because you're not taking your diabetes medicine. Plus, your stomach probably hurts because your blood sugar is high, so there's alot going on here. Are you at least using your insulin?"

She looks sheepish. "I've been so depressed, I haven't wanted to take anything." She smiles very endearingly. "Yes, I take my insulin, but the needles are so big!"

"The needles are 1/2-inch, my dear. I'll get you 5/16th-inch needles next time. But look, we can get the social worker over here to talk with you, but you have to take your meds. If your sugars are high and your stomach hurts, what good are the meds doing you? We've talked about the complications that diabetes can cause, and I don't want to see you on dialysis and blind with amputations and a heart attack."

"You're frightening me," she says.

"Good. I think I need to frighten you once in a while," I reply, smiling. "As for your depression, it may also be worse because you haven't taken your antidepressants for three weeks. I really want you to feel better, you know. Will you take them now?"

"I think so. But my stomach......"

"Let's see. You went to the gastroenterologist, who recommended some tests. You missed the ultrasound, then you missed the endoscopy. After that you didn't come back to see him and then you forgot your appointment with your primary doctor, even though we called to remind you the day before." I look at her, exasperated but disarmed by her smile.

"We have to start over. First, take your meds, use your insulin, check your blood sugar four times a day, and then come in to see the doctor. Can you do that?"

"I want a insulin pen. I'm tired of all these needles." She crosses her arms.

"You want an insulin pen? Let me make sure it's covered by Medicaid and I'll fax a prescription today. How's that?"

She smiles like a child and thanks me several times as I put on my coat and gather my things, heading for the door. I'll leave her with her silent son, her belligerent and pregnant daughter, and the ubiquitous apples.

"It's my pleasure, truly. I just want you to be healthy and not get sick."

I close the door behind me. It feels like snow. I drive across town to the next patient's house. He's not home and I'm not surprised. I knock on his neighbor's door. No answer. Damn. He's a tough one who I've written about before. The poster-boy of non-compliance. Another patient of mine who could have been his identical twin followed the same path and his esophagus exploded. I guess some people never learn, at least not in this life, anyway.

What's an earnest nurse to do? Cajole, beg, teach, illustrate, lead, insinuate, joke, threaten, frighten, ignore, dread, expect, relinquish, surrender. I think I like surrender best. Surrender to the depression, the anxiety, the trauma, the disintegration of family, the loneliness. Surrender to the giving up, the disenfranchisement, the poverty, the powerlessness, the disempowerment, the recalcitrant illness. Yes, surrender to it all and then decide to keep going anyway. To surrender does not mean to give up. It simply means to acknowledge that there are things in this world which one cannot change and to choose one's battles carefully. Like the Serenity Prayer says, "and the wisdom to know the difference."

As I push through some of these more challenging days, interacting repeatedly with traumatized people unable to fully hear my counsel, I remind myself that my job is to simply lead the patient towards health, but like the proverbial horse led to water, I cannot make them drink. Nonetheless, I continue to offer the cup of hope, the cup of solidarity, the cup of possibility. And when all else fails, there's nothing like surrender.

Two Years and Counting

Today, January 18th, is the second anniversary of Digital Doorway. These twenty-four months have delivered to me a golden opportunity to use the open book of the Web to splash my thoughts upon a screen and instantly broadcast them to the world. One year ago, I expressed surprise that DD has lasted twelve months. Now I can say with certainty that I would have been shocked had it not reached the ripe old age of two.

Statistically speaking, StatCounter tells me that Digital Doorway has now amassed over 37,000 hits in its lifetime, with most months seeing more than 1000 hits each. I have gratefully become a regular contributor to both Grand Rounds and Change of Shift, two wonderful blog carnivals which consistently offer the best of medical, nursing, allied health, and patient blogging. Digital Doorway has been featured in several on-line articles about nurse bloggers, and was recently nominated for "Best Literary Medical Blog" in the 2006 Medical WebBlog Awards, a humbling development, to say the least, but the likelihood of winning is quite low based upon the stellar competition. Still, a nomination is honor enough.

Aside from recognition and popularity (which honestly are a boon to this blogger's spirits), the personal connections which blogging has fostered are the real treasures of this experience. No matter how inconsequential the uninitiated might feel they are, on-line friendships---and the kinship that develops therein---is a phenomenon of the Digital Age which is yet to truly be measured or studied, in my opinion. Relationship and community have taken on a new identity and meaning in this post-modern world, and those of us partaking of this electronic democratic experiment have reaped the benefits and rewards which are too numerous to recount.

Sadly, a "digital divide" still does exist around the world, with relatively few privileged souls having access to this smorgasbord of communication and information. Hopefully, over the years to come, that divide will be bridged and more people will be allowed to have the same experience as their fellow citizens. Of this I remain quite conscious.

For the forseeable future, I can imagine no end to my blogging and sharing in this most gratifying of venues. My other two blogs have been born of my desire to share my thoughts and creative aspirations in varying ways, and I hope that those two sites also continue to flourish until their time naturally comes to an end.

Being the creator of something that to me seems so alive but that truly does not exist in the physical world is an interesting notion. Whatever its manner of being, I am fully satisfied with the venture, have every intention to continue, and again thank my beloved brother Ken for being the impetus for my naive beginning of this strange and wonderful journey of self-discovery.

A Rant

The local newspaper (which shall remain nameless) in our illustrious city (which shall also remain nameless) recently published an article quoting the Police Commissioner regarding a new way to regard and codify victims of crime.

Almost Orwellian in concept, said Commissioner is now categorizing crime victims as "authentic victims" and "inauthentic victims". When a crime victim is truly "authentic" in the Commissioner's eyes, said victim allegedly did nothing to "bring about or cause" the crime perpetrated against them, thus being seen as a true victim. "Inauthentic" victims are those who make lifestyle choices which put them at risk of, or more prone to, being the target of violence.

At face value, some white middle-class readers/citizens might automatically agree with such a codification. After all, if a gang member or prostitute is killed by gun violence, they essentially asked for it since they made life choices which put them in a position to be on the receiving end of those bullets. Whereas, if a white, middle-class person is downtown and is car-jacked and knifed, said individual is an "authentic" victim since they live a clean life and did not consciously place themselves in harm's way.

So, what's wrong with this picture? There are so many things wrong that I don't know where to begin.

First of all, forming judgements against victims of violent crime essentially gives the police the ability to respond differently to reports of crime based upon the neighborhood where the activity is reported. Racist police would undoubtedly be slow to respond to calls regarding low-income areas since anyone in that neighborhood automatically carries an "inauthentic victim" ID card based solely on their address.

Secondly, just because a person is white and middle-class and lives in a nice part of town does not preclude the possibility that that individual drives to the bus station every Friday night to score a bag of cocaine. Just because that individual has managed to avoid being caught in his illicit activity would not immediately confer upon that person "authentic" victim status, would it? Or do we assume under this program that white middle-class suburban folk never do drugs?

Third, when it comes to crime, an understanding of innocence until guilt is proven is a hallmark of our judicial system. If the police are allowed to pre-judge not only criminals but also their victims based upon perceptions of lifestyle, we may as well abdicate all judicial powers to the police and codify their judgements into law.

This is clearly a blatant attempt to manipulate crime statistics to better serve the interests of the city. When promoting the city as a haven for new business, the local government could very well publish only "authentic" crime rates, artificially decreasing the reported number of violent crimes in order to attract economic growth and investment.

All of us at the health center see this as a racist and classist manipulation of truth by the police of our troubled city, and it was decided today that we would publish a powerful letter to the editor to decry such a reprehensible policy. It seems that the proclivity to cynically spin numbers and statistics in order to benefit the rich and degrade the poor has trickled down from the Bush Administration to the cities and towns of the land. We citizens must stand up to such outrageous behavior and shout from the rooftops that we will not tolerate policies which undermine democracy, fairness, and equal protection under the law while simultaneously propagating racism and its ugly cousin classism. Such actions as these are really just rallying cries for the sane and justice-minded to take back aspects of our society which have been lost to the machinations of the cynical few.

And that is my rant for the day.

Nurses' Voices, Part II

Reading From Silence to Voice, a book I mentioned in a recent post, some thought-provoking ideas are brought to the fore vis-a-vis the image of nurses in the world. To wit:

---How does the public know a nurse is a nurse if everyone in the hospital (except for the docs in street clothes and white coats) wears scrubs with teddy bears and angels on them? Aside from the old nurses' caps, how can nurses be distinguished and identified?

---What kind of image of nurses do the angels and bears project? Is it less professional? Does it decrease how seriously nurses' work is taken?

---Why are there so many toys, figurines, and stuffed animals dressed in nurses' uniforms? What does this say about nurses and how they're viewed?

---What does it mean that doctors are ubiquitously called "Doctor So-and-So" but nurses are always referred to simply by their first name?

---How does the "angels of mercy" stereotype demean nurses and undermine their professionalism and technological prowess?

---Do nurses emphasize the notion of "caring" to their own detriment, ignoring their vast stores of technical knowledge and assessment skills?

---Does the public really know what nurses do (other than "caring" or nurturing", or being the handmaiden of a doctor?) Do nurses have a credible public image?

---Does the media know (or care) what nurses do? Do they want to hear nurses' voices regarding weighty matters of health and policy? Why do reporters' Rolodexes bristle with the names of doctors to call for opinions, but there are so few nurses on those lists?

These are meant as rhetorical questions in this context, food for thought and discussion. For me, some of the answers to these questions might be disturbing, at best. I, for one, am driven to distraction by those cutesy scrubs---no offense, folks, just personal taste. But sometimes when I see a nurse in scrubs adorned with teddy bear angels standing next to a doc in a tie and white coat, the nurse looks like she's in pajamas. Does it matter?

Anyway, this book is obviously pressing my buttons and raising my eyebrows, and I highly recommend it.

A Hero's Day

Today is the day to commemorate a hero, a true lion of hope and equality. So many, like him, have fallen at the hands of known and unknown purveyors of fear: Malcolm X, JFK, RFK, Gandhi, John Lennon, the students of Tiananmen Square and Ohio State, Rachel Corrie, and the Greensboro Five. Some theorists feel that Paul Wellstone could be added to that list. Still others are driven from their homelands around the world, their lives spared but their hopes for freedom dashed.

Famous or completely unknown and unsung, so many have dedicated their lives to the freedom of others, and to equality and justice. Actions small and large accumulate and exponentially multiply the effect.

At times I wonder if I'm not doing enough, if my candle should be burning more brightly. If we all cared enough, wouldn't all the problems already be solved? We can't all be Martin, John, Mother Teresa, or Rigoberta Menchu, but we can all be who we are, enacting change by embodying love and compassion in the world. Some do their part simply by living quiet lives of meditation. Others march in the streets and speak truth to power. Still others send money, write letters, or speak up for those without a voice.

And the others, you ask? Yes, there are still others who do nothing but fend for themselves and take all that there is to take. But even for these there must be compassion somewhere in one's heart, even if for now that place is closed and inaccessible. As for those who are purveyors of fear and sowers of division, must we not also feel compassion for them as well? Some of us are capable of such compassion, some even attain the bliss of true forgiveness. Still others even more enlightened might realize that those brokers of fear are no different than ourselves and fully deserve our compassion.

As for me, I continue to struggle to forgive some in the world who have wronged me, like those who murdered my closest friend in the prime of his life and the rest who did their best to obfuscate the truth. My hatred and anger are still not dissipated, and I know that these emotions will only cause me harm in the end, no matter how human they may be. I also have strong vitriolic feelings for those who I feel are responsible for the raping and pillaging of our country, our culture, our economy, our ecology, our very soul as a nation. Will I some day feel compassion and forgiveness for them? It is a tall order, I must say.

But in the spirit of Martin, today is a day to hold forth a vision, even if the more difficult emotions serve to cloud that vista from time to time, like an emotional cataract. Without that vision, all is lost, and only the clouds and darkness hold sway. I'm sure Martin forgives his transgressors and sees the bigger picture from the vantage point of enlightenment. We can all catch a glimpse of that picture from time to time, and when we do, it's a breath of fresh air. It may be a mad, mad world out there, but to paraphrase and twist the words of W.C Fields for my own purposes, "there's a hero born every minute". Let's prepare the way for the the heroes of the New World, the world that's just around the bend, the one which Arundhati Roy says that she can hear breathing.

Nurses' Voices

While browsing today at my local worker-owned collective bookstore, I finally purchased a copy of From Silence to Voice: What Nurses Know and Must Communicate to the Public. This book, along with Nursing Against the Odds: How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care, provide thoughtful and erudite information regarding the state of the nursing profession, its relationship to medicine, and nursing's image vis-a-vis the public and the media.

As a nurse blogger with a modest (and slowly growing) readership, I feel I too must pay attention to the public image of nursing, and do my best to dispel stereotypes, shoring up an image which is frequently tainted by media reports concentrating on striking nurse unions and so-called "killer nurses" who occasionally are prosecuted for malfeasance or worse.

The bloggers of the nursing profession are a front-line voice in the medical wilderness, and I'm pleased and honored to be a member of that informal alliance of minds. Stay tuned as my wider reading engenders further writing fueled by my reaction to the contents of said tomes.

Deus ex machina

deus ex machina: an agent who appears unexpectedly to solve an apparently insoluble difficulty.

Healthcare in this country is in crisis. Rising drug costs, millions of uninsured Americans, bankrupt hospitals, Big Pharma run amok---the most powerful and influential nation in the world still cannot care well enough for all of its citizens. While Senators and members of Congress have health coverage to die for (pun intended), so many of the working poor are denied even the most minimal of coverage. Seniors are forced to choose between paying for prescriptions or groceries, and insurance companies continue to deny certain types of care as costs skyrocket out of control.

Enter the deus ex machina, or at least the hope for some solution which will fall out of the sky and save us. Is it Canadian-style universal healthcare? Is it a market system? (Oh wait, that already failed miserably, right?) Where will we find our panacea of preventive medicine and cost containment?

In Massachusetts and California, governors and legislatures grapple with critical universal coverage mandates which could break the bank, but may just be one answer which could be followed by other states around the country if they succeed. I would never have imagined that Arnold Schwarzenegger, that movie-star playing a politician, would be the one who could actually pull it off. If he does, I'll gladly eat my hat. And here in New England, in Massachusetts specifically, perhaps Deval Patrick---the first African-American governor of that state, and only the second in all of U.S. history---is also poised to tackle universal healthcare which is mandated by law to swing into action on July 1st of this year. And who knows, maybe Nancy Pelosi will perform the miraculous, only to be thwarted by a cantankerous and staid Senate. (Talk about The Bride Stripped Bare By Her Bachelors, even.)

My patients are relatively lucky, receiving the benefits of a cutting-edge program which provides that with high quality care, timely follow-up, and personalized service. Still, drugs are denied, certain procedures and equipment are not covered, and certain specialties are becoming almost impossible to refer patients to as those provider groups stop accepting Medicaid all together. Something has to give, and usually the first thing to go is quality and equality.

So is there a deus ex machina? Will someone or something save us? Will Arnold's proclamations bear fruit, his iconic super-hero status actually managing to be the springboard to bring healthcare to the disenfranchised? Or will Deval Patrick, a descendant of the disenfranchised himself, turn a tide that has been carrying the poor out to sea for decades? Both of these scenarios are possible, and still others are yet to be born, or are now being hatched in minds around the country. But the rest of us cannot necessarily sit on our laurels and wait for others to solve the dilemma. Letters to the editor, calls to legislators, op-ed pieces, dreams and meditations, or even water-cooler chat---all are potential places for the birth of a kernel of an idea that could turn the tide. So, where is the deus ex machina? Apparently it is us.

Friday Evening Deneoument

Friday evening exhaustion settles into the bones. Family from out of state are arriving late tonight, and we putter around the house, preparing beds and removing the stains and crumbs of the week.

Two of our patients died this week. One went home from surgery, and on the second day post-op began to vomit blood. Instead of calling the nurse on call, the family asked a neighbor, who said that the symptoms were normal. She was dead by morning.

Another patient, a sprightly sixty-year-old who was also quite involved at my wife Mary's nearby senior center as a volunteer, suffered a massive hemorrhagic stroke and died several days later. A handful of women at the center combed the neighborhood, going door to door, asking for contributions for the family's funeral expenses. Here in this inner-city neighborhood, which may be the poorest in our state, more than six-hundred dollars was raised in twenty-four hours. The concept of community really means something here, especially when the going gets tough.

The mood in the office this afternoon was very busy, if not slightly slap-happy. Mary came to pick me up at 5:05 and there were at least six clinicians still on the phone, speaking with patients and hurriedly finishing notes. Most offices are dead by 5 on a Friday, but ours is often abuzz with last-minute necessities, critical labs, and eleventh hour calls for med refills. I had two no-shows late this afternoon, so I had the luxury of focusing on non-essential tasks, like reorganizing a crucial file cabinet where no one can find anything and minutes are wasted daily in frustration. The administrative staff does not seem to want to touch this disaster with a ten-foot pole, so I volunteered myself. Obsessive-Compulsive Disorder can really come in handy sometimes.

Working five days consumes one's week like a hungry animal. There seems to be so little time for anything else, and Friday evening is when the mind and body finally let down and allow the fatigue to truly come to the surface, at least if one is blessed---or perhaps cursed---with membership in the 9-5 club.

As Mary falls asleep next to me, I will sneak downstairs to await the late-night arrival of my brother and his family. Candles flicker in every room, and warm beds await us all.

Bon nuit.

Change of Shift - Vol. One, Number Fifteen

Change of Shift, that carnival of nursing thought through the vehicle of blogging, is up and running yet again and you can access the latest edition here.

There are so many talented and thoughtful bloggers out there, it's just too hard to keep up. Personally, I must admit that between work, home, my own blogging, and life in all its peregrinations, reading others' blogs is often something that takes a back seat to other responsibilities. However, when I do decide to dig in and take the pulse of the medical, nursing, or literary blogospheres, I am consistently reminded that there are innumerable individuals in the world who, like me, choose to share their experience in this most democratic of spheres wherein the individual may publish---direct and raw---from their living room to yours.

We are truly blessed that so many choose this form of publication, eschewing the world of agents, editors, and middlemen who only serve to stand between a writer and his or her potential audience. Without blogs, so many voices would be silent, unable to reach a wider audience, relegated to journals and notebooks gathering dust in countles homes. Instead, our words gather in the ethers and reach the eyes and minds and hearts of willing readers.

I am so thankful to have found this venue for my own creative expression. And many thanks to you, dear Reader, for coming along for the ride.

New Year, New Life

He and his wife have had AIDS for years. Did they infect one another? I think so. At any rate, here they are with school-age children and a life to live. What to do?

She is a model patient, taking her meds religiously, showing up for appointments and labs, doing everything she can to succeed. Her work and diligent focus have paid off and her virus has been completely suppressed for years. Free of opportunistic infections and other complications, her HIV lingers in the background like controlled diabetes and hypertension---it's there, but there's little to worry about. Barring unforeseen circumstances or aberrations, she will be a member of this generation that dies of heart disease along with her non-HIV infected peers, Goddess willing.

On the other hand, her husband is far from the model patient. Having gone off and on his meds for years, he has basically "blown" a number of meds for himself forever, the virus in his body building resistant mutations to any number of combinations of medications. One or two entire classes of meds may now be out of the question for him, and the new classes of drugs are slow to make it onto the market. Having failed to take his current regimen of five drugs for almost two months, he landed himself in the hospital with pneumonia, although he miraculously avoided pneumocystis carinii pneumonia (PCP), the most lethal for people with HIV infection. Lucky for him, it was run-of-the-mill community-acquired pneumonia (CAP), and Levaquin, a popular and powerful antibiotic, will eradicate that bug in a flash.

So, four days out of the hospital, today was Check-Up Number One with his favorite Nurse Care Manager. Lungs were OK, although he has some intercostal pain between some ribs from the weeks of coughing. No fever, normal vital signs, weight surprisingly steady but well below his optimal goal: things look pretty good. While hospitalized, an HIV Genotype was drawn, so that in two weeks or less, we will have a list of the many mutations created by the particular brand of HIV virus inside of his body, helping us choose which meds might still be efficacious, if any. The news may be surprisingly bright, but could also be rather grim. Only time will tell.

Meanwhile, back in the exam room....

"It's the New Year, and I'm ready for a new life," he says. His skinny frame is racked by coughing and I wait for him to catch his breath.

"You know this is serious, right?" I ask in Spanish. "We've had this talk before and you were ready to go, but then you got lost and here we are again."

"It's not like before," he says while looking down. "This time I'm going to do it. I have to."

"Well," I say in response, "that's great, but it will take alot more talking before we make any decisions about medications." I look at his wife, and she's nodding knowingly.

"Look," I add, "you cannot be having unprotected sex---not now, not ever. You could pass your HIV mutations on to her, and then you'll both be in trouble. She's in great condition---let's keep it that way."

"Yes, yes," they both say. "We need condoms."

"That's what I want to hear. I'll give them to you before you go." I close down the computer after I finish entering the vital signs and a brief note.

I walk down the hall next to his wife and he lags behind, as usual, winded and tired.

"What do you think? Is he serious?" I ask.

"I think so," she replies. "He says the New Year is his time to start again."

"I hope so," I say as I open the door for her.

"A million thanks," she says as she grabs my hand.

"My pleasure." I squeeze her hand and then shake his, as well.

"I want to see you every week---don't disappear!" I say to his back.

"Don't worry," he yells back. "We'll see you."

I smile as I open the door and head back towards the office. I think about their kids, one a teenager and the others some years younger. Do they know their parents' diagnoses? How much have they surmised? Do they know how their father's been playing Russian Roullette with his life?

I can't do all the work. The patient has to meet me half-way. Some do, some don't, others do for a while but lose their focus. If they only realized how easy we make it, what an embarrassment of riches is at their disposal in terms of the system set up to help them succeed. We've lost so many, and continue to do so. Will this couple both live long enough to tend to one another as old age sets in? Can they be one couple of their generation that survives that long, intact and relatively unscathed and unwidowed? As for the wife, I put my money on her living to be quite old, with grandchildren to coddle and grown children to enjoy. And for the husband? My jury is out, but the track record does not bode well. Still, I hold out hope as this New Year gets underway.

New Year, new life? Let's hope so.

God's Little Looney Bin

I have a patient who I see regularly for my second job as a per diem Visiting Nurse. Interestingly, her mother-in-law, who lives with her as well, was a patient of mine seven years ago when I was a full-time Visiting Nurse. Arriving early in the morning before my day-job begins, I am welcomed into their home like a beloved guest. Although the redundancy and sameness of the visits can sometimes feel monotonous, their collective and individual sweetness keeps things fresh, and I see it as yet another opportunity to be loving and accepting of others.

This particular patient is not very educated and has lived a very sheltered life. However, she is also a deep thinker and humanitarian in her own way, and getting to know her over the months reveals a complexity of thought in a person who, if I met by chance socially, I honestly might not take the time to get to know. Be that as it may, these professional therapeutic relationships are a way to open one's heart to those who one might not encounter otherwise.

When I first arrive around 7:30am, I open the unlocked front door and enter the dark living room. My patient sleeps in a hospital bed near the front window of the cramped room, and her husband sleeps in another hospital bed along the adjacent wall. An oxygen tank for my patient hums next to her mother-in-law's tank, the line for the elder woman's O2 running up the stairs. I call my patient's name softly, take off my coat as she stirs in her bed, her husband snoring loudly across the room. As I turn on the light, she wakes and sits up, rubbing her eyes like a child.

In the course of our weekly thirty minutes together, we converse about many things as I unlock the box holding her meds, take her vital signs, listen to her lungs, and do a cursory but thoughtful assessment. Sometimes telling me stories I've heard before, I listen with interest and inject humor into the conversation which makes her laugh and cover her mouth to hide her crooked and decaying teeth. My strange sense of humor is not lost on her, and she'll often remember things that I said previously and repeat them to me weeks later, laughing as if I had just said it again.

This past week, we talked about the recent violence in the city over the Christmas holiday, the people who take advantage of the poor, the social service agencies that, one by one, are coming under scrutiny and revealing systemic corruption at the expense of the needy. We also often discuss the environment, Global Warming, animals close to extinction, vegetarianism (she refuses to eat meat), and culture in general. She also talks a great deal about her health, her mother-in-law who she loves, her husband's health. She waxes poetic about my wife and me, and I try to wave off her heaps of unabashed praise.

Once in a while, she will say something that sticks in my mind, a gem that I write down in order to not forget it. Recently, after ruminating about the ills of the world together, she summed it all up by saying that perhaps this world was just "God's little looney bin" and we were all just permanent residents. I then told her about a line in one of my favorite films---My Dinner with Andre---wherein Andre describes New York City as a modern prison in which the residents are not only the inmates but also the guards, and that everyone has forgotten that they are free to leave at any time, and almost no one does. My innocent but thoughtful patient loved that image, and covered her mouth as she giggled.

Going upstairs each week, I greet her elderly mother-in-law if she is awake. The television is always tuned to the channel showing Catholic mass in Spanish. She lies on her bed, doing her Rosary, looking out the window. Our conversations are generally the same: I ask her how she is, she complains of various symptoms, I tell her a little anecdote, and I leave quietly, not before she blesses me, my wife, my son, and my dog. Working with Latinos, I have often experienced such blessings, some of which can go on for up to five minutes, although hers tend to be about a minute long. I give her a big kiss and hug, carefully go down the cluttered stairs, hoping to not be sucked into another long conversation with my patient before taking my leave and continuing my day.

Back downstairs, this kind but simple woman who receives few visitors will keep talking as I leave the house, and I often need to persistently attempt to bring closure to the ongoing conversation as I close the door behind me. Three years older than me, she always tells me how much she enjoys my visits, that she had fun, and looks forward to my next visit, which is usually only once a week.

Examining these visits, I can see that my dispensing of meds and taking of blood pressure is really only circumstantial to her. The important thing to her is the human interaction, the give and take of conversation. For me, it is a service, yes, but it is also honestly a way I keep just a little extra money flowing into my bank account. Community nursing often feels more like social work, and patients will embrace you not only as a clinician, but also as a friend. Those roles are fine, as long as boundaries are maintained and expectations are low.

Here in "God's Little Looney Bin", I flit from home to home, play a small but often vital role in someone's life, add comfort and kindness along the way, and hopefully encourage new habits of prevention and self-care which increase quality---and perhaps even quantity---of life. It is a curious and quite personal calling, and is never bereft of surprises. Looney bin or not, it's what we have, and whether I be inmate, guard, or both, I'll give it my all until it's time to say goodbye.

Evoking Compassion

One powerful way to evoke compassion is to think of others as exactly the same as you. “After all,” the Dalai Lama explains, “all human beings are the same—made of human flesh, bones, and blood. We all want happiness and want to avoid suffering. Further, we have an equal right to be happy. In other words, it is important to realize our sameness as human beings.”

---Sogyal Rinpoche

Varicella Strikes Again

Today I received a call from a patient whose appointment yesterday with his primary physician was cancelled for reasons unknown. He was quite distressed since he was experiencing severe discomfort on the right side of his torso and felt like he was about to lose his mind with the pain. I told him to come on over.

He grimaced as he sat in the chair next to me. His wife looked concerned.

"So, when did the pain start?" I asked.

"About two weeks ago," he replied. "And there was this rash under here, but now it's gone." He points to his ribcage, around the 6th and 7th ribs, I think.

His wife chimes in. "It was like a bruise, with little red spots. He was in so much pain, and he would sweat all night. I couldn't even touch that area, he would scream in pain. Then the rash went away but the pain didn't change."

My mind clicked into action. "Did you have chicken pox that you know of? Most people have."

"Oh, yeah, when I was 18. Kind of late, and it was really bad."

I take his temperature: 99.1. Low-grade fever, with pain along the line of three ribs on one side, the right arm also affected.

"I think you have Shingles," I propose.

He looks puzzled.

In my best Spanish, I explain how the varicella virus lives for decades in the basal root ganglia of the spine, bursting forth when we're older with intense pain and lesions along what we call a "dermatome" where the nerve travels from the spine along the rib to the chest wall. It's technically called Herpes Zoster.

I fetch a doctor, the same one with whom the appointment was cancelled the other day. He readily agrees with my diagnosis. Since the rash is gone, our plan is just to treat the significant pain with oxycodone and amitriptyline.

As a nurse, we are really not supposed to diagnose---only a doctor or Nurse Practitioner can do that. However, there are times when it is just so blatantly obvious that we can't help it. This was one of those times, and although I strive for humility in life, I couldn't help but feel some professional pride that I had hit the diagnostic nail on the head so definitively. A decade of experience does indeed begin to pay off eventually. Even amidst the stressors and struggles of the working life, the mountains of paperwork and avalanches of need, a simple and straightforward resolution to a problem presented in the examining room can offer a moment of great professional satisfaction. This was one of those times, and it lifted my spirits on an exhausted Friday afternoon.

The 2006 Medical Weblog Awards

I am pleased and humbled to report that Digital Doorway has been nominated for the 2006 Medical Weblog Awards under the category of Best Literary Medical Weblog. The competition is stiff, what with The Examining Room of Dr. Charles and The Cheerful Oncologist also nominated in this category---both formidably talented bloggers, as are the other nominees. Still, it is an honor to even be considered, and I thank whomever it was who nominated Digital Doorway in the first place.

Notes From a Home Visit

So, he sees his dead family members in his bedroom---especially at night---and they talk to him.

"Is he really hallucinating or is it just a culturally accepted Latino way of connecting with dead ancestors?" I pose this question to the Social Worker/Nurse who accompanied me on the visit to assess the patient's mental status.

I have written about this alcoholic hypertensive man in previous posts. He refuses most offers of care, takes few of the medications I prefill for him in a med box, and basically watches TV, visits with a few neighbors, and collects cans to trade in for nickels across the street at the package store. I know his kidneys and liver are going, but does he really understand?

He left school in Puerto Rico after the 3rd grade. His father gravely ill with cancer, it was my patient's premature responsibility to earn enough to care for the family. The sugar cane fields became his school, the plantation owners his schoolmasters. Now, fifty years old and illiterate in even his native tongue, the English-speaking world is a place upon whose fringes he exists, eeking out a lonely and narrow existence.

If he seemed content, I would feel more comfortable, but his depression is palpable, and his isolation apparent. He repeats himself so much, latches onto certain phrases and sentences, sometimes not responding to my original questions, circumventing my clinical inquisitiveness through redundancy. I lose my train of thought and then repeat my question or frame it differently in hopes of a more revealing answer. He is not a great historian. To wit:

"When did you last have any alcohol to drink?"

"Well," he pauses briefly and looks at the wall. "I had three glasses of water this morning and then cooked some pork and rice. After that I mopped the floor."

It took a few more questions to elucidate that he had a few beers on New Year's Eve.

"Do you understand that every beer you drink damages your liver some more?"

"I don't drink anything strong---just beer. It doesn't do anything bad, but it really hurts under here." He presses just below the right side of his ribcage in the area of the liver.

"That's your liver. I can feel that it's enlarged," I say as I palpate the organ.

"It's just my stomach." He looks away.

Where do I go with that statement? Can I convince a 50-year-old man with the education of an eight-year-old that his stomach is on the left side and that the pain on the right is his liver? Will he care? Will he listen? Should his brother take charge and have him hospitalized against his will? Should we just leave him be?

No answers come to the fore, so I'll abide by that age-old adage: "Don't just do something, sit there." Until I get a better idea, I'll do my best to keep him alive and let him guide my actions. And when the shit hits the fan, be there to pick up the pieces.

To See Differently

Well, nothing seemed terribly different at work today. The same patients called with the same types of complaints and needs. My co-workers were hunkered down at their desks with some occasional desultory talk of the weekend and our New Year's Eve exploits. Over all, though, everything was so much the same, except that I was trying to remember to write "07" on my notes rather than "06".

This is simply proof positive that things must change on the inside despite external circumstances. One can indeed resolve to floss every night, eschew sugar, exercise regularly, be more loving, listen more attentively, and say "Good morning, God!" instead of "Good God, morning!" when the feet hit the floor each day. But when those feet do hit the carpet, it's what's happening on the inside that counts.

The commute to work can always seem the same. That cup of coffee tastes like it always has tasted. The water-cooler chat with a co-worker seems no different than a thousand days before, and those voicemails sound like voicemails received any number of times in the past. Repetition and sameness can seem mind-numbing and bland, and I certainly had moments today when I was wondering why nothing seemed different. then I caught myself and realized that it was I who needed to adjust---it's all about my perceptions, not my expectations and assumptions.

Did I really think anything would be outwardly different today? Of course not. Did I truly expect that this one's need for methadone and that one's need for Xanax would somehow be transformed? Clearly not. Any change must come directly from my mind, my perceptions, my ability to see differently. It is truly all in the eye of the beholder, and this beholder certainly has alot of learning to do.

Preparing for Death by Finding Meaning in Life

According to the wisdom of Buddha, we can actually use our lives to prepare for death. We do not have to wait for the painful death of someone close to us or the shock of terminal illness to force us to look at our lives. Nor are we condemned to go out empty-handed at death to meet the unknown. We can begin, here and now, to find meaning in our lives. We can make of every moment an opportunity to change and to prepare—wholeheartedly, precisely, and with peace of mind—for death and eternity.

---Sogyal Rinpoche