Wednesday, February 28, 2007

The Indispensable Nurse

Why do we nurses feel indispensable? Why is calling in sick such an enormous undertaking fraught with misgiving and anxiety? What is it that makes it seem that the world will stop turning if we don't show up?

Being home sick today but taking calls from my coworkers as needed, I beg the question why absence from the office/unit/clinic can almost feel worse than just dragging one's tired tush to work in the first place. Nurses are reknown for not calling out when ill. I wonder which other industry equally creates such unequivocal martyrs.

On the practical side, it is understandable why not being able to come in to work can be a burden to others. Today, my trusty medical assistant had to call me six times in situations for which only I knew the resolution. In the course of my days, I promise patients prescriptions, referrals, test results, or other important matters which, in their lives, weigh heavily upon their minds until resolved or answered. Do I enjoy such alleged omnipotence? Au contraire! But how can one create one's job in which another could easily slip into one's chair and take over the controls without a thousand and one questions? Aside from an assembly line where each action is proscribed, defined, and reproducible, in matters of healthcare, the secrets to specific mysteries and patient-related conundrums are often held in a solitary mind. More fool we.

I have said before how even one day's absence from the workplace engenders reams of paper, piles of charts littering the desk, voicemail messages and email just waiting for an instant response upon one's return. Is there not a better definition of burnout than that?

Monday, February 26, 2007

Return

Wow. The return to work is overwhelming. Again. The layers of need seem endless, and the requests from patients keep coming.

This one has nausea, vomiting and diarrhea. This one seems to be having an anxiety attack and can't breathe. Another feels suicidal and wants to be hospitalized. Another's blood sugars are enormously high. Still another begins Hepatitis C treatment today and is in for the ride of her life in terms of side effects.

A patient with AIDS who has been MIA for quite some time manifested himself in our office today. Vague symptoms of "burning" on one side of the face and some discretely hidden fluid-filled vesicles on his scalp led us to suspect herpes zoster---"Shingles". I have never seen zoster on the scalp before, especially not without some active lesions elsewhere, like the arms or face or side of the trunk. The doctor can't be 100% but he is shuffled off to the ER for isolation at the hospital and empiric treatment with IV antivirals until proven not to have shingles. In his condition this could be fatal if left untreated. And to think I could have just turned him away in my crazed preoccupation with multiple simultaneous crises this morning.

It was a wild day, punctuated with a 90-minute reprieve for a lunchtime talk on recent AIDS treatment research at a local restaurant. "Reprieve" is questionable---the pile of charts on my desk and rapidly filling voice mailbox attested to my ever so brief absence from active duty.

After finishing my day's notes following a delicious dinner lovingly prepared by Mary---my favorite cook---the rest of the evening is about recovery, and steeling myself for the 'morrow.

Sunday, February 25, 2007

Genetic Factors in Chemical Sensitivity

A new German study published in Environmental Health, (Volume 6:6), posits that a gene variation of endogenous metabolizing enzymes may be responsible for some environmental sensitivities and reactions. The study of 800 randomly selected volunteers utilized a modified questionnaire to elicit reports of reactivity---or the lack thereof---to various chemicals ubiquitous in the environment. The authors state clearly in their conclusion of this controlled study that chemically sensitive individuals are found to be more frequent carriers of genetic mutations GSTM1, GSTT1 and NAT2. The chemicals effected by these mutations are responsible for the metabolism (and inactivation) of noxious chemicals---including some fragrances---that are seen to cause reactive symptoms of individuals identifying as having Multiple Chemical Sensitivity (MCS) or Environmental Illness (EI).

This study adds credence to the claims by those in the MCS and EI communities that there are quantifiable and qualifiable causes for environmental sensitivities which, if reproduced in subsequent studies, may eventually lead to improved diagnostic and treatment options. For these reasons, many of us have petitioned the American Medical Association, the Centers for Disease Control, the Centers for Environmental Health, and the World Health Organization to finally accept MCS and EI as true physical diseases worthy of study, medical documentation, and insurance coverage. One of my most recent posts shares my letter to the director of the AMA, my request now further supported by the results of this well-timed and welcome study.


Saturday, February 24, 2007

Steep Learning Curve

Realizing that one has Multiple Chemical Sensitivity (MCS), the learning curve is steep for both the individual, family, and friends. Not being a universally accepted diagnosis, it is difficult at first to find medical providers willing and able to assist in symptom management and diagnosis. Once that step is successful, next comes self-education, wading through reams of information, some derogatory, some on the fringe, but most thoughtful and informative. Armed with information, one then exits stage left into the real world, ready to protect one's self and educate others.

First, there's friends, those people in one's daily life, with whom one laughs, cries, recreates, and interacts. There are dinner parties, gatherings, outings, and simple spontaneous get-togethers. Asking those individuals to change their lifestyles to accomodate your sensitivities can certainly be a challenge on both sides of the conversation, and errors and miscalculations are unavoidable. Only the best friendships survive.

Next is family---whether nuclear or extended---and the extent to which one's family is involved in one's life dictates how far one has to go vis-a-vis explanations, exhortations, and requests for accomodation. Relationships can be strained, visits curtailed, and the chemically sensitive person left choosing between debilitating exposure and avoidance of family altogether. One would hope that family will believe and support the individual claiming to have MCS, but we know of circumstances where some people are marginalized or even ridiculed by their families. Having to recover from family visits can be even more taxing than usual when chemical exposure only exacerbates the almost inevitable stressors.

In terms of romantic relationships, marriages have ended---and others formed out of solidarity---but many relationships can still flourish, whether only one or both of the couple in question are equally effected by the illness.

Work can be the greatest challenge, and many sufferers with MCS eventually succumb to home businesses and financial strain---or ruin---in order to avoid the multiple chronic exposures to toxins at work. Perfumes, cleaning products---even printer inks from faxes and photocopiers---can elucidate reactions, cloud mentation, and decrease both productivity and enjoyment at work. The choice can be a difficult one, as can remaining in a situation which compromises one's health and well-being.

As for public life, that can be the most isolating choice one can make. Depending on the severity of symptoms, hotels, restaurants, bars, movie theaters, stores, cars, concert halls and the streets themselves can all be threats to well-being. How does one negotiate a world which feels so environmentally unfriendly and unsafe? Wearing a carbon mask can feel isolating, but can also allow the individual to be out in public. Oxygen can also help, but then one can certainly feel "medicalized". It's a difficult and slippery slope.

The answers are many, and the discussion is ongoing. Treatment and support from providers, friends, and family do a great deal to lessen the impact on one's life. The network of people and organizations fighting for recognition of MCS as a legitimate diagnosis affords one a feeling of lessened isolation and marginalization.

Those of us who experience environmental sensitivities live on a fringe where most people would refuse to even visit. For us, this fringe is where we need to be, until society and the medical establishment agree that we no longer need to suffer separately, in a world where we feel unsafe. Most of us feel that the world has a long way to go to catch up to what we already know, understand, and experience. It can be an isolating place, but it's our place, and when a great many people are isolated together, it is then not so lonely after all. No person is an island, but any one person can create his or her own island of sanity and health. I invite you to visit my island (fragrance-free, of course!).

Friday, February 23, 2007

La Meme Chose

Kim over at Emergiblog sent me a "meme" in which I am supposed to list five things I cannot live without as a nurse and one thing that I would covet. While I have never responded to such an invitation before, I thought I'd take a whack at it.

First and foremost, I could not survive as a nurse without my home, my family, my friends, my dog, and my beloved wife and son.
Second, I could not survive without the creative outlet and sanity of blogging.

Third, like Kim, music is one of the saving forces in my life. For me, Brian Eno, Over The Rhine, The Boards of Canada, Busdriver, Radiohead, Bright Eyes, Robert Fripp, and Harold Budd come to mind, but the list goes on and on.......

Fourth, the grace, wit and collective consciousness of my colleagues is no small part of how I survive the vicissitudes of my working life.

Fifth would have to be time: to rest, recreate, rejuvenate, exercise, write, read, and otherwise soothe my bedraggled mind and body.

And what would I covet more than anything else? All of the above are high on my list of coveted life-sustainers, so I will leave it at that. Perhaps I will add to this list in future, as another post or perhaps simply as a comment below.

I will not tag anyone just now. If you read this and are moved to consider what keeps you afloat in these troubled times, give thanks for that awareness and share it if you please.

Thursday, February 22, 2007

Whirlwind

It's another whirlwind day as I attempt to tie up loose ends and head off on a five-hour trek to be with my Mum for her skin cancer procedure. Yikes. Wet snow falling and many miles to drive....

The calls just keep coming as I try to end the day. No sooner is one progress note or task begun, then the phone rings and another project is born. Overload comes all too soon and all too often. Triage is the name of the game. At times, one feels like a soldier in a foxhole, shouting "Incoming!" as the next salvo shells the office. The walls quake with the impact as waves of unanswered human need and trauma batter the windows.

"Did anyone ever buy life-jackets?" we innocently shout over the din. "Sink or swim, my scurvies!" yells the boss from his perch atop the lookout tower. "There's rough weather ahead! Every nurse for his- or herself!"

At times our practice feels like an unwieldy and hairy beast slaloming with oversized skis over a tundra covered with obstacles, some sticky, some spiny and sharp, others like black holes which suck the life out of the unsuspecting nurse. Rounding a dangerous bend, one occasionally encounters a colleague skewered by his or her own iffy boundaries. "Do I lend a hand or pretend I didn't notice?" is a frequent thought that crosses the mind. Since we're nurses, we generally stop to offer a hand, or at least a pat on the back. Our resident psychologist kneels down alongside the impaled nurse and says, "So how does that make you feel?"

Five o'clock sounds, the boss's bird-clock sings its sweet song, and a "Yabba-Dabba-Doo!" bursts from his lungs. Oftentimes, it seems that no one even notices that 5:00 has come and gone. Some evenings, I leave around five and several colleagues are still at their desks, distractedly saying goodnight as I exit. Next morning, they're all in the same positions when I arrive at 9. Where do they keep those sleeping bags, anyway?

Wednesday, February 21, 2007

A Process of Healing

As we follow the teachings and as we practice, we will inevitably discover certain truths about ourselves that stand out prominently: There are places where we always get stuck; there are habitual patterns and strategies that are the legacy of negative karma, which we continuously repeat and reinforce; there are particular ways of seeing things—those tired old explanations of ourselves and the world around us—that are quite mistaken yet which we hold onto as authentic, and so distort our whole view of reality.

When we persevere on the spiritual path, and examine ourselves honestly, it begins to dawn on us more and more that our perceptions are nothing more than a web of illusions. Simply to acknowledge our confusion, even though we cannot accept it completely, can bring some light of understanding and spark off in us a new process, a process of healing.

---Sogyal Rinpoche

Tuesday, February 20, 2007

Is a Nurse's Work Ever Done?

From the moment I entered nursing school, people have turned to me for medical advice. Even as a novice with an armful of textbooks and more questions than answers, the requests for opinions began during school and have never ceased to flow. There's some old adage that every family needs a nurse. Why not a doctor? A lawyer? A plumber? I guess nurses just have that certain je ne sais quoi.

My step-dad is fighting pancreatic cancer right now, and with the long journey through testing, diagnosis, radiation and now chemotherapy, I am the go-to person for most of their questions, although my scientist brother (bless his heart) uses his substantial cerebral prowess to see us through as well.

Unfortunately, my mother now has early invasive squamous cell carcinoma of the face, and my job these past few weeks has been researching, reading, and extrapolating the information needed for her to make some informed choices. Her surgery is pending for this Friday morning, and I will thankfully be able to make the five hour trip to be there.

This evening, a friend called from a nearby city. After being sent home from the ER not once but twice, he was finally admitted two days ago with acute appendicitis after being misdiagnosed and sent home to suffer over a nine day period. Needless to say, he is on ice chips and IV fluids, awaiting the decision whether surgery will be sooner or later. I hope it's sooner. Meanwhile, he asked me to be his Health Care Proxy. I accepted without hesitation.

My blogging practice has elicited many questions to be posed to me via email over the last two years by perfect strangers, something I truly enjoy responding to. Today I received an inquiry about my position on 12-step programs. I hope my answer was sufficiently enlightening, or perhaps enlighteningly sufficient. I also recently received an email requesting my participation in an on-line survey by a Croatian university about healthcare bloggers, as well as an invitation to submit articles to NurseLinkup, a new online networking community for nurses.

Working in the healthcare field and teaching nursing for a while, I have written letters of recommendation for nursing school and job applicants, as well as agreeing to serve as a reference on various person's resumes. I have precepted nursing students, medical students, and medical residents, dragging them through the city on my rounds. I have also counseled friends interested in nursing school, edited papers for those friends, and assisted in their learning processes on some level or another, subsequently serving as career counselor (and reference) after graduation.

When I get home, I blog about nursing, answer emails, think about my patients, field family calls, and even read books and articles about nursing and medicine. I interact with other nurse bloggers on-line, co-facilitate a discussion group for nurses on Zaadz.com, and contribute regularly to on-line medical and nursing blog carnivals.

Yes, being a nurse is more than a vocation for me---it is truly an identity. Is this healthy? Is it too all-consuming? Am "I" lost amidst the general tumult? Beats me---I'm too busy being a nurse.

Monday, February 19, 2007

Networking Is Us

Electronic networking seems to be the social venue of choice these days, and the Internet is now awash with social and professional networking sites. Of course, the ubiquitous MySpace and Facebook are currently the darlings of the web. Also of interest, especially for those of you in need of professional connections, LinkedIn is a site dedicated more towards career development.

Tribe is a community worth exploring, although my favorite social networking site for interesting and personalized connection is Zaadz, a site committed to changing the world one person at a time. I have begun two "pods" (discussion boards) on Zaadz, one for nurses and the latter for people living with Multiple Chemical Sensitivity. Zaadz is worth a gander, but it's certainly not for everyone.

The newest site which I've discovered is NurseLinkup. Still in beta, NurseLinkup has some kinks to work out and development to explore, but should prove to be a valuable tool for nurses to connect both professionally and personally.

Happy networking, and please let me know of any other interesting sites you have found in your travels...

Sunday, February 18, 2007

MCS, Ad Nauseum

I have previously posted about Multiple Chemical Sensitivity (MCS) and my struggles with its implications for my daily life. Luckily, as our symptoms worsen, Mary and I are both seeing an MD in our area whose practice specializes in the treatment of MCS, even as the American Medical Association still refuses to recognize MCS as a true physical illness. MCS America, an advocacy organization, has petitioned the AMA, CDC, WHO, and other powerful bodies to finally recognize MCS as a physical illness, opening doors for research dollars, insurance reimbursement for treatment, and all of the benefits the sufferers of a certified illness receive. I am joining that political battle, and attach here a letter which I have drafted to the AMA which will also be cc'd to the WHO, CDC, and National Institute of Environmental Health Sciences (NIEHS). If anyone reading this post is moved to draft a letter or make a call themselves, I also attach names and addresses of key figurres and organzations below.

Thanks for taking some time to learn about this issue close to my heart (and health).


Dr. William G. Plested, III, MD, President
Board of Trustees
American Medical Association
515 N. State Street
Chicago, IL 60610


Dear Dr. Plested,

I am writing in regards to the petition which you have received from MCS America vis-à-vis the recognition of Multiple Chemical Sensitivity (MCS) as a physical condition.


As a registered nurse living with Multiple Chemical Senstivity, I am aware that the American Medical Association has yet to accept MCS as a viable physical diagnosis on the grounds that there is no known etiology and a paucity of replicable research. We are aware that Fibromyalgia, Chronic Fatigue Syndrome, Multiple Sclerosis, and Autism are all accepted diagnoses also lacking in known etiology, yet the Americans who suffer from these conditions benefit from research funding and reimbursible care under insurance coverage due to their official status as diseases. Thousands of individuals suffer from life-challenging symptoms due to exposure to various environmental chemicals and toxins, yet these individuals’ conditions are relegated to “psychogenic” second-class citizenship, thus deprived of care for their symptoms under most insurance coverage.


You may be aware that 32 states have now recognized Multiple Chemical Sensitivity/Toxic Injury Awareness Month by state proclamation, and ICD-10 codes have now been developed vis-à-vis symptoms related to toxin exposure and its symptomatology. While the Americans with Disabilities Act does allow for reasonable accomodations for individuals with MCS in the workplace, Medicare and Medicaid will not reimburse for any treatments prescribed for diagnostic tests or symptom control, leaving thousands of Americans paying out of pocket for medical expenses related to MCS. Accepted only as a psychogenic disease, there has still been no empiric study which documents the effectiveness of psychotherapy for remission of MCS-related symptoms, although individuals with MCS do find counseling helpful in terms of the resultant social isolation and loss of productivity which results from the often debilitating symptoms.



New diseases are frequently discovered, classified, and subsequently codified so that the medical, insurance and research communities can then study, treat, and determine the cause of the newly identified disorder. In the late 20th century, both Fibromyalgia and Chronic Fatigue Syndrome were looked upon as psychogenic disorders with no apparent cause. Now, through recognition and acceptance, fully reimbursable medical treatments are available, and research has continued in order to discover the etiology of these evasive conditions which affect thousands, if not millions, of Americans. Autism, for which no known etiology has been found to date, also receives millions of dollars of research funding each year in order to advance the understanding of a disease with wide distribution among the country’s population. And I am sure that I need not remind you that addiction and obesity are also now accepted as diseases rather than personal failings, acceptance of which has also exponentially increased availability of research funds and medical treatment reimbursable by insurance.


The fragrance and chemical industry is one of the most unregulated industries in our country today. Trade secrets are jealously guarded, and American children and adults are unknowingly exposed on a daily basis to countless chemicals with known neurological effects. It is no wonder that thousands of Americans have developed sensitivities and reactive symptoms to many of these compounds which permeate our air, water, household products, and food chain.


Please examine this issue closely, and you will see that there is no reason why Multiple Chemical Sensitivity should not be recognized as a viable physical/medical diagnosis. I implore you to support the many Americans lacking healthcare coverage for such debilitating symptoms, and recognize MCS for what it is: a chronic, often debilitating disease of unknown etiology deserving of empirical research, diagnostic testing, and compassionate treatment and symptom management from the medical and insurance communities.


Thank you for your time and consideration.


_______________________________________________________________



For those of you moved to take action:

Sample Script:

"Hi, my name is __________________and I'm calling in regards to the petition you recently received from MCS America. I wanted to voice my support for MCS recognition as a physical condition and ask what your plans are to accommodated this request."


Contact Information:


Dr. William G. Plested, III, MD, President

Board of Trustees
American Medical Association

515 N. State Street
Chicago, IL 60610
312-464-5000

800-621-8335


Dr. Julie Louise Gerberding, M.D., M.P.H., Director

Centers for Disease Control and Prevention

1600 Clifton Road

Atlanta, GA 30333

1-404-639-7000

1-800-311-3435

http://www.cdc.gov/netinfo.htm


Donald E. Shriber, JD, MPH, Director, CDC Washington

CDC Washington

200 Independence Avenue, SW, Room 746G

Washington, DC 20201

Phone: 202-690-8598
Fax: 202-690-7519


David A. Schwartz, M.D., Director

National Institute of Environmental Health Sciences

P.O. Box 12233, Research Triangle Park

NC 27709-2233
Phone: 1-919-541-3201
FAX: 1-919-541-2260

webcenter@niehs.nih.gov


Dr. Margaret Chan, Director-General

WHO Liaison Office in Washington

1889 F Street, N.W., Room 369
Washington, D.C. 20006
United States of America
Telephone: 1-202-974-3299
Facsimile: 1-202-974-3789

World Headquarters Office
Avenue Appia 20
1211 Geneva 27
Switzerland
Telephone: (+ 41 22) 791 21 11
Facsimile (fax): (+ 41 22) 791 3111

info@who.int


Daniel Epstein (Washington D.C., USA)
WHO Regional Office for the Americas
1-202-974-3459
epsteind@paho.org


Thank You!

Saturday, February 17, 2007

New HBO Special on Addiction

Just yesterday, I received an email from someone at HBO, asking me to consider encouraging my readers to tune in for a new 14-part documentary due to be aired in March. Based upon my reading of the advance materials and press releases, The Addiction Project will seek to "redefine drug and alcohol addiction". There will be a 90-minute centerpiece film followed by 13 additional films which will focus on "the neurological forces behind addiction, getting treatment, relpase, understanding particular therapies, and adolescent addiction." The films will apparently will utilize the model in which addictiojn is seen as a chronic brain disease, examining the environmental, behavioral, and genetic factors that can make an individual more vulnerable to substance abuse.

Due to my interest in addiction, its treatment, and the day to day struggles of my those facing its challenges, I am trusting that this series will be done well, will be well worth watching, and may help to continue the conversation already happening around the country vis-a-vis the disease model of addiction and recovery.My only regret is that I will not see the series myself, not having access to HBO. I'll just have to wait for the DVD.

HBO’S BIGGEST MULTI-PLATFORM MEDIA EVENT,

THE ADDICTION PROJECT,

A GROUNDBREAKING 14-PART SERIES, KICKS OFF

WITH CENTERPIECE DOCUMENTARY MARCH 15

--------

Project Defines Addiction As

A Chronic Relapsing Brain Disease That Is Treatable

--------

Entire Series To Be Offered Free To Cable Subscribers

During Four-Day Preview On HBO, March 15-18

--------

“How can we comprehend the concept of a person who wants to stop doing something and cannot, despite catastrophic consequences? That is what we are up against. Some people don’t want to speak about addiction, or compare it to other chronic diseases. Well, this is a disease, a treatable disease, and it needs to be understood. HBO’s ADDICTION project is an initiative that will help people understand more about this illness, its advancements and how to find help.”

-- Nora Volkow, M.D., Director of the National Institute on Drug Abuse


LOS ANGELES, Jan. 12, 2007 – One in four Americans has a family member who is struggling with addiction. Over 80% of people with substance abuse or dependence disorder started using before age 18. Currently, addiction affects 22.2 million Americans. Yet only 9% are receiving the treatment they need.

In partnership with the Robert Wood Johnson Foundation, the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA), HBO launches the ADDICTION project, an unprecedented multi-media campaign aimed at helping Americans understand addiction as a treatable brain disease, as well as spotlighting new medical advancements. Debuting THURSDAY, MARCH 15 (9:00-10:30 p.m. ET/PT), with the centerpiece documentary ADDICTION, the series is eye opening and ultimately hopeful, providing guidance in navigating the often-confusing world of addiction treatment and recovery.

For the first time, HBO will use all of its digital platforms, including the HBO main service, multiplex channels, HBO On Demand, pod casts, web streams, and DVD sales to support a campaign that includes a 14-part documentary series, a book published by Rodale Press, four independent addiction-themed films, a robust website and a national community grassroots outreach campaign funded by the Robert Wood Johnson Foundation. All films will initially be offered during a free HBO preview weekend from Thursday, March 15 to Sunday, March 18 in participating cable systems.

“HBO is utilizing all of its platforms to develop programming directly targeted to the various needs of the American public on this complex public health issue,” says Chris Albrecht, HBO’s chairman and CEO. “Our resources are committed to illuminating, demystifying and defining addiction – a problem that is riddled with misconceptions.”

The ADDICTION project showcases the work of many of today’s leading documentary filmmakers, including Jon Alpert; Kate Davis and David Heilbroner; Susan Froemke; Liz Garbus and Rory Kennedy; Eugene Jarecki; Barbara Kopple; Albert Maysles; D.A. Pennebaker and Chris Hegedus; and Alan and Susan Raymond.

ADDICTION brings together leading thinkers and organizations that are at the threshold of new treatments. Current advances in brain imaging science make it possible to see inside the brain of an addicted person, pinpoint the parts of the brain affected by addiction, and see how the addict’s brain differs, ushering in a great many advances in medical treatment. In fact, treatments for addiction are now as effective as treatments for other chronic relapsing diseases such as diabetes, hypertension or asthma.

A candid depiction of the emotional, psychological, social and political toll that addiction takes on the country, the ADDICTION project demonstrates conclusively that the disease is treatable and shows that there are millions of Americans in long-term recovery. Topics covered include: the nature of addiction, addiction in the workplace, and the protracted insurance battles waged by families, as well as the difficulty of finding and getting adequate treatment.

The ADDICTION project will be supported by an unprecedented 30-city nationwide community outreach campaign funded by the Robert Wood Johnson Foundation and coordinated by Join Together, Faces and Voices of Recovery, and the Community Anti-Drug Coalitions of America (CADCA).

The ADDICTION project is produced by John Hoffman and Susan Froemke and executive produced by Sheila Nevins. For additional information, visit hbo.com.




Friday, February 16, 2007

A Close Call on the Job

Last night, I was doing a per diem shift in the health center for the evening session. These evening shifts are generally low-key: a vaccination here and there, faxing prescriptions to pharmacies, joking around with the docs and medical assistants. However, one never knows when one's circumstance will be altered from its usual trajectory, and just such a situation arose last evening.

Suffice it to say that the detailed circumstances of the initial situation catalyzing this event are superfluous to the story as a whole. The main thrust of the idea is that a father of a young child was not allowed into the pod where the exam rooms are because the mother of the child was sharing some concerns with the doctor which needed to be communicated without the presence of the father. Needing further inquiry, the social worker had been called into the exam room, and the father was left in the waiting room to fume and pace. Unfortunately, all of this occurred without my having a shred of knowledge of what was transpiring.

As I sat at my computer in the pod filling electronic prescriptions, an agitated man appeared on the other side of the nurses' station, cursing and demanding access to his child and wife. A wild-eyed medical assistant calmly asked him to remain where he was as she took me around a corner to explain the situation in detail. While we were talking and my grasp of the situation grew, her gaze fixed over my shoulder and I turned around to see the man in question making his way quickly towards us up the hallway. He had crossed the nurses' station, passing a medical resident who was utterly clueless as to what was occurring, the OB/GYN doc also oblivious, dictating her notes by phone as he stormed past her.

Sensing both the gentleman's agitated state and the medical assistant's anxiety, I put myself between the enraged man and the medical assistant and did my best to try to de-escalate his fury. As his demands grew more fierce, my voice naturally rose to counter his. Knowing that I was taking a chance---but keeping in my mind that security had just been called and were at least five minutes away and were not even in the building---I stood my ground, raised my voice louder, and pointed towards the door at the end of the hall, demanding that he exit the pod immediately and wait calmly in the waiting room. Whether it was luck or some other form of beneficence, he somehow sensed that he was fighting a losing battle and stalked towards the door, entering the waiting room just as the security guard returned to restore order.

The conversation that immediately resulted from this encounter was one centered around what we would have done had he become physically violent prior to the arrival of the security guard. If he had swung at me or pulled a knife, how would we have handled the situation, and what liability would I personally carry if I were to strike him in self defense? What legal protections are in place to ensure that I will not be prosecuted or held criminally liable if I were to act to protect myself or another person, resulting in harm to this threatening man? (Furthermore, what would we do if he stalked us in the parking lot later that evening, attempting to "get even" for being publicly humiliated?)

Many of us working in the inner city with vulnerable and disempowered populations face risks when engaging in such employment. Threats of harm have been visited upon several of our providers over the years, and we all know that our work does carry some level of risk. Poverty, disempowerment, discrimination, classism, racism---they all contribute to the feeling of emasculation and helpless rage that many people in such circumstances can naturally feel, and when we uphold policies and procedures that do not make sense to a potentially volatile person, the resulting reaction can be explosive. Evidence of sexual or physical abuse of children is one area where staff feel legally and morally compelled to act quickly and comprehensively. Poor communication---or the lack thereof---can put other employees at even greater risk when they are not apprised of the situation and are then suddenly faced with an angry patient and no context in which to place such an explosive situation.

I realize that I was lucky that last night's episode ended with little fanfare. The potential for violence or the threat of violence was quite real, although our laughter later in the evening quickly dispelled any remaining anxiety. In the course of my years as a community nurse in the city, I have skirted drug dealers on busy sidewalks, visited known gang members on city blocks known for their illegal activity, and shuffled past suspicious-looking young men as they loitered in dark stairwells, stuffing emptied cigars with marijuana to make the ubiquitous "blunts" which fill the air with their distinctively aromatic smell. I have also been to a home where my patient's daughter's boyfriend had apparently hidden guns used in a gang-related crime. Oh, the places we go!

Of course, risk is relative in any line of work, whether it be personal injury or any number of potential hazards. When one feels that a brush with danger has been averted, one of course will naturally take stock, second-guess one's prior actions, and hopefully learn from experience, planning and strategizing for possibly similar scenarios in the future. There is always much to learn, and we will always equally hope that we never have to learn the hard way.

Thursday, February 15, 2007

What to Remember When Waking

In that first
hardly noticed
moment
to which you wake,
coming back
to this life
from the other
more secret,
moveable
and frighteningly
honest
world
where everything
began,
there is a small
opening
into the new day
which closes
the moment
you begin
your plans.

What you can plan
is too small
for you to live.

What you can live
wholeheartedly
will make plans
enough
for the vitality
hidden in your sleep.

To be human
is to become visible
while carrying
what is hidden
as a gift to others.

To remember
the other world
in this world
is to live in your
true inheritance.

You are not
a troubled guest
on this earth,
you are not
an accident
amidst other accidents
you were invited
from another and greater
night
than the one
from which
you have just emerged.

Now, looking through
the slanting light
of the morning
window toward
the mountain
presence
of everything
that can be,
what urgency
calls you to your
one love? What shape
waits in the seed
of you to grow
and spread
its branches
against a future sky?

Is it waiting
in the fertile sea?
In the trees
beyond the house?
In the life
you can imagine
for yourself?
In the open
and lovely
white page
on the waiting desk?

~ David Whyte ~

Wednesday, February 14, 2007

Love and Intention

Under my email signature on all outgoing missives, the following quote by Mother Teresa is always attached:

"I have found the paradox that if I love until it hurts, then there is no hurt, only more love."

On this day of all days, love is the notion we are urged to consider. Of course, being Valentine's Day, romantic love is assumed to be at the epicenter of such considering, and well it is for many of us. But there are many more forms of love, and they are all worthy of our attention. As well, we also remember those who are bereft, lonely, impoverished, ill, and otherwise lacking love in their lives. Yes, the media deluge us with images of heart and flowers, chocolates and cards, forming the basis of what we think we know love is. However, it is in our minds and hearts where we truly decide the meaning of love, and it is in our relationships with the human and non-human worlds where we externalize our vision of love, manifesting our vision through action.

Many of us wonder how to celebrate love, embody love and partake in cultural norms which bring us and our loved ones pleasure, while still bearing in mind the wider effects of our way of life and the decisions we make as consumers. Flowers, chocolate, diamonds---the things we have been taught to freely associate with love---cannot escape the gravest blemishes when under scrutiny, especially as we use the power of the purse to support the industries that provide them on the shelves of our stores. This is not meant to be a wet blanket on this day. Rather, it is yet another way to love, wherein we remind one another that our choices as consumers have consequences beyond our immediate perceptions. It is in both the small and the large that our actions ripple out into the world.

Today on AlterNet, Courtney E. Martin offers a view of love as activism, asserting that freedom is gained through our choices vis-a-vis relationship, love, and our actions close to home. Also on AlterNet, Julie Enszer describes the subtle ways in which gays and lesbians do (or don't) reveal their partners' gender in social situations. She then challenges us on this Valentine's Day to go the whole day without revealing the gender of our lover in social exchanges, feeling that sense of ambiguity---and occasional discomfort---which is then communicated and felt by the parties on both ends of those conversations.

Meanwhile, on Democracy Now!, Amy Goodman presented an expose on the low wages, child labor, and other human rights violations which support the commercial sale of cut flowers in the United States, propagated to a large extent by the Dole Corporation. A sobering dose of reality which, like Blood Diamond, has begun to popularize the notion that consumer goods can fuel conflict, slavery, and indecent treatment of human beings in the name of profit. Furthering our perceived indictment of all things Valentine, even chocolate is not safe from political strife, economic hardship, and humanitarian controversy when considered through the lens of fair trade practices.

Moreover, the V-Day movement strives to end violence against women, with Valentine's Day designated as V-Day. Describing the movement on their web-site as "a fierce, wild, unstoppable movement and community", their goal is no less than the complete defeat of violence against women and the victory of human rights and peace.

What, then, you may ask, is a loving yet earnestly concerned Valentine to do?

I would submit that there is no end to what one can do to propagate love while making wise and informed choices. Choosing Fair Trade chocolate and coffee is itself an act of love---towards others, self, and economic equality. Do I always practice such advice, you ask? No, I do not, but continually reminding one's self of the power of choice is often the first step towards freedom. Further, by treating the women in one's life with respect, by standing up against their unfair treatment and subjugation, by communicating through actions and words one's dedication to such a notion---that is a most powerful personal statement.

And the flowers? Sometimes we can't help ourselves when we buy those lovely bouquets, and none of us can deny the joy and delight on the receiver's face when presented with the thoughtful sweetness embodied therein. These are all simply choices, and in this consumer society, we all are prey to the whims and winds of the marketplace. If I buy flowers, I will certainly enjoy them, bless the person who picked and processed them, and give them with the love with which they are intended. One cannot live life afraid to act, yet one must also understand that each and every choice we make in life carries consequences often beyond our ken.

On this snowy Valentine's Day, I am home with my love, workplaces closed, the world moving at a crawl, the icy precipitation confining us happily to our home. Yoga together in the morning, a DVD, a nap, a simple exchange of cards, and a mutual conscious decision to eschew the drive to consume, rather giving each other the gift of time, of space, of presence, of shared love. Although I did donate money to the V-Day campaign in Mary's honor today, it is not the money changing hands which holds meaning. Intention, of course, is the central force, and through our intentions our actions must naturally follow.

Even amidst a consumer frenzy, be it Christmas, Valentine's Day, or Mother's Day, intention and the consciousness behind that intention holds the key. Coupled with right action, there is no end to the love that can be shared, and no end to the satisfaction which we can glean from a life well lived.

Happy Valentine's Day, from my heart to yours.

Tuesday, February 13, 2007

Evolution, Debate and Faith

Based upon articles and media reports, the debate over evolution---or the lack thereof---still rages around the world. This morning, National Public Radio broadcasted a short piece on the “Turkana Boy”, the complete skeletal remains of a 9-year-old boy discovered on the shores of Lake Turkana, Kenya in 1984. These remains, at 1.6 million years old, are the oldest-known specimen of Homo Erectus, and are poised to be publicly displayed for the first time at Kenya's national museum in Nairobi.

It appears that the evangelical Christian communities in Africa---specifically in Kenya---are afire with opposition to the theory of evolution, requesting that the Turkana Boy's remains be relegated to a back room of the museum with a posted caveat that evolution is still only considered a theory. As reported on CNN.com via a report from the Associated Press, Bishop Boniface Adoyo, the leader of millions of African Christians from 35 denominations, has stated that exhibits and scientific reports which support the theory of evolution undermine the church and its teachings. Stating recently that "these sorts of silly views are killing our faith," the bishop clearly verbalizes the perceived attack on faith which the religious community feels is being waged by the proponents of evolution, as well as the church's adamant refusal to consider evolution as even remotely possible within the Christian cosmology.

I'm not entirely certain why I was compelled to write about this issue this morning, but it sparked within me a curiosity regarding the intersection---or rather, collision---of science and religion, which frequently pose difficult moral questions. Whether it be evolution, stem cell research, abortion, or family planning and contraception, these hot-button issues test the waters of our culture and its ability to withstand apparently untenable moral dilemmas. Of course, politics plays a role when the government intervenes (take the case of Terry Schiavo, for example), or when political candidates are forced to take a stand on a timely and contentious "moral" issue. (Just what isn't "moral", anyway? And in terms of those "value voters" that are ubiquitously discussed at election time, don't we all cast votes based upon our "values"?)

When discussing evolution and the Turkana Boy, it will be interesting to see how this debate evolves (pun originally not intended). Being neither a scientist nor a theologian, the potential for compromise appears slim from my viewpoint. If the religious community refuses to allow for even the possibility of truth behind a widely accepted and validated theory, compromise and understanding appear beyond reach. And when the scientific community openly derides or mocks the beliefs and faith of the pious, agreement or understanding is further debilitated.

Boycotts of exhibits serve little to inform the public, rather simply fueling further ignorance and division. When children are denied the teaching of evolution---or are encouraged to discount its scientific basis entirely with complete absence of critical thinking---who is truly served? From the point of view of an individual without religious affiliation and raised in a devoutly secular household devoid of all notions of faith (except for Santa Claus and the Tooth Fairy, that is), I am honestly often perplexed by organized religion in terms of its dogmatically held tenets.

Seeing the violence and carnage often waged ostensibly in the name of religious belief or affilation (think Shiite versus Sunni, for instance, or perhaps the Spanish Inquisition), one may be led to believe that religious thought and belief have indeed precluded reason during countless human societies, both modern and historical. I try not to lose my faith in human kind and its ability to embrace dialectically opposed belief systems wherein faith and science can live relatively peacefully, perhaps even with some cross-pollination and intermingling concepts. There is room for both subjectivity and objectivity in most every realm of thought and inquiry, and I'm sure many authors and thinkers have already done a great deal to advance the cause of peace and reconciliation between the two seemingly disparate camps.

Albert Einstein once wrote in a letter dated February 10, 1954: "If God has created the world, his primary worry was certainly not to make its understanding easy for us". I think his statement still holds true, and I wonder if he would feel that any advancement has been made since his death, or rather that we humans still exist in a miasma of ignorance and mistrust of both one another and the universe at large. As for the Turkana Boy, I have no doubt that the ire his exhibition is creating in Kenya is not about to be dissipated by calls for understanding and acceptance, but I still hope that some incremental change---mind by mind, heart by heart---can contribute to a quiet groundswell of cooperative understanding, even amidst these ages-old questions still begging for answers which will undoubtedly always leave someone disappointed.

Monday, February 12, 2007

Adherence versus Compliance

Just the other day, a conversation was born amongst colleagues regarding two words/concepts that are used almost interchangeably in healthcare. Adherence and compliance, those somewhat subjective measures of how well a patient follows medical instructions, appear in medical charts, professional journals, PowerPoint presentations, scholarly articles, and all manner of medical ephemera on a regular basis. These concepts are even the subject of professional workshops and conferences. Our conversation centered around the difference between the two, and what it means when we use one versus the other, both, or neither.

First, we should begin with definitions. "Compliance" is defined by dictionary.com as "conformity; cooperation or obedience; accordance; the act of conforming, acquiescing or yielding; a tendency to yield readily to others, especially in a weak and subservient way." Hmmm (hand scratching chin pensively).

As for "adherence", our friendly neighborhood Internet dictionary defines this term as "the act of adhering; adhesion; the quality of adhering; steady devotion, support, allegiance or attachment." Also quite interesting.

What immediately grabs my attention is the notion that "compliance" is defined as a type of obedience, especially a subservient breed of obedience. Perhaps this is also why I seem to notice the term "non-compliant patient" used so often in medical charts. In this culture where doctors are somewhat deified and in which medicine can often take on a paternalistic pallor, definitions of a patient's relative obedience to medical advice would be the language expected of medical personnel when documenting patient behavior.

When we providers see ourselves as offering the patient the best, most inarguable advice, we must implicitly expect a certain obedience or acquiescence to our prescribed treatments. We all have known patients who seem so eager to please us, so passive and opinionless, that we wonder how much of their ingratiating attitude is simply displaced desire to please a demanding parent. While we do at times feel like substitute parental figures---even for elderly patients---these are not healthy roles for provider and patient to assume. Wanting a patient to "comply" with one's advice does indeed seem that one wishes to "bend" the other's will towards one's own. How healthy can this be for either party on a psychic level?

Conversely, the definitions of adherence bring to mind notions of support, devotion, and attachment, with "allegiance" bringing to mind a sense of something shared cooperatively by both parties rather than forced upon one by the other. Using this term in relation to a patient does certainly seem to carry a very different tone which lacks a certain paternalism that "compliance" seems to engender. Partnership and bilateral decision-making come to mind, rather than unilateral command and obedience.

I am remembering as I write this post that the visit note forms which our agency uses has a small section entitled "Medication Adherence" in which we document our assessment of the patient's medication-related habits. Was it a deliberate choice to use "adherence" rather than "compliance"? I'll have to ask my boss.

In the course of my blogging, I seem to write a great deal about patients who are not exactly following the medical script. I note that I recently posted a missive entitled "Non-Compliance, Apples and Surrender". Did I think about my choice of words or did compliance roll right off my tongue, or rather, keyboard? I must say that when it came to the patient in question, I naturally chose non-compliance. Perhaps it is when patients seem to be making choices which we know will certainly cause them harm that we see them in this way.

For many providers, I think there is a certain proprietary quality to some provider-patient relationships. Within our practice (and many others, I'm sure) there is constantly comments like, "She's my patient" or "He's not mine, he's hers." Ownership can be a positive aspect, meaning that the nurse or provider is taking responsibility for the individual's care. Similarly, our patients will say, "That's my nurse" or "She's my doctor". These are all socially acceptable and understood notions of belonging, of connection. We simply must be cautious in their contextual use.

Coming to the close of this particular missive, my jury is still out whether I feel it is "wrong" to use the term "non-compliant". It is certainly food for thought, and very worth pondering vis-a-vis my own practice and documentation. As I learned in nursing school, medical and nursing notes are legal documents, and labels which we apply to patients can haunt them for the rest of their lives, often coloring how a new provider will feel about a patient before even making their acquaintance. Not only do we carry the responsibility to do no harm in relation to our care, we should also be careful to do no harm with our words.

I may need to revisit this question as time goes on, and welcome any comments on the topic. This particular blog entry is very much a process of thinking out loud, and I welcome any reader to do the same. (But will you comply?)




Sunday, February 11, 2007

Now

The cells of our body are dying, the neurons in our brain are decaying, even the expressions on our face are always changing, depending on our mood. What we call our basic character is only a “mindstream,” nothing more. Today we feel good because things are going well; tomorrow we feel the opposite. Where did that good feeling go?

What could be more unpredictable than our thoughts and emotions: Do you have any idea what you are going to think or feel next? The mind, in fact, is as empty, as impermanent, and as transient as a dream. Look at a thought: It comes, it stays, and it goes. The past is past, the future not yet risen, and even the present thought, as we experience it, becomes the past.

The only thing we really have is nowness, is now.

---Sogyal Rinpoche

Saturday, February 10, 2007

Hybrid Heaven

Even though hybrid cars have detractors who feel that they do too little in terms of decreasing carbon emissions, we have wanted one for years. As conscientious people who are quite aware of our ecological footprint, we're always looking for ways to decrease our impact within the current parameters of our lifestyle. We are rabid recyclers, try to buy nothing that we don't really need, and are as likely to find furnishings for our home via yard sales, the side of the road, as well as dumpster-diving at area colleges when the students are moving out for the summer. Oh, the places we go!

Over the last few years I have researched hybrid cars and grease cars. For those of you who are unaware of this technology, any diesel vehicle can be altered to run on vegetable oil. The owner of such a car can simply stop at their local McDonald's and take away containers of used friolator oil which the restaurant must actually pay to dispose of. Yes, the oil must be filtered to remove pieces of french fries, but is then ready to power the vehicle. Alternatively, the car will also run on "Biodiesel" fuel, available at few venues currently, but slowly growing in availability as demand increases. However, the Union of Concerned Scientists is still recommending the purchase of a hybrid over a diesel in need of conversion due to biodiesel's proclivity to still produce nitrogen oxide compounds, a problem (in terms of smog pollution) which has yet to be fully resolved. (However, for anyone who already own a diesel vehicle---or municipalities with diesel buses or trucks---retrofitting for biodiesel is highly encouraged.)

Anyway, we have finally taken our first plunge and purchased a used 2003 Honda Civic Hybrid. Although we essentially "traded down" by giving up a 2005 Toyota for an older Honda with more mileage, it felt like it was time for us to put our money where our mouths are and make the shift. While the Civic hybrid does not have a distinctive shape or other features to distinguish it from other cars (only a small "Hybrid" emblem on the back of the car), the proof is in the pudding. While it's certain that Prius owners achieve instant "social recognition" that they are indeed driving an alternative vehicle based upon its distinctive design, we're happy with our more understated choice and have pledged to one another that we will never again purchase another standard fossil fuel car.

For those who might disparage hybrid cars as a fad that has little overall environmental impact, the Union of Concerned Scientists states the following on their website devoted to hybrid vehicles: "hybrids have better total ownership cost over five years or 70,000 miles than their direct competitors. [They] accredit the long-term savings to the fact that hybrids retain their value better than conventional vehicles, have moderate maintenance and repair costs, and have lower fuel costs. Intellichoice.com listed the Toyota Prius, Honda Civic Hybrid, Toyota Highlander Hybrid, and Ford Escape Hybrid as vehicles with the biggest five-year savings."

Small changes in lifestyle go a long way, and we recognize that we are priviledged enough to simply have the opportunity to make such a choice. While we both try our best to not preach about the things of which we hold deep convictions, we will begin to gently encourage our friends, loved ones and colleagues to consider the alternatives when needing a new vehicle. If we all vow to make even the smallest of changes within our means, the larger exponential effect will be both measurable and sustainable, and that is a truth which is conveniently easy to swallow.

Friday, February 09, 2007

The Search for the Magic Bullet

"I can't sleep. I sleep maybe four hours every night. If I go to bed at midnight, I get up at four. If I go to bed at four I get up at seven. It's crazy." She rolls her eyes in disgust.

"Well, there's a program we can send you to where they teach you how to sleep better," the kindly doctor says. "It's called sleep hygeine."

"It works for alot of people," I add. "Medications often don't do enough."

"No way," she replies vehemently. "I know my body, I know my brain. I just can't sleep. All I need is a pill to make me sleep." She crosses her arms. The doctor and I exchange glances.

"What do you do when you can't sleep?" He looks at her and then at me.

"Watch TV."

"You watch TV. Anything else?" I ask.

"Oh yeah, I smoke." There's silence in the room.

"How about your back?" the doc asks, changing the subject. "Is that any better?"

"Nah," she retorts. "It's worse. Hurts all the time. If I sit it's OK, otherwise it's torture. The muscle relaxants don't help either."

"How about the methadone?" the doctor asks. (The patient is on methadone three times a day for chronic pain.)

"No, it doesn't help at all. Can I get something else?" She crosses her arms again.

"We'd like to try physical therapy."

"I won't do that! That hurts! My friend says it messed her up!"

The doctor and I smile. "We can direct them regarding what they do. There's massage, cold and heat packs, ultrasound. You might really like it."

"I won't stretch! I know my body. I know that stretching hurts. I just want a pill."

The appointment's going nowhere, and we haven't even talked about her Hepatitis C treatment yet. We're both exasperated. No sleeping pill prescription is forthcoming, and she eventually concedes to a physical therapy referral. Will she go? Probably not.

Everyone wants the magic bullet, a pill to assuage their suffering. Many doctors use that arsenal of pharmacoepia to attempt to do just that, but sometimes we just want some proactive work to be done by the patient, some effort beyond opening a bottle and swallowing a pill. Sure, sleep hygeine education isn't anyone's idea of a good time, but what good is a pill when the patient has no inkling of how to properly prepare for a good night's sleep? We frequently dance along the edge of enabling such passive behavior. Of course we may give in at times, but sometimes we just say no to the easy way out.

Thursday, February 08, 2007

Valentine's Change of Shift

The Valentine's Day edition of Change of Shift is up. Please sail over any time. I'm honored to be included yet again.

Tuesday, February 06, 2007

The ACE Study

One of my colleagues shared some results of a strikingly poignant study with me today. The ACE Study is an on-going collaborative effort between Kaiser Permanente's Department of Preventive Medicine and the Centers for Disease Control and Prevention. The study posed the question of whether, and how, childhood experiences affect adult health decades later.

Involving 17,421 adults in San Diego, the findings "indicate a powerful relationship between our emotional experiences as children and our physical and mental health as adults, as well as the major causes of adult mortality in the United States", according to an article published by Dr. Vincent J. Felitti, MD. The study "documents the conversion of traumatic emotional experiences in childhood into organic disease later in life." The authors conclude that one does not just "get over things"---the effects reverberate for decades.

Looking at the population with whom we work, it makes perfect sense that our patients---burdened by childhood trauma of often unspeakable ugliness---manifest illness as adults as a direct result of what occured when they were helpless and innocent children. Obesity, COPD, addiction, intravenous drug use, emotional disorders---all are unequivocally linked to early childhood trauma. Similarly, occupational health and job performance as adults were equally shown to be strongly tied to negative childhood experiences. Perfect sense, indeed.

Just today I was confronted with a patient whose drug abuse and emotional distress is a direct result of childhood sexual abuse and molestation. I sat this morning in another patient's kitchen as she recounted for me the physical and emotional abuse she endured throughout her life and the way in which it has destroyed her chances of recovery. A third patient blinds himself with alcohol, denying all the while that it's a problem. His wife sits stonily across the room, her arms crossed tightly, eyes flashing with anger when she knows he's lying to me. What happened to him when he was a child? What abuse did she suffer? How can they escape its grasp?

Evaluating what this study means is daunting. If childhood abuse and trauma are directly correlated with adult morbidity and mortality, doesn't this underscore the fact that we have a public health crisis of epic proportions on our hands? As we vaccinate, evaluate growth charts, weigh, examine vision, check hearing and screen for scoliosis, is there something even more crucial which we're missing in our children and teenagers? For every vaccination record we conscientiously complete, is there undue suffering which we completely overlook? How do we see the signs? We can look for overt bruises and screen for depression, but many children will mask the effects of such abuse under layers of disassociation. A monumental task then looms: how to properly screen for these certain causes of morbidity and mortality?

The effects of trauma seem almost ubiquitous to me as I go about my work. And as mental healthcare is continually treated as a second-class issue in this country as compared to physical health---especially where prevention is concerned---I wonder how we, as a society, will learn to cope. As health plans emasculate mental health coverage to cut costs, "short-term therapy" becomes the only recourse, and we all know that the effects of trauma cannot be "cured" in eight sessions, perhaps not even in eighty sessions. As I mentioned above, we can screen a child's vision and hearing ad nauseum, but if we miss the subtle signs that they're being abused at home, our preventive healthcare is merely a shell of its potential reality.

As I delve deeper into the ACE study, I may bring my gleanings of that material to bear here on Digital Doorway. In the interest of humanity as a whole, I suggest we all take a good hard look at what this study is trying to communicate to us. But that is only the beginning. After we realize the truth of what we see, it will only beg the question: what now? And the future may depend on our answer.

Monday, February 05, 2007

The Return

I arrived to work at noon after a morning doctor's appointment, not having worked since last Wednesday. A text message immediately arrived on my phone---a unannounced patient is in the waiting room to see me.

Grabbing my stethoscope and my notebook, I rush out to the waiting room. The patient in question is across the room, but before I can make my way over to him I'm intercepted by someone else. I ask them to wait, but another patient materializes, wanting a word with me. Three more of my patients lurk in other corners. Is this a convention?

I put several of them off until tomorrow, deal with the issues needing immediate attention, duck into an exam room to sit in on another patient's doctor appointment, and head back to the office to catch my breath.

"Do you know that five of my patients were out there waiting to see me?" I ask incredulously as I enter the office. Two of the administrative assistants laugh knowingly.

"They had tents and sleeping bags set up all weekend, Keith. We told them you'd be back Monday at noon." They laugh again.

"Very funny," I reply. "Can I go home now?"

The phone rings apace all day. My voicemail is full but not overflowing. My mailbox? Stuffed. My desk? Covered in charts and papers. The state of my brain? Hmmm.

A massage at the end of the day slows me down. Then dinner with Mary nourishes me. Now we're baking tahini cookies as the wind howls outside and the temperature drops towards zero.

The return is over. Back to the fray.

Sunday, February 04, 2007

My Other Blog

I wanted to take another opportunity to shamelessly plug my other blog, A Nurse and His Treo. The subtitle for this venture is "the photographic adventures of a peripatetic nurse and his trusty smart-phone". This is a very fun project and creative outlet for me, and I invite you to peruse the site from time to time. My goal is to post one photograph every day for 365 days and I have so far posted for 74 consecutive days. You will find a link in the right-hand column of this blog, as well. Thanks again, and Happy Sunday.

Saturday, February 03, 2007

Nurses Need to Listen Carefully

This story just in from a friend in Connecticut, author unknown:

An elderly male patient is lying in bed in the hospital, wearing an oxygen mask over his mouth and nose, still heavily sedated from a difficult four-hour surgical procedure. A young student nurse appears to give him a partial sponge bath

"Nurse," he mumbles from behind the mask. "Are my testicles black?"

Embarrassed, the young nurse replies "I don't know, Sir. I'm only here to wash your upper body and feet."

He struggles to ask again, "Nurse, are my testicles black?"

Concerned that he may elevate his vitals from worry about his testicles, she overcomes her embarrassment and sheepishly pulls back the covers.

She raises his gown, holds his penis in one hand and his testicles in the other, lifting and moving them around.

Then, she takes a close look and says, "There's nothing wrong with them, Sir!!"

The man pulls off his oxygen mask, smiles at her and says very slowly, "Thank you very much. That was wonderful, but listen very, very closely......A r e - m y - t e s t - r e s u l t s - b a c k ?"


Friday, February 02, 2007

Grasping

Grasping is the source of all our problems. Since impermanence to us spells anguish, we grasp on to things desperately, even though all things change. We are terrified of letting go, terrified, in fact, of living at all, since learning to live is learning to let go. And this is the tragedy and the irony of our struggle to hold on: Not only is it impossible, but it brings us the very pain we are seeking to avoid.

The intention behind grasping may not in itself be bad; there’s nothing wrong with the desire to be happy, but what we try to grasp on to is by nature ungraspable.

The Tibetans say that you cannot wash the same dirty hand twice in the same running river, and “no matter how much you squeeze a handful of sand, you will never get oil out of it.”

---Sogyal Rinpoche