Wednesday, April 30, 2008

Wash Away the Pain

I want to wash the cells of my body with compassion. I want to wash the cells of the muscles that scream in pain at almost every moment of every day. How can I simply cleanse those areas of the aches and pains that dog my every moment? I've imagined removing the offending muscles and scrubbing them on an old-fashioned washboard, then squeezing them out and hanging them to dry in the sun. How I wish that that were possible. But reality reminds me that my muscles are stationary in my body, non-removable and permanent, and for better or worse they are mine for the duration.

Wash them clean? Scrub the pain away? Erase the trauma that lives at the root, at the place where the cells coalesce into scar tissue?

I enter the offending cells, and I identify the mitochondria and other organelles that live in a state of eternal inflammation. The prostaglandins and other chemicals on perpetual alert are sent on a long coffee-break, and I set to work with a scrub brush, burnishing the cells, removing debris with a microscopic dust-pan, sweeping out the physiological corners that are dusty with the detritus of pain. A high-pressure hose of compassionate cleansing clears the decks, and a clean slate of pristine muscle and tissue is left in its wake.

Can I truly do this with my mind?

Tuesday, April 29, 2008

Losses and Gains: The Calculus of Change

Spending time in my former office today as a consultant (something I now do on a weekly basis), I was struck by how sincerely I miss a handful of patients, and how much I truly don't miss a small group of my most needy former patients.

After three months of not working full-time following a seven year sojourn of intensive case management, I'm feeling the loss involved in saying goodbye and walking away from a number of close long-term connections. Periodically I think of calling one or another of my former patients, and one of these days I'll probably pick up the phone and do so. Those goodbyes can be hard, and the hellos can now seem equally challenging.

The intimate connections nurtured over those years came to be part and parcel of my life, and while that closeness eventually did indeed contribute to my experience of burnout and compassion fatigue, it also was a part of the fabric of my life, and now it seems like certain threads are sorely missing.

For now, I can sit with the uncertainty and emptiness that those losses have engendered, and I can also sit with the notion that calling and saying hello may be a new way of connecting (if, of course, I choose to do so at all). Providing such intimate and long-term care over time creates dependencies on both sides of the equation, and I am beginning to feel that some of those emotional equations are as yet unresolved. Will I attempt to balance them? Only time will tell.

Monday, April 28, 2008

Mindfulness Journal: What is Enough?

Today was the first weekday since we returned from vacation. While Mary went back to work, I did the things I needed to do, little of which involved making money. Picking up the car at the shop, a physical therapy session, shopping, banking, making copies, seeing a friend, walking the dog, making dinner---the day was full.

Despite the fullness of the day, nagging voices in my head questioned my motives and my commitments. Why didn't I do more? Why wasn't I more productive? What more could be done?

A few hours with a dear friend who lives at a Buddhist retreat center helped to quell those voices. My friend reminded me that I only stopped working full-time three months ago after twelve years of working forty hours a week. When I consider twelve years of work in one hand and three months of my current state of being in the other, I'm reminded (by myself and others---including my gracious wife) that I need to cut myself some slack.

This culture demands such productiveness from us, so much so that it can be one's undoing. There is little time or space for simply being, and simply being is a notion---and a practice---that it would behoove me to cultivate.

Sunday, April 27, 2008

Return!

We have returned from a wonderful journey to Boulder, Colorado and Santa Fe, New Mexico (as well as a number of points in between, including Ghost Ranch, an old haunt of American painter Georgia O'Keefe).

Traveling with chronic pain and Multiple Chemical Sensitivity certainly makes such ventures more challenging. One of the most difficult things for me was feeling quite limited in the amount of hiking and outdoor activities in which I could indulge without significant suffering in its aftermath. Still, I managed to enjoy the outdoors, take less vigorous hikes, and use medication to assuage my pain.

Now, returning to New England, I face important decisions as to how to earn enough money while not working full time. Pain is a limiting factor, yet bringing income to the table is crucial while still maintaining my health.

Another issue with which I am grappling is how to keep this blog alive and well without the frequent patient interactions which previously provided such excellent grist for my writing mill. I want to remain true to the spirit of this blog by providing commentary on nursing, health and healthcare, while still blogging about my own personal journey.

Suggestions are welcome, and feedback is treasured.

Friday, April 18, 2008

Off to the Southwest!

My beloved and I are taking our son and his beloved for a short one-week journey to Boulder and Santa Fe. I may or may not be blogging on the road, so please stay tuned and come back soon!

Happy Spring!

Thursday, April 17, 2008

Please Vote Before April 22nd!

I am announcing for the second time that a proposal submitted by my dear friend Imre Kepes in Massachusetts was selected as a top 20 finalist among nearly 5,000 entries nationwide by the Case Foundation for its Make It Your Own Awards, a grant program that "challenges people from all walks of life to discuss what matters most to them, decide what kind of community they want, and take action together". If you peruse the proposals of the 20 finalists, you will see an amazing array of projects which have the potential to change the world by empowering people within their own communities.

I am asking for your support to help Imre Kepes' project be selected by on-line voting to be one of the Final Four to be awarded an additional $25,000. The Case Foundation will also give $2,500 to the favorite charity of the first 10 people who vote for the four projects that actually become the Make It Your Own Awards Final Four.

Imre's project---The Community Vision Project of Holyoke, MA (a struggling post-industrial city which has seen better days)---will develop a team of youth leaders to inspire others and gather input from a cross-section of residents to develop ideas to make their community a better place. Together they will create a Community Vision Map that will graphically express these ideas and help to inform and mobilize the community. Action teams will work to turn these ideas into action. The Community Vision Project is a collaboration between the Holyoke Youth Task Force Youth Commission, Hampshire College and other youth programs and adults in the community.

To vote for the Community Vision Project to be one of the Final Four, please log onto http://miyo.casefoundation.org/node/6736/promote and simply click on the vote button. Voting ends April 22. Please note that after you have selected your "final four", you will receive an email to which you must respond in order to confirm your vote!

Thank you so much!

Tuesday, April 15, 2008

Learning to Surf

I spent the afternoon today at a nearby state college at the invitation of a friend who is teaching a credited course on meditation and stress management. Last year, my wife and I went to this same college as guest "lecturers", offering Laughter Yoga to the hesitant and oh-so-self-conscious young students. This time, I was on my own, and while I had trepidations about doing laughter exercises with this age group again, I'm happy to report that the presentation and experience actually met with great success.

At the end of the class, my friend offered homework which I myself took to heart. She described a poster from the 1970's of Swami Satchinanda. On the poster was a photo of the Swami on a surf board, robes and hair flying in the wind. At the bottom of the poster were the following words: "You can't stop the waves, but you can learn to surf." The students' (and my) homework is to write a short paragraph or two on what that statement means to us personally. Some of the students stared blankly until my friend explained further, and I watched as the message sank in.

Considering such a statement, I think first of the veritable deluge of information and images in which we are bathed each day. With junk mail, email, bills, loans, passwords, user names and appointments, we are utterly bathed in a river of data---both physical and virtual---in which we must sink or swim.

Next, emotions and thoughts wash through our minds and bodies from moment to moment. Depending upon our (learned or innate) skills in navigating such potentially tumultuous waters, we ride those waves throughout each day, doing so both mindfully and mindlessly, with relative measures of "success".

Throughout the minutes, hours, days and weeks of our lives, we can simply ask ourselves some pointed questions: Am I awake? Am I aware? Am I mindful? Am I allowing myself to be emotionally hijacked by my reactions, or am I able to be a witness to my own thoughts and emotions?

In the end, the waves move us and we move with the currents. At times we ride the waves with ease, skimming the surface like warriors of the heart and mind. At other times, we struggle and sink, swallowing water and flailing our arms, anxiously looking for the lifeguard to save our sorry selves.

No, we cannot stop the waves, and with the proper tools we can occasionally rise above the waters, sailing on with grace and grit. At other moments, there is just nothing to do but dive deep, braving those waters with conscious awareness, mindful of our choice to enter this uncertain and frightening realm of our own accord.

Today I sailed and tomorrow I may sink. The next day I may sink again. But if I can simply foster gratitude for the privilege of doing so, then the waves are just another manifestation of my own personal journey, and I can simply grab my board, dipping my toes once again in the undulating waters. And when the surf's up, there's nothing more to do but enter with mindful abandon.

Sunday, April 13, 2008

The Future of Elder Care, Part I

As my parents, friends and I myself age, I've been doing a great deal of thinking about the state of elder care in this country. The nursing home industry has indeed changed over the last few years, with the lion's share of changes having to do with offering specialized Alzheimer's and dementia care, assisted living, and palliative care for those in need. More and more long-term care facilities appear to be offering services which allow residents to move along a continuum from independent living to complete care, based upon an individual's changing needs. This is a welcome change, but there is so much more that can be done.

With the Baby Boom generation beginning to retire, I predict that the care of the elderly will be an enormous field with unlimited growth and employment potential over the next thirty years. Savvy and relatively wealthy, Boomers will alter the landscape of long-term care by demanding services that the marketplace will naturally bend over backwards to fulfill. For those in a position to finance and create specialized facilities for the care of the elderly, the adage of "build it and they will come" is incredibly apropos at this point in time when it comes to this burgeoning field of healthcare.

When this generation of elders begins to need care beyond what can be provided at home, facilities will indeed need to change in order to satisfy the needs of this new long-term care demographic. Gone will be the days of singing "Melancholy Baby" by the piano. Gone will be many of the entertainment and leisure activities enjoyed by the previous generations who came of age in the first half of the 20th century.

Boomers, having cut their teeth in the 1950's and 1960's, will have a whole new set of cultural sign-posts and icons under their collective belts, and their sensibilities and predilections will need to be honored and integrated as these individuals begin to enter long-term care. With James Dean, The Beats, Jack Kerouac, Woodstock, Richard Nixon, the Civil Rights Movement, The Beatles, the Women's Liberation Movement, and the sexual revolution as major cultural milestones as part of their collective consciousness, Boomers will need a new cultural environment within the long-term care setting which acknowledges their generational history.

As we can observe in many industries, the marketplace will follow consumer demand if a cohort of consumers has enough collective buying power to drive changes. I submit that the Baby Boom generation will do just that, and those of us savvy and caring enough to ride that wave will have the opportunity to provide specialized care to an enormous audience of consumers willing and able to pay for our compassionate services.

(I will be exploring this issue over time and welcome your comments and suggestions along the way. Stay tuned, and there will certainly be more to come.)

Friday, April 11, 2008

Mindfulness Journal #6: Mindfulness Conference

Today I attended an all-day conference on mindfulness and meditation with Terry Fralich, a former student of H.H. The Dalia Lama and Jon Kabat-Zinn. The conference focused equally on cultivating mindfulness, the neurobiology of mindfulness, and how to impart mindfulness practices and philosophies to patients and clients when appropriate.

Here are some nuggets:

---Two parents and their teenage son are walking across a barren desert landscape. The father turns to the son and says, "Stop asking when we're going to get there already. We're nomads, for crying out loud."

---If you have time to worry, why don't you have time to meditate?

---In Tibetan, the word meditation means "to become familiar with"

---We live in an age of "data smog" and "techno-stress"

---Mindfulness is full-hearted presence, which translates into presence/intention and kindness towards the self

---The reality of the moment multiplied by my reactions = suffering

---If my thoughts were a movie, I'd get up, walk out, and probably ask for my money back.

Thursday, April 10, 2008

Mindfulness Journal: Intuitive Writing

The label on my tea bag this morning says "Your intuition is your best friend".

Sitting in my writing group, I let the words fly and the keyboard sings beneath my fingers. I do let intuition move my fingers, and I allow the paragraphs to form:

The wind blows from behind me and the warm sun feels like a balm against my face and chest. The other writers sit inside in the cozy warmth, and we write simultaneously in a chain of support and solidarity.

Cars and trucks go by on the street, and I hear the sounds of birds mixed with the traffic. There’s a hum in the air---the hum of life moving along its inevitable trajectory.

Now a small plane cuts across the sky, probably on its way to the local airport. The pilot will land his plane, taxi to his parking area, and exit the plane with a smile. He will walk to the office, pay his monthly fee, joke with his buddy behind the counter, and walk quickly to his car. As he drives along Main Street, no one will know that he was just 15,000 feet above the city, circling over the mountains, the rivers, the farmland, the suburban sprawl. As he manipulates his car amongst the other cars, he thinks of his glorious hour in the sky, and he looks forward to Saturday when his seven-year-old daughter will join him for a spin. They’ll fly over her elementary school, and she’ll marvel at how small the playground looks. Then she’ll point to her best friend’s house and wave and yell hello. They will revel in their time high above the earth, in that perspective that height can bring. When they land, she’ll call her best friend on his cell phone and ask if she saw them fly overhead. Her friend will claim that she could see his daughter waving from the cockpit. He would never deny her the pleasure of believing the impossible.

Back here on earth, the wooden deck I sit on is warm from the sun. I admire the lonely stacks of wood on the other side of the stream that runs through the yard.

In this moment, the anxiety I’ve been experiencing of late is nowhere to be found. Even as I try to conjure it, it will not fully surface. Just this morning I mailed the envelopes containing money that the government is demanding in taxes. Even though I could be working this morning, I am giving myself the gift of writing with colleagues, of honoring my need for creativity and release. I think of the house and all of the work there is to do. I think of tasks undone. Still, even with those images conjured from the sea of uncertainty, I am at peace in this moment.

At times, I want a life that is so full, so fully engaged---a life bursting at the seams. I hear interviews with people who seem to never stop, whose every waking moment is engaged in creative pursuits and interesting work. I admire their tenacity and think how wonderful it must be to have such a full and interesting life. But when I have a week that’s just overflowing with activity, I long for space, for those long unfolding afternoons where anything can happen, where nothing happening is a coup d’etat, where spaciousness is a gift from the goddess of satisfaction.

The Goddess of Satisfaction. Perhaps she should be by new mascot, the one I turn to for succor. Perhaps she can stand on a dais next to the Goddess of Mindfulness, steering me away from the Devils of Ennui and Lassitude, not to mention the Diet Devil who tempts me over and over, seeking out those moments of moral, mental and physical weakness.

But today it is the sun that rules over all as I sit here on this deck, like the bow of an anchored ship. That proverbial dome of blue above me today is just that---a dome beneath which our mortal lives entwine and move, wittingly and unwittingly.

I am luckier than I know, and blessed beyond belief.

Monday, April 07, 2008

Shortages: Not Just for Nurses Anymore

Doctors are leaving primary care in droves. That's the word on the street. Even my own doctor is leaving our local health center to become a hospitalist. As malpractice insurance goes through the roof, paperwork requirements become more stringent, and reimbursement rates plummet (even for Medicare and Medicaid claims), it seems that more and more doctors are choosing to specialize, leaving the pedestrian boredom of primary care for the sexy remunerative opportunities of various medical specialties.

Now, I'm sure that the reasons for a primary physician shortage are far more nuanced than I have so flippantly elucidated here, but the sad reality is that millions of Baby Boomers will begin to retire any day now, and they will all be in need of long-term primary care and preventive medicine in order to keep them healthy and out of the hospital.

In this market-based system, it seems that generalist doctors are being forced to specialize as a way of coping with increasing costs and decreasing revenues. In medical schools, interns and residents apparently are also learning how financially unrewarding primary care can be, and when one considers the cost of attending medical school in the first place, it is no wonder that newly-minted doctors want to maximize their earning potential right out of the gate.

Some reports indicate that advance practice nurses (such as nurse practitioners) will begin to fulfill more and more primary care duties as the shortage of primary care doctors grows, and talk of a new Doctor of Nursing Practice doctoral degree may lead to even more nurses assuming a roles historically held by doctors. These moves may help to assuage the crisis, and all options should be on the table as the crisis deepens.

As for me, I will return to the care of a Nurse Practitioner who left our little health center a few years ago for another position and has now returned. I love the care I receive from a nurse practitioner, and see no reason why I should see a doctor when my NP is capable, competent, and clinically skilled. Sure, my doctor is leaving and I wish him well, but for me there's no crisis, just an opportunity for change.

For the country as a whole, a physician shortage is most certainly problematic, and a shortage of primary care physicians could be devastating. Couple this with an ongoing nursing shortage, and you have one big healthcare mess on the plate of the next president who takes office in nine months.

So, the docs fly the coop and we're left holding the primary care bag. Just how to resolve such a crisis remains to be seen, and it is all of us who will pay the price when the proverbial healthcare feces hits the fan.

Sunday, April 06, 2008

The Case Foundation's Make it Your Own Award

I am announcing that a proposal submitted by my dear friend Imre Kepes in Massachusetts was selected as a top 20 finalist among nearly 5,000 entries nationwide by the Case Foundation for its Make It Your Own Awards, a grant program that "challenges people from all walks of life to discuss what matters most to them, decide what kind of community they want, and take action together". If you peruse the proposals of the 20 finalists, you will see an amazing array of projects which have the potential to change the world by empowering people within their own communities.

I am asking for your support to help Imre Kepes' project be selected by on-line voting to be one of the Final Four to be awarded an additional $25,000. The Case Foundation will also give $2,500 to the favorite charity of the first 10 people who vote for the four projects that actually become the Make It Your Own Awards Final Four.

Imre's project---The Community Vision Project of Holyoke, MA (a struggling post-industrial city which has seen better days)---will develop a team of youth leaders to inspire others and gather input from a cross-section of residents to develop ideas to make their community a better place. Together they will create a Community Vision Map that will graphically express these ideas and help to inform and mobilize the community. Action teams will work to turn these ideas into action. The Community Vision Project is a collaboration between the Holyoke Youth Task Force Youth Commission, Hampshire College and other youth programs and adults in the community.

To vote for the Community Vision Project to be one of the Final Four, please log onto http://miyo.casefoundation.org/node/6736/promote and simply click on the vote button. Voting ends April 22. Please note that after you have selected your "final four", you will receive an email to which you must respond in order to confirm your vote!

Thank you so much!

Saturday, April 05, 2008

The Widening Circle of Compassion

Visualize someone to whom you feel very close, particularly someone who is suffering and in pain. As you breathe in, imagine you take in all their suffering and pain with compassion, and as you breathe out, send your warmth, healing, love, joy, and happiness streaming out to them.

Now, gradually widen the circle of your compassion to embrace first other people to whom you also feel very close, then to those about whom you feel indifferent, then to those whom you dislike or have difficulty with, then even to those whom you feel are actively monstrous and cruel. Allow your compassion to become universal, and to enfold in its embrace all sentient beings, and all beings, in fact, without any exception.


---Sogyal Rinpoche

Friday, April 04, 2008

Martin Luther King, Forty Years and Counting

It was 40 years ago today that Martin Luther King, Jr. was assassinated on the balcony of a Memphis, Tennessee motel. Like so many others---known or unknown---King worked tirelessly for the rights of others, and he was one more who fell unnecessarily to the unforgiving hand of violence.

Race still matters in this country, and it touches every person on Earth, and although King's dream is still not fully realized, we all carry the collective responsibility to see it through. From astronomical rates of incarceration for young men of color to predatory lending targeted at communities of color, there is indeed still a long way to go.

In memory of Dr. King, may we all still stand for justice.

Thursday, April 03, 2008

Of Order and Chaos

I enter the apartment building and stop at the security desk.

“Who are you here to see?” asks the surprisingly pleasant security guard. She is a large African American woman, and she regards me with a friendly and curious expression.

“I’m here to see Mr. A,” I reply, fingering the ID badge that's clipped to my jacket. “Visiting nurses.”

“Oh, God bless you,” she says. “Good luck. Tenth floor, turn right out of the elevator."

I travel the ten floors in the briefest of upward journeys, and make my way down the hall, looking at the numbers on the apartment doors. His door at the end of the hall is wide open. I stand on the threshold and peer in. I knock and a voice responds, welcoming me in.

“Mr. A? I’m from the visiting nurses. May I come in?”

“Sure, sure, come in, come in,” says a disembodied voice from inside.

I step inside the studio apartment. To my left is the kitchen, or what once was a kitchen and is now more of a storage closet which only pretends to be a kitchen. Every surface is covered with papers, pens, and trash. Even the counters are covered, and the sink is full of dishes as well as a sheaf of papers and a telephone book.

Mr. A pokes his head around the wall that separates the kitchen from the living room.

“Come in here, please, please,” he says invitingly.

The fax that I received on this patient said that he could be combative, distant, or uncooperative. This gentleman seems so much the opposite, at least at first glance, anyway.

“How are you this morning?” I ask, as I attempt with some difficulty to clear a place on the table to put my bag.

“Oh, not so good, not so bad, but I’m going to visit my sister later today.”

His accent could be Indian, or maybe Pakistani, but I don’t want to ask. His diagnosis is paranoid schizophrenia, after all, and as a nurse who is visiting him for the first time, I don’t want to potentially alienate him from the start.

I take in the rest of his living space. The twin bed in the corner is covered with papers, envelopes, and a few plates of partially eaten food. A rowing machine takes up most of the center of the small apartment, and I marvel at the flotsam and jetsam that covers every surface.

“Did you take your meds last night, Mr. A?” I ask.

“Oh yes, here you are,” he says as he hands me the pill container which yesterday’s nurse prefilled for him yesterday morning. It’s empty.

“How did you sleep last night?”

“Very well, thanks,” he replies. His eye contact is good, although he seems to be uncomfortable sitting still at the table with me.

“Oh, before I forget, could you sign this for me?” I hand him my visit note, which has a place for patients to sign as proof that the nurse was actually there for the visit.

“That’s for them to know you were here, right?”

“Yes sir, you have that right, “ I reply.

He is so conversant, so positive and forthright. He is like the opposite of what I was told to expect.

I survey the remainder of his living space and see piles of papers everywhere. There is trash on the floor, chicken bones, milk cartons, a few cardboard boxes. I wonder what trauma or experience caused him to live like this. Although his eye contact is good, there is a wariness that I am now picking up on, a sense that he is uncomfortable in his own skin. Still, I feel completely comfortable with him, and we smile at one another.

I busy myself filling his med box with his morning and evening pills, reading the list carefully and putting my initials in each little box after I place that particular pill in its rightful place. He watches me closely. Once I‘m finished with the meds, I double-check the list and feel satisfied that I did it correctly. I hand him his morning meds.

“Thanks,” he says as he pops them all in his mouth and raises a large mug of water to his lips.
I check his blood pressure and pulse, listen to his lungs, and questions him briefly about his bowels, his urinary status, his appetite, his sleep quality, all the while looking in his eyes, assessing his skin and getting a general intuitive “read” on his overall health.

“Thanks for coming,” he says, as he walks me to the door.

The floor, covered with trash and papers, is like the elephant in the room that I dare not mention. Were he my patient, I would slowly address these issues over time. But in my position as just one more nurse passing through, I leave the elephant for someone else.

We shake hands and I leave his apartment. Even though I have been to so many homes like this in the past, I am stunned by how this man lives, and by the quiet desperation that I saw in his eyes.

“And how was our friend today?” asks the security guard who blessed me just thirty minutes prior.

“Just fine today, just fine,” I reply. “Thanks for your help.”

“God bless you” is her reply, delivered with a wave and a smile.

The outside air is fresh and cold, and I welcome my reentry into the clean orderliness of the wider world.

Wednesday, April 02, 2008

Immeasurable Abundance

A dear friend who I've known since I was 13 years old sent me the following text message this afternoon:

"The essential nature of the Universe is immeasurable abundance."

This simple phrase was like a sword of clarity cutting through my day, and I felt quite uplifted by it. I've been worrying about money, work, taxes, my health, our house, chores, the endless list of to-do's.

This simple message told me to just take a breath and realize that there is enough time and energy to go around, that it will all get done in good time (and if not, see Monday's post.....)

Even more food for thought for a busy mind in the Information Age.

Tuesday, April 01, 2008

Connection and Wonder

The house was filled with screaming and playing children and I could barely think straight. Trying to fill med boxes and query my patient about her health, I was having trouble concentrating.

All of a sudden, I looked up from my work at the kitchen table to see four earnest young faces staring at me. Sensing an opportunity, I decided to set the meds aside for a moment and check my patient's blood pressure instead. The children watched with rapt attention as I wrapped the cuff around their grandmother's arm, their fascination growing as I began to pump up the cuff and place the bell of my stethoscope on the crook of her elbow.

Finishing with the blood pressure, I knelt down and offered the oldest girl my stethoscope. I guided the ear-pieces into her small ears and then placed the bell of the stethoscope on her sister's chest. She smiled and giggled as she listened to her sister's heart, lub-dub, lub-dub, lub-dub. Each child in succession took turns listening to another child's heart, and by the time we were done, they were calm as can be and simply beaming.

After I left the house, I wondered to myself just how common it might be for a simple experience---like using a stethoscope for the first time---to end up being a crystallizing moment in a child's life, perhaps laying the groundwork for their adult life. Whatever the outcome, I had a great moment with those children today, and whether they remember it or not, we all had that brief time of connection and wonder, and that was worth more than words can say.