As always, work is certainly a mixed bag these days. On the one hand, I had the wonderful experience the other day of reminding a patient that he has now achieved five years of having his HIV fully suppressed with no detectable virus in his blood (based on the most up-to-date assay that we have, anyway). His determination and desire to be healthy have kept him on the right road and now he is reaping the benefits. I explained to him how we can now view his HIV like his diabetes---a chronic illness controlled with medications and a positive lifestyle, with the goal of avoiding as many long-term complications as we can. As more and more people with HIV age, we will begin to see the data regarding how they fare as their bodies begin to go through the ageing process. We still don't know for certain how infected people of very advanced age will do in the long term, but it looks like we may have a chance to find out over the next few decades.
On the other hand, there are patients who never quite "get on the bus" and we track the slow and inexorable progress towards their eventual demise. There's not much to do in many of these cases except to be there when they crash. Then there are others who simply have lives too dysfunctional to fix, patterns of behavior and learned helplessness just too entreched. It is some of these individuals who can make a workday miserable.
Aside from the patients themselves, paperwork, organizational issues, the healthcare system itself, and other factors all combine to make the providing of quality care a challenge. Not everyone has the same work ethic, not everyone cares as much. And when money is the bottom line, everyone suffers.
Yesterday, we heard that an amazing doctor specializing in HIV in our community died of a heart attack while swimming from one island in Maine to another to raise money for an AIDS-related organization. Her loss is a shock to the community, especially since we lost another local HIV expert to suicide two years ago. When the healers die, those who rely upon them are stopped in their tracks. How many people see their doctors as something other than mortal and fallible?
Next week I have the entire week off to celebrate my birthday (41!) and soak in some of the final days of the summer before Labor Day heralds the beginning of school and that September feeling of renewal and change. In many ways I look forward to the autumn: the crisp air, wearing a jacket on the cool mornings, getting back to teaching on Thursday nights as the summer wanes and the leaves begin their transition. The end of August also heralds the beginning of the big harvest time when the abundance of autumn graces the land. As always, there is much to look forward to and cherish, and the mixed bag is just a fact of life on this awkward and lovely physical plane.
Wednesday, August 10, 2005
Friday, July 29, 2005
The Small Things
I have a patient with schizophrenia who I take out to lunch about once a month. Seeing as it was his birthday recently and he verbalized a desire for Chinese food, I took him somewhere different for a special treat.
Sitting for the first time with him in a real restaurant---not just a pizza place or delicatessen---I was struck by the normalcy of what we were doing. Here we were, two people talking about our families, making comments about the weather, the food, the Red Sox, passing the soy sauce, pouring tea. Given his somewhat different way of relating to the world (schizophrenia being essentially a personality and thought disorder), this gentleman's conversational skills can be somewhat lacking in the strict sense of social decorum and "normalcy", and his personal brand of logic can sometimes be challenging to follow. That said, our time together was lovely, relatively comfortable, and very satisfying for us both on several different levels.
During the course of the meal, he looked me squarely in the eye and said, "Y'know, I appreciate this more than you could ever imagine. I look forward to our outings (his word) so much, and it's such a breath of fresh air to go out and do this." He added later, "I wish there was a way I could repay you." I responded that he could repay me by taking the best care of himself that he possibly could. We shook hands heartily and he got out of the car.
This interaction reaffirmed for me the therapeutic value of this monthly tradition, as unconventional as it seems. I don't do this with any other patients, although I have been out for coffee with a few here and there. There's a technique in psychological treatment called "therapeutic use of self" which refers to the professional individual disclosing personal information in a nonmanipulative way in order to normalize the patient's experience, perhaps helping the client to see that the clinician can empathize based upon actual personal experience. I've practiced this technique by disclosing the fact that I take antidepressants, for instance, or that, yes, my cholesterol is also high and my reflux is out of control when I forget to take my medication. When convincing a patient to use a weekly pill-box, I'll often comment that I could never remember my meds without using one (a very true statement, indeed).
While I can't afford to pay out of pocket to take all of my patients to lunch every month, the value of my decision to do this regularly with this particular individual is worth much more than the actual cash value of said expense. It has become something that I simply plan on, and today exemplified for me the fact that the benefit is both therapeutically measurable and personally meaningful. The interpersonal connection and trust that's been created in this "clinical" relationship is something that I can see is a valuable tool in the therapeutic kit which I employ with this gentleman.
Today I acknowledge that it is often the small things that pay the largest, most meaningful dividends.
Sitting for the first time with him in a real restaurant---not just a pizza place or delicatessen---I was struck by the normalcy of what we were doing. Here we were, two people talking about our families, making comments about the weather, the food, the Red Sox, passing the soy sauce, pouring tea. Given his somewhat different way of relating to the world (schizophrenia being essentially a personality and thought disorder), this gentleman's conversational skills can be somewhat lacking in the strict sense of social decorum and "normalcy", and his personal brand of logic can sometimes be challenging to follow. That said, our time together was lovely, relatively comfortable, and very satisfying for us both on several different levels.
During the course of the meal, he looked me squarely in the eye and said, "Y'know, I appreciate this more than you could ever imagine. I look forward to our outings (his word) so much, and it's such a breath of fresh air to go out and do this." He added later, "I wish there was a way I could repay you." I responded that he could repay me by taking the best care of himself that he possibly could. We shook hands heartily and he got out of the car.
This interaction reaffirmed for me the therapeutic value of this monthly tradition, as unconventional as it seems. I don't do this with any other patients, although I have been out for coffee with a few here and there. There's a technique in psychological treatment called "therapeutic use of self" which refers to the professional individual disclosing personal information in a nonmanipulative way in order to normalize the patient's experience, perhaps helping the client to see that the clinician can empathize based upon actual personal experience. I've practiced this technique by disclosing the fact that I take antidepressants, for instance, or that, yes, my cholesterol is also high and my reflux is out of control when I forget to take my medication. When convincing a patient to use a weekly pill-box, I'll often comment that I could never remember my meds without using one (a very true statement, indeed).
While I can't afford to pay out of pocket to take all of my patients to lunch every month, the value of my decision to do this regularly with this particular individual is worth much more than the actual cash value of said expense. It has become something that I simply plan on, and today exemplified for me the fact that the benefit is both therapeutically measurable and personally meaningful. The interpersonal connection and trust that's been created in this "clinical" relationship is something that I can see is a valuable tool in the therapeutic kit which I employ with this gentleman.
Today I acknowledge that it is often the small things that pay the largest, most meaningful dividends.
Friday, July 22, 2005
Where Does the Time Go?
Seems like it was only yesterday that I posted on Tuesday night. My, how the week does fly. Working only three days, seems like I did the same amount of work I would normally do in five. Maybe I did.
Rose, mentioned in previous missives, is now in the hospital, deemed legally incompetent, and awaiting what comes next.
Another patient called me begging for prednisone for her worsening asthma. I declined and sent her to the ER. She's admitted now and I knew in my gut that prednisone wouldn't cut it. Looks like pneumonia. Sometimes I think about my nursing license when I make such decisions. Must think clearly and not just try to save the patient the inconvenience of an ambulance ride.
Another patient was in the ER today---brittle diabetic, alcoholic, eschewing his insulin and other self-care, sticking to his bottle instead. I don't foresee a happy ending there.
A medical student followed me on my rounds today and we were able to visit three very diverse and interesting patients in their homes: an alcoholic with Hepatitis C and bad pulmonary disease, just out of the hospital; a lovely older man with cancer who takes such good care of himself that I offered to pay him as a consultant to teach my other patients his secrets of success; and finally, a transgendered man (of whom I am exceedingly fond) with more life-threatening diagnoses than you can shake a stethoscope at, and he is still filled with joie de vivre and a strong will to live. Sometimes work can be inspiring, especially when someone takes such responsibility for their life and personal self-care.
That said, work fatigue is definitely weighing on my eyelids this evening, while my old nemesis "compassion fatigue" is nowhere in sight. The weekend is for the recharging of the batteries, and I'm so very pleased that my batteries aren't disposable.
Rose, mentioned in previous missives, is now in the hospital, deemed legally incompetent, and awaiting what comes next.
Another patient called me begging for prednisone for her worsening asthma. I declined and sent her to the ER. She's admitted now and I knew in my gut that prednisone wouldn't cut it. Looks like pneumonia. Sometimes I think about my nursing license when I make such decisions. Must think clearly and not just try to save the patient the inconvenience of an ambulance ride.
Another patient was in the ER today---brittle diabetic, alcoholic, eschewing his insulin and other self-care, sticking to his bottle instead. I don't foresee a happy ending there.
A medical student followed me on my rounds today and we were able to visit three very diverse and interesting patients in their homes: an alcoholic with Hepatitis C and bad pulmonary disease, just out of the hospital; a lovely older man with cancer who takes such good care of himself that I offered to pay him as a consultant to teach my other patients his secrets of success; and finally, a transgendered man (of whom I am exceedingly fond) with more life-threatening diagnoses than you can shake a stethoscope at, and he is still filled with joie de vivre and a strong will to live. Sometimes work can be inspiring, especially when someone takes such responsibility for their life and personal self-care.
That said, work fatigue is definitely weighing on my eyelids this evening, while my old nemesis "compassion fatigue" is nowhere in sight. The weekend is for the recharging of the batteries, and I'm so very pleased that my batteries aren't disposable.
Friday, July 15, 2005
Narcotic Nightmare
It seems that more and more of my time at work is taken up by patients in need of narcotic medications. As the "middle-man" between my patients and their providers at the clinic, I negotiate contracts around the use of narcotics and monitor patient's side effects, pain levels, and adherence to our agreements. While many people are sincerely in pain and certainly need narcotics to ease their suffering, there are always some whose motivations seem slightly dubious and cause confusion and difficulty for their providers. A history of substance abuse also complicates the picture and makes treating pain more challenging. It's times like these that I give thanks that I'm not a Nurse Practitioner and have no prescriptive authority. Put into the position of listening to a patient's complaints and assessing their needs, I know that I would be a soft touch, always erring on the side of believing a patient, even if my intuition led me to think otherwise.
Pain is widely under-treated in this country and I'm happy to assist in managing patients' pain, but it is admittedly a confusing and trying ordeal at times. While pain advocates in the medical world are pushing for more recognition of pain as the "fifth vital sign" (after temperature, pulse, respirations, and blood pressure), it is still not always clearly seen by providers and is treated with less than germaine levels of attention.
Many of the docs at the clinic only work part-time, so I often find myself negotiating for narcotic prescriptions when my patients call for refills. Add to that the fact that patient's charts are often MIA at the the clinic, making documentation and double-checking of doses even harder. I think I can say that this is my least favorite aspect of my job, one which causes me endless distress and cognitive dissonance. The fact that I started writing this entry just before midnight on a Friday underscores the notion that it weighs heavily on my mind.
I'd like to write about this some more in future, but send this missive out into the cyber-ethers to allow myself to let it go for my long, four-day weekend. A short vacation is in order and I must clear my mind of static.
Pain is widely under-treated in this country and I'm happy to assist in managing patients' pain, but it is admittedly a confusing and trying ordeal at times. While pain advocates in the medical world are pushing for more recognition of pain as the "fifth vital sign" (after temperature, pulse, respirations, and blood pressure), it is still not always clearly seen by providers and is treated with less than germaine levels of attention.
Many of the docs at the clinic only work part-time, so I often find myself negotiating for narcotic prescriptions when my patients call for refills. Add to that the fact that patient's charts are often MIA at the the clinic, making documentation and double-checking of doses even harder. I think I can say that this is my least favorite aspect of my job, one which causes me endless distress and cognitive dissonance. The fact that I started writing this entry just before midnight on a Friday underscores the notion that it weighs heavily on my mind.
I'd like to write about this some more in future, but send this missive out into the cyber-ethers to allow myself to let it go for my long, four-day weekend. A short vacation is in order and I must clear my mind of static.
Thursday, June 23, 2005
A Speech for Graduate Nurses
This speech will be delivered by yours truly this evening at 6pm.
I am sure that a vast majority of the audience gathered here tonight are family, friends, and loved ones of the graduates. The first acknowledgement I wish to make is for the sacrifices and endless hours of study and clinical that you needed to put up with as your family’s nursing student struggled his or her way through the program. As I look out at you tonight, I wonder to myself how many dinners were missed, how many games not attended, how often was your family’s particular nursing student locked in his or her room, studying for yet another exam? For your sacrifices and support, I encourage the graduates to stand and applaud you for your unerring support.
Speaking of family, several of our students experienced the loss of a loved one during this past year, and I ask for a moment of silence in memory of the family members who left this world during the last ten months, not to mention those who passed before. I believe that they are here in spirit, smiling down upon you all with unceasing pride.
Now that we have acknowledged the loved ones who kept the home fires burning while the students were battling the demons of nursing education, I would like to turn our attention towards these courageous and ambitious individuals who have been doggedly pursuing their education and professional betterment for the last ten months.
Often, when thinking of students, our minds may wander to the quintessential and stereotypical undergraduate—living in a dorm, buying food with a campus meal plan, perhaps buying clothes and other necessities with Mom and Dad’s credit card, possibly working a part-time job on- or off-campus to supplement financial aid. But these graduates sitting here in this auditorium tonight are a different breed of student altogether. Oh yes, many of these graduates have children, mortgages, rent to pay, spouses, ill family members who need tending to, bills, loans, debts, and, last but not least, full- or part-time jobs. While lecturing to this class, I was painfully aware that many students, after leaving a six-hour lecture from 4pm to 10pm, would rush home for a bite to eat, don a uniform or scrubs, and head out to an overnight shift in a nursing home or hospital, working 11 to 7, only to come home in the morning to get the kids off to school before collapsing for an abbreviated sleep before clinical or another lecture. This is nothing short of heroic, and I stand in awe of your dedication and hard work.
Having been there myself, completing two different nursing programs over the last ten years, I understand how much concentration and dedication it takes to forge ahead, even when the studying is laborious and the exams seem to never stop coming. Being adult learners, you have little time for socializing and leisure---if you’re not engaged in some type of study, class-time, or clinical experience, you are most likely helping your kids with their homework, cleaning the bathroom, or going grocery shopping. The fact that you are all graduating today, ready to be licensed professionals, is an amazing feat deserving of much praise and recognition.
It’s often said that nurses eat their young, and it’s also said that nurses are overworked, undervalued, and underpaid. Bearing that in mind, I personally find that there is nothing more satisfying for me than nurturing and encouraging new nurses to be their best and perform well, whether in school or in the workplace. As for overworked and underpaid, that may be true in some settings, but nurses are also held in high esteem in this society, and just saying that one is a nurse can feel extremely gratifying in almost any social situation. While not being self-congratulatory, nurses can count themselves as members of a profession which holds compassion, caring, and healing as three of its central ideals. Saying that one is a nurse is something I encourage the graduates to do with pride, as well as with humility.
Speaking of being a nurse, many of you may realize you’re really a nurse when everyone you know begins coming to you with every ache, pain and symptom they experience, fully expecting a definitive diagnosis. You also may find yourself washing your hands for a full minute in public restrooms and turning off the faucets with your elbows. On the bright side, whenever anyone asks for a pen, you’ll probably have three in your pocket. But it’s most disconcerting when you start checking out people’s veins for IV access while standing in line at the grocery store. Just try not to be too obvious, and refrain from touching strangers.
Despite the sarcasm and jokes, being a nurse is a noble and honorable profession, and it was a true honor and pleasure to be your professor for this past year, watching the light bulbs go off in your heads as we discussed the finer points of fluid balance and kidney function. You are a bright, kind, considerate, funny, and only moderately argumentative group, and I will miss you all very much. Thank you for your patience during my first year of teaching, and thank you for making the experience so heartwarming and enjoyable. My blessings to each of you today and always.
Monday, June 13, 2005
Oh My
The continuing saga of Rose........She actually refused to go in the ambulance on Friday night and avoided the police who were sent by Protective Services by leaving the house and staying with her daughter. The visiting nurses thought she was hospitalized so Rose missed her methadone and other meds all weekend. Damn!
Today I physically brought her to the clinic to see her primary doctor. After multiple telephone consults on the phone between us, Protective Services, and the hospital, we convinced the hospital to allow us to "direct admit" her, bypassing the ER and going straight to a room. I sent her home extracting the promise from her family that she would go to the hospital as soon as the call came that a bed was ready. I crossed every finger and toe.
At 6, the Admitting Dept called me--the bed was ready. A quick call to the daughter and Rose was on her way to the hospital, at least for a 24-48 hour tune-up while we buy time to figure out what to do next.
At 7:30, her daughter calls me on my cell while I'm at a meeting in my hometown for one of my volunteer gigs (she has Caller ID and has my cell # now)---Rose snuck out of the hospital fifteen minutes after her daughter dropped her off and was on their front step like a puppy dog within forty minutes! I pleaded and cajoled them to return, which they eventually did. Just now (10pm), I called the nurses' station on the floor where she is staying and suggested they give her some Ativan and post security at her door to keep her from leaving in the middle of the night and putting herself at risk on the dark streets. She has AIDS dementia, after all. The friendly nurse on the other end of the line agreed to bring this up with the attending physician stat. That was my 11th phone call about Rose today, and I interacted in person or on the phone with at least six other patients and/or providers in the course of the day---plus the ubiquitous paperwork which such interventions necessarily generate.
Now it's 10:30 and I ruminate. Could I have handled it better? Was my game-plan on Friday a mistake? Most likely. Will Rose get through the night at the hospital? I hope so. Will I sleep tonight? That would be nice. Does the week stretch before me like a gaping maw of unmet need and unknown crisis? Most definitely. Do I still love my work and maybe enjoy the adrenaline and drama? Is the Pope Catholic?
Well, The Daily Show with Jon Stewart is on soon. Must take a shower and settle in for some laughs. Maybe it's me who needs that Ativan......
Today I physically brought her to the clinic to see her primary doctor. After multiple telephone consults on the phone between us, Protective Services, and the hospital, we convinced the hospital to allow us to "direct admit" her, bypassing the ER and going straight to a room. I sent her home extracting the promise from her family that she would go to the hospital as soon as the call came that a bed was ready. I crossed every finger and toe.
At 6, the Admitting Dept called me--the bed was ready. A quick call to the daughter and Rose was on her way to the hospital, at least for a 24-48 hour tune-up while we buy time to figure out what to do next.
At 7:30, her daughter calls me on my cell while I'm at a meeting in my hometown for one of my volunteer gigs (she has Caller ID and has my cell # now)---Rose snuck out of the hospital fifteen minutes after her daughter dropped her off and was on their front step like a puppy dog within forty minutes! I pleaded and cajoled them to return, which they eventually did. Just now (10pm), I called the nurses' station on the floor where she is staying and suggested they give her some Ativan and post security at her door to keep her from leaving in the middle of the night and putting herself at risk on the dark streets. She has AIDS dementia, after all. The friendly nurse on the other end of the line agreed to bring this up with the attending physician stat. That was my 11th phone call about Rose today, and I interacted in person or on the phone with at least six other patients and/or providers in the course of the day---plus the ubiquitous paperwork which such interventions necessarily generate.
Now it's 10:30 and I ruminate. Could I have handled it better? Was my game-plan on Friday a mistake? Most likely. Will Rose get through the night at the hospital? I hope so. Will I sleep tonight? That would be nice. Does the week stretch before me like a gaping maw of unmet need and unknown crisis? Most definitely. Do I still love my work and maybe enjoy the adrenaline and drama? Is the Pope Catholic?
Well, The Daily Show with Jon Stewart is on soon. Must take a shower and settle in for some laughs. Maybe it's me who needs that Ativan......
Sunday, June 12, 2005
Mixed Emotions
My patient Rose who I wrote about recently was deemed legally incompetent on Friday due to my reporting her to Protective Services for the Disabled. Although I have mixed feelings about making such a report, I felt I had no choice based upon her deteriorating state, her children's inability to properly care for her, and the increasing risk that she and the entire building would eventually go up in flames (her bed is covered with cigarette burns from Rose nodding off while smoking).
I have been aware for months that Rose is not long for this world and I have been doing my best to put appropriate services in place. Given her untreated Hepatitis C and HIV, seizure disorder, anxiety disorder, history of trauma, and Xanax addiction, Rose's chances of survival in her current situation are next to nil, and I seemed to be the only person ready to step up and make the call that would legally change her status.
I have called the Department of Social Services once when I felt a patient's children were being neglected, and my hope was that this would lead to a better life for these children. I don't think it worked, but this has alot to do with the relative inefficiency of our state programs. In Rose's case, my hope is that a court-appointed attorney will become her legal guardian, and that she will be placed in an environment where her addiction, HIV, and anxiety can all be addressed appropriately, not by the band-aids that I continually attempt to put in place, often to no avail.
Tomorrow I return to work and hope that this situation can improve, that her life can be qualitatively improved and quantitatively lengthened, and that I won't suffer any negative consequences from taking action.
I sit here in the steamy heat and ruminate on my work, but now I must return to my regularly-scheduled Sunday afternoon.
I have been aware for months that Rose is not long for this world and I have been doing my best to put appropriate services in place. Given her untreated Hepatitis C and HIV, seizure disorder, anxiety disorder, history of trauma, and Xanax addiction, Rose's chances of survival in her current situation are next to nil, and I seemed to be the only person ready to step up and make the call that would legally change her status.
I have called the Department of Social Services once when I felt a patient's children were being neglected, and my hope was that this would lead to a better life for these children. I don't think it worked, but this has alot to do with the relative inefficiency of our state programs. In Rose's case, my hope is that a court-appointed attorney will become her legal guardian, and that she will be placed in an environment where her addiction, HIV, and anxiety can all be addressed appropriately, not by the band-aids that I continually attempt to put in place, often to no avail.
Tomorrow I return to work and hope that this situation can improve, that her life can be qualitatively improved and quantitatively lengthened, and that I won't suffer any negative consequences from taking action.
I sit here in the steamy heat and ruminate on my work, but now I must return to my regularly-scheduled Sunday afternoon.
Thursday, June 02, 2005
Small Victories
Some of you may remember Patient X from January and February postings. He is my patient who was hospitalized for alcoholic hepatitis and had moderate cirrhosis and very severe psoriasis. Well, I am happy to report that he is doing swimmingly well. He has not had an alcoholic drink since getting out of the hospital in January, his symptoms have all abated, he's losing weight, and his psoriasis is incredibly improved. He and his friends credit my weekly visits and demonstrated desire to help him for this astounding recovery. I think that my regular presence has simply shown him that others can care, and that his own self-care can pay enormous dividends. In short, this man's life is being extended---not necessarily by medical intervention, but rather by compassion, attention, and renewed self-respect.
Another patient of mine who had been seen as a lost cause can now finally enjoy having her advanced AIDS completely controlled and suppressed through the taking of antiretroviral medications. She has been free of any complications, is doing extremely well, and has energy to spend time with her school-age daughter and son. She is one of my stars.
Mr. D, someone who has failed many antiretroviral regimens due to his unwillingness to take his meds religiously, is now completely suppressed as well, with rising T-cells (immune cells) and a quantity of virus so low that we cannot measure it. He is seeing the benefits of this turn of events and looks great. His previous skin eruptions are gone and he is gaining weight. His wife--also with AIDS--has been much better about taking meds all along, and she is in excellent health. Their young children are benefiting directly from their parents' self-care.
In this line of work, we need to remind ourselves to take the time to count our successes, celebrate our victories--however small--and take a deep breath on occasion.
Today I am off from work yet again, preparing for a trip to Boston tomorrow for my son's graduation from The New England School of Photography. You, my dear Readers, will necessarily need to tolerate some photos of the happy event upon my return, not to mention gushing sentimentality about our wonderful boy---er, young man, rather.
Happy day to you all.
Another patient of mine who had been seen as a lost cause can now finally enjoy having her advanced AIDS completely controlled and suppressed through the taking of antiretroviral medications. She has been free of any complications, is doing extremely well, and has energy to spend time with her school-age daughter and son. She is one of my stars.
Mr. D, someone who has failed many antiretroviral regimens due to his unwillingness to take his meds religiously, is now completely suppressed as well, with rising T-cells (immune cells) and a quantity of virus so low that we cannot measure it. He is seeing the benefits of this turn of events and looks great. His previous skin eruptions are gone and he is gaining weight. His wife--also with AIDS--has been much better about taking meds all along, and she is in excellent health. Their young children are benefiting directly from their parents' self-care.
In this line of work, we need to remind ourselves to take the time to count our successes, celebrate our victories--however small--and take a deep breath on occasion.
Today I am off from work yet again, preparing for a trip to Boston tomorrow for my son's graduation from The New England School of Photography. You, my dear Readers, will necessarily need to tolerate some photos of the happy event upon my return, not to mention gushing sentimentality about our wonderful boy---er, young man, rather.
Happy day to you all.
Sunday, May 29, 2005
Rose
This is a work-related post about a patient with AIDS with whom I work.
Rose has had AIDS for about ten years. We've never treated her with antiretrovirals (the drugs used to stop the virus from replicating) because her mental illness, anxiety disorder, and predilection for Xanax and other drugs has precluded us having a clear shot at success. She has had relatively few life-threatening infections or complications but she is wasting away and we know it. A killer infection is only around the corner. With her itinerant lifestyle and inability to stay in one place and on task for more than a few days, she has been a poor candidate for treatment. Her Hepatitis C is also a worry, but the treatment for that can cause such intense emotional distress and suicidality that she would never withstand it. Her seizure disorder is another issue altogether.
Since I "inherited" her from another nurse almost two years ago, it's been an ongoing struggle to figure out exactly what to do with her. She has dropped out of our program several times and left the clinic entirely, always looking for a doctor who'll keep her supplied with Xanax. Now she's back with me for six months, and I feel like I am battling time.
I have successfully introduced visiting nurse services and Rose now has a daily visit from the visiting nurse whom she loves. By offering her home delivery of methadone (rather than going to the clinic every day), we are assured that she'll be home waiting for her daily dose. Now that this relationship is established, the thought is that we can now introduce further treatment.
Rose is now living in a three-story walk-up, with several of her daughters living upstairs. The electricity for all three apartments is in her name only, so I have had to intervene several times to keep the electric company from turning off the lights due to a bill over $1000. Rose spends most of her days in a messy double bed in the middle of the living room, with the TV on throughout the day. The sparse furniture is old and in poor repair, the apartment almost empty except for a shower seat in the middle of the dining room and some nasty leftovers or other detritus in the kitchen. No cooking happens in the apartment. Her daughter brings her food once or twice a day, at best, and Rose spends the majority of the day smoking. Cigarette burns dot the unwashed bed linens and I know it's only a matter of time before she goes up in flames with the rest of the building. Until recently, Rose's four-year-old granddaughter was living with her in this apartment, ostensibly abandoned by her mother, Rose's daughter. The other daughter who is the most responsible of Rose's children has taken custody of the four-year-old. The Department of Social Services has been called on the family numerous times.
Last week I felt forced to call Protective Services for the Disabled about Rose. I hated to do it, but I felt it was the only way to possibly get other agencies involved and consider taking legal action to put Rose in a nursing home, at least until we can get her stabilized. Although I don't think Rose's daughters are necessarily neglecting their mom per se, Rose's living conditions are abhorrent and are like what you might see in a movie or TV drama. Life imitating art? At best, Rose is self-neglecting, and that is enough to call Protective Services and report her as a risk to herself.
My goal is to introduce antiretrovirals as soon as I can, give Rose some immune protection against deadly infections, and watch as she gains weight and loses some of the dementia that has begun to set in. Whether some of this neurological damage is permanent from the vicissitudes of untreated HIV infection and years of IV drug use, it's hard to say. Perhaps if she stabilizes enough, we can send her to detox and break her Xanax habit. I am not overly optimistic, but I'm determined to at least give a very sincere attempt at suppressing her virus and perhaps prolonging her life, simultaneously putting into place services that might improve her daily plight.
As I sit in my lovely screened-in porch, listening to the many birds in the surrounding trees, the dogs snoring on the rug, a cold beer beside me, a warm meal in my belly, I think about Rose. I think about her life which is what it is, continuing throughout the weekend when my work is on hold and I go about my personal life. It's profound to witness such suffering up close, and it's also profound to realize that that particularly reality is not my own, at least not in this life, anyway. On Tuesday, I'll continue the struggle and see what the next step will be for her, as well as for dozens of others, most much better off than her, several somewhat worse. I take a deep breath of the flower-scented air here in my home reality, and I feel grateful beyond words.
Rose has had AIDS for about ten years. We've never treated her with antiretrovirals (the drugs used to stop the virus from replicating) because her mental illness, anxiety disorder, and predilection for Xanax and other drugs has precluded us having a clear shot at success. She has had relatively few life-threatening infections or complications but she is wasting away and we know it. A killer infection is only around the corner. With her itinerant lifestyle and inability to stay in one place and on task for more than a few days, she has been a poor candidate for treatment. Her Hepatitis C is also a worry, but the treatment for that can cause such intense emotional distress and suicidality that she would never withstand it. Her seizure disorder is another issue altogether.
Since I "inherited" her from another nurse almost two years ago, it's been an ongoing struggle to figure out exactly what to do with her. She has dropped out of our program several times and left the clinic entirely, always looking for a doctor who'll keep her supplied with Xanax. Now she's back with me for six months, and I feel like I am battling time.
I have successfully introduced visiting nurse services and Rose now has a daily visit from the visiting nurse whom she loves. By offering her home delivery of methadone (rather than going to the clinic every day), we are assured that she'll be home waiting for her daily dose. Now that this relationship is established, the thought is that we can now introduce further treatment.
Rose is now living in a three-story walk-up, with several of her daughters living upstairs. The electricity for all three apartments is in her name only, so I have had to intervene several times to keep the electric company from turning off the lights due to a bill over $1000. Rose spends most of her days in a messy double bed in the middle of the living room, with the TV on throughout the day. The sparse furniture is old and in poor repair, the apartment almost empty except for a shower seat in the middle of the dining room and some nasty leftovers or other detritus in the kitchen. No cooking happens in the apartment. Her daughter brings her food once or twice a day, at best, and Rose spends the majority of the day smoking. Cigarette burns dot the unwashed bed linens and I know it's only a matter of time before she goes up in flames with the rest of the building. Until recently, Rose's four-year-old granddaughter was living with her in this apartment, ostensibly abandoned by her mother, Rose's daughter. The other daughter who is the most responsible of Rose's children has taken custody of the four-year-old. The Department of Social Services has been called on the family numerous times.
Last week I felt forced to call Protective Services for the Disabled about Rose. I hated to do it, but I felt it was the only way to possibly get other agencies involved and consider taking legal action to put Rose in a nursing home, at least until we can get her stabilized. Although I don't think Rose's daughters are necessarily neglecting their mom per se, Rose's living conditions are abhorrent and are like what you might see in a movie or TV drama. Life imitating art? At best, Rose is self-neglecting, and that is enough to call Protective Services and report her as a risk to herself.
My goal is to introduce antiretrovirals as soon as I can, give Rose some immune protection against deadly infections, and watch as she gains weight and loses some of the dementia that has begun to set in. Whether some of this neurological damage is permanent from the vicissitudes of untreated HIV infection and years of IV drug use, it's hard to say. Perhaps if she stabilizes enough, we can send her to detox and break her Xanax habit. I am not overly optimistic, but I'm determined to at least give a very sincere attempt at suppressing her virus and perhaps prolonging her life, simultaneously putting into place services that might improve her daily plight.
As I sit in my lovely screened-in porch, listening to the many birds in the surrounding trees, the dogs snoring on the rug, a cold beer beside me, a warm meal in my belly, I think about Rose. I think about her life which is what it is, continuing throughout the weekend when my work is on hold and I go about my personal life. It's profound to witness such suffering up close, and it's also profound to realize that that particularly reality is not my own, at least not in this life, anyway. On Tuesday, I'll continue the struggle and see what the next step will be for her, as well as for dozens of others, most much better off than her, several somewhat worse. I take a deep breath of the flower-scented air here in my home reality, and I feel grateful beyond words.
Friday, May 20, 2005
Blessed Relief
Friday rolls around and the relief of two days free of caring for others is like a weight lifted, believe me. Today I was pushed to the edges of my patience with several patients, and I practiced compassionate listening even as I felt my impatient self wanting to scream in frustation, "Why the fuck can't you understand these simple instructions? Don't you get it???" Thank Goddess for self-control and restraint.
When one sees learned helplessness in action, it is difficult to just sit there smiling and say, "Y'know, I understand how you feel. Now let's talk about it". Instead, one wants to talk like you might talk to a recalcitrant child, threaten to take away priviledges, no sweets after dinner, no TV before bed. Instead, we plead, we cajole, we try good cop/bad cop techniques, we throw up our hands and decide to try again next week.
The diabetic patient who knows she should eat a small snack every few hours but only eats an enormous meal once a day and then has super-low blood sugars 12 hours later should know better--she just can't change her patterns of behavior. The woman with advanced AIDS who continuously buys Xanax on the street should know better, but her life of unbelievable trauma precludes such clearheadedness. The other patient with advanced respiratory disease should be able to stop smoking, since she constantly complains of not being able to breathe. But she can't. Her AIDS is fully controlled but the smoking will be her death. Can I change it? Probably not. Am I frustrated with her? Hell, yes.
I have a love/hate relationship with this work. I love the people, their humanity, their damaged selves. I love the ones who are self-sufficient and disciplined. I love the ones who are helpless victims of trauma. I've loved many who have died---the city is speckled with their memory as I make my rounds along the streets. I love many who will die, often due to their own inability to act conscientiously, and memories of them will also roam the streets and the corridors of my mind. I ask myself honestly if I am addicted to being a helper. Do I gain alot from being in this role? I'm sure I do, and only I can decide when the role no longer serves me (or them, for that matter).
When one sees learned helplessness in action, it is difficult to just sit there smiling and say, "Y'know, I understand how you feel. Now let's talk about it". Instead, one wants to talk like you might talk to a recalcitrant child, threaten to take away priviledges, no sweets after dinner, no TV before bed. Instead, we plead, we cajole, we try good cop/bad cop techniques, we throw up our hands and decide to try again next week.
The diabetic patient who knows she should eat a small snack every few hours but only eats an enormous meal once a day and then has super-low blood sugars 12 hours later should know better--she just can't change her patterns of behavior. The woman with advanced AIDS who continuously buys Xanax on the street should know better, but her life of unbelievable trauma precludes such clearheadedness. The other patient with advanced respiratory disease should be able to stop smoking, since she constantly complains of not being able to breathe. But she can't. Her AIDS is fully controlled but the smoking will be her death. Can I change it? Probably not. Am I frustrated with her? Hell, yes.
I have a love/hate relationship with this work. I love the people, their humanity, their damaged selves. I love the ones who are self-sufficient and disciplined. I love the ones who are helpless victims of trauma. I've loved many who have died---the city is speckled with their memory as I make my rounds along the streets. I love many who will die, often due to their own inability to act conscientiously, and memories of them will also roam the streets and the corridors of my mind. I ask myself honestly if I am addicted to being a helper. Do I gain alot from being in this role? I'm sure I do, and only I can decide when the role no longer serves me (or them, for that matter).
Monday, May 16, 2005
A Gentle Monday
A thankfully gentle Monday greeted the opening of my week. A morning work-out, a patient hospital visit, some clinic visits, and lots of desk-oriented work and calls. Today was a day when the work I do made sense:
-I spoke with a doctor about a patient who needs better diabetic care. We came up with a plan and I called the VNA to initiate the change.
-I visited a patient in the hospital, wrote a note in her chart, and later received a call from the hospital physician about the discharge plans.
-Later I sat in on a visit one of my patients had with his primary doctor. A great deal of useful information was exchanged and now I can follow up.
-Another patient didn't show for his appointment with his doc. I checked the computer and saw that he'd been in the ER. I printed out the notes and labs and will discuss them with his primary and initiate timely follow-up.
Just for a day, everything made sense and I could just do my work.
My colleague, meanwhile, was struggling with a patient who has a not-quite-broken arm which needs orthopedic attention. Unfortunately, none of the local ortho docs want to see a Medicaid patient if the patient's arm isn't actually fractured, so the patient languishes in pain. Another patient needs emergency oral surgery but no oral surgeons in the area accept Medicaid. We can load her up on narcotics but she needs surgery. What to do? Luckily, this was not my battle to wage today, but there for the grace of God go I......
Coming home, the dogs wag their greeting and we head to town for a book-reading at the local dog-friendly collective bookstore (see link to Food for Thought Books). The reading was cancelled, but we hung out with the friendly bookstore workers, the dogs soaking up the proffered love. We then wandered through the sunlit town, eating cookies and looking at flowers. The dogs only seemed interested in flowers that other dogs had peed on. What's up with that?
I give thanks tonight for a gentle day, a lifted depression, the peepers making their nightly appearance in the nearby swamps, and the knowledge that my love is on her way home.
May your days be gentle, fair Reader.
-I spoke with a doctor about a patient who needs better diabetic care. We came up with a plan and I called the VNA to initiate the change.
-I visited a patient in the hospital, wrote a note in her chart, and later received a call from the hospital physician about the discharge plans.
-Later I sat in on a visit one of my patients had with his primary doctor. A great deal of useful information was exchanged and now I can follow up.
-Another patient didn't show for his appointment with his doc. I checked the computer and saw that he'd been in the ER. I printed out the notes and labs and will discuss them with his primary and initiate timely follow-up.
Just for a day, everything made sense and I could just do my work.
My colleague, meanwhile, was struggling with a patient who has a not-quite-broken arm which needs orthopedic attention. Unfortunately, none of the local ortho docs want to see a Medicaid patient if the patient's arm isn't actually fractured, so the patient languishes in pain. Another patient needs emergency oral surgery but no oral surgeons in the area accept Medicaid. We can load her up on narcotics but she needs surgery. What to do? Luckily, this was not my battle to wage today, but there for the grace of God go I......
Coming home, the dogs wag their greeting and we head to town for a book-reading at the local dog-friendly collective bookstore (see link to Food for Thought Books). The reading was cancelled, but we hung out with the friendly bookstore workers, the dogs soaking up the proffered love. We then wandered through the sunlit town, eating cookies and looking at flowers. The dogs only seemed interested in flowers that other dogs had peed on. What's up with that?
I give thanks tonight for a gentle day, a lifted depression, the peepers making their nightly appearance in the nearby swamps, and the knowledge that my love is on her way home.
May your days be gentle, fair Reader.
Monday, April 25, 2005
Mental Health Day
Today is a planned mental health day. With prompting from my ever-loving partner, I requested this day off a week ago, planning to rest and recreate as a novel way to start the work week. It is a welcome balm.
This morning I try not to think about my patients but I will take a few moments to exorcise a few from my mind.
First, there's Q, a white middle-aged man with AIDS and a penchant for heroin, alcohol, and cocaine. Just last week, he left the hospital AMA (against medical advice) after a bout of pancreatitis, not to mention a large stone which is still lodged in his ureter (the tube from the kidney to the bladder). He had left a straw and white powder in the bathroom the day before, leading us to suspect illicit cocaine abuse. I wonder where he is now, and will wait for him to find me when he needs to be rescued.
Next there's my 350+ lbs Latina woman with severe asthma. I did my best to have her transferred from the hospital to a rehab facility, something I hope and pray happened over the weekend.
I also think about my wonderful 70-year-old woman with AIDS, diabetes, COPD, asthma, and schizophrenia. I worry for her health which is somewhat compromised at the moment. You ask me how she could NOT be compromised? I answer that, over all, she is amazingly healthy, believe it or not. However, I think she may be entering a final phase, but how many years she has left is up to the goddess.
Finally, there's my sweet gentle giant of a patient with AIDS and a new-onset dementia that we cnanot understand, not to mention new-onset diabetes which just will not come under control. The visiting nurse who sees him calls me daily with updates and we pray for things to resolve themselves. Time will tell, but I sense his days may be numbered. Then again, mine are numbered too, but I hope to have a bunch more numbers to go.......
Now that I've cleared my nurse's brain of a few worries, I can move on to the rest of my day. Unfortunately, at least 2 hours of that day will involve study and note-taking for tomorrow night's lecture on the urinary and reproductive systems. I just can't seem to escape nursing, even on a day off from it.
The sun is out, the dogs wait (somewhat) patiently for a walk, and my stomach rumbles. Thanks for reading, for tolerating my self-indulgence, and may your day be filled with grace.
This morning I try not to think about my patients but I will take a few moments to exorcise a few from my mind.
First, there's Q, a white middle-aged man with AIDS and a penchant for heroin, alcohol, and cocaine. Just last week, he left the hospital AMA (against medical advice) after a bout of pancreatitis, not to mention a large stone which is still lodged in his ureter (the tube from the kidney to the bladder). He had left a straw and white powder in the bathroom the day before, leading us to suspect illicit cocaine abuse. I wonder where he is now, and will wait for him to find me when he needs to be rescued.
Next there's my 350+ lbs Latina woman with severe asthma. I did my best to have her transferred from the hospital to a rehab facility, something I hope and pray happened over the weekend.
I also think about my wonderful 70-year-old woman with AIDS, diabetes, COPD, asthma, and schizophrenia. I worry for her health which is somewhat compromised at the moment. You ask me how she could NOT be compromised? I answer that, over all, she is amazingly healthy, believe it or not. However, I think she may be entering a final phase, but how many years she has left is up to the goddess.
Finally, there's my sweet gentle giant of a patient with AIDS and a new-onset dementia that we cnanot understand, not to mention new-onset diabetes which just will not come under control. The visiting nurse who sees him calls me daily with updates and we pray for things to resolve themselves. Time will tell, but I sense his days may be numbered. Then again, mine are numbered too, but I hope to have a bunch more numbers to go.......
Now that I've cleared my nurse's brain of a few worries, I can move on to the rest of my day. Unfortunately, at least 2 hours of that day will involve study and note-taking for tomorrow night's lecture on the urinary and reproductive systems. I just can't seem to escape nursing, even on a day off from it.
The sun is out, the dogs wait (somewhat) patiently for a walk, and my stomach rumbles. Thanks for reading, for tolerating my self-indulgence, and may your day be filled with grace.
Wednesday, April 20, 2005
I'm Being Tested
Taking into consideration the post which I wrote last night, it seems that I was being tested today. Examples:
*My 70-year-old patient with AIDS, diabetes and a host of other chronic conditions was recently in the hospital for an asthma exacerbation. While there, it was discovered that she has a mass in her chest which is pressing on her trachea and a pericardial effusion (fluid collected in the sac around her heart). Against difficult odds, I landed her a follow-up visit with a doctor at the clinic this morning. Of course, twenty minutes after the appointment time, her granddaughter calls to say that they can't make it to the appointment, but A. was feeling worse this morning. Maybe next week, she asks? My reply: maybe next week at her funeral (I said this silently, of course). I'll get another appointment for Friday if I'm lucky...
*A patient with untreated Hepatitis C and chronic pain that we treat with huge doses of methadone had been unable to move her bowels for more than a week and I feared an obstruction. We prescribed magnesium citrate and Fleet's enemas. She didn't return my calls for more than a week, and today called me an hour after her scheduled appointment with her doctor to ask if I could reshedule as she wasn't feeling well. It seems she had taken a laxative and was afraid to get on the bus since she felt like she was about to explode. She says she "forgot" that she had an appointment. (This next part is not for the squeamish) I explain that the pain in her belly and the liquid stool that she experiences could just be the watery part of the stool squeezing past the obstruction in her colon. She was not impressed.
*I visit a morbidly obese patient of mine (>350lbs!) in the hospital. She is so deconditioned and depressed (and agoraphobic) that she spends 20-22 hours of each day at home in her urine-soaked bed, surrounded by dust and detritus that only triggers further asthma attacks. I can't get her to clean her room, so I am trying to convince the local pulmonary rehab facilities to take her in for a few months of rehabilitation and specific care. They all say she's "inappropriate for their facility". So, we'll probably send her home to wallow in misery while chronic steroids weaken her bones.
*My colleague's patient needs dental work (as do all our patients). Medicaid no longer covers dental, and the one dental clinic in the area who accepts patients for free has made their free care application so difficult that most patients simply give up out of frustration. This particular patient made it through the hoops but needs transportation to his appointment. Medicaid won't pay for the van-ride to the appointment because dental isn't covered! They think they're saving money by denying poor people dental care, but they're happy to pay for ER visits when our patients have abscessed teeth and need Percocet for the pain. They also pay for the hospitalization once that infected tooth causes sepsis--infection of the blood. There's savings for you!
So many scenarios, too little time to describe them all in painful detail. What am I to do? Today's remedy was a few good bangs of the head against my desk. And a beer after work.
*My 70-year-old patient with AIDS, diabetes and a host of other chronic conditions was recently in the hospital for an asthma exacerbation. While there, it was discovered that she has a mass in her chest which is pressing on her trachea and a pericardial effusion (fluid collected in the sac around her heart). Against difficult odds, I landed her a follow-up visit with a doctor at the clinic this morning. Of course, twenty minutes after the appointment time, her granddaughter calls to say that they can't make it to the appointment, but A. was feeling worse this morning. Maybe next week, she asks? My reply: maybe next week at her funeral (I said this silently, of course). I'll get another appointment for Friday if I'm lucky...
*A patient with untreated Hepatitis C and chronic pain that we treat with huge doses of methadone had been unable to move her bowels for more than a week and I feared an obstruction. We prescribed magnesium citrate and Fleet's enemas. She didn't return my calls for more than a week, and today called me an hour after her scheduled appointment with her doctor to ask if I could reshedule as she wasn't feeling well. It seems she had taken a laxative and was afraid to get on the bus since she felt like she was about to explode. She says she "forgot" that she had an appointment. (This next part is not for the squeamish) I explain that the pain in her belly and the liquid stool that she experiences could just be the watery part of the stool squeezing past the obstruction in her colon. She was not impressed.
*I visit a morbidly obese patient of mine (>350lbs!) in the hospital. She is so deconditioned and depressed (and agoraphobic) that she spends 20-22 hours of each day at home in her urine-soaked bed, surrounded by dust and detritus that only triggers further asthma attacks. I can't get her to clean her room, so I am trying to convince the local pulmonary rehab facilities to take her in for a few months of rehabilitation and specific care. They all say she's "inappropriate for their facility". So, we'll probably send her home to wallow in misery while chronic steroids weaken her bones.
*My colleague's patient needs dental work (as do all our patients). Medicaid no longer covers dental, and the one dental clinic in the area who accepts patients for free has made their free care application so difficult that most patients simply give up out of frustration. This particular patient made it through the hoops but needs transportation to his appointment. Medicaid won't pay for the van-ride to the appointment because dental isn't covered! They think they're saving money by denying poor people dental care, but they're happy to pay for ER visits when our patients have abscessed teeth and need Percocet for the pain. They also pay for the hospitalization once that infected tooth causes sepsis--infection of the blood. There's savings for you!
So many scenarios, too little time to describe them all in painful detail. What am I to do? Today's remedy was a few good bangs of the head against my desk. And a beer after work.
Tuesday, April 19, 2005
Human Stories
A forlorn and needy patient of mine surfaced at the clinic today, after failing to show for bloodwork and an appointment with me last week. Based upon his unannounced arrival and my busy day, I directed him to be triaged as a "walk-in" in the clinic. Later on, the Physician's Assistant who saw and treated him called me into the clinical area for a chat. The patient's primary provider, a Nurse Practitioner with whom I share several other patients, was also present for the conversation.
As I bemoaned my patient's dysunctional patterns and innate ability to fall apart then come crashing into the clinic asking me to save him from himself, the NP looked at me and said, "Keith, every patient here has a story. Unfortunately for you, the ones with the toughest stories are referred to you. Without them, you wouldn't have a job." The PA added, "And that's why you have the hardest job of us all."
I realized that they were right. These stories all add up: AIDS, hepatitis, trauma, incest, abuse, neglect, generational cycles of poverty, diabetes, poor nutrition, class warfare, violence, disenfranshisement, racism, illness upon illness, learned helplessness, substance abuse, homelessness or risk thereof, splintered families, mental illness, lack of education----but how do we calculate their effects? How do we draw the line between individual responsibility and societal/cultural dysfunction? Of course, we wish to hold individuals responsible for their actions. Clearly, people can learn to be responsible, come to appointments, adhere to medical recommendations, choose to step up to the plate. As a white, middle-class American, these are basic expectations and assumptions that I can make of myself and impose on others. I can also judge others by their inability to adhere to my concepts of responsible action. Also, as a human being, I have the right to be annoyed with my patients who fail to plan and take appropriate action, only to look to me as a source of rescue in their time of need.
The secret here is balance. Can I recover from my annoyance, rise above my frustration, and deliver compassionate, high-quality care? Can I see my patients' dysfunction as what it is---symptomatic of so many other visible and invisible factors---and continue to educate, cajole, and empathize? Can I release my guilt over my own judgements and grievances, giving way to that heart-centered place of witnessing the pain of others and working to assuage it as best I can?
My work challenges my ability do just that, and more. Admittedly, some patients are individuals who I avoid at most every turn. I cringe when dialing their number, knowing that I could be opening a Pandora's Box by inviting myself into their painful and dysfunctional world. There are others for whom my tasks are a joy, their communicativeness and ability to be proactive in their own interest inviting me to gladly join them in a symbiotic partnership. For those who actively help themselves and meet me half way, joining them on that road is easy, intuitive, a pleasure to be of service.
This rumination is just that---a rumination. Each day is another opportunity, and my all-too- human failings can often shine through as I attempt to tackle the next challenge. I remind myself that my own judgements are not necessarily negative, as long as I can acknowledge them for what they are, and then move beyond them. Some days are easier than others, and empathy can wax and wane, as can any emotion. I do this work because I love it, because I have something to give, and the self-knowledge which is born of it is worth its weight in gold. Each day I offer what I can, and then move on, hoping that each day's learning will inform my subsequent life experiences. At the end of this challenging day, I close the proverbial book and welcome the forgiving embrace of sleep.
As I bemoaned my patient's dysunctional patterns and innate ability to fall apart then come crashing into the clinic asking me to save him from himself, the NP looked at me and said, "Keith, every patient here has a story. Unfortunately for you, the ones with the toughest stories are referred to you. Without them, you wouldn't have a job." The PA added, "And that's why you have the hardest job of us all."
I realized that they were right. These stories all add up: AIDS, hepatitis, trauma, incest, abuse, neglect, generational cycles of poverty, diabetes, poor nutrition, class warfare, violence, disenfranshisement, racism, illness upon illness, learned helplessness, substance abuse, homelessness or risk thereof, splintered families, mental illness, lack of education----but how do we calculate their effects? How do we draw the line between individual responsibility and societal/cultural dysfunction? Of course, we wish to hold individuals responsible for their actions. Clearly, people can learn to be responsible, come to appointments, adhere to medical recommendations, choose to step up to the plate. As a white, middle-class American, these are basic expectations and assumptions that I can make of myself and impose on others. I can also judge others by their inability to adhere to my concepts of responsible action. Also, as a human being, I have the right to be annoyed with my patients who fail to plan and take appropriate action, only to look to me as a source of rescue in their time of need.
The secret here is balance. Can I recover from my annoyance, rise above my frustration, and deliver compassionate, high-quality care? Can I see my patients' dysfunction as what it is---symptomatic of so many other visible and invisible factors---and continue to educate, cajole, and empathize? Can I release my guilt over my own judgements and grievances, giving way to that heart-centered place of witnessing the pain of others and working to assuage it as best I can?
My work challenges my ability do just that, and more. Admittedly, some patients are individuals who I avoid at most every turn. I cringe when dialing their number, knowing that I could be opening a Pandora's Box by inviting myself into their painful and dysfunctional world. There are others for whom my tasks are a joy, their communicativeness and ability to be proactive in their own interest inviting me to gladly join them in a symbiotic partnership. For those who actively help themselves and meet me half way, joining them on that road is easy, intuitive, a pleasure to be of service.
This rumination is just that---a rumination. Each day is another opportunity, and my all-too- human failings can often shine through as I attempt to tackle the next challenge. I remind myself that my own judgements are not necessarily negative, as long as I can acknowledge them for what they are, and then move beyond them. Some days are easier than others, and empathy can wax and wane, as can any emotion. I do this work because I love it, because I have something to give, and the self-knowledge which is born of it is worth its weight in gold. Each day I offer what I can, and then move on, hoping that each day's learning will inform my subsequent life experiences. At the end of this challenging day, I close the proverbial book and welcome the forgiving embrace of sleep.
Thursday, April 14, 2005
The Teacher as Learner
Internet connectivity problems at home have precluded posting since Monday's entry, not to mention astounding busy-ness on my part. That said, the week flows on towards its natural end tomorrow. Ah, the built-in entropy of the work-week.
After teaching on Tuesday night, I was struck by the fact that there is so much I need to learn in order to teach well. One might assume that, as a nurse with almost ten years of professional experience, I could expound on various topics with little preparation. Au contraire! As a "generalist" nurse with little specialty knowledge, there are some subjects about which I can talk quite knowledgeably, but there are many others which I have scant thought about nor dealt with directly during my tenure as a nurse. Home study, note-taking, and lecture prep are simply de rigeur these days, and I'll be admittedly relieved when the semester is over and I can rest my neurons a bit. Still, teaching is enervating and fun, and in the final analysis, I generally leave school tired but uplifted by my interactions with my students who often challenge my thinking with provocative questions, bringing their own unique visions of the world to class.
As a first-time professor, I'm relying on my students for feedback, and I try to read the energy in the class to determine whether I am hitting the mark or not during the course of a lecture. I also try to elicit verbal and written feedback but few have taken the initiative to offer constructive criticism. Last week, I was humbled when the class announced that I had been unanimously chosen to be the speaker at their graduation ceremony, and they waited on the edge of their seats until I would confirm my acceptance of such an honor, which I quickly did, of course. They may even hire my son as the graduation photographer (he will be a newly-minted professional photographer after his graduation on June 2nd).
Learning abounds, and it is often as teacher/professional/caregiver that we receive our most humbling and instructive lessons. Today I witnessed first-hand the enormous love and mutual respect between a mother and her thirteen-year-old son. They are both my patients, and we were meeting with the amazingly astute and gifted PhD-level psychologist with whom I work. I was first blown away by my colleague's counseling skills (she makes it look so easy!), and I was further enthralled by the sincerity of the mother's verbalized dedication as a parent of a troubled but lovable child. Thirdly, I was incredibly and wondrously struck by the slow but inexorable emotional opening demonstrated during the session by her son who is the only teenager on my caseload at this time. Something shifted during that session, and it was humbling and satisfying to be present for its unfolding.
Today I also learned some lessons from a married couple with AIDS---I think I've mentioned them before---who are both my patients. Her disease is much more well-controlled than his, but he has made some progress, only to regress when he decides independently to stop his meds for a few weeks from time to time. We spoke intently for thirty minutes or so and they were quite sincere in their gratitude and recognition that I am simply trying to assist them in making positive choices for themselves and their two small children. On the verge of tears, I assured them that I was not lecturing them, rather, I was simply communicating to them the gravity of their decisions and the potential repercussions which I could not promise to assuage if they chose to not follow the best medical advice available at this time. Our eye contact was intense, and the feeling of being together in that room---truly together as a team---was palpable.
Thursday evening presents itself as a deep breath, four fifths of the week behind me, the final push tomorrow. The struggle is to be in the present, and to glean from those daily interactions as much learning as can be squeezed from each morsel. I'm more successful some days more than others, but it's truly the only game in town.
After teaching on Tuesday night, I was struck by the fact that there is so much I need to learn in order to teach well. One might assume that, as a nurse with almost ten years of professional experience, I could expound on various topics with little preparation. Au contraire! As a "generalist" nurse with little specialty knowledge, there are some subjects about which I can talk quite knowledgeably, but there are many others which I have scant thought about nor dealt with directly during my tenure as a nurse. Home study, note-taking, and lecture prep are simply de rigeur these days, and I'll be admittedly relieved when the semester is over and I can rest my neurons a bit. Still, teaching is enervating and fun, and in the final analysis, I generally leave school tired but uplifted by my interactions with my students who often challenge my thinking with provocative questions, bringing their own unique visions of the world to class.
As a first-time professor, I'm relying on my students for feedback, and I try to read the energy in the class to determine whether I am hitting the mark or not during the course of a lecture. I also try to elicit verbal and written feedback but few have taken the initiative to offer constructive criticism. Last week, I was humbled when the class announced that I had been unanimously chosen to be the speaker at their graduation ceremony, and they waited on the edge of their seats until I would confirm my acceptance of such an honor, which I quickly did, of course. They may even hire my son as the graduation photographer (he will be a newly-minted professional photographer after his graduation on June 2nd).
Learning abounds, and it is often as teacher/professional/caregiver that we receive our most humbling and instructive lessons. Today I witnessed first-hand the enormous love and mutual respect between a mother and her thirteen-year-old son. They are both my patients, and we were meeting with the amazingly astute and gifted PhD-level psychologist with whom I work. I was first blown away by my colleague's counseling skills (she makes it look so easy!), and I was further enthralled by the sincerity of the mother's verbalized dedication as a parent of a troubled but lovable child. Thirdly, I was incredibly and wondrously struck by the slow but inexorable emotional opening demonstrated during the session by her son who is the only teenager on my caseload at this time. Something shifted during that session, and it was humbling and satisfying to be present for its unfolding.
Today I also learned some lessons from a married couple with AIDS---I think I've mentioned them before---who are both my patients. Her disease is much more well-controlled than his, but he has made some progress, only to regress when he decides independently to stop his meds for a few weeks from time to time. We spoke intently for thirty minutes or so and they were quite sincere in their gratitude and recognition that I am simply trying to assist them in making positive choices for themselves and their two small children. On the verge of tears, I assured them that I was not lecturing them, rather, I was simply communicating to them the gravity of their decisions and the potential repercussions which I could not promise to assuage if they chose to not follow the best medical advice available at this time. Our eye contact was intense, and the feeling of being together in that room---truly together as a team---was palpable.
Thursday evening presents itself as a deep breath, four fifths of the week behind me, the final push tomorrow. The struggle is to be in the present, and to glean from those daily interactions as much learning as can be squeezed from each morsel. I'm more successful some days more than others, but it's truly the only game in town.
Thursday, April 07, 2005
M'aidez!
Thursday at 12:45pm. At my desk at work, taking a breather. No guilt for blogging at work as I haven't taken a lunch break today. Come to think of it, the last time I took an actual lunch break was two weeks ago. (I'm afraid that's actually true.)
My plate seems so full today, the phone and beeper and cell-phone going off constantly since my arrival just after 9am. A patient with acute pancreatitis, long history of AIDS and new-onset dementia---now on his way to the ER for admission, his pancreatic enzymes are sky-high. Another patient with Hepatitis C and chronic pain hasn't moved her bowels in nine days---she's also on her way to the ER. The next call is from a patient with chronic asthma who calls me in distress--she's over 350 pounds and so deconditioned that her asthma just can't improve. I ran over to her house and we gave her a prescription for some prednisone. I have to work on getting her admitted to a rehabilitation facility for a few months of pulmonary rehab.
Then another patient calls---she was feeling suicidal, so her therapist told her to go the ER and tell them that she was an alcoholic and needed detox, why I can't imagine. So they sent her to detox for four days and she should've been in the psych unit. I must have a word with that very irresponsible therapist of hers.
The fun just continues non-stop. Must gallop off to put out the next brush fire. As Bugs Bunny would say, "it's a living, doc."
My plate seems so full today, the phone and beeper and cell-phone going off constantly since my arrival just after 9am. A patient with acute pancreatitis, long history of AIDS and new-onset dementia---now on his way to the ER for admission, his pancreatic enzymes are sky-high. Another patient with Hepatitis C and chronic pain hasn't moved her bowels in nine days---she's also on her way to the ER. The next call is from a patient with chronic asthma who calls me in distress--she's over 350 pounds and so deconditioned that her asthma just can't improve. I ran over to her house and we gave her a prescription for some prednisone. I have to work on getting her admitted to a rehabilitation facility for a few months of pulmonary rehab.
Then another patient calls---she was feeling suicidal, so her therapist told her to go the ER and tell them that she was an alcoholic and needed detox, why I can't imagine. So they sent her to detox for four days and she should've been in the psych unit. I must have a word with that very irresponsible therapist of hers.
The fun just continues non-stop. Must gallop off to put out the next brush fire. As Bugs Bunny would say, "it's a living, doc."
Monday, March 28, 2005
Homeostasis
We are all constantly in search of homeostasis, balance, equilibrium. Physiologically, the body consistently strives to keep things in check, running smoothly with little deviation---acid-base balance, electrolyte balance, fluid balance, blood volume. A normal body pH needs to be found in the very slim margin of 7.35-7.45. Potassium balance must be between 3.5 and 5 or all hell can break loose. Sodium is more generous with a normal range of 135-145 mg/dL.
On the psychoemotional side, how do we measure such notions as balance? Manic versus depressive? Joy versus despair? Just think of the language we use for sketchy and potentially emotional situations:
"I'm walking a fine line";
"You're on thin ice";
"He's playing with half a deck";
"She's teetering on the edge";
"I feel like I'm walking a tight-rope";
"I'm on the edge of my seat";
"They were walking on egg-shells";
"I'm juggling too many balls";
"You have so many pokers in the fire";
"It's neither here nor there".
From the look of things, we have plenty of language to describe our imbalances. Are there enough sayings to counter those assertions with balancing terminology? Please enlighten me, dear Reader, and share how you would verbalize balance. Can we create a nomenclature of homeostasis, or does it already exist and I simply cannot see the forest for the trees?
On the psychoemotional side, how do we measure such notions as balance? Manic versus depressive? Joy versus despair? Just think of the language we use for sketchy and potentially emotional situations:
"I'm walking a fine line";
"You're on thin ice";
"He's playing with half a deck";
"She's teetering on the edge";
"I feel like I'm walking a tight-rope";
"I'm on the edge of my seat";
"They were walking on egg-shells";
"I'm juggling too many balls";
"You have so many pokers in the fire";
"It's neither here nor there".
From the look of things, we have plenty of language to describe our imbalances. Are there enough sayings to counter those assertions with balancing terminology? Please enlighten me, dear Reader, and share how you would verbalize balance. Can we create a nomenclature of homeostasis, or does it already exist and I simply cannot see the forest for the trees?
Saturday, March 26, 2005
Life and Suffering
Thinking about the Buddhist refrain that "life is suffering", I reflect on the suffering which I witness so regularly, and gain perspective on my own:
The caring and compassionate wife with AIDS whose eyes fill with tears as we discuss her sweet and gentle husband who has worsening AIDS dementia which we just cannot explain since his virus has been completely suppressed for more than five years. He lies in bed moaning as we review his medications and discuss diapers, a shower seat, and visiting nurse services.
The very nice fifty-year-old man who recently entered my caseload---Hep C, HIV, alcohol abuse, heroin addiction, a history of multiple incarcerations, homelessness. Very earnest and recently detoxed. Really a pleasure to talk with, his childhood history and family constellation is still an unknown to me. What brought him to this place?
A woman with a history of such psychic and physical trauma that her life is consumed by pain, both real and imagined. Her level of personal insight and psychic resonance is negligible---a true train wreck from a clinical perspective. She, more than any other, invites "compassion fatigue" to develop, from neediness and consistent demonstration of powerlessness.
As I've written before, I know that I could easily be in the same developmental and life situation as these individuals if I had been less blessed in life, less priviledged, less loved. Children do not ask for trauma and poverty. Children do not invite such suffering. Entering as a clean slate upon which parents and the world can choose to inflict horror or beauty, the veneer of innocence and openness can be eroded away as the vicissitudes of life intrude. Who's to say why some are more resilient than others. It is not our place to bestow blame, for none of us are blameless, and none of us are wise enough to ascertain the true failings of another.
How much does my "Body Mass Index" matter in the face of what others experience? How important is it that I suffered ridicule as a less-than-physically-perfect child? No one can really judge how much those experiences affected me. My young mind and heart were vulnerable at the time, and the wounds still resonate today. My suffering was astronomically less than that of millions of other children, and my current state demonstrates that it did not preclude my growing to be a reasonably competent adult. This is my path, my own suffering, and while I should not judge it as unworthy of attention, I also remind myself of the relative ease with which I have moved through life.
Thinking again about my childhood obesity, I remember an aunt of mine, actually the partner of my eldest aunt. My clear childhood memories are very few and far between but I remember this one. We were at their home on Long Island for a family gathering. The adults were congregated in the kitchen or dining room. I came in to get something, and my aunt made a remark that I was an "L.A.". Everyone laughed uproariously and refused to respond to my questions as to the meaning of these initials. The event must have imprinted deeply in my brain, for about five years ago, for some reason, I remembered the event as if it had happened just yesterday, some long-dormant synapse sparking to life for a brief moment and bringing that memory flooding back. I realized that she had meant "Lard Ass" by that comment, I'm sure, and the bewilderment of that long-ago moment became mine again. Trusted adults laughed at my expense and refused to explain the source of their merriment, and thirty years later I clearly remember the moment. Such power of the brain to block out---and then recall---trauma (if I can call it that), regardless of its relative significance.
I use this illustration to elicit in my own mind the notion that, if that remark had been more abusive, more hurtful, if remarks of a derogatory nature had been made towards me daily throughout my childhood, perhaps accompanied by physical abuse, who would I be now? What would I be now? What other choices would I have made in life? This seemingly random assignment of each individual to a family constellation and series of life events bestows upon each person their own unique experience, and reactions to said experience.
These illustrations and memories are food for thought, written more as fodder for my own growth than for any reader who peruses these virtual pages. If this missive touches something for you, I'm glad for that, and invite you to comment, or just to reflect privately on that which is elicited. My suffering is my own, as is my recovery, a lifelong process to which I'm forever dedicated. This writing is powerful medicine, and my prescription of self-reflection will never expire.
The caring and compassionate wife with AIDS whose eyes fill with tears as we discuss her sweet and gentle husband who has worsening AIDS dementia which we just cannot explain since his virus has been completely suppressed for more than five years. He lies in bed moaning as we review his medications and discuss diapers, a shower seat, and visiting nurse services.
The very nice fifty-year-old man who recently entered my caseload---Hep C, HIV, alcohol abuse, heroin addiction, a history of multiple incarcerations, homelessness. Very earnest and recently detoxed. Really a pleasure to talk with, his childhood history and family constellation is still an unknown to me. What brought him to this place?
A woman with a history of such psychic and physical trauma that her life is consumed by pain, both real and imagined. Her level of personal insight and psychic resonance is negligible---a true train wreck from a clinical perspective. She, more than any other, invites "compassion fatigue" to develop, from neediness and consistent demonstration of powerlessness.
As I've written before, I know that I could easily be in the same developmental and life situation as these individuals if I had been less blessed in life, less priviledged, less loved. Children do not ask for trauma and poverty. Children do not invite such suffering. Entering as a clean slate upon which parents and the world can choose to inflict horror or beauty, the veneer of innocence and openness can be eroded away as the vicissitudes of life intrude. Who's to say why some are more resilient than others. It is not our place to bestow blame, for none of us are blameless, and none of us are wise enough to ascertain the true failings of another.
How much does my "Body Mass Index" matter in the face of what others experience? How important is it that I suffered ridicule as a less-than-physically-perfect child? No one can really judge how much those experiences affected me. My young mind and heart were vulnerable at the time, and the wounds still resonate today. My suffering was astronomically less than that of millions of other children, and my current state demonstrates that it did not preclude my growing to be a reasonably competent adult. This is my path, my own suffering, and while I should not judge it as unworthy of attention, I also remind myself of the relative ease with which I have moved through life.
Thinking again about my childhood obesity, I remember an aunt of mine, actually the partner of my eldest aunt. My clear childhood memories are very few and far between but I remember this one. We were at their home on Long Island for a family gathering. The adults were congregated in the kitchen or dining room. I came in to get something, and my aunt made a remark that I was an "L.A.". Everyone laughed uproariously and refused to respond to my questions as to the meaning of these initials. The event must have imprinted deeply in my brain, for about five years ago, for some reason, I remembered the event as if it had happened just yesterday, some long-dormant synapse sparking to life for a brief moment and bringing that memory flooding back. I realized that she had meant "Lard Ass" by that comment, I'm sure, and the bewilderment of that long-ago moment became mine again. Trusted adults laughed at my expense and refused to explain the source of their merriment, and thirty years later I clearly remember the moment. Such power of the brain to block out---and then recall---trauma (if I can call it that), regardless of its relative significance.
I use this illustration to elicit in my own mind the notion that, if that remark had been more abusive, more hurtful, if remarks of a derogatory nature had been made towards me daily throughout my childhood, perhaps accompanied by physical abuse, who would I be now? What would I be now? What other choices would I have made in life? This seemingly random assignment of each individual to a family constellation and series of life events bestows upon each person their own unique experience, and reactions to said experience.
These illustrations and memories are food for thought, written more as fodder for my own growth than for any reader who peruses these virtual pages. If this missive touches something for you, I'm glad for that, and invite you to comment, or just to reflect privately on that which is elicited. My suffering is my own, as is my recovery, a lifelong process to which I'm forever dedicated. This writing is powerful medicine, and my prescription of self-reflection will never expire.
Friday, March 11, 2005
A Week Well Done
The work-week comes to a close as fresh snow falls (once again) on our little abode. We are in our frequent postures---laptops on laps, fire in woodstove, dogs snoring, bellies full. This is redundancy I can live with!
With cancellation of my teaching obligation due to snow this past Tuesday, no other evening obligations all week, topped off by a brief overnight visit by our son and his girlfriend last night, I end the week with an unusual feeling of refreshed energy, no burn-out sensations in sight. Fatigue, yes, but a feeling of having lived well and embraced life all week with an appropriate attitude adjustment in operation.
Many stressful patient scenarios presented themselves this week but somehow I managed to stay above the fray. What is the magic ingredient that manifested this ability, you ask? Damned if I know, but I'd like to bottle it for future use when needed, kind of like a "Break This Glass in Case of Entropy" toolkit. But seriously folks, it was just one of those moments in time when the planets were aligned, my humors were in balance, I was not plagued by excess melancholia, and the stress just wouldn't stick, so to speak. While some people did push my buttons at times and I occasionally ran around like a mad chicken, there's a level at which the week did not exact an emotional and physical toll, and for this I'm exceedingly grateful. The weekend can begin with a willingness to enjoy, produce, relax, and create, all in the embrace of a loving home and a relationship which feeds my soul and spirit. That is priviledge of the highest order.
With cancellation of my teaching obligation due to snow this past Tuesday, no other evening obligations all week, topped off by a brief overnight visit by our son and his girlfriend last night, I end the week with an unusual feeling of refreshed energy, no burn-out sensations in sight. Fatigue, yes, but a feeling of having lived well and embraced life all week with an appropriate attitude adjustment in operation.
Many stressful patient scenarios presented themselves this week but somehow I managed to stay above the fray. What is the magic ingredient that manifested this ability, you ask? Damned if I know, but I'd like to bottle it for future use when needed, kind of like a "Break This Glass in Case of Entropy" toolkit. But seriously folks, it was just one of those moments in time when the planets were aligned, my humors were in balance, I was not plagued by excess melancholia, and the stress just wouldn't stick, so to speak. While some people did push my buttons at times and I occasionally ran around like a mad chicken, there's a level at which the week did not exact an emotional and physical toll, and for this I'm exceedingly grateful. The weekend can begin with a willingness to enjoy, produce, relax, and create, all in the embrace of a loving home and a relationship which feeds my soul and spirit. That is priviledge of the highest order.
Wednesday, March 09, 2005
I Am A Witness
This week I'm putting a fair amount of energy into the care of one particular patient named Q. Q has a 10-year+ history of AIDS, Hepatitis C, depression, severe anxiety, a seizure disorder, and a history of IV drug use. She has wandered into and out of our care for the last 6 or 7 years, never staying long enough for treatment of her AIDS to be considered. Her immune system being very compromised, we have not even been able to convince her to take medication regularly that would protect her from myriad opportunistic infections to which she is quite susceptible. Basically, she's one of those people who we have always thought would become acutely and fatally ill, and then have what we would call a "deathbed conversion"---deciding in the face of most certain death that she's now ready to take meds, too little and too late.
That said, Q has resurfaced along with her daughter, begging for home delivery of her methadone since she is too weak to walk, having seizures daily, and losing weight rapidly. My job has been to "rope them in", assess their actual willingness to do the work that needs to be done. With the family history as it's known to me, I can't put too much stock in their potential for success, but I'm doing my part to coordinate the resources so that the mechanisms of the system are set in motion on her behalf. Pleading with me to come to her house for a visit, I've refused and insisted that they come to the clinic, trying not to make it too easy for her. Yes, she's weak, but not too weak to come to an appointment, and always willing to come if we dangle the possibility of a benzodiazepine prescription as bait. This may sound macabre or manipulative, but given the situation and history, we know that incentives and carrots can work wonders with addictive personalities.
Now that we have her ostensibly hooked into care and wanting more from us, we institute visiting nurse services so that the nurse can come to her home every day and physically watch her take her seizure medications, sedatives, and antibiotics to protect her from infection. The nurse has a lock-box in the home to preclude any shenanigans on Q's part in terms of adherence to meds. Next we arrange with the methadone clinic to have the visiting nurse deliver methadone to her home each morning---something she wouldn't miss for the world---thus ensuring that she'll be home for the nurse in order to avoid withdrawal from missing her dose. If she can hang in there for two weeks of this first round of intervention, we add HIV meds to the mix and we're on our way. It's a long shot, but it's the only game plan I have, or death is certain within 12-18 months, perhaps sooner.
Just three months ago, I attended the funeral of a patient who just could not muster what it took to overcome his addiction and his intellectual deficits enough to seize the opportunity for treatment. Ms. Q may be the next to vacate her physical existence, but I'm willing to give it a go first. Another of my patients of whom I'm exceedingly fond (and who is very much like Q in many ways, although much more intellectually savvy) has succeeded in breaking her addictions, and her HIV is now completely suppressed, her immune system almost strong enough to withstand most infections which might have killed her earlier. I would like to see Ms. Q follow in her footsteps. Only time will tell.
The stories are many and I could go on for hours, giving fifty or sixty very interesting and compelling case histories. The point I want to make, however, is that I'm simply a witness to others' pain and struggle. I can't fix anyone and I can't force treatment on anyone. I offer options and I hold out my hand. There are days when I personalize my work---and those are the days when I suffer emotionally and drag myself home, exhausted and spent. Sometimes I hit my stride for a few days and sail along with my witness self intact, watching the action but refraining from reaction to it. The dance is difficult and I frequently falter but I work with what I have and come home and charge those batteries.
Another day is behind me, and for this I give thanks and embrace the evening in peace.
That said, Q has resurfaced along with her daughter, begging for home delivery of her methadone since she is too weak to walk, having seizures daily, and losing weight rapidly. My job has been to "rope them in", assess their actual willingness to do the work that needs to be done. With the family history as it's known to me, I can't put too much stock in their potential for success, but I'm doing my part to coordinate the resources so that the mechanisms of the system are set in motion on her behalf. Pleading with me to come to her house for a visit, I've refused and insisted that they come to the clinic, trying not to make it too easy for her. Yes, she's weak, but not too weak to come to an appointment, and always willing to come if we dangle the possibility of a benzodiazepine prescription as bait. This may sound macabre or manipulative, but given the situation and history, we know that incentives and carrots can work wonders with addictive personalities.
Now that we have her ostensibly hooked into care and wanting more from us, we institute visiting nurse services so that the nurse can come to her home every day and physically watch her take her seizure medications, sedatives, and antibiotics to protect her from infection. The nurse has a lock-box in the home to preclude any shenanigans on Q's part in terms of adherence to meds. Next we arrange with the methadone clinic to have the visiting nurse deliver methadone to her home each morning---something she wouldn't miss for the world---thus ensuring that she'll be home for the nurse in order to avoid withdrawal from missing her dose. If she can hang in there for two weeks of this first round of intervention, we add HIV meds to the mix and we're on our way. It's a long shot, but it's the only game plan I have, or death is certain within 12-18 months, perhaps sooner.
Just three months ago, I attended the funeral of a patient who just could not muster what it took to overcome his addiction and his intellectual deficits enough to seize the opportunity for treatment. Ms. Q may be the next to vacate her physical existence, but I'm willing to give it a go first. Another of my patients of whom I'm exceedingly fond (and who is very much like Q in many ways, although much more intellectually savvy) has succeeded in breaking her addictions, and her HIV is now completely suppressed, her immune system almost strong enough to withstand most infections which might have killed her earlier. I would like to see Ms. Q follow in her footsteps. Only time will tell.
The stories are many and I could go on for hours, giving fifty or sixty very interesting and compelling case histories. The point I want to make, however, is that I'm simply a witness to others' pain and struggle. I can't fix anyone and I can't force treatment on anyone. I offer options and I hold out my hand. There are days when I personalize my work---and those are the days when I suffer emotionally and drag myself home, exhausted and spent. Sometimes I hit my stride for a few days and sail along with my witness self intact, watching the action but refraining from reaction to it. The dance is difficult and I frequently falter but I work with what I have and come home and charge those batteries.
Another day is behind me, and for this I give thanks and embrace the evening in peace.
Wednesday, February 23, 2005
Scars
So often, my work is like looking at, dealing with, and addressing scars, both emotional and psychic. The physical scars are there too, of course, but it is the scars of trauma and life gone awry that make my work so challenging.
Today, once again, I had to actually tell someone that if they didn't start taking their health seriously and work with me closely, they would be dead within a few years. This scare tactic has worked before, and I see continued success in two people whom I have so directly challenged to "get on the bus" with me and do the serious work of recovery and healing.
In the course of this chilly but sunny day, I had to confront a certain individual who has never taken antiretrovirals---AIDS medications---and I had to tell her in no uncertain terms that the brain infection for which she was so recently hospitalized was a direct outcome of her ongoing refusal to concentrate and consider treating her underlying disease. She acknowledged that her inability to take her seizure medicines has landed her in the hospital several times with massive seizures, and I reminded her that if a major brain or lung infection takes hold at this point, she is most certainly going to die. She has so few T-cells (some of the cells that populate her immune system and give us a good indication of her immune health) that we sometimes joke in the privacy of our office that we could name each one since they're so few and far between. Poor gallows humor, I know, but so helpful when we're faced with such tragic realities.
Truly, it was not a "full-throttle" day, as it were, but I was more challenged than yesterday, and had many more plates in the air as I juggled my way through. Several times, I was struck with the awesome responsibility of assisting people through the healthcare system, of the underlying dysfunction of that system, and of many of my patients' natural or learned weakness in terms of self-care and self-direction. Many choices which seem like "no-brainers" (to borrow a very modern phrase) to me, are huge leaps for some of my patients to take.
For someone as priviledged as I, the obvious need to take medication to control a disease with which I am saddled is clearly obvious. Without a history of abuse, trauma, addiction, abandonment, deprivation, and disenfranchisement--not to mention second-class status in a world of white people who can't even see their own priviledge)---I can easily say "yes" to self-care, treatment, others' wish to assist me, the natural succor of love and compassion. But for so many people, the ability to say "yes", to rise above negative self concepts and self-loathing, is not so natural a skill. It is these individuals whom we try to reach as we send out the life-raft, offer a hand, extend ourselves a little more, offer a smile and a kind word on a consistent basis. Some take the bait, others try for a little while and eventually fall by the wayside. We will stop the bus and support them in their gradual or rapid demise, soothe their suffering and ease their pain, but there comes a point where there is no turning back and their death is only a matter of time.
I have watched these processes both as an objective witness and a committed player, attended the wakes and funerals, consoled the bereaved. It's not easy, I'll readily admit, and sometimes my frustration level is through the proverbial roof. That said, the show must go on, and whoever buys their ticket gets to play. For some, we force the ticket into their shirt pocket and drag them through the door. Others leave their ticket in the waiting room and return to the shooting gallery for their fix. There are always more tickets available but there are those who will never take the ride. My patient today is probably one of those who I will watch over as she fades into oblivion. I honor her scars, but can sometimes grieve her inability to take the proffered hand.
What do I do now? I offer consistent and caring advice for her to take. I meet her where she is and try to drag her further along if I can, either by logic or by coercion. If she doesn't take the bait, I do what I can and wait for her to crash and then pick up the pieces. If she dies, I tell myself I did my best and move on to the next person in need. It doesn't always feel like the best world in which to dwell, but I have my cozy abode, a woodstove, and a wife and dogs to curl up with when I get home. Priviledge has its benefits and its costs. I honor both, and begin anew each day.
Today, once again, I had to actually tell someone that if they didn't start taking their health seriously and work with me closely, they would be dead within a few years. This scare tactic has worked before, and I see continued success in two people whom I have so directly challenged to "get on the bus" with me and do the serious work of recovery and healing.
In the course of this chilly but sunny day, I had to confront a certain individual who has never taken antiretrovirals---AIDS medications---and I had to tell her in no uncertain terms that the brain infection for which she was so recently hospitalized was a direct outcome of her ongoing refusal to concentrate and consider treating her underlying disease. She acknowledged that her inability to take her seizure medicines has landed her in the hospital several times with massive seizures, and I reminded her that if a major brain or lung infection takes hold at this point, she is most certainly going to die. She has so few T-cells (some of the cells that populate her immune system and give us a good indication of her immune health) that we sometimes joke in the privacy of our office that we could name each one since they're so few and far between. Poor gallows humor, I know, but so helpful when we're faced with such tragic realities.
Truly, it was not a "full-throttle" day, as it were, but I was more challenged than yesterday, and had many more plates in the air as I juggled my way through. Several times, I was struck with the awesome responsibility of assisting people through the healthcare system, of the underlying dysfunction of that system, and of many of my patients' natural or learned weakness in terms of self-care and self-direction. Many choices which seem like "no-brainers" (to borrow a very modern phrase) to me, are huge leaps for some of my patients to take.
For someone as priviledged as I, the obvious need to take medication to control a disease with which I am saddled is clearly obvious. Without a history of abuse, trauma, addiction, abandonment, deprivation, and disenfranchisement--not to mention second-class status in a world of white people who can't even see their own priviledge)---I can easily say "yes" to self-care, treatment, others' wish to assist me, the natural succor of love and compassion. But for so many people, the ability to say "yes", to rise above negative self concepts and self-loathing, is not so natural a skill. It is these individuals whom we try to reach as we send out the life-raft, offer a hand, extend ourselves a little more, offer a smile and a kind word on a consistent basis. Some take the bait, others try for a little while and eventually fall by the wayside. We will stop the bus and support them in their gradual or rapid demise, soothe their suffering and ease their pain, but there comes a point where there is no turning back and their death is only a matter of time.
I have watched these processes both as an objective witness and a committed player, attended the wakes and funerals, consoled the bereaved. It's not easy, I'll readily admit, and sometimes my frustration level is through the proverbial roof. That said, the show must go on, and whoever buys their ticket gets to play. For some, we force the ticket into their shirt pocket and drag them through the door. Others leave their ticket in the waiting room and return to the shooting gallery for their fix. There are always more tickets available but there are those who will never take the ride. My patient today is probably one of those who I will watch over as she fades into oblivion. I honor her scars, but can sometimes grieve her inability to take the proffered hand.
What do I do now? I offer consistent and caring advice for her to take. I meet her where she is and try to drag her further along if I can, either by logic or by coercion. If she doesn't take the bait, I do what I can and wait for her to crash and then pick up the pieces. If she dies, I tell myself I did my best and move on to the next person in need. It doesn't always feel like the best world in which to dwell, but I have my cozy abode, a woodstove, and a wife and dogs to curl up with when I get home. Priviledge has its benefits and its costs. I honor both, and begin anew each day.
Thursday, February 17, 2005
There But For The Grace of God.....
As I went about my day today, visiting patients in the hospital, talking on the phone with a crying client, sitting in a patient's home as we discussed her recent hospitalization and current treatment for complications related to advanced AIDS, I was struck by the relative blessing of my own physical health. With comparatively minor problems of low back pain, depression, high cholesterol, a hiatal hernia and acid reflux disease, I am healthy and in no way compromised in my ability to live life and pursue my dreams. Having spent no more than seven days of my life in a hospital over the last forty years, I'm blessed with relative health, intelligence, priviledge, and assets of many kinds. I may feel sorry for myself from time to time, cry into my beer and pray for a change of lifestyle and scenery, but I can count myself among the many who are not enslaved to the care of a chronically diseased and debilitated body which seems to betray one at every turn.
There are many times in my day when I can say, "There but for the grace of God go I", and today was yet another of those times when that phrase can save me from further morose and self-indulgent rumination. Once again, I am reminded of the blessings I hold in the palm of my hand, the ways in which I self-indulgently revel in my sorrows, and how I can choose to see my half-full glass as actually overflowing with abundance. It is a daily choice---in fact, it is a moment by moment choice---to embrace what one is given and see it as truly enough. "There but for the grace of God go I" is a reminder that life can turn on a dime, and one must seize what one has in the present, since the most fleeting of blessings can be lost in a flash, without warning. Self-indulgence is a choice, and one is well-served to allow its visits to be short and few and far between.
There are many times in my day when I can say, "There but for the grace of God go I", and today was yet another of those times when that phrase can save me from further morose and self-indulgent rumination. Once again, I am reminded of the blessings I hold in the palm of my hand, the ways in which I self-indulgently revel in my sorrows, and how I can choose to see my half-full glass as actually overflowing with abundance. It is a daily choice---in fact, it is a moment by moment choice---to embrace what one is given and see it as truly enough. "There but for the grace of God go I" is a reminder that life can turn on a dime, and one must seize what one has in the present, since the most fleeting of blessings can be lost in a flash, without warning. Self-indulgence is a choice, and one is well-served to allow its visits to be short and few and far between.
Monday, February 07, 2005
Sketches of a Monday
I hit the ground sprinting this morning. Everyone seemed to be racing today. Skid-marks on the carpet. Chaos is a frequent visitor to our over-crowded office and today was no exception. Let me illustrate:
Patient #1: Advanced AIDS, now on meds and doing OK. Almost died from liver failure last time she tried antiretrovirals (AIDS meds) due to her poor liver status from Hepatitis C infection. She has new-onset mental status changes and may be failing the prophylactic regimen we have been treating her with to prevent toxoplasmosis (a brain infection), a full bout of which she had last year before she started her new AIDS regimen. The visiting nurse calls to tell me that she seems worse today and I plan to pay her a home visit in the afternoon. I worried about her all weekend.
Patient #2: severe depression with psychotic features, anxiety disorder, hypothyroidism, osteoporosis, asthma. Originally from South America. I've worked intensely with her over the last 12 months to help her apply for citizenship. I successfully found someone to take her to Boston two weeks ago for her interview with the Feds and we had the citizenship exam waived due to her psychiatric disability---not a small feat. She passed her interview with flying colors and will be ceremoniously made a US citizen at the Hynes Convention Center in Boston on Wednesday. I take time today to search the web for bus schedules and call a few taxi companies in Boston to get an idea what it will cost her to take a taxi to the convention center from South Station. She calls me: she isn't sleeping at all and wants sleeping pills. I have to speak with her primary doc who called out sick today. Hasta manana, OK?
Patient #3: Brittle diabetic with poor control of his disease, Hepatitis C. Lives in a motel with his 22-year-old son. They are both IV drug users but my patient has been clean for a few weeks and is trying to get it together. His son shoots up in front of him which is a big "trigger" for him. Patient never showed for our follow-up office visit last week, and while I'm at another patient's house, I receive a page that he's at the office waiting for me. I call the office and tell them to send him packing. He needs to make an appointment. No kid gloves for him.
Patient #4: forty-year-old male with AIDS (fully controlled with meds for four years), Hepatitis C (treatment for which he failed), narcolepsy, uncontrolled hypertension, depression, and a history of IV drug use (for which he's on methadone maintenance). He's been showing signs of mental deterioration over the last year. Neuropsychiatric testing shows major deficits. We treated him inpatient in 2004 for presumed neurosyphilis but now the symptoms are back. I visit him at home--he breaks down crying as we sit on his bed, his wife standing to my right, Planet of the Apes on the TV. He's having suicidal thoughts and thoughts of harming others. He doesn't feel at risk of doing anything but I give them the number for Psych Crisis, just in case. I make a note to discuss his case during our HIV Provider Meeting this afternoon at 4, if I can make it back in time to the clinic.
Patient #5: I spend 90 minutes in the depressing home of a new patient, meeting for the first time. Arthritis, severe osteoporosis with multiple fractures of various bones, bilateral cataracts, emphysema (and still smoking 1 pack per day!), coronary artery disease, angina,pernicious anemia, a metal plate screwed into his broken hip last fall. Not a happy camper. Where do I begin?
Patient #6: African-American female who has come and gone from our program several times. History of IV drug abuse, violence, incarceration for assault and battery, young son with sickle cell disease, lost one of two twins while pregnant last year, the surviving baby doing OK and sickle-cell free. Patient has severe COPD (emphysema), still smokes, suffers from crushing migraines, and has severe depression and a relatively chaotic life complicated by parole. Her head feels like it's going to explode. I manage to find her an appointment for tomorrow. Just hold on and go to the ER if you can't make it through the night......
Patient #7: dry alcoholic with anxiety disorder and recent deep vein thrombosis (DVT--a huge clot in his leg from his ankle to his thigh). Couldn't walk for three weeks and never called me. If a piece of the clot had broken off (common occurrence), it would've traveled to his lungs and killed him instantly. He's now on blood thinners but can't keep up with the instructions, blood draws, and dose changes. Hasn't taken any Coumadin for five days. Can I scream now?
There's so much more, but you get the picture. The constant headaches, no-shows to appointments (a HUGE problem!), complicated lives, dysfunctional families (they've taken the "fun" out of dysfunctional), drug abuse, poverty, Medicaid fraud, inability to understand and process instructions correctly, you name it.
Do I love my work? Yes. Do I feel that I change people's lives for the better? Yes, often. Do I sometimes feel like I can't take it anymore? Absolutely. This is a Monday where I question my resolve to continue but know that I will. My spirit still keeps me in the moment and I shoulder the responsibility and continue on. I sometimes pine to be a nurse in a small town doctor's office, swabbing throats and taking the blood pressure of arthritic Jewish matrons. Is that in my future? I doubt it. Thriving on Chaos is not just the name of a book.
Patient #1: Advanced AIDS, now on meds and doing OK. Almost died from liver failure last time she tried antiretrovirals (AIDS meds) due to her poor liver status from Hepatitis C infection. She has new-onset mental status changes and may be failing the prophylactic regimen we have been treating her with to prevent toxoplasmosis (a brain infection), a full bout of which she had last year before she started her new AIDS regimen. The visiting nurse calls to tell me that she seems worse today and I plan to pay her a home visit in the afternoon. I worried about her all weekend.
Patient #2: severe depression with psychotic features, anxiety disorder, hypothyroidism, osteoporosis, asthma. Originally from South America. I've worked intensely with her over the last 12 months to help her apply for citizenship. I successfully found someone to take her to Boston two weeks ago for her interview with the Feds and we had the citizenship exam waived due to her psychiatric disability---not a small feat. She passed her interview with flying colors and will be ceremoniously made a US citizen at the Hynes Convention Center in Boston on Wednesday. I take time today to search the web for bus schedules and call a few taxi companies in Boston to get an idea what it will cost her to take a taxi to the convention center from South Station. She calls me: she isn't sleeping at all and wants sleeping pills. I have to speak with her primary doc who called out sick today. Hasta manana, OK?
Patient #3: Brittle diabetic with poor control of his disease, Hepatitis C. Lives in a motel with his 22-year-old son. They are both IV drug users but my patient has been clean for a few weeks and is trying to get it together. His son shoots up in front of him which is a big "trigger" for him. Patient never showed for our follow-up office visit last week, and while I'm at another patient's house, I receive a page that he's at the office waiting for me. I call the office and tell them to send him packing. He needs to make an appointment. No kid gloves for him.
Patient #4: forty-year-old male with AIDS (fully controlled with meds for four years), Hepatitis C (treatment for which he failed), narcolepsy, uncontrolled hypertension, depression, and a history of IV drug use (for which he's on methadone maintenance). He's been showing signs of mental deterioration over the last year. Neuropsychiatric testing shows major deficits. We treated him inpatient in 2004 for presumed neurosyphilis but now the symptoms are back. I visit him at home--he breaks down crying as we sit on his bed, his wife standing to my right, Planet of the Apes on the TV. He's having suicidal thoughts and thoughts of harming others. He doesn't feel at risk of doing anything but I give them the number for Psych Crisis, just in case. I make a note to discuss his case during our HIV Provider Meeting this afternoon at 4, if I can make it back in time to the clinic.
Patient #5: I spend 90 minutes in the depressing home of a new patient, meeting for the first time. Arthritis, severe osteoporosis with multiple fractures of various bones, bilateral cataracts, emphysema (and still smoking 1 pack per day!), coronary artery disease, angina,pernicious anemia, a metal plate screwed into his broken hip last fall. Not a happy camper. Where do I begin?
Patient #6: African-American female who has come and gone from our program several times. History of IV drug abuse, violence, incarceration for assault and battery, young son with sickle cell disease, lost one of two twins while pregnant last year, the surviving baby doing OK and sickle-cell free. Patient has severe COPD (emphysema), still smokes, suffers from crushing migraines, and has severe depression and a relatively chaotic life complicated by parole. Her head feels like it's going to explode. I manage to find her an appointment for tomorrow. Just hold on and go to the ER if you can't make it through the night......
Patient #7: dry alcoholic with anxiety disorder and recent deep vein thrombosis (DVT--a huge clot in his leg from his ankle to his thigh). Couldn't walk for three weeks and never called me. If a piece of the clot had broken off (common occurrence), it would've traveled to his lungs and killed him instantly. He's now on blood thinners but can't keep up with the instructions, blood draws, and dose changes. Hasn't taken any Coumadin for five days. Can I scream now?
There's so much more, but you get the picture. The constant headaches, no-shows to appointments (a HUGE problem!), complicated lives, dysfunctional families (they've taken the "fun" out of dysfunctional), drug abuse, poverty, Medicaid fraud, inability to understand and process instructions correctly, you name it.
Do I love my work? Yes. Do I feel that I change people's lives for the better? Yes, often. Do I sometimes feel like I can't take it anymore? Absolutely. This is a Monday where I question my resolve to continue but know that I will. My spirit still keeps me in the moment and I shoulder the responsibility and continue on. I sometimes pine to be a nurse in a small town doctor's office, swabbing throats and taking the blood pressure of arthritic Jewish matrons. Is that in my future? I doubt it. Thriving on Chaos is not just the name of a book.
Saturday, February 05, 2005
The Saga of Patient X (cont'd)
For those of you who've been following the story of "X", my patient with alcoholic hepatitis, this is an update, of sorts. For those new to this site, you may wish to refer to several earlier posts, namely "Exhaustion" and "Recovery".
Last Monday morning, I paid a visit to X, who was, as I surmised he would be, hanging out at the bar which is his ersatz home, as it were, apart from his apartment which I've yet had the opportunity to visit. That said, I must say that he actually works at said bar and hall---cleaning, organizing, washing dishes, and otherwise pitching in for a small wage. It keeps him busy, off the streets, and allows him to earn a little cash which Social Security (SSDI) doesn't need to know about.
X greeted me warmly and eagerly, almost like a sheepish dog. He actually looked relatively well, his psoriasis less angry, his eyes less jaundiced. X swore that he's drinking only non-alcoholic beer (a step in the right direction, at least), eating well (apparently a chef's salad the day before), and drinking plenty of water. A cursory physical exam did indeed bear out the fact that the swelling of his legs is decreased and his blood pressure improved. The most worrisome factor now is a growing paranoia and anxiety which, thankfully, he's able to reconize and verbalize, adding that he's now eager to re-enter psychotherapy. I recommended decreasing his coffee intake from 8 or 10 cups a day to a mere two or three in the morning, in an attempt to decrease his anxiety and improve the quality of his sleep. While actions speak louder than words and many an eager patient will "yes" the well-meaning clinician to death, perhaps a renewed therapeutic relationship might solidify his tenuous and newly-found recovery, and break the pattern of poor habits which only serve to exacerbate his poor health, both physically and mentally. I take these signs at face value, and remind myself that even seven days free of alcohol is a gift that X is giving to himself. Stay tuned.
Another patient of mine who we will call "Y" had been in complete recovery, with fully suppressed HIV disease, excellent adherence to his meds, and a graduation last summer from an 18-month residential stay in a facility for Latino men with substance abuse issues. Having failed Hepatitis C treatment due to falling blood counts, Y still had shown great promise and was a model patient, quitting smoking and really cleaning up his act. After living in a lovely sober house for HIV+ men in recovery, Y disappeared last fall, ostensibly returning to Puerto Rico to see his family. He resurfaced two weeks ago, calling me on our office's 888 number from Puerto Rico, alerting me that he'd be back in town within two days. During a brief visit in the office several days later, I ascertained that he had stopped all of his meds and didn't currently have a place to live. I actually drove him to the bus station after our visit (a general no-no in my office these days), and he was planning to catch the next bus to a town 40 minutes to the east to stay with a cousin. Promising to return in two days for a clinic visit with a doctor, we parted with a hearty handshake.
Several weeks passed after he missed that appointment, and just this past Friday I received a call from a residential substance abuse treatment center in a city two hours from here, informing me that he's now residing at their facility. I requested a signed consent be faxed to me so that our two agencies could openly discuss his case, and having received that paperwork, am expecting a return telephone call soon to advance the discussion and learn the details of Y's current state.
These bumps in the road are just that---bumps---with the added caveat that for a person living with untreated AIDS and chronic Hepatitis C, recidivism back to drug use and avoidance of medical care can be exponentially harmful and worrisome. Nonetheless, when and if Y returns to my care, I'll plan to meet him where he's at, begin afresh, and walk the road with him, if he's willing to do so. Meanwhile, dozens of other greasy wheels beg for attention, and there's no shortage of needy patients for this nurse. Monday will open that office door once again, and I will surely hit the ground running, my plate fuller than it should be even before I sit back down at that cluttered desk, already littered with the flotsam and jetsam of last week's unfinished tasks. Oh my.
Last Monday morning, I paid a visit to X, who was, as I surmised he would be, hanging out at the bar which is his ersatz home, as it were, apart from his apartment which I've yet had the opportunity to visit. That said, I must say that he actually works at said bar and hall---cleaning, organizing, washing dishes, and otherwise pitching in for a small wage. It keeps him busy, off the streets, and allows him to earn a little cash which Social Security (SSDI) doesn't need to know about.
X greeted me warmly and eagerly, almost like a sheepish dog. He actually looked relatively well, his psoriasis less angry, his eyes less jaundiced. X swore that he's drinking only non-alcoholic beer (a step in the right direction, at least), eating well (apparently a chef's salad the day before), and drinking plenty of water. A cursory physical exam did indeed bear out the fact that the swelling of his legs is decreased and his blood pressure improved. The most worrisome factor now is a growing paranoia and anxiety which, thankfully, he's able to reconize and verbalize, adding that he's now eager to re-enter psychotherapy. I recommended decreasing his coffee intake from 8 or 10 cups a day to a mere two or three in the morning, in an attempt to decrease his anxiety and improve the quality of his sleep. While actions speak louder than words and many an eager patient will "yes" the well-meaning clinician to death, perhaps a renewed therapeutic relationship might solidify his tenuous and newly-found recovery, and break the pattern of poor habits which only serve to exacerbate his poor health, both physically and mentally. I take these signs at face value, and remind myself that even seven days free of alcohol is a gift that X is giving to himself. Stay tuned.
Another patient of mine who we will call "Y" had been in complete recovery, with fully suppressed HIV disease, excellent adherence to his meds, and a graduation last summer from an 18-month residential stay in a facility for Latino men with substance abuse issues. Having failed Hepatitis C treatment due to falling blood counts, Y still had shown great promise and was a model patient, quitting smoking and really cleaning up his act. After living in a lovely sober house for HIV+ men in recovery, Y disappeared last fall, ostensibly returning to Puerto Rico to see his family. He resurfaced two weeks ago, calling me on our office's 888 number from Puerto Rico, alerting me that he'd be back in town within two days. During a brief visit in the office several days later, I ascertained that he had stopped all of his meds and didn't currently have a place to live. I actually drove him to the bus station after our visit (a general no-no in my office these days), and he was planning to catch the next bus to a town 40 minutes to the east to stay with a cousin. Promising to return in two days for a clinic visit with a doctor, we parted with a hearty handshake.
Several weeks passed after he missed that appointment, and just this past Friday I received a call from a residential substance abuse treatment center in a city two hours from here, informing me that he's now residing at their facility. I requested a signed consent be faxed to me so that our two agencies could openly discuss his case, and having received that paperwork, am expecting a return telephone call soon to advance the discussion and learn the details of Y's current state.
These bumps in the road are just that---bumps---with the added caveat that for a person living with untreated AIDS and chronic Hepatitis C, recidivism back to drug use and avoidance of medical care can be exponentially harmful and worrisome. Nonetheless, when and if Y returns to my care, I'll plan to meet him where he's at, begin afresh, and walk the road with him, if he's willing to do so. Meanwhile, dozens of other greasy wheels beg for attention, and there's no shortage of needy patients for this nurse. Monday will open that office door once again, and I will surely hit the ground running, my plate fuller than it should be even before I sit back down at that cluttered desk, already littered with the flotsam and jetsam of last week's unfinished tasks. Oh my.
Tuesday, February 01, 2005
Midnight missive
It's going on midnight at the end of a long day. Every Tuesday finds me working my day-job, then commuting over to the community college to teach a class to LPN (Licensed Practical Nurse) students, away from home over 12 hours. Being only my second semester as a teacher, I'm still trying to find that correct balance between mind-numbing didactic lecture and somewhat-less-mind-numbing non-lecture activity. With reams of detailed information to cover, and a class of 25 tired adult students who also work and have personal lives and children to care for (several of my students work 11pm to 7pm after attending my 4pm to 10pm class!), I am hard pressed to keep it interesting and varied enough to hold their attention and make learning at least somewhat enjoyable, or at least not painful.
Tonight, I chose to spend 40 minutes reading aloud to the class from Sherwin Nuland's The Wisdom of the Body, the chosen chapter being a compelling story of a woman's brush with death from internal bleeding and a surgeon's heroic attempt to (successfully) save her life. The author writes so well--my students were on the edges of their collective seats and were the quietest and most attentive that they've ever been!
Overall, the class went well, and I end a long day in front of the fire with Mary and the dogs; Tina, the small grey canine snores at my feet, as she so often does. As the fire in the woodstove burns itself out, I prepare to retire to the warm bed and bid another day well-lived.
No regrets today. My work is done, it was done well, and I can sleep a tired but satisfied slumber. It's cold, the day was long, my brain is fried, but this is the current path of choice, and I embrace it today in its entirety. Life is for living, after all.
Tonight, I chose to spend 40 minutes reading aloud to the class from Sherwin Nuland's The Wisdom of the Body, the chosen chapter being a compelling story of a woman's brush with death from internal bleeding and a surgeon's heroic attempt to (successfully) save her life. The author writes so well--my students were on the edges of their collective seats and were the quietest and most attentive that they've ever been!
Overall, the class went well, and I end a long day in front of the fire with Mary and the dogs; Tina, the small grey canine snores at my feet, as she so often does. As the fire in the woodstove burns itself out, I prepare to retire to the warm bed and bid another day well-lived.
No regrets today. My work is done, it was done well, and I can sleep a tired but satisfied slumber. It's cold, the day was long, my brain is fried, but this is the current path of choice, and I embrace it today in its entirety. Life is for living, after all.
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