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.
Monday, April 25, 2005
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.
Friday, January 28, 2005
Viernes Se Llega! (Friday Arrives!)
In the course of my work, I sometimes feel like one of those circus clowns, running at full speed, dodging the other performers, and juggling numerous fragile plates in the air over my head as I continue to smile. It's a true juggling act of keeping multiple threads woven in my cerebral cortex, trying my best to remember the myriad details that need my attention: this one needs bloodwork; this one has an abnormal CAT scan that needs follow-up; the other needs a referral for the surgeon; and now my beeper is going off and cell phone ringing simultaneously as I'm paged overhead to meet a patient in the waiting room.
The patient in the waiting room has advanced AIDS that's perfectly under control, but his blood pressure is 170/112 today, and he fell yesterday during a dizzy spell and lacerated his shin. I check the wound which looks clean and is covered with steri-strips placed by an ER doc. His narcolepsy seems poorly controlled today as he nods off while on the exam table, and his wife says that they just can't remember to call me for refills of his Ritalin which helps keep him alert. I make a mental note to pay them a home visit soon to look over his meds and see where they've become confused. He failed his Hepatatis C treatment so that's one less thing to worry about in terms of meds, but I remind him that if he doesn't take care of his blood pressure, it will most likely kill him way before the AIDS ever does. (They're not joking about the "silent killer of hypertension".) I remind him of his appointment with the vascular surgeon for his horrible varicose veins, and also for the orthopedic surgeon for his herniated disk. Does he have the MRI films? Yes. Does he know where to go on Tuesday? He thinks so. Will he come in on Monday for a blood pressure check? OK. Keep those steri-strips dry and change the bandage every day, why don'tcha.
Meanwhile, another of my patients has come in to see his primary doctor, unbeknownst to me. The doctor finds me while I walk down the hall, letting me know that our mutual patient couldn't walk on his right leg for three weeks and never bothered to call us or go to the ER. He's feeling somewhat better, but we send him for a stat ultrasound of his leg and it's immediately confirmed that he has a deep vein thrombosis (DVT) from his ankle to his knee (a long clot traveling up a major leg vein). He's very lucky that a piece of the clot didn't break off and travel to his lungs. He would have died within minutes. We send him home with a prescription for Coumadin (blood thinner) and remind him to come in for bloodwork on Tuesday, without fail. By the way, we tell him, call us right away if you start having uncontrollable nosebleeds or your gums bleed while brushing your teeth. And please be careful shaving, OK?
The man with the DVT is followed by two of my favorite patients. A married couple, both infected with AIDS. She "bought in" early on and has fully suppressed virus and no side effects. He played around with his meds and failed a few regimens of AIDS drugs, and then came to me a year ago, desperate to try again, losing weight and wasting away. I had to scare him and tell him he had less than a year to live unless he worked with me closely, with great concentration and attention to detail. He decided to do it, and here we are. With frequent follow-up and a good rapport, they're a success story, with the virus under control for them both, their kids in school, newly approved Section 8 housing, and a sweet relationship. Our visits are peppered with laughter, jokes, and an ease which makes our time together flow smoothly and easily. I prefill his meds in two one-week boxes, give her an injection of Depo Provera, check their weights, and send them on their way. Hasta la proxima!
Papers and charts are piled on the desk. I make a few notes in my Palm Pilot, scribble some Post-It notes to leave on my desk for Monday morning, file my encounter sheets for the day, and turn off the computer for the first time since 9am on Monday.
The chaos and busy movement of the day are winding down, the phones are routed to the answering service, the beepers cease their sound, laughter fills the room, and we bid one another adieu, leaving the clinic to return to our families for the weekend, only one of us burdened with taking urgent calls until Monday morning rolls around again. It's been a job well done. I feel fairly crispy myself, perhaps medium well at this juncture.....
I arrive to the home fires burning in the woodstove, my lovely wife cooking yet another wonderful meal, the dogs wagging their tails, and the feeling of gratitude for a welcoming domestic scene which draws me in with its wholesome and restful embrace. We catch the end of "The Buena Vista Social Club" on the Independent Film Channel, and I cry as the group takes its well-deserved bows, having accomplished so much and brought joy and music to so many. My cup runneth over.
The patient in the waiting room has advanced AIDS that's perfectly under control, but his blood pressure is 170/112 today, and he fell yesterday during a dizzy spell and lacerated his shin. I check the wound which looks clean and is covered with steri-strips placed by an ER doc. His narcolepsy seems poorly controlled today as he nods off while on the exam table, and his wife says that they just can't remember to call me for refills of his Ritalin which helps keep him alert. I make a mental note to pay them a home visit soon to look over his meds and see where they've become confused. He failed his Hepatatis C treatment so that's one less thing to worry about in terms of meds, but I remind him that if he doesn't take care of his blood pressure, it will most likely kill him way before the AIDS ever does. (They're not joking about the "silent killer of hypertension".) I remind him of his appointment with the vascular surgeon for his horrible varicose veins, and also for the orthopedic surgeon for his herniated disk. Does he have the MRI films? Yes. Does he know where to go on Tuesday? He thinks so. Will he come in on Monday for a blood pressure check? OK. Keep those steri-strips dry and change the bandage every day, why don'tcha.
Meanwhile, another of my patients has come in to see his primary doctor, unbeknownst to me. The doctor finds me while I walk down the hall, letting me know that our mutual patient couldn't walk on his right leg for three weeks and never bothered to call us or go to the ER. He's feeling somewhat better, but we send him for a stat ultrasound of his leg and it's immediately confirmed that he has a deep vein thrombosis (DVT) from his ankle to his knee (a long clot traveling up a major leg vein). He's very lucky that a piece of the clot didn't break off and travel to his lungs. He would have died within minutes. We send him home with a prescription for Coumadin (blood thinner) and remind him to come in for bloodwork on Tuesday, without fail. By the way, we tell him, call us right away if you start having uncontrollable nosebleeds or your gums bleed while brushing your teeth. And please be careful shaving, OK?
The man with the DVT is followed by two of my favorite patients. A married couple, both infected with AIDS. She "bought in" early on and has fully suppressed virus and no side effects. He played around with his meds and failed a few regimens of AIDS drugs, and then came to me a year ago, desperate to try again, losing weight and wasting away. I had to scare him and tell him he had less than a year to live unless he worked with me closely, with great concentration and attention to detail. He decided to do it, and here we are. With frequent follow-up and a good rapport, they're a success story, with the virus under control for them both, their kids in school, newly approved Section 8 housing, and a sweet relationship. Our visits are peppered with laughter, jokes, and an ease which makes our time together flow smoothly and easily. I prefill his meds in two one-week boxes, give her an injection of Depo Provera, check their weights, and send them on their way. Hasta la proxima!
Papers and charts are piled on the desk. I make a few notes in my Palm Pilot, scribble some Post-It notes to leave on my desk for Monday morning, file my encounter sheets for the day, and turn off the computer for the first time since 9am on Monday.
The chaos and busy movement of the day are winding down, the phones are routed to the answering service, the beepers cease their sound, laughter fills the room, and we bid one another adieu, leaving the clinic to return to our families for the weekend, only one of us burdened with taking urgent calls until Monday morning rolls around again. It's been a job well done. I feel fairly crispy myself, perhaps medium well at this juncture.....
I arrive to the home fires burning in the woodstove, my lovely wife cooking yet another wonderful meal, the dogs wagging their tails, and the feeling of gratitude for a welcoming domestic scene which draws me in with its wholesome and restful embrace. We catch the end of "The Buena Vista Social Club" on the Independent Film Channel, and I cry as the group takes its well-deserved bows, having accomplished so much and brought joy and music to so many. My cup runneth over.
Wednesday, January 26, 2005
Recovery
Six inches of snow blanketed our region over night and this morning. The dogs seemed to be begging me to stay home and play, but I was a good little worker bee and drove the sloshy roads to work, the first stop being to get gas, shivering in the cold as I pumped fossil remains into my hunk of rolling steel and plastic. Next stop was a bar and hall in a nearby town, where I found my previously mentioned patient, "X", sitting at a table reading the paper as several older gentlemen drank beers at the bar. It was 9:30am. I felt like a visitor from another planet, or at least another era.
We ensconced ourselves in the very clean and well-kempt hall---replete with chandeliers, large tables and a dance floor---and I launched into my "scare-the-shit-out-of-him-with-the-naked-truth-speech". I showed pictures of a healthy liver, a fibrotic liver, a cirrhotic liver, and a cancer-ridden liver, and was very frank that his organ is enlarged, cirrhotic, and predisposed to failure, or possibly carcinoma, and that each drink of alcohol is akin to pouring gasoline on a roaring fire. He looked at me with his very sad (non-jaundiced) eyes and had little to say verbally, but his grave expression told me that I had hit home. That said, whether he can translate that into action and change remains to be seen, the tentacles of addiction being powerful and beseeching friends who will attract the afflicted person like the smell of barbecue will attract a hungry dog.
So, after having blown off his post-hospitalization follow-up visit, never filling his prescriptions that were given to him upon discharge, and drinking lots of alcohol since getting released, he is faced with an earnest nurse whom he trusts telling him that if he keeps drinking, he will most certainly die, and probably not with the kind assistance of a beautiful prostitute-turned-nurse like Nicholas Cage in "Leaving Las Vegas". He will most likely go into acute liver failure while in his apartment late at night, with various gruesome clinical situations unfolding too quickly for him to call 911---but wait, he doesn't have a phone. If his liver does go into acute failure, he might become extremely confused ("obtunded" is a term we like to use) from the rising level of ammonia (yes, ammonia) in his blood, poisoning his brain and curtailing his ability to think clearly. He might then hemorrhage internally or lapse into a coma, his friend with the spare key finding him stiff with rigor mortis in a day or two. These and other unpleasant scenarios certainly await him if he chooses to continue to walk down that road of addiction.
Will my candor pay off? Will he choose to move towards healing and recovery? I can't say, but I wouldn't hold my breath. I'll keep tossing him a line, offering my hand, but if his hands are busy with the bottle, my offers will go untaken, and I will attend yet another wake some time in the near future, just like the one I attended a few weeks ago. That gentleman was addicted to crack and cocaine, and try as I might, I could not turn him towards proper treatment of his AIDS, and he died of liver failure as well, a victim of his own trauma and loss, lapsing into a seizure and dying a quiet death in a specialized care center in Boston where we had sent him to die.
The saga of X will continue, as will so many other sagas that will go untold, those to which I am witness, and those which occur on the fringes of society where they reach their dramatic denouement with barely a ripple made or notice given. I dance in these lives, or at least on their outskirts, but there are often reluctant partners who refuse my hand and slip into the darkness. May their learning in the next life be less painful; may their souls know peace.
We ensconced ourselves in the very clean and well-kempt hall---replete with chandeliers, large tables and a dance floor---and I launched into my "scare-the-shit-out-of-him-with-the-naked-truth-speech". I showed pictures of a healthy liver, a fibrotic liver, a cirrhotic liver, and a cancer-ridden liver, and was very frank that his organ is enlarged, cirrhotic, and predisposed to failure, or possibly carcinoma, and that each drink of alcohol is akin to pouring gasoline on a roaring fire. He looked at me with his very sad (non-jaundiced) eyes and had little to say verbally, but his grave expression told me that I had hit home. That said, whether he can translate that into action and change remains to be seen, the tentacles of addiction being powerful and beseeching friends who will attract the afflicted person like the smell of barbecue will attract a hungry dog.
So, after having blown off his post-hospitalization follow-up visit, never filling his prescriptions that were given to him upon discharge, and drinking lots of alcohol since getting released, he is faced with an earnest nurse whom he trusts telling him that if he keeps drinking, he will most certainly die, and probably not with the kind assistance of a beautiful prostitute-turned-nurse like Nicholas Cage in "Leaving Las Vegas". He will most likely go into acute liver failure while in his apartment late at night, with various gruesome clinical situations unfolding too quickly for him to call 911---but wait, he doesn't have a phone. If his liver does go into acute failure, he might become extremely confused ("obtunded" is a term we like to use) from the rising level of ammonia (yes, ammonia) in his blood, poisoning his brain and curtailing his ability to think clearly. He might then hemorrhage internally or lapse into a coma, his friend with the spare key finding him stiff with rigor mortis in a day or two. These and other unpleasant scenarios certainly await him if he chooses to continue to walk down that road of addiction.
Will my candor pay off? Will he choose to move towards healing and recovery? I can't say, but I wouldn't hold my breath. I'll keep tossing him a line, offering my hand, but if his hands are busy with the bottle, my offers will go untaken, and I will attend yet another wake some time in the near future, just like the one I attended a few weeks ago. That gentleman was addicted to crack and cocaine, and try as I might, I could not turn him towards proper treatment of his AIDS, and he died of liver failure as well, a victim of his own trauma and loss, lapsing into a seizure and dying a quiet death in a specialized care center in Boston where we had sent him to die.
The saga of X will continue, as will so many other sagas that will go untold, those to which I am witness, and those which occur on the fringes of society where they reach their dramatic denouement with barely a ripple made or notice given. I dance in these lives, or at least on their outskirts, but there are often reluctant partners who refuse my hand and slip into the darkness. May their learning in the next life be less painful; may their souls know peace.
Tuesday, January 25, 2005
Exhaustion
It's 11:30pm and I'm exhausted. Mary is in that sweet state between waking and sleeping, and the dogs are on their way to that canine dream-land which we can only imagine. I will join them soon, but my brain is still spinning from the day.
The nature of my work can lend itself to mental, physical, and emotional exhaustion, with current loads of 80-90 patients each, my current roster numbering 83 individuals.
Imagine for a moment that you are a 60-year-old Puerto Rican woman with HIV, diabetes, hypothyroidism, major depression with psychotic features, and asthma. You speak no English and have a 2nd-grade education. Your family members also speak no English. How would you navigate the healthcare system? Or imagine you are a 35-year-old Latina woman with advanced AIDS, Hepatitis C, asthma, a seizure disorder, a history of trauma and physical abuse by your mother who burned your skin with hot oil and water for fun, and this caused you to pursue a life of self-medication with street drugs? How would you manage to take care of yourself and your children? How would you stay clean and do the right thing? How would you stay focused on your health when your history of trauma effects your every waking moment and decision?
These are just snippets to allow you to see the complexity and tragedy of some of the lives of which I am priviledged to be a part, welcomed into homes, confided in, and relied upon. I say it is a priviledge because it actually is an honor to be embraced by these individuals and their families. Yes, we see our share of death, of failure, of self-destruction and chaos, yet we see enough success and self-preserving valor in the face of grim odds that we feel it is worth our time and effort (and at times our mental health, frankly) to work in this community.
Tomorrow I go to visit a white gentleman in his late forties who is an alcoholic. I recently facilitated his admission to the hospital for alcoholic hepatitis. He came to see me and his liver was in such acute distress that his eyes were as yellow as a flourescent highlighter marker, his face a cadaverous pale yellow, and his ankles filled with fluid, almost the size of his thighs. After a 9-day stay in the hospital, delirium tremens (DTs) from alcohol withdrawal, and a general "tune-up", he is now back at home, hanging out at a local bar and drinking again. In his condition, drinking alcohol is like pouring gasoline on a fire. I don't know his whole history, but I imagine it's rife with abuse, abandonment, or worse. How do I convince him to stop drinking? How do I help him to see that he is slowly committing suicide? I guess I will do my best, and then rent "Leaving Las Vegas" and be reminded that some people will choose to self-destruct no matter what kindness is bestowed upon them. My meeting with him tomorrow may lead to little or no change, but I will remind him once again that help is their for the asking, and I will meet him half-way if he reaches out for it.
Consider this quote from Cracked, a book about addiction by Dr. Drew Pinsky: “We define ourselves by the way we relate to other people. We get deep, lasting, and meaningful satisfaction from giving selflessly to, and being present with, others. My patients can’t do that. They’re struggling with the effects of trauma suffered early in life when they were still developing the brain mechanisms that allow them to relate to other people and the world in general. Unable to trust, they grow up without a sense of self. They’re overwhelmed by feelings, unable to cope, always out of control. Their brains tell them to manage pain by getting loaded. Then, when they find their way to us, we ask them to go back and experience that powerlessness, the very thing that sent them off the rails in the first place. No wonder they resist.”
There are so many stories, so many struggles, countless people out there who deserve more, who deserve better, who have been dealt a bad hand either through genetics, poor choices, mental illness, or plain bad luck. If we think we can save them, we're wrong, and sometimes in our earnest efforts to effect change in the lives of those whom we seek to help, we lose sight of our own self-care. Thus, here I sit, just short of midnight on a Tuesday evening, pouring my heart out on this keyboard, with the realization that I will get up tomorrow and do it again. I don't write this out of a need for congratulations, praise, or moral kudos, I write it to share that this reality, this daily vision of the underbelly of urban America, greets my eyes each day and informs my own personal version of reality. I share it here as an exercise, an exorcism, a description, a way to loosen the hold of that troubling reality on my psyche as I prepare for the sweet forgetfulness of sleep which sometimes seems too brief.
Good night.
The nature of my work can lend itself to mental, physical, and emotional exhaustion, with current loads of 80-90 patients each, my current roster numbering 83 individuals.
Imagine for a moment that you are a 60-year-old Puerto Rican woman with HIV, diabetes, hypothyroidism, major depression with psychotic features, and asthma. You speak no English and have a 2nd-grade education. Your family members also speak no English. How would you navigate the healthcare system? Or imagine you are a 35-year-old Latina woman with advanced AIDS, Hepatitis C, asthma, a seizure disorder, a history of trauma and physical abuse by your mother who burned your skin with hot oil and water for fun, and this caused you to pursue a life of self-medication with street drugs? How would you manage to take care of yourself and your children? How would you stay clean and do the right thing? How would you stay focused on your health when your history of trauma effects your every waking moment and decision?
These are just snippets to allow you to see the complexity and tragedy of some of the lives of which I am priviledged to be a part, welcomed into homes, confided in, and relied upon. I say it is a priviledge because it actually is an honor to be embraced by these individuals and their families. Yes, we see our share of death, of failure, of self-destruction and chaos, yet we see enough success and self-preserving valor in the face of grim odds that we feel it is worth our time and effort (and at times our mental health, frankly) to work in this community.
Tomorrow I go to visit a white gentleman in his late forties who is an alcoholic. I recently facilitated his admission to the hospital for alcoholic hepatitis. He came to see me and his liver was in such acute distress that his eyes were as yellow as a flourescent highlighter marker, his face a cadaverous pale yellow, and his ankles filled with fluid, almost the size of his thighs. After a 9-day stay in the hospital, delirium tremens (DTs) from alcohol withdrawal, and a general "tune-up", he is now back at home, hanging out at a local bar and drinking again. In his condition, drinking alcohol is like pouring gasoline on a fire. I don't know his whole history, but I imagine it's rife with abuse, abandonment, or worse. How do I convince him to stop drinking? How do I help him to see that he is slowly committing suicide? I guess I will do my best, and then rent "Leaving Las Vegas" and be reminded that some people will choose to self-destruct no matter what kindness is bestowed upon them. My meeting with him tomorrow may lead to little or no change, but I will remind him once again that help is their for the asking, and I will meet him half-way if he reaches out for it.
Consider this quote from Cracked, a book about addiction by Dr. Drew Pinsky: “We define ourselves by the way we relate to other people. We get deep, lasting, and meaningful satisfaction from giving selflessly to, and being present with, others. My patients can’t do that. They’re struggling with the effects of trauma suffered early in life when they were still developing the brain mechanisms that allow them to relate to other people and the world in general. Unable to trust, they grow up without a sense of self. They’re overwhelmed by feelings, unable to cope, always out of control. Their brains tell them to manage pain by getting loaded. Then, when they find their way to us, we ask them to go back and experience that powerlessness, the very thing that sent them off the rails in the first place. No wonder they resist.”
There are so many stories, so many struggles, countless people out there who deserve more, who deserve better, who have been dealt a bad hand either through genetics, poor choices, mental illness, or plain bad luck. If we think we can save them, we're wrong, and sometimes in our earnest efforts to effect change in the lives of those whom we seek to help, we lose sight of our own self-care. Thus, here I sit, just short of midnight on a Tuesday evening, pouring my heart out on this keyboard, with the realization that I will get up tomorrow and do it again. I don't write this out of a need for congratulations, praise, or moral kudos, I write it to share that this reality, this daily vision of the underbelly of urban America, greets my eyes each day and informs my own personal version of reality. I share it here as an exercise, an exorcism, a description, a way to loosen the hold of that troubling reality on my psyche as I prepare for the sweet forgetfulness of sleep which sometimes seems too brief.
Good night.
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