Tuesday, October 17, 2006
A Cup of Grand Rounds
Please see Emergiblog for this week's Grand Rounds (with a creative Starbuck's theme). This is the first Grand Rounds to which yours truly has submitted a post for some time. Enjoy it with a cup o' joe.
Monday, October 16, 2006
Bureaucracy Now!---- A Rant
Healthcare is riddled---no, saddled---no, ruled and regulated----by bureaucracy. From visiting nurse agencies to hospitals to private practices, bureaucracy with both a capital "B" and lower-case "b" own the airwaves and pocketbooks of the healthcare system. Whether it be fiduciary or surgical, top-down bureaucracy rears its ugly head like a rabid marsupial. You know, all marsupials have deep pockets for the protection and nurturance of the young, and the only "young" spawned of the healthcare system is money, or its popular euphemisms, market-share and capital. And don't be fooled by a hospital that's a not-for-profit. Those wolves in sheep's clothing can devour weaker competitors for lunch and regurgitate a new "satellite" branch for dinner. But I digress.
Today, I was informed by a visiting nurse---in whom I place my complete trust and confidence, by the way---that a mutual patient of ours is in need of a wheeled walker. This patient, of undisclosed race, gender or age, has long-standing AIDS with various complications including dementia and mental status changes, a newly-discovered bone spur in the lumbar spine, worsening depression, newly manifested self-mutilating tendencies, hypertension, hypothyroidism, Hepatitis C which failed treatment with Interferon and Ribavarin (the standard of care for the "cure" of chronic Hep C), and chronic pain of unknown etiology. S/he has had several precipitous declines towards disability or death, and several subsequent and equally noteworthy recoveries, like a magical phoenix rising from the ashes of a recalcitrant body's failure to thrive.
Now, having gone from fully ambulatory to walking with a cane and then progressing to a manual wheelchair, this patient is beginning to regain some of his/her strength, and with assistance and perseverance---and despite massive depression, suicidal ideation, and self-inflicted cigarette burns on both hands---this courageous individual is in need of a walker to facilitate movement from the wheelchair to a standing position, the cane not being enough to support such a transfer.
I happily obtained the necessary paperwork from the medical supply company---paperwork which is, I must say, meticulously designed to comply with the bureaucratic hungers of both Medicare and Medicaid. Discussing this newly arisen need for equipment with the primary doctor, I rapidly obtained his signature, completed the paperwork with the necessary "Medicare-ese" needed in such delicate situations, and faxed said paperwork to the supply company forthwith, content to move on to other pressing matters, satisfied that my patient would then, through the miracles of modern communication technology and computerized billing, receive a home delivery of said device within 48 hours, as is the customary turnaround time with this particular company with whom we have a chummy (and somewhat bureaucratic) working relationship.
Ten minutes later, I received a call from the above-mentioned company to inform me that the doctor had not dated the form where he had signed it, so could I please add the date to the form and re-send it? (Couldn't the person on the other end fill in the date? Oh no, the uppity ones at Medicare would examine the signature and date with a magnifying glass, and a handwriting specialist would determine if they were both written by the same person!) Feeling more and more like this was a scene from Terry Gilliam's Brazil, I filled in the date---using the same color ink as the doctor, of course---and re-faxed the form, putting the original in an envelope to be mailed, since Medicare (read: "the bureaucrats") wants an original on file.
Again satisfied that I had done my nursely duty, I moved on to other (now even more pressing) tasks, and was interrupted by yet another telephone call from the medical supply company approximately an hour later. Was I aware that the patient already had a manual wheelchair? Yes, indeed. Was I also aware that the patient has Medicare as his/her primary insurance with Medicaid as secondary? Of course. Was I also aware that Medicare will not pay for a walker for a patient who already has a wheelchair?
I stared into space, noting all of the varied colors and relative positions of the push-pins on my bulletin board. Dissociation can be helpful in times of stress (as can Prozac).
"Do you mean to say that, even if my patient needs a walker to get up out of his wheelchair, he doesn't qualify?" I asked incredulously. The answer was affirmative. "Do you also mean," I continued, "that a patient who improves and becomes more ambulatory should therefore remain confined to a wheelchair because Medicare feels the paltry cost of a walker is just too much to provide for this person's improved quality of life and mobility?" I was informed that yes, in Medicare's eyes, he should stay in the wheelchair. I hung up the phone and put my face in my hands.
Big sigh.
So, yet another bureaucratic fight for this nurse to wage? So many other battles are pending, like the patient who lives in an apartment with severely sloping floors which the housing authority claims is fine, even for a patient with severe arthritis. Oh! the humanity (or lack thereof).
What bureaucratic nightmare will I encounter tomorrow? You can rest assured that one will most likely make its presence known sooner than later. And what is a lowly nurse, a mere cog in the healthcare wheel, to do? Yell? Scream? Rage against the machine? Abuse beer and benzodiazepines? Take your pick. Til then, let's hope no faceless bureaucrat in a cheap suit is sitting in some cubicle at Medicare scheming up even more insidious ways to save money and diminish the quality of life of its recipients. Then again, that's probably an apt job description for someone with no healthcare experience who is at this moment burning the midnight oil and doing just that. He probably has a boss who told him to stay until he could figure out how to screw one more Medicare recipient out of $50 this week. (And that boss probably gets a $100 raise for every $50 saved. Go figure.) So, let's just hope he has one too many tonight after work as he drowns his guilt with cheap gin at a local bar and calls in sick tomorrow. Maybe then I'll be able to get something done after all.
Today, I was informed by a visiting nurse---in whom I place my complete trust and confidence, by the way---that a mutual patient of ours is in need of a wheeled walker. This patient, of undisclosed race, gender or age, has long-standing AIDS with various complications including dementia and mental status changes, a newly-discovered bone spur in the lumbar spine, worsening depression, newly manifested self-mutilating tendencies, hypertension, hypothyroidism, Hepatitis C which failed treatment with Interferon and Ribavarin (the standard of care for the "cure" of chronic Hep C), and chronic pain of unknown etiology. S/he has had several precipitous declines towards disability or death, and several subsequent and equally noteworthy recoveries, like a magical phoenix rising from the ashes of a recalcitrant body's failure to thrive.
Now, having gone from fully ambulatory to walking with a cane and then progressing to a manual wheelchair, this patient is beginning to regain some of his/her strength, and with assistance and perseverance---and despite massive depression, suicidal ideation, and self-inflicted cigarette burns on both hands---this courageous individual is in need of a walker to facilitate movement from the wheelchair to a standing position, the cane not being enough to support such a transfer.
I happily obtained the necessary paperwork from the medical supply company---paperwork which is, I must say, meticulously designed to comply with the bureaucratic hungers of both Medicare and Medicaid. Discussing this newly arisen need for equipment with the primary doctor, I rapidly obtained his signature, completed the paperwork with the necessary "Medicare-ese" needed in such delicate situations, and faxed said paperwork to the supply company forthwith, content to move on to other pressing matters, satisfied that my patient would then, through the miracles of modern communication technology and computerized billing, receive a home delivery of said device within 48 hours, as is the customary turnaround time with this particular company with whom we have a chummy (and somewhat bureaucratic) working relationship.
Ten minutes later, I received a call from the above-mentioned company to inform me that the doctor had not dated the form where he had signed it, so could I please add the date to the form and re-send it? (Couldn't the person on the other end fill in the date? Oh no, the uppity ones at Medicare would examine the signature and date with a magnifying glass, and a handwriting specialist would determine if they were both written by the same person!) Feeling more and more like this was a scene from Terry Gilliam's Brazil, I filled in the date---using the same color ink as the doctor, of course---and re-faxed the form, putting the original in an envelope to be mailed, since Medicare (read: "the bureaucrats") wants an original on file.
Again satisfied that I had done my nursely duty, I moved on to other (now even more pressing) tasks, and was interrupted by yet another telephone call from the medical supply company approximately an hour later. Was I aware that the patient already had a manual wheelchair? Yes, indeed. Was I also aware that the patient has Medicare as his/her primary insurance with Medicaid as secondary? Of course. Was I also aware that Medicare will not pay for a walker for a patient who already has a wheelchair?
I stared into space, noting all of the varied colors and relative positions of the push-pins on my bulletin board. Dissociation can be helpful in times of stress (as can Prozac).
"Do you mean to say that, even if my patient needs a walker to get up out of his wheelchair, he doesn't qualify?" I asked incredulously. The answer was affirmative. "Do you also mean," I continued, "that a patient who improves and becomes more ambulatory should therefore remain confined to a wheelchair because Medicare feels the paltry cost of a walker is just too much to provide for this person's improved quality of life and mobility?" I was informed that yes, in Medicare's eyes, he should stay in the wheelchair. I hung up the phone and put my face in my hands.
Big sigh.
So, yet another bureaucratic fight for this nurse to wage? So many other battles are pending, like the patient who lives in an apartment with severely sloping floors which the housing authority claims is fine, even for a patient with severe arthritis. Oh! the humanity (or lack thereof).
What bureaucratic nightmare will I encounter tomorrow? You can rest assured that one will most likely make its presence known sooner than later. And what is a lowly nurse, a mere cog in the healthcare wheel, to do? Yell? Scream? Rage against the machine? Abuse beer and benzodiazepines? Take your pick. Til then, let's hope no faceless bureaucrat in a cheap suit is sitting in some cubicle at Medicare scheming up even more insidious ways to save money and diminish the quality of life of its recipients. Then again, that's probably an apt job description for someone with no healthcare experience who is at this moment burning the midnight oil and doing just that. He probably has a boss who told him to stay until he could figure out how to screw one more Medicare recipient out of $50 this week. (And that boss probably gets a $100 raise for every $50 saved. Go figure.) So, let's just hope he has one too many tonight after work as he drowns his guilt with cheap gin at a local bar and calls in sick tomorrow. Maybe then I'll be able to get something done after all.
Saturday, October 14, 2006
The Phlegm and the Fury
As a nurse, I absolutely dread the advent of flu season. Obviously, I personally dread getting the flu myself. It's debilitating, demoralizing, and seems to take forever to recuperate from. It necessitates lost days at work, eats up my earned time for future vacations, and can set me back physically for weeks.
Aside from my own selfish reflections vis-a-vis the flu, I loathe the inevitable confusion and rancor over flu vaccine stocks. First, we usually hear that last year's problems with inventory and distribution have been solved and that "this year will be different". Not long after that pronouncement, we generally learn that the clinic has not received the number of doses ordered from DPH, and that our affiliate hospital system is having problems obtaining its full allotment. Aside from that, tainted vaccine and factories failing inspection always seem to make the evening news.
As the patients' panic calls begin to pour in, I do my best to quell fears, subdue the masses, and fight to get my hot little hands on enough vaccine to inoculate the thirty or forty most vulnerable of my caseload. Failing my ability to adequately meet my patients' needs, I punt, sending them to any and every flu clinic that I can locate in the city.
For people with AIDS, cancer, hepatitis and COPD, a year without a flu shot seems unthinkable, although I try to also educate them that a vaccine will not protect them completely. It's also hard for them to understand that a bunch of scientists basically takes what amounts to an educated guess as to which strain will snake its way across the US this year. They've been wrong before, and sometimes you just have to get sick.
Aside from the struggles over the vaccine and its relative lack or abundance, the sick calls then begin. Patients with the flu---even though it's definitively a virus---inevitably want antibiotics. While some protracted viral illnesses will indeed manifest secondary bacterial infections in some part of the respiratory system, we try to assist our patients to "tough it out", weather the storm, soothe the symptoms with NSAIDS and fluids and rest, and call us in the morning. This tactic is the most difficult to finesse, especially when our patients are used to using medicines to eradicate symptoms. Sometimes, I tell them, you just have to slog through the phlegm and the fury to get to the other side. They're generally not amused.
So, as October winds up into the middle of the month, Flu Vaccine Fever will soon spread like TB on a hermetically sealed city bus. The symptoms: frequent calls as to when the shipment of vaccine will arrive; requests for prophylactic antibiotics; requests for prophylactic Percocet (why not?); and panicked calls with fears that the dreaded illness has finally struck pay-dirt in the patient's home. My mantra: fluids, Tylenol (Ibuprofen if any liver disease is present), more fluids, sleep, more fluids, more sleep, and still more fluids. And don't forget to sleep. And, oh, did I mention the fluids?
The Flu Vaccine Fever will soon be upon us. May compassion fill my heart, may patience be my guide, and may vaccine supplies flow like champagne at a wedding.
Aside from my own selfish reflections vis-a-vis the flu, I loathe the inevitable confusion and rancor over flu vaccine stocks. First, we usually hear that last year's problems with inventory and distribution have been solved and that "this year will be different". Not long after that pronouncement, we generally learn that the clinic has not received the number of doses ordered from DPH, and that our affiliate hospital system is having problems obtaining its full allotment. Aside from that, tainted vaccine and factories failing inspection always seem to make the evening news.
As the patients' panic calls begin to pour in, I do my best to quell fears, subdue the masses, and fight to get my hot little hands on enough vaccine to inoculate the thirty or forty most vulnerable of my caseload. Failing my ability to adequately meet my patients' needs, I punt, sending them to any and every flu clinic that I can locate in the city.
For people with AIDS, cancer, hepatitis and COPD, a year without a flu shot seems unthinkable, although I try to also educate them that a vaccine will not protect them completely. It's also hard for them to understand that a bunch of scientists basically takes what amounts to an educated guess as to which strain will snake its way across the US this year. They've been wrong before, and sometimes you just have to get sick.
Aside from the struggles over the vaccine and its relative lack or abundance, the sick calls then begin. Patients with the flu---even though it's definitively a virus---inevitably want antibiotics. While some protracted viral illnesses will indeed manifest secondary bacterial infections in some part of the respiratory system, we try to assist our patients to "tough it out", weather the storm, soothe the symptoms with NSAIDS and fluids and rest, and call us in the morning. This tactic is the most difficult to finesse, especially when our patients are used to using medicines to eradicate symptoms. Sometimes, I tell them, you just have to slog through the phlegm and the fury to get to the other side. They're generally not amused.
So, as October winds up into the middle of the month, Flu Vaccine Fever will soon spread like TB on a hermetically sealed city bus. The symptoms: frequent calls as to when the shipment of vaccine will arrive; requests for prophylactic antibiotics; requests for prophylactic Percocet (why not?); and panicked calls with fears that the dreaded illness has finally struck pay-dirt in the patient's home. My mantra: fluids, Tylenol (Ibuprofen if any liver disease is present), more fluids, sleep, more fluids, more sleep, and still more fluids. And don't forget to sleep. And, oh, did I mention the fluids?
The Flu Vaccine Fever will soon be upon us. May compassion fill my heart, may patience be my guide, and may vaccine supplies flow like champagne at a wedding.
Friday, October 13, 2006
Still Eating our Young?
The recent experiences of two friends who are newly-minted nursing school graduates underscores the notion that the needs of new nurses are not being met when they hit the ground running. In the hospital setting, especially, new nurses need gentle and constant nurturing and preceptorship in the first stages of their career. Taking into consideration that nurses in the hospital are dealing with acutely ill patients, often pre- or post-op, with a plethora of comorbidities and high risk of complications, new nurses cannot be expected to jump on that wagon alone for some time. It is disconcerting that some new grads seem to be getting the short end of the preceptor stick, as it were.
Having completely eschewed the whole hospital experience post-graduation (something I was told was professional suicide), I have not personally been responsible for six or more patients at a time on a Med-Surg floor, but in my current capacity as a Nurse Care Manager, caring for more than 80 chronically ill patients on an out-patient basis does give me some traction vis-a-vis the vicissitudes of detail management and multitasking.
I'm saddened that new nurses are invited into the intense environment of the hospital, given cursory orientations, left in the charge of preceptors who are themselves too stressed and overworked to do their junior colleagues justice, and then thrown to the wolves, often drowning amidst the acuity of their multiple patients and the resultingly overwhelming paperwork.
How many new nurses have been frightened away from their newly chosen career based on a devastating first work experience? How many new nurses have been proferred less-than-adequate guidance as they entered the fray?
Taking into consideration the overall nursing shortage, the simultaneous nursing faculty shortage, and the fact that nursing schools are turning away record numbers of qualified applicants due to that lack of faculty, it is even more imperative that new nurses be given the highest quality introduction to their new career as possible. If we lose them to other industries due to our lack of leadership and empowering mentorship, then it is not only us, but also the hospitalized and ill public, who will suffer in the end. Nursing shortages can translate into overworked staff, increased errors, increased nosocomial (hospital-born) infections, decreased satisfaction for both staff and patients, and overall poorer outcomes in both surgical and non-surgical patients.
It has been said for decades that nurses eat their young. You would think that after so much time, after so much experience garnered by so many, that this industry-wide practice by jaded and overworked nurses would come to an end. Apparently, it is still a nurse-eat-nurse world out there, and many a new grad is suffering because of such a widely tolerated atmosphere of poor management and lack of empathy for the new nurses in our midst.
If nurses wish to truly be the purveyors of health that they claim to be, then the nurturing must start with the self, extend to coworkers (and neophytes especially), colleagues, and then to the public at large in the form of our patients. If we do not care for ourselves and each other, we are truly only continuing outmoded practices propagated by the patriarchal paradigm. (Alliteration unintended but nonetheless entertaining.)
In a female-dominated industry, traditionally male managerial models of subjugation, humiliation, and trial by fire must be altered, or the unhealthy and overwhelming hell of being a new nurse may only be prolonged for decades to come. For all those who do indeed nurture the neophytes, thank you---your service will benefit more than you may ever know or experience. For those of you who are guilty of letting the struggling swimmers drown, it's time to embrace a new way of being and welcome those who join our ranks with open arms and willing hearts.
Having completely eschewed the whole hospital experience post-graduation (something I was told was professional suicide), I have not personally been responsible for six or more patients at a time on a Med-Surg floor, but in my current capacity as a Nurse Care Manager, caring for more than 80 chronically ill patients on an out-patient basis does give me some traction vis-a-vis the vicissitudes of detail management and multitasking.
I'm saddened that new nurses are invited into the intense environment of the hospital, given cursory orientations, left in the charge of preceptors who are themselves too stressed and overworked to do their junior colleagues justice, and then thrown to the wolves, often drowning amidst the acuity of their multiple patients and the resultingly overwhelming paperwork.
How many new nurses have been frightened away from their newly chosen career based on a devastating first work experience? How many new nurses have been proferred less-than-adequate guidance as they entered the fray?
Taking into consideration the overall nursing shortage, the simultaneous nursing faculty shortage, and the fact that nursing schools are turning away record numbers of qualified applicants due to that lack of faculty, it is even more imperative that new nurses be given the highest quality introduction to their new career as possible. If we lose them to other industries due to our lack of leadership and empowering mentorship, then it is not only us, but also the hospitalized and ill public, who will suffer in the end. Nursing shortages can translate into overworked staff, increased errors, increased nosocomial (hospital-born) infections, decreased satisfaction for both staff and patients, and overall poorer outcomes in both surgical and non-surgical patients.
It has been said for decades that nurses eat their young. You would think that after so much time, after so much experience garnered by so many, that this industry-wide practice by jaded and overworked nurses would come to an end. Apparently, it is still a nurse-eat-nurse world out there, and many a new grad is suffering because of such a widely tolerated atmosphere of poor management and lack of empathy for the new nurses in our midst.
If nurses wish to truly be the purveyors of health that they claim to be, then the nurturing must start with the self, extend to coworkers (and neophytes especially), colleagues, and then to the public at large in the form of our patients. If we do not care for ourselves and each other, we are truly only continuing outmoded practices propagated by the patriarchal paradigm. (Alliteration unintended but nonetheless entertaining.)
In a female-dominated industry, traditionally male managerial models of subjugation, humiliation, and trial by fire must be altered, or the unhealthy and overwhelming hell of being a new nurse may only be prolonged for decades to come. For all those who do indeed nurture the neophytes, thank you---your service will benefit more than you may ever know or experience. For those of you who are guilty of letting the struggling swimmers drown, it's time to embrace a new way of being and welcome those who join our ranks with open arms and willing hearts.
Thursday, October 12, 2006
Nervous System Reconstitution
Those of us who work with people with HIV and other immune disorders understand the concept of "immune reconstitution", when the patient's treatment of the virus eventually begins to restore the immune system. There are positive and negative aspects of this process, but the overall returning of immune function is a good thing in the end.
Just as immune systems must reconstitute, so do nervous systems, especially the nervous systems of stressed nurses whose lives seem to have gotten the better of them. Sometimes Nervous System Reconstitution entails taking time off to relax, be at home, and practice good basic self-care. Sometimes it means increasing exercise, sweating out the toxins and stress, working tired muscles into shape. At other times, food and drink is the answer, vital elements from nature literally feeding the cells, nourishing the tissues. Drinking water is important for cleansing cortisol, a stress hormone, from the body, and exercise also helps in this regard.
The prudent nurse or healthcare professional will decide to do what it takes to nurture the nurturer, prevent stress-based illness, and bring balance to the mind, body and soul. Many other modalities of Nervous System Reconstitution are there for the taking: friendship; creative pursuits; enjoyment of the arts; sports; taking care of one's responsibilities at home; pets; cleaning and organizing to decrease the stress of disorganization; time with children (or not!); meditation and other spiritual practices; yoga; massage; cooking; the pursuit of hobbies; gardening; the list is endless.
How can we as healthcare professionals, burnt out and crisp around the edges, hope to foster and encourage healthy living in our patients when we are walking on the edge of personal oblivion? How can we be so disingenuous as to expect our patients to follow our advice when our poor example is written in the lines of stress on our faces, in our hollow and fatigued eyes sunken with lost sleep and overwork, our short tempers, our obvious burn-out?
I have had a patient with a diagnosed thought disorder look at me and say, "You look really tired." I've had other patients look concerned and ask, "Did you eat lunch today?" Whether the patient is mentally ill or physically ill, our stress is perceived, and although we think that the world at work will fall apart without us, we eventually learn that the clock at work travels from 9 to 5 (or 3 to 11, or 11 to 7) whether we're there or not, and our well-meaning colleagues are entirely capable of covering for us when we're gone. We can make ourselves indispensable in the big picture, but that little picture yearns for a time out, and if we don't give it its due, it will come back to haunt us with a vengeance, bringing illness and unhappiness along for the ride.
Healthcare providers are notorious for being bad patients, often eschewing timely self-care because "there's not enough time". How many nurses are overdue for mammograms, dental cleanings, PAP smears, prostate exams? How many doctors ignore symptoms for which they would advise patients to seek attention? How often do we go to work sick, coughing on our patients because the office would never survive without us? When will we learn? When will we get it?
I'm guilty. I'm as bad as the rest. Luckily I have a spouse who can spot my stress in a heartbeat, who can see the signs, read the tea leaves, and threaten divorce if I don't call in sick. She will cajole and coerce, determined to convince me that caring for myself is also an act of caring for others, allowing myself to reconstitute and return, refreshed and available to begin again, providing better quality care because I have cared for my own needs. How many colds has she helped me to avoid? How many moments of spiritual torture have I side-stepped by simply taking a few days to myself? To calculate the value of self-care would need a calculator not yet invented, with circuitry which recognizes inner peace, balance, and a body and mind at ease.
For now my inner calculator will need to suffice, that barometer in my mind which tells me when I am walking a fine line between health and illness. Keeping that barometer in check should be a prime focus, a measure of contentment and balance. If I lose sight of that marker, if I let myself go to that edge too often, the consequences are just not worth the paltry rewards. No one loves a martyr, and I'll stake my future on the fact that my health will take me anywhere I want to go, but its demise will take me to only one place---an early grave---and I'm in no hurry to arrive at that final destination.
Here's to health.
Just as immune systems must reconstitute, so do nervous systems, especially the nervous systems of stressed nurses whose lives seem to have gotten the better of them. Sometimes Nervous System Reconstitution entails taking time off to relax, be at home, and practice good basic self-care. Sometimes it means increasing exercise, sweating out the toxins and stress, working tired muscles into shape. At other times, food and drink is the answer, vital elements from nature literally feeding the cells, nourishing the tissues. Drinking water is important for cleansing cortisol, a stress hormone, from the body, and exercise also helps in this regard.
The prudent nurse or healthcare professional will decide to do what it takes to nurture the nurturer, prevent stress-based illness, and bring balance to the mind, body and soul. Many other modalities of Nervous System Reconstitution are there for the taking: friendship; creative pursuits; enjoyment of the arts; sports; taking care of one's responsibilities at home; pets; cleaning and organizing to decrease the stress of disorganization; time with children (or not!); meditation and other spiritual practices; yoga; massage; cooking; the pursuit of hobbies; gardening; the list is endless.
How can we as healthcare professionals, burnt out and crisp around the edges, hope to foster and encourage healthy living in our patients when we are walking on the edge of personal oblivion? How can we be so disingenuous as to expect our patients to follow our advice when our poor example is written in the lines of stress on our faces, in our hollow and fatigued eyes sunken with lost sleep and overwork, our short tempers, our obvious burn-out?
I have had a patient with a diagnosed thought disorder look at me and say, "You look really tired." I've had other patients look concerned and ask, "Did you eat lunch today?" Whether the patient is mentally ill or physically ill, our stress is perceived, and although we think that the world at work will fall apart without us, we eventually learn that the clock at work travels from 9 to 5 (or 3 to 11, or 11 to 7) whether we're there or not, and our well-meaning colleagues are entirely capable of covering for us when we're gone. We can make ourselves indispensable in the big picture, but that little picture yearns for a time out, and if we don't give it its due, it will come back to haunt us with a vengeance, bringing illness and unhappiness along for the ride.
Healthcare providers are notorious for being bad patients, often eschewing timely self-care because "there's not enough time". How many nurses are overdue for mammograms, dental cleanings, PAP smears, prostate exams? How many doctors ignore symptoms for which they would advise patients to seek attention? How often do we go to work sick, coughing on our patients because the office would never survive without us? When will we learn? When will we get it?
I'm guilty. I'm as bad as the rest. Luckily I have a spouse who can spot my stress in a heartbeat, who can see the signs, read the tea leaves, and threaten divorce if I don't call in sick. She will cajole and coerce, determined to convince me that caring for myself is also an act of caring for others, allowing myself to reconstitute and return, refreshed and available to begin again, providing better quality care because I have cared for my own needs. How many colds has she helped me to avoid? How many moments of spiritual torture have I side-stepped by simply taking a few days to myself? To calculate the value of self-care would need a calculator not yet invented, with circuitry which recognizes inner peace, balance, and a body and mind at ease.
For now my inner calculator will need to suffice, that barometer in my mind which tells me when I am walking a fine line between health and illness. Keeping that barometer in check should be a prime focus, a measure of contentment and balance. If I lose sight of that marker, if I let myself go to that edge too often, the consequences are just not worth the paltry rewards. No one loves a martyr, and I'll stake my future on the fact that my health will take me anywhere I want to go, but its demise will take me to only one place---an early grave---and I'm in no hurry to arrive at that final destination.
Here's to health.
Tuesday, October 10, 2006
Illness, Change, and the Spectre of Loss
My step-father begins radiation this morning at 8:30, perhaps at this very moment. He will also take oral chemotherapy for the first six weeks and then perhaps change to intravenous therapy thereafter. The only cure for pancreatic cancer is surgery, and this is not a possibility for him, at least for now, and perhaps never. These are the times when living five hours away from one's aging parents is a painful and isolating experience.
Life-altering illness offers many lessons and will push one to the edge and beyond. Change is the only constant here, and there are so many with which one must cope. It is not only change which holds one in its grip, but the spectre of loss visits in guises both small and large. One might lose one's hair from chemotherapy. The ability to drive, to eat whatever and whenever one wants, the ability to control one's bodily functions may all be lost at any time in this complicated game. For every step forward, there can often be several steps back, a new aspect of loss appearing at any moment.
I would assume that the most devastating losses come in the form of the loss of independence and of dignity. Retaining independence becomes a major challenge as the body gives way, as symptoms preclude even the most basic of daily activities. And with the loss of independence, one may begin to feel a loss of dignity, of the self, of one's place in the world. When the individual becomes weak, incontinent, unable to toilet him- or herself, unable to bathe independently, these are the losses in which the person begins to lose quality of life and a true sense of self, or at least a sense of the self as one has known it.
Anticipatory loss is another aspect of illness. As a form of grieving, this manifests as one faces losses which are only around the corner. Depending on the form of disease, one can anticipate further deprivation and change. In progressive neurological disease, even the most simple function may be on the docket. The powers of speech, swallowing, hearing, touch, sexual function---these too can be taken away and remain but a memory.
The most devastating of all losses may be the knowledge that one will eventually leave one's loved ones behind. The worries and concerns may mount: Will s/he be OK? Will they be financially solvent? Did I do enough to prepare? Are my affairs in order? How much will my illness cost them, both emotionally and economically? Will my loved one be able to continue on without me? Who will care for them when they are sick or needy? Did I accomplish all that I wanted to accomplish?
Finally, beyond loss, one begins to look toward the future, one's future beyond this world. One examines the spiritual questions on the table, reflects on one's life, hopefully makes peace with the choices that have been made, and considers what will happen when the curtain closes on this earthly existence. The beliefs that have grown in the psyche and mind over the decades now come to bear. One's faith---or lack thereof---makes itself known. They say there are no atheists in foxholes, and the existential begins to take on more and more importance as the material world recedes. This is the time when the outer losses lose the crucial impact which they once carried, and the mind turns inwards towards matters of spirit, of faith, of making peace with both life and death.
I have watched a number of individuals enter, travel through, and complete this process. For those who lost function of outward communication and became demented or aphasic, their inner peacemaking was just that---inward---and I have not been privy to their process. For those who retained their mental capacities and ability to communicate until the end, the observer and loved one can glean much more from the experience and in some ways share more in that journey.
When the individual entering this phase of life and letting go is an intimate loved one (like a parent) rather than a patient, that is where the poignancy of this process takes wing, and also where the pain can become more visceral. This is the place where my mind and heart now dwell, and it's now my turn to walk this road as I have watched so many others travel with me as advocate and guide. The loss may be swift, it may be slow, but it is real, it is intimate, and its reality cannot be denied. I feel for my mother as she faces this gradual deneoument of her life as she has known it, and while I fear for her security and stability, I also must care for my own. This is no place for codependence and loss of one's center. This is a time for groundedness, thoughtfulness, spiritual insight, sensitivity, and compassion for myself as well as others.
As a family, we have crossed that threshold of loss and letting go, and the path which we will follow together has been trod for millenia. May we do it well, with grace and humility, and come through the other side stronger and more healed, and may my step-dad's losses and eventual passing be peaceful and as painless as possible, with suffering kept to a minimum. This is my wish for us and for all families who are on any portion of this universal journey of life, love, and death.
So be it.
Life-altering illness offers many lessons and will push one to the edge and beyond. Change is the only constant here, and there are so many with which one must cope. It is not only change which holds one in its grip, but the spectre of loss visits in guises both small and large. One might lose one's hair from chemotherapy. The ability to drive, to eat whatever and whenever one wants, the ability to control one's bodily functions may all be lost at any time in this complicated game. For every step forward, there can often be several steps back, a new aspect of loss appearing at any moment.
I would assume that the most devastating losses come in the form of the loss of independence and of dignity. Retaining independence becomes a major challenge as the body gives way, as symptoms preclude even the most basic of daily activities. And with the loss of independence, one may begin to feel a loss of dignity, of the self, of one's place in the world. When the individual becomes weak, incontinent, unable to toilet him- or herself, unable to bathe independently, these are the losses in which the person begins to lose quality of life and a true sense of self, or at least a sense of the self as one has known it.
Anticipatory loss is another aspect of illness. As a form of grieving, this manifests as one faces losses which are only around the corner. Depending on the form of disease, one can anticipate further deprivation and change. In progressive neurological disease, even the most simple function may be on the docket. The powers of speech, swallowing, hearing, touch, sexual function---these too can be taken away and remain but a memory.
The most devastating of all losses may be the knowledge that one will eventually leave one's loved ones behind. The worries and concerns may mount: Will s/he be OK? Will they be financially solvent? Did I do enough to prepare? Are my affairs in order? How much will my illness cost them, both emotionally and economically? Will my loved one be able to continue on without me? Who will care for them when they are sick or needy? Did I accomplish all that I wanted to accomplish?
Finally, beyond loss, one begins to look toward the future, one's future beyond this world. One examines the spiritual questions on the table, reflects on one's life, hopefully makes peace with the choices that have been made, and considers what will happen when the curtain closes on this earthly existence. The beliefs that have grown in the psyche and mind over the decades now come to bear. One's faith---or lack thereof---makes itself known. They say there are no atheists in foxholes, and the existential begins to take on more and more importance as the material world recedes. This is the time when the outer losses lose the crucial impact which they once carried, and the mind turns inwards towards matters of spirit, of faith, of making peace with both life and death.
I have watched a number of individuals enter, travel through, and complete this process. For those who lost function of outward communication and became demented or aphasic, their inner peacemaking was just that---inward---and I have not been privy to their process. For those who retained their mental capacities and ability to communicate until the end, the observer and loved one can glean much more from the experience and in some ways share more in that journey.
When the individual entering this phase of life and letting go is an intimate loved one (like a parent) rather than a patient, that is where the poignancy of this process takes wing, and also where the pain can become more visceral. This is the place where my mind and heart now dwell, and it's now my turn to walk this road as I have watched so many others travel with me as advocate and guide. The loss may be swift, it may be slow, but it is real, it is intimate, and its reality cannot be denied. I feel for my mother as she faces this gradual deneoument of her life as she has known it, and while I fear for her security and stability, I also must care for my own. This is no place for codependence and loss of one's center. This is a time for groundedness, thoughtfulness, spiritual insight, sensitivity, and compassion for myself as well as others.
As a family, we have crossed that threshold of loss and letting go, and the path which we will follow together has been trod for millenia. May we do it well, with grace and humility, and come through the other side stronger and more healed, and may my step-dad's losses and eventual passing be peaceful and as painless as possible, with suffering kept to a minimum. This is my wish for us and for all families who are on any portion of this universal journey of life, love, and death.
So be it.
Saturday, October 07, 2006
More on Compassion and Suffering
When speaking of compassion, one must also speak of suffering. The two seem to go hand in hand, the former a frequent consequence of the latter.
Many forms of suffering pervade the human condition: war, hunger, illness, crime, loneliness, imprisonment, enslavement, poverty, natural disaster. Where do we turn to ameliorate the suffering of others? Whose suffering do we choose to do something about and to whose condition do we turn a blind eye?
The entreating envelopes arrive in the mail almost daily: Amnesty International, The Human Rights Campaign, Oxfam, the list is endless. There is global suffering, local suffering, the plight of animals, of children, of women, of the sick, of the environment. Which envelopes do you throw in the trash? Which ones live on your desk for weeks or months? Which ones are returned immediately with a check? How does one decide where one's money is most needed? How does one not feel guilty about all of the worthy causes you just cannot afford to support?
For all the direct action in which an individual can take part, it seems that the soul, the very heart is the place for one to begin practicing compassion. One must first cultivate compassion for the self, learn to forgive ones self over and over again, assuage one's own suffering, and perhaps then extend that energy to others. I am often much quicker to excuse the behavior or actions of others while digging deep holes of self-blame and recrimination in my own heart and mind. Thus for me, the question is not necessarily how to cultivate compassion for others per se, but more how to simultaneously allow myself that same level of acceptance and peace. Perhaps from that place, one's actions towards the rest of the world come from a deeper, more grounded center built on self-love rather than guilt, on fullness rather than lack. Perhaps.
So, those envelopes that keep coming in the mail? I can guiltily drop them in the recycling box and hate myself for my shallow self-centeredness, I can send them each a pittance in an attempt to assuage my guilt, or I can simply send my money to the place to which I am guided by my heart, and continue to live a life driven by compassion, certain that what I produce and engender in this world will echo ever wider in ripples of compassion and love.
I think I'll choose to forgive myself and others, do what I can, release the guilt, release the pain, and wake up tomorrow and start again.
Many forms of suffering pervade the human condition: war, hunger, illness, crime, loneliness, imprisonment, enslavement, poverty, natural disaster. Where do we turn to ameliorate the suffering of others? Whose suffering do we choose to do something about and to whose condition do we turn a blind eye?
The entreating envelopes arrive in the mail almost daily: Amnesty International, The Human Rights Campaign, Oxfam, the list is endless. There is global suffering, local suffering, the plight of animals, of children, of women, of the sick, of the environment. Which envelopes do you throw in the trash? Which ones live on your desk for weeks or months? Which ones are returned immediately with a check? How does one decide where one's money is most needed? How does one not feel guilty about all of the worthy causes you just cannot afford to support?
For all the direct action in which an individual can take part, it seems that the soul, the very heart is the place for one to begin practicing compassion. One must first cultivate compassion for the self, learn to forgive ones self over and over again, assuage one's own suffering, and perhaps then extend that energy to others. I am often much quicker to excuse the behavior or actions of others while digging deep holes of self-blame and recrimination in my own heart and mind. Thus for me, the question is not necessarily how to cultivate compassion for others per se, but more how to simultaneously allow myself that same level of acceptance and peace. Perhaps from that place, one's actions towards the rest of the world come from a deeper, more grounded center built on self-love rather than guilt, on fullness rather than lack. Perhaps.
So, those envelopes that keep coming in the mail? I can guiltily drop them in the recycling box and hate myself for my shallow self-centeredness, I can send them each a pittance in an attempt to assuage my guilt, or I can simply send my money to the place to which I am guided by my heart, and continue to live a life driven by compassion, certain that what I produce and engender in this world will echo ever wider in ripples of compassion and love.
I think I'll choose to forgive myself and others, do what I can, release the guilt, release the pain, and wake up tomorrow and start again.
Tuesday, October 03, 2006
Detail Management
Detail management is the name of the game when faced with the daunting task of keeping track of so many individual lives. I often wonder if I'm doing enough, and whether my processes for managing such information is useful and efficient. They didn't really teach us such things in nursing school, so creative seat-of-the-pants creativity is often the modus operandi.
On a daily basis, I use a printed spreadsheet to track my contacts with each of my 80-some-odd patients, whether it be an office visit, home visit, or telephone call. This list, which I carry in my bag, gives me a snapshot of who's in touch, who's on the ouskirts of my orbit, and who is apparently MIA. I also have another spreadsheet which tracks whether I have had contact with each patient on a monthly basis. When I see several blank spaces in a row for a particular patient, I know that a few months have passed my by without my having lay eyes on that person, or at least checked in by telephone. I am not expected to see every patient every month, but I'm expected to make attempts at contact, and document each attempt accordingly for the patient's chart. As all nurses have drummed into their heads during nursing school, "if you don't write it down, it never happened". So, I record every disconnected telephone number reached, unanswered call made, or other attempt at finding the ones who got away.
Looking at these crude devices which I have devised for my own obsessive-compulsive purposes, I can see in a glance who the freqent flyers are, who is avoiding me, who might be dead, or who perhaps is just under the radar. Unfortunately, there are a few who have a string of blank spaces on my log, demonstrating the fact that if they truly are out there, they just cannot be found without hiring a detective. Perhaps they like it that way. Perhaps they don't care.
Just recently, I learned that one patient who I have never met is now in jail. Over many months of trying to find her, I ran into dead end after dead end. (Did I say this would take a private eye?) When I would check the hospital computer system periodically, I would learn that she had been in the ER, and I would consequently scour the electronic medical record for an updated address or telephone number with which I might contact her. These leads would generally fail, but one eventually led me to this patient's grandmother, who informed me that her poor misguided grandchild finally ended up in jail. "At least we know where ______is. S/he's fed, clothed, and taken care of medically", she said. I empathized with her and promised to contact the jail (where our doctors run the show) and follow up on her family member's condition. At least I found him/her and my colleagues over at the "Big House" can check in.
Trying to follow eighty people relatively closely and keep them straight in my mind is a challenge. Of course, there are a number of patients with whom I have worked for more than five years, and these are especially well-known to me from the salad days of our organization when we had the luxury of miniscule caseloads of thirty. What luxury that was! We had the time to really build relationships then, holding our patients' hands through every twist and turn of the healthcare rollercoaster. Now, in our current iteration, I still do my best to provide personalized care, but there is just not enough time to do it justice. As much as I liked my old way of practicing, it just is not sustainable. The up side of such a change is that more responsibility is put on the patients' shoulders where it really should be, although many simply fall under the weight of their own myriad needs. How to find that balance of empowerment and assistance? A good question to which I have no answer.
So, this very tired and overworked nurse tries his best against long odds, and I watch my colleagues do the same. We go to extraordinary lengths---often disappointed, manipulated, and otherwise thwarted, but some rewarding moments sneak through almost daily. The chaos is sometimes overwhelming, as is the chaos of having 19 clinicians in a relatively small space all talking on phones, sending faxes, emailing, dashing for medical records, and catapulting in and out the door to and from home and office visits to our hundreds of patients. It is a perplexing exercise, often quite frustrating, and I often long for simplicity and quiet, something which is rarely seen and would probably feel somewhat pedestrian and boring compared to the general maelstrom with which I'm acquainted.
It's 8:30pm, I just finished my notes after having dinner with Mary, and now I write about my work to exorcise it from my mind so that I can move on with a relatively clear head to the rest of my evening. This is a frequent practice, the office frequently being a place where paperwork just cannot be finished in peace. I look forward to moving on to laundry, bills, perhaps some reading, some emails, and then the big reward---seven or eight hours of sleep---which will allow me to get up and do it all again. With "retirement"(is that even possible these days?) perhaps several decades away, most likely, I know that a change of pace will be needed soon. Such ongoing stress takes its toll, and there will come a day when it will be time to leave this harried rat-race behind. Til then, this rat will get back up on that wheel tomorrow, nose to the healthcare grindstone.
On a daily basis, I use a printed spreadsheet to track my contacts with each of my 80-some-odd patients, whether it be an office visit, home visit, or telephone call. This list, which I carry in my bag, gives me a snapshot of who's in touch, who's on the ouskirts of my orbit, and who is apparently MIA. I also have another spreadsheet which tracks whether I have had contact with each patient on a monthly basis. When I see several blank spaces in a row for a particular patient, I know that a few months have passed my by without my having lay eyes on that person, or at least checked in by telephone. I am not expected to see every patient every month, but I'm expected to make attempts at contact, and document each attempt accordingly for the patient's chart. As all nurses have drummed into their heads during nursing school, "if you don't write it down, it never happened". So, I record every disconnected telephone number reached, unanswered call made, or other attempt at finding the ones who got away.
Looking at these crude devices which I have devised for my own obsessive-compulsive purposes, I can see in a glance who the freqent flyers are, who is avoiding me, who might be dead, or who perhaps is just under the radar. Unfortunately, there are a few who have a string of blank spaces on my log, demonstrating the fact that if they truly are out there, they just cannot be found without hiring a detective. Perhaps they like it that way. Perhaps they don't care.
Just recently, I learned that one patient who I have never met is now in jail. Over many months of trying to find her, I ran into dead end after dead end. (Did I say this would take a private eye?) When I would check the hospital computer system periodically, I would learn that she had been in the ER, and I would consequently scour the electronic medical record for an updated address or telephone number with which I might contact her. These leads would generally fail, but one eventually led me to this patient's grandmother, who informed me that her poor misguided grandchild finally ended up in jail. "At least we know where ______is. S/he's fed, clothed, and taken care of medically", she said. I empathized with her and promised to contact the jail (where our doctors run the show) and follow up on her family member's condition. At least I found him/her and my colleagues over at the "Big House" can check in.
Trying to follow eighty people relatively closely and keep them straight in my mind is a challenge. Of course, there are a number of patients with whom I have worked for more than five years, and these are especially well-known to me from the salad days of our organization when we had the luxury of miniscule caseloads of thirty. What luxury that was! We had the time to really build relationships then, holding our patients' hands through every twist and turn of the healthcare rollercoaster. Now, in our current iteration, I still do my best to provide personalized care, but there is just not enough time to do it justice. As much as I liked my old way of practicing, it just is not sustainable. The up side of such a change is that more responsibility is put on the patients' shoulders where it really should be, although many simply fall under the weight of their own myriad needs. How to find that balance of empowerment and assistance? A good question to which I have no answer.
So, this very tired and overworked nurse tries his best against long odds, and I watch my colleagues do the same. We go to extraordinary lengths---often disappointed, manipulated, and otherwise thwarted, but some rewarding moments sneak through almost daily. The chaos is sometimes overwhelming, as is the chaos of having 19 clinicians in a relatively small space all talking on phones, sending faxes, emailing, dashing for medical records, and catapulting in and out the door to and from home and office visits to our hundreds of patients. It is a perplexing exercise, often quite frustrating, and I often long for simplicity and quiet, something which is rarely seen and would probably feel somewhat pedestrian and boring compared to the general maelstrom with which I'm acquainted.
It's 8:30pm, I just finished my notes after having dinner with Mary, and now I write about my work to exorcise it from my mind so that I can move on with a relatively clear head to the rest of my evening. This is a frequent practice, the office frequently being a place where paperwork just cannot be finished in peace. I look forward to moving on to laundry, bills, perhaps some reading, some emails, and then the big reward---seven or eight hours of sleep---which will allow me to get up and do it all again. With "retirement"(is that even possible these days?) perhaps several decades away, most likely, I know that a change of pace will be needed soon. Such ongoing stress takes its toll, and there will come a day when it will be time to leave this harried rat-race behind. Til then, this rat will get back up on that wheel tomorrow, nose to the healthcare grindstone.
Saturday, September 30, 2006
Late-Night Thoughts
Many are the wonders of having a physical body. The scent of flowers, the feeling of grass on the soles of one's feet, the taste of a favorite food, a glass of wine, the gaze of one's lover, the feast of looking at art, the crunch of a cucumber. Physical existence offers such breadth of experience, such sensual delight, such a plethora of feelings and sensations building one upon another in a crescendo of stimulation and experience.
And there are the disadvantages, the ways in which the physical becomes burdensome, even painful. A cyst grows on a nerve root in my lower spine, causing incessant contraction of muscles that are like ropes under the physical therapist's fingers. A malfunction in the junction of my esophagus and stomach allows gastric secretions to bubble up and cause me discomfort. My step-dad's pancreas harbors an uncontrollably growing mass. My dog's kidneys failed, and twenty-eight days ago we eased his spirit from his tired old body and placed that beloved furry body in a hole in the earth. The ache which I feel from his absence is like a physical pain, although I know that it is not.
Life offers such contrast, such dichotomy of feeling and experience. Most of us would agree that it is better to have loved and lost then never to have loved, yet in that moment of loss it seems the pain will last forever. In the joyousness of health we leap through life and take our bodies' wholeness for granted. And when illness strikes, we long for the carefree days before we felt betrayed by that collection of cells we call our own. But is it truly a betrayal, or simply just another way of being in that body, of embodying our own existence?
Of course, we in the health and medical fields see optimal health---physical, mental, spiritual---as the goal of our work, and the desire of all. But there are those who seem to suffer---often from birth---from afflictions and illnesses over which they have no control. And even those individuals find meaning and purpose in life, often in spite of, or perhaps because of, their suffering.
At birth, our parents hope to see ten toes and fingers, an even number of limbs, hear a healthy cry, and observe us engaging the world with that first magical breath that transforms us from an aquatic cosmonaut to a terrestrial creature with feet on the ground and head in the sky. This long process called life offers such opportunity, such room for growth and transformation, and as parents we hold a vision of life without pain and suffering for our offspring.
But this business of having a body brings with it great risks as well. Illness, suffering, pain, loss, malfunction, death---they are all here with us on our journeys around the sun.
Working as I do with the chronically ill, I see some of the worst things that can happen to a body, the afflictions and struggles which can beset a human on his or her trajectory through this earthly existence. I can only conclude that there is great beauty in life---even in death---and that suffering, in its myriad forms, offers its own stark beauty, its own language of learning and growth. Still, I mourn for those who suffer needlessly, who experience torture, rape, brutality, and other unspeakable indignities, and I hope that even those who suffer so, when released from that suffering, know a peace beyond that which is imaginable for us remaining here on this three-dimensional side of the veil. My hope would be that it is so.
I will take the years offered to me and try to use them well. Pain and suffering be damned, there is nothing else to do but take this life in my own two hands and shape it with the force of my will. On this third ball of dust from the star we call The Sun, our lives unfold as so many stories of bodies and minds and hearts in motion. In pleasure or pain, life is what it is, and we simply take each day and live it as our truth, since no truth can be clearer than the one confonting us in the mirror each morning. And when you look in that mirror tomorrow, what, pray tell, will you say?
And there are the disadvantages, the ways in which the physical becomes burdensome, even painful. A cyst grows on a nerve root in my lower spine, causing incessant contraction of muscles that are like ropes under the physical therapist's fingers. A malfunction in the junction of my esophagus and stomach allows gastric secretions to bubble up and cause me discomfort. My step-dad's pancreas harbors an uncontrollably growing mass. My dog's kidneys failed, and twenty-eight days ago we eased his spirit from his tired old body and placed that beloved furry body in a hole in the earth. The ache which I feel from his absence is like a physical pain, although I know that it is not.
Life offers such contrast, such dichotomy of feeling and experience. Most of us would agree that it is better to have loved and lost then never to have loved, yet in that moment of loss it seems the pain will last forever. In the joyousness of health we leap through life and take our bodies' wholeness for granted. And when illness strikes, we long for the carefree days before we felt betrayed by that collection of cells we call our own. But is it truly a betrayal, or simply just another way of being in that body, of embodying our own existence?
Of course, we in the health and medical fields see optimal health---physical, mental, spiritual---as the goal of our work, and the desire of all. But there are those who seem to suffer---often from birth---from afflictions and illnesses over which they have no control. And even those individuals find meaning and purpose in life, often in spite of, or perhaps because of, their suffering.
At birth, our parents hope to see ten toes and fingers, an even number of limbs, hear a healthy cry, and observe us engaging the world with that first magical breath that transforms us from an aquatic cosmonaut to a terrestrial creature with feet on the ground and head in the sky. This long process called life offers such opportunity, such room for growth and transformation, and as parents we hold a vision of life without pain and suffering for our offspring.
But this business of having a body brings with it great risks as well. Illness, suffering, pain, loss, malfunction, death---they are all here with us on our journeys around the sun.
Working as I do with the chronically ill, I see some of the worst things that can happen to a body, the afflictions and struggles which can beset a human on his or her trajectory through this earthly existence. I can only conclude that there is great beauty in life---even in death---and that suffering, in its myriad forms, offers its own stark beauty, its own language of learning and growth. Still, I mourn for those who suffer needlessly, who experience torture, rape, brutality, and other unspeakable indignities, and I hope that even those who suffer so, when released from that suffering, know a peace beyond that which is imaginable for us remaining here on this three-dimensional side of the veil. My hope would be that it is so.
I will take the years offered to me and try to use them well. Pain and suffering be damned, there is nothing else to do but take this life in my own two hands and shape it with the force of my will. On this third ball of dust from the star we call The Sun, our lives unfold as so many stories of bodies and minds and hearts in motion. In pleasure or pain, life is what it is, and we simply take each day and live it as our truth, since no truth can be clearer than the one confonting us in the mirror each morning. And when you look in that mirror tomorrow, what, pray tell, will you say?
Thursday, September 28, 2006
Housing Hell
I watched the cockroaches crawl around the clean laundry in the basket next to the couch as I took my patient's blood pressure. I noted the single-pane windows, wondering about the coming winter's bitter cold. My patient complained to me that this apartment--to which she moved after we requested a first-floor apartment for her---has floors which are harshly askew, causing her to fall frequently.
I wandered around the apartment, noting clearly that the floors do indeed slant in one direction or another in each room, at times to a considerable degree. Her daughters, able-bodied and young, say that even they sometimes lose their footing from the missteps they take on the floors which are not unlike those in a carnival fun-house. My patient, who suffers from arthritis so severe that she receives intravenous chemotherapy every two months, has a difficult time negotiating the apartment, a cause of much frustration and anger on her part. This move to the first floor from the fourth is fraught with new challenges, and perhaps has been for the worse.
When I first met her, she lived in the building next door on a fourth-floor walk-up, the stairs becoming an increasing challenge as her disability worsened. I drafted a strongly worded letter to the landlord asking for urgent placement in a first-floor residence, or a building with reliable elevators. The landlord responded quickly but didn't even give her a chance to see the apartment. Before she knew it, she was moving, and the askance floors were immediately apparent. Several falls later, I'm considering my next steps. This is housing "approved" for Section 8---hasn't it been inspected? Are there structural problems with the underpinnings of the building which might endanger those on the upper floors? There is obviously something wrong. While I am not a social worker, these are battles I often choose to wage, and this one may cost me a great deal of time and effort. But if she breaks a hip, all hell will break loose and I want to head that disaster off at the pass.
Substandard housing for the poor is commonplace all over the world, and the United States is sadly no exception. Even low-ranking soldiers in the military live in government-issued housing that most of us would find unacceptable. When did viable housing become a priviledge in this society? Probably around 1492.
In my time as a nurse working in the community, I have seen some housing situations which were utterly appalling. An older gentleman with a unilateral leg amputation who I used to know lived in a hovel behind his nephew's house, wheeling himself over floor-boards decrepit with age and rot, a large hole in the bathroom floor daily threatening to swallow his wheelchair. I've seen rats, cockroaches, holes in floors, broken windows, missing locks, lack of ventilation, stifling heat in summer, lack of proper heating in winter, the list goes on. Granted, some public housing is abused by some tenants, slums becoming such when they are neglected and trashed by uncaring residents. But one must look sociologically at the source of the rage that damages such properties. As I have said before, those who feel cast aside and uncared for by society will, by default, be uncaring for their environment, and perhaps for their own well-being. Our responsibility to house the needy is enormous, and we are, in my estimate, failing miserably on many fronts.
There are some examples in our area of excellent housing for the elderly and disabled. Nicely maintained, with common rooms, landscaping, excellent security and organized social gatherings, these residences could serve as models for others. On the contrary, one year after Hurricane Katrina, there are still squabbles about what type of viable housing---aside from FEMA trailers--- to provide for those displaced by the storm. Luckily, some groups of service-oriented architects are creating models of cheap, durable housing which can be freely copied and altered---in a manner similar to open-source freeware on the Internet---a practice which may transform the idea of affordable housing for the future.
But that future seems far away as my patient slips and slides along her not-so-fun-house floors, and my rising ire against a corrupt system which provides such abominable living conditions for the most vulnerable among us slowly turns to rage. The housing authority in the city in which I work has lately been revealed to be rife with corruption of the most reprehensible kind. A prominent family bilked the authority of millions of dollars over many years, allowing said family's members extravagant home improvements while the poor of the city languished in substandard dwellings. For those individuals who were sent to jail, good riddance, and their post-release community service should include five years of living in the worst of the public housing for which they were responsible creating and maintaining in its sorry state. If that type of corruption is not a source of rage, I don't know what is.
So, it seems that for all of us out there fighting the good fight on behalf of those not able to fight on their own and win, there are others who will take advantage, corrupt the system, and provide shoddy work and horrible conditions in the interest of saving money and advancing their own wealth. If it didn't make me so angry, it would bring me to tears.
Someone might ask, is this what a nurse does? Is this how a nurse thinks? Should a nurse even involve him- or herself in such societal issues? The easy answer is "of course". Physical, emotional, and spiritual health has myriad aspects and properties, and the health of the home, the place where one rests one's head, has an enormous impact on one's sense of health, safety, and groundedness. A home which does not offer that which a person needs for their own protection and security and comfort is a home which lessens that individual's ability to be whole, to be productive, to feel valued.
The frustration in the eyes and voice of my patient who is negotiating those off-kilter floors is filtering down into her sense of self, her sense of her relative health, her well-being, her groundedness. How can one feel grounded when the floor beneath one's feet can fool the eye and the foot? Housing certainly is a right, not a priviledge, and those rights are generally worth a good fight. I think I'll be taking off the gloves tomorrow.
I wandered around the apartment, noting clearly that the floors do indeed slant in one direction or another in each room, at times to a considerable degree. Her daughters, able-bodied and young, say that even they sometimes lose their footing from the missteps they take on the floors which are not unlike those in a carnival fun-house. My patient, who suffers from arthritis so severe that she receives intravenous chemotherapy every two months, has a difficult time negotiating the apartment, a cause of much frustration and anger on her part. This move to the first floor from the fourth is fraught with new challenges, and perhaps has been for the worse.
When I first met her, she lived in the building next door on a fourth-floor walk-up, the stairs becoming an increasing challenge as her disability worsened. I drafted a strongly worded letter to the landlord asking for urgent placement in a first-floor residence, or a building with reliable elevators. The landlord responded quickly but didn't even give her a chance to see the apartment. Before she knew it, she was moving, and the askance floors were immediately apparent. Several falls later, I'm considering my next steps. This is housing "approved" for Section 8---hasn't it been inspected? Are there structural problems with the underpinnings of the building which might endanger those on the upper floors? There is obviously something wrong. While I am not a social worker, these are battles I often choose to wage, and this one may cost me a great deal of time and effort. But if she breaks a hip, all hell will break loose and I want to head that disaster off at the pass.
Substandard housing for the poor is commonplace all over the world, and the United States is sadly no exception. Even low-ranking soldiers in the military live in government-issued housing that most of us would find unacceptable. When did viable housing become a priviledge in this society? Probably around 1492.
In my time as a nurse working in the community, I have seen some housing situations which were utterly appalling. An older gentleman with a unilateral leg amputation who I used to know lived in a hovel behind his nephew's house, wheeling himself over floor-boards decrepit with age and rot, a large hole in the bathroom floor daily threatening to swallow his wheelchair. I've seen rats, cockroaches, holes in floors, broken windows, missing locks, lack of ventilation, stifling heat in summer, lack of proper heating in winter, the list goes on. Granted, some public housing is abused by some tenants, slums becoming such when they are neglected and trashed by uncaring residents. But one must look sociologically at the source of the rage that damages such properties. As I have said before, those who feel cast aside and uncared for by society will, by default, be uncaring for their environment, and perhaps for their own well-being. Our responsibility to house the needy is enormous, and we are, in my estimate, failing miserably on many fronts.
There are some examples in our area of excellent housing for the elderly and disabled. Nicely maintained, with common rooms, landscaping, excellent security and organized social gatherings, these residences could serve as models for others. On the contrary, one year after Hurricane Katrina, there are still squabbles about what type of viable housing---aside from FEMA trailers--- to provide for those displaced by the storm. Luckily, some groups of service-oriented architects are creating models of cheap, durable housing which can be freely copied and altered---in a manner similar to open-source freeware on the Internet---a practice which may transform the idea of affordable housing for the future.
But that future seems far away as my patient slips and slides along her not-so-fun-house floors, and my rising ire against a corrupt system which provides such abominable living conditions for the most vulnerable among us slowly turns to rage. The housing authority in the city in which I work has lately been revealed to be rife with corruption of the most reprehensible kind. A prominent family bilked the authority of millions of dollars over many years, allowing said family's members extravagant home improvements while the poor of the city languished in substandard dwellings. For those individuals who were sent to jail, good riddance, and their post-release community service should include five years of living in the worst of the public housing for which they were responsible creating and maintaining in its sorry state. If that type of corruption is not a source of rage, I don't know what is.
So, it seems that for all of us out there fighting the good fight on behalf of those not able to fight on their own and win, there are others who will take advantage, corrupt the system, and provide shoddy work and horrible conditions in the interest of saving money and advancing their own wealth. If it didn't make me so angry, it would bring me to tears.
Someone might ask, is this what a nurse does? Is this how a nurse thinks? Should a nurse even involve him- or herself in such societal issues? The easy answer is "of course". Physical, emotional, and spiritual health has myriad aspects and properties, and the health of the home, the place where one rests one's head, has an enormous impact on one's sense of health, safety, and groundedness. A home which does not offer that which a person needs for their own protection and security and comfort is a home which lessens that individual's ability to be whole, to be productive, to feel valued.
The frustration in the eyes and voice of my patient who is negotiating those off-kilter floors is filtering down into her sense of self, her sense of her relative health, her well-being, her groundedness. How can one feel grounded when the floor beneath one's feet can fool the eye and the foot? Housing certainly is a right, not a priviledge, and those rights are generally worth a good fight. I think I'll be taking off the gloves tomorrow.
Monday, September 25, 2006
Dizzy-less
I guess the spiritual Dramamine worked. The vertiginous feeling subsided and the working week began without dizzy spells, despite a poor night's sleep.
This is the second week which has begun gently, without the Monday morning explosion of need that can at times feel crippling. I even had spare time to offer a co-worker help with some debilitatingly tedious paperwork. That's one for the karma bank, I guess.
Each month, I try to at least make some effort towards contact of every patient on my caseload. Using the small spreadsheets that I've created to assist with this task, I keep track of who's been contacted, who's MIA, who hasn't returned my calls, who doesn't have a phone and was sent a letter. As the end of the month nears, I peruse my lists for a snapshot of the month's heavy hitters and frequent flyers, and it is blantantly clear who has not surfaced at all.
In care management, case management, and any situation in which many people are on a panel for one provider, it is always classically the squeaky wheel who gets the grease. The patient who calls incessantly, makes alot of noise and demands action---that's the person who consequently gets the attention. Most of those attention-getters are savvy and know how to capture me and focus my gaze in their direction, and their efforts are generally rewarded. For those who abuse it, they may be reprimanded gently and asked to consolidate their multitude of calls into just a handful, saving up problems and questions for a once-weekly check-in.
One patient of mine is very dear to my heart. She has multiple medical problems which are not necessary to this story, only to say that her pain and other symptoms cause her considerable distress and worry, leading her to schedule a plethora of appointments, often unnecessarily. Her children also have many medical and psychological problems themselves, and at times I wonder if she may display some symptoms of Munchausen Syndrome by Proxy, although I'm also aware of a movement of mothers who advocate against unnecssary and false allegations of Munchausens. That said, it's a very sickly family no matter how you look at it.
In terms of squeaky wheels, I guess she takes the prize, calling me with the most trivial news. To wit, "I'm just calling to tell you that the pharmacy only had ten of my pills and I'll have to pick up the rest tomorrow," or "I just called for my refills and they'll deliver them on Friday." Her sweetness and childlike innocence prevent me from getting too annoyed, and I occasionally ever-so-gently request that she not call with such trivial messages. I counter these comments with praise for her ability to keep track of a multitude of appointments and prescriptions needing constant attention and vigiliance. She may be a little mentally slow, but she is anything but disempowered. She may be a squeaky wheel, but she does it with such innocent guilessness. She really is a peach.
There are enough moments of sweetness and connection to keep me afloat, even amidst the onslaught of stress. I have to hold onto those moments like oases in the maelstrom, and try to let the stress simply flow by instead of drowning me in its tumult. Today was a success in that regard. May tomorrow be moreso.
This is the second week which has begun gently, without the Monday morning explosion of need that can at times feel crippling. I even had spare time to offer a co-worker help with some debilitatingly tedious paperwork. That's one for the karma bank, I guess.
Each month, I try to at least make some effort towards contact of every patient on my caseload. Using the small spreadsheets that I've created to assist with this task, I keep track of who's been contacted, who's MIA, who hasn't returned my calls, who doesn't have a phone and was sent a letter. As the end of the month nears, I peruse my lists for a snapshot of the month's heavy hitters and frequent flyers, and it is blantantly clear who has not surfaced at all.
In care management, case management, and any situation in which many people are on a panel for one provider, it is always classically the squeaky wheel who gets the grease. The patient who calls incessantly, makes alot of noise and demands action---that's the person who consequently gets the attention. Most of those attention-getters are savvy and know how to capture me and focus my gaze in their direction, and their efforts are generally rewarded. For those who abuse it, they may be reprimanded gently and asked to consolidate their multitude of calls into just a handful, saving up problems and questions for a once-weekly check-in.
One patient of mine is very dear to my heart. She has multiple medical problems which are not necessary to this story, only to say that her pain and other symptoms cause her considerable distress and worry, leading her to schedule a plethora of appointments, often unnecessarily. Her children also have many medical and psychological problems themselves, and at times I wonder if she may display some symptoms of Munchausen Syndrome by Proxy, although I'm also aware of a movement of mothers who advocate against unnecssary and false allegations of Munchausens. That said, it's a very sickly family no matter how you look at it.
In terms of squeaky wheels, I guess she takes the prize, calling me with the most trivial news. To wit, "I'm just calling to tell you that the pharmacy only had ten of my pills and I'll have to pick up the rest tomorrow," or "I just called for my refills and they'll deliver them on Friday." Her sweetness and childlike innocence prevent me from getting too annoyed, and I occasionally ever-so-gently request that she not call with such trivial messages. I counter these comments with praise for her ability to keep track of a multitude of appointments and prescriptions needing constant attention and vigiliance. She may be a little mentally slow, but she is anything but disempowered. She may be a squeaky wheel, but she does it with such innocent guilessness. She really is a peach.
There are enough moments of sweetness and connection to keep me afloat, even amidst the onslaught of stress. I have to hold onto those moments like oases in the maelstrom, and try to let the stress simply flow by instead of drowning me in its tumult. Today was a success in that regard. May tomorrow be moreso.
Sunday, September 24, 2006
Vertiginous
vertiginous \vur-TIJ-uh-nuhs\, adjective:
1. Affected with vertigo; giddy; dizzy.
2. Causing or tending to cause dizziness.
3. Turning round; whirling; revolving.
4. Inclined to change quickly or frequently; inconstant.
Dictionary.com is a wonderful source of fodder for the fatigued blogger, and today's Word of the Day sums it all up nicely.
These last weeks have been vertigo-inducing, with stress, sadness, grief, and anxiety to the fore, not to mention physical pain. At work, the constant river of complaints and maladies coming from my patients often manages to distract me from my own preoccupations, sometimes thankfully, sometimes annoyingly so. Sometimes I resent the distraction, and just want to focus on me. But for those eight hours each weekday, my needs and life take an ersatz back seat. Such is a life of service.
The dizzying pace of work often erroneously precludes self-care, and work at times seems to diminish rather than augment one's personal life. This is an unfortunate but true reality for many of us who work outside of the home and absent ourselves from our personal lives for nine or ten hours each day. Just trying to take time to call one's doctor or arrange a personal appointment while at work can seem like an enormous undertaking. When one works all day forty minutes from home, how does one take the dog to the vet, care for sick children, go to the dentist, pay bills, advocate for ageing parents, and otherwise manage the complexities of life? This daily separation from the needs of the homestead and family can weigh on the soul.
Now, we can't all be farmers living and working on our own land, and most of us wouldn't want to, anyway, and many a farmer would tell you that the lifestyle and hard work is not all it's cracked up to be. Those who are self-employed and work at home might long for an office to escape to, away from kids, dogs, laundry, and the myriad distractions that working at home would offer. At home, it would be so easy to decide to wash the dishes or organize the closet rather than get down to work. It's a wonder so many of us are unhappy and stressed. Are we trapped in a world we never made? Or are we simply not made for the world in which we are trapped? Nonetheless, here we are, and however vertiginous, our lives are of our making, our design. It's only a trap if we see it as such. Imprisonment is in the eye (and heart or soul) of the beholder.
So, at this juncture, at the dizzying age of 43, feeling set upon by the vicissitudes of a responsible adult life feeling slightly beyond my control, I will take my spiritual Dramamine and call you in the morning. Thus warned, I wouldn't blame you for leaving the phone off the hook.
1. Affected with vertigo; giddy; dizzy.
2. Causing or tending to cause dizziness.
3. Turning round; whirling; revolving.
4. Inclined to change quickly or frequently; inconstant.
Dictionary.com is a wonderful source of fodder for the fatigued blogger, and today's Word of the Day sums it all up nicely.
These last weeks have been vertigo-inducing, with stress, sadness, grief, and anxiety to the fore, not to mention physical pain. At work, the constant river of complaints and maladies coming from my patients often manages to distract me from my own preoccupations, sometimes thankfully, sometimes annoyingly so. Sometimes I resent the distraction, and just want to focus on me. But for those eight hours each weekday, my needs and life take an ersatz back seat. Such is a life of service.
The dizzying pace of work often erroneously precludes self-care, and work at times seems to diminish rather than augment one's personal life. This is an unfortunate but true reality for many of us who work outside of the home and absent ourselves from our personal lives for nine or ten hours each day. Just trying to take time to call one's doctor or arrange a personal appointment while at work can seem like an enormous undertaking. When one works all day forty minutes from home, how does one take the dog to the vet, care for sick children, go to the dentist, pay bills, advocate for ageing parents, and otherwise manage the complexities of life? This daily separation from the needs of the homestead and family can weigh on the soul.
Now, we can't all be farmers living and working on our own land, and most of us wouldn't want to, anyway, and many a farmer would tell you that the lifestyle and hard work is not all it's cracked up to be. Those who are self-employed and work at home might long for an office to escape to, away from kids, dogs, laundry, and the myriad distractions that working at home would offer. At home, it would be so easy to decide to wash the dishes or organize the closet rather than get down to work. It's a wonder so many of us are unhappy and stressed. Are we trapped in a world we never made? Or are we simply not made for the world in which we are trapped? Nonetheless, here we are, and however vertiginous, our lives are of our making, our design. It's only a trap if we see it as such. Imprisonment is in the eye (and heart or soul) of the beholder.
So, at this juncture, at the dizzying age of 43, feeling set upon by the vicissitudes of a responsible adult life feeling slightly beyond my control, I will take my spiritual Dramamine and call you in the morning. Thus warned, I wouldn't blame you for leaving the phone off the hook.
Saturday, September 23, 2006
Autumnal Musings and Confusions
Autumn arrives today with a cold rain and threats of frost over the last few nights. The rain precludes lighting a candle at sunset on my dog's grave---something I have done almost every night since his passing 21 days ago---but we can still light candles for him indoors with the same sacred and loving intention. The spirit world does not stand on ceremony, at least in my definition of such.
As summer comes to an end, the days of kids playing in the water park adjacent to our clinic also cease. Now hordes of children file past our office at 3pm every afternoon, backpacks and books over some shoulders, many sheets of paper and homework strewn on the already littered ground. Once past the crossing guard near the school across the street, the kids stream through our busy parking lot, slipping between cars, darting into traffic, locking eyes with drivers and silently challenging them to do anything about this daily invasion of youth. What worries me are the reckless drivers---both male and female---throughout the city where we work and thankfully do not live. Traffic lights and stop signs seem to mean little. Forget yield signs. They may as well not exist. Crowded residential streets are just freeways, and as a driver, I am often challenged by cars coming in the opposite direction who seem to intentionally drive in my lane, forcing me to slow down to avoid a head-on collision. It's chaos, and makes our crowded but rather pedestrian town look like a haven, which it is not.
Outside of our office yesterday, a fight between two boys broke out, a crowd of at least 100 kids quickly coalescing around the protagonists. We have broken up a number of these fights over time, and it seems that whenever we do so, one of our windows is invariably broken shortly thereafter. So yesterday we called the clinic security officer and he called for a cruiser. Our Latino colleagues with whom I work seem to take these periodic fights nonchalantly and are hesitant to get involved at all. Having grown up in Brooklyn, The Bronx, and elsewhere, they see these youthful turf battles as normal, although I'm sure they advise their own children to steer clear of such violence. I usually want to run outside and break it up, but they warn me that these days middle-school kids can be just as likely as teenagers or adults to carry knives or guns. However, just the sight of an adult with an official badge and a stethoscope around the neck can end most any fight. But am I just another example of a white do-gooder imposing my culture and ideals on a community where I don't live?
Other autumnal signs are the mums which were planted in the front of the clinic to spruce up the landscaping. Within several days, a few of the plants were dug up and stolen, a few others simply mutilated. Our landscaping is often vandalized, and sometimes I wonder why we bother, already spending hundreds on new windows and paint to cover graffiti. One must choose one's battles carefully.
Working in an area where poverty is prevalent, one becomes inured to litter, trash in the streets, the detritus of drug use, used condoms, and vandalism. Our office has thankfully avoided any broken windows for over three months after a rash of violence that cost us several thousand dollars. The schoolchildren fight periodically, the plants are stolen, the sidewalks plastered with school papers dropped like so much forgotten junk. I see families with small children walking along, the parents equally tossing candy wrappers, bags and juice cartons to the round, modelling for their children behavior which can last a lifetime. It can all come down to one notion, I guess: if you feel undervalued by the world and society at large, you will in turn undervalue that world yourself. You may even undervalue your own health. And that's where it comes around and bites you on the bottom.
I try not to be jaded. I try to approach these situations with a fresh perspective. I endeavor to also exmaine my own motives and reasonings. Today the beginnings of Autumn bring some sadness and a sense of loss as the deneoument of Summer comes to its anticlimatic completion. But here we are, and here we remain. Welcome Autumn, and may you lead us gently into the deep cold days of Winter.
As summer comes to an end, the days of kids playing in the water park adjacent to our clinic also cease. Now hordes of children file past our office at 3pm every afternoon, backpacks and books over some shoulders, many sheets of paper and homework strewn on the already littered ground. Once past the crossing guard near the school across the street, the kids stream through our busy parking lot, slipping between cars, darting into traffic, locking eyes with drivers and silently challenging them to do anything about this daily invasion of youth. What worries me are the reckless drivers---both male and female---throughout the city where we work and thankfully do not live. Traffic lights and stop signs seem to mean little. Forget yield signs. They may as well not exist. Crowded residential streets are just freeways, and as a driver, I am often challenged by cars coming in the opposite direction who seem to intentionally drive in my lane, forcing me to slow down to avoid a head-on collision. It's chaos, and makes our crowded but rather pedestrian town look like a haven, which it is not.
Outside of our office yesterday, a fight between two boys broke out, a crowd of at least 100 kids quickly coalescing around the protagonists. We have broken up a number of these fights over time, and it seems that whenever we do so, one of our windows is invariably broken shortly thereafter. So yesterday we called the clinic security officer and he called for a cruiser. Our Latino colleagues with whom I work seem to take these periodic fights nonchalantly and are hesitant to get involved at all. Having grown up in Brooklyn, The Bronx, and elsewhere, they see these youthful turf battles as normal, although I'm sure they advise their own children to steer clear of such violence. I usually want to run outside and break it up, but they warn me that these days middle-school kids can be just as likely as teenagers or adults to carry knives or guns. However, just the sight of an adult with an official badge and a stethoscope around the neck can end most any fight. But am I just another example of a white do-gooder imposing my culture and ideals on a community where I don't live?
Other autumnal signs are the mums which were planted in the front of the clinic to spruce up the landscaping. Within several days, a few of the plants were dug up and stolen, a few others simply mutilated. Our landscaping is often vandalized, and sometimes I wonder why we bother, already spending hundreds on new windows and paint to cover graffiti. One must choose one's battles carefully.
Working in an area where poverty is prevalent, one becomes inured to litter, trash in the streets, the detritus of drug use, used condoms, and vandalism. Our office has thankfully avoided any broken windows for over three months after a rash of violence that cost us several thousand dollars. The schoolchildren fight periodically, the plants are stolen, the sidewalks plastered with school papers dropped like so much forgotten junk. I see families with small children walking along, the parents equally tossing candy wrappers, bags and juice cartons to the round, modelling for their children behavior which can last a lifetime. It can all come down to one notion, I guess: if you feel undervalued by the world and society at large, you will in turn undervalue that world yourself. You may even undervalue your own health. And that's where it comes around and bites you on the bottom.
I try not to be jaded. I try to approach these situations with a fresh perspective. I endeavor to also exmaine my own motives and reasonings. Today the beginnings of Autumn bring some sadness and a sense of loss as the deneoument of Summer comes to its anticlimatic completion. But here we are, and here we remain. Welcome Autumn, and may you lead us gently into the deep cold days of Winter.
Wednesday, September 20, 2006
Hitting Home
With my step-dad diagnosed with inoperable pancreatic cancer, my nurse's brain is turned towards family. With me five hours away, my sister fifteen hours away, and my brother one hour away, there's alot to finesse and figure out about how his care will unfold. I will not go into specifics here as it would be unproductive, but I will say that I now find myself in the position of acting as Nurse Care Manager for my parents.
Emails are flying back and forth between the sibs and their spouses, trying to come to terms with the challenges ahead. One of my personal edges is figuring out how to think clearly and clinically about the situation, not losing sight of the fact that this is my loved one who is the source of my concern and interest. The difficult and somewhat contradictory trick is to not let my emotions cloud my thinking, while at the same time not let my clinical focus supercede the emotions which are now understandably reeling.
Based upon my observations of patients receiving dire news and undergoing life-transforming and potentially debilitating treatments, the astute nurse must treat the family as a system and contend with the problems at hand systemically, holistically. Now, I have no illusions that I can do that, but I do see that I carry the most medical information in my head, and have the greatest understanding of the system, the treatments, the potential roadblocks, and the places where I consistently see errors made.
Obviously, I want to forsee as many areas of challenge as I can, attempting to head some of these wild horses off at the pass, perhaps even completely avoiding some problems which might otherwise have reared their ugly heads. But I also realize that, in my human frailty and emotional connection to the situation, I can only do so much. There are other professionals who I might elect to pull into this process, and the family will all pull together to see this through to whatever end we must.
The reality of the situation hits home, and as I attempt to orchestrate what I see as necessary to arrange, I grapple with the emotions which now swim in my already crowded mind.
I pray for peace and clarity, and freedom from suffering for all.
Emails are flying back and forth between the sibs and their spouses, trying to come to terms with the challenges ahead. One of my personal edges is figuring out how to think clearly and clinically about the situation, not losing sight of the fact that this is my loved one who is the source of my concern and interest. The difficult and somewhat contradictory trick is to not let my emotions cloud my thinking, while at the same time not let my clinical focus supercede the emotions which are now understandably reeling.
Based upon my observations of patients receiving dire news and undergoing life-transforming and potentially debilitating treatments, the astute nurse must treat the family as a system and contend with the problems at hand systemically, holistically. Now, I have no illusions that I can do that, but I do see that I carry the most medical information in my head, and have the greatest understanding of the system, the treatments, the potential roadblocks, and the places where I consistently see errors made.
Obviously, I want to forsee as many areas of challenge as I can, attempting to head some of these wild horses off at the pass, perhaps even completely avoiding some problems which might otherwise have reared their ugly heads. But I also realize that, in my human frailty and emotional connection to the situation, I can only do so much. There are other professionals who I might elect to pull into this process, and the family will all pull together to see this through to whatever end we must.
The reality of the situation hits home, and as I attempt to orchestrate what I see as necessary to arrange, I grapple with the emotions which now swim in my already crowded mind.
I pray for peace and clarity, and freedom from suffering for all.
Monday, September 18, 2006
Navigating the Seas
They all seem to be navigating the seas of illness and the healthcare system. Doors close, doors open, opportunities are squandered, some forever lost. We serve as lighthouses, buoys, but sometimes even we can't save them.
There are surprises: a patient will take it upon themselves to advocate, to go after what they want, self-refer if need be, and make enough noise to be heard above the din. Of my eighty-three souls for whom I have been given some modicum of responsibility, the squeaky wheels do indeed get the grease. The ones who call constantly, ask for help, push for results, they receive the lion's share of my attention, by default. The others, the silent ones, they get drummed up when I have time to pursue them, as I poke in the corners of my case-load for hangers-on who just don't seem to connect the dots, or perhaps care not to do so. Even so, I seek them out and attempt to shine the light of compassion upon them. Some refuse, and they stay in the corners, still on my radar, faint bleeps of presence on the periphery.
Meanwhile, as some hover in the wings, others enter stage left with a flourish, demanding attention, flaunting their needs, shouting their ills to the seats in the balcony. Me, I'm in the orchestra, and I heed their call and strike up the band to accompany their soliloquy, make sense of their chaos, and elucidate what costumes and props we'll need for the next scene. Some scenes necessitate elaborate choreography, others are like a play by Sartre---stark, without affect, moving yet in no need of ostentatious staging. Still others are like a scene from Fellini, too difficult to describe----you just have to be there.
Our office would make a great prime-time drama: "Nurses on the Edge". There's drama, sex, violence, gangs, passion, drugs, crime, wisdom, tears, uproarious laughter. I think I'd want to be played by Ben Stiller (he played a Jewish male nurse in Meet the Parents, after all).
These seas are rough, and today I longed for a life-boat, or at least to exit gracefully stage left. But before I mix any more metaphors tonight, I'll simply admit that it's a wild ride, and I guess I'll hang on for dear life for a while longer. The life-jacket's at the ready, the life-boat a resume away.......
There are surprises: a patient will take it upon themselves to advocate, to go after what they want, self-refer if need be, and make enough noise to be heard above the din. Of my eighty-three souls for whom I have been given some modicum of responsibility, the squeaky wheels do indeed get the grease. The ones who call constantly, ask for help, push for results, they receive the lion's share of my attention, by default. The others, the silent ones, they get drummed up when I have time to pursue them, as I poke in the corners of my case-load for hangers-on who just don't seem to connect the dots, or perhaps care not to do so. Even so, I seek them out and attempt to shine the light of compassion upon them. Some refuse, and they stay in the corners, still on my radar, faint bleeps of presence on the periphery.
Meanwhile, as some hover in the wings, others enter stage left with a flourish, demanding attention, flaunting their needs, shouting their ills to the seats in the balcony. Me, I'm in the orchestra, and I heed their call and strike up the band to accompany their soliloquy, make sense of their chaos, and elucidate what costumes and props we'll need for the next scene. Some scenes necessitate elaborate choreography, others are like a play by Sartre---stark, without affect, moving yet in no need of ostentatious staging. Still others are like a scene from Fellini, too difficult to describe----you just have to be there.
Our office would make a great prime-time drama: "Nurses on the Edge". There's drama, sex, violence, gangs, passion, drugs, crime, wisdom, tears, uproarious laughter. I think I'd want to be played by Ben Stiller (he played a Jewish male nurse in Meet the Parents, after all).
These seas are rough, and today I longed for a life-boat, or at least to exit gracefully stage left. But before I mix any more metaphors tonight, I'll simply admit that it's a wild ride, and I guess I'll hang on for dear life for a while longer. The life-jacket's at the ready, the life-boat a resume away.......
Saturday, September 16, 2006
Courage
"Courage is a weapon we must use." ---Over The Rhine
The Cowardly Lion of Wizard of Oz fame got it mostly right. Courage is indeed part and parcel of living a full throttle life, and it's something we must cultivate from day to day, moment to moment, as life challenges us and throws its ubiquitous curve-balls. And sometimes those curve-balls just keep coming.
Yesterday I travelled to a relatively distant Northeastern city to accomany my step-father to an appointment at a large hospital. He has what turns out to be a inoperable tumor of the pancreas---inoperable because it's wrapped around the celiac access artery, making resection too risky. Thus, chemo and radiation ensue, and if that doesn't call for courage, I don't know what does.
For many, simply getting out of bed in the morning is an act of heroism. For all the talk of heroes these days---whether they be of the costumed superlative type, or the anonymous garden variety public servant who rushes into burning buildings to save strangers---there are many among us who have been, are, and will continue to be unsung, perhaps only to be feted by their loved ones upon their passing from this earth, that is if they have loved ones to celebrate them at all.
Pain, infirmity, loss of function, economic loss, grief, loneliness---so many are challenged by these life-limiting effects of disease and death. Still, so many also simply wake up each morning, set feet upon the earth, and move through yet another day, perhaps lucky enough to be kissed by sunlight or breeze, take a few moments to touch the soft fur of a dog, or feel the tickle of a dragonfly taking momentary respite on the back of one's hand.
We are challenged at every turn: our patience, our tolerance, our ability to listen, to feel, to communicate, to observe, to respond, to withold, to move forward, to be still. At times the world calls for our action, at times it yearns of rou lack of action, our ability to sit there and do nothing. But even inaction takes courage, wisdom, and above all, compassion.
What the world needs more than anything is bodhisattvas, active servants of peace, “clothed,” as Longchenpa said, “in the armor of perseverance,” dedicated to their bodhisattva vision and to the spreading of wisdom into all reaches of our experience. We need bodhisattva lawyers, bodhisattva artists and politicians, bodhisattva doctors and economists, bodhisattva teachers and scientists, bodhisattva technicians and engineers, bodhisattvas everywhere, working consciously as channels of compassion and wisdom at every level and in every situation of society; working to transform their minds and actions and those of others, working tirelessly in the certain knowledge of the support of the buddhas and enlightened beings for the preservation of our world and for a more merciful future.----Sogyal Rinpoche
The Cowardly Lion of Wizard of Oz fame got it mostly right. Courage is indeed part and parcel of living a full throttle life, and it's something we must cultivate from day to day, moment to moment, as life challenges us and throws its ubiquitous curve-balls. And sometimes those curve-balls just keep coming.
Yesterday I travelled to a relatively distant Northeastern city to accomany my step-father to an appointment at a large hospital. He has what turns out to be a inoperable tumor of the pancreas---inoperable because it's wrapped around the celiac access artery, making resection too risky. Thus, chemo and radiation ensue, and if that doesn't call for courage, I don't know what does.
For many, simply getting out of bed in the morning is an act of heroism. For all the talk of heroes these days---whether they be of the costumed superlative type, or the anonymous garden variety public servant who rushes into burning buildings to save strangers---there are many among us who have been, are, and will continue to be unsung, perhaps only to be feted by their loved ones upon their passing from this earth, that is if they have loved ones to celebrate them at all.
Pain, infirmity, loss of function, economic loss, grief, loneliness---so many are challenged by these life-limiting effects of disease and death. Still, so many also simply wake up each morning, set feet upon the earth, and move through yet another day, perhaps lucky enough to be kissed by sunlight or breeze, take a few moments to touch the soft fur of a dog, or feel the tickle of a dragonfly taking momentary respite on the back of one's hand.
We are challenged at every turn: our patience, our tolerance, our ability to listen, to feel, to communicate, to observe, to respond, to withold, to move forward, to be still. At times the world calls for our action, at times it yearns of rou lack of action, our ability to sit there and do nothing. But even inaction takes courage, wisdom, and above all, compassion.
What the world needs more than anything is bodhisattvas, active servants of peace, “clothed,” as Longchenpa said, “in the armor of perseverance,” dedicated to their bodhisattva vision and to the spreading of wisdom into all reaches of our experience. We need bodhisattva lawyers, bodhisattva artists and politicians, bodhisattva doctors and economists, bodhisattva teachers and scientists, bodhisattva technicians and engineers, bodhisattvas everywhere, working consciously as channels of compassion and wisdom at every level and in every situation of society; working to transform their minds and actions and those of others, working tirelessly in the certain knowledge of the support of the buddhas and enlightened beings for the preservation of our world and for a more merciful future.----Sogyal Rinpoche
Tuesday, September 12, 2006
Back in the Saddle
Well, here we are, back in work mode, my personal life having stabilized to some extent, the grieving process for my canine soul-mate continuing. My back pain is still with me, although somewhat diminished after a spinal injection three weeks ago, and now my step-father seems to have an apparently malignant mass in his pancreas, necessitating major surgery and other treatment. If only I could take a leave of absence to simply live my life, but no such luck.
At the office, we have the usual goings-on:
A patient dying of advanced cancer and AIDS took it upon himself (with help from his brother) to destroy a $3000 IV home infusion pump which they said "broke" on its own. They were apparently attempting to figure out how to extract the morphine from the pump to inject it all at once intravenously for a major dose of relaxation. Probably a good thing they failed----it most likely would have killed them both.
Patients struggle with psychiatric illness and the lack of services in our area. So many psychiatric outpatient facilities work on a "fee-for-service" basis, hence our patients---who tend to not show for appointments alot---get taken off lists and moved to the bottom, often losing all hope of treatment in town. That leaves us with dozens of the most fragile patients without proper psychiatric treatment. This fee-for-service idea has got to go. That's one of the things our program has going for it---we are paid an annual amount to care for our hundreds of patients and then we figure out how to care for them best. We don't bill for each contact, thus we are not desperate for visits, nor do we avoid visits which might take a number of hours to accomplish. We are relatively free from that economic disincentive to provide quality care.
That said, I struggle under a caseload of 83. How to keep that many people in my consciousness? How to remember what I need to follow up on each day? How to not lose the threads that need to be connected again in the fabric of care? I hobble along, sometimes stumbling, sometimes sprinting, sometimes collapsing from exhaustion.
A number of my patients have broken bones this year. One was hit by a car while crossing the street. Another patient with Multiple Sclerosis fell against the kitchen table and fractured her humerus. Someone else tripped on a wet floor and broke her ankle. I don't usually have this effect on people, but my patients break their bones at an alarming rate. Do they need pedestrian airbags?
Still others seem to develop multiple chronic injuries from out of the blue (sort of like I manifested a spinal cyst). This one has several meniscal tears in her knee. Another has herniated discs. Still another has a torn rotator cuff. These bodies sure take a beating.
My mind is spinning with scenarios, issues to deal with, patients to follow up on, people to call, referrals to make, treatments to assess. It seems that when you take 83 chronically ill people, put them all together in a big box, add poverty and stir generously, you get a recipe for multiple comorbidities needing a comprehensive and global approach to care managment. That's where I come in, and it is, I must confess, not an easy row to hoe.
But tomorrow's another day. And I'll be there.
At the office, we have the usual goings-on:
A patient dying of advanced cancer and AIDS took it upon himself (with help from his brother) to destroy a $3000 IV home infusion pump which they said "broke" on its own. They were apparently attempting to figure out how to extract the morphine from the pump to inject it all at once intravenously for a major dose of relaxation. Probably a good thing they failed----it most likely would have killed them both.
Patients struggle with psychiatric illness and the lack of services in our area. So many psychiatric outpatient facilities work on a "fee-for-service" basis, hence our patients---who tend to not show for appointments alot---get taken off lists and moved to the bottom, often losing all hope of treatment in town. That leaves us with dozens of the most fragile patients without proper psychiatric treatment. This fee-for-service idea has got to go. That's one of the things our program has going for it---we are paid an annual amount to care for our hundreds of patients and then we figure out how to care for them best. We don't bill for each contact, thus we are not desperate for visits, nor do we avoid visits which might take a number of hours to accomplish. We are relatively free from that economic disincentive to provide quality care.
That said, I struggle under a caseload of 83. How to keep that many people in my consciousness? How to remember what I need to follow up on each day? How to not lose the threads that need to be connected again in the fabric of care? I hobble along, sometimes stumbling, sometimes sprinting, sometimes collapsing from exhaustion.
A number of my patients have broken bones this year. One was hit by a car while crossing the street. Another patient with Multiple Sclerosis fell against the kitchen table and fractured her humerus. Someone else tripped on a wet floor and broke her ankle. I don't usually have this effect on people, but my patients break their bones at an alarming rate. Do they need pedestrian airbags?
Still others seem to develop multiple chronic injuries from out of the blue (sort of like I manifested a spinal cyst). This one has several meniscal tears in her knee. Another has herniated discs. Still another has a torn rotator cuff. These bodies sure take a beating.
My mind is spinning with scenarios, issues to deal with, patients to follow up on, people to call, referrals to make, treatments to assess. It seems that when you take 83 chronically ill people, put them all together in a big box, add poverty and stir generously, you get a recipe for multiple comorbidities needing a comprehensive and global approach to care managment. That's where I come in, and it is, I must confess, not an easy row to hoe.
But tomorrow's another day. And I'll be there.
Monday, September 11, 2006
Change of Shift Again
Please visit the newest edition of Change of Shift, a nursing blog carnival, here. Thanks for stopping in.
Wednesday, September 06, 2006
Hello Dear Readers
Hello dear Readers. Sadness has quite a grip at this moment. Work offers the distraction of tasks and other people to care for, but home brings the reality of loss and change that death delivers. Please see Latter Day Sparks for other writings, and understand that this blog will be more of what it used to be when this grieving process is not so new.
Thanks, and please return as often as you like. I shan't be in this state for too long.....
Thanks, and please return as often as you like. I shan't be in this state for too long.....
Sunday, September 03, 2006
Sparkey's Passage From This Earth
Dear Friends and Loved Ones,
Yesterday, September 2nd, 2006, at 2:20pm, Sparkey left his body and this physical existence in the most peaceful way imaginable. The screened-in porch was a sacred space---a shrine created lovingly by Mary---of photos, candles, objects of devotion, and mementos of Sparkey's sweet and noble life. The party lights were lit all night on Friday, the porch glowing, the cool breezes cleansing the space. Mary smudged the house with sage, and also smudged Sparkey several times briefly.
The vet arrived at 1:30, Tina already in the care of a neighbor, her shades drawn so that Tina would not see the vet's van and be traumatized by the sight of it. Rene and I dug the grave in the morning, the area protected from rain with a brown tarp suspended from surrounding trees, that piece of earth blessed and consecrated by the three of us before beginning our task. We had at the ready an urn of our dear friend Woody's ashes, several of Rene's wisdom teeth, three sticks representing the three of us, a bone unearthed while digging the grave (most likely buried by Tina some long-forgotten afternoon), and a sage smudge stick. We had chosen a lovely cotton tapestry of aqua and earth tones and Native American design in which to wrap his body. This fabric had covered a favorite chair in our house where he had lived as a puppy. The grave was round like a womb and three feet deep.
The compassionate doctor sat with us on the floor of the porch as we connected with Sparkey. He had ensconced himself in the very spot where we had planned for his transition to occur, and we only had to shift him slightly so that we could all kneel on the foam mattress at his head. The vet sat at his feet and explained that she would inject a strong sedative into his buttock muscle so that he would become very drowsy and probably fall asleep. Only when he was completely relaxed would she access a vein on his hind leg and insert a needle and small catheter which would allow for the overdose of anesthesia which would actually stop his heart. Following the first injection, we all brought our faces very close to his, looking in his eyes as they became heavier, telling him sweet things, what dogs to look for in his new home, and how grateful we were to him for his service and loyal companionship. Even after more than a minute, he still was not completely drowsy, his head moving slowly from right to left, approximately four inches above the bed. I had the image that he was already slightly above his body, trying to detach, and was looking from left to right to take in a final image of the three of us and the scene in which he was the central player.
Following a whispered conversation between myself and the vet, she injected another dose of sedative and he slowly lowered his head to the soft mattress covered with a maroon flannel sheet, closing his eyes for the last time. Crying, we all said goodbye and urged him to float on, and we each placed a hand on his heart which was still beating slowly. The doctor then began the infusion of anesthesia into the needle placed in a vein of his right hind leg. A small patch of hair had been shaved and that hair was stowed in a small wooden urn kept on hand for that purpose. With our hands we could feel his heart slow and then peacefully cease its motion. He did not take a final deep breath as is sometimes experienced. His heart simply stopped beating and his respirations halted. Beautifully, a single tear formed at the outer corner of his left eye, fully visible to the three of us, and we wept as this lone tear increased in size and then streaked down his lovely orange face. The muscles around his nose were the only ones which twitched for a minute or so, almost as if he was getting a last scent of this earth which he so loved.
Taking her leave, the very sensitive vet exited quietly, and we were left to tend Sparkey's beloved body in private. Rene brushed him down, and gathered some of the fur. We also cut some of his hairs from several places with a pair scissors. I fetched Tina from our neighbors and brought her to see her brother's body. Wrapping him in the chosen fabric, we carried him to the grave, lowered him in gently, each took a turn kissing his head, and tucked him in, his spine gracefully curved, his front paws below his chin. The three sticks, Rene's wisdom teeth, and the bone were placed in the grave, and some of Woody's ashes were rubbed into the fur over Sparkey's heart by each of us in turn. Finally, covering his head and face, we then took turns putting handfuls of dirt over his shrouded body. One of the most difficult things I have ever done was gently place a shovelful of dirt over what I knew to be Sparkey's head. It was at that moment that I knew he was gone forever and would never return. Rene assisted me in completing this task of closure, and we then had our private family time around the grave, Tina at our side.
His body is now resting in the earth, his soul free to run with his friends old and new, and we give thanks for this loyal companion who loved us so unconditionally. His grave is now our sanctuary, and we will tend it with as much love as he tended our home and lives.
Sparkey's body is dead. Long live Sparkey's spirit.
Namaste.
Yesterday, September 2nd, 2006, at 2:20pm, Sparkey left his body and this physical existence in the most peaceful way imaginable. The screened-in porch was a sacred space---a shrine created lovingly by Mary---of photos, candles, objects of devotion, and mementos of Sparkey's sweet and noble life. The party lights were lit all night on Friday, the porch glowing, the cool breezes cleansing the space. Mary smudged the house with sage, and also smudged Sparkey several times briefly.
The vet arrived at 1:30, Tina already in the care of a neighbor, her shades drawn so that Tina would not see the vet's van and be traumatized by the sight of it. Rene and I dug the grave in the morning, the area protected from rain with a brown tarp suspended from surrounding trees, that piece of earth blessed and consecrated by the three of us before beginning our task. We had at the ready an urn of our dear friend Woody's ashes, several of Rene's wisdom teeth, three sticks representing the three of us, a bone unearthed while digging the grave (most likely buried by Tina some long-forgotten afternoon), and a sage smudge stick. We had chosen a lovely cotton tapestry of aqua and earth tones and Native American design in which to wrap his body. This fabric had covered a favorite chair in our house where he had lived as a puppy. The grave was round like a womb and three feet deep.
The compassionate doctor sat with us on the floor of the porch as we connected with Sparkey. He had ensconced himself in the very spot where we had planned for his transition to occur, and we only had to shift him slightly so that we could all kneel on the foam mattress at his head. The vet sat at his feet and explained that she would inject a strong sedative into his buttock muscle so that he would become very drowsy and probably fall asleep. Only when he was completely relaxed would she access a vein on his hind leg and insert a needle and small catheter which would allow for the overdose of anesthesia which would actually stop his heart. Following the first injection, we all brought our faces very close to his, looking in his eyes as they became heavier, telling him sweet things, what dogs to look for in his new home, and how grateful we were to him for his service and loyal companionship. Even after more than a minute, he still was not completely drowsy, his head moving slowly from right to left, approximately four inches above the bed. I had the image that he was already slightly above his body, trying to detach, and was looking from left to right to take in a final image of the three of us and the scene in which he was the central player.
Following a whispered conversation between myself and the vet, she injected another dose of sedative and he slowly lowered his head to the soft mattress covered with a maroon flannel sheet, closing his eyes for the last time. Crying, we all said goodbye and urged him to float on, and we each placed a hand on his heart which was still beating slowly. The doctor then began the infusion of anesthesia into the needle placed in a vein of his right hind leg. A small patch of hair had been shaved and that hair was stowed in a small wooden urn kept on hand for that purpose. With our hands we could feel his heart slow and then peacefully cease its motion. He did not take a final deep breath as is sometimes experienced. His heart simply stopped beating and his respirations halted. Beautifully, a single tear formed at the outer corner of his left eye, fully visible to the three of us, and we wept as this lone tear increased in size and then streaked down his lovely orange face. The muscles around his nose were the only ones which twitched for a minute or so, almost as if he was getting a last scent of this earth which he so loved.
Taking her leave, the very sensitive vet exited quietly, and we were left to tend Sparkey's beloved body in private. Rene brushed him down, and gathered some of the fur. We also cut some of his hairs from several places with a pair scissors. I fetched Tina from our neighbors and brought her to see her brother's body. Wrapping him in the chosen fabric, we carried him to the grave, lowered him in gently, each took a turn kissing his head, and tucked him in, his spine gracefully curved, his front paws below his chin. The three sticks, Rene's wisdom teeth, and the bone were placed in the grave, and some of Woody's ashes were rubbed into the fur over Sparkey's heart by each of us in turn. Finally, covering his head and face, we then took turns putting handfuls of dirt over his shrouded body. One of the most difficult things I have ever done was gently place a shovelful of dirt over what I knew to be Sparkey's head. It was at that moment that I knew he was gone forever and would never return. Rene assisted me in completing this task of closure, and we then had our private family time around the grave, Tina at our side.
His body is now resting in the earth, his soul free to run with his friends old and new, and we give thanks for this loyal companion who loved us so unconditionally. His grave is now our sanctuary, and we will tend it with as much love as he tended our home and lives.
Sparkey's body is dead. Long live Sparkey's spirit.
Namaste.
Wednesday, August 30, 2006
A Correspondence is Born
My niece, a newly minted college student somewhere in New England, referred a friend to me for advice on exploring the joys and vicissitudes of nursing as a career. This thoughtful young woman who is entering her senior year in high school is filled with questions which I most readily and joyfully answer. This is affording me a golden opportunity to examine my motives for being a nurse, my reasons for remaining a nurse, and why and how I would ever consider encouraging anyone else to enter this profession.
Yes, nurses may still sometimes "eat their young", and hospitals may still use mandatory overtime to heartlessly over-utilize their nurses, while some of us struggle with caseloads which burst our brains' ability to provide what we feel is the most thoughtful, thorough care possible.
Still, I see a noble and genuine love of people driving many individuals to enter the nursing milieu, and a career which, historically, is portrayed as one which is grounded in compassion and caring. Nurses have made great strides (alongside some misguided backwards motion at times), and I still feel enormous pride vis-a-vis my chosen vocation/profession.
This correspondence, which I hope to integrate and share here on Digital Doorway, may open for me some more doorways to explore, and I'll be sure to share them here so that you can experience them with me. Stay tuned.
Yes, nurses may still sometimes "eat their young", and hospitals may still use mandatory overtime to heartlessly over-utilize their nurses, while some of us struggle with caseloads which burst our brains' ability to provide what we feel is the most thoughtful, thorough care possible.
Still, I see a noble and genuine love of people driving many individuals to enter the nursing milieu, and a career which, historically, is portrayed as one which is grounded in compassion and caring. Nurses have made great strides (alongside some misguided backwards motion at times), and I still feel enormous pride vis-a-vis my chosen vocation/profession.
This correspondence, which I hope to integrate and share here on Digital Doorway, may open for me some more doorways to explore, and I'll be sure to share them here so that you can experience them with me. Stay tuned.
Saturday, August 26, 2006
Turning Corners, Connecting Dots
Recovery, healing, and a new life reality are always around the corner. In healthcare, watching someone make that shift is incredibly gratifying.
Two of my current patients are both making great strides in their recovery, accepting help and attempting to make positive choices. One's drug of choice is alcohol. The other has a predilection for cocaine and heroin. Each one has other health problems which only magnify the urgency of making better choices: cirrhosis, hypertension, diabetes, neuropathy, depression, anxiety. No matter the constellation of comorbidities, the potential outcome---disability and death---is certain.
I try to offer a clean slate with each visit. My role, while multifaceted, is also quite simple. I provide guidance, compassion, tough love when needed, and a steady hand through the rough patches. I tell them: when the cravings come, call me. When the pain is too much, call me. When you feel like you're so afraid you want to die, call me. When you need a pep talk, call me. And these two people really do call---as do some others---and now it's paying dividends.
One of the secrets to guiding our patients towards health is getting them to pay attention. If they don't focus on the fact that their liver is affected directly by every drink, every drug, every decision, they just don't connect the dots. If they forget how important it is to tightly control their blood sugars, they lose sight of the prize. If they can't connect their current symptoms with their lifestyle choices, they're lost. Health is a complex entity, and seeing the lightbulb go off in their head is a gratifying moment in itself. Watching them use that lightbulb to illuminate their darkest corners of pain and regret is pure magic.
When it all comes down to it, it is compassion which drives the vehicle. Even when they come in, sit down in the exam room, and say "I fucked up. I used again this weekend. My life is over," I try to keep my expression neutral, my voice calm. "OK. You made a poor choice. But today you're here. Let's talk about today and tomorrow. What next? What's the next step?" I maintain my equilibrium, look them in the eye, hand reasurringly on their arm, my gaze steady but soft, open and inviting of confidence.
One man has been clean of alcohol since January of 2005 and has turned his life around. He is still struggling with the fact that he can't hang out with his old friends anymore and feels isolated. "I don't have much fun since I quit drinking. Everyone else seems to be having such a good time. It's lonely." But he keeps on the straight and narrow, and though his liver is riddled with cirrhosis, it seems we caught it just in time. While he may not be agood candidate for a transplant, he's a good candidate for a paradigm shift. He's living and eating well and trying his best. He turned a corner and never looked back. That liver will eventually kill him, but we don't focus there, turning our gaze forever on the present.
Another patient relapses again and again but now may be on the right road. I finally got him into an outpatient addictions treatment program and he's doing the work, plus going to meetings every day. Frightened of death and disability, knowing that his liver is damaged (but not yet beyond repair like the gentleman in the previous paragraph), he wants to do it all. He sees the cardiologist, shows up for appointments, sees our psychologist, and continues to make the right choices. We treat him like the respectable human being he is, with dignity and respect. He responds by coming back again and again, ready for more. I cant promise him he'll live forever, but I can promise him improved health and quality of life if he pays attention. And his attention is currently riveted----eyes on the prize.
For each patient who I cannot reach, who is lost to their own devices, there are several who respond to the call and step up to the proverbial plate. Their stellar performance, their willingess to engage again and again, that can keep me going. The others? I keep sending out the bait and trying to reel them in. Some respond from time to time, some crash and burn, many die. The hand is always there if they want it----if they can even see it. One such gentleman is now institutionalized forever, having ruptured his esophagus from intractable vomiting. He admits that he should have listened, that he should have known this day would come. Regretful and sad, his body filled with tubes, unable to ever eat or drink again, he is a living example of what happens when one fails to pay attention and falls into the abyss again. It's dark in there, and he was saved only by a miracle. He's a living example, a sad reminder to many. I feel such compassion for him, such sadness.
Back to the present, there are many more willing to take the leap of faith, and we're ready for them every day. What a treat to watch as a person turns that corner, beaming a smile of pride, and seems to finally "get it" in a way that is irreversibly joyful. The dark moments still come, the corners in need of illumination still harboring silent watchful demons, but there's still room for recovery and growth, the light filling the room with hope. That light is what we try to point out, and many thankfully refuse to shade their eyes and step over that threshold. It is a wonder to behold.
Two of my current patients are both making great strides in their recovery, accepting help and attempting to make positive choices. One's drug of choice is alcohol. The other has a predilection for cocaine and heroin. Each one has other health problems which only magnify the urgency of making better choices: cirrhosis, hypertension, diabetes, neuropathy, depression, anxiety. No matter the constellation of comorbidities, the potential outcome---disability and death---is certain.
I try to offer a clean slate with each visit. My role, while multifaceted, is also quite simple. I provide guidance, compassion, tough love when needed, and a steady hand through the rough patches. I tell them: when the cravings come, call me. When the pain is too much, call me. When you feel like you're so afraid you want to die, call me. When you need a pep talk, call me. And these two people really do call---as do some others---and now it's paying dividends.
One of the secrets to guiding our patients towards health is getting them to pay attention. If they don't focus on the fact that their liver is affected directly by every drink, every drug, every decision, they just don't connect the dots. If they forget how important it is to tightly control their blood sugars, they lose sight of the prize. If they can't connect their current symptoms with their lifestyle choices, they're lost. Health is a complex entity, and seeing the lightbulb go off in their head is a gratifying moment in itself. Watching them use that lightbulb to illuminate their darkest corners of pain and regret is pure magic.
When it all comes down to it, it is compassion which drives the vehicle. Even when they come in, sit down in the exam room, and say "I fucked up. I used again this weekend. My life is over," I try to keep my expression neutral, my voice calm. "OK. You made a poor choice. But today you're here. Let's talk about today and tomorrow. What next? What's the next step?" I maintain my equilibrium, look them in the eye, hand reasurringly on their arm, my gaze steady but soft, open and inviting of confidence.
One man has been clean of alcohol since January of 2005 and has turned his life around. He is still struggling with the fact that he can't hang out with his old friends anymore and feels isolated. "I don't have much fun since I quit drinking. Everyone else seems to be having such a good time. It's lonely." But he keeps on the straight and narrow, and though his liver is riddled with cirrhosis, it seems we caught it just in time. While he may not be agood candidate for a transplant, he's a good candidate for a paradigm shift. He's living and eating well and trying his best. He turned a corner and never looked back. That liver will eventually kill him, but we don't focus there, turning our gaze forever on the present.
Another patient relapses again and again but now may be on the right road. I finally got him into an outpatient addictions treatment program and he's doing the work, plus going to meetings every day. Frightened of death and disability, knowing that his liver is damaged (but not yet beyond repair like the gentleman in the previous paragraph), he wants to do it all. He sees the cardiologist, shows up for appointments, sees our psychologist, and continues to make the right choices. We treat him like the respectable human being he is, with dignity and respect. He responds by coming back again and again, ready for more. I cant promise him he'll live forever, but I can promise him improved health and quality of life if he pays attention. And his attention is currently riveted----eyes on the prize.
For each patient who I cannot reach, who is lost to their own devices, there are several who respond to the call and step up to the proverbial plate. Their stellar performance, their willingess to engage again and again, that can keep me going. The others? I keep sending out the bait and trying to reel them in. Some respond from time to time, some crash and burn, many die. The hand is always there if they want it----if they can even see it. One such gentleman is now institutionalized forever, having ruptured his esophagus from intractable vomiting. He admits that he should have listened, that he should have known this day would come. Regretful and sad, his body filled with tubes, unable to ever eat or drink again, he is a living example of what happens when one fails to pay attention and falls into the abyss again. It's dark in there, and he was saved only by a miracle. He's a living example, a sad reminder to many. I feel such compassion for him, such sadness.
Back to the present, there are many more willing to take the leap of faith, and we're ready for them every day. What a treat to watch as a person turns that corner, beaming a smile of pride, and seems to finally "get it" in a way that is irreversibly joyful. The dark moments still come, the corners in need of illumination still harboring silent watchful demons, but there's still room for recovery and growth, the light filling the room with hope. That light is what we try to point out, and many thankfully refuse to shade their eyes and step over that threshold. It is a wonder to behold.
Thursday, August 24, 2006
Change of Shift, Vol. I, No. V
Please surf on over to Change of Shift, Volume 5. Change of Shift is a new blog carnival by and about nurses and nurse bloggers. Please show your support by reading this newest edition. No charge!
Wednesday, August 23, 2006
A Question and an Answer
QUESTION: Tired nurse seeking fuel for his train running low on soul coal. Where does one turn? Exercise? Vacation? Gin? Meditation? Sleep? Narcotics? Dear Abbie? Dr. Ruth? Judge Judy? Dr. Phil?
ANSWER: Don't just do something. Sit there.
ANSWER: Don't just do something. Sit there.
Tuesday, August 22, 2006
Mid-Week Fatigue
Mid-week fatigue rolls in on this nurse who just finished a 12-hour day plus time at the gym early this morning. I have that boy-my-feet-and-brain-are-tired feeling. Bone tired. This chronic pain thing is draining. Part of my fatigue is the extra weight of pain and discomfort throughout the day, with lost sleep for extra spice.
Tired or not, the patients keep coming, each with their individual needs. So many interactions fill a day. Hours go by, with myriad details flying around my head like so many swarming flies.
Each interaction, each situation, calls for a certain level of awareness and presence. I try to bring to each patient a sense that I am fully there, fully listening, hearing their complaints and responding to them in a way which helps them to feel heard. Beyond hearing, I look for teaching moments, as well as ways in which my actions will benefit that individual in some way, assuage a pain, relieve a worry, mitigate an annoyance. There is so much to do, so many choices to make.
Sometimes the days are like being in an asteroid belt, dodging and sailing around so many obstacles, potential clashes and frictions always on the verge of manifesting themselves. At other times, it feels like a battlefield, and as the telephone calls and faxes and unannounced patients arrive, the support staff yell "incoming!" like infantry in a foxhole. Then again it can sometimes just feel like an office with alot of hubbub, while I coast atop the crest of the wave, few ruffles of my feathers even noticed as I breeze along. Still other days, it is a nauseating roller-coaster, the carnie on an extended break and the ride set on an endless loop. Then we reach for the barf-bag and pass the Dramamine.
No Dramamine today. Rather, a need for deep sleep uninterrupted by pain, muscles crying out, disturbing my needed rest. Pain can raise one's compassion---for one's self and for others. It can be a very human reminder of the mortal corporeal reality in which we are ensconced, the dangerous pull of gravity which wears down our resistance, pulling us to earth like the proverbial ball and chain.
This physical existence, this dragging around a body---it's enough to make one realize just how much work it takes to propel yourself along through life. As healthcare professionals, we try to remedy that weight as it is experienced by our patients, but we cannot carry their burdens for them. No. We use compassion, skillful listening, and our own life's truth to guide us in our guiding of others along these difficult earthly paths. I feel the weight of gravity today. May tomorrow its pull be less noticeable, the strain of physicality assuaged for all who need that sweet relief.
Tired or not, the patients keep coming, each with their individual needs. So many interactions fill a day. Hours go by, with myriad details flying around my head like so many swarming flies.
Each interaction, each situation, calls for a certain level of awareness and presence. I try to bring to each patient a sense that I am fully there, fully listening, hearing their complaints and responding to them in a way which helps them to feel heard. Beyond hearing, I look for teaching moments, as well as ways in which my actions will benefit that individual in some way, assuage a pain, relieve a worry, mitigate an annoyance. There is so much to do, so many choices to make.
Sometimes the days are like being in an asteroid belt, dodging and sailing around so many obstacles, potential clashes and frictions always on the verge of manifesting themselves. At other times, it feels like a battlefield, and as the telephone calls and faxes and unannounced patients arrive, the support staff yell "incoming!" like infantry in a foxhole. Then again it can sometimes just feel like an office with alot of hubbub, while I coast atop the crest of the wave, few ruffles of my feathers even noticed as I breeze along. Still other days, it is a nauseating roller-coaster, the carnie on an extended break and the ride set on an endless loop. Then we reach for the barf-bag and pass the Dramamine.
No Dramamine today. Rather, a need for deep sleep uninterrupted by pain, muscles crying out, disturbing my needed rest. Pain can raise one's compassion---for one's self and for others. It can be a very human reminder of the mortal corporeal reality in which we are ensconced, the dangerous pull of gravity which wears down our resistance, pulling us to earth like the proverbial ball and chain.
This physical existence, this dragging around a body---it's enough to make one realize just how much work it takes to propel yourself along through life. As healthcare professionals, we try to remedy that weight as it is experienced by our patients, but we cannot carry their burdens for them. No. We use compassion, skillful listening, and our own life's truth to guide us in our guiding of others along these difficult earthly paths. I feel the weight of gravity today. May tomorrow its pull be less noticeable, the strain of physicality assuaged for all who need that sweet relief.
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