Monday, March 28, 2005


We are all constantly in search of homeostasis, balance, equilibrium. Physiologically, the body consistently strives to keep things in check, running smoothly with little deviation---acid-base balance, electrolyte balance, fluid balance, blood volume. A normal body pH needs to be found in the very slim margin of 7.35-7.45. Potassium balance must be between 3.5 and 5 or all hell can break loose. Sodium is more generous with a normal range of 135-145 mg/dL.

On the psychoemotional side, how do we measure such notions as balance? Manic versus depressive? Joy versus despair? Just think of the language we use for sketchy and potentially emotional situations:

"I'm walking a fine line";
"You're on thin ice";
"He's playing with half a deck";
"She's teetering on the edge";
"I feel like I'm walking a tight-rope";
"I'm on the edge of my seat";
"They were walking on egg-shells";
"I'm juggling too many balls";
"You have so many pokers in the fire";
"It's neither here nor there".

From the look of things, we have plenty of language to describe our imbalances. Are there enough sayings to counter those assertions with balancing terminology? Please enlighten me, dear Reader, and share how you would verbalize balance. Can we create a nomenclature of homeostasis, or does it already exist and I simply cannot see the forest for the trees?

Saturday, March 26, 2005

Life and Suffering

Thinking about the Buddhist refrain that "life is suffering", I reflect on the suffering which I witness so regularly, and gain perspective on my own:

The caring and compassionate wife with AIDS whose eyes fill with tears as we discuss her sweet and gentle husband who has worsening AIDS dementia which we just cannot explain since his virus has been completely suppressed for more than five years. He lies in bed moaning as we review his medications and discuss diapers, a shower seat, and visiting nurse services.

The very nice fifty-year-old man who recently entered my caseload---Hep C, HIV, alcohol abuse, heroin addiction, a history of multiple incarcerations, homelessness. Very earnest and recently detoxed. Really a pleasure to talk with, his childhood history and family constellation is still an unknown to me. What brought him to this place?

A woman with a history of such psychic and physical trauma that her life is consumed by pain, both real and imagined. Her level of personal insight and psychic resonance is negligible---a true train wreck from a clinical perspective. She, more than any other, invites "compassion fatigue" to develop, from neediness and consistent demonstration of powerlessness.

As I've written before, I know that I could easily be in the same developmental and life situation as these individuals if I had been less blessed in life, less priviledged, less loved. Children do not ask for trauma and poverty. Children do not invite such suffering. Entering as a clean slate upon which parents and the world can choose to inflict horror or beauty, the veneer of innocence and openness can be eroded away as the vicissitudes of life intrude. Who's to say why some are more resilient than others. It is not our place to bestow blame, for none of us are blameless, and none of us are wise enough to ascertain the true failings of another.

How much does my "Body Mass Index" matter in the face of what others experience? How important is it that I suffered ridicule as a less-than-physically-perfect child? No one can really judge how much those experiences affected me. My young mind and heart were vulnerable at the time, and the wounds still resonate today. My suffering was astronomically less than that of millions of other children, and my current state demonstrates that it did not preclude my growing to be a reasonably competent adult. This is my path, my own suffering, and while I should not judge it as unworthy of attention, I also remind myself of the relative ease with which I have moved through life.

Thinking again about my childhood obesity, I remember an aunt of mine, actually the partner of my eldest aunt. My clear childhood memories are very few and far between but I remember this one. We were at their home on Long Island for a family gathering. The adults were congregated in the kitchen or dining room. I came in to get something, and my aunt made a remark that I was an "L.A.". Everyone laughed uproariously and refused to respond to my questions as to the meaning of these initials. The event must have imprinted deeply in my brain, for about five years ago, for some reason, I remembered the event as if it had happened just yesterday, some long-dormant synapse sparking to life for a brief moment and bringing that memory flooding back. I realized that she had meant "Lard Ass" by that comment, I'm sure, and the bewilderment of that long-ago moment became mine again. Trusted adults laughed at my expense and refused to explain the source of their merriment, and thirty years later I clearly remember the moment. Such power of the brain to block out---and then recall---trauma (if I can call it that), regardless of its relative significance.

I use this illustration to elicit in my own mind the notion that, if that remark had been more abusive, more hurtful, if remarks of a derogatory nature had been made towards me daily throughout my childhood, perhaps accompanied by physical abuse, who would I be now? What would I be now? What other choices would I have made in life? This seemingly random assignment of each individual to a family constellation and series of life events bestows upon each person their own unique experience, and reactions to said experience.

These illustrations and memories are food for thought, written more as fodder for my own growth than for any reader who peruses these virtual pages. If this missive touches something for you, I'm glad for that, and invite you to comment, or just to reflect privately on that which is elicited. My suffering is my own, as is my recovery, a lifelong process to which I'm forever dedicated. This writing is powerful medicine, and my prescription of self-reflection will never expire.

Friday, March 11, 2005

A Week Well Done

The work-week comes to a close as fresh snow falls (once again) on our little abode. We are in our frequent postures---laptops on laps, fire in woodstove, dogs snoring, bellies full. This is redundancy I can live with!

With cancellation of my teaching obligation due to snow this past Tuesday, no other evening obligations all week, topped off by a brief overnight visit by our son and his girlfriend last night, I end the week with an unusual feeling of refreshed energy, no burn-out sensations in sight. Fatigue, yes, but a feeling of having lived well and embraced life all week with an appropriate attitude adjustment in operation.

Many stressful patient scenarios presented themselves this week but somehow I managed to stay above the fray. What is the magic ingredient that manifested this ability, you ask? Damned if I know, but I'd like to bottle it for future use when needed, kind of like a "Break This Glass in Case of Entropy" toolkit. But seriously folks, it was just one of those moments in time when the planets were aligned, my humors were in balance, I was not plagued by excess melancholia, and the stress just wouldn't stick, so to speak. While some people did push my buttons at times and I occasionally ran around like a mad chicken, there's a level at which the week did not exact an emotional and physical toll, and for this I'm exceedingly grateful. The weekend can begin with a willingness to enjoy, produce, relax, and create, all in the embrace of a loving home and a relationship which feeds my soul and spirit. That is priviledge of the highest order.

Wednesday, March 09, 2005

I Am A Witness

This week I'm putting a fair amount of energy into the care of one particular patient named Q. Q has a 10-year+ history of AIDS, Hepatitis C, depression, severe anxiety, a seizure disorder, and a history of IV drug use. She has wandered into and out of our care for the last 6 or 7 years, never staying long enough for treatment of her AIDS to be considered. Her immune system being very compromised, we have not even been able to convince her to take medication regularly that would protect her from myriad opportunistic infections to which she is quite susceptible. Basically, she's one of those people who we have always thought would become acutely and fatally ill, and then have what we would call a "deathbed conversion"---deciding in the face of most certain death that she's now ready to take meds, too little and too late.

That said, Q has resurfaced along with her daughter, begging for home delivery of her methadone since she is too weak to walk, having seizures daily, and losing weight rapidly. My job has been to "rope them in", assess their actual willingness to do the work that needs to be done. With the family history as it's known to me, I can't put too much stock in their potential for success, but I'm doing my part to coordinate the resources so that the mechanisms of the system are set in motion on her behalf. Pleading with me to come to her house for a visit, I've refused and insisted that they come to the clinic, trying not to make it too easy for her. Yes, she's weak, but not too weak to come to an appointment, and always willing to come if we dangle the possibility of a benzodiazepine prescription as bait. This may sound macabre or manipulative, but given the situation and history, we know that incentives and carrots can work wonders with addictive personalities.

Now that we have her ostensibly hooked into care and wanting more from us, we institute visiting nurse services so that the nurse can come to her home every day and physically watch her take her seizure medications, sedatives, and antibiotics to protect her from infection. The nurse has a lock-box in the home to preclude any shenanigans on Q's part in terms of adherence to meds. Next we arrange with the methadone clinic to have the visiting nurse deliver methadone to her home each morning---something she wouldn't miss for the world---thus ensuring that she'll be home for the nurse in order to avoid withdrawal from missing her dose. If she can hang in there for two weeks of this first round of intervention, we add HIV meds to the mix and we're on our way. It's a long shot, but it's the only game plan I have, or death is certain within 12-18 months, perhaps sooner.

Just three months ago, I attended the funeral of a patient who just could not muster what it took to overcome his addiction and his intellectual deficits enough to seize the opportunity for treatment. Ms. Q may be the next to vacate her physical existence, but I'm willing to give it a go first. Another of my patients of whom I'm exceedingly fond (and who is very much like Q in many ways, although much more intellectually savvy) has succeeded in breaking her addictions, and her HIV is now completely suppressed, her immune system almost strong enough to withstand most infections which might have killed her earlier. I would like to see Ms. Q follow in her footsteps. Only time will tell.

The stories are many and I could go on for hours, giving fifty or sixty very interesting and compelling case histories. The point I want to make, however, is that I'm simply a witness to others' pain and struggle. I can't fix anyone and I can't force treatment on anyone. I offer options and I hold out my hand. There are days when I personalize my work---and those are the days when I suffer emotionally and drag myself home, exhausted and spent. Sometimes I hit my stride for a few days and sail along with my witness self intact, watching the action but refraining from reaction to it. The dance is difficult and I frequently falter but I work with what I have and come home and charge those batteries.

Another day is behind me, and for this I give thanks and embrace the evening in peace.