Monday, April 25, 2005

Mental Health Day

Today is a planned mental health day. With prompting from my ever-loving partner, I requested this day off a week ago, planning to rest and recreate as a novel way to start the work week. It is a welcome balm.

This morning I try not to think about my patients but I will take a few moments to exorcise a few from my mind.

First, there's Q, a white middle-aged man with AIDS and a penchant for heroin, alcohol, and cocaine. Just last week, he left the hospital AMA (against medical advice) after a bout of pancreatitis, not to mention a large stone which is still lodged in his ureter (the tube from the kidney to the bladder). He had left a straw and white powder in the bathroom the day before, leading us to suspect illicit cocaine abuse. I wonder where he is now, and will wait for him to find me when he needs to be rescued.

Next there's my 350+ lbs Latina woman with severe asthma. I did my best to have her transferred from the hospital to a rehab facility, something I hope and pray happened over the weekend.

I also think about my wonderful 70-year-old woman with AIDS, diabetes, COPD, asthma, and schizophrenia. I worry for her health which is somewhat compromised at the moment. You ask me how she could NOT be compromised? I answer that, over all, she is amazingly healthy, believe it or not. However, I think she may be entering a final phase, but how many years she has left is up to the goddess.

Finally, there's my sweet gentle giant of a patient with AIDS and a new-onset dementia that we cnanot understand, not to mention new-onset diabetes which just will not come under control. The visiting nurse who sees him calls me daily with updates and we pray for things to resolve themselves. Time will tell, but I sense his days may be numbered. Then again, mine are numbered too, but I hope to have a bunch more numbers to go.......

Now that I've cleared my nurse's brain of a few worries, I can move on to the rest of my day. Unfortunately, at least 2 hours of that day will involve study and note-taking for tomorrow night's lecture on the urinary and reproductive systems. I just can't seem to escape nursing, even on a day off from it.

The sun is out, the dogs wait (somewhat) patiently for a walk, and my stomach rumbles. Thanks for reading, for tolerating my self-indulgence, and may your day be filled with grace.

Wednesday, April 20, 2005

I'm Being Tested

Taking into consideration the post which I wrote last night, it seems that I was being tested today. Examples:

*My 70-year-old patient with AIDS, diabetes and a host of other chronic conditions was recently in the hospital for an asthma exacerbation. While there, it was discovered that she has a mass in her chest which is pressing on her trachea and a pericardial effusion (fluid collected in the sac around her heart). Against difficult odds, I landed her a follow-up visit with a doctor at the clinic this morning. Of course, twenty minutes after the appointment time, her granddaughter calls to say that they can't make it to the appointment, but A. was feeling worse this morning. Maybe next week, she asks? My reply: maybe next week at her funeral (I said this silently, of course). I'll get another appointment for Friday if I'm lucky...

*A patient with untreated Hepatitis C and chronic pain that we treat with huge doses of methadone had been unable to move her bowels for more than a week and I feared an obstruction. We prescribed magnesium citrate and Fleet's enemas. She didn't return my calls for more than a week, and today called me an hour after her scheduled appointment with her doctor to ask if I could reshedule as she wasn't feeling well. It seems she had taken a laxative and was afraid to get on the bus since she felt like she was about to explode. She says she "forgot" that she had an appointment. (This next part is not for the squeamish) I explain that the pain in her belly and the liquid stool that she experiences could just be the watery part of the stool squeezing past the obstruction in her colon. She was not impressed.

*I visit a morbidly obese patient of mine (>350lbs!) in the hospital. She is so deconditioned and depressed (and agoraphobic) that she spends 20-22 hours of each day at home in her urine-soaked bed, surrounded by dust and detritus that only triggers further asthma attacks. I can't get her to clean her room, so I am trying to convince the local pulmonary rehab facilities to take her in for a few months of rehabilitation and specific care. They all say she's "inappropriate for their facility". So, we'll probably send her home to wallow in misery while chronic steroids weaken her bones.

*My colleague's patient needs dental work (as do all our patients). Medicaid no longer covers dental, and the one dental clinic in the area who accepts patients for free has made their free care application so difficult that most patients simply give up out of frustration. This particular patient made it through the hoops but needs transportation to his appointment. Medicaid won't pay for the van-ride to the appointment because dental isn't covered! They think they're saving money by denying poor people dental care, but they're happy to pay for ER visits when our patients have abscessed teeth and need Percocet for the pain. They also pay for the hospitalization once that infected tooth causes sepsis--infection of the blood. There's savings for you!

So many scenarios, too little time to describe them all in painful detail. What am I to do? Today's remedy was a few good bangs of the head against my desk. And a beer after work.

Tuesday, April 19, 2005

Human Stories

A forlorn and needy patient of mine surfaced at the clinic today, after failing to show for bloodwork and an appointment with me last week. Based upon his unannounced arrival and my busy day, I directed him to be triaged as a "walk-in" in the clinic. Later on, the Physician's Assistant who saw and treated him called me into the clinical area for a chat. The patient's primary provider, a Nurse Practitioner with whom I share several other patients, was also present for the conversation.

As I bemoaned my patient's dysunctional patterns and innate ability to fall apart then come crashing into the clinic asking me to save him from himself, the NP looked at me and said, "Keith, every patient here has a story. Unfortunately for you, the ones with the toughest stories are referred to you. Without them, you wouldn't have a job." The PA added, "And that's why you have the hardest job of us all."

I realized that they were right. These stories all add up: AIDS, hepatitis, trauma, incest, abuse, neglect, generational cycles of poverty, diabetes, poor nutrition, class warfare, violence, disenfranshisement, racism, illness upon illness, learned helplessness, substance abuse, homelessness or risk thereof, splintered families, mental illness, lack of education----but how do we calculate their effects? How do we draw the line between individual responsibility and societal/cultural dysfunction? Of course, we wish to hold individuals responsible for their actions. Clearly, people can learn to be responsible, come to appointments, adhere to medical recommendations, choose to step up to the plate. As a white, middle-class American, these are basic expectations and assumptions that I can make of myself and impose on others. I can also judge others by their inability to adhere to my concepts of responsible action. Also, as a human being, I have the right to be annoyed with my patients who fail to plan and take appropriate action, only to look to me as a source of rescue in their time of need.

The secret here is balance. Can I recover from my annoyance, rise above my frustration, and deliver compassionate, high-quality care? Can I see my patients' dysfunction as what it is---symptomatic of so many other visible and invisible factors---and continue to educate, cajole, and empathize? Can I release my guilt over my own judgements and grievances, giving way to that heart-centered place of witnessing the pain of others and working to assuage it as best I can?

My work challenges my ability do just that, and more. Admittedly, some patients are individuals who I avoid at most every turn. I cringe when dialing their number, knowing that I could be opening a Pandora's Box by inviting myself into their painful and dysfunctional world. There are others for whom my tasks are a joy, their communicativeness and ability to be proactive in their own interest inviting me to gladly join them in a symbiotic partnership. For those who actively help themselves and meet me half way, joining them on that road is easy, intuitive, a pleasure to be of service.

This rumination is just that---a rumination. Each day is another opportunity, and my all-too- human failings can often shine through as I attempt to tackle the next challenge. I remind myself that my own judgements are not necessarily negative, as long as I can acknowledge them for what they are, and then move beyond them. Some days are easier than others, and empathy can wax and wane, as can any emotion. I do this work because I love it, because I have something to give, and the self-knowledge which is born of it is worth its weight in gold. Each day I offer what I can, and then move on, hoping that each day's learning will inform my subsequent life experiences. At the end of this challenging day, I close the proverbial book and welcome the forgiving embrace of sleep.

Thursday, April 14, 2005

The Teacher as Learner

Internet connectivity problems at home have precluded posting since Monday's entry, not to mention astounding busy-ness on my part. That said, the week flows on towards its natural end tomorrow. Ah, the built-in entropy of the work-week.

After teaching on Tuesday night, I was struck by the fact that there is so much I need to learn in order to teach well. One might assume that, as a nurse with almost ten years of professional experience, I could expound on various topics with little preparation. Au contraire! As a "generalist" nurse with little specialty knowledge, there are some subjects about which I can talk quite knowledgeably, but there are many others which I have scant thought about nor dealt with directly during my tenure as a nurse. Home study, note-taking, and lecture prep are simply de rigeur these days, and I'll be admittedly relieved when the semester is over and I can rest my neurons a bit. Still, teaching is enervating and fun, and in the final analysis, I generally leave school tired but uplifted by my interactions with my students who often challenge my thinking with provocative questions, bringing their own unique visions of the world to class.

As a first-time professor, I'm relying on my students for feedback, and I try to read the energy in the class to determine whether I am hitting the mark or not during the course of a lecture. I also try to elicit verbal and written feedback but few have taken the initiative to offer constructive criticism. Last week, I was humbled when the class announced that I had been unanimously chosen to be the speaker at their graduation ceremony, and they waited on the edge of their seats until I would confirm my acceptance of such an honor, which I quickly did, of course. They may even hire my son as the graduation photographer (he will be a newly-minted professional photographer after his graduation on June 2nd).

Learning abounds, and it is often as teacher/professional/caregiver that we receive our most humbling and instructive lessons. Today I witnessed first-hand the enormous love and mutual respect between a mother and her thirteen-year-old son. They are both my patients, and we were meeting with the amazingly astute and gifted PhD-level psychologist with whom I work. I was first blown away by my colleague's counseling skills (she makes it look so easy!), and I was further enthralled by the sincerity of the mother's verbalized dedication as a parent of a troubled but lovable child. Thirdly, I was incredibly and wondrously struck by the slow but inexorable emotional opening demonstrated during the session by her son who is the only teenager on my caseload at this time. Something shifted during that session, and it was humbling and satisfying to be present for its unfolding.

Today I also learned some lessons from a married couple with AIDS---I think I've mentioned them before---who are both my patients. Her disease is much more well-controlled than his, but he has made some progress, only to regress when he decides independently to stop his meds for a few weeks from time to time. We spoke intently for thirty minutes or so and they were quite sincere in their gratitude and recognition that I am simply trying to assist them in making positive choices for themselves and their two small children. On the verge of tears, I assured them that I was not lecturing them, rather, I was simply communicating to them the gravity of their decisions and the potential repercussions which I could not promise to assuage if they chose to not follow the best medical advice available at this time. Our eye contact was intense, and the feeling of being together in that room---truly together as a team---was palpable.

Thursday evening presents itself as a deep breath, four fifths of the week behind me, the final push tomorrow. The struggle is to be in the present, and to glean from those daily interactions as much learning as can be squeezed from each morsel. I'm more successful some days more than others, but it's truly the only game in town.

Thursday, April 07, 2005


Thursday at 12:45pm. At my desk at work, taking a breather. No guilt for blogging at work as I haven't taken a lunch break today. Come to think of it, the last time I took an actual lunch break was two weeks ago. (I'm afraid that's actually true.)

My plate seems so full today, the phone and beeper and cell-phone going off constantly since my arrival just after 9am. A patient with acute pancreatitis, long history of AIDS and new-onset dementia---now on his way to the ER for admission, his pancreatic enzymes are sky-high. Another patient with Hepatitis C and chronic pain hasn't moved her bowels in nine days---she's also on her way to the ER. The next call is from a patient with chronic asthma who calls me in distress--she's over 350 pounds and so deconditioned that her asthma just can't improve. I ran over to her house and we gave her a prescription for some prednisone. I have to work on getting her admitted to a rehabilitation facility for a few months of pulmonary rehab.

Then another patient calls---she was feeling suicidal, so her therapist told her to go the ER and tell them that she was an alcoholic and needed detox, why I can't imagine. So they sent her to detox for four days and she should've been in the psych unit. I must have a word with that very irresponsible therapist of hers.

The fun just continues non-stop. Must gallop off to put out the next brush fire. As Bugs Bunny would say, "it's a living, doc."