## Sunday, December 31, 2006

### New Year's Eve Ruminations

A friend sent me this incredible link to an on-line video which I highly recommend. You can find it here. It is an inspirational, humbling, and provocative evocation of what it means to be a citizen of the Earth at this point in human history. A fitting moment of reflection at the turn of the year.

Concurrently, I also recommend visiting this site for a microscopic view, equally humbling in its representation of the complexity and beauty of the world in miniature.

Both of these experiences provide ways to get out of one's own way and see one's place in the world for what it is---an infinitesimal part of the wider web of life. In our peripatetic lives---wandering from person to person, place to place, experience to experience---our own lives become so big in our eyes, and we so easily lose sight of the bigger picture. When we curse our broken toaster and lament the money we will spend on a new one, we miss an opportunity to think of those who have never known such luxury and convenience, and perhaps haven't even been blessed with a piece of wholesome bread to eat for months. Sure, a broken toaster is a drag, but if you can just go ahead and buy a new one without so much as a second thought, you have precious little to grumble about. I say this to myself more than anyone else.

It is so easy to lose perspective. Sogyal Rinpoche writes about "cherishing" one's self to such an extent that one wears blinders towards the plight of others. I remind myself more than anyone that gratitude is the key---giving thanks for what I have, not focusing on loss and what-if scenarios. On her desk, one of my colleagues has a quote posted next to her computer monitor: "If the only prayer you said in your life was thank you, that would suffice" (Meister Eckhart).

So, in keeping with the tradition, here's to letting go of the old, ringing in the new, and accepting the past as done. Any new year, be it secular or religious, offers a fresh start. The fact is, every sunrise offers a fresh beginning. Taking that thought even further, every breath offers an opportunity to start again. Imagine that, a "new year" every moment. "With this breath, another year begins. With this breath, another year begins....." (Let's just agree that a glass of champagne does not need to accompany each breath. since precious little would ever be accomplished!)

Tonight, Mary and I will make New Year collages to visualize our goals and aspirations for 2007. We will listen to our favorite New Year's Eve song, "Sacrificial Bonfire" by XTC, and probably be sound asleep at midnight.

For all you revellers, dreamers, seekers, and beings great and small: Happy New Year and many happy returns.

Sacrificial Bonfire

Lyric by: Colin Moulding

Fire they cried
So evil must die
And yields are good
So men pull back hoods and smile
The scapegoat blood spilled
Spittled and grilled it crackled and spat
And children grew fat on the meat
Change must be earnt
Sacrificial bonfire must burn
Burn up the old
Ring in the new
Assembled on high
Silhouette against the sky
The smoke prayed and pranced
And sparks did their dance in the wind
Shadows wore thin with less and less skin
And the clothes that were draped
Was all that told man from ape
Change must be earnt
Sacrificial bonfire must reign
Reign over good

## Saturday, December 30, 2006

### An Enlightened Vision of Death & Dying

It is crucial now that an enlightened vision of death and dying should be introduced throughout the world at all levels of education. Children should not be “protected” from death, but introduced, while young, to the true nature of death and what they can learn from it.

Why not introduce this vision, in its simplest forms, to all age groups? Knowledge about death, about how to help the dying, and about the spiritual nature of death and dying should be made available to all levels of society; it should be taught, in depth and with real imagination, in schools and colleges and universities of all kinds; and especially and most important, it should be available in teaching hospitals to nurses and doctors who will look after the dying and who have so much responsibility to them.

## Friday, December 29, 2006

### It's a Wrap

At 4pm today we locked the office doors, popped the champagne and sparkling cider, toasted a year well done, and called it a day, or rather, a year. There is always something satisfying about handing in that last paperwork of the year, submitting the final time sheet and expense report, dashing off those last emails, and shutting that door. It has a comforting feeling, leaving the year of travail and sweat behind, readying oneself to receive the new. Whatever happened, whatever failed to happen, whoever lived, whoever died, it's all part of the stream now, and we can let it all just wash away.

"See you next year!" was the refrain as we began to file out the door, some lingering to put final touches to their work, as always. Yes, Bono did indeed sing "nothing changes on New Year's Day", but something does change, if at least internally.

This evening afforded me a massage and a haircut, then a return home for a shower and a shave. Clean, shorn, with pajamas and the warmth of home, 2006 begins its denouement, and I could not be more content.

## Wednesday, December 27, 2006

### The Late December Challenge

Here we are at the fulcrum of the holiday season, with Christmas and Hanukkah behind us, Kwaanza beginning, and the secular New Year on the verge. The challenge for me right now is to embrace and finesse the need to return to work and contnue walking the walk while my heart and soul cry out for long naps, luxurious time with my sweetheart, and the natural desire for semi-hibernation and focus at home.

Patients' needs do not decrease in the holiday season---why, they seem to inflate. Survivors of trauma and family dysfunction are triggered during this time of year, and physical and psychological symptoms come to bear. I am myself not immune from such manifestations. and my deepest desire is to hole up and nurture my own heart.

Suffice it to say, this time of warmth and family and togetherness has a flip side which can lead to introspection, memory, and the need to look within.

Finding the balance between the inner and the outer is certainly the challenge of the day.

## Tuesday, December 26, 2006

### Compassion Versus Pity

Compassion is a far greater and nobler thing than pity. Pity has its roots in fear and carries a sense of arrogance and condescension, sometimes even a smug feeling of “I’m glad it’s not me.” As Stephen Levine says: “When your fear touches someone’s pain it becomes pity; when your love touches someone’s pain, it becomes compassion.” To train in compassion is to know that all beings are the same and suffer in similar ways, to honor all those who suffer, and to know that you are neither separate from nor superior to anyone.

---Sogyal Rinpoche

## Sunday, December 24, 2006

### Spiritual Identity in Middle Age

So, here I am, admiring our Christmas tree, a middle-aged man with nothing but Jewish roots traced back generations to the permeable borders of eastern Europe in the 1800's and early 1900's. Well, how did I get here, anyway?

Raised in a admantly secular, non-denominational home in suburban New Jersey, I grew up celebrating Christmas and Easter as the ubiquitously plastic-coated, gift-wrapped confections of post-WW II middle American culture that they generally are. My parents, both Jewish New Yorkers, left New York for the Jersey suburbs in 1951, assimilating into a predominantly white Christian culture, with a Christmas tree in the living room and chocolate bunnies in April. Occasionally visiting my observant Jewish cousins and extended family in New York and Long Island, I would get a fleeting taste of the alien Judaic world, returning to the safety and cultural anonymity of our assimilated existence.

Unlike some adult Jews who "rediscover" Judaism later in life, I continue to feel drawn in other spiritual directions, pagan and otherwise. Morphing from teenaged devout atheist to twenty-something agnostic seeker to middle-aged spiritual eclectic, I guess I'm just one who dares to not embrace the root culture, striking out for something uniquely my own. Some would call me confused, others would feel sorry for my loss of identity. Still others would simply see someone caught in a world he never made, making lemonades from so many lemons. However ill-defined, my spirituality and sense of self amidst the great Universality of Being is a constant work in progress, and while this is certainly not a dress rehearsal, I apparently still don't know my lines.

Some day, I'll exit stage left, and whether I meet St. Peter, Moses, the Buddha, Jesus, Paramahansa Yogananda or my old dog Sparkey, I know that ease and bliss await me in that Great Beyond. Will I know the script? Probably not. But just as I did while traipsing the Earth, I'm sure I'll just fake it 'til I make it.

## Saturday, December 23, 2006

### Unnecessary Disparities

On holidays, I always seem to think about my patients, especially those without family who spend those special days alone. This year is no exception. It's not my intent to throw a wet blanket on holidays and family time, but it is so easy to simply forget those who sit alone when millions of people feast and frolic with family. Several of my patients of whom I am exceedingly fond are certainly going to be alone on Christmas, and my personal challenge is resisting any guilt I feel while celebrating with my family, as well as resisting the urge to rent a van, pick them all up, and go out for a big Christmas dinner.

When my son was fourteen or so, I was a visiting nurse and had to work on Christmas Day by necessity. So, when I went on my rounds that day, Mary and Rene accompanied me, waiting in the car during some visits, and coming in to spread holiday cheer on others. It was a learning experience for my son when we visited an elderly gentleman who literally lived in a shack in someone's back yard. With bilateral amputations from poorly controlled diabetes, he struggled to survive, going to dialysis three times a week and trying to avoid falling through the holes in the bathroom floor as he rolled in his filthy wheelchair. Sitting on his equally filthy bed, we presented him with several simple gifts and my son got an eyeful of how so many people live around the world, even here in the ersatz Land of Plenty.

I feel like I could spend one of these upcoming holidays in the streets, handing out gloves and hats and snacks, redistributing even a little wealth among those who have less than they need and deserve. Come to think of it, working with the poor day in and day out, I don't feel an overwhelming urge to join the well-meaning thousands who pack the country's soup kitchens on Thanksgiving and Christmas as their annual pilgrimage of community service. As many soup kitchens and food pantries will tell you, holiday time---when people are more apt to be generous---is usually the flush time of the year. It's the other eleven months when we all need to awaken from our collective stupor and think of others without the reminders of ubiquitous Salvation Army bell-ringers in front of our local grocery store.

Are these reminders wet blankets? I hope not, but it is the time of year when we naturally give thanks for what we have, observe those who are not so blessed, and possibly resolve to do more
to assuage that overwhelming and unnecessary disparity.

## Friday, December 22, 2006

### Tis the Season

Today at our health center, the annual Community Christmas Party is held. One of the doctors, dressed as Santa, sits in one of the nurses' stations in a big red chair, surrounded by medical assistants and nurses dressed as elves. Hundreds of neighborhood children line up with their parents to sit on Santa's lap and receive an age-appropriate gift which has been lovingly wrapped by clinic staff over the last few weeks. Donations of toys pour in, and the wrapping paper and preparations take over several rooms from December 1st until today. Music plays in the lobby, food and drink are for the asking, and the health center gives back to the community yet again, this time with cheer, gifts, Polaroids of each child, and a spirit of giving that permeates the air.

Across the park at the Senior Center yesterday, my wife was involved in a toy distribution project which gives age-appropriate gifts to local grandparents, ensuring that each elder has at least one toy for each of their grandchildren.

Privately, Mary and I are raising money for a Jamaican friend who is trying to finish building his humble home before the winter rainy season begins. This disabled gentleman, a talented artist with Post-Polio Syndrome, helped us to repaint and decorate the Children's Ward of a poor rural hospital in eastern Jamaica when we were doing community development work with Global Children back at the turn of the century. Although our project has since ended, we continue to support this one person in improving his life, and we may sponsor him for a three-month visa in 2008. If any of you would like to donate as little as $2, please email me privately. One of my patients gave me and my wife gifts of perfumes, colognes and other scented products for Christmas. Since we both suffer from Multiple Chemical Senstivity, those gifts needed to be recycled elsewhere. Thus, I dropped them off at our local shelter for families in transition where they will be happily re-gifted. As this season of open-heartedness comes to a close, the giving and openness to others must continue to be propagated and expanded upon throughout the year. While I will always applaud the acts of generosity engendered by the spirit of the season, I urge us all to continue that practice, even as the memories of the holidays fade. The redistribution of wealth and prosperity certainly has a place at this time of year, as conspicuous consumption becomes the order of the day. Still, conspicuous consumption is part and parcel of the American Way, therefore conspicuous deconstruction of the consumer society must continue unabated. To all who give to others, sincere thanks. To all who live their lives in love and compassion, my heartfelt solidarity. To all those who are yet to open their hearts just a little bit more, there is no better time than now. ## Wednesday, December 20, 2006 ### A (New) Blog Is Born The original purpose of this blog was to have a creative space to ponder my life, write about it, and have a place to go at the end of the day where I can be myself and process this life on earth. Although that end has been accomplished, the vicissitudes of my work as a front-line community nurse do indeed garner the lion's share of my attention herein. Thus, I have created a tertiary blog (apart from Digital Doorway and Latter Day Sparks) where I will use my love of amateur digital photography with my Treo smart-phone (luckily provided by my work at no cost) as an extra key to creative expression. Please surf over to A Nurse and His Treo from time to time, if you please. You will find links to my two "side blogs" on the right of your screen. Thanks, dear Readers, and many blessings of the season. ## Tuesday, December 19, 2006 ### Will Atlas Shrug? "You know you could die tonight if you don't go to the hospital," I tell him. He lies on his messy bed, smelling of feces and vodka. A plastic bucket sits beside the bed as an ersatz spittoon. He misses more often than not, gobs of chewed tobacco caking the dirty wooden floor. I notice that the toilet seat is caked with feces. There are more than 20 empty vodka bottles piled behind his bed. He stares at the TV tuned to Spanish soap operas. "I won't go to the hospital. I won't go." He stares intently at the TV. "Look," I respond in Spanish. "Your blood pressure was more than 200/120 yesterday and today I can't even hear it. You have no pulse in your wrists, and I'm afraid your pressure may be dangerously low." "I'll stay here in bed and take my medicine. I'm not going anywhere, and that's that." He tells me he fell a few hours ago on his way to the bathroom. He was very dizzy. I call the primary doctor. She advises me to write a letter for him to sign, stating that he understands he is going against medical advice by refusing to go to the hospital. She also says he shouldn't take any more meds until I can recheck his pressure and pulse. He readily signs the paper with his shaky signature. "Are you sure you won't change your mind? I'll feel bad if you die, but that's not important. Your health is most important. Do you care that you could die?" "I don't care. I'm staying here." I leave messages on his brother's cell phone and land-line, saying that his life may be in danger but he refuses to go to the hospital. I know his brother is at his wits' end and doesn't know what else to do. This man, the oldest of six, is a helpless and hapless alcoholic, pouring vodka down his throat like gasoline on a fire. His end is written all over his face in pure and deep pain which I will never understand. I hide his medications in a kitchen cabinet so he won't take them by accident. I offer again to call an ambulance but he waves me away like a pesky fly. I walk down the four flights of the fire escape, feeling somewhat dejected. It's cold. The wind whips through the sorry city. He could die tonight. Does he really not care? Is he that far gone? What about the others who can't pay attention long enough to take their AIDS meds? And the smokers with COPD and asthma? And the other alcoholics with cirrhosis? And what about the diabetics who gorge on sweets and leave their pancreas abandoned on its own road to self- destruction? My shoulders hurt. Am I carrying the weight of the world? If I was Atlas, I'd probably shrug it off and take a long winter's nap. ## Sunday, December 17, 2006 ### A Short Break Dear Readers, Please pardon the brief period of silence. The holidays are upon us, and a weekend trip to visit family precluded my appearance here since last week. Please stay tuned and check back in the next several days. Merry merry. Happy happy. ## Wednesday, December 13, 2006 ### Area of Refuge I came across this sign recently while visiting a medical office building. On the pragmatic side, I wanted know what the meaning of this sign was. Where was the area of refuge? The arrow simply pointed to a non-descript hallway. Was there some hidden meaning? Was this hallway earthquake-proof? Fire-resistant? Spiritually protected? It seemed so mysterious. On the metaphoric side, I took the photo with my trusty little Treo smart phone solely in order to show other people that I actually saw this sign and felt that its metaphoric value far outweighed its practical and intended nature. We all need areas of refuge in our lives. Is it our living room? Our porch? Our workshop? Or perhaps a beach, or the mountains, the forest, a favorite city park. Some individuals find refuge in their own enlightened minds through meditation. Others find refuge in their bodies through exercise, yoga, dance, or painting. Still others find refuge in substances, both natural and synthetic, which disconnect them from their bodies for a while, or perhaps even make the body a playground of sensation and experience. In her beautiful book Refuge, the author Terry Tempest Williams uses the Great Salt Lake---its risings and fallings, and the lives of the wild birds around it---as a metaphor for refuge, as well as a geographic touchstone for the actual peace she experiences on its shores as she struggles with a seeming epidemic of breast cancer in multiple generations of women in her family. What is your refuge, dear Reader? Where does it lie? Is it within? Without? Have you not yet found it?Do you need a new one? Have you not tended your refuge for a while? Take a moment, if you like, and find that refuge---perhaps for the first time, or maybe for the thousandth---then give yourself the gift of visiting that sacred space soon. Namaste. ## Tuesday, December 12, 2006 ### Of Interns, Residents, and Sleep Deprivation---A Hippocratic Conundrum The hospital with which my agency is affiliated is a teaching facility. I fully support teaching hospitals and the vital service which they provide as training grounds for almost-minted doctors, and I try my best to be friendly and helpful with med students, interns and residents with whom I come into contact. The second-year residents who actually take on a caseload at the clinic cause me no end of frustration, however. While they leave for two months at a time for rotations through the ICU and OR, I'm left holding the bag, trying to figure out how to move forward with a patient's care when these clinicians are otherwise engaged and en absentia. Those interns and residents who choose to specialize in Community Medicine frequently cycle through our health center, and I am often asked to take some of those docs-to-be out into the wilds of the city for a realistic community experience. On one occasion, I brought a quite sheltered medical student on a home visit which turned ugly, the irate patient (with a history of violence towards medical providers) making threatening gestures and behaving in a very unstable manner. I wasn't sure if there was a firearm in the house or not, but my patient's alleged connections to drug dealers and a certain underworld element added to the sense of danger and excitement. That medical student sure got an eyeful, and he probably went on to specialize in something safe, far removed from drug-infested apartments and wild-eyed patients seeking Xanax. Luckily, no one was hurt, I kept myself between the student and the patient, and eventually talked my patient into an ambulance after dialing 911 as I followed him out into the street as he yelled and gesticulated, arms waving wildly. In retrospect, he was quite high and we were at great risk. Live and learn. Emphasis on "live". Apropos of medical residents and interns, I heard a story today on NPR detailing the travails of medical interns as they negotiate the 30 to 36-hour shifts often thrust upon them. Even though regulations were put into place several years ago to limit interns to 80 hour work-weeks with mandatory 10-hour rest periods between shifts, these standards are not enforced and wannabe doctors log inhuman hours, their sleep-deprivation often putting patients---and other clinicians---at risk. Numerous articles detail increased risks of medical errors, job-related injuries, increased incidence of car accidents, and most interns reporting having exceeded the limits put in place in 2003. A study at Harvard Medical School showed that "staying awake for 24 consecutive hours induces decrements in human performance similar to a blood alcohol level of 0.1 percent." The NPR story bandied about statistics that the risk of errors increases 700% when interns work 30-hour marathon shifts, and that the risk of fatal errors triples. One anonymous intern reported actually falling asleep while performing a cardiac exam, his head literally hitting the patient's chest. The Harvard study reported by NPR used instruments attached to the interns and residents to monitor their sleep/wake cycles, much like the instruments used to monitor astronauts' sleep cycles in space. The results are cold comfort. As a nurse, not only am I concerned for my patients who are hospitalized, I am concerned for my medical colleagues who are undergoing such an "education", for the drivers on the road at risk of accidents caused by sleepy interns, and for other employees who may experience injuries---such as needle sticks---when working alongside a sleep-deprived resident. Even when residents are rested, I still occasionally need to correct small errors or point out discrepancies to the precepting doctors at the health center. How many errors could be avoided if the 2003 guidelines---or even stricter edicts---were actually enforced and obeyed? Many sources state that a "culture of suffering" among generations of doctors keeps this practice alive. There is a sense that "if we could do it, they can do it" mentality, subsequent generations tormenting their juniors with the same long hours and deprivations which they survived during their own residencies. This smacks of fraternity-style initiation practices which fail to advance the cause---better doctors---without incurring great risk of harm. A conundrum of Hippocratic hypocrisy presents itself. That said, doctors used to smoke in exam rooms and nurses' stations---did we keep doing that just because it had always been so? Something needs to change, and when thousands of patient deaths are attributable to medical errors due to fatigue, a public health crisis looms before us with a horrendous human cost. Although many residents and interns and student nurses perform their duties very well, I have reminded patients who were uncomfortable being seen by a student that they have a right to refuse such care, demanding a staff doctor. As a student nurse, I was once or twice in the position of being told that I could not provide care to a patient, a "real nurse" having been requested. We must all recognize that subsequent generations of doctors and nurses must learn patient care in the real world with hands-on experience at every turn, and only this will create the generation of providers which we will continue to need ad infinitum. Still, when avoidable death, injury and illness result from the poor management of such programs, patients and staff suffer the very real consequences. Something must be done. Multiple studies have all yielded the same results: our medical interns and residents work too hard for too many hours, and provide hands-on care for our mothers, sisters, lovers, and children in debilitated physical and mental states . A 700% risk of unavoidable errors is unacceptable, and we will all continue to pray that it is not us---or our loved ones---suffering needlessly from medical bravado and hubris. Education is crucial, but human life trumps all. ## Monday, December 11, 2006 ### A Lightning Flash Life, as Buddha told us, is as brief as a lightning flash; yet, as Wordsworth said: “The world is too much with us: Getting and spending, we lay waste our powers.” It is that laying waste of our powers—that betrayal of our essence, that abandonment of the miraculous chance that this life, the natural bardo, gives us of knowing and embodying our enlightened nature—that is perhaps the most heartbreaking thing about human life. What the masters are essentially telling us is to stop fooling ourselves: What will we have learned, if at the moment of death we do not know who we really are? ---Sogyal Rinpoche ## Sunday, December 10, 2006 ### Illness as Metaphor Browsing through an eclectic used bookstore recently, I came upon a copy of Susan Sontag's small but mighty "Illness as Metaphor", published in 1978. Sontag uses her wisdom and literary talent to expose and debunk the myths which blamed the victims of tuberculosis (in the 19th century) and cancer (in the 20th century) for their own conditions, often exacerbating their suffering by propagating myths which have the power to discourage rational thinking and the pursuit of the best treatments for disease. Although I fully embrace the idea of the mind-body connection, certain writers, thinkers, public institutions and media sources have often used fear, ignorance, and outright bigotry to hold sufferers of certain diseases at arm's length, rendered single-handedly responsible for their plight. Fear of death will turn humans away from their suffering brethren, and Sontag points out that TB and cancer were hallmark cases in such treatment and myth-making. Making my way through the first few chapters, I immediately began to wonder how this idea has been treated by writers and thinkers vis-a-vis the AIDS epidemic. A quick Google search revealed that, lo and behold, Sontag had revisited the ideas of her original book in a follow-up treatise, "AIDS and its Metaphors", published in 2001, which I am now very keen to read. Although I have yet to finish the former work of Ms. Sontag and am as yet uncertain if I will agree with 100% of her thesis, I can immediately agree that language has been frequently used as a weapon against the sufferers of myriad diseases. I am sure Ms. Sontag will address in her second work the notion that AIDS began in the early 1980's as a "gay" disease, with large numbers of gay men in urban centers falling prey to a strange "gay cancer" erupting on the skin like so many bruises. The long-esgtablished marginalization and social isolation of the gay community allowed mainstream America to ignore its importance, many claiming that AIDS was a punishment by God visited upon the "wicked" homosexuals and their "unnatural"ways. Photographs of early protests even show evangelicals holding signs using the word "gay" as an acronym for "Got AIDS Yet?" or "God Abhors You." Words are powerful, and even those of us with the best intentions may at times use them to the detriment of others. In my position, it is all too easy to fall into blaming those affected by substance abuse, eschewing the disease model and embracing the notion that these individuals are wholly responsible for their actions and should know better. Life experience alone will convince most thinking individuals that substance abuse and the suffering it engenders goes well beyond a simple "personality flaw" of the sufferer. Similarly, depression---experienced by millions of people around the world---responds quite poorly to admonitions that one should simply "get over it" and "cheer up". Research bears out that substance abuse and mental illness have genetic, physiological, psychological, and chemical components over which we do not have complete control. Exasperation with a recalcitrant substance abuser is one thing---outright blame is another. AIDS, cancer, substance abuse, disfigurement, disability---any and all of these conditions can cause the uninitiated or ignorant to turn their faces in disgust or denial, the common denominator being fear. Fear of death, fear of mortality, fear of the unknown, fear of the "other"---our fears will often prevent us from looking another in the eye and see their suffering as if it were our own. Each day is an invitation to open ourselves to the suffering of others, and each time we embrace that opportunity, we further the causes of compassion and love. As Mother Teresa once said in one of my favorite quotes of all time, "I have found the paradox that if I love until it hurts, then there is no hurt, only more love." ## Friday, December 08, 2006 ### Interstice interstice \in-TUR-stuhs\, noun; plural interstices \in-TUR-stuh-seez; -suhz\: 1. A space between things or parts, especially a space between things closely set; a narrow chink; a crack; a crevice; an interval. 2. An interval of time. Today is a Friday at home. While the ostensible reason for not working is my dog's recovery from knee surgery yesterday, this is also a chance for me to take yet another breath amidst the maelstrom that can be the workweek. Earlier this week, I described a patient with AIDS who has dementia of unknown origin. Luckily, he came to his appointment at the clinic with our Infectious Disease specialist after leaving the hospital "AMA" (against medical advice) twice in one day. Aided and abetted by his family, this demented man in need of an extensive workup was back in the community where he should not have been until we had made some treatment decisions. With great skill, the whole team managed to convince him to be readmitted to the hospital---where he is safely ensconced as I write. A collective sigh of relief can be heard, despite the fact that we still have no known cause for his symptoms. Another patient has spun out of control again. I have taken her off of her AIDS medications since she just can't manage to take them correctly, if at all. She's living on a knife's edge and she knows it. Will her school-age children live through their teen years with or without their mother? What hope is there for them? Still another patient will simply not even talk to me about why he isn't taking his meds. He knows that his options for HIV treatment are dwindling, yet he continues to throw it all out the window, even as his wife is a model patient and takes her meds like clockwork. Yet another person has taken his recent hospitalization and illness as a sign from God that he now has a second chance. He has rededicated himself to his medications, his health, and his survival, especially in light of his granddaughter with whom he is totally enamoured. It's hard to care so much. Some patients engender such concern, while others engender quiet indifference, or at least a feeling like indifference. I guess we all have patients whom we would rather avoid, those who drain our energy and come across like psychic vampires, bottomless pits of unmet need. This may seem harsh, but down in the trenches it's a fact of life. There are some patients for whom we will move Heaven and Earth, and some for whom we are simply not disposed to go above and beyond. Motivation and the assuming of responsibility on their part has an enormous impact on how we finesse that dance. Anyway, it's time for some cuddle time with my little Tina, who moans in distress beneath the table. She's not the easiest of patients, but she makes up for it in so many ways. Her wish is my command....... ## Wednesday, December 06, 2006 ### Scenes From a Day at Work ## Tuesday, December 05, 2006 ### Bang Head Here In yesterday's post, I wrote of a patient with dementia who is driving me to repeatedly connect my forehead with the nearest wall. Today, my bruised forehead is crying, "Uncle!" As I described last night, my patient eventually arrived to the hospital after much hemming and hawing. He reportedly made it through the night---with some complaining--after undergoing some bloodwork, a chest x-ray and a CT-scan of the head. This morning, I arrived at the hospital with my Nurse Practitioner colleague and we read through the patient's chart. He was not in his bed, and we assumed that he was downstairs for his brain MRI and lumbar puncture. I noticed some discrepancies in the chart, left a note with my cell-phone number, and we were on our way. Two hours later I receive a call that said patient actually left the hospital---without a word to anyone---in a cab this morning in the company of his son who had spent the night with his father in the room. That was the first strike of the ol' forehead against the wall. I was then informed that he would lose the bed entirely if he did not return immediately. They had not deemed him a "flight risk" and the examining doc found him "competent". "How could he be competent when he thinks he bought a plane in Puerto Rico yesterday?" I retorted. There was stunned silence on the other end of the line. I banged my forehead again. Harder. I began to work the phones. No answer at the home phone but I managed to reach the patient himself on his nephew's cell. To wit: "Where are you? You're supposed to be in the hospital." "I had to come home. I was going to lose my apartment, and the plane that I bought in Puerto Rico." "You aren't well, and you have to come back now. Put your wife on, please." I tried to be patient, I really did. "Hello?" said his wife. "Why isn't he in the hospital? He's not well. You can't let him make decisions like this." "I don't know what to tell you," she replied. "Well, I'll just tell you that he needs to be back at the hospital immediately." "OK, we'll go now." I continue with my day, paging the attending doctor that he is on his way back to the hospital and they should hold the room. I call the Infectious Disease doc who deemed him competent and I suggest a real psych evaluation for competency and a sitter in the room for the duration. I also point out discrepanices I noted on the inpatient med list. An hour passes. And another. My forehead begins to feel better. My cell phone rings. It's the Infectious Disease doc. "Keith, I'm afraid I have bad news." I prepare my forehead for further abuse. "He came back to the floor, and we told him to settle in his room. He asked if he could go out to smoke, and the charge nurse told him he'd have to wait 30 minutes until everything was in order. When she returned to the room, he was gone. That was an hour ago." I put the call on hold, brace my hands against the wall, and continue making a lovely dent in the sheetrock wall next to my desk. There's probably chips of paint stuck to my forehead by now. Should I switch to a filing cabinet? I call the patient again, and the family is at a loss as to why he left again, who was with him, and why they allowed this demented person who thinks he owns a plane in San Juan to leave the hospital. I explain that his chest x-ray was abnormal, he needs a brain MRI, a CT scan of the chest, a lumbar puncture, and his serum ammonia level is high, dangerously so. "We'll bring him to the clinic tomorrow" is all they say. "OK, that will have to do." I finally give in. What more can I do? "He must come in tomorrow to see our infectious disease specialist---no excuses." I hang up the phone. Oh, my aching head. Maybe I should switch to meditation and abdominal breathing. But the feeling when my head hits that wall is just so satisfying........ ## Monday, December 04, 2006 ### Consternation and Potatoes Things seemed to be improving. I wrote of his situation recently and was encouraged by some signs of improvement reported by his wife and the visiting nurse. Now, things just seem to be going downhill. A call from the visiting nurse today informs me that he is increasingly unsafe in the home, the family not really coping as would be desired, and the patient's health at risk. Nightmares, violent dreams, wandering through the house at night, smoking in bed---not very good signs, I fear. So, many telephone calls later, and we manage a direct admission to the hospital without a trip to the emergency room. Not an easy task. The primary doctor pulled some strings and I received a harried call at 1pm that a bed was ready and the patient needed to get down there as soon as possible. I reached his wife, and she agreed to get him there within the hour. Five hours later, I'm washing potatoes for dinner and my cell phone rings. The Caller ID shows me that it's the hospital. "Oh good," I think, "the admitting doc is calling me for my input." Maddeningly, it's the Admissions Department. The patient never showed and the bed will be given to the next patient forthwith. I call my patient's family. "Oh, he's out with his nephew," is the response I receive from a rather blase family member. "Do you want his cell phone number?" The potatoes need cutting but I'm steaming mad. One call to the aforementioned cell-phone yields the information that the patient wants to go "tomorrow". The nephew says, "He's tired." "First of all," I said, "do you realize how much work went into getting this bed for your uncle? Second," I continued, "just this morning, he insisted that he bought a plane in Puerto Rico yesterday. Are you giving him control over when he goes to the hospital when he can't even feed himself and thinks he's in San Juan? Aren't you all even a little worried?" "I'll have him there in forty minutes," he responds. I resume preparing the potatoes and Mary comes home to see the look of consternation on my face. In some ways, it's no different than my patient who just didn't show up for her cholecystectomy and liver biopsy. "I was busy," she said when I called her, incredulous that she would no-show for surgery. Sometimes I wonder what it is we're doing. Sometimes I wonder what my patients and their families are thinking. Sometimes I would like my forehead to make repeated contact with a nearby wall. Sometimes I wonder what it would be like to wash potatoes from 9 to 5. At any rate, my hope is that by the time I post this missive, my demented patient is happily or unhappily ensconced in a safe hospital bed, and the grand neurological work-up can commence. Meanwhile, I'll get some needed sleep and leave the forehead banging for another day. Small potatoes in the bigger picture? Sure, but at times like these, there's nothing like a blog when one needs to kvetch. ## Saturday, December 02, 2006 ### The Winds of Compassion and Loss Today, December 2nd, 2006, is the 5th anniversary of the killing of Woody---our closest family friend and honorary uncle to our son---at the hands of the police. I do not wish to discuss the details of the event, and feel no need to publicly admonish those who took my dear friend's life so needlessly. Any readers who want the larger story can email me privately. This anniversary marks a closing of a chapter, our energies collectively focused on moving forward rather than being mired in the past. On the back of my car a bumper sticker states, "Love your enemies". Although this advice also applies to me, my ability to do so is still quite challenged in this regard. On some level, I still wish psychic suffering upon those who shot my friend, the final bullet penetrating his back as he lay handcuffed and bleeding on the ground. Love my enemies? Somehow, perhaps, I do love my enemies spiritually, but my all-too-human ego still cannot embrace them. Not being a stranger to loss, being connected with others who are also bereft, allows the winds of compassion to blow between us. I understand the denial and disbelief when the news first arrives, the gut-wrenching grief as the truth sinks in, the anger that rips through the fabric of sadness like a knife, and the lingering loss that remains when all other emotions have faded. It's a club to which most every human eventually belongs, and its members are legion and growing. This day also marks the three month anniversary of the death of our dear and loyal dog Sparkey. Sparkey and Woody were quite the pair, often barrelling together through the woods, returning to the house bleeding, limping, panting, and grinning from ear to ear. They seemed like brothers then, with matching red and golden fur, both unconditionally loving and loved. We miss them both so much, and hope they can frolic together in the grasses of some far-off heaven that is actually closer to us than it seems. As the winds whip the trees outside our home, may the aforementioned winds of compassion also blow, stirring up love, understanding, and connection wherever they circulate. As far as loss is concerned, I could not agree more that it is still better to have loved and lost, than to never have loved at all. Death doesn't erase love, it only changes the pathway the energies of love must travel between the beloveds. Embracing loss, embracing change, embacing grief---what more can one do but continue on, powered by love and compassion? On this day of remembrance, I choose to continue on, empowered and emboldened, with compassion as the fuel for living. ## Friday, December 01, 2006 ### World AIDS Day At the clinic today, a slide show depicting dozens of people who have died in the last twenty years of battling AIDS in our neighborhood was the close of the day's work. Patients and staff gathered together over snacks, pizza, and soda, acknowledging the day, what it represents, how far we've come, and how far we still have to go. The fact that someone is infected every eight seconds is no comfort. Just this afternoon, one of my itinerant patients surfaced. I have been trying to keep her on antiretrovirals for several years. I took over her case from a nurse practitioner who left our practice for a new life in the Southwest. When we discussed this woman, my colleague said, "She's a lost cause." Perhaps she was, but I took her at face value and invested in the relationship. Several years earlier, my former colleague and the patient's primary doctor had visited this woman at home and said goodbye, the patient's liver finally giving out from the effects of AIDS meds, a common occurence for meds that can burn up the liver. For some reason, that ravaged organ decided to have another go at life, and she bounced back from the brink of death. So here I was today, faced with this woman who has been on and off of crack and heroin, her school-age kids in and out of protective service, and her young adult daughter trying to hold it together for the family even as she struggles with mental illness and drug-addicted parents. The focus of the brief visit was explaining that we would stop the antiretrovirals. "Why?" she asked. "I need those meds more than anything else!" I have explained to her countless times that it's better to stop the meds altogether than to take them poorly. She looked at me and nodded, but I registered her discontent. I handed her a seven-day medication box prefilled with everything but her antiretrovirals, and sent her and her daughter on their way, admonishing them that I expect a phone call in six days to schedule the next med prefill. "Gracias, Keith!" they yell on the way out the door. As I watched the slide show, I imagined that I saw this particular woman's face flash across the screen as the background music swelled, Sarah McLachlan crooning "I will remember you." She may not be up on that screen this year, but eventually she'll be added to that lengthening roster of losses. Tears will be shed, and her children will be alone without her. How many more lives are also on the brink in a similar manner? We'll save quite a few, but there are always those who we just can't keep afloat. That said, our lifeboat has plenty of room, and I'll keep pulling on those oars until I no longer can sustain the effort. I will remember you. ## Wednesday, November 29, 2006 ### Of Demons and Dementia "Do you remember who I am?" I ask. He looks at me quizically. I can tell his brain is working overtime. He's lying in his bed, a Batman DVD playing with the volume low. The Joker fires guns and Batman saves the day. "You're my friend," he replies uncertainly. "That's right, I am," I smile into his eyes. "But I also have a name that you know." With a little prompting, he actually comes up with my name. He shakes his legs under the covers in childlike delight when I tell him he got it right. He seems so innocent, so pure. He looks at me in earnest. "I was in Puerto Rico yesterday. I bought a dog and an airplane." "Wow," I respond. "I thought you said you were in Puerto Rico on Sunday." "I went back again and bought the airplane. I paid the guy a hundred bucks and I fixed the engine. " He has AIDS dementia. Classic. Virus completely suppressed for years. Some changes to his white matter but no masses or lesions. People didn't used to live this long with a suppressed virus, so we're flying by the seats of our pants. He complained of devils and battled with them in his dreams. (Does watching violent movies help this situation?) An antipsychotic made him hallucinate. Now we'll try some steroids to decrease what we assume is brain swelling (he has a history of cerebritis). I'd love to take him to an acupuncturist or a naturopath. Maybe a shaman would be of service. But insurance doesn't cover such luxuries, so we have to use the tools at our disposal, thus more meds. We will eventually watch him slip away. Meanwhile, a local priest pays visits and helps to keep the demons at bay through faith and prayer. Maybe watching Animal Planet would be better. Another patient also shows signs of AIDS dementia, but his virus is not suppressed and never has been. He can't tolerate meds well, has a history of poor compliance with treatment, and the virus has mutated exponentially in his bloodstream. Pockets of various strains are probably biding their time in distant corners of his body, waiting for a chance to circulate and propagate. His brain has been attacked by toxoplasmosis a number of times, and other illnesses have plagued him over the years. How long can he hold on? This weekend, devils sat on his shoulder and tormented him. A visit to church helped to calm his hijacked mind. The best we can do is treat the virus, keep it as suppressed as possible, support him in his compliance to meds, and send him to a therapist for treatment of his underlying depression and PTSD. The more serene and clear his mind from day to day, the less painful psychic torture he'll endure. When faced with such conundrums of suffering, one can only be grateful for the small things that make life worth living. These gentleman are peaceful warriors, and we simply provide some tools for the battle, the least of which is a smile and a kind word. Love, after all, may be the best medicine around. ## Monday, November 27, 2006 ### Simply Goodbye He left six months ago for his homeland of Puerto Rico, certain that he wanted to die there. Five years of a professional yet intimate relationship were behind us: AIDS, cancer, remission, diabetes, wasting, cancer relapse, colostomy, and a downhill slide from there on. When hospice at home failed, and wet sheets, untaken meds, and benign neglect demonstrated that being alone in his own apartment was not working, his family whisked him away to Puerto Rico, where he could come to rest surrounded by the smells and sounds of his motherland. I was sad to see him go, but happy for his reception into the welcoming bosom of family, and honestly relieved that my years of urgent calls and emergencies were over. I had considered going to Puerto Rico to say goodbye, to visit him in his native land, but our financial situation and my responsibilities here stayed my hand. I also was just not sure that my appearing at his bedside would be truly beneficial to him, or only painfully remind him of all that he left behind, perhaps giving rise to unnecessary remorse and regrets that would have otherwise have remained blessedly subterranean. If I had gone, it would surely have been for me, not him, and I just wasn't convinced that it would be for the best. Instead, I erred on the side of caution, following the ages old adage, "Don't just do something, sit there." We did have one telephone conversation about four weeks after his departure. I called the home where he was staying in Puerto Rico and we chatted for a while. I told him that I loved him, and that God would bless him and his family. He blessed me as well, and we hung up. Although I had planned to call again, the number on a sticky note by my desk, it just didn't happen. Another goodbye, another letting go, another opportunity to say "I did enough". And I can say it truthfully. I did enough. No room for regrets. It's simply goodbye. ## Monday, November 20, 2006 ### Of AIDS, Lunch, and Words Today I was at a lunch for nurses and nurse practitioners whose work involves patients with HIV and AIDS. We meet monthly at a local restaurant (the tab picked up by a pharmaceutical rep) and discuss issues of import to us and our practices. The drug rep is quite respectful, never pushes her products, and brings in speakers who are in no way beholden to gear their talks towards our host's medications currently on the market. The food's great, the company is excellent, and we can all look forward to our meeting every month. The grilled salmon settled in my stomach very well, and I could just feel those fish oils decreasing my LDLs as I sat and listened to our local AIDS guru expound on the newest meds in the pipeline. What struck me so clearly is how far we've come in the treatment of AIDS, the voluminous knowledge breathtaking in its scope. I can hardly begin to describe for the uninitiated the dizzying array of terminologies and diagnostic tools currently at play. It is simply astounding, as is the very international effort to further the research and share the results of that research worldwide. When hanging out with providers or scientists who work in this field, there is a vast nomenclature which can leave the neophyte stymied and confused. Terms like "treatment-naive", "wild-type virus", "genotype and virtual phenotype" are bandied about in a way that demonstrates how they are second nature to those in the field. It is an intimidating ocean of knowledge in which I splash tentatively by the shore, sometimes up to my knees, and only several times have ventured too far and felt as if I was drowning. Not being a prescriber, I am free of the responsibility of prescribing such toxic medications, although my job entails monitoring my patients for side effects and helping them work through the potential misery while staying on course. Towards the end of the talk I asked our presenter how these terms come into popular use among the AIDS community. For instance, how did the term "viral fitness" come into being? Who introduced it? Who coined it? Is there some governing body that announces the adoption of such terminology? Our presenter acknowledged that, no, there is not a governing body that hands down decisions on which terms will "stick" and which will be jettisoned to the nomenclature dustbin. Generally speaking, influential researchers will use a term for the first time in a published paper, and that term will be picked up by others, make its way into the literature, be adopted into PowerPoint presentations, be repeated in articles and professional talks, and eventually fall into general use by providers on the front lines. I wondered aloud if it would be interesting to write an article or a book on the nomenclature of AIDS, from the early days of ARC (AIDS-Related Complex) and PWA, to some of the current terms like "deep salvage" and "lipodystrophy". I wondered if I could (or would) write such a treatise. After the lunch was digested and all of the talk somewhat assimilated, day to day life on the aforementioned front lines continued. One of my patients who has been living with AIDS for years, his virus currently suppressed for more than five years now, stopped by for a chat. Despite his excellent adherence to meds and our relative success in his treatment, he is wasting, losing weight alarmingly fast with no discernible cause. He smiled broadly, handing me a letter that came in the mail today, telling him that he was approved for 120 cans of Ensure per month for 12 months. My letters and applications had succeeded, and he would be assured of an extra 1000 calories a day for a year, not to forget the other nutrition therein. He beamed at me, and we even noticed that he'd gained a few pounds this month. Small victories mean alot. On the other hand, a long-time patient of mine who just can't seem to beat back his virus was once again in the hospital. His daughter called me on Friday, saying that her father had a high fever, difficulty breathing, and very marked irritability and confusion. Due to his history of toxoplasmosis and seizures, I urged a call to 911 and facilitated his care at the ER by phone. Sent home hours later without conclusive evidence of anything being wrong, he was back in the ER on Saturday with a higher fever and even more severe mental status changes. He's like Job, it seems, beset by complications and symptoms at every turn, poor guy. I was so sad to hear that he had taken a turn for the worse. On my way home tonight, I stopped at the hospital. His wife was placing a cool cloth on his forehead as I entered the room, and I held her as she cried on my shoulder. She' s HIV positive as well, but his health is always on the edge while hers holds steady. I've bent over backwards for this man, and I'll continue to do so, no matter how exasperating he can be. He looked at me as his eyes brimmed with tears. I put my hand on his forehead and felt its heat. His misery was palpable, although when I asked him how he felt, he said in Spanish, "I feel a little bit OK". I reassured him that everything possible is being done for him and that I'd be back tomorrow. Ducking into the nurses' station, I conferred with one of the residents following his case. She listened intently to my take on his last few years of treatment, and we bantered professionally about his case, those familiar words bubbling up into our conversation: opportunistic infections, toxoplasmosis, immunosuppression, fever of unknown origin, antiretrovirals. Our conversation centered on the clinical aspects of the case, but I also tried to infuse it with some of my understanding of the patient himself. We can all sometimes get so lost in the words, and we must sometimes make sure to remember to re-inject the patient back into the conversation. While the description of the lunch juxtaposed with the face-to-face patient contact may seem somehow incongruous, I guess the point that I'm trying to make is that there is a balance between the clinical separateness---all of the words and concepts that make up our understanding of an illness---and the patients themselves, their stories, their humanity, their flaws and strengths. Where there are reams of papers detailing resistance profiles, mutations and the genotypic profiles of various viral strains, we can never escape the reality on the ground, the human side of the equation about which there is scant research and relatively little attention. Those lunches and talks feed our minds and sharpen our skills, improving the clinical aspects of our care, the intellectual work which is part and parcel of the struggle. But we must always remember that all of these words and names and labels mean something about an actual person, a being of flesh and blood who cries, laughs, sleeps, and dreams. These are the places where the science and art of medicine and nursing intersect, and where the art, informed by the science, brings it all back to a simple hand on a forehead and a hug and a tear. The balance is easy to see, harder to attain, but crucial for us to truly deliver our best care each day. There is the nomenclature of science and the nomenclature of love and compassion, and we must speak them both equally fluently. ## Saturday, November 18, 2006 ### Disempowerment 101 "I really need you to take more responsibility," I said. "OK, I understand," he replied. "You know," I continued, "when you come in for your bloodwork, it's because I need to check your blood's clotting time. If your INR is too high or too low, then we have to adjust your Coumadin dose, otherwise you could end up with a clot or a bleed." "OK." He smiles. It's like talking to a ten-year-old. "When you come in for bloodwork, I need you to take an interest and call me for the results. I can't be chasing you down every week. This is the deal: when you have your INR drawn, I want you to call me aggressively the next day until we talk. I want you to think for yourself how important it is to know how much coumadin to take." "OK. I'll call you tomorrow, for sure." We shake hands. The next day is Friday. I wait until 3pm for his call. No dice. I wait til 4. Still no call. I leave a message on his voicemail with his dose for the weekend, chiding him for not calling me. Am I undermining my teaching by calling him and letting him know the dose even though he didn't call me? Yeah, probably, but I also can't let him run the risk of throwing a clot this weekend either. Hmm. So, I called my little ten-year-old in a forty-year-old body. Again. Better luck next time. Sigh. ## Thursday, November 16, 2006 ### Abscess Makes the Heart Grow Fonder "How did this happen to your arm?" I asked as I removed the bandage from his forearm. "Oh, I was doing something and I slipped and cut it." His eyes darted around the room as he muttered his answer. The hole in his arm is almost perfectly round, about 4 cm across and maybe 1 cm deep. It's granulating nicely, the edges clean. I dab on some Silvadene with a sterile tongue depressor after first cleansing the wound with sterile water. I cover it with 2 x 2 gauze sponges and wrap it nicely. I wish him well and head back to the pod to confer with the doc. The visiting nurses will watch it closely for signs of infection. "Don't tell me," I say, "an abscess from poor technique while shooting up, right?" "Of course," the doctor says. "What else?" It could pass as a large cigarette burn, but it's too deep. He was hospitalized for acute heroin intoxication (just shy of an overdose), plus a forearm abscess which had to be excavated by the surgeon. Not his first abscess, plus a little bacteremia for good measure. Poor guy. When I was a Baccalaureate nursing student, we had to do a community health project. Due to my persistence, my small group chose a inner-city drop-in center for IV drug users. We had health fairs and taught them proper technique for shooting up and how to clean needles with bleach solution. Our venue for learning was not a popular choice among the faculty, but if we could prevent a few infections along the way and befriend some addicts, wasn't a little harm reduction OK? We hung out with prostitutes, passed out condoms, and distributed bleach kits in "shooting galleries" around the city. It was quite an eye-opener for some of my suburban classmates. Oh, the things people will do to their bodies for pleasure, for forgetfulness, for escape from pain. Memories of trauma fade away as the heroin courses through the veins or the effects of the crack go straight to the brain. To sleep, perchance to dream. It can feel so good but only lasts so long. And the abscesses and infections and cellulitis? Call them occupational hazards. Compassion goes a long way, and if the abscess makes the nurse's heart grow harder, time for a vacation, or perhaps a new career. ## Tuesday, November 14, 2006 ### Driving Me Backwards (A nod to Brian Eno for this evening's title.) Working in this unfortunate city, doing outreach to patients' homes, navigating the pock-marked streets, I have come to know the city more intimately than I had ever cared to. Compared to my somewhat bucolic college town where I reside, the city is a troubled landscape of poverty, drugs, corruption, and mismanagement. Driving in this city---like in most inner-city environments---the generally accepted rules of conduct do not necessarily apply. Stop signs and red lights are apparently seen as no more than suggestions, hints at what action the driver or pedestrian might choose to take if they were so inclined. As I pass down many a city street, if I come upon a light just turning green for me, I will defensively slow down as I reach the intersection, assuming that a car or SUV could come careening from the left or right, through the red light, striking me as I cross the intersection in which I appear to have the right of way (at least as far as the traffic signals are concerned, that is). I sometimes feel my body contract ever so slightly as I drive through a green light, as if I'm just waiting for that eventual broadside impact delivered at the hands of a reckless city driver. In this city's culture, cars seem like weapons, and no one---literally no one---considers making a kind or considerate gesture. Coming from our genteel college town thirty minutes away---thirty minutes which might as well be one thousand miles---I'm used to drivers stopping in their tracks to wave other drivers on, people allowing a bus to cut into traffic, or pedestrians to cross the street. Here in the city, pedestrians pay no attention to "WALK" or "DON'T WALK" signs. Adults model for children that cross-walks have no meaning, that on-coming cars are something to challenge, not to respect. Children dart out from between cars, adults cross the street at any time, from any direction, bicycles go against traffic, and miniature motorcycles (often called "Crotch Rockets") blast down the side streets, piloted by absurdly young (unhelmeted) children or similarly absurd middle-aged men, perched precariously on these toy motorcycles with powerful and noisy engines that belch smoke and fumes. Utter chaos. How many times have I seen a car simply ignore a school bus and its flashing red lights? How many times have I seen an ambulance struggle to make it through a line of cars which refuses to follow commonly accepted practice and move aside for the screaming siren? How many times have I wanted to stop at a crosswalk to allow a pedestrian to cross, only realizing that another impatient car is sure to pass me illegally on the right at full speed and take that pedestrian's life in a nano-second? The Russian Roullette wheel seems quite busy in this topsy-turvy place, and I would never wish to hasten another's demise simply because I was trying to be nice, only succeeding to put another in unnecessary danger. City life---another reason why I choose to live in my semi-rural sub-suburban haven. Being in the city from 9 to 5 is quite enough, but full-time existence in this chaos of spurned rules and broken laws would just be too exhausting for words. Here's a quiet prayer for the city, its inhabitants, its rules that are constantly broken, and for those of us who travel its streets with frequent apprehension. May all red lights be honored, and may we all traverse the streets in peace. ## Monday, November 13, 2006 ### The Ghost of Patients Past Sometimes there are people who I just can't find. Sometimes they just don't want to be found. Sometimes they don't know they're lost. Sometimes they're dead (and then I certainly hope they know where they are). Anyway, being lost is a relative concept, after all. Today I saw that a patient I've been looking for over a 18-month period was actually in the hospital. Based on his history---alcohol abuse, uncontrolled diabetes, end stage liver disease, and intermittent homelessness---I figured we might just find him "in house" some day, or hear that he was dead. Luckily, he checked himself into the ER last week, inebriated beyond mentation, his ability to identify himself precluded by the alcohol coursing through his blood. Admitted as "John Doe", he eventually revealed his identity, and although he could not state the name of the hospital, his address, the date, day or year, he was eventually able to state the year of his birth. Thank God for small favors. This piece of information led to his "John Doe" bracelet being removed and our peripatetic patient labeled as no one but his own true self. Hallelujah. Enter the Outpatient Nurse Care Manager, alerted to the presence of said patient on today's in-patient roster, diligently dashing to the Neurological floor of the hospital to make some semblance of a connection with the lost lamb. Although said lamb did not seem to completely understand the purpose of this writer's visit, he was able to produce a crumpled piece of paper with what turned out to be an accurate telephone number for his brother, who thankfully answered his phone and agreed to drag his infirm brother for a visit at the clinic in a few days, following discharge later today from the hospital/hotel. What struck me at the time of my visit was this patient's similarity to a past patient who I once described. This gentleman had ignored the needs of his diabetic and diseased body, choosing to drug and drink and abuse himself beyond a level that could be imagined to actually support life. One day, despite dire warnings that a disaster was imminent if he didn't change his ways, this unfortunate gentleman began to vomit so uncontrollably and for so long that he eventually blew apart his esophagus, gastric contents pouring into his (previously sterile) abdominal cavity. Miraculously, he survived, and is now institutionalized, and will perhaps be the recipient of an artificial esophagus some day with any luck, but his battered body will never fully recover from the insults visited upon it. His response to us after he awoke from a weeks-long stupor: "I wish I had listened to you sooner." This is regret of the saddest kind. And we wonder if we could have done more to convince him. So, here we are, faced with yet another train-wreck of a patient, taking his body to the edge, taunting death and disability with a uncaring sneer, all of that alcohol pouring over a diseased body like gasoline on a fire. Can I convince him to change his ways and avoid a fate even worse than death? The odds are slim, but we'll try. Does he truly conjure the ghosts of patients past? Oh yes, but in many ways his own inner ghost is just waiting with baited breath for the opportunity to leap from its mortal vessel and cavort among the other ghosts haunting this city of ours. And if he's dead set on releasing his ghost, then there may only be so much I can do to deter his trajectory from this overpopulated path of self-destruction. Unfortunately, he has a great deal of willing company on this sad and nihilistic journey, and the influence of his compatriots may completely overpower any dent I could ever make in the armor of addiction. Ghosts, armor, disease, destruction---just par for the course on a very average day. God/dess help us all. ## Thursday, November 09, 2006 ### Codependency Is Us In the course of my work, there are always relationships which feel more personal than others, in which a more intimate connection is created over years of interaction. There are those which feel parental (either on my part or the patient's), those which feel dysfunctional, those which are a nice mix of personal and professional, and some which are "strictly business" ( I have very few of these, I confess). There are patients who say "I love you" whenever I see them, and I still experience moments of quiet discomfort as to how to correctly respond to such protestations. Then there are patients who are my chronological peers with whom I have a generational bond, not to forget those who are my juniors or my seniors. Transference, counter-transference and projection all play a part on this stage, and I am constantly vigilant for signs of codependency on my part. There's a patient that I've written about in the past who is on my mind. Being white and about my age, he shares with me certain cultural common denominators, despite his coming from a very different socioeconomic background---working class, alcoholic abusive father, no high school diploma, stints of homelessness, alcoholism, and life-threatening chronic illness. Taking those similarities and differences into account, it's no wonder that we get along on some levels, but are universes apart on others. And it is here that the codependency begins. My patient, having given up the drink and hopped on the wagon, no longer has the alcohol-soaked social connections which previously filled his life. While he is proud of his sobriety of almost two years, he also feels lonely in that sobriety, failing to find a social milieu in which he can make new friends and acquaintances. Underlying mental illness does indeed make his social life more challenging, and a curmudgeonly demeanor only adds to the boundaries which keep people at bay or on their guard when around him. Although he constantly complains that people look at him like he's crazy, his predilection for talking aloud and laughing to himself certainly keeps strangers at arm's length and precludes normal casual social interaction. Like I've told him before, if you act like the crazy guy on the bus, that's how you'll be perceived and treated. One reaps what one sows, even inadvertently so. Since he has lost his social circle, this gentleman looks to me, one of our counselors, and the administrative staff of our office as part and parcel of his social life. He sometimes exclaims that we are his "only friends", and he periodically cycles through undisguised crushes on various members of the front office administrative staff, at times bringing gifts (other than small offerings of candy or snacks) which cannot be accepted. He even went so far as to give our counselor (for whom he proclaimed undying love) a$200 portable DVD player which was refused on the spot. He was crushed for days.

Several times, I have taken this patient out to lunch, as I will occasionally do with my more isolated clients. As he complains of his loneliness and isolation, I sometimes feel pangs of guilt over my privileged life, comfy home, circles of friends, supportive wife, loving family, and ability to vacation and recreate (in moderation, of course) as desired. When he tells me that he has no one to go to a football game or movie with, my heart sinks. When I hear of his many solo trips around our region to various events, I cringe. Knowing what town I live in, he drops hints that he had looked for me downtown on a recent Saturday at the Farmer's Market but didn't see me. He comes to my town to see local college football and basketball games, sometimes sleeping on a couch in the Student Union if he misses the last bus back to his house (forty-five minutes away).

Many a time my mind has wandered to a scenario in which this gentleman---or another patient---visits my home. How would it appear to him? What would it tell him about me that he does not already surmise? What further levels of envy or jealousy would it engender? Would I end up in a situation similar to that of Richard Dreyfuss' character in What About Bob? He's even made comments that he may simply find my house one day and surprise me. Oh dear. What would Richard Dreyfuss do?

How many patients have I honestly considered taking home and caring for? Far too many. How many have I actually gone so far for? None, and never will I do so. How many former patients have I promised to maintain contact with after leaving a job for another? One, and that contact remains active. How many patients' children have I given Christmas presents to? Quite a few. Will I do it again? Seguro que si!

So, when is it codependency and when is it simply being human? When is it OK and when is it going too far? How guilty does one allow oneself to feel vis-a-vis the lacks in others' lives when compared to one's own? These and other questions loom large in such work, and no matter how firm one's boundaries, they will always rear their heads again.

Codependency, anyone?

## Thursday, November 02, 2006

### Another Change of Shift....Again

Once again, Change of Shift, that most venerable of nursing blog carnivals, is up and running at Disappearing John.

Enjoy, if you've time to do so.

## Tuesday, October 31, 2006

### Day of the Dead

He grimaces with pain, tears streaming down his face. My psychologist colleague and I sit with him and his wife quietly.

"I fight with the Devil in my thoughts. I hear voices. So many things...." He sobs. His wife confirms his suicidal ideation. The patient shares some trauma history with us, the memories of which could very well explain such psychic pain.

"You know", my colleague says gently, "sometimes when we're sick, and we have alot of time to lay in bed and think, memories come back that we might otherwise suppress."

He watches her intently.

"Those memories surface, and then we're faced with the pain all over again, pain that we might not be able or willing to bear."

He cries again.

This man, once robust and working 6 days a week despite his many chronic illnesses, was always barely able to make time to see me every few months due to his schedule. Now, he is a shell of what he used to be, signs of damage everywhere. He has been so battered by his physical health, and now his psychic and emotional and spiritual well-being are significantly compromised.

Our patient and his wife take their leave, she pushing him down the hall in his wheelchair.

My colleague and I look at each other, sigh, and move on to the next patients waiting for our attention.

Yes, it's Hallowe'en, the Day of the Dead. Many ghosts come out from under beds today, skeletons rattle in closets, as the veil between the worlds grows thin. It seemed like our patient was grappling with forces beyond his ken today, speaking of devils and voices and the haunting of his mind by unseen forces.

The sun goes down, the streets darken, and I wonder who else out there tonight grapples with such demons, as children dressed like devils and witches roam the streets.

I think of the small plaque that sits in the therapy room where we met with our patient. It reads: "And in a cruel age, I will sing of kindess" (Alexander Pushkin).

May choruses of angels sing of kindness this night, and may all those in need be blessed to hear their song.

## Friday, October 27, 2006

### Flu Flurry

The flu vaccines have arrived, and the flurry of vaccination has begun. Sore shoulders and fears of needles are the notions of the day. Hospitals and health centers practice "force protection", vaccinating employees against illness and lost productivity, unless, of course, the vaccine itself lands said employee in bed for a few days, a small price to pay for the ultimate avoidance of full-blown flu.

In the media and beyond, warnings and predictions of a pandemic loom large, some epidemiologists predicting an eventual worldwide scourge that will dwarf the death and destruction of 1918. Although this may eventually occur, it seems best as a healthcare provider to focus on the here and now, teaching self-care, hygeine and handwashing, protection of family and friends, and avoidance of those who are acutely ill. My immune-compromised patients are the ones for whom I am most concerned, as well as my patients with severe respiratory disease.

There is a certain panic that overtakes a segment of the population as the shipment of vaccine is inevitably postponed by the Feds. Even this year, despite previous experience, we received a small shipment which quickly disappeared, followed by utter silence from the Department of Public Health, leaving us in complete ignorance of the arrival of subsequent shipments.

In a recent post, I prayed aloud that the season's supplies of flu vaccine would flow like "champagne at a wedding". While the supply is not yet intoxicatingly large, some 400 doses arrived to the clinic this week, fifty of those routed to our office for vaccination of our "most vulnerable" patients. Who, then is "most vulnerable" among our caseloads? The 35-year-old with completely suppressed AIDS who has a fully reconstituted immune system or the elder with diabetes and COPD? Is it the schizophrenic with hypertension and daily contact with 100 others at a day program, or the morbidly obese homebound woman with asthma? These are rhetorical questions, obviously enough. They're all "vulnerable" and should all be protected to whatever extent we can do so. Hopefully, the supply will be abundant, and everyone who wants a vaccine will receive one forthwith.

In terms of planning for a pandemic, workshops and municipal plans abound, and I belong to a local group of trained volunteers who can set up a mass distribution site and vaccinate thousands in the span of a few days. Still, if people are going to get sick, there's just no stopping it no matter how many workshops we attend.

So, we do our best, jab as many people in the arm as we can, cross our fingers, and hope to survive this flu season unscathed.

## Monday, October 23, 2006

### Medicare Part D(uh)

Within the confines of our current state at my work-place, the patients of the program for which I work can only have Medicaid. Once they receive Medicare, we have been forced to cut them loose, the lucky ones over 65 making their way into our program for that population. But at times, some fall through the cracks, and then comes Medicare Part D, otherwise known as Medicare Part Duh. And all hell can break loose.

When someone becomes eligible for Medicare, we all now know that they must sign up for a Medicare Part D drug plan or face financial penalties. The Feds seem to enjoy creating these labyrinthine and ludicrous scenarios which penalize and confuse the huddled masses. The United States of Sadism.

As a case in point, just today a patient rolled into my office in his electric wheelchair. Physically disabled, with major depression and a anxiety disorder, this kind and soft-spoken gentleman needed my assistance. The fact that he is no longer "my patient" on paper means nothing to him, and just as little to me. He explains that he understands that he has new drug coverage and demonstrates this by showing me his new Medicare Part D Prescription Drug Plan card from a company which shall remain anonymous (to protect the guilty). He continued to explain that the pharmacy where he always fills his prescriptions has informed him that he now must pay $74.85 for his one-month supply of BuSpar, a medication for anxiety that he has taken for years. I look at the 1-800 number on the card and sprint to my desk. "Customer Service, may I help you?" "Yes, one of my patients is being denied a crucial medication and cannot afford the$85 to pay for it. If you don't help me, I'll reach through these phone lines all the way to California and strangle you." (I paraphrase here, obviously.)

"Well, I'm sorry to hear that, but this patient, or should I say 'member', has a $250 deductible which he must meet before we will may for any prescriptions. He will then have a monthly premium and co-pays for each prescription. Is there anything else I can help you with today?" "Do you mean that this 65-year-old man who worked all his life and now lives on a fixed income in subsidized housing must come up with$250 to make a deductible which is impossible for him to budget for?"

"Uh, yes, I'm afraid it does." Then an uncomfortable silence on the other end of the line until he says, "Is there anything else I can help you with today?" (As if he had truly helped me with anything.)

"Yes, please give me your home address and phone number so that I know where to direct the hate mail." (I didn't really say that, folks. I just hung up on the heartless managed care bastard who seemed to lack an ounce of compassion.)

Hanging up and putting my head in my hands, wondering how to explain all of this to my patient, a small nightlight-sized bulb went off in my head. As of the 1st of November, my dear patient who is currrenty in Managed Care Purgatory would be eligible for coverage under our program for people over 65 with Medicare! We would essentially become his payor and our nurses would then make all of the decisions about his coverage and medications, with no premiums or copays! (Sounds like a Communist conspiracy to me, Senator McCarthy.) Relief flushed through my veins like so much Bombay Sapphire Gin on a warm summer evening.

Shaking off the thought of a gin and tonic, I rummaged through the meds which I keep in a locked drawer for some of my patients, successfully "borrowing" fourteen 30mg BuSpar tablets from another patient. ("She'll never miss 'em!") But seriously, this gentleman will pay her back, so to speak, when he gets his next supply, and no one will be injured by the transaction. Another flush of relief. Shall we have another drink?

I press the small bottle of BuSpar into my patient's hands, his eyes smiling, my anxious perspiration drying, and we both take a deep breath knowing that we have subverted the dominant paradigm of Medicare Part D(uh) once again. Like my patient who was denied a walker by Medicare because he already has a wheelchair (did you hear that, Orwell?), this patient's only hope of skirting these insane rules and regulations is to seek shelter in our little program which ducks those guidelines and gives the people what they want at a price they can afford, and we have great clinical and economic outcomes, to boot. What more could a Medicare actuary ask for? (Well, deductibles and co-pays, for one, not not mention pricey premiums......)

Folks, I wish I could share with you the secret to what we're doing, the address of my company, and how this practice can be replicated throughout the land, but we just aren't there yet and I must still remain "geographically anonymous". But rest assured, this new breed of "managed care" certainly has a future, and if those actuaries would just get out of our way, maybe we'd be able to fulfill our mission and roll this new model of care out to the rest of you. Until then, keep fighting the good fight, and know that in many corners of this country and the world, brilliant minds are strategizing and conjuring ways to continue to stand this government's duplicitous and worthless schemes on their head. Millions suffer due to their incompetence, and until we think outside of the box---or forget the box altogether---we're trapped in a world we never made.

Gin and tonic, anyone?

## Sunday, October 22, 2006

### Anticoagulation Blues

Some of you nurses out there might have the responsibility of following patients who are on Coumadin, a powerful blood thinner used for many different clotting disorders. If you do, then you might understand the challenges posed therein, as well as what I call The Anticoagulation Blues.

This form of the blues occurs when a prudent and earnest nurse attempts to manage the care of a patient on coumadin who does not follow protocol. Such is the case with "P", a patient who has suffered from chronic deep vein thrombosis for more than ten years following an accident. This individual has more than once presented at the ER with leg pain and swelling, a subsequent Doppler ultrasound revealing a clot running from the instep to the groin. One small piece of that clot breaking off and travelling to the lungs would kill this person almost instantly from pulmonary embolism.

When tracking a patient on coumadin, it is necessary for several things to happen. For one, the patient must come in for timely bloodwork on a regular basis to have a PT/INR drawn, a test which shows the relative coagulability of the blood. Without this test, we cannot determine how "thin" or "thick" the blood is, and the patient runs great risk of either developing a life-threatening clot or life-threatening spontaneous bleeding. Once the test is drawn, it's necessary that the patient be available by phone for detailed tweaking of his or her Coumadin dose, and then must understand and implement the dose changes advised.

Enter P, stage left. This patient's phone is always busy or off the hook, or there's no answer. No matter how many times I've said, "You must take responsibility and call me for your results---it's your body", this person just can't seem to grasp the gravity of the situation. No matter how much I plead, admonish, or cajole, I still chase this patient down each week, and pray to God that nothing bad has happened when I can't get through. Just this weekend, I ended up calling six times on Saturday, finally reaching my patient today (Sunday), confirming Friday's results and the subsequent doses for the next three days. It's a distressing dance, this business, and the Anticoagulation Blues have me firmly in their grasp. So, strike up the band---a basic blues progression, if you will---and sing along. F-minor's my key.

My patient won't call
Or answer her phone
I'm here at my desk
with results all alone

She might bleed or clot
or just up and die
and then if she did
her fam'ly would cry

They'd blame me for this
and sue us all quick
and I'll lose my license or maybe feel sick

It's a sad story yes
You must really agree
It's a bad way to go
from a big DVT

Anticoagulation Blues
have got me again
coumadin on the brain
coumadin's not my friend

So if you're a patient
who needs this control
make sure you do what
by your nurse you are told

Or down you will go
gasping for breath
to meet your (here's the big finish) untimely, unseemly, and completely avoidable
Death

## Saturday, October 21, 2006

### 300 Million

Much fuss has been made about this magic number, 300 million, in terms of the population of the United States. Allegedly, according to the Census Bureau, we reached this noteworthy number just last week. According to the statistics, we have seen 30% population growth over the last 40 years, 60% of that growth being from births, the other 40% being due to immigration from abroad. 300 million---that's a big number.

So, what does it really mean? How does it effect me? Some commentators I heard on the radio noted that it means longer lines at Starbucks and busier streets. Waiting an extra three minutes for coffee at my local cafe (NOT Starbucks!) is really the least of my worries.

From my perspective, there are many meanings and reverberations of this massive population growth, and this is in no way an exhaustive list, by any means. To wit:

---increasing numbers of those living in poverty
---more children going hungry
---more Americans without health insurance
---an inadequate healthcare infrastructure to handle such growth
---more unchecked pedestrian-unfriendly development and sprawl
---more market share for Wal-Mart
---more gas stations, more banks, more delivery trucks, more congestion
---more people to whom corporations can peddle their unnecessary wares
---an exponential growth in the number of cars on the road
---more poor and working class people for military recruiters to target
---a devastatingly corpulent Military-Industrial Complex
---a further shortage in space in colleges and universities for worthy students
---increasingly crowded emergency rooms
---an exacerbated shortage of nurses and nursing faculty
---a riotously damaged environment
---a growing Prison-Industrial Complex
---further decimation of open space and farmland for unchecked development
---more schools that the federal government will not adequately fund
---more children left behind by the "No Child Left Behind" Act
---further demographic shifts into the sprawling suburbs
---the continued decline of numerous American cities
---more people for the government to exploit and deceive
---more intolerance of new immigrant populations and their needs

If I have left anything out, please do chime in. While I welcome new citizens and new babies entering the world, I simply see this country as inadequately prepared to support such growth at this time in history. While we can't (and should not) artificially stem the tide of births and immigration, we should, in my opinion, focus on developing strategies and methods for accomodating this expansion of the population judiciously and intelligently.

We need better funding for schools, legislation to curb sprawl and encourage "smart growth", wider use of renewable energy sources, clean mass transit, universal healthcare, universal access to higher education, low-interest small business loans, government subsidizing of nursing schools and nursing education, increased federal subsidies of student loans, expanded government stipends for healthcare workers choosing to work with vulnerable populations, more affordable housing, a narrowing "Digital Divide", job training for those unable to enter college, improved reentry programs for those leaving prison. I could go on, but you get the picture.

Yes, 300 million is a number which the media can latch onto. It smacks of pride and a cockily arrogant sense that America's power in numbers has in no way diminished. Yes, the number is large, and the population does indeed continue to swell, pregnant with possibility and fraught with the potential for disaster. In this land of plenty, we still see countless go hungry, our charitable institutions already stretched beyond capacity.

When we reach 325 million, what will the soup kitchens do then? How long will the ER wait be at that juncture? How many more stores will Wal-Mart have built in order to sell us even more items made in sweat-shops in Indonesia, China, and Mexico by workers unprotected by rights which we hold dear here in our own homeland, their environments degraded by lax regulations so that American companies can generate enormous profits at home? How many more billions will McDonald's have sold, further augmenting the obesity epidemic which strangles our healthcare system and economy with unnecessary costs?

300 million. We can put away the champagne and confetti now that the media has had its day. Now we must roll up our sleeves and decide whether we will allow this number to simply sink our society under the weight of its own metastatic expansion. We have a responsility to these new members of our human family here on this continent, and we'd better think fast.