Saturday, April 29, 2006

Even as We Dream....

"I pray for peace in this world and the happiness of all beings."

Our neighbor gave us this prayer written on a piece of paper today in honor of Sparkey, for whom we are having a weekend-long Living Memorial. Our son, who visited for the occasion, remarked how we always seem to find reasons to have parties.

Spring brings much newness: the earth awakens, the flowers bloom, the trees blossom, the owls nesting in our neighborhood have two baby owlets in their nest high above the ground. But with the passing of the seasons comes the passage of time and the necessary ageing that accompanies that phenomenon. Canines age seven biological human years for each year they tread the Earth, and our choice to accompany them on this symbiotic path means that we must also say goodbye when their time to depart approaches. A sad but true reality that no amount of denial will assuage.

Equally, humans too must face their mortality. Thinking of Sparkey's illness and the need for people who love him to say goodbye, I also think of a patient who is nearing his end, his family providing his care and watching him make the choice to no longer leave his bed. On Monday, the hospice nurse and I will sit with the family and our mutual patient and explain the options of withdrawing fluids and nutrition over a period of several weeks which will actually ease his suffering and allow him to begin the transition out of his body.

I think to myself: would we just withdraw Sparkey's fluids and nutrition and let him slip away with morphine and immobility, or would we simply euthanize him with the assistance of the veterinarian, precluding the need for such a drawn-out affair? The issue of humane death (for both humans and canines) is foremost in my mind these days.

Sunday will bring yet another opportunity to be with friends, gather my thoughts, observe the life around me, and prepare to re-engage in the workaday world once again on Monday. Sparkey's eventual departure, my patient's deneoument, it is all as it should be, even when I cannot even see the forest for the trees. Whatever the near future brings, being in the present seems to be the best way of arriving there. Tomorrow will be its perfect manifestation, and our world will continue to turn beautifully, even as we dream.....

Thursday, April 27, 2006

Nineteen Keys to Happiness

A poem by my dear friend, Gale Warner (June 7, 1960-December 28, 1991)

Rise before the sun does.
Drink snowmelt. Eat oatmeal.
Observe the habits of lichens.
Watch clouds. Remember
the names of plants.
Walk, or work, enough
so that your rest has bones,
but not so much
that you are too tired at day's end
to ease next to your love, read poetry
aloud, wrestle, tickle, belly-laugh.
Stalk ptarmigan. Swim naked.
Take good care of your teeth.
Spend no money. Make
no pollution. Plan books,
but do not write them.
If you must speak with someone,
let it be about the weather, animals,
or prehistory, or the design of greenhouses.
Think about children. Go barefoot. Invent
political parties. Plot community.
Wash the dinner pot immediately.

Wednesday, April 26, 2006

Good News Welcome Here

"You mean I'm actually a little better?"

"That's right. I'm thrilled," said the hematologist/oncologist.

"Wow. That's good," he beamed. I just smiled from my chair.

I've written about Patient X a number of times. He almost died from alcoholic hepatitis about eighteen months ago. He was living in the basement of a friend's business, drinking himself sick, psoriasis ravaging his skin, his gout painful and swollen. He was miserable and would lash out at every opportunity. I used to avoid him.

Then his liver crapped out and we read him the riot act. After discharge from the hospital, he went on a little weekend bender. The following Monday we had a frank discussion, and I offered him two alternatives: stop drinking, or die a wretched death. He hasn't had a drink since January of 2005, and the credit is all his. No AA. No meetings. No psychotherapy. Just him and his mind.

That said, he's not out of the woods forever. There is cirrhosis and permanent scarring of the liver that will never go away. Last month, he came to see me with complaints of black, tarry stool and vomitus like coffee grounds. Needless to say, that led to a hospitalization---stat.

Today was follow-up with his hematologist. He had been diagnosed with hemochromatosis---a dangerous iron overload in the liver and blood. Luckily, he had the type caused by damage from alcohol, not the genetically inherited variant. Thus, his current labs elucidate the fact that his liver, freed from the toxicity of alcohol intake, has recovered completely from the iron overload, illustrating for us that some of the non-cirrhotic areas have actually healed. As we enjoyed the fruits of this success, the hematologist and I exchanging very pleased looks back and forth, Patient X sat on the exam table beaming.

"You know I'm leaving for another hospital in six weeks," the doctor said. "You'll be following up with someone else next time."

"Can't I see you at that other place?" he asked like a puppy eager to please his master.

"It's a half-hour ride for you," she said, "but I'd be happy to continue to see you. After all, it'll only be an annual visit now."

"I'd be willing to take you there next year, Mr. X," I chimed in. I pictured taking him out to lunch, making an afternoon of it.

"Wow." He was beaming. "That's double good news. I get better, and I get to see you again next year."

The doctor's kindness and bedside manner is impeccable---just the right combination of warmth and clinical acumen. Perfect. In fact, she and I had an amazing and moving interaction with another mutual patient last year, and her manner is still amazingly consistent. I'll miss knowing that she's here in our hospital system, but she'll actually be working closer to my hometown, and we'll still bump into each other on the street from time to time since we both live in the same area served by her new hospital.

She describes for us her plans for a two-month break between jobs and a trip to another country this summer.

"Well, I'd better apply for a passport right away," quips Patient X. "I don't want to get left behind. Should I pack light?" We all laugh heartily.

This man has faced death without fear. Not only that, he has wrestled with his own addiction, grappled it to the ground, pinned its face into the dirt, and shown no mercy. He buried that addiction under the topsoil of his new love of life and desire to live. It's history, a memory.

"My old man forced me to drink a quart of whiskey when I was fifteen. Boy was I sick. I guess he wanted a drinking partner. That started it, and it didn't stop 'til last year. Jesus."

"I'm so sorry," the doctor said, hand on his shoulder.

"But this is great!" he continued, recovering from that memory. "All I want is to ride my bike, watch movies, eat well, and take my meds." His ruddy face was lit from within.

"Well, get some labs in six months, follow up with this guy" (she points a thumb at me) "and I can see you next spring."

"You got it, doc," he says. "Have a great time this summer. I mean it. And thanks again."

She closes the door and we walk down the hall.

"Congratulations," I say. "Want a ride home?"

"Nah. You go on. I gotta use the can, then I'll catch the bus." He shakes my extended hand, his foot holding the men's room door open.

"See ya."


"Don't be a stranger."


I exit into the sun and slight breeze, smiling. It's a very good day to live.

Monday, April 24, 2006

Short Poem for a Monday

There is a
communion wafer moon
dissolving on the blue
tongue of the sky.

Sometimes the whole world
is nothing so much
as an altar
inviting us to kneel.

---Linford Detweiler of Over The Rhine

Thursday, April 20, 2006

For the City

In my city of employ---which I call "The Little City That Couldn't"---drugs, political corruption, cronyism, gangs, prostitution, and illegality rule the day in many branches of city culture and life. The housing commission, city hall, they're all crawling with organized crime. Multiple social service agencies scramble for the measly dollars available to keep services afloat, house and feed some of the many homeless, care for the mentally ill, and deal with the soaring rates of HIV and drug addiction. It's a picture of bleak 21st century urban Amerika at its worst, and getting no better. The boards over the large windows behind my desk tell the continuing story of the damage done to property of agencies striving to improve the lives of the city's poorest and most disenfranchised inhabitants. Shattered windows still greet us regularly, and the owners of the building will not allow us to install bullet-proof glass. Thus, we have replaced more than half a dozen large windows in the last six months, a cost born by our already truncated budget.

Today, returning to work after one sick day and another day at a conference, I was informed that the director of a central social service agency in our portion of the city was shot while sitting in her car in front of her office, talking to a coworker at the end of the day. At 5pm, broad daylight, a Tuesday afternoon in the slowly heating city, the spring weather giving a taste of the simmer that settles on the city in the warmer months of summer. Caught in the crossfire of a gang-related shooting, the bullet lodged in her shoulder and did not penetrate past the muscle and sinew, sparing her vital internal organs, the heart and lungs. I hear she's doing OK, and will return to work soon.

My coworker who told me of the incident also reminded me of something I had blocked out: her partner, who used to work for us, was also caught in the crossfire two years ago, a bullet shattering her rear windshield. "They never found the bullet," she said. "It must still be lodged in my car somewhere."

Occupational hazards abound in any line of work. Miners, factory workers, surgeons, janitors, garbage collectors---there are many hidden dangers. We all just hope it won't happen, whether to us, someone we know and love, or someone we don't even know. Senseless violence and killing permeate the world we live in, and it seems to not even stop at some of our doorsteps. I count my blessings as I sit in my quiet, suburban/semi-rural home, safe from the dangers of the city. It's a strange dichotomy, this reality at home and that reality at work. It isn't a cookie-cutter world, and the knowledge of flying bullets so "close to home", so to speak, is enough to give one pause on even the most beautiful of spring days. Is it worth it? Can we all be frightened away? Perhaps some of us, but the struggle for the heart of our society is on, and it is often in the cities where that struggle is most actively engaged.

"It's just enough, just enough, for the city." (with a grateful nod to Mr. Wonder)

Wednesday, April 19, 2006

Hospice at Home, Hospice at Work

We're setting up a home dog hospice. We've moved our bedroom downstairs so Sparkey no longer has to negotiate the staircase up to the second floor. Mary and I both bought ground beef today (we're vegetarians!) to cook for the old guy. I have IV fluids, needles, and tubing ready to roll for the morning treatment before I leave for work. His medication box is all set up, as it has been for many months now, and we are rearranging things in the house to make it safer and more comfortable for his wobbly self. Mary purchased a special sling which we use to support his hindquarters as we walk him. It takes two hands now---one for the leash and one for the sling. Last but not least, we consulted an "animal communicator" to see if we could glean from him his wishes and needs. Is it days? Weeks? A month?

A long telephone conversation this afternoon between myself and a hospice nurse sorted out some of the needs of my very ill patient vis-a-vis his comfort and treatment. Tube feedings, suction, a home health aide, symptom management, a pressure-relieving mattress---the wheels are turning and I will squeeze everything I can out of the system for his benefit. Dying can be so complicated these days, and my job is keep that ride as smooth as possible for all concerned.

Death and dying at home or at work---it's all the same. It's about love, comfort, compassion, and dignity. Canine or human, the goals are interchangeable, the methods differing slightly in delivery but never in spirit or intention.

Monday, April 17, 2006

Getting Ready

"I hear you're burning out on this."

"Yes," he mouths, no longer able to speak from the effects of invasive cancer.

"I love and admire you so much," I told him. "We'll do everything we can to keep you comfortable and at home." We shook hands, the sound of the oxygen compressor filling the room in the vast silence that followed that simple exchange.

Then I called hospice and let them know that it's time to get their services on board. We're all getting ready.

From there, I went back to the office, took care of some business, and then went over to the local animal hospital, where my 13-year-old dog has been since yesterday. I sat in his little cage/cubicle with him. Renal failure manifests as vomiting and anorexia in dogs. He vomited so much on Sunday, and then he could barely stand. We packed him in the car and sped to the animal ER.

Interestingly, two years ago on Easter Sunday---the very same day two years ago---I rushed him to the same animal hospital, and it was acute pancreatitis. At that time, he had not yet begun failing in earnest, and I wanted them to do everything they could, even in the face of respiratory arrest. This time is different. The poor old guy is DNR/DNI. I visited him in the ICU after work today. He didn't even get up to greet me, though he licked my nose as I talked to him, looked him in the eye, and brushed him down, removing large amounts of winter undercoat. I sat in that cubicle for an hour, the IV whirring as it instilled fluids in his canine veins. I told him I loved him more times than I could count.

I guess we're always getting ready, be we canine or human. We're getting ready from the moment we leave the womb. We hope the journey will be gentle. We hope there will be joy along the way. We hope we will not suffer, nor will our loved ones. We hope to die in peace.

My first dog, my dear friend, will come home tomorrow and begin a final chapter of his life's winter. We will love him and feed him and give him IV fluids as long as he seems to not suffer. And when the time comes, when we're all ready and the signs are clear, we'll call the vet, she'll come to our home, and we'll tenderly hold Sparkey in our arms as he leaves this sweet earth.

Meanwhile, my patient, unable to have his life end so mercifully, will see it through to the bitter end, hopefully in the comfort of his sweet and lovely home. Which is better? Which is more "humane"? Who will experience the least suffering?

All beings deserve to die with dignity and freedom from suffering. May we be willing midwives to them all.

Friday, April 14, 2006

Truth and Consequences and Boerhaave's

Abuse of the self will only take you so far. I wrote about you here and here and here and rhetorically asked if there were any more I could do. I eventually decided that you could not be convinced that a painful and ugly fate awaited you around the corner. You seemed to be beyond hearing, beyond caring, beyond taking full responsibility for yourself and the consequences of your actions. Those actions came home to roost and it was not pretty.

Today, I visited you at the end of a trying week. There you were, clean-shaven, hair recently trimmed, your enormously swollen legs up on a chair. You shook my hand and almost smiled. Asked if you felt pain, you said "absolutely none". On this visit, you didn't tell me that you were hungry. Perhaps now you're used to the fact that your stomach is now an empty pouch, the esophagus above it non-existent.

The Infectious Disease (ID) specialist, a pretty young doc new to our facility, stops me in the hall and we discuss your case and your illustrious history of excess and poor choices. I tell of the many conversations you and I had had, or rather, the numerous times I had regaled you with tales of what would happen if you didn't clean up your act and take your health seriously. The doctor describes Boerhaave's Syndrome for me, and based on the fact that enormous amounts of gastrointestinal fluids and detritus poured into your chest cavity after your esophagus burst (and you did not seek medical attention for several days), we marveled that you're still among the living. We discussed the possibilities of you eventually having an artificial esophagus and what that might mean for your future.

I tell the curious doctor stories of how I would arrive at your apartment (prior to your eviction, that is) and knock, hearing sounds of hurried cleaning and movement behind the locked door. Of course, drugs and assorted paraphernalia were being summarily hidden upon my precipitous arrival, and you would deny all drug-related activity as we sat at your kitchen table, your friends in the other room, watching TV and smiling when I poked my head around the corner. You were a bomb waiting to go off. I just couldn't know what you would look like when the smoke cleared. Now we know what you look like, although the shape of the future is uncertain. Many months of hospitalization are ahead, with more surgeries, more complications, further discomforts and indignities.

I inform the ID doc that the floor nurse complained to me that huge herpetic sores covering your buttocks and scrotum are being treated only topically and seem to be spreading. Speaking of indignities, we ask you to stand and bend over your walker and we examine your buttocks with our hands gloved in those strange blue powderless latex-free exam gloves. She agrees to order intravenous acyclovir. Sometimes my intervention and input is all it takes to get something done. Other times, it's like screaming into the wind. I guess the wind's in my favor today.

As I take my leave of the floor, you're ambulating around the ward with the nurse and another helper. The urine collection bag dangles from your walker, I can see the outline of the feeding tubes which protrude from your abdomen under your hospital "johnny". Your ears look enormous in contrast with your gaunt face, skinny neck and close-cropped hair.

If only I could have shown you this potential future with a crystal ball, illustrating for you the fate which only you had the power to avoid. If only I could bring other troubled patients to see you, show them your feeding tubes, the CT-scan of your non-existent esophagus, have them sit with you a while, and perhaps decide to turn themselves around. If only the traumas of your earlier life of which I am ignorant had not occured, or you had recovered from them without turning to drugs and self-destruction. If only your siblings, who love their eldest brother despite his failings, could have helped you turn it around. If only.

You're in good hands now, off the streets, the life that you knew before a mere memory. While I regret your suffering, I also absolve myself of feelings of responsibility for this turn of events, knowing that I could not produce the deus ex machina that would magically transform your life and lift you from your despair. The deus ex machina can only be your own spirit now, a power within you that will carry you along this troubled road. May blessings of strength and courage anoint you at every step of the way.

Monday, April 10, 2006

Monday Morning Meditation

Sitting at the keyboard this Monday morning, the desire is to rise above the end-of-the-weekend-blues, embracing the week with open mind. When the calls to reenter the bed's warm cocoon are subsumed by the responsibility of the working week's commitments, the next best thing seems to revolve around the acceptance of what is, and the notion of seizing what life has offered.

Even as I make my lunch, pack my bag, clip on my beeper, and check my day's appointments on my Palm Pilot, I begin to tense up in anticipation of what could be seen as the onslaught of the day. Rather than being an onslaught, why can't it be a challenge, a gift, a call to service? Perhaps knowing that I won't return home for 14 hours makes my Mondays more difficult to face. But today, knowing that the semester of teaching will end in five weeks, I recognize that many hours usually spent preparing lectures and reviewing texts will soon be freed from the shackles of extracurricular responsiblity.

John Lennon once said, "Life is what happens when you're busy making other plans." I'll add that life is what happens whether you live in dread or wide-eyed wonder. How can I choose anything but the latter?

Friday, April 07, 2006

Of Blood Sugars, Balloons, and Blessings

A challenging home visit to see a schizophrenic man with very poorly controlled diabetes tested my patience this morning. A thought/personality disorder and a chronic illness in need of very tight control don't mix well. We conflicted and argued somewhat over his health and high blood sugars, his paranoia kicking in and making mincemeat of my arguments for improved self-care. For the first time, this gentleman really pushed my buttons and I held myself in check and brought the conversation around to a positive feeling again. The visit ended on a good note and I regretted that his brother/guardian had not been present for the session. Nonetheless, some headway was made and the door left open to further discussion, not to mention dramatic increases in insulin to counteract consistently and frighteningly high blood sugars.

The next visit was more pleasant and easy-going: a bipolar woman with emphysema, diabetes, a smoker’s cough, and a black cat who curled in my lap as we chatted. This woman’s blood sugars are superlative, and she spent most of the visit psyching herself up to quit smoking. Fortunately, a recent CT of the lungs revealed that shadows on a recent chest x-ray were just emphysema and fluid, not the dreaded cancer she fears. That said, further smoking will only increase the risk that, one day, another CT scan might bring most unwelcome news. She complained of the cost of nicotine patches and the fact that Medicaid won’t cover them. I asked her how much she spends on cigarettes a month. She laughed and looked away.

Trying to avoid the highway construction I noticed on the way downtown, I zigzagged my way through a neighborhood that I don’t always traverse. My descent down a narrow street was delayed by a strange sight: a red and pink heart-shaped helium balloon tied to a ribbon with one of those little plastic discs at the end of the ribbon to anchor it and keep it earthbound. The phrase “I love you” graced its flank in cursive script. This balloon was literally crossing the street, skipping up and down in the air, lightly touching the macadam as it made its way safely from one sidewalk to another. An oncoming car also stopped to let it cross. It reminded me of that scene from American Beauty, where the young man/filmmaker records the ballet-like gyrations of a white plastic shopping bag caught in the concrete corner of an alley by a temporary urban whirlwind. (The whole movie is worth that sequence, if you ask me.)

Having avoided the traffic, I leave the balloon to its own devices, Todd Rundgren’s song “A Dream Goes on Forever” in the CD player. You just never know the strange blessings that will cross your path in the course of a day.

Wednesday, April 05, 2006

I Wanna Get Out of Here

“I wanna get out of here.”

“I know, but not til you’re ready.”


Patient X, whom I sent to the ER first thing Monday morning, did indeed have an upper GI bleed (UGIB) but we just can’t elucidate where exactly that bleeding was happening. Notwithstanding, three units of blood and enormous amounts of IV fluids have stabilized him to a large extent. Sadly, despite his end-stage liver disease, obtaining a liver donation for transplantation in our sorry state is a challenge and a half, so we must simply deal with the liver at hand.

A note in the chart stated that the patient’s pain was being treated with intermittent Tylenol and Percocet. Even though I’m “just an outpatient nurse”, I left a note in the chart that perhaps straight oxycodone might be less risky in a patient with advanced liver disease since Tylenol is so harsh on the liver. Also, another note details the patient’s verbalized suicidality and desire to leave AMA early this morning. I leave another note that I can be called at any time to intervene in such psychosocial crises involving my patient. Unfortunately, I assume that very few members of the team actually read my notes.

“Did you really threaten to kill yourself and leave AMA, not necessarily in that order?”

“Yeah, I did.”

“Did you mean it?”

“At the time I did, but not now.”

“Well, cut it out.”


“I’ll bring you another newspaper tomorrow.”

“Thanks. Thanks again.”

“Behave yourself.”


Our lighthearted banter belies a deeper meaning, and I know my visit to the hospital means alot to him. We’ve come a long way, but we also recognize that his liver is shot to hell. What’s left unsaid is the issue of his mortality and prognosis, and this we leave for another day. Until then, I’ll bring the paper every day and keep Patient X in line.

Tuesday, April 04, 2006

Grand Rounds, History and Physical

A very interesting and creative form of Grand Rounds is up at UroStream this week. For the uninitiated, Grand Rounds is a weekly compendium of the best medical/nursing/allied health/patient blogging from around the blogosphere. Each week's host designs and publishes the week's submissions in the format of their choosing. This week's offering is well worth a gander, the caveat being that each link will take you to a blog that you will forthwith wish to visit again. Don't say I didn't warn you.

Monday, April 03, 2006

Monday Doth Give and Take Equally Enough

The day began with the unannounced arrival of Patient X, whose story I shared last year. Now in remission from alcohol abuse for more than a year, this gentleman not a year older than me is in failing health but relatively good spirits. Our relationship is very friendly, peppered with jokes and jabs at one another, but the professional/therapeutic boundaries are secure. He burns DVDs that he thinks my wife and I will enjoy. When I come to his house to check on him he puts out white paper plates with cheese and crackers, playing the host. I’ve helped him set up some electronics in his home, advised him on several purchases, and cautioned him about spending too much money on things he doesn’t need. Recently, I read through the owner’s manual of his new police scanner to help him understand how to use it. He gives me a hard time and I give it right back to him. It’s a jovial, very fraternal connection. He trusts me. I like him. It’s mutual.

“I feel terrible,” he said.

“You look like shit,” I replied.

His cirrhosis is advanced, which we know from a liver biopsy. It’s also enlarged, which was clear on the ultrasound. His colon is clear of cancer since the recent colonoscopy was negative, but we know there are esophageal varices (picture varicose veins in his esophagus) from the increased blood pressure in the “portal circulation” connected to the liver. It’s also clear that his liver has a hard time processing dietary proteins because his blood levels of ammonia are chronically high. (Yes, ammonia like you use to clean your floor---it’s a product of the breakdown of dietary protein, and a sick liver can’t get rid of the ammonia so it builds up in the blood.)

“My stool was black and tarry all weekend, and when I vomited it looked black like coffee,” he told me. “Like coffee grounds?” I asked. “Yeah, like used coffee grounds. How’d you know?” I felt his abdomen---not hard, not tender. His skin wasn’t yellow from jaundice. Last time he was in liver failure and he was jaundiced, his eyes looked like flashlights covered with yellow cellophane. Not today, though. His blood pressure, pulse, and temperature were all OK. But he was thirsty, and said he was peeing in small amounts. “I feel dizzy, and the side of my head’s been numb all weekend.”

Differential diagnosis? Well, I assumed some source of internal bleeding (colon, some part of the portal circulation around the liver, or esophagus?); dehydration from bleeding, vomiting, and diarrhea (despite lack of rapid heart rate and other signs); anemia (from blood loss, causing dizziness, pallor, and numbness of face and head). His ammonia level is probably not astronomically high because he’s not really confused as he has been when it was really elevated.

Course of action? Nothing else to do but call 911 and ask for an ambulance to come to the clinic and take him to the ER at our affiliated hospital. His primary MD was not in, all the other MDs were busy, and one of our NPs agreed with my plan as I called 911. I didn’t need anyone to eyeball him. This was a no-brainer.

The paramedics came quickly, carted him off, and I called the ER charge nurse to give her a heads up that he as on his way. An hour later, I was to receive a call from the aER resident to let me know that he was being admitted to one of the floors. I gave her quite an earful based upon knowing this patient so intimately for three years. She thanked me and hung up the phone.

My workday was now only 30 minutes old. How many voicemails did I have already?

The day continued in a similar fashion of busy-ness, and then I left for school to torture fledgling nurses with details of cardiac and endocrine disorders. I shared the story of Patient X, who is now safe in the hands of the medical team at the hospital. My students' humor and good-natured banter quickly dispelled my morose mood from the vicissitudes of the day.

I am now safe in the bosom of the homestead. One day down, four to go. Is it really only Monday?

Sunday, April 02, 2006

....and Sunday giveth more, but what of Monday?

Here it is, Sunday night, the clock ticking as clothes are laid out, lunch packed, last-minute lecture notes prepared, and Palm Pilot reviewed for Monday's schedule. The mind leaps into future/planning mode and the week's trajectory is mentally mapped.

Is there some excitment as the week looms on the horizon of morning? Honestly? Not tonight.

Is there a sense of wishing there was just one more day to be at home and care for self and family? Oh, yes.

Does it sometimes feel like work gets in the way of so many other things which cry out for attention and time? Astronomically so. It has nothing to do with hating work or resenting needing to do so. Work is said to be love made visible. Perhaps it's the Puritan work ethic, the forty-hour week, the paltry two weeks of vacation per year, and the pressures of productivity which decrease the joy experienced when working. I once had a caseload of 35 patients---a luxury. Now, with just over 80, the amount of information juggled at any given time is wildly stress-inducing. In this world where money rules all----whether it be a lack or an abundance thereof----many of us suffer while caught in the wheels.

What is a middle-class professional American to do? Embrace what is, put best foot forward, and try to do more than simply survive. If work is such a central aspect of identity and purpose, then make those hours count.

Short of that, plan vacation and early retirement.