Wednesday, February 28, 2007

The Indispensable Nurse

Why do we nurses feel indispensable? Why is calling in sick such an enormous undertaking fraught with misgiving and anxiety? What is it that makes it seem that the world will stop turning if we don't show up?

Being home sick today but taking calls from my coworkers as needed, I beg the question why absence from the office/unit/clinic can almost feel worse than just dragging one's tired tush to work in the first place. Nurses are reknown for not calling out when ill. I wonder which other industry equally creates such unequivocal martyrs.

On the practical side, it is understandable why not being able to come in to work can be a burden to others. Today, my trusty medical assistant had to call me six times in situations for which only I knew the resolution. In the course of my days, I promise patients prescriptions, referrals, test results, or other important matters which, in their lives, weigh heavily upon their minds until resolved or answered. Do I enjoy such alleged omnipotence? Au contraire! But how can one create one's job in which another could easily slip into one's chair and take over the controls without a thousand and one questions? Aside from an assembly line where each action is proscribed, defined, and reproducible, in matters of healthcare, the secrets to specific mysteries and patient-related conundrums are often held in a solitary mind. More fool we.

I have said before how even one day's absence from the workplace engenders reams of paper, piles of charts littering the desk, voicemail messages and email just waiting for an instant response upon one's return. Is there not a better definition of burnout than that?

Monday, February 26, 2007


Wow. The return to work is overwhelming. Again. The layers of need seem endless, and the requests from patients keep coming.

This one has nausea, vomiting and diarrhea. This one seems to be having an anxiety attack and can't breathe. Another feels suicidal and wants to be hospitalized. Another's blood sugars are enormously high. Still another begins Hepatitis C treatment today and is in for the ride of her life in terms of side effects.

A patient with AIDS who has been MIA for quite some time manifested himself in our office today. Vague symptoms of "burning" on one side of the face and some discretely hidden fluid-filled vesicles on his scalp led us to suspect herpes zoster---"Shingles". I have never seen zoster on the scalp before, especially not without some active lesions elsewhere, like the arms or face or side of the trunk. The doctor can't be 100% but he is shuffled off to the ER for isolation at the hospital and empiric treatment with IV antivirals until proven not to have shingles. In his condition this could be fatal if left untreated. And to think I could have just turned him away in my crazed preoccupation with multiple simultaneous crises this morning.

It was a wild day, punctuated with a 90-minute reprieve for a lunchtime talk on recent AIDS treatment research at a local restaurant. "Reprieve" is questionable---the pile of charts on my desk and rapidly filling voice mailbox attested to my ever so brief absence from active duty.

After finishing my day's notes following a delicious dinner lovingly prepared by Mary---my favorite cook---the rest of the evening is about recovery, and steeling myself for the 'morrow.

Friday, February 23, 2007

La Meme Chose

Kim over at Emergiblog sent me a "meme" in which I am supposed to list five things I cannot live without as a nurse and one thing that I would covet. While I have never responded to such an invitation before, I thought I'd take a whack at it.

First and foremost, I could not survive as a nurse without my home, my family, my friends, my dog, and my beloved wife and son.
Second, I could not survive without the creative outlet and sanity of blogging.

Third, like Kim, music is one of the saving forces in my life. For me, Brian Eno, Over The Rhine, The Boards of Canada, Busdriver, Radiohead, Bright Eyes, Robert Fripp, and Harold Budd come to mind, but the list goes on and on.......

Fourth, the grace, wit and collective consciousness of my colleagues is no small part of how I survive the vicissitudes of my working life.

Fifth would have to be time: to rest, recreate, rejuvenate, exercise, write, read, and otherwise soothe my bedraggled mind and body.

And what would I covet more than anything else? All of the above are high on my list of coveted life-sustainers, so I will leave it at that. Perhaps I will add to this list in future, as another post or perhaps simply as a comment below.

I will not tag anyone just now. If you read this and are moved to consider what keeps you afloat in these troubled times, give thanks for that awareness and share it if you please.

Thursday, February 22, 2007


It's another whirlwind day as I attempt to tie up loose ends and head off on a five-hour trek to be with my Mum for her skin cancer procedure. Yikes. Wet snow falling and many miles to drive....

The calls just keep coming as I try to end the day. No sooner is one progress note or task begun, then the phone rings and another project is born. Overload comes all too soon and all too often. Triage is the name of the game. At times, one feels like a soldier in a foxhole, shouting "Incoming!" as the next salvo shells the office. The walls quake with the impact as waves of unanswered human need and trauma batter the windows.

"Did anyone ever buy life-jackets?" we innocently shout over the din. "Sink or swim, my scurvies!" yells the boss from his perch atop the lookout tower. "There's rough weather ahead! Every nurse for his- or herself!"

At times our practice feels like an unwieldy and hairy beast slaloming with oversized skis over a tundra covered with obstacles, some sticky, some spiny and sharp, others like black holes which suck the life out of the unsuspecting nurse. Rounding a dangerous bend, one occasionally encounters a colleague skewered by his or her own iffy boundaries. "Do I lend a hand or pretend I didn't notice?" is a frequent thought that crosses the mind. Since we're nurses, we generally stop to offer a hand, or at least a pat on the back. Our resident psychologist kneels down alongside the impaled nurse and says, "So how does that make you feel?"

Five o'clock sounds, the boss's bird-clock sings its sweet song, and a "Yabba-Dabba-Doo!" bursts from his lungs. Oftentimes, it seems that no one even notices that 5:00 has come and gone. Some evenings, I leave around five and several colleagues are still at their desks, distractedly saying goodnight as I exit. Next morning, they're all in the same positions when I arrive at 9. Where do they keep those sleeping bags, anyway?

Tuesday, February 20, 2007

Is a Nurse's Work Ever Done?

From the moment I entered nursing school, people have turned to me for medical advice. Even as a novice with an armful of textbooks and more questions than answers, the requests for opinions began during school and have never ceased to flow. There's some old adage that every family needs a nurse. Why not a doctor? A lawyer? A plumber? I guess nurses just have that certain je ne sais quoi.

My step-dad is fighting pancreatic cancer right now, and with the long journey through testing, diagnosis, radiation and now chemotherapy, I am the go-to person for most of their questions, although my scientist brother (bless his heart) uses his substantial cerebral prowess to see us through as well.

Unfortunately, my mother now has early invasive squamous cell carcinoma of the face, and my job these past few weeks has been researching, reading, and extrapolating the information needed for her to make some informed choices. Her surgery is pending for this Friday morning, and I will thankfully be able to make the five hour trip to be there.

This evening, a friend called from a nearby city. After being sent home from the ER not once but twice, he was finally admitted two days ago with acute appendicitis after being misdiagnosed and sent home to suffer over a nine day period. Needless to say, he is on ice chips and IV fluids, awaiting the decision whether surgery will be sooner or later. I hope it's sooner. Meanwhile, he asked me to be his Health Care Proxy. I accepted without hesitation.

My blogging practice has elicited many questions to be posed to me via email over the last two years by perfect strangers, something I truly enjoy responding to. Today I received an inquiry about my position on 12-step programs. I hope my answer was sufficiently enlightening, or perhaps enlighteningly sufficient. I also recently received an email requesting my participation in an on-line survey by a Croatian university about healthcare bloggers, as well as an invitation to submit articles to NurseLinkup, a new online networking community for nurses.

Working in the healthcare field and teaching nursing for a while, I have written letters of recommendation for nursing school and job applicants, as well as agreeing to serve as a reference on various person's resumes. I have precepted nursing students, medical students, and medical residents, dragging them through the city on my rounds. I have also counseled friends interested in nursing school, edited papers for those friends, and assisted in their learning processes on some level or another, subsequently serving as career counselor (and reference) after graduation.

When I get home, I blog about nursing, answer emails, think about my patients, field family calls, and even read books and articles about nursing and medicine. I interact with other nurse bloggers on-line, co-facilitate a discussion group for nurses on, and contribute regularly to on-line medical and nursing blog carnivals.

Yes, being a nurse is more than a vocation for me---it is truly an identity. Is this healthy? Is it too all-consuming? Am "I" lost amidst the general tumult? Beats me---I'm too busy being a nurse.

Monday, February 19, 2007

Networking Is Us

Electronic networking seems to be the social venue of choice these days, and the Internet is now awash with social and professional networking sites. Of course, the ubiquitous MySpace and Facebook are currently the darlings of the web. Also of interest, especially for those of you in need of professional connections, LinkedIn is a site dedicated more towards career development.

Tribe is a community worth exploring, although my favorite social networking site for interesting and personalized connection is Zaadz, a site committed to changing the world one person at a time. I have begun two "pods" (discussion boards) on Zaadz, one for nurses and the latter for people living with Multiple Chemical Sensitivity. Zaadz is worth a gander, but it's certainly not for everyone.

The newest site which I've discovered is NurseLinkup. Still in beta, NurseLinkup has some kinks to work out and development to explore, but should prove to be a valuable tool for nurses to connect both professionally and personally.

Happy networking, and please let me know of any other interesting sites you have found in your travels...

Saturday, February 17, 2007

New HBO Special on Addiction

Just yesterday, I received an email from someone at HBO, asking me to consider encouraging my readers to tune in for a new 14-part documentary due to be aired in March. Based upon my reading of the advance materials and press releases, The Addiction Project will seek to "redefine drug and alcohol addiction". There will be a 90-minute centerpiece film followed by 13 additional films which will focus on "the neurological forces behind addiction, getting treatment, relpase, understanding particular therapies, and adolescent addiction." The films will apparently will utilize the model in which addictiojn is seen as a chronic brain disease, examining the environmental, behavioral, and genetic factors that can make an individual more vulnerable to substance abuse.

Due to my interest in addiction, its treatment, and the day to day struggles of my those facing its challenges, I am trusting that this series will be done well, will be well worth watching, and may help to continue the conversation already happening around the country vis-a-vis the disease model of addiction and recovery.My only regret is that I will not see the series myself, not having access to HBO. I'll just have to wait for the DVD.






Project Defines Addiction As

A Chronic Relapsing Brain Disease That Is Treatable


Entire Series To Be Offered Free To Cable Subscribers

During Four-Day Preview On HBO, March 15-18


“How can we comprehend the concept of a person who wants to stop doing something and cannot, despite catastrophic consequences? That is what we are up against. Some people don’t want to speak about addiction, or compare it to other chronic diseases. Well, this is a disease, a treatable disease, and it needs to be understood. HBO’s ADDICTION project is an initiative that will help people understand more about this illness, its advancements and how to find help.”

-- Nora Volkow, M.D., Director of the National Institute on Drug Abuse

LOS ANGELES, Jan. 12, 2007 – One in four Americans has a family member who is struggling with addiction. Over 80% of people with substance abuse or dependence disorder started using before age 18. Currently, addiction affects 22.2 million Americans. Yet only 9% are receiving the treatment they need.

In partnership with the Robert Wood Johnson Foundation, the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA), HBO launches the ADDICTION project, an unprecedented multi-media campaign aimed at helping Americans understand addiction as a treatable brain disease, as well as spotlighting new medical advancements. Debuting THURSDAY, MARCH 15 (9:00-10:30 p.m. ET/PT), with the centerpiece documentary ADDICTION, the series is eye opening and ultimately hopeful, providing guidance in navigating the often-confusing world of addiction treatment and recovery.

For the first time, HBO will use all of its digital platforms, including the HBO main service, multiplex channels, HBO On Demand, pod casts, web streams, and DVD sales to support a campaign that includes a 14-part documentary series, a book published by Rodale Press, four independent addiction-themed films, a robust website and a national community grassroots outreach campaign funded by the Robert Wood Johnson Foundation. All films will initially be offered during a free HBO preview weekend from Thursday, March 15 to Sunday, March 18 in participating cable systems.

“HBO is utilizing all of its platforms to develop programming directly targeted to the various needs of the American public on this complex public health issue,” says Chris Albrecht, HBO’s chairman and CEO. “Our resources are committed to illuminating, demystifying and defining addiction – a problem that is riddled with misconceptions.”

The ADDICTION project showcases the work of many of today’s leading documentary filmmakers, including Jon Alpert; Kate Davis and David Heilbroner; Susan Froemke; Liz Garbus and Rory Kennedy; Eugene Jarecki; Barbara Kopple; Albert Maysles; D.A. Pennebaker and Chris Hegedus; and Alan and Susan Raymond.

ADDICTION brings together leading thinkers and organizations that are at the threshold of new treatments. Current advances in brain imaging science make it possible to see inside the brain of an addicted person, pinpoint the parts of the brain affected by addiction, and see how the addict’s brain differs, ushering in a great many advances in medical treatment. In fact, treatments for addiction are now as effective as treatments for other chronic relapsing diseases such as diabetes, hypertension or asthma.

A candid depiction of the emotional, psychological, social and political toll that addiction takes on the country, the ADDICTION project demonstrates conclusively that the disease is treatable and shows that there are millions of Americans in long-term recovery. Topics covered include: the nature of addiction, addiction in the workplace, and the protracted insurance battles waged by families, as well as the difficulty of finding and getting adequate treatment.

The ADDICTION project will be supported by an unprecedented 30-city nationwide community outreach campaign funded by the Robert Wood Johnson Foundation and coordinated by Join Together, Faces and Voices of Recovery, and the Community Anti-Drug Coalitions of America (CADCA).

The ADDICTION project is produced by John Hoffman and Susan Froemke and executive produced by Sheila Nevins. For additional information, visit

Friday, February 16, 2007

A Close Call on the Job

Last night, I was doing a per diem shift in the health center for the evening session. These evening shifts are generally low-key: a vaccination here and there, faxing prescriptions to pharmacies, joking around with the docs and medical assistants. However, one never knows when one's circumstance will be altered from its usual trajectory, and just such a situation arose last evening.

Suffice it to say that the detailed circumstances of the initial situation catalyzing this event are superfluous to the story as a whole. The main thrust of the idea is that a father of a young child was not allowed into the pod where the exam rooms are because the mother of the child was sharing some concerns with the doctor which needed to be communicated without the presence of the father. Needing further inquiry, the social worker had been called into the exam room, and the father was left in the waiting room to fume and pace. Unfortunately, all of this occurred without my having a shred of knowledge of what was transpiring.

As I sat at my computer in the pod filling electronic prescriptions, an agitated man appeared on the other side of the nurses' station, cursing and demanding access to his child and wife. A wild-eyed medical assistant calmly asked him to remain where he was as she took me around a corner to explain the situation in detail. While we were talking and my grasp of the situation grew, her gaze fixed over my shoulder and I turned around to see the man in question making his way quickly towards us up the hallway. He had crossed the nurses' station, passing a medical resident who was utterly clueless as to what was occurring, the OB/GYN doc also oblivious, dictating her notes by phone as he stormed past her.

Sensing both the gentleman's agitated state and the medical assistant's anxiety, I put myself between the enraged man and the medical assistant and did my best to try to de-escalate his fury. As his demands grew more fierce, my voice naturally rose to counter his. Knowing that I was taking a chance---but keeping in my mind that security had just been called and were at least five minutes away and were not even in the building---I stood my ground, raised my voice louder, and pointed towards the door at the end of the hall, demanding that he exit the pod immediately and wait calmly in the waiting room. Whether it was luck or some other form of beneficence, he somehow sensed that he was fighting a losing battle and stalked towards the door, entering the waiting room just as the security guard returned to restore order.

The conversation that immediately resulted from this encounter was one centered around what we would have done had he become physically violent prior to the arrival of the security guard. If he had swung at me or pulled a knife, how would we have handled the situation, and what liability would I personally carry if I were to strike him in self defense? What legal protections are in place to ensure that I will not be prosecuted or held criminally liable if I were to act to protect myself or another person, resulting in harm to this threatening man? (Furthermore, what would we do if he stalked us in the parking lot later that evening, attempting to "get even" for being publicly humiliated?)

Many of us working in the inner city with vulnerable and disempowered populations face risks when engaging in such employment. Threats of harm have been visited upon several of our providers over the years, and we all know that our work does carry some level of risk. Poverty, disempowerment, discrimination, classism, racism---they all contribute to the feeling of emasculation and helpless rage that many people in such circumstances can naturally feel, and when we uphold policies and procedures that do not make sense to a potentially volatile person, the resulting reaction can be explosive. Evidence of sexual or physical abuse of children is one area where staff feel legally and morally compelled to act quickly and comprehensively. Poor communication---or the lack thereof---can put other employees at even greater risk when they are not apprised of the situation and are then suddenly faced with an angry patient and no context in which to place such an explosive situation.

I realize that I was lucky that last night's episode ended with little fanfare. The potential for violence or the threat of violence was quite real, although our laughter later in the evening quickly dispelled any remaining anxiety. In the course of my years as a community nurse in the city, I have skirted drug dealers on busy sidewalks, visited known gang members on city blocks known for their illegal activity, and shuffled past suspicious-looking young men as they loitered in dark stairwells, stuffing emptied cigars with marijuana to make the ubiquitous "blunts" which fill the air with their distinctively aromatic smell. I have also been to a home where my patient's daughter's boyfriend had apparently hidden guns used in a gang-related crime. Oh, the places we go!

Of course, risk is relative in any line of work, whether it be personal injury or any number of potential hazards. When one feels that a brush with danger has been averted, one of course will naturally take stock, second-guess one's prior actions, and hopefully learn from experience, planning and strategizing for possibly similar scenarios in the future. There is always much to learn, and we will always equally hope that we never have to learn the hard way.

Wednesday, February 14, 2007

Love and Intention

Under my email signature on all outgoing missives, the following quote by Mother Teresa is always attached:

"I have found the paradox that if I love until it hurts, then there is no hurt, only more love."

On this day of all days, love is the notion we are urged to consider. Of course, being Valentine's Day, romantic love is assumed to be at the epicenter of such considering, and well it is for many of us. But there are many more forms of love, and they are all worthy of our attention. As well, we also remember those who are bereft, lonely, impoverished, ill, and otherwise lacking love in their lives. Yes, the media deluge us with images of heart and flowers, chocolates and cards, forming the basis of what we think we know love is. However, it is in our minds and hearts where we truly decide the meaning of love, and it is in our relationships with the human and non-human worlds where we externalize our vision of love, manifesting our vision through action.

Many of us wonder how to celebrate love, embody love and partake in cultural norms which bring us and our loved ones pleasure, while still bearing in mind the wider effects of our way of life and the decisions we make as consumers. Flowers, chocolate, diamonds---the things we have been taught to freely associate with love---cannot escape the gravest blemishes when under scrutiny, especially as we use the power of the purse to support the industries that provide them on the shelves of our stores. This is not meant to be a wet blanket on this day. Rather, it is yet another way to love, wherein we remind one another that our choices as consumers have consequences beyond our immediate perceptions. It is in both the small and the large that our actions ripple out into the world.

Today on AlterNet, Courtney E. Martin offers a view of love as activism, asserting that freedom is gained through our choices vis-a-vis relationship, love, and our actions close to home. Also on AlterNet, Julie Enszer describes the subtle ways in which gays and lesbians do (or don't) reveal their partners' gender in social situations. She then challenges us on this Valentine's Day to go the whole day without revealing the gender of our lover in social exchanges, feeling that sense of ambiguity---and occasional discomfort---which is then communicated and felt by the parties on both ends of those conversations.

Meanwhile, on Democracy Now!, Amy Goodman presented an expose on the low wages, child labor, and other human rights violations which support the commercial sale of cut flowers in the United States, propagated to a large extent by the Dole Corporation. A sobering dose of reality which, like Blood Diamond, has begun to popularize the notion that consumer goods can fuel conflict, slavery, and indecent treatment of human beings in the name of profit. Furthering our perceived indictment of all things Valentine, even chocolate is not safe from political strife, economic hardship, and humanitarian controversy when considered through the lens of fair trade practices.

Moreover, the V-Day movement strives to end violence against women, with Valentine's Day designated as V-Day. Describing the movement on their web-site as "a fierce, wild, unstoppable movement and community", their goal is no less than the complete defeat of violence against women and the victory of human rights and peace.

What, then, you may ask, is a loving yet earnestly concerned Valentine to do?

I would submit that there is no end to what one can do to propagate love while making wise and informed choices. Choosing Fair Trade chocolate and coffee is itself an act of love---towards others, self, and economic equality. Do I always practice such advice, you ask? No, I do not, but continually reminding one's self of the power of choice is often the first step towards freedom. Further, by treating the women in one's life with respect, by standing up against their unfair treatment and subjugation, by communicating through actions and words one's dedication to such a notion---that is a most powerful personal statement.

And the flowers? Sometimes we can't help ourselves when we buy those lovely bouquets, and none of us can deny the joy and delight on the receiver's face when presented with the thoughtful sweetness embodied therein. These are all simply choices, and in this consumer society, we all are prey to the whims and winds of the marketplace. If I buy flowers, I will certainly enjoy them, bless the person who picked and processed them, and give them with the love with which they are intended. One cannot live life afraid to act, yet one must also understand that each and every choice we make in life carries consequences often beyond our ken.

On this snowy Valentine's Day, I am home with my love, workplaces closed, the world moving at a crawl, the icy precipitation confining us happily to our home. Yoga together in the morning, a DVD, a nap, a simple exchange of cards, and a mutual conscious decision to eschew the drive to consume, rather giving each other the gift of time, of space, of presence, of shared love. Although I did donate money to the V-Day campaign in Mary's honor today, it is not the money changing hands which holds meaning. Intention, of course, is the central force, and through our intentions our actions must naturally follow.

Even amidst a consumer frenzy, be it Christmas, Valentine's Day, or Mother's Day, intention and the consciousness behind that intention holds the key. Coupled with right action, there is no end to the love that can be shared, and no end to the satisfaction which we can glean from a life well lived.

Happy Valentine's Day, from my heart to yours.

Tuesday, February 13, 2007

Evolution, Debate and Faith

Based upon articles and media reports, the debate over evolution---or the lack thereof---still rages around the world. This morning, National Public Radio broadcasted a short piece on the “Turkana Boy”, the complete skeletal remains of a 9-year-old boy discovered on the shores of Lake Turkana, Kenya in 1984. These remains, at 1.6 million years old, are the oldest-known specimen of Homo Erectus, and are poised to be publicly displayed for the first time at Kenya's national museum in Nairobi.

It appears that the evangelical Christian communities in Africa---specifically in Kenya---are afire with opposition to the theory of evolution, requesting that the Turkana Boy's remains be relegated to a back room of the museum with a posted caveat that evolution is still only considered a theory. As reported on via a report from the Associated Press, Bishop Boniface Adoyo, the leader of millions of African Christians from 35 denominations, has stated that exhibits and scientific reports which support the theory of evolution undermine the church and its teachings. Stating recently that "these sorts of silly views are killing our faith," the bishop clearly verbalizes the perceived attack on faith which the religious community feels is being waged by the proponents of evolution, as well as the church's adamant refusal to consider evolution as even remotely possible within the Christian cosmology.

I'm not entirely certain why I was compelled to write about this issue this morning, but it sparked within me a curiosity regarding the intersection---or rather, collision---of science and religion, which frequently pose difficult moral questions. Whether it be evolution, stem cell research, abortion, or family planning and contraception, these hot-button issues test the waters of our culture and its ability to withstand apparently untenable moral dilemmas. Of course, politics plays a role when the government intervenes (take the case of Terry Schiavo, for example), or when political candidates are forced to take a stand on a timely and contentious "moral" issue. (Just what isn't "moral", anyway? And in terms of those "value voters" that are ubiquitously discussed at election time, don't we all cast votes based upon our "values"?)

When discussing evolution and the Turkana Boy, it will be interesting to see how this debate evolves (pun originally not intended). Being neither a scientist nor a theologian, the potential for compromise appears slim from my viewpoint. If the religious community refuses to allow for even the possibility of truth behind a widely accepted and validated theory, compromise and understanding appear beyond reach. And when the scientific community openly derides or mocks the beliefs and faith of the pious, agreement or understanding is further debilitated.

Boycotts of exhibits serve little to inform the public, rather simply fueling further ignorance and division. When children are denied the teaching of evolution---or are encouraged to discount its scientific basis entirely with complete absence of critical thinking---who is truly served? From the point of view of an individual without religious affiliation and raised in a devoutly secular household devoid of all notions of faith (except for Santa Claus and the Tooth Fairy, that is), I am honestly often perplexed by organized religion in terms of its dogmatically held tenets.

Seeing the violence and carnage often waged ostensibly in the name of religious belief or affilation (think Shiite versus Sunni, for instance, or perhaps the Spanish Inquisition), one may be led to believe that religious thought and belief have indeed precluded reason during countless human societies, both modern and historical. I try not to lose my faith in human kind and its ability to embrace dialectically opposed belief systems wherein faith and science can live relatively peacefully, perhaps even with some cross-pollination and intermingling concepts. There is room for both subjectivity and objectivity in most every realm of thought and inquiry, and I'm sure many authors and thinkers have already done a great deal to advance the cause of peace and reconciliation between the two seemingly disparate camps.

Albert Einstein once wrote in a letter dated February 10, 1954: "If God has created the world, his primary worry was certainly not to make its understanding easy for us". I think his statement still holds true, and I wonder if he would feel that any advancement has been made since his death, or rather that we humans still exist in a miasma of ignorance and mistrust of both one another and the universe at large. As for the Turkana Boy, I have no doubt that the ire his exhibition is creating in Kenya is not about to be dissipated by calls for understanding and acceptance, but I still hope that some incremental change---mind by mind, heart by heart---can contribute to a quiet groundswell of cooperative understanding, even amidst these ages-old questions still begging for answers which will undoubtedly always leave someone disappointed.

Monday, February 12, 2007

Adherence versus Compliance

Just the other day, a conversation was born amongst colleagues regarding two words/concepts that are used almost interchangeably in healthcare. Adherence and compliance, those somewhat subjective measures of how well a patient follows medical instructions, appear in medical charts, professional journals, PowerPoint presentations, scholarly articles, and all manner of medical ephemera on a regular basis. These concepts are even the subject of professional workshops and conferences. Our conversation centered around the difference between the two, and what it means when we use one versus the other, both, or neither.

First, we should begin with definitions. "Compliance" is defined by as "conformity; cooperation or obedience; accordance; the act of conforming, acquiescing or yielding; a tendency to yield readily to others, especially in a weak and subservient way." Hmmm (hand scratching chin pensively).

As for "adherence", our friendly neighborhood Internet dictionary defines this term as "the act of adhering; adhesion; the quality of adhering; steady devotion, support, allegiance or attachment." Also quite interesting.

What immediately grabs my attention is the notion that "compliance" is defined as a type of obedience, especially a subservient breed of obedience. Perhaps this is also why I seem to notice the term "non-compliant patient" used so often in medical charts. In this culture where doctors are somewhat deified and in which medicine can often take on a paternalistic pallor, definitions of a patient's relative obedience to medical advice would be the language expected of medical personnel when documenting patient behavior.

When we providers see ourselves as offering the patient the best, most inarguable advice, we must implicitly expect a certain obedience or acquiescence to our prescribed treatments. We all have known patients who seem so eager to please us, so passive and opinionless, that we wonder how much of their ingratiating attitude is simply displaced desire to please a demanding parent. While we do at times feel like substitute parental figures---even for elderly patients---these are not healthy roles for provider and patient to assume. Wanting a patient to "comply" with one's advice does indeed seem that one wishes to "bend" the other's will towards one's own. How healthy can this be for either party on a psychic level?

Conversely, the definitions of adherence bring to mind notions of support, devotion, and attachment, with "allegiance" bringing to mind a sense of something shared cooperatively by both parties rather than forced upon one by the other. Using this term in relation to a patient does certainly seem to carry a very different tone which lacks a certain paternalism that "compliance" seems to engender. Partnership and bilateral decision-making come to mind, rather than unilateral command and obedience.

I am remembering as I write this post that the visit note forms which our agency uses has a small section entitled "Medication Adherence" in which we document our assessment of the patient's medication-related habits. Was it a deliberate choice to use "adherence" rather than "compliance"? I'll have to ask my boss.

In the course of my blogging, I seem to write a great deal about patients who are not exactly following the medical script. I note that I recently posted a missive entitled "Non-Compliance, Apples and Surrender". Did I think about my choice of words or did compliance roll right off my tongue, or rather, keyboard? I must say that when it came to the patient in question, I naturally chose non-compliance. Perhaps it is when patients seem to be making choices which we know will certainly cause them harm that we see them in this way.

For many providers, I think there is a certain proprietary quality to some provider-patient relationships. Within our practice (and many others, I'm sure) there is constantly comments like, "She's my patient" or "He's not mine, he's hers." Ownership can be a positive aspect, meaning that the nurse or provider is taking responsibility for the individual's care. Similarly, our patients will say, "That's my nurse" or "She's my doctor". These are all socially acceptable and understood notions of belonging, of connection. We simply must be cautious in their contextual use.

Coming to the close of this particular missive, my jury is still out whether I feel it is "wrong" to use the term "non-compliant". It is certainly food for thought, and very worth pondering vis-a-vis my own practice and documentation. As I learned in nursing school, medical and nursing notes are legal documents, and labels which we apply to patients can haunt them for the rest of their lives, often coloring how a new provider will feel about a patient before even making their acquaintance. Not only do we carry the responsibility to do no harm in relation to our care, we should also be careful to do no harm with our words.

I may need to revisit this question as time goes on, and welcome any comments on the topic. This particular blog entry is very much a process of thinking out loud, and I welcome any reader to do the same. (But will you comply?)

Saturday, February 10, 2007

Hybrid Heaven

Even though hybrid cars have detractors who feel that they do too little in terms of decreasing carbon emissions, we have wanted one for years. As conscientious people who are quite aware of our ecological footprint, we're always looking for ways to decrease our impact within the current parameters of our lifestyle. We are rabid recyclers, try to buy nothing that we don't really need, and are as likely to find furnishings for our home via yard sales, the side of the road, as well as dumpster-diving at area colleges when the students are moving out for the summer. Oh, the places we go!

Over the last few years I have researched hybrid cars and grease cars. For those of you who are unaware of this technology, any diesel vehicle can be altered to run on vegetable oil. The owner of such a car can simply stop at their local McDonald's and take away containers of used friolator oil which the restaurant must actually pay to dispose of. Yes, the oil must be filtered to remove pieces of french fries, but is then ready to power the vehicle. Alternatively, the car will also run on "Biodiesel" fuel, available at few venues currently, but slowly growing in availability as demand increases. However, the Union of Concerned Scientists is still recommending the purchase of a hybrid over a diesel in need of conversion due to biodiesel's proclivity to still produce nitrogen oxide compounds, a problem (in terms of smog pollution) which has yet to be fully resolved. (However, for anyone who already own a diesel vehicle---or municipalities with diesel buses or trucks---retrofitting for biodiesel is highly encouraged.)

Anyway, we have finally taken our first plunge and purchased a used 2003 Honda Civic Hybrid. Although we essentially "traded down" by giving up a 2005 Toyota for an older Honda with more mileage, it felt like it was time for us to put our money where our mouths are and make the shift. While the Civic hybrid does not have a distinctive shape or other features to distinguish it from other cars (only a small "Hybrid" emblem on the back of the car), the proof is in the pudding. While it's certain that Prius owners achieve instant "social recognition" that they are indeed driving an alternative vehicle based upon its distinctive design, we're happy with our more understated choice and have pledged to one another that we will never again purchase another standard fossil fuel car.

For those who might disparage hybrid cars as a fad that has little overall environmental impact, the Union of Concerned Scientists states the following on their website devoted to hybrid vehicles: "hybrids have better total ownership cost over five years or 70,000 miles than their direct competitors. [They] accredit the long-term savings to the fact that hybrids retain their value better than conventional vehicles, have moderate maintenance and repair costs, and have lower fuel costs. listed the Toyota Prius, Honda Civic Hybrid, Toyota Highlander Hybrid, and Ford Escape Hybrid as vehicles with the biggest five-year savings."

Small changes in lifestyle go a long way, and we recognize that we are priviledged enough to simply have the opportunity to make such a choice. While we both try our best to not preach about the things of which we hold deep convictions, we will begin to gently encourage our friends, loved ones and colleagues to consider the alternatives when needing a new vehicle. If we all vow to make even the smallest of changes within our means, the larger exponential effect will be both measurable and sustainable, and that is a truth which is conveniently easy to swallow.

Friday, February 09, 2007

The Search for the Magic Bullet

"I can't sleep. I sleep maybe four hours every night. If I go to bed at midnight, I get up at four. If I go to bed at four I get up at seven. It's crazy." She rolls her eyes in disgust.

"Well, there's a program we can send you to where they teach you how to sleep better," the kindly doctor says. "It's called sleep hygeine."

"It works for alot of people," I add. "Medications often don't do enough."

"No way," she replies vehemently. "I know my body, I know my brain. I just can't sleep. All I need is a pill to make me sleep." She crosses her arms. The doctor and I exchange glances.

"What do you do when you can't sleep?" He looks at her and then at me.

"Watch TV."

"You watch TV. Anything else?" I ask.

"Oh yeah, I smoke." There's silence in the room.

"How about your back?" the doc asks, changing the subject. "Is that any better?"

"Nah," she retorts. "It's worse. Hurts all the time. If I sit it's OK, otherwise it's torture. The muscle relaxants don't help either."

"How about the methadone?" the doctor asks. (The patient is on methadone three times a day for chronic pain.)

"No, it doesn't help at all. Can I get something else?" She crosses her arms again.

"We'd like to try physical therapy."

"I won't do that! That hurts! My friend says it messed her up!"

The doctor and I smile. "We can direct them regarding what they do. There's massage, cold and heat packs, ultrasound. You might really like it."

"I won't stretch! I know my body. I know that stretching hurts. I just want a pill."

The appointment's going nowhere, and we haven't even talked about her Hepatitis C treatment yet. We're both exasperated. No sleeping pill prescription is forthcoming, and she eventually concedes to a physical therapy referral. Will she go? Probably not.

Everyone wants the magic bullet, a pill to assuage their suffering. Many doctors use that arsenal of pharmacoepia to attempt to do just that, but sometimes we just want some proactive work to be done by the patient, some effort beyond opening a bottle and swallowing a pill. Sure, sleep hygeine education isn't anyone's idea of a good time, but what good is a pill when the patient has no inkling of how to properly prepare for a good night's sleep? We frequently dance along the edge of enabling such passive behavior. Of course we may give in at times, but sometimes we just say no to the easy way out.

Thursday, February 08, 2007

Monday, February 05, 2007

The Return

I arrived to work at noon after a morning doctor's appointment, not having worked since last Wednesday. A text message immediately arrived on my phone---a unannounced patient is in the waiting room to see me.

Grabbing my stethoscope and my notebook, I rush out to the waiting room. The patient in question is across the room, but before I can make my way over to him I'm intercepted by someone else. I ask them to wait, but another patient materializes, wanting a word with me. Three more of my patients lurk in other corners. Is this a convention?

I put several of them off until tomorrow, deal with the issues needing immediate attention, duck into an exam room to sit in on another patient's doctor appointment, and head back to the office to catch my breath.

"Do you know that five of my patients were out there waiting to see me?" I ask incredulously as I enter the office. Two of the administrative assistants laugh knowingly.

"They had tents and sleeping bags set up all weekend, Keith. We told them you'd be back Monday at noon." They laugh again.

"Very funny," I reply. "Can I go home now?"

The phone rings apace all day. My voicemail is full but not overflowing. My mailbox? Stuffed. My desk? Covered in charts and papers. The state of my brain? Hmmm.

A massage at the end of the day slows me down. Then dinner with Mary nourishes me. Now we're baking tahini cookies as the wind howls outside and the temperature drops towards zero.

The return is over. Back to the fray.

Sunday, February 04, 2007

My Other Blog

I wanted to take another opportunity to shamelessly plug my other blog, A Nurse and His Treo. The subtitle for this venture is "the photographic adventures of a peripatetic nurse and his trusty smart-phone". This is a very fun project and creative outlet for me, and I invite you to peruse the site from time to time. My goal is to post one photograph every day for 365 days and I have so far posted for 74 consecutive days. You will find a link in the right-hand column of this blog, as well. Thanks again, and Happy Sunday.

Saturday, February 03, 2007

Nurses Need to Listen Carefully

This story just in from a friend in Connecticut, author unknown:

An elderly male patient is lying in bed in the hospital, wearing an oxygen mask over his mouth and nose, still heavily sedated from a difficult four-hour surgical procedure. A young student nurse appears to give him a partial sponge bath

"Nurse," he mumbles from behind the mask. "Are my testicles black?"

Embarrassed, the young nurse replies "I don't know, Sir. I'm only here to wash your upper body and feet."

He struggles to ask again, "Nurse, are my testicles black?"

Concerned that he may elevate his vitals from worry about his testicles, she overcomes her embarrassment and sheepishly pulls back the covers.

She raises his gown, holds his penis in one hand and his testicles in the other, lifting and moving them around.

Then, she takes a close look and says, "There's nothing wrong with them, Sir!!"

The man pulls off his oxygen mask, smiles at her and says very slowly, "Thank you very much. That was wonderful, but listen very, very closely......A r e - m y - t e s t - r e s u l t s - b a c k ?"

Thursday, February 01, 2007


During this latter portion of the week, I'm attending a three-day conference for providers vis-a-vis healthcare for the transgendered. Having had a number of transgendered patients over the years---and several friends and acquaintances---this was an opportunity that could not be missed.

As much as the gay and lesbian communities have gained relatively increased acceptance in this culture---although discrimination, both constitutional and popular, still abounds---the transgendered in this country lack even the most basic of rights and protections. When it comes to healthcare, the needs of this special vulnerable population are generally overlooked and disavowed. As a fringe group at the edge of society, it is often up to individual healthcare providers, mental health professionals, and sensitive business people to recognize the need for accomodation, recognition, and basic rights and dignity for those unheeded by government and society at large.

Americans seem to have no qualms with cross-dressing actors and sports stars who use drag as a method of economic gamesmanship, but real transgendered individuals are left in the cultural dust, bereft of a voice in the political arena and a seat at the proverbial table. That is changing, albeit slowly, and as the Trans and Intersex communities gain political strength and wider support, more protections and recognition will eventually be won. (Intersexed individuals are those born with "ambiguous" genitalia, a "condition" often treated as a medical emergency, the gender of the child chosen by the physician, often with devastating results.)

As a healthcare provider who has had a great deal of interaction with the transgendered community, I feel a certain duty and calling to position myself as an ally, and this conference is another way to feed my desire to do just that. As the notion of gender evolves, and the rigorously defended institution of a binary gender model slowly disintegrates, we all must eventually come to terms with the changes, embracing unprecedented inclusivity and sensitivity. If you're not yet there, educate yourself, and watch the paradigms shift.