Monday, October 29, 2007

Vicarious Traumatization

After eleven years of providing direct nursing care---all in ambulatory settings, mind you---I wonder when it will be time to take a break and approach my work in the healthcare field from another vantage point. While I, like many nurses, thrive on the interpersonal relationships which nursing engenders, I also long for a rest from the emotional tugging which is part and parcel of my work.

But what is it about that "emotional tugging" that is so exhausting, you ask? The answer, to a large extent, is vicarious traumatization, wherein the act of bearing witness to the trauma of others can lead to internalization of trauma and psychic distress by the clinician. Several studies cited on the American Psychological Association website conclude that clinicians with their own personal trauma histories are more likely to experience deleterious effects when working closely with patients experiencing trauma.

Taking into consideration that the majority of my patients have suffered multiple traumas and live chaotic and difficult lives, I am consistently in a place of feeling unable to fully relieve the suffering of those around me. Confronted day after day by individuals whose suffering continues largely unabated, I surmise that my own level of suffering appears to have concurrently elevated, perhaps in response to those for whom my efforts seem to have little effect.

Many of my patients experience depression, anxiety, PTSD, and other forms of mental illness and psychic distress, not to mention chronic pain. Interestingly, my own depression, distress and physical pain symptoms have become significantly exacerbated in the last few years, leading me to more fully appreciate and understand my patients' suffering based on my own experience. Having been diagnosed myself with PTSD six years ago following a friend's murder, I appreciate the long-lasting effects of such experiences and the immeasurable difficulty of recovery.

The concept of vicarious traumatization is one which we all---clinicians and non-clinicians alike---might understand, but it is only now, as my own physical and psychic suffering has become augmented, that I more fully comprehend the insidiousness of its impact on the unwary clinician.

Luckily, this Thursday, I will attend a "Behavioral Health Grand Rounds" at a local hospital, where several experts on vicarious traumatization will present their research, their findings, and their recommendations to those of us interested to know more. As my leave of absence approaches at the end of this week, this particular presentation could not be more timely. I welcome this information, and also welcome the self-realization that it may engender.

Thursday, October 25, 2007

What Lunch Hour?

As I begin to plan for a five-week unpaid leave from the rat race, I feel particularly sensitive to messages, both implicit and explicit, that communicate that overworking is a culturally accepted practice.

In the last few days, I have begun to notice an ad campaign by Dunkin' Donuts (I refuse to link to their website, just to spite them) that truly speaks to what drives me to take a break from work altogether. This ubiquitous American purveyor of non-organic, non-free-trade coffee and fatty, sugary treats is now propagating billboards which promote a lifestyle unfriendly to slowness and thoughtfulness. "Eat on the Run!" screams one billboard, while another colorfully suggests that I "Work Through Lunch!". What have we come to? How did I become another victim of American workforce culture?

A recent study in the UK cites data showing that fewer and fewer Brits stop working in order to eat the midday meal. An article on urges workers to take lunch breaks, and article after article cites the shrinking lunch hour and lengthening workday. In my own office, the majority of us eat lunch at our desks as we finish notes, check emails, and answer calls. And when five o'clock rolls around, so many of us seem to simply keep working since there seems to be no end to the work we need to do. No wonder we're all exhausted. The Japanese even have a word for death from overwork: Karoshi. At least it's not a purely American phenomenon.

So, those billboards that cajole us to work through lunch and eat on the run? Why not boycott Dunkin' Donuts, instead?

Tuesday, October 23, 2007

Moments of Sadness, Moments of Warmth

Today I had a moment of sadness as I told a patient that I would be going on leave for five weeks. As I began to tell her my plans, her face fell and she said, "I'll miss you so much, but at least I'll see you in December." This woman and I have a close relationship bordering on what seems like a friendship, and the genuine warmth between us is a gift, as it is with a number of my patients. I also assumed that she could read between the lines, and that this leave of absence may be more than I was saying.

Why was I sad? Because this temporary goodbye is, by extension, practice for a larger, more permanent goodbye in the future. Whether I will take permanent leave of my job by the end of the year, or whether I tough it out for a few months in hopes of seeing some programmatic changes, this leave of absence which begins in ten days will be a taste of what it might feel like to really say goodbye.

There are patients who tell me they love me. There are patients, like the one mentioned above, with whom I have a great deal of warmth and positive mutual regard after more than five years of getting to know one another. Granted, the relationships are one way in most respects, but that does not decrease their true humanity and genuine quality.

Just this afternoon, I was visiting a patient who has not filled several of her prescriptions for more than a week---including her morphine---because she has absolutely no money left, not even enough for a $1 copayment. What could I say? How could I react? I dropped a twenty-dollar bill on the table as I left her mobile home. She took my hand and thanked me so graciously, her eyes sparkling with tears. How does one say goodbye to someone with whom one has been so connected?

Confusion, sadness and anticipation all coexist. Whether that coexistence is peacable remains to be seen.

Monday, October 22, 2007

Compassion Fatigue, Monday Style

Today was the first Monday since I made the decision that a leave of absence is in the cards and coming soon. That said, my morning behaved in a way which underscored my need for a break and the "compassion fatigue" that has settled into my bones.

My first patient of the day was a 10am home visit to someone who lives in the subsidized housing near the clinic. I strolled through the lovely autumn morning and rang the bell, riding the rickety elevator to the third floor. My patient hangs out at a local community center, drinks what I fear is far too many beers on the weekends, and has personal hygiene which leaves much to be desired. Just last month, I visited and checked through her medications, noting that most of the prescriptions were dated from June of this year and had not been refilled since. Just to be sure, I called her pharmacy, and lo and behold, she has not filled a prescription in five months. With asthma, hypertension, high cholesterol, and a host of other chronic conditions, some of these medications are crucial to her well-being and survival.

"So," I began, "I see you haven't been taking your medications."

"Oh yes," she responded. "I take them every day like you taught me."

I shake my head. "Now, how can that be?" I ask, "when all of these prescriptions were filled in June and you haven't been back to the pharmacy since?"

She was speechless, stammered an excuse, and looked away.

"Look," I said. "These medications are not for my health, they're for yours. Either take them or not, but don't tell me what you think I want to hear. Tell me the truth."

"I'll start taking them all tomorrow, I promise," she said, putting out her hand for me to shake.

"We can shake," I said, "but I don't believe you today. We've done this before. See you next month."

"I love you," she said as I left her apartment, one of the few English phrases she knows.

I returned to the office, feeling angry that my months of work with her had done so little to effect her consciousness vis-a-vis her health. I drank a cup of coffee and went out to the waiting room to assess a patient who came in to see me without an appointment.

"I'm so anxious and depressed," she said with tears in her eyes. "I have chest pain, neck pain, back pain, a rash on my face, and my eyes feel hot. Also, I'm constipated, I'm nauseous, and I'm losing weight because I have no appetite. And the veins in my hands feel hot." She grabbed my hand as if to demonstrate the feverish heat of her fingers, which actually felt cool to the touch. Her husband sat on the exam table watching our interaction gravely as she enumerated her myriad symptoms.

Leaving the exam room, I went back to the office briefly, sat down, and literally lay my head on the desk, despairing over the fact that I had nothing to say to this tearful woman amidst her calamity of medical symptoms. Gathering my wits, I returned to the exam room, offered some supportive counseling, secured her an afternoon appointment with her doctor, and sent her home to rest for a few hours.

Did someone say compassion fatigue? This Monday morning onslaught of unresolvable circumstances in the face of multiple chronic illnesses and exhausted apathy seemed to wear on my soul like a grindstone. It was a day when my ability to be annoyed or have my patience worn thin was as raw as I could imagine it to be. (How may days until that leave of absence?)

Patience worn thin
compassion meter maladjusted,
crispy nurse lurches
towards rest
for the weary caregiver's soul.

Sunday, October 21, 2007

Time for a Break, Damn the Torpedos

Quite recently, I wrote that burnout had come to visit, and I was uncertain of what to do. That despair of not knowing has given away to the simple realization that something had to be done, and that has led me to make the decision to take a unpaid leave of absence in the interest of my mental, spiritual, emotional, and physical health. For a hard-working, dedicated, and relatively codependent nurse, the decision to do something so dedicated to pure self-care is nothing short of a miracle (and I think my wife would agree wholeheartedly). But a leave of absence is something whose time has come, even if the bank account may feel quite differently.

Nurses are reknown for working until they drop, giving their all for patient care, and going down with the proverbial ship, damn the torpedos. Well, I have realized that the multiple torpedos of chronic pain, depression, grief, and reactivated PTSD are enough to warrant some serious self-care, and I'm the only one who can make it happen (with a little prodding from "The Missus").

When unfathomable stress couples with an untenable workload, no accrued time off, and personal issues crying out for succor, a decision to abandon self-care at such a crucial time is tantamount to suicide. As I have felt myself slip into a coma of denial and stress-induced despair, there has been a simulataneous realization that if I do not intervene on my own behalf, more debilitating chronic illness---beyond my current health challenges---may force a permanent leave of absence in the future, complete with permanent disability and loss of function. Therefore, in the interest of self-preservation and my own well-being, something has got to give, and work seems like the best candidate to be jettisoned.

In terms of my own attachments and aforementioned codependence, concerns over the well-being of my patients and my colleagues abound. I worry over how my colleagues will cope in my absence. I experience anticipatory guilt over the burdens they will bear. I worry about my patients, their feelings of abandonment, as well as the fact that after a five-week break, I just may not be able to face the rigors of my challenging job anew. All that taken into consideration, there is no denying that I have no choice but to choose my own health over any mechanism of denial which I can fabricate. The time has come, and I have to take a stand for myself.

There is a huge leap of faith involved in taking a step towards healing. There is also an enormous well of self-preservation that begs me to act before it's too late. Luckily, I have the support and wherewithal to be able to relinquish a month's pay in pursuit of personal healing, and I am grateful for that luxury which many others could never achieve. I hope to use my time wisely, and make some decisions from a place of calm.

I intend to use this forum to process my experience, describe my struggles, and elucidate the path upon which I'm embarking. Please come along for the ride---I could use the company.

Monday, October 15, 2007

The Calculus of Burn-Out

It's time to face the facts. Burn-out and compassion fatigue are taking hold. Work is taking it's toll. The days are feeling heavy and the burdens of the day even heavier. Caring is hard work, and the burden of such caring can further weigh on one's soul. Subjected to the trauma and suffering of others on a daily basis, the emotional cost of such work is considerable. Calculate into the equation the physical effects of stress and its ramifications, and one crispy nurse results.

What to do under such circumstances? How to assuage the deep soul fatigue that plagues the earnest nurse? When no vacation time or sick time is available and the additional stress of the holidays approaches, where does one turn? When chronic pain, diminishing health, and depression bite at one's heels, what decisions can be made to turn the proverbial table?

These are the questions I ask myself today. Answers will, no doubt, be forthcoming.

Thursday, October 11, 2007

Clinical Conundrum

The scenario is not easy: a hearing-impaired, cognitively-impaired patient with a history of undocumented head injury is newly diagnosed with diabetes. He now has no local family, the last family member having moved out of state three months ago. Due to the lack of documentation and the fact that the patient has only been in the U.S. for several years, I have no access to any medical records which will allow him eligibility for the Department of Mental Health, the Department of Mental Retardation, or the state head injury program. He is able to basically care for himself and does not need personal care. The only services I have been able to cobble together is a homemaker for three hours per week. He has no car, no friend with a car, and lives relatively far from the nearest supermarket. He also has a very limited income.

How do I teach someone with such a low educational level and cognitive deficits how to change his diet and lifestyle in the face of a new diagnosis of diabetes? How do I educate an individual who is functionally illiterate to read ingredient and nutrition labels on groceries before purchasing them? Like many inner-city residents, he generally shops at small, local grocery stores which carry a limited selection of foods at considerably higher prices. The nearest supermarket is a significant distance, and my patient cannot carry two heavy bags of groceries very far. As food costs rise with the price of fuel, his limited resources are squeezed, and his food stamp benefit has not risen---and will not rise---to accommodate the increased prices at the supermarket. Unfortunately, food pantries generally distribute canned and packaged foods high in sodium, added sugar and carbohydrates---just what a new diabetic does not need in his diet as he tries to make new choices.

Speaking of choices, what are mine? Let him flounder in a food desert? Commit to taking him to the grocery store each month when his check arrives? Push for further neuropsychological and cognitive testing with the bleak hope of increasing his chances for admission to a head injury program? The options are limited and the task is Herculean.

These are the types of scenarios over which the earnest nurse loses sleep.

Tuesday, October 09, 2007

Post-Traumatic Workday Syndrome

It was in many ways a typical day following a three-day weekend. My voicemail was teeming with messages by the time I sat down at my desk at 9:15am. Emails were summarily ignored until the afternoon. The phone rang as if it had a mind of its own, and patients---whether scheduled to see me or not---seemed to be in the waiting room of the clinic every time I passed through. At one point, as I walked through the waiting room to find a patient for a scheduled visit, I was literally accosted by three other patients who "just happened" to be lying in wait nearby. I was like a zebra trying to skirt around the edges of the oasis and not be seen by the predators in the grass. But, like the zebra, I am all too noticeable in my environment, and surreptitiousness is next to impossible.

By noon, my head was swimming, and I heard a small voice in my head calling for nutrition---anything to keep the engine going. Buried in paperwork and charts and partially completed tasks, I skipped the microwave and ate my leftovers at room temperature (a common practice, and probably healthier, if you believe the rumors about the dangers of microwaved food). Luckily, a patient scheduled to see me in the clinic at noon was a no-show, since I had double-booked myself for a home visit to another patient at the same time. As I force-fed myself my lunch, I called patient #2 and said I'd be 30 minutes late. (He may be unemployed and disabled, but his time is valuable, too.)

Three o'clock, and the pace slackened only briefly before starting up again just before 4, and it was all I could do to get out the door to pick up Mary down the street at the Senior Center by 5:15, knowing I had a meeting at home for the Medical Reserve Corps of my town for which I volunteer my services. Leaving the office, I knew full well that there were more than fifteen unfinished visit notes in my bag, a number which will only be further increased as soon as I hit the tarmac tomorrow. Will I finish those notes tonight before bed or tomorrow at breakfast? It's possible, but the trauma of the day may only lend itself to a swim, a snack, and retirement to the oh-so-needed bed. (Did someone say "retirement"?)

That said, the remaining business of the day will need to simply fade to the background, or my unfinished work will only interrupt and short-circuit my need for restful sleep. How to turn it off? That is a life's work in and of itself, and tonight is a good opportunity to practice letting go.

Thursday, October 04, 2007

A Sweet Epidemic

I looked at the test results and knew immediately what it illustrated---my patient is diabetic. Not only is this patient newly diagnosed, I have been directly involved in diagnosing four new diabetics this year alone. Diabetes, along with morbid obesity, is truly an American epidemic, and the Latino community is most likely the hardest hit.

According to the New York Times, public health officials are expecting "a huge wave of new cases (that) could overwhelm the public health system and engulf growing numbers of the young, creating a city where hospitals are swamped by the disease's handiwork, (and) schools scramble for resources as they accommodate diabetic children." And just imagine the effect on the workforce, productivity, and the cost of healthcare.

With a food supply imbued with fats and sugars, a growing population of obese, poorly educated and poverty-stricken citizens, and a society which thrives on convenience, speed, and a sedentary life on remote control, the stage is set for an epidemic of proportions never before imagined. As Americans become sicker and more disabled, and a larger portion of the society reaches old age, healthcare premiums and the cost of healthcare in general could very well outstrip the ability to properly care for those aging with chronic illness.

Disparities in how healthcare dollars are spent play a large role in the tactics used to improve public health and educate the populace. According to the same New York Times article mentioned above, 1,000 New Yorkers were infected with TB last year in the face of a $27 million expenditure on TB prevention and treatment. Meanwhile, with diabetes expected to engulf more than 1 million New Yorkers in short order, New York allots less than $1 million for diabetes education and outreach each year. There is a calculus of scale when dealing with disease, and we seem to be failing the class miserably.

The American Diabetes Association estimates that the cost to the nation for the care of individuals with diabetes in 2002 amounted to approximately $132 billion. For the treatment of all cancers combined, the country spent approximately $171 billion that same yeat. Simple math will tell anyone paying close enough attention that the epidemic of obesity and diabetes in America must be brought under control, or we will have a public health nightmare beyond our wildest dreams within a generation.

So, when I educate my patient about his new diagnosis of diabetes, I am not just doing it for him. Of course, I share with my patient the goal of a long and healthy life free from the ravages of an insidious and potentially fatal chronic disease. More broadly, I strive to also keep him healthy for the good of the society, the healthcare system, the economy, and the future care of others who will some day need to benefit from high quality healthcare just as he does now. The sugar coursing through his blood does its damage quite silently, and it is my job to partner with my patient so that he does not become just one more statistic related to the development of avoidable kidney damage and preventable blindness.

When it comes to this new 21st-century epidemic of diabetes and obesity, the current news---and the predictions for the future of American health and healthcare---is anything but sweet.