The call came at 3am on Saturday, less than 12 hours since my visit to the home (see previous post). A tearful sister-in-law was on the other line, apologizing for waking me. I thanked her heartfully for the call, asking if everyone was OK and if Hospice had been called. They were apparently called just before me and were on their way to the home. I offered condolences and some advice---drink water, stay close to his wife---and hung up the phone, informing my wife that my patient had died. Lighting a candle in the dark dining room, I offered this soul my blessings and encouragement to be on its way back to the Source. I smiled and went back to bed.
In the late morning, driving in the car with my wife and son towards my niece's graduation party in another state, I called my patient's wife to check in. She was composed, voice slightly shaky. I urged her to drink water, eat small frequent meals, and stay close to family, especially during the first day or two. Her response---"Oh, we never have any problem eating in this family"---was followed by genuine laughter from her and her sister in the background. She thoughtfully gave me the details for the wake and funeral, both of which I'll be sure to attend. I told her I loved her, a blessing which she promptly returned.
Another soul leaves the earth. Another family grieves while simultaneously experiencing the sweet relief that a long period of suffering and transition is now over.
May all beings be free from suffering.
Sunday, June 18, 2006
Friday, June 16, 2006
Today We Said Goodbye
On my way home from work today, I stopped by the home of a patient who has been slowly withering away from invasive and incurable cancer for many months now. With care by the local VNA/Hospice organization in place, he receives excellent care which allows him to stay at home rather than to die in a nursing home. As I have mentioned in previous posts, this gentleman's wife works six days per week, and her tenacity and courage in the face of her husband's slow death has been nothing less than heroic. Her friends and family have all pulled together, taking shifts at the bedside, learning to suction his tracheostomy, administer medications through a gastric tube, and do all of the things required for the home-based care of a dying human being.
Usually, when I make my unannounced visits, one of the wonderful personal care attendants who the family has hired with funds from our organization is at the home, tending to my patient, or quietly watching TV in the living room, always attentive for the slightest hint that there is a need for suctioning or other assistance in the bedroom down the hall. Long gone are the days when he would ring a bell for help and then mouth the words he wished to communicate, always refusing to write down his requests, relying instead on his caregivers to read his lips, or failing that, his mind.
Today, I was very surprised to find his wife at home at 4pm, and we had a heartfelt hug and a long tete-a-tete on the living room couch. We discussed the funeral arrangements, the wake, the obituary, the high cost of funerals, and her sense of peace that all of these details are arranged and ready to be put into action at a moment's notice. I praised her for her courage and strength, and reaffirmed for the umpteenth time that she has given her husband a priceless gift: the chance to die at home, surrounded by the sounds, smells, and feelings of a house where he feels comfortable, safe, and at peace. I encouraged her to talk to him up until the final moments, since hearing is said to be the last sense to fail, and that her encouraging words and expressions of love will do wonders for him as these final hours go by.
Moving into the room where her husband has lay for months, I followed this steady and surprisingly peaceful woman into the room. I've been visiting weekly for months, the hospice nurse doing all the work, my role being more to sit back and observe, getting involved in decisions that need my input, as well as keeping the primary doctor apprised of the situation. He lay there on his back, as always, the trach bubbling with secretions, his chest rattling, all of his accessory muscles of respiration working away. As his body tries harder to capture as much air as possible, it has recruited the shoulder, neck, and abdominal muscles to expand the lungs as far as they can go, and this type of breathing pattern is very common at this stage of the dying process. Eventually, long periods of breathlessness---apnea---will begin, marking yet another transition as he heads towards respiratory arrest. The morphine has been administered every three hours up until now, and I quickly call the hospice nurse to inquire if we can increase the frequency to every hour in order to lessen any discomfort and air hunger which our mutual patient might be experiencing. We all know that narcotic analgesics depress the respiratory center in the brain and can ostensibly hasten death, but when weighed against the potential for unnecessary suffering as the patient begins to possibly feel like he's drowning inside his own lungs, it's a worthwhile endeavor. Her affirmative answer gives us the green light and I instruct the attendant and wife to start giving morphine hourly.
With each of my visits over the last month or so, I've always spent a few minutes telling this lovely gentleman that his wife will be OK, that he is loved and safe, and that he is free to go at the time of his choosing. I have consistently given him a kiss on the forehead and told him I loved him before taking my leave, and I do not take that ritual lightly. My love for him is genuine, as is my admiration for him and his family, especially his wife and sister-in-law. They are truly special in my eyes.
Being a creature of habit, I again took time to talk with him while his wife looked on. I kissed him on the forehead, telling him with certainty that this would be the last time that I would see him in this body, this vehicle of learning and loving. I told his wife that I could not see him lasting through the weekend, and that I would hazard a guess that he'd be gone within twenty-four hours. As always, she promised to call me when he dies---no matter the hour of day or night---so that I can light a candle for his spirit as soon after his passing as possible.
Not being a hospice nurse or visiting nurse, I cannot currently have the honor of pronouncing a patient dead, something which I did a number of times as a visiting nurse. Doing a pronouncement is a solemn yet beautiful mission: one arrives at the home after that long anticipated telephone call and does what one must do. I remember receiving that call one evening about six years ago. I had requested that I be the nurse to pronounce my patient, and the call came on my cell-phone when I was at the creek nearby my house with my dogs, having a late afternoon swim. I told the daughter who placed the call to simply keep everyone calm, that there was no rush to call the funeral director, and that they could have several hours to simply be in the presence of their loved one before we did anything at all. I reiterated that the death was not an emergency, and that I would be there within the hour. I ran home with the dogs, showered, and drove the thirty minutes to their home, arriving as the driveway was filling with the cars of friends and relatives who had received similar calls with the news. This scene is, I think, quite typical:
The family and friends are gathered. The deceased person lays quietly in bed. There is often low lighting and candles, hushed voices in the home. Sometimes children are playing and laughing, life naturally continuing even in the presence of its denouement. A thoughtful family member or friend washes dishes or prepares food, people chat, cry, laugh, tell stories. It's an unoffical wake for those in the closest circle. The hospice nurse or visiting nurse arrives. People gather around, the nurse going into the room to see the patient, check for vitals, and determine official lifelessness. The nurse checks the time, fills out the death certificate (at least in my state, anyway) and decides with the family how long to wait to call the funeral home and allow the body to be taken. That last time I did a pronouncement which I remembered in the preceding paragraph, we had some food, sat at the table, chatted about the patient/loved one, and called the funeral home about an hour after I'd arrived. The funeral directors were quite nice and efficient, and when the body of my patient was safely stowed in the hearse, I took my leave and went home.
Back in the present, I will not have the opportunity to render that service this time. That's for someone else to do. My work for this family as of late has been one of background support, and I'm fine with that role. Knowing he's in good hands, well medicated, relatively comfortable and held in the hearts of his friends and family, my stewardship of this scenario is basically at a close. I release this soul, send him lovingly on his way, and bless his family as they begin the process of walking the earth without him physically at their side.
May all beings be free from suffering. May all beings find peace in life, and in death.
Usually, when I make my unannounced visits, one of the wonderful personal care attendants who the family has hired with funds from our organization is at the home, tending to my patient, or quietly watching TV in the living room, always attentive for the slightest hint that there is a need for suctioning or other assistance in the bedroom down the hall. Long gone are the days when he would ring a bell for help and then mouth the words he wished to communicate, always refusing to write down his requests, relying instead on his caregivers to read his lips, or failing that, his mind.
Today, I was very surprised to find his wife at home at 4pm, and we had a heartfelt hug and a long tete-a-tete on the living room couch. We discussed the funeral arrangements, the wake, the obituary, the high cost of funerals, and her sense of peace that all of these details are arranged and ready to be put into action at a moment's notice. I praised her for her courage and strength, and reaffirmed for the umpteenth time that she has given her husband a priceless gift: the chance to die at home, surrounded by the sounds, smells, and feelings of a house where he feels comfortable, safe, and at peace. I encouraged her to talk to him up until the final moments, since hearing is said to be the last sense to fail, and that her encouraging words and expressions of love will do wonders for him as these final hours go by.
Moving into the room where her husband has lay for months, I followed this steady and surprisingly peaceful woman into the room. I've been visiting weekly for months, the hospice nurse doing all the work, my role being more to sit back and observe, getting involved in decisions that need my input, as well as keeping the primary doctor apprised of the situation. He lay there on his back, as always, the trach bubbling with secretions, his chest rattling, all of his accessory muscles of respiration working away. As his body tries harder to capture as much air as possible, it has recruited the shoulder, neck, and abdominal muscles to expand the lungs as far as they can go, and this type of breathing pattern is very common at this stage of the dying process. Eventually, long periods of breathlessness---apnea---will begin, marking yet another transition as he heads towards respiratory arrest. The morphine has been administered every three hours up until now, and I quickly call the hospice nurse to inquire if we can increase the frequency to every hour in order to lessen any discomfort and air hunger which our mutual patient might be experiencing. We all know that narcotic analgesics depress the respiratory center in the brain and can ostensibly hasten death, but when weighed against the potential for unnecessary suffering as the patient begins to possibly feel like he's drowning inside his own lungs, it's a worthwhile endeavor. Her affirmative answer gives us the green light and I instruct the attendant and wife to start giving morphine hourly.
With each of my visits over the last month or so, I've always spent a few minutes telling this lovely gentleman that his wife will be OK, that he is loved and safe, and that he is free to go at the time of his choosing. I have consistently given him a kiss on the forehead and told him I loved him before taking my leave, and I do not take that ritual lightly. My love for him is genuine, as is my admiration for him and his family, especially his wife and sister-in-law. They are truly special in my eyes.
Being a creature of habit, I again took time to talk with him while his wife looked on. I kissed him on the forehead, telling him with certainty that this would be the last time that I would see him in this body, this vehicle of learning and loving. I told his wife that I could not see him lasting through the weekend, and that I would hazard a guess that he'd be gone within twenty-four hours. As always, she promised to call me when he dies---no matter the hour of day or night---so that I can light a candle for his spirit as soon after his passing as possible.
Not being a hospice nurse or visiting nurse, I cannot currently have the honor of pronouncing a patient dead, something which I did a number of times as a visiting nurse. Doing a pronouncement is a solemn yet beautiful mission: one arrives at the home after that long anticipated telephone call and does what one must do. I remember receiving that call one evening about six years ago. I had requested that I be the nurse to pronounce my patient, and the call came on my cell-phone when I was at the creek nearby my house with my dogs, having a late afternoon swim. I told the daughter who placed the call to simply keep everyone calm, that there was no rush to call the funeral director, and that they could have several hours to simply be in the presence of their loved one before we did anything at all. I reiterated that the death was not an emergency, and that I would be there within the hour. I ran home with the dogs, showered, and drove the thirty minutes to their home, arriving as the driveway was filling with the cars of friends and relatives who had received similar calls with the news. This scene is, I think, quite typical:
The family and friends are gathered. The deceased person lays quietly in bed. There is often low lighting and candles, hushed voices in the home. Sometimes children are playing and laughing, life naturally continuing even in the presence of its denouement. A thoughtful family member or friend washes dishes or prepares food, people chat, cry, laugh, tell stories. It's an unoffical wake for those in the closest circle. The hospice nurse or visiting nurse arrives. People gather around, the nurse going into the room to see the patient, check for vitals, and determine official lifelessness. The nurse checks the time, fills out the death certificate (at least in my state, anyway) and decides with the family how long to wait to call the funeral home and allow the body to be taken. That last time I did a pronouncement which I remembered in the preceding paragraph, we had some food, sat at the table, chatted about the patient/loved one, and called the funeral home about an hour after I'd arrived. The funeral directors were quite nice and efficient, and when the body of my patient was safely stowed in the hearse, I took my leave and went home.
Back in the present, I will not have the opportunity to render that service this time. That's for someone else to do. My work for this family as of late has been one of background support, and I'm fine with that role. Knowing he's in good hands, well medicated, relatively comfortable and held in the hearts of his friends and family, my stewardship of this scenario is basically at a close. I release this soul, send him lovingly on his way, and bless his family as they begin the process of walking the earth without him physically at their side.
May all beings be free from suffering. May all beings find peace in life, and in death.
Tuesday, June 13, 2006
Grand Rounds, Haversian Style
Please take some time to visit Grand Rounds, this week's carnival being held over at The Haversian Canal. Enjoy!
Monday, June 12, 2006
The No-Show Show
The urban community health center where I work has a 30-40% no-show rate for scheduled appointments. There are many theories about why this may be, including that if impoverished people feel undervalued in the healthcare setting, they will also learn not to value their health, healthcare or medical providers. This same theory has also been used to describe the reason for the amount of trash littering poor urban neighborhoods: if people do not feel valued and live in areas which are neglected by the powers that be, polluted with industrial waste, and suffering from infrastructural neglect, what would cause pride of place to be engendered? These are all good theories which, for me, hold a great deal of water.
That said, when a community health center's funding from its parent hospital organization is based upon productivity, and a 30% overall no-show rate plagues that facility, the patients will eventually suffer due to decreases in staffing, fewer available appointments, and a decreased standard of care delivered by overworked staff. The picture becomes more gloomy as the cycle expands.
This chronic lack of motivation or value effects many providers on a variety of levels. In terms of mental health, we refer our vulnerable populations to community mental health centers for management of mental illness and psychotropic medications. Due to the economic constraints placed upon the mental health agencies, their providers are generally paid on a fee-for-service basis. Thus, when our patients are referred and subsequently miss two or three appointments, they are automatically discharged from the practice and placed back on a waiting list which can be as long as six to eight months. Without a psychiatric provider, the patients decompensate, and return in crisis to the clinic, where the overworked staff and providers struggle to provide mental health care and psychotropic medication management which they are inadequately prepared and staffed to deliver. Suicidality and psychiatric crisis visits to the ER abound, but the local Psych Crisis unit is under pressure from the state, so the client is generally screened out of an inpatient stay and sent back out into the community, back to the six-month waiting list for mental health care and a primary doctor who would rather discuss their diabetes or HIV rather than their schizophrenia or bipolar disorder. You can see where this could lead.
For myself, today was a typical example. I had a tightly booked day, no home visits planned, but a number of clinic visits and a great deal of paperwork to do, let alone telephone calls, faxes, and a few urgent walk-ins who I attended promptly. I even squeezed in a 90-minute visit to the hospital to help organize a dying patient's discharge to home and a 75-minute lunchtime conference at a local restaurant. Amidst this controlled chaos, two of my patients no-show'd as I waited for them by filling my time with other tasks. While a no-show frees up time unexpectedly, it often wreaks havoc with a carefully planned schedule and precludes my ability to see a patient who would have gladly filled that spot. I did indeed turn down a few calls for visits today which I may have squeezed in without the patients who simply ignored (or forgot) their appointments with me.
But the piece de resistance today came with a 1pm telephone call from the surgical office. To explain, a patient called me last Thursday after an ER visit during which she had received a diagnosis of cholelithiasis and cholecystitis. After she pleaded for expedited attention, I pulled all of the strings at my disposal, landing her an appointment with one of the best surgeons in the area for the following day, Friday. She went to this appointment, and much to her pleasure (and my surprise) was scheduled for surgery today (Monday) at 11am with the same surgeon. I was extremely grateful to my colleagues for making this process so seamless, and I gave my patient explicit instructions for weekend symptom managment.
The 1pm call came from the surgical nurse, informing me that the patient did not show for surgery. The OR was prepped, the surgeon was ready, the team prepared for a cholecystectomy and simultaneous liver biopsy which we had requested at the last minute due to the patient's underlying untreated Hepatitis C. Understandably, the surgeon was peeved, having lost thousands of dollars of surgical income, and the incredibly busy OR whose schedule and waiting list are bursting at the seams was also negatively effected.
And the patient? MIA. I left a message on her machine, stern but not harsh. Is she OK? Did she have an emergency over the weekend? Did she realize the ramifications of not showing for the surgery? Did she realize that this surgeon may never agree to see her again, along with all of the surgeons in his practice? (And, I thought, is she dead? The best excuse for a no-show.)
So what do we make of this scenario and that which is described earlier in this post? How do we correct this insidious problem? How do we stem the tide and decrease the deleterious effects of such dynamics on both our patients and our medical practices and staff? Is there an answer to our dilemma when we actively choose to serve the poor, vulnerable and disenfranchised with quality medical care? There are no easy answers. This was not the first time one of our charges failed to arrive for a scheduled surgery, and it will not be the last. There are truly few answers, and each question or potential response only begs a host of other considerations. For all of our efforts, the show must go on, and the No-Show Show will no doubt be a popular attraction for many years to come.
That said, when a community health center's funding from its parent hospital organization is based upon productivity, and a 30% overall no-show rate plagues that facility, the patients will eventually suffer due to decreases in staffing, fewer available appointments, and a decreased standard of care delivered by overworked staff. The picture becomes more gloomy as the cycle expands.
This chronic lack of motivation or value effects many providers on a variety of levels. In terms of mental health, we refer our vulnerable populations to community mental health centers for management of mental illness and psychotropic medications. Due to the economic constraints placed upon the mental health agencies, their providers are generally paid on a fee-for-service basis. Thus, when our patients are referred and subsequently miss two or three appointments, they are automatically discharged from the practice and placed back on a waiting list which can be as long as six to eight months. Without a psychiatric provider, the patients decompensate, and return in crisis to the clinic, where the overworked staff and providers struggle to provide mental health care and psychotropic medication management which they are inadequately prepared and staffed to deliver. Suicidality and psychiatric crisis visits to the ER abound, but the local Psych Crisis unit is under pressure from the state, so the client is generally screened out of an inpatient stay and sent back out into the community, back to the six-month waiting list for mental health care and a primary doctor who would rather discuss their diabetes or HIV rather than their schizophrenia or bipolar disorder. You can see where this could lead.
For myself, today was a typical example. I had a tightly booked day, no home visits planned, but a number of clinic visits and a great deal of paperwork to do, let alone telephone calls, faxes, and a few urgent walk-ins who I attended promptly. I even squeezed in a 90-minute visit to the hospital to help organize a dying patient's discharge to home and a 75-minute lunchtime conference at a local restaurant. Amidst this controlled chaos, two of my patients no-show'd as I waited for them by filling my time with other tasks. While a no-show frees up time unexpectedly, it often wreaks havoc with a carefully planned schedule and precludes my ability to see a patient who would have gladly filled that spot. I did indeed turn down a few calls for visits today which I may have squeezed in without the patients who simply ignored (or forgot) their appointments with me.
But the piece de resistance today came with a 1pm telephone call from the surgical office. To explain, a patient called me last Thursday after an ER visit during which she had received a diagnosis of cholelithiasis and cholecystitis. After she pleaded for expedited attention, I pulled all of the strings at my disposal, landing her an appointment with one of the best surgeons in the area for the following day, Friday. She went to this appointment, and much to her pleasure (and my surprise) was scheduled for surgery today (Monday) at 11am with the same surgeon. I was extremely grateful to my colleagues for making this process so seamless, and I gave my patient explicit instructions for weekend symptom managment.
The 1pm call came from the surgical nurse, informing me that the patient did not show for surgery. The OR was prepped, the surgeon was ready, the team prepared for a cholecystectomy and simultaneous liver biopsy which we had requested at the last minute due to the patient's underlying untreated Hepatitis C. Understandably, the surgeon was peeved, having lost thousands of dollars of surgical income, and the incredibly busy OR whose schedule and waiting list are bursting at the seams was also negatively effected.
And the patient? MIA. I left a message on her machine, stern but not harsh. Is she OK? Did she have an emergency over the weekend? Did she realize the ramifications of not showing for the surgery? Did she realize that this surgeon may never agree to see her again, along with all of the surgeons in his practice? (And, I thought, is she dead? The best excuse for a no-show.)
So what do we make of this scenario and that which is described earlier in this post? How do we correct this insidious problem? How do we stem the tide and decrease the deleterious effects of such dynamics on both our patients and our medical practices and staff? Is there an answer to our dilemma when we actively choose to serve the poor, vulnerable and disenfranchised with quality medical care? There are no easy answers. This was not the first time one of our charges failed to arrive for a scheduled surgery, and it will not be the last. There are truly few answers, and each question or potential response only begs a host of other considerations. For all of our efforts, the show must go on, and the No-Show Show will no doubt be a popular attraction for many years to come.
Sunday, June 11, 2006
The End Is (Always) Near
Every week, I check on my patient who has been battling cancer and living at home with the help of hospice care and the devotion of his family. At my last visit on Thursday, he was sixteen days without any nutrition, receiving morphine and a few essential medications with a cup of water via g-tube daily. Each visit, I put a hand on his forehead and one on his chest, whispering in his ear that he has been brave and strong, that his wife will be OK without him, and that his time to let go is near. His wife tells me that she gives him permission to go every day, and he has indicated in his obtunded state that he's beginning to see dead relatives in the room. Each visit seems like it may very well be the last, and I keep expecting that call which will tell me he has left this world for the next.
Similarly, my old dog was given two months to live a few months ago, and I pump him with IV fluids every night in an effort to support his slowly failing kidneys. This journey of living and moving towards death is being chronicled on my other blog, Latter Day Sparks. Even as his death seems always around the corner, his continued apparent joy of living is what shines through most clearly. Even as we commemorate his life and memorialize him while he is still with us, we've chosen his burial place and begun to make some plans. Our sweet time with him is so limited, but so cherished.
When I think about it, I can picture the faces of dozens of patients and friends and family members who have passed from this world. How was the quality of their living? What was the quality of their final days, their actual death? Was peace the final sum of their lives' rotations around the sun?
Even as death surrounds us and we prepare for the loss of loved ones near and far, even as death fills the news media and reminds us of the suffering in the world, we embrace each sunrise and live our days in awareness of their numbered reality. As my patient awaits his death, perhaps resisting its inevitable gravitational pull, I understand that each day, each breath, could also be my last, as well. When we know that someone is dying, we of course try to make our moments with that person meaningful, with the thought that we might never see that person again. Carrying that notion forward, each time we see a patient, a friend, a neighbor, a loved one, could also be the last time we lock eyes with that unique individual. May every interaction be informed with that reality, that potential for finality, for a desire for true and honest and authentic discourse.
The end of days is prophesied, but we have no idea what that really means. Global warming, nuclear disaster, pestilence or plague may rob us all of our full lives. A slight miscalculation can send our bicycle into traffic, our car off the road. A lifetime of dietary indiscretion or simple genetic predisposition can block our coronary arteries and send us into arrest at any moment. We may even be struck by lightning.
All of that said, it is only the present, the moment in which we live and breath, that anything real and authentic can occur. As we struggle to save for retirement (a recommended practice, to be sure), pay off debts (also recommended), raise our families and make a living, every moment is truly an opportunity. Working with the ill and disabled, I always try to remember that "there but for the grace of God(dess) go I."
Yes, the end is always near for us all, but each day is also a beginning. Armed with this knowledge, what more can one do but bring this awareness to our days, console the ill, support
the dying, offer succor to the impoverished, and give thanks for another chance to love.
As Mother Teresa said, "I have found the paradox that if I love until it hurts, there is no hurt, only more love."
Similarly, my old dog was given two months to live a few months ago, and I pump him with IV fluids every night in an effort to support his slowly failing kidneys. This journey of living and moving towards death is being chronicled on my other blog, Latter Day Sparks. Even as his death seems always around the corner, his continued apparent joy of living is what shines through most clearly. Even as we commemorate his life and memorialize him while he is still with us, we've chosen his burial place and begun to make some plans. Our sweet time with him is so limited, but so cherished.
When I think about it, I can picture the faces of dozens of patients and friends and family members who have passed from this world. How was the quality of their living? What was the quality of their final days, their actual death? Was peace the final sum of their lives' rotations around the sun?
Even as death surrounds us and we prepare for the loss of loved ones near and far, even as death fills the news media and reminds us of the suffering in the world, we embrace each sunrise and live our days in awareness of their numbered reality. As my patient awaits his death, perhaps resisting its inevitable gravitational pull, I understand that each day, each breath, could also be my last, as well. When we know that someone is dying, we of course try to make our moments with that person meaningful, with the thought that we might never see that person again. Carrying that notion forward, each time we see a patient, a friend, a neighbor, a loved one, could also be the last time we lock eyes with that unique individual. May every interaction be informed with that reality, that potential for finality, for a desire for true and honest and authentic discourse.
The end of days is prophesied, but we have no idea what that really means. Global warming, nuclear disaster, pestilence or plague may rob us all of our full lives. A slight miscalculation can send our bicycle into traffic, our car off the road. A lifetime of dietary indiscretion or simple genetic predisposition can block our coronary arteries and send us into arrest at any moment. We may even be struck by lightning.
All of that said, it is only the present, the moment in which we live and breath, that anything real and authentic can occur. As we struggle to save for retirement (a recommended practice, to be sure), pay off debts (also recommended), raise our families and make a living, every moment is truly an opportunity. Working with the ill and disabled, I always try to remember that "there but for the grace of God(dess) go I."
Yes, the end is always near for us all, but each day is also a beginning. Armed with this knowledge, what more can one do but bring this awareness to our days, console the ill, support
the dying, offer succor to the impoverished, and give thanks for another chance to love.
As Mother Teresa said, "I have found the paradox that if I love until it hurts, there is no hurt, only more love."
Saturday, June 10, 2006
Technology and Its Discontents
Healthcare and technology almost seem inseparable these days. Everywhere one turns, technology has improved (and often complicated) healthcare workers' and patients' lives. Where are the points where technology breaks down, where human interaction is negatively impacted, and where technology gets in the way? Where also are the places where the enhancements provided by technology are undeniable and documentable? And when are new technologies simply not worth the cost of their operation, both personal and financial?
I've never worked in a hospital, but I've spent enough time visiting hospital floors to understand that technology rules the roost, whether it's the documentation of vital signs or the administration of meds. The hospital with which my agency is affiliated uses laptops on wheels which the nurses roll through the corridors, entering meds and patient data, as well as retrieving orders and consults. Medications are dispensed from a robot in the nurses' station wherein the nurse enters an ID code and PIN with the corresponding patient data, and the med is then delivered on a tray, labeled with the medication strength, dose and frequency, as well as the patient's name and date of birth. It's like a pharmacological ATM but the currency ranges from atenolol to zithromax rather than in tens of dollars. It has apparently cut down on medication errors enormously, a benefit that cannot be denied
At the clinic where my agency is housed and with which we are even more intimately affiliated, the hospital system is piloting an electronic medical record. Our clinic "went live" last week---only one of three sites to do so at this juncture---and IT staff swarmed over the place for the first five days, providing technical support to the often frustrated doctors as they began using the system in real time. Will it improve patient care, productivity and job satisfaction? The jury is out, and we all understand that the learning curve is high, with the first six months a party of trial and error. The benefits of prescribing electronically with the computer system automatically faxing prescriptions to the chosen pharmacy was a great selling point to the docs, who will have less and less need to use hand-written prescriptions which can be lost (and illegally altered).
Within our agency, we have two programs. The one for which I endlessly toil uses an electronic database for tracking medications, some lab values, and demographics, but our visit notes are still hand-written in prehistoric fashion. We are all required to carry company-issued cell-phones and alpha-numeric pagers, and almost all of us carry Palm Pilots with our schedules, address books, and medical software which we download from the Internet. (I highly recommend ePocrates, a free program which allows one to carry the entire list of FDA-approved medications with dosages, side effects, interactions and costs, not to mention herbs and home remedies, insurance formularies, as well as additional software for diagnosis and treatment available for a fee. There is also a desktop version of ePocrates available for free.) Our other program uses an interactive electronic medical record which we occasionally envy, except when it crashes and we hear no end of complaints from the other side of the office. At times like those, I like my handwritten notes just fine, thank you.
On any given day, I carry my company-issued and mandated pager and cell-phone which we must have on and within reach from 8:30am until 5:00pm when the on-call nurse takes over. I also carry my aforementioned Palm Pilot, pens, business cards, sticky notes, and keys, and that's just the equipment that I actually have on my person all day. We each also have a networked desktop computer. That said, we all feel fairly content with our technological set-up, although we sometimes feel burdened by it at times.
Our manager has decided to purchase each of us a "Blackberry", a pocket device which performs the combined tasks of beeper, cell-phone, Palm Pilot, and wireless email access. We'll be expected to carry (and not lose) these $500 toys as we go about our daily work, hi-ho. But there is mutiny in the wind. Over the last few years, a number of us have lost our cell-phones and pagers and Palm Pilots from time to time. We all know pagers and phones are a dime a dozen, made with throw-away materials, easily and relatively inexpensively replaced. Those of us who choose to carry Palms do so at our own risk and expense since they're not essential to carry out our duties. I have argued---to no avail---that these Blackberries are too expensive, too risky, and bound to eventually be lost, stolen or broken. Our supervisor has informed us that we will need to be especially vigilant since we will be personally and financially responsible to replace a lost device. This is a point at which I say,"If it's not broke, don't fix it." Up until now, if someone loses a cellphone, they at least have a pager through which they can be reached, and vice-versa. Now, with an all-in-one device, a loss will mean the individual loses phone and paging capablilites along with Palm Pilot interfaces, and the cost of replacement is astronomical and born by the employee. This technological change has us up in digital arms.
Change---whether it be the development of the wheel, the advent of the cellular phone, or the invention of the outdoor gas grill---brings with it challenges and hopes for the future. Tired of charcoal and lighter fluid, the post-modern hunter-gatherer can simply buy a tank of propane and barbecue the night away with no muss, no fuss, and no gaseous fumes. That same hunter-gatherer can roll along the highway on rubber pneumatic tubes at 80mph, talking to far-flung friends and family as a way to avoid making tedious telephone calls at home (except where cell service is spotty, that is--"Damn you, T-Mobile!"). Now, the itinerant nurse, continually tethered to the office by an electronic umbilical cord, is forced to adapt to a new technology which may be super cool, but offers very little in terms of added value when measured against calculated risk and relative cost. This nurse, using the wheel and the cell-phone to offer individualized care to those in need, now faces the daunting task of protecting and obsessing over a device with which (s)he would rather not be encumbered, especially in light of the substantial financial cost of momentary forgetfulness or disorganization. At this moment, unnecessary change is maddening.
What then does this itinerant nurse do? Refuse to carry said device with risk of being told there is no other choice? Take the risk of carrying said device and spending several days' wages to replace it if lost? Or does the nurse band together with his or her coworkers and demand the right to be part of the decision to make such drastic and apparently useless change?
These are the questions I ponder this weekend, wondering how my coworkers and I will handle this dilemma. We all agree that technology is useful and convenient in many forms, and adapting to new technologies simply de rigeur in this digital world. But is such adaptation palatable when delivered with the force and finesse of an unwanted intubation? Stay tuned, dear Readers, as this battle of wills dramatically unfolds in an office not-quite-near you.
I've never worked in a hospital, but I've spent enough time visiting hospital floors to understand that technology rules the roost, whether it's the documentation of vital signs or the administration of meds. The hospital with which my agency is affiliated uses laptops on wheels which the nurses roll through the corridors, entering meds and patient data, as well as retrieving orders and consults. Medications are dispensed from a robot in the nurses' station wherein the nurse enters an ID code and PIN with the corresponding patient data, and the med is then delivered on a tray, labeled with the medication strength, dose and frequency, as well as the patient's name and date of birth. It's like a pharmacological ATM but the currency ranges from atenolol to zithromax rather than in tens of dollars. It has apparently cut down on medication errors enormously, a benefit that cannot be denied
At the clinic where my agency is housed and with which we are even more intimately affiliated, the hospital system is piloting an electronic medical record. Our clinic "went live" last week---only one of three sites to do so at this juncture---and IT staff swarmed over the place for the first five days, providing technical support to the often frustrated doctors as they began using the system in real time. Will it improve patient care, productivity and job satisfaction? The jury is out, and we all understand that the learning curve is high, with the first six months a party of trial and error. The benefits of prescribing electronically with the computer system automatically faxing prescriptions to the chosen pharmacy was a great selling point to the docs, who will have less and less need to use hand-written prescriptions which can be lost (and illegally altered).
Within our agency, we have two programs. The one for which I endlessly toil uses an electronic database for tracking medications, some lab values, and demographics, but our visit notes are still hand-written in prehistoric fashion. We are all required to carry company-issued cell-phones and alpha-numeric pagers, and almost all of us carry Palm Pilots with our schedules, address books, and medical software which we download from the Internet. (I highly recommend ePocrates, a free program which allows one to carry the entire list of FDA-approved medications with dosages, side effects, interactions and costs, not to mention herbs and home remedies, insurance formularies, as well as additional software for diagnosis and treatment available for a fee. There is also a desktop version of ePocrates available for free.) Our other program uses an interactive electronic medical record which we occasionally envy, except when it crashes and we hear no end of complaints from the other side of the office. At times like those, I like my handwritten notes just fine, thank you.
On any given day, I carry my company-issued and mandated pager and cell-phone which we must have on and within reach from 8:30am until 5:00pm when the on-call nurse takes over. I also carry my aforementioned Palm Pilot, pens, business cards, sticky notes, and keys, and that's just the equipment that I actually have on my person all day. We each also have a networked desktop computer. That said, we all feel fairly content with our technological set-up, although we sometimes feel burdened by it at times.
Our manager has decided to purchase each of us a "Blackberry", a pocket device which performs the combined tasks of beeper, cell-phone, Palm Pilot, and wireless email access. We'll be expected to carry (and not lose) these $500 toys as we go about our daily work, hi-ho. But there is mutiny in the wind. Over the last few years, a number of us have lost our cell-phones and pagers and Palm Pilots from time to time. We all know pagers and phones are a dime a dozen, made with throw-away materials, easily and relatively inexpensively replaced. Those of us who choose to carry Palms do so at our own risk and expense since they're not essential to carry out our duties. I have argued---to no avail---that these Blackberries are too expensive, too risky, and bound to eventually be lost, stolen or broken. Our supervisor has informed us that we will need to be especially vigilant since we will be personally and financially responsible to replace a lost device. This is a point at which I say,"If it's not broke, don't fix it." Up until now, if someone loses a cellphone, they at least have a pager through which they can be reached, and vice-versa. Now, with an all-in-one device, a loss will mean the individual loses phone and paging capablilites along with Palm Pilot interfaces, and the cost of replacement is astronomical and born by the employee. This technological change has us up in digital arms.
Change---whether it be the development of the wheel, the advent of the cellular phone, or the invention of the outdoor gas grill---brings with it challenges and hopes for the future. Tired of charcoal and lighter fluid, the post-modern hunter-gatherer can simply buy a tank of propane and barbecue the night away with no muss, no fuss, and no gaseous fumes. That same hunter-gatherer can roll along the highway on rubber pneumatic tubes at 80mph, talking to far-flung friends and family as a way to avoid making tedious telephone calls at home (except where cell service is spotty, that is--"Damn you, T-Mobile!"). Now, the itinerant nurse, continually tethered to the office by an electronic umbilical cord, is forced to adapt to a new technology which may be super cool, but offers very little in terms of added value when measured against calculated risk and relative cost. This nurse, using the wheel and the cell-phone to offer individualized care to those in need, now faces the daunting task of protecting and obsessing over a device with which (s)he would rather not be encumbered, especially in light of the substantial financial cost of momentary forgetfulness or disorganization. At this moment, unnecessary change is maddening.
What then does this itinerant nurse do? Refuse to carry said device with risk of being told there is no other choice? Take the risk of carrying said device and spending several days' wages to replace it if lost? Or does the nurse band together with his or her coworkers and demand the right to be part of the decision to make such drastic and apparently useless change?
These are the questions I ponder this weekend, wondering how my coworkers and I will handle this dilemma. We all agree that technology is useful and convenient in many forms, and adapting to new technologies simply de rigeur in this digital world. But is such adaptation palatable when delivered with the force and finesse of an unwanted intubation? Stay tuned, dear Readers, as this battle of wills dramatically unfolds in an office not-quite-near you.
Wednesday, June 07, 2006
Desperation and Empowerment
The workdays flow by, often inundated with faxes, emails, patient visits, charts, labs, and other flotsam and jetsam. Sometimes it seems we're all simply buzzing with the energy of staying on top of our patients' care. I currently "care manage" 84 people, many of whom have extremely complex medical conditions and comorbidities. Their poverty and relative level of disempowerment only adds to frequent feelings of desperation (both on my part and theirs). That desperationis not always quiet, but it can be profound for both patient and provider.
Reading recently about the lack of infrastructure for the care of people with AIDS in Africa, I'm astounded by the lack of awareness our patients have of their relative fortune vis-a-vis their healthcare. We have access to every medication on the market for which our patients pay absolutely nothing. We have complete and unfettered access to the most cutting-edge blood tests, including genotyping which elucidates for us the exact mutations of virus replicating in our patients' bodies at any given time. Doctors in Africa probably only dream of testing genotypes, let alone having the vast armada of medications needed to work around such mutations once they're revealed.
However, even as we note that our patients are blessed with the availability of care and medications, we also must bear in mind that such blessings are indeed relative, and even here in Amerika---"the land of milk and honey"---poverty and powerlessness serve to undermine our patients' ability to fend for themselves and take their healthcare into their own hands. We must also examine our own patrician attitudes which may only serve to perpetuate their dependence and seeming lack of will, disempowering them even as we feel righteous in our work with the poor and disenfranchised.
That said, it's just that when I see those dying souls in Africa bereaved for lack of access to life-saving medications, I can feel justifiably disgusted that my patient may simply fail to call the pharmacy for a refill, or worse yet, simply not take his medications as they gather dust on his dresser. No one can live inside the mind of another. No one can know the processes which bring a person to a certain frame of mind, a certain way of being. Past traumas and indignities are suffered only by the individual, and my white, middle-class priviledged self can never truly understand the plight of another.
Luckily for us all, the dawn brings each of us a new opportunity. For my patients, it might be an opportunity for empowerment and self-actualization and self-care. For me, the provider, it might be a new perspective, or perhaps a newly discovered well of patience and humility. It is all so complex, this being human. And when one attempts to help others in this complex and multidimensional world, one's emotional, class, and cultural baggage also comes along for the ride.
May the dawn bring us all a new chance, and the ability to seize the day in unprecedented and life-affirming ways.
Reading recently about the lack of infrastructure for the care of people with AIDS in Africa, I'm astounded by the lack of awareness our patients have of their relative fortune vis-a-vis their healthcare. We have access to every medication on the market for which our patients pay absolutely nothing. We have complete and unfettered access to the most cutting-edge blood tests, including genotyping which elucidates for us the exact mutations of virus replicating in our patients' bodies at any given time. Doctors in Africa probably only dream of testing genotypes, let alone having the vast armada of medications needed to work around such mutations once they're revealed.
However, even as we note that our patients are blessed with the availability of care and medications, we also must bear in mind that such blessings are indeed relative, and even here in Amerika---"the land of milk and honey"---poverty and powerlessness serve to undermine our patients' ability to fend for themselves and take their healthcare into their own hands. We must also examine our own patrician attitudes which may only serve to perpetuate their dependence and seeming lack of will, disempowering them even as we feel righteous in our work with the poor and disenfranchised.
That said, it's just that when I see those dying souls in Africa bereaved for lack of access to life-saving medications, I can feel justifiably disgusted that my patient may simply fail to call the pharmacy for a refill, or worse yet, simply not take his medications as they gather dust on his dresser. No one can live inside the mind of another. No one can know the processes which bring a person to a certain frame of mind, a certain way of being. Past traumas and indignities are suffered only by the individual, and my white, middle-class priviledged self can never truly understand the plight of another.
Luckily for us all, the dawn brings each of us a new opportunity. For my patients, it might be an opportunity for empowerment and self-actualization and self-care. For me, the provider, it might be a new perspective, or perhaps a newly discovered well of patience and humility. It is all so complex, this being human. And when one attempts to help others in this complex and multidimensional world, one's emotional, class, and cultural baggage also comes along for the ride.
May the dawn bring us all a new chance, and the ability to seize the day in unprecedented and life-affirming ways.
Sunday, June 04, 2006
Fun Facts
These fun facts are courtesy of the website of Bodies: The Exhibition, which I plan to see as soon as I can manage to do so. For those of you not in the know, this exhibition present dozens of complete human bodies, preserved in toto, with the skin removed, in various poses. A polymer was injected into the bodies to perfectly preserve them: nerves, blood vessels, organs and all.
Did You Know?
• A cough releases an explosive charge of air that moves at speeds up to 60 mph.
• Every time you lick a stamp, you consume 1/10 of a calorie.
• A fetus acquires fingerprints at the age of three months.
• A sneeze can exceed the speed of 100 mph.
• Every person has a unique tongue print.
• According to German researchers, the risk of heart attack is higher on Monday than any other day of the week.
• After spending hours working at a computer display, look at a blank piece of white paper. It will probably appear pink.
• An average human drinks about 16,000 gallons of water in a lifetime.
• A fingernail or toenail takes about 6 months to grow from base to tip.
• An average human scalp has 100,000 hairs.
• It takes 17 muscles to smile and 43 to frown.
• Babies are born with 300 bones, but by adulthood we have only 206 in our bodies.
• Beards are the fastest growing hairs on the human body. If the average man never trimmed his beard, it would grow to nearly 30 feet long in his lifetime.
• By age sixty, most people have lost half of their taste buds. By the time you turn 70, your heart will have beat some two-and-a-half billion times (figuring on an average of 70 beats per minute.)
• Each square inch of human skin consists of twenty feet of blood vessels.
• Every human spent about half an hour as a single cell.
• Every square inch of the human body has an average of 32 million bacteria on it.
• Fingernails grow faster than toenails.
• Humans shed about 600,000 particles of skin every hour - about 1.5 pounds a year. By 70 years of age, an average person will have lost 105 pounds of skin.
• New babies at rest breathe between 40 and 50 times per minute. By age five it decreases to around 25 times per minute.
• The total surface area of the alveoli (tiny air sacs in the lungs) is the size of a tennis court.
• The lungs are the only organ in the body that can float on water.
• The lungs produce a detergent-like substance (surfactant) which reduces the surface tension of the fluid lining, allowing air in.
• Your heart is about the same size as your fist.
• An average adult body contains about five quarts of blood.
• All the blood vessels in the body joined end to end would stretch 62,000 miles or
• The heart circulates the body's blood supply about 1,000 times each day.
• The heart pumps the equivalent of 5,000 to 6,000 quarts of blood each day.
Saturday, June 03, 2006
A Big Issue
Obesity seems to be everywhere. An epidemic, they say. I think I believe them, whoever they are.
Driving through my city of employment yesterday, I was stunned as I saw what appeared to be a parade of obese individuals wherever I turned. Since I work in neighborhoods where a preponderance of poor people reside I am exposed to the lives (and dietary habits) of American's urban poor on a daily basis, and it seems that eating healthily may be beyond the grasp of many who subsist on welfare and food stamps. McDonalds appears to be stellar in its ability to ensconce itself in poor neighborhoods, as is Burger King, KFC, and other purveyors of fat-laden, carb-heavy, calorically-dense foods. Add to that the ubiquitous 99-cent fast-food sandwich enticements seen on billboards and signs across urban (and suburban) America, and you have the beginnings of the recipe for carbohydrate/fat addiction and rampant obesity, not to mention pre-diabetes and hypertension.
So, who's to blame?
Well, fingers can point in multiple directions simultaneously. Corporate Amerika does its best to super-size our populace by flooding the market with fast food. In the inner city, supermarkets and farmer's markets are often miles away and virtually inaccessible by public transportation, especially for the disabled, the elderly, and single moms with small children. If one does make it to the supermarket, more and more foods are packed with unnecessary extra carbohydrates through the ubiquitous use of high fructose corn syrup. Even as soy milk gains popularity as an alternative and "healthy" beverage, companies make their product more palatable by pumping it full of corn syrup or "evaporated cane juice", the new flavor enhancer du jour. Whether it's organic or not, evaporated cane juice is just another word for sugar, something the American public needs alot less of, especially children.
Public schools make financial deals with Coca Cola and other predatory companies who use the lure of "free" technology and computers to insinuate themselves into the educational environment, but the devil is in the details. In exchange for such faux largesse, schools deliver to their children carbo- and sugar-laden snacks and foods, often available ad lib through the venue of vending machines in the cafeteria. Interview any cohort of schoolchildren during lunchtime and many will be subsisting on Doritos and Coke as a main course and candy for dessert. Many groups in local districts seem to be fighting back, demanding the removal of vending machines from schools and the provision of healthy meals and snacks. It's an uphill battle.
Sadly, globalization has led not only to the sharing of technology and the opening of "call centers" for American companies in Bombay, it has also led to the globalization of the obesity epidemic to previously healthy societies. Asia is now seeing unprecendented obesity among all age groups, with fast food and Americanized high-sugar dietary choices becoming the norm, leaving traditional eating habits in the dust. Not only do we as Amerikans consume more energy per capita than any other society on earth, we also share our love of fattening foods, poor health, and gas-guzzling SUVs with the rest of the world as well. We tax the world economic and healthcare infrastructure with the weight of our addictions and the unsustainable habits which we so freely share with the world at large (pun intended).
Government can easily be implicated here, from poor public health planning, corporate hegemony, the influence of big business, and the Every Child Left Behind Act. Resources galore are wasted in preparing our students to pass rcailly biased standardized tests, while our children's nutrition is ignored and physical education funding cut in the interest of the bottom line.
So where from here? BigPharma is now rushing to create a "magic bullet" for obesity, pills that will curb appetite, burn more calories, or cause the consumer to retch violently when eating anything with high caloric value (I made that one up). Are pharmaceuticals the answer? Is gastric bypass the panacea for thousands of obese teenagers raised on X-Box, Doritos, and sugar-laden breakfast cereals? Is poor urban planning only going to increase our reliance on cars, erasing sidewalks and the idea of shopping on Main Street and walking to the store? As more and more entertainment is delivered to our homes without more than the click of a mouse or remote, Americans will be more than ever frozen in their recliners, the yard-sale exercise machine gathering dust in the garage. Eventually, robots will vacuum, wash our laundry, and pick up the mail, while we eat microwaved meals as we surf the InterTV-Net for infotainment.
Hyperbole aside, maps of obesity trends in the US show rapid growth in the obese population of our country, and the healthcare costs of such an epidemic are staggering. A study commissioned by the American Obesity Association (AOA) estimates the healthcare-related costs of obesity in the United States for 1994 was over $7 billion! And that was more than a decade ago. The AOA website states:
"The Lewin Group examined the costs of fifteen (15) conditions causally related to obesity. They included: arthritis, breast cancer, heart disease, colorectal cancer, type 2 diabetes, endometrial cancer, end-stage renal disease, gallbladder disease, hypertension, liver disease, low back pain, renal cell cancer, obstructive sleep apnea, stroke and urinary incontinence."
We obviously need to get this monster under control before it controls us, our economy, and our country's future. Public health experts believe that gains made vis-a-vis increased lifespans in the last 100 years may be eventually lost due to the health effects of obesity and its sequelae. It is an enormous problem of as-yet-unseen ramifications for the future, and if any of your children would like a career in medicine, let them know that the care of people with diabetes and heart disease and other complications of obesity is a sure bet for the future of medical careers and paychecks. That said, make sure your children are free of the epidemic, or they too will only serve to feed the medical machinery that devours the dollars needed to stem the tide of obesity-related morbidity and mortality.
Did I say it was a big issue? Big may be the understatement of the year.
Driving through my city of employment yesterday, I was stunned as I saw what appeared to be a parade of obese individuals wherever I turned. Since I work in neighborhoods where a preponderance of poor people reside I am exposed to the lives (and dietary habits) of American's urban poor on a daily basis, and it seems that eating healthily may be beyond the grasp of many who subsist on welfare and food stamps. McDonalds appears to be stellar in its ability to ensconce itself in poor neighborhoods, as is Burger King, KFC, and other purveyors of fat-laden, carb-heavy, calorically-dense foods. Add to that the ubiquitous 99-cent fast-food sandwich enticements seen on billboards and signs across urban (and suburban) America, and you have the beginnings of the recipe for carbohydrate/fat addiction and rampant obesity, not to mention pre-diabetes and hypertension.
So, who's to blame?
Well, fingers can point in multiple directions simultaneously. Corporate Amerika does its best to super-size our populace by flooding the market with fast food. In the inner city, supermarkets and farmer's markets are often miles away and virtually inaccessible by public transportation, especially for the disabled, the elderly, and single moms with small children. If one does make it to the supermarket, more and more foods are packed with unnecessary extra carbohydrates through the ubiquitous use of high fructose corn syrup. Even as soy milk gains popularity as an alternative and "healthy" beverage, companies make their product more palatable by pumping it full of corn syrup or "evaporated cane juice", the new flavor enhancer du jour. Whether it's organic or not, evaporated cane juice is just another word for sugar, something the American public needs alot less of, especially children.
Public schools make financial deals with Coca Cola and other predatory companies who use the lure of "free" technology and computers to insinuate themselves into the educational environment, but the devil is in the details. In exchange for such faux largesse, schools deliver to their children carbo- and sugar-laden snacks and foods, often available ad lib through the venue of vending machines in the cafeteria. Interview any cohort of schoolchildren during lunchtime and many will be subsisting on Doritos and Coke as a main course and candy for dessert. Many groups in local districts seem to be fighting back, demanding the removal of vending machines from schools and the provision of healthy meals and snacks. It's an uphill battle.
Sadly, globalization has led not only to the sharing of technology and the opening of "call centers" for American companies in Bombay, it has also led to the globalization of the obesity epidemic to previously healthy societies. Asia is now seeing unprecendented obesity among all age groups, with fast food and Americanized high-sugar dietary choices becoming the norm, leaving traditional eating habits in the dust. Not only do we as Amerikans consume more energy per capita than any other society on earth, we also share our love of fattening foods, poor health, and gas-guzzling SUVs with the rest of the world as well. We tax the world economic and healthcare infrastructure with the weight of our addictions and the unsustainable habits which we so freely share with the world at large (pun intended).
Government can easily be implicated here, from poor public health planning, corporate hegemony, the influence of big business, and the Every Child Left Behind Act. Resources galore are wasted in preparing our students to pass rcailly biased standardized tests, while our children's nutrition is ignored and physical education funding cut in the interest of the bottom line.
So where from here? BigPharma is now rushing to create a "magic bullet" for obesity, pills that will curb appetite, burn more calories, or cause the consumer to retch violently when eating anything with high caloric value (I made that one up). Are pharmaceuticals the answer? Is gastric bypass the panacea for thousands of obese teenagers raised on X-Box, Doritos, and sugar-laden breakfast cereals? Is poor urban planning only going to increase our reliance on cars, erasing sidewalks and the idea of shopping on Main Street and walking to the store? As more and more entertainment is delivered to our homes without more than the click of a mouse or remote, Americans will be more than ever frozen in their recliners, the yard-sale exercise machine gathering dust in the garage. Eventually, robots will vacuum, wash our laundry, and pick up the mail, while we eat microwaved meals as we surf the InterTV-Net for infotainment.
Hyperbole aside, maps of obesity trends in the US show rapid growth in the obese population of our country, and the healthcare costs of such an epidemic are staggering. A study commissioned by the American Obesity Association (AOA) estimates the healthcare-related costs of obesity in the United States for 1994 was over $7 billion! And that was more than a decade ago. The AOA website states:
"The Lewin Group examined the costs of fifteen (15) conditions causally related to obesity. They included: arthritis, breast cancer, heart disease, colorectal cancer, type 2 diabetes, endometrial cancer, end-stage renal disease, gallbladder disease, hypertension, liver disease, low back pain, renal cell cancer, obstructive sleep apnea, stroke and urinary incontinence."
We obviously need to get this monster under control before it controls us, our economy, and our country's future. Public health experts believe that gains made vis-a-vis increased lifespans in the last 100 years may be eventually lost due to the health effects of obesity and its sequelae. It is an enormous problem of as-yet-unseen ramifications for the future, and if any of your children would like a career in medicine, let them know that the care of people with diabetes and heart disease and other complications of obesity is a sure bet for the future of medical careers and paychecks. That said, make sure your children are free of the epidemic, or they too will only serve to feed the medical machinery that devours the dollars needed to stem the tide of obesity-related morbidity and mortality.
Did I say it was a big issue? Big may be the understatement of the year.
Friday, June 02, 2006
Denial is a River....of Apathy
Visiting a patient today, his friend/assistant complained to me how my patient is not taking good care of himself, neglecting his medications at times, smoking, eating poorly, even in the midst of terminal cancer and other disease processes.
When I questioned my patient's friend about her own health, she shared with me an apathy so deep that I was shocked by her clear articulation of its breadth and depth. With blood sugars usually in the "300 to 400" range, she described for me how her apartment is often like a "candy store". Addicted to sugar and sweets, she now injects well over 200 units of insulin per day, barely convering her insulin needs. "Every time I see the doctor, they look at my numbers and raise the insulin again," she laughs, as if it were a game she were playing. And perhaps she is. When I ask her about the potential consequences of her actions, she laughs again. "I'm already old. In 20 years, I'll weigh 100 pounds more!" She gestures at her already obese body. She's 41---my age. We share the same birth year: 1964. She sees her life as almost over.
Flabbergasted, I paint a picture of dialysis, amputations, blindness, cardiac disease, nursing homes. She only laughs more. "Anyway, the Lord is coming, the world is ending, so I don't have to worry about it. I'll go to Heaven." When I ask her what will happen if the Lord does not return to Earth in her lifetime and she gets gravely ill, she looks thoughtful for a moment, then laughs again. I hold her hand and tell her that I care about her and want her to survive and be healthy.
"I'm not going to change. I'll just keep getting fat. I love sugar. There's just no reason to try."
No. Denial is NOT a river in Egypt. But it runs deep, and its waters are treacherous beyond belief.
When I questioned my patient's friend about her own health, she shared with me an apathy so deep that I was shocked by her clear articulation of its breadth and depth. With blood sugars usually in the "300 to 400" range, she described for me how her apartment is often like a "candy store". Addicted to sugar and sweets, she now injects well over 200 units of insulin per day, barely convering her insulin needs. "Every time I see the doctor, they look at my numbers and raise the insulin again," she laughs, as if it were a game she were playing. And perhaps she is. When I ask her about the potential consequences of her actions, she laughs again. "I'm already old. In 20 years, I'll weigh 100 pounds more!" She gestures at her already obese body. She's 41---my age. We share the same birth year: 1964. She sees her life as almost over.
Flabbergasted, I paint a picture of dialysis, amputations, blindness, cardiac disease, nursing homes. She only laughs more. "Anyway, the Lord is coming, the world is ending, so I don't have to worry about it. I'll go to Heaven." When I ask her what will happen if the Lord does not return to Earth in her lifetime and she gets gravely ill, she looks thoughtful for a moment, then laughs again. I hold her hand and tell her that I care about her and want her to survive and be healthy.
"I'm not going to change. I'll just keep getting fat. I love sugar. There's just no reason to try."
No. Denial is NOT a river in Egypt. But it runs deep, and its waters are treacherous beyond belief.
Thursday, June 01, 2006
Service
A framed poster of Marian Wright Edelman hangs in the hallway of our clinic alongside numerous similar posters of people of color who have changed the world. The quote on Ms. Edelman's poster stopped me in my tracks the other day:
"Service is the very purpose of life. It is the rent we pay for living on this planet."
Among many accomplishments, Ms. Edelman established the Children’s Defense Fund, "the most powerful voice ever created for the millions of poor children in the United States" (according to the National Women's History Project).
It seems that my life has become centered around the service of others, either through nursing, teaching, or various volunteer projects in which I've taken part. While it may be possible to lose one's way by ignoring one's own growth and needs in the interest of altruistic service, I've found that one can often find one's self through the medium of service. When I look at those who have endeavored to devote themselves to the welfare of others: Martin Luther King, Jr., Mother Theresa, Mahatma Gandhi, I don't see egoless waifs whose personalities were lost in the wake of their call to serve. What I see are dynamic individuals who brought their visions to fruition and silmultaneously achieved self-actualization and ersatz sainthood.
Ayn Rand professed that true altruism could not exist, because every human act---whether for the benefit of one person or a multitude---is essentially a selfish act, even when couched in altruistic desires. She felt that even the most seemingly selfless person gains from their actions in some way (if only by increased self-esteem), thus making selflessness essentially impossible.
We all might experience a feeling of accomplishment or well-being for a deed well done. Does this diminish our altruism? Does it demean our desire to serve? Does the benefit to one's ego preclude the benefit felt by the recipient of our largesse? I would say no to all three rhetorical questions, and will continue on my path of service and good will for as long as that path is aligned with my soul. Whether altruism is absolute seems to me to be beside the point. Any amount of ego boosting would seem a small price to pay if a small corner of the world is uplifted or bettered by one's actions on the ground.
Service with a smile? As often as possible. To paraphrase that ubiquitous McDonalds sign in front of that fast-food monolith of capitalism: "Billions and Billions Served".
"Service is the very purpose of life. It is the rent we pay for living on this planet."
Among many accomplishments, Ms. Edelman established the Children’s Defense Fund, "the most powerful voice ever created for the millions of poor children in the United States" (according to the National Women's History Project).
It seems that my life has become centered around the service of others, either through nursing, teaching, or various volunteer projects in which I've taken part. While it may be possible to lose one's way by ignoring one's own growth and needs in the interest of altruistic service, I've found that one can often find one's self through the medium of service. When I look at those who have endeavored to devote themselves to the welfare of others: Martin Luther King, Jr., Mother Theresa, Mahatma Gandhi, I don't see egoless waifs whose personalities were lost in the wake of their call to serve. What I see are dynamic individuals who brought their visions to fruition and silmultaneously achieved self-actualization and ersatz sainthood.
Ayn Rand professed that true altruism could not exist, because every human act---whether for the benefit of one person or a multitude---is essentially a selfish act, even when couched in altruistic desires. She felt that even the most seemingly selfless person gains from their actions in some way (if only by increased self-esteem), thus making selflessness essentially impossible.
We all might experience a feeling of accomplishment or well-being for a deed well done. Does this diminish our altruism? Does it demean our desire to serve? Does the benefit to one's ego preclude the benefit felt by the recipient of our largesse? I would say no to all three rhetorical questions, and will continue on my path of service and good will for as long as that path is aligned with my soul. Whether altruism is absolute seems to me to be beside the point. Any amount of ego boosting would seem a small price to pay if a small corner of the world is uplifted or bettered by one's actions on the ground.
Service with a smile? As often as possible. To paraphrase that ubiquitous McDonalds sign in front of that fast-food monolith of capitalism: "Billions and Billions Served".
Tuesday, May 30, 2006
The Age of AIDS
I hope that some of you can watch the new Frontline special, The Age of AIDS on PBS tonight. I plan to watch it, especially in the knowledge that this is the 25-year anniversary of the beginning of the epidemic. FYI, it is actually a two-night special, and will certainly be repeated.
When I was a young art student in Philadelphia in the early 1980's, I came to personally know a number of gay men who began to exhibit symptoms of massive weight loss, strange pneumonia-like infections, and purplish splotches on their faces and arms. The idea of a "gay cancer" attacking the male homosexual community gained ground quickly in those early years, and due to my connection to the arts community and its large gay subculture, I was witness to the beginnings of the devastation that was to follow.
Looking back, I clearly remember a gay acquaintance of mine---a fellow painter---who made it very clear that he wanted me to be his lover. Never having had romantic feelings for men, I politely rejected his ardor, and our acquaintance never amounted to much, although we had a few mutual friends and would see one another at various art openings around the city. Several years later, before I left Philadelphia, he died a miserable death, riddled with Kaposi's Sarcoma and pneumonia, apparently having wasted away to a mere shadow of his former robust self. It's only now that I realize how profoundly life-altering a choice it would have been if I had entertained his offer of companionship. At that time, heterosexual infection was still relatively unrecognized, and although I had dodged an enormous bullet, the risks for young adults in the early and mid-80's would only grow.
A few years later, as a newly-trained massage therapist, I leapt at the opportunity to volunteer my services at a free holistic AIDS clinic in a relatively small New England city hit hard by the epidemic. Both gay men and IV drug users were affected most profoundly, although it was mostly only the gay men who flocked to the clinic for free medical advice, acupuncture, massage, support groups, and a place to feel at home. With my wife as a counselor, we both subsumed ourselves in this community which embraced everyone who walked through its doors. Free of the professional boundaries of a medical practice, we partied together, had meals together, raised money, created friendships, and developed a small network of interconnected lives who all worked tirelessly to improve (and possibly prolong) the lives of our affected brethren. Men dominated the clientele, but there were women as well, and the mix was enlivening and exciting. We were part of something great. I remember dinners, healing sessions, fund-raisers, Halloween parties with over-the-top drag shows, and funerals galore. Funerals. Memorial services. And more funerals. And more. Mary and I practiced Reiki on one of our dear friends as he lay on his deathbed. This kind soul, who had been at the top of his game in the publishing world in New York City, who would hum show tunes as I massaged his slowly wasting frame, died in the middle of the night with his beloved sister holding his hand, people chanting and praying around his bed. We were not there for his death, having gone home to tuck in our young son in the big haunted house where we lived at the top of the hill.
Now, in my current professional role as a nurse, clearly deeply affected by my earlier life experiences, I still marvel at the insidiousness of the virus, its ability to mutate and gain resistance to powerful medications, and its clear agenda to infiltrate every walk of life, nationality, race, and religion. What was once "the gay cancer" has become the most lethal epidemic in memory, and its grip on Africa and Asia tightens like a noose with each passing year. While I may not work exclusively with patients with HIV or AIDS, I currently carry fifteen people on my caseload who are infected, and have probably lost half a dozen in the last five years. For every victory, there's a dismal failure. For every stellar patient who takes his or her meds like a champion, another can't seem to stay focused long enough to follow through. The city where I work has been violently attacked by the virus, and politicians' fears of a needle exchange program have furthered the epidemic by tacitly allowing dirty syringes to pass from hand to hand.
As a Baccalaureate nursing student several years ago, I and a few classmates wandered the back streets of another devastated town under the guidance of a heroin addict in recovery, visiting the places where junkies shoot up, handing out condoms and bleach kits, preaching the gospel of clean needles and safe sex. Much to our professors' dismay, we held a health-fair at a local drop-in center for IV drug users, teaching them clean injection technique, how to sterilize needles, skills which could prevent infection with HIV, not to mention dangerous abscesses of the arm from poor injection technique. It's called harm reduction, and we did it well, if not a little clumsily. Did we save lives? No one can say. But one piece of information can go a long way, and I like to think that the effects of our work may live on in some child somewhere, whose parent used those techniques to avoid infection and thus give birth to an uninfected child. How I hope that that may be the case.
So, my friends, take a moment to acknowledge this anniversary, whether you have known someone infected with the virus or not, whether you work with infected individuals or not, whether your family has been touched or not. It is a passage in human history worth pausing for, and a time for even a brief reflection at this historic time.
May all beings be happy. May all beings be free from suffering.
When I was a young art student in Philadelphia in the early 1980's, I came to personally know a number of gay men who began to exhibit symptoms of massive weight loss, strange pneumonia-like infections, and purplish splotches on their faces and arms. The idea of a "gay cancer" attacking the male homosexual community gained ground quickly in those early years, and due to my connection to the arts community and its large gay subculture, I was witness to the beginnings of the devastation that was to follow.
Looking back, I clearly remember a gay acquaintance of mine---a fellow painter---who made it very clear that he wanted me to be his lover. Never having had romantic feelings for men, I politely rejected his ardor, and our acquaintance never amounted to much, although we had a few mutual friends and would see one another at various art openings around the city. Several years later, before I left Philadelphia, he died a miserable death, riddled with Kaposi's Sarcoma and pneumonia, apparently having wasted away to a mere shadow of his former robust self. It's only now that I realize how profoundly life-altering a choice it would have been if I had entertained his offer of companionship. At that time, heterosexual infection was still relatively unrecognized, and although I had dodged an enormous bullet, the risks for young adults in the early and mid-80's would only grow.
A few years later, as a newly-trained massage therapist, I leapt at the opportunity to volunteer my services at a free holistic AIDS clinic in a relatively small New England city hit hard by the epidemic. Both gay men and IV drug users were affected most profoundly, although it was mostly only the gay men who flocked to the clinic for free medical advice, acupuncture, massage, support groups, and a place to feel at home. With my wife as a counselor, we both subsumed ourselves in this community which embraced everyone who walked through its doors. Free of the professional boundaries of a medical practice, we partied together, had meals together, raised money, created friendships, and developed a small network of interconnected lives who all worked tirelessly to improve (and possibly prolong) the lives of our affected brethren. Men dominated the clientele, but there were women as well, and the mix was enlivening and exciting. We were part of something great. I remember dinners, healing sessions, fund-raisers, Halloween parties with over-the-top drag shows, and funerals galore. Funerals. Memorial services. And more funerals. And more. Mary and I practiced Reiki on one of our dear friends as he lay on his deathbed. This kind soul, who had been at the top of his game in the publishing world in New York City, who would hum show tunes as I massaged his slowly wasting frame, died in the middle of the night with his beloved sister holding his hand, people chanting and praying around his bed. We were not there for his death, having gone home to tuck in our young son in the big haunted house where we lived at the top of the hill.
Now, in my current professional role as a nurse, clearly deeply affected by my earlier life experiences, I still marvel at the insidiousness of the virus, its ability to mutate and gain resistance to powerful medications, and its clear agenda to infiltrate every walk of life, nationality, race, and religion. What was once "the gay cancer" has become the most lethal epidemic in memory, and its grip on Africa and Asia tightens like a noose with each passing year. While I may not work exclusively with patients with HIV or AIDS, I currently carry fifteen people on my caseload who are infected, and have probably lost half a dozen in the last five years. For every victory, there's a dismal failure. For every stellar patient who takes his or her meds like a champion, another can't seem to stay focused long enough to follow through. The city where I work has been violently attacked by the virus, and politicians' fears of a needle exchange program have furthered the epidemic by tacitly allowing dirty syringes to pass from hand to hand.
As a Baccalaureate nursing student several years ago, I and a few classmates wandered the back streets of another devastated town under the guidance of a heroin addict in recovery, visiting the places where junkies shoot up, handing out condoms and bleach kits, preaching the gospel of clean needles and safe sex. Much to our professors' dismay, we held a health-fair at a local drop-in center for IV drug users, teaching them clean injection technique, how to sterilize needles, skills which could prevent infection with HIV, not to mention dangerous abscesses of the arm from poor injection technique. It's called harm reduction, and we did it well, if not a little clumsily. Did we save lives? No one can say. But one piece of information can go a long way, and I like to think that the effects of our work may live on in some child somewhere, whose parent used those techniques to avoid infection and thus give birth to an uninfected child. How I hope that that may be the case.
So, my friends, take a moment to acknowledge this anniversary, whether you have known someone infected with the virus or not, whether you work with infected individuals or not, whether your family has been touched or not. It is a passage in human history worth pausing for, and a time for even a brief reflection at this historic time.
May all beings be happy. May all beings be free from suffering.
Monday, May 29, 2006
Paradox Now
Ah, what magic a long weekend can work for the soul. Leisure, something which many people lack in their lives for a variety of reasons, is such a necessity for mental and physical health. I can see that many of my own physical symptoms in the last few months have been absolutely stress related. As summer begins to dawn on the horizon, I spend more and more time outdoors, exercising and soaking up the sun. It's a time for healing, but also for deeper questions.
Watching a film last night, Paradise Now, I was reminded how many people in the world live in environments of constant stress and trauma, with leisure and stress relief something of an unattainable panacea. In the film, two Palestinians in the West Bank are chosen for a suicide mission in Tel Aviv, and each one must grapple with his conscience. Aside from the socio- and geo-political implications of the film, what I took away from it was a sense of how people all over the world live in situations in which respite from stress---often a level of stress which is trauma-producing---is often not an option. In Darfur, Palestine, Congo, Iraq---life is interwoven with the constant and relentless threat of death or dismemberment. On many of the streets of rural and urban America, hunger and poverty rule the day. How many American children go to bed hungry each night?
I'm struck by the paradox of reveling in my long weekend, recovering from the stress of full-time, well-paid work, replete with comprehensive health insurance and relative job security. Of course, it's a given that stress is relative, and there's no question that I deserve rest and renewal within my middle-class bubble. However, in the larger scheme of things amidst the general tumult of the world, my struggles to lose a few pounds, decide if we can afford having someone clean our house twice a month, or how long we can go on vacation this summer take on a somewhat anemic pallor. Clearly, perspective is key in this moment, and one must not lose sight of one's place in the puzzle, playing with the deck that's been dealt. Middle-class guilt for one's luxuries serves no one, but at the same time blinders to others' plight serve no one as well.
The conclusion which I draw this morning is that awareness of one's relative priviledge is key, while mildly indulging one's needs is not evil or disingenuous, as long as one retains a view of the larger picture, using that position of relative priviledge to positively effect the lives of others.
Some rhetorical questions:
Does the quintessential "wounded activist" serve anyone through his or her self-denial of pleasure? Does not the blind purchase of goods at Wal-Mart made in Chinese sweatshops help to perpetuate the globalization (and Wal-Martization) of the world? Does simply doing one's work and living a balanced and non-ostentatious life improve the lives of others indirectly? Do political bumper-stickers with catchy slogans preclude the need for real political activism in one's life? How do my actions from day to day truly effect the lives of people in Darfur, Palestine, South Central LA, or Basra? Does my purchase of a new refrigerator negatively impact some individual life somewhere in the world? What do my purchasing habits say about me? How does the sum of my actions define me in the larger scheme of things? Am I doing enough? Am I walking my talk? Where is my energy best spent? Am I more blinded by my priviledge than I can truly see?
I realize as I write that these are not necessarily the words of a person embracing a national holiday and paid day off with complete equanimity. I'm choosing to not live my life like a blind and ignorant bull in the china shop of the world. I want to acknowledge the paradoxes inherent in being a middle-class white American with full-time work, health insurance, my own home, and the luxury of time and material well-being. One must accept where one is, change that which one chooses to change, and live life according to a chosen path. I simply find it necessary to periodically examine that path, take stock of my position in the wider world, and determine if I'm truly living the life that I desire. Blindess is an option, but I choose today to re-open my eyes.
Watching a film last night, Paradise Now, I was reminded how many people in the world live in environments of constant stress and trauma, with leisure and stress relief something of an unattainable panacea. In the film, two Palestinians in the West Bank are chosen for a suicide mission in Tel Aviv, and each one must grapple with his conscience. Aside from the socio- and geo-political implications of the film, what I took away from it was a sense of how people all over the world live in situations in which respite from stress---often a level of stress which is trauma-producing---is often not an option. In Darfur, Palestine, Congo, Iraq---life is interwoven with the constant and relentless threat of death or dismemberment. On many of the streets of rural and urban America, hunger and poverty rule the day. How many American children go to bed hungry each night?
I'm struck by the paradox of reveling in my long weekend, recovering from the stress of full-time, well-paid work, replete with comprehensive health insurance and relative job security. Of course, it's a given that stress is relative, and there's no question that I deserve rest and renewal within my middle-class bubble. However, in the larger scheme of things amidst the general tumult of the world, my struggles to lose a few pounds, decide if we can afford having someone clean our house twice a month, or how long we can go on vacation this summer take on a somewhat anemic pallor. Clearly, perspective is key in this moment, and one must not lose sight of one's place in the puzzle, playing with the deck that's been dealt. Middle-class guilt for one's luxuries serves no one, but at the same time blinders to others' plight serve no one as well.
The conclusion which I draw this morning is that awareness of one's relative priviledge is key, while mildly indulging one's needs is not evil or disingenuous, as long as one retains a view of the larger picture, using that position of relative priviledge to positively effect the lives of others.
Some rhetorical questions:
Does the quintessential "wounded activist" serve anyone through his or her self-denial of pleasure? Does not the blind purchase of goods at Wal-Mart made in Chinese sweatshops help to perpetuate the globalization (and Wal-Martization) of the world? Does simply doing one's work and living a balanced and non-ostentatious life improve the lives of others indirectly? Do political bumper-stickers with catchy slogans preclude the need for real political activism in one's life? How do my actions from day to day truly effect the lives of people in Darfur, Palestine, South Central LA, or Basra? Does my purchase of a new refrigerator negatively impact some individual life somewhere in the world? What do my purchasing habits say about me? How does the sum of my actions define me in the larger scheme of things? Am I doing enough? Am I walking my talk? Where is my energy best spent? Am I more blinded by my priviledge than I can truly see?
I realize as I write that these are not necessarily the words of a person embracing a national holiday and paid day off with complete equanimity. I'm choosing to not live my life like a blind and ignorant bull in the china shop of the world. I want to acknowledge the paradoxes inherent in being a middle-class white American with full-time work, health insurance, my own home, and the luxury of time and material well-being. One must accept where one is, change that which one chooses to change, and live life according to a chosen path. I simply find it necessary to periodically examine that path, take stock of my position in the wider world, and determine if I'm truly living the life that I desire. Blindess is an option, but I choose today to re-open my eyes.
Friday, May 26, 2006
Attrition and Addition
Working in the same place for any number of years (five in my case), changes of personnel are to be expected. During my tenure in my current place of employ, we've survived a number of "goodbyes" to beloved staff-members, several programmatic and funding changes, and various other challenges which small non-profits must face as they grow and evolve. Today saw one of my closest friends from work take her leave. In fact, she is the only person from my work-place who I regularly socialize with outside of work, and her loss only began to truly hit me today. This particular person and I often go out of our way to offer one another hugs, kisses, and warm fellowship that can truly make a difference in the trajectory of a day gone haywire. Her absence beginning next week will be difficult to overcome quickly. With her not at her desk, it'll be like a smile missing a shining front tooth.
Just as I'm beginning to digest this particular co-worker's departure, celebrating her new chapter of life with a group dinner out on Wednesday and a cake and gifts today, yet another colleague announced her imminent departure in 14 days, followed by yet another whose departure date is set distantly for September. Just as our office is undergoing a major shift of responsibilities and practice coordination, some of the cogs are removing themselves from the wheel, and we will soon all be reeling from the effects of such personnel loss. Of course, we have lost many others over the years as well, living to tell the tale each time. But each time a member of the team leaves, worries surface that the new replacements won't "gel" as well, that the sense of family and connectedness will be undermined, that what we have worked so hard to create will feel different, less intimate, less cohesive. While I am generally one who welcomes change, stability in a stressful workplace is key to success and satisfaction, and each change which threatens stability does not necessarily bode well for the future.
On the bright side, someone of whom I am exceedingly fond and with whom I worked within another agency some ten years ago was just hired to join our team in a somewhat administrative capacity. We will not be sharing patients, per se, and she will not be directly involved in my day to day practice, but her presence in the office is a "good fit" and brings some fresh energy and ideas to the fray.
So, attrition and addition were foremost on my mind today, even as the calls and pages, unannounced visits and constant multi-tasking pummeled my tired brain and body. Now a long three-day weekend awaits, Friday night relief seeping into my bones like a nectar.
Just as I'm beginning to digest this particular co-worker's departure, celebrating her new chapter of life with a group dinner out on Wednesday and a cake and gifts today, yet another colleague announced her imminent departure in 14 days, followed by yet another whose departure date is set distantly for September. Just as our office is undergoing a major shift of responsibilities and practice coordination, some of the cogs are removing themselves from the wheel, and we will soon all be reeling from the effects of such personnel loss. Of course, we have lost many others over the years as well, living to tell the tale each time. But each time a member of the team leaves, worries surface that the new replacements won't "gel" as well, that the sense of family and connectedness will be undermined, that what we have worked so hard to create will feel different, less intimate, less cohesive. While I am generally one who welcomes change, stability in a stressful workplace is key to success and satisfaction, and each change which threatens stability does not necessarily bode well for the future.
On the bright side, someone of whom I am exceedingly fond and with whom I worked within another agency some ten years ago was just hired to join our team in a somewhat administrative capacity. We will not be sharing patients, per se, and she will not be directly involved in my day to day practice, but her presence in the office is a "good fit" and brings some fresh energy and ideas to the fray.
So, attrition and addition were foremost on my mind today, even as the calls and pages, unannounced visits and constant multi-tasking pummeled my tired brain and body. Now a long three-day weekend awaits, Friday night relief seeping into my bones like a nectar.
Wednesday, May 24, 2006
Private Hell
It was 9am and she reeked of alcohol. As I passed through the waiting room, she cornered me and launched into an unstoppable diatribe. Ducking into an exam room, I allowed her to vent and share her pain with me. "I relapsed last night. I drank with my boss, then I pawned my car for $70 and bought some cocaine. I can't take this anymore. I'm so alone." Her affect and obvious self-loathing were painful to behold, and though I had appointments pending and my beeper would not stop vibrating, I grabbed a Nurse Practitioner familiar with her and the three of us hunkered down for some straight talk. In the end, we got nowhere. She left without agreeing to detox or other treatment and a vague promise to call us later when she had gotten her car out of hock. (Suprisingly, she would actually call us later to report that she was OK. Thank God for small miracles.)
After she left, the NP and I looked at each other and shrugged our shoulders, giving in to the notion that we were powerless to change her life, powerless to keep her with us when she didn't want to be kept, and frustrated that so many people live in such isolated and private purgatories.
Other personal purgatories revealed themselves to me today as well, as they do most every day. We are witnesses to suffering, as I have said before, and it is not our job to fix, to repair, to alter the course of others' lives by sheer power of will. There are forces at work much larger than us against which we have little transformative power. The best we can do is open doors and illuminate pathways, cajoling and teasing our patients towards different choices and better alternatives.
Coming back to my small town with good schools, excellent infrastructure, and tax dollars hard at work for the benefit of middle- and upper-middle class families, I realize that I can't change the dynamics and machinations of inner city life. There are slum lords, corrupt officials, drug dealers, gangs, organized crime, institutional racism and economic apartheid which all contribute to the plight of the poor. It is all of our responsibility to turn that tide, but in the course of a day slogging through the swamps of chronic illness, poverty, and lives of desperation---be that desperation quiet or not---I at times lose sight of the benefit which my therapeutic interventions may have.
At times, I wish that I was one of those movers and shakers who takes on the system, challenges the status quo, and creates a new society from the ashes of the old. Alas, I am not so much of a leader, opting instead to do my work in the quiet of one-to-one interaction and therapeutic relationship, in the hopes that my work will have some small impact while others with a larger grasp of the global issues work to undermine the foundations of the larger framework which only serves to further oppress the oppressed.
Please forgive this rant. It is just a tip of the iceberg of the rage and sadness felt while witnessing first-hand the misery of those living in the belly of the beast---urban America.
After she left, the NP and I looked at each other and shrugged our shoulders, giving in to the notion that we were powerless to change her life, powerless to keep her with us when she didn't want to be kept, and frustrated that so many people live in such isolated and private purgatories.
Other personal purgatories revealed themselves to me today as well, as they do most every day. We are witnesses to suffering, as I have said before, and it is not our job to fix, to repair, to alter the course of others' lives by sheer power of will. There are forces at work much larger than us against which we have little transformative power. The best we can do is open doors and illuminate pathways, cajoling and teasing our patients towards different choices and better alternatives.
Coming back to my small town with good schools, excellent infrastructure, and tax dollars hard at work for the benefit of middle- and upper-middle class families, I realize that I can't change the dynamics and machinations of inner city life. There are slum lords, corrupt officials, drug dealers, gangs, organized crime, institutional racism and economic apartheid which all contribute to the plight of the poor. It is all of our responsibility to turn that tide, but in the course of a day slogging through the swamps of chronic illness, poverty, and lives of desperation---be that desperation quiet or not---I at times lose sight of the benefit which my therapeutic interventions may have.
At times, I wish that I was one of those movers and shakers who takes on the system, challenges the status quo, and creates a new society from the ashes of the old. Alas, I am not so much of a leader, opting instead to do my work in the quiet of one-to-one interaction and therapeutic relationship, in the hopes that my work will have some small impact while others with a larger grasp of the global issues work to undermine the foundations of the larger framework which only serves to further oppress the oppressed.
Please forgive this rant. It is just a tip of the iceberg of the rage and sadness felt while witnessing first-hand the misery of those living in the belly of the beast---urban America.
Tuesday, May 16, 2006
Grand Rounds Comes Around----Again
Here's the current edition of Grand Rounds, up and running at Doc Around the Clock, featuring links to articles by yours truly and countless excellent healthcare bloggers from around the world. Again. Never a dull moment.
Saturday, May 13, 2006
A Letter to My Students on the Occasion of Their Final Exam
To The Students of the 2005-2006 Evening LPN Program,
Well, folks, here we are at the end of our nine months together, and I am truly sad to see you go. You’ve been a great class, and I’ve learned a great deal from all of you. As was said by some famous person, the roles of student and teacher are often reversed.
I wish I could affirmatively say that I have sufficiently prepared you all for the NCLEX, covering every detail that might confront you when you sit in front of that dreaded computer screen, but alas, it’s not my place to say whether you’re prepared or not, nor can I affirm that we did all that we needed to do. The fact is, we covered a great deal of ground but could never do it all in nine months no matter how hard we tried. It will now be up to each of you to prepare for that last major hurdle before you can officially enter the nursing profession.
That said, I want to leave you here with a few pieces of advice.
Practice
Nursing is called a “practice” because, in my opinion, it takes constant practice to be the best nurse you can be from day to day. As your practice develops, you need to be continually willing to learn and grow---both professionally and personally---or you’ll stagnate. Continuing education credits are something that many of us dread fulfilling, but continuing education is crucial to staying abreast of what’s new and different out there in the world. Medicine is constantly changing and evolving, and we need to evolve with it if we want to be up to date and savvy in our work. So, to that end, be interested in learning. When something doesn’t make sense, look it up, ask someone, or try to discover more about it. Let your curiosity lead you to always learn just a little more. It’s the exceptional nurse who’s willing to ask why and then find the answer.
Technology
I can’t emphasize enough that you must continue to increase your comfort with technology. By this I mean computers, the Internet, search engines, email, chat rooms, blogs, databases, spreadsheets, on-line research, on-line journals, etcetera. Many hospitals (and maybe nursing homes, as well) now employ laptop computers on wheels that the nurses must use for orders, notes, and other documentation. Some facilities are moving in the direction of electronic medical records (EMRs) and you have to be ready to deal with this reality. If you’re already skilled and comfortable with some forms of technology, include this on your resume under the heading of “Skills”. Potential employers want to know who can sit down at a computer and need only a little coaching to get started. If you have the ability to take some computer classes at MCDI or another school, take advantage of that opportunity as soon as possible. You can mark my words that being conversant with technology will only increase your ability to find a job you like, the caveat (remember that one, Lindsay?) being that lack of understanding of such information can be a professional liability.
There are many places on the Internet for nurses to surf for information and I want to point you in the right direction. As I may have mentioned in class, if you need to find something out about anything, go to Google and simply type in what you’re looking for. I use it daily and have rarely been disappointed.
Medscape is a great free resource on the Web, and I recommend that each of you sign up. Just go to www.medscape.com/nurseshome. You can create an account and then come back as often as you like to look for articles, support, links to other sites, and updated information, as well as conferences and on-line CEUs. You can sign up for various Medscape email updates, or you can just check the site at your leisure.
Other sites of interest:
www.allnurses.com General nursing site
www.globeofblogs.com A blog registry site. Find blogs on nursing or anything
www.blogger.com A great way to start your own blog.
www.digitaldoorway.blogspot.com: my blog where I mostly write about my work, and link to many other medical and nursing blogs of great interest and variety.
Professionally-speaking
I recommend you collect letters of recommendation from anyone you work with that would be willing to write one for you. Keep a file of these, and also ask those individuals if they’ll serve as references for you when you apply for jobs down the road. Also, keep an updated resume on your computer at all times, changing it as necessary depending on the job you’re applying for. After you accumulate more experience, you can have several versions of your resume on hand and you can target them towards different types of facilities.
Once you have some experience under your belt, start to look around and find out what facilities and agencies are hiring LPNs. Dialysis units, doctors’ offices, schools, some VNAs---there are many places open to hiring LPNs. I know for a fact that ____________will hire skilled LPNs for their HIV/Mental Health, Pedi, and MedSurg teams. This is something to look forward to.
I know most of you would rather not think about it, but furthering your education is also something that you can consider. Being an LPN is great, but if you want to broaden the scope of your practice, consider eventually becoming an RN, if not a BSN. While it of course involves more loans, more studying, more sacrifice, and lots of work, it also involves greater ability to pick and choose your work environment, as well as larger paychecks. It is only food for thought, but definitely worth considering.
Nurses Eat Their Young
You may have all heard the phrase, “Nurses Eat Their Young”, and I have heard a few stories from some of you who already have experienced the callousness and rigidity of some of those nurses out there. No matter how poorly you might be treated by some of those seasoned nurses, be careful to not repeat history when it’s your turn to mentor someone new. I always try to be exceedingly kind and helpful to nursing students, because I remember that “there but for the grace of God go I”. It was not long ago that I was in the same boat, and it’s no fun when all you want to do is learn to do your job and someone seems to go out of their way to make you miserable while you try. If we each decide to break that cycle, many more novice nurses will stay in the profession and pass that kindness along to the next generation.
The Future
As your teacher, I feel a responsibility to be available to you if you do indeed need a letter, some advice, or another form of support over the next few years. Since I don’t plan to continue teaching at ________at this time, below is an email where you can reach me.
You have all done a courageous thing, and I am so impressed that you have done it. Between raising children, owning and renting homes, working 11-7, maintaining family obligations, getting ready to have a baby, or saying goodbye to your parents and loved ones, you have all undertaken a huge task and should be very proud of yourselves.
Congratulations, good luck, and please keep in touch as you enter the world of nursing. I look forward to hearing about your successes and challenges, and will entertain any questions you have along the way.
Respectfully,
Keith Carlson, RN, BS
nursekeith@gmail.com
http://www.digitaldoorway.blogspot.com
Well, folks, here we are at the end of our nine months together, and I am truly sad to see you go. You’ve been a great class, and I’ve learned a great deal from all of you. As was said by some famous person, the roles of student and teacher are often reversed.
I wish I could affirmatively say that I have sufficiently prepared you all for the NCLEX, covering every detail that might confront you when you sit in front of that dreaded computer screen, but alas, it’s not my place to say whether you’re prepared or not, nor can I affirm that we did all that we needed to do. The fact is, we covered a great deal of ground but could never do it all in nine months no matter how hard we tried. It will now be up to each of you to prepare for that last major hurdle before you can officially enter the nursing profession.
That said, I want to leave you here with a few pieces of advice.
Practice
Nursing is called a “practice” because, in my opinion, it takes constant practice to be the best nurse you can be from day to day. As your practice develops, you need to be continually willing to learn and grow---both professionally and personally---or you’ll stagnate. Continuing education credits are something that many of us dread fulfilling, but continuing education is crucial to staying abreast of what’s new and different out there in the world. Medicine is constantly changing and evolving, and we need to evolve with it if we want to be up to date and savvy in our work. So, to that end, be interested in learning. When something doesn’t make sense, look it up, ask someone, or try to discover more about it. Let your curiosity lead you to always learn just a little more. It’s the exceptional nurse who’s willing to ask why and then find the answer.
Technology
I can’t emphasize enough that you must continue to increase your comfort with technology. By this I mean computers, the Internet, search engines, email, chat rooms, blogs, databases, spreadsheets, on-line research, on-line journals, etcetera. Many hospitals (and maybe nursing homes, as well) now employ laptop computers on wheels that the nurses must use for orders, notes, and other documentation. Some facilities are moving in the direction of electronic medical records (EMRs) and you have to be ready to deal with this reality. If you’re already skilled and comfortable with some forms of technology, include this on your resume under the heading of “Skills”. Potential employers want to know who can sit down at a computer and need only a little coaching to get started. If you have the ability to take some computer classes at MCDI or another school, take advantage of that opportunity as soon as possible. You can mark my words that being conversant with technology will only increase your ability to find a job you like, the caveat (remember that one, Lindsay?) being that lack of understanding of such information can be a professional liability.
There are many places on the Internet for nurses to surf for information and I want to point you in the right direction. As I may have mentioned in class, if you need to find something out about anything, go to Google and simply type in what you’re looking for. I use it daily and have rarely been disappointed.
Medscape is a great free resource on the Web, and I recommend that each of you sign up. Just go to www.medscape.com/nurseshome. You can create an account and then come back as often as you like to look for articles, support, links to other sites, and updated information, as well as conferences and on-line CEUs. You can sign up for various Medscape email updates, or you can just check the site at your leisure.
Other sites of interest:
www.allnurses.com General nursing site
www.globeofblogs.com A blog registry site. Find blogs on nursing or anything
www.blogger.com A great way to start your own blog.
www.digitaldoorway.blogspot.com: my blog where I mostly write about my work, and link to many other medical and nursing blogs of great interest and variety.
Professionally-speaking
I recommend you collect letters of recommendation from anyone you work with that would be willing to write one for you. Keep a file of these, and also ask those individuals if they’ll serve as references for you when you apply for jobs down the road. Also, keep an updated resume on your computer at all times, changing it as necessary depending on the job you’re applying for. After you accumulate more experience, you can have several versions of your resume on hand and you can target them towards different types of facilities.
Once you have some experience under your belt, start to look around and find out what facilities and agencies are hiring LPNs. Dialysis units, doctors’ offices, schools, some VNAs---there are many places open to hiring LPNs. I know for a fact that ____________will hire skilled LPNs for their HIV/Mental Health, Pedi, and MedSurg teams. This is something to look forward to.
I know most of you would rather not think about it, but furthering your education is also something that you can consider. Being an LPN is great, but if you want to broaden the scope of your practice, consider eventually becoming an RN, if not a BSN. While it of course involves more loans, more studying, more sacrifice, and lots of work, it also involves greater ability to pick and choose your work environment, as well as larger paychecks. It is only food for thought, but definitely worth considering.
Nurses Eat Their Young
You may have all heard the phrase, “Nurses Eat Their Young”, and I have heard a few stories from some of you who already have experienced the callousness and rigidity of some of those nurses out there. No matter how poorly you might be treated by some of those seasoned nurses, be careful to not repeat history when it’s your turn to mentor someone new. I always try to be exceedingly kind and helpful to nursing students, because I remember that “there but for the grace of God go I”. It was not long ago that I was in the same boat, and it’s no fun when all you want to do is learn to do your job and someone seems to go out of their way to make you miserable while you try. If we each decide to break that cycle, many more novice nurses will stay in the profession and pass that kindness along to the next generation.
The Future
As your teacher, I feel a responsibility to be available to you if you do indeed need a letter, some advice, or another form of support over the next few years. Since I don’t plan to continue teaching at ________at this time, below is an email where you can reach me.
You have all done a courageous thing, and I am so impressed that you have done it. Between raising children, owning and renting homes, working 11-7, maintaining family obligations, getting ready to have a baby, or saying goodbye to your parents and loved ones, you have all undertaken a huge task and should be very proud of yourselves.
Congratulations, good luck, and please keep in touch as you enter the world of nursing. I look forward to hearing about your successes and challenges, and will entertain any questions you have along the way.
Respectfully,
Keith Carlson, RN, BS
nursekeith@gmail.com
http://www.digitaldoorway.blogspot.com
Friday, May 12, 2006
From ICU to Fishnet Stockings
Today I paid a nursing home visit to my morbidly obese patient with COPD and asthma who was only a month ago intubated in ICU with a recalcitrant asthma exacerbation. Obese, asthmatic, agoraphobic, diabetic, depressed and anxious, she is generally stuck in her dusty bedroom which reeks of urine, unable to summon the strength of will and body to do much else. Several of her children are now on the same self-limiting path, and she blames herself for not empowering them to take charge of their lives. She knows that she has clung to them too rabidly, just as her parents did to her in Puerto Rico. But alas, the cycle continues, and now several of her grandchildren are demonstrating the same pattern. Nature or nurture?
I had not seen her for nine days. The last time I came to this nursing home, she had just been transferred from the hospital to this facility for some reconditioning and rehabilitation. After four weeks in the hospital---one of which was in ICU---she needed some time to gain back some strength. Today, two days before Mother's Day, I find her in her room with three of her daughters. They have brought all of her jewelry for their mother to select from, and I see my patient---all 375 pounds of her---perched on the edge of her bed. She is smiling, bedecked in pointy brown leather shoes, fishnet stockings, a skirt, a low-cut blouse, several gaudy necklaces, earrings, and a hat on her head at a jaunty angle. She beams at me as her daughters argue over some jewelry.
"Girls, muchachas---I'm not dead yet! That's MY jewelry anyway!"
The women continue their good-natured dispute, one daughter pocketing a key-ring she'd been eyeing.
"I'm not getting involved in this family argument, " I say, taking my place near the window.
We chat, and when questioned, my patient tells me that there's a Friday afternoon concert at 2pm downstairs, and she wanted to look nice for the occasion. With most of the residents of this home 20-30 years her senior and confined to wheelchairs in the hallway, my patient looks like she's from another world. And indeed she is. An enormous Latina woman relegated to this facility of mostly white elders with various diseases of the aged, she is out of place, I must admit. There just don't seem to be any rehab facilities specifically for the younger set. Not much money in it, I guess.
As we talk some more, her daughter admonishes my patient for talking to me from under the visor of her hat with her eyes hidden from my view the whole time. She tips the hat back and smiles sheepishly.
I wish her a fun time at the concert, a lovely Mother's Day with family visiting her with homemade Puerto Rican food on Sunday, and I promise to stop by every week until she comes home. She thanks me, her daughters turn back to the jewelry, and I make my way back down the hall among the maze of dazed-looking residents parked along the walls in their wheelchairs. I picture my aging parents in such a place and cringe. The ubiquitous smell of urine and feces is a reminder of where I am.
Outside, the rain pours down, and I open my umbrella for the dash to the car. A few more home visits and then back to the office. Another day in the life.....
I had not seen her for nine days. The last time I came to this nursing home, she had just been transferred from the hospital to this facility for some reconditioning and rehabilitation. After four weeks in the hospital---one of which was in ICU---she needed some time to gain back some strength. Today, two days before Mother's Day, I find her in her room with three of her daughters. They have brought all of her jewelry for their mother to select from, and I see my patient---all 375 pounds of her---perched on the edge of her bed. She is smiling, bedecked in pointy brown leather shoes, fishnet stockings, a skirt, a low-cut blouse, several gaudy necklaces, earrings, and a hat on her head at a jaunty angle. She beams at me as her daughters argue over some jewelry.
"Girls, muchachas---I'm not dead yet! That's MY jewelry anyway!"
The women continue their good-natured dispute, one daughter pocketing a key-ring she'd been eyeing.
"I'm not getting involved in this family argument, " I say, taking my place near the window.
We chat, and when questioned, my patient tells me that there's a Friday afternoon concert at 2pm downstairs, and she wanted to look nice for the occasion. With most of the residents of this home 20-30 years her senior and confined to wheelchairs in the hallway, my patient looks like she's from another world. And indeed she is. An enormous Latina woman relegated to this facility of mostly white elders with various diseases of the aged, she is out of place, I must admit. There just don't seem to be any rehab facilities specifically for the younger set. Not much money in it, I guess.
As we talk some more, her daughter admonishes my patient for talking to me from under the visor of her hat with her eyes hidden from my view the whole time. She tips the hat back and smiles sheepishly.
I wish her a fun time at the concert, a lovely Mother's Day with family visiting her with homemade Puerto Rican food on Sunday, and I promise to stop by every week until she comes home. She thanks me, her daughters turn back to the jewelry, and I make my way back down the hall among the maze of dazed-looking residents parked along the walls in their wheelchairs. I picture my aging parents in such a place and cringe. The ubiquitous smell of urine and feces is a reminder of where I am.
Outside, the rain pours down, and I open my umbrella for the dash to the car. A few more home visits and then back to the office. Another day in the life.....
Thursday, May 11, 2006
GR, v. 2, n. 33
Yet another excellent edition of Grand Rounds is now up at Aetiology. Stop by for a perusal of this week's offerings......
Tuesday, May 09, 2006
Gems
Today I attended a workshop/conference on Spirituality and Healing with a very famous keynote speaker (who shall remain nameless in order to preserve the relative geographic anonymity of this site). Individual small-group workshops focused on mindfulness meditation, walking meditation, drumming, aromatherapy, acupuncture, and various other modalities and perspectives on healing.
That said, this conference fed my soul like no other has in some time. Aside from the keynote speaker (the main attraction for my attending in the first place), this experience renewed my sense that there are countless healthcare professionals out there who are willing to put time and energy into personal growth, as well as the spiritual needs of their patients. While the majority of the attendees were nurses, there was adequate representation by pastoral counselors and social workers, as well as a smattering of occupational and physical therapists, a recreation therapist for seniors, and a small cadre of open-minded and interesting physicians. The main speaker explored some very cogent ideas related to spirituality, care of the psyche of the patient and caregiver, as well as the more ancient underpinnings of the roots of some modern medical and psychiatric practices.
To wit, I learned that the etymological roots of the word psychotherapy lead us to understand that "psycho" means "psyche" which in the original Greek meant "soul", and "therapy" comes from the ancient Greek word "theros" meaning "nurse". Hence psychotherapy actually means literally "to nurse the soul".
I also learned that Heraclitus said that "you can never discover the limits of the soul, no matter how many roads you take, so deep is its mystery." This one is worthy of further exploration, perhaps in a future post. This led to a discussion centered around the notion that while "spirit" speaks of things of a higher nature, as in spirituality, the intellect, and connection to a higher source beyond the earth, "soul" traditionally refers more to things closer to earth---or actually in the depths. While spirit gives us our connection to the greater and larger, soul gives us our connection to the internal, the underworld, the underbelly of the self. They don't say "dark night of the soul" for nothing......
Other ideas which were floated:
How does it feel when we walk into a clinic or hospital? What are the textures and colors like? Is it inviting? Are the artistic depictions of humans normal and colorful and full of life, or are the exam rooms filled with pictures of diseased organs and flayed bodies showing everything that could be wrong with one's internal organs? Do we have flowers in the exam room or little plastic models of disembodied kidneys? Is the waiting room like a living room or a bus station? How do we make our healthcare facilities more healthy and inviting, more nurturing of the soul and spirit, more restful?
Finally, one of the best quotes of the day came from a participant who shared a story of a patient who approached the dying process with great humor, aplomb, and dignity. He had said one day, "I've never seen a hearse pulling a U-Haul." That one really gave me pause and perhaps will be fodder for a future post as well. Gives new meaning to the phrase, "you can't take it with you."
All in all, a nurturing day of reinvigoration and release. Gratitude all around.
That said, this conference fed my soul like no other has in some time. Aside from the keynote speaker (the main attraction for my attending in the first place), this experience renewed my sense that there are countless healthcare professionals out there who are willing to put time and energy into personal growth, as well as the spiritual needs of their patients. While the majority of the attendees were nurses, there was adequate representation by pastoral counselors and social workers, as well as a smattering of occupational and physical therapists, a recreation therapist for seniors, and a small cadre of open-minded and interesting physicians. The main speaker explored some very cogent ideas related to spirituality, care of the psyche of the patient and caregiver, as well as the more ancient underpinnings of the roots of some modern medical and psychiatric practices.
To wit, I learned that the etymological roots of the word psychotherapy lead us to understand that "psycho" means "psyche" which in the original Greek meant "soul", and "therapy" comes from the ancient Greek word "theros" meaning "nurse". Hence psychotherapy actually means literally "to nurse the soul".
I also learned that Heraclitus said that "you can never discover the limits of the soul, no matter how many roads you take, so deep is its mystery." This one is worthy of further exploration, perhaps in a future post. This led to a discussion centered around the notion that while "spirit" speaks of things of a higher nature, as in spirituality, the intellect, and connection to a higher source beyond the earth, "soul" traditionally refers more to things closer to earth---or actually in the depths. While spirit gives us our connection to the greater and larger, soul gives us our connection to the internal, the underworld, the underbelly of the self. They don't say "dark night of the soul" for nothing......
Other ideas which were floated:
How does it feel when we walk into a clinic or hospital? What are the textures and colors like? Is it inviting? Are the artistic depictions of humans normal and colorful and full of life, or are the exam rooms filled with pictures of diseased organs and flayed bodies showing everything that could be wrong with one's internal organs? Do we have flowers in the exam room or little plastic models of disembodied kidneys? Is the waiting room like a living room or a bus station? How do we make our healthcare facilities more healthy and inviting, more nurturing of the soul and spirit, more restful?
Finally, one of the best quotes of the day came from a participant who shared a story of a patient who approached the dying process with great humor, aplomb, and dignity. He had said one day, "I've never seen a hearse pulling a U-Haul." That one really gave me pause and perhaps will be fodder for a future post as well. Gives new meaning to the phrase, "you can't take it with you."
All in all, a nurturing day of reinvigoration and release. Gratitude all around.
Monday, May 08, 2006
Cities, Violence, and Loss
Yet another shock was delivered to us today, just several weeks after one of our colleagues at a neighboring agency was caught in the crossfire of a gang-related shooting. It seems an elderly patient of ours and her husband were murdered during a break-in at their apartment. Apparently, the intruder forced his way in as the husband was leaving the apartment. Our patient was killed as she lay in her hospital bed. I cannot elucidate any more, but it's another shocking reminder that we work in a city where random violence and senseless brutality are still rather commonplace. Many of my colleagues also live in this city, while I and several others escape each night and return to our homes in much more relatively sedate and characteristically quiet New England towns. "Escape" takes on a new meaning in this context.
There's a scene in My Dinner With Andre---one of my favorite films of all time---in which the main character describes for his dinner companion his vision of New York City. He describes a city which is in fact an ersatz prison in which the citizens were originally the inmates but eventually became their own guards, holding the keys to their own freedom but blindly perpetuating their own misery and isolation. Does the fate of such troubled cities indeed rest in its citizens' hands, and does the power to alter the fate of the inhabitants actually reside in the streets and homes and businesses which make up that urban conglomeration of people and lives?
This little city where I ply my trade is riddled with corruption, violence, cronyism and poor management on most every level. Drugs and gangs seem to rule the streets, the police and city hall fighting a losing battle against the perpetual tide. The saddest part of this brutal equation are the innocent lives which are shattered, literally caught in the crossfire, taken out in the heat of the moment, murdered for a pittance.
Where is the power to change? Where does it reside? In whom does the responsibility rest? Can cities such as ours turn themselves around, and if so, what will it take?
We grieve for the family of the murdered elderly couple, bereft of their parents and grandparents, who lived quiet and humble lives in a city they called home. May their souls rest in peace, and may their grieving family members eventually find healing and solace.
There's a scene in My Dinner With Andre---one of my favorite films of all time---in which the main character describes for his dinner companion his vision of New York City. He describes a city which is in fact an ersatz prison in which the citizens were originally the inmates but eventually became their own guards, holding the keys to their own freedom but blindly perpetuating their own misery and isolation. Does the fate of such troubled cities indeed rest in its citizens' hands, and does the power to alter the fate of the inhabitants actually reside in the streets and homes and businesses which make up that urban conglomeration of people and lives?
This little city where I ply my trade is riddled with corruption, violence, cronyism and poor management on most every level. Drugs and gangs seem to rule the streets, the police and city hall fighting a losing battle against the perpetual tide. The saddest part of this brutal equation are the innocent lives which are shattered, literally caught in the crossfire, taken out in the heat of the moment, murdered for a pittance.
Where is the power to change? Where does it reside? In whom does the responsibility rest? Can cities such as ours turn themselves around, and if so, what will it take?
We grieve for the family of the murdered elderly couple, bereft of their parents and grandparents, who lived quiet and humble lives in a city they called home. May their souls rest in peace, and may their grieving family members eventually find healing and solace.
Sunday, May 07, 2006
Winding Up, Winding Down
The weekend winds down, and I begin to wind myself up for the week ahead. I accomplished a great deal this weekend, including having a nice nap each day in the hammock. Time well spent.
This week marks the end of my current teaching career. I must say, no matter how much I love my students---and I do---it will be a sweet relief to no longer have exams, lectures, overheads, power-points, and other detritus to deal with all year. I truly love the act of teaching---the moments of laughter, of watching a student "get" something crucial, the crystallizing ideas coalescing in understanding and synthesis---it is very gratifying. But on top of a full-time job that demands such energy and commitment, teaching has been a psychic burden which I am ready to shed.
Beyond the mechanics of teaching, and the preparation and responsibility involved, I have always found nursing school to be somewhat deadening. The rote memorization, the need to teach towards the licensing exam---it all makes the process less alive for me. Grading students on their performance on multiple-choice tests is a frustrating but necessary evil which sometimes precludes the desire to spend time delving deeper into issues which cannot be addressed on such standardized exams.
In my teaching, I try to impart my excitement, my fascination, my sense of justice and socioeconomic equality, my commitment. I try to use stories, scenarios, and anecdotes to illustrate the reality of patient-provider interactions and the mystery and subtlety of such relationships. Sadly, the reams of information needing to be reviewed and lectured upon often precludes such non-linear teaching, keeping us information-oriented, away from the realm of feelings and relationships. This is a hole in nursing education, and area which I think is often overlooked in the interest of the "harder" scientific aspects of nursing.
I will honestly miss teaching, but I'll be sure to find opportunities for teaching which do not necessitate my standing in a classroom and talking until my throat is hoarse. In my mind, there are many changes needed in nursing education which I will not address in this forum, but I recognize that there are areas sorely lacking and in need of attention, especially on the comunity college level. Some day, perhaps, as a retired nurse, I'll return to academia and give it my all, acting as a change agent to reinvigorate the education of nurses. For now, I will gracefully bow out of that world, and leave the teaching to others more comfortable with the process than me.
This week marks the end of my current teaching career. I must say, no matter how much I love my students---and I do---it will be a sweet relief to no longer have exams, lectures, overheads, power-points, and other detritus to deal with all year. I truly love the act of teaching---the moments of laughter, of watching a student "get" something crucial, the crystallizing ideas coalescing in understanding and synthesis---it is very gratifying. But on top of a full-time job that demands such energy and commitment, teaching has been a psychic burden which I am ready to shed.
Beyond the mechanics of teaching, and the preparation and responsibility involved, I have always found nursing school to be somewhat deadening. The rote memorization, the need to teach towards the licensing exam---it all makes the process less alive for me. Grading students on their performance on multiple-choice tests is a frustrating but necessary evil which sometimes precludes the desire to spend time delving deeper into issues which cannot be addressed on such standardized exams.
In my teaching, I try to impart my excitement, my fascination, my sense of justice and socioeconomic equality, my commitment. I try to use stories, scenarios, and anecdotes to illustrate the reality of patient-provider interactions and the mystery and subtlety of such relationships. Sadly, the reams of information needing to be reviewed and lectured upon often precludes such non-linear teaching, keeping us information-oriented, away from the realm of feelings and relationships. This is a hole in nursing education, and area which I think is often overlooked in the interest of the "harder" scientific aspects of nursing.
I will honestly miss teaching, but I'll be sure to find opportunities for teaching which do not necessitate my standing in a classroom and talking until my throat is hoarse. In my mind, there are many changes needed in nursing education which I will not address in this forum, but I recognize that there are areas sorely lacking and in need of attention, especially on the comunity college level. Some day, perhaps, as a retired nurse, I'll return to academia and give it my all, acting as a change agent to reinvigorate the education of nurses. For now, I will gracefully bow out of that world, and leave the teaching to others more comfortable with the process than me.
Wednesday, May 03, 2006
Home
She's going home. As her body is consumed by cancer, weight loss, advanced AIDS, and debilitating illness, her only desire is to return to Puerto Rico. With the cancer treatment done and no further hope of stemming the tide of rapidly reproducing cells to any helpful degree, there is nothing more to do but look for comfort, succor, spiritual nurturance, and the respite of the family's warm embrace.
Laying on her bed in a slowly emptying apartment---she's selling everything she owns in preparation for the journey---she looks more and more wasted and wan each time I visit. Although the visiting nurses come twice a day, I'm shocked that they haven't noticed the reddened areas on the iliac crests, a sure sign that skin breakdown and bed-sores are on the way without intervention. I also notice that the inside bony prominences of the knees are very red--she is laying on her side with knees together almost all day and night. I instruct her to put a pillow or folded towel between her knees at all times when in bed. I'm disappointed the VNA didn't catch these subtle but crucial changes.
She shares that she hasn't taken her antiretrovirals (the meds used to control HIV) for a week because she vomits whatever she puts in her stomach. I plan to order meds for these symptoms within the hour after a quick call to my NP colleague. We speak of other symptoms, I take notes, and the HIV case manager who I brought along probes more deeply for answers which I think may be more forthcoming in the presence of this other compassionate professional that she has known since first arriving here.
While she doesn't speak of depression per se, this is a spiritual crisis of huge proportions, and it is clear that faith and the power of the mind are hard at work. This individual may have only completed the fourth grade, but there is a depth of soul and spiritual wisdom that far outweighs any intellectual capacity which might be lacking.
We discuss more concrete issues and plans, medications, symptoms, egg-crate mattresses, bed-sores, diabetes, and the need for Ensure and vitamins. We make some decisions, look forward to some changes which may alleviate some discomfort, and prepare for a day in the near future when she will leave this lonely apartment behind and return to her hometown. The sirens, the jackhammers of the construction crews, the smell of exhaust through the open windows, the long winters, they will all be a thing of the past, a figment of memory. She will stay with her sister, her brother and father down the street, cousins and other extended family nearby. Perhaps these five years in New England will then seem like a dream, an extended journey which perhaps occurred on some other plane of existence. Perhaps when she hears those familiar tropical sounds---the birds, frogs, and insects of her beloved island---and smells the soil, air, ocean breeze and rich home cooking---it will be like returning to the womb, to the culture and land which cradled her from birth to adulthood.
I regret not setting more services in place sooner, but each week I add yet something more in order to assuage suffering or alleviate symptoms. Since she is too weak to go to the doctor lately, it feels like I'm running the show, bringing reports to the primary physician after each of my home visits, making recommendations, and getting a green light on most every suggestion I make. This is where my role is crucial. This is also where the stakes are higher and my errors of judgement or lack of action could have dire consequences.
My goal is to keep her healthy enough to make the trip, leave this odd New England world behind, and melt back into the comfort and familiarity of home and family. Gods, goddesses and angels of comfort and healing whose very existence I often question, bless these ensuing weeks and allow safe passage for this dear soul, and guide me well in my actions. If home is where the heart is, then bring this child where her heart longs to be.
Laying on her bed in a slowly emptying apartment---she's selling everything she owns in preparation for the journey---she looks more and more wasted and wan each time I visit. Although the visiting nurses come twice a day, I'm shocked that they haven't noticed the reddened areas on the iliac crests, a sure sign that skin breakdown and bed-sores are on the way without intervention. I also notice that the inside bony prominences of the knees are very red--she is laying on her side with knees together almost all day and night. I instruct her to put a pillow or folded towel between her knees at all times when in bed. I'm disappointed the VNA didn't catch these subtle but crucial changes.
She shares that she hasn't taken her antiretrovirals (the meds used to control HIV) for a week because she vomits whatever she puts in her stomach. I plan to order meds for these symptoms within the hour after a quick call to my NP colleague. We speak of other symptoms, I take notes, and the HIV case manager who I brought along probes more deeply for answers which I think may be more forthcoming in the presence of this other compassionate professional that she has known since first arriving here.
While she doesn't speak of depression per se, this is a spiritual crisis of huge proportions, and it is clear that faith and the power of the mind are hard at work. This individual may have only completed the fourth grade, but there is a depth of soul and spiritual wisdom that far outweighs any intellectual capacity which might be lacking.
We discuss more concrete issues and plans, medications, symptoms, egg-crate mattresses, bed-sores, diabetes, and the need for Ensure and vitamins. We make some decisions, look forward to some changes which may alleviate some discomfort, and prepare for a day in the near future when she will leave this lonely apartment behind and return to her hometown. The sirens, the jackhammers of the construction crews, the smell of exhaust through the open windows, the long winters, they will all be a thing of the past, a figment of memory. She will stay with her sister, her brother and father down the street, cousins and other extended family nearby. Perhaps these five years in New England will then seem like a dream, an extended journey which perhaps occurred on some other plane of existence. Perhaps when she hears those familiar tropical sounds---the birds, frogs, and insects of her beloved island---and smells the soil, air, ocean breeze and rich home cooking---it will be like returning to the womb, to the culture and land which cradled her from birth to adulthood.
I regret not setting more services in place sooner, but each week I add yet something more in order to assuage suffering or alleviate symptoms. Since she is too weak to go to the doctor lately, it feels like I'm running the show, bringing reports to the primary physician after each of my home visits, making recommendations, and getting a green light on most every suggestion I make. This is where my role is crucial. This is also where the stakes are higher and my errors of judgement or lack of action could have dire consequences.
My goal is to keep her healthy enough to make the trip, leave this odd New England world behind, and melt back into the comfort and familiarity of home and family. Gods, goddesses and angels of comfort and healing whose very existence I often question, bless these ensuing weeks and allow safe passage for this dear soul, and guide me well in my actions. If home is where the heart is, then bring this child where her heart longs to be.
Tuesday, May 02, 2006
Grand Rounds Again
Since you're here, I will direct you to the latest edition of Grand Rounds, the always entertaining and informative blog carnival dedicated to all things related to the worlds of medicine, health, nursing, healthcare, and all permutations therein.
Monday, May 01, 2006
What Price Efficiency?
As I went about my day today, I noticed the plethora of tasks and errands which I accomplished. While I marvelled in a way at what I had done, it led me to wonder what price one pays for such a high level of activity and obsessive-compulsive action.
In the course of my day, I checked email; answered calls; visited a dying patient at home and counseled his wife on the need to now decrease fluids and nutrition in the interest of comfort (more on that perhaps tomorrow); visited a patient in a nursing home; picked up flowers and coffee and chocolate for Mary on her first day of her new job, then picked up seven orders of falafel for Mary and coworkers at a downtown restaurant. After lunch, I sat in on a visit with a patient and a doc who was unfamiliar with her, sent some faxes, made calls, met with my boss, wrote my notes, and then tied up the loose ends of the workday in preparation for teaching from 6:30-9:30. Between 5 and 6pm, I sat at my desk and finished writing an exam for tomorrow's class, emailed it to the college for xeroxing and had a snack before driving up to the college to teach. The came a few hours of lecturing on HIV which I actually really enjoyed. Phew.
On the way home I called my mother from my cell phone, then debriefed with Mary about our days while giving Sparkey his meds, packing my bag for the gym tomorrow morning, loading Mary's car with some things for her new office, taking a bath with Mary, then giving Sparkey his IV fluids. Phew again.
Now I am finally in bed and letting my thoughts flow as I wonder indeed what price I pay for trying to do so much.
Living a full life? Agreed.
Enough leisure time? Almost never.
Chronic pain and fatigue? Often.
Does something have to change in this picture? The answer seems easy enough.
In the course of my day, I checked email; answered calls; visited a dying patient at home and counseled his wife on the need to now decrease fluids and nutrition in the interest of comfort (more on that perhaps tomorrow); visited a patient in a nursing home; picked up flowers and coffee and chocolate for Mary on her first day of her new job, then picked up seven orders of falafel for Mary and coworkers at a downtown restaurant. After lunch, I sat in on a visit with a patient and a doc who was unfamiliar with her, sent some faxes, made calls, met with my boss, wrote my notes, and then tied up the loose ends of the workday in preparation for teaching from 6:30-9:30. Between 5 and 6pm, I sat at my desk and finished writing an exam for tomorrow's class, emailed it to the college for xeroxing and had a snack before driving up to the college to teach. The came a few hours of lecturing on HIV which I actually really enjoyed. Phew.
On the way home I called my mother from my cell phone, then debriefed with Mary about our days while giving Sparkey his meds, packing my bag for the gym tomorrow morning, loading Mary's car with some things for her new office, taking a bath with Mary, then giving Sparkey his IV fluids. Phew again.
Now I am finally in bed and letting my thoughts flow as I wonder indeed what price I pay for trying to do so much.
Living a full life? Agreed.
Enough leisure time? Almost never.
Chronic pain and fatigue? Often.
Does something have to change in this picture? The answer seems easy enough.
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