Prima Facie

prima facie \PRY-muh-FAY-shee; -shuh\, adverb:
1. At first view; on the first appearance.

adjective:
1. True, valid, or adequate at first sight; as it seems at first sight; ostensible.
2. Self-evident; obvious.
3. (Law) Sufficient to establish a fact or a case unless disproved.

To many of us, the desire for healing, for health and wholeness is prima facie, or obvious, a self-evident goal and marker of life's quality. From our priviledged middle-class vantage point, we go to the dentist for prophylactic cleanings, make sure we see our doctor, read labels on the foods we buy, make informed decisions about our healthcare and diet, and see this as a responsibility and a wise decision.

As healthcare providers, we are often faced with individuals who don't seem to make the same choices, who appear to behave in ways which would lead some observers to decide that our patients don't really care about themselves and have blatant disregard for the tenuousess and preciousness of life. But this is never truly as it seems.

What does one say to the middle-aged man whose father lashed out in blind drunken rages and threatened to kill the child who next spoke a word? How do you help him to see past his own addiction, his predilection for the numbing qualities of cocaine and alcohol?

How do I impress upon the thirty-year-old with AIDS that this current regimen of antiretrovirals is his final chance, that if he blows this one by not taking his meds correctly and religiously, the virus will mutate in ways which will preclude any futher successful treatment, pending the invention of new drugs which he could tolerate?

What do I say to the woman whose history of trauma leads her to acts of desperation, to somatic complaints for which we have no remedy, to blind rages that no counseling can relieve?

When patients' state insurance cuts all dental care for four years, ceases to pay for eye glasses, and does not cover $50 pairs of compression stockings for peripheral vascular disease, how does one convince a patient that they are valued and should value themselves? Patients have said, "The government doesn't value my dental health, why should I?"

How does a citizenry feel valued when their taxes increase, their benefits shrink, and the government appears to consistently abandon its neediest members while pursuing questionable policies which only enrich the wealthy and well-connected?

So, prima facie, at first appearance, it is easy---too easy---to impose our own middle-class standards of self-care and conscientiousness on our patients. We see their plight through eyes which have never been denied glasses. We speak through mouths which have received the dental care which they needed. We leave for work, bellies filled with nutritious food which fuels our morning, an equally nutritious lunch packed in our bag or awaiting us at a local restaurant of our choosing. As tax-paying working citizens, we feel validated, our education and relative luxuries cushioning and softening our days and nights.

Sure, it's easy to be self-righteous, to preach the gospel of the priviledged. It's another to see the plight of the disadvantaged and forgotten, and see clearly with eyes stripped of their middle-class blinders. Can I always do it? Not a chance. I'm as guilty as the rest.

We must all be reminded time and again, and we healthcare providers must also remind ourselves that there is only so much we can say, so much begging we can do, so much pleading we can verbalize. There are those whose psychic spines seem to have been broken beyond repair. It's hard to not be discouraged, not to feel angry, to blame the patient, their families, the government, the world, "the system". Our perceived powerlessness can be maddening to the point of tears.

At first appearance, there is so much we just cannot fix. But in the end, we fix that which is fixable and we move on, letting compassion guide our steps and hearts, and allowing realism to remind us that we can only do so much, and even we must sometimes let go.

Prima facie.

Eskimolitos and The Economics of Poverty

The heat gripped the city tightly today. The children pranced in the sprinkler park, and the elders sat in the shade of the trees playing Bingo and dominos. The youth played basketball, oblivious to the heat and the dire warnings of poor air quality and smoggy humidity. I don't know how many times I warned people to be careful in the heat today, sounding like a broken sweaty record.

At my wife's senior center, popsicles from the Department of Elder Affairs made the rounds---the Puerto Ricans call them "Eskimolitos".

All of our patients receive checks from Social Security on the first of each month, making that a relatively quiet day for the medical providers. Unfortunately, today---the hottest day of the year---was "Check Day", and hundreds of our clients and patients rushed around the city to cash checks, pay bills, shop, and otherwise hurriedly rid themselves of the small amounts of money with which they subsist on a monthly basis. I spent some time today worrying about the many people in compromised health who, out of force of habit, spent the hottest part of the day on the simmering streets.

This line of thought led me to consider the economics of poverty and how our patients do---and don't---manage their funds. In previous posts, I've described the extortionate prices that our patients pay for leased household furnishings and the money that's squandered on such high interest rates and fees. Similarly, our clients generally do not have bank accounts, choosing simply to cash their checks at a check-cashing facility (which takes a cut, of course) and subsequently paying their bills from the same store (with additional fees paid for each money order written). Add to this the extraordinary amounts which people pay for premium cable television service, and it's no wonder that when push comes to shove, there's precious little money left for such things as prescription co-payments and extra fluids and popsicles for hot weather. It's enough to make a nurse steam with incomprehension.

So, there they all ran, the macadam soft under their shoes, their monthly stipend from the federal government dwindling at each stop. Some walk, some take the bus, some get rides from neighbors, friends, and family members. Their children hopefully learn to use banks, checks, debit cards, and on-line bill-paying, leaving the old-fashioned money orders and fees to the elders. Check Day is a monthly phenomenon, an orgy of consumption, a rush to fill the cabinets and stock the fridge, pay the rent, and flatten the bills. With poor planning, the final week of the month then becomes a time to scour the cabinets for that last can of beans, visit the free lunch program, or find a ride to the food pantry.

Today, the heat be damned, they criss-crossed the city in a mad dash of accomplishment and consumption (not to mention responsible bill-paying, a praiseworthy practice). One diabetic and asthmatic patient of mine arrived to the senior center sweaty and dizzy, with a blood sugar of 59 and a roaring headache, but it was nothing that a little Eskimolito couldn't cure.

And the temperatures will only rise tomorrow.

Monday Evening Nurse Syndrome

Symptoms: fatigue, with a modicum of feeling wired and drained at the same time; feelings that the week will be endlessly long; profuse diaphoresis from summer heat; muscular soreness from nerve root cyst and bulging lumbar discs; moderate thirst without compromised skin turgor or change in urinary output; did I say fatigue?

Symptom management: swim at creek with dogs; relaxing computer time, blogging and emailing; fruit smoothie for dinner (frozen banana, blueberry-pomegranate juice, soy milk, watermelon); 15-minute sunset bike ride; gin and tonic with organic lime juice while sitting on screened-in porch listening to crickets and locusts; looking at the face of my love; cool shower; 7 or 8 hours of sleep in air-conditioned room after gin and tonic settles nicely; toothbrushing mandatory, flossing is elective procedure.

Diagnosis: Monday Evening Nurse Syndrome; alteration in weekend relaxation.

Prognosis: good, as long as the swims, gin and tonics, and air-conditioned sleeps are adhered to as rx'd.

Treatment Goal: happy nurse, without burnout or compassion fatigue, ready for the world tomorrow.

Likelihood of successful treatment: high.

Likelihood of similar symptoms in future: also high.

Likelihood of ability to cope with said symptoms in future: unquestionably high.

Overall prognosis: positive, with proper maintenance and adherence to treatment.

Additional rx: gin and tonics, ad lib. Adhere to Prozac rx. Add ice cream or chocolate prn.

Hoping for a Miracle

"I relapsed," he said over the phone. "I was shooting cocaine diluted in vinegar. Plus I was drinkin' a whole lot. I almost died in detox."

His liver is almost gone, and he just keeps pouring gasoline on the fire. We'll meet on Wednesday with my psychologist colleague and try to come up with a plan.

Another patient who I've been trying to find for six months also finally surfaced. His liver is also mostly shot, and he hasn't had a drink or used drugs in three months, or so he reports.

"Can't I have just a few beers a day?"

"Well, that's asking for trouble, really. We need to keep you clean. Plus, your diabetes is way out of control."

He regards me dubiously, then talks about liver functions, bilirubin, hepatitis viral load. Very impressive grasp of the issues, but still not sold on the sobriety part. Denial, I guess.

Some of our success stories are walking the streets today, while those who were not so successful (in our terms, anyway) are in the next world, hopefully learning some of the lessons they missed down here.

We all carry our pains and losses and traumas, and we all have deep-seated reasons for why we are who and what we are. It's hard to not judge another for how they choose to cope, but we might find their moccasins pretty damn uncomfortable if we tried them on for a day.

For every patient who manipulates us and pulls the wool over our eyes (or tries really hard to do so), there's another who's forthright, honest, authentic, and easy to read. The very sweet gentleman who I mentioned at the beginning of this missive is a troubled soul with a trauma history to which I am not yet privy. If I actually heard his story, his recidivism vis-a-vis drug use would make even more sense, but I can hear the plaintive note in his voice which calls desperately out for help, and we'll keep extending a compassionate hand. Whether he takes that hand remains to be seen, but for now we hope that our presence in his life can cause some small shift, some minor changes that could lead to major decisions about improved life and health.

We've seen some miracles, and I have no doubt that there are more to come. If he shows up to our appointment on Wednesday, that will be the first. If he comes to the next one, even better. If he goes on the wagon, gets with the program, stays clean, turns himself around and begins to help others do the same, then that's a miracle of the highest order (and we know several who have done just that), and I'll be the first to congratulate him on his recovery. Until then, that hand is extended, and the rest is up for grabs.

The Nurse as Vet

I was visiting a patient today to follow up on a finger lesion that we biospied in the office on Wednesday. Although my patient was moderately concerned with her finger---which, by the way, looked considerably better---her main concerns rested with her cat (pictured here) who apparently has a upper respiratory infection.

Said cat---"Timmy"---has been sneezing and anorexic for days, and only today began taking azithromycin. My patient was mostly concerned with ongoing anorexia on Timmy's part.

Being a nurse who likes to please, I performed a cursory exam of the surprisingly cooperative feline, felt his belly, palpated his nose and throat and sinuses, checked out his nose and mouth and ears, and concluded that he had no acute GI symptoms and was most likely not eating due to a combination of the antibiotics and a cold. I urged my patient to relax, keep plenty of fluids and cat food available to him at all times, and recommended she follow up with her vet if Tommy isn't better by Monday.

As for the finger, the wound culture has so far grown out gram-negative rods and we're waiting to see if the herpes culture is positive or negative. While my patient has already had one lung removed due to adenocarcinoma, I don't think the finger will be killing her any time soon. (Interestingly, she reports having had a colonoscopy recently and thinks that the finger with the lesion was the one that they had in a pulse oximeter. Could she have picked up an infection from poorly cleaned medical equipment? It wouldn't be the first time.)

As for Timmy, I expect a full recovery and give him a prognosis of a very long and happy life, along with the occasional URI.

Grand Rounds as Garden

A lovely and visually pleasing edition of Grand Rounds is now up at Medical Humanities. Well worth a gander, I dare say.

Article on Nurse Bloggers Featuring Yours Truly

A very positive and informative article on nurses of the blogosphere is now up on the Advance for Nurses website. Written by Teri Polick, the article features Digital Doorway, Death Maiden, and Emergiblog, with quotes from each blogger interspersed with descriptions of blogs, as well as the nuts and bolts of blogging. Please surf on over.

A Little Shell Shock

After such a balanced and blissful weekend, the reality of Monday morning was difficult to digest. As the morning wore on, my internal mantra of "maintain the relaxation of the weekend within" lost its power and I was then lost to the stress of the day.

I occasionally came up for air, especially when Mary arrived just before noon, knocking on the window behind my desk. I opened the office door to see her, a vision in a lovely summer dress, saying "Can you come out to play?" Smiling, she held our lunch in her hand for us to enjoy by the sprinkler park as children frolicked in the splashing water, some of which misted us as we ate watermelon and organic pistachios. I walked her halfway across the park back towards her sweet Senior Center and we kissed goodbye. She didn't know it, but I looked back three or four times to watch her cross the expanse of grass towards her workplace. I just couldn't stop watching her. It was like my soul was crossing that field. Then I headed to the office and plunged back into the melee, the simplicity of lunch in the park with my love giving way to the complexity of the endless needs of my patients.

It was uphill from there.

Perseverance

Imagine that you had gone all your life without ever washing, and then one day you decide to take a shower. You start scrubbing away, but then watch in horror as the dirt begins to ooze out of the pores of your skin and stream down your body. Something must be wrong: You were supposed to be getting cleaner and all you can see is grime. You panic and fling yourself out of the shower, convinced that you should never have begun. But you only end up even more dirty than before. You have no way of knowing that the wisest thing to do is to be patient and to finish the shower. It may look for a while as if you are getting even dirtier, but if you keep on washing, you will emerge fresh and clean. It’s all a process, the process of purification.

Whenever doubt arises, see it simply as an obstacle, recognize it as an understanding that is calling out to be clarified or unblocked, and know that it is not a fundamental problem but simply a stage in the process of purification and learning. Allow the process to continue and complete itself, and never lose your trust or resolve. This is the way followed by all the great practitioners of the past, who used to say: “There is no armor like perseverance.”

---Sogyal Rinpoche, from the website Rigpa

You can have daily meditations on living and dying emailed to you from this page.

A Summer Friday in the City

As the temperature peaked around 93 or so today, the "11th Annual Summer Party for Kids" roared its way through the sun-soaked afternoon in the park adjacent to our office and clinic. My wife's senior center for low-income Latinos is on the other side of the park, and people of all ages came to the information tables and the newly-refurbished sprinkler park. Snacks, a DJ, tents for shade, and gifts for the children completed the picture, along with a fire-truck and a police K-9 unit demonstration. Bike helmet and other safety demonstrations were key aspects of the displays. At lunchtime, I took some time out of my day to wander around the celebration with Mary and a coworker.

For all the troubles in this very troubled town, there are still good people making good things happen. Our health center, for example, hosts a Christmas party for the neighborhood children every year, complete with Santa, elves, a very impressive Santa's workshop, substantive gifts for every---and I mean every---child who shows up, free Polaroids of each kid with Santa, music, free food, and the promise of a very good time. The amount of hours put into this undertaking are astronomical and the planning and gift-gathering begin each summer.

All of the numerous social service agencies in our end of the city---serving an 83% Latino community---have banded together to form a committee to oversee and guide the overarching plans for knitting this community together and providing comprehensive services to families and individuals, taking into consideration health, healthcare, economics, elders, children, teens, families, addicts, sex workers, IV drug users, and newborns. The vision is astounding---the implementation will be a challenge. Nonetheless, a well-meaning and ethnically diverse team has assembled itself to transform and restore this community, and there are times when I feel that I could not work anywhere else. Even as the city collapses upon itself---or threatens to---the movers and shakers continue to plow ahead to bring their visions to fruition. To wit, my program of care management for the most vulnerable members of the community was born---and is sustained---by such tenacity of will and desire to serve. That underpinning of heart is what keeps me where I am.

As I watched the children frolic in the sprinkler park and the people chat under the trees, it became easy to overlook the trash, the violence, the corruption, the homelessness, the desperation that walks these streets. Even for a moment, frozen for a summertime pause of sun and water and laughter, the promise of community unfolded and placed a gently soft hand upon the faces of those gathered in such innocent joy and celebration of life. These are instants that cannot, and should not, be taken for granted, and they are truly miracles, conscious manifestations of the power of positive energy, the will to serve, and the desire for togetherness that I feel lives in us all.

Burns, Recovery, and Compassion

On my way home from work today, I tuned into NPR and heard a very intense and moving story about military burn victims from the Iraq War being treated for their injuries. Several of the soldiers featured in the story were burned on more than 90% of their bodies, and contrary to expectations, several of those have actually survived. No matter how negatively I feel about the war and its humanitarian (and geopolitical) consequences, these stories of human suffering bring tears to my eyes and occasionally a knot to my stomach, like they did today. Since it would be easy for the reader to click on the link to read and/or listen to the actual story, I don't choose to encapsulate its contents here in this forum.

Aside from the accounts of the soldiers' misfortunes and incredibly painful treatment---some extensive burns require debridement of the charred skin down to a subterranean layer of viable and healthy tissue, exposing thousands of screaming nerve endings---I was extremely touched by the nurses and doctors who were interviewed. One must consider the fact that the staff are working with individuals who are horribly disfigured, often lacking recognizable faces and features. It was explained that pictures of the soldiers before their burns are always hung on the walls around their beds---posing with families and loved ones---to remind the burn unit staff that these are real people with real families, who used to have features that distinguished them and identified them. The supervisors want the staff to know what these men and women really look like, and to treat them from that perspective of wholeness and the recognition of their complete selves.

One nurse described how he has a place along the highway on the way home where he stops to cry, meditate, or scream, so that he can arrive home having released some of the emotions which were generated during the workday. Another describes "cramming" emotions away---a sure recipe for burnout and substance abuse, in my book. Coping mechanisms can sometimes be overwhelmed when such trauma is witnessed, and I can only imagine how a nurse or doctor must feel as he or she debrides an extensive burn, exposing raw nerve endings and tissue. The screams and tears and curses must be powerful and strong. (This is why I hate clinic evenings when I have to give three, four or even five vaccinations to a one-year-old child all at once. The terror and pain in that child's eyes---and the caterwauling screams---are enough to put me over the edge with guilt.)

Such suffering is witnessed by so many around the world---whether parents, children, soldiers, nurses, or the infirm themselves---and I sometimes wonder how we---humanity---carry the weight of such suffering on our collective conscience. Aside from the right or wrong of war, the good and bad things inflicted upon human beings by other humans beings, there are stories of heroism, compassion, and incredible kindness around every corner. This story which beamed to my car across the airwaves today was just one small reminder of one small corner of the drama experienced by a relatively tiny portion of this multicellular organism we call humanity.

Even as I write, at this moment, those burned soldiers dream morphine dreams of blissful forgetfulness while a mother in Beirut mourns her three-year-old killed by a bomb, or an Israeli settler bemoans the ruins of his home, or a homeless man in the city where I work drops his bottle of beer, clutching his chest as a heart attack commences to extinguish his unsung life. And at that same moment, hundreds---perhaps thousands---of children are born into this world as new parents weep with happiness despite the pain which they know their children may endure in the course of a lifetime on this spinning globe.

Those stories opened something in my heart today, and I'm grateful for the moment of reflection and connection to others. These are the moments when one can sometimes get in touch with that collective unconscious of which Carl Jung spoke, that undercurrent of connectivity which binds us all in our shared humanity. Perhaps this story opened my heart as I thought of an old friend undergoing surgery for cancer today, or another friend recently hospitalized with a dangerously high fever induced by a tick-bite, or the daughter of a former boss who suddenly died this week at 33. The drama is multifaceted, and I can choose to send all beings a wish for happiness and wholeness, recovery and hope. Stories can do this to us, and that ability to listen and recognize the suffering and tribulations of others may be the key to cultivating more compassion each day. Compassion for others---an important lesson worth learning again and again.

The Probation Tax

We have a patient whose age, race and other identifiers are inconsequential. Suffice it to say that this client is physically disabled in a major way and has managed to remain substantially independent despite his disability, living on his own, maintaining an apartment,with frequent visits with his children by several different women. This very kind gentleman was on the wrong side of the law as a young adult, was convicted of some small-time non-violent drug offenses, and has been on probation for some time. His Probation Officer seems to be one of those individuals in law enforcement who goes out of their way to make others' lives miserable, and we have gone to bat for this most exemplary of clients several times. Anyone on our team who gets to know this individual cannot help but be fond of him. He's a very magnetic and genuine personality.

Our client has expressed determination and a fierce desire to pursue an education, overcome his disability, and enter the workforce. Eager to help others, he has grand plans for how he would actualize himself and bring his many gifts to others. Through many applications and beaureaucratic processes, my coworker enabled this gentleman to be approved for classes, training, and a free home computer to facilitate his academic success. Our pleasure at seeing his face light up when talking about his future is beyond measure, and his plans for the future only seem to expand.

This week, a huge monkey wrench was thrown into the works in the guise of The War on Drugs. It appears that, due to misdemeanor drug possession charges and mandatory minimum sentencing laws with prolonged probation, this gentleman---who is eager to make something of himself, give back to the world, and contribute to society---is thwarted in his desire by the fact that his past convictions and current probation preclude his ability to receive even one dollar in financial aid. With classes ready to be registered for, a computer ready for delivery, and training all set to commence, his dreams and aspirations are now dashed against the rocks of misguided government action.

While white collar criminals bilk retirees of millions, slum-lords charge outrageous rents for substandard housing, the Big Dig in Boston collapses under its own weight, and members of law enforcement (including the CIA and FBI) appear to profit from involvement in the international drug trade, this promising young man with so much to give cannot receive the education he needs to remove himself from the rolls of Social Security Disability and create a new life. For all the talk of the "rehabilitation" of criminals, the government's denial of financial aid for the education of those on probation for minor non-violent crimes flies in the face of all logic and ethics. If this society was to put into words its goals for the future of non-violent offenders, those words would certainly reflect a desire for such individuals to receive education and training which would make them productive, peaceful, tax-paying citizens contributing to the welfare of the larger society while simultaneously pursuing self-mastery and personal fulfillment.

So, in light of this maddeningly Kafkaesque outcome, our protagonist cannot pursue his dreams, better himself, or otherwise lift himself from poverty and economic reliance upon the state, because his previous actions preclude his receiving financial assistance for training and education. Rather, he should languish in uneducated disability, unable to obtain the skills training needed for advancement and gainful, tax-paying employment. It's just another great example which proves that the War on Drugs is really just a War on the Poor; and the war, my friends, is simply never over.

Poverty, Consumption and the Pursuit of Happiness

The other day, while helping a patient put together an application for a social service program, we went over some monthly bills which she had brought to my office to include as documentation of her expenses. Other than her subsidized rent, her monthly bills included a cell phone, a land-line, cable TV, and monthly payments on leased furniture. She has no credit cards (and those who do pay extortionate interest rates!), but the interest and fees she pays for her leased furniture more than makes up for her lack of a Visa or MasterCard.

I often forget that many of my patients actually lease their furniture and large-screen TVs from local leasing companies. I'm genuinely shocked at the size of some of my patients' television screens and the excessively massive furniture (all black with fake gold and chrome plating) which crowds their apartments and homes. I was also shocked a few years ago when I realized the enormous amounts of money which is spent on the leasing of such home furnishings.

While perusing my patient's lease agreement, I could see that a mediocre dining-room set with four chairs, retailing at around $600, was going to cost this woman on a fixed income more than $1300 by the time she finished the payments over several years. Add to this mix the great risk which she runs of having the items reposessed if she happens to become ill, get hospitalized, or otherwise miss a monthly payment, thus forfeiting all of the money which she has already paid on said furnishings. This type of exploitation (and poor judgement) makes my blood boil.

After she left my office, I spent some time pondering the reasons behind such behavior and consumption. I had asked her why she leased under such horrible and exploitative terms rather than simply saving up money and purchasing a dining room set outright for much less money, and she could not necessarily answer me in a way that explained her actions. What I surmised from her answer is that "this is what is done" and she didn't necessarily have the skills to do anything differently. I was perplexed, but was (and am) undaunted in my determination to more fully understand.

From my solid middle-class perspective, it's relatively easy to not see the other side, to turn a blind eye to the eagerness of those less fortunate to rise up, or to at least have surroundings which make one feel more comfortable and on a par with others. Don't so many of us strive for more? I told myself to look deeply at the circumstance of a disabled person with multiple illnesses, perhaps a history of emotional trauma, and generations of poverty and struggle. That person watches TV, takes in thousands of commercials and advertisements enticing him or her towards a better life of conspicuous consumption, and numerous television shows and movies portray beautiful people in beautiful surroundings enjoying comfortable furniture, the latest technology, the most chic of homes, and the latest and greatest gadgets and toys. Cinderella stories---in the form of "American Idol" and "The Apprentice", for example---demonstrate that ordinary people can transform their lives and reap the benefits of fame and wealth almost overnight. The economically disadvantaged watch these shows with zeal, look around at their homes, and are determined to bring some semblance of that wealth into their own living rooms and bedrooms.

Is this a fair theory? Are they victims of the free market and the media's relentless presentation of the contentment which consumption might deliver? Do they, in their desire for a more comfortable life, miss an opportunity to reexamine how they wish to spend the little money with which they manage their lives? And when they complain that they don't have the $1 co-payment for their antihypertensive medication (and believe that they should not have a government-mandated co-payment in the first place), is it fair to remind them how much they pay for cable and their dining room set? Is it really my place to use that moment to instill a new way of looking at consumption, economics, and priorities? Am I right to suggest that they downgrade their cable to the $60 package so that they have $15 for medication co-pays each month? My jury is out.

Reflecting on these questions, I examine my own life and financial state and the choices which I make. Do these choices point towards a desire to have more, to live in a way which my income and level of education do not necessarily reflect? Do I also make choices which some would find suspect vis-a-vis the realities of my situation? Do I even have the right to question others' motivations in this regard?

We all strive for happiness and comfort, and in a consumer culture that happiness and comfort is often reflected in our purchasing habits. I feel strongly that I cannot properly address this issue with any substantive acumen in this post, as it would take a great deal of research, reading, and contemplation to get to the heart of this very complicated socioeconomic issue. The bottom line is that I see individuals with whom I interact on a regular basis make choices which may be deleterious to them economically, and which, in my opinion, are based on artificial desires created by suits on Wall Street who decide in boardrooms what the next gimmick may be which they will peddle to the poor masses as those mega-corporations behind these "objects of desire" seek ever-expanding profitability and market control.

Although this may seem far from healthcare-related, economic health and savvy financial planning are actually integrally entwined with health, healthcare, and self-care. An individual's priorities might dictate how often an individual refills prescriptions, how important they feel it is to spend a dollar on the bus ride to a doctor's appointment, or whether they choose between a cable upgrade or fresh vegetables. Consumerism drives our culture and economy (and our healthcare system), and our patients are often pawns in a game which they perhaps are unware even exists. Or perhaps they willingly play that game, openly acknowledging that they desperately want what the purveyors of consumer goods offer so willingly. It is a conundrum of a dizzying order, one with which I struggle, and one which certainly impacts my patients' health---and my sanity.

The next time a patient tells me that they can't afford a dollar for a medication prescribed by their doctor, my response will be colored by these thoughts which I have pondered here, unfortunately never having reached a satisfactory conclusion from which to draw a pearl of wisdom and insight.

The pursuit of happiness, did you say? Yes, and that pursuit may very well take some to Wal-Mart to buy cheap goods made in sweatshops, whether I like it or not. It may also make a woman who can barely afford her rent choose to lease a dining room set for $1000 which she does not have.

This is an exercise in tolerance, in understanding, of confronting internalized classism, and of coming to terms with aspects of our society which drive me to the brink.

May all beings be happy. May all beings be free from suffering. May I be more understanding and compassionate. And while we're at it, may all beings in need find an extra thousand dollars in their bank account on the day they need it most.

Execution and the Medical Professional

Having just watched Now on PBS with David Brancaccio, I was moved to write about tonight's story which discussed the role of doctors and nurses in the executions of condemned prisoners. The Now reporter presented what I felt was a relatively dispassionate airing of the various sides of this very controversial issue, the website providing further facts and figures for the curious.

Whether one opposes or supports capital punishment, the myriad questions raised in its discussion are thought-provoking and quite worthy of consideration. The media has recently focused a fair amount of attention on the various court decisions which have ruled lethal injection as a flawed form of execution which is in dire need of readdressing. Many opponents have stated that the cocktails used for the euthanization of animals in the United States are far more effective in producing a soporific effect with no apparent experience of pain than those used in our prison system today. Horrific stories have been published of condemned prisoners complaining of pain while undergoing injection, one particularly gruesome account detailing that technicians needed 90 minutes to complete the execution of a man who kept raising his head from the gurney to say "It ain't workin'!" These stories send chills down my spine and underscore the next questions that I will raise.

In these times, we have come to understand that execution has become "medicalized", in that it no longer involves a firing squad or hangman---it now involves IV access, the administration of sedatives and narcotics, and the need for medical oversight of such an undertaking (no pun intended). During tonight's show on PBS, a nurse from Georgia who participates in executions was interviewed about her experience. In her descriptions of the executions in which she takes part, she carefully stated that she does not see herself---nor the anesthesiologists who actually push the plungers---as executioners. She sees the execution team as a group of professionals carrying out orders, the "executioner" actually being "The State". This Kafkaesque denial of responsibility was difficult for me to swallow, as was a doctor's statement that by solely overseeing the heart monitor and vitals of the "patient", he was not actually participating in the execution, rather, he was advocating for the prisoner and assuring that no undue suffering was occuring.

To wit, the AMA states clearly that a doctor "should not be a participant in a legally authorized execution. Physician participation in execution is defined generally as actions which would fall into one or more of the following categories: (1) an action which would directly cause the death of the condemned; (2) an action which would assist, supervise, or contribute to the ability of another individual to directly cause the death of the condemned; (3) an action which could automatically cause an execution to be carried out on a condemned prisoner." Additionally, the American Nurses Association states that "participation in executions is considered contrary to the fundamental goals and ethical traditions of the [nursing] profession."

Taking into consideration the Hippocratic Oath of "do no harm", as well as the many pledges taken by (and professional standards imposed upon) nurses, takng active part in the carrying out of executions seems to be a contradiction of any medical code of ethics with which I am even vaguely familiar. Reading the AMA position statement, even consulting with the administering personnel would be a violation of the physician's role as healer. That said, some doctors' defense of the practice---and continued participation in such---has led to proceedings and investigations, although whether licenses have actually been revoked is unknown to this writer.

This article by Atul Gawande, MD, is certainly worthy of perusal. Dr. Gawande is firmly against the participation of any medical professionals in state-sanctioned executions of any kind, and his article was published in the March 23rd edition of NEJM earlier this year.

When considering "non-traditional" roles for doctors and nurses and other medical professionals---whether it be participation and medical oversight of interrogations at Guantanamo Bay, oversight of medical experiments on those unable to defend themselves (remember the institutions for the mentally retarded in the 20th century?), or the doctors who colluded in the Nazi experiments in the 1940s---one must bear in mind the ethical and moral issues underscored when such acts are committed by said indivduals. While there are some stellar prison healthcare facilities which offer state of the art compassionate care to the incarcerated, there are those in the shadows who, rather than contributing to the health and recuperation of the imprisoned, actually are complicit in the extinguishing of those lives.

Whether we can truthfully say that "The State"---a faceless entity---is the true executioner or not, many of our brethren and colleagues are taking part in the ending of life for reasons other than the relieving of suffering. One might argue that execution provides "closure" and relief from suffering for the loved ones of the victims of violent crime. That said, it is still a stretch---in my mind---that there is any precedent for a medical professional to take part in such an act and still truly call him- or herself a healer.

Change of Shift, Vol. I, No. II

The second edition of Change of Shift, a blog carnival for and about nurses and nursing, can be viewed by clicking here. Please pay a visit if you are so inclined.

Of Vacation's End and The Sisyphus Syndrome

I knew that vacation was over when I walked into the office and a patient's boyfriend was waiting for me. My patient gets a narcotic prescription every Tuesday and I guess I had failed to make sure the script got written on Monday before my return to work. Oh well. I found a sympathetic doc who didn't mind penning the script and sent the boyfriend on his merry way.

Next came the mailbox filled with papers to review, the email inbox to slog through, and the new technology in the form of a Treo smartphone which needed a great deal of attention and detail management. Juggling my old Palm Pilot, old pager, new Treo, old cell-phone (with all the numbers I need and no way to transfer them to the new phone)---it was a post-modern mess. See this post for the recent history of our office's techno-struggle.

I jokingly asked the administrative staff if they had sent out a notice to all of my patients that I would be back at 9am today because the phone began to ring and didn't really stop all day for the most part. Aside from the few prescriptions I called in and fax'd, my day did not feel very "nurse-like"---more administrative and desk-based. What is "nurse-like" really like, anyway? Probably however I feel at any point of the day is nurse-like enough, dammit.

As a "wellness and health broker"---a term (that I think I made up) which I have come to see as indicative of some aspects of my work---I felt today like there were so many threads which I again needed to find and pursue. My brain's problem was the fact that remembering the details of what comes next for approximately 80 people is a Herculean task (or is it more Sisyphean? You be the judge!) Who was it who needed a follow-up visit this week? Whose blood sugar is most uncontrolled? Who died? Who's in the hospital? Whose med box needed filling today? What about those narcotics? Did that patient I love really go to Puerto Rico to die? Sisyphus would surely let this rock go a-tumblin'.

The devil is certainly in the details, as the saying goes, and the devil of details is certainly the devil I know intimately. Does one become a nurse because one enjoys the micro-management of endless minutiae? Do all nurses make those little boxes next to the items on their t0-do lists and then garner a perverse pleasure from checking those boxes off? Again, you be the judge, folks, but my obsessive-compulsive side sure likes being a nurse.

So, as Zen Mind, Vacationer's Mind gives way to Worker-Bee Mind, I'll do my damndest to make the evenings and weekends their own little vacations, while still being the (watered down) productive-obsessive which I am to my core.

The circus-tent of work as a nurse never ceases to entertain, even if that entertainment sometimes carries a certain sadomasochistic aura. I re-enter the fray, rested and vacated, but still sadly longing for the briefly carefree days of vacation. Head down, nose already sharpening on grindstone, can that softening and loosening of the tightened mind which occurs on holiday still retain its afterglow? Stay tuned......

Technology and Its (Dis)Contents

The issues around technology in our office are becoming more clear as the weeks since my last related post go by, although we all understand (don't we?) that technology that's supposed to make our work "easier" is not always so, or at least not in the beginning, anyway. Those post-modern learning curves are steep these days.

Anyway, our bosses have chosen to purchase Treo phones for us, which are basically "smart phones" which provide Palm Pilot capability, cell-phone service, alphanumeric paging, as well as the ability to wirelessly check email, write Word documents, alter spreadsheets, carry huge files of medical and pharmacological data, and a gamut of other functions. Contrary to popular belief, these small machines---with thousands of times more memory than the Lunar Module---will be insured, and we providers will not be financially responsible for their replacement if lost. We'll just be summarily fired, no questions asked. (Now that's an occupational hazard!)

The upside is that these devices will eventually allow us to have reams of information available to us in the field as we visit patients at home or accompany them to appointments. We will eventually be able to record vital signs and other data in the phone rather than relying on little slips of paper in our pockets. And when we eventually have laptops upon which we access EMRs (Electronic Medical Records---it's the future, folks!), we'll be able to "sync" the phone/PDA to the computer, share and back up data, and then some. The phone will also serve as a wireless connection to the Internet, allowing us to access patient medical records from remote locations. (So, I'm in a neurologist's office in another city with a patient for a consult, and I need her most recent lab results, and this doc is not privy to our hospital's database. I quickly access my info and---voila!---said information is in my hand.

The downside? A relatively expensive ($500) toy for which I am responsible will no doubt cause this obsessive-compulsive no small amount of checking and double-checking to see if I haven't lost it yet today. Hardware and/or software problems will cause loss of not just one function but many, including appointments and phone numbers, cellphone, and pager. Could be incredibly inconvenient when malfunctioning. Another downside? I get addicted to such a device and feel I just have to purchase one for myself when I eventually leave this workplace. Another? OK, why not? The entire technological infrastructure of the United States collapses overnight when Saudi Arabia and China decide to pull all investment in the American economy out from under our currency. The stock market crashes, the World Wide Web is reduced to a sputtering DSL line in Omaha, and we're reduced to scrawling lab results and vital signs on portable chalkboards. And my Palm crashes and I miss my haircut appointment. Devastating. I could think of others, but that's enough for now. I wouldn't want to look like a technological curmudgeon now, would I?

On the bright side, the on/off button on my (personally purchased) Palm Pilot is on the fritz and the "5" button on my (workplace-purchased) cellphone is pokey. Plus, my pager only receives a percentage of the messages sent to me from the support staff. Now why can't that Smart Phone take a set of vitals?

Adding to the digital fun, I'm now able to fax prescriptions to any pharmacy I choose directly from our hospital system's new on-line prescription function without even having to find the paper chart and record the prescription that I called in on a medication flowsheet. An electronic message is generated which ends up in the inbox of the prescribing doc whose name I used in vain to order said prescription. S/he then digitally "signs" the script after the fact (or comes to find me and wrings my neck for refilling that patient's Ultram again!) An added benefit: when one of my patients ends up hospitalized, all of their meds---refill history and all---are universally available to anyone in the system. Pretty nifty, at least until the system crashes with the economy and we have no paper record. (We may be forced to re-think the whole stone- and-chisel medical record practiced before the time of Hippocrates. I heard that the curved chisel revolutionized the recording of blood pressures. Imagine chiselling 146/80 in Roman numerals!)

So folks, until the digital economy collapses under its own weight, I will play with my new Smart Phone and report to you the vicissitudes and joys of its presence in my professional and personal life. (Do you think I don't use that work-subsidized cell-phone for all it's worth?) When the technological shit hits the fan, I may mourn its passing while simultaneously thinking, "Good riddance to all of that! Now where's my old hand-cranked phonograph? Oh no! I replaced all my old vinyl on CD!

From the technology desk here at Nursing Central, yours truly bids you bon nuit.

Grand Rounds per Medviews

Grand Rounds is up and running this week at Medviews. Cruise on over for a view.

Thinking Globally

Blogging about health and healthcare, it's easy to focus on the microcosm, the minutiae of the lives and struggles right here on the urban streets of America. But amidst our struggles for the lives of our patients, we also must occasionally expand our focus outward towards the global issues affecting health and healthcare. The worldwide movements to eradicate AIDS, malaria and tuberculosis are high-profile issues which garner the celebrity power of Bill Gates and Bono to trumpet their cause. This is all well and good, and that trio of diseases is well deserving of our attention.

Tonight, on the way home from work, I was lucky enough to be listening to Fresh Air with Terri Gross on NPR. On this particular segment, Dr. Paul Epstein of the Center for Health and the Global Environment at Harvard Medical School was discussing his research findings indicating that global warming and climate change are having a more profound effect on public health than previously suspected. (You can listen to the interview here.)

Dr. Epstein postulates that the explosion of asthma and allergies around the world are seen to be directly related to global warming, as is the rising number of mosquitoes and insect-borne illnesses. around the world. We already know that the power and frequency of storms such as Katrina are said to be directly caused by climate change, but do any of us realize that desertification in Africa causes dust storms which travel across the Atlantic and cause exponential increases in asthma in previously unaffected children in Trinidad, and that mold spores in said dust from Africa infects Caribbean coral reefs and causes their disintegation? Do we also understand that airborne diesel fuel particles can increase the power of pollen to enter the lungs of poor urban populations who live along truck routes in our cities?

Some of this information is, sadly, not terribly surprising and seems to make sense in the sorry scheme of things. Those of us who work in urban centers already know that poor urban populations suffer more greatly from the effects of pollution, ground-level ozone (smog) and other poisons which disproportionately contaminate the air where the poor and working class live. What we may not also realize is that even affluent areas and places long considered to have healthy air are now no longer the bastions of oxygen and clarity that we once enjoyed. The air in the Caribbean, once considered a place where the wealthy could travel for their health, is now seeing pollution and ozone rates like never before.

With the release of Al Gore's new documentary, An Inconvenient Truth, perhaps a quantum leap forward will be engendered worldwide, and massive lifestyle change and sociopolitical shifts of consciousness will begin to take place on a global scale, and the powers that be which hold the purse-strings of the world economy will step up to the plate and abandon the pursuit of profit which has, to a large extent, fueled (no pun intended) the imminent demise of our planet as we know it. Then again, perhaps not, and the voices in the wilderness will continue to cry out as the asthma rates sky-rocket and desertification drastically decreases our ability to feed the hungry with our ever-diminishing amount of viable topsoil.

So, is global warming a public health issue? What has the power to convince us? Is it increased rates of asthma and environmental allergies? Is it decreased food production due to net loss of topsoil, with millions suffering needlessly from malnutrition? Is it water shortages around the world and the dehydration that it engenders? Is it exponential increases in melanoma? Or is it pandemics of insect-borne diseases which will drive us into action?

I ask myself these questions as well, dear Reader. I am as guilty as the next, as unconscious as the others, and my car pollutes no less than my neighbors'. We are all complicity, we are all suspect, and if the health effects of global warming do not touch us now, there will eventually be no escape. So, from the barrios to the suburbs, we all must start thinking, acting, and actively changing, not just for the earth, but for our very health and that of our children. After all, the personal is political, the political is personal, and health---of the individual or the collective---can be very personal indeed.

A Viral High Five

My blogger friend Ian Miller over at ImpactED Nurse in Australia runs an excellent and well-designed site which is both instructional, moving, and amusing. This week, he chose to post a "Viral High Five" which highlights his five current favorite blogs. I am humbled and grateful for his having chosen Digital Doorway for this honor. He wrote:

• Digital Doorway: Keith is a nurse working with the Latino community of a New England city in the US. His writings are moving, astute and crafted. They demand a switch from surfing, to floating face down in wonder of the deep.

I was speechless after reading such a description of my writing, touched beyond words, and grateful for someone so erudite and talented to nod in my direction. At Ian's behest, I now present to you my current "Viral High Five" which will now infect five other bloggers to reciprocate and do the same. (Note: there is no assumption or desire on my part for Digital Doorway to be included on those subsequent lists. Having been on one, let's give others the limelight.) That said, I will also say that there is no way I can fit my favorite blogs and bloggers into a measly little list of five, so see this list as a taste rather than a meal---a morsel, if you will, with promises of further sumptuous courses to follow in good time. Enjoy, and may the infected go on to infect others equally as wonderful.

Genre Cookshop: a (mostly photographic) blog by my cousin Nancy Bea Miller, a talented fine artist and photographer, as well as a devoted mother of three boys, one of whom is autistic. Nancy Bea shares stories from her daily life, often taking seemingly mundane moments and transforming them into magic, either through her camera lens, her perceptive writing, or both. A touch of humor, irony, and plain old beauty all mix together to create a lovely site to visit again and again.

ImpactED Nurse: what can I say other than that Ian runs a lovely site riddled with gallows humor and real life stories from Down Under. "Departments" of the site include: Piss and Vinegar, Nurses' Desk, The Funny Bone, among others. Ian offers a treasure trove of commentary, medical stories, and humanity. Please pay him a visit.

The Happystance Project: Tony Plant, an award-winning facilitator providing Laughter Yoga and Stress Relief workshops to caregivers in the UK, runs a site which takes progressive views on caring, caregivers ("carers" in British English), mental health, and public health to new levels. Tony is an advocate for children, the mentally ill, and anyone who needs a helping hand. He also supports and advocates for "carers"---those individuals who provide aid and assistance, either in a professional or personal capacity. His service to the world is unique and laudable.

Graceful Presence: Bhuddist philosophy and inspiration permeate this site which is like a breath of fresh air on a mountain morning. Akilesh and Meredith take turns regaling us with quotes, anecdotes, poems, and meditative missives which offer not only soothing notions but deep mysteries and awe. There is a large Bhuddist presence on the web which I am only now discovering. Their thoughtful links will lead you further.....

Swamp Things: "Swamp4me" is a woman in North Carolina whose work seems to take her into the Carolinian swamps near her home on a daily basis. Although my phobia of snakes occasionally will cause me nausea when I come upon a serpentine photo which Swampy has happily posted after a day's fine work, I heartily recommend a cruise over to her corner of the Southeast via the World Wide Web when you need a dose of Nature's wonder. Her lovely photos of muskrats, birds, (ugh!) snakes, and other creatures of the swamps and woods are a sight to behold. Her regular commenters are also worth a read.

So, dear Readers, these are five sites worth visiting of an untold number for whom I do not have room at this time. Please see my links for other suggestions, and enjoy the creativity and talent of those who choose to wear their digital hearts on their sleeves.

No Exit

Her calls are consistent in their regularity and in their production of stress hormones in my body. They are consistent in other ways as well. Dramatic. Tearful. At times explosive with anger and frustration (on her part) and quiet frustration (on my part). She almost always calls on Friday afternoons as we are beginning to wind down the week. Inevitable and fruitless for us both.

She suffers from doubtlessly debilitating illness and pain. She's been abandoned by friends and family. She is utterly alone. With a history of addiction to pain medications, Borderline Personality Disorder, depression, social anxiety, and a host of other physical complaints, the mix is volatile. She has no car, hates to take public transit, but lives within walking distance of the Emergency Room where she's a very frequent flyer. Her isolation is devastatingly complete, yet she abhors psychotherapy and psychiatry and chronically skips medical appointments. It's my job to keep her from falling through the proverbial cracks. Yet fall she does. Those aren't cracks---they're caverns.

The calls are mostly identical:

"I'm in so much pain."

"I know. What would you like me to do for you?"

"I don't know." (Sobbing.)

"It's 4:30 on Friday afternoon. I can't get you seen here. Do you feel like hurting yourself?"

"No. I'm in so much pain." (More heart-wrenching sobs.)

"Do you want to call Emergency Psychiatric Services?"

"No! I need you to admit me to the hospital." (A hint of anger now.)

"For what?"

"For my pain. Admit me for my pain."

"I can't do that. They wouldn't admit you for that. Do you want to go to the ER?"

"No."

"What do you want me to do?"

"Nothing. Nothing. You don't understand my pain. Thanks alot." (Click.)

She'll often call back after hanging up on me, contrite and sweet, but still crying. The second call is mostly the same and we finally agree that she can go to the ER where she'll wait a few hours, get an injection of morphine and a Rx for 30 Percocet. The next night, around 2am, she'll call the on-call Nurse Practitioner who will have basically the same conversation with her that I did on Friday. The following week will be mostly the same.

This person is a failure of our system. I have failed her. We don't keep her out of the ER. Those visits cost thousands, not to mention her numerous calls to 911 and the dispatching of needless ambulances. Her pain and other symptoms are often precipitated by isolation, angry telephone calls from her hateful mother, and occasional visits from her estranged husband who asks her for money to buy cigarettes. We spin endless variations of the same conversations and go nowhere. Progress is nonexistent. Her doctor, of whom I am exceedingly fond, has no answers for us. It's a revolving door of frustrating calls, anger for her and frustration for me. My impotence in this arena is obvious and painful.

As I sit here in bed late on a Saturday night, my heart goes out to her in her suffering. There is nothing I can do to assuage her pain. Her past is a shadow to me which I have not explored and could never penetrate. I am not a psychotherapist and have not touched on those realms with her because I know I am too unskilled to handle what might be exposed to the light of day. Her suffering is her own and I acknowledge my helplessness in its powerful grasp upon her troubled psyche.

There are those who we can help, who we can lead to healing, to wholeness. There are others---and they are many---whose healing is beyond our ken, and whose shadows of past wrongs and abuses are beyond our capacity to understand or rectify.

Does compassion fatigue set in during interactions with this patient? Do I feel powerless and impotent in her care? Can I see no end to this merry-go-round of suffering, reaching out, and the failure to change anything which might be alterable in this woman's life? I chose the title for this piece by borrowing a title of a play by Jean-Paul Sartre, that cheery existentialist in early 20th century France who created such masterpieces of human drama and suffering alongside his comrade and lover Simone de Beauvoir. No Exit is a fitting title for this clinical conundrum in which I find myself, and the ambiguity of that title underscores the pain which the human beings on both side of this real-life drama must bear.

Emolument

emolument \ih-MOL-yuh-muhnt\, noun: The wages or perquisites arising from office, employment, or labor; gain; compensation.

Ah, the wonders of dictionary.com, which gives me food for thought and fodder for writing. Sometimes a simple definition can be the jumper-cables for a fatigued writing battery. Sometimes not.

Recently, emolument was the word of the day, and it informs the feeling that another work-week is over and a paycheck is in the bank, thankfully enough. Like many people in these post-modern times, however, payday now comes every two weeks rather than every Friday so that 50% of all weeks end without that gratifying sense of renumeration which concretely rewards one's labors of the previous five days. That paycheck, whether weekly, bi-weekly, or even monthly, is a physical manifestation of the consistent exercise of one's powers to move and produce in the world. Taking into consideration the fact that there are many people who lack the opportunity (or physical or mental health) to achieve such an accomplishment, the salaried among us must periodically count our blessings that we are granted the luxury and priviledge of earning a living. More than anyone else, I remind myself of this fact as I recover from a busy week and reflect on my Friday evening fatigue.

The gratification of being paid relatively well for work which feels honest and worthwhile is indeed a priviledge whose potential transcience is important to remain aware of. That paycheck deposited in my bank account is a manifestation of the energy which I expend in the world through service to others. While it is not the soul reason for being the professional that I am, it's a certainty that supporting my family has been a driving force behind my professional aspirations and accomplishments. I do not take for granted the opportunity which my relative health and ability have afforded me, and I am grateful for my work, my patients, and the dollars and cents which sustain my own financial solvency. As the saying goes, money isn't everything, but it sure helps.

Nurses and Bloggers and Carnivals, Oh My!

As an avid supporter of nurses and nurse bloggers, I'd like to draw your attention to a new nursing blog carnival known as Change of Shift, which has been lovingly created by Kim at Emergiblog. Kim works as an ER nurse in the San Fransisco Bay Area and uses humor and real life stories to entertain and educate. Change of Shift is not meant to compete with Grand Rounds, that most prestigious of medical blogging carnivals to which docs, residents, patients, nurses, EMTs, and other individuals contribute on a weekly basis, including yours truly. Rather, it is a blog carnival meant to showcase nurses, nursing, and others' experiences of such. Kim is inviting anyone with anyone to say about nurses or nursing to contribute, whether it be humor, stories, accolades, or constructive criticism. I fully intend to participate (and host occasionally) and thank Kim heartily for her efforts.

Wake

He lay there in the coffin, surrounded by flowers and loved ones, his features supple and natural. I've heard that funeral directors call this a "memory picture"---the last image of a loved one that many people see before a familiar body is cremated or interred. Tonight I understood more clearly the meaning of that euphemism, but also the importance in many cultures of the opportunity to see the body of a loved one without the tubes, tracheostomies and other indignities frequently visited upon a human body ravaged by disease. Everyone remarked how wonderful he looked, and this was the first time I could truly say that the deceased really did look great, and I will actually carry that image of him with me forthwith.

This burgeoning multigenerational and racially and ethnically diverse family was inspiring, complex, and a genogram-maker's dream. As I worked the crowd and met person after person, a map of the family took form in my brain, and I began to more fully appreciate the depth and breadth of the support and intimacy engendered by this clan. Many close friends who seemed like siblings filled the rooms of the funeral home, and I tried to chat with as many as I could, increasing my knowledge of the family and its interconnections. It's interesting to gain such insight as my work with this family has now actually come to an end, but this knowledge is a piece of the puzzle which helps to more fully inform my practice as a nurse and cement this experience in my mind and heart.

As I was introduced around---or introduced myself in some instances---people would say, "Oh, you're the Keith that we've been hearing about for the last two years!" Luckily, the reputation which preceded me was a positive one, and the feedback which I tried to take in with grace and humility was a very nice way to end my workday. So many times, one can be somewhat uncertain as to how one is perceived, and a clear reflection of one's impact on another human being is truly a gift.

Tomorrow, the funeral will see our final view of his body, handsomely clad in a dark green suit with lovely black mandarin-collar shirt and tasteful gold jewelry. The notes, children's drawings, and other mementos---along with his black fedora with jauntily-placed red feather---will all be sealed within the fancy coffin and lowered into the verdant earth.

It happens all over the world, this process of mourning the dead and placing their bodies in their culturally appropriate container, be that container wood, metal, fire, or water. In Tibet, bodies are sometimes left on mountaintops for vultures to devour, sending the body back to the Source in a visceral (and to some shocking) fashion. But the body is only a vehicle, a vessel from which we are eventually released, and its corporeal existence will deteriorate as it should according to the dictates and wishes of its loved ones who care for it in its final days. As for the spirit and the soul, some of us see its eternity and rejoice in its freedom from this mortal coil.

As the funeral card memorializing my patient reads:

"I shall lead you
through the loneliness,
the solitude,
you will not understand;

but it is My shortcut
to your soul."

Grand Rounds With Dr. Serani

Please visit the blog of Dr. Deborah Serani for the newest version of Grand Rounds, the wonderful weekly medical/nursing/allied health blog carnival.