Healthcare, Politics, Cynicism and Hope

If you are aware of the following current statistics vis-a-vis healthcare in the United States, then you are aware that the system is broken and apparently breaking more every day.

• Nursing shortage: 587,000 new needed by 2016
• Physician shortage: expected, indeterminate
• Uninsured Americans: 47 million
• National healthcare costs: $2.1 trillion/yr
• Employment-based healthcare: 9% drop since 1996
• Healthcare premiums, annual growth: outpacing wage increases x 3
• Long-term care: growing need
• U.S. life expectancy: 77-80 years of age
• U.S. population: 305.4 Million
• Median Income: $46,000

And if you're of voting age, then you probably have considered both major candidates' healthcare plans (or perhaps healthcare has simply been overshadowed by the current economic crisis that is sweeping the globe).

At any rate, I have plenty of misgivings about both candidates' healthcare plans (see my previous post entitled Obama, Healthcare, and a Trio of Mythic Figures). While I hope that somehow, as a country, we will some day figure out how to actually provide quality healthcare for the majority of Americans, my inner cynic is strong these days when it comes to the machinations of government, and even the idea of a President Obama and a largely Democratic Congress does not assuage my deeply held feeling that America is simply not up to the task.

On that note, freelance writer Jen Rotman has posted an informative piece about the state of healthcare vis-a-vis the current election on the website Online Nursing Degrees, and I highly recommend giving her article a thorough read.

As a provider of healthcare, I certainly hope for the best when it comes to what will happen when a new Democratic administration gains control of the White House, but in light of the current economic turmoil, I feel little hope for the kind of healthcare reform that this country truly needs.

Perhaps in a year or two, I'll happily eat these words and smile as reports surface, detailing how a miraculous bipartisan show of intellect and economic astuteness actually created a conduit through which affordable healthcare for all was enacted.

Just imagine: every child in America fully insured; elders able to afford their medications; the employed and unemployed fully covered. It's a nice vision, and one to which I will cling by the slenderest thread of hope. But will it happen in my lifetime? Just in case, I won't hold my breath waiting to find out.

Dementia and Devotion

In the home they have owned for more than 40 years, they live their lives as they always have. The same trees are visible through the kitchen window. The grass is still green. The grandfather clock given to them by her parents for their tenth wedding anniversary still chimes in the foyer. The curtains and the sofas haven't changed in years, and the silver flatware in the breakfront drawer still evokes memories of Thanksgiving dinners, birthdays, and family gatherings galore. From the kitchen linoleum to the wood paneling in the family room, little has changed in this cozy suburban home.

While the outward appearances are relatively static, it is her dementia that has permanently changed the calculus of their relationship. It began with mild, transitory forgetfulness, only to slowly escalate into full-blown dementia as the months went by without a formal diagnosis. She would walk into a room and stand there, utterly stumped as to why she was there. He would leave her in the frozen food aisle to look for light bulbs in another part of the grocery store, and when he would return to find her, she would still be there, staring blankly at the ice cream display, apparently lost in thought but actually lost in the absence of cohesive thought.

At a certain point, it was apparent that she could not be alone. She could no longer bathe herself, toilet herself, dress herself, or make even the most rudimentary decisions. Luckily, if a plate of food is placed before her, she will still reflexively use her fork or spoon to scoop up food and bring it to her mouth. Sometimes, the fork spears nothing but air and she must be redirected to bring it down to the plate again. At other times, the food will fall back to the plate or into her lap, but she won't notice. She will bring an empty spoon to her mouth with the same motion and intention as a spoon laden with mashed potatoes. She doesn't recognize the difference, and he monitors her intake with the eyes of a loving, doting husband of 55 years.

He has refused all assistance other than skilled nursing and physical therapy. A home health aide? Never. Meals on wheels? Not a chance. Day care? Unthinkable. She is his project, his object of devotion, the love of his life and the mother of their children. His days revolve around her, and he revolves around her like a moon around a planet with a strong gravitational pull.

Her eyes seem aware, yet it is not clear what they register. She responds to some questions but not others, and it is uncertain how much of her response is reflexive rather than real. Her shuffling gait, her blank gaze, her apparent lack of interest in anything happening around her---these are hallmarks of her state of mind, and he must long for the days of lively conversation and verbal interplay. How lonely he must be, prematurely bereft of his friend, his lover, his bride.

"You see how her hair is set?" he asks. "Friday is Hair Day," he explains. "I wash it, set it, dry it, and then brush it out and spray it. Just like she used to do. We make her beautiful for the weekend when the kids and grandkids come to visit." He smiles proudly.

Sitting in the chair, her hands passively resting in her lap, she stares at me, smiles, and almost looks through me. I hold her hand, tell her I would like to take her blood pressure, and she raises her arm and places it on the table. I thank her for her assistance. She smiles again.

Placing the tools of my trade in my bag after making some final notes, I shake her hand and get up to leave. Her husband walks me to the door and we shake hands warmly.

"You're the model husband, and I can see that she's receiving the best possible care here at home," I say as we shake hands.

"Thank you," he replies. "I try my best. She's all I have, and I want her here with me."

"Let us know if you need more help," I say as I enter the breezeway between the kitchen and the garage. "You're doing a wonderful job and she looks so well-cared for. Take care, and her primary nurse will be back on Tuesday to check that elbow."

"Bye bye, and thanks for coming over." He waves and closes the door.

What other slow and silent human dramas are occurring in the other well-kept homes on this quiet street? How many other spouses are devoting their every minute to the care of a beloved who is no longer quite as healthy and vibrant as they used to be?

Devotion and love are the engines that drive relationships and lead us to selflessly focus our energies on the human objects of that love. Here was a stellar example of how that type of deep, lifelong connection manifests in real life. Despite the sadness and loss that underlie such a situation, the human manifestation of that devotion and love is truly an inspiring sight to behold and an honor to witness.

Blog Action Day---Poverty Around the World

Today is Blog Action Day 2008, and this year's goal is to raise awareness about global poverty by having thousands upon thousands of bloggers use their blogs as virtual soap boxes. With the global economy in turmoil and governments planning massive bailouts of banks the world over, we must not lose sight of those for whom the news of a stock market plunge or a failed bank means nothing. Yes, we must do something to keep the economy afloat, but a bailout of the world's poor is more than paramount, and it doesn't even seem to be part of the conversation.

Almost half the world's population---more than 3 billion people---live on less than $2.50 per day. The Gross Domestic Product (GDP) of 41 of the most indebted countries in the world is less than the combined wealth of the seven richest countries.

Meanwhile, a billion people around the world cannot read or write, and an estimated one billion children live in poverty. Speaking of children, 640 million children live without adequate shelter, 400 million lack access to clean water, 270 million have no access to healthcare, and 29,000 children die every day due to the ravages of poverty. (Please click here for source material.)

29,000 children. Every day. Dying, perhaps in their parents' arms. Perhaps alone. Perhaps in the arms of a sibling or a stranger in a refugee camp. 29,000 children dying every day while we go about our business, fret about our 401(k)'s, and fill our gas tanks on the way to the movies.

29,000 dead children every day. Or, 1 child every 3 seconds, or 20 every minute. That's like a tsunami similar to the one that occured in 2004 happening every day.

What's wrong with this picture?

Many countries have apparently been irreversibly impoverished by the actions of the International Monetary Fund (IMF) and The World Bank as loan programs and economic restructuring policies destroy indigenous food production, flood markets with cheap subsidized grain from the United States, and otherwise cripple developing nations, cutting off their economic legs at the knees.

I'm no economist, but it's plain to see that the global economic and banking organizations that lend money to struggling nations do so by imposing conditions that create a level of servitude and financial share-cropping that is inhumane at best, and criminally nefarious at worst. The gap between rich and poor in the United States is ever widening, and the gap between rich nations and poor nations is so vast as to be unfathomable.

And what kills children around the world in the face of crumbling economies, market bailouts, subsidized American grain, decaying infrastructure, and crippled healthcare systems?

Hunger kills children. Diarrhea and dysentery kill children. AIDS kills children. Measles, mumps, rubella, malaria and tuberculosis kill children. War kills children, as does living in refugee camps without adequate shelter, food, clothing and medical care.

If even a fraction of the world's annual military spending was redirected towards ending poverty, we would be well on our way. In 2006, approximately $1200 billion was spent globally for military purposes. Many experts agree that the eradication of poverty and the forgiveness of the developing world's debt on a massive scale would do more to decrease global terrorism and promote peace than any possible amount of increased spending on military might.

So, as a race of beings living on this troubled planet, we weigh our options. Even as 29,000 children die each and every day, we make choices which do nothing to alleviate the suffering that poverty brings to so many. Even as the American economic system implodes upon itself and drags the rest of the world with it, we choose to rescue those who do not deserve to be rescued, and we turn a blind eye to those who've been waiting in vain for a fabled rescue that may never arrive.

In the hour or so that it's taken me to write this blog post, 1200 children have died somewhere on this planet. 1200 children have given up their lives and joined the scores of others who have also died wholly unnecessary and preventable deaths. Tuberculosis, hunger, measles, diarrhea, dehydration---the reasons are many, as are the causes.

Humanity holds the answer to such problems in the palms of its collective hands. But will we ever act? Will we ever wake up and realize that the fate of all is inextricably bound, that our actions have repercussions far beyond our borders?

Today's 29,000 children all lived lives as valuable as any others. We are too late to prevent today's unnecessary deaths, but perhaps we can still prevent tomorrow's.

Blog Action Day: October 15th---Poverty!

October 15th is Blog Action Day, an annual event wherein bloggers from around the world join together and post about a single subject having to do with improving lives, calling attention to important issues of the day, and sparking a global conversation.

In 2007, Blog Action Day focused on the environment, and in 2008, poverty is the focus of thousands of bloggers who will all post about some aspect of poverty on the same day.

If you're a blogger, please consider joining and adding your voice to the conversation. If you're not a blogger, please consider starting a blog today and making your first post about this crucial global issue. If you are neither a blogger nor a person who cares to become one, please tune in to the Blog Action Day website on October 15th, follow links to some of the many posts submitted, and leave comments for the participating bloggers so that we know you're out there and listening.

Thanks, and please check out this video from the Blog Action Day staff.



Blog Action Day 2008 Poverty from Blog Action Day on Vimeo.

The Irony of Mental Health Parity

(Note: This is my ninth post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)

In June of this year, I reported on Nurse LinkUp that Congress was poised to once again begin a concerted push to pass legislation bringing parity for insurance coverage for mental health, including addiction, eating disorders, and any illness classified in the DSM-IV. That effort basically failed, and it is only now, just prior to the end of this Congress, that mental health parity legislation has actually become law.

We are all by now (nauseatingly) familiar with the $700 billion financial bailout recently passed by Congress and signed into law by President Bush in the waning days of his presidency (more on that in future). As a part of that package, most health plans are now required to cover mental illness and addiction with the same level of access and cost as any physical illness. After years of struggle, editorials abound, almost ubiquitously praising the legislation which was added to the latest---and ultimately successful---version of the bailout plan.

Beginning, I believe, in 2009, all group insurance plans and companies with more than 50 employees must offer health insurance coverage that provides equal benefits for mental health treatment, potentially benefiting 113 million insured Americans, as well as approximately 82 million self-insured Americans who are not protected by state-mandated mental health parity legislation. Interestingly, 38 states currently have some form of parity laws on the books, a fact of which I was previously ignorant.

Paul Wellstone (D-MN), the late Senator from Minnesota, was one of the great champions of the mental health parity cause, along with his colleague Pete Domenici (R-NM). The bill, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, was named for the two senators and honors the posthumous legacy of Wellstone's tireless fight for the rights of Americans living with mental illness and addiction. And it was Senator Edward Kennedy (D-MA) and his son Representative Patrick Kennedy (D-RI), who used their political muscle and clout to ease the bill through the Senate and the House.

As someone who has struggled with depression since childhood, I can attest that obtaining coverage for mental health can be a challenge, especially if one needs ongoing treatment rather than the "episodic care" often covered by many health plans. I can also confirm that many health insurance plans charge much higher co-payments for mental health visits, and impose nonsensical and arbitrary limits on the number of outpatient visits per year.

In terms of inpatient care, insurance regulations regarding mental health are notorious for prematurely cutting short crucial inpatient treatment for mental illness, addiction, and eating disorders. It is plainly obvious that inpatient treatment teams know best vis-a-vis the length of stay which would be most efficacious for a particular patient. Naturally, some oversight should be involved so that billing abuses do not occur, but bureaucrats and statisticians should not be making decisions that only clinically trained professionals should make. The imposition of arbitrary limits on the length of stay for the treatment of such chronic conditions belies the fact that insurance companies are generally more concerned with profitability than the effectiveness and quality of care. In fact, I would hazard a guess that forcing a patient out of detox or an inpatient psychiatric unit before they are clinically ready for discharge more than likely leads to worse outcomes, more frequent relapse, and higher costs over the long term.

Global Ironies: Mind the Gap

Ironically, on October 10th, World Mental Health Day (one week after mental health parity became a legal reality in the United States), the World Health Organization announced that as many as 75% of people living with mental disorders in developing countries receive no care or treatment of any kind. The irony is that while we in the United States pine for lower co-payments and equal access to care, those living in war-torn nations, developing nations, and non-industrialized countries suffer immeasurable harm without even the merest hope of treatment.

The WHO study points out that nine out of ten people in Africa who live with epilepsy are entirely untreated. It also starkly points out that while most countries spend approximately 2% of their health dollars on mental health, one-third of people with schizophrenia, half of those living with depression, and seventy-five percent of those struggling with addiction go untreated worldwide. And tragically, one person dies from a completed suicide every forty seconds of every day, somewhere in the world, mostly due to untreated mental illness.

These numbers tell a story, and even as the United States prepares to tackle the issues of mental illness and substance abuse more fairly, the WHO is calling for governments, foundations, donors and mental health activists to increase funding for treatment worldwide. The program, entitled Mental Health Gap Action Program (mhGAP): Scaling Up Care for Mental Health and Substance Use Disorders, asserts, according to the WHO press release, that "with proper care, psychosocial assistance and medication, tens of millions could be treated for diseases such as depression, schizophrenia, and epilepsy and begin to lead healthy lives, even where resources are scarce."

To bolster their case, the WHO's recent studies demonstrate that "in low-income countries, scaling up a package of essential interventions for three mental disorders – schizophrenia, bipolar disorder and depression – and for one risk factor – hazardous alcohol use – requires an additional investment as low as $US 0.20 per person per year." Claiming that treatment of mental illness, addiction and neurological disorders such as epilepsy should not only be "evidence-based" but "value-based", the WHO plan includes "assessing countries' needs and resources; developing sound mental health policy and legislation; and increasing human and financial resources" in order that "people with these disorders are not denied opportunities to contribute to social and economic life and that their human rights are protected."

Global Parity: A Laudable Goal

So, as mental health parity becomes law in the United States and we continue to wrestle with the needs of the uninsured and the under-insured, the rest of the world---especially the developing world---needs our assistance to offer even the most basic of mental health care to millions and millions of deserving citizens. Mental health is not a luxury, and many in the fields of mind-body medicine (and also mainstream medicine, for that matter) strongly believe that good physical health is simply not possible without solid mental health. In fact, recent research demonstrates quite clearly that untreated depression can absolutely lead to physical symptoms including chronic pain.

I would assert that those who have so valiantly and tirelessly fought for the rights of the mentally ill here in the United States should now challenge themselves to broaden their visual field, take in the big picture of global mental health, and direct some of their energies in supporting the timely efforts of the World Health Organization.

As the global financial system continues its apparent implosion, we can naturally expect the incidence of anxiety, depression and substance abuse to rise as people attempt to manage lives thrown into chaos by economic hardship. We in the United States recently won a long twelve-year battle, happily enough. But now is not the time to rest on our laurels. Now is the time for action on a global scale. It is in humanity's best interest to see that all people have access to treatment for improved mental health, and it is our moral and ethical duty to further that cause.

China Off the Hook

Based on yesterday's post, most readers must have surmised that I have strong feelings about the Chinese government. Those same readers can also correctly surmise that I am disappointed this morning that none of the Chinese dissidents on the short list for the Nobel Prize were nominated. I'm sure that the Chinese government is breathing a sigh of relief, a reprieve that they simply do not warrant.

As I wrote yesterday, the awarding of the Peace Prize to a Chinese dissident struggling for basic human rights would have offered a counter-weight to China's moment in the sun as the undeserving host of the 2008 Summer Olympics. But that was not meant to be.

This morning, the Nobel Committee announced from Oslo that it was awarding the Nobel Peace Prize to former Finnish President Martti Ahtisaari for his role as an effective and accomplished global mediator who influenced the resolutions to conflicts in Kosovo, Namibia, and other troubled countries. While I am sure he is a very deserving and esteemed individual, I cannot help but regret the great opportunity squandered by the Nobel committee to make a globally impactful statement about China's continuing repression of free speech and political and religious freedom.

Perhaps next year will be the time when China's dissidents receive the attention, recognition and notoriety that they deserve. Many of us already know that China's ability to unrealistically polish its image only gets easier as its global economic power and influence grows, even as its penchant for environmental degradation and rampant repression of freedoms goes unchecked.

The Nobel Peace Prize: Dissidents On the Short List

Tomorrow, Friday the 10th of October, the winner of the Nobel Peace Prize will be announced. Following on the heels of the prizes in medicine, physics, economics and literature, the awarding of the Peace Prize is the crowning moment of the Nobel process.

Rumor has it that Gao Zhisheng, a Chinese dissident, will be awarded the prize. Zhisheng, who has been arrested, detained, and almost assassinated due to his role as the winning lawyer in a case against the Chinese government for the religious freedom of practitioners of Falun Gong, was kidnapped in 2007 and has never been seen again. It is believed that Gao is in the custody of Chinese authorities, that he has suffered torture at the hands of Chinese authorities, and that he was removed from Beijing during the Olympic games following a suicide.

Many of us around the world felt strongly that the International Olympic Committee's decision to give the Chinese the opportunity to host the Olympics sent the wrong message to a country where religious persecution and the revocation of basic freedoms is still widespread. The irony of China's sugar-coating of its horrendous environmental policies and deep-seated political myopia is not lost on those of us who opposed Beijing's hosting of the Olympics on moral and ethical grounds.

Thus, the awarding of the Nobel Peace Prize to a well-known missing Chinese dissident would be a well-deserved slap in the face of a country that still has not learned to value the diversity, individuality, and basic human worth of its citizens.

Reflections on Doctors Has Been Published

I am very happy to announce that a chapter which I submitted to Kaplan Publishing for inclusion in a new book of non-fiction by nurses has been included in the recently published volume, Reflections on Doctors: Nurses' Stories About Physicians and Surgeons.



The book is the first in Kaplan's newest series, and I am honored and thrilled to have been included. I cannot reproduce my chapter here on Digital Doorway, so the only way for interested readers to actually read my submission is to buy the book or to some day check it out of a library.

A review of the book has been published on Blissful Entropy, a wonderful nursing blog.

Here is Kaplan's press release about the book:

FOR IMMEDIATE RELEASE

REFLECTIONS ON DOCTORS Nurses’ Stories about Physicians and Surgeons

Editor: Terry Ratner, RN, MFA

Anyone who has been a patient or visitor to a hospital knows that the long-time image of nurses as helpful ladies in white who administer IV’s and wake patients every four hours to take their temperature, is not the role of modern-day nurses. Coming from varied educational paths and scopes of practice that place them side-by-side with doctors, nurses are no longer the “obedient handmaidens” to doctors that they once were perceived to be. If they disagree with doctors’ orders, nurses today can and do refuse them. The relationship and power dynamic between nurses and doctors has evolved with nurses now trained to ask questions and seek answers.

Through nearly two dozen provocative essays REFLECTIONS ON DOCTORS: Nurses’ Stories about Physicians and Surgeons (Kaplan Publishing; September 2008; $14.95 Paperback/$16.95 Canada), readers are taken behind the closed doors of the OR, the rapid pace of the ER and to many other venues where medical situations are exceedingly intense, and the integrity of the intertwined relationship between nurses and doctors is consistently challenged.

As REFLECTIONS ON DOCTORS’ editor Terry Ratner, RN, MFA says, “The nurses of this anthology represent a spectrum of voices and perspectives, reflecting upon their work alongside physicians. The majority of these nurses have witnessed revolutionary changes in the nurse-physician relationship over time. They are our messengers, our heroes and our scribes.”

The intimate and at times shocking stories in REFLECTIONS ON DOCTORS abound with the honesty of each writer’s respect of and concern for the nursing profession, and the care that patients receive from doctors and fellow nurses alike. For example, in her fascinating essay A Truth about Cats and Dogs, Adrienne Zurub, RN, MA, CNOR says of the competitive environment within the cardiothoracic operating rooms where she has worked, “Arrogance, entitlement, outstanding talents(nurses and surgeons), and palpable confidence dominate the entire operating room suites. A nurse pushes herself or himself through this encompassing fog of testosterone. I say testosterone because the surgeons, the ones who are in charge, are all male. To work in this environment, one has to have the personality and the chutzpah—the balls—to think quickly and react perfectly. Weakness or hesitation is normally not considered an option.”

Readers are further privileged to the gentle musings of nurses such as Keith Carlson, RN who in his essay Where the Heart Rules states, “What I have learned in partnership with these outstanding doctors is that nurses, although often undervalued in outpatient settings, can serve in proactive, clinically meaningful roles if doctors willingly and consciously choose to utilize their specific skills and knowledge base.”

Many of the essays in REFLECTIONS ON DOCTORS provide readers with clear-cut explanations of various medical terminologies, interesting history of the nursing profession and glimpses into its future. The diversity of all the essays is appealing to both new and seasoned nurses, as well as to someone simply interested in understanding the importance and ever-changing relationship between nurses and physicians. Further topping off this collection of engaging essays is a reader’s guide designed to, says Ratner, “stimulate meetings of the minds and begin crucial conversations in hopes of understanding the nurse-physician relationship.”

# # #
REFLECTIONS ON DOCTORS
Nurses’ Stories about Physicians and Surgeons
Terry Ratner, RN, MFA, Editor
Kaplan Publishing
September 2008
$14.95 Paperback/ $16.95 Canada
ISBN 978-I-4277-9825-I/ Nursing

ABOUT THE EDITOR
Terry Ratner is a registered nurse, freelance writer and creative writing instructor. Her nursing career has spanned more than 17 years at Banner Good Samaritan Medical Center, a level-one trauma hospital in Phoenix. She has written for many publications including NurseWeek, Nursing Spectrum and John Hopkins Nursing.

Public Health and Me

Tomorrow, I begin my position as interim Public Health Nurse right here in my own New England hometown. Having never worked in my town (after almost fifteen years of residence in the area), it will be an interesting experience to actually be a "public figure" for the first time.

While my position is indeed interim, I'm coming on board just at the beginning of flu season, and since I'm the individual who literally holds the key to the town's flu vaccine supply, I have an idea I am about to become very popular.

Understandably, everyone is anxious to get their flu shot. The elderly residents of the town see the annual flu clinic and make-up flu clinic as an inalienable right, and the government's push for the majority of Americans to be vaccinated this year has driven this point home quite widely. Town employees, police, EMTs and firefighters also need to be vaccinated quickly and efficiently in order to decrease the likelihood of such essential personnel being sickened over the winter.

With the CDC and other government agencies expecting this year's vaccine to be more effective than last year's, I'm expecting a great deal of interest in and around town vis-a-vis the influenza vaccine. Our clinics will most likely be very busy events, and I'll need to champion that cause and do it well.

Meanwhile, I'll be taking care of daily infectious disease surveillance, TB case management, as well as other sundry responsibilities that I guess I'll figure out tomorrow.

I start this new job knowing that I'm standing on the shoulders of Lillian Wald and other famous nurses who had the vision of actually creating the institution of public health nursing in the first place. It's an honor to enter this new arena of my profession/vocation, and I look forward to growing personally and professionally throughout the process.

The Autumn Harvest Change of Shift

The newest edition of Change of Shift, hosted by yours truly over on Nurse LinkUp, is now up and running for your reading pleasure. Please pay us a visit!

Economics and Confusion

Thinking further about the economic issues that I touched on in my last post, it's so hard to get one's brain around what's happening here in the U.S. this week. With such dire news and warnings of financial Armageddon, how does one tease out the truth from all of the hyperbole?

Articles abound about what will happen if the bailout doesn't pass. Blame is passed from hand to hand. But where do we ordinary citizens fit in? What do we stand to lose or gain in the process?

Economics is one area where this nurse is most weak when it comes to understanding the bigger picture. Understanding my own personal economy is difficult enough. But I just can't stop thinking that many of the people in need of a bailout themselves are going to be left in the dust no matter what happens.

Whether we look at the notion of fighting poverty, rejecting what seems like a rescue of Wall Street, or using that $700 billion to help Americans keep the homes they are about to lose, there is enough confusion and different versions of "the Truth" to keep us all reeling from a dose of 21st century financial vertigo.

At this time in history, there are intelligent arguments in favor of nationalized healthcare, while Americans are going into bankruptcy just to pay for healthcare they can't afford but literally can't live without. Meanwhile, many people are losing their homes in record numbers and Wall Street speculators and investment banks look to the federal government to rescue them from their own excesses.

So, where is the bailout for the thousands of poor Gulf Coast residents who lost their homes and have still not been able to return home?

Where is the bailout for first responders disabled in the aftermath of 9/11 and unable to return to work and normal life?

Where is the bailout for the homeless, the uninsured children, the wrongly incarcerated, the disenfranchised, the disabled?

Where are the reparations for slavery? For Native Americans?

These are just some of the questions that come to mind as the sum of $7 billion is bandied about so blithely.

Economics and the Elderly

(Note: This is my eighth post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)

So, as the bad news splashes across the headlines and the denizens of Wall Street throw up their hands to ward off the falling sky (that they themselves created), the elderly here in the United States are facing some tough economic times of their own as we turn the corner to 2009.

Reports now tell us that premiums for drug coverage under Medicare Part D will rise an average of 31% in the coming year. For some seniors, most of whom are on fixed incomes, a monthly increase of $50 to $100 could spell economic disaster, especially when one considers the simultaneous (and often astronomical) rise in the cost of food, gas, general healthcare costs, home heating, and other necessities.

As I recently reported in an article on Nurse Linkup, Bloomberg, The Associated Press, medical websites, and other independent news outlets are all reporting the inevitability of these increases, the writing already being on the proverbial wall.

To add insult to injury, changing Medicare rules may make some seniors' lives a living hell as they attempt to navigate the shifting sands of Medicare Part D.

And just as the economic climate intensifies with bad news and dire forecasts, American seniors also face the daunting task of negotiating the spending caps created under the Medicare Part D regulations. These rules limit annual reimbursements for medications to $2,510. When this magic number is reached, Medicare recipients must then be on their own purchasing medications until they have spent a total of $5,726, whereby Medicare will begin paying for medications once again. Confused? You should be. If some fortunate seniors are able to purchase expensive "gap coverage" for this period of time, they may break even or come out slightly ahead. For those unable (or too confused or intimidated) to do so, their economic peril may await.

So, what does this say about our country? Who are we? What are we doing to our seniors and disabled citizens? When pharmaceutical lobbyists have more influence than seniors (and their advocates) in the writing of the Medicare Part D regulations, we all know who loses.

Senior citizens are vulnerable members of our society, many of whom have worked all their lives, diligently paid their taxes, and now must struggle to make ends meet in the Autumn and Winter of their lives. Sure, the global economic crisis has indeed cast its pall on almost everyone, but even as the U.S. Congress holds midnight meetings to rescue Wall Street from its excesses and errant ways, no one is talking about how to rescue vulnerable and sick seniors as they fall down their own financial rabbit hole.

No doubt, even as the "rescue" ensues, some CEOs and others in power will somehow come out ahead, making off with money that is not rightfully theirs at a time when that money should be trickling down rather than up.

When I think of the cold months of winter ahead, I think of middle class and working class senior citizens who honestly don't know how they'll make ends meet. Meanwhile, in the halls of Power, there's money to be traded----and made.

The ADN Track: History and Diversity

Please click here to read my recent article (published on Nurse LinkUp) regarding the history of Associate Degree nursing programs, an affordable educational trend which diversified the field of nursing and afforded many people like myself a convenient and fulfilling educational experience.

Interim Public Health Nurse

Today I accepted a temporary position as the Interim Public Health Nurse for my town of residence, ten hours per week! The nurse who has been in the position is leaving after thirteen years (to become a school nurse, of all things). I am stepping in for at least three months and will be responsible for disease surveillance, Tuberculosis Case Management, immunization tracking and clinics, and other public health issues. I am excited and nervous, and could be in the running for the full 26-hour position at the beginning of 2009.

Survey of Medical Bloggers Now Published

In late 2007, I was contacted by a research group at The University of Rijeka School of Medicine in Croatia. This group was conducting a study of medical bloggers, their blogging habits, and their motivations for blogging. The study, entitled Examining the Medical Blogosphere: An Online Survey of Medical Bloggers, has been published in the Journal of Medical Internet Research (JIMR), the "leading peer-reviewed transdisciplinary journal on health and healthcare in the Internet age".

To read this very interesting paper, please click here, and a slide show of the findings can be found posted on the blog of one of the article's lead authors.

I was honored to be involved as a anonymous subject of the survey, and feel that increased attention to the importance of blogging on the fields of medicine, nursing and healthcare is crucial at this time in history.

Blogging has indeed revolutionized journalism. It has also created a uniquely twenty-first century portal for the dissemination of information vis-a-vis the world of medicine from a variety of sources, filtered through the personal experiences of individuals within the healthcare field. Nursing is of particular interest to me, of course, and I can see that blogging has become a tool of empowerment for many nurses, allowing the profession yet another "voice of agency", to paraphrase Bernice Buresh and Suzanne Gordon, the brilliant authors of From Silence to Voice.

It is my hope that this survey and article by the team from The University of Rijeka will serve as an impetus for further study of the phenomenon of medical and healthcare blogging. I would also encourage researchers to more closely examine the more narrowly defined field of nurse bloggers, who have truly begun to find their collective voice over the last few years.

My thanks to the University of Rijeka team, and additional thanks to the Journal of Medical Internet Research for their recognition of the importance of blogging and its intersection with nursing, medicine, and healthcare.

Nurse LinkUp to Host Change of Shift!

Hear ye! Hear ye! Nurse LinkUp will be the host of the next edition of Change of Shift, (the premier blog carnival for nurse bloggers) which will be posted in its glorious entirety on October 2nd, 2008.

Deadline for submissions is high noon on Tuesday, 9/30/08. Please email all entries to nursekeith@gmail.com.

Remember--you don't have to be a nurse blogger to submit, but the post should be related to medicine, nursing, health, healthcare, etc.

The Office of the National Nurse

(Note: This is my seventh post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)

Unbeknownst to many Americans, a grassroots campaign to create an Office of the National Nurse has been underway for several years. While many in the nursing community recognize that the Surgeon General plays an important role in managing and overseeing the health and health education of the nation, it is also recognized that nurses are woefully underrepresented when it comes to our national priorities vis-a-vis healthcare and prevention.

With a global nursing shortage in full swing at this pivotal historical time, we still see that neither presidential candidate in the current race fully acknowledges (or plans to adequately address) the shortage and its potentially devastating effects on the health and healthcare of the country. Many involved in the campaign to create an Office of the National Nurse feel that the office "would strengthen efforts by nurses in every community to assist in initiating a nationwide shift to prevention to yield improved health outcomes" nationwide.

Since 1871, the Surgeon General of the United States---the nation's "chief health educator"---has overseen and guided the health of Americans. Charged with overseeing the U.S. Public Health Service, the Surgeon General is appointed by the President and approved by Congress for a four-year term. According to the official website of the Surgeon General, this individual's duties include, but are not limited, to:

• Protect and advance the health of the Nation through educating the public, advocating for effective disease prevention and health promotion programs and activities, and, providing a highly recognized symbol of national commitment to protecting and improving the public's health
• Articulate scientifically based health policy analysis and advice to the President and the Secretary of Health and Human Services (HHS) on the full range of critical public health, medical, and health system issues facing the nation
• Provide leadership in promoting special Departmental health initiatives, e.g., tobacco and HIV prevention efforts, with other governmental and non-governmental entities, both domestically and internationally
• Administer the U.S. Public Health Service (PHS) Commissioned Corps, which is a uniquely expert, diverse, flexible, and committed career force of public health professionals who can respond to both current and long-term health needs of the Nation
• Provide leadership and management oversight for PHS Commissioned Corps involvement in Departmental emergency preparedness and response activities
• Elevate the quality of public health practice in the professional disciplines through the advancement of appropriate standards and research priorities, and
• Fulfill statutory and customary departmental representational functions on a wide variety of federal boards and governing bodies of non-Federal health organizations, including the Board of Regents of the Uniformed Services University of the Health Sciences, the National Library of Medicine, the Armed Forces Institute of Pathology, the Association of Military Surgeons of the United States, and the American Medical Association.

From a nurse's perspective, what is missing from the Surgeon General's overall equation is the more robust input of a nurse who would serve more as an equal to the Surgeon General in terms of his or her ability to effect and implement healthcare policy in the interest of the American people. At this time, the U.S. Public Health Chief Nurse Officer (CNO) serves as Assistant Surgeon General, representing the Surgeon General's interests and opinions, and otherwise working in a subjugated role that the medical community might deem fit for a nurse.

The goal of the organizations and individuals behind the drive for an Office of the National Nurse is "to elevate and enhance the Office of the PHS Chief Nurse to bring more visibility to the critical role nursing occupies in promoting, protecting, and advancing the nation's health."

The proposed role of the National Nurse would be to:

• Assist in the initiation of a nationwide cultural shift to prevention.
• Bolster efforts to focus the public on healthy living.
• Intensify roles for nurses, including students and retirees, in community health promotion.
• Provide greater support to the Surgeon General in calling for improvements in health literacy and reduction in health disparities.
• Encourage all nurses to spread prevention messages in their communities.
• Encourage participation of nurses in Medical Reserve Corps (MRC) units.
• Provide leadership to network with existing volunteer health promotion efforts.
• Strengthen linkages with providers, nursing programs, and public health leadership.
• Serve as a visible national spokesperson for professional nursing.
• Increase public awareness of nursing roles and contributions.
• Enhance nursing recruitment and education throughout all communities.
• Support and justify additional funding for nursing education, research and service.

The National Nurse would work to slow the growth of preventable diseases; promote health awareness, increase health literacy, and reduce health disparities; promote health careers and increased resources; enhance visibility and public recognition of nursing.

It is the opinion of many involved in the call for the establishment of the Office of the National Nurse that it is time for nursing to have a seat at the nation's healthcare table. While some might argue that the aforementioned Chief Nurse Officer of the U.S. Department of Public Health already adequately fulfills that role, most still see that role as one of subservience to the Surgeon General rather than one of professional equality. Just as nurses are rarely consulted by the media for their expert opinions vis-a-vis the various challenges faced by the nation and its beleaguered healthcare system, the government also fails to fully utilize nursing's unique and crucial input to the fullest extent possible, in the interest of the health and well-being of the American people.

The establishment of the Office of the National Nurse would set a new standard for a more accurate and realistic recognition of nursing's importance to health and healthcare in the United States. If the federal government enthusiastically and publicly embraced nursing, making its crucial contributions crystal clear, perhaps the public, the media and the private sector would all then have a greater understanding of, and appreciation for, the multitudinous ways in which nursing impacts the health of millions of Americans.

Most importantly, however, the establishment of this office would certainly bring an important voice even more strongly to the ongoing conversation about health and health care in America. A National Nurse could, in effect, deliver a unified message of preventive health at a time when millions of Americans---including millions of children---live without health insurance or access to regular primary care. At a time of crisis and uncertainty vis-a-vis the health of the country, the Office of the National Nurse could very well be a welcome, stabilizing and empowering voice of reason and prevention.

I fully support the drive to establish such an office, and hold out hope that a new administration will recognize nursing's contributions to the health of the nation, and give thoughtful consideration to an idea whose time has come.

The Prospects for More Meaningful Work

Sometimes things just happen. Yesterday I received an email from the person who serves as the Public Health Nurse for the little college town where I live (population: 20,000 residents + 25,000 students, more or less). She's stepping down from her post and the town is looking for an interim part-time nurse (10 hours per week +/-) to organize, plan, and implement the town's flu clinics for the season, as well as track the handful of TB cases and other reportable diseases in the area.

A few emails and a phone call later, and a meeting has been set up for me to discuss the position with the Powers that Be. No muss, no fuss. Perhaps not even a formal interview. (One confounding factor: I have tickets to fly to Brussels to visit old friends and will be gone November 4th-12th. Deal breaker? We'll see.)

Meanwhile, I await a call for an interview in the local inpatient psych unit.

More meaningful and remunerative work may be just around the corner.

Nursing Away From the Hospital

I am an occasional guest blogger on NurseConnect. Please click here to read my latest column which was submitted in response to a question regarding my choice of specialty: ambulatory care, home care, and hospice.

I Did It

Well, I did it. After twelve years of eschewing taking a job in a hospital, I have applied for a part-time position in a local inpatient psychiatric unit. Things have been very slow at all of my per diem jobs, and while I'm very hesitant at this juncture to commit to a solid position, finances are telling me that it may be time to at least have 16 or 20 hours of assured work each week. So, this 24-hour per week position consisting of two 12-hour shifts may fit the bill.

Although I swore off the dreaded "two years of Medical-Surgical nursing after graduation" (something I was told at the time was professional suicide), I just recently decided to apply for this position as a stop-gap measure at a time when I am need of more regular work. Granted, I have been quite determined in my anti-hospital stance, but working in a psychiatric milieu is a far cry from the rigors of Med-Surg, and since I've done such a great deal of outpatient psychiatric nursing, perhaps it's high time I take a peek "on the inside".

Anyway, I haven't even had a call back for an interview yet, so please stay tuned for the developments vis-a-vis this interesting turn of events.

Nurses' Voices, Nurses' Image: Nurses' Power

(Note: This is my sixth post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)

I have recently been re-reading From Silence to Voice: What Nurses Know and Must Communicate to the Public, by Bernice Buresh and Suzanne Gordon. What I am most struck by is that nurses still have not necessarily found their collective voice, and despite the media attention given to the global nursing shortage, I still believe that Buresh and Gordon's thesis still holds true: the public still does not fully understand what nurses do, and until that day comes, nurses' real value as clinicians will not be common knowledge.

Buresh and Gordon touch on many themes and areas of interest vis-a-vis nurses and their relation to the public, to doctors, and to one another. While I will not provide a review of the book---nor a comprehensive enumerating of its content---there are certain area which pique my interest, and I encourage curious readers to order a copy of the book and explore some of these issues for themselves.

Doctors Cure, Nurses Care

When I first heard this phrase, I was moderately disturbed by it for several reasons. Doctors, by and large, receive the lion's share of praise and gratitude when a sick patient is cured of an illness. Granted, doctors undergo a great deal of training and education in order to offer curative treatments for a variety of diseases, yet all too often, the work of nurses is grossly overlooked when it comes to successful treatment. While nurses do indeed carry out many orders originated from doctors, nurses use their own brand of critical thinking and autonomous action in order to perform specialized patient care. The public may not be aware of this fact, but many actions taken by nurses are initiated by nurses themselves, and the professional clinical assessments performed by nurses will often lead to changes in treatment and greater overall success.

Sure, nurses care, and nursing is seen by the public as a "caring" profession. However, nurses utilize scientific methods, skilled observation, and keen assessment skills to monitor patients' progress. Nurses are not just "the caring eyes and ears of doctors"---nurses are skilled professionals fully involved in patient care---and patient cures.

The Nurse as Angel, Teddy-Bear, and Child

In their book, Buresh and Gordon make one thing clear: nurses' self-presentation says a great deal to the public, and images of nurses that instill themselves in the societal zeitgeist are difficult to dispel.

Somewhere along the line, the "angels of mercy" moniker became attached to nurses as a group. Granted, in the early days of nursing, nurses' ability to act autonomously was extremely limited, and we were, by and large, the handmaidens of deified doctors. However, as much as that regrettable history has largely changed, the image of the nurse as angel unfortunately persists quite widely in our culture and websites galore promote gifts and baubles that continue to diminish nurses' professionalism. Images such as this one drive home the point: nurses are childlike individuals with starched white hats who love teddy-bears. Adding insult to injury, nurses can actually be depicted as winged angel/teddy-bears, further enforcing the infantilization (and deprofessionalization) of our profession. Would doctors allow themselves to be thus represented to the public?

Rather than being perceived as cherubic angels and childlike creatures, this writer feels that being perceived as the valuable and skilled professionals who we truly are would allow the public to have a much more accurate perception of what we do, and our importance to the care of millions.

The Clothes on Our BackNurses' uniforms have certainly changed over the years, and as scrubs have become the norm for nurses in most clinical settings, many companies have capitalized on the popularity of such utilitarian clothing. Now, designer scrubs covered with angels, teddy-bears (there they are again!), and any number of cartoon-like images adorn the hard-working bodies of nurses around the world. If nurses want to be taken seriously by the public---and by doctors and other professionals---how does the wearing of such (in my opinion) unprofessional clothing help our cause?

Picture this: a team meeting occurs midday to discuss a patient on the adult oncology floor. Present at the meeting: a medical resident, a medical student, the attending doctor, the oncologist, two unit nurses, a social worker and a respiratory therapist. Of all of the professionals in the room, who would possibly be wearing pink scrubs covered with teddy-bears and hearts, and a pin on her chest saying "Doctors Cure, Nurses Care"? And what message does this convey about the nurse's self-image and how the other professionals present in the meeting should perceive him or her?

What's in a Name?

In From Silence to Voice, Buresh and Gordon make their case that nurses being addressed by first name only is also a major image problem when it comes to the public's perception of us a collective whole.

When doctors introduce themselves to patients or other professionals, they always do so by using the title "Doctor" before their name. This practice immediately creates an impression that the doctor is a professional, that he or she has a name that should be remembered, and a hierarchy of power and authority is clearly established from the start.

Conversely, we nurses almost ubiquitously introduce ourselves by first name only, ostensibly to break down the barriers between patients and nurses, assisting the patient in overcoming fears and anxieties related to their treatment. While this tactic may have some limited benefit, Buresh and Gordon argue that "if nurses introduce themselves by their first names only, they are asking to be regarded as nonprofessionals because that is the conventional way that nonprofessionals present themselves."

The "first-name only convention", as the authors have named it, makes it significantly more difficult for individual nurses to receive recognition for their work when only their first names are known. It also creates a hierarchical structure in which the doctor stands alone as a figure of authority, towering above the patient and nurse with (patriarchal or matriarchal) power and authority.

Interestingly, many nurses will argue that introducing ourselves as "Nurse Smith" or "Nurse Cadmus" is awkward at best, but also brings to mind the infamous "Nurse Ratched" from "One Flew Over the Cuckoo's Nest". Granted, Nurse Ratched is a mythic and hated figure in the pantheon of film and modern literature, yet do we see doctors eschewing their well-earned title due to historical figures such as Dr. Kevorkian or Dr. Mengele (of Auschwitz fame)? Absolutely not. Doctors use their title so commonly and so frequently that the word "doctor" simply holds too much cultural power to be diminished by one literary (or real-life) character who used that title for ill.

As for "naming practices" between doctors and nurses themselves, further examples of an unequal playing field emerge, with nurses almost continually subjugated to a diminished status by always being addressed by first name by both patients and doctors, whereas doctors maintain their professionalism and authority through the use of their title and last name.

Taking Credit Where Credit is Due

All too often, the work of nurses is diminished by nurses themselves. When thanked for their work, nurses will frequently say, "Oh, I didn't do much. The doctors really did the hard part." Or when a nurse is asked what he or she does, the answer will often be, "I'm just a nurse." This diminution of nurses' worth does little to cement in the public's collective mind the utter importance---the crucial presence---of nurses in the healthcare system. The "just a nurse" phrase---used all too painfully often---hurts nurses' cultural standing and diminishes the profession in the public's eye.

Nurses need to stand up and take credit for the work that they do. Buresh and Gordon urge nurses to say "You're welcome" when they are thanked. "I am so glad that I could assist you in learning so much about your diabetes, Mr. Smith" or "It was my pleasure to provide your post-operative nursing care, Mrs. Jones"---these are statements that take credit for nurses' actions, acknowledge patients' gratitude, and accept responsibility for providing crucial nursing care that directly impacts patients' recovery and health.

Nurses' Agency

Buresh and Gordon recommend that nurses discover their "voice of agency". According the authors, "the voice of agency is the voice that says: 'I helped the patient to walk after surgery so that she wouldn't get blood clots in her legs' or 'I taught the patient how to take his medications so that they would be effective and produce fewer side effects.' The authors further illustrate their point by reminding us that "the voice of agency is the voice that conveys the message, 'I'm here. I am doing something important.' "

For nurses to develop their own agency---their own power---nurses must first claim and recognize the importance of what they do. As Buresh and Gordon elucidate so clearly in their book, patients do not learn self-care skills in a vacuum. Someone must teach them those skills, and it is nurses who bring their knowledge and education directly to patient care. When recovering from surgery, it isn't doctors who monitor patients every fifteen minutes, using a lifetime's worth of learning to perform important expert assessments. Nurses use a wide variety of skills---often on an autonomous basis---to provide patients with the care and attention they need for optimal health.

While nurses are indeed held in very high esteem by the general public in surveys and polls, most members of that adoring public would be hard pressed to actually describe what it is that nurses do. As Bernice Buresh and Suzanne Gordon make so abundantly clear, it is up to nurses to claim their rightful place of importance in the care provided to patients in a variety of settings. Nurses need to proudly speak of their work with a voice of agency and power, and communicate clearly---to the public, the media, their families, their friends, and their colleagues---that nursing is important, that it is meaningful, and that what nurses do contributes to successful patient care and positive outcomes. We must forgo the teddy-bears, the hearts, the flowers, the useless diminutive statements and self-deprecation, and claim our professionalism for our own.

Nursing's voice must be heard, and Buresh and Gordon feel that the time for that voice to be clearly heard is now.

Creative Responses to the Nursing Shortage

I am an occasional guest blogger on NurseConnect, and I invite you to read my latest post, Creative Responses to the Nursing Shortage, posted on NurseConnect today. I think the post offers an interesting perspective, detailing ways that individuals, educational institutions, and healthcare facilities are responding to the crisis at hand.

Nine Months' Gestation

It is now nine months since I eschewed full-time work (after twelve years of having my nose on the nursing grindstone), and I am examining both where I was and where I am now. Questions abound, but answers seem resolutely elusive.

There is something to say for the regularity of a full-time job. A steady pay-check is a type of financial stability that most people see as a gateway to economic ease (or at least some semblance of economic ease if the pay is moderately good). That reliable deposit into the checking account is a means to an end, allowing one the ability to put food on the table and gas in the ever-hungry tank. That said, when one decides to piece together a livelihood, there is certainly room for shakier ground and relative uncertainty.

Whether working per diem, full-time, or part-time as a nurse, one always has the feeling that one's skills are in demand. Still, finding work of interest, coordinating multiple scheduling needs of various employers, and allowing some open time for that unexpected call----it is all a juggling act extraordinaire.

After nine months of putting together a per diem lifestyle, I am entering the Autumn feeling somewhat tired from the uncertainty but simultaneously hesitant to make any solid commitment on a weekly basis to any one employer. Sure, some steadier income would be nice, but the flexibility that my new work- and lifestyle have bestowed upon me is truly difficult to consider giving up. Beyond being a juggling act, it is a conundrum, a paradox, a riddle for the earnest nurse to solve.

When visiting my former workplace as a per diem consultant, I see how my former colleagues are still slogging away in the trenches of front-line urban healthcare. As attractive as that mission is (both personally and politically), serving the poor, disenfranchised and chronically ill is no picnic, and I left that world nine months ago for a very good reason: stress was causing me to become ill, and that constellation of illness was thoroughly depleting my life force and joi de vivre.

Now, working from home part time and piecing together a different sort of work life, I wonder how long I will carry on doing what I'm doing. Nursing always allows one great breadth of choice in terms of what one does at work, and I have even had thoughts that there may be---one day---a time when "Nurse" is no longer part of my identity. Still, for now, nursing is part and parcel of my being and identity, and I continue to put together a personal life that makes sense and brings at least some money to the table.

After all, when it comes to work and stress, if I compromise my health in the interest of work, there will be nothing of me left to enjoy the fruits of my labor. So instead of working more in order to have more, the key is most likely in wanting less, consuming less, and thus working only enough to meet my modified needs. But then again, that is so fundamentally un-American. What is the earnestly thoughtful nurse to do?

Nine months' gestation finds me in a thoughtful place. What will another nine months bring? I am as curious as you, dear Reader, and I only hope that any further vocational labor pains are gentle as I ride the waves of this ongoing challenge.

Change of Shift Goes Pulp Fiction

The newest edition of Change of Shift, everyone's favorite nurse blog carnival, is now up and at 'em at Nurse Ratched's Place. (Even yours truly got in on the action this time.) Enjoy!

Thoughts Turned to The Gulf Coast

I am simply thinking today of the many citizens of the American Gulf Coast who are living as evacuees, wondering when they can once again go home, and when life can once again resume some semblance of normalcy.

My thoughts also stray to the vulnerable patients evacuated to safer ground, the healthcare personnel who have risked their own safety to remain with those too frail to travel, and the families of those few patients who died during evacuation.

The experience of repeated trauma and stress can certainly take it toll, and my heart goes out to those once again living on the edge.