With the dying of my patient last week, the transfer of a time-consuming patient to a nursing home, and another patient discharged from the hospital today, there is a temporary lull in the proverbial storm. Thank you, Powers That Be!
Luckily, my work life has taken a turn towards quiet this week as things at home are in full swing. Our newly renovated basement apartment is now rented, a painting party last night (including the new tenants) finished a first coat on almost all of the walls, and that home-under-construction feeling is almost done, the operative word here being "almost". Until the new tenants have moved in, the small touches and fixes completed, and a sense of normalcy ensues, I won't feel completely able to rest at home. It's recently seemed like we're under seige, with the normal routines somewhat convoluted and the fabric of our daily lives slightly altered. When is life not altering in some unforgiving way, you ask? Rarely is it not, but the crispness and coolness of autumn will be welcome as the home-front settles down.
Four weeks into my third semester of teaching nursing, my prep-work from last year is now bearing fruit. Without having to study, take notes, prepare lectures, and create overheads every week, I am relieved of the constant preparation and now feel like I can more fully enjoy teaching, although those 13-hour Thursdays are wearing at times. Nonetheless, I love sharing my knowledge---such as it is---and trying to inspire yet another group of interested adults as they enter the nursing world. It's one thing to discuss pathophysiology and medications, but it's a completely different pursuit to actually explain what one does as a nurse, especially when speaking of the intangible, the ethereal, the energetic/intuitive aspects---this is the "art" of nursing. One must not forget the pathophys, but one must also bear in mind the humanity of the person behind that anatomy and that illness. Memorization can get one just so far, and then the emotional and spiritual aspects of one's self must emerge and connect with others meaningfully. Imparting this is a challenge, especially in a classroom setting. I hope that my colleagues on the clinical front can take time to address the real human needs of our students' patients. It is still humbling to teach, and even more humbling to know that my words are guiding and shaping human minds that will directly address the physical, emotional, and spiritual needs of the ill and dying.
May my words be effective in communicating what needs to be said clearly and efficiently. May these students go out into the world and touch others in a way which is always effective and occasionally transformational. May I also simply make it through each day and come out the other side.
Wednesday, September 28, 2005
Saturday, September 24, 2005
In The Neighborhood
The neighborhood where I work is a troubled area rife with poverty and its discontents: drugs, crime, and frequent violence. As I noted in a November post, my car was broken into prior to Thanksgiving and I lost my car stereo and a sense of safety and invulnerability.
Some other neighborly incidents:
One day last year, I was exiting the clinic with a doctor with whom I work. We came outside for a breath of fresh air around 3pm and immediately noticed something was wrong: his car, a 99 Honda Accord, was sitting on four plastic milk crates, all four wheels having been removed while the car sat in the clinic parking lot in broad daylight! Those 99 Hondas are a hot item!
Our noble medical director fought to have a small store included in the plan for the building in which the clinic has been housed for some years now. The little store caters to the Latino population in the neighborhood and supplies many elders with milk, avocados, and many Latino staples at decent prices, the store being a short walk from the nearby subsidized housing projects. There are often electric wheelachairs and scooters parked outside--the store is too small for even a small wheelchair, and only two school-age children are allowed in at a time to protect against shop-lifting. That said, the windows of the little store are broken with bricks and stones---and occasionally bullets---an average of four to six times a year. This Latino-run business serves the community well, but still suffers from vandalism, which could cause increased prices or possibly a permanently closed store.
Just outside the store, the landlord paid for some lovely shrubs to be planted a few years ago. The following week when we returned from a long weekend, the shrubs had been stolen, dug out from the ground with their root-systems still intact. Luckily, the replacement shrubs have escaped a similar fate.
Last week, one of my favorite docs was working late at the clinic, attending an HIV providers' meeting and finishing some notes. He left the building and began to back his car out of the lot, but remembered something on his desk and ran back inside, locking his car behind him. He was only in the building for ten minutes, but by the time he came out, his trunk was broken open, a window smashed, and all of the contents of his car had disappeared: stethoscope, brief case, car stereo, CD collection, and other flotsam and jetsam. This particular doctor works 50 hours per week, splitting his time between the clinic and the county jail, where he provides award-winning HIV-care for incarcerated men and women. His dedication to medically underpriviledged populations is an inspiration.
The same night as the theft from this doctor's car, a teenager was knifed to death just three blocks from our clinic on a street where many of our patients live. The son of one of our patients witnessed the murder---as did a dozen other people, it seems---but no one is talking and the perpetrator was never apprehended.
So, this is my work neighborhood, but this area is also graced by hundreds of lovely and giving people, a community garden worthy of a Puerto Rican "finca", the sounds of children and adults in the park on sunny afternoons. I am greeted daily with salutations of "hola", "buenos dias, doctor", and "Dios te bendiga" (God bless you). It is a microcosm of the wider world. I love it, I hate it, I long to leave it, and I cannot think of doing so. It is my neighborhood for more than forty hours each week, and it is in my blood. Although I generally feel safer in New York City than I do in the city in which I choose to work, I feel protected and blessed, knowing that my karma of service will shield me from harm and mistreatment.
May all beings be happy. May all beings be free from suffering, and may this neighborhood---and all places where people and animals make their homes---be blessed with freedom from violence, from Boise to Baghdad. This is my wish in this moment. May we all strive to make it so.
Some other neighborly incidents:
One day last year, I was exiting the clinic with a doctor with whom I work. We came outside for a breath of fresh air around 3pm and immediately noticed something was wrong: his car, a 99 Honda Accord, was sitting on four plastic milk crates, all four wheels having been removed while the car sat in the clinic parking lot in broad daylight! Those 99 Hondas are a hot item!
Our noble medical director fought to have a small store included in the plan for the building in which the clinic has been housed for some years now. The little store caters to the Latino population in the neighborhood and supplies many elders with milk, avocados, and many Latino staples at decent prices, the store being a short walk from the nearby subsidized housing projects. There are often electric wheelachairs and scooters parked outside--the store is too small for even a small wheelchair, and only two school-age children are allowed in at a time to protect against shop-lifting. That said, the windows of the little store are broken with bricks and stones---and occasionally bullets---an average of four to six times a year. This Latino-run business serves the community well, but still suffers from vandalism, which could cause increased prices or possibly a permanently closed store.
Just outside the store, the landlord paid for some lovely shrubs to be planted a few years ago. The following week when we returned from a long weekend, the shrubs had been stolen, dug out from the ground with their root-systems still intact. Luckily, the replacement shrubs have escaped a similar fate.
Last week, one of my favorite docs was working late at the clinic, attending an HIV providers' meeting and finishing some notes. He left the building and began to back his car out of the lot, but remembered something on his desk and ran back inside, locking his car behind him. He was only in the building for ten minutes, but by the time he came out, his trunk was broken open, a window smashed, and all of the contents of his car had disappeared: stethoscope, brief case, car stereo, CD collection, and other flotsam and jetsam. This particular doctor works 50 hours per week, splitting his time between the clinic and the county jail, where he provides award-winning HIV-care for incarcerated men and women. His dedication to medically underpriviledged populations is an inspiration.
The same night as the theft from this doctor's car, a teenager was knifed to death just three blocks from our clinic on a street where many of our patients live. The son of one of our patients witnessed the murder---as did a dozen other people, it seems---but no one is talking and the perpetrator was never apprehended.
So, this is my work neighborhood, but this area is also graced by hundreds of lovely and giving people, a community garden worthy of a Puerto Rican "finca", the sounds of children and adults in the park on sunny afternoons. I am greeted daily with salutations of "hola", "buenos dias, doctor", and "Dios te bendiga" (God bless you). It is a microcosm of the wider world. I love it, I hate it, I long to leave it, and I cannot think of doing so. It is my neighborhood for more than forty hours each week, and it is in my blood. Although I generally feel safer in New York City than I do in the city in which I choose to work, I feel protected and blessed, knowing that my karma of service will shield me from harm and mistreatment.
May all beings be happy. May all beings be free from suffering, and may this neighborhood---and all places where people and animals make their homes---be blessed with freedom from violence, from Boise to Baghdad. This is my wish in this moment. May we all strive to make it so.
Friday, September 23, 2005
Death Pays a Call
Yesterday morning, we were able to smoothly transfer my dying patient to his home for his final hours with family. The hospice nurses met me at the home, and we spent 90 minutes teaching the caregivers different techniques: how to move and reposition him to maintain comfort and decrease pressure on bony areas; how to administer extra IV morphine and Ativan for pain and agitation; how to provide oral, skin, and catheter care; what to do when his breathing changes and he slides into unconsciousness; what to do when he dies. The nuts and bolts of midwifing a death.
A call came late yesterday afternoon that the family was beginning to implode, verbally attacking the main non-family caregiver, creating a very stressful atmosphere. Although the dying gentleman was almost in a coma, hearing is always the last sense to be lost, and he reacted with grimacing and great agitation to the interpersonal melee unfolding around him. I was able to calm the situation somewhat over the phone, and hoped that all would be well enough for my dear patient to have a peaceful night, which would later prove to be his last night on earth.
I arrived to the home at noon today, and all was well and tranquil. My patient's respiratory rate had been decreasing and becoming more irregular, with longer and longer pauses between breaths, a sure sign of his steady decline toward death. His urine output was becoming darker and more scant, signaling that his kidneys were actively conserving fluids, producing as little urine as possible, trying their best to keep the body's fluid and blood volume at an acceptable capacity for the cancer-ravaged body. He was now completely unresponsive, the room's ambient sound being that of the pneumatic bed and oxygen tank whirring as white noise above the sounds of traffic through the window and voices from the kitchen and living room.
Saying that I knew this would be my last time with him, the family allowed me a few moments alone at the bedside. I communicated in Spanish that he was now free to leave, the family was together, friends gathered, everything in readiness for his departure. There was nothing more for him to be concerned about, all business had been taken care of, and nothing now stood in the way of him leaving his body. I encouraged him to thank his body for its service, and prepare to leave it behind for good. I kissed his forehead and left the room.
In the living room, I was generously offered a huge plate of traditional food which was impossible to turn down. We ate and chatted, and I shared with several people that the dying will often wait until all is quiet and no one is at the bedside to take their leave. It is a common phenomenon, perhaps because the dying person wishes to spare his or her loved ones from witnessing their departure, preferring to do it alone. After all, we are born alone and die alone, and no one can travel those passages for us. It is a singular event in life and one to be faced with aplomb and tranquility if at all possible, not to mention great courage and humility.
Not fifteen minutes had transpired between my goodbye soliloquy in the bedroom and finishing our meal in the living room when someone went to check on the dying man who was the central focus of everyone's attention for so many days now. I was abruptly called into the bedroom, and I immediately confirmed what was vividly apparent--he had died quietly after I left the room, leaving his body while we all ate our lunch together in the living room. Perhaps he really took to heart what I had said and realized it was time to go. Perhaps he would have died at that time whether I had been there or not, but being given permission to go, being blessed on one's way is a gift that can always be given to the dying, and I felt honored that I was given the gift of being present during this death, both for the dying and the living.
The scene that followed was classic: tears, hugs, weeping sons arriving afar receiving urgent cell-phone calls, neighbors coming to pay their respects. I, the professional, wandered from room to room, offering helpful words, concrete advice, fielding questions, and preparing the body. Not being a visiting nurse, per se, I am not licensed to pronounce a patient dead and sign the death certificate in Massachusetts, although I have been priviledged to perform this service in the past when I did have that legal right and responsibility. I called the hospice nurse and reported the time of death, requesting a nurse be dispatched as soon as convenient.
Exiting the building after warm goodbyes filled with kind words, a certain fullness pervaded my spirit, and a level of emotional exhaustion that cannot be described, along with a feeling of elation and freedom as well. Unfortunately, three more very busy hours of work would then ensue, robbing me of the opportunity to further explore this state of being. I was instead ruthlessly flung back into the maelstrom of the day, removed from the timelessness that seemed to pervade that apartment as we contemplated the death of a very noble man.
But now I can reflect on the experience, bless this soul on its journey, and enjoy the knowledge that my guidance played a small part in this soul's ultimate transition from the physical world to the spiritual realm.
Yes, Death paid a call, and I would say that the call was a sweet one.
A call came late yesterday afternoon that the family was beginning to implode, verbally attacking the main non-family caregiver, creating a very stressful atmosphere. Although the dying gentleman was almost in a coma, hearing is always the last sense to be lost, and he reacted with grimacing and great agitation to the interpersonal melee unfolding around him. I was able to calm the situation somewhat over the phone, and hoped that all would be well enough for my dear patient to have a peaceful night, which would later prove to be his last night on earth.
I arrived to the home at noon today, and all was well and tranquil. My patient's respiratory rate had been decreasing and becoming more irregular, with longer and longer pauses between breaths, a sure sign of his steady decline toward death. His urine output was becoming darker and more scant, signaling that his kidneys were actively conserving fluids, producing as little urine as possible, trying their best to keep the body's fluid and blood volume at an acceptable capacity for the cancer-ravaged body. He was now completely unresponsive, the room's ambient sound being that of the pneumatic bed and oxygen tank whirring as white noise above the sounds of traffic through the window and voices from the kitchen and living room.
Saying that I knew this would be my last time with him, the family allowed me a few moments alone at the bedside. I communicated in Spanish that he was now free to leave, the family was together, friends gathered, everything in readiness for his departure. There was nothing more for him to be concerned about, all business had been taken care of, and nothing now stood in the way of him leaving his body. I encouraged him to thank his body for its service, and prepare to leave it behind for good. I kissed his forehead and left the room.
In the living room, I was generously offered a huge plate of traditional food which was impossible to turn down. We ate and chatted, and I shared with several people that the dying will often wait until all is quiet and no one is at the bedside to take their leave. It is a common phenomenon, perhaps because the dying person wishes to spare his or her loved ones from witnessing their departure, preferring to do it alone. After all, we are born alone and die alone, and no one can travel those passages for us. It is a singular event in life and one to be faced with aplomb and tranquility if at all possible, not to mention great courage and humility.
Not fifteen minutes had transpired between my goodbye soliloquy in the bedroom and finishing our meal in the living room when someone went to check on the dying man who was the central focus of everyone's attention for so many days now. I was abruptly called into the bedroom, and I immediately confirmed what was vividly apparent--he had died quietly after I left the room, leaving his body while we all ate our lunch together in the living room. Perhaps he really took to heart what I had said and realized it was time to go. Perhaps he would have died at that time whether I had been there or not, but being given permission to go, being blessed on one's way is a gift that can always be given to the dying, and I felt honored that I was given the gift of being present during this death, both for the dying and the living.
The scene that followed was classic: tears, hugs, weeping sons arriving afar receiving urgent cell-phone calls, neighbors coming to pay their respects. I, the professional, wandered from room to room, offering helpful words, concrete advice, fielding questions, and preparing the body. Not being a visiting nurse, per se, I am not licensed to pronounce a patient dead and sign the death certificate in Massachusetts, although I have been priviledged to perform this service in the past when I did have that legal right and responsibility. I called the hospice nurse and reported the time of death, requesting a nurse be dispatched as soon as convenient.
Exiting the building after warm goodbyes filled with kind words, a certain fullness pervaded my spirit, and a level of emotional exhaustion that cannot be described, along with a feeling of elation and freedom as well. Unfortunately, three more very busy hours of work would then ensue, robbing me of the opportunity to further explore this state of being. I was instead ruthlessly flung back into the maelstrom of the day, removed from the timelessness that seemed to pervade that apartment as we contemplated the death of a very noble man.
But now I can reflect on the experience, bless this soul on its journey, and enjoy the knowledge that my guidance played a small part in this soul's ultimate transition from the physical world to the spiritual realm.
Yes, Death paid a call, and I would say that the call was a sweet one.
Wednesday, September 21, 2005
Comfort Measures
As the week progresses, my patient with stomach cancer declines. The progression of his illness over the past few days has necessitated conferences with the family and health care proxy, meetings and phone calls, and finally a decision yesterday to institute "CMO" status: Comfort Measures Only. This means we have withdrawn IV fluids and IV antibiotics, ceasing all discussion of how to stem the growth and ferocity of the cancer. He is now simply on morphine and oxygen, with a urinary catheter inserted. Death is certain, perhaps within 2-3 days.
The family took it well, although there are several members who were not present for our discussion yesterday afternoon and who will need some education. Hospice nurses are coming to the hospital this afternoon to meet with me and the patient's health care proxy/caregiver, and we will initiate a transfer to home for the late afternoon if all goes well. There he'll be surrounded by family and friends who will be encouraged to maintain a peaceful and quiet atmopshere. Hearing is said to be the final sense to be lost prior to death, so even if the dying person seems to be unconscious, it is a golden opportunity to say anything that has been left unsaid.
Things have moved along at a rapid pace for this lovely gentleman, but the care which he is receiving is motivated by love and a deep respect. I assume he will not survive the week. I too will say my good-byes......
The family took it well, although there are several members who were not present for our discussion yesterday afternoon and who will need some education. Hospice nurses are coming to the hospital this afternoon to meet with me and the patient's health care proxy/caregiver, and we will initiate a transfer to home for the late afternoon if all goes well. There he'll be surrounded by family and friends who will be encouraged to maintain a peaceful and quiet atmopshere. Hearing is said to be the final sense to be lost prior to death, so even if the dying person seems to be unconscious, it is a golden opportunity to say anything that has been left unsaid.
Things have moved along at a rapid pace for this lovely gentleman, but the care which he is receiving is motivated by love and a deep respect. I assume he will not survive the week. I too will say my good-byes......
Sunday, September 18, 2005
Cognitive Dissonance
Yesterday's post brought home to roost some cognitive dissonance which I've been experiencing as of late. If you read this blog regularly, you might guess that this dissonance revolves around work and identity.
In my full-time day job, I now have approximately 8o patients for whom I am responsible. A medical assistant follows about 25 of those patients, but I am still legally responsible for their care and carry them all under my license. The pace at which I live my 9 to 5 existence can be exasperatingly fast. Being a healthcare setting, everything I do must be properly documented, nursing notes being legal documents to which one affixes one's signature. I teach my students that any note which a nurse signs can later be used in a court to question your actions (or lack of action) in any circumstance in which the nurse was involved. Omission of information can sometimes be as damning as adding information. What you did not do can sometimes be the subject of inquiry. While I do not live my life worrying about potental law-suits, I always bear in mind that a prudent nurse will document well and completely, affixing a signature with as much confidence as possible.
With that in mind, I examine what a day can be like: planned home visits or office visits with patients; dozens of calls and voice-mails; spontaneous walk-in visits from unexpected patients; frequent crises which need immediate attention; interactions with other professionals; case conferences; documentation; internet research; symptom management; care plan reviews; and myriad other administrative and clinical tasks which cannot be listed here for lack of time and willingness to do so. Each call and each action necessitates documentation. The pile of unfinished notes grows throughout the day, and with my sieve-like brain under stress, doing notes the next day and remembering what transpired is a challenge. I sometimes feel like I need to explode or the information will begin to leak out of my ears in an unsightly manner.
The stress of my work is palpable. I serve a population which is poor, with low levels of education and sophistication (with a few exceptions), lives of crisis, strained relationships, financial hardship, and chronic illness. The level of dependence and need can be overwhelming and I often long to remove myself from the struggle. However, there is such life in what I do, such satisfaction in the positive aspects, that it keeps me coming back. My agency is also a pilot program providing cutting-edge care to underserved populations which is only equalled in two or three other programs in the country at this time. There is a political nature to our work which is enthralling, and while we're still figuring out how to do what we do (and convince others that it works and is worth replicating around the country), we struggle with the burdens under which we toil. Large caseloads, needy patients, and overseers who demand a great deal from us in order to justify our existence.
Looking objectively at my work, when I think of leaving for another position, I imagine how much easier it could be, how much more sane. But then I look at this team of people with whom I work, the heart and good-will at the center of our work family, coupled with the political and social ramifications of what we are doing, and I cannot find it in my heart to seriously examine other work opportunities. I've been offered a full-time position at a corporate visiting nurse agency which is begging me to work for them, but it is just that: a corporate for-profit national chain of nursing agencies which lacks a true vision other than profit and providing generally competent nursing care. While I am attracted by the small caseloads and change of pace, I'm not drawn to the people, the work environment, or the politics of the organization. I do per diem visits for this agency a few times a month, but involvement beyond that seems unlikely to me.
Healthcare in this country is in crisis. Services to the poor are consistently being cut. Disparities of race and socioeconomics are even more apparent as the aftermath of Hurricane Katrina shares its lessons. I struggle to stay afloat, to maintain my composure, but my dedication to serving these populations does not wane. The cognitive dissonance is born from concern for my own well-being, my own health, and the consequences of stress on my body and mind. For now, I stay put and make the best of it, looking for ways to maintain health, strike a balance, and save myself from long-term consequences of stress. Reading Tracy Kidder's book Mountains Beyond Mountains recently, I'm struck and awed by Dr. Paul Farmer's tireless worldwide struggle to bring healthcare to some of the most underpriviledged people in the world. It's people like him who inform my own career decisions and empower me to stay the course. It has been said that no one would want "I wish I had worked more" engraved on their tombstone. But perhaps "I'm glad to have helped so many" would be a worthy alternative epitaph. The secret lies in how to lengthen others' lives without consequently shortening one's own.
In my full-time day job, I now have approximately 8o patients for whom I am responsible. A medical assistant follows about 25 of those patients, but I am still legally responsible for their care and carry them all under my license. The pace at which I live my 9 to 5 existence can be exasperatingly fast. Being a healthcare setting, everything I do must be properly documented, nursing notes being legal documents to which one affixes one's signature. I teach my students that any note which a nurse signs can later be used in a court to question your actions (or lack of action) in any circumstance in which the nurse was involved. Omission of information can sometimes be as damning as adding information. What you did not do can sometimes be the subject of inquiry. While I do not live my life worrying about potental law-suits, I always bear in mind that a prudent nurse will document well and completely, affixing a signature with as much confidence as possible.
With that in mind, I examine what a day can be like: planned home visits or office visits with patients; dozens of calls and voice-mails; spontaneous walk-in visits from unexpected patients; frequent crises which need immediate attention; interactions with other professionals; case conferences; documentation; internet research; symptom management; care plan reviews; and myriad other administrative and clinical tasks which cannot be listed here for lack of time and willingness to do so. Each call and each action necessitates documentation. The pile of unfinished notes grows throughout the day, and with my sieve-like brain under stress, doing notes the next day and remembering what transpired is a challenge. I sometimes feel like I need to explode or the information will begin to leak out of my ears in an unsightly manner.
The stress of my work is palpable. I serve a population which is poor, with low levels of education and sophistication (with a few exceptions), lives of crisis, strained relationships, financial hardship, and chronic illness. The level of dependence and need can be overwhelming and I often long to remove myself from the struggle. However, there is such life in what I do, such satisfaction in the positive aspects, that it keeps me coming back. My agency is also a pilot program providing cutting-edge care to underserved populations which is only equalled in two or three other programs in the country at this time. There is a political nature to our work which is enthralling, and while we're still figuring out how to do what we do (and convince others that it works and is worth replicating around the country), we struggle with the burdens under which we toil. Large caseloads, needy patients, and overseers who demand a great deal from us in order to justify our existence.
Looking objectively at my work, when I think of leaving for another position, I imagine how much easier it could be, how much more sane. But then I look at this team of people with whom I work, the heart and good-will at the center of our work family, coupled with the political and social ramifications of what we are doing, and I cannot find it in my heart to seriously examine other work opportunities. I've been offered a full-time position at a corporate visiting nurse agency which is begging me to work for them, but it is just that: a corporate for-profit national chain of nursing agencies which lacks a true vision other than profit and providing generally competent nursing care. While I am attracted by the small caseloads and change of pace, I'm not drawn to the people, the work environment, or the politics of the organization. I do per diem visits for this agency a few times a month, but involvement beyond that seems unlikely to me.
Healthcare in this country is in crisis. Services to the poor are consistently being cut. Disparities of race and socioeconomics are even more apparent as the aftermath of Hurricane Katrina shares its lessons. I struggle to stay afloat, to maintain my composure, but my dedication to serving these populations does not wane. The cognitive dissonance is born from concern for my own well-being, my own health, and the consequences of stress on my body and mind. For now, I stay put and make the best of it, looking for ways to maintain health, strike a balance, and save myself from long-term consequences of stress. Reading Tracy Kidder's book Mountains Beyond Mountains recently, I'm struck and awed by Dr. Paul Farmer's tireless worldwide struggle to bring healthcare to some of the most underpriviledged people in the world. It's people like him who inform my own career decisions and empower me to stay the course. It has been said that no one would want "I wish I had worked more" engraved on their tombstone. But perhaps "I'm glad to have helped so many" would be a worthy alternative epitaph. The secret lies in how to lengthen others' lives without consequently shortening one's own.
Saturday, September 17, 2005
More Musings on Nursing
As a thunder storm roars through the area, I set aside my school-prep and reach for the laptop. The rain spatters on the transparent roof of the porch, the smell of ozone in the air....
What a week! I have a number of patients weighing on my mind, as well as my professional life and career in general.
First, the gentleman with gastric cancer grows worse, death somewhat closer every day. This weekend they'll be starting palliative radiation in an attempt to slow the bleeding in his stomach from the mass which has grown there. The cause of his intractable vomiting is now clear: the mass is completely blocking the outlet from his stomach to the small intestine. Anything that enters his stomach has nowhere to go but back up from whence it came. His oncologist broke the news to him that he will never eat or drink again. He stared into space at that moment, a tragic realization sinking in.
We also had the very difficult discussion of resuscitation status and whether or not he wanted to be DNR/DNI (Do Not Resuscitate/Do Not Intubate). I had to explain the reality of what would happen if his heart stopped: the "Code Team" would come running from all over the hospital, they would put an artificial airway down his throat, and they would commence CPR immediately. In his condition, many ribs would be broken in the process, and it would be a traumatic and potentially violent event for everyone present. What we call a "Code Blue" is not pretty, and it is rarely depicted realistically on television. He has chosen to be DNR/DNI. On Monday, I'll go straight to the hospital and ascertain whether or not they decided to place a tube in his small intestine through which he could receive feedings and fluids, bypassing his ravaged stomach. He clearly stated that he wanted us to do everything to keep him alive and comfortable as long as possible. He has been in my thoughts all weekend.
My sweetheart of a patient recently discussed in another entry, is still in the hospital, the mass in her chest still unidentifiable after four biopsies. A more invasive surgical biopsy was attempted but aborted when her oxygen level and blood pressure began to crap out during the induction of anesthesia. We sit together in her hospital room holding hands every day as she becomes thinner and more dejected, never failing to ask me about my wife, son, and dogs, and to send her blessings for their well-being. As her face grows thinner and more gaunt, her eyes become more prominent, orbs of love and faith tinged by the knowledge of her obvious mortality and shortening life. She also will not leave my mind this weekend.
Aside from work, I now have school and teaching added to the mix. I struggle to learn my students' names, try to correct mistakes I made last year as a novice professor, and make good use of the materials created through hours and hours of preparation last autumn. Today I was able to simply edit and slightly change an exam created last year, cutting the time for preparing the exam for printing from several hours to perhaps thirty minutes. Teaching is a pleasurable activity made burdensome by the preparation involved, but as I gain experience and make us of my materials from last year, the ratio of burden to pleasure should widen.
That said, teaching gives me a way to take the nuggets of knowledge which I glean from my direct work with patients, and distill them down into illustrative stories which I can then relate to my students in a way which brings our subjects of study to life. The correlation and relatedness of my clinical work and teaching helps me to see my work in a different light, as well as to use my relationships with patients as a teaching tool.
I find my identity as a nurse very strong right now, and while I yearn for a time in the not-too-distant future when my work is not so central to that identity, I accept for now that there's plenty to learn about myself in that milieu. My greatest hope is that I will intuitively know when I'm ready to make a change and create a simpler, less stressful worklife. Until then, I bounce from the frying pan to the fire and back again, yearning for the days when I can rest on the back burner.
What a week! I have a number of patients weighing on my mind, as well as my professional life and career in general.
First, the gentleman with gastric cancer grows worse, death somewhat closer every day. This weekend they'll be starting palliative radiation in an attempt to slow the bleeding in his stomach from the mass which has grown there. The cause of his intractable vomiting is now clear: the mass is completely blocking the outlet from his stomach to the small intestine. Anything that enters his stomach has nowhere to go but back up from whence it came. His oncologist broke the news to him that he will never eat or drink again. He stared into space at that moment, a tragic realization sinking in.
We also had the very difficult discussion of resuscitation status and whether or not he wanted to be DNR/DNI (Do Not Resuscitate/Do Not Intubate). I had to explain the reality of what would happen if his heart stopped: the "Code Team" would come running from all over the hospital, they would put an artificial airway down his throat, and they would commence CPR immediately. In his condition, many ribs would be broken in the process, and it would be a traumatic and potentially violent event for everyone present. What we call a "Code Blue" is not pretty, and it is rarely depicted realistically on television. He has chosen to be DNR/DNI. On Monday, I'll go straight to the hospital and ascertain whether or not they decided to place a tube in his small intestine through which he could receive feedings and fluids, bypassing his ravaged stomach. He clearly stated that he wanted us to do everything to keep him alive and comfortable as long as possible. He has been in my thoughts all weekend.
My sweetheart of a patient recently discussed in another entry, is still in the hospital, the mass in her chest still unidentifiable after four biopsies. A more invasive surgical biopsy was attempted but aborted when her oxygen level and blood pressure began to crap out during the induction of anesthesia. We sit together in her hospital room holding hands every day as she becomes thinner and more dejected, never failing to ask me about my wife, son, and dogs, and to send her blessings for their well-being. As her face grows thinner and more gaunt, her eyes become more prominent, orbs of love and faith tinged by the knowledge of her obvious mortality and shortening life. She also will not leave my mind this weekend.
Aside from work, I now have school and teaching added to the mix. I struggle to learn my students' names, try to correct mistakes I made last year as a novice professor, and make good use of the materials created through hours and hours of preparation last autumn. Today I was able to simply edit and slightly change an exam created last year, cutting the time for preparing the exam for printing from several hours to perhaps thirty minutes. Teaching is a pleasurable activity made burdensome by the preparation involved, but as I gain experience and make us of my materials from last year, the ratio of burden to pleasure should widen.
That said, teaching gives me a way to take the nuggets of knowledge which I glean from my direct work with patients, and distill them down into illustrative stories which I can then relate to my students in a way which brings our subjects of study to life. The correlation and relatedness of my clinical work and teaching helps me to see my work in a different light, as well as to use my relationships with patients as a teaching tool.
I find my identity as a nurse very strong right now, and while I yearn for a time in the not-too-distant future when my work is not so central to that identity, I accept for now that there's plenty to learn about myself in that milieu. My greatest hope is that I will intuitively know when I'm ready to make a change and create a simpler, less stressful worklife. Until then, I bounce from the frying pan to the fire and back again, yearning for the days when I can rest on the back burner.
Thursday, September 15, 2005
Among the Living
Yes, dear Readers, I am still among the living.....er, blogging, as it were. This last week has been a storm of busy-ness, my time to write completely precluded by...now, what was it called? Oh yes, life. Yes that's it, life got in the way of this other very important aspect of life which is near and dear to my heart. This blogging business is certainly addictive and tonight my "blogging jones" must be satisfied, at least desultorily.
Blessedly, last weekend was not overridden by work and chores. Rather, it was filled to overflowing with the celebration of Mary's birthday which happens to fall on September 11th. We have spent the last four years striving to reclaim her birthday which seemed to be usurped by the 2001 event which cast a long shadow over anyone wanting to use that day for celebratory purposes. Needless to say, we spent the better part of the weekend celebrating in the appropriate manner.
On the homefront, we are having our somewhat finished basmement almost completely finished, with a small kitchen and new floors and windows, in hopes of renting the space to a lucky grad student or young couple who do not mind living in a very dry basement with two windows. That process has taken a great deal of our time and energy. While we are not doing the construction ourselves, anyone who has had construction done in their home at any time understands the disruption that it can cause to one's accustomed living patterns, not to mention the process of seeking out, and interviewing, potential tenants. More on that, perhaps, at a later date.
School is back in session and I just completed evening #2 of lecture in the LPN course which I am teaching for the 2nd year in a row. One of my greatest challenges is learning my 24 students' names, as well as the fact that I teach from 5:30-9:30pm after working an intense 8-hour day. Having taught the class last year, my prep time is thankfully less taxing this time around, but I still spend a fair amount of time at home in preparation. Is it worth it? Maybe I could make better money elsewhere, but the act of teaching is an exciting process which I do sincerely enjoy.
My work soars along at sonic speeds. The gentleman with stomach cancer of whom I recently wrote is failing fast, and I helped to get him directly admitted into the hospital on Tuesday when I visited him at home and he was obviously dehydrated. I was sharing with my students this evening that, when visiting a patient at home as an autonomous nurse, there are many judgement calls which I must make which do give me pause. I have luckily never made a decision that ended in a premature death, but I always know that my license and my conscience are both on the line when a patient's life is at stake. It can be a scary thought which often informs our decisions as healthcare professionals.
Aside from that, my life has been a piece of cake with not much to blog home about. I just had to post something tonight and say hello to whomever has hung in there and checked in to see if I would surface after a week's pause.
Now for some quick prep for tomorrow and off to bed with my honey.
Bon nuit.
Blessedly, last weekend was not overridden by work and chores. Rather, it was filled to overflowing with the celebration of Mary's birthday which happens to fall on September 11th. We have spent the last four years striving to reclaim her birthday which seemed to be usurped by the 2001 event which cast a long shadow over anyone wanting to use that day for celebratory purposes. Needless to say, we spent the better part of the weekend celebrating in the appropriate manner.
On the homefront, we are having our somewhat finished basmement almost completely finished, with a small kitchen and new floors and windows, in hopes of renting the space to a lucky grad student or young couple who do not mind living in a very dry basement with two windows. That process has taken a great deal of our time and energy. While we are not doing the construction ourselves, anyone who has had construction done in their home at any time understands the disruption that it can cause to one's accustomed living patterns, not to mention the process of seeking out, and interviewing, potential tenants. More on that, perhaps, at a later date.
School is back in session and I just completed evening #2 of lecture in the LPN course which I am teaching for the 2nd year in a row. One of my greatest challenges is learning my 24 students' names, as well as the fact that I teach from 5:30-9:30pm after working an intense 8-hour day. Having taught the class last year, my prep time is thankfully less taxing this time around, but I still spend a fair amount of time at home in preparation. Is it worth it? Maybe I could make better money elsewhere, but the act of teaching is an exciting process which I do sincerely enjoy.
My work soars along at sonic speeds. The gentleman with stomach cancer of whom I recently wrote is failing fast, and I helped to get him directly admitted into the hospital on Tuesday when I visited him at home and he was obviously dehydrated. I was sharing with my students this evening that, when visiting a patient at home as an autonomous nurse, there are many judgement calls which I must make which do give me pause. I have luckily never made a decision that ended in a premature death, but I always know that my license and my conscience are both on the line when a patient's life is at stake. It can be a scary thought which often informs our decisions as healthcare professionals.
Aside from that, my life has been a piece of cake with not much to blog home about. I just had to post something tonight and say hello to whomever has hung in there and checked in to see if I would surface after a week's pause.
Now for some quick prep for tomorrow and off to bed with my honey.
Bon nuit.
Tuesday, September 06, 2005
Out of the Frying Pan
Today I was involved in a scene at a patient's home that was straight out of a movie. My patient, a middle-aged man not born in this country, has a history of polysubstance abuse, Hepatitis C, violence, a personality disorder, and a former life of foreign miltary service with a history of committing and witnessing violent acts of warfare. I will not disclose his city of residence, age, or his country of origin.
People involved in this gentleman's care are often afraid of him. He can cut an imposing figure until you look into his eyes and see the wounded child crouching in his heart. This man lives in fear and psychic pain, and his family member with whom he lives also lives in fear and pain. I was called to the home because it was apparent that my client had possibly taken way too many antipsychotics and benzodiazepines over the weekend, prescribed medications that he will frequently supplement with crack cocaine. The fact that he has recently been under threat from a local gang does not inspire confidence in his coping and interpersonal skills.
Based on an urgent request from the primary physician, my unannounced arrival to the home with a third-year medical student in tow did not meet with a warm welcome, although his family member was relieved that we had come. When the situation became somewhat threatening, I was sure to always keep myself between the patient and the medical student in my charge, and constantly de-escalated the conversation and redirected the patient to why I felt he should go to the hospital.
At one point, my patient was on his hands and knees in the kitchen, babbling incoherently in his native tongue mixed with English, crying like a baby. Shortly after, only semi-coherent and walking very unevenly with eyes at half-mast, he exited the home to smoke outside and I knew that there was no stopping him. From previous experience, I understood that physical touch of the most minimal kind could send him over the edge, so I simply followed him outside, leaving the medical student to chat calmly with the family member, who, when asked, reassured me that there were no weapons in the home. (Later, I would glean a great deal of information from the medical student, who truly got an "ear-ful" while I was outside.)
Once outside, speaking with the primary doctor on my cellphone, I asked her to call 911 and request a police cruiser and an ambulance. After fifteen minutes of following my patient up and down the hot street, the ambulance arrived and we coaxed him onto the stretcher as he whimpered and pleaded for mercy. The police arrived ten minutes later when we were getting ready to leave the scene and return to the clinic. Better late than never, I guess. They must have been at Dunkin Donuts.
This was simply a 60-minute scene at the end of a day filled with telephone calls of desperation, illness, another unfolding crisis, two lovely and uneventful home visits, and the odd prescription refill. A day in the life.
So here I sit on the porch, the frogs and cicadas beginning their evening chorus, and I prepare to officially document all that I did at work today before I forget the gory details. It was a rude awakening from a perfect weekend, and I'm pretty sure I missed the frying pan.
People involved in this gentleman's care are often afraid of him. He can cut an imposing figure until you look into his eyes and see the wounded child crouching in his heart. This man lives in fear and psychic pain, and his family member with whom he lives also lives in fear and pain. I was called to the home because it was apparent that my client had possibly taken way too many antipsychotics and benzodiazepines over the weekend, prescribed medications that he will frequently supplement with crack cocaine. The fact that he has recently been under threat from a local gang does not inspire confidence in his coping and interpersonal skills.
Based on an urgent request from the primary physician, my unannounced arrival to the home with a third-year medical student in tow did not meet with a warm welcome, although his family member was relieved that we had come. When the situation became somewhat threatening, I was sure to always keep myself between the patient and the medical student in my charge, and constantly de-escalated the conversation and redirected the patient to why I felt he should go to the hospital.
At one point, my patient was on his hands and knees in the kitchen, babbling incoherently in his native tongue mixed with English, crying like a baby. Shortly after, only semi-coherent and walking very unevenly with eyes at half-mast, he exited the home to smoke outside and I knew that there was no stopping him. From previous experience, I understood that physical touch of the most minimal kind could send him over the edge, so I simply followed him outside, leaving the medical student to chat calmly with the family member, who, when asked, reassured me that there were no weapons in the home. (Later, I would glean a great deal of information from the medical student, who truly got an "ear-ful" while I was outside.)
Once outside, speaking with the primary doctor on my cellphone, I asked her to call 911 and request a police cruiser and an ambulance. After fifteen minutes of following my patient up and down the hot street, the ambulance arrived and we coaxed him onto the stretcher as he whimpered and pleaded for mercy. The police arrived ten minutes later when we were getting ready to leave the scene and return to the clinic. Better late than never, I guess. They must have been at Dunkin Donuts.
This was simply a 60-minute scene at the end of a day filled with telephone calls of desperation, illness, another unfolding crisis, two lovely and uneventful home visits, and the odd prescription refill. A day in the life.
So here I sit on the porch, the frogs and cicadas beginning their evening chorus, and I prepare to officially document all that I did at work today before I forget the gory details. It was a rude awakening from a perfect weekend, and I'm pretty sure I missed the frying pan.
Friday, September 02, 2005
Take a Breath
Friday morning, a day off from work, elongating the Labor Day weekend to four days. Hallelujah.
What a week. The Gulf Coast disaster has engulfed the national consciousness as New Orleans seems to slide into absolute chaos. Mary has approximately fifty family members in the New Orleans area, thirty of whom are first cousins. We did not have word from any of them until last night and we're thankful that they're all safe, although several homes appear to have been lost. Another good friend escaped to Austin and thinks he'll remain there permanently.
Aside from the tragedy in New Orleans, Florida, and Mississippi, the stampede and scores of unnecessary deaths which resulted in Baghdad earlier this week is also fuel for despair and a desire for change in the world. One could see why certain segments of society might see this as the beginning of "the end times". I don't know about the end of the world, but I sure would like to see an end to needless suffering in the world.
Closer to home, the biopsy of my dear patient's chest mass was inconclusive other than to say that there is necrotic tissue in there, underscoring the notion that the spots on her lungs are very likely malignant. The next move is a trans-tracheal or trans-esophageal exploratory biopsy, basically a tube with a camera snaking through the trachea or esophagus into the chest to take a real-time peek at what's happening in there. I stopped by for a visit to my patient's hospital room yesterday, prior to leaving for my four-day weekend. Her depression and loneliness were palpable, and we sat on her bed holding hands. I noticed that she hadn't touched her lunch, and for the second day in a row I encouraged her to drink an unopened can of Boost to keep her energy up and receive at least some nutrition. She agreed to do so only if I shared it, so I poured the lion's share into a cup for her, and drank the remaining 1/4 can of thick vanilla liquid after a quick toast to her health. (I thought to myself, "If doctors I know have taken AIDS medications just to see how the side effects feel, I can stomach a bit of Diet Boost".) It wasn't bad really, though I bet the chocolote is better.
The gentleman with metastatic stomach cancer who I've recently written about is beginning to fail. Although he is still home, he's now taking almost nothing by mouth due to his almost constant nausea and vomiting. This does not bode well for him ever being able to tolerate chemotherapy, so I've begun the difficult conversation about end-of-life issues, such as resuscitation status, health care proxies, funeral arrangements, etcetera. Due to the family's insistence and my encouragement for them to explore every option, we're now researching putting in a "J-tube", a feeding tube which would bypass the stomach by going directly into the small intestine. It is an easy procedure in which a small incision is made in the central abdomen and a small tube is inserted into the jejunum, the first section of the small intestine which attaches to the outlet from the stomach. Specially prepared food is then injected through the tube directly into the intestine where the majority of nutrient absorption occurs. Many people don't realize that it is altogether possible to live without a stomach since very little happens there in terms of digestion, other than the breaking down of foodstuffs into what comes to be known as chyme. Granted, the stomach assists in the absorption of Vitamin B-12 and several other nutrients, but its lack of involvement in the digestive process can be replaced by other therapeutic means.
With both of these patients in tenuous situations, and one of them at home in need of daily checking in and symptom management, it was very difficult for me to let go and tell them I would be back in 5 days. There's a certain "ownership" of a patient's care that one can begin to feel, and one can often experience resistance to entrusting these tasks to others, no matter how trusted and skilled they are. There is also admittedly an ego-level attachment to not "missing out" on some turning point, something perhaps akin to what a parent might feel when their young child experiences a developmental milestone while at day-care. ("Oh, Mrs. Smith, little Sallie took her very first steps today! I wish you could have been there!"---I imagine many daycare providers are sensitive to this post-modern parenting conundrum and perhaps refrain from telling a parent everything a child does, for fear of the parent feeling utterly destroyed that they missed a child's first step....) But I digress.
Anyway, as you have surmised, attachments can hinder a healthcare provider's ability to "let go and let others". For now, though, I sign off from both work and blogging, preparing instead for a 48-hour trip to lovely Cape Ann, Massachussetts, where we will visit friends and frolic with my brother and his family who are vacationing there. Having lived in Gloucester, MA for several years as newlyweds, there's a nostalgic feeling to our visits to the other side of the state, and the weather looks promising. Our son and his girlfriend will also be there for the weekend, so we look forward to some needed family time. Even as we rest and recuperate, we'll of course bear in mind the suffering of others, and remember that there but for the grace of God(dess) go we.
Signing off til Sunday or Monday, giving thanks for the Labor Movement, the kind folks who brought us the weekend.....
What a week. The Gulf Coast disaster has engulfed the national consciousness as New Orleans seems to slide into absolute chaos. Mary has approximately fifty family members in the New Orleans area, thirty of whom are first cousins. We did not have word from any of them until last night and we're thankful that they're all safe, although several homes appear to have been lost. Another good friend escaped to Austin and thinks he'll remain there permanently.
Aside from the tragedy in New Orleans, Florida, and Mississippi, the stampede and scores of unnecessary deaths which resulted in Baghdad earlier this week is also fuel for despair and a desire for change in the world. One could see why certain segments of society might see this as the beginning of "the end times". I don't know about the end of the world, but I sure would like to see an end to needless suffering in the world.
Closer to home, the biopsy of my dear patient's chest mass was inconclusive other than to say that there is necrotic tissue in there, underscoring the notion that the spots on her lungs are very likely malignant. The next move is a trans-tracheal or trans-esophageal exploratory biopsy, basically a tube with a camera snaking through the trachea or esophagus into the chest to take a real-time peek at what's happening in there. I stopped by for a visit to my patient's hospital room yesterday, prior to leaving for my four-day weekend. Her depression and loneliness were palpable, and we sat on her bed holding hands. I noticed that she hadn't touched her lunch, and for the second day in a row I encouraged her to drink an unopened can of Boost to keep her energy up and receive at least some nutrition. She agreed to do so only if I shared it, so I poured the lion's share into a cup for her, and drank the remaining 1/4 can of thick vanilla liquid after a quick toast to her health. (I thought to myself, "If doctors I know have taken AIDS medications just to see how the side effects feel, I can stomach a bit of Diet Boost".) It wasn't bad really, though I bet the chocolote is better.
The gentleman with metastatic stomach cancer who I've recently written about is beginning to fail. Although he is still home, he's now taking almost nothing by mouth due to his almost constant nausea and vomiting. This does not bode well for him ever being able to tolerate chemotherapy, so I've begun the difficult conversation about end-of-life issues, such as resuscitation status, health care proxies, funeral arrangements, etcetera. Due to the family's insistence and my encouragement for them to explore every option, we're now researching putting in a "J-tube", a feeding tube which would bypass the stomach by going directly into the small intestine. It is an easy procedure in which a small incision is made in the central abdomen and a small tube is inserted into the jejunum, the first section of the small intestine which attaches to the outlet from the stomach. Specially prepared food is then injected through the tube directly into the intestine where the majority of nutrient absorption occurs. Many people don't realize that it is altogether possible to live without a stomach since very little happens there in terms of digestion, other than the breaking down of foodstuffs into what comes to be known as chyme. Granted, the stomach assists in the absorption of Vitamin B-12 and several other nutrients, but its lack of involvement in the digestive process can be replaced by other therapeutic means.
With both of these patients in tenuous situations, and one of them at home in need of daily checking in and symptom management, it was very difficult for me to let go and tell them I would be back in 5 days. There's a certain "ownership" of a patient's care that one can begin to feel, and one can often experience resistance to entrusting these tasks to others, no matter how trusted and skilled they are. There is also admittedly an ego-level attachment to not "missing out" on some turning point, something perhaps akin to what a parent might feel when their young child experiences a developmental milestone while at day-care. ("Oh, Mrs. Smith, little Sallie took her very first steps today! I wish you could have been there!"---I imagine many daycare providers are sensitive to this post-modern parenting conundrum and perhaps refrain from telling a parent everything a child does, for fear of the parent feeling utterly destroyed that they missed a child's first step....) But I digress.
Anyway, as you have surmised, attachments can hinder a healthcare provider's ability to "let go and let others". For now, though, I sign off from both work and blogging, preparing instead for a 48-hour trip to lovely Cape Ann, Massachussetts, where we will visit friends and frolic with my brother and his family who are vacationing there. Having lived in Gloucester, MA for several years as newlyweds, there's a nostalgic feeling to our visits to the other side of the state, and the weather looks promising. Our son and his girlfriend will also be there for the weekend, so we look forward to some needed family time. Even as we rest and recuperate, we'll of course bear in mind the suffering of others, and remember that there but for the grace of God(dess) go we.
Signing off til Sunday or Monday, giving thanks for the Labor Movement, the kind folks who brought us the weekend.....
Tuesday, August 30, 2005
Mi Hijo
I spent a few minutes at the bedside of my patient in the hospital today. I sat in a chair to the right of her bed and rested the side of my face on the bedrail so that our faces were aligned, her head resting on her pillow. We spent several minutes smiling at one another and looking into each other's eyes. Of course, she asked me for news of my wife, son and dogs, and I told her a story of Mary calling me in a panic this morning when one of Sparkey's nails broke off and he was spurting blood all over the house. She laughed and said "bendito!" ("poor thing").
While I was sitting at her bedside, I noticed that the site of the needle biopsy on her upper chest was bleeding through the lame little bandaid that someone had pasted there, and I alerted the nurse that she needed a pressure dressing on the area. While holding a gauze sponge in place while the nurse searched for dressing supplies down the hall, I took the opportunity to not only hold the gauze in place, but also to perform a little Reiki on my patient's heart chakra. We stared into one another's eyes and breathed, chatting nonchalantly until the nurse returned and broke the spell. In a way, though, the nurse entered our little tete-a-tete with her own caring energy as the she dressed the area more securely and placed a nasal cannula on my patient's nose so that she could have receive some oxygen. I translated for the two of them and we all had a few sweet moments as a triumverate. After the nurse left the room, I said "Are you depressed, my love?" She nodded very sadly and we were silent for a few more moments.
At times my visits to see my hospitalized patients are more social than anything else, and at other times I am advocating, cajoling, fostering communication, or simply adding my two cents based on my intimate knowledge of the patient from outside the clinical austereness of the institutional setting. This visit was filled with meaning for me on many levels.
As I was leaving the room, my patient said, "Gracias por su visita, mi hijo" ("Thanks for your visit, my child"). The way many of our patients say "mi hijo" sounds like "me-hoe"---one word, really almost one syllable in the Puerto Rican vernacular. Coming from some of my younger patients, it feels somehow strange, but from this 69-year-old woman---old enough to be my mother---a grandmother with HIV and a myriad of illnesses but with a bright light in her eyes, it's like a benediction. I'll visit her again tomorrow, and I will hold her hand when we deliver the verdict on her biopsy.
There are many ways to be an "hijo", and this is one way that sinks deep into the heart and lodges there forever.
While I was sitting at her bedside, I noticed that the site of the needle biopsy on her upper chest was bleeding through the lame little bandaid that someone had pasted there, and I alerted the nurse that she needed a pressure dressing on the area. While holding a gauze sponge in place while the nurse searched for dressing supplies down the hall, I took the opportunity to not only hold the gauze in place, but also to perform a little Reiki on my patient's heart chakra. We stared into one another's eyes and breathed, chatting nonchalantly until the nurse returned and broke the spell. In a way, though, the nurse entered our little tete-a-tete with her own caring energy as the she dressed the area more securely and placed a nasal cannula on my patient's nose so that she could have receive some oxygen. I translated for the two of them and we all had a few sweet moments as a triumverate. After the nurse left the room, I said "Are you depressed, my love?" She nodded very sadly and we were silent for a few more moments.
At times my visits to see my hospitalized patients are more social than anything else, and at other times I am advocating, cajoling, fostering communication, or simply adding my two cents based on my intimate knowledge of the patient from outside the clinical austereness of the institutional setting. This visit was filled with meaning for me on many levels.
As I was leaving the room, my patient said, "Gracias por su visita, mi hijo" ("Thanks for your visit, my child"). The way many of our patients say "mi hijo" sounds like "me-hoe"---one word, really almost one syllable in the Puerto Rican vernacular. Coming from some of my younger patients, it feels somehow strange, but from this 69-year-old woman---old enough to be my mother---a grandmother with HIV and a myriad of illnesses but with a bright light in her eyes, it's like a benediction. I'll visit her again tomorrow, and I will hold her hand when we deliver the verdict on her biopsy.
There are many ways to be an "hijo", and this is one way that sinks deep into the heart and lodges there forever.
Monday, August 29, 2005
The C-Word
Another week begins, yet I approach it with renewed energy and no post-vacation malaise. What a relief.
For those of you who were following the story of my patient with metastatic stomach cancer earlier this month (see The Language of Illness and Stories Unfolding), he's back home from the hospital and we are aggressively managing his nausea and other symptoms. Whether or not we move ahead with chemotherapy remains to be seen. He's not long for this earth and my goal is to keep him comfortable and free of unnecessary pain and suffering. Intractable vomiting and dehydration is no fun, and we've managed to put out that brush-fire for now. I stand ready for the next one.
Sadly, one of my favorite patients---a 69-year-old Puerto Rican woman (whom I see as a "free care" patient since she's too old for our program) with HIV, hypothyroidism, asthma, emphysema, diabetes, anxiety, and depression with psychotic features, is in the hospital with what appears to be metastatic cancer to her lungs from a mass connected with her thyroid gland. Previous biopsies of this mass in what is called her "mediastinum" (the upper chest area) have been benign, and I feel so badly that perhaps now the time has come where the mass has taken on more sinister and lethal qualities. An avid smoker, she goes through one or two packs a day, and a great deal of my time has been spent trying to convince her to quit smoking over the last four years, all to no avail. With her HIV and diabetes under perfect control, I have focused on her respiratory health. It is a widely held opinion that one cigarette can be the one that activates cancer cells to begin their uncontrolled growth, and this is the turn of events which I have most feared.
My connection with this sweet woman is precious. Since she speaks no English other than being able to say "good weekend" or "I love you", our relationship is conducted entirely in Spanish. Every time we converse---whether it's on the phone or in person---she insists on asking me how my wife, son and dogs are doing, and smiles so beatifically as I recount for her my son's latest accomplishments, my wife's career changes, or the dogs' latest trip to the vet. I also ask about her family, and we always close our conversations with "Dios te bendiga" ("God bless you"), a salutation which I freely share with many of my Latino patients as a way to respect their cultural practices. She carries a bright light within her, even in moments of paranoia and fear when her face is mask-like and stiff. Over the years, she has fed me Puerto Rican food, brought me countless bags of plantains to bring home to my family, and will settle for nothing less than a kiss on the lips when saying goodbye. I always comply.
Today, sitting on her hospital bed and chatting, she seemed to have no idea that we are suspecting that cancer is growing within her. I hinted that we were going to run some tests and do a biopsy, but I hesitated to use the "C-word" just yet. Her mental health is tentative, and I didn't want her to lose sleep tonight unnecessarily. When the results are in, I'll make sure that I'm present for the conversation in which we inform her of the cancer and how it has spread. For now, I cling to the very dim hope that the shadows on the CT-scan were not metastasis, and that the mass is localized and operable.
She would be the third patient on my caseload with active cancer, and the burden which these individuals carry along with their families and loved ones is great. I do my best to walk alongside them on this difficult path, but it cannot be more true that one must always walk alone when faced with mortality and death. Courage and optimism go a long way, but misery and depression certainly play their hands as well.
It is these moments of profound humanity which most engender one's humility.
For those of you who were following the story of my patient with metastatic stomach cancer earlier this month (see The Language of Illness and Stories Unfolding), he's back home from the hospital and we are aggressively managing his nausea and other symptoms. Whether or not we move ahead with chemotherapy remains to be seen. He's not long for this earth and my goal is to keep him comfortable and free of unnecessary pain and suffering. Intractable vomiting and dehydration is no fun, and we've managed to put out that brush-fire for now. I stand ready for the next one.
Sadly, one of my favorite patients---a 69-year-old Puerto Rican woman (whom I see as a "free care" patient since she's too old for our program) with HIV, hypothyroidism, asthma, emphysema, diabetes, anxiety, and depression with psychotic features, is in the hospital with what appears to be metastatic cancer to her lungs from a mass connected with her thyroid gland. Previous biopsies of this mass in what is called her "mediastinum" (the upper chest area) have been benign, and I feel so badly that perhaps now the time has come where the mass has taken on more sinister and lethal qualities. An avid smoker, she goes through one or two packs a day, and a great deal of my time has been spent trying to convince her to quit smoking over the last four years, all to no avail. With her HIV and diabetes under perfect control, I have focused on her respiratory health. It is a widely held opinion that one cigarette can be the one that activates cancer cells to begin their uncontrolled growth, and this is the turn of events which I have most feared.
My connection with this sweet woman is precious. Since she speaks no English other than being able to say "good weekend" or "I love you", our relationship is conducted entirely in Spanish. Every time we converse---whether it's on the phone or in person---she insists on asking me how my wife, son and dogs are doing, and smiles so beatifically as I recount for her my son's latest accomplishments, my wife's career changes, or the dogs' latest trip to the vet. I also ask about her family, and we always close our conversations with "Dios te bendiga" ("God bless you"), a salutation which I freely share with many of my Latino patients as a way to respect their cultural practices. She carries a bright light within her, even in moments of paranoia and fear when her face is mask-like and stiff. Over the years, she has fed me Puerto Rican food, brought me countless bags of plantains to bring home to my family, and will settle for nothing less than a kiss on the lips when saying goodbye. I always comply.
Today, sitting on her hospital bed and chatting, she seemed to have no idea that we are suspecting that cancer is growing within her. I hinted that we were going to run some tests and do a biopsy, but I hesitated to use the "C-word" just yet. Her mental health is tentative, and I didn't want her to lose sleep tonight unnecessarily. When the results are in, I'll make sure that I'm present for the conversation in which we inform her of the cancer and how it has spread. For now, I cling to the very dim hope that the shadows on the CT-scan were not metastasis, and that the mass is localized and operable.
She would be the third patient on my caseload with active cancer, and the burden which these individuals carry along with their families and loved ones is great. I do my best to walk alongside them on this difficult path, but it cannot be more true that one must always walk alone when faced with mortality and death. Courage and optimism go a long way, but misery and depression certainly play their hands as well.
It is these moments of profound humanity which most engender one's humility.
Tuesday, August 16, 2005
Carnival Time!
For those of you not familiar with "blog carnivals", these are virtual gatherings of bloggers wherein a host blogger puts out a call for blog entries related to a given topic and interested/invited bloggers step up to the plate and submit either new or old writings. The host then posts links to all of the entries within a narrative on their own blog. Here is a link to an article which describes carnivals well.
I am pleased to announce that two of my recent Digital Doorway entries are included in the latest version of Grand Rounds, a medical carnival which "makes its rounds" every so often. I hope to host a future version of Grand Rounds in the coming year.
Thanks to all who sent birthday wishes by comment, email, or telepathy, and blessings to you all!
More soon!
I am pleased to announce that two of my recent Digital Doorway entries are included in the latest version of Grand Rounds, a medical carnival which "makes its rounds" every so often. I hope to host a future version of Grand Rounds in the coming year.
Thanks to all who sent birthday wishes by comment, email, or telepathy, and blessings to you all!
More soon!
Friday, August 12, 2005
Stories Unfolding
As I anticipated, the meeting at the oncologist's office this morning was pretty heavy. In attendance were the patient in question, his son, his close friend, myself, and the oncologist, a very kindly woman whose chair-side manner was impeccable.
The news was as I expected, based upon my reading of the CT-scan report and biopsy results: advanced adenocarcinoma of the stomach with metastasis to the liver, adrenal glands, and very likely lymph node involvement throughout the abdominal cavity. In other words, it couldn't be worse.
I allowed the doctor to lead the conversation, chiming in as necessary, the son and friend and I all translating for the patient who speaks less than ten words of English. There were tears, a verbalized desire for aggressive treatment, and a thumbs up in defiance of the odds so squarely stacked against survival. The doctor was very clear that surgery was not an option, and that chemotherapy---if it didn't make the patient feel worse---might prolong his life by a few months. I was very cognizant of her choice of words: months. With a cancer so advanced, survival is short-lived, and we don't talk in terms of years. There are no years left. A harsh reality by any measure.
Our meeting was classic in many ways. The patient and family members listened quietly while the doctor spoke in soft tones. A few moments after she made the diagnosis and the prognosis unmistakably clear, my patient began to cry and reached out for his son, embracing him strongly, man to man. Then he reached the other way and hugged his dear friend who was sitting on his left. Then he embraced them both and the three of them wept together. At this point, he looked up and gestured for me to take his hand. We were all four of us physically connected, the doctor quietly observing, as this lovely and soft-spoken gentleman began to digest the fact that he had been handed a death-sentence, that his body had betrayed him and was, even as we sat there, producing non-functional cells at an alarming and unmitigated rate. He began to grasp that the chemotherapy might slow the growth of the cancer but could not arrest it completely, and that the side effects of the chemo could be gruesomely uncomfortable, perhaps even deadly. All of this cascaded down upon him and upon the minds and hearts of his loved ones as we sat in that air-conditioned and spartanly modern room.
Breathing in the scene in which I was an active participant and keen observer, I could feel the expanse of the city around us, the thousands of lives careening through the streets, the myriad other life stories unfolding in that instant. It was a poignant moment of existence for me: here we were, facing death and suffering in the face, the person facing the challenge being embraced by his loved ones, the compassionate professionals observing and noting the details of the moment, present, yes, but also somehow detached.
Throughout this time, I noticed the oncologist move her stool closer to the patient, leaning in when she needed to speak of the more difficult issues. Her body language was open, her eye contact steady, her voice level and professional but compassionate. She touched his knee at just the right time, and we all sat in silence when it was needed. When the doc left the room for a few minutes of consultation with her superior, I took a deep breath and reminded everyone to do the same. Towards the end of the appointment, the supervising physician came in and made his presence known in the most gentle way. It was as if he'd been there all along. His presence was reassuring but not domineering, masculinely strong yet not patriarchal. He knew what he was doing.
When witnessing scenes such as this, perspective is the word which mostly comes to mind. That could have been me, my wife, my mother, my brother; any one of us could be on the receiving end of such a conversation, such a life-altering moment. It is profoundly humbling when one is reminded so starkly of one's diminutive stature in the scheme of things, yet also the power and focused energy which the changing course of one life can command. We are all truly stories unfolding.
The news was as I expected, based upon my reading of the CT-scan report and biopsy results: advanced adenocarcinoma of the stomach with metastasis to the liver, adrenal glands, and very likely lymph node involvement throughout the abdominal cavity. In other words, it couldn't be worse.
I allowed the doctor to lead the conversation, chiming in as necessary, the son and friend and I all translating for the patient who speaks less than ten words of English. There were tears, a verbalized desire for aggressive treatment, and a thumbs up in defiance of the odds so squarely stacked against survival. The doctor was very clear that surgery was not an option, and that chemotherapy---if it didn't make the patient feel worse---might prolong his life by a few months. I was very cognizant of her choice of words: months. With a cancer so advanced, survival is short-lived, and we don't talk in terms of years. There are no years left. A harsh reality by any measure.
Our meeting was classic in many ways. The patient and family members listened quietly while the doctor spoke in soft tones. A few moments after she made the diagnosis and the prognosis unmistakably clear, my patient began to cry and reached out for his son, embracing him strongly, man to man. Then he reached the other way and hugged his dear friend who was sitting on his left. Then he embraced them both and the three of them wept together. At this point, he looked up and gestured for me to take his hand. We were all four of us physically connected, the doctor quietly observing, as this lovely and soft-spoken gentleman began to digest the fact that he had been handed a death-sentence, that his body had betrayed him and was, even as we sat there, producing non-functional cells at an alarming and unmitigated rate. He began to grasp that the chemotherapy might slow the growth of the cancer but could not arrest it completely, and that the side effects of the chemo could be gruesomely uncomfortable, perhaps even deadly. All of this cascaded down upon him and upon the minds and hearts of his loved ones as we sat in that air-conditioned and spartanly modern room.
Breathing in the scene in which I was an active participant and keen observer, I could feel the expanse of the city around us, the thousands of lives careening through the streets, the myriad other life stories unfolding in that instant. It was a poignant moment of existence for me: here we were, facing death and suffering in the face, the person facing the challenge being embraced by his loved ones, the compassionate professionals observing and noting the details of the moment, present, yes, but also somehow detached.
Throughout this time, I noticed the oncologist move her stool closer to the patient, leaning in when she needed to speak of the more difficult issues. Her body language was open, her eye contact steady, her voice level and professional but compassionate. She touched his knee at just the right time, and we all sat in silence when it was needed. When the doc left the room for a few minutes of consultation with her superior, I took a deep breath and reminded everyone to do the same. Towards the end of the appointment, the supervising physician came in and made his presence known in the most gentle way. It was as if he'd been there all along. His presence was reassuring but not domineering, masculinely strong yet not patriarchal. He knew what he was doing.
When witnessing scenes such as this, perspective is the word which mostly comes to mind. That could have been me, my wife, my mother, my brother; any one of us could be on the receiving end of such a conversation, such a life-altering moment. It is profoundly humbling when one is reminded so starkly of one's diminutive stature in the scheme of things, yet also the power and focused energy which the changing course of one life can command. We are all truly stories unfolding.
Thursday, August 11, 2005
The Language of Illness
I have a 64-year-old male patient with severe osteoporosis and a few other health issues like anemia of unknown origin. His main complaint has been pain which we eventually chose to treat short-term with Percocet, upping the ante to long-acting morphine when the Percocet couldn't touch it. A few weeks ago, he sat under a tree outside of his apartment building and said that he wouldn't take the morphine any more and he only wanted Percocet. This type of behavior often speaks of addiction (or at least dependence) but we gave in, at least for the meantime. Meanwhile, after grasping at straws regarding his anemia, we sent him to a gastroenterologist to see if perhaps he was bleeding internally, and also to treat his esophageal reflux disease.
Yesterday I received a call from the gastro provider that they needed to send him for an emergency abdominal CT-scan which later revealed the fact that his abdomen is riddled with cancer that has metastasized from his liver to his stomach, adrenal glands, and lymph nodes. Now his pain makes sense, although his symptoms were always vague (and we were worried about Percocet dependence!). My, how things turn on a dime.
Now the game-plan has changed and I will accompany him to an emergency visit with an oncologist tomorrow. I don't look forward to the look on my patient's face when we hear what I expect to hear: that the cancer is already profoundly spread throughout his abdomen, and the chance of curing him is almost nil at this juncture. I can see that we will be stepping gingerly onto a new path of palliative care as he begins what may be a very rapid decline. His stalwart friend and advocate will be there with us tomorrow morning, and it will be up to me to translate all of this new information---literally and figuratively---into something that my patient can grasp.
The language of illness and death can be harsh and forbidding. My job is to distill it into digestible syllables and be there to pick up the pieces of grief. All in a day's work, I guess.
Yesterday I received a call from the gastro provider that they needed to send him for an emergency abdominal CT-scan which later revealed the fact that his abdomen is riddled with cancer that has metastasized from his liver to his stomach, adrenal glands, and lymph nodes. Now his pain makes sense, although his symptoms were always vague (and we were worried about Percocet dependence!). My, how things turn on a dime.
Now the game-plan has changed and I will accompany him to an emergency visit with an oncologist tomorrow. I don't look forward to the look on my patient's face when we hear what I expect to hear: that the cancer is already profoundly spread throughout his abdomen, and the chance of curing him is almost nil at this juncture. I can see that we will be stepping gingerly onto a new path of palliative care as he begins what may be a very rapid decline. His stalwart friend and advocate will be there with us tomorrow morning, and it will be up to me to translate all of this new information---literally and figuratively---into something that my patient can grasp.
The language of illness and death can be harsh and forbidding. My job is to distill it into digestible syllables and be there to pick up the pieces of grief. All in a day's work, I guess.
Wednesday, August 10, 2005
Mixed Bag
As always, work is certainly a mixed bag these days. On the one hand, I had the wonderful experience the other day of reminding a patient that he has now achieved five years of having his HIV fully suppressed with no detectable virus in his blood (based on the most up-to-date assay that we have, anyway). His determination and desire to be healthy have kept him on the right road and now he is reaping the benefits. I explained to him how we can now view his HIV like his diabetes---a chronic illness controlled with medications and a positive lifestyle, with the goal of avoiding as many long-term complications as we can. As more and more people with HIV age, we will begin to see the data regarding how they fare as their bodies begin to go through the ageing process. We still don't know for certain how infected people of very advanced age will do in the long term, but it looks like we may have a chance to find out over the next few decades.
On the other hand, there are patients who never quite "get on the bus" and we track the slow and inexorable progress towards their eventual demise. There's not much to do in many of these cases except to be there when they crash. Then there are others who simply have lives too dysfunctional to fix, patterns of behavior and learned helplessness just too entreched. It is some of these individuals who can make a workday miserable.
Aside from the patients themselves, paperwork, organizational issues, the healthcare system itself, and other factors all combine to make the providing of quality care a challenge. Not everyone has the same work ethic, not everyone cares as much. And when money is the bottom line, everyone suffers.
Yesterday, we heard that an amazing doctor specializing in HIV in our community died of a heart attack while swimming from one island in Maine to another to raise money for an AIDS-related organization. Her loss is a shock to the community, especially since we lost another local HIV expert to suicide two years ago. When the healers die, those who rely upon them are stopped in their tracks. How many people see their doctors as something other than mortal and fallible?
Next week I have the entire week off to celebrate my birthday (41!) and soak in some of the final days of the summer before Labor Day heralds the beginning of school and that September feeling of renewal and change. In many ways I look forward to the autumn: the crisp air, wearing a jacket on the cool mornings, getting back to teaching on Thursday nights as the summer wanes and the leaves begin their transition. The end of August also heralds the beginning of the big harvest time when the abundance of autumn graces the land. As always, there is much to look forward to and cherish, and the mixed bag is just a fact of life on this awkward and lovely physical plane.
On the other hand, there are patients who never quite "get on the bus" and we track the slow and inexorable progress towards their eventual demise. There's not much to do in many of these cases except to be there when they crash. Then there are others who simply have lives too dysfunctional to fix, patterns of behavior and learned helplessness just too entreched. It is some of these individuals who can make a workday miserable.
Aside from the patients themselves, paperwork, organizational issues, the healthcare system itself, and other factors all combine to make the providing of quality care a challenge. Not everyone has the same work ethic, not everyone cares as much. And when money is the bottom line, everyone suffers.
Yesterday, we heard that an amazing doctor specializing in HIV in our community died of a heart attack while swimming from one island in Maine to another to raise money for an AIDS-related organization. Her loss is a shock to the community, especially since we lost another local HIV expert to suicide two years ago. When the healers die, those who rely upon them are stopped in their tracks. How many people see their doctors as something other than mortal and fallible?
Next week I have the entire week off to celebrate my birthday (41!) and soak in some of the final days of the summer before Labor Day heralds the beginning of school and that September feeling of renewal and change. In many ways I look forward to the autumn: the crisp air, wearing a jacket on the cool mornings, getting back to teaching on Thursday nights as the summer wanes and the leaves begin their transition. The end of August also heralds the beginning of the big harvest time when the abundance of autumn graces the land. As always, there is much to look forward to and cherish, and the mixed bag is just a fact of life on this awkward and lovely physical plane.
Friday, July 29, 2005
The Small Things
I have a patient with schizophrenia who I take out to lunch about once a month. Seeing as it was his birthday recently and he verbalized a desire for Chinese food, I took him somewhere different for a special treat.
Sitting for the first time with him in a real restaurant---not just a pizza place or delicatessen---I was struck by the normalcy of what we were doing. Here we were, two people talking about our families, making comments about the weather, the food, the Red Sox, passing the soy sauce, pouring tea. Given his somewhat different way of relating to the world (schizophrenia being essentially a personality and thought disorder), this gentleman's conversational skills can be somewhat lacking in the strict sense of social decorum and "normalcy", and his personal brand of logic can sometimes be challenging to follow. That said, our time together was lovely, relatively comfortable, and very satisfying for us both on several different levels.
During the course of the meal, he looked me squarely in the eye and said, "Y'know, I appreciate this more than you could ever imagine. I look forward to our outings (his word) so much, and it's such a breath of fresh air to go out and do this." He added later, "I wish there was a way I could repay you." I responded that he could repay me by taking the best care of himself that he possibly could. We shook hands heartily and he got out of the car.
This interaction reaffirmed for me the therapeutic value of this monthly tradition, as unconventional as it seems. I don't do this with any other patients, although I have been out for coffee with a few here and there. There's a technique in psychological treatment called "therapeutic use of self" which refers to the professional individual disclosing personal information in a nonmanipulative way in order to normalize the patient's experience, perhaps helping the client to see that the clinician can empathize based upon actual personal experience. I've practiced this technique by disclosing the fact that I take antidepressants, for instance, or that, yes, my cholesterol is also high and my reflux is out of control when I forget to take my medication. When convincing a patient to use a weekly pill-box, I'll often comment that I could never remember my meds without using one (a very true statement, indeed).
While I can't afford to pay out of pocket to take all of my patients to lunch every month, the value of my decision to do this regularly with this particular individual is worth much more than the actual cash value of said expense. It has become something that I simply plan on, and today exemplified for me the fact that the benefit is both therapeutically measurable and personally meaningful. The interpersonal connection and trust that's been created in this "clinical" relationship is something that I can see is a valuable tool in the therapeutic kit which I employ with this gentleman.
Today I acknowledge that it is often the small things that pay the largest, most meaningful dividends.
Sitting for the first time with him in a real restaurant---not just a pizza place or delicatessen---I was struck by the normalcy of what we were doing. Here we were, two people talking about our families, making comments about the weather, the food, the Red Sox, passing the soy sauce, pouring tea. Given his somewhat different way of relating to the world (schizophrenia being essentially a personality and thought disorder), this gentleman's conversational skills can be somewhat lacking in the strict sense of social decorum and "normalcy", and his personal brand of logic can sometimes be challenging to follow. That said, our time together was lovely, relatively comfortable, and very satisfying for us both on several different levels.
During the course of the meal, he looked me squarely in the eye and said, "Y'know, I appreciate this more than you could ever imagine. I look forward to our outings (his word) so much, and it's such a breath of fresh air to go out and do this." He added later, "I wish there was a way I could repay you." I responded that he could repay me by taking the best care of himself that he possibly could. We shook hands heartily and he got out of the car.
This interaction reaffirmed for me the therapeutic value of this monthly tradition, as unconventional as it seems. I don't do this with any other patients, although I have been out for coffee with a few here and there. There's a technique in psychological treatment called "therapeutic use of self" which refers to the professional individual disclosing personal information in a nonmanipulative way in order to normalize the patient's experience, perhaps helping the client to see that the clinician can empathize based upon actual personal experience. I've practiced this technique by disclosing the fact that I take antidepressants, for instance, or that, yes, my cholesterol is also high and my reflux is out of control when I forget to take my medication. When convincing a patient to use a weekly pill-box, I'll often comment that I could never remember my meds without using one (a very true statement, indeed).
While I can't afford to pay out of pocket to take all of my patients to lunch every month, the value of my decision to do this regularly with this particular individual is worth much more than the actual cash value of said expense. It has become something that I simply plan on, and today exemplified for me the fact that the benefit is both therapeutically measurable and personally meaningful. The interpersonal connection and trust that's been created in this "clinical" relationship is something that I can see is a valuable tool in the therapeutic kit which I employ with this gentleman.
Today I acknowledge that it is often the small things that pay the largest, most meaningful dividends.
Friday, July 22, 2005
Where Does the Time Go?
Seems like it was only yesterday that I posted on Tuesday night. My, how the week does fly. Working only three days, seems like I did the same amount of work I would normally do in five. Maybe I did.
Rose, mentioned in previous missives, is now in the hospital, deemed legally incompetent, and awaiting what comes next.
Another patient called me begging for prednisone for her worsening asthma. I declined and sent her to the ER. She's admitted now and I knew in my gut that prednisone wouldn't cut it. Looks like pneumonia. Sometimes I think about my nursing license when I make such decisions. Must think clearly and not just try to save the patient the inconvenience of an ambulance ride.
Another patient was in the ER today---brittle diabetic, alcoholic, eschewing his insulin and other self-care, sticking to his bottle instead. I don't foresee a happy ending there.
A medical student followed me on my rounds today and we were able to visit three very diverse and interesting patients in their homes: an alcoholic with Hepatitis C and bad pulmonary disease, just out of the hospital; a lovely older man with cancer who takes such good care of himself that I offered to pay him as a consultant to teach my other patients his secrets of success; and finally, a transgendered man (of whom I am exceedingly fond) with more life-threatening diagnoses than you can shake a stethoscope at, and he is still filled with joie de vivre and a strong will to live. Sometimes work can be inspiring, especially when someone takes such responsibility for their life and personal self-care.
That said, work fatigue is definitely weighing on my eyelids this evening, while my old nemesis "compassion fatigue" is nowhere in sight. The weekend is for the recharging of the batteries, and I'm so very pleased that my batteries aren't disposable.
Rose, mentioned in previous missives, is now in the hospital, deemed legally incompetent, and awaiting what comes next.
Another patient called me begging for prednisone for her worsening asthma. I declined and sent her to the ER. She's admitted now and I knew in my gut that prednisone wouldn't cut it. Looks like pneumonia. Sometimes I think about my nursing license when I make such decisions. Must think clearly and not just try to save the patient the inconvenience of an ambulance ride.
Another patient was in the ER today---brittle diabetic, alcoholic, eschewing his insulin and other self-care, sticking to his bottle instead. I don't foresee a happy ending there.
A medical student followed me on my rounds today and we were able to visit three very diverse and interesting patients in their homes: an alcoholic with Hepatitis C and bad pulmonary disease, just out of the hospital; a lovely older man with cancer who takes such good care of himself that I offered to pay him as a consultant to teach my other patients his secrets of success; and finally, a transgendered man (of whom I am exceedingly fond) with more life-threatening diagnoses than you can shake a stethoscope at, and he is still filled with joie de vivre and a strong will to live. Sometimes work can be inspiring, especially when someone takes such responsibility for their life and personal self-care.
That said, work fatigue is definitely weighing on my eyelids this evening, while my old nemesis "compassion fatigue" is nowhere in sight. The weekend is for the recharging of the batteries, and I'm so very pleased that my batteries aren't disposable.
Friday, July 15, 2005
Narcotic Nightmare
It seems that more and more of my time at work is taken up by patients in need of narcotic medications. As the "middle-man" between my patients and their providers at the clinic, I negotiate contracts around the use of narcotics and monitor patient's side effects, pain levels, and adherence to our agreements. While many people are sincerely in pain and certainly need narcotics to ease their suffering, there are always some whose motivations seem slightly dubious and cause confusion and difficulty for their providers. A history of substance abuse also complicates the picture and makes treating pain more challenging. It's times like these that I give thanks that I'm not a Nurse Practitioner and have no prescriptive authority. Put into the position of listening to a patient's complaints and assessing their needs, I know that I would be a soft touch, always erring on the side of believing a patient, even if my intuition led me to think otherwise.
Pain is widely under-treated in this country and I'm happy to assist in managing patients' pain, but it is admittedly a confusing and trying ordeal at times. While pain advocates in the medical world are pushing for more recognition of pain as the "fifth vital sign" (after temperature, pulse, respirations, and blood pressure), it is still not always clearly seen by providers and is treated with less than germaine levels of attention.
Many of the docs at the clinic only work part-time, so I often find myself negotiating for narcotic prescriptions when my patients call for refills. Add to that the fact that patient's charts are often MIA at the the clinic, making documentation and double-checking of doses even harder. I think I can say that this is my least favorite aspect of my job, one which causes me endless distress and cognitive dissonance. The fact that I started writing this entry just before midnight on a Friday underscores the notion that it weighs heavily on my mind.
I'd like to write about this some more in future, but send this missive out into the cyber-ethers to allow myself to let it go for my long, four-day weekend. A short vacation is in order and I must clear my mind of static.
Pain is widely under-treated in this country and I'm happy to assist in managing patients' pain, but it is admittedly a confusing and trying ordeal at times. While pain advocates in the medical world are pushing for more recognition of pain as the "fifth vital sign" (after temperature, pulse, respirations, and blood pressure), it is still not always clearly seen by providers and is treated with less than germaine levels of attention.
Many of the docs at the clinic only work part-time, so I often find myself negotiating for narcotic prescriptions when my patients call for refills. Add to that the fact that patient's charts are often MIA at the the clinic, making documentation and double-checking of doses even harder. I think I can say that this is my least favorite aspect of my job, one which causes me endless distress and cognitive dissonance. The fact that I started writing this entry just before midnight on a Friday underscores the notion that it weighs heavily on my mind.
I'd like to write about this some more in future, but send this missive out into the cyber-ethers to allow myself to let it go for my long, four-day weekend. A short vacation is in order and I must clear my mind of static.
Thursday, June 23, 2005
A Speech for Graduate Nurses
This speech will be delivered by yours truly this evening at 6pm.
I am sure that a vast majority of the audience gathered here tonight are family, friends, and loved ones of the graduates. The first acknowledgement I wish to make is for the sacrifices and endless hours of study and clinical that you needed to put up with as your family’s nursing student struggled his or her way through the program. As I look out at you tonight, I wonder to myself how many dinners were missed, how many games not attended, how often was your family’s particular nursing student locked in his or her room, studying for yet another exam? For your sacrifices and support, I encourage the graduates to stand and applaud you for your unerring support.
Speaking of family, several of our students experienced the loss of a loved one during this past year, and I ask for a moment of silence in memory of the family members who left this world during the last ten months, not to mention those who passed before. I believe that they are here in spirit, smiling down upon you all with unceasing pride.
Now that we have acknowledged the loved ones who kept the home fires burning while the students were battling the demons of nursing education, I would like to turn our attention towards these courageous and ambitious individuals who have been doggedly pursuing their education and professional betterment for the last ten months.
Often, when thinking of students, our minds may wander to the quintessential and stereotypical undergraduate—living in a dorm, buying food with a campus meal plan, perhaps buying clothes and other necessities with Mom and Dad’s credit card, possibly working a part-time job on- or off-campus to supplement financial aid. But these graduates sitting here in this auditorium tonight are a different breed of student altogether. Oh yes, many of these graduates have children, mortgages, rent to pay, spouses, ill family members who need tending to, bills, loans, debts, and, last but not least, full- or part-time jobs. While lecturing to this class, I was painfully aware that many students, after leaving a six-hour lecture from 4pm to 10pm, would rush home for a bite to eat, don a uniform or scrubs, and head out to an overnight shift in a nursing home or hospital, working 11 to 7, only to come home in the morning to get the kids off to school before collapsing for an abbreviated sleep before clinical or another lecture. This is nothing short of heroic, and I stand in awe of your dedication and hard work.
Having been there myself, completing two different nursing programs over the last ten years, I understand how much concentration and dedication it takes to forge ahead, even when the studying is laborious and the exams seem to never stop coming. Being adult learners, you have little time for socializing and leisure---if you’re not engaged in some type of study, class-time, or clinical experience, you are most likely helping your kids with their homework, cleaning the bathroom, or going grocery shopping. The fact that you are all graduating today, ready to be licensed professionals, is an amazing feat deserving of much praise and recognition.
It’s often said that nurses eat their young, and it’s also said that nurses are overworked, undervalued, and underpaid. Bearing that in mind, I personally find that there is nothing more satisfying for me than nurturing and encouraging new nurses to be their best and perform well, whether in school or in the workplace. As for overworked and underpaid, that may be true in some settings, but nurses are also held in high esteem in this society, and just saying that one is a nurse can feel extremely gratifying in almost any social situation. While not being self-congratulatory, nurses can count themselves as members of a profession which holds compassion, caring, and healing as three of its central ideals. Saying that one is a nurse is something I encourage the graduates to do with pride, as well as with humility.
Speaking of being a nurse, many of you may realize you’re really a nurse when everyone you know begins coming to you with every ache, pain and symptom they experience, fully expecting a definitive diagnosis. You also may find yourself washing your hands for a full minute in public restrooms and turning off the faucets with your elbows. On the bright side, whenever anyone asks for a pen, you’ll probably have three in your pocket. But it’s most disconcerting when you start checking out people’s veins for IV access while standing in line at the grocery store. Just try not to be too obvious, and refrain from touching strangers.
Despite the sarcasm and jokes, being a nurse is a noble and honorable profession, and it was a true honor and pleasure to be your professor for this past year, watching the light bulbs go off in your heads as we discussed the finer points of fluid balance and kidney function. You are a bright, kind, considerate, funny, and only moderately argumentative group, and I will miss you all very much. Thank you for your patience during my first year of teaching, and thank you for making the experience so heartwarming and enjoyable. My blessings to each of you today and always.
Monday, June 13, 2005
Oh My
The continuing saga of Rose........She actually refused to go in the ambulance on Friday night and avoided the police who were sent by Protective Services by leaving the house and staying with her daughter. The visiting nurses thought she was hospitalized so Rose missed her methadone and other meds all weekend. Damn!
Today I physically brought her to the clinic to see her primary doctor. After multiple telephone consults on the phone between us, Protective Services, and the hospital, we convinced the hospital to allow us to "direct admit" her, bypassing the ER and going straight to a room. I sent her home extracting the promise from her family that she would go to the hospital as soon as the call came that a bed was ready. I crossed every finger and toe.
At 6, the Admitting Dept called me--the bed was ready. A quick call to the daughter and Rose was on her way to the hospital, at least for a 24-48 hour tune-up while we buy time to figure out what to do next.
At 7:30, her daughter calls me on my cell while I'm at a meeting in my hometown for one of my volunteer gigs (she has Caller ID and has my cell # now)---Rose snuck out of the hospital fifteen minutes after her daughter dropped her off and was on their front step like a puppy dog within forty minutes! I pleaded and cajoled them to return, which they eventually did. Just now (10pm), I called the nurses' station on the floor where she is staying and suggested they give her some Ativan and post security at her door to keep her from leaving in the middle of the night and putting herself at risk on the dark streets. She has AIDS dementia, after all. The friendly nurse on the other end of the line agreed to bring this up with the attending physician stat. That was my 11th phone call about Rose today, and I interacted in person or on the phone with at least six other patients and/or providers in the course of the day---plus the ubiquitous paperwork which such interventions necessarily generate.
Now it's 10:30 and I ruminate. Could I have handled it better? Was my game-plan on Friday a mistake? Most likely. Will Rose get through the night at the hospital? I hope so. Will I sleep tonight? That would be nice. Does the week stretch before me like a gaping maw of unmet need and unknown crisis? Most definitely. Do I still love my work and maybe enjoy the adrenaline and drama? Is the Pope Catholic?
Well, The Daily Show with Jon Stewart is on soon. Must take a shower and settle in for some laughs. Maybe it's me who needs that Ativan......
Today I physically brought her to the clinic to see her primary doctor. After multiple telephone consults on the phone between us, Protective Services, and the hospital, we convinced the hospital to allow us to "direct admit" her, bypassing the ER and going straight to a room. I sent her home extracting the promise from her family that she would go to the hospital as soon as the call came that a bed was ready. I crossed every finger and toe.
At 6, the Admitting Dept called me--the bed was ready. A quick call to the daughter and Rose was on her way to the hospital, at least for a 24-48 hour tune-up while we buy time to figure out what to do next.
At 7:30, her daughter calls me on my cell while I'm at a meeting in my hometown for one of my volunteer gigs (she has Caller ID and has my cell # now)---Rose snuck out of the hospital fifteen minutes after her daughter dropped her off and was on their front step like a puppy dog within forty minutes! I pleaded and cajoled them to return, which they eventually did. Just now (10pm), I called the nurses' station on the floor where she is staying and suggested they give her some Ativan and post security at her door to keep her from leaving in the middle of the night and putting herself at risk on the dark streets. She has AIDS dementia, after all. The friendly nurse on the other end of the line agreed to bring this up with the attending physician stat. That was my 11th phone call about Rose today, and I interacted in person or on the phone with at least six other patients and/or providers in the course of the day---plus the ubiquitous paperwork which such interventions necessarily generate.
Now it's 10:30 and I ruminate. Could I have handled it better? Was my game-plan on Friday a mistake? Most likely. Will Rose get through the night at the hospital? I hope so. Will I sleep tonight? That would be nice. Does the week stretch before me like a gaping maw of unmet need and unknown crisis? Most definitely. Do I still love my work and maybe enjoy the adrenaline and drama? Is the Pope Catholic?
Well, The Daily Show with Jon Stewart is on soon. Must take a shower and settle in for some laughs. Maybe it's me who needs that Ativan......
Sunday, June 12, 2005
Mixed Emotions
My patient Rose who I wrote about recently was deemed legally incompetent on Friday due to my reporting her to Protective Services for the Disabled. Although I have mixed feelings about making such a report, I felt I had no choice based upon her deteriorating state, her children's inability to properly care for her, and the increasing risk that she and the entire building would eventually go up in flames (her bed is covered with cigarette burns from Rose nodding off while smoking).
I have been aware for months that Rose is not long for this world and I have been doing my best to put appropriate services in place. Given her untreated Hepatitis C and HIV, seizure disorder, anxiety disorder, history of trauma, and Xanax addiction, Rose's chances of survival in her current situation are next to nil, and I seemed to be the only person ready to step up and make the call that would legally change her status.
I have called the Department of Social Services once when I felt a patient's children were being neglected, and my hope was that this would lead to a better life for these children. I don't think it worked, but this has alot to do with the relative inefficiency of our state programs. In Rose's case, my hope is that a court-appointed attorney will become her legal guardian, and that she will be placed in an environment where her addiction, HIV, and anxiety can all be addressed appropriately, not by the band-aids that I continually attempt to put in place, often to no avail.
Tomorrow I return to work and hope that this situation can improve, that her life can be qualitatively improved and quantitatively lengthened, and that I won't suffer any negative consequences from taking action.
I sit here in the steamy heat and ruminate on my work, but now I must return to my regularly-scheduled Sunday afternoon.
I have been aware for months that Rose is not long for this world and I have been doing my best to put appropriate services in place. Given her untreated Hepatitis C and HIV, seizure disorder, anxiety disorder, history of trauma, and Xanax addiction, Rose's chances of survival in her current situation are next to nil, and I seemed to be the only person ready to step up and make the call that would legally change her status.
I have called the Department of Social Services once when I felt a patient's children were being neglected, and my hope was that this would lead to a better life for these children. I don't think it worked, but this has alot to do with the relative inefficiency of our state programs. In Rose's case, my hope is that a court-appointed attorney will become her legal guardian, and that she will be placed in an environment where her addiction, HIV, and anxiety can all be addressed appropriately, not by the band-aids that I continually attempt to put in place, often to no avail.
Tomorrow I return to work and hope that this situation can improve, that her life can be qualitatively improved and quantitatively lengthened, and that I won't suffer any negative consequences from taking action.
I sit here in the steamy heat and ruminate on my work, but now I must return to my regularly-scheduled Sunday afternoon.
Thursday, June 02, 2005
Small Victories
Some of you may remember Patient X from January and February postings. He is my patient who was hospitalized for alcoholic hepatitis and had moderate cirrhosis and very severe psoriasis. Well, I am happy to report that he is doing swimmingly well. He has not had an alcoholic drink since getting out of the hospital in January, his symptoms have all abated, he's losing weight, and his psoriasis is incredibly improved. He and his friends credit my weekly visits and demonstrated desire to help him for this astounding recovery. I think that my regular presence has simply shown him that others can care, and that his own self-care can pay enormous dividends. In short, this man's life is being extended---not necessarily by medical intervention, but rather by compassion, attention, and renewed self-respect.
Another patient of mine who had been seen as a lost cause can now finally enjoy having her advanced AIDS completely controlled and suppressed through the taking of antiretroviral medications. She has been free of any complications, is doing extremely well, and has energy to spend time with her school-age daughter and son. She is one of my stars.
Mr. D, someone who has failed many antiretroviral regimens due to his unwillingness to take his meds religiously, is now completely suppressed as well, with rising T-cells (immune cells) and a quantity of virus so low that we cannot measure it. He is seeing the benefits of this turn of events and looks great. His previous skin eruptions are gone and he is gaining weight. His wife--also with AIDS--has been much better about taking meds all along, and she is in excellent health. Their young children are benefiting directly from their parents' self-care.
In this line of work, we need to remind ourselves to take the time to count our successes, celebrate our victories--however small--and take a deep breath on occasion.
Today I am off from work yet again, preparing for a trip to Boston tomorrow for my son's graduation from The New England School of Photography. You, my dear Readers, will necessarily need to tolerate some photos of the happy event upon my return, not to mention gushing sentimentality about our wonderful boy---er, young man, rather.
Happy day to you all.
Another patient of mine who had been seen as a lost cause can now finally enjoy having her advanced AIDS completely controlled and suppressed through the taking of antiretroviral medications. She has been free of any complications, is doing extremely well, and has energy to spend time with her school-age daughter and son. She is one of my stars.
Mr. D, someone who has failed many antiretroviral regimens due to his unwillingness to take his meds religiously, is now completely suppressed as well, with rising T-cells (immune cells) and a quantity of virus so low that we cannot measure it. He is seeing the benefits of this turn of events and looks great. His previous skin eruptions are gone and he is gaining weight. His wife--also with AIDS--has been much better about taking meds all along, and she is in excellent health. Their young children are benefiting directly from their parents' self-care.
In this line of work, we need to remind ourselves to take the time to count our successes, celebrate our victories--however small--and take a deep breath on occasion.
Today I am off from work yet again, preparing for a trip to Boston tomorrow for my son's graduation from The New England School of Photography. You, my dear Readers, will necessarily need to tolerate some photos of the happy event upon my return, not to mention gushing sentimentality about our wonderful boy---er, young man, rather.
Happy day to you all.
Sunday, May 29, 2005
Rose
This is a work-related post about a patient with AIDS with whom I work.
Rose has had AIDS for about ten years. We've never treated her with antiretrovirals (the drugs used to stop the virus from replicating) because her mental illness, anxiety disorder, and predilection for Xanax and other drugs has precluded us having a clear shot at success. She has had relatively few life-threatening infections or complications but she is wasting away and we know it. A killer infection is only around the corner. With her itinerant lifestyle and inability to stay in one place and on task for more than a few days, she has been a poor candidate for treatment. Her Hepatitis C is also a worry, but the treatment for that can cause such intense emotional distress and suicidality that she would never withstand it. Her seizure disorder is another issue altogether.
Since I "inherited" her from another nurse almost two years ago, it's been an ongoing struggle to figure out exactly what to do with her. She has dropped out of our program several times and left the clinic entirely, always looking for a doctor who'll keep her supplied with Xanax. Now she's back with me for six months, and I feel like I am battling time.
I have successfully introduced visiting nurse services and Rose now has a daily visit from the visiting nurse whom she loves. By offering her home delivery of methadone (rather than going to the clinic every day), we are assured that she'll be home waiting for her daily dose. Now that this relationship is established, the thought is that we can now introduce further treatment.
Rose is now living in a three-story walk-up, with several of her daughters living upstairs. The electricity for all three apartments is in her name only, so I have had to intervene several times to keep the electric company from turning off the lights due to a bill over $1000. Rose spends most of her days in a messy double bed in the middle of the living room, with the TV on throughout the day. The sparse furniture is old and in poor repair, the apartment almost empty except for a shower seat in the middle of the dining room and some nasty leftovers or other detritus in the kitchen. No cooking happens in the apartment. Her daughter brings her food once or twice a day, at best, and Rose spends the majority of the day smoking. Cigarette burns dot the unwashed bed linens and I know it's only a matter of time before she goes up in flames with the rest of the building. Until recently, Rose's four-year-old granddaughter was living with her in this apartment, ostensibly abandoned by her mother, Rose's daughter. The other daughter who is the most responsible of Rose's children has taken custody of the four-year-old. The Department of Social Services has been called on the family numerous times.
Last week I felt forced to call Protective Services for the Disabled about Rose. I hated to do it, but I felt it was the only way to possibly get other agencies involved and consider taking legal action to put Rose in a nursing home, at least until we can get her stabilized. Although I don't think Rose's daughters are necessarily neglecting their mom per se, Rose's living conditions are abhorrent and are like what you might see in a movie or TV drama. Life imitating art? At best, Rose is self-neglecting, and that is enough to call Protective Services and report her as a risk to herself.
My goal is to introduce antiretrovirals as soon as I can, give Rose some immune protection against deadly infections, and watch as she gains weight and loses some of the dementia that has begun to set in. Whether some of this neurological damage is permanent from the vicissitudes of untreated HIV infection and years of IV drug use, it's hard to say. Perhaps if she stabilizes enough, we can send her to detox and break her Xanax habit. I am not overly optimistic, but I'm determined to at least give a very sincere attempt at suppressing her virus and perhaps prolonging her life, simultaneously putting into place services that might improve her daily plight.
As I sit in my lovely screened-in porch, listening to the many birds in the surrounding trees, the dogs snoring on the rug, a cold beer beside me, a warm meal in my belly, I think about Rose. I think about her life which is what it is, continuing throughout the weekend when my work is on hold and I go about my personal life. It's profound to witness such suffering up close, and it's also profound to realize that that particularly reality is not my own, at least not in this life, anyway. On Tuesday, I'll continue the struggle and see what the next step will be for her, as well as for dozens of others, most much better off than her, several somewhat worse. I take a deep breath of the flower-scented air here in my home reality, and I feel grateful beyond words.
Rose has had AIDS for about ten years. We've never treated her with antiretrovirals (the drugs used to stop the virus from replicating) because her mental illness, anxiety disorder, and predilection for Xanax and other drugs has precluded us having a clear shot at success. She has had relatively few life-threatening infections or complications but she is wasting away and we know it. A killer infection is only around the corner. With her itinerant lifestyle and inability to stay in one place and on task for more than a few days, she has been a poor candidate for treatment. Her Hepatitis C is also a worry, but the treatment for that can cause such intense emotional distress and suicidality that she would never withstand it. Her seizure disorder is another issue altogether.
Since I "inherited" her from another nurse almost two years ago, it's been an ongoing struggle to figure out exactly what to do with her. She has dropped out of our program several times and left the clinic entirely, always looking for a doctor who'll keep her supplied with Xanax. Now she's back with me for six months, and I feel like I am battling time.
I have successfully introduced visiting nurse services and Rose now has a daily visit from the visiting nurse whom she loves. By offering her home delivery of methadone (rather than going to the clinic every day), we are assured that she'll be home waiting for her daily dose. Now that this relationship is established, the thought is that we can now introduce further treatment.
Rose is now living in a three-story walk-up, with several of her daughters living upstairs. The electricity for all three apartments is in her name only, so I have had to intervene several times to keep the electric company from turning off the lights due to a bill over $1000. Rose spends most of her days in a messy double bed in the middle of the living room, with the TV on throughout the day. The sparse furniture is old and in poor repair, the apartment almost empty except for a shower seat in the middle of the dining room and some nasty leftovers or other detritus in the kitchen. No cooking happens in the apartment. Her daughter brings her food once or twice a day, at best, and Rose spends the majority of the day smoking. Cigarette burns dot the unwashed bed linens and I know it's only a matter of time before she goes up in flames with the rest of the building. Until recently, Rose's four-year-old granddaughter was living with her in this apartment, ostensibly abandoned by her mother, Rose's daughter. The other daughter who is the most responsible of Rose's children has taken custody of the four-year-old. The Department of Social Services has been called on the family numerous times.
Last week I felt forced to call Protective Services for the Disabled about Rose. I hated to do it, but I felt it was the only way to possibly get other agencies involved and consider taking legal action to put Rose in a nursing home, at least until we can get her stabilized. Although I don't think Rose's daughters are necessarily neglecting their mom per se, Rose's living conditions are abhorrent and are like what you might see in a movie or TV drama. Life imitating art? At best, Rose is self-neglecting, and that is enough to call Protective Services and report her as a risk to herself.
My goal is to introduce antiretrovirals as soon as I can, give Rose some immune protection against deadly infections, and watch as she gains weight and loses some of the dementia that has begun to set in. Whether some of this neurological damage is permanent from the vicissitudes of untreated HIV infection and years of IV drug use, it's hard to say. Perhaps if she stabilizes enough, we can send her to detox and break her Xanax habit. I am not overly optimistic, but I'm determined to at least give a very sincere attempt at suppressing her virus and perhaps prolonging her life, simultaneously putting into place services that might improve her daily plight.
As I sit in my lovely screened-in porch, listening to the many birds in the surrounding trees, the dogs snoring on the rug, a cold beer beside me, a warm meal in my belly, I think about Rose. I think about her life which is what it is, continuing throughout the weekend when my work is on hold and I go about my personal life. It's profound to witness such suffering up close, and it's also profound to realize that that particularly reality is not my own, at least not in this life, anyway. On Tuesday, I'll continue the struggle and see what the next step will be for her, as well as for dozens of others, most much better off than her, several somewhat worse. I take a deep breath of the flower-scented air here in my home reality, and I feel grateful beyond words.
Friday, May 20, 2005
Blessed Relief
Friday rolls around and the relief of two days free of caring for others is like a weight lifted, believe me. Today I was pushed to the edges of my patience with several patients, and I practiced compassionate listening even as I felt my impatient self wanting to scream in frustation, "Why the fuck can't you understand these simple instructions? Don't you get it???" Thank Goddess for self-control and restraint.
When one sees learned helplessness in action, it is difficult to just sit there smiling and say, "Y'know, I understand how you feel. Now let's talk about it". Instead, one wants to talk like you might talk to a recalcitrant child, threaten to take away priviledges, no sweets after dinner, no TV before bed. Instead, we plead, we cajole, we try good cop/bad cop techniques, we throw up our hands and decide to try again next week.
The diabetic patient who knows she should eat a small snack every few hours but only eats an enormous meal once a day and then has super-low blood sugars 12 hours later should know better--she just can't change her patterns of behavior. The woman with advanced AIDS who continuously buys Xanax on the street should know better, but her life of unbelievable trauma precludes such clearheadedness. The other patient with advanced respiratory disease should be able to stop smoking, since she constantly complains of not being able to breathe. But she can't. Her AIDS is fully controlled but the smoking will be her death. Can I change it? Probably not. Am I frustrated with her? Hell, yes.
I have a love/hate relationship with this work. I love the people, their humanity, their damaged selves. I love the ones who are self-sufficient and disciplined. I love the ones who are helpless victims of trauma. I've loved many who have died---the city is speckled with their memory as I make my rounds along the streets. I love many who will die, often due to their own inability to act conscientiously, and memories of them will also roam the streets and the corridors of my mind. I ask myself honestly if I am addicted to being a helper. Do I gain alot from being in this role? I'm sure I do, and only I can decide when the role no longer serves me (or them, for that matter).
When one sees learned helplessness in action, it is difficult to just sit there smiling and say, "Y'know, I understand how you feel. Now let's talk about it". Instead, one wants to talk like you might talk to a recalcitrant child, threaten to take away priviledges, no sweets after dinner, no TV before bed. Instead, we plead, we cajole, we try good cop/bad cop techniques, we throw up our hands and decide to try again next week.
The diabetic patient who knows she should eat a small snack every few hours but only eats an enormous meal once a day and then has super-low blood sugars 12 hours later should know better--she just can't change her patterns of behavior. The woman with advanced AIDS who continuously buys Xanax on the street should know better, but her life of unbelievable trauma precludes such clearheadedness. The other patient with advanced respiratory disease should be able to stop smoking, since she constantly complains of not being able to breathe. But she can't. Her AIDS is fully controlled but the smoking will be her death. Can I change it? Probably not. Am I frustrated with her? Hell, yes.
I have a love/hate relationship with this work. I love the people, their humanity, their damaged selves. I love the ones who are self-sufficient and disciplined. I love the ones who are helpless victims of trauma. I've loved many who have died---the city is speckled with their memory as I make my rounds along the streets. I love many who will die, often due to their own inability to act conscientiously, and memories of them will also roam the streets and the corridors of my mind. I ask myself honestly if I am addicted to being a helper. Do I gain alot from being in this role? I'm sure I do, and only I can decide when the role no longer serves me (or them, for that matter).
Monday, May 16, 2005
A Gentle Monday
A thankfully gentle Monday greeted the opening of my week. A morning work-out, a patient hospital visit, some clinic visits, and lots of desk-oriented work and calls. Today was a day when the work I do made sense:
-I spoke with a doctor about a patient who needs better diabetic care. We came up with a plan and I called the VNA to initiate the change.
-I visited a patient in the hospital, wrote a note in her chart, and later received a call from the hospital physician about the discharge plans.
-Later I sat in on a visit one of my patients had with his primary doctor. A great deal of useful information was exchanged and now I can follow up.
-Another patient didn't show for his appointment with his doc. I checked the computer and saw that he'd been in the ER. I printed out the notes and labs and will discuss them with his primary and initiate timely follow-up.
Just for a day, everything made sense and I could just do my work.
My colleague, meanwhile, was struggling with a patient who has a not-quite-broken arm which needs orthopedic attention. Unfortunately, none of the local ortho docs want to see a Medicaid patient if the patient's arm isn't actually fractured, so the patient languishes in pain. Another patient needs emergency oral surgery but no oral surgeons in the area accept Medicaid. We can load her up on narcotics but she needs surgery. What to do? Luckily, this was not my battle to wage today, but there for the grace of God go I......
Coming home, the dogs wag their greeting and we head to town for a book-reading at the local dog-friendly collective bookstore (see link to Food for Thought Books). The reading was cancelled, but we hung out with the friendly bookstore workers, the dogs soaking up the proffered love. We then wandered through the sunlit town, eating cookies and looking at flowers. The dogs only seemed interested in flowers that other dogs had peed on. What's up with that?
I give thanks tonight for a gentle day, a lifted depression, the peepers making their nightly appearance in the nearby swamps, and the knowledge that my love is on her way home.
May your days be gentle, fair Reader.
-I spoke with a doctor about a patient who needs better diabetic care. We came up with a plan and I called the VNA to initiate the change.
-I visited a patient in the hospital, wrote a note in her chart, and later received a call from the hospital physician about the discharge plans.
-Later I sat in on a visit one of my patients had with his primary doctor. A great deal of useful information was exchanged and now I can follow up.
-Another patient didn't show for his appointment with his doc. I checked the computer and saw that he'd been in the ER. I printed out the notes and labs and will discuss them with his primary and initiate timely follow-up.
Just for a day, everything made sense and I could just do my work.
My colleague, meanwhile, was struggling with a patient who has a not-quite-broken arm which needs orthopedic attention. Unfortunately, none of the local ortho docs want to see a Medicaid patient if the patient's arm isn't actually fractured, so the patient languishes in pain. Another patient needs emergency oral surgery but no oral surgeons in the area accept Medicaid. We can load her up on narcotics but she needs surgery. What to do? Luckily, this was not my battle to wage today, but there for the grace of God go I......
Coming home, the dogs wag their greeting and we head to town for a book-reading at the local dog-friendly collective bookstore (see link to Food for Thought Books). The reading was cancelled, but we hung out with the friendly bookstore workers, the dogs soaking up the proffered love. We then wandered through the sunlit town, eating cookies and looking at flowers. The dogs only seemed interested in flowers that other dogs had peed on. What's up with that?
I give thanks tonight for a gentle day, a lifted depression, the peepers making their nightly appearance in the nearby swamps, and the knowledge that my love is on her way home.
May your days be gentle, fair Reader.
Subscribe to:
Posts (Atom)