The Calculus of Caring

For reasons of liability, my colleagues and I are encouraged to refrain from transporting patients in our own cars, and we are told in no uncertain terms that the risk is ours if we choose to do so. At various times, I have attempted to eschew taking patients to appointments in my car, but every time I do it "just this once", I'm reminded of how often it seems like the easiest and most convenient thing to do. The poor and disabled often have great difficulties with transportation. Through Medicaid, van service to medical appointments can be arranged, but it takes a prescription from the primary doctor which has to be renewed every year. The patient then has to call to arrange rides which often prove to be unreliable, especially when Medicaid contracts the rides out to private vendors and taxi companies. Still other patients are unable to use the phone to schedule appointments due to hearing impairment, language barriers, or cognitive deficits, while others simply cannot negotiate the series of voicemail message hoops which must be jumped through to speak with a real operator. Couple that with frequent wait times of up to 30 or 60 minutes to schedule a ride, mental illness, and physical disability---frustration and exasperation reign.

Taking all of this into account, I choose wisely when I take a patient in my car, and I try to use that close proximity and captive audience for therapeutic purposes. Being in a car can foster conversational intimacy. The car is like a cocoon in which the driver and passenger ride---private, temperature-controlled, comfortable, quiet. Sometimes deep conversations can be engendered simply by the simultaneous closeness and relative lack of eye contact that drivers and passengers must somehow finesse in order to converse. Keeping my eyes on the road with occasional glimpses towards the passenger seat, my patient is able to be in their own world but speak to me freely, and this can often bring about aspects of conversation which might be less comfortable while sitting together in an exam room at the clinic or even in the patient's living room. I appreciate this difference and make use of it in various ways.

My work allows me the ability to see patients in their homes, experiencing their personal daily environment, interacting with their family and children, looking in their refrigerators and cupboards to assess their nutritional practices (with permission, of course), while also assessing their home for physical impediments which might compromise their safety or otherwise thwart their independent self-care at home. I also attempt to ascertain if there are firearms in the home, smoke alarms, working locks on the doors, safe electrical wiring and outlet use, and relative cleanliness. This information---generally unavailable to any doctor---is also under-appreciated by most doctors and not taken into account during those brief patient visits, although the providers with whom I work are more tuned in than most to the psychosocial aspects of our patients' lives.

Today I visited a patient who is basically squatting in her oldest daughter's apartment for want of a better situation. She sleeps in a medium-sized bedroom with her two school-age children, sharing an inflatable queen-size bed. To my surprise, a one-year-old pit-bull was curled in her lap as she sat on the bed, and I was greeted by this new family member's demonstrative and unbridled affections. She obviously sensed her owner's positive reaction to my entrance, and immediately embraced me as one of the pack. I sat on the dirty carpet and communed with this canine soul, who looked into my eyes as only a dog can.

This woman is dear to me, and we have had many heart to heart talks over the years--some in the car, some at the clinic, many in her myriad apartments. Due to our friendly intimacy and familiarity, I imagined that rolling on the floor with her new puppy was in no way professionally inappropriate. It was, in fact, therapeutic for us all.

These relationships each have their own tenor and particular rhythm. With this particular person, I sit on the floor, play with the dog, and we chat about much more than her health, always bearing in mind that this is a professional relationship, a helping relationship of therapeutic value. In this type of work, we sometimes walk a fine line, the boundaries blurring, but building relationships is what it's all about, after all. Without those warm bonds, it's nothing but clinical rapport, which to me is a chillingly stiff boundary which holds little interest for me.

So yes, these folks admittedly live in a corner of my head both night and day, but the value which I derive from these relationships repays me for my labors in the larger scheme of things---the karmic and dharmic bank, if you will. It's the calculus of caring, the mathematics of the calculation a mystery, and the final result so much more than the sum of its parts.

Redundant Malignancies

Tomorrow I have to face informing a client that his cancer has returned. I became privy to this information late on Friday afternoon, the primary doctor calling me on my cell-phone to give the results of the biopsy. I played phone-tag with the surgeon, who confirmed in a message that the bad news was indeed true. I know I'm the best person to do the telling, but it's a wrenching task about which I'm cringing tonight. Being the bearer of troubling news is never a comfortable role to play.

Meanwhile, another patient of whom I am exceedingly fond faces a rough road as his cancer resurfaces. A new round of chemo is upon us, and my energy is spent in coordinating care, alleviating symptoms, and giving support in whatever way is best.

The last time I faced several surges of patients' recalcitrant malignancies, two deaths followed quite swiftly. Am I facing yet another round of deaths around some not-too-distant corner? Perhaps. It's par for my course, and it's a course I choose to run.

What More Can I Do? I Guess There's Always More...

This morning, the visiting nurse found you by chance. You were standing on a street corner in the unseasonable warmth of the winter sun. She swept you into her car, called me, and brought you to my office, transferring you from her car to mine before I whisked you off to the Wound Clinic for your appointment. Magically, we were only fifteen minutes late.

Your open wound looks better, but now that you're homeless I explained that it was now up to you to find me, not vice-versa. You swore up and down that you will follow up and stay in close contact. Your health is precarious and the stakes are high.

Your life is a mess. You're homeless, addicted to cocaine and heroin, no longer go to the methadone clinic, and rarely take good care of yourself, making poor choices under the best conditions. I was very clear with you today that I will no longer chase you down and bend over backwards. You must do some work, show some motivation, reach out and stay in touch.

Did I motivate you? Does the progress we're making with the healing of your wound bring you hope? Does having someone show compassion bring you closer to self-love? I hope so. Your life is as valuable as any other, but you first have to value it yourself.

Tonight you're out there somewhere, hopefully not on the street. There are some harsh realities in this world, and you have been visited by your share of difficulties. I pray that you make some positive choices for yourself. May clarity of mind and a desire for healing plant themselves in your consciousness in the days to come. I won't give up on you, but I place the responsibility squarely where it belongs---on your tired shoulders.

What More Can I Do? Nada.

I discussed you in Part I and Part II of this "series" of posts. Last week, your sister called to complain that you are being evicted from your apartment for drug-related violations of your rental agreement. Seems a guest of yours tried to sell heroin to an undercover cop in your parking lot, and your neighbors have been complaining of the unsavory characters who hang about your place. She asked me to call the Housing Authority and vouch that you are clean and sober to assuage their concerns. How can I do that when the methadone clinic reports repeatedly dirty urines and the visiting nurse has seen new track marks on your arms this month? You've made a messy bed, and now your sleep in it will only become increasingly uncomfortable.

In a last-minute effort, I referred you to the local legal aid society and put you in the sights of an earnest and helpful paralegal who was unable to save you from yourself. I drove over to your apartment in a driving rain yesterday morning and met with the Sherriff and the Housing Authority representative to discuss your imminent eviction. A moving van was on the way to take your belongings to storage, your sister crying in the corner, blaming me for not intervening and stopping the eviction while herself refusing to take you in. The police were also on their way to "assist" you and your sister in vacating the premises as the locksmith changed the locks. After a talk with the Sherriff and other officials, I drove away, knowing full well that within a matter of hours, you would be on the street, the bandages on the gaping wounds on your legs soaked with rain, your massively edematous (swollen) leg aching in the damp cold.

Where are your friends who so readily took advantage of your dry apartment as a shelter from the cold and a place to shoot up? Where are your siblings who bemoan your circumstance yet deny you shelter? Where is your common sense which has been superceded by your addicted brain? The cruel cold world was waiting to swallow you whole, and there was nothing I could do other than refer you to the local shelters and beg you to call me on our office's toll-free number.

You sat there with an incongruous half-smile on your face as the reality of your pending eviction became clear. I, your last hope for salvation, had failed to remedy your sorry situation, and now you faced being turned out as the city streets flooded from the incessant rain, sewers overflowing and icy roads running like small rivers. Cold and cruel is right, more accurate than any of us sheltered suburbanites can know.

Where are you today? How long until you lose that leg? I know we'll miss that appointment with the wound specialist tomorrow---you'll never call. In this morass of misery, heroin and cocaine are most likely your only friends, the only source of temporary succor you can find. I fear that your death is imminent, and my power to prevent it nonexistent. These are the harsh realities, and I pray in this moment for your freedom from suffering in whatever form that freedom might take.

Namaste.

One Year of Digital Doorway

Today marks the one year anniversary/birthday of Digital Doorway, which was born with a brief post last January 18th.

In some ways, I'm shocked that I've stuck with it so long. I'm also shocked that DD receives 100-200 hits on a weekly basis. And according to StatCounter, I have had more than 8700 pageloads since I began tracking in February of 2005, putting my actual total close to 10,000, which is difficult for me to believe. That said, while many of those hits might be seconds long---if that!---the general volume of traffic is both appreciable and appreciated. I am also appreciative of my blogger friends and colleagues with whom I have developed on-line friendships and correspondences, and send great thanks to everyone who links to me out there in cyber-space.

When I began blogging at my brother's behest on January 18th of 2005, it was somewhat unclear what my blog would actually be. While, on one hand, I could have focused entirely on healthcare in general and my work as a nurse specifically, I found that I just have too many pokers in the fire to produce a consistent blog on one subject, although many people do it very well, I may add. And while there are advantages to having a "special interest blog" (ie: being easily categorizeable on blog search engines), it's also quite liberating to have a blog that is a constantly shifting and surprising entity, covering varying topics but also returning frequently to some central themes: health, personal healing, compassion, etcetera. Not being bound by topic and subject, my entries are born from the day's events, dreams, interactions, and thoughts.

The benefits for me have been too numerous to mention in full: personal and professional insights; valuable feedback from readers; a welcome and immediate creative outlet, free of editors and publishing woes; a feeling of connection to the wider web of folks out there who are moved and determined to communicate their thoughts and experiences and dreams to a wider, unseen audience.

As the blogging phenomenon continues to develop and mutate, I'm sure we will see changes in how blogs are recognized, categorized, published, and disseminated. I imagine a relatively small percentage of Internet users actually visit blogs regularly, and it will be quite interesting to see how those numbers change over the ensuing years.

For now, I'm gratified that DD has some regular readers, is linked on a number of sites, and has attracted comments and readers from various corners of the ethers. If aspects of my writing or style are disappointing to some, my apologies, and the wonderful thing about this medium is that there is simply a dizzyingly inexhaustible number of individual voices from which to choose.

On this one-year anniversary, I give thanks for such a simple and creative tool, and look forward to another year of introspection and exploration. Thanks for joining me on whatever portion of the journey you choose.

The Patient Patient

No wonder they call them "patients". I accompany my patients to many appointments, whiling away the hours in myriad doctor's offices as we wait to be seen by some specialist or another. I make small talk with my patient, discuss our strategy for the visit, answer my pager, make calls, jot notes in my Palm Pilot, finish notes from previous patient encounters, and otherwise try to make use of this sudden "down time". Sometimes, my patient will nap in their waiting-room seat, and on a rare occasion, I too will succumb to Morpheus' mid-day visits, catching a brief snooze as the TV in the corner of the waiting room blares CNN and other patients and their family members desultorily leaf through magazines or stare into space.

Is their an etymological link between patience the virtue and the patients who wait in doctor waiting rooms around the world? Perhaps not, but I see the correlation on a daily basis, and I cultivate my own personal stores of this quite useful virtue, seeing it as an occupational hazard which can, in some ways, lend itself to learning Zen and the Art of Waiting in Medical Waiting Rooms.

For anyone who has ever waited for what seemed to be an inordinate time for the doctor to see you, I feel your pain. Are you frequently a patient? Then begin a meditation practice and use those hours for your own self-growth and exploration. Doctor's offices won't be changing any time soon, so we all must practice our patient patient skills, or continue to suffer in those exhaustingly banal waiting rooms which never offer enough comfort to alleviate the pain of unwillingly inhabiting them for extended periods.

Here's to patience, patients, and those who can gracefully combine the two.

What More Can I Do?, Part II

The patient whom I discussed in this post received an eviction notice this week. It seems he actually missed his court date and will be summarily removed from his home by the Sheriff quite soon. This is not the first time I've encountered such a situation, and though my patients often look to me to somehow magically solve these housing nightmares, the best I can do is point them in the right direction.

For people with HIV, there are specialized housing advocates and programs, replete with housing case managers who go to bat for clients and fight to prevent homelessness and needless evictions. For people without HIV, there are housing advocates and legal aid for the poor, but it is a uphill battle, more so for someone who has little or no command of English, no money for transportation, debilitating illness, and an addiction which often precludes timely and thoughtful action under duress. For as I have seen in so many cases, when the going gets tough, the addict goes copping. You see, stress and seemingly insurmountable circumstances can be a natural trigger for substance abuse---a sad but brutal equation.

If a patient lives in subsidized housing and I have documented in their chart that they are actively abusing substances, I cannot testify for them or sign an affidavit stating that they're clean and sober (as some of my patients have asked me to do over the years). If I testify that a client is clean in my sincere effort to ward off an eviction, and then my notes are subpoenaed, I would be in deep professional and legal doo-doo. That said, a number of my star patients have been in sticky legal situations and I've gone above and beyond to help them, often because they are so proactive in helping themselves and refuse to be victims, and have done their utmost to keep their lives on track.

Sadly, there are a number of people out there who, for one reason or another, just cannot get it together, and cannot pay attention long enough to focus on their well-being and stability. As non-sensical as it may seem to some, learned helplessness and abject hopeless victimhood can be devastating in certain populations, especially where language barriers and cultural differences erect even more roadblocks. It is often just these individuals who come to me and my colleagues: physically broken, emotionally stunted, socioeconomically disengaged, and weighed down by poverty, mental illness, or as previously stated, substance abuse. These are the "train-wrecks" of the community health centers, and their care---often ignored and disavowed by most of the system---becomes our rallying cry. While that cry may at times feel more like a whimper for mercy, none of us are in it for the glamour or the glory and we choose our work quite knowingly. Compassion fatigue is real, but one needs huge stores of patient compassion (and compassionate patience) in this business.

Will this particular gentleman be out on the street next week? Perhaps. Did I connect him with just the right people in an attempt to assuage this dire situation? Oh, yes. Am I powerless to do more? In my mind, yes, unless I choose to take him home with me (an impossible, improbable, and altogether inappropriate idea).

Will another gentleman be incarcerated for something he swears he did not do? Maybe. Did I write a heart-felt letter to the judge, declaring my patient's poor health, poor immune status, and sincere attempts to better himself? Absolutely.

Did I come home to my cozy home and leave them all to their own lives and battles as I enjoy my weekend with family and friends? You bet. If the caregiver does not care for himself, there will be no more care left to give.

What more can I do? For now, I err on the side of self-care, and the pieces will simply fall where they may. I cannot fix it all and I never will.

What More Can I Do?

You are a middle-aged man with poorly-controlled diabetes. You inject heroin and cocaine periodically. Since your veins are shot, you often inject using a technique called "skin popping" wherein you inject under the skin rather than intravenously, sometimes developing infected abscesses in your arms that have to be surgically debrided. You have massive lymphedema (picture elephantiasis) of one leg, and ulcers frequently open on your legs and arms. You go to methadone every morning, but they're going to discharge you because your toxicology screens keep coming up positive for opiates and cocaine.

I'm worried that you may lose your leg or die from an infection. I have the visiting nurses see you every day to dress your wounds and administer your medications and insulin. As far as the open wounds, I now have you connected at the Wound Clinic. Since transportation is an issue, I actually pick you up and take you personally to your appointments so that your treatment is expedited. I also serve as translator. When you're sick I come to the house to visit you, and I keep your primary physician updated regarding your status. When you miss an appointment, I reschedule it since you don't have a phone. The visiting nurse and I consult about you almost every day. Only a handful of patients in the United States have this type of intensive and personalized healthcare delivered to them at no cost. I wish you could grasp the reality of that.

Despite all that I do, you still miss appointments, avoid the visiting nurse, skip medications, make excuses, and increase your chances of harm to yourself. I don't know your complete history, but I imagine there is a long story rife with psychic trauma, perhaps violence, abandonment, addiction, family stress, poverty, mental illness, and learned helplessless. I have no idea what experiences brought you to this point. From my standpoint of relative normalcy and stability, I cannot really understand your life, but only empathize with what it must have been like.

I want nothing more than to spare you frightening and painful outcomes which are lurking around every corner, but I can only do so much. Compassion fatigue is real, no matter how traumatic the patient's past. There's a point where I have to decide that I'm working too hard for you, doing too much, enabling you to not help yourself. Where do I draw that line?

Drawing to a Close

We drank champagne at work today. The masses clamored for the office to shut down early and our boss relented, even though he was planning to let us all go early anyway, just like he did last Friday, the day before Christmas Eve. The corks popped, we drank a toast, and the lights were turned off, leaving the last twelve months of love and labor behind us.

The turning of the year often naturally predisposes one to reflection and review. More than eighty people have been under my care this year, several dying quite peaceful deaths while surrounded by loving family and friends. The year also saw relapses and remissions of addiction, domestic violence, divorce, recovery from alcoholism, resurgence of cancer, improved health, and continued chronic physical and psychiatric illnesses. With so many patients, I can't say that everyone is better or worse---there is a continuum of recovery and rehabilitation, and they all find a different place along its trajectory, that place often changing from day to day.

Professionally, it's been a year of proving my mettle (to no one other than myself) and holding my own, often putting in more hours than I might like in a given week. More and more, the management of information has become part and parcel of my job, something they never really mentioned in nursing school. Still, I feel good about what I've been able to accomplish, the care I've given, the lives I've been able to touch, the students I've guided and laughed with.

Reflecting further, I also recognize certain skills and areas of assessment that I would like to develop: neurological assessment; cardiac assessment; further improvement of my Spanish, especially in relation to psychosocial counseling

I could go on, but it's just too uninteresting.

On the other work-front, I now have a three-week break from teaching---also known as stuffing the minds of nascent nurses with too many facts and potential scenarios. One more semester, and I plan to retire from my stint as college professor, glad to have learned that I can do it, and glad (in some ways) to leave it behind me.

Anyway, life at work evolves and shifts, but also remains quite constant. The basic calculations are the same, the cast changes from time to time, but the underlying feeling is continuous, and these three-day weekends? They're priceless. What is one golden lesson learned? Self-care is paramount. A sick and depressed caregiver is no use to anyone in this world.

Here's to another year of satisfying work, and continued gratitude for the luxury and blessing of having such work to fulfill myself and my place in the scheme of human endeavor.

Blogstipation

noun. To be unable to think of anything to blog about, i.e. writer's block for bloggers.

---as found on Samizdata.net

Paradox

I use this quote by Mother Teresa as the "signature" on my email account...

"I have found the paradox that if I love until it hurts, there is no hurt, only more love."

What more can I say on the eve of Christmas Eve?

O! Merciful Monday!

The week begins, not with a roar, but with a relative hum. While some of the usual suspects surfaced as expected, the intensity of said surfacing was subdued. Is it the coming of the holiday season? I would think not---things usually heat up about now. Let's just say it was a day in which there was room to breathe and think clearly. Any day like that is worth exulting over.

That said, the usual holiday and winter-time mood shifts are also making themselves known. Financial stressors, winter's tightening grip, and the shortening days all take their toll, but the coming Solstice actually signals the beginning of the (slow but steady) return of the light, the sun going down 30-60 seconds later each day after December 21st, taking us all the way to the heady days of late June's summer cauldron. But I digress in thinking of the more verdant times ahead....

Today I did what any prudent Nurse Care Manager would do: a patient has difficulty waking up early enough to shuffle her school-age children off to school, so I bought her an alarm-clock in the guise of a Christmas present. It was accompanied by toys for the kids as well, and I explained that the clock is actually a gift for the kids, although they would much rather oversleep and miss as much school as possible. Hopefully, my gift will pay dividends in improved educational outcomes and life opportunities for these young ones. You just can't care for the parent if you don't notice (and try to improve) the plight of the kids. Nursing is so much more than blood pressures.....

I was able to give good holiday news to another patient today. She went off of her AIDS medications (unbeknownst to me) for various psychosocial reasons about six weeks ago, and I was afraid that her virus would bounce back and mutate with ferocity in the face of such an opportunity. Luckily for her, the bloodwork came back unscathed and we will restart meds right away. A lovely Christmas gift of continued good health.

The day was capped off by administering a 100-question final exam to my beleaguered students. From the looks of things, people did fairly well. I consciously made the exam only modestly difficult, a welcome reprieve for them at the end of a long semester.

This entry is simply "a day in the life". Nothing profound, nothing earth-shattering. Just the fatigued chattering of a tired Monday-night nurse.

Buenas noches.

Ghost in a Machine

Previous post details system error.

Progress report:

Nurse 9.0 reboot relatively successful.

No hardware malfunction found, except for chronic low-back pain and sundry medical problems (ie: gastroesophageal reflux disease, hyperlipidemia, and enlarged prostate).

Software occasionally malfunctions secondary to pharmaceutically-corrected clinical depression.

Nurse's "better half" is source of continued solace and joy, as is offspring.

Canine companions: ditto, although ageing rapidly.

If nurse is really a "ghost in a machine", care of said machine is paramount.

Off to bed.

System Error

+Warning: healthcare provider system error/
+Nurse 9.0 program malfunction.
+Available memory at 98% capacity.
+Hard drive malfunction.
+Input overload.
+Processor speed at full capacity.
+Suggest re-boot system, replace hardware, or call manufacturer.

Thanks, I Needed That

Sometimes positive feedback can lift one's spirits and renew one's commitment. While pondering what to write about today, I considered several comments which came my way in the last few days and went straight to my heart.

At my workplace recently, there was a "consumer meeting" in which some of our patients voluntarily came to a group meeting to give their honest feedback about our program and what it means to them. My supervisor described how one of my patients---a gentleman with paraplegia from a gun-shot wound to the spine---emotionally exclaimed how this is the first time that he feels like a human being in terms of his healthcare. He said how amazing and strange it is to have a nurse who actually calls him on the phone from time to time to offer assistance and make periodic home visits. He said, "You have no idea how that feels." My supervisor admitted that, listening to this testimonial, tears came to his eyes.

Just today, I struggled to make it to work in a snowstorm only to receive a cell-phone call just before arriving that I was welcome to work from home and not risk coming out in the storm. Somewhat disappointed that I had missed an opportunity for a snow-day, I was rewarded in my efforts by being able to assist a patient in obtaining an urgent ultrasound and an urgent visit with one of our doctors. While she may have been able to make it to one of those appointments today without my help, she certainly would not have achieved both. Leaving work early, I was even able to drive her home, stopping at her pharmacy along the way to pick up her medications which she admitted would not have happened due to her disability, the snowstorm, and not having a car. Her gratitude was overwhelming, especially when she said, "No one cares like you do."

A student in my class to whom I have given some extra support and compassion said some embarrassingly laudatory things (thankfully privately) about me last night as she packed up her things at the end of class, and I found myself truly grateful for being "seen" by her, even though the support I have offered did not seem worthy of such unbridled praise.

While I may sometimes forget how the little things that I do for others can be very meaningful for the recipients---even when what I do seems so relatively minor---I also remind myself how the feedback which I receive from those whom I serve can only strengthen my resolve that my work is worthwhile and tangibly effective. For every patient who is unable or unwilling to show appreciation for what they are receiving, there are ten whose gratitude is like a balm, a reinforcement that helps me to continually recommit to my work. Feeling that how one earns one's living has value for others is priceless in its abililty to sustain one in moments of stress and overwork.

We were reminded by my boss just yesterday that our agency---and the specialized care which it provides---is being watched by many in the healthcare delivery industry around the country. The results of our work has been published in professional healthcare management journals,
studied by The Robert Wood Johnson Foundation and by the Boston University School of Public Health. My commitment stems from the fact that what we are doing may eventually serve as a blueprint for delivering compassionate and quality care to disabled and underserved communities of patients around the country. An opportunity to possibly be part of healthcare history is a driving force behind our collective passion for our work.

On this snowy evening, I can feel good about the energy I put out into the world, despite the headaches, frustration, and overwhelmed feelings which abound. These small doses of positive feedback will go a long way toward refreshing me in my continued pursuit of finding meaning in daily life.

I really did need that.

No Rest for the Weary?

Is there no break from cancer around here? Just as I hoped that all of my patients and their famlies were enjoying a uneventful holiday weekend, I come to work to learn that one of my favorites---a middle-aged man with inoperable throat cancer---was in ICU over the weekend after "bleeding out". Tumors actually grow their own veins and arteries, damn them, and some of those blood vessels can be rather friable (fragile). My patient developed severe hemoptysis (spitting up blood) and was rushed to the ER. He's now out of ICU and out of the woods---temporarily---but the spectre of further bleeds looms large, as does the fact that the inoperable tumor is beyond the practical benefit of further chemo or radiation. With a tracheostomy for breathing and a gastric tube for receiving nutrition, medications and liquids, the notions of quality of life, pain control, and the ability to remain comfortably at home come to the fore.

I just lost a beloved patient to cancer not three months after my other sweet guy succumed to it as well. Now patient #3 is showing signs of decline, all when the week of the fourth anniversary of my best friend's murder is upon us, the actual anniversary being this Friday, December 2nd.

Ah me, oh my: death, illness and Winter sure can pack a triple whammy. All of this, however, is assuaged by the warmth of home, the love of family and friends, the dawning of the Solstice in just over three weeks, and the turning of the year, as arbitary as that may seem. Bono may have once sang, "Nothing changes on New Year's Day", but everything can change if one views it through the proper lens. My friend was murdered---but we've grown, he's moved on, and we're the stronger for it. So my patients die---we all must follow suit, and it's a priviledge to see them through the process. So the Winter is long---Spring and Summer are just that much sweeter for it.

Is there rest for the weary? If they seek it, it's in the very breath they take.

Transissues

A friend of ours divulged to us the other night that he is undergoing a transformation from living as a biological man to living as a woman by choice. He is assuming a female name, dressing as a woman, and embracing a feminine identity that he has felt near and dear to his heart since he was very young. This incredible conversation sparked my desire to write about my work with transgendered clients, something I have yet to address here on DD.

My friend's private journey aside, I have had the pleasure to have a number of transgendered patients over the years and it's developed into one of my keen professional interests. Having always considered myself a gay/lesbian/bisexual ally, my close work with the transgendered has led me to embrace the role as transgender ally as well. In my current job, I have had one patient who was a female-to-male (FTM) transgendered individual, and I currently have two MTF patients with whom I am very close. Their experiences inform my current (limited) knowledge base.

Last November, at a conference of the Association of Nurses in AIDS Care (ANAC), my eyes were opened wider than ever by Sam Lurie, the speaker who delivered the Plenary Address on Transgendered Health Care. Sam's approach to trans healthcare entertains, educates, and advocates on a variety of levels, and since that conference my interest has been duly piqued.

When thinking about this issue, the average person makes assumptions, remembers the "trans-sexual" label which seemed to be so popular in the 70's, and images of trans stereotypes may cometo mind. I have vague memories of a famous football player who underwent gender reassignment surgery when I was a kid, and somehow that image became confused with another memory: Joe Namath, another football star, doing a commercial for men's panty hose. But I digress.

Thanks in large part, I think, to the success and political acumen of the women's rights, civil rights, gay rights, and AIDS rights movements, the transgendered community has gained political power, entered the mainstream consciousness, joined forces with the Gay, Lesbian, and Bisexual communities, and forced society to gaze deeply at its definitions of gender. Now for some, this may be such a stretch as to snap the cognitive rubber-band, figuratively speaking, when taken in context with the current culture wars over the definition of marriage. But be that as it may, issues of gender and gender identity are and will continue to be part of the cultural zeitgeist and call for our (divided or undivided) attention.

That said, from the point of view of a healthcare provider who wants to be "trans-friendly", the germaine issues are many. First of all, one must become familiar with the nomenclature of the trans community in all its form and derivations: FTM, MTF, trans-man, trans-woman, op, non-op, and the list goes on, many terms being used within the trans community itself which I would not use in my own conversations. (This is similar to how the African-American and gay communities have re-adopted terms that were previously used as derogatory in the wider culture, breathing new life into those terms for the purpose of empowerment and self-definition.)
The health issues which a transgendered person faces are many. Contrary to popular opinion, there are many people who define themselves as trans who have not had---and will never have--- gender reassignment surgery. Perhaps there are economic barriers to such a radical transition, or perhaps the person is comfortable with their biological genitalia and simply prefers to "present" as the other gender. This is sometimes referred, as I have learned, to being "Op" or "Non-Op", and I have also seen the term "Pre-Op", meaning someone who is preparing for surgery, although that preparation may last a lifetime and never actually occur.

Surgery aside, many FTMs and MTFs will choose to undergo hormone therapy, a course which will cause physical, physiological, and even emotional changes for the individual. If a man takes "feminizing hormones", he will grow less facial and body hair, develop a softer voice, softer curves, and lose muscle tone, gaining fat in the hips and more of the familiar "hour-glass" shape of a female body. A woman taking testosterone will find her voice deepening, facial hair growing in, and muscular growth occuring. Both of these groups will find, aside from physical changes, documented alterations in thinking and communicating styles, lending credence to the theory that gender is widely dictated by hormone levels which can be altered and adjusted based on the way in which the individual wishes to present to the world and and be perceived by the world.

Hormone therapy presents challenges to the healthcare provider, both in its execution and monitoring. While there are protocols for such therapy available to the curious and conscientious provider, many doctors might feel uncomfortable with such "off-label" usage and decline to be involved. Not covered by any insurance, cost and availability become factors, and the quality of hormones obtained through the black market could be questionable, as well. Off-label or not, patients need expert guidance, compassionate care, professional oversight, and an unbiased advocate.

Picture this: you are a woman who has always felt that your true identity was male despite the genitalia with which you were born. You decide as a young adult to undergo hormone replacement therapy, knowing that it is most powerful and effective before a person is in their twenties. You grow facial hair, hair on your legs, arms and chest, your muscles develop, your voice deepens, and you are able to go out in the world and "pass" as a man.

There are several complicating factors in our scenario, however. Perhaps you would like gender reassignment surgery but it is an economic impossibility for you, or perhaps it is not even a question and you're happy with your current body vis-a-vis hormone replacement. Being biologically female, you must undergo a pelvic exam and PAP smear every year, an exercise which tests all of your abilities to advocate for yourself and educate others about your healthcare needs. When you enter the health center, you are seen as a man and there is no doubt as to your gender. However, when you get to the front desk, you need to communicate to the receptionist that you are there to see the gynecologist. How does she or he react? Do they ask why, as a man, you need to see the gyn? Do they verbally abuse you for being a freak? Do they "out" you in front of the other patients standing in line? When they realize you are trans, do they loudly ask, "SO, DID YOU HAVE 'THE OPERATION' YET?" (This would be akin to me walking up to a patient in the waiting room and asking if I could see their genitals!) How many of these trials and tribulations will you endure for the sake of your health? How will you decide which rest room to use? How many dirty looks can you entertain? How much of this stress is worth it?

Once you make it into the exam room, the next challenge is the medical assistant. Will you need to explain again that, yes, you look like a man, but yes, you have a vagina and need a PAP smear? Will you overhear the medical assistant giggling with her colleagues in the nurses' station? How will the gynecologist react when she walks in the room? Will she be understanding? Repulsed? Judgemental? Refuse to examine you? Maybe this will be your last pelvic exam for the next ten or fifteen years. Avoidance of such traumatic experiences might be understandable, but could have grave and perhaps fatal consequences.

As you can see, most of us would never even consider such scenarios, let alone think about how to assuage fears and change insitutional policies which discriminate against the transgendered community. As a healthcare provider in a world of fixed gender definitions and rigidly held beliefs and stereotypes, advocating for patients on this level can be an uphill battle on the institutional and cultural level. But having seen the pain and confusion which such experiences can cause, I am on the side of advocating, fighting, and pushing for equality and healthcare parity for a population whose needs are many, and who are, whether our culture accepts it or not, here to stay.

A Call, A Death, A Final Goodbye

The call just came at 5pm. Mary answered my cell-phone and received the news: "A" stopped breathing just moments ago. The hospice nurse is on her way to pronounce her dead ,and the family is gathered around her diminutive body which has ceased its earthly rhythms.

A votive candle is now lit in the lap of the Buddha statue on our dining room altar. In some cultures, candles are lit for the newly dead to light their way through the confusion of the first hours of death. It is said in the Tibetan Book of the Dead that the "Bardo" stage---the stage of transition following death---can be shocking and confusing for the unprepared soul, and there are specific meditations that can be practiced to usher a soul through the Bardo towards enlightenment.

"The Tibetan Book of the Dead (also called The Bardo Thotrol) from Tibetan Buddhism was traditionally read aloud to the dying to help them attain liberation. It guides a person to use the moment of death to recognize the nature of mind and attain liberation.

"It teaches that awareness, once freed from the body, creates its own reality like that of a dream. This dream projection unfolds in predictable ways both frightening and beautiful. Peaceful and wrathful visions appear, and these visions can be overwhelming. Since the awareness is still in shock of no longer being attached to and shielded by a body, it needs guidance and forewarning so that key decisions that lead to enlightenment are made. The Tibetan Book of the Dead teaches how one can attain heavenly realms by recognizing the enlightened realms as opposed to being drawn into the realms of seduction that pull incorporeal awareness into cyclic suffering."

I loved “A” more than any patient that I can remember. I can’t quite put my finger on why that is. Maybe it was all of the cigarette-smoke-laden plantains that she gifted to me over the years in her inimitable way. Maybe it was the way she would react with genuine surprised delight when I would arrive at her home, even if we had just hours earlier agreed upon a time for my visit. Maybe it was how, even in her most sickly state, she would inquire after my son and wife and dogs, sending her blessings to them and all of my extended family. I realize that this past Friday was the only time she had not asked that ubiquitous question, her mind being too disengaged from her body to make such an effort, although I’m sure that the intention existed in her mind, even if the words were unsaid.

It's funny how I never tired of her questions, her inability to grasp some of the things I tried to teach her, her reluctance to make changes that we felt were necessary for her health. She was apparently knowingly infected with HIV by a man whom she had met during her fifth decade of life, but she embraced and rallied around that diagnosis with determination, and her steadfast adherence to the medications kept her virus completely at bay for many years, even at the time of her death. Was the cancer that grew in her chest related to HIV even though she had no detectable virus in her blood? Perhaps, but the data is still not there for us to draw any firm conclusions. Whatever the case may be, she smoked like a chimney and only stopped when 24-hour oxygen was absolutely required to sustain her.

Over the last five years, I would often use "A" as an example of the complicated nature of my patients: HIV, diabetes, hypthyroidism, anxiety disorder, major depression, psychosis, history of suicide attempts. But I would also use her as an example of the closeness and personal satisfaction that I gleaned from my work, emotional depth created in such bonds of professional therapeutic relationship and, yes, friendship. Granted, the friendship in its active form was somewhat conditional based upon a one-way relationship of my visits and attentions to her health, but the true spiritual friendship and bond was one born of a kinship that neither of us ever defined and only recently verbalized. Just a few weeks ago, while visiting her in the nursing home, A and I agreed that perhaps we had known one another in a past life, and that there was no way to fully understand why we felt so closely connected. She was quite lucid at the time of that visit, somewhat sad and thoughtful, but readily agreed that our kinship was special to her.

A was a gem, and I will miss her dearly. There was something magical about her that touched me deeply. I am blessed to have known her, and I send her my love and blessings as she leaves this earth, leaves her body, and leaves her family to carry on in her memory. Goodbye, dear friend.

Goodbye?

I left work early, determined to visit my dying patient and check in before the weekend. Being Friday evening, the traffic was snarly, but I braved the morass and made it there safely.

Asleep in bed, "A." was curled in the fetal position, turned towards the wall, the hum of the pneumatic mattress and oxygen tank providing ambient white noise. Her daughter sat with me on the adjacent bed and we talked of A's life, her history, their relationship, family. She showed me some photo albums and I beheld images of A's more distant past which had been mostly a mystery to me. I always know that a larger life and history exists behind and within every patient: childhood, adolescence, family, travel, work and career---but those stories do not always enter into the ongoing conversation, frequently lost in the shuffle of health problems and medical care. Nonetheless, these details always help to flesh out one's portrait of the individual and are infinitely enlightening.

After some time, "A" awoke, and it seemed to take her a few minutes to register who I was. The change from three days ago was striking. She seemed wasted, thin ("cachectic" in medical terminology), and disoriented. She sat on the edge of the bed with our help, and made efforts to stand, which she did with my assistance. When I inquired where she wanted to go, she had nothing to say, so I invited her to dance, and we stood there, almost motionless, my arms around her, her right hand hooked in my belt, her left hand holding my right hand. Her daughter stood by, saying "Baile, mama!", "Dance, momma!". The excitement over, we sat on the big bed which sits just adjacent to the hospital bed, and "A" leaned against me as I held her upright, my arm around her thin shoulders. I said "I love you" in Spanish, and then in heavily accented English (the way she would say it, the "v" in love more like two "F's", sounding more like "luff"). She said "I luff you too" in her gutteral and congested voice which now emanates from her tightened throat. It was a poignant moment, and then the energy began to shift as I prepared to leave for home.

A's daughter asked me about A's fluid intake, and I advised her to keep it as minimal as possible in order to keep her lungs from filling up with fluid. I explained how A's kidneys are shutting down, producing little, if any, urine, and her daughter confirmed that A's urine output in the last 24 hours had been scant, and quite concentrated, a sure sign that her bodily processes are waning. I suggested popsicles as a nice treat and source of fluid and fructose, and told her how she can make her own or buy some at the store. The weight of A's small frame was pressed against my side.

Taking my leave once again, I said goodbye, again not knowing if this was the final goodbye, or just another moment of letting go, preparing for the real thing. When A's daughter had been out of the room, I had told A that she was free to go when she felt the time was right, that there was nothing to fear, that she was loved and cared for, and that her family would be OK after her departure. I remembered the last time I had told a patient that several months ago, and he had died within thirty minutes. I think A may last through the weekend, but I wanted her to know that she could consider leaving her body when she felt it was apropriate and right, and I know that my word holds great sway for her. Her vacant stare could not convey the deeper comprehension that I know she was experiencing in that moment.

These goodbyes are not just that---they are also hellos to the next incarnation, the next permutation. We practice and practice all our lives, letting go of possessions, people, places, experiences, ideas, concepts, delusions, desires. "A" is about to let go of the greatest anchor to the physical world---her 69-year-old body---and she can do so with peace and equanimity. I wish her well these next few days as she continues her process of release, and if I do not see her again in this life, I can bless her on her journey with a clear conscience and knowledge that our souls shared a connection that is greater than the sum of our physical selves. Those connections are eternal and incorporeal, yet no less real than the shaking of hands, the warmth of fleshly contact. There is nothing more satisfying than true connection with another. Blessings on you, A, as this physical journey draws to its natural close. To paraphrase Elizabeth Kubler-Ross, we live until we say goodbye.

A Sweet Visit

I finally made a visit to my dying patient's home, or rather her daughter's home. I say that she's dying, but aren't we all? There she was, laying on her side in a hospital bed with a special pneumatically-controlled mattress provided by the hospice nurses. These beds are now de rigeur when patients are bed-bound and dying at home---pressure points and needless skin ulcers are avoided. A very valuable tool that most people in the world lack as they lay on their death-bed. What relative luxury.

Now that she's home and really only on "comfort measures", she receives morphine gel by mouth as needed, Ativan and Haldol liquid for anxiety and agitation, oxygen around the clock, and other "as needed" meds for nausea and other symptoms. Due to the large mass in her chest, she is limited to very soft foods and small amounts of liquids. It's said that a human can live a month without food, but only a week without water. At her current intake, she is able to just sustain herself, so no one knows how long this process might last. If the cancer is not advancing, she could remain in this state for some time, though the risk of infection and other complications is always high.

With "comfort measures only", she is no longer taking her HIV meds, diabetes meds, thyroid hormone, etcetera. She is now on a bare-bones regimen geared towards comfort and freedom from pain and psychic distress. This is often very difficult for the unitiated to understand, but it is quite standard practice in these sorts of situations. Additionally, as someone's body begins to shut down and they remain more and more confined to bed, drinking excessive amounts of fluids can only serve to cause fluid accumulation in the lungs, leading to pneumonia, congestive heart failure, or at least the feeling of drowing in one's own fluids. Not pleasant, but also a difficult concept for many families of the dying to grasp and accept. It seems cruel to limit fluid intake, but it is enormously helpful to the lungs and kidneys as they begin their deneoument.

I sat with this woman for about thirty minutes. As always, she asked about my wife, son, and dogs, and looked very deeply into my eyes. Her pupils seemed enormous, and her eyes themselves appeared equally huge---dark pools of feeling and life. I could not get over her eyes and told her how large and profound they seemed.

When asked if she believes in reincarnation, she replied "yes" quite quickly. I inquired about what other lives she has led, and she said that she had been an animal that lived "in the mountains". Pressed for more details, she could not elucidate other than to say that she has been many different animals in her time and that this life is her first as a human. She did, however, state clearly that she and I had met before, but I forgot to ask in what form I had made her acquaintance.

As is frequently the case when I visit her over the last few months---whether in the hospital or at home---we spent a fair amount of time looking into each other's eyes, both with and without a smile as we did so. I encouraged her to close her eyes, and stroked her face and head as she rested on her arm, the small stuffed moose which I gave her in the nursing home cradled in the crook of her neck. In her broken English, she looked at the moose and said, "I love you, cookie", hugging its plush softness to her face.

Sitting in silence at the side of the bed, I wondered to myself what might be going on in her mind at this time, no anti-psychotics to control her long-standing mental illness and anxieties. That said, when asked about her fears and concerns, she readily replied that she had no fears and no concerns, and felt no fear of neither death nor suffering. She seemed at her most peaceful---more so than at any other time in our five-year acquaintance.

I took my leave reluctantly, needing to head back to the clinic. Since I am no longer her medical provider, I can come and go as a friend, assured that the hospice nurses are providing the best care and comfort to my beloved friend. I know the day of her departure is not far off, and feel fairly clear that it will happen before the year turns its unavoidable corner.

Death can be soft, clear, almost effortless, and this is truly my wish for my friend. May death visit her with the gentlest of caresses, and whisk her away in a rush of flower-scented breath. This is my request tonight. May it be granted. May she pass with ease. May her passage be one of joyful release and return to the source. May she return to whence she came, and know that she graced my heart as she passed through this harsh, troubled, and painfully beautiful world.

Occupational Hazards

Identifying as a caregiver in this world is a sword with at least two edges. Being a caregiver---"giving care" as part of one's daily work in the world---is in many minds a noble cause and profession. This may be true to some extent, yet it brings with it many hidden occupational hazards. As I have discussed before, "compassion fatigue" is always around the corner, along with many of the other so-called "negative" emotions. Direct care of other human beings is a tiring occupation yet offers numerous rewards of spiritual, if not monetary, value.

Teaching brings its own rewards, as I have discovered. Having been offered a position as a full-time teacher/program coordinator, the pull of education has had some influence in my world, yet my hesitation to enter that sphere full-time is quite strong. Being dedicated to caregiving, I understand that I would need to continue to work in a direct care setting even if I accepted a position as a teacher. How else can a nursing professor teach the art and science of nursing if not him- or herself still immersed in the world of patient care? So that career choice would still necessitate having multiple jobs and multiple professional roles. I was also just offered a position as a nursing supervisor/manager for a local office of a corporate nationwide visiting nurse agency. As a man in a predominantly female field, I would then join the ranks of men who have risen from the ranks of caregivers into that of management, adding to the perception that men rise more easily to management positions in nursing in large part due to their gender. True or not, this is a prevalent dynamic in the field and one which I am hesitant to become a statistical member of.

For all of its flaws and shortcomings, I still feel an emotional and professional allegiance to my current full-time position, providing care in a cutting-edge nurse-run organization which may eventually serve as a model of delivering medical care to underserved chronically ill populations around the country. Taking into consideration the stress, the tension, the huge caseload, the frustrations, it still feels like home, for now at least.

And teaching new nurses? Does it still hold my attention? Yes, yet the cognitive dissonance comes in the knowledge that continuing to work forty-plus hours each week in a full-time job on top of a committment to teaching a four hour class one night each week is wearing me down. The amount of my leisure time hours spent in preparation for teaching eats away at my overall peace of mind, a consistent feeling of having "more to do" hanging in the air of my home. As much as the act of teaching is enjoyable and satisfying, doing so in the context of so much other hard work is a definite source of stress and unrest. I am currently quite clear that I will finish out the academic year at the school, seeing my current group of 23 students through to graduation, and cease my teaching activities, simplifying my life both at work and at home. If one's health and happiness begins to suffer from one's professional choices in life, one must make changes that will ease the tension and dissonance that such choices can bring.

I realize that this missive is quite self-indulgent and introspective, but remind myself that it is "blogger's license" at its self-centered best. Where else can one ruminate in an unedited fashion on the vicissitudes of one's life and career? If you made it through this rather banal piece of writing, thanks for your indulgence.

Sustenance

Another nursing home visit to my former patient today, a cuddly stuffed moose in hand as a gift of comfort. She is sliding down that slippery slope of rapid deterioration and escalating illness, further driving home the fact that her family could no longer handle her care at home.

While I perched on the edge of her bed, she informed me that the doctors will be putting a tube into her stomach through a hole in her abdomen through which she can receive fluids, medications and food, now that the mass in her chest precludes almost all swallowing. I explained the procedure and how this "g-tube" will work. We talked about her fears, joked a little, and she of course asked about my wife, son, and dogs. She was so happy to hear that my son is visiting us this weekend, as if she herself would be the recipient of that visit.

The love between us and our mutual admiration and appreciation was palpable to me today. This 70-year-old woman and I share a soul connection that reaches beyond the clinical into a place of utter humanity and connectedness. There is that place where souls meet and other boundaries melt away, and although it can be rare in a provider-patient relationship, the realization that one has even briefly touched that potential is enough to overwhelm one's heart with an incomparable feast of emotional sustenance.

One Love

Since my attempts to visit my (now former) patient at the nursing home were scuttled every day by the vicissitudes of my work-life, I simply went there today after work. I'm often exhausted on Fridays at 5, but seeing her before the weekend felt like an absolute necessity. Over the last few days, the tearful calls from my patient's daughter have been numerous, a great deal of my already busy days interrupted by panicked calls. Learning that she is now considered a hospice patient increased my need to pay a visit.

The nursing home visit was enough to reestablish our heart connection. I entered the room to find daughter, grandson, grandson's wife, and one-month-old great-granddaughter visiting my significantly skinnier patient. Although she denies trouble swallowing and is receiving daily radiation to her upper chest, I have no doubt that the realization of her terminal state is sinking in, depression becoming the underlying factor behind the loss of appetite, or at least the desire to eat.

After the family took their leave, we sat on the bed holding hands, the three other women in the shared room all sitting in their small spaces watching their separate TVs. This institutional room is cordoned off into four sleeping areas with those ubiquitous and oh-so-ineffective "privacy curtains" found hanging from the ceilings of hospital rooms everywhere. It's sort of like being in a dorm room with three roommates, but none of you are studying, you all have some chronic illness or illnesses, and the activities scheduled for the "students" leave much to be desired, as does the food. The smell of urine is as ubiquitous as those flimsy curtains, and many residents simply sit in wheelchairs with empty gazes, marking time between meals. The lucky ones are visited by family members who bring homemade food, flowers, crossword puzzles, and books. The less lucky residents simply languish and make the best of an inadequate situation.

Meanwhile, my dear patient and I sat looking into one another's eyes and breathing together. I told her in Spanish that our connection is one at the soul level, and that I would keep her in my thoughts and visit as often as I could. As expected, despite her suboptimal circumstances, she inquired after my wife, son, and dogs, and was genuinely interested in the details of my response. We blessed one another and verbalized desire to see one another on Monday "si Dios quiere" ("God willing"). I playfully tapped the tip of her nose and left her with a wink, her smile fading as I reached the door.

Listening to Bob Marley's "Exodus" CD on the way home, I was reminded of the lyric I had heard this morning on my way to work: "Ooh when the rain falls it don't fall on one man's house". Although Bob was then referring to the eventual fate of the "downpressors" who oppress the poor and covet the riches of the earth for their own gain, I took it at that moment as signifying the fact that any of those people in that nursing home---my patient, or the woman in the wheelchair who was sitting and staring into space---they are all me, my brethren, my family, my mother or father. It was yet another moment of seeing the bigger picture, the forest for the trees, the life taken for granted, the gratitude for life so easily forgotten. They are only a reflection of us, as we are of them, no more or less deserving of love and compassion. It was a truly human moment, a reminder of so many gifts. I smiled and continued down the road towards home.

One Love, One Heart.

A Sad Moment

I've sent my second patient in as many months to a nursing home, and it's always a difficult and painful decision. In this most recent case, it is my 69-year-old patient with AIDS, depression, psychosis, and a large mediastinal (upper chest) mass which has turned out to be spindle cell sarcoma, a rare cancer which is very difficult to treat and impossible to cure. Although her daughter has cried many tears over the decision, her brief time at home last week demonstrated for us quite clearly that she is far too complicated and gravely ill to be managed at home, but far too stable to remain in the hospital. Hence our decision.

Even though this patient is no longer in our program, I have been seeing her as a "free care" patient for more than a year, no reimbursement coming to us for my work. Now that she's landed in long-term care, my official job is over, and I will simply visit her as a friend and try to console her for her loss of freedom and increasingly serious illness. Long gone are the days of my weekly visits to her house to fill her med box and chat, almost always leaving with a gift of plantains and fruit. Although our conversations have always been in Spanish, she still has consistently gone out of her way to say "I love you" and "happy weekend", even as her discomfort and pain increased. And when I visit her in the nursing home---no matter how distraught she may be---she will still ask me about my son, wife and dogs, and will, as always, appear to relish the answer when I tell her that they are all well.

I know that I have added quality and love to this woman's life, but I'm saddened that her life may reach its denouement in an institutional and foreign atmosphere, away from the smells and sounds of family life. Can I mourn for another who is not yet gone?

Crack!

Two of my patients who've been clean for many months are now using crack again. In times of stress, many of us turn to food, TV, slothfulness, and other addictions. In some lives, the lure of a cheap and fleeting high is too much to bear.

Last Friday, I called a patient that I haven't seen for a while and told her she'd been on my mind and I wanted to pay her a visit. She said that she'd been thinking of me at the moment that her phone rang and was not surprised to hear my voice. An hour later, I was at her apartment. After the usual pleasantries and inquiries about her health, I could tell that she had something to say but was having trouble forming the words. Due to her hesitancy and the way she looked at the floor and avoided my eyes, I knew that she had "picked up" again. I moved from the couch across the room, sat down next to her on the other couch, and put my arm around her shoulders. "Digame", I said. "Tell me". She admitted to using crack and I quickly assuaged her fear of judgement and reassured her that these things happen and we would work with her to find a way through to the other side. Her shame was a palpable presence in the room.

After giving her a flu shot and several hugs and words of encrouagement, I took my leave and moved on to other people, other places. Today I received a call that her heat wasn't working but she reassured me quickly that her bill was paid in full and it was just the fault of the landlord, not her drug use. But it's a sign that things are not as they should be. Again.

Addiction coils around the reptilian brain like a slithering blight, blocking out the light of reason. Ah, the failings and treachery of the human heart and mind.