Late-Night Thoughts

Many are the wonders of having a physical body. The scent of flowers, the feeling of grass on the soles of one's feet, the taste of a favorite food, a glass of wine, the gaze of one's lover, the feast of looking at art, the crunch of a cucumber. Physical existence offers such breadth of experience, such sensual delight, such a plethora of feelings and sensations building one upon another in a crescendo of stimulation and experience.

And there are the disadvantages, the ways in which the physical becomes burdensome, even painful. A cyst grows on a nerve root in my lower spine, causing incessant contraction of muscles that are like ropes under the physical therapist's fingers. A malfunction in the junction of my esophagus and stomach allows gastric secretions to bubble up and cause me discomfort. My step-dad's pancreas harbors an uncontrollably growing mass. My dog's kidneys failed, and twenty-eight days ago we eased his spirit from his tired old body and placed that beloved furry body in a hole in the earth. The ache which I feel from his absence is like a physical pain, although I know that it is not.

Life offers such contrast, such dichotomy of feeling and experience. Most of us would agree that it is better to have loved and lost then never to have loved, yet in that moment of loss it seems the pain will last forever. In the joyousness of health we leap through life and take our bodies' wholeness for granted. And when illness strikes, we long for the carefree days before we felt betrayed by that collection of cells we call our own. But is it truly a betrayal, or simply just another way of being in that body, of embodying our own existence?

Of course, we in the health and medical fields see optimal health---physical, mental, spiritual---as the goal of our work, and the desire of all. But there are those who seem to suffer---often from birth---from afflictions and illnesses over which they have no control. And even those individuals find meaning and purpose in life, often in spite of, or perhaps because of, their suffering.

At birth, our parents hope to see ten toes and fingers, an even number of limbs, hear a healthy cry, and observe us engaging the world with that first magical breath that transforms us from an aquatic cosmonaut to a terrestrial creature with feet on the ground and head in the sky. This long process called life offers such opportunity, such room for growth and transformation, and as parents we hold a vision of life without pain and suffering for our offspring.

But this business of having a body brings with it great risks as well. Illness, suffering, pain, loss, malfunction, death---they are all here with us on our journeys around the sun.

Working as I do with the chronically ill, I see some of the worst things that can happen to a body, the afflictions and struggles which can beset a human on his or her trajectory through this earthly existence. I can only conclude that there is great beauty in life---even in death---and that suffering, in its myriad forms, offers its own stark beauty, its own language of learning and growth. Still, I mourn for those who suffer needlessly, who experience torture, rape, brutality, and other unspeakable indignities, and I hope that even those who suffer so, when released from that suffering, know a peace beyond that which is imaginable for us remaining here on this three-dimensional side of the veil. My hope would be that it is so.

I will take the years offered to me and try to use them well. Pain and suffering be damned, there is nothing else to do but take this life in my own two hands and shape it with the force of my will. On this third ball of dust from the star we call The Sun, our lives unfold as so many stories of bodies and minds and hearts in motion. In pleasure or pain, life is what it is, and we simply take each day and live it as our truth, since no truth can be clearer than the one confonting us in the mirror each morning. And when you look in that mirror tomorrow, what, pray tell, will you say?

Housing Hell

I watched the cockroaches crawl around the clean laundry in the basket next to the couch as I took my patient's blood pressure. I noted the single-pane windows, wondering about the coming winter's bitter cold. My patient complained to me that this apartment--to which she moved after we requested a first-floor apartment for her---has floors which are harshly askew, causing her to fall frequently.

I wandered around the apartment, noting clearly that the floors do indeed slant in one direction or another in each room, at times to a considerable degree. Her daughters, able-bodied and young, say that even they sometimes lose their footing from the missteps they take on the floors which are not unlike those in a carnival fun-house. My patient, who suffers from arthritis so severe that she receives intravenous chemotherapy every two months, has a difficult time negotiating the apartment, a cause of much frustration and anger on her part. This move to the first floor from the fourth is fraught with new challenges, and perhaps has been for the worse.

When I first met her, she lived in the building next door on a fourth-floor walk-up, the stairs becoming an increasing challenge as her disability worsened. I drafted a strongly worded letter to the landlord asking for urgent placement in a first-floor residence, or a building with reliable elevators. The landlord responded quickly but didn't even give her a chance to see the apartment. Before she knew it, she was moving, and the askance floors were immediately apparent. Several falls later, I'm considering my next steps. This is housing "approved" for Section 8---hasn't it been inspected? Are there structural problems with the underpinnings of the building which might endanger those on the upper floors? There is obviously something wrong. While I am not a social worker, these are battles I often choose to wage, and this one may cost me a great deal of time and effort. But if she breaks a hip, all hell will break loose and I want to head that disaster off at the pass.

Substandard housing for the poor is commonplace all over the world, and the United States is sadly no exception. Even low-ranking soldiers in the military live in government-issued housing that most of us would find unacceptable. When did viable housing become a priviledge in this society? Probably around 1492.

In my time as a nurse working in the community, I have seen some housing situations which were utterly appalling. An older gentleman with a unilateral leg amputation who I used to know lived in a hovel behind his nephew's house, wheeling himself over floor-boards decrepit with age and rot, a large hole in the bathroom floor daily threatening to swallow his wheelchair. I've seen rats, cockroaches, holes in floors, broken windows, missing locks, lack of ventilation, stifling heat in summer, lack of proper heating in winter, the list goes on. Granted, some public housing is abused by some tenants, slums becoming such when they are neglected and trashed by uncaring residents. But one must look sociologically at the source of the rage that damages such properties. As I have said before, those who feel cast aside and uncared for by society will, by default, be uncaring for their environment, and perhaps for their own well-being. Our responsibility to house the needy is enormous, and we are, in my estimate, failing miserably on many fronts.

There are some examples in our area of excellent housing for the elderly and disabled. Nicely maintained, with common rooms, landscaping, excellent security and organized social gatherings, these residences could serve as models for others. On the contrary, one year after Hurricane Katrina, there are still squabbles about what type of viable housing---aside from FEMA trailers--- to provide for those displaced by the storm. Luckily, some groups of service-oriented architects are creating models of cheap, durable housing which can be freely copied and altered---in a manner similar to open-source freeware on the Internet---a practice which may transform the idea of affordable housing for the future.

But that future seems far away as my patient slips and slides along her not-so-fun-house floors, and my rising ire against a corrupt system which provides such abominable living conditions for the most vulnerable among us slowly turns to rage. The housing authority in the city in which I work has lately been revealed to be rife with corruption of the most reprehensible kind. A prominent family bilked the authority of millions of dollars over many years, allowing said family's members extravagant home improvements while the poor of the city languished in substandard dwellings. For those individuals who were sent to jail, good riddance, and their post-release community service should include five years of living in the worst of the public housing for which they were responsible creating and maintaining in its sorry state. If that type of corruption is not a source of rage, I don't know what is.

So, it seems that for all of us out there fighting the good fight on behalf of those not able to fight on their own and win, there are others who will take advantage, corrupt the system, and provide shoddy work and horrible conditions in the interest of saving money and advancing their own wealth. If it didn't make me so angry, it would bring me to tears.

Someone might ask, is this what a nurse does? Is this how a nurse thinks? Should a nurse even involve him- or herself in such societal issues? The easy answer is "of course". Physical, emotional, and spiritual health has myriad aspects and properties, and the health of the home, the place where one rests one's head, has an enormous impact on one's sense of health, safety, and groundedness. A home which does not offer that which a person needs for their own protection and security and comfort is a home which lessens that individual's ability to be whole, to be productive, to feel valued.

The frustration in the eyes and voice of my patient who is negotiating those off-kilter floors is filtering down into her sense of self, her sense of her relative health, her well-being, her groundedness. How can one feel grounded when the floor beneath one's feet can fool the eye and the foot? Housing certainly is a right, not a priviledge, and those rights are generally worth a good fight. I think I'll be taking off the gloves tomorrow.

Dizzy-less

I guess the spiritual Dramamine worked. The vertiginous feeling subsided and the working week began without dizzy spells, despite a poor night's sleep.

This is the second week which has begun gently, without the Monday morning explosion of need that can at times feel crippling. I even had spare time to offer a co-worker help with some debilitatingly tedious paperwork. That's one for the karma bank, I guess.

Each month, I try to at least make some effort towards contact of every patient on my caseload. Using the small spreadsheets that I've created to assist with this task, I keep track of who's been contacted, who's MIA, who hasn't returned my calls, who doesn't have a phone and was sent a letter. As the end of the month nears, I peruse my lists for a snapshot of the month's heavy hitters and frequent flyers, and it is blantantly clear who has not surfaced at all.

In care management, case management, and any situation in which many people are on a panel for one provider, it is always classically the squeaky wheel who gets the grease. The patient who calls incessantly, makes alot of noise and demands action---that's the person who consequently gets the attention. Most of those attention-getters are savvy and know how to capture me and focus my gaze in their direction, and their efforts are generally rewarded. For those who abuse it, they may be reprimanded gently and asked to consolidate their multitude of calls into just a handful, saving up problems and questions for a once-weekly check-in.

One patient of mine is very dear to my heart. She has multiple medical problems which are not necessary to this story, only to say that her pain and other symptoms cause her considerable distress and worry, leading her to schedule a plethora of appointments, often unnecessarily. Her children also have many medical and psychological problems themselves, and at times I wonder if she may display some symptoms of Munchausen Syndrome by Proxy, although I'm also aware of a movement of mothers who advocate against unnecssary and false allegations of Munchausens. That said, it's a very sickly family no matter how you look at it.

In terms of squeaky wheels, I guess she takes the prize, calling me with the most trivial news. To wit, "I'm just calling to tell you that the pharmacy only had ten of my pills and I'll have to pick up the rest tomorrow," or "I just called for my refills and they'll deliver them on Friday." Her sweetness and childlike innocence prevent me from getting too annoyed, and I occasionally ever-so-gently request that she not call with such trivial messages. I counter these comments with praise for her ability to keep track of a multitude of appointments and prescriptions needing constant attention and vigiliance. She may be a little mentally slow, but she is anything but disempowered. She may be a squeaky wheel, but she does it with such innocent guilessness. She really is a peach.

There are enough moments of sweetness and connection to keep me afloat, even amidst the onslaught of stress. I have to hold onto those moments like oases in the maelstrom, and try to let the stress simply flow by instead of drowning me in its tumult. Today was a success in that regard. May tomorrow be moreso.

Vertiginous

vertiginous \vur-TIJ-uh-nuhs\, adjective:
1. Affected with vertigo; giddy; dizzy.
2. Causing or tending to cause dizziness.
3. Turning round; whirling; revolving.
4. Inclined to change quickly or frequently; inconstant.

Dictionary.com is a wonderful source of fodder for the fatigued blogger, and today's Word of the Day sums it all up nicely.

These last weeks have been vertigo-inducing, with stress, sadness, grief, and anxiety to the fore, not to mention physical pain. At work, the constant river of complaints and maladies coming from my patients often manages to distract me from my own preoccupations, sometimes thankfully, sometimes annoyingly so. Sometimes I resent the distraction, and just want to focus on me. But for those eight hours each weekday, my needs and life take an ersatz back seat. Such is a life of service.

The dizzying pace of work often erroneously precludes self-care, and work at times seems to diminish rather than augment one's personal life. This is an unfortunate but true reality for many of us who work outside of the home and absent ourselves from our personal lives for nine or ten hours each day. Just trying to take time to call one's doctor or arrange a personal appointment while at work can seem like an enormous undertaking. When one works all day forty minutes from home, how does one take the dog to the vet, care for sick children, go to the dentist, pay bills, advocate for ageing parents, and otherwise manage the complexities of life? This daily separation from the needs of the homestead and family can weigh on the soul.

Now, we can't all be farmers living and working on our own land, and most of us wouldn't want to, anyway, and many a farmer would tell you that the lifestyle and hard work is not all it's cracked up to be. Those who are self-employed and work at home might long for an office to escape to, away from kids, dogs, laundry, and the myriad distractions that working at home would offer. At home, it would be so easy to decide to wash the dishes or organize the closet rather than get down to work. It's a wonder so many of us are unhappy and stressed. Are we trapped in a world we never made? Or are we simply not made for the world in which we are trapped? Nonetheless, here we are, and however vertiginous, our lives are of our making, our design. It's only a trap if we see it as such. Imprisonment is in the eye (and heart or soul) of the beholder.

So, at this juncture, at the dizzying age of 43, feeling set upon by the vicissitudes of a responsible adult life feeling slightly beyond my control, I will take my spiritual Dramamine and call you in the morning. Thus warned, I wouldn't blame you for leaving the phone off the hook.

Autumnal Musings and Confusions

Autumn arrives today with a cold rain and threats of frost over the last few nights. The rain precludes lighting a candle at sunset on my dog's grave---something I have done almost every night since his passing 21 days ago---but we can still light candles for him indoors with the same sacred and loving intention. The spirit world does not stand on ceremony, at least in my definition of such.

As summer comes to an end, the days of kids playing in the water park adjacent to our clinic also cease. Now hordes of children file past our office at 3pm every afternoon, backpacks and books over some shoulders, many sheets of paper and homework strewn on the already littered ground. Once past the crossing guard near the school across the street, the kids stream through our busy parking lot, slipping between cars, darting into traffic, locking eyes with drivers and silently challenging them to do anything about this daily invasion of youth. What worries me are the reckless drivers---both male and female---throughout the city where we work and thankfully do not live. Traffic lights and stop signs seem to mean little. Forget yield signs. They may as well not exist. Crowded residential streets are just freeways, and as a driver, I am often challenged by cars coming in the opposite direction who seem to intentionally drive in my lane, forcing me to slow down to avoid a head-on collision. It's chaos, and makes our crowded but rather pedestrian town look like a haven, which it is not.

Outside of our office yesterday, a fight between two boys broke out, a crowd of at least 100 kids quickly coalescing around the protagonists. We have broken up a number of these fights over time, and it seems that whenever we do so, one of our windows is invariably broken shortly thereafter. So yesterday we called the clinic security officer and he called for a cruiser. Our Latino colleagues with whom I work seem to take these periodic fights nonchalantly and are hesitant to get involved at all. Having grown up in Brooklyn, The Bronx, and elsewhere, they see these youthful turf battles as normal, although I'm sure they advise their own children to steer clear of such violence. I usually want to run outside and break it up, but they warn me that these days middle-school kids can be just as likely as teenagers or adults to carry knives or guns. However, just the sight of an adult with an official badge and a stethoscope around the neck can end most any fight. But am I just another example of a white do-gooder imposing my culture and ideals on a community where I don't live?

Other autumnal signs are the mums which were planted in the front of the clinic to spruce up the landscaping. Within several days, a few of the plants were dug up and stolen, a few others simply mutilated. Our landscaping is often vandalized, and sometimes I wonder why we bother, already spending hundreds on new windows and paint to cover graffiti. One must choose one's battles carefully.

Working in an area where poverty is prevalent, one becomes inured to litter, trash in the streets, the detritus of drug use, used condoms, and vandalism. Our office has thankfully avoided any broken windows for over three months after a rash of violence that cost us several thousand dollars. The schoolchildren fight periodically, the plants are stolen, the sidewalks plastered with school papers dropped like so much forgotten junk. I see families with small children walking along, the parents equally tossing candy wrappers, bags and juice cartons to the round, modelling for their children behavior which can last a lifetime. It can all come down to one notion, I guess: if you feel undervalued by the world and society at large, you will in turn undervalue that world yourself. You may even undervalue your own health. And that's where it comes around and bites you on the bottom.

I try not to be jaded. I try to approach these situations with a fresh perspective. I endeavor to also exmaine my own motives and reasonings. Today the beginnings of Autumn bring some sadness and a sense of loss as the deneoument of Summer comes to its anticlimatic completion. But here we are, and here we remain. Welcome Autumn, and may you lead us gently into the deep cold days of Winter.

Hitting Home

With my step-dad diagnosed with inoperable pancreatic cancer, my nurse's brain is turned towards family. With me five hours away, my sister fifteen hours away, and my brother one hour away, there's alot to finesse and figure out about how his care will unfold. I will not go into specifics here as it would be unproductive, but I will say that I now find myself in the position of acting as Nurse Care Manager for my parents.

Emails are flying back and forth between the sibs and their spouses, trying to come to terms with the challenges ahead. One of my personal edges is figuring out how to think clearly and clinically about the situation, not losing sight of the fact that this is my loved one who is the source of my concern and interest. The difficult and somewhat contradictory trick is to not let my emotions cloud my thinking, while at the same time not let my clinical focus supercede the emotions which are now understandably reeling.

Based upon my observations of patients receiving dire news and undergoing life-transforming and potentially debilitating treatments, the astute nurse must treat the family as a system and contend with the problems at hand systemically, holistically. Now, I have no illusions that I can do that, but I do see that I carry the most medical information in my head, and have the greatest understanding of the system, the treatments, the potential roadblocks, and the places where I consistently see errors made.

Obviously, I want to forsee as many areas of challenge as I can, attempting to head some of these wild horses off at the pass, perhaps even completely avoiding some problems which might otherwise have reared their ugly heads. But I also realize that, in my human frailty and emotional connection to the situation, I can only do so much. There are other professionals who I might elect to pull into this process, and the family will all pull together to see this through to whatever end we must.

The reality of the situation hits home, and as I attempt to orchestrate what I see as necessary to arrange, I grapple with the emotions which now swim in my already crowded mind.

I pray for peace and clarity, and freedom from suffering for all.

Navigating the Seas

They all seem to be navigating the seas of illness and the healthcare system. Doors close, doors open, opportunities are squandered, some forever lost. We serve as lighthouses, buoys, but sometimes even we can't save them.

There are surprises: a patient will take it upon themselves to advocate, to go after what they want, self-refer if need be, and make enough noise to be heard above the din. Of my eighty-three souls for whom I have been given some modicum of responsibility, the squeaky wheels do indeed get the grease. The ones who call constantly, ask for help, push for results, they receive the lion's share of my attention, by default. The others, the silent ones, they get drummed up when I have time to pursue them, as I poke in the corners of my case-load for hangers-on who just don't seem to connect the dots, or perhaps care not to do so. Even so, I seek them out and attempt to shine the light of compassion upon them. Some refuse, and they stay in the corners, still on my radar, faint bleeps of presence on the periphery.

Meanwhile, as some hover in the wings, others enter stage left with a flourish, demanding attention, flaunting their needs, shouting their ills to the seats in the balcony. Me, I'm in the orchestra, and I heed their call and strike up the band to accompany their soliloquy, make sense of their chaos, and elucidate what costumes and props we'll need for the next scene. Some scenes necessitate elaborate choreography, others are like a play by Sartre---stark, without affect, moving yet in no need of ostentatious staging. Still others are like a scene from Fellini, too difficult to describe----you just have to be there.

Our office would make a great prime-time drama: "Nurses on the Edge". There's drama, sex, violence, gangs, passion, drugs, crime, wisdom, tears, uproarious laughter. I think I'd want to be played by Ben Stiller (he played a Jewish male nurse in Meet the Parents, after all).

These seas are rough, and today I longed for a life-boat, or at least to exit gracefully stage left. But before I mix any more metaphors tonight, I'll simply admit that it's a wild ride, and I guess I'll hang on for dear life for a while longer. The life-jacket's at the ready, the life-boat a resume away.......

Courage

"Courage is a weapon we must use." ---Over The Rhine

The Cowardly Lion of Wizard of Oz fame got it mostly right. Courage is indeed part and parcel of living a full throttle life, and it's something we must cultivate from day to day, moment to moment, as life challenges us and throws its ubiquitous curve-balls. And sometimes those curve-balls just keep coming.

Yesterday I travelled to a relatively distant Northeastern city to accomany my step-father to an appointment at a large hospital. He has what turns out to be a inoperable tumor of the pancreas---inoperable because it's wrapped around the celiac access artery, making resection too risky. Thus, chemo and radiation ensue, and if that doesn't call for courage, I don't know what does.

For many, simply getting out of bed in the morning is an act of heroism. For all the talk of heroes these days---whether they be of the costumed superlative type, or the anonymous garden variety public servant who rushes into burning buildings to save strangers---there are many among us who have been, are, and will continue to be unsung, perhaps only to be feted by their loved ones upon their passing from this earth, that is if they have loved ones to celebrate them at all.

Pain, infirmity, loss of function, economic loss, grief, loneliness---so many are challenged by these life-limiting effects of disease and death. Still, so many also simply wake up each morning, set feet upon the earth, and move through yet another day, perhaps lucky enough to be kissed by sunlight or breeze, take a few moments to touch the soft fur of a dog, or feel the tickle of a dragonfly taking momentary respite on the back of one's hand.

We are challenged at every turn: our patience, our tolerance, our ability to listen, to feel, to communicate, to observe, to respond, to withold, to move forward, to be still. At times the world calls for our action, at times it yearns of rou lack of action, our ability to sit there and do nothing. But even inaction takes courage, wisdom, and above all, compassion.

What the world needs more than anything is bodhisattvas, active servants of peace, “clothed,” as Longchenpa said, “in the armor of perseverance,” dedicated to their bodhisattva vision and to the spreading of wisdom into all reaches of our experience. We need bodhisattva lawyers, bodhisattva artists and politicians, bodhisattva doctors and economists, bodhisattva teachers and scientists, bodhisattva technicians and engineers, bodhisattvas everywhere, working consciously as channels of compassion and wisdom at every level and in every situation of society; working to transform their minds and actions and those of others, working tirelessly in the certain knowledge of the support of the buddhas and enlightened beings for the preservation of our world and for a more merciful future.----Sogyal Rinpoche

Back in the Saddle

Well, here we are, back in work mode, my personal life having stabilized to some extent, the grieving process for my canine soul-mate continuing. My back pain is still with me, although somewhat diminished after a spinal injection three weeks ago, and now my step-father seems to have an apparently malignant mass in his pancreas, necessitating major surgery and other treatment. If only I could take a leave of absence to simply live my life, but no such luck.

At the office, we have the usual goings-on:

A patient dying of advanced cancer and AIDS took it upon himself (with help from his brother) to destroy a $3000 IV home infusion pump which they said "broke" on its own. They were apparently attempting to figure out how to extract the morphine from the pump to inject it all at once intravenously for a major dose of relaxation. Probably a good thing they failed----it most likely would have killed them both.

Patients struggle with psychiatric illness and the lack of services in our area. So many psychiatric outpatient facilities work on a "fee-for-service" basis, hence our patients---who tend to not show for appointments alot---get taken off lists and moved to the bottom, often losing all hope of treatment in town. That leaves us with dozens of the most fragile patients without proper psychiatric treatment. This fee-for-service idea has got to go. That's one of the things our program has going for it---we are paid an annual amount to care for our hundreds of patients and then we figure out how to care for them best. We don't bill for each contact, thus we are not desperate for visits, nor do we avoid visits which might take a number of hours to accomplish. We are relatively free from that economic disincentive to provide quality care.

That said, I struggle under a caseload of 83. How to keep that many people in my consciousness? How to remember what I need to follow up on each day? How to not lose the threads that need to be connected again in the fabric of care? I hobble along, sometimes stumbling, sometimes sprinting, sometimes collapsing from exhaustion.

A number of my patients have broken bones this year. One was hit by a car while crossing the street. Another patient with Multiple Sclerosis fell against the kitchen table and fractured her humerus. Someone else tripped on a wet floor and broke her ankle. I don't usually have this effect on people, but my patients break their bones at an alarming rate. Do they need pedestrian airbags?

Still others seem to develop multiple chronic injuries from out of the blue (sort of like I manifested a spinal cyst). This one has several meniscal tears in her knee. Another has herniated discs. Still another has a torn rotator cuff. These bodies sure take a beating.

My mind is spinning with scenarios, issues to deal with, patients to follow up on, people to call, referrals to make, treatments to assess. It seems that when you take 83 chronically ill people, put them all together in a big box, add poverty and stir generously, you get a recipe for multiple comorbidities needing a comprehensive and global approach to care managment. That's where I come in, and it is, I must confess, not an easy row to hoe.

But tomorrow's another day. And I'll be there.

Change of Shift Again

Please visit the newest edition of Change of Shift, a nursing blog carnival, here. Thanks for stopping in.

Hello Dear Readers

Hello dear Readers. Sadness has quite a grip at this moment. Work offers the distraction of tasks and other people to care for, but home brings the reality of loss and change that death delivers. Please see Latter Day Sparks for other writings, and understand that this blog will be more of what it used to be when this grieving process is not so new.

Thanks, and please return as often as you like. I shan't be in this state for too long.....

Sparkey's Passage From This Earth

Dear Friends and Loved Ones,

Yesterday, September 2nd, 2006, at 2:20pm, Sparkey left his body and this physical existence in the most peaceful way imaginable. The screened-in porch was a sacred space---a shrine created lovingly by Mary---of photos, candles, objects of devotion, and mementos of Sparkey's sweet and noble life. The party lights were lit all night on Friday, the porch glowing, the cool breezes cleansing the space. Mary smudged the house with sage, and also smudged Sparkey several times briefly.

The vet arrived at 1:30, Tina already in the care of a neighbor, her shades drawn so that Tina would not see the vet's van and be traumatized by the sight of it. Rene and I dug the grave in the morning, the area protected from rain with a brown tarp suspended from surrounding trees, that piece of earth blessed and consecrated by the three of us before beginning our task. We had at the ready an urn of our dear friend Woody's ashes, several of Rene's wisdom teeth, three sticks representing the three of us, a bone unearthed while digging the grave (most likely buried by Tina some long-forgotten afternoon), and a sage smudge stick. We had chosen a lovely cotton tapestry of aqua and earth tones and Native American design in which to wrap his body. This fabric had covered a favorite chair in our house where he had lived as a puppy. The grave was round like a womb and three feet deep.

The compassionate doctor sat with us on the floor of the porch as we connected with Sparkey. He had ensconced himself in the very spot where we had planned for his transition to occur, and we only had to shift him slightly so that we could all kneel on the foam mattress at his head. The vet sat at his feet and explained that she would inject a strong sedative into his buttock muscle so that he would become very drowsy and probably fall asleep. Only when he was completely relaxed would she access a vein on his hind leg and insert a needle and small catheter which would allow for the overdose of anesthesia which would actually stop his heart. Following the first injection, we all brought our faces very close to his, looking in his eyes as they became heavier, telling him sweet things, what dogs to look for in his new home, and how grateful we were to him for his service and loyal companionship. Even after more than a minute, he still was not completely drowsy, his head moving slowly from right to left, approximately four inches above the bed. I had the image that he was already slightly above his body, trying to detach, and was looking from left to right to take in a final image of the three of us and the scene in which he was the central player.

Following a whispered conversation between myself and the vet, she injected another dose of sedative and he slowly lowered his head to the soft mattress covered with a maroon flannel sheet, closing his eyes for the last time. Crying, we all said goodbye and urged him to float on, and we each placed a hand on his heart which was still beating slowly. The doctor then began the infusion of anesthesia into the needle placed in a vein of his right hind leg. A small patch of hair had been shaved and that hair was stowed in a small wooden urn kept on hand for that purpose. With our hands we could feel his heart slow and then peacefully cease its motion. He did not take a final deep breath as is sometimes experienced. His heart simply stopped beating and his respirations halted. Beautifully, a single tear formed at the outer corner of his left eye, fully visible to the three of us, and we wept as this lone tear increased in size and then streaked down his lovely orange face. The muscles around his nose were the only ones which twitched for a minute or so, almost as if he was getting a last scent of this earth which he so loved.

Taking her leave, the very sensitive vet exited quietly, and we were left to tend Sparkey's beloved body in private. Rene brushed him down, and gathered some of the fur. We also cut some of his hairs from several places with a pair scissors. I fetched Tina from our neighbors and brought her to see her brother's body. Wrapping him in the chosen fabric, we carried him to the grave, lowered him in gently, each took a turn kissing his head, and tucked him in, his spine gracefully curved, his front paws below his chin. The three sticks, Rene's wisdom teeth, and the bone were placed in the grave, and some of Woody's ashes were rubbed into the fur over Sparkey's heart by each of us in turn. Finally, covering his head and face, we then took turns putting handfuls of dirt over his shrouded body. One of the most difficult things I have ever done was gently place a shovelful of dirt over what I knew to be Sparkey's head. It was at that moment that I knew he was gone forever and would never return. Rene assisted me in completing this task of closure, and we then had our private family time around the grave, Tina at our side.

His body is now resting in the earth, his soul free to run with his friends old and new, and we give thanks for this loyal companion who loved us so unconditionally. His grave is now our sanctuary, and we will tend it with as much love as he tended our home and lives.

Sparkey's body is dead. Long live Sparkey's spirit.

Namaste.

A Correspondence is Born

My niece, a newly minted college student somewhere in New England, referred a friend to me for advice on exploring the joys and vicissitudes of nursing as a career. This thoughtful young woman who is entering her senior year in high school is filled with questions which I most readily and joyfully answer. This is affording me a golden opportunity to examine my motives for being a nurse, my reasons for remaining a nurse, and why and how I would ever consider encouraging anyone else to enter this profession.

Yes, nurses may still sometimes "eat their young", and hospitals may still use mandatory overtime to heartlessly over-utilize their nurses, while some of us struggle with caseloads which burst our brains' ability to provide what we feel is the most thoughtful, thorough care possible.

Still, I see a noble and genuine love of people driving many individuals to enter the nursing milieu, and a career which, historically, is portrayed as one which is grounded in compassion and caring. Nurses have made great strides (alongside some misguided backwards motion at times), and I still feel enormous pride vis-a-vis my chosen vocation/profession.

This correspondence, which I hope to integrate and share here on Digital Doorway, may open for me some more doorways to explore, and I'll be sure to share them here so that you can experience them with me. Stay tuned.

Turning Corners, Connecting Dots

Recovery, healing, and a new life reality are always around the corner. In healthcare, watching someone make that shift is incredibly gratifying.

Two of my current patients are both making great strides in their recovery, accepting help and attempting to make positive choices. One's drug of choice is alcohol. The other has a predilection for cocaine and heroin. Each one has other health problems which only magnify the urgency of making better choices: cirrhosis, hypertension, diabetes, neuropathy, depression, anxiety. No matter the constellation of comorbidities, the potential outcome---disability and death---is certain.

I try to offer a clean slate with each visit. My role, while multifaceted, is also quite simple. I provide guidance, compassion, tough love when needed, and a steady hand through the rough patches. I tell them: when the cravings come, call me. When the pain is too much, call me. When you feel like you're so afraid you want to die, call me. When you need a pep talk, call me. And these two people really do call---as do some others---and now it's paying dividends.

One of the secrets to guiding our patients towards health is getting them to pay attention. If they don't focus on the fact that their liver is affected directly by every drink, every drug, every decision, they just don't connect the dots. If they forget how important it is to tightly control their blood sugars, they lose sight of the prize. If they can't connect their current symptoms with their lifestyle choices, they're lost. Health is a complex entity, and seeing the lightbulb go off in their head is a gratifying moment in itself. Watching them use that lightbulb to illuminate their darkest corners of pain and regret is pure magic.

When it all comes down to it, it is compassion which drives the vehicle. Even when they come in, sit down in the exam room, and say "I fucked up. I used again this weekend. My life is over," I try to keep my expression neutral, my voice calm. "OK. You made a poor choice. But today you're here. Let's talk about today and tomorrow. What next? What's the next step?" I maintain my equilibrium, look them in the eye, hand reasurringly on their arm, my gaze steady but soft, open and inviting of confidence.

One man has been clean of alcohol since January of 2005 and has turned his life around. He is still struggling with the fact that he can't hang out with his old friends anymore and feels isolated. "I don't have much fun since I quit drinking. Everyone else seems to be having such a good time. It's lonely." But he keeps on the straight and narrow, and though his liver is riddled with cirrhosis, it seems we caught it just in time. While he may not be agood candidate for a transplant, he's a good candidate for a paradigm shift. He's living and eating well and trying his best. He turned a corner and never looked back. That liver will eventually kill him, but we don't focus there, turning our gaze forever on the present.

Another patient relapses again and again but now may be on the right road. I finally got him into an outpatient addictions treatment program and he's doing the work, plus going to meetings every day. Frightened of death and disability, knowing that his liver is damaged (but not yet beyond repair like the gentleman in the previous paragraph), he wants to do it all. He sees the cardiologist, shows up for appointments, sees our psychologist, and continues to make the right choices. We treat him like the respectable human being he is, with dignity and respect. He responds by coming back again and again, ready for more. I cant promise him he'll live forever, but I can promise him improved health and quality of life if he pays attention. And his attention is currently riveted----eyes on the prize.

For each patient who I cannot reach, who is lost to their own devices, there are several who respond to the call and step up to the proverbial plate. Their stellar performance, their willingess to engage again and again, that can keep me going. The others? I keep sending out the bait and trying to reel them in. Some respond from time to time, some crash and burn, many die. The hand is always there if they want it----if they can even see it. One such gentleman is now institutionalized forever, having ruptured his esophagus from intractable vomiting. He admits that he should have listened, that he should have known this day would come. Regretful and sad, his body filled with tubes, unable to ever eat or drink again, he is a living example of what happens when one fails to pay attention and falls into the abyss again. It's dark in there, and he was saved only by a miracle. He's a living example, a sad reminder to many. I feel such compassion for him, such sadness.

Back to the present, there are many more willing to take the leap of faith, and we're ready for them every day. What a treat to watch as a person turns that corner, beaming a smile of pride, and seems to finally "get it" in a way that is irreversibly joyful. The dark moments still come, the corners in need of illumination still harboring silent watchful demons, but there's still room for recovery and growth, the light filling the room with hope. That light is what we try to point out, and many thankfully refuse to shade their eyes and step over that threshold. It is a wonder to behold.

Change of Shift, Vol. I, No. V

Please surf on over to Change of Shift, Volume 5. Change of Shift is a new blog carnival by and about nurses and nurse bloggers. Please show your support by reading this newest edition. No charge!

A Question and an Answer

QUESTION: Tired nurse seeking fuel for his train running low on soul coal. Where does one turn? Exercise? Vacation? Gin? Meditation? Sleep? Narcotics? Dear Abbie? Dr. Ruth? Judge Judy? Dr. Phil?

ANSWER: Don't just do something. Sit there.

Mid-Week Fatigue

Mid-week fatigue rolls in on this nurse who just finished a 12-hour day plus time at the gym early this morning. I have that boy-my-feet-and-brain-are-tired feeling. Bone tired. This chronic pain thing is draining. Part of my fatigue is the extra weight of pain and discomfort throughout the day, with lost sleep for extra spice.

Tired or not, the patients keep coming, each with their individual needs. So many interactions fill a day. Hours go by, with myriad details flying around my head like so many swarming flies.

Each interaction, each situation, calls for a certain level of awareness and presence. I try to bring to each patient a sense that I am fully there, fully listening, hearing their complaints and responding to them in a way which helps them to feel heard. Beyond hearing, I look for teaching moments, as well as ways in which my actions will benefit that individual in some way, assuage a pain, relieve a worry, mitigate an annoyance. There is so much to do, so many choices to make.

Sometimes the days are like being in an asteroid belt, dodging and sailing around so many obstacles, potential clashes and frictions always on the verge of manifesting themselves. At other times, it feels like a battlefield, and as the telephone calls and faxes and unannounced patients arrive, the support staff yell "incoming!" like infantry in a foxhole. Then again it can sometimes just feel like an office with alot of hubbub, while I coast atop the crest of the wave, few ruffles of my feathers even noticed as I breeze along. Still other days, it is a nauseating roller-coaster, the carnie on an extended break and the ride set on an endless loop. Then we reach for the barf-bag and pass the Dramamine.

No Dramamine today. Rather, a need for deep sleep uninterrupted by pain, muscles crying out, disturbing my needed rest. Pain can raise one's compassion---for one's self and for others. It can be a very human reminder of the mortal corporeal reality in which we are ensconced, the dangerous pull of gravity which wears down our resistance, pulling us to earth like the proverbial ball and chain.

This physical existence, this dragging around a body---it's enough to make one realize just how much work it takes to propel yourself along through life. As healthcare professionals, we try to remedy that weight as it is experienced by our patients, but we cannot carry their burdens for them. No. We use compassion, skillful listening, and our own life's truth to guide us in our guiding of others along these difficult earthly paths. I feel the weight of gravity today. May tomorrow its pull be less noticeable, the strain of physicality assuaged for all who need that sweet relief.

Barely Living

Her home feels like a tomb. Her paranoia causes her to barricade the front door with the couch and hide in her room upstairs. She's lost her Personal Care Attendant services, her family have abandoned her, and she spins relentless webs of paranoia as she cowers indoors on even the nicest summer days.

The level of trauma which she has experienced in her life is something which I cannot begin to fathom, and the chaos of her mind is also beyond my ken. I can tell that it's muddy in there, but the muddiness is not within my ability to clarify. What I am able to provide is concrete: an appointment with our psychologist for an assessment, prefilled psychotropic meds in an easy-to-use daily med box, the number for psychiatric emergency services, holding her hand as she cries.

I offer a hug when I get up to leave her barren apartment which once teemed with life---children, teens, neighbors, grandchildren, visitors. The house feels so lonely, there are barely echoes of its former life. I know her husband died in this house and his ghost must haunt her still, not to mention the horror of finding him in their bed, blue and lifeless.

She complains of voices constantly telling her "horrible, horrible things." She peers through the curtains into the bright sunlit street and demonstrates for me how her paranoia manifests in fear-based obsessive-compulsive behavior.

What can I offer? Empathy? Sympathy? Emergency phone numbers? An appointment? Medications? I feel like what's needed here is an all-out exorcism, and I leave the darkened home, sobered and sad.

"Barely living" is what I think as I walk towards the clinic. Can we really prescribe a return to life?

On Blogging and Connectivity

I realize that I spend a great deal of my time either thinking about blogging, talking about blogging, or actually writing on my blogs. I am a great proponent of the medium, have now appeared in at least one article about nurse bloggers, and participate in two ongoing and regular blog carnivals which gather together the "best" of the bloggers in the medical, nursing, and allied health fields.

In the mainstream media, "blogger" or "bloggers" are generally lumped into one category---the political blogger---that pesky nuisance (or brilliant iconoclast, depending upon your opinion on the matter, of course) who breaks a story faster than ABC and makes Dan Rather look like a dinosaur (an easy task, I know, but still laudable, in essence).

Aside from the political pundits who inhabit the blogsophere, there are countless categories of bloggers filling the Web with what some might call drivel, but which I consider a portal into the lives, loves, longings and interests of millions of souls staring at a screen, fingers typing with intention. While some blogs which detail the ins and outs of rechargeable batteries may not be my cup of tea, the fact that an individual feels strongly enough about those batteries to publish his or her thoughts about them and share them with the world is, by nature (at least in my mind) a worthwhile task. Whereas some might postulate that the "battery blogger" needs to get a life, perhaps his life includes time devoted to filling one small mini-hectare of cyberspace with his opinion on the merits of various batteries. Is this in itself bad or good, productive or not? The person shopping for the ultimate rechargeable battery would certainly be grateful for the information on offer.

Strolling through any blog search engine will reveal that there are many, many people with something to say. The worth of those words and pictures are completely subjective, but the sense of connection and community which these communications can foster is certainly worthy of exploration. I'm interested to see what scholarly and popular tomes are written (on real paper) in the near future, examining the effect of blogs on culture, social connectivity, and the dissemination of information and opinion on a global basis, be it about batteries or Babar.

To some, sitting in front of a computer to "connect"with others might seem somewhat of a conundrum. Why not meet like-minded others in a cafe? A bar? A local gym? A meeting or club? Yes, all of the these are distinct possibilities, yet meeting people these days and forming friendships can be a slow and painstaking process, especially as life has taken on a propulsive velocity that precludes the practice of sitting in the town square and watching the people go by as we chat with neighbors and friends, making new friends and acquaintances in the process. The fact of the matter is that meeting for lunch, then going out for drinks, then getting one's families together to meet one another, is often a prohibitive experience for many new friends. If one is a parent, the taxiing and ferrying of children to and fro---and the complicated social lives of children---make it even more difficult for working adults to simply spend time over coffee, chatting and deepening friendships the old-fashioned way. For better or for worse (probably for worse), our culture has changed, and this type of easy social discourse is much more difficult to achieve, perhaps even in smaller towns previously untouched by the speed of life in the 21st century.

With blogs can come community, connectivity, and a sense of belonging. Nurse bloggers "meet" on-line and form strong professional and personal bonds. Posting comments on one another's blogs leads to personal email transactions, then telephone conversations, even face-to-face meetings. After a year of blog and email communications, my wife and I actually visited a blog-friend of mine in her hometown and we have begun a friendship built upon the foundation of the multitudinous and deep sharing we have done in the digital realms. The friendship moved from the virtual to the physical plane, and we are richer for it.

Beyond blogs, on-line social networking communities have created even more cohesive groups where individuals find like-minded people and congregate to discuss topics or issues of interest. often leading to "real-time" meetings, even international conferences and the like. Tribe, MySpace, Zaadz, Care2---these sites all carry the promise of connectivity, community, a sense of belonging, and a way to find those who share your interests without standing at a bar, ordering a beer, and asking the person next to you if they happen to like Jean Paul Sartre and would be interested in discussing Nausea with you for an hour or so. Zaadz is where I put my attention, a place dedicated to bringing together people who want to change the world. I also concentrate on the relationships fostered between myself and other bloggers, and the sense of true connection is something only the initiated can truly understand and appreciate.

I am by no means covering all of the aspects of blogging and social connectivity which could be put forth in such a missive. These are simply the late-night ramblings of a dedicated blogger and admitted email addict who sees that much good can come of such predilections, as long as one maintains normal real-world social discourse, takes time to read real paper books, drink coffee unhurriedly with friends at outdoor cafes in dappled sunlight, and delight in the scampering of a puppy pursuing a stick thrown by its owner in the neighborhood park. There is room for connectivity of all kinds in this world, and we all know that too much of any good thing---blogging included---can only myopia make.

So now I will peel my eyes from the screen, pick up my book, pour some tea, and connect with myself through the magic of literature and the fire it lights in my imagination. Meanwhile, millions of bloggers fill the ethers as they share their lives and loves and inspirations, digital tendrils snaking around the world, connections made, severed, reconnected and strengthened. What a tangled web we weave......

Moonlightin' Nurse

Now that my teaching days at the community college are done, I'm stepping up my moonlighting at two other per diem gigs. This nurse and his blushing bride don't seem able to earn quite enough from 9 to 5, so some evening shifts are de rigeur in terms of financial survival and debt relief, at least for now.

This evening was four home visits for a local visiting nurse agency which had woo'ed me for more than a year to take a full time position. I've refused their offers time and again---including a managerial position---but have taken on the mantle of "Evening Per Diem Nurse" simply to increase deposits to my checking account.

Interestingly, both of my per diem gigs reflect the nature of two previously held jobs during my early career as a nurse. My current work as a per diem visiting nurse harkens back to my previous employment at a locally-owned visiting nurse association which afforded me the opportunity to work somewhat autonomously, visiting 8 homebound patients per day, but bound and gagged by the specific orders signed by the supervising physician. I found that role stifling and clinically limited and lasted only a few years before being swept off my feet to the job which I now hold.

My second per diem position is within the community health center where my full-time care management program is housed as a contracting agency. I primarily chose to work per diem at the clinic so that I could gain access to various employee benefits at the hospital of which the clinic is a part, namely the employee gym where I work out several times per week for $20 per month. Aside from that, it gives me an insider's view of the health center and some measure of an edge when it comes to facilitating care for the 80 patients on my roster during my day job.

Wearing several different hats as a nurse can be confusing at times if one loses sight of what the particular scope of practice is for the position of the moment. While I may occasionally experience "role confusion" (ie: wanting to make an autonomous decision in my clinic role as Pod Nurse before realizing that this autonomy belongs to my full-time job), I'm relatively capable of maintaining my differentiation depending upon the role in which I am presently embodied.

Examining my three distinct clinical roles and their defined scopes of practice, I am immeasurably grateful for the breadth and depth of the autonomy which is the cornerstone of my full-time job, a reason why I remain in such a stressful and demanding professional position. Overseeing and managing the care of 80 people whose clinical disposition, comorbidities and occasionally chaotic lives can be an enormous challenge, but the freedom of practice which is the central aspect of my role more than makes up for the frustrations and vicissitudes of the job.

As much as it's difficult to work in two other positions which place me in a more, shall we say, "subservient" nursing role (ie: simply carrying out doctor's orders with relatively little room for personal initiative), spending time in those other "hats" gives me time to pause and reflect on the singular nature of what I do from 9 to 5, the authority and trust placed in me by my bosses and the doctors with whom I co-manage patients, and the ability which I regularly exercise of making clinical judgments and enacting plans of action vis-a-vis those judgments.

All this is to simply say that my "other jobs" can often serve to reinvigorate my 9 to 5 experience rather than just exhaust me due to the extra hours of labor after the 5 o'clock whistle blows. Would I rather not feel the need to work more than just my full-time job? Sure. But when push comes to shove, the Man Who Would be Nurse does what he must do, and then comes home to reap the rewards of a day's work well done.

Eavesdropping

You are a fly on the wall of an exam room today, and I'm facing a patient whose choices are not always the best, but she shows great promise.....

"I'm so worried about my liver, I've been thinking of killing myself."

"Well, your liver really isn't that bad."

"Are you sure? I'm so nervous. I took one of my mother's Ativans this morning. I just couldn't take it. I'm gonna die."

"We're all gonna die someday. I could die when I leave work tonight. You may outlive me by thirty years. But here we are right now."

"I don't wanna die. I'm shittin' myself."

"Look at the computer screen with me for a second. Do you see those lab values compared with two years ago? That indicates inflammation and damage to the liver. You were much worse off at that time. We're making progress."

"But I just did crack recently and was in detox for days! I keep telling myself that I don't really drink, but I have this whole box full of nip bottles. I just guzzled one after another."

"Look, everybody makes mistakes. The fact is, you went to detox, now you're clean. You've got a fresh start, a chance to begin again. Every day you're clean is a victory. Every hour you're clean is a victory. Don't look at the bigger picture---it's too overwhelming. You can say to yourself, 'Wow, I didn't use today. I didn't have any cravings. That's great! I went an hour without thinking about drugs. Wow!' "

"But I'm so worried. I went to the methadone clinic today, and somebody said, 'Hey, you look all stressed out. Want some Xanax? I've got some rock [cocaine] you could have.' Jesus, don't these people get it? I just got out of detox and they're offering me rock! Shit!"

"Part of recovery is changing the people you hang out with. Seeing those same old people every day just triggers you to use, or at least to crave it."

"But that's the thing----the methadone clinic is crawling with druggies. And the staff don't want me to get off of methadone---they don't want to lose clients. I need to get off of that stuff and away from those assholes."

"There is a place where you can be detoxed off of methadone safely, but you have to go every day for at least a month and really get with the program. There's counseling, nurses, a doctor to oversee your care, and they'll communicate closely with me. We also need to get you into therapy and to see a psychiatrist. If we don't deal with the depression and anxiety, we're missing a big piece."

"I wanna do it all! I'm ready. You've been so good to me, all I want to do is get it together. I don't wanna die, not any time soon. Do you think I have a chance?"

"You have all the chances you need right here in front of you. Let's go one step at a time. You look good, your labs aren't that bad, and you're ready to roll. Let's get you referred to those programs, and then for a liver biopsy so we know exactly what we're working with, OK?"

"All right. I'm ready. I'm gonna take good care of myself this weekend, go to meetings every day, and come see you Monday."

"Great plan. I really think you can do this, and we're here to help you make the right choices. Call me Monday."

"OK. It's a deal."

And with a handshake, she's gone, swallowed by the world, and the streets that tempt her at every turn. May every force for good in the universe be with her........

Prima Facie

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

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

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

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

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

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

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

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

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

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

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

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

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

Prima facie.

Eskimolitos and The Economics of Poverty

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

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

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

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

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

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

And the temperatures will only rise tomorrow.

Monday Evening Nurse Syndrome

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

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

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

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

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

Likelihood of successful treatment: high.

Likelihood of similar symptoms in future: also high.

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

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

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

Hoping for a Miracle

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

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

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

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

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

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

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

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

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

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