Friday, November 28, 2008

Kick in the Pants

So lately the news has had this story about a young boy whose last wish was for people to donate to the homeless. It was a heartwarming story of courage and selflessness with the end result being that the child died in his mother's arms and swarms of Americans donated stuff to the homeless. In this holiday season and these times of economic uncertainty it was a lovely story of hope. That said, it always irks me that it takes a dying child's wish or some such tragedy to get people to open their eyes and see what goes on daily within our nation. The news reported that they had hundreds of phone calls asking how they could donate. Ahem, do people really not know what kinds of agencies need help?

Okay, okay, I'm a social worker, I know. I know where every homeless shelter is, I know stats on the number of people that are homeless, I know what every homeless shelter has on their wish lists. I know most every community resources available within a 50 mile radius of my hometown. But, do people really not know? Do they really have no clue how some people live day to day, standing in line for a bed, standing in line for a soup kitchen, ducking into food pantries hoping their neighbors don't see their bags of non-perishable food from church shelves.

The city I work in has 6-7 homeless shelters which have been overflowing since summer. The pennies people dump in the salvation army bucket at the doors of malls aren't going to cut it this year. Agencies are overwhelmed by the number of requests for help. Somehow this is all okay as far as legislators are concerned. Few policies have been made or changed to help these populations particularly considering our economic climate. Outreach workers visit people who live under bridges in this city, scout out those who are living in the woods and along the river. And, the rest of the population sits in relative luxury, in one of the wealthiest states in the country, concerned about losing their mcmansions, obsessing over providing their children with the best christmas ever. It's the children that get it, the kids that see what goes on and want to donate their gifts, whose last wish is that those who go without get something this year and it's the adults who may follow their lead of their children or decide to ignore the issue.

Thursday, November 6, 2008

Singing Through Pain

She was in pre-med, her family had refugee status from a country in Africa. She was so excited that night in the living room with her friends that Obama was going to win. Then she collapsed, she bled out, and she died. No reason. No clue, no previous medical history.

Her family traveled most of the night from another state to see her. They cried out in anguish over this beautiful girl, their daughter, their sister, who looked as though she slept, her dark skin showing none of the patterns of death, none of the pallor. They huddled together, crying out in their native tongue over this horrible loss and I left the room to give them their time.

I sat in the hall, listening to a language I did not understand but knowing exactly what they said. And then, suddenly, there was singing, a beautiful song that wound from one voice to the next, each member having a verse, then singing together again. They sang and they sang, giving voice to their pain in the most beautiful way I have ever heard, in a dialect only they could understand. I could only imagine that they sang their daughter and sister's spirit back to their homeland, to their ancestors, to a place of peace.

I am so humbled to have been there to witness this, so privileged to have heard this family sing through their pain.

Friday, October 24, 2008

Safety Is Not in Numbers

So as I've said I work in a large inner city trauma center. We see about 83,000 patients a year in the ED. That's a lot. Not sure how many come in as trauma patients are sudden death but a fair number I'd imagine. Many of those are ones that I am directly responsible for in terms of providing family support. Lots of times, due to cultural reasons, every single relative and friend of the patient comes to the hospital. Frequently, this leads to a virtual wake happening in the family rooms of the ED. There is anger, falling on the floor, screaming, pulling of hair and gnashing of teeth. Sometimes it is managable, often it is not and becomes a safety issue.

I have found that I am less and less tolerant of out of control behavior. I respect culture, hell, I seek it out and find it interesting and enlightening. I gotta say though, is it really appropriate to disrupt an entire department by screaming and rolling around on the floor? I mean, I get it, I'm sorry for the loss, I am sure their heart is breaking but it scares other people, it escalates other family members, it often makes patients of family members. It makes it difficult to provide comfort. I also understand and respect that family wants to see their loved one, wants to be with other family members. I just wonder if it really needs to happen in the ED. We aren't equipped to handle 20-30 grieving family members whether they are in or out of control. We have two rooms, they aren't huge. They are far away from security and other staff, they are somewhat enclosed. We really have no idea who it is that we are allowing back into that area and what their intent might be. Our ED is in the inner city. We have gang members, we have many, many violent deaths. Often I am the only one down there with these people. I am not six feet tall. I am not muscular. My own children do not find me alarming even when I am mad. I am assertive but that is not going to matter to someone who is pissed off and wants revenge or has manufactured some sort of vendetta to avenge his father's death.

I bring my concerns to security who does not see an issue. This makes me so mad I could scream. We are not a rural hospital set in Amish country. Somebody did not get killed by being run over by a horse. They were murdered. They committed a violent suicide. They are part of the underserved population who may not have gotten appropriate medical care. They died at a young age, for a variety of reasons. Their families are pissed. Their families are shocked, they are at a loss, they are not very often in their right mind. Some families are okay to deal with. they cry, they may yell or scream, they may collapse but they do not adversely affect other patients or staff members.

A study was done at New Jersey hospitals using incident reports between 1992 to 2001 and it was found that 100% of the 50 hospitals in the study reported violent events in their ED's. 61% of employees reported threats, verbal abuse was reported by 90% of workers and almost one third reported assaults. Of assaults that occurred verbal or physical, 72% were not reported through an incident report. A survey of over 1000 ED nurses in PA indicated that during their careers 97% experienced verbal abuse, 94% had physical threats, and 66% had been physically assaulted. More than a quarter of psychiatric nurses believe that violence is to be expected in their line of work. So, really, I am not talking out of my ass. I value my life. I am the mother of three children who need me. I am not willing to risk my own health and safety because other people who do not do my job refuse to accept that allowing unrestrained numbers of people in an enclosed area is a safety issue.

Monday, October 20, 2008

Suffering is Over

A ten year old died today. It got me on so many levels. He was between the ages of my girls, he had blonde hair, he was cute, he had a terrible disability with many many surgeries ahead of him and multiple hospitalizations. He was apparently the life of the party, he was brave, he was the center of his extended family's life. He no longer has to suffer. It's possible that he is now standing and running on his own, he can eat by himself, he can breathe. I am hoping.

I cried right along his mother, I felt the despair of his father, I know his family will miss him terribly. I made them hand and footprints of his poor feet, his limp and white hands. The feet that never walked, the hands that weren't able to grip but were so loved, so treasured. His grandfather took the prints with love, he hugged me and kissed my cheek, he was so grateful for this small memory of his grandson's life. I was so honored to have made them, to have been able to be a part of this beautiful family for a short time, to have taken part in their grief and stepped over with this little guy from this world to the next.

Monday, September 29, 2008

More Facts

So reportedly the US is the richest country in the world. Supposedly. Let's see what that means. The US is ranked behind Cuba, Denmark, Israel, Germany, Norway, France and Sweden in infant mortality. So out of 1000 babies, 6.30 will die before age 1. We are ranked behind the same countries except for Cuba in life expectancy. We can expect to die at age 78.14 while France enjoys wine and cheese until age 80.87. That's totally unfair. 16 percent of out gross domestic product is spent on health care. The UK spends about 8.3 percent, and despite copious cigar smoking in Cuba, they only spend 7.6 percent. To break that down even further, approximately $6700 is spent annually on each American for health care. Now wait, I thought I was the one that spent that on co-pays and premiums. I had no idea the government contributed! Apparently that includes the 47 million folks that are uninsured as well. The projected expenditure for Medicaid and Medicare for the year 2017 is 1.26 trillion dollars. That's up from 559 billion dollars spent on those two programs in 2007.

Now what's kind sad is the fact that in 1945 President Truman had a plan for a national health program. Unfortunately for us the American Medical Association and the House of Representatives shot it down as a "communist plot." However, as early as the 1910's reformers had a national conference on social insurance and earlier than that, lumber, mining and railroad companies recognized the need for good health among their workers and offered it to their workers to keep up with production.

Let's look at some other statistics now. In my state, which is one of the wealthiest in the nation boasts a population of 283,000 that are food insecure throughout the year. 25% of those that visit food banks are working families. Our state food banks service 350,000 people per year. That's a lot. In 2007, 7.9% of people in my state were living below the poverty level. Guess what the definition of poverty level is? For a family of four you can't make more than $18,100 per year to get some state benefits. Um, that's pretty low. The median value of a home in my state is around $157k which equates to about a $1,265 mortgage payment per month which according to stats is unaffordable for about 60% of the state's population. So, even if you have a shitty apartment in a shitty neighborhood and are food insecure, but you make say, $18,300, you may not qualify for any state benefits because you are too rich. Makes sense doesn't it?

There is a great site called www.nationalpriorities.org. A pretty eye opening website I think. For example, my town contributed something like $168.2 million to the Iraq war effort. This amount of money could have provided health care for 55,577 people. You can put in your town and see what the trade off is for what has been spent on the war so far. Very interesting.

So we are heading into the cold season and oil is at an all time high. I worry about these families, hell, I worry about my own family. Food or heat, medicine or food, clothing or gas to get to work, its pretty scary and I have a good job. I've already hit up people in my department for old coats and shoes for the homeless closet, because God knows, we are going to need it.

Help Wanted

I just saw a sign advertising a job for a garbage truck driver. It can't be that hard can it? I mean, you just drive a truck around and pick up folks garbage with a mechanical device. I also hear they pay well. I could sit there, listen to music, enjoy the fall foliage on my run, wear a t-shirt and jeans (well, maternity jeans but still), not have to speak to another human being for hours at a time. It sounds really wonderful. I'm having them fax me an application. If I get the job perhaps my rants will be about other types of "garbage." (har de har har har)

Wednesday, September 24, 2008

Facts

At any given time there are over 4000 homeless in my state (in New England).
Last year shelter workers had to turn away 30,000 in need of shelter for lack of room.
2000 people, including 400 children are in shelters everyday.
One January night in 2007 when the temperature was 20 degrees, a count all around our state was taken. There were found to be 3,325 households homeless. Of these, there were 392 families and 797 children. 10 percent of these families were found sleeping on the street or in places unsuitable for habitation.
With heating oil, food prices and other commodities at an all time high this year, I can only imagine what January will look like this year. I have stocked up my homeless closet with hats, scarves, mittens, socks and sweatshirts and coats. It won't be enough. I have many packets of information at the ready for those who need shelter. I don't know if it will help.
Why is this so prevalent in this country when so many have so much?
I hate this time of year..............I feel so helpless.

Until Death

He wants to give up but is worried. He feels he hasn't told his family everything. He worries about his wife, will she be okay? Will his sons take care of her? Will his daughter stay with her awhile? It's been 60 years together. He has so much to say but breathing is so hard. His wifes eyes fill with tears. "It's okay hon. It's okay. Rest now" He does rest, and he holds her hand and caresses it, the hand that he pledged his love to so many years ago. She kisses him and smoothes his hair. She pulls up his blanket that covers his emaciated frame, the frame that swung their children in the air, the frame that provided her the comfort of his embrace. And they sit there together, no words are needed after years of learning each others looks, body language and sighs. She is there when he passes to the other side, she closes his eyes, she folds his hands, she kisses him, sighs and goes to meet their children.

Monday, September 22, 2008

Feelings, nothing more than feelings..........

OH, MY, GOD! She's crying. Quick get kleenex, stat! Send in the militia of social work and pastoral care, bring in a carton of kleenex, particularly the scratchy, millimeter thin kind that shreds with one blow. She's crying, for God's sake because she is overwhelmed. Her father is in the room dying, they have just made the decision for a DNR/DNI order, he is getting meds to make him comfortable. She has a right to be upset. She has the right to cry and sending in a militia of "caring people" isn't going to make the situation any less upsetting. Truth is, she has been up all night, has been thinking about this decision for weeks, she hasn't had breakfast and barely ate dinner last night. She is thirsty, she feels grungy after being up all night and really would appreciate a hot washcloth and some coffee, maybe a muffin and some orange juice. These are readily had around here and so I bring them. She really has made peace with her decision, she is just glad that he won't suffer anymore, she understands the ramifications, she wants Dad to pass with the dignity that he held throughout his life.

Some folks really don't want to talk. Some folks prefer being alone in their pain. Some just want some nice ice cold water. Some want to talk to their loved one alone. Some wail, some sniffle, some yell. Some love to talk and talk. It's cathartic to talk about their loved one's life. He was a teacher, an artist, an architect, a bus driver. She was a nasty old biddie but I loved her. He was a dirty old man but a fabulous painter. They just need time. They need their feelings, they need to cry, and sometimes, they need to cry alone.

Tuesday, September 16, 2008

Today

So it's 8:46am. I got here approximately 46 minutes ago and today has declared itself as "Beat Your Significant Other Day." I have three patients. All beaten up by significant others. I haven't even had my coffee yet.

Coffee, then domestic violence. 'sigh'

Wednesday, September 10, 2008

Pissed

She's pissed that he wrecked his car. What she should be pissed about is that he drank so much and then wrecked his car. She's known he's an alcoholic for years but that's not what she is upset about. I guess the hard reality of living with an alcoholic is too much to bear so it's easier to get angry about the wrecked car than his disease.

He is so annoyed that she is in the hospital again. She's here every week. She takes her meds, she goes to dialysis, she seemingly does everything she is supposed to do and yet she is still here. He is tired, he needs a break, he thought about not coming to the hospital with her today but decided that he should. So he yells at the doctor. It is the doctor that is responsible for this continual failure. It would suck to actually grieve about the fact that she won't get better because of her disease process and that eventually he will lose her.

They are so angry that they have been waiting for over an hour to be seen. Other patients have come in and seen the doctor already. Why is it that we have had to wait so long? Why isn't my sore throat a priority? The truth is, if they had done what they were supposed to when they were seen for the same thing two days ago it wouldn't have gotten worse and they wouldn't be back here waiting.

He is beyond furious that I won't give him a taxi voucher for him to get home. He got one last week that was for over $100. He hates the doctors where he lives, he took a bus to get here, he signed out AMA the last hospitalization, he refused the prescriptions he was given. His friends won't give him a ride home. In fact, they won't even answer the phone anymore. It is far easier to blame the establishment than take responsibility. It is far easier to be furious that acknowledge his loneliness and despair that he can't seem to stop drinking, that he is now alone, that he lost his leg last year, that he just doesn't care anymore.

She tries to hit anyone that goes by. Her eyes are wild. She is now in restraints. She howls like a wild animal caught in a trap. She lets loose a stream of expletives towards her nurse, the doctor, towards myself. "How dare you!" " I want out!" "Why didn't you just let me die?" She mumbles off into tears. "I just wanted some peace.............." and then, another stream of foul language and yelling. So angry, so disgusted that she is still here and we saved her from dying.

Anger directed inward or projected at those who tried to help. It is blatant, it is subtle yet frightening in it's intensity. It is misdirected, it is too hard to be okay with the sadness that came before the storm. To be sad is to acknowledge the loss of something, to be angry is to blame for the loss that has occurred.

Tuesday, September 9, 2008

Tom and Huck

Maybe you had a neighborhood like mine with tons of kids zooming by on their bikes, climbing trees, playing hide and go seek running in bands throughout the neighborhood. Or maybe you didn't. It was somewhat reminiscent of Tom Sawyer and Huck Finn in the summertime, kids everywhere, running down to the beach, showing up at home with dirt smeared faces and torn clothes. And this is what I hoped for my children. When I first moved into my house almost five years ago I wasn't sure that there would be many children to play with although the street was perfect, tree lined, a brook at the bottom, a dead end street, quiet. This weekend turned into a Mark Twain book and I was ecstactic. All the children were out, the weather was warm and sunny, Reese and Mosey were thrown out of the house, as were all the other kids, bikes came out, sidewalk chalk, wagons, balls, kids zooming down the street on their bikes yelling to each other as they went, the younger ones pedaling as fast as they could to keep up. Everyone ended up at my house climbing on the swingset, making tons of noise, the screen door banged a thousand times as kids came in and out for drinks of water and bathroom breaks. Mosey scraped her knee so out came the lawn blanket and some quiet games for awhile, marbles and a building set, a couple of books and popsicles. And I smiled from the front porch with my coffee. This is what I wanted for my children, dirt on their faces, bandaides on their knees, strawberry popsicle juice dripping down their chins staining their shirts playing marbles on the blanket in the spring sun. All I needed now was some whitewash to start painting the fence, aaah, now that would be perfect.

Saturday, September 6, 2008

A Grassroots Organization Worthy of Joining

So somehow I have to figure out how to take maternity leave without losing my house. Did you know that the US and Australia are two of the only countries without some sort of paid maternity leave? I know women who have gone back to work two weeks after delivery. This is terrible for both mother and baby. We are one of the wealthiest countries in the world and we don't give a hoot about families or healthcare. Check this out; a graph of countries and what they offer for paid maternity leave. Even the poorest countries in Africa have it. http://en.wikipedia.org/wiki/Paternity_leave What is up with this? I"m not usually a huge political activist but whining isn't going to solve anything......

Join!

http://www.momsrising.org/maternity



Federal employees may be the first ones to reap the benefits of paid maternity leave if the bill passes. Why not everyone else?

Tuesday, September 2, 2008

Bureaucratic nonsense

Today I see this guy who has cancer, diabetes, and a host of other chronic conditions. He is weak and pale, he has no ride home. He is estranged from his family, has few friends, was living at a nursing home for a couple years but managed to get out and live on his own, to his credit. He makes about $925 a month about $250 of which goes to back child support for his children who are now adults. His rent is $500 a month which around here is cheaper than cheap. He then has co-pays from Medicare for about 10 different meds. He has no car and lives in a rural area which has no public transportation. He will need followup doctor visits. One day he was desperate to get his meds from the drugstore so a friend lent him his car so he could get them. The guy, though previously a truck driver now lacks a drivers license. He gets into a fender bender and gets charged and now has to appear in court. He has no idea how he will get there.

This man is not eligible for Medicaid for some bizarre reason. He is so sick most of the time that he is virtually unable to follow through with getting the child support changed, and work with his state worker so that he can qualify for Medicaid. At this point he literally has to choose whether to take his meds or eat. He can't get to most of his doctors appointments due to his lack of transportation but is getting weaker and weaker. He is not yet sixty so he doesn't qualify for protective services, so we get him a visiting nurse. He wonders why he even bothered to work and try to get out of the nursing home since he is so much worse off financially and medically than before.

Granted, this man has probably made some poor decisions, he has likely burned a ton of bridges but at least he has tried to become independent. Why do we reward those who stay in costly nursing homes and never try to fend for themselves and cause those who attempt to be independent become more dependent in the long run because they lack the resources to maintain their independence? How is one to survive on less than $700 a month when one has a chronic disease, is in already cheap housing and has to pay out of pocket for transportation. How is a sick man supposed to schlepp into state workers offices to fight over bureaucratic nonsense? We need universal healthcare.

Thursday, August 28, 2008

Senseless

I'm sorry your parents were stupid and you died today. I really am. They didn't mean for you to come to harm, they loved you, they really did. Your family misses you terribly and I'm not sure that they will ever fully recover. I'm sorry little guy. I hope you never knew what hit you.

Limits

I have to say that this year I have learned a lot about the whole issue of limiting ones care and about the folks that while extremely ill, still want everything medicine wants to offer. For me, if I were to become terminally ill, couldn't communicate with people, had to have someone else take care of me, well, I wouldn't be able to stand it and would ask for hospice but many, many patients and families don't see it that way.

I have to say I have a pretty hard time with seeing what I perceive to be tremendous suffering. I hate to see diapered, contracted, drooling people, assuming that they are unaware of their surroundings, and are in some sort of psychic or physical pain. I curse their conservators or their family members for not changing their code status, for not just making them comfortable and allowing them to pass into the next world peacefully. However, my assumptions are not always correct. Some who appear this way are actually cognizant of their surroundings and are communicative in ways that are not immediately apparent. These folks somehow are actually okay with being ill and content to live their lives in their current state of being. It's hard to understand why, it's extremely hard to put myself in their shoes. I often question their sanity. I shouldn't be so judgemental. I guess I should applaude their ability to stand steadfast in their desire to live whatever their condition. Perhaps there is some sort of closure that they haven't experienced yet, perhaps a life task that has not been completed. It's hard to know and harder for those who care for them to accept.

Sometimes I wonder if we as medical providers offer too much to these folks. I question the ethics of continuing to offer life saving or prolonging treatment and medication to those who appear to have zero quality of life. For some providers it's hard to justify thousands of dollars worth of medical care for a seemingly vegetative or uncommunicative person, or one that while communicative, is curled into a ball and unable to participate in life except for verbal discourse with those who have the time for him or her. Years ago, some of what we now have to offer wasn't available and many people died a more natural death, there were fewer nursing facilities, fewer vegetative and contracted people lying in beds or wheelchairs. Now, there are more and more people who live this way because we have the technology to keep people alive and many people want to be kept alive no matter the consequences. They are okay with not being well. I should be okay with it. I'm not. I can understand it but I wonder what it is that makes people unable to call it quits. Is it fear of the unknown? Is it a personality of dependence and entitlement that some people are okay with requiring someone to take care of them? Is it tenacity? Is it appreciation of life whatever the physical or mental state? And what it is with the medical profession who says it's not okay to call it quits. Who is alarmed if someone wants to die, states that they don't care anymore and have had enough.

I consider the state of my 91 year old grandmother. It will be a terribly sad day when she dies. She has been the matriarch of the family. Her piano playing has been a hallmark of family gatherings and of community goings on for over 60 years. She is now mostly deaf. She cannot see. She sees people and things that aren't there due to Lewey Body dementia or Charles Bonet syndrome, or a conglomeration of both. She is frail and needs assistance for almost every aspect of her daily life. She can't really participate in therapy to get stronger at this point because she can't see and is so afraid of falling, is so weak at this point that it is a monumental effort to have her do anything beyond sit in her chair day after day. This is not my grandmother. She has expressed that she is not okay with this state of affairs but she is still here. Her doctor continues to prescribe her medication for her high blood pressure, her eyes, and whatever else she takes medication for. The meds aren't going to make her better. Are they keeping her alive? Are they prolonging the inevitable and possibly the biggest blessing for her? I wonder. She is still brought to the doctor, her meds are still filled, and we are still concerned about her blood pressure. Should we be? Why are we not more concerned with the fact that she has lost her personhood, her independence, her zest for life. That she is subsisting in a grey world of uncertainty as she shuffles, assisted, to the bathroom where she is naked in front of strangers.

Limiting care is such a grey area. People, as in every other aspect of their lives, are so different from each other, choose vastly different ways of existing. It is hard to know when to applaude or jeer at the tenacity of ill people who still want to live despite their illnesses. It's hard to know whether to explore the reasons behind their seemingly poor decisions to continue or boost them up psychologically for the next medical onslaught. I have no answers. I must be respectful of their decisions. But it's hard sometimes, and it's disheartening to see continual human suffering that the person or their family has chosen. That I think is the hardest part. That the perceived suffering has been a choice someone made. A choice to be in the world no matter the cost.

Tuesday, August 26, 2008

Master's Degree Anyone?

So here are my qualifications; I have an AA degree, a BSW (which is a four year degree), a MSW (which is indeed a masters level degree), and a LCSW (licensed clinical social worker) which cost me several hundred dollars, 3000 hours post graduate work, 100 hours face to face supervised work, and a humongous test, to acquire. It also costs me $150 per year to renew, although for nurses and other professional disciplines that make a ton more than me only have to pay about $50 a year (doctors I know you have to pay lots more). I have over ten years of experience in social work and have been in the medical field even longer than that so I do know the difference between my butt and my elbow.

Pet peeve number one: a brand new nurse out of a RN, not BSN program makes more than I do.

Pet peeve number two: I am not here to do babysitting for patients children because I am a social worker, love children, and have nothing better to do.

Pet peeve number three: Just because you do not know what I do does not mean that I am any less busy than you are and therefore should be given the tasks that you do not want to do because you are "too busy."

Pet peeve number four: Because you are confused about what a social worker does does not mean that you get angry at me for not agreeing to babysit, get taxi's for patients and find a homeless person a non-existent pair of shoes.

Pet peeve number five: I do have more peeves but the above four are the ones that really annoy me.

Now, I understand that there are tasks in my daily job description that are mundane which I will happily do. I understand that in the course of my day I do plenty with patients that is not necessarily at a master's level. However, given my education and experience and the fact that I actually do a bang up job of what I do every single day I am here, do not talk to me as though I am your personal gopher or that I do not know what I am talking about.

Thank you.

Wednesday, August 20, 2008

Knocked Up

It appears that being a knocked up collegue of those in the medical profession gives my esteemed collegues the license to comment on the size of my abdomen, suggest that perhaps my dates are wrong because I have had too much sex and have no idea when I may have become pregnant, suggest that when I am short of breath that I have a PE and need a ddimer drawn and a chest x-ray. Turns out I now have asthma due to the delightful flora and fauna that are drifting about this time of year. I am now on 10mg of Singular thank you very much. At this time I am not going to die of a PE. Praise God.

It has been difficult I must say to carry out my duties as the ED social worker in what has been an incredibly busy summer while maintaining adequate hydration and nutrition and emptying my bladder at frequent intervals. I am appreciative of the leeway by collegues have given me in the endless line at the bathroom. I am appreciative of my nurse friends who have said they will throw me a huge baby shower. I need one! I am forever grateful.

What makes it more difficult however are comments about my "baby's daddy", being "knocked up", being too big for gestational age, and "you look tired". Which of course I am. Guess it's not enough to be the mom of two girls at home, have a stressful job, being an "elderly multigravida", not being able to get any extra sleep and having my partner away a good share of the time. I love medicine, I enjoy my job for the most part, I appreciate my collegues, I really do, but they are more than welcome to be supportive and extra welcome to keep their less supportive comments to themselves.

Monday, August 11, 2008

There is someone for everyone

It's amazing. Really. A couple homeless folks who have been together for over ten years, adamant that they not be separated in a shelter, coming in together for a "tune up."

Functioning in their dysfunction. Together.

Still here

I just found out you are still alive. It's been several months since I saw you last and I feared you had finally succumed to a life of heroin.

I've lost count on how many times I sent you to rehab. I remember the time you came in with pneumonia, were filthy, dope sick and desperately needed clothes and a wash and I did that for you and you thanked me.

I don't know why you out of so many others sit on my brain, and why I continue to help you. I really don't.

Maybe it's because one time I saw you, you were clean. Your eyes were bright, your hair was washed and combed, you had some meat on your bones and I felt hope.

Hope. That must be what keeps me coming back to this place. To turn the corner and see you there looking good. To turn the corner and see you looking bad but knowing somehow you are the reason I keep plugging away. To see if your still here.

Wednesday, August 6, 2008

Waiting

They pace, they sit, they smoke, they fall asleep, all waiting.....waiting for news.
They call and call, and leave messages.
They give directions to the hospital.
They stand up when you walk in the room, their faces are hopeful or tear stained.

And I don't have the answers. I rarely do. I wish I did but it's not proper. I must wait myself for the Doctor, the one in charge, the one who has the labwork, the CT results, the diagnosis.
I wait, go back to the patient, go back to the family, walk the well worn path between the trauma rooms and the family rooms.

"They are still with him now." "You can see him soon" "We'll have more information soon."
But I know.
I know that they are already dead.
I know that their injuries will bring death.
I know that their injuries will make them disabled.
Or I know that they are completely fine but the Doctor is tied up and can't see the family yet.
Or they are completely fine and the family won't believe it until they talk to the Doctor. What I have told them isn't good enough. I am just the messenger.

And so I lie. Or tell half truths. Or make something up. Or reminisce with them.
"Tell me about your loved one."

So we wait together.
Or I wait exasperated. "can you please talk to the family?" "please talk to them, they've been waiting for a half an hour." "Can I tell them something until you have a minute?"

And then the Doctors come and they tell and they leave and I am left with the family and the result of the news.
And I wait for the family to absorb the news. To stop sobbing so I can tell them they can see them.

Then they wait with him. Wait for death, wait for life. Waiting.............

Frustrated

So we are all aware of the folks who come to the ER for three hots and a cot, maybe some percocet, a new pair of socks, if they are lucky a pair of hospital pants. I am frequently asked to provide rides home to folks who lack the foresight to determine how they might get home once they take the ride in the ambulance for whatever non-emergent complaint they might have. The ER can become a haven for the homeless, the abused, and the otherwise non-coping folks of the city. Many have state aid, recently there are more who don't and won't qualify.

We no longer have free prescription assistance at the hospital, the new health program in the state can't be enrolled in unless you haven't had insurance for over six months, which really doesn't make a whole hell of a lot of sense. In order to qualify for medicaid you have to be incredibly poor, you also often have to be on disability.

Which brings me to another issue. Why is it that those who have had asthma since they were a child but are on medication and it is well controlled get social security disability and medicaid but my mother who had a shoulder injury which left her unable to play the piano which was her life's work, had a hip replacement, and is nearing 65 can't get it because she is not disabled enough. She can't lift her arm at this point above her waist. She still tries to teach but it's pretty hard and discouraging. She doesn't qualify for health insurance because of her pre-existing conditions, she makes too much money for Medicaid because she is actually trying to work for a living. Our health system is broken.

People with state entitlements use the ED as primary care and yell at staff when they aren't seen immediately, don't get lunch while waiting to be seen for a sore throat, and also want a free ride home because when they called the ambulance for their sore throat it didn't occur to them they wouldn't have a ride home. People without state entitlements also use the ED as primary care because they won't be required to pay. They will also frequently get free socks, free lunch, and maybe some free clothes along with free medical care because they will ignore the bills and collection ageny letters that will inevitably come.

There are clinics that operate on a sliding fee scale, or if you are too poor, will care for you for almost nothing, will help you sign up for state programs and help you with meds. There is also a free mobile care clinic that provides meds for chronic conditions for free, will provide care for free.

But it's easier although less pleasant to take a free ride to an emergency department, wait for several hours, abuse the staff, not follow up, be non-compliant, and possibly end up in more dire straits because of it.

The system is broken and nobody want to take responsibility for it.

Naked

Okay, so I am supposed to be the bleeding heart of the department, the one who always feels sorry for folks. I really can't say that I am until it comes to this subject. Being naked.

So this somewhat larger woman is involved in a car accident, she is covered in lacerations and abrasions, she is put on a board with a collar and her clothes are cut off and she is now completely exposed to the ten to fifteen people in the room. Now I realize that the patient must be exposed to determine injury but then can't we throw a towel over her privates? Come on people! Can you have the slightest bit of empathy? Do they really need to continue to lie there at the mercy of others completely nude? So I walk in and stick a towel over her lower half and upper half which earns me points with the nurse and deducts points with the doctor. Sometimes I ask and sometimes I don't. To me it is pretty clear that when half the huge population of medical folks that were there at the start have left that the person is going to live and the rest is just x-rays and lab draws. So the person can now be covered.

How about the demented folks in rooms with their butts hanging out of their johnnies, completely oblivious to the fact? When we go by can we cover them up? How about the female patient having a pelvic exam and having every Tom Dick and Harry walk in like it's no big deal? Or the intoxicated frequent patron who has somehow forgotten his clothing and has a blanket that keeps falling off? I firmly believe that whatever the complaint, the frequency of care in the department that each person should be in some way covered. No exceptions. Besides, there are children in the department who don't need to be exposed to the exposed.

A pet peeve of mine but also a testament to maintaining patient privacy and dignity. If we can't do this one thing I hate to think what else we cannot do.

Patients Like Family

I don't know you, or I've known you for minutes, or hours but I know things about you that most wouldn't know after years of knowing you. I wiped your tears, I held you, I brought you ice when you punched a wall in anger and grief. You are my patients, you are my families, you are those who have lost the loves of your life, fathers, mothers, wives, husbands, children, lovers...............and you grieve, sob, so many ways you show your despair. I am there to see it all. I sit with your emotion, I sit with you when you crawl on the floor, when you curl into a ball, when you sit with your head in your hands and sob, when you sit and say nothing at all. I caught you when you fell, I held you when you needed something to hold onto and most of you won't remember my name and that's okay. Some names I remember, some I don't, most of all I remember the breaking of hearts, the sighs, the looks of disbelief and the tears that though bitter and full of fear will with time, bring healing and mend the broken heart.

The Faces of Grief

It is the poised and well-dressed women who slumps to the floor, heels discarded, rocking back and forth, wailing, knowing that her son was taken from her too soon.

It is the man, late in life who sobs, who slams his hand on the chair, who then becomes overcome and crawls like a child knowing his wife, who has suffered will find peace without him.

It is the child who is silent, whose tears well but do not spill, who kisses her daddy’s hand and tells him she will see him again someday.

It is the daughter who smiles, who reminisces, who understands that her father would have wanted to die quickly doing what he loved.

The son can only punch the wall and leave a mark, he has no words but anger for his pain. He wants revenge, he wants to know who killed his mother, where is the sick bastard, I’ll kill him, I’ll kill him, he says, over and over.

It is the wife who is silent, she feels relief. She is finally free to be herself. She is no longer the victim of his tirades, she survived and he didn’t. But the pain is still there, so many things unsaid, so many holes to be mended.

It is the friend, sobbing in the corner, unsure of where to be, who knows more than the family, who can’t share it, won’t share it, will hold the secrets in their heart. Whose pain will be more acute because the phone won’t ring anymore and there will be no more secrets to tell.

It is the lover, the partner, who wasn’t known until now. They pretend to be "just a good friend", but their heart is torn in two. Tears roll unchecked, their body shakes with sobs yet, no one else in the room knows why, and they won’t be able to say, at least not yet, perhaps never, maybe someday.

It is the husband who cries in fear, wondering how he will now care for the children alone. She did everything, she was his soulmate, they just celebrated their 7th anniversary yesterday. Why? She was fine.

The family can only stare in horror and disbelief. They huddle together like animals in a storm, and they are in a storm, the storm of grief, the storm of the unthinkable happening today, tonight, this unbelievable day. What will we do now? What? We don’t understand.

The faces of grief are never alike, they wail, they seethe, they smile, they are shocked. They are tearful, serene, and beyond words. They eventually take on a recognizable appearance that others are more comfortable with though the heart and soul looks for recognition in it’s weakened state. The body seeks relief, the mind continually questions the rationality of death, the taking of one who is loved, one who is hated, one who had no one but somehow still touches us. It is in touching us that we begin the search for the meaning of that which was taken, to start answering the questions we never thought to ask, to explore the topics never put into words. Death touches the face and reshapes it, each person a different mask, a mask that in time can seek reshaping into beauty or remain contorted in pain.

Return to Childhood

Your face is wrinkled, unlike a child, yet your body is soft, plump, curled into itself, wanting touch.

You are confused, fearful, grabbing hands as they walk by, dependent, sometimes pleasant and trusting, sometimes angry and defensive. The face is questioning, hopeful, eager to find kindness.

We have talked about your life with you, conjuring images of your childhood, your early years, your marriage to your sweetheart, it has been over fifty years and your face still softens with their name, your eyes glisten with memories.

I have held your wrinkled hands, I have smoothed your hair, I have dried your tears and listened when you shouted, when you railed against the world, against God, angry that you can no longer understand what is happening to you, why you are here in this noise, in this pain, in this unfamiliar and foreboding place.

How long has it been since you have felt a caress, since you have heard "I love you" from those you love? Do you dream of kisses from long ago? Feel your lovers arms about you, holding you tight, loving you? Do you feel your child's soft body in your arms, do you hear their cries in the night, but not remember their names?

I wonder at those who are silent, whose faces are blank, whose bodies are curled from want of use. I wonder at the thoughts inside. Are they already in places beyond, though their body continues to breathe? It is a mystery, it brings tears to my eyes. I want to hold them and remind them that they were once alive.

You are what keeps me awake at night. Your faces and grief causes a lump in my throat. Yet you also bring joy to me as we talk of your past and your wishes for life after your body has ceased to live.

I wish you peace, I will hold your hands, and sometimes I will kiss your face and put my arms around you because I know that you yearn for touch and will find solace in the stranger that I am.

Tell me your stories because I will remember them and hold them in my heart and share them with those who care for you because it gives you a face.

You have returned to childhood and perhaps that is merciful. May you find peace in your memories and find joy at the end.

The Haunting

You visit me in my dreams, pale faces, smooth and gnarled hands.

Your face suddenly appears before me, out of the blue and my eyes fill with tears.

I didn't feel anything at the time, I was numb, going through the motions of your loved one's grief. Holding them as they cried over your body.

Words spill from me and I must write them or I will be overtaken by ghosts. They will visit me over and over, as though daring me to grieve.

Please find peace dear spirits. You will be remembered by me. Even if the world forgets you, I will remember your last breath and when your spirit left and those who cried for you.

Your names are written in my book. Your stories are remembered. Be at peace and find the light.