It is estimated that there are approximately 500 trillion synaptic gaps in the human brain, or roughly each millimeter of the cerebral cortex (the top most portion of the brain one would obeserve if popping off the skull cap) containing approximately 1 billion. The significance of the synaptic gap is that it remains an abyss in its' complete understanding. It is terribly complex. There are any number of ways that disruption and catastrophic failure of any body system can occur. Yet when it happens correctly it is like an experienced and beautiful symphony, composed of smaller instruments, the sounds they make produced at just the right moment, under the direction of the conductor can sound as beautiful as the "fur elise:, or the "Ode to Joy", Scientists are working feverishly to better understand what happens in this nano environment. In terms of modern biochemistry, our advances have allowed us to increase the power of the electron microscope of life, or that is attain a more "molecular" understanding of our body and the extraordinary mechanisms that exist to keep it alive and thinking. It is a miracle unto itself. In order for a heart beat to occur, or to move your finger, or to think about the events of the days past, a complex chemical reaction takes place in the brain. It starts as elecrical, a change in the polarity of the cell membrane of the neuron, the polarity reverses and opens a series of floodgates that cause a chemical change, or a release of calcium into the space outside of the cell; then the neurochemicals are escorted from one axonal body across the synaptic gap to the dendritic body on the other side. Like taking a boat from North America to Africa. This is a rather simplistic explanation of an event that contains quite literally libraries full of information on just this subject. Understanding it more allows us to better control when and which neurochemicals cross this synaptic gap and make the difference between holding our bowel movements and crapping our pants. From a systems prospective, all of these impulses travel to other areas of the body bringing with them information like telling the heart to beat 60 beats per minute, or telling the lungs to breath more rapidly because carbon dioxide is building up, or telling the kidneys to make more urine because sodium concentration is too high. They travel to the other areas of the body along the superhighway of the central nervous system which starts in the medulla of the brain and travels down protected by 7 cervical vertebrae, 12 thoracic vertebrae, and finally 5 lumbar vertebrae where it terminates at the coccyx. The vertebrae themselves when studied are nothing short of a miracle as they are a series of bones which sit on top of each other much like building blocks; positioned in just such a way to afford maximum protection of this delicate superhighway within a 155 pound average person that moves about space and contorts their spine in a variety ways from sitting, standing and walking, and falling. It functions perfectly until the forces of physics start to penetrate the fortress. It is then that the connections may become disrupted.
It is 1995 and Christopher Reeve, the famous actor who portrayed superman, considered an avid and experienced english equestrian rider was running and jumping his gates wearing full body protection including a helmet. He is scheduled shortly to do a publicity video about the importance of safety gear and horseback riding. On his last gate which stood 3 and one half feet high, his horse suddenly could not anticipate where to plant its' hind legs in preparation of making the jump. Becoming confused, the horse stopped abruptly. The force of the stop caused Reeve to "roll up" the horses' head and over where he landed on the back of his head. He weighed roughly 200 lbs, traveling at 9.8 m/s/s in a projectile arc and hit the ground with the back of his head first. According to Newton's second law, the force exerted on the top of his spine was roughly 1000 kg/ square inch. Feel free to correct my kinematics, it's been a while. But the force was enough to fracture the first two cervical vertebrae and transect, or severely bend, like when you take a rope and make a 90 degree bend in it, and cause him to be paralyzed from the neck down, unable to breath unassissted because the nerve that told his diaphragm (the bellows of the breathing effort between your chest and abdomen) had been disrupted. There was a road block. The connection could not be made. I have never been that fond of horses. As a child of nine or ten I remember sleep-away camp in Shohola Falls Pennsylvania called "Buck and Beaver" where I was more apt to choose rifelry with a BB gun first, then a pellet, then a .22 gauge rifle, or kayaking, canoeing, anything but horseback riding. I wasn't particularly fond of their smell and to be quite honest, they were big animals and scary. The prospect of falling off was just too much to bear. The horse that waited for me to mount waited a long time. As a matter of fact, he waited until about a month ago when after my oldest daughter's riding lesson, her instructor talked me into going for a brief trail ride with her, to see how she was progressing. There I stood in front of playboy stricken with fear, almost paralyzed and phobic. . Suddenly, the horse loomed dauntingly over me as if it wanted me to reach out and scratch its' nose. Which I did. "Don't know if that's a good idea." I nonverbally pleaded with her instructor. I had ridden horse once at that camp and vowed never to ride again. In the back of my head, all my synapses were flooded with ideas like "if injury myself how can I support my family" "ahw come on Dad, it'll be okay" hemmed my daughter's instructor; I looked into my daughter's eyes to see only expectant jubilation at the thought of riding horses with her dad. I put on the helmet and said "let's do this." Connie, my daughter's riding instructor, taught Julia on her first day, and me on this day, RULE#1: never let your horse sense fear. This is an interesting concept. A horse is trained to never fear its' rider. It must willingly, or unwillingly obey the commands it receives in the form of tugs on the reigns and gentle kicks to its hind quarters to travel right or left, start to gallup, stop, go backwards, do nothing, or cantor. A horse is "broken" when it can no longer act impulsively or instinctually when tacked and mounted (saddled) by a rider. Riding a horse becomes complicated when the horse senses that its' rider has fear. You see, to the horse, the rider CANNOT be afraid of the horse, (simply by mounting the horse, you infer to the horse that you are not afraid and by holding its' reigns, you now control the horses every move.) so if the horse senses fear it is sensing that the rider is afraid of something else in the immediate environment. If its' rider is spooked then the horse freaks out. It is in this moment that the discipline of the horse breaks down self preservation kicks in, and it can then start to act instinctually, such as when encountering a snake, a horse rears up to come down on the snake full force thus killing it and evading the perceived threat. He forgets that you are on him. You are then subject to the forces of nature and gravity and circumstance. How you land, and on what you land determines whether you live, die, or are paralyzed from the neck down unable to breathe unassisted by an artificial respirator. Mounting the horse, I felt oddly out of balance; I quickly corrected this by adjusting my feet in the stirrups. Gave myself a little more support, felt more comfortable. Every ounce of my being focused on not being afraid. I often tell my students when they enter an exam room, or perform any type of procedure, act like you've done it a thousand times. The patient will perceive your confidence and feel more comfortable in your care. Even if you are thinking in the back of your mind "please god let me not kill this woman" Don't show it. The reigns felt smooth hard and cold in my hands. I was amazed at how little movement here or there would cause the horse to respond. Connie says first time riders instinctively hold their reigns in too tight, which is horse language for STOP. Pull back REALLY far and the horse will start moving backward. I remember the giggles I heard from my daughter as she started to see me move in the reverse direction. "Dad, loosen up on those reigns" Connie calmly called from ahead. I don't even remember her actually looking behind her to see what was going on. And so I did. The rest of the ride was pretty uneventful. It was a leisurly ride through apple, pear and raspberry orchards with breathtaking vistas of the shawangunk mountains and the miles of farms that surrounded us. It was actually quite relaxing. The look in her eyes when we dismounted was all the encouragement I needed.
Today was "family fun day" at Rocking Horse Ranch in Highland New York. It is a cowboy themed resort that features an indoor water park. I am not quite sure what indoor water parks have in common with horses, but apparently they are quite a pair. Also available were trail rides, pony rides, arts and crafts, etc. The minimum riding age at the ranch is seven. For safety reasons they are fairly firm on this. My daughter was having none of it. I stood at the front desk blankly figuring out how I was going to get her on a trail ride. Lou, the manager overhead me talking with the front desk girl and approached. Without me saying a word, she pretentiously looked up at the manager and said " I have my own helmet and I ride at coyote ridge all the time with aunt connie. I even rode at the Ulster County Fair." She pleaded. Lou agreed to "try her out in the corral" Which is exactly what they did. But before she mounted the horse, I remember she came down from the mounting stage, walked up to the front of the horse (despite being repeatedly told by the handler to return to the mounting stage) and held out her hand in fornt of it's nose as if introducing herself. She pet him a few times and then proceeded to mount. The wrangler, although disenchanted with her breach of policy; riders mount only from the stand and never approach the horse on the ground. Nonetheless , he was impressed that a 5 year old little girl had the knowledge to perform a simple yet crucial first step in the pre-flight checklist of horseback riding that so many riders frequently forget to do out of habit. Connie taught Julia to let a horse smell you, and touch you, pet the horse, stroke the horse, speak to the horse and reassure the horse in calm tones so that the horse knows who is mounting and perceives you as no threat. Imagine standing blindfolded and then having 200 lbs dropping on your back. The concept is stirring. The handler had her mount and gave her a series of instructions which she followed to a TEE. He was amazed and agreed to let her ride. We did the intermediate trail ride which involved walking and gallupping (a slow jog) Julia in front of my watchful protective eye at all times. Yet she was the experienced one, I, the novice. We laughed the whole ride. After the first gallup, Julia looked back at me to see if I was keeping up with her, which I was. I made a funny face and said"OOOOH Daddy's butt is hurting after that one." Julia giggled and said "Daddy you're being silly, you have stand up in the stirrups when you start the run." HHMM interestingly enough, on the second gallup, I actually used the stirrups to stand up a bit and sure enough, she was right. I, a man of age 39 years, masters and post graduate prepared in the sciences, well read, whose vocation was in fixing broken people and preventing people from breaking, husband, father of three girls, had learned something from his five year old daughter. A connection was made. In the complicated play that is acted out each day of our lives, the endless rushing, the never ending list of things to do. Time stood still enough for me to know that this would be my connection to my daughter. It was on this day for the first time in many years that I was not thinking about the bills, my practice, a patient not fairing well, a parking ticket that needed to be paid, or Christopher Reeve who has since passed away, but instead was awe inspired by what I had created and nurtured as she of 44 lbs and five years of age sat atop a one ton beast and controlled him without fear. Today was the first feeling in my life of great accomplishment. New synapses are forming. They will undoubtedly take me on a journey to a part of my mind that I have yet to discover. I am a horse man now. I will learn with my daughter.
It is difficult for a parent to cross this "synaptic gap" and connect with your child. I eagerly await what will come of Abigail and Chloe. How will I connect with them. Also of my wife. How will I continue to connect and reconnect with her?
It is a ride I WILL take. Fearless and in control.
Sunday, October 3, 2010
Monday, September 27, 2010
Saying Goodbye
My daughter Julia is 5 years old, in earth years that is. She harbors a curiosity of nature and her unpredictable forces. She marvels at the smallest of details, how a wooly mammoth curls up in her hands, how a caterpillar becomes a butterly, the weeds in daddies grass and why they grow so much and why daddy hates them, pods of "fairy hair" that grow in our backyard and being careful not to open them until they are ready. She loves nature hikes through the seasons and is starting to take note of how when one season ends, a new begins. She knows summer has gone and she laments for her days on the beach, swimming in our pool, running through the baclyard with ice pops dripping down her arms, chasing her sisters. She knows winter is coming.
She is becoming quite adept at horseback riding. She rides western style and is taught by a stought old-school original who goes by the name of connie, she owns coyote ridge, the stable where she rides. Connie has a keen insight on nature and is more at home surrounded by horses than of her own family, who are very much like her. She is a tough woman. She has been thrown, kicked and stomped more times than she cares to think about and her body shows these signs through her severe arthritis. Her face is aged with weather and sun, you can tell she is a woman of the outdoors. If Julia twists her ankle, or burns her hands on the reigns, or otherwise hurts herself, Connies response is usually a quiet but comforting "cowboy up kiddo" meaning you've got to be tough. Yet she also has a soft side. Everyone of her horses is an extension of herself. She says her soul lives in each and every horse. This is palpable if your are forunate enough to be in her presence. On our way to lessons today. we passed by a cemetary in which a crane was lowering a vault into the ground. I slowed the truck and said out loud "how sad" Julia replied "what daddy, what is sad?" someone died I replied, and they will soon be buried, that is what is happening. "Oh, were they sick?" I said I didn't know. she said yes daddy that is sad, are you going to tell mommy? Sure, baby, I will I replied.
I pulled into the stable which is usually hustling and bustling with cars pulling in and out yet today was unusually quiet. One of the stable hands was standing outside the barn, a long look about her face. Carla was 15 or 16, a regular around the stable and a tough girl in her own right. As I approched, she looked at us foreloarnly and said very quietly "Little man is not so good, Connie is with him, we're waiting for the vet." From the look in her yeyes, I knew what was happening. Connie emerged from little man's stall when she heard us. She was different today. Gone was the rugged exterior, brown, wrinkled and dusted, her face was wrought with sadness. Underneath the facade was her raw emotion. Little man, a dwarf horse was 36 years old. A horse's life expectancy is about forty years. Little man was primarily the childs horse. On any given day little man hauled the excited little bodies of toddlers and preschool children arounf the arena probably thousands of times. He had a gentle disposition. He was a calm and confident horse; he was a horse you could put your child on without fear. He also served as a companion to the hundreds of horses that were temporary visitors to the barn, a stable mate that would take the fear of the unknown from a horse about to be sold or moved from the environment from which it had been accustomed to. Horses are no different from humans, they don't like change at all. He was the senior of the corral. Connie had little man his whole life. He was born a colt into her arms 36 years prior, and now he lay in her arms panting and seizing. A constant unending seizure. It was likely due to a tumor growing inside his head. Connie had seen the changes over the past several weeks. His eating slowed down, he seemed to constantly want to be left alone. A far cry from social creature this animal had been his whole life. Connie said yesterday he tried to get out of the corral several times, likely wanting to go off and die alone as so often animals do.
I will never forget David Angel. His last name was so appropriate. Angel. A messenger from the heavens sent to reveal my destiny, my life's work. I had cared for David for almost six months now. David was a hospice patient; I his home health aide. It was a position I had to take a two week class to become certified to do. Not much to the job. Mostle assisting clients with personal grooming, a blood pressure here or there, but mostly to assist the family so that they could go about living and continue whatever lifes work they had to do. His family was kind. His daughter, Angelique was an intenist working in a local urgent medical care, her husband a forensic psychiatrist at the local state psychiatric hospital. His wife was ever present and scrutinizing my every touch with him. Whether I was helping him wash his face and hands after eating, wiping his bottom following a bowel movement or checking his blood sugar and giving him insulin. This was something I was not supposed to do. His daughter however, upon learning of my intentions to attend nursing school and then possibly medical school took me under her wing and taught me of what was to come. We would have a lesson each day I would come. She helped me to understand a bit more of what was happening to her father. David had severe Alzheimer's Disease. A disease I would later revisit as my first nursing assignement after graduation two years later. Alzheimer's Disease is chronic dementing disase. Which means it robs a person of their higher mental faculties and eventually their physical faculties. There are many theories on what causes it from environmental, to genetic. It can only be diagnosed through post mortem autopsy. The cranial vault is cracked open and what appears to cover the outer covering of the brain, also called the meninges is a moss like substance known as Beta amyloid plaque. It is distinctly identified from microscopic examination. They appear as tiny barbed wire fibrous tangles of sewing thread that distribute all through the cerebral cortex. A person loses their orientation, ability to calculate and comprehend, they lose their ability to identify first simple objects and then- loved ones. They have virtually no short-term memory. It is not uncommon to hear stories from local policemen finding these people wandering, naked sometimes in the dead of winter outside on the street. They know not what they are doing. Eventually they forget to eat, to walk, they become wheelchair or bed bound, have to be fed by hand or through a tube, and eventually die from complications due to immobility. Pneumonia and bloodclot to the lung are usually what ultimately sets these poor souls free. The burden of this disease is on the son's and daughters they no longer recognize and strike out against in fear as they feel the loss of control over their environment. The wives they no longer recognize, the faceless grandchildren they once held in their arms. If you find yourself caring for someone with this disease however there are moments of revelation, or clarity; even in their most severely demented states where they have lost their ability to talk or communicate. You see, their long term memory is somewhat preserved. While they are still verbal they will sometimes act out times of their lives with stunning detail. I have had family members say they have learned answers to questions about previous events that have long remained a mystery only to be blurted out so spontaneously and serendipitously by this person who has not spoken in several years. We called them moments of clarity and if you were fortunate enough to be present for them you gained a clearer understanding and appreciation for what their family members were going through. I have had dozens.
David had been nonverbal and bed bound since I met him. I knew of his life only through the stories shared by his wife, daughter and son in law. I remember the day I got the call from his daughter. "Dad is not well, Mom is not well, I can't deal with this, you have got to get over here." Almost within minutes of her call, the hospice nurse had called to tell me that she was putting him on 24 hour care, which meant that his death was likely iminent. This is when the family needed the most support. The dying person would be going through changes, or "stages" as I have later learned from my wife, herself a distinguished and respected hospice nurse. The family needed to be guided through these changes, and be told of what to expect and to reassure them that there was no pain, nor suffering. It was time to say goodbye. I arrived at the Angels house in the late evening. Although I had seen David almost welve hours earlier, he looked much different. His cheeks were sunken and hung from his face like drapes. His mouth hung half open, his lips crusted with secretions, his eyelids half open revealed cloudy almost opaque eyes that did not track, or move as they often did when he was at least awake. His breathing was quite rapid and shallow, his skin below his chest was ice cold and almost wet. The bottoms of his legs took on an almost marbling appearance, which I later learned was the result of the shutdown of the circulatory system. I had never been with a dying patient, nor did I know how to "help" a dying patient, and was uncertain of my role, Yet instinctively I maintained my composure and assumed the role of his final caregiver. Stella, his wife, had told me her daughter had said her goodbyes and felt things would move along quicker if she wasn't there. His wife also felt this to be the case, but could not leave him to die alone. He would be left to die with me. I stood in the corner of the room and watched as she sweetly leaned over him to whisper in his ear. What she said I could not tell you. After a few moments she very gently kissed him on the forehead and laid a single finger to his lips almost shushing him. She turned gazing at the floor and walked out of the room. Before she left she grabbed my arm very tightly and said "you will stay to the end" With that she left. I stayed in the corner of the room for several minutes putting the picture together trying to figure out what to do. I was scared and nervous. Yet I was not saddened. David was about to be freed from his earthly prison of a body. I took a towel from his bedside and wet it with some cold water. I gently washed his forehead, his face, his neck. I used a swabstick to get all of the crust from the corners of his mouth. I placed a cold towel behind his neck. I washed his arms, his legs, his genitalia, turned him to make sure there were no feces. Then I sat. I held his cold lifeless hand in mine and started to talk about the day, the news, the weather, what I was studying in school. I then thanked him for allowing me to in someway be a part of him and his families life. I told him about how his daughter was "tutoring" me in medicine. remarked about how Stella's Matzoh ball soup was "stellar" with a bit of a laugh, and other topics of interest. I don't quite remeber exactly how long I talked for but I suddenly stopped. His breathing was starting to change. His breaths were becoming more and more shallow, almost like he was gasping and fighting for every breath until eventually none came. Unblinking I watched his face. There was no breath. I felt for a pulse in his wrist, there was none. His eyes remained half open. I gently used the pads of my index finger to close his lids over his eyes and held them for about a minute. Again there was no breath. Goodbye my jewish friend, godspeed, were the last words I said to him before I called the hospice nurse. His wife held vigil in another room, I called her in. I expected wailing, I expected inconsollable grief, shrieking, crying, from the woman who had shared her bed with him for the last 56 years. She walked in calmly, looked at him and said "he is at peace now" "He suffers no more" I moved away from the bed so that she could get closer, nad when I was about six or eight from the bed I could see the look on his face. It was a half smile. Very comforting to look at. David had died on his own terms. The way he wanted it. Somehow I facilitated this. I felt as though I had orchestrated this final act in his life. I don't know whether or not this has been said before, but I believed from then on that there was no moment more meaningful in life than that of being present and as a source of comfort to a person who lies taking their final breaths. It was a priveledge, an honor- I heard my calling.
Julia had wanted to say goodbye to littleman. Like probably hundreds of other kids before her, her connection with littleman was that he was the first horse she had ridden on at just two years of age barely able to walk. She didn't remember it, but she saw pictures and watched video later that afternoon of her "early" equestrian days. Connie didn't think it was such a great idea, she was probably right, this was not a peaceful and serene scene. Littleman was laying on his side, his lips drawn up showing his teeth panting, seizing every minute or two his hind and fore quarters tremoring violently. This horse was visibly suffering. Connie was probably ready to get a pistol out and finish the deed herself if it were not for the presence of others. He only seemed to calm somewhat when connie laid her hands on his head. I heard her mumbling under her breath "where is that goddamn vet!" Julia was at the other end of the barn. Intrusively I asked Connie, I think she'll be okay, can Julia say goodbye?" "Are you sure you want her to see this?" she returned. "I think she needs to do this." was my retort. She nodded. I called Julia, before she got to the stall I explained again to her that littleman was sick and will die today. I told that he did not look like the horse she had romped with over the past year or so, I explained what was happening and that it might frighten her, she continued to insist, I could not stand in her way. Though five years old in age, her soul is old and understanding. She crept very slowly around the corner if the stall and peeked her head around the side like a child walking through a haunted hause attraction knowing a scare was coming trying to anticipate from which direction it would come. Then she completely moved herself in full view of littleman. She was silent and not fearful as she watched connie tried to comfort littleman. I knelt down beside her and whispered in her ear "Say goodbye honey" She said nothing. "I held her hand tightly and nudged her to leave and saw a tear forming in the corner of her eye and she very sweetly and very quitely said "goodby littleman, have a good ride"; she turned and walked away. As we were leaving I saw the vet pull up in the dusty pick up truck, she quickly got out with two syringes in her hand, one crossways in her mouth, she moved quickly past us towards the stall. One syringe contained a lethal dose of a phenobarbital, a benzodiazepan, that would stop the seizures and render unconsciousness. The second most likely pancuronium, an agent that would paralyze all the muscles in his body including his diaphragm that acts as a bellows for breathing. The third most likely potassium chloride, this would stop littlemans heart if the phenobarbital didn't already. By then Littleman would be gone. Julia was done saying goodbye.
She is becoming quite adept at horseback riding. She rides western style and is taught by a stought old-school original who goes by the name of connie, she owns coyote ridge, the stable where she rides. Connie has a keen insight on nature and is more at home surrounded by horses than of her own family, who are very much like her. She is a tough woman. She has been thrown, kicked and stomped more times than she cares to think about and her body shows these signs through her severe arthritis. Her face is aged with weather and sun, you can tell she is a woman of the outdoors. If Julia twists her ankle, or burns her hands on the reigns, or otherwise hurts herself, Connies response is usually a quiet but comforting "cowboy up kiddo" meaning you've got to be tough. Yet she also has a soft side. Everyone of her horses is an extension of herself. She says her soul lives in each and every horse. This is palpable if your are forunate enough to be in her presence. On our way to lessons today. we passed by a cemetary in which a crane was lowering a vault into the ground. I slowed the truck and said out loud "how sad" Julia replied "what daddy, what is sad?" someone died I replied, and they will soon be buried, that is what is happening. "Oh, were they sick?" I said I didn't know. she said yes daddy that is sad, are you going to tell mommy? Sure, baby, I will I replied.
I pulled into the stable which is usually hustling and bustling with cars pulling in and out yet today was unusually quiet. One of the stable hands was standing outside the barn, a long look about her face. Carla was 15 or 16, a regular around the stable and a tough girl in her own right. As I approched, she looked at us foreloarnly and said very quietly "Little man is not so good, Connie is with him, we're waiting for the vet." From the look in her yeyes, I knew what was happening. Connie emerged from little man's stall when she heard us. She was different today. Gone was the rugged exterior, brown, wrinkled and dusted, her face was wrought with sadness. Underneath the facade was her raw emotion. Little man, a dwarf horse was 36 years old. A horse's life expectancy is about forty years. Little man was primarily the childs horse. On any given day little man hauled the excited little bodies of toddlers and preschool children arounf the arena probably thousands of times. He had a gentle disposition. He was a calm and confident horse; he was a horse you could put your child on without fear. He also served as a companion to the hundreds of horses that were temporary visitors to the barn, a stable mate that would take the fear of the unknown from a horse about to be sold or moved from the environment from which it had been accustomed to. Horses are no different from humans, they don't like change at all. He was the senior of the corral. Connie had little man his whole life. He was born a colt into her arms 36 years prior, and now he lay in her arms panting and seizing. A constant unending seizure. It was likely due to a tumor growing inside his head. Connie had seen the changes over the past several weeks. His eating slowed down, he seemed to constantly want to be left alone. A far cry from social creature this animal had been his whole life. Connie said yesterday he tried to get out of the corral several times, likely wanting to go off and die alone as so often animals do.
I will never forget David Angel. His last name was so appropriate. Angel. A messenger from the heavens sent to reveal my destiny, my life's work. I had cared for David for almost six months now. David was a hospice patient; I his home health aide. It was a position I had to take a two week class to become certified to do. Not much to the job. Mostle assisting clients with personal grooming, a blood pressure here or there, but mostly to assist the family so that they could go about living and continue whatever lifes work they had to do. His family was kind. His daughter, Angelique was an intenist working in a local urgent medical care, her husband a forensic psychiatrist at the local state psychiatric hospital. His wife was ever present and scrutinizing my every touch with him. Whether I was helping him wash his face and hands after eating, wiping his bottom following a bowel movement or checking his blood sugar and giving him insulin. This was something I was not supposed to do. His daughter however, upon learning of my intentions to attend nursing school and then possibly medical school took me under her wing and taught me of what was to come. We would have a lesson each day I would come. She helped me to understand a bit more of what was happening to her father. David had severe Alzheimer's Disease. A disease I would later revisit as my first nursing assignement after graduation two years later. Alzheimer's Disease is chronic dementing disase. Which means it robs a person of their higher mental faculties and eventually their physical faculties. There are many theories on what causes it from environmental, to genetic. It can only be diagnosed through post mortem autopsy. The cranial vault is cracked open and what appears to cover the outer covering of the brain, also called the meninges is a moss like substance known as Beta amyloid plaque. It is distinctly identified from microscopic examination. They appear as tiny barbed wire fibrous tangles of sewing thread that distribute all through the cerebral cortex. A person loses their orientation, ability to calculate and comprehend, they lose their ability to identify first simple objects and then- loved ones. They have virtually no short-term memory. It is not uncommon to hear stories from local policemen finding these people wandering, naked sometimes in the dead of winter outside on the street. They know not what they are doing. Eventually they forget to eat, to walk, they become wheelchair or bed bound, have to be fed by hand or through a tube, and eventually die from complications due to immobility. Pneumonia and bloodclot to the lung are usually what ultimately sets these poor souls free. The burden of this disease is on the son's and daughters they no longer recognize and strike out against in fear as they feel the loss of control over their environment. The wives they no longer recognize, the faceless grandchildren they once held in their arms. If you find yourself caring for someone with this disease however there are moments of revelation, or clarity; even in their most severely demented states where they have lost their ability to talk or communicate. You see, their long term memory is somewhat preserved. While they are still verbal they will sometimes act out times of their lives with stunning detail. I have had family members say they have learned answers to questions about previous events that have long remained a mystery only to be blurted out so spontaneously and serendipitously by this person who has not spoken in several years. We called them moments of clarity and if you were fortunate enough to be present for them you gained a clearer understanding and appreciation for what their family members were going through. I have had dozens.
David had been nonverbal and bed bound since I met him. I knew of his life only through the stories shared by his wife, daughter and son in law. I remember the day I got the call from his daughter. "Dad is not well, Mom is not well, I can't deal with this, you have got to get over here." Almost within minutes of her call, the hospice nurse had called to tell me that she was putting him on 24 hour care, which meant that his death was likely iminent. This is when the family needed the most support. The dying person would be going through changes, or "stages" as I have later learned from my wife, herself a distinguished and respected hospice nurse. The family needed to be guided through these changes, and be told of what to expect and to reassure them that there was no pain, nor suffering. It was time to say goodbye. I arrived at the Angels house in the late evening. Although I had seen David almost welve hours earlier, he looked much different. His cheeks were sunken and hung from his face like drapes. His mouth hung half open, his lips crusted with secretions, his eyelids half open revealed cloudy almost opaque eyes that did not track, or move as they often did when he was at least awake. His breathing was quite rapid and shallow, his skin below his chest was ice cold and almost wet. The bottoms of his legs took on an almost marbling appearance, which I later learned was the result of the shutdown of the circulatory system. I had never been with a dying patient, nor did I know how to "help" a dying patient, and was uncertain of my role, Yet instinctively I maintained my composure and assumed the role of his final caregiver. Stella, his wife, had told me her daughter had said her goodbyes and felt things would move along quicker if she wasn't there. His wife also felt this to be the case, but could not leave him to die alone. He would be left to die with me. I stood in the corner of the room and watched as she sweetly leaned over him to whisper in his ear. What she said I could not tell you. After a few moments she very gently kissed him on the forehead and laid a single finger to his lips almost shushing him. She turned gazing at the floor and walked out of the room. Before she left she grabbed my arm very tightly and said "you will stay to the end" With that she left. I stayed in the corner of the room for several minutes putting the picture together trying to figure out what to do. I was scared and nervous. Yet I was not saddened. David was about to be freed from his earthly prison of a body. I took a towel from his bedside and wet it with some cold water. I gently washed his forehead, his face, his neck. I used a swabstick to get all of the crust from the corners of his mouth. I placed a cold towel behind his neck. I washed his arms, his legs, his genitalia, turned him to make sure there were no feces. Then I sat. I held his cold lifeless hand in mine and started to talk about the day, the news, the weather, what I was studying in school. I then thanked him for allowing me to in someway be a part of him and his families life. I told him about how his daughter was "tutoring" me in medicine. remarked about how Stella's Matzoh ball soup was "stellar" with a bit of a laugh, and other topics of interest. I don't quite remeber exactly how long I talked for but I suddenly stopped. His breathing was starting to change. His breaths were becoming more and more shallow, almost like he was gasping and fighting for every breath until eventually none came. Unblinking I watched his face. There was no breath. I felt for a pulse in his wrist, there was none. His eyes remained half open. I gently used the pads of my index finger to close his lids over his eyes and held them for about a minute. Again there was no breath. Goodbye my jewish friend, godspeed, were the last words I said to him before I called the hospice nurse. His wife held vigil in another room, I called her in. I expected wailing, I expected inconsollable grief, shrieking, crying, from the woman who had shared her bed with him for the last 56 years. She walked in calmly, looked at him and said "he is at peace now" "He suffers no more" I moved away from the bed so that she could get closer, nad when I was about six or eight from the bed I could see the look on his face. It was a half smile. Very comforting to look at. David had died on his own terms. The way he wanted it. Somehow I facilitated this. I felt as though I had orchestrated this final act in his life. I don't know whether or not this has been said before, but I believed from then on that there was no moment more meaningful in life than that of being present and as a source of comfort to a person who lies taking their final breaths. It was a priveledge, an honor- I heard my calling.
Julia had wanted to say goodbye to littleman. Like probably hundreds of other kids before her, her connection with littleman was that he was the first horse she had ridden on at just two years of age barely able to walk. She didn't remember it, but she saw pictures and watched video later that afternoon of her "early" equestrian days. Connie didn't think it was such a great idea, she was probably right, this was not a peaceful and serene scene. Littleman was laying on his side, his lips drawn up showing his teeth panting, seizing every minute or two his hind and fore quarters tremoring violently. This horse was visibly suffering. Connie was probably ready to get a pistol out and finish the deed herself if it were not for the presence of others. He only seemed to calm somewhat when connie laid her hands on his head. I heard her mumbling under her breath "where is that goddamn vet!" Julia was at the other end of the barn. Intrusively I asked Connie, I think she'll be okay, can Julia say goodbye?" "Are you sure you want her to see this?" she returned. "I think she needs to do this." was my retort. She nodded. I called Julia, before she got to the stall I explained again to her that littleman was sick and will die today. I told that he did not look like the horse she had romped with over the past year or so, I explained what was happening and that it might frighten her, she continued to insist, I could not stand in her way. Though five years old in age, her soul is old and understanding. She crept very slowly around the corner if the stall and peeked her head around the side like a child walking through a haunted hause attraction knowing a scare was coming trying to anticipate from which direction it would come. Then she completely moved herself in full view of littleman. She was silent and not fearful as she watched connie tried to comfort littleman. I knelt down beside her and whispered in her ear "Say goodbye honey" She said nothing. "I held her hand tightly and nudged her to leave and saw a tear forming in the corner of her eye and she very sweetly and very quitely said "goodby littleman, have a good ride"; she turned and walked away. As we were leaving I saw the vet pull up in the dusty pick up truck, she quickly got out with two syringes in her hand, one crossways in her mouth, she moved quickly past us towards the stall. One syringe contained a lethal dose of a phenobarbital, a benzodiazepan, that would stop the seizures and render unconsciousness. The second most likely pancuronium, an agent that would paralyze all the muscles in his body including his diaphragm that acts as a bellows for breathing. The third most likely potassium chloride, this would stop littlemans heart if the phenobarbital didn't already. By then Littleman would be gone. Julia was done saying goodbye.
Friday, September 24, 2010
Hindsight is 20/40
July 9, 1980 is a day that though I didn't understand then, I understand now was a defining moment in my life. I do not remember much of the later 70's, bits and pieces come to me here and there, but for the most part I see faded faces, muffled voices. I cannot see who is talking, nor can I understand what it is they are saying. I do remember standing in line outside of the matamoras theater, waiting with my two sisters to get tickets to go see The Empire Strikes Back, George Lucas sequel then, prequel now to the original star wars released five years earlier, which to this day I might add, can recite most of the lines start to finish for most of the characters. Yet I am still unclear of how I got into that line, who drove, what we talked about on the way. I know we left from my Aunt Esther's house. I remember seeing my mother approach, and I remember her almost whimsical face, attempting strength and composure, I don't remember sadness though, I remember relief was her overall tone. I remember her holding onto me tight like a mother would hold onto her child preventing a fall from a height that would cause certain death. She whispered softly into my ear, "it's over, he's gone" referrring to the death of my father. I rememeber the wailing of my sisiters, and the feel of wet skin wrought with tears as her cheek pressed against mine. Fast forward thirty years later- Mr. G, a fairly healthy seventy year old man and patient of mine for my first five years of practice sat quietly next to me in my office, we had just completed his annual physical. His hands nervously folded and unfolded the New York Times crossword puzzle of which he was an avid and vocal fan. I'm sure it also helped to pass the time while he waited in my waiting room. His only complaint this year was that of a month or so of diffculty swallowing liquids and soft food, and that occasionally if his head was turned in just such a way, that he would have pain when swallowing. No weight loss. He never smoked or drank a day in his life. I jokingly asked him what he did for fun. "chased women" He wryly replied giving his second wife sitting across from him a half wink. He was a widower ten years prior, his wife tragically killed in an automobile accident. This was his second wife.
I often wonder if my father's medical record could be found anywhere. There hasn't been much advancement in the treatment of esophageal cancer, but there are signs. Thanks to an Australian physician approximayely fifteen years ago, we leard that GERD or gastroesophagel reflux disease is a condition that is not caused as was previously believed to be the case by excessive acid secretion from the proton pumps of the stomacg, but rather by a bacteria that caused inflammation and weakening of the stomach wall. An acididophilic, thermophilic beast that thrived in the harshest conditions of the acid filled hot environment of the stomach. Tums was no match for this guy. We learned it would take antibiotics. It is discovered fairly easily through the use of routine endoscopy, a procedure that has been done for decades. A biopsy is taken from the stomach and grown in a petri dish. If the symptoms persist, and are not treated appropriately, the cells that line the farthest end of the esophagus (the tube leading from mouth to stomach) will begin to change into pre-cancerous cells which we call Barretts Esophagus. By this time one would have daily quite severe symptoms of heartburn, one often mistakes the severe pain of heartburn for that of a heart attack. Belching, passing gas, chest pain and pressure, these symptoms would most certainly be waking one up at night at least several times per week. If the disease is not found at this point it will progress to fulminant esophageal cancer, an adenocarcinoma. This diagnosis yielded a prognosis of less than 3 months thirty years ago; today...3-6 months.
I was concerned about Mr. G- I referred to my local gastroenterologist who as expected performed a routine upper endoscopy- as expected he biopsied a suspicious looking inflamed bulging area in the lower two thirds of his esophagus, 1 week later I received the pathology report. Esophageal Adenocarcinoma was confirmed. I had my receptionist call him for an office visit immediately. Again, he sat nervously next to me in my exam room. I flipped through a few pages and came to his report. There would be no dancing. Mr. G was not a dancer. He was a no nonsense man who liked the truth no matter how jagged it was. I looked him square in the eye and said Mr. G we have a problem. You have cancer. It is in your throat. Silence. He nor his wife appeared not that surprised. There was no weeping. There was no self-pity, there was no "why me?" He stoicly gazed back at me and said what now? What do I do? How long do I have? I told him that only the good lord above was privy to that information, but did hint that this was a particularly aggressive cancer. I gave him the choice of fight or flight. He chose to roll up his sleaves.
A whole body scan revealed no evidence of metastasis. Several axillary (arm pit) and mediastinal (chest wall) lymph nodes were negative for disease as well we had a good shot at surgical resection for a cure. That is exactly what we did. Further pathology showed the 2.5 inch tumor had grown into the 2nd layer of his esophageal wall and that he cells of the tumor were "poorly differntiated" which means that there was no discernable organization to the different parts of the cell. No nucleus, no ribosomes, etc. T2N0. A poorer prognosis, nonetheless, Mr. G had almost 1/2 of his esophagus removed, the surgeon reported good margins. 3 rounds of taxotere, 5fu and cisplatin, and although bald, nauseous and with burning feet, 4 years later Mr. G is alive with no evidence of recurrence of his cancer. He met his grandchildren, two sons and daughter in florida later that month to celebrate his yearly birthday. He was no longer 72. He was 5. Five years survival past diagnosis. Neither his oncologist nor surgeon could explain.
Because Medicine is practiced by humans it is subject to the imperfections of those humans that practice it as a craft. There are good practitioners and bad ones. Some will miss the subtle symptoms, some will reognize them and make the diagnosis. I often wonder what kind of doctor cared for my father. Did he miss subtle symptoms, or did my father seek care too late. It was a differnt time then. It matters not to his sapponified body that lays six feet under the grass of a cemetary in Port Jervis, NY.
I often wonder if my father's medical record could be found anywhere. There hasn't been much advancement in the treatment of esophageal cancer, but there are signs. Thanks to an Australian physician approximayely fifteen years ago, we leard that GERD or gastroesophagel reflux disease is a condition that is not caused as was previously believed to be the case by excessive acid secretion from the proton pumps of the stomacg, but rather by a bacteria that caused inflammation and weakening of the stomach wall. An acididophilic, thermophilic beast that thrived in the harshest conditions of the acid filled hot environment of the stomach. Tums was no match for this guy. We learned it would take antibiotics. It is discovered fairly easily through the use of routine endoscopy, a procedure that has been done for decades. A biopsy is taken from the stomach and grown in a petri dish. If the symptoms persist, and are not treated appropriately, the cells that line the farthest end of the esophagus (the tube leading from mouth to stomach) will begin to change into pre-cancerous cells which we call Barretts Esophagus. By this time one would have daily quite severe symptoms of heartburn, one often mistakes the severe pain of heartburn for that of a heart attack. Belching, passing gas, chest pain and pressure, these symptoms would most certainly be waking one up at night at least several times per week. If the disease is not found at this point it will progress to fulminant esophageal cancer, an adenocarcinoma. This diagnosis yielded a prognosis of less than 3 months thirty years ago; today...3-6 months.
I was concerned about Mr. G- I referred to my local gastroenterologist who as expected performed a routine upper endoscopy- as expected he biopsied a suspicious looking inflamed bulging area in the lower two thirds of his esophagus, 1 week later I received the pathology report. Esophageal Adenocarcinoma was confirmed. I had my receptionist call him for an office visit immediately. Again, he sat nervously next to me in my exam room. I flipped through a few pages and came to his report. There would be no dancing. Mr. G was not a dancer. He was a no nonsense man who liked the truth no matter how jagged it was. I looked him square in the eye and said Mr. G we have a problem. You have cancer. It is in your throat. Silence. He nor his wife appeared not that surprised. There was no weeping. There was no self-pity, there was no "why me?" He stoicly gazed back at me and said what now? What do I do? How long do I have? I told him that only the good lord above was privy to that information, but did hint that this was a particularly aggressive cancer. I gave him the choice of fight or flight. He chose to roll up his sleaves.
A whole body scan revealed no evidence of metastasis. Several axillary (arm pit) and mediastinal (chest wall) lymph nodes were negative for disease as well we had a good shot at surgical resection for a cure. That is exactly what we did. Further pathology showed the 2.5 inch tumor had grown into the 2nd layer of his esophageal wall and that he cells of the tumor were "poorly differntiated" which means that there was no discernable organization to the different parts of the cell. No nucleus, no ribosomes, etc. T2N0. A poorer prognosis, nonetheless, Mr. G had almost 1/2 of his esophagus removed, the surgeon reported good margins. 3 rounds of taxotere, 5fu and cisplatin, and although bald, nauseous and with burning feet, 4 years later Mr. G is alive with no evidence of recurrence of his cancer. He met his grandchildren, two sons and daughter in florida later that month to celebrate his yearly birthday. He was no longer 72. He was 5. Five years survival past diagnosis. Neither his oncologist nor surgeon could explain.
Because Medicine is practiced by humans it is subject to the imperfections of those humans that practice it as a craft. There are good practitioners and bad ones. Some will miss the subtle symptoms, some will reognize them and make the diagnosis. I often wonder what kind of doctor cared for my father. Did he miss subtle symptoms, or did my father seek care too late. It was a differnt time then. It matters not to his sapponified body that lays six feet under the grass of a cemetary in Port Jervis, NY.
Sunday, September 19, 2010
A time long gone
People inherently ask me all the time why I do what I do. From patients to family members, residents, other colleagues. My answer almost invariably I didn't choose this. This chose me. The hours are not great-24 hrs/day. Including on call. The benefits- I have none, not exacly, some, but no golden parachute, I promise you this. The pay, considering the amount of time I went to school, figure in student loans, malpractice, 60-80 hrs per week, suddenly the pay is not that good. What is it that keeps me coming to the office on a daily basis? I can't explain it, but it starts I'm sure in a time long gone.
My father was 50 when I was conceived. Talk about muscle-bound sperm :). had he been alive today he would be 90. I do have 90 year old patients, they are not in short supply. One of the benefits of modern medical technology is that we live longer. I am most proud of an 89 year old patient, lets call her Sophie. What is interesting about sophie, is that I also cared for her mother who died peacefully at the ripe age of 109. She may have been my toughest customer. I also took care of her son, her 3 daughters, their 2 childrens, some cousins, neices and nephews as well. I knew where they all went on vacations, who got into college, who got married, who got divorced, who died, etc. She died peacedully surrounded by her family on a spring morning, which is exactly the way she wanted it. I digress.
Medicine today is very industrial. There is no shortage super groups that will scoop you up and take you as their patient and offer you 1 stop shopping for all your primary and sub-specialty needs. Got a cold, we've got an ENT for that. Stomachage? We've got a GI guy for that! Need your x-rays, ct scans and mammograms done too? We've got a full service radiology suite from routine radiography all the way up to state of the art 64 slice ct scanners that can actualy map coronary artery disease in your heart fairly accurately assuming that your heart rate is below 55 beats per minute. However there is a catch. I have gotten these people in my practice. They come to me very distrustful, almost jaded, feeling like they have been violated in some way. These people are moved through these practices like cattle. The days of fee for service are long gone and now we must muddle through the maze of managed care in order to receive payment that THEY deem as appropriate for the care that has been rendered. It is a complicated process that requires a sequence of diagnosis codes to match procedure codes that must be submitted in the proper format as dictated in their terms and conditions contract that we sign after we jump through all of the hoops of their credentialing process which typically takes in upwords of six months. I am not enthralled with the whole process. This us todays medicine.
Being conceived at 50 by my father however, I believe planted a gene in me, perhaps a mutation, that takes me back to those times. The times when doctors make house calls, which I do if needed. A time when you took the amount of time you needed to spend with a patient not distracted by a double booked schedule that will allow you to pay your bills and not take a salary. I frequently find myself running behind, sometimes by as much as an hour or two at times. Most patients are not too upset by this because they know that when they're time comes and they need extra time with me they will not be ushered out the door for the next patient to keep time. I also genuinely like to take the time to know my patients, not just their medical history, the medications they take or are allergic to. I want to know where they work, are they married, children, interests, hobbies, etc. That makes the peron whole. We do not treat lungs, we treat the PATIENTS lungs. We do not treat the heart. Wet treat the PATIENTS heart. The patient is the sum total of all these characteristics, and I find it helps me offer them a better standard of care. I also sit WITH patients, not across from them. I do not wear an imposing white coat. Hugs do not require co-pays. I come off as human as possible. After all, nurse practitioner and patient are equal. We are both humans, we share a similar gene sequence. We eat the same foods. We both go to the bathroom. We have children and families, we live in the same community. I am as human as they. So often is this lost. It happened in a time long gone.
My father was 50 when I was conceived. Talk about muscle-bound sperm :). had he been alive today he would be 90. I do have 90 year old patients, they are not in short supply. One of the benefits of modern medical technology is that we live longer. I am most proud of an 89 year old patient, lets call her Sophie. What is interesting about sophie, is that I also cared for her mother who died peacefully at the ripe age of 109. She may have been my toughest customer. I also took care of her son, her 3 daughters, their 2 childrens, some cousins, neices and nephews as well. I knew where they all went on vacations, who got into college, who got married, who got divorced, who died, etc. She died peacedully surrounded by her family on a spring morning, which is exactly the way she wanted it. I digress.
Medicine today is very industrial. There is no shortage super groups that will scoop you up and take you as their patient and offer you 1 stop shopping for all your primary and sub-specialty needs. Got a cold, we've got an ENT for that. Stomachage? We've got a GI guy for that! Need your x-rays, ct scans and mammograms done too? We've got a full service radiology suite from routine radiography all the way up to state of the art 64 slice ct scanners that can actualy map coronary artery disease in your heart fairly accurately assuming that your heart rate is below 55 beats per minute. However there is a catch. I have gotten these people in my practice. They come to me very distrustful, almost jaded, feeling like they have been violated in some way. These people are moved through these practices like cattle. The days of fee for service are long gone and now we must muddle through the maze of managed care in order to receive payment that THEY deem as appropriate for the care that has been rendered. It is a complicated process that requires a sequence of diagnosis codes to match procedure codes that must be submitted in the proper format as dictated in their terms and conditions contract that we sign after we jump through all of the hoops of their credentialing process which typically takes in upwords of six months. I am not enthralled with the whole process. This us todays medicine.
Being conceived at 50 by my father however, I believe planted a gene in me, perhaps a mutation, that takes me back to those times. The times when doctors make house calls, which I do if needed. A time when you took the amount of time you needed to spend with a patient not distracted by a double booked schedule that will allow you to pay your bills and not take a salary. I frequently find myself running behind, sometimes by as much as an hour or two at times. Most patients are not too upset by this because they know that when they're time comes and they need extra time with me they will not be ushered out the door for the next patient to keep time. I also genuinely like to take the time to know my patients, not just their medical history, the medications they take or are allergic to. I want to know where they work, are they married, children, interests, hobbies, etc. That makes the peron whole. We do not treat lungs, we treat the PATIENTS lungs. We do not treat the heart. Wet treat the PATIENTS heart. The patient is the sum total of all these characteristics, and I find it helps me offer them a better standard of care. I also sit WITH patients, not across from them. I do not wear an imposing white coat. Hugs do not require co-pays. I come off as human as possible. After all, nurse practitioner and patient are equal. We are both humans, we share a similar gene sequence. We eat the same foods. We both go to the bathroom. We have children and families, we live in the same community. I am as human as they. So often is this lost. It happened in a time long gone.
Genuine
I genuinely care about people and am quite interested in them. Patterns of socialization and family dynamics are fascinating. Sometimes I see myself in a sort of "priestly" position, sitting on the other side of the confessional where people reveal their deepest, darkest and most personal secrets as they seek atonement. I am humbled by others trust in me to share this information. There are of course confidentiality laws that I strictly abide by and at no point in this blog will actual names, or specific enough clinical cases that name names by proxy ever be used. I may from time to time ask patients if I may write about their particular encounter of course changing names. Some will not mind at all I imagine. Some might be offended imagine too. I haven't asked yet. But I will.
I see myself not as a nurse practitioner, but more a student of life. Though 39 in age, I have learned much from those I encounter on a daily basis. It is a recipe in progress. I see people at their best and worst. I have witnessed family members fight over money as they sit bedside with their "loved one" taking dying breaths. I have witnessed a wife whisper into her dying husbands ear -"you deserve this you bastard", I have placed a three year old onto the chest of her dying mother, because her father was too wrought with grief and lacked the strength to do so. I have also seen my fair share of "odds-beaters" people who should otherwise be dead but clinging to life with a strength that cannot be measured by pulse oximeters, or swan-ganz catheters. I have seen a pancreatic cancer spontaneously disappear, without explanation. I have seen motor vehicle accident victims with amputated arms and legs only to be reattached, and go onto walk out of the hospital, without the assistance of wheelchairs or crutches. This is not battlefield trauma grade stuff, though it is no less life altering. I part with these esperiences feeling enriched. I feel more whole, more human, yet I grow seemingly more puzzled. Sometimes numb. I genuinely feel some connection, be it almost always imexplicably to whosoever lives or dies in my hands. The bigger picture is that these are decisions I do not make. It is true that our technology has increased our life expectancy, and that as a result through medications, chemo, radiation, surgery, whatever, we stand better chances of living through certain clinical situations now as opposed to say thirty years ago. There is a bit of academia that goes into when to use this technology and how to use this technology, but why does it at times fail when it should succed and succeed when it should fail. Why is it attempted in the face of almost certain failure. Why is it not used when there is a clear clinical benefit. The is no genuine answer.
I see myself not as a nurse practitioner, but more a student of life. Though 39 in age, I have learned much from those I encounter on a daily basis. It is a recipe in progress. I see people at their best and worst. I have witnessed family members fight over money as they sit bedside with their "loved one" taking dying breaths. I have witnessed a wife whisper into her dying husbands ear -"you deserve this you bastard", I have placed a three year old onto the chest of her dying mother, because her father was too wrought with grief and lacked the strength to do so. I have also seen my fair share of "odds-beaters" people who should otherwise be dead but clinging to life with a strength that cannot be measured by pulse oximeters, or swan-ganz catheters. I have seen a pancreatic cancer spontaneously disappear, without explanation. I have seen motor vehicle accident victims with amputated arms and legs only to be reattached, and go onto walk out of the hospital, without the assistance of wheelchairs or crutches. This is not battlefield trauma grade stuff, though it is no less life altering. I part with these esperiences feeling enriched. I feel more whole, more human, yet I grow seemingly more puzzled. Sometimes numb. I genuinely feel some connection, be it almost always imexplicably to whosoever lives or dies in my hands. The bigger picture is that these are decisions I do not make. It is true that our technology has increased our life expectancy, and that as a result through medications, chemo, radiation, surgery, whatever, we stand better chances of living through certain clinical situations now as opposed to say thirty years ago. There is a bit of academia that goes into when to use this technology and how to use this technology, but why does it at times fail when it should succed and succeed when it should fail. Why is it attempted in the face of almost certain failure. Why is it not used when there is a clear clinical benefit. The is no genuine answer.
The beginning
My mother has always said I have a gift for writing. How many sons or daughters have been told by their parents that they are are "beautiful" or "gifted", or somehow or the other been lead to believe a half truth based on the good intentions of their parents who were looking at their children through rose colored glasses in the hopes of building up self-esteem. Seemingly well intentioned, sometimes accurate, but at some point for some people, there is a realization that maybe Mom wasn't right. I guess we'll let the readers decide. Anyway, for a nut and bolt to work, they have to be the same size. The threads have to be uniform; they have to have tensile strength. Then and only then will they be able to keep whatever it is they're holding together-together. After all (I know, I just started my sentence with a preposition) isn't that we all try to do every single day of our lives and with every breath we take? Keep it together? Well, sometimes it falls apart. We don't know when it starts or how it starts, but it starts somewhere. It starts small, usually so small that we overlook it. A series of events generally follows which leads to catastrophic failure.
My name is Sasha Gaer. I live in upstate New York with my wife and three children ranging in age from 2 years to 5 years; all girls. We live in a modest house in a modest neighborhood. My wife is a hospice nurse. I am a nurse practitioner, board certified in family health. I specialize in primary care, allergy related asthma and the treatment of obesity. This blog will serve as a sounding board for a task that was described by another physician as a vitally important task that can take an ordinary healthcare provider and make them an extra-ordinary healthcare provider. That is writing, or rather the catharsis of writing. As a nurse practitioner, it is all too easy to become entangled in the web of ordinariness. I mean, look at what I do on a daliy basis. I get to the office each morning, my receptionist hands me my schedule for the day. Coughs, colds, abdominal pain, headaches, chest pain, diarrhea, sore throat, diabetes and hypertension follow-ups, a few yearly physicals, lyme disease, routine lab follow-ups, etc. In between each office visit there seems to be a never ending line of pharmaceutical representatives all trying to jockey their drugs into my bag of tricks. There are phone calls from patients. " Mr. Y called and he says he has been having chest pain" or Mr. Z called, and said he has had abdominal pain and fevers for the last 48 hours. South four vassar hospital is on the line, they have their fourth consult for you, a patient in respiratory failure, severe asthma exacerbation. I have flu shots to give, B-12 injections to give. Pulmonary function tests to perform. EKG's to perform. I contend with our billing department daily to make sure all is well with our accounts receivables AKA managed care, office staff have complaints about patients, patients have complaints about office staff. It is almost interchangable with a day in any's life. Why do I feel compelled to wear my heart out on my bandwidth? (used to be heart on a sleeve) To be quite honest, I'm not sure. Not sure where this will exactly lead, but like my mother has been telling me to do for years, you have to pick up the pen and start somehere.
My name is Sasha Gaer. I live in upstate New York with my wife and three children ranging in age from 2 years to 5 years; all girls. We live in a modest house in a modest neighborhood. My wife is a hospice nurse. I am a nurse practitioner, board certified in family health. I specialize in primary care, allergy related asthma and the treatment of obesity. This blog will serve as a sounding board for a task that was described by another physician as a vitally important task that can take an ordinary healthcare provider and make them an extra-ordinary healthcare provider. That is writing, or rather the catharsis of writing. As a nurse practitioner, it is all too easy to become entangled in the web of ordinariness. I mean, look at what I do on a daliy basis. I get to the office each morning, my receptionist hands me my schedule for the day. Coughs, colds, abdominal pain, headaches, chest pain, diarrhea, sore throat, diabetes and hypertension follow-ups, a few yearly physicals, lyme disease, routine lab follow-ups, etc. In between each office visit there seems to be a never ending line of pharmaceutical representatives all trying to jockey their drugs into my bag of tricks. There are phone calls from patients. " Mr. Y called and he says he has been having chest pain" or Mr. Z called, and said he has had abdominal pain and fevers for the last 48 hours. South four vassar hospital is on the line, they have their fourth consult for you, a patient in respiratory failure, severe asthma exacerbation. I have flu shots to give, B-12 injections to give. Pulmonary function tests to perform. EKG's to perform. I contend with our billing department daily to make sure all is well with our accounts receivables AKA managed care, office staff have complaints about patients, patients have complaints about office staff. It is almost interchangable with a day in any's life. Why do I feel compelled to wear my heart out on my bandwidth? (used to be heart on a sleeve) To be quite honest, I'm not sure. Not sure where this will exactly lead, but like my mother has been telling me to do for years, you have to pick up the pen and start somehere.
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