Thursday, May 27, 2010

The patients that stood out to me today

The patients that stood out to me today were:

55 year old woman with no way to get into Parkland and 1) uncontrolled insulin-resistant diabetes, maxed on all the oral hypoglycemics we can give (metformin, glipizide, pioglitazone); 2) bipolar disorder controlled on olanzapine and fluoxetine; 3) hypertension managed with lisinopril; 4) hyperlipidemia marginally controlled on simvastatin; 5) OA, for which she takes ibuprofen; 6) and she’s also taking aspirin and multivitamins.

6 year old girl c/o 2 week history of red eyes with exudate and dry skin on her hand. As the encounter unfolded, she said she was crying every day, had headaches, and insomnia. Her father is in jail since February and it’s unclear when he may be reunited with his family. Photo: Nora and me

21 year old woman in NAD from Burma (Karen) c/o cough and feeling warm at night. The first thing I noticed was head lice, then a normal exam until her lungs, where I auscultated rhonchi in all fields – what!? Renee listened and found the same thing. So she walked in with a cough and out with pediculosis and community-acquired pneumonia, probably mycoplasma. I started her on a challenging regimen of clarithromycin, prednisone, albuterol, ibuprofen. Also permethrin for the pediculosis.

Mary saw a woman I’d seen 3 weeks ago. At the time she was in respiratory distress and I called 911. They declined to transport her to a hospital because she didn’t have any symptoms other than SOB (lungs clear, no fever, etc.). Nora took her to the Baylor ER, where she was admitted (for >week) with a pneumothorax.

We ask all patients, have you ever been physically or sexually abused? It’s not an uncommon question, but we take care in how we ask it, trying to create a space where people can say yes vs. just tossing it out and then on to the next question. And here I was in exam room 2, with Nora and a 32 year old woman who answered, “Yes.” She was raped when she was 18 and this was the first time she’s said anything about it. And so there we were and after I worked her up, left so that Nora could sit with her, listening, the woman crying, Nora talking in the soft connecting way she has. Paroxetine, regular visits, “You came to the right place.”

How long, how long must we sing this song, how long, how long?

Thursday, May 13, 2010

What I said at a graduation ceremony yesterday evening

Congratulations. To the graduates who worked so hard for this wonderful achievement – the FNPs and this, the first group of DNPs from Baylor – the first BSN to DNPs in the nation! Congratulations to the families of the graduates who supported them and sacrificed to help them. Congratulations to the faculty who taught and mentored the graduates. And congratulations to Dean Lott, Dr. Brucker, Dr. Faucher, Mrs. Kurfees and everyone else involved for creating the DNP program. What a great day this is. Photo: One of the DNP graduates when she was an undergrad - outreach in the community garden

What great opportunities lie ahead for all of you.

You/We have the great opportunity to heal the sick. Like anyone else, we can (and should) be kind and gentle. Like anyone else we can pray for and with others. Like anyone else we can support and contribute to the efforts of people working to heal the sick. But in our case we also touch people physically – with kindness and gentleness. We can often heal the body, and even play a part in the healing of the spirit.

I’m still just overwhelmed by this – by this daily contact with the suffering and need and hope of the world. And it seems such a privilege, such a wonderful thing to talk with a person, examine that person, and then understand what is the problem, why it occurred, and best of all, what to do to manage or heal the problem – and then do it! I well remember the first person whose illness I cured. She was about 50 years old and looked about 60 – a person who’d had a hard life. She had been treated as an outpatient at a major medical center for pneumonia, but the treatment was unsuccessful. I gave her clarithromycin and it worked! We were both very happy.
And so we do countless variations on this – people with diabetes and hypertension and pharyngitis and otitis and asthma and acne and along the way we ask questions like, have you ever been physically or sexually abused? On most days are you mostly happy or mostly sad? Is there anything else? What questions do you have?

Here is something one of my students wrote in her journal: “When she admitted to having thoughts of killing herself it just added to the weight in my heart … when we prayed it was the first time I participated in spiritual care. I didn’t know what to do because while Lupe was praying I started to cry, but tried to stop because I had to get through the rest of the day.”

So we work to heal the sick and lift up the oppressed and as we work to provide holistic care to as many people as possible, we must remember that there are others waiting to be seen and if we take the time to do a 100% job in all dimensions with one person, another person may get nothing. So we work smarter and faster and learn to deal with priorities, but still, there is much to do, much left undone. – there is a deep ache in the world, a groaning inwardly while they wait, while we wait.

Let me read to you what I wrote in my journal last week – about Albert Schweitzer:
  • Schweitzer suffered from major depression while he was in a French POW camp. Through his depression he became aware of “the fellowship of those who bear the mark of pain” – and he further realized that all people bear pain – and in this way (and other ways) he understood that we are One.
  • He discovered that the ideal is the human capacity to experience and express reverence for the miracle of life … and to act on that reverence.
  • The greatest happiness is through seeking and finding ways to serve. And he discovered that people who set out to do good should not expect others to help move boulders out of the way; in fact, others will sometimes move boulders into the path of those trying to good.

Like Dr. Schweitzer we all see things that need to be done.

Who and what will you see? People who are hungry? People who are thirsty - who thirst for freedom and justice? People who are strangers in a strange land? People who are naked – naked of dignity and of hope? People who are sick – sick in body or sick in heart? People who are in prison – in prison like Paul or in prisons of a different sort. What will you see and what will you DO.

Here is something else from my journal – about a woman in prison …

A middle-aged woman came into the clinic today. Her chief complaints were diabetes and asthma. The promotora who saw her in intake asked two depression screening questions and on the basis of the woman’s answers then administered a more complete depression screen, which also was positive. When I saw her she said that “something happened” when she was 8 and 9 years old. It turned out that she had been systematically molested when she was a child. She had not told anyone other than her mother until today. One of her children has been asking her, “Mommy, why don’t you ever hug me?” The answer, which she hasn’t been able to say, is that she cannot. There is something about physical affection between family members… because, naturally, it was a family member who molested her. She and I talked for awhile and it was intense there in exam room 4. When we were done, I told her I was glad she came in and that she had come to the right place. I gave her medications for the diabetes, asthma, and depression (or more accurately, PTSD). She’ll see our psychiatrist next week...

There is much left undone by the ones who went before us, by the Apostle Paul, by Maimonides, by Albert Schweitzer, by Mother Teresa, by countless people – and these people, dear ones, are our colleagues, our brothers and sisters in faith and works. They would ask that we carry on; that we see the poor and the afflicted and that we do something about them – that we do something about the individuals who cross our paths AND that we create even greater opportunities – programs for adult survivors of abuse, for children whose potential is swallowed up in the hard life of poverty, for prostitutes, for drug addicts, for people seeking to break free from so many different prisons. So much left undone.

'Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. 35For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, 36I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.' Photo: The students had a shower for this Karen woman who was pregnant. You can see the guys are having a great time.

You/we have the rare opportunity to heal the sick. To relieve suffering. To help the world be a better place. To be a part of the great dream of mercy and human dignity.

I’ll end with the Oath of Maimonides* (gender-adjusted)

The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all times; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.

May I never see in the patient anything but a fellow creature in pain.

Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of a person can extend indefinitely to enrich itself daily with new requirements.

Today we can discover our errors of yesterday and tomorrow we can obtain a new light on what we think ourselves sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling

Saturday, May 8, 2010

Written at other times

Things written in March or April or some other time.

Six months ago I bought a book, The Hill Fights: The First Battle of Khe Sanh. I was holding it for the right time and this (the day after getting home from hospital) was that time. As I read about this terrible battle that I’d been in, I thought about how over the years Jeff would say things to me about the way I was in Vietnam. Reading this book I began to understand what he was saying. About 1 in 7 (~15%) Marines actually fight. Of that 15%, not that many are what you would call true hard-chargers. The book made this clear and then I read this: “As soon as I told them I was wounded, they crawled over and patched me up.” I was one of the two that got to him. I even took his photo (situation described pp. 94-95). I was a hard-charger. And here is an amazing thing: so is Leslie. She is straight out of the Book of Five Rings – she’s burnt out and beat down, but never conquered. Photo: Taken at the Hill Fights
Written 2 days before I went to the hospital. Today I heard a talk by a distinguished physician (Harvard faculty, Director of Ethics and Palliative Care at a major medical center, and President of the Albert Schweitzer Fellowship). The speaker talked about service and about Albert Schweitzer, who, before becoming a physician, was a noted New Testament and J.S. Bach scholar and a well-known organist (recitals still available on CD – here is example: What stood out most to me … Photo below: The reason why
  • Schweitzer suffered from major depression while he was in a French POW camp. Through his depression he became aware of “the fellowship of those who bear the mark of pain” – and he further realized that all people bear pain – and in this way (and other ways) he understood that we are One.
  • He discovered that the ideal is the human capacity to experience and express reverence for the miracle of life … and to act on that reverence.
  • The greatest happiness is through seeking and finding ways to serve. And he discovered that people who set out to do good should not expect others to help move boulders out of the way; in fact, others will sometimes move boulders into the path of those trying to good.

I thought about some of the people who put boulders in my path. What I wrote about this seemed unseemly, so it’s gone into the void of deleted.

About a week after I got home from the hospital I found out I'd been on a vent for a day & night. I had no recollection and still have none. I also realized I was 11 days in the hospital.

From 2007 trip to Burma

Pulled into Moulmein about 2pm. It's hot as blazes today - the first day without rain since we got to Hong Kong. Taxi man said 2000 kyats to hotel. I said, last time 1000. He said, Okay 1500. It turned out to be about a 1000 kyats ride to the Thanlwin Hotel. The closest room to what we wanted was a big room with shared bath and aircon that barely worked and a fan that turned at about 20-30 RPMs.

We caught a tuk tuk shared with two Chinese women with all kinds of gold and heavy perfume on to the Aurora guesthouse where they had no rooms available. Photo: The Breeze

We're really hot by now and everywhere involves at least one long flight of stairs and we're a little dehydrated since we've had only a few sips of water on the long bus ride knowing that there would be 2 stops at most. Actually the bus stopped once for lunch/toilet break (sorry I didn't get a photo of the toilet at the bus stop - which wasn't bad at all, for a squat toilet). So anyway, we're standing outside the Aurora GH, dripping with sweat, (I'm) feeling dizzy, wondering what we'll do if we can't find a room. I left Leslie sitting, dripping on a suitcase on the sidewalk while I took a moto to check out the Breeze GH. They had 2 rooms available, one for $15 with aircon and one really big one with 20 foot ceiling and big windows overlooking the river, but fans only for $18 - "natural aircon" says the man showing me the room. I say we'll take the aircon, but my wife will decide for sure. Back I go to Leslie and we load ourselves and luggage all into one trishaw - oh we were a sight to see! Photo: From the Old Moulmein Pagoda exactly as Kipling wrote: "By the old Moulmein Pagoda, Lookin' eastward to the sea,"

Lonely Planet says the Breeze is "funky, but adequate." By now we understand part of how things work, so asked if they turn off the electricity at night. He tells us they have a generator, so we take the aircon room. So here we are, in a room with tile walls like a giant bathroom (photo above) and glad to be here - especially given the ceiling fan that moves briskly. The Breeze is funky but okay and it's right on the huge Thanlwin River and our room very conveniently has a bowl for spitting betel nut juice into - what more could you want?

Several times on this trip Leslie has said, "My father would not believe it if he saw me now." I guess this continues that tradition.

Tuesday, May 4, 2010

Cali! Roses!

In mid-April we headed for California – a couple of days in Berkeley, then I went to San Jose for a conference while Leslie stayed in Berkeley with David, then a few days in Berkeley, a few days in San Francisco, back to Berkeley, and then home. Photo: Sidewalk in front of Star Market. Where the dogs are is where we sit and drink coffee

Ahhh, Berkeley, the land of my dreams, where almost every yard looks a lot like ours, where almost all the houses are old and graceful, where Walmart isn’t, where drivers always stop for pedestrians, where developers aren’t running hog-wild through communities tearing down homes to build mac-mansions and even bulldozing whole blocks. Of course it helps that our life in Berkeley consists of fixing breakfast, walking to the Star Market or Semi-Freddie’s Bakery for coffee and pastry, walking on to Safeway to shop, bus back to David’s, fix more food, read, take it easy … We had a very good time with DK (who is working very hard). Photo: The future is now - CK and the shopping cart he shares with Leslie

San Francisco was good. We took the bus from David’s to the BART station, except while we were standing at the bus stop a woman pulled up and offered us a ride to the station. How great is that! BART went straight to downtown SF, we got off at Montgomery, and walked to the hotel. Photo below: Sidewalk in front of the Star Market in Berkeley, on Claremont

We stayed at the Grant Plaza in Chinatown - $69 base rate with windows overlooking Grant Avenue. We could walk north on Grant a few blocks and cut up the hill to Stockton and except that the buildings are just a few stories high, it was almost like being in Hong Kong. We ate twice at the New Moon Restaurant – a huge plate of roast duck and pork on rice. Once we got BBQ pork, the crispy skin off the half a pig hanging at the end of the counter and once we got char sui, which is what we wanted. Also a 20 minute walk to the Yummy BBQ Kitchen on Broadway and vast quantities of dim sum 3 pieces for $1.50. A few minutes past that is North Beach where we checked out cafes and groceries, hung out at City Lights, spent a few minutes at the park, and had an espresso at CafĂ© Trieste.

Walking south on Grant for four blocks we caught the bus to Japantown to shop at Ichiban, then transfer to Clement Street, the “new Chinatown” where we made it to cheap dim sum Mecca, Good Luck Dim Sum, where we feasted on more than we should have eaten for $7!!! We had an espresso at a depressing electronic gambling place, spent some time at Green Apple Books, then went back to Good Luck for just one more round of chive dumpling with shrimp. Photo: Dim sum at Good Luck

Back in Berkeley, David and Matt fixed linguine and clams for us for dinner, and that was nice. So were the chocolate chip cookies I made. Had a leisurely packing, picked a lemon from the tree by David’s balcony, and caught the shuttle to the airport. Had we had one fewer bag, we could have taken BART, but we were bringing things home for David so took the van. Photo: Mirror shot at the New Moon
There are 15 or more roses in our front yard. There are bushes, ramblers, and climbers. A few, like New Dawn (1930) and Don Juan (1958) are more modern, but most, like Zepherine Drouhin (1868), Cecile Brunner (1894), and Perle d’Or (1884) are old garden roses. The fragrance is intense, with the classic rose scent of Maggie and the delicate bouquet of the New Dawn in magnificent bloom on the arbor at the walkway to the house and again over the front door mixed in with the Confederate jasmine climbing with countless tiny star blooms all the way to the peak of the roof.

There’s a place I can sit on the front porch where even in the daylight hours I’m almost invisible to any but a person with a keen and searching eye. I look out and see the herbs and perennials blooming to the arbor with all its roses and in the evening, the “welcome lights.”

Last night I saw my first firefly of the year and tonight, a hummingbird at the delphiniums.