A Day at an Abortion Clinic

REFLECTING ON: Observing at an abortion clinic and confronting my previously unchallenged ideas on the subject...

Having not donned my forest-green scrub top in a while, at 5:30 yesterday morning, I found myself again feeling like a complete fraud as I dressed up to “play nurse”. I moved slowly as I pulled up my multi-pocketed, khaki scrub pants, and closed my eyes for long periods of time. At the end of one sleepy head nod, I opened my eyes to stare down at my left sleeve: the iron-on UCSF patch—my official sponsor. I wondered if or when I ever was ever going to feel confident or competent as a nurse. Such is the life, I suppose, of a student in an accelerated program.

My destination was a San Francisco abortion clinic where they perform abortions for patients in their first and second trimesters (up to 22 weeks). As someone who had never been to an abortion clinic in any part of my personal or professional life, my expectations were distorted by the vague abstractions of what I had heard in lectures, seen in the news, and read in books. Though it was vacation, I had chosen to volunteer at this clinic for this very reason: my total lack of actual experience with the subject. In addition to educating myself, my decision to volunteer was intended to confront my fears regarding abortion. In being totally honest with myself, I realized that I wanted nothing to do with the abortion process. My natural inclination is to run away from situations like these due to some misplaced instinct to survive. I have quickly realized, however, that being a nurse often requires me to walk towards these less-than-comfortable situations in order that I better serve my patients. How can I be objective and caring if the greater part of my brain is sorting through basic instincts? So I take a deep breath and take a step closer to my fears.

Although these greater, mostly inexpressible thoughts were swirling around my gray matter as I got ready, I could verbalize one constant preoccupation: I was nervous and concerned that I wouldn’t be of any use. I suppose “being of use” isn’t so much the point during a day of observation, but I always like to show that I can be helpful. Part of the “disease to please” I suppose, where I always try to find someway to help. Later, after I had observed eight abortions, I was glad to just sort through my thoughts.

While on BART and Muni, I spent my time reviewing pregnancy and abortion terminology as well as the pharmacological actions of Mifeprestone, Misoprostate, and Methotrexate—drugs used in medically induce abortions. Memorizing things like these is a part of my “comfort-routine”, where I control for as many variables as possible. Memorizing facts, though challenging and requiring discipline, is easier than wrestling with the swirling and unpredictable emotional variables. I can memorize what is known and understood. In contrast, I can only blankly repeat sentences when something is beyond my mind’s grasp. As much as I crammed, there was no way I could prepare myself for truly understanding the mechanics of abortion.

I foggily made my way through the hospital’s labyrinth of hallways and, after ringing a doorbell, stepped into the clinic. Luz, another nursing student in UCSF’s MEPN program, was already there. Everyone was friendly and this surprised me somehow. I even heard one of the nurses say, “Oh good, the students are here.” Reflecting back, my surprise was the first clue to my true, thoughts on abortion. If I had been completely honest with myself, I halfway expected that everyone in the clinic would be quiet and forlorn, perhaps in constant state of mourning, because after all, weren’t they killing babies here?

And with that flash of thought, I was truly taken back. Floored really. Completely and totally shocked. Did I really just think that? But I had always flown the pro-choice flag…and now…shit…was all my talk just lip-service and yet another unchallenged idea in my personal cache of thoughts that define me as liberal and open-minded? Am I really that naïve? In the abstract, I had somehow rationalized that there was a clear delineation as to the point where life began and ended such that each of these medical professionals, with exacting precision, were able to determine beyond a shadow of a doubt when and how life began so as not to destroy any potential, any thought, any love, or any laughter…as if the next great Mozart or Martin Luther King might be at the clinic in fetal form, or perhaps just a really good kid. I don’t know…starting out with thoughts like these, I knew it was going to be one hell of a day.

At the nurse’s station, I stood next to Luz, blankly repeating words and sentences to myself. Luz seemed more at ease than I. Madison, an experienced nurse at the clinic, approached us while tossing up a coin, which I knew had something to do with me. Without asking, I called heads, won the toss, and was asked to choose my preceptor: Madison or some other woman. As I hadn’t met the other woman and I liked Madison’s style—direct, thorough, and smart—I chose Madison.

Madison shot out a million words a minute and walked about just as fast. Talking while walking seemed to synergize her speed, making her blurry on any photograph. One minute we were in the med room drawing up a cocktail of fentanyl, versed, and atropine and the next we were whirling passed the nurse’s station and reviewing patient information. She explained that the fentanyl, an opiate, is for stopping pain; versed is a central nervous system depressant used to relax the patient; and the atropine, a parasympatholytic, is employed in order to maintain the patient’s heart and breathing rate, as well as for prophylaxis against a vasovagal response. Madison had not only told me the pharmacological action and reason for each drug, but she had also managed to summarize the procedure, and even began to discuss abortion complications—all in about 3 minutes. My head was spinning when we entered the procedure room where there was a already a patient prepped and ready to go. I would need more time to take it all in.

As I learned and asked questions, twenty-three abortions would take place that day. The patients ranged in ages from 14 to 30 years and their fetus’ gestational age ranged from 7 to 14 weeks. I observed no immediate complications.

Ella was our first client. She was thirty-three, married with two kids and didn’t want another. She told me as much while I sat with her during the pre-procedure counseling session. She had had this procedure once before and somehow seemed cheerfully resolved to go through it again. Her “cheerfulness”, I admit, was my bias, but I can only report what I see. Who knows how she really felt?

In Ella’s chart, we would write that she was a G4P2—gravida 4, para 2, indicating that she had been pregnant a total of four times, and had carried two of them to at least 20 weeks. This fetus was 14 weeks. Ella’s confident body language and willingness to look at medical personnel in the eye seemed to indicate that she was at peace with her decision. Somehow that put me at ease, too, which allowed me to pay close attention to the tools and mechanics of her abortion.

The procedure took place in an older operating room with wall-to-wall tile. The room was extremely cold and in the center of the room was Ella, lying on the operating table with her legs propped up, spread, and secured by the stirrups. She was draped with the infamously small hospital gown, but probably didn’t care about the cold because of the fentanyl. Behind the table sat the equipment that monitors each patient’s oxygen saturation, respiration rate, heart rate, and blood pressure. At the foot of the table was a draped cart of sterile tools. Under the drape was a bowl for betadyne, which is used to clean each patient’s vagina inside and out. Near the bowl was the speculum, a vice-like tool that is inserted into the vaginal canal so that the clinician may have direct access to the cervical canal and uterus, where the fetus is developing. Next to the speculum was a wrapped sterile cloth that contained several sterile dilators—10-inch metal rods of increasing diameter that would probe from the external to the internal os of the cervix, allowing for full access to the uterine cavity. Depending on the age of the fetus, the clinician will use either a manual or electric vacuum, either of which would require a plastic tube, the cannula, to be attached to it. The cannula is inserted through the cervical canal and into the uterus. One one end that is insertedinto the uterus, the cannula is beveled and the other is attached to the vacuum. The cannula serves as the primary tool for terminating the fetus and is guided into the uterus via an ultrasound image. The ultrasound is live, essentially showing a video of the procedure’s main event: destruction of the fetus. The amniotic sac is more salient in earlier pregnancies, with a small but distinguishable fetus growing at one side of the placenta. The head is just barely visible, as well as small arms and legs. If the fetus is in the second trimester, like Ella’s, the fetus’ spine is obvious, and upon careful examination, one can even see a tiny fluctuating blur of black and white: the beating fetal heart. The plastic cannula would normally be invisible on an ultrasound image, but is obvious because of its barium coating. Once the cannula is placed into the uterine cavity next to the fetus, it is twisted and pumped up and down while connected to suction. The fetus, placenta, and amntiotic sac are being speared, broken apart, and then sucked into the vacuum container. The clinician performing the procedure will make several passes with the cannula in order to ensure that all of the contents are aspirated. Then, to further ensure that there are no more fetal contents within the uterus, another tool, the curette, will be employed. The curette has a handle similar to a screw-driver with a long metal rod extending from it. At the end of the rod is a metal loop that is used to gently scrape the uterine walls to ensure all fetal material has been removed. Both of the physicians that I observed carry out this part of the procedure described the sensation of scraping the empty uterus as “grainy”. Once empty, the uterus shrinks back into its flattened position, the walls of which are now flush unto themselves, with no fetus present. On the ultrasound, the physicians described the flattened uterus as having two parallel “silver” lines that represent the uterine endometrium.

Ella’s abortion followed this precise operation. No complications. No pain. She was groggy from the medicine, but after recovering from the procedure, she left the hospital and was driven home by her sister. In the recovery room, she smiled at me, ate crackers, and talked easily with the nurses and other patients. Again, I found myself surprised by the ease in which she and everyone around her had adapted to the events I had just witnessed. This included myself. I did keep my surprise quiet for fear of being branded a heretic. I suppose if I had I been injected with a fentanyl cocktail, I could have watched a train wreck while singing “Frère Jacques”, but I hadn’t, and nor did I have the years of experience that could allow me to fully gain professional distance and objectify the patient while sinking into a rhythm of automaticity.

I had a strong emotional reaction. What I had observed was this: one minute there was an observable human figure on the ultrasound and the next there was not. In the interim I observed blood being suctioned from Ella’s uterus and into glass jar that had a cheesecloth filter for catching solid tissue. At one point, the electric vacuum became clogged and the doctor had to withdraw the cannula from Ella. A scant amount of blood dripped from Ella’s vagina to the blue drape beneath her. Clearly, there was tissue obstructing the beveled end of the cannula. The doctor brought it to a bowl and tapped the cannula twice on the bowl’s edge. A clump of tissue loosened and fell; the doctor returned to the procedure and all eyes were back on Ella except for mine. My gaze remained fixed on the bowl where saw a small, dismembered arm with a hand. I counted five fingers and noticed the arm was bent at the elbow.

I strained to hide a flash of grimace. My eyes watered for a second and would have betrayed me had I not looked with feigned interest at the vacuum. Ella had her eyes closed anyway. Nobody in the room was looking at me. My nostrils flared and I thirstily inhaled air. All I could think was, “Get it together Nat…we’ll work this out later,” which I repeated at least seventeen times. My eyes returned to the arm and I noted veins below translucent skin. It was the left arm. I thought I could see the head of the humerus. It was approximately 5 cm long.

The facts were comforting to me. I looked around and noted instruments and where we were in the procedure. And with that, I moved from being emotion-filled to diagnostic-filled, which I found as alarming as first seeing the arm. The sting of what I had just seen was still with me, but was sublimated into fascination by examining the anatomy of the fetal remnants. My head was in two places at once.

Upon leaving the operating room, the emotional pull returned, forcing me to bend my mind around what I had just seen. This was heavy, heavy stuff but there was no time to think; there was another procedure to perform. I was on Madison’s schedule now. The rest of the abortions were for fetuses 8 weeks or less, which somehow seemed more acceptable to me. I couldn’t see the fetus as well, and they weren’t as developed as the 14 weeker, so it wasn’t as hard to watch. There were no more tissue obstructions either.

In between patients, Madison and some of the other nurses expressed their disbelief that some of their patients actually wanted to take the fetal remnants home with them for a funeral. Madison was clearly frustrated, “I mean, I can see wanting to have a funeral if it is a medically necessary abortion and you wanted the child to begin with, but for an elective abortion? I just don’t get it. And besides, most of our girls are on Medicaid…so you’re telling me you can’t afford an abortion, but you can afford a funeral?”

“Maybe they’re trying to show somebody,” I said, surprising myself. I had turned a corner and tried to picture the life of the person who had been on the operating table outside of the procedure. “Maybe they’re trying to let someone know that this is what they had to go through.”

“True,” Madison said, “there’s a million reasons to get an abortion, and we only see part of it. I guess the bottom line is that everyone should have access to it, regardless of their reason or means so they can be safe—it’s going to happen no matter what. I know we sound callous, but don’t think for a second that we don’t love what we do. It’s important. Women need to be bale to safely choose this procedure.”

Clearly, the day one decides to have an abortion shouldn’t be a happy day in anyone’s life. But for Luther, it clearly was. Although all the nurses had discouraged Susan from having her partner in the room while the procedure was taking place, she was adamant about having him there. “I didn’t get pregnant by myself,” she insisted. At with this, everyone acquiesced, and he was fetched from the waiting room. It was late in the day and this was the next to last procedure. When Luther came into the operating room, Susan was already laying back on the table. Her face had changed as soon as he entered the room: passionate to impassive in two seconds flat.

When I first saw Luther, all I could think was that he was a grubby little boy. Mannish in stature and size, I suppose, but his body language put him at 17 tops. His sweats were crusted up with dirty liquid stains and a distinct odor followed him into the room. I recognized the smell immediately—that of a dirty, neglected home. I had been in hundreds during my days as a social worker and group home counselor, and most of them smelled the same: stale cigarette smoke, dirt, must, and sweat all combined to create one of the most pungent smells in my memory.

Luther was taking off his hat as he entered, which I offered to take from him. He handed it to me and was signaled to sit down next to Susan. When he spoke, his words were saccharine, “It’s gonna be alright baby, baby—you’ll see. All these people are gonna take real good care of you.”

It sounded like bullshit to me. His words were hollow and unconvincing like those of a bad actor. Luther looked around at the staff after each sentence, as if looking for approval, and spent very little time looking at Susan. As the procedure progressed and the staff would offer encouraging words, he would mimic them like a myna bird, “It’s going alright baby, baby…just breathe baby, baby.” And although he said all the right things, I couldn’t help but think he was quietly celebrating because I could see him smile. A new feeling overwhelmed me during Susan’s procedure: that she was brave.

Perhaps Luther was relieved to not be a father at such a young age. God knows I was relieved to hear that an old girlfriend’s pregnancy test came back negative when a much younger Nat went through a pregnancy scare at age 18. So perhaps he was happy, but Susan was clearly not, and I think she wanted him to see that. Later, Madison told me she noticed the same thing, “I hate it when they perform like that.”

While Susan was in recovery, I realized that I had not given Luther back his hat. I went to find Luther in an otherwise empty waiting room and before I even got to the door, I noticed a new smell: the small room reeked of marijuana. Nobody had been smoking in the room, otherwise there would have been smoke, but somebody had clearly smoked recently and brought the smell in with them. When I looked at Luther, his eyes were bloodshot. I held up the hat, and said, “I have your hat.” Luther stood up, breathed heavily, and then sat back down, clearly overwhelmed. I tossed him the hat and said, “Good luck. Take care of Susan.” His head darted back to the television without another word. Stoned was no way to start out as a father.

Now I was relieved that Susan had the abortion. She knew she was doing what was best for her, Luther, and her unborn child. Having seen the situations that unwanted children can be born into, and the havoc that being brought up in a poor, neglectful, and/or abuse-ridden home can do to a child, I am certain that some people are better off not having been born. It hurts me to say it, but I think it’s true.

The gross reality of the abortion procedure leaves a lot for me to reconcile. Am I justifying a form of murder? Perhaps, but when exactly does life begin? Is it with the first mitotic cell division or the first heart beat? Is it the first lucid thought? A lot of unknowns. And what would happen if the child were to be born? Have I grown so self-absorbed to think that humans are so important that every single hint at a life should be preserved when there are millions of already born humans that don’t even get their basic needs met? More unknowns, though I’m inclined to answer yes to that last question.

I suppose it doesn’t really matter how I answer any question, because the reasons that a woman has to get an abortion are her own, and determining their “validity” is as difficult to ascertain as determining when life begins. The reality of the situation is that the procedure will continue to take place, whether legal or not, and to provide women with safe options is of the utmost importance.

My head was still spinning when I got on the bus to go home. It still is.

Stanford Life Flight

Phenomenal. Today I did a "fly-along" with the folks at Stanford Life-Flight. I got to go on three flights. The first was to a public relations event where we showed off for the some folks in Santa Cruz county. The second flight was to a hospital in the central valley to do a transfer and the third was to do a "scene" landing for a traffic accident. We were not able to land at the traffic accident because of its remote location, it was dark, and the fog prevented any and all visibility. Seriously fun.

All I can say is that this experience was riveting. I find the whole nursing thing pretty overwhelming on land--imagine trying to put an I.V. in a trauma patient while enclosed in the tiny passenger quarters of a helicopter! Amazing. One day I might get there, but for the time being I think I need to get things right while not wearing a flight suit.

Some may think this is a strange way to spend winter vacation, but like I've said before, I'm all in. Here are some pics of the day:

http://homepage.mac.com/gnattychad/PhotoAlbum26.html

"Only-oxycodone-will-make-my-muscles-strong-again"

REFLECTING ON: Maintaining objectivity even in the face of a med-seeking patient...

It had already been a long day before Grace and I had entered a Community Care Home in the East Bay. My feet were dragging as we passed the neglected lawn and entered the assisted living facility for adults. Folks here at the “home” have both mental and physical disabilities. We were there to see Polly, whom Grace, my preceptor, told me was a hard case. We got much more than that.

The front waiting room was a mix of 1970s décor that I’ve mostly seen in shitty dive bars, funeral homes, and my grandma’s living room. The walls were olive-green velour and the furniture was of the finest cracked vinyl. Doilies adorned the coffee table and ceramic Halloween decorations sat on top of those. Halloween had passed a week ago, but the heavy layer of dust let me know the decorations had been there longer than that. The front desk sat unmanned, so we peered down the nexus of hallways that sprouted off this bizarre portal. The halls were wide and dark and smelled strongly of cigarette smoke with a hint of emesis, emptied colostomy bags, and chicken curry. As I searched for signs of life, I only noticed shadowy corners and a cold breeze that did nothing to alleviate the pungent smell of “group home” living.

Grace and I called out and were answered with muffled, unintelligible shouting. For some reason, we took that as our cue to walk further down the hall. A man in a wheel chair with one leg suddenly rounded the corner. He wore old hospital pants and booties, a stained white v-neck t-shirt, and a brimmed beanie. Around his neck he wore a money sign medallion emblazoned with plastic gems. Never looking up, he moved quickly passed us while sneering at everyone and no-one.

As we worked our way from the a slowly disappearing exit sign, we found a second desk with a short, stout, worn and once-pretty Filipina woman passing out meds from behind it. She wore no identification, had deep, dark circles under her eyes and was only identifiable as a staff member because she donned Dickies scrubs and was behind the counter instead of in front of it. Without identifying herself, Grace asked if we could see Polly. The worn woman looked down at our badges, sniffed, and then shouted something in Tagalog down an empty corridor. A short man, whom I later found out was named Ben, scurried around the corner, gestured for us to follow him, and then disappeared again. We walked briskly toward the spot that he had disappeared at, only to find him at the end of another hallway, pointing towards an open doorway. He disappeared again. I felt like I was following the white rabbit down the hole. It was only at this point that I realized the hallways were lined with doors, which were painted the same color as the walls. Ben had moved so quickly I never saw his face.

As we entered the tiny, double-occupancy room, a trembling mass of a human lay awkwardly in its bed. She lie with her neck pinched so that her head deviated at a near perpendicular angle from her body—as if she lacked the will to move from a clearly uncomfortable position. This was Polly. I smelled pee and stale smoke and hoped that my nose would habituate soon. A mop of unkempt hair that I vaguely recognized as a grown-out bowl-cut hid her glazed over half-mast eyes. I watched a flash of recognition cross her gaze and Polly launched her into her performance almost immediately. “I-am-in-so-much-pain. I-am-shaking-all-the-time. Oh, Grace, what-am-I-going-to-do?”

Her staccato words came out like a 4th grader reading aloud round-robin style from a history book. This was clearly a script. She never deviated from this style. I kept looking for an unpredictable inflection in her tone or something that would give actual meaning/life to her words, but found nothing but all-too-recognizable med-seeking behavior. As the act played out, with Grace responded by making monotone, half-hearted assurances that everything would be okay, I half predicted the back of her hand to fall to her forehead like a damsel in distress. Then, as if I willed it, she did exactly that, “Oh why-oh-why won’t-the-doctor-give-me-oxycodone?” Her hand fell against her brow. “Only-oxycodone-will-make-my-muscles-strong-again-and-I-will-be-able-to-walk-again. Oh, oh. What-will-I-do?”

I looked away to hide one of those smiles that just can’t be hid, inhaled deeply, and attempted regain my composure before I took her vitals. In order to get her blood pressure, I had to unwrap her from the four sweatshirts she was wearing, which was a near impossible task given her unwillingness to sit up. I finally settled on taking her radial BP on her forearm. 140/80. She cried out when I mentioned this number but stopped when I told her that 140/80 was my normal BP. Not horrible, but not great. Temperature was 36.5 C, HR 85, and RR 20. Unremarkable really, outside her slightly lower temp, which I attributed to her lack of movement and the many open windows. Her physical exam yielded still more unremarkable information except for her right lower leg being edematous (+2 pitting), which I attributed to her recent knee surgery. The site of the surgery was reddish, but seemed to be healing well. When I felt around the site of the wound, she launched into a new script, “Oh, please oh please do not touch me like that. AHHHHHHHHHHH! So much pain. So much pain. I was attacked last week by a man that lives here. He’s crazy. He ran into me on purpose with his wheel chair. He’s got one leg. I don’t know why he did that. He’s so mean. I think they are going to evict him. Oh. Please. Let me escape this place.”

Her last sentence actually sounded convincing. I was ready to leave too. My ears burned, which they do sometimes when I’ve about had enough of just about anything. By herself, Polly was manageable, but I had already seen too much that day. Luckily, Grace dismissed us, “We’re going to go see what is going on with your meds and we’ll be right back.”

The hallway smelled better than the room, but I quickly realized that I didn’t want to be there either. As we approached the med desk, I felt like a re-enactment of Michael Jackson’s Thriller video was taking place. People were moving everywhere in random directions with various parts of their bodies hanging while other parts twitched. All of them wore blank expressions and were moaning or drooling. One woman in a wheel chair with a lazy eye and a half paralyzed face was shouting, “I want my god damn mail. It’s a fucking federal crime to withhold my mail. Give me my meds and give me my mail. You fucking crooks.” The one legged man in the wheel chair egged her on, and then turned quickly to face me, flashing a sly smile.

I found it easy to dismiss both the wheel-chair-lady and Polly’s complaints because they were crazy, looked funny, and were incredibly manipulative. Any legitimate concern that they might have was so hidden beneath the layers of lies and psychosis, I felt less than obligated to advocate for them. I was concerned and surprised by how easily I switched into that mode. Judgment. Hmmmmm. “Better get a handle on that, Nat.”

Grace had worked her way through the zombie melee and was talking to the worn woman. As I sat down at the med desk, Grace handed me a list of the meds and asked me to cross-reference them with what they had behind the counter. My mind switched out of judgment mode and phased back to my very green clinical skills. I was trying to remember everything to check: medication name, dosage, time, expiration date, prescription date, mode of administration…what else? I was sure I would miss something with the groans in the background. Fucking hell. The woman in the wheel chair was now ramming her chair into the counter. I moved down a seat and went to work.

I wasn’t a minute into the list when I noticed something that wasn’t on my list: the vicodin were huge and there were only two of them at the bottom of the pill bottle. When I opened up the bottle and held it to my eye, I saw that there were two 800 mg Ibuprofen tabs at the bottom. Then I went to my green skills list: prescribed on10/23 with 90 pills, 1-2 pills PO q 6 hrs, PRN. What was that? 8 pills max/day? 8 x 14 days passed=112 pills. 112pills-90perscribed pills=22 pills that couldn’t have been given because they didn’t exist. 22missing pills/8pills a day=almost 3 days of missing pain meds, assuming that she had consistently getting the maximum dose at the regular six hour interval. There was not way this place was consistent. Couldn’t happen. Too god damn crazy to be regular.

I smelled bullshit because narcotics were involved. I switched back into judgment mode and was happy to observe that I didn’t just apply my bullshit detector to the patient. Was I being too hasty to judge? No I had done the math right. There’s now way this place was regular in its dispersal of the meds. No fucking way. I was, am still pretty sure someone was pocketing the hydrocodone and switching it with an over-the-counter pain med. Jesus. Okay, maybe Polly was med-seeking, but she also had a legitimate concern. Now I felt bad. My judgment almost allowed me to ignore the facts. God I love facts and diagnosis based on them.

I looked to Grace and nodded toward the bottle as I handed it to her. Grace is hip to the fact that I’m a skeptic and like unspoken communication. She looked in the pill bottle and frowned. Then she spoke, “Good catch, Nat.”

When we brought the information to the worn woman’s attention, her English suddenly got worse and she had a harder time understanding us. She also couldn’t produce the PRN record, saying that it was locked up in the boss’ office and that the boss wasn’t around. Now the bullshit smelled stronger than the piss and cigarettes. I looked around and caught more Thriller video. Then I looked at the worn woman’s tired eyes and felt a tinge of sympathy. Shit. I would want some narcotics too if I worked here everyday. I smiled at her and said, “You’ve got a hard job. I used to do this too and it’s tough.” She smiled back as she hung up the phone with her boss. Then she lead us out of the facility, closing and locking the door behind us.

Pride, prejudice, and nursing

REFLECTING ON: Personal prejudices and confronting them while providing home care to patients during my community health rotation.

So I think it’s pretty clear that I have a strong prejudice towards rich folks. I judge them and am convinced that their money is what contributes to their swollen egos and entitlement. I have had enough negative experiences with them that I also hold the belief that their lack of humility within the healthcare setting is what allows them to make unnecessary demands and strike fear into the hearts of all healthcare providers because of their access to attorneys. They ask for help yet threaten lawsuits, which in my opinion, is the factor in hospitals and most institutional settings being unable to provide the necessary resources to all parts of their patient population.

Then I met Susan and all my prejudices fell by the wayside. She’s 94, has a metastasized abdominal tumor that, because of its advanced progression, could only be debulked rather than removed. Even after the debulking surgery, her GI system struggled to work through her colostomy. Sometimes her stool was green, sometimes light brown. Today it was orange, though she referred to it as “a tawny mustard”. Susan was so yellow as she lay against her white sheets, we now think the cancer has spread to her liver. I later learned that Susan used to have the healthy habit of running marathons. Her heart sounds confirmed that story: regular and strong like a Swiss watch.

Her husband, though well intentioned, was having a difficult time switching roles from high-powered banker to home-care provider—he recently had a run in with the washing machine where he put in too much detergent and flooded the laundry room. Even if he could provide competent care, Susan had an enormous amount of pride and wouldn’t let him switch her ostomy bag. Though she had tried at first to switch the bag by herself, the fact that she had relented to let us provide care indicated to me that she knew her time was close. She wouldn’t talk about that directly, though, and refused to be seen by hospice. Understandably, Susan wanted to continue to see the nurse that she had become comfortable with. Now, in her twilight, she had so little control and was being threatened with having to see a whole new batch of people. How’s that for humility?

In Susan’s perfect Pacific Heights mansion with a perfect view of the Bay, we changed her colostomy bag, switched her fentanyl patch, and drew blood for labs to confirm in our suspicions regarding her liver.

The perfect view doesn’t matter much when you’re in pain.

Nurses Come From Monkeys (Evolution Related)

Today I had an interesting interaction with my nursing preceptor, Grace, for Community Health Nursing. She happens to live near me, so she was giving me a lift home at the end of the day. Now that the guise of work had lifted, we stopped talking about the vitals of others, and shifted to those of our own lives. We spoke of our significant others and various other things. I felt somewhat honored because I know that Grace doesn’t reveal much to anybody at the office. It was then I realized that I probably spend more concentrated time with Grace than I do with anyone else, including my wife!

Somehow, we came to the subject of religion, and she asked me what I believed. I explained my very grey version of agnosticism, which includes both my version of God as well as evolution. She nodded enthusiastically as I elaborated how my version of god allowed me to explain the unexplainable, miracles, and also allows me to show no prejudice towards other religions that fundamentally want to do the right thing (How can 837 million Hindus be wrong?). When I touched on evolution, she stopped nodding. Grace was clearly distraught, “So you believe we came from monkeys?”

I affirmed that I did. Not only that, I thought we came from much simpler organisms that appeared anywhere from 3.5 billion to 500 million years ago. She asked me how I could believe this. I then went on to explain meiosis and mitosis, the very real possibility of gene mutation, natural selection, and the cumulative “effort” of such selected mutations that allow us to evolve from single-celled organisms to monkeys to me. How can bacteria and humans have similar assemblies of DNA? If we’re so different, how is it that we can slip in a genetic code for a drug, such as an antimilarial, into a yeast genome, and suddenly that yeast is creating pharmaceuticals that are consumable by humans? We have got to be connected! I explained that I thought that the similarities are just too great to ignore.

Grace did not seem amused. I was thoroughly confused. Surely, I thought, this woman, who has a background in science and clearly seems knowledgeable about pathophysiology and pharmacology, could appreciate that I believed in such things. I did not think that I was questioning her faith, merely explaining mine. Somehow, in explaining my faith, however, I had questioned hers. Of course, I did not realize this until later, and since I was on a roll, I then went on to explain how, the miracle, and where I believe this greater force that some folks call God comes in (which I’m willing to accept has a different name and a form inconceivable to us at this moment in time), is in the smallest elements of our understanding. How did the atom come to be? How did the neutron, proton, and electron find each other and form elements? How did quarks and leptons create these three parts of the atom? And the force! What about the force? How does an invisible force orchestrate this fantastic dance between such small parts that create everything that we live and breathe? Inconceivable! And, in my mind, wonderful at the same time. That is the miracle. That is what blows my mind. That’s what God is to me. Wow. Right?

Almost as miraculous was that I explained all this in between the Ashby Ave. Exit and my exit—about 7 miles (albeit there was heavy traffic).

Grace had to drop me off before she could have a chance to respond. She was still friendly, but somehow “within herself”. I’m sure that she will be polite to me when I see her again, but I wonder if she will treat me any different because she know that what I believe is different than what she believes. Once we start talking shop again, I bet we’ll be back to our old selves.

This experience got me thinking about how I should deal with patients that believe such radically different things from me.

Prescribing a Squirt Gun

REFLECTING ON: Community health rotation placement and treating patients in their homes...

For my Community Health clinical rotation, I’ve been assigned to work at a nursing agency that provides in-home care to patients that have been discharged from the primary hospital. Grace is the nurse that I have been assigned to work with. She’s Puerto Rican and mainly of African descent. Spanish-speaking patients do a double take when she switches fluidly English to Spanish. She’s subtle like that—holds her cards close and lets the patient reveal him/herself. I could take a lesson. Silence is sometimes the best diagnostic tool.

We visited three patients: one foot amputee, one renal failure with dementia, and one pressure wound. They had names too, but HIPAA wouldn’t like me revealing them. The foot amputee patient didn’t take to “patient education too well. We encouraged him to elevate his foot, which he explained he couldn’t do because it made him uncomfortable. I decided to play the “dumb student” and ask Grace why a patient should elevate his foot in order to heal an infected wound. Of course I already knew, but I just thought a conversation between professionals might be less irritating to the recalcitrant foot amputee. We’ll see.

I was excited to observe wound care because, although I practiced on latex models in skills lab, my clinical placement on the oncology unit didn’t have much opportunity to manage wounds. If the low-platelet, neutropenic leukemia patients had a wound, they were usually sent to the ICU. I like skills and technical stuff, so I’m juiced that my community placement opens the opportunity to work in people’s homes as well as practice new clinical skills.

The second patient we met was a 94 y.o. Brazilian woman with acute renal failure, diabetes, and slight dementia. She lives with her 84 y.o. sister and an obviously unstable dog. The dog is named “Sister” until they realized she was a he, necessitating a name change to “Brother”. Sometimes they still call Brother “Sister” due to his being neutered.

I consulted the patient’s vitals, lab values and history. I listened to the concerned cousin that provided 8 hour/day care to both her family members. In addition to monitoring her weight, liquid/food intake, diet, blood pressure and bathroom habits, I determined that the dog was a primary concern. While I was there, the dog attacked every family member at least once, Grace twice and nipped my hand until it bled. When it jumped on our patient, it went right for her slowly healing IV wound, which had become infiltrated during a recent hospital visit. Grace and I will be prescribing a squirt gun to deal with the dog. I mean, this woman isn’t exactly a quick healer.

"CLASS" test

REFLECTING ON: Being obsessed with grades...writing to teacher that has urged us to stop nit-picking tests and start thinking about matters of substance.

"Dear P--,

I told myself that I wouldn’t buy into the grades and the nonsense and the madness….but I did. Damn it. I’m all in and all about learning what I need to know in order to do this job. If I do this, I will learn what is important, which may or may not be included on the class test. But, if I am to pass the CLASS test, the real definition of class, I will realize that my sincere effort and desire to be competent can’t be graded so the grades shouldn't matter as much.

I'm trying to get this new learning curve-ball that's being thrown at me. Let me explain.

I'm trying to get the actual lesson here. I've had a fair number of "teachers" in my life, at least in name, but very few mentors. I think that's what you are trying to say here: chill out and get the real knowledge of what it means to be a good nurse. Not a wanna-be doctor, not a heal thyself case, and not an academic: a nurse. Working on it.

I gotta realize that this process is a harsh reprogramming of my mind. Having forced myself to stay academically competitive all my life (I mean, I got in to UCSF, right?) has put me at a mental disadvantage sometimes when looking for the "real" lesson. Clearly, many of us, especially me, need to be challenged to get past the nit-picky details of what we have memorized to get 4.0s, 90%ile GREs and find true, substantive, practical knowledge (wisdom?).

We'll get it--just in different ways.

I personally need to have some yell, "Hey buddy, what are you doing?" every once in a while to be reminded of what I'm actually trying to do here (something I'm still not sure I even know). Keep in my ear and maybe I'll just get it. I personally look forward to you yelling "Let's get it started" every morning.

Take care,

~Nat

Patients as Heroes

REFLECTING ON: Interacting with patients on the Oncology Unit at the Hospital where I have been assigned clinical rotations...

There was a distinct feeling that I got Thursday and again yesterday at the end of clinicals: this is doable. Not only that, I got the distinct feeling that I was meant to do this. I am built to be a nurse.

One of the issues that I continually confront with a “do-gooder” personality is offering help in situations where perhaps it isn’t always requested, needed or appreciated. Though there are certainly subtleties and nuances in providing care to patients, generally speaking, I am there to help and it is most certainly needed. It feels good to be needed and appreciated. Such a contrast from my last job where I continually had to grow thick skin, suck it up, and deal with all sorts of abusive language/behaviors without much of a grain of appreciation. I don’t know how I did it for as long as I did.

I am working on the oncology unit for my first clinical rotation. Everybody there is dealing with the big “C”. Generally speaking, it is my impression that in American society, cancer is synonymous with death. Sure there are treatable types, but the word “cancer” seldom describes good news unless you are defeating the disease.

These patients my heroes. They are humble, possibly because they have no choice, but nearly all of them are kind—and attitude is something that they do have a choice in. I don’t want to romanticize their situation that is so far from glorious, but then again, perhaps we need a new definition of glory.

I met this man, Alfonze, a 29-year-old father of two, who is fighting Acute Lymphoblastic Leukemia for the second time. His prognosis is not good: his cancer has metastasized. To compound matters, his youngest son is also fighting cancer at another hospital.

Bright-eyed and bushy tailed, I walked into Alfonze's room yesterday to practice taking vitals just as he had received the news that a second tumor was found in his son. The expression on Alfonze's face was clear: he already knew the second tumor was a death sentence.

Writing “Death sentence” sounds harsh to me right now, but I am not going to mince words here. I am not going rehash some tired words that “everything is going to be okay”. What a line. Try as we might, we cannot control everything—we are not gods. Not me and not the physicians who write the treatment orders. Everything is far from okay. A father and son that I know have a greater probability of dying this year than they do living and that is so far from okay.

And yet, here is Alfonze, being so kind to me as I fumble with the blood pressure cuff. That is glory: bravery manifested as kindness while facing almost insurmountable challenges. Alfonze is glorious. My definition of glory includes people that fight with dignity and character.

Nurses eat their young

REFLECTING ON: Nurse burnout and the old school...

The last thing I wanted to do was make waves on my first week of clinicals. Oh well. But I swear this really had nothing to do with me…this time anyway.

So there I am, in the oncology unit’s nurse’s lounge, sitting down and trying to “play nurse” with my preceptor, Lee. I’m looking at the patient file and literally trying to figure out what “MAR” means (let alone its contents) when this mean looking nurse comes in and scolds me, or more appropriately put, tears me a new one. “You’re not supposed to be in here doing work—this area is for relaxing only.” Please meet Mildred, and for all terms and purposes, this is a fitting way to meet her.

Confused, I look to my preceptor who is now making a thorough examination of the ceiling. Mildred continues, “Not only that, the student nurse shouldn’t be taking seats from an actual nurses doing actual work.” Sweet. I just stepped on toes, got thoroughly trounced, and I don’t even know what MAR means. Since Mildred is belittling me and addressing me in the third person, I think it’s safe to say that I shouldn’t ask her.

So, wow. Okay. Let’s not lose our cool. Clearly there has been a misunderstanding. Let’s approach this logically and diplomatically. After all, we’re all professionals here. “I didn’t know”, I say, “my apologies…I’ll move my work somewhere else.” I’m a bit miffed that my preceptor hasn’t said anything to Mildred since she was the one that told me to sit in here, but I let it go. Completely resolved to avoid further confrontation, I begin gathering my effects.

“And maybe the student could clean up while he’s at it.”

No way. This is a power play and I am having none of it. I don’t care if I get moved to another floor or even if this is how students are normally treated. This woman has no manners. And if this is how nursing students are treated, I don’t want any part of it. Having worked with emotionally disturbed boys for nearly a decade, I’ve developed thick skin to insults that range from my manhood to my mother…but this third-person nonsense has got to stop. God I hate bullies.

Standing up, I look at Mildred, “Okay. I get it. I’m the new guy—and a student to boot. But the student’s name? His name is Nat.” Extending my hand in a manner of greeting I am more accustomed to, I stare at Mildred straight in the eye. “Nice to meet you.”

For all her bluster and braggadocio, Mildred crumpled like a house made of cards. Extending a limp wrist handshake, she mumbled, “Well you’re still a student to me,” and walked out of the room.

Feeling vindicated, I turned to Lee who sat there stunned. “Wow, way to stand up to Millie there. She does that to everyone. She’s of that old-school style of nurse. You ever hear the saying, ‘Nurses eat their young’, well that’s Millie.”

I hadn’t heard the saying and my first reaction was that it was just horrible. Nurses eat their young? Yuck. Just disgusting. I mean, I get it, some folks need to toughen up sometimes, but I’d rather not feel that I’m going to be consumed like the runt of the litter in some unspoken, pseudo-Darwinesque training program while learning a profession that presumably embraces compassion. I mean, there’s got to be middle way. Right?

The following week, I, yet again, inadvertently crossed Millie, but this time she avoided me altogether. You see, someone had “unknowingly” assigned me to her patient caseload because I had unwittingly done pre-lab on one of her patients. Instead of shifting me off that set of patients, they shifted Millie. When I realized what had happened, a very flushed and very angry Millie stormed passed me shouting, “Twenty-five years here and they treat the students better than me!”

Later I learned that Millie had thrown a magazine and then broken down into tears in the nurse manager’s office. Clearly, this had nothing to do with me. Another veteran nurse confided in me that Millie had been the “elephant in the room” for a while now. I just happened to be the last straw that blew in and broke her back.

Millie was clearly experiencing burnout, and was given some mandatory vacation. I never saw her again that quarter, but I certainly am reminded of her on a daily basis. Burnout is a common affliction in the nursing profession. There are tireless nurses and there are tiring nurses that are under the delusion that they are the former. Having seen first-hand the exhausting and emotionally jarring work that nurses do, it surprises me that there are not more Millies in the world. I feel simultaneously sorry for and leery of Millie. Sorry, because I later heard that Millie, in fact, was an excellent nurse. And leery because I am scared that I, too, have the potential to act like her and not know it.

If I ever act like Millie, you have full permission to put me in check. I’ll thank you for it later.

Gungo Ho Balance

REFLECTING ON: General thoughts on the first week...

I’ve been up since 5:00am. I figure 6 hours of sleep is how I will roll during the week and then I will catch up a bit on the weekend. I feel so out of sorts and overwhelmed with all of this right now. We’ve been assigned like 1 billion pages of reading, and none of it is all that mellow. I mean, it all has to do with saving lives, right, so how could any of it be mellow?

As I read the pages over and over, I am inundated with the same thought: can I really do this? I answer, “Of course I can. Others have done it before me and so can I.” But I’ve never done this. I’ve never been through this. It is SOO overwhelming I can’t even describe it in words.

Then, the logical part of my brain kicks in: Okay, so if you can’t do all of the reading, then probably most other people can’t as well. Just keep working and do the best you can, Nat.

I really hope that working hard and plugging away is enough.

I’m going to school with some pretty cool and interesting people. Several of them even seem balanced so I’m going to try to take some hints from them.

Today, Sonia said that we were really lucky. We get to learn what we really want at an outstanding institution and that’s all that we have to do. We get to do this. It’s a privilege. It’s true. Not an obstacle—a great opportunity.

I get to work really hard and become competent at helping people. I get to be dedicated and focused and supported. I am lucky.

First Day at Clinicals

REFLECTING ON: First day of clinical rotation of first quarter at UCSF, written to fellow classmates...

Just got home a second ago and this is where I am at: I feel tired before I've even begun. Thoughts started percolating about this whole experience so I thought I'd share...please feel free to chime in and reflect too.

As the scrubs hit the laundry basket, the gargantuan-ness (I made that word up) of what I've/we've chosen to take on hit me like an anvil. Despite the fact that I got this week's "to do" lists almost done, I've got my PDA crammed with our schedule to keep me on point, I got books (and even feel like I really dig Patho), and maybe I've got some knowledge about some things in the past, really, when I stop to think about where I'm at right now, I have got no clue.

Clinicals really brought home the reality of this situation.

While on the oncology floor this morning, immune-compromised patients strolled by us, each with about fifteen IV bags filled with chemo, I became pretty damn humble. One patient shuffled on by with her nurse and managed to wave and smile at us. Yeah, I've got good intentions, but I felt like an impostor in my scrubs. You know, kinda like dress up or Halloween. No matter how I try to build myself up in my mind right now, somehow I cannot believe I'm going to be a nurse!

I also can't believe I'm seriously considering buying a fanny pack. Seriously. Though it's ridiculous, the whole fanny-pack thing is an appropriate metaphor in this whole MEPN situation. Two weeks ago, I wouldn't have ever thought that I would DREAM of buying a fanny-pack. I have never liked fanny packs. Even in the early eighties, when I was like five, and fanny packs were considered semi-socially acceptable, I thought fanny packs were silly. Now I think I need a fanny pack and what's worse: I want it to match my scrubs.

I left the comfort of my previous identity and hung it up on the coat rack as I walked into UCSF.

Yes, I know there's a learning curve. And yes I get that I'm really only expected to be a glorified volunteer in the beginning. But that somehow doesn't change the fact that I am really starting to realize the gravity of our work. It's simultaneously intimidating and awesome.

Some part of me keeps on reminding me that starting from scratch is good. You know, like doing pull ups or eating Brussel-sprouts. Builds character--or so I'm told.

I guess that's just it: I thought I was done with my character. I thought I knew who I was. I was competent at what I did--some might even say good. Now I know nothing. Now I am rebuilding my character, or more appropriately put, adding on to what I once thought was finished.

This will be good. Just not always so comfortable.

I am humbled and honored to be in this program with all of you. Truly.

Have a good weekend.

30

As my time at UCSF draws closer, I become more anxious and more unfocused, though its ironic because all my efforts are to become more focused. I spend so much time fretting about what I need to do next—the “plan”—that I seldom get anything done. The image of being stuck in the mud in a truck comes to mind. I really need to relax. I swear I’ve forgotten how, and that, if anything, is what I really need to do before starting this program—full of voomph and vitality—show ‘em I haven’t forgotten how to live. The reason I stress so much is because I feel it necessary to compensate for all the experience and things that I don’t know and haven’t been exposed to. I cannot believe sometimes that I am going into the medical profession. Clearly this wasn’t meant to be. I wasn’t ever on this path. Nobody showed it to me, and yet, here I am—heading down this path that I didn’t think possible.

My mind is a jumble with thoughts of what I was supposed to do and rebelling from that type of functional fixedness. It’s time to look beyond the perceived form and perceived function of my life and really look at what I am all about. I swear I never saw it before. That’s why it’s so important that I relax and flow a little more. Focused flow, if you will. Previously, going to Mexico and traveling would be an ideal way of finding such a thing, but, no longer—not for me right now. I get so out into the universe that I forget how to walk when that happens. If I can just sit, though, and pay attention to what is around me without freaking out everytime I see something—“I must grasp this! I must own it I must own it now. Now I tell you, get in my brain you bastard!” Well, that just doesn’t look good or seem all that enlightened. It’s the juggernaut approach to self-actualization and I like to think that I am ever so slightly more sophisticated than that. Hell, I’m thirty aren’t I? Thirty. Hmmm. 30. I just need to look at the numbers because I just don’t identify them with me. I’m not 30! Not by a long shot. I guess it’s the government and all sorts of social institutions and, by default, my interactions with them that make me tell them that I am thirty makes me thirty, but I am not thirty by a long shot. No siree. Seriously. Fine, I’m a little shook up about it, but this is exactly what I was talking about earlier—I don’t recognize the form of 30 as me, nor its function. People see 30 as old and incapable and stricken with afflictions that make them less viable. I am viable, god damn it. I am viable. I am thinking and focused and more thoughtful than I ever have been in my life. Never mind the filling in of the abs with pudge—the abs are still there—just hiding.

It strikes me now how much I associate physical capability with mental ability. As if I am physically healthier, I can think and remember better—even interact in the world in a more enlightened manner. I suppose that makes sense to a certain degree and maybe I should pursue that—can’t hurt. I do think, however, it’s all rooted in my mind—this stress that I “MUST KNOW THIS NOW”. It’s overwhelming and not helping me at all. I need to relax, sit with, and be patient with the world, and perhaps, I will actually hear what is being said to me instead of it being drowned out by mindless self-chatter.

Yeah. Let’s try that.

Youngblood and me

REFLECTING ON: Adulthood versus childhood....

So, I gotta little story that I must tell. Last week, when I was volunteering at the ER, I met this guy that made me think of my whole Cal experience and thought that I would share. So. First a little background. Every Thursday, I volunteer from 9pm-midnight. In addition to the normal “go-fer” jobs and scrubbing gurneys, it’s my job to relay information between patients and families as well as calm the folks down in the waiting rooms that have been, well, waiting. If you’re a patient, it’s not fun to come to the ER—an unexpected event goes down and then: boom! There you are, stuck in the ER—totally at the whim of the institution and its elements. I get it. It sucks. Some of the waiting room folks get a little cross with me. I try to imagine switching places with them and be as sympathetic as I can. It’s not always so easy. “…No mam, I don’t know what it’s like to not pee for a whole day. It must be pretty painful [woman is also talking on her cell phone while talking to me, she finishes drinking a Diet Coke]. We’re working to get you in as soon as possible. In fact, provided we have no more ambulances come in, you’ll be next. It’s just that we had those three ambulances come in back-to-back with strokes and heart attacks so we had to bump you down. [woman becomes incredulous] Why isn’t it a first-come, first served basis? Well, we have to treat the most severe illnesses first so that those people have a better chance at recovery and, well, don’t pass on. [woman now getting gruff and demanding] Can you at least have some water? Uhm…well. I can check with your nurse, but given your condition it’s probably best that you not drink any more liquids. Drinking liquids will put more pressure on your bladder and increase your pain. I’m not a clinician, but those are just my thoughts. [woman becomes just mean] Okay, I won’t share my thoughts. [husband stands up and demands that I get her water without talking to the nurse] Sir, I understand that this is a really lousy situation that your wife is in but I have to at least check with the nurse about the water. No. No sir, I’m not discriminating against you—I would do the same thing for any patient here.”

All the while I’m trying to be cool, I am wearing khaki pants, white shoes, a white polo shirt, and a RIDICULOUS blue smock that is akin to something you would wear when you were in pre-school and about to get down with some water colors and/or finger paints. It makes me look goofy and a little less like a man. It’s okay though: I’m not there to be a man—I’m there to help out and learn.

So last Thursday, after attending to my normal waiting room duties, I come back into the ER and I notice this guy in the corner. Now normally this particular bed is reserved for the drunks that come in so that they can sober up (read sober up as “pass out and get an IV full of electrolytes and vitamins”). But I notice this guy is anything but passed out. In fact, while lying down on the gurney, he’s jubilantly shouting gibberish rhymes at the top of his lungs while arching his back, belly-up, as if in the throws of a tantric, rhyme-induced orgasm. Hey, at least he’s happy. But he’s also very loud and that doesn’t help the guy next door recovering from a stroke. I walk up to him and he’s singing…

“Ringa ding ding/I can find out if your life is in a sling…”

He’s so tickled by his verse that he shrieks like a two-year old meeting Big-Bird for the first time. It’s at this point that I notice his eyes are like freaking saucers. I mean there is barely any iris to be seen—all pupil. It’s like he’s in the midst of a full, pupil eclipse with the smallest ring of blue surrounding this vacuous black circle. I’m pretty sure he’s on a hallucinogen, though the nurse seemed to think he’s on meth. He has a healthy complexion and I didn’t notice any of the scabs or ashen skin tone that I see with folks on meth. This guy is “on one” in a way that I've seen before. My guess is LSD or mushrooms.

“Ringa ding ding/The man with the ring [he’s looking at my wedding band] thinks he’s the king, while I lay back and bask/The light the light, something I won’t fight, and that my friend is also your task.”

I smile and really look at his face. He looks like an angelic cabbage patch kid. His face is rosy and his blond hair is tussled in every direction. He’s only wearing one Teva and his shorts, I notice, are unzipped. This one-sandaled cherub has got a zeal painted across his face that, though I believe is chemically induced, I am slightly jealous of because he is obviously feeling something good that I am worlds away from. I’m pretty sure that he thinks he has the answer. I’m jealous of that too. I snap away from my thoughts and concentrate on the task at hand. Time to establish rapport. “Hey man, you’re having a good night, huh?”

He squeals with glee. Apparently he has now regressed to around six months old and starts playing peek-a-boo with me. He hides his face under the hospital blanket that is now hiding his unzipped shorts, and then re-emerges with another rhyme. “The cat and the mouse are off to play house/where will you be when…”

The nurse signals me to come over. I excuse myself, but he hardly notices that I have left because I can still hear him reciting more rhymes. The nurse asks that I establish a rapport with him so that we can get his name and insurance information. Our rhyming, saucer-eyed boy is a John Doe at this point. Though establishing rapport was what I was already doing, I acquiesce to the chain-of-command and tell the nurse he’s got a good idea. It’s better than acting like a know-it-all. More squeals in the background. The nurse also charges me with the task of calming him down. I agree, and as I walk back to him, I begin formulating a strategy. Okay, fine. I have no strategy. I really feel that this is one of those things that I am gonna have to feel out. I also wonder if this is a part of a volunteer’s normal duties. No matter. This beats scrubbing blood and feces off gurneys and making runs to the pharmacy. I’m back. He’s in mid rhyme and incorporates my presence into his ramblings. “…and was told with a kiss. Dismiss! Dismiss! The ringed man told Mathias, though I…”

“…sat in a bed and spoke gibberish.” I interrupt and finish his rhyme. He is overjoyed at finding a playmate. Gleaning his name from the rhyme, I realize that the saucer-eyed boy is named Mathias. More squeals—this time louder than before.

“Mathias, I need you to tone it down a notch. Your voice is loud and bothering some of the other patients. We got some pretty sick people here tonight and they’re not having as much fun as you.” He seems to think about what I’ve said but says nothing. I’m surprised. I guess that was the point though—he’s now quiet.

Mathias closes his eyes and smiles. I note to myself that whatever he’s tripping on, he must be having a good trip, because he hardly seems to care that the toe on his non-sandaled foot is bleeding, though not severely. Not only that, one of the veins in his right hand is connected to an IV bag of 0.9% sodium chloride. I've never done hallucinogens, but that’s the sort of stuff that I would perseverate on if I were on tripping. I’m sure I would go into a post-apocalyptic scenario where I wholeheartedly believed that the machines I was attached to were taking over my body. I do that when I’m sober.

I’m also impressed that he’s so upbeat while in the hospital. So much of how I feel is determined by where I am in physical space. I remember once being in the most disgusting bathroom I’d ever been in my entire life: shit smeared on the walls, flies hovering above me, flickering, buzzing fluorescent lights overhead, and an account of a sexual escapade scrawled on the bathroom stall beside me. After taking a quick piss, I almost ran out of there, but then paused and wondered if I was ever locked in a place like this, could I be mentally strong enough in to ever find happiness again. I’m kind of crazy, I think to myself, who thinks like that?

Damn reality…I feel that I have been dealing with it for a while.

While Mathias silently trips, I continue to trip on my own thoughts for a while. First to the front of my mind where there are lists of things to do. I check off bills that I’ve paid and think about how to find scholarships in order to pay for the nursing program I got just into. I wonder if my wife, Masako, is watching TV or studying. I then begin to worry that I haven’t been nice enough to her lately. Being married is a big deal and makes me nervous sometimes. I start thinking about our life together and the concept of “forever”. Our life is finite, but they say that we will be together forever in the ceremony. Wait. No they don’t. They say ‘Til death do us part. Why did I interject the forever part in there? Forever seems a lot more overwhelming than ‘Til death do us part. I take comfort in that thought. Typical me—always making things more overwhelming than they need to be. At least death is guaranteed. My thoughts become tangential and race around in a blue blur for a while. Then I look back to Mathias.

Mathias’ enormous eyes have opened and stare directly at me. Normally I avoid people’s direct stares, but he is so obviously content with life that I allow our eyes to meet for a full minute. Our inhalation and exhalation begins to match. We say nothing. Oh my God, I kind of feel like he’s scraping the back of my brain with his intensity. Then, as if suddenly completely lucid, he says, “I’m glad you’re here.”

I tell him that I’m glad to be there too. Taking note of this sudden fling with lucidity and forever being practically fused the task at hand, I want to ask him what he took, what his name is, and what his health insurance ID is. Bad idea. He’s only begun to come down. I ask Mathias what he’s thinking. Mathias smiles quietly but then suddenly looks overwhelmed. It’s the first time I’ve seen him without the smile of a zealot. Not wanting him to go on a bad trip, I tell him that he doesn’t need to tell me, but that if he wants to talk about what he’s thinking, I’m right there.

“I’m so juiced to be dying,” he says.

My gut reaction is to be sarcastic and condescending. Although normally I would have praise for a thought like this, I have already unconsciously characterized Mathias as a green undergraduate who has yet to truly live independently. How can he possibly be “juiced” to be dying when he’s hardly experienced life? Thoughts like this pass in a flash and then I remember my task. “Why’s that?” I ask, trying not to let condescension creep into my vocal cords.

“We’re living this monument—this huge thing and we get to experience it! Life, man. It’s really fucking spectacular. I feel it right now in every pore of my body.”

Although I continue to feel glib, condescending and dismissive, I want to believe what he’s saying because it’s true. Life is spectacular. Experiencing it is amazing. Why can’t I remember that? At the same time, this little boy named Mathias has barely begun to pay dues or feel the thumb of responsibility.

Suddenly, my mind abandons all pretense. I want to be on what he’s on. I want to feel unworn. I regain mental composure. I reach out my hand to shake his. His hand meets mine. It’s warm. I wonder where his hands have been. I like warm hands better than cold hands, though. “I’m Nat.”

“Mathias,” he replies.

“What’d you take tonight, Mathias?”

“SHROOMS!” he exclaims, and I watch his eyes just about pop out of his head. Just saying the word brings on a psychedelic roll of ecstasy. His eyes roll so far back into his head that I can only see white between his eyelids.

“Nice. So, this may be a silly question, but other than good, how are you feeling tonight? You know, is there anything else going on that you feel?” I’m intentionally not asking his last name and insurance information because I still can’t quite gauge how he will react. I really hope he doesn’t have a rhyming relapse and feel that the wrong question might send him back. Mathias ignores the latter part of my question.

“Really, really good. I FEEL SO FUCKING GOOOD! I feel lucky. Just laying here is soooo good. God damn it’s GOOD!” He begins to howl just like a coyote and bridge his back while thrusting his pelvis towards the heavens. The security guard looks to me for reassurance, I extend my open hand that signals him to hold up for a second.

“Mathias. I know you might have forgotten, but we have some really sick people here tonight. Some of them are on the verge of dying. I think they would like it very much if you could not yell.”

“They’re lucky.” I hear this and my interest in his cosmic voyage slams to a dead-stop. I thought I was condescending. How can he presume to know what they’re going though? He’s lying there, totally healthy, and aside from being in a temporary, self-induced, chemically altered state, he is completely healthy and will walk out of here in a few hours. There’s a woman here tonight who vomited up feces because of intestinal blockage. She also has pancreatic cancer and will most likely die within a couple of days. This kid will probably just get the munchies. I am angry with this boy and want to slap the taste out of his mouth. I hope I am keeping a calm exterior. He begins to speak again, “But I am like them, too. From my first breath I was dying, and so are they.”

I regain a small, tepid interest in his thoughts. At least he’s thinking about interconnectedness. That’s good. "He’s just naïve," I think to myself, "He’s not bad so much as he is green. You were like that once too. In most respects, you still are."

I calm down a bit. I can tell my ears have become red. They do that when I’m holding something in.

“I don’t think there’s any such thing as a selfish action.” Mathias says it in a way that makes me think it is an implied question. I bite. I probably shouldn’t debate with a tripped-out undergraduate in the Emergency Room that is only known by his first name, but I suddenly feel that it is really necessary to ground this guy.

“Well, I gotta disagree with you there Mathias. I think all actions are inherently selfish, except for maybe mothers protecting their children. You know, like the mama bear syndrome? Even then, she’s protecting her kin, not someone else’s necessarily.” As soon as I finish, Mathias is silent and I regret even having entertained what he was saying. Of course, he and I were just both thinking about death as being comforting, so I wonder if he picked up on that?

“What about Mother Theresa?” Mathias questions. I am glad he isn’t tripping so hard. He’s beginning to show signs of logic.

“I’m sure she gets her kicks from helping folks. I mean, I know she does amazingly hard work and it leaves her exhausted, but my gut tells me think that she must get something good out of it. If helping lepers made her feel like she was being rubbed out of existence by a thousand cheese graters, I have a feeling that she would stop. I’m no Mother Theresa, but I like helping people too. Helps me sleep at night—I feel like I’ve maybe left the world a better place than when I woke up. If it made me feel bad, I think I’d stop.” I wonder where the cheese grater metaphor came from. Mathias just harrumphs and wrinkles his forehead. I can tell he’s significantly calmer than twenty minutes earlier. I don’t know why, but I figure it’s time to ask him his name. “Look, Mathias, we gotta get you in our system and give you a name other than John Doe. Even better is if you could also tell me your medical insurance provider, medical ID number, and social security number.”

“Oh. My name is Mathias Youngblood. I don’t know my medical insurance information or my social.”

Wow. He doesn’t know his social security number. Mathias is a child, but at least he’s asking good questions and thinking about interconnectedness. At least I still am too.

“Okay Mathias. I’ll be frank with you. We can either have you figure out this information by calling one of your roommates or you can call your parents. Or, if you like, we can call your parents. Again, I can’t force this information from you, but it would make taking care of you a bit easier. What do you got?” I realize my tone has gone from rapport-building to no-nonsense and decide to tone it down a notch.

Mathias responds surprisingly quickly, as though he really wants to resolve the matter. I’m always surprised when people are cooperative. “Well, I just moved into a Co-op and don’t really think my roommate will be much use to us. Go ahead and call my parents.”

My friend used to live in a Co-op at Cal. That was a place where just about do anything could happen. Always seemed like an adventure was at hand. I remember standing on its roof with a whole bunch of folks, three stories up, and screaming at the sun to celebrate its setting. Wow. That was a long time ago. I’m starting to feel sad—like I’ve lost someone.

My thoughts return to Mr. Youngblood. He still wants to be taken care of. He willingly tells me his full name, address, and contact information for both his parents. I give this information to the nurse and he calls his folks, explaining where Mathias is and how he got there. I can hear Dad yelling over the receiver. I turn to Mathias and he has fallen completely asleep. Apparently the sedative they gave him finally kicked in. I look to the clock and see it’s well past midnight and time for me to go. The smock comes off and I say goodnight to the charge nurse and security guards. I gotta get home and get some sleep—I got work in the morning.

UCSF!

A flood of things to write about. The most of important of which is that I got into UCSF!! I really can’t believe it. I almost think that I’m not worthy. There’s something there that I need to think about, but it’s too late to get too deep tonight. I had to read the letter three times and then over the phone to my Mom to believe it. Wow. Life is going to change significantly.

"You Want Mayo"

REFLECTING ON: Feeding a quadriplegic man as a volunteer, written as assignment for Communications class on the importance of listening, pre-UCSF

In my spare time, which I don’t really have a lot of, I volunteer in the Emergency Department of a hospital in the East Bay. It’s a trip. In addition to cleaning up gurneys that have been peed, pooped and bled on, I spend a lot of time running around, acting as a communication liaison between patients and their anxious family members out in the waiting room. “Anxious” is a nice way of putting it. At any rate, the conversations I have, by and large, are very much one-sided where I am listening to or diffusing some sort of frustration that someone is experiencing. I sympathize with the patient’s and family’s situation—it sucks to have to wait for several hours in the ER while someone else is almost completely in control of your fate. I get it; I try not to take that little fact for granted. The conversations that I have with these folks, however, typically aren’t very long—two minutes tops. Last night, however, a nurse asked me if I could feed a man whom we’ll call Ishmael. Ish, which I called him, is a quadriplegic. He was in the hospital for some infected bedsores and just had some pain medication. The food, he said, helped settle his stomach from the medication. When I heard the cross-over about Ish, my mind immediately raced to the thought, “If he’s a quad, why would he need pain medication since he can’t feel anything.” Then I just let it go. Shit, if I were paralyzed from the neck down, would want some painkillers too.

The point here, however, is that while I fed this man his turkey sandwich, I realized I became the most attentive listener that I have ever been. I listened with my ears and eyes, watching and listening for the subtlest cues as to what he wanted to do next: talk or eat. I knew that he knew that I didn’t know how to feed him and I so I told him so. He just said, “That’s alright, just ask yourself how you would want to be fed a turkey sandwich, and then verbalize those questions to me.”

“You want Mayo?” I asked, and took it from there. I watched his eyes dart to what he wanted while we chitchatted about other things like the tattoos on his arms. I thought it was cool that a quad would get ink done despite having “non-working” arms and legs. He was a pretty self-aware person—able to see how newbies like myself saw him and made subtle efforts to distract me from be overwhelmed by his general situation in life. The tattoos were a good example of that—it diverted my thoughts from his gnarled fingers and emaciated arms and made me think of his life beyond the bed. Pretty clever really. Of course, maybe I’m over thinking things—maybe he just liked tattoos. At any rate, as we talked about the symbolism of the monkey-riding-the-elephant tat that he had on his right shoulder, I intuitively put down the sandwich, grabbed the can of coke, put a straw in it and gave him a sip. He burped, and I gave him another bite, noticing that he didn’t like eating the crust. When he was all done I wiped his mouth off with a napkin and then the transport person came and got him. While he was being wheeled away he said, “Good talking to you.”

“Likewise,” I said, though I really had hardly spoken but a few questions.

Ish’s obvious, physical need made me listen better than I had in a long time. I was able to listen with all my senses. The subtle yet distinct dignity with which Ish conducted himself made me wonder if I could be as perceptive as he obviously was. It seems to me that although many of us have the less obvious, less physical needs than Ish, we often still need to have those needs perceptively listened to.

Running While Laying down

REFLECTING ON: Interaction with dying patient while volunteering in East Bay Emergency Room, pre-UCSF

Tonight, my glass is filled with wine and I’m raising it to Mrs. Martinez. I will quaff deeply, and breathe easy, for Mrs. Martinez. Just an hour ago, I watched this short little abuela struggle to breathe in her own body. Her lungs were filled with fluid from pneumonia and her cancer had metastasized to her chest cavity, putting added pressure on her lungs. Normal breathing rate is 12-15. She was breathing 40 breaths per minute while sitting down. She was running a marathon without moving. It’s weird the things that I notice while events like this are going on—she was still wearing her knit hat to cover her shiny baldhead, even when the physician was intubating her trachea. They administer drugs that paralyze her swallowing/gag reflex muscles like succinylcholine. And here I am, taking mental notes on the procedure, drugs that are administered, O2 levels, hear rate, and such, but I wasn’t totally sure that I should be there. They made the family members leave the room yet I was permitted to stay. The doctor even asked me top close the curtain so that nobody else could see. I suppose I get to stay because I know how to react in this situation—which is to not react, speak succinctly when spoken to, do what your told, and stay out of the way. The family might get hysterical, I suppose, and interfere. But it’s their grandma—their mother. I watched one nurse joke with another nurse while he was administering paralytic drugs to her chest and throat muscles. I kind of wanted to slap him awake so he could see how desensitized he appeared. Like I said, this is someone’s blood—best not to take that for granted. Then again, sometimes it’s the distance that allows us to do an “objective” job. I felt like a fly on the wall—a gnat that nobody wanted around. I guess everybody has to learn in some manner or another, and shit, that’s why I took this no-pay gig…this is all for the experience. I can’t help but be pissed at the college students that come in drunk with debaucherous, self-inflicted injuries when there are folks like Mrs. Martinez one room away. Self-inflicted injury just seems so fucking selfish and wasteful—a waste of time and resources that could be better allocated to people that are legitimately in need. It’s one in the morning and I gotta wake up early. Not only that, I got to wake up early, be on my shit, and I NEED to learn Spanish. I spoke Spanish two times this evening and made things work because of it. I gotta get fluent.