Tuesday, October 23, 2007

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.

Friday, October 12, 2007

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.