My little brother, Elliott, was born at eight and a half months with a clubfoot. That was an outstanding outcome given the complicated nature of the pregnancy. Under doctor’s orders, my Mom had been bed-bound for the last three months of her pregnancy after her amniotic sac prematurely broke, induced labor but then miraculously resealed itself. Bottom line: today Elliott is healthy and my hero. He's 22 now and going to nursing school.
Elliott’s actual birth followed the pregnancy’s theme of dramatic and unexpected events. Already on edge due to the previous complications, when my Mom’s water broke for the second time at 5:30 am on November 19, 1986, my Dad drove us to Kaiser Sacramento at over 100 miles per hour. I was nine years old. When we arrived, all the doors of the hospital were locked due to an ongoing nursing strike. We pounded on the doors for what seem like hours. My Dad had me run up and down the hospital looking for open doors. As I ran, I can distinctly remember watching nurses picketing while my Mom lie panicked on the sidewalk. I did not understand why they wouldn’t help us. I still don’t. My Mom suddenly screamed in panic because she knew Elliott was well on his way. This was her third child. My Dad, always heeding the call of an emergency, grabbed the locked steal and glass sliding door, and with the superhuman strength that you read about, unhinged the door and moved it to the side. An alarm went off that triggered the attention of an irritated, all too casual nurse to walk down an extremely long hallway and yell at us, “What the hell is your problem?” My Dad ignored her, carried my Mom passed her and to the nursing station of the birthing center, and got the help of a more interested staff member. Almost fully dialated, she went straight to the birthing room. While on the gurney, my Mom howled just like a wolf and could be heard throughout the hospital.
In the shuffle, I was left with the nurse we had first met. She put me in a little square room and said, “That your Mom?” I nodded, she snorted, told me to stay put, and closed the door. I REALLY didn’t like her. Following my Dad’s example, I ignored her and left the little square room and followed the still audible howls. In my mind, the hospital staff was suspect and I wanted to make sure my Mom was okay.
I followed my Mom’s howls through a labyrinth of hallways and doors. I found her. The birthing room had a large window and I had arrived just in time to see my Dad cutting Elliott’s umbilical cord. Elliott was born at 7:00 am. Another nurse came up to me and told me I wasn’t supposed to be there. I just looked up at her and pointed through the glass and said, “That’s my brother.”
Showing posts with label nursing. Show all posts
Showing posts with label nursing. Show all posts
Tuesday, June 9, 2009
Thursday, May 1, 2008
“There’s a boy in here”
This is me venturing out of my personal narratives and into an op-ed style...
While doing an observation at a pre-school for my Pediatric Nursing course, a four-year-old girl entered the classroom and, curious to identify the strangers in her classroom, asked her teacher, “Who are the new people?” Her teacher responded plainly by stating that we were nursing students. The little girl’s face quickly changed from an innocent and curious expression to being conflicted and confused. She took a long pause and then looked up at her teacher and said, “But there’s a boy in here.”
Indeed there is a boy in here—right smack-dab in the middle of many people’s privately held stereotype of what a nurse looks like. The little girl, of course, is certainly not without adult company. On more than one occasion I have been asked, “So you’re going to be a male nurse?” as if I was still in the process of choosing my sex as well as my profession.
Yes indeed! I’m a “murse”. Or, more accurately, a “mursing” student. And to be perfectly honest, I’m never offended by people’s surprise at a man becoming a nurse; not only do I revel in throwing people for a loop, I understand that some part of their stereotype is not without basis. According to the 2002 U.S. Department of Health and Human Services’ National Sample Survey of Registered Nurses, only 5.4 percent of RNs in the United States are men. Given the fact that registered nurses constitute the largest health care occupation, with 2.5 million jobs, the chances of interacting with a female nurse are pretty likely.
What does trouble me, however, is the all-too-frequent follow up question, “Why didn’t you go to medical school?” Given that 72.2 percent of physicians are male, I suppose I should probably expect this question, too. And yet, I am simultaneously fascinated and deeply concerned by how infrequently the flip side of this question, “Why didn’t you go to nursing school?” isn’t being asked of medical students. Clearly, nursing is not on equal footing with medicine.
I believe that the reason that this question isn’t asked points to a different, very misguided part of the nursing stereotype that is seldom discussed openly: that nursing is some sort of a lesser, sloppy-second alternative to medicine—particularly for a boy. I take serious issue with this aspect of the stereotype not only because is it categorically untrue, but also because this belief is extremely dangerous due to its roots in the long-standing power struggle between men and women. Historically, women have been professionally subjugated to men due to the inaccurate and sexist perception that men are smarter than women.
The reason that this hushed stereotype still exists is rooted in socially constructed and learned behavior. As exemplified by the four year-old at the pre-school, from a very young age we learn gender rules on a variety of subjects that range from toys and clothes to behavior and jobs. Consequently, I believe that the average Joe and Josephine on the street quietly subscribes to the idea that nursing, being female dominated, is also associated with the female personality attributes of caring and empathy while medicine, being male-dominated, is associated with the male personality attribute of scientific objectivity. Or, put more simply, RNs are sensitive girls and doctors are scientific boys. Furthermore, this translates to why Joe and Josephine view medical science, being more quantifiable than the ever-ambiguous emotion, as being equated with intelligence, while they view nursing as less intelligent.
It is absolutely time to smash these perceptions. Easy. Although it is true that nursing fosters a slightly more nurturing perspective than medicine, nursing is an incredibly dynamic field that includes nursing research on subjects not traditionally associated with nurses. For example, a colleague of mine, Monica R. McLemore, a Ph.D. Candidate and American Cancer Society Fellow at the University of California, San Francisco School of Nursing, recently described her research to me, “Simply put, I study the isoforms of CA125, which is a tumor marker of ovarian cancer. I also attempt to correlate these isoforms (using kilodalton size as a proxy for the true amino acid sequence, since I'm not THAT well funded) to serum concentration.” How about them apples?
As a man within a traditionally female-dominated profession, I am acutely aware of the fact that my presence in this profession is still perceived with some discomfort due to the fact that the socially constructed stereotypes of yesteryear still govern many people’s perception of the field. My message to you is this: let’s evolve people. It is absolutely time that we embrace a more enlightened perspective in order to truly understand the incredibly dynamic and diverse field of nursing.
While doing an observation at a pre-school for my Pediatric Nursing course, a four-year-old girl entered the classroom and, curious to identify the strangers in her classroom, asked her teacher, “Who are the new people?” Her teacher responded plainly by stating that we were nursing students. The little girl’s face quickly changed from an innocent and curious expression to being conflicted and confused. She took a long pause and then looked up at her teacher and said, “But there’s a boy in here.”
Indeed there is a boy in here—right smack-dab in the middle of many people’s privately held stereotype of what a nurse looks like. The little girl, of course, is certainly not without adult company. On more than one occasion I have been asked, “So you’re going to be a male nurse?” as if I was still in the process of choosing my sex as well as my profession.
Yes indeed! I’m a “murse”. Or, more accurately, a “mursing” student. And to be perfectly honest, I’m never offended by people’s surprise at a man becoming a nurse; not only do I revel in throwing people for a loop, I understand that some part of their stereotype is not without basis. According to the 2002 U.S. Department of Health and Human Services’ National Sample Survey of Registered Nurses, only 5.4 percent of RNs in the United States are men. Given the fact that registered nurses constitute the largest health care occupation, with 2.5 million jobs, the chances of interacting with a female nurse are pretty likely.
What does trouble me, however, is the all-too-frequent follow up question, “Why didn’t you go to medical school?” Given that 72.2 percent of physicians are male, I suppose I should probably expect this question, too. And yet, I am simultaneously fascinated and deeply concerned by how infrequently the flip side of this question, “Why didn’t you go to nursing school?” isn’t being asked of medical students. Clearly, nursing is not on equal footing with medicine.
I believe that the reason that this question isn’t asked points to a different, very misguided part of the nursing stereotype that is seldom discussed openly: that nursing is some sort of a lesser, sloppy-second alternative to medicine—particularly for a boy. I take serious issue with this aspect of the stereotype not only because is it categorically untrue, but also because this belief is extremely dangerous due to its roots in the long-standing power struggle between men and women. Historically, women have been professionally subjugated to men due to the inaccurate and sexist perception that men are smarter than women.
The reason that this hushed stereotype still exists is rooted in socially constructed and learned behavior. As exemplified by the four year-old at the pre-school, from a very young age we learn gender rules on a variety of subjects that range from toys and clothes to behavior and jobs. Consequently, I believe that the average Joe and Josephine on the street quietly subscribes to the idea that nursing, being female dominated, is also associated with the female personality attributes of caring and empathy while medicine, being male-dominated, is associated with the male personality attribute of scientific objectivity. Or, put more simply, RNs are sensitive girls and doctors are scientific boys. Furthermore, this translates to why Joe and Josephine view medical science, being more quantifiable than the ever-ambiguous emotion, as being equated with intelligence, while they view nursing as less intelligent.
It is absolutely time to smash these perceptions. Easy. Although it is true that nursing fosters a slightly more nurturing perspective than medicine, nursing is an incredibly dynamic field that includes nursing research on subjects not traditionally associated with nurses. For example, a colleague of mine, Monica R. McLemore, a Ph.D. Candidate and American Cancer Society Fellow at the University of California, San Francisco School of Nursing, recently described her research to me, “Simply put, I study the isoforms of CA125, which is a tumor marker of ovarian cancer. I also attempt to correlate these isoforms (using kilodalton size as a proxy for the true amino acid sequence, since I'm not THAT well funded) to serum concentration.” How about them apples?
As a man within a traditionally female-dominated profession, I am acutely aware of the fact that my presence in this profession is still perceived with some discomfort due to the fact that the socially constructed stereotypes of yesteryear still govern many people’s perception of the field. My message to you is this: let’s evolve people. It is absolutely time that we embrace a more enlightened perspective in order to truly understand the incredibly dynamic and diverse field of nursing.
Tuesday, December 11, 2007
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.
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.
Friday, December 7, 2007
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
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
Wednesday, November 7, 2007
"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.
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.
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.
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.
Monday, March 12, 2007
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.
Friday, September 1, 2006
UCSF Personal Statement
REFLECTING ON: I guess the entrance people read this and thought it was good enough...gives you and idea of what I did before UCSF...
Shortly after graduating from Berkeley, I found myself standing in front of thirty-five street-wise sixth graders in a dilapidated classroom in Newark, New Jersey. I was drawing a diagram of the irrigation systems of ancient Mesopotamia. My back was to the class and I heard someone cracking jokes about my drawing. It was Esperanza. After making several home visits to determine why Esperanza never did her homework, I discovered that her father was a crack addict and that her mother was a prostitute. Despite her distressing living situation, Esperanza still smiled at me and quipped that I was a better teacher than an artist. Then she stopped smiling, looked me dead in the eye and said, “Mr. Chadwick, I don’t mean to be rude, but what the f--- do I need to know this for?” The class collectively gasped and I had an epiphany: not only did few of these kids care about ancient Mesopotamia, but this knowledge could not help them at all with their most pressing problems. It was in this moment, in the heart of Newark, that I dedicated my life to helping people who had the greatest and most immediate needs.
Esperanza's question has had a profound effect on my professional career. Since that time, I have only held occupations in which I could help underserved youth with their most urgent needs. Upon returning to the Bay Area, I filled the role of surrogate parent to twelve severely emotionally disturbed (SED) boys as a group home counselor at St. Vincent’s School for Boys. During twenty-four-hour shifts, I learned to navigate the ebb and flow of their volatile natures while teaching them basic life skills. Next, I continued my work at Treasure Island Job Corps where I forged partnerships with local businesses and unions in order to place inner-city youth in construction and childcare jobs. Most recently, I returned to the classroom at Timothy Murphy School in order to teach academic subjects to the St. Vincent’s population. Though it was not uncommon for me to dodge a thrown chair in the middle of a lesson, my student’s extraordinary stories of survival and obvious need inspired me to show them how learning could enrich their day-to-day lives.
Whether I was working with a “student” or a “client”, I came to realize that the most appealing part of my work has been helping each person to gain the tools they need to survive their personal crises. I have chosen to pursue a career in nursing because it is a natural extension of my desire and talent for helping people through extraordinarily stressful circumstances. Nursing offers me the unique opportunity to integrate my crisis management experience with a precise set of science-based assessment and intervention skills that will have a significant impact on the health of an individual. Taking Chemistry, Physiology, and Anatomy has only confirmed my sincere interest in understanding the human body and has further inspired me to learn the methods to heal it. In order to help the people that are most critically in need, I intend on becoming a Critical Care Clinical Nurse Specialist in an Emergency Department. Through direct patient care, I believe that nurses are the critical link between a patient’s needs and the road to recovery. I am excited to combine the skills I have acquired as an educator and social worker with those that I will learn in order to become an outstanding nurse.
To gain a better understanding of Critical Care Nursing, I have been volunteering weekly in the Emergency Department of an East Bay hospital. Knowing that all experience is what one makes of it, I have observed, investigated, and absorbed as much as possible. Mostly though, I clean as many beds and stock as many supplies as quickly as I can so as to let the nurses and doctors do their work. And they do work. Hard. I once asked a veteran nurse named Maureen why she had become a nurse. Immediately “Moe” sized me up for what I was: a little green. She said that although she did her job because she enjoyed helping people, “it ain’t all superman stuff where you’re bringing someone back from the brink of death. Sometimes you’re just wiping butts.” At first I was puzzled by Moe’s blunt response. Then I realized that she was testing me. Moe was trying to tell me that there are many parts of caring for and healing a person and some of those duties are far from glamorous.
Although indeed “it ain’t all superman stuff,” each interaction with a patient or their family is a unique opportunity for assessment and intervention, no matter where that assessment might take you. I have watched in awe as RNs skillfully and thoughtfully navigate the countless different situations that bombard the Emergency Department. I have observed RNs assist in resetting dislocated shoulders, rapidly assess heart attacks and administer nitroglycerin, restrain violent drunks, soothe a woman that had to identify her deceased sister, irrigate the wound of a man that was hit directly between the eyes with a hockey puck, calm an erratic 17 year-old that had ingested psychedelic mushrooms, do a blood transfusion on a woman with a hemoglobin level of three and a scabies infestation, and perform countless other duties that boggle my mind. Even more impressive than the breadth of technical knowledge the RNs applied in each case was the obvious compassion they showed each patient.
I want this job. I want to know how to do what they do.
I am resolute in my decision to become an Emergency Room nurse. Emergency nursing enthralls me because I can fundamentally help people to heal, and in turn, pursue the things that give their life meaning. It would be an honor and a privilege to undertake my nursing education at UCSF.
Shortly after graduating from Berkeley, I found myself standing in front of thirty-five street-wise sixth graders in a dilapidated classroom in Newark, New Jersey. I was drawing a diagram of the irrigation systems of ancient Mesopotamia. My back was to the class and I heard someone cracking jokes about my drawing. It was Esperanza. After making several home visits to determine why Esperanza never did her homework, I discovered that her father was a crack addict and that her mother was a prostitute. Despite her distressing living situation, Esperanza still smiled at me and quipped that I was a better teacher than an artist. Then she stopped smiling, looked me dead in the eye and said, “Mr. Chadwick, I don’t mean to be rude, but what the f--- do I need to know this for?” The class collectively gasped and I had an epiphany: not only did few of these kids care about ancient Mesopotamia, but this knowledge could not help them at all with their most pressing problems. It was in this moment, in the heart of Newark, that I dedicated my life to helping people who had the greatest and most immediate needs.
Esperanza's question has had a profound effect on my professional career. Since that time, I have only held occupations in which I could help underserved youth with their most urgent needs. Upon returning to the Bay Area, I filled the role of surrogate parent to twelve severely emotionally disturbed (SED) boys as a group home counselor at St. Vincent’s School for Boys. During twenty-four-hour shifts, I learned to navigate the ebb and flow of their volatile natures while teaching them basic life skills. Next, I continued my work at Treasure Island Job Corps where I forged partnerships with local businesses and unions in order to place inner-city youth in construction and childcare jobs. Most recently, I returned to the classroom at Timothy Murphy School in order to teach academic subjects to the St. Vincent’s population. Though it was not uncommon for me to dodge a thrown chair in the middle of a lesson, my student’s extraordinary stories of survival and obvious need inspired me to show them how learning could enrich their day-to-day lives.
Whether I was working with a “student” or a “client”, I came to realize that the most appealing part of my work has been helping each person to gain the tools they need to survive their personal crises. I have chosen to pursue a career in nursing because it is a natural extension of my desire and talent for helping people through extraordinarily stressful circumstances. Nursing offers me the unique opportunity to integrate my crisis management experience with a precise set of science-based assessment and intervention skills that will have a significant impact on the health of an individual. Taking Chemistry, Physiology, and Anatomy has only confirmed my sincere interest in understanding the human body and has further inspired me to learn the methods to heal it. In order to help the people that are most critically in need, I intend on becoming a Critical Care Clinical Nurse Specialist in an Emergency Department. Through direct patient care, I believe that nurses are the critical link between a patient’s needs and the road to recovery. I am excited to combine the skills I have acquired as an educator and social worker with those that I will learn in order to become an outstanding nurse.
To gain a better understanding of Critical Care Nursing, I have been volunteering weekly in the Emergency Department of an East Bay hospital. Knowing that all experience is what one makes of it, I have observed, investigated, and absorbed as much as possible. Mostly though, I clean as many beds and stock as many supplies as quickly as I can so as to let the nurses and doctors do their work. And they do work. Hard. I once asked a veteran nurse named Maureen why she had become a nurse. Immediately “Moe” sized me up for what I was: a little green. She said that although she did her job because she enjoyed helping people, “it ain’t all superman stuff where you’re bringing someone back from the brink of death. Sometimes you’re just wiping butts.” At first I was puzzled by Moe’s blunt response. Then I realized that she was testing me. Moe was trying to tell me that there are many parts of caring for and healing a person and some of those duties are far from glamorous.
Although indeed “it ain’t all superman stuff,” each interaction with a patient or their family is a unique opportunity for assessment and intervention, no matter where that assessment might take you. I have watched in awe as RNs skillfully and thoughtfully navigate the countless different situations that bombard the Emergency Department. I have observed RNs assist in resetting dislocated shoulders, rapidly assess heart attacks and administer nitroglycerin, restrain violent drunks, soothe a woman that had to identify her deceased sister, irrigate the wound of a man that was hit directly between the eyes with a hockey puck, calm an erratic 17 year-old that had ingested psychedelic mushrooms, do a blood transfusion on a woman with a hemoglobin level of three and a scabies infestation, and perform countless other duties that boggle my mind. Even more impressive than the breadth of technical knowledge the RNs applied in each case was the obvious compassion they showed each patient.
I want this job. I want to know how to do what they do.
I am resolute in my decision to become an Emergency Room nurse. Emergency nursing enthralls me because I can fundamentally help people to heal, and in turn, pursue the things that give their life meaning. It would be an honor and a privilege to undertake my nursing education at UCSF.
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