Hey, Folks!!
I am home with the craziest migraine today. I get them from time to time. I can mostly muscle through them, but I've had this one for 3 days. Just sitting here looking at this computer screen makes my left eye feel like it wants to explode.
Definitely time for some intervention, so I am going to get a shot of Imitrex in a little bit. Its nice to be able to get seen at the doctor's office on a moment's notice. Membership does have its privileges.
Its funny how we get our inspiration sometimes. I've been somewhat of an insomniac for the past few years, usually getting by on 4 - 6 hours sleep in a good night. That's 2 - 4 hours on a really bad night. Sleep has never really been a close friend of mine.
Part of managing my migraines is making sure I don't go without enough sleep for too long or it will catch up with me. And since I've probably only slept a total of 10 hours the last 3 nights, the severity of this migraine has come as no surprise to me.
But Sunday night when I found myself imitating a raccoon at 2 am, I started flipping through channels on the TV and landed on channel 72, which is the Oprah Winfrey Network. I was kind of geeked to see that "March of the Penguins" was about to come on. I guess if I was going to sacrifice a good night's sleep, watching these odd little birds and listening to Morgan Freeman's flawless narration was as good a reason as any.
It was the first time I'd seen it since it came out in the IMAX theaters in 2005. If you've never seen it you should. It is one of the most beautiful films I've ever watched. The plot revolves around the migration and mating rituals of penguins in Antartica. Their existence hinges on the thousand year old tradition and for reference, the animated movie "Happy Feet" is loosely based on the premise of "March of the Penguins."
After mating, the female penguins leave the mating grounds, with their eggs in the care of the male, to make the long hike back to the water's edge to gather food for their soon to be born chicks. That journey takes nearly 2 months, which means that the male penguins would go without food for that entire time. Many of the male penguins would not survive those two months and in turn, neither would their chicks. For the father penguins that did survive, if their chicks hatched before the females made it back with food, there was a good chance that they would die of hunger.
I was lying in bed, thinking that being a penguin might be the most awful thing to be in the world. If I was a penguin, I'd pray that some adventurous human caught me in a net and sold me to the zoo. They could put me with a nice, civilized male penguin. Once my egg was laid, the nice zoo people could put it in a warm incubator until it was ready to hatch. See all that hiking back and forth in all that cold, dodging walruses, and scrounging for food when there is a good chance that in the end it might all be for nothing??? Stop playing. Ain't nobody got time for that.
As the scene of the female hike cuts to the mass of male penguins huddled together, plodding slowly about the mating ground, trying to shelter themselves and their unhatched babies from the bitter cold, Morgan Freeman's easy voice interrupted the silence.
"No matter how cold it is or how hungry they are, the fathers must keep moving. If they don't, they will die."
It's easy to forget that "survival" is a relative term.
What we consider necessary to survive is completely based on our own egocentric view of life and what we have gotten used to.
Same for penguins.
Same for my patients.
Last week, I saw a young, female patient who had been living on the street for years. She had been trying to get a bed at the shelter for some time, but she had to kick her drug habit before they would take her in. She had been given temporary housing at a half-way house but said that she did not feel safe there. So she chose to live and sleep on the streets.
I asked her how she could feel safe sleeping in public bathrooms, in parks and at transit terminals, but not in a secured, supervised place.
She looked at me and said, "Yeah. The house I grew up in was supposed to be a secure, supervised place, too. I expect to find trouble in the streets."
That was lost on me until her case worker let me in on her history. She'd suffered multiple kinds of abuse at the hands of her stepfather, who had actually beaten her to within inches of her life at one point. Her mother would make the excuse to the schools that it was discipline for her rebellious nature. DSS had taken her away for a short time, only to send her back to have the cycle repeat itself. Broken jaw. Bruised lung. Forced abortion under the suspicion that the baby was her stepfather's. She finally left when she 17 and never looked back.
She was kind of like the penguins.
No matter how cold or hungry she got in those streets, she had to keep moving. Her survival depended on it.
On Friday afternoon, as I was leaving to go run an errand, she stopped me and told me that for the last few nights she had been sleeping on the sidewalk. She had used flattened cardboard boxes for padding and a trash bag for cover. She asked me if there was any way I could get a blanket for her.
I told her that I would see what I could do, but I had all intentions of telling her I asked around and could not find one when I came back.
But as I pulled back into the shelter parking lot and pressed my key fob to lock my car doors, I remembered that I had one of my daughter's blankets and pillows that she used for school naps and road trips in my trunk.
It took me a second to decide that I would let my patient have them, because it was my baby's pink velour blanket and her Disney Princess pillow, which I knew were her favorites. Having "favorites," though, meant that she had a variety to choose from.
Even in a matter of life and death, my patient, like the penguins, didn't have as many options.
So I popped my trunk, took out the blanket and pillow and walked back into the shelter courtyard where I saw the patient looking like she had waiting on me.
When she saw the blanket and pillow in my hands, a grin spread across her face and she ran and hugged me to the point that I was embarassed by the attention that it got from the other residents standing outside.
I told her that my child would be very upset if she knew I had given away her favorite blanket and pillow.
The patient apologized and said, "I'm sorry. I hope she's not too sad."
The truth is that it's ok.
She might be sad for a second.
But the important thing is that she'll survive.
Towanna
Tuesday, August 28, 2012
Thursday, August 23, 2012
Jesus & Michael Jackson...and Star Wars
Good morning, All!!!
First, prayers go up to KB and her family as her Mom recovers from a recent heart attack. She is a living witness that what looks impossible to man is so easy for God.
2 Corinthians 5:17. That power right there can heal a broken spirit and the wounded flesh. Better get you some.
I got a call the other day about some health ministry business at the church back home. I am trying to decide how involved I am going to get into that situation at this point. Not because I don't want to get involved, but when I was fully involved, I experienced some of that church politickin' that I've heard so much about. Didn't like it. Not one little bit.
But don't get me started on that. This blog might get shut down.
Its cool, though. I finally realized that God has given me gifts that the people at home needed, but were not ready to accept from me. As much as I wanted to bring better things to my people at home, God had to move me out of that situation to show me that the work that He sent me here to do was not going to get done in that environment. And I have been judged harshly for that.
The good thing is that harsh judgment is the proof that what I did was right. Otherwise, I'd be still pulling my hair out trying to please people who had already made up their minds that they were not going to be pleased. Especially not by me.
Chile. Boo.
God sent me here to save the world. I don't owe anyone an explanation of my purpose.
Plus, I don't know about you, but ain't nobody over here got time for that.
But I digress. Because only Jesus and Michael Jackson know what I mean.
I was talking to my supervising physician the other day about how I wanted to go into emergency medicine in my next life. That adrenaline rush is something else.
I told him how frustrated I get when a patient comes to me from the hospital or emergency room without complete care, like just enough was done to justify getting them out of there.
Its just seems like we need folks to change the culture of emergency medicine in this area. Especially for the poor and uninsured populations.
I have an elderly, male patient who is diabetic. He'd had a toe amputated a couple of weeks before the first time I say him. He said that he had seen the surgeon just a few days before that and had been released from care. He had been being seen at a free clinic to have his diabetes managed. Obviously, though, the diabetes had not been under good control as witnessed by the fact that he had to have a toe amputated.
He was coming to see us to establish care and said that he was told by the surgeon to follow-up with a primary care provider for management of the amputation site. I took a complete health history that was only significant for a personal and familial history of diabetes. He had no history of drug, tobacco, or alcohol use. His blood pressure was excellent and his weight was appropriate for his height.
But when I asked him about his medications we hit a bump in the road.
He was wearing an old-school fanny pack. He unzipped it and started pulling out insulin pen after insulin pen after half-empty insulin pen. Lantus. Novolog. Regular and 70/30. Humalog. Levemir.
"Which ones are you supposed to be using?" I asked him.
His reply: "What's the difference?"
Among other things, he told me that he was using the insulin 3 times a day after meals and wasn't really sure what combinations of insulin he was using. What he did tell me was that he usually gave himself 2 - 6 units each time depending on what he ate and that he did not have a meter to check his blood sugar.
His finger stick blood sugar and rapid A1C in the office that day was 174 fasting and >13.0 respectively.We drew a complete metabolic panel to check his kidney and liver function and a lipid panel to assess his cholesterol.
His physical exam was essentially normal.
That is until we got to his feet.
Now I am no surgeon, but I was pretty sure that releasing this man from his care was probably not a good idea.
Where the "pinky" toe of the right foot had been was a open wound, oozing green and yellow pus with a gangrenous flap of skin hanging off. The other four toes were all blistering, bleeding, or oozing pus in some combination. It was obvious that he was going to have to lose at least part of that right foot. The left foot was in better shape, but not by much. If he did not have some intervention immediately, it would suffer the same fate as the right one.
As I stood there examining his wounds, it suddenly hit me that he had not made a sound the entire time...because he had absolutely no feeling his feet at this point. The out of control diabetes had completely compromised his circulation. There was no telling how long he had been walking around like that.
We were able to get in touch with the surgeon's office. It was Friday and he had left early, but I did speak to his nurse who gave me an appointment for first thing Monday morning. I told here that I would clean and dress his wounds and put him back on some antibiotics until then.
As I suspected, the surgeon decided to amputate his forefoot. The surgery was scheduled for Wednesday morning. I fully expected that we would not see him back at the shelter until at least late Thursday or Friday morning.
But I should have known better.
That same Wednesday afternoon, one of the shelter's staff came to the clinic area and asked KB and I if we had time to come check on a patient that was bleeding in the day room.
We followed him through the double doors to the day room and our eyes settled on a heavy trail of blood leading to a table near the front desk. When we finally spotted the source of the bloody scene, I realized it was my patient. He'd had his foot amputated that morning and was discharged back to the shelter just hours later. The patient's story was that he stayed in recovery for about 2 hours before he was discharged. He had walked back to the shelter from the hospital.
No wheelchair. No crutches. Just a gauze dressing and a blue "shoe" with velcro straps.
His leg was propped up on a chair and underneath the chair was a widening pool of blood. His once white bandages were completely red and blood was actively pouring from the wound. The patient was sitting there like nothing had happened and I was actually grateful for the fact that he could not feel anything. I asked the shelter staff to call 911 because there was no way I would be able to stop that bleeding. KB and I gloved up and began to wrap his foot with layer upon layer of gauze. It only took the ambulance a few minutes to get to us, but by the time they did, there was a red spot growing on the wad of gauze we had just put in place.
Not long after the ambulance picked him up, he was back at the shelter. Apparently, on the walk back to the shelter, he'd busted open his stitches. At least this time, the hospital had given him a cab token for the ride back.
I saw him back a few days later. He'd been set up to be seen at a foot clinic for follow-up. We got him a new meter, ordered him some diabetic shoes and started him on Metformin, Lantus and 2.5 mg of Lisinopril for kidney prophylaxis. I thought about adding mealtime insulin, but felt that it would just complicate things for him at that point.
Plus, and I don't know if this can really be described as a good thing, but the good thing about many diabetic homeless patients is that most of the time, they have not been taking their medicine correctly, if at all. That means that even if their A1C is off the chart, there is great potential that you will have a marked improvement in the control of their blood sugar within the first few months of consistent therapy.
All of this happened a couple of months ago. I've seen the patient back a couple of times. KB and I have taken a lot of time educating him on his diabetes and his treatment regimen. In the process of all this, we found out that he only has a 3rd grade education and can barely read.
He also told us that he actually had a meter at one time, but that he did not know how to use it. No one ever offered to show him how to use it, so he just didn't. We made sure that we got him a one touch meter with visual prompts to make it easier for him.
Sometimes, it just takes us to recognize that a patient's failure to take care of themselves may be based upon our failure to give them all the tools they need to do so. The patient-provider relationship is meant to be both altruistic and symbiotic. Responsibility for success and failure must be equally shared.
That patient is doing very well these days. He came into the clinic for labs earlier this week was ecstatic to show us his blood sugar diary. His fasting that morning was 96. I can't wait to see what his A1C looks like.
I am proud of and excited about the work that we do in the community. AF and HL are doing a great job at planning health education program planning for the residents at the shelter. We have our diabetes class coming up here soon and the turnout should be massive.
My work has got me giddy. Like a Star Wars geek at a Sci-Fi convention.
Towanna
First, prayers go up to KB and her family as her Mom recovers from a recent heart attack. She is a living witness that what looks impossible to man is so easy for God.
2 Corinthians 5:17. That power right there can heal a broken spirit and the wounded flesh. Better get you some.
I got a call the other day about some health ministry business at the church back home. I am trying to decide how involved I am going to get into that situation at this point. Not because I don't want to get involved, but when I was fully involved, I experienced some of that church politickin' that I've heard so much about. Didn't like it. Not one little bit.
But don't get me started on that. This blog might get shut down.
Its cool, though. I finally realized that God has given me gifts that the people at home needed, but were not ready to accept from me. As much as I wanted to bring better things to my people at home, God had to move me out of that situation to show me that the work that He sent me here to do was not going to get done in that environment. And I have been judged harshly for that.
The good thing is that harsh judgment is the proof that what I did was right. Otherwise, I'd be still pulling my hair out trying to please people who had already made up their minds that they were not going to be pleased. Especially not by me.
Chile. Boo.
God sent me here to save the world. I don't owe anyone an explanation of my purpose.
Plus, I don't know about you, but ain't nobody over here got time for that.
But I digress. Because only Jesus and Michael Jackson know what I mean.
I was talking to my supervising physician the other day about how I wanted to go into emergency medicine in my next life. That adrenaline rush is something else.
I told him how frustrated I get when a patient comes to me from the hospital or emergency room without complete care, like just enough was done to justify getting them out of there.
Its just seems like we need folks to change the culture of emergency medicine in this area. Especially for the poor and uninsured populations.
I have an elderly, male patient who is diabetic. He'd had a toe amputated a couple of weeks before the first time I say him. He said that he had seen the surgeon just a few days before that and had been released from care. He had been being seen at a free clinic to have his diabetes managed. Obviously, though, the diabetes had not been under good control as witnessed by the fact that he had to have a toe amputated.
He was coming to see us to establish care and said that he was told by the surgeon to follow-up with a primary care provider for management of the amputation site. I took a complete health history that was only significant for a personal and familial history of diabetes. He had no history of drug, tobacco, or alcohol use. His blood pressure was excellent and his weight was appropriate for his height.
But when I asked him about his medications we hit a bump in the road.
He was wearing an old-school fanny pack. He unzipped it and started pulling out insulin pen after insulin pen after half-empty insulin pen. Lantus. Novolog. Regular and 70/30. Humalog. Levemir.
"Which ones are you supposed to be using?" I asked him.
His reply: "What's the difference?"
Among other things, he told me that he was using the insulin 3 times a day after meals and wasn't really sure what combinations of insulin he was using. What he did tell me was that he usually gave himself 2 - 6 units each time depending on what he ate and that he did not have a meter to check his blood sugar.
His finger stick blood sugar and rapid A1C in the office that day was 174 fasting and >13.0 respectively.We drew a complete metabolic panel to check his kidney and liver function and a lipid panel to assess his cholesterol.
His physical exam was essentially normal.
That is until we got to his feet.
Now I am no surgeon, but I was pretty sure that releasing this man from his care was probably not a good idea.
Where the "pinky" toe of the right foot had been was a open wound, oozing green and yellow pus with a gangrenous flap of skin hanging off. The other four toes were all blistering, bleeding, or oozing pus in some combination. It was obvious that he was going to have to lose at least part of that right foot. The left foot was in better shape, but not by much. If he did not have some intervention immediately, it would suffer the same fate as the right one.
As I stood there examining his wounds, it suddenly hit me that he had not made a sound the entire time...because he had absolutely no feeling his feet at this point. The out of control diabetes had completely compromised his circulation. There was no telling how long he had been walking around like that.
We were able to get in touch with the surgeon's office. It was Friday and he had left early, but I did speak to his nurse who gave me an appointment for first thing Monday morning. I told here that I would clean and dress his wounds and put him back on some antibiotics until then.
As I suspected, the surgeon decided to amputate his forefoot. The surgery was scheduled for Wednesday morning. I fully expected that we would not see him back at the shelter until at least late Thursday or Friday morning.
But I should have known better.
That same Wednesday afternoon, one of the shelter's staff came to the clinic area and asked KB and I if we had time to come check on a patient that was bleeding in the day room.
We followed him through the double doors to the day room and our eyes settled on a heavy trail of blood leading to a table near the front desk. When we finally spotted the source of the bloody scene, I realized it was my patient. He'd had his foot amputated that morning and was discharged back to the shelter just hours later. The patient's story was that he stayed in recovery for about 2 hours before he was discharged. He had walked back to the shelter from the hospital.
No wheelchair. No crutches. Just a gauze dressing and a blue "shoe" with velcro straps.
His leg was propped up on a chair and underneath the chair was a widening pool of blood. His once white bandages were completely red and blood was actively pouring from the wound. The patient was sitting there like nothing had happened and I was actually grateful for the fact that he could not feel anything. I asked the shelter staff to call 911 because there was no way I would be able to stop that bleeding. KB and I gloved up and began to wrap his foot with layer upon layer of gauze. It only took the ambulance a few minutes to get to us, but by the time they did, there was a red spot growing on the wad of gauze we had just put in place.
Not long after the ambulance picked him up, he was back at the shelter. Apparently, on the walk back to the shelter, he'd busted open his stitches. At least this time, the hospital had given him a cab token for the ride back.
I saw him back a few days later. He'd been set up to be seen at a foot clinic for follow-up. We got him a new meter, ordered him some diabetic shoes and started him on Metformin, Lantus and 2.5 mg of Lisinopril for kidney prophylaxis. I thought about adding mealtime insulin, but felt that it would just complicate things for him at that point.
Plus, and I don't know if this can really be described as a good thing, but the good thing about many diabetic homeless patients is that most of the time, they have not been taking their medicine correctly, if at all. That means that even if their A1C is off the chart, there is great potential that you will have a marked improvement in the control of their blood sugar within the first few months of consistent therapy.
All of this happened a couple of months ago. I've seen the patient back a couple of times. KB and I have taken a lot of time educating him on his diabetes and his treatment regimen. In the process of all this, we found out that he only has a 3rd grade education and can barely read.
He also told us that he actually had a meter at one time, but that he did not know how to use it. No one ever offered to show him how to use it, so he just didn't. We made sure that we got him a one touch meter with visual prompts to make it easier for him.
Sometimes, it just takes us to recognize that a patient's failure to take care of themselves may be based upon our failure to give them all the tools they need to do so. The patient-provider relationship is meant to be both altruistic and symbiotic. Responsibility for success and failure must be equally shared.
That patient is doing very well these days. He came into the clinic for labs earlier this week was ecstatic to show us his blood sugar diary. His fasting that morning was 96. I can't wait to see what his A1C looks like.
I am proud of and excited about the work that we do in the community. AF and HL are doing a great job at planning health education program planning for the residents at the shelter. We have our diabetes class coming up here soon and the turnout should be massive.
My work has got me giddy. Like a Star Wars geek at a Sci-Fi convention.
Towanna
Tuesday, August 21, 2012
Love & Help Us Columbia
Good Day, Folks!
Did you miss me?
I know you did.
The last 7 days of my life have been so hectic. I am just getting a minute to take a breath. But that is what I love about the road I'm traveling right now. Never a dull moment. Change is constant. Adaptation is a must.
And that's adaptation. Not assimilation.
But there are a few constants in my life that I know I can always count on: God, my family....and drug seekers.
In that order.
Clinic gets busier every day. The busier it gets, the higher it seems some of the patient's want to ramp up their craziness.
I had a female patient who we banned from even stepping foot into the clinic area because every time we saw her she seemed to be looking for a confrontation. Her story was that she broke her wrist 15 years ago and wanted me to give her Percocet, which is a schedule 2 drug that I can't prescribe anyway. I refused her because when I checked her in the SCRIPTS database she was getting narcotics from several sources --- including a doctor in Charlotte who she was traveling back and forth to see. If she was smart, she would have filled the script in North Carolina and then it would not have shown up in SCRIPTS because it only covers South Carolina controlled substances.
We got a report back from an orthopedic surgeon who saw her in consultation that said when he refused to give her pain medication, she requested that he amputate her hand.
Talk about cutting off your nose to spite your face.
But she showed up on Friday and asked us to check her blood sugar. "No" was on the tip of my tongue, but KB, blessed spirit that she is, told her yes and asked her to sign in and have a seat in the waiting room.
Now this was around 3 pm. We were still seeing our regularly, scheduled patients and I was about to start a well-woman exam so she was going to be waiting for a few minutes.
I think 30 seconds passed before she walked back in screaming that we were "playing with [her] life." KB was in the room working up a patient, so I took a deep breath and tried to explain to her that we would be with her shortly, but that she walked in while we were really busy and she just needed to be patient for a few more minutes.
But the more I tried to reason with her, the louder she got. So I got loud, too.
And you can ask my sweet siblings, KB, or my cousin's wife, Keisha, but when I get loud, you might as well shut your operations down for a moment. I'm not going to stop until I know you've heard me.
So I (loudly) explained to her that she had been banned from the clinic for her prior behavior and that we were only seeing her as a courtesy. Not an obligation. I told her to leave or I would call security to remove her.
As I walked towards her, she started to back her way out of the door.
"I'm going to a higher authority to report you."
I thought to myself, "And??? You aren't the first and you won't be the last. What else?"
Then she played her trump card.
"I know you and the rest of these people smoke crack. You old crackhead m*****f*****!"
Now this caught me off guard. I've been called a lot of things in my life.
But never a "crackhead mofo". She get's major props for that one.
I wish all the irate patients had such original thoughts. I can only be called a "b-word" so many times before I get completely bored with it.
The really frustrating thing about this woman is that even after we banned her from our clinic, I made arrangements for her to see a provider at another site. And she behaved in the same way with him and now he has refused to see her.
More frustrating than that is that this lady really has some serious health problems including diabetes, high blood pressure and lung disease. But she never gave me a chance to help her with what I really needed to help her with because she is blinded by her addiction to those pain killers.
I'd like to manage her diabetes, get her blood pressure under control, help her to quit smoking and try to keep her out of the hospital for her frequent COPD flares.
But regardless of your race, religion or socio-economic status:
Help only helps those that help themselves.
And love don't love nobody that don't love themselves.
Be good, y'all.
Towanna
Did you miss me?
I know you did.
The last 7 days of my life have been so hectic. I am just getting a minute to take a breath. But that is what I love about the road I'm traveling right now. Never a dull moment. Change is constant. Adaptation is a must.
And that's adaptation. Not assimilation.
But there are a few constants in my life that I know I can always count on: God, my family....and drug seekers.
In that order.
Clinic gets busier every day. The busier it gets, the higher it seems some of the patient's want to ramp up their craziness.
I had a female patient who we banned from even stepping foot into the clinic area because every time we saw her she seemed to be looking for a confrontation. Her story was that she broke her wrist 15 years ago and wanted me to give her Percocet, which is a schedule 2 drug that I can't prescribe anyway. I refused her because when I checked her in the SCRIPTS database she was getting narcotics from several sources --- including a doctor in Charlotte who she was traveling back and forth to see. If she was smart, she would have filled the script in North Carolina and then it would not have shown up in SCRIPTS because it only covers South Carolina controlled substances.
We got a report back from an orthopedic surgeon who saw her in consultation that said when he refused to give her pain medication, she requested that he amputate her hand.
Talk about cutting off your nose to spite your face.
But she showed up on Friday and asked us to check her blood sugar. "No" was on the tip of my tongue, but KB, blessed spirit that she is, told her yes and asked her to sign in and have a seat in the waiting room.
Now this was around 3 pm. We were still seeing our regularly, scheduled patients and I was about to start a well-woman exam so she was going to be waiting for a few minutes.
I think 30 seconds passed before she walked back in screaming that we were "playing with [her] life." KB was in the room working up a patient, so I took a deep breath and tried to explain to her that we would be with her shortly, but that she walked in while we were really busy and she just needed to be patient for a few more minutes.
But the more I tried to reason with her, the louder she got. So I got loud, too.
And you can ask my sweet siblings, KB, or my cousin's wife, Keisha, but when I get loud, you might as well shut your operations down for a moment. I'm not going to stop until I know you've heard me.
So I (loudly) explained to her that she had been banned from the clinic for her prior behavior and that we were only seeing her as a courtesy. Not an obligation. I told her to leave or I would call security to remove her.
As I walked towards her, she started to back her way out of the door.
"I'm going to a higher authority to report you."
I thought to myself, "And??? You aren't the first and you won't be the last. What else?"
Then she played her trump card.
"I know you and the rest of these people smoke crack. You old crackhead m*****f*****!"
Now this caught me off guard. I've been called a lot of things in my life.
But never a "crackhead mofo". She get's major props for that one.
I wish all the irate patients had such original thoughts. I can only be called a "b-word" so many times before I get completely bored with it.
The really frustrating thing about this woman is that even after we banned her from our clinic, I made arrangements for her to see a provider at another site. And she behaved in the same way with him and now he has refused to see her.
More frustrating than that is that this lady really has some serious health problems including diabetes, high blood pressure and lung disease. But she never gave me a chance to help her with what I really needed to help her with because she is blinded by her addiction to those pain killers.
I'd like to manage her diabetes, get her blood pressure under control, help her to quit smoking and try to keep her out of the hospital for her frequent COPD flares.
But regardless of your race, religion or socio-economic status:
Help only helps those that help themselves.
And love don't love nobody that don't love themselves.
Be good, y'all.
Towanna
Tuesday, August 14, 2012
Awareness & Lucidity: Miss Cleo I Need You....
Since I have a late start to clinic today, I decided that now might be a good time to put up a new entry.
Remember the patient from my earlier blog who I told you that we rode that rollercoaster with one afternoon? She came back to see me last week. She looked well. I put her back on her blood pressure medication and the level of gratefulness that she showed us was phenomenal.
I mean, we have a lot of lame people in this world with big ugly houses and big ugly American-made cars walking around with their noses turned up in the air acting like someone owes them the privilege. Then you have people like this particular patient who, for all the hard knocks she's had in her life, still retains the simple decency in her heart to be able to smile and say thank you. She may not know it in her current circumstance, but that is part of a supernatural joy from the Lord that will help to sustain her.
I have a lot of interesting patients that come to see. And I mean interesting as people. Completely independent of their current circumstance.
A few weeks ago, a patient came in with a weird Czechoslovakian sounding name. Even weirder was the fact that he was really tall, really thin...and black.
I asked him where he got such a last name. He said that the story was that his Great-Great-Great-Great Grandfather was bought by a Russian businessman and taken back to the Soviet Union where he married one of the mulatto slave women who was rumored to be the slave master's daughter. Just after Emancipation in the United States, they were allowed to return to the States with their freedom. When they were asked their names to enter into the ship travel log, they just gave the slave master's last name. And if rumors were true that his Grandmother was the slave master's daughter, only his "Grandfather would go to Hell for telling that lie."
By my count he was something like 7th generation in this country. He showed me a picture of his father, with his mulatto skin, wavy hair and thin nose, sitting with his mother, a tall, thin black woman, wearing polyester bell bottoms, and a perfectly rounded afro with pick sticking out of it. You know? The black one with the fist on the handle. (Yeah. I know you knew). I guess he "went" to his mother's side of the family because his father had obviously picked up some features from that Russian gene pool. If he had not told me, I would have never thought that he was anything other than black. But while I was doing his ear, nose and throat exam though, I did get close enough to see that his jet black hair, that looked like a brillo pad from a distance, was actually really curly and thick. I guess that if you don't get anything else from the white side of your family, you can always count on "good hair."
At the main homeless clinic site, we have one particular patient who we see EVERYDAY. Several times a day. She is not a bother. More of a pleasant nuisance. But still. On most days, ain't nobody got time for that.
She first came to us for treatment of her high blood pressure, diabetes and bipolar disorder. She was on so many medications that I really didn't know where to start with her. On top of that, she could not give me a really clear medical history.
Most worrisome that day was the fact that while I was talking to her, she was sitting on the exam table unable to hold her head up. I would ask her a question and midway through her unintelligible answer, she would nod off on me. Each time I would wake her up and a few minutes later, we'd repeat the scenario.
I finally got what I thought was a complete enough history from her, ordered some lab work, did a referral back to mental health to manage her bipolar disorder, and put her back on the medications she told me that she was taking that I thought were appropriate.
Two weeks later, she came back. In the same state. Wanting refills on her Seroquel. I knew that she shouldn't need a refill already if she was taking the Seroquel as I prescribed it. I took her to the exam room and for the portion of time that she was awake and I was able to make out what she said, I found out that she had been self-medicating and taking way more Seroquel than what I had prescribed.
We established that she was not trying to harm herself. I did a urine drug test on her and she was completely clean for any street drugs, narcotics or benzos.
I decided to take a different approach with her at that point.
We discussed that she should only take the medication I gave her as they were prescribed and that if I was unable to trust her to do that, I would no longer see her. She agreed and I agreed to refill the Seroquel. But I had no intention of doing so. She was also on a couple of other medications to manage her bipolar disorder that did not have the sedating effect on her. I decided that I would give her some time off of the Seroquel and see what happened.
A few days later she came in to ask about her Seroquel. Of course, we did not have it because I had not authorized it to be refilled.
What we did have was a completely different woman standing in front of us.
The usually matted wig that she wore had been replaced by a new, slick, jet black version of a chin length bob. Her weird outfit choices had become a simple pair of blue jeans, a t-shirt and flip flops. Hoops in her ears. Rings on her fingers. A pretty crucifix around her neck. Lip gloss on her lips. Mascara on her lashes. And a look of awareness and lucidity in her eyes that we had never had the privilege of seeing.
She said that she was sorry that she did not come back to check on her medication earlier. But in the last few days she had been out looking for jobs and working on the goals that the shelter staff had set for her in her program plan. She'd gone back to the cosmetology school where she got her degree to see what she needed to do to get her license reinstated.
The more she spoke, the more in awe we became of the difference in her from those first visits.
Who was this well-spoken, intelligent woman?
And what was she doing here?
Since those days in April, we have found out a lot about her story. There has been violence and heartbreak in life. She's had to overcome many things just to be in the place where she is now. What is really amazing is that she has been great at teaching the clinic staff important lessons about ourselves and our interactions with our homeless patients.
I remember one day I had a disagreement with a another female patient who had been diagnosed with schizophrenia and a personality disorder,
That day, I think I'd forgotten my Rules for Mental Health 101.
1. Never try to reason with a schizophrenic
2. There is no treatment for a personality disorder.
The patient was upset that I refused to feed her habit. I explained to her that I was a primary care medical provider. Not a mental health provider. Her diagnoses were of a sort that I did not feel were in my scope of practice, but I would be glad to refer her to the appropriate care.
Homegirl looked at me and said, (and I quote):
"That's cool and all. But are you going to give me my valium, flexeril, lithium and adderall?"
Funny thing is, she'd started off asking me for Effexor and Lortab.
I refused and she left very upset.
Later I found out that the personality disorder she'd been diagnosed with was of the "multiple" kind. I guess "Brenda" had asked for the Effexor and the Lortab. But by the time the request for the valium, flexeril, lithium and adderall had been made, "Jackie" had taken over.
Apparently, she was upset enough that she'd gone outside and went into a full on rant about how she could not stand me. I was a B-word and I did not like female patients. (I'm not sure if it was "Brenda" or "Jackie" who was responsible for that, though).
I'd already been accused of not liking "people like" them.
Not long before that, I had also been accused of not liking white patients.
Yeah. Biggest chauvinist, elitist, racist in the world.
What the EFF ever. Is that all you got? Chile, puh-lease.
Anyway, my patient who I'd taken off of the Seroquel came in for her daily drive-by and asked me if I was ok.
I explained to her that things like that didn't bother me, so much as it reminded me how careful that I need to be about not allowing my personal feelings to overcome me in a situation like that.
This is my job that we are talking about. Not my family life or my social circle. There was no need to fight fire with fire.
We stood and talked about a few others things. And while we talked I noticed that she was kind of giving me the "up/down." You know, like she was sizing me up.
I asked her what was wrong and she said, "Can I tell you something?"
I said yes and she made me promise that I would not be offended.
I promised.
But I didn't really mean it.
She said to me, "You have a sweet spirit, but there is an edge to it. Like you got your guard up and if someone rubs you the wrong way, the sweet is gone and the edge will cut them like a knife."
She was right. The sweetness was planted there by nature. The edge had been cultivated by nurture.
I wanted her to keep talking.
"You have a hard time dealing with people because most people can only see clearly enough to see the edge."
Bingo.
But then she caught me off guard.
"But you need to take responsibility for that."
Ok. So its my fault?
Now I'm a little offended.
But (and in my Kanye voice) Imma let you finish.
I asked her to explain that to me.
She continued, "Look at how you are standing. The whole time that we stood here talking, you had your arms folded. It doesn't bother me, but other folks might take it as you not being open to what they are saying to you. You lead with that edge and you got better things to lead with."
Anyone who knows me, knows that I fold my arms when I am thinking really hard. I also frown and purse my lips together for the same reason, which I inherited from my Mama. The problem is that I think that I just assumed that people will know those things without them knowing me, me actually telling them...or them being psychic. (SN: Where is Miss Cleo?)
When I realized that she was right, that I had stood there with my arms tightly folded and my face in my concentration grimace, it hit me.
Its like the moment I realized that not everyone has (or appreciates) my brand of humor. There have been plenty of occasions when things that I find hilarious have made Facebook folks "feel some type of way" and I ended up with my status hijacked by someone who misinterprets my intent.
Nobody knows who I am until I show them. If I always led with that "edge" that she had just talked about, that is who people will think I am and I will never have the opportunity to present myself as a complete package.
Wow.
And all this time, I was thinking that she was the one lacking in awareness and lucidity.
Towanna
Remember the patient from my earlier blog who I told you that we rode that rollercoaster with one afternoon? She came back to see me last week. She looked well. I put her back on her blood pressure medication and the level of gratefulness that she showed us was phenomenal.
I mean, we have a lot of lame people in this world with big ugly houses and big ugly American-made cars walking around with their noses turned up in the air acting like someone owes them the privilege. Then you have people like this particular patient who, for all the hard knocks she's had in her life, still retains the simple decency in her heart to be able to smile and say thank you. She may not know it in her current circumstance, but that is part of a supernatural joy from the Lord that will help to sustain her.
I have a lot of interesting patients that come to see. And I mean interesting as people. Completely independent of their current circumstance.
A few weeks ago, a patient came in with a weird Czechoslovakian sounding name. Even weirder was the fact that he was really tall, really thin...and black.
I asked him where he got such a last name. He said that the story was that his Great-Great-Great-Great Grandfather was bought by a Russian businessman and taken back to the Soviet Union where he married one of the mulatto slave women who was rumored to be the slave master's daughter. Just after Emancipation in the United States, they were allowed to return to the States with their freedom. When they were asked their names to enter into the ship travel log, they just gave the slave master's last name. And if rumors were true that his Grandmother was the slave master's daughter, only his "Grandfather would go to Hell for telling that lie."
By my count he was something like 7th generation in this country. He showed me a picture of his father, with his mulatto skin, wavy hair and thin nose, sitting with his mother, a tall, thin black woman, wearing polyester bell bottoms, and a perfectly rounded afro with pick sticking out of it. You know? The black one with the fist on the handle. (Yeah. I know you knew). I guess he "went" to his mother's side of the family because his father had obviously picked up some features from that Russian gene pool. If he had not told me, I would have never thought that he was anything other than black. But while I was doing his ear, nose and throat exam though, I did get close enough to see that his jet black hair, that looked like a brillo pad from a distance, was actually really curly and thick. I guess that if you don't get anything else from the white side of your family, you can always count on "good hair."
At the main homeless clinic site, we have one particular patient who we see EVERYDAY. Several times a day. She is not a bother. More of a pleasant nuisance. But still. On most days, ain't nobody got time for that.
She first came to us for treatment of her high blood pressure, diabetes and bipolar disorder. She was on so many medications that I really didn't know where to start with her. On top of that, she could not give me a really clear medical history.
Most worrisome that day was the fact that while I was talking to her, she was sitting on the exam table unable to hold her head up. I would ask her a question and midway through her unintelligible answer, she would nod off on me. Each time I would wake her up and a few minutes later, we'd repeat the scenario.
I finally got what I thought was a complete enough history from her, ordered some lab work, did a referral back to mental health to manage her bipolar disorder, and put her back on the medications she told me that she was taking that I thought were appropriate.
Two weeks later, she came back. In the same state. Wanting refills on her Seroquel. I knew that she shouldn't need a refill already if she was taking the Seroquel as I prescribed it. I took her to the exam room and for the portion of time that she was awake and I was able to make out what she said, I found out that she had been self-medicating and taking way more Seroquel than what I had prescribed.
We established that she was not trying to harm herself. I did a urine drug test on her and she was completely clean for any street drugs, narcotics or benzos.
I decided to take a different approach with her at that point.
We discussed that she should only take the medication I gave her as they were prescribed and that if I was unable to trust her to do that, I would no longer see her. She agreed and I agreed to refill the Seroquel. But I had no intention of doing so. She was also on a couple of other medications to manage her bipolar disorder that did not have the sedating effect on her. I decided that I would give her some time off of the Seroquel and see what happened.
A few days later she came in to ask about her Seroquel. Of course, we did not have it because I had not authorized it to be refilled.
What we did have was a completely different woman standing in front of us.
The usually matted wig that she wore had been replaced by a new, slick, jet black version of a chin length bob. Her weird outfit choices had become a simple pair of blue jeans, a t-shirt and flip flops. Hoops in her ears. Rings on her fingers. A pretty crucifix around her neck. Lip gloss on her lips. Mascara on her lashes. And a look of awareness and lucidity in her eyes that we had never had the privilege of seeing.
She said that she was sorry that she did not come back to check on her medication earlier. But in the last few days she had been out looking for jobs and working on the goals that the shelter staff had set for her in her program plan. She'd gone back to the cosmetology school where she got her degree to see what she needed to do to get her license reinstated.
The more she spoke, the more in awe we became of the difference in her from those first visits.
Who was this well-spoken, intelligent woman?
And what was she doing here?
Since those days in April, we have found out a lot about her story. There has been violence and heartbreak in life. She's had to overcome many things just to be in the place where she is now. What is really amazing is that she has been great at teaching the clinic staff important lessons about ourselves and our interactions with our homeless patients.
I remember one day I had a disagreement with a another female patient who had been diagnosed with schizophrenia and a personality disorder,
That day, I think I'd forgotten my Rules for Mental Health 101.
1. Never try to reason with a schizophrenic
2. There is no treatment for a personality disorder.
The patient was upset that I refused to feed her habit. I explained to her that I was a primary care medical provider. Not a mental health provider. Her diagnoses were of a sort that I did not feel were in my scope of practice, but I would be glad to refer her to the appropriate care.
Homegirl looked at me and said, (and I quote):
"That's cool and all. But are you going to give me my valium, flexeril, lithium and adderall?"
Funny thing is, she'd started off asking me for Effexor and Lortab.
I refused and she left very upset.
Later I found out that the personality disorder she'd been diagnosed with was of the "multiple" kind. I guess "Brenda" had asked for the Effexor and the Lortab. But by the time the request for the valium, flexeril, lithium and adderall had been made, "Jackie" had taken over.
Apparently, she was upset enough that she'd gone outside and went into a full on rant about how she could not stand me. I was a B-word and I did not like female patients. (I'm not sure if it was "Brenda" or "Jackie" who was responsible for that, though).
I'd already been accused of not liking "people like" them.
Not long before that, I had also been accused of not liking white patients.
Yeah. Biggest chauvinist, elitist, racist in the world.
What the EFF ever. Is that all you got? Chile, puh-lease.
Anyway, my patient who I'd taken off of the Seroquel came in for her daily drive-by and asked me if I was ok.
I explained to her that things like that didn't bother me, so much as it reminded me how careful that I need to be about not allowing my personal feelings to overcome me in a situation like that.
This is my job that we are talking about. Not my family life or my social circle. There was no need to fight fire with fire.
We stood and talked about a few others things. And while we talked I noticed that she was kind of giving me the "up/down." You know, like she was sizing me up.
I asked her what was wrong and she said, "Can I tell you something?"
I said yes and she made me promise that I would not be offended.
I promised.
But I didn't really mean it.
She said to me, "You have a sweet spirit, but there is an edge to it. Like you got your guard up and if someone rubs you the wrong way, the sweet is gone and the edge will cut them like a knife."
She was right. The sweetness was planted there by nature. The edge had been cultivated by nurture.
I wanted her to keep talking.
"You have a hard time dealing with people because most people can only see clearly enough to see the edge."
Bingo.
But then she caught me off guard.
"But you need to take responsibility for that."
Ok. So its my fault?
Now I'm a little offended.
But (and in my Kanye voice) Imma let you finish.
I asked her to explain that to me.
She continued, "Look at how you are standing. The whole time that we stood here talking, you had your arms folded. It doesn't bother me, but other folks might take it as you not being open to what they are saying to you. You lead with that edge and you got better things to lead with."
Anyone who knows me, knows that I fold my arms when I am thinking really hard. I also frown and purse my lips together for the same reason, which I inherited from my Mama. The problem is that I think that I just assumed that people will know those things without them knowing me, me actually telling them...or them being psychic. (SN: Where is Miss Cleo?)
When I realized that she was right, that I had stood there with my arms tightly folded and my face in my concentration grimace, it hit me.
Its like the moment I realized that not everyone has (or appreciates) my brand of humor. There have been plenty of occasions when things that I find hilarious have made Facebook folks "feel some type of way" and I ended up with my status hijacked by someone who misinterprets my intent.
Nobody knows who I am until I show them. If I always led with that "edge" that she had just talked about, that is who people will think I am and I will never have the opportunity to present myself as a complete package.
Wow.
And all this time, I was thinking that she was the one lacking in awareness and lucidity.
Towanna
Saturday, August 11, 2012
I Dun Fixed That Mailbox...
Today we got an e-mail from our grant administrator notifying us that our little homeless program scored an "A-" rating from the federal oversight office.
I'm a bit offended by that minus sign. Why bother giving us an "A" if you are just gonna toss a minus behind it? I would almost prefer a "B." Almost.
See, my contract is up for renewal in November. That "A-" gives me the leverage to go in and ask for a 20% raise. They'll probably offer me 10. I'll push the issue for 15. I'd settle for 12. But don't tell them I said that.
More good news came last week when I got word from the Nursing Education Loan Repayment Program that they are going to pay back the majority of my outstanding student loans. Hands together in prayer that the contract gets finalized. Even if its not, thank the Lord anyhow.
I've been struggling to write this blog entry for the past 3 days. Its not for lack of material. But sometimes its difficult to frame all I want to say in the way that I want to say it. Like I said before, I have a million stories. I want to include the ups, the downs, the joys, and the sorrows of what I do, but I don't want to lose focus on my purpose here.
Yesterday, CK came to give me report on a new patient that had been added to the schedule. Not unusual. But here is the kicker.
She was pregnant. And HIV positive.
I have a rule.
I don't touch pregnant women.
I have seen pregnant women on the rare occasion for colds, and rashes and bladder infections and all that good stuff. In most cases, I will treat them with medication if the drug I am going to prescribe is Category A or B. Anything else and I send them to see their OB provider. The crazy thing is that I've also had OB providers send their pregnant patients to me to manage things like blood pressure or diabetes. But if they don't know, why do they think I do???? I know a little something about birthing babies. But I also don't like what I know. So I don't touch them. Creates the potential to kill 2 people at once. And ain't nobody got time for that.
And HIV patients?
I also have a rule.
If they are already seeing an HIV specialist, that means that they are covered under the Ryan White Grant. Technically, I am not allowed to see them and they must see their HIV provider. In that case, we'll call and get them an appointment to be seen. If they do not have an HIV provider, I will see them, do the initial work-up and HIV panel and refer them to an HIV provider. In either case, if they are sick that day, I will see them and treat them if I can and have them follow-up with their HIV provider immediately. As with any patient, I try to avoid having too many cooks in the kitchen.
Especially if an HIV patient in on anti-retroviral therapy (ART), I am cautious about providing care. Those type of medications interact with EVERYTHING. For example, if an HIV patient is on ART and they come to me to be treated for reflux, it would be simple enough to put them on Prilosec. Except that Prilosec is a proton-pump inhibitor and interferes with how ART works. That doesn't mean they can't take it. Just means that someone more schooled in that arena should make that call. Not me. I know my limits. And that is one of them.
So anyway, this patient is pregnant and HIV positive. She did have and OB as well as an HIV provider who she saw regularly. I tell CK that if she has a minor issue, I will see her. But if she was here for anything related to the HIV or her pregnancy, we'd have to send her somewhere else.
CK tells me that she has a "rash" on her leg and thinks something may have bitten her.
Sounds simple enough. I agree to see her and CK brings her back to the exam room.
The patient tells me that she noticed a quarter sized red spot on her left lower leg the day before. It was painful, but she thought nothing of it. When she woke up that morning, her entire leg was red, swollen and painful.
I started to exam her leg and noticed that not only was the leg red and swollen, but the patient jumped off of the table at the slightest touch of my fingertip and her leg felt like the top of a warm stove.
Immediately, two things came to mind:
A blood clot or an infection.
I did not see any vector wounds or anything that looks like she might have been bitten. The redness in her leg was diffuse, but streaky and looked to be moving upwards. It had progressed quickly over 24 hours. The swelling was only mild and I'd felt much warmer extremities in the presence of clot. She did not have any calf pain. Her pedal pulse was normal. Her Homan's sign, although neither very sensitive or specific for a blood clot, was negative. She could bear weight, had no chest pain or shortness of breath. She did have a low grade fever. Other than the specific complaint about her leg, she seemed to be fine.
My money was on the infection. I could hit her with Category B Keflex four times a day for a week. But the fact that the cellulitis developed without a point of entry meant that her immune system was compromised. And doubly so by the HIV and the pregnancy. The oral antibiotics might not make up enough ground for her weakened immune system. Even if it would, with the way our pharmacy services worked, it would be 24 hours before she would get the medicine.
And what if it was a clot? Although the presentation wasn't classic, stranger things have happened. If I let it go unchecked for a week, with her risk factors, that was asking for trouble.
I may have been over thinking it all. But the best thing was to send her to the hospital. They could decide whether to treat with oral vs. IV antibiotics and rule out a clot immediately.
So I asked CK to call 911.
Not a big deal in the grand scheme of things. But I remember when I worked as a floor nurse, a physician told me that calling the MD after 11:00 pm was the sign of weakness in a nurse.
Not that I believed him. If I had patient going bad at 3:00 in the morning, getting cussed out by the doctor for waking him up was the least of my worries. But just like most people, I have an ego. Especially when it comes to my competency as a provider. And calling 911 felt like a weakness in that moment.
See, I'm not used to asking for help. I never really learned to, because I've never really had to. Maybe because in most places I've gone, I ended up being the smartest person in the room. Maybe. Or maybe I just need to find better places to go.
Even in school, I hated group work because the pace in which a task got finished was dictated by the slowest person in the group. When I took Microbiology, I had the worst lab partner....ever. Its wrong for me to say, but when she withdraw because she was flunking the lecture portion of the class, I went out and had a drink after class to celebrate. This meant, I could finish the course by my lonesome.
You see, my preference is to take full responsibility for anything I do. No matter the outcome. I hate sending patients to the emergency room when I know that I know what's wrong with them and I could potentially fix it.
But I've learned, that as it relates to many things in my life, its just really not about me.
I could not compromise this woman or her unborn child for the sake of my ego. The chance just wasn't worth taking.
So off she went in the ambulance. With me sitting at my desk second guessing myself.
As I was leaving work that day, I ran into this patient on her way back into the shelter. She walked up to me and said, "You were right. They said its an infection. But they did do an ultrasound to rule out a clot because I'm pregnant."
They gave her a weeks worth of four times a day Keflex and told her to follow-up with her regular provider if she did not improve or got worse. I half-nodded at her offer of thanks and went on my way.
It will sound crazy, but it gave me no satisfaction that I was right.
I want to be the one to "fix" my patients.
Just like Mister fixed that mailbox.
So's I know when theys been messed wit.
Towanna
I'm a bit offended by that minus sign. Why bother giving us an "A" if you are just gonna toss a minus behind it? I would almost prefer a "B." Almost.
See, my contract is up for renewal in November. That "A-" gives me the leverage to go in and ask for a 20% raise. They'll probably offer me 10. I'll push the issue for 15. I'd settle for 12. But don't tell them I said that.
More good news came last week when I got word from the Nursing Education Loan Repayment Program that they are going to pay back the majority of my outstanding student loans. Hands together in prayer that the contract gets finalized. Even if its not, thank the Lord anyhow.
I've been struggling to write this blog entry for the past 3 days. Its not for lack of material. But sometimes its difficult to frame all I want to say in the way that I want to say it. Like I said before, I have a million stories. I want to include the ups, the downs, the joys, and the sorrows of what I do, but I don't want to lose focus on my purpose here.
Yesterday, CK came to give me report on a new patient that had been added to the schedule. Not unusual. But here is the kicker.
She was pregnant. And HIV positive.
I have a rule.
I don't touch pregnant women.
I have seen pregnant women on the rare occasion for colds, and rashes and bladder infections and all that good stuff. In most cases, I will treat them with medication if the drug I am going to prescribe is Category A or B. Anything else and I send them to see their OB provider. The crazy thing is that I've also had OB providers send their pregnant patients to me to manage things like blood pressure or diabetes. But if they don't know, why do they think I do???? I know a little something about birthing babies. But I also don't like what I know. So I don't touch them. Creates the potential to kill 2 people at once. And ain't nobody got time for that.
And HIV patients?
I also have a rule.
If they are already seeing an HIV specialist, that means that they are covered under the Ryan White Grant. Technically, I am not allowed to see them and they must see their HIV provider. In that case, we'll call and get them an appointment to be seen. If they do not have an HIV provider, I will see them, do the initial work-up and HIV panel and refer them to an HIV provider. In either case, if they are sick that day, I will see them and treat them if I can and have them follow-up with their HIV provider immediately. As with any patient, I try to avoid having too many cooks in the kitchen.
Especially if an HIV patient in on anti-retroviral therapy (ART), I am cautious about providing care. Those type of medications interact with EVERYTHING. For example, if an HIV patient is on ART and they come to me to be treated for reflux, it would be simple enough to put them on Prilosec. Except that Prilosec is a proton-pump inhibitor and interferes with how ART works. That doesn't mean they can't take it. Just means that someone more schooled in that arena should make that call. Not me. I know my limits. And that is one of them.
So anyway, this patient is pregnant and HIV positive. She did have and OB as well as an HIV provider who she saw regularly. I tell CK that if she has a minor issue, I will see her. But if she was here for anything related to the HIV or her pregnancy, we'd have to send her somewhere else.
CK tells me that she has a "rash" on her leg and thinks something may have bitten her.
Sounds simple enough. I agree to see her and CK brings her back to the exam room.
The patient tells me that she noticed a quarter sized red spot on her left lower leg the day before. It was painful, but she thought nothing of it. When she woke up that morning, her entire leg was red, swollen and painful.
I started to exam her leg and noticed that not only was the leg red and swollen, but the patient jumped off of the table at the slightest touch of my fingertip and her leg felt like the top of a warm stove.
Immediately, two things came to mind:
A blood clot or an infection.
I did not see any vector wounds or anything that looks like she might have been bitten. The redness in her leg was diffuse, but streaky and looked to be moving upwards. It had progressed quickly over 24 hours. The swelling was only mild and I'd felt much warmer extremities in the presence of clot. She did not have any calf pain. Her pedal pulse was normal. Her Homan's sign, although neither very sensitive or specific for a blood clot, was negative. She could bear weight, had no chest pain or shortness of breath. She did have a low grade fever. Other than the specific complaint about her leg, she seemed to be fine.
My money was on the infection. I could hit her with Category B Keflex four times a day for a week. But the fact that the cellulitis developed without a point of entry meant that her immune system was compromised. And doubly so by the HIV and the pregnancy. The oral antibiotics might not make up enough ground for her weakened immune system. Even if it would, with the way our pharmacy services worked, it would be 24 hours before she would get the medicine.
And what if it was a clot? Although the presentation wasn't classic, stranger things have happened. If I let it go unchecked for a week, with her risk factors, that was asking for trouble.
I may have been over thinking it all. But the best thing was to send her to the hospital. They could decide whether to treat with oral vs. IV antibiotics and rule out a clot immediately.
So I asked CK to call 911.
Not a big deal in the grand scheme of things. But I remember when I worked as a floor nurse, a physician told me that calling the MD after 11:00 pm was the sign of weakness in a nurse.
Not that I believed him. If I had patient going bad at 3:00 in the morning, getting cussed out by the doctor for waking him up was the least of my worries. But just like most people, I have an ego. Especially when it comes to my competency as a provider. And calling 911 felt like a weakness in that moment.
See, I'm not used to asking for help. I never really learned to, because I've never really had to. Maybe because in most places I've gone, I ended up being the smartest person in the room. Maybe. Or maybe I just need to find better places to go.
Even in school, I hated group work because the pace in which a task got finished was dictated by the slowest person in the group. When I took Microbiology, I had the worst lab partner....ever. Its wrong for me to say, but when she withdraw because she was flunking the lecture portion of the class, I went out and had a drink after class to celebrate. This meant, I could finish the course by my lonesome.
You see, my preference is to take full responsibility for anything I do. No matter the outcome. I hate sending patients to the emergency room when I know that I know what's wrong with them and I could potentially fix it.
But I've learned, that as it relates to many things in my life, its just really not about me.
I could not compromise this woman or her unborn child for the sake of my ego. The chance just wasn't worth taking.
So off she went in the ambulance. With me sitting at my desk second guessing myself.
As I was leaving work that day, I ran into this patient on her way back into the shelter. She walked up to me and said, "You were right. They said its an infection. But they did do an ultrasound to rule out a clot because I'm pregnant."
They gave her a weeks worth of four times a day Keflex and told her to follow-up with her regular provider if she did not improve or got worse. I half-nodded at her offer of thanks and went on my way.
It will sound crazy, but it gave me no satisfaction that I was right.
I want to be the one to "fix" my patients.
Just like Mister fixed that mailbox.
So's I know when theys been messed wit.
Towanna
Wednesday, August 8, 2012
Excuse me. People Like Who?
Good Morning, Saints!
And only a few people should think that refers to them. The rest of you? Y'all are sinners just like me. So, stop fooling yourselves.
Just kidding. But seriously.
Yesterday's blog was a killer, huh? I'm really interested in seeing how her situation plays out. I promise to keep you posted.
In the meantime, let's lighten the mood. (And I get really pissed every time I think about this situation, so I will do my best to keep the profanity to a minimum. But my best might not be good enough. So, um, sorry in advance).
Most of you who might be reading this grew up where I grew up. If we were poor back then, I didn't know it because everyone around us lived the same way for the most part. I never wanted for a thing, so in my mind it was all good.
It wasn't until I went off to college that I realized that "rich" people really existed. That there were people not on scholarship, who could afford to pay cash for college and didn't need financial aid was AMAZING to me. It was a sign of the sheltered life that I had led in my small community and at my 100% black, working class high school.
But the advantage that I did have was that my parents had instilled in my brothers, my sister and me that once you became an adult, what Mama and Daddy have no longer applies to you. That means that a wo/man who is not willing to work just does not want to eat.
Now I might be the most bleeding heart liberal in the world when it comes to certain things. I am sympathetic to the suffering of the sick, the poor, the homeless, children, and the elderly. I might be delusional, but I truly believe that my ordained purpose in this life is to change something big in this world through the work that I am doing. Sometimes it feels like a suicide mission, but hey, they are much worse fates than martyrdom.
What I am NOT sympathetic to is grown, able-bodied fools trying to get over on the system for a check that they don't deserve.
Case in point...
I have, or I should say had, a 30-something year old, 6'2", 210 lb., male patient (wearing a wife beater, basketball shorts, a doo-rag, and a huge CZ earring in his right ear --yes, I judged him. As I should have) come to me for the first time complaining about numbness, tingling and pain in his left foot. If you read Drug Seeking 101, you know that this raised an eyebrow for me immediately. But I gave him the benefit of the doubt because he said that a car had run over his foot a few months ago and it had "not been right since."
He'd gone to the emergency room and all the x-rays were negative according to him, but he felt that he needed to see an orthopedist for a second opinion. In the meantime, and of course, he wanted something for pain.
I examined his foot. And the exam was completely normal. He had full range of motion. His plantar and achilles reflex were normal. His pedal pulse was normal. I had him close his eyes and he easily distinguished between light touch and pin prick sensations. Hell. I even did the monofilament test on him which was also completely normal. So either nothing was wrong with his foot or he was doing a really bad job of trying to fake it.
He said that the problem was mostly when he did a lot of walking, which was most days. My best guess at that point was that when his foot was run over, there was some damage to the lower portion of the nerve responsible for feeling in the top of the foot. And when he did a lot of walking, the tissue surrounding the nerve became inflamed causing a bit of compression of the nerve and the resulting pain and numbness that he felt.
I explained to him that we could send him to ortho, but because it was not an emergency, the provider who was contracted to see our uninsured patients was swamped and it would be January before he was able to see anyone. In the meantime, I prescribed him ibuprofen, strengthening exercises, rest, and ice or heat to his comfort. I also suggested that he go to one of the local drug stores and get an inexpensive brace for support, but he said that he had no way of paying for one. So I gave him one of our stretchy ace wraps and showed him how to wrap his foot for support.
I guess I really looked like Boo Boo the Fool that day. Or this guy took my kindness for weakness. Either way, I think that he thought he had found a professional pawn in his scheme to work the system.
For the next couple of months, I saw this fella every week. Sometimes twice a week. One day it was his foot. Then it was food poisoning from the new Hibachi restaurant from across the street, which was funny because 50 other people from the shelter ate there. And he was the only one that got sick.
Once, he came in with an empty pill bottle asking for refills. The medication was acyclovir and had been originally given to him at the ER. (I'll let you google it to see what its used for). I explained to him how the medication was usually taken and that it was only taken on a daily basis when frequent re-occurrence was an issue. He said that wasn't an issue, but that he had read on Wikipedia that the virus can migrate to your nerves and spinal cord and cause brain damage. He said that he felt like he was running a fever and he was worried that the condition had moved from his genitals to his spinal cord. (O_o). Yeah, folks. That is why you need to refrain from the internet medicine.
After that particular visit, I figured that it would be in my best interest to get his records from the hospital. I had him sign a release and in quick turn around, the hospital had faxed his complete ER record to our office.
And when I sat down and began to read, I thought that someone was playing a really funny joke on me.
Multiple visits over the past few months for:
1. A "spider" bite. With absolutely no signs of a vector wound, swelling, rash or anything at the site where he said he was bitten. The ER provider commented that there may have been "some delusional thought" present and "patient may need referral to mental health services."
2. The feeling that someone had "messed with" him while he slept. Turns out that he was constipated.
3. Several visits in relation to having unprotected sex. I won't explain further.
4. Food poisoning. Multiple visits. And it turns out that he had already been seen in the ER when he came and saw me for the same episode of food poisoning.
5. Foot pain. 6 times in 4 months. Always with the same outcome. Completely negative work-up.
These, among other things, are for what this man kept abusing the use of the emergency room. The more I read, the more I thought that maybe there was some legitimacy to the idea that he may suffer from a type of hypochondria or obsessive compulsive disorder. But other than the frequent medical visits for seemingly ridiculous reasons at times, I had no real justification for that.
And then, a few days later, I got my answer.
I stopped by the main office to check my mailbox. I had gotten near the bottom of the stack of paper that I had pulled out of my cubby when I saw his name in the RE: line of a letter from the disability determination division of Vocational Rehabilitation.
You mean to tell me that all this time, he really wasn't crazy? That he was actually trying to build a disability case?
Chile, puh-lease. Cuz he was NOT doing a very good job of it.
And then I began to have flashbacks.
On several occasions when he'd come to see me, he'd asked me about contacting lawyers to pursue the person that had run his foot over in order to have them pay him medical bills. I told him that seemed reasonable. He'd also asked about getting a copy of the note from his food poisoning visit so that he could take it back to the Hibachi place and see if they would pay for his medication. I told him that didn't make sense...because the visit with me didn't cost him anything and our program was going to pay for his medication.
What was this kid really playing at?
Was he going to get a lawyer to sue the spider that bit him?
Or have the person that "messed" with him in his sleep brought up on charges and slapped with a civil suit?
And whoever made it necessary for him to take acyclovir? They better lawyer up. Right now.
It would be a few weeks before I saw him again. Apparently, he had been banned from the shelter for something he had done. I never found out what. That might be because I didn't ask.
Then one day, on my way home from work, and I actually saw him walking a few blocks down from the shelter. With a pimp in his stride. I watched him as he hot-footed it, jay-walking across a couple of intersections trying to beat traffic. I had to chuckle to myself. Obviously, that foot was doing alright today.
Two days later, he shows up wanting to be seen. KB asked him what he wanted and he said that he needed a refill on his ibuprofen. I stood on the other side of the partition and listened to her explain to him that according to the computer, he still had 4 refills on his ibuprofen. He could call in a refill request and just go down to our pharmacy and pick it up.
His explanation was that he did not have the number to the pharmacy because the label on his pill bottle was "messed" up and he did not have transportation to get there. He felt that it was our responsibility to get him his medicine.
So this is where I had to step in.
I tried to politely explain to him that in the real world, he could not walk into a provider's office and get the staff to go pick up prescriptions for him. It was his responsibility to do so and on occasions when KB has done so, she has done it as a courtesy. Not as an obligation.
I also explained to him that ibuprofen is also sold over the counter and that he could get some from the drug store at the next block.
The gentleman looks at me and says, "Every time I come in here, you get in my face."
My reply was, "Every time you come in here, you whine like a child."
Ok. Maybe not the best thing to have said. Cuz that set it off.
"I'm a man. That is why you don't like me. I'm a man. Plus, I know you don't like people like us."
I think my head spun around 10 times on my neck when I heard him say that.
"Excuse me. People like who?" I asked him.
At that point I noticed that the look in his eyes had changed, like he realized from the look on my face that maybe he should choose his words carefully. His lips parted. But no words came out. So I pressed him.
"Say what you mean? People like who?"
And then my rant began. For the next 60 seconds, I went off on him. I wish I could remember verbatim what I said, but the jist of it was to explain to this fool that he had no idea who I was or where I was from. That I could work anywhere in the world that I wanted to, but being there was my choice. That he was a lazy, able-bodied, description fitting, clown trying to get over on the system. That I have a 85 year old grandmother who would still get up and go to work everyday if she could. That his suffering was self-inflicted and that he, unlike most of the other folks there, had made a choice to be in his situation.
KB finally got up, put her hand on my shoulder, and said to me, "Its not even worth it."
And she was right. But it dang sure felt good to tell him off.
He sat there looking dumbfounded for a second and then he said to me, "I didn't want to come here anyway. My case manager told me to come here."
KB looked at him and said, "Well aren't you a man? A man wouldn't let anyone make him do something he doesn't want to do. Matter of fact, you don't ever have to come back."
I don't think he was expecting that. But he got up and left. And, miracles of miracles, his limp was gone.
You see sometimes the cure for what ails you is a good old fashioned telling off.
Some of the best medicine in the world.
Towanna
And only a few people should think that refers to them. The rest of you? Y'all are sinners just like me. So, stop fooling yourselves.
Just kidding. But seriously.
Yesterday's blog was a killer, huh? I'm really interested in seeing how her situation plays out. I promise to keep you posted.
In the meantime, let's lighten the mood. (And I get really pissed every time I think about this situation, so I will do my best to keep the profanity to a minimum. But my best might not be good enough. So, um, sorry in advance).
Most of you who might be reading this grew up where I grew up. If we were poor back then, I didn't know it because everyone around us lived the same way for the most part. I never wanted for a thing, so in my mind it was all good.
It wasn't until I went off to college that I realized that "rich" people really existed. That there were people not on scholarship, who could afford to pay cash for college and didn't need financial aid was AMAZING to me. It was a sign of the sheltered life that I had led in my small community and at my 100% black, working class high school.
But the advantage that I did have was that my parents had instilled in my brothers, my sister and me that once you became an adult, what Mama and Daddy have no longer applies to you. That means that a wo/man who is not willing to work just does not want to eat.
Now I might be the most bleeding heart liberal in the world when it comes to certain things. I am sympathetic to the suffering of the sick, the poor, the homeless, children, and the elderly. I might be delusional, but I truly believe that my ordained purpose in this life is to change something big in this world through the work that I am doing. Sometimes it feels like a suicide mission, but hey, they are much worse fates than martyrdom.
What I am NOT sympathetic to is grown, able-bodied fools trying to get over on the system for a check that they don't deserve.
Case in point...
I have, or I should say had, a 30-something year old, 6'2", 210 lb., male patient (wearing a wife beater, basketball shorts, a doo-rag, and a huge CZ earring in his right ear --yes, I judged him. As I should have) come to me for the first time complaining about numbness, tingling and pain in his left foot. If you read Drug Seeking 101, you know that this raised an eyebrow for me immediately. But I gave him the benefit of the doubt because he said that a car had run over his foot a few months ago and it had "not been right since."
He'd gone to the emergency room and all the x-rays were negative according to him, but he felt that he needed to see an orthopedist for a second opinion. In the meantime, and of course, he wanted something for pain.
I examined his foot. And the exam was completely normal. He had full range of motion. His plantar and achilles reflex were normal. His pedal pulse was normal. I had him close his eyes and he easily distinguished between light touch and pin prick sensations. Hell. I even did the monofilament test on him which was also completely normal. So either nothing was wrong with his foot or he was doing a really bad job of trying to fake it.
He said that the problem was mostly when he did a lot of walking, which was most days. My best guess at that point was that when his foot was run over, there was some damage to the lower portion of the nerve responsible for feeling in the top of the foot. And when he did a lot of walking, the tissue surrounding the nerve became inflamed causing a bit of compression of the nerve and the resulting pain and numbness that he felt.
I explained to him that we could send him to ortho, but because it was not an emergency, the provider who was contracted to see our uninsured patients was swamped and it would be January before he was able to see anyone. In the meantime, I prescribed him ibuprofen, strengthening exercises, rest, and ice or heat to his comfort. I also suggested that he go to one of the local drug stores and get an inexpensive brace for support, but he said that he had no way of paying for one. So I gave him one of our stretchy ace wraps and showed him how to wrap his foot for support.
I guess I really looked like Boo Boo the Fool that day. Or this guy took my kindness for weakness. Either way, I think that he thought he had found a professional pawn in his scheme to work the system.
For the next couple of months, I saw this fella every week. Sometimes twice a week. One day it was his foot. Then it was food poisoning from the new Hibachi restaurant from across the street, which was funny because 50 other people from the shelter ate there. And he was the only one that got sick.
Once, he came in with an empty pill bottle asking for refills. The medication was acyclovir and had been originally given to him at the ER. (I'll let you google it to see what its used for). I explained to him how the medication was usually taken and that it was only taken on a daily basis when frequent re-occurrence was an issue. He said that wasn't an issue, but that he had read on Wikipedia that the virus can migrate to your nerves and spinal cord and cause brain damage. He said that he felt like he was running a fever and he was worried that the condition had moved from his genitals to his spinal cord. (O_o). Yeah, folks. That is why you need to refrain from the internet medicine.
After that particular visit, I figured that it would be in my best interest to get his records from the hospital. I had him sign a release and in quick turn around, the hospital had faxed his complete ER record to our office.
And when I sat down and began to read, I thought that someone was playing a really funny joke on me.
Multiple visits over the past few months for:
1. A "spider" bite. With absolutely no signs of a vector wound, swelling, rash or anything at the site where he said he was bitten. The ER provider commented that there may have been "some delusional thought" present and "patient may need referral to mental health services."
2. The feeling that someone had "messed with" him while he slept. Turns out that he was constipated.
3. Several visits in relation to having unprotected sex. I won't explain further.
4. Food poisoning. Multiple visits. And it turns out that he had already been seen in the ER when he came and saw me for the same episode of food poisoning.
5. Foot pain. 6 times in 4 months. Always with the same outcome. Completely negative work-up.
These, among other things, are for what this man kept abusing the use of the emergency room. The more I read, the more I thought that maybe there was some legitimacy to the idea that he may suffer from a type of hypochondria or obsessive compulsive disorder. But other than the frequent medical visits for seemingly ridiculous reasons at times, I had no real justification for that.
And then, a few days later, I got my answer.
I stopped by the main office to check my mailbox. I had gotten near the bottom of the stack of paper that I had pulled out of my cubby when I saw his name in the RE: line of a letter from the disability determination division of Vocational Rehabilitation.
You mean to tell me that all this time, he really wasn't crazy? That he was actually trying to build a disability case?
Chile, puh-lease. Cuz he was NOT doing a very good job of it.
And then I began to have flashbacks.
On several occasions when he'd come to see me, he'd asked me about contacting lawyers to pursue the person that had run his foot over in order to have them pay him medical bills. I told him that seemed reasonable. He'd also asked about getting a copy of the note from his food poisoning visit so that he could take it back to the Hibachi place and see if they would pay for his medication. I told him that didn't make sense...because the visit with me didn't cost him anything and our program was going to pay for his medication.
What was this kid really playing at?
Was he going to get a lawyer to sue the spider that bit him?
Or have the person that "messed" with him in his sleep brought up on charges and slapped with a civil suit?
And whoever made it necessary for him to take acyclovir? They better lawyer up. Right now.
It would be a few weeks before I saw him again. Apparently, he had been banned from the shelter for something he had done. I never found out what. That might be because I didn't ask.
Then one day, on my way home from work, and I actually saw him walking a few blocks down from the shelter. With a pimp in his stride. I watched him as he hot-footed it, jay-walking across a couple of intersections trying to beat traffic. I had to chuckle to myself. Obviously, that foot was doing alright today.
Two days later, he shows up wanting to be seen. KB asked him what he wanted and he said that he needed a refill on his ibuprofen. I stood on the other side of the partition and listened to her explain to him that according to the computer, he still had 4 refills on his ibuprofen. He could call in a refill request and just go down to our pharmacy and pick it up.
His explanation was that he did not have the number to the pharmacy because the label on his pill bottle was "messed" up and he did not have transportation to get there. He felt that it was our responsibility to get him his medicine.
So this is where I had to step in.
I tried to politely explain to him that in the real world, he could not walk into a provider's office and get the staff to go pick up prescriptions for him. It was his responsibility to do so and on occasions when KB has done so, she has done it as a courtesy. Not as an obligation.
I also explained to him that ibuprofen is also sold over the counter and that he could get some from the drug store at the next block.
The gentleman looks at me and says, "Every time I come in here, you get in my face."
My reply was, "Every time you come in here, you whine like a child."
Ok. Maybe not the best thing to have said. Cuz that set it off.
"I'm a man. That is why you don't like me. I'm a man. Plus, I know you don't like people like us."
I think my head spun around 10 times on my neck when I heard him say that.
"Excuse me. People like who?" I asked him.
At that point I noticed that the look in his eyes had changed, like he realized from the look on my face that maybe he should choose his words carefully. His lips parted. But no words came out. So I pressed him.
"Say what you mean? People like who?"
And then my rant began. For the next 60 seconds, I went off on him. I wish I could remember verbatim what I said, but the jist of it was to explain to this fool that he had no idea who I was or where I was from. That I could work anywhere in the world that I wanted to, but being there was my choice. That he was a lazy, able-bodied, description fitting, clown trying to get over on the system. That I have a 85 year old grandmother who would still get up and go to work everyday if she could. That his suffering was self-inflicted and that he, unlike most of the other folks there, had made a choice to be in his situation.
KB finally got up, put her hand on my shoulder, and said to me, "Its not even worth it."
And she was right. But it dang sure felt good to tell him off.
He sat there looking dumbfounded for a second and then he said to me, "I didn't want to come here anyway. My case manager told me to come here."
KB looked at him and said, "Well aren't you a man? A man wouldn't let anyone make him do something he doesn't want to do. Matter of fact, you don't ever have to come back."
I don't think he was expecting that. But he got up and left. And, miracles of miracles, his limp was gone.
You see sometimes the cure for what ails you is a good old fashioned telling off.
Some of the best medicine in the world.
Towanna
Tuesday, August 7, 2012
Remedy for a Broken Heart...
Good Morning, World...
I'm without my right hand this week. KB is out of state at a church convention all week. I'm a bit on edge waiting for there to be some big fire to put out at work while she's gone. We had one or two smalls one yesterday, but nothing major. So we press on with prayers that this week goes smoothly. And I mean smoothly in the relative sense.....
About a week ago, it was the end of our day and I had just seen my last scheduled patient. KB was out doing a pharmacy run and AF was working at another site that day. It was CK, HL and myself in our "office" going over what follow-ups needed to be done for the day's visits. All of a sudden I see this flash of yellow out of the corner of my eye and I hear a voice say, "Can someone f---ing help me?"
It didn't really faze us too much. We get the F-bomb dropped on us almost daily. B-words. Mofos. Take your pick. There are only very rare cases in our line of work where we make the decision to fight fire with fire (and I'll tell you about one of those instances one day soon). The key is to never take any of it personally and read past the profanity to figure out what the patient is actually asking for. And this particular patient? She had just asked for help.
When I finally turned full face and got a good look at her, I also found myself close enough to her to pick up the smell of alcohol. She had on a simple yellow t-shirt and jeans and was holding what I recognized to be a prescription from one of the local hospitals in her hand. I asked her what we could do for her. And off she went...
For the next 15 minutes, we sat and listened as she told us her story. She had been raped 3 weeks ago while she was living on the streets. She did not report it because she has lived on the streets since she was a teenager and she has a well-known history of prostitution in the area. No one would believe her. And it wasn't the first time she had been raped. In her words, she just decided to "keep it moving." She had a long history of severe mental illness and had spent time in inpatient treatment too many times to count. She was a drug abuser and an alcoholic. She self-medicated regularly. And yes, she was drunk and high right now. She'd gone to a local mental health office for help that morning. They took her in for an emergency mental health assessment, but someone decided that her blood pressure high and it was more important that it be brought under control than for her mental health to stabilized. So a social worker put her in the car, dropped her off at the emergency room...and left her there.
Pause.
I spent 2 years working as a mental health nurse in a under-staffed, under-funded outpatient clinic. Whenever I had a patient in crisis that needed emergency stabilization, we had a either a family member or the police bring them in for an assessment. If we decided that they needed inpatient stabilization, it was our responsibility to find that patient a bed somewhere. And when I tell you that it is one of the most difficult processes in the world to maneuver, believe that difficult is an understatement. What I also know is that there were some members of our staff at that time, when they could not easily find placement for a patient, they would just pawn them off by sending them to the emergency room. But because the hospital did not designated "mental health" beds and most of the patients did not have insurance or a means to pay, it was not in their best interest to keep them there. On rare occasions, a sympathetic emergency room provider, would come up with some benign medical diagnosis, like "dehydration" to justify an admission. But that was on the very rare occasion. Most of the time, the patient was sent home. In the same condition as they had come.
Now, where was I?
Ok. So standing there listening to this lady talk, I knew that is how she ended up standing in front of us. She said that she had been told that her blood pressure was sky high and was given a prescription for blood pressure medicine. I asked her if I could see the prescription and when she handed it to me, I saw that is was for Hydrochlorothiazide 12.5 mg once a day. I asked if she had been given anything to bring her pressure down while she was at the hospital. She said no. Now, I am new to this nurse practitioner thing. But what I do know is that you only prescribe that dose of a water pill to someone with the mildest level of hypertension and no other co-morbidities. Not to someone with a history of uncontrolled hypertension, who has been off their medication and presents to the ER with ''sky-high" blood pressure.
So I asked CK to check her pressure. 156/98. Not great. But not awful considering that she was not on medication and her distraught state.
I explained to her that we would be happy to see her and help her get on the right blood pressure medication, but that she had to go through the enrollment process. That meant that she would not be seen today and we could not get her prescription filled today.
This news sent her into complete hysteria.
"I knew it was a f---ing lie when they told me you mother-----s could help me. Give me a piece of paper and a pen."
We obliged and handed her a piece of paper and a pen. She proceeded to write:
"To Whom It May Concern:
All you mother------s can kis my black a--. When you find me hanging..."
When I realized what she writing, I tried to take the pen from her hand because if I let her finish writing what I thought she was writing, this would become a whole other ball game.
I got a hold of the pen and began to explain to her what it would mean for me if she implied that she was thinking about hurting herself. At first she resisted what I was telling her, but after some coaxing she tore the note up and threw it away.
We sat her down. And then we just listened.
She was a crackhead. A prostitute. An alcoholic. She had 10 children. She could only speak to 2 of them...and they were in prison. The other 8? She had no idea.
Her mother was a prominent business owner in Columbia who would take nothing to do with her because she had an image to uphold. Her younger brother was a lawyer who had threatened to have the local dope boys kill her if she ever made trouble for her mother. She had a stepfather who would beat her severely and then make her stand in the trash can as further punishment when she was a little girl --- that is until she ran away at 13.
Since she'd been on the streets, she'd been raped by strangers and so-called friends. Beaten to within an inch of her life by men who said they loved her. After one beating, she ended up with a head injury that kept her in coma for a month and required her to have a part of brain removed.
At that point in her story, something gave away inside her.
Have you ever watched someone cry without crying? You know when they just sit absolutely still and quiet and the water just pours down their face like there is some kind of supernatural fountain flowing from behind their eyes?
As the tears rolled off her cheek, her face and body relaxed and she began to tell us about the days that she was in that coma. How beautiful her dreams had been while she was in that trauma induced sleep. How blue the sky was. How green the grass was. How the juice from the sweetest strawberries she'd ever tasted ran out of the sides of her mouth and onto the blindingly white dress that she was wearing.
In her coma, she had experienced something that she could never remember having experienced in real life.
Peace.
And her one wish, she said, was to just go back there because she had "a big old sore in her chest" that would never heal in this life.
There are million other things that I would like to share about this extraordinary story, but I don't have the time or the space here.
HL gave her hug which seemed to make all the difference in the world to her. CK tracked down her case manager who was able to find her temporary housing. And I agreed take care of her medical needs.
It was all we could offer at the time. It seemed to be enough for the moment. But she needed so much more.
That is the day that I went home and updated my Facebook status to read:
"I came up against something at work today that I couldn't handle. If anyone has the remedy for a truly broken heart, please share it with me."
I am not sure what has happened with her since then. We left her in the care of her case manager at the shelter when we left that day.
She is scheduled to see me on Friday.
But all the blood pressure medication in the world won't heal her broken heart.
I'll keep you posted.
Towanna
I'm without my right hand this week. KB is out of state at a church convention all week. I'm a bit on edge waiting for there to be some big fire to put out at work while she's gone. We had one or two smalls one yesterday, but nothing major. So we press on with prayers that this week goes smoothly. And I mean smoothly in the relative sense.....
About a week ago, it was the end of our day and I had just seen my last scheduled patient. KB was out doing a pharmacy run and AF was working at another site that day. It was CK, HL and myself in our "office" going over what follow-ups needed to be done for the day's visits. All of a sudden I see this flash of yellow out of the corner of my eye and I hear a voice say, "Can someone f---ing help me?"
It didn't really faze us too much. We get the F-bomb dropped on us almost daily. B-words. Mofos. Take your pick. There are only very rare cases in our line of work where we make the decision to fight fire with fire (and I'll tell you about one of those instances one day soon). The key is to never take any of it personally and read past the profanity to figure out what the patient is actually asking for. And this particular patient? She had just asked for help.
When I finally turned full face and got a good look at her, I also found myself close enough to her to pick up the smell of alcohol. She had on a simple yellow t-shirt and jeans and was holding what I recognized to be a prescription from one of the local hospitals in her hand. I asked her what we could do for her. And off she went...
For the next 15 minutes, we sat and listened as she told us her story. She had been raped 3 weeks ago while she was living on the streets. She did not report it because she has lived on the streets since she was a teenager and she has a well-known history of prostitution in the area. No one would believe her. And it wasn't the first time she had been raped. In her words, she just decided to "keep it moving." She had a long history of severe mental illness and had spent time in inpatient treatment too many times to count. She was a drug abuser and an alcoholic. She self-medicated regularly. And yes, she was drunk and high right now. She'd gone to a local mental health office for help that morning. They took her in for an emergency mental health assessment, but someone decided that her blood pressure high and it was more important that it be brought under control than for her mental health to stabilized. So a social worker put her in the car, dropped her off at the emergency room...and left her there.
Pause.
I spent 2 years working as a mental health nurse in a under-staffed, under-funded outpatient clinic. Whenever I had a patient in crisis that needed emergency stabilization, we had a either a family member or the police bring them in for an assessment. If we decided that they needed inpatient stabilization, it was our responsibility to find that patient a bed somewhere. And when I tell you that it is one of the most difficult processes in the world to maneuver, believe that difficult is an understatement. What I also know is that there were some members of our staff at that time, when they could not easily find placement for a patient, they would just pawn them off by sending them to the emergency room. But because the hospital did not designated "mental health" beds and most of the patients did not have insurance or a means to pay, it was not in their best interest to keep them there. On rare occasions, a sympathetic emergency room provider, would come up with some benign medical diagnosis, like "dehydration" to justify an admission. But that was on the very rare occasion. Most of the time, the patient was sent home. In the same condition as they had come.
Now, where was I?
Ok. So standing there listening to this lady talk, I knew that is how she ended up standing in front of us. She said that she had been told that her blood pressure was sky high and was given a prescription for blood pressure medicine. I asked her if I could see the prescription and when she handed it to me, I saw that is was for Hydrochlorothiazide 12.5 mg once a day. I asked if she had been given anything to bring her pressure down while she was at the hospital. She said no. Now, I am new to this nurse practitioner thing. But what I do know is that you only prescribe that dose of a water pill to someone with the mildest level of hypertension and no other co-morbidities. Not to someone with a history of uncontrolled hypertension, who has been off their medication and presents to the ER with ''sky-high" blood pressure.
So I asked CK to check her pressure. 156/98. Not great. But not awful considering that she was not on medication and her distraught state.
I explained to her that we would be happy to see her and help her get on the right blood pressure medication, but that she had to go through the enrollment process. That meant that she would not be seen today and we could not get her prescription filled today.
This news sent her into complete hysteria.
"I knew it was a f---ing lie when they told me you mother-----s could help me. Give me a piece of paper and a pen."
We obliged and handed her a piece of paper and a pen. She proceeded to write:
"To Whom It May Concern:
All you mother------s can kis my black a--. When you find me hanging..."
When I realized what she writing, I tried to take the pen from her hand because if I let her finish writing what I thought she was writing, this would become a whole other ball game.
I got a hold of the pen and began to explain to her what it would mean for me if she implied that she was thinking about hurting herself. At first she resisted what I was telling her, but after some coaxing she tore the note up and threw it away.
We sat her down. And then we just listened.
She was a crackhead. A prostitute. An alcoholic. She had 10 children. She could only speak to 2 of them...and they were in prison. The other 8? She had no idea.
Her mother was a prominent business owner in Columbia who would take nothing to do with her because she had an image to uphold. Her younger brother was a lawyer who had threatened to have the local dope boys kill her if she ever made trouble for her mother. She had a stepfather who would beat her severely and then make her stand in the trash can as further punishment when she was a little girl --- that is until she ran away at 13.
Since she'd been on the streets, she'd been raped by strangers and so-called friends. Beaten to within an inch of her life by men who said they loved her. After one beating, she ended up with a head injury that kept her in coma for a month and required her to have a part of brain removed.
At that point in her story, something gave away inside her.
Have you ever watched someone cry without crying? You know when they just sit absolutely still and quiet and the water just pours down their face like there is some kind of supernatural fountain flowing from behind their eyes?
As the tears rolled off her cheek, her face and body relaxed and she began to tell us about the days that she was in that coma. How beautiful her dreams had been while she was in that trauma induced sleep. How blue the sky was. How green the grass was. How the juice from the sweetest strawberries she'd ever tasted ran out of the sides of her mouth and onto the blindingly white dress that she was wearing.
In her coma, she had experienced something that she could never remember having experienced in real life.
Peace.
And her one wish, she said, was to just go back there because she had "a big old sore in her chest" that would never heal in this life.
There are million other things that I would like to share about this extraordinary story, but I don't have the time or the space here.
HL gave her hug which seemed to make all the difference in the world to her. CK tracked down her case manager who was able to find her temporary housing. And I agreed take care of her medical needs.
It was all we could offer at the time. It seemed to be enough for the moment. But she needed so much more.
That is the day that I went home and updated my Facebook status to read:
"I came up against something at work today that I couldn't handle. If anyone has the remedy for a truly broken heart, please share it with me."
I am not sure what has happened with her since then. We left her in the care of her case manager at the shelter when we left that day.
She is scheduled to see me on Friday.
But all the blood pressure medication in the world won't heal her broken heart.
I'll keep you posted.
Towanna
Sunday, August 5, 2012
Drug Seeking 101
The running joke whenever we get a patient who asks for something that the rest of the staff knows I'm not willing to give is that I look like Boo Boo The Fool.
Most of the time, the nursing staff can always give me a heads up on a patient who seems to sniffing out a controlled substance. Over the years, I have kind of learned to spot them from a mile away.
Taking a cue from Mr. Letterman, for your education, I give you:
The Top 10 Signs that You are Dealing With a Drug Seeker
10. They have no income or insurance, but swear they have an appointment with their "regular" provider coming up and just need some pain medication until their appointment...next month.
9. Before you even give them an idea of what you are going to give them for pain, they make the point of telling you that they have taken Tramadol before and "its not strong enough."
8. They are a brand new patient complaining of knee pain, and as soon as they sit on the exam table, they ask you if you need a urine sample from them.
7. They tell you that they have been in severe and chronic pain for years. But when you ask them what they have been taking for it, they tell you, "Nothing. I have just been dealing with it."
6. They answer in the affirmative to every sign or symptom that you ask them about. I mean, if your foot is "completely numb", how can you also describe the pain as "sharp"?
5. We provide them with their blood pressure medicine at no cost because they can't afford to pay $4.00 a month for the prescription, but they can afford to regularly see a psychiatrist and pay for monthly Adderall prescriptions with no problem.
4. They walk into the exam room holding whatever body part and make it a point to breath heavily and go "ooh" and "aah" over and over again for dramatic effect.
3. They threaten to go to the emergency room when you refuse to give them what they want. (*dials 911*) #kanyeshrug
2. Every other week they come in telling you that their medication was "stolen" out of a "locked" drawer to which only they have a key.
And the #1 sign that you are dealing with a drug seeker:
1. You can sit down and have discussion with me on the difference between natural and synthetic opiates and which ones will or won't show up on a routine urine drug screen.
Drug seekers, especially the obvious ones, annoy me. Not because I don't think there might be some level of legitimacy to their pain, but more because my intelligence feels insulted whenever I encounter a patient asking for an unreasonable level of pain management. I very often must explain to them that I get at least 5 people with similar stories asking for controlled substances every day. I mean, sometimes I wish they were more creative in their tactics just to break up the monotony of having me saying, "No."
Especially in the clinic environments where I work, a large part of the homeless population struggle with substance abuse and mental illness. I don't intend to help them self-medicate by becoming a pill factory. I've been threatened with physical harm and called out of my name more times than I can count by patients upset with me for not giving them Lortab or Xanax or Soma. Just let's me know that I am doing the right thing.
Towanna
Most of the time, the nursing staff can always give me a heads up on a patient who seems to sniffing out a controlled substance. Over the years, I have kind of learned to spot them from a mile away.
Taking a cue from Mr. Letterman, for your education, I give you:
The Top 10 Signs that You are Dealing With a Drug Seeker
10. They have no income or insurance, but swear they have an appointment with their "regular" provider coming up and just need some pain medication until their appointment...next month.
9. Before you even give them an idea of what you are going to give them for pain, they make the point of telling you that they have taken Tramadol before and "its not strong enough."
8. They are a brand new patient complaining of knee pain, and as soon as they sit on the exam table, they ask you if you need a urine sample from them.
7. They tell you that they have been in severe and chronic pain for years. But when you ask them what they have been taking for it, they tell you, "Nothing. I have just been dealing with it."
6. They answer in the affirmative to every sign or symptom that you ask them about. I mean, if your foot is "completely numb", how can you also describe the pain as "sharp"?
5. We provide them with their blood pressure medicine at no cost because they can't afford to pay $4.00 a month for the prescription, but they can afford to regularly see a psychiatrist and pay for monthly Adderall prescriptions with no problem.
4. They walk into the exam room holding whatever body part and make it a point to breath heavily and go "ooh" and "aah" over and over again for dramatic effect.
3. They threaten to go to the emergency room when you refuse to give them what they want. (*dials 911*) #kanyeshrug
2. Every other week they come in telling you that their medication was "stolen" out of a "locked" drawer to which only they have a key.
And the #1 sign that you are dealing with a drug seeker:
1. You can sit down and have discussion with me on the difference between natural and synthetic opiates and which ones will or won't show up on a routine urine drug screen.
Drug seekers, especially the obvious ones, annoy me. Not because I don't think there might be some level of legitimacy to their pain, but more because my intelligence feels insulted whenever I encounter a patient asking for an unreasonable level of pain management. I very often must explain to them that I get at least 5 people with similar stories asking for controlled substances every day. I mean, sometimes I wish they were more creative in their tactics just to break up the monotony of having me saying, "No."
Especially in the clinic environments where I work, a large part of the homeless population struggle with substance abuse and mental illness. I don't intend to help them self-medicate by becoming a pill factory. I've been threatened with physical harm and called out of my name more times than I can count by patients upset with me for not giving them Lortab or Xanax or Soma. Just let's me know that I am doing the right thing.
Towanna
Saturday, August 4, 2012
The Dream Team
As this blog progresses, I think its important that I not only tell you the patient's stories, but you should also get an understanding of the types of people that it takes to invest themselves into something that can sometimes be completely thankless.
Therefore, I give you "The Dream Team..." (initials only -- some of them transposed because I've asked no one's permission to do this)
KB --- Practice Manager/COO --- You ever clicked with someone the moment that you met? That was me and KB. This lady is a BOSS. In every sense of the word. Completely covered in a amazing anointing. Steady. Funny. Mogul minded. And all the way down to earth. I don't think we could have ever imagined that we would have found someone with such a perfect background to run the operations of the clinics. If I sound like her groupie, its because I am.
CK --- Certified Medical Assistant -- young, bubbly and completely obsessed with her hair. At first meeting, all I could focus on was the doobied hair and the colorful nails. Yes, I raised an eyebrow when she came in for her interview, but something else about her said we should make her a part of what we were doing. Admittedly, she has a lot to learn, but she seems to be a whiz at phlebotomy. She's way more shy than I would have ever imagined. But we want her to understand that she is just as much a part of what we are doing as anyone else is and that needs to be the steel rod running down her back everyday that she steps into the clinic. SAY IT WIT YA CHEST, CK!!! SAY IT WIT YA CHEST!!!
AF--- Eligibility Coordinator --- talk about a steady force. She comes to work everyday with the single minded purpose of getting her job done. She is smart and has a heart of gold. She is really versed in contracts and eligibility for services in and among the local programs. Sometimes, you need that person who is just responsible and calm to balance the frantic energy that can invade the atmosphere. Sometimes, I think that she might think the rest of us are completely insane.
HL -- Eligibility Coordinator --- Ok. She is great at her job and also has invaluable experience in benefits management and community programs. But she is absolutely hilarious with her quirky nature and if for no other reason, I'd like to keep her around just for the entertainment value. She wears her heart on her sleeve and the patients love her to pieces. We do, too. She's completely bathed in humanity, so we feel like we have to protect her from the not so sincere intentions of the patients who would try to take advantage of her generosity. If we could just get her to quit smoking, though...
YG --- Program Coordinator/Grant Administrator --- Our 6th man. This guy is the Don. You ever met someone who can get anyone to listen to what he has to say AND buy into it? This is that guy. And don't mistake what he says for propaganda. He just has a way of making the ugly truth a little prettier. He is new to healthcare administration. But he caught on fast. I think if he decides to stick with what he is doing, he could really make some major waves in the Richland Community. Dude got moves like Jagger. And he wears really nice shirt and tie combinations.
There's lots of other people on the fringes that help make what we do possible. But this is the core. A beautiful bundle of an eclectic mess. Its part of what I love about what I do.
Cause sometimes it takes crazy to overcome craziness.
Towanna
Therefore, I give you "The Dream Team..." (initials only -- some of them transposed because I've asked no one's permission to do this)
KB --- Practice Manager/COO --- You ever clicked with someone the moment that you met? That was me and KB. This lady is a BOSS. In every sense of the word. Completely covered in a amazing anointing. Steady. Funny. Mogul minded. And all the way down to earth. I don't think we could have ever imagined that we would have found someone with such a perfect background to run the operations of the clinics. If I sound like her groupie, its because I am.
CK --- Certified Medical Assistant -- young, bubbly and completely obsessed with her hair. At first meeting, all I could focus on was the doobied hair and the colorful nails. Yes, I raised an eyebrow when she came in for her interview, but something else about her said we should make her a part of what we were doing. Admittedly, she has a lot to learn, but she seems to be a whiz at phlebotomy. She's way more shy than I would have ever imagined. But we want her to understand that she is just as much a part of what we are doing as anyone else is and that needs to be the steel rod running down her back everyday that she steps into the clinic. SAY IT WIT YA CHEST, CK!!! SAY IT WIT YA CHEST!!!
AF--- Eligibility Coordinator --- talk about a steady force. She comes to work everyday with the single minded purpose of getting her job done. She is smart and has a heart of gold. She is really versed in contracts and eligibility for services in and among the local programs. Sometimes, you need that person who is just responsible and calm to balance the frantic energy that can invade the atmosphere. Sometimes, I think that she might think the rest of us are completely insane.
HL -- Eligibility Coordinator --- Ok. She is great at her job and also has invaluable experience in benefits management and community programs. But she is absolutely hilarious with her quirky nature and if for no other reason, I'd like to keep her around just for the entertainment value. She wears her heart on her sleeve and the patients love her to pieces. We do, too. She's completely bathed in humanity, so we feel like we have to protect her from the not so sincere intentions of the patients who would try to take advantage of her generosity. If we could just get her to quit smoking, though...
YG --- Program Coordinator/Grant Administrator --- Our 6th man. This guy is the Don. You ever met someone who can get anyone to listen to what he has to say AND buy into it? This is that guy. And don't mistake what he says for propaganda. He just has a way of making the ugly truth a little prettier. He is new to healthcare administration. But he caught on fast. I think if he decides to stick with what he is doing, he could really make some major waves in the Richland Community. Dude got moves like Jagger. And he wears really nice shirt and tie combinations.
There's lots of other people on the fringes that help make what we do possible. But this is the core. A beautiful bundle of an eclectic mess. Its part of what I love about what I do.
Cause sometimes it takes crazy to overcome craziness.
Towanna
Friday, August 3, 2012
Got So Much But Nothing to Give...
I've got a story to tell....
First, allow me re-introduce myself. My name is Towanna Enoch. I am a MUSC/Duke educated nurse practitioner. I have been a nurse for 8 years. A nurse practitioner for 9 months of those 8 years. I never quite had a chance to get my feet wet after graduation last Spring. I showed up at work on a Wednesday. 3 days of orientation and computer training. 2 weeks shadowing another nurse practitioner. Less than a month in, I was seeing a full schedule of patients and I was completely in love. Still am. Always will be.
Now, if you've been paying attention (and even if you won't admit it, I know you have) you know that I was tasked with/volunteered to be part of the start-up of a handful of homeless clinic sites in Columbia --- from the ground up. Now in a perfect world things would be, well, perfect, and I would have endless resources in order to accomplish what I have been tasked to do.
Unfortunately, that is not the case.
I'd be lying if I told you it was easy. Most days, our small staff and I find ourselves playing doctors, nurses, pharmacists, social workers, secretaries, accountants, and telephone operators. All at the same damn time. But even on our worst days, I still think my job is the best in the world. And I think I'm the best one for my job.
But this blog is not about me. This blog is about my patients. This blog is about what I have seen. What I see. And what I hope to see. I don't know that my perspective will do their struggle justice. I don't even know that what I am doing here is appropriate. All that aside, I feel that what will be shared here is necessary. Important. Maybe even a matter of life and death.
I should correct my previous statement. I don't have a story to tell. I have a million stories to tell, but I'd like to start with just one that I hope will convey the spirit of what I'd like to accomplish here.
And so it goes....
Wednesday, August 1, 2012
We were sitting at our makeshift nurse's station going over the days tasks. All of a sudden we hear a funny sound ---- like someone dragging a metal chair across the floor. But the sound wasn't steady. It was staggered. I looked at one of my nurse's and said, "It sounds like someone is scratching up our dang floor." I leaned forward in my chair to peep around the large partition that separated where we sat from the open door way leading to the exit. At first glance, my eyes fell on what I thought was the cutest little old man. holding on to a four-legged walker. The first thing that crossed my mind was that he was belonged to one of the respite beds at the shelter. But as I let my eyes linger on him, I realized that something wasn't right. He was holding tight to the walker with his right hand trying to move forward, but his left arm and leg just did not seem to want to cooperate. He opened his mouth to speak and I realized that the left side of his mouth also seemed to be stubbornly refusing to move in sync with the right side. My nurse and I assisted him to one of the recliners in the room and I asked him if we could help him. What he said was barely intelligible, but we were able to make out that he'd had a stroke 3 weeks ago. He was homeless and someone had found him in the street and had the ambulance transport him to a downtown hospital. He could not remember how long he'd been in the hospital, but he did know that he was discharged with only 2 days worth of medicine and no place to go. He had managed to get a bed a the local mission for a night or 2 here and there, but had been sleeping on the street for the past few days. He explained to me that he did feel well and just needed some medical attention.
I listened to his heart. Regular, rate & rhythm. No rubs, clicks or murmurs. His lungs. Clear to auscultation. Pulses were normal. No jugular distention. No bruits. No headache. No jaw or arm pain. No SOB. No nausea. No acute mental status change. But his blood pressure was 240/110. His pupils were dilated and only mildly reactive to the light that I shined into them. He explained that he was also almost totally blind and it seemed to him that his vision had worsened after the stroke.
His blood pressure needed to be brought under control to avoid another stroke. And it needed to be done in a hurry. I asked my nurse to call 911. I crushed an aspirin for him to take and watched the water I gave him to wash it down trickle out of the left corner of his mouth and down his chin. My heart nearly broke in two as I watched my medical assistant dab at his mouth with a tissue.
In the few minutes that we waited on the ambulance, among other things, I learned that his name is James. He is not a resident at the shelter where our clinic is housed. He said that he was standing outside the gates that morning, not knowing how he would make it through the day, when another resident of the shelter, who was also our patient, assisted him onto the grounds, fed him, shaved him, bathed him, gave him a change of clothes and fixed up the old walker enough that he could use it to get around a little.
Pause.
What I can promise you is that while James stood outside those gates that morning, at least 5 shelter employees walked or drove past him on their way into the building. My money would be on the fact that none gave a backwards glance.
Most of the people that live at this shelter have nothing in the vein of material possessions. What little they do have, they must ration in order to sustain even a meager existence. Many rely on outside donations of even simple things such as soap and toothpaste. Decent clothes, shoes and socks sometimes come at a premium. That one of the residents thought to give all he did when he really has nothing to give makes a sound so loud that we should all be deafened by the blast.
The funny thing is that some of us accumulate so much material foolishness trying to keep up with one another, we can't even wrap our brain around "giving" anything up for the greater good. Got so much, you got nothing to give. The irony is astounding.
And yes. I am talking about you. And her. And him. And my selfish ass, too.
Ok. Now where was I?
So the EMT guys show up. Looking annoyed of course. I give them a quick report, they strap James in and he's off to the hospital.
I wish I could tell you that this story has a happy ending. That he went back to the hospital, was nursed back to health, found a place to stay and lived happily ever after.
But I can't.
I went to the shelter on Thursday morning for a meeting and there was James. Sitting at a table in the day room with one of the residents, Martha, helping him to feed himself breakfast. Martha explained that she was there when he was brought in and cleaned up the day before. She saw him on her way in this morning and brought him in for breakfast. James had not been kept even overnight at the hospital. Blind. Nearly crippled. Not even overnight.
I didn't ask any questions. Because I didn't want to know anymore.
Besides, he wasn't really my patient. He was nobody's patient. Right? RIGHT??!!!!
I went to my meeting.
And when I was done, I got into my fancy BMW and I went and bought a fancy bag for one of my fancy friend's birthday.
Business as usual. I'm just like the rest of them.
Except.
I'm different.
I have serious work to do.
I might be in for the fight of my life.
Naw. There I go being selfish again..
I might be in for the fight for their lives.
The revolution many not be televised.
But I am going to do my best to blog the hell out of it.....
Towanna
First, allow me re-introduce myself. My name is Towanna Enoch. I am a MUSC/Duke educated nurse practitioner. I have been a nurse for 8 years. A nurse practitioner for 9 months of those 8 years. I never quite had a chance to get my feet wet after graduation last Spring. I showed up at work on a Wednesday. 3 days of orientation and computer training. 2 weeks shadowing another nurse practitioner. Less than a month in, I was seeing a full schedule of patients and I was completely in love. Still am. Always will be.
Now, if you've been paying attention (and even if you won't admit it, I know you have) you know that I was tasked with/volunteered to be part of the start-up of a handful of homeless clinic sites in Columbia --- from the ground up. Now in a perfect world things would be, well, perfect, and I would have endless resources in order to accomplish what I have been tasked to do.
Unfortunately, that is not the case.
I'd be lying if I told you it was easy. Most days, our small staff and I find ourselves playing doctors, nurses, pharmacists, social workers, secretaries, accountants, and telephone operators. All at the same damn time. But even on our worst days, I still think my job is the best in the world. And I think I'm the best one for my job.
But this blog is not about me. This blog is about my patients. This blog is about what I have seen. What I see. And what I hope to see. I don't know that my perspective will do their struggle justice. I don't even know that what I am doing here is appropriate. All that aside, I feel that what will be shared here is necessary. Important. Maybe even a matter of life and death.
I should correct my previous statement. I don't have a story to tell. I have a million stories to tell, but I'd like to start with just one that I hope will convey the spirit of what I'd like to accomplish here.
And so it goes....
Wednesday, August 1, 2012
We were sitting at our makeshift nurse's station going over the days tasks. All of a sudden we hear a funny sound ---- like someone dragging a metal chair across the floor. But the sound wasn't steady. It was staggered. I looked at one of my nurse's and said, "It sounds like someone is scratching up our dang floor." I leaned forward in my chair to peep around the large partition that separated where we sat from the open door way leading to the exit. At first glance, my eyes fell on what I thought was the cutest little old man. holding on to a four-legged walker. The first thing that crossed my mind was that he was belonged to one of the respite beds at the shelter. But as I let my eyes linger on him, I realized that something wasn't right. He was holding tight to the walker with his right hand trying to move forward, but his left arm and leg just did not seem to want to cooperate. He opened his mouth to speak and I realized that the left side of his mouth also seemed to be stubbornly refusing to move in sync with the right side. My nurse and I assisted him to one of the recliners in the room and I asked him if we could help him. What he said was barely intelligible, but we were able to make out that he'd had a stroke 3 weeks ago. He was homeless and someone had found him in the street and had the ambulance transport him to a downtown hospital. He could not remember how long he'd been in the hospital, but he did know that he was discharged with only 2 days worth of medicine and no place to go. He had managed to get a bed a the local mission for a night or 2 here and there, but had been sleeping on the street for the past few days. He explained to me that he did feel well and just needed some medical attention.
I listened to his heart. Regular, rate & rhythm. No rubs, clicks or murmurs. His lungs. Clear to auscultation. Pulses were normal. No jugular distention. No bruits. No headache. No jaw or arm pain. No SOB. No nausea. No acute mental status change. But his blood pressure was 240/110. His pupils were dilated and only mildly reactive to the light that I shined into them. He explained that he was also almost totally blind and it seemed to him that his vision had worsened after the stroke.
His blood pressure needed to be brought under control to avoid another stroke. And it needed to be done in a hurry. I asked my nurse to call 911. I crushed an aspirin for him to take and watched the water I gave him to wash it down trickle out of the left corner of his mouth and down his chin. My heart nearly broke in two as I watched my medical assistant dab at his mouth with a tissue.
In the few minutes that we waited on the ambulance, among other things, I learned that his name is James. He is not a resident at the shelter where our clinic is housed. He said that he was standing outside the gates that morning, not knowing how he would make it through the day, when another resident of the shelter, who was also our patient, assisted him onto the grounds, fed him, shaved him, bathed him, gave him a change of clothes and fixed up the old walker enough that he could use it to get around a little.
Pause.
What I can promise you is that while James stood outside those gates that morning, at least 5 shelter employees walked or drove past him on their way into the building. My money would be on the fact that none gave a backwards glance.
Most of the people that live at this shelter have nothing in the vein of material possessions. What little they do have, they must ration in order to sustain even a meager existence. Many rely on outside donations of even simple things such as soap and toothpaste. Decent clothes, shoes and socks sometimes come at a premium. That one of the residents thought to give all he did when he really has nothing to give makes a sound so loud that we should all be deafened by the blast.
The funny thing is that some of us accumulate so much material foolishness trying to keep up with one another, we can't even wrap our brain around "giving" anything up for the greater good. Got so much, you got nothing to give. The irony is astounding.
And yes. I am talking about you. And her. And him. And my selfish ass, too.
Ok. Now where was I?
So the EMT guys show up. Looking annoyed of course. I give them a quick report, they strap James in and he's off to the hospital.
I wish I could tell you that this story has a happy ending. That he went back to the hospital, was nursed back to health, found a place to stay and lived happily ever after.
But I can't.
I went to the shelter on Thursday morning for a meeting and there was James. Sitting at a table in the day room with one of the residents, Martha, helping him to feed himself breakfast. Martha explained that she was there when he was brought in and cleaned up the day before. She saw him on her way in this morning and brought him in for breakfast. James had not been kept even overnight at the hospital. Blind. Nearly crippled. Not even overnight.
I didn't ask any questions. Because I didn't want to know anymore.
Besides, he wasn't really my patient. He was nobody's patient. Right? RIGHT??!!!!
I went to my meeting.
And when I was done, I got into my fancy BMW and I went and bought a fancy bag for one of my fancy friend's birthday.
Business as usual. I'm just like the rest of them.
Except.
I'm different.
I have serious work to do.
I might be in for the fight of my life.
Naw. There I go being selfish again..
I might be in for the fight for their lives.
The revolution many not be televised.
But I am going to do my best to blog the hell out of it.....
Towanna
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