Boundaries

As I pulled into the parking lot of the nursing home I tried to become optimistic about the day. I told myself that today was going to be a good day and nothing will bother me. That it's all part of the job.

Well, as soon as I got into the lobby, I encountered a family that was crying. I hadn't even had a chance to take my coat off and I was hit in the face with the reality of working in a nursing home. My stomach sank.

And so the day began.

I'm lucky in that the PA that I'm working with is brilliant. He's been working as a PA for 12 years and before that he worked in a nursing home as an aide for 7 years. I'm lucky that he has a very sarcastic, witty sense of humor and a compassionate heart. He's amazing when it comes to dealing with the patients and their families. When a patient tells him that they want to die, he takes it in stride and finds a way to make them realize that it's not their time. The patients love him. The old ladies flirt with him and he loves what he does.

He takes the time to teach me as well. We basically move from floor to floor and round on our patients. We do a mini-physical on each patient and then we go back to the nurse's station to write in their charts, check labs, and write orders. He's spent a lot of time teaching me how to interpret labs. It's an absolute blessing to have him do this with me. I've learned so much from him and he helps me "connect the dots". There is so much to learn, so much to know, and he takes the time to make sure that I know it. He appreciates all of my questions and my suggestions. And he encourages me and reminds me that there is a light at the end of the tunnel. He reminds me that one year from now...I'll be getting a paycheck!

I've learned from this rotation that I need to work on my "boundaries". When I worked for the AIDS organization, I went to a lot of boundary workshops. I learned how to create distance between my work and my own life. Although I dealt with a very serious and horrific virus, I was able to leave it at work at the end of the day.

I'm finding the nursing home to be a completely different challenge. When I leave the facility, I do indeed leave it behind me. I do not think about the patients once I leave. But, the day does take an emotional toll on me. I'm surrounded by a population that is sick and dying and the overwhelming majority of them do not want to be in a nursing home. Some of them are very angry and upset that they are unable to live on their own anymore.

Today I saw an old man cry and it tugged at my heartstrings with such force that I almost had to leave the room. As we were examing him he started to talk about how much he wanted to go home. Then he started to talk about his wife and how he felt he was a burden to her and the family and that is why he was in a nursing home alone. Then his lips began to quiver and tears rolled down his cheek. Once again, my stomach was in knots and I felt tears welling up in my own eyes. The PA looked over at me and I couldn't make eye contact with him. If I did, I probably would have lost it. I just focused on looking at the patient. The PA put his arm around him and hugged him until he stopped crying. It was an amazing gesture on the part of the PA. Nowhere in our education are we taught about how to deal with patients in that capacity. It comes naturally for this PA and that is what makes him so good at what he does.

Seeing the old man cry tainted my day. I had a sinking feeling in my gut for the rest of the day and I realized it's probably because there is nothing more that I can do for these patients. They are dying. They have lived long lives and it's their time to leave this earth. And it will happen to everyone. That is what probably bothers me...everyone will die. I can help ease their physical pain but their suffering is a different story. Some accept their fate, but others are angry, bitter, and defiant of their fate. Some have outlived their entire network of family and friends and others have family, but no visitors.

I'm not saying that nursing homes are a bad place. They are very necessary in today's society and they do provide a social network as well as opportunities for arts, recreation and exercise. It's simply not an environment that I'm comfortable working in...not yet, anyway. For now, I want to work with younger patients and focus more on preventative health. I have more to offer in that capacity. Dealing with end of life issues is not my forte.

I'm sure that will come with time.

Not For Me

I'm not cut out for working in a nursing home. I have found something that I definitely am NOT interested in doing. I had an open mind going into this rotation, but overall...it brings me down.

I don't like watching old ladies cry.

I don't like being asked, "When am I going to die?"

I don't like being told, "I'm ready to die."

I don't like having conversations with families about "comfort care".

I don't like the desperation in the eyes of those with thriving minds, but failing bodies.

I don't like it when they curl up in a ball at the side of the bed and stay there all day.

I don't like the psychological torment that plagues the majority of them.

It's uncomfortable. It's awkward. It's not for me.

It's not death that frightens me.

It's the prolongation of death that does.

Medicine = a double-edged sword.

Home Sweet Home

The nursing home that I'm at now was built to resemble a resort. It's a very impressive looking complex with sunny yellow siding and manicured lawns. The lobby is bright and cheerful with a huge fishtank, chandelier and a spiral staircase. At first glance, it's a very comforting and elegant setting.

When I pulled into the parking lot this morning there were two ambulances parked outside the lobby. My stomach sank. I knew it was going to be a long day...and it was.

I met the PA in the lobby and we started the day off with our daily ritual. We stopped off at the cafeteria for a cup of tea. Since it was a relatively mild winter day we drank our tea outside on the loading dock. The PA quizzed me with board like questions as we sat in the sun and drank our tea. As we were sitting there a family-sized, powder blue caravan pulled up and a man in a three piece black suit got out and walked into the building. We both thought it was odd for a man dressed in a three piece suit to be entering a building through the loading dock area. But, we shrugged it off.

The man returned a few minutes later...pushing a stretcher with a body bag on it. The body bag was full. My mouth dropped open. I looked at the PA and he was equally confused. The man in the three piece suit opened up the back door of his caravan and slid the stretcher with the body into the van....right next to the other full body bag that was already in there!

The man in the three piece suit jumped back into his powder blue caravan and drove away. It took me a couple of minutes to process what I had seen.

Then the PA reminded me..."that's the only way home."

A Time For Change

2007 is all about change.

I change rotations every 5 weeks.

I finish my last rotation in August.

I graduate in September.

I PASS the boards in October.

I consider my options in November.

I start anew in December.

2007 is all about change.

I Miss Brooklyn

I miss the freedom I felt while living there.

I miss the neighborhood I lived in.

I miss the culture.

I miss the grocery store where English was the second language.

I miss the diversity.

I miss the twin-size blow up mattress I slept on for 12 weeks.

I miss the alternate side of the street parking.

I miss the fire hydrants.

I miss the pitter patter from the apartment above mine.

I miss the subway.

I miss the part of me that felt at home everywhere I went.

I miss Brooklyn.

Murmur

I was walking down the hallway of the nursing home with the PA when he asked me, "Did you hear the murmur on the last patient that we examined?"

My intelligent response was, "Uh...what murmur?"

He smiled at me and sent me back to her room. "Don't come back until you hear the murmur!"

All of this went down during day ONE of my long term care rotation. I was rusty. I didn't hear any murmurs during Pediatrics. My ears were out of tune.

I went back to her room and the nice little old lady let me listen to her heart. She was very patient with me. She was so patient that she actually fell asleep in her wheelchair while I listened for her murmur.

And then I found it. It took a few minutes but then I remembered the sound...harsh, blowing, 2/6, RRR murmur over the aortic valve. I was mighty proud of myself once I heard it. I bounced down the hallway and proudly reported back to the PA..."I heard the murmur!"

Again, he smiled at me. I could tell I wasn't impressing him that much.

Two days later the same PA sent me to examine a different woman. An 87 year old female with dementia, end stage renal disease and a slew of other maladies. I start every exam by listening to the heart and then the lungs and then proceed to rest of the body. Once my stethoscope hit her chest I immediately heard a murmur. Since I was alone in the room and my patient had dementia I just made a mental note of it and continued with my exam.

Afterwards, I went back to the nursing station to document my findings. I reviewed her chart and searched for documentation of her murmur.

I couldn't find it.

So I consulted with the PA about the patient's murmur.

He said, "You heard a murmur? I never heard one on her. Are you sure the sound was coming from her heart and not her lungs?"

I realized I had a choice. I could stick to my original diagnosis or I could doubt myself and recant my finding. It was possible that the sounds I heard were coming from her lungs. But something deep down told me to stick with the murmur.

"Murmur...FINAL ANSWER!" Then I jokingly stated, "Don't come back until you hear the murmur!"

He smirked at me, picked up his stethoscope and said, "Let's go take a listen."

The PA took a listen, then looked up and smirked at me again, "You're right...that's a murmur...I don't know how I missed that earlier!"

I just looked at him and smiled.

I finally impressed him.

Long Term Care

I started Long Term Care on January 2nd. I don't recommend waitressing at Brooklyn's hottest pan-latin restaurant (ahem, www.bogotabistro.com) two nights before the start of a new rotation. But, it was New Year's Eve and it turned out to be one of the best "Eve's" of all time. There's nothing like ringing in the new year surrounded by friends and "family". Thank you George, Omar and the cutie patooties!

I thoroughly enjoyed my two week break away from medicine. I finally got rid of the sinus infection that scarred my 5 weeks in pediatrics. Every time I felt like I was getting better, another kid would come in and cough on me. And then I'd get what the kid had a few days later. It really was one long month of coughing, sniffles, and headaches for me. But, the laughter and the kinetic energy that only kids can produce overshadowed my declining health!

So I started Long Term Care feeling physically healthy but intellectually sluggish. The first few hours of meeting a preceptor are crucial. In this case, the PA that I would be working with for the next 5 weeks hit me up with cardiology questions within 10 minutes of us meeting. I felt my stomach drop. Ugh...cardiology. UGH UGH UGH

I don't know why I have issues with cardiology, but I do. I have a love/hate relationship with identifying murmurs (S1, S2, harsh, blowing, crescendo, decrescendo, snaps, clicks, rubs, gallops, S3, S4?!?...) all of the medicines involved (diuretics, calcium channel blockers, beta blockers, nitrates, ACE Inhibitors...)and all of the intricate details of an EKG (S-T elevations, depression, t-wave inversion, "Wenky" who?).

The PA showed me no mercy. I was familiar with the questions he was asking me, but after 5 weeks in Pediatrics and a 2-week vacation...(errr...did I mention the champagne and tequila on NYE?) my brain kept coming up empty.

I've mastered the art of saying, "I don't know." When I really don't know something I look em dead in the eye and say, "I don't know." But, there are times when I think I know, but I'm not sure if I know, or I can't explain why I think I know what I know or if I really do know anything at all." During those times, I usually say, "I don't know, but...I DO KNOW THAT...xyz." So, I admit that I don't know exactly what kind of answer the preceptor is looking for, but I try to relay information that I truly do know and understand. I spit that back out and follow up by trying to show the direction of my thought process.

It seems to work.

It shows the preceptor that I am somewhat intelligent and it buys some time for my brain to kick into high gear. Sometimes I come up with answers and impress the heck out of myself. But other times I find myself grasping for an answer that I know I "should" know cold by now.

I carry around a small spiral notebook in my lab coat and I try to summarize the learning points/subjects that the preceptor spoke about during the day. If I don't know a question, I'll go look it up and write down the answer, because 9 times out of 10...I'll be asked the same exact question a few days later.

The first day of long term care was rough. It was my first time in a nursing home and at first glance, it was depressing. I didn't want to be there. I wanted to go back to Pediatrics. I was VERY comfortable in pediatrics. I felt like I knew stuff in Pediatrics and Primary Care. I felt like I had a clue.

Patients in long term care facilities have very complex medical issues. The average patient has between 10-15 different diagnoses and is on 15-20 different medications/supplements. My day involves sifting through piles of labs and reviewing charts. There is very little hands-on action. I mostly sit at a nursing station with the PA and we review labs.

It's absolutely mind-boggling.

I have a lot to learn!