Oliver Sacks and the loneliness of a great humanitarian doctor.

Oliver Sacks and the loneliness of a great humanitarian doctor.

In my long season of heartbreak and loneliness I once more look for a friend. I’m riding the tide of what Freud (who may have been wrong about everything but was also right about everything) called melancholia. Cognitive behaviorists might call it a slew of distortions.

In truth, I’ve many beautiful friends. Who show up. Clean the fridge in my new apartment. Set up my living room. Pour wine spritzers and sit on the deck and roll eyes at our happy, healthy, wrestling children.

So why this aching loneliness that just won’t quit? I fall in love with strangers four times a day. A quirky gesture, a turn of phrase, a graceful gait. That’s all it takes. But it’s unrequited; this sublimated love that has no real grit… maybe that’s what I can muster. Love that can’t be returned and will never be rejected. It’s utterly secret.

I’m in love with the world and my life in it. I’ll sound dramatic (no surprise) but every small accomplishment, every trip I take or task I finish I feel as though I’ve snatched it out from the maw of death. Ha! You can’t take it away now, I’ve lived it! I’ve moon gazed in the pouring rain with bare feet on steaming asphalt. I’ve eaten just-picked berries! I’ve smoothed the hair of my fluish child until he slept in my arms. It’s mine forever infernal eternity.

As is often the case, the right book finds me. I’m reading Oliver Sack’s memoir, On the Move. The fates saved it for the exact right moment. Oliver was not at all like me demographically. He was not like me in temperament. But we share two characteristics that buoy me when I feel low. First, the treatment of medical science as a humanity. Medicine as observation and experimentation in bettering our human existence. It indulges curiosity and regards no dogma in pursuit of understanding, helping, and healing.

Second, a protective self-enforced loneliness. Oliver was uniquely capable in his role as benevolent understander and wizened healer because of the isolation in which he held himself. Hundreds of close friends, thousands of adoring colleagues, tens of thousands of grateful patients, millions of entranced readers, but almost zero binding couple or familial loves in his life. However, I can attest: the grey tedium of monk-like living makes the wider world explosive with color, intrigue, stories to be learned, mysteries to solve, and hallucinations to manifest. That, I suppose, is the trade off.

I take heart that a mind so bright and wide walked the earth. If over the course of my life I manage one one-hundredth of his cleverness, curiosity, tender care of the sick, and generous story telling I would happily suffer an existence one hundred times as lonely.

Be mesmerized by one of his last interviews and storytelling sessions.

This is the gratitude I find at the bottom of the I’m feeling sorry for myself well. It is great and deep and sustaining.

Trauma story

Trauma story

I just visited with a teacher friend who was telling me about his adamant opposition the the ad-hoc trauma counseling the public schools are asking teachers to perform on their at-risk students.

“First we have to sit in a big circle,” he tells me.

“Stop. No no no no sir. Not a circle. There is no safe place in a circle of peers.” I say.

Trauma is the flavor of the DSM V. Who isn’t talking about trauma? We’re all a bunch of traumatized zombies walking around, unstoppable force, inflicting and receiving trauma. Unable to zombie stumble ourselves into an effective treatment for our trauma on trauma on trauma.

Maybe trauma is the flavor of the century. This thing that was never really a thing in centuries past. Before, it was as inherent to living as breathing. Unremarkable. It starts to make itself known in the Western World after the great wars. Life settles, the middle class thrives, and a coherent nuclear family of two heterosexual parents and 2.5 kids emerges. Vaccines keep children from dying, sterile technique and antibiotics extend the lives of their parents. Union strength brings forth OSHA and safer workplaces, risky agricultural labor is given to 6-lane-highway sized air-conditioned combines, and the quagmire land wars in Asia make conscription a political nuh uh. The twentieth century American person is now safe. Safe enough for a man to concern himself with the perilous moments he has lived through. And now we live in enough comfort to reflect ourselves awake all night.

 

I’m flashing back to my greatest lesson in trauma. One I’ve written about before. Part of the advantage of having experienced the bulk of traumatic life events in short sequence as a full grown adult is your ability to remember them. Half of me records the events and their aftermath, the other experiences them. I’ll tell you my two big takeaways when it comes to managing life’s garbage:

  1. Trauma is not concrete. It is a thing perceived. You can live through an act of terror, loss of a loved one, life-threatening diagnosis, and come out the other side a well-adjusted and intact human. Maybe even more grateful, more god loving, closer to family, any positive thing. But like a kid with a skinned knee who doesn’t know to cry until he sees the panic on his mother’s face, being forced to re-tell your story to “debrief” or in crisis counseling may be the point at which you recast yourself in the role of traumatized person and become a victim to it. If people are fine, just let them be fine.
  2. People are excellent copers. Never take away a person’s coping mechanisms without their consent and a thought through plan to replace it. Clinically we categorize coping as either positive or negative. Positive: seeks assistance of family. Keeps journal. Exercises. Negative: Abuses drugs and alcohol. Isolates. Overindulges in TV. Doesn’t eat/eats too much. In real life, it’s usually a mixed bag. But either way–negative coping may be superior to no coping. No coping mechanisms threaten a victim’s survival.

The constellation of coping mechanisms put together by each person is unique. If they are maintaining a functional life, I think of their elements of coping as precariously balanced weights on branching wire arms, like a Calder mobile. Remove one element and you’ll destroy the whole delicately strung installation. Clinically, we’d call this decompensation.

My greatest public decompensation occurred in a literal circle of my closest friends at a mandatory mindfulness retreat in the very posh renovated barn/private events space owned by my prestigious southern university. For me, coping is dependent upon keeping my brain engaged in obsessive, hyper-vigilant work on 2-7 jobs or projects at a time. I also use humor and self-deprecation to be able to maintain a detachment from myself and others. (I’m a criterion D and E girl). The closer I am to my fear of dying, which is not lost on me as poetic and appropriate for a nurse, the harder I go into being a straight A student. I can box out the reliving of various death-sentences I’ve been handed by focusing on the esoteric, the academic, the political, the theoretical. Also, avoiding eye contact is key. Making eye contact is lethal. It is hard to deny your physical existence when you are eye to eye.

So the day of this retreat, waiting on a cancer diagnosis, knowing my marriage was caputskies, worrying about where the money for food would come from that week, the last thing I wanted to do was slow down. The last place I wanted to be was present in my mind.

I was barely through the authentic antique barn doors when I caught a picture of a patron of our University. Her bleached smile and tailored skirt-suit. The pearls. The goddamn real towel hand towel on the vanity beside the photo. The meditative music on the Bose surround. I decompensated. I started crying and kept it up all through silent yoga (drip, drip, drip, sniffle, mournful moan) slipping and sliding through my tear puddle on the rubbery mat. I stifled wails with the real towel hand towels in the bathroom. My psych prof asked me the mandatory question, “are you thinking about harming yourself.”

It took may face two days to return to baseline puffy.

Another salient point from my visiting teacher friend. One he got from a biology teacher in grade school: Species don’t occur in nature. Individuals do. I love a botanical metaphor so let’s work this one. What he was trying to impart, that I in my thirties and my friend a decade older are just now beginning to grasp, is that no individual tree or frog or dog meets all the criteria set for them in the key used to decode what species you is. They’re missing a whorl, they have additional spots, their eyes are too prominent. The the designation of species is arbitrary. The tree’s leaves curl under not over. It’s not wrong until you tell it so. We create a holotype to further our own scientific pursuits, which are noble and even useful at a population level, but the human experience can rarely be perfectly described by a text. Not even the DSM.

This failing to see the individual for the species problem is what makes the mandatory part of trauma counseling so worrisome. There are people in this world who do great work reading a person and healing them without the assistance of a marketed standardized trauma scoring system and matching intervention workbook. I’ve seen priests do it. I’ve seen wives do it for husbands, husbands for wives. Friends for each other. Parents and children. Strangers you meet on a train. Books. Poems. Singing.

The hubris to think you can heal trauma with a tool approved by science is so beautifully American. Intention so good, execution a mess, outcome pretty sad. Please give people the chance to manage themselves. Seek only to change behaviors that harm self or others. Never ask for a change without a replacement coping strategy. Move slow.

And never, ever make people sit in a circle.

United States Health Care Reform:  Progress to Date and Next Steps | JAMA | JAMA Network

United States Health Care Reform:  Progress to Date and Next Steps | JAMA | JAMA Network

The president got published in JAMA! This is a lovely, academic, chock-full-of line graphs sum up of the past 6 years of changes. Uninsured rates are way down, access and quality measures improving. The economy has responded positively. The health care world is topsy-turvy, and it is undeniably rough in the ranks of hospital management. But in spite of the challenges to the health care industry, the protections that the Affordable Care Act legislation provided make me as a believer in health care as a human right happy. And very frustrated with my home state and others that have declined to expand Medicaid.

It’s strange and sad that I celebrated the upholding of the ACA in the office of a Free Clinic where I volunteered, thinking it might be the end of clinics covering adults below the federal poverty level with a patchwork of volunteer services, state funds, and grants. I’m sorry that virtually nothing has changed for the patients we saw at that clinic. Hospitals in non-expansion states are still going uncompensated for millions of dollars of care. The federal government DSH (disproportionate share hospital) dollars that used to support public hospitals with large numbers of uninsured have declined as that money was plowed into ACA program support. One last insult: if you are paying federal taxes in a non-expansion state, your money is fed into Medicaid for adults in other states, while your health infrastructure is starving. But that is not the main focus of the article. This is a celebration. A statistically-backed victory lap. But don’t take my word, listen to Barack Obama, JD:

The United States’ high uninsured rate had negative consequences for uninsured Americans, who experienced greater financial insecurity, barriers to care, and odds of poor health and preventable death; for the health care system, which was burdened with billions of dollars in uncompensated care; and for the US economy, which suffered, for example, because workers were concerned about joining the ranks of the uninsured if they sought additional education or started a business.

Source: United States Health Care Reform:  Progress to Date and Next Steps | JAMA | JAMA Network

(GOOD NEWS AFTER THE ARTICLE) This study shows so much of what’s wrong with medical research today | The Incidental Economist

This study shows so much of what’s wrong with medical research today | The Incidental Economist.

I won’t wade too deeply into this pool right now. Every moment I spend is borrowed time from NCLEX studying. But it’s worth mentioning that despite the incredibly difficult environment of academic research I see all around me nurse researchers doing what nurses are known to do–finding a way to make it work. They are making efforts to conduct unit-based research and if appropriate expand evidence based practice to other units and through professional networks to outside health systems. This research focuses on patient safety, quality improvement, and money savings to patient and health care system. Simple, cheap, and effective are markers of success. The example of using the blood pressure cuff to reduce kidney damage in cardiac surgery is right up the alley of unit-based nursing research.

Recognizing bedside nurses as professionals with the capacity to contribute in this essential way to the improvement of care (and bottom line) is mandatory for health systems moving forward. We are endlessly capable when given the time, the tools, and the support to make positive changes. It’s a super bonus that we aren’t stuck with the difficulties ($$$, popularity contests) of grant-dependent research.

At the health system I trained in a nurse is championing Enhanced Recovery After Surgery (ERAS) protocols. Unit by unit she is getting buy in and rolling it out. I’ve seen her data: it is significant. Patients are going home sooner and healthier.

So my plea to my fellow nurses is publish your work! Read each other’s studies! Let’s flex our skills. Let’s brag on each other. There’s a lot to be proud of.

Poetry Monday

Saturday I had the pleasure of listening to Margaret Mohrmann give the keynote at the UVA’s End-of-Life conference. Blow. Me. Back. The weight of the subject matter and her nimble language. The stories steeped in years of experience ecclesiastical and medical. Is frank compassion a thing? I think it may be her thing. One of the two times she made me well up (for my patients, for my loved ones, for me, for my fellow RNs & MDs, for humanity):

A Blessing for a Friend on the Arrival of Illness
by John O’Donohue

Now is the time of dark invitation
beyond a frontier that you did not expect.
Abruptly your old life seems distant.
You barely noticed how each day opened
a path through fields never questioned
yet expected deep down to hold treasure.

Now your time on earth becomes full of threat.
Before your eyes your future shrinks.
You lived absorbed in the day to day so continuous
with everything around you that you could forget
you were separate.

Now this dark companion has come between you.
Distances have opened in your eyes.
You feel that against your will
A stranger has married your heart.
Nothing before has made you feel so isolated
and lost.

When the reverberations of shock subside in you,
may grace come to restore you to balance.
May it shape a new space in your heart
to embrace this illness as a teacher
who has come to open your life to new worlds.
May you find in yourself a courageous hospitality
towards what is difficult, painful and unknown.

May you use this illness as a lantern
to illuminate the new qualities that will emerge in you.
May your fragile harvesting of this slow light help you
release whatever has become false in you.
May you trust this light to clear a path
through all the fog of old unease and anxiety
until you feel a rising within you,
a tranquility profound enough to call the storm to stillness.

May you find the wisdom to listen to your illness,
ask it why it came,
why it chose your friendship,
where it wants to take you,
what it wants you to know,
what quality of space it wants to create in you,
what you need to learn to become more fully yourself,
that your presence may shine in the world.

May you keep faith with your body,
learning to see it as a holy sanctuary
which can bring this night wound
gradually towards the healing and freedom of dawn.

Can This Treatment Help Me? There’s a Statistic for That – NYTimes.com

Can This Treatment Help Me? There’s a Statistic for That – NYTimes.com

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Can This Treatment Help Me? There’s a Statistic for That – NYTimes.com

Who over the age of 65 doesn’t take an aspirin a day? For every medical intervention practitioners look at a cost/benefit analysis. Sometimes it’s a big deal–we surgically remove the tumor on your spine at great risk to your life and mobility, but there is a strong possibility of removing and curing your cancer–that benefit outweighs the risk. Sometimes it’s not. Take some calcium supplements. They might help but they probably won’t hurt. Just whatever!

Practitioners make recommendations based on studies and evidence which are analyzed using statistical methods. We know that the average person has no concept of what statistical chance actually means. We’re just hairless apes, y’all. The same is true for docs. And this nurse.

This article illustrates beautifully what we are talking about when we talk about the metric commonly used in analyzing efficacy of treatment: N.N.T. or number to treat. Eat it up. I feel like I learned a thing today.