Let's Just Think...

"Hold Her Until You Fall"

Our patient had overdosed on a substantial amount of over-the-counter medication. He was admitted to our hospital and the next day, the Resident caring for the patient informed me that he wouldn’t be able to leave our hospital until he spoke with me. 

When I arrived to his room, our patient (surrounded by an extremely supportive family) informed me that his overdose was impulsive and precipitated by an argument with his grandfather. While he informed me that he didn’t intend to take the pills, he expressed his frustration with his relationship with his grandfather and the shame involved with having to move back home as a result of the break-up of his relationship and the loss of his job.  He had also recently gained custody of his daughter (an infant).

He informed me that, after the argument, he took the pills, realized what he had done and came to our hospital. 

His grandfather had a slightly different story of the events that took place that day.

He informed me that there had been an argument about an extremely inconsequential topic. That his son became angry and left the room. His wife, upon seeing her grandson lift his cupped hand to his mouth, asked him “did you take those pills?”. 

“No” said our patient. 

When asked again by his grandfather if he had taken the pills, he admitted that he had. He informed his family that he didn’t feel his life had meaning, that it wasn’t worth living. He said he didn’t want to go to the hospital and didn’t want to receive help. As his grandfather recounted the story, the patient looked down at the floor, not wanting to make eye contact with any of the members of his family present in the room at the time. 

The patient’s grandfather had a look in his eyes I will not forget. He looked right at me with fierce determination and said: “I picked up his daughter and put her in his arms and I said to him ‘If this is the last time she’s going to see you, I want you to hold her and look into her eyes until you fall’.”

We all stood together silently in the room; it was almost like a prayer - the legacy and loving support of an entire family surrounding a son - adrift. 

“Then what happened?” I asked

Lifting his gaze from the floor, the patient looked at me and said “I told them to get me to the hospital.”

Wisdom and Insight

"It's like the ebb and flow of the tides" my mom told me last week, when I had called her to review some of the more challenging events in my life that I have been navigating lately. In learning about the “perfect storm” of foreclosure, relationships that end and autoimmune illnesses, I have learned about the importance of having a tight routine  to stay grounded while making decisions quickly. I also know that relying on family and friends for additional support is always good too.

Long ago I developed a team of people to help me when "life gets in the way" as my rehab professor used to say. So the other day, I contacted my financial planner, Beth Jones at Third Eye Associates to review some of my financial backed decisions as I wanted to make sure I was on the right track. We had a great discussion and after talking to her for the initial few seconds, I "got it" that this call was filled with some of the insight and wisdom I needed to keep on track; I grabbed my pen and started writing. 

Here are her 7 quotes that inspired me:

1.  "You gotta let go of the idea that you are a failure and all of the frustration that goes with it and do what is appropriate today." For me, failing in a relationship has been something that has been difficult. My parents have been married for over 55 years; losing a relationship after 12 has been troubling in that while I would like to learn from the lessons of the past, taking a long hard stare into a failed relationship can be extremely draining emotionally. Additionally, having all of the financial stressors that go with a failed relationship only makes these issues tougher to face.

2.  "Keep it really simple." - Simple right? - I could tweet this.

3.  "Allow your feelings to be there but don't let them encompass you." Speaks to the importance of moving through the feelings and emotions we have instead of getting "stuck" or detatching from them completely. 

4.  "Find a fully, functioning adult and then go play." This was the tail end of a discussion about knowing when you've learned the lessons you need to move forward. While I like to think that I know a lot about relationships, when you're in the middle of one that's not going well, it's not always easy to figure out how to resolve issues and conflicts. It’s also difficult to get back to “you” from the “us” as a couple.

Retrospectively, it reminded me of the time I had attended a conference with Melody Beattie only to hear (at the last minute) that she would not be coming. While I was disappointed, I later heard that her absence was a result of a tragic incident where her son had been killed while skiing. One of her books that addressed this issue a few years later, spoke to the importance of being yourself and not letting people change you, your values or beliefs. In thinking about what makes a great relationship, I wonder if it has more to do with just accepting each other for who we are without having to adjust to become someone you’re not. While I think I learned this lesson in “counseling school”, I think that as “life got in the way” - as my professor used to say, I got a little lost. Or - there’s a huge difference between learning about something in a college course vs. experiencing it firsthand.

5.  "It is what it is: an appropriate action right now in the world that you're living in and with the circumstances you're dealing with." - This when discussing how to navigate a foreclosure. Jimmy Buffett once said "I may or I may not be indecisive". When I make fast decisions under stress, it's not always easy to figure out which ones are the best and if the ones I'm making are appropriate.  This year has been filled with decisions that need to be made without having all of the information needed to make the decision and then having to hold on for the ride. 

    One of my colleagues recently lost her home as well. She told me “I lost my home - wait a minute, that’s not right, I lost my house” she said, and then clarified the difference between the house that had been auctioned to the home where she was now living with her family. Through it all, her story inspired me as she never lost faith - ever. Yes, there were days when she struggled and you could see the pain in her eyes as she decided what to take with her and what to let go. Now whenever I see her, she is cheerful, smiling and happy with where her journey has brought her.  It’s amazing and gives me hope.

6.  “Make it very manageable with very low overhead.” This was the suggestion for finding a new place. And while that’s a very important recommendation with regard to size and living space, here’s what I know for sure: As I sit her in my house / home in Germantown MD, it occurs to me that I am at my best when I am on the back deck of the boat in Brenton Cove (which honestly, my closest friends will tell you in a second). You can take me away from Rhode Island, the salt water, the fog, the high - and yes, the low tide (and the smell that goes with it), the muffled sound of fog horns in the early morning as well as the lobstah, chowdah, steemahs, and grilled swordfish and no matter where I am in this world, I will always live in a home that looks like the interior of a yacht club and my foul weather gear and sea boots will always be tucked away somewhere in a closet. There will be an expensive clam shell door knocker. Someday there will be a nice expensive weather station and a large autographed yacht print from Onne van der Wal. And yes, it would all be nice if it overlooked the beach on Anna Maria but for now, I’ll have to wait. 

7.  “Move forward and prosper - have the living space and peace of mind to create what’s possible.” It’s time.

All this from my financial planner, Beth Jones at Third Eye Associates.  If you’re looking for a financial planner, these guys are the best.  And I’m so incredibly grateful for having people in my life that have an immense amount of wisdom, compassion and insight that is far beyond their chosen careers and talents.

 

Steve Jobs & The Art of Being Adopted

 

Yesterday, upon hearing the sad news of Steve Jobs death, I went looking for this video as his commencement speech at Stamford is one of my favorites. There were a little over 6 million hits on this video. Less then 24 hours later, the number of people accessing this video has surpassed 7.5 million which speaks volumes to the impact of his life, his endeavors and inspiring career upon all of us.

My favorite part of this video is when Steve talks about being adopted and the promise his parents made to his biological parents to make sure he went to college. I love the fact that he didn't let his formal education interfere with his love and passion for knowledge and creativity.

Like Steve, there are a few of us adopted kids roaming this planet..wreaking havoc on those "reallies" (our term for children who remain with their biological parents - the ones who are "really" biologically related).  A few years ago, I was working on a crisis team when one of my colleagues (a licensed, independent clinical social worker) learned there was a patient waiting for her (for an assessment) who was adopted. As she gathered her clipboard with her assessment form to go meet the patient and their family, she said "Adopted and foster kids are so screwed up that there's not a lot you can do to help them". 

At once I was torn between wanting to throw up and wanting to slug her; I was beyond apoplectic.

I know (sadly, she didn't) that there are a lot of great people in this world who are (or were) adopted: Eleanor Roosevelt, John Lennon, the poet - Langston ("What happens to a  dream deffered..") Hughes, Larry Ellison, Sharon Stone, Stephen Spielberg, Leo Tolstoy, Presidents Bill Clinton and Gerald Ford, Olympic athletes - Greg Louganis, Kitty and Peter Carruthers and Scott Hamilton and musicians Sarah McLachlan, Faith Hill and Tim McGraw just to name a few.

Yesireebob there are a lot of us walking this planet challenged with the ginormous task of having to teach our adoptive parents to look like us. 

After his gold medal win in the winter olympics in 1988, a Sports Illustrated reporter interviewed Scotty Hamilton and asked him about the challenges of being adopted and not knowing your biological parents and how this may or may not have affected his motivation to "go for gold". His response was that he recognized the importance of being your own person as you may never know where you come from, so you create a path of your own - you create your own legacy.  For him it was part of that drive in creating his own legacy that fostered his motivation to achieve and help others.

Steve Jobs did a masterful job of this - creating a legacy that has inspired and fueled generations of individuals, corporations, schools and teams to go far beyond what they may have realized because of the products that he (and his team at Apple) created. 

..."and it's the ones who are crazy enough to think they can change the world - who actually do." 

Healthcare Fault Lines: Mental Illness

One of the most difficult to navigate "fault lines" in any emergency department or hospital is access to care for patients with mental illnesses. Even with hospitals that have inpatient behavioral health units in their hospitals, getting patients "upstairs" to the care and the treatment they need can be extremely challenging. 

For patients and families enduring the challenges of mental illness on a daily basis, this fault line can be extremely frustrating as well. - Personally and professionally, there is nothing more exasperating then having to endure the stigma of mental illness (as described in the video above) and have the necessary discussions to be able to access the care you need. In an ER, this is also challenging because of the nature of the disclosures you need to make to get the help you need to providers who who use strong defenses to endure the emotional challenges of their day and the needs of all of the patients in their care.

It's not easy, but it is necessary.

The National Alliance for Mental Illness reports:

"One in 17 people in America lives with a serious mental illnesses such as schizophrenia, major depression, or bipolar disorder. About one in 10 children live with a serious mental disorder. In recent years, the worst recession in the U.S. since the Great Depression has dramatically impacted an already inadequate public mental health system. From 2009 to 2011, massive cuts to non-Medicaid state mental health spending totaled nearly $1.6 billion dollars. And, deeper cuts are projected in 2011 and 2012. States have cuts vital services for tens of thousands of youth and adults living with the most serious mental illness. These services include community and hospital based psychiatric care, housing and access to medications."

Additional information provided by the National Alliance for Mental Illness includes the following:

• Mental illnesses are serious medical illnesses. They cannot be overcome through "will power" and are not related to a person's "character" or intelligence. Mental illness falls along a continuum of severity. Even though mental illness is widespread in the population, the main burden of illness is concentrated in a much smaller proportion-about 6 percent, or 1 in 17 Americans-who live with a serious mental illness. The National Institute of Mental Health reports that One in four adults-approximately 57.7 million Americans-experience a mental health disorder in a given year.
• The U.S. Surgeon General reports that 10 percent of children and adolescents in the United States suffer from serious emotional and mental disorders that cause significant functional impairment in their day-to-day lives at home, in school and with peers.
• The World Health Organization has reported that four of the 10 leading causes of disability in the US and other developed countries are mental disorders. By 2020, Major Depressive illness will be the leading cause of disability in the world for women and children.
• Mental illness usually strike individuals in the prime of their lives, often during adolescence and young adulthood. All ages are susceptible, but the young and the old are especially vulnerable.
• Without treatment the consequences of mental illness for the individual and society are staggering: unnecessary disability, unemployment, substance abuse, homelessness, inappropriate incarceration, suicide and wasted lives; The economic cost of untreated mental illness is more than 100 billion dollars each year in the United States.
• The best treatments for serious mental illnesses today are highly effective; between 70 and 90 percent of individuals have significant reduction of symptoms and improved quality of life with a combination of pharmacological and psychosocial treatments and supports.
• With appropriate effective medication and a wide range of services tailored to their needs, most people who live with serious mental illnesses can significantly reduce the impact of their illness and find a satisfying measure of achievement and independence. A key concept is to develop expertise in developing strategies to manage the illness process.
• Early identification and treatment is of vital importance; By ensuring access to the treatment and recovery supports that are proven effective, recovery is accelerated and the further harm related to the course of illness is minimized.
• Stigma erodes confidence that mental disorders are real, treatable health conditions. We have allowed stigma and a now unwarranted sense of hopelessness to erect attitudinal, structural and financial barriers to effective treatment and recovery. It is time to take these barriers down.

We, as providers and individuals have miles to go to access the levels of care  that our patients and families deserve; but as the Chinese philosopher Lao-tzu said: "A journey of a thousand miles begins with a single step."

If you or a loved one needs help and is in crisis and seeks help in an Emergency Department, here are 5 things that can help:

1. Bring any medications and dosages that the patient is presently prescribed with you and provide to the healthcare team.

2. Bring the names and contact information of the patient's providers and, if you can, contact them to let them know you (or your family member) are in crisis.

3. Be prepared to wait: accessing care for patients can sometimes take hours depending on bed availability and transportation.

4. If the patient is not willing to seek help on a voluntary basis, let the providers know of your concerns and why you feel inpatient involuntary treatment is needed. Let them know the symptoms you have seen starting with the most acute symptoms first. If you are concerned about your (and your family member's) safety - let people know.

5. If you are in immediate crisis, don't hesitate to contact the National Suicide Prevention lifeline at 1.800.273.8255

Need Additional Information? If so, contact the following:

• National Institute of Mental Health
• National Alliance for Mental Illness
• National Institute for Alcoholism and Alcohol Abuse
• National Institute on Drug Abuse
• Treatment Advocacy Center
• Article: A Mental Health Crisis In Emergency Care
• American Foundation for Suicide Prevention: Risk Factors
• Sidran Institute
• Suicide Prevention Lifeline
• Bring Change 2 Mind

Thanks for your help and support!

Mastering the Art of Coping with Cancer

The phone rings at the desk where I'm sitting: "you should come down here".

"Okay, I'll be there in about 5 minutes, I'm just finishing up." The fun part of my job is that you can't always say what your doing to substantiate the need for extra time, you just have to say when you can get there.  I think 5 minutes is too long, but with the person I am sitting across from it is not enough time.

After 5 minutes, I grab my keys and go downstairs into the ED. In our trauma room there are two slight women (mom and her daughter), both dressed in black, hovering over a man (mom's husband) who is boarded and collared on the guerney. "He's going to be flown out" the Charge Nurse tells me. At the same time comes the confirmation of this by the unit secretary who confirms "the helicopter's going to be here in 25 minutes".

Mom looks extremely tired, like she hasn't had a good night's sleep in weeks and hasn't had a nice, relaxing dinner in quite awhile either. I ask "is there anything I can get for you?" which transcends to the question of whether I can get them a bottle of wine  - "and an IV" (jokes her daughter). They both laugh before quickly getting back down to the seriousness of her husband's illness. "We've been doing this for several years" his wife says. She describes the long battle her husband has with cancer and the uncomfortable routine they have developed with hospitals, physicians and their care. She tells me about the time he was at Hopkins and she had fallen asleep in a chair that they had pulled out for her in the room where he was staying. "In the middle of the night, someone came and wrapped a warm blanket around my shoulders". I suspected she had spent many nights in the hospital where he was - maintaining her vigilance over her husband; her 'true north'. 

"He's a fighter, I've never heard him complain about any of it - any of the symptoms he has or the pain he is in; he just keeps going - his mental strength is amazing and he's such a wonderful man."

She looks carefully at him - consciously lying on the stretcher - boarded and collared after falling and hitting his head. Her daughter steps away from his room with her husband for a few minutes leaving her mother and I speaking quietly about the condition of our patient. "I'm scared" she says quietly, affirming that she has always fought right along with him but this time, something seems different. She has been tightly holding my hand for a minute or two and I just want to give her a huge hug and not let her go and tell her that it's all going to be okay and her husband is going to be fine...

but I can't, so I don't.

Instead, we have a conversation about the art of "knowing" - energetically knowing when it's time  to have the conversations you need to have but for now, this time, just relying on the legacy of your family. "Sometimes the stress in caring for those we love comes and goes - when you feel like you're running out of strength and having trouble navigating everything that's going on, it's okay to rely on the legacy of who you are as a family to pull you through". - Important to rely on the collaborative strength "of all of you because if one person is struggling to cope, together, you can still get through whatever you need to." We discussed the upcoming events that were going on in their family and how the members of her family could help manage the events taking place with her husband on his way to an intensive inpatient stay.

I ask her and her daughter if they need directions to get to the hospital where we are transferring out patient. They laugh - "no, we know how to get there - several different ways...driving backwards".  The strength of their routine was evident - as is the love for for their husband and father.

The helicopter had arrived and they were transitioning him from his ED bed to their stretcher.

I went into the kitchen to get them a few bottles of water for their trip to the hospital. I had asked if they wanted fruit or something to eat on the way: "No" patient's daughter answered, "we're okay - I'm getting really good at forcing her to eat and I'm more then willing to stop along the way if we have to". - I remembered a time my mother and I had gone to eat when my dad was in the hospital in Boston with his autoimmune illness. The food at the hospital was phenomenal and they had some Asparagus soup that we came to love, but the day he was admitted, we sat across from each other trying to figure out how to manage what had happened.

At that time, food was a chore.

I saw the same look in her mother as I had seen in mine over 10 years ago at that restaurant in the Brigham. It didn't matter what was on the plate in front of you - could've been lobster or a great rib eye - it just wouldn't matter, nothing was appealing.

I handed the bottles of water to our patient's daughter. Mom walked forward to kiss her husband before leaving. As she exited the room, she grabbed my hand - "thank you" she said. I gave her a hug "drive safe and try to get some sleep".  Seeing the look in her eyes made me want to just go somewhere quiet in the hospital and have a good cry and say a prayer for them - but (unfortunately), that part of our hospital is still under construction. - So I go to the second best place - a quiet hallway where no one ever goes. 

Leaving the department I look out the door to see if I can see them, but they are gone and all I can see is the group of people in the front lobby watching to see the helicopter take off. 

Here's the top 5 things we've learned as a family in coping with cancer and the other autoimmune illnesses that have come our way:

1. Develop a routine. The more comfortable the routine is, the less you have to worry about external (outside of healthcare, treatment and symptom management) stress getting in your way.

2. Keep track of all of the "tried and failed" medications or care so that you don't have to repeat things that have already been unsuccessful. 

3. If the neighbors ask if they can bring food - don't say "no" - accept all offers because thinking about what to cook for dinner is brain energy better spent at the hospital. 

4. Have a plan, as a family. Know who has the power of attorney and phone numbers and contact information for all physicians, offices and hospitals. Get to know all of the providers who are caring for your loved one and don't hesitate to ask questions about anything from side effects of medications to the prognosis for the illness. 

5. What's the identity of your family? What are the strengths that each of you bring to the table and how can you support each other during stressful times? A little insight into this now will serve you well with any stress that may come your way - use your collaborative strength but also pay attention to those times when there are moments to have tough conversations about decisions that may need to be made. 

 

Why I love the J-Mac story

I love the story of Jason McElwain not only because of the record breaking shots he threw for his basketball team at Greece Athena High School, but also because it sparked the potential that I think we all have to achieve greatness. Whether it's helping your team win, or helping someone else, I sometimes wonder about how we call upon that which is buried deep within us, to come forward and help us achieve.

I once heard Dr.Calvin Butts give a presentation about addiction at a conference where he referred to this as the "still small voice from within". The one that tells us to "keep going" when the times get rough, or "it'll be okay" if we are in pain, or "take your shot" as is the case with Jason McElwain.

I suspect Mr. McElwain knew that he had the potential he did and in this case, it was only a matter of time and having the patience and grace of waiting until he was called to join his team on the court.
I think there are lessons for all of us in his actions and strength.