Let's Just Think...

Alcohol

When I started college, I entered as an English major with a passion for Emerson and Thoreau as well as poetry and Russian literature (an interest that started in high school). I had "a thing" for Anton Chekhov and his short stories, several of which hovered on the topic of drinking and alcoholism and all of the turbulance that accompanies it. 

As my freshman year transcended to my sophomore year, I changed majors again and again and again. It got to the point where I would call my parents and my mother would ask "So, what are we majoring in today?"  - As Jimmy Buffett once said "I may or may not be indecisive".

Having finally ended up majoring in Psychology, I never really gave up my passion for literature and poetry because of the way the novels and stories that I read accentuted the lessons I learned in my Psychology courses: Abnormal Psychology, Developmental Theory and one of my favorite courses of all time - Perception and Psychophysics.

When the topics of addiction and alcoholism came up in our senior Psychology seminar, Anton Chekhov returned to my life.  It was never just "psych" it was the lessons of Erickson, Skinner and James along with those who wrote about relationships, history and  the consequences that came "with a dream deferred".

Over the weekend,  a masterful lesson in Alcoholism extended throughout our hospital in a way that was like a fishing net cast over a wide ocean. In one part of the hospital, a patient was detoxing and trying to communicate her needs through shaking and the slurred speech. She referred to my colleague as her sister and asked her family (none of whom were present in the room), to "push in the chair!!".

Our discussion flowed into a collaborative fusion of our knowledge via lessons learned from our own insightful experiences and lessons learned from alcohol: previous use, abuse, relationship struggles with our families, our children and our own upbringing. Everyone from the physicians to the nurses and techs had both similar and different perspectives of alcoholism and addiction. It was fascinating to watch as the topic seemed to hover like a stormy cloud on the second floor until it got on the elevator and headed downstairs to our Emergency Department. 

The two traumas were called right around shift change. A car accident with two people needing to be "extracted" from their vehicles. 

Like the progression of addiction, the rest of the night became worse as each moment went from one discussion to the next. I looked at my colleagues working feverishly to save each life in the two trauma rooms in our department. Then looked into the faces of the families as we told them the news of their critical loved ones. 

Nothing good comes of alcohol use. 

I walked into the chapel, our Chaplin who had been called in met with one family while the other family still sat quietly in our consult room - waiting for more news. It seemed like everyone was crying.

Our clinical team was steadfast in the way they navigated through hours of care for our patients and their families. In the end, one patient had died while the other remained in critical condition, stable enough to be transferred to receive the continued care he needed. His wife sat stoically in the passenger side of the ambulance. I waved as I walked by her hoping she had the inner strength to get through the next several hours. 

Nothing good comes of alcohol use.

A life once filled with an immense amount of talent and potential was gone. Two families will never be the same. 

Anton Chekhov once said: " We shall find peace. We shall hear angels, we shall see the sky sparkling with diamonds."

Are We Providing Good Care or Fostering the "F"?

If you look at the map, our hospital in WV is about 2300 miles from Tucson Arizona where 1 year ago today we shared our prayers along with feelings of sadness and loss with six families who lost a loved one as a result of the actions of a young man with mental illness. With 13 other individuals wounded in the same event, it is difficult to avoid taking a long hard stare at the way mental illnesses have affected our lives, our state and our nation.

At our hospital, we see patients with mental illnesses frequently. Is this surprising? – No. The National Alliance on Mental Illness (NAMI) website reports that “we’ve all been hit by the worst economic times and highest unemployment in more than 25 years. Those unemployed workers are reporting symptoms of severe mental illness four times more than people who still have jobs. Four times as many report thoughts of suicide.” Additionally, NAMI reports, “returning combat veterans are experiencing very high rates of serious mental illness, suicide, addiction, homelessness, and incarceration related to posttraumatic stress disorder.”

“How are you?” I frequently ask the patients and families in our Emergency Department who have presented with symptoms of mental illnesses. The responses usually consist of a wide range of issues and situations that are not easily solved within the few hours they are with us: “I’m about to lose my house”, I’ve been out of work for the last year and a half and can’t find anything”, “ I just found out I had cancer”, - or – what I think of as the ‘perfect storm’ of emotions and stress:  “my wife and I aren’t getting along – ever since I lost my job, we’ve had financial arguments which are affecting our relationship and the children, the house is about to get foreclosed...we have no where to go”.

Each story seems more heart wrenching then the one that came before it. But what is even more difficult is looking into the eyes of the patients across from me and seeing their ‘heart’; their emotional pain, vulnerability, frustration, fear, anger, hurt, abandonment, disappointment - you name it, the emotions are there. Emotions that sometimes lie buried under situations or dynamics of fighting to keep your family together or pounding the pavement looking for a job only to face rejection over and over and over again.

And yet, as heart-wrenching as these stories are, I’m glad to be having a conversation with each patient as opposed to helping families with locating a funeral home and additional support after the successful suicide of a loved one.

In 2009, the National Alliance on Mental Illness published their report “Grading the States” which listed West Virginia having a grade of “F” (the national average was a “D” – which was the grade given to West Virginia in NAMI’s 2006 report). Arizona – where the shootings in Tucson took place, received a grade of a “C” in 2009. Just under ten miles from the east of us, Maryland received a “B” – one of the highest grades in the country as there were no states that were worthy of an “A”.

But what do these grades mean?

In short, they mean that we (those of us providing care for our patients and families) need to be better then we are. We need to have the open discussions about the provision of care for patients and families who present to Emergency Departments with suicidal ideation, depression, anxiety, bipolar, schizophrenia and addictions and understand that all of these are real, treatable illnesses and not major character flaws. We need to understand that the face of mental illness is not some stranger off the street – it’s the patients and families in our care, our co-workers, our neighbors, our friends, our families and sometimes ourselves.

We need to protect and strengthen out state’s mental health care system and understand that doing so is an investment that will provide real benefits for patients and families in providing them with the care, support and resources necessary to address the illnesses they have.

As providers and as a community, we should also ask ourselves how we can apply the lessons learned from the events in Tucson to our own communities. In his Statement on The Arizona Tragedy and Mental Health Care, Michael Fitzpatrick, the Executive Director of the National Alliance on Mental Illness stressed the importance to “objectively determine every factor that may have contributed to this tragedy so we can act on lessons learned”.

He specifically listed ten questions to begin this process which included asking:
1.      Was there a diagnosis?
2.      What is the full medical history?
3.      When were the symptoms first noticed?
4.      Did family members receive education about mental illness and support?
5.      Did the person or family ever seek treatment only to have it delayed or denied?
6.      Was the person seen by mental health professionals? By whom? How often?
7.      Was treatment coordinated among different professionals?
8.      Was the person prescribed medication? Was it being taken? If not, why not?
9.      Was substance abuse involved?
10.     What may have triggered this psychiatric crisis?

Here are my questions:

What would the care provided for patients and families in West Virginia look like if we asked these 10 questions on every patient in our care? Would West Virginia still have an “F”? What if we implemented similar processes to those of our “B” grade Maryland colleagues. What if we looked at the vast difference in the commitment process for patients in Maryland vs those in West Virginia and made adjustments as needed to insure safe and expeditious access to care? 

I wonder if it is a coincidence that two of the states with the highest grades: New York and Maryland are also referred to as “2PC” states; states which require two physicians to commit a patient where as states with lower grades (including West Virginia) do not have that process in place? I wonder if implementing the 2PC process in West Virginia would be more cost effective then the presently established treatment process?

While I like to think this is an easily attainable goal, sometimes the more important task is just to provide good care for the patients we see instead of letting them (and their families) "slip through the cracks" again and again by not acknowledging the presence of their symptoms or their need for care.

We have to look back at the intricate needs of each state's NAMI report card and the symptoms and goals of the patients and families in our care and ask ourselves:
Are we providing good care or fostering the "F"? 

"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.

 

All The Dawgs in The House

 

The video above is one of the many songs from The Gap Band - this is one of my favorites. The title of this post is a lyric taken from their CD (at that time, it was a cassette) entitled "Ain't Nuthin' But A Party".

The cassette I had of their music (originally) was given to me by a patient as a "thanks" for taking care of him. "I want you to have it" he told me back in 1994. His illness was in the end stages and it was only a few months later that he died.  My other patient, William, died while he was in our program when he developed an opportunistic infection and was admitted to the local hospital.

While he was in the hospital, he had that burst of energy and motivation that is sometimes seen in patients right before their die. He told me "I want to be an AIDS educator, I want to be able to visit high schools and talk to students and tell them 'don't ever think that this can't happen to you'." I was inspired by our discussion and the interactions I had with both of "my guys" (I always think of them as 'my guys') when they were in the outpatient program that we had developed for patients with addictions and psychiatric illnesses. 

On the evening he was admitted to the hospital, William called to 'check in' and tell me he wouldn't be in group the next day. As we talked he told me about an interview he had had with the local newspaper in New Haven CT where he was from. He said that, initially, he wasn't interested in speaking with them but then changed his mind when he realized he would have the ability to share some of the things he had learned as a result of his illness and the powerful addiction he had developed to cocaine. He went on sharing some of his insights into his illness before he had to end the conversation when the nurse came into his room to give him medications. He said 'good night' and told me he would contact me when he felt better to let me know when he would be returning to the program.

The following morning I arrived to my office and received a message from the hospital that he had died at 4:00am. 

My other patient had successfully completed our program and had left his Gap Band tape with me before leaving for Hartford to stay in a halfway house. He was much quieter then William was, choosing to keep his tapes playing in the walkman clipped to his belt before group started and whenever we were on break from groups. The Gap Band was his favorite, he told me, because the energy in their music motivated him to keep going. 

On the day he left, he handed me the cassette saying that he wanted me to have it as he felt he wouldn't need it and had "all of their music in my head anyway".  I told him I thought he should keep it but a day or so later when I returned to my office (after he had left the program), I found the tape sitting on my desk under a pad of paper with a note on top of it that just said "thanks".

Both of my guys inspired me when I had the opportunity to help them almost 18 years ago.

18 years ago.

Here's the thing about my guys: at least four days out of every week, I drive an hour to and from our hospital in WV. On at least 3 of those 4 days, while driving and listening to XM radio, I hear a song by The Gap band.  It never fails - and it is at once, haunting, sad, inspiring and comforting.

Hi guys.

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." 

That Thingy Over There: A Romp Around Terminology

Dedicated to all my Nurse Buds, Clinical Peeps and the Yacht Club Crew.

Years ago, when dinosaurs roamed the planet, my brother and I raced one-design sailboats. Our purple bluejay “Chicken of the Sea” was a fun little boat to sail but one of us, I can’t remember who (and yes, I wouldn’t tell you if I could remember) had a problem with the names of all of the lines at the foot of the mast. Try as we might, we couldn’t always get it together with that which needed to be raised up or down, pulled in or let out.

There was always yelling. 

“Pull that thingy over there!!” one of us would say.

“Which one?” the other would ask - which just lead to more incessant pointing - “that one, that one, NO - THAT ONE!!!”

(jib sheet, main line, and every halyard subsequently became referred to as “thingy”) 

To solve all of our problems, my mother took all of the lines off the boat and brought them all down into the laundry room of our home. She bought many tie-dye kits and in a matter of hours all of our thingies (halyards and sheets) took on a new life of their own.

The main halyard was green, the jib sheets were purple, the spinnaker sheets were a great shade of orange that faded with the sun and salt water. 

Our world became easier as we raced. I would hear “pull in the purple one, let out the orange one..” it was the sweet color of communication. 

Over the last few years, I have been asked to be more cautious around the clinical terms I use when analyzing people / situations (insert “symptoms and dynamics” here if you studied psych). This has not been easy for me. My colleague and nurse wizard, Kathy Weil used to help me present our psych protocol to teams throughout the hospital where we worked. In the elevator on the way to each department she would say to me “now try not to be so clinical this time” and then interrupt me if, during our presentation, she would witness the glazed over look of the nurses and techs we were presenting to. I struggled (and continue to) with changing the terminology; and I’ve come to know “the look” when it’s flashed my way by my nurse colleagues. 

It’s frustrating as I know none of my nurse colleagues would ever enter a room and say “we’re going to hang a bottle of this water stuff to go through a tube into your arm so that you will not feel so dry”, or I’m going to put a bunch of small, white circular, sticky things all connected to wires over your body so we can connect them to an electronic dohicky and watch your heart beat. Instead we use a bunch of acronyms and sometimes scarey terms like IV, EKG, EEG, MRI, CVA, TPA, TPN, stroke, ‘mets’, 'septic' and the one that freaks me out - “widow maker”.

All of which (I think) are a little more overwhelming then ‘depressed’, ‘anxious’ or ‘symptomatology’ and if I were to bet a nice lobster dinner (with chowdah and steemahs), I’d say that “widow maker” freaks more people out then “bipolar”, "suicidal" or “traumatogenic” - just sayin’. 

And yes, sometimes I’d much prefer to tell people they’ve “drifted a little too far from the mother ship” then tell them that I think we need to refer them to an inpatient unit - but that’s not appropriate. It can be a little frustrating for someone who’s a shrimp fork short of a place setting or half a sandwich short of a combination plate. And it wouldn’t make my NAMI colleagues pleased at all. 

Throw in the fast pace of an ED and the stress that goes with it to the terminology mix and watch what happens. Recently, one of the nurses was performing CPR and wanted to get a little higher over the patient. “I need a footstool” she said. One of my colleagues went outside and came back with one of the stools that the Docs sit on when interviewing patients - the one with the wheels - while another came in with the metal footstool - the one she was referring to. The nurse (who had switched with a colleague from performing CPR) took it all in stride as she was handed the footstool, looked at the stool with the wheels and said “yeah, that might be a little too challenging”.

And it’s all relative anyway. - I have a close friend who is an acupuncturist. One day I went to see her as I had been feeling really tired and she said “yeah, you have a little too much water energy”. A few months before when I had some pain, she had told me “I think you have a block in your triple heater meridian”.

“A block in my triple heater meridian? - you’re kidding right?”

She explained what she meant in terms I would understand (yes, she ‘dumbed it down’ for me) and then put a few needles in my right ankle which made a lot of sense to me given she had just explained that ‘triple heater meridian’ was nowhere near my right ankle.  At the end of it all, I felt much better.

That’s eastern medicine - the one that’s been around for 3000 years as opposed to the “newer” western medicine that has only been around for a few hundred. The closest thing I’ve ever heard to the term “widow maker” in Eastern medicine is what’s referred to an “H/W - husband / wife imbalance” which isn’t all that different when you think about it - based on the acuity I guess.

But in my world of clinical psych, maybe it would all just be a  whole lot better if we got back to colors. “She’s feeling a little blue” (for depression) or maybe “that orange person over there” for someone who’s psychotic and drifted a little to far - who maybe needs their sails pulled in...that’s the purple thingy.

 

Of Death, Angels & Dinosaurs

 

Our 6 y/o little guy and his younger sister were standing alongside the stretcher holding his mom’s hand while his father encompassed both of them in his outstretched arms. All of them were crying.

“I’m going to miss mommy.” he said. 

“She’s going to be with the angels - watching over you wherever you are. When you have sad days, she’ll be there with you and when you have good days when you’re doing something you love like playing soccer, she’ll be there with you too”, I told him. His little sister watched quietly - her eyes following her brother’s movements.

Then, far from left field and presented in a manner that only 6 year olds can, he announced “I like dinosaurs!”.

“I do too” I told him, trying to think of the scary one from Jurassic Park but not able to remember as a result of where we were and what had just happened.  It didn’t matter; he continued to tell me about how many dinosaurs he had and that he had received one for Christmas. Remembering this gift also brought him back to the present and the sadness that he felt - I could see it in his beautiful dark eyes as they transcended from happy thoughts of dinosaurs to looking back at his sister, his father and then down towards the floor.

There is a long journey ahead for this family.

At the end of the day - as we sat quietly in the chapel, the lessons for me came back to the two that I have come to know best that are most familiar to me now:

1. That sometimes it is more important to just be with someone then it is to try to fix what has happened.
2. That when those closest to us die, we remember how we loved them and, more importantly, that they were loved. 

Mission Congruence

Several years ago while driving on route 95 to New Haven, I looked up and saw a sign that said "Yale New Haven Medical Center: Advancing Medicine Since 1839."

1839: Since before the civil war; Martin Van Buren was President.

Now there's a legacy.

We (as a nation) have a come a long way since then. So has Yale New Haven Hospital as their mission is: "..to provide sensitive, high-quality, cost-effective health care services to all patients, regardless of ability to pay; to be the primary teaching hospital for Yale School of Medicine and offer training opportunities for nurses and allied health care professionals; to provide the setting for ongoing clinical research that helps bring medical advances from the laboratory to the patient's bedside; and to serve the community as a public health advocate and provide support and services which respond to the area's health care needs through health education, health promotion and access to care."

Sometimes when I'm bored - I look up the missions of the hospitals where I've worked (or been a patient myself) - just to see what drives (philosophically) the teams who are caring for me.

Here's what I've found so far (and yes, for the record, a member of my family was at Yale):

Holyoke Medical Center (MA): "Our aim is to ensure that when you turn to us for help, your experience will be as comfortable and convenient as possible. At Holyoke Medical Center, we’ll treat you right."

Rutland Regional Medical Center (VT) - Vision: "To be the Best Community Hospital and Health System in New England" 

Dartmouth Hitchcock Medical Center (NH): We advance health through research, education, clinical practice and community partnerships, providing each person the best care, in the right place, at the right time, every time.

The Stonington Institute (CT): To provide superior behavioral healthcare services that: clients recommend to families and friends, physicians prefer for their clients, purchasers select for their clients, and employees are proud of.

St.Vincent's Medical Center (NY) -  Drawing on its Roman Catholic heritage, SVCMC's emphasis was on "patient-focused healthcare, with a special mission to provide care for the poor and disenfranchised."

"Respect: The basic dignity of the human person is the guiding principal in all our interactions, policies and procedures.
Integrity: Integrity is the consistency between the Catholic identity we profess and the ways in which we act it is that quality of truthfulness, which fosters trust.
Compassion: Compassion is the way we share deep concern, love and care toward each person.
Excellence: Excellence is our way of demonstrating that we can always be more, always be better."

St. Vincents filed for Chapter 11 bankruptcy earlier this year (which is why there is no link here). Of all of the hospitals where I have worked, never have I felt so grounded in the work I was doing then I did at St. Vincent's.  While part of the healthcare system closed it's doors, other hospitals were sold to different healthcare companies and I think that, with those sales, the mission described above transitioned to that of the purchasing company. 

It was sad really - seeing an organization so dedicated to helping the poor ending up in bankruptcy. I understand it financially - but that doesn't mean I have to like it.

Adventist Healthcare: (MD) "We demonstrate God’s care by improving the health of people and communities through a ministry of physical, mental and spiritual healing."

Johns Hopkins Medicine: (MD) "The mission of Johns Hopkins Medicine is to improve the health of the community and the world by setting the standard of excellence in medical education, research and clinical care. Diverse and inclusive, Johns Hopkins Medicine educates medical students, scientists, health care professionals and the public; conducts biomedical research; and provides patient-centered medicine to prevent, diagnose and treat human illness."

Jefferson Memorial Hospital: (WV) "The mission of West Virginia University Hospitals-East is to improve the health status of Eastern Panhandle residents by providing high-quality health and wellness services, expanding access to care, and participating in the education of healthcare professionals."

Initially when I started reading mission / vision statements, I thought they looked good - both on the walls of the organization or in the marketing brochures that you would see at conferences and grand rounds presentations. But it sometimes seemed like there was a difference between what was written on the walls of the organization or the marketing brochures and the way the care was actually provided to patients and families.

I "got it" about the importance of having a clinical team in line with the mission of the hospital when having family members under the care of the teams at Brigham and Women's Hospital (MA) and Yale New Haven (CT). Of note, the mission of Brigham and Women's Hospital is: "...dedicated to serving the needs of the community.  It is committed to providing the highest quality health care to patients and their families, to expanding the boundaries of medicine through research, and to educating the next generation of health care professionals. Walking into these hospital on a daily basis, you could feel the mission in action - see it in the way people demonstrated care for my family.

Sadly, I sometimes saw the lack of congruence - when professionals would say or do something that was out of line with the mission of the hospital. I started recognizing it in my own work (yes, I mess up too) and in the interactions with (and of) my colleagues and the patients and families in their care. 

"Oh god, he's back here again!" (when referring to a multi-recidvist patient)

"They just want three hots and a cot"

"She's just med seeking"

"He's circling the drain.."

"I don't like working with psych patients"

"If she just took the meds the way she's supposed to.."

To me, the term "congruence" means that if you're going to say things like "I'm sorry, we did everything we could" or "the results of the tests are not good" then you have to reconsider the effects of using phrases like those listed above. I think (my opinion only) the compassion and energy necessary to provide care to patients and families on a daily basis is readily more available to us when we leave out passively judgmental or cynical comments about the patients in our care. 

What does it take to live the mission of the organizations where we work; where we spend as much time (if not more) with our colleagues then our own families and friends?

What would our life be like if we honored the mission of St. Vincent's and "provided care for the poor and disenfranchised" or if you just took a long hard stare at the mission of your own organization and incorporated it into your own life?

Maybe It's About How You Spend Your Day

It was a very sudden death: the husband had been sitting with his wife who reported they had been "just talking about things - life, how our day had gone and what we were going to do tomorrow". After asking her if she wanted him to bring her some tea, he had just fallen to the side and lost consciousness before ever hearing her response. She got up and called 911 and then helped him to the floor and held him until the ambulance came.  

The ambulance transported her husband to our hospital where our ED team had tried unsuccessfully to resuscitate him. 

Almost an hour later, she stood looking lovingly over him while her frail hand held his. "We had just been laughing" she said. "About what?" I asked, curious to know where her thoughts had taken her. "We had been working on a puzzle; he was on one side of the table and I was on the other. I had asked him if he had wanted to switch sides - sometimes we do that to get a fresh look at the puzzle we're working on. But he just laughed and said 'it's not going to help'. There was too much sky and a lot of green - and a lot of flowers."

Then came the question about wanting tea.

I have a friend who's elderly father had spent a warm August afternoon sailing with his best friend in their small 13' Herreshoff sailboat when he had had a sudden heart attack and fallen overboard. Brooks (my friend) said "he was dead before he hit the water, but what a way to go".  Her father's friend who had been sailing with him, pulled him out of the water and tried to resuscitate him but he was gone. He was buried at sea a few days later - their large family yacht anchored a few hundred yards away from their home which overlooked Long Island Sound. After his ashes, an ivy wreath had been dropped into the water and slowly floated away with the current. We all stood quietly on the foredeck of the yacht and watched as the wreath drifted in the direction towards the area where he had been sailing. It was beautiful.

I'm not a big fan of death - especially when there's still so much to do.

But when I think about what would make me most happy in a transition from life to death, it would be to have my final moments fully content in doing something that I love - like sailing on a warm summer afternoon or trying to sort out the perspectives of earth and sky while working on a puzzle with someone who loves me.

You Can Stand At The Top.....

If you're like me, you know the picture: a beautiful cold, sunny day in Vermont sometime around mid-February.  - About to get off the chairlift at Bear Mountain / Killington.

As you leave the top of the chair you can see the line of people ahead of you - standing at the top of the trail looking down. 

Nothing irks me more. 

I ski past them and head down - skiing from mogul to mogul to mogul; plant the pole, around and down. 

When I turn to look back, it seems like there are more of them - still up there, paralyzed,  lining the top of the trail trying to figure out how to navigate the double-black diamond that is "Outer Limits" while the rest of us have just started down the mountain having left the fear & anxiety behind.

While I understand the nature that some people have of overanalyzing routes / paths, which moguls have the least ice, and where the sun lights the trail, my preference is to just keep moving. As in life, there are always going to be moguls that come up fast completely surrounded by ice or rocks that we may not see - you can ski over them or around them, but just keep going. -

Nothing good comes from standing at the top frozen in time.

There's a lot that I love about skiing. The speed at which you have to process information, depth, perception, speed and light. And then there's the view - on a sunny day you can see for miles as you look across the forests and mountains with the snow on the trees and smell the crisp air encompassed by the scent of the pine trees - there is nothing more beautiful.

In the late afternoon, as the crowds start to leave and descend to the lodges below for some hot chocolate, it gets even better as there is the cold, intimidating silence of the darkness drawing near. While I know that, like the others, I have warm sweaters and sweats in a bag in the lodge down below, there's something uplifting about staying up on the deck at the top of gondola barn and having the mountain for a little while longer. 

It is only during that time that we wait:  for more of the trails for ourselves as we enjoy the rest of our time on the mountain. 

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. 

 

"Let's Just Think About What We're Doing Here"

My mother used to say "let's just think about what we're doing here" all the time when I was growing up. It had a way of grounding us and making sure we (my brother and I - and yes, sometimes my dad) were making the best decisions based on the information we had available to us. We would frequently consider other ideas and perspectives as well. - I think this was a trait she obtained from working as an ED Nurse for several years, but it has also helped me develop quite an analytical way of thinking.

The other day, I was sitting with an elderly gentleman in the family room of a hospital. He was looking stoic in his jeans and shirt along with a white International Harvester hat he didn't take off. We were discussing his wife's illness and how sick she had become and what our care involved. There were three of us in the room sitting across from him: the charge nurse, our ED Doc and myself.  "Your wife's very sick", the ED Doc said. "I know" her husband replied. He provided an excellent report on the care he provided to her as well as her exercise. He had provided her with her medications and taken her to her appointments and provided her with her physical therapy. Just looking at him, I could tell that there was a very regimented routine they followed to make sure she kept going and doing what her physicians recommended - he was a trooper. 

But her symptoms were such that she needed a much more intensive level of care and needed to be admitted to the hospital, and because of her acuity, there was a need to make decisions about what her treatment would include and how aggressively we would provide care for her if her symptoms were to worsen.

We needed to have a "let's just think about what we're doing here" conversation.

As the physician asked questions about her care, the man answered with the "maintain course and speed" look he had had when he described their routine. But now we needed to have a discussion with him about their plans and 'quality of life'. We came to that critical point in healthcare communication where the physician needed to slow down and communicate with our husband in a way that pulled both of them away from their routines and closer to their hearts so that their difficult discussion could lead to even tougher decisions. - Not an easy task.

Let's just think....

They both spoke a little more about tests that needed to be done and labs he had ordered. He left the room stating he would return when they had more test results and, as it was late at night and change of shift, we also introduced him to our night shift charge nurse who had just received report on his wife's care up to that point. 

After they left, I shut the door behind them and sat down across from him again - just the two of us alone in our family room. 

"I know you love your wife very much and you've worked very hard to take care of her" I said. Under his International Harvester baseball cap, I could see the tears in his eyes as he looked directly at me and then down towards the floor. 

As difficult as those moments often are, I've come to love them for what they tell me about the legacy of family and the relationships we have. We talked a little more and then I left him in the care of our charge nurse and doc who were still deciding on her care in their own "let's just think about what we're doing here" way that helps us all provide better care to the patients and families we serve.

The Best Career Advice I Ever Received

As I've watched the news about the economy and the over 500,000 job losses for the month of April, I've been thinking about the career I've had and what I have learned.

The best career advice I ever received was from a charge Nurse that I worked with in a hospital several years ago. We had been working really hard on a day that was really busy and filled with many admissions to our unit. She had had to make some difficult decisions about staffing and patient care and had ended up having a disagreement with the nurse manager. I caught up with her in the medication room when she was pouring meds for the evening. It was obvious to me that she was still frustrated with the disagreement she had had but being the professional that she was, didn't tell me the specifics of what had happened.

What she did tell me has stuck with me ever since.

She told me there would be days in my career when I would have to make difficult decisions about patient care, about the skils I had that were based on who I was as well as what I had learned in college and that with every day, there would be challenges to consider in the decisions that we all made individually and as a team.

"Don't ever let your job compromise your integrity." she said.

I haven't and it hasn't.
And it was the best advice I've ever received.

Linkedin to the very small world

This weekend, I was introduced to DallasBlue - no, it's not a new blender drink or an NHL hockey team, it's an organization that helps you take your Linkedin Network to new heights.

I'll admit it, I'm on a mission to help support the retention of healthcare professionals throughout the United States. I needed a bigger network. As I looked for connections and ways to introduce myself to others without being intrusive, I ran into DallasBlue.

In short, I started the weekend with my own network of 35. Less then 30 hours later, it's in the hundreds and there are still e-mails coming in from all over the world. While I actually think I can respond to each new connection personally and individually, what strikes me the most is where these connections are coming from. Many are from "out west" (I'll admit it, I'm an 'east coast kid') while others are from all over the world. This morning I was reading e-mails from Finland, the Ukraine, Poland, Australia and New Zealand. And while I sat there responding to each of them, I wondered what they thought of Americans, our country, our nation, our economy, our democracy. I wondered if they were working, sleeping, studying. I wanted to write "good morning" as it was early for me (east coast time) - and then I realized, I had no idea what time zone they were in. Even now, the e-mails continue to come in. I have given up responding for now as (as Robert Frost wrote) "I am overtired of the great harvest I myself desired..."

I am now part of a worldwide network of people who may not agree with my politics, my beliefs, my decisions, my values or my goals but whom are willing to link to me and network with my small group of 35. I like to think that while we may all have an abundance of differences, our one similarity may be to make the world a better place by supporting those of us who need assistance in being able to do whatever it is we do - better.

On this day, I have learned that the world is nowhere as big as I once thought it was and that there is a great power in community. How amazingly cool is that?

Who are we; and what will be our legacy?

The other day I was talking to a friend of mine about people I know (or am aware of) who are adopted. Steve Jobs (the CEO of Apple Computer) entered the discussion as I am aware that he is adopted and am always impressed with, not only the way he leads Apple and Pixar, but the legacy of the company he has created and how it seems to reflect on the man he is. He discussed some of the aspects of his adoption at a recent commencement speech at Stamford. There are many lessons to be learned from this presentation.

The Elephant in the middle of the room that no one is talking about.

This morning I was reading Jamie Notter's Blog (http://www.getmejaimenotter.com) - one of my favorites. On 9/6 he wrote a great article about Ego in companies and how this is a topic that many people talk about. The article can be found by clicking here http://www.getmejamienotter.com/getmejamienotter/2007/09/do-work-and-psy.html

This is the thing: I've run across many articles about Pay for Performance in healthcare and, for the most part, I think it's an innovative idea that really needs to be considered. My problem with this idea is that in looking at performance, you have to consider the way we (as healthcare practitioners and professionals) respond to the stress in healthcare environments as well as the way in which we process the information we obtain, the conversations we have with patients, their families and our colleagues and the way all of this affects us.

This topic reminds me of the elephant in the middle of the room that no one wants to talk about. Sure - we'll talk about topics such as 'leadership', 'team work', 'performance initiatives', 'success factors', 'executive intelligence' but underneath all of this is ego.

Ego: who we are and what we bring to the table as people and professionals.

Every single day to the 6000+ hospitals throughout the United States.

And if you don't think the stress of the healthcare environment affects you, think again.  The question is, how are you handling the speed of the environment, the conversations your having, the looks on the faces of patient after patient after patient as they walk through your Emergency Department doors.

The answer? - Defenses.

You use them, I use them - we all have them. The self-protective mechanisms that we use either consciously or unconsciously that lets us do the work we do and care for the patients who are requiring our attention. And how well you manage those defenses affects the quality of your performance.

That's the discussion we need to be having in healthcare; and I think Jaime's thoughts on this issue are a great place to start.

what will be your legacy?

A few years ago, I came across an article written and incorporated at Minolta (the copier company). They were utilizing the topic of legacy to illustrate some of their leadership responsibilities and practices. One of these involved having the members of their company review their “Responsibility of Success”.

The questions asked in the "Responsibility for Success" help define the legacy that their workforce leaves on their organization. While sometimes it's easy to think that these practices only apply to the organizations leadership, it is difficult not to see how these values or the answers to these questions can reflect the mission, attitudes and legacy of an entire organization.

"What will our legacy be?

• What will yours be?
• What mark will you make?
• Years from now, will your team look back at this time and feel it was time well spent?
• Or will they feel used?
• When you tell your children what you accomplished here, will they be proud?
• Will you be proud?
• Did you help your community?
• Were your business practices honorable?
• What was stronger in your workplace, ideas or politics?
• Was it all about money?
• If so, what did you end up doing with that money?
• Were the sacrifices too great?
• Did you ask others to make sacrifices that were too great?
• Were you committed to positive change?
• Were you committed to providing opportunity?
• Did your organization set an example for your industry?
• Did people really want to work for your organization?
• Did you have fun?
• Did you make a difference?

Did you make a difference? - Isn't that a great question?

I love this and applaud Minolta for paying attention to the legacy that we all leave not only in our families but in our careers as well.

As we journey into the new year, I think we all should consider what our legacy will be. How can we contribute to our families, our workplace, our community and the world (yes, not just the nation - the world).

What will be your legacy?