Cynthia Stock

An amazing author for your soul!

Service versus being a servant

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In forty years of nursing, I fought for respect and autonomy in my profession. I pursued a graduate degree and believed a higher level of education would not only enhance my clinical practice, but would also earn colleague status with doctors wherever I worked. For the most part, this has been true.

In the critical care setting, my specialty, adaptation to change, continuing education, and the ability to make sound clinical decisions has been instrumental in the practice of nursing. A four year degree has become the expected entry level education. Certification in this specialty and the pursuit of a higher degree is becoming more commonplace. Both are encouraged and economically supported by health care institutions. This sounds like nursing is advancing as a profession.

Enter the new ad campaign by a large health care conglomerate that praises the “servant” who cleans up messes and changes the sheets. The ads devalue the educational requirements, both basic and ongoing, the responsibilities assumed, and the commitment to best patient outcomes manifested by consummate professionals. The portrayal of health care providers as servants discomfited me.

As a nurse, I have been a witness to and caregiver in the most deadly epidemic in modern times. I have watched women infiltrate medicine and men infiltrate nursing. I have lived a history in which critical care grew from the MASH units on the front lines of war into the technology driven units in tertiary care facilities. I have watched drugs come and go, so-called best practices be replaced by better practices, and health care become a right. I recognize my profession is one of service. I know that without the patient I am nothing. Without the trust of someone who allows me into his or her life at a most vulnerable time, I cannot do what I am trained to do. But I am not a servant.

Conversely, when I come into the hospital, I want an educated professional familiar with the latest technology, the newest drugs, the best treatments, and the dedication of someone who is prepared for his job. I neither want, nor expect a servant.

I am a professional nurse. I empty trash, clean the floor, clean up excrement, and turnover a room. I have successfully resuscitated a patient before the doctor could arrive. I started an IV when a patient was bleeding to death as the doctor stood over me and told me I had to find a vein. I have made countless decisions in treatment plans, made critical notifications, participate in interdisciplinary collaboration to devise the best plan of care, wept with families, attended funerals, and shared the pain and joy of loss and recovery. I am and will always be in service to my patients. However I am not a servant.

 

Why does ED happen

Wake-up Call

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I confess. I called myself a feminist in the early 70s. The focus of that label centered on equal rights, sexual freedom, access to birth control, and abortion. In college I met a fellow who told me if I wanted to date him I needed to be on the Pill. I didn’t see that as sexual freedom at all, just another Y-chromosome telling me what to do with my body. I moved on, got an IUD, and rallied in support of Roe v. Wade.

Today I look at the insidious movement to turn back time and shudder with amazement and fear. Amazement that young women today seem unconcerned about forces at work seeking to take control of their most private, personal decisions. Fear that so many people are verbal and passionate and self-righteous about doing so.

 Then I picked up When She Woke, by Hillary Jordan, and amped up my anxiety. I believe more people need to read this novel today. Jordan creates a world in which radical conservatives rule the country. The laws of the land are extreme end-results of the trend I see in modern attitudes. Hannah Payne aborts the child conceived during her affair with a well-known, married leader of a megachurch. When her act is discovered, she is sentenced to sixteen years of “chroming,” a process which turns her skin red. The Scarlet Letter in the extreme. All criminals are subject to such punishment with crimes being color coded. There is no need for imprisonment when the color of your skin defines who you are and what you have done.

When She Woke allows the reader to accompany Hannah on her quest to find a new life and redefine herself as a woman. Raised in a fundamentalist home, she must reconcile her faith with the cruelty and prejudice she encounters as a Red. Even more difficult is her break from the traditions of a rigid social upbringing. She learns to take control, make her own decisions, and not judge herself as she escapes the oppression of her family and community. How relieved was I to reassure myself Hannah’s life occurred in a fictitious world? Not much.

Enter the 21st century and a “Perspective” published in the Jan. 16, 2014 New England Journal of Medicine called “Physicians and the (Woman’s) Body Politic,” by Alta Charo, J.D. The essay sites numerous cases in which the law supports the incarceration, admission to mental institutions, or forced medical/surgical therapies of pregnant women claiming protection of the unborn as justification. State laws targeting abortion providers have burdened them with restrictions deemed “unwarranted and unjustified” by the American Congress of Obstetricians and Gynecologists. And then there is the transvaginal ultrasound, mandated in an effort to keep women from choosing abortion. Invasive, dehumanizing, it is a diagnostic test that should be decided upon by the patient with the physician. A legislator in a state, or the nation’s, capitol cannot know the circumstance of every pregnant woman. It is ludicrous to pass general legislation for health care that is driven by the individual patient. Would there ever be a law mandating someone engaged in high risk social behavior be tested for Hepatitis B or HIV? A law regulating eating and BMI?

In When She Woke, the Novembrists are members of a group of rebel-activists helping Hannah escape a community where she will be ostracized and abused. When asked why they do what they do, the spontaneous response is: “It’s personal.”  Sexuality, pregnancy, and child-bearing. Personal choices. Not to be influenced, regulated, and interfered with by outside forces. When She Woke is a wake-up call, a warning about the possibilities of what could happen in the atmosphere of today’s politics and voter distraction.

Why does ED happen

A Matter of Life, Death, and Miracles

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In the weeks since the cardiac arrest and the declaration of death for Jahi McMath and brain death for Marlise Munoz, the media has conducted a discourse with ethicists, an elementary school class, the grieving family, and medical professionals. Maybe I missed it, but nowhere have I heard anyone speak with health care professionals, specifically nurses, assigned to care for either of these patients. In this group of care providers, a continuum of emotions and opinions about what is ethical and humane would abound.

After forty years of nursing, I still find most disturbing the provision of care to those who have no chance of a meaningful recovery. I have cared for a patient who was declared dead. The Harvard criteria for brain death includes: unresponsiveness, apnea (no respiratory effort), absence of movement, no reflexes, a flat electroencephalogram, no central nervous depressants in the body, and a core body temperature greater than 32 degrees. The beside nurse observes more subtleties. There is a vacancy in the eyes, an emptiness, and a lack of recognition of the outer world. Many times I have sensed an absence well before the body declared itself done with this life. No one can verify if the spirit transcends the body, but in my experience it seems that way. And it feels that way. Does this change the type of care I, or any professional, provides? No. I still talk to the person as if I’ll get a response, and I handle the body with the upmost tenderness and respect. This doesn’t change the lack of reciprocity in the human connection between this nurse and the specific patient.

Part of the conundrum with end-of-life decisions stems from the failure to differentiate life from living. In the cases of Ms. McMath and Ms. Munoz, a heartbeat defines life. But when she was alive, Ms. Munoz defined living by her ability to do certain things. She did not want life maintained by mechanical means. Each individual defines living differently. For many people, work and certain activities define who they are. For me, I am a nurse, a fitness nut, a reader, a writer, a wife, a homebody, a thinker. I am not sure which roles I could give up, which things I could stop doing, and still feel life had enough value for me to want to live. For me a heartbeat is not enough of an existence to justify the consumption of finite resources that would better serve another human being. These things I have discussed with my husband, my attorney, and have set down in an Advance Directive.

“What about miracles?” you might ask. Have I seen them? Yes. I still cry when I remember walking down the hall with a patient who suffered a catastrophic brain injury. When I saw his father’s face morph with the recognition it was his son coming down the hall, I knew I had been privy to something divine. I can give you all the scientific rationale for why the boy got better: his youth, perfect timing, a tenacious, committed doctor and team of nurses. I can only speculate about a force present, not prescribed by any medical practice. My question to you is this: “If it truly was a miracle, would it have happened had we done nothing?”

When Jahi McMath’s family prays and talks about God’s miracles, I wonder if they could surrender to their faith, remove all life support, and wait for God’s intervention? At a time when they were most vulnerable, experiencing the worst grief parents can endure, the media spotlighted decisions of the most delicate, private nature. I wonder where the reporters will be six months from now. And I wonder if the family will rethink their decision once they have begun to deal with, not only what they have lost, but also with what they have begun.

You may say: “It’s easy for you to say, you haven’t ever been there.” But then you don’t know me or the kind of nurse I am. I remember the first patient I “lost” on my first Christmas Day on the job. I remember my father, my husband’s son, my neighbor, saying they were ready to go when the quality of their lives became intolerable, all for very different reasons.  My mouth went dry and I felt embarrassed and sad when I read an article in the newspaper about my own challenged grand-daughter who suffered a brain injury at age six weeks. She is seventeen years old, requires total care, and has never uttered a word. She receives tube feedings, never to enjoy the delightful taste of chocolate or grapes or a well-cooked steak. She passes urine, stool, and has gone through adolescence. Someone must attend to all of her bodily functions.  I believe all of us have “been there” at some time and bear the wound of loss deep within us.

Perhaps that is the point of this discussion. These situations are so personal, so private, that people calling the hospital to get information must have a security code. Then how has it come to pass that the law, bureaucrats, and outsiders, who have no knowledge of the people involved, impose decisions on virtual strangers about life and death.

Each person’s definition of living or quality of life determines the path he chooses to its end. I demand this as a sanctified, inviolate right for myself and exclude input from all other external sources. Life, death, and miracles, all very private concerns.

Why does ED happen

Who should be driving this bus?

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On a Wednesday several years ago, I underwent a Moh’s procedure for a basal cell carcinoma along the crease on the side of my nose. I went in to my dermatologist’s office expecting the result to be a spot the size of a standard pencil eraser head. After the procedure, the doctor’s assistant packed my nose with a mound of gauze, instructed me not to take it off for twenty four hours, and scheduled me to meet with a plastic surgeon on Friday. Being a nurse, I had to see what required such a dressing. I pulled back the tape. My husband had no idea what I was doing. I screamed and started to cry. He ran into the bathroom fearing something horrible had happened. It had. I looked into the mirror and found an excavation that covered two-thirds of one side of my nose. It leaked serous red drainage and I imagined one good sneeze would blow half my nose wide open.  I re-taped the bandage and cried some more. Nothing and no one prepared me for the end result of this “simple” office procedure.

 

I met with the plastic surgeon on Friday. He didn’t have a cosmetic practice. He limited his work to reconstructive surgery for cancer patients. When he removed my dressing, he didn’t flinch, but he did schedule me for emergency surgery on Saturday. I went through my pre-op work up and went home. Let me say in all honesty, I can’t sit still. I expend nervous energy through motion, the treadmill, the elliptical machine, or the recumbent bike. Thoughts of equipment acquired MRSA paralyzed me and locked me inside my house climbing the walls.

 

Then I received a call from the plastic surgeon’s office. My insurance company would not authorize my procedure. I felt the same devastation I experienced the first time I saw the hole in my nose. The office manager gave me a contact number at the insurance company and suggested I call and talk to the nurse. I live in CST. The call went to a location in EST. I spoke to a nurse at the end of her day. She repeated the denial with scripted kindness. “I want to know who else I can speak to. You. Have. Not. Seen. This.” My voice turned shrill. I cried. She told me a doctor made the final decision. Out of pity, or perhaps because I was a nurse, the voice at the end of the phone gave me the number of the physician deciding the fate of my face.

 

CST-4 p.m. EST-5 p.m. An M.D. ready for the week-end. I explained my situation, explained the high-risk-of-splash area in which I worked, a CVICU, explained how my level of physical activity correlated with my quality of life.

 

“We’re not approving your procedure.”

 

“You haven’t even seen it. How can you decide it when you haven’t even seen it?” He was trained to respond, not react. I hung up the phone, mouth dry, my reservoir for tears empty.

 

My husband took pictures from several angles. I wrote an appeal. We decided if we had to we would pay for the emergency surgery.

 

Jump forward to 2013. Last week-end, a general surgeon I worked with for over thirty years vented to me about the state of health care. A family member, who seemed to think she earned her medical degree trolling the Internet, challenged his prescription of Reglan to prevent her mother from developing a sluggish bowel. She listed her concerns based on whatever site she had visited. The doctor calmly discussed the benefits of avoiding a bowel obstruction versus the risk of the drug side effects. “If she develops them, we can stop the drug.”

 

He went on to tell me how recently he found a printed form on one of his post-op patient’s charts asking him to justify his order for I & O (intake and output). I & O is a basic, easy to access tool for fluid management. His patient fell into the high risk group of geriatrics, with marginal renal function, who had an abdominal procedure which is notorious for causing significant fluid shifts. The rationale for measuring I & O is common sense. Yet someone, somewhere asked this experienced, proficient surgeon to explain his order.

 

Both of these scenarios raise the question: Who should be driving this bus? When it comes to pre-approval of necessary procedures, can and should these decisions be made without face-to-face contact of some sort? Every case is different. Emergency plastic surgery of the nose is not a cosmetic elective procedure. A career, a healthy lifestyle, the ability to be up close and personal doing a job without offending a client depends on it. My procedure was reconstructive surgery for cancer. Without it I would never have been able to approach a patient again. Dr. 5 p.m. EST didn’t care about that. Do lay people not realize the Internet provides information about care practices in general without consideration of the individual? In the health care system, knowledge is power, but it is not a license to micro-manage and out-guess licensed health care providers. Does asking a practitioner to justify basic orders improve patient care and alter outcomes? I would not want a cab driver to fly a plane on which I was a passenger. I would not want a quarterback to perform my open heart surgery? In the changing world of health care, decision making needs to rest with bedside health care providers, not insurers, Internet educated family members, and not a hollow voice on the end of a phone.

Why does ED happen

Katy Butler-Teaching us all about life

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The last time I cried reading a book, the imagery and exposition from Barbara Kingsolver’s The Lacuna gave birth to those tears. This time the intricate weave of fact, emotion, and the intimate details of the death of Katy Butler’s father and her mother’s journey as a caretaker hit me with such force I wept.

 Knocking on Heaven’s Door resonated with both my professional and personal soul. As a nurse celebrating my fortieth year of bedside practice, I doubted a “non-medical” person could show me much I hadn’t already seen. But when Ms. Butler shared her poignant memory of the tender touch rendered by the technician who shaved her father, she affirmed my practice of shaving men daily. From that point in the book, I knew she understood my point of view as a seasoned practitioner.

Today nursing students get out of school having never shaved a patient. I have written stories about the intimacy of this daily ritual and have had readers comment that they twisted their faces to accommodate my blade as they read my description of men responding to the comfort of this simple ablution. This minor deficiency in nursing student experience is symbolic of the health care behemoth in which technology increases exponentially, while the ethics of human dignity founder.

Thanks to scientific advancements, medicine has the capacity to do more and more and more. When I started my first job in critical care, there were no arterial lines, no pulmonary artery catheters, and no one knew to use positive end expiratory pressure on a ventilator. Today these technologies are commonplace. Just like children today grow up with computer technology, I grew as a nurse and embraced change every year I practiced. I don’t know when I shifted from a young upstart, hungry to understand and implement every new thing, to someone who remembered the calling of my profession.  In my quest for knowledge and expertise, I placed the people in my care second on my list of priorities. Ms. Butler provided me with the insight to why and how this happened. She illustrated how this approach to health care devours a family. And she created an impetus for rethinking the goals and practice of health care delivery.

After her father’s first stroke, Ms. Butler and her mother embarked on a difficult, tumultuous course to provide the best care for him. It seemed after every decision, another challenge requiring another decision appeared. For every step forward, her father took two steps back. In the process, Ms. Butler’s fiercely independent mother, a loving wife, experienced a loss of life of her own. In an effort to keep Mr. Butler home and maximize his recovery, Mrs. Butler subsumed her needs. An act of love, no doubt. But the decisions posed a threat to her physical and emotional survival.

Ms. Butler’s description of the last years of her father’s life can be summed up succinctly. Survival doesn’t mean recovery. She raises the question that is “the elephant in the room” in any family discussion about health care decisions. For every individual the answer is different. Just as someone made choices about how he lived, should he not direct how he dies?

The availability and cost of advanced medical technology act to complicate the factors in the decision making process. Ms. Butler describes the irony of Medicare’s willingness to pay for a costly pacemaker while denying the cost of a “truss” to help provide comfort to her father until he could be cleared for a bilateral inguinal hernia repair.

How did our culture get to a place where modern “lifesaving” allows a person to know “the suffering of life without its joys, and the helplessness of death without its peace”?

The diminished value attributed to the family practitioner is a starting point. I remember Dr. Barrow, our family doctor. He treated my anemia when my blood count dropped so low I fainted after a penicillin shot. He addressed my teen-aged depression. He made house calls. He knew my family and the context of our lives. With the advent of multiple specialists and an ever-changing reimbursement structure, family practitioners are pressed for time if their offices are to survive. Reimbursement is driven by time, not talking, treatment, not affirmation of the individual as a bio-psycho-social being where three spheres interact to define what health is for that person.

The next problem, simply put, is our passion for technology leaves little room for compassion and planning. In the urgency to fix a problem, an intervention is chosen and implemented with no time for assess the far reaching effects of one procedure. The team members where I work rarely get to see patients on their way home. The question of how a family will function after a patient is discharged hardly is a consideration when recovering a patient from open heart surgery or inducing hypothermia after a cardiac arrest. Real time crises diminish the truly fundamental issue of what will happen after discharge. Anticipation and planning for this must begin the day of admission.

Every hospital uses social workers who manage an amazing portfolio of resources. Care must be planned around the family as a unit, not just the patient as an individual. Family harmony versus dysfunction. Children who are retired to care for their parents versus those who still work. Parents who demand their independence versus those incapable of demanding anything. There is no fool proof recipe to cover all situations. Successful transition of a patient from the hospital to the community is a tabula rasa, a work of art attempting to recreate life after a health crisis.

For many, differentiating between life and living raises the ultimate conundrum. Is living being warehoused and immobile in bed, in a nursing home. As a person with multiple sclerosis, I have spent many lonely, waking hours trying to find the answer. Believing I have it, I have an Advance Directive. For me living means reading, writing, working out, and talking politics, thanking patients for letting me share in the journeys of their lives, waking in my bed, next to the familiar curves and aroma of my husband. Living is not just a heartbeat or a respiration.

Every day I go to work, I confront the problems and issues in Knocking on Heaven’s Door. Because I am a nurse, I am biased, but not jaded, when I espouse my solutions. The power, truth, and insight of Ms. Butler’s book make it must reading for health care professionals, anyone with a frail parent or sick relative, and anyone critical of our current health care system. But reader beware: there will be tears.

 

 

 

 

 

 

Why does ED happen

The Risk/Benefit Analysis

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The discussion of the long term effects of repeated concussions on football players seemed to peak with the Super Bowl. Prevention, signs and symptoms, progressive effects, and league responsibility became common topics heard in the media, the work place, and home. A question asked by some, stated as fact by many, involved career choice. For athletes who love the game, enjoy the adrenaline rush of competition, and have the talent to earn salaries beyond the imaginations of most, would they do anything else?

This quandary transcends high profile, top-dollar sports.

In 1971, my nursing professor, Rose Sandling, told a story about working in the Emergency Room. A window washer fell through a window. He rolled into the ER on a gurney. Without hesitation, Rose scooped both arms under the man to log roll him and examine his back for injury. Glass riddled his back and sliced her hands. This was years before gloves became an essential part of physical examination. Lab tests revealed the man had syphilis. Rose received appropriate treatment and continued her career. I never gave her tale a second thought.

The first time I stuck myself with a needle I knew it was “clean.” Still a novice on a busy day, I jammed an 18 gauge needle through my thumb and thumbnail as I hurried to draw from a vial of sterile saline admixture. It happened so suddenly I felt no pain, grimaced at the thought of pulling it out rather than the feeling. The experience taught me when I could afford to hurry and when I had to take careful, methodical steps.

By the late 70’s, the first cases of what became known as AIDs, appeared. No one knew anything about the disease except that once symptoms appeared, death followed shortly thereafter. Wearing personal protection at the bedside never occurred to anyone until many health care providers, me included, went home with traces of blood and body fluids invisibly stuck in cuticles, knuckles, and skin tears. I never thought about the risk of exposure to what was then unknown.

Jump forward fifteen years. I pushed a syringe into a sharps container so the next person to use the container wouldn’t come in contact. I pulled back a bleeding finger and an18 gauge needle. Hospital protocol during that period did not mandate testing of the employee, and the source of the needle contamination was unknown.

“Should I have myself tested?” I asked a friend who happened to be an infectious disease doctor.

“It depends on what you want to know.”

I grew up in the generation of free love, women’s liberation, female empowerment, and modern technology. I wasn’t promiscuous, but I allowed myself freedom of thought and action. I had been artificially inseminated before donor screening and regulations were instituted. And I had been a nurse before the age of gloves. Indeed. What did I want to know?

I obsessed about my decision. A limit existed between time of exposure and testing. What if I tested positive? What then? HIV. Hepatitis. Either meant a drastic change in my life and that of my son’s. Might this be one of those times when ignorance would be bliss?

I tested negative for all communicable diseases on the screening panel.

Last week I removed a line from the brachial artery of a man who had been anti-coagulated. His line leaked a serous pink fluid and a bruise blossomed around the insertion site up and down his arm. The line had to be removed. I lost count of how many times I had done this procedure. Cut the sutures. Apply pressure with 4 x 4s of gauze. Pull the line. Hold pressure. Hold more pressure. I pulled the 4 x 4s back to assess the site. It appeared stable. For five seconds. Then a fountain of pulsating blood sprayed my face. I felt the reflex blinking of my left eye to wash away foreign matter. I didn’t stop holding pressure on the arm, but flagged down a nurse walking by my room and asked for help. When he walked into the room, his eyes widened just a trace, just enough to share the shock he felt. I applied more gauze while he put on gloves. He took over holding pressure.

I hurried to the bathroom after grabbing a plastic “bullet” of sterile saline used by the respiratory therapists. Thoughts of my sight came first. I flushed my left eye until it felt clean. Then I looked in the mirror. Blood freckled my face. My bangs clumped from the wetness. For some reason, the spots on the bridge of my nose bothered me more than those on my cheeks and forehead. I scrubbed them first. My usually blonde hair remained pink-tinged despite a liberal splashing of water.

This time I didn’t hesitate to get tested. Chronic illness had landed the patient in our ICU three times in the past six months for congestive heart failure and gastric ulcers. I knew his cardiac history, his transfusion history, his social history, and felt confident about his test results. But. While I waited for official confirmation, doubt drilled its way into my head and the “What ifs…” infected my consciousness.

Such is the nature of my career. As a nurse, I bought a house by myself, raised a child, enjoyed some travel, and went back to school. The dangers inherent in my profession have changed. Some are more deadly. It doesn’t matter. I have no regrets. I am a nurse. I would do it all again.

 

 

Why does ED happen