A clear, sunny 70 degrees; nice enough to be in shirtsleeves, but not warm enough to need a fan, you couldn't have ordered up a nicer day! On this perfect day, Mr. DS, Dear Schoolmate, her Beloved, and I set out to sample the Brandywine Valley's grapey offerings.
Our first stop was Twin Brook Winery in Gap, PA. Nestled behind an historic farmhouse, the tasting house was at the top of a long flight of stairs. The wine bar was ready for us though. As the last tour wandered downstairs for a barrel tasting, we bellied up to the ornate bar and sampled the offerings. We started with whites and worked our way to the reds. Some where pretty good, others we just ok, but every drop was a new adventure.
Since we wanted a barrel tasting, we headed down to the cellar where Tim Jobe, the wine maker answered our questions and shared the upcoming reds. Most notable was the Merlot. The best way I can describe the taste is that I felt a smile happen at the back of my throat. We all agreed we wanted to be on the list when this Merlot was ready. Incidentally, Tim said that he lost his wine assistant, but unfortunately, he wasn't looking to replace him. Had anyone told me in high school that a chemistry degree could be used in wine making, I would have treated the whole affair with more seriousness. I rediscovered a love and affinity for chemistry when I was taking classes for nursing school. Alas, yet another career that shall never be.
We enjoyed a picnic lunch of Tim's homemade gumbo, and bread and cheese brought by Dear Schoolmate. We reminisced, shared stories, and laughed ourselves silly in the sun. Mr. DS took pictures of the vineyard, and then we headed off to the next stop.
Our next stop was Black Walnut Winery, located in a repurposed historic building on Business 30 in Coatesville. With its exposed beams and original hardwood floors, this building just cries out for an intimate reception or party. It's a wonderful space. We were provided with 7 tastings and again, we started with the whites and moved along to the reds. It should be noted that this winery does not grow its own grapes. They purchase from a grower and blend based on the quality of what's available. I walked away with a lovely half dry Pinot Gris. I'm looking forward to trying this wine with risotto.
Our last winery had the most surprising and winning environment. Located at the end of a residential block in Coatesville, the Stargazer's Vineyard featured sweeping landscapes and a repurposed building with a dramatic glass front. Here again, we were had 7 tastings and were given bottle cap "tokens" to keep track. For me, the star of this show was the sparkling brut. It was very crisp and dry with no oaky aftertaste at the back of the throat. I could have used all my tokens just tasting that wine, but there were other intriguing options. There was a Tinto, a red desert wine and a Pinot Noir that found their way home with me.
One of the unique features of the Stargazer's tasting was the inclusion of local producers. There was a cheese monger featuring raw milk cheeses and a vendor from Fat Spike Lavender. I went home with two cheeses and the most heavenly lavender spray that I can use on linens and skin. It really smells like you are walking through a field of lavender.
My car was transformed into a wine-mobile, and by the end of the day, the trunk was full of wine and cheese and loveliness. We were tired and sun-baked but absolutely stoked about all the glorious wine we tasted – all without having to buy a plane ticket!
Friday, April 2, 2010
Tuesday, March 23, 2010
2nd Annual Nursing Spectrum Networking Event Review
Once again I found myself heading to Dave & Buster's in Philadelphia for the Nursing Spectrum Networking Event. After last year's disappointing experience, I was doubtful about giving it a second chance. But as fate would have it, I was so annoyed at my minders at my current job, I thought it would be a good attitude adjustment to feel as though I at least had options.
Well, my experience this year was somewhat different than last year and I was pleasantly surprised. I think the key to getting the most out of these events is to arrive early. If they open the doors at 8:00am, be there by 8:15. I had my pick of parking in the garage. The line for registration was not awful; I waited for about 10 minutes tops and since I was one of the first 500 registrants, I received my Nursing Spectrum tote bag. I had not pre-registered, but I was able to register on site, and that line was actually shorter than the line for those who had pre-registered.
The disadvantage of arriving so early is that most of the recruiters are not present yet, so you are sort of obligated to attend the Continuing Education session. I was able to find seating, even though the session was crowded. This morning's topic was Case Management. I decided to attend because while I have heard of case management, I didn't really know what it was all about. The speaker was Catherine Mullahy and she was excellent in spite of the audio problems with the microphone cutting in and out. It was obvious that Mullahy was a seasoned presenter. Her slide presentation served to organize the material she was presenting, but she was able to respond to audience feedback without missing a beat.
In a nutshell, she explained that case management was about connecting the patients with the services they needed at the appropriate time and at the best cost. So case management is something many of us do without being nurses. If you have had a sick family member and have coordinated the doctors and appointments and home care and medications and follow-up therapy, and wrangled with insurance companies and other service providers, you have done case management.
One of the most interesting points she made was how patients with similar diagnoses might not need the same level of case management. Mullahy used the illustration of how a woman, age 50 diagnosed with cancer, having excellent medical coverage and a supportive family, being treated at a University hospital with access to Nurse Practitioners might need limited case management, if any. On the other hand, another 50 year old woman diagnosed with cancer might have limited medical coverage, might be the sole support for her family, might be treated in a clinic-based health care system where she sees a different doctor every time, and English is not her first language. This woman would need more case management because at the very least, she will need someone to make sure that any communication barrier between her and her health care providers is addressed.
She also explained how case managers in hospitals are often placed in serious ethical dilemmas because in most instances, the case manager is supposed to help get that patient out of the hospital at the lowest cost, but that might not be the best for the patient. As nurses, we have an ethical responsibility to always place the patient first. Because of this ethical responsibility, it has been the traditional for nurses to be kept out of the loop when it comes to how much it costs to treat a patient. However, if a nurse case manager is responsible for keeping costs as low as possible, then there is an ethical dilemma. You're setting up that patient for a return visit to the hospital, which means you're placing them at risk for nosocomial infections, poly-pharmacy, medical errors, and diminished autonomy. Mullahy's presentation raised my awareness and gave me something to think about.
As an aside, I have to once again call out my colleagues for some rudeness that I witnessed. A woman came into to the presentation late (happens all the time) and tried to sit in an empty seat in front of me. The woman sitting next to the empty seat got all huffy and said "there are other empty seats, you know". Yes there may be other seats in the room, but your empty seat is right near the door and it's silly to expect that someone is going to schlep across a room, in search of an empty seat. Get over yourself.
On a more positive note, I did see more recruiters than last year, although maybe that was because I got there early. There was some diversity in recruiting as well in that not everyone was strictly hands on nursing. I was able to speak with some recruiters who seemed to be genuinely interested in my experience set. So that was a good thing. I even ran into a colleague with whom I attended classes when I was taking my nursing school pre-requisites. It was good to learn we both got through after our paths diverged; we had both traveled a long road.
Overall, I give it a B+. The lessons learned were: you don't have to pre-register, get there early so you can get convenient parking, get your bag, and so you can take advantage of the free Continuing Education seminar.
Well, my experience this year was somewhat different than last year and I was pleasantly surprised. I think the key to getting the most out of these events is to arrive early. If they open the doors at 8:00am, be there by 8:15. I had my pick of parking in the garage. The line for registration was not awful; I waited for about 10 minutes tops and since I was one of the first 500 registrants, I received my Nursing Spectrum tote bag. I had not pre-registered, but I was able to register on site, and that line was actually shorter than the line for those who had pre-registered.
The disadvantage of arriving so early is that most of the recruiters are not present yet, so you are sort of obligated to attend the Continuing Education session. I was able to find seating, even though the session was crowded. This morning's topic was Case Management. I decided to attend because while I have heard of case management, I didn't really know what it was all about. The speaker was Catherine Mullahy and she was excellent in spite of the audio problems with the microphone cutting in and out. It was obvious that Mullahy was a seasoned presenter. Her slide presentation served to organize the material she was presenting, but she was able to respond to audience feedback without missing a beat.
In a nutshell, she explained that case management was about connecting the patients with the services they needed at the appropriate time and at the best cost. So case management is something many of us do without being nurses. If you have had a sick family member and have coordinated the doctors and appointments and home care and medications and follow-up therapy, and wrangled with insurance companies and other service providers, you have done case management.
One of the most interesting points she made was how patients with similar diagnoses might not need the same level of case management. Mullahy used the illustration of how a woman, age 50 diagnosed with cancer, having excellent medical coverage and a supportive family, being treated at a University hospital with access to Nurse Practitioners might need limited case management, if any. On the other hand, another 50 year old woman diagnosed with cancer might have limited medical coverage, might be the sole support for her family, might be treated in a clinic-based health care system where she sees a different doctor every time, and English is not her first language. This woman would need more case management because at the very least, she will need someone to make sure that any communication barrier between her and her health care providers is addressed.
She also explained how case managers in hospitals are often placed in serious ethical dilemmas because in most instances, the case manager is supposed to help get that patient out of the hospital at the lowest cost, but that might not be the best for the patient. As nurses, we have an ethical responsibility to always place the patient first. Because of this ethical responsibility, it has been the traditional for nurses to be kept out of the loop when it comes to how much it costs to treat a patient. However, if a nurse case manager is responsible for keeping costs as low as possible, then there is an ethical dilemma. You're setting up that patient for a return visit to the hospital, which means you're placing them at risk for nosocomial infections, poly-pharmacy, medical errors, and diminished autonomy. Mullahy's presentation raised my awareness and gave me something to think about.
As an aside, I have to once again call out my colleagues for some rudeness that I witnessed. A woman came into to the presentation late (happens all the time) and tried to sit in an empty seat in front of me. The woman sitting next to the empty seat got all huffy and said "there are other empty seats, you know". Yes there may be other seats in the room, but your empty seat is right near the door and it's silly to expect that someone is going to schlep across a room, in search of an empty seat. Get over yourself.
On a more positive note, I did see more recruiters than last year, although maybe that was because I got there early. There was some diversity in recruiting as well in that not everyone was strictly hands on nursing. I was able to speak with some recruiters who seemed to be genuinely interested in my experience set. So that was a good thing. I even ran into a colleague with whom I attended classes when I was taking my nursing school pre-requisites. It was good to learn we both got through after our paths diverged; we had both traveled a long road.
Overall, I give it a B+. The lessons learned were: you don't have to pre-register, get there early so you can get convenient parking, get your bag, and so you can take advantage of the free Continuing Education seminar.
Monday, March 1, 2010
Friday Night, Saturday, Sunday
I am grateful that my life is fairly free of drama not of my own making and is completely free of earthquakes.
Weekends begin on Friday evenings especially when there is no work obligation on Saturday. I got home fairly late because I didn't leave work until after 4:30. By the time I got home, relayed the day's events to Mr. DS, checked email and decided to go out to dinner, it was after 5:30. Then it was the decision of where to go. I was still feeling full from a big lunch and Mr. DS was approaching the level of hunger where he doesn't even taste what he's eating. The usual suspects were proffered. It was decided to visit the Star diner. I should have suggested the Franconia Heritage Diner. We have been meaning to try it and I'm betting it's heavy on the Mennonite cooking. But alas, I overate at the Star and was so uncomfortable afterward that it occurred to me to purge. I did not. My back was bothering me so I did some yoga stretching and ended up dozing off. Mr. DS put on "How it's Made" to kill time before the weekly ritual of "The Soup". They should bottle that stuff, it's better than Ambien.
Woke up about 5 minutes before "The Soup", and Mr. DS was fast asleep. I did not wake him up but Watched part of the show, then decided to wake him up to go to bed. Went back to bed and fell asleep with the TV on. Did not make it to "Chelsey Lately".
Woke up Saturday morning on the late side. Actually woke up because of the damn cat yowling, then fell back to sleep. Woke up again and decided that since it was a nice day, we should take a little drive. Mr. DS wanted to know if I had a plan for the day. Berger's remains are ready at the vet, we need to go get them and then I wanted to go to Market Fair. Mr. DS's phone goes off. A job has failed and he needs to log in to work and fix it. When all is said and done, we don't end up leaving until 10:30.
We drive to Trenton. My favorite gas station is not open on Saturdays. I wonder if they observe a Sabbath or if business is so off on Saturdays because there is no train station traffic, it is not worth being open. It occurs to me that this is probably the last time I am coming to this vet and to this gas station, where I bought gas for so many years. (I have a whole gas and mileage database starting back from 2004). I collect Berger's remains while Mr. DS stays in the car. This is the last time I am coming here, I think. And then I think about how most of the time, you never realize that you're never going to do a particular thing again. It would be nice if we could be more mindful of those lasts. And then I remember that I still need to write Dr. K and his staff a thank you note. I think he disagreed with me about not putting Bergers to sleep the last time I brought him in, but I thought it would have been wrong to do it without Mr. DS there and I really believe that it is better to let your pet pass at home surrounded by his people, assuming that he is not in pain. And I don't think Bergers was in pain.
So I put the little green bag containing Berger's remains on the floor of the back seat, next to my sack of overdue library books and then we get gas at the Mountain View BP and I asked Mr. DS to give me directions to Princeton without getting on I95. He GPS'd us all the way there. On the way, I recognized the road as one I had been on during on of the blizzards of 2001. I knew that I95 would be a mess so I decided to slink down one of the Princeton side roads that I used to use when I was delivering flowers. It was probably not a good idea to do that, given the poor visibility and my car was new but very light weight in the back and very bad under slippery conditions and the tires it came with were instruments of death when the road was icy. But I made it home in one piece. I think it took about two hours to get home. I had the radio turned to the talk radio station out of NYC, 770 WABC. It's known for having all the right-wing commentators on it, but I always turn to that station when I'm feeling anxious because it's the station my parents used to have on in the car when we would be driving to NYC or Connecticut on a Saturday afternoon. It was much less right-wingy then. There was a host on Saturday named Lynn Samuels who was decidedly not right-wingy. I remember that she was very funny and I used to love, love, love listening to her show where she would talk about all the crazy things New York City politicians would do. Or she would talk about some crazy thing that was going on in her apartment building and ask people to call in and share their opinions. I thought it would be the coolest thing to be a New Yorker like Lynn Samuels. My folks would listen to her show and they would laugh along with her too and it was one of those nice moments that you remember with your parents on a car trip, when things are calm and nice and nobody's arguing or longing to be somewhere else when there's no possibility of that happening.
So we finally get to Princeton via the back road and I point out to Mr. DS the restaurants that I have eaten in that he's never been to and I point out the houses where I used to have pet sitting clients and I think about how they are probably not there anymore, just like I am not there anymore and they probably wouldn't remember who I was, even though I had a key to their house and collected their mail and turned their lights on and off and fed their cats and cleaned their litter boxes. I would spend time in their houses after I finished what I needed to do with their pets just sitting on the couch or at their kitchen table wondering what it would be like to be a part of this family or what would it be like to know them as friends. Would they invite me for the 4th of July? Or did they rent a place at the beach in the summer and have friends visit for the weekend? I would pet their cats if they were friendly and wonder what they saw. If the cats were not interested in me, I would look at the photos on the walls and on the shelves, wondering if some day I would ever have a house where some pet sitter might come and look at my pictures and wonder about my life and what it would be like if they knew me or were part of my family.
We get to the Mexican restaurant in a strip mall in Princeton. This was one of the first places I ever came to when I moved to New Jersey. It was small and safe and full of quaint little shops like the stationary store where you could get lost for hours looking at the stickers and invitations and fancy wrapping paper. The rotation of shops has changed, but it has remained something you only find in a place like Princeton, which is full of people who don't want to be bothered by the convenience. This Mexican place has been there since before I started coming to this mall, but I never went there until I was taken as a guest by one of the volunteers who worked with me at Recording for the Blind and Dyslexic. She was a very sweet lady, who was married to a very important man over at Merrill Lynch. She didn't hold a job outside the home and she had no children, so she volunteered a lot. She was always happy and relaxed. She's the type of person that trouble does not bother and one night she invited me to come to dinner with her, since her husband wasn't going to be home and she took me to this little hole in the wall Mexican place, but the food was very good and I liked it a lot. And she and I talked about all kinds of things, like how I got to New Jersey, and we gossiped about the politics of RFBD and how she would like to do more, but she didn't want to feel like she was buying her way in because there was already a lot of old money who were on the board and sort of wary of new comers.
So Mr. DS and I ate our lunch at this restaurant and I remembered all this and I wondered about KF and I hoped she was OK and that her husband didn’t get shafted too badly when all that stuff happened with Merrill Lynch. She was a nice lady and I think all she wanted to do was help people and that's incredibly hard to do when you have to work to support yourself. Over lunch, I told Mr. DS about the latest machinations of my mother with regards to my aunt and their brother and I felt myself getting angry about the whole situation because it was stupid. If you overheard this story from a stranger, you would say that the situation is totally stupid and that the woman and her stupid plan involving a lie is the dumbest thing you've ever heard. But it's not someone else's overheard story that you will leave at the restaurant like your wadded up napkin; this is a story that will come back to haunt me in a few months or next year and I will wish I had taken some other steps to prepare myself for what will happen.
And then we get into the car to drive to the Market Fair, but I'm hoping to stop at the Small World coffee for some awesome plain old coffee. But it is a nice day and there is NO parking on Nassau St. In fact it is teeming with people trying to cross the street and being unable to see around the snow banks and cars are parked awkwardly because of all the snow that is piled next to the sidewalks. So I hope maybe I can get to the other Small World, the one I used to go to when I worked at the Princeton Unit of RFBD and I would get a large coffee with milk and a bagel with butter and orange marmalade, which I don't even particularly like, but something in the universe told me to have the marmalade with their bagel and butter it was one of my favorite meals ever. But alas the traffic on Nassau was terrible and I could see that Witherspoon St. was even worse so I skipped it. Maybe I will have another chance for Small World coffee the next time I came to the dentist.
So we proceeded to Market Fair down Alexander St. which runs through the university campus next to where Albert Einstein lived and the world's least recognizable Wawa next to the Princeton train station. And Soonja's café was still there. I thought I took Mr. DS there one time, but he said that I never did. Maybe I thought he wouldn't like it, so I never took him there. They have the best yam noodles. I think he'd like it now.
So arriving at Market Fair there is no parking, even though I circle around, at last parking hear the Big Fish restaurant, which I am surprised to find is still there. Mr. DS says that we ate there at least once when we were dating. And I agree that we went there at least once, but I don't remember going with him there a lot because they are mainly a fish restaurant (as the name implies) and Mr. DS will eat fish but he doesn't crave it the way I can when I want a really beautiful salmon. I went there more with girlfriends like SG and JU. It was more of a chick place to eat. So we go into Market Fair and everybody must be in the movies because there is really nobody in the mall, certainly the parking lot suggested that there would be more people shopping. But really it was mostly families with strollers not paying attention where they were going.
So I went to Anthropologie and bought my candles using my birthday discount and then I suggested a coffee at Starbucks which would be far inferior to the one we would have gotten at Small World, but I felt bad for making DS come out to this stupid mall with me. So we stood on a long line and got our coffees and walked over to the Barnes and Noble so I could use use the ladies room. And Mr. DS stood in the stacks holding two coffees while he waited for me. And I came out of the ladies room and tried to be all cute and pick-up artist and said "do you come here often?" and he said "no. I could never pick anyone up here, so I stopped trying. But this place used to have the best computer book section and I used to come all the way out here just for that." So we wandered around the store, losing each other then finding each other. Then we decided it was time to go since we were not even looking at anything anymore.
And then we drove home and on the drive, I felt so sleepy, even after the coffee, but the sun was bright in my eyes and I was warm from the heated seat and I opened a window to let some fresh air in.
We stopped at the craft store so I could return some yarn that I did not end up using for Mr. DS's afghan. And I picked up a new crochet needle. And Mr. DS stayed in the car and surfed the internet while I did my errand. And finally we got home and I gave Mr. DS the green bag to carry upstairs. And I wanted to cry, but I couldn't.
On the couch I started a new crochet project using new yarn that I thought was pretty nice. And I actually read all the instructions before I started so there would be no surprises. But the project is really simple and the instructions were very brief so I could not give myself that much credit.
Mr. DS made "emergency pizza" for dinner. It refers to the frozen pizza we keep on hand for when we get a little hungry but don't want anything too big. The pizza was tasty, but the crust hadn't crisped enough to my liking. That didn't stop me from eating it and following it with some Whole Foods Key Lime soda.
We watched Star Trek from our Netflix cue and it was better than I thought it would be. Even though there were enormous plot holes, I liked it well enough. And then we went to bed.
Woke up Sunday to the cat yowling again. At around 7am I suggested that we go to the gym. We were the first ones there and we were able to do our circuit with no waiting and then do cardio. I started my cardio on the Stairmaster because there was a woman on the bike next to Mr. DS, but when she finished, I got on that bike and sat in her warm seat and probably her sweat. She was one of those who didn't wipe. I never think I am going to be able to finish the cardio part of the workout, partly because it is boring and partly because my heart rate tends to climb quickly and until I am comfortable with that rate, I want to stop. But I know if I keep going, I will become accustomed to it and it will be OK.
After the gym, we went to the diner I like best for breakfast because the waitresses remember who you are even if they don't know your name and they bring you coffee and refills without you having to ask them. If I were going to have a diner, this is the kind of diner I would want to have, and these are the kinds of waitresses I would want working there. The only serve breakfast and lunch, so you can't take the place for granted...you can't just show up any old time. We discuss the plot holes of last night's movie and try to convince each other of who is more of a Star Trek nerd. Of course Mr. DS wins because he remembers more details about the show than I do. But when I was like 10 and 11, the world rose and set by Star Trek and my parents were concerned about my obsession. I paid the tab and tipped the waitress 30% because it’s a small bill there and I figure they are worth every penny they get there. The Koffee Korner. We didn't go there for a long time after we moved here. We always joked about going there and finally we did one day, and since then, we wondered what took us so long.
I drove us home and I took a shower and did a load of laundry for both of us. Then I worked on my crochet project a little more and called my friend who had left a message on Saturday. I yakked with her for about an hour while Mr. DS took a shower and got ready to go out. We were going to look at two houses with the realtor that afternoon and while I yakked on the phone, I mapped out how to get there. There were three other houses that Mr. DS had found and he wanted to do a drive by. So I mapped them out in relation to where we were going to meet the realtor. I got off the phone and I think I committed us to do something on Friday night this week, which is cool because we don't often have anything to do on Friday nights. And then we drove out to look at the three houses and then we went to wait for the realtor at the house we were supposed to see. But we were early or she was late, so we got some coffee and abysmal snack cakes at the Wawa on the Pottstown Pike (how many of them do you suppose that there are on the Pottstown Pike?). We met the realtor back at the house and we looked at that house and another house and we talked about another house that we had already seen and about another house that we may want to see and about the houses we are planning to see later in the week. And we all ate the Dove chocolate candies that the homeowner had left out for us and then we left.
On the way home, I thought there was a 5-Guys burger place in Collegeville, but I got it wrong. It was #1 Burgers instead and it really sucked because the service was slow and the food came out cold and they got our orders wrong, even though there were three people behind the counter and not too many people in the restaurant. And the burgers weren't that hot anyway, 5-Guys was way better. And I said that I felt bad for screwing up the burger dinner, we should have gone to Specks if it was open, or even the other Mexican place that is pretty good in Collegeville. But Mr. DS was cool about it. He said that we were not wrong in assuming the food would be good because there were two cop cars out in front of the place.
And we drove home with a big yellow moon hanging over the road. And I coasted in neutral a lot of the way home because there are a lot of hills that will carry you a long way if you just take the car out of gear and let it roll.
Weekends begin on Friday evenings especially when there is no work obligation on Saturday. I got home fairly late because I didn't leave work until after 4:30. By the time I got home, relayed the day's events to Mr. DS, checked email and decided to go out to dinner, it was after 5:30. Then it was the decision of where to go. I was still feeling full from a big lunch and Mr. DS was approaching the level of hunger where he doesn't even taste what he's eating. The usual suspects were proffered. It was decided to visit the Star diner. I should have suggested the Franconia Heritage Diner. We have been meaning to try it and I'm betting it's heavy on the Mennonite cooking. But alas, I overate at the Star and was so uncomfortable afterward that it occurred to me to purge. I did not. My back was bothering me so I did some yoga stretching and ended up dozing off. Mr. DS put on "How it's Made" to kill time before the weekly ritual of "The Soup". They should bottle that stuff, it's better than Ambien.
Woke up about 5 minutes before "The Soup", and Mr. DS was fast asleep. I did not wake him up but Watched part of the show, then decided to wake him up to go to bed. Went back to bed and fell asleep with the TV on. Did not make it to "Chelsey Lately".
Woke up Saturday morning on the late side. Actually woke up because of the damn cat yowling, then fell back to sleep. Woke up again and decided that since it was a nice day, we should take a little drive. Mr. DS wanted to know if I had a plan for the day. Berger's remains are ready at the vet, we need to go get them and then I wanted to go to Market Fair. Mr. DS's phone goes off. A job has failed and he needs to log in to work and fix it. When all is said and done, we don't end up leaving until 10:30.
We drive to Trenton. My favorite gas station is not open on Saturdays. I wonder if they observe a Sabbath or if business is so off on Saturdays because there is no train station traffic, it is not worth being open. It occurs to me that this is probably the last time I am coming to this vet and to this gas station, where I bought gas for so many years. (I have a whole gas and mileage database starting back from 2004). I collect Berger's remains while Mr. DS stays in the car. This is the last time I am coming here, I think. And then I think about how most of the time, you never realize that you're never going to do a particular thing again. It would be nice if we could be more mindful of those lasts. And then I remember that I still need to write Dr. K and his staff a thank you note. I think he disagreed with me about not putting Bergers to sleep the last time I brought him in, but I thought it would have been wrong to do it without Mr. DS there and I really believe that it is better to let your pet pass at home surrounded by his people, assuming that he is not in pain. And I don't think Bergers was in pain.
So I put the little green bag containing Berger's remains on the floor of the back seat, next to my sack of overdue library books and then we get gas at the Mountain View BP and I asked Mr. DS to give me directions to Princeton without getting on I95. He GPS'd us all the way there. On the way, I recognized the road as one I had been on during on of the blizzards of 2001. I knew that I95 would be a mess so I decided to slink down one of the Princeton side roads that I used to use when I was delivering flowers. It was probably not a good idea to do that, given the poor visibility and my car was new but very light weight in the back and very bad under slippery conditions and the tires it came with were instruments of death when the road was icy. But I made it home in one piece. I think it took about two hours to get home. I had the radio turned to the talk radio station out of NYC, 770 WABC. It's known for having all the right-wing commentators on it, but I always turn to that station when I'm feeling anxious because it's the station my parents used to have on in the car when we would be driving to NYC or Connecticut on a Saturday afternoon. It was much less right-wingy then. There was a host on Saturday named Lynn Samuels who was decidedly not right-wingy. I remember that she was very funny and I used to love, love, love listening to her show where she would talk about all the crazy things New York City politicians would do. Or she would talk about some crazy thing that was going on in her apartment building and ask people to call in and share their opinions. I thought it would be the coolest thing to be a New Yorker like Lynn Samuels. My folks would listen to her show and they would laugh along with her too and it was one of those nice moments that you remember with your parents on a car trip, when things are calm and nice and nobody's arguing or longing to be somewhere else when there's no possibility of that happening.
So we finally get to Princeton via the back road and I point out to Mr. DS the restaurants that I have eaten in that he's never been to and I point out the houses where I used to have pet sitting clients and I think about how they are probably not there anymore, just like I am not there anymore and they probably wouldn't remember who I was, even though I had a key to their house and collected their mail and turned their lights on and off and fed their cats and cleaned their litter boxes. I would spend time in their houses after I finished what I needed to do with their pets just sitting on the couch or at their kitchen table wondering what it would be like to be a part of this family or what would it be like to know them as friends. Would they invite me for the 4th of July? Or did they rent a place at the beach in the summer and have friends visit for the weekend? I would pet their cats if they were friendly and wonder what they saw. If the cats were not interested in me, I would look at the photos on the walls and on the shelves, wondering if some day I would ever have a house where some pet sitter might come and look at my pictures and wonder about my life and what it would be like if they knew me or were part of my family.
We get to the Mexican restaurant in a strip mall in Princeton. This was one of the first places I ever came to when I moved to New Jersey. It was small and safe and full of quaint little shops like the stationary store where you could get lost for hours looking at the stickers and invitations and fancy wrapping paper. The rotation of shops has changed, but it has remained something you only find in a place like Princeton, which is full of people who don't want to be bothered by the convenience. This Mexican place has been there since before I started coming to this mall, but I never went there until I was taken as a guest by one of the volunteers who worked with me at Recording for the Blind and Dyslexic. She was a very sweet lady, who was married to a very important man over at Merrill Lynch. She didn't hold a job outside the home and she had no children, so she volunteered a lot. She was always happy and relaxed. She's the type of person that trouble does not bother and one night she invited me to come to dinner with her, since her husband wasn't going to be home and she took me to this little hole in the wall Mexican place, but the food was very good and I liked it a lot. And she and I talked about all kinds of things, like how I got to New Jersey, and we gossiped about the politics of RFBD and how she would like to do more, but she didn't want to feel like she was buying her way in because there was already a lot of old money who were on the board and sort of wary of new comers.
So Mr. DS and I ate our lunch at this restaurant and I remembered all this and I wondered about KF and I hoped she was OK and that her husband didn’t get shafted too badly when all that stuff happened with Merrill Lynch. She was a nice lady and I think all she wanted to do was help people and that's incredibly hard to do when you have to work to support yourself. Over lunch, I told Mr. DS about the latest machinations of my mother with regards to my aunt and their brother and I felt myself getting angry about the whole situation because it was stupid. If you overheard this story from a stranger, you would say that the situation is totally stupid and that the woman and her stupid plan involving a lie is the dumbest thing you've ever heard. But it's not someone else's overheard story that you will leave at the restaurant like your wadded up napkin; this is a story that will come back to haunt me in a few months or next year and I will wish I had taken some other steps to prepare myself for what will happen.
And then we get into the car to drive to the Market Fair, but I'm hoping to stop at the Small World coffee for some awesome plain old coffee. But it is a nice day and there is NO parking on Nassau St. In fact it is teeming with people trying to cross the street and being unable to see around the snow banks and cars are parked awkwardly because of all the snow that is piled next to the sidewalks. So I hope maybe I can get to the other Small World, the one I used to go to when I worked at the Princeton Unit of RFBD and I would get a large coffee with milk and a bagel with butter and orange marmalade, which I don't even particularly like, but something in the universe told me to have the marmalade with their bagel and butter it was one of my favorite meals ever. But alas the traffic on Nassau was terrible and I could see that Witherspoon St. was even worse so I skipped it. Maybe I will have another chance for Small World coffee the next time I came to the dentist.
So we proceeded to Market Fair down Alexander St. which runs through the university campus next to where Albert Einstein lived and the world's least recognizable Wawa next to the Princeton train station. And Soonja's café was still there. I thought I took Mr. DS there one time, but he said that I never did. Maybe I thought he wouldn't like it, so I never took him there. They have the best yam noodles. I think he'd like it now.
So arriving at Market Fair there is no parking, even though I circle around, at last parking hear the Big Fish restaurant, which I am surprised to find is still there. Mr. DS says that we ate there at least once when we were dating. And I agree that we went there at least once, but I don't remember going with him there a lot because they are mainly a fish restaurant (as the name implies) and Mr. DS will eat fish but he doesn't crave it the way I can when I want a really beautiful salmon. I went there more with girlfriends like SG and JU. It was more of a chick place to eat. So we go into Market Fair and everybody must be in the movies because there is really nobody in the mall, certainly the parking lot suggested that there would be more people shopping. But really it was mostly families with strollers not paying attention where they were going.
So I went to Anthropologie and bought my candles using my birthday discount and then I suggested a coffee at Starbucks which would be far inferior to the one we would have gotten at Small World, but I felt bad for making DS come out to this stupid mall with me. So we stood on a long line and got our coffees and walked over to the Barnes and Noble so I could use use the ladies room. And Mr. DS stood in the stacks holding two coffees while he waited for me. And I came out of the ladies room and tried to be all cute and pick-up artist and said "do you come here often?" and he said "no. I could never pick anyone up here, so I stopped trying. But this place used to have the best computer book section and I used to come all the way out here just for that." So we wandered around the store, losing each other then finding each other. Then we decided it was time to go since we were not even looking at anything anymore.
And then we drove home and on the drive, I felt so sleepy, even after the coffee, but the sun was bright in my eyes and I was warm from the heated seat and I opened a window to let some fresh air in.
We stopped at the craft store so I could return some yarn that I did not end up using for Mr. DS's afghan. And I picked up a new crochet needle. And Mr. DS stayed in the car and surfed the internet while I did my errand. And finally we got home and I gave Mr. DS the green bag to carry upstairs. And I wanted to cry, but I couldn't.
On the couch I started a new crochet project using new yarn that I thought was pretty nice. And I actually read all the instructions before I started so there would be no surprises. But the project is really simple and the instructions were very brief so I could not give myself that much credit.
Mr. DS made "emergency pizza" for dinner. It refers to the frozen pizza we keep on hand for when we get a little hungry but don't want anything too big. The pizza was tasty, but the crust hadn't crisped enough to my liking. That didn't stop me from eating it and following it with some Whole Foods Key Lime soda.
We watched Star Trek from our Netflix cue and it was better than I thought it would be. Even though there were enormous plot holes, I liked it well enough. And then we went to bed.
Woke up Sunday to the cat yowling again. At around 7am I suggested that we go to the gym. We were the first ones there and we were able to do our circuit with no waiting and then do cardio. I started my cardio on the Stairmaster because there was a woman on the bike next to Mr. DS, but when she finished, I got on that bike and sat in her warm seat and probably her sweat. She was one of those who didn't wipe. I never think I am going to be able to finish the cardio part of the workout, partly because it is boring and partly because my heart rate tends to climb quickly and until I am comfortable with that rate, I want to stop. But I know if I keep going, I will become accustomed to it and it will be OK.
After the gym, we went to the diner I like best for breakfast because the waitresses remember who you are even if they don't know your name and they bring you coffee and refills without you having to ask them. If I were going to have a diner, this is the kind of diner I would want to have, and these are the kinds of waitresses I would want working there. The only serve breakfast and lunch, so you can't take the place for granted...you can't just show up any old time. We discuss the plot holes of last night's movie and try to convince each other of who is more of a Star Trek nerd. Of course Mr. DS wins because he remembers more details about the show than I do. But when I was like 10 and 11, the world rose and set by Star Trek and my parents were concerned about my obsession. I paid the tab and tipped the waitress 30% because it’s a small bill there and I figure they are worth every penny they get there. The Koffee Korner. We didn't go there for a long time after we moved here. We always joked about going there and finally we did one day, and since then, we wondered what took us so long.
I drove us home and I took a shower and did a load of laundry for both of us. Then I worked on my crochet project a little more and called my friend who had left a message on Saturday. I yakked with her for about an hour while Mr. DS took a shower and got ready to go out. We were going to look at two houses with the realtor that afternoon and while I yakked on the phone, I mapped out how to get there. There were three other houses that Mr. DS had found and he wanted to do a drive by. So I mapped them out in relation to where we were going to meet the realtor. I got off the phone and I think I committed us to do something on Friday night this week, which is cool because we don't often have anything to do on Friday nights. And then we drove out to look at the three houses and then we went to wait for the realtor at the house we were supposed to see. But we were early or she was late, so we got some coffee and abysmal snack cakes at the Wawa on the Pottstown Pike (how many of them do you suppose that there are on the Pottstown Pike?). We met the realtor back at the house and we looked at that house and another house and we talked about another house that we had already seen and about another house that we may want to see and about the houses we are planning to see later in the week. And we all ate the Dove chocolate candies that the homeowner had left out for us and then we left.
On the way home, I thought there was a 5-Guys burger place in Collegeville, but I got it wrong. It was #1 Burgers instead and it really sucked because the service was slow and the food came out cold and they got our orders wrong, even though there were three people behind the counter and not too many people in the restaurant. And the burgers weren't that hot anyway, 5-Guys was way better. And I said that I felt bad for screwing up the burger dinner, we should have gone to Specks if it was open, or even the other Mexican place that is pretty good in Collegeville. But Mr. DS was cool about it. He said that we were not wrong in assuming the food would be good because there were two cop cars out in front of the place.
And we drove home with a big yellow moon hanging over the road. And I coasted in neutral a lot of the way home because there are a lot of hills that will carry you a long way if you just take the car out of gear and let it roll.
Friday, February 12, 2010
Hacky-Schlacky Lentil Soup
Add low sodium vegetable juice to red lentils in a 2-to-1 ratio. Bring to a simmer. Add more liquid as necessary. Season to taste with what you like. Takes about 30 minutes...enough time for your rice to cook. It's nutritious fast food when you just don't wanna. I added frozen spinach to another batch to give it color. Serve with naan...or Wonder bread.
Wednesday, February 10, 2010
Going Bareback**
One of the unique aspects of nursing is that you are likely to work side by side with someone who has been practicing vastly longer than you have. Nursing is not a profession where long years of experience automatically translate into management. Many nurses do not want management because it takes them away from the bedside. Instead, they are compensated with other perks of seniority such as first dibs on shifts and holidays, the option of choosing whether or not to interact with problem families, and the license to practicing nursing the way they learned it, no matter how long ago that was.
Now I love working with nurses who have been around forever. They have done everything and they have seen everything and for the most part they are happy to share everything they know with you, so long as you come with an appropriate attitude. This doesn't mean you grovel, but it does mean that your bachelors degree does not trump their diploma and 20 years on the floor. While it is said that nurses eat their young, this had not been my experience…or maybe working 15 years in the software industry with ex-military folks who didn't care about my hurt feelings was good preparation for nursing.
Case in point, my new manager, Kyle. About a month into my first job, I was transferred from the acute care unit to the ventilator unit. I don't know how much input Kyle had into this decision, but it was the Director of Nursing's will that I replace the nurse who was transferring to another facility. I could see immediately that everyone loved April, the nurse who was leaving. Meanwhile Kyle had not acknowledged my presence even after a week of orienting to the unit. I wasn't sure this was going to work out so well. Even after April left, Kyle barely spoke to me. He would talk to the respiratory manager and the lead nursing assistant when he wanted to know what was going on. I said nothing. I was determined not to fail what was clearly some test of my metal.
While the day shift is undoubtedly the lighter of the shifts, I think it is the hardest shift to transition into. If anything weird is going to happen with a patient, it happens between 12am and 7am. There are simply less people in the building to help you if something bad happens, your access to doctors is diminished, you can't get STAT anything. Most 911 calls happen on the 11pm to 7am shift. When you come on for the day shift, you have to catch all the events of the last shift and help finish some of the work. Things like IV dressing changes, catheter changes, certain blood tests get left for the last minute. In order to move the process along, I follow the nurse coming off shift to give her a hand and get report.
On this day, I was following Maggie, a forty year nursing veteran. Maggie is tall and wiry with a whisky voice from too many cigarettes and a tanned hide from too many afternoons on the golf course. She started working the night shift after her husband died. There was something I admired about the candor of her grief. It was raw, but not maudlin. "The wee hours are when I miss him most," she would explain. "By the time I get out of here, it's morning and I have the day ahead of me." She had certainly figured out a way of making the best out of a bad situation.
"Come help me change this catheter on Mrs. Gillian," she said, waving me into the room. "She's just so big, I can't possibly move her on my own." Another thing about Maggie is that she is blunt in a way that we're not anymore. What used to be an "alcoholic" is now a "history of ETOH abuse" and what used to be "an overweight patient that requires two staff to move" is now a "bariatric" patient. There is no mean-ness in Maggie, she's plain-spoken. But it's jarring to hear the forbidden words made flesh. Call it what you will, at five feet and 250lbs, Mrs. Gillian was a big woman.
So I followed Maggie into Mrs. Gillian's room. It's still dark outside and the fluorescent light is on over the sink. This combined with the flickering of the TV makes me feel like we are working clandestinely. Mrs. Gillian, who is conscious, but unable to communicate except by grimacing, sweating profusely and breathing against her ventilator is expressing her displeasure. Her breathing on the ventilator makes a noise similar to a donkey's bray. It is dissonant, patternless, and echoes in my head on nights when I can't sleep. It sounds like pain to me.
"Did she push this thing out?" I ask, starting to feel a little dizzy. Her breathing was so uncomfortable and she was using so many muscles to breath against the ventilator, she expelled the catheter. The golfball sized balloon that would normally keep the catheter in place was still in tact, laying at the foot of the bed. "Oh yes," Maggie responded while pulling a new catheter out of its wrapping. "She does it all the time. I don't know why we keep putting new ones in. She's got to be in agony. But then she has these bed sores, so I guess we keep doing it until the doc says otherwise." Maggie continued unwrapping the catheter. She checked the balloon by inflating it just a little and then she lubed the tip. She cleaned Mrs. Gillian's perineal area with the cleaning swabs that come in every catheter kit. Then I rolled Mrs. Gillian to her side so that Maggie could approach from behind, something they don't teach you in nursing school. It's not the "official way" of inserting a catheter, but it's how you do a big patient on an air mattress when the target area is obscured by folds of skin and legs that are clenched shut.
Just when I think I cannot hold Mrs. Gillian steady anymore, Maggie is done. I roll Mrs. Gillian onto her back and straighten out her bed clothes. Something was wrong. Maggie hadn't been wearing gloves. I know I saw her wash her hands but the pack of sterile gloves was laying on the mattress with the rest of the used kit. No way, I thought, she couldn't have. But she didn't. Maggie was washing her hands again as I cleaned up the rest of the kit. "Thanks for your help," she said as she walked out of the room.
I washed my hands and went out to the nurses station, which was abuzz with the morning's activities. In the background a respiratory therapist was opening a bag of chips. "I brought food!" she announced. Maggie sailed over to the bag. "Thank you so much. I'm starving," she said. She reached into the bag, pulled out a handful of chips and walked away. "No chips for me," I thought to myself.
Just then, Kyle picked up the bag of chips,"Who brought these in?" Kyle asked, enthusiastic about free junk food so early in the morning. He grabbed a paper towel and was about to pour some out when I said "I wouldn't eat those if I were you." Kyle looked at me as though I was the junk food police. "Why not?" he retorted. "A certain someone inserted a catheter bareback this morning then had their hands in that bag you've got there," I stated matter of fact-ly and then turned back to Amy, the desk nurse. "Bareback?" Ken asked? "Yeah," I said, without looking up from Amy, "no gloves." A muffled squeal escaped from Amy, "Ooooh, she did that for you too?"
Kyle held the bag of chips by his fingertips and dropped them into the trash. As he breezed by me on his way to morning meeting, he said, "Bareback…I like that."
Kyle stopped ignoring me after that.
**Names are changed.
Now I love working with nurses who have been around forever. They have done everything and they have seen everything and for the most part they are happy to share everything they know with you, so long as you come with an appropriate attitude. This doesn't mean you grovel, but it does mean that your bachelors degree does not trump their diploma and 20 years on the floor. While it is said that nurses eat their young, this had not been my experience…or maybe working 15 years in the software industry with ex-military folks who didn't care about my hurt feelings was good preparation for nursing.
Case in point, my new manager, Kyle. About a month into my first job, I was transferred from the acute care unit to the ventilator unit. I don't know how much input Kyle had into this decision, but it was the Director of Nursing's will that I replace the nurse who was transferring to another facility. I could see immediately that everyone loved April, the nurse who was leaving. Meanwhile Kyle had not acknowledged my presence even after a week of orienting to the unit. I wasn't sure this was going to work out so well. Even after April left, Kyle barely spoke to me. He would talk to the respiratory manager and the lead nursing assistant when he wanted to know what was going on. I said nothing. I was determined not to fail what was clearly some test of my metal.
While the day shift is undoubtedly the lighter of the shifts, I think it is the hardest shift to transition into. If anything weird is going to happen with a patient, it happens between 12am and 7am. There are simply less people in the building to help you if something bad happens, your access to doctors is diminished, you can't get STAT anything. Most 911 calls happen on the 11pm to 7am shift. When you come on for the day shift, you have to catch all the events of the last shift and help finish some of the work. Things like IV dressing changes, catheter changes, certain blood tests get left for the last minute. In order to move the process along, I follow the nurse coming off shift to give her a hand and get report.
On this day, I was following Maggie, a forty year nursing veteran. Maggie is tall and wiry with a whisky voice from too many cigarettes and a tanned hide from too many afternoons on the golf course. She started working the night shift after her husband died. There was something I admired about the candor of her grief. It was raw, but not maudlin. "The wee hours are when I miss him most," she would explain. "By the time I get out of here, it's morning and I have the day ahead of me." She had certainly figured out a way of making the best out of a bad situation.
"Come help me change this catheter on Mrs. Gillian," she said, waving me into the room. "She's just so big, I can't possibly move her on my own." Another thing about Maggie is that she is blunt in a way that we're not anymore. What used to be an "alcoholic" is now a "history of ETOH abuse" and what used to be "an overweight patient that requires two staff to move" is now a "bariatric" patient. There is no mean-ness in Maggie, she's plain-spoken. But it's jarring to hear the forbidden words made flesh. Call it what you will, at five feet and 250lbs, Mrs. Gillian was a big woman.
So I followed Maggie into Mrs. Gillian's room. It's still dark outside and the fluorescent light is on over the sink. This combined with the flickering of the TV makes me feel like we are working clandestinely. Mrs. Gillian, who is conscious, but unable to communicate except by grimacing, sweating profusely and breathing against her ventilator is expressing her displeasure. Her breathing on the ventilator makes a noise similar to a donkey's bray. It is dissonant, patternless, and echoes in my head on nights when I can't sleep. It sounds like pain to me.
"Did she push this thing out?" I ask, starting to feel a little dizzy. Her breathing was so uncomfortable and she was using so many muscles to breath against the ventilator, she expelled the catheter. The golfball sized balloon that would normally keep the catheter in place was still in tact, laying at the foot of the bed. "Oh yes," Maggie responded while pulling a new catheter out of its wrapping. "She does it all the time. I don't know why we keep putting new ones in. She's got to be in agony. But then she has these bed sores, so I guess we keep doing it until the doc says otherwise." Maggie continued unwrapping the catheter. She checked the balloon by inflating it just a little and then she lubed the tip. She cleaned Mrs. Gillian's perineal area with the cleaning swabs that come in every catheter kit. Then I rolled Mrs. Gillian to her side so that Maggie could approach from behind, something they don't teach you in nursing school. It's not the "official way" of inserting a catheter, but it's how you do a big patient on an air mattress when the target area is obscured by folds of skin and legs that are clenched shut.
Just when I think I cannot hold Mrs. Gillian steady anymore, Maggie is done. I roll Mrs. Gillian onto her back and straighten out her bed clothes. Something was wrong. Maggie hadn't been wearing gloves. I know I saw her wash her hands but the pack of sterile gloves was laying on the mattress with the rest of the used kit. No way, I thought, she couldn't have. But she didn't. Maggie was washing her hands again as I cleaned up the rest of the kit. "Thanks for your help," she said as she walked out of the room.
I washed my hands and went out to the nurses station, which was abuzz with the morning's activities. In the background a respiratory therapist was opening a bag of chips. "I brought food!" she announced. Maggie sailed over to the bag. "Thank you so much. I'm starving," she said. She reached into the bag, pulled out a handful of chips and walked away. "No chips for me," I thought to myself.
Just then, Kyle picked up the bag of chips,"Who brought these in?" Kyle asked, enthusiastic about free junk food so early in the morning. He grabbed a paper towel and was about to pour some out when I said "I wouldn't eat those if I were you." Kyle looked at me as though I was the junk food police. "Why not?" he retorted. "A certain someone inserted a catheter bareback this morning then had their hands in that bag you've got there," I stated matter of fact-ly and then turned back to Amy, the desk nurse. "Bareback?" Ken asked? "Yeah," I said, without looking up from Amy, "no gloves." A muffled squeal escaped from Amy, "Ooooh, she did that for you too?"
Kyle held the bag of chips by his fingertips and dropped them into the trash. As he breezed by me on his way to morning meeting, he said, "Bareback…I like that."
Kyle stopped ignoring me after that.
**Names are changed.
Tuesday, February 2, 2010
Before You Go
When I do nursey stuff, I work in a ventilator unit. I say "when" because I used to do it full time. Now I do it part time and every time I work, I remember why I can't work there full time. When the house is full, I am responsible for up to 13 patients. On any given day, half of those patients are in a persistent, vegetative state, one fourth are "awake" and one fourth have an actual hope of going home. Of those folks who are "not awake" some are DNR/DNH (do not recussitate/do not hospitalize) and those who are not, should be. DNR means that if I find you unresponsive, I will not initiate any life saving measures such as CPR and I will not send you to the hospital. Do not hospitalize means that if you have something wrong with you like lethally abnormal electrolytes, we will try to manage the situation in-house, but we won't send you to the hospital. It is one of the steps the road to hospice or comfort care.
This weekend, I cared for a woman who was actively trying to die. It is a privilege to care for people in this state. Sometimes you're the last touch they feel, the last voice they hear. If you are the last bridge between this world and the next, you always hope you made the "here" better for them. This woman was in agonizing pain when the morphine wore off. It hurt when I wiped her mouth or repositioned her hand. So my job for the day was to make sure the morphine didn't wear off.
By now, we all know that hearing is one of the last senses to leave when someone is dying. In my practice, I recommend the patient be surrounded by family talking about the positive things that are happening. If the TV is the patient's only company, I make sure it's tuned to music. What a patient should not be hearing is "I don't want to send my mom to the hospital for a blood transfusion, I already told that stupid doctor that!" What we have here is an ambivalent son. He doesn't want his mom to suffer, but he doesn't want to let her go.
At this point, I suggest we step into the nursing office. I explain that the Responsible Party (the person who has legal authority to make health care decisions on a patient's behalf) canceled the "Do Not Hospitalize" order on Thursday and with blood work as abnormal as this patient has, I have to follow the orders of the on-call doc unless the on-call speaks to the Responsible Party directly.
(It should be noted the the on-call doc has NEVER seen this patient and practices medicine in such a manner as to keep the patient safe and not get sued. I leave it as an exercise to the reader to decide the order in which these occur.)
At this point, the son is actively trying not to wring my neck. He is frustrated because he knows he argued his step-dad into canceling the DNH order earlier in the week. Step-dad knows the score and understands that his beloved is not going to recover and is suffering. Son is not ready to let go of his mother. Who is? I tell the son that I will not send his mom to the hospital if he will help me get the step-dad in touch with the on-call. It's the only way. Son gets on the cell phone - it goes to voice mail. Step-dad is on his way home, somewhere between Philadelphia and the Poconos.
Finally we are able to get the step-dad connected with the on-call and a new DNH order is obtained. End of shift, I go home.
But I'm still thinking about work. What happened here is mostly avoidable. Mom is probably in this situation because she did not have a living will. Without the living will, this family had to go to court to decide that the spouse and not the son would would make decisions on behalf of this lady. This case is not isolated. Many of my patients are not married to their companions. But without any document indicating who should make decisions or who should execute the decisions you have already made, you will be kept "alive" until your heart gives out (not a good death), some other party will choose for you, or your companion will have to go to court to "prove" that you are a family.
You don't have to be married and you don't need a lawyer. For a few dollars, organizations like Five Wishes provide living wills in simple language. All you have to to is fill it out, get it notarized, then give it to your doctor or make sure your companion has it. The red tape in a nursing home is ten-fold. Your family has enough to worry about with you in a coma. Before you go, do them a favor and execute a living will.
This weekend, I cared for a woman who was actively trying to die. It is a privilege to care for people in this state. Sometimes you're the last touch they feel, the last voice they hear. If you are the last bridge between this world and the next, you always hope you made the "here" better for them. This woman was in agonizing pain when the morphine wore off. It hurt when I wiped her mouth or repositioned her hand. So my job for the day was to make sure the morphine didn't wear off.
By now, we all know that hearing is one of the last senses to leave when someone is dying. In my practice, I recommend the patient be surrounded by family talking about the positive things that are happening. If the TV is the patient's only company, I make sure it's tuned to music. What a patient should not be hearing is "I don't want to send my mom to the hospital for a blood transfusion, I already told that stupid doctor that!" What we have here is an ambivalent son. He doesn't want his mom to suffer, but he doesn't want to let her go.
At this point, I suggest we step into the nursing office. I explain that the Responsible Party (the person who has legal authority to make health care decisions on a patient's behalf) canceled the "Do Not Hospitalize" order on Thursday and with blood work as abnormal as this patient has, I have to follow the orders of the on-call doc unless the on-call speaks to the Responsible Party directly.
(It should be noted the the on-call doc has NEVER seen this patient and practices medicine in such a manner as to keep the patient safe and not get sued. I leave it as an exercise to the reader to decide the order in which these occur.)
At this point, the son is actively trying not to wring my neck. He is frustrated because he knows he argued his step-dad into canceling the DNH order earlier in the week. Step-dad knows the score and understands that his beloved is not going to recover and is suffering. Son is not ready to let go of his mother. Who is? I tell the son that I will not send his mom to the hospital if he will help me get the step-dad in touch with the on-call. It's the only way. Son gets on the cell phone - it goes to voice mail. Step-dad is on his way home, somewhere between Philadelphia and the Poconos.
Finally we are able to get the step-dad connected with the on-call and a new DNH order is obtained. End of shift, I go home.
But I'm still thinking about work. What happened here is mostly avoidable. Mom is probably in this situation because she did not have a living will. Without the living will, this family had to go to court to decide that the spouse and not the son would would make decisions on behalf of this lady. This case is not isolated. Many of my patients are not married to their companions. But without any document indicating who should make decisions or who should execute the decisions you have already made, you will be kept "alive" until your heart gives out (not a good death), some other party will choose for you, or your companion will have to go to court to "prove" that you are a family.
You don't have to be married and you don't need a lawyer. For a few dollars, organizations like Five Wishes provide living wills in simple language. All you have to to is fill it out, get it notarized, then give it to your doctor or make sure your companion has it. The red tape in a nursing home is ten-fold. Your family has enough to worry about with you in a coma. Before you go, do them a favor and execute a living will.
Friday, January 29, 2010
Gabriella 1992-2010
Ballet, Piddle-Kitten, Boo-boo Girl, Gabriella-Just-So. She had a lot of nick names, but she was first and foremost, Gabriella. Her origins were dodgy. One day in January 1993, I received a call at work from HeWhoShallNotBeNamed*. There were these two kittens that someone found outside and there were people who were willing to take one cat or the other, but not two together, and he thought they really should stay together, can he bring them home?
I "reasoned" to myself: we already have three cats. One more isn't much work and really two more is just a little more work than one..."OK, bring them both."
When I came home there were two kittens in a cardboard box. Gabriella was a brown and black tabby with the cutest white paws that looked like she was wearing slippers. She looked up at me with her big green eyes and started meowing. "She's talkative," I said. Some how "talky" became "gabby" but that didn't sound dignified. So "gabby" became "Gabriella" and it instantly seemed like the perfect name.
Friendliest of the bunch, she would jump up on visitors and paw at them until they gave her the attention she craved. She loved teaser toys and chased them long into her senior years. She overcame diabetes and accepted blood tests and insulin shots with grace and dignity. When I was in nursing school, she loved to sit right next to me on the couch as I studied or wrote up care plans. She loved to be brushed and groomed. Just the site of the comb and she would come running and purring and nuzzle you until you brushed her.
She and Bijoux were engaged in a love affair. Many times I came home to find them curled up together on the couch or the bed. The sound of the door would wake them out of their sleepy rapture and they would through a guilty glance at me before one or both of them would jump off the bed...the spell broken.
Late last year, we started noticing that Gabriella was walking into us or not getting out of our way like she used to. She also wasn't responding to her teaser toys. I brought her to her vet who immediately suspected retinopathy related to high blood pressure. We took her to the specialty vet, who confirmed the original diagnosis. We started her on a course of blood pressure medication and her sight was restored within a few weeks.
Early this month, she started vomiting and having diarrhea and wouldn't eat. We went back to the vet and what I suspected was confirmed, lymphoma. We started her on prednisone, prilosec, and metronidazole to help control the diarrhea. We also started her on fluids. Her appetite was restored after a few days. She went back to eating her old food if it was watered down into a slurry. She did very well for a couple of weeks until this past weekend, when she stopped eating and stared throwing up blood tinted vomit. I made an appointment with her vet on Tuesday morning. On Monday night, she still would not eat. Out of desperation, I offered her ice cream. She ate it. I gave her milk, she lapped up two cap fulls and then would not eat any more. She walked back to the bedroom and crawled under the bed.
On Tuesday, I woke up at 4am to the sound of Gabriella breathing. She was under my side of the bed. I went to the floor and checked her. I knew what was happening. I put my hand on her to let her know I was there. She left us at 6am.
She was a companion of mine for almost 18 years, traveling from wherever she came from in New York to New Jersey to Pennsylvania. I can still remember the first time I saw her sitting up straight and tall, with her white paws in perfect alignment with her chin and I thought "well doesn't she look prim and proper and just so?"
She was precious and we miss her.
*A former companion.
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