Saturday, October 22, 2016

Heart Work

One of the units I’m assigned to is pre-op, but I’d never had a conversation with anyone there until Thursday. Usually I just walk through the unit and smile and say hello to patients waiting to have surgery and their family members. On this day, a patient immediately engaged me and talked for 45 minutes about her long and really terrible medical history, which has involved two organ transplants so far. For one of them, she went to another country where they give you an organ from whichever criminal they have most recently executed. According to this patient, they test these organs for some things but not others, and she ended up with an organ that wasn’t very good.

During our talk, I began to feel a little green around the gills. I mindfully noted, “Very unpleasant, very unpleasant,” and noticed the feeling of my feet on the floor. I felt completely drained after our visit. One of the staff chaplains told me later that we don’t have to listen to a tale of this kind. We are welcome to interrupt and bring the focus back to something more immediate. At the place where I did CPE in the summer, we were instructed to study patients’ charts before seeing them, but here we don’t have to do that, and so I have no idea what is wrong with most of my patients unless they happen to mention it. Reading charts more than once made me very queasy, but it depended on the day, and I knew it was something I would get used to in time. It may well be that I end up realizing that I can be of more help if I do know in some detail what a person is dealing with. There is a difference between a joint replacement in an otherwise healthy person and stage four cancer.

On that same day, I got a phone message from F. saying that he wanted our relationship to be over. We have taken turns saying this to each other, or announcing a break, for many months, but I’m thinking maybe this was the real end. It is sad. I have seen the very dear facets of his personality, and I have many wonderful memories of us. Likely no one will ever be that in love with me again. But over the past year, I have too often seen parts of his personality that I find intolerable, and I have not been able to think of any way to get the nicer, more reasonable fellow back. That person seems to be gone for good, and I would rather spend my very limited social time with people who are cheerful, rational and tuned in.

So that was a hard day, and also a day when I rode my bicycle to work, which I have done only a few times. I like getting fresh air and saving money, but I felt wiped out by the end of the day. Maybe cycling to work is just too much exercise right now. I made a stupid mistake before I left work, as well. I’m also assigned to post-op, where people wake up from anesthesia, so I thought I’d swing by and see if the double transplant woman had survived her procedure. In post-op they said she’d gone back to her room on the transplant unit, so I went there and found her looking as if she’d spent the day at a spa. She was wide awake, looked great, and started complaining immediately. Fortunately, her doctor came along within ten minutes, so I could say, “Nice to see you after your procedure!” and leave.

The transplant unit is kind of a bummer. A pall hangs over it. I literally have the easiest units in the hospital—mainly joint and spine surgeries, though some of those are being done on cancer patients—and now I’m wondering if I only like this so much because I don’t have to hang around the transplant unit, or a neurological ICU, or an oncology unit. Also, the thrill of having the identity of chaplain is wearing off. I’m going to continually have to drop that and refocus on just being awake. If I don’t want to be “the chaplain” and if I get depressed visiting gloomy units, is this really a good career path for me?

Also on that day, I saw a patient whose baby (now several years old and perfectly fine) was born very premature and was in the ICU for more than a hundred days, an experience which permanently changed the patient’s perspective about what is important in life. When I went into his room, I asked how his day was going, and he politely asked in return how I was doing. I said “OK” and he picked up on that right away and inquired further! I decided to be honest and said, “I had a visit with a patient earlier that affected me; it’s kind of stayed with me.” That was all I had to say and the conversation went on. It felt good not to insist on being The One Who Is Fine (Let’s Talk About Your Problems), and when I recounted this exchange to the aforementioned staff chaplain later, she approved of my having been honest and not having insisted on remaining somehow above the patient.

We periodically get emails from the manager of the spiritual care department, Sarah, second in command to Paul. They always make me smile. We got one this week that began, “Dear hardworking and heart-working chaplains!”

Going Home

Last Monday I had my first on-call shift at the children’s hospital, which is huge and beautiful and new and very, very quiet. The hallways are almost deserted. As at my usual campus, we have a list of units to “round” on when on call, so I made my way to each of them, and, in the emergency department, spent time with a young Asian couple whose baby was having seizure after seizure. I visited another young girl about to be released from the emergency department and we played hide and seek. Her youngish mother, holding a small baby son, said she needed “prayers and love.” She said she never gets more than four hours of sleep. Accordingly, I prayed for her, which was mystifying for the young lady patient. The mother explained that, though she herself had grown up Catholic, prayer was something her daughter had never seen before.

The conventional wisdom is that it’s way better to be on call at this other campus because, for one thing, the sleeping room is supposedly much nicer, but that was not my experience. The bed was quite uncomfortable, and I counted 11 different sources of light remaining after the main light was turned off, including three things directly overhead that blink all night. I finally wrapped my head in a towel to make it dark, but it was not a comfortable night. The next day I ran the morning meeting at that campus—it was nice to see my colleagues who work there—and then took the shuttle back to my usual campus.

My patient visits are becoming longer, and I’m starting to have friendly relationships with the nurses on my units, one of whom showed me a picture on her phone of her one-year-old. I also met one of the two Catholic priests who regularly come to our campus to visit patients. He asked where I went to seminary and I said I’m a Buddhist. He said, “Ah, so you pray to the Lord Buddha?” Now wary of letting anyone persist in a misunderstanding, I said, “No, not really,” and he said, “You follow Buddhist philosophy,” which I could agree with.

On Tuesday I had a very long visit with a woman who looked rather stupefied; she had had a stroke. She said repeatedly that she wanted to “go home,” so I said I needed to ask if she was feeling suicidal. She said not at all; she wanted to go home. To heaven? No, she wants an apartment of her own! She lost her former place, where she’d been for years, because when it was time to sign the annual lease, she was in the hospital. That doesn’t seem like something that should cause you to lose your housing, but the patient talked to someone in a government office who confirmed that it often happens just that way.

During this conversation, a great feeling of tenderness and love for this patient welled up in me, and then gratitude that my job is literally to go around offering love to people. This is liberally extended in return. I pass a workman who says, “Good morning, chaplain!” with a big smile, and the driver of the TWMC shuttle says, “It’s a pleasure to have you aboard, chaplain.” As Paul, the head of the spiritual care department warned, we are giant blank screens that people project all kinds of things onto, both positive and negative. Some people see chaplains as agents of God, deserving of great respect. Others associate chaplains with terrible experiences they have had with organized religion.

Tuesday evening, Lisa C. and I had a wonderful feast at Esperpento: garlic shrimp, sautéed mushrooms, roasted potatoes with aioli, sautéed cabbage, a potato and egg omelet.

On Wednesday, I visited a patient whose name in the chart had been replaced by a row of asterisks. I was thinking that this must be a mental patient, as their names are routinely concealed. The patient had a woman visitor who said she was the patient’s sister and who glared at me throughout the short visit. The patient herself seemed kind of out of it, but pleasant enough. I delivered my standard remarks and then left. The visitor didn’t hurt my feelings. I was thinking, “You don’t want me to agitate your mentally ill sister—I get it.”

I went to chart the visit and had to “break the glass”—explain why I needed to see the chart and enter my password. Then I could see the patient’s actual name, at which point a giant wave of energy passed through my body: this was a very famous person I saw many times on TV in the 1990s. I thought back to her appearance and realized that, yep, that was her

The name of a mentally ill patient is actually listed as <restricted>, I realized later. When the name has been replaced by stars, or asterisks, it’s usually because the person is a star (famous), or a forensic patient (someone who is in the hands of the law; there will be guards posted outside the door), or someone who doesn’t want to be found, such as someone who is being stalked or is the victim of domestic violence.

Sunday, October 16, 2016

Bravery in Covenant Group

The spiritual care department at TWMC (Truly Wonderful Medical Center, as the hospital where I work is known in this blog) is required to try to visit 92 percent of patients within 24 hours of their being admitted to the hospital; I think this has to do with money we get from Medicare. This is tracked via periodic “chart review” weeks, where our supervisors review our statistics. In a department meeting this past week, Paul, the director of spiritual care, said that the numbers for chart review in September are never very good, and that a year ago, the new clinical pastoral education students saw just 63 percent of new patients. Those students worked hard to improve, and the average for the entire year ended up being 93 percent. My group, I am very proud to say, hit that same 93 percent level in our very first chart review week! (My personal score was 100 percent.)

During that meeting, one of the CPE supervisors mentioned that her phone number is wrong on a department list. Paul asked, “Is it off by much?” (Like if it’s only a digit or two that is different, or there is an 8 instead of a 9, that might be fine.)

In “covenant group” last week (which in my first unit of CPE was called “interpersonal relations group,” or something like that), we each did a brief check-in and then just kind of sat there, waiting to see what would happen. After a bit, one of my peers shared something that Anita, one of our supervisors, had said that had bothered her, and another thing, and another thing, and another thing. Anita took all of this in and then said, “I would like to come from my heart in responding to you,” and then she apologized for the impact of her words, which impact of course had not been intended.

I was quite surprised that my peer had seen Anita’s words as she did; they had seemed exactly the opposite to me. Anita later shared that it was hard for her to hear my peer’s feedback, and also that she felt a bit angry that my peer assumed she was motivated by unkindness.

It was quite a powerful exchange. I was very impressed that we are already doing the work my summer peers and I only got to at the very end of the unit, and only because Samantha’s knee was firmly in our backs. I was also impressed by my colleagues’ honesty, vulnerability, and ethical conduct. Another person in the group said, “I love working where you get to have this kind of discussion.” I really appreciated that Anita didn’t argue with my peer’s perceptions or try to explain them away. She wasn’t defensive. She apologized right away. That was reassuring to me and made me feel safe, as the day will certainly come when I have something difficult to share. It also made me realize that we can really hurt others when we assume their motives are bad. We think they are hurting us, but it might be just the other way around.

I described earlier an untoward incident I had at the psych unit in September. After that, Paul led a didactic on working with psychiatric patients in which he pointed out that a psychiatric patient is a human being—just like me—whose greatest tool for coping—his or her brain—is impaired. He said that these people are demonstrating courage by seeking treatment, and he encouraged us to be brave about facing our own fears.

Accordingly, when we are choosing what units besides our own to cover, I often volunteer to cover the psych unit, but didn’t have the occasion to visit there until Friday, when I was asked to see two patients. The hallways were deserted as I approached and I felt kind of nervous, like there might be a deranged person hiding behind a potted plant. Remembering the instructions I’d been given, I took my shoulder bag off, tucked the strap inside, and carried the whole bag under my arm, so the strap couldn’t easily be used to strangle me; men are instructed to remove their ties.

Once inside the inpatient unit, I had a short, perfectly fine conversation with one of the patients, a woman, though the look in her eyes was unnerving. The look in the eyes of every patient I’ve seen there is kind of unnerving, a combination of mental illness and drugs. Maybe mostly the latter. Another woman overheard us and asked if I would read to her from the Bible. We went into the day room—I made sure we stayed close to the door, through which was visible the nearby nursing station—and I read to her, and she expressed pleasure and gratitude afterward.

Finally, I went to see the other patient I’d been asked to see. He was inside his room and invited me in, but this is another thing we’re never supposed to do, so I said I’d rather talk elsewhere, and we also went into the day room. I remembered this patient from the group I attended the day I first visited this unit. I recalled a tip Jodie had given us and said, “I can give you five minutes.” (This is not to be mean, but in recognition of the fact that a psych patient might easily talk for an hour and that a chaplain has many patients to see.)

Among other things, he told me about having dated a famous singer and how sad it was when she died, of anorexia. He teared up and then said something self-critical about crying. I said that it’s important for us to grieve our many losses and that tears are a powerful way of doing this. Near the end of our time together, he said, “You’re a good listener. That’s an important skill for a Christian woman to have.” I thanked him, and told him I’m Buddhist, and he said, “So am I! I have an altar in my room. Would you like to see it?” (He went on to say that his teacher is so powerful that if you get within eight inches of him, you die instantly.)

I told him I would have to see his altar another time (a white lie—I would like to see it, but don’t plan to go into his room) and we parted very congenially near the nursing station, with smiles and a handshake. A nearby staff member beamed at us. I now feel much more enthusiastic about providing care at this unit. It wasn’t so much a matter of discovering that I can do this as remembering it. At the soup kitchen, there are many guests with psychiatric difficulties, and I get along with them very well, so this is not something I can’t do; in fact, it’s something I’m good at.

Yesterday I had tea at La Boheme with my walking friend, and we had a nice, long chat.

Thundering Down the Path

Two weeks ago, I felt joyful and engaged and energetic all week at work—and profoundly, staggeringly exhausted that Friday evening, when I had a burrito with F. at Taqueria San Jose. It was a lesson in how compassion fatigue might sneak up on a person. It might be an inch away before one realizes it is there at all. The following night, I had dinner at Old Jerusalem with Lisa and David, visiting from Seattle, and two other folks. It was great to see David and Lisa.

At work, I’ve been getting very good results by observing the patient I’m visiting, identifying what emotion his or her facial expression most nearly suggests, and asking, “Are you a bit [whatever emotion]? Am I reading that correctly?” Eight times out of ten, the patient says, “Yes, I am,” and tells me more about it. One patient who prides himself on being inscrutable said, of my being able to detect that he was sad, “You scared the shit out of me!”

Another thing that can be quite powerful is to mentally count to three after a patient stops talking and before I say anything else. Nearly every time I do this, the patient starts talking again, and this is presumably something he or she really wants to say, since it’s not in response to anything I have just said, or to my asking a question.

Along with our statements of service, we had to produce a creative work of some kind. I really liked this, because it allowed me to spend several days thinking of the various things I might do, after quickly ruling out performing an interpretive dance: shall I write a haiku? Paint a painting? Draw a drawing? Drag the keyboard out of the closet and compose a tune? Do something involving my photographs? I thought it was wise of our teachers to make this assignment, because creativity is a potential source of joy and self-nurturing as this work deepens (or at least continues), and perhaps a good way to address compassion fatigue, which I learned in the Sati Center program is inevitable: if you stand near a bonfire, your clothes will smell like smoke, and if you’re around a lot of suffering, you will experience compassion fatigue.

I remember one day during my summer unit of clinical pastoral education reporting that I was having trouble sleeping. One of the staff chaplains said difficulty sleeping can be a symptom of compassion fatigue, which he said you can indeed have after just eight weeks of CPE (as was true for me at the time). He said we need to remember to do the things that bring us joy, such as hobbies we might have let fall by the wayside. He said people confuse compassion fatigue with burnout, but they’re not the same. Compassion fatigue comes from dealing with all the emotions that arise in caring for dying or ill people—our cup is overfull with feelings. Burnout is more when we hate the whole system, hate our boss, etc.

I asked if there’s such a thing as being a hospital chaplain without being stressed out and he said that in itself, it doesn’t have to be an overwhelming job. He said he’s gotten to the point where his job per se doesn’t unduly burden him, but he said it’s not a simple, mindless job, and it will always be challenging. When you add in running a household, raising kids, and all the other things we do (such as putting gel on the ear of a cat), there is the potential for stress.

Another thing we have to watch out for is allying with a patient against one of the staff or a family member, a la the “Drama Triangle” or Karpman Triangle, in which there is a victim, a persecutor, and a rescuer. The chaplain is prone to leaping into the role of rescuer, but needs to remember to check his or her assumptions: Is the patient’s father really a jerk? Are the nurses truly mistreating the patient? Perhaps so, but the chaplain should inquire further: “What has happened that makes you feel this way?”

It’s mild, as problems go, but I’m finding that one of the most challenging parts of the day is when I arrive at work and am with seven or eight other codependent “helpers” in one small room. Part of it is just accommodating everyone’s need to stow his or her stuff, change his or her shoes, get some tea, and maybe use the one (yep) computer we all share. The choreography is complicated. At the beginning of the unit, I noticed how people’s anxiety levels would rise and fall, and how palpably that could be felt in the room. Now we are past the orientation phase and there is much less anxiety, plus I think that many (though not all!) of us have figured out that it’s best to try to keep things quiet and low-key in the morning.

In my second verbatim of the unit, I wrote about a visit where I left the room when I thought the patient had had enough of delving into emotions for one day (the one who said I scared the shit out of him). Our discussion made clear that more likely it was I who had had enough, or, at any rate, that I should have checked my assumption by asking the patient explicitly if he would like to continue talking. When I said that I need to be at the top of my game when it comes to self-awareness, I guess I should have added that my top game is probably like other people’s not-top game. I felt discouraged after discussing this verbatim—am I an emotional cripple?—but remembered what Samantha said during the summer: we can do good work while doing our own work. I shared that with Jodie in our weekly meeting, and she enthusiastically agreed.

After three weeks of feeling very purposeful and even buoyant, there was a day this past week when my attitude was noticeably more downbeat. I found myself starting to worry about money. One of my peers has a spouse who is a software engineer (“That allows me to be a chaplain,” she said) and another is married to a doctor. I am lacking a software engineer or doctor spouse, but I do have savings, and I’ve also had enough of worrying about the future. I did that all summer, and it was not fun. This is what I’m doing, and I find it to be profoundly meaningful, so I’m going to keep thundering down this path, as a colleague at my former job once said, until I hit an unmistakable dead end.

I suppose no mood of any kind can last forever, and I also think I was starting to feel the strain of thinking I have to be happy and nice all the time—which are not things any CPE supervisor would ever instruct anyone to do. I don’t have to be happy or nice. I have to be present, and this I can do. It was also a day when, for one reason or another, I did not see a single patient the whole day. The next day, I saw a lot of them, and felt happier.

Saturday, October 08, 2016

Poorly Healy Stump

What one patient’s chart says he has.

One patient I saw this past week, not yet 50, had gotten terrible news and said that if it were up to him, he would decline chemotherapy and let things take their natural course, but his loved ones aren’t in agreement, so he is going forward with treatment, even though his greatest fear is of being in pain, and he is aware that chemotherapy may well be horrible. Per the feedback on my first verbatim, I felt free to own my reaction: “I must confess that I feel distressed hearing you say this. I understand that if it were up to you, you would not go forward with treatment, but I hear your love and concern for your relative and your partner.” He said he doesn’t even dare tell his partner what his wishes are. Sad. I put all of this in detail in his chart, and I also told his nurse, who looked gravely concerned to hear it.

Another patient I saw this week said, “You have the affect of a chaplain.”

The nurses on my units are starting to recognize me as their chaplain and to ask me to see this or that patient, such as ones that are crying, agitated or complaining a lot.

Friday afternoon I and three others from my overall group went to a fancy center on campus where they simulate patient encounters, using real actors, to support professional development. I worked with a pharmacy student and a medical student to examine / interview a “patient,” decide what his problems were and write a plan of care. I have yet to lead an actual patient in a guided meditation and figured this was a perfect opportunity to practice, so I did that. I think the patient had been instructed to seem depressed, and he never once smiled at the pharmacist or the doctor, but he did actually smile at me.  

My colleagues had no idea what a chaplain did when the afternoon began, but expressed enthusiasm by the end of the day. They also said they were envious that I get to dive right in and ask about things they feel are off-limits to them, like the emotions of the patient. The medical student said she liked the meditation herself; all three of us were in the room at all times. We are responsible for caring for patients’ families and for staff members, as well, and we’ve been told that providing care to one staff member translates to better care for ten patients. 
Several faculty members were present to lead debriefing sessions after the simulations, and Jodie happened to co-lead mine. She was beaming at me in a very tender fashion, so I think she was pleased with my performance. We will all receive videotapes of ourselves so we can see what we look like in action, and we will receive our peers’ feedback on how we did interacting with the patient and how our teamwork was. We will also find out what problems real doctors thought the patient had, and what their own plan of care would be.

Based on my experience over the summer, I honestly thought this clinical pastoral education program was going to be a year of nonstop misery, but it is absolutely, completely fantastic. I love it, and so far, I am savoring every moment. I am literally getting paid to do something I would do, and have done, for free. Every single day, I get to bring to bear what means the most to me—my practice of being awake—and I am invited to bring my whole self to work and to open my heart, while also trying to be at the top of my game in regard to self-awareness and interacting with my peers. On top of that, academic instruction is offered during the workday. I like everything about it, even just walking down an empty hallway knowing I’m a chaplain.

At VFMC last summer, I was able to do all of my writing assignments during the day. By cheating: Someone clued me in to a hidden bank of public computers, and I went there and did all my writing, so I wouldn’t have to do it over the weekend. I’m doing the same thing at TWMC—but with their explicit permission. Jodie said to go ahead and take a couple of hours a week for writing, which is more than enough time.

Over the summer, I tried to arrange things so that I would have one day each weekend to spend with a friend, but I’ve let that go, and it feels better to have really cleared the decks. All I do, I can say without too much exaggeration, is work and sleep. I understand that this might sound horrible to most people, but to me it seems simple and wonderful: every single thing I do is something I want to do and/or am deeply honored to get to do.

High Above the Malarial Swamp

Our schedule seems straightforward: attend the morning meeting and then see patients until class starts, or see patients all day if there is no class, but every single day seems to require invoking special procedures. For instance, whoever is on call doesn’t come in until time for class or 4:15 p.m., whichever comes first, so his or her floors must be covered until then. In another variation, if a person assigned to one campus is on call at the other, the next morning, he or she returns to his or her usual campus and takes the on-call pagers for part of the day, sharing the load with the person already on call at that campus.

At first, this seemed stressful: something weird is going to happen every day? But it’s actually kind of a good thing, because it gives us plenty of exposure to units other than our own. My wise friend Lisa C. said one thing she thinks about at work is what actions will make the most difference to her co-workers, so when it’s time to parcel out units to cover, I am often the first to raise my hand and just take whatever is at the top of the list. One day this past week I spent the entire morning with a very agitated young woman in the “psych zone” of the emergency department. Another day I had a long visit with a woman who has had stage four cancer for years and wanted to talk about her end of life wishes; she said none of her friends or family members want to talk about it.

When we’re on call, we carry four pagers: our own, the on-call pager, the Code Blue pager for the campus where we’re on call, and the Code Blue pager for a campus where only day surgery is done, so a Code Blue there would be rare and one at night or on a weekend rarer still.

I grossly oversimplified matters when I said that TWMC has two campuses. Actually, there are at least four, including the county hospital, plus various other facilities here and there. I haven’t had time to research it, but I was told that parts of the one where I’m assigned date back to the 1600s (could that be true?), built up the hill from the malarial swamp below. The building that houses our student office is the oldest building on campus. Jodie mentioned that it is not due for lead testing until 2017, so she brought in a home kit and tested the one drinking fountain in the long hallway outside our office. It passed the test, but ever since she mentioned that, I’ve been taking my water bottle home at night and filling it the next morning as I pass through the student union so that I drink at least one bottle of water each day that (probably) doesn’t have lead in it.

The bathroom is far cry from all the lovely corporate restrooms I frequented for 18 years. My new work bathroom is shabby and has two cramped stalls and no counter space for my toothbrush or sunblock other than the ledge of the sink itself.

One day this week, Anita accompanied me on joint visits to patients and gave me some really nice feedback, particularly on my ability to connect with patients. She suggested, “You might want to do joint visits with your peers.”

“Oh, yes, to see how they do it,” I agreed.

“No, so they can see how you do it,” she said. Very flattering.

My initial visits can be very quick, since there is very high turnover in my units and we are supposed to see 92 percent of patients within 24 hours of their being hospitalized. Anita advised prolonging my initial visits long enough to figure out if the patient needs to be seen again before our normal five-day follow-up. She also said weekends don’t count as part of the five days, which I was surprised but pleased to hear.
During one of our visits together, I was asked to pray, and did so. Anita said afterward that it’s fine for me to pray in the name of Jesus Christ if I’m comfortable doing that (which I am), but she doesn't think it’s good for me to let a patient assume that I’m Christian: it is deceptive or even dishonest. She suggested that I could say, “How wonderful that you have that connection with God. I connect this way ... ” I might want to do this if it’s clear that the patient is making an incorrect assumption about my religion.

Now, at VFMC last summer, when I asked what I should do if a patient asks about my own religion, Samantha said that I could answer by saying, “I’m part of a multifaith group of chaplains.” Since I am comfortable praying to God and so forth, Samantha said that if the patient pressed further, I could honestly say, “I’m an interfaith chaplain.” That is, she didn’t exactly say, “Why, tell them you’re Buddhist!”

So, how wonderful to find that at TWMC, the assumption is that I would say, “Why, I’m a Buddhist!” They are truly interfaith. On Friday, I announced it left and right, and felt even more joyful than I usually do. I felt liberated. As it happened, one patient was himself Buddhist and said he wonders if, per karma, his illness means he is being punished for something.

I said that Buddhism does include the concept of karma, but the Buddha also taught about sickness, old age and death—could this be natural sickness? He tried on the phrase: “Natural sickness.” I will follow up on that if I see him again.

Newly But Enthusiastically Burmese

On call last Sunday evening, I was busy with one patient visit after the other until 10 p.m., and after that enjoyed a solid eight hours of sleep. Some of my peers complain they can’t rest in the sleeping room due to noise in the hallway, but with a fan turned on and aimed straight at me—the same way I sleep at home—I have slept very comfortably there so far. Actually, I think I sleep better there than I do at home.

That evening, I was paged to the emergency department and told that a patient had died and that his family would be arriving soon. When I got there, I was shown into a small conference room and soon the family was brought to me. I wasn’t told explicitly that I should impart the news, but it seemed obvious that that was my assignment.

Once we were all seated together, one family member asked, “How is Dad?” Uh oh: she thought he was still alive.

I asked, “What have you been told?”

“They said he has stabilized.”

While I was thinking of how to word what I would say next, another family member asked, “Do you have something to tell us?”

I replied, as gently as possible, “Yes. I need to tell you that your father has died.” They cried a bit and we talked some, and then they went to the room to be with their loved one. The next day, a fellow student reminded me that we are forbidden to share any medical information whatsoever, and our supervisors confirmed that, though no one yelled at me. So that was probably the one and only time I will announce a death (though doesn’t that seem like the kind of thing a chaplain would do?). In the future, I will make clear to whoever summons me that someone else needs to break the news.

The time I was on call prior to last Sunday, I went around to the various ICUs in the evening to see if a chaplain was needed, as we are instructed to do. Every person I spoke with said, “No, I don’t think so.” Last week, however, at two units in a row, the person at the front desk said, “Yes! Can you see [this patient and this patient and this patient]?” When it got close to 10 p.m., I ceased advertising my availability and headed for the sleeping room. Therefore, I didn’t go to the final few ICUs—we have five of them, and twenty operating rooms—but everyone knows they can page us.

Last Monday, I presented my first verbatim. My self-awareness was applauded, which felt good. I asked what I should do in the future if an unhelpful impulse arises, such as to try to fix the patient’s feelings, which occurred in this visit and which I acted on. Jodie said she does not think of such impulses as unhelpful. For one thing, they may be useful in learning about myself. They may also provide emotional energy to draw upon, or provide a clue to something in my relationship with the patient it would be good to understand better.

If a patient is willing to discuss his or her feelings—if he or she takes a “deep dive”—I should ask if I can sit down, to make it clear that I have time to listen and am happy to do so. Also, asking, “May I get a chair?” builds in a pause that may deepen the conversation.

We are regularly reminded to question our assumptions. If a patient says he is, for instance, estranged from his children, I should not conclude that he is estranged from his children. Rather, I could ask, “What happened that makes you feel that way?” The patient’s perception of the situation may or may not be accurate.

It is also fine to share our own feelings: “This course of action sounds sad, but so does that one. This is a big deal.” If we go slightly astray, we can claim our own reaction: “I find myself wanting to give you hope, but what you’ve said is very sad. Forgive me for trying to push hope on you.”

Jodie said that if we say something really stupid (“Have a good day!”, to the mother of a young child with cancer), we can own it: “I’m sorry, that was a ridiculous thing to say. I know that just making it through the day would be wonderful.”

My group of five students has two supervisors, Jodie and Anita, who has just been authorized to supervise students. Anita suggested in our verbatim session that I pay attention to what happens when I get triggered, such as experiencing what seems like a disproportionate amount of emotion. Knowing my own symptoms can help me recognize
over-identification when it happens again, which it will over and over.

Later, one of my peers recounted a visit he’d made that day. When the patient said he didn’t want to talk to a Catholic priest, which my peer is, he deflected by telling the patient, “I come from Burma.” (He later came clean.) Amid much laughter, we decided that from now on, when we get into sticky situations, we’re going to say, “I come from Burma,” though I don’t know if we’ll be able to produce our peer’s extremely winning smile.

Sunday, October 02, 2016

A Visitor from Kentucky

I am thrilled to find the time to post something: pretty much a miracle, considering that this weekend I had to complete: the first verbatim of this first unit of clinical pastoral education (a word-for-word account of a visit with a patient, as best the aspiring chaplain can remember it, plus analysis and description of this and that), the design of a 20-minute interfaith service I will lead on Tuesday, and my statement of service, which is meant to explain why I want to do this work and what I believe my spiritual foundation for it is. The latter also required completing a creative project, which I finished an hour ago.

I cut out a favorite photograph of myself and stuck it to a white piece of nice paper, which in turn was joined to a piece of cardboard, for sturdiness. I put gold star stickers here and there, and drew little stars with a purple marker. I added various pieces of chaplain-related encouragement I have gotten from friends, the words winding among the stars. It looked so nice when it was done that I laminated it.

This same weekend, I had to do laundry, go to Rainbow, go see the shirt lady, and do various other chores. I also managed to have dinner with Karen V. on Friday night at Santaneca. My landline died several days ago, so I also had to call AT&T, which was a horrible experience, and I also got an email saying my email password had been stolen and to change it. After I did that, the email on my iMac no longer worked and I had to call Apple. Just as Apple answered the phone, I spilled an entire glass of water onto my desk. Ugh. Nonetheless, I got it all done, with one precious hour to spare.

CPE is going surprisingly well, one day at a time. Having done the summer unit makes a vast difference. I’m not having to figure out from the ground up what must fit into my schedule and what has to go. We are asked to do a tremendous amount, but we are treated very kindly and generously. We get comp time for any minute we spend beyond the normal work day (which is only seven and a half hours) and $16 worth of free meals in the cafeteria each time we are on call.

On my fourth day, I was meeting with my supervisor when her phone rang and I heard her say, “I’ll go right now.” Someone on campus had suffered a ghastly self-inflicted injury and chaplain support was needed. I trotted along behind Jodie hoping the body was not in situ and was glad to find it wasn’t. I could never be a paramedic. Jodie supported the witnesses by encouraging them just to pace up and down and to breathe, two simple and effective ways to metabolize shock, or emotions in general.

In the first week or so, I found myself feeling impatient with more than one peer. Five of us are at the other main campus and nine at the one where I am assigned, and it is challenging to be crammed with so many people in one tiny student room, with everyone’s anxiety levels spiking up and down all day However, I believe that my happiness this year depends greatly on my relationships with my peers. I must ask myself how I can help them to feel safe, relaxed and cared for. This past week, we met as a whole group and each took 15 minutes to tell our life story, focusing on an important transition, a time we felt understood by someone else, and the first time we realized we were different from or the same as others. Many of the stories were tremendously touching. I felt an expansive sense of love for these people. They are so dear. I especially appreciate being in a group with several people in their 20s.

My initial impression of the student room was that it was smelly, dingy and depressing, but now that I have spent more time there, I see that it actually has high ceilings and tall windows that open, and that there is a view of part of the Golden Gate Bridge. From a classroom on a higher floor in that same building, I could see the Marin hills and a sailboat moving slowly toward the ocean. It made me think of all the lovely relaxing moments I’m going to have a year from now. In fact, from many places inside the hospital or on campus, there are splendid views of Marin and downtown San Francisco. It is actually a very beautiful place.

There has been lots and lots of orientation and various kinds of training, including on how to put on and take off various pieces of personal protective equipment. Somewhere along in there, I did manage to see a patient or two, but the first day I really saw patients was during “chart review” week. At the place where I was over the summer, we had to track every single minute we spent doing anything, which was stressful and burdensome. Where I am now, you’re kind of on your honor most of the time, and periodically they have a week where you try to make initial visits to 100 percent of your patients who have been in the hospital for 24 hours or less, and to make five-day follow-up visits. For this first chart review, they said we didn’t have to worry about the follow-up visits.

Furthermore, you can do one unit at a time. Once you’ve managed to see every new patient for a given unit, you can call or email your supervisor and say, “Check the system right now!” before a new patient arrives. I am very lucky in that three of my five units are exempt from chart review: the waiting room (of course), and pre-op and post-op; the turnover in the latter two areas is just too high.

That leaves me with two units, one with eight beds and one with maybe 30; I haven’t really studied it yet. Last Monday, for mysterious reasons, the smaller unit was entirely empty. This seems to happen a lot, that units close and re-open suddenly. Jodie said, “Zero patients! That means you automatically get 100 percent.” Seeing all of zero patients counts as success. That left just my one big unit, where 16 patients were new. Nearly all the rest had never been seen by a chaplain, unless they’d been there so long that someone from the previous year of CPE had seen them, but I didn’t have to worry about that at the moment.

I rushed over there and visited all 16 in the course of two hours, and had one visit substantial enough to write a verbatim about. Yay! I was shocked when I noticed two days later that nearly every single patient in that unit was brand-new, meaning that they all needed initial visits, which if I had time to do, I would do, but I don’t. The pressure is only really on when it’s chart review time, so that is lucky. I also don’t have time to read much of anything. Every day I throw another inch of reading material onto the stack, and maybe in retirement I will read it all.

One day I was taken by a peer on a tour of the psych unit, where we examined a rosary to make sure it could easily be broken, and thus not used to strangle anyone. When it did break, the psych unit worker said, “OK, these are kosher.”

“So to speak,” I added.

During that tour, I needed to use the restroom and my peer took me to the nearest one. Outside the door was a staff member with a patient, who was older and shorter than I am, and reaching to touch anyone who came near him. I turned to go through the bathroom door and felt hands on my shoulders: the patient. I said to him, “I’m going to be in here by myself,” and I went into the bathroom and put both of my hands on the door to close it. The patient pushed on the door a bit; I pushed a bit harder from my side. I repeated, “I’m going to be in here by myself,” and I pushed harder. So did he. I managed to get the door closed and then I noticed that, under the nearly closed door of the single stall was a pair of red hospital socks.

“Is there someone in here?” I asked, feeling nervous.

No one answered, and no feet were to be seen when I bent over and looked under the stall enclosure, but the paranoid thought crossed my mind that whoever had removed the socks was crouching on the toilet seat, and I decided not to open the door to the stall, and to find another bathroom. Except that the grabby patient was still standing right outside the door to the bathroom, along with my peer and the staff member, so I was trapped between either two mental patients—we’re never supposed to go into any such patient’s room—or between a real one and an imaginary one.

Finally the party outside the door moved along. My peer said later that the staff member had mishandled the situation, that he should have realized that I was in effect trapped in the bathroom and moved the patient away immediately. He said he was angry about it and that he was going to mention it to a supervisor there.

One day I read that of 10 patients who are the subject of a Code Blue—the patient’s heart or breathing has stopped and resuscitation is attempted—only two will recover enough to leave the hospital. I recall Samantha saying last summer that many doctors have specified that they do not wish to receive CPR in any circumstances, because the recipient is never be the same afterward.

We begin each day with a morning meeting where whoever was on call the night before goes over who is where that day and leads an interfaith reflection: sharing wisdom, reading a poem, leading a brief guided meditation. This is a lovely way to start the work day, and reminds me why I want to be a chaplain.

I intended to ride my bike to work, but so far I’m still taking Muni. One nice thing about that is being able to call my mother while I’m doing the walking portions of the trip, and another nice thing is being able to read a novel or magazine while en route.

One day we had a didactic, as they call them in CPE, on end of life options, including the Aid in Dying law, led by the director of spiritual care, Paul. Paul mentioned that you can’t put in an advance directive anything like, “If I get sick, I want you to shoot my brother-in-law in the head.”

My first on-call, a week or so ago, ended up going extremely well, meaning that I got a full night’s sleep. With a portable fan on and aimed at me, the unpleasant smell in the sleeping room (different from the student office) was undetectable. In the evening, I visited a dead person whose appearance would have terrified me before CPE and which now didn’t faze me in the slightest. I asked her relatives to share memories and we had a lovely 30-minute visit. There was a page at 9 p.m., but that visit only lasted five minutes. The next time I was summoned was for a Code Blue, which occurred precisely as ten minutes of meditation ended the next morning: perfect.

I had just the breakfast I’d envisioned and a wonderful salad for lunch in the cafeteria that day, paid for by TWMC, and I felt fine, since I’d gotten plenty of sleep. I know I won’t always be that lucky. Some of my co-workers have looked wretched after their on-call shift, and reported being up nearly all night and feeling terrible.

One evening at home, I pulled my bedcovers back and sat down on the edge of the bed. From the corner of my eye, I could see Hammett respectfully examining something on the other pillow: an enormous (relative to anything you want to see on your bed) sparkling green grasshopper. Normally I’m perfectly fine with putting a clear plastic container over a spider or bug, sliding a piece of cardboard under it, and dropping it out the window, while hoping for its safe landing, but this creature was so large and so unexpected, I thought this might be more a job for Tom, who came right down and actually walked the grasshopper downstairs and out into our building’s small backyard.

He said he didn’t think there was another on the premises and that he suspected it had arrived with some packaged item. My new work shoes, still in their Amazon wrapper! Yes, there were some folds where a grasshopper could have been concealed. I guess this grasshopper liked dark, hidden places, since when he left the package, he made for a spot under my blanket. Can you imagine if I’d woken up with him on my face in the middle of the night? I looked to see where the package had come from: Kentucky. A handsome Kentucky grasshopper, now very far from home.

Sunday, September 18, 2016

Whatever You Have to Do Today, You Can Do It

There are lots and lots of young people on the TWMC (Truly Wonderful Medical Center) campus, certainly the students, but even the people who work there look awfully young, going by the pictures posted on the walls of the units I’m assigned to. I noticed a lot of people marching right up the center of the sidewalk, which struck me as arrogant, but if that’s the culture, that’s the culture: I must adjust. I was also realizing that probably 98 percent of the brand-new medical students are scared; anyone who is not scared is probably overusing substances. I’ve developed a silent practice of looking at a student and thinking, “You can do this. Whatever you have to do today, you can do it.” I’m saying the same to myself.

The palliative care chaplain came to visit our class one day last week. She is a Theravadan Buddhist who has been meditating for 50 years, and she brought a force field of calm into the room with her. I could feel it unmistakably from several rows back.

Someone else in our group of 14 students has taken my usual role, which is to ask a million questions about every possible thing that might happen. It’s interesting to watch anxiety rise and fall for individuals and the whole group, and to notice my judgments of others’ anxieties, which is a strong indicator that I am intolerant of those feelings in myself. Am I really calm, or just clamping down on feelings?

I was taken by various outgoing interns to visit the areas I’m assigned to in the hospital. Two of them are low-acuity (people aren’t acutely ill) with high turnover, meaning long pastoral relationships probably won’t develop. A third is the pre-operative area, where people are busy being visited by nurses and the anesthesiologist, etc. The fourth is the post-operative area, where people are under anesthesia, and after they wake up, they go somewhere else, judging from my own experience. Finally, I have been assigned to a waiting room! Paranoid thoughts arose: Did they deliberately give me all the low-stress areas in case I flake again and these areas end up not being covered? Every single one of my peers has an ICU, or the emergency department, or a unit where babies may die. But I will take what has been given to me and do my best with it. I gather a lot of people didn’t get the assignments they wanted, and our teachers said they didn’t want to ignore that disappointment, but it is their experience that people end up feeling that whatever units they were assigned to were perfect for them.

I was worried before my summer unit of clinical pastoral education that I would react to the hand sanitizing gel. They had two kinds, and neither turned out to be a problem, though one smelled kind of nasty. TWMC has a different kind, and it immediately made my hands feel a bit irritated. But I mentioned that to my supervisor and she said there was a student two years ago who was sensitive to chemicals, and there is some other stuff such people can use.

I was kind of disappointed to learn that, because I was thinking this would end my CPE experience, and I was already kind of looking forward to quitting. “Oh, well! I really, really tried!” I would also then have to avoid TWMC permanently for my own medical care, lest they terminate me during a mammogram or pap smear.

TWMC has two campuses. One is new and beautiful and in a part of town with superb weather, not too far from where I live. The campus where I’ve been assigned is old and shabby and smelly: atmospheric. The weather there also is not very good. It tends to be overcast and chilly. The small student room in particular is revolting. It smells, it has little natural light, and the chairs are stained. Instead of having lockers with locks, we have unlocked filing cabinet drawers, one per student, in which to store our valuables. This room is a good hike from the actual hospital, separated by maybe four buildings, two of which are being torn down.

One day I found three boxes of doughnuts in the student room. New student (not me): “I’d better not.” Outgoing student: “What?? Not eating doughnuts is not a choice. You have to eat doughnuts!” Now I see why several people have said that everyone gains 20 pounds during their year of CPE. This is all quite different from VFMC (the Very Fantastic Medical Center), where I was during the summer. Our student room there was a large office we shared with staff chaplains and a handful of other employees. Two walls were entirely covered with a lovely, soothing hand-painted mural. Natural light streamed in several large windows. The hospital itself seemed clean and new and beautiful. We each had a locker with a lock. Adjoining the office was a gorgeous yoga studio with a bamboo floor. Not one single time did I lay eyes on a doughnut. (Because they are not a health-supporting food and we were in a hospital!) We would have treats if we had a celebration, but only then, and leftovers, even of sweets, would sit for days before they finally disappeared.

Here’s one good thing: At VMFC, if you’re there on weekends because you’re on call, you have to round on your normal units (visit the patients there). At TWMC, if it’s the weekend, your only task is to respond to pages. Of course, that very well might end up being a whole day (and night) of work. One person who showed me around said he didn’t find his duties there particularly stressful. He said the hardest part was when a young patient who wasn’t expected to die did.

Despite my low-acuity areas (waiting room!), I will have plenty of exposure to dying and death when I am on call. This gives me the opportunity to mention that at VFMC, the sleeping room was a whole apartment located in a building across the street from the hospital. At TWMC, the sleeping room is a cramped, foul-smelling room inside the hospital and just yards from the main entrance, so it is probably noisy. There are no windows in it. It’s just big enough for a fold-out bed. We can’t go in it until 9 p.m. on weeknights—two hours past my bedtime—and we get off at 4:30 p.m., so the student chaplain may have to find somewhere to twiddle his or her thumbs for four and a half hours.

At 54, I think I’m the oldest person in the group (also older than every supervisor, I believe). There is a woman who is 50 and a couple of people who appear to be about 45, and everyone else is 26, give or take. Good thing I didn’t put this off any longer.

Needless to say, I did not sleep well the night before starting CPE nor really any night since. However, whatever I was sick with I never noticed again after the first day, after starting to take Sudafed, per the precisely correct recommendation of my doctor’s assistant.

Friday we got off a little early, so I went to 24th St. and the Castro in search of shoes; my feet are killing me. Yesterday I got up at the crack of dawn and did my laundry, talked to my 40-year friend on the phone, took Hammett to the vet, ate, went to see F. at his place, went to the mall in further search of shoes—it was very hot and sunny; I felt dazed and bedraggled—went to a shoe store on Mission St., went to see my shirt lady, came home and ate and went to bed early. I’m going to try to make it so weekday and weekend bedtimes are about the same.

Today I went to Rainbow and did my cooking for the week, which for the next year will consist of slicing three cucumbers and boiling some eggs. I sorted through all my various pieces of paper and emails and electronic documents for TWMC and made a giant list of questions and things to do. I wrote an assignment that is due Tuesday, after new employee orientation tomorrow. I have a massive backlog of reading, which I will just have to fit in somehow. Like, it would be good to read the stuff about being on call before Friday, when I’m on call, but I don’t see when I’ll be able to do this. On-call starts at 4:15 p.m. and goes until 4:30 p.m., so on Saturday, I will be the only chaplain at that campus of the hospital, no doubt confused and exhausted, and certainly unshowered.

However, having done the summer unit makes an enormous difference. I would be going completely crazy if not for that. Much that I heard last week was already familiar to me, plus TWMC uses the exact same charting system as VFMC, but in an even simpler way, thank Sam. Also, speaking of Sam, it’s so great to have a built-in friend. I would not have even been able to do the assignment I was doing today if not for having done the summer unit and if not for Sam emailing me his so I could get an idea.

Please feel free to point out typos and obvious mistakes here—I suspect there will be a lot of both over the next year.

Wednesday, September 14, 2016

First Day

Wow. Even with basically no sleep and a probable brain tumor, this was like night and day compared to my first day of clinical pastoral education this past summer. It makes a big difference to be with people who are really, really nice. I’m sure they can be jerks (just like me) and are perfectly capable of being firm when necessary, but the whole vibe is kind and gentle and supportive and warm.

Sam said there is one supervisor he’s not crazy about—she keeps kind of yanking his chain—so I knew she would end up being my supervisor, but it turned out she isn’t. My supervisor is a very nice woman who has a small child. She told me just to go with the schedule for now and they’ll try to get me caught up next week.

There are 14 people in the whole group, six of whom are Buddhist, and another couple “Budd-ish.” At least one person reported having no religious affiliation at all. Everyone was extremely friendly. One young man turned to me and asked, solicitously, “How is for you to be here today?”

There was an abundance of breaks. We heard 45 minutes about this, then had a 15-minute break, then heard 45 minutes about that, and had another break. Mid-day, we were treated to quite a yummy catered lunch while we met with members of the Professional Advisory Group. One session was on the health, dental and vision coverage we have all been signed up for, which sounds like excellent coverage. We also did a session on charting. They use the exact same system that we used at VFMC, but in a simpler manner; they mostly just have us make selections from lists and actually discourage lengthy narrative. They pointed out that the patient gets to read whatever we write, so simpler might be better.

Besides finding out who my supervisor is, I found out which campus I’ll be at and which units I’m assigned to. One is orthopedic surgery, which I also had at VFMC, but someone pointed out this might be different. There will be some people who have joint replacements followed by smooth recoveries, but others who have had the same surgery fail six times in a row and have come to TWMC as a last resort. One of my colleagues was assigned to pediatric oncology. A chaplain who works there said not to worry that our assignments will have an adverse effect on getting jobs later. He said people do not care what particular unit you worked in and that we will get jobs because employers will know we went through a very rigorous CPE program.

I’m in a small group of five people: the woman who took my place when I dropped out (Budd-ish), a woman who is Christian and into yoga, a fellow from Burma who is a Catholic priest, and another man who is, like me, a Theravadan Buddhist.

One thing I learned from this summer was not to take tons of notes, because they just have to be typed up later, which takes time, and may be rarely if ever consulted. I took very few notes today.

At the end of the day, we all went out to a sunny spot in a nearby park and put on a temporary altar—a colorful blanket on the ground—an object we’d brought along to symbolize our feelings about the transition now underway. We each described our object, and while this kind of thing might not be naturally something I’d think of doing, I could really appreciate each person’s sincerity and openness. These are lovely people. We also had been asked to bring along a poem or prayer rolled up like a scroll and tied with a ribbon or piece of yarn. We put all of these in a basket and then each took one. I had to tie mine with string, but it was really a perfect poem, by Molly Fumia, and the person who ended up with it, who is one of our supervisors, was delighted by it.