Monday, July 15, 2019

Walking Like a Walking Person

Late in June at County Hospital, there were only two palliative care patients for me to see, so Clementine sent me to the ICU, where there were at least three horrible situations: a PVA (pedestrian versus automobile) accident that had resulted in brain death; a young parent accidentally caught in gang crossfire, also brain dead; the savage beating of a young woman.

I went into one room to find a doctor comforting the sister of one of the brain-dead patients. The doctor had taken the sister tenderly in her arms and was crooning into her ear. It was a tour de force of compassion, particularly given that the doctor probably has to do this five times a week. The sister was weeping, and then said, resolutely, “I’m going to let you do what you need to do,” by which she meant withdraw life support.

It’s impossible to know, but I wonder how it would have gone if the doctor had stood six feet away with her arms folded, saying, “There’s nothing more we can do.” Maybe then the sister would have yelled the words heard very often around the ICU: “Well, you’re not going to pull the plug! You’re not going to give up on her!”

One morning at the end of my 24-hour on-call shift at my paying job, I spoke to the person taking over. Fred asked, “How are you?” I said, “Oh, fine,” and then I added, “except for my right knee, which is killing me.” I’m not sure why I said that, and I expected Fred to say, “Sorry to hear that,” and that would be the end of the conversation. Instead, he said, “What’s the history of this problem? Where does it hurt?”

He told me that he had once been in an accident that had given him knowledge of such matters, and he hypothesized that my kneecap was being mashed against the joint. He said that when he had a similar problem, an acupuncturist treated the twin indentations under the kneecap known as the “calf’s nose.” This was helpful, but Fred figured there was no reason he needed to pay an expert to do this, so he went and bought his own acupuncture needles, boiled them in water, and stuck them in the indentations under his knee, with good results.

I was going to call my PCP the very next day for a referral to physical therapy, but when I thought about what Fred had said, it explained my symptoms exactly. Accordingly, I began doing quad stretches many times a day, and there was immediate improvement. A couple of days later, I went to have a massage, and my massage person worked on my right quads and suggested putting arnica gel on my knee, along with Tiger Balm and CBD oil, either spaced out or all at once. He said arnica is good for sore muscles, and the other two are good for inflammation, but via different compounds, so it’s worth it to use both. (Actually, all three are good for inflammation.)

Thus I found myself on the phone to the nearest marijuana dispensary, placing my very first order. I looked at their website before I called and couldn’t believe how many products they have. I explained that I wanted CBD oil without THC and the helpful employee pointed out various options and said she’d put my order in a bag for pickup. I’d thought I would have to provide my full name and address, or even show ID, but I only had to give my first name.

The next time I discussed my knee with Fred, he had more suggestions, including that I should go see the chiropractor in my PCP’s office, who Fred thinks is wonderful. I said, “Is he going to mess up my spine?” I had never in my entire life seen a chiropractor, but this one really is wonderful. Friendly and enthusiastic, he explained what was going on, released various frozen spots, and gave me some additional exercises to do at home. He said it was not in fact a case of my kneecap being mashed against the joint, but rather patella tracking disorder, due to a ligament that he said is slightly “lax.” He explained why stretching my quads helped. He said my focus does not need to be on growing cartilage but rather on lessening inflammation. My knee is not entirely better—maybe this is now a chronic situation of occasional achiness and stiffness—but it’s much improved and I can walk pretty much like a person who can walk.

Little Miracle Baby

One day late in June, I did a refresher for the two students I’d most recently trained at work in the use of the electronic charting system. I thought it might make more sense after they’d been using the system for awhile, and I could tell that some pieces of information were making sense to them for the first time. In the afternoon, the staff chaplains had our monthly meeting, and in the evening, Tom and I watched half of the Democratic Presidential candidates debate online. (That is, we watched the whole thing; half of the 24 candidates were debating.)

My right knee at that point had been hurting for about a week, which can happen if I slack off on my exercises, or perhaps for no discernible reason at all. I’ve been in physical therapy for this at least three times over the years. My father reminded me that the original injury likely was one I received at age 23 or 24, when I worked for PG&E, in the general construction department, when I fell off a telephone pole and got a lot of big slivers and also gave my knee a good thump. The co-worker supervising my pole-climbing practice said, after I fell, “Get back up the pole, Bugwalk!” Today I would say, “No, I won’t!”, but back then, I followed instructions, and fell maybe four times in a row. There was a worker’s comp claim, and it was determined that PG&E was at fault, and in fact permanently responsible for my knee, though I suspect if I called them up and asked them to pay for physical therapy, it would be an uphill battle.

Usually my knee feels better as soon as I get back to my stretching and strengthening exercises, and this time was no exception. In fact, my knee felt so much better that one day at work, I walked up the stairs from the second floor to my unit, on the tenth floor, with no ill effects. Accordingly, after lunch, I did the same thing again, and by the time I got to the tenth floor, I was in excruciating pain, which refused to budge, no matter how faithfully I did my exercises. The night Tom and I watched the debates, I could hardly walk. One thing that made it noticeably worse was sitting down; every time I stood up again, there was a sharp uptick in pain.

Once in a while, I get extremely dizzy, which I attribute to stress. Toward the end of Clinical Pastoral Education, I had three or four days in a row of dizziness, and the night Tom and I watched the debate, I suddenly got extremely dizzy just before bedtime. During the night, I sat up for some reason or other, and noticed that I still felt awfully dizzy.

At 2:10 a.m., my work pager went off: a dying baby was in need of baptism. I was genuinely afraid I was going to fall while making my way to work and end up in the ED myself, but somehow I got there, painfully folding my knees to get into a cab and painfully extracting myself again at the hospital. It was the worst possible night for the pager to go off: both sitting and standing were problematic.

The baby in question was one day old and had already coded (stopped breathing) at least once. The doctor had explained to his parents that he would not live. I performed the baptism and then I prayed for the baby, saying, in part, something like, “Of course we pray for a miracle, but if we can’t have the miracle we want, we give thanks for this miracle: that this baby is alive and breathing right this minute.”

Later I was kind of slapping my forehead over that: so often clinicians have to temper a family’s hope for a miracle—why on earth did I introduce the idea myself? Also, it was kind of stupid to give thanks for the breath of a baby when that baby was only breathing due to being on a ventilator, and would die once the ventilator was disconnected. However, the parents seemed comforted.

I spoke with the doctor while we waited for other family members to arrive to hold the baby for the first and last time. The doctor said that during his residency, 80 babies a year died. He studied how to help families with bereavement and learned that it’s important for family members to see the efforts to revive a patient who has coded. He talked about how, even if they know a baby will die, they give the baby a couple of days on life support, to give the parents a chance to start to come to terms with saying goodbye.

I asked him what he does to care for his own emotional well-being and he said that he doesn’t need to do this frequently, but now and then, it’s essential for him to go unburden himself to one of his two or three best friends.

Three days later was my next work day. I was sure the electronic health record (EHR) would say that the baby had died at the age of one or two days, but the baby was still alive. I went to visit, and found the baby doing well, with thrilled family members at his bedside. When I told a nurse this story, she cooed at the baby, “You little miracle baby!”

Update: this baby, who was “cold and blue” upon arrival at NICU went home “in good condition” a couple of days ago.

Cornbread Cake

In mid-June, I went to visit my parents and sister and Amy and Ginny in Michigan. I didn’t get to see my uncle because he was at his cottage up north. It was a lovely visit, doing all the things I enjoy doing there: hanging around with my parents, getting caught up with my sister, watching MSNBC (Rachel!), going to Seva with Amy and Café Zola with Ginny.

It was also nice to be with Jack the cat, upon whom my father dotes, worrying over his appetite, shopping for new kinds of food, cooking things Jack might like. I joked to a friend about my father saying, “I have bought these 95 kinds of food for Jack and have tasted them all. I think this one is the best.” That’s an exaggeration, but not by much. I told my friend that my father is an excellent cat father and that he’s like that with people, too. He goes well out of his way to care for those he has identified as being in his flock: Mom, his own children, other relatives, Jack the cat, and another person I have finally concluded is my half-brother, since we in effect share a parent.

During my visit, my father hosted a birthday celebration for me: pizza delivery and cake suitable for the person who avoids sweets. He has approached this problem different ways over the years. This year, he made a cornbread cake, omitting the cup of sugar the recipe calls for. It had buttermilk in it, and was moist and pleasing. As for frosting, he was thinking he would put cream cheese on it, and was wondering what might be added to the cream cheese. I suggested fruit-only preserves. He used strawberry and the result was wonderful—light and delicately sweet.

When my mother said later in the day that she could go for another piece of cake, my father said there should be plenty in the fridge, as he had had to test his recipe by making it more than once, of course.

Back at home and at work, I greeted a patient on a gurney in the hallway who turned out to have likely C. diff. From now on, I will wait until the patient is situated in his or her room and any instructions about precautions have been posted.

I was asked to visit a dying patient whose mother wanted someone to read the Bible to her. When I got to the unit minutes later, her nurse said, sounding shocked, that the patient had just died. When I went into the room, I saw the patient lying on her bed with her eyes wide open, and I got a tingling sensation all over my body. (A similar thing happened once before with someone who had just died: goosebumps on my shins.) I spoke directly to the patient, since the strong energy in the room made it seem she was still there in some sense.

I also visited a patient who has lived in his car since parting from his spouse two years ago. A nurse in the ED wrote in his chart note that patient was “inappropriately focused on needing to move his car.” Worrying about your car being towed is far from inappropriate if your car is also your home, contains all your possessions and is the thing that prevents you from having to sleep on the sidewalk or in a shelter. I swallowed the urge to send the nurse a message to that effect.

Finally, I visited a patient who had left the hospital a month prior with a newly transplanted organ and high hopes. Bad labwork had put him back in the hospital.

I went for a sleep study late in June, after having noticed that my sleep requirement seemed to have gone way up. Long ago, I was diagnosed with mild sleep apnea after a sleep study, and thought maybe it had worsened, accounting for what seemed like undue weariness—needing as many as 13 hours of sleep some nights, with nine hours a night, which I had considered a minimum, now insufficient.

The technician festooned me with wires and said that if I woke up at least 15 times per hour in my first two hours of observed sleep, I would then be set up with a CPAP machine to try out for the rest of the night. He had me try a few different ways of attaching a CPAP to my face, and said that 75 percent of people being studied end up qualifying to try the CPAP. If a CPAP was indeed needed, then I was looking forward to having one and enjoying more restful sleep, but I was hoping I wouldn’t need one—not to have the diagnosis, hassle or expense.

I caught myself waking suddenly from sleep at least three times soon after retiring, so I was sure the technician would be coming along with the CPAP, but he never did. As for improved sleep, that has already occurred, thanks to my new PCP, who, when she ordered the sleep study, also reminded me about proper sleep hygiene: no screens starting two hours before bedtime, taking magnesium in the evening, not lying awake in bed for more than 15 minutes.

I have been faithfully following these instructions, including that I take 500 mg of magnesium glycinate 90 minutes before bedtime. Maybe five or six times, I did get up and read in my dimly lit room until I felt really drowsy, which more than once took hours, and I felt lousy the next day, but now, as a rule, I fall asleep fairly easily and quickly, and sleep much more soundly than before. Nine hours, alas, really isn’t enough, but if I sleep nine hours on work nights and maybe 11 or 12 hours one night a week, and 10 or 10.5 hours the rest of the week, it seems to balance out.

Sufficient Unto the Day Is the Evil Thereof

It ended up taking a week to dry out my apartment. I was left with (and still have at this moment) the various holes in my various walls and removed kitchen ceiling as previously described.

Like, here's my little hallway.

Here’s Hammett with the final dehumidifier.

And Hammett tenderly licking one of the fans.

Early in June, I got an email newsletter from one of the leaders of the street retreat I’ll be going on. He was reflecting on another retreat just concluded, and about how much help the retreatants had gotten from actual homeless people:

Street generosity comes in many forms. A woman in her 70s and who has been sleeping on park benches for decades, like a Bodhisattva walking through the hell realms with joy, quietly lured rats away from our sleeping area with scraps of food she had saved in her handbag.

Rats near the sleeping area?!?

Close on the heels of that alarming transmission, my mentor group met, including a person who had been on that retreat. She joined a few minutes late because she had spent the whole day in the ER dealing with a painful symptom that arose on retreat and lingered afterward. The retreat “did me in,” she confessed.

She also said that she spent too much time preparing, since you don’t need much: the clothes you’re wearing, a plastic bag in case it rains, one dollar. She said she wondered afterward why she had thought there was so much to do beforehand. She also said there was no overlap between what she worried about beforehand and what actually ended up being difficult (i.e., what she should have been worrying about). Encouragingly, she said everyone’s mala was different, so there is no need to fret about making the right kind.

Early in June, I went to the annual palliative care retreat in Marin, a fantastic day of seeing colleagues, meeting new people, eating, making art, singing.

By drawing myself a picture as I walked around my floor of the hospital at my paying job, I finally solved the mystery of why I have to turn 11 corners to go all the way around something that is basically a square.

Several weeks ago there was a half-time job for a palliative care chaplain at the Truly Wonderful Medical Center, where I did my Clinical Pastoral Education. That obviously was my job. I applied for it, and over the next couple of weeks, mulled over the pros and cons of taking that job versus staying where I am. Then I realized I had not been invited for an interview! This was a lesson in acceptance and humility. (I heard soon after that that a CPE peer of mine whose demographics are very different from mine had been invited for an interview. I’m pleased to say that, after about ten seconds, I was able to sincerely wish that he will get the job and that it will be a big success all around.) It was also simplifying: I guess I don’t have to try to decide whether to leave the Very Fantastic Medical Center or not.

And whether or not I have the title of “palliative care chaplain,” I am one. When I walked into the room of one patient, he said, “I was going to call for you! I would like to discuss what happens next, like my burial and so forth, and also what the spiritual meaning of this is.”

I said, “Would you like to discuss those things right now, with your family present, or another time?”

He said, “Right now. Please sit down.”

Once upon a time, I might have been flustered by that. I might not have known what to say or how to approach such a conversation. I might even—worst of all—have tried to install hope in the patient: “Maybe you’re not going to die!”

Another reason that conversation was great, from my point of view, was that the patient’s sister, who is very devout, mentioned a part of the Bible I actually recognized. “Matthew, chapter six,” I said, and we nodded and smiled at each other. That was extremely satisfying. That’s literally the only chapter of the Bible I would be able to recognize. It’s the one that, in the King James version, ends with my favorite line in the entire Bible: “Sufficient unto the day is the evil thereof.” I must have heard that in church when I was a small child and never forgotten it, because I have always known it. It means not to worry about yesterday or tomorrow. The Lord’s Prayer can also be found in that chapter, and the thing about the lilies of the field.