ACA

I bunched these works under the name “ACA.”

As in Obamacare?

Yes. The Affordable Care Act. But more than half of these works are set before that act became law.

Let me guess: Not much has changed.

Correct. There are 50 years between Frederick Wiseman’s “Hospital” and the docuseries “Lenox Hill.” The hospital as an institution has not evolved in half a century. What I like about “Lenox Hill” is that they discuss the business of running a hospital. Talent attracts surgeons who will do procedures that will generate income for the hospital system. Caring in a capitalist society is a business, whether you’re a safety net hospital such as Metropolitan Hospital or a fancy community hospital such as Lenox Hill. So Richard Widmark’s Chief of Surgery character in “Coma” can feel justified in his shady scheme.

(d. Frederick Wiseman, 1970)

(2020)

Do you think Paddy Chayefsky saw Frederick Wiseman’s “Hospital” and then wrote “The Hospital”?

They’re set in the same hospital. Most likely yes. As much as I love Chayefsky (a fellow DeWitt Clinton High School graduate), “The Hospital” has not aged well.

Because of the hospital murders?

A message with a blunt scalpel: Hospitals kill because they don’t care. I enjoyed that. Also got a kick out of seeing Frances Sternhagen asking for insurance information from a patient in the emergency room. And Stockard Channing as an ER nurse. The main reason it hasn’t aged well is Diana Rigg’s character, Barbara. She’s an ex-nurse, a counterculture foil to George C. Scott’s Chief of Staff MD. She works out her daddy issues / institutional issues with him overnight.

(d. Arthur Hiller, 1971)

Not a good portrayal of nursing in the media.

Nor is Elizabeth Ashley’s nurse in “Coma.”

Well, she’s scary in person.

The nurses in “The Student Nurses” are more exemplary.

Isn’t that a soft core flick?

Yes. But they were drawn better than Chayefsky’s nurses. My nursing professor would’ve probably failed me if I admitted to liking “The Student Nurses.”

(d. Stephanie Rothman, 1970)

Tell me a moment when you were a student nurse. Did you fantasize about marrying a doctor?

No. “Grey’s Anatomy” had just premiered and our nursing professors demystified a lot of their storylines in class. As soon as we did clinicals, that demystified a lot of Hollywood Hospital. Believe it or not “The Student Nurses” really did remind me of being a student nurse. 

Where were their preceptors?

I know, they had no preceptors! They were student-nursing on their own! Independent learning. They were assigned to different clinical areas, the way we as student nurses were. But it shows you that nursing’s purview is wide. I think the movie is so insightful about that. The student assigned to community nursing  became part of a social justice endeavor. Nursing can go beyond the hospital.

That nurse falls for a radical in a poor community.

It’s a skin flick with a lot on its mind. Maybe because it was a skin flick that its director Stephanie Rothman managed to get away with a lot. Like talking about abortion honestly.

Could you imagine paying to go see this movie to get titillated and then bump into an abortion subplot?

You got a lot of sex before getting to that plot point. It showed you what an elective abortion was during that time.

If you knew a doctor who could come to your house ...

True. Abortion runs through this group of works. “Coma” has a therapeutic abortion in its plot. When the patient ends up in a coma, how you feel about her depends on whether you’re pro-choice or pro-life.

(d. Michael Crichton, 1978)

If one were pro-life, one would think she deserved to be hung in wires, like the comatose patients in the movie?

I must say that was a lot of OR manpower for a therapeutic abortion. 

It’s not that intense anymore. “Never, Rarely, Sometimes, Always” walks you through the 3-day process. 2 days if you had an early appointment.

(d. Eliza Hittman, 2020)

I thought that would be a nail-biter like “4 Months, 3 weeks and 2 days,” but it’s not. And then I realized we are not 80s Romania yet. Abortion is still legal in this country, but access has become difficult. There’s no shady doctor in “Never, Rarely, Sometimes, Always.” The obstacles are also not easy. 

The movie talks about the abortion procedure in a factual and non-judgmental way.

The most painful part of that movie was the questionnaire. Not the procedure.

A good questionnaire can mine the truth.

That scene is pure acting. Reminds me of some Acting I exercise when we were given the most ordinary words and act it as a scene.

If there’s a main theme that courses through these works it’s that of access. That’s what Obamacare was supposed to do, right?

Access to abortion in “The Student Nurses,” “Coma,” and “Never, Rarely, Sometimes, Always.”

Also access to care.

Metropolitan Hospital is still around, thank God. There are two moments in Wiseman’s “Hospital” that stand out. The doctor calls New York Hospital (now New York Presbyterian - Cornell) and complains about sending a patient from there to Metropolitan’s ER. The implication is that the patient was probably not a desirable patient financially for them. The other moment is when a psychiatrist phones for help to prevent a gay hustler from ending up in an institution.

Access to the top, in the case of “The Beauty in Breaking: A Memoir.”

The author of that book, Michel Harper, writes about being passed for a promotion because she’s black and a woman. Her experiences as an emergency medicine MD are similar to the scenes in the emergency room in “Lenox Hill.”

(2020)

Tell me a moment when you were breaking.

Breaking as in crying? Like that neurologist in “Lenox Hill”? A night when my patient died surrounded by his family and I cried with them. I cried some more in the staff bathroom. Then I received my new admission later that night. He was a patient I had taken care of before and lost his vision because of his worsening disease. He didn’t see me cry because he was blind. But I went to the bathroom again and cried some more.

What was the beauty in that?

Michele Harper likens it to kintsugi after you piece yourself back together. You don't have access inside me - You can’t see it, but I’m mended with gold, silver, and platinum inside.

Pall Care

Palliative care may have been a new terrain for me as a student nurse, but it was a place I felt comfortable navigating. Hence, I gravitated towards oncology. My interest in works about death and dying is a busman's holiday. It's a peek at the other side, the patient's side.

In the three works below, terminal illness is characterized as new terrain. With the diagnosis appears new shades that contour the characters' physical worlds. Light is perceived anew, so is breath, and so are priorities. In terms of diagnoses: Nina Riggs writes about her breast cancer journey, Molly Shannon's Joanne has leiomyosarcoma, and the patients in "Extremis" represent the typical medical ICU population.

I appreciate "The Bright Hour" and "Other People" most for their honest humor. They appealed to my morbid sense of humor. Part of what draws me to these works is that it is a terrain (barring a swift death) that I will likely enter. Protracted illness is a product of modern medicine. The works provide an aerial view of the terrain, not street directions. In all three, what one can clearly see is that autonomy in how one chooses to die is a value to be upheld. 

The Bright Hour (2017)

by Nina Riggs

Memoir: terminal

Diagnosis seen as new

Terrain and new light.

Other People

(2016, dir. Chris Kelly)

Year with dying mom.

Home turns to new terrain for

Caregivers, patient.

Extremis

(2016, dir. Dan Krauss)

Too brief exam on

Palliative challenges in

Modern medicine

The Year that Was

Pausing to reflect on the year that was before looking ahead.

Some of the highlights of the past year:

Homemade bhelpuri: The first winter in 5 years not spent in India. The polar vortex visited and after the 15th snowfall, I regretted not going there. This consoled me. 2015 will remedy this homesick feeling. 

Fire Island Pines: This is why our book club is better than yours. Can't ask for a better way to spend an afternoon with a group of friends and more often catch up on our lives, and then talk about the book. My favorite book club pick this year: Tim O'Brien's "The Things They Carried." The first chapter can stand alone as a masterful short story. The woman in the wine store talked to me about it when I was picking up my contribution to bring to the gathering. 

Closure: My fellow nurses / co-workers ate our feelings. It was the first time I attended a patient's memorial service. It seemed fitting to be one of the first persons to provide him care and see him at the end. I reflected on how much his death affected me. To see his family and friends recognize me after months of not being in the oncology unit anymore felt so gratifying. If I have doubts about how much difference I make in the patients I see, I just think of this day.

Difficult to top this one. All productions I see at the Metropolitan Opera House will be measured against this. 

Waded my feet for the first time at the Jersey Shore. A brief summer jaunt, serenaded by Johnny Mathis. 

My combat gear. This is how I start my day before I leave my desk. 2014 saw me complete my first year as a full fledged nurse practitioner. Lots of ups and downs. Different kinds of stress than before. These are my essentials. When I have them all on me, I'm ready to go.

Just when I thought my day was going bad, a former patient's family member sees me and gifts me a bottle of champagne on the spot as a thank you for his father's care. I live for surprises like these. Hoping for more of these in 2015.

The penultimate ride from Disneyland before heading home to New York. (The last one was from Big Thunder Mountain, of course.) May all my days be full of adventure and joy like this. 

KS, Baby

Walked into a scene right of "Angels in America" last night.
This play is so embedded in me that it will never leave me.
30 years in the AIDS epidemic, I saw my first Kaposi's sarcoma last night, uncommon in the age of antiretrovirals - and the scene below flickered in my mind.



In eliciting the "history of present illness," I saw that the patient and his partner were more like Prior and Louis. I was spared the crying, but not the drama of it all.

Dropsy

Finally getting around to "Downton Abbey", a Masterpiece Classic update of "Upstairs / Downstairs" on PBS last year.
Loving it more now that they introduced a nurse as one of the main characters - an undesirable addition to the titled family because of her profession. She saves a man's life by advocating for pericardiocentesis and a dose of adrenaline on a patient with dropsy.

Dropsy?!

"Dropsy to the heart or the liver?" she asks.

What in Flo's sake is dropsy?
A colloquial British term I've never heard of?
Google to the rescue; dropsy means edema.
So, what other archaic terms for medical conditions that have gone the way of smallpox.
Le grippe, consumption, ague, coryza, Saint Vitus's dance, suppuration ...
Not to mention the more recent ones. We don't call it left-sided or right-sided heart failure anymore. It's now either systolic or diastolic dysfunction.

Since gerontology will be my specialty, someone old enough is bound to use them. I can only imagine:

"What can I do for you today, Mr. Smith?"
"My podagra's acting up again."

Grumpy

When it comes to patient interactions, I usually follow the David Mamet school of acting (and playwriting):
Only NOW matters.
History is in the periphery, if at all.
Took care of a patient I've labelled as grumpy.
In previous admissions, even when he was ambulatory, he was grumpy.
When he was admitted acutely ill, he was grumpier.
Yet, his children has showered him with patriarchal affection.
I have no doubt they really love him.
He's loved by all, except me.
I don't see what is lovable in him.
I know that my compassion reserve has been running low for awhile now.
But I don't believe my feeling that way towards him was from that.
What I needed was to see who he was -
An "aha" from a qualitative research presentation that said having a picture of the patient before his or her illness has helped nurses in caring for the whole person rather than treating the person in the bed as a bundle of symptoms.
Maybe if I knew about him better,
I would've felt about him differently.

Gut Feelings

We nurses use a lot of our gut feelings -
it's not scientific, but if the Spidey sense tingles, we tend to be more vigilant.
I don't know if I lost that sense the other night.
Called in to consult on a patient that another nurse was taking care of.
She said she doesn't look right and that we should call a Rapid Response or RRT.
I said not yet. I guess I needed to wait and see some thing before we activate the RRT.
More from the other nurse's insistence than my own gut feeling that we activated it anyway. (She had probably more nursing experience than I did).
Everyone else seemed to see something and I did not.
I didn't have that gut feeling this time,
but all around me, the other responders said the patient's vital signs were normal, but there's something quite not right.
Did I second guess myself?
Am I not in tune with my gut feelings anymore?
I felt like Chip in "Beauty and the Beast" when all around him sang, "There's something there that wasn't there before."

Research Day

You can never escape your teachers.
Spent all day on nursing research -
a symposium at work, then class.
Don't know about other professions,
but no matter where you practice nursing,
you are bound to see your teachers.
Nurses in academia conduct their research in order to be utilized in practice. You meet them when they disseminate their findings.
Sitting in front of my teacher from 3 years ago,
being informed about a research she had done (in which I was a survey participant) was surreal.
I thought to myself I hope she wouldn't embarass me in my place of work and I hope I made her proud.

I'm afraid I'm leaning towards being a qualitative researcher.
In class, my research professor, who's big on quantitative,
heard her previous class jeer last week's lecturer who used aesthetic inquiry.
She told her class: "You need more humanities!"
If nursing is a science and art, the art part is lacking and that'll be my part.

Live! Nude! Models!

3 years of bedside nursing and I finally got to see a normal vagina:
on a live human model for a GYN exam in Advanced Health Assessment class.

Still not sexy to me.

The Business of Caring

St. Vincent’s Is the Lehman Brothers of Hospitals
Its demise was only the beginning. An alarming number of New York’s major medical institutions are teetering on the financial edge.
By Mark Levine from "New York" Magazine

An astute blow-by-blow description of St. Vincent’s demise. I don’t think of HHC hospitals as safety nets, because all hospitals are safety nets. Once you walk into an E.R., whether you can pay or not, you will receive care.

“They often come into the hospital through emergency rooms, which are required by law to treat anyone regardless of ability to pay and where the cost of care is much higher than it is in other settings. New York hospital patients tend to stay in the hospital longer than others; the city’s average of 6.6 days per hospital stay is more than a day longer than the national average (older people can’t be sent home to walk-ups until they’re capable, non-English speakers require translators to provide discharge instructions, and so on.”

Spurred on by Joint Commission, there’s a new focus on length of stay. An anecdotal example: Families who reside in the U.S. bring their family member from their native countries to the hospital straight from the airport because he or she is sick. The patient stays in the hospital for the work-up and cannot be discharged because diagnostic tests cannot be done outpatient due to lack of insurance. What happens to length of stay?

There’s a comment about salaries in the article, but no one seems to say outright that the taxes from the salaries pay for the uninsured. To put it differently, I’m paying for you to be cared by me – I’m paying myself to work. And I get your attitude on top of that? Sorry, but I did not get myself to a nunnery.

New York City expects all of its hospitals to be charity wards and not in the business of flipping beds. I’m all for benevolence and indiscriminate caring. However, the business of caring as we know now does not make room for charity. As the article puts it, “In New York hospitals, it helps to be smart, but it helps, above all, not to cater to the poor.”

PE, cont'd

Wouldn't you know it? My teacher brought up the Stanford 25 (previous post) in class because Dr. Verghese was profiled in in the NY Times. I was ahead of the curve.

Physician Revives a Dying Art: The Physical
By DENISE GRADY
Published: October 11, 2010
At Stanford, Dr. Abraham Verghese is on a mission to bring back something he considers a lost art: the physical exam.

I volunteered that I had read this two weeks ago and brought up the limitations chimed in by other MDs in BMJ. She seemed put off by that. I agreed with her though that RNs beat PA's and MD's when it comes to "touch"-ing a patient. Because we're a touchy profession.

PE

On "The Fading Art of the Physical Exam," by Richard Knox from NPR.org

I'm not for going back to the days of Dr. Quinn, Medicine Woman or even Dr. Kildare.

Since I will be a “mini-doc,” as my Advanced Health Assessment prof put it, the Stanford 25 seems like a standard to look up to as a program objective. (There are limitations/criticisms.) Nurses are trained to do a physical exam (PE). Yes, we learned these PE skills in nursing school, but do not keep it up. Depends on where we practice. In a hospital setting, MDs and diagnotic machines are within easy reach, so nurses' PE skills rust. Upon review, not many of my nursing preceptors emphasized PE skills in practice when I was a student. Many of my colleagues do not carry a stethoscope around, so I can bet they don’t listen to breath sounds or bowel sounds and are only forced to use it when they have to take a BP manually.

Future

"More nursing jobs will be created in the next decade than in any other single profession. The Bureau of Labor Statistics projects that nearly 600,000 new jobs for registered nurses will be created by 2018."

Nursing Offers A Healthy Employment Future
by Tamara Keith, NPR.org

I am for recruiting nurses.
But this is not the way to do it:
"The fact that the wages are pretty high also sort of separates it from many occupations that would be growing";
And "You can work any hours you want ... particularly if you're a bedside nurse."
"Nurse Jackie," "Mercy," and "HawthoRNe" do not tell you everything.

Will there be an inflationary effect?
Because there is a need, the bar lowers in order to meet that need.
(Diploma programs, associate degrees hinder the profession than advance it.)
I don't consider myself as one who eats their young,
But I may have to eat the old.
"Nursing is a young person's game," a professor said.
Entry-level at 40 and above? For 12 hours on your feet? Think again.
By no means am I agist,
But going there for the wrong reasons will send you back sooner to square one.
That is burnout - a source of the shortage not mentioned in the article.

Cranial Nerves

Those pesky cranial nerves again. To remember them ...

In Class, per our instructor: "On Old Olympus' Towering Top A Finn And German Viewed Some Hops."

How I remembered them in Anatomy and Physiology and has served me well since: "On Occasion Our Trusty Truck Acts Funny A Good Vehicle AnyHow."

How I will remember them from now on: "Oh Oh Oh Tubby Teens And Fat Virgins Give Very Shitty Head."

Mandate

Get pricked or get fired. Unless you have a demonstrable allergy to eggs.

New York state issued a mandate for all health care workers to be immunized with this year's flu vaccine and the H1N1 vaccine when it's available.

When you tell people they HAVE to do something, it stirs people to the verge of mutiny.

"While we encourage nurses to be immunized for the flu, we do not agree that nurses should be required to be immunized every year as a condition of employment.The seasonal flu vaccine is not 100% effective and sometimes is highly ineffective, as it was in 2005 and 2007. There is no guarantee that in any given year, the public will benefit from mandatory immunization of healthcare providers." -New York State Nurses Association

Give me this year's flu shot, but don't give me the H1N1 shot.
The swine flu vaccine is a rushed product. It's considered safe based on studies from a small limited sample. My tin foil hat senses government-corporate conspiracy when the new vaccine falls under the PREP Act. That means the vaccine manufacturer(s) has immunity from lawsuits related to the vaccine. So, those who will develop Guillain-Barre, Steven-Johnsons, or anaphylaxis are simply trading one illness for another.

Uncertainty fans fear and I'm throwing in some kindling here. But for a health care model that values patient autonomy, none can be found in this situation. Of course, the state and our employers don't see us as patients, even though we are the receiving end of that needle. They see us as workers and vaccination is like insurance for them. Human subjects in research are lucky. They have informed consent. I don't and I feel like a guinea pig in this process.

Bedside Chat

03:00. When therapeutic communication is best.

"Baby, I just want my youth back."

"So do I, Ms. ___. But that goal is not possible. However, we can try to manage your pain while you're here in the hospital."

"Baby, I'm sick. Physically. Emotionally. Sexually."

Therapeutic silence. The kind when I'm trying not to laugh.

Brain Mets

Brain metastasis can sometimes be hospital-funny-sad.

Patient: I can't stand up! Wh-why is that? Wh-What's happening?

Patient's Friend: Babe, you're sick. You have cancer.

P: I have cancer? Oh. I forgot. I have cancer.

Sweet

How to kill your nurse with kindness: M&M encrusted pretzels presented by a patient.
Of course, I ate it. And rued the sugar crash that ensued.

Marks

The Internet: a giant tree for people to carve their names and leave their mark in this world. Recently, a patient's spouse suggested I look up a You Tube video of her deceased husband. “You should see him before he got sick. You can see him dance a traditional Greek dance.” This was especially more poignant when I viewed the video, because throughout his length of stay he could hardly move his legs.

Whenever I google a patient's name, a sense of irrational guilt creeps up before I click “search.” It's this HIPAA business drummed into me. I feel less of a voyeur when a patient or patient's family suggests I look up his/her name on the Internet.

The first time I looked up a patient's name was to find out whether she was who she said she was. If she was published, then I would definitely find a book that she authored. It turned out she was a professor and her ratings on Rate My Professor would make me think twice about registering for her class. From fact-checking, I went on to reading patient obituaries. What I wanted was the knowledge that the patients I cared for were more than persons with diagnoses. I didn't want to define them by their illness. There's some comfort to see that friends and family miss them from looking at the online comments on the obituaries. But I wanted to color their lives for my sake. Maybe because I never asked them in the first place. So I look for the marks on the tree, that they were here, that they lived.

Nurses Week

Happy Nurses Week!

I know I'm not the only one who looks forward to this week. We groan because we have to do another poster board. But in exchange for that, the hospital gives us some swag. This year was the cheapest gift of them all. It was a black eco-friendly re-usable grocery bag. At least they fed us cookies, ice cream, and breakfast.

None of this makes the job any easier though, only slightly appreciated for a week.
Let me vent: I picked a medical oncology unit to work in because I wanted to avoid psych, maternity, and pediatrics. But recently, I feel like I've been working in all those departments at the same time. I've seen more younger patients. (Naturally, as I grow older, there will be more patients younger than me.) I've encountered more bipolar patients, not to mention patients whose mental status are affected by their disease. There's not enough compensation from Nurses Week when someone curses you out, spits at you, and chews out their restraints. It's not a psychiatric floor, so we can't call the kind of code where security officers show up and someone gives Haldol, Ativan, and Benadryl to the patient. We've had new mothers as patients, too. Post-partum depression and cancer combined? I described the unit to my supervisor as "brutal." She said, "We prefer to call it challenging."

Background: National Nurses Week is celebrated annually from May 6, also known as National Nurses Day, through May 12, the birthday of Florence Nightingale, the founder of modern nursing.