It's going down tonight.

Me: Can I borrow that chart?
Dr.: Um, excuse me, but I am doing very important... uh... doctor things.
Me: Uh huh.
Dr.: Where is this guy?
Me: How would I know? I'm just a lowly and unimportant nurse.
Dr.: Ah ha! Did you know writing yourself is a sign of psych issues?(He was looking at my left arm which, as usual, was covered in scribbled vitals signs.) At least you haven't covered your face!

The Dr.was referencing a walk in patient who stopped by today covered HEAD to TOE in words in black marker. With answers to questions. Including the words, "deaf," and "mute." And other choice words like "stupid." But after a few minutes of doctors mouthing things at him and him pointing at various body parts... he finally yelled, "Don't you get it? I'm here to get a walker!"

****************************************************************************

Today was kind of hectic. It wasn't the kind of day you question your career over, certainly. But it was the kind of day that made me nervous all eight hours that I was forgetting something or that a med error was just about to get made. Or that someone was going to stroke out as soon as I turned my back. So at the end of my shift my boss told me I could have tomorrow off. "Are you sure?" I asked? "Yep," she answered, "we're covered and have extra. Happy New Year!"

****************************************************************************

Resolutions? Not this year. Blame Billy Joel. He loves me just the way I am.

I would like to make more time.

It's never a good thing when the admissions nurse brings your patient to the floor and then just starts laughing as she hands over the paperwork. And then laughs all through report. And ends report with, "good luck!" And then laughs more.

But I suppose it's better than some other things. Like ... if she was crying. Or... bleeding.

*********************************************************************

Instead of rehearsing without the practical half* of Three Hole Punch, Steph and I went to Andala and had a heart to heart. It was a long time coming and a perfect way to spend a cup of chai. Meanwhile, we overheard a group of middle aged war protesters griping about "people," and how "they just don't understand." It made me glad I didn't stick with my original major: Social Thought and Political Economy. I am all for making change happen, but hearing their circular conversation brought me back to way too many class discussions in the basement of the Butterfield Dorm. It's why I left in the first place.

**********************************************************************

As the new year draws closer I feel obligated to talk about The Past and The Future.
Without the self indulgent details that no one cares about besides my mother ( "This year I have a bigger room but I pay less rent!") I would at least like to announce that overall** 2008 Misch wins over 2007 Misch. By a long shot. It makes sense. This was a huge transition year for me so my learning curve was steeper than usual. Nick sat across from me at the Clear Conscience Cafe a few weeks ago and smiled. He said, "you're just getting exponentially better." For now, by the grace of God, he's right.


* This makes Steph and myself the flaky half if you couldn't guess that.
** We looked at five categories including job, romance, spiritual development, living situation and improv/comedy. Scores were rated 1-5.

scapel, clamp, sponge, farts

I love my stethoscope. It's a simple classic Littmann, and was a gift from my college roommate Jen for getting into the School of Nursing. I love the new RN computerized charting system. Oh! And I am a huge fan of the mini portable 02 sat reader because it's so handy to bring into patient rooms. But my favorite thing at work right now is The Fart Machine.

One of the nurse practitioners set up in the work room one day last week. She kept hitting the remote and amazingly realistic noises began to fill the air. She let me borrow the fart machine to use all day on the floor. The results were amazing. I made grumpy co workers smile. I made friends with a respite aide who I work with often but rarely speak to, and I got laughs from housekeeping staff who don't speak the same language as I do. Just as in Tokyo, some humor doesn't need language. Like fart humor.

Clinically speaking the results were even more significant. I used the machine wisely. For example, I didn't use it when I was with my patient with extreme paranoid schizophrenia because I know it would have agitated her quite badly. But I made the most out of every appropriate opportunity.

For example, I worked with a new admission who hated needles but needed a flu shot because she's so high risk. As I prepped the injection she was very jumpy, unable to sit still. I took my time as I got everything ready and hit the button in my pocket as I approached her. She made eye contact with the NP in the room, who shrugged at her. I hit the button again and her jaw dropped but she recovered quickly. As I swabbed her arm with the alochol pad I hit it a third time, and she couldn't be polite any longer and asked, "Are you farting?" I responded by saying, "sorry, rough breakfast," and letting out five more honks, which sent her over the edge. I showed her the button she was so amused and distracted that when I said, "here we go," she held out her arm and I stuck her with no problems at all.

I made a ton of patients laugh the first day with the machine, but my favorite was this woman who has a terminal diagnosis and is here for some real respite care. She is in almost constant pain despite her long list of pain medications, and rarely leaves her bed. I bent over in her room to pick up a cup and hit the button. She jumped. I excused myself, and she told me it was alright. It happened again and I grabbed onto the bed and she asked if I was ok. But then I just kept pushing the button, contorting my face each time until she was screaming with laughter. Tears rolled down her face, and she got out of bed and followed me down the hallway telling people, "listen, my nurse has broccoli for breakfast! Listen!" She told me I made her day.

And that is why The Fart Machine is my favorite new clinical tool.

Isn't there anyone who knows what Christmas is all about? Sure, Charlie Brown...

This Christmas post from one of my favorite blogs, A Day in the Life of an Ambulance Driver, was one of the best things I read all week. It says everything I would want to say about this time of year, and the work that people in public service positions do.

In addition, it references the verses from the Gospel according to Luke that are used in the final third of A Charlie Brown Christmas when Linus delivers his spotlight speech. Predictably, one of the most powerful scenes I remember from my childhood and to this day one of my favorites to re-watch.

*****************************************************************

Christmas at the Whitakers'

Christmas was full of traditions at my house growing up. The rest of the year was relatively free of ritual, so we piled everything into two days it seems. On Christmas Eve we always went to mass at St. Theresa's church in West Roxbury where I sang in the choir. Dad would come just to hear me sing, he said. It was one of the two or three times a year he'd go to church. We'd all go to Mario's Italian Restaurant for dinner afterwards. At home we would each open one present. And no matter how old we got we'd read 'Twas the Night Before Christmas. Over the years it became ironic and goofy but we'd do it anyway. Dad would build a fire and then we would all fall asleep on the high wrap around couch in our living room watching A Christmas Story or It's a Wonderful Life. My little brother would sleep on the trundle bed in my room and we'd stay awake late and get up at the crack of dawn.

But things change, and so with that in mind I bring you a scene from last night at Mom's new condo:

I looked up from the window ledge I was carefully icing and watched as Brian began decorating the top of the roof with red and blue gumballs. "Feeling patriotic?" I asked. "I like the way it looks," he said and we both burst into the first seven words of "Proud to be an American," which is all we knew. Mom painstakingly hand crafted icicles from the ledges. "That shit is bad ass," Brian proclaimed, and Mom sat back to admire her work.

As Brian began to plot the correct angle for some chocolate solar panels on the roof he started to curse, "Shit! It's going down!" The three of us watched as a sink hole appeared in the center of the house and swallowed all the gumballs. "F*ck," said my baby brother lighting another cigarette, "we should have waited for the frosting to set."

We fixed the roof but then a wall fell over. We uprighted the wall and Brian went to work on the Eastern windows, but he had been drinking a bit and the next thing I heard was this:

"What the hell is that?" (mom)
"What? There's snow on them." (Brian)
and a pause.
"It was a blizzard, ok, Mom?"

Just as I had completed the fortune cookie rock salt on the chocolate walk way there was a loud sucking noise and all the electricity went out. It flashed back on and then crashed out a second time. In the entire complex, and the one down hill from what we could tell through the windows. We pulled out flashlights and lit candles and tried to work in the dark. "Now we have an excuse for the way it looks," said Mom.

The roof kept sloping off, and so Brian and I decided we had to hold the pieces in place for fifteen minutes to let it stick. He kept letting go and shifting the table causing me to yell, "every time you let go, the terrorists win." Mom held Brian's beer up to his lips for him to drink and when I noticed Brian laughed so hard that Mom spilled the beer down his chin. "My family," I intoned, making everyone laugh harder as my side of the house shifted angles again.

The power returned and was met with mixed reviews, "Well at least we'll have a stove in the morning. But still no excuse for this house."

We stared at the house. One side of the roof was frosted, the other was bare. The frosting had huge thumb prints in it from Brian hanging onto the sides. Mom's icicles dripped to the ground like elf snot. One half of the holly branch I had crafted fell to the ground. Brian's windows still looked like someone had wiped their mouth on the side of the pastry. The roof split again, revealing the hole and shedding light on the American gumballs stranded inside.

"Well," I said, I should get ready for midnight mass.What time is it?"
"Good luck," said Brian taking a swig of a second beer, "It's flashing 9 o clock over there, and the microwave says it's zero time."

"What this house needs," I said, "is some support."
"It's not too late to throw the whole thing away and pretend we never tried," answered Mom.

Brian and I rigged some chocolate bar support beams for the roof and let it set overnight. He retired to the basement to play video games online and Mom went to bed. I fixed my frosting covered hair in the bathroom mirror and slipped out the door to go to church on my own, my first time in this new town that Mom lives in.

As I knelt in the crowded chapel surrounded by families and children, I kept picturing my brother holding onto the house, my Mom lighting his cigarette for him, her own held tight in her lips as the gum drops dropped off the windows one by one onto the kitchen floor and I thought maybe we had found a new tradition.

When I mentioned this to them later my mother's response? "Hell no."

Three Things

1. Boston Healthcare for the Homeless was featured yesterday on The Daily Grommet. The video interview with Cheryl Kane, RN will be featured for four more hours as their front page but is still available to view in the archives after that.

2. Three Hole Punch would like to issue a very warm welcome to our new director, Scott Braidman. Scott has been working with the ladies of 3HP for years now in various capacities, beginning with a five year presence in Mission:IMPROVable at UMass Amherst as a performer and producer. He graduated UMass with a degree in theater, and now performs regularly at Improv Boston in the Family Show. He has performed with Improv Asylum's NXT cast, recently directed What Does America Mean to Me by Boston's own Marc Hirsch at Improv Boston in 2008, and is currently featured in Improv Boston's 8th Annual Holiday Show.
Scott is joining us just in time for 3HP's upcoming debut of our first full length show: Flirty Laundry, which will run Wednesday nights during the Hump Night at Improv Boston. And we're all very excited about it.

3. I lied. There were only two things.

Too long to stay in a dress.

[This entry is edited from a more descriptive version on lj.]

Quinn met me at the bookstore on MassAve and we had a nice dinner at Tavern in the Square while we watched the Ravens game. Quinn and I exchanged "where we were when Obama was elected," stories because it's been that long. I indulged in allowing him to pick out my wine because it reminded me of old times.

After that we caught The Holiday Show at IB featuring a ton of really talented friends of mine. Liz was sure that I would be offended by some of the sketches but I found most of them quite funny and recommend the show to everyone who hasn't seen it yet at least once. The cookie dough scene made me gasp for air, and the medley was indescribable , but the turkey song was my favorite part, mostly because any time Scott Braidman acts like any kind of animal I lose it.*

After the show it was off to the Tavern once again, this time to celebrate Kevin's birthday.

In the morning I woke up at Shan and Ted's and saw that the weather was worse than ever. Against every ounce of better judgment we didn't call off rehearsal and instead we called a cab which barely made it up the hill to get to us. The ride to Central was precarious and I picked cat hair off my dress and leg warmers in silence as we slid back and forth on the hills of Somerville. I didn't know how upset I was with the situation until my roommate loo_arrgh called me to ask if I wanted anything from Java Jo's and I wanted to cry because YES, YES I did. I wanted an I Hate Egg on a wheat bagel and a small chai latte. And I wanted to be at home with her harmonizing to Christmas carols. But I didn't cry I just thanked her sadly and told her I would be home later.

Shannon and I were grumpy. Not with each other, but in general. Starbucks was closed which made me grumpier than I already was. The wind attacked us from all sides and it was then that Shannon realized she didn't have a key to the new locks at IB and that no one would be there to let us in.

Then Shannon and I stood in the snow, wet and cold and alone on Prospect Street and laughed for five whole minutes. We didn't even stop laughing long enough to make apologetic phone calls to Steph and Liz, we just laughed the whole time we gave them the news.
The only thing that stopped my laughter was the discovery of Sunday Brunch Buffet at Tavern.** I was shocked into a silence as we entered the room. After being outside in the storm it was a breathtaking sensory experience. Inside there was yellow light, dry heat, classic Christmas music, servers in goofy red hats and the smell of every single thing I wanted to eat for the rest of my life.

Shannon and I looked at each other with complete understanding that "rehearsal," was about to become, "drinking mimosas all morning while we eat chicken wings and talk about our personal lives." Steph and Liz shared this unspoken understanding so when the taller half of Three Hole Punch arrived we ate yogurt, fruit and chocolate cake and we over -shared until Liz was crying laughing and Steph was pounding the table. We did a bit of 3HP business, but mostly we congratulated ourselves on the discipline it took to have a rehearsal despite the weather.

We left Shannon off to take a cab home and the sexy half of Three Hole Punch and I went to Downtown Crossing for some Christmas shopping.

We shopped until it got dark . I stopped noticing how wet and cold I was after a while. I took the Orange line to JP and at FHS I passed Laura. For minute, she didn't recognize me, and we both stood across a puddle of slush on Washington Street and eyed each other, me squishing in my pink cowgirl boots never meant to see snow, and she adjusting her hood and looking miserable to be outside. It was the same look I know I had at 10:30 this morning when I was forced from my nest on Shan's couch into the brink.

I found out from DJ Cage that Keith canceled our party and so I am officially free for the night to relax.

Such a wonderful way to start the week.

* Scott doing an alpaca impression drives me to tears.
** which is where I live now. Inside Tavern in the Square.

I was underneath the tree and thinking about the stars.

For Catholics in the Unites States the official Christmas season began three weeks ago, at the start of Advent. Although for many people Christmas ends the next day, in my culture Christmas lasts until January 6th. I knew a wonderful priest by the name of Father Douglas, and he preaches at the Newman Center in Amherst, Ma and he used to stand really firm on this. He would "order," us with a gleeful look on his face to not stop the celebrating and the joy and the dancing and the carols until the 6th.

However, I'd like to take it even further than just five weeks.

In the book Jesus and Buddha As Brothers Thich Nhat Hanh writes about the Buddhist tradition of "Beginning Anew," and compares it to the Christian idea of baptism and being "born again." In a chapter called "Let the Child Be Born Unto Us," taken from an address he gave December 24th 1996 he asks all Christians to recognize that

Jesus Christ is born every moment of our daily life- not only on Christmas day, because every day is Christmas day, every minute is a Christmas minute. The child within us is
waiting each minute to be born and born again.

(A bit more info: The Globe recently ran an interesting article about the intersection of Buddhism and Christianity and reactions to the concepts from everyone to lay people to the Pope. Since I have been studying this intersection since high school when Grandminister of Funk Toro wrote me one of the nicest letters I have ever received, I found this small media piece interesting.)

I live my life mindfully. At least, I try to. It's takes discipline, and it's something that needs to be actively practiced. Because of this practice I hold the belief that Christmas and the idea of Christmas can be every moment of every day. You can interpret that secularly to mean that every day should be filled with the goodwill and inclinations of generosity that permeate "the holidays." I think that's fine and can certainly cause more good than harm. On a more theological level I would also add that every moment can be rebirth of spirit, a confirmation of purpose and a redefining of salvation. And although I experience it as a Christian, I also believe you don't have to be any particular religion to live your life that way.

Merry Christmas Saturday, everyone!

..and I spend every day reconfiguring my senses...

EDIT: This post got a little carried away, but recently I have had people ask me how I am able to do so much and not get worn out, and I think this answers it.

Because of the weather forecast for Boston tonight, which involves six to twelve inches of snow depending on who you ask, I have been asked to come in to work a bit early to ensure enough help during the storm. I don't mind that at all, and I have a planned shift tonight of about 2pm to 11:30pm although I know logically that it's the third shift who will have the absolute hardest time getting there and so I may end up working into the night. But here's why I'm okay with that:

Last year, during my first terrible snow storm as a BHCHP employee I stayed on when my relief was late. I didn't mind because I didn't think I could safely get home anyway at that point. My car was completely snowed into the back of our parking lot (we were still located in Jamaica Plain back then) and I would have had to walk about half an hour to my apartment in snow drifts as high as my hips. The woman relieving me had been at work at her other job, at one of the hospitals downtown, where she had just put in an eight hour shift on a med surg flor. She still managed to get to us even with the T halfway shut down. She came in the door rosy faced and covered in snow and ready to keep working. It was pure inspiration, and it gave me the energy to stay for the whole next shift in place of another call-out.

It was one of the first of many moments I would realize how much of a team we are and how blessed I am to work in a place where people really feel committed to each other, to the patients, and to the work we're all there to do. I don't think you can beat that kind of atmosphere in a working environment.

However, I took that energy burst I had from working that shift and I put in way too many extra hours in the next two weeks. I thought I was superwoman. And I ended up crashing hard.

It's easy to get burned out in many public service roles. It happens all the time. It happened to me in 2004 while I was working in Agawam as a CNA. I'm not talking about being tired and overwhelmed and needing vacation. (Which is exactly when you should take a vacation!!!) This was a permanent burn out which required a change of jobs. It's a terrible feeling and it's hard to rise above, even when it's not as permanent as the situation I found myself in.

Since then, I have found that the only way to stay on top of the joy and rewards of work like this is what I like to call a constant reconfiguration of one's senses. Broken down, it means to know yourself really well. It's important to know your own limits and to be honest about them. They may not be the same as someone else's limits. It doesn't do a nurse any good to try to be someone he or she is not. It's necessary to understand your boundaries. And to take time every day to really center and listen to your own needs. And to allow yourself to be gentle with yourself.

Being self-gentle is not related in any way to hedonism, which I despise; it's not my intention to promote that anyone only seek what is pleasurable and easy. I tend to weigh in more on the belief that self sacrifice is necessary for the greater good. I believe that only by sacrificing parts of yourself can you know yourself. But you need to know yourself before you start to sacrifice yourself. I have been in several relationships that have failed due to sacrifices being made all wily nilly without any knowledge of what was at stake.

The beautiful thing about a constant reconfiguration is that you always have room to change and grow. We know we have to push all our limits, because only then can we grow. But you need to take an inventory as you do it. You need to do it with utmost self awareness. It's the difference between changing your mind and being considered inconsistent. Anyone who reads Overcoming Bias knows you can change your thinking patterns, but you have to be familiar with them first and foremost.

Through honesty I own my life more than ever before, even though I still give so much of my life away. People laugh when I say "I do what I want," because I am often talking about leaving the house wearing two different socks. But it 's an easy attitude to maintain throughout every area of my life when I'm honest with myself. Even when I realize I've stretched myself a little too hard, it's alright as long as I admit that and reclaim myself afterwards. I am not overwhelmed by the idea of staying at work tonight because I have mentally prepared for it and it is what I want to be doing.

And it's a lot easier to stay like this when I am working in an environment full of people doing the same thing, which is what makes BMH so great right now. Everyone here is willing to go an extra mile for each other and for the job because we're passionate about what we do and we take care of ourselves enough to stay that way. It's easy to continue to give when the entire team is doing the same thing, and when we're letting each other take turns.

And on that note, I think I'm ready to head into work.

Diabolical Tales Part II

Thanks to Cosmic Control Productions' own Brandon Kane for posting this movie trailer for Diabolical Tales Part II on face book today. Seventeen year old me is in it, so I thought I'd post it instead of the super depressing entry I had written for today about hospice care.

Yay!

Theater for the Homeless

I received this email today. If anyone would like to join me, I am off work this weekend and would love company.

The Factory Theatre in association with Holland Productions presents...
THE HALFWAY HOUSE CLUB by, Philana Gnatowski

....what happens to the broken hearted? For four mismatched strangers seeking mending, a halfway house promising a 14-step program provides hope. Through the walls that these cupid's rejects create and break in their one room sanctuary, an exploration of individual failures at love and how to reconnect through their flaws emerges. December 18 @ 8pm December 19th @ 8pm December 20th @ 2pm & 8pm

All proceeds to benefit BOSTON HEALTH CARE FOR THE HOMELESS

Tickets available now at: http://www.theatermania.com/boston/shows/the-halfway-house-club_150334/
For more information visit: www.thefactorytheatre.org

Boston Health Care for the Homeless Program has been managing the broken hearts and other physical ailments of Boston's homeless since 1985. They provide medical, mental health, and dental services to 11,000 homeless men, women, and children a year at over 80 different sites around Boston with clinics in the city's homeless shelters and three of its major hospitals. This summer, they moved into their new home Jean Yawkey Place, located a half mile from the Factory Theatre next to Boston Medical Center, and here they run their own halfway house for broken hearts, the Barbara McInnis House. The Barbara McInnis House is an inpatient medical facility with 104 beds that provides short-term medical and recuperative services for homeless people far too ill for life in shelters but not sick enough to warrant a hospital stay. In this way, the Barbara McInnis serves as a literal halfway house, a house for homeless persons halfway between the shelters or streets and the hospital. You can find more information about Boston Health Care for the Homeless Program at their website, www.bhchp.org.

Myths about the Homeless #1

When I tell people that I work with the homeless more often than not the topic of drugs and alcohol follows soon after. I would like to take just a minute to acknowledge that yes, many of the homeless in the Unites States have a substance abuse problem. Sometimes it is the cause of their homelessness, and sometimes it is a response to their homelessness. Sometimes the people I know with homes and jobs seem to have more of a SA problem than my patients. I've have patients whose only illegal drug use is "pot, to help with the bone pain," often admitted by a man or woman dying of cancer with mets. I would hardly classify this as a drug problem. (I see it more as a legislation problem.) Notwithstanding, I know my share of junkies.
However, I also just thought it would be nice to talk a little bit about other ways people can become homeless.

According to the National Coalition for the Homeless:

Homelessness results from a complex set of circumstances that require people to choose between food, shelter, and other basic needs. Only a concerted effort to ensure jobs that pay a living wage, adequate support for those who cannot work, affordable housing, and access to health care will bring an end to homelessness.

Although many men and women who experience homelessness have a substance abuse problem, other reasons for homelessness in the United States include the rate of poverty (Both the poverty rate and the number of poor people have increased in recent years, up from 12.5% or 1.1 million in 2003 (U.S. Bureau of the Census, 2005).), our declining economy and lower rates of employment, a lack of housing and a sharp decline in the availability of assistance on a national and local level.

It's a socio-economic perfect storm. You're born poor, the economy gets worse, and because the economy is worse the value of any public assistance that hasn't already been cut to provide tax breaks or justify more spending on war is so low that it's not going to help you a bit. The poor stay poor or get poorer. The middle class is disappearing. It's not new news.

People become homeless when health care is not affordable or accessible. This occurs particularly when the conditions are chronic and would require extensive and expensive medications and medical interventions such as cancer, HIV and AIDs, renal failure and diabetes. Or as people get older and need more assistance maintaining their deteriorating bodies. Also included in high risk for homelessness are people with medical or trauma induced disabilities (MS, MD, ALS, or victims of a spinal chord injury, stroke survivors etc). These individuals, in addition to high cost of sustainable living have the added disadvantage of being mostly unable to earn an income, and rely almost solely on SSI*.

Elder abuse and neglect causes homelessness. One of my patients was dropped off at a bus terminal by her family, never to be heard from again. Bye, bye grandma! Bye bye medical bills!

Homelessness happens in situations of natural disasters, mental illness, domestic abuse and failed immigration from foreign countries.

So, although a lot of times drugs add to the problems, causing high risk behaviors, or simply just incapacitating people from self care... it's not just about alcoholism or a meth addiction. And there is a large percentage of people to whom it can happen to.




* By the way, trying to survive on SSI these days is like saying you're going to ride a unicycle to work every day this winter. It can probably be done by a small percentage of people. Like people in perfect health with no surprise obstacles. But it's really tricky and you're going to get hurt.

Last night my brother came over

Three Snapshots of my Weekend

Friday.
He's pacing in the basement room of the theater. His suit is spotless and impeccable, and his eyes are wide, and brimming with excitement and joy. He is sweating and antsy. He doesn't stop moving. All around us people are smiling because they know why he's come all the way from L.A. Upstairs there is a young lady marking the turn of another year in her life. She believes he's in Las Vegas but has been secretly hoping he'd find a way to get to her for her special day. He's planned his entrance to the second. I leave him there and run upstairs just in time to see her eyes light up at all the friends gathered in her name. But nothing compares to that moment when he approaches her from behind, and whispers in her ear. The room applauds, but around them time and place slip away and the rest of us get a small view into heaven.

Saturday.
My mother puts down her tea as the second song on the CD begins to play. "I can't NOT dance to this song," she says. And so we spend the next hour of her birthday dancing around the living room laughing like children. We kick off our socks for better traction. We sing, we tell stories. We plan the Christmas menu. But the whole time, we are dancing and dancing.

Sunday.
"I'm really worried about her," the nurse says, " I can't find her anywhere in the building." I take the elevator to the atrium. The scene that greets me makes me forget why I am there for a moment. The sky outside the huge glass panes is completely dark. Headlights sweep the glass as cars go by, but the beams never make it inside. Instead, the glow of low lit lamps give the large community room a homey warm feeling. On all of the couches, patients are gathered. Some are reading, others play chess. One man is hunched over a table using colored pencils to design a card for his little daughter. A woman in the corner picks up scratchy Christmas carols on a tinny radio. On the porch several men huddle together sharing cigarettes and stories of the street.
By the windows there is a Christmas tree. The lights on it burn steady in rainbow colors, and at the top an angel shines brightly. She seems to be guarding the men and women all around her.

I find the missing patient in a rocking chair across the room. She smiles weakly and says, "I know they must be worried, Shell, but I was hurting too much to get up. I'll go with you now."

As we slowly walk to the doors, I turn around for one last look. I notice a detail I hadn't seen. Beneath the tree is a small creche. The perfect wooden figures stand posed in a scene thousands of years old. Mary, Joseph and their baby boy- once cold and homeless, found respite.

EMTs

NOTE: as usual when I write about my work environment all names and situations are changed in order to protect private patient information and to respect the privacy of co workers. Also, I am compelled to inform you that my opinions are my own and do not represent BHCHP as a whole.

Because I do not work at a hospital proper, there are certain policies and procedures in place for when a patient's condition deteriorates to the point of needing more acute care. These cases of course, can be broken down into emergent and non-emergent situations. For example, if Mr. A has a wound that just isn't healing, he may be considered for a hospital admission where he could receive more specialized care. That's non-emergent. Emergent could be a patient with a rapid change in condition such as a seizure, a heart attack or a loss of consciousness secondary to a fall.
Those types of rapid changes warrant a 911 call.

The other day I had a patient, we'll call him Mr. B, whose blood pressure began dropping over night. Mr. B can be said "run low" anyway, but this drop into a range of 85/58 was new. The night nurse reported Mr. B to be nauseous, had a poor appetite, and was hot and clammy to the touch, with a fever of 100.0. None of this is particularly strange during flu season, but Mr. B is a special case because he is a chemo and radiation patient. Fevers and changes in condition must be watched very carefully. The night nurse told me they had been encouraging fluids, but she was very concerned about the patient.

I went to go see him. It was just as the 11-7 nurse had said. He had been vomiting for the past few hours; we kept encouraging him to drink sips of juice and water as often as possible, but it was to no avail because after about an hour on my time his BP had dropped even more significantly. He was severely dehydrated, and needed to be checked out at a hospital. When his provider arrived, we called the hospital, notified Mr. B's oncologist, and sent Mr. B over via non emergent transportation.

This is where the trouble began. It wasn't a 911 call. Mr. B wasn't in crisis, he needed IV fluids, but wasn't in any imminent danger. He was breathing, had a steady pulse, and had not lost consciousness. So we called a private ambulance company. Now, I know it must be really crappy to be non emergent ambulance drivers in this situation. I'm sure these guys are not using their skill sets to the top of their game; they are very well educated, they know a lot about emergency care, but they are just being used as transporters. They are not responding to a crisis, they are there to wheel people like Mr. B onto the truck and stay with him in case his condition worsens on the way over to the hospital.
That being understood, someone has to do this job. It can't be paramedics, because we need them available for actual emergencies, and it can't be taxi drivers because they don't know anything about emergencies. So someone has got to do this non emergency handling of problems.

And more often than not, the people who are called in for the job take it out on the nurses. It began when I was called out to the hallway and they began drilling me about the patient's condition. I told them all I know, and then with a scathing look at his partner, one of them asked me, "so he's just.. vomiting? and has a fever?" Caught off guard, I stammered that his BP had dropped significantly. He stared at me. "So why this hospital? Why not a closer one?" I was stumped, of course the answer was that this patient was an oncology patient at the other hospital and needed to be seen by his primary, but I couldn't think. The EMT sighed dramatically, "Ok, so why is this guy here to begin with? " He was holding the patient's chart. In his hands. I had already told them he was there for respite during his chemo and radiation, and repeated myself and said we just needed him worked up because his vitals were tanking. Meanwhile, another patient began calling for me. Then Mr. B's NP appeared and took over. When she returned she told me how the EMTs had made fun of her for calling an ambulance for a patient just because he had the flu.

The patient did not "have the flu," as it turned out. He was dehydrated, and had some severe electrolyte imbalances as a result. He could have gone non responsive, or gotten a life threatening heart arrhythmia.

There is a lot of animosity between medical personnel of varying educational backgrounds and specialties. I had been following urban paramedic, until he was unable to write anymore due to being activated in the armed services again. Both my parents were EMTs. I get it. Sometimes the nurses who make a 911 call are not competent. They get scared, they dial three numbers. Ok, I can see it happening.
But more often than not people are just following policy. When I was a CNA working overnights in assisted living I had to call 911 for a patient with chest pain one night that wouldn't go away with aspirin. In this facility, there are no higher ranking medical people on at night than a CNA. I called my boss, an RN and he told me to call 911. I didn't have access to nitro or to oxygen, as we were an assisted living building, not a hospital. When the ambulance got there the paramedics checked her out and the pain went away with some 02. I asked that they leave her with me but they told me they had to take her. Protocol. Her family was FURIOUS with me. They called my boss and said that their mother often claimed she had chest pains when she just wanted attention. And now they had to pay for an ambulance an an ER visit. My boss stood by my actions. What if that one time she had not been doing it "for attention?" What if she died that night? If I hadn't called 911 and something had happened, then what?

Similarly, Mr. B had to go get checked out. He's a cancer patient. You don't mess around with a fever in a patient undergoing chemotherapy. He could be severely neutropenic. And it's not really an EMT's place to question why we're sending someone out. They can ask questions to get a feel for what care might be necessary on route to the hospital, but to question an order to send someone out seems ridiculous. Am I going to say, "Oh, you are right.. you better just be going then?" I believe their protocol demands they bring the patient with them unless the patient refuses outright. So are they going to talk me out of a concern and then just leave with no one in the truck? It seems unlikely. So their sarcasm and commentary only serves to belittle nursing staff, and to undermine authority. Which is not useful in high stress situations, even if they are not a matter of immediate life or death.

I do not want to perpetuate the bad blood between EMTs and nurses. Or nurses and doctors or nurses and aides or doctors and surgeons or nurses and nurses any of the like for that matter. And so I will refrain from saying some of the things that ran through my head during the rest of that morning. Instead I will make a plea to everyone, everywhere:

If you do not like your job; if you do not find joy in doing what you do; if you do not go home at the end of the day feeling good about what you've done... quit.

And if you claim that you'd like what you did if it weren't for the people, please re examine your motives. Most of us work in this field to help people. It's that simple. We've come here from different walks of life and for different reasons, but it all boils down to that one thing. We help people. So why be nasty to one another? It's only going to delay the service we provide. It's going to make us all feel badly about one another. How can we help others if we can't trust each other? How can I trust you when you are trying to make me look like an idiot? The system only works as well as one part can depend on the other. So EMTs, hold back your eye rolling. And for goodness sake stop asking me if this patient is homeless as if homeless is some new contagion. Nurses do not talk down to the EMTs, and if they do ask a reasonable question you just can't answer, admit it and grab the chart. Then maybe we can all go home at the end of the day and feel good about what we do.

If not, you're in the wrong place.

holding hands in the snow; this is what i thought of

It all began Friday evening. Friday was my first day off in a very long time. I had slept very well and probably brought myself up to the minimum level of rest needed for most humans. For someone having been so deprived for so long of adequate resting periods, I felt like I could probably fly or catch a bullet in my teeth.

Friday night I MC'd the 10pm Friday Night Face Off show, which was really fun. Bobby's notes indicated the same. Immediately afterwards Theresa and I ran over to the Phoenix Landing for Marcelo's 30th birthday party. After a couple of drinks, and some successful singing and dancing with friends, the amount of time I was spending dodging creeps outweighed the amount of fun I was having. (More on this later.) Theresa and I left, and caught a train to the North End.

We arrived in the North End right before last call so we slipped in Luca's. "Ahhhh!" Theresa breathed, "I am home again." We each ordered a drink, and proceeded to empty our hearts to one another. When we knew all each other's recent and most glamorous secrets and the bar lights began sliding up, we regrouped and walked the five steps to Improv Asylum for No Rest for the Wicked Funny, a 24 hour fund raiser for Globe Santa. Improv Boston Mainstage had joined IA on stage for a few hours, so we sat back and watched, and then I got up to do a few scenes with IA and Seriously Bent. Theresa got a ride home before I did, and I split a cab with
some IB folks. On the way back to Cambridge I made a split decision to sleep at Robert's, therefore making my morning commute easier.

As I curled up on the aptly nicknamed "Misch couch," in his room because it is about my length, I remembered to set my alarm, and then promptly fell asleep. When I woke up I was bombarded with texts and phone calls the sum of which was that no one else in our 11am "Family Show" slot could make it to IA. Robert called me a cab and the cab driver, a terrifying lady who cursed every other word and reminded me simultaneously of one of my patients and the playground Moms I encountered growing up in Boston, drove me to my car. I tipped her well for not killing me, changed into a different shirt and comfortable shoes at my car, did my hair in the bathroom at IB and then hopped on a train. As usual on trains I ran into Nate and we chatted about Asian culture until my stop.

I stayed and performed with IA as an NXT member, not as an outside rep, for a good six exhausting hours. It was really fun, and they raised way more money than they had even set out to do, so it felt very worthwhile to be a part of that. Kudos to the IA hardcore cast who stayed on stage for 24 hours straight!

I returned to Cambridge, retrieved my car and met Adam for dinner at Bukura in Jamaica Plain. After a leisurely and delicious dinner we drove back to Cambridge and saw the 8pm Mainstage Show. I thought I must have looked (and smelled) quite haggardly by then but Adam complimented me to the contrary. Still, when the show was over there was nothing I could think of as more appealing than a shower and my own bed.