Empathy

Empathy is a very important to me. I feel that to be a competent caregiver both professionally and personally I must have empathy. To be a wife I must have empathy. To be mother to three boys with challenges, I must have empathy.

I want the people involved in the care and education of my boys to have empathy. My children are happy boys and are leading full lives; they are creative, funny, active and engaging. They do have difficulties with various issues and situations, some things are beyond their capabilities. Some things they will never master, but with the correct leadership and education I expect they will conquer their own world and continue to lead full and joyful lives. They don’t need sympathy or pity.

As a Nurse Practitioner I encounter many situations that require empathy. There are very few professions outside of the health care professions that are as intimate and invasive of the individual as our professions are. People come to us and trust that we will preserve their dignity and integrity. We are strangers and they often trust us with some of the most important and private issues in their lives. We have usually entered a care giving profession because we really do want to help people, the work is too hard and the hours are too long to want to be there for any other reason.

I am a Family Nurse Practitioner, I have for the last 9 years done Women’s Health Care. I have a varied professional background. I never dreamt I would do Women’s Health Care and OB. I was more interested in fast paced, adrenaline producing situations and complicated multiple diagnoses. My professional history includes time working in a Pediatric Burn ICU, Coronary ICU, Cardiovascular Surgery ICU and working as the Inpatient Coordinator for Heart and Lung Transplant programs at three different large transplant hospitals. Now I do pap smears and STD testing and colposcopy. How did I end up here? How did I end up loving this position as much if not more then the ones I have had in the past?

One thing that all my various positions have required of me is empathy. The ability to look at the patient’s situation and understand it. I don’t need to feel it to recognize what they are going through; I don’t even have to agree with it. I just have to understand it.

When a woman comes to me for her well woman exam or a problem she trusts me, a stranger, to invade her body and perform procedures that are quite foreign to her. I will be touching her in intimate and private areas, I will be asking her embarrassing questions and expecting her to answer with honesty. I will be bombarding her with information in a very short amount of time and I will be doing what is routine to me. If I am able to show empathy to her and acknowledge her fear and anxiety in my actions and words and gain her trust she will be more likely to be forthcoming with answers to questions that I am asking, she will be more receptive to information that I am giving her. She will have an uncomfortable exam instead of a painful and embarrassing one and she will trust me enough to come back. Maybe then the information that I have given her on health and safety issues will actually mean something to her.

I saw a woman in her mid forties; she had not had any kind of healthcare since her last child was born, 11 years ago. At that time she had a Bilateral Tubal Ligation and felt no need to continue routine exams since she didn’t need any birth control. She originally came in to the clinic that day at the insistence of her husband and daughter because of severe low back pain and bleeding from her vagina after intercourse for about two years but had now been constant for a few months. She was there with her sister because the pain in her low back was so severe that she couldn’t drive.

She was terrified. Her last pregnancy was a difficult one and her delivery was complicated and the whole experience had her convinced that she had no need to ever seek health care again. She filled out our medical history form and I felt that she had been quite honest in her responses to the probing questions. One thing that put up a red flag was that she had an abnormal pap smear 11 years ago. She never returned for follow-up. She had lost trust in the caregiver that performed the Pap smear and never went back.

With this information all before me, prior to even meeting this woman I knew it would be a challenge. She was the last patient on a day that had been long and was already running over an hour late. I was tired. In my mind I was asking the rhetorical question, why do they always wait until problems become so bad and then they are the last patient of the day?

I knocked and went in and introduced myself to the patient. She sat at the end of the exam table a tall, elegant and poised woman. She sat with at straight back and stiff limbs and when I offered my hand to her to shake, she gripped it firmly. She promptly told me that she didn’t want to be there. She then introduced me to her sister who brought her and wouldn’t let her leave. From there she proceeded to tell me that she had avoided healthcare professionals and she didn’t trust us and would rather die of blood loss that let anyone touch her again. What? Why was she here then? She came at the insistence of her family; she still had the ability to say no. Tension enveloped the room and I wanted to run, to go home and be with my family and spend the evening doing family things. I knew right then that my family would be having dinner without me that night.

I took a seat on the stool and asked her to just talk to me and let me know what was going on. I sat as she started and stopped a few times, I didn’t rush, and I didn’t interrupt except with a few utterances to let her know I really was listening. She finished her story and I sat a few more minutes, acknowledged how really hard it must have been for her to be in the clinic that evening and how scary it must be to know something is wrong and to have to rely on someone else to figure it all out. I let her know that I was very concerned, I asked her to allow me to examine her. She was not sure she could manage an exam that evening. I offered her the opportunity to make another appointment in the next few days to return after she had thought about what I had said and what my concerns were. I did tell her I would call her and check on her the next day and we would set up her appointment at that time. She agreed that that may be the best.

I left the room, started writing my note about our interaction and the plan when her sister came out and asked if there was still time to do her exam. By now it was an hour and forty minutes since the clinic had closed. I went in to find the patient a bit tearful and yet stoic and ready to do the exam. She has decided that if I was able to take the time to listen to her and allow her to make a few decisions that she was able to make the decision to be examined at that time.

It was a very difficult exam. It was painful and there was significant bleeding and I knew as soon as I put in the speculum that my news to her would not be good. I found a large lesion on her cervix and her cervix was hard and fixed in place and her pain increased dramatically with the exam. I finished what I was able to do and had her get dressed and then went back to talk to her.

I told her that I was certain that the lesion that I saw was an invasive cervical cancer. I offered at that point to work on securing grant money to do a colposcopy to rule in the cancer and then she would be able to obtain emergency Medicaid for treatment and I could then refer her to a Gyn Oncology clinic. Reluctantly she agreed to come the next week to my dysplasia clinic. I was very concerned that she wouldn’t show up and had the manager of the clinic call and assure her she had funding for her and to set up and then confirm her appointment.

The next Thursday as I was driving in to the clinic I felt quite anxious that she wouldn’t be there. I suddenly felt very invested in the well being of this patient. As I walked in the back door the assistant was walking with this woman to the counseling room. She was there and was the first patient of the day.

We did diagnose invasive squamous cell carcinoma of the cervix in the biopsies that I did that day. We were able to get her emergency Medicaid and she did get treatment and is now home and doing well and enjoying her family.

She sent me a card the other day. She thanked me and said that her family thanked me. She then added that the time I took to really understand what she felt was what changed her mind. She called it my “gift of empathy”.

Last of the spring tomatoes...

I picked tomatoes this morning to have in a salad this evening. It is the last of the tomatoes from this plant. No more blossoms. Time for this poor plant to hit the compost pile.

It is time to plant my fall tomatoes. We should have tomatoes well into November if the weather will cooperate.

Grand Rounds

Grand Rounds Volume 2, Number 44: The Garden is up at Medical Humanities , please take the time to walk through the garden, it is a really nice collection along the path.

The Drought

We are still on stage 3 water restrictions here in our city. We are able to water once a week, one inch. Some of the neighboring communities have moved to stage 4, no outdoor watering. The lake that we get out water from is very low and what was once water is now a meadow. This bridge usually spans the lake. This picture is from the City of Allen website. I think it must have been taken a few weeks ago, when I drove over this bridge today, it is all overgrown with weeds in this area.

The restrictions are anticipated to continue thru the end of 2007. We are expecting that we will be moved to stage 4 restrictions in our city soon. Even if we were to get allot of rain it will take a long time to replenish the reserves and the North Texas Municipal Water District is working on alternate sources.

This is our first casualty to the drought. This was a River Birch that we planted in a rather soggy area of the yard to help with the drainage issue. The drought has alleviated the soggy area and also this wonderful shade tree. The rest of the yard is holding up so far...

My lone tomato plant is hanging in there but I think this will be the last of the tomatoes for this season, time to get some planted for the fall.

Paris

For the last 2 1/2 years, one day a month I travel to Paris to staff a colposcopy clinic. Paris, Texas that is. I look forward to this day each month. It offers me a change of pace and I enjoy working with the staff at the clinic. It is a 90 minute drive each way on most days. The WHCNP that is the clinician at the clinic was a student that I was able to mentor/precept five years ago and it is nice to watch her as she matures in her role. I enjoy the patient population and the role I fill in this community. This is what I really think I was meant to do when I became a FNP.

One thing that strikes me each time I go is the different expectations of the patients that I see. I am a big city girl, have always lived in or on the fringe of a large metropolitan area and have had easy access to all that I may want or need. The clinic is across the street from a feed store and next door to a car repair shop. The stockyards are a few blocks away and I can often hear as well as smell them. The patients that I see are medically indigent hard working people. Many haven't ever had adequate healthcare. Many haven't ever been anywhere but in Paris and the neighboring communities.

When patients come in to see me they are scared and feel overwhelmed by the whole process and the diagnosis that brought them to me. I will often be seeing women that haven't had any healthcare for years and they came in for an exam because of problems and were found to have an abnormal Pap Smear. The women that I see at this clinic have few resources and I rely on private, state or federal grants to pay for the colposcopy, unfortunately the grants don't pay for treatment. When the colposcopy and biopsies reveal a high grade dysplasia or an invasive cervical cancer I can usually get them emergency Medicaid if I was able to get them on a grant for the diagnostic procedures in the first place. Unfortunately the struggle doesn't stop there. It is difficult to find a physician that takes Medicaid for Gyn Oncology in Paris Texas, it is difficult to arrange transportation to Dallas if they need to go there for treatment and it is difficult to explain the urgency of obtaining care when they have the more pressing immediate concern of feeding their families and keeping a roof over their heads.

I feel good about what I do there, I feel frustrated by the situations I encounter and I feel angry that we make it so difficult for these hard working folks to get the basic care that they need. I will keep making that drive each month, I will keep on working to get the care that these women need and I will keep being frustrated. I will keep on loving my job!

It is so hot....

We are definitely in the dog days of summer here in North Texas. It is already 101 degrees today and it is just after noon. It was 85 degrees when I got up this morning at 6AM.
On the way home from work yesterday there were cars stalled on the sides of the freeway and you could see the waves of heat rising from the cars ahead of me. We have been under heat advisories for several days and a high temperature of 98 sounds like a cool breeze. We are still suffering a severe draught and have water restrictions in place. I feel like I am living in a cave since we are keeping all the shutters and blinds closed to try to keep out the heat. We have had hotter summers here, but this is still a miserable time.
The boys are tired of indoor activities and it is too hot to just send them out to play, I load them up with water bottles and sunblock and we have lots of shade, but they wilt after about 10 minutes and come in panting and red and miserable. I think I am ready for winter, but if it is anything like last winter, it never really cooled off.
But please don't misunderstand, I do love living in Texas!

Riding Horses

Today was A.'s second horseback riding lesson. He was so excited on the way to the stables and talked nonstop about "his" horse Prancer that he rode last week. He will keep the same horse for the 6 classes that he is signed up for.
We got there a bit early and spent some time talking and grooming Prancer. Then he learned how to saddle her.

I have one very excited 7 y/o. He is doing something that his brothers aren't involved in and it is something we can share. He is cautiously confident at this point. I think that is good.

Getting ready for the new school year...

In just a few short weeks, on August 9th, my boys will be heading back to school. It is an anxious time for me. I worry how they will do.

Will my youngest be able to transition into a full day classroom. Will life be easier for him with the security of a highly structured day or will he find the classroom to stimulating and have difficulty with that. He did so well in PPCD, with a small class and so much support. (This is a photo of him getting on the bus when he was 3 y/o.) So many what-ifs....

I am also concerned about my oldest, the pressures of 4th grade, the fact that he is dysgraphic and 4th grade is when writing becomes so important in the curriculum. Will he find friends that he can relate to now that he has found that joy over the summer, or will he feel like the outsider again.

My middle son is already worrying about the bus. We have taken steps to protect him on the bus this year but in his 7 y/o mind it is terrifying. He is doing very well on his medication and is laughing and active again, enjoying the things that little boys should enjoy, making silly noises, riding his bike, running around and making messes. Unfortunately both appointments we have had with the counselor have been cancelled at the last minute due to illness of her child. We will try again on Tuesday.

I wonder if I will ever start a school year without this anxiety that I feel for my children. I talk to other moms and they express much different feelings from mine. They worry about getting new clothes and shoes, new haircuts and backpacks. I am worrying about before school appointments with Doctors and therapists and filling out forms for the school nurse and resource team. I am scheduling meetings with the special ed bus driver, the school counselor and the resource teachers to give my boys a chance to meet these people that will be so important to their success in the coming year. By the time school starts each year, I am exhausted. I need a vacation.... unfortunatly the schedule just won't allow for that.

Ramblings...

I had lunch today with a long time friend. We met at a local eatery and settled in for our usual 3 hours. Soon a very familiar looking woman sat down at a table nearby. It only took a few seconds to realize who she was. It was a good day!

Just a little background on me. In my 20 years as a nurse I have had many different roles. While in school I worked in a pediatric burn hospital, first as a unit secretary and then as a burn tech. When I graduated I worked on a surgical floor where we had patients following reconstructive plastic surgery. That was a good start since it taught me time management and organization and compassion and empathy.

After six months I wanted more excitement and moved to Houston to work in a big Hospital in the Texas Medical Center. There I learned how to be an ICU nurse. I felt that this was my true calling in life and thrived in the role. I did a 6 month comprehensive nursing residency and took a position in the "Cardiac Critical Care Unit". This was a busy place that only admitted the sickest of the medical heart patients, we never had a patient admitted to our unit to "rule out" an MI, these patients were on several IV meds to keep their heart rates up or down, their blood pressures up or down and we always had a few balloon pumps and occasionally a patient on "fem to fem bypass". It was an exciting time, it was the mid 80's and many research protocols were being done in our unit. It was also a time of the resurgence of heart transplantation, and the realization that it was no longer an experimental procedure.

In 1987 I decided to return to school to earn my MSN, I chose to follow the Clinical Nurse Specialist tract in Critical Care. I focused on heart and lung transplant nursing. Soon I was offered a job at the hospital on the heart transplant team. I still remember the first patient whose transplant I coordinated, I had actually taken care of him in the ICU when he had decompensated a few times. He was a 24 y/o man who had a viral induced cardiomyopathy. He was a big guy and finding a heart to fit was proving to be a difficult task. On December 10th 1988 I spent the late evening and night in the operating room making sure that everything went well as we performed a heterotopic heart transplant, otherwise know as a piggyback transplant, the donor heart was attached to his failing heart. He thrived with the transplant and was out of the hospital in record time for the late 80's, he went home 6 days after transplant! I stayed in touch throughout the years and was even in his wedding in South Dakota in 1990. I received a call from his wife in January of this year. He passed away peacefully. He had lived a good life and was ready. I cried, I felt like an era of my life was over.

In 1990 I moved on to Minnesota and worked as a transplant coordinator there. Unfortunately it was just not the move I had hoped for and I missed home. I moved back to Texas a year later but this time to North Texas to open and run a new heart transplant program at one of the major hospitals in North Texas.

It was at this time that I met this incredible woman. She was one of the patients that put her trust in a very competent but new team to give her a chance at living when her heart was failing rapidly. She is really a lovely woman with a smile that lights up a room. We became friends.

I left the job in 1994, once it was up and running and growing and I was burning out, I wanted to start my family and felt that it was too much for me to this job and have children.

We stayed in touch and I was honored to be invited to the 10 year anniversary celebration of her transplant. It has now been 15 years. She is healthy and active and has just returned to school to get her Master's degree in counseling.

I am in awe of her and all the folks that put their trust and lives in our hands. I am in awe of the families that so unselfishly give at their time of grief. I am very honored to have been a part of that and have the chance to be touched by so many lives.

When I left that job I tried my hand at administration for a large home health agency, soon to realize that this was not for me, I missed my patients, I applied and then was accepted into a Family Nurse Practitioner program as a non degree seeking student, I finished in the spring of 1997.

I have never had one moment of regret. I love my work, I love my role. I am still a nurse but can now provide more comprehensive care for my patients. Life is good.

Rain!

We have had a very dry year here in North Texas. The lake that is the local water supply is down almost 12 feet. We have outdoor water restrictions in place, we can water our lawn one day a week and that is on Tuesdays. When driving through the neighborhood, we see allot of brown lawns.

Yesterday it rained! Not a drizzle, not a soft gentle rain, but an all out bold and beautiful soaking. You can see the joy that this has brought us! We were out in the street dancing in the rain, a soaking wet, joyful dance. I would be happy to have it rain like this for a week. But today the sun came out and dried up all the rain again...

Tomatoes!

I haven't been very successful in years past growing tomatoes. I love to have fresh from the garden tomatoes to eat but living in North Texas it was hard to keep the plants contained in the spring and fall and they were often destroyed by the local wildlife that enjoy frequenting my gardens. Summers are impossible to grow anything because of the heat. So rarely would we enjoy many fruits of the vine.



This year my boys wanted to try again so off we went to look for a "patio variety". We planted it in early April, just a few leaves on a small stem, in a pot on the patio, since it is a "patio variety". We have been eating tomatoes every day now for about 6 weeks and it keeps on producing! A fresh tomato for the 4th of July salad today!

Life in the fast lane!

Has it really been this long since I decided to start this blog? I had thought I would post a bit more frequently but it is already July and here I am. We have essentially unplugged for the summer and I am turning on the computer at home only a few times a week to check email or to do a bit of research or shop. We have also turned off the TV for the most part. Amazing how quiet it is these days! Things are rarely quiet with three boys in tow!

One of my biggest concerns for the summer had been childcare for my guys. It is challenging to find a good and convenient place for all three. I found a place not too far from home that is a school age specific "Activity Center". I spent time with the owner/director explaining the issues with my oldest (S. who is 9) and youngest (J. who is 5) sons and gave her information on Asperger's Syndrome and Autism. So far two of my guys are having a really good summer. I think for the first time ever my oldest feels like he is accepted for who he is and has made a few friends, he is excited about going everyday. My youngest has the structure he needs and the ability to move and be active and despite a few wetting accidents has done well. His speach has hampered a few things but since he is verbal they are working it out.

Unfortunatly, my middle son (A.) is having a very rough summer. Actually this started during the school year when he was being bullied on the bus on the way to school. Of course he wouldn't tell us about the bullying, I had to do a bit of detective work to find out what was going on. A nieghbor's daughter revealed to her that he was being both verbally and physically bullied and didn't want it to get worse so he was keeping quiet. I took it to the school and they did act on it but it started again about two months later. I had A. start weekly counseling with the school counselor. He is an avid reader so we found some books on bullying and those seemed to help him know what to do and he seemed to have some increased confidence.

Once school was out I really thought he would find some joy in all the new summer activity and would really do much better. He is a very athletic boy and this activity center has an indoor playground, gymnastics and karate classes and organized noncompetitive soccer and kickball, as well as swimming three times a week. He has chosen to sit inside the TV and video game room and watch others play video games, he doesn't even want to play them himself...he loves games, and he panics if he misses the daily afternoon movie that is shown for those that are not going swimming or doing the other activities. He never smiles and at home he is in tears more than half the time. He told me that he feels like crying all the time and "just can't keep a smile on his face". We went to see the Child Psychiatrist that manages his ADHD meds on Friday and he was put on Lexapro. My heart is breaking for my little boy, he is only 7 years old, this should be a carefree time for him. Hopefully we will see improvement by the time we return to the doctor in two weeks. I have also arranged for him to start counseling with a child psychologist who has experience working with siblings of children on the autism spectrum.