aiiii... I was evil last week. That'll teach me to try to stop my antidepressant medication. I really know better. I have done it before and it never works out for me. So, last week before I resumed my medication, I had this patient who was REALLY pissing me off. I honestly don't often get pissed off by patients. I don't. I love my patients, and I try to do my best by them. But this guy... well, first of all, I could smell him from the other end of the building. He likes cheap, loud cologne. I hate it passionately. So I was pissed immediately, just from his swirling miasma. I have even told him how offensive I find his cologne. It makes me sneeze, makes my eyes water and generally makes me unhappy. So the mere fact that he wore it when he had an appointment with me was clearly an affront.

I enter the room and Bubba, as we'll call him here, was in a rare good humor. He has reasons not to be. He has insulin dependent diabetes with all the nasty things that go along with it - poor vision, nerve damage that causes pain in his feet and legs, heart damage, early kidney failure.... the list goes on, but you get the idea. He comes here for pain management mostly. And he does have pain, no doubt about it. But geez.... he has gradually worked Doc until he is on oxycontin 80 mg twice a day along with which he gets 180 hydrocodone tablets (eg, vicodin, lorcet) a month for his breakthrough pain. Eighty milligrams of oxycontin is equivalent to 8 of the highest strength percodans, and he takes two of them a day -- which is like taking SIXTEEN percodan a DAY. Plus 6 lorcet a day in case the oxycontin doesn't do it. Well, he's a big man, and he and Doc settled on his pain medicine regimen. None of my business.

Except Doc wasn't there that day, and I had to see Bubba. Bubba had last gotten his medicines 19 days prior to this particular day. He was there to see me for two reasons. He was out of his lorcet already (ONE HUNDRED AND EIGHTY of them!!) not to mention that he had on one of his brother's fentanyl patches, and he liked it and wanted some of them too! (Fentanyl is a high-power synthetic narcotic delivered through the skin.... or IV in the operating room. It is easily as strong as the oxycontin, if not stronger.) He wanted more lorcet, since he was out.

Hence the good mood, I suppose. I mean, I don't know how he walked. Or stood, or even spoke. If he indeed took all his prescribed meds, (and lord knows, he may have been selling most of them and still had enough left to be high as a kite all the time), it is a wonder the added fentanyl that he decided on his own to use didn't kill him.

I chastised him for doing that. I told him it was against the law, and indeed was a felony, both for him to take it and for his brother to have given it to him. Not to mention it could have killed him, considering all the other narcotics he was taking. He became surly. He let a tear drip down his cheek. He started whining (oh gawd how I hate whining, especially from grown men!) about how severe his pain was, how I didn't understand how often he lay awake at night crying, and about how much he wanted to be dead. Yes, he emphasized to me, he just really wanted to be dead more than anything.

Oh dear. He shouldn't have said that. It was so calculated to make me just go all soft and buttery and sympathetic. I gave him the cold fish-eye and said, Bubba, you are a grown man. If you really wanted to be dead you COULD be. I went from there into a rant: You sure have plenty of drugs to do it with! And I bet you have at least 16 guns in your house! (here he interjected sadly that someone had stolen all but 3 of his guns -- which I ignored and continued) You are willing to risk not only your life and health taking all these drugs, but you are risking MY license! How dare you? I wouldn't risk my license for someone I liked, I SURE wouldn't risk it for YOU! I ranted on in that vein for probably ten minutes.

When I stopped to take a breath, he asked me, Does that mean you aren't going to give me any more lorcet today?

I was spent. I shook my head and left the room. I could still hear him complaining that he was out of lorcet and really needed more.

I am better this week. I haven't ranted at a single patient.

And finally, a warm and personal HI! to a special girl out there. :)

Health Care for All

I have come to the conclusion that if you need health care and can't get it any other way, (i.e., you have no insurance, you have no money, you have no credit cards....) you go to a small town or country doctor. Many people have caught on to this. I don't know quite how... maybe it is word of mouth from their country cousins. All I know is that the small rural practice where I work has recently been flooded with new patients -- from the nearby big city.

It struck me as odd from the beginning. The nearby big city is full of health care providers of every ilk and specialty. They have several large hospitals to which they may refer extremely ill patients. They have excellent reputations (well, some of them, anyway.) It blew my mind to see a patient with several serious, non-routine diagnoses in my office recently. I am not even a doctor, I am a nurse practitioner. Not to belittle my expertise in any way, but hey, I know my limits! The woman listed the names of her specialists for her various conditions. I sat there bemused, and finally asked her, "Why did you come here? You were getting the best of care." Her answer? Money, of course. She had lost her insurance when she was laid off from her job. She couldn't afford the specialists' fees. She couldn't afford her medications. She had heard that we would see patients on a sliding fee basis, and that we would help them get free medicine.

So I got out my books, and with her knowledge of her own condition, what I was able to look up, and her list of her current meds, we were able to map out a care plan for her. She was stable on her meds. I had forms from the companies that made them so that we could apply for free or reduced cost medicines. I did a physical exam and documented her current condition so we could be alert for changes. I looked up what labs to order and ordered them.

She fully understands that I have no expertise in her conditions. I fully understand that she is stuck with me because her financial situation won't pay for the specialists she needs. Perhaps I should refuse to take on the care of a patient so complex, but surely I am better than nothing.

But I deeply resent out current system in which patients must utilize care that is less than optimal. Yes, I'll do my best for her. But she deserves better.

contemplating... 

The Angry Greek Man

'Twas a long time ago; so long I am not sure my memory is fully accurate, but let me try to get the story right...

I was desperately in love. I was lonely, bereft, recently abandoned by my ex-husband, and coming to the realization that I was a lesbian. I had had a crush on a woman; a writer with whom I had been acquainted for quite some time. She had moved to Greece and married a Greek man, but I knew she was a lesbian. I didn't know really why she married. It didn't matter though. She seemed a safe distance away, so I professed my crush to her and waited to see what would happen.

What happened first was a wonderful and passionate correspondence between the two of us. Her letters were clever, witty, biting, sarcastic, funny and tender. I suppose mine were doltish by comparison. She was a most talented writer.

Before long it was time for the holidays. She was coming home from Greece with her husband to spend the holidays with her family. And to see ME! I was beside myself. I hardly even acknowledged to myself that she had a husband. I was going to see her. I might touch her. I would smell her hair.

At the time, I lived far in the country down almost three miles of dirt road. I lived in a large house with my two very young sons. I did have a helper -- an old black man named Talmadge. Talmadge looked after us well. I think he felt sorry for me -- a divorced woman alone in the world with no man to look after her. Talmadge spoke in a deep 'Geechee accent which was difficult even for me, a hardcore southerner, to understand. Besides caring for me and my boys, he figures in this story a little later, so I figure I might as well introduce him now.

The holiday came, and so did my wonderful beloved and her immaterial husband. I had worked hard getting my house cleaned and welcoming. I cooked all day. I sent my boys off with their father. I selected wine. I still smoked then, and I smoked a lot that day. They arrived at last. She was beautiful. We talked of many things, but the only one I remember was his hideous foot fungus, the sight of which I was treated to because I am a nurse, and that's what happens when you are a nurse. It grew late. I begged them to stay the night. Somehow, she ended up in my bed, while the egregious Greek man was left on the couch downstairs.

I remember she and I giggled and talked and cuddled nearly all night long. We smoked, though the cigarettes seemed not to agree with her. We finally slept.

When it was morning at last, we sat in bed looking at one another wondering what on earth we had done. The house felt empty except for ourselves -- a fact we discussed in whispers. Finally we gained enough courage to go downstairs to look. Of course he was gone.

We walked outside and could see the distinctive footprints left by the Greek man's shoes in the driveway. They went to the road and took a left turn -- toward Talmadge's house. We laughed nervously at the idea of the Greek with his thick Greek accent meeting up with Tal and his thicker 'Geechee one. My nameless (here anyway) love called her parents' home to see if he was there. He wasn't. So I called Talmadge to see if indeed he had encountered His Greekness. He had.

Talmadge told me how he had just left his home very early in the morning and encountered a lone "white man" walking on the dirt road near his house. Tal picked him up because the man was well-dressed and looked utterly lost and out of place. Apparently it took a while for them to understand one another, but Tal finally understood that the man wanted to go to the bus station. (His wife and I had a guilty giggle over this-- sometime in the previous evening we had laughed over the fact that one thing all small towns seem to have in common is a bus station.) Tal delivered the Greek to the local one, and that was the last anyone ever heard of him.

My beloved had wildly mixed emotions over that, but not I. I was thrilled. She was mine alone now. The way was clear. I wasn't burdened (as she was) by the guilt of having treated him rather horribly. But of course, neither of us knew at that point that she was



pregnant.

Conifera 

I have to comment on the woman whose dog's feet smelled like fritos. They did indeed. I had NEVER before noticed the aroma of dog feet, but her noticing that interesting aspect of her dog's composition has had me sniffing dog feet ever since. And you know what? They ALL have frito-feet. I just hope this isn't because they tend to step in their urine.

Animals are odd creatures. I have found out other fascinating things about animals along the way. For example, if you wrap an ace bandage around a cat's belly, it can't walk. It will stumble and fall. I have tried this on many cats. The bandage doesn't have to be wrapped tightly. No cats were injured in any way during these experiments. I swear. I love animals! But it is a weird truth that they cannot walk with any stability with a bandage around their bellies. I do need to do further research though, and find out if this is true of anything wrapped around their middles, or only elastic things.

I have also learned a strange and interesting thing about parrot behavior. My parrot likes to nip fingers, but he won't do it as long as I stare into his eyes aggressively. But if I am doing that, he will duck his head under my hand where he can't see my eyes, and nip my fingers from BELOW my hand. Damn bird. But this is a very limited experiment. I have only used it on one bird. I'll let you know when I have collected more data.

I don't know what it is about animals that appeals to me so much. Clearly, I spend too much time with mine. I often think how much simpler (and less smelly) my life would be with no pets. But somehow, I have managed to always have at least one in my life, and usually far more than one. Even if I do nothing to actively acquire animals, they just show up. Right now the count is pretty moderate: one dog, four cats, one bird, and a couple dozen fish. Not bad really, until I want to go on vacation. It is almost as hard to get someone to keep your animals as it is to get someone to keep your kids...

oh -- to the woman with the frito-footed dog -- give me a call sometime. It might be interesting to catch up a bit. :)

The nun's belly was so smooth and utterly unmarred. No scars, no bruises, nothing but a modest expanse of alabaster skin. I put my hands on her belly, gently at first, lightly scanning the lovely skin to get a sense of it before probing more deeply. I started over on the left side, the unaffected side. I pushed in with my fingertips, causing a slight wince. Releasing the pressure caused more than a wince. I asked her where it hurt and she indicated her right side. I moved my hands to the painful side. Before I even applied pressure, I could feel warmth and fullness. It wasn't apparent to my eyes, but my hands could tell something was wrong. I pushed in very gently, causing pain. When I released my pressure this time, the nun blanched and gasped. I told her what I thought -- that her appendix was infected. She refuted me -- it couldn't be -- she had Ash Wednesday services the next day, and she was flying to Seattle the following Monday. She simply was too busy to be sick.

But she looked sick. This lovely nun normally had a sparkly, shiny aura. She always smiled. She smiled this day too, but it wasn't a glowing smile. She was grey.

I agreed not to send her immediately to the hospital. She agreed to let me draw blood and arrange a CT of her abdomen for the next morning. (This was late in the day. I could get the CT early the next morning, prior to her Ash Wednesday services.) I was worried. I made her promise to go right to the ER should her pain worsen, or her fever go up. She agreed.

The next morning we got a fax from the imaging department. The nun had appendicitis. The hard thing was finding her. I called her home, the church, her emergency number. All I got was recordings. I left messages, but was not happy about it. I was considering calling the police to go find her, but first asked my doctor what he would do.

One of his talents is knowing everyone. He knew who the nun's best friend was. He called her and told her what was going on. The friend knew where she was. Within 15 minutes she had called me back and we made arrangements for her to go right to the hospital.

Her appendix was removed in short order, and she was home in time to make her flight to Seattle.

And I will never forget her lovely smooth belly. It was the prettiest belly I have ever seen. I think I am in love.