Caterpillar to Butterfly

I walk in the room and see a husband and wife sitting on opposite sides of the exam table. I've seen him before. He's a gentle and sweet African American man. I've never seen his wife, my patient today. She has a heaviness about her; brows furrowed, shoulders slumped. I start talking about her medical issues and she asks her husband to leave the room.

"You look depressed. Do you feel sad about something?" I ask her. I have no idea what will unravel. She tells me her aunt recently passed away. She passed away two years to the day after her mother passed away. "I visited my aunt in Tennessee before she died. She didn't know who I was." She continues her story in a monotone voice telling me she doesn't understand why this woman would die on the same day as her mother. "Why would God do that? My mother and aunt were so close. They were best friends." I tell her that hospice workers notice people holding their death for a special day. "Maybe she chose this day so she could be with her best friend. Maybe this is the day SHE wanted to die," I tell her. She looks down and then back at me. "I never thought of that. Is that really true? People do that?" "Yes" I tell her. "It's true" She waits a few moments and then says, "I like thinking of that. My heart feels better than it's felt in two years."

As some sadness lifts from her heart, she now smiles and sits up taller. She begins the story of her childhood. "My mother was fierce and wonderful" she tells me, eyes now sparkling. She tells me she grew up in Memphis and her mother and aunt took her to civil rights marches. She was a little girl when they took her to hear Martin Luther King speak. She says kids were at the marches to protect the adults from being attacked by dogs. She looks at me in the eye and speaks slowly and deliberately. She's drawing me into your childhood. I'm convinced to pay attention. She remembers being a little girl at a civil rights march. A dog was growling at her, pulling on the leash ready to attack. At the other end of the leash was a "mean son of a bitch looking cop." She says, "I can still remember thinking that dog was going to attack me. I dream about it sometimes." She tells me how much white people did for them. "They put their lives on the line for us and they didn't have to do that. They haven't been thanked enough for what they did. I really think so. They need to be thanked. We couldn't have done it without them." She continues, "My mother always loved Tony Bennett and so do I. He wasn't afraid to be a part of the civil rights movement."

She's animated now and looks like a different person than she did ten minutes earlier. "I remember when we were first allowed to go in a store through the front entrance. People were still afraid to do that so not many people did. But my mother? She would roll her shoulders back (she sits up tall and demonstrates her shoulders rolling back), grab my hand and we'd walk proudly through the front door." I find myself fighting back tears. I want to stay all day and listen to her.

She tells me her kids have no idea how lucky they are. They say, 'Hey dude, whatever.' "They don't know how they got here. "They think they've always had it this good," she says. I tell her she needs to write these stories down. Write them down for her grief, for her children, for all of us.

She tells me she has never told these stories out loud and thanks me. I tell her she has given me a gift, sharing something so intimate to her. We hug each other and both have tears in our eyes. We have come from two different backgrounds, fighting for the same cause, meeting in a clinic room, embracing each other. I walk out of the room and feel like I've gotten up too fast. I'm lightheaded and in a daze. I've been listening to greatness, something so wonderful and deep. I stepped back in time and now I need to adjust to life on the other side of the clinic door. I've watched a caterpillar turn into a butterfly before my eyes. I realize she has so much more to say.

She and her family helped change our country. Her mother was "fierce and wonderful" and together they fought a fierce and wonderful fight. They helped us elect the first African American president. This warrior is poor and has no health insurance and that isn't right. I can't stop thinking about her.

Knife Attack

He's 22 years old and a new patient to the clinic. He's hispanic with a crewcut. He's wearing shorts, sandals, and an undershirt. He's here with his mother. He says he needs to have a knife wound repacked. As he takes off his undershirt his mother winces and looks away; I drop my jaw in amazement. His abdomen had been filleted open and after a long surgery is now stapled shut. The wound extends from below his breastbone to his pubic bone, about 12 inches. "Can you take out these staples?" "Oh no, you need to go back to the hospital for that", I say. I see a bandage taped on his left side and a long gash on his left arm which is closed with stitches. "What happened?" I ask as I inspect how perfectly his core had been stapled shut. "I don't know man. I don't really remember. Some guys came at me with a knife." His mother winces some more and says, "I have hard time looking." Spanish is her first language. 

He says he drove to his mother's house after he was attacked outside a Mexican restaurant and then was taken by a medic to the hospital. "You drove?!" I imagined his guts spilling out in his car. "Your car must be full of blood." "Yeah man. The cops have my car now. Do you think I'll get it back?" "So you were able to drive to your mom's house but you don't remember who attacked you?" It occurs to me I'm not the only one to ask him that. When the police questioned him in the hospital they must have said the same thing to him 15 different ways. 

He was put back together at a county hospital which is also a trauma center. This kind of attack, unfortunately, isn't new to these doctors. I imagine a young doctor, anxious for the trauma training, hurrying to be the first to scrub in. Stomach, spleen, liver all closely inspected for damage, guts put back to their proper position, then meticulously stapled shut. 

"Can you pack this wound again for me?" pointing at the bandage on his left side. "The nurse at the hospital told me it's 7 inches deep." (Wounds like this need to be repacked everyday so they can heal from the inside out). He tells me his mother feels sick when she does it so he does it himself. I pull what seems like an endless amount of gauze from his side. His wound looks good. He's done a good job these last couple days. I clean it and repack it. As I push the packing tape in, I don't feel any resistance for just about 7 inches. Then, finally, I can't put anymore tape in. I clean the gash on his arm and rebandage it. I send him home with enough supplies to pack his gaping hole by himself over the weekend, keeping in mind that most people wouldn't be able to do this on their own.

A drug deal gone bad? A gang attack gone good? A random slaughter? For a moment I put myself in his mother's place, one of my kids brutally attacked with a knife. But then as quickly as I'm in her shoes, I'm out. It's too unimaginable. 

The Safety of his Car

He's dressed in dirty blue jeans with a urine stained front. His plaid flannel shirt has seen better days. His head is covered with a blue baseball cap. He apologizes for his appearance. He's never been to the clinic before and he's here because he's had a headache for a week. I take his blood pressure and it's high, no doubt the reason for his headache. He tells me he was told he has high blood pressure a year ago at the emergency room but he hasn't taken any medication for this. 

He tells me he's safe in his car. He's been living in it since his wife and kids left him. He says apologetically, "I never used to look like this. I know I don't look very good now. I don't like to be around people or open spaces." He tells me about the voices he hears in his head. He knows they aren't real and he constantly has to remind himself of that.  I watch his eyes dart around the room like a caged tiger. I know he wants to escape. "Have you seen a counselor?" I ask him. He says no and tells me he knows he needs to be on medication but he can't afford it and it's too hard for him to leave the safety of his car. 

"Where do you get your food?" I ask him, imagining him waiting in a crowded food bank line and wondering how he can tolerate that. "I steal my food." "How do you do that?" What follows is a detailed explanation of how he regularly steals his food from the grocery store. "I bring in an empty paper bag from that store and I start filling it. I usually pick one part of the store each time I go. If I go to the produce section, I make sure no one who's working there sees me. Then I walk towards the check-out line and just walk out with another customer like I know what I'm doing." "And you've never been caught?" "No. But sometimes I think they know I do this and just look the other way."

He tells me his car was ticketed for being parked too long so he has to move it. He doesn't know where he'll go. He's afraid since he can't pay the ticket, his car will be towed soon. "But that's your home" I say to him. I tell him I want him to meet with the social worker after his doctor's appointment and he agrees. I can tell he's been here too long; too long away from the safety of his car. 

I go to check on him after his appointment with the doctor but he's gone. He leaves before he can have his blood drawn. He leaves before he can be treated for his headache. He leaves before he can meet with the social worker. 

I haven't seen him since.

Apology accepted

As I walk past the area where someone sits to get his blood drawn, a man stands there waiting. He's a tall African American man with a fit body. He extends his hand to me, "Hi there. I want to apologize to you again." I look at him and can't think of why this man is apologizing to me. He looks familiar. "Boy, I was really in a bad place when I talked to you like that. I never talk to people that way." I nod my head pretending that I know what he's talking about and hoping he will say something to jog my memory. "It's been ten months since I've had a job and now I'm moving to Atlanta for a construction job." I'm starting to remember now: 

Almost a year ago, this same man comes to the clinic wanting his pain medication and some results of blood work. When I meet him in the waiting room, his arms are crossed and he's very agitated. I tell him I can discuss his blood work but he needs to come back in a few days for his medication as he's too early for his scheduled prescription time. He gets very angry and I even hear him say under his breath, referring to me, "Bitch." I step back but don't get defensive. My only interactions with him up to this point have been good ones. I leave him to look at his chart. I'm reeling a little bit by his behavior and being called 'Bitch.' I take a few recovery breaths as I look in his chart. There is nothing alarming about his behavior noted. 

I bring him out of the waiting room and have him sit on a chair in the hall. He is angry looking and doesn't look at me. I say, "Hey. What's going on with you? I've never seen you act like this before. You're being very disrespectful to me." I watch tears come to his eyes. He tells me he just got laid off. He tells me two weeks earlier he had to identify his brother's body at a morgue. We talk for a few minutes about his life. As we part, he extends his hand to me and apologizes. A few days later, he comes back to the clinic and asks to see me. He apologizes to me again.

Now ten months later, "I had no right to talk to you the way I did. I want to thank you for how you handled everything. What you said to me was exactly the right thing." I am struck by the thought he has given this, still apologizing to me almost a year later. I put my hand over my heart and tell him how touched I am. He says to me, "I'll never forget the respect you showed me." I thank him and tell him he can let this go now. I wish him luck at his new job.

This interaction reminds me to step away from a bad situation and give it some breathing room. It also reminds me the importance of giving someone space to tell their story. 

The Emotional Layout

I've had a long absence from my blogging. I have many stories and sometimes it's too tiring to write them down. I will focus on some stories in my next few blog entries. Some will still portray human resilience and some will portray ugly desperation. 

The economy has depleted the few safety resources our patients have had and this has turned their already chaotic lives inside out. They become desperate with their physical and emotional pain, even more trapped than they once were.

Many patients are on a scheduled monthly narcotic prescription. Often, patients try and get their narcotics a few days, a week early. Is their pain so uncontrolled this month that they needed to use more medication? Or are they wanting it early to get some extra to sell? Often patients lie about stolen or lost narcotics in order to get more oxycodone (percocet) that they can sell on the street. At times my job has been turned into a detective, such as asking to see police reports for stolen prescriptions and sometimes finally busting them for their lies. Many of our patients surround themselves with others as desperate as they are and so I believe some stolen narcotic stories. Others just don't make sense. On occasions when someone is caught in a flat out lie, we don't get the police involved. We tell them we can treat them for their medical problems but they can no longer get their narcotic prescriptions through our group of clinics. It's time consuming and tiresome for the staff.  

We are seeing more depression and  suicide attempts, more anger and volatility, more illness. I don't feel as emotionally or physically safe there as I once did. I believe some patients are a step away from pulling out a gun and using it. Our former security guard was very good. He had a strong presence and good intuition. He even patrolled around the clinic and asked people doing illegal activity to leave. Our staff felt safe with him there. He took the bus to work and started receiving threats from those who recognized him on the bus. I don't think they were our patients, but rather those he'd been keeping his eye on outside the clinic. So he quit. The security guard we've had for almost a year wants to be earnest and is a nice guy but having him as a security guard is a joke. He's about 5'4" and is terrified to approach anyone. When he's needed, he doesn't know what to do and has come to me for direction. I have often seen him asleep in the lunch room. Stories about him and others to come.

Surviving

Sometimes I think about all the patients I see who have dead children. Some from an act of violence, some from a disease; lives full of tragedy. Recently, a woman came to our clinic as a new patient. She brought with her a box full of her medical records. She was petite and pretty with short light brown hair. She looked her age at 45 years old but she's had more tragedy than anyone should be expected to survive.

She begins her story, listing the horrible things in her life with the same emotion given to reading a shopping list. "I have hepatitis C. I think I got that a long time ago when I experimented with drugs and now I have cirrhoses of the liver."  She stops looking at the papers in her box long enough to say, "Oh and I've been treated for PTSD". "What's your PTSD from?" She continues her list, licking the tip of her index finger and sorting through her papers."One of my daughters was murdered by a boyfriend. I watched another daughter's husband being murdered in my house..." 

I turn away from my computer and look at her, in horror. I lean against the wall to sturdy myself for more. She goes on, "I was stabbed in my back by my ex-husband and then when he and I were in the car one time, he reached over and punched me in the face so many times that I've had 8 facial reconstruction surgeries. Now my ex is in prison for molesting his new wife's daughter." She smiles sometimes but never cries. The only words I could muster up were, "Oh my God." I am not only struck by the things she tells but by the emotional detachment with which she tells it. She's busy finding the papers she needs to show the doctor. She's busy surviving. 

Suburbia Verses Inner-City

Yesterday, I was sitting outside a coffee shop in my quiet suburban neighborhood, when suddenly an overweight woman wearing an apron ran out of her ice cream shop, yelling and pointing at a young man who was running away from the scene. "He stole the tip jar!", she yelled. "Does anyone have a cell phone?! Someone, call the police!". Within one minute two police cars arrived and as I watched them get out, hands over their guns, I couldn't help but laugh. Has working at my clinic jaded me? All this police activity for someone who stole a tip jar from the ice cream shop. I tried to imagine a frantic phone call to the police station near my clinic about a stolen tip jar. I could see the officer answering the phone and then looking at it with a quizzical face, shaking his head at the idea that someone would bother the police for this, then hanging up. 

Today, I was busy assisting with a procedure on a patient when there was a little action outside the clinic. The security guard told me he was standing in our parking lot and was watching and listening to two men argue. All of a sudden, one of them pulled out a gun and shot it, missing the person with whom he was arguing. I'm assuming he meant to miss since they were in such close proximity. As he was telling me the story, one of the doctors asked what happened. When he told her, she very casually  said, "Oh, is that what I heard." And then continued working at her desk. 

Our security guard's only weapon is his walkie-talkie. His company hasn't even provided him with a cell phone. So he stayed outside to keep witnessing, and asked a patient to go in the clinic and call the police. He then called his boss and told him he really thinks he needs a cell phone. Gee, ya think?

 

Spinning Out of Control

The patient population at the clinic can be very difficult and I am realizing the layers upon layers of poverty. Their lives have been teetering on the edge, in some cases, since they were born. Many patients are demanding and rude and their volatility has been getting more explosive recently. With so many job losses, budget cuts, and reduced resources, the nurses have become a verbal punching bag. It is common these days, for patients to interact with me in a disrespectful and uncivil manner. My stomach is often tied in knots as we interact. I have written about the hardships and the sadness I see. Here is an example of another way poverty expresses itself. While this patient also faces hardships and sadness, she is so angry and hostile that she makes it impossible for me to advocate or have compassion for her:

A patient is refused a prescription until she makes another appointment with her doctor. She yells so loudly at me, that I hold the phone a foot away from my ear. "WHY THE HELL CAN'T I HAVE THIS?! WHO DO YOU THINK YOU ARE?!" This goes on and on until she finally demands, "LET ME TALK TO THAT NURSE THAT DON'T TALK TOO GOOD ENGLISH!" I can't help myself. I reply, "You want to talk to the nurse that don't talk too good english?" "YEAH! PUT 'ER ON! NOW!" I manage to calmly tell her that she's being rude and disrespectful and if she doesn't calm down I will need to hang up the phone. She doesn't calm down so I warn her that I am hanging up and then do. 

Poverty's cycle; how it starts, how it presents itself, and how it continues, is a wheel that spins out of control. It tries to drag others in to gain momentum. It's complex and it's ugly and it needs to be stopped in its tracks.

Weekly Groceries

I open my pantry then refrigerator, hoping to find something to eat before I go to work. After searching for a few seconds I close them disappointed that there isn't much food in my house; a good reminder that it's time to go grocery shopping. I quickly slap together some peanut butter and crackers to take with me. It's raining again and I'm not looking forward to my commute. 

I drive through puddles and hear the rain pound on my windshield as I make my way slowly down a busy street. I feel my stomach growl and review my shopping list in my head: all the basics, plus my favorite cheeses, some truffle oil, and my favorite chocolate.

Then I pass the food bank near my clinic and I make myself look. There is always a long line on the weekend as people try and get something for their families for the week. I look at the people in line today, in the rain. Some are wearing coats, some are holding an empty box over their heads to try and keep dry. I wonder what the cold rain sounds like as it hits the boxes on their heads. It must sound different then it does on my windshield as I sit in my warm car. I see young and old, black and white, and everything in-between. I wonder how long they've been there in the rain, slowly inching their way toward food, their commute for the day. A poor person's traffic jam.

Health Insurance Claim Denied!

I decided to tackle an insurance company for a patient today. Actually, this was worse than an insurance company. This was a company that health insurance companies use to review and then deny coverage. They do the ultimate dirty work. 

English is not this patient's first language and I'm convinced he was lied to and taken advantage of by his insurance company. He was referred to a specialist last year by one of our doctors and had a procedure done. He says he called his insurance company before the procedure to make sure it would be covered. They told him it would be covered but then he got a bill for $4,000 with a letter saying he hadn't finished his 9 month waiting period for a pre-existing condition. He was 3 days short of his 9 month waiting period. He has now lost his job and has no more coverage and no money. He's been sent to collections. 

First I talked to a woman who kept repeating what his letter, which I had in front of me, said. "After a careful review by our company, we have determined that you did not comply with the 9 month waiting period for a pre-existing condition and therefore your claim has been denied." But he called and was told this would be covered. He doesn't have a penny to his name. Trust me, he never would have done this if someone didn't tell him it would be covered. Surely you must have record of this conversation." I said. She wouldn't acknowledge or deny such a conversation but just kept reading what was in the letter. Then she transferred me to someone higher up the predator chain. 

This woman, who had already been briefed of the conversation by the first woman was ready for me. She told me she couldn't discuss this case because I wasn't the patient. I imagined her face looking like a cross between a bulldog and a pitbull. "But I have the letter right in front of me and his English isn't very good," I pleaded. She repeated, like a robot, that he did not wait his full 9 months and therefore the claim is denied. "He's 3 days short of his 9 months! You're kidding, right?" Sadly she wasn't. This conversation could have been right out of Michael Moore's movie, "Sicko". "He can go through the appeals process again if he wants but it will just be denied again." The more I tried to explain his situation, the more I realized she didn't care. She couldn't care because if she did, she couldn't work at a place like that. 

"Can I ask you a question?", I said. "Do you LIKE your job?" She replied by demanding to know if I like my job. "I love my job. But then again I'm an advocate for my patients." Then she said, "I know you're just mad because your clinic won't be paid for this procedure." "No, that's not true. I'm doing this for HIM. He didn't even have his procedure done here. I'm just advocating for my patient." She replied by demanding to know my name again and telling me she doesn't like my attitude. 

MY attitude?! Doesn't she get it? She's the one with the attitude and most people in America would think so. I got off the phone and was cheered by a couple of co-workers. I wonder how people can spend their day denying the poor their medical coverage. I suppose one can only do this if they don't have an ounce of empathy. I wonder what would happen if all the money spent to deny claims were used for universal healthcare. I suppose she'd be the one out of a job.

Lucky Boy

He's three years old. He has long black kinky hair tied in a ponytail. He looks more like a she than a he except that he's wearing jeans with a brown leather belt, brown shoes, and a plaid shirt. He's with his foster mother who turns out is his aunt. He calls her mommy. She has permanent custody of him. His biological mother was using crack while she was pregnant with him and he was rescued from the crack house when he was a baby.

His foster mother was very heavy set and looked older than her 36 years with a mottled dark complexion. She wore a purple printed bandana tightly on her head to cover her hair. Her fingernails  were long and they didn't look like her real nails but she said they were. They had the most intricate design which was perfectly applied. Her toenails matched her fingernails. She told me it only took a few minutes for someone to paint them. 

I ask him about his friends and about his favorite foods but he's acting like a tired three year old, putting his hands on the computer followed by falling on the floor. I realize I'm waiting for her yell at him and threaten him as I've seen too many times with other patients. Instead, she picks him up from the floor and puts him on her lap and as he squirms away, she laughs. She tells me how smart he is and how happy she is that they live together.  

His Own Personal Arsenal

He was a 48 year old new patient to our clinic. He had a pasty white face and grey scraggly hair. His wire rimmed glasses drooped past his cheekbone. He talked to me in a serious monotone voice.

I asked him questions I ask every new patient. One question I ask is, "Do you own any guns." It is illegal for someone to own a gun if they have been incarcerated and whenever I ask those patients that question, I usually get a resounding "No!" followed by something like, "I'm not going back to that hell hole." I stopped asking my Somali patients that question a long time ago when I was laughed at by an interpreter. She told me that these Somalis have fled a country full of violence and that's the last thing they would want to own. 

Occasionally, our African American or Caucasian patients have answered, "Yes" and then I ask them if there is a trigger guard, if the ammunition is kept separate from the gun, and if the guns are locked up. They have almost always answered, "Yes" to these questions.

"Do you own any guns?", I asked this pasty white patient. He immediately said, "Yes I do. I have one loaded, cocked, and ready to go. It's sitting right on my coffee table". "On your coffee table?!" I said without even thinking. "Yep. As soon as I moved here, I started hearing gunfire. So I decided I needed to protect myself". "Okay, so you have one gun?" "No, ma'am. I have five pistols and two rifles. I have another pistol ready to go, sitting next to my bed." 

I instantly became afraid of this paranoid man and didn't want to ask him anymore questions. I did, however, ask him if he brought one to the clinic. "Not on my person but I've got one ready in my car. "

I don't know if it's legal to own this many guns but I sure wasn't willing to ask him. 

Advocating

I'd like to respond to a comment from the previous blog entry about advocating everyday for my patients. Thank you for that comment. 

I have always believed it is my responsibility to help those who have a difficult time helping themselves. I want to be an advocate for my patients and think this is a necessary part of a nurse's job. Sometimes this means I can help make their life just a little bit easier and sometimes it means I can teach them how to help themselves, thus being a part of a larger and broader social movement. Either way, it is a privilege. 

It can be very draining and sometimes I work the whole day and don't feel appreciated for what I do. Patients have yelled at me, "What kind of nurse ARE you?" or they might hang up the phone on me. Sometimes they speak to me with an edge in their voice that says they expect something and if they don't get it they'll be mad. 

I need to constantly remind myself that they are a product of their upbringing. This doesn't mean it is all right to speak to me or anyone else this way. Their lives are chaotic and most have never been taught how to communicate in an appropriate manner. Maybe they are so used to being looked down upon and treated with little respect that they, in turn, treat others with disrespect. 

I have had many occasions when I've felt I made a difference in someone's life and have felt appreciated. These encounters are part of why I can do this job. Here are examples: a homeless man came to the clinic in a wheelchair. His gout, a very painful disease, had flared up. His leg was red and swollen and he was shaking with pain as he answered the questions I asked. While he was waiting for the doctor to see him I spent a few minutes listening to him tell stories about when he traveled around the world as a musician. I hadn't talked to him in a few months until he called again the other day. His gout had flared up again and his voice was shaking. As I talked to him he said, "For some reason, you have taken  a special interest in me. I don't exactly know why you have but I think you are a very kind person". That one sentence said a lot. Was I the only person who he felt has cared about him? Did he not feel he deserved my kindness? I strive to take a special interest in all my patients and to treat them all with kindness. I thanked him for telling me this but I doubt he understands how important it was for me to hear it. 

Last week, a woman came to the clinic. She was crying because her sister had died the night before from a brain tumor. She hadn't slept in a few weeks,  anticipating her sister's death. She had an appointment at the funeral home later that day and she needed to pick up her six grandchildren from school. She takes care of them everyday so her daughter can work. She was my age but looked 20 years older. Her life has been more difficult than mine. After talking to her I made sure she could see the doctor in the next hour so she could be with her family. About two hours later, I happened to walk by a room from which she was coming out after seeing the doctor. She walked over to me, still crying, and put her arms around me. As she hugged me, she thanked me for helping her. She asked me if she could show me a picture of her grandchildren. She pulled from her purse a picture of six children standing with her, a tree in the background. As she pointed to each of them telling me their names I saw her happy and hopeful.

These are the stories that make me feel like I'm doing a good job.

One View

I open the door that leads from the clinic area to the waiting room. I see 24 people sitting on 24 chairs sitting on dirty blue carpet. Some chairs are covered in old, stained upholstery. Some are covered in old, stained vinyl. All have held years of peoples' lives, years of stories. People in the waiting room are varying shades of color, most are dark. Some are white. Some are dressed in their native country's clothes. There are young and there are old. I see canes and walkers. I see children playing with toys. It is standing room only. I smell old tobacco. I smell alcohol. I smell bad perfume. I smell unshowered people. They look sad and tired. Most have been waiting there for hours. Some of them have appointments and some don't. For a few moments I think I'm working in a clinic in a third world country. Then I remember I'm looking at the poor in a major US city. They all look up at me hoping it will be their name I call to leave the holding pen. When I call one person's name, I want to call them all because I can't stand that they've been waiting so long. It is now only one person's turn to tell me their stories. 

I find out what brings them here, what ails their body and what ails their mind. I try to make sense of their lives. I discuss their illnesses, their medications, their often unimaginable tales. Some speak English, a lot don't. There is often an interpreter in the room. I've heard many African and Asian languages and I've gotten good at figuring out what African country someone is from by listening to them and looking at them. 

Too many times someone's English isn't good and they don't bring an interpreter. It can be painstaking for them to tell me why they're here and painstaking for me to figure it out. It's not just that they don't speak our language but they've come from such a different culture and view their bodies differently. For instance, Somalis often think there is something wrong with their liver or kidneys but when I ask them to point to the pain, it's not where these organs are. 

I try and make sense out of their chaotic lives as I describe their problems succinctly in the computer for the doctor. Now they wait again. They might be here most of their day.

Dardos Awards

When I started working at my clinic, I would tell stories about my patients to my friends. I kept hearing over and over again, "You have to blog about these." So I started Caterpillars to Butterflies. I gave my blog this name because I've always had a fascination with butterflies. Once crawling sluggishly, then trapped in their cocoon, they are rebirthed into something so beautiful. Dressed now in their distinctive colors they gently dance on flowers. So many of the patients I meet feel trapped in their lives. It is a privilege for me to try and help them find their beauty; their own distinctive colors. I hold hope that if found, they too will gently walk down a new path.

It didn't really occur to me that people would actually be interested in reading these stories and when I started getting comments, it inspired me to write more. I write because most people don't ever see what I see everyday. I write because I hope to give these people attention and pay tribute to the stories of their lives. I write because it helps me alleviate some of the stress I feel at this job.

I recently received an award from two different people. Their blogs are fantastic and I am honored to have received an award from them.

The Premio Dardos Award is given for recognition of cultural, ethical, literary, and personal values transmitted in the form of creative and original writing. These stamps were created with the intention of promoting fraternization between bloggers, a way of showing affection and gratitude for work that adds value to the Web.

Here is what Citizen K said:

She hasn't been at it long and I wish she'd write more, but Molly The Dog's Caterpillars to Butterflies is already a must-read for Citizen K. Molly employs plain, repertorial language to tell stories of her experiences as a nurse at an inner city clinic, writing in a way that combines realism with compassion.

Here is what Fox Home said:

Caterpillars to Butterflies is written with passion, compassion, generosity and wisdom about performing some of the most exhausting work in the world, helping those who are at the extremity where they cannot help themselves.

If you follow my blog, please don't forget to add me to your blog list so that those who read your blog will be introduced to mine.

Thank you!

The Trafficker

I saw a patient today who was just released from an eight year prison stay. He came to the clinic because the bullet that's lodged in his back is causing him pain. He's 33 years old. He was shot when he was 16 years old in a fight and he couldn't walk for two years. This fight also left him blind in one eye from being kicked in the face.

He was in prison in another state and just moved back here to live with his mother for a while. He wore a black knit cap over his short afro and spoke in a soft voice. He answered my questions saying, "Yes, ma'am" or "No, ma'am".

I asked him why he was in prison and he said, "Trafficking". Now, you'd think I've heard enough stories that I'd immediately know what he meant. But instead, I started wondering why someone would need to be in prison that long for some traffic tickets. Fortunately, I didn't make a fool of myself by asking him how many traffic tickets earned him such a long prison sentence. He was "trafficking" cocaine.

He used to use cocaine, marijuana, and something called "sherm". "I don't know what it is, but that's the street name", he said. "It's a liquid that you smoke and it's what's used to embalm somebody". After wondering to myself how brain cells he must have killed smoking that, I asked him when was the last time he used drugs. He said, "Man, I been in prison and just got out. I ain't using nothin' no more". He assured me he wants to change his life and he doesn't ever want to go back to the "hell hole".

He has six kids from four different women. Six kids without a father, four women raising kids on their own; loops in the long complicated chain of societal disfunction. He tells me he wants to contact some of his kids and try to form a relationship with them. I told him how great and important that is. I told him maybe he can teach them what he learned from being in prison. He told me he wants to do that. I hope he can.

More gang activity

As I'm taking the long subway ride to work, I wonder what I will encounter during my day. Will I need to call the paramedics? How many times today will I hear heart wrenching stories and be amazed at the survival of the human spirit? I feel a rush of adrenaline as I arrive at the clinic. I try to mentally prepare myself and perhaps one needs to crave a little bit of this rush in order to work there.

On this particular day, I noticed police cars driving slowly back and forth by the clinic. I figured they must be looking for something or somebody. Then, as I was talking to a patient in a room with the door closed, I could hear yelling. I couldn't tell if it was coming from inside the clinic or outside until I heard a police siren. When I was done with my patient, I began walking back through the small and narrow hall which leads to my small and narrow desk when I saw 7 police cars, lights flashing, and 3 gang unit cars. I stood there looking out the window, watching boys and young men, hands spread on the police cars. It appeared there were two cars full of people involved in this mess. The police pulled a bat and something else that was small (was it a gun?) out of one of the cars. I watched as the police repeatedly searched through everyone's hair and patted them all down. Opposing gangs, ready to fight. One of the kids couldn't have been older than 10 years old. Was he the little brother of one of the other kids there? What kind of future does he have? And as I watched this, I thought about how heartbroken their mothers must be.

Two gang shootings happened right there about one month ago. The police must have been tipped off this day and that's why they were patrolling. There has been in increase in gang activity in this area and I fear it will be getting worse. I know when the economy is bad, the crime rate goes up. These kids don't see a future of learning and earning an income and they don't see a future where they feel safe. Their power and safety comes from belonging to their gang and it is dangerous for us all.

If opposites could have attracted

She's 20 years old. She's been through more than anyone should have to go through in their entire lifetime and she is surviving so far. She was beaten and sexually abused by her father while he was drunk and high on street drugs. Her mother was too drunk and high on drugs that she never came to her defense. She was in three foster homes and homeless. She's the only one in her family to finish high school. She's the only one in her family not to use drugs or alcohol. She thinks she's bipolar because she gets mad at her girlfriend for things she knows she shouldn't be mad about and then feels so bad, that she apologizes. She thinks she's bipolar because both her parents are and her mother, who is "shacking up with some dude" and still high on drugs told her she is.

I told her she needs to be evaluated by a psychiatrist to determine if she's bipolar. I told her anyone who has experienced as much as she has would have mood swings and deep feelings. I told her she's an absolutely amazing person and a survivor. I promised her we'd help her get the help she needs.





She came to the clinic with adoption paperwork that needed to be filled out. The paperwork needs to be signed by a doctor saying she doesn't have any mental illness, and she is basically a healthy person. She's in the process of adopting a 7 month old baby that has been in her foster care since he was 4 months. This baby will need a bone marrow transplant as soon as the adoption goes through. She's hoping to move the process along so she and her husband can help save his life.

Her husband works with homeless youth and she used to be the director of a food bank. They've cared for a total of 14 foster babies in their home. She got these babies from women who would come to the food bank and couldn't care for their babies. She didn't have them long enough to get very attached, except for one baby. This baby lived with them for 9 months and was finally sent to live with her grandmother. "This baby will always be my baby", she says. She and her husband have also adopted their nephew. She says because of state budget cuts financial help will be cut off for people like her who adopt very medically challenging babies. She and her husband have no medical insurance. I told her she has a beautiful big heart.

I wish this first patient, born into a family full of hate had had a guardian angel like this woman, so full of love.

A Woman's Choice

She's 20 years old and has been feeling tired, with an upset stomach so she decided to see a doctor. When the medical assistant found out the date of her last menstrual period, she did a pregnancy test. It was positive. I walked in the clinic room to give her the news. She was a very beautiful African American young woman with many fancy light brown braids down her back. I sat down to tell her and when I did, she didn't express much emotion. I asked her what she wanted to do. She began talking to me, never looking at me, as though I was sitting at another place in the room. "I already had an abortion and it was a horrible experience. There's no way I'm going to have another one". I asked her to tell me what happened. She told the wall across from her that it hurt and she didn't think they took very good care of her. I told her I could give her names of very good places that would make sure it didn't hurt and would take good care of her.

She began to tell me about her dreams of going to college in the fall. She wants to be a medical assistant but now doesn't know if she can do it. She started telling me in a young, whiny voice how tired she is and wants a note to let her employer know why she keeps putting her head down on the desk. I was struck by the immaturity of this, the need for a note from her doctor, like she's still in high school and needs an excuse because she has the flu. She's about to cross that bridge to adulthood too soon, I thought.

I asked her if the father will be involved. She doesn't think so. I told her she will have to put her life on hold. I told her if she thinks she's tired now just wait for the baby. I told her that having a baby is a beautiful thing when someone is ready but if she's not ready, then this isn't the right time. I felt angry inside that she didn't think about using birth control. I realized how much I didn't want her to have this baby. I saw in front of me, yet another young woman in poverty have so little chance to change her life. I saw another African American baby growing up without a father. I saw the cycle of poverty going on for another generation. And I saw myself being judgmental of her decision.

I left the room and came back in with some phone numbers for her to call if she changes her mind. It was then she told me she doesn't feel good, morally, about having another abortion. Then it hit me. I'm pro-choice and that means I believe it is HER choice to make, not mine. It's important this woman make the decision that will make her feel like she did something right. It's her belief system that has ruled her decision; a belief that she feels at her core. But as I sit here, I am thinking about the future of this mother and baby, stuck in poverty, stuck in a prison so difficult to escape.

One of the lucky ones

Her skin was dull and pale. She had dark circles under her eyes. Her hair was blond, or at least that's what she wanted people to think. It was dry, like straw. She's been staying with her friend for the last three months. After living on the street for four years, a friend found her and told her to "come home". She feels safer than she's felt in a long time. She tells me how comfortable she feels talking to me because I'm wearing jeans, not scrubs or a uniform.

"Where did you actually sleep when you were on the street", I asked. "Sometimes in a shelter. But mostly I'd just keep walking until I couldn't anymore and then I'd just lay down and go to sleep". I sold my body for four years. But I'm done now and I want to start taking care of myself". She pulled up her sleeves to show about 30 scars on each arm where a "trick" had burned her with a cigarette. She's been raped, held at gunpoint, and incarcerated for prostitution. She told me so many bad things happened to her while she was on the street and it's taken her three months to start sorting through some of it. I told her how proud she should be of herself, how it's never too late to start over. Never too late to start taking care of herself.

The homeless are so vulnerable. Women and children on the streets, especially so. So far, she is one of the lucky ones. She is off the streets for now.

Pharmacy update

It was announced today that our group of clinics bought the pharmacy! What a relief for our patients. What a relief for my heart.

And now for something completely different...

I want to pay tribute to musicians who died this year. Maybe you do too. Take a listen:

Creepy-crawlies on a homeless man

It's been a long time since I've written. So many stories, so much snow, so little time.

Our nurse practitioner came to me yesterday in a panic because she couldn't figure out a way to get a homeless man some medication to get rid of his scabies. He obviously can't afford any medication. I reminded her that our clinic can write off the cost of a medication through the public health pharmacy I've written about. (An update on the pharmacy to come). I've seen scabies quite a few times in our clinic. Scabies is a parasite that burrows under the skin and causes severe itching. Burrow markings and scratch marks can usually be seen. I've never actually seen the parasite as they are as small as the head of a pin and they hide. I've read it's possible to see 3 or 4 on somebody.

The NP told me there were so many scabies on this man and she'd never seen anything like it. She asked me to come and look. When I went into the clinic room, I saw a man who looked to be in his 70's but was 52 years old. He wore a blue knit cap, a flannel shirt with a T-shirt underneath. His jeans were stained with urine. His face was very red, perhaps from drinking but I don't know. He was asked to open his flannel shirt to expose his T-shirt. There on his shirt on his chest were literally hundreds of scabies parasites, crawling all around. He rolled up his sleeve and his arms were bleeding from his scratching. He thinks he was infected from a mission shelter he stayed in when it was very cold.

I apologized to him that the pharmacy he need to use was closed until Monday, two days from then. I assured him the medication would be ready for him to get on Monday morning. I couldn't even Imagine having to wait two days in his state but his response was, "Ok, That's all right. I can wait". He demanded nothing, expected nothing. I told him it was very important to wash his clothes in hot water and dry them on a high heat. (He really should throw his clothes away but it's all he has). I instructed him how to use this cream all over his body and told him he must put on clean clothes afterward. I asked him if he has access to any other clothes. He told me he has a friend he stays with every once in a while who could give him some clothes. I reminded him of the protocol again before he left that he needs to follow but wondered if he could really follow it. Would anyone actually let him into their house? Can he wash his clothes? Can he find clean clothes? Can he follow the medication instructions?

As I was pondering these questions, I made sure our clinic room was disinfected, and made sure the chair he was sitting on in the lobby was disinfected. And I said out loud once again, "We don't treat our poor very well".