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.