Tuesday's Laugh at death

Memorial Monday - Two Presidents

Clarissa Harlowe Barton
Dec. 25, 1821 - April 12, 1912
Teacher, Nurse, Humanitarian
Founder and first president of the American Red Cross

at Find a Grave

- - -

Franklin Delano Roosevelt
Jan. 30, 1882 - Apr. 12, 1945
Thirty-second President of the United States

at Find a Grave
FDR Home, National Historical Site

Every Tuesday, let's try to laugh at/with death.

Photo: Sylvain Gaboury/Film Magic
from New York magazine

Paul Rudnick is a funny guy. He writes regularly for the New Yorker magazine, often contributing to the weekly humor column, 'Shouts and Murmurs,' which is where I generally encounter his work. He's also written several plays and movie screenplays.

I just finished his latest book, I Shudder: And Other Reactions to Life, Death, and New Jersey. I really needed it. It's a quick read, but if you still don't have enough time, this snippet from page 242 provides a worthwhile taste:

Here's what I know about death and grieving: None of it makes any sense, although I will always cherish the words of a woman who spoke at a friend's memorial, and who began her affectionate remarks by saying, "God knows, Ed was cheap." Here's what I know about New Jersey: If you're a citizen, be proud of it. I know a guy from Piscataway who would tell people that he was from the more posh Princeton, which was forty-five minutes away. I always wanted to tell him, Darling, you're still from New Jersey. Who are you kidding?

And here's what I know about love: Don't let go.

Memorial Monday - Jerome "Jerry" Brudos

Jan. 31, 1939 - Mar. 29, 2006

Known as 'The Shoe Fetish Killer.' A native of Webster, South Dakota, he was a former electrician, who became serial kiler, and later one of Oregon's most notorious inmates...Although he was convicted of 3 murders, he confessed to four, and was suspected of at least 6 others...Brudos died at the age of 67, at the Oregon State Prison, from colon cancer.

from Find a Grave

photo added by K

My selections for this somewhat-regular feature are pretty much made at random. I have no idea what I'm going to find whenever I start looking.

Most of the entries at Find a Grave feature people from the fields of politics, professional sports, the military, art, and literature, and while I respect them and their accomplishments, I'm more interested in learning about others who may not be well-known, or whose deaths prompt me to think about things that I may not otherwise have thought about.

I recently featured two women who were murdered, and today's anniversary for the death of a man who murdered many women reminds me of the first principle of the code for ethical practice by nurses, as articulated by the American Nurses Association:

The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.

I'm not saying it's easy, or perhaps even always possible, to accept that every human being has the right to skilled care whenever it's needed. But maybe once any of us starts to draw a line, where do we stop?

Memorial Monday (on Tuesday) - Barney B. Clark, D.D.S

Jan. 21, 1921 - Mar. 23, 1983

He was the first fully artificial heart transplant recipient, having recieved (sic) it in Salt Lake City, Utah in 1982, and died 112 days post transplant.

From Find a Grave

Photo added by Ron Moody

From the biographical sketch included in the description of the Barney B. Clark papers held by the University of Utah Marriott Library Special Collections:

In June of 1954 (Clark) was informed by his physician that he had contracted a case of hepatitis. Unknown to him, this was to be the first in a long line of illnesses that would plague is (sic) life from time to time. Due to his smoking habit, he eventually contracted emphysema (May 1978); and then there was the idiopathic cardiomyopathy which deteriorated the muscle in his heart.

In 1980, Dr. Clark was referred to Dr. Jeffery Anderson for treatment. Dr. Anderson tried to manage his condition medically. The treatment included administration of digoxin, furosemide with potassium supplementation, warfarin, captopril, prednisone, azathioprine, and a trial of the investigational new inotropic drug amrinone.

Unfortunately, all of these drugs proved unsuccessful in preventing further cardiac decomposition.

Dr. Clark was first introduced to the artificial heart in 1982 when he went to visit the animal research barn, and he went home to Seattle to decide on the surgery with his family. But (his wife) Una Loy knew right from the start that he was going to do it. Although he did want to help advance the medical research, what he really wanted was a much better quality of life than he had been experiencing the last few years. He truly believed that this artificial heart would give that to him; and it probably would have, if he hadn't been suffering from so many other problems. He was admitted to the University of Utah Medical Center for the transplant at the end of November in 1982. He signed the consent form, required by the Institutional Review Board (twice), and then due to complications, he went into surgery earlier than expected.

Even though the operation was successful, they had a lot of problems at the start.

First, he developed an air leak in his lung that had to be corrected surgically. Then, he suffered from seizures of an undetermined nature. Next, there was also a broken valve on the left ventricle of the artificial heart that had to be repaired. And finally, due to the necessary anticoagulant, he suffered from terrible nose bleeds which also had to be fixed surgically.

Even though preparations were made for him to go home at the end of April, he never made it. He suffered from aspiration pneumonia in early March which sent him back into the ICU, and he never left it again.

On March 21st, Dr. Clark suffered from reduced renal function that induced a high fever. And on March 23rd, he suffered from multiple organ system failure that caused a circulatory collapse which killed him at 10:02 that night. It wasn't the artificial heart that killed him, it was everything else that was going wrong with him at that time.

Evidence-based opposition

Yeah, OK - that was too easy. But it's been over a week, and I've got to post something.

I'm working on some stuff and will be back with it soon.

Thanks to Fightin' Digby.

For a contrast in both substance and thinking, see Scott Lemieux.

More fishin'

This time with my bare hands...

Be back soon.

Memorial Monday - two women murdered

Virginia Voskerichian
Sep. 14, 1956 - Mar. 8, 1977

She was murdered by serial killer David Berkowitz, also known as the "Son of Sam."

From Find a Grave
Photo added by Stan Buturla

- - -

Shirley Ann Bridgeford
1933 - Mar. 8, 1958

She was the second victim of notorious serial killer Harvey Glatman.

From Find a Grave
Photo added by Scott Groll

In plain sight

He sorta looks like Paul Farmer...

My mother always said, "The best place to hide something is right under somebody's nose," though that sentiment didn't prevent her from stashing the ten-pack of Reese's Peanut Butter Cups under the dish towels in the top drawer to the left of the sink when she returned from each week's grocery shopping excursion.

Then again, maybe it proved her point.

Anywhoozle, I just made my monthly $100 donation to Partners in Health, and this time I made it in honor of the ever-observant Eric Widera of GeriPal fame. The dude won a contest, and this was his prize.

If you're confused and really want to figure this out, you'll just have to poke around on your own. (Hint: be sure to check the top drawer to the left of the sink, under the dish towels.)

Gone fishin'

Interesting fishing, indeed

Actually, I've been busy with some other stuff recently, and thus have been unable to update this blog as much as I'd like. I'm also attending the Assembly tomorrow, and so it might be another couple of days before I can wrap up a couple of longer posts that I have in the hopper.

I considered learning how to Twitter in time for the Assembly, based on Christian's enthusiasm for the medium, but in the crush of recent activities (family stuff, job interviews, sunbathing, etc.) I've opted for something simpler.

So, I'll be there with little more than a spiral-bound notebook, several pens, a few copies of my resume, some Death Club for Cuties business cards, a Pallimed sticker kit, and my Flip. I'm not even bringing a laptop to download onto, and will instead focus on quality video.

I hope to feature the results here next week.

Hanx to Jan Nordgreen at Think Again! for the pic

Memorial Monday - Lucille Hegamin

Nov. 29, 1894 - Mar. 1, 1970

Born Lucille Nelson, she was one of the earliest female blues singers ever to be recorded. Her career began while she was a teenager touring the south as part of a traveling tent show. In 1920, Lucille, who had moved to New York City, made her first recordings on the Victor Record label. She later appeared in numerous Broadway musicals including a production known as "Creole Follies." Like many of the "classic blues" singers, her career began to fade in the early 1930's. She left the music behind her in 1934 and became a registered nurse in New York City, a job she held until the late 1950s. She came out of retirement to record again in 1961...

from Find a Grave
photo added by Adam Maroney

Complete Recorded Works, Vol. 1 (1920-1922)

"It's a life panel..."

More here.

Update: I also blogged about this general issue last August, here.

Memorial Monday - Christof Probst

November 6, 1919 - February 22, 1943

Christoph Probst was one of the leaders of the "White Rose," an anti-Nazi resistance movement among German students in Munich. Along with friends Hans and Sophie Scholl and Alexander Schmorell (q.v.), Probst wrote and distributed leaflets condemning the Nazi regime and calling for sabotage against the war effort. After the Scholls were caught distributing the leaflets in public, they and Probst were interrogated by the Gestapo and tried by the notorious Nazi People's Court. Found guilty, they were executed on Feb. 22, 1943, in Munich's Stadelheim Prison.

from Find a Grave

photo added by M.Altinsoy

h/t Daniel Gilbert

It's actually pretty comforting

Yup, this must be the place...

I was using Google Maps the other day to locate a residential hospice. The address on file included Street View, so I zoomed in for a closer look.

A bunch of theories

The correct answer is "nine."

I’m very much looking forward to a couple of upcoming events – specifically the AAHPM/HPNA Annual Assembly in Boston, and my next online grad school course.

I’m only attending the Assembly on Friday, but it promises to be an active day with an early start, a late finish, and a chosen emphasis on the intersection of end of life care/nursing education with social networking technology.

With regard to my next online course, I’m not sure if I’ll be signing up to start in early April or early May. But it’ll be on theories and conceptual models. I like that kind of head work, and am completely up for it.

I’ve been attracted to several models and theories over the years, and have incorporated them into my evolving practice with varying degrees of success. The course will be an opportunity to explore them in greater depth, as well as a chance to learn about others.

The following theories and models resonate with me for different reasons, and they appear in no particular order:

Robert Altemeyer’s work on authoritarianism is a useful way to examine and understand the motivations and behaviors of people and groups. Altemeyer has identified the characteristics of people who need to be told what to do, and who approach life’s challenges in very stark, explicitly black/white terms. Rules are not just important for such people, who he describes as ‘authoritarian followers,’ they’re essential. Altemeyer also looks at those who exploit these followers, calling them ‘authoritarian leaders.’

Robert Hare’s work on psychopathy is as chilling as you might imagine. Psychopaths aren’t nice people, but unfortunately they’re out here in the real world, and they’re out here in surprisingly large numbers.

I’ll spend more time applying the work of both to the nursing profession. At best, I believe it’s important to understand the extremes, if only to better understand the milder pathological forms we encounter. That said, my professional path has most certainly crossed with colleagues whose actions and attitudes more closely fit Altemeyer’s and Hare’s prototypes.

A professor of nursing at a local undergraduate program has done work on the hostile workplace and bullying behavior in nurses. That’s another topic of great personal interest, and this professor’s publications have directed me to several theorists whose works form a good foundation for exploring the phenomenon. For starters, I’ve just ordered Behind the Mask, by Dana Crowley Jack a book that explores violence and aggression in women.

This focus also leads me to the broader field of feminist theory, and to Jo Ann Ashley, author of Hospitals, Paternalism, and the Role of the Nurse.

I think Richard Schwartz’s Internal Family Systems model is a useful framework for understanding our own psychodynamics. I think it also has value for approaching and developing relationships with colleagues and patients.

I recently stumbled upon the Tidal Model developed by Poppy Buchanan-Barker and Phillip Barker. Wow. I’ll be poking around with this one for quite some time.

Finally, in a post here last November I pointed to Human Relationships at the End of Life: An Ethical Ontology for Practice by David Wright, Susan Brajtman, and Vasiliki Bitzas. Their basic message is useful without further explanation, namely that we can be confident of having a sound ethical foundation for our decision making if we engage with patients on the basis of a compassionate relationship. But I welcome the chance to dig more deeply into this thought.

Not just about a fish

John McPhee is one of my favorite writers. His latest piece in the New Yorker's February 8th issue has already been archived, so if you don't have a subscription you'll need to snag the copy at your local library.

Here, he writes about the pickerel, a fierce freshwater fish that I also used to catch at the small pond in Hudson, New Hampshire where my uncle had a camp. I didn't like eating fish much as a kid - except for hot, greasy chunks of deep fried battered haddock.

Catching fish was another story, and I'd go after all of them with enthusiasm.

Pickerel aren't very active in the summer, when we usually fished at night for horned pout. But we always caught pickerel on the tip-ups we set in holes dug through the ice.

McPhee weaves his recollections about fishing for pickerel with those of his father's death from a stroke. The elder McPhee was a physician, and the author writes of the family's first encounter at the hospital bedside:

I was startled by the candor of the doctor. He said the patient did not have many days to live, and he described cerebral events in language only the patient, among those present, was equipped to understand. But the patient did not understand: "He can't comprehend anything, his eyes follow nothing, he is finished," the doctor said, and we should prepare ourselves.

Wordlessly, I said to him, "You fucking bastard." My father may not have been comprehending, but my mother was right there before him, and his words, like everything else in those hours, were falling upon her and dripping away like rain. Nor did he stop. There was more of the same, until he finally excused himself to continue on his rounds.

About that paper...

OK, so it came down to using either this image, or one featuring that unfunny cable-guy redneck comedian dude. Call me elitist.

Anywhoozle, with regards to the APA-formatted research paper that I've groused about a couple of times - I finally got the freakin' thing done.

It's about blogging. If you read it, you'll learn the origin of the term innertoobz, and be introduced to my unified theory of blogging.

Powerful stuff.

Someone's story - The man on the bench by the sea

Seaside bench

from johngpson's photostream at flickr

The first continuing education program on palliative care that I ever attended was held at the Beth Israel Medical Center in Boston, in 2003. I don't remember how I heard about it, but it was a day-long program, and there was no cost for me to attend other than $20 or so to park my car. I even got lunch.

Most of the people there worked at BI, or at one of the other nearby hospitals. I think I was the only man, and one of the few there who didn't work in oncology. I was doing outpatient hemodialysis at the time, and it was that clinical experience that really sparked my interest in end of life care. I've always thought of hemodialysis as the ultimate form of palliative care - it doesn't cure end stage renal disease, it just addresses the consequences and the symptoms of that fatal illness.

I don't recall making very good connections with those colleagues at the time, but I don't know if it was due to my being a stranger among people who knew each other professionally more closely, or my own social awkwardness.

The following year, I signed up for the first Art and Science of Palliative Nursing course developed through the Harvard Medical School's Center for Palliative Care, which has been offered annually ever since. That was when I knew that I had found a group of like-minded colleagues, and when I knew I wanted to work and learn among them. I haven't looked back since.

There's just something about the character of nurses who've chosen this work that resonates with me. Maybe it's the level of maturity, or the shared acknowledgement and acceptance of our mortality. I've found that nurses in this field don't have the kind of need to prove themselves, or to outshine or even put down their colleagues, in ways that nurses in other settings can sometimes display and sadly act upon. It's like everybody working in end of life has finally figured out what's really important. I don't know.

But there you have it.

One of the things I like about this work is the role narrative plays in end of life care. Everyone who works in it seems to not only have a huge collection of stories, but also the eagerness to share them, and the ability to recount them so compellingly.

Here's a story told to me by a nurse who manages a residential hospice and home hospice service in an oceanside community:

The nurse had come to speak about bereavement to a church group, and while there several people told her that one of their members had recently lost his wife. They said that he had become very withdrawn, and had resisted all of their attempts to reach out to him. He spent many hours of every day simply sitting on a bench across from the church, looking out at the sea. She saw that he was sitting there even as they spoke. They asked the nurse if she could go over and talk with him.

She didn't think that was a very good idea, and instead soon placed a call to one of her agency's social workers. She described the situation to her colleague, and gave her the location.

The following day, the social worker happened to be walking her dog in that area. The man was sitting on the bench. The social worker stopped for a minute, sat on the bench to re-tie her shoes, and resumed her walk.

Since she needed to walk her dog at the same time every day, she continued to use the route that brought her by the bench. Each day the man was there. Sometimes she stopped, and sometimes she didn't. Sometimes she sat for a moment, at other times not. She always looked towards the man, and when their eyes met she silently acknowledged him. A week or two passed.

Finally, one day she sat at the other end of the bench, looked over to the man, and said hello. "It's a beautiful view from here, isn't it?" she asked him. "Yes, I like it," the man replied.

"I often see you here when I'm walking my dog," the social worker continued. The man said nothing, and they both sat silently for several minutes before she got up and continued her walk.

This continued for several more days, with the man and the social worker simply exchanging nods or brief greetings when they met.

One day while sitting together in this way, the man reached over and patted the dog. He then began to talk about his wife, and how they would often walk together along the ocean-edge path. He told the social worker that be missed his wife very much.

It's not my story, but I know it's true.

Spot the subtle change and win a prize

You might have to look hard, but it's right here in the blog.

What's the prize?

I will honor the winner(s) in March when I make my monthly donation to Partners in Health. There's a spot in the online form to designate one or more names when the donation is in honor of somebody.

That somebody could be you! ;^)

Hanx to Christian at Pallimed for the whole contest/prize idea...

For J, her family, and her dad

Yesterday, I attended the funeral held for J's dad. J is of one of my dearest colleagues.

She's the physician's assistant who manages the day to day ICU care of neurosurgical patients, along with a nurse practitioner and first year resident. She's bright, capable, confident, and very caring. I include her among the clinicians who influence the way I think about my practice, who guide it, and who I most like to work with.

That's the way it is, isn't it? We look back on years spent in school, or anywhere, and count the best teachers we've had or friends we've known on the fingers of a single hand.

One of the ways that J and I work together is to extubate patients. In our unit, unless the patient is at very high risk for needing reintubation, or has a prior history of difficult intubation, the actual process of extubating them is pretty straightforward. It's done by a nurse and a respiratory therapist, and is over in a matter of seconds. Of course, those few seconds are the anticlimax to lots of careful assessment and preparation, which is where J comes in. The senior resident on the team, or maybe an attending, may note on rounds, "Let's try to get this person extubated." But the team quickly moves on to their next patient, so exploring that possibility, and making it happen when it's the right thing to do, is one of the ways J and I work together.

I've developed a mantra: "Breathe, or die."

It's not a threat, or a sign that either of us takes anything we do lightly. Far from it.

It's a simple statement of fact, and it keeps us keenly aware of the seriousness of it all. The mantra is a way to be sure that what we're going to do is something that should be done.

J's dad died suddenly and unexpectedly. It was an accident. He had two daughters, a wife, and several sisters. His brother died before him, as did his father and uncle who started the manufacturing business that he ran.

I read his online obituary, and looked at his picture there. J's father stands relaxed in a vested tuxedo. Perhaps the photo was taken at her wedding.

I've accepted the fact that I'm older than many of my colleagues, and that I'm even older than some of my colleagues' parents. Now I'm older than at least one colleague's deceased parent.

The funeral was held at a small catholic church tucked away in a pocket of rural New Hampshire. The place was filled. I was pleased to hear the priest who gave the eulogy. He spoke well, and he spoke well of J's dad. He knew him.

At the end of the service, a pianist and a singer in the choir loft began the tune, 'How Great Thou Art.' The musical arrangement was a simple one, and at first the singer's voice was soft, even a bit hoarse and almost bluesy. He slowly gained force with each line, and by the end he was firm, clear, and direct. It was moving. It fit the time and place. It fit our reason for being there.

Then, just a few short seconds after the last notes of the hymn faded from the piano, a man standing just outside the door began a dirge on his bagpipe, and continued playing as we all filed past.

I didn't go on to the cemetery, and returned home along the same quiet back roads I had taken earlier. I thought about the music I had just heard, and about the power music can have at a time like this.

I love listening to opera, though I often don't know the specifics of a particular story when I first hear it. What really grabs me is the sound of the singing, and its emotion. I've been told that, in Italy, opera goers are as passionately involved during a performance as the most rabid Red Sox fans at Fenway Park.

I was lucky to be in the stands for Clay Bucholtz's no-hitter. I understand how someone sitting up in a music hall balcony can be brought loudly to their feet upon hearing a performer really nail it.

There's an episode of 'Six Feet Under' that features a famous aria from Pucini's last opera, 'Turandot,' as part of a man's memorial service. It's a quieter than usual performance of the well-known piece, 'Nessun Dorma.'

The priest who spoke at the funeral talked about the catholic faith in everlasting life, though he presented it as a certainty, as something that catholics know to be a fact.

I have to admit that I'm not nearly as sure about all of that.

I'm going to send a note to J in one of my daughter's cards. I don't know when I'll next see and work with her, or even if. I think I'm also going to include a CD that my son's band recorded. He's the drummer, and he calls their sound a mix of rock, funk, raggae, and rap. They write most of their own stuff, including a tune called 'Life Goes On.' Maybe it will fit a time and mood for J at some point.

For now, here's a 1980 performance of 'Nessun Dorma' by Luciano Pavarotti, with Zubin Mehta conducting the New York Philharmonic. I'm told that this clip shows Pavarotti in his absolute prime. I found another by him here, in a 2006 performance that's listed as his last one ever. He died the following year. I also enjoy watching this version by Roy Cornelius Smith, which has the added benefit of featuring the song in the context of the staged opera.

Maybe the priest is right, and everlasting life is a lead pipe cinch. If that's the case, I hope it unfolds like Pavarotti's singing.

Nessun dorma! Nessun dorma!
Tu pure, o, Principessa,
nella tua fredda stanza,
guardi le stelle
che tremano d'amore
e di speranza.
Ma il mio mistero è chiuso in me,
il nome mio nessun saprà!
No, no, sulla tua bocca lo dirò
quando la luce splenderà!
Ed il mio bacio scioglierà il silenzio
che ti fa mia!
(Il nome suo nessun saprà!...
e noi dovrem, ahime, morir!)
Dilegua, o notte!
Tramontate, stelle!
Tramontate, stelle!
All'alba vincerò!
vincerò, vincerò!

Nobody shall sleep!...
Nobody shall sleep!
Even you, o Princess,
in your cold room,
watch the stars,
that tremble with love and with hope.
But my secret is hidden within me,
my name no one shall know...
No!...No!...
On your mouth I will tell it when the light shines.
And my kiss will dissolve the silence that makes you mine!...
(No one will know his name and we must, alas, die.)
Vanish, o night!
Set, stars! Set, stars!
At dawn, I will win! I will win! I will win!