Here I am sitting alone in a Whole Foods in Frisco, CO mulling over an ethical dilemma. I wanted coffee and a croissant (because pastries solve my problems ::sarcastic font::), and my flagrant efforts to flag an employee to ring me up were fruitless. Since they leave both items available for the taking, I served myself, sat down, wondering whether I should consume them and discard the evidence. I mean, I spend so much money on the overpriced items in this damn store, anyway, that I’ve earned it–right? I sat down and, naturally, pulled out my iPhone for company and distraction, delaying the decision.
I happened to read this article chronicling one woman’s experiences as an employee in the ER that led to her precipitous burnout and subsequent resignation within a year.
And I started to cry.
Right there in the Whole Foods dining area, surrounded by patrons jovially noshing on their breakfast burritos or chia yogurt, wearing puffy jackets, hats with the Pom Pom on it that look ridiculous outside of a ski town and, of course, Colorado-themed apparel.
The last time I cried spontaneously in public like this was all-too frequently during the year following my Mom’s death (about six years ago–well there was a particular heartbreak last year that caused an isolated episode in my car, but that doesn’t count). The spontaneous tearful episodes grew less and less frequent until I could control my emotions until a few occasions a year when I was sequestered in the confines of my bedroom. Ok, so sometimes it still happens uncontrollably when I miss her, but I feel like losing a mother is an appropriate cause for tears.
A job, though?! A job shouldn’t provoke such strong emotion. It’s a means to earn money to pay for things low on Maslow’s hierarchy, like food and shelter and security. And, if you’re lucky, you can afford the luxuries higher on the hierarchy and maybe even one day achieve that “self-actualization” that I’ve heard about but never really understood (the spiritual side of me assumes this cannot be discerned until after death–but that might just be an excuse for not pursuing it on this Green Earth). I digress.
I cried because I very closely identified with this woman’s story. I, too, worked officially in the ER for a year before experiencing the same burnout that she did. Even about three years of training in the same institution couldn’t have prepared me for the complicated blend of emotions, feelings of helplessness one moment and elation the next and frustration–always. Oh and feeling dumb most of the time, to boot. So I, too, quit and took a minor step down the stress level to work with High Risk Heart Failure patients at the same indigent-serving hospital.
After learning the ropes in HF, I realized (and would sarcastically comment to others when I described my job) that I used to watch people die quickly in the ER and then I watched people die slowly of HF–people that were alinated from the system for one reason or another. I’d get angry over those that “slipped through the cracks” of US healthcare and would die eventually after struggling unduly, without the resources that they deserved. I was perhaps even more angry, though, over those who–by their own behaviors and neglect–were not only ill but also taking advantage of the system, bastardizing it for their own self interests. The worst people never seemed to die, though–“the Cockroaches.”
I started becoming hollow. I didn’t have time to spend as I’d like with friends and family. And when I did, I was completely, emotionally empty. I wasn’t “there” at all. I tried to maintain romantic relationships, but I’d become either withdrawn and distant, or that individual would be the object of my venting–certainly not his job and certainly to conducive to cultivating a healthy relationship.
So I quit. And dramatically this time. I had the opportunity to work for a start-up sports nutrition supplements company in Colorado–across the country from my home town, Atlanta. So I made the leap of faith, and loved the life! This “work” didn’t even feel like work at all. “Seriously?! People answer emails and go to events and make money?!” I travelled. I met a lot of amazing people. And I justified my actions. “Oh I’m ‘helping’ people by giving them the tools to do well at their triathlons, which people obviously do for some existential reason. Ergo, I’m helping people achieve their existential life goals…”
Well, my heart knew that this wasn’t how my soul needed to “help” people (no offense intended to those in this and similar industries). And perhaps Serendipity intervened because things didn’t work out with that company after a short period of time, forcing me to, again, revisit the occupational and vocational questions that have pervaded my life since high school.
You can read about what I called the Existential Opportunity elsewhere in this blog. Cliffs notes: ultimately, I decided that I needed to work as a Nurse Practitioner because it is a gift and a skill that I’m pretty good at, that brings me joy (ultimately–in the Fr. Michael Himes definition), and that the world needs me to do.
And I found a small, entrepreneurial practice that delivers care in Long Term care facilities–like rehab and nursing homes. The culture of the company satisfied my entrepreneurial spirit and provided a lot of opportunity for advancement. The schedule was far more flexible than any NP job I’ve heard of, the pay was supposed to be good (based on volume, so efficiency was rewarded rather than punished as in my previous NP jobs), and it’s NURSING HOMES for Goodness’ sake! The work would be easy. These are just old folks hangin’ out and playing bingo, …right?
Turns out long term care is perhaps even more stressful than the ER in many ways. I identify with this patient population far more closely than my previous jobs in Atlanta mostly because these people could be my own grandparents. I spend far more time with them than any ER patient (even those with the most ridiculously long wait and/or holding times)–I have a total of about 40 patients who I see at minimum a few days a week, at least in passing if not for an official patient visit. I’ve learned how to decipher the expressive aphasia of one particular 85-ish-year-old, bubbly patient, who follows me around and has ventured on a quest to set me up with her widowed son, who I can only imagine is somewhere in his 60s (really? Has it gotten that bad for me?) I’ve learned what level of nonsensical speech is normal for one patient with Alzheimer’s versus another. And how to make those with the highest levels of cognitive impairment respond appropriately to the specific questions I need answered in order to properly care for them.
Also, some days I feel like I’m working in an ER–except without the resources and staffing to properly address emergencies. And often without the legal authority to intervene, given that many patients’ Advance Directives dictate Do Not Resuscitate (if you haven’t filled out a form, there’s a standard form in each state, like CO’s MOST form. Do it today and give someone a copy!)–which I fully support; however, I never fathomed how difficult it would be to stand at the bedside helplessly, watching someone actively dying without the ability to do anything. At least in the ER you can aggressively mash on someone’s chest or start and IV and push a bunch of drugs or DO something, anything–even when you know those actions won’t make a difference.
Particularly challenging are those patients who are not under Palliative Care or Hospice services–which brings me to the other challenge pervading Long Term Care, Emergency Medicine and every area of medicine, for that matter–the legal nature of the US system. “If I give this actively dying, non-hospice patient Ativan and morphine to make them comfortable, am I going to get sued for potentially ending her life early by depressing respirations?” I’ve asked myself more than once. I then spend so much time I could be actively engaging with the dying patient and/or his/her family thoroughly documenting the justifications for why I left the patient uncomfortable or why I potentially expedited the patient’s “expiration” in an effort to “CYA” in hopes that I won’t be one of the unfortunate ones brought to trial for trying to do my best in the complicated and convoluted world of healthcare.
There’s also tragically young people in nursing facilities with heartbreaking stories along with–not surprisingly–many personality and psychiatric disorders that raise a boatload of ethical and legal issues–particularly when their previous providers didn’t have the patience, time and/or resources to appropriately address the true root of their “unspecified abdominal pain” or “atypical chest pain” or “early onset dementia with aggressive behaviors” or whatever nonspecific diagnosis was documented in conjunction with high doses of narcotics and/or benzodiazepines that–in the provider’s defense–the patient adamantly demanded. Now those patients are not only struggling with a crazy autoimmune disorder or quadriplegia or Cerebral Palsy along with a legitimate psychiatric disorder (I, too, would struggle with depression at minimum if I were trapped for life in a facility with 90-year-old demented folks), but they too have a dependency on medications that AREN’T EVEN ADDRESSING THEIR COMPLAINT! (Narcotics are the worst for chronic pain–another post for another day, but it essentially makes the pain as well as depression worse. If you break a bone or have a kidney stone, it’s a different issue. And benzos help in conjunction with things like cognitive-behavioral therapy. I digress again.)
I had a particularly challenging week last week, riddled with ethical dilemmas far greater than whether I discretely consume coffee and a pastry without notifying the Frisco Whole Foods staff (for the record: I didn’t–after writing this, I approached the register and paid for them). No, these ethical dilemmas contribute to determining the quantity and quality of life an individual will enjoy–dilemmas that determine whether that person dies peacefully and with dignity, or whether my hands are tied, listening to the family bicker over their selfish interests in such indecision that they fail to notice their “loved one”audibly grunting in pain as they breathe perhaps their last few breaths–pain that no one should have to endure.
So I ran to the mountains. By myself (big thanks to Debi for providing the accommodations!!) And for the ninth time in my life (? I lost track) I wonder whether the stress and emotion of this “vocation” is worth the paycheck. How much self-sacrifice can I tolerate while maintaining my own emotional, spiritual and physical health? I have a couple days to think about it before I return to work on Monday. And remind my boss that I cannot work more than four days a week, as I stated from the beginning–perhaps I need to drop down to three. Because I truly love the work and know that in need to continue to do it in some capacity. But maybe just not full time.
Soooo is anyone looking for a part-time former marketing professional turned NP turned start up entrepreneur turned NP again to do 10-20 hours of mindless work a week? I know someone with availability.
In the meantime, you’ll find me on the slopes!