The Club

,"One. In thirty years, just one."

The inpatient units of urban medical centers are busy places, and a week or so ago this one was no exception. Every chair in the central station area was occupied by a being focused on a task, but those beings frequently and quietly interchanged as one moved out into the corridors and patients' rooms and another came to the desk intent in consultation or gazing with furrowed brow into a computer screen. So much activity, an ambience of organized clutter, ample space to move about, but standing still risky business. Phones, faxes, pagers, someone's (forbidden in this area) cell phone, all those computers, occasional laughter, an ongoing white-noise-like drone of multiple simultaneous conversations.

I watched Ann as she spoke, and all the rest faded into background oblivion. Now in a senior inpatient position, she worked for years, thirty of them, as a nurse in the Emergency Room. And saw it all and did it all. The homeless and other down-and-outers tended to congregate there, and Ann took them in, treated their maladies of the moment, and let them hang out, where it was warm (or cool) and dry and safe. She had many, many "regulars" returning frequently with the same or still another problem, and for thirty years she dispensed emergency treatment, a human connection, access to a temporary safe haven, and a push in the right direction given in the eternal hope that the recipient would seize the momentum and continue on a constructive path. But the regulars kept returning, with another wound, another illness, another accident, the same old problem flaring up again, or just a desire for a safe place to be indoors for awhile. More treatment, the human connection again, the temporary haven, another "push," and out the door . . . only to return in a week or month or whenever.

And such characters they were! One was tattooed literally from the base of his skull to his feet, and a colorful fellow he was, too, in more ways than one. In and out of the ER for years, a "regular" dubbed "Tattoozie" by the staff. Here he is again, another problem, another story, patch him up, joke with him, give him the little lecture about the need to change his ways, and send him on his way until the next time. Eventually Tattoozie faded away as so many did, and the ER staff would wonder from time to time what had happened to them all, knowing that most probably whatever it was wasn't good, but not having time to wonder too much, because the next generation of regulars, and others, was streaming in the door.

Years passed, and one day while working in the back of the ER Ann was paged and asked if she had time to go up front, because someone was there to see her. She went, and approaching the front desk saw a tall, impeccably groomed man in a three-piece suit waiting for her and looking remotely, very remotely, familiar. She stared.

"You don't remember me, do you?" he asked.

As Ann studied his face for a moment, trying to clear the cobwebs from the deepest corners of her memory, he turned his head slightly, and just above the crisp white collar around his neck she saw the tip of a tattoo she once knew well.

"Tattoozie!" she exclaimed! "What happened to you?"

"I got Jesus," he responded, "and I've always wanted to come by and thank you for all the times you took me in and took care of me."

The sense of my eyes moistening slightly was a welcome relief after hours in the dry hospital air, and I blinked and told Ann, "I know. I was the nurse for Cabrini-Green."

Someone hit the "slow motion" button as Ann's and my eyes met then. She said quietly, "Then you do know." Turning away she fed a page into the copy machine before looking back to me. "Thirty years. In all those years only one came back. Just one."

"Yes, but you got one," I said quietly.

"I did. I got one." A small smile, our eyes met once more, and click. Confirmed mutual membership in The Club. And the pagers and phones and conversations and person trying not to be impatient in waiting for my seat came into focus once again.

There is a club-like camaraderie among those who have served in the trenches, be they in battlefields, on the front lines of wars on crime, or at the juncture where the ill and injured meet those who work to make them whole again. I am of the generation that served in Vietnam, and have heard countless times, "You weren't there, you don't understand." And I know that I don't and can't understand. I rode with Chicago police officers for years as they escorted me in and through Cabrini-Green. We swapped stories, I listened to their accounts of what had happened the night and day before, they learned to help me with bandages, counseling, and reconnaisance missions through the trash to locate incriminating evidence to explain why a blood sugar was elevated or a patient suddenly presented with an "altered" mental state. But when one of their own was killed in the line of duty and I would join the thousands of police officers from around the country paying their respects at the funeral I did not need to be told that I did not understand their loss. I understood mine, which was bad enough. But theirs would remain forever unfathomable to me.

And so it is among those of us who have shepherded the Tattoozies of the world through Emergency Rooms for thirty years, downed cold pizza and bad coffee in hospital corridors at 3 AM, banged on a chest and breathed our own breath into a "coding" body only to watch helplessly as it slipped into the next world, watched the sun rise through dingy hospital windows after a 12-hour shift that seemed at least three weeks long, caught new babies coming into this world and the tears of parents when other babies left it, saw the patient who wasn't supposed to make it walk out the hospital door on Christmas Day to go home to celebrate with family, and sat in stunned silence as the "routine" case went terribly, inexplicably wrong and the consequences were dire. "Gray's Anatomy" and "House" and "HawthoRNe" and all the rest don't begin to capture the bond that starts growing over undergraduate textbooks and the anatomy lab, through the development of sufficient knowledge and skill to work with confidence, to achieving a practiced eye and inexplicable intuition that "knows" in an instant what's afoot and what needs to be done. Often Club members speak in shorthand, or not at all, when they communicate; they know. And when seconds count that knowing is invaluable.

There's strong mutual trust and respect among Club members; there must be. For when the patient's life, the integrity of the team, and our individual livelihoods are at stake time and time again and every moment lost means heightened danger, we must know that our colleagues have our backs, and we theirs, so that together we can move a seamless operation forward with no looking over shoulders, our own or one anothers', to be sure all is right and proper. If that trust is violated, expulsion from the Club is prompt and permanent. This is not an act of anger, rather it is one of necessity and sadness, and we may speak for years of our hope that the expelled member availed him- or herself of assistance and was able to begin anew down a better path. I suspect the severity of this action is one reason doctors and nurses sometimes are tempted to protect a wayward colleague whose practice is not quite up to par or who has made errors in judgment. There is a sense of "there but for the grace of God go I," and a fervent hope that the troubled associate will see the light and make it right in time. We are human, we are capable of corruption and greed. Ignorance, fatigue, and short-sightedness exact their toll on us as they do on everyone. We have complementary strengths and different weaknesses, and no doubt the highest good is served by our truly collaborative efforts. But "outsiders" cannot know the nature and strength of the bond that ultimately unites us.

There are "associate" members of the Club, who are the therapists, counselors, dietitians, and so many others whose knowledge, skill, and contributions are in no way lesser, but whose services are more narrowly focused and temporally limited. There may not be a Registered Dietitian or Physical Therapist in the hospital at 2 AM on the Fourth of July, but you can bet there are doctors and nurses. For patients to heal and achieve the most complete rehabilitation possible nutrition and therapy are critical, and it is dietitians and therapists who will discern when a subtle change in a lab value indicates a need to tweak a tube feeding or when a slightly misplaced assistive device portends a fall. But those aren't the colleagues we expect to make decisions at the juncture between life and death, and few have had as much cold pizza and bad coffee watching the sunrise through dingy windows at 5 AM as have nurses and doctors.

And there are "emeritus" members of the Club, those who leave clinical practice to pursue careers in such fields as administration, bench science, medical sales, and teaching. These folks are respected as once having been "one of us," but with the awareness that they have lost their "edge," and have not experienced the real work of clinical practice in the circumstances of today. Health care changes rapidly these days, and those who harken back to their experience of even a few years ago already are "out of the loop" of contemporary practice and its context. This is not to denigrate administrators, basic scientists, business people, or educators; their roles, too, are important and respected. But they may not be the people you most want to call when decisions about your health need to be made.

There is even "cross-Club communication." Some years ago I treated Willie, a Cabrini-Green resident who, with diabetes, high blood pressure, and a myriad of other problems, had undergone bypass surgery on his legs in an attempt to improve his circulation and prevent amputation. The surgery failed, and Willie was left with gaping wounds on both legs, and little blood supply to help heal them. So I visited Willie for a very long time.

One day I walked in, looked at him, and said, "Willie, you're going for a ride." He nodded as I picked up the phone to call "911," and knowing Willie's strong dislike of hospitals, that nod was all I needed to see to have my decision validated. Now I don't remember what problem Willie had that day, but I set about completing my evaluation, gathering data for the paramedics, and preparing Willie for transport. The ambulance came, left with Willie on board, and "my" cop and I began the long walk down the highrise stairs.

"Suze, how'd you know he needed to go?" the cop asked me. He continued, "I mean, I'm not saying he didn't. And as you were doin' your stuff I saw what was happening and could tell that he really needed to go. But you just walked in the door and said, 'You're going for a ride.' You hadn't touched him, and he hadn't said anything. How'd you know that?"

How to explain. I looked at him, a tactical team member turned homicide detective, and countered, "How do you know who's the bad guy?"

A pause.

"Oh," he said, knowingly. Click. One Club meets another.

That conversation with Ann ten days ago was important, because I go to that medical center as an outside liaison, representing my home care company and helping to transition patients from the hospital to home. But although my name tag says "RN," there is no way for people to know if I am an active or emeritus member of the Club. In fact, I continue to maintain a clinical practice. And this is not, as I suspect my boss believes, just to "keep my hand in" practice or to satisfy a personal interest akin to a hobby. It is also because I know that to work effectively with the doctors and nurses who send their patients to my home care company I need to remain an active member of the Club. I must keep my "edge" razor sharp, speak their language, and be able to translate patients' at-home needs and circumstances into words their hospital- and community-based doctors and other providers can understand. I need to be fluent in the shorthand of the day, and to demonstrate that I still have my colleagues' backs, no matter our roles or professional affiliations. I hold a fancy title about "business development" now, but to be successful in my work, to grow and develop my company, to build relationships that matter, and to assure that clinical excellence happens, my most important credential is my intangible membership in the Club. It's not just about being able to answer a patient-care question that a non-clinical person could not; rather it's about speaking the language and having a common bond of experience with our collaborating providers. I made sure Ann knew that my Club "membership card" bears the date "2010."

Particularly with so many people unhappy in their work, or lack of same, these days, I am grateful for the opportunity every day to touch lives and make a difference, and that is the work of clinical practice, of Club membership. It took a year and a half, by the way, but Willie's legs healed and he recovered. The next time he got in trouble, he called me, and when I picked up the phone and made a plan with him, he said, "Thank you." (Hey, Ann, I got one.) And for all the frustrations and inefficiencies of the health care non-system these days, the next time you pick up the phone to call for help, thank your lucky stars whether or not the person responding has a fancy title or a corner office in an executive suite, as long as she or he is a member in good standing of

the Club.

And What Will They Say?

One gorgeous late summer afternoon last year my dog's delight at the dog beach prompted me to seek a similar treat myself. So I hopped on my bike and headed for my favorite local sandy shore. Settling on a spot, I pulled out the old sheet that serves as a beach blanket, and bent to spread it out as I had a million times before . . . and saw stars. Sudden, sharp, jolt-out-of-nowhere, take-my-breath- away-and-don't-give-it-back pain in my lower back. I hadn't twisted or turned, hadn't picked up anything, hadn't bent or moved strangely, but in a flash I could barely move at all. No positioning, no deep breathing, nothing seemed to help, so I gingerly reclaimed my bike and laboriously trudged slowly home, pushing the bike and trying not to breathe too much, because it hurt too badly.

When my first-ever deliberate mixing of drugs and alcohol (a cold beer to wash down an over-the-counter pain reliever) and hours of rest interspersed with various efforts to find a comfortable position failed to bring relief, my neighbors put my shoes on my feet and gingerly carted me off to the Emergency Room. There I was asked repeatedly to sit down, despite having explained that if I did so getting up again would be excruciatingly painful, and perhaps impossible; examined by a most deliberate medical student; and graced with the presence of the attending physician for approximately 90 seconds, after which came the pronouncement that my problem was muscle spasms, which would go away if I took a narcotic pain reliever and a sedative, and then got a good night's sleep, thereby relaxing the muscles involved. I then was to find and see an internist, and have a MRI somewhere along the way. An injection of a narcotic was administered to jump start the process.

So, after the obligatory pass through the drive-up pharmacy window, my neighbors carefully deposited me back home, where I downed the prescribed pills, and went to bed . . . only to wake up unable to move because every part of me seemed directly connected to my back, and anything more than twitching a finger sent that sharp, stabbing pain shooting through me once again. In desperation I figured a way to turn over while keeping my back straight, then push myself up with my arms, and finally shift my weight forward until I was standing on my feet. I then could shuffle to the bathroom, and swallow more pills. I felt groggy and mentally cloudy, but the physical pain remained as strong. The earliest available MRI appointment was a week away. The internist was out of the question.

A physician friend who had been monitoring my (lack of) progress via text message finally declared that if those drugs weren't helping me it was clear that I had slipped or torn a disc and would need surgery; he had a wonderful surgeon standing by, and was coming to get me. Back surgery? Me? Oh, no! I insisted on one more day.

The next day dawned with equal misery: Drugged stupor, and excruciating pain. There were two more doctors I wanted to see, who practiced together in what we loosely termed an "Arthritis Clinic" that we took on the road to various senior communities. More friends to the rescue, and my stuporous self was deposited among the oldsters in my very own clinic. "I won't even touch her until she has that MRI," shouted the MD. But the Doctor of Chiropractic sitting next to him, who also happens to hold the MD degree but chooses to practice chiropractic medicine, grinned slightly, watched me move, listened to my tale, and repeated, "I know what this is." He got me on the exam table (somehow!), did some kind of manipulation for just a moment, and asked how I felt. The answer was, "Fine" [shocked!]. He showed me three simple exercises and told me to do them twice a day, recommended that a Physical Therapist friend stop by and give me a few ultrasound treatments, and promised that I'd be good as new in a week.

He was right.

The Emergency Room and doctor there cost thousands of dollars and yielded an incorrect diagnosis and ineffective treatment. Had I agreed to see the surgeon and undergo surgery the cost would have been much greater, and the surgery would have proven unnecessary. Of course I would have lost time at work and created additional expense for my company, not to mention the unpleasantness of the post-operative recovery period I could have anticipated. The MRI would not have been cheap, and would not have yielded useful information, and of course my insurance company and I paid for the drugs that didn't work. I can only speculate about what the internist might have done, and that speculation includes additional costly tests and referrals to more (expensive) specialists. My problem was capsular entrapment; the chiropractic manipulation released it, and the drugs didn't touch it because the capsule doesn't have a blood supply. The MRI would not have visualized it, and blood tests and scans would have yielded normal results.

I have written previously about my concern about the availability of health care providers to meet the needs of those who need services. The "cousin" of that concern is the larger issue of how we are to evaluate and treat health needs, who best can serve patients with different problems, and how these providers shall be paid. My hunch is that if the full spectrum of reputable health care providers were covered by insurance and were not subjected to MD "gatekeepers," treatment would be more holistic and effective, and less costly.

Modern medicine is wonderful, and its doctors (MDs) knowledgeable, skilled, and concerned. But it is but one perspective, and one set of tools for maintaining and repairing the incredibly complex human organism. It is about the diagnosis and treatment of pathology, according to one model, and one set of standards. There are others.

One fifteen minute session with a perceptive and skilled chiropractor did what hours in the Emergency Room, drugs, expensive tests, and surgery could not. The doctors were not wrong; rather they were practicing without the tools they needed to do the job that I needed done. They did the best they could with the knowledge and tools they had. The chiropractor brought another set of knowledge and skills; this one happened to be the one needed. Some years before an accupuncturist brought me relief for a chronic tendonitis that medicine and therapy had not touched. As a nurse, trained in the science of people's experience of and reactions to changes in their health states, and in teaching and collaborating to move people towards their health goals, I have knowledge and skills that MDs do not. Certainly they have knowledge and skills that I lack. Are patients not best served when we work together?

As a patient, I want my providers to have a full "toolbox" from which to select the treatments that are best for me. Sometimes those will be prescribed and overseen by MDs, but other times a psychologist, chiropractor, accupuncturist, nurse, therapist, or other professional will better serve my needs. A prominent physician at a major medical center once remarked in a presentation at a scientific meeting that one of the things he had learned from his "colleagues in reflexology" was the value of the light touch in a physical exam. Reflexology? Snake oil for sure, I would have thought. But this highly credentialed, accomplished, and respected physician and professor had troubled to learn what "colleagues" in that field had to offer, and had come away with something of value. My guess is that more of us could benefit from such open-mindedness.

There is the legitimate argument that many "alternative" or "complementary" methods and treatments remain untested by rigorous scientific research; this is important. However, it also is true that this research often is blocked or given very low priority in the competition for funds and support, thanks to the overarching influence of western medicine and associated lobbies and interest groups. So support for research continues to go primarily to the sorts of problems and methods that have received priority for years, with fine results . . . but also at the cost of equally valuable findings in other fields of health care practice.

The House and Senate now have passed "health care reform" legislation, and are beginning the arduous process of hammering out their differences to reach a compromise package that can be passed by both chambers and signed by the President. I still get a headache thinking about this. But whatever the final bill that emerges, I wonder not only who will answer the phone call for an appointment, and the call light at the hospitalized patient's bedside, and the other pleas for health care help. But also I wonder when those responding providers meet the patients who summoned them,

What will they say?

Will they have only the perspective, tools, and training of western medicine, or will they be able to offer a full complement of health science and skilled, reputable practitioners to evaluate and meet those patients' needs in the most comprehensive, creative, and cost-effective ways possible? What tools do you want your providers to have in their toolboxes? Perhaps it's time to let your legislators know.