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Cerasela Shiibarn photoThis post is written by Cerasela Shiiba RN, BSN, a graduate student in Community/Public Health Nursing at Hunter-Bellevue School of Nursing where she received her BSN and the Sara Aronson Hunter College Alumni Award in 2013. As a professional registered nurse she is committed to advocating for the underserved, addressing gender inequality and gender violence. She attributes her passion for community nursing to her nursing education and growing up in a small village in Romania.

Waiting, I will not be here for long. My friend will return from seeing the doctor soon. Watching people makes waiting interesting. I have time to observe details. Grey chairs are lined up in rows.  Monet prints with thin black wood frames give the room a French style. Vibrant golden frames would better reflect the time era.

Several patients are sitting and waiting.

I turn my head towards the “Welcome New Patients” sign placed on top of a glass window.  A timid-looking middle-aged man slowly opens the door and enters. Ah, I can have a story now. The man stands in front of the reception desk and looks through the window glass.  The medical assistant slides open the small window on the lower portion of the large glass. She is dressed in white scrubs. Her name is embroidered in grey calligraphic forms, Vera,B.  From the middle of the room, I see only her upper body. She leans forward, trying to fit her red hair pulled in a bun through the small window.

“Your name,” she says quickly and in a voice loud enough for all to hear. 

Jose has to bend down to answer her through this small opening.

“Jose.”

“What type of insurance do you have?”

“I don’t have one,” he says in a low voice.

Vera takes her eyes from the paper, while placing the clipboard on the desk. Click.

She turns her sight towards her colleague. She raises her eyebrows and continues her interview.

“Who told you to come here?” she says in an impatient voice.

The glass window acts as a barrier between Jose and health care.

“The doctor, two days ago, I went to ER. I had back pain. They told me, I have kidney stone.

The doctor said to come here today, for follow up.”

“Well, we don’t take people without insurance.”

Jose is one of 41 million immigrants, 46% of whom are Hispanic. Undocumented immigrants are close to 20 million and they are not covered by the Affordable Care Act, according to the Migration Policy Institute. Undocumented immigrants do not have access to insurance even when research shows that, “Undocumented immigrants may not be contributing to the increase in health care costs in the United States and that addressing health care needs of this population could in fact reduce expenditure.”

I strongly believe that everyone must have access to health care, including undocumented immigrants. Undocumented immigrants are not eligible for ObamaCare even if they work, live, and engage as members of our communities. In New York State undocumented immigrants do not qualify for private health insurance.  

Why can’t people like Jose have access to health insurance?

Financial costs are always the first argument you hear against making health insurance available to undocumented immigrants.

But there are costs to be considered not making it accessible – financial and human.

Undocumented immigrants do not seek preventive care.  They will wait until their symptoms are worse or their pain unbearable. Then they seek care in the emergency room. The cost of treatment and the management of an acute health issue can be complicated and costly. Sometimes it requires the person be admitted to the hospital to stabilize a newly diagnosed or unmanaged chronic illness. Perhaps preventable if this person had access to primary care.

It would make sense for undocumented immigrants to be included in the Affordable Care Act (ACA). Access to preventive care is crucial in reducing the cost of health care. Chronic diseases could be identified at earlier stages; therefore the cost of treatment will be reduced. These situations could had been avoided if the ACA would include all people, including undocumented immigrants. During the debates on the ACA Obama avoided discussing the inclusion of undocumented immigrants in the health care reform.

Immigration reform and lack of action in Washington impeded inclusion of undocumented people. 
I believe there are no simple answers. However, one way to solve this problem is perhaps to extend  Federally Qualified Health Centers (FQHC) in local communities that serve vulnerable population regardless of their immigration status. FQHC are part of the safety net providers such as: public hospitals, clinics, charity organization and local health departments. Safety net providers are financially strained due to limit on reimbursement for their services.

Or maybe, extending the access to Emergency Medicaid. At this time, undocumented low-income immigrants are only qualified for emergency Medicaid.
Increasing public awareness, taking an active role in advocating for this vulnerable population through debates, research, writing, blogging, participating in local and national government, and supporting bills that reform ACA to include this population.

It is vital for undocumented immigrants to have equal access to health care. The story does not end here. It is just the beginning of a greater mission, universal health care for all.

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This post is written by Cerasela Shiiba RN,

HealthCetera

Devorah Goldberg photoThis post is written by Devorah Goldberg, RN, BS, a bedside nurse on a general medical-surgical unit at NYU Langone Medical Center. Ms. Goldberg is a graduate student in the Adult Nurse Practitioner program at Hunter-Bellevue College of Nursing and received her baccalaureate degree in nursing from Adelphi University in 2013. You can read more by Devorah Goldberg and her life as a registered professional nurse – the meaningful relationships with patients, families and colleagues and her experiences facing rough spots as she moves along her journey as novice nurse on her blog, Tales of RN DG.

The staggered breaths painted shapes on the monitors. It jotted out perfect waves for one minute, and childlike scribbles the next. Those scrawled shapes relayed fluctuating signals; between hope and dread, between life and death. It was as if the ‘angel of death’ was there, had his sword in hand, target area marked, blade in place, but hesitant to make the hit. The breaths were present, but were the waves of storm rather than the waves in a surfers dream; rocky, damaging and unpredictable. The heart beat like a stationary race-car, rapid but thready, and unable to perfuse the body’s arterial racetrack. The translucency of the skin, windowed a dense yet motionless being.

Lips moved in prayer, while minds weighed the depth and upshots of their decisions. DNR. Legs raced as if on a mission, but never leaving as far as the edges of the bed. The corridors signaled the finish line, only centimeters away but reaching it meant the end was met, so the feet tread those areas cautiously. Those lips whispering prayers, dreaded, yet awaited the finish line.

The hours passed by. The screens fluctuations between the dreaded straight line and a perfect QRS wave confused the humans reading the signals. They asked me if it was the end, the monitor seemed unsure. I enter the quarters of the beating monitors possibly masking a life gone by; I am face to face with the thin wrinkled being curled up in the sheets, gasping for each breath, and a morphine infusion running in attempt to wash the pain away.

I felt the pulse. Thready and fast. It seemed to weaken as the seconds passed by. I kept my hand on the pulse, for at that moment it was the only sign of life, yet proof of its nearing end. Perhaps if I let my fingers go, that life might slip away, right through my fingertips.

My job is to promote life, and here I was anticipating death. My job is to chase away the ‘angel of death’ and here I felt like mapping out the directions for his next stop.

The ‘angel of death’ was well acquainted with the being curled up in the wrinkled sheets; the ‘angel of death’ had chased this being before. He didn’t wait till her 93 years to greet her. His multiple introductions to this being began over 65 years prior when she cooked for the Germans in the barbed wired gates of Auschwitz. The ‘angel of death’, marked his target back when she was out there fighting diseases in the concentrations camps, he was there when she  used to sneak in potato peels to share with her bunk mates, he was there every morning when she awoke before sunrise to the threatening barks of the soldiers on guard.

Now she can surrender, because she has already made her victory. Every day that she lived, and made lives through the offspring she produced and raised, made her the victor. We watched as her chest rose and fell with trepidation, each movement using much effort, until all efforts were used. We called the doctor, he marked the time, and we covered her. Her soul had won its last fight.

The monitors stop, their frantic scribbles and the straight line of defeat stretches to eternity; and our hands meant for healing are cuffed to our backs preventing us from evading  the inevitable footsteps of ‘the end”.  Yet perhaps an even greater challenge is when that line marches on, merging with all the other listless strings of lifeless pulses. This was the first, so it hurt; but so did my first IV insertion and the many ‘firsts’ of painful things I had to initiate for the good of the humans it was inflicted upon. Time and experience forms an armored defense that can make each patient’s death a little less personal and a little more algorithmic. Experts might argue that such is an uncomfortable inevitable, but deems it unwise to bear the burden of each meeting with the ‘angel of death’. Yet one can also choose to take each opportunity to familiarize oneself with the tragedy it brings and practice the touch of caring that goes beyond the life of the being in the bed sheets. The challenge is to continue to be the blessing that escorts one’s journey from one world to another.

How can we be that blessings despite the forces that monotones those moments into listless tunes with each death we encounter? Dr. Vidette Todaro-Franceschi , RN PhD FT advises that it is how one faces death  that prevents that burnout, that oscillating rhythmicity, that predictable sensation we may acquire as we repeatedly guide patients and families towards their loved one’s line of defeat . How can we conquer that intoxicating compassion fatigue hovering and buzzing over our nursing care, threatening to sting our compassion with every straight lined monitor and pulseless being that we encounter?

We swap that hovering sting with a “butterfly power” and we “flutterbye”.

Dr.Vidette Todaro-Franceschi, RN, PhD, FT coined this verb based on meteorologist Edward Lawrenz’s idea of the “butterfly effect”. The flapping wings of a butterfly that we see are connected to another event somewhere out in this world, and we were meant to witness it for a reason.

Dr. Vidette Todaro-Franceschi describes nurses providing care as butterflies flapping their wings, We think we are a separate entity providing care for a specific human being, but we are really one entity with the human being cared for. We are present during this most vulnerable and unforgettable time in a patient and their loved ones lives, because we were meant to be there and be a part. To be truly compassionate is not to see compassion as what a caregiver does, but to view our nursing care with a sense of belonging.

Wiklund and Wagner write how we are one with individual and their family, we are mutually engaged and must acknowledge our own and the other’s dignity and vulnerability to consistently provide compassionate care. We must view each experience as event connected to us, that we are a part of it; we are one with the patient and the experience.

Death happens to each person only once. When we guide those through that death path, it is a first for us, as one entity, at that time. The first one always hurts; and so with each race to meet that straight line, we must slip out of our cocoon and flap our wings with our patient. Each race confronted is a first; to flap our wings, to “flutterbye”.

Every greeting with the ‘angel of death’ should not build a comfort and familiarity that dampens the sadness that rides along with its presence, rather each experience forms and molds us. That is what will define one’s commitment towards learning and perfecting our practice and skill of caring. Rather than be smoothed out and molded, with each experience I hope to be sculpted and refined.

From my ‘Novice’ meeting to my ‘Expert’, I shall attempt to not to lose sight of the person under the sheets, the being behind the numbers and the family tiptoeing close by.

Written by Devorah Goldberg, RN, BSN

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This post is written by Devorah Goldberg,

HealthCetera

clip_image002This guest post is written by Rusty Greene, RN, a student in the doctor of nursing practice program at the Hunter–Bellevue School of Nursing in New York City. He was a student last spring in CHMP senior fellow Joy Jacobson’s narrative writing class for graduate nursing students. Names have been changed in this post to protect anonymity.

Two years ago, I got a tattoo. I never thought it would help someone die.

My right upper arm is covered with a sketch of a seahorse. My uncle and my grandfather have the same tattoo. Both of them were in the navy. They got the tattoo because the seahorse symbolized strength and determination.

I got mine for different reasons. When I was at an aquarium several years ago, I saw the seahorses. They are strange creatures indeed. The males give birth and they are coated in a crusty layer of bone. The wings on their backs flicker like tiny prehistoric appendages. After the fathers give birth, they care for a brood of over 1,000, knowing that more than 950 of them won’t survive.

Seahorses are rugged and resilient. But they also bend the rules of gender. They turn the concept of caring on its head. The concept of “nursing” is not particular to the female of the species.

This is something I understand because I’m a male nurse.

In nursing school, I took many courses on compassion, the empathic response, and palliative care. While I believe anyone is capable of mastering these skills, the tone of these subjects often takes a female perspective. This is particularly true when discussing burnout and fatigue. In fact, the concept of compassion fatigue has been bandied about over the past few years as a very real and uncomfortable condition for nurses and caregivers in general. It is often discussed in the context of having a healthy work/life balance, where a nurse must juggle the demands of caring for strangers only to go home and tend to children, a husband. and a mortgage.

Additionally, when discussing care of the dying, medical literature sometimes goes to the other extreme, providing a sometimes cold and cookie-cutter set of guidelines to help patients “pass.” An Internet search will give you several examples. To combat the sterile nature of these reports, some will say that it is okay to cry with your patients and hold their hand when they are dying. I had a professor in nursing school who said she even climbed into bed with a patient and held her as she died of breast cancer. To me, that seems like a bit too much.

So the messages are mixed. Have compassion but don’t deplete yourself. Follow best practices but tailor them to your own nursing style. Have a big heart but be a man. More often than not, these messages remain muddled. But sometimes, circumstances can create the perfect moment of clarity.

It was Saturday night and Alex was dying of AIDS.

I remember walking in to bathe him near the end of my shift. I entered his room with a basin full of warm water and some liquid soap. As is almost always the case with those who are dying, the room was preternaturally still, as if the air was waiting for the event common to us all but rare in its profundity. Alex was moving on, expiring, “going to the next life.” All of us only get to do it once and it is a singular experience. The atmosphere seems to know this.

I pulled back Alex’s sheets to reveal his frail and failing body. From feet to neck, he was covered in tattoos. They were intricate, colorful designs that swirled on his flesh, dancing this way and that. Then I looked into Alex’s eyes and I saw terror. His “moving on” wasn’t going to be easy. And I had to find a way to comfort him.

I showed him my tattoo and explained its significance. He smiled as best he could and said, “Nice.”

As I was washing his leg, I tentatively asked him about a palm tree and some goldfish drawn on his knee. He explained as best he could about getting that particular tattoo in Florida when he was on vacation with an ex-girlfriend. And at that moment, I saw something soften in his eyes. He went on to describe several more images on his body. A series of stars drawn in Amsterdam on his right shoulder. A black butterfly on his left pectoral muscle that he called “Dark Hope.” The more he shared, the more he relaxed. “Have a good night,” I said softly when I was finished.

“You too,” he said.

Alex died the next day.

Somewhere in between the lectures, the textbooks and the life experience, a space for healing was created. There were no tears. There were no hugs. It was just two guys talking about their tattoos. But it was deeply emotional. I didn’t feel exhausted or distraught or less of a man for caring very deeply about my patient. And Alex finally got some rest.

They say a picture is worth a thousand words. That night they were worth far more than that.

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This guest post is written by Rusty

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