dude. so much to say.

worked all weekend last weekend. skipped class this morning because I stayed up all night watching a disk of House. had a mini-crisis (almost entirely self-created) last week because I hadn't done an assignment that was worth 50 points of a 1000 point class average. At the same time, it was a 6-8 page care plan for a stroke patient - you know, integral skills to have for the field! The stuff that I'll be doing non-stop from here on out in nursing school! eep. Eighteen mini-panic attacks later, I turned it in, not even late, and complete with all five journal articles, cited in APA format. This time the payoff for resolving the drama that I created wasn't so good, didn't really feel worth it. fuckit.

Finally went to Campus Health to put my cloudy, smelly urine in a cup and find out if it's a uti without the pain and burning (i've been symptomatic for about a year now, and have only recently had health insurance and easy access to a clinic to see someone. Can we say functional limitations in healthcare?) Starting cipro today and I even managed to advocate for a follow-up urine sample to be ordered to ease my mind that it is resolved with the drugs.

Signed a lease on a passive solar apartment yesterday - wow oh wow it is cool! big windows, brick floors, W/D, and no pet rent. exactly what I wanted, although not on the side of town I was hoping for.
May is looking a little crazy-making - finals the first week, a much belated birthday party for the kid the second week. The semester starts (with my first clinical rotation!!!) and later that afternoon, I'm leaving for a four day retreat in the mountains in the third week, and then I'll get to pack and move before June 1. sigh. I really don't understand how I've been able to pay a security deposit before the summer fin aid dispersement.

found out this weekend that one of the cool kids from work is going to join the Army for six years. I teared up, and then handed him my address like I was in the third grade and had just found out my family was moving to Georgia. I was embarrassed, and sent this email today. Still a little embarrassing, but it feels resolved now.
Hey R!
I saw you on campus the other day, and realized I could look up your email through the campus directory. I wanted to apologize for throwing a little tantrum the other night. It was such a shock to realize that I wouldn't see you again at work (and since that's the only place I see you of course, then it's not likely that we'll meet again). I was a little surprised at how upset I was, and didn't really know what to say (or what was appropriate to share without being creepy and weird, you know?).
It's odd to think about the loss of a close acquaintance - you are someone that I'm always happy to see, and who I really enjoy talking with. I like the way that you are sarcastic, but not often nasty (probably since I think that I tip that balance too often toward just being rude, as opposed to funny or clever). You manage irony without being an asshole - which is a rare gift, it seems. I think that you're crazy smart and genuinely a sweet person. You remind me of my kid in a way (and I know that's weird to say - and possibly to hear) and that's most of the reason that I was upset to hear you are going into the Army. I don't know anyone personally who is serving in the military right now - and so I'm privileged to be (sarcastically) academic and removed from the whole situation.
My dad was in the Marines, mostly before I was born, and I know that it was important to him to enlist, and to serve his time. I also know that he was a unspeakably different person after having served than he would have been without the experience of service in Vietnam, and I usually think of the loss of innocence, the gain of the burden of seeing horrible things. I don't really have a concept of the other more positive pieces that he spoke about regarding his service - the discipline, the feeling of being a part of something that made a difference, the actual 'service' part of serving the country. I had this irrational hope that time could be just frozen, that we could just talk when I happen to work with you, and talk about how ridiculous the world (and the restaurant) is... The thought of you being at the whim of the nutbags running this country's military takes my breath away, truly. At the same time, I want to say that I support your decision, since I know that you've thought it through carefully, and I feel like you have the strength to handle the experience. Other than having a kid, I've never done something like this that so immediately and profoundly affects my life.
I would be proud if my son grew up to be like you.
I wish you all the best. I'd be happy if we kept in touch - it would be good to know how you are doing.

with love, kati

Yep, it's officially reiterated - I'm a geek.

What are you going to be when you grow up? Jesus said, God.

The kid and I have been having this lovely conversation about God the past few days. It started as a bit of a stand-off about diety gender, when he said He and I said She, and he said god's not a girl, and I said, God is both and neither. There's nothing you can think of, or see, or feel that's not god. The kid chewed on that and agreed and that's where we've been for days, pulling out the most random things we can and testing if we believe they're god - they always are. :-)

So, last night, he says, I can't go to sleep because what if the world ends tomorrow?

hmm. That's a show-stopper, dude. I take a deep breath. I begin, "Well, I can see how that would be really worrying to think about. but there's times, baby, when you can think of a thing (and even think it over and over) that doesn't make you happy or healthy or doesn't help you at all. there's times when you need to let go of the thought, put in a box or a balloon or whatever, and let it drift off. Thinking something over and over doesn't mean that you have to pay attention to it over and over; sometimes it means you have let go of it over and over."

He said, I can't put in a box or a balloon. I just can't. It's too scary to ignore. (and also, he wants to keep talking and keep not sleeping!)

hmmm. more deep breaths. (I'm mentally working through The Work at this point and wondering how to frame it up without a lecture.)

Kid, do you think that that thought is god?

Yes.

I do too baby.

silence.

sleep.

'night, baby.

Christian Pharmacists and Plan B

I attended a lecture today hosted by the Christian Pharmacist Fellowship on campus about right of conscience and Plan B.

Two things were striking to me.

The lecturer spoke briefly about independent practitioners vs dependent practitioners. This is very interesting to me in light of the recent lecture in our Disciplines of Nursing course on negligence, beneficence (doing good for a patient - treating each patient with utmost of my skill and ability) and non-maleficence (not harming a patient - which can at times mean going up the chain of command until a prescribed treatment that I know to be harmful to this patient is removed from the orders).
RNs are dependent practitioners in that we are providing only the medication, and in some cases, the treatments (such as dressing changes, restraints, O2 administration, etc) that is ordered by a physician, nurse practitioner, or physician assistant. That dependence on orders does not in any case excuse us from liability or responsibility to the patient's health and care.
I think that the lecturer conflated this concept of responsibility and dependent practice. He gave two examples of when a prescription violates what the pharmacist knows of the patient (interactions with other medications or treatments, and I'm drawing a blank on the other example) as support for the exercise of a right of conscience. He kept saying - Wouldn't the pharmacist have the right of conscience to refuse to dispense a medication they know or suspect to be likely to cause blah blah side effect?
Maybe I don't understand what "right of conscience" means. That sounds like negligence, and it's covered in the nursing practice act from our state. It isn't based on my personal moral convictions. The refusal to fill a prescription that may cause a lethal interaction with existing meds is motivated by the pharmacist's professional knowledge and ethical imperative to act, not a moral objection to the patient's death. It seems that he was drawing a connection between two dissimilar situations - one of medical knowledge and professional standards, and one of moral imperative being used for professional conduct. The impetus for non-maleficence is not moral in basis - it is via professional standards of care. The impetus (within my limited understanding from listening to this brief discussion) for refusing to distribute Plan B is that there is a small risk that it could prevent the implantation of a fertilized egg, deemed a human life, and could therefore be promoting abortion (as opposed to preventing pregnancy). The argument is that pharmacists may not be required to give a patient access to a drug that could kill a baby when the pharmacist has a moral objection to that death.
This risk is small, and exists with all manner of other medications, this idea is the direct result of targeted campaigns to frame Plan B as an abortifacient instead of contraception, and in my opinion the objection to contraception is likely the more prevalent moral objection of pharmacists. Furthermore, objection to contraception is so often concurrent with denial of the circumstances that lead to unwanted sexual activity. Women's health IS unique in that we are both able to become pregnant after sex with a man, and not able to avoid sex with a man.

Here's what I wished he would have talked about: Pharmacists seem to be a special kind of dependent practitioners. They are not directly administering meds, as an RN does with an IV push; they are making it available to the patient, with counseling and education. I wonder how this changes the debate, if at all. Some of the students seemed to be leaning towards the decision to dispense, but with vigorous counseling. It made me a feel a little itchy to hear the kinds of questions they would ask - sexual activity, usual birth control methods, informal referral to a primary practitioner - because of the likelihood that personal judgments would creep into a conversation like that. Is that okay for a pharmacist to ask those kinds of things? Is it okay for that kind of conversation to be taking place at the counter in a typical pharmacy?

The second point that I waited afterward to discuss (but never got a chance to, because I felt uncomfortable pushing ahead of pharmacy students) was regarding this idea that pharmacists can either give out the meds or step out of the process, but facilitate the patient's ability to get Plan B somewhere else. Number one - who decided that? (I'm sure a quick google and I can answer myself) But my question at that point becomes, why not just give it yourself? If the moral drive is so strong that you would advocate for the patient not taking Plan B (and again, I wonder how pharmacists can manage to be in practice without a clear understanding of the mechanism of the drug), then how can it be satisfying to send them to another pharmacy? What if the woman does become pregnant after unprotected sex because of her inability to get Plan B and ends up having a surgical or medical abortion? Are the rules about this different in an area where there is only one pharmacy, like an isolated rural town or military base? What if there are functional limitations on access - such as the patient does not own a car, or is only allowed a short break from work, and sending her across town or asking her to wait an hour until Pharmacist McWillingtoDispense comes on?

There was a brief conversation about the possibility that a Christian pharmacist may feel uncomfortable giving a transgendered person their hormone therapy, because of a moral objection to their decision to pursue gender re-assignment. It seemed that most in the room were in agreement that this would be motivated by a personal bias, rather than Christian doctrine, and everyone nodded when the lecturer said that it would be wrong and illegal to refuse needed medication to a black person because of racist attitudes. again - the example isn't good enough. What I wanted to understand was - how are you teasing out moral or religious motivations from personal opinions or bias? How can you absolutely say that they are different? And why did you retreat to the "easy" example of racial discrimination to respond to the question of transgendered rights - were you making the point that blacks are legally protected from discrimination but people who are transitioning from one gender to another are not?

I hope that my best friend from high school will comment to this - she's recently gotten her PharmD and started her own pharmacy, which is such an incredible accomplishment that I don't think I've made a big enough deal about. I'm so proud!