Susan Mazer's Blog

As we begin 2012, it would be stunning to actually have NEW resolutions.  I say this because as we look to healthcare challenges, few of them are new: insufficient access for the poor; budgetary constraints for those insured; avoidable hospital infections; cancers that are curable, and others that defy treatment — all continue to burden patients, families, and employees in the medical field.

Having been involved with the environment of care for over two decades, I have looked extensively at the correlation between a patient’s condition and the surrounding physical environment.

Hospital noise is a natural result in institutional settings that house a lot of people and require a myriad of activities and machines. Noise directly affects those in the environment, resulting in sleep deprivation, increased pain and anxiety, stress and confusion, staff burnout and family distress. Because of the duality of being both an outcome and a risk factor, noise often is uncontrollable and unmanageable.

The good news is some methods have been implemented to control levels of ambient noise. However, the approaches used to lower noise have not been sustainable or consistent from hospital to hospital. This year, with HCAHPS having economic implications and bringing forward the environment of care as a performance standard, it is more important than ever to find a model for a quiet environment.

The bottom line: noise is a cultural trait…and changing that culture…requires a new paradigm of caring.

For the last two years, I wrote about the World War I Christmas Truce when roughly 100,000 German and British troops amassed at the Western Front laid down their arms for a day. The sound of shelling and gunfire gave way to the singing of carols; the exchange of volleys and sniper bullets gave way to the exchange of food and small supplies. The two sides met one another in “No Man’s Land,” where some played football and others buried the dead. This year, I again offer, for myself, the Christmas Truce, this time, of 2011. Here is what I wrote and still feel:

When so much of the world still faces the horrors of war, the cruelty of poverty, injustice, and uncertainty, I choose to set aside cynicism and disbelief, replacing these with the hope and wonder I had as a child. I feel grateful to be able to write to you using technologies that have made the world more transparent and peoples far away feel connected. We are fortunate to live in a time when scientific discovery has eradicated many fatal illnesses and brought hope for a future of better health. Philanthropy is being redefined as millions of people give a little to help so very many. Now is a great time to be alive, with the world changing so fast that tragedy turns into hope because time thrusts us into the future.

Yes, I am an optimist in this season when it is so easy to forget the Christmas Truce of 1914, a moment when the human spirit triumphed over tragedy and exhausted soldiers singing of Silent Night, Holy Night in Flanders Fields changed what is possible for all of us.

Dallas and I wish each of you a good, warm, and loving holiday, that next year shall renew our collective capacities for peace, hope, health, and an inspired future.
So, I include the Christmas truce carol as it is as appropriate now as it has ever been…
~ Susan Mazer

A Carol from Flanders

In Flanders on the Christmas morn
The trenched foemen lay,
the German and the Briton born,
And it was Christmas Day.

The red sun rose on fields accurst,
The gray fog fled away;
But neither cared to fire the first,
For it was Christmas Day!

They called from each to each across
The hideous disarray,
For terrible has been their loss:
“Oh, this is Christmas Day!”

Their rifles all they set aside,
One impulse to obey;
’Twas just the men on either side,
Just men — and Christmas Day.

They dug the graves for all their dead
And over them did pray:
And Englishmen and Germans said:
“How strange a Christmas Day!”

Between the trenches then they met,
Shook hands, and e’en did play
At games on which their hearts were set
On happy Christmas Day.

Not all the emperors and kings,
Financiers and they
Who rule us could prevent these things —
For it was Christmas Day.

Oh ye who read this truthful rime
From Flanders, kneel and say:
God speed the time when every day
Shall be as Christmas Day.

~ Frederick Niven
   (1878–1944)

October is stunning…the complexity of the fall colors is breathtaking.  And at some point in November, a good wind will come and blow all of these leaves to the ground, creating the thick blanket of leaves that we all begin to rake!

The healthcare environment has approached its Fall; meaning, the sounds are of many colors, volumes, and timbres, rendering an almost impenetrable wall of sounds that is deafening nurses to critical alerts.  In October, I was part of a delegation from the acoustic community to attend the first Medical Device Alarm Fatigue Summit in Washington, DC. The topic was exactly as I just described.  The auditory environment in the hospital, with the complexity of multiple alarms for each patient amidst an already highly orchestrated background noise, has finally shown itself to be an actual risk factor.  The outcome of this facilitated workshop, attended by over 300 people from biomedical engineering, to nursing, to medicine, to medical product manufacturers and the FDA and Joint Commission, came up with immediate and long-term measures to reduce the challenges that are now being lived through each day.

The environment of care, as Florence Nightingale so clearly stated, either contributes to recovery or is itself a risk factor.  This identified challenge in the auditory environment illuminates the need to design a healing sound environment, rather than one out of control.

Every fall, I remember school days, hot Septembers in Detroit, and new school clothes. This fall, it remains hot, but with today’s economy, schools are struggling, making me wish that kids were not subjected to the ups and downs of issues over which they have no control.
We might all take a step back and ask what would it be like? To not be subjected to the bad news getting worse day after day, newscast after newscast, headline after headline. Not that we should    ignore what is going on. The larger question is what we can do? And where do we stand to improve our own world without being assaulted by the world we cannot seem to impact?

For every patient, their personal focus is the immediate world around them. Watching the news, wars, and politicians telling us about the impossible rather than the possible, the roller coaster economy, and its related stresses over and over is hardly good for patients’ health or ours.

Think about how you can bring a more positive and compassionate approach to your patients’ world. Then be the change.

Blue sky, amazing clouds, mountains...the dynamics of a world in motion.

On Sunday, June 5th, 1983, my mother, Beatrice L. Mazer,  died of a heart attack, sparing her from the terminal cancer that the doctors were going to report to her the next day.  I use the word “spared” because that is how all of us felt.  My Mom skipped the pain, the anxiety, and the long and arduous process of dying from cancer.  She just blinked and was gone.   To this day, 28 years later, when we recount that day, we all agree that Mom “won.”

My Mother was an advocate for the underprivileged in Detroit, teaching in the inner city in a school that was at the heart of where the 1967 race riots ignited.  After teaching 12 years, she became and advocated for educators and schools, working full time for the Detroit Federation of Teachers as a mediator.   She began working with the teacher’s union when collective bargaining was a dream and teachers had neither job security, any benefits, and little real professional status.   She was also on the first Board of Directors of the Health Alliance Plan of Michigan (HAP), the largest HMO in Metropolitan Detroit.

Within my memories of her, I also find my recollection of the Detroit public schools when the worst offense a student could make was to wear a hat in school or chew gum.  It was a time when I could walk to school and, in high school, catch a public bus downtown to Cass Tech which was in the heart, again, of distressed neighborhoods.  And, we lived in integrated neighborhoods, went to integrated schools, and enjoyed the best of Jewish and African-American cultures.  I got a stunning education that took me to Stanford on a graduate fellowship.

In my mothers work with the DFT, she met Bernie and June Fieger, parents of Geoffry Fieger whose name became nationally known as the attorney for Dr. Jack Kevorkian.  Small world, when I think about it.

On June 3, 2011, Jack Kevorkian died.  As the New York Times reported of his life, “His stubborn and often intemperate advocacy for the right of the terminally ill to choose how they die is widely credited with sparking a boom in hospice care in the United States, and with making physicians more sympathetic to their pain and more willing to prescribe medication to relieve it.”   Today, my sister in law, Susan Talon Mazer, is a clinical nurse specialist working in palliative and hospice care.

I am not sure how I would have felt to be able to choose between helping my mother “skip” the dying process and going through the arduous and painful decline of cancer to reach the same outcome.  However,  I am as grateful today as I was then, that the spontaneous heart attack was her ticket out of what would have been a terrible death.     As my cousin, also a nurse, told me, she did not even know she died.

Healthcare today is tending to end of life issues so much more openly than was common 30 years ago…even if it is imperfect in accepting death as an inevitable outcome of life.   The costs involved in end of life care remain high not because dying is expensive, but because denying its inevitability levies extraordinary  human and economic costs.   When my Dad died just 5 years ago, it was not difficult to decide not to prescribe antibiotics when his body became septic as the result of a pressure wound (bedsore).  He was bedridden, never to walk again due to a hip fracture, and for him, the infection was a way out of a life that was no longer worth living.  We knew he had been waiting for some way to get out of where he was…and this was it.

I am not sure how we each can decide in advance how we want the last chapter written.  In older movies, the screen would just come up and read, “THE END.”  Today, we know the movie is over when the credits come up.  So, perhaps the end of life is both about “THE END” and the credits. In either case, end of life is what it is…the end of the last chapter.

Rain makes rainbows. How could it be that easy?

In our time in Hawaii this month, the end of each rainstorm revealed a rainbow…and maybe that is how I would like it.  Lots of sound and lights…thunder and lightning…and then a rainbow.  Philosopher, Alan Watts, wrote, “Spring comes and the grass grows.” And with only these six single syllable words, he put into perspective how nature and life moves on without our permission.  During our  12 days in Hawaii,  it was sunny, warm, rainy, and wet.  And, aside from all the recent natural disasters, the political and economic threats around the globe and at home, the plants still grew, the flowers still bloomed, the waterfalls were rich and the rainbows shined gloriously.

This month, I share with you the views that we saw to remind you as nature reminded us:  Spring comes and the grass grows.  Life is. Enjoy the rainbows.

The waters wash the sands, the clouds decorate the sky...and we get to witness it all...

And, Mom still won.

May is Nursing Month in celebration of the birth of Florence Nightingale.  Each year I renew my interest in her work, am in wonder of her insights, and remain stunned at what she knew that we are still learning.  Nightingale was born into an Aristocratic family, wealthy, well educated.  At the time–in the middle of the 19th century–,  little was demanded or expected of her other than marrying into the same social class and giving birth to the next generation of aristocrats.  However, she took a different position, questioning this very narrow role for women and wondering why it was that those with means well beyond their needs had little concern for the poor, the sick, the orphaned, and the destitute who lived just on the other side of the gates that surrounded the family estate.

It is clear that this question is one that has yet to be answered and she would be well within her rights to ask again and again of the same people, about the same social disparity.  As I write this, we are looking at an international crisis in many countries regarding social welfare, support for the poor and a safety net for a middle class weakened by the current recession.  For some the recession may not end for years; for others, it never happened.  Unlike the Great Depression, this recession did not impact everyone the same way.

Amidst the economic challenge is the very difficult and un-resolvable dilemma in the U.S. healthcare system. It makes me think of the automobile industry that was bailed out, the banks that were bailed out…the “too big to fail” excuse for billions  of dollars in federal funding to ensure the whole financial system did not crash.  Well, it is clear that our whole healthcare system is on the brink of failure and the push is to let it fail.  Why are the lives at stake not as important as the money at stake?  Why is it that the sick kids invisible to the system because their parents are invisible, are so expendable when the stock market, and the various big banks were clearly not?

Nightingale would look us all in the eye in disgust for values gone awry.  She would say to each of us who have so much more than we need that we should be ashamed.  And, she would look at the casualties of the many wars we have been engaged in the past 10 years and fight to her last breadth for their right for the best care, as she would fight for a patient’s right to the most compassionate and highly skilled clinician to help them recover.  Furthermore, as she would defiantly stand against a system that at that time and at this time,  would rather let the sick die than change, daring us question the tenet that receiving care is a human right, not an economic privilege.

For additional information on Florence Nightingale and her life, please download the Healing HealthCare System’s 5-part  podcast series: Florence Nightingale in Her Own Words

Time is hardly slowing down for any of us.  In fact, with faster internet speeds, social media, cloud software, and ever present smart devices, none of us can authentically take a real vacation from our lives…it follows us everywhere.  While there has been some control in the past regarding cell phone use in hospitals, at this point, most hospitals who can, provide wireless access to their patients and families, online access for patients to check their own lab reports, and email communications between physicians and patients.  The world is spinning faster for so many of us, but not all of us.

With all of this, there remains a segment of our population in the U.S. and, as well, whole communities in other countries, who are living in real time, not cloud time, for whom “I phone” implies a communication rather than a device.  There are those for whom Medline, WEBMd, and PubMed are foreign codes for a world that is inaccessible. What does this mean for providers, for physicians and nurses, and for families who remain outside the circle of knowledge which is growing by the gigabyte as I write this?

At the recent National Association of Broadcasters Annual Exposition in Las Vegas, Gordon Smith, the President of NAB, spoke to the continuing value of free, on-air television.  The need that remains for communities to have access to their own neighbors, to know the weather, to receive news relevant to what is happening in their own town.  He spoke of this within the context of the ongoing fight for bandwidth, for IP television streaming, for everything that these communities do not have.  There are health implications in all of this discussion. For example, understanding the importance and effectiveness of hand-washing specifically during the flu season has been touted redundantly on television programs on health…on cable health programs…that are unreachable to an economically challenged senior who has an old television and can’t afford to pay for cable. Recalls of entire food lots because of e-coli contamination, toys that have proven dangerous to toddlers, and defective automobiles have only been successful because of media alerts that go viral.

The C.A.R.E. Channel remains a closed-circuit channel that is easily accessible to everyone who can see a television while in the hospital, everywhere.  It is also provided at not cost to patients and most often as an open channel on the television.  When patients contact us, we can send an ol’ fashioned standard-definition VHS or DVD.  (Yes, VHS is still viable to many an elderly person!) We may remain a diverse society that must care not only for those who are living in the future of now, but also for those whose present is in some ways unencumbered by the pressures of continual access, expectation, and technological wonder.

I think I have a handle on all of this technology.  As many of us, I have and use a smart phone, a laptop computer, an IP Television, wireless internet everywhere that matters to me, and a Kindle app on everything.  In my doctoral work, I have virtually visited and used libraries all over the academic universe, have communicated with scholars internationally that I may never meet, and have done all of this from my laptop wherever I find myself.    However, when I see a much younger person handle all of these, I realize that I am translating through older paradigms…that technology is a second language to me, not a primary one.  Clearly, I am not the only one, with e-readers offering the real look of a virtual turned page to satisfy my own attachment to the past.   I still understand why the controls for DVD’s  look like it did with VHS…when the forward arrow “>” had relevance in the physical world.  However, with non-linear video formats, we can jump around and it is more about the timeline than the actual tape moving across the magnetic heads of a tape recorder.   We borrow still from the manual typewriter to use a qwerty keyboard, which was developed to deal with the physical arms of the typewriter not crunching upon each other.

Studies have continued to show that only through multiple and diverse paths of learning, with the use of both personal and technological tools…accompanied by real people speaking with real people…is information transformed into action.  So, while the future holds the magic of invention and innovation, the relationships around us remain the most powerful in influencing our lives and our health.   And, yes, time will continue to push forward whether we embrace it and jump on the treadmill of an ever faster moving world, or try to hold on to a pace much slower.

And, the sea rose up from its core to wash away decades of development, generations and whole families, communities, and farms. And, too, the people rose up as the sea to wash away decades of oppression, of hopelessness and despair, of powerlessness. This month in the year two-thousand and eleven, on the eleventh day of the third month, we saw evolution and revolution occur simultaneously, each involving massive loss of life, each changing whole communities and families forever, each unstoppable. The forces of nature push and the forces of  freedom pull to create a new, generative world.

This past month the world has witnessed cataclysmic changes that surpass the collapse of the Berlin Wall and the break up of the Soviet Union, that remind us of the Tsunami in the Indian Ocean and the failing of the levees in New Orleans.  Whole societies have been transformed either by will or by nature, creating a future both uncertain and undefined.

Here in the United States we remain glued to the media that bring vivid images of suffering and struggling, of injury and courage.  And, we are safely tucked into our lives that, in so many ways, are only dreams to so many living under oppression.  In Japan, where the whole society prided itself on its judicious preparedness to counter the threats of earthquakes and other natural disasters, the realities of the uncontrollable forces of the moving earth and rising waters is still difficult to comprehend.

Forces beyond our control confront each of us during our lifetime, be they illness, joblessness, social and economic unrest, or threats of denial of health care.   It seems to me that in the face of what is going on around us, the imbalance of health care access that has dominated the body politic and threatened our economic security pales to its solvability.  Yes, we can solve this… Yes, we have enough.  Yes, we have the skills, the knowledge, the resources, and the pressing need to take care of our own.

I cannot leave the issues that seem insurmountable in the face of the uncontrollable.  Do we need a natural disaster to wake us up?

I am moved by the demonstrations of selfless courage in Japan, of relentless and life-threatening determination in Tunisia, Egypt, Bahrain and Libya as I sit so safely at my computer writing this.  It is personally shameful to me to read the article earlier this week in the New York Times that was headlined, “I-Pad-2: Shortage due to Japan Tsunami.”   It was perceived as equally shameful to readers who were aghast at this implication that this was a real problem in the face of real problems!

In Bahrain and Libya, peoples fighting for their rights of self-determination caused political earthquakes that will forever change the politial and social terrain of their homelands.  In Japan, the strongest earthquake recorded caused a Tsunami that took the lives of untold thousands and redrew a coastline and a country.

An article coming from The Guardian in the UK, reported on the abandoned and suffering, often dying elderly trapped in hospitals, in their homes, in nursing homes following the Tsunami and days following. Without a doubt the pain of how a natural disaster forces a kind of triage is experienced by a whole family, whole community, and a whole culture. 

What does this say about who we are?  What can we learn from how we respond to such traumas? Each time some cataclysmic event occurs, we are called upon to respond in our own sphere of influence to make some kind of sacrifice, whether it be in the form of donating financial support or time spent witnessing the event from afar.  The larger question, for myself, is what is there for me in this that if I was fully conscious to its implications, my own life, my own impact on those around me, my vision and determination in living a relevant life would become instantly more urgent.

What makes for good elder care?  How could one design a skilled-nursing facility to support those who are residents and those who are rehabilitating?   I have been in many and few inspire me to want to live there…at least, any time soon.   At the same time, needs change and how we actually choose our place and space to  live and thrive changes as we move through the chronology of life.

My sister had a knee- replacement last week; she chose on her own, of the many local skilled-nursing facilities, a rehabilitation facility that is older than others but had the top rating in recent write up in the local paper.  The facility  in Sparks, NV was built in the 70′s as a nursing home.  However, today, in 2011, in addition to long-term care residents who live there, there are now short-term residents who are recovering and rehabilitating.    The needs of rehabilitating patients are very different than those who cannot rehabilitate.  Perhaps the most interesting part of the experience in such a home is the impact that one group of patients can have on another.

I found when I was involved with my Dad’s stay in a skilled-nursing facility in Michigan that, at some point, everyone is equal, families connect, and the regularity of seeing the same people and staff day after day.  In many ways, normal is redefined and those one never knew before become so critical in caring for a parent…

For a start, here are some pictures from our travels in the US and India that tell perhaps more than words could possibly say about the global elderly….so much life and so many years… and still in the middle of living.

Alabama...looks so good!

How can we tell what life is like or the many stories that live on the faces of the elderly?  What do these faces say about our global society, its history and its present?   From the woman squatting restfully for hours, smoking a pipe, to the farmer in Alabama living to this day next to Dallas’ parents country place, to a woman begging on the Chain bridge in Budapest…and, the open market Inley Lake in Burma…what does it say about the diversity in the world of aging?

The pictures here are of two people, probably differing in life more than age.  The man on the right has lived across from Dallas’ parents farm for 60 years…  He took the one last goose that Dallas’ Dad had raised (the rest got nipped by dogs…) and it lives to this day.

The woman on the left…in Burma…smoking a pipe of Beetle juice…sitting the same squat that she was able to do as an young child.  And, no she owns no property nor seeks anything more but to smoke her pipe…at least from where our camera saw her.

In Linley Lake, Myanmar, the markets draw the mountain people.  The woman on the left sits near her wares, covering her head from the relentless sun….and experiences the west only from the currency we have with us.

This past December, on the Chain Bridge over the Danube separating (or connecting) Buda and Peszt in Hungary, this woman held out her cup.  It was so cold and windy…and she stood looking at us.   The immediate contrast of our taking a river cruise with her standing on the bridge…was striking and may never leave me.  Yes, we put money in her cup…but there will never be enough money.  This is now no longer an undeveloped society; rather the bridge is located only feet from a 5-star hotel…several of them…and 20 minutes from the Palace District.

From Estonia, Photographer Tero Leponiemi writes:

What is interesting and fascinating in aging? Is it the furrows in the face, or glance in the eye? Elderly people are those members in the society, who have witnessed the differences in all its varieties the most. One of my characters, who was born at czarist times, has seen the first republic of Estonia, Soviet time, German occupation and new independence and aspires to integrate into West. How can a person cope with so many different regimes – and give his signature to the social agreement? How our elderly generation has coped with changing times, changing society and culture?

Getting older is often accompanied by deteriorating health, aching joints, and sometimes it grasps from one’s heart. Despite that, memories and primarily feelings can be as colourful and warm, as earlier. A phone call from a child, visit from grandchildren or birthday greetings do not change throughout different ages or world orders. Warmness of people, close to you, is a bridge, lasting all ages.

Visit the photographic essay,”Old Age—coming along?” from an old-age home in Estonia…  at http://www.socialdocumentary.net/exhibit/Tero_Leponiemi/1076

For those of us who are watching our parents age, or have already gone through this generational transition and profound loss, for those of us facing our own aging process regardless of our chronological age…much to contemplate…..

It is difficult to put together the best of our society with all its failings. The best of our advanced health care system with it being out of reach to so many. The civility and generosity that define our communities with the violence that continues to challenge our understanding. The miraculous recovery now in process of Gabrielle Giffords is evidence of the courage of those around her and the medical skills that met her in the hospital.  It is the best of who we are.  How do we reconcile all of this..how do we make sense of our own humanity to each other in the face of unnecessary tragedies?

When Florence Nightingale became aware of the grave conditions of the British Army Hospitals in the Crimean war, her call was to take care of the wounded, to get into action.  The relationship between nursing and war has a long history.  The ways in which nurses have long been sought out to tend to the wounded, the ill, to be at the bedside of those during epidemics, speaks to the core mission of nursing.  Nightingale’s environmental interventions were, at the least, what changed the mortality rate so dramatically, from 42% to 2%.  However, upon returning to Britain after the war, she expanded her work into public health and hospital construction and remained driven to improve the quality of healthcare, not just for a few, but for all.

What does this say to each of us about what we do amidst the tragedies in Tucson and, even more recently, the school shootings  in Los Angeles?  For me, personally, living according to the ethics of good works requires that I move past my own anger at the situation and their perpetrators into looking into my own community for how I might improve the environment and make it less opportunistic for violence and the hatred behind it.  I am not great at this…busy schedule, the hustle of daily living and everything else that entails the hours of the day…forces me to carve out time to do something…anything…that points to a better world.   I have come to the conclusion that the footprint of my life is not determined by my shoe size; rather it may well be determined by how far I am willing to go beyond the path laid out for me each day.

I was born in Detroit and this wonderful city where I received a stunning education, rich in history and music, has been plagued by violence and collective helplessness.  Therefore, the ravages of violence are not foreign to me…although, I must admit that I find myself desensitized to current news rants that repeat over and over the many social and economic problems we are facing without any solutions.

Then, what is there for us to do?  I offer this suggestion from author, Kurt Vonnegut, Jr::

“What should young people do with their lives today? Many things, obviously. But the most daring thing is to create stable communities in which the terrible disease of loneliness can be cured.”

When we look at the isolation of disease, of poverty, of depression, of financial despair, the outcomes are a threat to the health of our communities and those who live in them.   In each case of a mass murder, the perpetrator was isolated, seldom authentically integrated into healthy relationships.  One could make a case for the community of gangs and terrorist cells, but I would argue that collective isolationism and despair can become a basis for group connectivity.

Nightingale knew of these social ills. She was most critical of her aristocratic colleagues who felt no responsibility for the poor and ill.  She ventured into social work in her first position as the head of a home for ill governesses, adding to her task not only moving these women into recovery, but finding them work following their rehabilitation.

The times we live in are mired with controversies of values, economics, and over personal rights.  In this week’s New England Journal of Medicine, an article discussing the need for nurse practitioners to no longer be denied their ability, skills, and competence in providing primary care services  (“Fairman, Julie A., Rowe, John W., Hassmiller, Susan, Shalala, Donna E., . (2011) Broadening the Scope of Nursing Practice. New England Journal of Medicine 364:3, 193-196) was met with a response from the American Medical Association that was not helpful in defending a sole physician led model.  I hope that both physicians and nurses join together to reconsider the model of care needed for an equally-accessible health care system clearly needed and called for at this time.

Clearly this month is one of confusion to me.  My thinking is everywhere, touching on issues seemingly unrelated that, for me, are primary.  I am not sure how it will be next month, but I invite you to consider what jumps out for you regarding priorities of consideration…  I think confusion mixed with considered concern may be the best we can do.