In Part 1 of of our Non-Reader Spotlight with Rebecca Klaes we talked about all the life that's preventing Rebecca from reading for pleasure right now. She kindly agreed to find time to read a book with me though, and I suggested she pick. She chose Atul Gawande's Being Mortal, a nonfiction book considering how medicing can not only improve life but also the process of its ending. Then we talked about it!

Jac Jemc: I believe you were reading this on an airplane, right? Would you mind sharing where you were headed and why? 

Rebecca Klaes: I had planned to read on the airplane, but did not. I had journaling to do for my trip since it was school sponsored and I was receiving clinical credit for my Community Health course. It was also the middle of the night, so I was trying to get some sleep to avoid some of the jet lag.

I was headed to Zambia on a mission trip. I'm a nursing student and my school, North Park University, hosts a health clinic at Hope Fellowship in Twapia, an impoverished village outside of Ndola. (My host family was in Ndola.) Zambia still follows a lot of the British ways such as free education but the families have to pay for uniforms. Most families cannot afford uniforms for their children. To help with this problem, Hope not only supplies the education but uniforms for the children and lunch too! There are approximately 350 students at the school with only 8 teachers. My school's yearly trip to conduct the healthcare clinic is usually the only physical the children get each year.

At our health clinic, we tested the children (grades 1-7) for malaria and gave them a head-to- toe physical. If we found anything, we supplied them with the medication, such as for ringworm (which was also a frequent issue among the kids). Unfortunately, we had limited resources and could not treat everything. For example, one child complained of a toothache. Upon inspection, his tooth was severely decayed. I'm not a dentist by any means, but the tooth most likely needed to be pulled. Although their healthcare is minimal, their dental care is less. All I could give him was about 2 weeks worth of pain killers, similar to Tylenol.

My school has also tried to help with this dental issue. Previous years, they handed out toothbrushes and toothpaste for the children to take home. However, they quickly disappeared - Probably sold to pay for other necessary items. Now, the toothbrushes are kept at school. After the kids are fed lunch (for some children, it is the only meal they get a day), the kids brush their teeth. The kids get excited to be the toothpaste person! According to my professor, their teeth are looking better, but obviously still need help.

JJ: Tell me about when and how (paper/e-reader) you read the book we decided to read together. 

RK: Paper! I don't own an e-reader. A few years ago, when I was working, I tried reading through an app  on my phone. I couldn't read through the first chapter before removing the app. I guess I'm old-fashioned. I read the book when I had down time at night or while we were on Africa time! (Long story short... we were always picked up hours later than what we were told)

JJ:Was it tough to focus? Did it feel like work to read? Did you wish you could be doing something more leisurely with that time? 

RK: I found it easy to focus! I had minimal responsibilities. When I was at home with my host family, they took extremely good care of us.  The whole time I was there I only managed to help dry dishes a handful of times and make dinner one night. They washed our clothes by hand and refused my help. My host sister said I'd slow her down. :-( When I wasn't reading, I was enjoying Indian Soap Operas with my host family.

JJ: Did what you read here have any influence/impact on what you were doing on your trip? Did you find moments of resonance? 

RK: Our main focus was at the school. We did spend one day on a walking tour of the village and I discussed culture with my host family. In Zambia, they focus on relationships. Most people do not get jobs outside of the home because they want to be home if someone should stop by to visit. This is one of the reasons why there was a difference between "American time" and "African time". The individuals who drove us, would always come in and visit with our host families for quite a bit.  Like I mentioned above, one day we were told we were going to be picked up at 10 to go to a wedding, but did not get picked up until 12:30. Surprisingly, we were not late! It is custom for the bride to make the groom wait. The pastor informed us that his wife made him wait over 4 hours on the day of their wedding! Back to the topic at hand, I found it interesting that the people of Zambia would rather take the time to visit with other people than worry about anything else. In the book, it demonstrated how most Americans are preoccupied with themselves and their own lives (employment, their spouse and children) that they do not have the time or effort to care for the elders.

My internship for my Gerontology course happened to be a week after I returned to America. It was with Little Brothers - Friends of the Elderly. This is a non-profit organization that befriends the elderly. Their motto is "flowers before bread" that expresses that people need special pleasures before the necessities. (sounds a lot like the way of life in Zambia!) They find elders that have limited social contacts and includes them in different events. My job was to help during the vacation week. The elders vacationed in a beautiful home in Batavia. They took trips to go out shopping, to go to the casino, to go out to eat, etc. The first night, we went to The Golden Corral for dinner. As I walked around with endless foods to choose from, all I could think of is how much food that would probably get thrown away at night. It was interesting to see the stark difference of the cultures: in Zambia, they don't have much in material goods but take the time to visit with everyone; in America, we have excess goods but have numerous people who are alone. The elders that I "vacationed" with were healthy. Our instructor wanted us to see elders outside of the hospitals to really get to know how they can function on a daily basis. The last day of my internship, I was able to help a different "population" of their clientele. I had the chance to visit homebound elders in their own homes. One of my elders had his leg amputated 4 years ago and received a prosthetic. Unfortunately, he was still confined to a wheelchair. There were also other issues I observed in his apartment that I relayed to Little Brothers. Little Brothers not only befriends the elders but have additional resources available to help the elders as needed. I did not ask if they had a hospice to refer the elders to when necessary, but they do have Social Work Support available for the elders.

JJ: Are you planning on focusing your nursing career in gerontology specifically or is it more of a "it's gonna come up throughout my career no matter what so better to prepare" type thing? 

RK: I was told at the beginning of nursing school, not to pre-select an area of nursing that you'd be interested in. Overall, each course I have taken, I have been interested in! I am having a hard time choosing a specific area I would like to work in. As of right now, I would like to work in the ER. This way, I will be able to work with people of all different ages with all different types of health issues. I also figure that I'm young enough to have the energy to keep up the quick pace. When I feel like I'm getting "burnt out" then I can look at other areas of nursing. I chose the book because it appeared to encompass quite a few of the areas I studied: gerontology, ethics, health policy & politics and some research. Gawande did an amazing job covering all the different aspects of aging in America and the choices that most elders have to make, along with some of the progressive choices out there!

JJ: Since reading the book, I've been going on a bit of Gawande bender reading lots of his articles in the New Yorker. I'm really into the way he's shifting focus from health and survival to well-being, but that's such a tricky line and to make it work in practice, I think people probably need a fair amount of reprogramming as to what they expect of their health care providers. For a while now, it feels like the thought has been: Whatever the doctor says to do, I do, and that decision is driven by what will give me the longest life. But I like the idea of having more responsibility and options than that. This is a long-winded way of asking: What was the experience of reading the book while in nursing school? What are your thoughts on how these changes could be implemented? 

RK: I give doctors lots of credit. They are very knowledgeable, but it seems as if their knowledge is very focused on their specialities (which is where the money is at). Not too many people see a Primary Care Physicians (PCP) and not too many medical students head in this direction. The PCP's look at the whole patient and not just the medical issue at hand. PCP's get to know the patient on a more intimate level. For example, about a year and a half ago, my oldest son was sick. I took him to the ER and did a follow up visit with a resident doctor since his pediatrician was booked. The ER and resident doctors discharged my son without a second thought. I knew he was sick and needed care, so I persisted. We went to another ER, which that doctor called our pediatrician. Even though the 2nd ER doctor discharged him, our pediatrician called us to set up a follow up appointment. Our pediatrician, who knows my son, noticed that he was not himself - she admitted him to the hospital. There, they did an echocardiogram and saw that his coronary arteries were dialated. They treated him for Kawasaki disease.

Throughout nursing school, we are taught not to mindlessly follow the doctor's orders. The doctors have multiple patients and they're human too! Especially when administering medication, we, as nurses, need to double and triple check everything. There have been occasions that nursing students have caught what could have been a medical error!

Personally, I think that people need to take ownership of their own health! I'm not talking about going to Google with every ailment you might have, but to become knowledgeable about your choices. This might be TMI...Before nursing school, I did the "normal" thing and had my sons circumcised. I didn't think twice about it. I didn't do my research. I figured that since doctors do this surgery all the time, it was probably necessary. After my second son, the doctor commented that my son could be a Chippendale now. That stunned me! During my OB rotation, I had the chance to observe one performed. the doctor told us that it was a cosmetic surgery. I had to walk out. The baby was in so much pain. I started researching circumcisions further to find out that America is the only country to routinely do them. Previous studies on how it prevents UTIs/HIV in boys are flawed. There is also some excuse on how it prevents penile cancer, yet the American Cancer Society does not endorse this. Now, I am trying to spread the word and inform expecting parents. I suggest that they take 30 minutes to watch the YouTube video "Elephant in the Hospital". It goes through why male circumcisions still exist in America.

I feel like I'm rambling. Bottom line doctors are people too. Gawande spoke about how he and his parents are all doctors and they still avoided talking about the tough topics. I found it interesting when his parents were asked about hospice care for his father and both parents answered immediately but opposite. His father knew he was dying and did not want to prolong the process or be a burden for his family. He wanted to live the rest of his life out on his terms. His wife still wanted him to fight and try any treatment available. This is also seen with patients in intensive care units. The families do not want to "give-up" and keep the patients on multiple machines to keep them alive. I can't find the statistical numbers, but it is outrageous the amount of money that is spent on health care for an individual's last few months of life when the quality of life is not there. There are instances of when the patient have written testimonies that they do not want to be resuscitated (DNR), yet the family member that is the power of attorney ignore their wishes. If there are living wills that are written out, I believe, that it should be followed.

JJ: Have you read other books on this topic?

RK: A great book on health care in general is The Truth About Getting Sick in America: The Real Problems with Health Care and What We Can Do. Dr. Tim Johnson gives great ideas on how we can give Americans better care. His ideas overhaul the medical practices, the malpractice, the health insurance...basically the whole system!

Care for residents/patients is difficult with limited resources. The biggest lack of resource is actually nursing. There are nursing shortages, hence why there is no uniformity in nursing degrees. There are bachelor degrees, associate degrees, and nursing diplomas. Larger hospitals have the money to pay and retain their nurses and therefore demand higher education. Not too many nursing homes have the financial abilities to do this.

Here in America most hospitals (depending on the unit) have a nurse to patient ratio of 1 to approximately 6 (ICUs usually 1:1 or 1:2). Nursing homes the ratio is much higher (I believe 1:30) and the Zambian nurses we worked with told us that their ratio is about 1:60/70 patients! That doesn't usually leave much time to get to know the patient, conduct full assessments and give them the best possible care. Idealistically, I believe that in order to provide better care would start at staffing. In nursing school, we are told not to restrain (either physically or medically) patients for our convenience. If we have to be told this directly on multiple occasions, makes be think that there may be a problem with this. The patient may be "safe" but it comes at a cost of their quality of living. 

JJ: I was floored by the stats Gawande shares, that when they introduced a dog, two cats and 50 birds to each floor of a nursing home that the prescription of drugs, particularly psychotropics dropped by up to 50%. I want to believe it, but it seems almost too good to be true? 

RK: A few of my professors have mentioned this nursing home before. I believe it! Unfortunately, health care facilities and nursing homes are businesses and most solely look at the bottom line. So, when all those animals are added, those are more costs: for the animal itself, for employees to spend the time caring for it, for its food, for its vet care, etc. When I did my psych rotation at LGH, one of the patients told me about the dog that visited the department earlier in the day. He was so excited to tell me about it! I did not have a chance to talk with the dog's handler, but I can only imagine the impact on the patients if the dog or other animals were permanent residents of the department.

JJ: Did you read other books on your trip or was this the only one? 

RK: This was the only one that I was able to complete.

JJ: Thank you so much for taking the time to read and consider the book so carefully. It was a pleasure!