Times, they are a changin’

This will be the final post as a Family Nurse Practitioner….

I am about to change this blog from the the HonestNP to something else. You see, when I deployed with the DE Air National Guard, I was among a small handful of members who were left behind in remote Ethiopia for a week without weapons, medical supplies, lodging, vehicles, proper communications, or Security Forces. While the first C-17 collected the bulk of our group, the plane I was expecting to take me to Camp Lemonnier, Djibouti in order to complete the second half of my deployment in 2015-16, broke down in the capital city of Addis Ababa, thus stranding us. To cut to the chase, Big Blue made the insipid decision to send Security Forces back to their stationed base on a hard-return-(to) duty. In other words, these members were due, by way of their orders, to return to their home station in England by a certain date. Rather than leave them with us to protect us as the locals had turned on us and the vacuum of power we had created by leaving, the decision was made to strand eleven Air Force members without any viable means of survival. We were left behind. The exact words given to us were, “You are not our priority”. Imagine being told that less than two weeks after a mob of 17 locals, intent to murder your team, were captured with RPGs, machetes, and other weapons, less than a half mile on the sole road to your location. Fortunately, for me, I survived the AK-47 held to the back of my head, ate the live bugs and mud placed in my food to prove I was iron-tough (which deflected another ambush), and safely made it with my team out of the jungle.

For years I worked mental health programs of various sorts. Sadly, I finally admitted to my VA psychiatrist I am no longer safe to practice medicine. It is not feasible to see patients when the reason they are in front of me escapes me halfway through the visit. Divulging this secret broke my heart. Broke. My. Heart. I had worked incredibly hard through thirteen years of college to earn my Doctorate in Nursing Practice only to hang up my stethoscope because my brain will not cooperate with my desire.

On the bright side, the trauma brought about some other gifts. I will put a pin in those at this time. I believe I will be shutting down this blog. Life is very good when you believe. In yourself. In God. In your family. I can honestly say the blessings I have received, particularly over the last year, are far beyond my wildest dreams. God certainly kept his eye on this sparrow. I am grateful. I am loved. I am saved. My brothers and sister saved me. How lucky and blessed I am indeed.

Please, let the NPs handle this.

I have sat back and watched this pandemic play out in a pathetic patchwork of peewee power players from fifty states (or are we up to fifty-one now?) attempt to reign in a mystical microbial double-mask-is-a-must virus for over a year with as much effectiveness as Lorena Bobbitt with a butter knife. The effectiveness of an 81-year-old self-certified king of the lab lost his credibility when he initially said masks would not work against this wretched unseen killer striking down our families and friends last Spring. He forgot everything us nurses ever learned in Microbiology 101, 201, 301, and so on down the line to our Doctorate. If it is dangerous, wear PPE until otherwise assured. Personal Protective Equipment. As in every nurse worth her salt at the very least made her bones on the med-surg floors in nursing school (and beyond) wearing a gown, gloves, and a mask in rooms when patients were living with MRSA, the flu, C. diff (the gift that keeps on giving in any nursing home), and any other creepy contagion. And heaven forbid lest we forget the media was so worried about everybody else except nurses when the 2009 SARS H1N1 epidemic hit.

We had patients stacked like cord wood in the ERs across America. Lined in the hallways in our med-surg and telemetry units. Would you believe our pregnant nurses were told to take these patients? Yes, initially they were until the CDC finally got its act together. In the meantime, us nurses stuck together, terrified as we were, and took the SARS patients from the pregnant or immune-challenged nurses. WE were not stupid. However, the Dr. Fauci’s of the world were so busy slowly studying the virus that they forgot the thousands of healthcare workers with immune issues faced with caring for these patients. It. Was. Crazy. Our local communities brought us food and snacks because some of us had to work extra shifts and cover for those of us who got very, very sick. We had a pregnant nurse end up in the ICU because the CDC could not come up with guidance.

That being said, as someone who has served two decades in our armed forces, I can tell you how many of us have whispered amongst ourselves pertaining to the handling of this virus. This is only my opinion and does not represent that of my unit or military. Just me, citizen NP. The honest NP who tells you how it really is. The one who did not stop seeing patients when the rest of the doctors closed up shop and did only telemedicine. Not the country doc I worked for. No way. He is a doctor’s doctor. He stood up and faced it head on. He is the kind of doctor I want to be when I grow up. Just saying. He is amazingly kind, outrageously knowledgeable, and didn’t flinch at this pandemic.

If I were the President, I would have told the world to look at their Microbiology Book 101.  Get a vaccination ready with the help of all the scientists of the world. Work together people. It doesn’t matter who or how. Just get it done as one team, one world, one fight. Then, for the United States of All People Regardless of Anything Anyone Has A Darned Problem With Because Now Is Not The Time To Argue Darn It All tell the nation the following:

The moment the population achieves a percentage of those who have had the disease (natural immunity) + those who have the vaccine = herd immunity will give everyone regardless of whatever whoever has a darned problem with because now is not the time to be divided but a time to be the darned U n i t e d S t a t e s of America that we are and always will be the ability to remove their masks.  So, instead of it being a lockdown, look at it as a “Race For The States“.  The states to reach that herd immunity % first removes their mask.  Period.  As each state reached their goal percentage, remove their mask. Period.  Use the Air & Army Guards to set up strategic vaccination sites in addition and conjunction with communities both rural and urban so that every breathing person has the opportunity to get vaccinated.  NPs like me would be more than happy to deliver to shut-ins.  After all, it is what we do.  Right back to the Crimean War. We go to where the people are who need us most. We don’t care. Send out roving teams to those who cannot get out in urban and rural areas.  Period.  This vaccination=herd immunity could have been achieved in record time, and we could have then helped every nation in the world. One nation. One world. One fight. Done and done.

See, NPs get it done. Too bad we cannot get rid of that crazy collaboration agreement that the legislators in PA want to hold onto. Of course, all we have to do is wait until they hang onto their blessed power and age up to Dr. Fauci. Then they will need a house call. Since their doctors are too busy playing golf to be bothered doing house calls, who they gonna call? The honest NPs. Then the collaboration agreements will break and fall away, just like the unfair bondages that have held back so many professionals in the past.

May you have good health. Good weather. And always a good NP to take care of you.

Fighting for independence: NPs vs. the 50 states

The Pennsylvania legislators have finally seemed to get on board with nearly half of our 50 states to break the cumbersome bonds of collaborative agreements.  Right now, nurse practitioners are being forced to practice under a two-physician contract agreement in order to give routine care to Pennsylvanians who desperately need medical care.

This desperation stems from two things.  First, the health care system has been and continues to be in a state of shambles.  Second, and most urgent, is the little-known fact that the nearly 11,000 nationally certified nurse practitioners in Pennsylvania are being held to a decades (decades!) old law that requires NPs to “collaborate” with not one, but two physicians in order to practice.  There are about 38,000 active physicians in Pennsylvania (General Assembly of the Commonwealth of Pennsylvania, 2015, p. 11).  Many physicians do not want to be bothered with the cumbersome paperwork slowly, ever so slowly processed by the Pennsylvania Board of Nursing.  Although the website states two weeks, it is more like two months to process.

Worse yet are physicians who never step foot into an NP-led practice, typically in rural areas, but they are named as collaborators.  And the NPs pay on average $5,000 annually each to those physicians just for a signature.  It’s like being held hostage but never getting the resolution.

Should one of those “collaborative” physicians retire, fall terribly ill (think stroke), or die, the nurse practitioner must stop practicing.  I personally know an NP who owned her own clinic in a rural area and did house calls when one of her collaborative physicians had a stroke and retired.  No warning. It just happened.  And until she found another doctor to agree to sign on, she had to close her practice.  Three weeks.  Closed.  Patients had no care for three weeks. Tell me, after over 15 years of practicing, how is that fair?  Will her mortgage company cut her a break?  Her light and power company?  No.  Not any more than that Commonwealth of Pennsylvania.

Fortunately, the legislators of the great Commonwealth of Pennsylvania have passed SB717 and now it will head to the House of Representatives.  The Pennsylvania Coalition of Nurse Practitioners (2017) states, “Senate Bill 717 and House Bill 765 would end this costly, arbitrary and outdated mandate and make Pennsylvania a full practice authority state.”

Already, 21 other states plus the District of Columbia have granted full practice authority to their NPs.  However, Pennsylvanians in rural and underserved areas may soon be able to rejoice as NPs who have completed an unprecedented three-year “training period” and 3,600 hours under the aforementioned collaboration agreement would be able to apply to work independently.  (One can only imagine how many months it will take the PA Board of Nursing to process the flood of applications).

It is maddening, as a doctoral-prepared NP, that I should have to work with two physician collaborators.  If the Pennsylvania branch of the American Medical Association, who has fought this break in antiquated wink-wink boys’ club tradition was so concerned about the health of Pennsylvanians they would have jumped in to break the collaboration and made physicians available via a hotline to support what they call “mid-level” practitioners.  Instead millions have been wasted on both sides and years have gone by while tragically underserved Pennsylvanians, my neighbors, people I know and have heard of via word of mouth, have suffered with no access to care.  No. Access.  To.  A.  Medical.  Doctor.  Or.  NP.

There are plenty of patients who prefer a board certified physician.  And I have learned under and alongside wickedly intelligent physicians to whom I will always be grateful.  But there are also patients who love NPs and welcome our prevention as well as treatment modality.  There is enough room for everybody.  We should respect each other. Stop throwing verbal stones.  However, aside from that, get rid of the collaboration agreement.  And once that is done, fix this new, upcoming law because even when it is passed, Pennsylvania’s collaboration will remain the most antiquated in the entire 50 states.  And that, my dear friends, is unacceptable.

 

Sinus infection? Allergy? Cold?

One of the most often seen complaints in primary care is the basket of nasal stuffing/dripping with headache.  Some patients come in, absolutely certain it’s “another sinus infection because I get them all the time.”  Others are sure it’s “the same allergies I get all the time.”  And yet the final category are those who are certain the cold will kill them, likely before the end of the day.  Each of these unfortunate souls can find it hard to keep up with the mad-paced electronic-super charged society we live in. Many wait until they can no longer take it.  Others rush in after just a mere few hours of symptoms.

So how do I figure out what is really wrong with the patient?  Above all else, listening to the patient’s story as to what their symptoms are and how it unfolded offers much guidance.  For instance, a patient who felt fine and then “suddenly” felt like they were “hit by a Mack truck” are more likely to be suffering from a viral illness of some sort.  Colds, you know, the ones which make you look like Rudolf the red-nosed reindeer and cause a sharp spike in Kleenex stock, are viral.  They don’t need antibiotics to cure.  In fact, so sorry all of you who want an antibiotic for every sniffle, antibiotics will do no good for a cold or viral illness.  None.  Zero. However, if a patient pushes, sometimes I will give in after I tell them they will still get better in about 7-10 days because that is about how long most viral illnesses last.

Other markers of the cold/allergies/infection are ones I see when I examine you.  I really do like to check your ears, nose, and throat.  Your ears could have wax build up or fluid behind your eardrum.  Both can be painful.  Both can seem rather abrupt. But the treatment is very different.  Your nose is a wonderful clue box as I call it.  Oh the things the inside of your nose tell me!  And your throat is a lovely indicator of allergy (the back of your throat looks kind of like a cobblestone street) or some other nasty things I may need to address.  I’ve found strep throat  by sight and I’ve also found folks who have just eaten something bready like a bagel of which remnants can look remarkably like white pustules back there.  (You might want to brush your teeth and don’t eat anything before you come in to see me).

While you’re there, I like to see how your blood pressure is doing.  Today’s American diet has led to blood pressure problems at very young age.  It’s no longer just for those over 40.

And very often, folks like to tell me about what’s going on in their life.  Most of all, they need to vent to someone who won’t tell others.  And who will listen.  And who will care.  Because I truly do care about my patients.  I care about their families.  And I like patients to show me a quick snapshot of their pets.  It’s something to bond over.

The next time you get sick, remember to tell your practitioner about how quickly or slowly you fell ill.  Tell us about how long you’ve been sick.  And know your symptoms.  If the answer to every question is “yes”, I’m often suspect the patient wants a quick antibiotic because a lot of the questions I ask do not apply to every cold/viral/allergy illness across the board.

And by the way, I like patients who look things up on Google.  Why not?  Sometimes when I am incredibly busy, they often have an idea as to what is going on and will be sure to tell me about those symptoms so I can verify with a few more questions and a good physical exam.

Ears clogged? Popping? Clicking?

It doesn’t matter what time of year it is, most days bring at least one patient complaining of their ears being clogged, popping, or clicking.  Some folks say they “can’t hear” and it usually comes on rather suddenly versus very slowly over a period of weeks or months.

Sometimes it follows a cold.  Other times it accompanies allergy season.  I like to let the patient tell me their story, as in, “tell me what happened” or “tell me about it” so they know I am listening and tuned in to hear clues about what additional questions I may need to ask.  When I start to ask questions, it’s called a “drill down”.  Think of it as a funnel.  I start by asking broad large questions, like catching everything going through. Then, as I pick up clues, I funnel the questions down and ask more focused questions. Usually by then I have only a few things I think could be going on.  That term is called “differential diagnosis”.  So the funnel goes from a big wide mouth to a tiny, little one with only a few things medically wrong which could fit through the opening.  That’s the drill down.  It guides my physical exam and what differential diagnoses I feel could be in the mix.

So when a patient states they have popping and clicking and feel like they are “hearing under water” or “everything sounds far away” or they “can’t pop their ears”, I am usually pretty sure they have fluid in their ears or their ears are clogged up due to something such as ear wax or allergies.

That’s about time when I take a look.  Let’s say I see fluid or the exam guides me to believe the issue is allergies.  One thing I use is a 4-5 day course of Sudafed (regular is fine) or my favorite is Fluticasone proprionate (Flonase).  It has a light steroid in it which shrinks the area in the ear enough to help open things up.  For allergies, it’s a nice medication.

Now here is the most important thing: it’s how you use it!  I tell my peeps it’s about HOW you use the nasal spray.  When you go to spray it, hold the bottle.  Then CROSS YOUR ARMS.  By doing this, you angle the tip of the bottle so that it points towards your sinus cavity and ears versus going right straight down the back of your throat.  Then you spray and sniff VERY lightly.  Not even enough to sniff a flower.  It should feel as if it is going to run out of your nose for about 10 seconds.  But it won’t.  Your nose is like a sponge.  If you spray and sniff and you can taste it down the back of your throat, you sniffed too hard.  Your throat may feel great but it sure won’t do anything for your sinuses or your ears.  I’m sure there are videos on YouTube by the manufacturer as to how to use this medication the best way.  But that’s how I tell my patients to use it and most of them have reported pretty good relief.  Remember to be patient.  It can take about 2 weeks to get relief.  The ears are tough little buggers and don’t want to drain fast.  They may pop a little more before they heal.  If it lasts longer, then go see your health care provider.  Again, I’m not giving you medical advice, I’m just ruminating about what’s worked for me and my patients.

It sure is helpful to have something to fix your ears.  I’ve had patients return after a course of this nasal spray and tell me they were so sure it wouldn’t work, and, wow, weren’t they surprised when it did.  Sometimes NPs have to work just a bit harder to win over patients.  That’s okay.  I have a lot of time to win them over one at a time.

Allergy season: Which product? When to take?

Oh allergy season is upon us.  If you haven’t already started an allergy pill, hurry on up down to the Piggly Wiggly and pick up a bottle, box, or carton.  Today.  To-day.  I know the ads show allergy sufferers dancing through fields of hay fever and snuggling next to Fluffy the super-furry long-haired white cat.  Apparently, the drug companies want you to believe their allergy medication works “in as little as 30 minutes”.

Okay, people, here’s the truth.  If you want the best allergy coverage, start taking allergy medication about two weeks before your allergy season begins.  Spring allergies?  Then start no later than March 1st.  Late summer?  Start July 1st.  Fall?  Start September 1st.  Now remember my disclaimer, my comments are not meant for everyone and not intended to replace the advice of your health care provider.  However, in general, it takes about two weeks for allergy medication to seat itself in your system and cover most of the symptoms.  You know, the runny nose, watery eyes, itchy ears, and throat.  While you can get relief quickly, full coverage relief is best achieved after two weeks.  That means heavenly 24 hour relief.

Here’s a pearl I’ve learned which may or may not apply to you.  For indoor allergies, I’ve found Claritin works fairly well.  Yes, it will work on outdoor allergies, too.  But it sure does seem to cover indoor pretty well.  And, yes, the store brand is fine for most people although some patients don’t do as well with the binding ingredients.  You will have to decide that for yourself.  For outdoor allergies, Zyrtec covers fairly well.  For most people, taking allergy medication at night is a pretty good idea because it can make you tired.  Relief from allergies and a good night’s rest.  Not bad.  Allegra is also a good alternative.  Patients ask about the stuff behind the counter, for example, Claritin-D.  The D is a decongestant.  In general, most people do not need it.  It is not very often, in fact, that the decongestant is necessary except in short-term periods.

If your ears are feeling “clogged” and popping or clicking, it’s often because they are not clearing properly.  It is often on the heels of a cold or allergy-related.  I’ll talk about that in my next post.  It’s something you can buy at the pharmacy as well.  So stay tuned….

Job Search & Networking

This week I attended a national conference for nurse practitioners (NCNP 2017).  The original intent was to learn the newest guidelines on common ailments I encounter in primary care practice. However, with recent events, I found myself in need of networking to see about locating a new employer.  Here’s what I found…

Being outright honest about why I parted ways with my previous employer was refreshing to both parties.  I did not bash the folks I used to work for.  Instead, I quickly noted our disagreement and stated I enjoyed working for the previous company and would miss them but things did not work out as I had hoped.  It was truthful and heartfelt.  Speaking negatively about a previous employer, even when, by many accounts is could have been justified, would have been poor form.  It is not in my character.  My grandfather used to tell me the only two things people can’t take away from you are your character and your education.  He was right then and that statement continues to hold true today.

Another thing I found was that the nurse practitioners I met from around the country were engaged in refreshing their knowledge. They enjoyed networking with others regardless of geographic origin as much as I did.  I’ve picked up a few words in another language which has been fun, too.  It is apparent the days in which health care providers earn their license and then practice the same way year after year until they retire some decades later are gone. NPs are vested in their patients’ health and wellness.  That entails constant refresher courses as guidelines for every major and minor disease, ailment, and injury change faster than they can be printed.

It’s been the type of week which reinforces why I became a nurse practitioner.  I have met other NPs who also strive to do the best they can to do right by their patients.  I’ve also picked up clinical pearls, those tid bits of information which successfully guide medical decisions to help my patients recover or cope with medical illnesses.

When I return home tomorrow, I will get on the plane as a better NP, have more friends, and maybe, just maybe, a new job in the pipeline.  I sure do hope so.

If no job materializes, I know God will have the right job waiting at the right time just for me.  It’s kind of like a prescription for medication, follow the right  steps and then wait and in time things will work out just fine.

 

Those who are supposed to care

Sometimes we as health care practitioners (HCPs)are the ones who are ill or injured.  When that occurs, we generally believe the other HCPs around us, and particularly, those whom we work so hard for, will treat us with caring respect. For some HCPs, especially some employers, that is simply not going to happen regardless of the nature of the injury.  Large facility employers have adequate policies in force to protect both the employer from lollygaggers and the employee from heartless owners who purposefully disregard obvious painful, debilitating injuries.  Smaller places of practical care often  have policies which evolve spontaneously, usually to the benefit of the employer.  It is not until times of such disability that employers reveal what type of wizard is truly behind the curtain.

In the course of our employed lives, which accounts for roughly 70% of our time on this earth, realizing that our employer is not the wonderful, caring being we had believed them to be.  The slow realization that the previously beloved employer is focused only on money production can be agonizing.

After much thought, two end products should result when the employees care more about each other than the employer could ever claim in front of the Almighty.  First, the injured practitioner should give swift, adequate, professional notice.  Save yourself.  In order to be the best NP one can be, it is an absolute necessity to care for oneself and about oneself.  Working for any practice that only treats employees well when those employees are, um, well, is like continuing to date someone after they have shown themselves to be untrustworthy.  Save yourself.

The second end result should be to evaluate future employers more carefully.  Weigh smaller versus larger practices.  Ask about written policy handbooks.  And what to expect if policies are overhauled.  Are employees grandfathered?  It is important to know.  Save yourself from jumping too fast. 70% can be a long, long time.

Sadly, finding out how an employer treats injured employees is often something we understand after the process has started.  Worse is that this has to be written about at all.  Our society has become so completely romanticized with the PC of everything that it is difficult to understand how any employer can be so callous as to watch an employee physically suffer day after day and then verbally and policy-driven attack them.

However, if you are genuinely kind, truly and authentically kind to co-workers and patients, rest assured those fine people will be tremendously supportive right through to the last-minute of the last day.  And that, my friends, is why being honest and kind triumphs over hardened money-driven hearts every single time.

Save someone else this season

Oh the flu season is upon us.  And it’s hitting the east coast like a ’72 Chevy Nova tearing across the county line to get to the all night diner before it closes.  If you’re young and healthy and one of those who don’t mind feeling like you got trampled by a herd of cattle, that’s your business.

However, before you even know you’re sick,  you can infect others.  That means  your time at work, the trip to the grocery store, and the local convenience store can be costly to ten or twenty of your community members.  If they are young and healthy, great.  You can all watch Netflix and take Instagram your misery in unison.  But if they are very young or very old or have poor immune systems (think those fighting cancer or breathing problems), the flu can be downright deadly.  D E A D L Y.  As a previous hospital floor nurse, I’ve seen it.  And it is pitiful to see the families come in to visit their loved one.  Over and over they say, “But I just saw them.  They were fine“.  That’s how fast and furious the flu hits.  How horrible it can be.  How uncaring and non-selective it always is.

The idea of vaccinations is driven by something called “herd immunity”.  Just like that herd of cattle that ran roughshod over folks in your town already, the herd can also surround and protect those same folks as well.  If enough people get vaccinated, the herd is effectively “immunized” or protected against, in this case, the flu.  That means the community  is less likely to suffer the huge flu epidemics we hear about on the news which cause us to say, “Well, I hope I don’t get it.”  So don’t get it.  Get the flu vaccine instead.  If it is the injection (a rather small needle unless you are a total and complete woos), it is NOT a live vaccine.  You cannot get the flu from the flu vaccine.  You CAN get a reaction which makes you feel sick which is GOOD.  It is your immune system building resistance to the flu virus so that if your body sees that virus again it will smack it down like a Tennessee Lady Vol defending the net.

Please get the flu shot.  You can get it all the way through until April.  Just like you can get the flu through April.  Look around at your family.  The babies.  Toddlers.  Grandmas and Grandpas.  Protect them.  Protect other community members’ babies.  Grandmas who make the best birthday cake frosting ever.  Think about others.  The world sure is a lot bigger than just you.  And you can’t get the flu from the flu shot.  No matter how much you say otherwise.

 

 

Those left behind…still

Today was my house call day…or half day.  I wish it were a full day.  Or a whole day.  Or a few days of my week.  I love my home visits.  My patients are largely the forgotten ones.  The ones who spent hours under the sun as children, playing in cops and robbers in the dirt, their mommas calling when the lights came on, years raising kids (older, forgotten versions of themselves), and now they have shrunk down into brittle memories of their parents.  They can’t get to the office and most don’t have family to shuttle them into our office.  They have outlived their “people”.  So they have me.

The first house was to what could clearly be something right out of a Hollywood haunted house movie set.  Dilapidated two-story.  White paint worn off the wood decades earlier.  Second story windows boarded up.  Front porch screens torn.  Sometimes Cecil answers the door. Sometimes not.  I pick my way across the broken floorboards and stray-not-so-stray cats and carefully sit at his table so we can chat about what ails him.  He is forgetful and usually refers to me as “that nurse”.  I know he’s secretly happy to see me.  I’m pretty much all he has these days.

The next house is a brother/sister team who have more ailments than I have time to list.  And some of them painful.  Their house smells like something illegal.  I ignore it and take my migraine medication as soon as I get back in my car, leaving the window half-open so my other patients don’t finger me.  Narcotic medications are so tightly regulated, they can’t get them from their specialists.  This is what happens when too many prescriptions were written then narcotics were getting into the hands of the wrong people and then legislators had their usual knee-jerk reactions.  Patients who were good, honest people now suffer.  They can’t make it in to pick up a monthly prescription.  Nor can they drive every thirty days to their pharmacy.  Because they can’t drive anymore.  A neighbor checks on them once in a while and they get meals on wheels.  It would be an ethical violation for me to prescribe and pick up their narcotics.  Of course, not unless something happened.  But in this day and age, who wants to risk their whole life and license?  So as long as I don’t see it, I don’t say it.  No harm, no foul and they are not in writhing pain.

The third and fourth houses are much of the same.  These are the forgotten people.  The invisible ones.  The houses we all drive by, the ones which look almost vacant but not quite.  We wonder who lives there from time to time as we zoom by on our way to work, to run errands, to pick up our kids.  What I wonder is, what do those next door neighbors think?  What do they wonder?  Do they wonder enough to drop by?  To clip the bushes?  To cut the lawn on a regular basis?  Not ask, hoping for a polite turn down, but just get up on a Saturday and just do.  Who brings them food?  Who takes care of them when they outlive their family?  Close friends?

They don’t all go to nursing homes.  Or to live with families.  Or drop dead the moment they have ceased to be able to care for themselves.  No.  They are forgotten.  Forgotten too much, too often.