Bringing It Home

by Tilda Shalof

  “The best training would be at a debt collection agency,” Magda says. “You have to nag people, make them feel guilty that they came to the hospital. We’re supposed to be a brick wall, not a sieve, and not admit anyone. It’s not a directive but that’s the message management gives us.” Magda wears a crisp white lab coat over casual clothes, corduroy pants and a T-shirt. A stethoscope hangs out of one pocket and the pocket on the other side sags from the weight of her phone, a reflex hammer, and her wallet. Her appearance is professional, but her tousled bright red hair and flushed cheeks make her seem like she’s got skin in the game, like an indignant family member, complaining about the substandard care her own parents are receiving.

  “The emergency department is the worst place for an elderly person but they come here because they have nowhere else to go, and our job is to send them back home,” she says as we sit at the nursing station to review the list of patients currently in the ER. Among others, there’s a fifty-year-old homeless man with a fever, a child with a stomach ache, a teenager who is threatening to jump off a bridge, a distraught fifty-six-year-old woman who hasn’t slept for three nights in a row, an eighty-eight-year-old man who had a “neurological episode,” and a seventy-year-old woman with pains in her arm, plus a few more. They’ve all been triaged, with top priority for a “one,” which is stroke, head trauma, hemorrhage, or possible heart attack, all the way down to the “fives,” who are the walking wounded.

  “They’re like, ‘Really? Why are you here?’ ” as Magda puts it. “Some of these people make me wonder if they’d have come here at all if they had someone to care for them at home.” She nods over at a wild-eyed person who looks like he lives on the street. “Or, if they had a home, which is what our febrile ‘urban outdoorsman’ needs.” The man she’s referring to is sitting in a row of chairs inside the treatment area along with ten other worried-looking people, none of whom appear, at least outwardly, to be experiencing an emergency.

  “They’re the ‘chair people,’ ” Magda says, “the ‘breakfast club.’ They’ve passed triage, they’re making progress, so it lessens their stress.”

  Since Magda’s specialty is geriatrics, she zeroes in on the “crinklies and wrinklies” whose only crime is “TMB – too many birthdays.”

  (Please note: hospital slang can be deceiving. The assumption is that people who use these crude short-forms are callous and unfeeling. Paradoxically, it’s often the opposite. I know wonderful, caring nurses and doctors who speak this way, and terrible ones who never do. I’ll take the wisecracking nurse who actually cares over the sweet-talker who’s only keeping up a pretense. As for Magda, despite her jokey talk, I feel how deeply she cares.)

  Magda charges forth to our first patient. “We’ll start with the ‘neurological episode.’ Probably a stroke or AGI – ‘acute gravity incident.’ You know, FDGB – fall down go boom. Falls are the most common reason an elder comes to the ER.”

  We wend our way though the noisy, crowded treatment area where patients are either waiting in individual private rooms or lying in the hallways on gurneys around the nursing station. One of these is Magda’s patient, a seventy-year-old man who’s unwashed, unshaven, and barefoot, wearing only a flimsy hospital gown. He’d been on his way to the kitchen without his walker and fell over his cat. He got to the phone and called 911. “I didn’t want to call the kids and bother them on the weekend.” His only complaint is feeling “weak and dizzy.”

  “ ‘Weak and dizzy’ – that’s what they all say,” Magda says to me. “We have to ask a lot of questions, tease it out, figure out the puzzle.” Magda does that and examines him at the same time. She finds good range of motion, and some sensitive areas and bruises on his back and legs. After ruling out injury from the fall, she advises him to use a walker, get rid of scatter rugs, and put bars in the shower. Magda admits her advice may or may not be followed.

  “He’s on the edge. If I had the time, I’d do a cognitive assessment and delve into how he’s been managing since his wife died. There are lots of red flags that need follow-up, but that’s not part of my job. We’ll send out a home care nurse to assess the situation, but for now, he’ll go back home, but will probably come back at some point. His diagnosis? ALC.”

  “Alternate level of care?”

  “No. À la casa. Remember, T ’n’ T is our mantra.”

  “What? Tea and toast?” It’s the known fallback meal of elders living alone.

  “No, Treat and Turf, as brutal as it sounds. Remember, ‘brick wall,’ not ‘sieve.’ I’ll get a bad rep if I admit too many. Okay, let’s go see the woman with the pain in her arm.”

  “I took my nitro, it didn’t help.” A well-groomed, bejewelled lady in white tennis shoes lies on the stretcher, her purse clutched to her side. Magda does an ECG and asks her about her pain, but the woman’s answer reflects another agenda. “My rent went up by thirty-four dollars, but I still have my mind, thank God. My husband will have a word with the landlord.” Magda orders blood work, asks more questions, then we step aside for her to fill me in. “She’s a multi-millionaire widow who’s a frequent flyer. She comes here every weekend on her housekeeper’s day off. We can’t admit her – normal vitals, an unremarkable ECG, and mild confusion won’t cut it – but it’s not safe for her to go home. Diagnosis? NPTG – no place to go.” Magda’s only recourse is to call a niece who agrees to come get her, but only later this evening.

  The ER – not only a walk-in clinic and a hotel, but now an adult day care.

  Magda knows the next patient, too, an eighty-six-year-old woman with frontal lobe dementia. “The brain shrinks to the size of a walnut, then a grape,” Magda explains. The husband brings her in when she doesn’t take her meds and gets aggressive. This morning he woke up to her hitting and kicking him and threatening to stab him.

  “She didn’t mean it,” he excuses her. “It’s not her. She’s really very sweet.”

  Magda tells me that home care case managers (aka “care coordinators,” plus other titles) – the professionals who go into clients’ homes to assess what services are needed – have visited her at home, but each time she rallies and acts somewhat normal. They have urged the husband to put her in a nursing home for his own safety, but he can’t bring himself to do it. Besides, she would need a locked ward that can handle violent patients, and there’s a shortage of those beds.

  Magda is more worried about the husband than the wife. From the nursing station, we observe him standing at her side. He’s exhausted and frightened, hunched over, his eyes downward, looking ashamed, like all victims of abuse. Despite the danger to him, Magda has no choice but to send them home.

  “At least he got a few hours of respite here with us,” she says wearily.

  The ER is now a patient lock-down, a caregiver sanctuary.

  “Let’s hope we don’t read that she murdered him in tomorrow’s newspaper,” Magda mutters.

  Next!

  Nurses often feel stressed, but I’m not stressed. I’m distressed. In thirty years as a nurse, I’ve seen many shocking things, but never anything as disturbing as this, never as many unsafe situations, elders not getting the care or treatment they need. It’s shocking and frightening, too – because we’ll all be there ourselves, one day – or someone we love will be.

  “We pray for a urinary tract infection or a fracture so we have a reason to admit them for ‘crisis placement,’ just to give the family a breather. But if we admit them they’ll become bed blockers, waiting for placement – that phrase makes them sound like a piece of furniture, doesn’t it?” Magda pauses briefly to come up for air, then dives back down to continue her rant. “For seniors, a hospitalization is a huge setback. Every day in bed, they lose 5 per cent of muscle mass and thus mobility.”

  Yet, once discharged home, alarming new problems ensue. One in six patients is readmitted to hospital within ten days of discharge home; one in five elderly patients is readmitted within ten days. Most of these readmissions would not have been
necessary if there had been proper follow-up care. Unbelievably, the cost of readmission to hospital for these avoidable problems amounts to a $1.8 billion drain on the health care system.

  “One lady was discharged home even though she wasn’t able to ambulate to the bathroom and she had no one to buy a commode for her. ‘Sure, we’ll save your life, but we can’t get you a potty.’ As for physiotherapy after a hip replacement or speech therapy after a stroke, you only get three visits. Yet walking and talking make all the difference in a person’s quality of life, wouldn’t you agree? In the hospital, patients get everything they need, but next to nothing at home. It’s basically YOYO – you’re on your own. It’s no wonder that a few days later they bounce back atcha here in the ER.”

  Magda explains what I’ve known for a long time. Patients are sicker than ever and hospital stays are shorter than ever. People are sent home too soon, in a fragile condition, and have to cope with oxygen, medications, IVs, drains, and dressings in a debilitated condition. It’s no wonder they develop complications and need readmission. It’s easy to see why caregivers feel overwhelmed and can’t cope. “But why do the surgery in the first place if patients can’t recover at home properly?” Magda asks.

  Yet, in all fairness, Magda acknowledges that some people’s expectations are out of line. “They expect five-star service. One lady complained that her ‘demands aren’t being met,’ and asked for ‘someone to come over to cut up my carrots.’ An argument could be made that a mani and a pedi are good for mental health, but should the government cover that, too? Where do we draw the line on services we can offer? Canadians are not used to paying for health care, but we can’t provide everything to everyone all the time. Choices have to be made.”

  I’m getting the picture: there’s a shortage of long-term care beds. Home is where people want to be, but it’s not always the safest place. Family caregivers struggle to give care, but get pushed to the brink, which can lead to abuse or neglect. Magda knows of families who keep a parent at home just so they won’t lose the parent’s pension income, which would go to the nursing home. She tells me about “granny-dumping.”

  “One grown-up daughter abandoned her elderly mother on the ER doorstep, saying she simply couldn’t cope with her anymore. Neighbours came to pick her up, but she wandered off and was found in the basement of the apartment building in a nightgown, babbling incoherently.”

  Magda asks if I want to see more, but no, I’ve seen enough. For today, anyway. But just as I’m about to leave it all behind me, I notice a security guard escorting two homeless women to the door. A nurse follows close behind, telling them gently, “It’s just that you come here all the time.” They look at her with imploring eyes. “I’m sorry but there’s nothing we can do for you.”

  I don’t blame her. What, really, can she offer them?

  For years my friend Annie has been telling me about her work. She’s a public health nurse who counsels “at-risk” mothers living in “high-risk neighbourhoods.” When describing what she does, she mentions terms I’m unfamiliar with, such as “fostering maternal attachment” and the “social determinants of health.” I ask her to explain.

  “It’s about helping the baby and mother connect to each other,” Annie says. “It’s about the effect of poverty, diet, unemployment, education, and homelessness, on people’s health.”

  Apparently, “high-risk” doesn’t mean hypertension, diabetes, high cholesterol, and lifestyle choices, which is how we define it in the hospital. Out here, “high-risk” means poverty, drugs, crime, new immigrants, or refugees fleeing disaster zones or oppressive regimes. I ask if I can visit her at work. I need to see it – no, experience it, first-hand – to understand it. But Annie deals with sensitive, sometimes politically charged situations. There would be scads of red tape and administrative hoops to get through for me to be allowed to visit. It would too long to arrange. I’m disappointed, but let it go.

  The other ongoing annoyance is that Judith has not returned my calls or emails. (Where in the world is she? It’s not “Where’s Waldo?” but “Where’s Judith?” Mogadishu? Bukhet? Hong Kong? You’d need a GPS to keep up with her. No wonder she jokes that, asked where she lives, she answers “Air Canada.”) But suddenly, the reason for her silence dawns on me. September is the time of year for the High Holy Days. First, there’s Rosh Hashanah, the Jewish New Year; then Yom Kippur, the Day of Atonement; Sukkot, the Festival of Thanksgiving; and Simchat Torah, a celebration of the Torah. Judith is busy with family celebrations and synagogue attendance and I likely won’t hear from her for a few more weeks.

  At least there’s Audrey. Since returning home from Trenton last week, I’ve received three letters from her – toadstools, autumn leaves, black cats, and orange pumpkins on these ones – including clippings of articles on health care, about new books she thinks I’d like, or about the Kemptville Panthers junior hockey team, for my sons. There are questions, too, which I answer in my reply, and then a request. But first, she presents her latest vital signs.

  October 15, 2012 0845 hours

  Sugar 13.7

  B.P. 119/61

  Heart 63

  Stable condition

  Why do nurses wear such big watches?

  Younger ones use their smartphones to tell time.

  Is it better for your heart to sleep on your right side or your left?

  It doesn’t matter. Whichever side is more comfortable for you.

  Was the SARS outbreak your worst nursing experience?

  It was definitely scary, but I felt proud to be a front-line nurse at that time.

  Does VON stand for “Very Outstanding Nurses”?

  No, but I will pass on your suggestion.

  My dear Nurse Tilda,

  Promise me you will come to my 80th birthday bash. It will be on February 6th, if I make it till then. It would be a dream come true to have you there. Please don’t let me down.

  It’s October. Four months away. I write back to tell her to stay alive and I’ll try to be there.

  SHWARMA AND HUMMUS AT DR. LAFFA

  NEWS FLASHES FROM THE ICU … beep, beep, beep … wait for it …

  Rita got a baby! (A six-month-old girl she adopted from China.)

  Joni is engaged! (Boy, that was fast. Didn’t she just meet the guy a month ago?)

  Sadly, Malcolm’s mother died. (He took care of her at home these past few months.)

  I’ve been keeping up with my ICU peeps on Facebook, but you can’t hug or congratulate or console in the virtual world like you can in the real one, so I’m here in person to coo over baby pics with Rita, admire the sparkle on Joni’s hand (“fairy dust,” she calls it), and comfort Malcolm – plus work a twelve-hour day shift in the ICU. That niggling apprehension I always get whenever I’ve been away from the ICU, the worry that I’ve lost my touch, disappears within minutes as my confidence returns and I’m back in the zone, capably caring for a patient who is three days post-op abdominal surgery for a bowel obstruction and still intubated and heavily sedated.

  “Welcome back,” they all exclaim when I arrive at the nursing station at the beginning of a day shift. “Where’ve you been?”

  “Are you broke? Is that why you’re back?”

  “Perhaps a bad case of writer’s block? Need some new material?”

  No, none of the above. I love it here, I keep telling them. This is home. I’ve been travelling, doing some research. A few more weeks, then I’ll be back at work as usual.

  “What’s it like?” they all ask (silently smug, I’m sure, ready with their I told you sos).

  “Interesting,” I say mysteriously, leaving it at that. Fascinating, in fact, but they wouldn’t have believed me (nor would I have, if I hadn’t experienced it myself). Nor could I have explained why. I’m still figuring it out. But for today, it’s great to be back in my stomping grounds with old friends. After all, laughing and eating lunch together with your pals is another thing you can’t do in cyberspace, isn’t it? After all, li
fe is with people.

  Life Is with People was the title of a treasured book in my father’s library. It was about the Polish shtetl at the turn of the century, and the tight communities of Jews whose daily lives were interconnected through celebrations, losses, and everyday activities. My father loved that book, and I still have his copy with his handwritten notes in the margins and entire paragraphs highlighted. Whenever I spent too much time hiding indoors during my shy, reclusive childhood or my loner teenager years, my father would point to that book on the shelf. “Don’t shut yourself away,” he’d say, paraphrasing from the Talmud, the book of rabbinic commentary on the Torah. “Life is with people.”

  But I haven’t closed myself off from the disturbing scenes I witnessed the other day with Magda. None of it was a complete surprise to me, but to see it up-close-and-personal brought it home. For some time now, it’s been hard to miss the screaming headlines in the Toronto Star: “Seniors in Crisis, Begging for Care,” “Family Caregivers Overwhelmed,” and “Home Care Is Broken.” Like everyone else, I’ve known about this crisis (predicted to only get worse with our aging, chronically ill population), but only vaguely and from a distance. The whole subject has been a bit like being aware of a genre of music that you chose to avoid, thinking you won’t like it. That kind of music is not my taste, you tell yourself. Yet, when you decide to open yourself up to it, you surprise yourself by getting into it. Or maybe it’s like learning a word for a concept that had previously been a formless, emerging awareness in your brain – highbrow words like inchoate or ubiquitous, let’s say. Suddenly, that word pops up everywhere you go. Is it something new, or was it always there but you weren’t attuned to it?