by Tilda Shalof
BERNADETTE (CHUCKLING): When I worked in the ER and they’d bring in a cold corpse just so we could document the death, I’d make it show a reading by jiggling the bed a little, just to freak them out.
ENID: Remember the eccentric doctor who’d fall asleep while you’d be talking to him, especially over the phone? He’d write his orders on a napkin or on the back of an envelope or any scrap of paper. He had a thing about enemas. Once, I called to tell him a patient had died. “Give him a soapsuds enema. That’ll revive him.” “I can do that, doctor, but he’ll still be dead,” I said.
UNUSUAL REQUESTS
HAILEY: A client asked me to meet him in his barn. “My cow is sick,” he said. At his request, I took its temperature, but had no idea what was normal for a cow.
LOIS: Speaking of cows – that reminds me – I once had to milk a cow for a client. This cow wasn’t partial to strangers and she let me know her displeasure. Let’s just say I had to go home to change my clothes and take a shower.
BERNADETTE: I cut the hair of a black woman and it stuck out, making her look like a porcupine. What to do? I went to the drugstore to buy special gel to tame it down before her son got home.
COLLEEN: Just the other day, a client told me how much he could get for me if I performed certain services on the street.
ME (GASPING): What did you say?
COLLEEN: “You couldn’t afford me!”
LOIS: Once, I changed the clothes on a corpse when the family didn’t like what she was wearing.
BERNADETTE: One night I got a call late at night. “I need you to come. My penis pains.” So, I had to go out in the middle of the night to change a crotchety old man’s catheter.
ENID: I used to keep a pile of newspaper in the back of the car to rest my bag on it, if the house was too dirty.
BERNADETTE: One woman kept a dead cat at the end of her bed. She didn’t believe it was dead, so wouldn’t let me dispose of it for her.
CLIENT APPRECIATION
HAILEY: I was given a toaster, once. Another time, a lobster. A live one. And every Christmas an elderly client tried to give me a tip. I tried to explain why I could not accept money. One year, I thought I had gotten through to her when all I received was a wrapped box of Pot of Gold chocolates. I always gave the garbage men Christmas gifts. This one busy year, my children began to holler as the truck rolled up the street on the last pick-up day before Christmas. I had forgotten to buy them something, so I grabbed the box from Mrs. P and ran outside. The truck lingered, then blew the horn, and the two men waved at me. I felt warm inside that they appreciated my gift. Later, my boss asked if I’d opened the present. She said Mrs. P had put a twenty-dollar bill on top of the box.
LOIS: Back in the eighties, we had to collect payment for each visit. An elderly man I saw weekly for a bath paid two dollars for a visit. One day he told me wanted to give me a raise – to $2.25.
MOLLY: Years ago, in the Annapolis Valley, I cared for an AIDS patient. His partner had died and he had to move in with his elderly parents due to his failing health. The farming community and friends shunned him. His father never accepted his sexuality. I cared for him until he died at home. His funeral was by invitation only and I was invited. What an honour.
The next morning on the drive from Yarmouth to Halifax, I scan the horizon for Oreo cows, red squirrels, and spider monkeys. Don’t spot any, so I drop off for a snooze. I loved last night, where I enjoyed wine but no whine. None of the griping or whinging, none of the put-upon, hard-done-by, I-don’t-get-no-respect, they-don’t-pay-us-what-we’re-worth attitude that too many hospital nurses have. That probably doesn’t describe the majority of us, but one could easily get that impression, as those nurses are the most vocal and noisy. When hospital nurses get together, it seems like there’s always something to gripe about or to feel indignant, even outraged, about. Complaining feels so good – getting it off your chest, discharging your bile, shooting off your mouth – but it leaves an unpleasant aftertaste.
I open a paper I’d folded and put into my purse. Last night, as I was leaving, Lois gave me a photocopy of a newspaper article written by Nurse Letty Neaves Drennan, a graduate of the local school of nursing, class of 1946, who became a member of the Victorian Order of Nurses. She describes the “techniques for a proper home visit.”
When you arrived at the home, if it was a new case or your first time there, you introduced yourself and asked if they had a section of newspaper. You unzipped your sleeves and folded them up, took the green soap and a paper towel to the bathroom sink, and washed your hands using the paper bag for your used towel. At this point, you attached your white cotton apron with its button hole at the top onto the second brass button on your uniform jacket and tied the apron ties. For whatever care you had to give, you took what you required and sat it on the newspaper, closed the bag and you started the care and didn’t open it again unless you washed your hands.
… I recall one home I went to where the young boy who was a little backward had had an operation and I was visiting to do his dressing. The mother’s love for him was so evident and she was coaching him in such a way in social graces and behavior that I am sure he achieved his potential and more. I can still feel that love between the mother and her son.
In these fast-paced times of constant change and with the world in flux, it is comforting to know some things are immutable, timeless. It’s just like Stuart McLean, Canada’s foremost storyteller, writes in his book, Notes from the Neighbourhood, “Everything changes and then – nothing changes.”
THE SMILING GOAT
JUSTIN DEFTLY JUGGLES MULTIPLE BALLS. They’re his morning clients we’re going to visit in downtown Halifax, all within walking distance. One wants to be seen first thing in the morning; two others live in the same building, but one wants him to come in the morning, the other in the afternoon, after she’s had her hair done.
“No worries. I’ll swing back later,” he tells her cheerfully.
In the hospital it’s more like, I’m here. It’s now. Now or never. Take it or leave it. You, your family, your meds, your pain, your needs – they’re on my schedule.
Just when I thought I’d seen all there was to see in home care, I get to accompany Nurse Justin Bragg on his rounds. It doesn’t take me long to realize that Justin has a few things to teach me. He parks his car on a tree-lined boulevard that leads in one direction to Dalhousie University and in the other to the city centre. From here, we’ll go on foot, client to client. Before we enter each home, Justin gives me a brief summary of each client’s history.
We see Wanda first. She’s a retired pediatrician living on her own in a downtown apartment building. When Justin first started taking care of her a year ago, she enjoyed peppering Justin with questions to test his medical knowledge. Lately, her mental condition has been declining. Wanda had always been a meticulous dresser and well groomed, but a few days ago, Justin came in to find her standing in the kitchen with her bra on backwards, her hair askew. Today, Wanda looks forlorn. Her housecoat is rumpled and dirty, and it doesn’t take a stretch of the imagination to envision one of her droopy sleeves getting snagged on a stove burner.
Last night, Wanda had a fever and went to the ER, where she was diagnosed with a urinary tract infection and sent home. “I’m feeling better today, Sylvia,” she tells Justin. “I don’t need those pills anymore.”
Justin doesn’t correct the name she calls him, nor when she asks me, looking over at him adoringly, “Don’t you just love the women of VON?”
“Yes, Justin is a fine woman,” I say, teasing him and going along with her mix-up.
Justin takes her temp – at 37.8°C it’s elevated – and asks if she’s tired. “Yes, from wasting my time last night in the hospital. I demand that something constructive be done right away.” Justin gently explains that she has a fever and must continue to take the antibiotics until they’re finished. He tells her that a storm is brewing and Hurricane Sandy is on its way. It might hit Halifax, so Justin
suggests backup plans in case the storm prevents him from getting to her, but she isn’t listening. She’s staring at the pills he’s offering her.
“Are these mine?” Her eyes narrow at him. “They’re not my pills.” He checks each bottle together with her, but she’s still not ready to take them. “They’re not the right colour. Are you giving me the genetic pills or the real ones?”
As a doctor, I’m quite sure she knew the difference between generic and trade medications – could probably even describe their molecular composition. Justin brings her a glass of water to take her pills. “I make them laugh, I make them cry,” she mutters and drinks them down. Justin sits at her dining room table, finishing up his charting. He nods at that and also when she says, “You’ll never know what you’ll find in these boxes down there.” She searches under the table, then looks up to tell us about a tasty lunch she ate years ago. “It was the best turkey sandwich. It didn’t need mayonnaise. It was a wild turkey brought up in the field.”
“A happy turkey,” Justin says, again joining her where she is.
“How much longer can Wanda live on her own?” I ask Justin as we walk along the sidewalk to the next client. “She’s right on the edge.”
“It’s a fine line, isn’t it? She wants her independence, but at what point does it affect her safety? Does she have a right to live in a way that is unsafe? She lives in an apartment building, so her actions could affect other people. Is she mentally competent enough to make that choice? Some days yes, some days no. In the elderly, an infection almost always compromises their mental status, so her confusion may be transient. There are many factors that need to be taken into consideration. It’s complicated.”
“So, what do you do, so that you can sleep at night – so that we all can?”
“Today, there’s a significant change in Wanda’s state of mind. I’ll call the office and arrange for another nurse to visit this evening and we’ll take it from there and monitor her closely. The goal with Wanda is her goal – to keep her home as long as possible.”
The consensus is clear, but only now do I fully realize it: everyone wants to be home.
We go up the elevator of an apartment building to meet Maude, who is morbidly obese to the point of near immobility. She is a diabetic who complains of pains in her legs. Justin examines them and finds nothing of concern. “You’ve got to keep moving,” he encourages her.
“I’m perfectly okay,” she tells me as Justin takes her blood pressure. “As long as I can stay at home.”
Maude’s doctor has made adjustments in her medications, but the new meds haven’t been delivered yet from the pharmacy. “I’ll check with you later to make sure you got them. Your blood pressure is a little high today.” I have a feeling that call is also intended to be a reminder for her to actually take them. These pills can’t be skipped. Her blood pressure is high at 170 over 100. Justin is all over this minutia. These small things are huge; each detail could be a matter of life or death, just like in the ICU, come to think of it.
“How’s the blood sugar?” Justin asks.
“Oh, it’s right as rain,” she tells him, and shows him her daily recordings. “I have diabetes. But just a little bit, mind you.”
“Your numbers are good,” Justin says, and she beams. “I’ll do anything so that I can stay at home,” she says again. “I need a little help now and then, but I’m seventy-five and when you get old, people wait on you.”
“You deserve it,” I say.
Maude looks at Justin. “I don’t know what I would do without Justin.”
Fortunately, Maude also has ample family supports, friends that check up on her daily, and neighbours that run errands for her. It’s an ideal arrangement. But a disruption in any component of this set-up – a break in the chain or a loose link – could threaten the whole system. These fragile elders living alone in the community are teetering on the brink between life and death.
One thing is obvious: Justin is loved by all. For some clients, his visit is clearly the highlight of their day. They await his arrival and all have questions ready for him: How should I handle …? What should I do if …? Why does …? If my rash looks worse.…”
There’s another common feature with all of Justin’s clients. In each home, the kitchen table is command central; it’s the “headquarters” for treasured items, equipment, supplies, and sometimes random objects.
On Wanda’s kitchen table there was a jar of leaky batteries, a huge magnifying glass, a stack of dated Hungarian newspapers, and old photographs.
On Maude’s table there was a plastic toothpick dispenser; a serviette holder; a basket full of pill bottles; silk flowers in a vase; a mug of dried-up pens; a bottle of hardened coral-coloured nail polish; lion, elephant, and monkey letter openers; salt and pepper shakers (salt is Santa and pepper is Rudolph the Red-Nosed Reindeer); an automatic blood pressure cuff still in its unopened box from the store; and a mini tower of sugar-free cookies.
Saskia is our next client, and while Justin attends to her, I cop a glance into her kitchen: on the table is a stained quilted placemat, a Barbie doll stuck into a toilet roll holder, a ceramic duck with a blue ribbon around its neck, a pile of cassette tapes of Russian folk songs, a jar of pennies, and a handwritten list of phone and PIN numbers.
Since Saskia is on an antibiotic and Coumadin, a blood thinner, which may interact, Justin calls the lab to arrange for a blood test to check if she needs a medication adjustment. Then he calls her son, Boris, to remind him to make sure she gets the blood test. Fortunately, he’s able to take time off work to get that done.
“My son is in charge of me,” Saskia says proudly. “He takes care of all my affairs.”
I consider that disclosure. Even in some of the “best” families, there’s always potential for financial shenanigans, but what choice does a vulnerable elder like Saskia have?
Saskia has talked with Justin about moving in with Boris and his family, or possibly going to an assisted living home, and, one day, a nursing home.
“Be good to your kids,” she advises me. “If you’re not, don’t expect they’ll be good to you.”
She and I chat while Justin puts in a call to the pharmacist to alert him to a possible change in Saskia’s Coumadin prescription, and to get her pills administered in a blister pack, which will make it easier for her to take the right ones at the right time. He knows she can be a little confused at times. In fact, as we are chatting, she gets up suddenly, goes to the kitchen, and stands there looking puzzled. She opens a cupboard door, then shuts it. Opens a drawer, then slides it closed again. “I can’t remember what I came here for.” Standing there looking puzzled, she takes a sip of her now-cold coffee.
We leave her to figure that out and Justin adds her to the list of clients who now need to be seen by a nurse twice daily. Justin’s next client is Marnie, whose messy apartment is full of souvenirs from around the world – African masks and pre-Columbian figurines, Persian rugs, and Greek archeological finds. Despite these beautiful things, when I peek into her kitchen, there is no table at all.
Marnie is – or once was – stunning. Her classic beauty has been ravaged by alcoholism. A photograph of her smiling, standing with a pilot beside an old DC-47, shows she was once statuesque, with wavy auburn hair and a great figure. Now, she’s thin and sad-looking. As unscientific as this sounds, she looks unwell. Her hair is unwashed and her faded cotton shirt is wrinkled and buttoned on the wrong holes.
“Applesauce,” she says listlessly, when Justin asks what she ate for breakfast.
A string quartet plays on a dusty old turntable. I concentrate on the music to avoid thinking about Marnie. It’s Beethoven’s String Quartet, No. 14. Cerebral and ethereal, it’s one of his last compositions before he died, a piece of music that has fond associations for me of an old boyfriend, a music major, who taught me a lot – about music, that is. (Not Mr. Thunder Bay of the “New York was taken” line, another beau.) For a few moments, it takes me away.
“How’s the drinking, Marnie?” he asks gently.
“Haven’t had a drop for awhile. Six days.”
“Good girl,” he says in an encouraging, but not patronizing, way.
“But what did you actually do there, for Marnie?” I wonder out loud as Justin and I walk along a downtown street with funky little boutiques and cafés on either side. “It was like a social visit. How can that be cost-effective?”
“My purpose was to check on her. That helps her stay at home. It costs our health care system fifty-five dollars for my visit, which is a lot less than if she was in a nursing home.”
We stop at The Smiling Goat, a hip little coffee shop next to the elegant Lord Nelson Hotel and take a break to sip espressos and talk about – what else? – wounds. Typical nurse convo. Incredibly, there are a lot of people walking around with breaks in their skin and holes in their bodies. There are necrotic gangrenous wounds, diabetic amputations, dehiscence when a wound ruptures, pilonidal cysts (deep, painful fissures, often around the rectum, that require packing), ragged venous stasis wounds, and cookie-cutter arterial wounds. (In the hospital I have seen extreme wounds. Recently, we had a patient from a nursing home who was admitted to the ICU with sepsis from a nasty pressure ulcer wound on his buttocks. Privately, we called it the “swimming pool,” because it was fluid-filled, had a deep end and a shallow end, and a flap of skin that looked like a diving board (maybe “you had to be there …”).) We chatter about malodorous drainage, serous ooze, and purulent pus while we drink delicious coffee. Justin is an expert in wound care, but if he encounters a tricky or unusual wound, or something he’s unfamiliar with, he snaps a photograph and sends it to a wound care nurse specialist for a consultation.