by Tilda Shalof
“I’m on only six, sometimes eight, per day. I’d love to be off altogether, but I have pain. You don’t believe me.”
“I do believe you and I want you to keep coming here.”
“I’ll only come if you’ll help me.”
“I want to help you. You are important to this practice.”
Tears spring to Jade’s eyes as her anger breaks. “The thing is, I think you actually mean it.”
“I do, but I don’t want this clinic to be known as an easy place to get narcotics.”
Looking both vindicated and victimized, Jade appeals to me. “I’ve tried to educate Kathryn about fibromyalgia. That it’s an individual thing. That it’s caused by emotional trauma. There’s one drug that gives me relief, but she” – Jade stops to flash a scornful look at Kathryn, who is unperturbed – “won’t order it for me. She only knows what the textbook says.” Jade glowers at her. “Educate yourself,” she scolds. “Use your brain.” She jabs at the side of her head. “Why did you do that to me?” She starts to cry.
Kathryn hands her a box of tissues. “As I told you, Jade, I can’t substantiate ordering that drug for this diagnosis.”
“Lots of people in my fibromyalgia support group get this drug from their doctor. Why won’t you order it for me? At first, when you didn’t renew my pain meds, I was scared. Now, I’m angry.” Her face is tight and twisted. “I don’t want to end up in hospital. They treat you like shit in there. I’d rather die than go to the hospital.” Jade storms out of Kathryn’s office in a huff, her problem far from resolved. Kathryn turns away from her computer, crosses her legs, and swivels her chair to face me. “So, what do you think? What’s your impression?” she asks me.
“Typical drug-seeking behaviour. Jade tried to manipulate you, but you didn’t budge. Why didn’t you tell her she’s addicted and recommend she go to rehab?”
“She’s not ready to hear that and I haven’t won her trust. Not yet, anyway. I hope to in time.”
We turn to other matters as we wait for the next patient.
I ask Kathryn about the turf wars I’ve heard about between doctors and NPs.
“In my experience, you get treated the way you act. Our focus is prevention, theirs is treatment. It’s different. We do not replace doctors, but we can diagnose, prescribe, order tests – everything a general practitioner does. It sounds radical but back in the sixties RNs weren’t even allowed to take blood pressure – that was something only a doctor could do.”
“Do doctors see NPs as competition, taking patients away?”
“Most see the relationship as collaboration. We don’t make as much money as they do and we cost the health care system a lot less, but there’s more than enough work for all of us. We need to play nicely together in the sandbox. It’s best for patient care.”
“I have heard them express concerns about safety. They say, how can a nurse with two extra years of education equal eight years of medical school?”
“It’s a reasonable question,” Kathryn admits, but doesn’t know the answer. “Even skeptical doctors admit they haven’t had safety concerns so far, but time will tell.” She thinks it over and has something more to say. “Concerns about safety? Here’s what’s not safe. Recently, I had a patient with right lower quadrant pain and all five signs of acute appendicitis, including McBurney’s. I prepared a note, sent her to the ER and I called them, too, to tell them she was coming. She ended up sitting for ten hours in the ER because, as they told me later, ‘We don’t read NP’s notes. We make our own diagnoses.’ Of course, it ruptured. I was livid. Yes, there are still pockets of resistance, but overall I’d say it’s improving.”
Kathryn sees more clients – Sebastian, a morbidly obese man with sickle cell anemia who suffers from depression and poverty. He’s a lovely, sensitive gentleman, soft-spoken and truly sad. After tweaking his meds and renewing his prescriptions, Kathryn takes time to look at the cartoons he’s brought to show her. He is creating a graphic novel about death as opposed to attempting suicide himself. Kathryn treats a woman for her migraines, then a teenager with an infected ear piercing with whom she also manages to do some counselling about safe sex. By the afternoon, Kathryn is still going strong, but I need a break.
“What’s the most important thing I can help you with today?” I hear her say to the next client and as I duck out of her examining room to take a break and stretch my legs, I run into Krystina Nickerson, one of the 360 social workers. She looks waaay cool and badass in jeans and a denim jacket, sporting an asymmetrical haircut with blue highlights, a peacock feather tat on her left foot, and a dancing cherub behind her ear. She invites me into her small, cozy lair of an office, to tell me about her role in this clinic.
“How does the word get out that this town is the place to come if you’ve hit hard times?”
Peterborough was a once thriving town, Krystina explains. Geographically, it’s at the crossroads of small town and big city, and the gateway to the northern, more rural areas of the province of Ontario. Like many small towns these days, the middle-class jobs are gone. Canada Packers, General Electric, Quaker Oats, and Westclox are all successful companies that closed their offices here because of the free-trade agreement with the U.S. and the downturn in the economy. All that’s left are dollar stores, cheap shoe outlets, and little emporiums that sell beach towels, cheap luggage, and velvet paintings. This town has developed the services that the down-and-out need.
“We have soup kitchens, food banks, drop-in centres, and shelter beds, but without affordable housing, without work, people feel shame. Most want to get off welfare, but they’ve become demoralized, depressed, and desperately poor. Some are suicidal and turn to alcohol and drugs. Many have fallen victim to addictions. It’s a harsh world and they are some of our most vulnerable. They need our protection.”
Krystina practises “narrative therapy,” which asks, “What is the person’s story?” and examines the meaning of life events to that individual. She connects her clients to political activist groups, like the Rainbow Coalition, LGBTQ youth groups, and sex-worker’s rights’ groups. “Being involved politically gives people a sense of control over oppressive forces.”
She works from a “non-oppressive world view,” and is critical of the failed strategies of law enforcement and prohibition, as well as abstinence requirements and punishing systems. Krystina believes that a solution is to embrace a harm reduction approach that would include safe-injection sites, methadone clinics, and needle exchange.
“Where did you learn this grassroots, radical style? At home, from your parents?”
She laughs at that idea. “They learned from me!”
Her hard-core, liberal, political stance is so completely at odds with my more traditional, conservative hospital sensibility that it takes me aback. But I can feel myself opening to this way of thinking, especially when Krystina confirms the prejudice that Jade reported she’d experienced in the hospital. I hate to think that happens, but I know that it does. I wish I could say that we weren’t that way, but there are still hospital staff who see the word “addict”‘ or “IV drug user” or “homeless” in the patient’s chart and label and stigmatize that person. When patients come into the ICU “with no fixed address,” with lice or scabies or track marks or nicotine-stained fingers, we rush to clean them up, scrub them down, disinfect them, and feel we’ve done our duty. But our actions speak volumes; I am mortified to realize how unsuccessful many of us are at stamping out our biases, or at least at keeping our judgments silent and invisible.
The phone rings and Krystina takes the call. I eavesdrop on her conversation. “Cool. I’m glad you’re okay … I want you to get your butt back in here … you’re going through a rough time … I want to hear all about it.”
Her softly lit office has a bookshelf filled with gifts from clients. On the wall is a framed sign that says, “You may not be bigoted … but that comment was.” On a corner table there are smooth stones, each with painted messages: “No M
eans No”; “Consent is Sexy.” Many of Krystina’s clients are sex-trade workers whose erratic, chaotic lifestyles make it hard to keep appointments, so once a week, the clinic hosts a drop-in potluck with an NP, an RN, and a social worker on duty. They also offer access to a shower, toiletries, clean clothes, washer and dryer.
Krystina gets off the phone and we turn to the subject of safe-injection sites, but my hospital way of thinking gets in my way again. “Harm reduction” strategies are a hard sell, especially to those of us who work in the hospital.
“Doesn’t that merely encourage the addictive behaviour, by making it easier, more readily available? Don’t you feel it’s enabling them?”
“No one – and I mean no one – would be on these substances if they didn’t have to be. They all want to get off. Harm reduction recognizes this reality and keeps people safer by reducing infections and overdoses, rather than requiring abstinence, which is too demanding for most people.” She offers me a rudimentary example of harm reduction thinking.
“Take handouts to panhandlers. People say they’ll only spend it on booze or drugs. A harm reduction approach argues that, yes, they use these substances, but at least you reduce the likelihood they’ll obtain them in dangerous or illegal ways.”
Krystina makes a convincing argument, but I cannot imagine myself giving out crack mouthpieces, clean needles, and syringes to heroin addicts. I can’t see myself working in a safe-injection site, advising people how not to overdose, helping someone find a useable vein to shoot – though these are things that street nurses commonly do.
“You could once you realize that drug addiction is a life-threatening condition. You’ll have a better appreciation for harm reduction once you realize that this approach saves lives. All harm reduction is,” Krystina says, “is about not judging or giving advice.”
“What I do realize is that in order to be that way, you need to know the person’s story.”
She nods. “Their story tells you who they are, it takes you to where they are.”
And where I am right now is finished – at least for today.
Kathryn has invited me out to dinner and we’re ravenous. We put on our coats, scarves, gloves, and boots to walk to the Indian restaurant around the corner. The thought of samosas, a fiery vindaloo curry, a vegetable biryani with a Kingfisher beer is making my mouth water. But just as we’re about to go out the front entrance, a young girl, hugely pregnant, arrives at the door, a tall, skinny guy trailing right behind her. Both wear flimsy jackets and look around seventeen or eighteen. Are they trying to escape the cold or are they looking for narcotics? My guard shoots up. Are there any controlled drugs on the premises? Kathryn and I are here alone. It’s already dark. Reaching into my coat pocket for my keys and phone, I plan our getaway.
“I’m hungry.” The girl giggles. The boy tries to grope her but she shoves him away.
Kathryn goes to the kitchen where she finds a box of crackers, some packages of pudding, milk, and a bottle of vitamins.
“Serena stopped coming for prenatal care – that’s always a huge red flag to alert us to put in a call to Children’s Aid, which, by law, I had to do,” she tells me. “One day she brought in a urine sample to prove she’s clean so she can keep her baby, but I had to dump it. It’s worthless if I haven’t seen her produce it. She’s still using so we told her we’d have to apprehend her baby as soon as it’s born until she’s well enough to look after it herself.”
“How did she take that?”
“Not well. She was furious. She left the clinic, laughing her head off, calling out to us, ‘Try to catch me if you can.’ I asked the Children’s Aid worker, ‘How do you do this work? How do you sleep at night?’ ‘By knowing I am keeping babies safe,’ she said.”
As we go back out to give Serena the food, Kathryn lowers her voice. “At first, we supported their relationship, until we discovered it was abusive. He’s pleasant tonight, but he has a violent side. She needs to step up and make better choices. If she’s not able to do that, we’ll have to step in.”
Serena takes the few supplies gratefully. She tries to brush away the boyfriend, who is swooping at her again. She tries to act annoyed. “Remember what happened last time?” I wonder if “last time” refers to the bruises on her face and neck or her pregnancy? He tugs at her skimpy jacket, trying to cover it over her belly. Then they sail out into the cold, dark night, arms entwined, chirping back and forth to one another like love birds.
Catch me if you can.
I radio a message to the new life on the way. Stay where you are, as long as you can. It’s safe in there, and warm, too. Out here might not be.
Kathryn and I look at each other. I turn off the lights and she locks the door behind us.
After an encounter as unsettling as that, most people would think it impossible – even unconscionable – to enjoy a nice meal over carefree conversation, yet that’s exactly what we do. I know. I know. It seems so unfeeling – even callous – but Kathryn and I are seasoned nurses. Serena is not the first, nor the last. We can’t fix everything, but we are dedicated to spending our days making a start. So, yes, we enjoy the dinner and each other’s company, and, at the same time, we hold the girl, the boy, and the baby on its way in our minds, in our hearts.
BEYOND ALL PREJUDICE
WHEN KATHRYN MENTIONED that the RNs in the clinic work to the “full scope,” I was intrigued to know more. This term is often bandied about, but what does it actually look like in the real world? Nurses tend to underestimate, not overestimate, their capacity to take action. It’s a timidity born from years of feeling subservient to doctors and a long history of reactive behaviour, rather than taking initiative. So, I’m interested to sit down with the RNs of the 360 Clinic to learn more about their role. Elena is slim and graceful, with salt-and-pepper hair. A few years younger than me, her two kids are still school-aged. Katy has long blond hair in a swingy ponytail and is eight months pregnant. She’ll soon be off on a year-long maternity leave.
The conversation starts and flows along with little prompting from me.
KATY: Helping people who are struggling with life is rewarding. It’s more real than nursing in the regimented hospital environment and there’s more opportunity to be creative. Besides, people don’t live their lives on a hospital schedule, by our rules – you can’t sleep in, you have to take your pills when we say – and it’s so noisy, even at night. And yes, it can be challenging to do a dressing change in someone’s filthy home where flies are buzzing around or a cat is walking over your sterile field, but you have to show respect and improvise on the spot.
ME: Do you have areas of specialty?
KATY: I love wounds! The drippiest, most infected, complicated, and challenging wounds are my favourites. Said like a true nurse, right? It’s tangible evidence that what you’re doing is really helping. I’ve done some extra courses on wound care, since it’s my forte. We have a surprising number of clients here with wounds. We have some very sick people here.
ME: You say “sick” like we do in the ICU, about patients we’re particularly worried about.
KATY: That’s true out here, too. My other specialty area is foot care, counselling about pain control and diabetic management, plus I run support groups for tobacco cessation.
ELENA: My particular interest is mental health, especially people living with depression. My other areas of focus are COPD and hypertension. These are some of the clients I’m working with right now.
ME: It seems to me that to care for this population, you have to get over your own prejudices and biases, if you happen to have any.
KATY: I’ve always worked with this population and have enjoyed it. I do have a problem with infestations. I’m not big on them. Don’t get me wrong. I’ll deal with it, but I have a phobia.
ELENA: Sometimes it’s hard for me with pregnant moms who don’t take care of themselves or their kids. This morning, my appointment with a sixteen-year-old girl and her baby was a no-show. When I thi
nk of all that it takes to be a parent – and she can’t even make it to her child’s appointments for a checkup? It’s disheartening. But it absolutely breaks my heart when I see neglect, especially of children. I take my role as a mom so seriously. There’s a woman I’m working with now. She’s a twenty-five-year-old sex-trade worker who came in wearing a mini-skirt in the middle of winter. She’s a drug user, using bad heroin with baking soda mixed in, and had huge, inflamed abscesses along the veins on both arms. Every night she bounces from couch to couch. Then she tells me she’s pregnant. It’s hard to sit by and watch her make choices that are affecting another life.
KATY: I am prepared to deal with the reality of what’s out there. It’s not always pretty and it’s not what I want for myself or my child, but it’s easy for me to say that. I’ve had a different upbringing. Sometimes you struggle to understand people’s choices. I took care of one woman who had a huge, infected wound on her vulva. “Will you let me put a dressing on it?” I asked her. “It will get in the way of my work,” she said. “An open, infected wound will get also get in the way of your work,” I told her and tried to reason with her, but in the end, I could only give her a bunch of supplies, show her how to clean it, and away she went. I haven’t seen her since. She had just taken a hit and was high, so I don’t know how much sunk in.
ELENA: One of my clients had been in hospital for septicemia and IV antibiotics. Only forty years old, they made her a DNR so there would be no resuscitation in the event of an arrest. They went ahead and made that decision based on their impression of her, without even discussing it with her. Another patient had severe anxiety and was suicidal. She also had pneumonia, but that was overlooked. The mental health issue becomes the sole focus – or the opposite happens, where the focus is the medical problems and their mental or emotional state is ignored. These complex patients have the highest needs, but often get the worst care. When we send them to the hospital and they get treated like that, we destroy the trust we’ve worked so hard to build. We once had a patient in respiratory distress, but he refused to go to the hospital because of the way he was treated the last time. Already in the emergency department, they feel the disgust that people there have for them.