Bringing It Home

by Tilda Shalof

  ME: What’s it like working with nurse practitioners?

  KATY: I haven’t worked with doctors. The hospital never appealed to me. I can’t imagine having to hunt down a doctor when I need one, or the rudeness that my friends who work in hospitals deal with. Here, it’s not like that. There’s no hierarchy. Also, there isn’t the tension that comes from billing for services. We’re all on salary here and spend as much time as each patient needs. Here, the philosophy is holistic nursing, looking at the physical, social, mental, spiritual – all with a focus on prevention. Here, we all speak the same language.

  ELENA: Yes, there is no conflict of interest that you have with piecework or private health care. There’s no profit motive. It’s just about what the patient needs. Sometimes I think about becoming an NP myself, but I know I’d miss being an RN. Being able to diagnose and prescribe is not really my thing. I like the conversations, the picking up the pieces, the coordination of it all.

  KATY: Yeah, I like sneaky assessments, like looking like you’re doing one thing but at the same time doing another. Having a conversation, but really figuring out what the client needs and how you can help. I’m not the authoritative figure. I leave that to the NPs. For example, when I do tobacco-cessation groups, I tell them about my own experience with smoking and how I struggled with quitting for many years. The main thing is to keep them coming back.

  ELENA: We hope that any patient who’s fallen off the wagon or has had a setback of any kind feels comfortable coming back here. They know we won’t scold them or make them feel guilty. We never give up on anyone. I tell them, I don’t care what you do; you’ll never get fired from this clinic, even if you relapse.

  KATY: Relapse is good, I tell them. Then we can look at it and figure it out. Now you know. It’s good that you came back. If you relapse, that’s fine. Just keep coming back.

  ELENA: The main message is that we’re here for you if you want to stop or cut back.

  ME: What’s your work schedule like?

  KATY: Tuesdays and Wednesdays, I’m the go-to RN and Elena has her booked appointments for counselling and diabetic teaching. The other days we switch. We each have programs we are responsible for, like COPD, hepatitis, prenatal care, and sexual health.

  ELENA: We have same-day spots because there are always some walk-in clients, so we make sure to be flexible. So many people only want a quick fix, like at a walk-in clinic. But here, we’re like, “Let’s talk.” They have to put in the work. It takes time.

  KATY: That reminds me of a client I am working with now. He is overweight, diabetic, and inactive, but wants me to help him apply for a scooter. Meanwhile, he’s still walking around. “That’s the only exercise you get,” I told him. “If you get the scooter, you won’t even be doing that.” Actually, we had a laugh over that together.

  ELENA: People test you all the time. One patient was on 110 mg of methadone a day, which is a huge amount. Yet, she was exhibiting aggressive behaviour. We had a conversation and she admitted she had a stash of carries. We try to build trust so they can be honest with us. Some of our clients come to us because they’ve been “fired” by their family doctor. That would never happen here. These are people whose lives are not straight and reliable. Many people have chaotic lives. If you can’t afford food, or if you’re in a rooming house or shelter, if you’re depressed or have no transportation, it’s understandable that you might miss an appointment. Home is the place where you take care of yourself. How can you be healthy if you don’t have a roof over your head? It’s basic. If we can’t get them in here, we know we’ll see them when they get their welfare cheques and can buy a bus ticket. We see them if we hold a potluck lunch. We choose a date just before they get their welfare cheque because that’s when they need it the most.

  KATY: Our clinic is not going to save society, but on an individual basis, one by one, we can make huge improvements in people’s lives. We had a client who was in his mid-fifties, living in a rural area, with zero money. Mentally, he was very disturbed with paranoia, aggression, and hallucinations. He also had diabetes. He was so lost, so alone. He missed too many appointments with his psychiatrist, so she dropped him. We arranged for him to see a psychiatrist in our telemedicine network by video-conferencing. The psychiatrist was in Toronto and the patient was here. We found him housing. “You guys helped me, my mind is clear.” Now, he has a job with a trucking company. Another guy walked around with only socks on his feet all winter. He had swelling in his legs, infections, and urinary and bowel incontinence that led to behaviour issues where he’d throw his stool all over the room in the shelter. The psychiatrist said he was a medical patient, the doctors said he was a psych patient. Meanwhile, he was so lonely, tortured by nightmares, and kept being bounced around from place to place. He’d go to the emergency department two or three times a day out of sheer loneliness. When they discovered he had a year-old untreated hip fracture, that got him admitted to the hospital. We went there, showered him, took care of the wounds on his feet and his infections. I can’t say all’s well with him but he’s definitely doing better. Families sometimes give up on these people. That’s so sad.

  ELENA: There was another lady, very low-functioning, barely thriving, malnourished, with poor hygiene, and rotting teeth. We brought her here and got her blood pressure under control. We did her laundry, then showed her how to do it herself. With her, we had to work hard to build up trust. Eventually, we got her shelter in a local motel, even though she was a smoker. But we saw a huge turnaround with her, even in that gross motel that was overrun with mice. She had socks, a bed, a TV. We brought her food. It was more than she’d ever had, so she was happy. She’s in long-term care now and very content. Many people are isolated like that. There are literally thousands of people in this country who have absolutely no one to care for them.

  KATY: The survival of the human spirit – we see a lot of that here. So many of our clients have been kicked down, have no hope – it’s inspiring to see them make even small steps.

  ELENA: It’s sad, but we also see so many inspirational stories of courage. We cope by working together closely and supporting one another. This work is very rewarding. To me, it is very meaningful. You are accompanying people on their journey. That’s why I love this population. They are literally on the margins of society. Primary care is all about building relationships.

  KATY: As nurses, you cannot be detached. In school, they teach you to keep a distance, that it’s not healthy to get emotionally involved. It’s never been that way for me. I feel a lot of emotions for the people who come to this clinic and I like feeling those emotions, whatever they are. I don’t shy away from feelings. It’s life. It’s real. It’s their life and you’re sharing it with them. Why wouldn’t I feel for them?

  Another NP in the clinic is Donna Dailey who almost didn’t become a nurse, much less a nurse practitioner. “I finished high school at sixteen and you had to be seventeen to apply to nursing school. I was too impatient to wait, so I became a paralegal.” She’s a full-figured gal after my own heart, stylish with brilliant white hair, black jeans, a tomato-red blazer, and funky red boots. It took twenty-two more years for Donna to find her way to nursing. At first she worked in a GP’s office as a family practice nurse doing well-baby exams, vitals, immunizations, and reviewing lab results. Nine years later, when her kids were grown up and she was a grandmother, Donna studied to become an NP, but her husband was in a terrible car accident and she became his caregiver. Her father became terminally ill and was dying as she wrote her final exam.

  “As soon as I was done, I flew home to be with him. When I received my diploma and licence in the mail, I didn’t even care. It didn’t feel worth all the work.” She was very discouraged but got her mojo back when she joined a family practice team in northern Labrador and was mentored by the six doctors of the team. “They taught me so much. Eventually, one said, “ ‘I’m going on holidays …’ ”

  “Don’t tell me he asked you to cover for him!”<
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  “An NP never covers for a doctor,” Donna is quick to explain. “We don’t replace physicians. We work together with them.” But she emphasizes that an NP works differently than a doctor. “The way I practise is not about body parts, organ systems, or pathology. If a patient comes in with a headache, I do a complete exam. I talk to them about lifestyle, diet, exercise, stress. We have a conversation. No one gets past me without a conversation. At the end of the day, it’s not rocket science to diagnose an ear infection, to treat someone’s blood pressure, or to help them manage their medications. What people need most is to have a place to go, someone who will listen and care and will help them find what they need. NPs give people the primary health care they need and it reduces wait times. It’s crazy, patients in the ER getting their ears syringed, blood pressure meds renewed, or foot care!”

  Donna loves this population. “These are complex individuals, each desperately needing a holistic approach. You have to look at the whole picture. You can prescribe meds, but what if they can’t afford them? You can order tests, but what if they can’t get back for the results? It’s about listening, observing, watching. Ninety per cent of your diagnosis comes from your assessment and asking questions – only 10 per cent from tests. I have to tease out the mental illness versus the behaviour, identify the main issues and what needs to be addressed first, and assess the level of the client’s participation in their care.

  “We treat a lot of at-risk youth. They’re mad at the world. Behavioural issues. Substance abuse. Run-ins with police. Getting into trouble. Dropping out of school. Establishing trust is the most important thing.”

  “How do you do that?”

  “By sitting, and asking questions, and then listening. You ask a question like, ‘How was your childhood?’ and magically, a door is opened. If they are using I say, ‘You use for a reason. Perhaps it’s to avoid the pain of something else in your life? We need to help you wean off the substance you’re hooked on and start building a repertoire of other strategies.’ ” Donna leans in closer, with a secret to reveal. “Here’s my belief. If there’s a person in front of me struggling emotionally or psychologically, I’ll say, ‘When we don’t get what we need at an early age, or we’ve been exposed to trauma like sexual abuse, abandonment, poverty, or violence, we grow up but our emotional self doesn’t grow in sync. We stay stuck back there and there’s catch-up to do.’ It starts with forgiving themselves.”

  “Not the parent or the person who did them wrong?”

  “Children always feel they are to blame. I tell them their parents could only do what they knew. They did the best they could. ‘You will have to take over from here.’ We try to help them get to the point where they can say, ‘This happened, but now I can make different choices.’ ” She smiles at how much she loves her work. She’s still smiling even when we compare salaries and discover she makes only slightly more than a full-time hospital RN in Toronto. “None of us went into this for the money,” she says. “We’d be fools if we did.”

  Donna likes to solve puzzles. She tells me about a patient who came in with a shoulder injury – a dislocation. She ordered an orthopedic consult, but in the meanwhile, the patient also had pain from the elbow down. “I wondered if it was nerve pain from an impingement, so I imaged the elbow to check for an evulsion fracture – didn’t want to miss that. ‘Why did you x-ray the elbow?’ the orthopedic doctor demanded. I never mind if my work is questioned. I like putting together the whole picture, coordinating the team and making sure everyone knows what is happening with the patient. I like preventing people from falling through the cracks. That is so satisfying.” She sits back contentedly. “Yes, I do love this population,” she repeats. “But, I have to admit, I love my patients wherever I am. I like to get to know people, not just fix their problems.”

  SOCKS AND CONDOMS

  NURSE PRACTITIONER KATHY HARDILL takes a handful of condoms out of her backpack and approaches a young woman in thigh-high black boots standing on the street corner in front of a grocery store. She’s teetering on high heels, wearing a black camisole, a lightweight windbreaker over her shoulders, and purple tights. It’s twelve o’clock in the afternoon, but she’s already hard at work. As Kathy told me at the start of our walk through the streets, parks, and back alleys of this town, “Sex work takes place around the clock, not just at nighttime.”

  “Do you need any condoms?” Kathy asks in a friendly, respectful way.

  “No, I’m good. But thanks.” She returns to scanning drivers. She’s desperate to land an afternoon job, likely to buy a drug fix; as Kathy also explained, in this town, most of these women are selling their bodies for drugs. Kathy stands with her while she scans the oncoming traffic, chatting for a few minutes. She hands her a card for the 360 Clinic. “Come see us whenever you like.”

  “Whenever I think a woman is working, I ask her if she needs condoms,” Kathy says as we carry on with our walk.

  “It’s a great icebreaker,” I say as a joke, but I guess there’s some truth to that. “How do you identify a woman who is working the street?”

  “Many I have gotten to know individually, but they all work like her, walking slowly, scanning cars, searching for a man and trying to make eye contact.”

  Kathy Hardill is one of Canada’s first “street nurses.” She’s an NP, teacher, researcher, scholar, and gonzo political advocate on behalf of the poor, homeless, and mentally ill.

  “I’m taking you out on the street with me,” she said, moments after we’d first met. We put on our boots and coats and headed outside.

  “Are we driving?” I asked, turning toward the parking lot.

  “No, we’ll be taking bus number eleven.” She made her two index fingers into ones, and motioned walking.

  Now, as we walk along the sidewalk, heading for the centre of town, Kathy explains how she works. “I move around, learn the community, hang out with the people, get to know them. I make myself available, show them I’m approachable. I’ll see them where they are, take care of them wherever they want me to – a crack house, a back alley, a parking lot, on a park bench. I go where the person is, rather than make them come to us. Clinics and appointments don’t always work for them.”

  We trudge on through the snow, slushy in patches where the sun’s rays fall. It has warmed up a bit today. Kathy notes that this increase in temperature – perhaps a harbinger of spring? – will make one less hardship for the homeless to endure.

  Today Kathy is on the lookout for two individuals she’s worried about. She’d like to offer one of them an intramuscular injection of penicillin to treat his STD.

  “I try to make a plan with the person. I always say, ‘If I take a test and the results are wacky and you need treatment, how am I going to track you down? Is there somewhere you go every day?’ I won’t take blood work or do any tests unless I believe the client will act upon the results.” She checks a parking lot tucked behind a bank and a pet food store. “I’m sure I’ll find him. If not today, then tomorrow.”

  The other person Kathy is looking for was cold and sockless last time she saw him. She wants to give him a pair of gloves and some warm wool socks.

  “So many of the problems that homeless people have with their feet – like infections, blisters, frostbite – could be prevented by wearing dry, warm socks.”

  (I must bring this matter to the attention of my sock-knitting colleagues at the next meeting of the Bagel Club. Oh, how the yarn will flow and the knitting needles fly!)

  “I always have socks to give out. Like the condoms, they’re a way to help me engage with them. Socks and condoms also send the message that I’m all about keeping them warm and safe.”

  Every nurse has at least one patient – some have many – they carry around with them for the rest of their lives. I have mine. For Kathy Hardill, it was an art professor who lived in a shack with holes in the roof. Whenever it rained, the shack would flood with filthy water, complete with floating raccoon corpses. Once, the profess
or had to wade through the water to get to his precious paintings, which he tried to save as he moved from place to place. Eventually, he lost them all. Kathy’s first nursing intervention was to get him a pair of boots. When she saw that he was limping and had a sore foot, she wanted to offer treatment, but he didn’t care about his feet. “They’re the least of my problems,” he told her.

  In addition to socks and condoms, Kathy hopes to soon hand out the new harm reduction kits that are currently in preparation. Before we left her office, Kathy had shown me a sample. It contained a set of multicoloured cookers, so each person can identify their own, filters, a tourniquet, needles, and little vials of sterile water for injection.

  “You mean someone might shoot up with unsterile water, straight from the tap?”

  “Or spit. Or puddle scum. Pickle juice. Toilet water. Whatever they can find. Thus the abscesses you’ve seen on people’s arms,” she says grimly.

  I walk along beside Kathy, taking this in. We stop to enter a public toilet, both women’s and men’s; we check under a train trestle, looking for homeless people or working women. All the while, she’s still searching for two people, scanning the streets and checking laneways and also telling me more about the risky business of sex work.

  “It’s indoors or outdoors, in all types of weather. It’s men with mini-vans that have a baby seat in the back. It’s guys from all walks of life.” Kathy stops to check under the awning of a closed-up canteen used only in the summer. “It’s dangerous work. There’s even a ‘bad date list.’ ” It’s a confidential website where women can post licence plates, emails, telephone numbers, or anything that identifies bad johns.