Thursday, July 29, 2010


In Kitchen Confidential, Anthony Bourdain describes his fellow cooks as "wacked-out moral degenerates, dope fiends, refugees, a thuggish assortment of drunks, sneak thieves, sluts, and psychopaths,"

Never having worked in a restaurant beyond the unfortunate few months I hostessed at Denny's, I can't tell you whether I agree with him or not. But what I can tell you is that if a year ago you had asked me to describe a health care facility's nursing staff, I would have said something like they are neat, educated, professional, impersonal, hurried, interchangeable people. That was before my first day in Long Term Care, when I was shocked to find that my new coworkers resembled the grizzled veteran waitress at Denny's who has two trailers (one for her shoes and one to live in) much more than my previous Health care Worker Ideal.

In the nurse's station, I saw people who eat McDonald's for dinner, say they "ain't puttin' up with that shit" and wear long acrylic fingernails. People who live in trailers, or if they are under 25, with their parents. People who I thought were shockingly casual with the residents. Both the aides I trained with would go into a resident's apartment, plunk down on the nearest surface (be it a chair, a walker, or a bed) and casually ask that resident if he or she was ready for dinner, or whatever it was. That first week, I was horrified.

After having been at the facility for a few months now, I'm starting to understand the more unspoken rules among the staff: yes, they do swear in the nurse's station, but only with the door shut so residents don't overhear. No, I don't approve of the girls that date guys who take control of the couple's only car and drop their girlfriends off for work hours early and then call every five minutes leading up to the end of their shift, but as it turns out, neither does anyone else. Yes, they are very informal and casual with the residents, but these are people that they bathe, toilet, feed, and put to bed 5 days a week. These are people who say "Thanks, love you honey!" as we are walking out of their doors after helping them. And most importantly, though staff will cover for one another over small indiscretions such as texting when you could be charting, when it comes to actual patient care, they will bust anyone who is being neglectful. Because whether they're trashy or not, they love their residents. And I can respect that.

So now I'd describe long-term-care health care workers as half dysfunctional Wal-Mart family, half fierce patient advocates. And while I certainly hope to emulate the latter half of that and not the first, I've made peace with the rest of it. As long as they're caring for our residents properly, I've got no problem with them. And vice-versa.

And I've got my own acrylic nails now, too.

Monday, July 26, 2010


Working with elderly people is a balancing act. Sometimes it feels like I have a facility full of grandparents, all prying into my personal life and kvetching about the everyday things that grandparents do (mail not arriving early enough in the day, why would a pretty girl like me get tattoos of all things, remote controls have too darn many buttons these days). Other times I see them as patients, as boxes on my run sheet (that's the sheet each aide carries around that tells us who we're responsible for that day and what they will need) that I'm never going to have enough time to check off.

Right now I do both home care and facility work, which is normally a nice balance. With home care, I get to spend one-on-one time with my client, and see him or her in their own environment. I can make sure that they have clean clothes to wear, or learn to recognize their children by the photos on the walls. At the facility, I get the faster pace, the medical environment, and the teamwork.

Usually it's reasonably easy to balance all this, and to try to see my clients as somewhere between the meddling grandpa and the low blood pressure number. I try to keep their diagnoses in the back of my mind when conversing with them, and check up with them without making it feel too much like an evaluation. I deflect the personal questions with my stock answers ("When will you have children?" "When the stork gets my address right!") and try to come up with ways to get the shy new resident to let me bathe her or the cranky old man to get out of his room and join in life a little more.

However, Jimmy is both my home care client AND a resident at the facility, and it's hard for me to leave him behind when I clock out at the end of my shifts. I happen to know Jimmy's family, and have for years, long before I ever began caring for him. And Jimmy has Alzheimer's. When I'm falling asleep at night, I have to force myself to stop mentally calculating whether Jimmy got enough protein to help him recover from a wound he is healing up from, or trying to come up with ways to help him remember the things he wants to remember. At his dinnertime, on my days off, I hope his aide remembered to escort him to the dining room. And when he declines, reaching a new stage in his disease, unraveling a little further, I feel weighted down imagining the tangled synapses in Jimmy's brain and trying to understand what the world must seem like to him these days.

Jimmy is the first client I cried in front of. Jimmy's wife is dying, and because of his memory loss, he doesn't remember this. I told him both of those facts: your wife is dying and you cannot remember it. I asked him if he wants to be reminded of it or not, because maybe it would be easier to not know. And I cried. Jimmy said he does want me to remind him, as many times as it takes, so I did. I've probably told Jimmy 20 times that his wife is dying, and I've cried a lot of those times. Because every time I tell him, it's the first time all over again. And it hurts him and surprises him and he reacts differently depending on the day. Sometimes he asks why no one told him this before, and I explain that I have, and that he's asked me to make sure he knows about it, which is why I'm telling him now. And I ask him if he wants me to tell him again, and he says yes. So we've continued for a few months now.

This week, though, I think it's time to stop telling him. I offered him that option, the burden of that knowledge, when he was still present enough to make an informed choice. But I can see that has passed. Jimmy isn't the same as he was then. He's deteriorated further.

I was hoping it was an infection, something that would be reversible. I collected samples from Jimmy and pushed for him to go see his doctors. Some days now he resets so frequently that I haven't finished answering his question when he asks it again. He refuses to eat, staring balefully at nothing, and I know, I know he doesn't know why he feels compelled to be contrary but he just can't help himself. It sucks. Jimmy is currently a man who cannot take on any extra responsibilities. So I'm not telling him about his wife anymore. And I'm not crying in front of him anymore. But tonight I'm crying for him, for the loss of him.

And in the morning, I'll go and have another day with him, and enjoy every second that he's able to come back through the confusion and be who he is. And when he can't, I'll keep him safe during the in-betweens. A lot of really excellent writers say that nursing is an art and a science, and explain what it's like to be around life and death really eloquently. I'm not an excellent writer, and big concepts like that are hard for me to express. So I'll just say that on days like this, nursing doesn't feel like an art or a science. It feels like a duty that I couldn't put down even if I wanted to, which I don't. It's just holding on to what you can and letting go of the rest. And sometimes that's sad.

Sunday, July 25, 2010


Bitsy is a homecare client that I had a few months back, who holds two special honors:
1. She is the MOST positive, optimistic person I have ever met.
2. She's the one that kindled my newfound love of football.

Bitsy is in her late seventies, but looks a little older than that because she has Parkinson's which causes her a lot of stiffness and difficulty walking or moving. She also has a few little spasms and tics, which, this being Bitsy we're talking about, are completely adorable; a prissy little head shake, ramrod posture, and a tiptoed gait.

Bitsy was living with one of her daughters when I began taking care of her, and her boundless bright-sideyness is even more striking considering that before she came to live with her daughter, she spent a few months in an adult family home where she was neglected. That neglect came at a time when Bitsy was recovering from a broken knee, and nearly permanently cost her the ability to walk. If you're curious about adult family homes or what's being done to rectify that type of situation, there's a great series called Seniors for Sale that covers the main points. And if you're thinking "no way in hell am I clicking on something that depressing" then that's just fine too. No judgement here; it really is sad.

By the time I got to know Bitsy she was regaining her ability to walk using a walker as long as someone was there to hold onto her gait belt just to be safe. She said the first time she was able to walk outside after moving in with her daughter, she was so happy she cried with joy. Bitsy is so funny and adorable, I think the best way to describe her is by sharing some of her quotes:

"That lemon-lime sports drink is delicious, but it's so rich! I'm as full as can be!"

"We went to Kmart the other day to find some cute pants for these long legs of mine, and did you know they had a wheelchair there for just anyone to use? It was the best thing! I was getting too tired with my walker but they let me use that wheelchair, and I got to see all the clothes there. Kathy Ireland has clothes there! And it's air conditioned! And it's so big, and so organized. It's really just beautiful. And we stayed so long with that wheelchair of theirs, it really felt like I was on a vacation!"

After watching a Christian stand-up comedienne DVD, Bitsy laughed and clapped at how "She talks about regular everyday things like going to the grocery store but she makes it SO FUNNY!"

Bitsy regularly marveled over the deliciousness of jello, how delightful it is to watch baseball games on television, how well the "little fellow over at the church" rings the bells every Sunday, and how funny the nurse that helped deliver her youngest child was all those years ago.

Looking at things the way Bitsy does is pretty great. And if you want to feel like you're right there with her, here's a clip of one of her favorite groups singing one of her favorite songs. Watch it and imagine a prim, idiosyncratic lady with giant knitting needles sitting next to you and singing along.
The Cathedrals "Movin' up to Gloryland" on YouTube

Wednesday, July 21, 2010


Lanie is a very determined, frequently confused lady who lives at the facility I work at. Up until recently, Lanie lived in our locked memory care unit. This is something that most bigger places offer, because think about it: people with memory loss tend to wander, but don't have the skills they need to keep safe while they wander around. They might be trying to get back to a house they lived in 40 years ago, and not realize that they need to watch out for cars when they're trying to cross the street. So a locked unit may sound harsher than it really is. At my facility, it's not even physically locked; you enter a key code to enter or exit. If you fail to enter it right, it sets off an alarm and one of the aides from that unit comes to see what's up. If you're an old person escaping, they talk you into coming back. If you're a new employee that forgot to enter the code, they laugh and turn off the alarm. Even if you did the same thing earlier that day. Oops.

But back to Lanie. Lanie is a skinny little old lady who walks with a walker and whose apartment is sparsely decorated. It features Jesus and Baby Dolls prominently. Lanie is generally content to just sit in her living room, looking out the window, or maybe flipping through a magazine or catalogue. When it's time to eat, one of us gets her and walks her to the dining room, seats her, and orders whatever we discussed with her earlier, since she'll blank out when it's time to tell the server what she wants.

Occasionally, Lanie gets hungry a little earlier than normal and stalks the halls crankily, complaining about how they moved the elevator again and she can't find the dining room in a crazy place like this.

One of my job duties is to take turns with the other aides passing out evening snacks for the diabetics after the nurse has done blood sugars and insulin injections. This keeps anyone from bottoming out overnight (hopefully) and is usually a pretty fun little chore, especially if I've managed to snag anything unusual from the kitchen to make it more exciting. The night they gave us Activia instead of Yoplait yogurt was a big one, let me tell you! Although we staff were all a little worried we'd be up to our elbows in poop the next morning.

Lately, the last few times I've been wheeling that snack cart up and down the hallways around 8pm, Lanie has popped out of her room looking for all the world like a geriatric CIA agent in some combination of a nightie and another garment. One night she had jeans aka "dungarees" on under her nightgown. My favorite was when she had on her pink trench coat over it, collar popped and chin low.

Lanie summons me with a loud "PSSST!" on these occasions, gesturing impatiently for me to come huddle in her doorway with her. I abandon my snack cart mid-pass, and walk over quickly to her. What Lanie has to say on these occasions is usually some variation on how "That room is a mess and I'm LOCKED IN there, and I can't get it straightened out!" Never mind that she's out in the hallway and therefore not locked in anywhere. Lanie's got something in mind and she wants it done now.

I usually start troubleshooting with "Do you need to go to the bathroom?" followed by closing her blinds (always a big relief) and pulling back her covers (usually gets me a "THAT's the stuff! Good girl!"). If Lanie is still feeling locked in, I check to make sure things aren't in unusual places. The other night, she'd partially disassembled her air conditioner. Not because she was too hot or too cold, just to unlock herself, you see. So I put it back together, which earned me a hug and the privilege of hanging up her pink trench coat.

I don't know much about Lanie or what she did with her life, but I like to imagine that maybe she was a great chess player, a spy, or someone who worked underground in tunnels. She's got a low-pitched gravelly voice and intense eyes. I can see her formulating strategies and melting around corners and into shadows. Lanie may just be getting unlocked in her apartment now, but I bet she could crack safes before. Maybe that's why Lanie's not in the memory care unit anymore; those doors couldn't hold her.

Sunday, July 18, 2010


There are different buzzwords that you hear a lot when you start learning about the world of senior care. "Aging in place" refers to someone staying in their own home. "Cognitive impairment" is the newer polite alternative to saying someone is confused, demented, brain-damaged by stroke, or senile. And any discussion about where/how/who will care for old people is bound to include opinions about how to "preserve dignity."

It's an emotional topic for families. They are used to seeing Grandma or Mom as a capable woman, and know that she worked for years as a nurse, or teacher, or Air Force pilot, or whatever it is she did. And even though she may not really be that same woman anymore in many ways, they want to have the stage set as if she still is the same as ever, as much as possible. Some families are against the use of mechanical lifts for that reason, because they think they are "dehumanizing." Some dislike certain terms; I have one client whose daughter doesn't like me to call myself her father's Caregiver. She prefers the term "escort" which I hate because my job is this:

and is NOT:

All in all, I'm not very sensitive about dignity. The truth is, getting old isn't a dignified experience. You lose abilities you used to have, and rely on others more. Your body is deteriorating. But you know what? It happens to EVERYONE who lives long enough. So there's no point being embarrassed about it. I think we may as well just be practical and do things the way that's the easiest for the old person. It's more comfortable and safer for them to be transferred with a mechanical lift? Use one. They need to be wearing diapers/briefs? Get some. The dickering about what to call someone's caregiver or whether or not Grandpa should wear a life alert pendant is more about the families than the person, lots of times.

But this week, at my job, I turned into the one saying "That's not dignified!" And it surprised me. What finally pushed me into that camp?

My facility's new policy that when we change someone's disposable brief, we must write the date, time, and our name ON THEIR ACTUAL BRIEF. Now that's impractical enough, but add to that the fact that if I check their brief, and it's clean, I must cross out the previous time and add the new one. Seriously. Which means that instead of a 2 minute trip to the bathroom to check, I need to decide if I want to be the jerk that writes on someone's butt while they're wearing the brief, the jerk that makes them take it off so I can write on it and put it back on, or the jerk who avoids the first two options by throwing away a perfectly fine one so that I can write on a new one in the other room where they aren't watching me autograph their underwear and then put that one on them.


I agree that not changing people when you're supposed to is horrible and can lead to health problems. But a small chart in their bathroom for staff to initial? Dignified. Writing on someone's underwear every 2 hours? Not.

Wednesday, July 14, 2010

Oh, Gross!

When I tell people what I do for a living now, a lot of them get hung up on the fact that I wipe butts and change adult diapers. I get asked "Do you have a really strong stomach?" (answer: no) and "Is that the worst part?" (again: no). It's just like anything else; you get used to it. It's just another task that needs to be done, and it's one that has a pretty obvious correlation to whether my patient is comfortable and healthy or not. Would you be feeling good sitting in a soaking wet diaper? Would it be fun for you to no longer be able to get up and go to the bathroom when you need to? Of course not. So by handling those things promptly, I improve someone's quality of life instantly. Not bad, really.

Besides, I'm a blood phobic, so anything involving blood is approximately 8,000,000times worse in my mind than any poop, vomit or urine could be. Blood makes me faint, usually. I mean really faint. Out cold, hitting my head on the way down type of fainting. Yikes.

So you can imagine how anxious I was when one of my clients had to have his toenail removed recently. Completely gone. Double yikes.

He got home with a sheet of instructions that read "soak foot for 10 min daily, loosely apply bandaid, can use small amount of antiobiotic ointment if needed". Wow, thanks for the hints about what I'm going to see under the weird blue gauze you packed him in, doc. Scribbled on a prescription notepad was the additional "for first treatment, remove bandage first. If dressing sticks, use peroxide to loosen."

Oh. Okay. Bandage sticking to never before exposed skin?? That can't be fun.

I got my client settled, got all my supplies lined up, and gloved up. Oh my lord, how I love disposable gloves. I cannot imagine doing this job without them. The first nurses were SAINTS to do what they did, and to do it bare-handed.

I gently began removing the dressing from this poor man's foot, and blood really started flowing. Like dripping-onto-the-carpet flowing. Crap! I got that bandaging off as fast as I could and dunked his foot into the little basin of water, which immediately began looking as if a shark attack had taken place. My client was woozy at this point, and shut his eyes, claiming to be too much of a "sissy" to look. Me too, buddy. Me too.

Luckily the bleeding stopped after a few minutes in the water, and after a very messy dry-off, the beast was safely bandaged up again. Ew.

I left that apartment a little woozy myself, and vowing to inspect my own feet every night for the rest of my life so I never, EVER have to have that done on myself. But you know what? I did it! I dealt with a bleeding wound without fainting, vomiting, or freezing up. I'm awesome! I'm brave! I'm a nursing assistant rockstar!

I'd also still prefer a diaper to that, no contest. Especially one as aptly named as this ...

That's right, buddies, me and the disposable briefs? We'll prevail!

Saturday, July 10, 2010

I walk you, too. I mean, like.

Sometimes, communicating with my clients is like interpreting someone who's just learning to speak English. The sentiments are often clear, but the words themselves are odd. Whether they're officially diagnosed with dementia, Alzheimer's, stroke, or aphasia doesn't really matter. You've just got to try to listen hard and when all else fails, pantomime. Which is extra fun when what you're trying to communicate is "I'm going to wash your genitals now". It makes pantomiming brushing teeth or sitting down just delightful. Sometimes, though, once you get to know someone's particular brand of language-slips, the pantomimes become unnecessary.

Take the lady in my assisted living facility who has a fairly complicated getting-ready-for-bed routine. Not only do she and her husband BOTH SPEAK AT TOP VOLUME ALL THE TIME, but the words that substitute in her brain are often just barely related to what she means. She'll gesture at the door, telling me to leave the wicker a little bit open. She'll ask me to bring her wire, pantomiming holding a walker in front of her. She'll tell me she'd like a drink of can. But once you get used to her, it's fairly easy to tell what she wants.

At the other end of the spectrum, I have a homecare client whom I bathe 2x/week. Originally from Japan, and currently on pain mends that increase her confusion, her conversation tends to be a mix of Japanese and English that's largely unrelated to what's happening around her. Luckily, she's a friendly and easygoing type, and that is making her life much easier now that she's got others doing things for (and to) her all the time. My favorite is when I ask her "are you cold, or ok?" and she'll gaze around the room slowly, then finally make eye contact with me. I can see she's hearing and understanding me, and I'm pleased we're communicating. And then, impossibly slowly, she'll ask "Are ... you ... talking ... to ... me?". I smile and say yes, waiting for an answer about her comfort level. And instead I'm rewarded with a smile back and an "Oh ... thank you!".

Both of those pale in comparison to my now-foulmouthed ex-Navy fella, Jimmy. Jimmy has Alzheimer's, and is just getting to the stage where he begins to substitute inappropriate words for appropriate ones. The best part about Jimmy is that when he says something shocking, and I say "Jimmy! You said you wouldn't talk to a lady like that!" he is genuinely contrite. Not because one shouldn't ask "Does she like to f**k?" about someone he's never met, or talk about whores in a doctor's waiting room. Nah, Jimmy is just surprised and sorry that apparently those things have just recently become "not nice things to say".

I love all my goofball clients. They may not have words or manners, but they make themselves understood and I can tell that they walk me too. I mean like. They like me too.

And just to show you I didn't make all this up:

(thanks, wikipedia!)
and to help you understand that brain picture:
"Why Swearing?" by dementia expert Teepa Snow

Thursday, July 8, 2010

First Day

Although I'm a nursing aide now, I consider my first day in the medical world to be my first day as a caregiver for elderly folks. At the time, working at CareCo* was just an in-between job, to hold me over until I found something better in social services. After all, I'd taken care of my own grandparents, and one set of dentures is the same as another, right?

After a short training video and a background check, I was on my way to the Golden Gables* retirement campus to meet my first clients, a couple in their 80's named Ginny and Peter Smith **. My Brand New Boss Betty was to meet me there and introduce me to the Smiths, then I would come in and keep them company, maybe tidy up the house a bit, prepare some supper, see them safely into bed, and be on my way. Sounds simple, right?

Only when I pulled into the driveway of their Golden Gables Duplex, Betty hopped out and said "Mr. Smith had a fall, you know how to get to Sacred Heart's ER*, right?". When I shook my head no, startled, she hopped back into her car, calling "Follow me!". Shortly, there I was in an ER exam room with Betty and the Smiths, both of whom looked impossibly skinny, wrinkled, and helpless. Betty handed me the client book with all their info in it, said "Good Luck! Stay with Mr. Smith until he's either sent home or admitted, and then take Mrs. Smith home. She has dementia, so be sure you remember how to get there, because she won't be able to tell you. I'll talk to you tomorrow to figure out your schedule for the week." and walked out the door.

I faced the two people I was now responsible for, wondering what the hell I was supposed to be doing. Over the next few hours, I tried to make polite conversation with Ginny, and keep her and Peter from bothering the nursing staff too much. I tried to distract Ginny to keep her away from Peter long enough that he could have a bowel movement in private in the exam room, in some toilet contraption I'd never seen one of before. And finally, when Peter was admitted, I took Ginny home to her Golden Gardens Duplex that was anything but golden inside; they had a small dog, a cat, and a bird, all of which defecated EVERYWHERE due to neglect. Overwhelmed, I picked up the worst of the poop with my CareCo provided disposable gloves, and sat on the couch with Ginny watching television until the poor woman who was taking over for me arrived.

And astonishingly enough, I went back the next day, and the next. And now, almost a year later, I not only know that toilet contraption is a bedside commode, but how to get someone on and off of one, and how to clean it out when they're done. Without even gagging.

Until next time,

*not the real name
**also not their real names. Nothing in here will be named by real names, so I'll quit it with the footnotes from here on out.
*** okay, one more, I couldn't resist - who else is a Scrubs fan here?