Patience

One of my favorite, and oldest, little old ladies died recently at the GreatRep (the dementia care facility that I still work part time at).

Patience was seriously a bad-ass. She was the oldest living person I've ever met, at several years past 100. She still walked, fed herself, and talked when she died. She was chronically cranky, hated to get up early in the mornings, so we always let her sleep in and woke her up after everyone else had eaten their breakfasts. She was known for her particular style of combativeness - Patience would grab your scrub top's neckline, haul you in, and scratch the bejesus out of you while she shrieked "ouch! Owww! Hurting me!!".

But that's not all Patience was, of course. She still had a great sense of humor, and often seemed aware that her increasing deafness was a good source of entertainment. One day, in the dining room, she incited a food fight with another resident, a man. When the med tech on duty approached her to redirect her, she said "Patience, you're such a rascal!" and Patience stared at her for a beat, then said "I'm such an asshole?!?" then laughed maniacally.

Patience would constantly sing in a low, grumbling monotone, similar to her speaking voice. Very old songs, like Springtime in the Rockies, or The Battle Hymn of the Republic. She'd also talk out loud, verbalizing her thoughts, which she may or may not have been aware she was doing. If you were walking by her and stopped to say hello, give her a kiss, or wave at her, she'd often mumble "that one smiled. That one smiled. That one was happy." in her repetitive, robotic voice.

My favorite ever moment with Patience was when I was trying to put her to bed one night. She was being very resistive to standing up, not wanting to leave her comfy couch in the living room and walk down to her room. Patience had never had children of her own, but was a devoted aunt whose nieces and nephews still visited her until the end of her life. So, trying a different approach, I said "Auntie Patience, I want to go to bed but I'm scared to walk there by myself. Will you take me?". She grudgingly pulled herself up with her walker and headed to her room with me. She used the bathroom, brushed her teeth, put on her nightgown, and then, to my surprise, plopped down on her coffee table! She leaned back, pointed at the bed, and said, in her deadpan way, "Go ahead. You sleep now, I'll watch you. You go to bed. I'm here." Just thinking about that is enough to make me cry.

It's not often that the staff at a nursing home really loves and adores a combative resident, but we all loved Patience. Who else would repeatedly strip in the common area, to the point we had to go plunk her in her room where the nudity was more appropriate? And then when we checked on her later, we found her wearing only panties and a bedsheet tied around her neck like Superman's cape, singing Take Me Out to the Ballgame!

So, Patience, you were a delight. I miss you already. And I know you would understand that it's with great affection that I share the following photo of what you reminded me of at the breakfast table every morning, since you never mellowed out enough to get your hair combed until you'd been up for a few hours.

Simplicity of success

After 3 long shifts as a med tech at my facility, I went and worked my once-a-week evening shift caregiving, and for the first time, it felt like a relief. We've got multiple residents on a lot of medications right now, many of which would normally be PRN's and therefore not my department. However, one of the nurses wrote them in our book as nursing orders, so for the first time we're giving medications that absolutely must be given at a certain time and that is really stressful with this population. You just never know if or when these people are going to cooperate with you.

So anyway, we've still got the Darth Vader Choker running around. He's a reasonably nice guy a lot of the time, but when he gets combative, it's scary. He's a big man (and remember, he lifted one nurse clear up off the ground by choking her). During report today we were told to "keep a close eye on him" and perform "frequent checks" because he's been peeing everywhere. And housekeeping is getting mad because he peed on the drapes and it's expensive to clean them. I'll file that under "not urgent". If it's that expensive to clean the place when he pees all over stuff, how about NOT ADMITTING people that we KNOW ahead of time are going to freak out when toileted and have a pattern of voiding inappropriately? Duh.

Anyway, Mr. Vader has been on a streak of bad days lately. So when we spotted him dozing on a couch in the hallway after dinner, I suggested to the other aide who was assigned to him that we go try to put him to bed right away, before his meds wear off. We got a wheelchair, because he was all zonked. We gently woke him up, told him we would help him get to bed, and plopped him in the wheelchair.

Once we had him in his room, I started with "Let's take a look at your feet." because apparently that's how his daughter would start his care. He was a contractor for years and years, and for all I know, he thinks he did it today. So I acted as though he had. I said "We want to make sure you didn't step on any nails or anything. Construction sites can be tricky." he was awake now, and agreed. I took off his shoes and socks. I continued "All right, those look good, no problems there. I think we better check your knees too, make sure they didn't get roughed up at all. Can you stand up?" He could, with our help. He didn't even notice that we were taking his pants off to check his knees, was just glad that his knees were okay. We continued like this until he had everything off, used the restroom, washed himself up with a washcloth, brushed his teeth and laid down in bed wearing only a brief. It was amazing. Such a change from his other days. I think if he could be appropriately medicated, he could be compliant like this all the time - he was aware of what we were doing, was doing most of the work himself, and was pleasant to be around.

It was the most successful moment I've had with this guy since he moved in.

And after all the stress of the last few days, it was a really pleasant change - sometimes it's nice to go back to basics.

In Which I Get Judgemental

You know those things you think about people but you aren't supposed to say because it's mean/prejudiced/snotty etc.? That's what this is about.

I recently trained a new employee at the GreatRep, who seemed nice. She's CNA certified but hasn't worked as one before. However she was working as a caregiver at a group home for developmentally disabled adults. Lower volume/patient load than what we do at the GreatRep, but same basic principles plus she's been through the CNA course so she should already know the essentials from that. Seems like a reasonably good hire, is polite, reads and writes English well.

The first red flag for me was when she mentioned something about her home life; that she had been traveling around the world or something for a few years (the first few years of her son's life) and then finally came back because she fell in love with her high school non-sweetheart, and now they're engaged and living with her son's Father. Huh. I generally think one needs a pretty good reason not to be around for their child's first few years of life, and wanderlust doesn't really count in my book.

The second one was that she was complaining about her job at the group home and how the stress of combative residents there was triggering her PTSD (acquired when she was younger, not through serving in the armed forces but ostensibly by having an effed up childhood). Uh-oh. Our residents get combative, and even though they're mostly old ladies, they can be a little scary at times. Would this be a good fit for her?

Answer: nope. Apparently even though she quit her job at the group home and now only works part-time at the GreatRep, she was STILL calling off frequently, wanting to go home early, etc. That's such BULL! Our jobs are hard but do-able when we're fully staffed. Leaving your coworkers short-staffed for no good reason is totally rude and shady.

Then the other night she insisted she had such a bad back injury that she had to go home. Seriously? Even though you were sitting there talking to me like everything was fine and bustling around preparing your dinner? I don't buy it. I think that this girl has a crazy family and that made her crazy, and then she hasn't bucked up and gotten un-crazy. Which sucks, because she's a parent now. And instead of growing up and holding down a job, she is hoping to get disability or something after working part time for a few weeks. Ugh.

I know it's not kind to assume people are going to suck if they tell you they had a bad childhood or whatever, but here's the thing: if they've gotten over it enough to function well? They won't tell you right away. They'll be aware that doing so is inappropriate. People can come from chaos and turn out wonderfully, but those are the people you're surprised to find out were raised so horribly. The ones where you go "Oh, that all makes sense" are the ones who need to get their butts into therapy and figure their crap out.

Or at least not come work with me. Sheesh.

What a Winkle

I absolutely love the weird conversations I have with my dementia residents, and there's one that pretty much always takes the cake. "Cookie" hallucinates and can be very difficult to deal with, but she's often very focused on wanting to see a doctor and wanting every person she sees to be a healthcare professional. So I usually address her as Ms. Oven instead of Cookie, and emphasize that I'm a nursing assistant rather than a caregiver in order to get her cooperation. I once had to wrestle a wet incontinence brief away from Cookie, who gave it up only when I told her I needed the sample for the Doctor. Gross.

Anyway, over the weeks, Cookie has come up with some good ones; telling me the Borg are trying to get her when I go to wake her up in the morning, hitting on the life-size dancing Santa that we had up at Christmas, telling my female coworker what a "gorgeous guy" she is.

The other day I went to get Cookie up out of her armchair to go use the bathroom, and she had a little stuffed animal sitting on her walker. "Look at my Baby!" she said, as I approached her, "Isn't he cute? What should I name him?"

Her stuffed animal was a little moose, so I said "How about Bullwinkle?"

Cookie blinked at me for a long moment, then said "He's from . . . where? He's a Winkle, you say? Is he a Winkle?"

I answered "I think he might be, what do you think?"

"Yes, probably. A Winkle."

Oh, Cookie!

Dr. Bill

Dr. Bill is a homecare client that I had way back when. He had been a client of CareCo for a very long time even then, so I assume he still is - I just don't have him on my roster right now. Dr. Bill was a retired doctor who lives in a swanky gated retirement community. He also has Parkinson's. But unlike Bitsy, his Parkinson's seemed to have skipped through the more common symptoms (stiffness, tremors) and gone right into dementia. Don't get me wrong, he had some slight mobility effects, and was very stooped over, so much so that child-sized furnishings would have been no challenge for him. But all of that paled in comparision to the big, bright banner of paranoia that Dr. Bill carries with him at all times.

To begin with, you should know that Dr. Bill believes himself to be an employee, not a client, of CareCo. When caregivers come to his home, he often believes us to be conducting trainings, meetings, or on a break. Dr. Bill drafts endless letters to the CareCo staff, quitting over and over again, and blaming his Parkinson's on the workload he shoulders at CareCo.

Sometimes he writes these out longhand, in his tiny, cramped, Parkinson's "microscript". Sometimes, apparently I am his secretary, and he dictates them to me on his home computer. Sometimes he settles for leaving voicemails at the CareCo office line. But Dr. Bill is always certain he doesn't want to work there anymore, and that they keep trying to stop him from quitting.

Apart from these obsessive resignation letters, Dr. Bill's other main hobby is reading and rereading his bills, and trying to call and argue with any bank, credit card, or utility company foolish enough to send him one. I really don't know why his family doesn't have them sent to a PO Box instead so they don't occupy his mind so much, but perhaps they like him to stay busy in his own way.

Sometimes these two processes mix in Dr. Bill's mind, and sometimes his other preoccupation, the fear that someone is stealing his pills, creeps in there as well. That's when the letters get really exciting. Scrawled on envelopes, legal pads, catalogues, are things like "Last count: 62. Must make a list of HI suspects. Big Boss Betty. Office Assistant Annie. Caregiver Cathy. Bill for VISA $33.86. What is this for? Cost of replacing missing pills? Call police."

Adding to all this is the fact that Dr. Bill has one of those printer/scanners that can function as a copy machine. So if Dr. Bill has, say, two envelopes full of his rantings that he decides should belong on one sheet of paper together, he photocopies them onto one. Over and over. And then rolls up the paper into a long tube, puts a single rubber band around it, and stores it in his closet for further rumination later on. He had a large supply of these crazy collages.

As you can imagine, Dr. Bill goes through a lot of office supplies this way. So one day, he asked me to drive him to the office supply store for more rubber bands and printer paper. We successfully got his supplies and were on our way back to his home for me to prepare him some lunch, when a two-story dental office caught his eye as we drove by.

"Pollyanna! Stop the car! Turn around! That's where I need to go!"

Gamely, I swung the car around, and drove by again, more slowly.

"There! That's the place. I gotta call them and tell them I need to see them. The real office is on the second story, but YOU'RE not supposed to know that."

Always wanting to be polite and humor him, I just replied "All right Dr. Bill, we can look up their phone number when we get home."

I turned the car again, taking a side street to get reoriented in the correct direction.

"Wait, Pollyanna, there was something else there too. Where did it GO? Dammit all anyway."

Luckily, Dr. Bill has a sweet tooth and can always be redirected with promises of pastries. Especially at lunchtime. So we made it back to his place, supplies in hand, for lunch and then more photocopying. Just like always.

Authenticity

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.