Ha HA! Triumph!

I'm so on top of this whole going-back-to-school thing, I'm giving my nightmares bad dreams; no more anxiety dreams here! I'm kicking ass, taking names, and chewing bubblegum all at the same time.

This whole being poor thing? Not so bad when it comes to financial aid. I am getting a FULL TUITION WAIVER at the community college for the next 3 quarters! Plus $250 for books each quarter. Yessssss!

This means that I'm planning to take 10 credits per quarter and haven't figured out how much work that means I'll do. If I can afford to cut back to working 3 10-hour shifts, I'll do that. If not, I'm gonna have to keep working full time, since my awesome financial aid does nothing to help me pay rent or get food to eat.

Nonetheless, I'm very, very excited. It's looking like I have about a year's worth of prereqs to do before I can apply to the Accelerated BSN program at my state's university. So I'm going to need to get myself some very good grades in chemistry, anatomy and physiology, and the like.

I can't wait to get back to school. I frickin' love science. And science classes. I'm so excited!

Dementia Facility FAQ's: What family members are probably wondering.

We've had a few tours come through the GreatRep lately, as well as out-of-town family members come into town to see some of our residents. It's interesting to see how people react to the place their first time, and it made me think about what they're probably wondering but don't ask. So here's my version of what you might like to know about a dementia facility, and my answers:

1. Doesn't it bother them to know they're locked in here?
Surprisingly, no. None of my residents have ever said anything like that to me, and very few are aware that they cannot exit certain doors without setting off the alarms. We have secure courtyards they can go outside in, and we just redirect them away from the front door if they're up there fussing with the keypad (it requires a keycode to open it without setting off the alarm). People with dementia are very inwardly focused, for the most part, and get more so the more their disease progresses. So our little world inside the facility is usually big enough for them. It helps that it has a circular part of the floor plan which is good for walking/pacing.

2. Why are all those people dozing in chairs? Why aren't they awake?
The most common answer is that most of them don't sleep all through the night. I just worked my first overnight shift at the GreatRep and was very surprised at how often I was informing people that no, it's still the middle of the night, and helping them back to bed. I figure that even the ones who can't get up and talk probably spend a good portion of their time in bed awake too, so they just kind of doze off whenever they're tired. They're on more of a 24-hour schedule, like a newborn. And yes, if they're hungry or thirsty in the night, we give them snacks.

3. Why is that lady making that noise/yelling for help/hitting that chair?
I don't know. Sometimes repeating the same words or phrase over and over is soothing for people with dementia, it's called perseveration. Unfortunately, sometimes that phrase is something hard to listen to, such as "help me help me help me" or "hurry up hurry up" or a repetitive action, like banging on whatever is in front of them. We try to mitigate, redirect, and keep them occupied with other things but there's nothing we can really do to make someone stop doing a behavior like that.

4. What about privacy? Won't you sometimes be doing some things in front of other residents? We had a family member complain this week because the podiatrist was in to do foot care, and was set up in a room at the end of the hall which isn't closed off from the hall. They thought it was inappropriate to do foot care out in the open. The thing is, you have to consider the logistics; sometimes there isn't enough space in each person's room to set up a podiatry station. Also, see #1 about the inward focus. Very few of the residents pay too much attention to what the other residents are doing for any long span of time. Some have friendships and stick together, but then they don't mind if their friend is present while their feet are being worked on. We don't change their clothes or use the restroom in front of others, and if they're getting a brief change in bed, their roomate is asleep/cannot see over to their side of the room plus it's still quite dark.

5. Why are you feeding them? Why are they incontinent?It just happens that way; over time, almost everyone become incontinent to some extent, and eventually they stop feeding themselves. That's why they're getting 24-hour care now. We use mechanical lifts called sit-to-stands so that we can still give everyone the chance to use the toilet, and whether they void on it or not is up to them. That's what the briefs are for. I think this is probably one of the biggest reasons I'd have a hard time keeping someone at home and caring for them myself. Everyone incontinent really should be changed approximately every 2 hours. I couldn't do that at home. We've got a full staff and we all get to go home and sleep between shifts, which is why we're able to do our jobs well. Having worked in this field and seen how hard it is, I think I would be totally willing to put myself or a loved one in a good care facility; I just don't see how it'd be feasible to do otherwise.

Vasovagal EXTRAVAGANZA!

We had a new nurse on 2nd shift tonight, so all us aides were trying really hard to be helpful, make sure she knew who each resident was so she wouldn't give them the wrong meds, tell her who to take seriously when they did/or said things and who to ignore and they'll stop.

But because she's new, she didn't know the difference between "Polly gently flagging down the charge nurse to come into a resident's room" and "Polly panicking and trying desperately to get your ass in here STAT but I can't leave this woman alone right now". So NewNurse wasn't as fast as I wanted. But it all turned out okay.

You see, there's a little thing called "vasovagal response" or, as you may learn to call it "fainting because you need to poop or are pooping".

This clip from Scrubs illustrates it very nicely:



Yep, it's a real thing. Pooping and fainting. What a combo.

There are a few of my old ladies that have this occasionally, but the one I was working on tonight had not ever done so since I've been working at the GreatRep. So you can see why I was alarmed when Nellie lay limp and unresponsive (but not dead! I checked that first!) in her wheelchair. I patted her hands with increasing force. Called her name with increasing volume. Patted her face. And then I brought out the big guns. Nellie HATES it when you touch her mouth or brush her teeth, and the absolute most annoying thing you can do to her is stick your fingers in her mouth. I popped on a glove and stuck a few in there, to and got no reaction, which is when I panicked and desperately waved NewNurse to come in NOW.

She also couldn't get Nellie to come to for a while, but after we both hollered and patted and pestered the hell out of her for a bit, Nellie cracked one eye open to glare at us, at which point I started breathing again. And got a whiff. And then a big, poo-shaped light bulb went off over my head. It spelled out VASOVAGAL in morse code. And Nellie woke up in time to have the biggest BM I've ever seen her have in my life. I mean softball sized, and round like one too.

Sheesh.

So my little poop-weasel is all right, and was back to normal within a few minutes of passing that beast.

And you know what? Seeing it didn't make me faint too. Whew!

PS Next weekend is my last weekend of clinicals which means I'll have a real live day off on St. Patrick's day! I cannot wait!

P-P-Pollyface has a P-P-P-Plan

The other day I got to play that dancing game for the kinect at a friend's house, and it is SO FUN. But now I think everything in a Lady Gaga way, which is why the title of this entry is full of P-P-P's like P-P-P-Pokerface. I also have been saying scu-ruh-huh-huh-hubs instead of scrubs.

Anway, the point is I have a Plan. Remember how I said I needed to get my butt into school to be a nurse so that I don't have to work this hard for this little money for the rest of my life? Well, I'm registered.

First I'm going to finally go get my CNA Certification, which will get me a (tiny) raise at my current job, and make me qualified to work in a Skilled Nursing Facility if I decide to leave my current job for a different place. I'll also be qualified to work in a hospital but that's more of a pipe dream; most CNA's would like to work in one, but pretty much every CNA works in long term care instead.

Secondly, I did my admission to our local Community College for fall quarter of 2011 to start doing my prereqs. Yeah buddy! I'll keep working while I'm in school, of course, so I'll probably just do one class per quarter. We'll see. I need to get good grades in them so I can be admitted to that baccelaureate program I want to get into to convert my BA into a BSN. So if I want to be a Straight-A Polly, I should probably make sure I'm also Has Time To Sleep Polly.

Look at me, I'm bettering myself! Not buttering myself. Maybe if I buttered myself, I could join the Haus Of Gaga. But buttering myself wouldn't be vegan. Or pleasant.

Neglect

I see some weird situations in my line of work. Families who get up in arms about every little thing (such as how many fun-sized candy bars in the "for staff" dish are being eaten daily) and families who are almost impossible to get a hold of so we end up improvising mightily to try to get the resident's needs met. Old people who insist on wearing multiple pairs of underwear, or none at all. People who swear up and down that they lost a box of puppies, or that I work for the railway.

But the weirdest and saddest thing I see is neglect.

We got a new resident this weekend at my facility, who apparently was moved in by his private caregiver, to whom he pays the ungodly amount of $4,000 per month. Caregiver dropped him off and then took the weekend off. The marketing director at my facility apparently thought this was okay, even though she did the intake interview (not the director of nursing, which is who should have been given the opportunity to assess him before he moved in) and should have known that he cannot walk unassisted AT ALL. This is her job. To find out if people are a good match for what we can offer them, and to be sure they will be cared for adequately if they move in with us. She didn't do that. She failed, completely, at her job in this case.

So, since he was supposedly independent and his caregiver took off, this poor man spent the night in his armchair, peeing into a cup when he needed to pee. In the morning he tried to get up, and fell. Was taken to the hospital in an ambulance, and was readmitted to our facility and now suddenly needs to be on assistance. So I'm in his room, trying to figure out what stinks of urine (everything) and how I'm going to get this man cleaned up. His daughters have flown in from another state, horrified at the situation. They're in there, and I'm giving them a shopping list (waterproof bed pads, vinegar, briefs, hernia belt, etc.) and directions on how to get to the stores that sell this stuff.

The marketing director, who, along with the criminally neglectful "caregiver", created this mess, comes breezing in and pulls me into the other room to tell me to "call him Sir" rather than Mr. So-and-So, which I was doing. Then, as if to soften that blow, mouths "Don't worry, you're doing a good job" to me.

Oh. Hell. No.

Normally I appreciate hearing thanks or validation about my work. I love it when my residents say "Thank you so much honey" and give me hugs when I tuck them into bed. It makes me a little teary when they say "I'll miss you, doll, come say goodnight if you have a chance before you go home. Drive carefully!". This is a job where I feel I am making a difference every single day. And I love that.

But do I need validation from this woman who created a situation where the Director of Nursing's BEST option was to let this man fall so his family would see he needs help from sane people? No, no, no, I do not.

I'm not ashamed to admit that I fantasized about putting his filthy blankets in her office and suggesting that she wash them for Sir. Or tossing her the most disgusting hernia support belt I've ever seen in my life and watching her catch it with bare hands. Or telling her to brush this man's teeth, which were so discolored at this point, I won't even tell you what it looked like when I finally did get him to let me clean them.

What I do is difficult. And I don't need any fake-ass "compliments" from people who just don't get it, even if they work in eldercare and should know better.

And this poor man's "caregiver"? The family is prosecuting her. So my new resident is being cared for, and the person that neglected him is caught. Now that's a happy ending in my book. Though I may still have to find a way to put something disgusting in the marketing director's office ... and then tell her what a good job she's doing while she cleans it up.

Shift Reports: Take it to the next level

Even though we use shift reports to communicate among nursing staff about what our residents have been up to, sometimes a resident will misbehave so outrageously or so consistently that management decides ALL the employees should know about it and be on the lookout. This usually comes down to the people who keep trying to escape (ie "flight risk") and those who really, really, REALLY don't want to be on any kind of diet.

You wouldn't think those two things would be on par with one another in terms of inconvenience, but you've never seen an octogenerian ranting and raving in the dining room about having to eat "grass" at every meal (salads) or about not being able to get a second dessert. They can get loud!

So when someone takes it up to that next level, management prints up a flyer or 10 and leaves them in employee-only areas: kitchen, break room, nursing station, and by all employee exits. That way, when the teenage boys from the dish pit are headed out back to smoke, they know that if they hear someone on the other side of the fenced courtyard saying "Open the gate, let me out!" that they shouldn't. For example. Or when the waitstaff sees Mr. Whomever sitting there for an hour waiting for shift change so he can order a second lunch, they need to call an aide (like me) to convince him to move it along and wait until dinner time.

My favorite thing about these flyers is how much they look like Wanted posters at the post office. I like to imagine the "flight risk" residents strolling away from the building in slow motion, with Bon Jovi's Wanted Dead or Alive playing in the background. Who says that the "steel horse I ride" can't be a walker or mobility scooter instead of a motorcycle?

Add to that the complete awkwardness of most of the photos used in the flyers, and you end up with something like this:

RESIDENT NAME: Mrs. Ballyhoo
[followed by an awkward photo of said resident, such as this one I found by googling "Grandma"]

ATTN: FLIGHT RISK
DETAILS: Resident has Alzheimer's and is a flight risk. If you see resident unattended, please escort her back to the memory care unit. Under no circumstances should you open a door for this resident.

or something more benign, like:

RESIDENT NAME: Mrs. WhoDat
[another google result for Grandma]

ATTN: Diabetic
DETAILS: Resident is noncompliant with diabetic diet. Offer her the "special" pie and do not say it's sugar free. Resident will stay at table and order multiple lunches. Call nursing staff if this happens. Small portions only.

For whatever reason, these fliers crack me up. Especially when a lot of people have been rebelling and the walls are practically plastered with them. The kitchen always has a lot, saying who needs thickened liquids (ew) and who needs their food mechanically softened. But when the back door to the facility starts getting filled up, you know it's been a long week!

Shift Reports

One of my absolute favorite parts of my job at the facility is coming in and catching up on the week's shift reports. Each shift (day, evening, noc/overnight) the aides and nurses write down anything notable that applies to our residents. That way, each shift, as they come on, gets a verbal report where we hit the highlights (Mr. Smith needs to catch the bus to go to the bank, Mrs. Jones fell earlier, Mr. Brown is drunk again) and then can read in the shift report for any further details.

Generally what makes the reports funny is what our residents have been up to. This week, for instance included the following gems:

Noc shift "Mr. X paged at 4am. When I responded to his call light, he asked where his daughters are. I told him they had gone home two days ago and would be back to visit again soon. Resident was confused, asked, 'Well ain't I in heaven?'. Told him he's still alive and was probably dreaming. He said 'ok' and went back to sleep."

Apparently heaven is a giant nursing home where we all have page buttons to ask the big questions in life, or get our briefs changed. Who knew?

I also liked: Noc shift "Went in at 3am for location verification check on flight-risk resident in apt. 123. She woke and started screaming for me to 'Get the hell out'. Resident was in correct location, as expected."

Then there are the ones that are funny because of typos or spelling errors that the staff has made. I was signing off on all our new care plans for our new residents yesterday, and saw that apparently one old man is "ablaze to get in and out of bed unassisted". Damn, he must be motivated!

I also like ones along the lines of "resident has a bruise on butt cheek" or "small sores on both sides of the crack". Descriptive and clear, just not professional. Same with "Evening shift please remember to take out so-and-so's bathroom trash before she goes to bed. No one can stand the stench".

My final favorite things to see in the shift reports are about our residents who hide the stuff they don't like. Don't think that TED hose (tight socks for diabetics) are comfortable? Hide them. Dislike your dentures? Stash them somewhere weird. I love seeing "Housekeeping found TED hose under bed. Told resident if he keeps hiding them his daughters will have his doctor prescribe another pair at his expense. States he doesn't care and will never wear them. TED hose missing again". And "upper dentures found wedged in easy chair cushions. Removed and cleaned, put in soaking cup with polident. AM shift, please encourage resident to wear them tomorrow".

Shift report logs = comedy gold, don't you think?

Crossing the line

The other day, in between shifts, I stopped at a fast food restaurant for a rice and bean burrito. Tasty! Since the home I was headed to doesn't have any toilets without "hats" in them to collect urine, I figured I'd better use the bathroom there. I walked in and was hit with that cloying, suffocating smell, and instead of thinking "Oh gross, jeez!" like a normal person, I thought "Oh! It smells just like Mrs. So-and-So's bathroom! Does someone in here have an ostomy bag?". Then I saw that one of the stalls had an out of order sign on it and probably something ungodly was in there.

That's when I knew I'd crossed the line and would never have a normal sense of what is and isn't disgusting again. I think it's inevitable when you spend your days toileting, changing, bathing and all around dealing with sick and elderly people.

It takes something really beyond the pale to get to me anymore, and if something does manage to grab my attention through sheer revulsion on my part, it's probably making me laugh at the same time.

So in no particular order, here's the short list of things I still get grossed out by. It's not for the squeamish!

1. Changing a brief or doing peri-care on a male who has a "#3" in there. If you're not familiar with this term, use your imagination. It's not a #1 or #2, although the presence of either or both of these increases the horror exponentially. Nope, a #3 is the other thing that can exit the urethra. Yep. Ew.

2. Poop on the shower floor. Something about the wet plopping sound and the way the steam just turns it into a vaporizer of fecality that will have you longing for Vicks or anything strong and mentholated to coat your nasal passages in. And the cleanup is a real bastard.

3. The smell of old, stale urine, especially if the urinator has a UTI or has been drinking alcohol. You wouldn't think it could possibly smell as strongly as poop, but it sure can.

4. The smell of blood mixed with any of the preceding three ickies. Adding in the smell of blood to any of those is the only thing that currently makes me gag and dry heave immediately.

What about you all, which of these is the grossest to you? If anyone says "none" and means it, you deserve a bronzed section of intestine to show what a strong stomach you have.

See, it stuff like this that makes healthcare workers into a subculture. No one else wants to hear about this junk, let alone thinks it's as funny as we do!

Paternalism

I've written here before about dignity being a hot topic among those in the eldercare field. This month, I've been thinking a lot about rights and paternalism. We're working with adults, and they generally retain the rights all adults have: to vote, to make financial decisions, where to live, etc. A few of our residents have court-appointed guardians (family members) because they weren't able to handle those rights anymore. But for the most part, you can't really tell your parents or grandparents what to do unless they're so confused they don't notice you're doing it. We use words like "encourage" and "persuade" and "offer" a lot when talking about getting our residents to bathe, eat, take their meds, etc. Because that's all we really can do. It's easy to think of old people as overgrown children (especially because bald, toothless, and diapered describes babies just as well as very old people). But they're not children, and don't want to be talked to like they are. Usually that makes sense to me, and there aren't many rights that I want to take from the people I care for. The "right" that I have the most difficulty with at my facility, though, is the right to get drunk.

The idea of an elderly alcoholic is a little weird and off putting, probably because you either had one in your family, or because you think old people are unintelligible and clumsy enough sober. I wonder if we know fewer elderly alcoholics because the WWII generation tends to hide it more, or because alcoholics usually die younger?

At any rate, the fancy-shmancy AL facility I work at has a bar, and has a handful of alcoholic residents. This adds up to a lot of falls and a lot of belligerence for staff to handle. We're constantly speculating as to why the bartenders serve as many drinks per resident as they do, but my instinct tells me that they probably want to avoid the ugly scene that happens when you cut a drunk off, so they cave.

This weekend, I had a run-in with one of my drunken "frequent fliers/fallers". While he was still sober before dinner, I took him outside to smoke. Residents who smoke have to turn over their matches, lighters and cigarettes to nursing staff, and we store them where we keep the meds. If they want to go out to smoke, a lucky aide (sarcasm here - I'm a nonsmoker) gets their things and escorts them out, then takes the person inside again and puts their things away. This is because not only is it state law that you cannot smoke in a public building (including bars, even) but we've got a lot of oxygen tanks throughout the building for people who need them to breathe, and those are combustible.

Smoking and drinking go hand in hand, and the last thing we want is our drunk residents trying to smoke in their apartments, setting themselves on fire, and having their oxygen tanks fuel that fire. A lot of people could die that way.

So despite my general non-paternalistic approach, you can probably see why, when Mr.Perma-Rugburn (from drunken falls) whipped out his own lighter, I reached over and snatched it out of his hand. I've learned from past experience that he won't hand them over when asked or told. He was pissed. I was pissed. I labeled it with his name and room number, and stuck it in my supply bag to store with the rest of his smoking paraphernalia in the nurse's station.

And then another employee from a different department spoke up, "But I'm the one that bought it for him". Picture Pollyanna with steam coming out of her ears and red as a tomato. This jackass, also an adult, went and bought lighters for someone who could easily incinerate this building and all the people in it?!?!? I glared and shook my head at this employee, wishing desperately that there weren't uninvolved residents around who don't need to hear me chewing out someone they know and trust.

So what to do now? The next day I put out an APB for that employee, hoping to catch him as he went off shift, but he was too fast for me. Bah.

Later that evening, I was thinking maybe I was overreacting and should pull the stick out and calm down. Until I got a page and went in to see Mr. Rugburn sprawled on his floor once again, drunk as could be, furniture scattered everywhere, insisting that a very pregnant employee should be helping him up and slurring all the while.

This dude, plus the one who is buying lighters and cigarettes for him?

They need a little paternalism. Or a LOT.

Subculture

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.

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.

Lanie

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.

Dignity

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.

Ugh.

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.

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!

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