VANISHED Part 2 of 3

When the clinic first opened last year, Margaret would saunter in holding Josie’s hand, pulling her along. While Margaret’s stringy hair and disheveled clothes reflected an indifference to her own appearance, Josie always looked neat. Like a treasured, well cared for doll. Her deeply wrinkled face blank but her blue eyes held a sparkle. She didn’t talk but nodded her head and smiled when spoken to. Who knew what she understood?

Margaret took good care of Josie because as long as Josie lived, Margaret had a roof over her head. Some of the residents in the building complained about Margaret’s erratic behavior, but it never became such a problem that she faced eviction.

“Can ye weigh Josie this mornin’?” Margaret asked.

Since Margaret refused to enroll herself or Josie in our clinic, I kept a record of their visits in a manila folder in the top desk drawer. There was a sheet for each person who, like Margaret and Josie, wandered in occasionally for a weight or blood pressure check.

The last time Josie stood on the scale, I moved the beam until it balanced at 90 pounds. Josie began to teeter. I grabbed her arm just in time before she tipped over.

“Josie was ninety-two when we weighed her last week,” I said.

“Mother of God!. She’s a bag of bones. I can’t get her to gain an ounce.” Margaret shoved Josie’s shoes on and yanked her out of the chair. She pulled and picked at her with one hand as she gripped her elbow with the other. Josie’s expression remained flat. I listened to Margaret fussing at Josie as they headed toward the elevator.

I didn’t mind weighing Josie although Margaret never uttered a “thank you” or “Is this a good time for us to stop in?” Since Margaret was known for mood swings and bursts of anger, laying eyes on Josie every so often gave me a chance to check for any signs of abuse.

Occasionally Margaret said, “I may let you take care of me.” She hinted she had some god-awful condition. However, it became apparent she had no desire to leave the doctor she had been seeing. Frankly, I was glad not to have Margaret as a patient. And she frequently suggested she would register Josie at our clinic, too. None of this materialized. I believed Margaret collected advice from health care providers, testing one theory against another and choosing which one she favored at the moment.

—to be continued.

VANISHED Part 1 of 3

A feverish Chicago summer ebbed into autumn. No telltale falling leaves signaled the change of seasons on this block of concrete walkways surrounding the massive twenty-story apartment building. I yanked open the heavy door. Inside the foyer, through the grimy glass doors, I noticed Margaret parking Josie, in her wheelchair, in front of the elevator. When Margaret saw me, she ran to unlock the door before I got a chance to grab the key from my purse. Had she been waiting for me? My neck muscles tightened.

“Top of the morning to you,” Margaret sang out in her Irish brogue, exposing black and broken teeth. Her face was impassive in spite of her hearty welcome. My eyes skimmed over her quickly. She was empty handed and the pockets in her cardigan sweater, and in the cotton dress it covered, weren’t bulging. She sometimes stashed the ice pick under Josie’s lap blanket. Margaret chose not to come to the clinic for health care so I didn’t know what medication she was taking to control her paranoid schizophrenic personality, or if she took medication at all. Her aggressive outbursts occurred randomly. I had heard secondhand stories where she had brandished the ice pick. So far as I knew, she hadn’t hurt anyone. I kept my guard up with Margaret and worried about Josie.

When she came from Ireland ten years ago, Margaret was much younger than sixty, the cut off age to live in this senior building. So she petitioned the Chicago Housing Authority to allow her to live with her aunt. Margaret’s attention had kept Josie out of a nursing home.

Up to a month ago, Margaret literally pulled Josie behind her as she rushed around going nowhere. When Josie became unsteady on her feet, Margaret put her in the wheelchair and bundled her up as if to fend off an infiltrating enemy.

“How are you doing today?” I said to Josie’s pixy face as she peeked from the blanket shroud. She blinked. My neck muscles relaxed. I fantasized Margaret would push Josie around in her wheelchair after Josie was dead and none of us would catch on until Josie started to stink.

Something had to disturb Margaret more than usual for her to wait for me this early in the morning. “Josie won’t eat.” Margaret said abruptly to the ceiling, avoiding my eyes. “I put food in her mouth and she spits it out.”

We had been around this topic before. Margaret wanted to believe Josie was just fine, thank you. Any advice I gave could be met with a disagreeable outburst. “You could try to give Josie small feedings and soft food like pudding, ice cream or Jell-O.” I held my breath while Margaret fussed with Josie’s blanket. “You can’t force Josie to eat, if she doesn’t want to,”

“Glory be, she not eating enough to keep her body alive,” Margaret shrieked.

Just then, the elevator doors opened with a loud scraping sound, emitting the usual stench: urine and beer. A reminder that last Friday was the first of the month when social security checks were placed into the mailboxes. Many of the old timers who lived in the building cashed their checks and spent the weekend in an alcoholic stupor.

Margaret changed the focus of her frustration as she pinched her nostrils with her fingers. She yelled in a nasally voice, “It is an insult to the good people in this building that the drunks cavort and carry on so, pissing in public places.” Her demeanor could have been misinterpreted as an attempt at humor, but I knew better.

An elderly man stepped off the elevator and nodded his head in greeting as he maneuvered around Josie’s wheelchair. Margaret whipped the chair about, through the doors that the man graciously held open and both women faded into morning fog. I suspected Margaret would wheel Josie into the clinic later today, asking, again, why Josie wouldn’t eat.

—to be continued.

WHY DO WE WRITE?

I attended the book signing this past August. Farther Along, written by my friend and mentor, Carol Henderson, which told the stories of thirteen mothers (she is one of them), a bakers dozen as Carol points out, who had lost children at various ages.

I was prepared to cry. I don’t do well with death of children, even adult children. Children shouldn’t die before their parents. Maybe that’s why I choose geriatrics as my specialty. Old folks die. It’s expected. No surprises. I can deal with that.

I teared up but didn’t cry and was somewhat unprepared for the humor, serenity, and lack of self-pity as the six mothers read sections from the book. But then ten years had passed since the women came together under Carol’s guidance and direction. Certainly bereavement takes time to absorb, rant and rage against, come to terms and eventually accept the grievous loss that will never be forgotten until one’s dying day.

How fortunate the women found each other and Carol. Writing their stories seems to have brought them to a better place than they would be if they hadn’t immersed themselves in writing.

Why did these women write?

Carol says in her book:

“Writing about deep and traumatic matters, as many studies now confirm, is good for our physical health. Reflective writing actually lowers pulse and blood pressure, increases T-cell production, and boosts the immune system. Writing can help us cope with chronic conditions like physical pain—and the loss of health, of dreams, and, yes, of children.”

We all write for different reasons. I am haunted by my patients. They walk around in my memory and defy me to ignore them. I need to tell their stories.

“Why do we write? To make suffering endurable. To make evil intelligible. To make justice desirable and . . . to make love possible”

Roger Rosenblatt, Unless It Moves the Human Heart: The Craft and Art of Writing

Why do you write?

CARING AND THE MALE NURSE

Back in the ‘80s I ran a clinic for the elderly that was housed in an apartment on the tenth floor of a Chicago high rise. My patients came to see me, a nurse practitioner, in the office but in many instances I would later check up on them in their apartments in the building or their homes in the surrounding neighborhood. When my office practice became too busy to make these outside visits, I hired a community nurse.

She was a new nursing grad and an older woman who chose nursing as a second career. I figured as a wife and mother of two children she would have life experience to function independently. I was wrong. Her insecurity and lack of nursing experience translated into an uncaring façade. She left for a hospital position, which provided a more structured environment.

The second nurse I hired was older, too, but with years of public health/community nursing practice. She made scheduled home visits based on the patients’ needs; no one fell through the cracks as they did with the inexperienced nurse. She took blood pressures and monitored blood glucose levels, set up weekly pillboxes for the forgetful patients and started a quality control chart review. Not an especially emotive person, she did her job with efficiency and coolness and soon left to make more money than she did in our not-for-profit clinic.

Enter Dave*

Laura A. Stokowski, Just Call Us Nurses: Men in Nursing, Medscape, posted: 08/16/2012, tells us men tend to choose “fast-paced specialty areas, such as critical care or the emergency department.” But here was Dave, a thirty-something, husband and father of two with a wealth of nursing experience knocking on my door. He was seeking a low tech, high touch job.

Of all the applicants, he was most qualified. I figured my male patients would appreciate dealing with a guy since our office was comprised of all women. But what about the cohort of female patients? I had found them, on the whole, to be reserved, private and at times, overly suspicious of health care providers, myself included. How would these ladies relate to a man performing personal care? I wish I could say I didn’t have these thoughts. But in spite of them, I did hire Dave.

Besides being clinically competent, Dave demonstrated the art of caring. A skill not often credited to men. He was genuinely interested in his patients and employed his knowledge and nursing skills to improve their health and quality of their lives and independence. What more can you expect from a good nurse?

* Not his real name

DEMISE OF THE PHYSICAL

Back in the early ‘80s when I ran a not-for-profit clinic on the west side of Chicago for older people before annual physicals were considered “nonspecific” or “inefficient” or “potentially harmful” [“Let’s (Not) Get Physicals” (Elisabeth Rosenthal, The New York Times, June 3, 2012)] I did a complete head to toe exam on each patient who registered, including vaginal exams on the women and rectal exams on the men.

I enjoyed the mechanization of the whole process. Take out your reflex hammer. Tap elbows, wrists, knees, and heels. Put it away. Take out your stethoscope. Listen to lungs, heart and bowel sounds. Put it away. Methodical and expedient. A whole hour was allotted to this first visit. Hard to believe in light of today’s harried health care system.

I remember telling myself to keep my facial expression bland. The slightest furrow on my brow shot a message to my patient—she found cancer or something equally horrible. As if the physical exam was an accurate barometer of health and well-being. As if I, the nurse practitioner, a.k.a health professional or primary care provider, had some secret connection to the Almighty and not only could find abnormalities but could predict life expectancy.

The physical seemed like a test or maybe a comparison of one older person to his/her peers. I can see Mr. Brown sitting at the edge of the exam table as I auscultated and percussed and said such things as “great lungs sounds” or “your heart beat is strong.” And after the exam I pronounced “you’re in great shape.” His smile radiating as he stepped down from the exam table probably thinking of himself in better shape than others his age. Then the common compliment: “That was the best exam I ever did get!”

Although I no longer practice as a nurse practitioner, I mourn the demise of the complete physical. Back thirty years ago when nurse practitioners were attempting to secure our identity as primary health care providers, the physical exam was a powerful tool signifying we could do what doctors did. And Medicare reimbursed this service. It was a vehicle to get us where we wanted to go—to become legitimate in the eyes of our clients and employers.

The physical, like my first car the gold Studebaker convertible my dad bought me that already was 12 years old, was serviceable but became too expensive and unreliable to keep forever.

But what a great ride.

My car was gold and in better shape.

NURSE PRACTITIONER VERSUS PHYSICIAN’S ASSISTANT

Last week in a restaurant in Lyon, France, my tablemate turned toward me and asked, “What’s the difference between a nurse practitioner and a physician assistant.”Lyon

My husband and I were on a tour. Our traveling buddies consisted of older folks like ourselves. The woman knew I was a retired NP and had told me she frequently saw either an NP or PA when she went for routine medical appointments. She was satisfied with either but didn’t know the difference.

I became an NP in the early 80s and worked in Chicago when NPs were trying to expand our practice by gaining prescription privileges. We were much maligned by the traditional medical establishment. “If nurses want to act like doctors, let them go to medical school” or something to that effect seemed to be the mantra of the American Medical Association. (Both the AMA and the Illinois Medical Association are located in Chicago).

I, with other NP’s, worked in a not-for-profit clinic on the west side of Chicago, caring for the medically underserved. There were few general practice doctors in this part of the city—most set up offices in the more affluent sections. In spite of the fact we NPs were supplying an unmet need, better accomplished if we could prescribe necessary medications, we were seen as competition.

Physicians counteracted the influx of NPs by cultivating their own homegrown subordinates: the physicians’ assistant. I, for one, thought the PA mimicked the doctor’s role in treating illness and didn’t take into consideration the broader aspects of patient needs: physical, mental, psychosocial, economic and functional ability. Aha, we all have some prejudices at one time or another.

As I dipped my crusty baguette into the last bits of a creamy Mornay sauce on my plate, I debated how to answer. Now here was an opening for me to tout the superiority of NP’s.baguettes

At first I did bore my table companion a bit by describing educational paths and state requirements of each profession. But then, remembering the many PA’s I had worked with over the years, I said, “There really is little difference. Both want you to stay healthy and independent.”

 

 

 

ONCE A NURSE, ALWAYS A NURSE By Jane Van De Velde, DNP, RN

My nursing career has taken me down many paths over the years. Presently, I am a Reiki Master Teacher as well as the founder of a nonprofit organization called The Reiki Share Project.

People often ask me what I “do.” And I usually begin by telling them that I am a registered nurse.

Their next question is…”Where do you work?”

This question always trips me up. People seem to think that if you aren’t employed as a nurse, then you stop being a nurse.

However, in my heart and my mind, I am always a nurse—no matter what. My nursing education and experience influences the way I view and interact with the world on a daily basis.

Thanks to all those client caseloads that I managed, the patient assessments I conducted and plans of care I wrote and implemented over the years; thanks to all those papers I wrote for graduate school—I am very systematic in my everyday approach to problem solving, organizing my life, and getting things done. My experience in dealing with patients also serves me well in my Reiki practice. And I have found joy and satisfaction in the process of writing articles, developing Reiki teaching curriculums and putting together newsletters for my nonprofit organization.

Thanks to that dying hospice patient who taught me that even though her life was nearly over, she could still experience healing on many levels—I bring that lesson forward to my Reiki practice knowing that even though curing many diseases may not be possible, there is always the potential for healing.

Thanks to all those hours of attending to patients and caregivers—I have honed my listening skills and have learned that sometimes that’s all that people want—just to be heard. So my husband, children, family, friends, and Reiki clients give me the opportunity to continue refining these skills.

Thanks to all those elderly homebound clients I visited who served me coffee and cookies, treated me like an honored guest, and sometimes begged me to stay just a little bit longer. I learned that simply being quietly present is a wonderful gift that we can give to others. Our “time” is a gift.

So, I continue to do my nursing work every day both personally and professionally in my Reiki practice. And I have developed a new response to the question: where do you work? I tell people that I am self-employed.

SOB SISTERS

Thanks to my friend Lois Roelofs and her post “Growing Older In “Style,” I found Ari Seth Cohen, a twenty-eight-year-old who is spotlighting “stylish senior citizens.” Love it. Older women—and men—who ignore the old adage: “dress your age.”

looking good

How come a twenty-eight-year-old man finds older people so fascinating? Well, I was sure there had to be an older role model in his life. And indeed there was—a grandmother. Aha!

Back in the 80s at my first job as a gernotological nurse practitioner, Betty, a social worker, and I conducted monthly orientation sessions about geriatrics for new nursing staff. Geriatrics was a new medical specialty at the time and Betty and I wanted to sensitize the group to aging issues.

Betty had the nurses imagine themselves at different stages of life. Invariably, someone would object to the exercise, not surprisingly, when Betty had them imagine looking at themselves in a mirror at different ages. “Now you’re 80 years old. What do you see? How do you feel? How are you dressed?”  (We would, as a matter of course, excuse anyone who didn’t want to participate.)

There were incidents of tears. On one occasion a woman picked up her purse, notebook and coat and stormed out of the room shouting her disapproval of our experiential process. From that day on, our boss dubbed us the Sob Sisters.

However, the majority of our class enjoyed the exercise. Those most enthusiastic usually mentioned an older person in their life that they respected and cared about. This anecdotal experience of mine carries over to the assessment of Ari Seth Cohen. He sees older folks in a positive light to be celebrated and acknowledged. Thanks to his grandmother.