Let me count the ways—to make a home visit.

As a home health nurse, I made visits in Chicago, Washington D.C., and right before I retired, in the areas surrounding Raleigh, North Carolina. I didn’t climb over the roofs in New York City, nor did I ride a horse or a bike. Unlike the nurses in the Visiting Nurse Service of New York City (1893), or the nurses in the Frontier Nursing Service in Kentucky (1925), and more recently, the midwives depicted on the TV show: Call the Midwife, I drove a car.

One of the handicaps I had in driving a car back in the 80s was that there wasn’t a GPS. Being directionally challenged, I lucked out when I discovered I could put a compass on the dashboard of my vehicle. And even more lucky that I could calibrate the compass on the straight north and south streets of Chicago. I rarely got lost after that. However, I do remember a time that I almost didn’t make a home visit because I couldn’t find the patient’s home. 

I was going to see a new patient in Chicago’s western suburbs; an area where I was unfamiliar. I had looked up the directions back at the hospital before setting out. We kept a stack of street maps in the chart room. For some reason, the directions I wrote down didn’t work. I stopped at a phone booth (remember those?). That phone booth and the others nearby hadn’t been serviced. No one had come to remove the quarters that blocked the coin insert. My stash of quarters were worthless. I found a gas station attendant that let me use the office phone to call the patient’s home. (N.B. The first staff member to visit a new patient made an entry in the patient’s record with accurate directions to the home).

As much as I felt inconvenienced without a GPS, how did my predecessors, who rode on horseback or bikes or climbed over roof tops, find their patients?

The Chicago winters caused the greatest panic: The windshield wiper that stopped working as I drove on the highway in a snowstorm or the time I tried to make a “careful” right turn on an icy road but the car decided to skid sideways in another direction. I carried a shovel in the trunk to dig my way into a parking space when I visited patients who lived in the city. 

Driving in D.C. could be aggravating. The summer roads crammed with tourists. Presidential motorcades halting traffic. A slight dusting of snow would show the incompetence of drivers from tropical countries. 

While I’m most comfortable driving in big cities, the farmlands of the South have challenged me. After one especially wet spring, I drove into a rural town I had never heard of and parked on the lawn in front of a small wood frame house. I sloshed to the front door. No one was home. I tried to call (I had a cell phone then). No answer. 

Back in the car, I couldn’t get any traction to move. I spun the wheels, digging the car deeper into the soggy ground. After I called my auto insurance company to approve a tow, I called a nearby service station. The mechanic at the other end didn’t recognize my patient’s address. Not remembering the name of the main road, I would have to walk a quarter of a mile to read the street sign. The car door barely opened over the lawn. I ventured into the cold rain, hoping not to lose my footing on the muddy, rutted road. 

The tow truck came quickly after I identified myself as a home health nurse in need of getting to my next scheduled patient.  

The local police chief came along for the ride. He was in the garage when my call came in. He thought he could be of some help in tracking down my location. Would I have had such personal attention in Chicago or D.C.? There are trade-offs. 

I would love to travel back in time and sit with other visiting nurses. I can’t even imagine the challenges they would describe getting to their patients’ home on horseback, or over tenement roofs, or on bikes. I probably would have no cause to complain about driving a car.

Home Visits Can Be Fraught With Danger

As I write my second book, which is about the home visits I have made over the years, I am resurrecting memories from my mind and the pages of my journals. Today’s post shows a time when I didn’t use common sense and how home visits can be fraught with danger. 

One day in early fall, on my drive back to the hospital after making all my scheduled home visits, I found myself passing by a patient’s apartment on the westside of Chicago. Since I was ahead of schedule, I decided to drop in, unannounced. I had the time. My patient had a caregiver: a tall, muscular man who always opened the door to the first-floor apartment wearing a long blond wig and thick make-up. Despite his flamboyant appearance, he gave competent care to his charge: a bed-bound, uncommunicative middle-aged man with multiple sclerosis. An exotic array of visitors wandered in and out of the apartment. My patient’s mother, strikingly average looking compared to the rest of the visitors, lived in rooms above her son’s and was often present when I came. However, this day I walked into an unlocked and empty apartment. Only my patient, lying in bed in the darkened bedroom, was present. 

Neither the caregiver, nor the patient’s mother, or anyone else familiar to me entered the apartment while I was there. However, as I finished with my evaluation, a man opened the unlocked apartment door. He wasn’t anyone I had seen before. My patient smiled at him knowingly.

The man removed his jacket and tossed it on the sofa. We introduced ourselves. His eyes moved down my body. Acutely aware of the precarious situation I was in—alone in that apartment with a strange man and unhelpful patient—a band tightened around my chest. 

“I’m just leaving,” I said as I promptly packed up my nursing bag. 

Safely back in my car, my breathing heavy and my hands shaking, I chastised myself for making this impulsive visit. No one back at the office knew where I was. It was a time before cell phones. What If something had happened to me?  I didn’t want to think of that. I never again made an unscheduled home visit. 

Sometime after that impromptu visit, at a nursing conference, I sat fixated as another home health nurse told a story about the time that she had made a scheduled visit. She rang her patient’s doorbell. He didn’t answer. It was later that she found out he had been murdered. And in hearing more detail, she discovered that the murderer had likely been in the house the exact time she was ringing the bell. Good thing the door wasn’t unlocked. 

Home visits can be fraught with danger. 

NURSES REALLY MAKE A DIFFERENCE

 

Betsy, a writer friend, emailed me the story she had read in our workshop since I had to miss the class. She knows I hang on every episode of her life in Ireland where her second child was born and she negotiated the daily vicissitudes of a different culture. In this episode she had left the hospital with her new baby girl. She happily accepted the offer to have a nurse visit her and the baby at home.

Her daughter is in college now but Betsy still remembers how helpful the nurse was—and knowledgeable and reassuring, which, in turn, made me remember the article I read not too long ago by David Bornstein, The Power of Nursing (NYT, May 16, 2012) about nurses who made regular home visits to at-risk pregnant women and continued these visits until their children reached the age of two. The program, Nurse-Family Partnership (NFP), conducted studies that demonstrated the visits improved both child and maternal health and financial self-sufficiency and provided a five to seven point boost to the I.Q of these children. Plus many more positive results.

NFP, which has been around since the ‘70s is implemented in forty states, empirically proves what many of us already know: nurses REALLY make a difference. Training paraprofessionals to do the nurses’ job didn’t yield the same outcomes.

We nurses do make a unique contribution. No one else can fill our shoes.

Home Visits Can Be Fraught with Danger

 

One time, long ago, at a nursing conference, I sat fixated as a fellow nurse told a story about the time she rang the doorbell at her patient’s house, and he didn’t answer. It was later that she found out he had been murdered. And in hearing more detail, she discovered that the murderer had likely been in the house the exact time she was ringing the doorbell.

Home visits can be fraught with danger.

One time I visited a patient who wasn’t on my list for that day only because I was in the neighborhood and had the time. He was bed ridden and unable to speak. He had a caregiver, a tall, muscular man who wore a long blond wig and make-up but masculine clothes, such as jeans and a sweat shirt. He was attentive and capable and flamboyant. An exotic array of visitors wandered in and out of the apartment. My patient’s mother, strikingly average-looking compared to the rest of the visitors, lived in an apartment above her son’s and was often present when I came. However, this day, unannounced, I walked into an unlocked and darkened apartment. Only my patient, lying in bed, was present.

Neither the caregiver, nor the patient’s mother, or anyone else familiar to me entered the apartment while I was there. However, as I finished with my evaluation, a man opened the unlocked apartment door. He wasn’t anyone I had seen before. In fact, he was unimpressive in slacks and button-down shirt. My patient smiled at him knowingly. We introduced ourselves. His eyes moved down my body. Acutely aware of the precarious situation I was in—alone in that apartment with a strange man and unhelpful patient—a band tightened around my chest. I promptly packed up my nursing bag and left.

Safely back in my car, I chastised myself for making this impulsive visit. No one back at the office knew where I was. It was a time before cell phones. What If something had happened to me . . . .  I didn’t want to think of that. I never again made an unscheduled home visit.

As I work on my second book, which is about home visits, I contemplate my experiences. I want to include the various unsafe situations visiting nurses may find themselves. It’s not just the “iffy” neighborhoods that may hold danger.

For example, I have previously posted a story about a patient that might have been murdered by a family member. When I drove down the tree-lined street in a middle-class neighborhood to make a last follow-up visit to the widow, it never occurred to me that foul play, and not terminal cancer, could have caused my patient’s death.

There are other dangers to home visits, of course. One nurse I knew broke her leg while stepping on an uneven floor; another was attacked by the family dog. Environmental conditions, such as inclement weather, flooded roads and extreme temperatures, are a constant threat to home visits. Once my windshield wipers died on me as I drove on the highway in a snow storm.

Yes, home visits can be fraught with danger.

The Murder Building

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Originally posted on February 19, 2012 

 

When I visited a patient in my caseload that lived in an “unsafe” part of the city, I went in the morning. Right after the pimps and drug dealers had called it a night and before the shop keepers pulled up the bars over the store windows and the women came out to sweep the sidewalk litter into the streets.

One day Pearl, the social worker, asked to come with me to see a patient. She had a meeting in the morning so we left after lunch against my better judgment. If I were going to go to an iffy part of the city, this was the last place I would want to visit. The Chicago Tribune ran a story a few weeks previously about the “Murder Building.” I knew by the address it was next door to my patient’s apartment.

Everyone knows it simply as “the murder building.“

“They call it `the murder building` because people have been known to go into that building and not come out,“ said one young man standing on a nearby street. “You got to stay away from that place. Things go on in them halls you don`t want to see.“

What does that say about the neighborhood we drove through and the scattering of young men gathered on the stoops, some leaning against the parked cars, all seeming to be without a sense of purpose? I felt their eyes following us.

My patient lived on the second floor of a three story apartment building with his common law wife and various other relatives. The front door was locked and since there wasn’t a bell, I had to stand under the window and yell the patient’s name. The patient’s wife would come to the window before she sent one of the grandchildren down to let me in. This was before cell phones.

I dreaded leaving the safety of the car. Did any of the men think we carried drugs? I scooted out and quickly grabbed my nursing bag from the trunk along with a white bathroom scale. The patient was on tube feedings. It remained unclear if his wife was able to manage the procedure and give the feedings on schedule. I was monitoring his weight as evidence of success.

When Pearl and I completed our visit, we took quick, long steps to the car, avoiding eye contact with anyone near-by. As I stuffed my bag and scale into the trunk, I felt someone tap me on the shoulder. I waited for the command to hand over my nursing bag. Instead a soft voice asked, “Before you put that scale away, would you weigh me?”

I turned to see an older man with short gray whiskers on his chin and a pleasant smile. He moved aside as I slammed the trunk closed and carried the scale to the sidewalk. He took his shoes off and stepped on the scale. “I can’t see the numbers,” he said. I read them off to him, he stepped down, retrieved his shoes and said, “thank you.” Behind him stood a young man with dreadlocks. “Can I get weighed too?” He slipped out of his high tops. I called out his weight and he left with a “thank you.”

Behind him a line of men snaked along the sidewalk. Pearl emerged from the car and began joking with the men, young and old, as they waited their turn at the scale.

Back in the car, the scale packed away in the trunk, Pearl and I drove to the corner. As we pasted the Murder Building, ominous and frightening with smashed windows and debris scattered around its foundation, I realized a building doesn’t define a neighborhood.

There Are Some Patients We Never Forget


This was first published on January 29, 2012.

 

When you have been a nurse as long as I have there are patients who take residence in your memories and resurface frequently. They could almost be family except they have a short history in your life. What they were like before or after you knew them usually remains a mystery.

Mr. G was a cantankerous, legally blind, brittle diabetic I had taken care of in the late 80’s. His house was the worst on the block: paint peeling off the frame, rickety wooden stairs and overgrown weeds. Thankfully he lived close to the  police station because I had to drive there one day when Mr. G didn’t answer the door. He was convulsing on the floor as I peered through the window. I had to beg the police to break down the basement door to enter because Mr. G often complained to me how many times they had axed into the front door and how expensive it was to repair. He frequently had hypoglycemic reactions.

Mr. G. gave himself insulin injections using low vision equipment to measure out the dose. His much younger wife worked full time, leaving him lunch, usually a sandwich, piece of fruit and a drink on the dining room table. He had confided in me that he thought she was having an affair with her boss. Having an active imagination (I’m a writer aren’t I?), I wondered if his wife was trying to kill him. Maybe the house, inside and out, was in deliberate disarray leading to a potential life-threatening accident. I don’t remember the other scenarios I entertained as I drove to and from his home.

When I left my job to move to another state, my friend, co-worker and fellow nurse practitioner, Jane Van De Velde, took over his care. He died on her watch. She recently emailed me with remembrances about him.

“But I really remember his memorial service. It was so touching, all the people who attended and spoke so highly of him. I was literally brought to tears. I got up and spoke about how wonderful it was to see another side of someone–the strong, healthy, community-involved and well-respected side. We saw him at end of life when he was so very ill and depressed and visually impaired.”

Jane adds, “There are some patients we never forget.”

Amen

Laughter: the measure of a friendship

I believe the better the friendship the more raucous the laugher—the real belly laughs that make you think you are going to die of asphyxiation. I have a number of friends that are enjoyable to be with but I have just two or three that make me really laugh.

Donna and I worked in home care at a Chicago area VA in the late ’80s. Our caseload mostly included veterans who were elderly with chronic disease or dying of cancer. Both NP’s, we worked four-ten hour days a week, each covering for the other on the day we had off. Jane, a third NP who worked with us, had young children and requested to work a regular schedule.

Many times after work, Donna and I lingered in the large 4-bed room on a deserted patient unit that served as an office for us three NPs. Each of our desks was centered against a wall. No other furniture filled cavernous room. Donna and I would take turns rolling our chairs next to the other’s desk. We discussed our patients before we wandered off into the personal and humorous. Our laughter ricocheted off the walls. If we became raucous, we didn’t care since there was no one nearby to complain.

After my husband and I had moved to the DC area, Donna came to visit. At one of my favorite art museums—The Phillips Gallery, Donna and I burst into unrestrained laughter. I can’t remember the trigger. What could be so funny in an art gallery? The other patrons gave us wide berth while we two middle-aged women tried to control ourselves. The more we worked to settle down, the harder we laughed. That was the last time Donna and I were together.

In 2000, Donna moved to southern Illinois and I to North Carolina. We emailed and occasionally spoke on the phone. In 2013, Donna was diagnosed with lymphoma.

During one of her remissions she reviewed my manuscript checking for any inaccuracies in my descriptions of NP practice in the 80’s. I sent her a thank you bouquet of flowers.

Now as I ready my book for publication, I am composing the Acknowledgements. The realization that Donna won’t see a formal appreciation saddens me. She died on July 9th.

I will miss her laughter.

Don’t Question the Doctor Part 2

I posted last week about my friend Lois’ run in with a nasty doctor soon after she graduated nursing school in the 60s.

Here is my story about working with a difficult physician that took place in the mid 80s.

The medical director, Doctor X, sat me down in her office on my first day as a nurse practitioner in a home care program at a large VA Medical Center and said, “When the doctor and nurse disagree, the doctor WINS.” She repeated this twice with a glare to discourage whatever protest I might be considering.

I can still see her fleshy face framed by cropped curly hair and a white lab coat stretching over her heavy shoulders. We sat in two chairs in her warm office facing each other without a desk between us. Did she know something about me that prompted this confrontation? Or was she always so caustic with nurse practitioners? She was a rising star in the organization. I didn’t expect this intimidating behavior.

I nodded my head as if I agreed with her dictum. What good would it do to argue since I hadn’t a clue what kind of disagreement we would have? What could happen in a health care setting that would be black or white, right or wrong, a doctor wins and a nurse loses?

What reassured me that Dr. X and I might never have a run in was that I would have autonomy when I made home visits. And I would call another doctor on the team if I needed advice, not the medical director.

One day, while visiting a patient his wife stated, casually, that Dr. X had stopped by on her way home from work. She felt flattered that the medical director would take the time to see how she and her husband were doing. What reason did Dr. X have to visit and not tell me? Not wanting to involve the patient’s wife in a conspiratorial alliance, I smiled and said nothing.

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Dr. X visited a second patient. The scenario was the same: wife mentions the visit, I smile and say nothing. An uncomfortable sense of being under surveillance hounded me. What was Dr. X looking for?

Shortly after, Dr. X was promoted to a leadership position and left the home care program. There was no fallout from her clandestine visits to my patients. Would there have been if she stayed with the home care program and continued her unorthodox conduct?

I am grateful that I didn’t need to confront her—for surely I would lose.

THERE ARE SOME PATIENTS WE NEVER FORGET

01/29/2012 BY MARIANNA CRANE

When you have been a nurse as long as I have there are patients who take residence in your memories and resurface frequently. They could almost be family except they have a short history in your life. What they were like before or after you knew them usually remains a mystery.

Mr. G was a cantankerous, legally blind, brittle diabetic I had taken care of in the late 80’s. His house was the worst on the block: paint peeling off the frame, rickety wooden stairs and overgrown weeds. Thankfully he lived close to the police station because I had to drive there one day when Mr. G didn’t answer the door. He was convulsing on the floor as I peered through the window. I had to beg the police to break down the basement door to enter because Mr. G often complained to me how many times they had axed into the front door and how expensive it was to repair. He frequently had hypoglycemic reactions.

Mr. G. gave himself insulin injections using low vision equipment to measure out the dose. His much younger wife worked full time, leaving him lunch, usually a sandwich, piece of fruit and a drink on the dining room table. He had confided in me that he thought she was having an affair with her boss. Having an active imagination (I’m a writer aren’t I?), I wondered if his wife was trying to kill him. Maybe the house, inside and out, was in deliberate disarray leading to a potential life-threatening accident. I don’t remember the other scenarios I entertained as I drove to and from his home.

When I left my job to move to another state, my friend, co-worker and fellow nurse practitioner, Jane Van De Velde, took over his care. He died on her watch. She recently emailed me with remembrances about him.

“But I really remember his memorial service. It was so touching, all the people who attended and spoke so highly of him. I was literally brought to tears. I got up and spoke about how wonderful it was to see another side of someone–the strong, healthy, community-involved and well-respected side. We saw him at end of life when he was so very ill and depressed and visually impaired.”

Jane adds, “There are some patients we never forget.”

Amen

SILENT NO MORE

When will nurses cease to be invisible? The web site The Truth About Nursing discusses an article about Hillary Clinton’s hospitalization in which the author did not make one reference to nursing hospital room(MatthewLee, “Hillary Clinton hospitalized with blood clot,Bloomberg Businessweek, December 31, 2012 *). The Truth About Nursing suggests if Clinton needed to be hospitalized then she needed nursing care or she could have received treatment at home. Think about it. Can hospitals function without nurses? Instead doctors were the only ones mentioned that monitored and assessed her condition while she was an in-patient.

Do you think doctors stay at the bedside of their patients 24/7? No, they go home for dinner. If there were a problem, most likely they would be paged by the nurse on duty—perhaps at 2 a.m. Or they would hear how the nurse independently solved the problem when they made rounds the next day. Or not.

Unfortunately, to our detriment, we nurses avoid seeking attention for what we do that improves patient outcomes. Because we are so self-effacing, is it any wonder the media rarely mentions us and therefore “reinforces the damaging misimpression that physicians provide all the health care that matters.”?

Isn’t it time we spoke up for ourselves, demanding recognition for what we do? It is a sad fact that the media have long ignored nurses and nursing practice. Nurses continue to shun publicity as if calling attention to what we do is a sign of hubris. I’ve mentioned in the past that I had asked nurses in a hospital where I worked to write stories about what they did that made a difference in a patient’s life. I received few submissions. The most common reason for not writing was they didn’t want to sound as if they were bragging.

I have been guilty of not taking credit for my nursing actions in the past. The story I wrote for The Examined Life Journal, Invisible, tells of a time back in the early ‘80s when I told a doctor that I believed the patient for whom he just wrote a discharge order should remain in the hospital. The challenge there was to avoid the old doctor-nurse game. But, and this is the big but, I never told the nurse with female ptpatient I was worried about the fluid in her lungs, her labored breathing and lethargy. So she never knew a nurse made a difference in her care when a few days later she went home without those troubling symptoms. Now, years later I wrote my story.

Let’s all of us nurses start speaking out by following a suggestion from The Truth About Nursing:  email authors Mathew Lee and Marilynn Marchione at mlee@ap.org and mmarchione@ap.org, stating our concerns about omitting any reference to nursing in their article. And send a copy of your email to: info@truthaboutnursing.org

I plan to do that. I hope you will, too.

*A P Chief Medical Writer Marilyn Marchione in Milwaukee contributed to this report.

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