The Bad Ones

THE BAD ONES #03

/ jonathanrobb / 6 Comments

The patient was an eighty-eight year old man who lived at home with his wife, both of whom were surrounded by a perpetual cloud of smoke despite our nurse’s continued requests that they butt it while we visit. He was a man just managing to stay at home by the skin of his teeth – or, more accurately, by a lot of effort from the support services put in place to keep him safe at home, services neither he nor his wife appreciated. They both had a diagnosis of dementia and shared a common lack of insight into their own failing health and poor living circumstances. Neither acknowledged the nicotine-stained walls or ceilings, the carpeting stained with old and fresh dog shit, or their own deteriorating bodies and minds stained with years of neglect and abuse. In their estimate, they were, ‘…doing fine, and we don’t need anyone barging in and taking over!’

But despite his shortcomings, this wasn’t enough to make him one of the bad ones. Once you got past the bluster and opened a window to air out the house, both he and his wife were pleasant in their own confused and belligerent way. The problem was the patient’s GP.

The patient had returned home from a short stay in hospital due to his yo-yoing health, and, as hospitals are prone to do in an effort to prove they did something to help the patient, they had played around with his medications. This slight tweak on their behalf often means a mountainous headache of work for us. Easily one of the most infuriating and frustrating aspects of my job is attempting to get a list of my patient’s medications, complete with the drug’s dose, route, and frequency, and topped off with a signature from the prescribing doctor, so that I may legally administer those medications.

Perhaps you’re reading this, thinking, “Surely, that’s not so hard a thing to obtain. A doctor would have on file the current medications his patient’s are taking.” This world of doctors keeping an up-to-date list of their patient’s medications is one that belongs in a medical utopia, a place where patients are keen to participate in their health and old stoma bags smell like vanilla essence. Unfortunately, I operate outside that sphere, and consider it lucky if the GP I’m corresponding with has a computer on which to type a list of medications. The stereotype of illegible doctor’s handwriting is very real.

The client’s GP was a doctor I was familiar with, and I knew him to be a man resentful of assisting in any way. His choking arrogance always seemed to get in the way. So, knowing this, I rang his office.

‘Hi, this is Jonathan the district nurse, I was just hoping to speak to the doctor regarding Mr X.’

‘Oh, sure,’ his secretary replied, ‘I’ll pop you through.’

*On-hold music* – wait time 30 seconds.

‘Yes.’

‘Hi, Doctor, this is Jonathan the district nurse. I’m just ringing because Mr X has returned home from hospital. He was diagnosed with GORD while in there and commenced on Nexium, and I was hoping you could add this to his medication authority and fax it through to us.’

*Click*

He had hung up.

I rang again.

‘Hello, Doctor’s office.’

‘Hi, this is Jonathan again. The Doctor just hung up on me. Could you put me through to him.’

‘Oh. Sure.’

*On-hold music* – wait time 1 minute.

‘Yes.’

‘Doctor, it’s Jonathan again. We got disconnected. So as I was saying, we just need a new medical authority so we can administer Mr X his new medication.’

‘What is all this?’ he grunted. ‘I’m sick of doing all this work for your company. Why don’t you have your own doctor on staff?’

‘You know how we operate, Doctor, how community health operates. You’ve worked with us for years. You know we don’t have our own doctor on staff.’

‘I’m sick of doing all this over the counter work, it’s ridiculous.’

‘Sorry, I’m not following you. What do you mean “over the counter?”’

‘Well, it’s not face-to-face, is it? I’m not billing for this.’

‘Oh, so you’re worried about your money?’ I chuckled.

In retrospect, laughing may have been the wrong tact to take.

*Click*

I squeezed my mobile phone, envisioning the pathetic old doctor’s neck, and rang a third time.

‘Hello,’ his secretary said.

‘Yeah, it’s Jonathan again.’

‘ I thought so, it’s why I didn’t answer with the spiel. Is it a connection issues or is he angry?’

‘Oh, he’s angry. Can you put me through again?’

‘I can try.’

*On-hold music* – wait time 3 minutes.

‘Are you still there?’

‘I’m still here,’ I replied.

‘The Doctor’s busy at the moment—’

‘Uh-huh.’

‘—but tell me what you need and I’ll see what I can do.’

I detailed what was required, explaining that my persistence was only to ensure the patient got his medications and remained out of hospital. I did my best to stay calm and jovial with the secretary, reminding myself that her employer’s childishness was no fault of hers, that she was the only one attempting to help, and that she had to put up with the megalomaniacal wanker for hours at a time. Once I had repeated what I needed and she wrote it down, she assured me that she would have it faxed to me by the end of the day. I thanked her, sincerely, and hung up.

It’s hard to work in an industry full of contradictive people claiming to be there to care for others whilst only caring about themselves. It’s hard to advocate for your patient against the very people who should be helping. It’s hard to remain professional while those you deal with act like children. And it’s too easy to think, ‘Why do I continue to work in this faulted system?’

The secretary was true to her word, and by the end of the day I had a medical authority with the patient’s new drug added to the list. Unfortunately, the previous authority had two medications that, due to the Doctor’s past laziness, had only been scrawled on by hand, and hadn’t come across with the new list. I would have to phone him the next day to have them added.

He was one of the bad ones.

THE BAD ONES #02

/ jonathanrobb / 1 Comment

I was visiting to admit him, a skinny Indian man recently returned from hospital. He was sixty, and previous to his recent surgery had been completely independent. He’d had years of back pain and recently gone in for a surgery designed to relieve pressure in his lower vertebrae. Unfortunately, during the operation, damage had been done to his nerves resulting in a neurogenic bladder. He had lost the ability to consciously relax the sphincter between his bladder and urethra, thereby releasing urine. In other words, he could no longer piss on command.

I was there to educate him on the catheter that had been inserted to ensure his bladder could still empty. I went through the usual process of introduction and listening to his recount of events before beginning to detail how to properly care for his new urinary system. He stopped me, and asked instead if I could remove his catheter.

After digesting his request I explained that couldn’t do as he asked, that without a catheter his bladder would continue to fill, that the pressure in his renal system would build and he’d be in extreme discomfort, and, if left unrelieved, could damage his kidneys.

Again, he stopped me, shaking his head and waving his hands, dismissing what I’d said. He told me that if I removed the catheter he would urinate. He assured me that if he could just relax, he could get a flow going.

I begun explaining about his neurogenic bladder, and again he cut me off, eyes closed and head shaking. ‘They have told me this in the hospital,’ he said. ‘But I know my body. If you take it out, I will be able to pee.’

I empathised with his difficulty in coming to terms with his new disability, but felt a bloom of frustration open in my gut. I tried again.

I explained, patiently, that in fact he’d had the opportunity while in hospital to do exactly that, that the hospital staff had removed his catheter and after an hour had scanned his bladder and found a litre of urine inside his body and not a drop out. I reminded him that they done this on two separate occasions, a week apart, and each time he’d been unable to void.

He was frowning now, jaws clenched as he waved his hands in front of my face. ‘I couldn’t do it there!’ he said. ‘There was too much pressure, with their machines, and their waiting. I am home now. I can do it now.’

I bit down my exasperation while requesting he not interrupt me, and to lower his hands, and explained that anyone with conscious control of their bladder would be able to pee if they had a litre of urine pushing down on their sphincter. He interrupted me.

‘No! Take it out and I will show you. I don’t want it anymore.’

This conversation continued for an hour. Despite my argument that it was in his best interest to keep the catheter in, he continued to command me to take it out. I told him that once the catheter was out, and he failed to urinate, he would be in agony. That his bladder would feel like it was ready to rupture and there would be no one around to insert a new catheter to relieve it. That he’d have to return to the hospital, something he insisted he wouldn’t do.

I explained that I wasn’t saying this to antagonise him, only that it was the truth. He rebutted with threatening to pull the catheter out.

By this point, over the hill of vexation and down again, I couldn’t repress a chuckle. A catheter has a balloon in the tip with a diameter of about four centimetres to hold it in place in the bladder. A male urethra has the diameter of about one centimetre. Pulling out a catheter without the balloon deflated is a painful process.

I detailed this, using the simile of pulling an apricot through a straw, and recommend that he not try it. He told me he would do as he liked.

In the end I slumped back in my seat and said I wouldn’t do what he wanted. He told me to leave.

When I got back to the office I contacted the hospital and informed them of the outcome of my visit, and they madly scrambled to have an ambulance and a bed ready if he did remove his catheter. I hung up the phone annoyed that they had to work harder to compensate for this man’s idiocy.

It’s hard to fight to save someone from themselves. It’s hard when their voice is raised and respect is gone, and you’re debating reason while they’re debating stubborn ignorance. It’s hard to keep caring about their wellbeing when they don’t care about your professional knowledge. And it’s easy to think, ‘Why don’t I just leave them to the consequences of their actions?’

He was one of the bad ones.

THE BAD ONES #01

/ jonathanrobb / 1 Comment

My brother pointed out to me the other day that I don’t tell the stories of the bad ones, that on my site I’ve shared many stories of the good patients I’ve met, but have failed to document the more sour interactions. He, of course, has heard countless stories of exasperating patients, of those people I visit who have deemed themselves free of the need to conform to the social norms of politeness, respect, and quiet often, hygiene. His observation was accurate — it was with deliberate intent that I excluded those episodes from this site.

But after the discussion I realised that by focusing only on the uplifting exchanges, I’m not accurately portraying my profession, and in a larger sense, my community. Laborious and infuriating personalities make up the web of society as much as, and sometimes more than, the pleasant. By ignoring this branch of humanity I’m also ignoring the insights and experiences that come with them, as distasteful as those insights and experience can be.

So here we go…

 

The inside of her house was lined with a layer of dust and cat hair, an accumulation of years. It was something I couldn’t just see and smell, but could taste, to the point that simply breathing in the air felt like a fouling act. It was as if each breath was coating the insides of my lungs with its own layer of dried skin flakes and moulted cat fur.

I was there to attend to wounds on her lower legs. She was forty-five years old; young, given the average age of our clientele. She had wounds due to years of uncontrolled diabetes — the consistent high level of sugar in her blood had killed the micro-vessels in her legs, reducing the amount of oxygenated blood delivered to her skin. Without proper circulation, her skin integrity weakened and ulcers developed, which then failed to heal due to the same poor quality circulation that caused them.

It’s importance to stress that in her case “uncontrolled diabetes” isn’t a reference to undiagnosed diabetes. The patient had known of her condition and had had years of doctors and medical specialists educating her on the necessary exercise and dietary requirements needed to manage her disease. She weighed one-hundred and fifteen kilograms and her blood sugar results were perpetually high.

This was not a picture of a woman who had heeded medical advice.

She scooped four cats from her single bed, throwing them out the door, before falling face first onto the mattress so I could attend to her wound care. Her bulk filled the bed, her affected legs sticking out like twin wrapped hams. I peeled away the soaked and soiled dressings while she complained about how her wounds wouldn’t heal. Her limbs were stretched tight with oedema and yellow slimy pockets of broken skin rung her calves, the angry red edges like bruised and swollen lips.

I looked around her house, breathing shallow breaths, focusing on the decade worth of dirt that coated her home. Dirt that a half-an-hour vacuum once a week could have avoided. That a thirty-second swipe of a cloth could have wiped away at the time, but instead, years of voluntary neglect had accumulated into a stain that could only really be cleansed with fire. I took in these details and wondered if it was worth explaining for the hundredth time ways in which she could aid her own wound healing. Ways such as losing weight, eating a well-balanced diet, exercise, and stopping the consumption of soft drinks.

I began, knowing the words would be wasted, but she cut me off.

‘Yeah, yeah, I know all that. Every nurse goes on about it. I’m just sick of it.’

I fought to resist asking why then does she still spend her days eating chips on a couch that has moulded into the shape of her body.

A colleague of mine once decided she would wear this patient down with positive enthusiasm. She went in offering support and encouragement. She sat and talked to her about how we would help her heal her wounds if she would only help us. That we would aid her every day to bring her weight down and correct her diet. That it didn’t have to be a monumental thing, but just small acts done daily. Acts like walking to the letterbox.

Her letter box was ten meters from her door, and my colleague suggested that when she had finished tending her wounds, she walk with her to the letterbox on the way out as a form of exercise. The patient agreed.

Once she had dressed the patent’s wounds and hoisted her work bag, my co-worker said,

‘Come on, then. Walk me to the letterbox.’

The patient sat on the couch, looking at the nurse as she thought about it, then responded with a shrug,

‘Nah.’

It’s hard to care about another person’s health when they don’t care about it themselves. It’s hard to squat and lift heavy legs, to scrap muck away from weeping wounds, to walk into a home that makes you feel ill when the other party isn’t doing their fair share. And it’s too easy to think, ‘Why am I bothering when they aren’t?’

She was one of the bad ones.