Coming Out

Bandages-583

The following account has been written with the full blessings from those involved. I do not make a habit of gossiping about my colleague’s personal lives with patients, but in this case, Bette and I had chatted about the situation in the office at length. She agreed that it would be fine for us to answer questions about her and Tina.

Many of the patients on the DN caseload were born in the 1920s. Some were born in the First World War. The world that surrounds them now bears very little resemblance to the one that they were born into.

There have not only been massive changes in technology, travel and communications, but also in society; in how we live our lives and in the relationships that we choose, and are allowed, to make.

If you were born, for example, in 1925, when many of my patients were born, you would live for forty-two years before homosexuality was legalised. That is forty-two years of absorbing perceived opinion from your family, your friends, your neighbours and the media. The words and phrases that you might associate with the subject were ‘criminal’, ‘degenerate’ or ‘abnormal’. That is of course if you heard anything at all, because it was a taboo subject and many people would have grown up in complete ignorance of such a thing.

It must take an enormous mental effort for many people born years ago to understand same sex relationships.

On our team we have a nurse, Bette, who is in a civil partnership with Tina. Using a sperm donor, Tina got pregnant and her and Bette now have Jamie, an extremely bonnie, robust one-year-old boy.

Now, just try and imagine how Bette and the rest of our team went about explaining this to people born in the 1920s, sometimes earlier and often later. As it was not Bette who was carrying the baby, we somehow managed to avoid tricky questions until she went on ‘Paternity’ leave… (that IS what it was referred to by the NHS).

I have talked about laughter in previous blog posts, but coming back to the office to regale some of our experiences in explaining the situation to patients caused endless giggling. We all, including Bette, had the utmost empathy for these patients. We never thought them ‘narrow-minded’ or ‘bigoted’, we just saw them struggling to grasp a totally alien concept. Of course, the media has provided them with a tremendous amount of information, and TV dramas like Last Tango In Halifax provide a backdrop that goes a long way to normalising this for them. It is, however, still rare for them to come across ‘the real thing’ close to hand.

There were many reactions from both men and women on our caseload, but two stand out in my mind, both of them from women. Firstly Agnes.

Agnes, sitting beside her husband John, asked :  ”How’s Bette? We haven’t seen her for weeks. To tell you the truth we were a bit puzzled because she told us that she was expecting a baby, but it didn’t show? Have I got that wrong?”

‘‘Well”, I said, not feeling entirely at ease, ”That is because it is her partner Tina who is carrying the baby.”

There was a silence as Agnes and John looked at each other. I could almost hear the cogs slowly turning in their brains.

”So”, said Agnes, ”does that mean that Bette is a…” (long pause) ”… you know, a um, um…” (another pause) ”One of them, you know. What are they called?”

I took a deep breath. ”Yes, Agnes, that’s right. Bette is Gay. She is a lesbian.”

”Ooh. Hmm” said Agnes. She then said sadly ”… And we thought that she was such a lovely girl.”

”Well,” I said, ‘‘the thing is, Agnes, that you can actually be both. You can be Gay and a lovely person.”

”Hattie,” she said, ”I am not one to judge and each to their own, but it just in’t natural. And that is all I have to say on the subject.”

…However, she continued to say: ”If she comes back in here, I will be polite, because I am not a rude person, but it just won’t be the same. I just won’t feel relaxed.”

I said, ”Well Agnes, you are right, things won’t be exactly the same, because she now has a baby and that will mean that you will have so much to chat about. You’ve got babies in your family, so you can natter on about baby stuff.”

She pursed her lips up even tighter: ”It’s no good how much you try to dress it up Hattie, it just feels very odd to me, and John feels the same.”

John didn’t say a word.

Don’t you John.” This was not a question.

That was the end of the conversation, because she closed her mouth tightly shut. It is true that she was always polite when Bette visited, but it was a struggle for her to come to terms with the situation. I am not judging Agnes. She has to be seen as a product of her times, and the concept of a same sex couple having and bringing up a baby was simply something that she could not understand – and therefore accept – but she would not have dreamt of being rude or offensive.

Another patient, Joyce, asked the same question. Joyce lives alone, having been widowed five years ago after nearly sixty years of marriage.

I gave the same reply: ”Bette’s partner Tina is having the baby.”

Joyce looked puzzled and asked, ”Is Tina a woman?”

”Yes Joyce, she is,”

”Well, Hattie, how on earth did that happen?”

I have faced some of the most difficult questions that can be asked, ”Am I dying?” being right up there with the most challenging, but this question came pretty close.

I heard myself stumbling over the words. ”Well, you know, there was a man and he sort of helped out and now she’s pregnant”.

”Hattie, are you telling me that Bette’s partner had sex with a man to get pregnant?”

”No, no I’m not saying that Joyce. No, not at all.”

”Well then, what are you saying? How did she get pregnant?”

It occurred to me to use the words that Bette had used when I had asked the same question myself. I have known Joyce for many years and felt that I knew her pretty well, and I thought that she could take it, so I said, ”Well, Joyce, it was a ‘turkey baster’ job.”

”A what?!”

I couldn’t have stuttered and stumbled over my words more if I had tried and in the most clumsy fashion I said,

”Well, some sort of big syringe, rather like a turkey baster, is used to insert the um, the … you know … the stuff, the sperm into Tina, and now she is expecting a baby.”

Joyce was clearly stunned. Her jaw literally dropped.

Then she said, ”NO! Nooo! Really? Really?” Joyce was chuckling in disbelief. ”Oh my word, yes I see. I suppose that would be how it was done. Well, well. Gosh, I never expected that. Well Hattie, you have certainly given me something to think about this morning. I must tell Pam,” (her oldest friend), “… she will be completely fascinated and amazed!”

We had clearly opened the floodgates on this one, because there followed a torrent of questions:

”So, Bette is a lesbian? Is she a, what do you call it? a Gay? Have they had one of those ceremonies? Will the father be involved with the baby? So the baby will have two mothers?”

I’m not really sure that I answered all the questions accurately, because some of this is strange for me too. If I’m honest, I have had to get my head around it as well and I’m a good 30 years younger than Joyce. But it’s easier for me, because I was brought up in a world where society was already changing and I have no memory of homosexuality being illegal, whilst for my children, born in the 1990s, this is all completely natural. They don’t give their friends’ sexualities a second thought.

That morning we had a brilliant conversation which was as enlightening for me as it was for her. She talked about how totally shocked her parents would be at this information and about the perceptions that she was brought up with in the 1930s, forties and fifties. She freely admitted that she found it difficult to accept male homosexuality, but she saw this as ‘her’ problem. I decided that Joyce was really broadminded and trying very hard to learn about something that would have been alien to her for much of her life.

I admired the fact that she was inquisitive, enquiring and interested. However, what I liked (and still do like) about Joyce was that she cared about Bette, Tina and Jamie. She has taken a great interest in them. She loves to see photos of them all and still chuckles with me about the turkey baster.

Joyce has a really brilliant sense of humour. I went to see her last week and she asked, as always, about Bette and her family. I told her that they were all happy and in good health and that Jamie was nearly walking. She said,

”Well that’s lovely news Hattie, thanks for updating me. Pam is popping in later this week and I can fill her in, she always asks about Bette. In fact,” she said with a twinkle,  “Pam and I are thinking of ‘coming out’. ”

 

”Just Call Me….”

A few years ago, a close District Nursing friend of mine, Gwen, was asked by a GP to visit an elderly woman who needed ‘sorting out’. This is my memory of her brief account of that first visit.

Gwen approached the old woman who was afloat on a sofa sodden with a few days’ worth of urine and excrement.

She bent down and said ”Hello, I’m Gwen. What would you like me to call you?”

The little, bespectacled, white haired woman peered up and said:

”I am Mrs Fucker and you can Fuck off”.

Thankfully Gwen did not fuck off and following a great deal of soap, water, upholstery cleaner and subsequent lengthy organisation, she was able to ensure that Mrs Fucker remained safely and happily at home for another two years.

Carry On Nursing!

Now and then days come along, which, when you reflect upon them in the wee small hours of the night seem utterly surreal.

In the middle of a shift, when you are in ‘the thick’ of the action, you literally are just reacting and responding to various scenarios, not exactly without feeling, but certainly in a knee-jerk, problem solving sort of way.

As I lay in bed unable to sleep recently, I realised with a jolt that my actions that day had pretty directly ended two peoples lives. Legally, I hasten to add.

I also realised that I had laughed a great deal that day. In fact at the end of the day, back in the office, there was a point where three of us were verging on the hysterical, unable to stop laughing. Tears rolling down our faces. What sort of monsters are we?

It was one of those days where two patients at the end of their lives ‘trumped” everything else on the caseload and took total priority.

I arrived at a familiar house early in the morning to see Ivy and her husband Ernest. Ivy has had dementia for many years and now, in a cruel stroke of fate, also had stomach cancer. Her main symptom was vomiting, naturally accompanied by anxiety. All the stops had been pulled out and the NHS, Social Services and Marie Curie were all involved. Nothing mattered other than trying to get on top of Ivy’s vomiting and achieving peace and calm.

With the GP, we decided to set up a Syringe Pump. The pump is a really useful gadget that we often introduce at the end of someone’s life. It is very simple. We put whatever medication fits the bill in terms of symptom relief into a syringe, attach the syringe to a little battery powered pump and press START.

The pump chugs along for 24 hours, administering a steady, even dose of painkillers or anti-sickness drugs or drugs to relieve anxiety or drugs to relieve a ‘bubbly’ chest, until the District Nurse pitches up the next day and re-fills it for another 24 hours.

The process of setting up a pump is time consuming because it involves haring around to the surgery to speak to a GP and get medication prescribed. Getting the prescription to the chemist. Getting the Pump and all the paraphernalia that goes with it back to the patient and then a great deal of concentration in a quiet place. Personally, I need to be somewhere away from the patient and the family so that I can mutter under my breath to myself, ensuring that I am calculating the controlled drugs safely and drawing up the correct doses.

I set up the pump, but Ivy was still ‘not right’. The medication in the pump can take up to 6 hours to be effective, and I certainly could not leave her as she was. She had deteriorated significantly since the previous day when I had visited. Then she had been lying on her hospital bed watching with intense concentration, an afternoon quiz show. Ernest and I had chuckled as she shouted out in rapid staccato, her totally incorrect but also, rather tellingly, semi-related one word answers to the questions. It reminded me of the ”The Two Ronnie’s: answering the question before last” sketch.

So, we all relaxed a little knowing that the pump was gently feeding Ivy with medication to settle her. However, her face was still screwed up. She was rigid and her eyes were open and staring straight ahead. In a wonderful example of forward planning, which we and the GPs are now getting more practiced at, Ivy had in her house a ”Just In Case Bag”. This bag contains ampoules of drugs that can be given by a registered practitioner right then and there, so that no time is wasted having to call GPs and race to the chemist.

I gave Ivy a small, prescribed dose of a benzodiazepine (rather like Valium), via intra-muscular injection into her thigh. I hoped that this would settle and calm her. At the very least I hoped that it might reduce her anxiety. This method of administration should take effect in about 15 minutes and hopefully last for up to 4 hours, at about which time I knew that the Syringe Pump medication would have started to ‘kick in’. Sure enough, by the time I left, Ivy was sleeping soundly. Her eyes closed and her mouth slack.

I promised to pop by later and see how things were.

I headed off to a nearby Residential home. Having seen my last patient there, I was just writing up notes in the office, when I overheard one of the carers saying:

”Well, his feet are blue now, he has just been sick again and I don’t think he looks as if he will last long. …….We have called his daughter and someone is sitting with him”.

I have to tell you that I am no saint, and given the list of people that I had still to see that day, I did for a moment pretend that I had not overheard this, keeping my head buried in the notes and wondering how small I could become, (not very). Eventually, after a shameful 1 minute, I felt compelled to say;

”Who is this?”

A grateful carer took me to see this gentleman and I was very glad indeed that I had asked.

He looked frightened. He had recently been sick. In a strangely similar scenario to my earlier time with Ivy, his face was set and his eyes were staring. His breathing was rapid and shallow. I knelt down and took his hand which he grabbed and clasped very tightly. He didn’t respond to my questions. His feet were indeed blue and his legs were mottled with yellow and blue patches. His hand was cold.

The carers were quite rightly very concerned about him and told me that they had called the GP the previous day who had visited and prescribed a Just In Case Bag, suspecting that he was ‘nearing the end of his life’.  All well and good, but it had not occurred to anyone to let the District Nursing team know. We could have got on top of this 24 hours earlier.

Thank Heavens for Just In Case Bags. Feeling that I was in a deja vu situation I administered this gent with exactly the same dose of the same drug that I had given to Ivy just over an hour before. I then spoke to the GP and after discussion we got the ball rolling with organisation for a Syringe Pump to alleviate the vomiting and reduce the patient’s anxiety and discomfort.

I then groaned, realising that our team’s only two Syringe Pumps were actually in use on other patients, one of which was Ivy.

After a couple of frantic calls I located a spare pump about 15 miles up the road with a neighbouring team. One of their nurses agreed to meet me in a rather clandestine fashion in a lay-by, just off a major roundabout about 10 miles away.

Just as I put the phone down, it rang again. It was the surgery telling me that Ivy had just died. My mind raced. Was my first thought for Ivy, or for the now available pump? I fear it was probably the latter.

People of a certain age often ask: ”How did we manage before mobile phones?”. But seriously: ”How did we manage before mobile phones?” ……….A call to cancel the lay-by meeting, a call to ask another colleague, Sarah, to be waiting around the corner from Ivy’s house and a call to Ivy’s family to (genuinely) express my sympathy and ask if they minded me coming over to see if there was anything I could support them with and to casually mention that it was usual for us to detach the pump from the patient at the earliest opportunity. Honest…….it is.

This is now like a Carry On film. Screeching to a halt outside Ivy’s house and seeing Sarah’s car idling nearby, I raced in. The moment I crossed her threshold, any appearance of rushing had to stop, and the the slow motion button was pressed. Ernest and I hugged. I could almost feel in that hug the weight of years of grieving already experienced, right from the beginning when Ivy began to forget things and got muddled, to recent months, when she no longer recognised him or her children.

I went into Ivy’s room where the Marie Curie nurse was doing her best to wash and dress Ivy in clothes that Ernest had chosen. I detached the pump, collected all its accoutrements and as surreptitiously as possible got out of the front door. Sarah magnificently pulled up in her car and I passed the whole lot through her passenger window. She sped off to the home, where I said I would join her as soon as I possibly could.

I felt at last that now I could actually give priority to Ivy and Ernest. The carer and I finished washing and dressing her. We both talked to her as we rolled her from side to side, pulled up knickers, put on cosy socks, got her arms into sleeves and brushed her hair, all the time trying to be as gentle as possible. I found myself apologising as an arm was twisted unnaturally into a sleeve. Force of habit. I have never met anyone who didn’t talk to their patients after death. Goodbye Ivy.

And then it was  On, On, On. Back to the home. Race, Race, Race and then slow motion again as I entered the quiet room  where another life was ending. A daughter sat holding her father’s hand. He was sleeping now and his face was relaxed. His eyes were closed. She was talking to him about her mother, his deceased wife. She was saying;

”Do you remember when we …..?” and

”Wasn’t it funny when you….?” and

”Mum loved it when you…..?”

As Sarah and I prepared the Syringe Pump, our patient sighed his long last breath. His daughter said; ”Dad?”, ”Dad?” and then to us with panic: ”Has he gone? Has he died? Oh God”. Even the most expected death can seem unbelievable.

As a formality, I felt for his absent pulse. Sarah put her arms around his daughter and we both sat with her for a while in silence whilst she wept. We then quietly left her alone.

An hour later we were in the office relating the day to another colleague. The day’s story had developed and morphed into comical farce. We told the story with great drama, humour and artistic license. We lapped up the generous, rapturous appreciation from a colleague who understood and simply knew about these things. We shrieked with laughter as I spoke to the GP on the phone about giving both patients the same dose of the same drug and both patients dying soon afterwards. He said down the phone…”Must have been a dodgy batch!”…mock horror, more hysterical laughter.  See what monsters we are?

This is a funny old job. Two human beings leave the world together on what becomes a crazy day. There is a  great deal of  completely inappropriate laughter from the so-called caring profession, whilst two families mourn their dearly loved father, mother and wife.

And I lay in bed, in the dark that night and felt a delayed jolt at what I had done on that day. That I had given two people a drug that enabled them to relax enough to die.  Had I, in effect, killed them? It was too much for me to get my head around and so I went to sleep.

PS: In case you need reminding about The Two Ronnie’s sketch. Here is the link: www.youtube.com/watch?v=BvmRI6K8TS8

It might make you chuckle.

Telling it like it is

A few months ago, we had a 2nd year student on placement with us for 3 months.

It was a particularly harrowing time, but paradoxically also a very interesting time to be a student with the team. We had 3 patients who were approaching the end of their lives.

One patient in particular absorbed our team on a daily basis, as we struggled to enable her to stay in her home where she desperately wished to be. We were visiting her up to 3 times daily as well as liaising with her GP, the Consultant from the Palliative Care team and the Palliative Clinical Nurse specialists. The challenge was to control her pain which at times was ”off the scale”.

Emotionally, it was also a challenge. This woman was a wife, a mother, a daughter and a friend to many. We all found it tough, but there was also much humour and laughter and many was the time that I left her house smiling despite feeling wretched that her life was ending too soon. Our student, Emma,  integrated well into our team and the family looked forward to and appreciated her input as much as any of us.

At the end of Emma’s placement, she wrote a lovely reflection of her placement. This young patient actually defined Emma’s placement and I hope and expect that she will remember her all her life.

As a result of Emma’s reflective piece of writing, (and cutting a long story short!), our team was nominated for an award. Four of us (including Emma) travelled to London this week to make a presentation to a group of 6 people, none of whom were health professionals. I was very nervous so wasn’t concentrating well enough on their introductions but I remember that one of them was in the police force and another worked in an Insurance company in customer relations.

We saw this as a great opportunity to convey to a group of non-health professionals, the details and realities of our role in the community.

We each had about 5 minutes to speak. The following is just my section:

I was born in 1963 and I am 52 years old.

I won’t try and figure out the average age of all of you in this room today, but the chances are that in the next few years some of you may develop health problems that prevent you from leaving your homes.

At the moment you probably cannot imagine requiring someone to come into your house to enable you to survive. I struggle to imagine this happening to me also.

But it may very well happen and I am concerned that there may not be anyone around to look after me.

I will be retiring from District Nursing in roughly 10 years time. That is around 2025. Many of my colleagues will also be retiring around that time.

Emma, the student nurse here, was born in 1993 and she is now 21 years old.

If she remains in this area she may well end up looking after me! Of course the person that ends up looking after me may not even be born yet.

Maybe you are wondering about the type of problems that you or I might need to have to justify a District Nurse visiting us at home…….

Well, the list is pretty much endless, but for starters:

Imagine you bash your leg and find yourself with a wound that will not heal. It might turn into a leg ulcer that needs dressing and bandaging once, twice or more a week, but you are housebound and cannot get to your surgery. You will need a District Nurse to visit your house and assess the wound, investigate why it is not healing and manage it for you at home.

 Imagine that as a middle aged man, your prostate gland starts to increase in size and prevents you from peeing normally. One day, you might find that you cannot pee at all……..you will be pleading for a District Nurse with a catheter and the knowledge and skills to insert it and then help you manage it at home.

 And if you think that that sounds grim,  imagine not being able to manage to poo either……..well?….. the District Nurse can help you with this also, as well as trying to ensure that it does not keep happening.

 Imagine that you are diabetic, but you do not have the dexterity in your fingers to give your own insulin. The District Nurse will help you with this daily (sometimes twice daily) as well as monitoring your blood sugars and making sure that you are eating and living as healthily as you can.

 Imagine that you can no longer imagine. You might be disorientated, confused and anxious. You may have dementia: you will need a District Nurse to coordinate the myriad of health care specialists that become involved in your care. This can be a terrible time for partners, daughters, sons, siblings and friends, but the District Nurse will be there to support these people, point them in the right direction and more often than not, be a shoulder to cry on.

 Imagine every possible type of wound from straight, neat, zipped up post-operative wounds, to deep, dark, fungating cavities that often smell and leak and cause a great deal of pain. The District Nurses are experts in wound care and will work hard to tackle these problems.

Imagine NOT getting pressure ulcers and NOT becoming malnourished and NOT falling in your home……..because District Nurses work very hard trying to prevent all these things.

And finally, imagine getting to the end of your life and having a District Nurse working with you and those you love to ensure that you have as little pain, anxiety and fear as possible, and that you can leave this world whilst in your own home, in your own bed with your family, friends and pets nearby.

And now imagine that there are not enough nurses out there with these many skills.

Imagine listening to a politician or a health minister saying in 2025:

’Well, we could definitely see a District Nurse crisis looming back in 2015. All our experienced District Nurses were coming up for retirement and the community teams clearly failed to make District Nursing an attractive and exciting career option for students and newly qualified nurses. For that reason, we are very sorry, BUT there are just not enough skilled nurses to look after you at home’’

 In 2014 the Royal College of Nursing referred to District Nurses as ‘’critically endangered’’, facing extinction by the end of 2025 if urgent investment was not made:

http://www.rcn.org.uk/newsevents/press_releases/uk/district_nurses_face_extinction_in_2025

We need to get young blood into the Community as a matter of urgency, which is why our team places so much importance on and invests so much time in our student nurses.

Hearing Emma tell us how much she enjoyed her time with us and reading her evaluation of her experience was uplifting for us. She did us as much good as we did her, because it reaffirmed that enthusing young nurses about District Nursing is about as important as it gets and we feel passionately about this.

The End!

The first comment from one of the middle aged male judges was:

”I think that I need to get to a Well Man Clinic”…………..

Chaos Theory

It is a  quiet, misty Autumn day.

I have a complicated list of patients to work my way through.

I am in the car when I receive a phone call from our community physio: ”Morning! Could you meet me and the Occupational therapist (OT) at this address? The social worker has asked us to visit these sisters and have suggested that District Nursing (DN) input will be necessary”. It seems that a neighbour has phoned the surgery to report concerns that this pair are failing to look after themselves adequately at home.

The GP has visited and has immediately contacted social services. The social worker has visited and has been desperately trying to untangle the situation and get some urgent home care into the house. This is late 2014 and the government ‘austerity’ measures are really coming into their own, meaning that it is increasingly difficult to find adequate and timely home care.

Whilst the social worker tries to work some magic, she asks the OT and the physio to visit and assess the couple’s mobility, and to see if any equipment might help the home situation. District Nurse input is required to assess the couple’s skin, their nutrition, their continence and their medication. Apparently one sister is diabetic which must be a priority.

I mentally juggle my planned list and shunt the patients with lesser, (though still vital) needs down the page of my diary….they may even topple off the bottom, only to join the bulging list for tomorrow. I weave my way down narrow lanes to a very pretty village, where it would seem unlikely that I would find much in the way of a dysfunctional household.

The physio and OT are waiting outside a pleasant, semi-detached 1930s house. We make our way through a reasonably well maintained  front garden to the porch. When no-one responds to our knocks on the door, we venture in uninvited as it is unlocked. We are nearly felled by the immediate stench of urine and faeces, but continue undeterred shouting ”hellooo!” as we go. A cat appears and starts to curl its body around our ankles, meowing incessantly.

We tentatively peer into the downstairs rooms and find no-one. Up the stairs we go and find the sisters in a large bedroom at the back of the house. In the bedroom are two single beds. One sister lies in bed the correct way round, the other sister has her feet up against the head board and her head at the foot of the bed. There are two buckets on the floor in the corner of the room. Each bucket is half full of cloudy, stale urine. There are purple and gold chocolate eclair wrappers floating on the surface. The strong smell of ammonia has us all reeling.The carpet has plops of faeces on it.

The sister nearest me is wearing a fleece dressing gown tied at the waist with a cord that has faeces stuck to it. She looks up with a big smile on her face. ”Good Morning! My Goodness, what a lot of you! How can I help you?” She is charming and gracious considering that three NHS uniforms have marched into her house unannounced.

Over the next 90 minutes, the three of us conduct what is really a thorough piece of detective work. We have some baseline information that the other two printed off from the surgery computer. I learn from this that one sister  has Vascular Dementia and has been cared for by the other sister, whose own cognitive state seems fragile to say the least. They have become what social workers refer to as a ‘creaking gate’ of a couple: hanging on by a thread to their normality and independence. For this pair, on this particular autumn morning, the gate has just slipped off its hinges and is swinging in the breeze.

The problems multiply by the minute. At every turn, like Holmes and Watson, we find clues emerging from the bedroom, the bathroom and the kitchen. I go into the kitchen and look in the fridge. As well as a few tins of cat food, I count 12 full unopened tubs of ”I can’t believe its not butter!”. I open the freezer below and find 2 shelves stocked full of ”I can’t believe its not butter!”. I am not particularly surprised to find 4 more tubs of ”I can’t believe its not butter!” in the bread bin. It is difficult for me to resist saying to the physio, ”you just won’t believe what’s in the bread bin!”………..and then we both get uncontrollable giggles and have to pull ourselves together.

For my part, I have  to examine both these people. I feel strongly that I am invading their privacy and threatening their independence. I am a total stranger who has  walked into their house. Not only have I wandered around inspecting their personal space, but I then have to lower soiled knickers, lift night dresses, remove damp socks, check them from head to toe for pressure sores and other wounds or injurys. I have to prick fingers for blood sugars as well as take blood from the vein of one sister.

Thermometers in ears, cuffs on arms, fingers on pulses. I have to discuss their bladder and bowels with them and their diet. I have to snoop around for their tablets. I have to quiz them on their family, their friends, their shopping habits, their money. WHO is doing the shopping? I feel like Big Brother. They are so obliging and courteous, which makes me feel worse. The system (which I feel is in itself a ‘creaking gate’) is infiltrating this household and is removing their protective facade.

The three of us, with the social worker and the GP have to try and create some order out of this chaos. We divvy up the spoils and my list, scrawled in the corner of my diary page, includes the following: Order a commode/order pressure relieving equipment/speak to the GP and practice nurse about diabetes/ arrange blister packs for tablets with the chemist/order dressings for various wounds/ speak to GP about bowel medicine/try to obtain a urine specimen/incident report on Grade 2 pressure sore/speak to GP about mental health assessment/ write care plans for each problem…..(so far that is 6 care plans, as well as a file of notes, including 14 page complex assessments  for both women)/try to ascertain consent for all this, depending on the couple’s mental capacity. Clearly they are not eating well at all, unless the constituents of ”I.C.B.I.N.B’! are especially nourishing. They certainly are not washing. The cat, however, is doing pretty well all things considered. No care plan for the cat.

In the absence of family or any other support network, social services and the NHS have to do their best with dire resources to keep this couple and their cat healthy and safe. Ideally we want to keep them together. We have to try and keep them in their own home in the village where, it appears,  they have lived for many years. The social worker is pretty much doing her nut trying to get an agency, any agency to provide carers to come into this house at least twice a day. The ‘crisis community care team’ is at full stretch and cannot provide care until after the weekend.

There are no beds in any local homes, and even if there were, the pair have made it very clear that they ‘are absolutely fine’ and want to stay put, thankyou very much. Good on them, but nightmare for us. This sort of visit can be really satisfying. In fact if I had no other patients to see in the day I would thoroughly enjoy getting my teeth into this situation and sorting it out from stem to stern. However the reality is that I still have a list of wounds, injections and dying patients to get to and so all the hard work and documentation that is necessary to organise this ‘mess’ will be done well after my shift has finished, or (for Gods Sake don’t tell), at my kitchen table in the evening.

Fast forward one month: A carer visits the two women twice a day (√), they are spotlessly clean (√), the house is clean (√), the cat is still alive (BIG √), there are fewer tubs of ”I.C.B.I.N.B’! in the fridge and some normal food (√), there is a commode in the bedroom (√) and………. grab rails and perching stools and bed rails and pressure relieving mattresses and cushions and  pendant alarms and blood sugar machines and super duper District Nursing care plans and alcohol hand gel and gloves and dressing packs and wound dressings (√√√√√√√√)….in fact its a little like a hospital ward, except that its not. It is the sister’s lovely home and they have not become what we call ‘revolving door’ admissions to a District General Hospital. It has taken time and a great deal of hassle for a great number of professionals, but the health service and Social Services have untangled total chaos and helped to create a stable, safe and, I would say, a happy household.

My World is a Leg Ulcer

Warning: This is a long Post.

Apologies but I just couldn’t reduce my word count.

NB Its a great deal shorter to read than the time I take to dress and bandage a leg ulcer, so bear with me.

I sometimes wonder how much of my week is spent sitting on the floor on my bottom, legs wide apart to accommodate another pair of legs, the knees of which are at my eye level. I would kneel if I could but it buggers up my knees.

Have you got an image of this in your head?

I reckon that District Nurses spend more time dwelling on life below the knees than any other group of health professionals. Except possibly for podiatrists.

The reason for this concentration on the lower body is that the majority of our patients are not as mobile as they used to be. If it were not for the declining mobility of the ageing human being, our caseload would probably be reduced by about 75%. Reduced mobility feeds District Nurses with pressure ulcers, chest infections, constipation, urinary tract infections and leg ulcers.

The causes of these leg ulcers are many and varied. Having boldly stated above that walking less is a common factor for ulcers, it has to be said that there are plenty of mobile but limping younger people, (mostly men, who are paying the price for being motorbike petrol heads in their youth), now walking around in their middle age with stained, itchy skin around their ankles and little wounds that ‘just will not heal’.

Most leg ulcers fall into two groups: those that are venous (to do with your veins) in origin, and those that are arterial (to do with your arteries) in origin.

Nobody wants a leg ulcer, but if it is your lot to have one, then opt for the venous. Thankfully 90% of all ulcers in the UK are venous, and they affect 1:500 people in the UK. It is estimated that 1:50 people over 80 years old in the UK has one. These are NHS figures and they explain why I spend much of my working life on my bottom.

In the old days, when I was starting out on the district in London 30 years ago, the ulcers were appalling. You could smell the legs from the front door step. The walls of the house were impregnated by the smell of sodden bandages. The carpets beneath the chairs where the patient’s sat all day were saturated with serous fluid that had soaked in over the months. Occasionally (great excitement) we found maggots. You can imagine that in this sort of environment these people had lost all but the most tolerant and loyal of friends. They often became isolated and despairing. Most of them, however were stoic, this being the generation that had been born at the end of the 19th and the beginning of the 20th century and so therefore assumed that this was their lot and you just did not make a fuss.

And then Christine Moffatt came along and began to change all that. She is now Christine Moffat CBE FRCN PhD MA RGN DN, ( I like the DN stuck on the end). She started us all using compression bandaging for venous ulcers. By squeezing the leg using graduated compression to the lower limb, we improved the venous return to the heart and we reduced the oedema (the swelling) to the leg, and the ulcers started to heal.

Ulcers are still an unpleasant cross to bear, but they are largely manageable and often curable.

So, we run a leg ulcer clinic pretty much every afternoon at our base. We also see people with ulcers throughout the day in their own homes. Ulcers literally dominate our day.

Ulcers can be nothing more that a little wound on an ankle that persistently will not heal, or they can be circumferential  (pretty much enveloping a lower leg), raw, leaking, smelling and above all extremely painful wounds that cause a great deal of angst and ultimately can make someone feel pretty depressed.

The good news is that we can usually improve or heal the venous ulcers. Even the arterial ulcers, with the help of the Vascular Team at the hospital stand a fighting chance these days.

We diagnose which kind of ulcer we are looking at by using our ears, eyes and hands. The patient’s story is really important, and usually by the time we have listened to the story we can have a pretty good stab at making a decision about what sort of ulcer this is.

For example, if a patient said:

‘’Well Nurse, I have had varicose veins all my life and I fractured my hip last year and my feet do swell so’’, then it might be safe to start wandering down the venous road.

If, however the patient said:

‘’I can’t put up with this any longer! The pain is excruciating, especially at night. I have to sleep in my chair most of the night, I can’t have my leg up! For gods sake do something!….Oh, and by the way I am diabetic’’, then we would start wandering down the arterial road, which really means patching up the wound as best as we can and getting them referred to the vascular team.

We also feel the temperature of the foot and leg and look really carefully at the ulcer itself. If we feel foot pulses we feel particularly happy. And then we use a very useful piece of kit called a Doppler machine. This measures the blood pressure in the arms and the legs. If the blood pressure in the legs is the same as, or greater than that in the arms, all well and good……your ulcer is possibly/probably venous.

But if the pressure in the legs is less than the pressure in the arms, well then, the arterial blood is just probably not getting all the way to the lower leg and toes, and we can surmise that the ulcer may be arterial in origin. Oh, and if they are diabetic we are especially wary.

So that is the extremely brief whistle stop tour of the diagnosis. The reality is that these people have had enough. They are sick of the pain. They are sick of the smell. They are sick of fluid trickling down their legs into their shoes and slippers. They are sick of not being able to leave their house.

So, if the diagnosis allows us to, we put them into compression bandaging, thanks to Christine Moffatt, see above.

It is hard work. First of all, these legs really benefit from a lovely soak in warm, deep  water with an added emollient in an oval shaped, refuse sac lined floor cleaning bucket. These are heavy. We then slap on lots of moisturising cream. Each wound then has to be measured and regularly photographed. The appropriate dressing, evidence based of course, is chosen and applied. Then the bandaging is applied: either 2 layer or 4 layer (we have different bandaging systems). Some patients have 4 layers to each leg. That is 8 bandages in total.

Whilst bandaging, it is a fact that I am sometimes losing the will to live as I rock back and forth, arms wide, getting the correct tension as I make my way up the leg. I wait for the predictable ‘’NOT TOO TIGHT!!’’ as I get to the ankle, which I ignore and mouth set in a tight, thin line I grimly continue to the knee.

These days, I am not sure who is the slower and creakier getting to their feet after this procedure, the patient or myself. It will in all likelihood, be what eventually necessitates me giving up my job, because I am no longer the supple young thing who used to spring up and down from the floor. Some afternoons I am so immobile myself after all the bandaging that I reckon that I am more in danger of an ulcer than the patient.

There does usually, however, come a day when we say:

‘’Do you know Doris, I think we can safely say that this wound is healed. We can put you into compression stockings now’’.

A moment of stunned silence. Is it almost regret?

The feelings are certainly dominantly happy. No more thick bandaging, meaning that Doris can return to normal shoes without stuffing feet into NHS black, velcro boots. The pain has gone, the leaky legs have gone, the smell has gone, but so too will the regular chirpy banter with our team go. We get to know Doris’s and Alfred’s very well over a period of months, not to say years, and maybe it is inevitable they almost grieve for the rather unconventional social life that it has given them.

For me, however, the best bit is producing the gory photo taken on Day one, back in the mists of time, and comparing it to this beautifully shaped, well moisturised, intact leg and saying:

‘’Look, Doris. This was taken on the first day that we met you’’

And her saying:

‘’Ugghhh! It was revolting!’’

It may seem rather insignificant to heal a leg ulcer but it is tremendously satisfying. It would be interesting to add up how many nursing hours it took to do so. It would be equally interesting, yet worrying, to see how all those nurse’s knees and backs are faring in 20 years time.

Clean as a whistle

 

Presently I am mentoring a 2nd year student nurse.

To improve her clinical skills, we simulated a wound dressing change on my knee.

Aseptic (sterile) Technique  -the procedure that medical  staff use to prevent the spread of infection,  is pretty much the  most important nut to crack in the clinical skills tool box. You may as well pack up your black lace ups and go home if you can’t get this right.

It’s the principals that you need to get wedged into your brain, rather than the mechanics of the specific job. If you can do your utmost to keep the patient’s environment free from contamination then theoretically you could perform a sterile dressing in a sewer if necessary.  Possibly.

District Nurses have a tendency to be rather smug about the Aseptic Technique practiced by nurses on hospital wards. The total luxury of having a dressing trolley on wheels, which you gracefully spray and clean in smooth left to right strokes so that it gleams in the light from the perfectly poised lamp fixed above the bed. The dressing pack that you spread out on the top of the trolley and that you can access so easily from the bed (raised to the perfect height) that the patient is lying on. The ‘Arc of easy reach’ within which your scissors, probes, primary and secondary dressings lie.

Aseptic technique is used for most clinical procedures. One such procedure is urethral catheterisation into a bladder. Clearly, the procedure has to be aseptic to prevent the introduction of bacteria into the lovely warm and wet environment of the bladder.

You have to be careful when performing a male catheterisation, as you are pushing the wobbly rubber catheter tube through a long pipe (the urethra), and on the way you have to negotiate the prostate gland, which you really do not want to aggravate. Apart from this, however, the way is clear. You only have the choice of one entrance.

Female catheterisation is, in my opinion, a very different and more difficult kettle of fish.

For a start there are three entrances to choose from. It is rare to mistake the anus for a urethra, (always a first time), but it is relatively easy to catheterise a vagina accidentally. I’ve done it. On more than one occasion. The female anatomy appears increasingly less well defined as we age, and frankly what you see down there in poor light can be confusing.

We had a patient a few years ago now, whose re-catheterisation was a challenge to say the least. She lived in a really filthy environment. She had 7 or 8 cats and kittens. She was a chain-smoker. Hand washing in this patient’s bathroom basin and drying with her ‘once white, now brown’ towel was simply not a viable option unless you wanted your hands to be dirtier after than they had been before. Oh, how we love Alcohol gel.

Filled with trepidation and pessimism, I would weave my way in and around all of the well-used cat litter trays and arrive at the low squidgy sofa, where this woman spent her day. On my knees and using the bedside light with tasselled shade, tipped on its side and hopelessly aimed between the patient’s legs, I would open my dressing pack on the grubby, shaky stool beside the bed. I am sure that a risk assessment at this point, particularly for fire, was necessary but we used to skip that bit.

Squinting between two great white thighs, pinching my sterile rubber catheter in the fingers of my right hand, whilst trying with my other hand to locate the correct Hole in 3, I would take the plunge. Frequently, a cat or kitten would stroll across the sterile field and or even curl up on it and start purring. Occasionally they might even start doing that kneading, pawing, clawing thing that cats do on a carpet, but on my STERILE field instead. It is a miracle that those catheters entered this particular bladder without a trace of cat hair, cat drool or worse on the tips.

In the meantime the patient would shout, and I mean shout; ‘’IS IT IN YET?!’’ whilst I was virtually on the sofa with her, poised like a snooker player pointing the cue at the corner pocket.

I cannot describe the relief of seeing the golden urine coming down the tube and into the bag, confirming that the catheter was in the right place. I couldn’t inflate the catheter balloon quickly enough, to ensure that it could not fall out. Hallelujah. The patient, bless her, never shared my or my colleague’s anxiety about this procedure. She had a faith in us, which always eventually it seemed, was well founded. We always parted on very good terms, myself: slightly euphoric, her: quietly amused. Both of us mightily relieved.

The relief at knowing, God willing that I would not have to face that for another 10 weeks. The possibility that it might be my day off next time and it would be the turn of one of my colleagues.  The light footedness with which I would dance out to my car and breath in fresh air, free of the stench of cat shit and nicotine.

At these times, I would dream of a beautiful, shiny, gliding dressing trolley parked beside a gleaming sink with hot water, soap and clean hand towels.