Scenario 3: Never Assume!
….. It’s the end of the day and you’re headed to see your last patient who is a new admission. You’re tired and very relieved, as the directions to the home are easy, peasy and the referral which you skimmed this morning didn’t look so bad. Praise Jesus, or whoever you praise… You pull up to the home and sit in your car a bit, now reading the paperwork thoroughly. It appears to be just a dressing change to a small wound from a cat scratch to the patient’s right foot. The patient was seen at her PCP office a few days ago and she has no real significant past medical history to speak of. Less documenting… Yay! It is noted that the patient is alert and oriented, lives alone, and is very independent….. AND…… Wait for it…….. She only takes a baby aspirin daily! You have just struck admission gold you lucky dog. What a great way to end the day, you think to yourself, smiling from ear to ear as you grab your nursing bag and start happily climbing the stairs up to the house two at a time, with a pep in your step because it looks like you will be out of here in no time. Cha-Ching!
And….. Then you woke up from the dream that you were having. How could you be so naive? What is this, amateur hour? You know better than this!
Ding Dong… It’s the visiting nurse, you say as you pop your head in the door. “Come in,” a voice calls out from inside, along with a coughing, hacking, convulsing type of fit. You become a bit nervous now as this doesn’t sound very good. Opening the door wider, you walk in and loudly (always loudly) start to say, are you ok, but the words can barely escape your lips. You are completely overcome with a cloud of cigarette smoke so thick, that you can barely see in front of you. Your eyes start tearing and burning out of their sockets as you drop your nursing bag to the floor overwhelmed by the smell and slightly start becoming disoriented. You are completely overtaken by the smoke and are about to turn around and run to escape it… But then you hear, “Over here sweetie,” from the back of the home, along with a few more coughs and gasps. You blink a few times to see if your eyes have become acclimated to the environment, they haven’t. You could just leave and say no one was home right? I mean you have a right to life, a right to survive for god’s sake. It’s only natural to want to breathe! But you’re morality and the whole reason you got into this damned profession kicks in and you realize that you can’t leave because you’re a nurse and you care…. Or maybe you used to care, or you supposedly care. You have questioned this caring thing on occasion. But you do not have any time to debate this! The longer you’re here the less likely of your survival. You envision a giant ash tray in the back of the house with 5000 butts burning in it. I mean, who can smoke this much? You think to yourself. You remember you’re the nurse and cannot discriminate (I made a funny there). At least it can’t appear that you’re discriminating, and Joe Camel needs care to, you suppose.
I’m coming, you yell, now coughing and gasping yourself. You grab your bag off the floor and open the front door, stick your head out and take a giant breath. I’m going in, you say to yourself. God, why can’t anything be easy, you maddeningly think, as you start to blindly make your way to the back of the home. On your way, you hear a familiar hum and spot what looks like an oxygen concentrator (obviously Joe Camel is on O2) in the hallway and feel for the tubing. Maybe we will blow up today too…. Perfect ending to a perfect day, you say to yourself.
How anyone is surviving in this atmosphere is beyond anything explainable. It seems often in home care all that we have learned about the human body is tested. It consistently defies everything we have been taught.
Hello, you say again, continuing to follow the tubing to a closed door. Your make up is running down your face. You can feel it. You already have a noticeable wheeze and your breathing is becoming more intense and labored.
Instant emphysema….. Defying medicine daily.
Panic starts to set in. I’m going to die here, you think. “I’m in the bedroom sweetie.” the voice croaks with more coughing… You feel the door knob and hurriedly open it. You can see the outline of what you think is a person, in what appears to be a chair, seemingly right in front of you, but you’re not quite sure. The gray, sickly color of the smoke is almost the same color as the gray, sickly (possible) person in the chair. You then see the red end of a burning cigarette coming from the smoke cloud and obviously smoke isn’t smoking itself…… Or is it? Maybe you’re O2 Sat is so low that you hallucinating. You slap your cheeks and assume that this must be your patient smoking in the smoke and then let out the only two words you can now barely manage to muster as you are taking your last breaths on this planet and your organs are beginning to shut down…….. Open window, you say to the cigarette, gasping, as you start to bargain with God for another chance at life. “OK sweetie, open a window.” the cigarette says appearing suspended in air while moving slightly in-between coughs. You scan the room and see what appears to be a window. You assume this because the dripping color of yellow in this small square area is a bit brighter than the darker, runny stained yellow covering the rest of the room. You feel around and fling it open while simultaneously falling to your knees and then slamming your face against the screen, taking a few giant breaths. Smoke pours out of the room and the air begins to clear. You slowly become alive again. A few minutes later, and still on your knees, you cough out the last cough you can manage without a lung collapse and stick your hand out towards the patient, which you can now see is a little old lady; a little yellow, gray, leather shoe looking lady, but a lady none-the-less. Hello….. I am the visiting nurse, you say pulling your face away from the screen. Let’s talk about oxygen safety first, shall we….. cough, cough.
Scenario 5: You Can’t Always Believe What You Read…
The smoke has cleared a bit and you survived…. For now. You pull up a chair next to your patient and begin your assessment as you cannot get done with this day fast enough. So, you have a little foot wound from your cat I see, you start to say to your patient while looking down at her…… Oh my God! You shout, looking at what was once a leg…. maybe. Apparently, this patient’s cat is a ferocious tiger monster. The leg, (if that’s what you want to call it or half eaten, tiger mauled raw hamburger appendage) has +100 pitting edema and looks as red as the burning cigarette tip in the ash tray next to the patient. Her dressing is obviously on the floor and looking closer, it appears the tiger has been rubbing against the leg all day as the wound bed is covered with a thick layer of orange fur. The serous drainage is spilling over the threshold of the room into the hallway which you just walked through (note to self: burn shoes). This looks pretty bad, you say to your patient as you look around nervously for the tiger monster. Did your doctor give you anything to take for this when you saw him the other day? you ask. “Nope,” your patient states. “Not that I remember, and I am not going to the hospital!”
Of course, you’re not, you think to yourself. Life could never be that easy.
So…. What can you do? You call the PCP and after getting disconnected and being placed on hold for 20 minutes, then getting transferred to three different people and explaining the situation each time to each one of them, you are told you will get a call back, which you know that you never will. Or you may get the call next week. Little old leather lady doesn’t have a week. You then go on to change your patients dressing as ordered, but that then took much longer than expected because the monster tiger cat appeared and walked all over your sterile field (I use that term very, very loosely and laugh out loud as I write it). The beast then went on to take the last rolled gauze you have and is chewing it in the corner while giving you a death stare. You leave the monster be because, well, obviously you saw what it did to the leg that you’re wrapping now with a make shift rolled gauze of 4×4’s you McGyvered together with tape.
You complete the wound care (if that’s what you call it) along with vital signs and the rest of your head to flaming red, draining, ouchity, ouch, ouch, tree trunk with toes assessment. There were a few issues along the way, like when you asked to see the patient walk, because well, she doesn’t. And bathing….no dice there. What about toileting? Yup, sure, if you consider the recliner she is a fixated to a toilet.
Essentially, your patient sits in a chair all day refusing to go to the hospital dying a slow death, while her cat uses her as a scratching post and is happy to be there instead of the ED down the street. This description will be the start of your clinical note and you will find the start of quite possibly many of your clinical notes over your home care career.
Now the last part, as we save the best for last…… Let’s talk about your medications, you say, sounding hopeful. You’re in the home stretch. You just need the doc to call back sometime this century and next review her meds and how she takes them. You take a big gulp and say, the referral states you only take a baby aspirin, and well, you also have the oxygen……. while holding your breath awaiting a response. There is a long pause and you start to plead with God in your brain to let this be true… pretty, pretty, pretty please. Your patient smiles and points to a table across the room. “My meds are in there” she states. You look across the room to where she is pointing and notice a giant storage bin that in black sharpie has the words CHRISTMAS DECORATIONS on it crossed out and underneath is the word, MOM’S MEDS. You walk over slowly not wanting to lift the cover but you have to. It’s your job, damn it, you tell yourself, psyching yourself up. Maybe there is just a little bottle of 81mg aspirin at the bottom all by its lonesome self just rolling around right?
And then again, you woke up………..
Don’t get me wrong… you do sometimes get that, Golden Admission. But in home care, you have many challenges and need to improvise from time to time. My real point is that you cannot always trust what you read. It can be a very different picture in someones home. Sometimes it’s pretty and sometimes it ain’t.