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Sunday, February 27, 2011

A Day at Hospice House - Part Two

This is a continuation of a piece I posted last week. To read the first one, click here.

I scoot over to room 406, and, indeed, my patient is squirming around in bed and picking at the air and his bedclothes. He denies pain but appears delirious. Judging that it is not due to his morphine drip, which he has been on at a relatively low dose for several days and knowing it is too early to give him more lorazepam (Ativan) without a chat with the doctor, it’s time for another approach. Since the morphine and lorazepam did little to calm him, I opt for a dose of haloperidol (Haldol).

Then it’s off the the medication room, where I draw up 0.5 milligrams of haloperidol, dilute it in 10 milliliters of normal saline and grab some more saline to irrigate his subcutaneous infusion site before and after I give the drug. Another nurse is ahead of me, so ten minutes drag by before I can prepare my medication. (Our med room is way too small).

Back in the room, I deliver the medication, flush the infusion site, assure my patient’s son that I will return in 10 to 15 minutes to see what results we get from the new drug.

Suddenly it is 8:30, and I have another patient to assess. She is 72 years old and is in Room 412. She is dying of pancreatic cancer and controlling her pain has been a challenge. Not a large woman by any means, her hydromorphone (Dilaudid) drip has been titrated up to 2mgs per hour, and she is still uncomfortable. I also notice that she has developed end of life respiratory secretions and is beginning to have the dreaded death rattle that some patients have. Again, I table the physical assessment and seek relief for my patient. She can have a bolus (extra dose) of medication, and I push firmly on the top of her medication pump and 2 mgs of hydromorphone is delivered through her intravenous catheter. I can also titrate her drip to 2.5 mgs, and I do that as soon as the bolus has been delivered. Her pain eases, but the secretions are still a problem. I check her chart and see that she has not had any medication for secretions, so I go back to the med room and and draw up 0.2 mgs of glycopyrrolate. I administer the medication by IV push. I reassure her and he family that I will return to reassess her pain shortly.

I dash back to 406 to find a sleeping patient and tiptoe out of the room.

On my way back to Room 412, I stick my head into 411 and find that the patient is having more prolonged periods of apnea and her feet, legs and hands are mottled. Mottling is an irregular arrangement of spots or patches of color on the skin that often looks like brusing and which heralds the end of life. However, some patients stay mottled for several days before passing on, and some patients never mottle. So, I sit with the patient’s husband. He wants to know if it is time to call his family to come see her before she dies. Advise him that it would be a good idea to call them, explaining that I would rather have a false alarm than face a situation when family members and friends were not able to see his wife before she dies. As he pulls his cell phone out of his pocket, I step across the hall to Room 412.

I glance at my watch. It is already 9:30. Two and a half hours have gone by, and all I have done is basically put our fires. I find my patient breathing easier and sleeping. Another assessment to do......click here for the next installment

© cj Schlottman

Sunday, February 20, 2011

A Day At Hospice House

Disclaimer: This series in no way represents real patients. It is a compilation of many different patients and many different situations. Any resemblance to actual patients is purely coincidental. There is no such thing as a typical day in hospice care. Some are busier than others and each individual patient has his or her own special needs.

My eyes flap open at 4:43 AM, two minutes before my alarm clock beeps to wake me. It happens every work day, but I am convinced that if I were to fail to set the clock, I would somehow oversleep. It’s just another crutch in my life.

Honey, my Lhasa Apso, begins to lick my face, and Belle, her buddy the Boxer, walks around to my side of the bed and pushes her nose onto the bed next to my arm, demanding that I pet her, too. There is no resisting either of them, so I haul myself up on the side of the bed and turn off the clock.

The three of us shuffle through the house to the door to the deck and back yard, and off they go, returning quickly, knowing that a dog bone is be ready for both of them. I snap a pod into the coffee maker and eagerly push the pulsing blue “brew” button.

I take my coffee out onto the deck and when the weather is cold, light the propane heater. It has been cold a lot lately. I sit, check my e-mails and texts on my Blackberry, smoke (No, I haven’t completely quit yet), and in general, wake up. I simply cannot wake up and jump into my scrubs and rush out the door. I need the waking up time to center myself. Sometimes I practice a short yoga program to further ground me.

At 6:15, having kenneled the dogs in their playpen, I leave for work. It is dark, not trace of light yet in my neighborhood. I arrive at work at 6:30, 15 minutes early, so I can get some coffee and organize myself for the day. I retrieve my stethoscope from my locker, get out several of the report sheets I have designed for myself, and at 6:45, I clock in and get report from the night nurses.

There are three of us nurses here today, and we have nine patients, so we each take three, trying always to have the ones we had the day before.

As soon as report is over, I make what I call “sneak a peek” rounds on my patients. I check to make sure they are sleeping or at least comfortable if awake. Then I check their charts for new orders and take their medication records out of their notebook and put them in mine. That is when my day begins in earnest.

I begin with physical assessments. Today, I find that the patient, in room 406 (lung cancer that has spread to his liver and lymph nodes) is awake and restless, a little agitated. He is only 58 years old and was a heavy smoker. So, the assessment goes on hold while I get some medication to soothe him and give him some peace. The medication does little to calm him, so I give him a bolus of morphine, which is delivered via a subcutaneous catheter in the skin around his belly button and connected to an electronic pump. He begins to doze. I continue the assessment and enter the data into our system using a computer in his room. He is sleeping when I leave the room.

The patient in 411 (end stage Alzheimer's) is still asleep, and I quietly do her assessment, finding that her respirations are slow, and that she is having episodes of apnea. The expression on her sleeping face peaceful, even childlike. Her husband, who spent the night on the daybed in her room, expresses his concerns about her condition. He is a devoted caregiver who is exhausted, with health issues of his own.

The phone on my hip vibrates. I reassure the husband, reminding him gently that her slow breaths are part of the process, and I walk out into the hall to answer my phone. I learn that the patient in 406 is once again restless and agitated. I check my watch. Only an hour has passed since I medicated him.

To be continued next week......click here.

© cj Schlottman

Saturday, February 12, 2011

Ennui - Again


What makes a writer avoid writing? For two days, I have been dodging my laptop, haven’t even checked my email or looked to see what Jenny Matlock is up for this week’s Saturday Centus. Thinking about writing a blog post to publish sets butterflies flapping around in my stomach.

Today, I have washed three loads of laundry, walked for an hour on the treadmill carrying a three pound weight in each hand, brushed the dog, attacked my bathroom with the Swiffer vac, washed my hair, picked up yard trash created by the recent winds. I turned on the TV and tuned to the PGA golf tournament at Pebble Beach. All this to avoid writing.

I used to watch golf tournaments with Clint on Saturday and Sunday afternoons. Now, doing so just makes me miss him more than usual, so I did some channel surfing to find something else to keep me company and found, well, nothing. There are dozens of channels to choose from, but I can’t get worked up over programs with names like Lobster Wars or Real Housewives of Atlanta or Cupcake Wars. College basketball holds no appeal for me. Nor does rugby. I finally settled on a tennis tournament, then realized it was a rerun from last year.

I’m certain I should be watching some news channel or other to stay current on the situation in Egypt, or what our congress is up to or how many people were killed today in Iraq and in other places all over the world, but I’m not up to that. So, I chose a music channel called Soundscapes. Clint used to call it the yoga music channel.

Ennui. I’ve written about it before. Trying too hard never solves anything, so, I’m going to stop trying to write and, instead, read some posts from the blogs I follow. Then maybe I'll do some yoga - or not.

© cj Schlottman

Sunday, February 6, 2011

First, Forgive Yourself

“Patients weep when they discover they are their own victimizers and not the victim of others. They weep when they discover they are responsible for their own suffering. As I expose an imaginative, subjective interpretation, their world changes according to their concept of it, their own vision.” Anaïs Nin - Diary of Anaïs Nin, Volume 2, 1934 - 1939

After much anxiety and weeping and self-doubt, I am here to put the story of the Man Friend to bed - forever. There is plenty of blame to go around, and like Nin’s “patients,” I have discovered my responsibility for my own suffering.

I did and said things I should not have done and said, I left unsaid things I should have said, I acted in ways that are anathema to my authentic self, and I am here to own up to it. I have not and will not reveal secrets. That, at least I can claim as a personal victory.

I take responsibility for not getting out of the relationship with the Man Friend last summer when it became obvious that he did not have my best interests at heart, that he was unable or unwilling to forgive me for my mistakes. I knew he was a heavy drinker, (which he admits) and I had been warned by others that he was capable of turning on me without provocation, but I simply did not believe them. I admit that I was so needy and lonely that I allowed him to hurt me on more than one occasion, then took him back. There. I said it. I was weak. I do not blame him for my weakness. I was needy. I do not blame him for my neediness. I’m not weak now. He unwittingly forced me to reach into myself and find the strength I forgot was there.

I have forgiven myself for my mistakes, and having learned valuable lessons about my own weakness and naiveté, as well as my strengths, this is my last post on that chapter of my life.

© cj Schlottman

Happy Birthday, Baby Brother

02/05/11 Saturday Night

Dear John,

You should be 56 today instead of dead, and I miss you as much now as I did when you died in 2000. You should be here to see Walker growing into a man and the artist he wants to be. You would be proud that he is at The University of Georgia, your alma mater. You should see his work and be here to help him along his path to self-discovery. No one knows better than you how hard it is for a young man to grow up without a father.

You should be here to deal with those teen issues that Lisa faces with Wil. You should hear him play his oboe and the the French horn and the piano. He’s in the Atlanta Symphony Orchestra as well as the All State Band. He’s driving!

You would be glad that I spent this afternoon at Zona Rosa. You, who wrote so completely from your heart, would be happy to see me working on doing that myself. You would like Rosemary.

It’s late and I’m spending the night with the Ducks, so I will finish this letter tomorrow. Now that everyone has settled in and I have the opportunity to write down my feelings, I’m too tired to do it. My eyes get so fatigued and my vision blurs after a long day. And yes, I know I am getting old.

Sunday Morning

Last night, after everyone got settled and the bird stopped squawking, I finally got to bed. I didn’t sleep well. Some personal problems that you don’t need to know about are eating away at me, but I will deal with them.

I keep thinking about the time we had together in Memphis during May, where we went three months before you died so you could have alternative treatment for your kidney cancer after the doctors said there was nothing left for them to do but call Hospice. I wish I had known about Hospice back then. I would have encouraged you to take advantage of it. Or maybe not. I didn’t believe you would actually die. I thought that if I wanted you to live, I could will you not to die. Denial is a great psychological defense mechanism, but you could have benefited from Hospice.

The doctor in Memphis put on you a diet that included calves’ brains, and I prepared them for you every morning, scrambling them into eggs. I even found a store where I could find them fresh instead of canned. You were the picture of determination as you forked every bite into your mouth. We went to a formulating pharmacy and bought all manner of supplements for you to take.

Those precious two weeks are so dear to me. We went to the Peabody Hotel twice to see their famous ducks march into the lobby while we had a drink. We went to see Erin Brockovich during its first run and both loved it. We strolled down to Beale street and rummaged through old record stores and both lamented the presence of a Hard Rock Cafe in the heart of Memphis. It just didn’t seem right, seeing it there in the middle of all that musical history.

You were so tired. I remember you being so very tired but determined to live. You napped often but always managed to drag yourself up to go and do something. The only thing we missed was going to Sun Records. I remember when you started to cough up blood and it scared me, the nurse, to death. The cancer was in your lungs and even in your heart, yet you kept going, pushing yourself to go to museums and movies.

We slept together in a king sized bed in one of those hotels that offers a continental breakfast and some sort of packaged supper every night. To save money, we mostly ate there. Those days will forever live in my heart, so scarred now with loss.

Just before Reggie arrived to spend the third week with you, Clint flew in to take me home, and the three of us went to Graceland. I remember how it wore you out, how determined you were to stay on your feet long enough to complete the tour. We even took time to shop for silly souvenirs.

You stayed in Memphis for one more week of treatment during which, you were basically heated up in an effort to kill some of the cancer cells. In late July, you and Lisa and the boys came to see us on Saint Simons. You were actually stronger after your treatments, and I believe they bought you some extra time. Three weeks before you died of pneumonia, you dragged your kayak down the dock and put it in the creek for what none of us knew would be your final ride in it. Determined and stubborn, you refused help from any of us, either getting the boat to the creek or hauling it back up the dock.

You died living, not dying, and for that I am grateful. My only regret is that, when Lisa called me at our friend’s house in North Carolina and told me you had pneumonia and were going on a ventilator, I didn’t leave that minute to be by your side. Since it was already 9:00 PM, and we were in the mountains, I decided to wait until morning. Lisa called me at 2:30 AM to say your heart had stopped beating.

You never admitted to me that you were dying. You talked to Mama and Paul and Lisa about it, but, in your way, you tried to protect me from it. I think you did the right thing. I would not have had believed you, anyway.

Happy Birthday, Baby Brother. Losing you was like losing a child. I don’t have to remind you that, when you were two months old and Daddy died, Mama gave you to me. As long as you lived, I always felt responsible for you and always did everything I could to make your life better. But I couldn’t save your life. I couldn’t make you live, no matter how hard I tried.

I love you, Claudia

© cj Schlottman

Copy editing by Addie Duck

Tuesday, February 1, 2011

Happy Birthday


Happy Birthday, My Darling,

You should be 77 today instead of dead. There are no words to express how I miss you, your touch, your warmth, the way you cherished me, the way you made love to me, the way you sneaked up on me to kiss the back of my neck.

I spent 12 hours at work today, and every time I turned around, I was writing the date on one form or another, constant reminders of the fact that you are gone forever. You would have been proud of me, though, the way I threaded that INT into that old lady’s vein without making her cry. Up until today, I have been able to make the vein but not thread the catheter. It was a tremendous ego boost for me. You probably know that I looked to the sky and said, “Happy Birthday, Poppy,” when I finished dressing the site. It’s hard to believe that I am having to relearn skills at which I was so sharp in years past.

Your last birthday, when you turned 75, we had a party for you with a cake with your picture on it and balloons and confetti, and you got down out of your wheelchair and played with the twins on floor. The others wondered if you would be able to get back up into your chair, but I never had a moment’s doubt. You were a strong willed and stubborn old coot, and I knew we could get you up.

Oh, you should see Abbey and Drew now. They are like two weed eaters buzzing around and leaving destruction in their wake. Shannon handles them so well. You would be so proud of her and the life she is making with her family.

The last year and a half has been the longest and most painful time of my life. No therapy or medication can take from me this emptiness, this sense of being so alone. Work helps, but when it is over, you are still gone and I am still alone.

My social life is pretty much shot, but I don’t want to go into that. You don’t need to know everything. Just know that I have been injured and that I am recovering quickly. I take great strength from my memories of you. I will fix my social life when I am ready.

Under Rosemary’s excellent tutelage,I am writing better poetry these days and there is comfort is that. Sadly, many of my pieces are based on my pain from losing you. I find it hard to write about anything happy or beautiful Maybe one day I will be inspired by a flower or a tree or a smiling baby, that that day will be long in arriving, I fear.

For now, most of what I feel is still tender and sore. I do miss you so very much, so very deeply. I am straining to write this, feeling as though there is nothing to say. So, I’ll just say “Happy Birthday.”

I will love you forever,
Your Fat Girl