Dementia Wins By A Landslide !

I worked in various nursing homes during the years I worked as an RN, starting in 1985.  I worked as a ‘floor’ nurse, charge nurse, supervisor, and administrative (desk) nurse.  Nursing homes really are quite delightful places to work, and while nursing home nurses are often looked down upon by hospital nurses (I’ve done that kind of nursing too), the skill set required is extensive.  They have to have a bit of knowledge about all medical specialties (except obstetrics, though one gentleman did scream that he was giving birth to a calf in an emergent situation…my guess is that most people in a 3-4 block area knew of his distress; his doc felt that Haldol was a good ‘post-partum’ drug… I don’t like Haldol for the elderly; it was designed for schizophrenics- but it did quiet him down).  There are the medical issues that put people in nursing homes to begin with, and then there are those folks with dementia who can be so totally heartbreaking to watch…or a source of some humor. If we didn’t chuckle, we’d weep.  The following are from some decades ago… some of the rules were a bit ‘different’ back then, though nobody ever did anything to make the situation worse.

One woman I remember was very distinguished in her outward appearance. She was always ‘put together’ in how she dressed and in her appropriate greetings of people she met in the halls, but had no clue about hygiene or changing her clothes regularly.  Usually the certified nursing assistants (CNAs) could get almost every resident into the shower without too much hassle, but this lady was persistent in her refusal.  Nursing home residents have the right to be sloppy…when they are coherent enough to know the risk/benefit of their decisions.  When a green cloud follows them, and people fall like dominoes in their wake, something has to be done.  That’s when the administrative nurses have to jump in and figure something out.

The first thing to do was notify the family and get their permission to bathe Mrs. Cloud, even if she refused. They were the legal guardians since she couldn’t make decisions, so that wasn’t hard- they were thankful we were looking out for her (they were also out of town, so couldn’t be ‘hands-on’). The next thing to do was to figure out a plan.  The assistant director of nurses (ADON) and I were the ones who somehow got blessed with this task assignment, and thought we had a pretty good idea of how to get the job done. We got Mrs. Cloud into her private room, and carried on some generic, though tangential conversations as we got her overcoat off, and then talked about getting her clothes washed (that was usually less threatening than actually talking about showers up front).  OY.  We got the coat. We were doing pretty well with the dress, but getting down to her slip, and undies, we noticed that she had about 4 pairs of caked-on pantyhose. Each of those pantyhose required getting Mrs. Cloud back on her bed, ‘scootching’ the hose down, and then removing them…. x 4. Between each ‘scootch’, she’d bolt up and try to run off, so we’d have to get her seated again, then lying back on the bed so we could continue ‘scootching’.   The ADON and I were sweating by the time that was over.  The slip, bra, and undies were a piece of cake after the pantyhose circus.

So, we get Mrs. Cloud into her shower- after all, if we’re going to clean her clothes, why not get a nice warm shower (sounded like a good line)… she wasn’t happy, but went for it. We had the towels and washcloths ready. But…. oops. I forgot the body wash.  The  poor ADON was left wrangling Mrs. Cloud in the shower as I sped out of the room to find body wash.  I found what we needed, and we finished the shower from hell with no casualties.  A few minutes later, I saw Mrs. Cloud in the hallway, all fresh and sans cloud-o-funk, and she greeted me as if she’d never seen me before- very polite with a superficial smile. She remembered nothing. Crickets.

I also worked ‘the floor’ at night for a while.  One night, another confused little lady was wandering in a sort of frenzy, and was visibly tired. She had a sleeping pill ordered, so I offered her one. She wouldn’t take it.  I opened up the capsule, and mixed it with a tablespoon of orange juice in a one ounce plastic ‘shot glass’ medicine cup. I offered her a little nightcap, and she was so happy to take it.  I had poured some plain orange juice to get rid of any funky taste in her mouth, and she looked at me- dead serious- and said “Oh, Honey- I can only have one”.  She traipsed off to bed and finally got some sleep.

Another night, I was doing my routine work on the 11-7 shift, and one of the CNAs comes flying up the hallway off  one of the ‘pods’ (a grouping of rooms), calling my name as if she’d just witnessed Jack the Ripper field dressing a dozen deer in the back room.   I immediately went racing down to meet her, and follow her to the room in ‘distress’.  I stopped cold when I saw the elderly gentleman (also confused as all get out) sitting completely naked, bolt upright in his bed, grinning from ear to ear with his sheets and blankets all over the place. He was ‘splashing’ the gel from his gel mattress (as much as someone can splash something with the consistency of applesauce).  He had managed to puncture the mattress (used to protect skin), and had that gunk all over the place. It was hysterical.  I didn’t want to laugh at him, but it was hard to maintain anybody’s dignity at that moment. He was having a ball !  We got him cleaned up, and my only comment to the CNA was the need to differentiate between something that is life-threatening and something that is an inconvenience, but essentially harmless.  We didn’t need blood curdling screams in the middle of the night for a little  gunk on the floor (well, OK, it was a lot of gunk).

We also had a  hoarder.  The facility towels and washcloths, junk- didn’t matter. And she was possessive.  Anybody who went to clear out the stuff for laundry to rewash had to have someone else ‘stand lookout’, or the poor ‘lone’ retriever would be yelled at for a good 3-5 mintues, until the hoarder forgot why she was mad. One afternoon, one of the activity aides found a family of mice (mama and babies….LOTS of babies) living in a leftover popcorn bag (from movie and popcorn day), and a cake in a plastic bakery container that was so old that nobody could figure out the original flavor and/or color.

One of my favorite little ladies was superficially appropriate, but 2-3 minutes into a conversation there was no doubt that some bulbs were dimming. She was generally cheerful, and had a buddy she hung out with. She also was not fond of showers or combing her hair (think Einstein plugged in to a household outlet), but would let me check her skin weekly (per required protocols everyone got weekly skin checks- head to toe). The CNAs and I got into a routine of doing the skin checks in the shower room, and since I needed to see ALL of her skin, she’d agree for the CNAs to ‘hold’ her clothing…funny how the shower would get turned on, and she’d get nice and clean- she was always very agreeable once she felt the warm water. One day before getting showered, she walked past one of the mirrors, and saw herself. She literally gasped loudly and stepped back from her own reflection… she looked at me and asked about a hairbrush.  At least she still knew it was her own reflection- some lost that.

Nursing homes get bad reputations, but there are so many nice ones. I had the chance to work at two that I really liked, each for about 2.5 years.  The residents become like extended family, and some of their families also became part of the daily routine.  I’ve worked with CNAs who have been at the same facility for over 30 years…when offered promotions, they refused, not wanting to leave ‘their’ people. ❤  I’m incredibly thankful for the coworkers and residents I met when I was working at those facilities. 🙂

ROFL at Dementia…or Die Crying

My mom ended up with dementia as a result of radiation for brain cancer. She had the tumor surgically removed, but they wanted to zap the surrounding area a bit to make sure they nuked everything that might cause trouble later.  Seems nuking a brain doesn’t always go without issues.  I was 1200+ miles away, but saw her nearly every Christmas when she and dad came to visit me en route to their winters away from the Midwest. Sometimes the changes were very noticeable.  Mostly, I heard things over the phone; we talked often.

I remember a brief period of time when she knew she was starting to decline. That was terribly sad. She’d tell me “I don’t remember things as well anymore”.  She started labeling things, and even wrote her own obituary; she knew she wouldn’t be able  for much longer. It was heartbreaking. I’d been an RN for many years at that point.  I knew what was coming.  It didn’t really take that long for her memory to be unreliable for current things. She still remembered the past fairly well, so we talked about that.  I’d ask her questions about recent events now and then to assess where she was in the progression of the dementia. If I got too inquisitive, she’d ask to talk to the dog. Literally.  SO, I’d put the phone to the dog’s ear, and get the dog to ‘talk’. That would make mom happy.  She loved her ‘granddogger’.  She thought it was a riot when Hannah (dog) would howl if I said “woof”, or “bow wow”.  That was the cue for showtime. Mom loved that. And it got her out of answering my questions.  The dog was ‘safe’.

Mom went through the usual memory issues, and then her judgement got weird. Normally, before dementia, mom was very polite and had great manners- sometimes even a bit prissy. Not with dementia !  She was generally agreeable, but it was better not to tell her ahead of time if she was going to get out of the car on outings. For a long time, she preferred to sit in the car and wait for dad- doing word find games or reading when she still was able.  But then the dislike for doing anything unfamiliar started. On one Christmas trip to see me, we went to a nice little town known for their antiques, and a little town diner that had great bread pudding (I’m told; I hate the stuff).  SO, Dad and I got her into the wheelchair and got ready to move the chair up the three steps into the restaurant. Other patrons were immediately helping with the door, and before she could get too bent out of shape, she was sitting at the table.  If we would have told her ahead of time, there would have been all sorts of wailing and gnashing of teeth.

She was wheelchair bound except for a few steps, but would order the buffet at a restaurant… like the buffet fairy was going to whisk it tableside for her.  Dad went and got her what he figured she’d like, as many times as she wanted (she wasn’t a big eater, so it wasn’t more than one refill- usually of something starchy).  He and I, with our stable feet, would order the sit-down stuff.  But, mom would be happy.  He did all he could to make every day something that was as pleasant, and pleasing, as possible.  Her last years were one long, huge gift from him.  There weren’t many days when he didn’t at least get her out for a ride, even if just to some random place, and home again.  He didn’t let her just ‘sit’.

Dad took most things in stride. He’d been through a lot with mom, and figured they’d just get through whatever came along.  He called me one day in a moderate panic.  “I don’t know what I’m going to do with your mother”.  Uh oh. She was “MY mother”…. that couldn’t be good.  I asked him what was going on.  Seems that whenever a telemarketer called, she’d say “yes” to whatever they were peddling.  Anything.  Stuff started showing up on the doorstep that was baffling him.  When he asked her, somehow he got an answer that involved some “nice person on the phone”.  Oy.  I suggested unplugging the phone when he ran to the store, or some other brief outing. She couldn’t use the phone any longer, but he didn’t like that idea; he wanted to be able to call her. She wasn’t one to get up on her own, and wasn’t able to wander, so he could get out for up to a couple of hours if he popped in a movie, and helped her to the bathroom before he left; it was their system, and it worked for them.  Anyway, he ended up getting a Tele-Zapper, and calling the various vendors of the stuff that showed up; they were understanding and cancelled any subscriptions, and accepted returns of any items.

And don’t call her during a movie.  If dad had put a movie in for her before stepping out for a bit, and mom got a call, she’d say “I’m watching a movie. I can’t talk.”   Click.  Dial tone.  Manners?  Zippo.  It would be a movie she’d seen about a bazillion times, but it was all semi-new to her.  She especially liked “The Cutting Edge” skating movie.  I used to skate, and she took me to lessons.  The town they lived in was a big winter sports area, and skating had always been part of the local culture.  She used to sew costumes for local skaters when I was little.  She made my little skating skirts when I was four years old.

Thanksgiving often occurred repeatedly in June or July.  Instead of trying to force her memory into reality, Dad went looking for pumpkin pie.  It might take  3-4 stores, but he’d get it, and make her happy.  She’d be clueless a couple of hours later at most, but he didn’t ever want to be ‘mean’ to her.

One trip to some 5-star resort in the Phoenix area got a bit awkward.  After finishing lunch, dad went to wash his hands. When he got back to the table, the head waiter and some guy with a tray of chocolate and bottle of champagne were talking to mom.  What now? The head  guy then congratulated dad on his anniversary (this was in February; their anniversary was in August).  They left the chocolate and champagne (which mom couldn’t have with her seizure medication), and left.  He called me and asked me what he should have done; he didn’t want to embarrass mom.  I told him just don’t show up again at that place for another year. They’d already left the stuff at the table; it wasn’t usable for anyone else at that point.

When the seizures started, dad was dumbfounded at the weird behavior mom displayed. One night he called me all upset. “She’s speaking in tongues again” he half hollered.  Huh?  We’d all gone to the same church since I was a baby, and while they believed in tongues, it wasn’t a holy roller tongue-speaking crowd. Clapping was considered a rousing expression of appreciation.  (Swedes, ya know!). And ‘again’ meant she’d done this before.   He put her on the phone.  She was making NO sense.  He got back on the phone and said she was also taking her clothes off.  MY MOM?  Stripping for the heck of it?  Something was wrong.  I told him I thought she was having temporal lobe or frontal lobe seizures, and he needed to take her to the ER.  I didn’t know how long it would last, and with her history of the right frontal brain tumor, this needed to be checked.  So he got some friends to help load her in the car, and off they went. She was admitted, and started on seizure medication.  The ‘religious’ outbursts stopped.

The dementia progressed, and every Christmas I’d see the latest level of decline.  She could still talk, but her memory was shot.  She transposed past familiar places into the city we would be passing through.  “Where is the Talcott building?”.  Well, gee mom, about 1200 miles northeast of here…. but I couldn’t just say that; she still had feelings, and now and then would feel badly if she was ‘wrong’.

I had decided to move back home to help dad take care of her. He was so adamant about not putting her in a nursing home, even though she was a full-time job.  He wanted to be the one taking care of her.  I didn’t want him to be alone in that.  One of the last things I remember about her  was him calling me to come and “look at your mother”.  When I went upstairs and went to the bedroom where she was sitting in her favorite chair, I had to keep myself from cracking up.  She had put her wig on backwards, and it looked like a fuzzy ski jump hanging over her nose.  I asked her if she was coming or going. She said “It’s really on backwards? He’s not messing with me?”.  I assured her it was indeed on backwards.  She fixed it. Sort of.

They went on their planned 3-month trip to the Phoenix area for the winter. I was staying in their house as I got used to being back in my hometown (a big adjustment from the friendly South).  I had no idea what was going to transpire towards the end of that three month trip.  That’s for another post.  But I will always remember that dealing with dementia is a very difficult process.  Without some humor, it would be soul consuming.

I Miss Nursing, Really, I DO !!

When I was still working as a registered nurse, I don’t know how many times I heard, or how many times I said, “I wish I could retire NOW”.  I graduated in 1985 from an ADN program, and very soon after getting my license (we had to wait for snail mail back then) moved away from home to begin my career in a state/city 1200 miles from home.  I was so excited!

At first, I was the typical newbie. I was idealistic and knew just enough to not kill someone on purpose. That’s all nursing school teaches. It takes experience to make someone ‘good’, and that takes time and enough brain cells rubbing together to ignite a spark now and then.  Those first few years, I loved all of my patients, and everything they did was something to learn from.  The poop and puke, not so much, but I had a good gag reflex, and could smile through anything.  I didn’t even mind being elbow deep in someone’s butt sore if that’s what needed doing. And I was a supervisor’s dream- not married, no kids, and phone always turned on with no answering machine.  Yep. A huge target from the get-go; I’d pick up extra shifts, even at the last minute if I was home and answered the phone.

Then I grew up. Many things became decidedly less amusing.  The call-light jockey topped the list. When I found out that the spiel in nursing school about the call light meaning I didn’t ‘meet my patient’s needs well enough’ was a bunch of hooey, I learned to hate that thing. Some people are just so scared, or so regressed into the self-centric view of the world when they’re sick, that they need some sort of contact, a LOT.  I never minded the legitimate things patients needed, or even wanted.  But there was always some nitwit who had the audacity to complain about the brand of orange juice the hospital served.  Really?  And I can do WHAT exactly, at 2:00 a.m., about that particular life-threatening issue?  Maybe run out and grab a few nice juice oranges, and get to fresh squeezing them for ya? Eh?

Most patient families were very nice, and appreciative. They knew the real reason they were there- to support someone in getting well.  And then there were the invaders.  These are the families that send out messages to all known living relatives within a single day’s flight away that there’s free coffee in Junior’s room, and the nurses have nothing else to do but bring refills.  Though they do complain about the lack of service when there’s a Code Blue in the next bed. Go figure. Lack of pulse? Lack of coffee?  Tough call.  I’ll get back on that one.  But spell my name right if you’re going to take it to the supervisor, got it?  Thanks a bunch! 

 Doctors were another part of the equation. Most were great to work with, and knew if I was calling at 2:47 a.m. that it wasn’t to keep me awake;  something wasn’t good, and it couldn’t wait for 3 hours when he/she might start drifting in to do rounds.  I couldn’t just leave a note on the chart. One or two didn’t return my calls at all. That would make me so mad. Easy enough to fix that one- call the doctor he/she had ordered a consult from, and let them know that I knew  they weren’t the primary doc, but since he/she wasn’t returning my calls, did they want to do something about the guy having seizures who had never seized before? No? Well OK, just thought I’d ask.  That usually got the doc I really wanted to discuss the matter with to call back (after a brief call from their ‘real’ colleague)  apologizing for the phone upstairs not working right.  Uh huh.  Blame the phone. It worked when the other doctor called…

There was the one neurosurgeon who had a vast reputation as both a superior physician and world class asswipe.  One of his patients had the hiccups as a side effect of one of the IV meds we had to give them.  And every last doc but him would order a bit of a sedative to get rid of them; they’d go on for hours if nothing was done, and it was cruel and unnecessary.  But I had to call and report the hiccups anyway (even knowing the patient wouldn’t get anything to help) since  it was the patient who was miserable.  The asswipe doc told me there was nothing to do for hiccups but put a paper bag on someone’s head. SO, I wrote the telephone order, IN THE CHART, “Paper bag to head as needed for hiccups”, and signed/dated it.  He had to cosign that order. He’d given it.  He was still a jerk after that, but at least he’d address his patients’ needs a bit better.  This is when we all still used pen and paper charts.

This was about the time I learned to clean up diarrhea from one end of the bed to another, and then go on dinner break and eat chili. No problem.  In a pinch, I’d use a little kidney-shaped puke pan to warm up my Lean Cuisine Chicken Chow Mein…kinda looked like it belonged in there, to be honest. Made the docs nuts to see me in the back room with a fork in a puke pan.  But then they got to know me, and they were glad that’s all I’d dreamed up.  🙂

One of my  horror docs was a real genius who thought if he didn’t know about something that meant nobody would call and bug him about it. *rolling eyes*  Picture this:  a very sweet, but cash strapped guy who was diabetic, and could either get his diabetic meds OR the test strips to check his blood sugar. He wasn’t non-compliant for fun. He chose to get the medicine.  He ends up in the ER with some nutso blood sugar in the 600’s, and the ER gives enough insulin to get it to the mid-400’s (should be about 70-100 for the normal person- and I’d taken care of many diabetics who ended up permanently vegetative for ultra high or low blood sugars; nothing to joke around about. This guy wasn’t in that range, but I wanted to keep him there). The guy is awake, and with the program, so stable enough for the floor. OK, fine. The dude gets to the floor and I’m checking orders. Nothing for blood sugar checks after getting IV insulin, and still not in a normal (or tolerable) range. Lab isn’t due for several hours to check the regular blood work.  And I’m supposed to sit on this guy not knowing if he’s tanking, or has bounced high again after the insulin’s duration maxed out?  I don’t think so!  SO I call Dr. Genius, and ask about blood sugars since I’d checked one on admission to the floor, and it was still rocking in the 400’s (he was a bit irked that I’d checked it). There was no sliding scale insulin (the dose depends on the blood sugar, taken right before giving it), no orders to check the blood sugar (which would be standard), and the guy was still too high.  The MD I would never subject a corpse to responds “If I don’t know about it, I don’t have to fix it”.  *crickets*  I got nothing for that one (aside from an immediate call to my supervisor to let her know).

People really need to know what nurses have to deal with on the phone with some doctors. It’s nuts. Then they’re supposed to be diplomatic to not make the doc ‘look bad’.  I learned that his image is not my problem. If a doc wouldn’t give an order to deal with something, I’d let the patient know. No problem.  Fortunately, the vast majority of doctors I worked with knew that it was a team effort, and I was the part of the team that meant THEY didn’t have to wipe butts, serve coffee, have their arm halfway to Mars inside someone’s butt sore, get spit on, duck flying objects, referee family fights about Grandma being resuscitated until she turned inside out, not be able to pee for 8 hours easy, and sometimes 10-12, and on and on. Most doctors knew that the nurses had their backs.  I was up all night, it didn’t make any difference to me if I had to call someone, but the good ones left me orders for a lot of the ‘what if’ situations, so they knew that if I was on the phone, something wasn’t OK.  I didn’t send him/her to med school, and it wasn’t my fault he/she was on call!

But I miss those nights (and days).  They were my life.  Once a nurse, always a nurse.