“It’s not just a job…it’s an adventure.”
Forget House. If those TV script-writers really want to come up with a winning show about medical care involving a house, they should write about home health care. I mean, seriously. They’d never have to make anything up, for one thing, except to change the names. Plus, if you went by the TV shows, you’d think the only real health care was performed by physicians in hospitals. In real life, however, most health care happens in a lot of other places, and most meaningful health care is not performed by doctors. And let me tell you, a day in the life of the average visiting nurse or CNA or rehab therapist makes a Quentin Tarantino flick look like Snow White. Having a sense of dark irony is almost a job requirement. When you get a new patient who is just home from having open heart surgery, she is sure to live alone in a split level with stairs everywhere, and no one to help her out but an overprotective, incontinent German shepherd with a bad attitude.
Since having to recover from my own cancer sleigh ride, I’ve had a foot in both camps, as it were. Being a patient and a clinician at the same time, I’ve often felt like I’ve been plunked into a weird parallel universe. On the one hand, my compassion for my patients has immeasurably deepened, and on the other, so has my disillusionment with the health care system. Since I can’t take you all with me on my daily rounds, this post is for you, in an attempt to convey how my job has helped lighten my heart all these months, at the same time that it has regularly sucked me dry. Everything I describe here is based on actual experience. But the identifying details have been changed so I don’t get fired for breach of confidentiality.
There’s nothing quite like being a physical therapist in home care. Forcing a person to get out of her nice comfortable bed, and walk on her new knee joint, when she just got home from the hospital yesterday and feels like dog crap, is a sure-fire way to endear yourself instantly. Plus, you get to use cool stuff like a stethoscope, a blood pressure cuff and a goniometer (which is a plastic thingy that measures joint angles). And make no mistake — props count. If you’re really lucky, you might get to use a pulse oximeter. Or maybe wear surgical gloves and change an occlusive dressing with Tegaderm, this waterproof bandaging stuff that’s like cling wrap and gets all snarled up especially when you’re wearing surgical gloves. The up side of home PT is that PT’s don’t have to insert Foley catheters. And if things get too bloody or poopy (which we call a Code Brown), you can get a home care nurse to deal with it, leaving you free to attend to the glory stuff like giving people neck rubs and teaching them to walk again.
It’s not all glamour though. Once I was teaching an old man with emphysema how to cough hard enough to get the phlegm up after a bout of pneumonia. He was really trying, but when your lungs don’t work right, it’s tough to take a big enough breath to huck a louie, as we say in Rhode Island. Finally, he sucked in air with all his might and coughed as hard as he could — and sent his dentures flying across the room. And like all the dorky PT’s you’ve ever met, I stood there afterward, patting his shoulder and enthusing, “Way to go, Mr. Jones!! Good job!”
Frequently, I see patients who reside at assisted living facilities, some of which provide special services for people with dementia or folks who need rehab after surgery. I went to visit a patient at one such place recently. One of his neighbors there is often found wandering the halls, carrying a stuffed elephant under her arm and smiling wanly. As I sat at the nurses’ station, reviewing a chart, she strolled up and suddenly pointed her finger at my nose. Her smile changed to a scowl, and in the most dire and threatening tones, she told me, “I know what you’re up to!” No further explanation was forthcoming. Her behavior can escalate easily to physical aggression, so it’s best to ignore it if possible — we call this “extinguishing.” We also call it getting the heck outta there. I got a much warmer reception from my patient, who punctuated our entire visit by asking me why he was there and when was he going home. I sometimes wonder that myself.
My next patient for the day was so far MIA. This is not an unusual experience in home care. No matter how carefully and predictably you plan your visits, no matter how often you see the same patient at the same time on the same two days every week, sooner or later, he’ll disappear from the face of the earth and you will be unable to find him. The problem is, it’s not at all unrealistic to worry that he’s lying unconscious or has been rushed to the ER. I’d already called this gentleman twice, first thing in the morning, and got no answer. Okay, I thought, still sleeping maybe. An hour later, I called again. Still no answer. In the bathroom probably. Now it was close to my appointment time, and still no answer. Might have lost his hearing aide. I checked my laptop to see if any other home care people were scheduled to see him. Nope. Called the office to see if maybe he called in to cancel. Called his daughter. Got her voice mail. Called the hospital to see if he was in the ER. Called to see if he had an appointment with his doctor. Nope, zip, bupkis. So, I drove to his house, knocked, got no answer, walked around the house, looked in the windows and found nada. Time to give up the search. But now I had to call three other patients to see if one of them would see me earlier so that I didn’t twiddle my thumbs for an hour. I got lucky and drove to see a patient with a cute cat and a really clean bathroom that’s safe enough for a personal pit stop. Total bonus points.
After that, I saw a patient I couldn’t get to a few weeks ago, because all roads to his neighborhood were closed due to our recent flooding rains. I noticed he was sitting out on his patio, so I joined him there. Thank heaven, it wasn’t raining anymore, and it was a comfy, if breezy, sixty degrees Fahrenheit. This meant I was wearing a short-sleeved tee-shirt, and my patient was in a cable knit turtleneck sweater with a quilted down vest over it and a Red Sox cap on his head. He gave me a hot flash just looking at him. Meanwhile, I saw through the sliding glass doors that all the furniture inside was pushed around and his son was running a steam cleaner over the carpeting. I also noticed his dog licking his flanks, which were damp, as in recently bathed. Long story short, his house was infested with fleas and his son was trying to do something about it. Naturally, I started to itch. It’s like a Pavlovian response. In my case, it also meant I could not and would not enter the house so that I could wash my hands as I usually do at the kitchen sink. Fortunately, we all carry waterless hand disinfectant, so I slathered that on instead. There are certain limits to what kind of PT you can do on a patio, but home care does require a great deal of creativity, so I managed.
Then I got paged by the office. I like to think I’m fairly hip as far as technology goes, but these days, working in home care means I have to carry, on each visit, a laptop, a cell phone and a pager, plus my work bag with my soap and paper towels and vinyl gloves and stethoscope and a bunch of other junk, in and out of my car, several times a day. I keep meaning to come up with some kind of special tool belt or cargo pants or something just for people in home care, but I haven’t gotten around to it. I pulled over and called the rehab scheduler at the office, who informed me that one of my patients had been rushed to the hospital (not the one who was MIA), so could I shuffle things around and do an assessment on a new patient? I said I thought I could. This meant, among other things, that I had to plug my laptop into the car adapter, log into the secure server that stores all our patient data, synchronize my laptop with the server, open up the documentation software again, find the new patient the scheduler stuck on my schedule, download the discharge documentation she’d sent me by email, open up that PDF, read, figure out where this person lived, figure out how to rearrange the rest of my schedule, call a bunch of patients, and figure out where I was going next.
Needless to say, this is not the work of a moment, so now I was behind schedule and running late. Par for the course. I caught one break, which was that my MIA patient — remember him?? — finally answered the phone. He’d been out getting an X-ray earlier and now had to go to the lab to get some blood drawn. No, he didn’t think to call us to let us know. In any event, he had no time for me that day and I had one less person to see.
My new patient was available, so I went there next. I asked him if I could see how he was getting to his bathroom using his walker. He said no I could not. Instead, I was treated to a discourse on his own personal theory of pain management, which amounted to a rationalization about why he would not take any pain medication and therefore why he was in too much pain to do anything except play World of Warcraft on his flat screen TV. I guess recovering from falling off a ladder just wasn’t very important. As it happened, the patient after him was annoyed that I’d arrived just when her favorite soap opera was on. She refused to start therapy until she’d finished watching the last twenty minutes of the show. When I asked if she had TiVo or anything so she could record it for later, she yelled at me not to talk to her until the show was over. Must have been “Dis Your PT” Day.
My last patient of the day was recovering from a bout with congestive heart failure. Normally, this was a fairly easy visit. She had a monitor system in her home that took her weight and vital signs each morning and transmitted them to our office, where a nurse monitored the data to make sure she remained stable. She and I were working on her endurance, so we usually took a short, gentle, timed walk, checking her vitals before and after. Then we’d practice her technique for safely getting in and out of the shower, which she was instructed not to do by herself. When I arrived, she had a black eye, a sling on her right arm, and a chastened expression on her face. She explained that she had tried taking a shower by herself yesterday, “because I don’t want to keep putting you girls to so much trouble.” Fortunately, she had not lost consciousness when she fell, and was still wearing her Lifeline button, which she remembered to push. So now, she had incipient congestive heart failure, poor endurance, bad judgment, a bruised right orbital ridge, a mild concussion, and a fractured right humerus. And of course, she’s right-handed. We call this job security.
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