the strandline

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Bryony has a startled look.
‘Fancy seeing you here!’ she says, even though we’ve never met before. ‘How are you?’
‘I’m fine, thanks, Bryony. How are you?’
‘Been better,’ she says, slumping back into the chair.
She’s been living in that chair and this front room for some days now, ever since her arthritic knees became too painful to carry her upstairs.
‘I moved into this house when I was thirty,’ she says. ‘Can you believe that? Now look at me. Ninety-four this Christmas.’
‘Were you born on Christmas Day?’ I say, checking the notes.
‘Near enough.’
The other clinicians have made creative attempts to make her life tenable at home. They’ve set up a micro-environment – a zimmer frame to help her stand, a commode at right-angles to her chair, and a moveable table with water and tissues and so on. Physio is starting soon, the pharmacist is reviewing her meds, carers are coming in three times a day – but even so, she’s at the limit of what can be accomplished.
‘I’ve come to do two things,’ I say, opening my bag. ‘One is to put some riser feet onto the chair and the put-you-up, and the other is to take another sample of blood.
‘Another one? I won’t have any left.’
‘There are just a few bits and pieces they need to run.’
‘I don’t mind. You do what you have to do. I’m in your hands.’
I put the riser feet on first. It’s a difficult job on my own. The put-you-up Bryony’s been using as a bed is one of those heavy sofas that lie flat. It can’t be comfortable. There’s such a curve to it, the only thing that would stop you rolling straight on the floor is the wall on one side, or the deep gulley that runs down the middle.  When I go to move the sofa out, the whole thing partially collapses. Thick cobwebs stick to my trouser legs. There’s a cloying smell of damp about the place.
‘Almost done,’ I say, trying to sound bright.
‘Don’t you go hurting your back.’
‘I’ll try not to.’
I help her onto the commode so I can put the riser legs on the chair. She can hardly weight bear, and I make a mental note to change her status to double-up.
It takes a while to move all the books and newspapers and ancient bank files that have accumulated round the chair over the years. When that’s done and I’ve got some room to work, I find that the chair is as weighty and unwieldy as the sofa. No doubt it was a handsome piece of furniture in a showroom in ninety-fifty, but the velvet has rubbed through to the ticking and the sculpted wooden feet are as sticky as if they were carved out of old toffee.
‘There we go! That should make it easier to jump on and off,’ I say, taking a step back and brushing my trousers down. I replace the old cushion she was sitting on with the special, pressure-relieving kind, and help her back on.
‘How does that feel?’
‘Better,’ she says.
‘Good. Now then. I’ll just wash my hands, then I’ll see about getting that blood.’

*

There are two types of patient: those that look away when the needle goes in, and those that pay attention.
‘What did you do before you retired?’ I ask her, then: ‘Sharp scratch.’
‘Children’s books!’ she says, lowering her face so much that her nose is almost touching the crook of her elbow.
‘How lovely! In what respect?’
‘In respect of getting them published.’
‘Well!’ I say, pushing a Vacuette into position and waiting for the blood to fill to the line, ‘I can’t think of a nicer thing to do.’
‘I enjoyed it,’ she says. ‘Are you getting what you need?’
‘Yep. It’s coming through nicely.’
‘Good. I’ve always had good veins.’
Then she sniffs and slowly looks up again to survey the place: the lines of books quietly composting on the bookcases, the dusty china dogs on the mantelpiece, a forgotten cereal bowl, packets of medical supplies, and a seascape, still vibrantly blue despite its surroundings, hanging where it’s probably always hung, from the picture rail that runs like a strandline around the upper quarter of the room.
‘Who’d have thought I’d end up like this?’ she says, as I tape some gauze to her wound.
‘There!’ I say, dumping the needle in the sharps bin. ‘All done!’
‘Yes,’ she says. ‘I believe so.’

it wasn’t the pie

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Ironically, of the two of them, Pete’s wife Sue had seemed worse. Her ulcerated legs were weeping through the bandages, and her breathing was laboured – exacerbated by a recent chest infection, and by all the cigarettes she’d smoked that morning.
‘I’d go mad if I didn’t have something,’ she said.
It was just yesterday I’d seen them both. I’d let myself in with a key from the keysafe, heard shouting from the front room. They were bickering over a Fray Bentos steak and kidney pie.
‘Am I putting two of these in?’ Pete said, presenting the blue and white tin to Sue, who was flipping through a TV Quick on the sofa.
‘Two? I’m hardly going to eat a whole one by myself, am I?’
‘Well I don’t know.’
‘No you don’t, do you’ she muttered.
He pulled the tin back again to scan it for clues.
‘For Pity’s sake! Just heat the one’ said Sue.
‘I’ll go and put the oven on then, shall I?’
‘You do that.’
‘Just this one?’
‘Just that one, Pete.’
‘And who’ll do the taters?’
‘Leave them on the side with the carrots.’
‘Carrots. Gotcha.’
‘And don’t go anywhere near the microwave.’
‘ Microwave. Yes.’
He hobbled off into the kitchen, stopped, and suddenly waved the tinned pie off to the side, like he was trying to pass it to someone only he could see. A moment later he drew the pie back into himself, and studied it closely again.
‘Alzheimer’s,’ said Sue.
‘Oven’s on,’ shouted Pete, coming back into the sitting room, still holding the pie.
‘What have you brought that in here for?’
‘What?’
‘The pie, love. The pie.’
‘Oh! Well! I’ll go and put it on then, shall I?’
‘Oh my good God.’

*

Next morning, Michaela had asked me to find out from the District nurses what the plan was for Pete. He’d only been referred to us following a recent report from the GP that his mobility was a little off, and the two of them were struggling to cope at home. As it turned out, over the past week we hadn’t actually needed to add too much on the care side. They had all the equipment they needed, and clinically he’d been okay. So we were referring back for on-going care to the DNs, especially Sue and her leg ulcers. Michaela particularly wanted to know if they thought Pete would benefit from more physio.
‘Do you mind?’ said Michaela. ‘Thanks, Jim!’

I had the time, it was a nice day, so instead of phoning I tucked the notes under my arm and strolled over to the District Nurses’ block.

Their offices are very different in character to the Rapid Response team, lighter and more spread out. They have a water fountain, plants – healthy ones – hanging from the tops of cabinets, the whole place open and sunny and relaxed. Sometimes, going in to work at the Rapid Response is like putting your head in a wasps’ nest and whacking it with a stick. This all felt much more humane. I resolved to get out of the office more often, and do more of these things face to face.

Rachel, the nurse I needed to see, was on the phone, so I took a seat opposite. I didn’t mind waiting. After a while she finished her call, took her feet off the chair, and turned her attention to me.
‘Hello!’ I said. ‘I’m Jim, over at Rapid Response. I’ve just popped over to ask you about Pete Rogers…’
‘Dead,’ she said.
‘What?’
‘He’s dead.’
I looked at the folder, as hapless as Pete with his Fray Bentos pie.
‘Peter Rogers? January twelfth, nineteen thirty-six?’
‘Yes. Sixty-two Alderney Drive. That Pete Rogers.’
‘Dead?’
‘Yes.’
‘Are you sure?’
‘I should think so. I was the one who certified.’
‘I can’t believe it. I only saw him yesterday. He seemed fine.’
‘He’s not now. What exactly did you want?’
‘Well one of the things was to find out whether you thought he could benefit from some more physio. Which I take it is a no. I just can’t believe it.’
‘We’re pretty furious, actually’ she said. ‘There were no anticipatory meds…’
‘He wasn’t palliative, was he?’
I flipped through the notes, to the GP summary we’d been faxed a couple of weeks ago.
‘Active problems – Alzheimer’s, mild COPD. Nothing about palliative care.’
‘Just hold it there a moment,’ she said. I relaxed the folder on my lap and looked at her. She gave me a coldly appraising look. ‘Tell me who you are again and what it is you do,’ she said,  ‘because I can’t tell from the way you’re dressed.’
‘I’m what they call an Assistant Practitioner. It’s a band four role, clinical assistant.’
(We’re supposed to wear a light blue tunic, but they’re unbearably hot to wear in the car, so most of us just wear polo shirts.)
‘Let me see those notes,’ she said. I handed them to her.
‘He seemed fine,’ I said as she flipped through the most recent assessments. ‘They were arguing over a pie.’ After a moment I added: ‘I hope it wasn’t the pie.’
‘Resp rate twenty. SATS of ninety-two. Who wrote this?’ she said. ‘If I’d found obs like that I’d have been straight on to the GP.’
‘Really? COPD patient. Smoker. SATS of ninety-two aren’t that unusual. And a resp rate of twenty doesn’t score anything.’
She wasn’t listening to me, but trying to read the name of the nurse who’d made the observations.
‘Can I have a copy of these notes?’ she said, handing them back.
I hesitated. I didn’t want to appear obstructive, but there was something steely in her manner that put me on my guard.
‘I’m sure that’s fine,’ I said. ‘But I think you’d better come and talk to my manager first.’
‘Why?’
‘I don’t know. Just to go over the facts and make sure everything’s clear. I don’t know enough about it.’
‘You could just run them through the copier.’
‘I’d rather you spoke to Michaela, if that’s okay.’
‘Tell her I’ll be over in five minutes.’

*

Michaela was as shocked as I was when I told her Pete had died.
‘Peter?’ she said. ‘Oh my God! Are you sure?’
But then when she checked through the notes on the system, the story began to unfold. The DNs had gone in and found him. There was a DNACPR in place. He’d suffered a cardiac arrest and that was that. Unexpected, in the strictest sense, anticipated to some degree. Certainly not palliative.
‘She’s coming over for the notes,’ I said to Michaela. ‘She wants a copy.’
‘I don’t mind. She can have a copy if she wants a copy. But I’ve just got to make a quick call to cancel the carers.’
She picked up the phone just as Rachel was coming down the aisle, covering the ground as smoothly and purposefully as a pilot on a travelator at the airport. She stopped at my desk and looked down at me.fraybentos
‘Won’t be long,’ I said.
She took a seat, folded her arms.

queenie

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It’s a reasonable request. Could Queenie provide me with a specimen of urine? (She has dementia and short term memory loss, but lately she’s been a bit more confused, and I’ve been sent round to screen out the obvious things first). I have a papier mache kidney bowl to put in the toilet. All she has to do is sit and go as normal, then leave it in situ for me to dip.
‘It doesn’t have to be much.’
‘It won’t be much.’
‘Whatever you can manage, Queenie. And don’t forget – don’t flush.’
‘Righto.’
She holds my hands as I lead her through the kitchen, down the two perilous concrete steps to the tiny toilet out back. She gives me a brave, astronaut-going-into-the-module kind of wave, and then closes the door very slowly and precisely. There’s a pause, some muttering, and then the sound of a bolt being slid firmly into place.
‘All right?’
Ye-es.
‘Shout if you need me.’
Will do.

That was an hour ago.
Since then I’ve tried everything I can think of to tempt her out. Good cop, bad cop. Pleading. Subtle psychological manipulation. Tea and biscuits.
‘Come on, Queenie. I can’t stay here all day.’
Well go then.
‘I can’t do that either.’
Why not?
‘Because I’d worry something was wrong.’
Nothing’s wrong.
‘Well prove it and open the door.’
No.

I could close my eyes and draw this door. Tongue and groove panelling, black gloss paint as heavy as if it had been dipped in a vat of tar before it was hung.
‘Come on, Queenie. You must be finished by now, surely.’
No! Just – go and sit in the lounge. Read the newspaper or something.
‘Are you stuck?’
Why would I be stuck?
‘Because you’ve got a history of getting stuck.’
Don’t be ridiculous.
‘And when you do get stuck you don’t use your pendant.’
What pendant?
‘Exactly. The pendant on your wrist.’
Why can’t you just leave me alone?
‘I’ve got a duty of care.’
Nonsense.
‘I can’t just walk away, can I? Your carer’s not due in till tea-time. You could be stuck in there for hours.’
I’m not stuck.
‘I just can’t think why else you’d take so long to come out.’
Go away and give me five minutes, would you?
‘What’s keeping you?’
 What’s keeping me?
‘Yes. What’s keeping you?’
My thoughts.
‘Can’t you come out and have those thoughts back in the lounge? You’d be more comfortable.’
Five minutes! Is that too much to ask?
‘You said five minutes five minutes ago. I can’t keep giving you five minutes-es. It’s been an hour already.’
Why don’t you both leave me alone?
‘What do you mean, both?’

She grumbles and grunts unintelligibly. There’s some non-specific shuffling, the sound of a hand on the bolt – and then nothing.
‘Queenie?’
What?
‘Are you all right in there?’
Of course I’m all right.
‘I’ve made you a nice cup of tea.’
Put it in the lounge and I’ll drink it later.
‘It’s a shame to let it go cold.’
Why don’t you just go back to the hospital and leave me be?
‘I have to see you first before I go. I have to know that you’re all right.’
Goodness me.
‘This isn’t reasonable behaviour, Queenie.’
Of course it is.
‘I wouldn’t say so. Locking yourself in the toilet for an hour when you have company isn’t reasonable behaviour.’
And you’d know all about it, would you?
‘I do now.’
I don’t know what you’re on about.
‘Look. Here’s the plan. I’ll give you five more minutes to finish off and open the door. If you don’t, I’m afraid I’m going to have to break in.’
You’ll pay for it if you do.
‘I’m afraid you’re leaving me no choice. You’ve got a history of falling, getting stuck and not calling for help. So I’d be failing in my job if I just walked away.’
No you wouldn’t.
‘So I’m giving you five more minutes. After that, I’m going to unscrew the handle and open the door by force.’
It’s a threat easier made than carried out. The screws are all glooped over with paint, and I haven’t got a screwdriver.
‘All right? Five more minutes, and then I’m coming in.’

I move away into the kitchen, fold my arms, lean back against the sink.
In a picture frame on the window ledge is a black and white picture of a man in a naval uniform. He’s leaning in to the camera with his hat tipped back and a grin like a music hall turn. The kitchen itself is set up like a ship’s galley, optimising the narrow space with a bank of cupboards on one side, and an aluminium work surface facing it. But if it started out ship-shape, it’s spent too long in dry docks now. There are dark cobwebs high up in the corners, and the only clean cups and utensils are the ones on the draining board the carers are washing and reusing.
‘Right! That’s your five minutes up, Queenie. I’m coming in!’
I rattle the handle.sailor
Wait! Just wait!
More shuffling noises, curses and grunts.
‘And don’t flush the…’
The toilet flushes.
A bolt thrown back and the door opens.
‘You can go off people, you know’ she says.

losing track

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Mrs Barnes is already washed and dressed, sitting on the end of the bed with a soft and rather bemused expression, like the shoemaker astonished to find all the wonderful things the elves accomplished overnight.
‘Shall we see about some breakfast and your medication, then?’
‘I think I can manage that,’ she says. ‘I’m not doolally.’
But half way down the stairs she stops and turns round.
‘What are we doing?’
‘Going down to the sitting room. To get some breakfast.’
‘Right-oh.’
And on we go.

The old place feels more like a house of doors than rooms. It has an eery, abandoned feeling, as if I’d closed my eyes for a second, every door had slammed shut, and the echo had run on through the years.
‘Here we are,’ I say, opening the door to the lounge.
She shakes her head sadly, and lumbers bad-hip first towards her favourite chair.
‘Ahh!’ she says, dropping back into it and caressing then tapping the armrests. ‘Lovely. Now then. Who are you and what do you want?’

*

With everything done I sit opposite Mrs Barnes, filling in the yellow sheet.
‘Where are you off to now?’ she says, sipping her tea.
‘The middle of town.’
‘That’ll be nice.’
‘So if there’s nothing more I can do for you, I’ll be off.’
‘Thank you for coming,’ she says. ‘I do appreciate it.’
‘You’re welcome. And don’t worry. I’ll put the key back in the key safe.’.
‘What key?’
‘This one. The one I used to let myself in this morning.’
‘And where are you going to put it?’
‘I’ll show you, if you like.’
She follows me to the front door. I demonstrate the keysafe, tucked away down to the right of the door, by a desiccated fuchsia in a cracked plastic pot.
‘The key goes in here like this – and then when anyone needs to use it, like the carers or the ambulance – God forbid – they can just fish it out. See? It’s all perfectly safe.’
‘If you say so.’
‘Loads of people have them. But don’t worry. You don’t need to have anything to do with it.’
‘Righto.’
‘Bye then, Mrs Barnes. Lovely to see you.’
‘Lovely to see you, too. Take care.’

I turn round at the top of the path expecting to see the door closed, but Mrs Barnes is still standing there, looking around. I wave to her. She stares in my direction and doesn’t react at all.

Just as I’m getting in the car – which is parked on the road at the end of the path – I see her suddenly waving to me. I hurry down again.
‘What’s up?’
‘I haven’t got my keys. What have you done with them?’
‘I didn’t use them, Mrs Barnes. I used the keysafe to get in.’
I point to it, but I think she thinks I mean the plant.
‘The what?’
‘The keysafe. Look.’
I go through it again; she watches over my shoulder.
‘So what have you done with my keys, then?’
‘Nothing. I don’t know where your keys are. It might be worth checking your pockets. I wouldn’t mind betting you put them in there and then hung your coat up or something. Or have a look on the furniture, the tables and chairs.’
‘Tables and chairs?’ she says, amazed at the thought.
‘It’s easy to put things down. You know – to lose track.’
‘How am I going to get in and out if I haven’t got my keys?’

I go back into the house and have a quick look round, but there’s no trace of the keys. Mrs Barnes is still standing by the front door, and I’m just wondering what to do about the keys and how to explain it all to her when she waves me over.
‘Where can I get that fixed?’ she says.
She’s pointing to the concrete path, which is crumbling in places.
‘I don’t know. You could try the council.’
‘This isn’t council,’ she says.
‘No? Well – maybe the best thing to do is ask a member of your family to do some ringing around.’
She looks blank.keys
‘Have you got any family? Sons, daughters…’
‘What do you mean?’
‘You know. Relatives. Nieces. Nephews, friends…’
I trail off uncertainly.
Her eyes cloud over and she bites her lip.
‘Mrs Barnes?’
But the moment is gone just as soon as it came, and her face relaxes again.
‘And what have you come for?’ she says.

control

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I’m due to rendezvous outside the patient’s address at four. I’m a little ahead of schedule, though, so I find a shady spot to park, and settle down to check my emails.
Just down the road a bus is suddenly at loggerheads with a van. The van didn’t give way to the bus, and now they’re both stuck, neither reversing, both of them leaning on their horns occasionally. The bus driver puts his hazards on and tries to get off the bus, but there’s not even room to do that. Traffic builds up north and south. Pedestrians stop and watch, some of them filming on their phones. Eventually, after about ten minutes or so, the van driver reverses. I wonder what’ll happen when the bus passes the van, but incredibly, he gives him a decorous little wave, like the Pope offering benediction from the balcony. In retrospect, I figure that’s even more infuriating than a lot of shouting and swearing. I admire his control.
Rosa’s blue car pulls up behind me.
‘All right?’ she says, coming round to see me, pushing her bling sunglasses up onto her head. ‘Waiting long?’

We’ve come to see Lena, an elderly woman who suffered a stroke a few years ago and is now looked after by her daughter, Carol. It’s not clear why we’ve been called in. The regular carers have pulled out for unspecified reasons – often code for a falling-out with the family. I haven’t been to Lena yet, but Rosa has, and she gives me the lowdown.
‘She’s a donkey on the edge, so watch yourself,’ she says, hefting her bag onto her back and slamming the boot shut. ‘She stands over you the whole time and tells you what you’re doing wrong. Just let it wash over you, if you can. She’s already had a run-in with a couple of the others. I don’t know what the long-term plan is, but it’s all a bit of a mess so just keep your head down and do your best. Oh yeah – and the other thing she does is try to get you to take out the rubbish. I don’t mind, particularly – anything for a quiet life – but it’s a bit cheeky. It’s not even clinical waste half the time, and she’s perfectly capable of doing it herself. See how you feel, though.’

Rosa leads the way into the flat, whose door has been propped open with a caterpillar-themed draught excluder. There’s a radio playing loudly in the kitchen at the far end, no other signs of life.
‘Hell-ooo!’ sings Rosa. ‘Car-ers!’
No-one comes. Lena’s room is immediately on the left, but just as we start heading in a figure appears at the far end of the corridor – Carol, a lean, middle-aged woman with tight curly hair and the kind of glasses you might doodle on a picture. It’s alarming how much those glasses intensify the sharpness of her expression.
‘I’m sorry – and you are…?’
‘Rosa.’
‘Yes. Not you. I’ve met you before. This other gentleman…?’
‘I’m Jim,’ I say. ‘Rosa’s colleague.’
‘Right. Well. Mummy’s through there, as you know. The enema worked yesterday so that’s a relief. You know what to do, don’t you? I know you do, because you’ve been before.’
‘Yes,’ says Rosa.
‘Let me know if you need anything,’ says Carol, and she retreats back into the kitchen.

Rosa risks a told you so face, and leads the way in to Lena.

Our call here today seems pretty straightforward. Lena’s pad is clean and dry, so after freshening her up and applying the bed sore creams, we straighten things out and get ready to leave.
‘What do you think you’re doing?’
Carol is standing in the doorway.
‘Lena’s pad was clear so … erm… everything looks good.’
‘It certainly is not good. You haven’t helped her empty her bowels.’
‘I’m sorry?’
‘Her bowels! Her bowels! Oh for goodness sake! Haven’t you been trained…’
She stamps round to Rosa’s side of the bed and snatches the control from her.
‘Give me that!’ she says, raising the bed up again. ‘What is the point of you coming if you can’t do the simplest thing? Okay, mummy. There we are…’
She unfastens the pads, then rolls her on her side by pushing on her hip.
‘That’s it, mummy. Now draw your knees up. Good. Okay. Now push, mummy! Push!
Lena begins making grunting sounds as she bears down. Carol grabs a tissue from a box at the foot of the bed and manually expresses the bowel motion like a midwife delivering a baby.
‘There we go! That’s it! A little more!’
Then she tosses it into a nearby bin and rolls her mother onto her back again.
‘The carers have been doing this for three years,’ she says, fixing the pad into position again. ‘Three!’
‘Well – we haven’t,’ says Rosa. ‘And I have to say, this isn’t part of what we do.’
‘What do you do, then? Nothing of any use.’
‘No. If the patient needs their pad changing and what have you, we’re happy to take care of that. And if they need the toilet we’ll help them onto a commode…’
‘She can’t stand, for God’s sake!’
‘No – well, she should really be hoisted, then.’
‘I don’t have a hoist.’
‘Either way, we can’t do any manual bowel procedures. That’s for the nurses. We’d be in big trouble…’
‘I don’t like your attitude. I want you out of my house. Right now. And I’ll make sure that you never come back.’
‘I’m sorry you feel like that,’ says Rosa, peeling off her blue gloves.
We’re half way down the corridor when Carol shouts out:
‘And take the rubbish!’sunglasses

 

eva

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Somehow Eva’s regular carers have managed to tidy up the kitchen sink – a colossal task. Now, it rises out of the terrible mess of the rest of the flat, as improbably defined as the Spratly islands the Chinese built in the South China Sea.
‘How are you, Eva?’
She’s sitting on the sofa, mournfully puffing on an e-cigarette, her right arm in a cast.
‘It wouldn’t be so bad if it wasn’t for this,’ she says, raising it an inch, then settling it back down in the sling again.
It’s hard to know where to stand in Eva’s flat, let alone do anything to help. There’s rubbish everywhere, but if I move something to make a little room, she gets cross. When I use a supermarket bag to start collecting up her used pads, she complains I’ve wasted a good bag.
‘Put it here, next to me,’ she says.
The sofa is her mother ship, the place she really lives, all manner of things stuffed between the cushions – a Ziploc bag of documents (her one concession to order); medication, phone, newspapers, spare pads. Anything that doesn’t fit gets dumped on the coffee table. There’s no room for me to pick a way through it all, let alone someone in her condition. And now that her arm’s in a cast – well, I can’t think how she’ll manage.
Eva is wearing a large, baggy t-shirt with a big red heart in the middle saying All You Need Is Love. It hangs clear of her body though. There’s no flesh to fill it out because Eva’s body has been ravaged by years of alcohol abuse. She’s more like an anatomical model, all the chords and veins and bony prominences of her body cruelly exposed, like one of those plastinated cadavers in an exhibition, put in everyday poses – playing cards, riding a horse, sitting on a sofa smoking a cigarette and ordering a carer about.
I clean her up as best I can, change her pad, and fetch her a little trifle from the fridge, finding a way to wedge it in her lap so she can eat it one handed. Whilst she tucks in, I clear away what I can and then pull out a yellow sheet to record what I’ve done this visit.
‘Pass me one of them tea lights,’ she says. After a great deal of tutting and pointing, I finally manage to see what she means: a box of them, balanced on a pile of junk a million miles of crap away on the other side of the room.
‘What do you want them for?’
‘Put one on the table and light it. It’ll clear away them flies.’
‘There’s no way I’m going to put a lighted tea-light in the middle of that table.’
‘Why not?’
‘It’ll set the place alight. It’s a fire hazard. The whole place’ll go up in about five minutes. And then where would you be?’
‘Out the door, mate. Where d’you think?’
‘How?’
‘How d’you think? I know what to do when there’s a fire.’
‘The smoke would finish you off before you made the door.’
‘Are you going to light it or not?’
‘No. Sorry.’
‘Then I’ve got no further use for you. You seemed all right when you came in but I’ve changed my mind now. I’ll ask the nurse to do it when she comes.’
‘Good luck with that.’
She studies me whilst I write out the yellow sheet.
‘Are you always like this?’ she says eventually.
‘What? Safety conscious?’
‘No. Getting other people to do your work.’

sleepy bananas

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The early shift are sitting round the big table in the middle of the office, busily writing down their work for the day. The schedule was drawn up the day before, but every morning it’s the same. It’s as if the Co-ordinator allocates each of them a particular set of clothes, setting them out neatly in piles, with their names on top, only for them to swap everything, every last thing, socks, shoes, pants, hats.
‘If you do Eric and Vera you’ll be East for that double-up lunch call with Tom, and I’ll be freed up to do that hoist with Sonia… ‘ and so on. It’s so automatic they barely have to think about it, trading one patient for another whilst they chat about this and that.

‘Quick! Somebody get me a banana.’
‘Why?’
‘To put in my porridge.’
‘Well it just so happens I do have one in my bag from yesterday. It’s a bit sleepy, though.’
‘I don’t care if it’s wide awake. I just know if I don’t get a banana I’ll never make it to lunch.’
‘There you go, mate.’
‘Wow! Thanks! That’s a nice one!’

‘I had to take Bruce to the vets in the end.’
‘Not again!’
‘I know. That’s the third time this year. I’ll be on some kind of register. But that stone he swallowed never came out and he started looking a bit strange. The vet had to operate and it came to fifteen hundred quid.’
‘Fifteen hundred! What was it – a diamond?’
‘Sam went to the vets n’all. He loves that ball chucker we got him, but he went haring after the ball and came back with a limp. The vet said he’d probably pulled something, so keep him on the lead for a few weeks, give him anti-inflammatories, see how he goes. Two weeks later he was still hobbling about so we had to go back. First thing she said was “Did you keep him on the lead?” And she looks at Neil, and he goes “Weeeeelllll…”
‘That’s pathetic. I know it’s difficult, but still.’
‘Men are such pushovers.’

‘Who wrote these directions? Here, look at this .. third box on the right, second row behind bins, green door to left…what the hell? It’s like some kind of test’
‘I can’t even read the writing.’
‘Do you remember that one we had down by the park? Take key on ledge over second door – open closet opposite, keysafe in electric cupboard,  red nail polish, blah, blah….
‘Yeah? Then what? Take key to Mordor, throw in lake of fire.

‘Did anyone make contact with old Blundell yesterday?’
‘I managed to talk to him through the letterbox.’
‘That’s something, then. At least we know he’s not lying under a pile of crap. Well – let me rephrase that. At least we know he’s not lying dead under a pile of crap.’
‘I asked him if he was on the floor, and he said no, the bed. And then he shouts out: ‘Who sent you?” Which threw me for some reason, so I just said “The NHS”. And he goes “Well tell the NHS I’m not interested.”
‘Political.’
‘He’s a funny old stick, Mr Blundell. It’s sad how he’s living.’
‘Have you been in there?’
‘Rank. Like a dirty protest. Shit everywhere.’
‘Lily bought him some fish and chips the other day and when I went in they were all trodden in. I’ll never eat fish and chips again.’
‘I still don’t really get the whole capacity thing. I mean, you only need put your head round the door.’
‘Apparently he was at Baker House for rehab last year and he scrubbed up beautiful. He was wandering round like how d’you do and goodness me and all that. All he needed was a top hat and a cane. But then the minute he steps back in that flat, bingo. He’s off, back to his old rotten self.’
‘It’s a shame.’
‘It’s a real shame…’

‘Have you done Mr Smedley yet? Have you seen the set-up there?’
‘Is he the one with the ceiling hoists downstairs and up?’
‘Yeah. It’s amazing. Like one of them indoor railway tracks, or Alton Towers, with all these tracks snaking everywhere, through the walls, the works. I went yesterday to help Mario change his catheter, and I’m not kidding, it took about an hour and a half. We had to hoist him out of the wheelchair, push him out of the lounge to the stair lift, lower him into that, ride him up the stair lift to the top, hoist him up again, along the track into the bedroom, so we could change him on the hospital bed. And the whole time he’s giving this running commentary on what goes where and how he wants it. I said to him, I said ‘Next time I come I’ll bring you a little peak cap.’
‘How d’he take that?’
‘He laughed. He said he’d always wanted a train set.’

And so it goes on, everyone talking at once, overlapping each other, bidding, counter-bidding, rubbing names out on the rota and then writing them back in again, all against a constant background of gossip and anecdotes and banter – until the clock on the wall has moved on ten minutes, and suddenly the desk is empty again, just a scattering of open folders, coffee cups, pencils, uncapped biros – and off to the side, splayed like an orchid in an empty, instant porridge pot, the spotty brown skin of a banana.

the lottery

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The house has a bright, Mediterranean feel, crisp, white walls, a flat-topped roof, planters spilling with colorful flowers, and beyond the end of the garden, field after field swooping right and left in diminishing shades of green and brown all the way down to the sea.
I knock and wait.
After a while a woman appears behind the frosted glass in the middle of the door, but after trying the handle unsuccessfully a few times, she melts away again.
‘It’s locked, June. Where’s the key?’ she shouts.
I wait some more.
Eventually the garden gate opens and she peers round the side.
‘What do you want?’ she says.
‘I’m Jim, from the Rapid Response Team at the hospital. Come to see June.’
‘Oh. All right then. I suppose you’d better come in.’
I follow her through the gate and into the house via the kitchen.
‘It’s someone from some kind of team. At the hospital. He says he wants to see you,’ she says.
Who is it?’
June is sitting in an armchair with a commode to her right and a zimmer frame in front. The commode is doubling as a table, with a brown towel draped over the seat and the controls to June’s riser-recliner strategically placed on top.
I introduce myself again and shake her hand.
‘Just a flying visit to change the rubber ends on your frame’ I tell her. ‘Nothing to worry about.’
She relaxes back in the chair.
‘How are you feeling today?’ I ask her, putting the frame on its side and pulling off the ferrules.
‘No better,’ she says, lacing her hands over her tummy. ‘Steadily getting worse.’
‘I’m sorry to hear that, June. Anything particular today?’
‘Everything. My walking. I can’t get about like I used to.’
‘Shall I have a quick look at your notes…?’
‘Be my guest. If you can understand any of it.’
June’s condition is well documented. The District Nurses are case managing. Once the new ferrules are on, the plan is to discharge back to them.
‘It’s so hot today,’ she says, fanning herself with a leaflet about care alarms. ‘Don’t you think?’
‘Ye-es. It’s been a terrible summer,’ says the other woman, sitting on the opposite armchair, putting a large handbag on her lap and rummaging around in it.
‘There was all that rain.’
‘D’you know, I can’t even remember the rain…’
‘There was rain,’ says June, nodding gravely. ‘It’s been a very bad summer.’
‘You live in a lovely part of the world,’ I say, setting her frame upright again.
‘Too hilly. Shall I try it out?’
‘If you like.’
She stands and hefts the frame expertly.
‘Better,’ she says, ‘Definitely better. What do you think, Maureen?’
‘Oh yes,’ says Maureen. ‘I preferred you better with the stroller, though.’
‘The stroller,’ says June. ‘Now that was good. You could sit down on that. But it went for a burton like everything else and now look.’
She sits down again.
I start writing a note in the folder.
Maureen has found what she was looking for in her bag: a £100,000 scratch card, and a coin to rub it with.
‘I always thought I’d like to live in a hot country,’ I say. ‘But we went to Italy on holiday this year and you know what, after a few days I seriously wondered whether I could. I mean – it was so hot…’
‘The earthquake,’ says Maureen. ‘That was dreadful.’ And she starts rubbing furiously at the scratch card with the coin.
‘It’s all there is in the news these days,’ says June. ‘Terrible things all the time. I don’t know what’s happening to the world…’
‘Well, I suppose there’ve always been earthquakes…’
‘…wars, politics, people starving to death, horrible accidents…’
‘I know. It’s bad sometimes.’
‘It is bad.’
‘But looking on the bright side…’
Maureen  purses her lips, gives the scratch card a blow, then holds it up to the light.
‘Anything, Maureen?’
‘No.’

small world

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Petra, Ema’s great-grand niece (I think – the fax is so scrappy it’s almost illegible) opens the door. She seems exhausted, her heavy make-up and long, coal black hair emphasising the pallor of her complexion.
‘Come in,’ she says, pushing the door wider and then immediately retreating. ‘Thank you for coming.’ There’s only room for me to step inside and then shut the door behind me. I’m thrown for a minute. Even though from the outside it seems like a normal end of terrace house, for some reason the party wall on my left narrows to the width of the door, widening out further into the house. Different coloured paint on the other walls makes it feel like I’ve walked into an optical illusion. When I follow Petra down the corridor, I fully expect to decrease in size.
I glance into a room we pass a room on our right. There’s an ancient woman sitting in an armchair.
‘Hello!’ I say.
Petra sighs.
‘No,’ she says. ‘Is not that one.’
‘Oh.’
We pass further through, to a bed in a backroom, and Ema, lying like a corpse with her eyes closed, her jaw slack, her hands gently folded on her tummy.
‘Here is Ema,’ says Petra.
‘Is there a yellow folder?’
‘A yellow folder?’
‘Yeah. You know. The nursing notes.’
‘No. No yellow folder. Is nothing.’
‘Oh. Okay. Not to worry.’
I put my bag down and go over to Ema to rouse her as gently as I can.
There’s a scream from the sitting room. ‘Ana!’ says Petra, and goes to see. I remember making out the word dementia on the referral, but it suppose they meant the sister rather than the patient. Maybe Ema is Ana’s carer, and Petra has come in to help from somewhere now that Ema has fallen ill.
‘Hello!’ I say, as Ema opens her eyes. ‘Sorry to give you such a rude awakening. My name’s Jim, from the hospital. I’ve come to see how you are today.’
‘Terrible,’ she says after a moment or two. ‘Thank you.’
‘I’m sorry to hear that. In what way do you not feel well?’
She blinks and smiles, unlacing her fingers just long enough to make a gesture of  saintly forbearance.
‘Are you in pain?’
‘No. No pain.’
‘Do you feel sick? Or have you been sick?’
‘Perhaps. A little.’
‘Short of breath? Dizzy?’
She shakes her head.
‘Any change today? Or much the same, would you say?’
‘Same thing. Always too much.’
‘Well. I’m sorry to hear that.’
I look at the faxed referral again. It’s almost impossible to make out much beyond the sketchy 5/7 unwell, poor E&D, hx hyponatremia, something something obs & bloods pls. We would have requested clearer information, but the Bank Holiday means that getting back to the referrer will be nigh on impossible. And anyway, the request itself was straightforward: obs, bloods – a little lacking in context, perhaps, but sometimes you just have to go with what there is.
I start a new obs chart and run the basics.
I can hear Ana protesting next door.
But I’m her sister! I should know what he’s doing in there!
And Petra, speaking in her flat tone:
– You cannot disturb him. He has come to do the blood.
I’m her sister!
– Here. Have more grape.
I don’t want a grape. I want to see my sister.
I unplug my ears from the stethoscope and call through: ‘It’s okay, Petra. I don’t mind if Ana comes through.’
But there’s no answer. Everything goes quiet.
‘Honestly. I don’t mind at all.’
I carry on examining Ema.
Everything seems fine – blood pressure, temperature, SATS and the rest. Nothing obviously neurological, no acute injuries. It’ll all hang on the blood test, I think, as I get the kit out.
‘Where are you from originally?’
‘Croatia,’ she says.
‘No! Really? We were just there! On holiday! Whereabouts in Croatia?’
‘Trogir.’
‘Well it’s a small world, as they say. That’s where we were! It’s beautiful there. The castle, the mountains. The lovely blue sea. We loved it.’
‘Thank you.’
I tighten the tourniquet and decide which vein to go for.
‘How old were you when you came to this country?’ I say, unsheathing the needle.
‘Four, five. I don’t remember.’
‘Have you been back at all? Sharp scratch…’
‘Thank you!’ she says, tensing a moment, then relaxing as the immediate pain of it changes into something else. ‘Yes. A little, but lately – not so much.’
Ana starts shouting next door again.
But it’s my sister! I want to know what he’s doing to my sister.
– He taking the blood, auntie. Don’t worry.
I want to be in there.
– No. He need peace and quiet.
We’re sisters!
– Yes. I know that.
‘I really don’t mind if she comes through’ I call over my shoulder, but there’s no reply, and it all goes quiet again.
With the last vacuette done, I release the tourniquet, withdraw the needle and tape a square of gauze to the wound. ‘I’ll check it in a few minutes and see if you need a plaster,’ I tell her. ‘But that’s it – the worst part’s over. All done!’
‘Thank you!’ she says.
Petra appears in the doorway again.
‘Ready to go?’ she says.
‘Yep. Just a sec whilst I write up the yellow sheet…’
I half expect to see Ana pop-up behind Petra, but for whatever reason, she stays in the sitting room.
When I’m packed up and I’ve said goodbye to Ema, I follow Petra back along the corridor. I glance in at the door of the sitting room as I pass. Ana is still in the armchair. She turns to look at me, her face bunched over her gums in anger.
‘Ema says she and Ana were born in Trogir,’ I say to Petra as I
reach to open the front door. ‘We were in Trogir just this week! On holiday!’
Petra doesn’t reply.
‘Small world!’ I say as I step outside.
‘Yes,’ she says. ‘Thank you for coming.’And she closes the door, slowly and firmly, without any discernible click of the latch.

trogir

a question of time

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‘What did you do, before all this?’
‘Me? I was a mechanic.’
‘That’s a pretty cool job. Although I don’t know so much nowadays, with all that on-board computer stuff.’
‘Yeah? Well, at the end of the day, you still went home with dirty hands.’
‘I just wish I knew more about it. It’s a bit of a black art, to tell you the truth. Every time I hear a funny noise in the engine I think crap – that’s another two hundred quid at the garage.’
‘Depends on the garage. Depends on the noise.’
‘Definitely. Okay – if you just reach over to me with your left hand and we’ll roll you…’
Chris is a palliative patient, newly on the books. His cancer has developed a rare complication, leptomeningeal carcinomatosis, a kind of main-lining of cancer cells via the cerebrospinal fluid, leading to widespread metastases, neurological complications and a rapid deterioration. He was diagnosed just a couple of weeks ago, and yet already he’s lost the use of his legs, and all bladder and bowel function. It’s been a mad scramble to organise any kind of workable care environment at home. The hospital bed, hoist, table and armchair take up so much of the little room, there’s barely space to move. At least there’s a large patio window overlooking the garden, so it doesn’t feel too enclosed.
There’s a shelf to the side of the bed, and a framed photo of Chris and his young daughter, Chloe, just ready to go up to big school.
‘How’s she feeling about that?’
‘Good. She’s good. I mean she’s anxious about it, like you would be. But the fact is she’s outgrown the old school and she’s ready to move on. She came in wearing the new uniform yesterday and she looked a real treat.’
He goes quiet for a bit so we cover by making lots of business like comments about the sling, the manoeuvring of the hoist and so on. He seems to recover himself though and when we ask him if he’s ready to transfer to the armchair he says ‘Yep! Take her up!’
‘Sorry about all this,’ he says, swinging in mid-air.
‘No! We’re just sorry you’re having to go through it.’
‘Yeah, well.’
We get him set up in the armchair, then tidy up the space, put clean sheets on the bed, make everything good. His wife Sarah comes down with a tray of breakfast. We collect our things, shake his hand and go.

*

The way the rota works, I don’t see him for almost a week. I’ve been told to liaise with Rachel, a live-in carer from a specialist agency.
One of Chris’ eyes has closed, and he only has limited use of his hands and arms. When I go down the stairs and into the room he’s sitting up in bed, the carer taking a bowl of porridge away from him as he struggles to clear his throat from the last spoonful. After a few minutes the coughing eases enough for him to gasp hello.
‘Are you having more difficulty swallowing?’
He nods.
‘I’m sorry to hear it. I’ve come to see how I can help this morning.’
Chris shakes his head and looks at Rachel.
‘I think Chris wants to stay in bed today,’ she says. ‘I’ve just checked his pads and they’re clean, so that’s okay. And he’s had a wash.’
‘Great. Well – if you’re sure there’s nothing I can do, I’ll crack on.’
I give his hand a squeeze and then head back upstairs. Sarah says goodbye at the door.

*

A few days later I hear from the others that Chris has died. We’ve all dealt with terminal patients before, and although their deaths are always sad, on the whole they tend to be older, coming to the end of a long and chronic illness. This was a whole new order of death, though. I can’t imagine how difficult it must have been for him, and the thought of his last few hours fills me with horror. I know there were anticipatory meds to hand, but who gave them to him? What effect did they have? Did he become unconscious as his breathing deteriorated and his SATS dropped? If the meds are for pain, would they be given for anxiety as he became hypoxic – because of course the opiate effect would be to depress his breathing even further and hasten his death. I want to ask all these questions frankly of someone, but of course there’s no time. We have many other patients to attend to, many more than we can handle. And the fact that our proportion of palliative patients is increasing is a sign of the difficulties being experience by specialist teams across the board. Chris becomes a footnote, a war-story to be shared amongst the carers and clinicians back at the hospital.

I just wish there was more time.