Agnes? It’s up to YOU!

Agnes is telling me how she fell down the stairs.

She’s sitting on a chair with her legs crooked up. There’s something so slow and deliberate and precise in the way that she describes how she normally negotiates the stairs, which – along with the gestures she makes with her arms, slowly out to the side and back, her long, spindly fingers reaching out to grab imaginary banisters – that makes me think of a sloth. Her words are sloth-like, too. She even blinks slowly. I need to get on and replace the dressing on her leg, but it’s impossible to interrupt her, and besides, I have to admit, I’m a little hypnotised by the monologue.

‘…and so, you see, I have my technique. And my technique is this: I place my left foot on the first stair like SO…. and then I very carefully reach up with my RIGHT hand to grasp the handrail that runs up the RIGHT side. And once I have a FIRM grasp of the handrail with my RIGHT hand, I transfer my weight forwards, and then begin to move my RIGHT foot up to join the LEFT. And then once I have my balance, I very carefully transfer my weight a little forwards again. And then I reach out with my LEFT hand until I have a firm grasp of one of the bannisters on the left. And then I gently pull forwards with THAT hand, and transfer my weight so that I can swing up my RIGHT foot. Now… all this is very well and good. And in this way I manage to make it all the way to the top, where the stairs turn in a little tuck to the LEFT. But the problem at his point, you see, is that the bannister on that corner is much fatter. Do you follow? It’s shaped … like THIS … (and she describes two curves in the air with those weirdly etiolated fingers, like a potter describing the outline of a shapely vase)… and of course, a shape like that is much more difficult to grasp… to get a good PURCHASE on. Normally I can manage it … by reaching a little further forwards… and almost crawling at the critical point… but that PARTICULAR day I’m sorry to say I DIDN’T manage it, and I toppled backwards…. d’you see?…. and I bounced all the way back down again, like a giant tennis ball or something. And I lay in the hall and shouted out for help, but none came. And after a few hours I said to myself… Agnes? It’s up to YOU! And little by little I crawled to the phone. And in THAT way I managed to summon help. And after a while the ambulance people came, with a key they’d fetched from Gerry across the road. And everything was alright in the end, thank goodness. Except this wretched leg, of course, and a little wounded PRIDE…’

She blinks slowly and sadly, and then seems to brighten as she looks up at me again.

‘So NOW!’ she says. ‘Tell me what it is you’ve come to do?’

Rick the duck

Gavin lives in a new development near the station.
‘It’s tucked away,’ he’d said to the call taker. ‘Ours is the one with the triangular balconies.’

Except – they’re actually rectangular.

‘Maybe he got his shapes mixed up,’ says Alexi, pressing the buzzer. ‘Maybe it’s more of a geometrical crisis.’

It’s a smart, designery place, with a wide, plate-glass main door and giant chrome handle, the name etched into the glass in bold lettering – the kind of details you might expect to see on a hotel. There are lots of nice touches, in fact. A rack of multicoloured letterboxes, a series of inset lights. And then out front, a garden area that incorporates some old industrial features, with a slatted wooden walkway snaking gently up to road level alongside a wall with climbing hand grips. A kid on his way to school is demonstrating their use, doing some last-minute bouldering on his way to school, his mum creeping up the slope beside him, his superheroes backpack in one hand whilst she checks her phone in the other.

We’ve come out early because Gavin has rung the service to say he was going to kill himself. The person who took the call tried to give him the crisis number for Mental Health, but he rang off, so our only options are to call the ambulance service or go ourselves. We know the ambulance is appallingly stretched, and we’ve got space this morning, so we’ve come along to triage the call in person.

Gavin comes down to meet us at the front door, although he could just as easily have buzzed us in and let us come up. If you didn’t know he’d made such a distressing call you would never have guessed. He’s a trim, easy-looking guy in his early fifties, stubbly white hair, tanned complexion, dressed in a white cotton shirt and trousers, and comfy sports sandals. He could have stepped out of a catalogue for the stylish retiree.
‘Have you been here before?’ he says, pleasantly. ‘Follow me.’
He shows us up to his flat, a smart, bijou studio overlooking the communal gardens. There are art prints and photos around the place, a bookshelf crammed with art books – Van Gogh, Goya and the like – an expensive SLR camera on the coffee table, and then a smaller bookcase with Penguin classics and a few self-help titles, and on the wall a collection of DVDs that reads like a list of the Fifty Films You Must See Before You Kill Yourself.

‘Take a seat,’ says Gavin, smiling pleasantly, and then running his hand backwards and forwards across the silvery stubble on the top of his head.
‘How can we help?’ I say, as Alexi and I sit on the sofa.
‘You can’t,’ says Gavin. ‘No-one can.’
I nod as neutrally but encouragingly as I can. Alexi’s leg begins to jiggle up and down. He has his obs kit on his lap. I know he’s keen to get stuck in medically.
‘So – you rang the office saying you wanted to kill yourself?’
Gavin takes a long breath and closes his eyes.
‘I’m sorry things are so difficult for you at the moment,’ I say. ‘But just to be clear – have you done anything to hurt yourself this morning, Gavin? Or made specific plans to do that?’
‘I’ve been planning to kill myself since I was nine,’ he sighs, carefully pulling out a chair and sitting down. It’s an odd and not entirely comfortable configuration – me and Alexi side-by-side on a low sofa, looking up to Gavin on our right.
‘I have monsters in my head,’ he goes on, rubbing his stubble again, as if that’s all he can do these days to contain them.
‘Do you have a support worker? Or a number to call when things get difficult?’
He shakes his head.
‘No-one can do anything,’ he says. ‘I’m dangerously ill. I have severe heart problems. Lung problems. I almost died when I was rushed into hospital. They didn’t know what was wrong. I collapsed several times. It’s been going on for years. I’m on every medication you can think of.’

We’d looked over his past medical history before setting out. There’d been nothing about heart problems or any other medical issues other than some minor orthopaedic work in the past. He’s not on any medication for anything other than Mental Health.

‘I’m constantly dizzy,’ he goes on. ‘I have pins and needles. I can’t breathe. My legs aren’t working properly. This morning I went outside and collapsed….’
‘I’m sorry to hear that, Gavin. What happened?’
‘My legs buckled.’
‘Did an ambulance turn up?’
‘No,’ he says. ‘I managed to get up again and crawl back inside.’
He looks at me and sighs.
‘I’m fighting for breath,’ he says. ‘I can’t speak. I’m dangerously ill, but no-one can do anything. I know more about my condition than the most senior doctors in the country. I have to tell them what’s wrong with me, and that can’t be right, can it?’
‘It does sound difficult for you.’
‘I’ve tried every approach under the sun. You name it, I’ve done it. Deep meditation, CBT, group therapy. I’ve been exorcised. I’ve done cleansing rituals. I’ve swallowed every antidepressant and antipsychotic that was ever made. I’ve even written a book about my experiences…’
He reaches over to the table behind him and produces a red plastic document pouch bulging with paper.
‘It’s not quite ready to be published but when it is it’ll change the way they do medicine in this country.’
‘What’s it called?’
Don’t Think I Won’t Because I Will’ he says.
‘Amazing.’
He puts it back on the table.
‘The thing is, Gavin – we’re a little limited how we can help you this morning. As you know, we’re a community health team. We either support people coming out of hospital or try to stop them going in to begin with.’
‘I see,’ he says.
‘So – I think this morning we’ve got two options. One is to help you contact the Mental Health crisis line, or the other is to call an ambulance to take you to hospital. I really don’t think hospital is the right thing to do, though. It’s horribly busy there at the moment – definitely not the place to go if you’re feeling anxious or – you know – delicate. So why don’t we ring the crisis line? See what they have to say? They’re the experts. How does that sound?’
He nods, then crossing one leg over the other and hooking his hands around the knee, waits for me to make the call.

The line is answered almost immediately by Rick, a mental health liaison nurse I know well. Rick is the most affable guy you could wish for, addressing the most extreme behaviours with such a soft Irish accent it immediately makes you feel better.
‘Jim!’ he says. ‘How funny! What’re ya doing there today? How can I help…?’
I explain the situation as evenly as I can, then pass the phone over to Gavin. It’s strange to hear Gavin describe his situation: struggling to breathe… collapse…. monsters…. all in the most conversational tones. I can hear Rick responding, gently but firmly getting to the nub of it all. After five minutes, Gavin hands me the phone back.
‘That’s fine, Jim. Leave it with me. I’ve got his notes here. There’s a few bits and pieces we can do. I’m going to ring him back in five minutes and talk some more, but it’s fine if you want to toddle off. Thanks for coming out – and it’s so lovely to talk to you again…!’
‘You, too! See you soon.’
I put the phone back in my pocket.
‘So – is that okay, Gavin? Rick’s going to ring you back in five minutes, and we’re going to head off. But in the meantime, if anything happens, you’ve got some numbers you can call, including 999 in a desperate emergency.’
‘My whole life is a desperate emergency,’ says Gavin, rising and smiling pleasantly. ‘I’ve had fifty years of it.’
‘Good luck with the book,’ says Alexi.

Back outside, we tear off our plastic aprons, our masks and gloves, and breathe in the sharp morning air.
‘I couldn’t work in mental health,’ says Alexi.
‘Me neither,’ I say. ‘I thought about retraining as a counsellor at one time, but I’m not sure I’ve got the patience.’
‘Rick is amazing, though,’ says Alexi. ‘Did you see the way he coped with it? It was like water off a duck’s back. Is that the expression? Water off a duck’s back?’
‘It is!’ I say.
And I think of Rick as one of those lush Mandarin ducks, button eyes and punky hair, splashing about in a big old pond somewhere, bobbing under the water, up again. Under. Up. Shaking off the water. Basically loving it.

primed

Rita stands in the doorway, shifting her slippered weight from side to side in an effort to stop Randolph the dog running out. Randolph is a Jack Russell. Almost completely white, but with splodges of black here and there on his head, as if it was late in the day when they made him and they ran out of paint.

‘Excuse the stickiness in Harry’s room,’ says Rita. ‘Only I spilled his Lucozade and it’s gone all tacky.’

They’re a perfect combination, Rita and Randolph. They could both have stepped out of a painting by Beryl Cook – the cheeky strippergran and her chubby lapdog. Except, you’d need a measure of reinforcement to take Randolph on your lap these days. His delicate legs don’t seem big enough for his hefty body, like someone no-nailsed the legs from a Chippendale desk onto a boiler. The most extraordinary thing about Randolph is his eyes, though. Made of clear blue glass. He stares up at me, and when I bend down to let him sniff my hand, he gives me such a sad and searching look I feel as if I’ve mind-melded with a Vulcan.

‘Harry’s through here,’ says Rita, leading us through the house, along a laminate wood hallway, Randolph’s paws making an emphatic snickering noise as he runs ahead, doing one of those comedy, sideways skids at the turn.

‘Careful!’ says Rita.

Harry is in bed watching the news channel with a frozen expression. Randolph tries unsuccessfully to leap up onto the bed, so Rita gives him a boost. Once he’s made it, Randolph licks Harry’s face, then turns to look up at us, as if to say: There! Ready for you now!

Rita is right about the floor. You have to consciously wrest your foot up from it to stop yourself from permanently sticking. My shoes feel so generously coated I’m tempted to try walking up the walls and across the ceiling – and I would have done it, too, if I could be sure Randolph wouldn’t bark and cause a rumpus.

‘I’ll get some soapy water on that,’ says Rita.

We’re halfway through the assessment when there’s a knock on the door. Randolph launches himself off the bed, crashing against a chest of drawers, then skittering out of the room.
‘Coo-ee!’ sings a woman.
‘That’ll be Joyce,’ says Rita. ‘The first thing she’ll mention is the Amazon boxes. You wait.’

Eventually a leaner and older version of Rita appears in the doorway. She dumps her bags in the hallway, comes into the bedroom to kiss Harry lightly on the forehead, then straightens up again and gives us all a smile-shrug combination that seems designed to say both ‘sorry I’m late’ and ‘isn’t that just like me.’

Then she takes a breath and looks straight at Rita.

‘I see you’ve been online again,’ she says.

the fowling piece

Bill shuffles slowly through the bungalow to his front room, nudging the zimmer frame forward a stretch, working his way painfully back into it, nudging it forward again, his back curved, his neck craning forwards and the skin of his neck slack, like one of those ancient Galapagos tortoises you might see in a documentary, sensing the ocean, inching through the sand towards it.
‘No rush,’ I say to him. ‘Take your time.’
He stops.
‘I’m afraid Time is pretty much all I have these days,’ he says. ‘But at least it means you get a chance to enjoy my gallery.’

There’s a generous spread of photos around us across the walls. A lifetime’s worth, carefully framed and aligned, the early ones faded to the blurry impression of an umbrella or a hat, the new ones hypercoloured portraits of great great whatevers in gowns and mortar boards holding scrolls up with a satisfied expression that seems to say: This is what it all means.
‘Quite a family,’ I say.
‘Yes,’ he says, starting the painful business of moving those enormous velcro shoes forwards again. ‘We did pretty well.’

The front room has three, wide windows that overlook the garden. The sun is so bright it’s like we’re on the deck of a ship overlooking a sea of green. If it is the sea, though, that must be King Neptune, wielding a spade instead of a trident, waving cheerfully as he plants out a row of blood red geraniums.
Bill waves back.
‘Dylan comes every Tuesday. And I’ve got Malcolm at number fourteen who pops in now and again. And my sons are often over. So I don’t do too bad.’
After his recent fall and long stay in hospital, though, it’s clear Bill needs carers to come in every day for help washing and dressing. That’s why he’s been referred to us, and why I’ve come over to do the assessment today.

Taking pride of place on the wall above the fireplace is a large, antique fowling piece, its intricate plates and decorations and its great curved butt making it look more like a gigantic clarinet or something. Below it on the mantelpiece is an extemporary shrine to Bill’s wife June who died last year. There’s the order of service, a dried flower, and then a line of photo frames either side of the two of them at various ages, June always on the left, Bill on the right (although from their point of view it was the other way round, I suppose).
‘We were married sixty years,’ he says. ‘We had a wonderful life.’
‘How did you meet?’
‘At a dance. June was with her friend, Daphne. Daphne tapped her on the shoulder and said to her: See that man over there? He’s alright, isn’t he? And June said: Hands off! He’s mine. And here we are, all those years later. Mind you – her mother wasn’t keen. She was what you might call difficult. She said to me, she said: William? You’ll marry that girl over my dead body. But then she popped her clogs three weeks later, so I suppose you could say it was a sign.’
‘Wow! That’s quite a story!’ I say to him.
‘Yes! Yes, it is,’ says Bill, staring at the mantelpiece – although, whether at the shrine or the gun, it’s impossible to say.

Andre the Nurse

The flat we want is actually round the corner, on the front. Parking there is impossible, so I arrange to meet Andre the nurse outside the Chinese restaurant in an adjacent side street. There’s no time for much conversation; a squall of rain is sweeping in off the sea – so fierce it almost tears the boot from Andre’s car and empties the contents – all the dressings and folders and so on – out into the street. People squeal as they pitter past us, holding bags over their heads, wrestling with umbrellas turned inside out.

‘Let’s go!’ snarls Andre, and we run.

Andre the nurse reminds me of Andre the Giant from The Princess Bride. Not so much in height, although he is pretty tall. It’s more in demeanour, the same lunkishly, lowering kind of look. An ogre in a nurse’s tunic. Andre is basically harmless, though. I’m sure he could spend many happy minutes stroking a dove’s head – if a dove was ever dumb enough to land on his outstretched paw. And if it survived the stroking, and flew off in a dazed and crooked line, I’m sure the dove would feel affectionately towards him, too.

We’ve come to visit Rick, a patient referred to us by the GP, more as a welfare check than anything else, and to see if our team could help out in any way, with care or therapy or nursing and so on. ‘At risk of unconsciousness or death’ the referral had said, bleakly.

‘We’re ALL at risk of that, my friend!’ snorts Andre, buzzing the intercom half a dozen times, and then banging on the main door with the edge of his fist, with such brutal energy you’d think it was a SWAT team calling rather than a nurse from the hospital.

There’s no reply, just as there was no reply from the patient’s phone. Andre seems ready to pick up the block and shake Rick out, but luckily a delivery guy turns up with a code to get in, so we tailgate the rather anxious looking guy and then trudge up the plush steps to the third floor, grumbling about the weather all the way up.

Once we find Rick’s flat, Andre bangs on the door with such force the whole thing jumps in its frame.
‘Nurse!’ he shouts, which would have any sane person leaping from the bathroom window.
I look through the letterbox. The flat is silent, everything under sheets, buckets and paint trays and rollers on the floor.
‘I think it’s being refurbished,’ I say, straightening up. ‘He must be somewhere else.’
Andre sighs, goes to the flat next door and bangs on that, too.

Amazingly, an elderly woman opens it.

‘Oh – so sorry to disturb you,’ says Andre, using a whispery tone of voice so sinister the woman visibly recoils. ‘Me and my esteemed colleague are nurses from the hospital,’ he says. ‘I wonder if you would be so kind as to tell us where Rick is, please?’
The woman shudders, shuffles back in alarm, slams the door. There’s the sound of several bolts being thrown, a chain rattling on. Maybe a small wardrobe dragged into position.
‘Thank you so much!’ says Andre, giving a little salute to the door, then glares at me like I’m somehow responsible.
‘I’ll ring the office,’ I say.
‘You do that, Jimmy,’ says Andre. ‘Meanwhile I will stand here and think about why God is punishing me like this.’

The coordinator sounds sleepy.
‘Yes,’ she yawns. ‘The address is wrong. He’s in a flat on the other side of town.’
‘Great.’
She texts us both the new address. Andre stares down at his phone as if he can’t decide whether to put it in his pocket or on the floor so he can stamp on it.
‘Come on, Jimmy!’ he says, choosing the former. ‘We can’t stay here the rest of our lives.’

The squall has settled into something more terrible, a hybrid inundation somewhere between a hurricane and the Great Flood. Even with the wipers on full it’s difficult to see where I’m going. It gets so bad I could be persuaded I’d left the road completely and was driving along the sea bed, following a whale that fails to indicate when it turns left. More by luck than skill I end up outside the alternative address; Andre parks in front of me and we both run with our coats over our heads to the entrance to the flats, a battered black door with a font of water rushing out of a broken downpipe across the pavement and over our shoes.
Andre beats on the door.
‘Come on! Come on!’ he says.
Just before we have to stop knocking and start treading water, the door opens and Rick stands there, his long hair matted, his beard worse.
‘Yes?’ he says, holding on to the door, then resting his face against the edge of it. ‘Can I help you?’
‘We are nurses from the hospital. Can we come in please?’
It sounds like Andre’s asking for sanctuary, which in a way, of course, he is. Luckily it seems to work. Rick releases his grip on the door and drifts back into the flat.
‘Your doctor asked us to visit,’ says Andre, shaking his coat and slapping the rain from his bald head. ‘Your doctor is worried about you.’
‘Oh?’ says Rick. He trails further back into the flat, sits on something that must have been a sofa once, and starts rolling a cigarette. He’s surrounded by empty cans of lager, and I’m impressed he managed to sit down without disturbing any of them.

Andre drags a stool over and tries to explain the reason for the visit, growling through the basics with the patience of a WWF wrestler called ‘The Nurse’. Rick is oblivious, though, fastidiously licking the strip of gum on the cigarette paper, rolling it, admiring it, then lighting it with the snick of a match.
‘Yes?’ he says, blowing smoke. ‘Er-hmmm.’
‘So this being the case, would you be accepting of such help from us, please?’ says Andre.
‘No,’ says Rick, picking strands of tobacco from his lips. ‘No, I would not.’
‘Do you understand what I am telling you?’ says Andre, almost tearing the folder in half.
Rick sighs, hooks the hair from his eyes, and – strangely – closes them when he looks at Andre
‘Like I said, officer,’ he says, ‘I’m perfectly fine.’
‘Okay. Good. You are perfectly within your rights to refuse, my friend,’ says Andre, trembling from the effort of control. Would you be so kind as to sign here, then?’
‘What’s this?’
‘This? This is a form to say that you do not want any help from us, and that you understand the risks involved in not accepting help,’ says Andre, handing him the paper and tapping with his pen where he wants Rick to sign.
‘What risks?’
‘Unconsciousness and death’ says Andre.
And the way he smiles at Rick, it’s like he doesn’t mind which.

a difficult climb

I haven’t been to this block before and I’m confused by the entrance. There’s no intercom anywhere I can see, and the door seems to be closed. It reminds me of another block on the other side of town. The only way in is to phone the resident and ask them to release the front door, or to knock on the window of the scheme manager’s office (an arrangement that always baffles me, because really – how difficult do you want to make life?)

So figuring this is another place like that, I phone the patient again.

‘Oh really?’ huffs Angela. She lowers the phone and shouts for her daughter to go down because the nurse is ‘outside and doesn’t know how to open a door.’

She says something else, too, but it’s muffled so I can only guess.

After a few minutes, Frances waves to me from the lobby as she approaches. She’s a cheerful, red-faced, middle-aged woman in a bulging tartan skirt and yellow cardigan, her hair so frizzy the hairdresser must stand on a ladder to prune it with shears. But then – I’m so busy remarking on her extraordinary look I don’t realise she’s miming for me to push the door. Which I do – and find it’s been open all along – just a little stiff. And just inside the lobby to the right is a second set of doors with an intercom to the side.
‘How embarrassing!’ I say. ‘Sorry to drag you all the way downstairs!’
She shrugs cheerily.
‘Salad!’ she says.

I know from the notes that Frances has a form of expressive dysphasia that means she struggles to speak in complete sentences and often uses the wrong word. I’d read that she’d come back to live with her mum after her stroke, but that Angela was struggling now, had fallen recently and needed a home assessment.

‘This is such an interesting building!’ I say, making conversation as we walk up the stairs.
Frances nods and smiles back at me, her eyes wide but her lips tightly pursed, as if there were a pressure of words wanting to come out but she couldn’t be sure which to use.

She shows me into the flat – a large, coolly shadowed place with dark parquet flooring, antique furniture, serious photographs in serious frames, and at the furthest end, a floor to ceiling window overlooking the park.

‘Hello Angela!’ I say, putting my bags down. ‘I’m Jim, the nursing assistant from the hospital, come to see how you are and what help you might need.’
‘Have a seat,’ she says, nodding to the scallop backed affair opposite her.
‘Thanks!’
I settle in. Frances climbs up on a stool at the little cocktail bar to the left, stuffs her hands under her thighs and starts gently swinging from side to side whilst Angela scrutinises me. Between the great bony arc of her mouth and her hooded eyes, it feels like I’ve been granted an audience with a giant, royal frog.

‘I can’t believe I had such a struggle getting in,’ I say, laughing drily. ‘I was standing there, pulling away…’
‘You push,’ says Angela.
‘Yes!’ I say, closing my eyes and shaking my head from side to side, like Stan Laurel. ‘I know that now!’
‘Hmm,’ says Angela.

It’s a struggle to make any progress after that. If Angela was resistant to the idea of help before I arrived, nothing I can say now improves the situation. My mouth dries. I become horribly self-conscious, feeling like an imposter who found all this equipment down in the lobby and tried it on for a laugh.

Frances beams at me from her stool, chipping in with non-sequiturs. The shadows in the room close in, take on more weight.

‘What a lovely view of the park!’ I say, finishing off her blood pressure. ‘Beautiful! All the … you know… trees.’
Angela nods.
‘My husband chose this place,’ she says. ‘Then he died.’
‘Oh. I’m sorry.’
‘He was a climber. He went to the Himalayas.’
‘Wow!’ I say, looping the stethoscope back round my neck, just exactly the kind of thing a fraudulent nurse would do. ‘The Himalayas!’ I say, making too much of it. ‘Even I’ve heard of the Himalayas.’

‘Sandwiches!’ says Frances.

Angela ignores us both.

‘He was a well-respected climber,’ she says. ‘He was so good, he used to train people in climbing. All over the world. There wasn’t a mountain he hadn’t climbed. And then, of course, he went to the Himalayas…’
She trails off, gravely rolling down the sleeve of her blouse, like a surgeon about to give bad news.
‘Oh…?’ I say.

She doesn’t react.

I’m desperate to ask if that’s how her husband died, plunging off Mount Everest or being buried alive in an avalanche (all of which I’d rather be doing right now). But that would be a difficult question at the best of times, and I feel about as ready to ask it as a Yeti would feel to knock on the door of a tent and ask if I could come in for tea.
‘So… what happened?’
Angela frowns up at me.
‘What do you mean – what happened?’ she says. ‘We bought this place! What do you think happened?’
I look over at Frances.
‘Christmas!’ she says.

Frankie & Rita

If you didn’t know better you’d think Frankie’s wheelchair was a time machine. A particularly down-at-heel version, ruined by food debris, bodily fluids, scorch marks. And if it is, you’d have to think he’d leant too hard on the joystick, because suddenly he’s found himself in a brilliant new flat – a futuristic development, all chrome, glass and sharp corners – without an abusive partner, but with a beautiful dog. And the dog is strangely quiet, with deeply golden eyes and a deeply golden manner. And Frankie is slumped in his chair, as if this last leap has wiped him out, and he needs a good long sleep to catch up.

‘Sorry I didn’t answer your call,’ he says, slowly rousing and raising his chin, hooking aside his great mass of hair, stroking his beard into some kind of shape, his great silver skull rings glinting dully in the overhead spots. ‘Only I was a bit distracted.’

It’s always impossible to know what to do with Frankie. It’s obvious to anyone who deals with him that his problem is drug addiction. Frankie is the kind of user whose entire life has been sacrificed on the altar of altered states. You couldn’t name a drug he hadn’t swallowed, snorted, pumped in his veins or shoved up his rectum. He’s something of an expert in the field, and his destroyed body is his CV.

‘Rita!’ he says, leaning so far out of the chair I can’t help putting a hand out. By some miracle of gravity he stays seated, though. Rita leans up to accept a stroke.

‘She’s a good girl!’ says Frankie, mussing her head a couple of times then flopping back into the chair. ‘She deserves better.’

Rita turns her golden eyes up to me as if to say: You see?

We chat about how our service can help – which isn’t much, it has to be said. The flat is as good and well-adapted as you could wish for. Certainly better than the certified Pit of Hell I saw him in just a couple of years ago. And whilst his drug use is gradually working its magic on the place, still there’s room to move, and you can breathe with a measure of confidence, and there’s light coming in at the window.

‘I want to kick this shit,’ says Frankie. ‘I really do. Ya know? It’s not good for you. But I had that guy from mental health come by the other day, and he sat there, and he said did I want to go on the methadone. And I said to him What? Substitute one drug for another? Why would I wanna do that? I wanna come off the shit completely, ya know? Start over. Get on with my life. So he said Suit yourself. Just like that. And then he sat there, looking round. He was really mean. A mean, horrible, uncaring kinda guy. What’s he doing, being in a job like that? He oughta be caring for people, not judging them and making dumb suggestions. I told him to get out and not come back. But I tell you what, though. I’d LIKE him to come back. ‘Cos if he did I’d put some gloves on. And I’d give HIM some gloves, because I’m a fair-minded kinda guy. And I’d say C’mon on, then! Let’s settle this, man to man! Because I’m not a violent person, y’know? I teach street kids Taekwondo and Jiu Jitsu – but only for self-defence, yeah? Not aggression. And there’s a big difference, my friend. A BIG difference.’

He strokes his beard thoughtfully for a while and seems to fall straight asleep. I can’t imagine how he’d teach martial arts having only one leg. But maybe that was some years ago, before the drugs took over and he lost not just the leg but everything else.

I fuss with Rita whilst the physiotherapist wakes Frankie up to talk about options. Rita is a staffie, solid as a pommel horse, with a fleshy mouth and nipples like tire valves. Her eyes really are the most incredibly warm, extravagantly deep caramel colour. I can’t help staring into them, and blinking slowly, whilst she pants with her big fleshy mouth, and widens her eyes, and draws me in.

It’s an effort to break free.

‘Rita’s lovely!’ I say, eventually standing up again, as the physio writes something in the folder, and Rita curls up by the wheelchair’s footplate. ‘Where did you get her?’

‘Rita?’ says Frankie, orienting himself to me in a blindly approximate way, much like a bear might look to the mouth of the cave in the middle of winter. ‘Dunno mate. She just kinda showed up.’

the sea captain

Alex reminds me of the sea captain in The Simpsons. If you rapped the TV with a wand, pulled the sea captain out of the screen by the shoulders of his great coat, gave him a shake to fill him out, swiped off his captain’s hat, pulled out his corn cob pipe and substituted it with a cheap Russian cigarette, took off one of his legs and sat him in a wheelchair – you’d have Alex. The orneriness you could leave.
‘No, no! Not there! THERE!’ he glares. I take a step back.
‘Okay. Off you go, Alex. I’ll stand here just in case.’

Alex has a routine for everything, which is fair enough of course, except it’s all so inappropriate and hazardous you have to bite your lip and cross your fingers and everything else and hope beyond hope he manages it. But the thing is – he invariably does. Which is half the secret with Alex.

‘How come he doesn’t bite your head off?’ says the coordinator. ‘Everyone else he tears a new one.’
I shrug.
‘Maybe he sees me as as pushover.’
‘Yeah?’ she says. ‘Or a kindred spirit. Still, at least he gets to see someone.’
I don’t like the way she says ‘someone’. There’s something of the dot dot dot about it.

Alex is what you might call a non-compliant patient. In fact. he gives non-compliance a bad rap. He’s forever self-discharging against advice, then throwing his hands up and calling for help. Then when the help comes, he puts so many demands on the various clinicians and therapists and carers he makes any meaningful intervention impossible. And to make the situation worse, he talks. And talks. And talks. Great rolling monologues that brook no interruption or question. Vast avalanches of discourse that will bury the novice unless they know the trick, which is to surf his words to a rapid and professional dismount on the beach, which, in this Alex-worthy, extended metaphor, would be the corridor outside his flat.

And breathe.

Which is, of course, the other thing about visiting Alex. Those Russian cigarettes.

I don’t know who supplies them, or who makes them. I’m guessing they’re secretly rolled out in Chernobyl or somewhere, a novel way of offloading waste. Because they stink. It’s the kind of spoiling, roiling, super-leafy stink you’d get if you took a flamethrower to a compost heap. With a splash of detergent to zip the whole thing up. I’d guess if I walked out of Alex’s flat and straight into an X-ray machine, you’d see noxious curls of the smoke wedged like bed springs in my bronchioles. Coughing doesn’t help. You need the respiratory equivalent of a douche.

Which is why I wasn’t keen to see Alex again.

‘I can’t believe he’s back on the books.’
‘Yeah. Well. Whaddya gonna do?’
‘What is it this time? It can’t be care. The carers hardly last a minute.’
‘I don’t know,’ sighs the coordinator. ‘He went into hospital with an AKI. They changed his meds and he self-discharged without anything. Refused to sign a non-concordance. And now he’s back home calling the ambulance every five minutes. So I think they figured they’d either refer him back to us or wheel him off the pier. And these days the pier’s fully booked.’

I have a nightmare vision of Alex as a figure on a carousel – one of those garishly painted wooden versions, all brightly coloured eyes and flaring nostrils, scattering equipment and pills and ambulance sheets as they go round and round and round.

‘Anyway, just go and see he’s okay, try to make sense of where we are now. Maybe get him to sign a non-concordance,’ says the coordinator. ‘And stamp his reward card.’

When I get there, it’s difficult to find anywhere to park. There’s a fire engine, a fire officer’s car, a rapid response ambulance car and an ambulance truck, and a small crowd of people on the pavement. I excuse my way through just as a throng of emergency officers lumber out through the lobby in hazmat suits. At first I wonder if it’s Alex, and the team are all suited up because they heard about his cigarettes. But weirdly, the patient on the stretcher is an elderly woman looking perfectly healthy, wearing a comedy, cliche-old person Astrakhan coat with a fur hat, her handbag clutched to her chest. She waves to the crowd as she emerges on the trolley. I’m surprised the crowd don’t burst into applause – but actually what they do is start moving away, somewhat disappointedly, as if what they really wanted was something more dreadful and entertaining.

It seems odd to go into the block, but there’s no reason not to and the warden is standing nodding and smiling at me.
‘Come for Alex?’ she says. ‘Good! You know where to go…’
And leaves me to it.

Alex is where he always is at the start of any visit, which is smoking one of his goddamn cigarettes over by the closed window.
‘Hello Alex!’ I say. ‘You wouldn’t mind putting your cigarette out, would you?’
‘I haven’t finished it.’
‘No, but I don’t smoke so I’d really appreciate it if you did.’
‘It’s my house.’
‘I know, but still. Thanks. That’s very kind…’ (hoping it’ll clinch the deal – which, miraculously, it does). He nips out the burning end as if he were dead-heading a rose, and rests it tenderly in the ashtray.
‘There were loads of emergency services down in the lobby,’ I say, to kickstart the meeting. ‘I was worried. I thought it might be you.’
‘Me?’ he says. ‘Why? I’m not the only person who lives here.’
‘No,’ I say. ‘That’s true. You’re not.’

And even though the next half an hour will be filled with Alex telling me everything about those lost weeks, where he’d been and what happened to him, who he talked to and how he put them right, what they wanted him to do and what he ended up doing – with much better results – and so on and so on. But instead, just for one moment, one, slender unexpected moment of silence, backgrounded by the sound of slamming ambulance doors outside, framed by the melancholic curls of smoke rising from the pinched cigarette in the ashtray next to him, Alex stares at me, and I stare back, and we don’t say a word.

I’m tempted to break the silence and say ‘Ahh! Squiddy!’ – affectionately, like the Simpsons Sea Captain when he meets his nemesis, the giant squid, again.
But I don’t.
I adjust my mask.
And the whole visit goes ahead as normal.

hovercrafts & game shows

One of those headlong, breathless mornings, where I’m furiously trying to fit too many visits into too few hours, with the hopeless intention of being back in time to relieve Mandy on the desk at one. Mandy only came in because she heard we were short. ‘One day they’ll put up a statue of you in the marketplace,’ I tell her, almost spilling the tea I’ve made as an extemporary thank you. ‘What – so the pigeons can shit on me?’ she says. ‘Thanks for the tea.’

It’s the kind of morning where I’m overly conscious of my heart. I feel it swinging on a piece of frayed string, side to side, side to side, the joke pocketwatch you might hang inside the ribcage of a medical skeleton. All my timings might work if everything clicks – here then here then here via there – tick tick tick. Back by one. Yeah, right.

And of course, not one thing goes to plan.

The first assessment turns out to be much worse than the breezy drive-by the GP promised in the referral. I’m met at the door by a carer so stressed you can see it trembling through her like a tractor on a pinking idle. She has her mask under her chin like it’s stopping her mouth falling open into a scream; even worse than that, she’s carrying a knife.
‘Can you pull your mask down, too?’ she says, gesturing with the knife. ‘My hearing’s not what it was.’
I tell her I’ll speak up, then, because I can’t really take the mask off. It’s more for the patient than my benefit.
‘She’s jabbed, though,’ says the carer, like she did it personally, with the blade. ‘Twice.’
Even so, I tell her, she can still get pretty sick with Covid. Especially given how frail she is. I say I’m sorry but I just can’t do it.’ This doesn’t go down well. I follow the carer into the kitchen. She rushes through a handover whilst she dices her fingers with the cucumber. ‘Can you at least help me change her?’ she says.
‘Of course!’
‘She’s stuck on the sofa.’

All in all I’m at the house for two hours, late for my next call.

But it’s fine. It’s okay. This next one should definitely be quick. I’ve been asked to drop in to an elderly patient just to check his obs, see how he is, weigh him and check his pressure areas, so we can discharge from our service. It’s a formality. I can make up time there.

I let myself into his flat with the keys from the keysafe. A Welsh dresser narrows the hallway and I have to turn sideways to get through. There’s a ribbed-glass door just ahead so fiercely illuminated it’s like stepping onto the deck of a spaceship orbiting the sun – except, a spaceship with a threadbare carpet and faecal footprints tracking from the soiled cot bed in the corner to the captain’s chair by the window. Before I go any further I put some shoe covers on. Check my fob watch. The air is thick and noisome.

‘Hello Mr Carpenter,’ I say, going over to him, lightly waking him up by resting a gloved hand lightly on his shoulder.
‘Wha-at?’ he says, with a start, wide-eyed at the rustling, white-gowned alien looming over him.

At first glance he seems immaculate. Like James T Kirk started modelling in his dotage for a geriatric gentlemen’s outfitters, smartly put together in a sharp check jacket, pink stripe shirt, belted trousers and some impressively elaborate leather boots that zip up right and left from the toe to the bend of the ankle. I can see a glob of faeces on the heel of his left shoe, and a slide mark emerging from the hem of his trousers.
‘My name’s Jim. I’m a nursing assistant. From the hospital. Come to see how you are!’
He bats the air, then linking his hands on his lap, rests his head back again.

He’s obviously been incontinent, but before I do anything else I run a set of obs to see if he’s acutely unwell or not. Everything seems fine, though, and his vagueness is probably due to his advanced dementia. I help him stand up, loosen his trousers, and peer into the horror below. His mobility is pretty poor, and I know I’m not going to be able to wash him on my own – especially given the tiny bathroom with no aids of any kind. I sit him down again whilst I ring his care company. He’s not due another call until the evening, they say – and no, they don’t have anyone they can send out to help me. ‘He needs more care,’ I say. ‘We’re in discussions about that,’ they say. So I phone the office. Mandy says the only person available to come out is Tim, a new carer still on induction. ‘It’ll be the Jim and Tim show!’ she says. I tell her I’m almost certainly going to be late back. ‘Don’t worry,’ she says. ‘I’ll just stay on a bit longer.’ I tell her the statue will be made of gold, with diamonds for eyes. ‘Oh yeah?’ she says. ‘Just make it in concrete and throw me the diamonds.’

Whilst I’m waiting I clean Mr Carpenter’s hands, then go into the little galley kitchen to make him a cup of tea. There are sandwiches laid out for him on the side – not that he’d have any idea they were there. When I give them to him he eats them hungrily, taking big toothless bites, craning forward at the neck like an ancient tortoise with a lettuce leaf. Whilst he’s tucking in I strip his bed down, clean it up and put on fresh linen. Use antiseptic wipes to get the worst of the mess from the carpet.

Tim arrives. Between us we help Mr Carpenter up, strip him down, walk him to the bathroom, clean him off. Tim is great, chatting to Mr Carpenter and teasing out little scraps of information. Apparently Mr Carpenter was a civil engineer. ‘How amazing!’ says Tim. ‘My brother’s an engineer. He makes hovercrafts.’
‘I’ve been on a hovercraft,’ I say.
‘Oh really?’ says Tim.
‘Yes,’ I say. ‘To the Isle of Wight.’
The Isle of Wight suddenly seems like a very strange name. The Isle of Wight? I really went there? On a hovercraft?

Meanwhile, Tim is saying how his brother was always interested in bridges.

We dress Mr Carpenter in a new set of clothes – sans jacket, unfortunately, which also has to be added to the small mountain of soiled clothes and bed things we leave for the carers to deal with later. Then we help him back to the armchair which we’ve cleaned and covered in a beach towel, and settle him in. He eats the other half of his sandwich whilst Tim pours some orange juice and puts the glass beside him. Mr Carpenter smiles and holds up the remaining crust from his sandwich – working the upright part of it like a hinge.
‘Come on Down!’ he says. ‘Come on Down!’
‘The Price is Right! Bruce Forsyth!’ I say.
Mr Carpenter stares at me, then drops the crust back on the plate.
‘Finished?’ says Tim. ‘Good!’ then takes the plate away.

here to help

It’s a cliche that dogs look like their owners. But whilst I wouldn’t say it was true, even someone as cynical as me would have to admit that Ralph the Shih Tzu is a dead spit for his owner, Robert. They have the same overhanging mullet, the same bug-eyes, the same extravagantly friendly, panting smile – to the extent that if I picked up this squeaky banana toy and threw it across the room, I’m not sure which one of them would get there first.

‘So what happens now?’ says Robert, sitting on the edge of his chair, whilst Ralph plumps himself down at my feet so I can scraggle his ears.

Robert’s mum is entering the final stages of her illness. The district nurses are organising the End of Life nursing care, and they’ve referred to us for additional care support and any extra equipment that might need providing at short notice.

I explain exactly what it is we can offer, how the system works, what’s going to happen next. Robert writes notes on the front page of the folder I’ve given him. There’s a lot to process – mostly how the teams come together, who does what and so on. It’s taken me a few years to figure it out, so I’m not surprised Robert struggles to understand. I try to simplify it to the basics – what time the carers will come in, what they’ll do.

‘I’m grateful for anything,’ says Robert. Ralph swipes at my leg with a paw. I scraggle his ears some more. His back leg begins to twitch.

‘He’s lovely,’ I say.
‘I rescued him,’ says Robert.
‘From the pound?’
‘From the neighbours next door but one. I think the kids wanted a dog, but then went off the idea. Poor thing. He never got a walk. They used to go out all the time and leave him behind a baby gate in the kitchen. I went round one day to help them with their fridge, and I felt sorry for him. So I said do you want me to take him for a stretch round the block? And they said if you like. So I did, and it became a regular thing. We just kind of clicked. He came and stayed with me for a week when they went on holiday. I didn’t hear from them when they got back, and when I went round and said what about Ralph then? And they said you may as well keep him. So I did.’
‘He landed on his paws.’
‘I think so. We both did. Didn’t we, Ralph? Eh?’
Ralph gives him a glance, then puts a paw out, taps my leg, and bows his head ready.