failed discharge

please welcome on stage

~ jim clayton ~ 2 Comments

Thomas is alert but strangely neutral, propped up on the ambulance trolley, his white hair wild on the pillow, his mouth slack. He’s put on so much weight it’s taken a team of four to wheel him off the ambulance, up the drive, through the portico and into the house. Jenny the OT and I have arrived just in time to help, although there’s not much for us to do other than carry in all the bags of personal possessions, drugs and so on. The patient transport crew are a loud and pleasant bunch, eyes smiling over their masks, plenty of to you / to me banter as they patslide Thomas into bed, make things good, get ready to go. One of them nods for me to follow her back out to the truck, though.

‘I don’t know what help you can give them,’ she says. ‘But I gotta tell ya – I’m worried about the daughter. She’s a donkey on the edge. See what you think. Personally – I don’t know – I wouldn’t put money on it.’

The story is that Thomas went into hospital after a fall, stayed a month, then got transferred to a nursing home for a few weeks’ rehabilitation. Meanwhile, the hospital OTs visited the house, put in a hospital bed, stand aid, commode and so on, and then referred him to us for more therapy and nursing support, along with bridging care until a full time agency can take over. All in all it’s about as much as anyone can do short of adoption, or residential care, of course. But we’ve been tasked to visit for the initial assessment, to see how it all looks, and if the plan is workable.

The house is like a spacious, somewhat incongruous pink Spanish villa, set back on a rise at the head of the close. Thomas’ hospital bed has been set up in the L of the vast, low-ceilinged living area, with bare stone walls, a heavily-timbered fireplace, brasses hanging here and there, a hunting horn, a few framed portraits. Even though it’s hot and bright outside, the late summer morning doesn’t penetrate overmuch; what light there is only makes it so far through the patio glass at the far end, lying like a glossy green sweat on the backs of the clubby sofas and chairs.

In fact, the scale of the place is a little overwhelming. It’s the details that make you dizzy. On the wall behind the head-end of Thomas’ bed is a giant oil-painting of a horse’s head; at the foot of the bed, on a granite pedestal, a fish tank filled with tiny silver fish.

Thomas’ daughter, Helen brings in a giant mug, filled almost to the brim with tea.
‘Don’t spill it!’ she says to him, putting it on the overbed table.
He glances down, shakily jerks his hands, the tea slops.
‘Look what you’re doing!’ she says.
I take the cup from him, move the table to one side, hand the cup back to Helen.
‘He really needs one of those spill-free mugs – you know – the ones with the spout.’
‘What – like kids use? For kids?’
I nod.
‘That’s it!’
‘Have you got any?’
‘We don’t carry them. But you can get them anywhere. The supermarket, pharmacy…’
‘A beaker for kids? You mean Tommy Tippee?’
‘A lot of people use them.’
She looks horrified, takes the tea back into the kitchen.

Whilst Jenny starts doing the paperwork and an audit of the equipment we’ll need to check, I run some basic obs. It’s immediately obvious things aren’t right.
‘I think this is looking like a failed discharge,’ I say, looping the steth back over my neck.

Alice and Frank, two of our most experienced carers, turn up for the lunchtime call. It’s good to see them – they’re so cheerful and grounded, it immediately makes any situation a hundred times better. Between us we set about sorting Thomas out, log-rolling him, tearing off his pads, cleaning him up, putting on fresh pads, changing the sheets, sitting him up again. Thomas coughs throughout. Frank raises his eyebrows at me.
‘Tested for Covid?’
‘A month ago.’
‘Oh-kay…’

Helen appears in the doorway. She stands watching us, her arms folded, staring at the pile of sheets on the floor.
‘What’s that?’ she says. ‘Why’s that there?’

Jenny goes over to her to explain the situation whilst we finish up.
‘They’ve just had to clean your dad up and make him comfortable. Have you got a washing machine?’
‘What do you mean? I’m not doing any washing.’
‘It’s not too bad, Helen. It just needs tossing in the machine with a tab of something.’
‘Well you can do that because I’m not. Isn’t that what you’re supposed to do?’
‘No, I’m afraid not. We’re effectively an emergency service. The carers will be coming in four times a day for bed washes, pad changes, and then simple meal prep and medication if that’s needed, too. But everything else – things like washing, cleaning, shopping – well, they’re all classed as domestic chores. You’ll need to find someone to cover that if you can’t.’
‘Well I’m certainly not doing it,’ she says. ‘Why should I? I’m not touching anything soiled.’
‘You can put gloves on.’
‘Gloves? Gloves? I’m not putting gloves on. Look – you do what you have to do, but I can’t … I just can’t… I’ll go and stay at a friend’s if that’s what you think’s going to happen.’
Jenny looks over to me.
‘It might all be a little academic…’ I say, feeling Thomas’ pulse again. He sits propped up on the pillows, the focus of everyone’s attention, his mouth bouncing up and down, mute as a ventriloquist’s dummy who still has a whole bunch of things to say – important things, mad things, funny things – but the hand some time ago let go of the lever, and left him on stage to carry the show alone.

about george

~ jim clayton ~ Leave a comment

I’d met George a few times in the past, so I had my doubts.

‘You have to take him,’ said Lyra, the manager of the rehab unit. ‘He’s been here six weeks and it was only supposed to be a couple of days.’
‘But you say he’s hoist only now?’
‘Yes.’
‘In that house?’
‘Yes.’
‘And it’s been cleared? It was so tiny and cluttered. You’ve actually managed to fit a hoist and a commode in there?’
There’s an ominous pause.
‘Yes,’ she says. ‘I wouldn’t be sending him home, otherwise. Would I?’

The conversation hadn’t started well.

George had been referred to us for an initial assessment. I’d phoned the unit to clear a couple of things up. When the first person answered I went through the usual spiel: Hello. My name’s Jim. I’m a nursing assistant from the Rapid Response team. I’m just calling to find out about George’s discharge today.
‘Oh. Hold on. You need to talk to another nurse.’
She put the phone down on the desk without muting it, so I could hear her calling out (although the other person was too far away to hear): I don’t know. Some guy asking about George…. I don’t know what he wants…. Why don’t you speak to him?…. Well where IS she?…..
Then some general clattering, muttering, background noise. Laughter. Eventually someone else picked the phone up from the desk.
‘Hell-oo?’ she said, in that drawn-out, slightly hesitant voice you might use for a sales call or worse.
‘Oh – yes – hello! My name’s Jim. I’m a nursing assistant from the Rapid Response team. Sorry to bother you. I’m just calling to find out about George’s discharge today.’
‘Who?’
‘George Masters.’
‘No. Who are you?’
‘Me? I’m Jim. Nursing assistant. Rapid Response Team.’
‘Just a minute…’
She puts the phone back down on the desk, again – without pushing the mute button.
I don’t know. He says he’s a nursing assistant called Jim. Asking about George.
There’s some toing and froing between the two, then she picks the phone up again.
‘What is it you want exactly?’
‘Well – two things. One is that on the discharge summary they give an address that’s different to the one we’ve got. So we need to clear that up. And the other thing is to find out what time he’ll be home.’
‘Just a minute…’
She does the same thing. This time, I’m waiting for five minutes, hanging on the phone, listening to all the traffic and fuss of the unit. Just as I’m about to hang up and call again later, the phone gets picked up by someone else.
‘Hello?’
‘Hello. Erm. Yep. My name’s Jim. I’m a nursing assistant from the Rapid Response Team. Erm.. can I ask who I’m talking to?’
‘My name’s Sheila. How can I help?’
‘Are you a nurse, or …’
‘Yes – I’m a nurse.’
‘Great! Do you know about George Masters?’
‘What about him?’
I take a breath, then go into the two things I need to know about George so we can be there to do the initial assessment.
‘You need to speak to Lyra,’ she says.
‘Who’s Lyra?’
‘The unit manager… LYRA…!’ she shouts, so loudly I have to lean away from the receiver. She slams the unmuted phone back down on the desk.
Another five minutes.
Eventually the phone gets picked up again.
‘Hello? Lyra speaking?’
‘Hi Lyra. Can I just say, before I go on – I’m not all that happy with the way this phone call has gone. I’ve spoken to three different people. They’ve all put the phone down without even muting it, so I can hear them shouting across the unit…’
‘Don’t get clippy with me,’ says Lyra.
‘I’m not clippy, I’m just saying…’
‘I don’t appreciate your tone…’
‘All I’m saying is that it’s been really frustrating ringing your unit today….’
‘We’re busy. What d’you expect?’
‘Everyone’s busy.’
‘I think you need to look at the way you speak to people. Who did you say you were?’

We struggled on with the conversation, but by the time I hung up I was sweating more than a pilot who’d spent half an hour fighting to stop a plane crash.

‘So – when’s he home?’ said Anna, who was due to handle the initial assessment with me.
‘She’ll call me,’ I said. ‘Maybe.’

To be fair, from that point on Lyra was more amenable. I think it was because she was desperate to discharge George, who’d been a disruptive presence on the unit, constantly ringing his button, throwing tissues everywhere, generally playing up. I’d met George before, of course, and I knew he could be difficult. But when I’d known him he was still at home – a tiny, cluttered house with a kitchen whose ceiling was halfway down and whose downstairs toilet was so unspeakable you wanted to clean it up with a flamethrower. He had a cute dog, though – a perky little brown and white Jack Russell called Lily, so it would be nice to see her again.
‘I’m sorry about the way the phone call went,’ said Lyra. ‘We’re completely rammed here, as you can imagine. And I’m having to get by with agency nurses, and they don’t know the routine.’
‘That’s okay. I’m sorry if you thought I was clippy.’
We laugh about it.
End the call.

Later that day I’m sitting in George’s front room. We’ve just hoisted George from the wheelchair onto the hospital bed, but already he’s talking about putting himself on the floor because ‘it’s too early for bed,’ even though he couldn’t sit in a chair without three feet of rope and a crash mat. The neighbour who we were told would be coming round with shopping and generally keeping an eye on things is actually self-isolating and not leaving his house. To add to the woeful picture, we’ve just found out the boiler doesn’t work. Our team have been asked to provide bridging care four times a day, but even so you couldn’t say with any confidence that George would be safe between calls. He really needs some kind of residential facility. Still – at least Lily the dog has been rehomed.

There’s nothing else for it.
I ring Lyra.
She answers.
I tell her the situation.
There’s an ominous pause…

drishti’s miracle

~ jim clayton ~ Leave a comment

Ella’s son John is furious. Not with us, he says, every now and again, like a cartoon bull kicking and raging around the ring, stamping his hooves, blowing smoke through his nose and ears – then stopping in a cloud of dust to bow to the rodeo clown.
‘Look at her! They may as well have fly-tipped her by the side of the fackin’ road. Like a fackin’ fridge or some’ink.’
‘I know it’s stressful, John, but just try to ease it back a little if you can…’
‘I’m not ‘avin a go at you, mate,’ he says. ‘It’s the fackin’ hospital. And the ambulance. I mean – what was they thinkin’? We’re back to square one. This is exactly the fackin’ situation she was in when she went in in the first place.’ He suddenly seems tangled up in all those ‘ins’ and stands there, breathing hard.
Even though John makes you want to take a step back, and maybe even pick up a cushion or something, I have to admit I can see his point. Ella is a bariatric, self-neglecting patient who’d been admitted after being stuck on the sofa for several days. And even though the flat has had a rudimentary ‘deep clean’ whilst she’s been away, it’s still pretty awful, and here she is, back on the same sofa. The two ambulance crews must have sweated and struggled hauling her in their carry chair up that crooked flight of stairs. And I suppose gravity and the relative height of the chair to the sofa must have worked sufficiently in their favour to make the transfer. But since we’ve been on scene to do the initial assessment and see what Ella needs in the way of therapy, nursing and care support, she hasn’t been able to get up, even with the most enthusiastic, hands-on encouragement. To all intents and purposes, John is right. She’s landed back where she started. If Ella can’t get up from the sofa we’ll simply have to send her in again, as a failed discharge.
It’s a difficult situation, made worse by the fact it’s already six o’clock in the evening. If we call for an ambulance they’ll mark her as low priority. We could be here till midnight.
‘Well I can’t stay,’ says John, reading my mind. ‘I’ve got my own family. I’ve got work in the morning. I’m fackin’ Hank Marvin’ and there’s fack all in the fridge. I mean – where’s the thinkin’? Where’s the planning? Hey? It’s fackin’ pathetic. I told ‘em this’d happen. I told ‘em exactly what’d happen. And what happens? This! This happens! Fackin’ unbelievable.’

I’m here with Drishti, the physio. I know how busy she’s been today, and lately. How much it would mean to her today to finish work on time and get home to her family.
‘There’s no point in us both staying,’ I say to her. Drishti is so essentially kind, though, she won’t have it.
‘No, no,’ she says. ‘Let us remain together and see what we can do. It’s never too late for a miracle.’

The thing I need to do with the most urgency now is redress Ella’s leg. She has varicose eczema. At some point she’s pushed the dressings down and been working away at the scabs. From time to time she reaches down, absent-mindedly pulls off another bloody scrap, and puts it in her mouth. It’s difficult to keep an eye on her to stop her doing it, especially with John ranting around the place.
‘Please don’t do that!’ says Drishti, gently guiding her hand back down and wiping it with a tissue. ‘It’s really not a good thing to do,’ she says.
I clean the leg with saline and re-dress it whilst Drishti calls for an ambulance.
‘Four hours minimum’ she says with a sigh, hanging up. ‘They say it is a busy night. When is it NOT a busy night?’
‘I don’t suppose you’d be able to stay with your mum…?’ I say to John.
‘What? You’re havin’ a laugh, mate? Four hours? I’ve been ‘ere too fackin’ long already. I’ve got my own fackin’ life, y’know?’
‘Has you got anyone else? Any siblings?’
‘I’ve got my sisters, but they’ve washed their hands. They don’t want to know.’
‘What about friends? Neighbours?’
‘There’s no-one. That’s what I told ‘em! She hasn’t been out o’ the flat in seven years! I fackin’ told ‘em all this! I can’t stay, mate. I gotta get up early.’
‘Okay,’ says Drishti. ‘That’s fine. You can go.’
And it’s only when he turns to hurry out of the door that she gives me a steady, sorrowful look.

I call the office to let them know what’s going on and to see if they have any brilliant ideas.
Lawrence is co-ordinating.
‘Ah!’ he says. ‘Oh dear. Erm….Well! Yes. I see the problem.’

If I’d written a film script set in the eleventh century, and there was a scene where a troupe of marauding knights were riding towards a monastery, and the monks were frantically running around, and one of them, a particularly tall and ascetic looking monk, was desperately loading up a cart with armfuls of ancient books and scrolls and things, tripping over his habit, cursing mildly, and then the ass gave a jolt and a wheel fell off, splashing the monk head to sandals in mud, just as the knights came clattering into the yard, swinging their swords, and the monk turned to deliver his line straight to camera: ‘Well. Isn’t that just bloomin’ typical!’ – I’d be sure to cast Lawrence as that monk.
(He already has the haircut).

‘Oh dear!’ he says. ‘Damn and double-damn. Okay. Right. Well. I suppose I could relieve you when the office closes. If you like? I live nearby, so it wouldn’t be so bad for me…’
‘That’s kind of you, Lawrence,’ I say. ‘Maybe it won’t come to that.’
I tell him we’ll keep in touch, and ring off.

We settle in – as best we can, given the environment.

Ella says she’d like to watch some TV. We give her the remote and she flicks through the channels, eventually landing on a reality show about a couple looking to buy a house. They’re standing on a terrace overlooking a fiercely blue harbour dotted with yachts.
‘You won’t see that in Bradford,’ the presenter says.
The couple smile but they look uneasy, shielding their eyes from either the sun or the presenter, it’s hard to tell. I suppose the idea is they could live anywhere. Maybe the next place they show them will be underwater or something.
‘That looks nice’ says Drishti. ‘Hot, you know?’
Suddenly a mobile phone rings somewhere. Drishti locates it in Ella’s hospital bag. She hands it to her.
‘Hello…?’ says Ella, still watching the TV. ‘Yeah. About an hour ago…’
I raise my eyebrows.
‘Ella?’ I say. ‘Sorry to interrupt. Would you mind if I had a quick word with them?’
‘It’s the nurse’ she says into the phone. ‘Okay. Jes’ a minute…’ She hands me the phone, then leans to the side to carry on watching the TV.
The caller is a woman called Stella. She works for a befriending service. Apparently Stella had been expecting Ella home and was planning to come round to see she had everything she needed and so on. I explain the situation, and ask if Stella might be able to stay a little longer until the ambulance arrived.
‘Medically she’s okay,’ I say. ‘It’s just she needs someone to keep an eye on her.’
‘That’s fine’ says Stella. ‘No problem. I’ll be straight round.’
‘Thank you so much,’ I say, then hand the phone back to Ella.
‘Who was that?’ says Drishti.
‘That was your miracle!’
I go to the window, draw the net curtains aside, and look out at the night sky, fully expecting to see a star detach itself, glide gently and magnificently down to earth, hop pointedly across the lawn, and ring the bell.