It’s 7am, coffee in one hand and three bags in the other, I race out the door and mentally prepare for another morning in Sydney traffic. I arrive on the ward for the whiteboard meeting. The team bulges out of the small room: the ward resident, nurse, physiotherapist, occupational therapist, dietitian, social worker, bed manager and speech pathologist. I’m glad to hear that there were no falls over the weekend, though Mr P, an 84-year-old war veteran having rehab after a hip fracture, tried to get out of bed for a shower at 3am this morning. He’s not very close to the nurses’ station so we decide to swap him with another patient, who’s settled in now and is less at risk of falls. He needs a bed alarm too, just in case he tries to get out of bed overnight again.
I’m already late for the next meeting – a multidisciplinary case conference with the Geriatric Flying Squad. It’s not as glamorous as it sounds – I’m yet to swoop down to a patient from my helicopter, arriving in aviators and a bomber jacket. We respond to the most vulnerable older people at home, who have limited supports and are struggling in the community. We keep them out of hospital – the chaos and alarms of the Emergency Department are not ideal for the frail and elderly patients with cognitive impairment. I apologise for being late and spot the delicious fruit cake baked by our wonderful social worker.
We discuss the list of community clients, summarising decades of complicated life stories and family dynamics into five-minute digestible pieces. There’s a 70-year-old man referred from Homeless Health for concerns about his cognition – he’s currently in emergency accommodation but has been sending the bulk of his Aged Care Pension to his family overseas. There’s a 94-year-old lady with advanced Alzheimer’s disease who was seen over the weekend for confusion. The nurse noticed that she had a large bruise over her calf and wasn’t sure if it was caused by their dog, as reported by her daughter. I plan to see her this week with our social worker. Unfortunately, it’s not uncommon for elder abuse to rear its ugly head.
My first visit is to a 92-year-old retired truck driver in a Department of Housing unit. The unit block is known to have some criminal activity, so I am accompanied by our Clinical Nurse Consultant (CNC). I hear that he’s presented five times this month to hospital with breathlessness and anxiety. He has long-term COPD and the community respiratory CNC is struggling to convince him to stop calling the ambulance.
We’re greeted by a broad smile and I notice that his clothes look at least two sizes too big. I hear about his childhood, how he was estranged from his mother and grew up on a farm. He got married when he was seventeen and hasn’t been quite the same since his wife’s passing. Her ashes are in the wardrobe in their bedroom and this is his only source of comfort. I ask about him calling the ambulance and he says he’s recently experienced a home invasion and doesn’t feel safe, which perpetuates the vicious cycle of dyspnoea and anxiety.
I perform a cognitive screening test and despite not having any formal schooling, he drew a perfect cube and was able to name ten animals in one minute. He agreed to his carers visiting more frequently to provide some more support, and to make sure he’s eating his meals. He’s not ready to leave his home yet, so this will be a discussion for next time. On the drive back, I reflect on how loneliness affects our most vulnerable.
It’s just past lunchtime and we’re back at the office. I use the spare clinic room to express breastmilk for my five-month-old daughter. It’s hard being away, but just as I’m missing her, my mum sends a photo of her enjoying tummy-time, which makes me smile. As I make my way back to the office, I’m stopped in the corridor by a patient’s daughter – her floral dress and red lipstick are in stark contrast to the sallow, worn-out person I met two days ago. She takes my hand, a gesture of gratitude that we convinced her mother to come into hospital for rehabilitation after not leaving the house for months – she’s even enjoying the hydrotherapy!
It’s almost a rite of passage as a community geriatrics registrar to experience home visits designed to make you appreciate the limits of human survival. When our CNC, who’s had at least ten years in dementia care nursing, tells you you’re in for a tough one, you make sure you have your gumboots and thinking cap on. We arrive at the house, and it looks like any other on the quiet suburban street, until you open the door. The stench slaps you in the face – a pungent mix of urine, cigarette smoke and alcohol. The floors are sticky under my shoes as I’m led down a cluttered hallway to the room where Mrs D is lying.
I hear that she fell three days ago and hasn’t been out of bed since. The room has a commode, half-filled with human excrement, with stains of all shades of yellow and brown on the bed sheets. I realise the smell of alcohol is coming from her daughter who was tasked with her care. I observe Mrs D’s skeletal frame, with a sun-hat framing her gaunt face and I am struck by her fingers and lips – they’re blue. The next hour is a discovery quest: her husband who is wheelchair-bound, the fact that her son is recovering from a seizure, the drug concoction of diazepam, tramadol and fentanyl at her bedside, and that she doesn’t want to go to hospital.
The next hour is life and death, it’s clear that without medical intervention, this stained bed will be her deathbed. How do I respect her wishes? Does she have capacity to decide for herself? How do I ensure her remaining days are dignified? As I’m contemplating these questions, her husband enters the room, carrying the burden of the situation with his kyphotic spine and sunken eyes – he’s not ready to lose her and with this she reluctantly agrees with treatment. We wait for the paramedics to arrive and I speak to the Emergency consultant to let them know the details.
As I’m sitting in peak hour traffic for the commute home, I hear my phone ring and am glad to see my husband’s number pop up on the screen. We debrief about the day and trade war stories – I tell him that my day in community geriatrics isn’t too different to his, in transplant medicine, which earns a hearty laugh. I’m greeted at the door again with a broad smile – this time it’s my daughter’s toothless grin. I’ve missed the evening feed but can’t wait for cuddles and story-time (after a shower of course)!
Please note names have been changed to protect patients’ privacy.