Tuesday, December 27, 2011

The Sights and Sounds of Christmas Shouldn't Include Blood and Sirens

The Christmas Eve meal was pretty well prepared and in the oven. We were planning to eat at 3:30 p.m. My mother-in-law arrived early, and she visited with my husband as I finished up with last-minute kitchen preparations. I glanced at the clock – 2:10 p.m. My mother and her sister were to pick up my grandmother at her assisted living facility at 2:00, so they should be arriving any minute. I glanced up and saw Mom’s Jeep pull into our driveway, and I told my husband, “Mom is here with Mam-ma.” He and his mother started for the door to greet them, as I searched for something in the pantry. Then I heard my mother scream for my husband to come quickly. My grandmother had fallen. I rushed outside to see her lying lifeless on the driveway. We thought she had had a stroke. My husband rushed to call 911 as I hurried toward my Mam-ma. That’s when I saw the pool of blood forming under her head and trailing down our driveway.

In a panic, I ran inside and told Greg that Mam-ma was bleeding. He told me to get a rag and apply pressure to her wound. I ran inside and got a wet rag. Looking back, I don't know why I thought it had to be wet, but in my panic, I ran the rag under the faucet to dampen it! I knelt beside Mam-ma and pressed it tightly to her head. Her eyes were fixed, her mouth was open, and she was totally unresponsive. I thought she was dead.

I applied pressure, and asked, "Mam-ma, can you hear me?" A few seconds later, she said, "Yeah." We covered her with blankets. Thankfully the temperature had risen into the fifties and the day was sunny, so the concrete driveway was cold, but dry. As I applied pressure, the blood soaked through the rag and poured on to the concrete underneath. Greg brought me even more rags, as the pool of blood continued to grow on the concrete. We kept assuring everyone that head wounds bleed a lot and often look worse than they are. But since we didn't dare move Mam-ma to look, we had no clue exactly where she was wounded... or how bad it truly was.

The ambulance arrived after about 10 minutes, and my grandmother was placed on a back-board and fitted with a cervical collar. She was transported to the hospital emergency room, which is maybe two minutes from our house. A few hours later, CT-scans indicated no internal head or neck injuries. Once the bandages were removed and everything was cleaned, only a small puncture wound inside a larger hematoma sat behind her right ear. The only pain she complained of was from the back stabilization board. The ER staff said that this necessary precaution is "one of the worst things we do to people." She begged me, "Please, please... get me off this thing." But I was unable to do so until the results of the scans were read. I would guess she was strapped down about two hours.

When we could see that this was going to take a while, my husband came to the ER and sat with my grandmother, while I hurried home and finished heating our Christmas dinner and got it on the table for everyone. I ate with my family - Mom, her sister, my mother-in-law, my sister and her husband - knowing it might be my only chance to eat for the rest of the night. Then I returned to the ER and traded places with my husband. By this time, the doctor had given her a shot of something called Nubain for pain.

Greg said he asked Mam-ma, "Are you hurting?" and she said she was not. But when the doctor came in, he asked her if she was in pain, and she said "Yes." So he promptly ordered pain medication and gave her 5 mg of Nubain. He also wrote a prescription for pain medication for the next 2 days and said we needed to hurry to Wal-Mart to get the prescription filled, because the pharmacy would close early on Christmas Eve. It was now about 5:30 p.m.

This prescription should have been a "red flag," but in our shock and confusion, we didn't think to question it, so Greg headed to Wal-Mart to get the medication. Meanwhile, the doctor prepared to discharge my grandmother, declaring that he had “no medical reason” to keep her.

I could not believe it... and I tried to plead my case with him... Wasn’t it enough that she was 99 years old and had just had such a nasty fall? Didn’t her high blood pressure and her “loopiness” from the pain medication he had just administered qualify her to stay? Could he not consider that she was dismissed from a six-day hospital stay only 12 days earlier? He insisted his hands were tied.

The assisted living facility was contacted, and the nurse said they were understaffed and they could not perform “neuro” checks every 2 hours, as prescribed. I did not feel my grandmother was steady enough to stay in her apartment alone anyway.

The doctor suggested perhaps Mam-ma could stay with a family member. I just looked at him and said, "She fell trying to get into my house. Do you really think that's a good idea?" He agreed this was not a great option, but he said he was just trying to offer me some possible solutions. His final suggestion was, “I guess you could take her to apartment and stay with her there overnight.” I just walked away from the desk.

I was at my wits’ end. I didn’t know what to do. I called my husband and told him this while he waited at Wal-Mart. He was not a happy camper, but he told me the choice was ultimtately mine. I told him I guessed we would have to pray hard and take our chances in my grandmother’s apartment. Greg suggested I call my mom and relay all of this information to her and see what she thought. I looked up and saw a sign beside a door where I was standing. It said “Chapel.”

I stepped inside the chapel to call my mom, and as we talked, I started to fall apart. I looked at plaques that hung on the wall. They were scriptures, and the first thing I saw was Philippians 4:6-7..."Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God. And the peace of God, which transcends all understanding, will guard your hearts and your minds in Christ Jesus." Then I read Lamentations 3:22-23..."Because of the LORD’s great love we are not consumed, for his compassions never fail. They are new every morning; great is your faithfulness."...followed by Psalm 23, and finally... Jeremiah 29:11..."For I know the plans I have for you,” declares the LORD, “plans to prosper you and not to harm you, plans to give you hope and a future." All scriptures are from the New International Version (NIV).

My mother insisted that she would stay with my grandmother at her apartment, and I reluctantly agreed. I knew that I was physically stronger and more able to manage Mam-ma, but neither of us had any business handling a 99-year-old injured woman who was spaced out on pain meds. Then I said a prayer before I left the chapel and asked God to handle this… to take my worries and fretting and give me peace about this situation.

When I stepped back into my grandmother’s exam room, I was visibly upset… and so was the charge nurse who had been treating my grandmother. I am not sure she hadn't been crying, too. Her face was red and she was sniffling. She had spent an hour cleaning Mam-ma's head wound, and I have to say, every single staff member - including the attending physician - was absolutely wonderful with Mam-ma. I expressed again my concerns and frustration… and the nurse agreed that I was right to be concerned. Then she asked which doctor my grandmother had seen when she was hospitalized earlier in the month.

I told the nurse name of my grandmother’s last hospitalist, and she said, “He’s on duty all weekend. I can ask the ER doctor to call him if you want and see if he will admit your grandmother - at least overnight.” She didn’t make any promises, but it was worth a shot. Of course I wanted her to ask! I thanked her for doing this, and she left to talk with the attending physician. A few minutes later, she returned to tell me that the attending had indeed agreed to call the hospitalist, who had agreed admit my grandmother for overnight observation.

I cannot tell you the overwhelming peace and relief that flooded me when the nurse offered to talk with the doctors. I cannot begin to express how I felt when she returned to tell me that the hospitalist had agreed. I was so grateful to God for working out what I could not… and for directing me into that chapel for a few minutes. There, as I read those scripture passages, God gave me what I needed… hope, peace, reassurance that He was in control… and love overflowing.

Orders were written, and Mam-ma was wheeled upstairs by the charge nurse. I continued to thank her for being there - for helping me - for caring. She said, "My hands were tied until you asked..." It was then that I realized... I had to ask to speak to the hospitalist. Since Mam-ma's primary care physician is the nursing home staff doctor (and practicies in another city and does not have admitting privileges at our local hospital), we had to find someone who had treated her and could vouch for the necessity of admitting her. Once I recognized her hospitalist's name on the white board, we had a chance!

Upstairs, the nurses on the floor - some of them childhood friends, and all of them good "new" friends from 2 weeks ago - jumped up and began to get Mam-ma settled. To a nurse, they were appalled that there had been any question about admitting my grandmother. One dear LPN said, "Were you supposed to pour her into your car after this shot of Nubain?" For the record, this is not a necessarily bad pain medication - the concern was my grandmothers size and age - and the dosage administered.

Every time they stood Mam-ma up or moved her in the least, she vomited. The nurses agreed to watch her and hold off on giving anti-nausea medication, in case the sickness was related to the head injury. Mam-ma was settled in bed by about 7:00, but she seemed restless. She kept saying, "Debbie, you go on home." I decided she might rest better if I left, so I returned to my family gathering for a while.

When everyone had eaten and visited, we declared our "Christmas" over and done, and all of the family members went home around 8:30 p.m.. I returned to the hospital to sit with Mam-ma for a while. The LPN asked me, "What are you going to do... are you staying?" I asked her if she felt it was necessary, and she said, "No... but I want your phone number written on the white board." I placed my contact information on the white board and reminded the nurses I was less than 2 minutes away any hour of the night or day. I also reminded them that my grandmother is a DNR - Do Not Rescusitate - patient. Be sure you remind the staff of this, if you have such directives as a DNR and/or Living Will. Apparently it does not always transfer on the records!

I sat with Mam-ma until about 10:00 p.m., kissed her goodnight, and returned home. Christmas morning, I was back about 9:30 a.m. - the nurses had said the doctor would make rounds by 10:00, they hoped. And he was pretty well right on time. Before he even examined her, he said, "We'll monitor her today, and maybe she can go back to her apartment tomorrow." I was thrilled by this news. But at the same time, I had to ask myself... how did we so quickly get from "We have no medical reason to keep her," to monitoring her for two nights in the hospital? The only answer I have is the grace of God and His divine countenance to put the right nurses - and this hospitalist - in the key places Christmas Eve.

Amazingly, Mam-ma is doing very well. She was dismissed to return to her apartment the day after Christmas, and we had her back in her own bed by about 1:00 p.m. The hospitalist told me that this will be mostly a "behavior modification" issue... helping my grandmother remember to ask for help when getting up for the bathroom, to go to meals, etc. In talking to my mom and her sister, we have determined that Mam-ma got out of Mom's car under her own steam and did not wait on Mom to come around and help her.

While Mom got the walker from the back of her Jeep, Mam-ma got out, closed her door, and was inching along the side of the vehicle. Mom's sister, who is probably 4'10" and about 85 lbs., saw Mam-ma wobble and tried to grab her coat. She says she quickly realized if she hung onto the coat, she would be pulled down atop my grandmother... so she let go. We are assuming that Mam-ma's blood pressure dips when she first stands, and she must wait and count to 5 before taking a step... giving her body time to catch up. We think this explains the other 2 falls, both of which occurred when she bent over or turned too quickly while standing.

The nurses at the hospital admonished me that Mam-ma was going home as a "full one-person assist" when getting up for anything. She is weaker than ever now. In talking with the nurses at the ALF, we agreed that she truly doesn't remember to call for help... and she doesn't mind well, to boot! So the R.N. and I both talked to Mam-ma about calling for help. I asked Mam-ma, "What are you supposed to do when you need to get up?" "Call for help," she answered. I told her that was right and asked, "Where is your 'call button'?" She answered, "I don't know." I reminded her it was in the chest pocket of her pajamas.

The R.N. printed ten signs that remind Mam-ma to call for help before getting up. She taped them all over Mam-ma's apartment - the walls, every door and drawer, and above her bed. Even as she did this, Mam-ma started to get up out of bed unassisted. "This is good," I thought... "she will see first-hand how Mam-ma does." We reminded Mam-ma to call for help, and she said, "Well, y'all was both here." We agreed, but after the nurse helped Mam-ma to the bathroom, she turned her back for a few seconds, and Mam-ma was trying to stand on her own. She said, "I can see that this will not work."

I asked what else could be done besides 10 signs on the walls and doors, and she said, "I'm going to talk to the aides right now and order room checks every 30 minutes. If that isn't enough, I will put an alarm under her bed." Somehow, I have a feeling we will have that alarm before the week is over. The nurse said surely if an aide came in every 30 minutes and tried to second-guess what Mam-ma might need - bathroom break, something to drink, etc. - we could prevent her getting up unattended. We are all shocked that nothing was broken in this latest fall, and we are so worried that she will break something the next time.

Meanwhile, the ALF nurse shed some light on why the ER attending physician was so reluctant to admit my grandmother. Medicare has tightened the reins on admits and discharges and what they will cover. It is possible that this doctor felt that the hospital would not be reimbursed for Mam-ma's stay, because it occurred within 30 days of her last visit. The nurse told me, "I could have easily given you a dozen or more viable reasons to admit your grandmother," but apparently this doctor chose to go strictly "by the book." I want to give him the benefit of the doubt... but I'm struggling, given her age, high blood pressure (193/118) and her general condition.

The ALF nurse was also less than pleased that a woman weighing 113 lbs was given such a strong dose of pain medication - and a "take-home" prescription for Hydrocodone. She could not understand why someone with a history of falls would be prescribed narcotic pain medication and dismissed. I don't get it, either... and my grandmother will never see the Hydrocodone!

I feel that the staff at the ALF is doing everything possible to help me keep my grandmother safe. Physical therapy will begin later this week to strenghten her physically and cognitively. The goal is to get Mam-ma up on her feet again... with the help of a walker, of course. I asked the hospitalist if he could order a wheelchair for her, but he explained to me that this needs to be a last resort - and he does not want her in a wheelchair 24/7, because her skin tissue can deteriorate from sitting, and she would be at risk for infection. I am so glad this guy is so thorough. That had not occurred to me... and some doctors would have said, "Sure!" and written this order, just to placate me.

From what I have been reading, part of the new Medicare initiatives involves encouraging hospitals to do a better job of treating the patients while they are there... AND sending the proper care directives home with them to prevent a return stay and better rehabilitate the patient. I understand this completely, and for the most part, I've observed more detailed discharge directives for my grandmother. MY JOB is to follow through on these and make sure they are all communicated properly and nothing falls through the cracks!

As we left the hospital, I told one of the nurses, "I learned several new things this trip." She replied... "You will learn new things every time you come. It's not always things you would wish to know, but you will be better for it." What did I learn this time?

  1. Do not be afraid to advocate for your patient. I told more than one nurse, "I know you are sick and tired of looking up at the desk and seeing me standing there to ask you something." More than once, I was told, "If you don't advocate for your grandmother, nobody will. Do not ever back down or hesitate. We understand completely."
  2. Do not be afraid to question or challenge the medical staff. Now I know to ask to speak to the hospitalist if we are in the ER. Had my grandmother's doctor been one who had hospital admitting priviliges, I would have asked for him/her. But now I know to ASK! Question medications... What is this?... Why is it being given?

    My grandmother will often say one thing one minute and another the next, as in "No, I don't hurt anywhere," followed by "I hurt all over." And because we are not sure which is true, I would rather she be given something for pain on the off chance she really was hurting. But you still should know exactly what is being administered, what procedures are being performed, what the ramifications are of these... and WHY they are being done.
  3. This was not a new revelation, but I need to remind you that the medical staff does not know your loved one like you do. On Mam-ma's last visit, the doctors kept wanting to tinker with her blood pressure medications, because one day her BP would be extremely high, and the next it would be very low. I explained that she has done this for years now... several days of high blood pressure, followed by a day or two where it bottomed and she could barely move. Once they understood that this is "just Polly," they left the medications alone and let her body level out on its own.
I also made a point to "prove" to several nurses just how poorly Mam-ma follows instructions. While making sure she was safe and didn't fall and hurt herself, I let more than one nurse see how she gets ahead of you and will not wait for assistance. It didn't take long for them to get the necessary alarms and precautions in place.

Finally, I have been monitoring my grandmother's weight gain. When my mom and I visited a few days before Christmas, Mam-ma's ankles were swollen again - and I was alarmed. I questioned this and was told, "She's only gained seven pounds - but she is eating well." I pursued this and got the nurses to understand that "a pound a day" is too much weight gain... and it was not from eating well! Now the ankles are once again little and bony, and the hospitalist and I made sure that orders transferred that no more than a 3-lb. weight gain is acceptable. And I will be checking!

I was prepared to lose my grandmother on our driveway Christmas Eve. I felt God’s peace and calm there in a way I cannot begin to describe. But I am grateful that He chose to wait for another place and time for this inevitable event.

Meanwhile, I am reminded once again that God is in control… that I am His, and He blankets me with His love, grace and peace. I am also reminded of His perfect timing. Our little Timothy returned to live with his mother on December 3rd after being with us and my sister for nearly 4 months. Mam-ma entered the hospital on December 6th. I had little time to grieve the departure of Timmy. At the same time, I was so thankful that I was not trying to balance his care with that of my grandmother.

I had been pretty sad about celebrating Christmas without our babies. After all, the joy and excitement of children truly "makes" the holiday. But one of my first thoughts as I sat on the driveway holding Mam-ma's head and watching the pool of blood increase was... "I am so glad Timothy is not here watching this!" I have no doubt that my husband and other family members would have helped me care for the baby while I bounced back and forth to the hospital and ALF. But I thank God that he put Timmy back with his mom, where I am confident he is safe and happy... and I can concentrate on my grandmother. It's her "season" now. The other benefit is that I can truly rest and rejuvenate when I am not with her, instead of having to immediately focus on the care of a toddler.

I do not know what lies ahead. I felt quite certain another fall was imminent... I just didn't know it would happen like it did. Christmas Day as my mother sat beside my grandmother's hospital bed, Mam-ma told her, "I wish I had died." I know she is so ready... and I am trusting God and His timing. I am resting when I can, and talking to Timothy on the phone every few days. In a somewhat weary voice, his mother told us Christmas night, "Timothy was so excited about Christmas that he would not go to bed last night, so we opened gifts at 1:30 a.m. He finally conked out about 3:30 and slept until noon!" Imagine if I had come home to THAT! The best blessing of my Christmas Day came when that little guy said, "I opened presents, Aunt Debbie and Uncle Greg!" God gave Him a happy, "normal" family Christmas... and that in itself was my best Christmas gift.

I hope your holidays were less eventful. I pray that you find a good balance in the coming year, and that you trust God to meet your needs. Trust Him to work things out even when you cannot see a solution. Believe that He will give you the right questions to ask... and the perfect answers, as well. I know it's a little late, but Merry Christmas!

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