Mike's Last Day At VNAB -Labor Day 9/1/08

Mike’ Last Day at the VNA- Labor Day 09/01/08
(
9 RVs no Admits or s/p’s)

After nearly 15 years ,of amazing encounters and very hard physical and mental work (see my resignation letter) it comes down to this last day and as I traveled down so many streets, past so many apartment buildings of all kinds, group homes and private residences remembering so many patients and families I had encountered I just want to record these last patient visits each special and representative .

Molly ,age 91, in a rather posh assisted living facility, former math teacher in NYC, had been married 65 years ,her “Red” had died … yesterday waiting for the25 minute saline soak integral to her special dressing change she had said to do some computer work if I wanted while waiting but instead I took the time and she shared her life story …and how she slept in a single bed in this room while her husband was in a hospital bed beside her while he was sick until he died and as she said this her voice started to tremble and she cried slightly and so did I just imagining and I reached out to touch her shoulder…and there was a bond there of shared humanity and, the realization that we are here together with our beloveds for a time then so painfully separated and perhaps reunited… she was ready after a very good life when the time comes
…
Kathy- I had also seen the day before, when I had set up a time she agreed to for her injection then had to change it when I received a call in the field for another time sensitive visit…I had apologized for the change and she had let loose with all the frustration she felt at being hobbled by her hip repair and being sick of these Lovenox injections etc., that she was tired of waiting past noon ,had been up since early and just wanted to take a nap…as I was suggesting I could come later she just hung up on me- the first patient who had ever done that in 15 years. (Literally a handful of patients over the years had declined a visit from a man/male nurse- “You sound nice and all ,but your nurse wide isn’t comong with you –so I’ll wait until tomorrow ) So I tried again in the evening on the way back to the office and she kind of grudgingly agreed during the 10 minute visit I just validated her frustration, that’s mostly what she or anyone needs and she was fine and thankful to have me come back this morning and give her the last “thankchrist “ shot …

Sammie C- a VNAB legend, seen for so many years by so many nurses , often bid to keep his sugar in line and him out of the ER…he was one of Sandy Grant’s special people and Dennis Cunningham’s , and mine- having seen him in 3 different apartments , a gentle soul living for years with AIDS due to the Anti-retro virals…had been a hairdresser for a time, owned 2 houses, had 3 kids and some scattered grandchildren , my same age ,things fell apart when he started doing drugs and hence his immune status- his Alzheimer afflicted Mom reputedly a onetime big drug dealer …he did his best to mind her when she rambled and wandered at night – there has been a stream of pretty affable yet clearly dysfunctional “family and friends” floating in and out at times in various states of pharmacologic consciousness –Sandy had been there once during a police raid. There was the odd seizure here and there , a few episodes when he was “pimped up” uncharacteristically doing some Super Fly imitation, many times Sammie was lethargic or obviously on something or just holed up in the house sleeping his way through but through it all Sammie was Sammie …sincerely liked hearing of my life …as we sat around his kitchen table , so often so damn hot with a pot of some kind of gizzards boiling away on the greasy stove , I’d share some details of current event s ,the basic wonders of computers and the internet or some personal experience thoughtful or funny and he’d be genuinely interested –the content might have been world’s away from his or very close to home – but he always really appreciated that any nurse did not just run in and out for the usually very basic diabetic check but instead made it a personal meeting. Sammie said he’s miss me as we shook hands and I will definitely always remember him…

Kim- as happened often this was a one time encounter- I’d do the basic research to find out pt’s age (confirm the sex because as with a Kim it could be either) nurse ,MD, dx, wound care ,etc. Lisa McNeil –over my 15 years probably the best nurse overall professionally and personally and bi-lingual to boot ,did her usual for her but actually rare for other equally time-pressed nurses great work of specifying on the weekend list exactly what wound care and evaluations and tasks to be done…Kim needed an abd wound dressing changed ,I really did not have time to check the reason for the surgery – but could give my basic teaching on wound precx, s sx inf, pain meds ,timing , Tylenol adjunct and preventing nausea and constipation (rarely taught in the hospital discharge) It was a relatively quick visit for this 58 year old white male stranger nurse caring for a 35 year old black female in her 2nd floor apartment with a number of cute kids all around …and as always I hope I made her more comfortable ,got her to laugh a little, did not talk too much and left with us both a little better for the encounter .

Herb – as I start to write this as often happens since we moved to the laptops I can’t remember initially who Herb was,where he lived or what he needed…there is something about this kind of “data entry “ documentation that “goes in but does not stick or come readily out”…He lived on Dunreath St off Warren past McDonalds ( bathroom OK , but service and food terrible – I so much preferred the Burger King in Grove Hall next to Uncle Neil’s fire station,near where I parked opposite Ma Dixon’s restaurant hoping for a day’s work with Dooley Bros. trash…the BK where I ate most Sundays for the almost 4 years St Clair and I worked together early on and where Cyndy and I would infrequently meet for lunch) anyway Herb was a youngish 80, had a memory problem, not sure what kind of work he had done ,but for sure one daughter and family lived on the first floor and another on the 3rd and it was mostly good . All he needed from me was basic bilateral LE minor woundcare- done with empathy and friendliness. It was so good as I left to have his teenage grandson come through the door , calling Hi Boppa, how are you and see them exchange hugs…family sysems and support or dysfunction = such an integral part of health for each and every one …and over these years I have seen every degree from near isolation and abandonment to heroic care for a parent,grandparent, sibling , spouse or friend.

Ana P- living on Annunciation Road ( “Assassination Road” per the cabbies for the NU Professor kidnapped and thrown off one of the roofs – but also site of one of the best Visiting Nurses sing-alongs when we did a rave up version of “Hey Jude” for Betty and her grown son Treyan …see VMA for a very special part of my VNA years and PS –Screw HIPPA! ) only 44, a little less English than my Spanish (after so many courses ,3 times to Guatemala…I can just basically get by but have such regard for those who come here and become so fluent in English while speaking 2-3 other languages …we will press on to keep our braincells from atrophying ) so many digressions but there really were so many aspects to this “job”…well Ana at only 44 had a physical struggle = very obese , a temporary ileostomy, one of the largest abdominal incisions I had ever seen, confusing orders on the weekend ,unclear whether to be once or twice daily – that first weekend it was definitely twice as I explained to the MD on-call the set-up for a recurrence of infection ,what you would want in care for your family member or I for mine – I never really did anything heroic with the care just be kind and competent and provide the follow through for the poor weekday case-managing primary nurse …this had been a “General Dynamics” dressing change a la Richard Allen, hot and noisy in the apartment ,sometimes the dtr helpful with translation or explanation,sometimes Ana was alone , but on this last vist the wound was so much smaller, the skin around the ostomy no inflamed, the hemorrhoid pain bearable with a doctor’s visit coming the next day . As always as I left she was a little closer to healing and as usual not needing or able to communicate the significance of this last day for me I gave a tender hand on the shoulder and Buenos dias ,amiga….

Rose ….I decided not to make this my last visit of the day, just too final and emotional after seeing her for somewhere around 10 years , the patient I had cared for the longest and knew best … from that first visit back then she was a bit wary of the “guy nurse” ,but we gradually found common ground and I learned of her life of struggle = born with Spina Bifida about 1955 , never able to walk, always “wheelchair fast”, had been a “victim” up to her teens of what she felt amounted to “medical experimentation and humiliation ,complete with those photos where they have a little black rectangle over your face” to just barely disguise your identity and humanity, this had been very painful and scarring for her…she had been married for a time, had been part owner of a stock car/always loved the thrill of racing, had moved to Boston from Conn after her divorce ,worked in her PCP’s office for a time,had been very mobile,had some abusive relaitonships ,but over time became more and more disabled with respiratory and chronic wound and pain complications and housebound ,even when the recurrent mechanical problems with her electric wheelchair were resolved (unconscionable rigamaroll many times for a part or repair = this chair was her essential mobility from bed,around her cramped apartment…crowded with stuff from “home shopping network” that commercial club for shut-ins, with her 4 beloved cat companions …live in PCAs either took advantage by stealing or not really living up to their part of the deal…Rose was generous to a fault,so good hearted ,was fascinated by her TV lifeline animal/racing/shopping/surgery –medial oddity and Lifetime melodramas and the creepy films where an innocent female was stalked in her home by some violent madman. The VMA had visited at least twice at Christmas, the last several years she had not been up to it. I had once visited Rose in he hospital when at death’s door she had called 911 and been admitted to BMC and was there for most of the summer and I could see that for her to be in the hospital was to utterly give up all her autonomy ,to be bed bound and at the mercy of whatever nursing care was available ,to have to explain her story again and again, to plead to be listened to ,to be so often frustrated and at times ironically isolated . Rose appreciated the fact that I listened, that I knew her that we could laugh together and discuss common/shared or different interests as distractions to the needed nursing care for her chronic skin problems and pain….usually 10/10 because to be hospitalized for a pain evaluation and pehaps better pain regime would mean that loss of autonomy and she would rather suffer and be in control. Speaking of suffering I have detailed the most neeedlessly painful (for myself and a patient) experience I have encountered in 17 years of nursing due to a conflict with MV my manager over finshing in 12 hours = if you can’t some one else would see have to see Rose ( who would reject anyone who did not know her because of the aggravation – reply “that’s her choice” ) Briefly after caring for her for about 9 years I did not see her for about 6 months …other very caring and competent nurses took by place –Katie W helped with my prep notes, but it was just so personally punitive , to be “yanked off the case” instead of the promised alternating… it finally ended up in an ethics conference discussing boundaries , and my special violations of sending vacation post-cards and singing at Christmas…this did definitely cross a line for me – the causing of totally unnecessary and truly unethical emotional pain for poor Rose…it was just a power struggle over hours paid and “patient demands” vs VNAB control…in the discussion I had with the Veep of Ethics she commented how infrequently an MD contacted the VNAB and how Rose’s PCP had requested to have me put back on the case…and finally I was ,seeing Rose frequently and this was our last visit …we really had an unusal “therapeutic “/friendly nurse –pt relationship – I have such respect for her bravery and empathy for her suffering …we parted with a hug and some tears from both… and an intention to keep in touch and revisit at Christmas…
Daisy G- a one time encounter, lived in the revitalized Orchard Park where I had picked up trash so many years ago when it was so delapidated , but still a high concentration of ailing individuals and families…Daisy was bed bound,somewhat demented but pleasant and well cared for by her grand-daughters –reminder with the confusing orders and primary caregiver not at home ,go with the flow listen respectfully and with good humor to the patient and family , stick with the care basics,document well and leave a voice mail as needed for good communication and continuity –later of course for me as I jot down notes in the home, finding the computer a barrier there ,just a reference ,and much more effective when I can recollect my thoughts quielty later= works for me.

Aida – my very last patient ,had not answered when I called earlier ,but I tried again (persistance) and she did. I had admitted her a week or so before for a rather large arm abscess due to IV drug use…she was in her 40’s, good pesonality,bilingual, married, adult child and had said the abscess happended from a fall…I had not pursued the IVDA at the time feeling it was not useful…just tried to be a good ,supportive nurse ,make the dressing change easy, pain managemment effective , and complications less likely. I was surprised when she told me that she had gone back to a program, had had a hard time for the past 6 months ,relapsed,but was back doing what she needed to. We talked about that , her plans - I briefly told her that her about our plan and that she was indeed my last VNAB patient. She gave me a sincere hug and thank you as I left for the cab-that’s it the last patient, probably my last caregiving in an inner city home after 15 years …

the last cab ride to the Braintree office another unique aspect of this nursing experience – I had worked in the Harbor and Hyde Park offices each such odd space ( with “Reactonary/Recovering Rich” BC High 1955, wife a former nun , Principal of Cathedral, basically a good hearted if slightly odd felllow a devotee of politics local and national,smart but rather acidic…so many drivers over the years St Clair my street pal, Benny with the bootlegged videos in the front seat, Dick who had headed the MBTA Police and suffered a major political appointment upset and downturn in fortune rna for kKingston selectman and I wrote his main pitch letter, Steve of the horrible breath night and color blindness and awful reflexes but also in recovery and recovering from the loss of his wife, Al so eccentric and happy go lucky, with a gallon jug of urine in the front seat because he would not stop for a bathroom break , who conducted his passenger surveys and driving so slowly would proclaim “every time they honk it’s a victory for our side “ and sincerely that “the city is ours”, Cavenack a gentleman and entreperner from Haiti who had imported cars and busses to sell for cash on the Port au Prince dock, whom I had to lift the cab off when it slipped off the jack in the Burger King parking lot – “I planned it that way” , and a host of others so often leasing for up to $100 daily plus gas other expenses before a dime for themselves and driving for 12 hours a day for weeks on end here from Sudan because there was better opportunity here than as a doctor or dentist there…)
An on this last day Cyndy and I had checked in with each other as we usually did and unusually we were able to rendez-vous back at the office; I cleaned out my stuff and we were able to adjourn to Bertuccis for a celebratory early supper= we made it safely! I finished the laptop documentation by 10:30 (never a 12 or 7.5 hour day for me- as I joked I never got the keys to the time machine at orientation ) or so at home and “transferred” in and that was the end of the last day.
We had told our colleagues that we did not want any gifts or to go out and that we would bring a light breakfast in the RV the next Sunday 9/7 (fortunatley a hurricane side swiped us and aftrer some wild wind and rain blsted through and the sun was out in the AM. We turned in our laptops,some required items and adjourned to the parking lot - had left the driver’s door open for the first time and there was a great sign= “Just Retired”…and we munched ,opened funny and thoughtful gifts and very generous giftcards from Jayne,Maura,Rhonda (discharge orders) Diane ,Val,Anne and sister Joan came in on crutches, Dennis-writer/actor /film-maker /bi-lingual nurse who had recently returned from a year in South Africa with his wife ,and Rachel who had cared for our unforgetable patient Jim Tyree years ago …it was a lovely send off …and Cyndy and I skipped out the door hand in hand, so very fortunate and grateful for the work we had done, the folks met and cared for and learned from and with such a wonderful road ahead!!!

Addendum – because it summarizes as well as I can the 15 years ,the longest and most intensely,most challenging and most meaningfully I have worked in my life…

Dear Maura Vitello, Managers and Colleagues:
cc- Joanne Handy, Keren Diamond…

As I stated verbally in March of this year after almost 15 years at VNAB I will be resigning as of Labor Day, Monday, September 1,2008.

I attached this comment to my last evaluation: “ I will continue each day to take the 2/4-6 or equivalent assignment I am given, help as requested, and give the most efficient and compassionate care to each patient I can.” I sincerely believe that I have done just that.

Of course, not being the “shy and retiring type”, I would like to share briefly some reflections and perspectives.
After 14 years as a High School English Teacher (in Randolph and Silver Lake –Kingston) with an involvement in health education programs for the Silver Lake School District, I was inspired (and still am) to be a nurse by my Family Nurse Practitioner wife Cyndy. After graduating from Quincy College School of Nursing in 1991, I ‘had my baptism by fire” in Med/ Surg at Cambridge Hospital, then moved on to a long established weekend program at Spaulding Rehab which was eliminated just 7 months later. Having been The Quincy Visiting Nurses’ first male home health aide (with Carol Morris as my manager and supporter- small world!) during my nursing school training, I was drawn to community health and had two immediate opportuities - weekend positions at Quincy Visiting Nurses or VNA of Boston.

I chose VNAB for the opportunity to serve the inner-city community, where my parents and in-laws had grown up. The experience has been truly extraordinary in so many ways over these years! It has been both such a tremendous gift and challenge to be a VNAB nurse- first of course (as we all do) to try always to be a “healing force” to the degree possible in the lives, families and homes of the thousands of patients I’ve encountered. I could write volumes (and maybe I will, anonymously of course per HIPPA) about these profound, unique, unusual, delightful, depressing, somewhat “dangerous”(as in the time I had arranged to visit calling at 9AM,confirmed with pt and no answer to door at 10AM, pt had been murdered within that hour...what if?), but ultimately inspiring and life enriching experiences. So many times I have been amazed by the strength, resiliency and spirit of patients who are disabled, infirm or elderly as they cope with seemingly insurmountable health and environmental challenges, even being part of some stirring “home-going” ceremonies along with family and friends when death inevitably came, but faith and hope and love remained.

It has been a real challenge to give the care- the weather, home conditions (from the most impoverished apartment /rooming house/shelter, even a few fields and cars to a wealthy architect’s penthouse), through community parades and festivals and the truly daunting documentation – from the hand charting in the Harbor Office in the extremely wearying wee hours- that 24 hour position = mostly 34 hours, up to 37 hours from Saturday AM through Monday AM, to the current “fujitsu laptop data headlock”. Always it has been the dedicated and donated efforts of the nurses keeping the Agency afloat in the tempest of today’s healthcare- For my own part I calculated several years ago that I had donated at least 4000 hours of “free time”- but that’s another story. It has been such a privilege to work with and learn from so many talented and dedicated nurses, therapists, staff and managers-especially my remarkable team-mates on the Southwest Weekend Team.

Most special, indeed unique, is that Cyndy and I have shared this chapter of our lives as nurses at VNAB, she on the MCH team and I on the Adult. In addition to serving as MNA representatives, and sharing the general Agency “trials and triumphs”, we have had shared patient encounters. On a few occasions I have seen a patient for a C-Section dressing change and Cyndy arrived to care for her newborn, or I could alert the new Mom “when your baby comes home, your nurse on the weekend might be my wife”, or Cyndy might do a BP check in the AM and I would do the PM follow up. What other couple is so fortunate to have this commonality?

Of course both being nurses, I for 17 years and Cyndy for 33 years, 26 of them as a Family Nurse Practitioner, we have every nurse’s sense of how precious,
Fragile and finite life is. For that reason and because and while circumstances allow, we have decided to ‘retire early’ and it’s more of a renewal, really, to have as much time together as possible. For the next 5 years, at least, we plan to travel the eight winter months around North America in our ‘eco’ motor home with four summer months at home by Quincy Bay. We intend to write, stay environmentally active and do some nursing work and volunteering.

All my best to each of you and yours personally and professionally. Continue to take the best care possible of yourselves and your patients.

Gratefully,



Mike Cotter, RN
5 Post Island Road Quincy, MA 02169
postisland@verizon.net

(In memoriam – St Clair Brathwaite- my cabdriver and friend on the streets, August 1997, Age 49 and Sandy Grant-wonderful teammate, human being and superb Nurse, April 2006, age 37 – both of you are remembered always...)