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Trouble With a Capital T...

When you have worked in home care for as long as I have, you often have a sense of when there is going to be a difficult case that Challenges you. It’s not because your boss says “good luck to you” after she hands you the referral, or when the referral itself gives you the clue of a tough case by the type of medications that the patient takes. It’s often when you arrive at the home itself that you know how bad it is going to be. You can be lost and unable to find the home (this happens more than you think) and all of a sudden you slam on your brakes and see this one lonely little house sitting all by itself and you just know that this must be the place your looking for and sure enough it usually is. I would like to call it a sixth sense but all it really is, is what the house looks like.

I pulled into “Steven’s” driveway and before I got out of the car, I took a deep breath and said to myself, “Let’s do this.” As I got out of my vehicle, I could see that he had been unable to maintain his home, the grass was knee high, the paint on the house was chipping and dirty and the mailbox was attached to the iron railing with a coat hanger. “MMMmmm” I said to myself, “I wonder what this is going to be like.”

I knocked on the door and heard a very quiet voice say “what do you want?” I identified myself as the visiting nurse and asked if I could please come in. The mystery voice behind the door yelled “I don’t care.” I was a little startled after that but it was only the beginning. I opened the door to a smell that was unfamiliar, one I have never smelled before and have yet to smell again to this very day. The house was dark, all the curtains were pulled and the shades were down, there was a little light on; it sat on the floor next to the chair my new patient was sitting in.

There sitting in this dirty, torn, material hanging out of it chair was “Steven.” The VNA had received a referral straight from the doctor’s office, requesting that we see this patient for home safety evaluation and for what may be a possible case of cellulitis of the hand. I knew before I got there this was going to be one of those cases, most of the “Patient can’t come into the office to see us referrals,” from the doctor’s offices are usually like that. The patient had not seen the Doctor in over a year and would not leave his home to do so, so the doctor called in the VNA to do the assessment.

“Hi my name is Marilyn, I am the visiting nurse and I have come here today because the doctor wanted us to check you out.” “My name is Steven” he said it very quickly in a monotone voice. As I moved closer to him, I noticed that my feet were sticking to the floor as I walked; I looked down and saw that it was the carpet, I was sticking to the carpet “ewe” I thought.

“Steven, I need just a little more light in here, do you mind if I open a window shade?” He responded yes, I opened the shade to let in the light and when I turned around I saw him standing there right next to me, I was a little startled to say the least. I backed up a little and I began to assess the situation. “Steven why don’t you sit back down so I can have a good look at you and your injured hand.” He did as I asked him but didn’t say a word.

I asked to see the hand that was hurting him and he shot it right up into my face, again I was a little startled. I assessed his hand, it was dirty and had finger nails about one inch long, with dirt caked under them. I asked him if there was somewhere where he could wash his hands; he jumped up out of the chair and went into the kitchen, without saying a word to me.

The Kitchen was dark as well and I knew where that odor was coming from. The sink was filled with dirty water with a thick layer of scum over it, about an inch thick. “Ewe not there” I said, let’s try the bathroom” he walked past me and led me to the bathroom.

My eyes must have popped open wide when I saw this man’s bathroom, because he looked at me and he looked as if he was going to cry. The sink was totally black with grime, slime and dirt, the shower had no curtain and it too was black in color around the ring of it and at the bottom and his toilet didn’t look any better. This is one of those times I wish I could have taken a picture because no one is going to believe me about this home.

I swallowed hard and said “Ok, Steven lets wash those hands with my soap, it doesn’t need water.” So I went to my bag, which I had hung on the door, the safest place to put it for now and grabbed my soap and showed him how to use it, “just rub it into your hands and let the soap do its job.”

As he was doing this I got a real good look around and saw what he was wearing, he had on sweatpants and a sweater with a coat over it. As I look down at his pants I noticed that they were wet, but not like an incontinent wet but an oily substance. I had to ask. “Steven, what is that all over your pants?” he looked down between his legs and said “oh that is oil”, “what kind of oil” I had to ask. He took a deep breath and said “cooking oil, I rub it on my legs so they won’t get chapped.” “Oh” I said, not really knowing how to respond to this.

“Well, let me look at your hand, Steven.” What I saw were little areas of redness and some drainage coming from the nail of his middle finger, I put gloves on and I squeezed it and it started to drain as he yelled at me that it hurt. It was indeed a very small area of cellulitis, so my next step was to call the doctor to discuss a plan for his infected finger before it got worse, I would recommend an antibiotic for him. I was afraid to ask him for his phone but I left mine out in my car, he led me back into the kitchen, but before he turned the light on, I noticed the stove was going…all four burners and next to it was a piled high to the ceiling were empty pizza boxes. Now I was scared, “Steven, I have to shut the burners off, with that gas going so close to those boxes it’s a fire hazard!” “Oh no” he cried back, “that is how I heat the house!” I was lost at this point, what am I going to do for this man, he was unstable and his home was the same. I shut the burners off and I warned him not to turn them back on again. I then told him that I had to go outside to make some phone calls, due to the fact that he did not have a phone for me to use.

I went outside and took a deep breath, a really deep breath; I needed the fresh air, “what am I going to do for this man.” The first call was to my manager. “Oh God, Marilyn do you think your even safe in that house?” After telling her of the situation, I told her I could manage but we need a Medical Social Worker (MSW) to immediately assess this man and to assist with some emergency community resource plans. My plans were to call the town hall and get the board of health involved and inform the town nurse of the situation as well. My boss agreed with the plan and I began to make phone calls.

I called the Doctor for the antibiotics and to update him with the plan and assessment; I told him I felt unless we do something for this man he was not safe in the home. The board of health came down and at first wanted to condemn the house, “but this is all this man has.” I told them let's work together and come up with a better plan. So we worked with the town and got Steven used furniture, we had a company come out and clean his home and one to fix his broken gas heat. I continued to visit and assess him and I even brought him two new sweatpants and clean socks and told him no more oil. The MSW in collaboration with psychologist was able to get him started on new medications so he could function more properly and live freely in his home.

Steven learned to trust me, throughout his care with the VNA he slowly became a different man. He finally made it to the doctor’s office with the help of “the ride,” transportation that the MSW had set up for him. He was able to walk down the street to the store and buy meals, instead of having everything delivered. It was nice to see Steven get out and be more independent. The community services had really helped him out and even though I thought he was trouble from the start, it turned out that I changed his life with just a few phone calls from my car.

Not all the cases like Steven’s turn out this way, we were very lucky, that the town he lived in had all the resources that they did and were able to provide him with what he and his home needed. There are times when Steven’s name comes up every now and then when my boss and I are talking about tough cases, mainly the disgusting homes that we have to sometimes go into, he is at the top of our list. We both saw him at his worst and at the finished product of our work and both of us agree that he is a success story and that is what keeps us going.

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