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A District Nurse working in a rural area writes:
It’s Christmas Day and it is my turn to work, providing District Nursing cover to two practices which have a total of nearly 15,000 patients in a rural area of 200 square miles.
On duty from 8.30am, I make contact with my colleague who is covering the two neighbouring practices. As part of the “lone working policy” we keep in telephone contact, providing support or advice when needed, and sharing visits if one is busier than the other. Fortunately, after an intensely busy period when each weekend in December all four practices were supporting terminally ill patients and a number of patients with high demands, things look like being quieter for this Christmas period. Only absolutely essential visits are being undertaken today.
In the past week it has been very cold with snow and freezing conditions making it very difficult to travel, particularly on the rural roads within the practice area. Now, although the main roads are clearer, there is still snow on many side roads with the compacted ice making driving treacherous.
My first visit is to John, a young man who has been discharged for Christmas. John had emergency surgery last week for Chrohn’s disease. He needed a bowel resection and formation of an ileostomy. He and his wife were unprepared for such radical surgery and are having difficulty coping, emotionally as well as physically, with the changes in their life. They also have two small children. A visit is requested to support John in caring for his stoma and assisting him in changing the stoma bag. I set off, with extra equipment in the car for the day ahead. I have put in my walking boots, walking poles, gloves and scarf.
My visit to John is challenging. I help him change his stoma bag and check his wounds which are progressing well and look healthy. However, emotions are running high in the home, with his wife unable to look at the stoma or provide the support that John needs. The happy voices of the small children help to lighten the atmosphere and one hopes that time will help them all to come to terms with the new situation.
I visit Alf next. Alf has metastatic bone cancer from cancer of the prostate gland. His prognosis is poor and his condition has been complicated by the development of a pulmonary embolism. My team have been providing treatment to Alf for the past 6 months with the daily administration of the injection Enoxaparin, an anti-coagulant. In most cases when a patient requires prolonged treatment with an injection they, or their immediate family, are educated to self-administer their medication. However Alf’s condition prevented him from doing this and, unfortunately, his elderly wife, Lucy, has a genuine phobia about needles which prevented her from carrying out the treatment. The 6 month course of treatment is almost complete but Alf will remain on the District Nursing caseload for regular palliative care support. The injection given, my visit is a short one as Alf and Lucy are preparing to spend the day with their family. A time of happiness for them but poignant as Lucy and the rest of the family are aware it will be the last Christmas they have with Alf.
My next visit is to Jim. Jim has Type 2 diabetes. He has developed one of the recognised complications – circulatory problems in his feet. Although he is an intelligent man, Jim did not seek medical intervention as he has a fear of doctors and healthcare settings. About a month ago Jim phoned the surgery and requested a visit from the District Nurse, saying he had a “small problem with a toe”. On visiting Jim we discovered he had a severe infection in one of the toes on his right foot. Despite his phobia Jim has spent nearly a month in hospital having intravenous antibiotics and a stent inserted to try and improve his arterial insufficiency. He now has advanced necrosis in four of the toes on his right foot with the 2nd toe being completely black.
The surgeons are treating the foot conservatively at present and he requires a visit on alternate days for a dressing change. Desperate to be at home for Christmas he was discharged four days ago and will return to hospital in January for amputation of either some of his toes or possibly his foot. Jim lives a reclusive lifestyle. His home is a remote cottage accessed down a track from a narrow country lane. There is no electricity in the cottage and only cold water from the taps. Heating is in one room only, on a wood-burning stove, and lighting and cooking is by gas light and hob. Jim is unmarried but has a female friend staying at present to look after him.
Driving very cautiously I manage to negotiate the winding lane and park at the end of the track. From here it is about a ½ mile walk along the track, which is still completely snow-covered. I don my boots, hat and gloves and on this bright, crisp, Christmas morning I enjoy walking along the track with my walking poles to keep me steady. It is very peaceful and I catch sight of a heron, fishing in the stream and a buzzard soaring overhead. When I reach the cottage I am glad of the walking poles to help fend off the three distinctly aggressive geese which Jim keeps as pets. (I had hoped they might be for the Christmas table, but no, they’re still here!)
Jim is pleased to see me and I proceed to redress his foot. He has had a dose of morphine prior to my arrival as the procedure is very painful. With some relief, I find all his toes are still attached. I am aware that one of these days one of us is going to find the most necrotic of the toes will have become detached. I’m glad it hasn’t happened on Christmas morning! I make the return journey to the car - sun still shining and a real joy to experience this peaceful place on such a morning. I reach the car and continue driving on to my final patient.
The final visit has been requested by the Continuing Care team to check a patient who has come home from Nursing Home care for three days over Christmas. Jackie is suffering from advanced Lewy-Body Syndrome, a form of Parkinson’s disease, and is totally dependent on others for all activities of daily living. She has a very supportive husband and family who are coping very well and who are so happy to have Jackie at home with them even for such a short time. There is an air of happiness and contentment despite the tragic nature of this debilitating illness.
Visits complete for now I return home where my own family is excitedly waiting for me. It is early afternoon and I am on duty until 4.30pm. I keep in contact with my colleague, Amanda, who has also finished her visits. We both hope for no further calls but will alert the other if we are called out. Christmas is a special time for families and for the sick. Today’s visits have all been valuable ones. The importance of respecting each person’s individuality, and their lifestyle choices, has been emphasised by my contacts today. While there have been some challenges, I feel confident that my patients needs have been met and, with careful planning, I have maintained my own personal safety.
Names have been changed.