When a patient arrives on the unit, the first thing that that gets done is an admission assessment. Much like the process people goes through when renting a car from Avis, and like all the documentation that’s required before they drive away -- an initial assessment is done to record the dents and dings and other things that need to be brought to management attention before treatments begin.
It’s not exactly like the examination that’s done on a trashed car after getting off a plane after long trip – it’s not a, you break it-you bought it paper trail of woes kind of examination -- It’s the finding of that exact place the bookmark got left, so we can read ahead and see the ending of the novel that is you. Or at least a place to start, and a starting point to work out from.
All context come from talking, information from tests and procedures can only give you information, the art comes in the things both said and unsaid by a patient, and this comes with careful give and take, and it comes in words.
In the navy, I was part of a team that gave medical exams to pilots for their required FAA certification. Each member of the team did isolated parts of the whole exam – lab tests, x-rays, EKG, etc. At the end of all these isolated events, the pilot went into a comfortable office and sat with an aging flight surgeon for five minutes. At the end of this, the old guy would yell out the door for one of us to follow-up something and it was always something important –or something that led to something else that was important. All he did in that office was review the tests and ask apparently casual questions. He would then come up with a picture the rest of us could never see in a thousand years. All he did was talk.
So I talked with Mr. Posey.
He was retired from the army, where he had worked for 20 years as a cook. Most of his time in the service was spent in the area around his home state of Georgia. His retirement consisted of working as a civilian cook at the same base he was discharged, and doing the same job. He was in now in California with his wife on a vacation to, “get away and relax a bit,” and to visit his grandchildren. He remarked at one point in our conversation, "this relaxing thing is going to be the death of me.” He didn’t say it in a funny way, but rather, as a statement that he was putting out of effect, or maybe as a tryout phrase to see if might be true.
As I fiddled with the intravenous lines, and worked them into places I could easily remember in a crisis, we talked little, and mostly around, about the possibility of his impending death that I had brought up earlier. We angled around things in our talking. We talked about his life and the lessons that it had taught him, but we talked about these things in a philosophical general kind of way.
Posey spoke to me in a quietly reflective voice, with slow speech and a noticeable soft drawl. At times, he paused as if he had lost something, and then stared at another something behind me for a few seconds, until he caught himself and continued. He talked of mistakes he had made, and how they were giving him some perspective about the process he was going through now. He also told me that he wouldn’t change a thing about the past—that he had needed to do the things he had done in order to be who he was. “Everything I’ve done and all the things I’ve been through in my life seem pretty inevitable when I look back at them,” he said.
As we talked, I let him ramble for the most part, but occasionally reasserted my control by asking medical history questions from a prepared questionnaire that the hospital provided and required. I did the control thing because, that’s what we did -- we nurses –I had been trained to seize dominion over my immediate environment when working, and to keep a heavy thumb on all the pieces I could touch around me.
I understood that Posey was not talking about anything real when he talked to me. He was talking from his memories as he rambled. He had started the process of adding and subtracting, to this side or that, to a ledger he was keeping in his head. He was running the numbers as he talked to me – weighing and measuring his life in the safety of his past. He understood, that at some point soon, there was going to be a big thick line at the bottom of a page of numbers, and beneath that line, a sum. As he talked, he was getting the numbers straight. He was making sure that he would get credit for answering all the questions completely, for filling out the bubbles in number 2 lead.
I also understood that the way you talked was sometimes more important than the things you said.
At some point I asked him how he managed to stay in Georgia his entire military career, when most service people were moved around every three years. He told me that he had been out of state a couple of times- one time for the war, and another time for “A bomb testing”. He told me that Georgia looked “pretty good” after those two trips, and that no one in charge of things ever wanted to lose a good cook once they had one.
As we wrestled for control of the direction of our talking, Posey rambled into a story about his trip to Johnston Island in the early fifties. He had been sent there to cook for people doing testing atomic bomb testing. I sat, sort of fascinated, on the edge of his bed and listened. (I wondered at the time if he knew I was a big A-bomb fan – not in their use, but in their bigness as a symbol.)
Posy had been attached to temporary duty as a general cook on the island in 1957, and spent 18 months feeding people, as others set up old surplus army equipment to be exploded, and then collected, after the bomb test, for evaluation. Posy said that it was a non-stop party the entire time he worked there – all 18 months, “fifths of booze for a dollar, and no women to interrupt us”, as he put it. He told me that the actual bomb blasts were the best part of the trip, “I couldn’t believe that I was living in a time when a thing like that was possible”, and, “The power of the blast made every thing and every thought smaller than their right size”. He described it as a “William James’s type of spiritual awakening,” and that, for the first time in his life, he was really aware that something bigger than himself was going on.
He told me about a high altitude test that they had shot up in a Thor rocket, that it had blown out all their radio communications, and had turned the night into day for over 5 minutes. He told me of the green blob that had replaced the whole of the sky, and that it was “shot through” with changing colored streaks.
As we were talking, I rummaged around and broke open an admissions kit, a bundle of toiletries and other odds and ends that every patient got on admission. I took out a basin from the kit and filled it up with warm water, and then opened a soap packet and dropped it into the basin. With a wash clothe, I started to give Posey a bed bath as we continued our talking. The bath was to get the last 24 hours of dirt and sweat off him – the stuff not left on the ER gurney earlier. Posey was a dirty boy, and smelled bad as well.
I have always been in the minority about this, but I think the bath is more about getting close to my patients than getting them clean. I kind of mess the wash clothe around with slightly soapy water – it’s almost an affect the way I do it, with my the real purpose disguised – I’m really looking at my patient in detail, and listening to what they sound like really up close. This also fosters a kind of intimacy that allows them to share more with me than they would with their doctors. Naked – Intimacy – it works for in aspects of life. I like to do the bath early in my shift, or shortly after the more formal part of an initial assessment. It helps me to get both a baseline and a starting point to pivot the rest of my day around.
I noticed: Posey had small pale legs with cold feet, a large abdomen resting on narrow hips, and a medium-sized barreled type of chest. His hands were cold to the touch and he was having difficulty breathing with any exertion – even the exertion of moving around in bed. Getting him up and over to the side of the bed caused him to breath heavily. He needed to “take it in stages” in order to make it, and needed my help to keep steady once he was there.
As I fake-washed Mr. Posey, I shared with him some of my life. I talked about growing up in a military family and moving to new places every few years. I talked of the 3-year relationships that I had tended to develop with others over my lifetime, and told him that I envied him for his sense of home. I talked about my family, and about the grandfather I had only met once, when small. I told him that my grandfather was only a picture to me, and that I spent a lot of time trying to attach a living breathing life to that picture.
I guess the thing about intimacy is that it’s shared- you got to give to get. I shared with Mr. Posey as I washed him, and he listened quietly, if somewhat breathlessly.
As I helped him back into bed after the bath, I noticed that his feet were puffy and swollen after only 15 minutes of hanging off the side of the bed. I put the head of the bed elevated about 45 degrees to help with his breathing, and then left the room to call the doctor and give him an update.