House Calls to Remember, Lessons Learned
On Jan 8, 2013, at 3:56 PM, James Algiers <james.algiers@gmail.com> wrote:
Dear Louie,
A look back at how things were, how they are, and perhaps a few lessons.
House Calls to Remember, Lessons Learned
Many lessons could be learned by the present practitioners of medicine. The marvelous tools of today are remarkable in making years of added productive life available. Judicious use of medication, surgical procedures, and diagnostic tools enables the management of previously deadly diseases and injuries. But, there are great voids in the understanding of life as lived by patients.
In the present day, there is a lack of knowledge as to just how patients really live and what might be threats to their health arising in and from the intimacy of their homes. Sometimes one is amazed that children survive the dangers of the home or that seniors live to collect another year of social security. Folks live in spite of the accidents and screw-ups of, and in their homes. Many dangers exist in the home and present true threats to life and limb. The age-old method of health care delivery, the house call, gave much to the understanding of personal family problems, and threats to individual and family security.
I well recall notable episodes with families over the past years. The house call was expected at times of crisis. It aided in diagnosis and often in the prevention of further harm. Sometimes it was revealing, sometimes diagnostic, many times hilarious, often fruitless and time-wasting, but always interesting.
On occasion even worth remembering and writing about.
I recall one house call, in the middle of the night in the immediate neighborhood, so close that I might have walked. I was summoned, went to the house, and found the elderly grandfather seated in the lower hallway on a straight-backed chair bleeding quite vigorously from a long laceration on the top of his bald head. The ensuing history of multiple visits to the bathroom during the night, of daily soiling of his underwear from urinary dribbling constantly during the day, and of becoming irascible added to the dramatic presentation of his beginning cognitive disorder.
He had summoned help that night, but there had been no response; he then walked to the bathroom, stumbled on the throw rug above the open stairway, and tumbled down the steps, striking his head on the wooden step and lacerating the top of his head. He was a tough old man, slightly confused and in need of an exam, six sutures, and admission to the hospital. All was accomplished that night, without the sirens of the present emergency squad, and the history was obtained within minutes by observation and examination.
I believe the suturing done in the kitchen was $25, the history dictated over the phone, including the house call at midnight, was $50, and the subsequent daily visits of $15 per visit. He was operated for prostatic obstruction, his head healed, he regained urinary retention, and amazingly the confusion at night cleared so that he again went home. He lived in the same home, had a bedroom next to the downstairs bathroom, and the hallways were devoid of scatter rugs. He lived for four more years, there were no more night house calls and Joe slowly again became confused but slept well at night.
This house call demonstrated the completeness of observation of the incident, the multiple causes of the accident, the frazzled condition of the family, and the toughness of the old man. I am sure all would have felt better if an MRI of the head had been obtained; none was available. If the emergency squad had been summoned, the neighborhood would have been disturbed and the outcome would have been no better.
In fact, the night visit resulted in an awareness of his sundowner syndrome secondary, not only to the slowly progressive cognitive disorder but to his incomplete emptying of his bladder. The head wound was secondary to the frazzled daughter who forgot to wash the hall rug and failed to pick up the rug, to clear the floor. One of the kids failed to pick up the play truck and the old man hit his head on the truck lacerating the top of his head. Also learned that night was the beginning alcoholism of the son in law husband who was not at home, but arrived out of shape, during the suturing of the old man’s head. That problem too was remedied when the old man’s bladder problem was corrected by prostate surgery.
End of story. But another episode, this time on the south side of town; this time at six in the morning. I was called, Geo was sick. Geo was the grandfather in a three generational family. Geo was a chronic alcoholic and had been having a bad week. His daughter was upset, crying, and the police arrived. Because Geo complained of chest pain, the officer called me to attend. Again the emergency squad had not been called, because there was no emergency squad. On arrival bedlam was present - all the lights were on over the first floor and the front porch window had been shattered; a heavy ashtray lay on the lawn. The cops had established order. I went in. Four generations of the family were up and noisy. The police were making order, the new baby was crying, the grandmother was sobbing, and the baby’s milk was boiling on the stove.
One of the younger kids was sobbing and holding his wrist. He had fallen down the stairs when summoned during the free for all. The stair railing was missing and the kid had fallen in his haste to respond to the family affair going on in the dining living room off the front porch. Who threw the ashtray was in question, but the barefooted grandmother had stepped on broken glass and cut her foot. An unmarried daughter with a newborn was threatening to leave home, most all wished she would. With the help of the police, the order was restored. George’s chest pain disappeared, and the kid was sent to the hospital emergency room where the local surgeon set the Colle’s fracture; I sutured the foot laceration, agreed with the daughter that social services should be notified, then called the “county.” Please might they find a suitable flat for her and her newborn, and a neighbor assisted in getting the other two kids to school on time? All this was accomplished in about two and one-half hours, at six in the morning, without a social worker, just the policemen and I.
I failed to mention, there were a few neighbor gawkers, and the carpenter repaired the stairway handle the next day. George calmed down, drank much less, Grandma rearranged the cupboards and secured the glasses, the kids went to school, the cast was signed and the daughter married her friend, and the child’s family became complete.
I suppose records are better kept now, and the services are more comprehensive, but that house call worked out to everyone’s satisfaction.
One might ask just what is the reason for this chapter. The composition is in preparation for “A Lesson on Household Dangers”. In each case noted there are a number of hints, and statements, which indicate that home calls uncover many causes of potential or actual accidents or catastrophes. Some of these accidents are caused by housekeeping shortfalls, some by carelessness, and some by psychological and habitual problems. The cases are to gain attention to the home as being a place of accidents and catastrophes for individuals and families.
The first case demonstrates that elderly persons in the family need special care and observation. They are prone to develop nocturnal wandering when upset by physical problems, in this case, urinary frequency, and nocturia. Here the old man began to wander in the upstairs hallway, a darkened hallway; in order not to disturb the household. His attempts were almost disastrous. The carelessly thrown rug, a scatter rug almost caused his demise. Rugs of this nature should not be in the homes of elderly persons. If possible bedrooms for the elderly ought to be on the first floor.
Both cases demonstrate that family problems ought to be discussed before alcoholism develops as a method of family coping. Many times the adult male loses his position in the extended family and resorts to alcohol instead of family conferences and seeking psychological help. Both of these cases were corrected with professional help. And both cases were from divergent social positions, yet the problems generated were similar.
The second example identifies commonplace accidents of falling from unprotected stairways; with no hand bars. The absence of handrails on stairways and in and around bathtubs and showers causes untold numbers of falls and fractures. There is no excuse; hand bars in showers, in bathrooms, and on stairwells, are necessary, and if deficient, in accidents become a compensable element in litigation.
Electric cords lying on floors, especially in the homes of elderly persons along with the always present scatter rugs break many hips and shoulders. The absence of night lights in hallways, bedrooms, and traffic areas has caused many falls and fractures. Deaths in the elderly occur so often after a fall, a fracture, or a head injury. Many do not realize the critical balance of life or death in the aged. A fall, or a fracture disrupts that balance and many have died following a fall and a fracture. Most falls happen on ground level, over scattered items, in darkened areas, and do occur with alcohol, excitement, family panic, arguments, and disruption.
The kitchen needs evaluation. Dishes should be easily reached and managed from standing floor positions, not reaching from a chair. A step stool, safe and secure is valuable in the kitchen. Dry floors are a must, especially on the hard surfaces of the kitchen and bathroom. Bath rugs need rubber bottoms, and proper slip-free bathmats belong in bathtubs and showers. They are a must, as are secure handrails above and around the tub.
All of these things are relatively easy to do and well worth it if they prevent an accident or worse. And with that, Louie, I’ll sign off.
Keep the faith but use the hand rails,
Jim
