Florence: “And the Rest of Me Too?”

Florence had bilateral leg ulcers, and a bowel infection that caused frequent and uncontrollable diarrhoea, nausea and vomiting. As the door to her room was opened, a foetid odour emerged. She was an overweight woman, dressed in a hospital-issue nightdress. She lay in bed most of the day. She had been admitted for management of the two infections and had received intravenous antibiotics for this purpose. When Florence was comfortable she conversed readily. She made wry observations and comments about her situation. She told me a story about when she used to be a credit collector, recalling the most ridiculous excuses she came across for reasons people defaulted on payment:

“The best one I ever heard was a woman who said she hadn’t paid it back because her lightbulb had gone and she couldn’t see to write out the cheque”.

Florence experienced daily severe pain when the wound dressings to her leg ulcers were changed. Replacing dressings involved slow removal with saline of

the existing dressings that often adhered to her red raw broken skin, followed by irrigation of the wounds, followed by tight rebandaging of both legs. Florence expressed pain loudly: she cried, suffered palpitations and panic attacks, her breathing was rapid and she sweated profusely. This often began some time before the dressings were actually changed, indicating that an aspect of her pain was fearful anticipation of the actual physical pain. She had begun to

request higher and higher doses of analgesia before her dressing changes; staff were increasingly alarmed at the potential for addiction. The dose had therefore been capped pending a review by the chronic pain team - for which there was known to be a wait of several weeks.

6.3.1 Alienation

My impression was of an isolated and alienated woman. She was symbolically separated from her family, and literally separated from the ward as a result of being in a side room. All contact had to comply with ‘barrier nursing’ principles for infection control (Figure 15). The door to the room had to be kept closed.

‘Contact precautions’ had to be taken by anyone in contact with her, whether or not they have actual physical contact with her body. This included a white plastic disposable apron, and blue disposable nitrile or rubber gloves. The strict infection control measures served to protect staff and other patients from cross-contamination, yet they had a profoundly isolating effect.

Figure 15: Contact Precautions

These had to be disposed of in the Clinical Waste bin before exiting the room, marked with a bright orange ‘biohazard’ symbol. On several occasions, I observed how this approach to her care left her feeling degraded and humiliated. The following excerpts are from a reflective piece I wrote after witnessing an encounter with a senior registrar:

Pippa, the senior registrar, examines Florence, who has been admitted with infected leg ulcers. She has tested positive for the C Diff gene and has been ‘symptomatic’, in other words, has been experiencing severe diarrhoea. She is in a single side room and the hospital policy stipulates that the door has to remain closed at all times, and that anyone going in must wear

protective clothing - a white plastic pinafore, and pale blue nitrile gloves. As the registrar talks to her, she stands by the bedside, her arms folded. Florence complains that her belly hurts and the Registrar visibly blanches. She asks her junior whether there are any disposable stethoscopes on the ward. When she is told that there are not, she realises she must use her own stethoscope.

She performs the required examination rapidly, reassures

Florence that “everything sounds okay, some good bowel sounds there” and walks briskly to the foot-pedal bin where she disposes of her pinafore and gloves. Outside Florence’s room, she wipes the bell of the stethoscope repeatedly with sterilising alcohol gel, wrinkling her nose while she does so.

6.3.2 Loss of Hope

The main plan for Florence was to cure her infections. The other focus was on rehabilitating her so that she would be well enough to go home. Staff were concerned that this was increasingly unlikely and that she was ‘giving up’:

One of the nurses emerges from Florence’s room, quietly closing the door behind her. She has just finished changing the wound dressings on Florence’s legs. The sister asks how she is doing, and the nurse replies “it’s like she doesn’t want to make

progress, like she’s giving up. You have to talk to her now to get her to talk to you; before, she would ask you stuff. It’s like she’s lost everything”. The sister responds that Florence has been in the hospital for a long time. “All her obs are fine, nothing acute happening, but she’s just giving up. It’s sad, really.”

Staff tried to encourage her to sit out of bed, to encourage her to build up strength and independence. The mental health team had concluded that she was “very much taking on a sick role” through her reluctance to get out of bed.

Staff were concerned about how little effort Florence was making to walk. She had been discharged from the physiotherapy service because the pain from her legs prevented her from doing the prescribed exercises.

On one occasion when the sister was giving her morning tablets, I observed the following interaction:

Sue (ward sister): “Let’s get these legs out of bed today, yes

Flo?”

Florence: “And the rest of me too?”

(both laugh)

Intended as a joke, this interaction nonetheless points to the ongoing imperative for staff to emphasise rehabilitation. This interaction is further examined in chapter 9 where I consider the potential for interactions to cause suffering. The humour in Florence’s response appears to be a relief for both of them but it also indicates poignantly how the focus on one part of her body risks inadvertently disconnecting her as a person. Her body – or rather, the sum of problematic body parts – becomes the focus of care.

The general perception among staff was that she was gradually becoming more and more dependent which went against the grain of the agenda in which

patients were rehabilitated and discharged as fast as possible. When patients did not also share this goal, it led to tension and conflict:

Rebecca (about Florence): “I don’t mean to sound mean but she’s not helping herself. Her husband is on at her too about needing to walk again, and she’s not ever even really sick”.

Conversely, patients who know the rules demonstrate at least an intention to walk, even if they lack the ability. They then earn approval from staff, as overheard when staff were marvelling at the fit and motivated 98-year-old patient admitted the previous day: “She’s really good, this lady, she just wants to get going”.

Florence’s perspective was predictably somewhat different. She pointed at her legs and told me how the pain felt as though her skin were on fire. Her eyes filled with tears as she described what the wounds looked like underneath the bandages. She did not think they were improving and was gradually trying to get her head around the possibility that she faced the prospect of daily wound dressings for the rest of her life. Her wounds signified her suffering, but it was not purely physical. Her face visibly recoiled at the odour as the bandages were

removed, and she averted her eyes from the sight of the raw weeping flesh. I asked her what her current goal was, and she told me “to get through the day”.

Getting back upon her feet was low in her list of priorities at this time.

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