Thank God for My Ass
Therese Zink
I am not referring to my back side, although I do have a well developed gluteus maximus due to my stocky German build and 15 miles of running every week. My ass is Jimmy, a shy miniature donkey (think Shrek’s pal) who has been the companion of my horse, Indy, on my 20-acre farm for almost four years. Recently Jimmy saved my ass. Please pardon my crass language, but it is the truth.
About eight one evening, my cell phone chimed as I was driving home. The local nursing home needed help with an elderly gentleman who had been admitted three days earlier. My partner had given him some furosemide late that afternoon for congestive heart failure, but Mr. Olson was still edematous and very short of breath. “The family is upset and wants me to do something,” the nurse reported. “His hemoglobin is four and his potassium is six. Will you talk with the daughter?”
A hemoglobin this low would require a transfusion of several units of blood and the potassium suggested kidney failure. “Sure,” I responded. Not wanting to be the student who lost her homework, I said, “But I don’t know him. Please read me his diagnoses and tell me what meds he’s on.”
It took the nurse several minutes to tick off the list, which included some dementia and repair of a thoracic aneurysm seven years ago.
“How old is he?” I asked wishing I was not the one on call.
“Eighty-eight,” she informed me. “He’s very sick. DNR-DNI. The family is pushing me to do something. The daughter is really upset.”
As I drove in the darkness toward home I took a deep breath and readjusted the phone next to my ear. My new challenge flashed like a neon sign—the distressed family of a new patient that I didn’t know. “Any thoughts?” I asked the nurse.
“The daughter is a handful. Good luck.”
“Put the daughter on,” I said and prayed for inspiration.
“This is Janet,” the voice said. “You know me. My husband and I borrowed your donkey for our church’s Christmas nativity pageant.”
I thanked God for the connection, some place to start this conversation. “Of course, Jimmy. That was a cold day.” I said and remembered that the shepherds, kings, even Mary and Joseph, wore snowmobile suits under their cloth costumes. Thick Sorel boots peeked out beneath their flowing robes. Jimmy was insecure without his buddy, Indy. So this manager scene had had a horse and a donkey. Janet and her husband had given me the photos on a CD that I had cut and pasted into my Christmas letter to family and friends. “I am glad to talk with you again, but I am sorry about the circumstances. Tell me your understanding of what’s going on with your Dad?”
Janet cleared her throat. “My mom cared for him at home for six years. He started having trouble walking two weeks ago, so I started coming every day to help her. We decided he needed more than we could do and looked for a nursing home. There was an opening here, so we moved him last Friday. He’s gone downhill since.”
I heard the frustration and recrimination in her voice: Why was he doing worse, not better at the nursing home?
“The nurses tell me he has a lot of fluid in his lungs,” I said. “We can help him breathe easier.”
“Can you help him get better?” Janet asked.
“He is very sick. I don’t think he will recover from this. We could send him to the emergency room, but that would just be temporary and I think it would be very hard for him.”
“Are you sure?”
“He is very sick,” I reiterated. “The ER would probably want to admit him to the ICU.” I explained his lab work. “Today we have options, but the question is what your Dad wants and how what we do affects his quality of life.”
“Is he dying?” she asked.
“Yes,” I said. Of course Janet wanted to know when. I assured her that I didn’t know. “This might take some time or it might happen quickly.”
“Should I call in the family?”
I asked where they lived. All were out of town except for her Mom, who could come in tonight if needed. I suggested that Janet tell her Mom what I had told her and let her make the decision. “I can talk with her tonight if you want and I’ll be at the nursing home in the morning.” Luckily weekly rounds were tomorrow. The conversation with Janet lasted about 20 minutes. She seemed calmer when I asker her to hand the phone to the nurse. I gave orders for morphine and reviewed the furosemide orders. The nursing home did not bother me the rest of the night.
The next morning on rounds, Mrs. Olson was stretched out in a recliner covered with a quilt. Her handiwork, I suspected. I examined Mr. Olson who slept peacefully, the head of his bed elevated to a ninety degree angle. He was also propped up with pillows, his hands and ankles were edematous; he was sleepy and did not have much to say. I reviewed his chart. His primary clinic had done a physical last week and drawn some blood. Based on yesterday’s values his kidney function was much worse. No blood count was done, so with a hemoglobin of 4 and no obvious source of bleeding now, I guessed that he had been anemic for awhile.
I asked Mrs. Olson to join me in the conference room. A plump and affable woman, she adjusted her eyeglasses and sat down at the table between the nurse and me. We were joined by a medical student who was shadowing me for the semester. “What did your daughter tell you?” I asked.
Mrs. Olson’s explanation made it clear that Janet had understood what I’d said last evening. Aware of my tight chest, I collected myself as if I was about to guide my horse across a jump, my senses on high alert to read every nuance. Married for over fifty years, in the last decade Mr. Olson had overcome a number of “close calls” with his health. Seven years ago there was his thoracic aneurysm diagnosed at Mayo Clinic after they returned from vacation. “The doctor told us that it could have burst at any moment. If it had happened at the cabin, Roy would have died. We were just plain lucky.” She shook her head. The smile lines around her eyes and mouth indicated the joy-filled life they’d had together. “The ache had bothered him for a few days. You know, he didn’t really want that surgery. He was ready to go then.”
I did the math in my head; for that surgery he was 81.
“But we wanted him to have it, so he did.” She explained his tough recovery. “In hindsight, he might not have done it.”
We discussed that recovery would be very difficult this time. I explained how we would make him comfortable and suggested that we involve hospice. Mrs. Olson had considered being a hospice volunteer and agreed readily. “I am glad he is here. I could not have handled this at home,” she wiped a tear from her eye. “He is ready to go.”
I thought about the language we use for death, dancing around the actual word: move on, pass on, go, expire... “It sounds like he’s had a good long life,” I said and took her hand. I’d been doctoring long enough to see how patients often choose their time to die, waiting for a child to arrive from out of town, or dying when someone took a break knowing it was too much for him/her to be present. Now that Roy Olson was in the nursing home his dying process could accelerate. I assured Mrs. Olson that I would talk with Janet when she arrived. I called hospice and continued my rounds.
In her late 30s, Janet arrived after her chores. Her long blonde hair displayed her Scandinavian heritage. I shook her hand. Her grip was firm and the skin dry and tough, the hand of someone who worked outdoors. We’d met at the nativity display. She was decorating the church while her husband and daughter tended to the manger scene.
We gathered in the conference room, around the same table. “Good to see you again, Janet. What questions do you have?”
“I need to understand this. My siblings will ask me exactly what is happening.” Her voice was like fingernails on a blackboard.
I braced myself and explained that Mr. Olson’s organs were shutting down. I talked about the fluid backing up into his lungs because his heart wasn’t pumping, the kidneys not filtering the toxins from his blood, the low hemoglobin not carrying much oxygen.
Janet sat forward, “But he has bounced back so many times before. Why not once more?”
I shoved my defensiveness away and tried to find the words to explain that too much was broken. Mrs. Olson was quiet as Janet grilled me and asked me to go through her father’s chart with her. She fired questions about his rapid decline. I slowed my breath and focused on her, finding the patience to answer her questions.
“I am not a health professional, but I need to understand this,” she said again. I ignored my watch and thought if I invest now, this would have a better outcome.
Janet sat back. Maybe I had repeated the details enough. Maybe I had finally said it in a way she could understand. Maybe it was because the hospice nurse joined us. Janet shifted from accuser to daughter. She thanked me and asked, “How’s Jimmy?”
“He is fat and happy,” I said. “He doesn’t have to do anything but eat.” I had just returned from a medical trip to Nicaragua where all donkeys were gaunt with thin coats. “In Nicaragua they’d call him gordo.”
We all laughed. I reassured them that I was as far as the phone and left them with the hospice nurse. Mrs. Olson trailed me out of the room.
In the hall she clutched my elbow and said, “This is very hard for Janet.”
“It’s hard to let go.”
“They were very close. They farmed together.”
The next evening when I was in the barn cleaning Jimmy’s stall, I got a call from the nursing home. “Mr. Olson has died,” the nurse said. We need to have you sign cremation papers.” They would fax them to me at home that evening. After shoving my cell phone into my pocket, I reached for Jimmy and rubbed him behind his ears, long and tan trimmed with a line of black. His entire black mane stands upright like a punk rocker’s haircut. I told him how much he had helped me the last 48 hours. Jimmy turned his rear-end toward me, his favorite place to have scratched.
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