Thursday, May 29, 2014

Career Stories: Centenarians

Doll on display at the Dickinson House in Manotick, Ontario

Over the years I have the honour of meeting a few centenarians who aged with grace and dignity. Most of the patients I work with are aging badly with any number of chronic and degenerative diseases. We all want to know the secret to growing old well, maintaining our independence, health and quality of life in later years. 

Marija was a 99 year old lady who lived independently in a city apartment. She shopped, cooked, cleaned and looked after her 93 year old sister who had dementia. Marija was elegant with erect posture, a long braid around her head, and a beautiful face. She grew up in Eastern Europe and lived through harrowing times during World War 2. She worked hard when she and her husband came to Canada in the 1950s and raised her family while holding down a domestic job. 

Marija tripped over the edge of a step and broke her hip in a fall. She had surgery and returned home in a few days, quickly learning to get around with a walker. She would be in the kitchen cooking homemade soups and stews when I visited and never had a complaint about pain or misfortune. I discharged her from service after a few visits but received an invitation later in the year from her daughter to attend her 100th birthday party. She recovered well from her fracture and continued to live independently in the community.

I met another 100 year old lady who also returned home following a hip fracture. (Hip fractures were  my bread and butter when I did home visits!) Her hospital course was more complicated after surgery but she had a cat at home and that motivated her to get walking again. Clara had fallen off the toilet in the middle of the night but was wearing a Lifeline device and was able to call for help. She laughed when she described the good looking young firemen who came in and lifted her from the floor. 

On Clara’s wall was a framed certificate presented on her 50th anniversary of using insulin. It bore the name of Sir Frederick Banting, the Canadian physician, researcher and Nobel laureate who first used injected insulin to treat diabetes in humans. Clara developed insulin-dependent diabetes in the 1950’s and followed her diet and medication plan faithfully in the years before home blood sugar testing and fast-acting synthetic insulins were available. To reach 100 years of age, almost 60 years of them as a diabetic, is amazing considering the many people who manage this illness poorly and suffer debilitating complications in their middle years.

Both Marija and Clara lived routine lives, ate simple, wholesome meals, had interests outside of themselves and accepted life’s ups and downs without fear or bitterness. They obviously had inherited some good genes as well!

Recently I met a 99 year old man who had a productive life and currently resides in a minimum care facility. He gets around independently with his walker and enjoys a good conversation as well as several short naps throughout the day. He told me it didn’t matter if he celebrated his 100th birthday or died tomorrow. He had a successful career building large high rise apartments but life had gradually ground to a halt after he retired in his 80s. He had outlived his friends, wife, siblings and some of his children. He was cheerful and matter-of-fact but recognized we only live one day at a time. In the end our quality of life is of more value than the quantity of years we may accumulate. 

Saturday, May 24, 2014

Ottawa Birding

We spent a few days in the Ottawa area visiting our daughter and new son-in-law. There is so much to see and do in the capital region but it is May and birding was near the top of my list. I decided to explore the area around their home rather than driving to more distant birding hotspots and was not disappointed. Spring was slow in arriving this year and as a bonus, mosquito season was also delayed. My husband was fishing in the Algonquin Park area while I was in Ottawa and he reported that it was the first spring fishing trip that was not accompanied by black flies and mosquitoes. Black flies and deer flies are pests that will keep me out of the bush no matter what bird may be around. Mosquitoes made their debut about the middle of this week but a bit of spray kept them at bay.

I decided to find the Bluebird trail and Osgood Link Pathway which are south of the Ottawa Airport. The first two bird boxes were at a busy intersection and a pair of Eastern Bluebirds and Tree Swallows were settling in as neighbours. I have seen Tree Swallows trying to evict Bluebirds from a nesting box they wanted but there was no aggression between these birds.

The female Bluebird was very busy gathering nesting materials while the male supervised and sang and flitted about.

Bluebirds are not commonly found in our home area and I may see only one pair a year. I seldom see them at this close range and was fortunate that they were not bothered by my presence.

I started walking the Osgoode trail near the 5th kilometer marker a little after 7 AM. This section of trail follows a marsh and creek and dense mixed bush making it ideal birding (and mosquito) territory. The was plenty of bird song but finding the singers was a challenge due to the fact that new leaves have grown quickly in the recent warm weather.

I found two very loud and persistent male vocalists;- the Rose-breasted Grosbeak in the canopy and the Common Yellowthroat in the bushes.

Female Rose-breasted Grosbeak
Their mates were busy with home building and worked quietly undercover in their dull plumage.

A very loud drummer accompanied the singers and it took some time to locate him. I rarely see a Pileated Woodpecker but they are more common in the Ottawa area.

My favourite bird singer is the Veery and they were present in this section of trail. Other Thrushes scurried around in the underbrush as well. My species count was 32 in about an hour and a half of early morning birding including several first of the year finds for me. There was still plenty of time to see tulips, flowering trees and The National Gallery in the city after breakfast.

Wednesday, May 21, 2014

Career Stories: The Positive Power of Belief

In the 1970s it was still acceptable to give placebo medication to patients without their knowledge. The physician would write an order for an inert pill for pain or other symptoms and staff would whisper to each other when the “medication” was given. Placebos are rarely ordered now and can only be given with consent by the patient which undermines the theoretical effectiveness of belief. Belief is strong medicine and there is physiological evidence that placebo treatment does work. 

Home care therapists were assigned a portable ultrasound machine for treatment of soft tissue inflammation and pain. Each treatment is about 5 minutes in duration and sometimes there is slight warmth emitted from the head of the machine. Generally there is no sensation except for pressure on skin as the therapist applies the gel and applicator in a circular fashion. I personally have never observed any value in ultrasound treatments, on myself or any patient, and it is hard to do a clinical study to prove its efficacy. 

I had a referral to give an ultrasound treatment to a lady who had received them in the past. She was sure this was the answer to her back pain and I took the portable unit into her older home. To my dismay all the electrical outlets were ungrounded and I could not plug the machine's three pronged cord anywhere in the house. I made a completely unethical decision, pretended to plug in the machine, and went on to give her a “massage” with the ultrasound head. She insisted that the treatment was wonderful and her pain was much improved. 

Another old lady had a very stiff neck with crepitus and pain with the slightest movement. I gave ultrasound treatments, massage, and mobilizations over the course of a month with absolutely no improvement. One day I returned for another visit. Her pain was completely gone and she had full range of movement. A friend had given her garlic cloves that had been soaked in cider vinegar for a month and she was eating one each day. I rejoiced with her and was very relieved to be done with that cervical spine! Was the garlic and vinegar a cure or a placebo? I suspect it was a bit of both but it was undoubtedly more effective in treating inflammation than anything the doctor or myself had offered.

A physiotherapist often spends a lot of time with a patient and we are practitioners who touch people in the course of treatment. Few doctors physically examine or touch their patients anymore relying instead on test results and prescriptions. A sympathetic, listening ear is a good way to start a patient on the road to healing. I truly believe that compassionate human touch is essential for health and is lacking in the lives of many people.

Most of what I do professionally is validated clinically but I never discount the placebo effect or minimize a positive experience that cannot be explained.

Monday, May 19, 2014

Winter Springs to Summer

The beginning of May and October are my favourite times of year, seasons of transition, colour and beauty. Spring is unpredictable and sometimes rushes by with its succession of introductions and openings. This year rain and fog shrouded several days of soft greens and quiet blooms. This week we finally squeezed in our annual spring walk through the woods while there was a severe weather watch in place and large thunder heads intermittently blocked the sun.

It was a long, hard winter and some warm, artistic soul yarn bombed some trees along the trail. They either really hated the blankets or really loved the trees.

All the spring ephemerals were blooming at the same time this year instead of spreading their charm over three or four week.


Trout Lily...

May Apples...

Marsh Marigold...

Jack in the Pulpit...

and Trilliums. We come year after year to admire the carpet of white.

Raven is now three years old and behaves well off leash with us. It was almost 30 C on this humid afternoon as she stopped to rest by this knoll covered with Trilliums. Wild Ginger is growing at the edge of the trail where she is sitting and its blooms are at the base of the stems, covered with dead leaves.

I rode through the bush again today, five days after these photos were taken. Most of the flowers are finished and the leafy canopy has closed off much of the light. Ferns are growing rapidly and in a short time mosquitoes will keep me away from these trails until there is a fall frost.

Happy Victoria Day!

Wednesday, May 14, 2014

Career Stories: Homeless by Choice

I did home care visits in the core downtown area of our city for five years. Beautiful condos faced the park and a block away others lived in filthy apartments above main street stores. 

Ingrid was a middle aged schizophrenic who had lived on the streets in several cities. She understood her subculture well and knew where to sleep and where to get a meal. She was resourceful and capable in spite of her paranoia and delusions. She was obsessively clean, hated indoor spaces and had strange religious leanings. I never inquired about her past but would do so if I met her today. At the time I did not understand mental illness very well. She did not smoke, drink or do drugs and to our knowledge did not have a police record. 

Ingrid also suffered from renal failure and was on peritoneal dialysis. She carried bags of dialysate with her and hung them from any available place including tree branches when she did her treatment. On top of this she had a parathyroid adenoma which she refused to have treated. As a result her calcium and phosphorus balance was disrupted and she developed severe osteoporosis. Inevitably she fell and broke her femur and the surgeon stabilized the break with an intramedullary rod. Social Services found an apartment for her and the hospital donated an old hospital bed that was destined for a third world country. A telephone was installed so we could keep in touch with her. I visited the day she was discharged from hospital with cautionary warnings from the case manager stating she was threatening, angry and unpredictable. 

For some reason Ingrid and I hit it off and she allowed me to visit her a couple of times a week. It was late winter but she kept the windows of the apartment wide open at all times. The only furniture was the hospital bed but she had a pail, mop and bottle of bleach which she used to clean the floors daily. She lived with purpose and appeared content with her lifestyle.

Because of her severe osteoporosis, the fractured leg became shorter than the other by almost 2 inches as the bone collapsed around the break. One day I visited and she was unable to bend her hip at all. The intramedullary rod had shifted upward into her pelvis. I wanted to call an ambulance to take her to the hospital but she refused. She would only go if I took her so I got her in the back seat of my minivan where she had to stretch out across the seat as she could not sit. She was admitted and the surgeon removed the rod completely. Her gait pattern was terrible as she limped on her shortened leg with the walker. Social Services paid for shoes, a shoe lift as well as a new walker. She needed a sturdy wheeled rollator with a seat but she would only accept a folding aluminum walker. Everything she owned had to be lightweight and portable. I would see her pushing the walker down the street, dialysis bags dangling on the side as she limped with her peculiar gait. She would be lucky if the walker lasted six months with the heavy use it received on rough pavement.

A few weeks later I went to visit her at the apartment and she was gone. No one had seen her leave but the place was clean and empty except for the hospital bed. We heard through the grapevine that she had moved to the streets of Windsor following whatever voices commanded her life. Her resilience was remarkable and I often wonder what became of her. Was she ever institutionalized or did she die as she lived, on her own terms?

Saturday, May 10, 2014

Birding Close to Home

White-crowned Sparrows in our yard
May is the best month for birders and it would be lovely to spend it at any one of the birding hotspots on the north shores of Lake Erie or Lake Ontario. The weather this week was dominated by cold north winds but migrating birds were finally aided by a southerly flow over the past couple of days. Spring migrants are passing through our neighbourhood too and I enjoyed a couple of outings this week. 

Am Tree Sparrow, Baltimore Oriole, E. Kingbird, Yellow-rumped warbler, White-throated Sparrow, Mallard Duck

I rode my bike to a nearby nature area and saw my first warbler and Eastern Kingbird. Our yard is hopping with sparrows and in just a few minutes on the deck one evening, there was an American Tree Sparrow, a Chipping Sparrow, Song Sparrow, White-throated and a White-crowned sparrow. The House Sparrows that are nesting in the light standard in front of our house don't count.

I generally sleep with the window open and am awakened at 4:30 AM by chirping Robins. By 5:30 AM they are joined by a chorus of Cardinals, Blue Jays, Chickadees, Doves and White-throated Sparrows. The sun doesn't rise until 6 AM right now but we do not need to set our alarm clock. I cannot complain about the noise as it is far less jarring than a rooster call in Mexico.

We left the house just after sunrise this morning to check on the second nest of Bald Eagles we found two weeks ago. The first Eagle nest adjacent to the Osprey nest was abandoned this week. Hopefully they find a new place with kinder neighbours. These Bald Eagles appear to be getting along famously and hopefully they will be successful in raising a family this season.

It is the season of motherhood and life is springing up everywhere. Happy Mothers' Day to all!

Wednesday, May 07, 2014

Career Stories: Young Aaron's Crutches

Many Old Order Mennonites in our region do not have provincial health insurance and their community helps cover the costs of hospitalization and health care. But modern ways are making inroads and young Mennonites are sometimes seen driving buggies and talking on cell phones even though they do not have land line phones in their homes. Others have accepted government health insurance and that is how I met Aaron and his family. 

Aaron fell from a hay wagon as a young boy and injured his hip. As he grew, the hip became externally rotated to the point where the surgeon told me the right foot went north and south and the left foot ran east and west. Aaron had corrective surgery when he was about 18 years old and I drove to the family farm to see how he was progressing with his mobility. At the time of my first visit he was not able to weight bear on the affected leg and had to hop with crutches. 

The farm lane was long and Aaron stood with a group of men outside a shed. He was using a pair of vintage crutches the likes I had only seen in the Pyramid of Crutches at the Saint Anne de Beaupre shrine near Quebec City. They were solid wood, of fixed size with no adjustability in length or handle position, and looked to be at least 75 years old. I would guess that the average height of an Old Order Mennonite man of middle age or older is 5’8” tall. But the younger men are growing taller like many in their generation. The crutches were far too short for Aaron but in his community you make do with what you have. Many people had used those crutches over the years. 

I went into the house to do my assessment and charting. A large table was in the centre of a dining-living room. The walls were fully lined with chesterfields and wooden chairs and the room could have seated dozens of people. A couple of young children peered around the corner at me, a foreigner in their world. 

I found a pair of tall adjustable wooden crutches in the donation cupboard. They were in new condition and had clean foam covers on the top. I took them to Aaron on my next visit and adjusted them correctly for his height. He was delighted with the gift and could move about with greater speed and agility. The family admired the crutches and I am certain they will be passed around the community and used for the next 75 years.

Aaron’s hip eventually healed and he was able to walk without crutches. His left leg still turned out a little and was slightly shorter than the right leg. He could move without pain and resumed his normal activities on the farm. He was destined to develop early arthritis in the joint requiring a joint replacement in the future, but corrective surgery was a success in the short term. Aaron’s future as a productive adult was assured and he would surely have sons who could help him if he developed mobility problems as he aged. Such is the strength of this community.

Saturday, May 03, 2014

A Visit to Toronto's Distillery District

I visited a good friend in Toronto who took me on a tour of the Distillery District .The site was once The Gooderman and Worts Distillery and stands near the lakefront, west of the downtown core. There is plenty of construction in the area as Toronto prepares to host the 2015 PanAm Games. The athlete's village is just west and adjacent in the Canary District. When the games are over there will be a large number of residential units available along with retail and recreational facilities. 

This was an unpleasant part of Toronto when I lived here in the 1960s and it is amazing to see the transformation of the old limestone and brick buildings which are well over 150 years old. It is not surprising that it is a popular spot for movie shoots, weddings, photography and tourism. Today was rainy and cold, the sky and light uninspiring for pictures. I have to return on a sunny morning or evening in the summer.

There were plenty of shops to step into to get out of the rain. We looked at antiques, spices, art, chocolate, vintage and eco clothing, and much more.

The area is described by National Geographic as "A hip new neighbourhood within the best preserved collection of Victorian industrial architecture in Canada". If they mean "hip" as in "hipster" there were a few of them as well along with many people of diverse backgrounds. A marching band of teenagers from Chicago played a few songs in the rain which was rather random but added to the eclectic charm of the cobblestone courtyard.

Toronto has many interesting neighbourhoods and this one is well worth a visit. As a bonus it is a short distance from Tommy Thompson Park, one of the best birding areas in the city. My friend drove me through the trendy Cabbagetown neighbourhood and we followed the Don River Valley back to her home. We saw a couple of blooming forsythia and magnolia trees but leaves are not yet out on the trees. She took a little detour to show me a small green space that was a mass of blue Scilla flowers. Spring will surely arrive this week!

Thursday, May 01, 2014

Career Stories: Never Too Old

1975 Graduates

I started my career as a physiotherapist almost 40 years ago. Today I work with therapists and assistants who were not yet born when I graduated. The only constant over the years has been change;- employers, technology, practice, standards of care and more. I trained at a time when passive modalities were widely used. We spent hours in labs learning how to apply hot packs, set up shortwave diathermy, nerve stimulators, ultrasound and even microwave machines for deep heat. (Microwave ovens were not available for home use in the early 1970s.) We learned massage techniques and studied how to apply traction to the spine. We suspended limbs in slings that were clipped to wire cages to facilitate active assisted exercise. Hours were spent learning postural drainage and manual percussion. Physiotherapy developed as a profession during the world wars and polio epidemics of the 20th century and focused on massage, exercise, ice, moist heat and electrical modalities. 

My first job was in a general hospital where therapists rotated to different areas of service every three months. The rotations included outpatients, rehabilitation which included stroke, spinal cord and amputee rehab, general medicine, orthopaedic surgery, chests, both medical and post surgical and intensive care, neurology and paediatrics. Service rotations are rare now but we gained experience in treating a wide variety of of conditions. In the mid-1970s we had no computers, MRI, CT scanners or diagnostic ultrasound. Joint replacements were not available at our hospital and patients with femoral fractures spent months in bed with their limbs in traction. Orthopaedic surgeons did meniscectomies, discotomies, osteotomies for knee arthritis and other surgeries which are seldom done any more. We worked under doctor’s orders and most treatments were conducted in a routine fashion without detailed assessment on our part. If the doctor ordered a hot pack, that is what the patient received.

Medicine has changed immensely in the last four decades and my practice includes many techniques unheard of when I was a student. Learning new treatment techniques is not as challenging as developing good clinical and patient assessment skills. Human motivation and behaviour must be understood to give effective treatment. I have worked in acute care hospitals, a rehabilitation hospital, home care, nursing homes, schools, research labs, and have found my career to be rewarding in every setting.

I still work full time and do not have a retirement date in mind. One of our gerontologists, a brilliant young doctor who is under 40 years old said to me this week, "Keep on working or you will decline." We must stay engaged and involved with life at every age.

Many patients have inspired me, some have saddened me, others have amused me. Their stories have become part of my life. The following accounts are based on true events but the identities of people involved must be protected. For that reason names, locations, and time may be altered. Here is the first instalment.

George- Never Too Old To Learn

Working as a home care physiotherapist was the most enjoyable job of my career in many ways. Self-scheduling, working from home, driving the open road and meeting a variety of interesting people were among the perks. I covered a section of a city and a large rural township where many older residents had long associations with the area. 

I met George, an octogenarian, following his knee replacement surgery. Widowed after spending a number of years caring for his wife who suffered from Alzheimer’s disease, he enrolled at the local university and earned a geography degree. His field studies included a lot of leg work in the township and that pushed him to have his arthritic joint replaced. 

The house was small but long windows brightened two walls of his living room. A computer was in the corner and a work table was strewn with papers and books. George had a full head of white hair, a strong stocky build and bowed legs from lateral compartment collapse of his knee joints. A collection of walking sticks stood in a barrel at the door, from strong knobby tree limbs to ornate carved and painted canes. 

Physiotherapy visits included an assessment and a set of painful exercises. The only patients who are prepared for the pain of a knee replacement are those who have had one in the past. I helped George progress from a lift walker to a wheeled walker to a cane for walking and showed him how to descend and ascend his basement stairs  After my work was done he shared his knowledge of the area often pulling out maps and books with enthusiasm. I learned about four nearby kames and came to understand how the many kettle lakes in the area were formed. A nearby moraine that filtered and balanced ground water was threatened by city expansion. He knew the name of the lake that once covered the area where we live and I understood why our property is largely sand and gravel.

George finished his therapy successfully and started working on his masters degree. I received a referral to see him the following year when he was 85 years old and recovering from his second knee replacement. He still had an infectious love of learning and showed me a special achievement award from the university. 

I see older adults working on work puzzles and short games to maintain their mental abilities. I never met another senior who was a passionate university student participating in classes with people one third his age. The exercise he got on trails and fields also kept his mind and body fit. He never uttered a bitter word or complaint about past losses and regrets. 

I remember George as I drive or walk in the region. Every hill and gully is unique and has its own history. Rivers cut through ancient glacial fields and change is never ending. He embraced change and forged new paths in old age, never too advanced in years to take up a new challenge.