A Whiff of Memory

He was diagnosed with dementia several years ago. His high intelligence beforehand, supportive family and set routines allowed him to live alone in his house in the country until recently. He came into hospital with an infection and delirium and is now waiting for a long term care bed. His body is strong and he is accustomed to walking outdoors. The locked unit is confining and frustrating so I try to take him outside for a walk a couple of times a day. He picks up sticks on the lawns and checks the downspouts and drains of the outbuildings. We sit at the lookout over the river and watch the Turkey Vultures circling above. Like many people with dementia, he has lost his nouns, including the names of his children and his deceased wife. I talk about our surroundings and he responds politely with normal conversational cadence and tone but the words he strings together make no sense at all. 

As we walk along a ridge at the back of the property we come upon a sweet, strong smell. I ask him if he knows what it is. 

“Lily-of-the-valley,” he responds without hesitation.

I pick one stalk of fragrant white bells and put it in his buttonhole as we walk back to the locked unit.

Career Stories: Suicide Threat

The news this week brought discussions about employee mental health, medical confidentiality and fitness to work to the forefront. What prompted a young co-pilot to deliberately crash a plane full of innocent passengers and crew into a mountain? Could this tragedy have been averted?

The most difficult experience in my career involved a co-worker. At the time, I was the professional practice leader for a group of therapists at a private company. Each January I met staff individually for a performance review and goal setting exercise. One therapist was a gifted practitioner but was indifferent to the bureaucratic processes we had to follow. A free spirit, she struggled with personal and professional relationships and boundaries. She garnered the most thank you notes from patients and the most complaints from management.

During our interview she told me she was planning to end her life but also told me not to tell anyone. I did not know how to respond at the time to her comments which made me very uncomfortable. After she left I called a social worker as well as the owner of the business and they both advised me that I could do nothing without her consent. 

Two weeks passed and I kept in contact with her at work but still wondered what to do. I contemplated calling her family physician but in the back of my mind I hoped she would get over her melancholy and get on with life. 

We had a staff meeting one afternoon and she did not show up. I knew something was wrong and drove to her home in another town after asking the office staff to contact her next of kin. It was mid January and her car was in the driveway. There were no footprints or tire tracks in the fresh snow and I walked around the house looking in all the windows. Her next door neighbour, who was a policeman, saw me and came over with a key to the house. I was very afraid when I entered the house with him but we did not find her. I opened her work appointment book and saw that she had scheduled no patient visits after the previous morning. 

I called the police. Her closest friend who lived two hours away arrived later in the day. 

The neighbour found her body. She bled to death, alone, in the snow in the wood lot behind the house. I sat in the back of a police cruiser that cold, dark night completing a written report while responding to questions from the detective. In disclosing my conversation with her earlier in the month, I was asked by the officer why I didn’t do anything. 

I was devastated and immobilized with guilt and grief for weeks. I sought counselling and was told again that there was likely nothing I could have done to prevent her well planned suicide.

I still cannot accept or believe that. 

Well over a decade has passed and I can now drive by that house without crying. I have learned much more about mental illness and suicide in my current work on a mental health unit. With the explosion of information on the internet since this event, it is easier to access helpful resources.

If I found myself in a similar situation now, I would not promise confidentiality and would pursue help far more aggressively. The advice I received did not feel right and I would trust my own instincts instead. More than one life could depend on it.

Here are some suicide prevention resources:

Waterloo Region Suicide Prevention Council  

Canada Suicide Hotlines - (links to international hotlines too)

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. 

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.

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?

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.

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.

Broken

The old lady had a severe reaction to drugs prescribed to treat a nasty infection. Delirious and weakened, she quickly developed permanent nerve damage and was transferred to another hospital. Three months later she was still unable to sit, stand or walk.

Her elderly husband walked the long corridors from the main entrance at noon, slowly, painfully with his cane. He sat by her side until she went to bed in the evening and then walked slowly, painfully with his cane back to the car.

Every day…waiting, watching, hoping that she could walk again and come home.

We worked with her in the mornings, flexing stiff limbs, encouraging normal movement, trying to get her upright again.

He waited one day for the doctor, wanting answers, wanting assurance that she would recover. Accusations, anger, angst spilled out in the words that echoed in her room.

The next week he waited again for the doctor.

“I was talking to you from my heart and you were talking to me from your head. That is why we clashed and I am sorry," he said.

The doctor replied compassionately, “It’s all right, I have been there too.”

The old man had no way of knowing the pain in the doctor’s words, spoken as a father who was unable to save his own child’s life.

Broken bodies can't always be fixed but broken hearts meld together.

Papa's Little Girl

She stood less than 5 feet tall when fully grown and shrunk more as she aged. A strong accent revealed her French-Canadian heritage.

“I am short because Maman ran out of goods. I was her 18th child, the baby of the family born in 1927.”

Nine chubby babies died as infants from fevers, nine survived.

“That is why Maman always wore black,” she explained.

“Papa worked as a lumberjack in the Ottawa valley until he saved enough money to buy a farm. He was a good father, always cheerful and optimistic. Anytime Maman was fretting about something he would put his arm around her and say,
“It’s not so bad now, everything will be fine."
And Maman would laugh." 

Her childhood was happy, surrounded by a large family. Papa used to carry her on around on his shoulders because she was so small.  Maman could plow a field as well a man and the children looked after each other outdoors while she worked. She kept a garden, made bread and big meals. Papa loved his animals and had to hire someone to slaughter them for food. The children had one outfit worn for school, play, church and sleeping until it was full of holes and had to be replaced. They were not rich in material goods but this was life in the 1930s in Eastern Ontario.

Papa sold the farm when he got older and died soon afterward. A sister took Maman in, but Maman would not eat and died at the the age of 84, a few months after Papa.

The tiny lady is now 84, sick, frail, and recent events are difficult to remember. Her children are too busy with work and life to visit much, but warm childhood memories bring a light to her eye and smile to her face.

“It’s not so bad now, everything will be fine.”

After all, she was Papa’s special little girl.

The Best Gifts

His brain was injured in an accident at work and he spent weeks in intensive care. Now alert, he has big gaps in his memory. Impulsive and distractable as a three year old child, he struggles to regain his ability to eat and walk and make sense of the world around him. His wife has scarcely left his side since that day their lives changed three months ago.

Holiday advertisements flash on the television screen and she says to him,

“I haven’t even started my Christmas shopping.”

With a rare flash of insight he replies,

“We don’t need presents. We have each other.”

She looks at him with surprise, her eyes filled with tears.

The gift of life is priceless. The gift of love is eternal.

The thief comes only to steal and kill and destroy.
I came that they may have life and have it abundantly.

John 10:10

Fear Not...

She walked into the coffee shop and sat at the table next to me.

“Hello!” she smiled brightly in my direction.

I looked past the bright pink jacket, fashionable sunglasses and short, stylish white hair and recognized an old patient who was headed for the obituary column the last time I saw her.

“This is the first time I have driven myself into town,” she said proudly.

She was a loner, crusty and irritable at times with staff. Untreated cancer gnawed her flesh and spread to her brain... two falls, two broken bones and two surgeries to fix them. But she refused any treatment for the cancer.

We recommended a move to a nursing home but she insisted on returning to the old farm house and her cats. She had run the farm alone since she found her young husband dead under the tractor decades ago. There were no children, just neighbours down the road who could not be there at her beck and call. She was not religious, nor was she delusional, but fear was a stranger to her. She was accepting of life or death on her own terms.

“I don’t think about what is inside me,” she said.  “The doctor told me the cancer is not growing...”

 “You know,” she said, “I do my own cooking, cleaning and shopping.”

Behind her smile she reminded me that we predicted she would always need help with these things.

She ordered lunch as I finished mine. I could not stop looking at her, sunken flesh filled out again, healthy, strong and independent.

We thought she was in denial of the reality of her prognosis. Maybe we were in denial of the power of fearlessness and determination in the face of a dreaded diagnosis.

I gave her a hug as I left and returned to work, less inclined to judge based on facts and appearances alone. Some things cannot be explained. 

The human spirit can endure a sick body, but who can bear a crushed spirit?
Proverbs 18:14

Time to Tango

She is almost 92 years old and still has determination written on her lined face. At first she appeared cranky and demanding but after our first few sessions, it was apparent that was just her protective front. She has led a fiercely independent life since coming to Canada from Eastern Europe after the Second World War.

“I didn’t speak a word of English when I arrived”, she tells me.

She attended night school after work learning to write a new alphabet and speak a new language. She remains conscientious, arriving for her therapy sessions thirty minutes early and working diligently at her exercises. She completes her leg exercises quickly and I tell her to slow down.

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She learned to dance in secondary school in the old country and the tango was her specialty.

“If you have the right partner and the right parquet the dance is easy”, she tells me.

1-2-3-4, 1-2-3-4, 1-2-3-4, 1-2-3-4.

“Do you think my legs will be ever be the way they used to be?” she asks.

I wonder if she means before she broke her hip on the church steps, or before her stroke a couple of years ago. Surely she is not wanting to do the tango on her next birthday.

I tell her she is one of my favourite patients and she grabs my hand, her eyes filled with tears.

“Do you really mean that?” she asks.

I assure her that I am being honest and tell her I wish she could do the tango again.

“If you have the right partner and the right parquet the dance is easy”, she says again with a smile.

1-2-3-4, 1-2-3-4, 1-2-3-4, 1-2-3-4...