The greatest miracle of all, the human being.- - Marya Mannes
Health is [horizontal ellipsis] a blessing that money cannot buy.- - Izaak Walton
Many pictures sit on the mantle of my fireplace: my husband, my mother, my children, my grandchildren, my high school graduation, and Miss Ruby.
Miss Ruby taught me how to be a good community health nurse ministering to the needs of the patient within the community setting. She had diagnoses of paranoid schizophrenia and congestive heart failure. Back then, any good community health nurse knew it was the congestive heart failure diagnosis that required the "skilled" component needed for eligibility to receive services covered by insurances in the home.
The plan of care was projected for a 9-week period. If Miss Ruby cooperated, I could have her stabilized in about 3 weeks. Her weight would be stable. She would be compliant with her medications and avoiding salt, all within 3 short weeks. Only then could I discharge her.
Miss Ruby possessed a medical diagnosis considered a revolving door in community health. Her congestive heart failure kept her returning to Mercy Home Health and to my care. Miss Ruby had no reliable support systems. Once, she showed me a picture of her sister who she swore was a "witch." To prove this fact, she kept this picture of her sister under "wi" in the "W" volume of her very old Encyclopedia Britannica. If I recall the psychiatric term correctly, this is called loose association.
I marveled that Ruby possessed a Taber's dictionary and consistently looked up any medical term not familiar to her. She swore to me that the generic furosemide did not work as well as the trade Lasix. She taught me the importance of family and community support systems for a medically and mentally ill client in the home setting.
Once in the middle of the hottest summer on record, I turned her corner to approach her home. As I drove up the street, I saw a raggedy figure dressed in a heavy coat, scarf, hat, and boots pushing a shopping cart up the street. My attention was pulled to this woman traveling along the curb. It was Ruby-short of breath, leaning on the shopping cart, and inappropriately dressed for the weather. Her refrigerator had broken in the middle of the night. She needed ice to breathe, she told me. There were no "crumb crushers" (children) around to go to the store for her.
I followed her up the street and parked in front of her house. She needed my help to get up the stairs. Had she taken her Lasix that morning? Of course not!! Then she would "pee all up on herself" on the way to the store. Was I crazy?
Miss Ruby paid neighborhood children to go to the store for her. She cooked small meals for herself, adamantly refused to allow anyone to help her tidy up her home, refused to go into a nursing home, owned her home, and allowed only me, the nurse, to enter it. However, I was not allowed to touch her at any time. This got a little tricky when I had to place my stethoscope on her chest, back, and stomach to auscultate her lung, heart, and bowel sounds, but we always managed, Miss Ruby and I.
I remember once knocking on her front door for 10 minutes with no response. I felt apprehensive. She never went anywhere. Where could she be? I made my way to the alley behind her row home, ripped my blouse on the thorns of a wild rose bush (wild like my Ruby), picked my way across all the trash in the alley, and had the neighborhood crumb crushers asking me a million questions as I made my way to the back door.
"Does Miss Ruby pay you to take care of her?"
"Are you Miss Ruby's nurse?"
"Do you know Miss Ruby is crazy?"
I could see Ruby through the back door cooking at her old stove. When I knocked, she directed me to the front door to let me in. The back door was heavily bolted shut for security reasons, and she "was not going there" to undo the locks and let me in that entrance.
It turned out she was making cornbread in a heavy cast iron frying pan on the stove-the "true way" to make corn bread. She served me a hot piece and, before I could verbalize my protest, poured buttermilk all over it. Because she rarely cared for me and never trusted me, this was an event. How could I refuse? I hate buttermilk, and Miss Ruby had critters crawling all over her home-everywhere. Community health nurses called them "moving wallpaper." Could this be the nurse-client therapeutic piece? I remember thinking, "If this cornbread crunches (critter?), I am going to throw up. Lord, help me!!"
I must have made a face as I had a bite of the mushy cornbread.
"What's your problem, girlie? Don't you like it?" she asked.
"No, it's very good, " I lied.
"Who's the datburned crazy one here?" she said, "you or me? I can tells you don't like it."
One time shortly after that, she answered the door with a turban on her head, a gold cloth wrapped around her entire body, a heating pad with its cord tied around her neck and flapping on her back, and a pair of black boots up to her knees. When I asked her why she was dressed up, she told me it was to do battle with me because I was an "evil concubine."
She had noted that I mentioned my "crumb crushers" several times but never my husband (I was a single parent at the time). She settled in a bit after I told her I was legally separated. My psychiatric instructor would have been proud of me. I did not validate or negate her belief system. She must have gotten her term from her Bible. I believe the woman at the well was a "concubine."
Medication teaching and adherence is always a challenge with a paranoid client. Ruby swore I was trying to poison her. She had been hospitalized in the past for her psychiatric diagnosis and discharged to the community on medications, which would control her diagnosis if she took them. She always stopped taking them. The few times I found her with a fluid overload, the doctor gave me an order to administer extra Lasix in the home setting. She quickly agreed to this because she hated to leave her home and be hospitalized.
Once when I arrived at her home, I found her sprawled on her chair telling me she could not move her arms or her legs. Now she had double-dosed herself with Lasix and put herself in potassium depletion. That was the day she refused to go to the emergency room, and I had to commit her involuntarily because she was a danger to herself. I still have not forgiven myself for that one. It was necessary to keep her alive, I know, and I was an "evil concubine." Probably there would be no more mushy cornbread for me after this episode.
"What is your problem, Girlie?"
"The crumb crushers on the street can look in on me," she lied.
"You are my problem," I told her. "I love you Ruby. Stop playing with your medicine."
"I will do what I wants to do. Get your hands off me. You gots only one right and one left and you can't always be right."
She came back to the agency after this for her last admission. I remember asking her if I could hug her. She squinted her eyes and stepped back a giant step.
"Make it quick, Girlie."
And then, after a full two-second hug, "Back off, Girlie."
"Let's do what we gots to do."
The last time I went to Miss Ruby's home, I could not gain access at the front or the back door. None of the crumb crushers were on the street. Her sister, as usual, could not be contacted. I called the local hospital and was told she had been found dead on her bathroom floor that morning. Had she played with her medicine again? Did she need an extra dose of her Lasix that day?
I mourned Miss Ruby as I would a close family member. I had helped her keep her independence in her home. I had eaten her mushy cornbread. I had shared in her humanity and her life. She was a miracle in my life. I am grateful for the experience.