Friday mornings were busy in crisis services. Maybe people who hung on tight all week started worrying that they wouldn’t make it over the weekend. Maybe people who lived too much for the weekends worried their lifestyle might overcome them before Monday. There were four people waiting in the emergency department for assessments when me and my teammate Viv arrived at 0730. After a brief report from Linda, the Team Leader, we checked the office for phone messages then put our heads together to decide how to divide the workload.
About once a week someone who felt they could wait it out overnight called the office after hours to request a next-day appointment. Last night a man named Lowell left his number for a call-back. Of the four folks waiting, Viv was familiar with two. Of those two, she believed there was one person she could quickly re-direct. So I agreed to call Lowell and schedule him in at ten-thirty, my last appointment of the morning. He answered the phone immediately, as though he had been sitting beside it all night willing it to ring. Yes, he would be there at 10:30 and yes he knew where the office was.
The first client I went to meet up with still needed to sober up a bit before we could be sure of all the safety issues. Sadly, there was no detox centre in Carter, so the hospital became the defacto spot for people to overnight when they pushed their intake past the limit. The nurses really didn’t like these folks. Notwithstanding the fact that they were difficult to assess, it was this particular cluster of people who were more likely to get aggressive. Being assaulted is not uncommon for nurses, especially in emergency departments and although some people with acute psychosis, who are out of touch with reality, can be very scary, it’s the people who are intoxicated on drugs and alcohol who pose the greatest risk. And of course these are just the cats to whom we have to provide the most direction, redirection and redirection so they stay in bed, stay out of other places, don’t yell and use obscenities and so on. Anyway, crisis client number one today had just dozed off and there was no collective appetite for me to rouse him right at this moment!
Crisis client number two was a person I met few weeks ago. She was in-and-out of the bedded unit for a few years but then she was stable for about a year. Now she has started to show up again but we have been able to keep her out of hospital. She was awake and eager to talk, so my priorities were clear. “Hi Jill” I said as I walked through the curtain into her corner of the department. “I’m not sure if you remember me. We met about two weeks ago. My name is Hattie Crawford.”
“Yup, I remember you. You’re the new one. I didn’t know you before.” She appeared alert and her memory was apparently good. “Look at that short hair. You look like a radical, feminist dyke!” She laughed a little too loudly. “Well, I’m not really that radical, Jill” I smiled. I liked my hair real short so my looks often invited comments like this. Jill’s speech was rapid and clipped but coherent as she was talking to me. She wore tight jeans and I couldn’t make out the message that had worn off the front of her oversized t-shirt. Her dirty blonde hair was pulled back into a ponytail. Her mouth was moving but otherwise her behaviour was relatively still. I wondered if there was a hint of mania, or elevated mood in her presentation. Or, sometimes people had loose brakes and wide filters because they have had to expose their intimate lives to professionals all too often and in so many ways. Sometimes people with histories in the system have brakes that are a little too tight because they have had their trust breached. I thought perhaps Jill checked the first box.
“Do you want to talk with me here or should we shoot over to the interview room where it may be a little more private?”
“I’ve got nothing to hide from anyone!” Again, her voice was about a half a decibel too loud.
“How about this,” I interjected “there are some other folks here who are kinda sick. Let’s go over to the interview room and then we won’t disturb them. Savvy?”
“Cool with me” she nodded, gathering up a fleece sweater as she scissor-kicked off the adjustable bed. She slipped on her running shoes stepping down onto the backs so they slid on like slippers. I let the nurse assigned to Jill know where we would be. She rolled her eyes in exasperation. I knew people like Jill could be a distraction in a busy emerg but I made a note to make sure I gave the nurse feedback she needed to understand Jill’s difficult life.
As it turned out, once she started to open up, Jill was aware she was in a spiral. She recognized that her circumstances contributed to her mental state. Not her exact words, but I took from her description that she didn’t have the skills or the resources to keep herself in the housing and social setting that kept her stable and out of ‘the loving arms of the system’, as she called us. As often happens, when people with long-standing mental health problems are managing well, they turn away from the people and programs who can support them…and sadly the people who can support them often welcome the break. There is always more work to do than there are souls to do it, or money to pay for it for that matter. It was my impression that Jill she was living in a very good situation, she was connected to the long-term mental health team and she had a reasonable regime of medicine now, which it sounded like she was using on a somewhat regular basis and which seemed to be keeping her on the rails. But I sensed all this was in jeopardy now.
My innocent question intruded her repartee. “Jill, everything was going so well for you…we can get it back if we act now. What can we do to help?”
She became still as if pausing to collect her thoughts. She breathed deeply then looked me square in the eyes. “I hate it! I hate living the way you all want me to.” Words spilled vehemently from her lips. But it did not strike me that she was angry.
I was a bit taken aback by her disclosure. “Hmmm. Tell me what you want?” This might be the question she was angling for.
“I don’t want to be under the microscope. I don’t want the landlord to call the police if I am up all night. I don’t want to feel drugged up so I can’t get out of bed in the morning. I don’t like getting fat from these meds” again the intensity but clearly more frustration than anger, at least anger that I had to worry might be directed at me.
“Alright. Let me get my head around this. You are here in emerg now. You were here two weeks ago. You don’t wanna be here; I don’t wanna see you here. I’d rather run into you at the library.” She held my gaze and nodded. I had her attention. “So, step one: how do we crank it back so these visits to emerg are out of the picture? I doubt the landlord called the police because you were sitting quietly watching the moon over the rooftops…I’m guessing there was more.” I paused to let her fill in the gap.
“OK. I had the music a little loud. I had Craig Betts over and we were singing along. That old bat knocked on the wall and told me to keep it down, so I said go fuck yourself!” Craig was another familiar name. A bit sketchy but he was her friend so it was none of my business.
“Was this the first time, or have there been other times the landlord has complained?”
Jill slumped just noticeably in her seat and looked away before she answered. “Craig is living with me now. I love him and he has nowhere to go. You can’t make me tell him to move out. I won’t do it!”
I figured this was a good time to hear Jill out. I didn’t interrupt but I guided and encouraged her to reveal the details of the past three months. Jill explained that her friend Craig was evicted because he didn’t pay his rent. Jill let him sleep on her couch because she wanted to help him and because she was lonely. Then they became intimate. Craig liked to drink beer and smoke pot; Jill was interested in these diversions as well. The long-term mental health team that had been providing support was running into resistance because Jill was withholding some of these facts. She believed they would chastise her for letting Craig move in and they might have tried to talk her out of it, for obvious reasons. Jill’s timetable was turned around and she had become a night owl. Had this been me, the landlord might have done the same thing but the police wouldn’t have fetched me along to the hospital. They might have just delivered the same lifestyle pep talk I was about to deliver.
“You still haven’t answered the one important question I have. Before we move on, what do you want? This crisis thing doesn’t seem to be the way to go…”
“I want to have fun! I want Craig to love me!” was her quick response.
“That’s reasonable”. Her look was inscrutable. “But, how can we do all that and keep you out of emerg?” I wasn’t sure how reasonable her wish sounded to me but it was her wish and it met her test of reasonable and that was the only place we could productively work from. After another fifteen minutes or so, we sawed off at me calling in her community support worker who would take it from here. Jill’s situation would be tenuous for the next while but if the team hopped up their support they might guide her through it. I wasn’t convinced Craig was the best boyfriend but Jill had to come to her own conclusion about that.
Client number one was now awake and rambunctious but his family had also arrived and they were prepared to manage him. They were speaking with the doctor on duty which left me a few minutes to seek out the eye-roller and provide a little context that might help her to be a bit more understanding and welcoming the next time she encountered Jill, since I was pretty sure that there would be a next and likely a next-next time
At ten-fifteen Jenn texted to say Lowell had called to cancel his appointment. Ordinarily, a no-show was a chance to catch up on paperwork but I had a nagging feeling about this guy. All nurses know that their gut can’t be ignored. I looked through my notes to find his number and called him back. No answer. I wrote up my note and completed the scales on Jill. I checked to find out that the duty doctor had discharged client number one and there was no further need to me to follow up. I called Lowell again. No answer. There was no clear protocol around people who used the crisis service to arrange next day appointments, other than to call them back and make it happen, and of course document all that. I wasn’t in a position to call out the troops.
Before I ate my lunch I called Bridie to confirm her appointment at 1300 hours. Yes, she was still on for it and yes Doug was joining her. I tried Lowell again, No answer. Rudy and I rehashed last night’s Leaf game as we picked away at our lunch. Our observations were meant with the interest of true fans but also revealed our deep betrayal. A couple of years ago, the Leafs were about to move on in the playoffs when they allowed three goals in the last five minutes. That stake still burned in our hearts. Just before Bridie arrived I called Lowell once more. When there was still no answer, I decided it was time to document. I recorded his name, time of call, and the number of attempts I made to try to reach him. These details would be most helpful if he called back again to complain but least helpful if something happened to him.
Bridie and Doug arrived on time. As an absolute indication of her perpetual hope and resilience, she smiled warmly. I knew she and Doug had spoken with the kids and I was keen to hear how it went. I was hoping her smile might signal the answer.
“How are you two?” I opened, once they had settled in their usual seats. Human beings are funny creatures. People almost always sit in the same places. I am no different. When Jody and I go to the movies, if I’m not in my usual seat it takes me a long time to focus and I unconsciously, sometimes even consciously, glare at the people who are in ‘my’ seat.
“We are working on things.” Doug offered. No smile from him. If it was even possible, he looked even more exhausted.
“I know you had a chance to talk to the kids. That must have been rough.”
“The social worker from the oncology team was great. She had given me lots of tips and said I could call her to talk afterwards to see if there was anything she could do for me or the boys right away. Joey doesn’t really understand what’s going on. He’s only four. Yesterday when he didn’t think I was watching him, he was sitting on the sofa holding his breath. When I asked him what he was doing he said he wanted to know how it was going to feel to stop breathing”. While Bridie explained Doug stared at his clasped hands. “They tell me this is natural curiosity. Jamie seems less curious. I think he does understand how serious this is. He’s gone quiet and he isn’t even interested in all the pizza dinners we’ve been having. They are both going with me to St. Germaine’s the day after tomorrow to meet up with Shirley, the social worker”.
“How are you two after telling the boys? I can’t imagine how awful it was”.
Without looking up, Doug offered “It was all kind of a blur…Bridie did most of the talking. I watched them hear her words and try to…figure it out”.
Bridie continued. “There were some things I knew I could say, things I had practiced. I’m not sure if they heard my message that I will love them long after I’m gone or that I want them to love each other for me…but I will repeat that again and again”. Doug reached his hand over and cupped her thin shoulder. Bridie’s cheek moved almost imperceptibly toward the hand on her shoulder. She paused, and swallowed. “I’ve been thinking about the radiation, Hattie. For Jamie’s last birthday we went to a Blue Jay game. He asked me if we could do that again this year. I want to get to that. His birthday is May 16. This is the end of January now, so I need three or four months. I figure the radiation can do that for me.”
“Bridie, this is obviously very important to you and to Jamie. And to Doug”. I added when he looked up. “Have you talked to your oncologist?”
“The oncologist mentioned it in the first place.” Doug explained. “She said shrinking the tumor would be a short term solution to manage the pain. We are going to talk with her more about it Monday. We will meet up with her while Shirley spends some time with the boys”.
We spoke for a while about the in’s and out’s of radiation. Both Bridie and Doug had done their homework and they understood the physical toll the treatments could take. They knew that in Bridie’s situation the treatments were palliative and they knew that external radiation was required because the internal drink that contained radiation precluded contact with small children for a period afterwards. Despite the many improvements in cancer care, with aggressive and advanced tumors people still needed to make hard decisions about the very invasive treatments like radiation.
Bridie saw the benefit of reducing her pain and getting to her son’s special birthday request. But her feelings were mixed. “I am sorry that I will get to Jamie’s birthday but I probably won’t get to Joey’s in July…and I won’t see Lynne’s first birthday. I want to give some thought about how to recognize them in a special way. A little extra time can help me out with that too”.
“We’ll take it one step at a time, Bird” Doug looked her deep in the eyes and smiled. “We will get through this.” I could see the strength he lent her.