I have been a home healthcare and hospice field nurse in the city of New Orleans for 15 years. My territory includes the famous St. Charles Avenue, home to dozens of historic mansions, and the Lower Garden District, with its beautiful antebellum homes and famous above-ground graveyards. It also includes Central City, a struggling neighborhood where the only food that can be found is at tiny corner stores, and the Lower 9th Ward, barely repopulated since Katrina, and a "food desert" where it takes three city buses to get to the nearest grocery store. There are also large, unsightly, low-income senior apartment buildings with 24-hour armed guards, but nearby you would find million dollar apartments (also with armed guards).
Recently my day started in a poor neighborhood called Hollygrove, where I made a discharge visit. I took the usual precautions for a high crime neighborhood: park only where I can get out easily, keep the car running when I'm in it, and call the family first to make sure the door is unlocked. My patient is an 87-year-old family matriarch with past medical history of poorly controlled diabetes, high blood pressure, and morbid obesity. On admission, her family spoke as if they were taking good care of her. After careful questioning, and checking her glucose meter, I "busted them"; they did not realize her meter had a memory. They admitted they weren't taking her blood sugar ("it makes her mad"). They were not insisting that she take her medicine ("she doesn't feel like it"), nor were they following dietary restrictions for her ("she eats what she wants"). After 60 days of seeing her weekly, the family is checking her glucose a few days a week, her med box is empty when I arrive; however, no real progress was made in her dietary habits. I think I could make further inroads, but she has Medicare HMO that is extremely restrictive, to say the least.
My next two stops were patients with central lines receiving home antibiotic therapy. The first, a 67-year-old retired attorney who lives in the famous Lower Garden District in a stunning antebellum home, is getting Vancomycin daily, and Flagyl three times a day via Mediballs. The other is a 72-year-old man who lives in a poor area of the Irish Channel, only a few blocks but a "million miles" from the attorney. He too, is getting Vancomycin daily and Ceftin BID; however, he is getting his meds via open tubing and drip count. (Remember drip count? Neither did I!) I called the infusion company to ask why he wasn't at least getting his meds with a Dial-a-Flow, and her answer was that "this is all the insurance would cover." Guess what insurances? The first man has Medicare with Blue Cross secondary; the second man has the same HMO as the first patient of the day.
Both of those patients required lab tests. I drew the blood, filled out the paperwork, drove to the lab (quite a distance away), paid to park, went into the lab, and filled out the paperwork, all for no money. Zero. This is a real pet peeve of mine: if I want to do volunteer work, it should be for my church or the Girl Scouts; not for a for-profit home healthcare agency.
While on my way to my next patient, I noted that traffic along Claiborne Avenue had come to a complete standstill in both directions-as far as the eye could see. I got out of my car, joined the crowd, and started dancing. It was a funeral "second line," a New Orleans tradition that is unlike anything in the world. It must have been someone important because there were three brass bands! The Mardi Gras season, which takes place every year for 11 days and ends the Tuesday before Ash Wednesday, is another time when crowds gather in New Orleans for parades and merriment. It is virtually impossible to make visits to patients in the French Quarter during this time, so patients have to stay with family or friends outside the French Quarter if they are going to need visits.
After a 30-minute delay, I was back on the road. My next two stops also involved two people with similar stories. One was a 58-year-old schoolteacher who had had a total knee replacement, 3 days prior, and had just returned home; the other was a 63-year-old day laborer who was 8 days out from a total left hip replacement. I performed the admission on the schoolteacher, telling her that she would get nursing visits three times a week for 2 weeks for incisional care and pain management, and physical therapy three times a week for 4 weeks, then transfer to outpatient therapy for another month. I then made my last of three allowed visits to the day laborer. I told him that he would be discharged after his fourth therapy visit, and that he would need to continue therapy at home on his own. Insurance? The teacher has state teachers' health insurance, the day laborer has Medicaid.
My last patient of the day was a 36-year-old man who is quadriplegic due to a fall off a ladder 3 years ago at work. This was his recertification visit for his 7th certification period. He has stage IV bilateral hip wounds that won't heal. He has not followed instruction on pressure relief, spends all day in his chair, and is not taking dietary supplements to promote wound healing. He refused a wound vac, because he "moves around too much, and won't be able to manage it." Workers Comp pays for every-other-day nursing for wound care, and ships an amazing amount of supplies. However, they know they will get everything back when his lawsuit is finalized later this year. This will no doubt leave the patient with no money, and no insurance other than Medicaid, which may pay for weekly nursing visits at the most.
On my way home, I did my usual calculations. Two routine visits, two discharges, one recertification, one admission. Then 3 more hours at home doing the paperwork after 6 hours on the road. That is a day in my life.