I spent most of the time with a largely aphasic, bedridden, elderly Russian man (we'll call him Mr. B) with contracted arms and legs, restraint mitts on both hands, an IV, a Foley catheter, and a stage 4 bedsore on his tailbone. He spoke little English (the only word he spoke that I could understand was Finish, indicating that he was done with his lunch), and unlike the last time I was with him, two weeks prior, he spoke almost not at all, even in Russian.
I didn't know (or if I had heard about it some previous week, I didn't remember) about the bedsore until I was changing his adult diaper and saw that the ulcer's dressing was nearly off. Maybe there's no good time to see a stage 4 pressure ulcer, but while wiping bacteria-laden feces in close proximity to the ulcer has to be one of the worst possible times. In addition to this, I now for the first time saw that Mr. B knew how to take off his restraint mitts (placed on his hands after he had pulled out his G tube and nearly pulled out his Foley catheter) using his teeth. So now, feces, open wound, possible pulling out of tubes. Not good.
After a short period of figuring whether I could handle the situation myself, I decided to seek help. Before I left the room I spoke to Mr. B (who could not understand me, but I spoke to him nevertheless) and made sure his position, tubes, bed, room, were all generally safe. I found a CNA who brought me to the LPN—a Russian man about my age—who was making the rounds for dressing changes, etc.
The LPN was not pleased that I had begun changing the diaper before he had tended to the wound, but he remained calm and didn't seem to feel any extra urgency. When he arrived in Mr. B's room, he talked to me about my education, my career plans, and Mr. B's condition as he methodically went about cleaning the area and redressing the ulcer—it looked like a gaping red mouth with areas of white, necrotized tissue. All the way down into the muscle and the bone. I didn't see the bone, hiding as it was behind the flesh, but the LPN invited me to put a gloved hand inside to feel it. (There is no pain, he said with his Russian accent, There are no nerves left.) Underneath the relatively soft cheeks or tongue of the mouth, a tooth, a broken bone. Mr. B didn't flinch.
Changed sheets and diaper twice, at least; always just as we were halfway done, Mr. B began another bowel movement. We just kept up with it. After the LPN left to finish his rounds, I stayed with Mr. B for a few minutes to make sure he was safe and comfortable. I talked and gestured to Mr. B about the importance of not taking the mitts off, but he didn't care. Aside from removing medical apparati that he didn't enjoy, Mr. B (like many elderly residents I've seen) ran his fingers over everything, as though it were a compulsion. It looked like he was reading the world around him, rubbing the edges of the sheets and feel the CNA's hand. That was two weeks ago, but now this form of communication and exploration was denied him.
It was going to be a short day; after the residents' lunch, we were done with our final clinical. The LPN had put tape on Mr. B's restraints to prevent him taking them off, and I had informed the CNA that the tape wasn't holding. There was no more I could do. I had learned a little more about the realities of feeding, positioning, and keeping clean residents who can do little for themselves; about the lethargy and silence that can come with debilitation and despair; about gaping red mouths with teeth on old men's tailbones. I had talked to Mr. B, asked him questions, tried to joked with him, knowing that he couldn't understand; I had touched his arm and looked into his pale blue eyes.
As I got ready to leave the room, I placed the call light on the corner of his bed and pointed it out to him. I said that if he needed anything, he could press the button with his mouth, the same way he gets his mitts off. And he smiled, for the first time that day. I'm not sure why, since he couldn't understand what I said, and couldn't be laughing at my little joke. But anyway, I felt something as we shared that smile, like I had done my best and made some good decisions and made a real connection with an old man who needed a real connection, even more than I did. And I almost wanted to stay.