The Party.

I walked into a calm room, my patient asleep, roommate and roommate's husband quiet.  I gently wake the patient and take my time navigating the patient into our ambulation session.  Due to personalities of the morning that had to be seen due to impending discharge, I was not able to get to her room at the late morning hour which had previously worked well.  People with Alzheimer's do better with consistency, and they do better in the morning due to what is called a sundowning effect.  I was pushing my luck with 1:30pm, so I strove to make the transition as calm and easy as possible.  The orientation phase going smoothly as previous days, a good sign.

A PT popped his head in to the room.  "Are you seeing the other patient in this room?"  I respond a simple no. 

I again work towards re-orienting my patient to the fact that she is in the hospital, and that it why her room seems different and messy.  That the footsteps she hears outside are other nurses and doctors.  That we don't need a coat because we will be staying inside.  I have to lean in to speak close to her ear so that she hears and understands everything.

An OT comes in to see the roommate, who is on the other side of the dividing curtain.  She has a brassy voice in the first place, but the roommate is also partially hard of hearing.  Loud discussion between the roommate, OT and husband ensue. 

"Who is that?  Who is there?" 

"It is the OT to see your roommate." 

"Someone should tell them that this is not an appropriate time to have a party." 

I re-orient to being in a hospital.  She mentions the coat again.  I re-orient to our staying inside. 

The roommate's nurse enters.  Apparently there is some question that is now involving multiple opinions.  Four voices go back to being three, then the PT comes in again to consult, then two doctors pause within five feet of the door to discuss something from down the hall.  My patient has a hard time hearing me over the others, but we are able to get up to start our walk. 

But once vertical, the visual of an unrecognizable room meets the audio of unrecognized voices.  She begins to get frustrated about the clutter in her room.  The noise has surpassed her threshold, and I can tell that this won't end well, nor will the path run smooth.  At this point we have not walked, only stood, but for the sake of her safety I will run with whatever direction she gives be it a walk or a return to bed or something else entirely. 

I offer a handhold assist, which we have used successfully for the last two days. 

"No.  I don't need it.  I take my privacy seriously.  No one let's you have your privacy anymore.  I can't move when you hold me back." 

"I'm only here to make sure you stay safe." 

"Oh, good.  Thank you." 

"You're very welcome." 

"Oh, sure, [mocking tone] you're very welcome."  She sticks her tongue out at me.  Bad sign. 

"Would you like to go back to bed and get comfortable?"

"I can't get comfortable.  I don't want give up that easily."  She starts to walk toward the door, so I follow and guard, cautious that yesterday she was minimum assistance for balance but today rejects any offer of assistance. 

We come within two feet of the door, and the nurse practitioner walks up.  "It's good to see you up."

"What?"

"It's good to see you up."

"Oh, okay."  She fiddles with her hospital bracelet on the left arm, and with the wound dressing on her right arm.  Both arms and legs show signs of slight edema, just enough that her socks and bracelet and all other apparatuses fit tightly, so she fiddles with them out of noticing their presence but not understanding what it is.  The NP notices, takes her hand.

"This looks a little tight, does it feel okay?"

"Does what feel okay?  This room is a mess."

The NP quickly realizes that she added too much on top of the activity at hand.  But instead of a gentle apology and exit she attempts to explain herself.  I keep my sigh to myself, waiting, still guarding.  After a full minute of bumbling discussion that does nothing to soothe the patient, the NP goes to check on the situation with the roommate.  Five voices.  A joke, followed by laughter.  My patient takes one step to the right diagonal.  Pauses.  Turns and takes a step to the left.  Pauses.  She doesn't know where to go, or what to make of the scene.  I'm dying to get her back to her bed.  She doesn't deserve to be bed bound, but the usually succinct OT session is obviously not going to end any time soon.  To have her ambulatory while riled up could become dangerous if she doesn't allow me to continue guarding.  Last thing I want is for her to become so upset or so fearful that she falls. 

"There's just too much.  Too much people.  People with their parties."  I offer to go back to her bed.  I try to emphasize that there is something home-like about it to draw her interest.  She has none of it.

One of the nurses who was already one of my favorites looked up from a nursing cart.  The nurse has had my patient before.  She gives a knowing face of the difficulty when the patient is confused.  I motion for help, saying that it's too loud to get her back to her room safely.  We are a mere 15 feet away from her bed. 

The nurse takes her hand, begins anew with re-orienting the patient.  It takes a dozen exchanges and a full minute for each step, but this nurse understands the safety issue and is very patient with keeping the patient on board with the return to bed.  At this point I let the nurse guide verbally.  Because of the time that has now passed in an agitated state, I have become associated with the offending noise and privacy invasion.  I don't fight it.  I'm only glad the nurse is able freshly re-achieve a voice of calm separate from the rest of the chaos, despite having been another addition on top of everything else.  You use what works. 

Slowly, eventually, we get to standing next to her bed.  The "party" is down to three voices, but it is still loud enough.  I move myself to standing behind my patient where she cannot see me, because having the nurse in front is enough to keep her upset about sharing a small space.  We re-orient her to the fact that this is her bed, that this is a hospital.  Eventually she sits on the side of the bed.  I am still there in case she needs assistance with sit-to-supine, since I'm not sure if/how her function changes when agitated. 

The OT calls over to me, asking if I have the roommate on my caseload. 

"No," I say softly.

OT.  "Is everything okay?"

Nurse.  "It's the party.  It's a little too noisy."

OT.  "Party?  Hah!  What party?!"  Still brassy and loud.  They are walking toward the door, passing by the foot of my patient's bed.

Nurse.  "The noise is too much for her.  We'd like to keep it quieter, if we could."

OT.  "Okay."  Still brassy.  They pause as a group, all within view of my patient, all looking.  "I just wanted to see if Laura has this patient on her list." 

I shake my head.  "No, sorry." 

OT.  "Okay.  Thanks."  They continue walking out, continue talking.  Pretty sure they failed to realize that the noise was an issue.

Patient.  "Why does she have to be here?"  Pointing at me.

I can take the hint.  "I'll leave you with your nurse."  The nurse nods that she's okay.  I take my leave.

Forty minutes.  That's how long it took to orient the patient, by happen chance get her agreeable to stand, have things go south, and then the time required to return the patient to safety.  You cannot predict, but it still weighs heavy on my heart to have contributed to the exact opposite of what this patient needed.  Would she have become agitated by the "party" had I not woken her, had I not added physical activity to the list of offending overstimulation?  Logic says possibly.  My heart says probably not. 

PT fail.

Tomorrow she goes early, come hell or high water.  The other patients can simply wait their turn.