Back in my professional days I was a physical therapist working for a home health agency. My geographical area was a working-class section of town which included one of the poorer neighborhoods.
Many of these people had come to Portland to work in the shipyards during WWII. After the war was over there was an aggressive attempt to 'send' African American immigrants 'back' to the states they'd originated from (not a proud part of this city's heritage). Failing this measures were taken that resulted in people being concentrated into neighborhoods which functioned as effective containment zones for the low income. Many of these areas gentrified while we were away in St. Louis. Places that 10 years ago I would have made an effort to have my work done before dark are now quite upscale.
Mary was living with her long-time boyfriend Lucius in an apartment in the heart of the poorer part of town. Her medical history said that she'd had 11 children, all of whom had been taken away because she was unable to care for them. She was a few years older than me. Her immediate need for physical therapy services was that she'd sat down on her sofa one day and couldn't get back up. Her diagnosis was morbid obesity and osteoarthritis.
She'd been taken by ambulance to the hospital. She had been evaluated in the ambulance rather than taken in to the ER. I'm trying to puzzle out the reason for this now, and it doesn't seem right to say it was because there were no stretchers or beds that could accommodate her: it seems a hospital MUST be required to be equipped to accommodate even unusually large or heavy people. I wonder if the rationale was to triage her in the ambulance and see if her condition warranted a hospital admission. If not, why bother taking her inside, particularly since she was on welfare and had no other medical insurance? So she was sent home and trundled to bed by the EMT staff and a few weeks later I got the referral.
She'd been bed-bound for the intervening time before I went to do an evaluation. She had been up a few times--to accomplish this she would "call the paramedics" and they would set her up in a chair in her front room for a few hours until she'd call them again to put her back to bed. Obviously, use of emergency services in this way wasn't sustainable and I was supposed to help her get her independent mobility back.
The problem was not only was she bed-bound, but she was also room-bound. She had a wheelchair that accommodated her, but it would not fit through her doorway into the hall. To be able to leave the room she was going to have to be able to walk a few steps through the doorway, far enough into the hall that the wheelchair could be unfolded behind her so she could sit down. Then she was home free for the rest of the apartment. After that there was the matter of 4 steps from her front door to outside.
Curiously, vulnerable in her immobility and dependent on the good will of her neighbors should there be a fire, she hated African American people. She appeared to have no shame about this, or awareness of the practical downside of such a stance. Her boyfriend worked nights (in addition to being paid to be a full-time caregiver for her) so she was alone. She didn't seem to realize how much wider her own margin of safety would be if she had a friendly and cooperative relationship with people around her: she could watch their houses during the day and they could look out for her at night.
I proceeded on the first prong of my attack: could I get her ambulatory? For her to be able to move about independently would be the optimal outcome. I had one of the local medical equipment stores come to the apartment and he immediately had me suspend attempts to stand with a walker: "The weight limit on these is 300lb; it could break and that would be a liability issue." So while we waited for the reinforced walker to be delivered I worked on leg strengthening exercises. Her knees were painful, so we had to proceed slowly.
The walker arrived, and I could see its limitations immediately: she would still be room-bound even if she could stand up and walk a few steps. The walker was too wide to fit through the doorway. If she was going to be able to walk and if that was going to have any practical application she was going to have to move into the living room of the apartment and that would be her base of operations.
Additionally her bed was low enough that getting up was painful for her and too much of a strain for her knees. To effectively strengthen her quadriceps muscles I needed to be able to work with her in standing, but the pain it took to get her to standing preventing being able to work. She needed a higher surface to reduce strain on her joints, and to enable her to exercise more effectively.
Getting her to the front room was going to be a problem. She'd progressed to a point where she could bear weight on her legs and the walker for a few seconds, and on good days might be able to take a step or two. The floorplan of the apartment was such that if we started her from the very end of her bed, she could be through the doorway in 3 steps, make a u-turn through the opening from the hallway into the living room, and arrive at another resting place in 3 or 4 steps. The logistics were that if she could stand long enough we could walk her to the doorway, then she'd need so sit down for a moment while I folded the walker then maneuvered it through the doorway and then set it back into position once it was through. We'd need something on wheels she could sit down on while I moved the walker, then we could position her to stand up again. A few more steps and then she could sit down on the end of a bed that Lucius was going to get. Between my visits he collected mattresses and piled them up in the front room to make a surface high enough that she theoretically could stand up from more easily. He also bought an office chair that was higher than her wheelchair and more maneuverable. The plan was to have it behind her as backup as we made the transition.
A pleasure of home health is the different quality of interaction when I'm on someone's home turf. The intimacy of being in someone's home, with their pictures on the wall, their treasures, their individuality intact changes the professional footing to one I find satisfying. I enjoy the privilege of being trusted. We had lots of opportunity to talk, so I learned a little about Mary and Lucius. They were very generous to me, often feeding me lunch or a late afternoon snack if my work had been so hectic I'd not had an opportunity to stop. Lucius was a good cook, and very devoted to Mary. Mary confided to me her humiliation when her family wouldn't accept her, or allow her to sit on their furniture because they thought she'd get it 'dirty' somehow. Apparently there had been a period where they had their children with them, because she told me with some pride that with food stamps and Aid to Families with Dependent Children she'd 'pulled in a good income.' I looked forward to seeing them, and they were glad to see me.
So on moving day I helped her stand with the walker. She managed two steps and then said she could go no further. Lucius was behind her with the office chair and she sat. The chair squealed, but held. To avoid stressing the support on the chair we didn't push it by its back to move it forward, but instead I squatted on the floor and grabbed its base and pulled it from there. We made it into the hallway, but she couldn't get up again. So, committed, I tugged at the base of the office chair and duck-walked backward and Lucius pushed from behind and we made it through the hallway opening, around the turn to the waiting bed (pile of mattresses) to which she rolled herself. And sank, right into the middle, like a body will sink a trampoline. OMG, I had not foreseen that. There was absolutely no way she'd be able to get up from there--she was truly imprisoned. She'd not wanted a hospital bed, but there was no way around it now. There was no going back to the bedroom. She would have to stay where she was for a day or so until the specially reinforced hospital bed could be delivered, but she and Lucius felt they could manage that. In the meantime the landlords had given written permission for a ramp to be built outside to make the apartment accessible, so that was being put into place.
Plan B, failing Plan A (to get her independently walking), was to get her mobile with her boyfriends' assistance--and without having to call paramedics. The height-adjustable hospital bed arrived, and since it was placed in the front room she could now enter and exit the apartment, in a wheelchair (once the ramp was in place), with her boyfriend's assistance. I worked a while longer on the goal of strengthening her legs to the point where she could walk, but it became clear that there weren't the resources available reach that goal. Medicaid said she'd had enough of a chance for that, and plan B was going to have to suffice. So we said our goodbyes. A few years later I read her obituary and wondered how Lucius was.
I wonder about her many children, too, where they are and what their own lives are like.