Island Nurses

by Howie, Leonie; Robertson, Adele;

  ‘You don’t want those sorts of memories,’ she says.

  ‘No problem there, Adele,’ Sven said. ‘I’ve thought this through. I know we need a fire that burns between eight hundred and a thousand degrees. Well, I’ve got three tonnes of dry pūriri here, ready to go. Heat’s not going to be a problem.’

  Adele is feeling panicky herself, now. She is starting to run out of arguments.

  ‘What do your sisters think of this idea?’ she asks on a sudden inspiration.

  There is a short silence on the phone.

  ‘They’re not here yet,’ he says, sounding evasive.

  Adele breathes a sigh of relief. Surely no daughter will allow her mother to be treated this way.

  She stops worrying and, sure enough, she is present at an Auckland crematorium about a week later where there is a wonderful, packed farewell for Sven’s ma.

  A few months later, Adele asks Sven whether he thinks he might have been a bit manic after his mother died.

  ‘No, not at all,’ he says. ‘Ma and I talked it over. It’s how she wanted it.’

  ‘What changed your mind? Was it your sisters?’

  ‘No, it was the number of people who rang and said they really wanted to say goodbye to Ma but couldn’t get to the island.’

  Adele breathes a sigh of relief—but she has never been able to talk her colleague into relieving for her in the north of the island again.

  The islanders’ need to be self-reliant exposes them to all sorts of risks that people on the mainland will never encounter—wind turbines that need servicing up ladders, and roofs that need to be climbed regularly so that solar panels can be cleaned. People have to walk streambeds collecting parts of their water turbine after yet another flood has demolished their micro-hydro scheme, or they have to shimmy past a chugging generator in a dark, shadowy shed . . . Heating water is often done the old-fashioned way, using a wetback on a wood stove. Having a soak in an outdoor bath heated by a wood fire underneath can be a heavenly experience, but it is not without its dangers. There is one case Leonie thinks of in particular where the daughter of a local rural fireman had returned to the island for a visit, and needed no persuasion to have a bath in the tub that her father had ingeniously contrived to heat with a safe firebox beneath the bath and a flue alongside it—a bit like a pizza oven with a bath perched on top. She had a lovely soak and felt thoroughly spoilt, but as she went to reach for her towel at the end of it, her delicate derrière made contact with the flue. She sustained serious burns to both buttocks—a painful reminder.

  But Leonie has another story about the health risks that attend living off the main electricity grid.

  Leonie takes the call. She quickly alerts Ivan and Peter.

  ‘It’s Richard,’ she says, naming a man whose property is at the extreme southern end of Aotea. ‘He has sustained a leg injury. Sounds very serious. He has told Patty that he has completely severed his foot on the fly-wheel of his generator.’

  Ivan and Leonie race to their vehicle. They drive to rendezvous with the policeman, whom Leonie has summoned: his vehicle is also the local ambulance. The two vehicles quickly travel in convoy along the rough road to Richard’s block. They park at the bottom of the steep track—and even by Aotea standards, this is a steep track—Ivan grabs his bag and sets off at a run, with Leonie and the policeman lugging emergency packs and struggling in his wake. It is early evening by now, and dark under the trees. They slip and stumble up the track: the policeman leads the way, but every now and again, he loses his footing and slips back towards—sometimes even past—Leonie. He blames his footwear; he has not yet broken in the tread on his new boots, he exclaims. Leonie is not too upset; the halts give her a chance to suck in a breath or two. Her footwear is sturdy: she is wearing her new Birkenstock sandals.

  They finally reach the scene. Richard is sprawled outside the little shed that houses the generator, at a moderate distance from his house. Ivan is kneeling beside him, assessing the scene and surveying Richard’s injuries by torchlight, and his friend is there, too, supporting, but looking pale and anxious.

  Leonie lights her own torch to increase visibility. It shines on Richard’s lower leg. She can see that the foot is completely disarticulated at the ankle. She closes her eyes momentarily. It appears to be merely hanging by an inch-wide skin tag to the rest of the leg. The distal—or bottom half—of the tibia is protruding through the stump, denuded of all but shreds of muscle and cartilage. The fibula appears to have been fractured and the skin at the bottom of his leg looks to be significantly contaminated with debris and is pale and devitalised. It is not a pretty sight, although it is better than she was expecting. Because she has not been in a war zone she has no experience in this kind of traumatic amputation, and nor has she previously been aware of the phenomenon of vasoconstriction, where the body reacts by reducing the arterial blood supply to amputated limbs. She had been expecting vast quantities of blood spattered around, pooling on the ground and gushing from the injury.

  ‘I’ve made a bad blue,’ Richard says, almost conversationally. ‘I knew the key-way on the driveshaft of my generator had a sharp point on it. I was going to file it off, but—you know—it ended up being one of those round-to-it jobs . . . So I was in the shed, trying to do something to the genny, and the key-way gets hold of the trackies I was wearing. First I know about it, I’m rotating through the air and crashing into the machinery. The trackies were gone. Oh bugger, I thought. I tried to get up, but then I realised my foot was flapping around and I was standing on the bare knuckle of my ankle. Not good. So I hit the floor and dragged myself up on the door to yell to Patty.’

  The first she knew of it, his wife confirms, was when Richard yelled, ‘My foot’s come off! You better call Ivan!’

  Peter arrives, and that galvanises Leonie into action. Though he is stoic and his vital signs are stable, Richard needs medication to relieve the pain. Ivan needs to insert a large-bore angiocath into each of Richard’s forearms. Peter is supporting the foot to keep patent (open) any surviving blood vessels to try to maintain the viability of the foot until we can properly dress and splint the limb.

  ‘It’s in,’ Ivan says, having inserted the first angiocath. Leonie connects it to the fluid bag and asks someone to stand to hold it high to increase the flow. She turns to pick up the syringe of analgesia, but this occasions an unfortunate movement of her foot. The fancy side buckle of her Birkenstock catches the IV line and rips it out before Ivan can make it secure with tape.

  Precious saline hoses on to the ground. Ivan looks at her impassively.

  ‘Leonie, pass me another sixteen-gauge angiocath,’ he says, and even adds ‘please’. Leonie complies, and squats awkwardly, with an apologetic look on her face. She remains where she is until this second angiocath is in place, safe and sound.

  More people arrive. It is the volunteer firemen, who are here to carry the stretcher. When Ivan judges him ready, Richard is lifted and carried carefully down the treacherous slope. Richard is six-foot-five (and a half) and is longer than the actual stretcher’s capacity, and this concerns Ivan who is supervising from the rear. It is dicey on the dark, steep track, and inevitably one of the stretcher-bearers slips over. Richard lurches sideways. The others hastily counter-balance to rescue the situation. Richard is safe.

  At the roadside, the sheer length of Richard creates problems. The stretcher cannot be clipped into its usual safety slots, because his splinted foot would protrude from the rear door. All kinds of frantic rearranging of the vehicle interior ensues, with jury-rigged restraints applied to the stretcher. It is not perfect but it’s safe, and soon they grind off to the health centre to prepare for the helicopter and evacuation to Auckland Hospital. Finally, after the safety lights are positioned around the airfield, the helicopter lands.

  Everyone is exhausted as they watch the winking lights of the helicopter recede into the inky blackness to the west.

  Richard is back on the island eight weeks later. He has suffer
ed several set-backs in his recovery, but now he has had a prosthesis fitted over the healed stump. At first, we were concerned about the remoteness of his situation and the uneven terrain he would have to negotiate every day, but his progress and stability has been rapid.

  ‘Soon as I was home, I came right.’ He grins. ‘Once home, I never looked back.’

  Home counts for so much. And for the islanders Aotea is home.

  ________

  * Not her real name.

  Chapter 11

  NEARING THE END

  ‘It’s a daunting privilege,’ Professor Rod MacLeod, a palliative care specialist, writes in the introduction to Snapshots: On the journey through death and remembrance, ‘to accompany people who are approaching death. One of the challenges is to balance the role of guiding and encouraging with the acknowledgment that people must travel the last part of the journey in a way that is uniquely theirs.’

  No less than standing beside a mother as she gives birth, nursing a person as death approaches is a very sacred time. Often an intimacy is created within the circle of carers, and the rest of the world is somewhat closed off. The hallmarks of palliative care are seen as compassion and to alleviate suffering in order to secure the maximum possible quality of life and, ultimately, a ‘good death’. The same palliative care specialist quoted above compares approaching death to walking along a mountain ridge. Factors beyond your control—the weather and the terrain—may affect the journey, and the final gate can be seen, first in the distance, but steadily drawing near. We have found this analogy helpful, because inevitably, as rural nurses, we have often been called upon to walk the journey besides people we know very well.

  We all approach death in a different way. Just as we have learned to tailor births on the island to the individual woman’s choices, so we have sought in every palliative situation to accommodate the wishes and needs of the patient along with those of their family. It is humbling to see how people approach this time—children willingly suspend their lives on the mainland or even further afield in order to become their parent’s carer; partners—often frail and elderly themselves—spend hours just sitting holding their loved one’s hand or snuggling up beside them on the bed. The same scenes are bound to occur on the mainland, but on the island, there is not the same access to the range of professional support services available elsewhere—the family is far more to the fore. It is almost unheard of for a Great Barrier Island patient reaching the terminal phase to choose (or to be compelled by family choices) to make the exhausting physical journey to a hospice. Generally speaking, it is just the family and friends caring, with the health team guiding, with increasingly frequent visits as death draws near.

  She is still the same gracious, wonderful woman we all know, even though she is in her nineties and the end is close. She has decided not to seek further investigations while at the hospital for her cancer-like symptoms. She has chosen instead to return to her island home until she dies.

  ‘I know I have made the right decision,’ she has said to Leonie several times. Even now that it is plain that the end is near, she is content.

  Leonie is primly sitting in her beautifully appointed bedroom as they review her care. She herself is propped on a stack of plump pillows.

  ‘Do you have pain?’ Leonie asks.

  ‘No, not really. I think it is really well controlled with those pills you arranged. But I’ve noticed I’m increasingly unsteady on my feet at night when I get up to use the commode. It’s OK during the day when my helper is here. I do so appreciate her care, but I worry about it at night.’

  Leonie wonders if there is anyone in the community she may be able to cajole into taking on night relief duties.

  ‘I must admit, Leonie,’ the woman says, ‘it has gone on long enough. I was ready to go ages ago. I can’t see the point of being on death’s door for months.’

  Leonie commiserates.

  ‘I just wish it would hurry up. It is hard on my son. I don’t think he is getting enough sleep. He’s not as young as he once was, you know.’

  They both laugh together. She listens to her patient’s stout heart, and, while there are faint indicators of failure, the beat is steady and surprisingly strong.

  As Leonie is putting her equipment away, the woman lowers her already hollowed-out voice to a conspiratorial whisper.

  ‘Look at this, Leonie.’

  She delicately throws back her covers and shows Leonie her ‘pullup’ nappies. Against her tanned skin she has rolled the waistband down so that they are the shape of a bikini bottom.

  ‘That is an improvement, isn’t it?’

  Leonie laughs out loud. It is typical of her patient—classy to the end.

  She cheekily splashes some of her perfume on Leonie as she is about to go. ‘This is one of my favourite scents. Have you smelled it before?’ She shows Leonie the bottle. ‘It suits you. It’s called Joy.’

  For a few weeks afterwards, even after the end has come for her patient, each time she gets in her car, Leonie fancies she can catch the lingering scent of Joy.

  There is a short pause on the other end of the phone after Leonie has answered it. Then a voice choked with emotion says: ‘Can you come now?’

  Leonie has been expecting this call—perhaps not so soon, but even so, it is not a surprise.

  She had a visit to this patient scheduled for this afternoon, but her instincts tell her something important is happening. She summons Ivan too, in case he is needed, and they climb into their car and head off.

  It was only fifteen months ago that she and Ivan visited this man’s home to inform him of the test results that confirmed an aggressive cancer. A mainland specialist had made the compassionate decision to ask Ivan to deliver the news to him on the island rather than to drag him across to the mainland, just to hear the tragic diagnosis. Their patient was a young man in his prime, a beloved husband and the adored dad of two daughters; in the aftermath of that terrible news, they all clung together and cried. Over the last fifteen months, his strong faith in God has clearly become his strength, sustaining him, and helping him along a difficult path: his palliative management has been challenging. His extended family and friends have supported him and his family wonderfully well every arduous step of the way.

  At the top of the steep driveway, Leonie and Ivan get out of the car. The home has a stunning view over the beach: there have been many days, lately, where all their patient has wanted to do is gaze out the window at his beloved beach and the surf break where he has spent some of the best moments of his life—riding the waves, or simply walking in the squeaking sand hand-in-hand with his three girls.

  They quietly let themselves in the ranch slider of his room. His wife is cradling him in their big double bed, and it is immediately obvious that his end is close. His breathing is laboured and shallow. Leonie quickly heads out through the house to fetch his daughters, and then she and Ivan step into the background. Soon afterward, surrounded by his family—his loving wife and his weeping daughters—his breathing slackens and then, finally, stops. He has slipped away from them to be with his Lord.

  ‘Sorry to call you up here so suddenly,’ his wife tearfully says. ‘He didn’t want me to be alone when it happened. He asked me to contact you. I just didn’t realise that his death was so close.’

  Outside, as they emerge from the room, Leonie gazes out over the beach far below. The waves are still rolling in from the broad Pacific, rearing as they near the land and breaking, casting themselves on the sand and then drawing back. As each wave spends itself, another is gathering behind it.

  ‘Come in,’ the woman says, her face streaked with tears. ‘He’s through here. He is not in a good way, I’m afraid. He’s saying all sorts of stuff. Just so you know . . .’

  Leonie is accompanied on this visit by one of the GPs from the health centre. They are here to see a man she knows very well. He is a colourful character, and his life has had more than its share of ups and downs. Leonie remembers grieving wi
th him and his wife when their son died, twenty years ago. She remembers laughing with him over the antics of his grandchildren. She also remembers as though it was yesterday when he first presented with what he described as an annoying lump in his throat, and was referred to the mainland. He had reported recently that the oncologists had discovered another cancer. It was the second time he had faced the disease, and Leonie empathised with him as he contemplated another round of draining trips back and forth across the Hauraki Gulf to hospital stays and out-patient clinic appointments.

  Leonie remembers the pang she felt when he told her that the surgeons had pronounced the disease inoperable. And today, she has learned that he has secondaries in his brain and that he has returned to the island. He is not expected to live long: perhaps no more than a few weeks.

  His wife shows Leonie and the doctor through to his darkened room where the patient is lying in bed, his frame ravaged by the disease. They have with them some literature they give people when they are facing the end, mostly information about palliative care options and what to expect. It is a time to answer family questions and discover expectations so that they can guide his care. But the patient pre-empts them.

  ‘There’s got to be something you can give me to end all this. If I was an animal, they’d have put me down weeks ago,’ he says.

  Despite his wife’s warnings, Leonie finds this brutal request unexpected. She feels tears spring to her eyes, and momentarily she does not know what to say. The GP remains by his bedside, quietly reassuring him and openly teasing out his fears. There is an intimacy in this moment—a time to leave his care in the GP’s skilful hands.

  Leonie puts her arm around her patient’s wife’s shoulders and leads her out of the room into the kitchen, where she slumps at the kitchen table as Leonie makes a pot of tea. The cup steams in front of the grieving wife as she sobs, head in hands, and Leonie tries to imagine the conversation in the bedroom.