Home visits

I remember when I was very young, our family GP, Dr. Bannister, would come to the house with his black bag. My mother would usher him into our bedroom and he would sit down on the bed to examine my brother and me. He would ask mum for a tablespoon (using the handle as a tongue depressor) so he could diagnose communal pharyngitis. The fever and malaise, and maybe rash, was chalked up to a virus or strep. Some scribbled notes were made on a file card, and he was off, leaving behind a prescription for penicillin—and a reassured parent. It worried me that he took the tablespoon with him. Later on, he diagnosed my adolescent mumps (no orchitis, thankfully) on a home visit. When I was 22, studying mathematics, I got appendicitis, and a call-out doctor summoned the ambulance. I lost my appendix, found my wife-to-be, and the rest is history. I thought I’d scribble my own notes about the times when I was privileged to make a “domiciliary visit.” I was a fourth-year medical student, doing a GP rotation in Eaglesham (a more prosperous suburb of Glasgow). My colleague Mike and I were dispatched to the Robertson house, with instructions to “find out more.” We were met at the door by Adrian, a tall thin young man in his mid-30s, with a sad face and a monotone voice. He seemed to be mentally handicapped. He invited us in and went away to make tea—while we interviewed his mother, Sarah. Sarah said she had been recently widowed: Her husband had taken ill and died in hospital soon after. Furthermore, the hospital wouldn’t tell her what had happened and refused to issue a death certificate. I looked at Mike and he stared back. “How dreadful,” we muttered. “We have to help you get . . .”. Adrian rushed in and, in an intense outburst, shouted “Nooooooo . . . ! Noooooo. . .! It’s all in her head!” To cut a long story short, Adrian had myotonic dystrophy. He was sharp as a tack, just disabled by his phonetics. Sarah, on the other hand, was psychotic and had quit taking her drugs. Her husband had left her years ago, and was very much alive! We learned not to judge a book by its covers. A memorable experience. Home visits were not part of residency training. But in practice, as an internist, I gleaned a lot of information when I visited a Parkinsonian patient in his rancher. If he fell down, there was no way his diminutive wife could do anything for him, save calling 911. A short time later, I visited Ellen, 63, a single woman in town. She had been diagnosed with locally advanced breast cancer. She declined surgery, and chemotherapy, and was “making preparations.” Her left breast was a fungating mass. What bothered her—more than dying—was the smell. I told her I had done research in my undergrad years (as a bioengineer) with carbon fibre cloth. It could absorb many chemicals, including those that cause the stench she lived with every day. I found some for her, and this became the bra padding she needed. She could entertain visitors without the stigma of mal-odour. She didn’t need the constant reminder of mortality that this situation conferred. It wasn’t morphine. But it made me feel empowered as never before. In a previous article, I told the story of Ted, a Hungarian violinist, who had been sent home from hospital with advanced lung cancer. His wife, really not up to the job of being his palliative care nurse, called my house a few blocks further into the wooded countryside. “Ted is dying,” she said, “Can you come straight away?” Not knowing who Ted was, I suggested they might call an ambulance, but no, they wanted me to find their house—in the dark—right away. Marla was in the driveway, flagging me down. Ted told me all about his wonderful career, his violin collection and his love of Tokaj (Hungarian dessert wine). The neighbours, Ted, Marla and I all had a glass (Ted’s was chased with IR-Morphine), and the night passed peacefully. He did too, a few days later. I felt I had been part of his life journey, not just as a bookend. Mary, a neighbour of mine, came home from her cystectomy with a bundle of dressings, tweezers, antiseptic wash and the like. Community health nurses were visiting every other day, changing the dressing, in an attempt to justify a precipitous post-op discharge. I crossed the street to say hi. I looked at the wound (well I had to, I’m the doctor from across the street). My eyes were met with a red, angry, oozing gash. “That’s not how wounds were supposed to look where I trained,” I said. I took a photo that was e-mailed to the surgeon’s desktop that night. She was in the OR the following day, unzipped and gushing pus. Magic. Most recently, I was asked—by nurse acquaintance Linda—if I could see Marge. Marge was 94. A retired RN, she had come to end her long life in a nursing home—some 30 minutes drive away. She had heart failure and was short of breath. Linda had worked with me some years previously and knew of my interest in HF. I made a house call to the residential care home, completed a consult, changed her meds, and bingo. She was better in short order. She said she felt she could “dance on the table.” A year later, her pulse dropped (off beta-blockers): Everyone felt a pacemaker was a step too far. A thyroid supplement helped a bit. I visited a few times (with COVID gown and mask). Last week, she took a turn for the worse, and her demise seemed inevitable. At 97, she slipped away quietly with family beside her. I was told the extra time allowed her to have some frank discussions with her family: They were very appreciative of her care. I was left wondering: Why is it we don’t do GIM consults more often in nursing homes? When quantity has been assured, can we say the same for quality? I don’t think I’ve ever regretted the home visit, a wonderful opportunity to see the patient with the disease, not just the disease the patient has.

Casebook of a Community Internist

Home visits

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Blog Author

Hector Baillie

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