Prevention of Tuberculosis—Sources through Which Calls are
Received—Entering the Home—Telling the Truth to the Patient—Truth
for the Family—Disposal of Sputum—Danger of Expired Air—Isolation
of Dishes—Linen, Household and Personal—Disinfectant and Other
Supplies—Phthisiphobia.
=The Prevention of Tuberculosis.= The object of the nurse’s work is to
prevent the spread of tuberculosis—it is not to cure the disease. In
doing the preventive work, it often follows that the patient himself is
immensely benefited, and his disease apparently arrested. This arrest,
however, is incidental—it is not the real object of the work, which is
the protection of individuals as yet uninfected. In no other branch of
nursing is there so much misunderstanding, so much placing of the cart
before the horse, and so much emphasis laid on the wrong thing. Nurses
themselves when they first begin the work fail to recognize the real
issue, and think that it is the actual care of the patient which is the
thing to be considered. This is totally wrong—_we work through the
patient to gain our ends, but he himself is not the main object_. It is
necessary to grasp this fact firmly, and keep it constantly in mind.
This will not only prevent much disappointment and discouragement, but
it will lay the foundation for more intelligent work.
On entering the home of the consumptive, the nurse has before her two
responsibilities, the family and the patient. The former is infinitely
larger and more important, since it is the family, as yet uninfected,
which must be protected from the patient, or source of the disease.
Instead of “family” substitute the word “community” and we have the crux
of the situation—the protection of the community from the danger to
which it is exposed. This protection may be accomplished largely through
care of the patient, but care of the patient, only, as such, is a
secondary matter. The vital and important concern is the welfare of his
family. To confuse these two issues, and put the patient first, and the
family, which means the community, second, would delay indefinitely the
result we hope to attain. As far as possible, the interests of the two,
patient and family, should be identical, but whenever a choice must be
made between them, the welfare of the community has the right of way.
This is why effective tuberculosis work must place the emphasis on the
control of the last-stage cases, since it is the advanced case which is
of most danger to society. For example: we have two families, one of
which contains a moderately advanced case, whose outlook is favourable,
while the second contains a last-stage case with a hopeless prognosis.
Both patients are equally intractable; the nurse has but a limited time
at her disposal, and must choose between the two, since she cannot
divide her days equally between them. From the point of view of the
individual, care of the earlier case would better repay her time and
effort; from the standpoint of the greatest good to the greatest number,
she must concentrate her efforts on the advanced case, since it is this
one which is immediately dangerous. The earlier case is less of a menace
to those about him; his obstinacy and refusal to follow advice mean loss
of that precious time in which life and death are determined—but if he
chooses, however wilfully, to waste this time, it is his own loss after
all. It involves no one else. On the other hand, much more is involved
in the advanced case. Here the patient’s death is inevitable, but it can
be kept from occurring amid circumstances which would drag down others
with him.
In the majority of cases, the death of the patient is the issue to be
expected, however much it may have been delayed or postponed—a result
saddening and discouraging to those whose previous training has been to
preserve life. What nurses are not trained to see, and what many of them
have neither imagination nor faith enough to see, is the number of lives
that are probably saved through the safeguarding of a dying individual.
It has been said that the world would be infinitely better off if every
consumptive in it could die to-day, since by this loss the people of
to-morrow would be saved. The nurse must cease to reckon in terms of
hundreds of patients—she must reckon in terms of the thousands who come
in contact with these patients. The amount that can be done to protect
these thousands is the standard by which the work must be judged a
failure or a success. If she bears this constantly in mind, she will not
become so easily discouraged.
Therefore, to sum up once more: upon entering the home, the nurse’s
first care is the family, and her second is the patient himself. But it
is by working through the latter that the former may be reached. The
patient himself is the point of attack, and if in the ensuing pages he
becomes so prominent as to delude one into thinking that his welfare
alone is the final goal, he is only made prominent in order that we may
reach our goal more quickly.
=Sources through Which Calls are Received.= The nurse goes to the
patient’s home, in the first instance, at the request of some one who
has sent her. This may be a physician, a dispensary, a neighbour, or she
may even go on her own shrewd suspicion that some one is ill. When the
door is opened to her knock, she must be careful how she explains her
coming. If a municipal nurse, she should never say that she has come
from the Health Department, for this conveys a suggestion of authority
which is often most alarming. Since the patient has been referred to the
Health Department from one of the sources just mentioned, it would be
more tactful to name the agency through which the call was received.
When calls are anonymous, such as by letter or telephone message, or
when the sender gives his name but asks that it be withheld from the
patient, the task of gaining an entrance is often one of considerable
difficulty, and requires much strategy. Calls of this sort should never
be refused, since in this way many advanced cases are brought to light.
It is also a wholesome indication that the community is learning to take
an intelligent interest in an infectious disease, whose presence is
recognized as a menace. These cases can best be managed if the nurse
assumes the responsibility herself, saying that in a roundabout way she
has heard that there is illness in the house, and so has called to offer
her services. As a rule, her offer will be readily accepted, for a case
reported in this manner is usually advanced, and, as we have said
before, when the neighbours diagnose tuberculosis, they are frequently
right.
=Entering the Home.= As a rule, when a nurse presents herself at a house
and explains her errand, the door is opened wide and she is cordially
asked in. In some instances, it is held half-shut, in a dubious manner,
and she is admitted with reluctance. Sometimes it is banged in her face.
It is a great satisfaction to gain an entrance into homes of the latter
class; to win the confidence of such patients is a victory worth having.
The surest formula for entering all homes is a broad smile; to stand on
the doorsteps and grin like a Cheshire cat disarms suspicion, and once
across the threshold, the victory is won.
=Taking the Patient’s History.= The facts concerning the patient must be
gathered in his home, and they are of two kinds, those concerning his
physical and those concerning his social condition. The first thing to
be done is to establish a feeling of trust between the patient and the
nurse. As a rule, all patients are communicative, and a few adroit
questions will open a flood-gate of confidence from which can be
gathered full details concerning their personal and family affairs. This
gives the nurse much of the information which she needs not only for her
charts and records, but also in order to deal intelligently with each
case. For unless she understands the patient, and knows something of his
social and economic condition, she will not be able to give helpful
advice. But the nurse must also bear in mind that tuberculous persons
are frequently shy and sensitive, and it may be difficult to obtain
their true histories. They may be more ready to describe their physical
symptoms than their social condition, and facts about their employment,
hours, wages, life insurance, and so forth are not always forthcoming.
It is inadvisable to make notes in the presence of the patient, for
among the poorer classes there is a fear that their words, when noted in
a book, may in some mysterious manner be used against them.
Occasionally, in a matter of some importance, distrust may be quieted by
asking, “May I just write that down? The doctor will be interested in
that and I want to get it right,” but it is well to remember that
suspicions once aroused are difficult to quiet, and that for the welfare
of the community it is better to teach them to use their sputum cups,
than to antagonize them by too many questions. The nurse should get all
the facts the chart calls for, but with certain patients this may take
considerable time. At each succeeding visit she can ask another question
and a more intimate one, until she collects, little by little, all the
data she requires. But it is a mistake to keep on asking
questions—collecting statistics—at the expense of confidence and
good-will.
It is true that when a patient goes to a dispensary, he is prepared to
answer many questions, but there is this difference—it is he who seeks
the dispensary. When the tables are reversed, when he is not the seeker
but the one sought, he must be handled carefully. There are of course
many patients to whom this does not apply, and who willingly volunteer
every detail of their lives, but these are not the majority. The others,
the more sensitive ones, make up three quarters of the visiting list.
The antagonizing of a patient by tactless questioning is an unfavourable
commentary on the method of handling him.
=Telling the Truth to the Patient.= The most difficult of the nurse’s
duties, and the saddest, is to tell the patient the nature of his
disease. Yet this must be done, for unless he knows from the very
beginning, it is impossible to exact from him that intelligent
co-operation upon which rests his sole hope. Only on the rarest
occasions is there any justification for withholding this knowledge. If
a patient has but a few more days to live, or if a hopeless case is
surrounded by scrupulous care and attention, this information may, if it
seems best, be withheld. But these are exceptional instances. To hide
the truth from an early or moderately advanced case would be criminal.
Apart from the first shock, people are never really injured by being
told the truth, and we all know of hundreds of cases in which lives have
been ruthlessly sacrificed through the policy of silence.
The truth need not necessarily be brutal—it can be made full of hope,
interest, and encouragement. In her efforts to encourage the patient,
however, the nurse must be exceedingly careful never to use the word
“cure.” Tuberculosis is never cured in the sense that typhoid fever is
cured, for example. At best, it is only arrested—that is, brought to a
standstill, to a point where the destruction of the lung tissue goes no
farther. Thus, if a person loses one or two fingers from a hand, a cure
would imply that these lost fingers could be made to grow again. The
lung tissue destroyed by tuberculosis can not be replaced or renewed any
more than lost fingers can be renewed. Yet a lung, in spite of this
loss, is still able to serve its owner well and enable him to lead a
useful and happy life, just as a hand which has lost a finger or two may
still be a fairly useful hand, and serve its owner well. This
distinction between arrest and cure must be made perfectly clear to the
patient, and he must also be taught that whether the arrest of the
disease is temporary or permanent depends in large measure upon himself.
His improvement depends upon his thorough understanding of his illness,
and upon his ability or willingness to co-operate as to treatment.
According to Dr. Minor,[3] it is not so much what a patient has in his
lungs, as what he has in his head; namely, common-sense, which
determines his recovery. Therefore to keep a patient in the dark
concerning his condition, and yet expect him, without knowing the
reason, to do over and over again the tiresome routine things necessary
to improvement, is to expect the impossible.
Footnote 3:
Dr. Charles L. Minor, Asheville, North Carolina.
In making the best of things, the nurse must never over-encourage the
patient. A half-starved, overworked person, suddenly put on a régime of
fresh air, rest, and abundant food, will often make surprising
advances—up to a certain point. This improvement may be so marked that
it will raise false hopes of its continuance and the nurse must never
jeopardize her reputation and the confidence imposed in her, by
extravagant statements as to what may be accomplished. The overconfident
patient mistakes temporary improvement for permanent cure. Tuberculosis
is like a concealed enemy, crouched and ready to spring the moment one
turns one’s back, and it requires constant vigilance to guard against
it. If this fact could be securely drilled into the patients, there
would probably be fewer relapses.
=Truth for the Family.= If now and then an exception may be made in
informing the patient of his condition, there are no conceivable
circumstances under which this knowledge should be withheld from his
family. The significance and danger of tuberculosis must be fully
explained to all who are exposed to it. It is the “family” who
constitute public opinion as far as the patient is concerned, and we
must depend upon it to keep the patient up to the standard of living
which means his improvement and their protection. The nurse should fully
explain the situation to some older, responsible member of the
household. This can best be done out of the patient’s presence. She must
speak very plainly, using words within the comprehension of her hearers,
so that they cannot fail to grasp her meaning. The patient needs this
knowledge in order to get better—the family need it in order to protect
themselves. It is a sad fact, but a frank appeal to the selfish instinct
is usually productive of better results than one made upon higher
grounds. Both points should always be made, but the instinct of
self-preservation may be aroused with less prodding than is needed to
awaken rudimentary altruism.
=Disposal of Sputum.= The nurse has by this time prepared the way for
the prophylactic supplies, which she carries in her bag. These consist
of a tin cup, fillers, paper napkins, disinfectant, and so forth. She
must teach the patient how to use and dispose of them, as well as their
advantages—the latter reason not being always apparent to the ambulatory
case. She must teach that danger to himself and others lies in the
sputum coughed up from his sick lungs, and that the simplest way to
receive it is in the little tin cup, whose waterproof filler can easily
be burned. To the advanced case, with profuse expectoration, these
light, convenient little cups are a great improvement over the household
spittoon, which should be banished at once. Bed patients, or those too
weak to raise even this light cup to their lips, may be taught to
expectorate into the paper napkins, of which they should be given a
large supply. A simple way of disposing of these napkins is to pin to
the bedclothes a large paper bag (such as are used for groceries), into
which they may be thrown. Failing a paper bag, a cornucopia made of
newspaper will answer the purpose, the object being to let the patient
himself place this infective material in a receptacle which can be
burned in its entirety, without its contents being handled by anyone
else.
The problem of destroying sputum cups and their contents is often
difficult. The proper and only sure way is to burn them, and no other
course should be considered. Yet in summer, when many patients have no
coal fires, but merely gas or oil stoves, many difficulties arise. Under
such circumstances the patient may wrap his cup in a newspaper, place it
in a galvanized iron bucket, and then set it on fire. This is a
nuisance, as well as somewhat dangerous, and since these fillers and
their contents are hard to burn, the simpler method of throwing them in
the gutter becomes an irresistible temptation. To see that these fillers
are properly destroyed requires constant supervision and instruction and
is one of the most important of the nurse’s duties.
The patient should destroy the fillers himself—they should be handled by
no other member of the family, unless of course he is too weak and ill
to do it. Even when very ill, however, it is nearly always possible for
him to remove the filler from the cup and place it in a newspaper, which
is then rolled up by someone else and carried out to the fire. Needless
to say, the nurse must teach those who touch or handle this cup how
important it is to wash their hands thoroughly afterwards.
=Danger of Expired Air.= After giving him the tin cup and fillers, the
nurse must then give the patient a supply of paper napkins, and explain
their purpose. These are primarily intended to hold over the mouth when
coughing. The nurse must explain that bacilli are liberated in great
numbers during these coughing attacks, and that it is harmful to live in
a room filled with these invisible organisms. Most patients, knowing
themselves to be infected, are indifferent to the welfare of those about
them. Therefore, in trying to make him careful, the nurse will have to
appeal to his selfish instincts, and show that what is bad for other
people is equally bad for him, and so diminishes his chances of
improvement.
It is comparatively easy to instruct a patient in the use of his sputum
cup, but to obtain any sort of carefulness in this equally grave
matter—liberation of bacilli in the expired air—is well-nigh impossible.
This is partly due to the nature of the disease—in its most infectious
stages, the patient is so racked with paroxysms of coughing, that it is
impossible for him to keep his mouth covered, or to think of anything
except his own sufferings.
On the street, these paper napkins may be used to spit into, the patient
carrying them home again in the waterproof pocket pinned inside his
coat. Fine details of this sort are difficult to insist upon,
however—the convenience of the street and of the gutter making a
stronger appeal than any newly acquired æsthetic valuations. This is of
minor importance, however; the real danger lies in the home.
=Isolation of Dishes.= The consumptive should have special dishes
provided for him, which should never be used by any other member of the
household. If the family can afford it, they should buy dishes of a
special pattern, unlike those in general use, since in this way the
chances of mixing them are greatly lessened. Otherwise, constant care
must be taken to keep them apart. The patient’s dishes should stand on
their own corner of the shelf, be washed in a separate dishpan, and
dried with a special towel. Once a week, for general cleanliness’ sake,
they should be boiled. Any dish which may have got mixed with them, or
has inadvertently been used by the patient, should be boiled before
being used again in the household. The patient need not necessarily know
that his dishes are isolated, since details of this kind are explained
to the family rather than to the sick man.
If he is a bed patient, it is an easy matter to isolate his dishes,
without his knowledge; when he is up and about, it is much harder.
Patients are particularly sensitive about this, and some families,
rather than risk hurting the feelings of the invalid, prefer to boil the
dishes after every meal. This adds so much to the work of the busy
household that after a time all attempts at isolation are dropped. This
matter calls for considerable vigilance on the part of the nurse.
=Linen, Household and Personal.= All linen, including clothing and bed
linen that has been used by the patient, should be boiled before it is
washed. There seems to be some prejudice against this previous boiling,
as the family are apt to maintain that it makes it more difficult to get
the linen clean afterward. The nurse should overcome their objections,
and emphasize the necessity for the utmost caution in regard to this
infective material.
=Disinfectant and Other Supplies.= At a later visit, the disinfectant
may be given, as well as the waterproof pockets and books of
information. During the first visit, it is better to give only the most
important of the supplies—the tin cup, fillers, and napkins—and to save
the rest for another time. For on her first visit the nurse is a
stranger—later, she becomes a friend. Therefore she will make better
headway if on her first appearance she does not burden the family with
too much instruction and too much detail. It is better to say too little
than too much, better to leave something unsaid until the next time,
rather than overwhelm those she visits with a mass of advice which they
cannot assimilate. Her first visit has been made as the bearer of
distressing news, no matter how gently and carefully it may have been
broken, and the distress and confusion which often arise fill the minds
of her hearers to the exclusion of nearly everything else.
During her later visits, she will have ample opportunity to say all that
should be said—and at each succeeding call she will find that much of
what she said the time before has been forgotten, misapplied, or
altogether ignored. Tuberculosis work means the constant and incessant
repetition of the same thing, trying by every device imaginable to point
the way, to make an impression, to obtain some slight degree of
carefulness which may mean the protection of other people.
=Phthisiphobia.= People frequently reproach the nurse with the fact that
her teaching tends to alarm the patient and his family, and to produce a
community phthisiphobia which works great hardship in individual cases.
As far as the community is concerned, fear of tuberculosis is a good,
wholesome sentiment, and infinitely preferable to ignorance and
indifference. We cannot have too much of a public opinion which declines
to be exposed to this disease, and which will therefore provide the
machinery to cope with it. As far as the family is concerned, we have
never been able to produce _enough_ fear of tuberculosis. It would
greatly facilitate the campaign if the first feeling of alarm and
apprehension could become permanent, instead of very transitory and
fleeting. Tuberculosis is so slow and insidious in its onset,—there is
nothing spectacular, by which we can demonstrate to the ignorant mind
the relation between cause and effect, exposure and infection,—that the
educational method alone is inadequate to deal with the situation. If
the alarmed patient and his household could or would continue the
preventive measures which at first so strongly appeal to them, and which
in the beginning they apply with boundless enthusiasm, we should have
comparatively little difficulty. But the disease is chronic and slow;
the scare wears off, and the cry of “Wolf, Wolf” loses its value. And
then follows a relaxation of prophylactic measures. Each time the nurse
must stir them up anew—encourage, threaten, alarm, coax, bribe,—do
everything in her power to awaken them from their mental apathy and
drowsiness, which, as in morphia poisoning, precedes death.