Saying Goodbye

My daughter Julia is 5 years old, in earth years that is. She harbors a curiosity of nature and her unpredictable forces. She marvels at the smallest of details, how a wooly mammoth curls up in her hands, how a caterpillar becomes a butterly, the weeds in daddies grass and why they grow so much and why daddy hates them, pods of "fairy hair" that grow in our backyard and being careful not to open them until they are ready. She loves nature hikes through the seasons and is starting to take note of how when one season ends, a new begins. She knows summer has gone and she laments for her days on the beach, swimming in our pool, running through the baclyard with ice pops dripping down her arms, chasing her sisters. She knows winter is coming.
     She is becoming quite adept at horseback riding. She rides western style and is taught by a stought old-school original who goes by the name of connie, she owns coyote ridge, the stable where she rides. Connie has a keen insight on nature and is more at home surrounded by horses than of her own family, who are very much like her. She is a tough woman. She has been thrown, kicked and stomped more times than she cares to think about and her body shows these signs through her severe arthritis. Her face is aged with weather and sun, you can tell she is a woman of the outdoors. If Julia twists her ankle, or burns her hands on the reigns, or otherwise hurts herself, Connies response is usually a quiet but comforting "cowboy up kiddo" meaning you've got to be tough. Yet she also has a soft side. Everyone of her horses is an extension of herself. She says her soul lives in each and every horse. This is palpable if your are forunate enough to be in her presence. On our way to lessons today. we passed by a cemetary in which a crane was lowering a vault into the ground. I slowed the truck and said out loud "how sad" Julia replied "what daddy, what is sad?" someone died I replied, and they will soon be buried, that is what is happening. "Oh, were they sick?" I said I didn't know. she said yes daddy that is sad, are you going to tell mommy? Sure, baby, I will I replied.
     I pulled into the stable which is usually hustling and bustling with cars pulling in and out yet today was unusually quiet. One of the stable hands was standing outside the barn, a long look about her face. Carla was 15 or 16, a regular around the stable and a tough girl in her own right. As I approched, she looked at us foreloarnly and said very quietly "Little man is not so good, Connie is with him, we're waiting for the vet." From the look in her yeyes, I knew what was happening. Connie emerged from little man's stall when she heard us. She was different today. Gone was the rugged exterior, brown, wrinkled and dusted, her face was wrought with sadness. Underneath the facade was her raw emotion. Little man, a dwarf horse was 36 years old. A horse's life expectancy is about forty years. Little man was primarily the childs horse. On any given day little man hauled the excited little bodies of toddlers and preschool children arounf the arena probably thousands of times. He had a gentle disposition. He was a calm and confident horse; he was a horse you could put your child on without fear. He also served as a companion  to the hundreds of horses that were temporary visitors to the barn, a stable mate that would take the fear of the unknown from a horse about to be sold or moved from the environment from which it had been accustomed to. Horses are no different from humans, they don't like change at all. He was the senior of the corral. Connie had little man his whole life. He was born a colt into her arms 36 years prior, and now he lay in her arms panting and seizing. A constant unending seizure. It was likely due to a tumor growing inside his head. Connie had seen the changes over the past several weeks. His eating slowed down, he seemed to constantly want to be left alone. A far cry from social creature this animal had been his whole life. Connie said yesterday he tried to get out of the corral several times, likely wanting to go off and die alone as so often animals do.
     I will never forget David Angel. His last name was so appropriate. Angel. A messenger from the heavens sent to reveal my destiny, my life's work. I had cared for David for almost six months now. David was a hospice patient; I his home health aide. It was a position I had to take a two week class to become certified to do. Not much to the job. Mostle assisting clients with personal grooming, a blood pressure here or there, but mostly to assist the family so that they could go about living and continue whatever lifes work they had to do. His family was kind. His daughter, Angelique was an intenist working in a local urgent medical care, her husband a forensic psychiatrist at the local state psychiatric hospital. His wife was  ever present and scrutinizing my every touch with him. Whether I was helping him wash his face and hands after eating, wiping his bottom following a bowel movement or checking his blood sugar and giving him insulin. This was something I was not supposed to do. His daughter however, upon learning of my intentions to attend nursing school and then possibly medical school took me under her wing and taught me of what was to come. We would have a lesson each day I would come. She helped me to understand a bit more of what was happening to her father. David had severe Alzheimer's Disease. A disease I would later revisit as my first nursing assignement after graduation two years later. Alzheimer's Disease is chronic dementing disase. Which means it robs a person of their higher mental faculties and eventually their physical faculties. There are many theories on what causes it from environmental, to genetic. It can only be diagnosed through post mortem autopsy. The cranial vault is cracked open and what appears to cover the outer covering of the brain, also called the meninges is a moss like substance known as Beta amyloid plaque. It is distinctly identified from microscopic examination. They appear as tiny barbed wire fibrous tangles of sewing thread that distribute all through the cerebral cortex. A person loses their orientation, ability to calculate and comprehend, they lose their ability to identify first simple objects and then- loved ones. They have virtually no short-term memory. It is not uncommon to hear stories from local policemen finding these people wandering, naked sometimes in the dead of winter outside on the street. They know not what they are doing. Eventually they forget to eat, to walk, they become wheelchair or bed bound, have to be fed by hand or through a tube, and eventually die from complications due to immobility. Pneumonia and bloodclot to the lung are usually what ultimately sets these poor souls free. The burden of this disease is on the son's and daughters they no longer recognize and strike out against in fear as they feel the loss of control over their environment. The wives they no longer recognize, the faceless grandchildren they once held in their arms. If you find yourself caring for someone with this disease however there are moments of revelation, or clarity; even in their most severely demented states where they have lost their ability to talk or communicate. You see, their long term memory is somewhat preserved. While they are still verbal they will sometimes act out times of their lives with stunning detail. I have had family members say they have learned answers to questions about previous events that have long remained a mystery only to be blurted out so spontaneously and serendipitously by this person who has not spoken in several years. We called them moments of clarity and if you were fortunate enough to be present for them you gained a clearer understanding and appreciation for what their family members were going through. I have had dozens.
     David had been nonverbal and bed bound since I met him. I knew of his life only through the stories shared by his wife, daughter and son in law. I remember the day I got the call from his daughter. "Dad is not well, Mom is not well, I can't deal with this, you have got to get over here." Almost within minutes of her call, the hospice nurse had called to tell me that she was putting him on 24 hour care, which meant that his death was likely iminent. This is when the family needed the most support. The dying person would be going through changes, or "stages" as I have later learned from my wife, herself a distinguished and respected hospice nurse. The family needed to be guided through these changes, and be told of what to expect and to reassure them that there was no pain, nor suffering. It was time to say goodbye. I arrived at the Angels house in the late evening. Although I had seen David almost welve hours earlier, he looked much different. His cheeks were sunken and hung from his face like drapes. His mouth hung half open, his lips crusted with secretions, his eyelids half open revealed cloudy almost opaque eyes that did not track, or move as they often did when he was at least awake. His breathing was quite rapid and shallow, his skin below his chest was ice cold and almost wet. The bottoms of his legs took on an almost marbling appearance, which I later learned was the result of the shutdown of the circulatory system. I had never been with a dying patient, nor did I know how to "help" a dying patient, and was uncertain of my role, Yet instinctively I maintained my composure and assumed the role of his final caregiver. Stella, his wife, had told me her daughter had said her goodbyes and felt things would move along quicker if she wasn't there. His wife also felt this to be the case, but could not leave him to die alone. He would be left to die with me. I stood in the corner of the room and watched as she sweetly leaned over him to whisper in his ear. What she said I could not tell you. After a few moments she very gently kissed him on the forehead and laid a single finger to his lips almost shushing him. She turned gazing at the floor and walked out of the room. Before she left she grabbed my arm very tightly and said "you will stay to the end" With that she left. I stayed in the corner of the room for several minutes putting the picture together trying to figure out what to do. I was scared and nervous. Yet I was not saddened. David was about to be freed from his earthly prison of a body. I took a towel from his bedside and wet it with some cold water. I gently washed his forehead, his face, his neck. I used a swabstick to get all of the crust from the corners of his mouth. I placed a cold towel behind his neck. I washed his arms, his legs, his genitalia, turned him to make sure there were no feces. Then I sat. I held his cold lifeless hand in mine and started to talk about the day, the news, the weather, what I was studying in school. I then thanked him for allowing me to in someway be a part of him and his families life. I told him about how his daughter was "tutoring" me in medicine. remarked about how Stella's Matzoh ball soup was "stellar" with a bit of a laugh, and other topics of interest. I don't quite remeber exactly how long I talked for but I suddenly stopped. His breathing was starting to change. His breaths were becoming more and more shallow, almost like he was gasping and fighting for every breath until eventually none came. Unblinking I watched his face. There was no breath. I felt for a pulse in his wrist, there was none. His eyes remained half open. I gently used the pads of my index finger to close his lids over his eyes and held them for about a minute. Again there was no breath. Goodbye my jewish friend, godspeed, were the last words I said to him before I called the hospice nurse. His wife held vigil in another room, I called her in. I expected wailing, I expected inconsollable grief, shrieking, crying, from the woman who had shared her bed with him for the last 56 years. She walked in calmly, looked at him and said "he is at peace now" "He suffers no more" I moved away from the bed so that she could get closer, nad when I was about six or eight from the bed I could see the look on his face. It was a half smile. Very comforting to look at. David had died on his own terms. The way he wanted it. Somehow I facilitated this. I felt as though I had orchestrated this final act in his life. I don't know whether or not this has been said before, but I believed from then on that there was no moment more meaningful in life than that of being present and as a source of comfort to a person who lies taking their final breaths. It was a priveledge, an honor- I heard my calling.
     Julia had wanted to say goodbye to littleman. Like probably hundreds of other kids before her, her connection with littleman was  that he was the first horse she had ridden on at just two years of age barely able to walk. She didn't remember it, but she saw pictures and watched video later that afternoon of her "early" equestrian days. Connie didn't think it was such a great idea, she was probably right, this was not a peaceful and serene scene. Littleman was laying on his side, his lips drawn up showing his teeth panting, seizing every minute or two his hind and fore quarters tremoring violently. This horse was visibly suffering. Connie was probably ready to get a pistol out and finish the deed herself if it were not for the presence of others.  He only seemed to calm somewhat when connie laid her hands on his head. I heard her  mumbling under her breath "where is that goddamn vet!" Julia was at the other end of the barn. Intrusively I asked Connie, I think she'll be okay, can Julia say goodbye?" "Are you sure you want her to see this?" she returned. "I think she needs to do this." was my retort. She nodded. I called Julia, before she got to the stall I explained again to her that littleman was sick and will die today. I told that he did not look like the horse she had romped with over the past year or so, I explained what was happening and that it might frighten her, she continued to insist, I could not stand in her way. Though five years old in age, her soul is old and understanding. She crept very slowly around the corner if the stall and peeked her head around the side like a child walking through a haunted hause attraction knowing a scare was coming trying to anticipate from which direction it would come. Then she completely moved herself in full view of littleman. She was silent and not fearful as she watched connie tried to comfort littleman. I knelt down beside her and whispered in her ear "Say goodbye honey" She said nothing. "I held her hand tightly and nudged her to leave and saw a tear forming in the corner of her eye and she very sweetly and very quitely said "goodby littleman, have a good ride";  she turned and walked away. As we were leaving I saw the vet pull up in the dusty pick up truck, she quickly got out with two syringes in her hand, one crossways in her mouth, she moved quickly past us towards the stall. One syringe contained a lethal dose of a phenobarbital, a benzodiazepan, that would stop the seizures and render unconsciousness. The second most likely pancuronium, an agent that would paralyze all the muscles in his body including his diaphragm that acts as a bellows for breathing. The third most likely potassium chloride, this would stop littlemans heart if the phenobarbital didn't already. By then Littleman would be gone. Julia was done saying goodbye.