The view from the other side.

A personal journey through a foreign health care system (during a pandemic) as an advocate for my mum.

My mum, brother and me circa 1961

This is a blog that I have pondered on writing numerous times over the last year. It seems pertinent that it is the anniversary of the events I’m going to describe. I think this is partly a blog written to get things of may chest and move on from my anger, somewhat. It’s a story that began just over a year ago and describes what it’s like as a seasoned medical professional to become embroiled in an advocacy role for a relative in a foreign countries health care system.

In April of 2021 (in the midst of the global COVID pandemic) I received a message from my brother in Portugal that my elderly 83 year old mum had fallen at home and fracture her femur. He went on to say she had been admitted to the hospital and was going to have surgery next day. so not the best of news, but made worse by the fact I live in Minnesota, USA and my mum in Malta some 5250 miles away as the crow flies.

I contacted the hospital in Malta to try to find out what was going on an was informed my mum had undergone surgery and a nail and plate placed in he femur to stabilize the fracture, an was resting comfortably on the orthopedic ward.

What ensued next was the bureaucratic wrangling and red tape involved in getting permission to travel from the USA to Malta which had the USA on the COVID red list, which meant no US residents could enter Malta due to the pandemic. Luckily I have contacts in Malta who helped me navigate some of this, I got in touch with the Health Minister and applied for an entry permit on compassionate grounds. This process took 3 weeks to sort out, but finally got permission to travel to Malta, with some rules. I had to have two negative PCR COVID test and an Antigen test negative a week and 25 hours before flying. then on arrival I would have to be in quarantine isolation for 14 days and test negative on day 10 for my quarantine.

Great, so I booked my ticket via Amsterdam and headed to the airport. luckily my COVID tests were negative and I had all the paper work in order to enter Malta. BUT, I was refused boarding in Minneapolis because I didn’t have permission to transit in Amsterdam, which required different COVID documentation. I returned home with my tail between my legs.

So on returning home from the airport and after calming down, I received kind help from a Dutch twitter follower who gave me details of the government department in Amsterdam that could assist me in my transit application. I had to rebook all my flights and schedule a return flight via Rome as I was not allowed to transit back though Amsterdam as there were no connecting flights and Holland was also closed to US travelers other than transit.

One week later I returned to the airport after repeating my three COVID test routine. I had a slight hiccup solved by only having carry one luggage.

I landed in Malta after transiting through Amsterdam on May 15th, all my paper work and testing was in order and was health screened at Luqa Airport Malta and told to go immediately to my quarantine address and stay there for 14 days until contacted by the health authorities. I was also given a number to call to schedule a COVID test on day 10. this all seemed a bit bizarre as I was not instructed on how to get to my mum’s apartment to quarantine. Luckily a friend of my mother’s came to pick me up, I double masked, he had also done some shopping for me.

I arrived at my mothers apartment and had arranged with a friend to have a spin bike delivered so I could workout and maintain my sanity. It turned out to be a life saver. I ended up spending up to 8 hours a day spinning and watching the Giro D’Italia on TV.

Fourteen days is a long time to spend in a third story apartment, but I did have the internet and a great view

I passed my isolation time emailing and calling the hospital to try and find out details about how my mother was progressing and enquiring bout the rehab plan and future plans for assistance. Prior to her fall my mother lived alone in a third story apartment, with 30 steps and no lift (elevator). a small back story, in the November prior she had contracted COVID and was bed bound for several weeks, she became very frail and my brother had to fly in and take her to his home in Portugal to get care and recuperate. She had fully recovered and returned to Malta, at her request, in mid March.

I facetimed my mother to discuss with her how she was doing whilst I quarantined. She did not seem to be her normal self and found it difficult to answer my questions. She was adamant though she didn’t feel she wanted to return to her apartment as she was frightened of falling again.

Apart from the frustration and isolation, I was getting more and more distressed with the mixed communication from her care team, I talked to nurses, social workers and Physios, who all had different plans and messages for me, I was led to believe my mum would transition to the rehab hospital so she could be able to negotiate her stairs before being sent home. This plan seemed to change on a daily basis. Six days into my stay I received a call from the lead ward physio saying my mum was ready for discharge home? I asked if he had assessed her ability to climb stairs and informed him she had 30 up and down and no lift. He relied ”no, but he would try her on stairs the next time he saw her.” It was a bizarre discussion even after I informed him that i was an experienced ortho physio as well as a son? I would later come to realize that my mum was on the acute orthopeadic ward and that they wanted the bed for other acute surgical admissions.

After taking with the Physio I called the social worker and ward sister and informed them that my mother could not come home for several reasons, 1. I was in isolation and quarantined in her apartment, 2. She needed to be abe to negotiate 30 steps, up and down and 3. She would need nursing care and a full time support as on Facetiming her it was apparent she was catheterised. They agreed she would be kept on the ward until i could visit in person.

I started to realize that there was going to be a ot of work to do to make sure my mother was safe to come home and that she got the appropriate care and rehab.

Let me tell you 14 days is a long time to be o your own with minimal food, I did order some takeaways and got them left outside for me to pick up once the delivery guy had gone.

On day 10 I was allowed to drive myself to the government COVID tests center , luckily my test was negative but I still had to quarantine for the full 14 days

There were some moments of beauty during my isolation

On May 29th 2021 at noon I officially ended my quarantine. I took a long walk on the beach and enjoyed a burger at the local restaurant.

May 30th would be my first visit to see my mum. She was in the acute orthopedic ward of the National Mater Dei hospital, due to COVID regulations visiting was restricted to one person and for one hour a day. OMG I arrived early and spent the next 30 minutes looking for a parking spot in the underground parking garage, it appeared every man and his dog were visiting, this would be a daily occurrence as everyone had to visit in the restricted time window due to COVID.

Mater Dei hospital was absolutely enormous, it is the biggest general hospital in Malta. I had flashbacks to my days working in UK hospitals as I navigated my way through the corridors to find my mothers ward on the third floor, the smell always brings back memories of my time in North Tees general hospital during my residency year.

I eventually found my mum and had a tearful first reunion. It only took my a brief interaction with her to realize she was not her self, she seemed vague and somewhat confused. She had a walker by her chair and she was sat with her now surgically repaired eg straight on a stool for support. I asked if she was doing exercises and walking, she replied ”only walking, no exercises” She was catheterized and in an adult diaper as she reported she wasn’t allowed to walk to the toilet on her own. My formerly healthy, active , independent 83 year old mum was now a frail, immobile, diapered, catheterized “old woman?”

After a chat we went for a walk using her frame, she had an extremely stiff knee with approximately 30 degrees of flexion, her leg was oedematous, and she shuffled rather than walked. I tried to hide my distress with the whole situation. The hour passed quickly and before leaving the ward I went to the nurses station, to find 6 or 7 nurses all sat on their phones scrolling. I explained who i was and asked for a meeting with my mums care team. The staff nurse said she would talk to the sister and I should come back tomorrow to see what was happening.

I wandered my way back to the car, where I sat and cried for a good 10 minutes.

Little did I know that over the next few days I would cry a lot an have many bizarre encounters with my mother’s health care team and fellow health care professionals .

Next day I arrived early to play find the parking spot with the rest of the population of Malta, or so it seemed. it didn’t help that the hospital was also the national COVID vaccination center.

10am and I entered the ward, as I was passing the desk the nurse waved at me an said that my mother’s care team would be rounding tomorrow at 9am and could i join them to discuss my mum’s care plan. I felt a little easier and went to see my mum and walk with her. Note I said ”walk with her” I am not a fan of PTs saying to patients ”i’ve come to take you for a walk” these are people not pets, as health care providers we walk with a person not take them for a walk.

Anyway, a much less stressful visit and I left after the allotted hour to shop for food and enjoy an afternoon of freedom in the Malteses sun.

For anyone who hasn’t been to Malta it’s a tiny island in the Mediterranean, problem is the population is 514,564 (I just googled it) and there are over 400,000 cars (I googled that too) the roads are narrow and poor quality and everyman and his dog (I think I’ve used that already) seems to be out and about during morning rush hour , lunch time and early evening. Let’s just say that driving in Malta is an experience to behold and made worse by driving on the left hand side of the road, when I predominantly drive on the right at home in the US (I did learn to drive in the UK so I am familiar with the process)

Next day I arrived early at the hospital for the ward round. My mum’s Maltese male friend (86 year old boyfriend) also join us, at my request. The clinical team consisted of two Doctors from the surgical ”firm” two OTs, two PTs, one nurse and a hospital social worker assigned to my mother. The rounds reminded me of my early days in the UK when I would do morning rounds with the surgeons, on the medical and surgical wards. The lead doctor discussed my mums surgery and her progress and the team each told us their thoughts. I then got a chance to talk after listening to them all. I explained I was only there from the US for a few weeks to get my mum safe and settled, I explained her situation prior to falling and also explained that she was frightened of going home to 30 steps and feared falling again. the discussion seemed productive and it appeared that the plan would be to send my mum to the rehab hospital to get her fit to go home with social care and a daily nurse. after the rounds ended the social worker gave me a list of private companies that specialized in live in care assistants, it apparently I was now in charge of organizing this?

I chatted with my mum and her friend and it seemed we had a plan.

I left after visiting time feeling more optimistic, by the time I got home to the apartment I had received an email from the lead doctor stating that the team had met and decided my mum would be discharged home at the end of the week. WTF, I had just met with them and decided on a plan which apparently had changed during my drive home. I contacted the social worker and asked to meet with her. She arranged for me to meet at 9am next day and had arranged another meeting with the care team. By that evening I was spitting feathers I was that angry. Spin David Spin.

Next morning I met with the social worker who apparently was as shocked as I was at the change in plan, she relayed that she had not been consulted either. I discussed with social worker my concerns that my mother appeared to be having cognitive difficulties and appeared to be in the early stages of dementia, the social worker said that none of the medical team had noted this. I explained that I thought she was not fit to make her own care decisions and that she was terrified at being sent home. after our meeting we walked to the ward, where we were met, at the nurses station, by yesterdays care team plus a new lead male PT and the ward sister. We stood in the ward corridor and the sister began by saying that my mum was doing well and was ready for discharge? I asked how they though she would navigate 30 stairs on a walker shuffling ?The male PT piped up ”she did stairs with me this morning” I asked “how many?” he replied 15, I ask how he thought 15 was 30 and that this was unacceptable. The PT then became passive aggressive and told me she could sit on a chair half way up and rest. Let’s just say the next few minutes of interaction where not my proudest moments, but I feel where necessary, I informed one and all gathered that this meeting was totally inappropriate being held in a ward corridor in public view, with no privacy with basically 12 care staff trying to tell a patients son that he was wrong and that his mother was just going to be discharged. I also informed them that i was uncomfortable with their attitude and that they agreed on a plan the day before and changed it without discussing why with me. The tipping point for me was when the PT asked if my mum was “even”Maltese. (luckily she is she was naturalized on her 80th birthday)

I relayed to the care team that I also felt my mother was having cognitive issues and requested an assessment be done to evaluate her decision making abilities. after everyone calmed down the ward sister agreed and decided that after the assessment we would decide my mother fate next day. What became apparent after the meeting was that the goal of the acute ortho team was to free up the wards beds for other surgical cases. my mother had become a victim of the system and of COVID as the doctor kept saying the longer she stays here the higher the risk of infection. I later discovered that the rehab hospital plan was also off the table due to the COVID pandemic.

I left the hospital feeling drained and I am not ashamed to say I drove to a local tourist spot and had a giant piece of chocolate cake to clam my nerves.

Little did I know that the next three days would be a roller coaster ride of emotions. I returned to the hospital next day and on arriving on the ward was informed they hadn’t assessed my mum’s cognitive abilities yet, but at the end of visiting time the doctor and the social woke wanted to discuss a discharge plan with my mum and I? yep a new plan an new day, bizarre. My mu and I went for a walk and did some exercises for her knee. at the end of visiting as previously announced the doctor and social worker arrived. they sat with my mum, her friend and I to review our options, discharge home with support organized by me and the social worker. My mum listened and then told them she wouldn’t go back to her apartment under any circumstances, her boy friend then chimed in and said she could live with him? OMG the fly in the proverbial ointment. I had to step in and explain that he lived with his son and daughter-in-law and that there was no spare bedroom, plus I would need to chat with them first. Another day another cluster F^*k. it became apparent they just wanted my mum off the ward.

That evening I visited my mum’s friend and his son at their house. long story short my mum was not relocating to their house. I don’t drink alcohol, but if i did this would have been a few whiskies evening. Spin David spin 🚴🏻

Next day was ground hog day, another meeting with my mum, the doctor and social worker. I explained that my mum moving to her friend’s house was a no go, they replayed my mum had been cognitively assessed and was fine to make decisions. (I protested and suggested their test was wrong, they didn’t listen, I tried to insist that I have a background in cognitive assessment and as her son was aware she had mental issues, no ne would listen.) The doctor tried to explain to my mum that she was to be discharged home, my mum just kept saying no and crying. Another day, and no decision or solution.

On returning home i wrote a long email to the social worker outlining my concerns regarding my mums care and long term plan, I asked for solutions other than returning home. She replied later that day informing me my mother was eligible for state nursing home care as she was a Maltese citizen. that evening I formulated a new plan to put to my mum.

After playing the parking lottery next morning, I returned to the ward and chatted to my mum whilst we walked. Remarkably she was starting to walk quite well despite her still stiff knee. I discussed going to a nursing home and she just listened. once again the doctor and the social worker appeared at the end of visiting. Today was D day, the doctor sat on the edge of the bed and asked me if i had discussed the options with my mum, I nodded in the affirmative.

The doctor asked my mum if she wanted to be discharged home, she teared up and said ”no”, the doctor said “great then the nursing home it is.” That was it that was how my mum was sent to a nursing home. That afternoon she was discharged from the ortho ward to a long term elderly medical ward to await a place at a state nursing home. Ortho ward team mission accomplished.

I drove home dismayed.

Over the next few days my mum became more and more confused, i discussed this with the new ward staff, they suggested it just part of being moved and her surgery, I knew it wasn’t.

It took four days and I received a phone call that a place had been found in a nursing facility and my mum would be transferred directly from the hospital. The nursing home was a lengthy drive away close to the airport. That afternoon I went to buy some toiletries and new nighties for my mum. I arrived at the new nursing home for the hour visiting time only to be told my US vaccination certificate wasn’t acceptable and i needed a Euro COVID pass, luckily I showed them all my government clearance paper work and they let me in.

My mum was sat in reception waiting for the facility doctor to assess her. The facility was clean and the staff seemed friendly and caring. My mum was extremely confused and thought that she was at my house in the US. (once again a sign of her declining mental status) she was assessed by the doctor and placed on some new meds. I met with the facility coordinator to discuss finances and such. the hour passed quickly.

Next day I returned to the new home feeling happy that my mum was now in a caring environment. OMG it was the day from hell, my mum was agitated, confused and didn’t want to stay in the home, she was verbally abusive to me and told me i had put her in a home so i could go home to the US. I calmed her down and walked with her. she seemed confused, but I put this down to the new facility and her mental status.

That lunch time I had arranged to meet a friend for lunch, it never happened.

I had a front wheel blow out in my mum’s old car, then of course the spare would not come out of the boot (trunk) and when it did it was flat. I had no phone and limped the car to the nearest garage. the man at the garage was lovely and fixed everything and gave me a place to wash up. I cried again.

Next day I visited mum she was more settled but very confused, she was walking around without her walker, she had forgotten she had had surgery. this was my last day, I spent my time explaining this to her, but she didn’t seem to register. on my way home I stopped to get another bloody COVID test so I could go home

I left Malta and my mum with a heavy heart, but knowing she was safe and being cared for, little did I know what the next dew months would bring.

A week after arriving home I received a message that my mum had fallen in the home and was back in hospital. She had another surgery that week as according to the doctor her femur fixation had failed. she stayed in the hospital a week and returned to the home to rehab (they had on site physio). I facetimed her regularly, she was becoming more confused.

At the end of July I got another message she was back in hospital after another fall, she had this time fractured her same femur at the knee. Another surgery, more rehab and a return a new nursing home. This home was the national dementia care home. My mum had developed obvious dementia, so obvious even the ortho staff were now aware of it.

My mum has been bed ridden since returning to the new home. I visited Malta again this year and she is safe, well cared for and doesn’t know who I am. She has developed expressive aphasia which is distressing to those that interact with her.

If you have made it this for, bless you. I don’t think i intended anyone to read this, but writing it all down has been healing.

I miss my mum, I weep for our medical systems and health care professionals who are caring but focus on the wrong things. I am an advocate for person focused care, not discharge drive care, I want people to be cared about not just cared for. As health care professional we can all do better.

If you did read this far, thanks for caring.

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