The clock is reaching 9:30 a.m. and Rebecca A. Brown hasn't yet been able to pick up her state-issue, navy blue nursing bag and get out where she wants to be, with her patients.
She's stuck in her office at the Carroll County Health Department, filling out forms and making calls to let the patients' families know what time she'll be there. And, she still has to stop at the Washington Heights Pharmacy and pick up some catheter drainage bags because her supplies didn't come.
Mrs. Brown is a home health nurse. Her job is to bring health care to patients so they can stay at home rather than having to enter a nursing home.
Shortly before 10 a.m., Mrs. Brown breaks free of the office and heads out for the real part of her job.
"How are you?" she asks, as she bends over the bed and takes the hand of the white-haired occupant.
At first, Elizabeth Jordan says she's not doing well. But when you're 88 and you've had two cardiac arrests and you're living with a urinary catheter, doing well can mean just being able to get up with your walker and maybe go out on the deck to sit in the sun.
Mrs. Brown does blood pressure and temperature checks and asks about medicines the physician has prescribed. Then she does more. The patient's toenails need cutting, but they are very thick and she has hammertoes.
"I was going to ask you, Becky, do you know a podiatrist who will come out?" Rosemary Wiesner, Mrs. Jordan's daughter, asks. Yes, the nurse does.
Another problem: Mrs. Jordan used to love getting phone calls from her family, but the receiver shuts off her hearing aid. So she gave up trying to talk on the phone.
Mrs. Brown suggests a sticky-backed foam that can be used to cushion the receiver. Mrs. Wiesner's face lights up. "I'll get it today," she says.
Mrs. Brown takes a few minutes to chat about how fast the children of mutual friends have grown. Then she goes on to the farmhouse north of Westminster where Lucille M. Tabor lies motionless in a sunny first-floor room.
Mrs. Tabor's eyes can focus on faces. She can make sounds, shapeless noises from inside her body's prison. Her hands curl into fists. Her feet are twisted. She cannot chew food, move her arms or legs, or say what she hears or sees, or tell what she is feeling.
Mrs. Tabor has been in a coma since 1989. She was 36 then, and she had surgery for a brain aneurysm. Doctors told the family there was a 50-50 chance of recovery or death.
But no one explained that there was also a chance of something in between, family members say. They say no one explained about a living will or durable power of attorney that would have allowed Mrs. Tabor to direct disconnection of her feeding tubes and respirators if there was no chance of her recovery. Now, the family's hands are tied.
"I had a dream," says Hazel Scuikas, Mrs. Tabor's mother. "I dreamed she was awake and she said, 'Mommy, what's wrong with my hands?' And she straightened them out. And then she said, 'What's wrong with my feet?' And she straightened them out."
No one speaks. Even the great-grandchild snuggled into Mrs. Scuikas' arms is silent. Then Linda Cheyney, Mrs. Tabor's sister, blinks back her tears. "It's not going to happen," she says.
The family took Mrs. Tabor out of a nursing home to care for her at home. Mrs. Brown examines the patient and consults with Mrs. Cheyney on using magnesium citrate to force Mrs. Tabor's bowels, which have shut down, to move.
Then there is nothing more to do. Mrs. Brown backs her van around and heads for the home of Mary E. Barber.
During the drive, Mrs. Brown talks about her career. She hadn't planned to be a nurse. She was going to become a secretary and go to Washington, one of the more interesting career options available to female members of the Class of 1960 at Philipsburg (Pa.) High School.
Her parents pressed her to go into nursing. Years later, when two of the three children born to her and her husband Ed suffered endocrine auto-immune disorders, she concluded that a higher power must have been guiding her career choice. She spent a great deal of time with her son and daughter in the offices of medical specialists. The disorder killed her son. The daughter survives, but is disabled.
When Mrs. Brown went to work at Frederick Memorial Hospital in 1980, she says, she got to know the patients. When she became a home health nurse a few years later, she got to know their families. To her, involvement with the family is more rewarding.
The van arrives at the home of Mary Elizabeth Barber, who is waiting on the edge of her bed, looking sharp in a turquoise dress that flatters her white hair.
"Newspaper reporter, huh?" she says to the visitor accompanying Mrs. Brown. "I used to be married to a newspaper reporter. In the '30s. He worked for the News Post. Harry Riley."
If he was a newspaper reporter in those days, the visitor suggests, he probably didn't come home often.
"I didn't want him to come home," she replies.
She left him and married a Naval officer. They honeymooned in Honolulu where he was stationed, she says. But now she's 87, a diabetic with a pacemaker and a steel ball in her hip who can't walk far without her oxygen.
Mrs. Barber also has problems with her teeth. But there's no way to get her to a dentist and the home health nurses in Carroll County haven't been able to find a dentist who will make house calls.
A sports fan
Mrs. Barber says she can't lick her weight in wildcats, but she's doing OK. She has people to take care of her, and she likes sports, especially baseball, football and basketball. "The other sports I put up with, but I do like horse racing," she says.
Mrs. Brown moves on. She has other patients to see, other needs to try to find the resources to meet. The visits will not end until after 5 p.m. And then there's still the paperwork waiting back at the office.
She says that when she gets down, she talks and laughs with her colleagues. The county employs four full-time home health nurses and one part-timer, plus three or four consultant nurses who provide weekend coverage. The staff, including the supervisor, rotates on-call responsibilities to provide 24-hour coverage.
It's a small unit compared with some of the private home health care services, says Tami Becker, the county's home health supervisor.
The nurses work under the supervision of physicians. Patients who need home nursing care can choose county health department or private nurses, although sometimes fees are a factor.
County health departments' fees in Maryland are 5 percent more than Medicare reimbursements, with a sliding scale for patients who cannot afford to pay. The fee for a home health nurse's visit, for example, is $105.50; for a home health assistant's visit, $57.
Most patients move off the home health care list in two to four months, Mrs. Becker says. The nurses are always looking for resources, she says, to help people stay in their homes as long as they can.