How to Give Flu Shots in a Nursing Home—A Guide for the Nurse of a Certain Age

by Jeanne Howe

4:29 A.M. Stop trying to sleep. Wash your face and apply day cream to wrinkles. Think of the young woman in your writing class last night whose poem began, “Today I turned thirty, and something is wrong with the skin on my arm.” Smile at your mirror and get dressed anyway. Make coffee.

Quarter to 5. Retrieve the flu vaccine that has overnighted in your refrigerator. Pack it in the picnic cooler supplied by your employer, the red and white one conspicuously labeled LITTLE PLAYMATE by Igloo. Practice hefting LITTLE PLAYMATE by Igloo while picturing yourself conveying it into Golden Years Senior Facility with the poise and dignity of a bank president toting a brief case.

5:00…. A.M. …. Jiggle out through the predawn dark to find your car, locking the house door behind you while you manage a coffee cup, fresh lab coat, LITTLE PLAYMATE by Igloo, several armloads’ worth of supplies, and a shoulder purse that won’t stay on your shoulder. Do all of this without slopping coffee on the lab coat. You learned this kind of juggling in nursing school, back in the old century. (This kind of juggling is one small remnant of what you learned in nursing school back in the old century that is still relevant today.) Start the car and set the GPS.

5:08. Set off down the road, allowing plenty of time (as was taught in nursing school) to find this morning’s assigned work site some 60 or 70 miles across the mountains. Drive through tufts of Smoky Mountain fog while NPR Morning Edition’s reports of yesterday’s political shenanigans fade in and mercifully out. Sip your coffee but do not let it get anywhere near that lab coat.

6:30. Enter the outskirts of the little town that your employer has led you to believe contains, somewhere in the dark, Golden Years Senior Facility. Forgive your GPS for sending you on sequential U-turns. Forgive your GPS because you are aware that nothing—not even satellite science—can make the trip to a nursing home easy. This awareness was not taught in nursing school but comes to us all sometime later.

6:40. Ask directions at McDonald’s. Buy more coffee for the road, wherever it may take you.

6:50. Ask directions at the Exxon station convenience store.

6:55. At Golden Years Senior Facility, load your little fold-up wheelie carrier cart thingy with your employer’s steamer-trunk-sized blue plastic biohazard container containing:

rubber gloves
alcohol wipes
2x2 gauze sponges
syringes with needles
red plastic “sharps container” for depositing used syringes and needles

Oh, and also:

epinephrine emergency packets with doctor’s orders specifying dosages according to age and weight of that ostensibly extremely rare and possibly only hypothetical person you hope never to meet who wheezes and swells and turns red and breaks out in hives and tips over in shock right before your eyes after you have done whatever you have done and it’s too late to undo it.
Shock remains as patriotic and frightening as it was back in the old century:

red shock=anaphylactic, as in allergy, as in hypothetical possibility after flu vaccine, possibly including Lot No. 16219478 with which you are armed today as you go forth to war against disease and infirmity and defend the 21st-century public health
white shock=hypotensive, as in fainting, less scary than the other two
blue shock=blue shock=oxygen deficit: air isn’t getting in (respiratory blockage), or the circulation has quit (cardiac shutdown)

6:58. Good work—you’ve arrived. Check the time. Put on your lab coat that has no coffee stains, wrestle the wheelie cart up the handicapped ramp, along with the purse that still won’t stay on your shoulder and the LITTLE PLAYMATE by Igloo and, faking a practiced demeanor of professional dignity as you lug all this clutter (remember that bank president), go to the door of Golden Years.

7:00. Right on schedule. Nothing to it. Press the bell beside the locked and key-coded entrance door to Golden Years Senior Facility.
Ring again. Press your face to the glass. Wave a sleeve of your spotless white lab coat to persuade a passing employee in the hallway it’s okay to let you in. Go with the employee to what he optimistically calls the Activity Room. Wait while he and two staff members in uniforms featuring butterflies and Bambi agree that that table way over there against the window is your destination.

7:04 to 7:15, more or less. Maneuver your wheelie cart through the tangle of wheelchairs and walkers and canes and swollen ankles of what your dear old mother used to call dear old souls, to get to your assigned table. Dear God, who did these people used to be? Smile and excuse yourself as you step in front of five women who slouch in their Activity Room couch like children’s dolls perfectly groomed (lipstick, “the eternal perm”) but long ago set aside, left behind, maybe forgotten, and now grown very old. Shriveled. Bent. Barbies, Barbie’s Sisters, Cindies, American Girls. You can bet there’s at least one Betsy Wetsy. They give you a nonplussed, momentary glance before returning their blank gaze to the elephantine TV screen whose flickering creates the only impression of life on their blank faces. Forgive yourself for thinking of the sad-eyed looks of caged old dogs at an animal shelter.

7:15 to 7:30, more or less. Time is elasticized here at Golden Years. (Think of Dali’s drooping clock—maybe it tells the truth after all, in the right setting.)
Transfer plastic bouquet of autumnal orange asters and warty small gourds and accompanying lace doily from the table to the adjacent broad window ledge, where they go pink with the wasted promise of impending sunrise.
Spread your white paper tablecloth, put out gloves and the other supplies.
Ask a pretty, lavender-fragranced, surely-not-more-than-fourteen-years-old female staff member for a wastebasket to receive syringe wrappers and used gloves and Band-Aid papers and needle caps and such.
Put LITTLE PLAYMATE by Igloo and the sharps box on the window ledge beside your seat for your easy access but out of the way of Golden Years residents who will be coming to sit in the armchair you have placed on the other side of you.
Make available, on the table, HIPAA documents about privacy and CDC information concerning flu vaccine, knowing that nobody between here and eternity is likely to want any of those papers. Ever. Anywhere.
Again ask the staff person, who seems very kind to the people gathering in the Activity Room, if she can find you a wastebasket. Paper discards are piling up as you open syringes and prepare to draw up vaccine.
You will have to ask a third and fourth time, but you are patient and courteous.
You learned that in nursing school—another skill that is possibly still relevant today in select settings.

7-something else. Oh, hell, never mind the time. What
difference does time make, really? We all
have it.     More or less.     Until
we don’t. Or is it the other way around—time
has us? (You can tell your coffee is struggling.) What-
ever, time feels suspiciously slip-
per-y here at Golden Years.

Take time to look around. Do it even though it hurts. Recall the old nursing school instruction about differentiating sympathy from empathy. Sympathy, you were taught, connoted feelings of pity, remember?— being sorry for someone, but from an emotional distance that kept you safely separated. Empathy, that was supposed to be your goal instead. When you were successful, empathy would enable you to imagine yourself in their same place and look out at the world through their eyes. To be in their same fix. To feel as they feel. To live the life they are living.

I told you it was going to hurt.

Look again at those five little dear old souls on the couch facing the TV, staring now at a cooking program kitchen scene where a sparkling woman in a chef’s cap rhapsodizes about kale chips. These women may not have been inside a kitchen for a decade. Something is wrong with the skin on their arms. Their once competent hands lie veiny and spotted on their laps, crooked fingers curved arthritically against one another like mistakenly repeated parentheses.

All old girls, these dollies. Boy dolls—Ken, GI Joe—naturally have a shorter run. Racecar crashes, missteps out of airplanes, ill-fated encounters with dragons—those kinds of things stop their clocks.

There is one man in the Activity Room. Slumped in a chair against the far wall, he reminds you of Winston Churchill, a major hero from your earliest memories of old-century radio newscasts. Winston Churchill, not dead as we had heard, only sleeping. His activity is a periodic twitch of the knobby trigger-finger resting atop a green oxygen tank from which plastic tubing snakes up to hiss into broad, bulldog, Winnie nostrils.

Imagine that man dreaming. He is fifteen, not British at all but
Pennsylvania Dutch, right where he belongs, back
in Pittsburgh.  A summer night. He and rascally
boyfriends stand under stars in the bushy overgrowth of
Mount Washington’s overhang, competitively pissing off
the mountain to extinguish  flames belching up
from steel factory stacks across the Monongahela.

Those fires did in fact dim and die, but only many years later, and for
reasons over which the boys were entirely powerless. And by now,
if those comrades in mischief have lived
to be as old as this Winnie, their once proud
mountaintop fire hoses are capable
only of poor spurts
backed up by
little farts.

A middle-aged woman steps through the activities, wearing executive clothing and a smile you associate with prehistoric corpses found under the ice in Norway. She introduces herself to you, places an armload of papers on your table. These you recognize as the essential paperwork that authorizes you to inject dead viruses into these people without being guilty of assault (or battery; you never remember which, but either one a clear infringement of your Nightingale oath). The papers, practical in this setting not for their question about whether the patient is or might be pregnant but because they will generate a carbon copy for each person’s medical chart, are already filled out, as is the necessary procedure at nursing homes. Most have proxy signatures supplied by a son or daughter, acquired by telephone from a distance and co-signed by a staff person. A very few display shaky signatures somewhere in the vicinity of the intended signature line.

The smiling woman looks around the room and pulls out consent papers of the people present. She knows who they are even though they may not.

One by one she helps the dollies up from their couch and seats them in the empty chair beside you.
Greet each. Explain in a clear voice that you have brought her flu shot. Explain in a clear voice that you’re going to

●push up her layers and layers of long johns and sweaters and undershirt sleeves
●cleanse her flabby little deltoid
●insert your vaccine needle at a shallow depth that will not overshoot the so-called muscle mass
●apply a bandage,
and then…

she will be up to date for another year! Smile broadly as you say so, to signify your pride in this achievement the two of you will have accomplished in collaboration.

Another year, just imagine.
Dubious prize, whether you sympathize or empathize.
Whose side are you on, anyway?

When there is a lull, carry Winston Churchill’s shot across the room to him, since you are more mobile than he and his oxygen tank and tubes. And because he is still asleep.

A woman decked out in a gold dress-suit and clanking, dangling, star-spangled earrings clomps her walker in from the hallway, studies the tricky trajectory to your table, forges ahead fueled by a determination that nixes her frail appearance. Before you can read her intention, she hip-shoves aside the armchair you placed for folks like her, flips down the seat of her walker, and flounces into place next to you. The Golden Years executive shuffles through her stack of permission forms and hands you one. “This is our pool-table shark,” she says by way of introduction, throwing the old woman’s face into a wide smile that has had lots of help from a denture architect. “Damn straight,” says your patient, puffing her cheeks and blowing air under her upper plate as it takes brief leave of the roof of mouth and resettles itself with a poof and a toothy grimace. “I beat all the men, all the time. Girls kick ass.” Jangling her earrings with a head toss, she peels off her suit jacket, yanks up her satin blouse sleeve, thrusts out her itsy-bitsy shoulder to receive her shot. Her eyes inspect you, assessing whether you also kick.

The morning dissolves. Little Playmate keeps putting out vaccine Lot. No. 16219478, 0.5 ml IM at a whack. The red sharps box keeps receiving the used syringes with the self-retracting, reverse spring-loaded needles some smarty designed to keep people like you from sticking themselves with used needles. (That smarty did not get up at 4:29 this morning, but is lazing into the day somewhere in a tropical seaside, pink drink, umbrella in it.) Your wastebasket runneth over. Your hands get sore from pulling gloves on and off. Your heart aches. You marvel at how many of these people are younger than you. You try not to wonder about your own future. Hell with empathy. Someone brings you coffee.

Channel 13 shows the dozy dolls an automobile with pennies glued to every inch of its surface. QVC shows them sling pumps with three-inch heels. At intervals they are invited to “Ask your doctor if What-cha-ma-medicine is right for you—may cause drowsiness, forgetfulness, unsteady gait, partial or complete helplessness, partial or complete hopelessness, partial or complete pointlessness, insurmountable distance from beloved life-long others and familiar settings….”

An old man shuffles in from the hallway and crosses toward you, pulling from his pants pocket what he tells you is a can opener he used in Vietnam. He places it, still pocket-warm, in your hand. He shows you a small, faded photo of a young Asian woman holding a baby, tells you he has carried the photo since he found it among papers he removed from a boy soldier he killed in that war, tells you his wife found the photo last week and cried hard and hasn’t spoken to him since. The staff woman will later tell you his wife has been dead for years.

You don’t know it, but: U.S. military deaths in the Vietnam War’s peak years of 1968-1969 approached 29,000. In comparison, influenza deaths in the States during the same period were about 34,000, said to include, in Charlotte, NC, still conjoined 60-year-old Siamese twins Violet and Daisy Hilton, whose show-biz career had included tap-dancing with Bob Hope.

The TV features an operatic tenor whose frenzied arpeggios rouse the couch dollies and set them muttering. “Can you understand what he’s saying?” “No.” “Those people need to learn English if they’re going to live here.”

An unaccompanied Golden Years resident gently seats herself next to you and pulls the chair up to get close. Presents her permission form, which she herself has signed. Tells you she is a hundred years old. Puts a crooked finger on the birth date on her permission form: April, 1916.

You don’t know it, but: In the flu epidemic that began a year or so after this woman’s birth, approximately one-third of the people on Planet Earth were infected and symptomatic, and 50 to 100 million died. In feeble comparison, the world war of that four-year period killed an estimated 10 to 16 million.

Chat lightly while you pull on rubber gloves the same blue as her eyes, lift a filled syringe from LITTLE PLAYMATE, open an alcohol pad, raise her sleeve to expose her walnut-sized deltoid muscle while she tells you she is, like you, an RN.

Allow yourself a flickering glimpse down a long landscape of bygone white uniforms and stiffly starched nurses’ caps with those black ribbon stripes and funny shapes that
connoted a particular nursing school. Hear distant grenades and men’s cries of
the Second War. Picture this tiny woman reaching to hang IV bottles over
hand-cranked hospital beds, when IV bottles were made of glass and
had rubber tubing and needles the night nurses sharpened on
whetstones. See her optimism when sulfa and penicillin were
born, and when the first ’fifties tranquilizers began to
replace electroshock and frontal lobotomy.
Imagine her wonderment when herpes
and AIDS rose up out of sunny
California to darken
those days.

Talk nurse-talk, enjoy her as you work. Ask, “What was your area of practice?”
“Oh, lots of things, through the years. I worked with disturbed children, mostly. Lovely, wounded, fragile things, so many of them.”
Reply, “I see,” pressing a bandage over her injection site. “I imagine those were the kinds of patients that, after they finally leave you to go home, you wonder for years what lives they might have been able to make for themselves from there on.”
Lightly she’ll lay a bent, spotted hand on your arm. “There was this one redheaded girl. Beautiful. She came back again and again. I loved her. Of course I couldn’t say that to her—you know the rules.”
You do know.
Flashback of yourself waving good-bye to Phyllis, then Brian, then
Laura, all of whom you loved in professionally ethical silence,
as they left the long-term psychiatric hospital of a kind
no longer existent under current-day funding,
headed out to who knows where or what.

“What do you suppose ever became of your redhead?” ask her.
She’ll stand (three tries, nose over toes). Her shadow will enlarge to engulf you as she rises, even though morning light from the window would have it otherwise. “Oh, maybe she’s here,” she’ll say, sweeping her arm toward the sleeping dolls but doing it in a way that you both know includes you too.

2:00 P.M. Finally. Get up out of your chair (one try only—so far, so good) and take off your lab coat. Oh, no… just look at that coffee dribble by that button right there! Disassemble your nursing station and put the flowers and gourds back where you found them on their doily and throw your wadded-up paper tablecloth in the wastebasket that was so hard to get and wheel LITTLE PLAYMATE and the big blue box and its now harried contents down the ramp to your car.

Drive back toward your employer’s office to return the unused vaccine and supplies. Never mind the GPS or the clock. You’re here now but moving on in no hurry, and with a clearer idea where you’re headed than earlier.

For the final few miles, choose the Blue Ridge Parkway. You’ll be alone for long stretches. Fall leaves ending their season will drop and scatter around you as you go. The road ahead will bend out of sight.

Jeanne Howe is a retired academic, a mostly retired registered nurse, and a several-times student in Great Smokies Writing Program courses. Her stories and poems have appeared in The Great Smokies Review, North Central Review, The Village Rambler, and Common Ground Review. She lives in Asheville, North Carolina.

About How to Give Flu Shots in a Nursing Home—A few days before the due date for an assignment in a cross-genre (poetry-prose integration) course, I did in fact administer flu vaccine to residents of a senior living facility. As I looked around at the old people starting their day in the “activity room,” this piece formed in my imagination, becoming one of those rare compositions that you don’t so much write as write down. In hasty moments between patients, I made quick but copious notes on the only accessible paper, the back of a flu shot permission form. The last steps were to add a few embellishments and respond to recommendations from my classmates and our instructor.