Thursday, August 24, 2017

The Other Shoe

Dad took a fall.

My daughter and I have arrived to Tokyo just three days prior and all three of us were headed out.  Dad was going to run an errand to the bank, which is a short bus ride away--an errand he runs often. My daughter and I were off to do whatever. We have just stepped out of the house and I was looking out for traffic to cross the street.  My daughter has gone ahead.  As I turned to tell my dad it was safe to go, he lost his balance. Unable to recover, he collapsed sideways.

It was like slow motion.  I reached out, but he was too far, and because he seemed as thought he would recover for just a second, I didn't step forward.  I couldn't believe how easily he fell. Then things returned to normal speed.  I rushed to his aid.  First, I took a wide stand and got a hold of his hand, like you would to pull a younger person who does not have trouble walking.  Then I realized, he lacked in strength to pull up. Just as I was going in to hold him, a lady came around a corner and rush to our aid.  She knew what she was doing.  With her leading, we managed to get him up to hold onto the fence. He seemed OK.  Shaken, but OK.  He said to just give him a minute so he can assess how he is.  His face scrunched up with pain whenever he tried to put weight on it.  I told him we should call an ambulance. He said wait. Then he said he wanted to go back inside for a bit.  I looked up and stared at the three giant steps to the front door and told him I did not think he could get up there . He said wait. Then he said, he would like to sit.  So with the lady still there, I ran into the house and grabbed a chair and put it right there on the side of the road for him to sit.  Then we sat him down. I thanked the lady, and she continued on to the bus stop repeating, "you should call."  I nodded.

"Dad, let me call an ambulance."

"Give me a a minute. I maybe able to get inside."

"Dad, let's call.  It's hot out here, and I don't think you can make it up."

"Just a little more time."

"Dad,  I don't want us to try and have you fall again."

"...OK. Maybe we should call."

I told my daughter, who was standing there frozen to go inside and wait for my instruction. Then I called.

Soon we were riding to a nearby hospital with my daughter in tow. I texted my brother at his work and my husband in Seattle.  I also realized I had not said much to my daughter. " He is going to be OK."  I managed to squeeze out. "I don't think there are too many kids in the States who has ridden an ambulance in Japan." I added. She smiled.  I was grateful she got to the age where I didn't have to worry about her every move. I deliberately took several deep breaths to remain calm. It has been an uneventful 6 years since my mother’s passing.  Now, we were heading into another storm. And when you combat a storm, you go through a steep learning curve in rapid succession.

Emergency Room
As my dad got rolled into ER, we were shown to the waiting area.  I filled out some basic paperwork and there we waited. After a couple of hours, a doctor came out and said,

“Well, it’s broken.”

I froze. It sounded like a textbook senior citizen injury and my dad was living it. The doctor showed me his X Ray and explained that his Femur Neck--which is the joint that holds your thigh bone to your hip socket--is broken, and because of that, his right leg has shifted position. If he wants to walk again, he heeds surgery.

My head was barely catching up to the fact that I let him fall in front of me and the bad information kept rushing at me. I took several more breaths. Focus on now, I kept thinking.  Focus on now and what to do in the next hour.  I texted my brother everything I was told partly as a way of recording it into my brain.   He was on his way.  I needed one more set of ears.

Less than 24 hours later, my brother and I were back at the hospital. Upon arrival, the nurse told us that dad is a bit disoriented and confused. She encouraged us to chat with him about how he got here and why--hearing the information from family sometimes helps bring order to mind.

My father is 91. Though he has shown evidence of  short term memory loss, he had not said anything out of the ordinary up to this point. But now, from the trauma of the fall and the events that followed, his brain was thrown into chaos of information. I entered his room and upon seeing me, he told me he was confused. Interestingly, he was fully aware that things were not making sense to him.  He said he could not recall what happened and how he got there. I explained the chain of events and that he will need surgery. I repeated this as many times as it took and answered his questions until it seemed like it was registering.

The doctor (also the surgeon) who was assigned to my father's case was a young female doctor, which immediately gave me comfort and confidence in multiple ways. She brought the copy of dad's X Ray and explained what the surgery is going to do in great detail laymen's terms. It is fairly standard that when this particular fracture occurs to a senior citizen, they would replace his hip joint all together with a metal joint.  She said given dad's age, there are, of course, risks in doing surgery but if he doesn't have it, he will never be able to walk again and possibly be bed bound, which will lead to more health issues. She said that she is going to take the next two days to run tests to make sure he is able to handle the surgery and with our go ahead (and his), it will happen on Monday--which was three days from then.

My brother and I agreed that surgery would be a worth doing and we recommended it to dad.  After the doctor explained everything, he (in his somewhat confused state) also agreed and understood that it would be better to have the surgery than not. The whole thing stressed me out. If he has the surgery, we might lose him from various complications.  He will gain mobility but will need to go through physical therapy and even with that, probably won't be able to move like he did before.  He was already walking with a cane. If he doesn't have the surgery, it will be worse.

Next day, my husband arrived as scheduled.  I was glad that my daughter had a playmate for the remainder of her trip.


My dad the bionic man.
Monday morning came.  I did not sleep well the night before as I was getting my head ready to face all kinds of possibilities. I looked at the picture of my mom and uttered, "don't come get him yet." I took her engagement ring that I had placed in front of that photo with her wedding ring for good luck.  In 24 hours, I may not have a dad. And if we lost him everyone would say "he lived to be 91. How great." That option did not feel great but I needed to be prepared.

My brother, I, and my sister in law headed to the hospital as my husband took our daughter to a Japanese language camp, which was starting that day.  Nurses talked us through some things, then the doctor came and went over the procedure, then the anesthesiologist (also a young female--go, Ogikubo hospital!) came and informed us that she will go with partial anesthetic--much like an epidural--which is safer for older folks. The surgery was to take about 2.5 hours.

We accompanied dad down to the surgical floor and waved him in. He disappeared as the doors closed.  I smiled and saved but my throat was bone dry and my heart pounding. We headed back up stairs to the waiting area and got comfortable. The next three hours was relatively fast as we three chatted about various things to occupy ourselves. I distracted my mind with things I can do with my own family and my brother and sister in law were making suggestions. The mood was light and casual and calming. I felt like things were going to be OK.

Eating at the hospital cafeteria.
My brother and his wife.
About 3 hours after dad went in, he came out.  Awake and waving. We exhaled. As my sister in law headed into work, my brother and I followed dad back to his room. And there we stayed for the next six hours as dad slept off his surgery.  The doctor told us it went well. No complications.


Two days after the surgery, dad contracted Aspiration Pneumonia--a very common type of pneumonia for senior citizens that is caused by food, drink, and/or saliva going down the wrong tube into their lungs and causing infection.  As people age, their throat muscle weakens, causing them to not swallow well and when they are bed ridden as my dad was for several days, the possibility grows bigger.  I didn't know any of that before that day.  Things you learn when someone gets sick. Things you don't want to know.

This was the second time I braced myself. Pneumonia for a 91 year old sounded like a death sentence. My brain was full of childlike panic and grown up conscience fighting each other. I just exhaled. I just let myself feel better and hope for more time with dad. The doctor said she has started him on antibiotics, and while he is being treated, he can only take in nutrience through iv because eating and drinking could worsen the condition. Dad looked weak.  He is build like a scarecrow anyway (as my husband describes, "hugging your dad is like hugging a coat rack") but he looked thinner and old. Because he is. He is old. Very old.

Meeting with A Social Worker
Two days since contracting pneumonia, dad was showing signs of improvement. He was alert, aware, and talking though still occasionally confused. I exhaled. My brother, my sister in law, and I met with the hospital social worker (side note, every one we've met up to this point has been younger than us) who consults with families on how to go forward in terms of patients' care. She told us that under a normal circumstance like dad's case, this particular hospital could only keep him up to a month with some basic level of physical therapy. That time line was now blurred a bit because of his pneumonia--but regardless, we needed to make plans for what comes next. Once his pneumonia is under control, we would move him to a rehab facility that would focus on PT and get him to a goal we set to get him home. While he is there (which could be a couple of months depending on how much he can handle), we need to assess what he will need at home, including daily nursing care, continuing PT, and equipment. She gave us some option of places all nearby, we discussed pros and cons and narrowed down our choices to two. Once the doctor gives a go ahead, she will put in a request on our behalf and he will be moved to the first place with an open bed. Then she explained some benefits we can claim from the city and gave us paperwork to fill out. She was very gentle in tone, clear in her explanation, and encouraging. It felt good to make plans. I walked out hoping he would be well enough to be moved while I was there.

Japanese Health Care
Health Care is socialized in Japan.  According to my brother, the government used to cover 100% of the cost--but then with the growth of elderly population, people started to take advantage and go to the doctor for little to no reason, and hang around the hospital for socializing. It was starting to cost the government enormous amounts of money--my brother said, "when it's free, some people think it's their right." So the system has changed.  Now, everyone is responsible for 30% of the cost. But then, you can cover that 30% if you also have private insurance, for things like hospitalization, etc. In addition, there is a nursing care benefits you can receive from the city--each city office sends out an agent when a senior citizen is hospitalized to assess the level of care they will need when they go home.  Based on that assessment, people can receive a variety of in home care, ranging from nursing staff coming to your house, taking you out to go to physical therapy, and equipment you might need like ramps and railings. But how much you can get for free is all based on the day of the assessment.  My brother told me a story of his colleague, who is in his 70s and has a mother who is 100. She lives alone without any problems but some time ago, she also took a fall and needed some help. She had an adequate amount of aid to start off, but then when the agent came out the second time, her competitive performance nature kicked in and functioned extremely well in front of them, thus decreasing the amount of care she could receive.  "Can you believe her?" He said. It's odd to hope for a bad result, but we were hoping that the agent would come on dad's bad day.

Dementia Land
As the days went by and his fever subsided, his confusion started to fade away and he was back to his normal forgetful himself.  About 10 days after his fall, his brother (Aki) and sister (Saeko) twins came to visit. I met them at the station and took them to the hospital. His face lit up when I walked them into the room, but then as we were chatting, he suddenly said,

"How is the house you are living in?"

We paused. I said,

"You mean, your house?"

"No, no, the new one."

"What new one?"

"Well, I thought that there was a piece of land up on the hill that our family owned and we had some houses built for all of us to live in.  And you are in the tall building."

We paused again. What is he talking about??  I was trying to get into his head to see where this was coming from and piece together something. My father grew up in a neighborhood in Tokyo called Sankocho, where his father had a large estate that survived the Tokyo bombing of 1945. After his death in the 60s, my dad decided to move away from that area and build a house of his own (where I grew up) and left his sister Tami (#2 of 5) in charge of the land.   She sold it, and a big condo was built and Tami and Aki moved into large units in the building. Since then, aunt Tami has moved out to be in a nursing home, but he grand daughter Naoko, here sister Junko and her family, and my cousin Toshi (Aki's son), all live in the building.  So I figured this was what he was referring to.

"Are you talking about Sankocho?"

Uncle Aki joined in.

"Oh, that must be it.  Yes, some of us live there, but Mimi is staying at your house in Ogikubo."

This line of questioning went on for w few days. Finally, I said to dad that I didn't quite know what he was talking about. Then he said.

"Oh--maybe I am confused."

"I think you might be."

Then he stopped asking about where I lived after that. It was more fascinating than upsetting to witness how his mind was confused.  What happens to your brain and memory when you are old and face trauma. In my dad's case, if I point out that he maybe confused, he would take a moment to think about it and realized it.  He did ask repeatedly where is cane went, his wallet, and other belonging, but if I told him every time that I took them all home and they are safe, the number of time he asked decreased. I did wonder if he was starting to slip away and if this was going to get worse.

Physical Therapy
Dad's PT=Saint like patience
As his pneumonia was starting to get under control, his physical therapy was starting.  The doctor said, about 24 hours after the surgery, he can put his weight on his leg and start moving.  A week of lying in bed has decreased his mobility and in order to regain it, he needed to move. It is amazing how weak dad could get in less than a week.  The day I watched his PT, he sat up and immediately asked if he could lie back down.  A young man who is working with him, very gently distracted him away from that thought encouraged him to move to the wheel chair where he had a back support.  The therapist talked him through where to place his feet, hands, and how to shift is weight, skillfully moved the IV and the catheter around as dad moved while supporting his weight and took his blood pressure after every move was completed. Never pushy but encouraging. Very, very patient. It was good to see my dad up right, but then when they moved to the rehab room and got him to walk (holding onto bars), my heart got lighter. He moved really slowly, but he was walking. All the worries that built up melted away at that moment--he is going to survive this.

New Routine
The hospital is not terribly far from our house which made this new routine managable.  It was a bus ride to the station, which is about 7 min.  Then walking to the other side of the station to catch a different bus, which was also about 7 min. The second leg had 3 bus options but they were less frequent. If I was in a hurry, I jumped in a cab. Once I was there, I went up to the 5th floor and signed in at the nurse station to get a visitor pass.  After 5pm on weekdays and on weekends, you go through the side entrance and sign in at the 1st floor with the security guard.

My dad changed room 3 times.  First day, he was on the 4th floor because that was what was available, but then he was moved to the 5th floor which is the floor with injury patients. He was in Room 10, then 6, then 3--they kept moving him closer to the nurse station as it became available so that they had a clear and immediate view of my dad.

The nurses worked in three 8 hour shifts. I typically saw the day nurse as she was in her last couple of ours into the night nurse as I left at the end of visiting hours at 8:00pm.  After a week, I pretty much knew who was on what shifts. My husband, daughter and I would go about our day doing things, then we would part at the station and I would head to the hospital and they would go home.  Or I would go to the hospital first, if our plan didn't happen until later in the day and they would meet me there and we would go out. My middle niece who works nearby would get off at 7:00pm, take the bus to the hospital and see my dad for about 40 min every day.  Other s came when they could depending on their work/school schedule.  When my brother came, he always came from home in a car so that we could get a ride. And whoever was there would text the rest to give any kind of update. I was glad I was physically there.  It is always harder and your imagination would grow wilder if you can't see what's happening. I did not have to imagine how my dad looked, or the hospital or the doctor. This was the only positive in the entire situation.

Family and Friends Who Know
I take it back.  There was another positive. I spent a lot of time with my brother. On the day of the surgery, we sat together for about 8 hours chatting on and off.  And through this whole crises, we discussed what could and should be done. There has been some of that since my mother's passing, but this was a concentrated circumstance. It good to compare notes on our perspectives from equal footing.  Also interesting because we have different experiences with our dad. I guess something about being a son v.s. a daughter.

It was also nice to spend time and talk about my dad with my uncle and aunt.  I had not gone out just with these two, perhaps ever, so I asked them questions about being twins, and their childhood and verified some stories I have heard from their points of view.

I also spent some time with my cousin (technically first cousin once removed) for the first time in years. Naoko is just five years younger than me who started her modeling career at the age of 15 and now runs a management company.  She also has been the sole care taker of her grandmother (my aunt Tami) until she went into a nursing home. She also lives right next door to her sister and her family in aforementioned condo and helps takes care of her niece nephew. She had just beat breast cancer and was joking about her "bald and fat" appearance in the most down to earth way. Her experience with my aunt and the fact that she knows my dad well made her a good resource for me. She seemed to embrace and understand aging minds, and have the great capacity for empathy--not focused on what should be done, but more on how they feel about what is happening, which is so easy to forget.

Should I Stay or Should I Go?
As the third and last week of our visit was starting, dad's fever shot back up to 102. He had just started back on solid food about 4 days before, and though he was of not showing much appetite, it was an improvement. But now, he was out like a light, breathing shallow, and looking weak again.


I sat by him and just held his hand. This was the third mental(?) heart attack. I was not ready for this set back. I just wanted to feel better and stay there.  I'm sure he did too. Logistics and worst case scenario rushed around my head--I was to start directing a show in two weeks. I pulled back to catch my breath and decided to just focus on whether to leave or stay one more week. I was back and forth and finally my husband told me to stay.  That he would take care of business at home and take our daughter back.

That Friday, I took my family to the airport and put them on the flight back to Seattle. My daughter, who I thought would have a hard time with this said, "It's good you are staying with Jiji." That was a gift. As I rode the train back, I was thinking about 6 years ago. I came to see my mother by myself for a week, which ended up being the last time I saw her.  It was a stressful trip not only because of my mom, but also that this was the first time I left my daughter, who was 4 at the time, for this long.  My dad took me to the station and we discussed mom's condition and what we hoped for her. He was going to pick up some bento that my mom requested on his way home. I told him I will come again in a couple of months and took this very train to the airport, crying most of the way because I intuitively knew I might not see my mom again. This time, I was riding it going towards my dad, wondering if this is the last time.

View of the Tokyo Sky Tree from the train

Pneumonia II: This time it's personal
I went back to the hospital and the doctor found me to tell me that his pneumonia had come back. She said this happens from time to time so they are once again going to take him off solid food and get him back on iv with antibiotics and fluids. I got home and rearranged my things--cleaned the guest rooms where we were and moved my things to my dad's room and change the sheets and climbed into his bed.

The next morning, I texted with my husband about this new development.  I sat in the bathtub and had a breakdown that was probably long overdue. Surrounded with his things, I sat in the house, wondering and hoping he will get to come back again.  Once, I was done with that, I got my stuff together and went back to the hospital.  His fever had gone down and though he seemed drowsy, he looked better. I sighed a big sigh.  My husband asked if I needed to stay longer than a week, and it struck me that I need to go back.  At least for a bit.  This was not the level of stress I could sustain.  I needed to get back to my own house, my work, and my own family to experience some normalcy to reset my mental health.  Once I figure that out, the week got a little easier and more focused.

My routine was to spend the morning checking my work email, sorting through dad's piled up paper and mail, have lunch, then head to the hospital.  I spent anywhere from 2 to 5 hours a day there.  Some days just sitting and watching TV while he slept, some day, chatting if he was feeling up to it. He would occasionally get confused about his iv, and his catheter and tug on the tubes so that they had to restrain him when he did not have a visitor watching.  This was difficult.  He would ask why he had mittens on, how it's hard to use his hands when he has them on or why his wrists were buckled to the bed.  No a fun sight or conversation.

So. Much. Mail.
He had his good day and bad day--the nurse told me that one evening, he insisted he was going home.  He raised his voice demanding.  My dad doesn't raise his voice.  He is the calmest, most even tempered man I know.  I can remember maybe ONCE in my life when he yelled at me and I was being a total jerk. I told her that is highly unusual and  she said it happens to the gentlest of people.  They sleep on and off all day and gain some energy at night and it manifests itself in frustration. All very logical. I don't know how nurses do it. But they are good at it.

At one point, dad told me that his body did not feel like his own. I can only imagine. He would get his phlegm stuck in his throat, but because he is so weak, he can't cough it out.  So then the nurses have to come in and suction it out, which is very very painful.  They first try to get him to cough it out, and use that as the very last resort but he often could not do it himself. They ask me to step out when this happens but I can hear the sound of the suction and his moaning in pain and it is the worst sound. I don't envy anyone in that room. When they finish, I go back in and hold his hand.

"That is hell" he says.

"I know.  It's awful. But there is no other way to prevent you from choking."


And so it went on like that for 7 days.

One time, he asked,

"How long have you lived in America now?'

"Let's see--34 years?"

"My goodness.  That is a long time."

"Well, I was 15 and I am almost 50 so..."

"How is your theatre?"

"Oh, it's good."

"We used to take a stroll down the hill from our cabin and talked about a lot of things--remember?"

"Yeah, I remember."

I do remember.  My family owns a cabin up on a mountain in Nagano (where the winter Olympics took place in 1999). We used to spend our entire summer there and my dad would get up in the morning and stroll down the hill to the resident center to pick up his news paper and I would accompany him.  We used to chat about whatever. Not sure what brought that specific memory on, but that is what he remembered at that moment which almost broke me.

But I sat there, not breaking.  Like he did for my mom.

Dad snoozing, me watching Sumo Wresting.
Some people growing with the sound of base ball.
I grew up to this sound.
My last day of visit came.  I spent much of the day there reminding him that I was leaving tomorrow but that I will come back in a couple of months to check on him. My middle niece who had stopped by almost every night after work joined me at the end of the visiting hours.  I kept my good bye short and like any other day.  He waived and said "have a good trip home." I looked back only once.

Since my brother has taken a lot of time off from work to tend to the hospital matters, I told him I could take myself to the airport.  I sent most of my things back with my family so I took a cab to the station and hopped on the train. I felt tired.  But also felt good to be going back.  I made a decision not to be consumed by stress and worries. Just get back and do my thing. My brother and his family was here. They will keep me updated.  Dad is in good hand.

It's been almost a month since I got back. I have successfully directed the production and now that is coming to a close.  Since my return, dad's pneumonia has relapsed 4 times.  But at the same time, his leg was healing fine and he has shown progress in his rehab. On his good day, he can walk with a walker and can take himself to the bathroom. But because of the relapse, he has little to no stamina, which slows down his rehab.  They have tried having speech therapist to tend to his swallowing to try to strengthen his throat muscle to prevent future relapse but that has not worked.  My brother called to discuss the option for the near future, which included feeding tube.  We decided that if eating food is the major cause for his pneumonia, and that is hindering his stamina (which it is), that was probably the best solution.  But for the time being, we decided (with his medical team) to wait and see.

After having that conversation, dad was eating better.  My brother thinks perhaps the notion of yet another procedure motivated him to eat more--but then another relapse occurred. Just this week, I got texts from my brother saying he needed my permission for DNR should it came to that. I gave permission then had another day of crying. Then out of that, I got on Amazon and ordered black dresses for me and my daughter. Just in case. That was morbid and comforting all at once.  You do what you can control, I suppose.

Then he rallied. Then his oxygen level plummeted, and my brother rushed to the hospital.  Then he rallied again. Right now, my biggest concern is that I would have the most inappropriate reaction when he goes. Which could be tomorrow, or 2 months from now, or 3 years.

What are you supposed to hope for a 91 year old?

I had a dream that he got to go home.  I guess that is what I wish for him.  That he gets to go home.

The other shoe is dangling. And I am also dangling.

Me and Dad circa 1970