Distressingly superficial

Skin is thin skinned and easily offended.

Two weeks ago at work, my cell phone rang. I do not know how I know to wince when the nursing home calls, but I do. I pull the phone out of my purse and, yes, there's the dreaded ID: "Sandy at Home." (The first nursing home employee whose name I absorbed in October 2014 was Sandy. She almost never is the one calling, but I haven't changed the contact record.) Sandy at Home, whoever she may be, never gives me happy news.
The nurse on the other end said, "She does not have a bedsore. She just has some excoriation, a few little places, and we will treat them with (ointment)."

Excoriation! It's not merely a synonym for harsh criticism. How did I not realize this? I have used the word for decades. It comes from Latin, ex meaning off and corium meaning skin. Excoriation is not just the act of abrading and degrading someone's spirit through blistering criticism as though the spirit were skin, it is also the act of abrading and wearing off actual skin.

Everyone has thin skin, not just my bedridden mother. We have the epidermis, which is thin. Below it lies the dermis, which in a young person is thick, a supportive pad of collagen and elastin; but with age that gradually thins.
My mom's dermis must be just about gone. Her bones are visible all over.

I once got to see down below skin's layers. Son Ben slashed his thigh open on a license plate bolt while playing basketball in the yard. In the emergency room treatment bay, I sat on a chair next to his gurney bed and peered at the wound until he begged the doctor to cover it up so I would stop looking. There was a blue-gray sheath over the thigh muscle, a bubbly yellow thickness, like living styrofoam, then the weepy, rose-colored dermis topped by the pale veneer of external Ben.

Another time I saw a black child right after he'd crashed his bicycle. The sidewalk had scraped some skin off his dark brown shoulder, and the wound was a bubblegum-pink hole. Ben's anatomy was interesting, but that poor child's wound was disturbing. I wish I could unsee it.

A few weeks before my mother-in-law Norma died, I was trying to haul her off her wheelchair to the bathroom when her leg dragged and the aluminum footrest drew an L-shaped cut on her lower shin. I wish I could unsee that as well. And un-do it.
The skin that slit freed was like onionskin. It wept until the day she died.
I used to imagine that when I gave her a glass of water, the leg would weep faster, as though she was a leaky jug. It didn't, but I imagined it did.

The day after we took my mother to the emergency room, Sept. 28, 2014, the intensive care unit nurses asked us how long she'd had her bedsore. Bedsore? My poor sister, who had been Mom's main caregiver, was startled. Living with Beth in her own home, Mom had only just taken to her bed for about a week  (exhausted by atrial fibrillation and water pills). So it didn't seem likely that she could have given herself a bedsore.
But a week is plenty of time to do that.

She might even have developed the sore because we got her an adjustable bed. When someone immobile is lying down and the head of the bed is mechanically elevated, his body might slide down the bed, with his skin dragging on the sheet. Here's a description from Mayo Clinic: "As the tailbone moves down, the skin over the bone may stay in place — essentially pulling in the opposite direction." Shearing force separates skin layers, making the place more susceptible to the damage caused by sustained pressure — the pressure of underlying bone on the skin that flattens capillaries and blocks fluids that bring oxygen and nutrients to skin cells. Eventually they die, creating first a red spot, then a blister, then a lesion, then a deep ulcer.

Months of nursing home care cleared up her bedsore, but the skin remained so fragile it tore open after it had healed.
When the hospice team took over, they put her on an inflating and deflating mattress. I saw one of those in action when we cared for Norma during her last summer, and so I was reassured by that mattress. And for most of 2015, her skin was good. Every so often she'd get a new little tear on a leg or ankle or arm, but Mom heals.
Then last month the mattress controller went nuts, overinflated the bed and ejected her out and onto the floor.
No harm done. But that air mattress went away.
Turns out there is a downside hazard to the inflating mattress. In its place came a foam block with a depression in the middle — like a foam nest.

But then she developed these excoriations.

All that to say this: At our quarterly care team meeting this week, the nurse reported the excoriations are clearing up. The foam pad appears to be working out. But as Mom decays, we should not be surprised if excoriations reoccur.

Just as with the metaphoric, spiritual kind, physical excoriation is not hard to inflict.
A girl in my high school once took the skin off the back of her hand in 20 seconds using a pencil eraser. I don't know whether she was crying out for help, curious or both. Surely it was painful, but yet she did it easily.

Mom isn't doing anything on purpose to excoriate her skin. But that very non-act of not doing anything is precisely how she is doing it. The weight of her body is crushing her skin so that any time she is moved, it abrades.

Ironically, the best way to protect our thin and fragile skin is to roll around on it, to make it move and stretch and knock about. When we lie down on it to die, it dies before we do.