"Lots of Sick People"

Here in my midwestern state, February has been like November at the hospital.  The census is up.  My supervisors are calling me, asking if I can come in, even on days when I have notified them I am in class at the college.  ("Well, what time is your class over?  Can you drive down and pick up a shift?")   When I come in for an 8 hour shift, I am always asked to stay for a 12.  If I am scheduled for Saturday, I am asked if I can do Sunday too (even though I have a 12 hour clinical on Monday).  If I weren't staring down the barrel of my licensing exams, I'd be happy to work.  And God knows I need the money, even now...

But, to be honest, 12 hour shifts are hard.  I had been chalking it up to my age (I'm 56), but even my younger student colleagues tell me they are wiped, the day after a 12.  Hardest of all, a much larger percentage of my patients are now very, very sick this time of year.  Most of the year, approximately a quarter of my patients are fighting for their next breath.  Now, fully half of my patients are fabulously sick, and they are not DNRs either ("do not resuscitate").  They are trach patients from skilled nursing facilities with pneumonia, patients with asthma and COPD with refractory exacerbations...  

I hate doing repeated nasotracheal suction ("NT suction") on my very sick patients.  It seems to me that we don't decide to install a soft nasal trumpet in a patient's nose to protect the nasal tissues until *after* the nasotracheal passages are all jammed up and irritated and edematous from frequent suctioning.  

With my adult patients, I try to talk them through an oral access instead of putting a suction tube in the nose -- inhaling, exhaling, swallowing on cue so that I can move from the back of the mouth into the trachea to get down and get out the junk.  Lots of surgilube, coaching, peaceful breathing.  Nasal passages are narrow and fragile, in my opinion, even in grownups.  By contrast, oral passages accomodate a lot of "stuff" going by, on a volitional basis.  It feels familiar to patients to go in through the mouth.  Patients put stuff in their own mouths on purpose, and take stuff in that way.  They don't shove things in through their noses, as a rule.  That's scary.  And they don't want me to shove anything through their noses either, if there's a choice.

First rounds on Wednesday, I had 56 treatments.  When I have that many, the hospital computer shows about 1/3 of my treatments as late.  So, I don't get such a good rating as an employee.  Of course I "stack" treatments, instead of staying with each patient until the treatment is finished.  Our protocol says that if the patient is alert, familiar with the treatment, and their vital signs are stable, we are supposed to go on to the next patient and come back to check the previous patient when their treatment is finished.  That's not the old fashioned way, but it makes good sense.  I do get jammed up sometimes in my "efficiency" ratings, at times like this -- even if my patient is getting a routine aerosol treatment, if they are frightened and anxious I won't leave them on their own.  So the next treatment is "late", but that treatment is not for a patient who is breathless and frightened.  It's for someone who is just supposed to have a treatment to keep things on an even keel. 

And then there's the business of getting the class work turned in on time.  But I hit the target this week.  Stayed up late, assignments done, turned in today.

It's still a good business.  Breathing matters.

Namaste::::Maize