"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   

            

"He can't hear a word you're saying"

Last week they called for Respiratory in the Emergency Department.  Since I'm a newbie who is mostly supposed to be doing floor care, I'm usually not available to run along for these -- even though they represent great learning experiences for me.  But this time I had finished all my treatments and charting, so I ran.

The patient was a big guy, apparently a drug overdose (party too hearty?).  He didn't respond to commands, but he was far from unconscious, flailing and moaning, and pushing the mask away with both hands.  It took a long time to get IV lines in, to get him sedated, to get restraints on him.  It became clear pretty quickly that we would have to intubate him.

The hospital was jammed that weekend.  There was only one ventilator left in the whole place (all the others were in use), and someone went off to find it.  So we were bagging this fellow for a long time.  The lead therapist's hands were getting tired, so I took a turn at the head of the bed.  The patient began to stir, then to toss his head, as the sedation was wearing thin.  I talked to him quietly, telling him where he was, what we were doing to him.  I told him to try not to be afraid, to try to relax as much as he could and to let me help him breathe with the bag.

The woman who was lead therapist on that response is someone who doesn't like me much.  I'm not her style at all.  She rolled her eyes and said, "Oh, for God's sake, Maize, you are so irritating.  Will you shut up and bag?  Believe me, this guy can't hear a word you're saying!" 

I'm a wise-ass by nature, but never at work.  Unlike my former work environment, smackdowns don't help the process in healthcare.  What I wanted to say was, "It's fun to pretend he's a person".  But I said, "Oh, we don't know that for sure.  I've been where is he now, and I could hear every word."  The other woman folded her arms and leaned against the cabinet.  "I guess no one can tell you anything, right?"

I kept bagging.  And I kept talking to the patient.  Eventually someone came along with more propofol, and the missing ventilator.

As someone who is new to allied healthcare, and as someone who has been a hospital patient from time to time, I object to the practice of treating a patient as if he were a pizza that had just been delivered to your workplace.  No one knows better than I do that we have a ton of stuff to do for a ton of people in not nearly enough time.  But it doesn't save time to act as if the patient is invisible.  I speak to my patients when they're awake, when they have tubes down their throats, when they're paralyzed, when their sedated -- and even when they're dead.  (I have a feeling they are still nearby somewhere.)  I'm learning a lot of things I can do to help, and I plan to keep learning.  But I'm still convinced the first and best thing I can do for a patient is to see them as a person -- a hurt person, a sick person, an unconscious person, maybe a dying person -- but a person.

Namaste,

Maize