Saturday, January 24, 2009

Respiratory Distress

...Is in the eye of the beholder. Seriously.
I get a call from a nurse. We will call her RN. I like RN. RN and I have never had a problem. She is telling me that my patient is in respiratory distress and would like a PRN treatment. I respond.

RN is sitting at a desk when I get to the unit of the hospital. My first thought is : "If the patient is in such distress, why is she not at the bedside?" Realizing that crazier things have happened, I go to the patient's room. The door is closed. I knock lightly, then enter. The room is dark, but in the glow of the bathroom light, I can see it. The patient and her husband are both sound asleep. I tip-toe to the bedside and see that respirations are normal. Her breath sounds are clear, save for a few scattered crackles in the bases, which does not surprise me, considering the patient's diagnosis. I tiptoe out of the room, and as I pass the desk where RN is sitting, I give her that look and let her know that the patient is sleeping like a baby. I go back to my laundry list of tasks to complete.

30 minutes pass.
My phone rings again.

RN: "Andrea, she woke up and is breathing so badly that she is sobbing."
Me: "Sobbing????" (This isn't the usual presentation of respiratory distress.)
RN: "Yes, she says it hurts so bad...."
Me: "Wait a minute. Is pain her problem?"
RN: "Yep. She says it hurts in her side."
Me: "You know, albuterol won't fix that."
RN: "Well then, she's short of breath."

I go to the room. Again, RN is sitting at the desk and the patient's door is closed. I enter to find her awake this time. I ask what the problem is and she says that it hurts to breath. I ask her to describe her pain, and she clutches at the right lower rib cage, explaining that it hurts to take a deep breath. I observe her and notice her wincing with each breath. I ask her if she is short of breath. "NoNotReallyItJustHurtsWhenITakeADeepBreathCanPneumoniaDoThatIDidn'tKnowPneumoniaCouldDoThat."
Long run-on sentences. Normal respiratory pattern (rate and depth). SPO2 is 98% on 1 liter of O2. Heart rate is 86. Breath sounds completely clear. I know that nothing I can do is going to help her. She needs her pain meds, which come from RN. I explain to her that we can try the treatment, but that it really won't help if her problem is pain. She is too vague, so I give the med. After the treatment, she insists she is cured. There is no more pain. (!!!!!) I am convinced she needs a psych consult. I leave the floor, but not before letting RN know that while I did treat the patient, she was not in respiratory distress. That while I would love to run around the hospital appeasing patients and nurses all night, I truly have patients who need me.

As I am walking out, I think I should stop and see the patient on Q4 treatments. She is due for the next one in 15 minutes. I walk in her room. She is sound asleep. I gently wake her and let her know it is time for her treatment. She blatantly tells me she doesn't want it, doesn't need it, and rolls over and goes back to sleep. I chart the refusal and go on about my business.

45 minutes pass. It's RN again.

RN: "Andrea, our patient in room xxxx is feeling short of breath and would like a breathing treatment."
Me: "Seriously???? I was just in there less than an hour ago and woke her up. She refused. What changed?"
RN: "She refused??? (soft giggle) Well she wants one now, says she is short of breath. She just got back from being downstairs smoking."
Me: "Let me get this straight: she wouldn't let me treat her 45 minutes ago, but then went down and smoked and wants me to make a trip up there to treat her because she is short of breath after her trip to the smoking area?"
RN: "Yep (louder giggle now)." Shall I tell her she's on your 'list'?"
Me: "Yes, thank you."

"Respiratory distress" and "dyspnea" and "shortness of breath" are all subjective terms that are used too loosely in a hospital at night. They know I have to respond to a call that uses those words. I trust that the nurses have used their assessment skills, that they know I am busy, and have filtered through some of the BS. This is not always the case. I got calls like these all night last night. All 12 hours. A lot of them weren't even from my assigned units of the hospital. They were from other nurses who didn't feel like they got a quick enough response from their therapist and started dialing random respiratory extensions until they get me. In a respiratory eutopia, we would have the staff to run around and do this random crap. At my place of employment, we do not. At 11 PM, the respiratory staff cuts down from 8 therapists and/or techs to about 4 therapists (no techs at night because we have to be able to handle it when we are called). I am one of the lucky 4. And if you divide the hospital into 4 equal sets of work units, you wind up with therapists who have anywhere from 5 to 8 units of the hospital. I had the entire 2nd floor of the hospital last night, plus NICU and pediatrics, for a grand total of 9 units of the hospital. I do not have time for bullsh*t calls like this. And with assignments like this, if there is a code at night, all of us respond because you are never assumed to be able to go to a code on your own floor. I have been known to have simultaneous codes going on at multiple units to which I was assigned. So in the middle of all of this, I had to respond to a code, which resulted in my brand new shoes getting doused with so much vomit that it soaked through to my socks. In the middle of it all, I have to call the supply people and have them deliver to me a fresh set of scrubs, shoe covers and a jug of hydrogen peroxide. I got the puke out of my shoe, but only by pouring the entire bottle inside and outside of it, then having my toes squish around in the peroxide-soaked shoe for the remaining 5 hours of my shift. Fun.

God, I hate being a "floor whore". Send me back to the ICUs or the ER. Please!

1 comment:

DK said...

GAKK! What a shift!! I feel your pain - we often get consults like, "the patient is crying, you'd better come quick!" Last night I got, "The patient wanted to jump out of a moving car when she had a BAL of .280. We need to you come down and do a safety eval even though she's sober now and says that was stupid and isn't endorsing any suicidality."

Why I why I beg not...invoke...the psych consult (shhhhhhh!!!).