Working at Home

The patient is in respiratory distress, lying in bed, diaphoretic and semiconscious. Each breath she takes requires monumental effort, and that effort isn’t enough to supply her body with enough oxygen to sustain her. Even with the nonrebreather and 10 liters of supplemental 02, her SpO2 is 85%, her lungs are full, her blood pressure 180/100, with a heart rate of 128. Three firefighters are in the room with her; one hands me the paperwork. The rest of us move her from the hospital bed to our stretcher.

She is 61, her name is Kathleen. The report is vague. Included with the interfacility transport page, the patient’s history and medications is the narrative: History of MS, found unresponsive at 0430 hrs., difficulty breathing, sat 80%, BP 160/80, HR 120, resp. 28. EMS called.

The nursing staff is conspicuously absent. The hall is empty—no aides, no dietary technicians, no doctors or visitors. There seems to be nobody home at the nursing home, except for rooms filled with people sleeping or staring at the walls, waiting for something to happen. A few peered at us as we rolled the stretcher past their rooms, no doubt wondering for whom the bell tolled this time, and when it would be their turn to be wheeled out.

This isn’t a fancy place, with privacy, pretty paintings and an abundance of staff. It’s a state-run facility operating with the bare necessities, two patients to a room and one RN for too many patients.

There is a nursing station near the elevator, and there I find somebody, finally. She is alone at the desk, phones ringing, a stack of orders in front of her, nearly overwhelmed. I take a deep breath and assess the situation and, instead of demanding a more cohesive report, simply ask her opinion regarding the patient.

“Good morning. Can you tell me something about Kathleen beside her vital signs?”

She looks up from her reports, leans back in her chair and regards me. It only takes a second, but I know when I’m being sized up. She is ready for confrontation.

“I think she has pneumonia and maybe a UTI. She’s normally talkative and alert. This is highly unusual for her. She wasn’t feeling well when my shift started; she normally asks about my daughter, but she didn’t tonight. Thank you for asking.”

She returns to the mountain of work, we continue on. I have no interaction with the person on my stretcher. She doesn’t know, will never know or ask about my daughter, or I hers. Her life story is a mystery to me, her presence in my life fleeting and soon forgotten. An IV, an EKG that’s unremarkable and a ride to the ER for an evaluation, and that is that. Later I find out she has pneumonia.

In a perfect world nursing homes would be properly staffed and nurses would not be overwhelmed. I hear a lot of people in our field question the competency of the staff at these places. Theirs is a world much different from ours. They know their patients far better than we do. They share their lives with them. We have no idea what it takes to spend eight, 10 or 16 hours with a patient, a week, a year or a lifetime. They do. They will be there for their patient’s final days, or hours, and experience suffering and death time and time again. They offer the people under their care far more than emergency medical treatment. Their input is valuable. I think we may have worn them down by treating them poorly when everything isn’t as we’d like it, and demanding better reports, better documentation, some intervention or, worse, simply ignoring them.

The nurse on duty did the bare minimum, but probably not out of laziness or lack of compassion. She too was trying to survive in a difficult environment. The clues were there, waiting for me to put the puzzle together. I could easily have treated Kathleen for congestive heart failure and subjected her to unnecessary treatment. By simply asking the nurse who knew the patient better than I her opinion in a friendly, nonconfrontational way, I was able to figure out what was wrong and treat the patient accordingly.

As a bonus, I got to feel better about myself by simply treating a colleague with a little respect.

2 Comments

  • MAEMTB says:

    Well said sir.

  • RI Schadenfreude says:

    Geriatric wards & nursing homes are, sadly, like burn units- staff starting at the bottom get assigned there and can't wait to graduate to another unit.

    It always burns my a** when I'm reminded how short-staffed these places are when I read about Governor Gump or some other RI Govt. clown adding people to their staff, or trying to justify their raises to the taxpayers. Thanks for putting the spotlight on this situation-I wish more were aware of it.

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Michael Morse

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