Abstract
Tranquility Base
It is 4:45 a.m. and although I have turned over to check the clock, gotten up to take a whiz, or readjusted the covers, my 7:30 patient is already up and moving. The first case of the day may not get started until 8:00 a.m., but that patient appeared at the hospital registration at 5:30 a.m.
Performing morning rounds on the day after surgery, I enter the room of the patient. He had undergone a major lower extremity procedure. He looks wan, pale, blurry-eyed and fatigued. I am puzzled, because the procedure was short, it went well, the patient was otherwise in excellent medical health, and quite fit. The fact that he looks quite fatigued is contradicted by his insistence that the pain is under good control and he is “chomping at the bit” to go home. “Okay,” I said, tilting my head quizzically and signing the discharge order. Because I am a casual interloper to the dynamics of the post-surgical floor, I failed to understand fully the activities which transpired in this person's life from the time we had finished in the O.R. until I entered the floor to make rounds the next day.
Let's do a flashback and follow “a day and night in the life of a postoperative patient,” remembering that this was an elective procedure in an otherwise healthy adult.
When returning from the operating room, our awake, but tired patient is transferred to his bed. The P.C.A. is connected, turned on, and recovery begins. If this was the first case of the day, generally the recovery process begins approximately 11 a.m. to 12 noon.
The first team arrives to apply the automatic blood pressure cuff. This inflates noisily approximately every 15 to 20 minutes.
Fifteen minutes later the IV runs dry and an alarm sounds, followed by a nurse sauntering in to change the solution. The patient begins to drift off, attempting to benefit from that pain-free period of time while the spinal is disappearing. The apnea team arrives; since there is a continuous morphine drip, it is necessary to apply electrodes to the chest for monitoring. This is tested and that team disappears.
The patient finally dozes off, only to be quickly awakened as the apnea meter goes off because they failed to set the lower limit of the pulse rate. The meter reads this as “bradycardia” but indeed it is merely the manifestation of the patient's slow heart rate from his level of fitness.
The meter is adjusted. Before the patient can drift off again, an inspirometer is brought in and he is instructed on how to use it. Sleep again arrives, but the apnea nurse sneaks in and tries to unobtrusively place a pulse oximeter on his finger. Because he has only a 92 saturation (he had been in a deep sleep for a short period of time), she admonishes him to take deep breaths.
Physicians Assistance students arrive with instructions to take a history and physical for the internist who was covering the case. They awaken the patient fully so they can take a complete history and do a physical.
Throughout the afternoon and the evening a continuous marching band parades through the room. It is composed of the “visitation volunteer” (designed to help lonely people feel good), a snack lady, a flower delivery person, plus assorted people doing vital signs and administering medications.
As night falls, the sleep-deprived patient hopes for a tranquility base. The lights shut down, and the night shift takes over. But there is a more pernicious type of “Macbeth” (he that murdereth sleep) in the environment. The staccato sounds of dry IV alarms, apnea monitors, and respirator noises punctuate the clatter of the night staff and permeate the thin door. The not-so-muted paging of nurse's aides mixed with frequent vital sign monitoring conspire to inhibit sleep.
So the next morning as I appear, perky, cheery, and freshly scrubbed, there should be little wonder why a flying bedpan may be the response to “Did you have a good night?”
Although we all realize there is an imperative to many of the intrusions occurring during the first several days of hospitalization, we often forget that many of these incursions are done for the convenience of the staff and not the comfort of the patient.
Modern hospitals do best managing the postoperative patient in the categories of pain control, mobilization, and medication recovery. As you may have guessed, I am talking first-hand of these experiences and realize that the hospital is not a good place to recover. For the patient there is nothing like the home bed, home TV, home cooking and the healing and salubrious effects of rest and a tranquility base.
