Saturday, June 22, 2013

You didn't do that right

Recently, I had the opportunity to get a warm blanket for an elderly patient. It turns out that there is a skill to giving a patient a warm blanket, not much of a skill, but enough that if you haven't mastered the skill and you perform the task, the patient will know.

Here are the key pieces: patients who ask for blankets are cold. Patients who ask for warm blankets are especially cold. The rate at which two objects tend towards each other's temperature is proportional to the difference in their temperatures, i.e., the warmer the blanket, the faster it cools down.

Here's how to do it ideally. Get your blanket(s) from the warmer. Do not unfold. Put the part of the blanket that has been on the shelf against your front. Wrap the rest up in a non-warmed blanket (only necessary if you have to walk to a different until as I did). Hurry back. Put the blanket down taking care to wrap up the side that had been against you with the loose end of the non-warmed blanket (extra blanket will not be there if the warmer is on your unit). Pull all the blankets off the patient and to the bottom of the bed--below the patient's feet. Be sure that several are untangled so that they can just be pulled straight up when you're ready. Leave a sheet on the patient. Unfold the blanket and put it on the patient, unfold the other blanket and put it on, then pull up the other blankets to insulate the warm blanket from the cold air. These steps must be done quickly or the blanket will lose its heat before it gets to the patient.

This particular patient had never had a skilled practitioner of warm blanket before and really appreciated my efforts.

As I thought about this patient, I realized that there was one nurse in Lebanon that I had who did not know how to do warm blankets. It's such a simple skill that really anyone who is reasonably dexterous can manage it. What she did wrong was unfold the blanket, then pull the old blankets down. This allows most of the heated blanket's heat to escape before it gets to the patient. I even said to her, "don't unfold the blanket until the old ones are off" as I was frantically trying to untangle them and get ready to accept the new one. As predicted, the warmed blanket was cold. I did not ask her for another warm blanket. I didn't ask for two reasons that I can identify: 1. I didn't get a warm blanket so why ask for something they won't give you 2. she did not listen to me when I told her how I like it done so I didn't really want to interact with her anyway. Remember, I speak the same language as the nurse, am articulate, hear well, am a doctor and still chose just to wait for the next shift rather than risk a repeat of that interaction.

When I think about our patients who won't "participate" but are still insisting on full treatment so doctors and nurses get mad at them and tell them they're not being consistent or making sense and roll our eyes when we're talking about them in the doctor rooms and then it turns out that they won't do PT because they therapist puts their prosthetic leg on in a way that has led to injury in the past and they told the therapist but they didn't listen and the doctor was too busy and the nurse never asked so they just feel like why should they bother trying to explain to us and the next thing you know people are saying what a difficult patient they are. My issue was just a stupid warm blanket, the consequences of a nurse getting it wrong are that I'm colder than I needed to be. Things not going well for some of our fragile patients could mean a non-healing stump wound or falling. I can see why one might become inconsistent and difficult.

My nice elderly woman was very happy with her warm blanket. I told her I couldn't cure her cancer, but I could help her get warm.

I am grateful for the warm blankets in my life, both literal and figurative. I hope I can always be warm.

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