Monday, June 11, 2012

Bad Doctors & Bitchy Nurses


           Nursing has a kind of collective intelligence. Like the beehive or ant mound a nursing station is aware and competent to deal with problems that the individual nurse may not even know exist. Unlike the independence of medicine in which each doctor is a law unto him or herself, nurses are always watching each other, commenting, suggesting—for good or bad. Because it’s still a profession largely made up of women there’s a lot of talk on a nursing unit and not all of it is helpful, but regarding the patient the differences in opinion often average out and a plan of action is chosen either explicitly or implicitly.
            When dealing with a bad doctor however—a physician who may not know what he or she is doing—the group can be a long time coming to a decision. At first there’s just a single nurse, or one or two nurses who have that feeling that “something’s not right.” And in between the time that the individual becomes aware and the group takes action sometimes the patient dies.
            The patient who died in this case was named Frankie, an African-American woman about fifty years old, with long fake pink fingernails and a difficult personality. Being African-American myself, my habit is always to keep an eye on black patients even if they are not assigned to me because in a healthcare system that is almost exclusively run by white people and in which minorities and the poor have traditionally been used as training cases for white doctors, blacks may be suspicious and resentful when in the hospital and therefore benefit from a little extra TLC. Frankie wasn’t suspicious enough—if she had been, she might still be alive. She trusted the doctor, she just didn’t want to be in the hospital, an attitude that showed surprisingly good sense. She was resentful, yes, but mostly about life, it seemed to me, and although she was not my patient she was my concern as a fellow black person in the white healthcare world.
            Frankie was in the hospital to have a tumor removed from her pituitary gland. If you’re interested in the functions of the pituitary gland—look it up, because to take care of someone with her condition, post surgery, a nurse doesn’t necessarily need to know the details, doesn’t need to know the physiology. “RN” is a generic title and unlike medicine, once you’re a registered nurse you can work anywhere, in any field. You’ll need to be oriented—to obstetrics, for example, or the emergency room certainly—but that training will only last weeks, at most a few months, and then you’re theoretically competent, because you’re mostly dealing with set procedures and watching for or controlling symptoms and you don’t really need to know that much about what’s going on inside, under the hood, the pathology, under the skin. The doctor is doing that. You hope.
            Still, some knowledge about pituitary tumors is helpful for purposes of understanding what happened to Frankie. The pituitary, at the base of the brain, is called the “master gland” because it secretes hormones that control bodily functions and control other glands that secrete other hormones. For the surgery, they go in through the nose. After the operation, the nurse is drawing blood and checking the dilution of urine to see if it’s been successful. Don’t ask me any more. That’s all anyone had told me—except, like in every other kind of surgery, there are possible complications. The most common unwanted outcome, according to my limited knowledge, is a leak of cerebral spinal fluid. If clear liquid starts dripping out of the patient’s nose, you have a problem. But that’s all you need to know here. So, Frankie had her surgery and was in and out of the hospital in two days. She didn’t like being there and if you were her nurse you didn’t particularly like having her as a patient but luckily for everybody, including Frankie, she was soon gone.
            Not for long. A couple of days later, as my shift began, the charge nurse told me to set up a tray of instruments for the placement of a lumbar drain in one of the rooms. The lumbar drain is what’s used to repair a cerebral spinal fluid leak.
           The patient this time—once again—was Frankie who was “back in the house,” in the hospital, lying on her side in a room, her hospital gown hiked up to reveal her backside and an impatient but pretty nice neurosurgery fellow gloved and waiting for me to assist. Three meds were needed: Versed to put Frankie in a state of “conscious sedation” where you’re not asleep but you (hopefully) won’t remember what happened; Fentanyl for generalized pain and lidocaine to deaden the place on her back where the big needle was about to enter the skin. My first job in nursing had been in a pediatric emergency room so this was nothing new. Every baby with a fever of unknown origin who came into the emergency room got a spinal tap, that needle in the back to get a sample of cerebral spinal fluid. My job was to bend the baby in two, so that the head approached the feet, to open the spaces between the vertebrae so the needle can enter easily. It looks pretty barbaric and probably is. Like a hundred years from now people will be viewing the videos with an expression on their faces that mimics what we would show today if doctors were still bleeding patients or reciting chants at bedside. Barbaric. The docs say a spinal tap looks worse than it is and that newborns who have a memory span of like two minutes max, forget the pain immediately afterward and that may be true. But they’re screaming their little heads off when you’re bending them and when the needle is going in, no doubt. Parents are “anxious,” to put it politely, and ask to stay in the room to provide support to their munchkin. Frankie was all alone.
            Luckily she was semi out of it, half-drugged and half-awake, she was somehow holding her lower back bent to expose the openings between the vertebrae, the doc missed the first couple of times and even with the pain medicine the patient was moaning in the fog. The solution to that problem was to give her more meds, which we did, but you had to be careful, checking her blood pressure and her breathing the whole time because she was getting a drug cocktail and different people react differently, in the calculus of drug administration, in a situation like that, two milligrams of a narcotic and two milligrams of a sedative add up to more than four milligrams. If my memory is correct, she had to get a little extra oxygen but the fellow eventually got the drain in.
                 My question was why they put a drain in her back if she was leaking spinal fluid from her nose? His explanation—this may sound like Brain Surgery for Dummies, an oversimplified view, but it worked for me—was that cerebro-spinal fluid circulating around the brain and along the spinal cord, was drained off down low to stop it from leaking out the nose and to give wherever the tear was, up in her head, a chance to heal without the constant drip drip drip. Who knows? It sounded kind of cool though—logical, you know, the way doctors explain something to the public, even to nurses? Besides, a RN doesn’t have to know why to do something, only how to do it or how to take care of the patient after it’s been done. Or how to recognize complications. So, like, the explanation fit all my conditions for compliance, and the neurosurgery fellow maintained sterility and was attentive to the patient, so like what was there to object to and would he have really given a shit even if there had been an objection from the nurse? Probably, yes, he would have, because his head had not yet gotten too big. Which is what this is all about.
            A nurse can stop a procedure if the patient is not being protected but it takes a pretty large pair to do that. Most of the time we just watch, we do what we’re asked to do and keep our mouths shut—until after the procedure, in the break room, talking trash, we might say something like “I wouldn’t let him clip my toenails!” or somebody goes off on the doctor for a wide variety of reasons that may actually have nothing to do with his surgical skill.
           

            The lumbar drain is a pain for everybody involved. For the patient it means a couple of days of bed rest, only able to get up to go to the bathroom and sometimes not even that. For the nurse it means going into the room every hour and checking the flow of fluid into the drainage bag to make sure it’s not too little or too much and checking the site to make sure there’s no infection. Frankie went through a couple of days of hell and went home again.
            Then she came back for another leak and had to have another drain placed. And then there was another leak after that—if my memory is correct.
            The last time she wasn’t my patient but something took me into her room, probably just covering for her nurse who was on dinner break or taking a pee or whatever. Frankie’s complications had been going on for a while, a few weeks, at that point. We—her and me—we’d never really gotten into a discussion about what had led her to have the surgery in the first place, how bad her symptoms were, what grade of tumor it was, because pituitary tumors, in the ranking of bad shit that can happen to you are not nearly the worst. This was somewhere between an elective surgery and a major surgery. My feeling was if she had the choice to make again, to have surgery or not to have surgery, guess what she would've decided?
            In her hospital room that last time we met there was no longer a drain but she was pretty much still out of it: sleeping all the time, not really eating, not refusing to take meds but taking them listlessly, without interest, you could have told her you were giving her anthrax capsules she just didn’t care anymore, lying there in a pretty summer dress that she had refused to trade for a hospital gown. No one visited her, she had no support network, no money, apparently no job, the hospital didn't turn anyone away. Well, maybe that’s not right—someone did call the nurse’s station once about her, during my shift. A friend. And since our interaction was only on night shift, maybe during the day someone did come to see her. And her bank account—well, that’s just a guess, she could have been a millionaire but don’t bet on it. In any case, that was it. She died a little while later. Can’t remember if it was in the ICU or the ER or at home. But one day somebody told me she was dead and it was clear to me what had killed her. She just got tired and gave up.
            The details escape me because we had a lot of deaths on the unit at that time. One of my sister African-American nurses who was about Frankie’s age was feeling bad one night: a diabetic and a smoker, working a lot of extra shifts at night to keep her family afloat which, in retrospect, seemed like a pretty lethal combination.
            So she went down to the ER on her shift and she was admitted to the hospital for testing and during the scans they found her insides full of cancer. She only lasted a few weeks—never left the hospital she worked in, she came in for a night shift and that was it. Another former nurse from the same unit died of a brain tumor in a room down the hall. Then an important anesthesiologist from another hospital came in with an advanced tumor and it was something to see because our staff neurologist, instead of ordering this and that, instead of trying this and that, and despite the wishes of the family who wanted everything done—the neurologist said no way, this is simply not survivable, and we will treat him—even though he is an important physician—we will treat him like anyone else and that means comfort care only.
            Another lady who had been my patient, we’d spent a rocky night together a few weeks before, not entirely her fault either—died too. She was in her seventies, had some kind of spinal tumor or messed up vertebrae, can’t remember which, and was diabetic, and she was my patient pre-operatively like the night before she got cut. She had mild Alzheimer’s or something missing from the attic and she had eaten dinner and forgotten she had eaten dinner and insisted despite my best efforts to convince her otherwise on ordering and eating a whole second dinner so that when we checked her blood sugar later that night it was in the ozone and she had to get enough insulin to put Charlie and the chocolate factory out of business. The surgery was a success, as they say, but the wound got infected—uncontrolled diabetes can do that, so they tell me, make wounds hard to heal—and she was getting all these antibiotics which didn’t help, and finally she just said to the docs that she was tired and wanted to be let go, she was tired like Frankie, may she rest in peace, not let go from the hospital but let go from life. That’s what the doctors did. They let her go. A couple of nights later another nurse called me into a room to help with a body and it was the same old lady. We zipped her up to roll her over to the morgue. Two more nurses came in. Everybody treated her very gently. Made me feel really guilty about our fight over that second dinner. As it turned out she didn’t have many more meals to go, right? She should have ordered the pie and ice cream while she had a chance.
            This isn’t about me. Nursing is about the patient not the RN, unlike medicine which is very often about the doctor. But, not to get weepy or anything, it wasn’t a good time for my career in the healing arts. Most of my prior experience had been in pediatrics and in pediatrics the patients don’t die so much. That may not sound scientific but it’s true. Unless you’re working on a cancer ward, kids are more resilient. They live to get sick another day. In contrast, the unit where Frankie died, most of the patients were middle-aged, at least, and had thirty or forty years of bad habits that make ordinary complications worse. One day the bill just comes due and you have to pay for the cigarettes and the booze, the fast food and fornication, Frankie was a smoker too and it may not have killed her but it definitely didn’t help. So, it was a confusing time for me. Didn’t much like the job—didn’t like working with adults—and certainly didn’t like them dying, especially not on my watch. Luckily, most people seemed to pass away on day shift.
            Still it was depressing like you wouldn’t believe. You felt, a lot of the time, like saying to the patient, “Excuse me, if you aren’t going to take that Valium, do you mind if I do?”
            But one thing that you couldn’t help but notice in the fog that was then my life as a RN was that on my unit we seemed suddenly to have a lot of these fuckin' lumbar drains and most of them traced back to surgeries by the same physician.

           
            There are only two kinds of doctors.
            Wrong, you say.
            There are surgeons and internists, pediatricians and clinicians who only take care of older adults—intensive care docs, cardiologists, emergency medicine, obstetricians.
            Infectious disease guys. And girls.
            Orthopedists. Ophthalmologists. Space medicine—sports medicine—psychiatristry, neonatalogy. Pathology. Many, many kinds of MD, right?
             Wrong.
            To a nurse, there are only two kinds of doctors. And you’ll know almost immediately when you interact with them which kind they are: if they are the kind of physician who listens to nurses, or the kind who doesn’t.
            The kind who do listen to nurses can be praised and set aside to discuss another day. Those who don’t listen are the subject for today. This group can be further subdivided into those who know exactly what they’re doing at every minute of the day and night and those who don’t have complete God-like supreme knowledge.
            Speaking of the first subgroup, it’s been my pleasure to know only one doctor who fit in that particular box, who knew exactly what he was doing at all times. He was a neurosurgeon at my first hospital and his example is instructive because you don’t see docs like him often. An example of his omniscience—because it’s important to get a feel for the good and the bad—especially among surgeons: One night the hospital pharmacist called me, there was trouble with one of this all-knowing doc’s medication orders.
            So, we had a patient belonging to this neurosurgeon and the patient, who was prone to violent seizures, had been prescribed an amount of anti-seizure medication that was higher than the recommended dose. Like twice as much. Medication errors kill a lot of patients and although we wanted this guy, the patient, down for the night, and not seizing, we didn’t want him out permanently, as in brain-dead or not breathing. So the task fell to me to call the doctor. This particular surgeon was not on call that night, so his partner answered the page and listened carefully to my concern about over-medication. He ordered the dose cut. We went about our work, me and the pharmacist, crisis averted, our asses covered for the shift or so we thought.
            The next night, the all-knowing neurosurgeon himself came to the nurse’s station and asked who had called his service the night before about Patient X. There was nowhere to run. So, for like the next ten minutes he ragged me in front of the nurse’s station, bent me over like his bitch, all the other RNs, residents, even the house supervisor came to watch: Why had his order been questioned? Well, sir, the pharmacist said the dose was too large. “The pharmacist? The pharmacist said? Is the pharmacist going to come and run the code if the patient goes into status [epilepticus, that is protracted seizures]?” Actually, the pharmacist was this really hot Vietnamese chick named Wendy who, in my juvenile imagination, was capable of many wonderful healing acts but probably not running the code if this patient went into status epilepticus. So, the answer was no. Score one for the doctor.
            “Will the pharmacist be doing the surgery on this patient?” No sir, again. “Are you going to do the surgery to ablate—” that is, burn away whatever the site was of the abnormal electrical activity in the brain that was causing the seizures? No sir, that would not be me.
            He went on for a while. Like anything else in life an ass-chewing at the nurse’s station has a rhythm and timing and you just have to let yourself go, become one with the abuse and the abuser, nodding at appropriate times—yes sir, no sir, you’re completely right, sir or ma'am—a glance or two at the clock on the wall to remind the physician of his busy schedule, with the sure and perfect knowledge that the doctor is going to run out of electricity in a moment or two and you can give Ms. Johnson, in Bed 712, who you can hear screaming across the unit, her long-overdue pain medication.
            But the thing about this guy, this neurosurgeon? He was right. He knew what he wanted, a high dose in this case, and he wanted his orders followed not because he was on a power trip but precisely because he wasn’t. That same surgeon who chewed my ass had been the first doctor to show an interest in me as a nurse, coming into the room during my care of one of his patients, like my second day in the house, nursing diploma in my back pocket with my stethoscope. He reminded me to get the patient up in a chair that day, so that Patient Y could sit up in the sun for a while, and then came by later to make sure that it was done. Which it hadn’t—for a variety of good reasons—none of which need to be explored here. This guy, the doc, was a senior surgeon and he took time out of his schedule to check back in to make sure the nursing staff (me) got his patient up to sit in the sunshine? Imagine. Some of his meticulousness was dictated by practicalities: he told me once that his yearly malpractice insurance premium was $100,000, and this was Texas, one of the most litigious states in the Union, so he was guaranteed to get sued. So when he ragged me in front of the nurse’s station that was actually cool with me. He knew what he was doing and the pharmacist and me had been just as worried about our licenses as the patient’s needs. But most of the doctors who rag nurses don’t have their act together like this guy did. So to my eyes he was the sort of the standard for ragging nurses and for care by a physician.
            Not all of the tension between doctors and nurses can be attributed to bullying and arrogance on the part of the doc. Much of the problem is that nurses get into a passive-aggressive mode with each other and with the physician. There's a big education and income gulf between the two, a class difference that plays itself out very often in petty behavior by nurses which doesn’t mix well with overbearing MDs. There’s also the lingering gender divide from the days in which nurses were all female and the doctors were mostly male, that has changed of course, now the majority of admissions to medical school in this country are women, and men are trying to make inroads into nursing, but not much has changed, really, because male RNs can be bitchy and jealous just like women, and female doctors can be bull-headed and self-delusional just like guys. In this high-tech age of smart drugs and gene therapies and laser surgeries, one of the great unresolved issues of healthcare is how for the nurse to bring something to the attention of a physician. And something they still don’t teach in med school is how for a physician to listen to a nurse.
            This is what they taught me in nursing school not too long ago: Say you see something wrong with little Bobby in Room 513 down the hall. First you call the intern and if he or she blows you off or if you’re still worried after speaking with him/her, you call the second-year resident, and if you still don’t like the answer you call the third-year, and if he says he’s busy, which he is, because the residents are always busy, and by now inter-professional relations are starting to fray and if you’re old-school, not literally but you were taught to be old school—from the days when doctors threw coffee cups at nurses and got away with it, which the nursing instructors, who really are old school, average age in their fifties, haven’t forgotten, believe me—or you’re just a little resentful of that little pediatric resident prick, or bitch, and this is the last time before they finish their residency that you’ll have a chance to make their lives hell, maybe you tell the third-year to get his butt down here and see the freaking patient or else you’re goina call the attending physician at home. Get the message? Sometimes there doesn’t even have to be that kind of bad blood for things to get nasty. As a new nurse my first calls to a surgeon at home, for whatever reason, bad karma you could call it, always seemed to be something minor that still needed to be addressed by the doctor, a low-grade fever, for example, or more pain meds, and the calls were always made at one-thirty in the morning, and from the heavy breathing on the other end of the line you knew right away what extracurricular activity you had just interrupted the surgeon in the middle of. He had been operating, yeah. Next day he comes in and looks at you like you’re a fool and asks couldn’t you write a Tylenol order yourself? And you could, but writing the medication order you know the doctor is going to write himself, if you ask him, seems like a slippery slope. You pick up the phone instead and interrupt his quality time with little Debbie, who may even work with you on the unit.
            So, there’s, like, a lot going on, behind the scenes and in front of the camera. Every call you make, every question you ask, can be interpreted as questioning somebody’s intellect or ability. God forbid that you say something in front of the patient. That really is wrong. Just a while ago, also in Texas, a physician who was accused of bad practice by a couple of nurses had the nurses arrested and charged. What do they call that at the Supreme Court? A chilling effect, that's right. You bet your ass—but more than that—when you question the doctor you bet your license to practice nursing. You bet your paycheck.
           You bet your livelihood.




            My personal suspicions concerning the surgeon who had operated on Frankie began one night, a month or two after she was gone. Another nurse called for the rapid response team on a patient who was showing signs of a blood clot or bleed in the brain. He was beginning to stroke out, yeah, but luckily for him the night was still young.
            Rapid response is a wonderful invention just short of a full code (when everybody runs around and beats on the patient’s chest or zaps him/her with electricity) that can be called anytime a nurse is uneasy. The patient doesn’t look right, not responding as they were a few minutes ago, labored breathing—whatever—you’re never wrong if you call. Suddenly everybody shows up like with a code, ER docs, senior nurses, respiratory therapy, the house supervisor, they all get together with the nurse who has the patient and everybody tries to problem solve, to decide if something needs to be done, transfer to another unit or surgery, a trip to MRI or CAT scan. Everybody just gets a look at the patient in case a full code really does have to be called later. It’s a great system that saves a lot of lives.
            So, after the rapid response that night, the docs were gone and the nurses were standing around in the hallway chatting and somehow the number of lumbar drain patients on the unit became a topic of conversation. There were three or four drains and at least two of them were patients who had been operated on by the doctor who did Frankie’s surgery. There was some clucking about that. "Does he know what he’s doing?" The charge nurse mentioned that this particular surgeon was very well-known in his field and he probably operated on more difficult cases, which might explain the number of complications, he was doing the hard ones. So the surgeon had his defenders. The house nursing supervisor, who had been a nurse for quite a while, mentioned that when she was in school and coming to this same unit for her clinical practice, an unspecified number of years previously, that same surgeon was already working here. That raised the obvious possibilty: Was he too old? That became the unspoken question. We all started clucking again. Completely unscientific, yeah, but that’s how the system works. Eventually, after enough un-informed discussion, the subject dropped again, until more drains or more complications arose, and someone suggested that maybe the issue should be brought to the unit’s nurse manager.
            Part of our reaction may have actually been personal. The surgeon in question was pretty much a dickhead. If you think something like personality or bedside manner doesn’t matter, you’ve never spent time on a nursing unit. This guy would do a handful of surgeries back to back every week or so and we had his standing orders on how to care for his patients, what labs he wanted drawn for example, and he would show up at six in the morning to see how the post-ops were doing. He never talked to the nurses, even the older ones who had been there a while.
            He didn’t have to stand at the nurse’s station to review the labs because he had computer access at home and saw the labs before he ever came in. So there was no interaction with us. If somebody tried to talk to him about Mrs. Johnson’s dilute urine he would just keep walking. He never brought brownies or candy at Christmastime—nurses are aware of that shit, believe me. So he was nobody’s favorite on the unit. It could have been personal and probably was. But there was still the matter of those lumbar drains that kept appearing. Something didn’t seem right.
            Then something happened—completely unscientific again—that raised my “index of suspicion,” as the diagnosticians say, even higher.




            There was a big supermarket near the hospital, complete with Starbuck’s and bakery where it was my routine after work, bleary-eyed and strung out from twelve hours of mostly-night work, to go and buy a bagel. One morning Frankie’s surgeon was there too, walking along a grocery aisle—and this sounds totally unscientific—but he looked disoriented.
            All the boxes of breakfast cereal on either side of him, this fifty-five or sixty-year-old guy, eyes bleary like mine, a pathetic figure looking like he didn’t know if he was coming or going. Problem was he wasn't just coming off shift. He didn't operate at night. Not only was my index of suspicion raised, my mind was made up. He was dangerous. Cocoa puffs or corn flakes and he looked like he not only couldn’t make up his mind but that the question itself involved relativisitic math. Worse. He just looked like he was past it, like a cop who can’t chase suspects anymore, or a salesman who can’t do cold calls anymore—a reporter who can’t dig anymore and who just rewrites other people’s copy.
            You see the same thing on the faces of nurses who have been at it too long, who need to retire, who mistake the digoxin for the diprovan and it’s just a matter of time until they kill somebody. You see it eventually on most people’s faces who are involved in stressful work. Maybe someone is already seeing it on mine. But with doctors you can’t say anything. Nor, in this case, was it my place to say anything because nothing had happened to any of my patients. But seeing him on the corn flake aisle, in the cruel first light of day, it was clear: he needed to spend more time teaching, telling people how to do it instead of doing it himself, or just get on his sailboat and float away. That was my feeling but there was no one to tell. You could bitch at the nurse’s station, or turn the incident about confusion among the breakfast cereals into a story for the break room, or the bar after work, but there was no real mechanism for sounding an alarm.
            Until a few weeks later, the end of my time at the hospital.
            My experience in the world of adult healthcare was coming to an end and none-to-soon, at a point in time when it was still my decision to make and not, for example, my clinical manager’s. Two years was long enough, thank you very much. Being on the rag all the time—being unhappy with the patient population—had left me just a step away from being an asshole with my coworkers, which was a point for me that was never that far away to begin with but that was suddenly too too close. Time to move on. That night though there was another of the pituitary tumor surgeries, the same surgeon, and like before the patient was doing well at first, the night after the surgery, they might even let her go home the next day. Then she called me into the room, a pretty young chick with her son or little brother staying with her on a cot next to her bed.
            Said she had gotten up to go to the bathroom and something started dripping out of her nose.
            You don’t want something bad to happen at night because your reactions are slower than during the day. It’s harder to recognize complications and if it requires action you’re usually slower doing what needs to be done. Luckily this complication was apparent and, for once, my patient load was reasonable and so we did it by the textbook. Told her not to get out of bed again . . . called and got an order for labs . . . called and told the internist on duty to come and check her out. Her neuro reactions were intact—the patient was scared more than anything else. The internist saw her and put her on bedrest, which didn’t quite reassure the patient because she got frightened with attention the same way she would have gotten frightened if no one was paying attention. The neurosurgery fellow on duty that night happened to be nearby seeing another patient and he went in to see her too. Ordered IV fluids and nothing-by-mouth, in preparation for surgery in the morning. Or—you guessed it—if they had to do a lumbar drain. Which they did. My mind was made up. A couple of days later was my exit interview with my manager and something needed to be said.




            Janie, who would be interviewing me and telling me goodbye, was my favorite supervisor. The best supervisor ever, in my modest opinion. She was a former ICU nurse, no nonsense, no favorites, no moodiness—the only thing important to her was whether you were taking care of the patients to her expectations or not. Nice but serious—serious all the time, which is cool because you always knew what to expect.
            Some nights she would get dressed in scrubs and come in and hang out and see how the shift team worked together, something none of my other managers had ever done before. My first day on the unit with her had actually not gone well. My patient assignment included this lady with messed up anatomy in one room, who needed to be catheterized because she was unable to pee on her own. The patient was talking me through the procedure, guiding me among her extraordinary body parts when two calls came in back to back about another of my patients, the lady in room 512 who had come in from an assisted living center with some kind of pseudo-stroke. The lady in 512 was on a cardiac monitor and the monitor, which actually was downstairs on the cardiac floor, showed she had gone into a low-degree heart block and a nurse from downstairs had informed me per protocol. We were cool so far. Next minute there was a call from the physician at the assisted living center telling me that what had actually happened was not a stroke but that they had mistakenly given this lady another resident’s daily medication. So, in the room, she was completely out of it and then her blood pressure started to drop. Rapid response. She wasn’t in bad trouble yet but she was headed that way and the idea was to get her problems dealt with before she crashed.
            Suddenly, after the rapid response call went out overhead, the room was filled with nurses and doctors and they listened to my explanation of what had happened, that she wasn’t really a stroke victim but a potential poisoning, with heart problems, so she needed to be watched closely and, frankly, not on a brain surgery unit.
           Then there was this sound of heels clicking down the hallway and it was Janie, the unit manager, she had heard the rapid response call overhead and she came into the room and someone said to her straight off, “She got the wrong patient’s meds,” and Janie, who doesn’t panic, but can show attitude, was about to show attitude, and said, “Well, I hope not in this hospital,” looking at me, meaning it better not have been my medication error, not on my first shift, and someone explained to her, no, at the nursing home, and Janie kind of relaxed, and got into her rapid response mode, problem-solving. The obvious solution was to get the patient out of neurosurgery. The doctors ordered her sent to a medicine-cardiac unit where they could deal with the wrong meds she had been given and watch her heart. Later, Janie came up to me in the medication room and listened to my apology for calling rapid response on a situation that might have been dealt with more calmly. But we were really busy and tracking down a doctor to write an order and getting a transfer done takes time, which no one had to devote to this lady, and rapid response cuts through all the usual hospital bullshit, especially if you’re not sure where the patient is headed, as in downhill or not, when you don’t know if the patient is really crashing or what. “You’re never wrong to call rapid response,” Janie said, something every nurse knows, but sometimes you need to hear your boss tell you nonetheless. After that, Janie was my hero.
            The first part of the exit interview was spent with me ragging the charge nurse from day shift, who had many faults, the biggest of which was that she was a stone cold bitch. It’s a nursing unit, what can you say? Bitchiness goes with the territory but that shit can be wrong, especially if it’s done at seven shift change with people who want to go home and solely because you have the power to do it.
            The good part was that everything was said in the charge nurse’s presence, with her having a chance to respond to every word, which made it professional, not gossip, which it would have been if it had been said behind her back. Janie and the assistant unit manger both listened calmly, watching the charge nurse sweat and letting me have my say, since, like my connection to the unit was history anyhow. Another nurse told me later that she walked by the room and heard me going off, which made me proud. Confrontation is not necessarily a bad thing if it's a controlled environment, you know?
            Then it was time to say what needed to be said about Frankie’s surgeon.
            Janie stopped me in mid-sentence.
            “It’s being tracked,” she said. And that was the end of the discussion.
            Janie was no fool. She kept her ear to the rails of the unit, in meetings just like this, and obviously someone had mentioned a concern already. A consensus had formed: not that the surgeon was fucking up, no one could say that yet, if ever, but that his number of complications needed to be reviewed. This was a decision that probably not even Janie could have made on her own. She, like me, was only a nurse and the surgeon involved was a very powerful and well-respected individual in the hospital hierarchy. He was better educated than either of us, or both of us combined. He also knew more about pituitary tumors and pituitary tumor surgery than we would ever know. Janie couldn’t have made the decision on her own. She would have probably taken it to the hospital’s chief executive, or practice committee, or whoever, to get permission to do the review of cases.
            Who knows how it turned out? Not me, motherfucker. That was my last time on the unit. The physician may have been okay after all, may simply have been what the charge nurse had suggested one night: he was famous and he took the tougher cases that had worse outcomes.
            Or maybe he really did fail the breakfast cereal test.
            The real issue is that there’s no way for a nurse, or even a family member, to question a doctor. Doctors are taught that omniscience shit, which allows them to deal with life and death issues the way other people don’t. When it comes down to it they have to make life and death decisions and sometimes they aren’t omniscient they’re just human. And you have to be able to question their performance without burying someone first.
            If not, you can end up like Frankie. You just don’t care anymore, or you’re dead, or both. 

1 comment:

  1. I'm not sure when this whole thing happened, but every hospital should have a quality and safety department. I think it's great you voiced your concerns to your manager, but it's ALWAYS ok at anytime to voice concerns to a quality and safety department because they can then alert the chief of the department or whomever else to start paying attention if they haven't already.

    On to doctors vs. nurses... Now that I've finished medical school and 4 years into my residency, I've learned a lot, mostly about teamwork.

    In my residency, we are required to do a team-building course which includes the nurses and technicians in the department. I WISH we had done that in medical school with the nursing and technical student and pharmacy students, etc.

    It was amazing and our department functions really well with hardly any cattiness because we learned how to speak to each other respectfully and we ALSO learned how to speak to each in front of patients.

    I hope this catches on, but at the very least I'll bring it with me wherever I end up practicing.

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