A Little Nurse Bashing to Start Your Day

For breakfast, how about some outrageous libel from physician-blogger Terry Simpson (Twitter: @DocSimpson). File this under how not to blog about a serious issue in health care:

The Arizona State Nursing board has asked that this nurse [Amanda Trujillo] undergo a psychiatric evaluation.  The board is charged with protecting the public. The public needs to be protected from “angels of death,” and needs to know if this is the act of an illiterate nurse, or someone who will tend to rogue behavior beyond the bounds of the profession.

Screen shot of yourdoctorsorders.com. Note the gratuitous "psychiatric evaluation" reference.

Note to Terry: I’m not quite clear on how likening a nurse to a mass murderer is not libellous. Or a constructive contribution to an important debate on patient autonomy and nursing practice.* Can you elaborate?

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*Because I think you do raise some issues in your post worthy of debate and discussion — though I might strenuously disagree. You seem to want a serious conversation, but you end up being an ass. Too bad.

“Monkey, Monkey”

[A rerun while I’m away. Originally posted 17/10/2009.]

The Observation Room.  Eight beds, separated by curtains, which gives the illusion of privacy, but of course any conversation can be heard clear across the room.  My colleague Karla is in Bed 5 helping a patient on the pan; I’m next door in 6 with a 40 year-old post-op hyster who’s come in with wound dehiscence.  She has a very doting family, who have supplied flowers, chocolates and also very cute stuffed monkey, which the patient has placed by her pillow.

Dr. Jove, her surgeon and generally a lovely man, comes bustling in, all bluff good cheer and exuding a well-fed happiness and concern.

Do you want the family to leave so you can examine the patient? I ask.

Oh, no, says Dr. Jove. Not to worry. I’ll tent, I’ll tent.  By which he means he will examine at the patient by making a tent of the blankets, and looking underneath. Voila! Patient modesty is preserved and the family can feel like it’s part of the health care team.

And so, like a magician, Dr. Jove makes a tent, and examines (from the bottom up) the patient, sighing and making tsk-tsk noises.

He looks up at the patient.

“Nice monkey,” he says, meaning the stuffed animal.

A pause, then a small, plaintive voice from the other side of the curtain. Karla has been listening.

“He didn’t really call it a monkey, did he?”

Irrefutable Evidence Dr. Weanus is Human

Dr. Weanus is old friends with Dr. Sendemtoemerg, the GP, having roomed with him as undergraduates at the University of Toronto. When Sendemtoemerg asks for his help in getting a patient admitted not having privileges himself (and therefore by-passing all that pesky business of being seen by Emergency) Weanus is ready, even eager to oblige. The patient, in fact, is not really that sick, having had influenza; she’s a touch dehydrated, and maybe needs an IV. More importantly to this narrative, she plays golf with Sendemtoemerg’s wife.

No problem, says Dr. Weanus, who believes his skill in cutting through the red taper and health care bureaucracy is legendary. Just send the poor dear to the Emerg, and I’ll admit her.

When Dr. Sendemtoemerg calls the ward clerk about this “arrangement,” the health care bureaucracy, i.e. me, is singularly not very impressed by this attempted end-run around the usual procedure, especially when the ED is already filled with admitted patients. Dr. Weanus knows this care plan is highly, um, irregular, if for the simple reason if every GP sent their patients to the ED “for admission” in this way we’d be sunk. Up the creek. Dead in the water. Pick your cliché. Our role in the larger functioning of the hospital is to prevent unnecessary admissions. We’re gatekeepers. Back-door admissions short-circuit the process.

“Absolutely not,” I decree. If this patient shows up at triage, she will go through the normal ED workup.

A little while later Dr. Weanus phones me. He is intensely irritated. He rants. He raves. He threatens. Why is this patient being seen by Emerg? Why is she not in a bed, awaiting my consultation? You are doing nothing for her! She is desperately ill! And so on. Standard Dr. Weanus, all shouty, sarcastic discourse.

I yawn. I know her labs are normal, and after a courtesy IV bolus, mostly a nod to Dr. Sendemtoemerg, she will go home.

Sometime after that I’m working on the staffing and I look up to see Weanus hovering over the charge nurse desk.

“I owe you an apology,” he says. His face is red. “My behaviour on the phone was inappropriate, and what I tried to do was wrong. I’m sorry.”

To say I am gobsmacked would be an understatement. One thing to note is I had become so inured to Weanus’s outbursts that I had to actually stop and think if he was that awful. (He was.)

“If the fool would persist in his folly,” said William Blake, “he would become wise.” Is it possible Weanus is learning? He’s reflecting on his behaviour. He’s trying to be a better person. Golly, he’s human after all.

How a Resident Views Nurses at Triage

Some amusing toing-and-froing in the comments of this post at Movin’ Meat, which originally dealt with media coverage of a triage miss and the death of child as a result. NurseK, Cartoon Character and others have some fun taking their resident-beating stick to a PGY1 for ill-advisedly smacking down triage nurses. The relevant excerpt:

PGY1 said…

“A febrile child with petechiae or purpura is a medical emergency, and this is clearly one of those cases where the triage nurse missed it.” 

At the risk of drawing some hate, why are nurses responsible for determining what constitutes a medical emergency? The clinical acumen of triage nurses depends on a combination of intelligence and clinical experience, both of which vary widely among ED nurses.

Same goes for doctors, you say? Compared to medical education & residency training, nursing school is brief. Nurses don’t do residencies and are taught by other nurses. How can we expect even an excellent nurse to have clinical judgment on par with a that of a physician who has trained for years prior to entering practice?

1/14/2011 4:47 PM

[Cue beatdown music — ed.]

I won’t rehash the rebuttals for this particular piece of wisdom. NurseK et al. do a better job than I could, but I have to add that PYG1’s observation that  “nurses . . . are taught by other nurses” (O, the horror of it all!) is pretty funny too. Old nurses like me have heard physician criticism of nurses performing triage for a very long time — usually in the form of “how can they — nurses don’t have the 27 years of education that make me a great physician!” or “how can they — they’re doing what physicians are supposed to do!” or “Look at how the stupid triage nurse missed this exceedingly esoteric complaint!” In the hospital where I first practised, the Chief of Emergency Medicine* was adamant nurses could not triage because triage was tantamount to diagnosis — and nurses don’t diagnose. In any case, he said, nurses didn’t have the critical thinking skills to do it properly. This attitude reflected then, as does PGY1 comment does now, a fundamental misunderstanding of role of the triage process and underscores the archaic notion of the role of nurses as uneducated and passive tools of physician knowledge and experience. Well, plus ça change, plus c’est la même chose.

Yet I have to say, in my experience, the attitude that MDs must micromanage every element of patient care is slowly disappearing  among physicians. Occasionally you get one who appears to have slept through the lectures on collaborative practice and the critical role of nursing on the health care team, but this is increasingly rare. I actually hope PGY1 isn’t one of these and does take something away from the reaction to her comment — namely, that her view of nursing is skewered. She seems to indicate she will. She’ll be a better physician, and ultimately, her patients will be better for it as well.

[UPDATE 26/01/11: Minor word changes for clarity.]

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*Fortunately, the Ministry of Health was pretty insistent nurses fill the triage chair. This physician was also the sort who if a nurse said “renal colic”, would say “aortic aneurysm” and proceed to treat on that basis — sometimes with unfortunate results.

We’re Either Boobified or Invisible. Is There Any Hope?

So two television shows demean and devalue nurses. Is there any hope things will ever change?

First, by way of Sean Dent at My Strong Medicine, is this charming example of the naughty nurse:

[Mehmet Oz of the Dr. Oz Show] introduces Angel Williams, and she appears wearing a traditional, short-sleeved white nurses’ dress that falls just above the knee. She also wears a red belt, and carries a nurses’ cap. Despite the impressive weight loss, she has not attained a shape that most people would associate with a traditional naughty nurse model. There is no suggestion that Williams, or anyone else who appears in the segment, actually is a nurse.

Oz asks Williams how she managed to dance away that much weight. She explains that she loves dancing and just decided she would do it while cleaning, cooking, and doing a range of other daily activities. Pressed about what inspired her, she says she had reached a point in her life where she was down and out, and she needed to make some changes.

Angel:  So I did. I started dancing and moving–and watching your show. You know, you’re the doctor that gets us eating right, thinking right, thinking bright. And I decided to apply all those things to my life.

Williams and Oz thank each other. Oz says he hears she’s going to teach him. She starts quietly laughing–apparently at the very notion that he, a celebrity physician, could learn anything from her! Oz says he’s serious, that he does the show in order to learn from how people answer his questions, and from questions they ask that he would never think of asking. So he asks her again to teach him. She asks the audience to stand up and join them, then prepares to lead them in some dancing.

Angel (as she unbuttons the top of her dress to reveal a red bra):  You know, we’re gonna get sexy too, we gotta, you know, be kinda sexy with it. (Now she puts on the nurse’s cap.) Gotta get my hat goin’. So, the first move, Dr. Oz–cause we’re your nurses, we’re gonna keep America moving for you, OK?

Oz:  Oh, I love it.

[via The Truth About Nursing. But read the whole thing.]

“We’re you’re nurses.” Yes, readers, I physically cringed when I read that. But Dr. Oz is pop culture bubblegum. For real contempt for nurses, you need to go to the respectable media. Paul McLean at Medical Ethics and Me:

Missing from the documentary is what should never be missing from this dialogue — the nurse’s viewpoint. Nurses are the Waldo of “Facing Death.” Where are they? The documentary is full of poignant scenes of doctor-patient and doctor-family dialogue, always difficult and sometimes brutally honest, and shines a brilliant light on a problem that, if society doesn’t sort out, money will forceably and inequitably decide. This is the subject underlying the country’s “death panel” insanity, and kudos to Frontline for looking at it rationally and insightfully. Kudos, too, to the doctors and families who’ve put themselves on display in situations that couldn’t be more difficult. Allowing cameras at such a time took extraordinary courage, but is of such great value.

[snip]

“Facing Death” is invaluable for any med student, for its view into when “doing no harm” gets particularly tricky. And yet, for all the poignant conversation and close-ups on care, nurses are mostly blurred motion and background noise. The one nurse quoted is the daughter of a dying woman at odds with her sister, who happens to be a doctor. The nurse/sister advocates for acceptance and compassionate care; the doctor/sister wants to do what’s required to maintain the parent’s pulse.

All is revealed through narrator, doctor or patient/family. No clergy is involved. No therapist. And no nurse.

[Via Ellen Richter’s Twitter feed]

So we’re either boobified by a physician exploiting a pop culture meme to the detriment of the nursing profession, or ignored, probably by the faulty reasoning that our voices don’t count in planning patient care. I’m not sure which is worse.

It’s been obvious to nurses for a very long time that the traditional media controls the narrative about nursing. We complain about inaccurate portrayals and demeaning stereotypes nearly on a daily basis. We heap almost excessive praise when the media gets it right. My own professional organization, the Registered Nurses Association of Ontario, for example, gives out prizes to journalists for the best stories about nursing in the old media. Notice, prizes aren’t given out to nurses telling their own stories, but rather for other people — non-nurses — telling our stories. This last is important, because the whole phenomenon of Web 2.0 is changing how the media and nurses themselves are portray nursing .

I’m beginning to think nurses should worry less about how the old media depicts us and focus more on how we describe ourselves through social media. Let me put it this way: I was alerted to both the PBS Frontline show and the dancing nurses by Ellen Richter and Vern Dutton respectively via Twitter, who pointed me to Paul McLean’s and Sean Dents’s post and the original link at The Truth About Nursing. Before I wrote this post, I posted on Mehmet Oz’s Facebook wall — as did Vern Dutton — about the inappropriateness of the show (and I encourage you to do the same). And now, I’m writing my own blog post, which I will Tweet and post on my Facebook page. The point is that it’s within the power of nurses ourselves to seize the narrative and tell our stories unfiltered either by cultural biases or media expectations — or even the likes of Mehmet Oz. I know my blog, in its own small way, has influenced and educated a number of people about what nurses know and about our pivotal, essential place in health care. Multiply that by growing number of nurse-bloggers and tweeters — and suddenly the traditional media looks a little less hegemonic. Mehmet Oz and PBS (as do any number of medical dramas) still need to be called out. Their antiquated attitudes aren’t quite irrelevant. But I’m hopeful. Because we increasingly own the narrative, it’s only a matter of time until we can say to all of  ’em, “To hell with you. We don’t need you.”

Dr. Weanus on Food Groups

Dr. Weanus is nothing if he is not meticulous. Accuracy in all things is his motto, even down to the nursing notes, which he now perusing like an editor reading a third-rate novelist.

Dr. Weanus feels it is his duty to point out errors in the charting, which he likes to point out with the glee of a child finding an Easter egg. Oh look! She wrote in the chart, an official legal document, “nauseous” not “nauseated.” She used “emesis” instead of “vomitus”! Distinctions without a difference, yes, but precision must be our watchword!

And then he comes to an error so egregious he must bring it to the charge nurse for rectification.

He hands me the chart on a 55 year-old Upper GI Bleed.

He points to the offending word. “Coffee-ground.”

Let me pause here. “Coffee-ground” as in “coffee-ground emesis” refers to the appearance of a particular sort of vomitus — it literally looks like coffee-grounds. It strongly suggests gastric bleeding. More to the point, it’s been a descriptive term used by nurses and physicians alike since, well, people began to drink coffee.

So I ask, what’s wrong with “coffee-ground”?

“It means the patient is bleeding! We don’t actually know that! This is unacceptable!”

Uh, actually, no. It’s a descriptor, not a diagnosis.

I catch myself before I can fully roll my eyes. What would you call it, Dr. Weanus?

“Well-cooked ground beef!”

That’s much better. Thank you Dr. Weanus!

Dr. Weanus on Nearly Having To See a Patient

Dr. Weanus always studies his patients’ charts carefully. Who knows what clues, what tiny bit of information, suitable considered, processed and digested in his mighty brain, may produce the cure, the telling analysis, the means of improving the patient’s quality of life or, at least, a higher OHIP* fee?

Can anyone really say? So he pours over the chart, stroking his chin thoughtfully: what does the radiologist mean exactly, when he sees a slight opacity in the chest x-ray? Why it means I will have to order —

And then, alas, tragedy. He is interrupted. What brilliant thought, what insight is lost forever we can only guess — and worse, he is interrupted by a nurse!

A nurse!

“About that palliative patient in Exams you were supposed to see —”

Dr. Weanus erupts. He is incandescent. He positively glows in Outraged Physician Radiation. How dare you? he shouts. Who referred this so-called patient? I spoke to no emergency physician! This is a gross violation of procedure! I categorically refuse to see this patient!

” — she died.”

He waves a hand dismissively. “Oh, that’s all right then,” he says.

Head down, back to the chart, cheerful even.

My favourite internist.

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*OHIP: Ontario Health Insurance Plan, i.e. who pays Ontario physicians.

Dr. Eagerpants and Patient Satisfaction in the Emergency Department

My newest bête noire, Dr.Eagerpants, was working — he’s apparently has designs on the Knob of the Year Award — so I accordingly have a blindingly bad headache. Posting will be necessarily brief.

Typical conversation:

Dr Eagerpants: Snarl gnash slobber grrr snutch fritz crump fdhgisk woof woof woof?

Me: No, I am not moving the the 89 year-old, nursing home, normotensive, DNR patient in controlled atrial fibrillation to the Resus Room because the nursing home thinks she’s “real sick.”

Dr. Eagerpants: Gnarl slurp burble meow hiss frumple woof?

Me: No, the physicians do not control the Emergency Department. If you wanted to run the department, you should have become a nurse.

Oy. And so on. And He supposedly did his residency at a Big Downtown Hospital.

***         ***          ***          ***          ***

On a not unrelated note, let’s talk about patient satisfaction. Two questions:

What is patient satisfaction in the Emergency Department? How can it be defined?

How can it be improved? Are there quick wins? Or paradigm shifts?

Another Take on DNR

89 year-old, death not immediately imminent, but certainly on that road, septic, obtunded, dehydrated, atrial fibrillation, blood pressure in her boots, Levophed drip. Previous history of Altzheimer’s dementia, congestive heart failure, myocardial infraction, osteoarthritis, CVA, etc., etc.

She’s a full code, by which we mean that if her heart stops, we do the full monty.

Numerous family members do shiftwork at the bedside, all extraordinary dedicated. They watch the cardiac monitor, then scrutinize my reaction if it beeps or whirrs.

Will she get better? they ask. She was well up to a day ago, they tell me.

I find this hard to believe, given her long difficult medical  history. I tell them as gently as possible that she may not survive, she is too sick, that her kidneys have shut down and her heart is tired.

Dr. Sivampillai, the internist, comes in. He reads the chart, and looks  thoughtfully at he family members clustered about the patient.  He’s a lovely, conscientious man. He shakes his head and sighs.

“She’s a full code, no?,” he asks. “And on Levophed too.”

“We’ve all talked to them.”

“They need to get used to it,” he says. Sure. Conventional wisdom.

But then he says: “Give them time — they very soon will get tired of all this, this toing-and-froing, and jumping at every beep from the monitor and then we will see them make her a DNR.”

Breaking the Asshat Barrier

In the middle of the chaos the other day, I got to deal with McSnit and Weanus, the former by telephone, the latter in the flesh. Weanus was having his usual tantrum about something or other, which I ignored, and he went away after writing a few orders. Thanks, bye, and don’t let the door hit you on the way out.

McSnit — well, we required his unique and special services as a surgeon in his particular subspecialty. It was a complicated case, the emerg doc had already talked to him about it; we needed some immediate direction, and also some pretty urgent intervention on his part. So I called Locating, who directly connected me to his Blackberry.

The connection was bad.

Can you hold for the emerg doc? I asked. It’s about Patient VW, he needs this, that and the other.

“I’m a busy man,” he says.

Click. The call was dropped.

So I thought: he knows the number — God knows he’s called me enough times with some spurious complaint —  and he knows the score: he’ll call back. I mean, a reasonable person would do the same, wouldn’t he?

Uh, no. We’re talking about McSnit.

I waited a couple of minutes, then when it was clear he wasn’t calling back, I paged him again.

His Blackberry was answered by a nurse.

Can I speak to Dr. McSnit?

“Oh,” said the nurse. “He can’t come to the phone. He’s scrubbed in and just started a procedure.”

In other words, instead of calling back about a complicated, critically ill patient he already knew about, who required his font of knowledge, skills and talent, or even waiting for the page, which he knew we would make, McSnit chose to begin a procedure. Immediately. I mean, he must have had the circulating nurse holding the phone to his ear in the scrub room.

Avoidance behaviour. Classic. And since McSnit is a reasonably intelligent person, he knew he was doing it, even as he walked into the procedure room. Which make it worse.

He’s just moved up my Dinkhood Scale, jumping five or six notches from Irritating Jerk to Asshat Deluxe. Well done, McSnit.