Mrs. Edwards' Spleen Gets Vented

70-year-old Mrs. Edwards rolled into the ICU at 0100, pale, sweaty and tachycardic with a blood pressure of 80/49. The night shift nurse, Rebecca, and a crowd of others deftly hooked up the heart monitor, intravenous lines, and other devices, checked her urine output, and peeked at her dressing, which was oozing just a bit. "I'm giving her another liter of LR," said Rebecca, wondering why this lady was transported in this condition. Mrs. Edwards' pallor and sweaty, cool skin were enough to tell her this could be a bad night. "What was her intake and output?" Rebecca was thinking that blood loss had driven Mrs. Edwards' circulation to the crisis point, and she wanted to know what to give her: more fluids, blood?

Mrs. Edwards' last blood gas showed metabolic acidosis from lack of oxygen to her vital tissues. The longer acidosis persists, the worse the outcome for the patient. This grim picture began to make more sense when the surgeon told the story of Mrs. Edwards' lengthy operation.

The chief surgeon, Christine, recalled aloud how she searched Mrs. Edwards' abdomen for the source of the smelly pus-blood-plasma mixture. After examining the usual suspects, the stomach, appendix and bowel, the surgical team moved on to the left upper abdominal quadrant, and found Mrs. Edwards' spleen encased in omentum, an apron of fat that envelops trouble spots, making a built-in physiologic bandage when something goes wrong in the abdomen.

Omentum wrapped around an organ signals trouble inside. Most people don't even know they have omentum (in fact, humans have two omenta: greater and lesser) although this under-appreciated structure could save their lives. Because despite what Dr. Oz said on Oprah, your omentum is not trying to kill you. (And craving meat is not a sign of anger, either, if you ask me.) Mrs. Edwards, I think, would vouch for the good intentions of her omentum.

Christine recounted how cautiously incising the omentum brought forth a flood of pus-filled fluid. Then Mrs. Edwards' spleen was removed, the surgeons flushed out the abdominal cavity, placed a drain to take away the residual nastiness, and closed Mrs. Edwards back up.

Unfortunately, removing the offending organ was not a cure. The infection had made itself a comfortable home in Mrs. Edwards' warm, moist abdomen, and it wasn't going away without a fight. Although antibiotics are a first line against sepsis, once septic shock sets in, the game changes. Antibiotics must be given early in the development of sepsis to be very helpful, and Mrs. Edwards had shown up in the Emergency Department a little too late for that, unfortunately.

So now, this obese older woman, minus a spleen and some omentum, was in dire need of intensive caring. On a ventilator with a tube in her throat and sedated, she couldn't speak, but she made her need for pain medication clear. Rebecca worked to stabilize her vital signs, treat her pain, and monitor for complications of shock, like acute renal failure and delirium.

When I arrived at 7:15 a.m., Rebecca had Mrs. Edwards nicely buttoned down. Fluids were running, pain was controlled, her family was informed, and she was alert enough to communicate, but sedated enough to be comfortable and forget. The forgetting is important. An ICU is loud, well-lit, and a place where uncomfortable, if not painful, things happen. For a long time, ICU practitioners gave drugs to induce forgetting with abandon. Now we know that moderation is better, because forgetting can prompt the brain to create memories that are scarier than the real ones. A daily sedation vacation even helps prevent pneumonia.

This story ends well. I checked up on Mrs. Edwards a few days later to find that she had left intensive care and was progressing toward discharge. I wondered if she knew that she had her omentum to thank, at least in part.

Joey on the Tightrope

All 330 pounds of Joey were lying in the intensive care unit, transferred from an outlying facility after he was resuscitated. The other hospital had him on a benzodiazepine infusion to calm him down in his delirium, but it made him stop breathing, and now poor Joey not only was withdrawing from alcohol, but his brain had been deprived of oxygen for a few minutes. His brain did not need that.

Joey's Mom has multiple sclerosis. While she held his hand and sighed from her wheeelchair, his hapless Dad sat in the ICU, saying very little. I tried to toss a little hope their way by telling them that we plan to remove the breathing tube today or tomorrow, but he just replied, "That's what they say every day."

Joey's Dad was right. We had tried day after day, but Joey flailed about dangerously in bed, getting close to hurting himself or his nurse, when the massive doses of sedatives infusing into his veins were decreased. The fanciest, newest of these drugs was dexmedetomidine, a drug that allows an undisturbed patient to"sleep" much of the time, yet be fully awake and alert when we touch him, speak to him, or move him. It works really well, but, its use is limited to 24 hours and its cost is 11 times that of the closest comparison drug. And "dex" is not the first-line drug for Joey's life-threatening problem: alcohol withdrawal-related delirium.

Problem is, the first-line drug is the one that made him stop breathing before, in the other hospital. That might have happened because it's lipophilic: it likes to hide in fat. And it takes a while to saturate the fat stores in a person of Joey's size. Once the fat is saturated, the drug starts working overtime and knocks out the drive to breathe. So it's a matter of careful monitoring and titration to keep patient and nurse safe from Joey's delirious flopping about while encouraging him to go on breathing.

His Mom tells me that Joey is the sweetest son in the world. He takes care of her, she says.

At age 34, Joey lives with his parents. He drinks a lot. His cholesterol is too high, his blood pressure is too high, and he has diabetes. Despite eleven days in the hospital, his yellowed toenails need cutting, his skin is flaking off in brownish scales, and his teeth need a dentist's attention. His legs have the characteristic brown tint of long-standing swelling caused by venous insufficiency, probably related to obesity and inactivity in his case. Some nurses misinterpret this as a sign of poor hygiene, which it is not.

I turn down the lights, speak softly to Joey, and slowly decrease the sedation as we work to free him from the ventilator in small steps. I feel as if I'm guiding Joey across a tightrope stretched over a threatening chasm. If I fail, down goes Joey, and possibly his parents, too.

At the end of my shift, Joey is cruising along nicely with less help from the ventilator and lower doses of sedatives. But now it's evening, and we do not remove breathing tubes from people like Joey in the evening; it's too dangerous when there are fewer people in the house in case of emergency. The plan: let him rest overnight and take out the tube in the morning with a full team of health care providers to assist in case it goes badly. Nobody likes "tubing" a 330-lb. person under good conditions, much less an emergency.

The next morning, from my office at the school of nursing, I check the electronic health record and find that Joey is off the ventilator.

Whew. Made it across the chasm.

Waitresses, sex workers, mothers, child care workers....all are included in the welcoming arms of a feminist ethos that values the work of women in society. Women in historically male occupations such as lawyers, physicians, business managers, and such are allowed entry, too.

But not nurses. Why?

Misogynistic stereotypes of dumb nurse-sexpots abound in Halloween costumes , television , and even in public service announcements for lung cancer . It's pretty plain that the profession takes its hits for being female-dominated (93% of nurses are women), intimate, and, in many ways, downright unpleasant . The work of nurses is the traditional work of women: personal, caring, and intellectual simultaneously, without a great deal of prestige or recognition. Nursing embodies precisely the sort of roles that should fire up feminists' advocacy engines.

Yet feminist media do not feature articles about support and empowerment of nurses, the largest group of health care providers. A search of feministing.com, for one, revealed a smattering of articles, mostly about lay midwives (who are not nurses) and breastfeeding. My subscriptions to Bitch and Ms. do nothing to make me feel included in feminism as a professional. As an artist, a woman, a wife, a sexual being, and a daughter - yes. But nothing about life as a nurse.

Nurses' workplace horrors rival those of the most mistreated workers anywhere. We face high rates of work-related injury, suboptimal staffing and mandatory overtime (in addition to the less-avoidable weekend, night and holiday shifts and exposure to hazardous body fluids and chemicals). If feminists supported the 2.6 million registered nurses in the United States, would it remain a dirty secret that 69 - 85% of nurses report having experienced sexual harrassment (mostly by physicians) on the job? (see Valente, 2004).

Nurses are, in many ways, the solution to health care reform. Why aren't feminist organizations telling the public that, for example, better funding for educating advanced practice nurses (APRN) to provide primary care would save health care dollars? APRN students in Seattle undertook a media campaign when the University of Washington increased their tuition to equal that of medical students, but feminist magazines and websites missed the story entirely. No matter that nurses pay our own way through graduate school because of lack of federal funding. No matter that medical residencies receive 375 federal dollars for every 1 dollar spent on nursing residencies (despite the much greater numbers of nurses needed in health care and the 27% rate of one-year turnover among new nursing graduates.)

Even the willingly ignorant cannot help but hearing of the critical nursing shortage . Much of the shortage is attributed to nursing faculty shortages caused by persistently low faculty salaries. A graduate education in nursing does not bring with it proportional increases in compensation. Most nurses remain educated in 2-year community college programs because there is a lack of drive for better-educated professional nurses, even though research shows better patient and organizational outcomes when nurses have more education. Nursing' recent emphasis on doctoral education for advanced practice nurses was met with opposition from the medical community, who apparently consider highly educated nurses a threat.

So, in nursing we have an underfunded, under-appreciated caring profession that gets little recognition and encounters active opposition to efforts to advance our status. Ninety-three percent of us are women. We place ourselves in both physical and psychological danger to nurse. We swim upstream to advance our educations. We work strange hours, skipping meals and breaks because employers do not staff adequately. We are customarily called by our first names, but we call our physician colleagues "doctor." Resistance in the hierarchical systems that exist in health care settings is met by firings, harrassment, and legal action for nurses.

What about this makes the nursing profession worth ignoring to feminists? Are feminists, too, buying into the stereotype of nurse as feckless doctor-servant? Is the whole nursing mess so hard to manage intellectually and emotionally that even the brave and smart are afraid to enter? Or are nurses viewed as so complicit in our own oppression that feminism can hardly be bothered?

Whichever, it's time feminism started paying attention.

Valente, S. M., Bullough, V. (2004). Sexual harassment of nurses in the workplace, Journal of Nursing Care Quality, 19(3), 234-241.

Nurse Jackie RULES!

Undoubtedly you've seen the Nurse Jackie ads occupying every sidebar and banner ad on the Internet. Perhaps you've read my previous posts about the inadequacies of the popular media in representing nurses. All of those less-than-completely-truthful rearrangements of electrons notwithstanding, I'm here to say this:

Showtime GETS it!

Showtime may have exhausted their advertising budget promoting Edie Falco in Nurse Jackie, but I'm not ashamed to report that it worked on me. I watched the pilot the first time I could find it (here, by the way), and I was more than pleased, despite the dissapointment of others.

Edie Falco's burned-out, capable, smart, deeply flawed Nurse Jackie is enough to make my community college nursing instructors turn in their graves (or shake a wrinkled finger, at least those who are still alive). She's screwing a pharmacist and talking back to snotty doctors, and then there's that little pain pill addiction thing. Fittingly, the meticulous Jackie opens a capsule of God-knows-what, counts out precisely 16 granules ("no more, no less"), and snorts them to get her through the day in spite of back pain (A.K.A. the nurse's curse) and as-yet-untold psychic pain.

Nurse Jackie's hospital is old, dark, religiously-affiliated and a little scary. Gigantic, vaguely Biblical figures painted on walls loom over Jackie and her nurse friend on breaks, threatening to swallow them up in the bureaucracy and powerlessness nurses fight daily in health care. This point is driven home when an administrator rebukes Jackie for working over 12 hours at a stretch, then asks her to work a double on Monday. I would have laughed, except it's the truth.

Plenty of nursing groups are up in arms about this show, including the American Nurses Association. "It's unprofessional!" "It's just another distorted image of nurses!" "We have a shortage, you idiots!" they cry. The professor in me would just like to tell the ANA this:

Dear ANA, perhaps you are unaware that we do not have a shortage of people who want to be nurses; we do have a shortage of educators and its cause is a shortage of money. Almost 40,000 qualified aspiring nursing students are turned away yearly. In light of these facts, please explain your argument that the image of nurses in the media is harming recruitment into our profession. I expect a double-spaced APA- formatted 5-page paper by Monday. Include suitable references.

Frankly, I think some people will never be satisfied. Characters MUST be flawed to be interesting; an icon of professional perfection cannot carry the burden of being a major comic-dramatic character week after week. Perfection is too simple; perfection is downright BORING. So Nurse Jackie saves lives, screws a coworker, snorts pain pills, tells off stupid interns, acts with great compassion and tenderness and flagrantly violates the ANA Code of Ethics in the course of a typical day. And that's why she rocks.

I haven't seen TNT's HawthoRNe yet, but I hear Jada Pinkett's another tough, smart, imperfect, unconventional nurse. And, no, I didn't hear that from the American Nurses Association.

Have you ever thought of hurting yourself?

What do you mean?

Have I ever thought of buying a gun, tilting my head back, opening my mouth, inserting the gun back toward my throat, and pulling the trigger?

Or do you mean have I ever hooked up with the wrong man just for fun, taking no precautions, and enjoying the foolish pleasure of risk-taking?

Are you asking if I have ever been absolutely certain I deserve all that is wrong in my life?

Or do you mean have I ever snorted coke, smoked dope, tossed assorted pills in my mouth, or bought a mysterious bright blue dot of something from a stranger in a bar?

Do you mean: Have I ever been silent when I was being demeaned by a well-dressed, wealthy man?

Do you mean to ask me if I let myself be intimidated by someone's social rank when they were still wrong?

Do you mean: Have I ever stewed over my mistakes and losses, forgetting every one of the triumphs and the obstacles overcome?

Or maybe you mean to ask if I've ever seen a knife in the kitchen drawer and found it oddly compelling, like the answer to my pain?

Do you mean this: Have I ever tried to do something difficult, then felt deeply unfulfilled when it was achieved?

Or do you mean: Have I ever wallowed in pain when there was sunshine outside?

Are you asking me if I have ever pinned all my hope on a flimsy promise?

The Knitting Must Stop!

A friend of mine had a baby in August. She credits me as her inspiration for studying nursing; now she's working on her PhD, studying hormonal aberrations in elite female athletes. So my baby gift had to be good. To purchase it, instead of patronizing Babies R Us or Target, I took the elevator to the 13th floor of a local hospital. There (not in the hospital's gift shop) I chose a fuzzy, pale yellow, hand-knit angora hat from among pumpkin-colored, flower-embellished, cable-knit, and striped varieties. It was hard to reject the pastel one with sweet little ears on top, but it wasn't gender-neutral. Darn.

The 13th floor is the mother-baby ward. The post-partum nurses sell these lovingly knit hats there for $20 each. The tiny hats are not made by good-hearted retirees, volunteers or hospital auxiliary ladies. They are knit by registered nurses who volunteer their time and money (and yarn can be expensive) and donate all the proceeds to the Lactation Support Program. Without nurse knitters, and limited grant money, there would be no Lacation Support Program for mothers who need help with breastfeeding.

Breastfeeding, to the uninformed, seems "natural", and thus, in the reasoning of the clueless, is assumed to occur effortlessly. As is often the folly of the ignorant, that which they do not understand is assumed to be simple. You may count the administrators of the hospital among the uninformed. In truth, mothers need coaching, support, resources and education to successfully breastfeed their infants. Many mothers who leave the hospital breastfeeding will give it up in a few months for lack of support. Support means time away from other responsibilities, a quiet & comfortable place, and education from an informed, caring individual, among other things. Many lacation consultants are nurses, professionals who have the requisite knowledge of growth and development, a dash of anatomy and physiology, and very strong interpersonal skills.

In addition to nursing skills, post-partum nurses have the dedication it takes to buy yarn and knit tiny hats in support of women, babies and health when their employr refuses to do so.

This is a common story. We nurses are lauded for selfless commitment to improving health when the health care system and our employers fail at the task. Today by e-mail I read of Michelle Battistelli, a nurse at Morris Hospital and Healthcare Centers in suburban Chicago. Michelle makes embroidered pillows that reduce pain for abdominal surgery patients. The American Nurses Association news brief said, "The ICU nurse and [her] colleagues wanted to do something to make it less painful for surgery patients when they cough, and holding the pillow against their stomach helps."

Why are nurses knitting and sewing? With patient safety, patient satisfaction, and other indicators of hospital quality under close scrutiny, why are hospitals not supporting programs that are known to improve patient outcomes?

Part of the reason is that health promotion doesn't "count" - literally - in our disease care system (it's not really a health care system; it runs on disease.) Hospitals are reimbursed on the basis of medical diagnoses, and breastfeeding success is not among them. Neither is pressure ulcer prevention, functional improvement, effective coping with loss, post-operative pneumonia avoidance or a host of other desirable health outcomes. Because there is no line item on the spreadsheets, the accountants miss all the dollars gained by prevention and health enhancement, work often done by nurses. Because there is no billable code for lactation consultants' services, nurses must knit.

If the accountants had access to a larger view, they'd notice that breastfed infants have fewer pediatrician visits as toddlers and do better in school, and the value of these outcomes would show up in support for breastfeeding consultations. If they could see a few steps beyond the immediate, they'd endorse the cost-effectiveness of buying pillows for people after abdominal surgery. But health care accounting systems, like all systems, see what they are built to see. And the nurses go on knitting and sewing.

What are implications of this situation for health care reform? In the current system, Hospital A competes against Hospital B, spending dollars on advertising and fancy machinery that add little or no value in terms of health outcomes. The disciples of Milton Friedman would say that costs are controlled through competition and open markets, but they are not referring to health care; they are referring to purchases of consumer goods where one purchase is not dependent upon another, as followup care depends upon the outcome of a hospitalization. They also are not referring to a system where costs are usually unknown to the consumer, as in health care. Health care as a market is also drastically different from consumer goods in that its availability is necessary for societal productivity: the sick use resources, but cannot work. Getting your hypertension under control is in no way analogous to buying a new Toyota. Thus my contention that multiple competing providers and insurers cannot work in health care, and the present crisis is evidence of that.

What will work is cooperation and transparency. We must have a single payer system where better coughing among abdominal surgery patients in the ICU translates into measurable, "countable" efficiencies that are shared across health care venues. Rather than paying for more procedures and more doctor visits after the surgery, let's pay for better coughing to prevent all that. Because of the interrelatedness of human health, because breastfeeding support produces kids who spend less time at the pediatrician's office later, we must have a single system that takes advantage of, rather than fights, this interrelatedness.

Human beings and our individual and collective health are interdependent, like strands of yarn knit into tiny baby hats; our health care system must also be.

Joe Takes Care of His Own, Perpetually.

Part I

It was June 3, 1976, when my sister Joan and her husband Ted went on their very first outing as a couple after the birth of their son. Aaron had been born nine months earlier, to the great joy of all of his family. He was the first local grandchild for my parents. He was a bit colicky, and, of course, a first child, so Joan had been reluctant to leave him, especially merely for recreation and relaxation.

But finally, she was ready to rebuild their social life. So while Joan and Ted rode roller coasters and ate amusement park food with their friends, my parents and I babysat Aaron. I was 17; with that combination of ignorance and arrogance best brought to life by a teenager. Aaron had one of those baby-walker things which, back then, were built narrowly enough to fit through a doorway.

We religiously kept the door to the stairway shut. Which is why I don't know even now how it could have happened. In seconds, Aaron fell down the 3 stairs to the landing by the garage door, his baby-walker upended. I reached down for him, then my mother grabbed him, and in a moment my parents were in the car, headed to the local hospital.

He was pronounced dead at 4:44 a.m.

Part II

My father went into the Navy after high school to avoid the factory worker life led by his father. He had a bright, scientific mind and a knack for the visual. Because he wore glasses, he had to choose one of the more cerebral military pursuits: he chose aerographer's school.

He was stationed in the Phillippines in 1942. Like the other Navy personnel, he evacuated to the island of Corregidor before the fall of Bataan and the Death March. When Corregidor fell in May, 1942, they were captured by the Japanese, transferred to burning hot, packed, stinking railroad cars, and sent to various prison camps in the Phillippines pending final transfer to Japan.

Upon arrival in their Japanese camp, Dad was chosen camp commander by the men. He did not outrank them; it was a democratic election. Although some officers in their ranks were initially miffed, they, too, grew to appreciate his leadership and heroism.

I don't know most of what happened in those prison camps. I do know, though, that Dad endured beatings and torture on behalf of those men for such infractions as demanding better food. Many of them felt indebted to him for life for his actions. One of them was a short, dark-haired man named Joe Perry.

When I was about 7, without announcement, a beautiful new blue bicycle arrived for me. It wasn't my birthday or Christmas. It was Joe Perry just thinking of Dad and his family. I don't know what Dad did for Joe - I wish I did. But there's no doubting that Joe was deeply grateful to my father and would be for life. Our family received kind greetings from Joe Perry every Christmas, every birthday and every first Communion without fail, including 1976.

Part III

Aaron died early on a Saturday morning. Our stunned and devastated family attended church that Sunday. We were barely able to find our way to the pew; the world was so unfamiliar now.

After we got home, Dad told us something he had seen. As he walked up to the altar for Communion, from the corner of his eye, he saw someone he knew. He turned his head to look and saw Joe Perry, standing in the communion line, tenderly holding Aaron in his arms.

Weeks later, we learned that Joe Perry had died. On June 3, 1976.