Florid Nightingale

Mrs. Edwards' Spleen Gets Vented

2011-03-31T12:20:00.000-07:00

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

2011-03-31T12:07:00.001-07:00

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.

2010-03-06T13:42:00.000-08:00

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!

2009-06-24T07:33:00.000-07:00

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?

2009-04-29T11:55:00.000-07:00

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!

2008-12-27T11:17:00.000-08:00

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.

2008-11-02T10:32:00.000-08:00

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.

Joint Commission, are you listening?

2008-10-21T08:41:00.001-07:00

I mourn for the demise of nursing care. I miss giving back massages, changing linens merely for comfort, sitting down to talk with people. I especially miss the value formerly placed on nursing measures as critical to quality health care.

Quality has been redefined to suit the criterion of measurability over any other. Now the ability to track standardized processes of care (not the outcomes necessarily) is the primary purpose of the medical record, and fluff like which position the person prefers for sleeping because of rib fractures and chronic back pain is devalued, and even discouraged. There is little room these days for individualization of care, which is where nursing has always excelled.

Because of the poor quality of its documentation of standardized processes, the hospital where I work is threatened with revocation of its Joint Commission approval - which means if our quality does not improve, we can't get Medicare reimbursement, and Medicare constitutes the major source of payment for any hospital. This could shut our doors.

Our Joint Commission status is "provisional," meaning if they show up and look around and find us wanting, we are history. To say our administrators are concerned would be like saying the KKK is concerned about the qualities of persons with enhanced dermal melanin content. Just doesn't quite capture the true spirit of the thing.

Pain management is one criterion on which our hospital was cited by Joint Commission. Certainly a worthy goal. The Joint Commission take on quality pain management requires that pain be quantified, treated, and re-assessed after treatment, and it follows that these elements must be documented such that they can be easily audited. Management has repeatedly stressed that nurses document these elements (not that nurses do these things.) Documentation is the only proof of adequate pain management that "The Joint" requires or desires. Indeed, our chief nurse executive informed us that one of the benefits of having computerized charting is that now she can tell who is documenting correctly and who is not - and disciplinary action can thus be taken. (Way to improve quality - threats!)

There is no evidence, unfortunately, that good documentation = good nursing care. There is nowhere to chart that, despite my giving the 71-year-old Cantonese-speaking lady more narcotic than was ordered, her pain was still a 7 out of 10. Nowhere to chart that her snoring respirations caused me enough concern that I was reluctant to increase her dose of narcotic further in spite of the pain she complained of whenever she was asked. Nowhere to chart that the non-verbal pain indicator scale did not concur with what she said when her son was there to translate. Nor is there anywhere to document that I spoke with the physician, who concurred with my plan. This is what quality nursing care looks like: letting her family remain at her bedside for comfort, judging cautiously how much narcotic to give and when, covering her with warm blankets when she was cold, believing what she said over the mandatory pain scale, wiping her forehead with a cool cloth when she vomited, speaking softly to her. But none of these actions is documented. None of them count.

The Joint doesn't know that these are quality nursing measures because they didn't even begin to ask nurses until 2003, when their first nurse advisory group was convened. The American Hospital Association and the American Medical Association have long been integral to the Joint Commission, but historically the American Nurses Association had been shut out.

There is hope: in 2008, one of the 13 Joint Commission officers is a nurse. In 2002, they released a white paper on the nursing shortage with recommendations for improving the supply of nurses. Some of the white paper covers what we already know: the shortage is unprecedented, people are aging, and nurses are crucial health care providers. Other parts of the report are insightful and action-oriented. The need for fiscal incentives to enhance nurse retention, ongoing education and federal funds for nursing enhancements in educational and health-care settings are plainly pointed out.

I am happy to conclude that "The Joint" is starting to get it, and I hope that one day they will stop to read all of what I put in my patient's chart and see how the individuality of each person informs my caring much more profoundly than a Joint Commission mandate ever could.

I will continue wiping foreheads and applying warm blankets. Perhaps there will be a time when such caring measures are also considered meaningful indicators of quality nursing care.

Intelligent, reasonable, educated Catholics support Obama

2008-10-06T08:38:00.000-07:00

Take a look here.

College students are SO CUTE!

2008-10-05T10:13:00.000-07:00

Salon magazine has a great article about Sarah Palin and the dumbing-down of the GOP (and America) here.

If this doesn't frighten you in preparation for Halloween, I don't know what will.

America has a long tradition of anti-intellectualism, borne, perhaps innocently, of trust in democracy, in the wisdom of the commoner, and the importance of hearing all voices in a country that strives for freedom. Or perhaps not. Maybe disdain for elitist smart people comes from a tragic belief that smart people are not like "us" (which means....hmmm...who? Dumb people like us?) Or maybe there's suspicion that well-groomed, college-educated, high achievers do not belong in positions of leadership in society. (Danger!! Capable person in decision-making position!! Danger!!)

Even my adult, post-graduate university students, (whose admission GPA, by the way, hovers around 3.8) live under the delusion that utter equality is both achievable and desirable. Taken to the extreme, they think being equal (a noble ideal, to be sure) means being identical. It does not; it means celebrating the differences among us and not considering them signs of inferiority. It means providing for identical opportunities, not identical rewards.

Assigning grades is a notoriusly contentious example of the fine distinction between equality and identicality. Grading, some students believe, is akin to judging them on their score in a rigged game of dice. All who play, they say, deserve an A!

Forgive my ignorance, but who ever told you that college grades were a measure of how hard you worked?

The mistaking of semi-objective measures of achievement for global judgments of suitability, acceptability, (or just about any kind of ability) turns otherwise well-intentioned students into little monsters clawing at my office door, pleading for me to turn back time and to even out all the messy, random, unfair, individual disparities that forced them to mark choice C instead of choice A, as their best friend did.

"You didn't return all my papers on time, so I should get an A." "Other students had better clinical schedules; it is hard, you know, working and going to school. (So I should get an A.)" "None of the other professors gave me a B. (So I should get an A.)" "I was raised speaking another language. (So I should get an A.)" "Well, you know that I was sick during midterm. (So I should get an A.)"

One student actually asked me how she is expected to get the material if it's not written on the slides and she does not listen in class!

WHAAAAAAATTTTT??? Help, Lord!!! I am abandoned in the cruel and savage land of hostile non sequiturs!!!

---- several deep breaths later ----

Peppered with such nonsense from packs of hungry 20-somethings, foaming from mouths full of perfect teeth, what is a professor to do?

For one thing, we should admit it: tests stink as measures of mastery. In nursing practice, or any other profession/job/trade, your effectiveness has zero to do with your ability to sit in an uncomfortable seat and make the right marks on a worksheet surrounded by 40 other people doing precisely the same thing. Professors know this, but students don't, and (in another ugly fact) grades do count for things such as getting into the right graduate school.

There is no elegant solution to this dilemma, so I hope you haven't read this far hoping for one. This insuperable state is the sorry source of grade inflation, and no one's come up with a solution to that yet.

Not even the college-educated elitists.

The dangers of exclusionary science, or: Can you trust your doctor?

2008-06-18T10:09:00.000-07:00

If you're female, perhaps you can't. People tend to think of their own doctors and medicine as a whole as objective, scientific and above all, ethical. Perhaps this is a coping tactic in the face of the unappealing truth that medicine is far from free of sociocultural bias. As an element of our society, the medical profession is subject to influence by modern social values. This influence becomes a problem, however, when it urges doctors to disregard science in favor of whim, driven by exclusionary doctrines that treat sections of the population as inferior.

Case in point: the "special" category of women's health (which, of course, applies to about half the people in the world) is but a few decades old. Nearly all of the research that informs current medical practice was done solely on white males. How did we get to this point? Here's a short history lesson:

Language "urging" (but not requiring) the inclusion of women in federally-funded health research was first published in the National Institutes of Health's (NIH) Guide to Grants and Contracts in 1987. In 1994, NIH finally enacted a Congressional mandate to include women and minorities in research. Prior to 1994, it was considered a good idea, but not mandatory, and the flimsiest of excuses (such as cost) would suffice for excluding half of the population to which the findings would be applied.

"Interference" by women's hormonal vicissitudes and the risk of pregnancy were cited as reasons for excluding women from research before 1994, although this was obviously many years after the development of oral contraceptives. Researchers apparently felt safe concluding that the factors that justified exclusion of women did not preclude generalizing the results of research done on white males to women of all races.

The media's love affair with breast cancer, when heart disease is the top killer of women, is emblematic of the sociocultural influence on women's health. Although public polls show that women think breast cancer is the top killer, breast cancer is not even the most common cancer killer of women. What is? Lung cancer. According to SEER, from 2001-2005, the "median age at diagnosis for cancer of the breast was 61 years of age." From a very large study of lung cancer published in Annals of Oncology (2002), "women developed the disease at an earlier age than men (60.02 versus 62.18 years; P <0.001)." In other words, both lung and breast cancer are usually found around age 60, so the "popularity" of breast cancer cannot be attributed to younger age at diagnosis.

There are alternative explanations for our culture's breast cancer fascination. Among them is the idea that lung cancer, and some other cancers, are self-induced whereas breast cancer is blameless. A second is that our culture loves breasts so much that damaged or missing breasts are seen as horrible, even if the woman survives. No one mourns a lost lung this way.

Most of the women answering those public polls do not know that heart disease is actually the greatest threat to their health. Heart disease is the greatest killer of both women and men, yet the image of the older man clutching his chest is what comes to mind when Americans think "heart attack." The so-called classic heart attack symptoms do not happen in women, who are more likely to experience jaw pain, back pain, fatigue, and nausea. Something's very, very wrong with this picture: although women die of heart attacks more than anything else, why do they still think the signs of a heart attack in a man are what they ought to be looking for? It's a different syndrome in women, but few women know that because of the emphasis placed on male symptoms of heart attack. Indeed, the science behind heart attack symptoms in women is relatively new - no one thought to do research on women and heart disease until after the 1994 NIH mandate.

This brings us to the terrifying tale of hormone treatment. Hormone replacement therapy was perpetuated by physicians who simply assumed that restoring a woman's youthful hormone balance would yield cardiovascular benefits. The temporal relationship between hormonal changes at menopause and increased incidence of heart disease later in life was never shown to be causal. Hormones were prescribed to millions of women for decades with barely a shred of evidence that hormone treatment decreased cardiovascular risk, or at least did not elevate it. In 1990, the FDA declined to add heart disease prevention to the list of indications for hormone therapy because of the lack of evidence. When the proper studies were finally done, it became clear that estrogen/progestin combinations actually increased women's risk of heart attack and stroke.

An early form of hormone treatment was diethylstilbestrol, or DES. The Food and Drug Administration approved DES for use in pregnant women to prevent miscarriage in 1947. The drug had not undergone safety testing, and as a consequence, many women who took DES suffered consequences that included breast cancer in the mothers and a higher rate of cancers and birth defects in their children. Nonetheless, the FDA did not remove DES from the market until 1971.

Estrogen has been used since the 1930s to treat hot ﬂashes and other physical changes that women experience at menopause. But starting in the 1960s, the list of reasons for women to take hormones began to grow. In 1966, the book Feminine Forever became a best seller with its claim that "menopause is completely preventable." The book's author, Dr. Robert A. Wilson, asserted that postmenopausal women who didn't accept hormone replacement were no longer truly female. Wilson traveled the country, lecturing on this topic and promising that with the help of estrogen therapy, "Every woman alive today has the option to remain feminine forever." He was later revealed to be a paid spokesman for a firm that sold estrogen replacement. Nice guy.

Dr. Wilson's tactic, reframing the natural as pathological in order to sell a treatment, is well-known in medicine. Consider the promotion of the medical diagnosis "micromastia" by plastic surgeons. Micromastia means small breasts. It does not mean inadequate mammary tissue to lactate and breastfeed a child, which would be a physiologic problem. It refers to a cosmetic problem that plastic surgeons can "cure."

So are you still confident that medicine's not sexist? I consider hormone treatment and the breast cancer fascination sufficient evidence of bias in medicine, but if you need more, just look up the derivation of the word "hysteria."

Tragic Humor in the SICU

2008-05-12T17:22:00.000-07:00

The surgical ICU in Cleveland where I worked in the '80s had a local reputation for keeping dying people alive with drugs and machinery. The director had a young son born with a fatal congenital condition and (we assumed) this drove a rigid reluctance to call an end to lifesaving treatment. I recall one frail elderly woman who, after months in the hospital and multiple ICU stays, was still being treated full steam ahead because "her quality of life is good." He explained to me paternalistically that at home she was sedentary, so being in the hospital wasn't much different.

As happened too often, I stood dumbstruck. I did not know how to respond to this statement. I didn't have the time to explain the meaning of quality of life to him. I didn't have the insight to refute equating movement with quality of life. So I limply stated my disagreement and went back to caring for her, tubes, drugs and all.

We SICU nurses knew the lady well; we'd nicknamed her, as we often did with long-term patients. Usually the names were goofy distortions of the person's actual name - terms of endearment. Sometimes they were cruel characterizations of a quality they possessed, like the obese heart patient we called Inertia.

The nicknames were one way of coping with dread, distress and disaster as we flailed the dying into staying alive another day. The doctors inserted tubes and ordered drugs that the nurses administered. We restrained wriggling hands and feet, improbably strong, so they wouldn't interfere with the treatment plan. Nurses listened as physicians explained to troubled families that this was merely a temporary, treatable setback. The families wanted to hear that Mom or Dad could recover if they only got over this latest insult. We almost never withdrew life support, as if we'd chosen a certain road and turning back now would constitute cowardice.

Going through a particularly long spell of poor staffing and drawn-out deaths was very hard upon the nurses. We were distressed about aggressive treatments to which we objected and were powerless to do anything but take part. We left work day after day knowing we hadn't had the time to do what we were educated to do for these suffering people. Nurses were at the breaking point when someone posted a sign on the janitorial closet that read Crying Room.

No one took down the Crying Room sign for days, not even the manager. She understood the horrors of inflicting painful dressing changes on the young woman whose cancer-filled abdomen had been eviscerated and sewn back together in a desperate bid to buy time. I will not forget the image of her crying through the bloody dressing changes or the ill-informed fear we had of narcotics and how her pain was egregiously under-treated in the face of such a surgical mangling. I still see the cringing faces of those people in pain, and every one I remember was African-American.

In that place, nurses needed humor to face complicity in these acts 3 days a week and not run away shrieking. We settled for a cynical humor that expressed our distress because we could not conjure one that raised our spirits.

Nurse: "How long do you think he will survive after this?"
Doctor: "I wouldn't advise him to buy any long-playing records."

Nurse (standing over the bedside of a "train wreck" patient dying from shock): "He's dead, Jim."

One resident wrote a Christmas song to the perky tune of Jingle Bells about a moribund man with a pancreatic abscess. I still remember the chorus with his name.

Now I am ashamed to have taken part in this feeble, dysfunctional mechanism for coping with moral distress, disempowerment, and racial discrimination. Advice to the young in nursing: if you think it's wrong, it is. If it's wrong, get out before you find yourself with a rip-roaring case of PTSD.

And if you worked in that SICU in Cleveland in the '80s with me, know that I remember, too, and I forgive you.

Please forgive me.

What I did on Saturday

2008-04-28T09:55:00.000-07:00

In the Trauma intensive care unit, tragedy abounds. People shoot each other; they get drunk and smash themselves and their cars; heart attacks make old men plow their Cadillacs into children; feckless pedestrians get broken by careless cell phone talkers.

The near-suicides are the worst, though. That's Jesse's story.

Jesse is only 24, but has already been in treatment for mental illness for 14 years. This time, for reasons inscrutable, he walked onto the highway hoping to get hit and killed. Well, he did get hit. There was glass in his lungs when he got to our ICU. The respiratory therapist who helped remove the glass said it "looked like a diamond mine" down there. I talk with his mother as she struggles to remain cheerful in the face of this weary scenario. Jesse gets sick - Jesse hurts himself - Jesse goes to the hospital.

Jesse broke his foot, bled into his brain, smashed his face, and got a rip-roaring case of pneumonia in the bargain. His lip jewelry was torn out, leaving a ragged necrotic crater. He stinks. He coughs up foul creamy green mucus like rancid pudding. It also drips from his tracheostomy, soiling his cervical collar and skin. He has diarrhea. He flails in the bed, exposing himself. It is impossible to keep Jesse clean and modest, but nurses do our best. Cruelest of all, Jesse is alert. Sometimes you almost wish there were a devastating brain injury to go with the other wounds, you know?

Some nurses blame his unsophisticated family for Jesse's state. Some people assume that somebody's got to be to blame; and it does wrap things up neatly. I doubt Jesse's story could be so pat. They never are.

I decide not to subject his sincere mother to another telling of Jesse's and her tribulations. I express sympathy and show her the good signs: blood pressure, heart rate, oxygenation. She smiles.

An interesting arrangement, or, BFU as a model of the problem with modern nursing education

2008-02-16T11:44:00.000-08:00

Irony 101:
This week, I diminished my employment by 30%. From full-time to 70% in one swell foop, and instead of crying, "What will we do without you?", my boss thanked me. More cutbacks in nursing education are occurring at Big Fat University up on the hill; she needs to find ways to save dollars and does not have the freedom in academia to just cut someone's hours. Non-tenured academics like me work on contract, and the university is required to employ us fully according to the terms of our contract, unless they choose "contract non-renewal" (a.k.a. firing your ass) when the term expires. A pretty sweet deal, to be sure.

The irony is that now I'll have more free time (not working 6 days a week will be a treat), make slightly more money, and probably be more effective in my role.

How can this be?

I am cutting out the fluff. I am concentrating on what matters. Attending fewer meetings. Leaving the policy-writing to others. Abandoning critical roles on crucial committees that absolutely NEED my blessed presence! Good Lord, I can almost see the first few bricks of the BFU tumbling down the hill already.

I'm putting on my scrubs and my athletic shoes. I'm tying back my hair, wearing only post earrings, getting up at 5:30 and nearly killing myself for 12 1/2 hours before going home feeling completely satisfied that I have done good work. I'm using my EKG calipers, relying on my pocket calculator and my stethoscope in the intensive care unit. I am leaving my cell phone at home. I am bringing my best negotiation skills to bear when a glib, self-certain surgical resident tries to gloss over a real issue that he'd prefer to leave to the ICU resident. I am making more money as a working ICU nurse than as a teacher and researcher while doing what I MUST to bring relevance to teaching.

Nursing is a practice discipline. One of the implications of this fact is that we have to practice nursing to maintain skill. (In a practice discipline, standing still = falling back.) Historically, however, there have been no opportunities for faculty to practice nursing, so our faculty have been forced to quit nursing in order to teach nursing. Nursing homes, home care agencies, hospitals and community organizations do not see the value of having an experienced and educated nurse on hand one or two days a week. It's full-time or nothing. Nursing faculty with PhDs simply have nowhere to practice!

Colleges refuse to pay for faculty to maintain their clinical practices. After all, they're not in the patient care business. I was an anomaly to negotiate 10% FTE in my first 3 years post-PhD for practice. Most nurses like me simply assume it has to be given up.

What went wrong? Well, one thing I know for sure is that those in control have a vested interest in suppressing the tremendous potential power of nurses. (Don't worry; I don't harbor fantasies about shadowy and sinister criminal men convening secret meetings in poorly-lit caves to plot against female-dominated professions. They actually meet in spacious, tastefully-decorated conference rooms and their names are prominently featured in organizational charts.)

At BFU, for example, the "Executive Leadership Team," consisting of MBAs and MDs, recently opined that our university does not need a baccalaureate nursing program because (paraphrased) "nurses can be trained in community colleges." When one considers that the last word in the organization's name is university, it seems counter-intuitive that these people would suggest educating nurses at the baccalaureate level makes no difference. Are they suggesting that nurses are the one exception to the general rule that more education = better performance in employees? Most organizations encourage their employees to advance their educations. Yet, the august ELT at BFU has determined, all evidence aside, that nurses can be educated in two years and a university degree is unnecessary.

They really can't be blamed for this. They are ignorant and they are exerting their right, as the ELT, to act in their own self-interest. Perhaps if the ELT included a single representative of the largest single group of employees in the organization, these things wouldn't happen.

What I Did on Tuesday

2007-10-02T19:25:00.000-07:00

My two persons were a developmentally disabled Latina whose lungs had failed (probably because her brain had failed, but no one really knew the reason for that) and a very lovely elder woman who did not belong in an ICU. I had the pleasure of saying good-bye to the old woman as I transferred her to the regular ward, delivering my standard line: "It's been a pleasure to get to know you and I hope I never see you again." That one makes people laugh. It is good to see someone leave intensive care. Occasionally I even get to send them home, which is even better.

The Latina was about 30 years old and had been living with her friend more or less independently before falling ill from unmanaged diabetes. She has a case worker, and a physician, but no one keeps an eye on how she is managing her diabetes day-to-day. The woman needs a nurse. Her blood sugar was well over 1000 (normal: 70-100) when she entered the hospital. This alone can cause coma, but once the metabolic derangements are fixed, the person should wake up. She did not. She was breathing around 30-40 times a minute when we decreased the amount of support offered by the ventilator to which she had been hooked up for 7 days. Although the respiratory therapist and I considered her rapid respiratory rate evidence that she was not ready to come off the machine, the physician in charge differed. He was right; with her brain problem, her respiratory rate was not a good indicator.

So we removed the breathing tube at about 6 p.m and minutes later she started making sounds like a squeaking door with each breath. This is called stridor, and it means the upper airway is swollen and at risk of shutting off completely. Just then, the ICU resident taking over for the night was rounding with the offgoing resident. They paused briefly outside her room. I asked them to come in and listen to her breathing, but they declined because they were rounding. (One does not interrupt rounds in a teaching hospital. Patients may be hemorrhaging all over the floor and turning four shades of purple, but one does not interrupt rounds.) I called the respiratory therapist and we agreed that an epinephrine treatment was required.

The oncoming resident appeared and, reluctant to take advice from underlings, suggested that we wait. He thought maybe it was just garden-variety wheezing, albeit the type you can hear from outside the room. So we waited a few minutes. Then he came up with the idea of giving an epinephrine treatment. Wow - thank God we had a physician in the house! If not for his self-absorbed pomposity, we never would have been treated to the thrilling drama of hearing The Learned Doctor ordering the correct treatment after ten tense minutes of waiting!

The respiratory therapist gave the treatment and she did sound better afterwards, but unfortunately it didn't last long. After about 10 minutes, she was back to creaking. Our doctor asserted that it was just wheezing again, so the savvy respiratory therapist gave another treatment, this time a combination of epinephrine and albuterol, which treats wheezing. I tried opening her airway with the jaw-thrust maneuver that every first aid class teaches. Nada. This confirmed that it was stridor; if it were only her tongue falling back, the jaw-thrust would have fixed the problem. We had something more challenging on our hands.

Dr. Pomposity returned to the room and I told him what I'd done, while preparing to assist with replacing the breathing tube in her throat. The respiratory therapist stood there and our friendly star collaborator of a physician asked him if opening the airway helped. (I forgot I was wearing my invisibility cloak.) Our Kindly-but-Wise Doctor Welby boldly, smartly, and valiantly peformed the jaw-thrust maneuver (actually, it was rather clumsy - he pushed down on her chin - or in other words, he did it wrong) and then announced that it was stridor because the jaw-thrust maneuver was not effective.

Once again, The Doctor saves the day! Whew! Where on earth would the poor helpless sick people be if not for the swift, learned intervention of our bright, committed, selfless, good-looking physicians? Doctors save lives every day! Consult your doctor before taking an over-the-counter vitamin pill! Consult your physician before beginning an exercise program! Do all of this because they are the ones who know! That is why this woman was able to manage her diabetes: she had a doctor! The doctor tells people what to do, and of course they do it, and everything is just fine!

This scenario tells of the enormous gap in understanding of human behavior in response to illness that is prevalent in our health policy. People need guidance, repeated education, coaching, support, and instrumental help (like transporation) to manage chronic illnesses. A prescription and a visit to the doctor every few months is not sufficient, and we will have to learn this as a society as our population ages and acquires more chronic illnesses. There is no fifth-generation targeted molecular miracle drug, fancy diagnostic test or minimally invasive robot-assisted nanotechnologic technique for this problem. The solution is routine contact with an educated, understanding and compassionate human being. And that is the hardest thing to do.

What I Did on Monday

2007-10-02T19:20:00.000-07:00

5:35 Awakened, made it to the kitchen for coffee. Thanked God for auto-brew.

6:25 Drove down the dreary highway, crowded for this ridiculous hour on a Monday. In my canvas bag a stethoscope, a peach for a snack, lip stuff, an extra pen light, goggles, extra hemostat, ibuprofen, and pseudoephedrine (to self-medicate on the go.) In my pockets are my scissors, id tag, some tape & alcohol swabs, the little notebook I've kept for over 20 years now packed with hard-to-find facts that ICU nurses need, and money for lunch and coffee.

7:05 clocked in

7:10 Got report on a 43 year old alcoholic, comatose from liver disease, and a 73 year old with emphysema and heart failure from an adulthood of smoking and obesity. When she stopped smoking, she got fat. The poor woman can't win.

7:30 Checked hemodynamic monitoring lines and vasoactive infusions. Probably the two most crucial elements of critical care nursing are obtaining accurate data and ensuring accurate medication delivery. (Well, that and making sure the person can breathe.)

8:30 The 43 year old alcoholic is in isolation for possible clostridium difficile, a bacterial infection that causes tremendous diarrhea. The best part of c. diff. is this: you can't stop the diarrhea, because that would retain the toxin created by the bacteria and potentially contaminate the bloodstream, leading to sepsis and death. So you have to let the person crap their eyes out. Fortunately, a new device that seals off the rectum and channels the runoff into a long wide tube helps contain the mess. Cost: $1100 - that's right, folks, an $1100 crap container. Remind me: Why are health care costs so high again?

9:30 The 73 year old lady's face is contained in a mask that seals off her nose and mouth completely with a set of tight-fitting velcro straps. This allows a breathing machine to apply constant pressure to her airway to ease her breathing. It's called BiPap. Some people use similar devices at home to treat sleep apnea. The odd part of this treatment is that it makes people feel like they are smothering. So almost everyone struggles to remove the mask, which makes their oxygen levels drop and their carbon dioxide levels rise. Carbon dioxide is a good sedative, so they are calm (but oxygen-deprived.) When you think about it, it wouldn't be a bad way to go: dying of oxygen deprivation, carbon dioxide's effects keeping you comfortable. Sort of a natural mercy in that combination. But my business is sustaining life, so I spend a fair amount of time putting the tight mask back over the patient's face, improving her blood gases while keeping her uncomfortable. Of course, a person dependent on a BiPap mask cannot eat. So malnutrition becomes an inevitable aspect of this treatment. My patient had not eaten in 3 days. It took me until 6:30 p.m. to get the doctors to order tube feedings for her.

(Love that word "order." It conjures up images of brave doctors in military uniform standing in the hallway pointing fingers and issuing commands to all within earshot. Captain of the ship!)
It's 6:30 before I get the docs back here to write the orders so this woman can have some nourishment. A nurse with a PhD waiting on them to read what the dietitian wrote and copy it verbatim onto the "doctor's orders" sheet seems pretty idiotic to me, but that's the way it is done. The hospital doesn't get paid if "the doctor" doesn't write the order.

10:00 The alcoholic is not being fed either. This is problematic because the liver synthesizes protein from nutrients. Even if we were feeding him, he would be at risk of undernutrition because of his broken protein synthesis mechanism. And he is physiologically stressed, increasing his caloric needs by about 30%. He is on a ventilator, so he cannot eat. They tried putting a feeding tube through his mouth into his stomach twice, but both times his fragile esophagus bled too much. Two reasons for this: one is that he has grown a network of frail, tortuous blood vessels in his esophagus to offset the high pressures generated by his diseased liver. The second reason is that the liver makes clotting factors, and his sick liver isn't up to the task. I ask the physicians on rounds what the plan is for nutrition: we wait until his lungs improve and we can get him off the ventilator. In other words, don't stand on one leg waiting for it. Not the answer I wanted. The answer I wanted was: we continue to correct his clotting disorders, then try again to pass a tube. Or we get a consult with someone who can pass the tube under xray guidance or direct visualization. But I think I know why they don't choose those options: it's only nutrition, after all. Study after study has shown the importance of initiating nutrition in ICU patients, but still physicians fail to value nutrition. (Nutrition is cheap and simple. How important could it be?)

12:30 I get away to grab a cup of coffee on my way back from dropping off the lady with emphysema in angiography for a permanent line placement. The device she is getting today accesses a large vein in the chest so she can go home on a potent vasodilator that will keep the pressure in her pulmonary vascular system down, thus controlling the strain on her heart. The lungs and heart should not be viewed as separate organs; sick lungs make the heart sick and vice versa. This drug she is getting, epoprostenol, is interesting. Its half-life is 6 minutes, meaning if the infusion is interrupted for more than a few minutes, she goes into heart failure. And we send people home on this drug all the time. There is a nurse called the "Remodulin nurse" (Remodulin is a brand name of a similar drug) who visits these patients in the hospital and then follows them home to be sure they know what they are doing with the infusion. First time I've ever heard of a nurse named after a drug. Advances in drug therapy have helped people with pulmonary hypertension live longer because of drugs like Remodulin. But at what cost? What does the drug itself cost? And what's the infusion equipment cost? And how about the full-time registered nurse who bears the drug's name? These costs are rarely measured, so no one knows. We can Google the retail cost of the drug, but that's all we really know. 1:30 Ahhh....lunch time. Cafeteria fare today: panini with avocado, spinach, tomato, bacon and cheese. Pretty good, really, with a Snapple diet peach iced tea. The only fluid I've had except that cup of coffee at 12:30. But every nurse knows drinking fluids only makes you pee, and that takes time! So nurses like me don't drink much on the job, even though I was sweating like a pig in my isolation gown, gloves and face mask. I know I don't smell all that good, which is not very appealing (and nurses should be appealing!)

2:15 Back from lunch, I notice the nurse covering me didn't get vital signs on my patients so I have to catch up. Then it's time to give an enema to the really sick alcoholic guy with diarrhea. This enema is not for constipation: it's to deliver a drug that removes ammonia-based toxins through the GI tract, in the hope that this will improve his brain function. Right now, the physicians are saying he is doing better because of these enemas. I ask, "How bad was he?" because now he is not responding to anything but noxious stimuli (like pain.) Hard to view this as any kind of improvement, but perhaps my observations are keener because the docs often do not enter the rooms of people in isolation. They rely solely on what they observe through the door and what nurses tell them. So their best information is secondhand, from a nurse who may have never seen the patient before today (like me.) Advice: if you or a loved one is in a hospital and in isolation, ask if the physician is going to visit. In fact, demand it. You are paying for it.
2:30 I check the last set of labwork and see that the labs are improving on my alcoholic friend. I look in the medical record and find an order to repeat the labs. I page the doc and ask if he really wants them redone - and remind him that a set was just sent and that he ought to look at them. He comes back and scratches out the order.

3:00 The lady who can't breathe is doing better. The respiratory therapist and I agree to take off the BiPap and see how she does with a high-flow face mask that delivers close to 100% oxygen. The night RN said she had difficulty swallowing water, so I give her pills with a spoonful of gelatin. She chokes anyway. I had asked the physicians to order a swallowing evaluation, and the speech pathologist arrives to do that. We decide it should wait a few days, until the lady can tolerate being off oxygen for a while.

4:00 Wrapped up in my own world, I haven't noticed that two other patients have crashed in the 9 hours I've been here. They both came from the floor (the acute care ward, where people go after they improve enough to leave intensive care.)
Now we have another new one, flown in from southern Oregon with a massive heart attack. A device inserted into his aorta pumps in sequence with his failed heart to strengthen its output. He is on a powerful anti-clotting drug; his right eye oozes blood. Before we can move him off the nasty sheets he's been on for 4 hours, we straighten out the invasive lines for monitoring and therapy in synchrony with the removal of the Lifeflight cables so not a beat is missed. Literally - a heartbeat. He lies on wrinkled dirty sheets for another 20 minutes, hardly conscious but able to hear everything going on. I do wonder if we sound as if we have no idea what we're doing in an urgent situation.
Marlene: "Rebecca, do you have the a-line over there?"
Rebecca: "Is this the a-line in his femoral? Looks like a venous line."
Teresa: "Yes, but it's through a side port so the waveform is bad. Are you synching the balloon pump to his EKG?"
Lifeflight nurse: "Yes, leave our EKG on for now. We have Nitro, Integrilin and dobutamine going through the CVP and PIV."
Marlene: "OK, let me know when you are ready to switch over. I'll connect the PA to our monitor. I'll send off labs, Rebecca."
Physician: "Get a mixed venous, too. Is that his blood pressure? Do you need access?" (Monitor read 68/41.)
Teresa: "The a-line is not zeroed yet. Read the NBP."
Rebecca: "The balloon pump is in his right, a-line left, and we have a PA so we have plenty of access."
Physician: "Okay, thanks."
And so on. What sounds to the uninitiated like chaos is actually exquisite teamwork. Two or three simultaneous conversations are occurring while hands whirl around him. Occasionally, someone leans down to whisper reassurance to him. This is some amazing work.
By 5, my day is winding down. Mrs. emphysema is breathing pretty well on the face mask. To give that much oxygen requires high flow, so the air is blasting away at her face. High air flow is good because that sensation stimulates the facial nerve, which sends signals to the brain of relief from breathlessness.

Mr. liver failure is stable, but again I decline to say improved. We will have to reintroduce the notion of feeding again tomorrow to the physicians in the hope that some action will take place. Some battles are fought slowly and politely. I send off the last set of labs in the hope his clotting times will continue to normalize and then we can talk about a feeding tube.

7:00 Same RN who had these two last night. Whew! I update her, sparing all the detail that a new nurse would need. On the road to home and a glass of wine by 7:40. I did good work today, and that keeps me coming back.

the logic of medical diagnosis

2007-05-25T07:50:00.000-07:00

Tuberculosis is caused by the tubercle bacillus. In order to get a confirmed diagnosis of tuberculosis, the bacillus must be found in the tissue. Other signs/symptoms, like apical opacities on the chest x-ray and cough, confirm the suspicion of TB, and may serve as "presumptive" critieria if the tubercle bacillus cannot be cultured from tissue, but if you ask any physician or read any general medical text, you will be told that the tubercle bacillus is the cause of TB. So one might ask: "Oh, doctors, why doesn't everybody exposed to the tubercle bacillus get TB?" Reasons like insufficient exposure and a strong immune system are cited in response to that question. Therefore, exposure to the bacillus is necessary, although not sufficient, for the development of tuberculosis. An example of a necessary but not sufficient causative agent.

Given that a cause can be necessary although not sufficient, let's look for cases where other combinations of necessary or sufficient agents are deemed causative by medical science. Please consider the case of smoking and lung cancer. An oft-cited statistic is that smoking causes about 90% of lung cancers. This figure includes former smokers, even those who quit decades before diagnosis. We know that smoking is not sufficient to cause lung cancer because 80% (or so) of smokers do NOT get lung cancer. (I am not a paid spokesperson for the tobacco industry; please bear with me here.) We also know that smoking is not necessary to develop lung cancer (of any histological type) because 10-13% of people diagnosed with lung cancer are never-smokers (disregarding the remote smoking question for the time being.) So here is a case of medical science concluding causality from a condition that is neither necessary nor sufficient to develop the disease.

I have asked physician colleagues what the criteria for causality are. Why things like gender, age, racial heritage, and so forth are treated as nuisances (confounders) versus causes when they are plainly linked to the disease. I've never gotten a satisfactory answer, or at least one that was logically sound to me. If only men are susceptible to prostate cancer, then having a prostate gland is a necessary, but not sufficient, condition for prostate cancer. If medical diagnosis is driven by logic, and if other medical causes are necessary but not sufficient, then what is the logical basis for excluding male gender from the list of causes of prostate cancer, particularly when we know that male hormone deprivation shrinks prostate tumors? Take away the "cause" and the problem becomes solvable. Maybe it's just too obvious that to have prostate cancer, you must have a prostate gland. Or perhaps demonizing maleness is anathema to medical hegemony, which is based in male power and domination. Perhaps we cannot consider maleness a problem in the way we regard a bacillus. We never have done so, although the medical machine does have a long tradition of treating most female ailments with removal of the uterus. (For more information on this statement, search the etymology of the word "hysteria.") I say this knowing that about 50% of young physicians are women - nothing kept them from joining up with the winning side. That wouldn't change their gender, now would it?

on suicide

2007-05-25T07:49:00.001-07:00

It is, of course, fundamentally selfish. Selfish to think that you, of all people, shouldn't have to put up with all this shit. Yes, you're right - this place is harsh, unjust, and ugly. No one said you'd have to deal with this. But no one said you wouldn't either. And anyone (like your cheery mother) who did say that lied.
Remember that suicide is terribly painful to others. They shouldn't have to deal with grief, guilt, and shame for generations because of your act. Suicide is more shameful, wrong as it is, in our society than murder.
If you do decide to do it, at least have the decency to do it properly. Don't merely shoot your face off, like the young man I met in my trauma ICU. Don't take just enough Xanax to spend the night in the Emergency Department, feeling more and more stupid as you slowly wake up. And don't take just enough Tylenol to damage your liver, so you can walk around yellow-eyed and swollen the rest of your life.
Suicide damages families. I know of a woman who killed herself, and the family tells each other stories about why and how, and some of them make up their own stories, and a lot of the facts don't fit, but no one mentions that. She killed herself in 1934, when my father was 16.
Don't think suicide ends it all. Nowhere near. It's an ugly start to sharing the pain that others didn't even know you were suffering. So start this way instead:
1. Tell someone - doesn't matter who as long as they know you.
2. Consider whether, as you are about to suck air into your lungs one last time, you might regret the choice. What will you do then? Nothing but die.
3. Think: no one else wants this. Only you want this. And maybe the devil. Don't give him the satisfaction.
If you believe in near-death experiences, people who've tried to kill themselves report much less satisfying experiences than others. Neutral, not joyful. I am counting on the joyful part of death myself.
I'm asking you, as someone who has seen too many people who've tried it and as someone who's contemplated it herself, not to do it. The voices that say you should are liars. The promise of ending your suffering is a lie.
So take your med's. and just try to go on - please.

the truth about angels and saints

2007-05-25T07:45:00.000-07:00

So they say to be merely a nurse is to help. Help sick people, poor people, dirty-faced little kids in need of hugs, and of course, to help doctors cure people. We are helping angels. We are saints. We are warmth in a cold, tiled hallway. We wear white dresses with white stockings, white shoes and usually white faces, too. Even after that chemo patient threw up on you and that drinker vomited blood all over the room, you still somehow remained white.

Nurses don't talk back. That surgeon who said you were ripe for the picking, like a nice, round, red cherry....he didn't really mean anything by it. They are just that way. When you felt the power drain from your body, and then when you felt powerless for not being able to keep from feeling powerless, it was just your feelings.

Everybody knows caring is not as good as curing. Everybody knows that talking with, monitoring, watching out for and teaching can't halt a killing blood clot in its path toward a feckless brain or image an athlete's torn meniscus with micron-sized resolution. Everybody knows nurses do what we are told, and things go just fine.

No one ever promised you wouldn't get backaches and heel spurs and bad dreams and reasons to burst out crying driving to the grocery store on Saturday morning. Yes, you may know the anatomy, pharmacology, pathology, psychology, theology and technology - but you are famous for smiling and doing what you're told so use that and nothing else, dear.

$33.75 an hour regardless of your graduate degree and 24 years of experience- every other weekend's mandatory: that's the contract language. The least experienced all work the night shift; it's always been that way. You get 15 minutes' break every 4 hours; that's the law. Try not to work overtime; it costs the hospital so much. And....by the way, we're short on Thursday and Friday - could you come in? It's unappealing for saints to negotiate, assert, determine, diagnose, advocate, act up, speak up and even save a few lives. Just don't talk about that part, okay? Clock out and go home, make dinner, put the kids to bed and kiss your husband, and when he is asleep, then think and grieve.

U.S. Healthcare is broken

2006-12-13T11:40:00.000-08:00

You've no doubt heard the title statement before. U.S. health care is indeed broken. We spend more of our GDP on health care than any other country in the world, but our outcomes are not superior. Our outcomes are not even as good as those of many other countries. Much internationally- cited medical research takes place on American soil, with American minds and American money. Nobel prize winners are disproportionately American - at least in the sciences. Individuals desiring advanced education travel from all over the world to our universities.

Yet we are the only industrialized nation without national health insurance. (South Africa lacks it, but apparently not everyone considers it "industrialized.") Some developing nations, and virtually all "first-world" nations provide better health care than the United States does to its citizens. With 40 million people lacking health insurance, and health care expenses the predominant cause of personal bankruptcy, plainly something is wrong here.

Pharmaceutical and medical device companies, insurers and the top-paid physicians (not all of them) are profiting from a system that is partly private, profit-driven and partly publicly-funded. The private interests don't want to give up their stake to an entirely public system in which they would cease to exist or make much less money, but the public system as configured now can't go on not benefitting from the lower-risk, lower-cost pool of insureds who are taking part in the private system. Those in the public system are the high-utilizers: the debilitated, the chronically severely ill. This pool of health care consumer is tremendously costly to care for, and the private system stays ahead by maintaining the prerogative to simply dump these people onto the public sysem when they become too costly to insure. Our system is largely tax-dollar funded, make no mistake: 60% of American health care is paid for in the public system through Medicare and Medicaid. Virtually all residents of long-term care facilities, for example, are cared for in the public system.
This intricate power tapestry has to be unraveled. A single, shared system, not a hybrid of public and private interests has to prevail if any semblance of justice is to be achieved.

Costly and innovative new therapies are developed and brought into medical usage without accounting for the costs. It is simply assumed that a $40,000/year cancer drug is worth the cost. People receive bone marrow transplants and then are pushed onto a system that lacks the resources to provide sufficient followup care. Insurance pays for three home health nurse visits regardless of the real needs of the older adult who has had a hip replacement. Fabulous new diagnostic imaging systems costing many millions are assumed to be worthwhile in the absence of evidence for them. Invasive procedures do not have to be shown cost-effective, merely safe for human use, before they are adopted into medical practice. In fact, there is no governing body for medical procedures at all, as the FDA governs drug approval. And no one pays attention to costs but the insurers and, of course, the patient who files for bankruptcy because his retirement fund was not large enough to cover a catastropic illness. This situation permits medical values (which are far from sinister, but biased nonetheless) to drive medical expenditures.

We need to reconsider our objectives and this will require a hard look at the values that drive health care. Medicine values life. Physicians are socialized to view death as failure, as the enemy. If a chemo drug doesn't stop a patient's cancer in its tracks, they say "the patient failed chemo." They "battle" disease. This "war on disease" mentality lacks perspective. Everyone will die. The discipline of medicine has succeeded (with help from personal hygiene, public sanitation and so forth) in extending lifespan considerably. Thanks to medicine, very few women now die in childbirth, which two centuries ago was a huge cause of premature mortality.

Our expanded lifepsan, however, has had consequences. It made senile dementia, cancer and heart disease part of our everyday lives. These are not diseases prevalent in societies where people died before 40 years of age. These are aging-related diseases. So now we need to deal with these diseases, and they are much more complex than the ones medical science solved in past centuries. They cannot be wiped out by a course of antibiotics. It's not by neglect that we haven't discovered "the cure" for cancer. It's because there is no one cure. This pathological process is tremendously complex; as soon as we've cut off one head, it sprouts another. We now have longer lifespans that are still lengthening, and older people who develop diseases that put huge demands on the health care system, leading to ever-increasing costs because we have not had the guts to draw the line somewhere, fearing it will be arbitrary wherever it is drawn.

We have to embrace realistic values that value human life but recognize limits, and then we have to draw that uncomortable line.