Wednesday, November 30, 2011

A Nurse is a Nurse is a Nurse?

Many years ago, I was a nursing student, pregnant with twins. I was placed on bedrest shortly after graduating, and ended up going into premature labor because of food-poisoning, which we later learned was Listeria. The boys were born 8 weeks early, were both on ventilators for a week, and stayed in the neonatal ICU for about 5 weeks before we could bring them home. My experience mothering those tiny boys inspired me to choose a position in the neonatal ICU, and eight months later, I started working. Most RNs fresh out of nursing school do not go straight into ICU, but I couldn't think of anything I wanted to do more. It was very challenging at first, and scary! I was part of the neonatal resuscitation team, which involved attending high risk deliveries as well as C sections, and intervening in whatever way necessary to stabilize a sick or premature infant. The neonatologists in our ICU were quite progressive: we were on a first-name basis with one another. We were permitted to become checked off in a variety of procedures, such as arterial and umbilical line placement and needle decompression of a punctured lung, in addition to ventilator management and routine care of these sick babies. Because of the nature of our work and our passion for it, we all became very highly specialized with a unique set of skills. Then, a for-profit, managed care organization took over our hospital. This brought about many changes in personnel and procedures, the most disturbing of which was the notion that "a nurse is a nurse is a nurse." For us, this meant that we were expected to cross-train in labor and delivery, another highly specialized branch of nursing. This was an absolutely preposterous, and potentially disastrous, plan. We were expected to spend three 12 hour shifts in labor and delivery, working alongside with a preceptor, and at the end of this 36 hour period, voila, we were going to be obstetric nurses! At the time, I was finishing up my bachelor's in nursing, and taking chemistry and physics courses in preparation for application to medical school. The internet had only recently become widely accessible, and I started doing a bit of research into cross training. What I found didn't surprise me; there were a wealth of papers already written on the subject, many of which focused on concerns about patient safety. The statistics on cross training weren't good: patient safety was jeopardized, job satisfaction went down, and the quality of care did not improve. I think what bothered me the most was the idea that we were now being perceived as warm bodies to fill a slot, instead of the professional, specialized nurses that we were. I compiled the statistics into a letter to our director of nursing, explaining why I would not be participating in the cross-training experience. Many of my co-workers initially signed the letter, but then, whited out their signatures for fear that they would lose their jobs. I was a little worried, too, but felt I had provided solid evidence to prove my point. A couple of days after receiving my letter, the director of nursing called me for a meeting. To my surprise and relief, she agreed with me on this issue. Shortly after that, I got accepted into medical school, and left nursing altogether. I think this incident was probably the genesis of my deeply rooted commitment to patient advocacy and professionalism...the idea that 36 hours of training on labor and delivery would make me competent to care for obstetric patients was just so incredibly absurd, dangerous, and disrespectful that I simply had to fight back.

Monday, November 28, 2011

Post Call Funk

     I am post-call and feeling funky, in the most unpleasant way. Taking 24 hour in-house call is like being an anesthesiology resident all over again: unpredictable emergencies of all kinds at any given hour are de rigueur, which combined with little or no sleep, create a Circadian biorhythmic hell. You get strange consults from the ICU at 3 a.m. that usually involve a request to place a central or arterial line in someone who is barely being kept alive on a ventilator with maximal hemodynamic support through a tiny peripheral IV, along with continuous dialysis. You are essentially being asked to go fishing for IV or arterial access on a dead person. Sometimes, the person actually has "do not resuscitate" orders on his or her chart, but these appear to be largely ignored in the quest for last ditch interventions.
     I am perpetually amazed by the lengths physicians will go to sustain life, with a seemingly complete disregard for the quality of life (or lack thereof) that is to follow. As a physician, I have sworn to "do good" and "do no harm" to my patients: to me, this includes knowing when to stop! I am somewhat of an anomaly in the world of private practice anesthesiology because I value patient safety and advocacy at the expense of "cutting corners" to keep surgeons and interventionists cranking out elective cases so that hospital and insurance administrators can stay very, very rich. Why does there even have to be such a trade off? Until American healthcare becomes less focused on expensive damage control, and gets out of bed with the insurance industry, big pharma, and greedy corporations, physicians will continue to be pressured to "produce", instead of "prevent".