One would think that patient care is the linchpin on which healthcare turns and the most important consideration of providers, yet these days there are instances, too many of them, when your care is not their priority.
I shy away from this topic. It's painful to consider, risky to acknowledge, and might seem self-serving, you know, the whining nurse looking for sympathy and an easier ride. But the day nurses stop educating and advocating for patients is the day we lose our souls, and patients, together with those who care about them and who might one day themselves become patients, have a right to understand how healthcare works and a duty to join with us to make it better when there are deficiencies that threaten both individuals' health and safety and public health and healthcare overall, now even with its astronomical bottom line not assuring good clinical outcomes or even basic safety.
Just a few days ago popular medical blogger KevinMD sounded the clarion call, writing about the need to reduce nurse burnout (http://www.kevinmd.com/blog/2016/01/reduce-nurse-burnout-treating-nurses-well-treat-patients.html), and noting that "the most overwhelming parts of nursing are the constant system failures" and that "health care organizations . . . function in a way that requires nurses focus more of their limited time and attention diagnosing system needs rather than focusing on patients['] care." That's not about making life cushy for nurses; rather it's the reason your pain medication is late, very late; your call light unanswered for an hour; your questions not heard, much less answered; and the significant decline in your condition unrecognized. Your nurse isn't off sitting in a break room somewhere absently thumbing through a tabloid while chatting on the phone with her boyfriend and waiting for her nails to dry. More likely your nurse hasn't sat down anywhere since arriving at work, her boyfriend long since gave up hope of being able to talk with her at all on days she is working (if he hasn't departed to take up with a more available partner), and she can't remember when her work-worn hands, chapped from being washed so often, last had a manicure.
Writing in The New York Times the very next day, Robert M. Wachter noted the problem of "businesslike efforts to measure and improve quality" having the result that "even superb and motivated professionals . . . come to believe that the boatload of measures, the incentives to 'look good,' had led them to turn away from the essence of their work" (http://www.nytimes.com/2016/01/17/opinion/sunday/how-measurement-fails-doctors-and-teachers.html?src=me&_r=0).
Both writers describe the problem of provider burnout and turnover; beyond this there is an abundance of data demonstrating the correlation between such variables as nurse staffing and clinical outcomes. Today I add my voice, telling you that the problem extends beyond hospital walls and into your own living room, which is to say that the beast of burnout is alive and well in home healthcare, too, with its fire-breathing ways threatening the clinical assessment and care you receive from the one who perhaps is the only healthcare professional you currently see. While hospitalized, patients see many doctors, nurses, technicians of various sorts, and perhaps therapists, dietitians, social workers, and others, and behind the scenes pharmacists are reviewing every drug order, a radiologist reads x-rays before the ordering doctor ever sees them, "case managers" are overseeing care, and more, so if something is missed or an error made, there is some likelihood that someone will notice. But it's a different story at home.
There, it's you, and your nurse and/or therapist(s) who visit intermittently (and never together, as Medicare and others frown on that no matter the benefits of joint practice and collaboration. Indeed, "care coordination" is required, but not permissible face-to-face and in the presence of the patient. Go figure.). If your home healthcare clinician misses something or hurries through instructions so that you don't understand exactly what to do the consequences can be grave before anyone else has occasion to notice.
The Centers for Medicare and Medicaid (CMS) determine what Medicare will reimburse and how the amount is determined. Most other insurers follow the CMS lead. This has resulted in a lengthy and cumbersome assessment tool along with a slew of documentation and "quality" requirements that nurses and therapists must complete. CMS further stipulates exactly which services within each professional discipline are reimbursable, and the requirements beneficiaries must meet to be eligible for any services in the first place. Clinicians must document, repeatedly, precisely which qualifying services have been rendered and that patients who received these services were verified, over and over, to be eligible for them. Individual states toss in additional parameters their surveyors will assess, as do accrediting bodies and organizations that purport to evaluate various forms of quality and bestow distinctions accordingly, or not (the "Magnet" designation for excellence in nursing is an example).
So when your nurse arrives on your doorstep for the very first time, no matter what problem or diagnosis you have, no matter what you need, how you feel, what your questions are, or what you already know, she or he will "teach" you how to be safe in your own home, even in the absence of any discernible safety risks, dangerous conditions, or lack of understanding on your part. Your nurse is required to determine whether or not you have received influenza and pneumonia vaccines and if not, why; whether or not you are depressed; how long it takes you to rise from a particular type of chair, walk ten feet, return to the chair, and sit down again; your nutritional risk, probably using a tool that doesn't actually measure risk at all; the likelihood that you will develop bedsores, again often using a tool developed for inpatient use whose indicators as operationalized there have little meaning in the home setting, and more. Your nurse is required to have you demonstrate, not just explain, how you step in and out of the bathtub or shower, how you dress yourself, how you walk, and how you get in and out of bed and up and down from a chair. The nurse must assess your pain and ask you to rate it on a ten-point scale; if you have no pain at all you still must give it a number. The nurse must discuss advance directives, your rights and responsibilities as a home healthcare patient, what constitutes an emergency and what to do if an emergency arises, how to contact the home health agency and what to do if you have a complaint, your treatment plan, and if for some reason you are inclined ever again to let this person into your home, when she or he will return and how often. Your nurse may be required to screen you for ebola risk or any other hot button issues of the day, and will have forms to fill out and forms for you to sign. Then your nurse can begin to examine you and assess your particular needs. He or she must look at and make a record of all the medications you have on hand and must reconcile this with the list provided by the hospital or your doctor. If you need to learn how to care for a wound or give yourself an injection or check your blood sugar or anything else, the nurse must teach you that. The nurse must be sure you have at least a basic understanding of your health problems and know when and how to reach your doctor. And the nurse must be "nice," assure that somehow in spite of all of this you are "satisfied," and discreetly keep repeating that she or he is providing "excellent" care so you will remember that word and rate the agency's services as "excellent" when completing your post-discharge survey.
In addition, after leaving you the nurse will need to spend at least one to two hours documenting this visit and filling out the required forms. Yours will be but one of five or six visits your nurse is expected to make that day, perhaps one or two less if some of the patients are new to home healthcare. Your nurse will travel through all kinds of weather, traffic, and road conditions, will deal with the absence of parking spaces and house numbers, and will respond promptly to all calls and email. If you or any of his or her other patients need lab tests, your nurse will draw the blood and/or collect other specimens, drive to some lab, find parking, walk to the appropriate location, do more paperwork, and then go back to the car to resume the day, without an extra penny or allowance for the time and effort this requires. Your nurse will attend endless meetings, complete online courses and in-person training whether or not she or he already has demonstrated mastery of the topic, and jump through a seemingly infinite number of hoops to obtain supplies for you, whether a gauze pad or an oxygen machine or anything else. Your nurse will chase doctors, track down those lab test results and see that they get where they need to go and that appropriate action is taken, and make many, many phone calls from home at night. Your nurse also will have his or her documentation questioned by people who haven't ever seen you and often haven't seen any patient at all for years, if ever, but who want to maximize the dollar amount to be made from your case. And, generally your nurse will be paid a modest, flat fee for making each visit to a patient, period. This means that time spent going to and from labs, making phone calls, sitting in traffic, documenting, and all the rest is uncompensated, with meetings and required training often compensated at a lower, below-market rate because those are not billable activities.
If you believe nurses actually do all of this every time they admit patients to home healthcare please message me: I have a bridge for sale in Brooklyn that you'd just love, and some land in Florida, too!
For one thing, our patients are sick or we wouldn't be there. Often they are elderly and have many problems at once. CMS requires that they be "homebound," which, while not meaning that they need to be absolute shut-ins, does mean that going out is a hardship and is something they do infrequently, usually for essential medical appointments. Suffice it to say they're often weak and frail. And if people just have returned home from the hospital it's a sure bet they're tired, because these days hospitals aren't places where people can rest. Nurses know no one in these circumstances can tolerate hours of "assessment" and "instruction."
Nurses also need to self-protect, the "Don your own oxygen mask first" principle. If nurses work eighteen hour days in order to meet requirements and see enough patients to make the money needed to pay their bills they'll soon hurt someone or have an accident themselves. So something has to give. Similarly, being compensated on a per-visit basis and having a "productivity" quota to meet for their employers, nurses need to be sure to make enough duly billable visits. If patients cancel appointments, are admitted to the hospital, suddenly decide to go stay with family at another location, or miss scheduled visits for any other reason their nurses suffer financially and may be penalized for failing to meet the productivity quota, unless it is possible to add more and more visits to subsequent and already full days. That breeds haste, less than thorough care, and heightened potential for errors.
Whatever the specifics of your situation, this may mean all the drop-down boxes on your medical record aren't checked on the basis on an actual assessment. Your nurse may have determined that it was more important that you be able to manage your IV line than that you be screened for ebola risk or that you demonstrate stepping into the shower, but those parameters still must be documented. So in the best of circumstances the nurse makes an educated guess, and uses the visit time to meet your most pressing needs rather than marching through all the required items at the expense of your and/or his or her own welfare.
But it takes an experienced nurse with keen clinical acumen to know which corners safely can be cut, as well as a certain amount of savvy to avoid detection in doing so. The less experienced and less well initiated do burn out and move on, if they're not first caught in the snare of an unfortunate error of judgment or practice. And even the veterans can guess wrong, or, being human, be swayed by such self interest as the need to compensate for canceled appointments by packing more visits into a single day than can be managed safely and well.
Not long ago I was called to see a patient who told his Physical Therapist that he had developed a sore on his foot in the hospital and although he thought it had healed it was bothering him. I found a massive pressure ulcer that could not have developed in the short time the patient had been home, meaning that the nurse who admitted him to home healthcare and determined that there were no needs for nursing, and that the patient needed only Physical Therapy, never examined that foot, even though the patient's particular problem put him at high risk for just that sort of wound in just that location. Instead, the nurse documented that the patient's skin was intact with no lesions or irregularities present. The untreated wound that the nurse overlooked and the patient couldn't see subsequently had significant adverse consequences for that patient.
Even more recently I read the clinical note of the home health nurse who saw a patient I had followed in the hospital. The patient had a complex medical history, but was hospitalized for a heart attack and had needed open-heart surgery. The home health nurse documented extensive diabetic teaching, and not a word about the patient's cardiac status or care. The patient had been diabetic for years, and control of that condition was not a current concern. A colleague who read the same note remarked that it looked like it had been "cut and pasted" from a standard template, something that certainly would have made the documentation process easier and faster. Although I imagine the nurse who saw this patient was "nice" and the visit may have been very pleasant, the job that needed to be done wasn't, and the patient was left at risk and uninformed. I wonder if she remembered to respond that she had received "excellent" care when her post-discharge survey arrived.
A Physical Therapist colleague has told of discovering that another therapist had been caught pushing an elderly, blind patient to hurry her through the session, while yet another therapist saved time and made money by having patients sign multiple visit forms when only one visit was made. That's fraudulent, and if caught would have cost the therapist his license, a hefty fine, and perhaps jail time, but it happened.
I don't believe people choose careers in healthcare and complete rigorous collegiate and often post-graduate training because they want opportunities to push elderly blind people, ignore wounds, teach irrelevancies, or commit fraud. That these happen is an alarm all need to hear, warning that something is going terribly wrong among good people who once had high ideals, passion for a profession, and a commitment to service. All too often in 2016 paperwork and profit are being prized over patients, supposed measures of quality are valued above quality itself, and looking good is valued more than doing good. The toll on providers is beyond sobering, and when you are a patient the cost to you may be extreme
When Your Care Is Not Their Priority
Wednesday, January 20, 2016
Wednesday, January 13, 2016
Blue Jeans
Blue jeans, soft, worn, and fitting just right do bespeak comfort, relaxation, and absence of pretense, but I never thought my jeans on my body would have that affect on someone else!
It was a cold, gray, late autumn afternoon back in the days when I routinely rose at 4:15 AM in order to be ready to make home visits in "the projects" while the local rabble rousers still were sleeping off the effects of the previous night. Starting that early meant I often was home by early afternoon and never making calls after dark unless I was "on call" and covering an emergency. That day had been rainy, with that penetrating dampness and cold that sets one's bones to shivering, and I was more than glad to go home to a warm house and slip into my favorite jeans and a soft, cozy sweatshirt. But then the phone rang.
"Corazón" needed a visit, that day. I had picked up a second, part-time job not long before, and Corazón, an elderly Mexican woman, was one of my early patients with that new company. I don't remember now what problem had arisen, but it was unlikely that anyone else in that very small and minimally staffed agency was available to see her. Darkness was gathering, meaning that I'd been going non-stop for twelve hours or more, and the prospect of taking the car out of the garage, driving the three or four miles to her home through late afternoon traffic, and then doing whatever it was that Corazón needed only left me feeling all the more tired. But I would go, I said to the caller, even though I cannot bring myself to change into proper work clothes once again, I told myself. Throwing on a coat, grabbing the necessary supplies, and beckoning my German Shepherd into the back seat, I set out.
Corazón lived with her son, "Joe," a big, imposing man with an air about him that suggested he was chronically dubious about everything. Behind eyes that seemed to think and feel much more than he ever said, he always had been receptive and courteous, but reserved, and as I drove I was a bit concerned about appearing too casual and therefore disrespectful in duds more suited for a night on the couch or a trip to the dog park than to a home visit to provide professional healthcare. But on that day at that time that family was lucky not to receive a nurse in a robe and pajamas, as my director said a few days later when I recounted this story to her. I climbed the front stairs and rang the bell.
Joe responded, and I launched into my explanation that I'd just learned Corazón needed me and had opted to respond quickly instead of taking the time to put myself together in a more professional-looking package.
I don't know that the first sentence was out of my mouth before Joe's face softened, all of the tentativeness and skepticism I might have sensed in our earlier encounters evaporated like a drop of water on a hot grill, and with a huge smile he ushered me into the home. Likewise, Corazón's smile when she saw me lit up her cramped little bedroom more than all the lamps in the home ever could have done. It was unsettling, the sensation one has when tempted to turn around to see if people are looking at and talking to someone else.
Understand that my normal dress for home visits is practical and not fancy or pretentious. If I need to climb on a bed or sit on the floor I do it, and any of a number of possible accidents could result in the need for a sudden change of clothes, so nothing requiring a trip to the dry cleaner or other high maintenance fussing is in my work wardrobe. Washable dresses, skirts, and slacks fill the bill and, one would think, hardly are off-putting.
But something about seeing me on the front porch in the cold dusk with jeans poking out below my coat and sweatshirt sleeves edging over its cuffs put Joe at ease more than ever before, and moments later, Corazón, too.
Throughout our remaining days together Joe's polite cautiousness and undertone of skeptical reserve never reappeared. Not once. It was so much easier to work in that home with the barriers dropped and only authentic connection remaining. And then came the moment when everything stood still.
After reviewing her latest test results Corazón's doctor told me her vital organs were failing irreversibly and there was nothing to be done that would save her. It was time for the family to make a decision about hospice care. All these many years later I don't remember for sure, but I hope the doctor had had a similar conversation with Joe. Corazón was bedbound at home, however, so the doctor would not have been able to talk directly with her.
I remember arriving at the home and talking with Joe about his mother's prognosis and the need to consider hospice care, and noting gently that someone needed to tell her and learn her wishes. Without missing a beat Joe responded, "You tell her." I asked him to consider whether this message might best come from a family member, priest, or even the doctor by phone, but Joe was firm: "You tell her." In Spanish, my second language, in which I yet was less than fluent at that time. "Really?" I asked. "Yes," he said firmly.
In over forty years as a nurse I don't believe there's been another time when I was the first and only person to tell someone that his or her body was failing, medicine could not change this, and she or he was going to die. There's the usual "We will keep you comfortable and help you to have as much good time as you possibly can" addendum, and then the "You will have medical and nursing care and the help you need as long as you live; now we need to decide how that is best to be provided" preliminary to the hospice discussion. But the whammy is the "There's nothing more we can do; I'm sorry" message. In Spanish.
As so often is the case, despite not having been told Corazón already knew, and she comforted me. I didn't see her for much longer after that, as she did enroll in hospice care. But before we parted ways, she made me a bracelet, in the colors of the Mexican flag, which to this day is one of my prized possessions.
I have thought off and on over the years since then that what turned the tide from perfectly adequate and polite encounters to something more profound was my happening to turn up in a sweatshirt and jeans on that one cold, dark late afternoon. Since then, although I have my respectable suits, white coats, and "business casual" garb and do wear them, I've turned up on many a doorstep in jeans . . . and even a bicycle helmet. And I've wondered if sometimes our "professionalism," or at least its symbols are ironic barriers to the authentic connections with those we serve and seek to influence intimately. I'm not advocating widespread dressing down; surely there is reassurance to be had when our doctors look like doctors and other professionals do the same, and how we dress affects how we conduct ourselves in the workplace. But that latter? That's the rub. We need to be mindful, I think, of any tendency to act out the role associated with the clothes we wear, because any acting is a way of being that is less than authentic. And it is compromised authenticity that others sense and from which they pull back.
These days I wear a white coat a good bit of the time, but make a point when I don it to be sure I'm not hiding behind it, and that in my speech, my demeanor, my smile, my being I am as fully present and real as I can be. Because no matter what our business and professional costumes may be - white coat, suit, clerical collar judicial robe, whatever - what most matters and assures the best outcomes is the sort of connection that comes with such things as
Blue Jeans.
It was a cold, gray, late autumn afternoon back in the days when I routinely rose at 4:15 AM in order to be ready to make home visits in "the projects" while the local rabble rousers still were sleeping off the effects of the previous night. Starting that early meant I often was home by early afternoon and never making calls after dark unless I was "on call" and covering an emergency. That day had been rainy, with that penetrating dampness and cold that sets one's bones to shivering, and I was more than glad to go home to a warm house and slip into my favorite jeans and a soft, cozy sweatshirt. But then the phone rang.
"Corazón" needed a visit, that day. I had picked up a second, part-time job not long before, and Corazón, an elderly Mexican woman, was one of my early patients with that new company. I don't remember now what problem had arisen, but it was unlikely that anyone else in that very small and minimally staffed agency was available to see her. Darkness was gathering, meaning that I'd been going non-stop for twelve hours or more, and the prospect of taking the car out of the garage, driving the three or four miles to her home through late afternoon traffic, and then doing whatever it was that Corazón needed only left me feeling all the more tired. But I would go, I said to the caller, even though I cannot bring myself to change into proper work clothes once again, I told myself. Throwing on a coat, grabbing the necessary supplies, and beckoning my German Shepherd into the back seat, I set out.
Corazón lived with her son, "Joe," a big, imposing man with an air about him that suggested he was chronically dubious about everything. Behind eyes that seemed to think and feel much more than he ever said, he always had been receptive and courteous, but reserved, and as I drove I was a bit concerned about appearing too casual and therefore disrespectful in duds more suited for a night on the couch or a trip to the dog park than to a home visit to provide professional healthcare. But on that day at that time that family was lucky not to receive a nurse in a robe and pajamas, as my director said a few days later when I recounted this story to her. I climbed the front stairs and rang the bell.
Joe responded, and I launched into my explanation that I'd just learned Corazón needed me and had opted to respond quickly instead of taking the time to put myself together in a more professional-looking package.
I don't know that the first sentence was out of my mouth before Joe's face softened, all of the tentativeness and skepticism I might have sensed in our earlier encounters evaporated like a drop of water on a hot grill, and with a huge smile he ushered me into the home. Likewise, Corazón's smile when she saw me lit up her cramped little bedroom more than all the lamps in the home ever could have done. It was unsettling, the sensation one has when tempted to turn around to see if people are looking at and talking to someone else.
Understand that my normal dress for home visits is practical and not fancy or pretentious. If I need to climb on a bed or sit on the floor I do it, and any of a number of possible accidents could result in the need for a sudden change of clothes, so nothing requiring a trip to the dry cleaner or other high maintenance fussing is in my work wardrobe. Washable dresses, skirts, and slacks fill the bill and, one would think, hardly are off-putting.
But something about seeing me on the front porch in the cold dusk with jeans poking out below my coat and sweatshirt sleeves edging over its cuffs put Joe at ease more than ever before, and moments later, Corazón, too.
Throughout our remaining days together Joe's polite cautiousness and undertone of skeptical reserve never reappeared. Not once. It was so much easier to work in that home with the barriers dropped and only authentic connection remaining. And then came the moment when everything stood still.
After reviewing her latest test results Corazón's doctor told me her vital organs were failing irreversibly and there was nothing to be done that would save her. It was time for the family to make a decision about hospice care. All these many years later I don't remember for sure, but I hope the doctor had had a similar conversation with Joe. Corazón was bedbound at home, however, so the doctor would not have been able to talk directly with her.
I remember arriving at the home and talking with Joe about his mother's prognosis and the need to consider hospice care, and noting gently that someone needed to tell her and learn her wishes. Without missing a beat Joe responded, "You tell her." I asked him to consider whether this message might best come from a family member, priest, or even the doctor by phone, but Joe was firm: "You tell her." In Spanish, my second language, in which I yet was less than fluent at that time. "Really?" I asked. "Yes," he said firmly.
In over forty years as a nurse I don't believe there's been another time when I was the first and only person to tell someone that his or her body was failing, medicine could not change this, and she or he was going to die. There's the usual "We will keep you comfortable and help you to have as much good time as you possibly can" addendum, and then the "You will have medical and nursing care and the help you need as long as you live; now we need to decide how that is best to be provided" preliminary to the hospice discussion. But the whammy is the "There's nothing more we can do; I'm sorry" message. In Spanish.
As so often is the case, despite not having been told Corazón already knew, and she comforted me. I didn't see her for much longer after that, as she did enroll in hospice care. But before we parted ways, she made me a bracelet, in the colors of the Mexican flag, which to this day is one of my prized possessions.
I have thought off and on over the years since then that what turned the tide from perfectly adequate and polite encounters to something more profound was my happening to turn up in a sweatshirt and jeans on that one cold, dark late afternoon. Since then, although I have my respectable suits, white coats, and "business casual" garb and do wear them, I've turned up on many a doorstep in jeans . . . and even a bicycle helmet. And I've wondered if sometimes our "professionalism," or at least its symbols are ironic barriers to the authentic connections with those we serve and seek to influence intimately. I'm not advocating widespread dressing down; surely there is reassurance to be had when our doctors look like doctors and other professionals do the same, and how we dress affects how we conduct ourselves in the workplace. But that latter? That's the rub. We need to be mindful, I think, of any tendency to act out the role associated with the clothes we wear, because any acting is a way of being that is less than authentic. And it is compromised authenticity that others sense and from which they pull back.
These days I wear a white coat a good bit of the time, but make a point when I don it to be sure I'm not hiding behind it, and that in my speech, my demeanor, my smile, my being I am as fully present and real as I can be. Because no matter what our business and professional costumes may be - white coat, suit, clerical collar judicial robe, whatever - what most matters and assures the best outcomes is the sort of connection that comes with such things as
Blue Jeans.
Wednesday, January 6, 2016
My Doctor Needs a Nurse
My doctor needs a nurse.
Several weeks ago while trying to find the ATM at an unfamiliar bank branch I found an unexpected patch of ice instead, and down I went, shattering the end of one of the long bones in one arm, rotating it forty degrees out of place, and bending it backwards. It was not one of my better days. After a stint in the ER I landed in the office of an orthopedic surgeon who took one look at my X-rays and explained that surgery was the only way to put me back together, and not long thereafter I had an opportunity to see the OR from a patient's perspective. Fortunately, the doctors were able to realign my broken parts without nearly the cutting and hardware they had anticipated, and I emerged with what looked like a mummified extremity and was dispatched home to recover.
By the next week I was feeling pretty chipper, if clumsy and less than glamorous wearing the sweatshirts and jacket of a large male friend (the only duds that fit over the surgical dressing on my arm), and set out for my first follow up appointment with the surgeon. I hadn't needed pain medication for a few days, and acute orthopedics not being my field it didn't occur to me to take any that morning.
It's standard practice to ask patients to rate their pain on a ten point scale, with zero being no discomfort at all and ten being the worst possible pain a patient can imagine. When that dressing came off my pain was 23/10, no doubt about it. Any movement or touch was excruciating, and I became lightheaded and nauseated just being examined. The surgeon told me my X-rays looked very good and I was healing well, and having ascertained that nothing was wrong medically proceeded to reposition my hand the way it needed to be for the new cast (pain 52/10). The orthopedic technician then went to work constructing that device (pain holding at 52/10, with me lying down on the table at that point so I wouldn't fall to the floor if I fainted). Once the arm was casted I felt better, although I probably took more pain medication that day than I had the entire previous week.
Fast forward another week and I was feeling like a new woman, swinging my cast around and mastering all manner of one-handed tasks. Preparing for my next appointment with the surgeon I considered taking pain medication, but felt so well that I opted against it. After all, I'd had an entire additional week to heal!
But back in the doctor's office there was a repeat of the previous week's experience, complete with me stretched out on a gurney in the cast room to keep from toppling over.
By the following week I was using the hand of the casted arm more, and had mastered carrying laundry baskets, washing dishes, and vacuuming . . . but, even so, before returning to the surgeon I loaded up on pain medication such as I hadn't taken since my first post-operative day. And the exam, x-rays, and casting process were the proverbial piece of cake, even if the patient was a little "loopy" all the while!
My doctor is on staff at multiple hospitals, chairs the department of orthopedic surgery at a major university, and works in the office of a large and busy orthopedic practice where the air of sophistication and competence is unmistakable. I see many distinguished and renowned surgeons bustling about when I'm there, as well as the technicians who make and fit the various devices that orthopedic patients need, assorted office staff, and a warm, funny, efficient medical assistant who keeps my doctor's practice humming. But I have yet to see a nurse.
And if there were a nurse on hand, I never would have experienced 23/10 or 52/10 or any number much above 4-5/10 again, no matter what the doctor and others were doing.
There are six parameters that nurses assess and manage, regardless of practice setting or specialty. I summarize them crudely when I teach so students easily can remember, and to this day call to mind the same six words every time I look at a patient and ask myself, "Is there anything else? What have I missed?" Those words are: Eat, sleep, move; pee, poop, pain.
No matter what sort of problem a patient has, what kind of doctor she or he is seeing, or where the encounter takes place, a nurse wants to know if and what a patient is eating, the extent to which this meets nutritional needs, and if there are problems or concerns surrounding intake of nutrients and fluids. If the "eat" cue triggers a nurse's radar there are a million assessment parameters and questions that may follow, but whether briefly or in depth, "eat" is assessed and evaluated.
Likewise "sleep." Is the patient resting and sleeping well or poorly, too much or too little, with or without aids? Are there nightmares or discomfort, does the patient need to be in a special position, does anything disrupt sleep?
And "move." How much or how little, how well or with what difficulty,is the patient moving? Are there pain, breathlessness, inertia, or simple bad habits? Is movement safe? How is posture, gait, and the process of getting up and down? Are there indications of complications of decreased mobility, such as skin breakdown, fluid in the chest, or extremities that no longer straighten out all the way? Is the patient manic, constantly in motion, anxious and agitated, unable to relax? How about balance, endurance, and the ability to execute movements needed to do daily tasks? Movement is a parameter that speaks volumes to the astute clinical nurse.
For all the jokes about elimination, it matters. Too much or too little, abnormal character of output, too many or too few trips to the bathroom, bleeding or pain or other symptoms, indications that waste is being retained instead of eliminated, it all matters. And more.
And pain. Is the patient comfortable, and if not, why? Location, severity, onset, duration, what makes pain better and worse, what the patient does to manage pain and how effective those actions are, how the patient copes, whether pain is acute or chronic; it's all important. Is pain physical, emotional, spiritual, or other? What's the patient's story about this aspect of his or her experience?
Eat, sleep, move; pee, poop, pain: This is what a nurse does.
I smiled more than once coming out of surgery and preparing to go home. Rolling me out of the OR the nurse asked if I needed to use the restroom. My first thought was, "Why? I haven't had anything to eat or drink since yesterday, and it's now afternoon!" But I realized I no doubt had been pumped full of IV fluids in the OR . . . and that the nurse needed to be sure I could urinate before I left. Once I was settled in post-op recovery the nurse offered me a sandwich and some juice. Processed turkey meat stuffed between two slices of white bread was the most delicious meal I'd had in my life, and I noticed the nurse noticing my wolfing it down. I did walk to the restroom, and dressed with the assistance of the friend who would take me home, and of the nurse. "Would you like a wheelchair when you leave, or do you think you can walk?" the nurse asked. "I think I can walk," I responded. "I think so, too, " she replied, with a tone both warm and deliberate such that I realized I had been assessed and deemed safe. A lay person might say, "Oh, the nurse was nice, and brought me something to eat and helped me get dressed," but I know that "eat, eliminate, and move" had been assessed and evaluated carefully. "Sleep" had been well monitored in the OR, and the nurse had instructed me about pain management before I went to surgery, explaining that afterwards I would not be in any condition to remember what she said.
Eat, sleep, move; pee, poop, pain: This is what nurses do.
And when we find problems, the solutions are not necessarily medical. A patient with nutritional issues may need a dietician or simply someone to go to the grocery store, not a doctor. Another with mobility problems may need a Physical Therapist, not a physician. Patients who are eating poorly, falling, and living in a dirty homes because they are alone and without help may need a social worker to set them up with community resources and support services, not more medicine.
Everyone needs to eat, sleep, move, eliminate, and be comfortable; hence everyone who engages in a healthcare encounter should be assessed by a nurse. Exceptions might be the person who needs only to pop into the local pharmacy for a shingles vaccine or a clinic for a TB test required by an employer, but where there are health problems to be solved, health screening and prevention to be done, and long term coping and planning to be managed, patients, all of them, need nurses.
Had there been a nurse in my surgeon's office, she or he would have insisted that my pain be managed. My doctor had examined me and looked at my x-rays; he knew that there was no medical issue of concern. The business of diagnosis and treatment, which is what doctors do, had been done, and while sympathetic, he was not overly concerned about my discomfort given that he understood there was nothing medically wrong. But a nurse would have said, "We need to manage this," and not let up until that was done. A nurse would have instructed me to pre-medicate in the future, and explained why (although my arm is healing, I still have a fracture. When the cast is removed there is no support for that broken part, and the weight of my hand is supported only by the wrist that is broken. That hurts!). An orthopedic nurse would have understood the movement and positioning that the doctor wanted, and would have guided and taught me to do this properly, as opposed to the doctor's saying, "Do it!" and scowling when I didn't quite do it right. A nurse would have asked how I was managing at home, and would have known if I was eating properly, including the nutrients I need for healing, if I was resting well, if the medications I was taking had caused constipation or diarrhea, and if I was moving about and functioning reasonably well and safely.
And a nurse in the office would have saved the practice time and money. Having me dizzy, nauseated, and unable to move or cooperate took more of the doctor's and technician's time, and that translates into dollars lost. Is this enough to offset the expense of a nurse's salary? Multiplied by the number of patients going to that office and the number of needs and problems they have that a nurse can anticipate, prevent, solve, and/or minimize, the answer is a resounding "Yes!"
Better care, better clinical outcomes, greater efficiency and cost effectiveness, there's no doubt about it:
My Doctor Needs a Nurse.
Several weeks ago while trying to find the ATM at an unfamiliar bank branch I found an unexpected patch of ice instead, and down I went, shattering the end of one of the long bones in one arm, rotating it forty degrees out of place, and bending it backwards. It was not one of my better days. After a stint in the ER I landed in the office of an orthopedic surgeon who took one look at my X-rays and explained that surgery was the only way to put me back together, and not long thereafter I had an opportunity to see the OR from a patient's perspective. Fortunately, the doctors were able to realign my broken parts without nearly the cutting and hardware they had anticipated, and I emerged with what looked like a mummified extremity and was dispatched home to recover.
By the next week I was feeling pretty chipper, if clumsy and less than glamorous wearing the sweatshirts and jacket of a large male friend (the only duds that fit over the surgical dressing on my arm), and set out for my first follow up appointment with the surgeon. I hadn't needed pain medication for a few days, and acute orthopedics not being my field it didn't occur to me to take any that morning.
It's standard practice to ask patients to rate their pain on a ten point scale, with zero being no discomfort at all and ten being the worst possible pain a patient can imagine. When that dressing came off my pain was 23/10, no doubt about it. Any movement or touch was excruciating, and I became lightheaded and nauseated just being examined. The surgeon told me my X-rays looked very good and I was healing well, and having ascertained that nothing was wrong medically proceeded to reposition my hand the way it needed to be for the new cast (pain 52/10). The orthopedic technician then went to work constructing that device (pain holding at 52/10, with me lying down on the table at that point so I wouldn't fall to the floor if I fainted). Once the arm was casted I felt better, although I probably took more pain medication that day than I had the entire previous week.
Fast forward another week and I was feeling like a new woman, swinging my cast around and mastering all manner of one-handed tasks. Preparing for my next appointment with the surgeon I considered taking pain medication, but felt so well that I opted against it. After all, I'd had an entire additional week to heal!
But back in the doctor's office there was a repeat of the previous week's experience, complete with me stretched out on a gurney in the cast room to keep from toppling over.
By the following week I was using the hand of the casted arm more, and had mastered carrying laundry baskets, washing dishes, and vacuuming . . . but, even so, before returning to the surgeon I loaded up on pain medication such as I hadn't taken since my first post-operative day. And the exam, x-rays, and casting process were the proverbial piece of cake, even if the patient was a little "loopy" all the while!
My doctor is on staff at multiple hospitals, chairs the department of orthopedic surgery at a major university, and works in the office of a large and busy orthopedic practice where the air of sophistication and competence is unmistakable. I see many distinguished and renowned surgeons bustling about when I'm there, as well as the technicians who make and fit the various devices that orthopedic patients need, assorted office staff, and a warm, funny, efficient medical assistant who keeps my doctor's practice humming. But I have yet to see a nurse.
And if there were a nurse on hand, I never would have experienced 23/10 or 52/10 or any number much above 4-5/10 again, no matter what the doctor and others were doing.
There are six parameters that nurses assess and manage, regardless of practice setting or specialty. I summarize them crudely when I teach so students easily can remember, and to this day call to mind the same six words every time I look at a patient and ask myself, "Is there anything else? What have I missed?" Those words are: Eat, sleep, move; pee, poop, pain.
No matter what sort of problem a patient has, what kind of doctor she or he is seeing, or where the encounter takes place, a nurse wants to know if and what a patient is eating, the extent to which this meets nutritional needs, and if there are problems or concerns surrounding intake of nutrients and fluids. If the "eat" cue triggers a nurse's radar there are a million assessment parameters and questions that may follow, but whether briefly or in depth, "eat" is assessed and evaluated.
Likewise "sleep." Is the patient resting and sleeping well or poorly, too much or too little, with or without aids? Are there nightmares or discomfort, does the patient need to be in a special position, does anything disrupt sleep?
And "move." How much or how little, how well or with what difficulty,is the patient moving? Are there pain, breathlessness, inertia, or simple bad habits? Is movement safe? How is posture, gait, and the process of getting up and down? Are there indications of complications of decreased mobility, such as skin breakdown, fluid in the chest, or extremities that no longer straighten out all the way? Is the patient manic, constantly in motion, anxious and agitated, unable to relax? How about balance, endurance, and the ability to execute movements needed to do daily tasks? Movement is a parameter that speaks volumes to the astute clinical nurse.
For all the jokes about elimination, it matters. Too much or too little, abnormal character of output, too many or too few trips to the bathroom, bleeding or pain or other symptoms, indications that waste is being retained instead of eliminated, it all matters. And more.
And pain. Is the patient comfortable, and if not, why? Location, severity, onset, duration, what makes pain better and worse, what the patient does to manage pain and how effective those actions are, how the patient copes, whether pain is acute or chronic; it's all important. Is pain physical, emotional, spiritual, or other? What's the patient's story about this aspect of his or her experience?
Eat, sleep, move; pee, poop, pain: This is what a nurse does.
I smiled more than once coming out of surgery and preparing to go home. Rolling me out of the OR the nurse asked if I needed to use the restroom. My first thought was, "Why? I haven't had anything to eat or drink since yesterday, and it's now afternoon!" But I realized I no doubt had been pumped full of IV fluids in the OR . . . and that the nurse needed to be sure I could urinate before I left. Once I was settled in post-op recovery the nurse offered me a sandwich and some juice. Processed turkey meat stuffed between two slices of white bread was the most delicious meal I'd had in my life, and I noticed the nurse noticing my wolfing it down. I did walk to the restroom, and dressed with the assistance of the friend who would take me home, and of the nurse. "Would you like a wheelchair when you leave, or do you think you can walk?" the nurse asked. "I think I can walk," I responded. "I think so, too, " she replied, with a tone both warm and deliberate such that I realized I had been assessed and deemed safe. A lay person might say, "Oh, the nurse was nice, and brought me something to eat and helped me get dressed," but I know that "eat, eliminate, and move" had been assessed and evaluated carefully. "Sleep" had been well monitored in the OR, and the nurse had instructed me about pain management before I went to surgery, explaining that afterwards I would not be in any condition to remember what she said.
Eat, sleep, move; pee, poop, pain: This is what nurses do.
And when we find problems, the solutions are not necessarily medical. A patient with nutritional issues may need a dietician or simply someone to go to the grocery store, not a doctor. Another with mobility problems may need a Physical Therapist, not a physician. Patients who are eating poorly, falling, and living in a dirty homes because they are alone and without help may need a social worker to set them up with community resources and support services, not more medicine.
Everyone needs to eat, sleep, move, eliminate, and be comfortable; hence everyone who engages in a healthcare encounter should be assessed by a nurse. Exceptions might be the person who needs only to pop into the local pharmacy for a shingles vaccine or a clinic for a TB test required by an employer, but where there are health problems to be solved, health screening and prevention to be done, and long term coping and planning to be managed, patients, all of them, need nurses.
Had there been a nurse in my surgeon's office, she or he would have insisted that my pain be managed. My doctor had examined me and looked at my x-rays; he knew that there was no medical issue of concern. The business of diagnosis and treatment, which is what doctors do, had been done, and while sympathetic, he was not overly concerned about my discomfort given that he understood there was nothing medically wrong. But a nurse would have said, "We need to manage this," and not let up until that was done. A nurse would have instructed me to pre-medicate in the future, and explained why (although my arm is healing, I still have a fracture. When the cast is removed there is no support for that broken part, and the weight of my hand is supported only by the wrist that is broken. That hurts!). An orthopedic nurse would have understood the movement and positioning that the doctor wanted, and would have guided and taught me to do this properly, as opposed to the doctor's saying, "Do it!" and scowling when I didn't quite do it right. A nurse would have asked how I was managing at home, and would have known if I was eating properly, including the nutrients I need for healing, if I was resting well, if the medications I was taking had caused constipation or diarrhea, and if I was moving about and functioning reasonably well and safely.
And a nurse in the office would have saved the practice time and money. Having me dizzy, nauseated, and unable to move or cooperate took more of the doctor's and technician's time, and that translates into dollars lost. Is this enough to offset the expense of a nurse's salary? Multiplied by the number of patients going to that office and the number of needs and problems they have that a nurse can anticipate, prevent, solve, and/or minimize, the answer is a resounding "Yes!"
Better care, better clinical outcomes, greater efficiency and cost effectiveness, there's no doubt about it:
My Doctor Needs a Nurse.
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