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.