Fast Food Nation: When Customer Service Competes with Patient Safety

by jparadisi

Drive-Thru Health Care by jparadisi

Calculating chemotherapy doses by surface area (m2) or kilograms was a smooth transition for me, a former pediatric intensive care nurse. In pediatrics, every medication, even acetaminophen, is dosed by weight. Tailoring chemotherapy doses to a patient’s weight was already a familiar concept; likewise dose reduction or withholding treatment altogether based on the patient’s lab values and assessment.

It’s a rare patient, however, who understands that her chemotherapy is prepared to order, not mixed ahead of time and awaiting her arrival, as if it’s fast-food made for the masses, preserved under a warming lamp.

This doesn’t matter as much if the patient receives his or her care in the hospital, but sometimes it creates unrealistic expectations in ambulatory oncology clinics. Somewhere along the line, good customer service has become confused with fast service, resulting in more and more patients with unrealistic expectations for their appointments.

It was one of those shifts when appointments backed up. Several factors contributed: Harsh weather conditions meant some patients arrived either late or too early for their appointments. The rapidly approaching holidays caused schedule changes for some patients. Of course, there were the normal, garden-variety delays: lab values requiring attention and patient veins that refused to accommodate IV catheters, etc.

Throughout the shift patients asked, “What’s the holdup?” Each time I thanked them for their patience, and validated the importance of their time. All shift long I explained, “One of the difficulties is that administering chemotherapy is not like making fast-food. Each treatment is made to order, measured against your lab values and tolerance. Our most important service is guarding your safety.” The explanation was received well, refocusing expectations on patient safety. Patients expressed appreciation for their nurses, oncologists, and pharmacists watching out for them.

The shift reminded me of a statement made by my husband, “Health care is neither inexpensive nor convenient,” and another one I heard a celebrity say on TV, “There’s never enough time to do things right the first time, but there always seems to be time to fix the mistakes later.”

Delivering prompt care is part of customer service, and as nurses, we should endeavor to keep appointments on schedule. However, our most important responsibility is patient safety.

How do you help patients keep their expectations regarding their care realistic?

Lessons About Medication Errors From Baseball

In the commercial, three guys are standing around a grill, talking about baseball. One of

painting by jparadisi

Baseball Card by jparadisi

them quotes a stat.

Another one says, “Really? Are you sure?”

The first guy says, “I’m 99.9 percent sure.”

The third guy says, “Then you don’t know.”

I don’t remember what product was advertised. I remember the commercial because the question of certainty came up regarding a medication order.

I was reviewing the chemotherapy orders:

  • Patient name and identifiers: √
  •  Orders are dated with today’s date: √
  •  The chemotherapy ordered is appropriate for the patient’s diagnosis: √
  •  The dosage is correct: Uh oh. Wait a minute.

The total dose (in milligrams) did not equal the product of milligrams times meter squared (m2). The reason was easy to spot, however.
The chemotherapy infusion was to be administered as a continuous infusion over two days. The order read:

xxxx mg of chemo drug X m2 = xxxx mg X 48 hours = total dose of chemo drug

The doctor meant to write:

xxxx mg of chemo drug X m2/every 24 hours = xxxx mg X 48 hours = total dose of chemo drug

I was 99.9 percent sure, which means I wasn’t certain. Unlike quoting baseball stats, there is no room for uncertainty in chemotherapy administration. Interestingly, a pharmacist felt 99.9 percent certainty was good enough and mixed the cassette sitting in front of me.

To be fair, this was not the patient’s first infusion. The pharmacist mixed the chemo based on past orders. Using a previous record to predict a result in the future is the definition of betting, which works in baseball, but not so much when administering chemo.

I called the office where the order originated. The nurse on the other end of the phone pulled up a copy of the order. “Oh, he meant to write every 24 hours. If I write that and fax it back to you, will that work?”

“Yes it would,” I said. “Are you certain?”

“I’m 99.9 percent sure.”

“Certain enough to sign your name to an order?” I asked.

There was a pause, and she said, “I’ll have the doctor take a look, sign it, and fax it back to you.”

I thanked her.

The corrected order, signed by the doctor, arrived on the fax machine. The checklist was successfully completed, and the infusion started.

I was 100 percent certain the infusion was correct.

Do you ever feel like the nurse holding everything up? What’s your opinion? Would you trust your familiarity with a patient’s past orders and go ahead with the infusion? Does your work environment support nurses delaying treatment while verifying orders?

I Am Living As Free As My Hair

Someone asked if I color my hair. I said, “No I don’t, I pay someone else to do it.”

Once my hair grew back after chemotherapy my attitude toward it was changed. Before treatment for breast cancer, the color, length, and style of my hair was linked to my identity. Enough people share this link with their hair that “having a bad hair day” is common parlance. When it fell out (alopecia) in fistfuls as I shampooed in the shower, fourteen days after my first chemo treatment, I cried, “Fuck, fuck, fuck,” like a demented chicken, even though I knew it would happen.

Nowadays, I experience my hair as an accessory; its color and length mercurially changes, like a hat, within the boundaries of our hospital’s dress code, which outlaws hair colors not found in nature. Contrary to Lady Gaga’s song As Free as My Hair, a nurse’s hair lacks total freedom. Here’s an example: a classmate in nursing school came to clinical rotation one morning with a new, short haircut. Her abundant, thick hair was spiked in a then-new punk hairstyle. It was cool, and I admired her for doing it. The school’s dress code demanded that hair be kept above the collar of a student nurse’s uniform at all times, but didn’t specify anything about how short it could be. Our clinical instructor became unglued over the unprecedented hairstyle, calling out the student in front of the class, and telling her she looked like she’d “combed her hair standing in front of a fan this morning,” before making her flatten down the spikes with a comb. Without a doubt, the hair of a nurse lacks freedom.

Anyway, the other day I was sitting in a salon, my hair wet and matted with a new color. It’s fall, and time to color over summer’s golden highlights with chocolaty, cherry red. It’s beautiful, and popular in the fashion magazines I thumbed through while the color set. Sorry, I don’t carry nursing journals with me to read during spare moments. At the salon, I read brain candy. It’s fun, which is good for my soul.

At the sink across from me, a young woman had her hair washed by a stylist, and was telling the stylist that she enrolled in nursing prerequisite courses this fall and hopes to get accepted into a nursing program next year. Nursing will be her second career: she is a recently laid off teacher. I’m not sure why it struck me as odd that a teacher would decide to become a nurse, because I know nurses who became teachers. I wonder if she has a better chance of finding a nursing job than a new teaching position without moving? Through social media, I hear finding a nursing job as a new grad or a returning nurse is pretty tough everywhere, not only in Portland. Does she know that many nursing departments are laying off through attrition, if not by actual termination? Who is telling these students that nursing will solve unemployment woes? In today’s economy, nursing job security is not what it was only a few years ago.

I also wondered how nursing and teaching compare as careers, so I searched the Internet to find out. The best information I found comes from blog posts and comments on the subject. AllNurses.com (Nursing versus Teaching Major, Feb 1, 2010) and College Confidential (Teaching Versus Nursing, April 26, 2010) had the most compelling conversations, in my opinion. In summary, both careers are described as challenging, overworked, and highly respected. As in other industries, neither guarantees job security in the present economic crisis.

Losing your hair, or losing your job alters your identity.

Inside the salon a woman gets a new haircut, and in time, perhaps a new career.

After a rinse and blowout, I left the salon with a glossy new hair color, still a nurse. I am living just as free as my hair.

The Volcano Lover

Cinder Cone with lava field in the background photo: JParadisi

Cinder Cone with lava field in the background photo: JParadisi

     Recently, I walked to the top of a volcanic cinder cone in the Cascade Mountain range, in Oregon.  I have been in love with volcanoes for decades now, since I first heard of the ruins of Pompeii in the fourth grade, and  images of cataclysmic geology flowed  like molten lava within my ten year-old imagination. 

     I read the novel, The Volcano Lover, by Susan Sontag, simply because of its title.  It wasn’t  as much about volcanoes as it was about submerged passion and possession, but I enjoyed reading it.

     It was weird, walking on the top of a volcano, though it’s been more than a millenium since its last eruption. Volcanoes in the Pacific Northwest don’t conjure tropical images of the goddess Pele hurling showers of orange and red molten stone at the lovers who displeased her. Pacific Northwest volcanoes are more subtle. They simmer quietly for eons, occasionally belching benign plumes of white steam, seen for miles.

     I didn’t live in Oregon when Mount St. Helen erupted in May of 1980. But I have seen large spirals of steam billow up to the sky from it,  like no cloud I’d ever seen before.  It was a few years ago. I had just gotten off work, and was going to my car on the top of the hospital’s parking structure, when I saw it. A coworker of mine, who I occasionally ate lunch with (we liked the same bench in the hospital’s garden during good weather) was the only other person there to see it. We sat on the hood of his car, watching the phenomenon, and congratulating ourselves for having the best seats in Portland for this spontaneous performance. A year or two later, I can’t remember, this same coworker, who loved nature, his family, and his patients, was shot in the head by an intruder in his home, who stole the very car my now deceased friend and I had sat on that day, watching the volcano, and wondering what would happen next. 

     You never know what’s brewing underneath.

     I thought about all of this while walking the cinder cone. Life is unpredictable. One day you’re healthy, the next, you or someone you love is in an accident, or diagnosed with a life-threatening illness. Or you get a phone call from a stranger, telling you  “I’m very sorry to inform you ma’am, that your loved one was found dead…”

     With this in mind, I refrain from judging my outpatients who irritably or sheepishly ask me to let them go out for a smoke, between their infusions of chemotherapy. A diagnosis of cancer motivates some patients to quit, but others find it so stressful, they don’t have it in them. Some of them berate themselves with guilt, because of it.  I do my duty, and encourage them to quit, but I know first hand that a healthy lifestyle doesn’t guarantee a cancer free life, and out of compassion, I share this knowledge with them. 

     I think about safety, and how to avoid danger, and this quote, from the sci-fi movie Demolition Man bubbles up from memory:

 “I have seen the future. Do you know what it is? It’s a 47-year-old virgin sitting around in his beige pajamas, drinking a banana-broccoli shake, singing, ‘I’m an Oscar Meyer Weiner’.”

     I’m learning that the rules we make for ourselves only create an illusion of control. We have choices, but we don’t have control. Or rather, we have control until it’s taken away from us, through illness, accident, or a violent crime. We walk, not realizing the volcanic turmoil underneath the smooth surfaces of our lives, until an eruption occurs.

     You never know what’s brewing underneath.