I’ve written and illustrated a new post for Off The Charts, the blog of the American Journal of Nursing, addressing the chronic issue of understaffing, and effect on the safety of nurses and patients. Below is the link to the post.
Understaffing: A Policy Oblivious to the Unforeseen Swerves of Life and Nursing Shifts
The Broken Elevator photo: jparadisi 2011
Saturday morning, David and I woke to a noisy buzzing alarm coming from the elevator in the hallway of our building. It was stuck on our floor with its doors half open. Because it’s the weekend, I’m not hopeful of it getting fixed promptly. Next, as if we are under attack from a conspiracy of machines, our normally silent dryer started making a loud thumping noise, like tumbling canvas shoes, but all that’s in the drum is a small load of delicates. David is on his computer, looking for a repairperson as I write this post. The coincidental mechanical malfunctions remind me that as long as things meet my expectations, I often take them for granted.
At a social event, I was surprised to see an ex-patient and his wife also in attendance. I remembered them vividly, because of the longer than expected amount of time spent admitting him to our unit. The husband had the misfortune of being discharged from the hospital on a Saturday evening. Commonly, hospitals have a minimum of discharge planners on weekends, and the discharge planner’s job is frustrated by the fact that most of the outpatient services he or she needs to coordinate are closed. Also, he did not have a primary care provider, meaning no physician or nurse practitioner was in charge of his outpatient follow-up. To fix this problem, he was given a physician referral, and a phone number to call on Monday.
He arrived in our ambulatory clinic on a Sunday morning for daily treatment in pain, after a difficult night at home. His wife and son accompanied him. The son was concerned about the eschar on his father’s wound, and I agreed with his assessment. Eschar is a dark, leather-like tissue formed on the surface of a wound. In the worst- case scenarios, it creates a tight band around an extremity, cutting off the blood flow to the body part below it. It increases the patient’s pain by preventing oxygen-rich blood from reaching the affected area. Fortunately, the body part below the eschar of this patient was warm to touch, with strong pulses, and a brisk capillary refill, so he wasn’t in imminent danger. He didn’t have a fever, and his vitals signs were normal, so pain control and obtaining a surgical consult became our priorities. We needed a doctor to write orders.
Luckily, the resident who treated my patient in the hospital was still there. I paged him, and told him what was happening. He agreed to see the patient in the clinic. This was generous of him, because once a patient is discharged from the hospital, technically, he is no longer responsible for his care. He wrote a script for breakthrough pain medication, and made a phone call for a surgical consult to address the eschar. In this way, the patient avoided a trip to the ER, the only other option on a Sunday. On Monday morning, a surgeon removed the eschar. I was pleased with myself for mobilizing the necessary resources on a weekend. The rest of the patient’s course flowed uneventfully until discharge.
The Dryer: Things That Go Thump photo: jparadisi 2011
At the social event, I approached the former patient and his wife to say hello. Looking at me blankly, they reciprocated, then awkward silence. Realizing I’d made a mistake, I said, “I didn’t mean to bother you. We’ve met before. I just wanted to say hello.” “Really?” said the wife. “Where would that have been?” Uh, oh. I mumbled the name of the hospital, but not the unit. Even the name did not prompt a recollection. They continued to stare blankly. I desired to end the interaction, unsure if I was circling the drain of a possible HIPPA violation. Complementing the wife on her earrings, I retreated to another part of the room.
Later, it occurred to me that their discharge ordeal wasn’t an ordeal to them, because by means of coöperation and teamwork, I fixed it. They expected a smooth discharge with seamless follow-up care, and they got it. They took it for granted, because they didn’t experience the frustration of falling through the cracks. They didn’t recognize me, because I hadn’t stood out. They did not experience poor care versus quality care. In their mind, I did my job, and that did not merit recognition. They are right.
I appreciate the effort hospital administrators make each year during Nurses Week to thank nurses. Recognition for a job well done is one way of saying, “Thank you.” However, a lack of recognition, because the person served is unaware of the effort made on their behalf, is a form of reward too. The best recognition of a job well done comes from within.
I still experience culture shock, since my transfer from pediatric intensive care to outpatient adult oncology nursing , over the difference in sedation use during procedures for pediatric and adult patients. What allowed me to tolerate 15 years of pediatric intensive care nursing (yes, it is as emotionally challenging as you think it is) was the routine sedation of the child going through procedures.
Adult patients know that when their healthcare provider says, “You may experience some discomfort during the procedure”, what we mean is “This is gonna hurt.” Remember, this is an industry that accepts anal leakage as a reasonable side effect of some medications. Adult patients are expected to lie still.
Like during a bone marrow aspiration. My patient cried before the oncologist arrived, but the doctor didn’t see that. She cried during the injection of the local anesthetic too. Her family looked concerned, but no one spoke up. Nurses, because of our extended contact with patients, are the emotional thermometer in the room. It is my practice to request from the physician a small dose of sublingual lorazepam to offer the patient before such a procedure, just to take the edge off, but it’s rarely ordered, unless the patient demonstrates high anxiety levels in front of the physician, which indicates the patient might not hold still. The procedure lasted only minutes (the oncologist was skilled), but I winced to see my patient hurt. This patient made it through bravely. The physical pain was quick, then over, but the pain of the procedure was potentiated by the fear of a blood cancer diagnosis. Lorazepam does not control pain. It does ease anxiety. She was big enough to hold still.
Perhaps I’m sensitized to this issue because I have been a patient needing a biopsy for a cancer diagnosis too. I remember the white noise of anxiety drowning out my ability to hear all of the information presented to me during the early weeks that my treatment plan unfolded. The surgeon, who was very good, wanted to do a biopsy of my lump in his office. It’s done all the time. I wanted the lump removed, under conscious sedation. That required an OR, and an anesthesiologist, the surgeon informed me. “That’s what I have insurance for,” was my reply. I know too much about procedures. I trusted my surgeon, and I wanted to be out while he did what he needed to do. A member of his office staff chided me about the request: “You’re a baby, I’ve had several lumps removed in this office myself, and went back to work afterwards.” I complained to the surgeon about the inappropriate comment.
Like a frightened child, I didn’t want to lie still.
