The bitter divide between sedation and coma

Is she not waking up because she's sedated? 

Are the medications making him stretch and move like that? 

Are the pupils not working because of the sedation?

No....no, we're not using sedation. This is from neurological injury.

I can never get over the implications of the difference between sedation and coma. A comatose patient and a sedated patient often look the same to visitors, loved ones, people walking by, and even consulting physicians or residents who first walk into the room and have to ask me if we're sedating the patient. But the difference is the entire world. Their entire world, that is. It's the difference between them waking up and getting out of here, or possibly (probably?) never waking up again

In a single sentence we're declaring with finality the next several months or years of their life. Are they going to return back to normal? Or will they require months of intensive rehab, or a life of nursing home care, or hospice, or will they die right on our unit in the cacophony of a failed resuscitation?

It astounds me that I have to have this discussion with people at, say, 3 am on the phone, in the night shift lull when I'm just starting to get tired. Sometimes the patient has been here a week and I feel like I'm the first person saying to this person that their coma is probably due to them being in a coma, not to sedation: "No, they've been off sedation for days." Or maybe they haven't heard the other times, or they need to hear it again, to have every possible second, third, fourth opinion. I think I would even do that.

I also reflect on how I was never trained to deal with these situations, but I'm still the front line 9 times out of 10 to break this news to people. And that goes whether it's a new emergency admission, or a patient who's been laying in our bed for a week. It's hard to tell a wife or husband or fiance or adult child or young child that the person we're talking about is not waking up not because of drugs we're giving them, but because they're just not waking up.

"All Nurses Should Be MSNs"

See, this is what scares me about nurses. This was a reader response to the APNs saying no to the DNP I posted about:

Kudos to you and your physician colleagues for supporting the idea (whose time is long overdue) of a well-educated nurse!!! I have always believed that if the AMA [American Medical Association] said, "We want all nurses to be minimally prepared at the masters level and all advanced practice nurses to be prepared at the doctoral level (research and/or practice) by 2015," that it would happen!  

Regina L. Payne, EdD, MA, MSN, RN, CWOCN 

I don't even know where to begin. All nurses having a masters? Do you want the industry to commit suicide?

Who is going to get their masters to make $50,000/year starting pay?

And why do we need to be validated by physicians? Nurses operate hospitals. Physicians put their patients in hospitals to be under our care. We are not coworkers or coequals; we are not comparable or competitive workers in the same career field. We do different jobs.

I have a feeling doctors don't care about validating this nurse, either. In the real world, nobody talks like this.  But this professor of nursing is willing to sacrifice US healthcare in order to achieve a pipe dream only she and other people like her care about.

Thankfully this would be such a burden on healthcare that it will probably never happen. But if this is how nurses in the academic establishment and the political lobbies think, I'm genuinely frightened.

What's happening to nursing anyway?

Does anyone else feel like nursing is going down the toilet? Man, I must be getting old if I'm saying something like that.

I was speaking with some of the more experienced nurses on the unit...some have decades, plural, of experience. Don't get me wrong, they love their jobs, and they're happy people. They're not your typical grumpy nurses. But they've seen a drastic shift in how nurses can work. You used to be able to work anywhere. You used to be able to quit and come back. Moms would leave for their kids and then come back years later; people would try stints in home health or agency work and decide to come back to the unit. You had total job security.

Nursing, one of them said, used to be in the hands of the nurse. Now it's in the hands of administration.

These people were hired the day they interviewed. Some of them were told to show up in scrubs for their first job interview, in case they needed them that day on the floor.

I can't even imagine that. If I quit, I don't think I'd be able to come back. I certainly wouldn't assume it, anyway. And I wouldn't assume I could get a job tomorrow. It's not just because the job market is dismal, but because the whole hiring process is now controlled by human resources, administrators and nursing officers I don't even know, etc. Even if your boss likes you, that doesn't mean they can take you back even if there is a position open.

There are other signs, too. It seems like every few weeks there's a new requirement placed on us. Not that I mind or shirk expectations, but many of these have a concealed threat to our job; if you don't perform, you're out, because you're easily replaceable. And they know you're not going anywhere else fast. The specialty certification is like that; it's mandatory or you're fired. That wouldn't have been possible ten years ago, I don't think.

The most significant change to me was that they decided that the 36 hour week (three 12 hour shifts), long the standard full-time schedule of the RN, is no longer full time. It's considered part time, with part time benefits. That's just mind-boggling. The only way they're getting away with it is they've grandfathered in the current 36 hour people. So generous of 'em. But all new hires are like this. I can't imagine how that's going. "Want a job? Well, guess what - you're going to have to work a standard full time nurse's week, but you're only part time. Hey, do you want this job or not?" You have few other options in today's market.

It can't be just the market, though, can it? I think in the last five or ten years there's been a change in how nursing and administration have interacted, and it's not in nursing's favor.  I realize administration has to run a hospital like a business, but that means that at the end of the day we're an expense rather than an asset. Despite the fact that hospitals don't exist without nurses.

I'm starting to see the appeal of unions.

Paging Dr. Nurse...

An interesting thing about the issue of the Doctor of Nursing Practice is that the news coverage and opinion pieces about it are mostly centered on what doctors think. Doctors, obviously, are not generally happy with nurses being called doctors. It is true that "Doctor nurse" seems like an odd title; however there is a valid point that pharmacists, dentists, and even many physical therapists are now doctorate-level clinicians but nobody gets up in arms about that. Doctors are obviously worried because we do frequently the same tasks, so DNPs infringe on their turf. But to me, that's neither here nor there.

I'm more concerned with what nurses think about it, and that information is a lot harder to find. I think the only nurses who write or publish in any venue are the ones behind this sort of thing.

In fact, the only published thing I could find was a statement called 'Advanced Practice Nurses Say "No" to a Mandatory Doctor of Nursing Practice Degree' (may require free registration at Medline) by Wendy Vogel, an NP in Georgia. Her statement, the readers' letters it generated, and her response to those letters are well worth reading. The upshot?

Increasing the education requirements will only sharpen the nursing shortage. In fact, other medical fields have already experienced this:

Nursing looks to pharmacy, medicine, and physical therapy and sees the need for a clinical doctorate to have "parity" with these professions. Yet, if one examines the Department of Health and Human Services' report to Congress about the pharmacy workforce, the conversion from the Bachelor of Science in Pharmacy to the Doctor of Pharmacy degree is deemed a major factor contributing to the nationwide shortage of pharmacists. We also see evidence in both pharmacy and physical therapy that required doctorates have severely influenced PhD enrollment. 

This seems so obvious that I don't know what the problem is. I've complained before that the shortage of nursing faculty in general is partly due to requiring Masters-level education even to be a first-semester clinical instructor. This is obviously absurd. When a nurse can make great money at the bedside, why would they expend the time, money, and effort to get their masters and then teach for minimal income? It's ridiculous. The only explanation I can find is that cushy academic jobs (in this case, those who run masters in nursing education programs) need a justification for their existence.

Is it the same story for the DNP? I think it probably is. Academic nurses, in this case the doctors who want to teach doctorate programs, need a justification for their existence. But it's going to ruin advanced practice nursing for the rest of us. As Ms. Vogel puts it:

So why would a new high school graduate want to consider a doctorate degree in advanced practice nursing? Why not pursue the career of a physician assistant...or a physician or a pharmacist? As with many careers in the healthcare field, nursing is fraught with shortages, decreasing reimbursement, increasing demands, burnout, and job dissatisfaction. When one compares the time commitment of education with the potential remuneration of each profession, nursing may very well lose.

Academic nurses have been fighting for forty years to be on a par with physicians. I don't think they realize that achieving that vision is going to be its own undoing.

Speshull snowflaeks

We're now required to achieve our specialty certification. For us ICU nurses that means shelling out a few hundred to sit for the CCRN exam, although we get reimbursed if we pass. I really can't complain, and I generally believe in specialty certification.

Especially if it's a scientific speciality.

I definitely think that there are so many nursing specialties out there that the "generalist" nurse could use more education than he or she gets in a standard "generalist" school in order to perform well. The fact that nurses without extra book-learning do well in these specialties is a testament to how rapidly they learn the practicalities of their field. But we in the critical care world, at least, know that not all nurses in our units are created equal, and this might bring some people up to par.

It seems blindingly obvious there should be a plain-jane nursing school, with offshoots or further study given for critical care, obstetrics, psych, etc etc. The advanced critical medicine we studied and the psychiatric medicine helped me be a more well-rounded nurse, but maybe not so much the obstetrics? I'm sure some of the nurses destined for the floors or doctor's offices got tired of advanced arterial blood gas interpretation after a while (slight understatement). And the professors all seemed to agree but shrugged that this is just how it is. "The generalist has to dabble in several specialties to be well-rounded." That doesn't explain why we did L&D rotations but not OR rotations.

Certification might help supply the lack of specialty education...however probably nothing will rectify the situation with the school. Unfortunately.

It is making many people upset, however. I mean, you can imagine if you've been a hard-edged ICU nurse for twenty years, you know you don't need the credentials, and you're going to resent the stress of sitting for the exam. Especially if you're a trauma nurse and you know that a bulk of the test is about advanced cardiac questions you never run into. I guess nothing is going to be that fine-tuned, however.

Don't talk politics

I figured out one way to ruin a conversation at the family Easter dinner: talk a nurse practitioner student's ear off about the doctorate of nursing practice.

The poor student I was probably cornering agreed with me that the doctorate shouldn't be required, but I think they were taken aback by how much I thought it was unnecessary. I felt kinda bad, because I don't usually declare a position on anything in casual conversation; let alone things that don't directly affect my immediate life. Maybe I'm just being nuts about it.

I think I should modify or clarify my position. I think a doctorate-level position is fine, possibly unnecessary or inefficient in today's (or any) market, but I'm also not "there", not at that level, and I don't know what the extra classtime and clinical orientation adds to the table.

I still think the American Academy of Colleges of Nursing looks like a lobby for expensive academic institutions, and I don't like how they're trying to squash the more efficient, less costly associate-level nursing colleges. I still think this is mainly driven by a spirit of competition with, or a desperate need for respect from, medical doctors. And that's obviously ridiculous.

I still think this has the potential to dry up the supply of potential nurse practitioners, anesthetists, and APNs. Why bother? The only benefit to this academic route over, say, medicine, will be if you already have a nursing degree and can continue along that route. That means not much new blood from high schools or colleges, from people outside of nursing.

In other news, Happy Easter!

Repeat c-sections vs. VBAC

Just wanted to draw attention to an excellent article over at S&S:

Science & Sensibility » Is Elective Repeat Cesarean Surgery Truly Safer Than Planned VBAC?

The short version is that in recent studies a vaginal birth after cesarean only has a marginally higher absolute risk over repeat c-sections. And this risk might be attributable to modifiable obstetric practices, like using induction drugs which are known to cause uterine rupture (!). The risk seems higher among practitioners who frequently abandon VBAC attempts and resort to a c-section--leading to, I would imagine, a higher instance of hemorrhage during an intrapartum (in-labor) c-section?

And none of the recent studies have taken the long-term effects of the cumulative scarring of repeat c-sections. I know some women who have had five, six, or seven repeat elective c-sections (I call them automatic c-sections), all because of an initial section. I know this is anecdotal, but some of the women certainly had problems later on, whether with their labors or with their babies. Makes sense.