What's So Scary About Healthcare? Putting Strangers In Charge of Yours.

The upcoming Halloween-themed Change of Shift centers on what scares you in healthcare. I feel like half my blog is about what's scary in healthcare. It was suggested that I should submit my ER story about an infant getting repeatedly and unnecessarily stabbed for an IV access. But I thought I'd write a little more about what scares me about institutionalized healthcare in general.

What scares me about entering a healthcare institution for services (i.e. as a patient or a parent) is that you're no longer in charge of yourself. You have to place your trust in people and institutions you don't know. You're subject to hospital policies and procedures when you sign the consent for admission and treatment. You're the subject of decisions by your doctor, who you hopefully know, and by whoever's covering for them, who you may not. You're subject to the decisions of nurses and nurse's aides whose education, skills, biases, and thinking ability you don't get to review before they enter the room. You're subject to a host of clinical decisions that you will never even see happen: the house supervisor might understaff the floor; the tired imaging tech who wants to go home might push your study off till tomorrow; the weekend pulmonologist might decide you can wait till Monday to get off the ventilator, even though you're ready to wean; the janitorial staff might've not sufficiently cleaned the C. difficile out of your bed. It's not cool.

My main contact with healthcare as a patient has been with midwives and with our family doctor. In both cases we've been able to discuss thoroughly where we're coming from, what our concerns are, what our priorities are, what will happen when this or that case arises. In other words, we got to know each other. Especially with the midwives—the interviewing and education process is extensive, since (unlike, unfortunately, most obstetric offices) it's one-on-one, occurs in the comfort of your own home (i.e. not in a rapid clinical environment where they're too busy for too many questions) and lasts for eight or nine months. And as I explained here, all the midwifery care we received was extremely consent-oriented. This is a model of care I'd like to see implemented in the 'real world' of healthcare. But I don't know how it's ever going to happen.

As a soon-to-be practitioner, it scares me that this busy, impersonal world is where I'll be practicing. But with all this in mind, I hope I'll do well. I've seen firsthand that a good nurse can rapidly establish rapport with a patient and their family, get down to their needs, and fit that into his or her day. Nurses often have to ask what exactly it is we're doing for a patient; then explain this to the patient and their family; and then hear the possible issues or concerns that the patient or family has about this treatment. Nurses, possibly more than any other healthcare staff, are poised to bridge that gap between the impersonal clinical environment of the hospital or office and the kind of personal, experienced patient-clinician relationship that I experienced with midwives or our family doc. The kind that people really need.

Are You Getting the Swine Flu Vaccine?

I've been mulling over whether to get the swine flu vaccine. Some hospitals in this area are requiring it of their employees. Mine are simply offering it. They almost seem hesitant to encourage it. There's a lot of controversy around it—you've probably heard of the lawsuit in New York against making the vaccine mandatory for healthcare workers.

Around here, some of my coworkers are for it, some are ambivalent, and many are against it.

The arguments: It's been rushed into production, the disease is not that harsh most of the time, flu vaccines apparently cause the flu, and then there's that whole thing with the 1976 swine flu immunization causing Guillain-Barré syndrome, leading to people suffering paralysis, needing mechanical ventilation, and more people dying from the vaccine than from the flu.

The rebuttals: The 2009 H1N1 vaccine is made the same way all the other influenza vaccines have been made, just with a different virus. Influenza vaccines have a good track record of being safe. And the 2009 H1N1 swine flu virus is different from the 1976 swine flu virus.

My take: I think the dead virus is probably safe to receive. I might wait and see how the vaccination program rolls out, as far as reports of adverse reactions. I certainly wouldn't get the live-attenuated virus, especially since I have kids.

I would recommend evaluating the potential costs and benefits, such as: is swine flu significant in your area? Does your patient population put you at a high chance of running into H1N1? As for Guillain-Barré syndrome, I'm not extremely worried, but I'm waiting to hear any reports of any adverse events occurring among vaccinees, especially when big cohorts like an entire hospital vaccinate. China says 14 had adverse reactions out of 39,000 swine flu vaccine recipients, but aren't saying what they were. As far as I can Google, no one else is reporting anything.

But it does bother me that no one knows what it is in vaccines that apparently causes Guillain-Barré—or seizures, high fevers, fainting spells, or the other adverse reactions that unquestionably occur (i.e. apart from autism) after immunization.  So I don't balk at anybody being cautious about them.

Image courtesy of the Public Health Image Library

Orthopnea: Sometimes the Patient Does Know Best

We had a "respiratory distress" transfer to the unit some days ago. The woman, significantly obese, is wheeled down in the a large armchair. In her clothes. That's committing at least two cardinal sins against ICU staff right there—the rules for unstable patients (i.e. if you can't breathe) are, no clothes, and in the bed! So the nurses, suitably, had a cow. The woman and her floor nurse tried to explain that she has such difficulty breathing that she sleeps in a chair, even at home. So I suggested leaving her in the chair. I mean, really, she looked fine except for not being able to breathe. I'm not being facetious. She was gasping like a fish, and only able to spit out 3-4 words at a time, but she could walk! Obviously she was a long-term COPDer or something, so she was compensating for this. But her blood CO2 was over 100 (which I didn't even know is compatible with life), so, not wanting to have to code or intubate her in a chair, we compromised by putting the bed into a chair position.

Within an hour we put her back in the chair.

Orthopnea is not a cool thing. When some obese people lay flat, their entire abdomen pushes up against their diaphragm, and they literally can't breathe. I've seen obese people start to black out because they're being forced or coerced or strongly encouraged to lay down. Do you want to code a 400 pound man? I don't.

I once heard a local story—this is purely hearsay, so don't subpoena me—about an obese man with a host of the usual end-stage problems (diabetes, heart attacks, dialysis, lives in a nursing home) who presented to the ER for whatever reason, and was allowed to sit in a chair so he could breathe...until the night shift nurse, who was new, made him lay on the cart, argued with him about it, and eventually got orders to put him in restraints to keep him in the cart...where he coded and died.

Is the moral of the story that we need more obesity/orthopnea education, or that if your patient says "I can't breathe" we should listen to them?

This is not a funny subject, but part of me almost wants to see the Charles-Dickens-derived term Pickwickian syndrome come back.

Biomedically Engineered Birthing Beds!

Darn it, I still like my modern birthing beds post from ages ago. It's a mind-boggling idea. People made these large expensive Transformer-like contraptions just to facilitate laying women flat on their back to push babies out? And to defacilitate any kind of human contact with the mother, except by the doctor? Next they'll invent vacuum pumps to just pull babies out without any human touch whatsoever, like we're milking cows at a dairy plant. Except they already kind of do.

You could put the AVE turbo birthing beds driven by maternity commandos up against a giant robotic KOKEN LM-064 Full Body Pregnancy Simulator (with storage case) in some kind of postapocalyptic American obstetric horror film.

This bumping of a thread, of sorts, was brought to you by the Livejournal user I ran across who made the icon above. Thanks!

EDIT:

Sweet. Nuff said. Courtesy of VBAC Lady's graphic designer friend.

Healthcare Reform, Maternity Reform, Nurse Reform

The new participatory medicine themed Grand Rounds is up. So let's address something right off the bat. Which population participates in, influences, and affects the practice of medicine the most, besides physicians? RNs! How many RNs were represented in the participatory medicine coverage? Only three! (Well, two—I'm not licensed!) There was my feeble attempt at a nurse's point of view—since we've been doing this for years. Nurses have to meddle with medicine more than anyone else without an MD license, and we have a vested interest in making more patients do this as well! So where was everybody?

Amy Romano, nurse-midwife and Science and Sensibility blogger, wrote how the push to change passive patients into engaged consumers can start by changing maternity care. She makes a few excellent points. Engaging one maternity health-consumer affects two or more people. Many women (and men, thank you very much) begin their path to active participation in their own medical care by investigating their birth options. That's how I started. These families tend to raise their children to be active, medically-literate critical thinkers, so the improvement can be exponential.

Unfortunately, a "doctor knows best" attitude prevails in most maternity care settings. Rather than honing their skills as effective, engaged consumers, women are learning to be passive recipients of standard protocol.

Not to mention the cost of obstetric care is astounding. Some of it is arguably unnecessary, so any increase in patient literacy and active participation will lead to savings, especially in public aid. Even a decrease in precautionary c-sections would make a huge impact.

And then there's Barbara Olsen's nearly confrontational challenge that failing to increase patient participation is tantamount to increasing medical errors:

In highly reliable systems, the intended outcome is delivered under both normal circumstances and when conditions destabilize...It's fair to say that the 100,000 or so unintended deaths due to medical errors and healthcare acquired infections that occur in the US each year disqualifies our industry from being a highly reliable one. So what does participatory healthcare mean for patient safety?

Tons, but here's one of the most obvious: When a patient is seen as a participant in, rather than the object of, care, the system becomes more stable. At its most basic, patient participation adds a valuable redundancy at high stakes junctures of care...patients are uniquely positioned to uncover a wide array of errors that have been set in motion.

This goes back to maternity care; heck, it addresses everything. Skeptical patients save lives. They save their own lives, their own health, or (in maternity care) the lives or health of their babies.

Personally, I think we RNs need to be larger voices for participatory medicine. We already have the concept of patient advocacy, but it needs to be expanded. Patient advocacy still lets us be the boss; we advocate for the patient because we know what's best for the patient. That's a great thing while the public is still medically illiterate and subservient to medicine, but if it lasts forever, we'll begin to occupy the same master-servant relationship with patients that we're trying to chip away from doctors and insurance companies.

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Also - Change of Shift is also up at Emergiblog, with a decided ICU/ER and nursing student slant. I like it!

Apparently I Don't Look the Part

I won a nursing school scholarship. It's divided into two payments, one in the fall and one in the winter semester (i.e. after January). Well, I graduate in December, so I thought I'd try my luck and see if they'll give it all to me this semester.

The scholarship foundation offices at the college recently relocated, so finding the office took forever. It was actually behind an unmarked door and I had to walk through a few other empty offices.

Finally I see a woman and ask her, "Is this the foundation office?" She eagerly says "Yes! You're here! It's right this way!"
Me: "..."
Her: "The copier! It's...it's...aren't you here to fix the copier??"
I awkwardly say something about winning a scholarship, and she's becomes mortified. "I thought you were from tech support!"

Apparently I don't look like a nursing student. I thought it was funny, and even offered to look at the copier anyway. She was too embarrassed to let me.

Participatory Medicine

The forthcoming edition of Grand Rounds centers on the concept of participatory medicine, which is a concept I'm familiar with even if the term is new to me. Participatory medicine is the idea that patients should be knowledgeable enough to competently manage their own healthcare; that physicians and healthcare practitioners encourage knowledge and allow participation; and that healthcare organizations, from hospitals to insurance companies, support this process financially and informatically (i.e. allowing access to your health information).

My first thought as a nursing student was that this is something nurses already do. We are not licensed to practice medicine—that's what the MDs do—but our daily work involves participating in that discipline. Whether it's carrying out medical decisions, questioning them, or suggesting them, nurses routinely use their knowledge to influence and alter the practice of medicine. It's defined in the idea of patient advocacy. We speak up for the patient when they are unable to, or lack the knowledge to do so. We speak on their behalf to physicians, hospital administrators, insurance companies (through case managers), and other health workers like physical therapists. There's nothing intrinsically bad about these other groups; but due to the busy nature of their work, and how they're spread across multiple patients, there are countless incidences when a patient would have a less optimal or adverse outcome if not for a nurse speaking for them to these groups.

The Society for Participatory Medicine delineates four types of people or groups for need to facilitate participation: the patient, the practitioner, the healthcare organization, and society at large. It occurs to me that nurses are possibly the only group to regularly take on two of those roles: that of the patient (as advocate) and that of practitioner.

Clearly most nurses enjoy this role, but they just as eagerly want patients and caregivers to shoulder more of this burden. We're not always there to advocate for you. We're can't call the MD for you like we do in the hospital. We can't drive you from home to the ER, deal with the insurance company, or handle family disputes about your care. Patients—people—need to be active and competent managers of their care 24 hours a day. How many hospital stays could be avoided by judicious management of heart failure or diabetes by the person suffering it, or by their family?

However, I think there are two major obstacles to participatory medicine. The first is that we, as a society, almost always relegate our own healthcare to physicians and institutions. I don't think an individual or a caregiver needs to have all the knowledge a physician or nurse has; but there's no reason they can't have competent knowledge of their particular condition. Competent enough to stand up to physicians or nurses making wrong decisions. The Speak Up Campaign is an excellent voice for this.

The second obstacle is that we, as a society, are very isolated and fragmented. We emphasize independence so much that even in intact families, you'll find parents and adult children and aunts and uncles in very loose contact, if at all. Every time I encounter a patient who fell in their home and laid there for days before being discovered by a neighbor, I wonder about this. It's terrible: they come in delirious, starved, dehydrated, septic, with skin sloughing off their arm or leg or whatever they were laying on...and they often don't survive it. But this didn't happen out of nowhere. These people almost universally had conditions which led to their fall: obesity, diabetes, weakness, heart failure. In the hospital we would assess them and call them a fall risk. There's an official nursing fall-risk scale, but it's almost always a common sense judgment. Why didn't their families do the same? Why are they living on their own? Or why isn't someone checking up on them regularly? And it doesn't have to be a drastic life-threatening condition; anytime I see a dinner tray sitting untouched in front of an elderly patient, and a family member sitting there idly, I wonder why it doesn't occur to them to do the basic, human thing of encouraging them to eat, or feeding them, or getting different food. In other societies, we humans take care of our parents as they age. It makes sense. But the US is different for some reason.

In sum: participatory medicine is great. Nurses are already doing it. Patients and their families need to be encouraged to do it more.

Should Nursing Students Be Allowed to Blog?

Code Blog ran a story about Nina Yoder, a nursing student who was expelled for blogging about patients. Later she sued her way back into school, on the grounds that she didn't violate confidentiality, professionalism, or her school's code of conduct; but not everyone agreed with the outcome of her case. The comments are illuminating, especially since someone posted an archived copy of her original posts.

Obviously this has implications for me, as a student blogger. I feel that it is within my rights to discuss healthcare and disease processes, using examples from the actual cases I see. I also feel I am allowed to write about being a student nurse and a working nurse assistant, and my thoughts on what it will be like to be a nurse in the current hospital system.

But not everyone agrees that you can write whatever you want about patients, even if you don't use their names, or you change facts about their cases. I have to say I agree. There's something not quite right about blogging from a professional stance just in order to complain about work or school, using specific patient stories as examples. I also don't like how sometimes we gossip about patients. And changing the facts doesn't sit well with me either. Blogging about patients is never quite like writing case studies for a journal, but I think it should strive to be something close to it. Publishing case studies, like blogging about patients, involves stories about nameless patients, but case studies are supposed to be educational and edifying; they instruct you or cast more light on some issue or problem by making it individual. I think good blogging can do that, too. Many issues in healthcare—say, poor treatment of the elderly, or depersonalized obstetric practice—can be strikingly illuminated by telling the individual stories which only we nurses, physicians, family members, and others involved in their care can tell.

I think it almost goes without saying that a certain amount of maturity and openmindedness is involved in doing this. I think the difference between Ms Yoder and myself is that she was using her blog to vent, to complain, and to air opinions which some would call honest, but others would call immature or naive. And I do think, as I commented in Code Blog, that nursing requires maturity and objectivity, and that nursing professors can and should prevent you from moving further in your education if they feel you're acting in an immature manner. I can't promise I always think, or write, like a mature and experienced nurse should write. But I try. That's partly why I subscribed to the Healthcare Blogger Code of Ethics. I'm also writing a privacy statement for this blog, based on what I've researched about what you should and should not be able to say online, both in respect to HIPAA and to the principles of nursing professionalism.

But I can see why nursing instructors who may be sued or lose access to a clinical site (i.e. a hospital refusing to let students from a your school come back) would have a hair-trigger sensitivity about nursing students who blog. I'm not sure how to allay those fears, except by blogging semi-anonymously and by strictly adhering to the Standards for Privacy of Individually Identifiable Health Information set forth by the people directly responsible for enforcing HIPAA. This includes no names, numbers, specific dates (birth, death, dates of care), and locations smaller than a state.

One note, however: Ms Yoder complained about her school, saying clinicals are 99% a waste of time. I'm sure this clinched the case against her in her professors' minds. But while it may not amount to constructive criticism, I have to say I've felt my time was wasted in certain clinicals and with certain clinical instructors. There are few ways to express this without getting into trouble, or at least having your comments fall on deaf ears—but I feel anyone would be justified in saying it, if it's true. We students have precious few hours in the real clinical setting before we're let out the gate as real world RNs, and every clinical hour should be productive.

Emergency Room Edumacation

Part of our clinical rotation this semester involves rotating to the emergency department to follow a nurse for a few days. Then we're supposed to write a paper about the experience, following an outline they gave us. I left the outline sitting on a desk on the unit where I work, and one of the ICU nurses helpfully scrawled the following answers on the paper:

1. Identify the assessments made by ED nurses when they encounter patients experiencing acute complex alterations in homeostasis:

HE'S A DRUNK

2. Relate examples of the levels of illness which the emergency triage system encounters:

I HAVEN'T HAD A BOWEL MOVEMENT IN 24 HOURS

3. Observe the role and responsibilities of the ED nurse and explain how these differ from the responsibilities of a floor nurse.

FLIRT WITH THE PARAMEDICS

4. Relate methods of crisis intervention for patients or families in crisis in the ED.

LOCK THE DOORS - KEEP FAMILY OUT

5. Develop a beginning knowledge of the nursing interventions which ED nurses must implement for patients in the ED.

TRANSFER TO ICU STAT

6. Relate the teaching needs of the short-term ED patient.

DON'T COME BACK.

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Osteological Anticlimax.

We had the most boring lecture in the world.

We're senior nursing students. We've just come off an intensive series of fascinating lectures and tough exams on the most advanced cardiac and respiratory stuff there is—arterial blood gases, electrolytes, CVPs, Swan-Ganz catheters, wedge pressures, open heart surgery, cardiac arrest, ACLS, respiratory acidosis, respiratory alkalosis, metabolic acidosis, ventilator modes, tracheostomies, chest tubes, pneumothoraxes (pneumothoraces?), chest trauma (bullets, knives), lung resections, laryngectomies, radical neck dissections, ventilator weaning. People have been saved from the clutches of death left and right in our young student minds these past couples weeks. So you can imagine our excitement, our intense interest, when we entered lecture the other day to find the subject was...

OSTEOPOROSIS!!

Not that it's a bad subject. It's just kind of...you know...first semester-y. It's a basic "care of the elder adult" subject. You can't talk to students about how nice it is to make sure people get calcium in their diet when the students are still thinking about how Ca²⁺ enters intracellular fluid in phase 2 of myocardial depolarization to produce heart contractions. (It is phase 2, isn't it?). We were almost too astonished to be bored.