Friday, December 14, 2007

Checklists for Healthcare Providers

There is no way healthcare providers can rely on their memories to guarantee evidence-based practices. We are too busy, too fragmented, and too hurried.

This article from The New Yorker explains why checklists work:
The Checklist

The biggest push in patient safety today is crew resource management which is based upon standard practices to achieve safety in the aviation industry. I think we will be seeing huge differences in medical/healthcare practices in the future.

Thursday, December 6, 2007

Attention to Detail...

I recently got my birthday card from the Commanding Officer. It was handed to me by one of the corpsmen on my old unit, F-2. I've been off that unit since July. The CO has seen me many times since then and knows my current assignment since I was called in to his office on a patient satisfaction issue a week ago and the appointment was set up weeks prior to that.

My first birthday card from this CO went to the ICU. I cut him some slack because he was relatively new to the command and I figured I was just another face in the crowd. To make a mistake like this a second time, well...I realized it just doesn't mean anything at all. So it went right into the trash.

As a believer in good stewardship and using limited resources wisely, it pained me. Whether the CO actually signed it or not, someone took the time to type out a message on command letterhead (good quality) and he signed it or someone stamped his name. Someone made sure my letter got out of his office. And then they couldn't follow through.

Saturday, December 1, 2007

The Business of Being Born

Celebrity actress/host Ricki Lake's new movie, "The Business of Being Born" points out that some of the most traditional practices of contemporary obstetrics have everything to do with the convenience of the physician, but can actually make delivery more difficult for the mother.

The Next Inconvenient Truth?

"Birth is miraculous, a natural process. But birth is also big business and this movie will change your mind about everything you think you know about it," said Sabrina McIntyre, a Fairfax County mom and former flight attendant who delivered one daughter by Cesarean section (c-section) and another at home by midwife.

To most people, the idea of giving birth outside of a hospital seems foolish and even dangerous: why would any parent limit their newborn's access to technology in the event of an emergency? Why would any couple put their child's life in the hands of a midwife instead of an obstetrician? "When my friend Ricki (Lake) approached me about making this film, I admitted to her that I was afraid to even witness a woman giving birth, let alone film one," said Abby Epstein, the Emmy-winning director of "The Business of Being Born." "I discovered that the business of being born is another infuriating way medical traditions and institutions -- hospitals and insurance companies -- actually discourage choice," said Epstein.

"The point here," observed Dr. Marsden Wagner, former Director of Women's and Children's Health, World Health Organization, "is there's not a good history in obstetric practice of careful study of the long term effects of all these interventions. This is why; if you really want a humanized birth, the best thing to do is get the hell out of the hospital."

A Movement Underway?

Arlington-based midwife, Tammi McKinley, said her practice has "boomed" with the number of women questioning high-tech birth. "Women are really starting to understand that all those gadgets don't always mean a safer birth, and women are looking to replace high-tech birth with high-touch birth," said McKinley, who delivered one child by c-section and her second at home by midwife.

Statistically, the use of c-section, a major surgery, is being widely employed, more as a measure of convenience for both doctor and patient instead of a last resort in the event of an emergency. Dr. Michael Brodman, Chief OB/GYN at New York's Mount Sinai Hospital, cites a study that reveals the peak hours for c-section procedures are 4:00pm and 10:00pm. Brodman interprets the data from the perspective of the hospital-based physician:
"It's obvious," he says, "that four in the afternoon is 'It's late in the day, I don't know what's going on here, I want to get out of here and the ten o'clock at night is, 'I don't want to be up all night.'"

-- In America, midwives attend less than 8% of all births and less than 1% of those that occur outside a hospital. At the same time, the US has the second worst newborn death rate in the developed world. Lake and Epstein ask, "Why do less than 8% of Americans take advantage of the benefits of midwifery, which is statistically safer and cheaper than physician-attended birth?"

-- The five countries with the lowest infant mortality rates in the March of Dimes report -- Japan, Singapore, Sweden, Finland and Norway -- midwives were used as their main source of care for 70 percent of the birthing mothers.

-- C-section is the most commonly performed surgery in the US, at a cost of $14 billion per year. Cesarean-delivery rates are now at an all time high in the United States, standing at 1.2 million, or 29.1 percent of live births in 2004. The increase represents a 40 percent increase in the past 10 years.

-- In one 1999 survey, 82% of physicians said they performed a C-section to avoid a negligence claim.

Jennifer Block, author of "Pushed: The Painful Truth About Childbirth and Modern Maternity Care," writes, "Too many Caesareans are literally medical overkill. Yet some US hospitals are now delivering half of all babies surgically. Across the nation, one in four low-risk first-time mothers will give birth via Caesarean, and if they have more children, 95 percent will be born by repeat surgery. In many cases, women have no choice in the matter. Though vaginal birth after Caesarean is a low-risk event, hundreds of institutions have banned it, and many doctors will no longer attend it because of malpractice liability."

She adds, "We've become dangerously cavalier...the Caesarean rate should be a major public health concern."

Natural Solutions to a "Medical" Problem
Midwives are definitely a viable solution; however, many find it difficult to assist with birthing because of the impossibility of obtaining malpractice insurance. Peggy Vincent, a midwife in California, writes candidly about her life as a midwife and the barriers she encountered with regulations and insurance in her book, "Baby Catcher: Chronicles of a Modern Midwife."

I am still bitter about my birthing experiences at San Diego Naval Medical Center. As an active duty sailor, I was not permitted to have a midwife assist with my labors nor was I permitted to have a homebirth. Consequently, I got the physician only on-call when I went labor and that resulted in a an emergency room physician (not even someone doing their residency) catching my baby for only the second time in his life. I suffered a fourth degree laceration (extending through the rectal mucosa to expose the lumen of the rectum) with an infant that weighed only 5 pounds, 13 ounces. At least, I didn't have a Caesarean, although they threatened me with that.

ABC News published a story on unassisted home births. You can view the story and comments here:
DIY Deliveries: More Women Go It Alone

Here's an additional resource on the history of childbirth. As someone who studied medical sociology, this book should add depth to the rise of the American Medical Association:

Friday, October 19, 2007

Relationships Critical in Effective Leading

This month's issue of Center for Creative Leadership says "the ability to build and maintain relationships and work well with others is in big demand - and in short supply."

While I might think a leader is the one on point setting the pace, it's the manager who collaborates amongst departments to share resources, develop programs, and train personnel while simultaneously integrating direct reports' career and family desires with senior management edicts. So who really adds more value to an organization?

CCL says "Organizations are increasingly operating in ways that involve interdependent, boundary-spanning work - creating a greater demand for leaders who are skilled at participative management, building and mending relationships and change management."

Today's Navy Nurse manager [Division Officer] usually cannot offer choice job assignments although senior management does try to match career desires with billet openings. I have found that giving an expected timeframe for this transfer to a coveted position helps as well as exploiting opportunities for cross-training when workload is light. It also helps that nurse develop relationships with nurses already working in that department so this person is not only getting the benefit of me "pushing" this person to that department, but the department is "pulling" that person to come work with them in staffing meetings.

We cannot pay someone more for working the off-shift, weekend or holiday. This past summer, when staff members were working 18-20 twelve-hour shifts and on-call for more, the Nursing Middle Management Council wanted to reward those staff members with----a pizza party. I rolled my eyes. "Why not reward them with something that REALLY matters?" I asked. "Why not submit a nomination for a Navy Achievement Award---something that would appear on a fitness report and be presented in front of peers by the commanding officer?"

The response? "I'm really busy. I don't have time to write up a nomination." So, calling Pizza Hut or Dominoes is the ineffective leader's gift to direct reports. And it gives me a very good insight as to this manager's relationship abilities.

Thursday, October 18, 2007

"Health" Magazine Writer, Suz Redfearn, Advocates Deceptive Practices

The teaser arrived in my email box---Nine Secrets Health Insurers Don’t Want You to Know---and I clicked. Suz Redfearn, a freelance writer, says that

To get tested, talk up your symptoms.Your insurer doesn’t want to pay for a colonoscopy if it’s not necessary. But if your best friend is diagnosed with colon cancer and you want the $675 test to put your mind at ease, here’s how to get one covered: Mention to your doctor that you’ve had some blood in your stool and a lot of gas lately—or simply that your bowel habits have changed.

First, this is obviously not a colonoscopy but a flexible sigmoidoscopy. It costs a lot more for the more extensive procedure that checks the right side of the large bowel in addition to the transvers and descending colon. And sedation typically is not given for the flexible sigmoidoscopy. Most patients do not require colorectal cancer screenings before the age of 50. These exceptions include those with a history of familial adenomatous polyposis, obvious changes in bowel habits (bleeding, changes in diameter of stools, and unexplained anemia), and first-degree relatives diagnosed with colorectal cancer.

The National Cancer Institute has a wonderful site that explains the various options available for colorectal cancer screening. I would encourage all patients to discuss their risks with their providers and not resort to subterfuge or lying in order to obtain a test that may not be necessary.

I sent a letter to Health stating my disappointment with their decision to publish an article that advocates lying and deception in the patient-provider relationship. Healthcare providers already manage patients who claim they take all their medications as prescribed, who exercise as recommended, and who avoid dangerous health practices. Let's add another nail of skepticism to the communication coffin.

Other blogs about this article include:
California Medicine Man
Kevin MD Medical Blog

Sunday, October 7, 2007

October is National Breast Cancer Awareness Month

In the summer of 1994, our neighbor wore a turban and we learned she had breast cancer. I remember being invited over to their apartment with walls lined with books from floor to ceiling. She and her husband had three children who were crammed into this little apartment.

One day we came home to find her crying in the hallway. "Are you okay?" we asked, concerned. She shook her head no. "It's in my bones," she said.

I've thought about her off and on over the years. The five-year survival rate for breast cancer with metastasis to the bones is 21%. I hope she is still alive; her husband and children deserve that much.

Breast cancer is the leading cause of death in women ages 20-59 while lung cancer is the leading cause of death in women ages 60 and older. Breast cancer diagnosed in the early stage, that is, while it is still localized to the breast has a 96% chance of survival. This is why mammography is so important. There are no early signs or symptoms of breast cancer; even the monthly breast self-exam (BSE) detects cancers at much later stages than radiology.

My annual mammogram is scheduled for this month and I am not looking forward to it. However, the inconvenience and pain of being diagnosed with breast cancer far outweighs the inconvenience and pain of this diagnostic exam.

For more information, please check

Thursday, October 4, 2007

Too Sick to Take Meds

From the Chicago Tribune:

"In a new study published Thursday, a group of University of Chicago doctors found many diabetics believe that the inconvenience and discomfort of their treatments, especially multiple daily insulin injections, were as bad as the complications that can result from not treating their disease.

"Some patients, 10 percent to 18 percent of the total, said their treatments were so arduous that they would be willing to die sooner -- some said up to 10 years earlier -- if they could stop their medications.

""Some of this might be lack of education and people not understanding the disease process," said Dr. Holly Mattix-Kramer, a specialist in preventive medicine and kidney disease at Loyola University Chicago Stritch School of Medicine. "We need to do a better job educating our patients about what preventive care means and how it may affect their life span.""

I wonder if the providers evaluated these patients for depression.

There is a lot of support given to patients who are diagnosed with cancer. We have cancer support groups, we hold fund-raisers, and we generally don't fault these people for getting cancer (well, maybe we think smokers have it coming....).

In any case, there is no support for diabetics. Many diabetics have made lifestyle choices that have predisposed them to diabetes and, for some, lifestyle choices may have delayed but did not prevent the onset of diabetes. So others look at these people and "should" all over them. "You should have watched your diet. You should have lost weight. You should have..."

You cannot be dumb when you have a chronic illness. You have to track all sorts of medications, the timing, the changes in your diet and lifestyle (to include exercise and stress management as well as checking your feet every night) and then tweak your dosages when the next evidence-based practices are published. This means multiple visits to your provider and pharmacy and maybe visits to the emergency department when you take too much or too little of a medication. Think about all the time spent on managing this illness...

A multitude of factors comes into play here---psychological costs as well as very real physical costs. My only hope, as an adult nurse practitioner and clinical nurse specialist in adult health, is that these patients make INFORMED decisions---that is, they understand the full ramifications of the radical steps they are about to make and understand they may not be able to change their minds once they start down that path.

If they are honestly able to make this decision (and not just overwhelmed with the sheer agony of it all), then we as fellow humans have an obligation to support them in their decision and to allow them to die with dignity and grace.

Wednesday, August 8, 2007

New Assignment

I've been in the General Surgery Clinic for a month now (no more Dead End Corridor!). Life here is certainly different from life on the Multi-Service Unit. For one thing, I don't supervise any nurses and I have a capable and confident HM3 who manages the clinic itself and trains new corpsmen.

My main role here is to assist with endoscopic procedures through administration of intravenous conscious sedation (IVCS). I thought this would get boring, but I've been pretty interested in all the cases we've done so far (57 cases, if you include the 6 in which I was supervised to re-certify for IVCS and the 6 I supervised another nurse to get her IVCS-certified).

Today we saw worms.

Dr C got the willies. "I can't wash my hands enough after this," he declared. He kept muttering, "Wait till my friends see this on You-Tube." Then he'd shiver some more.

Friday, July 27, 2007

Medical Mistakes Happen

This newspaper in Wisconsin details some of the medical mistakes healthcare providers make. Here is another link to a web site for journalists covering healthcare:

I regularly receive the ISMP newsletter (offers free CEUs twice a year!) and have been amazed at some of the errors RNs have made. As nurses, we are instructed to use the "6 rights" of medication administration:

  1. Right patient

  2. Right medication

  3. Right dose

  4. Right route

  5. Right time

  6. Right indication

However, using these 6 rights does not guarantee patient safety. Critical thinking skills are essential and even then they can fail the best nurse, especially in Hour 10 or 11 of a 12-hour shift on the third day of a string of 12-hour shifts.

Patients must take responsibility and ask questions about the medications that are being administered to them. I frequently encounter patients who have no idea what medications they are taking or what they're used for.

Here is a link to an online medication form that patients can use to fill out and carry with them at all times. The Institute for Healthcare Improvement (IHI) provides extensive information from hospitals nationwide who have implemented safer healthcare delivery practices. The site requires free registration to access information and I have found it to be a wonderful resource.

As an RN, I tell my patients they should always ask who the person is who is administering the medication (are they an RN? a CNA? a crazed patient from room 210 who is offering you his stashed medicines?). Patients should also ask what the medication is, the dosage, and what the medication is used for. The RN should also instruct the patient on the common side effects and what the patient should do if he or she experiences one of them. However, this would happen consistently in the ideal world and that's not where we live.

Thursday, July 19, 2007

Dinosaur Nursing

We were critically short-staffed before and now one of our nurses left on emergency leave this morning. You can't run a schedule with five nurses. In the meantime, I've been moved out of the MSU to General Surgery. They chose another nurse to cover both her clinic and the MSU which doesn't make sense. I still had to manage a physical readiness issue for one of the sailors and I am writing three end-of-tour awards for staff detaching in the next couple of months. I also have to turn over with the Division Officer who will be taking my place.

The other nurse covering the ward chose to have nurses work 8-hour shifts in addition to their regularly scheduled 12-hour shifts so a new graduate nurse was not left on his own on the night shift. I argued that the 8-hour shifts would actually be longer because things happen and staff would be reluctant to leave, even when their shift was over. She responded, "When I was a nurse at their level of experience, I had to work seven shifts to get four off!"

I replied, "Dinosaur nursing doesn't work nowadays."

She retorted, "These nurses are just BABIES! They need to suck it up."

Quietly, I said, "These nurses are not babies. They are adults who have different priorities." But she had already turned and walked away.

It's times like this that I have to apply the 5-year rule: Will this really matter in 5 years? And my response is no. And I am sick and tired of the phrase, "Suck it up."

Slow Leadership says this:

"...organizations rely on people's feelings of loyalty. Not loyalty to the business, mostly, but loyalty to colleagues, who will be forced to take up any slack if someone refuses to give up vacation time or work a 60 or 70-hour week." The best workers vote with their feet: "Those with the most courage, the highest levels of self-confidence, the greatest commitment to ethical principles, and the strongest personal values leave."

Slow Leadership continues: "One of the differences between high levels of stress and actual burnout is the presence of depression. Someone suffering burnout has given up. He or she no longer has the power to fight, nor the self-esteem to put the blame on the organization, where it belongs. The burnout victim was, typically, an ambitious high-flier, a good team player who gave and gave until
there was nothing left to give."

Finally, Slow Leadership says, "Work is part of life, not the other way around."

What I should have asked this senior nurse is, "Don't you remember how angry, how powerless you felt when you were given these demands? Didn't you vow then to never become that kind of nurse or leader?"

Thursday, July 12, 2007

Managing Across the Generations

One of the blogs I frequently read is Penelope Trunk. She posted a report published by Deloitte & Touche on managing across the generations. You can download the report here:

I also recently read a report in Training Magazine that despite beliefs generational differences exist, all generations share core values which include an emphasis on family.

My husband has told me I can "stay Navy" or I can stay married. The biggest change in regarding the Navy as employer of choice is the massive number of hours I work at the expense of time with my family. At this point, I am working over 50 hours a week. There have been times in the past few months where I have worked six 12-hour shifts in the space of seven days. Unfortunately, I am not the only one in this situation. This will have increasingly chilling aspects for Navy recruiting as it attempts to do more with less.

Thursday, June 28, 2007

My Learning Edge

Adam Kayce of "Monk at Work" has challenged me to push the envelope of my intellectual horizons...which I believe I do on a daily basis in my commitment to lifelong learning.

I just finished reading "It's Okay to be the Boss," by Bruce Tulgan of Rainmaker Thinking. I was a hands-off leader, which is great if you're leading Marines, but it wasn't the appropriate leadership or management style for the nursing unit I was assigned. It only took me 15 months to realize I needed to be more hands-on, more involved, and more directional.

When one of my staff members died at his own hand last year, I realized I didn't know as much about him as I wanted and now it was too late. I was very blessed to have had the conversations that I did with him, but I didn't ask the difficult or probing questions that might have given me more insight, might have made me more empathetic, might have given me more forgiveness. I vowed never to let that happen again. So I gave index cards to my staff members and asked them to write the names and addresses of someone who would care to hear news about them. I asked for their birth dates, their anniversaries, and the names of any children, their ages. I wish I could say I developed this myself, but Michael Abrashoff of "It's Your Ship: Management Techniques from the Best Damn Ship in the Navy," gave me the idea.

So far, I have written 15 cards to parents and friends discussing one or two qualities I admire in their loved ones, how happy I am to have them working on my unit and what they are doing or learning, and how much promise they show. My staff members are, for the most part, under the age of 24, away from home for the first time and half a world away. It costs at least $1800 to fly home and it cannot be accomplished over a long weekend. They are also in a profession where they can be called as an individual augmentee to any humanitarian or wartime mission.

It has taken being a mother and losing a shipmate to improve this particular leadership element in myself, pretty steep tuition at the School of Heartbreak and Brutal Experience.

Individual staff members have spoken to me over the past few weeks saying how much their family appreciated hearing about them. One staff member did not know that his family had received my card until he saw it posted on the refrigerator while home on leave. They didn't throw it away. That means a lot to me.

Saturday, June 23, 2007

Anything in the Nut Family

The ICU transferred a patient to us. Admitting diagnosis was "1. Salicylate Overdose, resolved. 2. Suicide Attempt 3. Depression."

In response to questions regarding allergies on her nursing assessment database, she wrote, "Anything in the nut family."

Sunday, June 10, 2007

Pathological Rib Fracture

A 77 year old male with no relevant past medical history checked in with back pain. Films showed an abdominal aortic aneurysm and a pathological rib fracture. On incidental findings, the patient also had a pathological hip fracture.

He had a mass in the left lower quadrant that I was quite able to palpate, although I was unable to appreciate the AAA (which, according to assessments, was a "pulsatile midline abdominal mass").

He is a full code---he and his family couldn't wrap their brains around the fact that if he were to code, we wouldn't be able to save him. We would break all his ribs and probably rupture his abdominal aorta, causing certain death.

I think the thing that made me saddest was what Dr J said when I called to get an order for Zofran. "Thanks for taking such good care of this patient."

And I wasn't doing anything different I wouldn't do for any other patient.

Saturday, May 5, 2007

Sudden insight on a late Friday afternoon

It never fails. I've promised The Husband I'll leave work by 1500 and it's now 1515. A nurse comes in to talk to me about an idea.

"Why don't we have a senior corpsman designated for each shift to check the work of the other corpsmen? That way all the I's and O's will be done, vitals will be recorded, and everything else will be covered."

"That's a good idea," I say. "Unfortunately, I only have two corpsmen scheduled for most shifts. You're asking one corpsman to essentially do double work. This might also develop resentment in both corpsmen as one does extra work and the other feels he or she can't be trusted to get the work done. I think the nurse should double-check the work of her corpsman."

Silence falls as we both ponder these ideas.

"You're probably right," he finally admits. "I hadn't considered only two corpsmen on each shift."

I then explained that our highly trained and motivated corpsmen would be transferring to other units within the hospital over the next few months. "They only have two years here, so we get them for a year and then they go somewhere else for training diversity."

All the corpsmen we currently had on the floor had arrived between late June and August 2006. I'll be losing them soon and getting a fresh crop in to train. My senior chief keeps me maxed out on corpsmen with the understanding that when he asks for one by name, I have to give him or her up. He will ensure I have a body waiting in the wings and I have to trust him on this. If I stubbornly hold on to that corpsman until the last minute, there may be no body waiting and I am now short-staffed.

"I never realized that," the nurse said.

I suddenly understood that I don't communicate the pressures I face in my daily Division Officer juggling. Maybe I'm doing such a good job I make it look effortless. I doubt that. Perhaps, as in Benner's Novice to Expert, my nurses are not proficient yet. The sole measure of success for them is completing all nursing tasks. For some, it's simply surviving another shift. I realized I do an abysmal job of mentoring and leading these nurses. On a med-surg ward where nurses have no desire to be med-surg nurses, this is a particularly difficult challenge. I guess it's time to implement the "Bloom where BUPERS plants you" strategy. And time to talk with these nurses one-on-one.

"I'd like to sit down with you to discuss what you'd like to get out of MSU while you're here," I tell the nurse. "Let's talk when I get back from leave."

Escaping the Dead End Corridor

Even though I'm on leave, I still went in to work today. I had the doctor look at The Son's induration (it was healing), I physically signed out on leave, and I reviewed my email and action items. I compiled statistics and submitted the monthly Division Officer report because I wouldn't be back before the deadline. I fretted about sending one of the corpsmen to the ICU.

Ultimately, the corpsman I decided on was the result of my reading Marcus Buckingham's book, "Now, Discover Your Strengths." If this corpsman sees something that needs to be done, rather than finding a junior corpsman to take care of it, he simply does it himself. He knows a lot from his year on the floor, he has college experience, and he is older and dedicated to the Navy as a career. His strengths are his maturity, his ability to take initiative, and his clinical skills and expertise.

His weakness, as he relayed to me, is his inability to delegate. "It's just easier and faster to do it myself," he said.

I have identified two concepts here:

1. Many times it IS much easier to do it yourself. Picking up litter and answering the telephone are low-level tasks that require no additional training beyond common sense and commitment to teamwork.

2. You should always be training your replacement. There was no need for me to submit a report while on leave. I should have trained someone else to do it. I have to explain where to find the data for the reports and how to update the charts. I have to obtain permissions for the other person to be a contributor online. I have to show them how to review and respond to requests for additional information from higher-ups. I haven't done any of that and it's only a monthly report, so I also need to generate a "how-to" for my desktop reference, "Instant Division Officer Handbook - just add respirations."

I've shoved fistfuls of paper into this 3-inch binder and I haven't organized anything and I haven't made it easier for the next person to step into my shoes. When I first arrived here, I dutifully noted the heavily stenciled warning above the double doors: Dead End Corridor No Exit. I joke that the sign leading to my office is a self-fulfilling prophecy. Well, it will be if I don't start training my replacement now.

Mary K & and Terrible, Horrible, No Good, Very Bad Day

We made bedside rounds that morning and one of the patients TOW'd from the ICU two days earlier was reporting a headache. Since that's one of my specialties, I asked, "Is this headache like headaches you've had before?" She said yes, and she treated it with Tylenol. We promised to get her relief. The plan was to discharge her home the next day.

Subconsciously we knew she just wasn't right, because everyone checked on her frequently. She started vomiting and told us it was related to the headache. Her only PRN medication besides Tylenol was MOM. She refused offers for us to get Zofran or phenergan. The doctor had ordered a doubling of her lisinopril dose and I reviewed the side effects. I went back to her room.

"Have you been taking lisinopril long? Did your headaches start with the addition of lisinopril?" She considered the question, and said no, the headaches started long after that. She was sitting in the chair, leaning her head against her hand, resting her elbow on the rolling table. "How bad is the pain?" She replied, "It's a 2." I went back to the med room and saw that I could at least give her another dose of Tylenol.

She never got it. When I returned to her room, the ward clerk was holding her hand and calling her name. She was splayed out in her chair, with her head at an odd angle. She was on telemetry so I ran for the bat phone to the ICU and told the listener on the other end to start recording strips. The LPN called for a code. The corpsman and I raced the crash cart down the hallway. We dragged her chair over to the bed where we lifted her up and laid her flat, her eyes open wide and drool running from the left side of her mouth. We opened the crash cart as the code team came up the back ladderwell from the ER. The other floor nurse was assisting with the efforts, so I stayed outside the room and managed the rest of the floor.

Another patient's oxygen saturation levels were dropping to the low 70's. His ABG's showed severe acidosis and the hospitalist went in to deliver the bad news to the patient and his wife. My patient had a final request so I had the legal officer get a lawyer from Big Navy to come and do a deathbed will. I witnessed his signatures on all the forms and when we were done, they had already taken the other patient away.

Without the bed, the room was cavernous. Crumpled 4x4 gauze and blood smeared the floor where they started an EJ instead of wasting time searching her non-existent antecubital veins. A freshly spiked and primed infusion set dangled on the edge of the trash can, unused. The chair had been shoved into the corner. It was a rave gone bad.

Back when I first started nursing, one of my intern friends coined a term: the Grillo sign. Practically everything in healthcare is objectively measured or assessed and identified by signs---Obturator or Psoas Signs, drawer sign, or Homan's Sign. For Dr. Grillo, this meant the radiologist didn't have to point out the abnormality on the films; the defect or problem was readily apparent, often at some distance from the viewer.

This patient stroked out. The signs were there. She'd reported nausea over the past few days and other non-specific or vague symptoms. Only a few tools exist for treating stroke on Guam: medications like mannitol to reduce brain swelling and vasoactives to control blood pressure, drilling holes in the skull to relieve swelling (a very bad sign), and prayer. These patients are not stable enough to medevac to Hawaii or Japan. And rehab is extremely limited for those who survive.

Would identifying her problem earlier have made a difference? I repeated this story so many times that day, to myself and to others who patiently listened, who must have been reminded of "what ifs" in their own careers as healthcare professionals. As others reassured me, everything had already been set in motion long before I assumed her care that day.

Ultimately, the long slow bleed filled the right ventricle of her brain. And now, it is a waiting game, as it is for the patient with lung cancer, while we wait for the next terrible, horrible, no good, very bad day.

Disruptive Physician Behaviors

My patient was convinced he was on a regular diet. "I can't eat jello and broth for breakfast," he said. "The doctor said I could eat real food today."

His diet orders were written"clear liquids." I paged the surgeon, a difficult task to do at 0900 on Sunday morning. He didn't return my page. I paged again and finally left a message on his cell phone at 0945. Good thing it wasn't an emergency.

He finally returned my call at 1015.
"I need orders for a regular diet," I said.
"He has orders. I ordered it when he was transferred from the ICU."
"No, sir, he doesn't. The only orders are for a clear liquid."
"Fine, give him a regular diet." Slam.

I went ahead and ordered a 2000 ADA diet (which should really be "carbohydrate-consistent" but just try re-writing deeply ingrained institutional habits) instead of a regular diet and didn't page him back to request a correction because he'd just slam the phone down again. We both knew what he meant.

Unfortunately, I had to page him later, this time for a patient experiencing bladder spasms. I have learned to be concise with the surgeon because he becomes impatient. I explained the patient was feeling the urge to bear down and urinate and was telling himself not to do it.

"He already has Ditropan ordered," he said.
"No, sir, he doesn't."
"Well, the urologist ordered it yesterday."
"No, sir, he didn't. When he came to examine the patient, the symptoms were not consistent with bladder spasms and he consulted YOU for input to give a one-time order for morphine and start around-the-clock Toradol."
"Fine. Ditropan 5 mg po TID." Slam.

Barely time to do a read-back and verification. Good thing I have a thick skin and lots of experience with surgeons. I never take anything personally because they're just operating (ha-ha) on a higher plane.

Unfortunately, I have a lot of junior nurses who don't have this experience and they are terrified to call for assistance, to request clarification, to ask for guidance, because the surgeon will condescend, belittle, and in some cases, yell at them. This surgeon is going on leave for two weeks in May. Maybe he'll come back a little less stressed, a little more rested. Then again, surgeons are a different breed from the rest of us---highly driven and deeply superstitious but skeptical perfectionists with poor bedside manners.

In the nurses' station, I laughed and repeated a comment made by the infectious diseases specialist regarding one of my patients whose oxygenation levels hover around 66%: "He's a
facultative anaerobe."

This surgeon overheard me and said, "That's mean. Even if it's the Department Head for Medicine, you shouldn't repeat things like that. That's just mean."

I don't think he grasps the irony.

Disruptive Physician Behaviors

Disruptive Physician Behaviors - Rhode Island

Practicing Excellence

"A healthy physician-nurse relationship is not just a nice thing to have; it is a competitive advantage driving clinical outcomes, patient safety, and staff retention. Interviews of nurses demonstrate that when physicians intimidate and behave disruptively, clinical care is impacted. Ninety-two percent of hospital-based nursing staff have witnessed disruptive physician behaviors and report a compromise in communication, collaboration, and information transfer. Nurses also reported disruptive physicians increase frustration, stress, and the quality of workplace relationships. When respectful, collaborative physician-nurse communication is in place, and nurses are encouraged to speak up in the face of patient danger, errors are reduced and care for patients improves.

“The physician’s role in workplace operations and performance is critical,” says Beeson. “Physicians are in a leadership position and will influence the perception, attitudes, and behaviors of others. A vested physician committed to reward and recognition, who clearly articulates expectations, who gets to know and takes care of staff, and models the behaviors consistent with their organizational mission, will create a high-performing unit.”