Gotta Read This: Why you don't want a stupid nurse

So, I was looking up some info on diabetic care and came across this posting, ponies from betelgeuse regarding "Why you don't want a stupid nurse" from 2006. I was so impressed with the frank discussion and explanation that I am putting it here, but I am also giving you this nurse's other blog site, Sinus arrhythmia, because she has some interesting stuff there.

Tuesday, October 24, 2006
Why you don't want a stupid nurse.
There's a blogwar going on this week between MDs and RNs. I'm not going to link to it, because the entire thing is infantile. The argument, in the few paragraphs that aren't raw insults and pissing contests, essentially highlights the deplorable state of communication between doctors and nurses.

Why do you care about this?

I'll tell you why you care that MDs and RNs do NOT communicate well. You have a body (presumably). The body will debilitate, sicken, fall apart and ultimately die. It is the way of bodies. It's what they do. When you come into the ER with chest pain, you bloody well want your nurses and doctors to be a flawless team, communicating well and quickly to save your life.

When your mother falls and breaks her hip, you bloody well want her nurse and her doctor to be on the same page on how to handle her pain and prevent infections. If something bad happens to your mom, you do not want a pissing contest between your nurse and your doctor. You do NOT want your mom's doctor to refuse to return pages at 0300 because he believes that the nurses "aren't calling for anything important". (True story.) The difference between 0300 and 0315 CAN be a big difference in your mom's condition. You do not want a doctor to prescribe some needed intervention for your mom, and have her night shift nurse just blow him off because she says, "Oh, that's just Dr. SonSo, he's not payin attention".

Complications will keep your mom in the hospital another week, exposing her to the most virulent germs you'll find anywhere, continuing her convalescence and worsening her overall health every single day. Fifteen minutes can mean a life-threatening drop of 10 to 20 points of systolic blood pressure (as it was in the case of the unreturned page.) (I got a specialty doc to get the fluids order. Patient went to the ICU, but lived.)

You care that doctors and nurses treat each other with mutual respect. You get sick, your spouse will get sick, your kid will get sick. It is what bodies do. You do not have to subscribe to the buddha's ideas to know that pain and suffering are unavoidable.

Okay, so say you're with me on this idea that nurses and doctors should treat each other with respect. You're a reasonable person. You're probably even a good person, and you think respect is a good idea. But you may not be a doctor or a nurse.

You're probably just Joe Person. What you can do to help fix any problem in health care?

So glad you asked.
1) Never say to a nurse "You're so smart, you should be a doctor." If I had a quarter for every time I heard that...

Here's what is wrong with that comment:
a) The implication that all nurses are dumb. Do you know how what it means when one pupil grows larger than the other? Think that a nurse, any nurse, needs to call the doctor at 0300 and what....ask them? By the time you're done dialing, patient's dead at worst, brain damaged at least. Some nurses are dumb. Some bankers are dumb. Some lawyers are dumb.

b) The implication that all doctors are smart. I guarrantee you that this is not true. Some doctors are most assuredly dumb. I work with one day in and day out, and I am leaving my unit because I can't stand how I keep preventing him from killing people. When the actionable event happens, I'm not going to be anywhere near it.

c) That nurses want to be doctors. I don't want to be a doctor. I chose to be a nurse. I gave up a fat salary being one of those scary-smart nerds who fix large computer systems to be a nurse. Money, above and beyond meeting my needs and wants-to-travel-and-buy-more-books, is not a motivator for me. Not being on call and working 80 hours a week is a motivator for me. Doctors spend five minutes a day with a patient, I spend 12 hours with them. Nursing and "medicine" (as if nursing isn't also medicine) are complementary pieces to providing good health care. One is not the flunked version of the other. Because doctors? The ones I know would not make good nurses.

2) Learn about what nursing is
The public doesn't know. They really don't. Do you know how I know this? Because since I've become a nurse, many of my dear friends find my stories apalling. Perhaps they think I'm painting myself a hero because of the times I say, "I stopped another person from dying yesterday." But every nurse does this every day to varying degrees of urgency.

TV has no idea what nursing is. I want you to understand that. When you watch tv, enjoy tv shows, think to yourself "This is fiction just like the Simpsons is fiction." Please. ER is a great show that shows doctors being heros, and Nurse Whatsername, Julianna Marguilies, going to medical school because she's Such A Smart Nurse. Don't even get me started on Grey's Anatomy. I hate that show.

Here's a fact to know: Doctors are not employees of hospitals. This is a fact in American hospitals. Doctors DO NOT WORK FOR THE HOSPITAL. The nurses do. Hospitals are run by nurses (or should be, they're actually run by MBAs, which is why health care is the state in which it is). Does it matter? No. But it should underscore that the doctors go home. Your doctor isn't available at many times of day/week. Who's there for you? Your nurse.

Nursing is about health promotion, and preventing disasters and complications. Pain and symptom management are things we do well, and work with the MDs to do well. I actually had a urology physician assistant once re-place a foley catheter into a man with prostate cancer and huge complications with his bladder function. The patient had been given dilaudid (high octane narc) for pain for the procedure. Good. The PA sat there, writing orders for the night, and I perched on the desk. PA says to me: "He shouldn't have any problems tonight." "Good," I said, "What are you writing for me for pain?" "He won't have any pain." I laughed. "Then you're writing your phone number down so I can call you at 2:30 in the morning when he complains of pain, right?" He looked at me, and I gave him dead-serious face. "Okay, here's an order for Vicodin." "Great. Thanks. Have a good, restful night." (Do you need to ask whether the patient needed the pain pill?)

You want that nurse who is good at predicting when you're gonna feel like shit. One who knows which med is gonna make you nauseated. One who knows you'll be in pain, and helps you avoid it.

Should you be in a hospital or your loved on is, ask your nurse questions. Lots of them. Most of us love to talk to patients, because hey, it's why we're nurses. I spent an hour with a patient and his wife two nights ago talking about "foot care and diabetes." Sound dumb? I mean, 'foot care'? Ask a diabetic who's had his foot amputated. There are a lot of them. It is one of the most common adverse conditions secondary to diabetes. Three nights ago, I noticed this patient has unequal pulses in his feet. The patient probably thought I was just being a sweet nurse and rubbing his feet to tuck him into bed. That's how people get the idea that we're dumb and sweet. We don't tell them the hundred little tiny things we watch for. I do. Not to show off, but because people usually really like to understand their bodies, particularly when they're sick. It gives them control over their lives, when almost everything about hospitalization and illness rips control away.

His right dorsalis pedis was weaker than on the left. Which meant either deep vein thrombosis, peripheral vascular disease, or some type of arterial insufficiency from the diabetes. A DVT could kill him, but I didn't think it was that. (Why? No "hot spots" on his calves, 0 pain, - Homan's sign.) So I go back to the desk and call Dr. Boob to ask for a NIVA, an ultrasound of his leg veins. After struggling with Dr. Boob not returning my page, and boring me with his self-importance, I got my NIVA order. Patient gets a NIVA in the morning, and it's negative for DVT. Had it been positive, I would have stopped the patient from dying by having that test done....based on my sweet "foot rubbing". It was pretty critical to rule out that as the problem. Don't you think?

So he's got arterial insufficiency, which is typical for diabetics. I talk with the patient and his wife talking about what this means, why they need to care, and what they can do to prevent becoming like my patient from last month with PVD...who had Boxing-Helena-esque gradual amputations. (I didn't mention that last bit.) You think the MD spent ANY time whatsoever discussing diabetes (a complex, lifelong disease process with huge implications for diet, lifestyle, constant medication administration and self-blood testing 4x/day, disease and medication side effects, not to mention family teaching on what to do when the patient conks out unconscious because of an adverse event), ....much less what to do differently to make sure the patient doesn't have his feet chopped off in 2 years?

Don't make me laugh.

Dr. Boob went in, asked "how physical therapy is going", said "we'll talk about discharge next week" and went home for the day. Of course, this is why I call him Dr. Boob. However, Dr. K, the consult doc who I do respect quite a bit...went in, discussed medication changes he'd made for the patient's discharge. (Again, this was Michelle, the night RN, leaving a note for the physiatrist about patient needs for insulin scrip before discharge because I'd spent an hour and a half the day before working with the patient on how to give himself insulin, what it does, how it works, etc.) So K made the decisions about what insulin he thought was needed for discharge. Cool. This is what I want docs to do. This is why "Dr. K" is "Dr. K" and not "Dr. Boob".

You want a smart nurse. You really, really do. Again I say, I'm not special. A lot of nurses can show you how much they know about your body and the medications your doc prescribes. A huge number of people don't hear the doc's explanation (if he or she does explain) about meds or diagnoses. They're in shock a lot. They're sick and feel shitty a lot. They need to hear things again (or for the first time). A lot of patients feel more comfortable asking someone they perceive as being sweet and foot-rubbing. They want to know about side effects. They want explanations in English, and forgive me, but that is one things doctors do NOT do well. It's okay. That's part of what nurses do.

The trouble with nurses is that we're bad at explaining what we do. Most second-career nurses who were in other fields before are exceptions to this. Nursing socializes itself to act meek or deferential. A century of the medical establishment running things is part of the historical reason, another other part we can blame on the very religious Florence Nightingale, who dictated that nursing have her interpretation of Christian values of self-sacrifice and poverty. Those of us who've been in other fields are used to talking about our work and many of us have been in fields where we're on even footing with other men, and are used to being regarded as professionals. Most nurses do not have this sensibility.

So I try to tell people that nurses are smart, and WOW, people believe me. When I was a programmer, I never had to insist "but programmers ARE smart". People know generally what geeks do. So I'm telling you stories about what nurses do. Pass it on. Please.

3) (And this is directed at Americans) Support legislation that nurses support.
Nurses get into the profession because we actually want to take care of sick people. We want the system fixed. We hate accepting an assignment of 8 patients and not taking care of any of them well because we're putting out fires all night. We know you hate it. We hate it more. Unionization has HELPED patient care in California, the studies show that. Yes, there is such a thing as nursing research and nursing journals. (There's New England Journal of Medicine and there's American Journal of Nursing.) Requiring a BSN degree as professional-entry nursing (as opposed to LPNs, Licensed Practical Nursing) has HELPED patient care in North Dakota.

So if you believe me about those things, it will actually indirectly help the cause. Your cause of wanting good health care when you need it.

I will rant later on the evils of Medicare, the abuses of the pharmaceutical companies. And what I think nurses need to do to fix nursing. As well as why you should care.

For now, that's my story and I'm sticking to it.
/jo, RN, BSN