Текст книги "The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital"

Автор книги: Alexandra Robbins

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Текущая страница: 16 (всего у книги 33 страниц)

In times of budget cuts and healthcare changes, hospitals may be reluctant to alleviate understaffing and/or to provide resources to help nurses deal with burnout, compassion fatigue, PTSD, second victim syndrome, and other assaults on their mental health. But administrators must openly acknowledge that their nurses’ health is worth the investment. Burnout and compassion fatigue have been linked to decreased productivity, more sick days, and increased turnover among nurses, which are correlated with higher patient mortality rates, lower patient satisfaction, and compromised patient care. Nurses suffering from these issues are more prone to make mistakes. The ISMP has reported that fatigue alone can cause reduced accuracy, inability to deal with the unexpected, slower recall, and reduced hand-eye coordination, all of which could greatly impact patient care.

Researchers have also found that nurse burnout is linked to hospital-acquired infections, which kill approximately 100,000 patients a year. The researchers theorized that burnt-out nurses might be less vigilant about washing hands (and reminding visitors and other clinicians to do so) and other infection control procedures. They calculated that in hospitals that reduced nurse burnout by 30 percent, the number of urinary and surgical site infections dropped by 6,239, which saved $68 million a year. Washing hands matters: When the Michigan Health and Hospital Association implemented a checklist to remind staff to clean their hands and keep the field sterile, within three months the median rate of infection in central line catheters had fallen to zero.

It would also behoove administrators to decrease staff turnover, and not only because hospitals must expend resources to train and hire new employees. Inadequate nursing staffing has been called a national emergency. When nurses resign from a hospital, they create a cycle in which the remaining nurses are left short-staffed and more stressed. A Drexel University study found that when nurse turnover rates increase, so do the odds of nurse injury and patients’ risk for pulmonary embolism/deep vein thrombosis.

Meanwhile, it is up to nurses to bolster each other, and to appreciate when hospitals get the system right. Nurses at a midwestern NICU rely on a particularly effective chaplain and each other’s strong support. After a tragedy, the team discusses the case to talk about the plan of care and what could have been done differently. They often follow up with parents whose children died in the hospital.

“One of the worst parts of coping with traumas and tragedies is when the family is present,” said a pediatric ICU nurse in New York. Parents might watch CPR breaking their child’s ribs, alarming bedside procedures, the monitor numbers dropping, or their children in an altered mental state. “Believe me, it’s shocking what we do to these children; the brutality of a [cardiac] arrest can be very intense. We are trained to be the eye in the storm, to stay calm. But in the periphery of the storm, that’s where some of the worst damage can be done; parents suffer PTSD, they have nightmares. So do we, though.”

Recently, as the New York nurse gave compressions to a baby in cardiac arrest, the child’s parents were on their knees sobbing and praying in the corner of the room. After the team had lost the pulse twice more, a doctor escorted the parents out of the room so they would not be present for emergency surgery. “The surgeon got there and the baby’s chest was opened at the bedside so he could do manual heart massage and his fellow could rewire the pacer wires. The child ended up being fine. That is the miracle of medicine,” the nurse said. “This baby left three weeks later in his parents’ arms with a Superman cape tied around his little neck. No residual neurological damage, no cracked ribs. Nothing. That’s what you have to remind yourself of the next time a kid codes and things don’t go so well.”

In the University of Akron study on burnout, 99.9 percent of the nurses surveyed nevertheless reported feeling happiness or pride during the previous week at work. “Sure, there can be an overall feeling of being burnt out at work, but things happen that give you that sense of worth, pride, and happiness,” a Kansas ER nurse told me. “I’ve been completely beaten down after three twelve-hour shifts in a row, then gotten a compliment from a patient that turned my feelings around. Helping a particularly sick patient can be physically and emotionally draining, especially when you’re feeling burned out, but if the patient opens their eyes and gives you a smile, or you get a sincere hug from the wife, that can make it all seem worthwhile.”

This fortitude is part of what makes nurses so incredible, and is one of many reasons that should convince administrators to consider nurses valuable contributors rather than replaceable employees. “I work where kids die,” an Arizona pediatric oncology nurse said. “What words can be used to describe that? If I allowed myself to, I would cry every day. Instead, I try to focus on the time that that sweet little life was a part of mine. I try to keep things as fun as possible for the child. Kids who are dying know they are dying. If I can elicit one little chuckle from them, then I’ve had a really blessed day.”

Nurses know to take solace and joy in the moments they are able to comfort a patient. Among the tragedies, miracles shine—wondrous flashes, whether flickers of hope or impossible resurrections—in which nurses played a part. These triumphs add up, and experienced nurses learn to clasp them close, to draw on them when they need a lift above the darkness. Instead of dwelling on lives lost, nurses can hold fast to remembrances of those they have rescued. Perhaps that’s also how Seattle Children’s should have considered Kimberly Hiatt. As Georgia nurse Brittney Wilson, who runs The Nerdy Nurse blog, said, “She made a mistake . . . but how many lives over those twenty-seven years did she save?”

JULIETTE

  PINES MEMORIAL, January

The ER was still overcrowded. Pines already had closed to ambulances twice the week before and turned the ER’s minor care room into a medical surgery unit. For this particular holiday season, out of twenty-three rooms in the ER, eighteen were occupied by “boarders,” patients who had been admitted to a hospital floor that didn’t have a bed ready. How could a hospital run an ER with only five rooms? As far as the nurses knew, eighteen boarders was a record.

Some nurses surmised that the patient overload was a result of some of Westnorth’s new policies and agendas; understaffing led to less frequent bed turnover and longer ER waits. Others guessed that because of the recession, more people had lost their health insurance, causing them to come to the ER instead of a doctor’s office. Sometimes, too, Juliette wondered if life spans were increasing. It seemed like fewer people were dying, and fewer patients had Do Not Resuscitate orders. “There are so many old people we shouldn’t be doing all these interventions on to keep them alive. Just let them be,” Juliette said.

Juliette had a 90-year-old patient who was nonresponsive, shaking, and exhibiting a sodium level of 171 milliequivalents per liter (normal range is 135 to 145), which indicated severe dehydration and/or kidney disease. Juliette readied herself for end-of-life comfort care.

Dr. Preston found Juliette at the nurses station. “Her daughter wants her treated,” he said.

“But she has an active DNR,” Juliette said.

Dr. Preston shrugged. “It’s not worth the cost of what the lawsuit would be to go against the family.”

Juliette’s jaw clenched. This was absurd and she was comfortable enough with Dr. Preston to tell him so. “Clark, you’re telling me, if I’m ninety and I have a DNR and I’m dying, but my daughter or husband says, ‘I want you to do everything you can to save her,’ that you would go ahead and try to save me?”

“Yes, we would. That’s what Pines wants us to do,” said the doctor as he scribbled orders for an IV, antibiotics, a catheter, and blood draws. “Pines wants us to go with the family’s wishes if the person isn’t awake or able to say anything.”

Juliette had seen this before at Pines. If the family was present and wanted the hospital to override the DNR, the staff would first try to convince the family that the patient’s wishes were clear. If the family insisted that the doctor keep the patient alive, he would usually do that.

“What is the purpose of having a DNR if we ignore it?” Juliette asked.

“Juliette,” Dr. Preston said, patting her on the back as he left the room, “take off your cape.”

This year, Juliette was scheduled as the charge nurse on Christmas Eve and New Year’s Day. Because Molly wasn’t flying home for the holidays, she had graciously volunteered to work eight hours of Juliette’s twelve-hour Christmas shift so that Juliette could spend most of the day with her family.

On New Year’s Day, when Juliette arrived for her shift as charge nurse, the waiting room was packed with drunks. This was the worst holiday to work because ERs were beset by hordes of intoxicated patients. There was a three-hour wait for patients to be seen. The trauma doctor was busy with the unusually high number of traumas that had come in overnight, including three teens whose car had crashed into a tree and a man whose wife had run over him on purpose. The charge nurse wasn’t supposed to have any patients at all, but every other nurse had several boarders already. Juliette assigned herself eleven patients.

She was glad to see that Ruby was on duty. A fifteen-year Pines veteran with wild curly black hair, Ruby was a recently divorced nurse who was prone to making off-color comments. She rubbed some colleagues the wrong way, but she had always been friendly to Juliette. On the few occasions when they worked shifts together, Juliette was quick to assist Ruby when she needed it and Ruby would reciprocate. It was helpful for nurses to have a partner like that.

Juliette was also relieved that Dr. Lee was the day’s trauma doctor. A small bespectacled Asian man, Dr. Lee was a favorite of the nurses. He was one of the rare Pines physicians who said “please” and “thank you” to them. He was patient, generous about sharing information with nurses, and receptive to nurses’ input. And another rarity: He was quick to respond when a nurse paged him.

Juliette moved as many intoxicated patients as possible into the hallway to clear the rooms. Even Dr. Preston stopped Juliette to whisper, “What are we going to do? We have no room for any new patients.”

“We just keep trying to move people out as best we can,” Juliette said.

At 11:00 a.m., Carla, a young nurse and a new member of the clique, approached Juliette. “Room Two is angry from waiting and may just go.”

“Fine, let her,” Juliette said. She stopped by the room. The patient, who had driven her Audi into a stop sign and had minor lacerations, was pacing and hollering, “I have to get out of here. I have to go.”

“You have to wait for the trauma doctor to give you discharge instructions,” Carla said.

“I want my clothes.”

“Your clothes were cut off of you at the scene because you crashed your car,” Juliette said. “The paramedics came to help you and you were put on a backboard.” The woman’s blood alcohol level was two times the legal limit.

“I want my fucking clothes!” she yelled. “I want my belongings!”

It was standard procedure for staff to cut clothes off of trauma patients for quick and easy access, if paramedics hadn’t already done so. “You wouldn’t believe how many people get upset because their clothes are cut off when we’re trying to save their life,” Juliette later explained. “If we can save an item because you’re awake and alert, we will, but if we can’t, we can’t. And the medics are prone to cutting things off right away.”

Juliette moved on to another room, expecting the woman to leave as soon as her discharge instructions came through.

The medic phone rang. “Pines, can you take two Priority One traumas?” Priority 1 meant a patient would die without imminent intervention.

Juliette gestured to the secretary. “Call Dr. Lee and find out if we can take them.”

“Stand by,” Juliette told the medics.

The secretary hung up the phone. “If it’s okay with you, he can do it, he says.”

“We’ll take them,” Juliette said to the medics. “Can you give me report?”

Juliette assessed her staffing. Her single trauma nurse was already overwhelmed and Juliette would need another. She assigned both of her techs to the incoming Priority 1 patients. She asked Ruby, who was in the center of the ER, to give report to her on her four patients so that Ruby could leave them to assist the trauma nurse. From that zone, Juliette could handle Ruby’s patients—mostly drunks—as well as her own and still observe enough of the ER to handle charge nurse duties.

Juliette moved a drunken dreadlocked man from Room 4 to the hallway, near a buxom 21-year-old who had vomited all over her low-cut minidress. When Dr. Preston walked by her, he shook his head to the nurses and murmured wistfully, “She was somebody’s New Year’s Eve dream date until she started puking on herself.”

The Priority 1s were an elderly couple who had been hit by a car. When the medics wheeled the couple in, Juliette assigned herself the patients. She was able to get the woman into the OR right away to treat abdominal bleeding, and the man into the OR within two hours for head bleeding. Juliette was glad she had accepted the traumas because they both needed immediate treatment. She later found out that both people survived.

After the couple moved upstairs, Juliette made her rounds. She could hear the Audi driver in Room 2 cursing at Carla. “You fucking bitch, I told you I want to talk to the doctor!”

Carla, looking stressed, exited the room. “What do you want me to do?” she asked Juliette.

“Just get her out of here. Discharge her.”

The woman was still yelling, between snippets of a conversation she was having on her room phone. Now she was refusing to leave. “I paid for this room!” the woman screeched. “I’m not leaving!”

Juliette picked up a hall phone and dialed 911. “I’ve got a verbally abusive, threatening patient I want out,” she told Dispatch. She returned to the patient. “Ma’am, you’re going to have to leave.”

The phone still at her ear, the woman paced in her blue paper scrubs. “I don’t have to leave, you fucking bitch.”

“You’ve been discharged. You have your things,” Juliette said.

“Whoever cut my clothes off is going to pay for them.”

“Fine. But I have a sick patient I need to put in this bed. You can wait in the hallway.”

“I’m not waiting in the hallway.” The woman resumed her phone conversation. “Can you believe these people?”

Juliette stretched a new sheet over the bed, then reached over and unplugged the phone from the wall. “I’ve told you: You need. To leave. The room.” She took the woman’s purse from the stretcher and handed it to her so she could clean the stretcher.

“Don’t you touch my shit!” the woman yelled. Juliette calmly headed to the room’s hand-sanitizing dispenser.

At that moment, the police arrived and ushered the patient out of the room while Juliette explained the situation to the officers. Immediately, the woman’s demeanor changed. In a saccharine voice, the woman said to Juliette, “I need some discharge instructions and you better have some backup for those things you’re saying about me.”

“Backup?” Juliette hooted. “I don’t need backup. It’s all written in your chart.”

Dr. Lee approached the patient. “I’m sorry it took so long. You are discharged. There’s nothing wrong,” he told her.

“Well, I need something for my pain,” she said.

Aha, Juliette thought. A drug-seeker. That’s why she demanded to leave, but then refused to. She just wanted a prescription.

Dr. Lee wrote her a prescription for Tylenol-codeine #3. The woman looked at the paper. “I’m allergic to that,” she said.

“Is it written in your chart?” Juliette said. She leafed through the chart. “Hmm, it doesn’t say here that you’re allergic to Tylenol number three.”

The woman glanced nervously at the police officers. “Never mind, I’ll just take it,” she mumbled.

The story in the ER for the rest of the day was how Juliette had heroically unplugged the phone on the patient. Afterward, three nurses told her that she had been a wonderful charge nurse. “You made New Year’s run smoother than usual, Juliette!” Ruby exclaimed. “It was so much less frantic. Great job!”

MOLLY

  January

Academy Hospital

Molly’s fertility doctor was offering her one last IUI cycle, her fifth. She would give herself shots for ten to twelve days, then have IUIs on two consecutive days. The protocol change meant that she had a clinic appointment on a morning she was scheduled to work at Academy. She hated to inconvenience Academy supervisors; Academy was the easiest money she made.

But the ER director assured her that the staff loved working with her and would try to accommodate her appointments. “You are an asset to our department,” the director said, and assigned Molly a 3:00 p.m. to 3:00 a.m. shift. She told Molly how much the managers appreciated that she was a hard worker, self-sufficient, and always willing to help other nurses.

A 25-year-old named Jan, a petite Hispanic nurse who had graduated from Academy’s nursing school, was one of the most grateful nurses at Academy. Like many of the baby nurses in the Academy clique, Jan would come to Molly with her questions rather than admit to the other baby nurses that there was something she didn’t know. Molly was happy to help nurses who wanted to learn from her. “I like teaching,” she explained. “I try to say stuff in a nice way so they don’t feel stupid. So many times in nursing school I was made to feel stupid, and I don’t want to do the same to other new nurses.”

In the early evening, Molly happened to see Jan standing in the supply closet looking confused.

“Do you need something?” Molly asked.

“What do I need to do a chest tube? They’re doing one STAT and I need to get back in there.”

Molly had drained chest tubes, which were used for patients with a collapsed lung, more times than she could count. The chest tube was inserted through the ribs to help the lung reinflate. “Okay, we need the chest tray for the doctor,” she said. Jan pulled the tray from a shelf. “We need the collection chamber for the blood or air coming out of the patient. We need some sutures. And then we need the sterile gowns and supplies for the doctor.”

After Jan collected the items, Molly followed her to the patient’s room, where a doctor was prepping the sterile field—cleaning the patient’s chest and opening supplies on a table covered in sterile drapes. The patient, a college student, was crying. A collapsed lung was painful and made it difficult to breathe. Like many young, thin males his age, the student had coughed and suddenly had shortness of breath. A chest X-ray had revealed the problem.

“Open up the collection chamber. You need to add water into the funnel,” Molly told Jan quietly so the patient wouldn’t realize that his nurse wasn’t experienced with the procedure. “The tubing needs to be attached to the suction. Good. Now we’ll wait for the doctor to insert the tube and then we attach the chest tube to the suction.”

After the successful procedure, Molly told Jan she had done well. Away from the patient, she told Jan a story. “Something to remember with chest tubes is if the doctor makes the hole too big in the chest, then air can escape into the rest of the body. Once I helped a doctor put a chest tube in a guy who was intubated. Well, every time the respiratory therapist squeezed the ambu bag, the patient’s balls would inflate!”

Jan started laughing. Molly continued, “The chest tube had just gone in, so they’re bagging him real fast and no one is noticing this but me. They started out normal testicle size but they were very large grapefruits by the time I figured out what was going on. The guy was naked and the air is tracking from around the chest tube hole through his lungs and into his groin. I had to say, ‘You know, his balls are blowing up every time you bag him.’ So they called in a cardiothoracic surgeon and had to suture the air leak shut.”

“I’m glad you didn’t tell me that beforehand,” Jan laughed. “Thanks for your help. I totally understand chest tubes now.”

Midshift, a 16-year-old girl was brought by ambulance to the ER from a school dance, where she had gotten drunk, thrown up, and passed out in the bathroom. When her father arrived, he screamed at her. Then the girl changed her story.

“Dad, I think when I was passed out, someone raped me,” the girl sniffled.

Her father immediately redirected his anger. He demanded that the nurses call the police and start an investigation. Everyone in the room except her parents knew the girl was lying.

Teen patients commonly said anything they could think of to avoid dealing with their parents’ reactions. Molly had treated dozens of teenaged girls who made up the same story, and not one of them had been sexually assaulted, creating what Molly referred to as “a ‘girl who cried wolf’ mentality.” Most patients didn’t realize that if police officers seriously considered somebody to be a sexual assault victim, they brought the patient to a hospital with a sexual assault nurse examiner (SANE) on staff, which Academy did not have at present. The patient wouldn’t come through triage or sit in the waiting room; the staff would usher her straight back to a private room for the SANE’s evaluation, a policy that Molly called “a very hush-hush process hidden in the ER.” Therefore, ER nurses knew that if EMS or the police brought a patient through triage, they did not believe the individual had been sexually assaulted.

When the father went into the hallway to call the police himself, Molly turned to the girl. “If you really were raped, we will do everything we can to help you,” she said. “If it’s not true, we have a big problem: Someone will get arrested, go to jail, and possibly serve time just so you can get out of trouble for drinking. Now tell me, what’s worse: being grounded for something you did or someone going to jail for something he didn’t do?”

The girl looked down. When her parents came back into the room, she muttered, “Maybe that didn’t happen. I don’t remember.”

On another occasion, the daughter of a local VIP got drunk at a school dance and passed out. A friend’s parents brought her to the ER. When the girl’s father arrived, he yelled so loudly that Molly closed the door to the patient’s room for a while. Soon after Molly opened the door again, the girl had an epiphany.

“Daddy, Daddy! Jesus is talking to me!” she shouted. “He’s showing me what I did wrong! Daddy! Kneel beside the bed with me and let’s pray! Dear God! Thank you for giving us your son to take away our sins! Thank you for showing me what I did today was wrong!”

The father fell for it. He knelt next to the bed with his daughter. “Praise God! Praise Jesus!”

“Daddy! We need to go to church when we leave here and let everyone know that alcohol isn’t the way. Jesus is the only way!”

Her father shook his head, feeling it. “Amen! Praise Jesus!”

“Daddy! I want to speak in front of the congregation and let them know that Jesus is good! Alcohol is not good! Daddy, this will never happen again!”

“Amen, baby. I love you.”

And the yelling was done. The Academy ER had a sticker sheet of glittery Oscar statues that were reserved for patients who put on Oscar-worthy acts. The nurses would stick one on a patient’s chart so that everyone who treated the patient knew what to expect. Some staffers didn’t like Oscar because it gave the practitioners preconceived notions. But Molly thought it was funny and a stress reliever.

Molly had to give credit to this resourceful teen. As a nod to her performance, Molly stuck Oscar onto the girl’s chart.

Citycenter Medical

One afternoon, medics brought in a woman who had attempted suicide by turning on a barbecue grill in her bedroom and inhaling the gas. It looked like she would survive. As Molly documented at the nurses station, a pregnant nurse walked by and sniffed. “Ta’quisha, you get grilled hot dogs for lunch?” she asked loudly. Ta’quisha, a tech, told the nurse about the attempted suicide; she was smelling the fumes off the patient.

“Now I’m hungry!” the nurse said.

At the end of the day, an ambulance brought in a 60-year-old man who had been found slumped over at his desk at work. The man twitched and his eyes rolled toward the back of his head. The staff at the nurses station was busy watching the attending doctor question the EMT to determine whether the patient had suffered from a stroke or a seizure.

“Is anyone watching him?” Molly asked, jumping up to help. “Does he have a line?”

After the patient was intubated and sedated, Molly brought him into radiology for a CT scan. The neurology team crowded into the viewing room, excited to see what had gone wrong in the man’s brain. As the scan materialized on the monitor, a voice behind Molly shouted, “I win!” She turned to see the neurology resident making the victory sign. “It’s not a stroke, it’s a seizure!” he said happily. “Who else had seizure?”

Many hospital staff members got through the day by relying on a morbid sense of humor. Molly had come to know the funnier doctors well enough that they joked with her frequently. It was impossible not to laugh at some of the patients, too, like the guy who came in with his penis stuck in a metal washer (it was a large washer). Or the middle-aged man who decided to experiment with his garden bounty one night when his wife was out of town. Unfortunately, he couldn’t then remove the cucumber from his anus. In the hospital, he was moved from the ER to the OR because, the small-fingered doctor told her nurses, “I wasn’t able to get it and it’s sideways now.” Molly noted, “There’s a multibillion dollar sex toy industry that’s discreet and online. Why do people use common household produce?”

Staff played games to make the day more fun, including Guess the Blood Alcohol Level pools. Some of the nurses kept a running list of the most amusing patient names to come into the ER. One doctor tried to crack up his nurses by writing ridiculous discharge papers, such as: “Dear Homeless Guy, I am disappointed that you are both drunk and smelly. That won’t get you any pussy.” This doctor also liked to joke with Molly about how to break fatality news to family members: “Raise your hand if your loved one is still alive. . . . Not so fast, you two!”