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: 23 (всего у книги 33 страниц)

In an Indiana NICU, “personal interaction is against policy,” a nurse said. Nevertheless, “When the kids are hurting or dying and the parents aren’t there, we will sing, kiss, rock, and love on the babies. We pull the curtain for privacy. You can’t help but smooch their tiny feet. That spot behind their neck is especially a sweet place to nuzzle. They love it.”

Sometimes we lie to you.

Nurses occasionally lie to protect a patient’s feelings or to make him feel more comfortable. A New York nurse told Reader’s Digest, “When you ask me, ‘Have you ever done this before?’ I’ll always say yes. Even if I haven’t.”

“We usually know the results of your tests before the doctors talk to you. We can tell when a loved one will have a bad neurological outcome but can’t tell you,” a Virginia pediatric nurse said. “We usually know what we would do, but can’t tell you what it is. We have to give you information in a nonbiased fashion so that you can make those decisions, even if we are dying to tell you what to do.” Even if patients specifically ask nurses, “What would you do in my situation?” some healthcare institutions have told nurses they cannot answer directly.

We are gross.

Nurses use toilet humor and are known for telling disgusting medical stories over meals (to the chagrin of non-nurse dining companions). And when they are out in public, “we are secretly looking at people’s arms to determine where we would start an IV,” an Arizona nurse said. “Sometimes if I’m out with a group of nurses, we’re like, ‘Wow, look at those veins. I could hit those from across the room.’”

At Pines, medics once brought in a 90-year-old man who had passed out after choking. A nurse grabbed a pair of forceps and pulled out a piece of chicken the size of half a deck of cards from his trachea. By then the man had gone too long without oxygen. Once his time of death was announced, Molly helped clean him up and tidied the room. “Then I washed my hands and immediately went and ate my lunch: leftover chicken!” she said. “Nurses are gross.”

Your DNR might be ignored.

Nurses in several states confirmed Dr. Clark Preston’s statement to Juliette that a family member can override a DNR, or Do Not Resuscitate order. While some nurses said that at their hospital, patients with signed, current DNRs are not resuscitated, several nurses told me that saving patients with DNRs “happens all the time.” The most common scenario occurs when an elderly or chronically ill patient with a DNR requires resuscitation and a family member tells the medical team to “do everything you can” to save the patient. Particularly if the family member has power of attorney (POA), nurses said he can change the plan of care.

“Theoretically we’re supposed to honor the DNR, but oftentimes the family will want the patient treated because they see the DNR as ‘giving up.’ We tell the families that the DNR means the patient didn’t want to be worked on if they’re in this situation. If the family tells us to do everything, though, then usually we have to, because the POA has the legal right to make medical decisions even if it overrides the DNR. Even if there isn’t a POA present, the next of kin still have the right to make decisions,” said a travel ER nurse based in Texas. “Families want us to ‘do everything,’ and if we let the patient die, we’re accused of killing them by refusing care. Because a POA can decide for the patient, it gets tricky if we try to honor the DNR. Basically it’s a lose-lose scenario.”

Medical providers can override a DNR because of a family dispute “and not really risk punishment,” said Arthur Caplan, Division of Medical Ethics director at NYU Langone Medical Center. If a DNR is vague or was filled out many years ago, physicians might doubt whether they can trust the document. “Think of a DNR as something that tells you a person’s wishes, but it’s not a binding order. Sometimes it can’t be binding because it’s confusing. Sometimes the family’s screaming a lot and we don’t want to cross swords with them,” Caplan said. “Sometimes the nurses don’t feel involved in these discussions with the physicians and don’t know why they decided not to treat further, so the nurses line up with the family. I have seen nurses fighting with each other about a DNR.”

It’s unlikely that the medical team will be penalized for overriding a DNR written with a patient’s consent, Caplan said, “because if you’re trying to keep someone alive, no lawyer will take that case.” If the medical team abides by the DNR, despite the family pushing them to override it, the family could sue, but would most likely lose. However, “Hospitals are afraid of being sued unnecessarily, so they tend to do what families want. Usually the patient with a DNR is pretty sick, probably not even talking. The family’s talking a lot. The easier route is to just do what they want. Forget a lawsuit; hospitals just don’t want to get into a fight. There’s a lot of deference to families who make a lot of noise, particularly families who are rich. I’m not sure every family counts the same.”

If there is time, hospital ethics committees can review cases in gray areas, such as when family members disagree. A New Mexico travel nurse said that physical fights break out among families over this issue. “People get desperate at the end,” said a California travel nurse.

The outcome may depend on the physician’s comfort with discussing the DNR process with family members, said a Canadian critical care nurse. “Patients have told me they wanted a DNR because they ‘can’t take it anymore,’ but doctors have overridden the patients’ decision because they said I was ‘playing God’ by advocating the patient’s request to die peacefully,” she said. When a Maryland hospice nurse told a physician that her patient had an advance directive for “no life-support measures in an end-stage condition,” the doctor replied, “I am not a lawyer,” and resuscitated the patient anyway.

The hospice nurse said that the waters would be less murky if doctors told patients’ families, “Your loved one filled out a form after a conversation with her physician that said she would want only comfort measures at this time. We would like to honor those wishes.”

Nurses also wish that healthcare providers did a better job of explaining resuscitation efforts to families, and that family members had more honest end-of-life discussions with each other. “I think if people better understood exactly what ‘do everything’ entails, they would be less likely to demand it,” said the Texas travel nurse. “Performing CPR is probably going to break multiple ribs, [some patients] will almost certainly die in the ICU after a prolonged barrage of horribly toxic medicines, and we can put someone on a ventilator but their anoxic brain injury means they’re never waking up again. If we could show families how much more horrible it is to prolong treatment of a dying person, perhaps they would choose differently.”

There are “codes” . . . and there are “slow codes.”

Some medical teams have a hush-hush way of dealing with discrepancies between a patient’s DNR and family members’ demands. In some hospitals, as a Missouri nurse told me, “there are lots of unsavory things that the polite public would make hay with,” including the slow code, a little-known term to the general public. Various units have different designations; at a Canadian hospital, medical teams distinguished between a full code, which they called “code 55” and a slow code, or “code 54.”

Some physicians will unofficially call a “slow code,” which will never appear in a patient’s chart, if a coding patient is elderly or chronically ill. The signal notifies a team that they are not expected to revive the patient but should go through some of the motions anyway. “Responders literally walk slowly, are slow to respond, give medications slowly, or hesitate to intubate so that the patient is unlikely to be revived,” said a Midwestern nurse.

“It’s often for the sake of a family who needs to see us doing something, anything,” said the Texas travel nurse. “We do [these things] when it’s painfully obvious someone is so far gone they can’t be saved, and occasionally when the patient is a DNR. The CPR and meds are the same, because it’s a dangerous line to cross if you withhold standards of care, but if it’s a young, healthy guy, we might code for 45 minutes, whereas with the elderly terminal DNR we will only code for 10. Usually we do a round of CPR, check for cardiac motion on the ultrasound, and then call it.”

A Midwestern nurse said the slow code is “not ethically appropriate” and used only by certain teams. As a Washington State PACU nurse explained, “Pounding on the chest of an extremely frail, elderly person is torture, not lifesaving. In instances when family members insist that we do all to keep them alive, it’s understood among the staff that the patient is a ‘slow code’ and no one hurries to get a crash cart. We do, of course, make the patient as comfortable as possible.”

We do not treat all patients equally.

Nurses work hard to give patients the best healthcare they can. But not every patient gets the same treatment. Respectful patients might get faster, kinder service than the pain-in-the-ass down the hall; grateful, thoughtful patients might get some additional perks: extra snacks, the newest DVD releases from the library, the best magazines from the waiting room, additional diapers in the postpartum ward. “I’m always happy to get something for the patient if it will make them more comfortable or make them smile,” said an Arizona pediatric nurse. “When an able-bodied parent asks me to fill the water pitcher because they don’t want to walk to the galley to fill it themselves, I get just a little pinched. The hospital is not a hotel, and I’m not your personal butler.”

The secret is simple. If you’re not nice, said a travel nurse in Colorado, “rest assured that every single person involved in your care will know about it. While we will never cut corners on medical care, you can be damn sure we won’t be doing you any favors or even acting as if we like you. You’ll get your extra cup of soda or warm blanket a lot quicker if you’re not a dick. Also, we won’t talk about you in the nursing station if you’re nice. We reserve the trash talk for the mean ones.”

And sometimes we are told to treat certain patients better.

Many hospitals treat VIPs better than the average patient, saving deluxe private rooms for celebrities and officials who know about them. While some luxury rooms are available to any patient who can pay, like those in the Johns Hopkins Hospital’s Marburg Pavilion, others are kept secret.

Nurses described accommodations that look more like spacious luxury hotel suites than hospital rooms, with kitchenettes, beautifully glass-tiled bathrooms, and other amenities. In one Washington State hospital, when a VIP comes in, the staff combines two rooms to make a large one. They are instructed to bring in a large-screen TV and the “VIP furniture.” After the VIP is discharged, a nurse there said, the furniture is removed and stored until the next VIP admission. “They do this for rich and influential people and we nurses are disgusted by it. Nurses are taught to treat each patient as an important person and to give our best care to each one of those patients. Personally, I find it insulting to our profession,” she said.

A Washington, DC, hospital has a VIP unit devoted to patients such as visiting foreign dignitaries, senators, and professional football players. “It doesn’t have typical hospital furnishings; the rooms are much bigger, with fancy bedspreads, decorative pillows, and lavish curtains,” said a Maryland nurse who used to work at the hospital. “The patients are served excellent food—much better than the food on the regular floors—and the nurses cater to their every whim. It’s a restricted floor, with no access from the regular elevators. Most people don’t even know this floor exists.”

In California, celebrities have been offered their own private nurse; one nurse said that her hospital “definitely bent over backward for anyone they considered important.” In other states, some administrators give nurses special instructions when VIPs arrive and will personally check in on the patient. When the nurses give report, they are supposed to remind the incoming nurse that the patient is a VIP.

VIP care becomes problematic when those patients unnecessarily take up resources that more critical patients need. “Sometimes they will get a one-on-one nurse or we are all told to give them extra-special treatment,” said a New Jersey nurse. “They can’t hold back a room in the ICU, but I have seen critical patients who should be next to the nursing station moved so that a relation of a board member, a big donor, or celebrity could have the better room even if their condition didn’t warrant that level of observation. At another local hospital they had an entire VIP section set aside; those rooms were not to be used for the riffraff.”

Every hospital at which a Virginia nurse has worked had “a couple of rooms, if not a floor, dedicated to VIPs, which is often hidden. At one hospital, there was a room specifically maintained only for the use of a very famous person with a very crappy heart. They’ll get the best food, the nicest rooms, the most accommodating physicians, and the nurses who are easiest to push over. The hospital left the VIP section completely empty unless a VIP was present. No intermingling. Politicians have such a warped sense of how the healthcare system works, because they never have to be part of the actual system.”

This discrepancy in care frustrates nurses, who observe firsthand when patients with similar health concerns have extremely different experiences. “Some people abuse the system and take up more of the doctor’s time, utilizing more resources and even taking up ICU beds. Sometimes they even dictate staying in the ICU extra days,” said a Washington, DC, pediatric nurse. “It doesn’t seem fair that one family is having a cushy experience, while the other is sleeping upright in a chair crammed in the corner just because they aren’t famous.”

We know you better than your doctor does.

Nurses want patients to remember that from the moment patients enter a hospital to the moment they leave, nurses—not doctors—will be more intimately involved with their care. “The doctor is at your bedside for all of three minutes unless you’re getting intubated or coding. The nurse is the one rapidly assessing you at the door, immediately determining what interventions need to be made, so that when the doctor does come into the room he has something more intelligent to say than, ‘Well, we’re going to get some labs and an X-ray,’ ” a North Carolina ER nurse said. “I get you undressed, on the monitor, cleaned up if needed. I will wash the blood and vomit out of your hair, and not gag or make you feel embarrassed that you’re sick. I’m the one who will go to the doctor and tell them you are having nausea, pain, or a neuro status change because suddenly you think it’s 1988. That will be the reason that you get a head CT, and we find a brain bleed and contact the neurosurgeon. And then I will be at your bedside for the next three hours while we wait, reassuring your mother. You will hardly ever see the doctor. You will always see the nurse.”

Sometimes we are forced to stay at work against our will.

Nurses told me about regularly being expected to stay 30 minutes, an hour, or 90 minutes past the end of their shift without pay. But inclement weather is an entirely different beast. “Our last snowstorm, they wouldn’t release the nurses until enough of the next shift made it in to cover the hospital,” said a Midwestern nurse. “During these times, we work, sleep, and shower at the hospital just to work another couple of shifts. If we can’t make it in, they’ll get us with a snowmobile if they have to. They’ve had army reservists drive out in their Hummers to get us. They make us stay against our will. Sucks when you have kids at home or are a single mom without a strong support system.”

Nurses don’t necessarily choose to work fourteen– to sixteen-hour shifts. “When nurses have attempted to refuse this overtime, we have been told this would be considered ‘patient abandonment.’ Nurses are not willing to abandon our patients,” an Ontario nurse told the Canadian Federation of Nurses Unions.

Don’t get sick on weekends, either.

Depending on the hospital, weekends and nights can be riskier for patients, some nurses said. “Half of this hospital is unavailable during those hours. A STAT echocardiogram isn’t always STAT,” said a Midwestern nurse. “There isn’t maintenance available, so you have to wait for Monday to get things fixed, which can be frustrating when it’s a procedure light that could help you out, or you have to move a patient because the monitor broke. If you run out of supplies, you have to make do until Monday.”

If a hospital’s technicians don’t work weekends, nurses might have to send special labs to outside techs, which can delay a patient’s care. Because some organizations’ housekeeping services are reduced on weekends, nurses have to take time away from patients to clean patient rooms or hunt down equipment themselves. If a hospital needs to work on the computers or the water system, the outages can also cause increased wait times. “It’s risky sometimes because of the staffing issues. We can’t staff for the what-ifs,” said a NICU nurse. “At night, our NICU nurses go to ER and Peds to draw labs and start IVs. That takes nurses off our unit and we’re temporarily understaffed. If there is a code or a delivery when this happens, it can be bad.”

Sometimes we put alcohol in your feeding tube.

If a patient with a history of alcohol abuse needs open heart surgery, a Maryland Cardiac Surgical ICU nurse said, he or she might get alcohol (supplied by the pharmacy) with hospital meals or through a feeding tube to prevent alcohol withdrawal symptoms such as elevated heart rate, anxiety, and shaking. A nurse in an Oklahoma cardiac unit who has administered this treatment to a patient said that, on physician’s orders, the pharmacy brought 60 ml of bourbon each night to the nurse and watched her pour it down a nasogastric tube. While this method is considered “old school”—hospitals more often give patients Ativan—“it is funny to say that you gave your patient a shot of bourbon as a medication order,” the nurse said.

That’s going in your chart.

Ever wonder what nurses are writing in your patient chart? If you say something offensive or off-the-wall, nurses chart it. If your family member creates issues, that goes in the chart, too. “I always chart when a patient is difficult or belligerent. I keep it objective and write direct quotes; it’s funny to have to type ‘Fuck you, bitch’ in medical documentation,” Molly said. Nurses chart everything because if a patient later sues the hospital, the evidence can diminish the patient’s credibility. Along those lines, Molly added, “If you claim to know someone, be someone, or say you’re going to sue, it doesn’t increase your chances of getting better service.”

You might not need the surgery your doctor says you need.

“Sadly, doctors and doctors’ offices bully people into having tests and procedures they don’t really need, especially the elderly,” said a Tennessee travel nurse. Similarly, “If I could talk to my patients before open heart surgery, I would probably advise thirty percent of them not to have surgery,” said a New York nurse. “Our fee-for-service healthcare system incentivizes doctors and hospitals to advise aggressive, high-cost treatments and procedures. Doctors undersell how much rehabilitation the successful recovery from heart surgery requires. Most patients tell me they didn’t know the recovery would be as difficult as it is. Every time I see patients over eighty-five opt for an aortic valve surgery because they were becoming short of breath on exertion, I scratch my head because many of these high-risk patients will not get back all the faculties they had before the surgery, and some won’t even make it out of the hospital.”

We cry over you.

They might not do it in front of patients, but nurses do cry about the people they treat, whether with patients’ families or on their own. “Because I’m a burly man, [people think] I am not affected as much, but I am,” said an Oregon murse. “Sometimes I cry on the way home from work.”

Some stories are too sad for even the most composed nurses to bottle away until after the shift. Nurses in Kansas, California, and other states told me about child abuse cases that led them to sob in the break room. A young Illinois nurse was taking care of a woman in her nineties and learned that “even when a patient can’t respond and their eyes are closed, they can probably still hear you.” While the nurse was talking to the patient, her preceptor laughed at her. “She can’t hear you and she’ll never open her eyes again. Stop wasting your time. We have a lot of other patients to get to,” she said and walked out the door. The nurse took the patient’s hand, squeezed it, and said, “I believe that you can still hear me, and I promise to take good care of you.” The woman lightly squeezed back. “I knew she heard me and I lost it right there. Even when patients may not be there all the way, they are still someone’s mother, father, sister, or friend, and deserve to be treated with respect,” the nurse said.

TV shows don’t get it right.

In reality, nurses manage many of the duties that viewers see doctors performing on TV, such as inserting an IV or catheter. “I laugh when I see shows like House or Grey’s Anatomy, where doctors are pining at the bedside of patients, giving them medications, or administering treatments. Doctors do nothing of the sort,” says an Arizona clinical education specialist. “They come by once a day, take a short look at the patients, review their chart, make orders, and leave.”

A New York hospital night-shift nurse said that sometimes his patients don’t see a doctor or a PA overnight. The nurse diagnoses the patient, determines the course of treatment, then treats the patient himself, sometimes without even calling the PA to approve the orders for fluid boluses, antihypertensives, diuretics, and other medications. “We reserve calls to the PA for fairly urgent matters, and handle whatever other issues arise ourselves. This can mean doing things that are beyond our scope of practice, but most of the PAs appreciate the uninterrupted sleep and will generally cosign any orders once they make their rounds in the morning.”

One major difference between TV and real-life hospitals is that many patients who survive in the shows would die in real life. A Texas clinical nurse specialist said, “In almost forty years, I can count on less than ten fingers the number of patients I’ve helped resuscitate who walked out of a hospital under their own steam. Even in a hospital, ninety-five percent of all codes fail to resuscitate the patient in an unwitnessed arrest” (if a person is found without a pulse and no one saw him/her collapse).

Some supervisors ask us to do things for which we’re not trained.

One reason an Air Force nurse left civilian nursing was because her supervisor skimped on her unit’s training. When an oncologist decided to admit patients to her unit who needed twenty-four-hour chemotherapy treatments, a nurse gave the staff a brief talk on the chemotherapy administration. “After that talk, we were expected to hang the agent [administer the medication] whether we felt comfortable with it or not,” she said. “I told my supervisor I did not feel comfortable administering the agent to any patients and she told me I was trained to do it. I told her a brief talk does not validate my competence to hang the drug. To protect the patient, I refused to do it. People who treat these patients have years of experience on an oncology unit, generally. I was working on a multiservice unit with ten to twelve patients at a time and could not care for the patient receiving the chemo appropriately. I didn’t want to administer the medication if I couldn’t monitor it effectively. From that day on, I was criticized for not wanting to do anything out of my realm of comfort.”

You make us value life.

Many nurses say that their work makes them appreciate the fragility of life. “Recently a perfectly healthy man slipped on the floor and severed his spinal cord. He will be dependent on others the rest of his life,” a Minnesota travel nurse said. “Think about not being able to hug your child, feed yourself, or scratch an itch. If every human spent even an hour on a nursing unit, it would change their perspective on what’s important. Before every hike I take, I dedicate it to one of my patients who will never be able to hike again. It’s a gratitude I never knew before I became a nurse.”

For nurses, each individual patient death is precious and, collectively, the deaths a nurse observes become a kind of memento mori, reminding her to cherish life. This appreciation is one of the threads that weaves nurses together. “Nursing keeps me grounded in my own mortality even when I’m helping someone die,” a former Army nurse in New Jersey said. “It’s a holy profession.”

We will try to do everything we can to help you.

California nurse Jared Axen was holding a dying hospice patient’s hand when he began to sing an old hymn. The woman, who didn’t speak English, hadn’t been responsive in days. But when Axen sang to her, she squeezed his hand, a response that soothed the woman’s family. Six years later, Axen, a classically trained musician, sings to some of his patients every day. “It gives them their humanity back,” he said. “Music is a common language that helps me connect with my patients.” Many patients also claim to feel better and to need fewer pain medications, Axen said. “It’s become a vital tool for my patients and their families.”

. . . And to save you.

In 2012, Emory University transplant nurse Allison Batson donated a kidney to 23-year-old patient Clay Taber, a recent Auburn University graduate. The 48-year-old nurse, a mother of four, told the media that her children were around Taber’s age, so his sudden rare illness, Goodpasture’s Syndrome, hit her hard. Batson, a hero, saved his life, and Taber now considers her part of his family. “I wasn’t even supposed to be on her floor, but the floor I was supposed to be on was full. And now we joke that we’re kidney-in-laws,” Taber told me. “I’d been on dialysis almost a year-and-a-half by the time I got the transplant. It was definitely something I never expected her to do. Just how selfless she is, willing to do something for a stranger, to change my life on a dime, was very heroic. I like to say she’s an angel sent down to help people.”