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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Chapter 2

Crossing Doctor-Nurse Lines

:

How the Sexy-Nurse Stereotype Affects Relationships with Doctors and Patients

“I will not be ashamed to say ‘I know not,’ nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.”

–Physicians’ Hippocratic Oath

“The intimate nature of nursing care, the involvement of nurses in important and sometimes highly stressful life events, and the mutual dependence of colleagues working in close concert all present the potential for blurring of limits to professional relationships.”

–Code of Ethics for Nurses, Provision 2.4

“Lots of hot residents and nurses rush off to have quickie sex in utility closets during night shifts.”

–a nurse practitioner in Virginia

MOLLY

  September

Academy Hospital

During Molly’s third week at Academy, a patient arrived at the ER already dead. Molly asked the charge nurse what kind of paperwork she needed to fill out.

The nurse, who was about 22, looked perplexed. “Honestly, I’ve never had a dead patient so I don’t know. Can you ask someone else? I’m not getting patients out of here quickly enough. It’s just too overwhelming.”

Molly tried not to show her surprise. How are you in charge without ever having seen a dead body? she wondered. Twenty-two-year-olds have no business being in charge of an ER.

The patient load would have been considered a breeze at Pines; Molly had already come to think of Academy as easy money. Nurses here typically had no more than four patients, few of the patients were critically ill, and patients spent no more than thirty minutes in the waiting room.

Molly wondered whether a recent shift in nurse training contributed to the girl’s inexperience. Traditionally, new nurses first had to work on the medical surgery floor to gain experience before moving to the ER and other critical care areas. The nationwide nursing shortage (or in some cases, short staffing) instead punted grads into more difficult areas of the hospital. Nurses were starting their career in the ER, OR, or ICU. “At Academy, some of the baby nurses don’t know what they don’t know,” Molly said. “And there are med students and new doctors who are also on the learning curve. At Pines, there were plenty of times that a doctor put in a wrong medication order, and an experienced nurse was there to say, ‘Hmm, that doesn’t seem right.’ But not at Academy. There’s potential for big mistakes with this young staff.”

Many of the doctors at Academy were egotistical, but Dr. Cynthia Baron took the cake. Dr. Bitch, as Molly referred to her privately, was a resident who resembled Malibu Barbie, swishing her impeccably blown-out hair as she sauntered down the halls. She rarely deigned to talk to nurses unless she was angry with them or needed something, in which case she treated them like preschoolers: “Hi, pumpkin, can you do me a teensy favor? Thaaanks.”

One day, a well-dressed 88-year-old woman came into the ER. Molly was prepping her assigned room when two nurses practically carried the wheelchair in, rickshaw-style, one tipping the chair back and the other holding the woman’s kicking feet to the leg rests to prevent the woman from pitching forward. Molly was horrified. Do you really need to do that to this poor little old lady? she thought.

“I just want to go home!” the patient cried, thrashing about as the nurses set the wheelchair next to the bed. “I don’t want your help!” She tried to walk out of the room, but she was unsteady, and the nurses, assuming the woman was suffering from dementia, returned her to the chair.

Molly, the patient’s primary nurse, quietly observed her. Dr. Baron poked her head into the room, saw the commotion, immediately ordered antipsychotic drugs for the patient, and left. Hospitals could hold a patient for seventy-two hours following an assessment, but Dr. Baron hadn’t evaluated the patient at all; she based the order on the patient’s initial behavior alone.

Finally, Molly spoke to the woman, who was again trying to escape her chair. She gently put her hand on the woman’s arm. “May I please speak to you for a couple of minutes?” she asked. “Everyone else, can y’all please leave the room so I can talk to my patient?”

The nurses shrugged and left Molly alone with the woman. Molly’s green eyes softened. Occasions like these were important, to nurses and to patients—the moments of exchange with another person on a human-to-human level.

Just because a patient wanted to leave didn’t mean the hospital could allow her to go. Where would she go? Who would make sure she got home safely? Molly wanted to learn the woman’s story to give her a chance to explain why she was in the ER and whether she would be safe if she were discharged. “So what’s going on?” Molly asked. “Why are you so angry?”

The woman sat down and calmly told Molly that her neighbor had taken her to her doctor’s office. The doctor told her she was in heart failure, needed new medications, and should probably move into a nursing home. When she rejected the plan, the neighbor drove her to the ER and left. “I’ve lived a full life,” the woman said. “I’ve outlived my husband and most of my friends. My doctor said I’d die if I didn’t take his advice. I’m fine with that. I’ve lived in my home for forty years. I don’t want to leave it. I have help. I don’t need doctors telling me what to do. I’m ready to go.”

Molly nodded. “That makes complete sense to me.”

Molly found Dr. Baron in the hallway and relayed the discussion. The doctor barely looked at her. “She’s not competent,” she said.

“We just had a very lucid conversation. She wants to go home and let nature take its course,” Molly replied.

“She can’t make her own decisions,” the doctor insisted.

“Come back to the room with me,” Molly said.

Dr. Baron followed her and addressed the patient. “What is today’s date?” she asked. To determine whether a patient was clearheaded, it was standard practice to ask the patient’s name, the date, and the name of the current president of the United States.

The patient was frustrated. “I don’t know or care what the date is.”

She knew her name and the president’s, but Dr. Baron said, in front of the patient, “She is not competent.”

“You’re so pretty,” the patient suddenly told the doctor.

Molly laughed. “Well, I guess you’re right,” she said to the doctor. Dr. Baron turned on her high heels and went straight to the nurses station to order a psychiatric consultation and a variety of lab tests. Luckily, Dr. Baron’s shift ended soon afterward. When the next physician, Dr. Ward, arrived, Molly explained the situation. She liked Dr. Ward. He took the time to listen to the nurses. Molly had seen the doctor respect even a new nurse’s input when she knew that a rhythm change on a heart monitor signified that something was wrong, though she couldn’t pinpoint exactly what was amiss.

Dr. Ward sat down with the patient to hear the same story she had told Molly. The doctor called the patient’s son, who confirmed that the woman was entirely competent and able to make her own decisions. He let Molly put the woman in a cab twenty minutes later.

“If I hadn’t advocated for her, she could have ended up being committed to the psych unit for observation while they prolonged this woman’s life against her will,” Molly realized. “I think a lot of ER docs forget that not everyone wants to—or needs to—be saved.”

A few days later, a patient came in with a bad bone infection in his foot. While at home, he had broken his foot by merely putting weight on it, and the already infected area began to bleed. Paramedics bandaged his foot and brought him to the ER. By the time he arrived, the bleeding was controlled but his blood pressure was low.

Molly started an IV and hung fluids to try to increase his blood pressure. Before long, the man looked better, was talking normally, and reported feeling fine. Molly ran a few blood tests to make sure.

When Dr. Baron came into the room, she declared, rapid-fire, “He’s hypotensive because of blood loss. We need to transfuse immediately.”

Molly shook her head. “I don’t think he could have possibly lost enough blood out of a foot wound to be hypotensive. I think he’s septic,” she said.

“I’m ordering blood,” the doctor insisted.

“I just ran an I-STAT and his H/H [a lab that shows blood volume] are normal.”

Dr. Baron raised her voice. “Since he started bleeding so recently, his H/H might not reflect the blood loss yet.”

“Or he’s septic,” Molly said. “His lactate is elevated.”

Dr. Baron couldn’t possibly let a nurse upstage her. She called the blood bank and ordered the transfusion, stat.

Molly reluctantly transfused the blood, per the doctor’s orders. The ICU doctor who came downstairs to examine the patient before transferring him looked confused. “Why are you giving blood for septic shock?” he asked Molly.

“You’ll have to discuss that with Dr. Baron,” Molly said. “I asked the same question.”

When Molly complained to the charge nurse, the nurse answered, “We get a lot of complaints about how she treats nurses. She’s been reported to the director of the medical staff several times. It’s frustrating that no one does anything about it.” Most hospitals Molly had worked at had individual doctors here and there who mistreated nurses, but at teaching hospitals like Academy, the overall egotism led to particularly horrendous communication.

One autumn afternoon, Molly was waiting for a call from gastroenterology to find out whether doctors were going to take an ER patient bleeding from the stomach to the OR or to the endoscopy suite, or if he was going to be admitted to a floor. She was at the nurses station talking to the charge nurse about the case when she saw the attending GI doctor, whom she had not worked with before, and a resident pushing a stretcher carrying her patient down the hall.

“Hey, that’s my patient!” Molly said.

She hustled down the crowded corridor after the doctors. “Excuse me! Where are you taking this patient?” she asked.

“I’m the attending,” the doctor announced.

“I understand that,” Molly responded, “but I need to know if the patient will be coming back to the ER or if he has been admitted. If so, he can’t leave until he has orders. I need to know who is writing the orders.”

Molly wasn’t trying to engage in a battle of egos; she had to look out for her patient. A patient leaving the ER for another floor needed to have an admitting doctor accept him so that someone was officially taking responsibility and writing orders. Because the patient had not yet been assigned an admitting doctor, once the GI doctor took him to another floor, the patient could potentially fall through the cracks of the hospital system. The charge nurse needed to know whether the patient would be coming back to the ER to be discharged after surgery or whether he would need a room elsewhere in the hospital. Otherwise, after surgery he could be left in the PACU (Post-Anesthesia Care Unit) with nobody managing his care.

The surgeon looked at Molly as if “I had a penis growing out of my forehead,” in Molly’s words. “How could I possibly question what he was doing?”

He scolded, “All you need to know is I’m taking the patient,” and continued down the hall.

The nurses and ER doctors within earshot were so accustomed to this behavior that they didn’t say a word.

Various doctors displayed this kind of egotism again and again. During another shift, police brought in a 27-year-old who was arrested for drunk and disorderly conduct. The officers had wrestled him to the ground to take him into custody, and he had cut his chin badly in the scuffle. Molly assessed the patient, who was covered in blood. She documented that the patient was calm, cooperative, and responding appropriately.

“I don’t have insurance and I don’t want a lot of stuff done,” he said. “Can we hurry this up so I can get out of here?”

“You obviously need stitches, so let’s get you triaged,” Molly replied.

In the patient’s room, the physician’s assistant created a chart for the patient; like Molly, she documented that the patient was calm and co-operative. Then the patient made the mistake of talking back to the doctor, who had a low tolerance for drunk patients. “Doc, I want to get the fuck out of here!” he shouted. “Leave me the fuck alone.”

Molly liked this doctor, but he had a habit of giving a psychiatric diagnosis to intoxicated patients who disagreed with him. “This man is a harm to himself and needs chemical restraints,” he declared to the PA. “Give him twenty milligrams of Geodon,” an antipsychotic that put people to sleep. The PA refused.

“What, are you too lazy to put it in?” the doctor said.

“I don’t think it’s the right thing to do,” she said, uncomfortable. “He’s not psychotic. He just disagrees with you.”

The doctor was unruffled. “I thought we had a better working relationship than that,” he said. Not only did he put the order in, but, worse, he deleted the PA’s chart and started his own, in which he stated that the patient was combative and a harm to himself. It was the sort of behavior for which a doctor could lose his license. But even if Molly were to complain to administrators, which she did not, she expected the hospital would ignore her. It was as if the nurses’ voices didn’t matter.

Doctor Versus Nurse

Molly’s experiences with egotistical doctors are not atypical. In fact, they barely scratch the surface of an even more disturbing trend, a doctor-bully epidemic that one doctor described as lurking in the “shadowy, dark corners of our profession.”

In news reports and hospital break rooms, stories abound of doctors berating nurses, hurling profanities, or even physically threatening them: shoving matches in the operating room; a surgeon pushing a nurse so hard mid-operation that he left a bloody handprint on her scrubs; physicians throwing stethoscopes, scissors, pens, or surgical instruments. Physical abuse by physicians is on the rise. In Maryland, a surgeon yelled at a male nurse, “Are you stupid or something?” and threw a bloody surgical sponge at him from across the room. A Texas doctor heaved a metal clipboard at an advanced-practice nurse and told her he was going to strangle her. A surgeon threw a scalpel at a Virginia nurse, who said, “He was angry because I didn’t have a rare piece of equipment he needed, so he endangered me and several others by throwing a tantrum.” North Carolina nurses referred to one doctor as “He-Who-Must-Not-Be-Named,” because he got into a fistfight with another doctor and physically assaulted a nurse.

Most nurses have been victims of or have witnessed doctor bullying. The Institute for Safe Medication Practices (ISMP), a nationally respected nonprofit watchdog organization, has reported rampant bullying in healthcare, including verbal abuse, threatening body language, condescension, and, though less common, physical abuse. A 2013 ISMP survey on workplace intimidation found that in the preceding year, 87 percent of nurses encountered physicians/prescribers who had a “reluctance or refusal to answer your questions, or return calls,” 74 percent experienced physicians’ “condescending or demeaning comments or insults,” and one in four nurses had objects thrown at them by doctors. Physicians shamed, humiliated, or spread malicious rumors about 42 percent of the surveyed nurses. As a New York critical care nurse said, “Every single nurse I know has been verbally berated by a doctor. Every single one.”

This is a global problem. Significant numbers of nurses in Australia, South Africa, Hong Kong, Canada, and many more countries are bullied by doctors, according to surveys. In 2010, a nurse in India committed suicide reportedly because administrators would not address her complaints about a doctor who was sexually harassing her. A nurse’s association president said, “This case has not been taken seriously because the victim is a nurse.” In South Korea, a 2013 survey found that more than half of nurses were sexually harassed; the majority of the assailants were doctors.

Doctor bullying has many serious ramifications. A 2013 study found that the more that nurses experience it, the more likely they are to report poor working environments and to quit their workplace and/or the nursing profession. This is not the first study to find a link between doctors’ intimidation and poor nurse satisfaction, yet researchers repeatedly have found that most nurses don’t speak out against the behavior.

Why is hospital bullying veiled in organizational silence? Nurses are afraid to report doctors because they believe administrators will prioritize and refuse to penalize physicians who generate revenue or garner media accolades. They worry they might lose their own jobs in retaliation, and they fear the stigma of being perceived by colleagues as a whistle-blower.

If precedence is indicative, these fears are justified. A slew of double standards protect doctors’ jobs but hang nurses out to dry. Many hospitals have fired nurses for reporting doctors’ inappropriate or incorrect treatment of patients, while allowing the doctors in question to continue to practice.

In Florida, travel nurse C. T. Tomlinson saw Lawnwood Regional Medical Center cardiologist Abdul Shadani preparing to insert a stent in a heart patient although the patient’s scans revealed no arterial blockages. (A travel nurse is an agency nurse whose jobs are temporary assignments in various locales.) “Sir, what are we going to fix?” the nurse asked, according to a New York Times investigative report. Shadani said the patient had a 90 percent blockage and inserted the stent; Tomlinson told the Times that other staff in the room did not object. Soon after Tomlinson reported Shadani to HCA, Lawnwood’s parent company and the largest for-profit hospital chain in the United States, Lawnwood did not renew the nurse’s contract. An internal, confidential memo reviewed by the Times admitted the nurse’s contract was not renewed because of retaliation. HCA did, however, initiate an investigation that found issues with Shadani’s treatment of thirteen out of seventeen patients, including several other unnecessary procedures. Tomlinson was reportedly correct—and an ideal patient advocate, hoping to protect patient safety—but the hospital let him go. Meanwhile, at the time of this writing, Shadani still works at Lawnwood.

In 2009, two Texas nurses filed an anonymous ethics complaint with the Texas Medical Board against Dr. Rolando Arafiles Jr. for conducting dangerous practices that risked patient health, taking hospital supplies to perform at-home procedures, and pushing patients to purchase herbal supplements that he conveniently sold on the side. When the board informed Arafiles about the nurses’ complaint, Arafiles enlisted the help of the county sheriff, a friend and former patient who participated in his supplement business. At Winkler County Memorial Hospital, Arafiles tracked down personal information for the patients listed in the complaint and gave it to the sheriff, who contacted them to determine the nurses’ identities. The sheriff obtained a search warrant to seize the nurses’ computers, where he found the letter.

A hospital administrator fired both nurses, who had worked at the hospital for decades, and who had not signed their letter because they feared exactly this type of retaliation. They had resorted to filing the complaint after months of unsuccessful attempts to persuade hospital administrators to investigate the doctor. Worse, Arafiles and the sheriff convinced the county prosecutor to take the nurses to trial in criminal court, charging them with “misuse of official information,” a felony with a maximum penalty of ten years in prison and a $10,000 fine. Charges against one of the nurses were dropped and the other nurse was acquitted.

In turn, the nurses filed a federal lawsuit against the county, the hospital, the sheriff, and other officials, charging that their First Amendment rights were violated and that their firing and criminal charges had been retaliatory. The women won a $750,000 settlement. State prosecutors then went after the sheriff, who lost his license, was convicted of retaliation, and sentenced to 100 days in jail; and the county attorney, who was sentenced to ten years’ probation. Arafiles pleaded guilty to retaliation and misuse of official information and received a sentence of two months in jail and five years’ probation. As part of his plea agreement, he surrendered his medical license.

It is confounding that initially, the nurses were fired but the doctor was not. The medical board charged Arafiles with violations including sewing a rubber scissor tip to a patient’s thumb, using an unapproved olive oil solution on a patient with a bacterial infection, failing to diagnose a case of appendicitis, and performing a skin graft without surgical privileges. But not until Arafiles was charged with a felony did he lose his license. The Texas Medical Board allowed Arafiles to continue to practice as long as he took additional classes, paid a $5,000 fine, and agreed to be monitored by another doctor.

As a result of this case, the Texas Legislature passed a bill increasing fines against doctors who retaliate against nurses reporting unsafe care, and protecting those nurses from criminal liability. The Winkler nurses’ story doesn’t culminate in a tidy, happy ending, however. Because of the case, the Legislature passed another law prohibiting the Texas Medical Board from considering anonymous complaints against doctors. Meanwhile, the Texas nursing board still permits people to complain anonymously about nurses. In fact, an examination of policies and calls to nursing boards in every state revealed that doctors in forty-one states can report nurses to state nursing boards without having to identify themselves.

So not only did the two nurses who advocated for their patients by reporting unsafe healthcare get fired, arrested, and criminally indicted (their necessary and heroic actions damaging their careers and their incomes until they won their suit), but future nurses were dissuaded from reporting dangerous practices at all. “It is shameful that nurses don’t get the same level of protection as physicians. If nurses face the possibility of being outed and then prosecuted, they will think twice before turning in a dangerous physician,” said Alex Winslow, executive director of Texas Watch, a nonpartisan Texas citizen advocacy organization. “The lack of protection for nurses puts patients at risk.”

This unequal treatment is ridiculously unfair and glaringly unsafe. Nurses are caught in a terrible conundrum: When they report dangerous doctors, they can be fired. But when they don’t speak up, people can die.

The biggest problem with doctor bullying is that hospitals are not a run-of-the-mill workplace, where bullying might simply cause individuals’ feelings to get hurt or departmental tensions to rise, which are not trivial matters but are at least self-contained. In hospitals, what The Joint Commission calls “intimidating and disruptive behaviors” can lead to medical errors, increase healthcare costs, and harm patients. These consequences are possible because certain doctors refuse to listen to nurses or because nurses are too intimidated to ask questions promptly, if at all. Nurses have reported that they have caught themselves making mistakes, such as mislabeling specimens, because they were so upset, stressed, or distracted by a confrontation with a physician.

Approximately half of surveyed respondents told the Institute for Safe Medication Practices that doctor bullying had caused them to change the way they react when they believe a doctor has made a medication error. These nurses tend to succumb to pressure to administer the medication anyway or to suggest the doctor give the medication himself. As a result, many respondents admitted that they “had been involved in a medication error during the past year in which intimidation clearly played a role.”

A national study of 6,500 nurses and nurse managers conducted by the American Association of Critical Care Nurses reported that many nurses are too intimidated to voice their concerns when doctors make mistakes during surgery. Despite mandatory safety protocols like checklists, more than 80 percent of nurses are still worried about “dangerous shortcuts, incompetence, and disrespect” at their hospitals. Of the nurses who admitted that patient harm or “near misses” occurred because of a doctor’s safety violation, 83 percent did not report the violation.

While any staff member might badger another, researchers say that doctors bullying nurses are most likely to jeopardize patient safety. Botched communications appear to be the leading cause of avoidable surgical errors. More than two-thirds of medical professionals say that disruptive behaviors have caused medical errors or patient deaths. Separately, The Joint Commission has found that in healthcare organizations nationwide, 63 percent of cases resulting in patients’ unanticipated death or permanent disability can be traced back to a communications failure.

How long will these preventable tragedies continue? Researchers have proven these links as far back as the 1980s, when a study of Intensive Care Units revealed that “the most significant factor associated with excessive mortality was the degree of nurse-physician communication.” When nurse-doctor relations are poor, patients die unnecessarily. More recently, the Workplace Bullying Institute reported that the mother of a toddler hospitalized for burns thought her daughter was thirsty because she was frantically sucking on wet washcloths. The mother called nurses into the room twice during the night, but the nurses only repeated the doctor’s insistence that the girl was fine. The toddler died of dehydration, according to the institute, because the nurses were too intimidated by the doctor to question him.

The story is shocking, but it’s only one of countless examples of patients suffering because of healthcare providers’ failure to communicate effectively. Consider this anecdote, which nurses reported in a 2010 survey jointly conducted by the Association of periOperative Registered Nurses and the American Association of Critical Care Nurses. During the surgical safety checklist, nurses saw that a surgery was erroneously scheduled for one side of the patient while the patient-verified permit listed the other side. When the nurses tried to stop the plastic surgeon, he told them the permit was wrong. “The patient was already asleep and he proceeded to do the wrong side against what the patient had verified, which had matched the permit. We could not get any support from the supervisor or anesthesiologist. The surgeon completed the case. Nothing was ever done. We felt awful because there was no support from management to stop this doctor. . . . We felt absolutely powerless to being an advocate for the patient.” (No further information was provided.)

Alan Rosenstein, the medical director of a nonprofit hospital alliance, is one of the leading researchers of physician bullying. He has surveyed thousands of medical professionals, many of whom reported outcomes such as the following, which he disclosed in a Journal of the American College of Surgeons article:

“Failure of MD to listen to RN regarding patient’s condition. Patient had postoperative pulmonary embolism.”

“Cardiologist upset by phone calls and refused to come in. RN told it was not her job to think, just to follow orders. Rx delayed. MI [heart attack] extended.”

“Communication between OB and delivery RN was hampered because of MD behavior. Resulted in poor outcome in newborn.”

In a presentation at an annual meeting of the Pacific Coast Obstetrical and Gynecological Society, researchers described similar issues among labor and delivery staff:

“When a nurse reported to the physician that her patient was highly anxious and had shortness of breath, the physician told the nurse to give the patient some Ativan and take some herself. Later that evening the patient was admitted to the ICU with congestive heart failure.”

“A nurse reported that the final sponge count was incorrect after a difficult tubal ligation. The physician was sarcastic and said that an expensive X-ray would be ordered because the nurse obviously suffered from obsessive-compulsive disorder. A sponge was found in the patient.”

“Doctor’s behavior has been hostile, aggressive, threatening, and escalating in the past months . . . including raging at charge nurses and unit director. . . . [L&D] nurses are working in a hostile environment and fear for their safety and well-being.”

It is important to note that these types of behavior are exhibited by some doctors, not all, and that incidents should be viewed in proper context. Tensions run high in life-or-death situations, and doctors may not have time to temper their tone or monitor their language when their priority is saving a life. The doctors considered the worst offenders are the specialists whose work is consistently urgent and carries the highest stakes. Doctors and nurses have reported that the most frequent bullies are general surgeons, cardiovascular surgeons, cardiologists, orthopedic surgeons, neurosurgeons, and neurologists. The hospital departments most likely to host doctor bullying are ORs, medical surgery units, ICUs, and ERs. In the OR, attending surgeons are more than twice as likely as anesthesiologists and nurses to exhibit this kind of behavior.

An American College of Physician Executives survey found that three-quarters of doctors are concerned about “disruptive physician behavior”; virtually all of the respondents said that it affects patient care. Yet “despite the best efforts of many, our profession is still plagued by doctors acting in a way that is disrespectful, unprofessional, and toxic to the workplace,” ACPE CEO Barry Silbaugh observed.

Ultimately, these issues can be attributed to a fundamental lack of respect between doctors and nurses, who should be considered separate but equal, yet too often are treated as master and handmaiden. To wit: When an attractive, young female East Coast ER doctor didn’t even try to save a man who coded in the ambulance on the way to the hospital, the nurses in the room complained to the hospital’s medical director. The director dismissed the nurses’ complaints patronizingly: “You’re just saying that because she’s young and pretty.”