Nurse PhD's Open Salon Blog

Tragic Humor in the ICU

Sun, 1 Apr 2012 14:04:11 -0400

The surgical ICU in Cleveland where I worked in the '80s had a local reputation for keeping dying people alive with drugs and machinery. It was in the inner city, and about half our population was poor African-Americans. The medical director had a young son with a fatal congenital condition and we assumed this drove his rigid reluctance to call an end to heroics. I recall one frail elderly woman who, after months in the hospital and multiple ICU stays, was still being treated full steam ahead because "her quality of life is good." He explained to me paternalistically that at home she was sedentary, so being in the hospital wasn't much different.

As happened too often, I stood dumbstruck. I did not know how to respond. I didn't have the time to explain the meaning of quality of life to him. I didn't have the insight to refute his assumption that body movement equals quality of life. So I limply restated my disagreement and went back to caring for her, tubes, drugs, powerlessness and all.

We nurses knew the lady well; we'd nicknamed her, as we often did with long-term patients. Sometimes the names were goofy distortions of the person's actual name - terms of endearment. Sometimes they were cruel characterizations of a quality they possessed, like the obese heart patient we called Inertia.

The nicknames were one way of coping with the dread and distress of flailing the dying into staying alive another day. The doctors inserted painful tubes and prescribed toxic drugs that the nurses administered. We restrained wriggling hands and feet, improbably strong, so they wouldn't interfere with the treatment plan. Nurses listened as physicians repeatedly explained to troubled families that each new problem was merely a treatable setback. The families wanted to hear that Mom or Dad could recover if they only got over this latest insult. We almost never withdrew life support, as if we'd chosen a certain road and turning back now would constitute cowardice.

Going through a particularly long spell of poor staffing and drawn-out deaths was very hard on the nurses. We were distressed about aggressive treatments to which we objected and were powerless to do anything but take part in. We left work day after day knowing we hadn't had the time to do what we were educated to do for these suffering people - to care. Nurses were at the breaking point when someone posted a sign on the janitorial closet that read Crying Room.

No one took down the Crying Room sign for days, not even the manager. She understood the horrors of inflicting painful dressing changes on the young woman whose cancer-filled abdomen had been eviscerated and sewn back together to buy some time and educate the surgical residents. I will not forget the image of her crying through bloody dressing changes or the ill-informed fear we had of narcotics and how egregiously her pain was under-treated in the face of such mangling. I still see the cringing faces of those people in pain. Every face that I remember is African-American.

In that place, we needed humor to face our complicity in these acts without running away, shrieking. We settled for a cynical humor that expressed our distress because we could not conjure one that raised our spirits.

Nurse: "How long do you think he will survive?"

Resident: "I wouldn't advise him to buy any long-playing records."

Nurse (standing over a patient dying of shock, in her best DeForest Kelley voice): "He's dead, Jim."

A surgical resident wrote a Christmas song to the perky tune of Jingle Bells about a dying man with a pancreatic abscess. Twenty-five years later I remember the chorus with his name. He was black, of course.

Now I am ashamed to have taken part in this feeble, dysfunctional mechanism for coping with moral distress, disempowerment, and racial discrimination. Advice to the young people in nursing: if you think it's wrong, it is. If it's wrong, get out before you find yourself with a rip-roaring case of regret.

And if you worked in that SICU in Cleveland in the '80s with me, know that I remember, too, and I forgive you. Please forgive me.

Naive, Uninformed, and Wholly Unrealistic

Sun, 1 Apr 2012 13:04:42 -0400

A Vision for Obamacare

Let's take a trip into the hypothetical United States of the future where the Affordable Care Act has transformed the health care industry* into one whose prime interest is health. In this election year, driven by hope of meaningful health care reform under a Supreme-Court-sanctioned Affordable Care Act, I've been thinking about how health care would look if health promotion (a goal not usually emphasized by the leaders of our medical-industrial complex) were as highly valued as illness treatment.

I realize my fictional health promotion system is a dream. I know that heroics and the swift, tangible gratification they provide are often chosen by human beings over the weak satisfaction of making something not happen. But, then again, fantasies can help us set goals. So here's my foolish, wacky, silly, naive, childlike, unrealistic list of what would happen in a reformed U.S. health promotion system, in no particular order, drawn from 30 years of observing health care:

First, no one would wait until after their coronary artery bypass graft operation or their heart attack to get a referral to cardiac rehabilitation. Ditto for pulmonary and post-cancer rehabilitation. And how about we start a rehabilitation program for everyone, not just those with certain diseases? Structured rehabilitation programs work for people who benefit from social interaction combined with healthy lifestyle education and exercise. These programs also relieve fears about exercise (in other words, people with heart and lung disease learn that exercise is safe for them.)
The ACA would not permit payment for drugs not shown to promote health. Drugs have to pass safety trials and to do what the drug manufacturer is claiming they will do. That claim, unfortunately, does not have to be a genuine health outcome. An example is statin drugs, ubiquitously prescribed to reduce cholesterol, and they do this just fine. Data, however, are lacking as to their ability to prevent any meanginful health outcome such as death, bothersome symptoms, diminished quality of life, increased costs, and functional decline. They have not been shown to prevent first heart atttacks, the indication for which they are most widely prescribed. In the future, the $69.5 million paid by the 24 million users of statins in the U.S. would have to be shown to make a difference to the individual and societal experience for the drug to be covered by insurers. Otherwise, it's just smoke and mirrors, isn't it?
Consumers would be informed. This means that people undergoing chemotherapy would not be surprised to find that hair loss is the least of their side effects. Disabling fatigue is the most common cancer treatment symptom, but people do not know this before they start chemo. Other side effects of which they not warned include infertility, depression and instant menopause for even young women. In my fictional health promotion system, everyone, no matter who, would understand the benefits and risks of their treatment regimen before one molecule of drug enters their body. This would necessitate skilled educators explaining, demonstrating and showing patients what to expect as many times as it takes, for as long as it takes, using many different methods.
Ditto for surgery. Relying on surgeons to do the explanation of risks and side effects is the fox guarding the henhouse. Especially given the way their self-worth has been confounded by their patients' "success." (Watch starting at 10:47.)
Just as my mail-in pharmacy phones me to remind me when it's refill time, people would be reminded by phone and email when their children need vaccinations, when they need that regular screening physical or colonoscopy, when to visit the dentist, when to get an eye exam, and so forth. We are overcome by information and demands on our time - the health care system must help people put priority on health maintenance, or it is forgotten.
Vitamin deficiencies are 100% preventable. A once-daily multivitamin for every citizen should be covered by the health care system. Calcium for women, too. Both of these are cheap.
Not-for-profit public exercise clubs with group classes would be available to every citizen for a small fee per visit. For personal trainers, we would pay out of pocket.
Every person could call a single toll-free number to get health coaching by a nurse or person with a degree in health education (i.e., people who are educated to do this well). The program would not be linked to employers or insurers in any way. Because I suspect assurances of confidentiality from employers who dole out discounts for taking part in insurance-company-run health improvement programs do not convince everyone. The bachelor's-prepared registered nurses and health educators who answer the lines would perform a focused health interview and use evidence-based strategies to help people live healthier lifestyles. No guilt; no blame; no overwhelming demands to fix everything at once. No idiotic "You should lose weight" to someone who has struggled their whole life with obesity. (I kid you not - I hear this from physicians; they do not know how to do health coaching. They do get paid to do it, however.)

That's my short list. Add your own health promotion plan features in the comments. And thanks for being unrealistic.

* Industry may not be the most apt noun because most of our health care costs are paid in public systems, primarily Medicare and Medicaid. I prefer industry vs. system because there really is no system; we have more of a mish-mash of systems.

Surrounded by Strange Priorities

Sat, 31 Mar 2012 22:03:18 -0400

A few years back, I diminished my employment by 30%, from full-time to 70%. Instead of crying out, "But what will we do without you?", my boss, who had given me glowing yearly reviews, thanked me. More cutbacks in nursing education were occurring at Big Fat University (BFU) up on the hill; and she needed to find ways to save dollars. Yes, the nursing shortage is global and growing. Yes, the nursing faculty shortage is even worse. Yes, the population is "graying" and the demand for nurses will only increase. Yes, the research shows that better-educated nurses save lives. But health care financing is tight and the schools are supported by hospital revenue to a good extent. And nurses cannot bill for our sevices at the hospital. So it's a done deal.

And anyway, I would have more free time (not working 6 days a week - what a treat!), I would make more money, and I'd likely be more effective in my academic role.

How can this be?

I decided to subvert the nurse-faculty employment paradigm, cutting out the fluff.Concentrating on what matters. Not volunteering. Attending WAY fewer meetings. Abandoning critical roles on crucial committees that NEED my blessed presence. I put on my scrubs and athletic shoes much too early in the morning, tying back my hair, eschewing most jewelry, showing up by 7:00 and nearly killing my aging self for 12 1/2 hours on my feet before going home feeling completely satisfied. I'd be using my reliable calculator and stethoscope, leaving my cell phone at home. I wouldd be bringing my best negotiation skills to bear when a glib, self-certain surgical resident tries to gloss over a real issue that he'd prefer to leave to the ICU resident so he can leave for the day. I'm telling the attending physician about the evidence that supports my practice although he thinks nursing is mostly hand-holding and voodoo. And I am making more money as an ICU nurse than as a teacher and researcher while doing what I MUST to bring relevance to my teaching.

Here's the deal: nursing is a practice discipline. One of the implications of this is that we have to practice to stay skilled. In a practice discipline, standing still = falling back. However, there are very few opportunities for faculty to practice nursing, so faculty are forced to quit practicing nursing in order to teach nursing. Nursing homes, home care agencies, hospitals and community organizations don't get the value of having an expert nurse on hand one-half, one or maybe even two days a week. It's full-time or nothing unless you give direct bedside RN care (as I do, although I'm an advanced practice nurse.) And nothing is the usual choice, because advanced practice nurses who do not make medical diagnoses and prescribe drugs are not reimbursed for our care. Nursing faculty like me with graduate degrees, years of experience, advanced practice licensure and multiple certifications simply have nowhere to practice nursing. We have a health care system that thinks there's no place for us.

Universities do not pay nursing faculty to maintain their clinical practices. After all, they're not in the patient care business. I was an anomaly to negotiate 10% FTE in my first 3 years post-PhD for practice. Most nurse faculty like me simply assume that practice has to be given up.

What went wrong? Well, one thing I know for sure is that those in control have a vested interest in suppressing the power of nurses. Control over health care goes to those who make the big bucks. (Don't worry; I don't harbor fantasies about shadowy, sinister men convening secret meetings in poorly-lit backrooms to plot against female-dominated professions. They actually meet in spacious, tastefully-decorated conference rooms and their names are prominently featured in organizational charts. This is not the place to explain, so I'll refer you to any of the many books and articles on the topics of paternalism, power, nursing, sexism, and health care.* And this blog post. )

At BFU the "Executive Leadership Team," (ELT) comprised of MBAs and MDs, once opined that our university may not need a bachelor's of science in nursing program because (paraphrased) "nurses can be trained in community colleges." When one considers that the last word in the organization's name is university, it seems counter-intuitive that any of these people would suggest educating nurses in a university setting is a bad idea. Are nurses the one exception to the rule that better education = better performance among professionals? Most organizations encourage their employees to advance their educations. Yet, a certain member of the august ELT at BFU - that member happened to be the dean of the school of medicine - himself determined, all evidence aside, that nurses could be educated adequately in 2-3 years at a community college and a university degree is unnecessary.

His proclamation is redolent of my grandmother's being deprived of a desperately-desired high school education because, in rural Ohio, only boys were allowed to attend high school. So much has changed in 90-some years.

The ELT really can't be blamed for this remark, I guess. The members are exerting their right, as the big bosses, to act in their own self-interest. Perhaps if the ELT included at least one representative of the largest single group of employees in the organization (and the largest single group of health care providers in the country), these things would happen less often.

As a part-timer at the School of Nursing, I would get to hear less of the ELT's antics, and that could only help me stay sane. Perpetual outrage is not good for a person.

* Such as:

Medicine as culture: illness, disease and the body in Western societies

By Deborah Lupton

Hospitals, Paternalism and the Role of the Nurse

by Jo Ann Ashley

For Her Own Good: Two Centuries of the Experts' Advice to Women (2005) by Barbara Ehrenreich and Deirdre English

Trickle-Down Economics Does Not Save Lives

Fri, 30 Mar 2012 18:03:41 -0400

This week the New England Journal of Medicine published an evaluation of Premier HQID, a Medicare pay-for-performance program that provides monetary incentives to hospitals to improve quality of care. Hospitals that perform well on certain measures get 1-2% bonuses and hospitals that underperform are penalized by the same amount.

In the study, a huge number of hospitals, 252 in the Premier program and 3363 not, submitted data to Medicare on 33 quality indicators for common conditions such as heart failure, pneumonia and joint replacement. Data from over 6 million patients went into the analysis.

The headline-making conclusion went like this:

"Tying financial incentives to performance, often referred to as pay for performance, has gained broad acceptance as an approach to improving the quality of health care....We found no evidence that the largest hospital-based pay-for-performance program led to a decrease in 30-day mortality. Expectations of improved outcomes for programs modeled after Premier HQID should therefore remain modest."

To me, and I imagine others who were not consulted when this program was planned, this finding comes as little surprise. Let me explain why:

Financial incentives in the program did not necessarily go to the people who prevent hospital deaths. They went to hospital administrators who had the freedom to use the dollars as they wished. So our tax dollars - make no mistake - might have paid for nurse education or better staffing, and they might have bought a fancy new office suite for the CEO, the benefits of which would presumably trickle down to the little people.

Almost all of the Medicare quality indicators concern processes of care, not patient outcomes. Processes (like which drugs are given and when) are only thinly linked to patient outcomes because of the complexity of human beings (whether patient or health care provider) and big organizations like hospitals. If the right antibiotic is given at the right interval before surgery, is there certainty that the patient will not have an infection post-operatively? Of course not. It helps, but the maddening and wonderful complexity of humans and organizations means the process can only boost the odds in the patient's favor, not ensure the desired outcome. In short, there are no guarantees.

All the hospitals in the study report their data on Medicare's Hospital Compare website; this characteristic was equalized because public reporting is widely understood as a way to improve hospital quality. However, this understanding is based upon assumption, not fact, and some emerging data suggest otherwise.

This new study's findings about pay-for-performance are not unique. I did find some evidence of success of the Premier program on (surprise!) Premier's website, where one can also find the list of Premier and other health care executives as well as the cadre of physicians who comprise the Premier board of directors. Again excluding the largest group of health care providers in the country.

Lest this post appear as a rant from a burned-out nurse, I will add that nearly 1 in 5 older adults discharged from a hospital is re-admitted within 30 days. About half of these patients saw a physician in the interim, so it appears doctor visits did not prevent readmission. Moreover, errors in health care are deadly - to nearly 200,000 people a year. And studies from across the globe show that nursing care saves lives.

And that's something that plainly does make a difference.

The System Is Working; Take Heart

Thu, 29 Mar 2012 14:03:06 -0400

It was not an unfamiliar line-up: three innocent passengers, one drunk driver, two pedestrians, an assault victim, a ground-level fall, and, near the end of the day, a lung resection, residing in the Trauma ICU.

At 7 a.m., I took the ground-level fall, which meant I would later accept the first admission. Mr. Zauter* was "ward status," - someone not in need of ICU care, but for whom there was no regular ward bed open. Fifty-nine years old, he was homeless and lived with paranoid schizophrenia, which was fairly well controlled with medications. His face was broken, swollen, and bruised. His eyes bulged with swelling, although I'm told it had gone down considerably in his four days here. His dirty long hair strayed into his weepy eyes, raising the risk of infection. There was a large intravenous line in his neck, and I didn't want his hair getting tangled up in that either. He also had a smallish bleed in his brain, on the left side under his smashed frontal sinus.

His wrists weren't fractured, suggesting that his face took the full impact of the fall. This observation was validated by the extent of his facial fractures. Did he pass out, then fall? No one, least of all Mr. Z., knew.

I asked if I could tie his hair back. "No," came the swift answer. Another tactic: "Well, you see, Mr. Zauter, your hair is sometimes getting in your eyes and in this big IV in your neck, and I'm concerned that could cause infection, which could be risky." "...Well, I'll think about it." He thought about it and declined my offer when asked again. But he compromised, saying "I'll keep my hair here," using his long fingers to brush it back over his ear. A partial win.

He had a visitor that afternoon who thoughtfully brought a coloring book, a magnifying glass, some applesauce, and pudding. When Mr. Z. saw him, he smiled broadly and greeted him with excitement. The visitor, a representative of one of two social service agencies that look after Mr. Z., stayed for a long while, just talking. He left behind a stuffed plush lavender-colored bunny that Mr. Z. cuddled with a smile, then proudly showed off when I next entered his room.

The other social service agency that looked after my patient provided routine check-ins and emergency shelter for people with substance abuse problems, another of Mr. Z's. life challenges. They will see that he is discharged to a safe environment after surgery, in cooperation with the hospital's social worker and case manager. Although they cannot house him, they can find him and talk to him, make it more likely that he will get his medications, and provide the support often denied the addicted, homeless and mentally ill.

In an ideal world, Mr. Zauter would have a loving family who cared for him and protected him from his diseases and their associated social circumstances. But in that world, there would also be no substance abuse, no mental illness, and no Trauma ICU. So we do the best we can.

*All names are pseudonyms in all my posts about nursing practice.