Second-class citizen

Overheard: "I thought about getting my degree from the community college, but I wanted a diploma that meant something." --BSN RN

Overheard: "Doctors are smarter than nurses. That's just life. I mean, we have to have a 3.4 GPA just to be considered. How many nurses do you know who can pull that off?" --1st year medical student

Said to me, after a long night: "You know what you should do? You should become a CRNA. Have a job that pays what someone of your intelligence deserves." --Internist in the ICU

I asked, "Why not a doctor, you don't think I'm smart enough to make it?" Surprised, he responded, "No, no, that's not it at all. It's a matter of cost-benefit analysis. You've already invested time and money as an RN. Why not pursue it as far as it will go?" To which I replied: "Maybe I'm tired of being treated as a second-class citizen."

As in WTF?!

Had patient with agonal respirations, unresponsive, upon entry to the room. Called for stat ABGs, etc. did the whole "blah ICU nurse blah" thing. One thing led to another and I ended up calling the ER and asking them to please please please wake up their doc and send him my way for a stat intubation.

Dr. Death enters the unit, hair sticking up all over the place, a crease on his cheek from the sheet. "Where is this stat intubation?" he growls, glaring at each of us in turn. "Over here," I called from the doorway. "She's--"

"She's satting just fine, is what she is," he snapped, looking at the monitor at the nurse's station. "O2 sat of 97% is not an emergency. What the eff are you doing up here, this could bloody well wait for anesthesia."

"They're busy in the OR, doc, and she's wicked acidotic."

"Don't give me that crap. I'm going downstairs." He stomped the entire way. Of course we're bagging but she has stridor audible from the doorway...if he had bothered to walk that far.

To make a long story short, the patient was fine, intubated before she needed an emergency trach, and this is the true story of how Dr. Death earned his nickname.

After a death

Upon Hearing About the Suicide of the Daughter of Friends
by Jo McDougall

Something called to her that Sunday afternoon, perhaps,
that she could not name.
You and I cannot name it, drawn to each other
by this news.
The young cry when they feel it
breathing beside them.
We may know it sometimes through its disguises,
say the sound of a car at two a.m.
grinding to a stop in a gravel drive.

No stethoscope?

I called Pronovost recently at Johns Hopkins, where he was on duty in an I.C.U. I asked him how long it would be before the average doctor or nurse is as apt to have a checklist in hand as a stethoscope (which, unlike checklists, has never been proved to make a difference to patient care).--Atul Gawande, "The Checklist"

I love Atul Gawande. I own all three of his books: Better, Complications, and The Checklist Manifesto. I have followed his articles in The New Yorker avidly, drinking in the insights—and having something to ruminate upon in the still moments of the early morning.

That said: a stethoscope doesn’t make a difference to patient care? Really? Perhaps to a surgeon they do not. Perhaps to someone with the ability and time to CT everything, it means little. Perhaps to one who does not perform his own physical assessment but relies instead on the word of other doctors and the staff nurses, it isn’t needed. But at one am the ability to auscultate a new-onset S3 is terribly important, as is the ability to auscultate lung sounds in a code situation. In those cases, I posit, a stethoscope isn’t merely making a difference—it is irreplaceable.

My CNO

So there was a mandatory meeting a while back. At this mandatory meeting, the CNO showed up. He was talking about ways to prevent patient falls, and the idea was--let's have a short meeting prior to every shift where everyone gets together and says who's a fall risk and who's at risk for pressure ulcers and who's at risk for infection.

'Scuse me? Is this the ICU? Aren't all of our patients either restrained or bedbound or crazy or very very sick or all of the above? If they are able to get out of bed without assistance then by God they are certainly a fall risk and either aren't an ICU patient or...you get the picture. All of our patients are at an increased risk for falls if they're mobile. All of our patients are at risk for pressure ulcers. All of our patients are at risk for infection. This is the ICU. Such a short report is a waste of nursing time and effort in this particular environment. It is an inefficient policy that will result in dubious compliance and will yield dubious results.

Lacking people skills, I might have said something to that effect. I also have a personal policy of assuming all of my patients are on the verge of falling/getting a pressure sore/crumping, which ensures I take measures to prevent said events on each patient, and I might have said that, too.

He leaned back in his chair and templed his fingers, then gazed up at the ceiling. "I respectfully disagree. Not every patient in the ICU is a fall risk, or at risk for pressure ulcers, or at risk for infection. If you have some evidence-based practice on which to base this assertion, then I might feel inclined to consider your opinion. As it is, I feel that a quick run-down of whose at risk will benefit the nursing staff. And--you need to erase the word assume from your vocabulary. Don't assume anything in nursing."

My mouth was agape. Just--oh my. Ooooh my. A hush fell over the room, with El Compadre making nervous glaces in my direction. I could hear her thoughts: ohmygoddon'tyoudaresayanotherword I CAN SEE YOUR THOUGHTS! Stop! and, to my shame, I closed my mouth and didn't say another word.

Sigh. We are so doomed.

Something I accidentally charted

"Agitated, tangled in bedding and wires, actively seeking to go home."

Unfortunately, THAT person was me. Oops.

When I call you

The other day I had issues. Serious change-of-shift issues. Well, my patient did anyway, which means I did. I called the primary--got the whole "I just do this one thing, I'm not qualified to give orders in this situation, that's why I wrote the consult for FP," etc.

"I understand, sir. I've paged them and I'm waiting for their response. Here is what I've done so far: (inserted foley with temp sensor, obtained labs, cultured everything, got another chest xray, given tylenol, iced the patient externally, hung refrigerated fluids, etc.) and I just wanted to let you know."

"Oh. Thank you. You need anything else?"

Many things, desperately. "Not at the moment, just your okay on everything I already did while I'm waiting for FP to call back. They hadn't been notified of the consult previously that I can tell."

"Sure, no problem. Keep me posted. Hey, by the way, make sure you let the vent doc know."

"Already done, sir."

Approximately 10 minutes later the FP resident on-call rings: "Did you page?"

"Yes, I did. I need to let you know you have a consult pending on the patient in bed 21. They've got a temp of 107 discovered on initial shift assessment, I've done all this (rattles off a long list of stuff) and I need you to come see this lady." Long pause. "Are you there?"

"Yes. Who is the patient?" I inform the resident. "Why is she in ICU?"

"She coded on the floor earlier today. She's vented and has a temp of 107. What else you want to do?"

Another long pause. "Spell her name." Holy Mother of God, you have got to be shitting me. "What did you say?" Shit shit shit, "Ah, nothing, just wondering what your ETA is."

"Who else is consulted on this patient?"

"Pulmonologist, cardiology, neuro, the renal guy. Look, she's way bad and I desperately need some medical management of this situation."

"Okay. Why am I consulted?"

Long pause (me, this time). "Medical. Management."

"My opinion is that you should call one of the other people consulted who have already seen this patient. My attending hasn't seen the patient yet, it sounds like you've got everything under control, and these other doctors have seen her already."

SHITTING ME. "You know what, fine. I'll let the primary know." Click.

-----AN HOUR AND MULTIPLE PHONE CALLS LATER-----

"Hey, River, there's someone out here looking for you," El Compadre pokes her head around the glass door. "Think it's your resident." I finish suctioning and step out to the desk.

"Hey, what's up." The resident looks at me, wide-eyed. "I would have come out here immediately if you had made me understand how bad it is." To which I replied: "When I call you, it's not for laughs. I don't call for nothing."

I don't call for nothing. Granted, many nurses and doctors do--those whom Shadowfax affectionately refers to as the "B team." But I don't. I am an ICU nurse. I have skills many doctors don't even know exist, like the ability to predict who will successfully extubate 9/10 times. Let me say it again: I don't call for nothing. If I call you, I need you.

Also. What part of "temp of 107 and I desperately need some medical management right now" on a s/p code mechanically ventilated sounds even remotely under control? How could I have made it plainer that I. Need. My. Resident? Yes, I had done the immediate, emergent things. By the time the resident arrived, I had antibiotics going and other things completed, too, thanks to the "sure, no problem" primary. However--I am not the doctor. And though I AM able to leap tall buildings in a single bound, I do not have prescriptive authority and, frankly, it is not my responsibility.

And something else--it wasn't even the middle of the night. It was, like, 8 pm. God save us.