Nurses’ week profile from OptumCare Clinician Insights

This past month the great people I work with at client Optum, interviewing subject matter experts and writing content for their Clinician Insights website, gave a great push to acknowledge nurses’ week. Together we went from concept to published article in under a month. Considering that the process is for a corporate client with markets blanketing the entire United States, this is feat to be proud of!

Please check out the results: a profile of the career Registered Nurse Debra Lietz, working in a WellMed clinic in Texas Hill Country. Talking with her about her work made me half want to be her and half want to be her patient. What a proud tradition, this nursing thing. Happy nurses’ week!

Debra Lietz: Nurse profile on OptumCare Clinican Insights

Surgery: what are you consenting to?

In the hospital recovery room, receiving patients from the OR goes like this: sometimes you have the chance to review their medical record between the time you are assigned and when they arrive. Sometimes (like when they are coming through the doors and someone calls your name), you don’t. A body shaped lump of warm white blankets wheels up in front of you. A few inches of face may be visible between linens and blue surgical cap may be visible. Make sure they’re breathing, O2 is good, responsive.

Report is given on the go, so you’ll only learn about what the surgery was, and how it went. Any health conditions directly related to the surgery. Age, sex, and allergies and you’re on your own.

The mystery burrito of hospital blankets starts to stir,  Holler, “You’re all done Mr. Smith, you did great!” The person on the other side of the anesthesia starts to reveal themselves.

I’m a nurse ’cause I love people surprises. Post-colonoscopy sass-mouthed grandmothers. Sweet big bubbas with gallstones who can’t stop giving sugar to the wife. Toddlers that wail and leak fat tears on the shoulders of their parents, sounding like an ambulance getting farther away as they head out to return to familiar cribs.

Truly, there is only one patient that I hate to see. And it’s the system of more care, not the actual patient that drives me nuts. The healthy 90-year-old hip replacement. Not because I don’t believe there are robust 90 year olds who, with new hips, could maintain their activities in much less pain.

Rather, I have seen too many come in great health but for the hip. And after surgery and anesthesia, kick up an atrial fibrillation/SVT that will land them in the ICU short term and sentence them to powerful medication for life, more surgical intervention, and put them at risk for death in at least 4 ways. We’ve fixed your mobility issue and given you a lethal arrhythmia. Being elderly is a risk factor, even when you come in healthy.

First, the problem: health economists are working their butts of to explain why we pay so much and get so little improvement in overall health measures in America. Austin Frakt, in his NYT article elaborates the argument of it’s the prices, stupid. We pay more per service because our country does not price control and regulate as aggressively as other top-of-the-heap nations. But then in through the comments section comes the argument by a data wonk with a blog who says that our prices are in line with the inflation and wealth, and it is the quantity, stupid, of care that’s out of control.

In this academic fight it’s safe to bet there is truth in both arguments. As a patient I don’t think $800 is a reasonable price for a urine dipstick test. As a bedside caregiver, the number of unnecessary and unhelpful procedures I’ve witnessed make me an unhappy nurse, patient advocate, and taxpayer.

The article that came out through Kaiser Health News this week investigates how an 87 year old patient with a DNR and no desire for a shock to the heart ended up with a internal defibrillator (to the tune of $60,000 Medicare dollars). As a cosigner on surgical consent forms, I totally get how it happened. Patients are able to say the words that describe their procedure (“fix my heart beat”) but often have not been educated in global implications. Outside of surgical site infections they may not know what they’re potentially signing up for.

I’ve excerpted my favorite parts of the article, but it’s gold all the way through. This is a corner of health care we must address to lower costs and improve the lives of our patients.

Shocking:
Nearly 1 in 3 Medicare patients undergo an operation in their final year of life.

Educational toolkit for joint replacement, sounds like a plan:
After Kaiser Permanente Washington introduced the tools relating to joint replacement, the number of patients choosing to have hip replacement surgery fell 26 percent, while knee replacements declined 38 percent, according to a study in Health Affairs. (Kaiser Permanente is not affiliated with Kaiser Health News, which is an editorially independent program of the Kaiser Family Foundation.)

Stories are more engaging teaching tools than statistics. Plug: I am for hire to research and write the stories needed to do better patient education:
In a paper published last year in JAMA Surgery and the Journal of Pain and Symptom Management, Schwarze, Kruser and colleagues suggested creating narratives to illustrate surgical risks, rather than relying on statistics.

Instead of telling patients that surgery carries a 20 percent risk of stroke, for example, doctors should lay out the best, worst and most likely outcomes.

Source: Never Too Late To Operate? Surgery Near End Of Life Is Common, Costly | Kaiser Health News

Happy nurses week my people of the people.

Here is what I know about nurses in year two of my practice: We are the strongest threads in our community quilt. Binding the diversity of incomes, ages, and cultures together with help, healing, and unconditional (sometimes tough) love.

We can simultaneously hold a cynical view of our fellow man and have the deepest reservoir of hope in humankind. That is to say we will complain bitterly while suffering twelve hours of abuse by a certain patient, and then stay four more hours to see them through when their condition deteriorates. We need to see them through.

If I am your nurse, you are my very own one. I will protect you, I will defend you, I will advocate for you. I’ll go toe to toe with the provider who endowed my hospital if I feel you are being hurt. If you need it, I might even bring you secret coffee from my very own stash. You must know—it is to you I will always be true. Not because you’re nice, though please consider being nice, but because you’re mine. If the building caught on fire I’d sling you over my shoulder and carry you down the stairs. (This isn’t policy, just a metaphor. Trust we have better evacuation plans). I’m not special. I’m “just a nurse.”

I’ll recognize you when I see you out in the world and under light less harsh than hospital fluorescents, but you likely won’t remember me. I don’t need you to. I’m one of many clad-alike interlopers palpating and auscultating and delivering medication. Our time together is sacred and secret. I’ll acknowledge your return to health in silence, with a smile that is overjoyed to see the color in your cheeks. You’re back at work or running the aisle of the grocery after your wild, beautiful children. My chest fills with pride as I think: She’s one of mine! Look at her, so well!

I don’t know any nurse who feels differently. We are for patients. What a noble group of people to share a name with. Every day I find time to do a little jig of joy to celebrate my membership in this club of tough, tender advocates for humans. Doing work that cares little for glory and much for justice. It’s the only gift I want.

Happy nurses week to all of you, you magnificent beings.

In which a childhood friend’s hospital hardship pulls me up short.

Friday night at the hospital knocked me off this high horse I’ve ridden lately. I’ve been on a big patient advocacy, let me share my story jag. Despite feeling like I’ve had every experience possible in the U.S. health care system (and some in Canada, Mexico, and the Republic of California), I really haven’t. And I’ve walked the halls of the hospital where I work long enough to become unfeeling to a lot of the suffering. It’s human, it’s survival, I’m still disappointed.

After removing someone’s problematic accessory organs in the OR Friday night I got a message from a friend, someone I haven’t really known since childhood, saying her dad was sick and she was there. I regretted not checking my phone earlier. I had already changed out of my scrubs, so riding the staff elevators to her floor I knew I was going to get the reception of an after-hours visitor. Chilly. I tried to hold my name badge conspicuously, but surely enough there were all those familiar unwelcoming looks. The you better not be here to make trouble side-eye. The it’s too late for your kind of nonsense head shake. I have been the the side-eyer. The head shaker. Damn.

I really don’t understand how we fit all the furniture plus two very sick people in those tiny hospital rooms. Maneuvering in to visit is human tetris. I hug my friend, take off my glasses and squat down to see if her father remembers me through the 20+ years and the onset of dementia. He kindly says hello. Asks again about necessity of the IVs. The stay overnight.

It was hot. Heat rises. We were high up. I would be in a perpetual sweat when I worked that floor, but fool that I am assumed it was my constant motion. Families complained, and though I may have apologized for the inconvenience I quickly dismissed it. Sorry about the heat but right now I’m trying to stop you from bleeding out internally. There is a famous meme that I am now ashamed to admit to using like a mantra:

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Damn again.

I was there briefly, only long enough to say hello and I’m sorry. To steal a fan from my home unit. Those shoe box sized white electric fans are the only hospital commodity more stolen than pillows. Soon the tech was hefting my friend’s father up and off to the bathroom, shaming him for walking three feet on his own (NO ONE WALKS ALONE is a safety campaign at my hospital as well as an apocalyptic vision of the future). Physically keeping him cornered until he crawled safely back onto his bed, the only surface a patient may occupy. As a nurse I’ve done this too. DAMN DAMN.

I understand and have embodied nursing’s motives for the way we treat patients. There are so many and their needs so great. The gown and the industrial linens, the bedside commodes and 3+ identifying armbands that become a patient’s most significant identity dehumanize but serve a critically important end. Hospital survival. Name, allergy, fall risk. Limb alert. Anticoagulation. Difficult airway. Oh god what have I become.

My friend is like me, a woman working in the caring professions derived from the great Lillian Wald. She’s a pro. She gets it. Just before leaving I leaned across the narrow hospital bed, now safely occupied, held my friend’s hands and whispered to her. I’m sorry I can’t help you. This is why I became a nurse and not a social worker. This human stuff is too hard! She replied, “This is why I became a social worker and not a nurse. This hospital stuff is to hard!”

It is too hard. But heaven help me. I’ll try to do better.

 

 

Valentine’s for broken hearts

There is this utterly sensible trend in health care where the providers of the highest acuity care seem to have the least first hand experience as patients. The first time a coworker commented “Sometimes I wish I’d been in the hospital so I’d know what having an IV placed felt like,” I was flabbergasted. Are there adult people that have avoided IV sticks? Yes, many. It makes sense that my colleagues are largely younger and healthier people, considering how tough the gig is on a body. Poor sleep habits, stress, inflexible schedules, repetitive back wrenching… it’s in the job description. But this lack of direct experience opens an even wider gap of understanding between provider and patient. They have no shared medical experiences. And medical experiences aren’t about the pain of the IV stick. It’s the subordination to your providers, a previously robust identity reduced to your name and birth date on your bracelet (plus fall risk meaning now you can’t even toilet yourself). How people cope with what we take away from them defines what kind of patient they appear to be.

So on this Valentine’s Day, Galentines for my feminist warriors, day of grumpiferous mourning for me, a tweet from Lucy Kalanithi reminded me to urge all health care people to read Paul Kalanithi’s When Breath Becomes Air. In this memoir Paul is able to recount in what feels like real time losing his identity as a promising neurosurgeon to cancer. His doctor self gives way and he becomes the patient. Being previously a young and healthy person, and falling victim to the trick all healthy people play on themselves (the way I am now is the way I will always be), his realization that his is terribly ill is heartbreaking. The chapter in which he discusses his scientific mind’s understanding of survival curves, trying to square the data with his individual, not-yet-a-statistic mortality, it rings so bitterly true.

Here is Lucy Kalanithi’s beautiful valentine to him. It speaks to living with loss. If you’re on twitter follow her post haste (@rocketgirlmd).

What Lucy says about grief and loss…blarg my heart. We have been a house in mourning for the past 14 months. My mother lost her true love and partner. I lost my father. I sometimes feel like I killed my father since it was my chest compressions that sent him out of this world, but that’s another post. If dad were here this February 14th I sure as shit would be sitting as his feet complaining about the quality of available suitors while he half listened until I wound myself down, then I’d get a “you’re fine sweetie girl”and a pat on the back and I would be fine. And he and mom would watch garbage TV and laugh at really stupid jokes and drink wine out of tumblers and genuinely enjoy one another.

In remembrance of the love between my parents I’m attaching my eulogy. All of us Crawfords were so lucky to get so very much of him.

So to bring it on back health care people of the world, depending on the statistics you go by we are somewhere between 60-80% likely to have someone’s loved one in our care as their life ends. Think about what it felt like to be Paul, what it feels like to be Lucy when someone asks to bring their baby into the ICU. Or tapes pictures all over the walls. Or changes their mind about end of life care 16 times. People often need guidance, and we can draw from training and experience to offer it. Maybe what has happened in your own life, or a book you read, is helpful. Keep that. Get rid of the rest. Like I said at the beginning: It’s a tough gig.

Culpeper cardiologist accused of striking hospital nursing director | News | dailyprogress.com

A Culpeper cardiologist faces a misdemeanor assault and battery charge stemming from a reported confrontation with a female nursing director inside Novant Health UVa Health System Culpeper Medical Center

Source: Culpeper cardiologist accused of striking hospital nursing director | News | dailyprogress.com

Hi Doc! I hope you get fired. And fined. Props to the nurse admin who pressed charges. I’M WITH HER.

I trained at this rural community hospital. It was not an extraordinarily hostile environment. In my limited experience it was probably a 4/10 on the pain scale of abuses nurses suffered at work. Still, I’m not surprised by this repulsive development. Workplace violence, mostly verbal, is a reality of hospital work. At UVa Culpeper there was almost no interaction between MDs and RNs. The general view of nursing was that this was a group of low class, poorly educated, lazy to the point of obstructionist women. A recipe for disaster.

Nursing should be a force to be reckoned with, different but equal to medicine. Respect and autonomy are harder to come by in community hospitals–but this is a battle worth fighting. It should be noted that difference between community hospitals with minimal nurse autonomy and governance and large academic medical centers, particularly Magnet organizations, is massive. Wherever they are, nurses must be empowered as professionals to participate in advancement of their own practice. We have an important job and we have to be nailing it: know the orders, read the notes, understand the clinical picture (plan even!), be engaged enough to know the why of every drug and intervention. Be twice as good as the doc. You know what I’m saying. Do it backwards in high heels.

I see two practices for improving our situation as a historically subordinate profession: 1.) (Dare I say it?) We are stronger together. Active nurse governance at your hospital. Sit on committees. Insist on getting paid for this time, because this is not the PTA and we are not volunteering. THIS IS A PROFESSION. 2.) Get to know each other. Inter-professional education has shown anecdotal promise, even if the studies aren’t strong. Hospital administrators, you can facilitate this at non-teaching hospitals. If you work at a teaching hospital you’ve got the advantage of working with baby docs. Share your experience, and they will often share their shiny new medical knowledge. Either way, just talk to people. Regardless of their credentials they are in fact people. Here are some topics of discussion to get you started: kids, dogs, mortgages, food, car repairs, patients. It’s hard to hate (or hit) someone whose humanity you recognize.