The Fifth Vital Sign.
It not only sounds like the title of a Bergman film, but pain as a vital sign is like a Bergman film in that it amounts to a conceptual sleight of hand. It has been elevated in the medical and nursing communities from a simple statement about a patient's response to illness or injury--the patient's perception of discomfort--to an indication of the patient's vitality; from a personal reflection upon the human condition of suffering to a quantifiable measure of that suffering. A Bergman film? Yes indeed.
Vital signs are measures of the physiological conditions associated with life-- vitality. The four traditional signs of vitality are blood pressure, pulse, respirations, and temperature. It is necessary to possess some quantity and quality of each of these in order to be alive.
Because they are physical, vital signs are measurable. As well, they may change in relation to the various physical conditions to which the human body is subjected, conditions like physical injury or disease processes. Vitals signs DO NOT depend upon what the patient says about them. They are related to conditions the patient cannot of his or her own will easily control or alter.
But what of pain?
As nurses we are told to think of a patient's pain as whatever the patient says it is. Traditionally, nurses "assessed" pain by asking patients where they hurt, what it feels like, how intense it is, when did it start, what exacerbates it, and what they've been able to do to ease it, if anything.
Now, we are encouraged to "measure" pain by having patients rate it on a scale of 0 to 10, with zero being no pain at all and 10 being the worst pain. We have changed pain from an experience that must be described to one that can simply be quantified.
So, what is the problem with this? Why is treating "pain" as a number potentially detrimental to ER nursing?
As a subjective measure of highly individualized experience, pain is not like the other vital signs. A temperature of 98.6 degrees may not be "normal" for everyone, but 98.6 for one person is the same as 98.6 degrees for another, just as a pulse of 80 in one patient is the same as a pulse of 80 in another. As well, 105 degrees is dangerous for anyone, not just those who think it is a high fever, just as a heart rate of 20 is dangerous for anyone no matter what they think of it (if they're able to mentate at all at this rate.)
But is 5/10 pain the same for everyone? Does the same broken bone produce the same pain for everyone? And how do we know that the patient having 5/10 pain is really having 5/10 pain? If it were another patient with the same injury, would the injury result in the same amount of pain? If a patient's pain of 5/10 eases to 3/10, is this the same as when their 7/10 pain eased to 5/10 or when another patient's pain decreass from 5/10 to 3/10?
When you think of it, the number a patient reports really doesn't mean a whole lot. Whereas "blood pressure of 100/60" tells me something specific about my patient, "pain of 5/10" does not. How am I to know how much pain this is? I know its less than 7/10 and more than 3/10, but I don't know what these values mean anymore than I do 5/10.
With the other vital signs, zero values can be interpreted as meaning no vitality. Zero blood pressure, zero respirations, zero pulse or zero temperature means a patient is dead. With pain, however, a patient with no pain (0/10) is not lacking vitality; this patient might be said to be healthier than those with pain. Oddly, the only immediately understandable and specific value on the pain scale is, in fact, zero.
Then there are the patients who complain of 10/10 pain. These patients don't really have a pain problem, they have a math problem. They don't realize that 10 out of 10 represents all the pain possible! I like to ask these patients "If I ripped your arm off, would you have more pain than the 10/10 throat pain you're complaining of now?"
Fundamentally, that is the problem with quantifying pain: it tells you nothing of the clinical significance of a patient's illness of injury. Other vital signs do.
A Bergman film, indeed.
Wednesday, August 29, 2007
Sunday, August 26, 2007
Types of Patients I: Suicidal Ideation/Attempt
My friend Camus once wrote that the fundamental problem of philosophy is whether it is better to live or to die, and that all other philosophical inquiry is based upon one's answer to this question. For if it is better to die, then one should honor that decision and kill oneself. No other philosophical question need be considered.
Of course, in The Myth of Sisyphus, Camus comes down on the other side of the question: regardless of the toil of human life and its miseries and let-downs, it is better to live than die. What one must do in life is find meaning.
Questions remain: why do people attempt to kill themselves; what is the difference between those who succeed and those who don't? The facile answer to the second question is, of course, those who succeed are dead. As for those who don't, these are the one's we often see as patients in the ER.
I divide suicidal patients into two categories: those who I judge have made a serious, truly lethal attempt, and those who have not made a serious attempt. In my ER (and probably ERs nationwide), we see more of the latter than the former. The predominant method of non-serious attempt is overdose. These are patients who ingest large but often unknown quantities of (usually) legal medications, often over-the-counter medicines like cough syrup, acetaminophen, and ibuprofen, but sometimes prescription medicines like anti-depressives or narcotics.
One thing that distinguishes this patient category is that the suicidal individual does not often know what sort of damage the drugs he or she ingested will do. It is not a serious, lethal attempt because the patient hasn't done enough research to know how much to take to kill themselves. Usually the patient has taken enough to harm the liver or the kidneys, but this is damage he or she will more than likely have to deal with later in life.
The smaller category of patients who make truly lethal attempts (some of which become successes), I have found, usually use more violent means. Handguns, hanging, jumping from heights, and machinery are truly lethal mechanisms of self-injury in this patient group. From the patient who laid down on his table saw to the patient who hung himself with a bed sheet, these are the serious attempts. (Incidentally, the former failed whereas the latter succeeded.)
There is often little else that characterizes these groups. Patients are young or old; some have a history of psychological problems, some don't; some have made previous attempts, others not. In fact, the common characteristic of suicide attempts and possible success is the unpredictable nature of the event.
For both categories, however, primary nursing care includes establishing the nature and extent of the patient's self-harm; responding to the patient's injuries with curative and palliative measures; providing a safe environment in the ER; contracting with the patient for no further self-harm (at least, not in the ER); and initiating psychological interventions, whether this be making an appointment with the patient's counselor or admitting the patient to the hospital.
A friend and fellow nurse often says that in order to do ER work a nurse has to "let go of the why." Often we have no idea why our patients do what they do. Suicide attempts are an extreme example of this.
I like to remind patients that self-harm and ultimately self-destruction are long-term solutions to often short-term problems. Whether or not this is helpful to them, I'm not sure. But it probably beats recommending Camus.
Of course, in The Myth of Sisyphus, Camus comes down on the other side of the question: regardless of the toil of human life and its miseries and let-downs, it is better to live than die. What one must do in life is find meaning.
Questions remain: why do people attempt to kill themselves; what is the difference between those who succeed and those who don't? The facile answer to the second question is, of course, those who succeed are dead. As for those who don't, these are the one's we often see as patients in the ER.
I divide suicidal patients into two categories: those who I judge have made a serious, truly lethal attempt, and those who have not made a serious attempt. In my ER (and probably ERs nationwide), we see more of the latter than the former. The predominant method of non-serious attempt is overdose. These are patients who ingest large but often unknown quantities of (usually) legal medications, often over-the-counter medicines like cough syrup, acetaminophen, and ibuprofen, but sometimes prescription medicines like anti-depressives or narcotics.
One thing that distinguishes this patient category is that the suicidal individual does not often know what sort of damage the drugs he or she ingested will do. It is not a serious, lethal attempt because the patient hasn't done enough research to know how much to take to kill themselves. Usually the patient has taken enough to harm the liver or the kidneys, but this is damage he or she will more than likely have to deal with later in life.
The smaller category of patients who make truly lethal attempts (some of which become successes), I have found, usually use more violent means. Handguns, hanging, jumping from heights, and machinery are truly lethal mechanisms of self-injury in this patient group. From the patient who laid down on his table saw to the patient who hung himself with a bed sheet, these are the serious attempts. (Incidentally, the former failed whereas the latter succeeded.)
There is often little else that characterizes these groups. Patients are young or old; some have a history of psychological problems, some don't; some have made previous attempts, others not. In fact, the common characteristic of suicide attempts and possible success is the unpredictable nature of the event.
For both categories, however, primary nursing care includes establishing the nature and extent of the patient's self-harm; responding to the patient's injuries with curative and palliative measures; providing a safe environment in the ER; contracting with the patient for no further self-harm (at least, not in the ER); and initiating psychological interventions, whether this be making an appointment with the patient's counselor or admitting the patient to the hospital.
A friend and fellow nurse often says that in order to do ER work a nurse has to "let go of the why." Often we have no idea why our patients do what they do. Suicide attempts are an extreme example of this.
I like to remind patients that self-harm and ultimately self-destruction are long-term solutions to often short-term problems. Whether or not this is helpful to them, I'm not sure. But it probably beats recommending Camus.
Saturday, August 25, 2007
My Friend Camus Said I Suffered Existential Angst
I used to be a college professor. I taught sociology at a major northwest university and was writing a PhD dissertation in political sociology focusing on agricultural social movements. I taught introductory classes as well as classes in social problems, the sociology of power, and social research methods. I liked teaching and I thought that it was important.
But it didn't seem important to others. My students just wanted grades and, eventually, a degree. My department just wanted me to offer as many classes I could as inexpensively as possible. The university just wanted me to keep my nose clean and cater to the students. The athletic department, of course, just wanted me to pass its athletes, no matter how deplorable their academic performance. Very few, it seemed, thought that teaching and, ultimately, learning was important.
At the same time, I was writing a dissertation that required me to become involved with political activist groups. The groups were suspicious of me as an academic researcher and the academic community was suspicious that I was becoming an activist, "going native," a la Carlos Castenada. In between these extremes, nobody but myself and my advisor seemed to care about my project. Several times people suggested that I "just do it" regardless of the reasons, as if writing a dissertation and attaining a PhD was no more than replicating a Nike commercial.
I didn't feel like doing that. I couldn't. I longed to find meaning in what I was doing, to understand why what I did was worthwhile, to me, to students, to the world. I played mind-tricks. "Oh, these students will realize eventually that what I taught them is important. Oh, the discipline will realize the significance of my research." But it wasn't happening. In short, I found myself in a state of existential angst.
What am I doing with my life? Do I contribute? Can I conceive of a world in which people who do what I do don't exist? Sadly, honestly, yes. Yes, I could.
And then tragedy struck. Someone very close to me was diagnosed with cancer, and soon thereafter became terminal. University life stopped; my research stopped. My future stood frozen in mid-air, in the stasis of waiting, waiting to see what cancer could do. To make a long story short, it kills.
In the short amount of time my loved-one had, I cared for her at home. I positioned her in bed and bathed her. I sat up with her at nights when she was too afraid to close her eyes for fear that death, not night, would overcome her. I gave her medicine. I made sure she had the people around her she wanted--her son, her friends--and kept the rest, the nonessential ones at bay. We reluctantly welcomed hospice into our life--nurses, aides, social workers, volunteers--and our life became different, defined as much by a prognosis as what we did or thought. I drank a lot.
In the end, at the end, she got what she wanted: to stay home with her child, not to die in a hospital. It seemed so little but it was my last gift to her. Ironically, she died in our living room.
But I got something as well. I realized that I had an aptitude for taking care of others, for nursing. Why did this shock me? I had been my son's primary care giver all his life, and I took care of the home, the yard, the cooking, the cleaning. I was already a nurse, just a nurse without training, without a license. Did it really shock me that I could do this sort of work and do it with pride and a sense of accomplishment?
I had grown up in the midwest. No one there had ever told me that men could be nurses. No one even held that out in front of me as an option. If I wanted to become a doctor, well, that was fine. But I didn't.
My experience taking care of a dying person taught me about what I wanted most: a sense of accomplishment in knowing that what I had just done for someone made a difference. I craved what teaching would not provide, nearly instantaneous feedback about the quality and effect of my actions, my mark on the world. This, I found in the small circle between nurse and patient, for no matter what I did for my loved-one, she responded. If I moved her wrong, she winced or cried; if I held her hand, she smiled; when I brought her son up into the hospital bed, she thanked me.
I realized that nurses receive this immediate affirmation in their daily jobs. They receive it primarily from their patients but also from communities and a society that respect them and their profession.
In many ways, nurses are like trash collectors. Not many want to be one, but we appreciate those who do. In fact, I can't imagine a world without trash collectors, any more than I can imagine a world without nurses.
But that was, literally, a lifetime ago, albeit someone else's life. I honor that life and its unfortunate end every day I go to work, because it helped me see the value of my own life and it is the reason I became a nurse.
But it didn't seem important to others. My students just wanted grades and, eventually, a degree. My department just wanted me to offer as many classes I could as inexpensively as possible. The university just wanted me to keep my nose clean and cater to the students. The athletic department, of course, just wanted me to pass its athletes, no matter how deplorable their academic performance. Very few, it seemed, thought that teaching and, ultimately, learning was important.
At the same time, I was writing a dissertation that required me to become involved with political activist groups. The groups were suspicious of me as an academic researcher and the academic community was suspicious that I was becoming an activist, "going native," a la Carlos Castenada. In between these extremes, nobody but myself and my advisor seemed to care about my project. Several times people suggested that I "just do it" regardless of the reasons, as if writing a dissertation and attaining a PhD was no more than replicating a Nike commercial.
I didn't feel like doing that. I couldn't. I longed to find meaning in what I was doing, to understand why what I did was worthwhile, to me, to students, to the world. I played mind-tricks. "Oh, these students will realize eventually that what I taught them is important. Oh, the discipline will realize the significance of my research." But it wasn't happening. In short, I found myself in a state of existential angst.
What am I doing with my life? Do I contribute? Can I conceive of a world in which people who do what I do don't exist? Sadly, honestly, yes. Yes, I could.
And then tragedy struck. Someone very close to me was diagnosed with cancer, and soon thereafter became terminal. University life stopped; my research stopped. My future stood frozen in mid-air, in the stasis of waiting, waiting to see what cancer could do. To make a long story short, it kills.
In the short amount of time my loved-one had, I cared for her at home. I positioned her in bed and bathed her. I sat up with her at nights when she was too afraid to close her eyes for fear that death, not night, would overcome her. I gave her medicine. I made sure she had the people around her she wanted--her son, her friends--and kept the rest, the nonessential ones at bay. We reluctantly welcomed hospice into our life--nurses, aides, social workers, volunteers--and our life became different, defined as much by a prognosis as what we did or thought. I drank a lot.
In the end, at the end, she got what she wanted: to stay home with her child, not to die in a hospital. It seemed so little but it was my last gift to her. Ironically, she died in our living room.
But I got something as well. I realized that I had an aptitude for taking care of others, for nursing. Why did this shock me? I had been my son's primary care giver all his life, and I took care of the home, the yard, the cooking, the cleaning. I was already a nurse, just a nurse without training, without a license. Did it really shock me that I could do this sort of work and do it with pride and a sense of accomplishment?
I had grown up in the midwest. No one there had ever told me that men could be nurses. No one even held that out in front of me as an option. If I wanted to become a doctor, well, that was fine. But I didn't.
My experience taking care of a dying person taught me about what I wanted most: a sense of accomplishment in knowing that what I had just done for someone made a difference. I craved what teaching would not provide, nearly instantaneous feedback about the quality and effect of my actions, my mark on the world. This, I found in the small circle between nurse and patient, for no matter what I did for my loved-one, she responded. If I moved her wrong, she winced or cried; if I held her hand, she smiled; when I brought her son up into the hospital bed, she thanked me.
I realized that nurses receive this immediate affirmation in their daily jobs. They receive it primarily from their patients but also from communities and a society that respect them and their profession.
In many ways, nurses are like trash collectors. Not many want to be one, but we appreciate those who do. In fact, I can't imagine a world without trash collectors, any more than I can imagine a world without nurses.
But that was, literally, a lifetime ago, albeit someone else's life. I honor that life and its unfortunate end every day I go to work, because it helped me see the value of my own life and it is the reason I became a nurse.
Friday, August 24, 2007
A Nursing Pitch
When I decided to become a nurse, several factors influenced my decision. I will address the philosophical, existential factors at another time. Here I would like to discuss the practical factors.
First, no one will get rich being a nurse, but nurses make very respectable living wages. My full-time job provides me about $45,000 per year, and in this small town, that puts me on-par with teachers, plumbers, and even some university professors. I own my home, I have a Subaru, and I take frequent vacations.
Second, when I decided to give up college teaching, I wanted to remain in my small town. Since the university is the largest employer, however, I would either have to remain there or find another decent job that would allow me to keep my home and support my family. So I did some research.
I discovered that not only was there a nursing shortage in the United States (as well as worldwide) but that rural America was disproportionately affected by this shortage. Apparently, urban and suburban areas with large hospitals and complex health care networks took the lion's share of the available nursing population. Since I wanted to live in Smalltown, America, I was almost guaranteed a job if I became a nurse.
Third, the aforementioned nursing shortage also nearly guarantees me a job wherever I chose to work. Given increases in the "old age" population and the crossover into middle age and beyond of the largest surge in United States population, the baby boomers, more and more people require and demand medical care, including nursing services.
FYI: For a look at statistics and opportunities, check out:
http://stats.bls.gov/oco/ocos083.htm#outlook
Fourth, and this fact near and dear to my heart, I work full-time but I work 12 hour shifts, not uncommon in the nursing profession. As a 12-hour shift employee, full-time is considered 3 shifts per week. What this amounts to is 12 shifts (therefore, 12 days) per month and 144 shifts (144 days) per year if I don't take vacation. The average 8 hour, five day a week worker puts in about 260 days per year. In short, I have over 200 days off per year, whereas the aforementioned average worker has only 105 days off. For someone who loves his work but also loves the variety of other activities in his life, nursing was definitely the way to go for me.
But those are just the practical aspects of choosing nursing as a career. Life is not always or sometimes even primarily about being practical. Stay-tuned for a discussion of the other reasons I became a nurse.
First, no one will get rich being a nurse, but nurses make very respectable living wages. My full-time job provides me about $45,000 per year, and in this small town, that puts me on-par with teachers, plumbers, and even some university professors. I own my home, I have a Subaru, and I take frequent vacations.
Second, when I decided to give up college teaching, I wanted to remain in my small town. Since the university is the largest employer, however, I would either have to remain there or find another decent job that would allow me to keep my home and support my family. So I did some research.
I discovered that not only was there a nursing shortage in the United States (as well as worldwide) but that rural America was disproportionately affected by this shortage. Apparently, urban and suburban areas with large hospitals and complex health care networks took the lion's share of the available nursing population. Since I wanted to live in Smalltown, America, I was almost guaranteed a job if I became a nurse.
Third, the aforementioned nursing shortage also nearly guarantees me a job wherever I chose to work. Given increases in the "old age" population and the crossover into middle age and beyond of the largest surge in United States population, the baby boomers, more and more people require and demand medical care, including nursing services.
FYI: For a look at statistics and opportunities, check out:
http://stats.bls.gov/oco/ocos083.htm#outlook
Fourth, and this fact near and dear to my heart, I work full-time but I work 12 hour shifts, not uncommon in the nursing profession. As a 12-hour shift employee, full-time is considered 3 shifts per week. What this amounts to is 12 shifts (therefore, 12 days) per month and 144 shifts (144 days) per year if I don't take vacation. The average 8 hour, five day a week worker puts in about 260 days per year. In short, I have over 200 days off per year, whereas the aforementioned average worker has only 105 days off. For someone who loves his work but also loves the variety of other activities in his life, nursing was definitely the way to go for me.
But those are just the practical aspects of choosing nursing as a career. Life is not always or sometimes even primarily about being practical. Stay-tuned for a discussion of the other reasons I became a nurse.
Monday, August 20, 2007
Remedial Health Education
Ideas about health vary. What seems like a healthy lifestyle choice to one may not to another.
Usually when we think about health, we think of the things we've been told to stay away from, things we're told not to do. Cigarette smoking, fatty foods, toxic waste dumps, chain saws, lead paint, heroin. We think of the risks we take when we don't heed the warnings of experts: objects are closer than they appear; do not operate while under the influence of narcotics or alcohol; unsafe at any speed; an apple a day...
But what about the things we should do to maintain our health? These axioms do not seem debatable to me: eat right, exercise, be careful. It really is this simple, and the common denominator is moderation.
We are incessantly bombarded by the media, our friends and family, with all the latest health scares and all the newest health fads. Mad cow disease, E. coli, leaded toys, Suzuki roll overs, weight loss diets, Adkins, abdomenizers, gastric by-pass. With all of this, who has time to remember the essentials?
In the ER, many patients come in with problems with which they subsequently leave only to return again at a later time with the same problem. Chronic problems like back pain, migraines, respiratory difficulties. It is discouraging because (1) it seems that we are not helping them maintain their health at all, and (2) the quick fix they receive in the ER often allows them to ignore the underlying issues that cause the symptoms for which they return again and again. Not only is this inefficient, it is dangerous to their health!
The solution, of course, is education, but often the ER is not the most appropriate place to educate patients about the causes of chronic problems. It is easy (and becoming more culturally appropriate) to tell people to stop smoking cigarettes; it is less easy to teach them how or to follow up with an effective health care plan.
And some chronic problems are caused by conditions which are almost taboo to even mention. Obesity is one. Telling a person to take their asthma medication on a regular basis is astute and may be considered good, prudent nursing education. Suggesting that they eat less and exercise more in order to shed the extra 80 pound sack of concrete they tax their diseased lungs with everyday might be considered offensive.
But shouldn't they hear this? Shouldn't someone educate them about the connection between obesity and respiratory problems, how mass affects the function of systems, how the increased size of anatomy may have deleterious effects on physiology?
A recent book by a prominent sociologist questions statistically the obesity epidemic. As an ER nurse, I do not know whether or not obesity is on the rise (although I suspect it is), but I do know that obese patients have problems others don't, and I see a lot of them. For the individual, it doesn't matter whether statistically there is an epidemic or not; one is either over-weight or not, relatively speaking, and morbidity is influenced by this fact.
I think the health education ER nurses should attempt should be simple, albeit remedial: eat right, exercise, and be careful.
Does anyone doubt it?
Usually when we think about health, we think of the things we've been told to stay away from, things we're told not to do. Cigarette smoking, fatty foods, toxic waste dumps, chain saws, lead paint, heroin. We think of the risks we take when we don't heed the warnings of experts: objects are closer than they appear; do not operate while under the influence of narcotics or alcohol; unsafe at any speed; an apple a day...
But what about the things we should do to maintain our health? These axioms do not seem debatable to me: eat right, exercise, be careful. It really is this simple, and the common denominator is moderation.
We are incessantly bombarded by the media, our friends and family, with all the latest health scares and all the newest health fads. Mad cow disease, E. coli, leaded toys, Suzuki roll overs, weight loss diets, Adkins, abdomenizers, gastric by-pass. With all of this, who has time to remember the essentials?
In the ER, many patients come in with problems with which they subsequently leave only to return again at a later time with the same problem. Chronic problems like back pain, migraines, respiratory difficulties. It is discouraging because (1) it seems that we are not helping them maintain their health at all, and (2) the quick fix they receive in the ER often allows them to ignore the underlying issues that cause the symptoms for which they return again and again. Not only is this inefficient, it is dangerous to their health!
The solution, of course, is education, but often the ER is not the most appropriate place to educate patients about the causes of chronic problems. It is easy (and becoming more culturally appropriate) to tell people to stop smoking cigarettes; it is less easy to teach them how or to follow up with an effective health care plan.
And some chronic problems are caused by conditions which are almost taboo to even mention. Obesity is one. Telling a person to take their asthma medication on a regular basis is astute and may be considered good, prudent nursing education. Suggesting that they eat less and exercise more in order to shed the extra 80 pound sack of concrete they tax their diseased lungs with everyday might be considered offensive.
But shouldn't they hear this? Shouldn't someone educate them about the connection between obesity and respiratory problems, how mass affects the function of systems, how the increased size of anatomy may have deleterious effects on physiology?
A recent book by a prominent sociologist questions statistically the obesity epidemic. As an ER nurse, I do not know whether or not obesity is on the rise (although I suspect it is), but I do know that obese patients have problems others don't, and I see a lot of them. For the individual, it doesn't matter whether statistically there is an epidemic or not; one is either over-weight or not, relatively speaking, and morbidity is influenced by this fact.
I think the health education ER nurses should attempt should be simple, albeit remedial: eat right, exercise, and be careful.
Does anyone doubt it?
If It Bleeds, It Leads...Maybe
Triage is the system by which nurses determine the order in which patients will be seen in the emergency room. It is a system that prioritizes care for those most likely to suffer debilitating outcomes from the injury or illness with which they present, the most serious of which is, of course, death. It is an imprecise system that makes caring for multiple patients easier for ER staff, while at the same time, frustrating for some patients.
In most service industries, first come, first served. This because the nature of the services rendered to various customers is usually nearly the same with no one customer's issues being more important or more serious than anyone else's. Think of taking a number and waiting until your number is called. "Now serving..."
Our triage system sorts the severity of health problems into three categories. "Emergent" problems (whether injury or illness) are the most serious, and it is these that lead, bleeding or not. If you come to my ER and you can't breath, or your heart has stopped, or you have severe chest pain, or you're bleeding uncontrollably, then you get served first. The potential negative outcomes of your condition are so extreme that you require immediate attention.
"Urgent" problems have less severe potential outcomes and require attention within about an hour. Asthma attacks, severe histamine reactions, open fractures or fractures with vascular compromise, burns and open wounds without systemic complications...you won't probably die from these, so you drop down the ladder a few rungs.
"Non-emergent" is the category of problems that requires that you be seen sometime today, but literally, you could sit most of the day in the waiting room without any severe or even mildly negative outcome. Yes, it is this patient who sits and watches the severed dangling limbs, the chest clutching heart attacks, and the blue anaphylatic reactions jump to the front of the line.
Of course, sometimes in life it's a good thing not to have to be first.
About 85% of ER nursing is caring for patients with non-emergent problems. These are usually minor injuries (e.g., finger lacerations, eye irritations, sprains and simple fractures) and uncomfortable or inconvenient illnesses (e.g., back pain, hives, nausea). Most of these patients could probably be treated elsewhere, like at their primary physician's office, but they come to us for a variety of reasons (which I'll discuss another time).
Another 10% of ER nursing is caring for the urgent problems of patients who are very uncomfortable and who require more immediate attention than they could probably get going anywhere else. Sometimes the severity of their injuries or illnesses requires specialized treatment, equipment, or procedures that are unusual or unlikely in other health care settings. These patients usually need IVs, x-rays, narcotics, electrocardiograms (EKGs), or oxygen; they may need frequent or constant monitoring of their vital signs, their blood sugar; they might require a surgical consult.
Emergent conditions comprise the final 5% of emergency nursing. These patients arrive by ambulance from traumatic falls, motor vehicle crashes, construction sites where they've severed their fingers or shot themselves with pneumatic nail guns. These patients walk in with the metaphoric elephant on their chest, the swollen and compromised airway due to a peanut allergy, the shard of glass in their back which punctured their lung when they were violently pushed through the plate glass window. These are the unconscious patients with head injuries, strokes, chemical overdoses (e.g., drugs, alcohol, carbon monoxide).
These patients command an ER nurse's immediate attention not because they're more fun to take care of, but because if not cared for immediately and properly, they risk the unforgiving dance with mister D. Nobody should want to be this patient just to be first, and no one should complain that this patient comes first. After all, we may all be this patient or our loved one might be this patient at some point.
Who wouldn't want to wait in the lobby with a sore throat while the ER nurse saves the life of someone else?
In most service industries, first come, first served. This because the nature of the services rendered to various customers is usually nearly the same with no one customer's issues being more important or more serious than anyone else's. Think of taking a number and waiting until your number is called. "Now serving..."
Our triage system sorts the severity of health problems into three categories. "Emergent" problems (whether injury or illness) are the most serious, and it is these that lead, bleeding or not. If you come to my ER and you can't breath, or your heart has stopped, or you have severe chest pain, or you're bleeding uncontrollably, then you get served first. The potential negative outcomes of your condition are so extreme that you require immediate attention.
"Urgent" problems have less severe potential outcomes and require attention within about an hour. Asthma attacks, severe histamine reactions, open fractures or fractures with vascular compromise, burns and open wounds without systemic complications...you won't probably die from these, so you drop down the ladder a few rungs.
"Non-emergent" is the category of problems that requires that you be seen sometime today, but literally, you could sit most of the day in the waiting room without any severe or even mildly negative outcome. Yes, it is this patient who sits and watches the severed dangling limbs, the chest clutching heart attacks, and the blue anaphylatic reactions jump to the front of the line.
Of course, sometimes in life it's a good thing not to have to be first.
About 85% of ER nursing is caring for patients with non-emergent problems. These are usually minor injuries (e.g., finger lacerations, eye irritations, sprains and simple fractures) and uncomfortable or inconvenient illnesses (e.g., back pain, hives, nausea). Most of these patients could probably be treated elsewhere, like at their primary physician's office, but they come to us for a variety of reasons (which I'll discuss another time).
Another 10% of ER nursing is caring for the urgent problems of patients who are very uncomfortable and who require more immediate attention than they could probably get going anywhere else. Sometimes the severity of their injuries or illnesses requires specialized treatment, equipment, or procedures that are unusual or unlikely in other health care settings. These patients usually need IVs, x-rays, narcotics, electrocardiograms (EKGs), or oxygen; they may need frequent or constant monitoring of their vital signs, their blood sugar; they might require a surgical consult.
Emergent conditions comprise the final 5% of emergency nursing. These patients arrive by ambulance from traumatic falls, motor vehicle crashes, construction sites where they've severed their fingers or shot themselves with pneumatic nail guns. These patients walk in with the metaphoric elephant on their chest, the swollen and compromised airway due to a peanut allergy, the shard of glass in their back which punctured their lung when they were violently pushed through the plate glass window. These are the unconscious patients with head injuries, strokes, chemical overdoses (e.g., drugs, alcohol, carbon monoxide).
These patients command an ER nurse's immediate attention not because they're more fun to take care of, but because if not cared for immediately and properly, they risk the unforgiving dance with mister D. Nobody should want to be this patient just to be first, and no one should complain that this patient comes first. After all, we may all be this patient or our loved one might be this patient at some point.
Who wouldn't want to wait in the lobby with a sore throat while the ER nurse saves the life of someone else?
Sunday, August 19, 2007
A Matter of Perspective
I am often asked, what is the difference between nursing and (to follow form) doctoring? It is an important question.
I first thought about the difference when in my 30s I decided to switch careers. I had been a kindergarten teacher (read: college professor at a major northwest university) and I thought about becoming a nurse. An acquaintance, a doctor, asked, "Why nursing? You're smart enough. Why don't you become a doctor?"
Ignoring her annoying condescension, I told her flat out, "Because I don't like doctors."
Now, a little older, mellower and perhaps wiser, I realize that this is not entirely true. What I know now is that I like what nurses do more than what doctors do. We often talk of doctors "practicing medicine" and refer to it as an "art," but we talk about "nursing" flatly as a verb, a noun, and an adjective. Doctors practice medicine; nurses do nursing.
Aside from the semantics, the main difference between being a doctor and a nurse (in my opinion) is best understood vis-a-vis the patient: doctors diagnose and treat problems; nurses address the plethora of potential responses patients have to the problem(s) they are experiencing.
A doctor diagnoses a malignant tumor, perhaps cuts it out or reduces it by radiation or chemotherapy. Clearly, it is the doctor against the tumor, and the doctor is successful in as much as the tumor ceases to be a problem.
But what of the patient's pain and fear; the occupational and family crises that result from a diagnosis of cancer; what of the alopecia (hair loss), anorexia (appetite and weight loss), the parasthesias and paralysis and the myriad other side effects of cancer treatments? Who "treats" these? In fact, nurses do.
Doctors cure illnesses and fix injuries; nurses do almost everything else. This is why more than 90% of a patient's care is done by nurses.
Ultimately, however, the total care of the patient is a team approach. This is why I've changed my mind about (some) doctors. In my ER, nurses and doctors work very closely together despite our differing foci and roles. We have a truly collegial relationship, and all for the good of the patients.
I didn't go to nursing school because I wasn't smart enough to be a doctor. I became a nurse because I was smart enough to know what I wanted to do, and that was to care for people, not just fix problems.
I first thought about the difference when in my 30s I decided to switch careers. I had been a kindergarten teacher (read: college professor at a major northwest university) and I thought about becoming a nurse. An acquaintance, a doctor, asked, "Why nursing? You're smart enough. Why don't you become a doctor?"
Ignoring her annoying condescension, I told her flat out, "Because I don't like doctors."
Now, a little older, mellower and perhaps wiser, I realize that this is not entirely true. What I know now is that I like what nurses do more than what doctors do. We often talk of doctors "practicing medicine" and refer to it as an "art," but we talk about "nursing" flatly as a verb, a noun, and an adjective. Doctors practice medicine; nurses do nursing.
Aside from the semantics, the main difference between being a doctor and a nurse (in my opinion) is best understood vis-a-vis the patient: doctors diagnose and treat problems; nurses address the plethora of potential responses patients have to the problem(s) they are experiencing.
A doctor diagnoses a malignant tumor, perhaps cuts it out or reduces it by radiation or chemotherapy. Clearly, it is the doctor against the tumor, and the doctor is successful in as much as the tumor ceases to be a problem.
But what of the patient's pain and fear; the occupational and family crises that result from a diagnosis of cancer; what of the alopecia (hair loss), anorexia (appetite and weight loss), the parasthesias and paralysis and the myriad other side effects of cancer treatments? Who "treats" these? In fact, nurses do.
Doctors cure illnesses and fix injuries; nurses do almost everything else. This is why more than 90% of a patient's care is done by nurses.
Ultimately, however, the total care of the patient is a team approach. This is why I've changed my mind about (some) doctors. In my ER, nurses and doctors work very closely together despite our differing foci and roles. We have a truly collegial relationship, and all for the good of the patients.
I didn't go to nursing school because I wasn't smart enough to be a doctor. I became a nurse because I was smart enough to know what I wanted to do, and that was to care for people, not just fix problems.
Let Sleeping Old Men...Sleep
It is true that medical care, especially emergency medical care, is expensive. Although I don't know much about how much things cost, the rule of thumb I use to help potential patients estimate the cost of being seen in the ER is "at least $300 just to walk in the door."
Part of this is a facility's charge (the cost of maintaining the space and equipment of an ER and staffing it with nurses, aides, etc.) and another part is the professional fee of the physician. Invariably, people complain about their bills.
I am often asked by friends and acquaintances why their ER bill was so high. More times than not, of course, they came to the ER with a trivial complaint about a pain or injury that was not life-threatening but merely inconvenient and annoying. They easily could have seen their primary doctor, but they didn't want to wait a few weeks, days, sometimes even hours, to have their problem addressed.
"Don't you realize," I answer them, "that you came to the ER with a sore throat, but we have to maintain the equipment and training and skills to resuscitate you if your heart and lungs stop! Pharyngitis sounds like it should have a cheap fix, but you came to a place where we can literally bring you back to life if you die!" That has to be worth something.
This happens all the time. The extreme happened yesterday.
The ambulance ($300 right there!) was called out at 0710 to an unconscious patient at a local assisted living facility. The patient was a 89 year old man with a cardiac and diabetes history. Upon arrival he was pale and somnolent, but responsive to verbal stimuli. Blood sugar was normal, there was no external injuries, and he had no complaint of pain. After a couple of cups of coffee, he was alert, interactive, and managed to feed himself breakfast.
Diagnosis: Drowsiness, possibly related to abnormal sleep pattern.
Cost to Medicare: probably in the $500-$600 range.
Cost of a McDonald's Egg McMuffin Meal* with coffee: $3.29.
Clearly it is not emergency care which is expensive; emergency care for non-emergency conditions is expensive.
Let sleeping old men sleep. It's cheaper.
* Of course I do not endorse fast food as a healthy alternative.
Part of this is a facility's charge (the cost of maintaining the space and equipment of an ER and staffing it with nurses, aides, etc.) and another part is the professional fee of the physician. Invariably, people complain about their bills.
I am often asked by friends and acquaintances why their ER bill was so high. More times than not, of course, they came to the ER with a trivial complaint about a pain or injury that was not life-threatening but merely inconvenient and annoying. They easily could have seen their primary doctor, but they didn't want to wait a few weeks, days, sometimes even hours, to have their problem addressed.
"Don't you realize," I answer them, "that you came to the ER with a sore throat, but we have to maintain the equipment and training and skills to resuscitate you if your heart and lungs stop! Pharyngitis sounds like it should have a cheap fix, but you came to a place where we can literally bring you back to life if you die!" That has to be worth something.
This happens all the time. The extreme happened yesterday.
The ambulance ($300 right there!) was called out at 0710 to an unconscious patient at a local assisted living facility. The patient was a 89 year old man with a cardiac and diabetes history. Upon arrival he was pale and somnolent, but responsive to verbal stimuli. Blood sugar was normal, there was no external injuries, and he had no complaint of pain. After a couple of cups of coffee, he was alert, interactive, and managed to feed himself breakfast.
Diagnosis: Drowsiness, possibly related to abnormal sleep pattern.
Cost to Medicare: probably in the $500-$600 range.
Cost of a McDonald's Egg McMuffin Meal* with coffee: $3.29.
Clearly it is not emergency care which is expensive; emergency care for non-emergency conditions is expensive.
Let sleeping old men sleep. It's cheaper.
* Of course I do not endorse fast food as a healthy alternative.
Friday, August 17, 2007
Nurses Do It with Patience
I know what you're thinking: Did he spell that right?
I did. In fact, I emphatically did!
Truth is, to be a nurse requires both patience and patients. To be a good nurse requires a lot more of the former, but a lot of the latter make it more interesting, albeit sometimes more frustrating.
Like most social statuses, a nurse can be defined in a variety of ways and in relation to various other social groups. Nurses are sometimes said to be care givers, healers, physician-lackeys, pill-pushers, even pill-poppers. Sometimes we are therapists, other times janitors, sometimes we are just the people who drunken patients spit on and curse.
Nurses vis-a-vis doctors might be understood differently than nurses vis-a-vis patients or members of the EMS (Emergency Medical System). It depends which side of the nurse you're on.
However you want to define the status, whatever roles you might assume nurses play in patient care, in nursing departments (e.g., ER, ICU, etc.), even in health care organizations and the national system (sic) of health care, there is one ubiquitous element of nursing: the essence is patience.
Nurses wait, and are required to understand the importance of waiting. We wait for doctors to write legible orders, for patients to finally confess their two pack-a-day habit or decide they'd rather have the enema than the pain of severe constipation, for EMTs (emergency medical technicians...those folks on the ambulance) to call in from the field to tell us how many patients we can expect from the head-on on the highway.
If nurses were not required to have patience, health care organizations would be poorer because people wouldn't utilize them; families would be burdened with the care of their own; and many sick people might be horribly misunderstood.
Odd that nurses need to have so much patience but doctors are not expected to have much of it. Compared to what nurses do, for doctors, health care is like McCare, WalMend. Patients want quick and easy diagnoses, quick procedures, and quick scripts. Doctors want to be in and out of patient rooms. Doctors, by and large, get paid by the patient--piece work. Nurses generally receive a salary or hourly wages. For nurses, patience pays off in ways it doesn't for physicians.
So, next time you see one of those bumper stickers "(blank) Do It with (blank)," remember where the nurses go, and that its patience, not patients.
I did. In fact, I emphatically did!
Truth is, to be a nurse requires both patience and patients. To be a good nurse requires a lot more of the former, but a lot of the latter make it more interesting, albeit sometimes more frustrating.
Like most social statuses, a nurse can be defined in a variety of ways and in relation to various other social groups. Nurses are sometimes said to be care givers, healers, physician-lackeys, pill-pushers, even pill-poppers. Sometimes we are therapists, other times janitors, sometimes we are just the people who drunken patients spit on and curse.
Nurses vis-a-vis doctors might be understood differently than nurses vis-a-vis patients or members of the EMS (Emergency Medical System). It depends which side of the nurse you're on.
However you want to define the status, whatever roles you might assume nurses play in patient care, in nursing departments (e.g., ER, ICU, etc.), even in health care organizations and the national system (sic) of health care, there is one ubiquitous element of nursing: the essence is patience.
Nurses wait, and are required to understand the importance of waiting. We wait for doctors to write legible orders, for patients to finally confess their two pack-a-day habit or decide they'd rather have the enema than the pain of severe constipation, for EMTs (emergency medical technicians...those folks on the ambulance) to call in from the field to tell us how many patients we can expect from the head-on on the highway.
If nurses were not required to have patience, health care organizations would be poorer because people wouldn't utilize them; families would be burdened with the care of their own; and many sick people might be horribly misunderstood.
Odd that nurses need to have so much patience but doctors are not expected to have much of it. Compared to what nurses do, for doctors, health care is like McCare, WalMend. Patients want quick and easy diagnoses, quick procedures, and quick scripts. Doctors want to be in and out of patient rooms. Doctors, by and large, get paid by the patient--piece work. Nurses generally receive a salary or hourly wages. For nurses, patience pays off in ways it doesn't for physicians.
So, next time you see one of those bumper stickers "(blank) Do It with (blank)," remember where the nurses go, and that its patience, not patients.
Human Nature (as opposed to the other kind)
What is it that encourages an emergency room nurse to want to share thoughts about the work he does? I suppose the same thing that encourages people to have children: the desire to see our tangible, and sometimes, irrevocable dent on the world.
It is true that most every profession is somewhat of a mystery to those who do not engage in it. Perhaps it is the mystery of emergency nursing--its mysterious language, tools, methods, etc.--that I would like to share. Perhaps it is the unusual situations I find myself in, the unusual patients I encounter during an average work day. Perhaps it is the all too common events--"accidents"--that damage and sometimes destroy peoples lives.
Perhaps it is just an impulse to try to dispel the effects of television. I have to do this in my job a lot. I thought I might do it in this space as well.
I want to make it clear at the outset that these opinions are mine and mine alone (of course, heavily influenced by the people and events around me) and are not to be confused with medical advice or information or official positions of individuals with whom I work or organizations for which I work.
Of course, I am open to suggestions and comments. Nurses are trained to listen well. Although I realize that blogs are not proper dialogues, I encourage you to share your thoughts and questions with me via this space. I will do my best to address them. As I say often in triage, "I am a nurse. What seems to be the problem?"
Oh, one more thing. If you are the sort of person who looks at or writes blog posts daily, you may be disappointed in my effort here. Whereas I usually have an opinion, I don't always have an opinion to share or time to share it. After all, I am an emergency room nurse.
It is true that most every profession is somewhat of a mystery to those who do not engage in it. Perhaps it is the mystery of emergency nursing--its mysterious language, tools, methods, etc.--that I would like to share. Perhaps it is the unusual situations I find myself in, the unusual patients I encounter during an average work day. Perhaps it is the all too common events--"accidents"--that damage and sometimes destroy peoples lives.
Perhaps it is just an impulse to try to dispel the effects of television. I have to do this in my job a lot. I thought I might do it in this space as well.
I want to make it clear at the outset that these opinions are mine and mine alone (of course, heavily influenced by the people and events around me) and are not to be confused with medical advice or information or official positions of individuals with whom I work or organizations for which I work.
Of course, I am open to suggestions and comments. Nurses are trained to listen well. Although I realize that blogs are not proper dialogues, I encourage you to share your thoughts and questions with me via this space. I will do my best to address them. As I say often in triage, "I am a nurse. What seems to be the problem?"
Oh, one more thing. If you are the sort of person who looks at or writes blog posts daily, you may be disappointed in my effort here. Whereas I usually have an opinion, I don't always have an opinion to share or time to share it. After all, I am an emergency room nurse.
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