Interaction Between LPN Nurse and Doctors

Hahn also consulted with an intern. The intern told Hahn to give the patient a drug called Lopressor, a beta-blocker that controls blood pressure and heart rate. But Hahn knew this was the wrong call. Aside from having had an aneurysm, the man also had chronic obstructive pulmonary disease (COPD), that is, lung disease. Lopressor is dangerous for anyone with COPD. If this patient took Lopressor, he might end up in the intensive care unit with serious breathing problems. Hahn explained all this to the inexperienced doctor and suggested he prescribe another drug, called diltiazem, which could safely deal with the patient’s elevated heart rate without aggravating his COPD. She also suggested that they use Lasix, a diuretic. During surgery, patients are often given a great deal of fluid. Sometimes it takes days for the body to eliminate this extra load. The patient had put on weight, which indicated that he might be “fluid overloaded.”

The intern followed her advice. When the medication began to have an effect on the patient’s heart rate and blood pressure, the online lpn programs decided he could be discharged. Hahn, however, recognized that the patient was still unstable. Even though he seemed to be awash in his own bodily fluids, inside his circulatory system there was actually not enough fluid. The edema, or swelling, he was experiencing was a result of fluid collecting outside of his bloodstream in tissues and between cells. As the medication helped his body eliminate all the excess fluids, it could put him at risk for low blood pressure, shock, or low blood supply to the heart, which could cause a heart attack. Even though his heart rate was steadier, Hahn knew he could still have a potentially fatal blood clot. If any of this happened at home, the patient could die. She wanted the patient to stay in the hospital, where his changing condition could be closely monitored and cardiologists could consult on his care.

With little experience handling this kind of patient, the intern, Hahn knew, was dealing in snapshots. In his sporadic contacts with the patient, he saw a man whose condition was improving, whereas Hahn anticipated a more complex trajectory of recovery that included not only highs but many potential lows. Finally, after she had discussed the matter with the intern, he concurred. The patient stayed in the hospital. When the cardiologist finally came to check his status, he agreed with Hahn. In order to be safe, the patient needed close monitoring.

As they listened to their colleague recount this experience later, nurses in the lecture hall nodded knowingly. When I suggested that Hahn’s story illustrates how nurses routinely diagnose problems, making lifesaving prescription and treatment recommendations and helping physicians avoid potentially fatal mistakes, Hahn agreed. “Yes, that’s true. We do that every day. But why,” she asked, her voice dropping in sadness rather than

The Under Appreciated Work OF a LPN Nurse

Hope we would never do anything that stupid.” This medical 53 confiscation of nurses’ contributions assures, as one nurse put it, that “doctors get all the credit when something goes right. We get credit only when something goes wrong.”

Ann Williamson, a nurse executive at the UCSF Medical Center (University of California, San Francisco) recounted an example of this problem of discredit. As happens every day in hospitals across the country, a nurse was working with doctors who were involved in the tricky maneuver of placing a feeding tube in the stomach of a patient on the intensive care unit. During the insertion it’s easy to mistake the trachea for the esophagus and to insert the tube into the lungs rather than stomach or small intestine. To do so means that fluid and nutritional matter will go into the lungs, where it could cause pneumonia or potentially drown the patient. So nurses and doctors use a variety of mechanisms to assure correct placement. Sometimes an X ray is taken to make sure the tube is correctly inserted. The nurse will also pump air into the tube and listen with a stethoscope placed over the abdomen to listen for gurgling in the stomach.

In this particular case an X ray was indeed taken, but the nurse wasn’t confident that the X ray technicians had read the right film or read it correctly. When he pumped air into the tube, he was certain that he couldn’t hear any gurgling in the stomach. On the other hand, he felt he could hear air moving through the tube when the patient breathed, a sign that the tube was misplaced.

The resident placing the tube disagreed. He insisted that the tube was correctly placed, that the X ray verified placement, and that it was safe to feed the patient through the tube.

Understanding the significance of a potential mistake, the nurse continued to object, insisting that another x ray be taken or that X-ray technicians verify that this X ray was read correct. Again the doctor objected. But the nurse stood his ground.

Ten minutes into the debate, the X-ray department called. “I hope you haven’t started the feedings yet,” the technician said. The nurse was right.

The tube had been placed incorrect.

Although the tube was finally placed correct and the mistake avoided, the nurse never got credit for his call. The doctor never came back to the unit to express appreciation for his persistence. What happened was not noted in the chart. Did the resident mention it in his discussions with his colleagues? Probably not. Was it used as part of a case study to teach medical students about the role nurses play in the hospital? Not that Williamson knew. The nurse saved the patient’s life, but from the medical point of view, his action simply didn’t exist.

CNA Nurse’s Daily Work

This failure to account for nursing’s contributions has been integrated 51 into the formal process of medical accounting, both financial and reportorial. Hospitals, for example, account for the cost of medications, medical tools, equipment, and supplies. Before the bundling of charges under DRGs (diagnostic-related groups), you could find out what an aspirin cost, what a scalpel cost, even what a pencil cost. And physicians, of course, have always billed for their services. But hospitals did not include a financial accounting of nurses’ services in any hospital bill or invoice. As if they were a sheet or pillowcase, nursing services were the original bundled service, integrated into the room charge. This, erroneously in my view, has led some American nursing elites to insist that the way nurses will finally make it onto the radar screen is to set up their own agencies and sell their services back to the hospital, just as physicians do.

In their discussion of how medical education, training, and work so often preclude a recognition of interdependence, Aron and Headrick explain that doctors have a limited ability to “understand work as a pro¬cess.”30 Given the accounting structures of medicine, it is difficult for nurses’ contributions to be included in the meetings, conferences, reports, and charting of medical care.

Medicine also routinely claims credit for nurses’ work in the chronicling of medical care in books, articles, columns, letters to the editor, or comments from doctors describing their work to a broader public. An interesting example is a letter to the editor printed in the New York Times. Physician Arthur M. Magun, director of quality assurance at Columbia University, is opposing efforts to reduce the grueling schedules of interns and residents, which range from eighty hours per week to over a hundred. Doctors should remain at the bedside as long as possible, Magun argues, because “experienced doctors realize that long hours at the bedside of a sick patient watching the drama of illness unfold and being there to understand the results of one’s intervention or lack of it are the best route to becoming an outstanding doctor.”31

A year later, surgeon Steven G. Friedman wrote an op-ed for the same paper on the shortage of candidates for surgical programs. Echoing Magun, he cited shortened resident hours as one of the causes of the crisis. “Will patients now be better off with shift workers (i.e., doctors who work shorter shifts) who have never seen the complete progress of an illness than they were with tired doctors who cared for them throughout the night?”32

For anyone who has actually tallied how much time surgeons spend at the patient’s bedside after they leave the OR, this image of the surgeon hovering at the patient’s bedside is almost laughable.