Over the next few weeks, as the agency circulated Molly among hospitals, she came to understand what he meant. South General nurses had nerves of steel. In this particularly disadvantaged part of the state, they saw extreme cases of medical and psychological distress. By contrast, on Molly’s first day at Academy, a college-aged patient had a psychotic break. She sat on her bed laughing and talking to an emesis basin that she held to her ear like a telephone. Molly could hear the “baby nurses” whispering, “Can you believe how crazy she is?” “They thought she was the most psychotic person they’d ever seen,” Molly said. “My thought was ‘That’s a big deal to y’all? That’s crazy?’”
At South General, medics once brought in a homeless guy high on PCP. When they tried to move him from the gurney to a stretcher, he jumped up, ripped off his clothes, ran naked into the full waiting room, and “helicoptered,” gyrating so that his noticeably long penis spun like a propeller. “To impress a chick, HELICOPTER DICK!” he shouted. While one nurse called security and gathered staff—it usually took several people to hold down patients on PCP because they had herculean strength—other nurses calmly ushered people to the other side of the large lobby, far from the now naked man.
“The South General nurses were like, ‘Hmm, naked man helicoptering in the lobby. Security was called, no big deal.’ That’s why I like South General,” Molly explained. “When he started screaming—‘Waaaa!’—and dove out the plate glass window, then he became a trauma.”
Citycenter Medical
On Molly’s first day at Citycenter, she felt sick to her stomach. She was not the nervous type, and certainly had never been anxious about a job before, even as a new grad. But she could see that Citycenter’s ER was extremely unsafe. First, the entire department was filthy: Blood spattered the walls, full urinals sat on counters in rooms that were supposedly ready for a new patient, and dried urine covered a utility room counter. Second, patient wait times were inordinately high. And because there was no dedicated trauma nurse, a nurse in Zone 1 was expected to drop all of her patients—the sickest bunch in the ER—when a trauma patient came in. Trauma patients could require one-to-one care for several hours, leaving the sickest patients neglected and in danger.
Molly’s anxiety was justified. That morning, she was assigned at least seven patients at a time, sometimes nine, which was more than she’d ever had at Pines, and too many for her to care for adequately. “How do you handle this kind of patient load?” she asked the other nurse in her zone.
“We can’t,” the nurse replied. “People are quitting left and right, which means an even bigger workload for the rest of us.”
One of Molly’s patients was a 400-pound drug addict who had been running around the city without pants. It had taken nine police officers to bring the man in. The ER staff had shackled him in four-point leather restraints and left him alone in an empty room. When Molly saw the patient, her jaw dropped. As Molly understood it, The Joint Commission instructed that patients in four-point restraints should have a one-to-one staffer who was supposed to document the patient’s behavior, note medical interventions, and offer nourishment and toileting every fifteen minutes. If the patient became cooperative, the staff was supposed to release him from the restraints. The patient’s chart said that since he had been in the ER, he had been quiet and cooperative, but tied down for hours.
Molly found Sarah, the charge nurse. “Where’s his sitter?” she asked.
“There isn’t one,” Sarah said.
“But TJC recommends a sitter for patients in four-point restraints,” Molly pointed out.
Sarah shrugged. “We tie people down here all the time. With the patients we get, we prefer it that way.”
The staff was generally competent and dedicated but spread so thin that they couldn’t consistently provide quality healthcare. Citycenter, where Molly was scheduled for several upcoming shifts, was in even worse shape than she had expected.
The Fertility Clinic
The next day, Molly was off from work so that she could attend her first appointment at the fertility clinic. The nurse at the desk showed her the list of tests the clinic wanted for the initial blood draw. Molly scanned it, concerned. Her husband’s health insurance covered only up to $10,000 of certain fertility treatments and didn’t cover in vitro fertilization. As a nurse, Molly typically made about $60,000 a year before taxes. Trey’s police officer salary brought in $77,000 before taxes. They were trying to save for a down payment on a house, but too many out-of-pocket fertility treatment costs would wipe out their savings.
Molly crossed the varicella, rubella, HIV, and hepatitis C tests off the list. She had been tested for all of them within the last two years.
“Why are these crossed out?” the nurse asked.
“I had those tests performed less than two years ago and I only get a certain amount of insurance funds, so I’d like to save money on tests that have been performed recently,” Molly said. The nurse shook her head and led Molly to the back room to draw blood.
The nurse frowned as she poked Molly. “You’re as tight with your blood as you are with your money,” she carped.
Molly ignored the dig. “I didn’t know what two of the tests on that list were. Could you tell me?”
The woman didn’t answer. After the draw, Molly watched the nurse label the tubes. She pointed. “These two here—what are those?”
“I can’t tell you,” the nurse said. She didn’t even look at Molly.
“Because you don’t know or because you aren’t allowed?” Molly asked, confused.
“Our policy is to not tell people.”
“That doesn’t make sense,” Molly said. “I’m paying for these. These are elective tests.”
“You’re a nurse. You understand,” the nurse said.
“No, I don’t understand. When my patients ask what a test is for, I tell them,” Molly said. The woman glowered at her and left the room.
Safe in the elevator hallway, Molly composed herself. Struggling with infertility was difficult enough; why did the clinic have to make the process so unpleasant? Typically, she chose her doctors based on their bedside manner, but she had selected her fertility clinic because of its success rates. Patients here dealt mostly with the nurses until the actual procedures. Still, she couldn’t help yearning for “someone to make eye contact, to have some inflection in their voice that shows they care about me, not just keeping their profits up,” as she phrased it. “At a fertility clinic, a little warm fuzzy would go a long way.”
That experience, and subsequent visits to the clinic, left Molly feeling like a number. On no occasion did clinic doctors or nurses introduce themselves before performing a procedure. As a result, Molly vowed to introduce herself clearly to each of her patients, to show them her badge, and to explain her role. “People aren’t taking the three seconds to say, ‘Hi, I’m Sandy and I’ll be doing a transvaginal ultrasound on you today,’ ” Molly said. “As a healthcare worker, I’m generally less sensitive to that type of stuff, but the fertility experience is making me feel horrible. My patients see me during an emergency. They’re probably more scared than someone going in for routine fertility testing. I will do a better job of putting ER patients at ease.”
Chapter 2
Crossing Doctor-Nurse Lines:
How the Sexy-Nurse Stereotype Affects Relationships with Doctors and Patients
“I will not be ashamed to say ‘I know not,’ nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.”
—Physicians’ Hippocratic Oath
“The intimate nature of nursing care, the involvement of nurses in important and sometimes highly stressful life events, and the mutual dependence of colleagues working in close concert all present the potential for blurring of limits to professional relationships.”
—Code of Ethics for Nurses, Provision 2.4
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br /> “Lots of hot residents and nurses rush off to have quickie sex in utility closets during night shifts.”
—a nurse practitioner in Virginia
MOLLY September
Academy Hospital
During Molly’s third week at Academy, a patient arrived at the ER already dead. Molly asked the charge nurse what kind of paperwork she needed to fill out.
The nurse, who was about 22, looked perplexed. “Honestly, I’ve never had a dead patient so I don’t know. Can you ask someone else? I’m not getting patients out of here quickly enough. It’s just too overwhelming.”
Molly tried not to show her surprise. How are you in charge without ever having seen a dead body? she wondered. Twenty-two-year-olds have no business being in charge of an ER.
The patient load would have been considered a breeze at Pines; Molly had already come to think of Academy as easy money. Nurses here typically had no more than four patients, few of the patients were critically ill, and patients spent no more than thirty minutes in the waiting room.
Molly wondered whether a recent shift in nurse training contributed to the girl’s inexperience. Traditionally, new nurses first had to work on the medical surgery floor to gain experience before moving to the ER and other critical care areas. The nationwide nursing shortage (or in some cases, short staffing) instead punted grads into more difficult areas of the hospital. Nurses were starting their career in the ER, OR, or ICU. “At Academy, some of the baby nurses don’t know what they don’t know,” Molly said. “And there are med students and new doctors who are also on the learning curve. At Pines, there were plenty of times that a doctor put in a wrong medication order, and an experienced nurse was there to say, ‘Hmm, that doesn’t seem right.’ But not at Academy. There’s potential for big mistakes with this young staff.”
Many of the doctors at Academy were egotistical, but Dr. Cynthia Baron took the cake. Dr. Bitch, as Molly referred to her privately, was a resident who resembled Malibu Barbie, swishing her impeccably blown-out hair as she sauntered down the halls. She rarely deigned to talk to nurses unless she was angry with them or needed something, in which case she treated them like preschoolers: “Hi, pumpkin, can you do me a teensy favor? Thaaanks.”
One day, a well-dressed 88-year-old woman came into the ER. Molly was prepping her assigned room when two nurses practically carried the wheelchair in, rickshaw-style, one tipping the chair back and the other holding the woman’s kicking feet to the leg rests to prevent the woman from pitching forward. Molly was horrified. Do you really need to do that to this poor little old lady? she thought.
“I just want to go home!” the patient cried, thrashing about as the nurses set the wheelchair next to the bed. “I don’t want your help!” She tried to walk out of the room, but she was unsteady, and the nurses, assuming the woman was suffering from dementia, returned her to the chair.
Molly, the patient’s primary nurse, quietly observed her. Dr. Baron poked her head into the room, saw the commotion, immediately ordered antipsychotic drugs for the patient, and left. Hospitals could hold a patient for seventy-two hours following an assessment, but Dr. Baron hadn’t evaluated the patient at all; she based the order on the patient’s initial behavior alone.
Finally, Molly spoke to the woman, who was again trying to escape her chair. She gently put her hand on the woman’s arm. “May I please speak to you for a couple of minutes?” she asked. “Everyone else, can y’all please leave the room so I can talk to my patient?”
The nurses shrugged and left Molly alone with the woman. Molly’s green eyes softened. Occasions like these were important, to nurses and to patients—the moments of exchange with another person on a human-to-human level.
Just because a patient wanted to leave didn’t mean the hospital could allow her to go. Where would she go? Who would make sure she got home safely? Molly wanted to learn the woman’s story to give her a chance to explain why she was in the ER and whether she would be safe if she were discharged. “So what’s going on?” Molly asked. “Why are you so angry?”
The woman sat down and calmly told Molly that her neighbor had taken her to her doctor’s office. The doctor told her she was in heart failure, needed new medications, and should probably move into a nursing home. When she rejected the plan, the neighbor drove her to the ER and left. “I’ve lived a full life,” the woman said. “I’ve outlived my husband and most of my friends. My doctor said I’d die if I didn’t take his advice. I’m fine with that. I’ve lived in my home for forty years. I don’t want to leave it. I have help. I don’t need doctors telling me what to do. I’m ready to go.”
Molly nodded. “That makes complete sense to me.”
Molly found Dr. Baron in the hallway and relayed the discussion. The doctor barely looked at her. “She’s not competent,” she said.
“We just had a very lucid conversation. She wants to go home and let nature take its course,” Molly replied.
“She can’t make her own decisions,” the doctor insisted.
“Come back to the room with me,” Molly said.
Dr. Baron followed her and addressed the patient. “What is today’s date?” she asked. To determine whether a patient was clearheaded, it was standard practice to ask the patient’s name, the date, and the name of the current president of the United States.
The patient was frustrated. “I don’t know or care what the date is.”
She knew her name and the president’s, but Dr. Baron said, in front of the patient, “She is not competent.”
“You’re so pretty,” the patient suddenly told the doctor.
Molly laughed. “Well, I guess you’re right,” she said to the doctor. Dr. Baron turned on her high heels and went straight to the nurses station to order a psychiatric consultation and a variety of lab tests. Luckily, Dr. Baron’s shift ended soon afterward. When the next physician, Dr. Ward, arrived, Molly explained the situation. She liked Dr. Ward. He took the time to listen to the nurses. Molly had seen the doctor respect even a new nurse’s input when she knew that a rhythm change on a heart monitor signified that something was wrong, though she couldn’t pinpoint exactly what was amiss.
Dr. Ward sat down with the patient to hear the same story she had told Molly. The doctor called the patient’s son, who confirmed that the woman was entirely competent and able to make her own decisions. He let Molly put the woman in a cab twenty minutes later.
“If I hadn’t advocated for her, she could have ended up being committed to the psych unit for observation while they prolonged this woman’s life against her will,” Molly realized. “I think a lot of ER docs forget that not everyone wants to—or needs to—be saved.”
A few days later, a patient came in with a bad bone infection in his foot. While at home, he had broken his foot by merely putting weight on it, and the already infected area began to bleed. Paramedics bandaged his foot and brought him to the ER. By the time he arrived, the bleeding was controlled but his blood pressure was low.
Molly started an IV and hung fluids to try to increase his blood pressure. Before long, the man looked better, was talking normally, and reported feeling fine. Molly ran a few blood tests to make sure.
When Dr. Baron came into the room, she declared, rapid-fire, “He’s hypotensive because of blood loss. We need to transfuse immediately.”
Molly shook her head. “I don’t think he could have possibly lost enough blood out of a foot wound to be hypotensive. I think he’s septic,” she said.
“I’m ordering blood,” the doctor insisted.
“I just ran an I-STAT and his H/H [a lab that shows blood volume] are normal.”
Dr. Baron raised her voice. “Since he started bleeding so recently, his H/H might not reflect the blood loss yet.”
“Or he’s septic,” Molly said. “His lactate is elevated.”
Dr. Baron couldn’t possibly let a nurse upstage her. Sh
e called the blood bank and ordered the transfusion, stat.
Molly reluctantly transfused the blood, per the doctor’s orders. The ICU doctor who came downstairs to examine the patient before transferring him looked confused. “Why are you giving blood for septic shock?” he asked Molly.
“You’ll have to discuss that with Dr. Baron,” Molly said. “I asked the same question.”
When Molly complained to the charge nurse, the nurse answered, “We get a lot of complaints about how she treats nurses. She’s been reported to the director of the medical staff several times. It’s frustrating that no one does anything about it.” Most hospitals Molly had worked at had individual doctors here and there who mistreated nurses, but at teaching hospitals like Academy, the overall egotism led to particularly horrendous communication.
One autumn afternoon, Molly was waiting for a call from gastroenterology to find out whether doctors were going to take an ER patient bleeding from the stomach to the OR or to the endoscopy suite, or if he was going to be admitted to a floor. She was at the nurses station talking to the charge nurse about the case when she saw the attending GI doctor, whom she had not worked with before, and a resident pushing a stretcher carrying her patient down the hall.
“Hey, that’s my patient!” Molly said.
She hustled down the crowded corridor after the doctors. “Excuse me! Where are you taking this patient?” she asked.
“I’m the attending,” the doctor announced.
“I understand that,” Molly responded, “but I need to know if the patient will be coming back to the ER or if he has been admitted. If so, he can’t leave until he has orders. I need to know who is writing the orders.”
Molly wasn’t trying to engage in a battle of egos; she had to look out for her patient. A patient leaving the ER for another floor needed to have an admitting doctor accept him so that someone was officially taking responsibility and writing orders. Because the patient had not yet been assigned an admitting doctor, once the GI doctor took him to another floor, the patient could potentially fall through the cracks of the hospital system. The charge nurse needed to know whether the patient would be coming back to the ER to be discharged after surgery or whether he would need a room elsewhere in the hospital. Otherwise, after surgery he could be left in the PACU (Post-Anesthesia Care Unit) with nobody managing his care.
The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital Page 6
