December 18, 2008, 1:53 pm

Nurses Are From Mars, Doctors Are From…Some Other Galaxy

Here is another in the series of “IVs and the Nurses Who Love Them”.

First things first: the cap is definitely a 10/10 on the Emergiblog Cap Rating Scale. I do notice a bit of “occipital slip”. The cap should be visible at the top of the head when the wearer is standing in front of a mirror.

Then again, this looks like a student so I shall cut her some slack.

This looks like a classic photo of “goldfish therapy”.

Either that or that’s a water balloon hanging up there.

It doesn’t even have a drip chamber!

(Check out the wall paper. It’s early American Twilight Zone.)

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Many thanks to Laurie Edwards at A Chronic Dose for including Emergiblog in last Tuesday’s Grand Rounds!

It’s a best-of-2008 edition, so be sure to check it out if you haven’t already!

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Nurses and doctors do not perceive the emergency department in the same way.

This is not a knock on my medical colleagues, merely an observation.

Actually, it’s more a realization that hit me after a recent shift.

My jaw still hurts from hitting the floor.

*****

In my county, hospitals are able to go on what is called “ambulance diversion”.

This means if the emergency department is overloaded with patients and cannot safely take another at that time, they are allowed to divert non-emergent ambulances to another facility.

It can help somewhat, but it isn’t perfect. Any cardiopulmonary arrests or life-threatening situation still go to the nearest hospital, even if they are “diverting”. And of course, there are always the patients who can walk in with a major STEMI (aka: heart attack).

But…it keeps routine ambulance traffic at bay until the department can safely handle another patient.

It’s something the night shift rarely has to invoke.

*****

This particular shift was different.

The department was full, with patients who had been there 3-4 hours and 3-4 triages in the wings.

It was one of those situations. Everyone who walked in had a serious medical issue. Abdominal pain was the theme of the day.

Every patient required a substantial work up. Tests were coming back positive for everything from appendicitis to ovarian cysts, bowel obstructions to pancreatitis, severe gastroenteritis to Crohn’s flare ups. Patients were requiring admission, surgery, pelvics, ultrasounds, CT scans, lab work, EKGs, multiple doses of IV narcotics, IV anti-emetics, IV antibiotics, and IV anti-fungals

Interspersed throughout this scenario were patients whose lungs decided that an oxygen saturation of 80% was a good idea, or who needed multiple sutures to piece them back together after head/knee/arm vs. cement/table/knife.

It was busy.

*****

The shift started with three nurses and an ER tech who work hard and work well together.

The doctor on duty was a great guy (and I’m not just saying that because my co-workers know I blog). He’s calm, friendly, unflappable and a great doc on top of it.

We do not get overwhelmed easily, but we were overwhelmed that night.

We approached the doc and told him we were going on divert unless he had any objections.

He didn’t and we diverted.

*****

One caveat of the diversion policy is a six hour limit in a 24 hour period.

This means we don’t divert unless we have to and we divert sparingly.

We used a considerable chunk diversion time that night.

*****

At 0330, our third nurse was off duty. Now we were down to two nurses. No dedicated triage nurse. No dedicated charge nurse. No nurses to call in for back up.

We were so out of ratio it was pathetic. We told the supervisor we were both filling out “Assignment Despite Objection” forms and we never ask for those. It was that busy and the patients were that sick.

*****

We maintained a full department until around 0530 that morning, when we went off divert.

So we had a solid six hours of non-stop running. No breaks, no meal, no bathroom, and worse, no coffee!

When we advised that we were going off divert, our doc said something that floored me.

He said, and I’m paraphrasing, that he figured we knew when we were overloaded so he let us (the nurses) decide when we needed to go on divert, but if anyone asked him why we were on divert for five hours he would shrug his shoulders and say he could have taken care of another patient.

Essentially, if there was any question, it had nothing to do with him.

Excuse me?

It’s a good thing I like this guy or I’d have smacked him upside the head.

*****

Let me state this diplomatically.

The nurses do the triaging of the patient and the rooming of the patients. We place the chart in the to-be-seen pile.

The ER doc examines the patient, decides what tests to order or confirms the tests we have already initiated per protocol, and then walks out of the room and onto the next patient.

All those orders that he writes?

They are carried out by the nurses.

The questions and requests from patients and family members? The continual assessment of the patient’s response, the continual reassessment of vital signs and symptoms? The placement of the IVs, the drawing of the labs, the placing of the foley catheters, the insertion of the NG tubes? The endless documentation of everything that goes on with the patient while they are in the ER? The running for ice chips, warm blankets, more pain medication, more nausea medication? The written report required before admission?

These are all done by the nurses.

*****

So while the nurses (and tech and secretary) were running our butts off trying to meet the needs of multiple sick patients for the entire shift, in the doctor’s eyes, we weren’t that busy and he could have easily done more.

While we shared the same space, we were definitely working in parallel universes.

And that’s when it hit me. It’s something I fundamentally knew, but had never heard it so clearly stated.

Nurses are from Mars and doctors are from…

…some other galaxy all together.

Either way, we don’t see this world through the same eyes.

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18 Comments

  • Maureen
    Maureen

    December 18, 2008 at 7:24 pm

    Kim,

    I am learning SOOOO much from your blog. As a patient I have always understood that the bulk of my care comes from the nurse, and that frankly, they make or break my experience. I had no idea however that the doctors were so out of touch. It sounds like a hellish shift for all of you, and I can’t imagine that doctor not backing up the divert decision when he could clearly see how busy you all were. BTW, couldn’t he have pitched in with some of the issues? Maybe I am just dreaming, but I imagine a doctor IS physically capable of getting a blanket or ice chips, or asking a nurse if there is something he or she needs?

    Thanks for another eye-opening post. You have my gratitude and admiration for the job you do. Wish you were in my local ER!!

    Hope you have a very happy holiday season and a new year filled with good things!


  • AlisonH
    AlisonH

    December 18, 2008 at 10:10 pm

    Wow.


  • Traumadiva
    Traumadiva

    December 19, 2008 at 9:27 am

    God I love your postings! Right on sistah! You just hit it right on! Thanks so much! Maybe you will enjoy a read of mine. Nurse Ratched is a fan!


  • ERMurse
    ERMurse

    December 19, 2008 at 9:44 am

    Kim,
    Sounds like your ED is working out of ratios on a regular basis. If your down to 2 Nurses then the max you can have is 4 patients. The ratio law requires that one RN be assigned to Triage and not counted. Every hospital I have worked at tries to skirt around the ratios by tricks such as averaging or giving the Triage or Charge Nurse a patient load. All violations. The only way you get their attention is to block off beds for all but critical patients when you exceed the ratios. When they see patients in the waiting room while open beds are blocked off it gets their attention and they up the staff. You have to present it as its their choice to block beds by not providing the staff not yours by following the law.


  • Candy
    Candy

    December 19, 2008 at 10:13 am

    Nurses are the choreographers of care. When you can’t accomplish your job (achieving quality patient outcomes) because you’re impacted by not enough staff, too many patients or other variables, it’s time to say enough. Every doc needs to shadow a nurse on one busy shift so they get an idea of what it’s like to be on the other side…


  • Matthias
    Matthias

    December 19, 2008 at 2:18 pm

    Great article!!

    There’re the same conditions here in Germany!

    Greetings from Germany (Europe), Berlin

    Matthias


  • Beach Bum
    Beach Bum

    December 21, 2008 at 6:25 am

    I’m only a medical student, just shadowing in the ER, but I have seen just how much work the nurses do.

    Last night, a challenging case came into the little ER I was working in that required several nurses and lots of other staff. It was interesting to me to watch how the rest of the ER ground to a halt while this one case was dealt with. Of course, immediately 10 people showed up in triage.


  • NPs Save Lives
    NPs Save Lives

    December 21, 2008 at 6:18 pm

    I’m hearing your plight. Too often the perceptions between doctors and nurses and NPs are often skewed. I hope you get some time off during the holidays to make up for it. Remember to take some “me time” to refuel because those patients need the excellent care you give them!


  • DBS
    DBS

    December 22, 2008 at 4:59 pm

    Right on the money. Love it when we have a
    d & c and the doc is like, “It only takes 5 minutes to do, what’s the hold up? Well, the patient isn’t even admitted yet, they have no IV, they have not signed the consent, they have not had a head to toe or a preop interview. Oh and then there’s the scrub tech and the nurse who have to assist you in the OR and they are currently in a c/s and oh yeah the nurse that has to recover the patient. hmmm…


  • ashesh
    ashesh

    December 22, 2008 at 5:07 pm

    I share your sentiment. I’m a pre-nurse student looking forward to become an ER nurse some day. It saddens me a lot that some doctors treat nurses like sh!t. I applaud you for bringing out an excellent point: there are some doctors all they do is give orders and have their orders carried out by nurses. And yet in all these, they hardly appreciate their workmates!!! Geez luiz I shall pray for some patience to come my way should I work side by side with such doctors.
    I’ve become a fan of your blogs and enjoy reading them


  • [...] Doctors and nurses share the same space at work but work in different spaces. After a night on divert, Kim realizes Nurses are from Mars, Doctors are from … Some Other Galaxy. [...]


  • Charity
    Charity

    December 25, 2008 at 1:08 am

    You have nailed it on the head. In one of my first lectures of nursing school, the professor said that the only reason people were in the hospital was because they needed NURSING care. The truest thing I ever learned in school. (That and “If the patient says they are going to die, believe them…”)


  • UnsinkableMB
    UnsinkableMB

    January 3, 2009 at 1:28 am

    Kim! Great post. This definitely applies to the operating room. My favorite is when surgeons ask us for highly specialized instrumentation on a whim in the middle of a procedure. If the surgeons did some pre-op planning, those trays could have been ordered and made available. How are we nurses supposed to know that the surgeon would deviate from what from his usual procedure? Instead the nurses are blamed for not having the foresight to have this instrumentation on site. Uh, I’m not the one who did a residency and a fellowship in orthopaedics…


  • nursey
    nursey

    February 25, 2009 at 1:52 pm

    I really thought this mentality existed only in the caribbean.Girl you are so right.You think you’re working as a team ,but then you find out…


  • anonymous
    anonymous

    February 25, 2009 at 7:21 pm

    Heh, I once, as charge nurse for the 3 ICUs, informed the medical director (who could then order trauma diversions etc) that we could not take any more patients–we had overflowed into all the available PACU beds even, which did not have adequate monitoring, so it wasn’t just lack of staff–and he said “that’s a nursing problem” and walked away…


  • Surgeon
    Surgeon

    March 1, 2009 at 10:08 am

    Fprtunately, you are able to divert outside the hospital, in contrast we really divert patients from ER to inside hospital ehere they are put in rows above and beside each other. We make sure that we use every available cm in the inwards including the floor and the walls. One nurse can be care giving 20 patients 3\4 of which are diverted from ER not so far. In such situations the doctors -including me- work as nurses in order to help.
    so dont be soare from upset. Doctors are from Mars too or may be Earth.


  • P. K.
    P. K.

    March 24, 2010 at 7:19 pm

    Typical Cerebral Flatulence episode from the chronically under-worked. One other way of looking at this TWIT, is to remember that in the long run it is a case of NURSES saving doctors’ butts and therefore the patient. I’m sure that at some time you and the others cover some of his work, usually trivial but possibly time consuming. Stop doing this for a while and suddenly this calm relaxed alien will suddenly find that he is running himself ragged, or at least not getting any break time. Then he can see your contribution to his peace of mind.


  • Joey
    Joey

    August 18, 2012 at 2:24 pm

    Kim,

    Thanks for another great post & insight for the rest of us into the intracacies of hospital management. I was 80% sure I was going to in MHA (eventually backed out but making hospital care more efficient still appeals @ a very core level). From my experiences as a patient however, I can see how the higher up you get (not to mention the doctor, but the hospital administrators), the more disassociated you get from the realities on the hospital floor. I assume it is the same thing with a corporation: all you see are labor costs as a number you want to minimize but you don’t necessarily see how extra time spent into customer service results in better customer retention (in this case, patient retention, goodwill toward the you, the doctor, and hence the hospital etc). I alluded to this in my comment to your post about how “care” is not accounted for in the economics of healthcare, but I imagine that if there were accurate third-party evaluators of patient satisfaction w/specific providers, then doctors & nurses would be closer to the same page. What do you think?


About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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