FEAR OF GETTING OLDER (FOGO)

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FOGO

 

It isn’t often that I applaud a drug company. In fact, I can’t remember if I ever have.

Here’s to Pfizer for creating an initiative to stimulate dialogue about getting older, which was described in the New York Times business section this past Wednesday (Elliott, Stuart. Pfizer to Inject Youth Into the Aging Process. The New York Times, 16 July 2014: B9. Print).

Pfizer has set up a website, getold.com, with links to Facebook and Twitter. The main audience is those in their 20s and 30s. Topics revolve around the affirmative aspects of aging, like “Why sex can be better when you’re older” and a story of 90-year-old who runs marathons. Okay, I admit a bit sensational but the emphasis is on the positive.

I only hope Pfizer’s effort to portray the elderly in a flattering light will help diminish ageism which is so prevalent in our society.

Thank you Pfizer.

I challenge you to take the FOGO quiz.

I HAD A DREAM

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Mercury Sphygmomanometer

 

In preparation for moving I discover the darndest things as I unpack dusty boxes stored in the attic untouched for years. This time it’s a mercury sphygmomanometer, packed in its original carton along with a “limited warranty” card that should have been filled out within ten days of purchase. Looks like I didn’t even open the box but put the blood pressure machine away for the day I would open my independent practice.

 

That would have been in the early 80s after I became a gerontological NP

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after I worked in Chicago with inner city, underserved elderly

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after I became frustrated with the lack of resources and left to become an administrator of an HMO

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after I knew I didn’t want to be in administration

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after going back to work as a nurse practitioner once again

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after moving to three different states

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after finally retiring from nursing . . .

I forgot my dream.

Do You Ever Hold Your Patient’s Hand?

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Marianna Crane:

I have found a nurse, Amanda Anderson, who is telling the public (via her blog: This Nurse Wonders) what nurses do. She is writing about her job, her observations, her feelings and the environment that nurses function in day-to-day.
She is writing her nursing stories.
I applaud her.

Originally posted on This Nurse Wonders:

photo

At work the other day, I witnessed something small that has taken up a big part of my thoughts since.

Some point in the shift, the phone rang, and I answered to a voice asking for the dialysis nurse. Common occurrence, as nurses come to the unit to dialyze patients regularly, and often nephrologists or other dialysis nurses call to give them orders or requests.

The dialysis nurse in request was one I’d observed before, though never worked directly with. I had already painted her in my mind as old, union-centric, and jaded. Once, I listened quietly as she talked loudly to another nurse about contract negotiations and the unfairness of nursing. To be short, I expected little from her; a burnt deadbeat.

But when I went to the room where she dialyzed a patient, I saw something that shamed my quickly-laced assumptions right out of me. There she sat, in…

View original 309 more words

THE HEALTH WAGON

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In the last post I wrote about Sandeep Jauhar’s essay in the New York Times, Nurses Are Not Doctors. Dr. Jauhar doesn’t condone independent nurse practitioner practice and he suggests that in order to expand the number of primary care physicians their salaries should be increased.

Somehow that last statement has hounded me. Not so much for the obvious reason that excessive physician salaries drive up health care costs but because I wouldn’t want my primary provider’s impetus to be money versus a genuine concern for his/her patients.

Okay, my reasoning is rather black or white. But I invite you to watch the 60 Minutes episode, The Health Wagon (try to ignore the Viagra ad). You will come away with an appreciation of the work nurse practitioners do to address the unmet health care needs in our country. Clearly they are not motivated by money. (The NPs practice in Virginia and can “diagnose illness, write prescriptions and order tests and x-rays”)

If you wish to bypass the video, visit The Truth About Nursing to read an overview of the program. Plus this is a great blog to follow if you want to keep up with nursing issues.

NURSES DON’T WANT TO BE DOCTORS

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For the life of me I don’t know why the New York Times published Sandeep Jauhar’s essay, “Nurses Are Not Doctors,” in the Opinion Pages on April 30, 2014. His essay argued that nurse practitioners shouldn’t practice independently.

As a nurse practitioner it’s obvious that I wouldn’t agree with his opinion but his case was lame. He cited only one study, which was published in 1999. It showed that primary care patients seen by nurse practitioners had 25 percent more specialty visits and 41 percent more hospital admissions than those seen by physicians. Not only was the study dated, it was limited in scope. Come on Sandeep Jauhar. Come on New York Times.

Jauhar further suggested we need more primary care physicians (true) and his solution to encourage graduates to go into primary practice rather than specialize was to increase salaries. Read Shikha Dalmia’s article in Forbes, August 26, 2009: The Evil-Mongering of the American Medical Association, in which she discusses the effects of excessive physician salaries and the historical basis for the physician shortage, which only shows how ludicrous Jauhar’s suggestions were.

Finally, he concluded that nurse practitioners are essential but only “as a part of a physician-led team.”

Angered by the slanted and self-serving article with a title that I had hoped never to view again in my lifetime, and the fact that I thought this essay so beneath the New York Times to print, I wrote a Letter to Editor:

As a retired nurse practitioner, I am disturbed by Sandeep Jauhar’s Op-Ed piece: Nurses Are Not Doctors (April 30). Over the years doctors have criticized nurse practitioners’ practice. “If they want to be doctors, let them go to medical school” has been the American Medical Association’s mantra in spite of the fact nurse practitioners have never claimed that they wanted to be doctors.

What disturbs me is Dr. Jauhar’s focus on limiting NP practice at a time when our health care system has been shown to be inadequate. US life expectancy at birth, 71 years, is ranked 35th. Slovenia ranks 33rd.   (WHO, 2013)We need to look at models where physicians, nurses, nurse practitioners, physician assistants and other health care workers can contribute their collective skills to deliver superior health services to all Americans. Rather than propose primary-care doctors get paid more and be designated the leader of the team, I would suggest he, along with the AMA, encourage the expansion of collaborative practice with the end result being accessible, cost effective and appropriate health care for all.

My letter didn’t get published. However, the ones that did and were supportive of nurse practitioners were authored by those more credentialed than I. They made excellent points in debunking Jauhar’s disparaging comments. And the 852 comments on line appearing over the next 17 days, until the comment section was closed, tipped in support of NP’s. (I didn’t check all 852 but did a sampling of the responses.)

Finally, let’s accept the fact that nurses are not doctors and don’t want to be and further agree to allow NP’s to practice “to the full extent of their education and training.”

Now let’s see if the New York Times publishes an essay from a nurse practitioner’s point of view.

Storytelling for Policy Advocacy

Marianna Crane:

Josephine Ensign takes nursing stories to a higher level–to promote policy advocacy. Read on–

Originally posted on Josephine Ensign's "Medical Margins" Blog:

PoppyStoryTime When I tell people that my work focuses on narrative advocacy, they mostly look at me funny and ask, “What’s that?” It is a more concise way of saying ‘storytelling for policy advocacy.’

A common definition of narrative is a story with a teller, a listener, a time course, a plot, and a point. Storytelling is as old as campfires and cave-dwelling. (The photo here is of my father telling Appalachian ‘Tall Tale’ stories to his grandchildren). Storytelling is how we learn about our world, about ethical living, about history, about ourselves. Within the healthcare arena patients and family members tell their stories to nurses and doctors and other members of the healthcare team. It is still a truism that something between 80-90% of the information needed to make a correct medical or nursing diagnosis comes from the patient’s history, from their story.

Storytelling and story-listening are not only important…

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INVISIBLE Part 3 of 3

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I trudged into the nursing station. The phone sat on an empty desk. Mary, the stocky, dark-haired charge nurse, faced the chart rack at the other end of the room. I avoided acknowledging her presence, keeping my eyes on the floor. Any word from her might shake my resolve. I stood by the desk and picked up the receiver with a trembling hand. I dialed the operator. When she answered I said, “Please page Doctor J. I’ll hold.”

From the corner of my eye, I watched Mary’s head bend in my direction as she leafed though one of the patient records. My body jerked when I heard a gruff voice say, “Dr. J here.”

I took a long breath and plunged in. “I’m Marianna Crane, one of the staff nurses on 2 West. You just left your patient, Ms. O, telling her she could go home today.” My heart drummed so loud in my ears that I barely heard the words coming out of my mouth. “I just want you to know that her lungs sound full of fluid. She has a productive cough, two plus pedal edema and is having problems urinating. I obtained 300 cc’s when I cathed her.” I gulped and raced on. “I don’t think she’s ready for discharge.”

Even though I had only glanced at his large frame as he exited Ms. O’s hospital room, I visualized his face turning crimson with anger at the audacity of a nurse questioning his judgment. An ominous silence planted itself at the other the end of the phone. The fact that my words couldn’t be taken back set my skin on fire. Was he still on the line? Finally, his voice pounded into my ear: “I’ll send the resident up to check her.” Click.

I stood with the phone pressed to my head. Then the realization hit. He had listened to me. I had accomplished what I wanted. I didn’t feel elated as much as relieved. Ms. O would get the work-up she needed. I hung up the phone.

Mary turned to face me. “Wow,” she said.

“The resident will come up to check on Ms. O,” I told her. I didn’t plan to stick around to discuss what had just happened. I marched out of the nurses’ station and up and down the hall twice until my heart no longer galloped. I barely talked to Ms. O while I gave her a bed bath. I feared I would blurt out that I had initiated a course of action that might delay her discharge.

While I was taking care of my other patients, the resident sauntered into her room and later an attendant whisked her down to radiology. I left before Ms. O returned to the floor. Before she received a diuretic to get rid of the fluid in her legs and lungs. Before the insertion of a Foley catheter to keep her bladder draining. And before the discharge order was cancelled.

When I returned to work three days later, Ms. O, dressed in a polyester pantsuit, sat at the side of the bed finishing her breakfast. She had taken the time to rouge her cheeks and apply a rosy lipstick. She smiled in recognition when she saw me. “I’m going home today,” she said with a chuckle that didn’t this time produce a paroxysm of coughing. She took the last bite of sausage and drained her coffee cup. Pushing the empty tray away, she shimmied off the bed on trim ankles. Her step, although slow, was steady. She settled into the wheelchair.

I pushed Ms. O through the hospital exit. The summer sun had yet to heat up the asphalt parking lot. A cab waited at the curb. I held her arm as she carefully stepped out of the wheelchair. She tried to press a couple of dollar bills in my palm. “Oh no.” I said, “Nurses are not allowed to take tips.” I stressed the word nurse.

To Ms. O I was just another hospital worker. As far as I knew, she had never asked why the resident appeared, examined her and delayed her discharge. She was unaware of my concern or the part I, a nurse, played in her recovery. And why would she know? I never told her. And surely her doctor hadn’t.

 

INVISIBLE Part 2 of 3

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“When did you urinate last?”

Ms. O looked at me blankly.

“I’m going to press over your bladder,” I said. I reached under the hospital gown and pushed over her pubic area. My fingers felt a soft swelling. Ms. O winced. “I think you’d feel better if I passed a tube into your bladder and got rid of the urine.” I didn’t need a doctor’s order for a straight catheterization—in and out. Ms. O nodded her head.

Back in her room with the supplies, I raised Ms. O’s bed so I wouldn’t have to bend over, draped her with a sheet and placed the catheterization tray between her spread legs. My hands, encased in sterile gloves, guided the thin, rubber tube into Ms. O’s urethra. Dark amber urine flowed from the catheter into the specimen container.

As the last of the urine trickled out of the tube, Ms. O sighed and said, “That’s such a relief.”

“Let me get rid of this,” I said as I gathered up the soiled equipment. “Be right back.”

In the dirty utility room, I sorted out the recyclable parts from the cath tray and tossed the disposable items. I measured the amount of urine before flushing it down the toilet. I tried to sort out what to do about Ms. O. What could be going on with her? She could have congestive heart failure, pneumonia or some other illness that would get worse without treatment. And no one would be home to notice her deterioration. She might become so weak that she could fall, maybe break a hip and then lie on the floor for days—be found dead. If she were lucky, a neighbor would find her in time and call an ambulance. If Ms. O survived hip surgery, she might not recover fully and off to a nursing home she would go.

I leaned against the cool tile wall. What was Ms. O’s doctor thinking? How could he have known Ms. O was retaining fluid? He ran in and out so quickly? Had he even bothered to listen to her lungs? Ms. O needed to stay in the hospital for a work-up to find out what was wrong and treat the problem. She shouldn’t go home until she was well enough to care for herself. What should I do?

Since I was employed as a staff nurse and reported to the nursing department, I should inform Mary, the charge nurse of my findings. She would go up the chain of command, relating my concerns to the nursing supervisor. The nursing supervisor would contact Ms. O’s doctor. What if the doctor dismissed my concerns? Would the nursing supervisor back down and let Ms. O to be discharged?

I could always bypass nursing altogether and call the doctor myself. Surely there was nothing wrong in that. I would report my findings and let him decide what needed to be done. That way it wouldn’t seem as if I was telling the doctor what to do.

With this decision made, the tightness in the back of my neck relaxed. I returned to Ms. O’s room. “Close your eyes and rest for a while.” I told her. I dimmed the lights and left the door slightly ajar.

Heading towards the nursing station to make the phone call, I reflected that hospitals had not changed that much since I graduated in 1962. Long corridors with patient rooms on either side, dirty and clean utility rooms and a nursing station at the end of the hall. What had changed was nursing education. I had attended a three-year nursing diploma program in New Jersey run by the Grey Nuns. Formally known as The Order of Sisters of Charity of Montreal, they “trained” me along with forty-three other females in my class to be subservient to physicians, all males at that time. When a doctor sauntered into the classroom to teach, we stood up, chanting in unison: “Good Morning, Doctor.” In the hospital, I would rise from my chair if a doctor entered the nursing station. Besides enforcing nightly curfew, weekly dorm room checks, and pressing us to attend daily mass, the nuns sent an implicit message: never question a doctor’s authority.

My first job after graduation was at a large inner-city medical center. I can only imagine how surprised—and maybe delighted—the physician felt when I stood as he lumbered into the small lounge off the nursing station. He happened to be a resident not much older than I. After he left, the other staff nurses encircled me. Never stand for a physician.

In the mid 70s I returned to college for a baccalaureate in nursing. An innovative professor at the university, who started her own home health agency, had quite an impact on our large group of mostly seasoned nurses. “Nurses see the whole patient, not just the disease entity,” she said. “You don’t exist just to follow doctor’s orders, After all, nurses spend more time with the patient than doctors do. You must serve as the patient’s advocate.”

We were also primed by the women’s rights movement to take responsibility for our practice, to challenge the blind authority of doctors and hospital bureaucrats. At that time I worked in a small branch of a Health Maintenance Organization (HMO) near my suburban home. Spurred on by my professor I asked the administrator if we nurses could schedule our own patients for education and monitoring. “I believe we could resolve patients’ problems and reduce visits,” I told him.

He agreed. We negotiated a fee of five dollars for a nursing appointment since this was an extra service not covered by the HMO. One middle-aged obese, diabetic schoolteacher came to see me every two weeks for a half-hour visit. I suggested she pack a lunch to avoid the school cafeteria and take evening walks with her husband. She lost weight and so did her husband. Eventually, her diabetic medication was discontinued. The experience of having patients make an appointment to see me, and their willingness to pay for the visit, prompted me to become a nurse practitioner. So there I was back in school again. One year done and one to go before I would graduate and be eligible to sit for the NP certification exam.

Now, thinking about my desire for autonomy and independence, I realized I was about to fall into old habits. How in the world could I permit the doctor to interpret my information and make his own decision? There was no way around it. I had to give this doctor a clear message: Ms. O shouldn’t be discharged. At the thought of confronting him, my neck felt like an icy hand was gripping it. I slowed my usual brisk gait as if by dawdling I could put off making this call. I knew I had no choice.

INVISIBLE Part 1 of 3

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“Invisible,” by Marianna Crane, originally appeared in the Examined Life Journal.

 

 

The cardinal rule of the game is that open disagreement between the players must be avoided at all costs. Thus, the nurse must communicate her recommendations (to the physician) without appearing to be making a recommendation statement. – – – The greater the significance of the recommendation, the more subtly the game must be played.

- 1967, Leonard I. Stein, M.D.

 

 

I left my patient, Ms. O, dozing in her hospital bed. Heading towards the nursing station, I clenched and unclenched my fists, steeling myself to make a call I didn’t want to make.

When I first ambled into Ms. O’s private room that morning, she was sitting up in bed with a breakfast tray in front of her. Her knobby fingers put down a half eaten slice of toast. The eggs and sausage were untouched.

“I’m done. I just want to keep the coffee.” I removed the tray and slid it onto the food cart standing in the hallway. Back in the room, I noticed a stale, musty odor. Sunlight filtered through the only window highlighting Ms. O’s greasy and matted hair. “How about washing up?” I said.

Ms. O’s pale face lit up with a smile. “I’d just love a shower.”

“Sure. Finish your coffee while I get the linens.”

It was the summer of 1980. I had just completed the first year of a two-year master’s degree program in nursing. I had taken this part-time job, working a couple of days a week, in a small community hospital near my home. When classes started back up, I figured, I would juggle being a full-time student with doing what I loved—caring for patients.

Outside of Ms. O’s room, my arms laden with sheets, towels and a hospital gown, I was aware of a tall man as he breezed by me, his copious belly encased in a dark suit. Over his shoulder he shouted back into Ms. O’s room, “See you in my office next week.”

“My doctor just told me I’m going home today,” Ms. O said, as I unfolded the fresh towels. Her chuckle, which trickled up her throat, exploded into a racking cough. When the episode was over, she sank back into her pillow, breathing deeply. Had her doctor heard that cough? He couldn’t have been in her room more than a minute or two.

“Are you okay?” I asked. The night nurse had recorded that Ms. O slept well and hadn’t indicated any problems. Ms. O gave me half a smile but didn’t speak.

“Well,” I said, “let’s get you up, showered and dressed.”

Pushing off the covers, Ms. O inched her legs toward the edge of the bed until they dangled over the side. Her bony hand pulled on my arm as she swiveled to a sitting position. This effort set off another coughing fit. What’s going on here?“ How long have you had that cough?”

“A couple of days. Seems to have gotten worse.”

Bending down, I pressed the skin over her thick ankle. My finger left a half-moon print on her leg.

“Do you usually have swelling in your legs?”

Ms. O glanced down. “No.”

“Who will be home with you?”

“I live alone.”

Something wasn’t right. I pulled out my Littmann stethoscope, a gift to myself after successfully completing the last class of the semester: physical assessment. In that course, my fellow nurse practitioner students and I learned how to take a patient’s history. We used each other to hone our diagnostic skills: we probed bellies with our fingers, placed stethoscopes over lungs, and tapped elbows and knees with a rubber hammer. We hadn’t practiced on patients yet. Instead, we listened to tapes in the computer lab of heart valves leaking, lungs wheezing and large intestines gurgling.

“I want listen to your lungs.” With my hand on Ms. O’s shoulder, I nudged her forward and placed my stethoscope on her scrawny back. What filled my ears were not the same clear blowing reverberations of my classmates’ young, disease-free air passages. What was I hearing? Rales? Rhonchi? Wheezing? The names of abnormal sounds jumbled in my head. “Cough, please,” I said, trying to sound like I had done this for years. We had learned that semester that coughing would clear mucus from airways, resulting in normal breath sounds. After coughing, Ms. O’s lungs were still waterlogged. I straightened up and pocketed my stethoscope.

Ms. O interrupted my thoughts. “I need to go to the bathroom.”

I didn’t like the pasty color of her face or the way her chest rose and fell with each breath. Better she stayed in bed. “Let me get you a bedpan.”

After helping her lie back, I raised her hips and slipped a blue plastic bedpan under her bottom. When I retrieved the bedpan a few minutes later, it was empty.

THERE ARE SOME PATIENTS WE NEVER FORGET

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01/29/2012 BY MARIANNA CRANE

When you have been a nurse as long as I have there are patients who take residence in your memories and resurface frequently. They could almost be family except they have a short history in your life. What they were like before or after you knew them usually remains a mystery.

Mr. G was a cantankerous, legally blind, brittle diabetic I had taken care of in the late 80’s. His house was the worst on the block: paint peeling off the frame, rickety wooden stairs and overgrown weeds. Thankfully he lived close to the police station because I had to drive there one day when Mr. G didn’t answer the door. He was convulsing on the floor as I peered through the window. I had to beg the police to break down the basement door to enter because Mr. G often complained to me how many times they had axed into the front door and how expensive it was to repair. He frequently had hypoglycemic reactions.

Mr. G. gave himself insulin injections using low vision equipment to measure out the dose. His much younger wife worked full time, leaving him lunch, usually a sandwich, piece of fruit and a drink on the dining room table. He had confided in me that he thought she was having an affair with her boss. Having an active imagination (I’m a writer aren’t I?), I wondered if his wife was trying to kill him. Maybe the house, inside and out, was in deliberate disarray leading to a potential life-threatening accident. I don’t remember the other scenarios I entertained as I drove to and from his home.

When I left my job to move to another state, my friend, co-worker and fellow nurse practitioner, Jane Van De Velde, took over his care. He died on her watch. She recently emailed me with remembrances about him.

“But I really remember his memorial service. It was so touching, all the people who attended and spoke so highly of him. I was literally brought to tears. I got up and spoke about how wonderful it was to see another side of someone–the strong, healthy, community-involved and well-respected side. We saw him at end of life when he was so very ill and depressed and visually impaired.”

Jane adds, “There are some patients we never forget.”

Amen

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