Who Changed the Rules?
Inspired by Lessons of the Cards
Reflecting on the never-ending changes in healthcare makes it easy to take a dim view of the current situation and perhaps even indulge in a bit of nostalgia for the “olden days!” Perhaps you remember those days—those days before electronic medical records (EMR) when a healthcare professional could simply jot a few notes on a flow sheet and handwrite a bit about the patient?
Recently, after being an invited guest physician to China, my cousin reminded me of the “chart” our family doctor maintained on each his patients in the 1960s. A single line contained the date, diagnosis, and treatment administered. During his trip, my cousin once again saw this simplicity as each patient carried their own small black book in which their Chinese doctor jotted down this info.
Monumental strides are currently being taken in China to embrace Western medicine. Yet I wonder if this is best for their nation and what the cost will be to traditional Chinese medicine? Is the EMR providing more or less in human interaction, continuity of care, or enhancing trust?
As we reflect on changes in healthcare and healthcare practice, although not always easy or comfortable; they have certainly brought us a long way. In the early ’70s, nurses were taught how to sharpen and reuse a hypodermic needle “just in case” the newly acquired single use syringes were out of stock! A colleague remembers adding a small morphine tablet to a syringe, drawing up a specified amount of normal saline, swirling to ensure all particles were dissolved, doing complex math for age/weight/dose, discarding the extra and finally administering this concoction by injection to her patient.
When I was a new graduate with a baccalaureate of science in nursing (BSN), I was assigned as a night charge nurse on a medical-surgical unit in a large hospital. Our unit had 26 post-surgical patients. The team consisted of a Licensed Vocational Nurse who gave injectable and oral pain medication as needed. There were two nurse aids who assisted with patient care. We cared for some very sick folks. At that time, cholecystectomy or gallbladder patients were in the hospital a minimum of five days following surgery. They had Jackson-Pratt drains coming from their large incisions and were in a great deal of pain.
Our practice was to put paper tape on the glass intravenous (IV) bottles. We drew lines on the paper tape to indicate the amount of fluid to infuse per hour. Then we visually counted the drops in fifteen-second increments, multiplied by four and determined if the rate equaled cc/hr. There were no inline devices to monitor or slow gravity feed; only a roller thumb clamp. The nurse aids were our lifeline. They would tell us which patients were ahead or behind on their IV fluids. My colleagues remember being convinced that we gave our patients great care. Yet, understanding current nurse-to-patient ratios whereby a nurse only cares for two to five patients makes me fearful that perhaps we left many things undone.
Another time I remember finishing a night shift, handing the keys to the narcotic drawer to the oncoming charge nurse, driving home, and crawling into my warm bed. The shrill tone of the phone broke my reverie. It was the day charge nurse calling to ask what time I had hung the liter bottle for the patient in room 6 bed A. I responded that I had hung it just prior to shift report at 0630. She gasped: “Well it’s 8 o’clock, and it’s empty!”
Most of us have probably experienced that sinking feeling when something unexpected happens and suddenly our careers and everything we’ve worked hard for just blasts us in the gut. My mind whirled with the ramifications of fluid overload. Did I just do harm? Did I put this patient into congestive heart failure or worse?
The day charge nurse and I discussed how the patient had been asleep when I changed IV bottles. Apparently, he had stretched his arm for comfort thereby changing the venous flow and suddenly gravity worked exceptionally well. Together the day nurse and I reviewed the chart of a 27-year-old male, excellent health, no cardiac conditions, in hospital for broken femur—all good news. The charge nurse called the physician to report the potential problem. The patient was monitored without negative outcome. Whew!
Where’s the Wildcards?
That had been a terrifying day, but other incidents made me as happy as being dealt a joker! The day we got the microdrip inline controller which metered a drop for every cc/hour--that was a godsend. The advent of the metriset in which to put our antibiotics, admixed by the RN and titrated to ensure the compatibility and flow of fluids. And, finally the day came when I was introduced to the new IV pumps our hospital was purchasing. That pump included a library of medications and appropriate dosing based on patient weight and normal parameters, presets for rates, and an alarm for every conceivable incident—it even had a KVO (keep vein open) feature that would never let the “IV run dry!” I nearly jumped with joy. While nostalgia has its moments, change has its benefits.
Many improvements in healthcare delivery, tools of the trade, and improved methods have given healthcare workers and their patients tremendous advantages. My husband recently had a cholecystectomy (gallbladder removal) in the morning, took a walk in the evening, and went to work the next day! I thought: Well, if ever I have a serious illness, this decade certainly offers hope. Together, we have made amazing strides in so many areas of healthcare.
Much of the rule changing in healthcare has been brought about by a deeper understanding of what we all can do to create more positive, safe outcomes for our patients and their families. So, while understanding how to play our hand requires patience and consideration on our part; playing by the rules benefits everyone.
As with the deck of cards, the one constant in healthcare—that has never—nor will ever change is the patients themselves. Like the 52 cards, two colors, and four suits of constancy; patients are no different than they were 25 or 50 years ago. Most Americans have been raised to be self-sufficient, to not need others, and to go it on their own. In addition, Americans, except for those trained in healthcare, have limited understanding of their own health and the way their bodies function.
There are several reasons why. First, our educational system has had a limited focus on health. Though this could be changing with grammar schools starting to focus on nutrition, health classes typically have been taught when children are in middle school. Unfortunately, that’s also a time when preteens find their bodies doing strange and unusual things. Too shy to ask questions, many students pretend to understand everything, especially when it comes to their bodies. Some teachers are as uncomfortable with this topic as their students! So, unless a person chooses the health field as a career, general education doesn’t effectively prepare them for important long-term health decisions.
An “Oh, Wow!” moment happens when we realize that most people treat their bodies like some people play Black Jack! Knowing we need to get to 21 to win, we gamble that the dealer will bust, and the house will lose. Putting our money down, we place our bets on the table. Then we cross our fingers and hope the dealer gives us winning cards.
Professional players understand many nuances of the game. They know their options. After seeing the first round of cards, professionals decide to hold, split, take a hit, or double down. Some pros are experts at managing the odds by counting cards or casing the deck.
However, most folks are not professionals. We don’t take the time to learn the nuances of the game. Instead we hope someone with more skill will mention when to hold, fold, or split. The novice hasn’t learned the strategies that lead to winning. They may simply quit after getting a little ahead, then move over to the slot machines. It’s easier there.
The slots used to be called “one-arm bandits” because at least one arm got a little exercise. Now, all it takes is one finger to poke the button.
Most adults think about their health in pretty much the same way. We don’t want to worry about our bodies and learn what makes them function well. Rather we eat, drink, and exercise without thinking about consequences. All with the hopes that we’ll be winners.
Over the years, healthcare providers have had minimal impact on the challenges of gaining support with patient self-accountability. We struggle to impress upon our patients the reasons why they should make lifestyle changes. An illness can truly be a “wakeup call”—a brief window of opportunity in which to make decisions to do things differently. However, most of our patients want a pill or potion to do the hard work for them. If we’re honest, many of us are like our patients! Most people resist making changes or putting in the hard work necessary to form a new habit.
When illness or injury strikes, perhaps for the very first-time, people start to realize they are not in control of their body, much less their future. Suddenly, they face a situation they cannot “fix!” So, these individuals come to the healthcare community—in fear, anger or silence! They come, trusting that we will do our best for them.
If you enjoyed reading this please leave a comment below! Check out my new book Lessons of the Cards, available on www.HazelCurtis.com and Amazon