Thursday, July 05, 2007

Geez, what a dumb nurse.

Make sure you read this post to the end before you make any quick judgments!

I was in the emergency department this week shadowing a doctor, and I was surprised when an older nurse came up to the doctor and said,

"I don't usually have trouble putting in catheters, but I have no idea why putting one in this guy is so difficult. Could you help us out?"

When I looked over at the patient she was pointing at, I gasped. How the heck could the nurse be that stupid?

I had to interrupt. Looking her right in those dim-witted beady little eyes, I said, "Excuse me, but are you trying to be funny?"

The patient was a 67-year-old male who had come in with a chief complaint of "I can't pee because my prostate is flaring up again."

No kidding you're going to have a hard time putting a catheter in, and what do you mean you don't know why?! The guy's got BPH (Benign Prostatic Hyperplasia). When the prostate has swelled up to the size of an softball, seeing as how the urethra runs right through it, of course it's going to pinch that urethra right shut. Especially when the internal zone of the prostate is the part that increases in size due to BPH.

I mean, come on - how could the nurse be that stupid?! I'm a flippin' first-year medical student and I know this basic stuff; she's been on the wards for decades and you're telling me you're clueless? Haven't you seen how big an enlarged prostate can get on gross pathology?

Okay, I'll stop this little anecdote right here and tell the truth - this didn't actually happen. I've never called anyone "dumb" and meant it, and don't intend to start now.

But it might have, had I not read what Kim at Emergiblog wrote after seeing BodyWorlds 3. (yeah I'm bringing up Kim again! can you tell I've found a new blog I love?) Don't forget, this is being written by a nurse of 28 years:

"I’m sure my mouth was open through the entire exhibit. There was so much I did not know or had forgotten over the years. I knew what was there, it was the proportions that astounded me.

  • The only thing standing between us and paralysis is a thin cord of nerves about 1/2 inch wide - the spinal cord. It seemed very fragile when viewed in a display of the nervous system, from brain to periphery.

  • The kidneys are so tiny - and now I understand in three dimensions where they lie in the body. I know why a 3 mm kidney stone causes so much agony as it travels down a ureter with a diameter of 1 mm. The spleen was smaller than I thought it was!

  • The uterus, which looms so large in my imagination, is extremely small. All those period cramps come from that tiny sac? Holy cow! The ovaries? Smaller than walnuts - my daughter’s dermoid cysts were larger than the ovaries they inhabited!

  • Sciatica? Well, that explains it!

  • I not only know about COPD, I saw COPD!

  • Cardiac tamponade? I see how it compresses the heart!

  • Smoking? Take a look at the two lungs that look solid black. You’ll never smoke again.

  • I saw why I can’t pass a catheter through an enlarged prostate."

End quote.

I'll be honest with you, and you'll see where that fable I told might have come from. After reading that list, my first thoughts were:

"Are you kidding me? You didn't know the spinal cord was 1/2" thick? You didn't know that smoking turns your lungs black?? I wouldn't have been surprised by ANYTHING on that list, and I'm just finished my first year! She's been a nurse for 28 years and STILL doesn't know all that stuff?!"

I suddenly looked up from my computer screen and felt a rush of shame come over me. I realized that if I had said that out loud, it would have no doubt come across as a jackass thing to say. The next thing in a rant like that could reasonably have been something like, "Geez, she is SUCH an idiot!"

How could I have thought something so rude? Me, of all people! After all my posts on interdisciplinarity and treating nurses with respect, after saying that I love and will always respect nurses because some of my good friends and my mom are nurses, and after pumping that same nurse who wrote that just this week, after having the purest and most idealistic of intentions, here I am pretty much bashing nurses already!

Then, I remembered something.

"That's right! I always knew that the nurses I went to undergrad with never really got the chance to work on cadavers and take pathology like I did."

And that's what I had been missing. Until now, I had never made the connection that unless you have taken pathology, or held a human kidney in your hand, it's actually pretty hard to visualize what an enlarged prostate looks like, or how thin the spinal cord is, or how small the kidneys actually are.

If I hadn't made that realization here, today, perhaps the little scenario I made up at the start of this post actually could have happened in a couple years when I'm on the wards.

I'm no better or smarter than Kim is. In fact, put me in a hospital or in front of a board exam right now and I bet you anything that Kim would answer more questions correctly and save more patient's lives than I would, after all those years of clinical experience under her belt. But already, after one year of classes, I was thinking thoughts that if spoken, could easily be interpereted as superiority, or simply being a jackass.

Yes, some doctors are assholes to nurses just because they think they can get away with it, because they have their own issues to deal with, because they're just assholes, or maybe because since orders have always been called "orders" they think it's okay to actually "order" other health professionals around. And after being through a year of medical school, I can almost sympathize with a doctor who stands up for him or herself and comes across as being a jerk, because after being through those first-year finals -- the most intense, trying time of my life -- I have a lot more confidence in myself, and quite frankly, after four years of this, I won't take crap from anybody.

But perhaps some of the barriers between professions aren't for any of those reasons. Perhaps some doctors come across as being jerks even if they try hard not to. Perhaps sometimes it's just because of simple misunderstandings.

Not because of a superiority complex, not because somebody thinks they're better than someone else, but because they just never took the time to stop and think about how differently we have been trained, and how our professions are designed to look at the same problem from different directions. And that's where the strength, the untapped gold mine of interdisciplinarity, comes from.

Yeah, I'm still fresh and new and idealistic, perhaps, but hopefully I can keep stopping myself whenever I think ignorant thoughts like that, and hopefully I'll continue to challenge myself to treat everyone with the respect they deserve. After all my good intentions of being kind to nurses, and then seeing my initial reaction to Kim's comments, clearly good intentions aren't all that it takes.

Thanks, Kim, for letting me pick on you without so much as asking, and I hope that this hasn't discouraged you from writing out your true feelings in the future, even though it it might make you vulnerable to ignorance people like me. I really do admire your writing.

Ever since Kim was kind enough to post this at Change of Shift (Grand Rounds of the Nursing blogworld, from my interpretation) I've noticed a lot of readers who have come from there. Those who want to read more about the difference between how doctors and nurses approach patients might want to take a look at the evil resident's take on this issue.


Anonymous said...

Pick away!!! No offense taken! My anatomy class was soooo long ago and my knowledge came from two dimensional textbooks.

What was so amazing to me was that when I thought of BPH, I knew the result of it, but had never seen a prostate! I knew lungs turned black, but I never saw two large chunks of charcoal hovering over a heart before.

When I pictured kidneys, they were always much larger in my mind, as were ureters.

Never in my mind would I have pictured the spinal cord as such a fragile piece of tissue.

I once said that I should go back and take anatomy and physiology now that I was old enough and experienced enough to appreciate it! Pathophysiology, too.

I tell you, that Body Worlds exhibit was THE most amazing thing I've ever seen! : )

Anonymous said...

can't wait to start anatomy, although will be kinda strange seeing/cutting up a dead person for the first time...

Anonymous said...

I am also a big proponent of respect between the medical professions. But based on my experience right now, I have to say that not all the blame for the rocky relationship lies with doctors. There are are RNs, NPs, and PAs who are very bitter about having to work with residents and medical students, and they can take it out on you, no question. It's a two-way street.

Anonymous said...

That's very true. A good friend of mine who is a nurse was telling me all about an R1 who didn't know the dosing for narcan and had to look it up. She thought this was a pretty big deal and that the R1 was totally clueless. I told her that there is a big difference between the "knowledge" we learn in med school and the practical application of that knowledge... which is why we have residencies! Granted, hopefully this stuff is being introduced in 3rd and 4th year, but it usually takes some time for everything to stick. I told her that this year, for example, we learned about antiarrhythmics. We learned about the classes, which ion channels they affect, which phase of the action potential they influence, what the indications and contraindications are, and what the pharmacokinetics and pharmacodynamics are. BUT... how much to give? No idea! That's the theoretical vs. the practical. I guess if we all had a little more patience with each other, a little more respect for the knowledge and experience that exist, and a little more acknowledgement and honesty in admitting what we DON'T know, we could go a long way to promoting better interdisciplinary relationships.

Anonymous said...

Good for you! You're observing yourself with the same objective, critical eye you're taught to use in diagnosis. I hope you never lose that knack for observing yourself. Communicating what you find is icing on the cake.

Anonymous said...

Nursing school must be changing. I had to take really in-depth anatomy and physiology classes (and now even MORE in-depth pathophysiology classes). Anyway, I hope the medical professions learn to play more nicely together; otherwise patients lose. :(

ERnursey said...

Thanks for remembering that we are all health care professionals and all bring our strengths to the table. If we all would remember to treat each other professionally and with respect it would go a long way.

anonymousRN said...

What is shown in anatomy textbooks is nothing like reality. Unfortunately my nursing program had a crappy anatomy class. (Not Nurse Ratched is lucky I think!) We watched videos, put together a plastic skeleton and looked at plastic limbs. Because our school was not associated with a med school we did not get the option to take a gross anatomy course like at other schools. Our pathophysiology class was even more of a gloss over. It all depends on where you go.
I loved seeing BodyWorlds for the same reason as Kim. I loved being able to walk around the people(?) and actually see the muscles, bones, organs and everything... everything I had heard and read about right in front of me! :)

Anonymous said...

Oh, vitum. Even after 4 years of med school, you still won't know anything. Not until you get into residency will you start to have a glimmering hope, and even when you're an attending on staff for 20 years, I hope you still admit to knowing very little. Be humble or someone will come along and humble you. ;)

Anonymous said...

I am adding this blog to my night shift reading. I loved the insight.

Anonymous said...

I was a little offended by your comment/story about the nurse. It seems to me you made up a story to make nurses look stupid? A little unfair. I am studying nursing at the moment, i chose to. I could have done med but decided i didnt want that kind of life long committment to one speciality. Nurses do amazing things for people, as do doctors and both make mistakes equally often and are often equally intelligent so ease up. Medical proffesionals can only get on if both are willing to accept the others knowledge and try to cut eachother some slack when things go wrong. Thats not to say you wont find bad nurses but there are some pretty average doctors out there.

Vitum Medicinus said...

Thank you for your comment Anonymous - hopefully you read the entire post as I asked a the top of the post. It wasn't my intention to make nurses look stupid - I was hoping the second-last paragraph would show that the first part of the story (meant to shock, of course!) is not how I actually view nurses!

Anonymous said...

I'm sorry but the real idiot here is the physician who ordered a foley for a patient with an enlarged prostate without first consulting urology.

Anonymous said...

A friend, who has had extensive experience with medical treatment for his family at both smaller and major hospitals, said to me just this evening that it seems like the more competent the doctor, the nicer the doctor is. The arrogant doctors gave the worst care. An interesting observation.


Suzanne said...

So interesting & encouraging to read. I believe you learn far more from mistakes,(or I would rather say those "ooops.... almost! errors".)Also from the honest or noticed errors of others, shich can be discussed or reflected on. Hence the Reporting line, tends to be anonymous, & I believe aids in collecting far more honest data....which will be directed to assisting In preventing errors.
Thankyou for your Blog.
Anonymous old nurse who has often felt inferior due to the lacks of, easily understanding difficult & unseen scenarious.