of the siteAn ICU nurse attacks Dr. Pezzi; Dr. Pezzi responds
Q: I find your comments regarding the satisfaction of ER nursing versus ER medicine to be truly disturbing. It is understood within the nursing profession that the public image of our profession is largely inaccurate. While nursing and nurses in general certainly remain within the public view, little attention is given to the actual role played by nurses in the healthcare system. In addition, the media only serves to exacerbate the problem, portraying nursing in subservient roles with no regard for the broad scope of practice which nursing is accountable for, or the broad knowledge base necessary to support this broad scope of practice.
What is surprising is to find a colleague with whom we work so closely that has such little understanding of the role played by nurses. Furthermore, while you proclaim to have the highest respect for the profession of nursing, you continue to refer to nursing and nurses in a demeaning and patronizing manner. I find this attitude to be prevalent within a number of your responses and certainly have no desire to read further posts that continue to address nursing in a negative and inaccurate manner.
You discuss the idea that the practice of medicine is more rewarding than nursing, noting that you feel the practice of medicine is more stressful and demanding. You go on to discuss the role of physicians in diagnosing and prescribing which is beyond the scope of nursing practice, and talk about nursing roles in a manner that does not begin to encompass the true scope of nursing practice. For example, you discuss nursing responsibility as either carrying out the actions that have been decided by others or carrying out such tasks as emptying urinals or making beds.
You note that there are many more nurses caring for a set number of patients than physicians discussing how this equates to more stress on the doctor as opposed to the nurse. While I agree that in relation to medical decisions the "buck does stop with the doctor," and this is a significant amount of responsibility, the greater number of nurses required to care for a set number of patients does not equate to less responsibility on an individual nurse. We are not taking a proportionately equal amount of responsibility between nurses and physicians and then dividing the nurse's responsibility between more people, rather nursing responsibilities are more time intensive. You mention often being the only MD in the department. While I am sure you could certainly use the help of more MDs, nurses are similarly understaffed and to try to deliver basic care with only one, two or three nurses would be impossible.
How some people mistakenly view nurses
I work in an intensive care unit where I often will spend multiple hours without leaving a patients room. Some patients are so sick that I might not leave the room for an entire shift. My responsibilities in this setting certainly require that I be able to interpret lab data and other tests in the context of the patient's condition in order to respond appropriately. I might spend all shift titrating pressors to maintain perfusion, titrating sedation to allow for adequate ventilation, monitoring blood gasses and working with RT to adjust vent settings to optimize ventilation. In addition to this, we are giving blood products, fluid boluses, other meds, and continuously monitoring the patient's responses to these treatments. Furthermore, the patient's basic care must be met, we must reposition the patient and monitor for complications such as skin breakdown, and we must manage nutrition, rotate the ETT, change the dressings and educate the family about the disease process. How is the family coping? Do they understand the information explained by the physicians? We must support the family and provide them with information so that they can make life and death decisions for their family members. All of this, while in the course of a 12-hour shift, the physician will see the patient on rounds and perhaps one more time. Nurses play a key role in performing in-depth assessments with a high level of skill and seeking appropriate treatment when necessary. Furthermore, just because a medication is ordered by a physician and is filled by a pharmacist does not make that medication safe to give. Perhaps the patient's condition has changed, or this medication is not compatible with another that the patient is receiving. The nurse is responsible for his or her own actions. In terms of medication administration, the "buck stops with the nurse." We have all seen inappropriately ordered medications for various reasons. How many times has a nurse saved your license?
This is only a very vague and general example of the responsibility and scope of practice of nursing in one setting. Certainly nursing roles in such settings as intensive care and the emergency room are very collaborative with nursing and medicine being highly interdependent. The function of a true team depends on the interdependence of members with each member being accountable and responsible. Certainly, the public image of nursing must be addressed, but how can we expect the public to understand our profession when those colleagues with whom we work side by side do not understand it? I urge you to re-evaluate your perceptions of my chosen profession.
Sincerely,
Jack, RN
Answer by Kevin Pezzi, MD: If only all nurses were like you, Jack! You are obviously intelligent and likely assiduous, whereas some of the nurses with whom I worked had a dearth of intelligence and a constellation of personality flaws that made them truly dangerous to patients. For example, did you read about the nurse who repeatedly touched items on my sterile surgical field without wearing gloves? First, there was no need for that imbecile to be in the room with me while I repaired a laceration; I certainly never requested his assistance, nor would he leave when I requested that. Second, after I told him to stop touching anything in the sterile field, he argued with me that what he was doing was OK! Touching sterile items with unwashed, ungloved hands is OK? Where? On Mars? He claimed that he was helping me rearrange the instruments. No thanks, I told him, I have the instruments arranged just as I want them, and I certainly didn't want them contaminated. But would he stop? No. He did it repeatedly on various occasions. I would turn around, and there he was, contaminating yet another sterile field. Nuts.
I could not understand how nursing schools could graduate people that idiotic, but a recent experience gave me some insight. Some doctors at our local hospital have been complaining about the poor communication skills of various nurses, so I tried to help by volunteering to teach English proficiency to nursing students. (And you thought that all doctors did was complain!) I was shocked by what I discovered. In my estimation, about 20% of the students were smart enough to be a registered nurse (RN), 30% should have been in the LPN program, and the other half were so lacking in intelligence that it was frightening! I discussed this with a friend of mine, an RN, who is an instructor at that school. After reading their essays, we both wondered if half the class was brain-damaged. However, my friend was equally alarmed by how pugnacious, rude, and insulting many of her students were. What engenders such truculence? Are students watching Grey's Anatomy and thinking that the residents’ contentious and disrespectful behavior is acceptable? When I was in medical school, I cannot recall any student who was insolent. We did not necessarily like all of our professors, but we admired and respected their brilliance.
In medicine, there is a tacit understanding that brilliance can compensate for a lack of social skills, but many of my nursing students, and many of my friend's nursing students, had neither social skills nor brilliance. For example, our students made errors that elementary school students should not make, such as repeatedly confusing "seam" with "seem" or "aloud" with "allowed." Their punctuation, grammar, and general manner of expression were equally pathetic. Some of the students improved as the semester progressed, but the inveterate stragglers made so many recurrent errors that I wondered if they were capable of learning at all. One of my friend's students sent an e-mail to the school administration complaining that her instructor (my friend) could not see what a wonderful writer she was! This student claimed that prior instructors were so impressed by her writing that her papers were used as models worthy of emulation. I almost fell off my chair in disbelief when I read the remonstrations of that student because her e-mail was riddled with several errors, including grammar, spelling, and overall sentence structure—thus manifesting that her English skills were indeed exiguous .
My goal in teaching my students was not to turn them into Shakespeares, but to hone their basic communication skills so they rose to a professionally acceptable level. As they were, in this next-to-last English class before graduation, half of the students were writing at an unsatisfactory level. Imagine that you read a note written by a nurse caring for you or a loved one, and this note was so poorly worded that it made you question if she had the intelligence to be a nurse. Wouldn't that note reflect poorly on nursing in general and that hospital in particular? If a person whose native language is English is so bewildered by basic English, is she truly intelligent enough to learn the more challenging aspects of nursing? I'm skeptical. On second thought, there is no need to be so namby-pamby. I don't question whether half of the students had the brains to be nurses, because I KNOW THEY DID NOT!
The nursing school's administration was also alarmed by the students’ inept English usage and militant behavior, but they did not want to flunk them (my recommendation) because they were afraid of being sued, as they had been by past students in similar circumstances. Thus, they felt the path of least resistance was to let them graduate, and foist their incompetence upon subsequent employers, patients, and co-workers . . . perhaps even a hapless ER doc who might wonder how nursing schools could graduate such morons! If you think that "moron" is too pejorative, perhaps you could suggest a more apt adjective that might explain why someone with an RN after his name can repeatedly and intentionally contaminate a sterile field, or why someone who will soon be a nurse writes like an elementary school student in dire need of remedial education. Seam, seem, aloud, and allowed are not “big words.” They are commonly used words that every child should be able to differentiate. After seeing them used in context 100,000 times or more before college, if someone still cannot correctly use them because their little brain cells never lit up and realized the obvious semantic differences, then that person is clearly too stupid to be a nurse and master things far more challenging, such as the liver’s cytochrome P450 system that is responsible for metabolizing drugs and chemicals. Since nurses are generally the ones administering or withholding drugs, as you noted, don’t you agree that patients would be safer if nurses understood hepatic P450 metabolism, including enzyme induction and suppression? I've yet to find a nurse who understood the P450 system. What is the chance that the dimwits who cannot distinguish aloud from allowed could comprehend P450 metabolism? Zero!
Want another example? Weeks after graduating from her 2-year school—that is, just two years out of high school!—a GN (not yet an RN) handed me an EKG that she just took on a patient. I glanced at it, told her that she had incorrectly positioned some of the leads, explained which were switched, and told her that it needed to be repeated with the correct lead positioning. She refused, insisting that she had positioned the leads correctly.
This nurse is too smart to contaminate a
sterile field, unlike the dingbat I worked with.
Now who is more qualified to judge that? A GN who is still wet behind the ears, or an experienced ER doctor? Now imagine that you are a member of the public, or perhaps a hospital administrator or board member. Do you want petulant nurses working for you wasting valuable time in a busy emergency department throwing such temper-tantrums? "I positioned the leads correctly, so I won't repeat the EKG. I won't, I won't, I won't!" I cannot recall exactly how much time I wasted with that nurse trying to get her to repeat the EKG. Whether it was 5 minutes or 15 minutes, it was just that much less time I had for other patients. Insubordination and refusing to follow orders are punishable crimes in the military, but nursing schools are somehow graduating nurses with a permanent case of PMS and room-temperature IQs who think nothing of arguing with doctors even when those nurses are absolutely, unequivocally, 100% dead wrong. And believe me, Jack, when nurses waste the doctor’s time in a busy ER or intentionally stick their frigging dirty fingers on a sterile field, I mean DEAD wrong.
You seem to be an intelligent fellow, Jack, so perhaps you could explain to my readers what is more objectionable: inept, truculent nurses, or writing about them? Doesn't the public have a right to know that not all nurses are good nurses? By the way, don't give me the lame response that all doctors aren't good doctors. Of course they aren't! However, there is a quantum leap between the intelligence and education of an average doctor versus an average nurse. Don't believe me? Try to find one doctor in the United States whose native language is English who writes at the level of half of my nursing students! I'm waiting . . . .
My girlfriend is a cardiology nurse with a master's degree at a hospital that claims to be one of the top "heart hospitals" in the nation, but what she knows about cardiology is much less than what I know. Go outside the realm of her specialty into other fields of medicine, and the knowledge gap is even wider. Yet when we met, she admitted that she "hated doctors" because they seemed to be arrogant people who didn't know much more than she did. Countless medical discussions later, she now says that she understands how doctors think, why they do what they do, and how their knowledge increment vis-à-vis nurses is anything but trivial. I've also gained insight into nurses, and this reinforced my opinion that far too many nurses are unhappy and professionally burned out with "bad attitudes," as my friend would say. She also says that all but one of her many nursing co-workers are "embittered, backstabbing people who take it out on each other." Her words, not mine. While many of her colleagues "know the basics," she said that she would not trust them working on a family member. And this is at a supposedly topnotch hospital! This hospital routinely pats itself on the back by paying for TV commercials in which it claims to provide nursing care in the top 3% of the nation. Yeah, right.
If you dug into my www.ERbook.net site a little deeper, you may have run across my story about one of the best ER nurses I ever knew. He had about 20 years of ER experience and was in charge of the night shift. On one uncharacteristically slow night, he approached me and asked if he could "play doctor": take a history, examine the patient, generate a differential diagnosis, order tests, x-rays, EKGs (and interpret them), order treatment, decide upon a final diagnosis and disposition—you know, do what ER doctors normally do. Since this was a slow night and I could supervise him, I gave him the OK to proceed. He looked flustered and stumbled on very basic ER cases that he had seen ER docs handle with aplomb thousands of times. When you watch someone do something, it is often deceptively easy to convince yourself that the activity is easier than it looks and that it'd be a piece of cake for you. I felt bad for this man because, from the hurt look on his face, it was clear he knew he had stumbled. He told me later that playing the role of a doctor had long been one of his dreams, and the dream did not turn out as he imagined it would. Had he obtained the same training as me, he could have been a topnotch ER doc. He had a high IQ, but not the training. Now consider one of my bird-brained nursing students. Could they fill the shoes of a doctor? It's laughable!
The best nurses I've known could have been good doctors if they obtained the requisite training. Most nurses could not hack medical school, and—as I witnessed—some cannot even hack nursing school; they graduate only because schools are cowered by the threat of a lawsuit. The nurses who know me well know that I respect good nurses and loathe bad nurses. I don't think the nursing profession is doing an adequate job policing itself. If they are, what is their excuse for the execrable ER nursing behavior that I discussed above? And what is their excuse for accepting (and graduating) nursing students who seem to have room-temperature IQs? Remember, it wasn't just me who was alarmed by how stupid those nursing students were; that sentiment was echoed by my nursing friend who once was staunchly pro-nurse and anti-doctor.
Frankly, I cannot understand nurses like you who object when I target your bad apples. Are they sacrosanct? Are you trying to delude the public into thinking that all nurses are well-qualified? You may be smart, but I doubt that you are smart enough to justify your position. Your first message failed to do that. As a smart ICU nurse, you are as representative of the average nurse as Miss Sweden is representative of the average woman. The average nurse does not have the same level of autonomy as you do, but even you must know that most of that autonomy stems from standing orders that give you direction. Otherwise, you would be practicing medicine without a license.
Speaking of that reminds me of some of the brash things my nursing students wrote, talking about how they would diagnose and treat patients in the future—apparently forgetting that associate's degree nurses are not legally qualified to do that. Interestingly, it was usually the real dumbbells in my class who evinced an intellectual arrogance about what they would do after graduating. They would make a diagnosis and propose treatments to patients, even ones with life-threatening problems. Excuse me, but isn't that within the province of medicine, not nursing?
You are not the first nurse to write to me objecting to my opinion that ER medicine is potentially more rewarding and satisfying than ER nursing. Sheesh, how easily peeved you are! Wouldn't it be great if everyone felt that their job was the most rewarding and satisfying one? Of course! Furthermore, I gave some justification for that opinion. If you want to sway my opinion, address the substantive merits of what I wrote in support of that conviction.
In conclusion, you sanctimoniously wrote, "I urge you to re-evaluate your perceptions of my chosen profession." I went into medicine with a uniformly positive opinion of nurses. My viewpoint was subsequently molded by what I witnessed nurses doing in the real world. I saw some wonderful nurses, many middling ones, and far more incompetent buffoons than I should have seen. Didn't you notice that I never criticized the superior nurses or even the average ones, unless they made a grievous error? It was the turkeys that I put in my sights! Yet this alarms you? Care to explain why?
We've had several incidents at our local hospital when nurses and nursing students have maimed and killed patients. All of their errors have one common denominator: inattention to detail. This is why I am alarmed by reading papers written by nursing students that have over a dozen errors per page, and many of those mistakes were made week after week in spite of the fact that I repeatedly corrected them! The thousands of errors I saw were not all rooted in ignorance; many of them reflected an “I don’t give a hoot” sloppiness that telegraphed their apathetic contempt for attention to detail. Would you want these bozos working on you or your child?
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The criteria for passing that nursing class were ridiculously lax. If one of their papers was unsatisfactory, they could revise it and resubmit it. I corrected their errors on the first paper, so it was easy for students to ensure that their revised papers were acceptable: all they had to do was to copy those corrections! What's next? Multiple choice exams that can be retaken after the instructor marks the correct answer? It's the same thing, and it is an academic farce!
You missed a major point: I am not a nurse, and I have no responsibility to toe the party line and give the public a whitewashed, sanitized depiction of the nursing profession. The raison d'être of my ER sites are primarily to paint an accurate picture of ER medicine to help people decide if that profession is the right one for them. To that end, I discuss the pros and cons of emergency medicine, and one of those cons is working with bad nurses who don’t know much but love to argue. What possible good could result from ignoring this subject?
My experience with the nursing students was not uniformly bad, however. After the semester ended, some students thanked my friend and me for being so hard on them because we taught them far more than other instructors had. We also had other students say that they wished they'd had us as instructors because they would have learned more. Think back and recall who your favorite instructors were. Were they the "just give me my paycheck and pension" types who didn't really give a hoot if your work was half-ass? Or were your favorite instructors the ones who challenged you to do more than you ever thought was possible? I think that everyone who goes into a healthcare profession should strive for excellence, but I witnessed that too many nurses don't have the same zest for excellence that I do. The totalitarian nursing PR machine, of which you seem to be a part, rails against docs who lampoon bad nurses. Tell me, why does that bother you?
I think what really galls you is that I do not respect all nurses. How could I? How can I respect nurses who intentionally contaminate sterile fields because of their stupidity or maliciousness? How can I respect nurses who injure patients because of inattention to detail? How can I respect sophomoric new nurses whose arrogance compelled them to argue with me about basic EKG findings? Considering that I have never met an experienced ER nurse who could completely read an EKG like a doctor would, what kind of ego does it take for a 20-year-old graduate nurse to throw a fit when I told her that the EKG was performed incorrectly? Don't argue, embryo, just do it!
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In your haste to judge me, you overlooked the fact that I have a viable plan for helping the nursing profession attract candidates who are more qualified, increase their pay, decrease their workloads, and achieve greater overall job satisfaction and career longevity. So, yes, I admit it: I loathe bad nurses, but that is not the same thing as saying that I loathe good nurses or nursing in general. Nursing is a great profession, and I would like to help make it better. Unlike many people who just talk about doing something, I actually did, volunteering my time even though I have 1001 other things to do.
I really do not want to teach English to nursing students; I would rather teach more advanced topics that could help them become outstanding nurses. Frankly, it frustrates me that the time I could have spent teaching those things was instead spent teaching remedial English.
Incidentally, my friend the nursing instructor quit her job after her first semester, citing many reasons, including a fear that two of her students would slash her car tires. Those thugs will soon become nurses, and if they argue with an ER doc about an EKG some day . . . well, it would not surprise me.
Update: Some of those students later graduated and began working at the local hospital. My nursing instructor friend overheard an experienced nurse grumbling about two of those new graduates, calling them "stupid and snotty." Yup.
Update #2: A few months later, one of the students, now working as a nurse on the cardiology floor, wrote a report in which she misspelled dementia twice, calling it "dimentia." One of the older nurses read the report and commented to my friend sitting nearby, "Oh, isn't that cute? She can't even spell!" She then went on to lament how nurses like that tarnish the reputation of the nursing profession and make doctors wonder about their level of intelligence when "Med/Nursing 101" words are misspelled repeatedly—indicating that the error wasn't a simple mental mistake, but instead an indication that the nurse is so dimwitted that she actually thinks dementia is spelled "dimentia."
Proof that I am not "anti-nurse"
More proof that I am not "anti-nurse"
Another nurse who objects when I say that medicine is potentially more rewarding than nursing
