Starting With Curious

By his own admission, it took Arnold Relman, former editor of the New England Journal of Medicine, until age 90 to realize the importance of nurses in providing quality medical care. It took me until a week after starting my internship.  My first rotation was on 3 Orange, the unit for medically complex children (including many ex-preemies).  In many ways, medical school had not prepared me well for residency.  I had never ordered feeds for a healthy baby, much less one with a 27-item problem list.  My first night on call, covering the entire team, I was asked to order a refill on a medication for someone else’s patient.  I checked my sign out list and wrote (with a pen, on paper) the order; 10 minutes later, the nurse paged me to double check whether that was really what I wanted to order.  It wasn’t: I had mistakenly ordered a soundalike medication, at a dose that would have been harmful if administered.  Embarrassed, I returned to the unit to correct the order.  I made some comment about making a rookie mistake.  The nurse just smiled and said, “It won’t be the last, but don’t worry because we’re all looking out for each other.”

Relman, after being hospitalized for 10 weeks after a fall, wrote a column for the New York Review of Books about his experience, in which he said, “I had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled.  This is a lesson all physicians and hospital administrators should learn.  When nursing is not optimal, patient care is never good.”

Amen. Over the years, I (and my colleagues) have been bailed out by nurses on occasions too numerous to count.  Mostly not because they caught errors – though in the era before computerized order management that was certainly important.  It’s the subtle change in a child’s behavior pattern that made the nurse call me to re-evaluate a patient who was developing hepatic encephalopathy.  It’s the funny movement that the consultant dismissed, which turned out to be decorticate posturing in a post-craniotomy patient.  It’s the question about why I selected a particular test that made me think through and decide on a different one that was just as good but less traumatic for the patient.  It’s putting a teenager with perplexing symptoms in a room and commenting, “She’s acting just like the aspirin ingestions we used to see,” arriving at the correct diagnosis hours before the physicians.  It’s the insight about family dynamics that allowed me to address concerns I might never have identified on my own.  The list is long.

It’s impossible to overstate my gratitude for all that the many nurses I have worked with over the years have done for our patients. Their job is intellectually, physically, and emotionally challenging, with rewards that are hardly commensurate with the demands.  And I also appreciate what they have done for me: for my education, my professional development, and my job satisfaction.  We share food on the night shift, we laugh and cry together, we brag about and complain about our families, we encourage each other, we look out for each other.  Those interactions, those shared experiences, illustrate what Join Together and Be Remarkable really mean.  Nurses are the embodiment of the Children’s Way.

No doubt Dr. Aziza, my pediatrician as a kid, was a nice man. But my main memory of him, 50 years later, is of having a tantrum and having to be dragged into his office when I realized I was going to get a shot.  Seriously, I still have a vivid recollection of my terror of that needle. (My mom probably does, too.)  I used to think it was me, that I was particularly fearful of sharp objects and pain.  But I now know that this is actually pretty normal.  What we healthcare providers like to call “iatrogenic pain,” which is a typically obscure way of saying “pain caused by us,” is a significant problem in pediatrics.  Even the youngest infants not only have a predictable negative physiologic response to things like needle sticks, but they have lasting effects as well, including aversion to subsequent healthcare encounters and behavioral distress. In other words, when providers do nasty things to kids – and needle sticks for immunizations and blood draws are the most common nasty thing we do – kids get scarred by it and act out.  (Sound familiar, mom?)

Fortunately, awareness of this problem is growing, and many people are doing something about it.  I am proud to note that Children’s Minnesota has developed what we call the “Comfort Promise.”  This is a commitment to offer all children and families at least one of several evidence-based interventions to minimize the pain of needle sticks when they come to our hospital or clinics.  These interventions include topical numbing medicine, positioning, and behavioral soothing measures.  For young infants, sugar water is also offered.

It does take a little extra time and effort for staff.  But when surveyed, children and families said needle pokes were the most unpleasant part of coming to the hospital. So living up to our values “Listen, Really Listen,” and “Kids First,” in the past couple of years we’ve managed to do this for over 90% of patients in the hospital, and we are now spreading it out to the outpatient clinics.

Now if only we could do something about those nasty swabs to test for strep throat….