Saturday, April 17, 2010

When Nursing Is a Team Sport -

Day shift had just started and a patient down the hall was having a
problem. I asked the nurse, Lisa, what was going on.

Jeff Swensen for The New York Times Theresa Brown, R.N.
"Not my patient," she said hurriedly as she carried a portable
defibrillator into the room, helping out until the patient's nurse
got there. One of the doctors shouted a question, and the nurse
quickly looked it up on the computer. The patient had a low magnesium
level and was experiencing P.V.C.'s, or premature ventricular
contractions, irregular heart beats that on their own are usually
harmless but can lead to dangerous cardiac arrhythmias when magnesium
levels drop.

I jumped in and called the pharmacy. Soon, the pharmacist arrived and
tossed me the bag of I.V. magnesium, which I quick walked down the
hall and gave to Mary, the patient's nurse. The doctor was in the
room by now and approved the magnesium order. I waited to see if I
was needed for anything else. "I think we're good," Mary said,
hanging the drug.

In his new book "The Checklist Manifesto: How to Get Things Right,"
Dr. Atul Gawande argues that health care has evolved to be much more
of a team, rather than an individual, effort. In fact, the book is as
much about the importance of teamwork as it is about checklists, and
he explains near the end, "In a world in which success now requires
large enterprises, teams of clinicians, high-risk technologies, and
knowledge that outstrips any one person's abilities, individual
autonomy hardly seems the ideal we should aim for."

He's completely right about how inpatient care is now provided. In
teaching hospitals, every patient's care is managed by a medical team
that can include doctors-in-training, nurse practitioners, physician
assistants, attending M.D.'s and doctors from other medical
specialties. Every team also includes the patient's nurse, who tries
to coordinate the work of the team members. Ancillary staff who often
go unremarked are also members of the team: pharmacists, occupational
and physical therapists, behavioral medicine specialists, social
workers, dietary experts and respiratory therapists. And often,
doctors, nurses and other workers who aren't assigned to the patient
must jump in when needed.

At the end of shift that day, we needed a team effort once again. I
was talking over the morning's events with Mary when a family member
of one of my new patients came to ask for help. "She's having trouble
breathing," the family member said.

This patient had only one lung and was already on oxygen, so hearing
that she was having a hard time breathing was worrisome. I hopped off
my chair and at the same time Mary sprang into action to help me.

I headed into the patient's room while Mary hurried to the nurses'
station, calling, "I'll grab a pulse-ox," the small machines we have
that check blood-oxygen levels.

In the room I learned that, in an effort to be kind, her family
members had removed her oxygen equipment so that she could put on a
nightgown she especially liked. I understood their impulse, but in
that situation it just wasn't a good idea. "How about we get her
stable and then worry about the nightgown," I gently suggested, and
they all agreed.

I put the oxygen back on the patient, and Mary brought me a pulse-ox
machine. As the patient breathed in, her oxygen level increased, but
she was still struggling.

"What about breathing treatments?" Mary asked. She left the room to
page a respiratory therapist who could administer a bronchodilator, a
drug that would open the lung passages, making breathing easier.

The respiratory therapist showed up, and we discussed the patient's
climbing heart rate, which was now much too fast. The drug usually
prescribed in a situation like this could have caused it to increase
even more, so the therapist chose a different drug. After it was
administered, another nurse, Sara, checked in to see if she was
needed. By then the patient's breathing was no longer labored, her
oxygen level was normal and her heart rate had not gone up. Relieved,
I told Sara we were fine.

In some ways it was a hard day — the action was virtually nonstop and
stressful as we focused on crisis situations that put our patients at
risk. But the truth is, I loved that day at work because we met the
ideal. Working as a team may be the model, but in reality we often
fall short. People are stressed or tired, egos get in the way,
someone needs to be two places at once and can't be, opinions about
the best course of action differ aggressively.

But on that rare day I got to bask in the feeling of all of us
working together, without conceit and without rancor, to do what we
strive every day to do best: take care of all our patients.