Category Archives: Personal Thoughts and Experiences

Advertisements

The Autopsy – a Dying Recommendation

In recent decades, there has been a marked drop in autopsy requests – an unfortunate occurrence. In the distant past, any death within the first 24 hours of admission triggered an autopsy. Any unexplained death in or out of the hospital; any accidental death with questionable etiology required an autopsy. JCAHO required 20% of hospital deaths to undergo autopsy as part of hospital accreditation; that requirement ended in the mid 70’s.

One objection to autopsy comes from families and we can well understand their reluctance. The loss is acute and painful; the thought of mutilating a loved one overrides the practical need to identify the cause of death.

In my review of medical records, an autopsy trumps any postulation by a treating physician. Why? Because when a patient is gravely ill, they often have a number of morbid conditions, any one of which could be fatal. A physician has the natural tendency to see the cause of death from the perspective of their specialty.

Virtually useless is the Death Certificate. Death certificates do not provide root cause, only an end result. Respiratory or cardiac arrest is inevitable in death, but those diagnoses provide no etiology; they cannot address the “why” of death.
If an employee dies in the course of work, has an MI, stroke or other “illness death”, an autopsy can offer the evidence needed in an otherwise uphill battle for causation.

In negligence or malpractice death claims an autopsy is invaluable, but all too often the family’s last concern is dissecting the cause. When questions later arise, that most valuable source of information – the patient and their true cause of death – is irretrievably lost.

From a public safety perspective, we can only speculate on the number of infectious diseases, chemical exposures and related information that may be lost.

Regardless of JCAHO recommendations, it is incumbent upon healthcare professionals to offer this option when the cause of death is not crystal clear. “Natural causes” is the most frustrating and misleading nomenclature in the healthcare dictionary.

The Changing Face of Body Language

As the daughter of an Army Drill Sergeant, I grew up around Fort Jackson, SC. We shopped at the PX, attended the Roman Catholic church on base, bought 29 cent gasoline and went to the movies for a quarter. But the place I seemed to spend most of my time was in the outpatient infirmary. I remember the wooden structures that were meant to be temporary when first constructed, the highly polished wooden flooring and ramps, the “shot” room where I received more than my share of Pen V for recurrent pneumonia and tonsillitis…many decades later it still feels like yesterday.

My most vivid memory though, is the nurses. All wore Army issue 100% cotton uniforms, starched and white, with sharp caps and polished shoes. From my vantage point, I could see little beyond large bosoms in sharp Playtex bras that preceded them into the room like the prow of a ship.  They terrified me. I remember hiding behind the medicine refrigerator when I knew a shot was imminent.

These nurses were tough, and a pediatric department was nonexistent. No lollipops for good behavior (and I would not have earned one in any event). I was expected to behave like a small soldier.

Many of these women had served overseas and their pride was evident in their bearing as they marched down the polished hallways, shoulders back and snapping salutes from the brow of their stern faces. They were subordinate only to God and outranking physicians. The distinction between the two was not always clear but my inferior position was never in doubt. My mom was also a nurse, and I secretly thought she identified with them more than me, her youngest national treasure. Of one thing I was certain; I would never become a nurse.

So much for that resolution. I too grew up to wear polished shoes and cap for graduation, but the hospital I worked for had a wonderful pediatric floor. Body language had changed.  I wore child-friendly smocks, tossed the cap after I kept losing it in the nebulizer tents, and there was a rocker in every room. No scary nurses allowed. Gently approaching children instead of pinning them down like feral cats was a solution the military had never conceived. Sheltering in mom’s embrace for injections took away some of the sting, and parents were calmed by having their own hands held after a particularly hard night.

When I transferred to ICU, body language was equally if not more central to the care of adults. They scrutinized our faces for indication of bad news as did their families. Amidst their lines, wires and tubing, they were vulnerable. Their spirits were buoyed by unhurried baths and clean bedding. Their families were less apprehensive when their loved ones looked well-cared for, and sometimes they needed a hug. They wanted to know we cared and that we would be there when the call light was not on, and that our shift ended when the work was done and not before.

In the latter 70s and early 80s, you did not wear gloves to start IVs, give baths, take vital signs or draw blood. Gloves were only required for trach and wound care, suctioning, Foley insertions, continent care and when isolation demanded it. Although today’s MRSA-resistant hospital environment demands protection for staff and patients, those gloves also communicate “unclean” to patients who crave human contact. Now more than ever, smiles and reassuring body language are indispensable to good patient care.

And honestly, who needs frown lines?

Do I Have Your Attention?

I don’t know – do you have mine?

I was strolling through Costco a few days ago (if I miss a week the staff become anxious) when I overheard a young man speaking at a moderate volume into his earphone. He was speaking, but he was not listening. He was providing IT support to a client who either could not follow his instructions or was utilizing a wholly different program than the one under discussion.

I am not an eavesdropper, usually, but it was clear that he was shopping for groceries and envisioning a computer screen concurrently, and not doing either effectively. He repeatedly misinterpreted the problem and provided incorrect troubleshooting. He resembled many IT technicians who have stolen hours of my life without resolving my problem.

How do you know if you have someone’s attention, and are you also guilty of not listening effectively?

Here a few telltale and annoying signs of inattention on the other end of the phone:
• Papers rustling in the background – either the person is going through their mail, lost an important document or has vermin on their desk
• The conversation is one-sided but for the occasional “mm hmm” that passes for “I hear you”
• The same information is requested more than once
• You clearly hear the clatter of a keyboard that is not in sync with the conversation

Most of us can multitask to some extent, but none of us can anticipate the critical points in a conversation that require our full attention. If you miss that key sentence and find yourself fumbling to catch up, you have dropped the ball. Concentrate on the caller, or ask if you can call them back (the attorney, the expert, your mother). No one likes to repeat themselves.

The Words We Choose

A nurse’s comment on last week’s blog prompted this week’s content. She asked me how an attorney could be impressed by her writing style if she had never submitted a report for his review. The reality is that others form opinions of us with the first contact that occurs, whether that is through verbal or written communication.

One of the hardest things to write is an introductory email to a potential referral source. What do we say to catch someone’s attention? How do we present ourselves in a positive fashion and highlight our strongest features? No matter how highly we value our services or believe in ourselves, the person we need to impress has his or her own priority. And it is not us.

Attorneys are no different from anyone else; their own needs take precedence. Ideally, your email to a potential referral source arrives in their inbox at the exact same moment they need what you have to offer. If your expertise is not needed, your offer of service may go unnoticed.

If your email includes a link to a site/article/story relevant to the attorney’s practice area, it may marinate in his Inbox like an electronic Postit, but that is far preferable to being ignored, or even worse, deleted. These are surefire ways to have your email deleted or ignored:

  • Writing a novella about your background
  • Failing to research his practice, so you offer him medmal services when he only does product liability
  • Describing yourself in superlatives or absolutes
  • Using poor grammar, misspelling words or otherwise appearing less intelligent than you really are
  • Saying the same thing everyone else does (like listing all the 40 skills you have that will make his practice run smoother, give him more time, make him more money and win him cases.

Keep that first email short, pointed, and professional; this says you respect his time. Making it longer will not ensure a response and might land you in the Trash no matter how well it is written. 

Grammar & Composition 101

I have read a number of first time reports sent to me for review by new LNCs. In the strictest sense, all of these reports were accurate representations of fact. In the literary sense, some were disasters.

When you compose a consultative report for an attorney, assume your reader is someone with no medical knowledge of the disease/injury/event/terminology. This is not true but it will help you write more clearly and avoid the use of medical abbreviations that are clear to healthcare personnel and no one else.

Many attorneys, particularly those who specialize in niche areas, are quite well informed about their client’s condition. Others make it their business to spend an inordinate amount of time researching the event around which their case revolves. Since most are quite bright, they can understand how a surgery should have proceeded, whether or not a delayed diagnosis made a difference in outcome or why the ER screening for pulmonary embolus might cause harm to a patient in the throes of pulmonary edema.

But no matter how well informed, they probably do not know why elevated BNP with CP radiating to the LUE might be a sign of STEMI. Nor should they have to. We walk the fine line between not talking down to our attorney while not assuming an unrealistic level of knowledge.

The point I am getting to (finally) is that no matter how skilled a nurse is in her medical charting, that skill does not enhance report composition and in fact, gets in the way of effective report writing. Your report may be the only contact some attorney clients ever have because they are out of state. I work with one attorney whose father was the editor for a national newspaper for 40 years. He avoided using LNCs “because they couldn’t write worth a damn” the few times he had worked with them. Regardless of their knowledge base, he could not respect professionals who had no knowledge of basic grammar and composition.

I’ll talk about how to let your fingers do the talking next week…and maybe the next few weeks after that…

Sleep is good. Work is good. Working without sleep…not so good

Sleep and work. We spend more time doing these two activities than anything else in life.

The need for a good night’s sleep is evident in the number of medications, therapies and sleep aids that promulgate the market. But we do not need advertising to tell us what we already know – a bad night’s sleep makes us miserable the next day, less efficient, moody and irritable. No sleep at all makes us dangerous at the wheel and to our patients.

For years I saw medical and surgical residents come through my ICU, sleep deprived, complete with bed-head and stumbling gait, reaching for a cup of coffee to jolt their nervous system. I never understood how being on call for 24-36 hours was a good thing for anyone but the attendings who were getting a good night’s sleep. It certainly wasn’t necessary to prepare students for being in private practice, and it occasionally put patients’ welfare in danger.

I could relate. I alternated between (3) shifts every two weeks. The coveted morning shift was bustling with activity, diagnostic studies, lab draws, ventilator weaning, PT, OT, breakfast and lunch. No way was I falling asleep on that shift. The afternoon shift was quieter, family more present, bedside and surgical procedures occurring when they could not wait until the next day, but never scheduled for 8pm. It was a time, with any luck, of relative respite for patients and staff.

But those night shifts. I well remember charting at 5am, standing up because I was trying to stay alert and literally sleeping on my feet. The circadian rhythm of my brain was not attuned to working at night. I could not sleep during the day for more than two hours, and felt like a zombie the rest of the time. Oh yes – I fell asleep at the morning wheel on more than one occasion. Thank goodness for that part of the brain that never truly sleeps.

“The stream of information (to the brain during sleep) is considerably reduced, but the brain is not fully disconnected from the environment. An inspection of the environment takes place to optimize safety during sleep. Stimuli…signaling danger are recognized, and may enter awareness, leading to a wake-up call, which allows the individual to react. This subconscious stimulus evaluation is regarded as having a guardian function for sleep.”

It’s no wonder that we spend so much time thinking about our work and worrying about our sleep. When either or both are out of balance, we are miserable and unable to enjoy everything that happens between these two activities – like family and friends, recreation and exercise.

Bones grow during sleep, brains recharge, and unless we have nightmares, a good night’s sleep cures many ills. Let sleeping dogs lie. Sleeping like a baby. Shhh! the baby (nurse, patient, doctor) is sleeping.