Category Archives: Personal Thoughts and Experiences

The Phenomenon of Memory

Repeatedly, we reviewers of medical records note distortions between immediate recall of an injury and successive changes in the description of said event.

Some perceive this as malingering, or at best, an attempt to inflate the value of a legitimate injury.

While exaggeration can be used for financial gain, the phenomenon of false memories is common to us all. Equally, a traumatic memory may be suppressed and forgotten, only to arise unexpectedly when the proper cueing occurs. This is seen with true Posttraumatic Stress Disorder. A patient burned at work functions well at home and around town, until driving past the place of their injury. Memories flood and incapacitate them.

When my children share memories of their childhood, they most vividly recall the negative events that stand out as an aberration. This would be more palatable if they equally recalled the care and love we had shown them on a regular basis, but it is not so. Daily and expected comfort and support, sadly, is not memorable. Pain and loss are more likely to be imprinted or suppressed in their developing psyche.

Within the context of an accident, the injured party must describe the event repeatedly for EMS, the ER, family, their personal physician, subsequent medical specialists, and their attorney.

If patients recover from their injury, eventually their support system will slowly fade away. They no longer need home health or mobility aids, their physicians see them less frequently, and their physical therapy eventually ends. Their family expects a return to normalcy.

But the patient may not have returned to their normal state. And that, to an injured person, is unacceptable. A new physician may hear a different rendition of the original accident, one that serves to impress upon the specialist the heinous nature of the injury.

The most accurate recall, in my experience, is in the emergency room, barring a head injury or loss of consciousness. When the description changes over time, our duty to the truth requires a methodical review of the medical records. In this way, we can often pinpoint the deviation in recall, allowing those who represent the patient to measure the accuracy of the event, and the reliability of their client’s memories.  AMA

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.

This Could Be You

Part One: Yes, I am talking to YOU

Do you consider yourself a good nurse, or put another way, would you want your family taken care of by someone just like you? Do you feel comfortable teaching new nurses “how we do it” at your hospital, or on your infusion team, or in your home health care agency or nursing home? I am willing to bet that you can recognize deviations in care, and recognize good care when you see it, and yet, let’s be honest. 99.9% of “us” nurses get the willies when we think about testifying in court. A part of this fear is the belief that we might find ourselves being deposed or on the witness stand, defending our own actions. Talk about a knuckle-biter.

Well, take a step back from that ever-present awareness that you could err, and think about the nurse who already accused of making a mistake and causing harm to a patient. Doesn’t she need help?

Who is that nurse? Not necessarily someone in PACU or CCU, but the nurse on the floor – the one giving or supervising tube feedings, suctioning an ET tube, helping a patient to the bathroom or pushing meds in an IV. Does that sound like anyone you know? In this world of computerized documentation, meant to make our job straightforward (or someone’s job, at any rate), you know how easy it is to miss a check box even though work was done – your Risk Management department delivers this message like your job depends upon it. Oh.

If you were the nurse whose care was being questioned, who would you want on your side? Who else, but another nurse who works in the same environment you do, who understands the rapid pace and demands upon your time, the responsibility for supervising the actions of others and the potential consequences of being nothing more than “there” at the time an event occurred.

Your nursing experience is what makes you so valuable to the legal system and fellow nurses, because you do not live in a world of textbooks and online research.

If  asked to review the medical records of the patient harmed in the hospital or any other setting, would you know how to do that? Of course you would; you know what belongs in a chart and therefore you know what is missing when you (don’t) see it.  Chances are quite high that if someone asks you to serve as an expert witness, harm did occur, because attorneys are not in the business of spending upwards of 100k to try a case that has no injury. Injury and merit, however, are not synonymous.

The question you would be asked is not “did a bad outcome occur”, but “did the bad outcome arise as a direct result of this nurse’s (in) action”? Can the nurse’s care be rightfully defended, who else was in the chain of command, and most importantly, was the standard of care met? Remember that nurse experts are not being asked to diagnose a condition; they are being asked what a reasonable and prudent nurse in the same setting would have done.

Next time, Part Two: When the shoe is on the other appendage.

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I am blessed, and if you are reading this now, you are also blessed. We both have electricity, internet access, computers, an education, and by default, the ability, or at least the opportunity, to “make something of ourselves”.

I forget about that sometimes, but all it takes is a little change to remind me. The electricity just returned after being off for four hours. Four hours, not four days. Suddenly I was excommunicated (the Catholic in me) from hundreds of people I may never meet, but are my friends by every definition of the word.

Gone was the air-conditioned comfort, reading lights, Netflix and worst of all, Dogs of War or whatever that Xbox game is that makes my teenage son scream like a little girl with his online gaming friends.

Might as well go to bed, which I did, but I have never noticed how quiet the house is without the sound of the air conditioner, fan, or my woosher (the civilized world calls it a sound machine, but it will always be my woosher, tuned to the ocean setting that reminds me of Sanibel).  What was left? The persistent sounds my dog makes in his undisturbed sleep – little snores, dry swallows, and an assortment of unidentified noises that jolt me into awareness at the precise moment I am falling asleep.

“Count your blessings”, “things could be worse”, “be glad you are not that one”, “at least you have your health”…things people say to comfort each other. In times of disaster, people must reach very deeply to find their gratitude but most will succeed. “At least we have each other”, as they mourn the loss of their home. These expressions are not platitudes; they are truths that guide our lives.

I know that I am spoiled when my biggest complaint is bemoaning the passage of time and youth, and I will spend more time being grateful, I promise. Although…I can still hear my dog swallowing above the sound of the woosher. I should wake him up and remind him that he too is blessed to have electricity, and that porcelain thing he is so fond of using as a water bowl.

My Story

Increasingly, nurses contact me for information on legal nurse consulting. This field is too rich and diverse for a simple explanation, and all I can share is my own journey. As Led Zeppelin said, “yes, there are two paths you can go by, but in the long run, there’s still time to change the road you’re on”.

I did not hear the term “legal nurse consultant” until 2005. Until then I had been a nurse – ICU, ortho, pediatrics, psych…from that moment forward, Google was my new best friend.

I looked into various programs that purported to turn me into a legal nurse consultant, indeed a wildly successful one. These programs were legion. Some were taught by universities, either in the classroom or online; others were agencies that offered “specialization” in numerous fields of study, and still others were more concerned with the business and marketing of legal nurse consulting. All offered certificates, but not certification. (The only certification recognized by the American Association of Legal Nurse Consultants is theirs, and you cannot become certified without 2000 hours of LNC work and passing the AALNC course of study. I have the hours, but not the time for studying…perhaps next year.)

I selected a course, learned a great deal, and acquired an impressive string of initials to add to my RN. I stopped using those when I realized they meant nothing. I read Pat Iyer’s Legal Nurse Consulting Principles and Practice, Nursing Malpractice, and Business Principles for Legal Nurse Consultants. I read Betty Joos’s Marketing for the Legal Nurse Consultant, bought a comprehensive handbook of legal terminology, and reviewed changes in nursing standards of care. I did the coursework for SANE certification, bought malpractice insurance, and joined too many organizations. The most useful group I joined was the JERKS, because you can never know too many LNC’s, or have too much advice and support.

I bought a color printer, created and printed a brochure; wrote, and constantly re-wrote, a cover letter to send to attorneys along with my c.v. I designed and printed my own business cards, and developed a website (now on my fourth). I switched from Word Perfect to Word and bought chronology software. I mailed ten packets a week for many weeks before someone called me and it was for the one thing I would not do – provide expert testimony.

Eventually, an attorney called me with three controverted workers compensation cases – cardiac, and he wanted me to help him overturn them. This, I could do, and he still uses my services. I found, however, (being a healthy skeptic), that I really love defense work. First nursing home litigation, then numerous premises liability cases, product liability, slip and falls, mold exposures, wrongful deaths, medical malpractice, World Trade Center merit assessments – each case was, and will always be, unique. The learning curve never flattens out.

I developed a profile on LinkedIn, started several groups, carefully built my network, and joined my local AALNC chapter. I presented a webinar on using LinkedIn and overcame some of my loathing of public speaking. I am president of my AALNC chapter, and our Board produced a very successful regional LNC conference in July. I love this path I have chosen, and I hope the journey never ends.

The Sickest People I Know are Nurses

It is true. These are legal nurse consultants, working at the limits of their physical capacity, and never complaining about aches, pains or the horrible nausea from chemotherapy. I have known some LNC ‘s for years before they told me they had cancer or Crohn’s or a debilitating orthopedic condition.

I am fortunate to be in good health. A major cold is enough to stop me in my tracks, each minute feels like an hour, and fleeting stomach upset makes me look twice at staying in bed.

But these nurses. One in particular is a dynamo; she projects positive energy, shares her contacts, knowledge and resources with others, and never complains. She has so much information in her head she should have her own search engine. She is on chemo, and just yesterday, she said to me, “Alice, this chemo thing is not that bad. My sister cut my long hair short so it wouldn’t be a shock to lose it; this Zofran handles the nausea, and those mouth sores respond pretty well to the medicated mouthwash. Anemia and thrombocytopenia will be a problem, but listen; I have a case I’m working on. Let me tell you about it…”

And, off she goes. Within the forums that I frequent, a good percentage of the LNC’s either currently have or have had cancer or other disabling diseases. Undoubtedly, the illness rate is higher than in the general nursing population. They work because they love it, they need the mental stimulation, they have families who depend upon their income, and because they are tough. No one is judging their consult report by how they dressed that day and no one will know if they were too sick to get out of bed when they wrote that excellent report.

They are nurses, and they are tough. If a legal nurse consultant tells you to get over yourself and get on with it, there is a good chance that she is speaking from personal experience. Listen to her.

Cliches of Independence

I have always heard that clichés were the conversational crutches of concrete people; that the truly bright and abstract among us do not think with the thoughts of others. But I have come to believe that behind every cliché is a solid foundation of truth, and the clichés surrounding independent employment are no exception.

It’s “feast or famine out there”. This is true, and truer still is the fact that independent work often results in famine and forgets to feast. For the newly independent legal nurse consultant, know this: never count on work that is promised to you, and never ever turn down work because you think you will be too busy to manage it. The attorney that calls you to check on your availability for a case may sound very sincere, and he may know that he needs your expertise. What he may not know is whether the adjustor that ultimately pays the bill will allow him to hire you. S/he may have miscalculated the tolling of a case, or the client may get cold feet, or simply go elsewhere for legal advice. I have congratulated many new LNC’s who are ecstatic that someone called them after seeing their brochure, email or marketing packet and said “I’ve got a case…”. The LNC will then turn down a job that paid half as much as their independent hourly fee because they want to remain available for this higher paying consult. Do not do this. Do not “count your chickens before they are hatched” for a very good reason; you cannot predict the hatch rate.

Attorneys know this lesson well. The very successful medmal attorney will only take a “case that has legs” (another cliché, although sometimes the legs take cases in the opposite direction). This is an attorney with “deep pockets”; it took me a while to learn all the nuances of that cliché. The majority of attorneys will take all but the most openly hopeless case in the knowledge that you “never know where your next meal is coming from”. They can juggle hundreds of cases if they have good support staff and strong organizational skills, but some will juggle those cases even without the requisite staff and skills, which is one of the reasons the retainer check, records or agreement never arrive as promised.

The other trap for a new LNC is the Friday afternoon call for an expert that is needed immediately. If I could recall the nurse who said it I would give her credit for the following: “Failure to plan on your part does not constitute an emergency on my part.” I really love that sentiment even though it is not a cliché. Fellow nurses, know that with rare exception, last minute requests are the result of poor planning. Poor planning goes hand-in-hand with failure to notify you that “Oh that case settled”. Do not be discouraged. The Declaration of Independence was the beginning of hard work, not the end of it. “Pick your battles wisely”, “Don’t get too big for your britches”, and “Don’t give up your day job” when you choose the route of independent LNC work. It really is a wonderful life.

As I write this, there are four projects that have been promised, three open cases I am working and two more that are in the pipeline. You will notice though, that I have time to write this blog. I have learned not to “put all my eggs in one basket” (clearly, poultry farmers have much wisdom to share). The projects were to be spaced so that one began as another ended, but I have no doubt they will hit in overlapping waves – less of a feast and more like Cloudy with a Chance of Meatballs. Oh well. I could eat.