Louisville Medicine Volume 70, Issue 1 | Page 33

A SECOND OPINION
people working in ICUs are working parents who have child care and school arrangements and cannot drop everything and fly off to Miami , even for the big bucks . They have baseball practice and Scouts and homework and somewhere in there , dinner to cook . Local nurses , feeling stiffed and unvalued , have quit in droves over the course of the pandemic .
Even though hospitals themselves took financial hits with Covid – losing lucrative elective surgeries and closing various outpatient services – executive salaries suffered least of all . Vikas Saini in the Feb . 10 , 2022 Health Affairs 1 pointed out that on average , hospital CEOs are paid more than unskilled hourly staff by a factor of 8:1 , and more than 80 % of them received bonuses throughout the pandemic . The largest salary outflow from hospital coffers goes to skilled employees , the nurses ; therefore the logical “ business model ” move - since hospitals became big businesses three decades ago - is to reduce the number of nurses , and “ manage ” salaries . That has been an ongoing reason for chronic nursing staff shortages : nurses are expensive ; hospitals try to “ get by ” with minimum staffing ratios .
Over time and with the never-ending crisis of COVID-19 , nurses have rebelled and left , worn and scarred to the bone . Those who remain are asked to “ work over ” and to work in units less familiar to them , with types of patients they do not always care for . This sort of setup , with ongoing fatigue both emotional and physical , can increase mistakes . “ Alarm fatigue ” is a real thing and paying full attention each and every time is an absolute requirement – but at 0345 there are only three of you for 12 ICU patients , with no aide , that attention is more fleeting than focused .
Every nurse should know by heart the “ Five Rights ” of medication giving : the right patient , the right drug , the right dose , the right route and the right time . Whether they pay heed , in a crisis , is another matter .
Ensuring safe practice – by docs and nurses and therapists of every stripe – is a professional responsibility each of us must shoulder , and nurture . Not knowing something is always possible and often likely , in which case , one asks for help quick . Not knowing should be felt first as fear , in the pit of your stomach , and next in your guilty conscience . Most often you ’ ve neglected learning something , though maybe you have simply never seen such a case . This realization must be followed immediately by consultation , to get the right answers and help for your patient . Not knowing happens to us all . But not knowing and not heeding that doubt – giving fully in to frustration and the anxious need for speed – is a normal human reaction to constant time stress . It ’ s just not a professional reaction to that stress .
The mantra , “ NEVER stop being afraid ” is how we keep our eternal vigilance intact . Getting more comfortable is inevitable but getting careless leads to pain and suffering for all . Every day , every moment you must focus on Not Being Wrong , Or Else .
Covid to cheer and care for their staffs – feeding them , offering counsel , offering bonuses , offering testing and time off ( which has shrunk with changing guidelines ). They have torn their hair out too .
But what they have not done , across the board , is to value them properly : they have not yet raised staff nursing salaries to previously unseen heights , only to keep raising them as time goes on . Taking care of your most essential staff members should mean paying them what they are worth : want the headaches of scheduling to go away ? Add more vacation time to that extremely generous pay , add top-notch child care to the workplace , add extensive nursing internships for new graduates and make CME one-to-one clinical encounter based . Make asking for help in the middle of the night easy , fast and reliable .
Thankfully , Ms . Vaught ’ s conviction led this week to probation , not jail time . But the very prospect of criminal proceedings for true errors – not intentional evils , like injecting people with potassium to murder them – is ugly and wrong . We have entrenched malpractice cases as civil ones : attempts to dissect and if needed , rectify medical errors via mediation or trial by jury . We have a long tradition and many precedents to guide the judge and officers of the court .
Yet cases felt to be extreme have gone to criminal prosecution for doctors as well . In April , the Ohio anesthesiologist Dr . William Husel 2 was acquitted of murder charges for his use of very high dose fentanyl for intubated ICU patients , many of whom got the fentanyl in the setting of terminal extubation to comfort care . His defense characterized his actions as purely palliative . The prosecution called it premeditated murder . The jury agreed with the defense . Dr . Husel has also faced multiple severe civil malpractice actions .
People who go around intentionally killing nursing home patients for twisted reasons of their own should be prosecuted criminally : that is murder . People who make medical errors or who deviate from standard practice but believe it to be in the best interest of the patient should be dealt with civilly , not criminally . There are gray areas in medicine that open up discussion and disagreement about best practices . Honest mistakes – as was Ms . Vaught ’ s – constitute malpractice , not premeditated murder .
The truckdriver who aims for you and mows you down is a killer . The driver whose truck turns over in high winds is having a bad luck accident . Let ’ s not confuse the two on the road , or in the Unit .
1 https :// www . healthaffairs . org / do / 10.1377 / forefront . 20220208.925255
2 https :// www . washingtonpost . com / nation / 2022 / 04 / 20 / william-husel-fentanyl-doctor-acquitted-ohio /
Dr . Barry is an internist and Associate Professor of Medicine ( Gratis Faculty ) at the University of Louisville School of Medicine , currently retired and mulling her next moves .
It ’ s not lost on nurses – an overwhelmingly female workforce still – that pay equity is mythical . Administrators have tried throughout
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