Dirty Little Secrets of Nursing, Part Four: It's not doctors directing your care.

I got into the same conversation this morning that I do every week, with the guy stocking produce at the local Crazy Grocery Store.

"How you doin'?" he asked.

"Inelegant." I replied.

"You look fiiiiine" he said, grinning and showing his two gold teeth.

We talked today about the time he spent in the hospital a few months ago. "Those doctors saved my life, you know" he said.

I didn't want to tell him this, but it was probably the nurses in the ICU here at Littletown General that saved his life. I know the doctors who cared for him, and I know that they're not around that much.

It's a dirty little secret of nursing: those handmaidens and helpmeets who take a subordinate role to the great Medical Deity are the ones directing your care. Nurses are the ones keeping an eye on your electrolytes, your fluids, your nutritional status, whether or not you're running a fever. Nurses are the ones, often, who decide whether or not you need a central line or a tube running through your nose down to your stomach. We're the ones who push for that indwelling bladder catheter. We're the ones who yell and screech when something goes wrong.

Nurses have more input into a patient's care--even including, sometimes, their surgical course--than most civilians recognize. I had a patient with a belly bleed the other day who was doing okay...but if he hadn't been, it would've been up to me to provide the information and the observation that would've been the deciding vote on whether to take him back to surgery.

If a patient codes, nurses run that code, doing compressions and giving meds, until the code doc shows up. That might be two minutes, or it might be twenty--or it might be never. I've taken part in three codes during which the code doc didn't show up until well after we'd gotten a steady rhythm back and the patient intubated and stable.

This makes sense, if you think about it. I'm there for twelve hours, taking over your care for a colleague who's been there for twelve hours. In the CCU, that means that I've been in your room a minimum of once an hour for that long shift, keeping a watchful eye on your vitals, waking you up regularly (sorry) to make sure nothing's changed with your mentation. The doc will visit for fifteen minutes in the morning before rounds. He'll spend ten of that fifteen minutes with me, five with you--enough to reassure you that all is going well, and to get a clear and comprehensive picture of what's actually going on from me.

In the specific case of my asparagus-stocking buddy, it was the nurse who had him for four nights in the Littletown ICU who noticed his crazy heart rhythms and suggested, not gently, that perhaps an implanted defibrillator was in order. It was because that nurse had pulled and saved EKG strips that the docs realized that yes, the nurse was right: dude was hovering on the edge of a heart attack. I don't know whether that nurse was a guy or a girl, or whether it was somebody with thirty years' experience or someone I graduated with, but the point remains:

It's a dirty little secret of nursing: sometimes we control your care.