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The nursing debate

Article

Physicians once said nurses would dilute their earning power and endanger patient safety.

Academy Animal Hospital, Springridge, Ohio

John Grant was closing the door to his Jeep Wrangler. In his right hand was a small bag filled with various paraphernalia of death. He looked at the door of Mrs. Jordan's small home and dreaded going in. He knew what awaited him there — a small Pekinese named Billy with multiple organ systems ebbing and clinging fitfully to life. This teetering at the border of existence is all too familiar to doctors of veterinary medicine. He was there because Mrs. Wilson had requested that he come to her house. He did this service infrequently but often felt good about providing this kind of service to a long-standing client.

Just then, his cell phone rang. It was Cathy Harmson, his registered tech at the office.

"Dr. Grant, Laura Ott just arrived with Jeeves. He was hit by a car, and his pulse is weak. He seems to be having some trouble breathing and is cyanotic but quite alert and responsive otherwise."

"OK Cathy, here is what I want you to do," he began. "Get Sarah and whoever else is there to help you. We need to get him some oxygen. First, examine the oral cavity for obstructions. Remove anything that is obstructing the airway. If nothing, then oxygenate or intubate if necessary and then get an IV line going. If the blood pressure is too low to get a good vein, then do a cut down like I have shown you in the past — use your best judgment. Once you have the IV established, follow the crash protocol listed on the wall with steroids and bicarb and call me back when all this is going ... OK?"

"OK, Dr. Grant"

Jeeves was an overactive Border Collie that unless leashed was more of a blur than a dog. John had thought in the past that this particular dog might be subject to road trauma because of his speedy nature and his owner's cavalier attitude toward supervision. His owner had even remarked in the past that she thought that Jeeves could outrun a car if pressed. It looks like she had been wrong.

DVM Newsbreak

John took a moment to reflect. This is the third time in the past six months this type of situation had occurred. During the other two times he had been up to his ears in alligators doing orthopedic procedures that had demanded his full attention. During both of these times, Cathy had come through in similar crash situations with flying colors. Even if he left right now to go back to the office, it might be too late.

John entered the Wilson home and found Billy laying in the kitchen in obvious distress. Thankfully, his end would be peaceful, and Mrs. Wilson was gracious and grateful.

As Dr. Grant entered the hospital, he could see a knot of people gathered over the treatment table behind the pharmacy. The hair raised on the back of his neck for a moment until he could see smiles on everyone's face as he closed in.

"Dr. Grant, Jeeves seems to be a lot better." Cathy cried with both emotion and restraint.

John looked the little zephyr over and smiled.

"He seems to have stabilized for the time being," he said. "Good job Cathy — now let us get him into X-ray and do some blood tests."

Bowen Animal Clinic, Springridge, Ohio

Paul Bowen, DVM, walked into the practice at 7:30 am. His one lone staff member, Jan, had arrived an hour earlier to check on the patients and clean the kennels. She was up front now answering the phone and checking in a few of the patients for the day. There were two other part-time people to help Jan with similar duties.

Jan could do most anything that came up. She worked about 25 hours per week and sometimes would put in an 11-hour day. Since she rotated with the other part-time people, Jenny and Marlene, she never worked a full 40 hours, but when she was there, she worked sometimes throughout the noon hour. The end of the day was a dreadful experience at times because she had to count and balance the books and make a deposit. She made deposits on her days off. However, she was always proud of her job and often referred to herself as a technician.

Dr. Brown was a polite and precise man. He was in his early 40s and never married. The practice was his life. He didn't realize it, but he was somewhat of a control freak and had his finger on every pulse beat of the practice. He felt that this was what was required in order to be successful. Paul did the ordering from cleaning supplies to controlled substances. He clipped his own surgeries and administered all medications and monitored all aspects of anesthesia. Jan and her two cohorts were plenty busy answering phones, cleaning and retrieving "stuff" for Dr. Brown. They were trained to sterilize instruments, run the laundry and clean the kennels. Dr. Brown often counted his own pills and ran the pharmacy pretty much by himself. When receiving patients, Dr. Brown mixed his own vaccines and did all the tests and fecals by himself while his staff mainly held the animals. Jan and all other staff members that rotated through the practice over the years still loved working with the animals. They just didn't get much delegated to them. The chance for growth in their jobs and their satisfaction with their work was minimal.

Yet for Jan, this day would be different.

"Dr. Brown, I will not be able to make a deposit at the bank tomorrow because I have to go to the doctor in Columbus. Can Jenny or Marlene make it instead when they are here tomorrow?" Jan asked.

Dr. Brown was not used to change. Jan had worked for more than 10 years and was reliable. Jenny and Marlene had worked for only about 12 months. He was caught in a dilemma.

"I'll go ahead and take the deposit myself at lunch," he replied.

While he was gone, a desperate call came in from one of Dr. Brown's neighbors — Mr. Cleaver. It seems one of his dogs had been attacked by what she described as Pit Bulls in the back yard. Jan was paralyzed. Dr. Brown was not often gone from the practice as he always brought his lunch. He did have a cell phone.

She called his cell phone. It was not receiving calls. He rarely used it anyway.

She called the bank. The teller looked out the window and told Jan that Dr. Brown looked like he was about the third in line at the outside teller window. The teller agreed to find a way to get Dr. Brown to the phone. A few minutes past, and Dr. Brown breathlessly came to the phone.

"What's the problem?" he asked.

Jan relayed the information.

"Is he still on the phone?"

"I don't know for sure — I guess so!"

"Tell him to come right in with the dog, and I will be there as soon as I leave here. Whatever you do, don't do anything until I get there."

Jan hung up the phone and then realized that she must have disconnected Mr. Cleaver in the process.

However, in less than five minutes Mr. Cleaver showed up with Darcy an unaltered male Yorkie that usually showed up at the practice with an attitude. This time however, Darcy was unresponsive and had labored breathing. Jan noted that the dog seemed to be blue around the mouth. She was unsure what that meant. She told Mr. Cleaver to wait.

"Where is Dr. Brown?"

"He is at the bank and should be right here."

"Is there anything you can do for him — he is bleeding all over the place."

"I am not really allowed to help. I might do something wrong. I wish I could. Let me bring him a warm towel. Dr. Brown should be right here."

Ten minutes passed. Darcy vocalizes a bit, then starts to yawn.

"What's happening?" Mr. Cleaver asked.

Jan could not answer and did not dare speak. She had a bad feeling.

Darcy became quiet again.

Ten more minutes passed.

Dr. Brown briskly moved to the front door. Instead of an animal hospital, he was walking into a funeral home.

"Dr. Brown, I wish you would have been here sooner."

Paul was mute. A train had delayed him. All colors turned to gray.

Who's right?

The cultures within these hospitals are obviously quite different. The doctor in each case has quite an opposite perception of the roles staff members are to take within the framework of the hospital.

In Dr. Brown's case I am sure that the death of this animal is acceptable in the sense that he (Dr. Brown) cannot be everywhere at once, and this patient and client rolled the dice and lost. The patient was in the right place at the wrong time. Dr. Brown is sad but is not likely to grasp to the potential error of his ways.

Dr. Grant, on the other hand, is leveraging his staff for the benefit of the patient. The patient, on average, will be better served. It can be argued that the outcomes could have been exactly opposite. While this is true, the averages would surely not bear this out. Training staff and allowing them to take on roles that many veterinarians feel are within their sole jurisdiction can save many lives and reduce the workload and stress of veterinarians.

Although consultants have advocated delegation of management duties, they have often left the delegation of duties directly assigned to veterinary medicine proper to the veterinarians. A large group of veterinarians would agree. They would resist letting any technician, certified or not, take on a role they feel is privy only to a veterinarian. This group of veterinarians, I believe, is stifling the future of veterinary medicine just when a misstep such as this could prove fatal.

Rewind the tape

Sixty years ago, physicians railed against the nursing profession. In their indignation, they felt that nurses were glorified gophers with little advantage other than bedpan obligations and TPR duties. It was erroneously felt that nurses, if assigned medical duties beyond their place, would ultimately dilute the physicians earning power and jeopardize the safety of patients.

Today, nurses do much of the technical and medical management of patient care. Nurses, in my experience, catch and repair many of the oversights that busy doctors overlook. Most doctors today are overwhelmed just doing diagnostics and medical planning. If nurses, nurse practitioners and physicians assistants were removed from the medical community, the system today would crash and burn almost immediately. Yet, physicians still drive nice cars and live in very nice homes. Their doom and gloom just didn't seem to come to pass. It reminds me of a lot of veterinary medicine.

Technicians today

Most veterinary technicians are well trained, and very dedicated to the profession and the animal community around them. I would match their compassion level for patients on a par with the human nursing profession. Most are underpaid (along with their bosses) for a variety of reasons, which are well documented and include the failure of a third-party system of payment in the profession, in my opinion.

Although hardly any certified technicians ever go into the profession for remunerative reasons, many leave for meaningful and interesting employment that affords improved long-term financial benefits. This is a great loss to all of us.

Everyone that has poked his or her head out of the cabbage patch realizes that the majority of technicians are out doing "something else" in about five years. This is a drain on expertise, experience and compassion that the profession can ill afford not to address.

Dr. Lane is a graduate of the University of Illinois. He owns and manages two practices in southern Illinois. Dr. Lane completed a master's degree in agricultural economics in 1996. He is a speaker and author of numerous practice management articles. Dr. Lane also offers a broad range of consulting services and can be reached at david.lane@mchsi.com.

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