Apply sparingly to right ear until nurse stops shouting
May 15, 2013
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JP AT LARGE
“Why can’t you tell me what happened to the refills?” The person interrogating me was a registered nurse. The volume of her voice had risen and her tone had become close to a shriek because I wasn’t playing monkey to her kid rattling the cage at the zoo.
She continued. “This was an e-prescription on February 15th. It was for clonidine 0.2 mg.”
“I know it is for clonidine, with instructions of i qd.”
“How do you know that?”
“Because I am looking at Mrs. Smith’s record as we speak.” My voice was very calm, as soothing as I could make it. This woman was not going to get the idea that she could get Jim Plagakis jangled. I was the picture of a well-mannered pharmacist — not my usual style, I admit.
“Well, then you can see that the prescription has five refills.”
“No, I can’t.”
“What? What do you mean, you can’t?”
“Our technicians are professionals. They know what a hassle it is when the refills run out and the patient needs the medicine. Recording the refills electronically is just as important to them as getting the instructions recorded accurately.”
I had a vision of the instructions I had seen on an e-prescription earlier that day. Apply one tablet sparingly to the right ear three times every hour for nausea and vomiting.
“Well, Mister, I am holding the chart. It says e-prescription with five refills on February 15th, sent to your pharmacy.”
I sighed. My Dalai Lama persona was fading. “Just authorize the refills right now, over the phone, and I will add them to the prescription.”
“We don’t do things that way.”
“How do you do it?”
“We have to get it authorized by the doctor.”
“What did you say?”
“No you did not. You used the . . . ”
“We are getting to the danger zone, ma’am. I am going to give the patient six tablets as an emergency supply so you can get this straightened out.”
“You can’t just give her tablets willy nilly. You have to wait for the doctor.”
“I’m confident that the doctor knows that discontinuing clonidine abruptly can put her life in danger. How do you spell your last name?”
“Why do you need that?”
“So the patient’s family can pass the correct name on to their attorney when the patient dies.”
The top of the pyramid
Nurses are at the top of the pyramid of patient care. They were the heroes of the 1918 influenza pandemic. Many died. Doctors blew smoke all over the place while the nurses dripped sweat from their brows as they leaned over patients’ beds.
My bed was in the hallway when I was admitted to Cleveland General Hospital with polio in 1950. I was usually awake when they removed a dead child from an iron lung in the middle of the night. After orderlies did their job with alcohol, it took less than an hour for the nurses to bring in the next kid for that iron lung.
Nurses were all over us, all day long. The ward was overcrowded. Two beds to a cubicle meant for one. The iron lungs down the middle. Parents were allowed to visit for one hour once a week. The nurses watched our bowels, stretched our atrophying muscles with love, and wrapped us in Sister Kenny’s steaming hot woolen towels.
When the doctors came in, the nurses were keenly attentive. Arms at their sides, nodding: Yes, Doctor, yes. I noticed that the doctors did absolutely nothing except boss the nurses around. My respect for nurses will never be diminished, but I will not tolerate a nurse questioning me as if I were some kind of nurse’s aide.
When the doc's out, watch out
Recently, The New York Times ran an article titled, “When the doctor is not needed.” In the near future, nurses (and pharmacists) will be shouldering much of the load for primary care. The reasons? Too many patients. Doctors who are too expensive.
The authors of the Affordable Care Act have keen eyes. They know how well pharmacists are educated. You will be ordering tests and prescribing drugs.
By and large, nurses still are not experts on drug therapy. They’re in the minor leagues in some small town where the Class A team is named the Fleas. Many of them need to stop pretending before they hurt someone.
Years ago, on the phone, I asked a registered nurse to slow down. I asked, “Was that Seldane (terfenadine, an antihistamine) or Feldene (piroxicam)?”
Her answer: “Yes.”