Politico had an interesting article adapted from author Alexandra Robbins’s work: The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital.  As Robbins states “If you want to know what’s really happening in a medical building, don’t ask a doctor. Instead, turn to the best-informed, hardest-working and savviest professionals in health care: Nurses.”  Below are excerpts from the article.

Don’t get sick in July. Every year in teaching hospitals at the start of July, medical students become interns, interns become residents and each successive class of residents moves up a level. These new doctors are immediately thrust into direct patient care. As the National Bureau of Economic Research reported, “On day one, new interns may have the same responsibilities that the now-second-year residents had at the end of June (i.e., after they had a full year of experience).”

This upheaval causes what health care workers call “The July Effect” in the United States and “August Killing Season” in the United Kingdom (where the shift happens in August). The changeover harms patient care, increasing medical errors, medication mistakes and the length of hospital stays. In July, U.S. death rates in these hospitals surge between 8 and 34 percent—a total of between 1,500 and 2,750 deaths. UC-San Diego researchers found that fatal medication errors “spike by 10 percent in July and in no other month.” In Britain, August mortality rates rise by 6 to 8 percent as new doctors are tasked with surgeries and procedures that Britons say are “beyond their capabilities.” Patients in English hospitals have a higher early death rate when they are admitted on the first Wednesday in August than patients admitted on the previous Wednesday.

Some doctors and nurses are placing bets about you. Several nurses around the country confessed that hospital staffers have wagered on patients. “Guess the Blood Alcohol” is a common game, where actual money changes hands. Other staff members try to guess the injuries of a patient arriving via ambulance. And surgeons have been observed playing “games of chance” during operations, placing bets on outcomes of risky procedures.

There are “codes” … and there are “slow codes.” Some medical teams have a hush-hush way of dealing with discrepancies between a patient’s Do Not Resuscitate order and family members’ demands. In hospitals, as a Missouri nurse told me, “There are lots of unsavory things that the polite public would make hay with.” While many people know from medical shows what a “code” means—a patient in cardiopulmonary arrest—most people don’t know about the “slow code.” Various units have different designations; at a Canadian hospital, medical teams distinguished between a full code, which they called “code 55,” and a slow code, or “code 54.”

Some physicians will unofficially call a “slow code”—which will never appear in a patient’s chart—if a coding patient is elderly or chronically ill. The signal notifies a team that they are not expected to revive the patient but should go through some of the motions anyway. “Responders literally walk slowly, are slow to respond, give medications slowly or hesitate to intubate so that the patient is unlikely to be revived,” said a Midwestern nurse.

Your DNR might be ignored. While some nurses said that at their hospital patients with signed, current Do Not Resuscitate order are not resuscitated, several nurses told me that saving patients with DNRs “happens all the time.” The most common scenario occurs when an elderly or chronically ill patient with a DNR requires resuscitation and a family member tells the medical team to save the patient. Particularly if the family member has power of attorney (POA), nurses said he or she can change the plan of care.

“Theoretically we’re supposed to honor the DNR, but oftentimes the family will want the patient treated because they see the DNR as ‘giving up.’ Often a family member is a POA and has the legal right to make medical decisions even if it overrides the DNR,” said a travel nurse based in Texas. “Families want us to ‘do everything’ and if we let the patient die, we’re accused of killing them by refusing care. Basically it’s a lose-lose scenario.”

Sometimes we put alcohol in your feeding tube. If a patient with a history of alcohol abuse needs open heart surgery, a Maryland Cardiac Surgical ICU nurse said, he or she might get alcohol (supplied by the pharmacy) with hospital meals or through a feeding tube to prevent alcohol withdrawal symptoms such as elevated heart rate, anxiety and shaking. A nurse in an Oklahoma cardiac unit who has administered this treatment to a patient said that, on physician’s orders, the pharmacy brought 60 mL of bourbon each night to the nurse and watched her pour it down a nasogastric tube. While this method is considered old school—hospitals more often give patients Ativan—“It is funny to say that you gave your patient a shot of bourbon as a medication order,” the nurse said.

That’s going in your chart. Ever wonder what nurses are writing in your patient chart? Everything. If you say something offensive or off-the-wall, nurses chart it. If your family member creates issues, that goes in the chart, too. “I always chart when a patient is difficult or belligerent. I keep it objective and write direct quotes; it’s funny to have to type ‘Fuck you, bitch’ in medical documentation,” said Molly. If a patient later sues the hospital, the documented evidence can diminish the patient’s credibility.

You might not need the surgery your doctor says you need. Some nurses said that doctors “bully” people into having unnecessary tests and procedures. “If I could talk to my open heart surgery patients before the surgery, I would probably advise 30 percent of them not to have surgery,” said a New York nurse. “Our fee-for-service health care system incentivizes doctors and hospitals to advise aggressive, high-cost treatments and procedures. Doctors undersell how much rehabilitation the successful recovery from heart surgery requires. Most patients tell me they didn’t know the recovery would be as difficult as it is. Every time I see patients over 85 opt for an aortic valve surgery because they were becoming short of breath on exertion, I scratch my head a little bit because I know that many of these high-risk patients will not get back all the faculties they had before the surgery, and some won’t even make it out of the hospital.”

TV shows don’t get it right. In reality, nurses manage many of the duties that viewers see doctors performing on TV, such as inserting an IV or catheter. “I laugh when I see shows like House or Grey’s Anatomy where doctors are pining at the bedside of patients, giving them medications or administering treatments. Doctors do nothing of the sort,” says an Arizona clinical education specialist. “They come by once a day, take a short look at the patients, review their chart, make orders, and leave.”




Sen. Al Franken led a group of 57 U.S. lawmakers who urged the Consumer Financial Protection Bureau (CFPB) to issue new rules “swiftly” that would eliminate the use of forced arbitration clauses in consumer financial service contracts, which can include nursing home admission contracts.  Franken and 41 U.S. House members and 16 of his colleagues from the Senate insisted that forced arbitration clauses can prevent consumers from getting legal relief; instead arbitration puts victims of neglect at a disadvantage. The lawmakers reiterated that Congress directed the CFPB in the Dodd-Frank Wall Street Reform and Consumer Protection Act (Dodd-Frank) to study forced arbitration clauses and gave the CFPB express authority to issue regulations to prohibit or limit these clauses in consumer financial contracts.

 “These clauses force individuals into private binding arbitration as a condition of buying a product or service, and are designed to stack the deck against consumers and ensure that the final outcome of forced arbitration is unreviewable by courts,” the lawmakers said in a letter to CFPB director Richard Cordray that was delivered last week.  “Forced arbitration clauses — often buried deep within the fine print of financial products and service contracts — harm American consumers by depriving them of their day in court even when companies have violated the law,” they continued.
The lawmakers maintained in their letter that the bureau’s study found not only that more than three in four consumers were unaware of forced arbitration clauses in their contracts, but also that consumers rarely use arbitration on an individualized basis, especially for small-dollar claims, and that there is no evidence that forced arbitration lowers costs for consumers.

“In total, the study conducted by CFPB at Congress’s request roundly confirms that individuals unknowingly sign away their rights through forced arbitration agreements, which do not reduce consumer costs for financial services,” the lawmakers said. “Moreover, forced arbitration shields corporations from liability for abusive, anti-consumer practices, encouraging even more unscrupulous business conduct at the expense of individuals and law abiding businesses.

“Based on this substantial bedrock of evidence, we urge the CFPB to move forward quickly to use its authority under the Dodd-Frank Act to issue strong rules to prohibit the use of forced arbitration clauses in financial contracts and give consumers a meaningful choice after disputes arise,” they went on to say.

To see the complete letter and which lawmakers signed it, 150521CFPBarbitrationLetter.