The Case of the Dirty Dentist

English: Putting toothpaste on a toothbrush. T...

English: Putting toothpaste on a toothbrush. The toothpaste is Crest Pro-Health Clean Cinnamon, 0.454% stannous fluoride, 0.16% w/v fluoride ion. Deutsch: Zahnpasta auf eine Zahnbürste auftragen. Русский: Выдавливание зубной пасты из тюбика на зубную щётку (Photo credit: Wikipedia)

Most of us wouldn’t think twice before checking that our silverware is clean at a restaurant.  But, when we sit in the dentist’s chair nervously eying the tray of gleaming stainless-steel instruments laid out beside us, we don’t pick them up and make sure they’re clean. We rely on our dental professionals to sterilize anything going into our mouth. That reliance may be a mistake.

Last week the Board of Dentistry performed a surprise inspection of oral surgeon Dr. Scott Harrington‘s Oklahoma office and found numerous problems with sterilization of instruments. The good doctor’s response when questioned?

“Dr. Harrington referred to his staff regarding all sterilization and drug procedures in his office,” the complaint read. “He advised, ‘They take care of that. I don’t.'” His attitude seems to be that not infecting his patients with blood-borne diseases is someone else’s job.

Other issues that came to light during the inspection included the doctors reuse of needles, disregard of expiration dates (one bottle of morphine expired in 1993) and his use of unlicensed assistants to perform tasks only a licensed dentist should perform, such as giving IV sedation.

Now over 7000 patients will undergo  testing to see if they contracted hepatitis or HIV due to the oral surgeon’s noncompliance with basic infection control practices.  In the meantime, don’t be fooled into thinking this is an isolated problem caused by one errant doctor.  On March 22, 2013 the Rhode Island Board of Dentistry temporarily shut a practice down after finding debris on multiple instruments in ‘sterile’ packages in exam rooms. No word on whether that dentist took responsibility for his office practice.

But, speaking of responsibility, how much responsibility do patients have to protect themselves from healthcare acquired infections? People have been trained not to touch someone else’s blood unless they wear gloves. People are encouraged to use barrier devices, such as condoms, during sex to prevent STD’s. Should our public health officials start a campaign to encourage patients to protect themselves during invasive procedures such as dental procedures, colonoscopies, and injections? If so, how can that be accomplished?

Recent articles have suggested patients ask dentists to prove they’re following guidelines in the care and maintenance of sterilization machines.  They’ve also advised patients to request to inspect the instruments prior to being removed from their sterile packages.  Other tips are to watch the dentist’s glove use, look at the overall office cleanliness, and quiz the dentist and staff as to how they handle reusable instruments. All excellent points, but it also requires a level of doctor-patient transparency and discussion that’s not usually seen. More importantly, how is your dentist going to react to his judgement and cleanliness being questioned?

In my work in the healthcare field, even the idea of a patient (or another healthcare team member) questioning whether someone has washed their hands before patient contact is a source of controversy. In a Swiss study, 76% of patients felt uncomfortable asking a nurse if she’d washed her hands and 77% felt uncomfortable asking a physician the same question. If patients don’t feel comfortable asking a simple question like that, do we really expect them to ask complicated, technical questions about sterilization procedures? Asking for clean instruments should be as easy as asking for a new knife or fork at a restaurant when the one on the table is dirty, but it isn’t.

English: South China Sea (May 16, 2006) - Hosp...

English: South China Sea (May 16, 2006) – Hospital Corpsman Steffon Corna sets up dental tools for a tooth extraction in the Dental Department aboard the Nimitz-class aircraft carrier USS Abraham Lincoln (CVN 72). Lincoln and embarked Carrier Air Wing Two (CVW-2) are currently underway in the Western Pacific operating area. U.S. Navy photo by Photographer’s Mate Airman Apprentice Brandon C. Wilson (RELEASED) (Photo credit: Wikipedia)

Will I stop going to my dentist? No. Will I ask to inspect the instruments for debris before my next procedure or cleaning. Yes. Hopefully he’ll understand, but if he doesn’t, I’ll tell him I’m holding him to the same standards I’d hold a restaurant to. I’m sure he doesn’t like eating off dirty forks any more than I do.

 

 

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I’m a Nurse, not a Saint

Priest

Priest (Photo credit: Wikipedia)

I am continually amazed and astounded by the things patients feel comfortable saying to me. It’s as if they think a nursing degree is equivalent to a counseling degree, a white set of scrub pants akin to a white collar, and a hospital or outpatient clinic room is the same as a confessional. It’s not.

Confessional

Confessional (Photo credit: cliff1066™)

Don’t mistake my words for a renunciation of confidentiality. My lips are sealed when it comes to protected health information and you, but, as in real life, there are times when people provide too much information. I’ve provided some examples so you can judge whether you need to be a little more discreet on your next hospital or doctor’s visit.

When I ask you to undress down to your underwear and cover yourself with a sheet, you don’t need to tell me, “I don’t wear underwear.” That is a surprise best left for the doctor. I’m not coming back in to check that you disrobed appropriately.

If I ask you to take off your shoes to be weighed, don’t apologize for the holes in your socks. Our office is only responsible for checking sock holes on alternate Thursdays in months that end in -Z. Any other time, don’t worry. We won’t be putting it in your permanent record nor will I be calling your mother (or the Emergency Room) to rat you out.

If I come in with an shot for your child, don’t tell them it won’t hurt. Chances are it will. I’ll try to minimize the pain, but since I can’t tell them to “suck it up, buttercup,” I’m hoping you’ll have your big girl panties on and shush them rather them tell them you’re sorry the “mean nurse” hurt them.  The mean nurse can’t do shit unless you give me permission, but I’m not telling your toddler “your mean mom made me do it.”

If I do a cervical check on your pregnant girlfriend, don’t ask her if she’s enjoying it. She’s not. Neither am I. Creep.

Never ask me to rub “extra hard” down there if you’re unable to clean yourself off. There are non-medical devices and non-medical personnel who can meet your needs much better than I can. Once you ask, the only “happy ending” I’ll think of is your discharge or death.

Don’t ask if you can strip down to your underwear to ensure your weight is “accurate.” I personally don’t want to see you half naked and believe stripping down for non-medical reasons should happen in your home, not in the exam room.  You can buy your own scale for the cost of a co-pay.

Going Down?

Going Down? (Photo credit: billhd)

Don’t expect me to believe that you need an early refill on your methadone, oxycontin, oxycodone, percocet or vicodin because the bottle you just filled fell into the toilet with the cap off, ruining all of the pills. Unless a major study at a prestigious medical center proves that toilets have a preference for narcotic painkillers, I’m suspicious. This never happens to anyone’s heart, allergy, or diabetic medicine. If you have to lie, go big or stay home. Don’t let drugs kill your creativity.

Remember I’m a nurse, not a saint.

Who Gets to Decide to Withhold CPR?

I’m not sure what I’d do if a patient collapsed in front of me and the administrator said, “No CPR. It’s our policy.” Since I’ve been a nurse, I’ve heard of slow codes, where the unspoken agreement is that if the person stops breathing the staff will purposely react as slowly as possible to give the person a chance to die, but I’ve never participated in one. The decision to either be resuscitated or be a DNR (do not resuscitate) is a personal one and the slow code takes that decision away from the individual. That goes against my philosophy of nursing.

English: CPR training

English: CPR training (Photo credit: Wikipedia)

Today’s news involves a nurse who did, in fact, stand by and refuse to do CPR when a patient went down. The facts seem simple. A woman collapsed in the dining room of an independent living facility. A nurse called 911 to report the incident. The 911 dispatcher asked the nurse to start CPR. The nurse refused, stating it was against company policy.

The 911 dispatcher didn’t give up. She asked the nurse to find someone who would start CPR, asking “Is there anybody that’s willing to help this lady and not let her die?” Again the nurse said no. The dispatcher continued to plead, as if the provision of CPR was the only surefire way to prevent this woman’s death.

Seven minutes 16 seconds later, emergency personnel arrived. The woman had no pulse and was not breathing. They started CPR.  The 87-year-old woman was declared dead at the hospital.

This has upset a lot of people. Upset some to the point that the police are trying to figure out if they can charge the nurse with a crime. The belief is that CPR would have saved this woman and the absence of CPR caused her death, and that’s not entirely correct.

According to Dr. Robert Shmerling in a post entitled, CPR: Less Effective Than You Might Think

“As opposed to many medical myths, researchers have reliable data concerning the success rates of CPR (without the use of automatic defibrillators) in a variety of settings:

  • 2% to 30% effectiveness when administered outside of the hospital
  • 6% to 15% for hospitalized patients
  • Less than 5% for elderly victims with multiple medical problems”

Another study that looked at out of hospital cardiac arrests found that successful resuscitation decreased with age. 40 and 50 year olds had a 10% chance of a successful resuscitation while patients over 80 only had a 3.3% survival rate.

No magic bullets here. There is no guarantee that CPR would have prevented this woman’s death. If she’d survived, there’s no guarantee of the quality of life she’d enjoy afterwards.

In this case, the independent living facility (not assisted living, not a nursing home, not a rehabilitation unit) maintains the residents are advised that in the event of a medical emergency staff members will call emergency services, but not provide CPR.  Employees are told the same thing.

The dead woman’s daughter said, “I don’t believe if CPR were done it would’ve helped or changed the result. This is not about my mother or me, this is about the policy of the facility, and we understood the policy, and I agree with what was done.”

Which brings me back to the original question. If the woman collapsed in front of me and, as a condition of living in the facility she’d agreed the staff wouldn’t perform CPR, would I have stood by and done nothing? With an underlying belief that the patient gets to make the decisions, I very well might have.

Will you still need me, will you still feed me when I’m seventy-four?

When my daughter was younger, she said she loved me so much that when I was old she’d get a wheelchair and push me wherever I wanted to go. Her sister said she’d push me off a cliff. I was in my early thirties when this conversation took place and since then I’ve wondered who will take care of me if I become old and infirm.

As part of my nursing education, I spent a fair amount of time in nursing homes. Afterwards, as a new nurse, I worked in hospitals. Both of these experiences convinced me that the majority of the elderly were frail, sickly, and unable to live on their own. It depressed me.

In the nursing home, the patients with dementia were the most labor intensive. One birdlike woman practically lived at the nurse’s station. She’d yell to each passing staff member or visitor, “Hey, lady. Hey, lady. Get me out of here. I have to go home.” Her idea of home was the home of her childhood and she’d often continue with, “my father will be mad at me. I’m late. Get me out of here.”  Sometimes I’d want to loosen her restraint and take her to this home that was still alive in her memory. Other times I’d sneak around so she couldn’t see me and ask me to help her. What I remember most is that no one ever visited her.

In the hospital, dying patients needed the most resources. Mouth care, turning and positioning, constantly assessing their level of comfort and providing medication were all involved in “aggressive comfort care”  as opposed to “comfort care only.” We knew we were fighting a losing battle, yet wanted to be proactive in preventing further complications and keeping the patient pain free. Sometimes family members would stand vigil, many times the nurses were the only silent witnesses to the winding down of a life.

It wasn’t until I worked in outpatient care that I realized many older patients were self-sufficient, active in their communities, and living at home without assistance. They didn’t need the services of a nursing home and, if they were lucky, the end of their lives happened in their home rather than in a hospital or ambulance. It gave me hope.

As my parents inch past seventy-five, I’ve also realized how many of the elderly live in their own homes and struggle to maintain their dignity while dealing with limited resources. There comes a time when you realize mom or dad isn’t able to manage their own life as they once were. I think that realization, for most children, is slow in coming and it takes even more time before the children try to step in and help.

Why is that? I think on some level we’re ashamed to acknowledge our parent’s physical problems. Intellectually, I understand that the elderly have a decreased sense of smell, touch, vision, hearing and taste. They may not notice the smell of spoiled meat, not see the stains on the dishes they’ve washed, not be aware of the loudness of the television while they’re talking on the phone, and eat the same food day in and day out. Their mobility is limited due to  loss of muscle, disuse, and degenerative diseases like arthritis. Their bowels don’t function as regularly as before. Their skin is easily damaged and slow to repair.

And most of us are busy, damn it. We have children graduating from college or getting married or having their own babies while we try to pay off parent PLUS loans, boost our 401k’s,  keep our marriages or relationships strong and maybe even find time to fulfill our own dreams. All this is going on while our parents start a slow decline and insist they can take care of themselves. They don’t want to be a bother.

So where do we put our time and effort? Into the problems we can fix. Babysitting grandchildren, advancing our careers, spending romantic time with our significant others, doing the things we always meant to do that we now have the time for. And the more our parents say they’re fine, we shouldn’t bother,  it’s no big deal, the easier it is for us to defer to their fine judgement and leave them to their own devices. I mean, really, they’re our parents.

Until the day we go over to their house and realize that they aren’t doing okay. They need our help. All of the things they did for us and taught us to do for ourselves have come full circle. They need help to wash themselves up and keep themselves clean. They need someone to monitor their meals and make sure they’re eating enough high quality food. They need someone to dry them off and look for signs of skin breakdown and intervene early. They need someone to clean their house, check the outdates on their food, and drive them to appointments. Much as they helped us to transition from dependent child to independent adult, we must now support them as they transition from independent adult to dependent parent. It’s not fun.

And for me, and I feel shame as I write this but I suspect others feel as I do, it is hard. It is hard to remind a parent to shower, to go to the bathroom, to wear a depends pad, to take their medications. It is hard because we now become the parents of the person who parented us. It is hard because we know deep down inside that our parents would never want us to see them as weak and in need of help so we must thrust ourselves into their lives and do it matter of factly and decisively. And we must somehow reconcile the parent of our minds, the strong, vibrant, healthy person we remember, with the person they have become from no fault of their own other than the passing of the years. And then we must love them and help them, all the while protecting their dignity and sense of self.

It’s a damn hard dance to do.

But still, I see adult children who do it every day. They stand by their mothers and fathers in the most intimate and embarrassing situations with a grace that doesn’t come from socioeconomic status or education. It doesn’t come from religious guilt or dreams of inheritance. It doesn’t come from a sense of obligation or duty or even payback. It comes from love.

And every time I see an adult child performing the most personal care for their parents with a smile and the attitude that it’s not a big deal, I am humbled. The question isn’t who will take care of us when we age, it is how we can do the right thing for the people who have done so much for us

Pat, August 20, 2011 - Curb

Pat, August 20, 2011 – Curb (Photo credit: pat00139)

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Keep Your Merit Badge, I’m Not a Boy Scout

Portrait of Miss Georgina Pope, head nurse of ...

Portrait of Miss Georgina Pope, head nurse of First Canadian Contingent during the Boer war. Possibly in her nurse’s uniform from Bellevue Hospital, New York (Photo credit: Wikipedia)

Last week Nurse K posted on her blog about a patient‘s last phone call. Read it here.

After wiping away some stray moisture from my eyes and clearing my nose (allergy season, you know), I thought about the moments that define us in our healthcare role.

Hospitals seek out touching stories to bolster their application for Magnet status or adorn their website. Their stories of how the healthcare staff went above and beyond to help a patient usually end up being fairly run of the mill. More in the vein of “the nurse took the time to ensure I knew how to make the bed go up and down” and “the food service staff cheerfully exchanged my tray to accommodate my gluten-free diet” than “someone did something totally unexpected and above/below their pay grade that mattered.” In my hospital experience of being on the receiving end of management’s praise, I’ve found the successes I’ve been credited with are the ones that least define who I am as a nurse.

I was acknowledged once for my help in cleaning up flooded exam rooms after someone left a faucet running over a weekend. The sad truth was administration had made deep cuts in the housekeeping department and there was no one available to clean up the mess. I picked up a mop and started in because we had a waiting room of patients to be seen. Eventually the housekeeping supervisor, embarrassed at his lack of employees, showed up to help. Administration congratulated our team effort to fix the problem. I got official recognition for going above and beyond and a free lunch in the cafeteria. Rather than being thrilled with the “honor,” I was incensed. Of all of the things I did in my job that were truly worthy of recognition, I got an attaboy for pushing a mop for two hours. Two hours I wasn’t available to triage or educate patients. Two hours I didn’t use any of my nursing skills. That is what administration deemed worthy of recognition.  It didn’t go over well when I told them instead of praising me, they should be asking themselves why they didn’t have enough housekeeping staff to handle emergencies.

Instead of addressing the underlying problem many of us face, too much to do with too little time and staff to do it, hospitals try to boost morale with meaningless honors and remain oblivious to the day-to-day things that really matter. And though we are more than willing to share our crazy stories, commiserate over the sad ones, and bemoan the incompetence of administration, we’re not willing to let down the walls and talk about the parts of our job that hit us in the gut and the situations that make us turn our heads so the patient can’t see our tears. We’re professionals. That stuff isn’t supposed to get to us.

But, it does. It stays with us.

And they are the moments I don’t offer up to the public relations machine of the hospital and I suspect many others do the same. Moments that remind us there is more to our job than tasks and checklists and documentation. Moments when we know that our lives will go on, but our patient’s will be changed forever. Because sometimes, in the confusion, turmoil and noise of our professional lives, we take a step back and do the right thing.

Those are the moments that define us.