Sung and unsung

 
January 25, 2011 -- Much of the press coverage of the tragic January 8 shooting of U.S. Rep. Gabrielle Giffords and others in Tucson, Arizona, has focused on the responses of the local health care system. Unfortunately, as is generally the case in reporting about such mass casualty events, only physicians have been consulted about the victims' status, and the coverage has given the impression that physicians provided all the hospital care that mattered. A typical example is a 3,500-word report by Denise Grady and Jennifer Medina that ran on the front page of The New York Times on January 15. The long piece describes the experiences of a paramedic and the husband of one victim, but otherwise it is devoted to the actions, opinions, and feelings of five University of Arizona Medical Center (UMC) physicians, sending the message that physicians alone were responsible for the skilled hospital care the victims got, even though expert nurses kept them alive from the moment they arrived. No nurse is identified or quoted. This is not just a matter of fairness and accuracy. When millions of people are told, in riveting terms, that physicians alone save lives, it confirms that only physicians are worthy of real respect and resources to do their work. We did see one minor counter-example:  a 565-word piece that ran today in the Arizona Daily Star and was aptly titled, "UMC nurses who staffed ICU called 'unsung heroes.'" Becky Pallack's story--the result of a press conference commendably held by UMC--does show that nurses were involved in caring for the victims and includes comment from two of them. Unfortunately, nothing we hear in the piece shows that nurses are autonomous professionals who were just as responsible for saving victims' lives as physicians were. Instead, there are statements about bonding and hugs. No doubt these reflect good psychosocial care, but sadly, they are also fully consistent with the unskilled angel stereotype. One UMC nurse says that "all we want as nurses" is to see patients thrive. But patients can't thrive if their nurses aren't respected.

"We certainly will watch for infection"

Nurses won't talk

Thanks and hugs
 

"We certainly will watch for infection"

The Times piece is headlined "From Bloody Scene to E.R., Life-Saving Choices in Tucson." It provides three perspectives:  that of Tony Compagno, one of the first paramedics on the scene; that of Bill Hileman, the husband of one of the victims; and that of trauma surgeons at UMC. No nurses are identified or quoted, and no care is described as having been performed by nurses. The word "nurse" appears only twice, once in a description of teams of "doctors and nurses" gathering in trauma rooms, and once in a passing reference to "nurses" traveling on a bus to the funeral of one of the victims. Yet even at Level 1 trauma center emergency departments like UMC, there are typically as many registered nurses as physicians, and UMC also seems to have at least five advanced practice nurses in its ED.

The report describes the bloody scene Paramedic Compagno encountered when he arrived at the Tucson shopping center where Giffords had been holding her outreach event. Frantic people directed him to the 19 victims, and he is quoted describing his efforts to get oriented and make decisions.

Mr. Compagno's job was triage: to assess the severity of injuries and label victims so that ambulance crews would know whom to tend to first . . . Mr. Compagno could see quickly that five were dead, seven were "immediates," needing help right away, and the rest could wait. The child receiving CPR was not responding, but Mr. Compagno was not about to write her off. "The little girl, I counted her as an immediate," he said. Instead of using labels, he simply directed each rescue team to a victim. The goal was to stabilize them and get them to the hospital as quickly as possible, because people with severe gunshot wounds need trauma surgeons.

This is a pretty good, short account of what the paramedic confronted and the triage he had to perform under great pressure. But actually, he was not the only one performing triage that day. At the hospital, skilled emergency nurses were deeply involved in that process both before and after the victims began arriving, including on the radio. But we won't be hearing about any of that. Instead, the final statement above--that "people with gunshot wounds need trauma surgeons"--foreshadows what we will hear.

Nine-year-old Christina Taylor-Green, Rep. Giffords, and eight other patients went to the trauma center at UMC. Christina arrived first ("still getting CPR, still not responding"). Apparently, her care was provided solely by two physicians.

"This was a 9-year-old girl," said Dr. Randall S. Friese, 46, a trauma surgeon. "Even though she had CPR beyond our guidelines, I decided to be aggressive." . . . "You decide, and you do," he said. "It's a personal decision, and I decided to be aggressive, just because she was 9." He tried a desperate last-ditch maneuver. Within about two minutes, he had cut open her chest, inserted a tube to fill her heart with blood and massaged the heart with his hand to try to start it beating again. "I had her heart in my hand," Dr. Friese said. "We filled it with blood. It still didn't want to beat. So, it was over. We're finished." At that moment, a resident stepped in to tell him a second patient had arrived, assigned to Trauma Room 5: Ms. Giffords. . . . He told the resident assisting him to fill Christina's heart and try once more to make it start beating again. By the time he reached Room 5, the resident had tried, and failed. Christina was gone.

For nursing, the issue in this description of these sad events is partly what the reporters find notable and partly what Friese finds notable, but the result is that no reader will imagine that anyone besides physicians played any significant role in trying to save Christina, even though skilled emergency nurses were surely monitoring her heart and airway, inserting IV's, calculating the correct dose of medications and injecting them, infusing blood, and managing what was surely a chaotic situation.

Next we hear about Rep. Giffords, and despite a fleeting reference to the "team," once again it is basically The Dr. Friese Show:

"I walked in and held her left hand, held it in both of my hands, and I thought to myself, 'I need to communicate with her,'" he said. "I was uncertain if she would hear me, that she would process my words. It turned out later that she probably did. That was my reward. I leaned in close to her, and I said, 'Ms. Giffords, you are in a hospital. We are going to take care of you.'"

Friese asked Giffords to squeeze his hand and she did, on one side. Then he "had" a breathing tube inserted, and "ordered" a chest X-ray and brain CT scan. The piece says that "Dr. Martin E. Weinand, a neurosurgeon, was ready to operate, but Dr. Friese thought that the chief of neurosurgery, Dr. G. Michael Lemole Jr., who was supposed to have the day off, should also be involved." Friese gets five sentences to explain that he got Lemole involved because it was "a political thing." Giffords needed surgery right away because of her severe skull and brain injuries, and surgeons sprang into action.

Dr. Lemole and Dr. Weinand studied the CT scans, tracked the path of the bullet and decided where to cut. . . . The surgeons plucked out bits of broken skull and dead tissue, and removed part of her skull -- less than half on one side -- to avoid pressure from swelling. Also to relieve pressure, they expanded the opening that the bullet had made in the dura, the membrane covering the brain. The skull bone, fractured by the bullet, came off in pieces, which are being kept in a freezer and will be put back during reconstructive surgery, probably months away. A bullet hits the skull like a meteor, Dr. Lemole said. Both start to break up, and shards of bone and metal can be driven into the brain. "The old thinking was to chase after them and pull them out to reduce the chances of infection," he said. "But we learned from the military that it can be worse to chase them" than to leave them there. . . . "We certainly will watch for infection," he said, adding that the greatest risk would be in the first two months.

"We" will watch for infection? Will readers have any idea that it is actually skilled nurses who monitor critical patients 24/7 for infections and other post-operative complications? And this account also completely plucks operating room nurses out of the operation, when in fact they played crucial roles in keeping Gifford alive, monitoring various aspects of her condition, maintaining the sterile field, arranging for and ensuring that there was adequate equipment and supplies, and advocating on her behalf as needed.

Next the Times offers the harrowing account of Bill Hileman, whose wife Suzi had taken 9-year-old Christina Taylor-Green to meet Rep. Giffords. When he arrived at the hospital, no one there could tell him about his wife, because they had not identified all the victims yet.

A woman who seemed to be in authority grabbed his wrist. She assured him she would find out what was happening. He still did not know if his wife was alive. By 11:45, Christina's mother, Roxanna Green, arrived. Her father came sometime later. The moment she identified herself, officials ushered her into a private room.

Who was this "woman" and who were these "officials"? Perhaps because they do not appear to have been physicians, it's not really important to find out. Hileman and other family members in the ED waiting room were fearful and angry. Finally, "[a] social worker from the hospital approached and took [Hileman's] hand. She offered a prayer." This helped. It's also the only hospital care in this piece that is not ascribed to physicians. Within an hour, "hospital officials had ushered the family members of the victims into a private area in the cafeteria." Hileman remained alone. He would not see his wife for hours.

For the rest of the report, it's back to the surgeons. We learn that "Dr. Peter Rhee, 49, the director of the trauma center at the hospital, was out running, listening to rap music,when a text message landed on his cellphone." Evidently, it was more important to devote four words towhat music Rhee was listening to than it was to note that, say, "Nurses monitored the wounded," or "Nurses gave vital medications." In addition, the UMC web site says that Rhee is the "medical director" of the trauma unit (the head physician), but the "director" of "UMC Trauma and Emergency Services" is Michelle Ziemba, RN, MSN, FNP, a trauma expert whose research interests include the use of telemedicine and other advanced technologies in trauma care. Oddly, there is no mention of Ziemba in the Times. Perhaps she was on one of her international consulting missions to the Balkans.

The piece notes that UMC is a Level 1 trauma center, the only one in the area. That means that UMC is

the only one that is accredited, with trauma specialists and operating rooms available around the clock to treat severe injuries. Standing by the roadside, Dr. Rhee called in. Several trauma surgeons were already at the hospital, along with two groups of residents. Anesthesiologists and surgeons from other specialties were volunteering to pitch in. Since it was a Saturday, operating rooms were free.

So, plenty of physicians and rooms, yes, but what about beds? Aren't those the three essential components of hospital care for victims of mass casualty events?

Rhee went to the hospital, and ambulances streamed in.

A trauma surgeon waited in the ambulance bay to assess patients and assign them to rooms. Teams of doctors and nurses had quickly assembled in each of the center's seven trauma rooms. . . . "I am running the mass casualty, making personnel assignments," Dr. Rhee said. "Somebody has to be in charge. I'm checking on the congresswoman in the operating room, looking at her brain. It looks viable to me. I'm making sure the anesthesiologist has blood, and the neurosurgeons have what they need."

We see the passing reference to nurses, but overall this passage tells readers that Rhee and the "trauma surgeon" in the ambulance bay were directing the nurses and everything else. And Rhee's quotes present a vision of care that includes only physicians.

The piece moves on to discuss the serious injuries to Suzi Hileman, who had been shot in the abdomen, chest and thigh. 

Within 30 seconds of looking at her, Dr. Bellal Joseph, another trauma surgeon, knew she should go into the operating room. Ms. Hileman was talking -- frantically, distractedly, but speaking in a full voice. That meant her airways were clear, a good sign. Dr. Joseph ignored what she was saying so he could stay focused. But he knew Ms. Hileman was in shock and petrified. Ms. Hileman does not remember this. She told her husband her last memory was being in a helicopter, feeling humiliated when doctors began removing her clothes. "The first thing I say to people is always the same," Dr. Joseph said. "You are in the hospital. You are going to be fine. You have lots of people doing lots of things for you."

While Joseph "ignored" what his agitated patient was saying so he could stay "focused," did anyone--say, a nurse--engage with the patient so she would not freak out completely and risk a worse outcome? For Ms. Hileman's surgery, we learn that "they" started intravenous lines in her arms and gave her a chest X-ray, a good illustration of how care is often described when physicians did not personally provide it. Alternatively, we may get a physician describing things that "we" or "lots of people" did, and readers are free to assume that means physicians. Consider:

In the operating room the purpose was clear: "All we are trying to do is control the bleeding," Dr. Joseph said. "We have to control the shock and basically stop her from dying."

The report says that Joseph made a long incision in Hileman's stomach and saw there was little internal bleeding, then made a small incision to examine her heart and saw no sign of damage.

But there were six bullet holes in her chest, abdomen and legs. He followed the possible trajectories, making sure that he was not missing any damage. He ran his fingers down her intestines, making sure that there were no holes that could potentially cause bleeding or infection. "I have held every piece of her organs in my own hands," he said. "Her heart was in my hand, her spleen was in my hand. Her liver was in my hand. There is no better scan that that."

And was her soul in your hand too? In any case, the account of Hileman's care concludes with a short note that her husband first saw her hours later "connected to a tangle of tubes." We do not learn about the functions of that complex array of tubes or who was managing them, or the patient generally, at that time. We do not learn that it was ICU nurses.

The report proceeds to have Rhee discuss additional patients by number, since they had not given permission for the use of their names. He explains various injuries and what he was doing to deal with them.

Patient 6 was shot in the chest and leg, and needed transfusions. "He kept bleeding," Dr. Rhee said. "I'm wondering if I have to take him to the operating room. But I know that if we can keep his blood pressure a little lower than usual, the bleeding could stop on its own." . . . While patients were in surgery, Dr. Rhee called a quick huddle of all the doctors still in the trauma center, and they reviewed the list of patients, with each doctor calling out additional information for all the others to hear. More patients were rolled in. One was shot in the ankle, and needed an orthopedic surgeon.

Just an orthopedic surgeon? And while Rhee was huddling with "all the doctors," were the nurses huddling? Or were they keeping the patients alive? Were nurses giving those transfusions? Or maybe they had all gone home; consider what happened next.

Within three hours, every patient was on the way to a hospital bed. The immediate trauma was over. Now, it was Dr. Rhee's task to identify the patients' families and tell them what happened during surgery.

It sounds like the patients wheeled themselves to their beds, and since the "immediate trauma" was over, they pretty much just relaxed until the next surgeon visit, just as in most of Terence Wrong's 2010 documentary series Boston Med. However, in fact teams of expert ICU nurses were keeping the patients alive round the clock; we will hear about these nurses in the Arizona Daily Star, though nothing about their life-saving. The Times piece goes on to describe Rhee's discussions with the victims' families in some detail, with a number of additional quotes from him.

The piece concludes with a description of Friese's attendance at Christina's funeral.

Five days after the girl's death, his secretary told him he was invited to Christina's funeral. He did not ask from whom the invitation came. Was it from the family? Or did the nurses planning to share a bus to join the thousands of mourners seek him out? It did not matter. Without hesitating, he decided he would go.

So nurses are attending the funeral by the busload, but the only person worth talking to about it is Friese? He explains that he never did meet Christina's parents, and he is glad, because he is afraid he would have been too emotional. The piece lingers on his emotional state, but closes with a matter-of-fact description of his arrival at the funeral.

When he showed up at the funeral in his blue scrubs and his white surgeon's jacket, police officers helped him move through the overflow crowd waiting outside the church. He was ushered right in. It was the first time he had ever attended a patient's funeral.

Of course it's fine for the piece to address how the physicians were affected by their contacts with the victims and their families. But despite what we see on prime time television, nurses actually spend far more time with patients and families than physicians do, and nurses use that time to provide advanced physical and psychosocial care, not just hold hands and fetch objects for physicians. We doubt the care of these patients was different, with the possible exception of Rep. Giffords, a VIP who probably attracted extraordinary physician attention. (Sometimes VIPs attract so much physician interest that nurses are unable to access the patient's side when they need to.) The piece's failure to provide the nurses' perspective here suggests that the nurses were not doing or thinking anything notable. 

Nurses won't talk

One of the New York Times reporters who wrote this story told us that she tried very hard to interview the UMC nurses involved in caring for the victims, but not a single nurse would speak to the reporters. We note that the ICU nurses discussed below did not seem to have any trouble at their press conference. But we know that some nurses are reluctant to be noticed. Some nurses are concerned about HIPAA, but of course that did not stop the UMC physicians from speaking about patients, whether by name or number, in the event that they had not given consent. We know also that some nurses tend to duck any kind of attention, perhaps because they fear that it could always become negative, or perhaps simply because they have been socialized to do so. For a decade, we have urged nurses to stand up and tell people what they really do for patients. When nurses fail to do that, the result is not just to make physician-centric reports like this one more likely, but to undermine the nurses' own claims to the resources they need to do their jobs. Of course, journalists have an independent responsibility to present an accurate picture of the world to their readers. The refusal of some to speak with the reporters is not much of an excuse, and we suspect that if it was really a priority for the New York Times, someone in the UMC management structure would have ensured that nursing input was provided along with the extensive physician input here.

On the whole, this massive Times report gives a pretty good sense of the experiences of several UMC surgeons in the wake of the shooting. But it fails to achieve what we take to be its actual goal, namely to give readers a good sense of the health care provided to the victims. That would require examining what the nurses were doing.
 

Thanks and hugs

We did see one much shorter piece about the aftermath in Tucson that does focus on the nurses' perspective, but sadly, we also found little there that will advance understanding of nursing. This Arizona Daily Star report focuses on trauma ICU nurses, and appears to have been the result of a press conference called by UMC. Indeed, the report says that UMC spokeswoman Katie Riley introduced the nurses at the conference, noting:

The unsung heroes of the tragedy of two weeks ago, I think, are some of the nurses who took care of our patients, especially those who work in the trauma ICU.

We certainly agree with that, and we commend the hospital for organizing the conference. And although this piece features no physicians, that is because, as Riley's statement implies, it is a small response to the usual avalanche of attention paid to the physicians elsewhere. Another positive feature of the story is this statement from nurse Angelique Tadeo about what happened when patients started arriving at the ICU after surgery.

Our training does kick in. We immediately go into triage mode: who needs what first, second.

That at least tells readers that nurses have training, and that they--not just physicians and paramedics, as Times readers were led to believe--did triage that day. Of course, saying that the training "kicked in" may make it seem that nurses do nothing extraordinary the rest of the day. Isn't their training kicking in every moment they're working? It might have been nice to get some detail on what triage the nurses did, which patients were more critical, how the nurses determined that, and what they did in response. In any case, the piece also describes what sounds like valuable psychosocial care the nurses gave to Rep. Giffords, which at least reminds readers that nurses were deeply involved in the care of the victims, something readers of the Times piece might easily have forgotten.

Unfortunately, the way that care is presented, and virtually everything else in the report, is entirely consistent with the widespread image of nurses as unskilled angels. We do hear about the nurses taking action in response to the crisis, but unfortunately, we don't get much more detail than the fact that they did. Think we're kidding? Consider what nurse Tracy Culbert said she did when she got the page about the incoming patients:  "We basically went into action." We also learn that other ICU patients "were moved" to make room, and that "nurses started preparing beds and care stations," while "more nurses came in to help." Getting a sense of advanced skills and life-saving yet? Try this:

"We treat everybody the same. It doesn't matter who they are, what their name is, what status they hold in society," Culbert said. "I think that we try to give every patient the best care that we can give them, and do everything we possibly can for them and their family."

Tadeo adds: "We knew what we were walking into that night and we were ready to jump in." We know that these nurses are just describing what they feel, and that's fine, but what they're saying is so vague and general that it adds nothing to public understanding of nursing. Sadly, we get no reason to think that the nurses were doing anything a lay person could not do. There is nothing about the expert care ICU nurses give based on their college science education, or how it often means the difference between life and death. Nurses cannot count on the public just knowing that, as physicians can.

We do get details about the care the nurses gave Giffords, but not about the complex array of fluids, medications and supportive and monitoring technology that the nurses surely had to manage to keep her alive. Instead, it's all about how the nurses "bonded with Giffords."

Tadeo found out she and Giffords both like the rock band Maná, so they listened to one of the band's CDs together every night.

That's good care since nursing research shows that music improves health, but with no explanation of it in clinical terms, it will just seem like a nice thing to do. Culbert says Giffords once reached up and examined the nurse's necklace, which has an impression of the thumbprint of her father, who died a few years ago.

Culbert told Giffords that she knew her father was just as special to her, and Culbert started to tear up." She reached up and she was holding my arm and rubbing my arm, and she reached in to pull me forward to hug me. I said, 'Gabby. you're going to make me cry.' And she patted my back, like 'it's OK.' That moment I'll never forget. It was something special between the two of us. She was trying to console me and she was the one that was hurt."

What can we say? That's beautiful, but again, it tells readers nothing new about nursing.

The last section of the piece is about thanks and hugs. It reports that the nurses thanked Tucsonans for all the free food and massages (!) they donated to keep the nurses going during their long shifts, which at least implies that nurses work hard. And President Obama also stopped by. Culbert notes that he thanked her and she "got a hug;" later, Giffords' husband Mark Kelly invited Culbert to the State of the Union address, where he was reportedly a guest of the Obamas (though he was shown at his wife's bedside during the speech later today). The piece closes with a quote from Culbert:

My biggest gift in nursing is when my patients come back and see me and they say thank you, and we get to see them live their life and be happy again. That's all we want as nurses.

That's an admirable goal, but without better understanding of nursing, it's going to be harder to achieve it. Of course, we know it's possible that the nurses at the press conference did make an effort to explain more specifically what they did to keep patients alive, and to convey that they are skilled professionals, but the newspaper chose to report only the emotional support and the vague "going into action" statements. But in any case, we urge all nurses to let people know that they don't just give and get hugs, but also save lives with their education and skills. With more respect and resources, nurses will see more patients thriving--and yes, there will be even more hugging.
 

See "From Bloody Scene to E.R., Life-Saving Choices in Tucson," by Denise Grady and Jennifer Medina, posted January 15, 2011 on the New York Times website.

See "UMC nurses who staffed ICU called 'unsung heroes'" by Becky Pallack posted January 25, 2011 on the Arizona Daily Star website.