Sunday, October 23, 2011

Fourteenth Chapter

Fourteenth Chapter
In which a dependency issue has resurfaced, a blamestorm is resolved and a charity established.

   Chicky is waiting in the outer office of her boss, June Tinney, RN, the Vice-president for Patient Care. They are old friends and comrades in arms, having worked together in the Med/Surg unit many moons ago. They have watched each other climb the ranks steadily over the years. June has been away the past week dealing with issues arising from the acquisition of a smaller suburban hospital into the University Hospital system. The phone on the desk rings, answered by Stella, June’s secretary, and Chicky is ushered into the inner office. June rises from her desk, and she and Chicky sit at a smaller conference table by the window which looks out on a garden courtyard.
  “It seems I picked a good week to be somewhere else. Tell me about it” June says. “I guess I‘ll start with the bad news first” replies Chicky. “When Mary Stuart arrived early in the morning on Monday to set up PACU for the day, she found Connie going through the sharp boxes and in possession of a couple of syrettes of Fentanyl and Morphine Sulfate that had been partly used and then discarded.” (Narcotics come in cartridges called syrettes that snap into a special syringe. Intended to be a single dose, sometimes less than the full contents are given) “Connie fled, but was stopped at the door by security due to Mary’s call. They took her to the ER and to make a long story short, toxicology showed her to be positive for Opiates. She was terminated on the spot.” June gave a sad look out the window. “What a shame. She had been doing so well with that pre-op coordination post.” “Is there anything we can do for her?” asked Chicky. “Very little, I am afraid” said June, “ I have talked to Larry (CEO of University Hospital) and he is willing to keep her on the insurance plan long enough for another round of rehab, but that is all.” “That is very generous and a lot more than I expected” said Chicky “I have drafted a report to the State Board of Nursing. Connie was on probation, so now the only question concerning the Board is whether they suspend or revoke her nursing license.” “I would not be optimistic there” June said “the nursing board is much tougher about these things than the medical board. With the Compact (an agreement among the boards of nearly half the states in the country concerning reciprocal licensure) whatever the status of her license here, it would be the same automatically in the other compact states. And non compact states would not be likely to give her a license either. Let me see the letter and I will co-sign it.”
   Not like State Medical boards. Unlike nursing which had a single board exam for all nurses in the country, every state had its own medical board exam. Each state board of medicine was fiercely independent, not unlike physicians themselves, and not inclined to be cooperative with each other. Chicky was thinking of several physicians she knew of who got into trouble and had licenses suspended or revoked. They just moved to another state and set up shop there. Not to mention that while suspensions were given out regularly, it was rare for physicians to have licenses revoked. There was the case of the so called hotshot transplant surgeon that the hospital had recruited from Harvard. The hospital was so eager to get this guy based on all his publications and addresses to medical conventions, they gave him tenure before they actually saw him in action. While intellectually and academically gifted, he turned out to be incompetent at performing surgery.  The hospital was stuck with him, so he was shuffled off into running the workman’s compensation clinic. The clinic was where people with on the job injuries went for evaluation, treatment and therapy, and recuperation time off work granted. It was also where these people went to have their care managed and to get their prescriptions. One day there were an unusual number of tradesman’s vans and trucks in the alley behind the hospital, and an unusual number of men in overalls with various logo patches for electricians, plumbers and the like coming and going. At the end of the week, a number of hospital employees were led out in handcuffs, including the director of the workman’s comp clinic. It turned out that he was giving weeks of time off to employees in exchange for the pills from the prescriptions he wrote. While he was out on bail and his attorneys delayed proceedings with all the tricks of their trade, he just went to the next state over and set up shop there. In the end he only got a six month sentence, and went right back to practice when he got out in the neighboring state.
   “Connie is single isn’t she?” June asked. Chicky nodded. “Well at least there is no spouse or children to be effected. It would be heartbreaking to have a family involved.” Chicky and June were both thinking of the anesthesiologist who died with dependency issues and the tragedy of his family. June thought out loud: “When we had a problem before, we went from having narcotics in multiple dose vials to the syrettes to avoid dilution of the drugs to cover pilferage. Also, the narcotics could be tracked with more precision. We never thought of any one going through the sharp disposal containers.

 It is a miracle that Connie didn’t pick up AIDS or Hepatitis. It’s unfortunate that the syrettes have needles attached to them.” Sharps, such as needles, scalpel blades, suture needles, etc. were placed in plastic puncture proof containers for disposal. This was necessary to prevent injuries and the spread of infections such as hepatitis, aids, or even garden variety bacteria. “I have been thinking along those lines myself” said Chicky “I think we have to set a policy and practice of having incomplete syrettes squirted down a drain before they go into the sharps containers. The wastage must be witnessed and signed into the record by two nurses or a physician and a nurse, just like when the drugs are signed out from storage.” “I think you are dead right on that” said June “it will be awkward and slow things down a bit. The nurses are going to find it burdensome, but it has to be done. I want it in place by the end of the week. Get some of the other nursing managers together and get it done.”
   Chicky nodded and moved on. “Then there is the donnybrook Dr. Bensalem has stirred up. It seems an emergency C-Section came to the OR without a Foley catheter. It was an extreme emergency, a placenta previa, none of the OR nurses or even the anesthesiologist noticed in the rush. The patient suffered a bladder tear, and the baby had a significant depression of APGAR, and had to spend a couple of days in the NICU. Dr. Bensalem wants to blame it all on the OR nurse, claiming that she should have noticed, and that she was slow and incompetent at getting a Foley into the patient midway through the procedure.” “Yikes” exclaimed June “Am I to take it that your nurse was able to get a Foley in under the drapes in all the blood and panic? That doesn’t sound like incompetence to me, she deserves a medal. And if I know Dr. Bensalem, your nurse was probably being yelled at the whole time. How is the baby and mother doing?” “They are both doing well. No sign of any impairment of the baby, only time will tell. The initial depression of the baby could be equally due to excessive anesthesia time or lack of blood supply because of the detaching placenta. The time under anesthesia does not seem excessive compared to other C-Sections.” Chicky recounted. She continued: “I understand where Dr. Bensalem is coming from. Obstetricians are being sued out of existence. Many OB-Gyns are restricting their practice to Gynecology and abandoning Obstetrics. Their malpractice insurance rates are skyrocketing.” June interrupted “That is still no reason to blame it all on your nurse. I know that some surgeons can be very nasty when under pressure, everybody understands that, and my impression is that most are very apologetic once the dust has settled. I wonder why Bensalem is making such a fuss this time?” I don’t know” Chicky said “In her incident report my nurse observed that neither the L&D nurse nor Dr. Bensalem gave any report of the patient’s condition as they arrived in the OR as per policy. That is something we need to tighten up on. And the L&D nurse’s notes indicate that Dr. Bensalem ordered a Foley removed in L&D. I talked to the L&D nurse involved, and she tells me the Foley was removed to get a better ultrasound image when Dr. Bensalem was diagnosing the patient’s condition.” “I will have a talk with the Chief of Staff” June said “I am sure the case will be discussed at this week’s M&M conference on Friday.” (M&M or Morbidity and Mortality is a weekly conference where all cases with less than expected outcome, with complications or where there is significant injury or death are discussed by the medical staff. M&M can be a very traumatic experience for a physician who must present and explain his or her decisions and care given). “I will also make sure that our legal counsel is apprised of the situation and suggest that she have a quiet word with Dr. Bensalem about slander and libel. Does your nurse seem to want to make an issue of the situation?” “No” said Chicky “I think that a simple genuine apology would fix things up there. She understands where Dr. Bensalem is coming from.”

  “Lastly, I have some good news to report” Chicky said. “Since her trip to Africa, Molly has been collecting opened but unused dressing materials, gloves and the like, things we would be discarding, to send to her contacts over there. She would like to see if she can get the other hospitals in the University system to do the same. She has nearly 600 pounds collected so far. Could we arrange for her to visit the other hospitals in the system? She would love to do a grand rounds presentation with her photographs.” June nodded assent and said “I think we could get her some time at the next executive meeting and get the leadership on board. We could probably help out with the shipping costs and red tape. I think the CEO would love to see such a project.” June beamed at her old friend. “Tell Molly to get ready to wow the brass.”

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