Nurse-doctor collaboration

I have finally landed a job in Denver with a 15 member critical care group that oversees care at three hospitals, covering about 120 critical care beds. That's a relief, and now I can continue on with my plans to write a couple papers, maybe to be published or maybe not. I submitted a draft of a paper on nurse-doctor collaboration in the hospital this month to a lawyer I'm working with at the University of Pennsylvania that essentially states that it's better for patient care and it's cost effective to have better collaboration between nurses and doctors ( a kid might say, "Well doy!") Since doctors and nurses come from different backgrounds it may be helpful to have some training together in medical and nursing schools. This might include having medical students and residents shadow nurses in hospitals and vice versa. Each could learn the stresses and duties of the other, allowing for better understanding of each other's roles, and perhaps breaking some of the barriers to communication that exist at varying levels of care.

The problem is that there would still have to be a decision-making hierarchy. The empowerment of nursing has stressed the traditional hierarchy of the hospital in that physicians have traditionally held decision making responsibility while also being held predominantly responsible if something goes wrong. The call for cross training in school has been from nurses since the risk for distress in interactions is usually born by nurses. Doctors can be assholes at times. Although I believe that more cross training may actually limit some of the stress felt by both parties it seems that our biggest problem in the profession is narcissism predominantly from the physicians side, less often within the nursing profession. Many in the hospital get their undies in a bundle because they aren't getting enough attention and praise. I'm guilty of this like everyone else. Maybe we would be better off if we could somehow send a message to doctors in training that we often bear eventual responsibility for the care of a patient, be it positive or negative, but that we work in a complex setting that requires the input from not only nurses but also pharmacists, respiratory therapists, medical assistants, nutritionists and effective administrators and an array of others that can make or break a system of delivery. Some humility seems in order. Physicians are successful, or not, as a consequence of the huge and complicated network of human interaction that makes up a hospital. The reputation of the Mayo Clinic was partially an outcome of two dedicated and inquisitive doctors, Charles and William Mayo, but it survived into the future because of Dr. Henry Plummer, who set up the administrative infrastructure at the Clinic that is second to none, the Sisters of St. Mary nuns who collaborated with the Mayo brothers to develop a deep system of nursing and the people of Rochester, Minnesota who helped the Mayo brothers establish there rather than somewhere else, supplying help with making hotels into hospitals and acting as host for this world renowned institution. The Mayo Brothers would not be the icons we know without the infrastructure that Dr. Plummer and the people of Rochester created.

As for nurses, these are generally the most kind and compassionate of the medical professionals that directly impact patients. They care for the comfort of a patient with such dedication and this is often out of a doctor's emotional range and ability to regulate time given the pull of many patients as structured expectations would have it. Nurses also gather personal information about patients that no doctor could gain since they are with patients and their families more during a hospital day than any other member of the hospital team. But a flaw in the nursing literature and one that I have noticed by practicing with nurses is that there is a desire for control and decision making that may not be institutionally warranted. It would take a social change to allow more control and responsibility to be given to nurses, and this would also require that nurses accept more responsibility for negative outcomes. At the University of Pennsylvania less than 10% of law suits name a nurse in addition to the doctors involved. It is even more of a rarity that nurses are solely named in law suits. If nurses want more decision making responsibility they would have to be willing to help restructure the decision making hierarchy in the hospital and accept the responsibility of negative outcomes due to that decision making. Not out of the question, but I think it would limit their ability to be the nurturing arm of care in the hospital, maybe I'm too paternalistic here. The evolution of nurse practitioners may prove me wrong. This seems to be a work in progress.

If I were king of the hospital I would suggest that doctors take a little more time to be genuinely more kind to their nursing colleague and to take advantage of the wealth of personal knowledge that the nurse may know about the patient that we are unable to obtain. Information that may be helpful in their care. To nurses, I would have to stress that in today's society doctors have eventual responsibility for the outcome of the patient so in cases of disagreement there must remain, for the time being, deferral to the treatment plan endorsed by the doctor. In the end some of this lack of understanding between the two groups, doctors and nurses, shadowing each other in training may allow for better understanding of each other's role in patient care and a chance for discussion and exchange of ideas that does not currently exist.

These suggestions are made with humility and a desire not be thought of as a know-it-all but as someone who cares a lot about how patients get treated in a hospital. Don't we all.

Fourth of July in Montana: The Shooting of Rattlesnake Jake

I found a good Fourth of July story reported by Mary Pickett in the Billings Gazette. This was a well constructed, front page, above the crease, story in this Sunday's paper describing Lewistown's 1884 Fourth of July celebration: it's first. Since they had just established a post office it considered itself a town and the town had to have a Fourth celebration. The story was told by a 90 year old retired history teacher, Margaret Seilstad. Her father had been a twelve year old kid in Lewistown, MT in 1884 and she gathered the story from him and his friends.

That 4th of July day residents of Lewistown planned a parade, including a local resident Bob Jackson dressed as Uncle Sam, horse races, and a dance in the evening. But Granville Stuart, a historic Montana figure, who ranched in the area, conveyed concern about the celebration since he knew that horse thieves and cattle rustlers were in the area, thinking that they may steal livestock while the ranchers were in town. The townspeople wrote him off and the show went on. Indeed, by Granville Stuart's prediction, a particularly nasty pair of thieves came to the celebration that day, Charles Fallon and Charles Owen, or Rattlesnake Jake, as Owen was known. He had shifty eyes, "like a snake".

Bob Jackson, Uncle Sam, had probably been drinking and got into an argument with another local resident at the horse races but, as it was reported, a fist fight did NOT break out. Jackson was Indian and French (Metis, or mixed native and European race). Fallen and Rattlesnake Jake were drunk and approached Jackson after the disagreement that did not end up in a fist fight. Jake didn't like Indians so he hit Jackson, Uncle Sam, in the face with his pistol. Fallen and Jake then mounted their horses and left. After Fallon and Rattlesnake Jake left the races local residents converged on Main St. and stocked up on rifles at the T.C. Powers and Brothers Store because...because why not? There was something brewing.

After the altercation at the races Fallon and Rattlesnake Jake went into Crowley's and Kemp's Saloon for a few drinks, apparently already drunk and in a foul mood according to Margaret Seilstad. Jake spotted another Metis member of the local community, Doney, and shot at him but missed. Doney drew his pistol and hit Jake in the shooting finger. Jake took his pistol in the opposite hand and returned fire. After Rattlesnake Jake returned fire the angered townspeople, with their recently acquired rifles, opened fire on Fallon and Jake. Although it's not clear exactly how the gunfight progressed one version has a wounded Rattlesnake Jake riding out of town trying to escape only to notice Fallon kneeling in the street "making his last stand", said Seilstad. A loyal Jake stayed with his friend and died, riddled with "five or nine bullets", the number and any other circumstances were not perfectly clear. Both men were wearing multiple coats, in July, which apparently made it harder to kill them.

Margaret Seilstad told the Gazette that as soon as the shooting started her father went back to his tent with a bullwhacker, the driver of a team of oxen, "to get more guns." The bullwhacker was eventually killed by a shot to the head, by Rattlesnake Jake.

Before the dance started that night citizens convened a coroner's inquest and decided that the residents killed Fallon and Jake in self defense, then they danced. Although it was impossible which of the many bullet shots actually killed each man, "half the town claimed firing the fatal shots."

The bodies of Fallon and Rattlesnake Jake were stored in an ice house and the next day were displayed against a wall in town. Fallen and Jake were initially buried on Hospital Hill, where the first hospital of Lewistown existed, "but it's now the location of the Fountain Terrace condos." The man who owned the land at the time objected to their initial burial site so the bodies of Fallon and Jake were dug up, lassoed, and dragged around town, eventually to be buried near a coulee outside of town. Margaret Seilstad's father followed the body on his horse and saw bits of hair and skin from the decomposing bodies snagged on brush. According to Seilstad, "he nearly lost his lunch".

There's a skull on display in Lewistown that is thought to be from Rattlesnake Jake, but a University of Montana graduate student specializing in forensics has argued that the displayed skull is probably from a much younger man with at least some African ancestry, not Jake. Another subtle fact remains as well. It seems that Jake was shot in the head with a buffalo rifle and there was no evidence of bullet trauma in the skull thought to be Jake's. But the skull is still on display as that of Rattlesnake Jake. This is the story of the first Independence Day celebration in Lewistown, MT.

There was no mention in the story of discussions between town members of the Second Amendment right to bear arms. Not in this town. There didn't seem to be disagreement. Happy Fourth of July.