A Skilled Nurse
Registered nurses are licensed to start intravenous lines, give injections, insert nasogastric tubes (through the nose and into the stomach), change sterile dressings, pack wound cavities, perform digital disimpaction, provide enemas, and insert urinary catheters into the bladder, just to name a few. The hospital management must allow you to have a reasonable level of comfort that the nurses are competent in performing whatever measures you need. Every hospital job application must include a skill checklist that documents the amount of experience a nurse has in performing all procedures. Additionally, a nursing education department is responsible for monitoring the skill level of all staff and per diem nurses. Thus you as the patient or family member should be entitled to such information as pertains to the services provided.
A case in point regarding the importance of assessing nursing skills is that of a man I'll call John Millhouse, who in August of 1995 entered a well-known cardiac surgery specialty hospital for a valve replacement. The surgery was successful. The problem started when John's blood test came in positive for tertiary syphilis. John had contracted syphilis during his days as a young Marine while on liberty in Seoul during the Korean War and had received penicillin for treatment. He did not quite get rid of the bug, so it flared up ten years later in chronic stage, and the doctor repeated the treatment in larger doses and over a longer period. The blood test at "Cardiac Hospital" only showed a prior exposure. Nonetheless, the infectious disease consultant wanted to treat John prophylactically with an intramuscular penicillin injection. The cardiac surgeon concurred and wrote the order.
A short while later, Nurse Jane, a recent nursing school graduate, went into John's room with the injection. This type of injectable penicillin is a viscous liquid, so the needle was long and wide to allow for rapid movement into the muscle. Nurse Jane inserted the needle into the center of the left buttock, causing exquisite pain that shot down John's leg. Apparently, she had cut through the sciatic nerve and some small arteries, causing internal bleeding in the gluteus maximus muscle. To compound the difficulty, John was receiving intravenous heparin, a powerful anticoagulant. He continued to bleed within the muscle for several days until the area became swollen, reddened, and hard as stone. A general surgeon came in and opened the buttock for removal of the large blood clot that had formed from five days of uncontrolled internal bleeding. The subsequent pressure against the lacerated sciatic nerve caused permanent severe pain and disability.
John's lawyer discovered during the deposition questioning that Nurse Jane had graduated from nursing college only six months before the incident and that this was the first time she had ever performed an intramuscular injection. If John had asked the right questions beforehand and insisted on getting an experienced nurse to give the injection, he would likely have averted a lifetime of hurting and hobbling.
In another case, Tim J., a sixty-two-year-old man, entered a university medical center for an abdominal hernia operation. He was an asthmatic and had difficulty swallowing due to a prior stroke. Consequently, he had a tendency to choke on his food, so someone had to monitor him during meals.
One day, the nurse left Tim alone after giving him his lunch tray, and, as should have been anticipated, he started to have a nonstop coughing fit because of a small amount of food stuck in his larynx. He rang the call bell and the nurse responded immediately and inserted a suction catheter into his throat while keeping him in a sitting-up position. This was the wrong move. The nurse should have laid him supine with his neck extended to maximize the airway and called for emergency medical intervention.
To make matters worse, the nurse continued ramming the tip of the suction catheter into Tim's throat for six minutes in an aggressive effort to dislodge and remove the food particles from the upper airway. The predictable result was that she triggered a massive lung spasm causing every air passage to close permanently and he died. Knowing that her husband was a potential choking victim, Tim's wife could have avoided this by asking the nurse to verbalize the standard emergency procedure for clearing the airway of food. She, like so many others, mistakenly assumed that any nurse would know exactly what to do in a crisis. We should be able to make that assumption, but the stark reality is that we dare not.