DiversityNursing Blog

By JOHN LELAND

Published: November 1, 2012

As two burners on his stove provided warmth on Thursday, Suzanne Gilleran, 47, carefully cut the gauze around Mr. Oberlin’s leg. “How’s your pain today?” she asked. “Did you take anything?”

As parts of the city edged toward some semblance of normal on Thursday, tens of thousands of people like Mr. Oberlin, who depend on essential home medical care, remained tenuously connected to lifesaving services by agencies like Partners in Care, an affiliate of the Visiting Nurse Service of New York.

At the Visiting Nurse Service of New York alone, more than 5,000 nurses, aides, social workers and others were out serving patients around the city during and after the storm.

Nurses and home aides, who often earn minimum wage or just above it, had to make a decision: go out in the storm or its aftermath, possibly risking their lives and ignoring conditions in their own homes, or make life possible for the patients depending on them.

“I saw six patients yesterday,” said Ms. Gilleran, who trains nurses at Partners in Care, and does not ordinarily make home visits. But because of Hurricane Sandy, the agency pressed all available registered nurses into field duty, as did other agencies around the city, often sending them into conditions made difficult by the weather: the power failures, the lack of public transit, the traffic.

It took Ms. Gilleran three hours on the express bus from Forest Hills, Queens, to get to Mr. Oberlin. Then there were the stairs. The lowest patient “was on the fourth floor,” she said, “the highest was on the 14th.”

“I realized,” she added, “I walked halfway up the Empire State Building, and most of the stairwells were pitch black.”

Allison Chisholm, 46, who works for the Visiting Nurse Service, lives with a frail mother in Park Slope, Brooklyn. When the lights started flickering during the storm on Monday, she had images of her mother falling in the dark. But she also had patients who needed her, including one receiving hospice care in a 12th floor apartment in Chinatown, and one needing an intravenous round of antibiotics in the West Village.

“It was treacherous driving during the hurricane,” said Ms. Chisholm, fitting an intravenous line into the arm of Jill Gerson, 71, who teaches social work at Lehman College in the Bronx. “But it’s just something you have to do as a nurse. That continuity of care helps the healing. I don’t see this as being heroic. I have a conscience. I need to get to sleep at night.”

Dr. Gerson had been hospitalized twice — first as a result of complications from a dental implant, then because of a reaction to her antibiotics. If she missed one day of antibiotics now, she would probably be all right, but two or three days could be life-threatening.

Dr. Gerson, who lives in the West Village, close to the Hudson River, stayed in her home rather than move in with friends, even as the water flowed down her street and into her basement.

“This woman has been saving my life,” she said, pointing to Ms. Chisholm.

Ghislaine Chery, 50, provides home care to patients at two housing projects in the Rockaways; under normal circumstances she travels with a guard. When the storm approached, and the Rockaways were subject to mandatory evacuation, she talked with her clients about leaving.

“After Irene, many of them had had to wait several days for buses to return, and they didn’t want to go through that again,” Ms. Chery said in a telephone interview. So they stayed — blind and in wheelchairs, blind and diabetic — counting on Ms. Chery, who lives on Long Island, to reach them with their medications and other essential services.

“I was here by 7:45 Tuesday morning,” Ms. Chery said. “I’ve been seeing 8 or 10 patients every day. It’s been a real experience.”

As the recovery drags on, a growing need is for mental health care. Scott Feldman, a social worker for the Visting Nurses, answered a call on Wednesday night for volunteers on Staten Island, where he lives. When he arrived at Tottenville High School, which was serving as a temporary shelter and evacuation center, he was directed to a couple in severe distress.

“They’d seen cars coming up their street, not being driven by anyone, just by the flood,” Mr. Feldman said. “They’d lost everything.” Then they tried to help another couple across the street, but had only been able to save the woman, Mr. Feldman said. “The wife was sleeping when I got there. The husband was waking up every hour screaming. So now what do they do?”

At Mr. Oberlin’s apartment, as Ms. Gilleran prepared to leave, taking the trash with her, Mr. Oberlin, who was a well-known countertenor and founding member of the New York Pro Musica Antiqua ensemble, beamed. “I can’t get over this service,” he said. “At the same time, I can see how expensive it must be.”

Dr. Gerson had a different opinion: “This service saves a fortune, because we don’t have to be in hospitals. They don’t pay these people enough.”

Ms. Chisholm waited patiently for the antibiotic drip to finish. She had a long way to go from the West Village back to Park Slope.

By ANEMONA HARTOCOLLIS and NINA BERNSTEIN

Published: November 1, 2012

Officials rushed to move the most critically ill patients closer to an emergency generator. After midnight, doctors heard shouts in the hallway. The basement fuel pumps had stopped working, and medical residents, nurses and administrators formed a bucket brigade to ferry fuel up 13 flights to the main backup generators.

By Tuesday, the elevator shafts at Bellevue, the country’s oldest public hospital, had flooded, so all 32 elevators stopped working. There was limited compressed air to run ventilators, so oxygen tanks were placed next to the beds of patients who needed them. Water faucets went dry, food ran low, and buckets of water had to be carried up to flush toilets.

Some doctors began urging evacuations, and on Tuesday, at least two dozen ambulances lined up around the block to pick up many of the 725 patients housed there. People carried babies down flights of stairs. The National Guard was called in to help. On Thursday afternoon, the last two patients were waiting to be taken out.

The evacuation went quickly only because Bellevue had planned for such a possibility before Hurricane Irene hit last year, several doctors said. But the city, which had evacuated two nearby hospitals before that storm, decided not to clear out Bellevue. In the wake of Hurricane Sandy, the consequences of bad calls, bad luck and equipment failures cascaded through the region’s health care system, as sleep-deprived health care workers and patients were confronted by a new kind of disarray.

A patient recovering from a triple bypass operation at Bellevue walked down 10 flights of stairs to a waiting ambulance, one of the dozens provided through the Federal Emergency Management Agency to speed patients across the metropolitan region.

Mount Sinai Medical Center, already dealing with the 2 a.m. arrival of a dozen psychiatric patients who spoke only Chinese, was struggling to identify the relatives of brain-injured traffic victims from Bellevue who arrived three hours later with only rudimentary medical records.

Maimonides Medical Center in Brooklyn was straining to meet a rising need for emergency dialysis for hundreds of people shut out of storm-crippled private dialysis centers. Patients who would normally get three hours of dialysis were getting only two, to ensure the maximum number of people received at least a minimal amount of care.

“The catastrophe is growing by the minute,” said Eileen Tynion, a Maimonides spokeswoman. “Here we thought we’d reached a quiet point after the storm.”

Every hospital maintains an elaborate disaster plan, but after Hurricane Sandy, the fact that many health care facilities are in low-lying areas proved to be something of an Achilles’ heel. Bellevue became the third hospital in the city to evacuate after the storm’s landfall, after NYU Langone Medical Center, just north of Bellevue, and Coney Island Hospital, another public hospital.

New York Downtown Hospital, the only hospital south of 14th Street in Manhattan, and the Veterans Affairs Hospital, just below Bellevue, had evacuated before the storm.

Hospital executives were reluctant to criticize their colleagues or city officials. But the sequence of events left them with many questions.

“All hospitals are required to do disaster planning and disaster drills,” Pamela Brier, the chief executive of Maimonides, noted. “All hospitals are required as a condition of being accredited, to have generators, backup generators.”

City health department and emergency officials have been particularly fervent about citywide disaster drills, she added, but “as prepared as we think we are we’ve never had a mock disaster drill where we carried patients downstairs. I’m shocked that we didn’t do that. Now we’re going to.”

The city’s health commissioner, Dr. Thomas Farley, defended the decision not to require evacuations of Bellevue, Coney Island and NYU Langone hospitals before the storm, which he said had been made in consultation with the state health commissioner, Dr. Nirav Shah.

Dr. Farley said they based the decision on their experience with Hurricane Irene, when they ordered the evacuation of hundreds of patients from six hospitals, including NYU Langone, and a psychiatric center, as well as of thousands of residents of nursing and adult homes.

“We saw there was definitely risks to patients from evacuations,” Dr. Farley said.

He added that, “As the storm got worse on Sunday, we did recognize that there would be some risk to health care facilities, so we took some steps to make sure that they were aware of that.”

But he said he considered the decision to wait a success overall: “There was no loss of life as a result of those evacuations.”

He said the city was still assessing what to do differently next time. “We certainly are seeing many more severe weather events in this city than we’ve seen in the past, that does mean we have to rethink the vulnerability of our health care facilities,” Dr. Farley said.

A major concern for hospitals is that traditionally, generators, fuel tanks and fuel pumps have been located in their basements. Both NYU Langone and Bellevue had actually shored up their defenses after Hurricane Irene, according to executives of both hospitals. Among other changes, both built flood-resistant housings for their fuel pumps.

But some circuitry, as well as tanks and pumps, remain on low floors, making backup systems vulnerable. The equipment is enormously heavy, so putting them on higher floors would require a great deal of reconstruction and possibly changes in building codes, said Dr. Steven J. Corwin, the chief executive officer of NewYork-Presbyterian Hospital, which has been taking on extra patients and bringing in extra staff.

Another serious issue is how long a hospital should expect to rely on a generator if the power fails.

“Heretofore, it was felt that generator power would be for a self-limited time, not more than a day — two, three at the outside,” Dr. Corwin said. “Now we’re looking at events where it could be a week.”

Alan Aviles, president of the Health and Hospitals Corporation, which runs the city’s public hospitals, said that all signs pointed against a storm emergency. “Up until an hour before the storm made landfall, the National Hurricane Center was saying that there was only a 5 percent probability of a storm surge over 11 feet in the area that would impact Coney Island, and they weren’t even showing a 5 percent probability on the East River,” Mr. Aviles said.

When the main power went off about 9 p.m. Monday, doctors and nurses were initially told not to worry, because the backup generators were working fine, people there at the time said. But by about 10 p.m., the basement was completely flooded, the pumps were flooded, and doctors were warned that they could lose backup power very shortly.

Critical-care doctors and nurses immediately began moving their patients to the area served by a lower-floor generator. Everyone moved quickly to disconnect patients from respiratory machines and then reconnect them.

A Bellevue doctor said midlevel administrators began begging their bosses to evacuate the hospital Monday night, when water could be heard pouring through the elevators, “like Niagara running through the hospital.”

“The phones didn’t work,” he said, speaking on the condition of anonymity for fear of being fired. “We lost all communication between floors. We were in the dark all night. No water to wash hands — I mean, we’re doctors!”

When the evacuation began, patients were bundled into red and orange sleds and dragged down as many as 13 or 15 flights of stairs. “If they were ventilated, someone was dragging them with a bag” of hand-pumped oxygen, one doctor said. “It was a herculean effort.”

Despite the power problems, Bellevue was able to print out some medical records or get summaries from doctors to send with patients. But landlines and cellphones were affected, and doctors and nurses said they wished some other form of communication, like walkie-talkies, had been available.

It was not until Wednesday, Mr. Aviles said, that everyone realized the situation was beyond repair and the final decision to evacuate everyone was made. “It was at that point that it was clear that it was just not tenable to keep patients for a longer term in the hospital,” he said. “We know that all these patients were successfully transferred to safety and are doing well, and I think that’s what’s important.”

By ABIGAIL ZUGER, M.D.
NYTimes.com

 
When a book is heavy with glossy photographs, you seldom expect too much from its words. In “The American Nurse,” though, it’s the narrative that hits you in the solar plexus.

Take the comments of Jason Short, a hospice nurse in rural Kentucky. Mr. Short started out as an auto mechanic, then became a commercial trucker. “When the economy went under,” he says, “I thought it would be a good idea to get into health care.” But a purely pragmatic decision became a mission: Mr. Short found his calling among the desperately ill of Appalachia and will not be changing careers again.

“Once you get a taste for helping people, it’s kind of addictive,” he says, dodging the inspirational verbiage that often smothers the healing professions in favor of a single incontrovertible point.
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Some of the 75 nurses who tell their stories in this coffee-table book headed into the work with adolescent passion; others backed in reluctantly just to pay the bills. But all of them speak of their difficult, exhilarating job with the same surprised gratitude: “It’s a privilege and honor to do what I do,” says one. “I walk on sacred ground every day.”

They hail from a few dozen health care settings around the country, ranging from large academic institutions like Johns Hopkins in Baltimore to tiny facilities like the Villa Loretto Nursing Home in Mount Calvary, Wis., home to 50 patients and a collection of goats, sheep and other animals on a therapeutic farm. Some nurses are administrators, some staff wards or emergency rooms, some visit patients at home. Many are deeply religious, a few are members of the military, and a handful of immigrants were doctors in their home countries.

All describe unique professional paths in short first-person essays culled from video interviews conducted by the photographer Carolyn Jones. Their faces beam out from the book in Ms. Jones’s black-and-white headshots, a few posing with a favorite patient or with their work tools — a medevac helicopter, a stack of prosthetic limbs or a couple of goats.

But even the best photographs are too static to capture people who never stop moving once they get to work. For a real idea of what goes on in their lives, you have to listen to them talk.

Here is Mary Helen Barletti, an intensive care nurse in the Bronx: “My whole life I’ve marched to a the beat of a different drummer. I used to have purple hair, which I’d blow-dry straight up. I wore tight jeans, high heels and — God forgive me — fur (now I am an animal rights activist). My patients loved it. They said I was like sunshine coming into their room.”

Says Judy Ramsay, a pediatric nurse in Chicago: “For twelve years I took care of children who would never get better. People ask how I could do it, but it was the most fulfilling job of my life. We couldn’t cure these kids, but we could give them a better hour or even a better minute of life. All we wanted to do was make their day a little brighter.”

Says Brad Henderson, a nursing student in Wyoming: “I decided to be a nurse because taking care of patients interested me. Once I started, nursing just grabbed me and made me grow up.”

Says Amanda Owen, a wound care nurse at Johns Hopkins: “My nickname here is ‘Pus Princess.’ I don’t talk about my work at cocktail parties.”

John Barbe, a hospice nurse in Florida, sums it up: “When I am out in the community and get asked what I do for a living, I say that I work at Tidewell Hospice, and there’s complete silence. You can hear the crickets chirping. It doesn’t matter because I love what I do; I can’t stay away from this place.”

The volume is not entirely about selfless service: It was underwritten by Fresenius-Kabi, a German health care corporation and leading supplier of intravenous drugs in the United States. Presumably, crass public relations motives lurk somewhere in the background. But that’s no real reason to be meanspirited about the result, a compelling advertisement for an honorable profession.

Young people with kind hearts and uncertain futures might just sit themselves down with the book, or wander through the Web site featuring its video interviews, www.americannurseproject.com, and see what happens.

By PAM BELLUCK

Published: October 8, 2012

“I thought I was going to see a regular doctor,” she said, but instead she saw “this giant screen.”

Suddenly, two doctors appeared on the video screen: dermatologists in Boston. A nurse in the room with Ms. Cohen held a magnifying camera to her face, and suggested she close her eyes.

Why? she wondered — then understood. The camera transmitted images of her face on screen, so the doctors could eyeball every bump and crater. “Oh my God, I thought I was going to cry,” Ms. Cohen recalled. “Even if you’ve never seen that pimple before, it’s there.”

That, she realized, was the point. Technology, like these cameras and screens, is making it affordable and effective for doctors to examine patients without actually being there.

More hospitals and medical practices are adopting these techniques, finding they save money and for some patients work as well as flesh-and-blood visits.

“There has been a shift in the belief that telemedicine can only be used for rural areas to a belief that it can be used anywhere,” said Dr. Peter Yellowlees, director of the health informatics program at the University of California, Davis, and a board member of the American Telemedicine Association. “Before, you had to make do with poor quality, or buy a very expensive system. Now, you can buy a $100 webcam and do high-quality videoconferencing.”

The technology is especially being embraced in professions like ophthalmology, psychiatry and dermatology, which face shortages of physicians. At Kaiser Permanente, dermatologists “sit in a suite in San Francisco” and tele-treat patients throughout Northern California, Dr. Yellowlees said. “It’s much more efficient than having 20 hospitals, each with a dermatologist.”

On Nantucket, an island 30 miles from the nearest spit of mainland, “telemedicine just makes a lot of sense,” said Dr. Margot Hartmann, chief executive officer of Nantucket Cottage Hospital. “It allows us to meet the mission of the hospital better because we’re offering more locally,” and saves patients the cost and time of flying or ferrying off-island, then driving to Cape Cod or Boston hospitals.

The island may be small, but it has strikingly diverse medical needs. Its year-round population of about 10,000 balloons to 50,000 in the summer. And while it is famous for wealthy visitors, its year-rounders are much less affluent. They include immigrants from many countries, and range from businesspeople to scallopers.

Nantucket has all the ailments one would find anywhere, plus some exacerbated by island life: skin cancer, tick diseases, water accidents.

“Most people are within an hour of some major hospital,” said Joanne Bushong, the hospital’s outpatient clinical coordinator. Not Nantucket. “We’re not practicing rural medicine; we’re practicing island medicine.”

Nantucket’s hospital has a handful of year-round doctors. While mainland specialists do visit, fog or storms can keep them from getting there. And specialists cost money. The hospital, millions in the red in recent years and now needing $60 million to replace its outmoded 1957 building, must pay for the specialists’ travel and lodging.

Telemedicine, done by doctors at Massachusetts General Hospital, saves some of those costs, and generates revenue because it means more tests are done on Nantucket. “If someone was going off-island to see a dermatologist, they would probably have their labs and X-rays done where that dermatologist was,” Dr. Hartmann said.

Instead, tele-dermatology saves nearly $29,000 a year because two dermatologists now visit only four times a year, but appear on screen six times a month and see 1,100 patients a year. Previously, dermatologists visited monthly, and always had “100 people on the waiting list,” Ms. Bushong said.

Nantucket also uses tele-radiology, having Boston radiologists, some specializing in certain body areas, read X-rays and scans. It has used tele-pediatrics twice, for a child in a car accident and one in diabetic crisis. Tele-stroke uses video neurologists to quickly determine if a patient’s stroke type warrants a clot-busting drug, tPA, or if tPA could harm the patient.

Tele-endocrinology, for thyroid problems and diabetes, is starting. And Nantucket hopes to have video sessions for autistic children “so parents would not have to take kids with autism off-island, since it’s hard to travel with them and it upsets them,” Ms. Bushong said.

Dr. Hartmann envisions tele-rheumatology and tele-psychiatry, among other teles. Instead of screens in one exam room and the emergency room, “I would love to see every room telemedicine-capable,” she said.

But there are limitations, nationally and on Nantucket. Dr. Yellowlees said interstate telemedicine was hindered by rules requiring that doctors be licensed in the state where patients are treated.

Insurance coverage varies, with Medicare and some policies covering telemedicine services only in rural areas. “If you’re in a city, Medicare will only reimburse if you’re in the same room as the doctor,” Dr. Yellowlees said.

And some telemedicine is not cost-saving or accepted by doctors on the receiving end. Memorial Hermann Hospital-Texas Medical Center in Houston ended a tele-I.C.U. program in which intensive care specialists monitored and assisted intensive care units at five other hospitals. It was expensive and not demonstrably better, and some doctors and nurses disliked being watched from afar, said Dr. Eric J. Thomas, associate dean for health care quality at University of Texas Medical School at Houston.

On Nantucket, Dr. Timothy J. Lepore, 67, a surgeon and the hospital’s medical director, sees value in some long-distance doctoring, but has some concerns. He especially prefers having a radiologist on-site because he believes that conferring in person helps prevent mistaken readings and gets quicker results.

Dr. Lepore said that one tele-radiologist misread a chest X-ray, missing that the patient had pulmonary edema, fluid in the lungs. And when Dr. Lepore injured a hamstring while running, a tele-radiologist said an M.R.I. showed Dr. Lepore had pulmonary edema of the hip, which was bizarre and impossible. His actual diagnosis: a torn hamstring.

Occasionally, Dr. Lepore said, “it just goes completely off the trolley.”

Dr. Efren Flores, a radiologist who divides time between Boston and Nantucket, said he has learned to heed Dr. Lepore’s insistence on fast, accurate tele-radiology readings because on Nantucket it is important to determine if patients can be treated there or must be flown to Boston.

Many patients appreciate that telemedicine saves them trips off-island, but not everyone likes it.

“There are some people who just flatly refuse, and I see them in person,” said Dr. Peter Schalock, one of the two Mass General dermatologists who treat Nantucketers remotely. He said he has had to get used to diagnosing without feeling a patient’s skin, relying on the nurse, Ms. Bushong, for that. “Somebody with 100 strange-looking moles, I can probably do in 10 or 15 minutes myself, when it might take half an hour with the camera. Definitely people with more interesting moles, I like to see myself.”

Still, “we’re pretty good at picking up what looks funky, to use a technical term,” Dr. Schalock said. “I really feel like we’re providing essentially the same quality care.”

So, in August Dr. Schalock remotely diagnosed eczema in Aaron Balazs, 35, but saw him in person in September and increased his medication dosage and switched him from a cream to pills.

Mr. Balazs, stationed on Nantucket with the Coast Guard, was not expecting video doctoring, and said initially “it was sort of awkward.” But he concluded “it’s definitely beneficial for both parties.”

By the time Ms. Cohen had her second session in August, this time with Dr. Schalock, she said, “I feel like it’s the same thing” as an in-person visit. She had accepted the mega-magnifying camera by then.

“It kind of freaks out some people,” Dr. Schalock said. “They say, ‘Oh my God, I should have shaved my legs!’ I’m not looking at the hair. I’m looking at the mole.”

From eyeglasses to the stethoscope to imaging the brain at work, a long list of inventions and innovations have changed medicine. Click here.

CNN|Added on November 1, 2012

CNN's Anderson Cooper talks to a nurse who became a viral sensation after she evacuated a baby during Superstorm Sandy.

Video

 By KATIE MOISSE (@katiemoisse) Nov. 1, 2012

Among all the rescues carried out during the chaos caused by Sandy, the most delicate was the mission to save embryos in rows of incubators that were in jeopardy when the NYU Fertility Center lost its power.

The Manhattan clinic lost power shortly after Sandy struck Monday night. A generator perched atop the 8-story building kept incubators running through the night, but flooding in the basement cut off its fuel supply.

"The generator ran out of gas around 8:15 Tuesday morning," said Dr. James Grifo, the clinic's director.

Without power, the incubators housing delicate embryos at womb-temperature for in vitro fertilization began to cool. But Grifo and his team took action, hoisting five-gallon cans of diesel fuel up darkened stairwells to feed the failing generator.

"It was really a privilege to be part of that," Grifo said of his staff's "heroic" efforts.

The fuel bought the team enough time to transfer the embryos into liquid nitrogen, where they can be stored indefinitely.

The embryos were secured as another urgent issue arose.

At 10 a.m., a patient arrived for an egg retrieval -- a surgical procedure timed down to the hour after a two-week run of expensive fertility drugs.

Grifo loaded the woman into his car, along with her husband and their baby, and rushed them to a colleague's clinic uptown.

"It's amazing what people can do when everyone's on the same page," Grifo said, adding that the rest of the clinic's patients were booked into clinics throughout the city to "salvage" their cycles.

"It's a testament to the people in New York who work in medicine," he added. "Some of our most vicious competitors offered assistance."

Sandy spawned record-breaking tides around lower Manhattan, prompting power outages from East 39th Street to Battery Park at the southern tip of the island. The NYU Fertility Center is on First Avenue and 38th street, just a block from the overflowing East River.

The storm forced the nearby NYU Langone Medical Center to evacuate 300 patients in gusts of wind topping 70 miles per hour. Cells, tissues and animals used for medical research were left to die in failing refrigerators, freezers and incubators.

But thanks to Grifo and his team, eggs and embryos at the fertility clinic were spared.

"Hopefully we'll get some babies out of it, and that'll be a nice story as well," he said.

Sandy was an example of what some fertility clinics call an "act of God," an unfathomable tragedy that patients are warned about before starting the IVF process.

"There's so much riding on this," said Dr. James Goldfarb, director of the University Hospitals Fertility Center in Cleveland. "Even when everything's going smoothly, it's stressful for women. But add the stress of having to start all over again, that's extremely stressful."