Tuesday, February 19, 2013

Nurse of the Future, 2025


It's time to say goodbye to her 'virtual' nursing cap. Dr. Jade Marciano is ready to hang up her stethoscope, finally. After all, she had been working as a nurse for 42 years now. After completing her Doctorate of Nursing Practice degree 10 years ago, she had moved on to the executive leadership position in the hospital.

“Hi, Tita Jade. I will miss your daily stops.” Her niece Charlene gave her a quick buzz on the cheek before she ran over to the ambulance ramp to meet the EMS trauma notification. Charlene is the senior nurse practitioner on duty.

Nurse practitioners had finally been integrated into the fabric of ED care. It had taken years of resistance from the medical community, but after the exorbitant malpractice insurance costs had driven down enrollment in medical schools, the emergency attending physicians had begrudgingly accepted the NPs to practice alongside the EM residents.

Dr. Jade chuckled at the thought of one clueless senatorial what’s-her-name candidate who had tried to belittle the nurses in her native country by implying that the student nurses could get by with limited education. Her concept of “room nurses” had angered the Filipino nurses, and she eventually lost the election in 2013. In her wildest imagination, she probably did not even think that nurses would even rise in stature even more.

The 2010 Institute of Medicine’s landmark report had been quite a revelation in its success. The hospital had achieved an unprecedented 100% BSN-prepared nursing staff, belying the prediction of a nursing shortage by 2020. A remarkable 35% of the ED RNs has Masters’ degree, and had been utilized as Senior Staff Nurses 5th level, with expanded responsibilities as patient care navigators and evidence-based practice advocates. The ED administration had wisely adjusted their staff by providing more Patient Care Techs and other ancillary staff to offset the higher salaries of these advanced practice RNs.

Dr. Jade is a prime example of the IOM’s vision. She was trailblazer in her profession, having collaborated with the physicians to introduce new care initiatives. She agreed that the public’s and medical community’s perception of nurses had greatly been turned around when faced with more educated nurses.

“Trauma Team, Resus 51”, a melodic announcement interrupted Dr. Jade’s thoughts. A patient from a multi-vehicular accident had just been wheeled by EMS, with a mechanical compressor performing CPR on the bloodied patient. There was no time for an intubation in the field.

In the age of microchips, only the most privacy-concerned patient would have an unknown medical history. The triage nurse bar-scanned the patient’s wrist and soon the patient’s recent medical history was displayed on a medical I-Pad Patient Screen under the cardiac monitor. The patient was an open book, a reality (and a necessity) in Big Brother's world.

Mr. C was a 35 year-old man with an AICD from a cocaine-induced cardiomyopathy. The EM-NP quickly deactivated the AICD. A glove EKG remained on the patient’s torso, a far cry from the bulb-suction EKG electrodes of Dr. Jade’s student years.

The ED attending wrapped a DBAC (Deep Bleeder Acoustic Coagulation) cuff on the patient’s upper arm to seal an arterial bleed. The trauma surgeon then activated the ultrasound zap to coagulate the severed vessel. The nurse had started her Trauma Bleed cocktail- Tranexamic acid (antifibrinolytic), Kefpush (an IV push antibiotic) , and Tetanus toxoid.

The EM-NP also had started an intraosseus line and gave a Blood Substitute polyheme on the accident scene; a necessary intervention in a depleted Blood Bank supply. There was no need for cross-matching; no chance for a transfusion reaction.

The ED attending stopped the compressor to check for the pulse. The patient pulse was steady and bounding, Sinus tachycardia was reflected on a sleek touch screen. The patient was still unconscious and was having labored breathing.

“BP 90/62, HR-120, O2 sat 92% on 100% non-rebreather.”, the nurse announced just loud enough to be heard by the Trauma Team, as well as to record the vitals on the lapel mike that was attached to her Dragoneer Head set. The hands-free device allows her to tape her assessments while she assists with patient care. As soon as she would have the time, she would review then accept the recordings on her own hospital-issued mobile phone to be written into the permanent electronic chart. Most of the nurses preferred the mike than typing into their mobile device.

NP Charlene assisted the Trauma resident in intubation and administered the dosage-controlled bar-coded RSI meds via the brachial line, and soon the resident inserted a Glidescope for easy tracheal intubation.

“ETT to vent, Tidal volume 500, F1O2 100%, AC rate 0f 16”. The trauma nurse continued to intone into her mike, as the respiratory therapist connected the endotracheal tube to the new compact-sized three-pound portable ventilator.

The trauma nurse had sent the blood tubes on the Chute to Lab, but gave the smaller sample tube to the Patient Care Tech for bedside testing.

The Patient Care Tech keyed in the results of point-of-care hematocrit, lactate and basic metabolic panel and transmitted the results on the Patient Screen. The ED attending reviewed the trended results, and nodded with satisfaction on the improved hematocrit level.

The Trauma attending brought out his newest gadget to show off, a hand-held body ultrasound scanner to check on a possible aortic dissection or any vaso-aneurysm. There was none, and suppressing a disappointed sigh, he called for the x-ray technician to come into the room.

The technician turned on the switch and the portable multi-purpose x-ray/MRI scanner lowered down from the ceiling. A series of clicks and lights emanated from the machine, creating a surreal glow around the patient.

A lacerated liver was displayed on the Patient Screen. Snapping to attention, a gaggle of trauma residents started to disconnect the patient from the cardiac monitor.

Even with the sophisticated and ultra-modern technology, the doctors still did not know how to calmly prepare the patient for transport, without unhooking the wrong tubes and tangling the IV lines. In their haste, they just wasted precious time. The nurses quickly took over, and finally declared the patient ready to go.

It all happened in twenty minutes, and off to the OR did the patient go. The RFID tracker recorded the patient’s move.

An audible decrease in the decibel and excitement level in the ED coincided with the patient’s transfer. And soon, the ED was back to its usual non-trauma frenetic pace.

Dr. Jade surveyed the newly-renovated ED, and decided that she will again propose more beds to be added. The patient daily census still remained in the 500s because of more hospital closings. The medical scene would remain a challenge.

Back at her corner Penthouse office, Dr. Jade enjoyed a 180-view of Brooklyn and Manhattan. It is a good feeling to have gone through it all. She had emerged triumphant.

From a simple nursing student in the Philippines in the late 70’s, where the students used to help sterilize the glass syringes and needles,, make their own cotton balls, reuse most supplies, and carry the metal patient charts for the doctors with their superior airs.

When she moved to the United States in the early 1980’s, she was thrust into a chronic care hospital. With 40 patients under her care, she was introduced to functional nursing. Most times, she gave out meds with only a 2x2 index card with transcribed hand-written medication orders.

In the 1990’s, she entered the world of emergency nursing and she was hooked. It was a world in transition. The nurses had to prove themselves against some medical doctors who could not believe that nurses should have a voice.

The 2000s was a year for innovations, and medical breakthroughs. Electronic charting decreased medical errors. And nursing was poised to take bigger roles in hospital leadership. In 2012, she started her Simulation journey. Now, all her nurses prepare for real-life nursing with mandatory intensive simulation experience in the state-of-the-art Sim Lab..

Now, in 2025, the transformed nursing workforce had fulfilled its promise to take a much-deserved equal acknowledgement from the public. Somehow, the world had embraced the new and expanded roles of the nurse. An empowered nurse.

Yes, it’s time to retire and hit the beaches with Max, her doctor-husband, 12 years her junior.