Why Do Some Nurses Prefer Night Shift?

I was reading a newly released medical thriller when I came across this passage:

“Nurses on night shift were often young (lack of seniority meant they had no choice but to work unpopular hours) and surly (i.e., pissed off about it.)”

Yes, that’s a quote. Perhaps I’m being oversensitive (okay, of course I am), but this is my profession and I don’t like me or my colleagues to be painted in such broad strokes so I thought I would give some reasons why some nurses actually prefer to work nights and are even very happy about it. These are not numbered according to importance.

1. Night Shift Differential. Nurses are generally paid a nice differential for working nights. This varies widely depending on the institution but can be a nice bump in pay. This may translate into working less and being able to spend more time with family or getting more bang for your buck for working the same hours.

2. We’re just night people. I know day shift people don’t understand that it is easier for some people to stay up all night. Our clocks are a little bit different than most other people. That’s a good thing, right? You don’t want your night nurses falling asleep and it’s a good thing some nurses like working nights because hospitals run 365/24/7. Personally, I think a crime has occurred if I have to be up before the sunrise. It feels wrong on a cellular level.

3. Child Care Reasons. Some families like to juggle one (or even both) parents working nights to limit or stave off daycare costs.

4. Less Administration on Site. This might be the night shift untold secret, but there are infinitely less administrators around during the night shift which means less overall scrutiny. I don’t mean to say night nurses are crazy with power and do inappropriate things, but there is a more relaxed feeling on nights because of this. Government entities don’t pop in at 0300 for a surprise inspection— though they might now that I’ve written this.

5. More Relaxed Pace. Many nurses prefer nights because of the more relaxed pace. Fewer tests and procedures to take your patient to. In the ER setting, less overall patients as the night goes on (though you also have less nurses to take care of those patients.) For inpatient and ICU nurses, doctors round during the day which is when the most orders are generated. Not having as many tasks leaves more time to truly connect with your patient. When we have only one or two ER patients at 4AM— we can spend a lot of time teaching and/or visiting with families.

6. They are smart, scrappy people. Not to say this isn’t true of day shift nurses, but night shift nurses usually have less resources available to them overnight. There are fewer people— fewer bodies to help in a code. Support services like lab, pharmacy, central supply, etc may not staff people 24/7 so if a patient needs something, night shift nurses have to think outside the box.

Overall, what raised my ire about these two small sentences from this author (a male physician) was the “surly” connotation. Even if a nurse doesn’t like to work nights, they do not take it out on their patients because of it. Are there cranky, surly nurses? Sure.

However, you can find them on both days and nights.

Love your night shift nurses. They are there for you when everyone else sleeps. And many are highly professional, excellent nurses with years of experience.

Child Abuse Injuries: Part 2/2

April is Child Abuse Awareness Month. Last post, I covered how a given history for an injury may be a signal that an injury was intentionally inflicted. Today, I’m going to cover how the injury itself may give off clues for an abusive injury.

Injuries suspicious of abuse:

1. Injury is beyond the child’s developmental level: You’ll notice this is the first clue I gave concerning the history, but it also plays into the injury itself and I’m going to talk specifically about infants. Any bruising in an infant to the face, head and neck when they are not yet pulling themselves up to a standing position is concerning for abuse. To create an injury, you have to fall off of or run into something and you need to have some velocity behind it.

2. The injury has a pattern: Consider typical childhood bruises. They are roundish in shape, of varying circumferences, and received from a low-velocity type injury . . . say the child running into a counter with their forehead. Anything that makes a visible pattern generally requires high-velocity force to imprint the pattern onto the skin. If I loop a belt and tap you with it, there likely won’t be any injury at all versus if I take it and swing it at you like a pitcher throwing a baseball, it has the potential to create a loop like bruise.

3. The injury in not over a bony prominence: Again, if you have children, think back to their younger days when injuries were common. When they fell, where did they bruise? Head (scalp, forehead, nose, chin), elbows, shins, and knees. Most often, kids fall or run into something in a forward motion. Bruising to the buttocks in a diapered child is particularly concerning. Often, they will fall onto their bottoms, but they also have extra padding.

4. There are a lot of bruises: This is not definitive but can be a signal for abusive injury, particularly if the pattern is not a normal bruising pattern as in #3.

None of these items is taken in isolation as a single indictment against the caregiver. Let’s say you accidentally drop a toy onto your 2 month old’s face while cleaning up. It causes a bruise and you want it checked by the pediatrician. The pediatrician is not going to report you. Why? You have a plausible story (dropping something onto the baby’s face), it is a low velocity injury (the bruise is probably small and round) and there is only one.

Medical professionals look at the totality of the child’s case: the history, the social environment, and the injury is considered before a report to child services is made. Reports are not made lightly.

The above offers some beginning guidelines. In the comments section, give a specific injury that might be concerning for abuse.

Child Abuse Injuries: Part 1/2

I read a lot of fiction. Okay, suspense fiction. What I find missing is an area that seems to be in few books yet inherently has a lot of conflict. Child abuse. What fiction titles are you aware of that, as a central theme, center around child abuse?

April is Child Abuse Awareness Month so I thought I’d do a few posts about child abuse injuries and how medical providers pick up on the fact an injury may be intentional or inflicted.

As a pediatric nurse, I’ve been witness to child homicide at the hands of abuse. Yes, it is murder. It’s a necessary part of my job in dealing with these families, perhaps even the confessed abuser, as I care for the child abuse victim. And yes, there is a lot of conflict in these situations.

How do we as pediatric medical providers begin to suspect that an injury is abusive? During the initial evaluation of an injury, confession among abusers is rare (perhaps, they will confess later.) Often, there is a history given to account for the injury. Both parts: the history of the injury and the injury itself can give red flags for child abuse. Today, let’s examine the story and how it may signal an abusive injury.

The story concerning the injury:

1. Is not realistic considering the child’s developmental level. This is more common than you might think. Most people cannot rattle off when a child should meet certain developmental milestones so they’ll say the child injured themselves in a manner that is beyond their developmental age. For instance, “my daughter broke her arm by rolling off the couch”. The baby is two-weeks old. Infants typically roll over starting at 3 months. Here’s a great resource for any writer/parent for developmental milestones.

2. The story changes. Just like other criminals, abusers can have a hard time keeping their story straight. Often times, the more abusers are questioned about the plausibility of the story, it will begin to change. Medical staff interviewing a potential abuser can be like a detective getting a criminal to confess. The doctor will often approach the caregiver several times to ask questions about the injury to see if the story changes. In later interviews, the doctor may say, “This injury is suggestive of abuse.”

3. The story has too much detail. This one may seem odd but it can be a red flag for abusive injuries. If you have children, think back to their toddler/elementary school years when they seem to come home with lots of bumps, bruises, cuts and scrapes. If asked, could you come up with an explanation for each and every injury? Likely, no. Abusers will try and explain away every injury. A non-abusive parent will be truthful and likely say, “I have no idea how that happened.” and then probably feel guilty about not knowing.

What other parts of a medical history/story might give a signal for abusive injury?

Civil War Medicine: Part 4/4

Today, we’re finishing up with Erin Rainwater’s amazing series on Civil War medicine. You can find Part I, Part II, and Part III by clicking the links.

Civil War Medicine: Hapless or Heroic in Retrospect? 

History has not always been kind to Civil War practitioners of medicine. The methods discussed in the previous posts seem barbaric to us now, and the lack of medical knowledge regarding foundational principles such as asepsis, infection, and sanitation is regarded as tragically antiquated. Their twenty per cent mortality rate is unacceptable by today’s standards. More horror stories abound. From our retrospective and often condescending viewpoint, we smugly judge one century’s standards by the current set. This is not only an unfair but a flawed verdict. The inadequacies of those medical care deliverers have received considerably more attention than their accomplishments, which were many.

If judged by the standards of their day, Civil War doctors and nurses should be hailed as remarkably successful.  With the existence of bacteria still only theoretical, with the available instruments and anesthesia, and with the indescribable numbers of patients inflicted upon them, the fact they saved lives in such unhoped-for numbers is a credit to their skill, creativity, and tenacity.

In the war that preceded this one, the Mexican-American War, ten men died of disease for every one killed in combat. During the Civil War, that ratio was reduced to 2:1. That alone is measurable evidence of an enormous advancement in medical care in the span of under two decades, much of which came about as a result of the war. The creation of frontline field hospitals, ambulance services, and the utilization of female nurses should cause modern historians to conclude that the maligned medical practitioners during the Civil War should be reckoned as heroic, not hapless. Their crude system of triage, setting aside men wounded through the head, chest or abdomen because they would most likely die seems brutal, but with the knowledge and little time available, it allowed surgeons to save those who could be saved. Modern mass casualty triage is not so far removed from this practice.

Aside from medical care administered to the living, advancements in post mortem measures took place as well. Prior to the war, embalming was usually only done to preserve specimens for scientific study. Because many families of killed soldiers desired to bring them home for burial, embalming became more commonplace.

I have only skimmed the surface in relating how the War Between the States necessitated numerous adaptations in the delivery of medical care, and how we benefit even today from some of those changes. These are just some examples of not only medical but also the many moral and social advancements that came as a result of the American Civil War. I truly hope these four posts have been educational and entertaining, and that perhaps this information will help you gain a greater appreciation of our sesquicentennial commemorations over the course of the next four years.

REFERENCES:

Burns, Stanley B., MD, FACS, “The Naldecon Gallery of Medial History,” Bristol Laboratories, © 1987.

Civil War Manuscripts, Library of Congress.

Downs, Robert B., Books That Changed Amercia.

Miller, Francis Trevelyan, ed., The Photographic History of the Civil War, Prisons and Hospitals

Ward, Geoffrey C., Burns, Ric, and Burns, Ken, The Civil War, An Illustrated History. Alfred A. Knopf, Inc., © 1990.

The Day Richmond Died.

www.civilwarhome.com/medicinehistory

www.civilwarsurgeons.org

www.members.cox.net/cwsurgn/civilwar

http://home.nc.rr.com/fieldhospcsa

*********************************************************************************************Erin Rainwater is a Pennsylvania native whose trip to Gettysburg when she was twelve enhanced her already deep interest in the Civil War. She attended Duquesne University in Pittsburgh, and entered the Army Nurse Corps upon graduation.  Serving during the Vietnam War era, she cared for the bodies and spirits of soldiers and veterans, including repatriated POWs and MIAs. Now living in Colorado, she is a member of a Disaster Medical Assistance Team, and has been deployed to disaster areas around the country. True Colors is partly based on her military and nursing experiences as well as extensive research. She also authored The Arrow That Flieth By Day, a historical love story set in 1860s Colorado, and Refining Fires, a uniquely written love story that was released in July, 2010. Erin invites you to visit her “virtual fireside”.

***Content reposted from January 31, 2011.***

Civil War Medicine: Part 3/4

We’re continuing Erin Rainwater’s four part series on Civil War Medicine. You can find Part I and Part II by clicking the links.

Conditions and Treatment

Unlike today, the majority of soldier deaths during the Civil War were attributed to disease. Unsanitary and close-quarter living conditions in the camps led to outbreaks of dysentery, typhoid, measles, smallpox, chicken pox, throat distemper (diphtheria), and other diseases. Scurvy and other nutritional disorders were prevalent, as was typhus from lice and fleas.

Mosquito-borne illnesses such as yellow fever and “ague” (malaria) also posed a threat, although they were believed due to “miasmic vapors” from stagnant waters. Minor wounds such as from a splinter, a scratched mosquito bite, or the rub of a boot could become infected and ultimately lead to septicemia and death. Lacking scientific knowledge regarding the causes of disease, physicians depended on a few standard remedies, such as quinine, calomel, ipecac and opium to cure most symptoms. Mercury was used to treat venereal disease, although it only cleared the symptoms and was not a cure. Nitric acid was poured on open wounds to kill infection. It also seared the flesh.

The physiology of some conditions, such as the gastrointestinal system, was surprisingly well known back then. The digestive process was understood, as well as the length of time for various foods to be digested. Much of this knowledge came from Dr. William Beaumont’s experiments and studies, including the observation of an open stomach wound in a man who’d been shot.

Gastrostomy tubes were used for feeding patients with such wounds, and drains were placed to remove infectious drainage and gastric juices. Cardiopulmonary-wise, physicians used stethoscopes to discern crepitant rales and rhonchi, heart murmurs, and friction rubs. They used percussion techniques in the physical exam to appreciate dullness and diminished resonance of the chest and abdomen. Mercury thermometers were available but rarely used. Fever was considered a disease, and temperatures were taken only to investigate unusual maladies or those of special concern. Doctors then were faced with some of the same frustrations of today: addicts pilfering drugs and alcohol, and well-intentioned family members offering food to patients with serious stomach and intestinal ailments and wounds.

Wounds, of course, were the other consideration in this war of inconceivable casualties. As bullet manufacturing changed during the war so did the wounds they left. The small- caliber round balls shot from a smooth bore musket often produced a different type of wound than the newer, faster velocity, conical-shaped slugs later produced. All had the capacity to incur catastrophic injuries beyond repair. In battlefront hospitals, there were few alternatives to amputation of limb wounds, and an experienced surgeon could perform the procedure in under ten minutes.

Later in the war, some surgeons experimented with blood vessel resection, but amputation remained far more common. Soldiers with head and chest wounds were given a poor prognosis, and often not considered treatable. Bullet wounds were the most common by far, but those from canister, cannonballs, shells, sword and saber had to be reckoned with as well.

It was considered routine that combat wounds become infected. Pus was considered “laudable” because the body was discharging poisons, a necessary adjunct to proper healing. In the rare instances pus did not appear, it was called “union by first intention” and considered an utter mystery. Yet there were five types of infections acknowledged as abnormal.

A triad of infections referred to as “hospitalism” included gangrene, erysipelas (a skin infection we now know is caused by strep), and pyemia (septicemia, or “blood poisoning.”) The mortality rate from these hospital-acquired infections reached ninety-five per cent. The survivor of a “routine” infection often became the victim of osteomyelitis, a chronic bone infection, and was doomed to a slow and painful death from a festering wound where entire sections of bone would be eaten away. Tetanus was present, though less common than other diseases, because most battles were fought on virgin soil unfouled by the manure that carries the tetanus spores.

Wet dressings could be applied utilizing a siphoning technique. One end of a strip of cotton or linen was placed in a container of water suspended over a wound. The other end of the material hung just above the wound but below the level of the water, thus providing a continuous drip. The nurse was freed up from having to return for frequent remoistening of the bandage. Oilcloths were placed to catch the excess water and drain it into a vessel on the floor.

With flies rampant, so were their eggs, or maggots. Although the critters caused no pain, female nurses were disgusted by them and their wiggling bothered the wounded men. Yet some discerning surgeons detected that wounds infested by maggots healed more rapidly, and that the little vermin actually cleansed wounds, digesting and removing dead tissue while leaving healthy tissue uninjured. Rats reportedly tendered similar results. Some modern day physicians have accepted maggot therapy as useful for debridement, although I’ve yet to see where rat therapy has become part of standard treatment.

Without the benefit of x-ray equipment, sometimes the only way to hit upon the location of a bullet was to take “soundings.” In my novel True Colors Cassie Golden, who at this point thinks she’s seen everything, watches in awe as a Confederate surgeon inserts a porcelain-tipped probe into a wound and taps it against various obstacles. She observes that the sound of tapping bone versus lead is distinguishable. Additionally, when the doctor rubs the white-tipped probe against lead it comes out streaked with gray—a sign it has detected its quarry. Like all nurses, she realizes that the learning process is never over.

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Erin Rainwater is a Pennsylvania native whose trip to Gettysburg when she was twelve enhanced her already deep interest in the Civil War. She attended Duquesne University in Pittsburgh, and entered the Army Nurse Corps upon graduation.  Serving during the Vietnam War era, she cared for the bodies and spirits of soldiers and veterans, including repatriated POWs and MIAs. Now living in Colorado, she is a member of a Disaster Medical Assistance Team, and has been deployed to disaster areas around the country. True Colors is partly based on her military and nursing experiences as well as extensive research. She also authored The Arrow That Flieth By Day, a historical love story set in 1860s Colorado, and Refining Fires, a uniquely written love story that was released in July, 2010. Erin invites you to visit her “virtual fireside”.

***Content reposted from January 24, 2011.***

Civil War Medicine: Part 2/4

We’re continuing our four part series with Erin Rainwater and her research into Civil War Medicine. You can find Part I here.

Changes in delivery of medical care resulting from the war.

When you look at the casualties wrought by the Civil War it is mind-boggling. The Battle of Antietam in Maryland was the single bloodiest day of the war. There were over 20,000 American casualties in a single day (North and South combined). The Battle of Gettysburg was fought over three days, and 51,000 men were killed, wounded or missing. In all, more than 620,000 men died during the four-year conflict.

Over half perished from disease, not battle wounds. These numbers are inconceivable, both in terms of lives lost and in the challenge of delivering medical care in a day prior to asepsis (germ-free), antibiotics, and helicopter aerovacs. As a result of the enormous casualties, many of whom were brought into nearby towns where churches, hotels, barns and even citizens’ homes were requisitioned by the armies and made into makeshift hospitals, a new system of medical care delivery was born of necessity.

Both governments ordered the swift construction of general hospitals to treat the injured and ill. Additionally, frontline hospitals were born of necessity. Initially, the ambulance service was maintained and run by the Quartermaster Corps. Around 1862, the medical director of the Union army, Jonathan Letterman (for whom the Army hospital in San Francisco was named) developed a system whereby ambulances and trained attendants were assigned to and moved with a division.

This provided for more immediate collection of the wounded from the battlefield and transport to dressing stations and on to field hospitals. The current system of rapid response and ambulance conveyance was conceived due to the necessities brought on by the Civil War. It is interesting to note that casualties from both sides were treated at the frontline hospitals.

When (unsterile) silk, cotton or catgut ligatures were at a premium, horse hair was boiled to soften the texture to make it pliable for use as suture material. It was noted by some that the infection rate dropped significantly when this was used. The same was true when a lack of reusable sponges led to the utilization of one-time use rags for cleansing wounds. Applying iodine to wounds and wiping instruments with chlorine between surgeries brought similar results, but without scientific data to prove a correlation, some physicians saw no sense in these procedures.

The surgeon general remained opposed to the use of civilians and women in the hospitals, but the lack of males to perform the required duties forced the issue. Dorothea Dix, highly respected as a crusader for improving conditions in prisons and hospital for the mentally ill, managed to convince skeptical military and government officials that certain women were capable of dealing with what the war did to men.

With the news of her appointment as Superintendent of Women Nurses in June, 1861 came torrents of applications from women offering their services. Working for no pay, Miss Dix personally looked after the well-being of the female nurses she hired as well as the soldiers to whom they ministered. However, in her attempt to weed out those merely looking for a husband, she would only hire women over thirty or married, strong, and plain of face and dress. Some hospitals’ chief surgeons rejected the hiring authority given Miss Dix, and in a show of defiance, refused to accept her nurses on their wards.

It took a literal Act of Congress to allow the surgeons to bypass her authority and hire nurses on their own. This is what happens to the heroine in my novel, True Colors, who is considered unacceptable by Miss Dix because she is under thirty, unmarried, and not so plain. Disappointed yet undaunted, Cassie follows in the footsteps of many of her fellow rejects and marches straightway to an Army hospital and applies directly to the surgeon-in-charge. She is fortunate in that this doctor had worked alongside British Army surgeons in the Crimean War a decade earlier, and was appreciative of the role of female nurses. He hires her on the spot.

The significance of the contribution of women nurses during this conflict should not be understated. Rather than being seen as mere helpers of the main players—interesting but insubstantial—available evidence indicates their activities had important ramifications in both the immediate medical sense and the broader social sense. Truly they were the forerunners of female nurses of our generation.

*********************************************************************************************Erin Rainwater is a Pennsylvania native whose trip to Gettysburg when she was twelve enhanced her already deep interest in the Civil War. She attended Duquesne University in Pittsburgh, and entered the Army Nurse Corps upon graduation.  Serving during the Vietnam War era, she cared for the bodies and spirits of soldiers and veterans, including repatriated POWs and MIAs. Now living in Colorado, she is a member of a Disaster Medical Assistance Team, and has been deployed to disaster areas around the country. True Colors is partly based on her military and nursing experiences as well as extensive research. She also authored The Arrow That Flieth By Day, a historical love story set in 1860s Colorado, and Refining Fires, a uniquely written love story that was released in July, 2010. Erin invites you to visit her “virtual fireside”.

***Content originally posted January 17, 2011.***

Civil War Medicine: Part 1/4

I’m pleased to host Erin Rainwater as she shares her expertise concerning Civil War Medicine.

Welcome, Erin!

Pre-war medical system.

This year marks the Sesquicentennial (150-year anniversary) of the beginning of the Civil War. If you’ve never studied it much, I recommend you use these four commemorative years as an incentive to expand your knowledge of it.

That war was a watershed time in our nation’s history like no other event before or since, in war or peacetime. It even changed the way citizens referred to their nation. From the time of the Revolution until then the country was thought of as a collection of independent states. Shelby Foote, the Civil War historian who made you feel like you were there, said that prior to the war people would say, “The United States are…” As a result of the war, it was grammatically spoken as “The United States is…” That’s what that war accomplished, Foote said. It made us an is.

There are many interesting facets regarding the standards of medical care and how it was delivered back when we were still an are. Some of what we read about seems barbaric to us now, yet American surgeons were up to international standards of medical science of the time. Furthermore, as often happens in time of war, this conflict quickly propelled physicians into the role of leaders in medical and surgical breakthroughs.

Prior to the war, cleanliness was regarded as insignificant except in respect to gross contamination by foreign matter. Surgeons operated in street clothes or donned a surgical apron. They might wipe bloody and pus-laden instruments on their aprons or a rag, but washing them wasn’t routine. Clean linens and washed hands were statistically proven to be of value but rejected as non-scientific.

Medical school in the 1860s was normally two years long. Microscopy was taught, as was the cell theory of tissue structure. Tissue samples were stained and analyzed, urinalyses and stool studies were performed.

The primary anesthetics available were ether and chloroform, each having its pros and cons. Chloroform was non-flammable, which made it preferable during the war when gunpowder was lying about and bullets flying about. It was also faster acting. On the down side, it was easier to overdose a patient with chloroform, and anesthesia-related fatalities were higher. Surgeons and attendants, however, were more easily overcome by the vapors of ether while performing surgery.

At the outbreak of hostilities, there were few military physicians, fewer military hospitals, and lack of a hospital corps. Nursing and other duties were performed by soldiers temporarily assigned to hospital detail, and who were not necessarily qualified nor of upstanding character. After the fighting began, civilian doctors flooded into the military system. Others chose not to join up but worked as contract physicians. Doctors not only were required to be skilled but were expected to organize, equip, supply and administrate their hospitals. The enlisting, training and disciplining of subordinates was also in their job description.

Female nurses were rarely tolerated. They were believed to lack the physical strength to help wounded men, and especially in the South they were considered too delicate and refined to assist a rough soldier in bathing and tending to personal hygiene. It was generally conceded, however, that women were more attuned to the emotional needs of the sick and more skilled at “sanitary domestic economy.”

As word of Florence Nightingale’s notable work in the Crimean War spread, women’s abilities in the field of nursing became more widely acknowledged. Some American physicians who had gone to the Crimea to assist the British came home reporting that the female nurses were undeniably competent and able to care for soldiers with war-related wounds and illnesses. It was finally becoming more seemly for females to care for male patients. Their pay, however, was half of what civilian male nurses received to care for military patients. In my novel, True Colors, Cassie Golden receives the standard pay for civilian female nurses working in a government hospital—twelve dollars a month plus meals. That is for twelve-hour shifts, usually five days per week but often more. And she was glad to have it.

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Erin Rainwater is a Pennsylvania native whose trip to Gettysburg when she was twelve enhanced her already deep interest in the Civil War. She attended Duquesne University in Pittsburgh, and entered the Army Nurse Corps upon graduation.  Serving during the Vietnam War era, she cared for the bodies and spirits of soldiers and veterans, including repatriated POWs and MIAs. Now living in Colorado, she is a member of a Disaster Medical Assistance Team, and has been deployed to disaster areas around the country. True Colors is partly based on her military and nursing experiences as well as extensive research. She also authored The Arrow That Flieth By Day, a historical love story set in 1860s Colorado, and Refining Fires, a uniquely written love story that was released in July, 2010. Erin invites you to visit her “virtual fireside”.

***Contest reposted from January 10th, 2011.***