Rules Change: The Cards Don’t

Inspired by Lessons of the Cards - Lesson 1

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Rules Change: The Cards Don’t - Connecting to the Heart of Caring in a Rapidly Changing World
Whatever Happened to Time-Honored Rules and Traditions?

A deck of cards can bring perspective to the situations we face with new change patterns that appear ready to crush us. First let’s look at how card games are played, and then we’ll see how card games directly relate to healthcare. In a standard deck of cards, there is a great deal of consistency and sameness.

There are always 52 cards in a deck. Should a card be missing, the entire deck must be tossed. The cards in a playing deck are printed in only two colors, black and red. That’s it! There are always four suits in a deck—Hearts, Clubs, Spades and Diamonds. Each suit has 13 cards and includes the “face” cards—King, Queen, Jack followed by number cards in declining order from number 10 to number one. This last card is commonly called the Ace. As basic as this sounds, it is important that you really connect to this message. For the thousands of games played with a deck of cards—that’s all there is! Basic, uncomplicated, simple, easy to understand---so why are card rules so challenging?

Here’s a true confession—I’m not a poker player. My face reveals way too much.  Plus, I find the rules to that game complicated and confusing. Whenever I’ve watched or tried to participate, the nuances make me a bit crazy. The dealer calls the games, then declares how that particular game will be played. Numerous books have been written to help people learn, but alas, it is all still too daunting for me.

I enjoy playing Hand and Foot but find, once again, the rules need to be negotiated before even dealing the cards. Most of my friends say the host home gets to set the rules. How can this be so confusing, I ask? There are only 52 cards, two colors and four suits. No doubt you can add your own set of confusing card game rules to this list. Bids, Counts, and Tricks, are all based upon a complex set of rules.

With healthcare, the rules of the game and even the rules of the house or hospital change constantly. Time-honored traditions no longer exist. If you’ve recently changed to a new employer, switched from a rural hospital to a university medical center, private to public, not-for-profit to a for-profit, in-patient to out-patient, urgent care to emergent care center, behavioral health to public health—there’s no choice but to learn their particular house rules.

And regulatory agencies make it even tougher. The Center for Medicare and Medicaid Services (CMS), The Joint Commission (TJC) and other regulatory bodies create and publish entire manuals to clarify their rules. Other game changers include the populations you serve. Although your license indicates that you are a nurse, therapist, physician, or other practitioner—being competent in the health community you serve is essential.

As an example, the knowledge and skill requirements between adult vs. pediatric practice is huge. Complicate all this with the varying department specific rules—think OR-ED-ICU-NICU-GI lab or disease-specific like oncology, respiratory, nephrology, and trauma. Overlay this with inpatient care, ambulatory care, and community health. Is it any wonder, healthcare professionals are as confused about how to play the game as I am about poker?

Who Changed the Rules?

Reflecting on the never-ending changes in healthcare makes it easy to take a dim view of the current situation and perhaps even indulge in a bit of nostalgia for the “olden days!”  Perhaps you remember those days—those days before electronic medical records (EMR) when a healthcare professional could simply jot a few notes on a flow sheet and handwrite a bit about the patient?

Recently, after being an invited guest physician to China, my cousin reminded me of the “chart” our family doctor maintained on each his patients in the 1960s. A single line contained the date, diagnosis, and treatment administered. During his trip, my cousin once again saw this simplicity as each patient carried their own small black book in which their Chinese doctor jotted down this info. 

Monumental strides are currently being taken in China to embrace Western medicine. Yet I wonder if this is best for their nation and what the cost will be to traditional Chinese medicine? Is the EMR providing more or less in human interaction, continuity of care, or enhancing trust?

As we reflect on changes in healthcare and healthcare practice, although not always easy or comfortable; they have certainly brought us a long way. In the early ’70s, nurses were taught how to sharpen and reuse a hypodermic needle “just in case” the newly acquired single use syringes were out of stock! A colleague remembers adding a small morphine tablet to a syringe, drawing up a specified amount of normal saline, swirling to ensure all particles were dissolved, doing complex math for age/weight/dose, discarding the extra and finally administering this concoction by injection to her patient. 

When I was a new graduate with a baccalaureate of science in nursing (BSN), I was assigned as a night charge nurse on a medical-surgical unit in a large hospital. Our unit had 26 post-surgical patients. The team consisted of a Licensed Vocational Nurse who gave injectable and oral pain medication as needed. There were two nurse aids who assisted with patient care. We cared for some very sick folks.  At that time, cholecystectomy or gallbladder patients were in the hospital a minimum of five days following surgery. They had Jackson-Pratt drains coming from their large incisions and were in a great deal of pain.

Our practice was to put paper tape on the glass intravenous (IV) bottles. We drew lines on the paper tape to indicate the amount of fluid to infuse per hour. Then we visually counted the drops in fifteen-second increments, multiplied by four and determined if the rate equaled cc/hr. There were no inline devices to monitor or slow gravity feed; only a roller thumb clamp. The nurse aids were our lifeline. They would tell us which patients were ahead or behind on their IV fluids. My colleagues remember being convinced that we gave our patients great care. Yet, understanding current nurse-to-patient ratios whereby a nurse only cares for two to five patients makes me fearful that perhaps we left many things undone.

Another time I remember finishing a night shift, handing the keys to the narcotic drawer to the oncoming charge nurse, driving home, and crawling into my warm bed. The shrill tone of the phone broke my reverie. It was the day charge nurse calling to ask what time I had hung the liter bottle for the patient in room 6 bed A. I responded that I had hung it just prior to shift report at 0630. She gasped: “Well it’s 8 o’clock, and it’s empty!”

Most of us have probably experienced that sinking feeling when something unexpected happens and suddenly our careers and everything we’ve worked hard for just blasts us in the gut. My mind whirled with the ramifications of fluid overload. Did I just do harm? Did I put this patient into congestive heart failure or worse?

The day charge nurse and I discussed how the patient had been asleep when I changed IV bottles. Apparently, he had stretched his arm for comfort thereby changing the venous flow and suddenly gravity worked exceptionally well. Together the day nurse and I reviewed the chart of a 27-year-old male, excellent health, no cardiac conditions, in hospital for broken femur—all good news. The charge nurse called the physician to report the potential problem. The patient was monitored without negative outcome. Whew!