The Door of Last Resort: Memoirs of a Nurse Practitioner

3. Nurse, Are You a Doctor?

64 Nurse, Are You a Doctor? Chapter 3 Engaging in the quiet privilege that is primary care evolved battles over several decades. Victories, losses, and compromises with physicians , physician assistants, nurses, and administrators constituted the backdrop of my career. Nurse practitioners gained authority to practice through legislation, and legislation is not an activity for the meek. Lobbying to garner legislators’ support, nurse practitioners advanced their scope of practice. Physicians’ more powerful counterlobbying force mandated , and continues to mandate, sustained hypervigilance by nurses as we counter the forces of power, money, and greed that threaten our entrance into primary care. Unable to defeat the nurse practitioner movement and its ability to provide services at lower health care costs, medicine ’s efforts have shifted to control nurse practitioner practice through regulations that constrain, limit, and otherwise obscure full independent primary care practice by nurse practitioners. Compromises between nursing and medicine to ensure incremental gains for nurse practitioner practice have resulted in cross-referenced regulations within state boards of nursing and boards of medical examiners that place limits on that very practice. Given nursing’s century-old history of control by hospitals and physician expectations of obedient subservience, efforts to limit nurse practitioner practice were certainly not unexpected. What I never anticipated was a backlash from nursing itself. Nurses testified against nurse practitioner practice at public hearings. Nurses bristled against working with nurse practitioners in practice settings. I watched as our profession Nurse, Are You a Doctor? 65 oppressed its own members. Then, as in all good stories, support came from unexpected sources. * Scrub the area, Marta barked at me. The area was a 2.5-centimeter laceration over the left eyebrow of a twenty-three-year-old male patient. He had been struck in several locations with a baseball bat in a gang fight at the intersection of Springfield Avenue and Irvine Turner Boulevard in Newark. Brought in by the police, he remained feisty even after sedation. On the outside corner of his right eye, he had a tattoo of a teardrop, a symbol, he told me, that he had scored one for his gang in the recent past—his present street battle a retaliation fight for his past victory. It was about 9 p.m. on a Saturday evening in the emergency department of University Hospital in Newark. The fast-track service closed at 10 p.m., with all patients admitted between that time and 7 a.m. triaged to the main room—the big room—usually reserved for more serious trauma or severe medical problems . With the heavy aroma of the staff’s garlic and onion pizza lingering in the air of the fast-track suite, I was nauseous, exhausted, with the early signs of a migraine headache emerging. My young patient was daunting. Still a postmaster ’s student in the University of Medicine and Dentistry of New Jersey’s nurse practitioner program, I would soon be going home after a twelve-hour shift. We were in a patient room littered with debris from servicing previous patients, sticky countertops and scattered empty four-by-four-inch-sponge dressing boxes—these sponges being one of the most commonly used items in patient care. It had been a busy early spring day in the fast track. But Marta was present. A physician’s assistant, Marta was experienced, and not shy about her skills. I had learned early on in my rotation in the fast track—I was there every Saturday for twelve hours for two years—that Marta was excellent at surgical procedures, management of sexually transmitted infections, and differential diagnoses. Marta also liked to teach. See one, do one, teach one: the axiom often quoted in medical education. This evening Marta asked the nurse to gather supplies for me, including sterile saline, a basin, more sponges, suture materials, and a Betadine-impregnated surgical scrub brush. Announcing that my patients’ wounds never get infected, Marta supervised my preparation of the laceration prior to suturing it. First, block the area with a Lidocaine injection, an anesthetic. Then, manually remove any debris in the laceration, including skin tissue and any baseball bat fragments or dirt. Finally, vigorously scrub the area with the betadine scrub 66 The Door of Last Resort brush. An antiseptic, betadine is a common solution used for this purpose. A dark amber color that stains skin, the betadine is then rinsed away with a sterile saline solution. We were...