Today was the day. It finally happened.
I finally pulled the D card. You know. The D card.
No, no, not that D card. Ew, gutter brain.
The doctor card.
Even though I graduated this past May with my FNP degree and started into my DNP program in August, I chose to continue working as an RN mostly because this affords me the time to work full time while having 4 days off to work on my doctor degree and to study for my certification exam. And I really like having full medical insurance. I’m a pretty sick little dudette.
Still, officially, I am both an RN and NP. This isn’t generally an issue because at work, my duties are to be the RN. Take orders from MDs, DOs, and NPs and make sure they are implemented and executed appropriately and thoughtfully. Once I get an NP job, my responsibilities will change.
But that doesn’t change the fact that my knowledge base has definitely expanded to diagnosing and treating patients with the mindset of a physician or practitioner. This is particularly useful when something is wrong with the patient and I know what needs to be done… but I just can’t do it until the overseeing physician gives me the actual order. But at least I can prep it all beforehand instead of scrambling for it after.
But the issue is that as an RN, people only see you as an RN. They don’t only rightly assume you don’t have as indepth of a knowledge as aphysician (or practitioner, for that matter), but they also wrongly assume you know nothing. There have been many situations where a patient or family has argued about a decision I made (the patient is unable to breathe, so instead of letting him eat, like the family wants, I get him on a BiPAP machine) or an explanation I gave (water and medication going into the lungs can cause pneumonia; it’s not just sugar), only to have the doctor repeat the same exact thing before they accept it.
Take into additional consideration that I look like I’m 22 when I’m almost 31, and now people think I’m too young to really know anything. I had a family member just today ask me a question, and as I began to answer, she looked incredulously at my specifically-colored nursing scrubs, cut me off, and asked, “Wait, you’re a nurse?”
Gee, thanks. What’s that supposed to mean? You old cow. Psh. At least I look YOUNG for my age, not the other way around like someone we know… *grumble grumble mutter grumble* I’m joking. Mildly.
It can be a battle, one that I’ve had to learn to fight every working day. It doesn’t help at all when I’m trying to do something, but the family thinks I’m too young.
So today, I took care of a patient whose daughter was very demanding, rude, and disrespectful. Every question she asked was asked at least 3 times in the same conversation. If I began to answer a question, she would cut me off with another question before I was even 5 words in. After wasting a precious half hour answering her repetitive questions (and getting cut off every time), when I would finally get to tend to my other patients, I would find her stalking the halls and bombarding my coworkers with the same questions.
Let me give a quick transcript of what happened, adapted to a very common and generic scenario (obviously got HIPAA reasons).
Some Family Member: What do you mean he can’t eat? Why not? He’s hungry and sick. He needs to eat or he won’t get better!
Me: Yes, I understand that, but we can’t let him eat right now because he failed his swallow evaluation. Every time he swallows, some food goes into his lungs.
SFM: Well, you can’t just starve him! He hasn’t eaten since breakfast this morning! Why can’t he eat?! And how do you even know that???
M: (resisting the strong urge to say that I hadn’t eaten since 5PM the day before because it’s always too busy to take a breakfast break, especially when I have to wake up at 4:30 AM and my lunchtime won’t be until approximately 4 PM today)
M: I know because he coughs almost after every swallow. I watched him struggle to swallow a pea-sized bit of food. If the food goes into his lungs, he’ll end up with pneumonia. If this is a chronic swallowing issue and we let him eat, he’ll just get pneumonia over and over. We tried it with nectar-thick, honey-thick, and pureed food. He coughed with all of them.
SMF: Well then, you’re just going to let him starve? Seriously?
M: Once he passes his swallow evaluation, he can eat again. If he’s choking, then he shouldn’t be eating. It isn’t at all safe.
SFM: Okay, then are you going to start him on fluids? He’s going to starve and get weaker!
M: It has been literally less than 3 hours since he last ate something. Not eating for any period less than 24 hours doesn’t affect a person as much as you might think. Last night, he went over 14 hours after dinner* without eating and he woke up in the morning perfectly fine. But if tomorrow, he is unable to eat, then we can ask the doctor to start him on fluids. (*Our dinner trays tend to arrive a bit earlier than what’s typical.)
Some SMFs will grumble and others will accept this.
There is a very large fear of not eating that people tend to have, which is understandable but not necessarily completely logical. This isn’t simply because after dinner, we may not eat until breakfast the next morning (or lunch at 4 PM if you’re me on a working day) and still be fine, but also because it is much more dangerous to eat and get very sick than it is to stop the cause and have a small fast. Eating is very important… until it becomes the cause of your problems.
ANYWAY, back to my story. So a more specific version of this conversation happened with this daughter. Each time she asked, it would be 30 minutes of her asking me the same questions, my answering her questions while getting cut off, then get going back to one of the questions she cut me off from earlier, her aggressively waving juice and water cups in my face, or telling me why he was coughing and how it had nothing to do with food (“It’s allergies!” “He has a sore throat!” “He’s got phlegm in his lungs!” “It’s the pneumonia!” “He wasn’t properly awake!” “He’s congested!” “Was he even sitting all the way upright?” “His throat is just dry!” “You know he has acid reflux/asthma, right?” …I tell you, I’ve heard it all. Someone hit me with some other ones!)
Six different times, she dragged me into the same conversation, same questions, same aggressively cutting me off, same repetition. Six times, I was dragged into 30 minutes of unnecessary conversation that was already explained by the speech therapist and corroborated by other RNs. Five times that she stopped one of my coworkers in the hallway to ask them questions about a patient they don’t know. A total of 3+ hours (of the 6 or so that she had been there) that she was occupying and taking away from my other sicker patients. All because she needed to ask me the same questions, tell me the same things, and come up with more illogical reasons as to why we clearly didn’t evaluate him properly.
But the final straw was at approximately a half hour before change of shift, when I still had to check on one patient, administer medications to another, and get ready to tell the incoming RN about my patients. She used a beeping machine to lure one of my coworkers into the room, only to bombard her with a slew of questions I had already answered more than 20 times before. I stepped in because this was my patient, not my coworker’s. She had things to do, too. This was extremely inappropriate of the daughter.
As she raised the same questions again, she frantically told me, “Listen! Listen to how congested his cough sounds!”
I interjected: “Yes. He’s aspirating and has pneumonia. A con-.”
She cuts me off. “Well CLEARLY that’s why he was choking on his food! How can you expect him to swallow properly with all that phlegm in his lungs? I can’t swallow when I’m congested either.”
Me? I’m baffled. A little lost for words. This is almost as good as the guy who tried to tell me that water and pills in the lung can’t cause an infection; only sugar can. Almost. Where the hell do people come up with this stuff? “Um… No. The phlegm is in his lungs. Food goes down his esophagus. They are two completely different areas. The phlegm deep inside his lungs is not going to keep the epiglottis open. That isn’t how it works. Also If you have trouble swallowing when you’re congested, you might want to see a speech therapist, too.”
She sighs loudly and rolls her eyes. “No, you need to take it out. Go in there and take it out!”
Me: “You… want me to go down his throat and into his lungs and… suck out the phlegm?”
She nods emphatically. “Yes!”
I stare at her. “No. No, absolutely not. He is perfectly capable of coughing up the phlegm on his own. He did it many times today. I am not going to force a plastic tube down his throat when he can -.”
She gets angrier. “No, you HAVE to get it out! And then he’ll be fine! Then he can eat!”
Me: “There is no harm in waiting for the speech therapist to evaluate him again tomorrow. But it isn’t happening today. I’m not go-.”
She snorts. “I never said do it now. When did I say that?”
I ignore her statement. She said it several times today. She asked my coworker about it before I stepped in. If that’s the case, then why is she making a big deal about getting his phlegm out so he can eat? But I don’t say that. I’m tired.
She continues. “He just needs to get it out and get tested with the thickened liquids.”
This time, I sigh. “I’ve already told you, we tried nectar thick, honey thick, and pureed. He co-.”
She spins around, grabs the containers of honey thick water and juice and waves them at me. “THESE! He needs these! They need to test him wi-.”
I throw my hands out in front of me and sharply cut her off. “No. You are going to stop cutting me off and let me finish what I have to say. I have explained to you at least 20 times over 6 individual conversations that we tried those. He coughed. With every swallow, he coughed. We tried puree, which is thicker. He coughed. Nothing worked. For the last time, we used those and he coughed incessantly. It. Didn’t. Work. Taking out his phlegm is not going to make his aspirating better because that isn’t the cause. That isn’t how this works.”
She immediately starts up the minute I finish my sentence. “No, I KNOW how it works! My mother was doctor so I know how it works! You don’t know because you’re not a doctor! My moth-!””
I feel the blood rush to my face as my fatigue and frustration boiled over into anger. The events of the day run though my mind. All day, she needlessly wasted my time, bothered my coworkers, tried to manipulate people to get what she wanted, was consistently rude, repeatedly cut me off from answering her questions, only to ask the questions another 50 times, disregarded everything I said, all in front of several other family members, and now she’s looking down on and disrespecting us because we are “only” RNs and her mother was a doctor, so that makes her more knowledgeable than us? Did she think, by declaring her mother was a doctor, that would give absolute credibility to her vague made-up nonsensical excuses and we would meekly accept it because as RNs, we don’t know anything? Doctors know everything, but a simple RN wouldn’t know that she’s pulling shit out of her ass to get what she wants. When she insisted that her father needed fluids or else he would starve, I told her that he didn’t need it just because he’s not eating for less than one day. He wouldn’t starve from that. Instead, she went to the doctor and whined about how dehydrated he was and how dry his lips and tongue were… but failed to mention that he had been on the BiPAP for over 12 hours that day and is an open-mouth breather. Because she knew that saying, “He’s going to starve” was not going to get him the fluids she desperately wanted, she instead said “dehydrated” because that’ll get fluids for sure.
And now, she’s trying to pull a half-assed lie over me, thinking that I’d be cowed by the fact that her mother is supposedly a doctor, something that she never had mentioned in the however many times they had been inpatients?
No. I wasn’t having it. She had been rude and difficult all day. But the frustration that had been building refused to let her disrespect me just because she thought I was a child nurse.
I cut her off with one short sentence:
“I am too.”
All conversations cease. The family members who were chatting on the couch stop and stare. She opens and closes her mouth like a goldish. “W…what? You are?” She looks at me in disbelief. Not surprising. I don’t even look old enough to be an RN, let alone look like I should be diagnosing patients and prescribing medications. Granted, not a lot of people know what NPs are and there really isn’t a term for it in other countries. It all translates to “doctor”, but I am not about to get into the nitty gritty details of the difference in the medical model versus the nursing model. All she needs to understand is that I am also someone with intimate and extensive knowledge of the human body; who diagnose and prescribe, give orders, and lead the medical care of a patient. And that just because I am an RN does not mean she has any right to take me for a fool. No RN should.
“I am. So understand that right now, you have 2 choices. You can either continue to make excuses for why he failed his evaluation and should be allowed to eat and possibly worsen his condition. Or you can be more concerned about the infection ravaging his body and put off eating for one more day, for his own safety. What is your choice? Is it more important for you that he eats? Or that we make sure eating isn’t the cause?”
Her demeanor has changed. Whereas all day, she stood in front of my, always standing to talk at someone, she is now sitting in the chair, not making eye contact. Her hands are neatly folded in her lap, and her voice is calmer, softer, and interestingly, more respectful.
“Absolutely, I want him to get better first. If eating is possibly making him sick, then waiting until tomorrow is much safer. And you’re right, he is getting the fluids, and the other doctor said it had vitamins in it, so he should be fine. They will come to test him tomorrow, won’t they?”
I assure her they will. And without another word, I leave the room. I’m feeling all sorts of emotions. Exhaustion. Elation. Pride. Fear. Embarrassment. Thoughtful.
It was a rollercoaster. My coworker who heard the majority of the exchange looked shocked and impressed. I could tell why; I felt exactly the same.
Exhaustion because i’m not generally a confrontational person. If a family or patient’s wants or doesn’t want something, my mentality is, “You have every right to accept or refuse act treatment I offer you. If you refuse, I’m not going to waste my time trying to argue with you. All I’ll do is reiterate the costs and benefits and ask if you’re sure.” The only times this doesn’t hold is if it is a treatment that is crucial or detrimental. Then I will push, but if the patient doesn’t want to take his multivitamin, why force him?
Elation and pride because I rarely stand up for myself. I don’t let people walk all over me, but I tend to choose my battles very carefully. But today, I stood up for myself. I made a point. I showed her not to judge a book by its cover because she was so wrong. I showed her that my coworkers and I are not just dumb nurses. We’re smart, intuitive, creative, and quite knowledgeable. Even if she continues to be manipulative, she’ll at least know that RNs are not to be trifled with anymore.
Fear because I don’t know what kind of backlash I might get. In essence, I pulled rank in a place where that rank really had no place to be. I didn’t use it, but it made a point. Would I be told I crossed a line?
Embarrassment because once I graduated with my NP, I told myself I would never use it while working as an RN. It’s free knowledge amongst my coworkers that I am an NP and currently getting my doctor in nursing practice, but I rarely share it with my patients because it isn’t in my job description. So I told myself, no matter how disrespectful or condescending someone was, if it came to it, I would back off and leave it to the doctors to clarify misunderstandings. My skills in effectively educating patients would be developted as an RN when I’m working as an RN, and an NP when I’m working as an NP. But today, I got pushed beyond a point I’ve ever imagined. Worse yet, someone witnessed it. I was a little mortified.
And finally, thoughtful because I said I am a doctor. In one sense, I am not a doctor. I am neither an MD, DO, nor a DNP. So in English terminology, I am specifically an NP. There is no “Doctor” in my official title. Not yet, anyway. But I am someone who can evaluate a person and diagnose him; come up with a treatment course; prescribe antibiotics; and head a medical team. I am a doctor, a person who specializes in the art of healing. I can doctor people. But I am not yet a Doctor.
Dr. Pandemonium, DNP, still has at least 2 more years before she can debut.
MDs, DOs , NPs. We’re all so similar and yet so very different. It’s no wonder that sometimes, the lines can blur.
Today, I pulled the D card.
And, yes, it felt amazing.