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AP seems unaware that any nurses�cared for hospitalized Hillary Clinton

Hillary Clinton 
January 2013 -- Much of the reporting about U.S. Secretary of State Hillary Clinton's recent hospitalization ignored the role nurses surely had in her care and suggested that physicians alone monitored and assessed her condition, tasks in which nursing is in fact critical. For example, an Associated Press report posted on December 31 on Businessweek's website and elsewhere didn't just note that physicians had "discovered" the clot, which is fair, but also said (relying on a statement by Clinton's spokesman) that "doctors" would "monitor" her medication, "continue to assess her condition," and "determine if any further action is required," evidently all by themselves. Nurses were not mentioned, even though they provide the majority of skilled care to hospitalized patients, particularly the skilled 24/7 monitoring and intervention that often means the difference between life and death (granted, providing good nursing care can be challenging in the case of celebrities, who tend to be swarmed by physicians). Many press accounts, when not directly crediting physicians for Clinton's care, adopted passive language in describing it, thereby further suggesting that physicians alone were responsible and further masking the role nurses actually played. Thus, the AP story stated that Clinton was "under observation" and "was being treated with anti-coagulants." This passive voice hides the fact that nurses would be the ones giving her those drugs and carefully monitoring their effects. And as far as we could see, the press consulted only physicians for expert comment--in the AP story that meant neurologists at Georgetown and Duke--when critical care nurses could also provide valuable input on the care and experiences of patients with blood clots. heparin injectionOf course, physicians play a critical role in caring for these patients and the news media should consult them. But the media's failure to tell the public about the critical roles that nurses also play reinforces the damaging misimpression that physicians provide all the health care that matters. The AP article was written by Matthew Lee with AP Chief Medical Writer Marilynn Marchione.

The AP story reports that Clinton is "under observation" at New York-Presbyterian Hospital "after being treated for a blood clot stemming from the concussion she sustained earlier this month." The 65-year-old Clinton had fallen and suffered a concussion "as she recovered from a stomach virus that left her severely dehydrated." The report says that, according to Clinton's spokesman Philippe Reines, "Clinton's doctors discovered the clot Sunday while performing a follow-up exam." Reines would not say where the clot was located, "but said Clinton was being treated with anti-coagulants and would remain at New York-Presbyterian Hospital for at least the next 48 hours so doctors can monitor the medication." Reines's statement reportedly continued: "Her doctors will continue to assess her condition, including other issues associated with her concussion. They will determine if any further action is required."

The reporting about Clinton's care, though limited, has problems. First, physicians are repeatedly credited for the care, and no one else is given any credit, suggesting to readers that only physician care matters. In fact, the nursing care matters at least as much; if Clinton did not need nursing care, she would not be admitted to the hospital. nurses surround a patientJust as troubling, the report credits physicians for specific care tasks in which nurses play a leading role, namely in the overall monitoring and assessing and the giving of anti-coagulants, or play a substantial role, namely in monitoring coagulation lab reports and determining if further action is required. Perhaps the most glaring example is the notion that physicians will be monitoring the medication, as if they will be standing near Clinton's bedside doing that; we guess with a celebrity anything is possible, but for 99.9% of patients, it is nurses who give and monitor medications, saving many lives in the process. It may be convenient for the media to treat one esteemed type of health professional as the only one that matters; it's an easy shorthand and it's been the prevailing practice for many decades. And here, Clinton's State Department team might have had a particular reason to reinforce the all-physician vision of health care. Perhaps they stressed the role of physicians, and physicians alone, in order to reassure the public that Clinton was getting the best possible care. Trust us--even the nursing is being done by physicians! We're not letting nurses anywhere near her! We hope that was not actually happening, since most physicians know little about nursing, and preventing nurses from doing their work would be putting Clinton's health at grave risk.

nurse taking blood pressureThe piece also consults two experts not involved in Clinton's care for basic information about blood clots. This report appeared before it was public knowledge that the blood clot was in Clinton's brain. "Dr. Gholam Motamedi, a neurologist at Georgetown University Medical Center," explains that the gravity of a blood clot depends on where it is. He notes that clots in the legs, common for someone who has been bedridden, are "no big deal" and are treated with blood thinners, but clots in the lung or the brain are more serious. He says that lung clots can be deadly and that clots in the brain can cause strokes. Motamedi notes that (in the piece's words) "keeping Clinton in the hospital for a couple of days could allow doctors to perform more tests to determine why the clot formed" and rule out other underlying conditions that may have caused it. And "Dr. Larry Goldstein, a neurologist who is director of Duke University's stroke center," adds that (in the piece's words) "blood can pool on the surface of the brain or in other areas of the brain after a concussion, but those would not be treated with blood thinners, as Clinton's aide described." Of course, later reports indicated that the clot was actually in one of the main sinuses (or drains) of the brain, and the blood thinners Clinton received were presumably to prevent other clots from forming as her brain healed itself.

Hillary ClintonWe do not fault the piece for consulting neurologists about the diagnosis and treatment of blood clots, but the failure to include any nursing input does give an incomplete picture and reinforces the sense that nurses know nothing important about the care of such patients. That is particularly true when part of what the report is getting at is how a blood clot patient recovers and what the ongoing risks are, subjects in which critical care nurses are expert. A nurse might have explained more specifically how such patients are treated and observed, how stable the patients might be and what they actually experience in the hospital. And the suggestion that Clinton would be kept in the hospital so physicians could perform tests is incomplete at best; if all Clinton needed was tests, she would not need to stay in a hospital, but could be tested on an outpatient basis. She needed the surveillance and intervention that nurses provide, something that cannot be done in a snapshot outpatient visit. Again, hospitals exist to provide nursing care.

On the whole, this AP article and many others gave the impression that only physicians were providing any significant care to Clinton, including in performing tasks like "monitoring" in which nurses actually play a leading role. By extension, reports like these suggest to an already ill-informed public that only physicians know anything important about critical care generally. We urge the news media to do better.
 

See the Associated Press article "Hillary Clinton hospitalized with blood clot" by Matthew Lee and Marilynn Marchione, posted on the BusinessWeek site on December 31, 2012. Marchione also wrote an extremely physician-centric piece about the plight of New Orleans hospitals in the wake of Hurricane Katrina in 2005.

Please email your comments to authors Mathew Lee and Marilynn Marchione at mlee@ap.org and mmarchione@ap.org, and please copy us at letters@truthaboutnursing.org. Thank you!