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Patients unattended

Dead man on sidewalkMarch 28, 2011 -- Today the New York Daily News ran a good piece by Alison Gendar about a New York City ED nurse who says she tried without success to get her colleagues at Roosevelt Hospital to treat a homeless man who was later found dead outside the hospital, and that she was then fired for trying to expose what happened. Nurse Danna Novak has sued the hospital, alleging that as a triage nurse in August 2009, she determined that the wheelchair-bound patient Daniel Iverson showed signs of a suicide attempt, not least of which was his claim that he had taken a lot of morphine. However, Novak says two other nurses argued that Iverson was faking and would have to wait. He was apparently an alcoholic who often visited the ED to complain of back pain or sleep off a bender. Iverson left the hospital and was found dead outside the next day, the victim of what an autopsy showed was an overdose of morphine and alcohol. The article is a sad look at the way urban EDs sometimes work, but it also shows readers that nurses can and must make complex, life-and-death assessments, and it suggests that nursing errors can have grave consequences. And of course, the piece also points up the vital role that nurses play as advocates and whistleblowers. Nurses are the skilled health professionals who spend the most time with patients, and they are probably the most likely to see when a patient is at serious risk. Needless to say, nurses should not be ignored, abused, or fired for trying to perform their vital role as patient advocates. The Daily News does not provide all this context, but it does offer readers a powerful example of the life-saving -- or life-losing -- potential of nursing care.

Daniel IversonThe article is "Nurse fired for trying to expose Roosevelt Hospital's neglect in death of homeless man: lawsuit." The piece includes a photo of Iverson (right) and begins with a quote from his half-brother Robert Watford, who was reportedly shocked to hear about Novak's suit. Watford says that "we were called to the hospital and told he had died," but "no one mentioned that he had been in the hospital earlier and not gotten care."

Then the piece backs up to explain Iverson's connection to the Manhattan hospital. It says the "51-year-old alcoholic" was "well-known to the emergency room staff" because he "would wheel himself into the hospital, his prosthetic left leg lying across his lap, to complain about back pain or to persuade someone to let him sleep off his latest bender, court papers say." But, according to the lawsuit, his August 2009 visit was different:  

When he came into the ER, he told Novak, the triage nurse, he was sick of living and had consumed 700 milligrams of morphine (70 times a normal dose), court papers say. She took his vitals, recorded a racing heart and low blood pressure, marked him "emergent" and rolled him to the resuscitation room. There, another nurse declared Iverson was faking it, the suit says. A second nurse berated Novak for being naive and said Iverson would have to wait for a doctor.

backstabbing the whistleblowerThe suit says Novak recounted Iverson's apparent suicide attempt, his physical condition and need for medical attention -- with no success. After listening to the exchange, Iverson turned his wheelchair around and rolled out of the emergency room, Novak claims.

The article says that a hot dog vendor found Iverson outside the hospital the next morning, "cold and gray," and that he was pronounced dead in the ED; an "Aug. 23 autopsy by the city medical examiner determined Iverson died of an overdose of morphine and alcohol, with sedatives in his system."  Novak's lawsuit reportedly says that "she told the ER's medical director her account of Iverson's care the day after his death," and that "the hospital tried to force her to quit and then fired her, claiming she left patients unattended." In response, the hospital told the Daily News that Novak's firing was "not related to Iverson's death."

zippered mouthsOf course it's impossible to say from this distance what really happened here, except that the outcome was tragic for Mr. Iverson. Even so, the piece does tell the public some useful things about nursing. First, it shows that triage nurses like Novak are charged with making complex, autonomous decisions about whether ED patients are emergent or not. According to her suit, Novak used her assessment skills to determine that Iverson was in bad shape, noting his heart rate and blood pressure. And she reportedly tried to advocate for her patient, even though she presumably knew that he was a frequent visitor to the ED and perhaps not someone the ED staff were thrilled to see back. It can be especially challenging for ED nurses to give good care to some patients who may return frequently with the same chronic problems and who may even fabricate health problems to receive food and shelter. The piece also suggests that Novak followed up after the patient's death with the ED's "medical director," which presumably means the chief of ED medicine, though it would seem that the more obvious manager to consult would have been the chief of ED nursing, since triage is a nursing responsibility, and to the extent there was any care breakdown here, it would seem to be a nursing problem. Perhaps the nursing manager was hostile. In any case, even the information about the two nurses who reportedly disagreed with Novak conveys something helpful, because it suggests that not all nurses are the same; as with physicians and other professionals, quality can vary.

whistleblowerFinally, the piece illustrates the difficult situation that nurses can find themselves in if they act as whistleblowers. Novak may have been trying to improve the hospital's care systems in following up about the problems with this patient, but according to her suit, the hospital's response was to force her out--a common experience for nurses who make similar efforts, as a prominent recent case in Texas made clear. Novak's claim that the hospital said she had left "patients unattended" is of course ironic, since in her account she was the only nurse who did not want to leave Iverson unattended. Nurses often lack significant power in clinical settings, and it can be difficult and risky for them to speak up about problems that more powerful persons in those settings may not wish to hear about. When nurses do advocate to try to improve care, they deserve support. Indeed, in some states, legislation provides some protection for nurse whistleblowers. The piece does not discuss the legislative situation in New York in this respect.

On the whole, the article gives readers a good sense of what nurses can and should do for patients, as well as the challenges that may deter nurses from meeting their duties--with potentially tragic results. We commend nurse Danna Novak for her courage and advocacy and working to hold nursing to a professional standard. We also thank reporter Alison Gendar and the Daily News for covering the story.

See Alison Gendar's"Nurse fired for trying to expose Roosevelt Hospital's neglect in death of homeless man: lawsuit," posted on March 28, 2011, on the New York Daily News website.

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