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Book critic Maureen Corrigan

Book critic Maureen Corrigan reviews Prague (Random House), the debut novel by Arthur Phillips.

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Other segments from the episode on July 30, 2002

Fresh Air with Terry Gross, July 30, 2002: Interview with Michael Berens; Interview with Kim Armstrong and Audrey Ludmer; Review of Arthur Phillip's new novel "Prague."

Transcript

DATE July 30, 2002 ACCOUNT NUMBER N/A
TIME 12:00 Noon-1:00 PM AUDIENCE N/A
NETWORK NPR
PROGRAM Fresh Air

Interview: Michael Berens discusses his recent investigative
articles about hospital-acquired infections in the United States
TERRY GROSS, host:

This is FRESH AIR. I'm Terry Gross.

Patients go into hospitals hoping for treatments that will make them better,
but sometimes they pick up infections in the hospital that are
life-threatening. Often, these infections are spread through unsanitary
facilities, germ-laden instruments and the unwashed hands of doctors and
nurses.

My guest Michael Berens is an investigative reporter for the Chicago Tribune.
This month he wrote a three-part series on hospital-acquired infections. He
reports that deaths linked to hospital germs represent the fourth-leading
cause of mortality among Americans behind heart disease, cancer and strokes.
The total was about 103,000 deaths in the year 2000, which is the latest year
that federal health inspection reports are available. Berens estimates that
about three-quarters of these deaths were preventable through better hygiene
and more sanitary conditions. I asked Michael Berens to tell us more about
how germs are spread in hospitals.

Mr. MICHAEL BERENS (Investigative Reporter, Chicago Tribune): If you examine
federal investigative reports and state reports, you'll just find thousands of
cases in which doctors conducted operations without washing their hands first.
You'll see thousands of cases in which nurses went bed to bed without washing
their hands.

One case in particular stands out of a doctor in Los Angeles who placed a
stethoscope on a patient who was just, you know, in the complete grip of
pneumonia, and this kind of moist, sweaty stethoscope that was placed on this
patient was placed directly on the chest of another patient who contracted
pneumonia. In another kind of breakdown we saw in Chicago, a tuberculosis
patient was allowed to wander the hallways of the hospital. Several other
patients contracted tuberculosis as a result of that contact and died.

GROSS: What did you find in terms of cleanliness, of how well and thoroughly
hospital rooms are cleaned so as not to spread germs from one patient to
another?

Mr. BERENS: I think one of the amazing findings was how often hospitals fail
to clean rooms between patient admissions. And this is a direct byproduct of
housecleaning staffs being pared down at least 25 percent nationally. What we
found in half of the Chicago hospitals, for instance, which is mirrored
nationally, is that housecleaning staffs were rubbing disinfectants on bed
rails, on walls, on floors and then immediately wiping it off. However, the
instructions for these disinfectants say that the solution has to sit on the
surface for 5 to 10 minutes minimal, otherwise it's not killing any germs.
But in the rush-rush of medicine today, these housecleaning staffs who are
given dozens, maybe hundreds of rooms to clean a night are just slapping it
on, wiping it off and rushing off to the next room.

GROSS: So you attribute that to staff cutting and cost cutting?

Mr. BERENS: Absolutely. I think if you talk to the American Hospital
Association, they will tell you that hospitals have never been in more dire
financial straits. In fact, they say it's never been worse since World War
II. Consequently, one-third of America's hospitals are bankrupt, one-third of
America's hospitals are teetering on the edge of bankruptcy. So with that
many hospitals financially challenged right now, one of the first recovery
methods is to cut your staff.

GROSS: Is the cleaning staff of a hospital supposed to be specially trained?

Mr. BERENS: Yes, absolutely. The cleaning staff has to be specially trained
on how to handle these sensitive solutions, which can be dangerous to them,
let alone the patients if they're exposed to them improperly. Also, the
cleaning staffs need to be trained on how to apply these disinfectants. And
time and time again federal inspectors will line up these cleaning staffs,
stand them in line and say, `Demonstrate how you put this cleaner on,' and
time and time again the cleaning staffs failed to put it on properly. What
this means for the patient is that when they go into a room in virtually any
hospital in America, they stand a risk of picking up the germs that were left
behind by the last patient.

GROSS: There's also a nursing shortage in the United States. In some places,
the shortage is because no one's applying for the positions. In other places
it's because of cost cutting, just like eliminating a lot of nursing
positions. And I'm wondering how you think the diminished size of nursing
staffs at many hospitals is contributing to the hospital-acquired infection
problem.

Mr. BERENS: America's nurses are the primary sentinel of our health-care
system. You subtract from that in any way and the patients are going to
suffer immediately. And I think there are just thousands and thousands of
cases out there that prove this point, often with tragic consequences.

GROSS: A Harvard School of Public Health study recently linked the staffing
levels of registered nurses to hospital-acquired infections. They found that
the lesser the number of registered nurses on staff, the more likely a patient
is to acquire urinary tract infections, hospital-acquired pneumonia and a
couple of other related infections. Why are those particular infections more
likely to happen if there were fewer registered nurses on the staff of a
hospital?

Mr. BERENS: Well, urinary tract infections, which are the most common
infection in a hospital, striking the largest number of people, are typically
caused from contaminated instruments. And so if nurses are rushing or there
are not enough nurses and their hands are dirty and they haven't had time to
clean their hands between patients, sometimes the equipment that they use
becomes contaminated. With pneumonia, which is a respiratory disease and one
of the most popular infections from a statistical point of view--this requires
constant monitoring of a patient to determine whether they're showing the
signs of stress, whether they're showing elevated fevers.

And in hospital after hospital--I continue to get messages every day from
nurses around the country who say, `You wouldn't believe how many patients
they make me care for on my shift.' One nurse just the other day said, `I
have 20 patients on my floor and I'm left alone with these 20 patients. If I
have two patients who go into a crisis, one of them is going to die.' With
these kinds of numbers, nurses often are rushing from crisis to crisis, and
the patients in between who don't need immediate attention but who do need
attention just don't get it.

GROSS: If you're just joining us, my guest is Michael Berens and he just
wrote a three-part investigative series on hospital-acquired infections. He's
part of the investigative projects team at the Chicago Tribune.

Did you find an example of a hospital that has made improvements and has a
decreased number of hospital-acquired infections?

Mr. BERENS: We found many, many hospitals around the country which had
significant devastating lethal outbreaks which then came back, corrected
problems and virtually eliminated every infection in the unit or even
hospitalwide. One of the most telling examples occurred in Detroit, I
believe, at Grace Hospital in 1997. This was a hospital where a germ broke
out in the intensive care unit of a nursery. It killed a baby, this germ
called pseudomonas, which likes to live in water, but which is typically
spread by touch.

The first baby died seven days after birth. Within a week or two, the germ
entered another baby, then another, then another. Four babies died very
quickly within just a few weeks. The hospital then began to realize that they
had an outbreak. By the time they got it under control, months later, 15
other babies contracted the same infection. As they tried to unravel what had
happened, they found the germ, after checking each of their employees, on the
hands of a respiratory therapist who had been allowed to go into the intensive
care unit to do medical care, but this person brought in a germ on their
hands.

They believe that this respiratory therapist, who I think, remarkably, had a
colostomy at the time from an illness, carried those germs from his or hers
own illness right into that nursery. Certainly, the infection rate in that
nursery skyrocketed, but the hospital, which has since been renamed under new
management, Sinai-Grace, has come in and instituted stricter infection control
policies that have virtually eradicated every germ in that nursery.

GROSS: What are their infection control policies, some of the ones we're
likely to understand as people who aren't--those of us who aren't doctors or
nurses?

Mr. BERENS: Well, the primary infection control policy--actually the one
that's the simplest to implement but, unfortunately, the deficiency that kills
the most people is washing hands. You would be surprised at how many people
just don't wash their hands in a hospital. And the studies show that doctors
are the worst offenders, not nurses. Beyond washing hands, the next probably
most common infection control procedure is what they call contact isolation.
If a patient has an infection, they should be isolated from other patients.

I don't know how many stories I've heard and seen documented where patients
with infections were allowed to leave their rooms and go down the hallway and
get a drink out of the public drinking fountain where other patients might go
to get a drink, or they're allowed to go down to the cafeteria. Those are the
kinds of things that just colonize an entire hospital with germs.

GROSS: Did you actually go to a lot of hospitals when you were writing this
series?

Mr. BERENS: It became kind of a joke in the newsroom, but one of my hobbies
for the last year and half, if you want to call it a hobby, was to visit every
hospital I could. If I was in town on a convention, I would go to a hospital
and eat my lunch there in the cafeteria. And I found the most remarkable
stories by just going into hospitals and sitting in the waiting rooms, sitting
in the cafeterias and just observing how nurses interreacted.

We saw a case in Florida where nurses took their lunches outside and sat on a
picnic table to eat their lunch. And these dozens of birds, including ducks,
would congregate at their feet, looking for crumbs that fell from the picnic
table. But as the birds are running around, they're brushing up against the
nurses' legs, they're brushing up against their lab coats. And then we'd
watch these nurses, who now have contaminated clothes, walk right back into
the emergency room or the operating room areas.

One of the other stories--or one of the other cases that I saw just from
sitting in a waiting room was a nurse who brought a giant bag of cheese puffs
to the nursing station. This was one of those king-sized bags. And she opens
it up and it's now become kind of a communal bag for the rest of the nurses
and the medical staff. And over the course of an hour, we watched as 21
people put their hands into this bag. Then we started following the nurses
and we watched them as they treated patients--doing blood pressure, taking
temperatures, changing bandages--and then they would come right out of the
patient's room, put their hand back into that bag, grab some cheese puffs,
then go off to another patient room. Never...

GROSS: Without washing their hands?

Mr. BERENS: Without washing their hands.

GROSS: So did that make it in the series?

Mr. BERENS: No, we didn't use the cheese puff example just because I had seen
that about two years ago when I was working on the nursing series, so I'd been
accumulating these anecdotes for years. And also it helped assure me that the
things I was seeing on paper in these federal investigative reports, I could
see for myself.

GROSS: My guest Michael Berens wrote a three-part investigative series for
the Chicago Tribune on hospital-acquired infections. We'll talk more after a
break. This is FRESH AIR.

(Soundbite of music)

GROSS: We're talking about hospital-acquired infections. My guest Michael
Berens wrote a three-part investigative series on the subject for the Chicago
Tribune. It was published earlier this month.

What inspired your investigative series on hospital-acquired infections?

Mr. BERENS: The hospital-acquired infection story was really an outgrowth of
our nursing investigation from a couple of years ago. As I was going around
the country and documenting how hospital staffs were being systemically
reduced to save money, I came across the fact that infections were really one
of the underlying issues when it came to patient safety. So after we were
done documenting nurses, we turned our attention to infections. And it was a
whole new territory for us. We had never really examined infections. It's a
topic that's very difficult to quantify because infection rates in this
country are considered confidential. So it was truly kind of cracking this
veil of secrecy and using, you know, literally dozens of information sources
and combining them for the first time, often in unique ways, that allowed us
to kind of get this inner portrait of what's going on inside America's
hospitals.

GROSS: What are some of the information sources you relied on?

Mr. BERENS: Some of the primary information was computerized databases of
medical records. For instance, in the state of Illinois, every patient who
enters a hospital is computerized and that information includes their age,
their sex, how many days did they spend in the hospital, every diagnosis,
every procedure that was performed, how did they pay for the procedure. So
you get dozens and dozens of pieces of information on every patient who goes
in.

So using those kinds of computer databases, for instance, we can zero in on
babies born in hospitals, of course, and look at how many infants contract
infections two days, three days, four days after birth, how many infants never
leave the hospital for some reason. And you can look at those codes and those
procedures and determine what happened to those infants. And you can do this,
as well, for adults, specifically in cardiac surgery, how many patients went
in for a bypass procedure and ended up having their sternum removed because it
was infected.

GROSS: If you were going into the hospital now, or had a friend or family
member who has, what's some of the things you'd keep an eye out for?

Mr. BERENS: If I was going into the hospital today, I would just religiously
adhere to the advice that nurses in California have told me. Never be alone.
And, in fact, the nurses of America have formed what they call buddy networks,
and this is where if a nurse goes into the hospital, she has five or six
friends or comrades or fellow employees who've agreed to monitor and watch her
in her room or his room, in many cases. And so nurses, themselves, are scared
to be alone in hospitals, and they've relayed this message to me and said, `If
you go to a hospital, you need to have someone there watching your care every
minute.'

GROSS: Well, that's really hard to do.

Mr. BERENS: Yes, it is, for most of us. So there have actually been stories
around the country where there are services now where patients are bringing
their own nurses with them to the hospital.

GROSS: Now your new series is on hospital-acquired infections, but in the
year 2000, you did an investigative series on nursing. And one of the
conclusions that you reached is that overwhelmed and inadequately trained
nurses kill and injure thousands of patients every year as hospitals sacrifice
safety for an improved bottom line. Can you elaborate on that finding?

Mr. BERENS: Sure. I think--what the Tribune found is that nurses have become
both victim and perpetrator. They're being placed into impossible positions
where it's almost guaranteed that they're going to make an error or that
they're going to fail or that they're going to be unable to provide adequate
care to all the patients. So many nurses are devoted and, you know, give
everything they have to their job. But when you give a nurse 20 patients and
expect them to provide superior care to each and every patient, it's just an
impossible situation. So the nurses become harried, they become overworked
and then the mistakes begin to happen.

One of the most common mistakes we found, and it's a very unfortunate mistake,
involves infusion pumps. Many patients who go to hospitals are connected to
infusion pumps, which regulate the amount of drugs that go into your body
through an IV. Nurses are rushing, so when they program those pumps to put
the medication amount into you, they often make a keypad punch error. Among
nurses it's called death by decimal. But if you're supposed to receive 5.2
grams of morphine and a nurse misses the decimal point, now you're receiving
52 grams of morphine, you're going to die.

GROSS: Does that happen much?

Mr. BERENS: It's happened in hundreds of cases every year.

GROSS: Well, you know, one of the things my mother used to always tell me is
when you leave the hospital, you should wash your hands. She would also
sometimes take off her shoes before she went home so as to not bring in germs
from the hospital. Do you think that's a good idea? Do you think that's
necessary?

Mr. BERENS: You raise what is an amazing finding, I think, scientifically,
and a recent study showed that for every patient who leaves the hospital, 16
percent of their family members will be colonized with the germs that that
patient brought home from the hospital. That means that those family members
are now carrying hospital germs, and if those family members have an open
sore, a wound or if they're medically compromised in any way, they're now a
likely candidate for an infection.

GROSS: What kind of response have you gotten to your series on
hospital-acquired infections from doctors, nurses and hospital administrators?

Mr. BERENS: I have to say the response to the infection series has just been
overwhelming, and I have to say it's just been sad. I gave received so many
tearful calls from patients, some calling from the hospital at the bedsides of
a loved one who's dying of an infection or who's just been diagnosed with an
infection, and they're asking for help. And universally, patients are asking,
`What can I do? What can I do?' and there's just not an easy answer to that.

I've received--maybe 30 percent of the messages have come from nurses who want
to describe the substandard conditions in their hospital. One nurse just
called me the other day and said that the hospital's now requiring all nurses
to take their own medical scrubs home and wash them and wear them from home
back into the hospital. Well, what we know is that if you wear your scrubs
from home into the hospital, you're carrying whatever germs are in your home
probably into the hospital. And we've already seen the tragedy from these
kinds of cost-cutting maneuvers.

GROSS: What kind of response have you gotten to your series from hospital
administrators?

Mr. BERENS: The hospital administrators not named in our story love it. The
hospital administrators who are named in the story are not so happy, I think,
at being identified with this infection issue. Most hospitals admit that this
is a major problem and, in fact, many of the issues that we've reported has
been well-known in the health-care field for over a decade. But I believe the
hospital industry's a little uneasy with the series in the sense that they
know it's going to awaken the public and more people are going to demand more
answers, and they're answers that the hospitals aren't necessarily willing to
give at this time.

GROSS: You still going to a lot of hospital cafeterias and observing or are
those days over?

Mr. BERENS: No, no, I plan to continue this just because I think it's a story
that we'll continue to follow. And by doing this personal observation,
although, you know, it's anecdotal, maybe even a little quirky at times, it is
very valuable because you get a sense of a hospital, you get a sense of its
ebb and flow. Are they cleaning it? Are the nurses happy? Are the staff
grumbling? Are nurses carrying food back up into the nurses' station, which
they're not supposed to do necessarily? Once you know what to look for, it's
almost, you know, an amazing adventure to go into a hospital and see how good
they are.

GROSS: Have you found any hospitals with good food in the cafeteria?

Mr. BERENS: I don't think I have found one hospital cafeteria where I'd say
I'd go back again.

GROSS: OK. Thank you very much for talking with us about your series.

Mr. BERENS: Sure. No, my pleasure.

GROSS: Michael Berens' investigative series on hospital-acquired infections
was published earlier this month in the Chicago Tribune. I'm Terry Gross, and
this is FRESH AIR.

(Announcements)

GROSS: Coming up, how the nursing shortage is affecting hospital health care.
We talk with two veteran registered nurses. And book critic Maureen Corrigan
reviews "Prague," the debut novel by Arthur Phillips.

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Interviews: Kim Armstrong and Audrey Ludmer discuss the nursing
shortage and how hospital cutbacks have affected hospital
health care in the US
TERRY GROSS, host:

This is FRESH AIR. I'm Terry Gross.

It isn't just common wisdom that good hospital nursing care increases the odds
of a good recovery. A recent study published in the New England Journal of
Medicine found that in hospitals with proportionately low numbers of
registered nurses, patients are more likely to have urinary tract infections,
hospital-acquired pneumonia and gastrointestinal bleeding. These findings
come at a time when many hospitals have cut back their nursing staffs to save
money while other hospitals are having trouble filling nursing positions.
Another recent study, published in the health policy journal Health Affairs,
showed many hospital nurses are burned out by staff shortages and rising
patient loads.

My guests are two veteran registered nurses. Kim Armstrong is a staff nurse
at a high-risk obstetrics unit in a hospital in the Seattle-Tacoma area.
Audrey Ludmer works in the Perioperative Care Center of a major Manhattan
hospital in the unit that performs endoscopies and colonoscopies. Both
Armstrong and Ludmer work in hospitals that have fewer nurses than they used
to. I asked Audrey Ludmer how that affects the amount of time she can spend
with each patient.

Ms. AUDREY LUDMER (RN): I'm lucky in the area I've chosen to work in. I
think part of the reason I chose to work there is that I get to work with one
patient at a time. Because of the nature of my work, I can only be with one
patient. But I'm under constant pressure to, you know, do an assembly line
kind of thing, to get them in and get them out and `Can't you do another case?
Can't you do another case? Can't you do another case?' So, yes, it affects
in--even though it's a short-term thing, you would like to do some teaching, a
little pre-op relief, anxiety, a little pre-op teaching, and something about
what's going to happen afterwards, but at times you rush it. You don't not do
it, you just don't do it as well, and pray to God when you ask `Do you have
any questions?' that the answer is `No,' because you may or may not have the
moment to answer those questions. And I feel bad for a patient who's
frightened because they need those extra few minutes and sometimes you're
really under pressure to not give it to them.

GROSS: Kim Armstrong, how is your day-to-day work affected by the fewer
number of registered nurses at your hospital now?

Ms. KIM ARMSTRONG (RN): Well, I agree with Audrey. I'm lucky in the area
that I work in that I'm primarily--when a patient's in active labor, I'm
one-to-one care. However, it has still affected me, even in that one-to-one
care, because we've decreased the amount of support systems we have. I pass
dietary trays, I do phlebotomy, I do respiratory therapy treatments, various
other things. I go from the moment that a patient enters my unit in labor
through the recovery period. I take care of the baby after they're born. And
all of it's done more or less as fast as we can do it. You know, we're moving
at 100 percent when we get there and, oftentimes, have to flex up to 120
percent. And there's other patients coming in that are not in active labor,
that you still try to oversee.

So the lack of backup systems has affected me, even my one-to-one care. When
I'm having to clean up instruments and make beds and that kind of thing, that
does affect the time that I could be spending elsewhere more profitably with
the patient and teaching them about their health.

GROSS: Now, Kim Armstrong, I understand the hospital where you work in the
Tacoma-Seattle area is bringing in nurses from other countries. Why are they
doing that?

Ms. ARMSTRONG: Because they need nurses on the floor. My hospital does have
posted positions for nurses, lots of them, in all sort of specialty areas.
They are bringing them in because they see it as a solution, even if it's a
short-term solution, to their staffing needs. In the state of Washington,
last year, or this year, actually, we passed a mandatory overtime law, which
prohibits employers and hospitals from forcing people to stay and work over
their assigned hours. And that's a very good first step in preventing what I
call as abuse of nurses, but it's--this is one of their answers to it. If
they can't get people to stay over voluntarily, they still have patients that
they need to care for. So they have recruited from the Philippines.

GROSS: And how do you feel about that?

Ms. ARMSTRONG: I think it's one of the most unethical ways to do any kind of
business that there is.

GROSS: Why is it unethical?

Ms. ARMSTRONG: You have a country, oftentimes a Third World country, that
America, because they have the bucks, can go over and recruit these nurses away
from their country. It severely impacts that country's ability to provide
health care to their own people. So even in countries like the Philippines,
that actually graduate more nurses than they need, these nurses are not the
new graduates that are coming, they're the experienced nurses from that
country coming here. Once these nurses get here, it's almost like they're
indentured servants.

GROSS: Audrey Ludmer, do you have a similar situation in the hospital in New
York where you work?

Ms. LUDMER: This is not a new problem in the hospitals in New York City. We
used to have H1-Visa nurses coming in. And it was very similar to what Kim
just talked about, in that the hospitals sponsored them and the country
allowed them in on H1-Visas. The H1-Visas went away a number of years ago
when it was prophesied that there would be too many nurses, and there was a
Pew study that came out and we were going to be extremely overstaffed and way
too many nurses.

So H1-Visa nurses seemed to go away; schools of nursing closed. People went
and found other professions. Hospitals started laying off nurses. It was
very interesting to live through it. Very strange, but very interesting. As
the population got sicker, the nurses became fewer. So it's not a new
phenomenon. It's not just the Philippines but Korea, India, England, Ireland.
The biggest problem is the cultural problem. The nurses from other
countries--and other countries themselves--just have different cultural norms,
and at times it becomes frustrating for both the nurse and for the patient in
trying to communicate.

GROSS: In addition to the language barrier, give me an example of a kind of
cultural difference that you're talking about.

Ms. LUDMER: Just of what is acceptable as far as communication, what is
acceptable as far as education, how you're treated as a patient, what is
expected of you as a nurse. Many of the foreign nurses are not quite as
assertive as American nurses are, so when you're trying to deal with a medical
establishment and sometimes you're trying to get your point across, something
is lacking in the fact of a nurse knowing that the doctor is, quote, unquote,
her "superior."

GROSS: To me, when you're a patient and you're trying to impress upon the
nurse, `Something's going wrong. I need help,' they may not get it.

Ms. LUDMER: They may get it, but if the physician is not catching on quickly,
they may let it go because...

GROSS: They may just defer and not push for it.

Ms. LUDMER: Exactly. Exactly.

Ms. ARMSTRONG: Right. Right. And that's a huge problem, because I don't
know about other states, but in my state, my license is based on what I do for
the patient. I am not responsible to my hospital, to the physicians, to
anybody else. I am directly responsible by law to the patient for the quality
of care they receive. I take that very seriously. These nurses coming in
from other areas are not usually as assertive. I work with foreign nurses
now. And even after years of being in the United States, they have a tendency
to defer to the physician. And in some areas, you can't do that. And it's
very frightening for these nurses in my mind that once they're here, if things
don't work out for them, they're going to feel trapped.

GROSS: Because in order to stay in the States, they have to keep the contract
with the hospital?

Ms. ARMSTRONG: That's correct.

GROSS: So they don't want to rock the boat.

Ms. ARMSTRONG: No.

GROSS: Do you think the foreign nurses are being hired at your hospital
because nurses aren't applying for the positions, or are the foreign nurses
paid cheaper wages? Is there kind of a financial issue there, too?

Ms. ARMSTRONG: Yeah, they will not be paid a cheaper rate than...

GROSS: OK.

Ms. ARMSTRONG: ...nurses here because we're under contract. My hospital
does have a union. So they will come in under our contract. But I think that
the hospitals see them as available, and certainly the wages that they're
going to be making in America are considerably more than the wages that they'd
be making in their home country. So it's a very big incentive for them to
come here.

Ms. LUDMER: I just wanted to add that the fact that they make the same
amount as the nurses in the hospital, the same thing where I am, but they
actually keep the wages down. Because instead of...

Ms. ARMSTRONG: Yes, they do.

Ms. LUDMER: ...increasing wages so more people will go into the profession,
they artificially keep the wages down by pillaging other countries and
artificially keep the salaries low .

GROSS: My guests are two veteran registered nurses, Audrey Ludmer and Kim
Armstrong. We'll talk more after a break. This is FRESH AIR.

(Soundbite of music)

GROSS: We're talking with two veteran registered nurses about the impact of
nursing cutbacks and the nursing shortage. Kim Armstrong works in a hospital
in the Seattle-Tacoma area. Audrey Ludmer works in a hospital in Manhattan.

Audrey Ludmer, you've been a nurse since 1968. What are some of the biggest
changes you see in the nursing profession from 1968 to now, in terms of what's
expected of you, how much support you have?

Ms. LUDMER: The biggest change has been in the amount of paperwork, the
amount of documentation necessary. I spend a lot, a lot, a lot of time doing
paper. At times, I spend more time with the paper than I do with the patient,
which is a bizarre and ridiculous thing when you think about it. But in order
to satisfy JACO, Medicaid, Medicare, HMOs, all the other insurance companies,
there's tons of paperwork. And when I'm not doing paperwork, I'm sitting at a
computer doing different kinds of work and different kinds of documentation on
the computer. The computer is not at the patient's bedside. It's not
anywhere near the patient. So, therefore, the more time I spend on a
computer, the less time I obviously spend with a patient.

The other thing I wanted to say is that nursing has become increasingly
complex. I am expected to have a running knowledge, the basis of which wasn't
even there in 1968.

GROSS: Like what?

Ms. LUDMER: Just disease entities, antibiotics. I remember when you had to
know all the drugs. You know, now it's like a joke. Nobody knows all the
drugs. Just new medications on the market, new diseases, new pieces of
instruments, new tests, new thoughts, new ideas, constant new re-education,
new education, new products, new services. Patients are much, much, much more
educated in what's going on and ask many more questions. It behooves you to
know all the answers. Just the amount of physicians and what they're
requiring and how they're requiring it and their turnover, just--your
knowledge base is amazing. It's astounding.

GROSS: Kim Armstrong, what are some of the biggest differences that you've
seen, some of the biggest changes you've seen from when you started in nursing
to now?

Ms. ARMSTRONG: Well, certainly, patients are much, much, much sicker than
they were 10 years ago.

GROSS: How so?

Ms. ARMSTRONG: How so? I always use this analogy that the patients that are
in the hospital right now on med/surg floor would have been in the PCUs and
ICUs 10 years ago. The ones that are on the floor now are much sicker. You
have a much heavier load, much more complicated disease processes than what
they were 10 years ago. Those patients that were in the hospital 10 years ago
are being cared for at home now through home health services, if they're
lucky. Many times they're being cared for by loved ones. The patients that
are in the ICUs now, I'm afraid, 10 years, 15 years ago wouldn't have survived
to be in the ICUs simply because our technology has increased so tremendously
in the last 10 years that these patients--we're keeping patients alive that
weren't alive 10 years ago.

GROSS: So what practically does that mean for you as a nurse?

Ms. ARMSTRONG: The knowledge base that you have to have of the new
technologies, of the new drugs--Audrey mentioned the drugs--I think that there
are now an average of a hundred new drugs that come on the market each week.
There is no way that we can keep up with that kind of knowledge. So we get a
new drug on the board, and it's like, you have to know what you're giving and
you have to stop and you have to look at what it is and the effects of it, and
the effects of it and all the other drugs that the patient's taking at the
time, and that without a lot of backup systems that we used to have with
pharmacy help and stuff like that. I'm very concerned that the nurses are the
end line; because we're the ones that administer the drugs, we have started to
become held responsible, and sometimes criminally responsible, for those
drugs. Nurses don't have--when they have hundreds of drugs sometimes to give
in one shift, don't have the time to also be the backup system, but yet we
have to be.

GROSS: Do either of you have an example of a time when you feel you averted
catastrophe by observing a mistake that was about to happen?

Ms. ARMSTRONG: Yeah.

GROSS: You want to tell the story?

Ms. ARMSTRONG: Yeah. We in labor and delivery give a drug called Pitocin.
It's to make the uterus contract. It's in a mixture of 10 milliunits within
500 ccs. And a bag ca--and it's mixed by pharmacy. A bag came up that was
marked 100 milliunits per 500 ccs, or 100 units per 500 ccs. And when I
caught it and called the pharmacy, yeah, that what was in it. But if I had
hung that on a patient inadvertently by not seeing where the decimal point
was, we could have really easily killed a baby and a mother.

Ms. LUDMER: The other thing I wanted to bring up--and it may not be so much
in Kim, but in my area where you have multiple physicians. And physician A
writes one regimen Physician B writes a second. Physician C writes a third.
They make no sense together. And they don't talk to each other and--because
they're each treating a different part of a person's body as opposed to
treating the patient. And it's the nurse that puts the pieces together and
says, `This is the patient. Let me get you all in a room and talk to each
other,' or, you know, tries to run interference between the different parties
to make sure that the patient is cared for properly.

GROSS: Is this is a bigger problem than it used to be because there are so
many different areas of specialization now and a patient at a hospital's
likely to be seeing three or four different specialists?

Ms. LUDMER: Well, there's that, that they're seeing so many people, but it's
also the fact that the length of stay has decreased dramatically so that
everybody's trying to do something very quickly.

GROSS: I understand that you have both been patients in your own hospitals.
Audrey Ludmer, from your point of view as a patient, what did you experience,
what did you see right or wrong with the medical staff?

Ms. LUDMER: Unfortunately, I've been a patient multiple times, and I can see
the changes. The last few times I was in a hospital, I made sure one of my
friends stayed with me overnight--one of my friends who was a nurse stayed
with me overnight. Each time I had surgery and was extremely out of it for
the first few hours after the surgery, I wanted to make sure there was
somebody competent there to watch what was happening to me. And, again, not
because the nurse aides are bad and not because the nurses are cruel, but
because they're just so overwhelmingly busy that I wanted to make sure that I
got the care that I thought I should be getting. And having been a visitor in
a hospital, I can tell you that that's not always the case, that nurses run in
and run out, because they're really running. They literally are running.
They're on a treadmill running.

GROSS: Kim Armstrong, what about you?

Ms. ARMSTRONG: Well, I saw very caring nurses who wanted to do an excellent
job, who didn't have the time to do it; that were working double shifts; that
didn't have time and made assumptions that because I was a nurse I could
figure it out myself. And I think since it wasn't my area of expertise I
didn't have a clue. I saw things omitted that I knew had been ordered for me
because I was very much my advocate and had it spelled out prior to coming in.
And it was because of lack of time. It was because I was a lower priority
patient on that floor because I was basically healthy with a minor problem
that needed overnight hospitalization that they were more concerned with their
higher level of acuity patients, their sicker patients, that those patients
needed them more than I did. I, too, had somebody stay with me overnight.

And if I could say anything to consumers out there is be aware of what's going
on with yourself and what's going on within hospitals and advocate for
yourself and ask questions. And make somebody--no matter how short of time
they are--answer those questions for you to your satisfaction.

GROSS: Audrey Ludmer, any consumer advice you'd add?

Ms. LUDMER: I just want to say something about nursing because it sounds like
we've been saying all the negative things, but there are a lot of extremely
positive things. Nursing can be extremely rewarding. You can certainly make
the difference in a person's life. Nurses are working as hard as they can
against great odds at times to provide the best care that they possibly can.

Ms. ARMSTRONG: I'd like to say one more thing. I agree with Audrey with what
she said about nurses. We do a great job telling the world what's wrong with
our profession but not what's right with it. And I don't know of another
profession that you can touch someone's life as effectively as you can in
nursing. I wouldn't trade it for anything. If I was to do it over, I might
make different choices, but I'd still be a nurse somehow, someway. So, you
know, people need to hear that it is a rewarding profession and it's
challenging every day.

GROSS: Well, thank you both so much for talking with us.

Ms. LUDMER: Thank you.

Ms. ARMSTRONG: You're welcome.

GROSS: Kim Armstrong works in a hospital in the Seattle-Tacoma area. Audrey
Ludmer works in a hospital in Manhattan. They're both registered nurses.

Coming up, book critic Maureen Corrigan reviews the new novel "Prague."
This is FRESH AIR.

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Review: New novel by Arthur Phillip called "Prague"
TERRY GROSS, host:

Another week, another fine first novel is published. At least, that's the way
this year has felt so far to our book critic Maureen Corrigan. Here's her
review of Arthur Phillips' new novel, "Prague."

MAUREEN CORRIGAN reporting:

Halfway through 2002, the verdict is already in. This is the year of the
great first novel. "The Lovely Bones" by Alice Sebold, "Everything Is
Illuminated" by Jonathan Safran-Foer, "The Dive from Clausen's Pier" by Ann
Packer--they're all stunners, written by folks young enough to be Philip
Roth's great-grandchildren.

In such an exceptional literary season, critics like me get awfully picky.
Judging any new novel, I feel like the legendary Dick Button issuing verdicts
on Olympic figure skaters. A clumsy gesture here and there, too much obvious
sweat gleaming off the page or a wobbly finish demotes a hopeful contestant
from the gold to the shadowy realm of the silver or bronze.

That's where Arthur Phillips' new, much heralded first novel "Prague" lands in
my estimation. In an ordinary year, Phillips might have gotten his face on a
Wheaties box, but the competition right now is as cutthroat as Tonya Harding
with a iron bar and a willing accomplice nearby.

"Prague" tracks the fortunes of five young American expatriates who travel to
Budapest in the early 1990s to find adventure, money, love and themselves.
`Hold on,' you geography experts might be saying, `Why is the book called
"Prague" when it takes places in Hungary?' The answer is that this novel is
an exquisite specimen of the irony age. Almost every character here is
self-mocking, self-divided and conscious of living a lesser life filled with
substitutes, whether they be lovers or careers or cities. Prague, which is a
more beautiful and booming city than Budapest, is a metaphor of dreams
deferred, like Moscow is for Chekhov's three sisters. It's where the
characters would rather be.

For instance, in an emblematic conversation, one ambitious young woman
excitedly tells a friend about a guy from home who's living in Prague now.
`He's trying to start a business making frozen desserts shaped like Proust and
Freud. And they're called Fin-de-sicles.' Almost every page of this novel is
filled with clever riffs like that one. Indeed, the opening scene in which
the characters play a nasty game called Sincerity, introduces Prague's
signature tone of brittle humor.

Seated around a cafe table on a late afternoon are the five principals:
Charles Gabor, a would-be entrepreneur, Emily Oliver, a diplomatic flunk
whose Midwestern niceness is either a vestigial trait left over from a
vanished America or a brilliant espionage cover and Mark Payton, a graduate
student working on a dissertation about the history of nostalgia. Appropriate
since he longs for any time other than his own. Also playing are John Price,
a fledgling journalist and the only employee at his newspaper not writing a
screenplay during working hours, and his older brother, Scott, a former
English major who now teaches at an English-language school, because like
almost every other English major, he discovers his degree is only valuable
proportionally to how far he wanders from home.

What happens to these lost generation Xers is far less interesting than how
Phillips describes it happening. And there you have the strength and the
weakness of "Prague" the novel. Stylistically, "Prague" is a delight.
Entertaining and often insightful comments on relationships, cuisine,
architecture, sexuality and the fall of communism abound. But the narrative
exhausts itself about halfway through. Phillips establishes his dramatic
situations and then lets them slump. It almost feels as though storytelling
itself is too earnest an endeavor for this relentlessly ironic novel; a novel,
after all, that's even distanced from its own title.

Maybe in the end, the most intriguing thing about "Prague" and the other first
novels I mentioned earlier is that they're bold in scope, spreading out over
time and space. Nearly 20 years ago, Tom Wolfe wrote a famous essay for The
Atlantic Monthly in which he contrasted his then new Dickensian the "Bonfire
of the Vanities" to the constricted and introspective fiction that had
dominated post-World War II American literature. This new young crop of
American fiction writers seems to be infected with Wolfe's ambition,
sidestepping small stories and instead attempting sweeping tales of grand
cities and great expectations.

GROSS: Maureen Corrigan teaches literature at Georgetown University. She
reviewed "Prague" by Arthur Phillips.

(Credits)

GROSS: I'm Terry Gross.
Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.

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