University Times

Ellen Rudy, dean of Pitt's School of Nursing, spent two months of her current sabbatical drawing blood, taking vital signs, emptying bedpans and otherwise toiling as a nurse in the UPMC Presbyterian Hospital emergency room.

"My nursing dean friends all thought I was crazy," Rudy says. "They said, 'Ellen, why on Earth would you want to go back to working in the ER?' "All I can say is, I loved it. It was hard work, but I loved being a nurse again." Rudy's sabbatical continues through December, but she regularly visits Victoria Hall to help nursing faculty prepare grant proposals to the National Institutes of Health. It's part of the sabbatical deal she struck with outgoing Senior Vice Chancellor for Health Sciences Thomas Detre: Along with doing research and working with faculty seeking external funding, Rudy could spend July and August revisiting life in the ER.

"Probably the most difficult thing for me when I became a faculty member was realizing that I would be losing my clinical skills," says Rudy, who worked at hospitals in Indiana and Ohio before earning her doctorate and going into academic administration. The career shift gave Rudy summers off and more time with her husband and three sons, but always there were those nagging fears: Her nursing skills were eroding. She was losing touch with hospital life.

"The last time I had done clinical [work] was at a small hospital in Kent, Ohio, 20 years ago," Rudy recalls. "Before last summer I was thinking, 'Oh, it can't have changed that much,' but I'll tell you, medicine and life in the ER have changed significantly." Rudy found that out the first time she walked Presby's halls carrying a full bedpan with her bare hands. A staffer approached her and whispered urgently, "Ellen, you can't do that without gloves!" Ruefully, Rudy explains: "For years, I had been preaching to my students, 'You can't let any body fluids get on you.' But while I'd been preaching, I hadn't worked in the clinical arena in 20 years. Back then, we didn't wear latex gloves for much of anything. But now, with AIDS and the threat of hepatitis B in particular, nurses wear gloves in every situation where they might come in contact with body fluids." Earlier in her career, Rudy had inserted IVs in patients' arms "a million times," she says. But now, instead of inserting an old-fashioned blood-drawing needle, she was using an angiocatheter, through which a needle advances a catheter into a vein; the needle then is removed, leaving the catheter in place.

"At first, I couldn't do it," Rudy confesses. "I had never started an IV with gloves on before, and I was using this new equipment, and I was a klutz. I had to make myself wear these stinkin' gloves and learn all over again how to do something as basic as inserting an IV." Most of her co-workers were patient and helpful, Rudy says, once they got used to working shoulder to shoulder with Pitt's nursing dean. Rudy had hoped to remain incognito, but someone alerted Presby's ER nurses by e-mail of her presence.

"Early on, the head nurse asked me point blank, 'All of my colleagues want to know why you're here. Are you spying on us?' But once they found out I wasn't on some secret mission or trying to tell them what to do, that I was willing to work hard and clean up poop along with the rest of them, they treated me wonderfully." Or, most did. "I wasn't 100 percent loved," Rudy acknowledges. "A couple of nurses let me know in subtle ways that they didn't think I should be there. They probably didn't like having such a beginner around, and they thought I was being self-indulgent." Presby physicians, however, were unfailingly collegial, Rudy found. "Oh, you hear stories about certain docs, but all I saw were respectful working relationships between physicians and nurses. Another thing that's changed dramatically since the last time I worked in a hospital is the way nurses have become the first line of diagnosis. Today, nurses assess the patient, draw blood, get a urine sample, start the cardiac monitor, order an EKG if they think it's needed — all before a physician even sees the patient. Years ago, I would have taken the patient's blood pressure, temperature and other vital signs, but I would never have drawn blood or ordered an EKG until a physician told me to." Drugs and the way nurses dispense them also have changed, Rudy notes. "Digitalis is still there but I'll tell you, there's not much else we use today that we used 20 years ago. All of the cardiac drugs and antibiotics have changed, for example.

"The last time I had worked in an ER," Rudy continues, "you would open a cupboard and there was any drug you wanted. If the physician wrote 'Darvon,' you went over and got some Darvon, gave it to the physician and wrote it on a chart. Today, you must charge individual patients for everything they receive, and individual nurses must account for every pill, every shot, everything. In the old days, the only drugs we signed out for were narcotics." Rudy despaired of ever mastering Presby's computerized Pyxis system of dispensing drugs. To use the system effectively under pressure cooker ER conditions, nurses must learn passwords, memorize generic and brand names for dozens of drugs, and maintain flawless records. Even using cheat-sheets, Rudy could not keep up at first. "I was in tears. I thought, 'I am never going to conquer this damn system.'" Systems like Pyxis have saved hospitals money and cut down on drug theft, Rudy points out. "The old system was a license for the staff to steal and misuse drugs." Some patients still go to great lengths to access Presby's drug supply, Rudy found. A favorite trick is faking symptoms of passing kidney stones; hospitals routinely prescribe morphine for the intense pain. "These people are pretty sophisticated. They know that X-rays don't always reveal kidney stones," Rudy says. "When producing a urine sample, these people will even prick a finger and mix some blood in with their sample, knowing that kidney stone sufferers typically have blood in their urine.

"Hospitals keep lists of known drug-seekers who make the rounds of ERs in town. One day I was there, we had a kid who came in, apparently in agony from kidney stones. We did tests but couldn't find anything. Eventually, we quit giving this kid drugs, and he just got up and left." Then there was the young man police brought to Presby's ER, who claimed to have panicked when he saw the cops coming and swallowed three packets of cocaine. If a packet burst in his gastro-intestinal tract, there was nothing doctors could do to save his life.

Physicians inserted a large tube through the man's nose down into his stomach, and pumped in 1000 cc's of a heavy-duty laxative. Rudy and her fellow nurses emptied bedpan after bedpan until the patient was excreting clear water. After 24 hours of treatment, there was still no sign of cocaine packets.

"It turned out, he'd made up the whole story," Rudy reveals. "Now I mean, is this bizarre? Why would anyone do that?" According to Rudy, "The weird people you see on [TV's] 'ER' are absolutely the truth. The only thing that is not true about 'ER' is the way they handle trauma. There's a very systematic and organized way Presby handles trauma that is really beautiful to see. There's a very clear protocol you follow. Everyone has a specific place to stand. It isn't as nutty as it's portrayed on TV." r Asked how life in the ER compared with meetings of Senate Council or the University Planning and Budgeting Committee (UPBC) — two Pitt governance groups on which Rudy has served — she positively cackles. "Oh, they're so boring! You almost feel like, when you're in those UPBC meetings, they don't even know what the real world is. It's almost like, 'Get a life here, fellas.'" After a faculty member of UPBC questioned the nursing school's teaching expenses, Rudy took him on a hospital clinic tour "to show him the real world of nursing education," she says.

"Our students are exposed to blood, to AIDS, to death, to babies being born. We're talking about 19- or 20-year-old kids. There is no comparison between their lives and the lives of their roommates who major in English and go to class and talk about Chaucer. I'm not putting Chaucer down, but emotionally it's a different world. I needed to go back and remember what that world is like." Rudy says she often felt at Presby like a none-too-bright, sophomore nursing student. "In many ways, I didn't know what I was doing. I was dumb as a stump. Dumb as a stump! And yet, people in that ER were kind and helped to educate me, and for that I will forever admire them. The few who were obnoxious and snotty, I don't ever want our faculty to be like that." Does Rudy plan to communicate to nursing faculty what she learned last summer? "Oh, I don't know," she says, shrugging. "The last thing our faculty want is for me to come back from sabbatical and preach to them like the converted. I think, generally, we have very good faculty who relate beautifully to students. But all teachers, from time to time, get discouraged with their students and want to shake them.

"I do plan to talk with our faculty a little bit about what it felt like to be a student, and remind them of how important it is to preserve the students' dignity. One thing I relearned from my own experience at Presby is: It isn't necessary to put people down to make them learn."

— Bruce Steele