Back to the point. Nurses and physicians at Kaiser Oakland sat together and figured out protocalls. That is algorithms for determining whether or not a patient could self treat at home or really needed to see a doctor. We were encouraged to make assessments (diagnoses) and always defer to an appointment if any doubt exists. We also would book the appointment with any number of docs (based on their specialty and the patient need(??does this doc inject hips??) That sort of stuff.
Three specialties evolved adult med., gyn., and peds.. In the evening the advice nurses answered for all three. Daytime we each had a separate call center. Midnight till six you automatically spoke with the nurses in ER.
In the old days we all sat in one room and you had a conversation with a patient and heard another six in progress (great learning tool). I remember once triaging a call for a chemical spill "Hey, I'm downwind from this stuff. Am I in Danger??" Immediately we were on the phone to the state police and 911. Had an ID on the chemical and spoke with an expert locally to find out about it. We formulated our approach and before the stuff was off the road we had reacted to the emergency community based situation and fielded calls specific to that situation. As a community of nurses we have triaged a major earthquake (loma prieta) and the immense trauma attendant. We triaged a fire that burned 3000 homes in one day in our community. We have knowledge of the years of sequellae that follow. Each call has an element of counseling. Each call is an opportunity. When you are interviewing a person about refills of medicine you assess if they have some knowledge of how that chemical works. You expand on what they know and give them thumbnail explanations or pearls of wisdom for them to use the next time they cogitate on the issue.
Sometimes you are exactly what the caller wants. It's cosmic. I recall a frantic female sounds about 25-45 y/o and definitely anxious. "Hi, I want to ask you a question?" Sure, what's up (me). "Well my husbands tongue is black, not just dark or blue but BLACK. I mean really?" Her voice quickens as she talks indicating she is very troubled by this. (me again) Well how long has it been since his last dose of Pepto Bismol? "He took some this morning. Hey! how'd you...?" Black tongue is occasionally a side effect of that medicine. It has something to do with the bismuth sub-salicylate. Bet his stools black too. "(shouting to her husband) Honey the nurse says it's the Pepto Bismol, yea really!". "(then to me) So how'd you know that. I can't tell you how worried I was". (you already did) "Hey so thank you, really! What's your name again..." We've bridged the divide, the conversation winds down but for a silent YES! and the obligatory hand jerk that accompanies a touchdown.
In Oakland, a Kaiser Advice Nurse has a social ranking just above that of minister/preacher, and just a notch below THE ALMIGHTY. When people find out you're an advice nurse they get naked at Safeway just to have you look at a rash.---The point is that in our town WE EXIST. Police, Fire dept.., US Mail, Advice Nurse.
Now when I orient another nurse to the biz I just let them listen to 8 hours of my conversation. This takes a lot of energy because after each call is an abridged history of the individual and the story 'so far'. Many of the calls in my current specialty GI are repeat offenders, chronic disease calls. So a call today continues a conversation of a week ago.I recognize voices and remember names this gives the impression that the individual on the phone is the only thing on my mind. Not a bad impression to convey when you are in this business. I make sure their condition is progressing as planned or enlist others in thinking about more effective intervention. Another category is an individual who will interface with the department prior to and after diagnosis. These folks will need information about procedures, what to expect, how long will it take, how to prepare. Afterward they need to know how to take the medicine, how to live with disease, how to think about surgery. A trainee leaves after a day of listening, buzzy as if they had spent 8 hours on the freeway at 80mph.
When I interview for nurses in this specialty I ask for experiences in theater, drama, or sales. The most difficult nurses to corral into the triage mode are the ICU CCU nurses. They felt that they weren't "doing" anything since they didn't even see the patient and they were 'stoked' on having lines and tubes and needles, and speaking to the patient like a pet. So they had a hard time with a patient that said "Girl! who died and made you boss, honey?!! I wanna talk to my doctor, not no #!*%*NURSE.." We have all learned to be more assertive and service oriented and case management prone. What we do is take a call and process that information to the top of the process "hill" hopefully the case will roll down hill after we let it go and the patient will get what they need.
Of course you always get a bunch of calls from patients with chest pain indicative of MI who refuse to call 911 insisting that "If I could only talk to my doctor, I'd be all right". You develop the skill to convince callers of the absolute necessity of following your instructions. Sometimes they die. The stories we tell each other in advice are like detective novels. We try to figure out the answer from clues the patient gives us on the phone. Imagine that you were talking to a friend on the phone and that person had his hand in a box and was feeling an object and the object was in a black velvet bag and his eyes were closed. What questions would you ask to get the reliable data you need to know what's in the bag. I might say that advice nursing is an intellectual pursuit but really feel it is more of a cognitive discipline. You can learn to become a keen medical interviewer /teacher /counsellor /advocate.
So today the pediatric advice is computer based. The event is documented on an electronic chart that is available to each person that contacts the patient next. The window that you use drives the process. Theoretically GYN is on the cyber ball too and medicine the largest of the departments not far behind. For the last five years we all are in front of a computer that accesses data bases for demographics, labs, x-ray, appointment history/future, diagnosis history, and drugs that have been filled at our pharmacy for each individual patient. (Think about how we can use this information in a call, since we have immediate access to lab and x-ray data on-line) We also access the Micromedex group of databases for drug interactions, Repro-risk, aftercare follow-up instructions (in English, Spanish and low-literacy). I actually found the aftercare for a sea urchin spine envenomation there while talking to the mother of a surfer/son who was punctured in Bali---I knew anyway since I'm a member of the surfers medical association(published)and have researched salt water injuries for another project(not bad for an ex-steelworker from Buffalo NY. SO I KNOW it comes in handy (esp.. the Repro-risk)
I've written a number of essays about my experiences and now I intend to teach on the web (with a focus on outpatient teaching)
If I get a chance to get another cup of coffee. I'll see if I can post them as editorial comments at http://www.nurseone.com
Thanks for listening Stay in touch
Tony
(I got the coffee but left off the spell-check, SORRY)