The Nurse’s Responsibility to the Conscientious Physician Only. In all tuberculosis work, the nurse is singularly independent. When the patient is in charge of the dispensary physician, or is in charge of a doctor in sympathy with the tuberculosis movement, she may be said to be acting under their orders. Or rather, there are no special orders, except in individual instances, for the routine prescribed is always practically the same. When a doctor reports a case, with the laconic statement, “John Smith, such and such an address, usual thing,” he has fully stated the situation. The doctor knows what should be done, and the nurse knows what to do, and further words are unnecessary. Therefore, when for any reason the patient gives up his doctor, the nurse can still continue to supervise and direct. Months may pass before the patient revisits a physician, and during these months the nurse is the only person in touch with him. She also knows how to advise and direct those who are in contact with him. When he finally calls upon a doctor again, her visits still continue without a break—there should be nothing in her teaching that is at variance with that of the newly arrived physician. The chronic nature of tuberculosis makes this situation possible, and also makes for the extremely independent position of the nurse.
Whenever the physician is in the vanguard of the anti-tuberculosis movement, he will recognize the nurse as an ally, not a rival. He will know that she will make no attempt to supplant him with the patient, since the chances are that she has been caring for the patient for months before he, the doctor, has been called in. He will regard her, therefore, as a highly efficient ally, who will relieve him of tiresome, time-consuming details connected with the case. She will take charge of routine matters that he has no time for, and thus set him free for larger and more important tasks.
If, on the contrary, the physician is one who exploits his patients, who keeps the nature of the disease hidden, whether through ignorance or design, and fails to give proper instruction as to its infectiousness, then we must look for nothing but opposition and antagonism. We must hear objections as to the nurse’s interference, to her uniform, to her tactlessness, to her scaring the patient to death—and we must consider the motives which underlie them. This brings us once more to the question—under these circumstances, what is the nurse to do? Is she to discontinue her visits, or is the value of her instruction to be nullified by contradictory advice? Is a physician, who has consideration for neither the patient nor the community to be allowed to jeopardize both?
To men of this stamp, the tuberculosis nurse owes nothing. Her business is to do her duty, even when it brings her to cross-purposes with them. She has been taught her work by the most advanced and progressive members of the medical profession, and in the homes of patients she is but carrying out the orders of these abler men. That they themselves may have no direct connection with the patient does not alter the situation. She is their agent, not the agent of the hold-overs from a passing régime. Therefore, we look to the former to establish their agent, the public health nurse, in a position of unassailable dignity and authority.
CHAPTER IX
Obtaining a Diagnosis—The General Dispensary—Sputum Examinations—Tuberculin Tests—Registration of Cases.
Obtaining a Diagnosis. As we all know, it is not the business of the nurse to make diagnoses, but it is emphatically her business to select cases which should be diagnosed, and to send them where this may be done. Therefore, if a community supports a tuberculosis nurse it will also find it necessary to establish a place where she may send her patients for examination—a special dispensary for the recognition of pulmonary tuberculosis. If there is no such dispensary, in charge of a capable physician, she may find it exceedingly difficult to obtain a diagnosis for her patients, without which her hands are tied. She cannot preach fresh air and prophylaxis to a person who has nothing but a “heavy cold,” no matter how serious may be the symptoms in connection with it. If the physician in charge of such a case is unable or unwilling to make a diagnosis, it is necessary to have some court of appeal to which the patient may be sent the moment he gives up his doctor or his doctor gives him up. As we have said before, the nurse must never influence a patient to change his doctor—on the contrary, she must be exceedingly punctilious in this regard—but when the patient is fickle and inconstant in his allegiance, she must take advantage of the opportunities offered to send him where he may be skilfully examined. The question of the special dispensary will be treated more fully in another chapter—here it is simply our purpose to show the need of such a place.
In a community which is beginning tuberculosis work, there are usually a few physicians who will generously volunteer their services in examining suspected cases. The nurse, however, will feel some hesitation in accepting these kindly offers, since to take full advantage of them would be to swamp these physicians with a class of patients which would leave them but little time for their private practice. These offers, however, may well be utilized in the formation of a special dispensary, since the same men would doubtless be equally willing to examine patients at some central locality. No matter how humble the quarters, how imperfect the equipment, it is necessary to establish as soon as possible a special place where these patients may be freely examined without any sense of intrusion or of incurred obligation.
The General Dispensary. In many cities, general dispensaries exist for the treatment of minor medical and surgical diseases. It is possible to send tuberculous patients to these dispensaries, and to get them examined and diagnosed, but as a rule this is not satisfactory. These general dispensaries are usually crowded, and the physicians in charge are unable to give sufficient time to the protracted, careful examination which the consumptive requires. However, failing a special dispensary, the nurse must take advantage of these general clinics and accept all the help they are able to give.
Sputum Examinations. In many States, the local or State Departments of Health maintain laboratories for the examination of sputum. The nurse as well as the doctor should be allowed the privilege of sending specimens for examination. If the findings are positive, the result is a diagnosis from which there can be no appeal. The difficulty with this means of diagnosis, however, is that many specimens are negative upon first examination. It may require repeated examinations to find the bacilli, or before their continued absence may be considered evidence that the patient is not tuberculous. Dr. Victor F. Cullen, Superintendent of the Maryland Tuberculosis Sanatorium, writes: