Many of these registration cards are duplicates, the case having already been registered by the attending physician, or the dispensary. If they are not duplicates, it is necessary to have the official registration in the handwriting of the physician himself—it is often needed when trouble arises over the fumigation of houses, and so forth. There is nothing official or authoritative about the nurse’s registration cards—these merely call attention to the fact that certain patients are under her supervision, attended by such and such a doctor. In most cases, the diagnosis given is a verbal one. Should any difficulty arise, this verbal diagnosis would not be valid, although it furnishes an excellent basis from which to instruct the patient and his family. Therefore the nurse’s registration card, if it is not a duplicate, serves to call attention to the fact that a certain physician is in charge of a case which he has not reported. The Health Department at once writes and asks him to report, and in this way the diagnosis is officially recorded.
In Maryland, the law calling for the registration of tuberculosis had been on the statute books some years, but was generally disregarded. The physicians failed to report their cases, and it was therefore impossible to estimate the amount or distribution of tuberculosis. To do this was the object of the law. How generally this regulation had been ignored may be judged from the fact that in 1909, the year before the Baltimore municipal nurses went on duty, the number of cases of tuberculosis registered by physicians was only 919, while the deaths from tuberculosis for that same year were 1400. In 1910, the first year that the nurses were on duty, the cases registered jumped up to 3202, while the deaths fell to 1234. This sudden increase in the registrations—an increase of over three hundred per cent.—shows the stimulating effects of a staff of active public health nurses.
How necessary it is to have the diagnosis recorded in the physician’s own handwriting may be judged by the following incident. There was a coloured man on our list, referred to us by a private physician. This patient was a model in a school of painting and drawing, and after a time the Health Department was flooded with complaints concerning him. These complaints came from pupils, who declared they were afraid to go to the classes, because the patient coughed so violently and spat so profusely. The students did not know he was tuberculous, but they suspected it, and therefore asked us to look into the matter. Finding that the man was one of our patients, we at once wrote to the directors of this school, telling them of this, and of the complaints that had been made against him. We further suggested that if he continued to pose as a model he should use the prophylactic supplies that the nurse had given him, and which he used faithfully enough in his own home. The Directors, however, would not take our word for this; they sent the patient to another physician, not the one who had originally examined him. To this man, the darkey protested that he had never seen a doctor in his life. The second physician declared that the patient did not have tuberculosis, wrote a note berating us for our interference, and called upon us for proof. A hurried search of the files brought forth the original registration card, sent in by the physician who had first diagnosed the case, and transferred it to the nurses of the Health Department. This fact at once threw a different light upon the matter, and we were able to uphold our contention. The first physician, however, had completely forgotten this patient, and had it not been for his registration card, on file at the office, we should have been in a very disagreeable position.
Since there is nothing authoritative about the nurse’s registration card, she must be exceedingly careful never to register a case unless it has been properly diagnosed. This information should be obtained from the physician himself, whether in writing, verbally, or over the telephone. She should never accept a third person’s word for the diagnosis, no matter how accurate it may seem. For example, if a patient’s mother tells the nurse that the doctor has just been in, and said her son had tuberculosis, the nurse must not accept this statement as sufficient. She must call upon the physician and ask him herself. Again, suppose the nurse has sent a patient to the dispensary, and, meeting him on the street an hour later, she learns that the doctor’s verdict was consumption. She must not take the patient’s word for this, obvious as its truthfulness may seem. It is necessary to be thus punctilious, to prevent unpleasant occurrences from taking place. The diagnosis of tuberculosis is too serious a matter to be accepted through any such irresponsible medium as the patient or his family.
To fill in the registration cards is the nurse’s work. To supervise these cards, and note their correctness and accuracy, should be the work of the superintendent of nurses, in whose name they should be signed. This transaction is one of the most important tasks of the office, and extreme care should be taken that non-tuberculous patients are not registered by mistake.
CHAPTER X
Prevention of Tuberculosis—Sources through Which Calls are Received—Entering the Home—Telling the Truth to the Patient—Truth for the Family—Disposal of Sputum—Danger of Expired Air—Isolation of Dishes—Linen, Household and Personal—Disinfectant and Other Supplies—Phthisiphobia.
The Prevention of Tuberculosis. The object of the nurse’s work is to prevent the spread of tuberculosis—it is not to cure the disease. In doing the preventive work, it often follows that the patient himself is immensely benefited, and his disease apparently arrested. This arrest, however, is incidental—it is not the real object of the work, which is the protection of individuals as yet uninfected. In no other branch of nursing is there so much misunderstanding, so much placing of the cart before the horse, and so much emphasis laid on the wrong thing. Nurses themselves when they first begin the work fail to recognize the real issue, and think that it is the actual care of the patient which is the thing to be considered. This is totally wrong—we work through the patient to gain our ends, but he himself is not the main object. It is necessary to grasp this fact firmly, and keep it constantly in mind. This will not only prevent much disappointment and discouragement, but it will lay the foundation for more intelligent work.
On entering the home of the consumptive, the nurse has before her two responsibilities, the family and the patient. The former is infinitely larger and more important, since it is the family, as yet uninfected, which must be protected from the patient, or source of the disease. Instead of “family” substitute the word “community” and we have the crux of the situation—the protection of the community from the danger to which it is exposed. This protection may be accomplished largely through care of the patient, but care of the patient, only, as such, is a secondary matter. The vital and important concern is the welfare of his family. To confuse these two issues, and put the patient first, and the family, which means the community, second, would delay indefinitely the result we hope to attain. As far as possible, the interests of the two, patient and family, should be identical, but whenever a choice must be made between them, the welfare of the community has the right of way.
This is why effective tuberculosis work must place the emphasis on the control of the last-stage cases, since it is the advanced case which is of most danger to society. For example: we have two families, one of which contains a moderately advanced case, whose outlook is favourable, while the second contains a last-stage case with a hopeless prognosis. Both patients are equally intractable; the nurse has but a limited time at her disposal, and must choose between the two, since she cannot divide her days equally between them. From the point of view of the individual, care of the earlier case would better repay her time and effort; from the standpoint of the greatest good to the greatest number, she must concentrate her efforts on the advanced case, since it is this one which is immediately dangerous. The earlier case is less of a menace to those about him; his obstinacy and refusal to follow advice mean loss of that precious time in which life and death are determined—but if he chooses, however wilfully, to waste this time, it is his own loss after all. It involves no one else. On the other hand, much more is involved in the advanced case. Here the patient’s death is inevitable, but it can be kept from occurring amid circumstances which would drag down others with him.