Wednesday, June 20, 2007


Top Stories from JCAHO:

“Correct Patient,
Correct Procedure,
Correct Site, EVERY TIME!
Compromised, Almost Comatose,
Surgical Team

The Standards JCAHO choose to Police v
The Standards JCAHO Choose to Ignore!

Did you Celebrate National Time Out Day?
Do We Need: “National Pass Out Day?”

“Try telling me it is safe to remain continuously
scrubbed into Surgery without a break for 12 hours:
not a single drink of water, any food or a chance to
urinate? Try convincing me that concentrating on
performing a critical, highly stressful, role in the
OR during Surgery while sick, dizzy and faint, does
not pose a serious risk to my patient, unconscious
on the OR table?

Please explain to the General public why JCAHO,
the Maryland Board of Nursing, MIEMSS, and so many
other Public Agencies, whoser mandate is to protect
US Citizens from unnecessary harm, still choose to
ignore the obvious risks posed by such negligent
abandonment of any member of the Surgical Team?"
Review & Sign the Petition:
Read the Letter of Appeal sent to well respected Doctors
at “America’s Best Hospital:”
“Deliberate Negligent Understaffing” Endangers us all;
Join the C U T ! Campaign to:
Control Understaffing Today!

A new C.U.T! CAMPAIGN PETITION will be posted shortly on the Care2, under Health.

I am eagerly seeking the Constructive Input and Support of individual Nurses as well as Nursing Websites on Campaign Issues. Please contact me and also visit the new TRANSPARENCY for EQUAL ACCOUNTABILITY in MEDICINE site at:

Tuesday, May 22, 2007


I owe a huge debt of gratitude to, to,, and this Blogspot Site for giving me a voice. Like a high tech “Speakers Corner,” a loud hailer on the world, the Internet can only help us to proclaim the truth with dedicated Websites like these. Humble citizens feel really helpless to fight injustice when all the press can focus on is Corporate grandstanding and sensationalist horror. I have certainly come to appreciate all the Internet Blog sites that have posted my comments or helped publicize this issue:,,, “The Justice Brigade” on My Space, “Talk back to Al” (Lewis) and informative Medical threads like and “Every Patient’s Advocate.” There are countless others I have yet to find on the web as the people’s voice grows louder by the day. The Internet gives ordinary people a unique opportunity to speak out at a time when the media is fast becoming a wanton propaganda machine by ignoring any responsibility to conscientiously inform the public.

In my last post, “An Exhausted Surgical Team Endangers the Patient,”
I posed the question: “How Long is Too Long for a Member of the Sterile OR Team to Remain Continuously Scrubbed into Surgery without a break?”

I recently contacted a well respected investigative reporter with the local Baltimore newspaper to explain my case and ask him to make inquiries at my former Hospital. He told me that staff left stranded scrubbed into Surgery for twelve hours without a break wasn’t really a story and it wasn’t worthy of any investigation. Before it would become an issue that he might look into “people” (yes he did say “people” plural) would have to die as a result of this negligence! Can you imagine the court case: “We were really sorry your mum died in Surgery due to a completely avoidable error, but my scrub had been bursting for a pee for over eight hours and her supervisor claimed she didn’t ask to be relieved?” Now that would make headlines all right!

At my Arbitration Hearing my former Hospital admitted on tape to leaving me stranded in Surgery for a period that was documented in the final ruling as 16hours (it was in fact 12hours) without relief. What is truly shocking is that 12 or 16hours of continuous work without water, food or urination was considered acceptable practice and not inhumane treatment of staff. It was OK simply because my Nurse Manager said that I hadn’t asked for a break.This shameful admission was also made to the Maryland Board of Nursing, EEOC and the Maryland Commission on Human Relations, but they all accepted the same fictitious excuse that would have made no sense even if it were true. Not one of these agencies bothered to consider the danger to the patient that any normal employee might present by working until they nearly passed out in Surgery.
Shame on Maryland Board of Nursing this is a very dangerous practice. Did EEOC or MCHR protect my human rights? No.

Fact: Nursing staff do not willingly accept or enjoy being “tortured” in the work place by inconsiderate Managers.

The onus should never be placed on an employee to beg for humane treatment so that they can concentrate while at work. It is the sole responsibility of Management to meet the basic needs of staff so that they can function safely in critical clinical roles without severe discomfort and deprivation that might ultimately cause undue risk to their patients. This issue must be addressed by Nursing Boards across the US.

We do not need to look to third world countries for newsworthy stories of abused and exploited employees suffering in the work place, it is happening here in the US and the public deserves to know what is going on. There is a duty to inform the public, in order to try and prevent inhumane treatment of staff regardless of whether even a single patient actually dies as a result. The same seasoned investigative journalist then said he needed evidence from a “recognized authority” that going without water, food or a chance to relieve oneself for over twelve hours while working was actually detrimental to the Surgical team functioning safely in the OR! I thought it was a “no-brainer.” While normal physical requirements for sustenance are already well documented in medical literature this was not enough to satisfy his verification of the facts. It was solid evidence that staff deprivation had already caused a number of patient deaths that might finally grab his attention.

In explaining himself he argued, why should the general public be unduly scared by the prospect of a potential risk? I say, how well would most people respond to such inhumane deprivation? I believe this is vital, because without public pressure via the media not only will Hospitals continue to take risks, our public agencies will blithely condone this dangerous conduct as irrelevant to patient safety, just as they did in my case. Would it be so terribly irresponsible for a reporter to warn readers that a situation existed in our Hospitals that was known to be unhealthy as well as downright cruel to Medical staff? In turn such deprivation might adversely impact the care of their loved ones receiving treatment, but then why should this consideration be the sole reason to take action? According to the journalist I spoke to there was no duty to inform the public of a potential risk, I needed to prove that people had died as a direct result of this ongoing negligence.
The Maryland Board of Nursing have no intention of investigating this issue and I doubt that any safeguards I suggested to them will ever be put in place without a major public outcry.

The truck drivers were prevented from hours of continuous driving due to the risk this posed to other motorists on the road: I guess a number of accidents occurred to prompt tighter restrictions. Even while under way a truck driver can pull over in a lay by to take a pee, plus they can still have a drink of water or eat a sandwich in the cab. Imagine if you couldn’t even scratch an itch for twelve hours straight! I am not suggesting that we bring snacks into the OR, but please know that Medical staff are human too. Airline companies do not refuse food and water to Pilots during a long haul flight by saying “the passengers have to come first.” By the way, how many of the passengers could avoid using the toilets all the way from London to Singapore? When Medical staff urgently need a relief break we are told that: “the patients must come first.” This is used to justify inhumane exploitation of staff. Run to the bathroom or take a quick bite to eat and you could be charged with “Patient Abandonment?”

We are horrified to learn of impoverished workers in third world sweat shops who are stuck behind machines for twelve hours of near slavery. Are they also deprived of food or water and prohibited from performing necessary bodily functions for twelve hours? At least some of these workers are seated. We usually stand throughout Surgery, but is twelve hours of standing under hot OR lights too much for the super-human Surgical team? Obviously Hospital Managers do not think we deserve to be treated like normal mortals; unfortunately the press would seem to agree. The Geneva Convention does not permit such deprivation to be inflicted on working POWs, so why is this “torture” acceptable for Medical staff doing highly technical life and death jobs in our Hospitals?
"Sorry about the inhumane treatment, but the jury is out because we are still waiting for patients to die as a consequence?"

The real crime of “Patient Abandonment.” is being committed by our Hospitals through the “Deliberate Negligent Understaffing” of clinical units. This dangerous staffing policy is excused by any cursory mention of the so called “Nursing Crisis” that these facilities consciously created in order to cut costs and bloat profits. Management can persist in forcing Nursing staff to continue working when they are dangerously fatigued and deprive them of basic human rights by threatening them with discipline and charges of abandonment. Refuse to work a double 16hour shift, mandatory overtime or take call because you know that you simply cannot safely continue working after long hours of stressful service and you too can be charged with “Patient Abandonment.”

Ignoring the real issue of staff fatigue places patients at serious risk due to increased incidences of exhausted staff making medical errors. However, when a patient is harmed the Medical facilities responsible for “Deliberate Negligent Understaffing” of their clinical units continually manage to deflect true accountability by blaming their overstressed staff with devastating charges of incompetence. It is truly alarming to discover how easily the public have accepted these warped and erroneous portrayals of incompetent Doctors and lazy, uncaring Nurses being responsible for the growing number of Sentinel Events in Healthcare. No one wants to be incorrectly labeled incompetent so the Nurses continue to leave in droves.

The current “Nursing Exodus” is a direct response to this impossible choice that staff are being forced to cope with. If the working environment became less toxic and more humane, if Nursing staff knew that they did not have to take risks with the care and safety of their patients, many would return to our beleaguered Hospitals. We need new legislation to put appropriate safeguards in place immediately. We need safe Nurse to patient ratios, an end to mandatory overtime, a humane relief break policy, the ability to call in sick without penalty, a safe mix of experienced and newly graduated staff, less reliance on temporary help and more regular staff to deliver safe patient care. This process will start when authorities finally recognize that all staff must be treated with humanity and there is no excuse for torturous conditions in any workplace. Those who blow the whistle on negligent practices must be protected from retaliation and listened to by our public agencies, government regulatory bodies and, when necessary, a conscientious investigative journalist.

Would you function dangerously knowing that a mistake at your job could kill your patient? You could tell your Manager, and get fired. You could report to “Risk Management” or a “Compliance Line,” and they will aid and abet in your untimely removal without cause. You could report to independent regulatory bodies and they will expect you to have reported internally first. They ignore the fact that doing so cost you your job; you have now become an unreliable informant seeking revenge so therefore they consider there’s no need to investigate.
You could go to the local press, but they are waiting for “people to die” before they are certain that the problem must to taken seriously. They might also prefer to wait until a “recognized authority” is prepared to state publicly that torturing Medical staff might pose a threat to the safety of their patients, before they will encourage a public outcry. You could spill the beans on the Internet in a Blog like this or post a Petition on Will it do any good? Will anybody listen?

To review and consider signing my Petition go to:

Monday, April 23, 2007


How Long is Too Long for a Member of the Sterile OR Team to Remain Continuously Scrubbed into Surgery without a break?
Although the general public might not understand that medical professionals, including the Surgeon, must leave the OR briefly during a lengthy Surgery, most conscientious practitioners realize that this is a normal safety measure necessary to combat fatigue. I am trying to get a consensus of feedback, from those who must routinely face this dilemma in the OR, as to what time frame is universally accepted as the maximum period that any member of the sterile team should ever be expected to safely function while scrubbed into Surgery without a break?

I am now enrolled in the National Institute of First Assists, “NIFA,” training program to become a First Surgical Assistant, but even as a Surgical Technologist, performing the “scrub” role, I had to concentrate on anticipating the Surgeons needs during a case. After how long would you consider that scrub role jeopardized by fatigue to the point where I might have lost concentration and focus on the operation? Can we really afford to take such risks and blithely talk of the increased incidence of medical errors as if these issues were completely unrelated?

While a Surgeon can, and should, demand that the person assisting him in Surgery is relieved briefly during a lengthy case, Nurses and Surgical Technicians fall under the control of OR Management. This leaves them vulnerable to the vagaries of inappropriate OR coverage as determined by the Hospital. As a consequence of Hospital “downsizing” to cut costs, redundancy of personnel has been severely limited. This has reached the point where during the off-shifts, especially at night and on weekends, there are no free staff to break people out of Surgery for even a quick run to the bathroom!

At an inner city Level One Trauma Center these off-peak time periods are covered by a minimal compliment of essential experienced medical staff, who must frequently deal with critical trauma cases, emergency returns to the OR and major Transplant Surgery. This was my regular OR shift assignment at my former Hospital for the last 2years of my 5year tenure. With just one Nurse and two OR Techs on duty after 11:30 PM on a Saturday night, this challenging shift already required knowledgeable, highly adaptable and versatile staff. However, inhumane levels of endurance plus the ability to tolerate severe deprivation for extended periods shouldn’t be part of any job description. The real question is, can critical OR personnel maintain concentration during complex cases under such radical extremes as 12hours continuously scrubbed into Surgery? The lack of redundancy among Nursing personnel is harmfully impacting ICU’s and other critical care units of many US Hospitals, but the physical limitations are severest in the OR.

Calling in call team people just to provide relief breaks is considered an unnecessary expense, despite the fact that there is a clearly established link between fatigue and medical errors. The sterile team scrubbed into Surgery must remain trapped without food or water until they are relieved which represents an unacceptable deprivation strain on the body. The inability to urinate when necessary is very unhealthy too. To simply “break scrub” and leave the OR without handing over to an assigned relief scrub and completing the necessary controlled counts is considered “patient abandonment.” However, there are currently no real safeguards within the existing US employment laws or OCHA standards to insure that critical Hospital workers, including those in the OR, are not left for hours of continuous, and dangerous, practice without a break. Under US law in most States: “Breaks are at the discretion of the employer.”

I was left stranded at the field without relief for 8, 10 and on the worst occasion 12 hours straight during a Liver Transplant while my patient was on bypass! I worked off-shifts in the OR of a busy downtown Hospital famous for its active transplant program. We saw more penetrating Trauma than any other facility in Baltimore, a city with a homicide rate that averaged over 300 a year. These abandonment situations impacted my ability to concentrate as my blood sugar plummeted; each time I reported becoming sick, dizzy and faint to the point of nearly passing out. Who needs to eat at night anyway? My Nurse Manager wanted me evaluated for a “sugar problem!” When I dared to complain that my condition in response to this hardship presented a danger to my patients I was targeted for removal, forced to take unpaid leave and then fired.

Incidents where any member of the OR team is forced to remain on task for that long should be documented in an “Incident Report,” as an extreme of this magnitude presents an unacceptable, and in most cases unnecessary, danger to the patient. How many normal human beings are expected to go for 12 hours without water, food or urination? The Geneva Convention strictly prohibits such inhumane treatment of working POWs! Why is this acceptable for critical Hospital staff?

I offered this mandatory Incident Report requirement suggestion to my former Hospital via their Compliance Line, only to be ignored as a terminated and vilified unreliable informant. Healthcare facilities know that the most effective way to deal with concerns and complaints is to just “shoot the messenger!” Compliance Lines were established to allow employees to report negligence, fraud and abuse without fear of retaliation, but in some cases they have become another layer of defense from external scrutiny. No current legislation exists to protect Healthcare Whistleblowers and Hospital Compliance Lines cannot always be trusted with impartial internal investigations when they know there is no potential possibility for independent oversight. .

The campaign of silencing a dissenter goes on long after they have been ousted in disgrace. I have contacted JACHO and other Accreditation Agencies as well as the Maryland Board of Nursing, but my warnings are easily discredited by my untimely removal from my job. A minor protocol change needs to be enacted immediately to prevent future incidents like this from becoming more commonplace exposing patients to potential harm through preventable negligent under-staffing. I cannot understand why so many Government agencies remain so complacent in refusing to review this situation rationally in the best interests of public safety.

There is a lot of talk about medical errors right now, but far less mention of the toxic work environment that is increasingly encouraging mistakes. This situation is getting steadily worse. While “At Will” employment laws silence those who dare to speak out, lack of a humane break policy condones driving Hospital staff until they drop: No big surprise that fatal or damaging medical errors and “sentinel events” are on the increase? Is it any wonder that a sponge or an instrument is inadvertently left inside the patient when the scrub is almost comatose after a stressful 12hour ordeal in Surgery? All the cross checking and elaborate safeguards are irrelevant if the Hospital staff are trying to function while so severely fatigued, hypovolemic or hypoglycemic that they are at the point of either falling asleep or passing out.

When will the various safety advocacy groups in the US finally address this very real problem and insist on proper protective legislation? There have been advances recently with limiting the Residents working hours and trying to stop mandated overtime for Nurses, but much more emphasis must be placed on eliminating unnecessary fatigue among all of our medical staff. Managers must be held responsible for providing adequate personnel to cover all of their shifts, including a redundancy of staff to relieve OR teams during Surgery and in other critical areas. If a Manager’s failure to provide relief was documented on a routine basis it would no longer be an acceptable form of staffing coverage! Such incidents would become the rare exception, confined as they should be to genuine emergency situations where there is absolutely no other choice.

“No one is more important than the patient unconscious on the OR table.”
This was the statement I gave to Hospital Lawyers at an Arbitration Hearing to determine my reinstatement. For this very prestigious Maryland Hospital the “Nursing Shortage” was a convenient excuse to justify unconscionable Managerial abuse that seriously endangered my patient in the OR. They claimed that the ER was busy and I had not asked for a break. The ER is an unrelated clinical area and just try begging for relief on a phone you cannot even touch! Doctors and Nurses face severe discipline when mistakes occur, but why isn’t a negligent Hospital policy that condones drastic staffing cut backs ever recognized as the real culprit? In some cases the administration even offers financial bonuses to further encourage self-serving Managers to implement inadequate staff coverage: greed works! Then, after clear indications demonstrate that deliberate under-staffing is continually putting patients at serious risk, they fail to hold repeatedly abusive Managers accountable as they drive dedicated staff until they drop.

This dangerous Managerial policy is focused purely on drastically reducing vital staffing costs to save money at the expense of creating a safe patient care environment that saves lives. We need proper safeguards in place to curb this negligent profiteering strategy before more patients are harmed unnecessarily. Additionally, when Healthcare employees are courageous enough to come forward and expose a pattern of ongoing negligent under-staffing practices or other dangers to patients they must be protected from retaliatory Managerial misconduct that threatens their job. If a Hospital’s internal Compliance Hot Line fails in their crucial self-policing obligation by refusing to investigate negligence or provide protection from retaliation they must be held fully accountable.

Whistleblowers should not face the third degree from Government Agencies who are all too easily fobbed off with fictitious excuses indicating a disgruntled former employee is seeking revenge. .Few will risk jail time to “seek revenge” by making sworn statements under oath to a States Attorney! All complaints and allegations must be taken seriously by accreditation agencies who’s primary duty is to protect public safety. No medical institution no matter how iconic, prestigious or powerful should be immune from rigorous scrutiny, as this lack of oversight encourages bending the rules, ignoring regulations and cost cutting that is harmful to safe patient care.

Relentlessly abusive Managers are a very valuable tool in generating increased revenue by facilitating staff downsizing without obvious layoffs. I call this the spineless approach to cost cutting, but it makes our Hospital working environment extremely dangerous for the patients. The current so called, “Nursing crisis” has come about through a deliberate and calculated policy of dangerous downsizing to target Nursing staff, but particularly the most experienced Nurses who are higher paid. Minimally trained assistive personnel are plugging the gaps, working under the direction of overwhelmed new Nurse Graduates who are being forced to take on responsibility they are ill prepared to face. The creation of a toxic work environment is driving Nurses to leave their chosen profession in droves. When Nurses are powerless to change under-staffing, and powerless to report negligent practices, the only way to refuse the dangerous policy of keep taking unnecessary risks with patient care is to leave: hence the Exodus.

The US does not have a “Nursing Shortage” it has a “Nursing Exodus!”
The US healthcare industry is still consistently expecting all of our medical professionals to take bigger risks by making do with unsafe staffing practices. This important patient safety issue desperately needs to be addressed immediately, so please consider signing the Petition mentioned below and post your comments on this subject directly on the Petition itself.

A personal letter of appeal and explanation from the author can be read at

. The author is still struggling to overcome the severe damage that wrongful termination as a Whistleblower inflicted on her professional reputation. In August 2005 she returned from Tsunami ravaged Aceh Province, Indonesia where she had worked for six month as an unpaid Medical Volunteer in Surgery at Cut Nyak Dhien Hospital in Meulaboh.
To see Kim, pictured wearing a flimsy ER cover gown over her scrubs in Surgery at this minimally equipped disaster zone Hospital; GO TO:
PACTEC at the UN Compound in Meulaboh:

This conscientious and dedicated Medical professional is calling for your help in the hopes that her Petition will precipitate meaningful debate on important issue like Under-staffing, Compliance and Whistleblower protections for Healthcare employees; eventually becoming a catalyst for new legislation of vital regulatory safeguards. While it will be gratifying just to make a tangible difference, personal vindication might remove the remaining barriers that still prevent her from reestablishing a worthwhile career as an NGO Medical Volunteer overseas. The author is also in the process of writing a book called: “ICONIC IMMUNITY,” detailing her experiences and the lessons learned. Please post your comments...