Alexandra Robbins is the author of The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital, from which this article is adapted. She will discuss her work at the Bethesda (Md.) Barnes & Noble on May 14 at 7 p.m. and at the Gaithersburg (Md.) Book Festival on May 16 at 2:15 p.m.

Welcome to the land of health care’s 1 percent. During the four years I spent interviewing and following nurses for my book, I was continually astonished by the red carpet some hospitals rolled out for certain classes of patients. A Virginia nurse explained that this is why Washington might not understand health care. He said, “Politicians have such a warped sense of how the health care system works because they never have to be part of the actual system.”

Politicians and other VIPs, it turns out, can get special access to critical care. Hospitals across the Washington area—and, indeed, across the country—have exclusive rooms and sometimes even separate floors for treating the rich and famous.


That surprise was hardly the only secret that transformed the way I understand the world of medicine while writing The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital. If you want to know what’s really happening in a medical building, don’t ask a doctor. Instead, turn to the best-informed, hardest-working and savviest professionals in health care: Nurses.

Many nurses call their profession—3.5 million strong in the United States and more than 20 million worldwide—a “secret club.” In the years I spent going behind the scenes in hospitals, I learned why. Their experiences are so novel, their jobs so intimate and occasionally horrifying, their combination of compassion and desensitization so peculiar, that nobody else could possibly understand what it is like to work in their once-white shoes.

“Doctors breeze in and out. They do not share the most intimate moments with the patients, but they are the ‘important’ ones who get the media accolades,” a New Jersey nurse practitioner told me. “It is the nurse who holds the hand of a patient without a family, who talks to them while they take their last breaths. It is the nurse who cleans the patient’s body, wipes away the blood and fluids, and who says goodbye to the patient for the last time.”

And it’s the nurse who knows best what really goes on in the florescent-lit, often-dizzying world of IVs, open-heart surgeries and oxygen monitors. Here are some of the health care secrets they told me.

Listen up—some of them might just save your life.

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Don’t get sick in July. Every year in teaching hospitals at the start of July, medical students become interns, interns become residents and each successive class of residents moves up a level. These new doctors are immediately thrust into direct patient care. As the National Bureau of Economic Research reported, “On day one, new interns may have the same responsibilities that the now-second-year residents had at the end of June (i.e., after they had a full year of experience).”

This upheaval causes what health care workers call “The July Effect” in the United States and “August Killing Season” in the United Kingdom (where the shift happens in August). The changeover harms patient care, increasing medical errors, medication mistakes and the length of hospital stays. In July, U.S. death rates in these hospitals surge between 8 and 34 percent—a total of between 1,500 and 2,750 deaths. UC-San Diego researchers found that fatal medication errors “spike by 10 percent in July and in no other month.” In Britain, August mortality rates rise by 6 to 8 percent as new doctors are tasked with surgeries and procedures that Britons say are “beyond their capabilities.” Patients in English hospitals have a higher early death rate when they are admitted on the first Wednesday in August than patients admitted on the previous Wednesday.

The residents who know enough to know what they do not know—and therefore listen to and seek out nurses for advice—are not the problem here. But too many residents, enamored of their M.D., won’t ask for help. “Nurses are correcting every error and preventing major mistakes every day,” said a Maryland solid organ transplant nurse.

If you must be hospitalized in July for particularly complex procedures, you might consider avoiding teaching hospitals.

Sometimes we are told to treat certain patients better. Many hospitals treat VIPs better than the average patient, saving deluxe private rooms for the celebrities, politicians and officials who know about them. While some luxury rooms are available to any patient who can pay for them, others are kept secret.

A Washington, D.C., hospital has a VIP unit devoted to patients such as visiting foreign dignitaries, senators and professional football players. “It doesn’t have typical hospital furnishings—the rooms are much bigger, with fancy bedspreads, decorative pillows and lavish curtains,” said a Maryland nurse who used to work at the hospital. “The patients are served excellent food—much better than the food on the regular floors—and they are given anything they request; the nurses cater to their every whim. It’s a restricted floor, with no access from the regular elevators. Most people don’t even know this floor exists.”

Across the country, nurses described VIP accommodations that look more like spacious luxury hotel suites than hospital rooms, with kitchenettes, beautifully glass-tiled bathrooms and other amenities. In one Washington State hospital, when a VIP comes in, the staff combines two rooms to make a large one. They are instructed to bring in a large-screen TV and the “VIP furniture.” After the VIP is discharged, a nurse there said, the furniture is removed and stored until the next VIP admission. “They do this for rich and influential people and we nurses are disgusted by it. Nurses are taught to treat each patient as an important person and to give our best care to each one of those patients,” she said.

VIP care becomes problematic when those patients unnecessarily take up resources that more critical patients need. “Sometimes they will get a one-on-one nurse or we are all told to give them extra special treatment,” said a New Jersey nurse. “I have seen critical patients who should be next to the nursing station moved so that a relation of a board member, a big donor, or celebrity could have the better room even if their condition didn’t warrant that level of observation. At another local hospital they had an entire VIP section set aside; those rooms were not to be used for the riffraff.”

Every hospital at which the Virginia nurse has worked had “a couple of rooms, if not a floor, dedicated to VIPs, which is often hidden. At one hospital, there was a room specifically maintained only for the use of a very famous person with a very crappy heart. They’ll get the best food, the nicest rooms, the most accommodating physicians and the nurses who are easiest to push over. The hospital left the VIP section completely empty unless a VIP was present. No intermingling.”

Some doctors and nurses are placing bets about you. Several nurses around the country confessed that hospital staffers have wagered on patients. “Guess the Blood Alcohol” is a common game, where actual money changes hands. Other staff members try to guess the injuries of a patient arriving via ambulance. And surgeons have been observed playing “games of chance” during operations, placing bets on outcomes of risky procedures.

There are “codes” … and there are “slow codes.” Some medical teams have a hush-hush way of dealing with discrepancies between a patient’s Do Not Resuscitate order and family members’ demands. In hospitals, as a Missouri nurse told me, “There are lots of unsavory things that the polite public would make hay with.” While many people know from medical shows what a “code” means—a patient in cardiopulmonary arrest—most people don’t know about the “slow code.” Various units have different designations; at a Canadian hospital, medical teams distinguished between a full code, which they called “code 55,” and a slow code, or “code 54.”

Some physicians will unofficially call a “slow code”—which will never appear in a patient’s chart—if a coding patient is elderly or chronically ill. The signal notifies a team that they are not expected to revive the patient but should go through some of the motions anyway. “Responders literally walk slowly, are slow to respond, give medications slowly or hesitate to intubate so that the patient is unlikely to be revived,” said a Midwestern nurse.

“It’s often for the sake of a family who needs to see us doing something, anything,” said a Texas nurse. “We do them when it’s painfully obvious someone is so far gone they can’t be saved, and occasionally when the patient is a DNR. The CPR and meds are the same, because it’s a dangerous line to cross if you withhold standards of care, but whereas if it’s a young, healthy guy we might code for 45 minutes, with the elderly terminal DNR we will only code for 10. Usually we do a round of CPR, check for cardiac motion on the ultrasound, and then call it.”

We know secrets about your doctors. Nurses have much to say about the doctors they work with. “If you want to know if a medical facility or a doctor is any good, ask a nurse [away from that facility],” said a Washington State nurse.

After the procedures, when witnesses dwindle, some doctors aren’t necessarily on their best behavior. An Arkansas nurse watched a cardiovascular surgeon check whether his female patient was awake. The doctor pulled down the sheet and twisted the patient’s nipple. “My reflex was as if he had done this to me: As soon as he touched her, I smacked him on the arm. He gave me the dirtiest look,” the nurse said. “A lot of nurses would like to smack their doctors once in a while.”

“Sometimes residents practice procedures, such as using a needle and catheter to remove fluid from the sac around the heart, on a patient after a code. We put a stop to this in our hospital,” said a nurse in the South. This practice does not occur as often as it used to. Before simulators were sophisticated enough for doctor training, physicians would “spend up to eight hours practicing on the deceased, which prevented family from coming in and they did not know why,” a North Dakota nurse said.

“The highest rated heart surgeon in U.S. News & World Report at my hospital is the one I would least want to have operating on my family member,” said a nurse in the Northeast. “It seems that more of his cases come out of the OR with bleeding complications. The consensus among the nursing staff is that this happens with his patients more frequently than our other surgeons.”

“Some physicians—especially psychiatrists—make rounds at night or very early in the morning so they don’t have to talk to the patients,” said a Texas nurse.

Some people impersonate nurses—and you have no idea. A medical/surgical nurse who has worked in a pediatrician’s office warned that when you call a doctor’s office to speak to a nurse, you might not actually reach one. “Parents call to ask the nurse a medical question about their child. The medical assistants, who are not nurses, pick up the phone saying, ‘Hello, this is the nurse’ and then give advice,” she said. “This is illegal and dangerous! Parents have no idea this is going on. MAs have taken a one- or two-year certificate training program, may not have a college degree, and do not have a license. I’ve heard them give incorrect advice. We worked hard to get where we are and it makes me mad when people think they can easily do our job. We have a two- or four-year college degree and a Registered Nursing License. If you are calling in to a doctors’ office, make sure you know who you are speaking to.” Ask whether you are speaking to a licensed nurse or to a Medical Assistant.

We might use a larger needle than necessary. Some doctors and nurses use punitive medicine, a practice that is not often discussed. Molly, one of the four fascinating nurses I followed for the book, saw a doctor order chemical restraints for a patient just because the patient talked back to him. Some nurses, including Molly, occasionally use larger needles than necessary to “punish” patients such as drug-seekers who frequently come to the ER only to score meds.

Sometimes we lie to you. Nurses occasionally lie to protect a patient’s feelings. A New York City nurse told Reader’s Digest, “When you ask me, ‘Have you ever done this before?’ I’ll always say yes. Even if I haven’t.”

“We usually know the results of your tests before the doctors talk to you. We can tell when a loved one will have a bad neurological outcome but can’t tell you,” a Virginia pediatric nurse said. “We usually know what we would do, but can’t tell you what it is. We have to give you information in a nonbiased fashion so that you can make those decisions, even if we are dying to tell you what to do.” Even if patients specifically ask nurses, “What would you do in my situation?” some health care institutions have told nurses they cannot answer directly.

Your DNR might be ignored. While some nurses said that at their hospital patients with signed, current Do Not Resuscitate order are not resuscitated, several nurses told me that saving patients with DNRs “happens all the time.” The most common scenario occurs when an elderly or chronically ill patient with a DNR requires resuscitation and a family member tells the medical team to save the patient. Particularly if the family member has power of attorney (POA), nurses said he or she can change the plan of care.

“Theoretically we’re supposed to honor the DNR, but oftentimes the family will want the patient treated because they see the DNR as ‘giving up.’ Often a family member is a POA and has the legal right to make medical decisions even if it overrides the DNR,” said a travel nurse based in Texas. “Families want us to ‘do everything’ and if we let the patient die, we’re accused of killing them by refusing care. Basically it’s a lose-lose scenario.”

Medical providers can override a DNR because of a family dispute “and not really risk punishment,” said Arthur Caplan, director, Division of Medical Ethics at NYU Langone Medical Center. If a DNR is vague or was filled out many years ago, physicians might doubt whether they can trust the document. “Think of a DNR as something that tells you a person’s wishes, but it’s not a binding order. Sometimes the family’s screaming a lot and we don’t want to cross swords with them,” Caplan said.

The outcome may depend on the physician’s comfort with discussing the DNR process with family members, said a Canadian critical care nurse. When a Maryland hospice nurse told a physician that her patient had an advance directive for “no life-support measures in an end stage condition,” the doctor replied, “I am not a lawyer” and resuscitated the patient anyway.

Nurses whom I spoke with wish that health care providers would do a better job of explaining to families what resuscitation efforts entail—and that family members had more honest end-of-life discussions with each other. “I think if people better understood exactly what ‘do everything’ entails, they would be less likely to demand it,” said the Texas travel nurse. “Performing CPR is probably going to break multiple ribs, [some patients] will almost certainly die in the ICU after a prolonged barrage of horribly toxic medicines, and we can put someone on a ventilator but their anoxic brain injury means they’re never waking up again. If we could show families how much more horrible it is to prolong treatment of a dying person, perhaps they would choose differently.”

Sometimes we put alcohol in your feeding tube. If a patient with a history of alcohol abuse needs open heart surgery, a Maryland Cardiac Surgical ICU nurse said, he or she might get alcohol (supplied by the pharmacy) with hospital meals or through a feeding tube to prevent alcohol withdrawal symptoms such as elevated heart rate, anxiety and shaking. A nurse in an Oklahoma cardiac unit who has administered this treatment to a patient said that, on physician’s orders, the pharmacy brought 60 mL of bourbon each night to the nurse and watched her pour it down a nasogastric tube. While this method is considered old school—hospitals more often give patients Ativan—“It is funny to say that you gave your patient a shot of bourbon as a medication order,” the nurse said.

That’s going in your chart. Ever wonder what nurses are writing in your patient chart? Everything. If you say something offensive or off-the-wall, nurses chart it. If your family member creates issues, that goes in the chart, too. “I always chart when a patient is difficult or belligerent. I keep it objective and write direct quotes; it’s funny to have to type ‘Fuck you, bitch’ in medical documentation,” said Molly. If a patient later sues the hospital, the documented evidence can diminish the patient’s credibility.

You might not need the surgery your doctor says you need. Some nurses said that doctors “bully” people into having unnecessary tests and procedures. “If I could talk to my open heart surgery patients before the surgery, I would probably advise 30 percent of them not to have surgery,” said a New York nurse. “Our fee-for-service health care system incentivizes doctors and hospitals to advise aggressive, high-cost treatments and procedures. Doctors undersell how much rehabilitation the successful recovery from heart surgery requires. Most patients tell me they didn’t know the recovery would be as difficult as it is. Every time I see patients over 85 opt for an aortic valve surgery because they were becoming short of breath on exertion, I scratch my head a little bit because I know that many of these high-risk patients will not get back all the faculties they had before the surgery, and some won’t even make it out of the hospital.”

TV shows don’t get it right. In reality, nurses manage many of the duties that viewers see doctors performing on TV, such as inserting an IV or catheter. “I laugh when I see shows like House or Grey’s Anatomy where doctors are pining at the bedside of patients, giving them medications or administering treatments. Doctors do nothing of the sort,” says an Arizona clinical education specialist. “They come by once a day, take a short look at the patients, review their chart, make orders, and leave.”

A New York hospital night shift nurse said that sometimes his patients don’t even see a doctor or a P.A. overnight. The nurse diagnoses the patient, determines the course of treatment, then treats the patient himself, sometimes without even calling the P.A. to approve the orders for fluid boluses, anti-hypertensives, diuretics and other medications. “We reserve calls to the P.A. for fairly urgent matters, and handle whatever other issues arise ourselves. This can mean doing things that are beyond our scope of practice, but most of the P.A.s appreciate the uninterrupted sleep and will generally co-sign any orders once they make their rounds in the morning.”

We know you better than your doctor does. Nurses want patients to remember that from the moment patients enter a hospital to the moment they leave, nurses—not doctors—will be more intimately involved with their care. “The doctor is at your bedside for all of three minutes unless you’re getting intubated or coding. The nurse is the one rapidly assessing you at the door, immediately determining what interventions need to be made so that when the doctor does come into the room he has something more intelligent to say than, ‘Well, we’re going to get some labs and an X-ray,’” a North Carolina ER nurse said. “I get you undressed, on the monitor, cleaned up if needed. I will wash the blood and vomit out of your hair, and not gag or make you feel embarrassed that you’re sick. I’m the one who will go to the doctor and tell them you are having nausea, pain or a neuro status change because suddenly you think it’s 1988. That will be the reason that you get a head CT, and we find a brain bleed and contact the neurosurgeon. And then I will be at your bedside for the next three hours while we wait, reassuring your mother. You will hardly ever see the doctor. You will always see the nurse.”