Confidentially Yours

The circle of care is a term of art which refers to the group of care providers surrounding a patient. This includes not only nurses, physicians, and other health care professionals, but also some others not so obvious, like the patient’s family and indeed, the patient herself.

Patient YZ comes arrives unwillingly by EMS into the Resus room the other day with a problem which could prove embarrassing both professionally and personally. Pt YZ also is a former employee of Acme Regional, now dismissed, and is now engaged in some very complicated litigation with the health corporation.

So we — meaning the Emerg staff — treat YZ as we normally would a patient in her condition. We weren’t even aware of YZ’s problems with Acme Regional until a steady stream of managers started washing up in the department, like so much flotsam. They would  peek their head through the Resus Room doorway, verify it was her, and then would retreat to the patient quiet room to have animated conversations. I have never seen as many nursing managers park themselves in our emerg, including the VP of Nursing, various program managers, and YZ’s former boss — and the presence of any of them had nothing to do with the patient’s actual care. It was a nasty confluence of high-powered, sanctimonious nurse managers gossiping, backbiting, and generally engaging in quality self-righteousness.

It was, in short, disgusting.

At which point I started to get very, very annoyed.  Clearly this was violation of patient confidentiality. So when one of the managers wanted to see the chart, I refused. You, I said, are not directly involved in her care — and it’s none of your friggin’ business.

“But,” she said “I’m in the circle of care.”

No, honey. I’m in YZ’s circle of care. The emerg doc is is in her circle of care. The lab tech is, the RT is, and her partner is. YZ’s poor embarrassed family is in the circle — you don’t think her husband didn’t notice all his wife’s former associates loitering around the patient quiet room? And quite possibly her lawyer as well, because I can see, being psychically gifted, another lawsuit for gross breach of confidentiality.

You, on the other hand, actually belong to a subset of nurses I am ashamed to be associated with.

Sales Pressure

So my ancient clunky Chevy finally died — it owed me nothing whatsoever, I might add — so Mister Man and me went out car shopping.  I hate this, dealing with car salesmen (yes, men — if there any women in car sales, I have yet to see ‘em) and their condescension and pushiness. It’s aggravation that I don’t need.

We went to one used car place, that has a good reputation in my neighbourhood, and we’re poking around this car and that one, looking for something decent, and thinking about which ones we might want to test drive.  The salesman comes out, slick and unnaturally tanned, and Mister Man talks to him about this and that. And then buddy says, “Well, I can’t stand here all day and wait for you to test drive every vehicle in the lot — I’m not the test drive guy. Just pick one, and when you’re back we’ll make a deal.”

I see Mister Man’s jaw just tighten a bit, and I know this jerk is not getting any of our business.  I thank the salesman, say we’ll think about it, and we leave.

In the car, Mister Man says, “If I’m going to give fifteen or twenty thousand to that jackass, I’ll drive every goddamn car on the lot buck-naked if it pleases me.”

So we went to another dealership, just down the road from our house, and were treated very seriously and respectfully, and we test drove several cars, and finally bought something brand-new, for just a few thousand more than the used because of factory and dealer rebates.

Well, I thought, buddy at the used car place really screwed himself out of a commission.  But then I thought, used car salesmen aren’t idiots, and obviously it’s a line that’s worked before — “I’m too busy to talk to you.” I wonder how many people have fallen for it?

Quite a few, I’m thinking.

And Then There’s Joan

Every department has a Joan.* Joan is a very bad nurse. I don’t mean bad, as in is rude to the patients, or leaves full commode chairs for oncoming staff.  (Though she does that too.) I mean bad as in I-just-killed-the-patient bad. Everybody has a Joan story.  She is that incompetent.  She’s the nurse who inflates the catheter balloon when it’s still in the urethra. She’s the one who hung D5W with the blood transfusion — and pushed Ancef at the lower port while the blood was running. She’s the one who who ran the insulin drip by gravity. And piggybacked a KCl bolus (when we still did those) by gravity. She’s the one who thought there was no real issue with the rectal bleed with a pressure of 54/p. And that the Seroquel od didn’t need a cardiac monitor. Or that the obtunded HBD was okay laying flat on his back.

Joan frightens me badly.  I am frightened to work with her.  I am frightened to follow her at shift change. I am frightened for her patients most of all.

We have tried remonstration. We have tried using each of these as colleague-to-colleague teachable moments. We have documented. We have complained to the manager. We done have everything short of calling the College of Nurses of Ontario.** Joan just carries on, oblivious and immovable.

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*Of course not her real name, and actually a composite of several “Joan’s” I have known over the years.

**Our fear and loathing of the CNO is obviously greater than our fear and loathing of Joan. Sad, but true.

She Wasn’t Right

She wasn’t right.

In Observation the other night where we, well, observe patients: holds and the frequently admitted and such. Then EMS offloads a 68 year-old woman into Room 4, acutely SOB, restless, history of COPD and a long, long cardiac history, nonSTEMIs and stents and whatnot: so not surprising. Chest actually sounds okay, no peripheral edema. No chest pain now or earlier.

But she isn’t right. I mean her vitals are stable, and she’s much less SOB with O2. She’s obese and getting her comfortable on the emerg stretcher is a challenge but she even settles into an uneasy sleep. Yet something is wrong. Nothing I can put my finger on. The only other abnormal finding, apart from her shortness of breath, is her cold periphery: hands and feet are ice.

The virtue of being an old emergency nurse is that when you think you need to move a patient into the Resus Room, the charge tends to listen to you. So we moved her. There’s moaning and kvetching from the two Resus Room nurses who were patient-free, happily bored and watching Nurse Jackie on the Net. Why did you move her in here? She’s stable, isn’t she?

I think: I love you both dearly, but you’re being lazy as all hell.

But I say: “She’s not right.”

My colleagues shake their head. WTF, they’re thinking. I don’t care. I give report then go to break, hoping to doze off for a few while listening to endless gabble on CP 24. I drift off, dreaming I think, of a warm beach and the sound of water . . . then a rude awakening.

“Code Blue, Code Blue, Emergency. Code Blue, Code Blue, Emergency.”

Shit. I know it’s her.

I run into the Resus Room. Compressions have started. What happened?

“She went into an idioventricular, then PEA.”

Compressions halt for moment for a pulse check. No pulse. We all stare at the monitor. Slow idioventricular, then nothing. Asystole. Compressions again, another round of drugs, then it’s all over.

Trop comes back at 64.8.

She wasn’t right.

Man Card

Buddy is 22 years-old, and buddy has had too much of the Molson’s.  Or so his girlfriend says. Buddy is semi-conscious, moaning and holding his stomach.

“Do something,” the girlfirend yells. “He’s sick!”

No, he’s  drunk. There’s a difference. But still, we do the usual I-drank-to-much routine: IV fluids, bloodwork, in bed, in the recovery position.

Ethanol level comes back.

12 mmol/L.

12, is what, half a beer? Buddy could’ve driven home. The legal limit is 17.

Buddy goes home, miraculously cured. Girlfriend is chastened, and maybe even a little disgusted.

It was Brad who summarized the situation.

“Buddy,” he said, “needs to turn in his man card.”

Mock Empathy

A friend of  mine said to me the other day:  ”I have empathy for the 43 year-old with two teenage girls dying of ovarian cancer, and the contracted 83 year-old guy with Alzheimer’s who’s breaking the heart of his wife, but for this” — she waved her arms towards the usual waiting room crowd of three month abdo pain and r/o H1n1 —-”today, I have no empathy. None, nada, rien. I’ve run out altogether.”

She paused to consider a minute, and adjusted her Littman slung over one blue-scrubbed shoulder, her lips pursed thoughtfully. “No wait,” she said. “I have fake empathy for those people. I save the real empathy for people who need it.”

I  looked her in the eye and nodded with understanding. After weeks of H1N1 hell I could empathize. With real empathy, not the ersatz stuff.

You’re kidding, right?

Patient A.B. has a bed on 5 South, a med floor notorious for NOT taking patients. Patient A.B. is a pleasant — as in nice-as-pie-pleasant — 45 year old woman with a very remote history of substance abuse as well as HIV infection related to, and well-controlled with antiretrovirals.  She is here for recurrent fevers and myalgias that may or may not be related to her HIV infection; she is presently well, afebrile and basically waiting to see Infectious Diseases, who ironically has an infectious disease himself and can’t come till the next day. She is easily the best patient — and did I mention nicest? —  I have today.

5 South has gotten wind of this patient from Bed Management, and all sorts of alarm bells are going off mostly, I am very sad to report, because of this patient’s HIV and/or substance abuse history. (In 2009!) I spend an hour trying to get this patient up to 5 South and into a decent bed — and just get flak from the floor.  She’s too fat, I’m told.  Seriously, and not that it should make any difference — but they can’t tell the difference between kilograms and lbs, apparently.  She had loose stools five days prior to admission — Sweet Jesus, she has C.diff!  She’ll disturb the patient in the next bed, who needs her rest. And so on. Finally they tell the charge to pick another patient, ’cause she ain’t coming, no way no how.  A.B., it seems,  has “too many issues.”

Is this a hospital, or what?  Since when does the floor get to pick and choose patients? Apparently, this is what Acme Regional Health does.

In my exasperation, I call the 5 South charge nurse and suggest to her that she needs to come down and explain to my patient what issue in particular prevents her admission to 5 South.

This goes over, um, poorly.

Meanwhile (and against my better judgment) I complain, loudly, to my manager about the shoddy treatment my patient has received at the hands of the hospital.

Nothing, of course, is done. A small fuss is made. A lot of stonewalling from the 5 South manager, with a dash of equivocation.  Accountability counts for squat.

Another day in the emerg.

Curse You, Google!

The usual DSI back pains are getting cleverer. Instead of the usual Toradol allergy, they’re getting sneaky and saying they’re allergic to all NSAIDs.

Which is the word they use, EN-saids. Like we do. And all of them? You’ve had a life-threatening  reaction to each and every one?

Yep.

And how does this allergy manifest itself?

“I get wheals, and hives and angioedema.”

Uhuh. And who in hell uses “wheals” and “angioedema” in everyday language?

Next patient.

And you’re still not getting any narcs.

Sushi, or, How to Misbehave in a Restaurant

Downtown the other day at one of those long soul-sucking conferences that leaves you seeking the solace and comfort of beer. With Mister Man safely ensconced at home with the dogs, I planned afterwards to wander for a little in Yorkville, go to a bookstore, and then thought I would find a place to eat and have that beer — you know, Lucullus dines with Lucullus, with books. But then came the flood, and I ended up walking blocks down Yonge Street in an rainstorm that would stagger a duck.

Finally, wet, tired, hungry and very thirsty I came across a Japanese restaurant* at Yonge and Alexander. I ducked in, wet and bedraggled, and even before I got my coat off ordered a Sapporo.

“In a can?” asked the waiter.

Yes, fine, whatever, I said. Just bring me a beer and a menu while I take off my skin and hang it up to dry.

I didn’t realize a can of Sapporo comes in 675 mL sizes. Which is a lot of beer. But I shrugged. I ordered the spicy maki special, and drank down the beer rather too quickly, and then ordered another.

Foolish me.

Did I mention the compulsory chopsticks? But this isn’t uncommon in Toronto.** I am by no means proficient in the art of eating with chopsticks, but I can manage sufficiently to handle noodles and sushi.

But the second beer was a really bad choice. I could barely hold the chopsticks by the time the maki came, and things went all pear-shaped afterwards. I ended up spiking the maki rolls, trying to pin the pickled ginger on top. Eating maki using the spear-it method struck me as being absurdly funny, so I giggled all through the meal. And dropped my book on the floor three times. You can imagine what the staff saw: ragged, soaked to the skin, laughing, drunk, and eating like a pig.

I am definite the staff surreptitiously took a photo of me, which they have by now posted by the till, with the instructions (no doubt in elegant Kanji script), “If you see this idiot, call the police.”

But the food was really good.

And I won’t tell you about the subway ride home.

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*I really want to go back to this restaurant, so posting a link is my way of making a karma-offering for bad behaviour.

** I’m sure they had a fork or two in a back room somewhere, but asking for one virtually certifies you as the Unhipster of the Day. And who wants to be drunk and unhip?

Viruses Look At Me and See a Target Pasted on My Forehead

For your information, yr. humble correspendent got the H1N1 shot last week.

And the nasty URTI* — cough, congestion, crap — contracted subsequent to said vaccination was pure coincidence. Besides, getting an Influenza-like Illness is, like, so two weeks ago.

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*URTI = Upper Respiratory Tract Infection. Not to be confused with UTI, which in most people is somewhat lower.