Punish the Nurse

I know this case as been making the rounds of the health care blogs, so if you’ve seen it before, you can perhaps safely ignore this post.

For everyone else, do you know what happens when nurses get all uppity and ethical and report a physician for breaches of safe practice? You get arrested and threatened with ten years’ imprisonment:

When veteran nurse Anne Mitchell wrote a confidential letter last year to the Texas Medical Board, complaining about a doctor she thought practiced shoddy medicine, she assumed it would be anonymous.

Instead, Dr. Rolando Arafiles Jr. fired her after reporting her to the local sheriff — a former patient and admirer of the doctor — for maliciously ruining his reputation.

Police in Kermit, Texas, searched Mitchell’s computer and found the letter, then charged her with “misuse of official information” in her role at Winkler Memorial Hospital, a third-degree felony in Texas under an abuse-of-power statute.

Today, 52 and out of work, Mitchell could face 10 years in prison for doing what she believed was her obligation under the law — to report unsafe medical practices.

Arafiles had, among other things, sutured the rubber tip of a glove to a crushed finger in order to protect it, and performed a skin graft in the Emergency Department which subsequently (and unsurprisingly) failed. In that wasn’t enough, Arafiles was flogging his own herbal remedies, consisting of white grape juice, to his patients on the side while providing treatment.

The second day of the trial proper was yesterday, and was full of interesting information. According to a local account, it turns out the arresting sheriff, who was so full of love and admiration for the good doctor, was selling the herbal supplement on side. And, incredibly, the physician himself thinks diabetes has no impact on wound healing.

It’s an unfortunate confluence of corrupt local politics and hospital complicity — the administration where Arafiles worked was fully aware of is shortcomings and refused to act — in a toxic culture of entitlement, where if things go wrong, and accountability is demanded, you blame the nurse. In the end, you have to wonder who needs to be on trial.

Call Me Paranoid

The ward clerks carry tremendous informal power in any emergency department, because they’re the ones who actually make the place run and bring a modicum of order to the chaos. As you know, I’ve been doing a run of charge the past week in preparation (it seems) for my formal enthronement and apotheosis as permanent charge in April, which means I have spending a lot of time in their company.

The oldest, most senior and most respected of them told me this week that I was “doing a good job” and I was going to “make a good charge nurse.”

I don’t take compliments well. You all know that. They make me a little crazy. I glowed for a while, then got to thinking. What did she mean by that? When is the other shoe going to drop? What is she really up to?

And We’re Going to Live Happily Ever After

A Tragedy and Farce in One Act.

(Curtain rises to reveal a triage desk in a busy Toronto-area Emergency Department.)

Boyfriend: (suavely) You’ll take my health card? I mean, she’s my fiancée.

Triage Nurse: (head down, writing) No. I need her health card.

Boyfriend: (the same) And then she drank, like, eight shooters in a row. . .

Very Drunk Hysterical Woman: (to Boyfriend) You’re a [expletive] [expletive] sucker. And I hate you.

Boyfriend: And when I told her she was drinking too much, she got mad and put her hand through the glass.

Very Drunk Hysterical Woman: (to Boyfriend, screaming) You [expletive] [expletive] sucker. (At top of her lungs) I hate you!

Boyfriend: (unperturbed) She loves me. We’re getting married in May.

Triage Nurse: (still writing) Right.

Boyfriend: And yeah, can we get a pregnancy test too?

(Curtain.)

Mama’s Boys

You get runs of things when you work at Triage. Some days it seems everyone has eaten a monster panzerotti and is presenting with bilary colic; last week there was a streak of people returning from Cancun or Montego Bay with clots along with their duty-free rum and calves looking like sausages.

Last night it was men coming in with chest pain, lacerations, Colles fractures, epistaxis, what-have-you. This is not, in fact, unusual. What was strange was they were all being chaperoned by their middle-aged mothers, who appeared to be sharing the same address. I’m not talking about university students living at home or anything like that. I’m talking about thirty-something guys with respectable jobs and hair on their backs.

Frankly, it was weird. One mother insisted on giving her son’s history, as if he were twelve or deaf or cognitively impaired (“Do you have any allergies?” “He’s allergic to kiwi fruit and nutmeg.”) Another helped her not obviously incapacitated son undress for an ECG, which to my mind crosses that invisible, yet definite, line between Mildly Amusing and Dude, This is Really Creeping Me Out.

I understand about boomerang children and guys living at home to save up money for a house and so on. Even so, a male friend of mine has a theory that guys — straight or gay — really want to leave home as soon as possible because they want to Get Some, repeatedly, and your mama’s presence in the room next door tends to cramp, even obstruct, the whole attendant process. As for the contrary, he says, the guys living with their moms into their thirties (and beyond) — well, draw your own conclusions. Like everything, it all comes down to sex, and the acquisition thereof.

I repeated this theory to a colleague of mine in an ill-advised moment of familiarity.

“Well,” she said, “Rupert was thirty-eight and lived with his mother till we got married.”

“Oh look,” I said, “that patient has fallen down.” And ran away, quickly.

This is why I blog. I just can’t keep my mouth shut.

A Good Poem I

eulogy

your secret purple voice, a soft violet arrow spoke, “uphill, uphill.”
the years of sally are near us, at the site of fire, and even the flat
bottom surface of a gem hasn’t such captivating skin, a behaviour so inextinguishable.
tonight it seems your biography donates itself to our eyes,
ignoring the paradox of an ending on a fresh-cut saturday.
your architecture is a description only and arresting, literally; the three
of us are made of apples, i’ve said it before. beyond words, you are
a thousand women, the upwards tang of motion. your inconceivable
surfaces are columns of turning, inscribed, elongated flowers.

— Michèle Katrina Thorsen

Dr. Weanus Rearranges the Furniture

Dr. Weanus, dire and annoyed, calls a hasty conference of myself (as charge) and the nurse educator. He cannot, it seems, work under these conditions any longer. He cannot effectively practice his art. His patient care is suffering! If there is no change, if we do not amend our ways, he says he may be forced to cancel his coverage at Acme Regional altogether, and retreat to the quiet comfort of an office practice.

Do not tempt us, we think, but instead inquire as to the disaster which has provoked these threats.

He leads us to the Resus Room. Empty, tidy for once, trays stocked, tubes in their places and at the ready, cables untangled and hanging neatly by the monitors.

What? we ask.

Can’t you see it?

See what?

“The overbed tables are on the left side,” he finally says. “How can I efficiently examine patients on their right, if the tables are in the way?”

“Um, push them out of the way?” asks the educator.

We are actually laughing out loud when we leave the Resus Room

Heat

The furnace is repaired. The cats have moved back to their accustomed places over the vents.

Some days, I think my entire existence, my work in the emergency department, the mortgage paid and bills settled, are for the benefit of the cats. In fact, I work for them. And the cats, cynical things they are, know it.

“You are Being Unappropriate!”

During a long day shift, which included, by-the-by, a multiple system trauma sent downtown and a VSA, a few of us, the doc and a couple of RNs, are by the Treatment Rooms desk, when Triage brings us a couple of charts. The first is a 24 year-old woman presenting as “Difficulty Swallowing” and the second, has the very unfortunate chief complaint of “Salty Taste in Mouth.” Some things you cannot make up.

Much mirth, all in completely adolescent bad taste, ensues. Is there any other in the Emergency? A patient or family member, clad in Middle Class Canadian Suburban Winter Attire, overhears us a little and waxes indignant. She marches up the to the nursing station, and announces, “You are being. . .”

A pause while she searches anxiously for that particular damning word

“. . .unappropriate!”

Which provokes more unappropriate laughter after she haughtily stomps off. Of course, we’re being unappropriate. No doubt about it. It’s a truism emergency staff, nurses and physicians alike, have a wicked black sense of humour, explained away by the uncontrollable stress we face. Regular readers have seen numerous examples of it on this very weblog. But like any truism, it needs some examination. It’s true emergency staff use humour to blow off steam. Some of the funniest one-liners I have heard have been uttered while body-bagging the particularly difficult, tragic, and ultimately unsuccessful code. It’s a coping mechanism. We have to laugh, lest the awful meaninglessness of it all overwhelms us.

But there are other reasons. You have to see any emergency department as a kind of pressure cooker, where egos as toothsome as sharks swim the corridors, with its own peculiar culture, jargon, ritual, etiquette and notions. Those new to the emergency are sometimes overwhelmed by the intensity. Humour allows newcomers to be socialized to emergency department esoteria, to share in its particular mores. It helps them to become one of us. And among the veterans, it sustains a sense of cohesion when times are tough, tempers flare, and tension runs high. In short, humour keeps us from feeding on each other.

All humour requires a theme and stock characters. The general theme — with variations — in emergency department humour is Our Unending War with Human Stupidity, the narrative features our own cleverness in dealing with the stupid, the stock characters typical: the Drug Seeking Individual, the Foreign Body in Unlikely Places, the Muffin in Distress, the Drama Queen, the Nursing Home Dump, the Too Stupid to Live, the HBD and Went Boom. But there is danger in creating the Us-and-Them mentality implied in warfare, because it also implies treatment and care according to our subjective whims. Labels and caricatures deceive and misrepresent, when what is needed is accurate assessment. The Muffin in Distress, after all, might be a septic gallbag; the Drama Queen, an ST Eelevation MI; the HBD, a cerebral bleed. Most of us, it’s true, work beyond the labels, and treat the patient, not the caricature. But we have all seen cases where the opposite was true.

Yet unlike hospital administrators or professional regulatory bodies or other bloodless types, I cannot pass judgement. I use humour myself. I am, at times, irredeemably unappropriate. But sometimes, life in the emergency department sucks, and in ways unimaginable to most people. To use a catchphrase, embracing the suck allows us to do our jobs.

Maybe You Want to Rephrase That

A long trying day at Triage, and at the end of it a youngish man tells the newish triage nurse about his penis problem, a Prince Albert gone sadly awry. Sounds like a cellulitis, she thinks, and writes up the triage note without thinking too deeply about it.

Chief Complaint: Swollen Penis

Which, of course is transmitted all over the department via the electronic patient tracker.

Being emergency staff, much hilarity, some of it surprisingly original vulgarity, ensues.

Battered Nurse Syndrome

So we have a television show which demeans, stupidifies and trivializes nurses and the nursing profession, and we have a marketing tie-in which presumably is aimed at the very same nurses, demeaned, stupidified and trivialized.

This should be evident to any nurse who has watched Grey’s Anatomy.

I wonder how many nurses actually buy them because of the show’s cachet. And to them, I ask, what the hell?