Archive for January, 2010

Unemergencies

Dear potential Emergency Department patients, just so you know, at 0241 in the morning, these are not emergencies:

Diaper rash times 1 day.

Sore finger. No decreased range of motion, no erythema, no apparent injury.

Drank too much, feel nauseated. (cf. “I think someone put something in my drink because I feel sick.”)

Smoked marijuana, feeling “weird”.

Can’t sleep.

For pelvic ultrasound, requested by GP three days ago. Pain resolved.

Gout, script refill for allopurinol.

Menstrual cramping.

Indwelling catheter replacement.

Abdominal pain times three months. Wanted to get it “checked out”. No other symptoms.

Vomiting times two, one hour ago.

Bladder infection, had one dose of antibiotics from GP, not better.

2 years old, had fever of 37.9, given Motrin, no fever at present, no other symptoms.

Chronic back pain, script ran out.

Constipation.

Migraine headache times 5 days, “only Demerol works!”

Pregnancy test requests, aka “missed period and have pain.”

RLQ pain times 2 hours. “Telehealth told me to come in, it might be appendicitis.” Then texting and laughing while getting vitals.

Please tape on your fridge for future reference.

Thank you.

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Apparently, Bigotry is Not a Barrier to Practice

A nurse in Queensland, Australia gets his licence back but really, if you were gay or lesbian (or anyone else, for that matter), would you want to be treated by him?

Sunshine Coast male nurse whose licence was suspended following an anti-gay tirade has been cleared to continue working with patients.

Equal rights activists raised concern over patient well-being after nurse Matthew George Price wrote an open letter to his former school last year calling for a “a world free of homosexuals”.

In the letter, published in a New South Wales school’s alumni newsletter, Mr Price declared himself a cured homosexual who was writing to world leaders including US President Barack Obama promoting “change”.

The Queensland Nursing Council suspended his nursing licence in August last year so it could assess his competence to work with patients.

Nursing Council executive officer Ross MacDonald yesterday told brisbanetimes.com.au the licence was re-instated two weeks ago.

“Mr Price was required to undergo an independent assessment to address concerns Council had about his fitness and competence for practice,” he said in a statement.

I’m pretty clear that holding idiotic or unpopular opinions shouldn’t be a barrier to holding a nursing licence. But it also occurs to me that Mr. Price might want to choose another profession where it might be more appropriate to spew his odious opinions. It’s not even a question of free speech. It’s a question of whether holding opinions dehumanizing others is compatible with being a nurse, its ethics and its ideals. And I’m thinking, maybe not so much.

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Inequality of Pressure

We insert tubes to bring balance,

Air sometimes suffocates

Twenty eight French, fifth intercostal space

Stabbing pain, again,

Can you hear your breath hissing out?

I saw your bright eyes seeing death maybe

Strong muscular limbs brought low,

Suddenly frail, by the downward curving metallic arc

Cursing, swearing, tough guy, fifteen

You hold your mother’s hand.

I saw your eyes watch the blood drain

Then shivering you could breath again.

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In Which TorontoEmerg Engages in Shameless Self-Promotion

Yes, your humble obedient correspondent and blogger has been nominated the much-coveted Big D Award for best nurse blogger in the known universe.  I am thrilled to tears, because, you know, beneath this crusty old emergency exterior beats the heart of a real nurse.

Anyhow. Many, many thanks for the nomination, Doctor D.

You can vote (preferably for me, but the other guys are pretty good too) here.

My co-nominees are really excellent bloggers as well, and their nominations are well-deserved: please check them out too.

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Even in Disaster, Breast is Best

Another consideration on the disaster in Haiti. The International Lactation Consultant Association points out the worst thing you can do is send infant formula:

Interventions to protect infants include supporting mothers to initiate and continue exclusive breastfeeding, relactation for mothers who have ceased breastfeeding, and finding wet nurses for motherless or separated babies. Every effort should be made to minimize the number of infants and young children who do not have access to breastfeeding. Artificially fed infants require intensive support from aid organizations including infant formula, clean water, soap, a stove, fuel, education, and medical support. This is not an easy endeavor. Formula feeding is extremely risky in emergency conditions and artificially fed infants are vulnerable to the biggest killers of children in emergencies: diarrhea and pneumonia.

As stated by UNICEF and WHO, no donations of infant formula or powdered milk should be sent to the Haiti emergency. Such donations are difficult to manage logistically, actively detract from the aid effort, and put infant’s lives at risk. Distribution of infant formula should only occur in a strictly controlled manner. Stress does not prevent women from making milk for their babies, and breastfeeding women should not be given any infant formula or powdered milk.

The trouble is, the intuitive response would be to send formula. It would help some poor infant, somewhere. Better than doing nothing, right? Unfortunately, in cases of disaster, a strictly utilitarian response is necessary, in order to save us, and more importantly, to save the people we are purporting to help, from our best impulses to do good.

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Some Days It Seems Like That

Manager (sententiously): You know, take away all the politics and paperwork, your real job is empathy — helping people.

Jaded Charge Nurse: No, my real job is to provided sarcastic and cynical running commentary.

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Those Marriage Blues

I’m feeling a little sour this morning.

Came to work after six blessedly restful days off only to find a clot of nurses talking in low excitement at the Charge Desk. Clots of nurses taking in low excitement can only mean trouble, and so it was: not one, not two, but three Emergency Department marriages officially Crashed and Burned on my days off, wreckage and debris everywhere, including one so spectacularly awful and humiliating that it takes my breath away a little to think about it. Some stories you need to be this tall to hear. I’m afraid that I will never be that big, though I am an encrusted old emergency nurse who’s heard a fair allotment of human stupidity and grief, and also am (practically) old enough to have grandchildren.

I’m friendly towards, yet not friends with, this last particular nurse, if you understand the distinction. I am a bit unsure of what I can do to offer support. Well-meaning and unsolicited but intrusive (and dare I say it, insensitive and unhelpful) advice is already being offered from all quarters, and of course, the departmental feeding frenzy has just started on the carcase of the marriage. My inclination is to write a short note, offering a standing invitation to dinner, and leave it at that — sometimes the offer of support is enough, I think.

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What You Don’t Want to Hear Me Say at Triage

“Let me see if I can find a bed for you right away.”

“You look a bit unwell.”

“Your blood pressure is a little low — let’s get a wheelchair.”

“Let’s do an ECG right away.”

“Can I get a stretcher at Triage, stat?”

“Call a code.”

“Your wife can register you while I bring you in.”

“Wait here while I find an oxygen tank.”

“Let’s put a few more abd pads over that cut.”

“How long have you had the black stools?”

“Did the drainage start after you hit your head?”

“At what time exactly did the chest pain start?”

“At what time exactly did you notice the right arm weakness?”

“Can you page the RT?”

“Can you page the doc to the Resus Room?”

The words “ST elevation”, “shock”, “distress”, “hypotension”, “precode”, “neurological deficits”, “CTAS 1“, “actively bleeding” and “new onset” in any context.

If, on the other hand, I send you to the waiting room with a urine specimen bottle, and tell you it’s going to be a longish wait, you should be grateful, happy and relieved: you aren’t likely to die.

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War is Hell. And Bad for Your Health.

Some interesting articles in the current issue of The Lancet (registration required to read some of the articles, sorry — but worth it) on the effect of war on health, and how these impacts on health are continually minimized. When we as nurses think of threats to health and well-being, we tend to think of things like smoking or diet, without considering larger systemic problems. Like war. Too inconvenient and challenging, maybe: war is an accepted instrument of foreign and domestic policy in every first world nation. We consume time and energy in our public discourse convincing ourselves that war is necessary evil, and even glorifying the carnage, while at the same time minimizing its very real and human impacts. As a culture, we like war.

And maybe as nurses being concerned with health and well-being, should challenge the culture a bit on this one?

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The Lancet also published in the same issue a scathing editorial regarding the humanitarian response to the Haitian earthquake:

We have repeatedly drawn attention to the fact that when viewed through the distorted lens of politics, economics, religion, and history, some lives are judged more important than others—a situation not helped by the influence of news media, including ourselves. This regrettable situation has resulted in an implicit hierarchy of crisis situations further influenced by artificial criteria, such as whether disasters are natural or man-made. . .

. . .The Lancet has been observing aid agencies and NGOs for several years and has also spoken with staff members working for major charities. Several themes have emerged from these conversations. Large aid agencies and humanitarian organisations are often highly competitive with each other. Polluted by the internal power politics and the unsavoury characteristics seen in many big corporations, large aid agencies can be obsessed with raising money through their own appeal efforts. Media coverage as an end in itself is too often an aim of their activities. Marketing and branding have too high a profile. Perhaps worst of all, relief efforts in the field are sometimes competitive with little collaboration between agencies, including smaller, grass-roots charities that may have have better networks in affected counties and so are well placed to immediately implement emergency relief.

Given the ongoing crisis in Haiti, it may seem unpalatable to scrutinise and criticise the motives and activities of humanitarian organisations. But just like any other industry, the aid industry must be examined, not just financially as is current practice, but also in how it operates from headquarter level to field level. It seems increasingly obvious that many aid agencies sometimes act according to their own best interests rather than in the interests of individuals whom they claim to help. Although many aid agencies do important work, humanitarianism is no longer the ethos for many organisations within the aid industry. For the people of Haiti and those living in parallel situations of destruction, humanitarianism remains the most crucial motivation and means for intervention.

No further comment seems necessary.

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First Trauma

A million years ago in a hospital way up north.

A snowstorm. Evening, and two snowmobiles, racing across a frozen lake. One slams into an exposed rockface.

Our first warning is a call from the OPP, a heads up. Accident, paramedics on scene, severe trauma, unresponsive. No whys or wherefores.

So we wait. My first, Rosie jokes deadpan, but it’s mine. I’m nervous, but my exterior is insouciant. I pretend we won’t be holding this patient’s life in our hands. If I think about the reality, I’m afraid I will lose it. I pretend I’ve done this before. I pretend, no sweat, I can do this. This is how emergency nurses are supposed to be. I’ve been socialized well.

We prime lines, ready boluses of crystalloids, hang blood tubing, dust off the fluid warmer, look for the Pentaspan, alert xray: a trauma is coming. The chaplain wanders through. Charge asks him to hang out for a while, just in case.

The EMS patches. Twenty minutes out. Police escort down slippery back roads. Twenty-seven year-old male. No history. GCS of 3, intubated, boarded and collared, large bore IV started.

We wait.

Then EMS arrives and suddenly the entire department is in the Trauma Room. Chaos, yet not chaos, care orchestrated complexly like a ballet, every move an iteration of Airway, Breathing, Circulation Disability, every treatment and diagnostic a search for stability.

Cardiac monitor. Assisted respiration. Lung auscultation. Another large bore IV, foley catheter, logroll the patient, I support the head — “On my count”, I say, then after stat shoot-throughs, portable chest films, pupils fixed, dilated, chest tubes, blood running through the fluid warmer, nasogastric tube, a tube in every hole, the saying goes, bloody dressings on the floor from a bleeding scalp wound, empty bags of saline count, one, two, three litres in. Hypotension. Heart rate at first rapid, compensating, now slowing.

Then the films. The doc looks at them and sighs. Shakes head. C1 fracture and dislocation. The spinal cord has been severed where it meets the brain, snapped clean like a dry stick by the force of the impact. There is nothing more. He’s dead. His body, his heart and lungs, strong and young and athletic, are receiving no signals from the brain. They just don’t know it yet.

He goes out to talk to the wife. Out of rote, we watch the cardiac monitor, sinus rhythm, watch his blood pressure begin to drop, his heart rate in slow decline.

His wife comes in. The charge holds her up. She says little. Her face is taut and pale, a declension of grief now and to come. No tears. Later, maybe, I think. She takes his hand and speaks softly to him. We can’t hear her words.

As she holds his hand, his heart slows more, the rhythm becomes idioventricular, irregular, then slows more again and at last, stops. One agonal breath. It’s over.

(And later, I reflect, and still ask myself now, when did death take him? When he struck his head against the cold lakeside granite? Was there any remnant of consciousness, when we worked on him so frantically? Having watched scores of deaths, why do I still wonder?)

After, we hear the story. She told Charge, dry-eyed, while waiting to speak to the doc. A lesson: there always is a story. Married three months. Pregnant. A fight. He and the boys liked to snowmobile. A lot. She didn’t want him going out on the lake, in the dark, in a snowstorm. She thought his friends were assholes. She told him not to come back that night. I hate you, she said. His back disappearing into the dark, snow closing behind him.

After, we prepare the body for the morgue. I’m breathing again. Rosie closes the door and we crack wise darkly. Another ritual. We tie off IV tubes, leave the other tubes in place. Nothing can be removed until the coroner has examined the body. Plastic crinkles as we heave the bagged body on the morgue cart.

We collect up the torn and shredded clothing, meaning to return them to the family and then this happens: pieces of brown glass fall out of the left pocket of his heavy brown coat. We look in the other pocket, and find a bottle beer, whole and uncapped.

Rosie quickly scoops up the tinkling pieces of glass from the floor, and throws them with the beer bottle into the trash.

The porter comes for the body, to take it to the morgue.

I am callow and green.

We need to report this, I say.

Rosie smiles. No, she says. What’s the point? He’s dead. Knowing won’t help anyone, now. Not him. Not his wife either. Why add to her grief?

There is no answer, just the creak of the morgue cart as the porter pushes it out of the department.

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