Archive for February, 2010

Best Management Drivel. Evuh!

A new directive from the muckety-mucks up on 6 West exhorts us drones staff RNs to “give patients their best hospital experience.” Unappended, thankfully, was the word Evuh and an exclamation ! point.

I admit my jaw dropped, just the tiniest bit, at this latest piece of moronicity. I mean, I thought I was in the business of providing safe, competant nursing care in order to promote homeostasis and restore patients to optimal health (or pick your nursing paradigm).

Apparently not. I am to provide an “experience”, like an amusement park ride. Though I am not quite sure what the “experience” entails. Name that smell competitions?  Puppet shows using tongue deprressors and sterile latex gloves? Slideshows of compound fractures and pleural effusions? Live catheterization demonstrations? Neck rubs? Tours of the psych ward? Cage matches between Internal Medicine and Radiation Oncology?

Have we actually come to the point where we are substituting a perception of good patient care for actual patient care? So it seems.

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Being Politically Incorrect About Political Incorrectness

Once upon a time, back when dinosaurs roamed the earth, which is to say in the early 1980s, political correctness was an ironical, self-referential way for those on the left to mock their own ideological pretentions. Later, in the early 1990s, the term was seized by those on the right to attack the left for supposed attempts to impose a rigid orthodoxy on the body politic. Politically incorrectness, therefore, became a way of declaring resistance against orthodoxy and conventional wisdom.*

Here’s my problem.

Lately, it seems political incorrectness has degenerated a bit. Preface any remark, not matter how vile or outrageous with “It might be [air quotes] ‘politically incorrect’ to say this, but. . . ” and you’ll likely get away with it. You’re being very brave, you see, and all politically incorrect.

The air quotes are vital.

So the other day I heard one of my nurse colleagues say, referring to Jamaican-Canadian peer, “I’m probably being [air quotes, always with the air quotes] ‘politically incorrect’, but I think she operates on island time.”

And another on a gay colleague: “I might be [air quotes] ‘politically incorrect’ but he’s that way because he had a absent father and a domineering mother.” (Amazing that particular chestnut is still out there. In 2010.)

I think I need to call bullshit.

Using air quotes and the phrase “politically incorrect” does not give you cover for spewing whatever empty stupid thought rattling around in your stegasaurus brain. Being racist or homophobic or whatever does not mean you’re being politically incorrect. It means you’re an asshat jerk, and no amount of [air quotes] “political incorrectness’ is going to fix it.

Unless you’re actually challenging rigid thinking or giving new insight on conventional wisdom, STFU.

Because I really don’t want to have to listen to you.

_________

*The abiding irony, of course, is most attacks against “political correctness” effectively amount to a defence of conventional wisdom.

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Favourite Poems (III)

Another Frost poem for you.

There are Roughly Zones

We sit indoors and talk of the cold outside.
And every gust that gathers strength and heaves
Is a threat to the house. But the house has long been tried.
We think of the tree. If it never again has leaves,
We’ll know, we say, that this was the night it died.
It is very far north, we admit, to have brought the peach.
What comes over a man, is it soul or mind—
That to no limits and bounds he can stay confined?
You would say his ambition was to extend the reach
Clear to the Arctic of every living kind.
Why is his nature forever so hard to teach
That though there is no fixed line between wrong and right,
There are roughly zones whose laws must be obeyed?
There is nothing much we can do for the tree tonight,
But we can’t help feeling more than a little betrayed
That the northwest wind should rise to such a height
Just when the cold went down so many below.
The tree has no leaves and may never have them again.
We must wait till some months hence in the spring to know.
But if it is destined never again to grow,
It can blame this limitless trait in the hearts of men.

Robert Frost

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On Death and Dying

A couple of articles of note, both longish, but definitely worth reading. For nurses, in any setting, providing care around death and dying is probably the most profound and meaningful thing we can do — and I have seen nurses do it exceedingly well, with sensitivity and empathy. Excerpts:

The Last Hours of Living: Practical Advice for Clinicians

Clinical competence, willingness to educate and calm, and empathic reassurance are critical to helping patients and families in the last hours of living. For most dying patients, predictable physiologic changes occur. Management principles are the same at home or in a healthcare institution. However, death in an institution requires accommodations that include ensuring privacy, cultural observances, and communication that may not be customary.

In anticipation of the event, it helps to inform the family and other professionals about what to do and what to expect, including matters such as when rigor mortis sets in, and how to call the funeral home, say goodbye, and move the body. Care does not end until the clinician has helped the family with their grief reactions and helped those with complicated grief to get care. Care at the end of life is an important responsibility for every health professional, and there is a body of knowledge to guide care.

Life Review in Critical Care: Possibilities at the End of Life

When any form of life review is undertaken, a life is examined, and questions such as the following are asked: Who am I? How did I do? How did I live my life? Thus, an important difference between reminiscence and review must be addressed. Life review is “not a random sharing of pleasurable past events, but rather a structured process containing a component of self-evaluation.”  Life review can be used with both patients and patients’ families; the outcomes include increased life satisfaction and accomplishment, promotion of peaceful feelings, and a state of integrity. Furthermore, Garland and Garland contend that life review has a distinct purpose in end-of-life care by upholding the unique value of each person’s life. These themes are consistent with Erikson’s theories of development: the final task is ego integrity versus ego despair. Ego integrity involves acceptance of the course of one’s life, acceptance of one’s place in history, absence of death-anxiety, and satisfaction with life. In contrast, ego despair echoes in the words of the poet Robert Frost: “. . . nothing to look backward to with pride, and nothing to look forward to with hope, so now and never any different.”

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Hospital Sleep is No Sleep at All

Guess what? Patients aren’t getting any. Sleep, that is.

Over time, studies have shown that sleep is important in the critically ill for healing and survival; yet there is consistent evidence that patients in the intensive care unit do not get enough sleep.

[snip]

Sleep deprivation impinges on recovery and ability to resist infection. It brings about neurologic problems such as delirium and agitation, and respiratory problems because it weakens upper airway muscles, thus prolonging the duration of ventilation and intensive care unit stay. Sleep deprivation may provoke posttraumatic stress disorder, withdrawal symptoms, depression, and continued sleep disruption. Sleep deprivation may reduce pain tolerance; increase fatigue in sympathetic nerve centers; increase sympathetic activity, leading to nocturnal high blood pressure; and blunt chemoreceptor responses promoting ineffective gas exchange.

Sleep is one of those things we nurses love to talk about, but we don’t actually do anything to ensure it. Hospitals (and the sometimes clueless administrators that run them) are as equally as negligent. The Emergency Department is frankly the worst place for patients to sleep, and yet in our 1st Floor Med/Surg/ICU Emergency there are always admitted patients, sometimes as many as 20 or more, spending days in the emerg — a situation not like to change as long as hospital managers continue to treat the Emergency Department as the equivalent of a hospital ward. (This is a problem pretty general in all emergency departments.) There’s no privacy, and patients are tortured with narrow uncomfortable stretchers,  bright lights, continuous noise, odd smells, the occasional scream, monitors beeping and an ambient temperature that ranges from frigid to tropical. Not exactly a place, you would think, conducive to sleep. And then we wonder when the patients get a little wonky — a phenomenon called ICU psychosis, or maybe when their recovery is unaccountably poor, or when mortality and morbidity rates start going up.

Florence Nightingale had some remarks about about noise and sleep:

There are certain patients, no doubt, especially where there is slight concussion or other disturbance of the brain, who are affected by mere noise. But intermittent noise, or sudden and sharp noise, in these as in all other cases, affects far more than continuous noise—noise with jar far more than noise without. Of one thing you may be certain, that anything which wakes a patient suddenly out of his sleep will invariably put him into a state of greater excitement, do him more serious, aye, and lasting mischief, than any continuous noise, however loud.

Never to allow a patient to be waked, intentionally or accidentally, is a sine qua non of all good nursing. If he is roused out of his first sleep, he is almost certain to have no more sleep. It is a curious but quite intelligible fact that, if a patient is waked after a few hours’ instead of a few minutes’ sleep, he is much more likely to sleep again. Because pain, like irritability of brain, perpetuates and intensifies itself. If you have gained a respite of either in sleep you have gained more than the mere respite. Both the probability of recurrence and of the same intensity will be diminished; whereas both will be terribly increased by want of sleep. This is the reason why sleep is so all-important. This is the reason why a patient waked in the early part of his sleep loses not only his sleep, but his power to sleep. A healthy person who allows himself to sleep during the day will lose his sleep at night. But it is exactly the reverse with the sick generally; the more they sleep, the better will they be able to sleep. (Notes on Nursing, V.)

Plus ça change, plus c’est la même chose. After 150 years, you’d think we would have learned something.

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Why I Blog Anonymously, and Ten Things About Me You Didn’t Know

The other day a rare visitor to the blog emailed me to ask why I blog anonymously. It’s a good question. I am deeply anonymous. Regular readers will know that I am fairly oblique in providing self-identifying details and, I have to add, engage in  fair amount of misdirection as well.

There are definite reasons for this. Unfortunately, this blog will probably never provide any income whatsoever, and certainly not in any amount to provide for my sustenance. In short, I have to work, and while I am pretty certain that the contents of the blog are not quite enough to get me fired — I do have a union position, after all— I am also pretty sure at the same time that my frequent mockery and criticism of my employer will make things uncomfortable enough for me to seek other employement. Which is highly inconvenient, for me at least. A corollary to this is anonymity gives me a certain freedom to speak the truth as I see it, without undue worry about retribution. Whoever wrote the tripe about having the courage of one’s convictions didn’t have a mortgage to pay, and in any case, is freedom of speech limited to those who can literally afford the consequences?

The second, more important reason, is that I do write about actual cases, with heavily altered details, demographics and circumstances. Anonymity provides an extra layer of confidentiality for these patients, and safety for the staff involved with them.

But because I know you are intensely curious, here are

Ten Fun Facts about TorontoEmerg

1. I am married.

2. Le Nozze di Figaro is my favourite opera.

3. Though this blog is (mostly) apolitical and focused on health care, nursing and also my own personal ramblings, I am a flaming left-winger.

4. I am also religious, converted later in life, consider myself Christian — though probably not in any way that would make an evangelical happy — and I am very active in my church’s charitable work and governance.

5. I think, frankly, that people who believe in Creationism or its bastard child, Intelligent Design, have a screw loose.

6. I don’t think 4 or 5 are contradictory.

7. I have always been an Emergency nurse.

8. I have worked in the U.S. health care system, and have seen its strengths and suckiness up close.

9. I drink red wine.

10. Writing this blog is a means of preventing craziness on my part.

Further questions can be directed to torontoemergencyrn(at)gmail(dot)com. Maybe I’ll do a FAQ.

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Poem

i’m marching away
towards the heart’s twigs and margins.
crossing corners where homeboys
giggle with beautiful hands.
where the vigil is thick. sweet.
where love flares up and sets fire to smoke.
i’m searching for requiems that have
veils of honey and
broken locks.

i’ll never see you again.

o memory of pancreatic light.
of distinct blossoms.
so far gone.

— Michèle Katrina Thorsen

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Signs

I was in the Emergency department of Yodelville Memorial Hospital the other day. I had a spill on some very unfriendly ice and badly twisted my ankle, and though I was pretty sure I didn’t have a tib-fib fracture, I wasn’t completely sure. (It wasn’t and the care in the Yodelville emerg was good.)

In the waiting room was this sign, at least 4′ by 5′, black on white:

I need this sign. I want to point it out to patients. It tells you, unless you are actually dying, to shut up. And the italics provide just the right soupçon of sarcasm, don’t you think?

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Big and Pink

So we were out in the country, which if you live in Toronto means somewhere north of Highway 7, driving along when suddenly we saw these hanging from the trailer hitch of a Dodge Dakota:

OK, they’re truck nuts. A cultural phenom worthy enough to rate an article in Wikipedia, and also the subjects of legislation in several U.S. states to have them banned. ( But can you legislate against bad taste? ) Me the naif had never heard of them till I actually saw them in their lurid pink-toned reality.

Three observations to would-be owners of truck nuts:

  1. The obvious: don’t they scream “I’m compensating”? Maybe not the best message you want to send to women you want to date?
  2. If you really think they’re the cat’s ass and must hang them, you maybe want to get a real — not a Dakota!pick-up, with a hemi? (See 1, above.)
  3. As a nurse, I have seen scrota by the gazillions. I guarantee yours aren’t as beautiful or large as these, which seem to represent the Platonic ideal of testicularity.
  4. Is also creepy. (See 1, above.)

With luck, their own ridiculousness will limit their popularity. I’d hate to see them attached to BMWs traipsing down the DVP. . .

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The Anti-Angst

The antidote to the Walmart-inducing existential angst I had a couple of days ago:

Think continually how many physicians are dead after often contracting their eyebrows over the sick; and how many astrologers after predicting with great pretensions the deaths of others; and how many philosophers after endless discourses on death or immortality; how many heroes after killing thousands; and how many tyrants who have used their power over men’s lives with terrible insolence as if they were immortal; and how many cities are entirely dead, so to speak, Helice and Pompeii and Herculaneum, and others innumerable. Add to the reckoning all whom thou hast known, one after another. One man after burying another has been laid out dead, and another buries him: and all this in a short time. To conclude, always observe how ephemeral and worthless human things are, and what was yesterday a little mucus to-morrow will be a mummy or ashes. Pass then through this little space of time conformably to nature, and end thy journey in content, just as an olive falls off when it is ripe, blessing nature who produced it, and thanking the tree on which it grew.

— Marcus Aurelius, Meditations IV.48

Might just be me, but I think this is particularly fitting for nurses, no?

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