Archive for February, 2010

Another Reason to Dislike Grey’s Anatomy, If You Needed One

What? They don’t represent reality?

Ha.

Researchers from Dalhousie University, Halifax, Nova Scotia, screened the popular medical dramas “Grey’s Anatomy,” “House,” “Private Practice” and “ER” to see if TV medical dramas were helping to educate the public about first aid and seizures.

The researchers found in 327 episodes screened, 59 seizures occurred. Fifty-one seizures took place in a hospital. Nearly all first aid was performed by nurses or doctors.

But the study found inappropriate practices such as holding the person down, trying to stop involuntary movements or putting something in the person’s mouth, occurred in 25 cases, or nearly 46 percent of the incidents.

Medical shows resemble real health care with real nurses and physicians in the same way that Chef Boyardee resembles real Italian food. In other words, you’re getting the Pablumized pop cultural interpretation of health care — and to put a kindly spin on it, it’s fictionalized.

I wonder how many people have self-treated themselves or treated their loved ones on the basis of what they saw on House, with predictably bad results.  And I wonder too how long it will be before you see the inevitable disclaimers preceeding medical shows.

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Sex Squad

Fight the Sperminator!

Brilliant sex education game from the Middlesex-London Health Unit, aimed at teenagers and young adults.

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The Great Suture Tray Debate

Many years ago, when I was but a mere slip of a nurse, fresh out of school, shiny and eager to help, my first job was in an emergency department at a hospital some distance outside of Toronto. This hospital was exceedingly old-fashioned and its relations between physicians and nurses were authoritarian and gender-specific. This is to say, the doctors saw themselves as gods on earth, and saw the nurses as some combination of submissive housewives, brainless handmaids, menial drudges and/or doormats, a view, a bit surprisingly, endorsed by most of the nurses themselves. A nurse who thought for herself, in their view, was suspect, and one who questioned a physician, was definitely heretical.

One of the nursing duties at this emergency was to prepare the suture trays for the physician to treat a patient with a laceration. I would unwrap the tray, place it on the Mayo table, then add into various cups Betadine, chlorhexadine, and saline, then drop in needles, syringes, the sutures themselves (having ascertained from the physician the type and size required), then careful to maintain the sterile field, loosely rewrap the whole kit. A pair of sterile gloves — we were expected to memorize the glove sizes of each physician —  and a selection of local anaesthetic, lidocaine 1 and 2%, with and without epinephrine, would complete the set-up.

One busy day a physician, who was so superior that he refused to remember the names of the nurses, and would cringe if addressed by his first name, stormed out of the suture room. He was terribly angry, but then he spent most of his life in a state of terminal irritation, so it was hard to tell the difference.

What’s wrong, Dr. Connard? we asked.

“The suture tray isn’t set up!” he shouted. “How can I function if you nurses aren’t doing your jobs? Please, please set up a tray. Otherwise it’s a huge waste of time for me.” And with that he slammed the chart in the nurses’ desk and clumped off.

The suture tray was missing a syringe, easily accesible by opening a drawer at his elbow.

His behaviour, needless to say, was a revelation, a clarifying moment. Up to that point I had accepted the conventional view of nurse-physician relations, where physicians made demands and nurses meekly obeyed. But clearly Dr. Connard believed some things were too trivial or menial for a physician to do and therefore belonged to the sphere of nursing, that nurses, and indeed hospitals in general existed for the convenience of physicians, that his time was somehow more valuable than the nurses, that physicians were our superiors, that we needed to be taught a “lesson” by behaving badly — a whole raft of antiquated attitudes, in fact, contained in that suture tray. And so the suture tray, for me, became a symbolic of nurses assuming their rightful place at the centre of patient care, collaborative rather than submissive.

I swore then-and-there I would never again set-up a suture tray for a physician, and thus far, I never have.

But the other day, Dr. Contentious, God love him, told me he wished nurses still set up the trays arguing, essentially, that his time was better spent actually suturing patients than hunting around for supplies, and if he can work efficiently, then patients will move efficiently through the department. Probably because I like the guy, and he was presenting the argument reasonably,* I was willing to give the idea a second thought.

He’s right that searching out supplies is a waste of time and much could be done in our suture room to make supplies far more accessible — and that’s something as charge nurse I can work on. But I am still not convinced. The suture tray, in the first place, is supposed to be sterile — and I can’t guarantee the sterility of an open tray once I turn my back on it. I’ve caught patients poking their dirty fingers around inside. after all. And again, there are some interesting notions of whose time is more valuable, mine or the physician’s. In other words, if I am spending the five minutes, setting up the tray, it’s five minutes I’m not doing nursey things, which presumably would also hinder patient flow.

In short, it’s a draw. but I’ll make Dr Contentious a deal: I’ll drop the chip from my shoulder (or at least move it a little) and set up trays if I’m not busy, as long as he acknowledges that effective use of my time — and setting up trays is not in that category — is also essential for good patient flow.

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*An incidental object lesson for asshat physician: treat me respectfully, and you’ll get the same in return.

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Acquitted

In less than an hour.

A West Texas jury took but an hour Thursday to acquit a nurse who had been charged with a felony after alerting the state medical board that a doctor at her hospital was practicing unsafe medicine.

The uncommon prosecution had ignited deep concern among health care workers and advocates for whistle-blowers about a potential chilling effect on the reporting of malpractice.

But after a four-day trial in Andrews, Tex., a state court jury quickly found that the nurse, Anne Mitchell, was not guilty of the third-degree felony charge of “misuse of official information.” Conviction could have carried a prison sentence of up to 10 years and a fine of up to $10,000.

A civil suit is now pending against the hospital, sheriff, and physician. Let’s hope they’re all spanked thoroughly, and the nurses involved get the best restitution of all: cold, hard cash.

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Angst

If there is anything more likely to provoke an existential crisis than sitting in a Walmart McDonald’s* overlooking a parking lot on a grey February day, I don’t know what it is.**

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*Why was I sitting in a Walmart McDonald’s? Don’t ask.

** Out of sixteen people sitting there, evenly divided between male and female, and including one child, there was not one smile and plenty of blank staring at the dingy beige walls. Perhaps they were sharing my inarticulate despair.

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Favourite Poems (II)

Fire and Ice

Some say the world will end in fire,
Some say in ice.
From what I’ve tasted of desire I hold with those who favor fire.
But if it had to perish twice, I think I know enough of hate
To say that for destruction ice
Is also great
And would suffice.

— Robert Frost

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Hypotheticals

Suppose you have a patient come in by EMS who shows all the signs of stroke: severe right-sided weakness, expressive aphasia, facial droop, with a known time of onset three hours ago. Suppose your patient is a youngish 54 year-old guy, with no medical history. Suppose your hospital’s Stroke Protocol calls for stat transfer — no CT, no blood work,  just pick up and go — to the Regional Stroke Centre 10 minutes down the road, and if the patient leaves immediately, he will just make it within the window of opportunity to get his thrombolytic, and hopefully make a full recovery.

Now suppose you inform the emergency physician of all of this, and he says, “I don’t believe in that shit!” and then proceeds to order the full stroke work-up, thus ensuring the patient will face permanent disability. The physician will not change her mind.

As charge nurse, do you:

  • Do nothing, because the physician knows best?
  • Do nothing, but write up the physician later, and discuss the matter with the manager?
  • Advise the family to take the patient in their own vehicle to the the Regional Stroke Centre immediately?

Assume there is no practical way to get the physician to reverse her decision before time running out, and that each of the choices carries potentially dire consequences for yourself or the patient or both.

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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 his 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.

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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?

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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.)

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