Archive for October, 2010
Just spent a wasted hour updating the linky-loos on the blogroll to your right. Why am I thinking the phase “updating my blogroll” is already a relic of a by-gone age?
And, oh yeah, check out the newbies.
According to the Pan-American Health Organization (PAHO), MSPP (Ministère de la Santé Publique et de la Population) reports, as of today, 30 October 2010, there have been 330 deaths from cholera and 4,714 confirmed cases. This represents a crude mortality rate of 7%. Cholera treated promptly has a mortality rate of 1-2%.
PAHO also issued a statement about the release of supplies from the PROMESS warehouse near Port-au-Prince Airport:
Since the start of the current cholera outbreak in Haiti, the Pan American Health Organization (PAHO) has distributed more than 64,000 sachets of oral rehydration salts, more than 3,500 liters of intravenous (IV) fluids, and more than 180,000 antibiotic tablets to treat patients suffering from the disease.
PROMESS, a PAHO-managed warehouse in Port-au-Prince that is the main source of essential medicines and medical supplies in Haiti, has distributed these supplies free of charge to hospitals and health facilities, including many that are staffed by international nongovernmental organizations.
Hurricane Tomas formed over the Lesser Antilles today. According to Jeff Masters at Wunderblog, the hurricane will likely strengthen to a Category 3 or 4 storm by Wednesday. As of today, he writes, “it appears that the Dominican Republic and Haiti are most at risk from a strike by Tomas, though the storm could move as far west as Jamaica, or as far east as the northern Lesser Antilles Islands.” It goes without saying that a major hurricane would overwhelm mitigation and containment of the epidemic, as cholera is spread through contaminated water.
The pseudonymous Dr. J has more on the historical and political context of the epidemic.
The Washington Post reports on protests against Nepalese soldiers in the U.N. Stabilization Mission in Haiti (MINUSTAH) and the possible, but as yet unproven, link between the soldiers and the outbreak.
HaitiLibre reported “violent clashes” in the transnational market town in Dajabón, Dominican Republic, near the Haitian border town of Ouanaminthe. The market itself remained closed Friday, despite efforts this week by officials in both Haiti and DR to reopen it. Officials closed the market because of fear of cholera transmission across the border, and because of unrest last Monday in the market itself over the DR’s decision to ban the sale of Haitian goods.
HaitiLibre also reports on the Haitians fleeing the epidemic into the Domincan Republic. Over 500 persons have been returned by the Dominican border police.
Crawford Kilian at H1N1 raises a point about the lack of information unfiltered by Western/Northern media or the good graces of the major NGOs:
Out of all the billions poured into Haiti in the last decade, couldn’t some country like the US, or some NGO, have found the money to build a decent government website, and train Haitians to maintain and update it?
I know most Haitians don’t have computers, let alone high-speed access. But the rest of us do, and we need to know what’s going on there—especially when a crisis hits.
Instead, we all have to rely on a handful of overworked doctors and journos, and the very slick websites of various NGOs eager to tell us what good work they’re doing and would we please donate to them.
If PAHO and CDC and Partners in Health and Medecins Sans Frontieres and the other do-gooders really want us to know what’s happening in Haiti, then they’d goddamned well better find some money to enable the Haitians to tell us themselves.
On the ground, good sources of information and of course needing donations:
[UPDATE: corrected mortality rate]
Kim McAllister over at Emergiblog is questioning her role as an emergency nurse. The source of her discomfiture? Patients seeking narcotics, or those we label as “DSIs”, drug-seeking individuals:
Getting patients out of pain [she writes] is one of the most rewarding aspects of emergency nursing. It’s as close as you can get to instant gratification – you medicate, the patient gets relief.
That isn’t what I’m talking about.
I’m talking obvious, blatant, in-your-face drug seeking that is becoming more obvious, more blatant and more in-your-face every day.
But the narcotics still flow.
And it’s getting harder and harder to be a part of that.
She places the blame for the increase in narcotic seeking patients squarely on the Joint Commission, which mandates U.S. hospitals to implement pain management measures when treating patients, and Press-Ganey, a survey company which rates hospitals according to patient perceptions.* Both of these institutions have created an atmosphere where emergency room physicians feel obligated to order or prescribe narcotics for anyone regardless of dependency, first to satisfy government regulation and in the second, to assuage patient perceptions of good care. (That the perception of good care is becoming more important than actual good care is a topic for another post.)
Kim McAllister’s frustration and sense of ethical distress is palpable. “I’m not helping anyone,” she writes. “I’m certainly not therapeutic in any way.” Emergency department nurses and physicians are not supposed to be an addict’s co-dependants, yet we’re often placed in the position of facilitating the addiction. We aren’t helping these patients by giving out more narcotics. How can I treat these patients ethically knowing that? It’s the moral equivilent of telling a Type II diabetic pound cake and Pepsi is an adequate breakfast.
As one old emergency nurse to another, I get it. But I have no words of wisdom for her. There aren’t any good answers, only judgement based on knowledge and experience. I can only humbly offer up for consideration what I’ve concluded. Your (and her) mileage my vary. For me, of course, it’s complicated. I have to ask myself, to start, who are the people who seek narcotics? If we eliminate those who want narcs to sell on the street, who need to be firmly escorted off the premises, and those who genuinely come to the ED in pain, we’re left with those with a drug dependency. Fine, you might say, send these loser addicts on their way. But notice how all three categories, and the last two especially, can overlap? What do you do with an acute bilary colic with an unwarranted fondness for Percocets? Tell her to suck it up, because she’s made her choices? More than a few times in my years as an emergency nurse I’ve seen physicians refusing to order pain control for large bone fractures because of a previous history of drug dependency. Is this ethical, or even wise? I’m not clear punishing drug addicts for their sins is part of the job description.
Only in the last few years I’ve to some sort of resolution, moving from where Kim is to a place of relatively less self-doubt. First, I recognize the truism that substance dependency is a disease, with its own etiology, pathology, and treatment. Very trite, yes, but something we all tend to forget in a culture that still views drug dependency as a moral failing, and a crime for the righteous to condemn and punish. Keeping this obvious fact firmly in mind allows the distance to see drug seeking as part of a medical condition, and focus on the patient, not the admittedly annoying behaviour. Secondly, I’ve come to realize we can’t fix addiction in the emergency department, during a two or three hour visit, in the same way we can suture a laceration or treat asthma. We never will, and beating ourselves up over this elementary fact is pointless. Addiction simply doesn’t work that way. It requires willingness on the part of the patient, and treatment modalities far beyond the capability of even the most experienced nurse or most sophisticated emergency department. Even getting the patient to recognize the need for treatment is a challenge in the ED: believe me, I’ve tried.
Hence, I am a pragmatist. Most drug seekers will come in with presenting complaints like lower back pain or migraine; these can be (willingly or no) given Toradol (and for those with a Toradol “allergy”, naproxen) and sent on their way. As for the rest, does it really matter? Giving the known drug addict IV morphine for renal colic (real or supposed) or sending her home with a script for ten Statex until she sees the urologist is not going to make a whit of difference in the course of her addiction. Of course she might sell them; at the very least, it encourages bad behaviour and multiple repeat visits. But again, so what? Is it our obligation to make that judgement? I’ve heard, “Oops, he really had pancreatitis! Maybe he wasn’t faking the pain!” too many times to count, I’m afraid. And do we want to be in a place where we actively discourage people already marginalized from seeking of health care?
I have no firm answers, and in the case of drug seekers, the answers tend to be coloured by experience and personal values. Admittedly, beneath the crusty exterior, I’m the prototypical bleeding heart. I prefer in the end, everything else being equal, to accept a patient’s description of pain at face value. It seems too risky and less ethical to act otherwise. But like I said, it’s complicated.
*In contrast, many emergency departments in Ontario, if not most, have sternly worded signs at traige that read, in effect, “Your narcotic prescription won’t be renewed here, so go ‘way.” We’re fortunate in Canada, as front-line nurses, not to have to deal with the Joint Commission, whose regulations often defy common sense and indeed occasionally border on insanity. Hospital survey companies like Press-Ganey do exist in Canada, but their influence on hospital policy and procedure are much less than in the U.S.
If you’re a health care professional, you know black humour. Inculcation starts early. When I was a student working through a med-surg rotation, I cared for a demented patient who was literally bleating like a sheep; my instructor, walking by her room, began to sing “Mary had a little lamb” before throwing a mock-shocked hand to her mouth, and giggling. Later on, younger and idealistic, I was appalled by what I now know is typical cynical emergency department humour. GOMERs* go to ground and GOMERs never die. Elderly patients with conspicuous luggage, dropped off by families unable to cope, have a “positive suitcase sign”. Certain patients get labels, humorous in intent, but not usually in execution. Repeat visitors are called “frequent fliers”, young women (“MIDs” — muffins in distress) and persons wanting narcotics (“DSIs” — drug seeking individuals). Codes and death are in particular subjects of black-toned laughter, as we rustle the body bags and remove the tubes. I’ve heard some remarkably dark humour after the death of children, none of which I can bear to repeat. As nurses and physicians, we’ve all been there. Something unbearably awful happens to a patient, and somebody cracks wise. It’s all wildly inappropriate, horrible, demeaning to us and to the patient. We laugh anyway. Is it unwise? Perhaps.
Recently I heard a physician make a comment that this patient is “a classic case of FTD”.
I as a naive medical student enquired what “FTD” meant?
The physician responded drly, “failure to die”.
This comment left me with a deep sense of discomfort and reminded me of the type of humor I had witnessed many times before in the ER, OR and ICU. Often in the health care profession we are placed under extraordinary amounts of pressure where human lives hang in the balance. Doctors and nurses say things which would horrify the lay public (or even sometimes ourselves in any other context).
I’ve heard the term “FTD” myself in my emergency department. It’s not a term I particularly like, though it has a certain currency with my younger colleagues. Having said that, I know exactly who this FTD patient is. She is the nonverbal, contractured, 80-something from the nursing home down the road, with Alzheimer’s dementia and multiple strokes, who’s come for the fifth time in three months in for aspiration pneumonia/urinary tract infection/blocked PEG tube. She’s the one being kept alive, almost pointlessly, because our professional ethics demand no less. I’ve written elsewhere about black humour. We can talk about how stress, and the peculiar institutional culture of health care agencies fosters gallows comedy in all of us. But I think now there is something more essential happening; the term “Failure to die” provides a real clue. Simply, black humour allows us to maintain a semblance of control, and perhaps more importantly, distance over the seemingly endless, ungovernable suffering of the human beings we treat. Having seen, assessed, and cared for such patients in the multiples of hundreds, I can understand the impulse intimately. And so it goes for all the other instances of black humour. Laughter is insurance against giving up completely.
Black humour can be unwise. Patients and families may overhear us, and misconstrue our words as indifference or callousness. Danger lies when black humour stereotypes and therefore devalues a patient or worse, dehumanizes or even demonizes. It can destroy empathy and distort objectivity. This is how nurses provide poor care, and physicians misdiagnose. The wisdom is having the insight to understand the sources of black humour in our own relative helplessness, and to recognize it, first, as an inevitable part of our practice, and secondly, as having a time and a place. Truthfully, we see ourselves in our patients. We are burdened with the knowledge of what will debilitate, and eventually kill us. We laugh against fear. To that end, perhaps, black humour allows us to remain fully human professionals and to carry on treating and caring for our patients with care and empathy.
*GOMER = Get Out of My Emergency Room, i.e. typically elderly, demented patients with chronic, complex and usually incurable conditions.
The Pan-American Health Organization (PAHO) reports as of yesterday, 27 October 2010, there have been 292 deaths from cholera and 4,147 confirmed cases. This represents a crude mortality rate of 7.04%. Cholera promptly treated has a mortality rate of 1-2%. There was no situation report issued yesterday, and these numbers are taken from the daily briefing, in which PAHO deputy director Jon Kim Andrus was careful to emphasize were compiled by the Haitian Ministry of Health and Population (Ministère de la santé publique et de la population — MSPP).
Andrus also outlined the strategy for containing the outbreak, developed by MSPP in close collaboration with international partners, including PAHO, the UN and NGOs. This strategy is directed at mitigating the number of new cases of cholera and rapid treatment of those infected. It includes community-based messaging campaign on describing handwashing, water purification, and how to prepare oral rehydration salts. In addition, there will be considerable action on the ground:
The Ministry of Health is also sending community health aides into poor and densely populated areas, including temporary settlement areas that were created after the earthquake, to actively seek out and refer the sickest people to the Cholera Treatment Centers, while at the same time giving them a first dose of oral rehydration salts.
They will also supervise measures in the local communities and neighborhoods to ensure clean drinking water and that proper waste disposal and maintenance of latrines is being done.
More than 60 community health aides are in the process of being deployed to the temporary settlement camps that were set up after the earthquake.
The community health aides are intended to support and complement the many Red Cross community health aides that are already working in the country on the ground.
The Ministry also will be establishing a network of community health posts, with the idea of having 1 post for every 25 families, that will have the capacity to treat diarrhea.
The overall strategy is aimed to strengthen primary health care centers across the country with 24/7 coverage, and to build new structures in addition to 33 designated hospitals nationwide that will serve as Cholera Treatment Centers for the most severe cases.
As noted yesterday, there is some optimism that these efforts are containing the outbreak. However, Haiti: Operational Biosurveillance (HOB) has this caveat:
From our perspective, we agree with PAHO’s recent statement today [i.e. yesterday --- ed.] about the epidemic and while we all would like to be hopeful, we are reminded of the recent 2008-2009 epidemic of cholera in Zimbabwe. Responders there were lulled into a false sense of security as the epidemic waned, only to be badly disappointed as the epidemic continued onward to produce 98,424 suspected cases and 4,276 deaths (Case Fatality Rate of 4.3%) from August 2008 to June 2009 that were officially reported. Fifty-five out of 62 districts in all 10 provinces had been affected, according to the World Health Organization.
Currently we are seeing 4,147 cases officially reported, with 292 deaths. We assume PAHO is reporting these as separate groups of people, where the total number of cases reported is actually 4,147+292= 4,439. If we generally assume that only 25% of cases display clinically apparent illness, we conservatively assume then there has been at least 17,756 infected people to-date. This is a truly alarming number of people, especially when considering 1) this is likely the result of under-reporting and 2) a large percentage of these infected individuals could be shedding pathogen into the environment for weeks post-infection.
Additionally, they add, “[T]he question of ecological establishment remains an open one as well.” If on cue, HOB reported yesterday the first case of cholera in Cité Soleil without a travel history from the Artibonite region, that is to say, a case apparently transmitted within Cité Soleil.
More on the protest Tuesday at the Médecins san frontieres (MSF) clinic in St-Marc. MSF’s account is here. BOH provides some context: the clinic was across the street from a school and took up a soccer field. They write:
- We have come to realize over the years that for communities coping with a high level of threat perception, especially during unexpected or non-routine infectious disease events, protection of children becomes an exquisitely sensitive nexus of concern that may lead to social outcry and even violence.
- Communities under collective stress such as is readily observed in St Marc have a high demand for coping outlets such as recreation and access to religious services, for example. Compromised access to such outlets is actually a key indicator that prompts us to monitor for civil unrest.
HaitiLibre has a different take, and they pull no punches: “It is unfortunate, “they write, “that ignorance of the people, can exacerbate a situation already extreme, but it is even more deplorable that the lack of authority of a government incapable of enforcing its decisions in an area declared on ‘high alert’ and to contribute, while agreeing to yield to the population, to more endanger this same population, it is supposed to protect.” The new location for the treatment centre, which was supposed provide 400 beds to relieve pressure on l’hôpital St-Nicholas, has not yet been determined.
On the ground, good sources of information and of course needing donations:
[UPDATE: corrected mortality rate]
But I have no time to savour my almost-victory: I have to go batten down the hatches.
The Pan-American Health Organization (PAHO) reports (PDF) as of 1800 yesterday, 26 October 2010, there have been 284 deaths from cholera and 3,769 confirmed cases. This represents a crude mortality rate of 7.4%. Cholera treated promptly has a mortality rate of 1-2%. Deaths are about equally divided between hospitals and the community; 96% of the deaths are reported from the Artibonite region, where the outbreak began. However HaitiLibre reports actual figures are somewhat higher: 304 deaths and 4,774 cases. [Via]
The slowing of the death rate and the confirmed numbers of new cases has generated some optimism that the outbreak has been contained. However, this outbreak has larger implications, and vigilance will still be needed, as Haiti: Operational Biosurveillance points out:
This is the first documented cholera epidemic in the Caribbean in many years, since the last pandemic of the early 1990s. WHO’s recent declaration that travel restrictions from Haiti will not be required raises serious questions of whether spread in the region is truly unlikely.
This would imply this is an ordinary outbreak / epidemic of cholera. It is not, and it represents a key epidemiological change for the Carribean region that should be monitored closely.
The Dominican Republic has closed its borders, however it is generally believed the border is highly porous. Should the epidemic continue, we expect to see cases there eventually. Jamaica is on high alert, as are other countries in the region. While we do not want to cause further damage to Haiti’s economy, the question of international travel restrictions should be re-examined at frequent intervals given the volume of multi-national responders flying in to assist.
Translocation of cholera to developing or undeveloped areas of the Caribbean, Mexico, Central or South America would likely present in a similar manner as seen in Haiti.
Noteworthy is the Dominican Republic’s decision to more closely regulate border traffic and, in at least one case, shut down a crossing altogether.
A report from the frontline in St-Marc.
Social unrest and a sense of dislocation and loss of power accompany societal crises like epidemics. Haiti: Operational Biosurveillance documented a couple of instances of this yesterday. Protesters stoned a Médecins san frontières clinic in St-Marc intended to provide rehydration therapy for cholera victims. The local community feared the disease would be brought into their neighbourhood. The clinic was moved to another part of the city. Additionally, the UN Mission for the Stabilization of Haiti (MINUSTAH) was forced to respond to a “community outcry” and rumours that Nepalese troops had carried cholera into Haiti, based an a reported outbreak in Kathmandu on 23 September 2010.
On the ground, good sources of information and of course needing donations:
[UPDATE: corrected mortality rate]
There’s been some discussion around here and in other places about what nurses ought to do when they disagree with the physician. The general consensus among nurses, is that we are professional obligated to advocate — even aggressively — for the best possible care and treatment for our patients. Theresa Brown’s recent article in the New York Times about her own conflicts with physicians articulates this point of view well. But what to do when that discussion fails, as it often does? The traditional answer, as all good nurses were taught in school, is to advocate up the food chain, either on the nursing side or the medical side. But sometimes this is not an effective approach nor is it realistic. Nurses are constrained by power structures and institutional culture which devalue the opinion of the front-line — a chief of medicine once told me three nurses witnessing a physician error was insufficient for him to do anything about it, because the physician herself denied the error — or perhaps managerial indifference; there are constraints of time (the problem must be dealt with immediately) or timing (going up the food chain in the middle of the night is difficult). The system, in general, can make it difficult for nurses’ voices to be heard.
So when all attempts fail at persuasion, we resort to other tactics and stratagems . Some nurses, like Maha at Call Bells Make Me Nervous, exceed their scope of practice and put their licences at risk trying to do right by the patient. Another example: we have all heard of nurses who will give a “generous” 5 mg dose of morphine (or whatever) if the patient has insufficient pain control, rather than fight the physician to up the amount. Or you can be like me, the crusty old charge nurse who gets tired of confronting physicians, and does end-runs to get desired results. Trust me, it’s tiresome and demoralizing for us to act this, and in the end, it’s bad for nurses and nursing.
Nurses, being nurses, tend to put the blame squarely on the physicians for not listening or for failing to engage in more collaborative practice. I am not sure this is completely fair. To be sure, some physicians will insist that theirs is the absolute final word when it comes to patient care, which is patently false theoretically, and impossible in practice; I’ve had more than one physician insist I was practising nursing “under his licence” and should therefore shut up. However, it is equally true these physicians are a small minority. And I will say, I have worked with many physicians, even in the emergency department setting, who represent the ideal in collaborative practice, who will discuss treatment plans in a manner in which nursing input and perspective is essential for good patient outcomes.
Obviously, the key here is good communication, and if we’re going to be honest — and I’m as guilty of this as anyone — nurses don’t communicate their concerns as well as we might. We can be adversarial, blaming, or judgemental, or worse, passive aggressive. We tend to forget that we possess a unique body of knowledge related to nursing and to our patients. This should empower us greatly, to advocate effectively, but often it doesn’t.
I want to back up a bit to the point where the nurse disagrees with the physician about the treatment plan, and bring in a recent interview in the New York Times with Dr. Peter Pronovost, the medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore. He speaks about flattening hierarchy and egos to maintain good patient care, about creating an institutional culture where patient safety is paramount and where management empowers and (more importantly) tangibly supports nurses to speak up. “In every hospital,” he says, “patients die because of hierarchy. The way doctors are trained, the experiential domain is seen as threatening and unimportant.”
He spoke about a situation where he knew a patient was going into anaphylaxis from a latex allergy, and having to confront the surgeon (even physicians have this problem!) to get him to remove his latex gloves:
“I said to the surgeon, “I think this is a latex allergy, please go change your gloves.” “It’s not!” he insisted, refusing. So I said, “Help me understand how you’re seeing this. If I’m wrong, all I am is wrong. But if you’re wrong, you’ll kill the patient.”
This, I think, is exactly the way to approach it. Show me how I’m wrong, because if I’m wrong, than all I am is wrong,and I hope so, because being right about this may harm the patient. Suddenly it isn’t about externalities. It isn’t about nursing judgement, or physician qualifications or ego. All of that is off the table. It’s about patient safety and about providing the best possible care. The next time I disagree with a physician, I promise to ask this: when disagreeing with physicians, nurses must be prepared to be wrong in order to best advocate for their patients. But then, so must physicians.