Archive for December, 2010

Crossing That Mysterious Line on Facebook

The other day EMS brought in a 58-year-old man to a certain Toronto-area hospital. His chief complaint? He had broken a toe nail. Left great toe, to be exact.

Seriously.

Now, I have a ten-dollar bill that says you think you know where I’m going with this: stupid ambulance-calling patient abusing the system, har-har, look at the dummy. Right?

Wrong.

One of my spies tells me there is a nurse at this hospital who posts tales of triage on her public Facebook page. She nailed — she thought — this particular patient just after Christmas, and didn’t bother to change the details of the chief complaint much to protect confidentiality.* Nor did she much conceal her contempt for this particular patient.

The detail the nurse neglected to mention on Facebook was this patient’s early-onset Alzheimer’s. He was just beginning to have some very serious cognitive problems; he called EMS when his toe began to bleed, then became quite agitated. His wife thought there was something seriously wrong.

Maybe not so funny now, right? Maybe more a case for social work and home care intervention than public ridicule?

I know there is a veritable cottage industry out there devoted to silly emergency department stories. Patients, in truth, do some very strange and funny things, and sometimes their appearance at the triage desk are for reasons less than credible. Hell, I’ve spun more than a few stories on this blog myself. I hope at the end of it I’ve respected both the patients and their confidentiality. But clearly the nurse above crossed a line. To me it feels abusive and frankly, rotten.  There’s a huge confidentiality issue. The context was deliberately left out: it’s not funny at all if you know the circumstances. The patient and family are in a particularly vulnerable situation.

But the question I have to ask is, where exactly is that line, and how do we know when we’ve crossed it?

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*I have, however.

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“It’s Not All Sunshine and Lullabies”

[One of the many great submissions to the Those Emergency Blues Prize for Writing. Posted here with permission.]

Author: RNRaquel

Blog: The Doctor Stole My Stethoscope

It’s Not All Sunshine and Lullabies

L & D is not always the happiest place in the hospital. Consider the case of Ms. H. Ms. H is a healthy 35 year old female, at 28 weeks gestation with her 3rd child. Thus far the pregnancy has been uncomplicated. One Friday morning, on her way to work Ms. H notices that the baby, a girl, is not moving as much as normal, so she calls her OB and arranges to come by for a quick check. Ms. H’s BP is up and her weight has gone up several pounds, much of which appears to be edematous. The doctor checks the fetal heart rate, which is 127. He offers her the option of going to the hospital for an ultrasound, which Ms. H accepts. The hospital can’t get her in for several hours, so the office nurse advises Ms. H to go home and try some caffeine to get the baby moving.

After waiting at home and still not feeling the usual amount of fetal movement, Ms. H drives herself to the hospital for the ultrasound. When the tech begins the ultrasound, she quickly stops and steps out to answer the phone, stating that the secretary is gone for the day, so she has to help at the front. The tech is gone for an unusually long time. Finally the tech comes back in the room accompanied by Ms. H’s OB. Ms. H immediately bursts into tears, sensing that whatever is coming is going to be unbearably painful. The MD takes her hand and simply says “It isn’t good”. The baby was dead and possibly had been dead for quite some time. The doctor gives Ms. H some options. She can go home, pack and come back the next day for induction of labor or she could go up to the floor immediately to start the process. He explains potential complications: infection, bleeding, DIC. He offers to order her Ativan and Ambien. Ms. H decides to go up to the floor for immediate induction.

The OB accompanies Ms. H upstairs and promises to call her husband, as she is still quite tearful. The doctor leaves to go write admission orders. Elizabeth, a veteran L & D nurse from Ireland, appears and gives Ms. H a hug. She gets Ms. H settled into a room, obtains a urine sample, and applies the ID bracelet. Soon it is shift change. Stacey, another veteran L & D nurse, introduces herself to Ms. H and hugs her also. Stacey inserts an IV and draws blood in a rainbow of tubes for stat labs. The OB returns and inserts Cytotec into the vagina to initiate the induction process.

The lab results come back quickly. Ms. H’s white count is high. Her platelet count and RBC’s are slightly low, and her liver function tests are abnormal, not the best findings. The OB orders two IV antibiotics to counter any infection that is present and then  leaves the hospital for the night. Ms. H’s husband arrives amidst more tears. The nurses contact a representative from a local support group for parents of stillborn infants and infants who die shortly after birth. The representative will later come visit Ms. H in the hospital.

Because of their other children, Mr. H has to leave for the evening. Stacey gives Mrs. H an Ambien and checks on her periodically throughout the night.

In the morning an infusion of Pitocin is started by Elizabeth, who has returned for the day shift. Elizabeth also hooks up a Dilaudid PCA, so that Ms. H will have some pain control. Ms. H is alert and oriented and occasionally tearful. Her spouse stays with her throughout the day. Elizabeth assist Ms. H in filling out the forms required for a death certificate. Ms. H names the baby Anna Elizabeth. As the day shift goes on, contractions begin and eventually grow stronger and more painful.

When the night shift staff comes on duty, Stacey returns along with a new grad RN, Candace, to take over care for Ms. H. The PCA is no longer providing sufficient pain relief. The nurses suggest an epidural, to which Ms. H readily agrees. Sheila, the charge nurse, comes in to help set up for the epidural. The Anesthesiologist arrives and coaches her CRNA student through inserting the epidural. Ms. H relaxes considerably once she obtains adequate pain relief. The OB returns and decided to do an amniotomy, breaking the water. Once the doctor leaves, the contractions increase in frequency and strength. Stacey, Candace, and Sheila all are present to deliver the stillborn baby.

The nurses whisk the baby’s small body off to the next room, where they clean her and wrap her in a blanket. The nurses obtain her handprints and footprints. They put a hat on her head and take photos of her. Then Stacey and Candace take the baby to her mother.  Tears stream down Mrs. H’s face.  Ms. H holds her baby and looks at her lovingly for a very long time as if trying to take in all the details and commit them to memory. The baby has fair white skin and lots of dark hair. Her eyelids are still tightly shut.

Eventually the nurses take the baby back, and Candace takes her body to the morgue. Stacey gives Ms. H an Ambien. The OB arrives back at Ms. H’s room and delivers the placenta without complications. Ms. H’s husband returns home to their children. Stacey and Candace pop in at least hourly throughout the rest of the night to assess Ms. H’s mental and physical status.

In the morning RN Elaine takes over Ms. H’s care. Elaine has been in L & D for 30 years. Ms. H’s husband and other two children are present at the bedside. Ms. H requests a chaplain to pray with them. Elaine asks if she would like the baby present for the prayer. Ms. H considers this and agrees, stating “Maybe it is the only thing I will ever be able to give her”.  It is a Sunday, so the main hospital chaplain is presiding over mass at his home church. Elaine calls and calls, everywhere she can think of. There seem to be no available ministers anywhere in the entire metropolitan area. Eventually a tall, bald man wanders into the room, introducing himself as one of the hospital’s assistant chaplains, stating he had just stopped into the office for a moment and saw the message. Elaine brings the baby to the room, and the chaplain and  family hold hands and pray. The two other children, 7 and 9, appear interested in the baby and both hug her. The chaplain leaves, and Elaine returns the body to the morgue,where an autopsy will eventually be performed. Elaine Brings Ms. H a decorative box, which contains a sympathy card signed by the nurses, the baby’s blanket and hat, copies of the footprints and handprints, as well as the photos. Ms. H is discharged to home at approximately 1500. -

These were some damn good nurses, who did their utmost to make a horrendous, heartbreaking situation at least somewhat bearable. I was not one of the nurses this time. In fact, I was the patient, Ms. H. Being the patient totally sucks, but when overcome with grief, it is excruciating. Those nurses gave me 100% and I took it greedily and gratefully. Now when I give a hug, hold a hand, or look in a face contorted with grief and pain, I draw on what those L & D nurses gave me in the midst of my deepest, darkest moments. Their love and compassion flow through me to my patients as though from a well that never run dry.

**One year and 3 months from the date of the loss of Anna, I gave birth to a healthy 9 lb baby boy. Life is good**

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Seeing the Back End of 2010

You might have noticed I was a little scarce after the holidays. Because I fell.

Thrice.

As in three times, all slipping on ice. After the third time, the husband started holding me — annoyingly — by the elbow, like he was doting on his ancient and frail gran. No serious injuries fortunately, but enough to cause some weird back-spasming thing and some exquisite pain in my left trapezius (I think). So not functioning too well, these last couple of days.

So to sum up this year:

Wretched back.

Badly sprained ankle.

Assaulted.

Ear infection and perf’d tympanum.

Gastro.

Enough, I said, is enough after the falls. I was angry enough to spit, and frustrated enough to cry.

But then I remembered this:

We spent a delightful Christmas Day with an old friend, who, by-the-by, has some fairly troublesome and significant medical problems. She insisted this year on cooking us Christmas dinner deluxe — complete with turkey and tortière and homemade pickles. It pretty well wiped her out. Afterwards, we had our usual perfunctory discussion about her well-being — she dislikes talking about it — and at the end, gazing at knuckles contorted by rheumatoid arthritis, she said, “Well, it beats the hell out of the alternative.”

And also I remembered this:

We spent a delightful Boxing Day with another old friend who cooks in the firm belief that too much is certainly not enough, so dinner began with cold shrimp, hot hors d’oeuvres and a  meat and cheese tray, wine, and processed merrily along through bread, mashed potatoes, gravy, stuffing, Caesar salad, broccoli with cheese sauce, wine, wine, wine, coffee by the gallon, cheesecake and ice cream. Her marriage is as at the edge of a cliff, and has been for the better part of a year. I fear the fall to the abyss will be rapid. She presided happily over the cheerfully chaotic — and loving — theatre of her family: this Boxing Day, for her, was a good one. It may have been the best five hours I have ever spent with her, watching her watch her family in her cramped kitchen.

It’s all a matter of perspective.

I have a home.

A happy marriage.

Good health.

A full pantry.

A garden.

An interesting and well-paying job.

Money in the bank.

A reliable vehicle.

Friends.

Love.

It’s better than the alternative. Much better.

So, no more whingeing and whining. But still, the end of 2010 won’t come fast enough.

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“We Do More In Our First Hour Than Most Do All Day”

[One of the many great submissions to the Those Emergency Blues Prize for Writing. Posted here with permission.]

Author: Sean Dent

Blog: My Strong Medicine

We Do More In Our First Hour Than Most Do All Day

I think we nurses should start advertising our skills like the Army does. You know that commercial or that saying about those in the Army do more before 6am than most do all day.

(As a side note: I tried to find that commercial with no luck.)

OK. So maybe it wasn’t the Army? It was some branch of military darn it!

Aanny Hoo..

I thought I’d just highlight the first hour of a nurse working at the bedside in a hospital. I’m going to be a lil biased and use a nurse working in the ICU (sorry).

Most nurses arrive 15 minutes before their shift just to brew their coffee, change their clothes (shoes mostly), gather their needed equipment (clipboard, stethoscope, pens/ pencils/ markers, scissors, etc.), get a lay of the land (in the break room and also out on the unit), prepare their day ahead (priorities), put their initials on and stash their lunch, use the bathroom (since this might be the last time you get there for quite a long time), do their hair / makeup (no – not me), and any other sidebars before they actually clock in!

Clock in

Oh wait I forgot. Most of us will still prepare ahead of time. We either have pre-printed report forms we write on during report, or we go to the computer and print out our report sheets, also print out a current census sheet and also view the staffing for the day to determine that plan of action.

Who’s here, who’s not. What’s the staff :patient ratio today? (yes, it will vary in some organizations) This is always about how understaffed the unit could or could not be.

OK.. Back to clocking in

Assignments and staffing

Staffing is assigned (or a vague attempt). Most of the time we try to be fair and even (when I say ‘we’ I mean the charge nurse with the input of the other staff nurses). If you worked the prior day we try to line you up with the same assignment (although that can change at the drop of a hat). Is there a secretary? What is the skill mix of today’s staff versus the complexity of the patient load? What is the severity of the patient illnesses(ventilated / hemodynamic monitoring /etc.)? Is there newer nurses who need experience? Are there orientees with preceptors (no preceptors)? Which patients have procedures and road trips? Any with multiple procedures? Surgeries today? Incoming and outgoing patients? Also what is the length of every staff members shift for the day? Who’s here for 8hr? 12 hr? Who’s coming in and when? Wait, are there student nurses visiting the unit today?

Pre-report analysis

This is where the ‘big picture’ is put together for each patient that you are assigned. Everything from admitting diagnosis, days on the unit, severity of illness, road of recovery, treatment plan, etc. All of the information needed is more than likely in numerous places. What is allowed, not allowed? Diet – fluid restriction / special diet / diabetic? Patient toileting needs (foley, voiding, assistance). Contact information allotment for change in patient condition as well as consents for procedures. What services are on this patients case (multiple medical services as well as primary care – ortho, surgery, pumonary, etc) What is the patients code status (full code? DNR?) Current therapies – everything from occupational and physical therapy to intravenous fluid status and needs. Any special precautions taken – is the patient in contact / droplet precautions?

Patient history – everything pertinent to their care. Allergies? Past medical illnesses? Past surgeries? Any and all of these findings will change and direct your care. Patients age is also pertinent to the customization of your care.

This is also the time to review all pertinent labs in regards to the patient. What’s normal? Abnormal? Why and why not for each finding. What to do about all your findings? What has been done for the lab values, what hasn’t been done. Who needs notified?

Report

This can be nurse to nurse, or a pre-recorded message. This is where the previous shifts activities are reviewed. This is when you compare what you know, what you expect to hear, what you expect to find with what actually is happening to the patient. What you read on paper and on charts never tells the full and accurate story of their care. EVER. Listen intently and list anything that is pertinent to your days activities. There are so many things to note during a report that they are too numerous to list. The bottom line is to extract every finite detail to try and prevent any mistakes during the application of your care, as well as customize what you do towards your patients needs

If you listened to a pre-recorded report you would then follow up and get any additional updates and have any questions you may have answered with the previous shift nurse.

Med check

This is where…

Oh wait. I think I lapsed past the first hour already? Whew…

I left out so much. I know I did. I tried to envision me at work, but there is so much that happens behind the scenes and ‘automatically’ that I can’t account for it all.

The message here is we have so much to do in such little time. You wonder why we nurses arrive early, cheat and prepare before we clock in??

That whole time management thing – yeah we got it.

LOL

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What I Found On My Desk

A brochure for scrubs. Because every nurse wants to be like the nurses on Grey’s Anatomy, i.e stupid and/or bitchy handmaidens props who exist to demonstrate physician superiority.

And into the trash it goes.

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Top 10 Popular Posts in 2010

For what it’s worth, the ten most popular posts for 2010:

1. Full Code (Not one of my best written pieces, frankly — but what do I know?)

2. Spam Bomb (At a loss to explain this, basically it’s a two-line squib warning people I was deleting a whack of spam. I think people google spam + bomb and show up here.)

3. Can We Stop the I’m-a-Male-Nurse-Who-Isn’t-Gay-Contrary-to-the-Stereotype Routine?

4. Florence Nightingale: Images and Words

5. Some Thoughts on “Independent” Nursing Practice

6. The Lady with the Lamp (Rather like this one.)

7. The Value of Nurses (Created a lot of discussion: I will add this as a permanent page, I think.)

8. How a Police Officer Can Get a Nurse Fired (More contention.)

9. Obesity in Children Equals Parental Neglect? (I got smacked a little on this, for suggesting obesity was a form of child abuse. However, the point remains, and I still haven’t changed my mind.)

10. Death in the Waiting Room

Apart from the first two, it’s a pretty representative list of the 400-odd posts I’ve made this year. Interestingly, none of my “first hand” accounts of emergency department silliness/stupidity/awfulness made the twenty except the terribly written post in first place; “Code” came in at #22, and it barely counts, being ancient history for me.

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Christmas VI

My favourite, mostly because I can sing the harmony. The First Nowell. King’s College, Cambridge.

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Christmas Day V

An Invitation to the Revels

Come follow, follow me,
Those that good fellows be,
Into the buttery
Our manhood for to try;
The master keeps a bounteous house,
And gives leave freely to carouse.

Then wherefore should we fear,
Seeing here is store of cheer?
It shows but cowardice
At this time to be nice.
Then boldly draw your blades and fight,
For we shall have a merry night.

When we have done this fray,
Then we will go to play
At cards or else at dice,
And be rich in a trice;
Then let the knaves go round apace,
I hope each time to have an ace.

Come, maids, let’s want no beer
After our Christmas cheer,
And I will duly crave
Good husbands you may have,
And that you may good houses keep,
When we may drink carouses deep.

And when that’s spent the day
We’ll Christmas gambols play,
At hot cockles beside
And then go to all-hide,
With many other pretty toys,
Men, women, youths, maids, girls, and boys.

Come, let’s dance round the hall,
And let’s for liquor call;
Put apples in the fire,
Sweet maids, I you desire;
And let a bowl be spiced well
Of happy stuff that doth excel.

Twelve days we now have spent
In mirth and merriment,
And daintily did fare,
For which we took no care:
But now I sadly call to mind
What days of sorrow are behind.

We must leave off to play,
To-morrow’s working-day;
According to each calling
Each man must now be falling,
And ply his business all the year
Next Christmas for to make good cheer.

Now of my master kind
Good welcome I did find,
And of my loving mistress
This merry time of Christmas;
For which to them great thanks I give,
God grant they long together live.

— Anon.

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Christmas Day IV

The Magi

NOW as at all times I can see in the mind’s eye,
In their stiff, painted clothes, the pale unsatisfied ones
Appear and disappear in the blue depth of the sky
With all their ancient faces like rain-beaten stones,
And all their helms of silver hovering side by side,
And all their eyes still fixed, hoping to find once more,
Being by Calvary’s turbulence unsatisfied,
The uncontrollable mystery on the bestial floor.

— Yeats

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Christmas Day III

Once in Royal David’s City: Choir of St. Paul’s Cathedral.

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