Archive for February, 2011

All I Can Manage Today are Random Thoughts

Just can’t get into the groove today: started two blog posts and after writing a couple of paragraphs, they both look like gibberish to me. Funny thing is, this is the very first completely free day I’ve had in a couple of weeks, and I had planned to get some serious writing done today. Focus seems to be the problem. Maybe it’s the fact the house looks like a hobo camp, or that the pile of laundry is rapidly gaining altitude, or that I have a some minor, yet pressing chores to do — in any event, the Muse has gone elsewhere today.

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One of the speakers at the Trauma Nursing Conference I went to a little while ago was from the Society of  Trauma Nurses, which seems to be principally known for providing the Advanced Trauma Care for Nurses course. STN markets itself towards the “leadership of trauma nursing around the world” and yet its stated aim is “become the premiere nursing organization in the world for advancing the nursing care of injured patients.” It might be the February crankies talking, but does anyone else see the contradiction in this? Or the condescension? I mean, how can anyone talk about being the best nursing organization in the known universe, while ignoring the front line? Isn’t leadership and excellence for all nurses? Incidentally, the speaker, Deborah Harkins, mentioned that on a membership survey 477 nurses identified themselves as “leaders” while only 36 were front-line staff. She didn’t seem to think this was a problem.

After Harkins gave her talk, I asked my table mates if any of them intended to join STN. Much hilarity ensued. My guess is that until STN changes its membership philosophy, its goal to be the gold standard for trauma nurses will prove elusive

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More about the conference. It was actually pretty well done, and worthwhile attending.  Only a couple of presentations were out-and-out duds. But I have to ask: perusing the program, why were the vast majority of presenters physicians? At a nursing conference?

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I saw a disturbing bright light in the sky the other day. Oh right, it was the sun.

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I’m going to clean out my linky-loos on the blogroll later today, maybe, after I do the laundry. Anyone have any tips on good nursing/health care blogs to add?

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Still no word about the leap to the Dark Side. I’m not that anxious about whether I got the job or not. But I dislike the wait. It’s like being told, “We are going to make a life-altering decision about you or not, and we’re going to string you along until the last possible moment before we reveal our choice.” That’s what aggravating.

 

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Nursing Can’t Compete with Grey’s Anatomy

In Ontario, secondary school students are required to do a set number of hours in community service as a prerequisite for graduation, and the Emergency Department at Acme Regional is naturally a sought-after assignment. The excitement! The drama! The glamour! Et cetera! However, students expecting the pace and intrigue of Grey’s Anatomy or House are pretty quickly brought to ground with the reality of the never-ending flow of nursing home patients presenting with the chief complaint of Very Old (with variations), unhandsome physicians with the appeal and charm of Voldemort, and unsexy middle-aged nurses griping about back pain. And then there’s me, the charge nurse, who sees these students as an opportunity to sort out that back supply closet which has been in shambles since 1975.

For these 17-and-18-year-0lds, it’s a reality check.

I was therefore interested  in watching the reaction of a particular student to a nearly continuous series of traumas and codes that presented the other day. If you’re an emergency nurse, you know the scene, the chaotic ballet of nurses and physicians organizing care and treatment, the chatter back and forth, people running in an out, and so forth. At the end of it, I asked the student her impressions.

“It’s not like Grey’s Anatomy,” she said, in her very serious, 17-year-old way.

No, I agreed. It is nothing like television. Not even in the teeniest way.

She went on. “I was really surprised by how much the nurses do.”

I brightened a bit. “Are you thinking about pursuing nursing as a profession?”

“Oh no,” she said. ” I really want to be a paediatrician.”

Sadly, I wasn’t all that surprised. I’ve had this conversation many times before, and I have yet to meet a high school student who excitedly, definitely wanted to be a nurse. Not one. For me, it’s interesting that even after years of positive advertising — think of Johnson & Johnson’s Campaign for Nursing’s Future, among many — the dominant societal meme about nurses and nursing is still one of passive and subordinate actors in providing health care, and that nursing is an inferior choice compared to medicine or even any of the other allied health professions. Which makes me think: why does the nursing profession remain so poor in articulating its own public image?

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Happy Hour FAIL

From The P.A.R.T.Y Program’s YouYube page —  I saw this video at the trauma conference I attended a couple of weeks ago. More information on The P.A.R.T.Y Program, which is aimed at reducing risk behaviours in youth, and which originated at Sunnybrook Health Sciences Centre in Toronto, can be found here.

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A Journal Article a Week (18/02/11): “Evaluation and management of apparent life-threatening events in infants”

Late again with his one, but then, now I’m caught up. You can sign up for the journal article a week challenge at Rob Fraser’s website Nursing Ideas. And really, what are you waiting for? If you had started with me, you’d have four articles read already!

APA Citation: Scollan-Koliopoulos, M., & Koliopoulos, J. (2010). Evaluation and management of apparent life-threatening events in infants. Pediatric Nursing, 36(2), 77-83. Retrieved from EBSCOhost.

The Skinny: Apparent life- threatening events (ALTEs) are under-reported and probably under-treated in the emergency department setting. This article provides an overview to causes and nursing management with a particular emphasis on care at home after the event.

Money Quotes:

“The hallmark of an ALTE is a parental report of a frightening, sudden display of the symptoms and a quick recovery with or without bystander intervention, such as stimulation or resuscitation.For example, parents may reportneeding to do cardiopulmonary resuscitation on their infant, yet whenthey arrive at the emergency department, a completely normal-appearinginfant is observed by the clinician. Parents may perceive that their reports are not believed by health care providers.”

“The relationship between ALTEs and sudden infant death syndrome (SIDS) is controversial. With less than 7% of patients diagnosed with SIDS having a previous hospital record of an ALTE, it is believed that not all ALTE victims are at risk for SIDS, but that there may be a subpopulation of infants who experience an ALTE who are at risk for SIDS, suggesting thery are not part of the same entity. Like SIDS, ALTEs occur more in the winter months and are associated with second-hand smoke exposure. Infant positioning has been implicated as a contributing factor.”

New Insights: 1. At home monitoring as described (80-81) is exceedingly complicated, even for health care professionals, and may effectively represent a barrier to care to parents.

2. Differentiating between central and obstructive apnea is essential in assessing infants presenting with ALTE, and should be done as part of obtaining the history at triage using CIAMPEDS.*

Why You Should Care: ALTEs can have a significant impact not only on neonates and infants, but also on caregivers who themselves who may suffer from psychological distress from witnessing these events. Nurses and nursing are in a unique position to provide support and counselling.

Next Week: Recognizing neuroleptic malignant syndrome in the emergency department: a case study.

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*CIAMPEDS: a mnemonic for paediatric assessment = Complaint, Immunization, Allergies, Medications, Past History/Pain, Events Surrounding, Diet/Diapers (important for assessing dehydration), Symptoms.

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MScN vs. MPH vs. MBA

As I’ve mentioned, I’m thinking seriously about doing my Master’s degree. So which degree? MScN? MPH? MBA? There’s a cool looking MBA programme with an emphasis in community development and public service I’ve seen. Is there any value in getting an MScN if you’re going into management? Anyone have any thoughts on this?

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In Which I Perform Tricks Like A Pony

By which I mean I went for an interview for that management position a few days ago. I got out the clothes I wear for state occasions, and marvelled, not for the first time, at how cat hair can get into an essentially hermetically-sealed closet. I bathed for some time in the milk of a ass, plucked out stray hairs, got dressed. I miscalculated the traffic and arrived a half hour early, just so I could had that extra bit of time to work on wreaking my composure. As as I walked to the location of the interview, I thought to myself, “I am such a fraud.”

The interview went well, as far as anyone can tell with these things. I got the usual questions. My strengths. Why I wanted the job. What leadership qualities would I bring. I spoke with conviction, I think, and I hope with eloquence  and even passion. I left feeling somewhat less fraudulent.

I have no idea if I got the position. Professional friendliness and an air of inscrutability set the tone. Two interesting things though. First, though I knew only one of the panel (of five!), they all knew me, or rather of me. Second, the panel deviated from the script of questions a few times — not to trip me up, but because they were genuinely interested in my opinions. I went into the interview with no expectations of actually being hired — maybe that was liberating. In any case, these give me reason to be mildly optimistic. We’ll see.

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A Journal Article a Week (11/02/11): Mentoring in emergency care: ‘growing our own’

Okay, this is late, and apologies to my co-conspirators Terri Schmitt and Rob Fraser, who challenges to every nurse to read a journal article a week is still open. You can sign up for this tremendous idea here.

APA Citation: Berezuik, S. (2010). Mentoring in emergency care: ‘growing our own’. Emergency Nurse: The Journal Of The RCN Accident And Emergency Nursing Association, 18(7), 12-15. Retrieved from EBSCOhost.

The Skinny: Introducing new graduates to the emergency department setting is challenging, and for the nurses themselves, can be overwhelming. Formal and informal mentorship can ease the transition and effectively integrate new nurses into the emergency department team.

Money Quote:

“Mentoring is a universal and effective strategy for nurturing nurses in what are increasingly stressful and challenging work environments. Graduates are the future of the profession, and the mentoring process allows new nurses to build on their optimism rather than having it extinguished by poor experiences and lack of support.”

New Insight: Maybe us old birds should take the initiative and be pro-active in offering our services in being mentors? I mean, we’re talking about the future of the profession here, right?

Why You Should Care: Do you really want to work with people, new grads or not, who aren’t really part of the team, or worse, don’t know what they’re doing? Sharing your knowledge and experience could make all the difference in the world.

Next Week (i.e. tomorrow!):Evaluation and management of apparent life-threatening events in infants.

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What Nursing Leadership Looks Like

Let’s talk about the qualities of leadership.

A little while ago I was at a nursing function, and the speaker was a nursing leader I tremendously respect. There was a bit of back and forth (as there often is at these things) and the conversation somehow fell to outpost nursing, then nursing in First Nations communities, and then to aboriginal communities in general — and then it went off the rails. I won’t say the discussion was racist — actually, let’s forget the tact and diplomacy and call it for what it is — it was racist and ignorant. It was certainly disturbing how little reflection and thought went into the comments from the nurses in the audience, and even more so, how the speaker seemed to enable the discussion.

I am flaming left-winger. I’ve told you this before. I am that person Glenn Beck warned you about. I believe that free speech is not just for the rich and the privileged. I think torture is an absolute wrong, and that politicians who tacitly permit it are criminals. I believe prisons are not only for justice, but for rehabilitation and restoration. I am anti-death penalty. Climate change is fact. And so on. Through my faith community I actually do some direct work associated with First Nations. Their issues and problems (our issues and problems, really) are complicated and, to be honest, controversial. I know, if superficially, some of the challenges faced by aboriginal peoples, not the least of which is the overwhelming legacy of 400 years of policy designed to marginalize them.

I was upset. I tend to wear my heart on my sleeve with these things. I had to think about this for a while. I didn’t suppose the speaker (or even her audience) had a racist intent, but then, if the effect is racist, what’s the difference?

At the end of conference, the speaker came up to me. “I saw you were upset,” she said. “I don’t want you to think I was being racist.”

I was, I said, and I did, a little.

“I was speaking,” she said, “out of my profound distress over conditions on the reserves.” She paused. “Can you tell me why I’m wrong?”

So I did. I felt immensely better about the situation. She saw my distress and was able to validate it. I was able do some education around an issue deeply concerning to me, and she asked me to follow-up with more information. I’ve made a contact and a genuine connection with someone who, as I’ve said, I respect greatly. But the real point is how many people — nurses — would see someone obviously upset about the content of her discussion, and not only act on it, but consider their own assumptions flawed?

Leadership takes courage. It takes courage to listen carefully, courage to face contrary opinion, and courage to face the possibility of being wrong. And of course, courage to fix a problem when you see it, and especially if you have created it.

My respect for this nurse, which was pretty high to start with, just went up a few notches.

 

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

[A rerun. I will be back tomorrow. Really. Slightly modified; first posted 27/01/2010.]

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

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“Saving JM from The Republic of Health Care Stupid”

[A rerun, first posted 03/01/2010. Things have improved with the Home First program. I am returning tomorrow.]

It’s been my firm belief in life that picking up the phone is always trouble.

I’m lurking innocently the other day around the ward clerk’s desk when the phone rings. The ward clerk is out smoking, I think, in the ambulance bay with the other ward clerk — they have a mutual pact to quit before the New Year and are absolutely sucking out every last tobacco-filled pleasure — and since there is no else but me and the ringing phone, I pick up.

“Acme Regional Emerg,” I mutter as indistinctly as possible. I’m hoping they think it’s the pizza place down the road and call back.

“This is Hilda from Windy Sunset Nursing Home.”

Great, I think. “Yes?”

“You sent back a patient yesterday with orders for Home Care. He’s supposed to get IV meds once a day. Do you know him?”

Uh, no. In the first place, I wasn’t actually here yesterday, the warden granted a day pass, and secondly do you know what percentage of the GTA’s population we see everyday? And also I am getting worried. Being an old emerg nurse, I know Trouble when it’s walking on tiny cat feet, and this has all the signs and symptoms of being a tiger. Or at least a puma.

I look around. There is neither ward clerk nor charge nurse I can pass this impending mess off to. I sigh. Let me pull the chart, I say and call you back.

I hang up. I now officially own the tiger. Or puma. I find the chart,and yes, there it is. JM is an 89 year-old guy, bedridden, Alzheimer’s dementia in its last ugly stages, who has somehow developed an elbow cellulitis that has engulfed much of his left forearm. And hey, there’s an order for Home Care who’s supposed to administer Ancef 1 g IV OD x 7d.

JM has now entered The Republic of Health Care Stupid. It’s a funny little country, this Health Care Stupid. Governed by a cadre of bureaucrats, it’s presided over by a quasi-divine entity called “The Minister”, who lives in a gilded palace called “The Ministry of Health”, where she is fed peeled grapes and allowed out occasionally for ceremonial spending announcements and ribbon-cuttings. Its principal products are regulations and directives, consultant’s reports, and catered lunches.

What? You have no passport for this fabulous land? No matter. You don’t need one. And once you enter, you can never leave!

So. The Stupid:

Home Care steadfastly maintains that nursing home nurses, being nurses and all, can maintain IVs and administer IV medications, and refuse therefore to service nursing homes. And if the nursing homes can’t administer the drugs, then the patient obviously needs a completely unnecessary admission to hospital. Nursing homes (and their nurses), on the other hand, are equally resistant to actually learning how to start and maintain IV lines. As for IV meds — forget it.

Immovable object meet irresistible force.

In short, EMS will have to pick up the hapless JM, and he’ll spend a goodly chuck of his remaining time on this earth being shuffled back and forth between Windy Sunset and Acme Regional Emerg (and costing the system thousands of dollars in addition). This is because Home Care and the nursing home sector have squabbled like dirty chickens for the last 15 years over who actually has responsibility for patients like JM.

Clearly, this is Home Care’s problem, not mine. (It says so on the chart!) There are several Home Care case managers flitting around the hospital. They have a mysterious, near-mythological office up on the 5th floor that no one has actually ever been in. Rumours that a wormhole will suck in unauthorized personages and transport them to a desolate planet with endlessly windy plains presided over by a cold and lifeless sun, or Winnipeg, are, I’m afraid, unsubstantiated. At any rate the case managers are a pleasant, likely lot, except for one I not-so-secretly call La Crusty.

So I call up to the love nest, or particle physics lab or batcave or whatever they call their office. Of course, I get La Crusty, not the nice ones. I explain the problem, the Twilight Zone-ish Predicament of JM. Why exactly won’t Home Care go into nursing homes?

“Snarl, arf growls nutter hiss sbapz, because warf nurrzsarf, snarf, and gnash,” says Crusty.

I see. Well, since the order is for Home Care, maybe you need to come deal with this poor guy et famille because already I am getting very, verytired of this whole business, and hey, I just only picked up the phone. I have my own patients to take care of, though no doubt JM will be mine before the day is done.

Silence. Sound of La Crusty’s head exploding.

I hang up. Fortunately Social Work is hanging around. I am beginning to really love Social Work. Instead of standing around talking about why problems can’t be fixed and then deciding to hold a (fully catered) meeting or ten to discuss further why they can’t be fixed, she actually fixes problems.

Remarkable.

In the end, the family has money, and they agree to hire a private duty nurse to come and give the drugs to JM in a fully staffed nursing home with nurses and everything, and with Home Care services available to any other citizen, so the poor guy won’t have the hell of laying on an ambulance gurney for seven days more or less continually.

Is this how our health care system is supposed to work? Really?

 

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