Archive for March, 2011
In the Resus Room the other day, the patient an elderly female patient presenting with a vague chest pain and a pair of (overly) doting children, a son and daughter. The patient herself is quite stoic and calm, bemused by all the ado, the children less so.
We generally allow only one visitor at a time into the Resus room. First up is the daughter. She fusses and coos and adjusts the blankets. The patient pats her daughter’s hand and says, “This is my favourite child. She’s the best.”
“I’m sure,” I say, “you say that about all your kids.”
“No,” she says firmly. “She’s my favourite.” The daughter positively beams.
The son trades places with the daughter. He fusses and coos and adjusts the blankets. The patient pats his hand and without batting an eye, she says, “This is my favourite child. He’s the best!”
We drank wine, too much wine, after dinner, laughed too loud, made music with the rims of the glasses and watched the candles splash light on the wall with gold fingers. I vented, just a little, and she listened. Why the hell am I a nurse? This was the general theme. She listened carefully and said nothing. After a while, the music became low and somber, and we switched to coffee and Cointreau. She played with her hair, twisting the bangs, and she asked me, suddenly —
“What was your best moment in nursing?”
I stopped and thought. I could see my reflection in the dining room mirror, dimly, and even I could see bone-tired in my face. But I thought about codes and trauma. I thought about why I was once made Employee of the Month. I thought of smaller moments of giving care— warm blankets, a back rub, a cup of ice chips, repositioning. I thought about missed findings. I thought about the time a patient an ambulance gurney went VSA while I was triaging her, and walked out of hospital ten days later. I thought about innumerable STEMIs caught and thrombolysed (and later sent for rescue cathetherization) within minutes of arrival. I thought about the times when I pushed for some extra intervention which made a real difference in the patient’s life.
I smiled. “There are too many.”
“Really,” she said. “No, really — what’s your best moment as a nurse?”
I thought again. I thought about speaking to the thirty-something husband of a woman dying from ovarian cancer, who didn’t know what to expect. I thought about the unexpected joy of assisting the delivery of a child in the Emergency. I thought about arranging for a patient to spend his last hours at home, and the gratitude of the family as they walked out of the department.
I had a revelation. Not a huge, life-changing one, not comfort really, but still.
“Maybe,” I said, “maybe, I hope, the best moment is yet to come.”
“I think so too,” she said.
And the candles burned and we watched their dancing light and the shadows the made on the wall, and drank coffee and Cointreau.
Where I grew up, it was traditional to start seeds on St. Patrick’s Day. Which is what I did: tomatoes, peppers both hot and sweet, eggplant, basil — no such thing as too much basil — broad-leaf parsley, lemon grass, and a whack of “old-fashioned” annuals, zinnias, portulaca in neon colors, asters, nicotiana.
Trust me, there’s no better cure to whatever gripe or complaint or crappy week you might have than holding a tiny capsule of life between your fingers and pushing it into soil, knowing in four months or so, you’ll be eating tomato sandwiches till you’re sick. In a month where hope was scarce and evil stalked the earth (as usual, but more so), planting a seed is reassuring. “Though I do not believe that a plant will spring up where no seed has been,” said Thoreau, “I have great faith in a seed. Convince me that you have a seed there, and I am prepared to expect wonders.”
Posted by torontoemerg in If You Gonna Have a Circus, You Gotta Have Elephants, Warm Fuzzies, What Nurses Really Want on Thursday 17 March 2011
My question: where can I get some, and how soon can they be delivered?
A few nights ago I was working in Fast Track, where the walking wounded go. It was insanely busy. Volumes were high, many of the patients were unexpectedly complex, and since the rest of the department was stuffed with then more acute ill (as usual), admitted patients began to fill Fast Track beds. In Fast Track, this has two consequences. First, there is physically fewer places to see people, and second, one of the Fast Track nurses is essentially seconded to assume care of these patients. The effect is to significantly disrupt patient flow. Delays, as they say, were significant, though we were working furiously hard to get patients in and out of the department.
After about five hours of wading though patients, I was flushing an IV line just outside from the Fast Track waiting room when I heard part of a conversation within.
“. . .I have never seen such slow and stupid staff as here,” a woman was saying. Someone else said something inaudible, and there was general laughter.
Nurses in the ED are generally very conscious of the public overhearing conversations, especially if the subject is sensitive or confidential. The walls have ears. On the other hand, patients don’t generally realize there is no sound bubble that prevents their conversations from being overheard elsewhere in the department. And I get that patients are in pain, are frustrated, are angry. But to say this woman’s comment was bone-breakingly demoralizing would be an understatement.
I wanted to take this woman around the department, to show her the challenges of running an Emergency Department when it’s full of admitted patients.
I wanted to give her the private Blackberry number of the hospital CEO so she could complain to him, directly.
I wanted to explain to her that I had been nearly continuously on my feet for those five hours, without a break, and my only sustenance had been two stale chocolate-glazed Timbits from God-knows-when.
I wanted to toss in my stethoscope and leave.
I wanted to tell her to shut the fuck up.
I didn’t do any of these. Instead I went to start the IV: a chronic anaemia patient who needed a top-up of a couple of units of packed red cells. Not complicated, but time-consuming. She would be taking a geri-chair for four or five hours, and when the transfusion was running, she would need frequent nursing assessment and documentation. She was sweet, patient and even grateful and marvelled I had the time to find a warm blanket and a tuna sandwich for her. There wasn’t any Hallmark moment in this, if you’re wondering. There was no object lesson, no redemption, no new courage to carry on, et cetera. She brightened my sour mood, but only a little. Being human, the comment lingered like a bad odour — C. diff, maybe — for the rest of my shift.
I mentioned the comment to my colleague of the day. He thought about it for a minute. “Maybe,” he said, “we should fulfil public expectations.” We didn’t, of course. But the thought was enough to bring the merest smile to my lips.
Was cleaning house the other day, and in the bottom of a jar full of old coins and religious medallions sent me by a Carmelite nun of my acquaintance (she’s determined to make a good Catholic out of me) I found my original ENC(C) pin. ENC(C) — Emergency Nursing Certification (Canada) — is awarded by the Canadian Nurses Association after documenting so much ED experience and education and writing a 4 1/2 hour exam; one needs to recertify (and gets a new pin) every five years.
I didn’t think much of the pin at the time — but now I remember how hard I studied for the exam, and why I wanted to be certified: intangible benefits conferred and values implied, which were all, in the end, very personal. Commitment. Education. A sense of professionalism. Competence. Dedication. Like me, the pin is a little tarnished in places. But it’s interesting how things so casually cast aside suddenly acquire great value after years of being forgotten.
So. I didn’t get the job. When Human Resources called at last, I did get a version of the much-mocked praise sandwich:
Top Slice — Praise: “The Hiring Committee was very impressed by your interview, and was particularly intrigued by your idea to eliminate the hospital deficit by wheeling “surplus” patients into Lake Ontario. . .”
The Meaty Filling —The Crappy News Which is the Real Purpose of this Phone Call: “. . . however ultimately some other hospital drone, carrying much less cat hair about their person, and also having a clear command of the English language, was chosen as the successful candidate. . .”
Bottom Slice — More Praise: “But the Hospital Corporation thinks you have potential and encourages you to apply to another of its many fine positions in the near future.”
To be honest, I was a bit disappointed, I think, because the interview went well enough to give me reason to believe I had some hope of getting the position. At any rate, my various spies tell me that I did quite well in the interview, there was a seriously ridiculous number of candidates, and — from an Important Hospital Personage — I am “on the very edge” of hanging up my greens forever. So stay tuned. I’m applying for another postion this week. Maybe this time I will utter the precise magical phrases.
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Mini-rant. Dear Prospective Emergency Department Patient: Please, when you present yourself at Triage, please refrain from bringing along your Tim Horton’s Extra Large Double Double and box of all-chocolate glazed Timbits. One, because it makes me doubt your sincerity and the validity/importance of your putative appendicitis, shoulder dislocation, haematemesis, giganto axillary abscess, Crohn’s exacerbation, pneumonia, myocardial infarction, major multi-system trauma, what-have-you; and two, more importantly, it causes me to spike my serum cynicism level, which I am trying to avoid. Thank you.
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I’ve been in conference/education Hell for the last few weeks, which is part of the reason for scanty posting. The other reason is that I’m pooped. Not from writing — it’s from the never-ending flood of patients lately, and also from some pretty horrific codes and traumas. Tons of shit — I mean some really awful things: I will have the image of the dead child we tried to resuscitate a couple of weeks ago etched in my mind forever, I think. We work in a culture which silently expects us to suck it up and deal with it. It shows how we treat each other as nurses, on how we relate to our families, on ourselves.
In short [she writes] if, really truly, your hospital is using 25/27 beds for admits and there is no way to transfer them out or transferring would be significantly delayed and six critically-ill people are coming in via ambulance…I don’t care what’s going on or what country you’re in, that’s a disaster. Seriously. If this is your hospital, and people are being shitmonkeys and refusing to assist you, start busting out the triage tags. Page every administrator out there. Say you have a disaster and are starting your Disaster Code. Maybe someone will cancel a meeting if the media starts calling.
I’m not sure if she’s fisking me, engaging in some not-so-gentle mockery, or using my post to buttress her conceptions about the nature of Canadian health care: referring to the Canadian public system as commie-pinko-socialist is probably a clue. In any case the point is taken: it was a disaster. It’s an ongoing disaster. It’s funny how sometimes it takes someone outside the situation to point out the obvious.
I will say, however, that Nurse K’s suggestion to implement the disaster plan — in Ontario, known as a “Code Orange”” — isn’t feasible. In my hospital, at least, it’s a decision that needs to be made jointly amongst the charge, the manager and the ED physician, and in any case tends to be reserved for external mass-casualty disasters, like busloads of HIV-positive haemophiliacs crashing on the 401, not for severe hospital-induced multi-system dysfunction. So what’s a harrassed, stressed-out charge nurse to do?
Nothing. Get all rowdy with equally harassed and stressed out bed flow managers. That’s about it.
The point is that at my hospital and at many others there is no plan.
Why? Because 1) we cope, and 2) hospital administrators see emergency department over-crowding as “normal”, intractable, and somehow not a serious hospital problem. Both are wrong. We do cope, but we carry on in way an over-heating engine run for a while before it finally seizes up and stops functioning. Sick time and turnover are increasing: not a sign of a well-functioning department. And the problem is fixable. I know the Ministry of Health is working, albeit slowly, on long-term solutions. But somehow, it isn’t better knowing various health officials, flaks and functionaries are busily at work introducing systemic reforms when the problems are much more immediate. If I can think of four or five ways to improve flow of admitted patients out of the ED without even opening new beds or breaking into a sweat, then surely it’s not beyond the grasp of hospital management. All it takes is will and prioritization — which sadly seems to be lacking.
Lewis Carroll’s famous nonsense poem. Some definitions of his portmanteau/nonce words can be found here. The poem is the subject of some highly serious analysis. Wikipedia:
Parsons describes the work’s “logical non-sense” as a “semiotic catastrophe”, since the words create a discernible narrative within the structure of the poem, but we don’t accurately know what they symbolise. She argues that Humpty tries, after the recitation, to “ground” the unruly multiplicities of meaning with definitions, but he cannot succeed, as both the book and the poem are a playground for the “carnivalised aspect of language”. Parsons suggests that this is mirrored in the prosody of the poem: in the tussle between the tetrameter in the first three lines of each stanza and trimeter in the last lines, such that one undercuts the other and we are left off balance, like the poem’s hero.
I am uncertain what a semiotic catastrophe would look like, but I am nearly sure Carroll would be pleased with the description.
‘Twas brillig, and the slithy toves
Did gyre and gimble in the wabe;
All mimsy were the borogoves,
And the mome raths outgrabe.
“Beware the Jabberwock, my son!
The jaws that bite, the claws that catch!
Beware the Jubjub bird, and shun
The frumious Bandersnatch!”
He took his vorpal sword in hand:
Long time the manxome foe he sought –
So rested he by the Tumtum tree,
And stood awhile in thought.
And as in uffish thought he stood,
The Jabberwock, with eyes of flame,
Came whiffling through the tulgey wood,
And burbled as it came!
One, two! One, two! And through and through
The vorpal blade went snicker-snack!
He left it dead, and with its head
He went galumphing back.
“And hast thou slain the Jabberwock?
Come to my arms, my beamish boy!
O frabjous day! Callooh! Callay!”
He chortled in his joy.
‘Twas brillig, and the slithy toves
Did gyre and gimble in the wabe;
All mimsy were the borogoves,
And the mome raths outgrabe.
— Lewis Carroll