Archive for July, 2011

So When Does This Become a Crisis?

I walked into the Emergency Department one hot morning a couple of weeks ago and found every last stretcher — twenty-five beds, including the two we try to reserve for trauma or codes — was filled with admitted patients; furthermore, five additional patients were waiting for consultants and likely admission. We were operating at 120% capacity even before the usual gamut of ED patients would begin flooding in.

Trying to manage an ED under these circumstances is like walking through an open field holding an umbrella during a thunderstorm. You know lightning is going to strike, and you hope like hell it doesn’t strike you. As charge nurse you start re-triaging the patients already under your management. Which admitted patients requiring cardiac monitoring can be safely parked in the hallway (in violation of fire codes) to make room for the syncopal vag bleed at triage? Which chest pain gets the last monitored bed? Is that MVC the paramedics rolling in nothing or a multisystem trauma?

And then, nurses providing care at the front-line begin to get frustrated and angry, because all of them chose to be ED nurses (as opposed to med-surg nurses), and they have lots of expensive education to validate their choice. In the event, they are helpless watching their elderly admits decompensating before their eyes.

Even more seriously, the sudden arrival of a trauma or a patient coding in the waiting room means a scramble to find room; in a scenario when seconds count, delay could be disastrous if there is no available bed to treat them. I don’t actually think the general public understands the fine line emergency department nurses and physicians walk between successful outcomes, where the patient is treated, made well, and discharged, and the morgue. Every health care professional in the ED practices with their heart in their throat and their licences over the fire.

So when does this become a crisis?

We’re told the principal cause of ED overcrowding is patients waiting for long-term care blocking acute-care beds. Not quite coincidentally the Toronto Star recently published an article about the appalling treatment an elderly woman received at the hands of a nursing home called Upper Canada Lodge in Niagara-on-the-Lake. The woman, named Sylvia Bailey, had a broken tibia which was left by nursing home staff untreated for twenty-three days.* She later died because of complications related to the fracture, and the case is now subject to a coroner’s inquest.

The two issues are not unrelated. Health care for seniors is vastly underfunded, and it’s reflected in both the number and quality of beds available. As a society we tend to give a lot of lip service to the care and support we give to seniors. In reality the frail elderly are at the bottom of the health care food chain. They aren’t glamorous or fashionable or have carefully managed public-relations campaigns associated with them. How many people do you see wearing a bracelet or ribbon for proper health care for seniors?

I tend to be quite cynical about this. The elephant in the room is that care for seniors is expensive, and no politician seems to be willing to state the obvious: provision of even adequate supports for a growing population of senior citizens is going to take a considerable mobilization of financial resources, i.e. increased taxes. Politicians love adopting seniors as a apple-pie issue. But given the current political climate which informs us we’re over-taxed, nurses are over-paid,and  the health car system is bloated, and throw in dodgy financial calculations by every provincial political party, any politician who tells you the case of Sylvia Bailey shall never be repeated, and ED wait times will magically disappear is flat-out lying.

So again, when do we decide this is a crisis?

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*College of Nurses of Ontario, are you listening?

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Flattery Will Get You Everywhere

It’s been a tough couple of weeks for Team TorontoEmerg. First, I’ve been working like a rented mule, and secondly, a colleague whom I trusted and respected sandbagged me with a nasty and embarrassing (and devastating) personal attack, which frankly put me in a bit of a tailspin. How bad was it? Think about being whacked hard across the face a couple of times with a 1″ bamboo pole, and you might get the idea.* I mention this not to whine — believe me, Mr. J. Doe has heard plenty of that — but merely to point out that life in the ED is tough enough. I mean it’s enough to face barking physicians, nurse managers who call us to their office only to reprimand, educators lying in wait to point out the merest flaw in our professional practice, not to mention the general opprobrium of our nurse-colleagues eager to pounce on any failure, without dealing with craptastic personal attacks as well.

Yes, today I truly love my profession. If I tell myself that enough, will it make it true?

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On the other hand, I got three compliments in the last two days, and if you’re an emergency nurse, you know that compliments from anywhere are as sweet as rainfall in a desert. First was  personal. A conversation I had with a patient during one of the rare days I actually was doing something clinical:

Patient: I’ve been coming to this hospital, I’ll bet, since before you were born.

Me: (fiddling with an IV) When did you start coming to Acme Regional?

Patient: 1971.

Me: Hehehehe.

Okay, silly and obvious. But oh-so-welcome. And then another patient told me flat out my care was exceptional. And then a management muckety-muck told me my name had come up during a meeting of even higher muckety-mucks. I am, apparently, attracting attention in a positive way in relation to the administrative secondment I’ve been doing. All of which takes away the sourness of the above. A little, anyway.

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I work with a nurse who in nearly every respect is a superb nurse. She’s clinically smart, knows her theory, advocates for her patient and provides excellent care. I was getting report from her the other day, and she was griping how this nurse didn’t do that and that nurse didn’t do this, and it occurred to me she has never, in my experience or hearing, said anything kind about any other nurse. Not ever. It’s almost pathological. I always come back to this question: how can nurses give exceptional care to their patients and then turn around to model themselves as fine examples of human malice? Does anyone have an answer that doesn’t involve a disquisition on horizontal violence and unequal power relationships in hierarchies?

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To my nursing colleagues, I have one request. Next time you’re on duty, or if you’re on duty as you’re reading me, go compliment one of your colleagues. Praise a difficult IV start or a successful catheter placement or some little piece of good nursing care. Do it. Right now. Trust me: by this one small act you’ll improve our profession immensely.

And then when you open your mouth to criticize or find fault with a colleague, find something else to say. Preferably something nice. Really. It’s not that hard. Remember how you felt when you were last sandbagged? And also, you’ll find here the difference between being a good or even superb nurse, and being an exceptional nurse —- and who doesn’t want to be exceptional?

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*So nasty, in fact, I’m seriously considering leaving Acme Regional. Why do I want to work within twenty miles of this person? The emotional response, I suppose, but one which is honestly how I feel, right now. Ask me again in two weeks.

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Hotocalypse

Hot enough for ya?

For you non-metric types, that 38C is an even 100F. I think I speak for most of my fellow Canadians when I say, “WTF?”

I suppose it’s redundant and unnecessary to add that staying out of the sun, finding a cool, air-conditioned place to hole up in (if possible) and drinking plenty of fluids (alcohol or tea or coffee don’t count in this regard as they tend to dehydrate) is the best way to prevent heat exhaustion or stroke. I really don’t want to see you in my emergency all floppy, syncopal and dehydrated because you’ve decided Thursday is the best day to practice for the triathlon or because you think the lawn needs a little trim before the weekend.

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Get Me the Frickin’ Goat!

If only there was a magic goat.

Part of an advertising campaign from the Nova Scotia Ministry of Health Promotion and Protection aimed at reducing harm from high risk behaviours. According to the No Magic Goat website:

911 is your friend.

The goat, not so much. (She bites, for one).

She’s cute and furry, but isn’t good for much if you screw up. If the shit hits the fan, and drinking does some serious damage, no goat’s going to save your ass. So, just for the record – if something like what you see in the video goes down at a party you’re at? You might want to think of calling 911 instead of calling for a goat. Did we really have to actually say that? Yes, we did.

You can see how the notion of seeking out The Goat for difficult or impossible situations could go viral. As in “Call a code blue. Where is that damned goat?” or “ICU won’t take the patient. Get me The Goat!” In the emerg, there are many, many scenarios like this where a magical goat would be very useful.

The Goat, incidentally, has — what else? — a Facebook page.

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Triage

The world in four patients, plus interruptions.

Who’s next? Come in.

Do you have your Health Card?

Take off your hoodie and sit down. What brings you in today?

Where exactly is the pain?

On a scale of one to ten, if ten is the worst possible pain, what number would you give the pain?

How long have you had it?

Three months?

What changed tonight?

How would you describe it? Sharp? Dull? Knife-like?

Is it constant?

Does the pain go anywhere else?

Any nausea or vomiting?

Any diarrhea?

Does the pain get worse after eating?

Last bowel movement?

Last menstrual period?

Any problems peeing? Feeling like you have to go all the time? Blood in your pee?

Any allergies?

What medications are you on?

Any medical conditions we should be aware of?

Here’s urine bottle. There are directions on how to collect a sample in the toilet.

Your blood pressure is okay.

Take this to the registration clerk over there. We’ll make up a chart, get some blood work done, and have you seen by the doctor, okay?

Yes, over there.

Hi there, who’s next? Come in.

I can’t estimate the wait time. Today is very busy. Do you want to see a physician?

Sorry.

Who’s next? Come in.

Do you have a Health Card?

Do you mind taking off your jacket so I can check your vital signs?

Thanks.

What brings you in today?

When did the chest pain start?

Does the pain go anywhere else?

What kind of pain is it?

Heavy?

On a scale of one to ten, if ten is an elephant sitting on your chest, and one is a chihuahua, what number would you give your pain?

Any nausea or vomiting?

Were you sweaty?

Any shortness of breath?

Any weakness or dizziness?

I’m going to to do an electrocardiogram now. Come over here , take off your shirt and lie down on the stretcher, okay?

This will take just a minute.

It won’t hurt.

You won’t get a shock.

Okay, I’m going to bring you in to a bed.

Can you register your husband?

Can you call the doc to Resus 2 stat please?

This is a 53-year-old patient, two hour history of retrosternal chest pain radiating into the jaw and axilla, positive associated symptoms,  ST elevation in II, III and AVF. He’s a bit hypotensive. I’ve called for the doc. Okay?

Hi there, who’s next? Come in.

Nuclear medicine is on the other end of the hospital.

I’ll find a volunteer to take you there.

Thanks. You’re welcome.

Hi there, who’s next? Come in.

Do you have your health card?

Can you take off your sweater? Thanks.

What brings you in today?

What medication?

I’m sorry, the doc won’t renew your prescription for Percocets?

You’ll need to get a new prescription from your family doctor.

Sorry.

I can get you in to see the doctor if you’re having pain, and we can treat that here.

I’m pretty sure any other emerg will tell you the same.

Sorry.

I’m sorry. This is the best we can do

You have to see your GP.

Sorry.

Who’s next? Come in.

Do you have your Health Card?

What bring you in today?

I”m sorry about the wait.

Your family doctor said you would be admitted right away?

The emergency physician will have to see you first.

Do you mind watching your language, and can you please tone it down?

Please don’t swear at me.

Look, I mean it. There are small children in the waiting room.

Can you call security?

Do you mind taking her to the quiet room for a few minutes so she can calm down, and I’ll triage her when she’s settled?

Who’s next? Come on in.

Do you have your health card?

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Three Strikes and You’re Out, and By Out, I Mean Dead

This story was plastered above the fold in yesterday’s print edition of the Toronto Star:

Gleb Alfyorov thought he was going to a hospital for help.

So did the judge who ordered a 30-day psychiatric evaluation of the Pickering teen.

“I want you to be with a team of specialists — nurses and doctors who can meet with you and talk with you about things,” Judge Susan MacLean told the troubled 16-year-old who had been convicted of breaking his older sister’s nose.

That night, a police cruiser dropped Gleb at Syl Apps Youth Centre in Oakville, a jail which was not set up to assess or treat him.

Gleb was strip-searched, interviewed and directed to cell 12. A stunning series of miscommunications kept him from receiving help.

Twenty-nine days later, he hanged himself from a ceiling grate in his cell with his black shoelaces. It was five days after his 17th birthday.

[But go read the the whole thing.]

Essentially, the story tells of a sixteen-year-old boy who had some serious (and undiagnosed) mental health issues and a history of substance abuse. Instead of being properly diagnosed and treated, various experts and professionals handled Gleb Alfyorov like an animal until he finally committed suicide in despair. It is ugly and depressing reading, especially if you’re a health care professional, because it appears, first, that no one bothered to look at Gleb Alfyorov’s chart, and second, no one could be bothered to act as his advocate. It’s pretty clear no one had actual responsibility for Gleb in any meaningful way.

In truth, he had three strikes against him anyway.

He had a  mental illness, and we all know how people with mental illness are valued, even by health care professionals.

He was a drug abuser, and we all know about the perception — and some of us believe it — that drug abusers are  scum and get what they deserve.

He had a criminal record, and criminals are no better than animals. Right?

In short, he didn’t have a chance. To health care professionals, people like Gleb Alfyorov don’t matter much. We might officially protest it ain’t so, but we know it’s true. They aren’t important, and they are a dime a dozen. They’re difficult, hard-ass cases. They don’t have the appeal of breast cancer patients or sick babies. Who really gives a shit, right?

The testimony at the coroner’s inquest will no doubt involve a lot of hand-wringing and complacency at the same time; some will and blame the victim and others will blame circumstance and everyone will avoid anything that looks like the acceptance of responsibility. Witnesses will say “the system” killed him, when in fact “the system” is actually composed of individuals whose action or inaction contributed to Gleb’s death.

When completed, the inquest will recommend some systemic changes which will hopefully improve a deeply awful system. But in the end, I think none of that will matter, until we get it through our thick skulls that young men like Gleb aren’t disposable, but human beings intrinsically worthy of being treated with respect and dignity. And no coroner’s inquest can change that attitude.

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Yep, Still Have A Pulse

My unintentional hiatus will have to continue for a few couple more days, anyway, so apologies to my regular readers and friends. My absence is for reasons I’d love to tell you about, but can’t (damn you, self-imposed anonymity!). Suffice to say work — I’ve been seconded to some administrative-like work, remember — plus some family obligations have rendered me figuratively mute. The end is in sight. Three cheers!

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Happy Canada Day

And all that.  No Cobourg frolic this year, unfortunately, just work, work, work

The dearth of posts the past week is not for lack of trying —  have several rattling around in the draft file, but circumstances — work and family commitments, and also some (usual) nursing nastiness, which I will probably write about in a couple of weeks  —  are keeping me away from the computer. Next week, frankly, doesn’t look any better, but I’ll try. Trust me, being unable to write for a week is leaving me very, very cranky.

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