Archive for October, 2011

All Nurses Are Not Equal

My best friend Reid made an interesting point the other day. “I have,” she said, “an alphabet soup of certifications. I have ACLS. I have BCLS. I have TNCC. I have ENPC. I have pieces of paper that tell me I can run traumas and defibrillate people. I have critical care courses up the wazoo. Some of these things I paid for on my own, because I wanted to improve my practice and give better patient care. So,” she concluded,”why the hell am I being paid the same as the med-surg nurse upstairs who has none of these?”

Good question. In Ontario, at least, the nurses union — ONA — has decreed that all nurses are equally qualified to work in every setting, and are interchangeable in terms of duty and practice. It’s a very pretty idea, but theoretically and practically speaking, it’s rubbish. Floating a med-surg nurse to the ED is a College of Nurses complaint waiting to happen. It’s dangerous for both patients and for nurses. Even ICU nurses have trouble coping in the ED setting (but for some reason, in my experience, the reverse isn’t as nearly as true.) The difference, I would argue, is not in the provision of basic nursing care or even the intent to provide good patient care but in skill sets, critical thinking and training. Emergency nursing, like any other high-acuity nursing speciality, requires considerable initial and ongoing education, but also, it’s important to remember, has a much higher standard of practice and responsibilities.

Further the lack of any differential in pay according to training/certifications acts as a disincentive for nurses to continue their ongoing education. For example, the fee for the Trauma Nursing Core Course (TNCC) is sometimes, but not always, paid for by hospitals, but in any case, there is no real recognition of nurses completing the certification. So apart from professional pride, why do it? Appeals to professionalism are a bit naïve and idealistic, and only go so far. If you can encourage any nurse to upgrade their skills and education by offering pay differentials, I would be for it. Better educated nurses with better skills and better critical thinking skills means better patient care, better outcomes and ultimately, higher nursing morale. The myth that all nurses are created — and remain — equal has to go.

 

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Page 23

A cool take down of the consumerism and the scarcely vocalized passions lurking in every IKEA catalogue.

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Where Breasts Meet Art


Breast casts of various celebrities customized and tarted up by artists (more breasts here) to be auctioned and proceeds going to the Keep-a-Breast Foundation, a charity which promotes breast cancer awareness. The charity has been in the news lately because assorted fuddy-duddies principals and school boards have banned students wearing  the charity’s “I ♥ Boobies” bracelets as a distraction. [Via.]

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Favourite Poems XLII

Two poems on the theme of Autumn.

Autumn Valentine

In May my heart was breaking-
Oh, wide the wound, and deep!
And bitter it beat at waking,
And sore it split in sleep.

And when it came November,
I sought my heart, and sighed,
“Poor thing, do you remember?”
“What heart was that?” it cried.

— Dorothy Parker

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To Autumn

O Autumn, laden with fruit, and stain’d
With the blood of the grape, pass not, but sit
Beneath my shady roof; there thou may’st rest,
And tune thy jolly voice to my fresh pipe,
And all the daughters of the year shall dance!
Sing now the lusty song of fruits and flowers.

‘The narrow bud opens her beauties to
The sun, and love runs in her thrilling veins;
Blossoms hang round the brows of Morning, and
Flourish down the bright cheek of modest Eve,
Till clust’ring Summer breaks forth into singing,
And feather’d clouds strew flowers round her head.

‘The spirits of the air live in the smells
Of fruit; and Joy, with pinions light, roves round
The gardens, or sits singing in the trees.’
Thus sang the jolly Autumn as he sat,
Then rose, girded himself, and o’er the bleak
Hills fled from our sight; but left his golden load

— William Blake

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“We Will Now All Be Unwilling Participants in a Social Experiment That Will Undoubtedly Place Canadian Lives at Risk”

My thoughts exactly, from Alan Drummond of the Canadian Association of Emergency Physicians. His full statement on the proposed repeal of the Gun Registry.

It is regrettable that we, as a nation, are about to embark on an unwelcome social experiment. The Conservative government has been very clear that they intend to finally abolish the gun registry. This is regrettable in so far as it is clear to Canada’s emergency physicians that the gun registry has, in fact, worked and the number of deaths from inappropriate firearms use has dropped dramatically since the institution of the Firearms Act. The government has consistently portrayed this act as a victimization of rural long gun owners, conveniently ignoring the clear scientific evidence that rural suicides with long guns are the principal issue in the tragic toll of Canadian firearms deaths. So we will now all be unwilling participants in a social experiment that will undoubtedly place Canadian lives at risk. Our question to our government is that relative to the perceived inconvenience and cost of registration, what will be the true cost, in direct human suffering, of their ideologically driven and scientifically bankrupt legislation.

Some inconvenient statistics, nicely compiled by the CBC:

Homicide by firearm
Firearm homicides, 2009: 179 (0.53 per 100 000 or about 30% of all homicides)
Firearm homicides, 1991 (the year stricter gun control was introduced):271 (0.97 per 100 000 people)
Types of firearms homicides, 2009:
Rifles or shotguns: 18% (36% in 1999)
Handguns: 69%
Prohibited firearms: 13%
Since 1995, when the gun registry became law, until 2009, the reduction in homicides by long guns: 52%
Spousal homicides caused by shootings, 2000-2009: 167 (23%)
Reduction in the rate for spousal homicides involving firearms from 1980 to 2009: -74% from nearly 3 per million spouses in 1980 to less than 1 per million spouses in 2009, according to Statistics Canada
Share of firearm-related spousal homicides involving a long gun: 50%(The rate of long-gun spousal suicides dropped about 80% between 1983 and 2009.)
Share of family-related homicides of children and youth (7 to 17 years), by shooting, 2000-2009: 26%
Of the last 18 police officers killed in the line of duty, as of August 2010, number killed by long guns: 14 (78%)
Suicide by firearm
Number of firearm-related suicides involving a long-gun, 2004: 475 ( 5.4 times the number of suicides with handguns)
Change in number of firearm-related suicides since the introduction of stricter gun laws in 1991 (as of 2009): -43%
Change in number of firearm-related suicides since the introduction of the Firearms Act in 1995 (as of 2009): -23%
Increased likelihood that a home where there are firearms is the scene of a suicide, than a home without a gun: 4.8 times (based on a 1992 U.S. study in the New England Journal of Medicine)

Incidentally, for you fiscal conservative types, the cost of treating a gunshot victim is about $450,000.

So, on one side of the debate, we have scientific and statistical evidence on the efficacy of the gun registry, expert opinion from health care professionals and the police, the physical and emotional cost of trauma, hundreds of deaths prevented and, on the other side, the hurt feelings of rifle owners. That’s pretty well what it boils down to, right?

[Update 29/10/11: Fixed formatting problems.]

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On the Gun Registry

Some people who have never seen a gunshot wound to the face

Globe and Mail headline: “End of long-gun registry seen as victory in war on Big Government.”

The headline could have just as easily read, “Government wants to kill Canadians to make Lanark County gun owners happy.”

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Watching Your Employees Die Gets You -1,000,000,000 Karma Points

This is pretty appalling. Actually no. It is un-freakin’-believable:

Last month, Julia’s daughter, Vianney, buried her mom, after the 67 year old woman died Sept. 8th at her desk, at Time Warner.
“She went to Time Warner and didn’t come home,” said Vianney.
What Vianney didn’t know, is that more could have been done, to save her mother’s life.
Garfield Hts. paramedics rush to the Time Warner Call Center off McCracken around 3 PM that day.
Meantime, as Nelson lay slumped at her desk, a fellow employee begins CPR but records confirm, when EMS arrives, the patient is not breathing and contrary to red cross training, CPR is no longer being performed.
So why did the employee stop CPR? well, we tracked her down. She wouldn’t go on camera, but what she told us on the phone is shocking.
The women tells us, and other employees confirm, that a supervisor ordered her to end her life saving efforts, and “get back on the phone and take care of customers.”

What’s worse, there was an Automatic External Defibrillator device close by, in a locked room, and the only person who had the key was out of the building. Time-Warner, the employer, stated they “responded appropriately to a medical emergency. Our company has procedures in place to respond to emergencies.” Evidently, at Time-Warner, “appropriate procedures” include standing by idly and watching people in cardiac arrest die and keeping AEDSs in locked rooms so no one can use them. But there is a silver lining. At least customer service was good.

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Sometimes Things Ain’t What They Seem

Niagara Health is taking a beat down lately. First it was an uncontrolled C. difficile outbreak, then a provincial administrator was appointed to deal with the outbreak, and now this:

When Doreen Wallace fell and broke her hip in the lobby of a Niagara Falls hospital, she figured at least she’d get help — and fast.
But that’s not what happened.
Instead, the 82-year-old Wallace — who was leaving with her son after visiting her dying husband at Greater Niagara General Hospital on Oct. 8 — was told by staff no one could help her until an ambulance was called.
To a hospital.
“It was horrible. It really was. Everybody who walked through the door stopped and stared at me,” said Wallace, who already had a broken arm from a previous fall. She ended up spending almost 30 minutes on the ground.
“I was inside the hospital. Why did they have to wait for an ambulance to come and pick me up?”
As she lay face down on a metal grate, her right arm slashed, a security guard called for help and two nurses from the emergency room came over. But Wallace’s son said they refused to help until paramedics arrived.
“I was floored,” said Mike Wallace. “We’re probably, maybe, like a 50-yard walk, literally, down to the emergency department.”

Almost predictably, Christie Blatchford weighed in, in the context of the stupid unthinking column I wrote about yesterday.

It’s an absolute given: With the great mass of Baby Boomers getting old, we too will weaken, grow frail and fall upon the mercies of the already badly faltering health care system. That system — what an amusing moniker that is for a bizarre and impenetrable collection of flourishing bureaucracies – does not change. It does not have the institutional equivalent of a “heart”; it does not learn from past mistakes; it does not respond to terrible plights; it does not bend.
There are already examples galore — just one the case of 82-year-old Doreen Wallace, who this month was leaving a Niagara Falls hospital where she was at her dying husband’s bedside, when she fell in the lobby and was left there, with what turned out to be a broken hip, face-down on the floor because 911 had to be called and an ambulance dispatched.
This had happened at this particular hospital several times before, where emerg staff seem to have a devil of a time treating anyone who doesn’t arrive by ambulance; it is contrary to hospital policy that it should happen; yet nothing seems to change.
I know what I’d do — fire the asses of anyone remotely involved in the decision that Ms. Wallace wouldn’t be seen unless she arrived the proper way. But that won’t happen.

Funny thing, this happens fairly often, and it’s a bit more complicated than you might think. Elderly hospital visitor falls down, goes boom. Someone says, “Let’s call those all-competent emerg nurses, they’ll know what to do,” ED nurse arrives, and the first thing she thinks about is c-spine protection as part of the ABCs. The point is, you just can’t simply move a patient who has fallen from standing height without protecting their neck. Especially elderly women, whose bones tend to break like eggshells. The result from moving a patient precipitously could be catastrophic if they have a cervical spine fracture. Patients in these situations need to be immobilized, which requires special training and equipment. (I’ve been trained how to immobilize necks, but that is by no mean true of all ED nurses. Or physicians, for that matter. In any case, I don’t do it often enough to be an “expert” practitioner by any means.)

Blatchford’s implication that hospital staff stood by callously and incompetently — her perennial complaint and modus operandi — is deeply unfair. If you don’t have trained staff or an available spinal board, the way give the best patient care is to call the paramedics, who are trained and have the equipment to offer c-spine protection. (In any case requiring spinal immobilization, I would defer to EMS without thinking twice.)

Or to put it another way, do you really want a porter (or whoever) scooping an elderly visitor into a stretcher and racing down the hallway to the ED for the sake of appearances (and drama, I might add) without knowing whether she has any c-spine trauma? The first rule of health care, after all, is to do no harm; on balance, it’s probably better to wait thirty minutes in relative discomfort (for the patient) for a paramedic with a spinal board, than face permanent paralysis or even death. The staff at Niagara Health probably made the best possible decision given the circumstances.

Granted, there’s the question of whether hospitals should provide the training and equipment so nurses can manage visitors who fall or otherwise injure themselves in public areas of the hospital. I would argue strongly yes. But I think that’s a separate discussion, involving prioritization and spending in an era where every health care nickel is being squeezed for the best possible value. Niagara Health could have done better, certainly, but not for reasons that Blatchford, or the rest of the media for that matter, imagines. Maybe she needs to, like, speak to an Emerg nurse or physician before rushing to conclusions.

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Says Blatchford, First We Shoot All The Nurses

I actually did a double take, and my jaw dropped, slightly when I read this:

It’s why, where I used to think that before I got really old I’d get me a gun so I could shoot myself, I now wonder if I won’t instead turn the weapon on some officious hospital executive, wanker bureaucrat or brute of a nurse.

Yes, it’s Christie Blatchford in her latest National Post column, taking her Canadian-health-care-is-the-Fifth-Horseman-of-the-Apocalypse shtick to new heights. It’s pretty tiresome, and a bit tasteless, given the high rates of violence nurses experience.

One also gets impression that Blatchford’s knowledge and experience of nurses and nursing runs in a straight line from Cherry Ames, Student Nurse to Nurse Ratched in One Flew Over the Cuckoo’s Nest to Annie Wilkes in Stephen King’s Misery. Funny how a self-proclaimed straight-shooting iconoclast ends up reinforcing predictable cultural stereotypes.

But let’s assume Blatchford’s hostility and ignorance isn’t willful. Maybe she really knows squat about nursing. I am willing to have her shadow me for a day in my emerg, under two conditions: first, she works the entire 12 hour shift, and second, she sits when I sit. Seriously, Christie, email me.

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Death to PowerPoint and Other Notions

Back again.Yeah, I’ve been away for a while, for reasons that have absolutely nothing to do with writing or blogging. However my unintentional sabbatical has had the benefit of leaving me refreshed and full of ideas and so maybe wasn’t such a bad thing after all. I mean, in the two years I have operated this blog, I’ve written something close to 700 (!) posts, so maybe a break was in order before my brain turned into cranial equivalent of this.

So what have I been doing? A little of this and a little of that, but mostly working at the administrative-type secondment I’ve been assigned to for the past few months. I’ve worked closely with a group of other nurses, which I have been thinking lately resemble the Seven Dwarves. Their names are Pouter, Shouter, Passive-Aggressive, Bashful, Grumpy, Beautiful, Grandma, and of course, we have a Princess as well. (There isn’t an Evil Queen, though I don’t exclude the possibility I may in fact be that person.) Beautiful and Grumpy I don’t see much, and in any case I like and get along with them. Ditto Bashful, Grandma, and Passive-Aggressive. Princess behaves, well, like a princess though she has children old enough to be in university. But she’s a likeable sort and always means well. Pouter is irritating me all to hell; she’s pouting because I, um, spoke harshly to her friend Shouter, who walks around rigidly and inflexibly, like an angry exclamation point.

Shouter is generally tiresome to deal with, to the point where everyone tends to avoid conversation with her — which of  further angers her and makes her even more rigid and inflexible. Also, I don’t exactly like her (though Lord knows I’ve tried) and the feeling is even more reciprocal on her part. Not very constructive, I know, but I’ve concluded that not every relationship needs to be “fixed” — and frankly, this one ain’t worth the time and effort.

All in all, the work is fascinating, but I will be very glad to finish. I am beginning to think I get along better with the cat than I do with most people.

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What else? A few interviews for other, more managerial positions, which in the inimical manner of Acme Regional’s Human Resources Department, have evidently fallen into the Hell of Waiting for an Answer. “Oh,” they say, “we’ll contact you in a few weeks.” I am not sure what machinations HR needs to carry out to spit out an answer, but there it is.

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Death by PowerPoint. I gave my very first PowerPoint presentation to an enthralled group of colleagues on the topic of sepsis, which my employer has discovered to be the worst threat to patient satisfaction metrics since inedible hospital food. (Seriously. One of the reasons given for beating down sepsis rates at Acme Regional is “to increase patient satisfaction.” And here I thought “Not Dying” was sufficient enough.)

This was my presentation, in thirty-three PowerPoint slides:

Sepsis is very bad and many people die from it. We at Acme Regional, in an effort to be accountable and responsive to patient concerns, are determined to crush sepsis like mice under a stampede of rhinoceroses. In history, sepsis was discovered by Louis Pasteur. He was French. Other French people include Charles de Gaulle and Victor Hugo. They died of something else. In conclusion, not all French people die of sepsis. Thank you.

It actually went very well, I didn’t hardly talk about coagulation cascades and endothelial function, and people were very impressed, etc., and asked pertinent questions at the end like they had paid attention. I was pleased. Having sat through approximately a billion PowerPoint presentations in my nursing career, I have come to the conclusion the key for effective presentations involve three simple rules:

1. Less is more.

2. Speak to the slides, not read the slides. (Your audience is literate, right?)

3. Avoid pathophysiology like Yersinia pestis.

Or else, you can can check this out for good measure.

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