Archive for November, 2011
Now Winter Nights Enlarge
Now winter nights enlarge
The number of their hours,
And clouds their storms discharge
Upon the airy towers.
Let now the chimneys blaze,
And cups o’erflow with wine;
Let well-tuned words amaze
With harmony divine.
yellow waxen lights
Shall wait on honey love,
While youthful revels, masques, and courtly sights
Sleep’s leaden spells remove.
This time doth well dispense
With lovers’ long discourse;
Much speech hath some defence,
Though beauty no remorse.
All do not all things well;
Some measures comely tread,
Some knotted riddles tell,
Some poems smoothly read.
The summer hath his joys
And winter his delights;
Though love and all his pleasures are but toys,
They shorten tedious nights
— Thomas Campion (1617)
A few days ago, we had VSA come into the department. According to EMS, the patient had collapsed while grocery shopping down the road; CPR was started almost immediately by another shopper; EMS arrived and gave the usual ACLS drugs — epinephrine and atropine, as well as defribrillating him, but the only rhythm showing on arrival was ventricular fibrillation. We shocked the patient again as soon as soon as we offloaded him onto a Resus Room bed — and (somewhat to the team’s surprise) the patient reverted a sinus rhythm with a palpable, if faint, femoral pulse.
Then the real work started to preserve circulation: intubation to manage the airway, peripheral IVs, drips of various inotropes and antiarrhythmics and sedatives to be set up, a central line and central venous monitoring, an arterial line, foley catheter, and (at the same time) beginning the therapeutic hypothermia protocol, to preserve the brain from ischemic injury. Therapeutic hypothermia is itself immensely complicated to implement, involving ice packs, iced saline boluses and iced continuous bladder irrigation to lower core body temperature below 34C.
As we were rolling the patient up to the ICU, I stood outside of myself for moment and thought, “This was all pretty awesome. We have given this poor guy a chance to live. I have a really awesome job.”
And when we transferred the patient into his bed, he began opening his eyes. We weren’t sedating him enough. But that was pretty awesome too.
The flu shot, that is.
I got mine yesterday. And no, I did not get any flu-like symptoms. So get it over it, and go get the shot. Now. Especially if you’re a health care professional. What I wrote during the glory days of H1N1 two years ago still applies:
Finally, I won’t tell you to get the vaccine, because it’s professional, or that the hospital is making you anyway, or because it’s the right thing to do, or because you’re saving yourself the misery of having the flu for a week or two, though these are all more or less valid reasons. However, getting the shot will prevent you from being a complete tool when you pass the virus to someone compromised — maybe even one of your colleagues, a patient or even, God forbid, a loved one — and end up killing them. I think this argument is nearly irrefutable.
So in summary: don’t be a tool. Get the shot.
Don’t make me nag you. Because you know I will.
Meaning me, of course.
I worked a (rare) Night 12 a few days ago. It was the usual dog’s breakfast of high acuity, walking wounded without end lining up at Triage, and the particular Emergency Department hell of having no beds for, you know, emergency patients, the department being a stunt double for a med-surg unit. But there was a small ray of hope. Or rather it was okay news-sucky news situation. We were to get a bed, the element of suckiness resting on the fact the bed was on 5 North, my perennial nemesis, where, I swear, reside the most obstreperous nurses in the history of the Universe.
(Excuses I have heard over the years from 5 North for not taking patients: too busy, patient too sick, patient too combative, patient [with normal vitals] too unstable, patient a drug abuser, patient HIV positive, on break, short-staffed, still on break, patient restrained, patient not restrained, swabs not resulted, patient unsuitable, no one to take report, too close to shift change, just about to go on break, you just sent us a patient, the bed isn’t clean, the patient hasn’t left the bed, the room needs to be cleaned, too late in the night, too early in the morning, the patient will disturb the patient in the next bed, it’s a male bed and your patient is female, still on break — well, I could on.)
So I told the primary RN to call up report. We need to move some patients in.
They won’t take report, came the reply. All the nurses are on break.
“What the hell?!? All the nurses?!?” I was incredulous. “How can all the nurses be on break?”
I called up to 5 North. “Can I speak to the charge?”
“She’s on break.”
“Can I speak to any nurse?”
“They’re all on break.”
“All of them?”
“Who’s looking after the patients?” As one might imagine, I was becoming a little agitated.
“I am,” came the reply.
“Who are you?”
“I am,” said the voice on the other end, “the nursing student.”
Dear sweet Lord, I thought. “Let me summarize,” I said. “You’re looking after 24 patients all by yourself, because all the RNs are on break?”
“Well,” said the student in a tone which made it clear she thought she was dealing with a plain idiot, “there’s a nurse sitting beside me.”
‘”Oh,” I said, thinking I had misunderstood the entire situation. “Can I speak to her?”
“No! She’s on break. I told you”
After which I lost it, just a bit. “So when your patient in 55 falls out of bed and fractures her hip because she’s been ringing the call bell for fifteen minutes because you’re trying to clean up the patient in 37, what are you going to do?”
“Oh, I’ll call the nurse to help.”
“But she’s on break!” I was nearly shouting.
Click. The student hung up on me.
Well, I thought. That didn’t go well. But then, after I went home and thought about it, wasn’t I guilty of the same bullying behaviour towards this student I have written about so critically? I heard afterwards I had reduced her to tears. Didn’t this make me the poster child for nurses eating their young? The student, after all, was not responsible for being placed in an compromising position, and being made to run interference against a nasty ED nurse (i.e. me) was fairly despicable. I should have recognized the circumstances and adjusted my own response accordingly — regardless of who answered the phone. In the heat and stress of the moments it’s all too easy to engage in awful behaviour and justify our bullying afterward in terms of providing good care or best practice. It’s all a lie. There isn’t ever justification for bullying. All I can say in my defence: I’m a work in progress. Like everyone
[Update: Yes, I misspelled “construction” in the title. I need a sub-blogger minion to proofread.]
Posted by torontoemerg in Health, I'd Better Feel Sorry for Myself 'Cause No One Else Will, Life in the Emergency Department on Monday 07 November 2011
In the Emergency Department, part of a nurse’s job in discharging patients is to figure out if they are good to go home, because in part it’s good nursing practice, but mostly you don’t want to have them bouncing back in a few hours because they didn’t understand something, or have a question. So you eyeball them, do some health teaching, review their prescriptions and follow-up, tell them when and if to come back — and assess their pain. This past week I’ve had five patients — all male, incidentally — who needed scripts for stronger analgesia than what is sold over-the-counter. The doc had overlooked this aspect of their care of them were reluctant to ask for good analgesia directly from the physician. They didn’t want to be seen as being unable to handle the pain. They all ended up with scripts after I advocated for them.
A few days ago, I had a very minor, but enormously painful procedure performed for a notoriously uncomfortable condition in my local (but not my) ED. I got handed a script, and when I was leaving when I noticed the physician neglected to prescribe any analgesia. Percocets or even Tylenol 3 would have been appropriate.
I pondered, briefly, whether I should ask for painkillers. I decided no. I was embarrassed to ask. I didn’t want to be labelled as drug-seeking. The sequel is now I am taking far too many 222s (ASA, codeine and caffeine) and Tylenol 1 than is really good for me (both of which can be gotten over-the-counter in Canada) and also Advil than is really good for me, and I still don’t have good pain control. Though I am feeling pretty spinny from all the caffeine in the 222s and T1s.
Barrier to care, anyone?
Sad to say, nurses and physicians in the Emergency Department still tend to manage pain like every patient is drug-seeking, or will become addicted or else is exaggerating their pain to so they get the “good stuff”; we eschew measurements like self-reported pain scales, instead relying on our highly subjective and unreliable judgment about whether the patient is actually in pain or about the patient’s relative worth. (I have witnessed physicians withholding narcotics from drug-addicts with large bone fractures. Ha ha, take that, you addict! I have also seen orders for morphine 1-2mg q4h for sickle-cell crisis — which, to my mind, manages to be racist, bad practice and plain awful, all at the same time. ) We disbelieve reports of chronic pain. We laugh when a patient presents with back pain and is taking Lyrica. We believe deeply as a culture that suffering somehow ennobles, but in reality only thing suffering does is make people suffer.*
It strikes me that even after
years decades of education about pain management, we still don’t really get it about pain control. If a crusty old emergency nurse like me worries about being labelled as DSI* for asking for ten Percs, do you think there might be something seriously wrong with our approach to pain management?
*I have yet to meet the patient whom overwhelming pain has made into a better person.3.
I swear Allie Brosh has channelled everyone who has ever suffered depression in this brilliant webcomic. Including me. Check it out by clicking on the graphic or the link.
I am really pleased to offer another poem by Michèle Katrina Thorsen. I have a couple more to offer over the next while.
my dreams of your recovery
at last disbelieving the
roar of medical swank;
the unraveling, dazzling myth
of an exquisite,
— Michèle Katrina Thorsen
If you work in the North, you’re familiar with the scene: patients in gowns, riding wheelchairs and trailing IV pumps scrambling over snow banks and icy walkways and braving frostbite-inducing winds to get off hospital property to have a smoke. I suppose for most of my readers, the image will induce a great big “Meh.” But a new article in the Canadian Medical Association Journal suggests otherwise, and that smokers who need to exit the hospital to smoke face special risks and little support in managing their addiction. Money quote:
Study findings affirm evidence that tobacco dependence treatment is inconsistently offered in hospitals and heath providers were uninformed about tobacco dependence treatment, despite availability of nicotine-replacement therapy at study sites. This treatment gap is perplexing, especially as within Canada there exists an evidence-based hospital tobacco dependence treatment program. Unintended patient safety consequences of smoke-free property necessitate effective tobacco dependence treatment during a stay in hospital simply as a risk-management action. Moreover, a health-promoting policy that causes patients to face diverse safety concerns (treatment disruption, infectious disease contact, exposure to adverse weather and possible violence) projects a contradictory health message.
Not helping, of course, are the usual (and sometimes, let it be said, judgemental) opinions of heath care professionals who view smokers adversely and see them as the authors of their own problems.* They tend to take the somewhat cavalier position that if smokers want to go outside for a cigarette, well, that’s their lookout. Elderly woman who falls on ice and fractures a hip while out for a puff? Hell, she brought it on herself by smoking! But is it actually humane to send sick people to the curb in the winter to tend to their addiction? Is it consistent with good nursing practice? And what about the liability and duty-to-care?
*I will never forget the physician who told a young, pain-wracked lung cancer patient that she was responsible for her suffering, and that she should go home and “deal with it.” But some HCPs like to play the blame game in general and especially with patients with addictive behaviours.