Archive for category Before I Start Throwing Things, I'd Better Write This Down
Posted by torontoemerg in Battered Nurse Syndrome, Before I Start Throwing Things, I'd Better Write This Down, When the Health Care Corporation Speaks on Monday 14 May 2012
More on the Texas hospital, Citizens Medical Center, which banned fat people from being hired. Citizens Medical Center, you might remember, made it policy to exclude new hires with a body mass index >35, and explicitly stated employees appearance should “fit with a representational image or specific mental projection of the job of a healthcare professional . . . free from distraction” for patients. Medscape has a video (sorry, couldn’t figure out how to embed) from a medical ethicist named Art Caplan with another point of view. Partial transcript:
Look, I’m all for trying to set a good example and I think there are plenty of businesses where being thin and being in shape really do matter. I guess if you run a modeling agency it is very important. But I’m not convinced, really, that putting in weight restrictions is the best idea in terms of sending out the right message or a necessary message to patients. Patients, I think, can work with their doctors to try to overcome common problems. Doctors see all kinds of patients with all kinds of habits and all kinds of lifestyles. I think patients can deal with seeing all kinds of healthcare workers with all kinds of habits and all kinds of lifestyles. If they want a thin one, they should be able to pick one, but I don’t think the hospital necessarily should have to say that only the thin ones can work here. [Emphasis mine.]
Really? That last bit sounds needlessly, well, stupid. Does he really think patients should be allowed to choose their health care providers on the basis of their appearance? “Let’s see. . . ” one can imagine patients musing, “that nurse is too fat. Tht nurse is too old. That nurse is too. . . dark. That nurse is too male. That nurse is too Muslim. That nurse is too gay.” And so on. Apart from fostering bigotry and discrimination, and demeaning and devaluing staff, in practical terms, you’d soon run out of nurses. I mean, not every nurse looks is thin, white, young and female.
One more thing. I understand there is a role for hospital policies regulating appearance: hygiene, facial hair, tattoos, uniforms and jewellery are usually targeted. Fair enough. I also understand the need for an ethicist to weigh (so to speak) both sides of the issue, but isn’t there some point where, after all is said and done, you have to say evaluating people of the basis of their body characteristics in general is just wrong? I don’t think that medical ethicist Art Caplan exactly said it was wrong. Making a value judgement, that employers treating nurses and physicians as human beings with inherent dignity and worth, is important. It might even be a good place to start.
[UPDATE] Also, too, these thoughts from a writer named Susan Pape at Policymic.com:
When I am in need of hospital care, I want the staff to be the best, hardest working, most talented, most caring available. I do not care if they are overweight. Employing health care providers on the basis of their competence is a matter of life or death …to me.
Obesity is not a choice, and it is not immoral.
Posted by torontoemerg in Before I Start Throwing Things, I'd Better Write This Down, Good Nursing Practice is Practising with the Heart and Mind, Nurses Behaving Badly on Tuesday 17 April 2012
Why does any discussion of breastfeeding makes people a little insane? I don’t exclude myself: even I get a little agitated. Here are some examples of what I mean:
Exhibit A: a recent post on breastfeeding at KevinMD.com sparked a small flame war in the comments. Barbara Bronson, an RN wrote there:
And guess what? Our kids — now in their twentie [sic] – turned out just fine. They have no allergies. They are smart. They’re not fat. They’re healthy. They are kind, and funny and athletic, and you couldn’t pick them out in a crowd. But if you read some of the research and most of the women’s magazines, you’d think we’d be hauled in for heresy for disclosing this seldom-talking-about fact: in the end, whether you breast-feed or you bottle-feed, no one — not even a physician, a nurse, a teacher or a psychologist – will ever be able to tell the difference.
So that’s why I was pleased to see the World Health Organization announce that although they recommend breastfeeding for the first six months of life, they say it may not be a realistic option for many. The report was published online March 14, 2012 in the BMJ Open.
The curious thing about this particular post is that it almost completely misrepresents the British Medical Journal article cited above. The BMJ article suggests an idealistic public policy approach to breastfeeding may be counterproductive — and only dealt with new mothers in a developed country. Bronson’s post managed to turn this important study into a disavowal of the World Health Organization’s breastfeeding guidelines. Of course, it said no such thing. (A far more accurate take on the BMJ article can be found on the Breastfeeding Medicine blog. Or just read the damn thing.) Not that is matters much: the debate degenerates into bomb-throwing between pro-formula-you-lactivists-are-Nazis and breast-is-best types. Who cares about the science, anyway — it just gets in the way of anecdotes and feelings.
(Yes, I am annoyed.)
Exhibit B: a city ordinance in Seattle protecting the rights of neonates to breastfeed publicly causes distress for those who prefer breastfeeding mothers to be unseen and unheard:
“We need to get to the point where breastfeeding is accepted by everybody,” said Schwartz of the Breastfeeding Coalition. Although businesses that break the law can face fines, she said the main goal was to educate people and change attitudes.
“It’s feeding your baby for heaven’s sake,” she said.
But advocates will have to overcome an ingrained hostility, as seen oozing in the comments on a KING/5′s story on the breastfeeding bill.
“Wanna feed your kid, great feed your kid, just don’t put up a bill board (sic) pointing to your saggy udders trying to get some attention,” wrote “freedomfrank” on the site.
“As far as I’m concerned, women with babies can get the (hell) out of any restaurant I’m in if they want to breast feed,” another commenter wrote. “You’re not special and we don’t give a rip that you have a baby.”
One woman wrote that she supported breastfeeding – had nursed her own kids – but just didn’t like it in public.
“I do not want to watch you when I am trying to eat or walking in the mall with my teen son,” she said.
Exhibit C: suffer not the little children unto me. Rachel Stone writes:
When he was one year old and decidedly cherubic—with chubby pink cheeks and golden curls—my family visited Rome, and, of course, Vatican City. I was prepared with skirts and modest tops for visiting St. Peter’s, but I hadn’t considered for a moment that breastfeeding might break the rules of modesty. So when my little cherub was hungry, I settled cross-legged in a corner, in sight of Michelangelo’s Pieta—that haunting sculpture where Mary cradles the broken body of her Son—and began to nurse, identifying, maybe for the first time, with Jesus’ mom as I cradled by own boy.
Seconds later, a uniformed guard came along, slapping his chest and saying, emphatically, “Latte, latte!? Latte? Uh, downstair! Uh, da batroom!” Of course: he wanted me to go breastfeed in the bathroom. Because nursing my son in that space was equivalent to a plunging neckline or a miniskirt.
All of this makes me a little crazy for the sheer stupidity. However, I get there is some deep cultural
resistance antipathy to breastfeeding in the West and particularly in North America. I happen to think this ambiguity — where Facebook bans pictures of breastfeeding but permits hypersexualized pictures of busty women — is utterly idiotic and tied up in some bizarre societal notions about breasts and sexuality, but I understand that others’ mileage may vary.
I get that nurses, midwives and other healthcare providers haven’t been the best at times supporting and encouraging new mothers to breastfeed. We nag, hector and finger-wag when we should be providing support and empathy.
But still, for all of that, breastfeeding is undoubtedly the best choice for most women and neonates. Yes, there are exceptions: neonates who can’t or won’t nurse, or physical, health or social/economic problems preventing the mother from nursing. But really, are theses exceptions so numerous to recommend formula as the equivalent choice for all neonates? To use an analogy, gold standard treatment for pneumonia is the prescription of antibiotics. Does the standard change because a few might not tolerate the drugs? It bothers me more than a little the nurse mentioned above would suggest bottle and breast are equivalent, whatever her own personal experience.
Something else which makes me unhappy: how the debate around breastfeeding is almost always framed from the perspective of middle-class women from developed countries like the U.S, Canada or Britain who have the resources to consider formula as a viable option. For most of the world’s women, the sheer logistics of bottle feeding are not feasible or realistic. These include consistent access clean water, soap, a stove, fuel, education, and nurse/midwife support, the formula itself and other supplies, or the money to buy it. According to the World Health Organization:
When infant formula is not properly prepared, there are some risks arising from the use of unsafe water and unsterilized equipment or the potential presence of bacteria in powdered formula. Malnutrition can result from over-diluting formula to “stretch” supplies. Further, frequent feedings maintain the breast milk supply. If formula is used but becomes unavailable, a return to breastfeeding may not be an option due to diminished breast milk production.
For many, if not the majority of women in the world, and especially the poorest, there is no option but breastfeeding. We should probably bear this in mind when discussing how “realistic” the WHO guidelines are.
Warning: my semi-annual politicalish post. When I read this, I admit I gawped:
$26,659: Our 2011 Medical Expenses
Yes, you read that right. And we had insurance coverage for everyone last year, including daughter, 16, and my son who is 23 years old. Let me break it down for you:
- Insurance Premiums……………..$14,179.04
- Prescription Costs…………………$ 7,198.00*
- Doctors Fees, etc…………………$ 2,068.49*
- Eye care……………………………..$ 404.28*
- Dental………………………………..$ 2,752.00**
- Mileage……………………………….$ 300.00
* Costs in excess of insurance coverage.
** No insurance coverage.
Our medical costs in 2010 were $18,636. The principal reason why our medical expenses in 2011 increased by such a large amount was because our insurance premiums increased from roughly $7,000 in 2010 to over$14,000 in 2011.
This same crappy, expensive health insurance will likely be cancelled because my wife’s former employer has filed Chapter 11 bankruptcy and has filed a motion with the bankruptcy court to cancel all medical benefits for retirees and their families. My wife is classified as a retiree because she became disabled as the result of her pancreatic cancer, and the surgical chemotherapy and radiation treatments she received in 2006, and was unable to return to work. The story of her disability is described in detail at this link. Fortunately she is covered by Medicare, but we will lose even this crappy insurance coverage for myself, my daughter and my son.
I have a rare autoimmune disorder that unfortunately was not properly diagnosed until after the time had passed for me to file a disability claim with Social Security. Thus I am not eligible for disability benefits or Medicare. New York has a program for younger children that my daughter for which my daughter might qualify.
Because the insurance exchanges required under the Affordable Care Act will not go into effect until 2014, it is unlikely that my son and I can find insurance until then, assuming that the Supreme Court doesn’t find the ACA unconstitutional.
Basically one large every two weeks for medical expenses. Can any American defender of the status quo tell me why this isn’t completely insane and morally bankrupt? Or any Canadian admirers of U.S. health care — I know you are out there — tell me why the American system is superior in the fair and equitable provision of health care?
Posted by torontoemerg in Before I Start Throwing Things, I'd Better Write This Down, Good Nursing Practice is Practising with the Heart and Mind, Life in the Emergency Department on Monday 02 April 2012
I found this story how a homeless woman died very disturbing:
Anna Brown wasn’t leaving the emergency room quietly.
She yelled from a wheelchair at St. Mary’s Health Center security personnel and Richmond Heights police officers that her legs hurt so badly she couldn’t stand.
She had already been to two other hospitals that week in September, complaining of leg pain after spraining her ankle.
This time, she refused to leave.
A police officer arrested Brown for trespassing. He wheeled her out in handcuffs after a doctor said she was healthy enough to be locked up.
She told officers she couldn’t get out of the police car, so they dragged her by her arms into the station. They left her lying on the concrete floor of a jail cell, moaning and struggling to breathe. Just 15 minutes later, a jail worker found her cold to the touch.
Officers suspected Brown was using drugs. Autopsy results showed she had no drugs in her system.
Six months later, family members still wonder how Brown’s sprained ankle led to her death in police custody, and whether anyone — including themselves — is to blame.
There seems to be no simple answer.
Actually there is a very simple answer. At some point in her care, a nurse or physician decided Anna Brown deserved to die. I don’t mean literally a health care professional wrote Anna Brown’s chart, “This patient deserves to die.” But someone decided — a nurse, a physician, or maybe it was a collective, Emergency Department judgment — that because Anna Brown was homeless, because she was black, because she was poor, because she had made multiple visits, because she was still in pain, because she advocated for herself by making a fuss, because she possibly had (undiagnosed) mental health issues, she was not entitled to proper care.
She was labelled. She was drug-seeking. She was crazy. She was a frequent flyer. And that killed her as surely as if a nurse had bolused potassium chloride.
I will tell you why I think this is true. Because Anna Brown had made repeated visits, and no one took her seriously. Because she told staff about her increasing pain, and no one believed her. Because she was unable to walk, and no one thought to ask why. All of these are enormous waving red flags for any emergency department health care professional, and neither physician nor nurse did anything about them. That’s the thing about labels: they contain their own little subjective judgements about patient care, and obscure the obvious.
If Anna Brown had been a middle-class white woman with a nice home, a job and a car, I am willing to bet — no, I know the outcome would have been different — or at least, she would not have died, gasping for air, from a pulmonary embolism on a cold jailhouse floor. There certainly would not have been any of this Kafkaesque horror of being in obvious distress with a deep vein thrombosis, about to throw a clot, and being utterly unable to get help at the very place where you might expect it.
I will let the public in on a little secret. We all do it. Each and every one of us. I don’t exclude myself. We all label patients. It is deeply embedded in the culture of health care to the point where it is an accepted practice. We all call patients drug seeking and crazy and frequent flyers and failures-to-die and failures-to-cope. We laugh at them. Hell, there are whole blogs and books devoted to the art of ridiculing patients we have already labelled. (Though when you think about it, there is nothing quite as charming as making fun of human beings who are powerless, is there?) Has any one ever thought labelling patients might cloud and impair clinical judgment? Or that it dehumanizes patients and is just plain wrong?
But the way Brown died was not the result of a few bad choices. It was the result of a myriad of institutional violences: white supremacy, the broken health care system, police brutality and the prison industrial complex, the racism and classism of the child welfare system, ableism and its intersection with racism, dehumanization and criminalization of (suspected) drug users, and the lack of housing as a human right, among others. Anna Brown did not die with the dignity we afford to human beings, but with the contempt we reserve for garbage. And a woman’s humanity is not just forgotten and cast aside with no systemic reason.
Don’t think I have much to add.
[UPDATE: A long time reader suggests instead of the word label, I should use "profile," as in "racially profiling." Once upon a time I might have thought the word unnecessarily inflammatory --- but now I am not so sure.]
[UPDATE II: Small corrections to syntax. Hobbit not cooperating.]
- Surveilling the Death of Anna Brown (bagnewsnotes.com)
Posted by torontoemerg in Before I Start Throwing Things, I'd Better Write This Down, Health Care, Health Care Policy That Matters to Nursing, If You Gonna Have a Circus, You Gotta Have Elephants, Random Thoughts on Friday 17 February 2012
A Republican supermajority has muscled two of the most restrictive anti-abortion bills in years through the Virginia House, despite bitter yet futile objections from Democrats, with one GOP delegate deriding most of the procedures as “matters of lifestyle convenience.”
And the ultrasound legislation would constitute an unprecedented government mandate to insert vaginal ultrasonic probes into women as part of a state-ordered effort to dissuade them from terminating pregnancies, legislative opponents noted.
“We’re talking about inside a woman’s body,” Del. Charnielle Herring said in an emotional floor speech. “This is the first time, if we pass this bill, that we will be dictating a medical procedure to a physician.”
The conservative Family Foundation hailed the ultrasound measure as an “update” to the state’s existing informed consent laws “with the most advanced medical technology available.”
The Oklahoma legislature passed a similar law a couple of years ago. Full disclosure, in case you didn’t know it: I dislike abortion, but I’m strongly pro-choice. Even if you are strongly against abortion on moral or religious grounds, I would like to know how a medically unnecessary, coercive, invasive procedure can be ethically justified in order for a patient to receive health care? (I think we can safely dismiss the Family Foundation’s reasoning as spin.) And if the patient is a 13-year-old rape victim, how is this not despicable and evil?
Another question I would like to ask: if you’re a health care professional, would you excuse yourself from participating or facilitating in enforcing this law?
Posted by torontoemerg in Before I Start Throwing Things, I'd Better Write This Down, Navel Gazing, Teddy Bears, Ribbons and Wristbands Make It All Better on Sunday 05 February 2012
Susan G. Komen Run for the Cure doesn’t have much of a direct presence on this side of the border, so I could watch the recent public relations train wreck here with a sort of Olympian dispassion and, I have to admit, grim satisfaction. Frankly I’ve never been a fan of Komen’s “pinkwashing” everything related to breast cancer, which seemed to both infantilize breast cancer sufferers and trivialize the larger social and health care issues related to the disease. Breast cancer sufferers need dignity and real research, I think, not pink ribbons used as a marketing tool for corporations. My mother died of breast cancer, you see, and my mother-in-law had a lumpectomy and radiation therapy six years ago, so I tend to wear these things on my sleeve.
So this video, which is making the rounds on the Interwebs, provides an antidote to all of Komen’s nonsense, and spells out as much dignity and courage as one could want in a YouTube video. Warning: delicate flowers easily offended by surgical scars may want to leave the room, or at least avert their eyes.
UPDATE: Minor editing/typo fixes. The first post by Android phone clearly leaves much to be desired, but as Samuel Johnson says, “It is not done well; but you are surprised to find it done at all.” Note to self: grow opposable thumbs. TE.
“We Will Now All Be Unwilling Participants in a Social Experiment That Will Undoubtedly Place Canadian Lives at Risk”
Posted by torontoemerg in Before I Start Throwing Things, I'd Better Write This Down, Health Care Policy That Matters to Nursing, Life in the Emergency Department on Thursday 27 October 2011
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)
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.]