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Charge Mommy

A few days ago, one of my colleagues said to me after a particularly frantic day in the ED, “You guys aren’t Charge Nurses, you’re Charge Mommies.” She is right. This is what we do:

  • tell all the kids don’t fight and play nice
  • fix boo-boos
  • give hugs as needed, or tissue
  • make sure all the kids get lunch
  • find things
  • repair broken toys
  • clean up little “accidents”
  • greet guests, and ensure they’re fed and comfortable
  • make sure everyone keeps the place tidy
  • assign chores
  • deal with the unpleasant relatives upstairs

The one thing I don’t do is enforce discipline. No spankings or time outs. I have a Manager Mommy for that.

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Karma Sweet Karma

The latest instalment of Nurses Behaving Badly featured the night charge and the day charge (i.e. me) getting a status asthmaticus organized in Resus 1 a few minutes after shift change. It’s probably reasonable to wonder why the two Resus Room nurses weren’t attending (and attentive to) the situation, especially after we paged the physician and the RT in quick succession for a possible intubation, and especially since both of them were less than twenty feet from where we were working.

We thought at first they were getting report on the only other patient in Resus, but after 10 minutes or so we began to wonder how long it actually takes to give report on a stable, routine, admitted, pain-free NonSTEMI.

Meanwhile we got the patient on high-flow oxygen, assessed, drew blood, did an ECG, set up stacked Ventolin treatments, placed two large bore IVs, hooked the patient up to the cardiac monitor and generally got organized to tube the patient.

Turns out they were looking at a jewellery catalogue, drinking coffee, texting, socializing, what have you.

Grrrr. And when the night charge asked our two colleagues to cease and desist from shopping and tweeting and trading bon mots and actually do some, you know, nursing, we got the “whatever” look: face squinched up, hands up in the air, eyes rolled. The look that manages to convey a dishful of entitlement and irritation, with a light sauce of fuck you to complete.

Double grr.

By the time I gave my report, it was nearly an hour after shift change. But what goes around comes around. There is cosmic retribution and it is just.  That night Nurse Tweedledee and Nurse Tweedledum received, in addition to the now intubated status asthmaticus:

A cursing psychotic patient in four point restraints

A cursing drunken 20-year-old who managed to pee and puke all over herself all at once

A VSA*

Another VSA

A non-compliant insulin dependant diabetic in DKA 

And just before shift change, a fulminating CHFer, which required them to stay long after their shift was over.

In short, they had a craptacular night. The complaints, the bitterness, I am told, from the pair was tremendous. They needed to leave. They had child care issues. Husbands needed vehicles — and one of them was written up for being late. They were tired as no nurse in the history of the universe was tired. Why are we so afflicted? they moaned. What did we do to deserve this?

Karma, baby, karma.

The cosmic lesson being simple, work starts promptly on the hour. Not after fifteen or twenty minutes of “social” time. Be considerate of your colleagues. They’ve been working for twelve hours and want to go home. Many, many, bonus points if you come in ten minutes before to get report so the nurse you’re relieving can get out on time.

To say I had any sympathy for either of them would be a bald lie. Can you say schadenfreude?

 

___________

*VSA = Vital signs absent.

 

 

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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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In Which I Swear, Repeatedly, or, TorontoEmerg Gets Bullied

I write this blog for a number of reasons: my own amusement, to educate, to share various random thoughts, to tell stories, to stimulate discussion on topics important to nursing, to provoke thought beyond the superficial, to challenge assumptions, and lastly, to rant.

Today I am going to rant.

Those of you with delicate sensibilities may want to get out. I am going to use some earthy language. Repeatedly.

So, to begin: I love my colleagues with the generous love I share with my family, but like some of family, they can be gaping assholes.

I’ve been seconded again for more administrivia duties. Since part of what I’m doing will have focus on improving quality of nursing work life, I am very excited and eager to do this. I believe making our work places better for nurses will, in the end, save nursing as a profession.

For this work, I needed to buy some markers. With the manager’s permission I (innocently) ordered a pack of multi-coloured, fine point Sharpies, which with the wholesaler’s discount came to $6.35 (six dollars and thirty-five cents) plus HST, and charged them to the departmental budget.

The markers arrived on my day off.

Then the nattering started, which (from reports) quickly escalated from a simple “why were these markers ordered?” to attacks on my integrity, discussions about my worth as nurse, and lurid suggestions I was dogging it.

From the reaction, you might have thought I was running a child prostitution ring in the Resus Room, and was using departmental petty cash for start-up costs. It was that bad.

One of my colleagues, a woman I previously thought as an ally, was incredibly hostile. “Why” she asked, “couldn’t you buy your own?” Of course, her anger left me slack-jawed and stupid and the correct answer escaped me at the moment: for the same reason I don’t buy my own kidney basins and bath flannels.

Yes, it was bullying, and afterwards, I reflected on the irony that so soon after writing on the subject I should become a victim of it myself.

So, it was hurtful.  But mostly it really, deeply pissed me off. Remember, I’ve been working with some of these nurses for ten years or more.

I know I’m a damn good nurse, and you’re lucky to have me, so fuck off.

I’m working hard to make your lives easier as nurses, so again, fuck off.

And yeah, I know about horizontal violence and the rest of that, but the bottom line: you are responsible for your behaviour. Stop being a high school gossip queen — and for some of you, you’re closer to retirement than your senior prom — and start being a nurse. Because when you undermine me or anyone of your nurse-colleagues, you’re really undermining yourself.

Another colleague, far more sympathetic, suggested that nurses have been doing it to each since Florence was beating the carpets at Scutari, and we are never going to stop acting, collectively, jerks.

I fear she may be right.

So I say again to those nurses who found it fun and interesting to shred my character in a few minutes time: um, fuck off. And fuck you. You aren’t worth my time.

End of rant. Thank you for your attention.

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Yep, It Was a Disaster

Nurse K had an interesting take on my blog post the other day about dealing with an over-crowded ED: it was a disaster, pure and simple:

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.

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In Which I Lose It, Just a Little, Over Emergency Department Overcrowding

My style as charge nurse could be described thusly: keep it smooth, keep it light. No fuss, no muss, no stress. Don’t worry about the externalities. Embrace the suck. All crises eventually pass. Three codes and a multi-system trauma? No problem! Bring it on! Our core competency is extreme competency at whatever is dumped on us. We’ll handle it.

Except for the other day, when I lost it, just a little, on the Bed Flow Facilitator. Her job, as her exalted title suggests, is to keep the patients moving in and out of beds, specifically to prevent patients from piling up in the Emergency. Theoretically, anyway.

In my ED there are 27 beds, 22 of which are monitored. When 25 beds are taken up with admitted patients boarding in Emergency, there’s a problem. The problem is exacerbated when I’m told at the bed flow meeting there “might be” only two beds upstairs available later — much later. The problem becomes dire when six ambulances roll in with six more-or-less critically ill patients, all of them in various stages of decompensation. I need beds. I need the admitted patients to go upstairs, so the ED can operate like, well, an emergency department.

I page the Bed Flow Facilitator.

No answer.

Page again.

Ten minutes later she calls back. She’s annoyed. ‘I’m in a meeting,” she says. Meanwhile across from my desk on an ambulance stretcher, my hypotensive esophageal varices is puking blood while the Resus room nurses and the porters scramble to make room for him.

I explain the situation. She blows me off. She doesn’t seem to grasp that the lack of emergency department space puts patients at risk. “I’ll see what I can do,” she says, “after the meeting.” She hands up.

Forty-five minutes later she calls back. Things are not better. We got the esophageal varices off-loaded — no Blakemore tube, thankfully, but an octreotide drip and a blood transfusion– but I still have a couple of active chest pains on ambulance stretchers, as well as a probable CHFer. There is no one else I can pull out to my impromptu and fire-department-prohibited hallway unit I’ve set up in front of the nursing station.

“Well,” she says. “I can’t do anything else for you.”

I calmly explain again that our ability to function is severely impinged by having no effective space to do our jobs.

She huffs. “It’s not my fault.”

Take note, reader. This is where I lose it.

“Then who’s friggin’ fault is it? No one ever takes responsibility for anything. It’s never anyone’s fault, and no one ever does anything about it! So, are you going to do your job, and try to to facilitate some movement upstairs, or what?”

“Stop wasting my time,” she says, and hangs up. I’ve made an enemy, I think. But wait: by end of shift, not two but eight beds miraculously appear. With three discharges, I actually have empty stretchers. Assertiveness (or losing it) sometimes works.

But the point is, I shouldn’t have to scream at hapless Bed Flow Facilitators to get patients upstairs. And the problem of emergency department overcrowding is not just limited to my ED: my sources tell me nearly every hospital in the Toronto region has been in a kind of gridlock since before Christmas, filled to capacity on a daily basis with admitted patients. Hospital administrators view the situation as an ED problem, not a hospital problem, as if we can somehow control the flood of patients coming through the doors. There are consequences. Sick time, for example, is going up in my ED, because of the stressful working conditions, and a couple of nurses have left the department altogether. Patient care is definitely suffering. It’s only a matter of time before someone dies because we can’t get them treated fast enough. Whose fault will it be then?

[UPDATE: minor grammatical and syntactical corrections. If I had a million dollars, I'd buy me an editor. A ten-year-old would do.]

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“How Not to Dump a Patient”

[A rerun. Craig and Ricky are no longer partners, incidentally, and I'm not sure if Ricky is even in the ambulance service any more.]

Tuesday morning, 0205, and I’m in charge. Ricky and Craig push an elderly female patient in a wheelchair through the ambulance doors.

These guys are capable and competent paramedics, by which I mean if they say a patient is sick, I tend to take then at their word. No quibbling and no second guessing.  Craig is a bit goofy, wiry-thin, rapidly approaching middle-age; he tends to diagnose patients in the back of his rig and elaborate his conclusions at triage. So he’s acquired the title “Doctor” among some of the emerg nurses —and this isn’t meant to be kindly. But he’s okay, really, he knows his stuff and that’s good enough for me. Ricky is well, Ricky. Younger, early thirties, maybe, good-looking in a solid, conventional way. I don’t mind telling that I’ve carried a small, private torch for Ricky for a couple of years, mostly because he exudes confidence,  stability and a sort of farmboy charm: if he weren’t married and I weren’t married and if I were twenty years younger. . . well you get the idea.

Craig pulls up to the Desk and winks at me. “Piece of cake,” he says. “She woke up with abdominal pain, nausea. No vomiting, no diarrhea. CTAS 3. Can we take her around to triage?”

I’m distracted by the psych patient who’s come up to tell me for the fifty-third time about the worms in her brain. I nod agreement, reassure the psych patient that the worms aren’t showing, wash my hands and walk around to triage. Ricky gives me the story: 79 year old, woke up with nausea and abdominal pain, extensive cardiac history, diabetes, hypertension, blah and blah and so on, with a med list as long as your right arm.

I look at the patient.

Patient looks like crap. Tachycardic.  Pale, cold, clammy.  RUQ pain, yeah, but boys, did you appreciate the audible gurgling or the laboured respirations or even the +3 bilateral ankle and foot edema?

Um, no. Ricky looks embarrassed and Doctor Craig has taken a powder to the paramedics room.  Then I get it: they’re trying to dump the patient. In other words, they’re trying to avoid an off-load delay by routing the patient directly through triage (and then to the waiting room) by pretending the patient is less sick than she is. Better, they figure,  than waiting with the patient on the EMS stretcher for a bed.

I shake my head. I’ve seen some games from some EMS crews before, like the time a crew dropped at triage a hypotensive rectal bleed passing clots the size of canned hams without a by-or-with-your-leave, or told an inexperienced triage nurse the suicidal ideation wasn’t flight risk. But not from Ricky and Craig. Never.

I don’t even bother doing her vitals.  Resus room, I direct Ricky — and in ten minutes, she is catheterized, diurysed, and bipaped.  CHF, of course: the RUQ pain was all the blood backing up into her liver.

I am severely annoyed. Not so much they “missed” the presenting complaint — that’s bad enough — but by the assumption I wouldn’t offload an obviously critically ill patient immediately. And they know I’m pissed off. Usually at night paramedics hang out in the emerg as long as reasonably possible, avoiding dispatch, shooting the breeze, trading war stories, flirting with the (much younger) nurses, buying coffee. Socializing. But Craig and Ricky are gone before I can get out of the Resus room to, um, express my concerns.

Craig has been avoiding me all week, and Ricky won’t look me in the eye. I still don’t understand what the rush was about. It wasn’t that busy, and the patient would have been offloaded quickly, regardless.

But I just want to ask them: whatever it was, was it worth losing my trust? Really?

 

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Pooped

Weekend from hell (and I see there’s plenty of misery to go around), a flood of angry patients, traumas, codes, a couple of bilary colics after that football thing, sick calls, running the department (literally) with a single bed and a gerichair back in Fast Track, management complacency and indifference because we cope (we always cope), nurses in tears, nurses having wee meltdowns and having cat fights with each other, no cardiac monitored beds, dreading a Code STEMI and having to make the decision which sick monitored patient will have to go to the hallway in front of the main nurses station, so I can give them half-assed care probably marginal to the Standards of Practice, all the while putting out fires in remote parts of the department, physicians bitching at me because they have no place to see patients, all the floors hostile and over census, so a simple request becomes a horrific wrangle needing the manager-on-call to intervene, internists being dicks, and surgeons more so, EMS on offload delay for endless hours on end, and whiteshirt supervisors standing at the Charge Nurse desk demanding I release their ambulances, ICU refusing vents again, and —

— and I’m tired.

Exhausted. Barely coherent. My brain feels like it was fried in motor oil and fed to a bear.

A drop of sherry, I think, and then to bed.

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Thought Du Jour

If we’re all so worried about infection control, how about we stop treating the housekeepers like dirt?

If we’re annoyed the patient hasn’t gone to the floor, how about we stop treating the porters like dirt?

If we’re having trouble getting our orders copied, how about we stop treating the ward clerks like dirt?

__________

P. S. If the internist treats you like dirt, it’s hardly an excuse to spread the joy.

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How Mr. Jones Died

Mr. Jones was 83-years-old when he died. He came to us by ambulance from with shortness of breath beginning a little after lunch. He was from a nursing home; he had the alphabet soup of morbidities: CHF, CVA, NIDDM, CAD, COPD  — topped off by dementia related Parkinson’s.

He had pancreatic cancer, and plainly, he was dying. His advanced directives, outlining the plan for end-of-life care stated no heroic measures, but if he became seriously ill, he was to be transported to the emergency department for evaluation.

The nursing home where he lived did just that. He went through the usual emergency department process — seen, treatment started and referred to the internist for admission — all the while obtunded and gasping for air, despite the high flow oxygen. He  was a tall man, broad-shouldered; he lay restless in the narrow emergency department stretcher, his gnarled feet hanging over the end.

A flood of patients had deluged the hospital. There were no beds upstairs. I talked with Bed Flow and we made Mr. Jones a priority for a bed. But somehow his criteria never met bed availability, and when I came back two days later, he was still in the Observation room — and still no room on the floors. I had Housekeeping look for a regular hospital bed for him. There were already three being used in the department, and the overflow of  admitted patients meant there were none to spare. The Obs room nurses provided comfort measures, did mouth care, applied barrier cream over bony prominences, repositioned every two hours. They did what they could, but in truth, they were not palliative care nurses, a unique speciality unto itself. He never opened his eyes and he died by inches. Mr. Jones finally went three days after admission. His feet were still hanging over the end as we packed him away in the body bag and sent him to the morgue.

For the nurses, who knew what care Mr. Jones deserved, the experience was distressing. For the family, it was devastating, a layer of suffering over grief. For the patient himself, we can only hope he knew little and felt less.

There is absolutely no space in the system for patients like Mr. Jones — elderly, debilitated and often requiring complex amounts of care — to die with dignity. Nursing homes, despite their demographics, are very poorly equipped and frankly don’t have the resources to deal with dying patients. They dislike having dying patients; they will send them to the emergency department even when the advanced directives explicitly state the patient is not to be transported. Emergency departments are similarly not geared for end-of-life care, even though death is something we deal with frequently. We have neither equipment nor expertise; we don’t even have ready access to expertise.

And yet the case of Mr. Jones is not exceptional. How can we ensure people can die comfortably and with dignity? It’s a problem, I think, without at quick fix, but is by no means intractable or even complicated. It means explicitly recognizing that for the majority of cases, the best place to die is not in hospital, but at home or under nursing care in the community, and providing the resources to make it possible. And if such patients must come to ED, giving us the tools to do our jobs properly, so we can provide safe, competent and ethical care. That would be a good start, and a necessary one.

Because all I can think, that might be me one day. Or you.

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