Some thoughts from an MRT. . .

Now I know we aren’t perfect but I feel like a rant about portable examinations.

If a portable examination is requested it’s because the patient is too ill to come to the department, not because they are in the bed nearest the window and it’s a hassle to get them out of the room. Portable exams give less information than a department film so why chose inferior diagnostics?

So the patient is too sick to leave the floor might there be a need for a nurse to help the MRT with the patient? Just saying, just wondering. Now this help isn’t for the MRT’s benefit – though lifting and maneuvering people one handed is tricky – it’s for the patient.. Even if your patient is sitting bolt upright and square on do you think it’s a kindness to have them pulled forward by one arm as the heavy cassette is placed behind them? Because this is what the MRT has to do if the patient can’t lean forwards.

Oh and please don’t all run the minute the portable machine comes trundling down the corridor. It isn’t radioactive. And if you don’t have time to move 2 chairs, a commode, a walker,  and a couple of tables out of the room what makes you think the MRT does??

You know if you help with the exam then I’ll help put everything back in it’s place.

In Emerg, when you call the tech for a stat film then do acknowlede ge them when they arrive, and maybe even stay to help, (see above re too sick to go to the department.) If you don’t hang around then do answer the tech when they ask if the patient can be sat up for the film, or have any other questions about your patient.

Points well taken. Remember it’s about the patients, right? I’m pretty sure too other health care professionals have similar valid gripes about us. Ladies and gents, we need to pull up our socks.

It’s also commonplace, that in certain health care institutions, the power structure, the hierarchy of heath care, is so rigid (and fragile) that any challenges to that hierarchy — such as a nurse questioning the God-like omniscience of a surgeon — must be ruthlessly suppressed.

Amanda Trujillo

So when a nurse interferes with the revenue stream, dares to challenge the organizational power structure, hospital’s only logical recourse is to utterly destroy the nurse’s career. Take the case of Amanda Trujillo. Engaging in standard, no, gold standard nursing practice, following hospital procedures and using hospital materials, Trujillo correctly ascertained a patient facing end-stage liver disease did not understand a proposed transplant procedure or its consequences, and desired palliation instead. According to usual practice at this institution, and with the support and knowledge of her immediate manager, she requested a multi-disciplinary team consultation to create a care plan.

Amanda Trujillo tells the story herself:

My name is Amanda Trujillo. I’m a registered nurse of six years , specializing in cardiology, geriatrics, and end of life/palliative care. Back in April of this year I was caring for a dying patient whom I had discovered had no clue about what they were about to participate in when they agreed to get a major invasive surgery. When I properly educated the patient using the allowed materials by my employer they became upset that the physician never explained details of the surgery or what had to be done after the surgery (complex lifetime daily self care). The patient also had no idea that they had a choice about whether they had to get the surgery or not or that there were other options. They asked about hospice and comfort care and I educated the patient within my nursing license and the nursing code of ethics. The patient requested a case management consult to visit with hospice to explore this option further in order to make a better decision for their course of care. I documented extensively for the doctor to read the next day and I also passed the info on to the next nurse taking over, emphasizing the importance of speaking with the doctor about the gross misunderstanding they had about the surgery. The doctor became enraged, threw a well witnessed tantrum in the nursing station, refused to let the patient visit with hospice, and insisted I be fired and my license taken. He was successful on all counts.

Let’s be clear about this and speak plainly: when the transplant surgeon found out about this course of events, mindful perhaps of lost fees, but heedless (it seems) of any apparent conflict of interest, and in fact, of any basic recognition of the principle of patient autonomy, he threw a temper tantrum, and demanded the job and licence of Nurse Trujillo.

The administrators at  Banner Del E. Webb Medical Center, heedless both of any apparent conflict of interest on the part of the surgeon, and in fact, of any basic recognition of the principle of patient autonomy, complied with this request. In the best tradition of blame-the-nurse, these faceless administrators — and I sincerely hope there are no nurses among them, because if there are, they are a complete disgrace to our profession — fired Amanda Trujillo. They then reported her to the Arizona State Board of Nursing, on the grounds that the request for the case management team somehow constituted a “medical” order, and therefore Trujillo exceeded her scope of practice. It’s important to realize these (hopefully-not-nurses) administrators designated this particular order as a “medical” order somewhat after the fact.

Very disturbing is the sheer maliciousness of the hospital administration at  Banner Del E. Webb Medical Center. Think about it for a minute. Even if you accept — and this is a  long stretch — that Trujillo exceeded her scope of practice, is the appropriate, measured response to ruin her practice, when the “error” was made in the best interest of the patient, in way that recognized and validated the patient’s right to autonomy?

Yet at some point an administrator decided the only appropriate, measured response was to utterly destroy the career of this nurse by screwing her over so royally she could never practice again.

(Nice job, Banner Del E. Webb Medical Center! I guess the best thing about this hospital you can say is that it it’s an awesomely bad, ugly, abusive place to work, if they would throw a nurse under the bus to appease a physician having a temper tantrum. It almost goes without saying that a place that is bad and ugly for nurses to work in doesn’t do much better for patient care. The case, in the event, pretty well makes that much clear.)

Amanda Trujillo’s hearing at the Arizona State Board of Nursing was supposed to have been yesterday. It was postponed for two months for a psychiatric evaluation because — wait for it — defending one’s self publicly on the Intertubes constitutes “retaliatory behaviour.” No, seriously. In the old Soviet Union, dissidents used to be labelled insane to discredit and marginalize them. Pretty well much the same obtains in modern nursing. Defy a physician, you get fired, you get investigated, and you get labelled crazy. And the Arizona State Board of Nursing facilitates the abuse, because as we all know, health care institutions never lie, and never have ulterior motives.

Nice.

So you want to be a nurse?

__________

Amanda Trujillo’s full story can be found here at Vern Dutton’s site.

Her Twitter feed is here.  Trujillo’s Twitter account seems to be deactivated this morning (26/01/12).  

Amanda’s new Twitter feed is here.

A Facebook page in her support is here.

Email the Executive Director of the Arizona State Board of Nursing, Joey Ridenour, RN, MN, FAAN: jridenour@azbn.gov

Complain to Banner Health here.

Nerdy Nurse’s perspective is here and here.

Please spread Amanda’s story as widely as possible. Every nurse is vulnerable to mistreatment.

UPDATE: 

Minor spelling corrections. Anyone know where I can purchase a hobbit to proofread?

Also:

Emergiblog:

Nurses not only eat their young, but God help you if the almighty Medical Establishment gets ticked off.

Nurses talk a great game. In the Halls of Academia and the Ivory Towers of Those Who Claim to Advance The Profession, it’s all “Nursing Is An Independent Profession” and we tirelessly “Fight For Our Right To Practice To The Full Extent Of Our Education And Training”.

Unless you’re down in the trenches doing patient care every day and someone gets angry that you have dared to advocate. And if that Someone is a Doctor, well, the bigwigs scatter to the four corners of the ring.

Musn’t create controversy.

Hell, they aren’t even standing on your side of the arena.

From Kim we also learn that the president of the Arizona Nurses Association (email the Executive Director, Robin Schaeffer: robin@aznurse.org) is the nursing director of Banner Del E. Webb Medical Center. Hence the deafening — and telling — silence of that organization.

And also Jennifer Olin. And NurseKeith.

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.

Thee for my recitative,
Thee in the driving storm even as now, the snow, the winter-day declining,
Thee in thy panoply, thy measur’d dual throbbing and thy beat convulsive,
Thy black cylindric body, golden brass and silvery steel,
Thy ponderous side-bars, parallel and connecting rods, gyrating, shuttling at thy sides,
Thy metrical, now swelling pant and roar, now tapering in the distance,
Thy great protruding head-light fix’d in front,
Thy long, pale, floating vapor-pennants, tinged with delicate purple,
The dense and murky clouds out-belching from thy smoke-stack,
Thy knitted frame, thy springs and valves, the tremulous twinkle of thy wheels,
Thy train of cars behind, obedient, merrily following,
Through gale or calm, now swift, now slack, yet steadily careering;
Type of the modern—emblem of motion and power—pulse of the continent,
For once come serve the Muse and merge in verse, even as here I see thee,
With storm and buffeting gusts of wind and falling snow,
By day thy warning ringing bell to sound its notes,
By night thy silent signal lamps to swing.

Fierce-throated beauty!
Roll through my chant with all thy lawless music, thy swinging lamps at night,
Thy madly-whistled laughter, echoing, rumbling like an earthquake, rousing all,
Law of thyself complete, thine own track firmly holding,
(No sweetness debonair of tearful harp or glib piano thine,)
Thy trills of shrieks by rocks and hills return’d,
Launch’d o’er the prairies wide, across the lakes,
To the free skies unpent and glad and strong.

— Walt Whitman from Leaves of Grass

10 Most Popular Posts (many of which were actually posted in 2010)

1. Can We Stop the I’m-a-Male-Nurse-Who-Isn’t-Gay-Contrary-to-the-Stereotype Routine? (An oldie-but-a-goodie. By far and away the most popular post.)

2. Full Code (Have no idea why. Badly written. Needs a do-over.)

3. A Medication Error Leads to Suicide

4. The Lady with the Lamp

5. More on Racism in Health Care (Suspect a Google search term.)

6. Images of Nursing: “I’m just a nurse”

7. The Placenta, The Nursing Student and the Teachable Moment (Widely tweeted and referred)

8. Florence Nightingale: Images and Words

9. A Fix for MRSA? (Ditto on the search term)

10. Maxims for New Graduates

My Favourite Posts from 2011

1. Under Construction

2. Sometimes Things Ain’t What They Seem

3. In Which TorontoEmerg Discourses on Some Aspects of Human Nature

4. So When Does This Become a Crisis?

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

6. The Most Useless Form on the Planet

7. Don’t Tell Your Patient This. Or That.

8. On the Dying Art of the Bed Bath

9. When Nurses Write About Physician Bullies, Don’t Shoot the Messenger

10. Clinical Days: A Short History

11. Empathy

12. Accessing CVADs is Like Killing Puppies, Only Worse

13. How Mr. Jones Died

14. I’m New. Please Be Kind.

One rainy night at Sacred Heart Medical Center, Eugene, Ore., I had a brief encounter with a man whose name I cannot recall, a man I shall never forget. He was one of my seven patients, near death and a DNR. During my initial rounds, he asked, barely audible, “Will you stay with me?” He was so frail, pale, old and tremulous. I said, “Sure as soon as I check my other patients.”

Vital signs, passing meds, chart checks, assessments and bathroom assistance for six other patients took up most of the next hour and a half. When I returned he was dead. I reasoned he was a DNR, no family, very old, end-stage multi-organ disease; now he was gone, and I felt awful. It was okay for him to die, it was his time—but not alone.

I looked around; scores of people were nearby providing state-of-the-art patient care. For this man, state-of-the-art should have been dignity and respect.

The last sentence is particularly striking — and true. It speaks to the core of what ought to be good nursing practice. In critical care areas we are sometimes entirely too focussed on the technical/technological aspects of care, when the reality is often much simpler. In the event, the wonder of it is not that such a program exists, but why it took so long for someone to come up with the idea, so obvious it seems in retrospect.

This is how it works:

A staff nurse generally initiates No One Dies Alone by calling pastoral care or, after 5 p.m., the nursing supervisor. The person who has signed up for that date is called. It is totally a volunteer program, and no minimum or maximum time has been set. The “compassionate companion” is provided with a parking pass and a meal ticket. We have a supply bag with a CD player, various CDs, a journal and a bible. We emphasize that any religious behavior will be initiated by the dying patient and not by the companion. Staff and the “compassionate companion” use an evaluation form in an ongoing effort to improve the program.

[. . .]

The reasons individual employees have volunteered are fascinating and as varied as their departments. Hospital carpenters, administrative heads, maintenance workers, nurses, secretaries, and kitchen workers have come forward. Some who come from large families cannot imagine someone being alone; others are alone themselves. One nurse from the cardiac cath lab has seen many die in spite of the high tech environment and care. He wanted to experience once again “why I became a nurse in the first place—to care for those who can no longer care for themselves.”

Other health care facilities operate similar programs, including a pilot project at the Royal Jubilee Hospital in Victoria. One can only hope the practice becomes universal.

Mary Hynes, of CBC Radio One’s Tapestry, broadcast an episode last year dealing with hope at the end of life, which included an interview with Sandra Clarke. It can be found here.