Archive for May, 2010
Posted by torontoemerg in Before I Start Throwing Things, I'd Better Write This Down, Life in the Emergency Department on Sunday 30 May 2010
Toronto hospitals and medical responders are bracing for a busy summit weekend, practicing simulation drills, updating emergency preparedness plans and in some cases, asking patients to reschedule appointments.
Hospitals are also trying to free up bed space during the summit week. The University Health Network — which includes the Princess Margaret, Toronto General and Toronto Western hospitals — is no longer accepting appointments for the day prior to the summit and asking patients to reschedule non-essential appointments on June 25, said UHN spokesperson Gillian Howard. The hospital will also try to expedite patient discharges that have already been scheduled.
Ain’t it grand that hospitals can suddenly free up inpatient beds when the Powerful and Mighty need to preen for the cameras, press the flesh and do Something Universally Important? When the rest of the time patients are left to rot in the Emergency Department hallways? And then there is this:
Obviously, there will also be medical plans for visiting dignitaries or heads of state who get injured or fall sick. While details are confidential, a Health Canada spokesperson said contingency plans for foreign VIPs include access to emergency medical care and a “comprehensive food surveillance program.”
It warms the very cockles of my heart, it does, knowing the Planetary Elites will be able to access the best in Canadian health care. And then what happens to the very ordinary patients who need to access the Big Downtown Hospitals from the ‘burbs and across the province when the summit is on? Like your son with the cerebral bleed, or your mother who needs the emergency cardiac catheterization? Maybe there should be some thought to that, rather than worrying about the quality of the Arctic char and the ice wines.
I might be a little crusty because I started off Friday morning with eight Admits in the Emergency Department and somehow ended up with twelve by end of shift, including two Day 4’s. Bleh.
When I was writing yesterday’s post and in contrast to it, I came across these posters from ANTaR — Australians for Native Title and Reconciliation. According to the ANTaR webpage, racism
has recently been recognised in a number of key reports as a threat to public health in Australia.
As a life stressor, racism directly and negatively:
- affects the cardiovascular system causing high blood pressure/hypertension and heart disease
- seriously affects mental health causing depression, anxiety and other psychological and psychiatric disorders
- contributes to low birth weight of newborns, as well as premature birth
Three out of four Indigenous Australians experience racism in their everyday lives.
One study in Western Australia found that 52% of urban residents and 69% of residents of a regional centre revealed prejudice against Aboriginal Australians. Nearly a quarter of the Indigenous children under 12 years surveyed had experienced racism in the previous 6 months. This was associated with increased cannabis and alcohol consumption in these under 12 year olds.
I suspect one would see similar issues among the First Peoples and other minority communities in Canada. [via Osocio]
my diary, night after night says
that i have outlived you.
my weird face at last just a paperclip,
the machine that was a cello
_______and i am less now, the way
boulders remember they were once small birds
I was called a racist a couple of days ago. The patient was upset, there was a slight delay in getting a bed, and the patient perceived our care was subject to some sort of a racial screen. Or else chose to make that argument. There was a lot of yelling and screaming in the waiting room: “You’re a bunch of racist pigs”, and then to me, “When you see a black person, you see dirt, don’t you?”
The patient was brought in, appropriately, and later signed out Against Medical Advice, because the lab was too slow with the blood results — more evidence, I suppose, of the racism of Canadian health care and the bigotry of the nursing staff, including myself.
It was ugly and stressful for everyone.
It is always a source of amusement to me that behaviour that wouldn’t be tolerated in, say, a bank or a grocery store is deemed to be perfectly acceptable in a health care setting. We have a duty to care, even if they are idiots. And further, the College of Nurses, the nursing regulatory body, virtually demands nurses establish therapeutic communication even with clearly out-of-control, manipulative and irrational patients to determine the source of their discontent and rage, and then tends to blame us when we can’t.
At the bank they call the police. In the Emergency Department we reward bad behaviour by expediting care and getting the patient out of our faces by quick dispositions.
It is, in fact, hugely disruptive to the entire department when the word “racism” is used. We — the nurses and physicians — tend to circle the wagons, because one unsubstantiated charge of racism can lead to a whole world of trouble, tens of thousands of dollars in legal costs, and a blemish on one’s professional record. The only possible defence is documentation, charting by the yard. Of course this delays care for everyone, including for the person who used the word. I spent at least an hour myself documenting, and ensuring everyone else documented as necessary as well — not an inconsiderable amount of time if you’re a charge nurse — and this meant because I was occupied doing the uselessly needful, the entire department operated less efficiently.
The registration clerk, who is South Asian, and who witnessed the whole nasty scene, was deeply and visibly angered. “Racism does exist,” said the clerk. “And people like that patient just trivialize the whole issue.”
The obverse of Rob Fraser’s post — “Are Nurses Innovators?” — over at Nursing Ideas. When I commented on his post, I thought that innovation among nurses is hampered by institutional and cultural factors, indifferent leadership and the unfortunately prevalent equivocation of innovation with negative changes to nursing work life and patient care standards. When many nurses hear the word “innovation”, frankly, they run the other way. The suspicion of innovation is so ingrained among bedside nurses that even when change can be demonstrably shown to improve patient care, resistance is almost always fierce and very frequently successful.
My classic story about resistance to change and innovation involved some telemetry nurses at the hospital way up North where I was first employed. The manager of the telemetry unit decided that the nurses there ought to be able to read cardiac monitors: the telemetry packs were actually monitored in the ICU. The advantages should be obvious: faster response to potentially lethal cardiac arrhythmias, real time correlation of symptoms, and for the nurses, gaining skill and knowledge to enhance their practice and patient care — greater satisfaction for all and decreased mortality and morbidity. Win for everyone. And the hospital was going to pay for tuition and time so each RN could take Coronary Care I!
What could possibly go wrong?
My spies tell me that even after 12-odd years the nurses on Telemetry still can’t read monitors. There and in other places where I have worked, nurses invariably presented the same reaction to change: No, not on my life, over my dead body. “Can’t do it” is the default position. The reasons given are almost always unchanged: will increase workload and therefore compromise patient care, don’t have the time, not given enough support, has not been communicated well: no, absolutely not, won’t do it, can’t do it.
I’ve thought about this failure of innovation frequently since. I’m not persuaded that using sophisticated strategy, i.e. engaging informal leaders, building consensus, getting buy-in or any of that would have made much difference. In my mind, the reasons for resistance are complex. Many nursing leaders, managers and hospital administrators fail to appreciate how deeply scarring the last couple of decades have been on the nursing profession. Massive cuts to nursing staff in the 90s (and ongoing in some places), increasing patient acuity and workloads, ever-decreasing ancillary services all have left an atmosphere of malaise and mistrust. Hospital administrators treat nurses and nursing as a human resources problem to be managed and disciplined, only slightly above the kitchen staff in the institutional pecking order. In such circumstances — in the hierachical, authoritarian model of management which has be the ne plus ultra of nursing culture, lo these many years — there is bound to be pushback to any innovation. It’s reflexive. And sadly, I don’t think it’s an exaggeration to state bedside nurses have been mostly right. Examples of hospital administrators and managers pissing on nurses in the name of innovation are legion.
So if top-led innovation is difficult, what about innovation from the front lines? Even harder, in my judgement. In the first place, innovation and creativity are not highly sought-after characteristics for front line nurses — though they should be. Innovation is never found on job descriptions. (I suspect — and I would love to hear from nursing managers on this point — that nurses who think too deeply are probably viewed as undesirable and more likely to cause trouble. Though if I were a manager, I would probably take the opposite point of view.) Secondly, managers and administrators (and bedside nurses themselves) tend to view innovation as a management function. If you’re a front line nurse, and you have an idea or read a study that would improve practice in your unit, the sad fact is that you will get very little traction unless your idea is already on management’s radar. Your peers will be unlikely to view your ideas as positive and will often actively try to undermine you. Managers are usually unwilling to engage in a process of change that involves much more than moving a linen cart from A to B if it involves negotiations with other departments: they have to pick their battles too. At the end of it all, who needs the aggravation?
Which leads me to my third point: institutional inertia. Let me provide an example. Some years ago, at a previous employer, I was involved in an ad hoc committee to revise the nursing assessment forms for the emergency department. The old forms were frankly useless, and we were quite excited about being the opportunity to create positive change for ourselves and our colleagues. (The fact we were so excited, actually, speaks volumes.) We worked very hard, and came up with some very presentable forms. Then the “approval” process kicked in. First the forms had to clear both the Manager and the department Nurse Educator. Then the physicians group had to approve them, because, apparently, mere nurses were incompetent to create forms for their own use. Then the manager’s manager would have to have a go at them, and then would send them around to various other interested parties and committees for approval, including the Housekeeping Manager(!) and the quarterly meeting of the Pharmacy and Therapeutics Committee (because, apparently, lowly nurses know nothing about deciding how to document medication properly), and finally to the all-powerful Medical Advisory Committee for final approval, because doctors are so much more smarter than nurses, especially when it comes to charting. Interestingly, the physicians had final say over nursing documentation.
Almost needless to say, the process broke down somewhere between the Nurse Educator, who promised to take our lovely forms forward, and the initial physician approval. They simply fell off the plate. But apart the inevitable breakdown in process, the interesting thing to note about this tale of disillusionment is that apart from the initial burst of creativity, nurses had no real control over the innovation, instead relying on the (sometimes) dubious expertise of others for validation and approval. Again, this speaks to how seriously, or not, nursing innovation is made and developed in practice. The conclusion one comes to, if you are among the 80-odd per cent of us in front line practice, is not much, who cares, and why bother. I don’t doubt nurses are innovators, at all levels, and I don’t think nurses are inherently resistant to change. But creating a culture and providing the leadership where nursing innovation is valued and rewarded — it clearly isn’t now — will require a revolution in thinking and practice — from hospital administrators and managers to the bedside. It’s maybe time to think about how we as nurses can do this — because ultimately, it’s about the future of our profession.
Up to the ICU the other night, helping to transfer a very chatty, cheerful and surprisingly young sick sinus syndrome.
I love the ICU. Usually. It is so — restful. Quiet. The yin to the Emergency Department’s yang. The gentle hum of the ventilators and the slight ping of the monitors is all you hear. No shouting or screaming. The consultants are polite and well-behaved. And the ICU nurses are always calm, collected, and speak in low, reassuring voices, ready to take you by the hand — and then you know everything will be all right. (They do this for the patients as well, I understand.)
I go there, and not only do I feel like napping immediately, but I feel like I will be supported in my choice.
I said I usually love the ICU. Regrettably, the Evil Line* is on tonight when we arrive, five RNs standing by the Nursing Station like so many vultures set on a country fence, meaning to go full tilt, and ready to rumble; maybe hoping for new meat, but seeing only me and Shelley, an old girl who’s senior enough to be my mother, and who makes the internists cry for for sport. No blood — or joy — from us, anyway: we keep our heads down. Smile and wave, Shelley, smile and wave, and what ever you do, don’t look them in the eye.
The patient surveys the scene: four very sour-faced nurses, obviously unhappy and annoyed to see us, and Charge Nurse looking like she just swallowed a marmot, whole.
In a loud jokey stage whisper he says, “They seem like a happy bunch!”
Charge Nurse jerks up her head, sharply. “What?!?”
*That is, a group of nurses who are commonly rotated through the work schedule together — a line. For some reason, the ones with the, um, difficult personalities often end up working together.
Victoria Day is the memory of ritual long past, an anachronism frozen for all time, from when Canadians gave notice of the Queen’s birthday in a holiday, and because it was the Queen, we had (and still have) fireworks.
Also: the traditional time to plant the garden, which I intend to honour, so no substantive nursing post today. Instead, a poem redolent of homage and the Imperial Age which Victoria represented and during which Canada, for better or worse, was a jewel of the Empire. Not a bad poem, as such poems, or any poem about royalty, go. It is fun to read, yet it verges on sentimental doggerel, I’m afraid.
The Bells and Queen Victoria
“Gay go up and gay go down
To ring the Bells of London Town.”
When London Town’s asleep in bed
You’ll hear the Bells ring overhead.
In excelsis gloria!
Ringing for Victoria,
Ringing for their mighty mistress–ten years dead!
Here is more gain than Gloriana guessed–
Than Gloriana guessed or Indies bring–
Than golden Indies bring. A Queen confessed–
A Queen confessed that crowned her people King.
Her people King, and crowned all Kings above,
Above all Kings have crowned their Queen their love–
Have crowned their love their Queen, their Queen their love!
Denying her, we do ourselves deny,
Disowning her are we ourselves disowned.
Mirror was she of our fidelity,
And handmaid of our destiny enthroned;
The very marrow of Youth’s dream, and still
Yoke-mate of wisest Age that worked her will!
Our fathers had declared to us her praise–
Her praise the years had proven past all speech.
And past all speech our loyal hearts always,
Always our hearts lay open, each to each–
Therefore men gave the treasure of their blood
To this one woman–for she understood!
Four o’ the clock! Now all the world is still.
Oh, London Bells, to all the world declare
The Secret of the Empire–read who will!
The Glory of the People–touch who dare!
Power that has reached itself all kingly powers,
St. Margaret’s: By love o’erpowered–
St. Martin’s: By love o’erpowered–
St. Clement Danes: By love o’erpowered,
The greater power confers!
For we were hers, as she, as she was ours,
Bow Bells: And she was ours–
St. Paul’s: And she was ours–
Westminister: And she was ours,
As we, even we, were hers!
As we were hers!
— Author Unknown
[UPDATE @ 0818] If you live in Ontario, since when have you ever seen a May 24th weather forecast like this?
The bad news is I had such a craptacularly (as Bart Simpson would say) awful night I’m nearly incoherent. One of the many, many highlights was having the wife (or symbolic, Oedipal mother, so enabling was her behaviour) scream for a warm blanket for her “cold” and “shivering”, drunken husband while I was trying to give IV diltiazem to an atrial fibber with a heart rate of 175, more or less.
I actually weighed this in mind, amazingly enough —
— for about 1/100, 000 of a second before turning my back and drawing up the diltiazem.
The good news for you, dear reader, is that I have material for several posts.
But first for me, a Gravol and two Tylenol 3, and bed.
Poetry of another sort. I don’t often post this kind of thing, but it matches my mood today, and I daresay, the spirit of the times. How many people do you think actually get it?
In honour of the birthday of Queen Victoria, commemorated by Canadians this weekend and regarded as the unofficial beginning of summer and the date to plant the tomatoes, a poem by her Poet Laureate, Alfred Tennyson.
Below the thunders of the upper deep;
Far far beneath in the abysmal sea,
His ancient, dreamless, uninvaded sleep
The Kraken sleepeth: faintest sunlights flee
About his shadowy sides; above him swell
Huge sponges of millennial growth and height;
And far away into the sickly light,
From many a wondrous grot and secret cell
Unnumber’d and enormous polypi
Winnow with giant arms the slumbering green.
There hath he lain for ages, and will lie
Battening upon huge seaworms in his sleep,
Until the latter fire shall heat the deep;
Then once by man and angels to be seen,
In roaring he shall rise and on the surface die.
— Alfred Tennyson