Archive for June, 2010
Patients are now arming themselves to fend off catheter-wielding nurses, apparently:
Venkat Milligan, 22, pleaded guilty Monday to drug trafficking and weapons charges after police found a loaded 9 mm Keltec pistol wrapped in a sock next to his bed at St. Michael’s Hospital.
Officers also seized 6.5 grams of crack cocaine, a quantity of marijuana, 99 hits of ecstasy, an electronic scale and a bulletproof vest from his room on the 14th floor at the downtown hospital, Crown attorney John Healy told court.
At the rate the housekeepers lose reading glasses and dentures, I’m surprised the pistol didn’t end up in the hospital laundry.
Posted by torontoemerg in Before I Start Throwing Things, I'd Better Write This Down, Life in the Emergency Department on Sunday 27 June 2010
Yeah, the whole night was ugly. We watched the live stream, crowded around computer terminals. Not the least of the ugliness was the patient we had to send 400 km away for specialized emergency treatment because, as I predicted, the Big Downtown Hospitals were in lockdown and weren’t accepting patient transfers.
As for what we witnessed last night: rubber bullets, tear gas, and pepper spray, nearly five hundred people arrested; mass vandalism and police brutality suppressing lawful dissent. A billion dollars gone, and what did we get for it? Smashed shops on Yonge Street and police state tactics.
A great day for Toronto and this country.
I am so angry I could spit.
Posted by torontoemerg in Battered Nurse Syndrome, Before I Start Throwing Things, I'd Better Write This Down, What Nurses Really Want on Sunday 27 June 2010
Knock me Over with a Feather Department: an article by a “health care executive”.
A study in the May 4 Journal of Clinical Psychiatry looked at the relationship between bed occupancy rates and absenteeism and found that those working in units that were 10 percent more crowded than the optimal rate had twice the rate of depressive illness than their counterparts in less crowded units.
The second study, appearing in the May 19 issue of Health Policy, is based on data from the 2005 National Survey of the Work and Health of Nurses in Canada. While looking at absenteeism in general, the report notes that depression is a “significant determinant” for missed work among RNs and LPNs, and that those who work in a hospital are more likely than those working in other settings to miss work.
Who’d’ve thunk? And also:
Healthcare workers are like firefighters: They do dirty jobs, look death in the eye every day and celebrate the joys of life, too–rescuing a kitten or delivering a baby. So why does the firefighter culture thrive? Low attrition? People clamoring to get in? Firefighters face their mortality every day and they have created a culture where they can talk about it, release it, joke about it and move on. The fire house is their community, their home.
Healthcare workers do their job and take it home with them. When they are burned out, they leave. Firefighters are treated like heroes; healthcare workers not so much. So part of it, in my opinion, is building cultures that recognize this and help people release the fear and anxiety. That is not part of any rewards and recognition system. It goes fundamentally deeper.
Nice rhetoric. And maybe even true. Unfortunately the author, having mastered the dark arts of Health Care Administration, doesn’t actually address the obvious fundamental issues like, um, staffing and quality of nursing work life.
Because I’m greedy and picked up overtime tonight. According to the Globe and Mail:
A crowd of black-clad protesters with bandanas covering their faces moved around the city centre, damaging property along the way. Several police cruisers were vandalized and two were lit ablaze as flames and black smoke billowed into the air. Sparks flew into the air from small explosions. Firefighters finally arrived after about 15 minutes.
Tear gas was deployed at College Street and University Avenue shortly after 4:30 p.m. ET, but a police spokesman said he did not know whether it was used by police or protesters.
Demonstrators also broke the windows of dozens of businesses, including a Scotiabank, CIBC, a McDonald’s and a Starbucks. Protesters also threw bricks at a CBC van, breaking its windows. TTC streetcars were abandoned on Queen Street; two were spraypainted with anti-summit graffiti and anarchy symbols.
Wish me luck. Into the breach I go — just hoping it all stays downtown. (Sorry Maha!)
A poem for the G8/G20.
America: A Prophecy [Excerpt]
. . .
Fiery the Angels rose, & as they rose deep thunder roll’d
Around their shores: indignant burning with the fires of Orc
And Bostons Angel cried aloud as they flew thro’ the dark night.
He cried: Why trembles honesty and like a murderer,
Why seeks he refuge from the frowns of his immortal station!
Must the generous tremble & leave his joy, to the idle: to the pestilence!
That mock him? who commanded this? what God? what Angel!
To keep the gen’rous from experience till the ungenerous
Are unrestraind performers of the energies of nature;
Till pity is become a trade, and generosity a science,
That men get rich by, & the sandy desart is giv’n to the strong
What God is he, writes laws of peace, & clothes him in a tempest
What pitying Angel lusts for tears, and fans himself with sighs
What crawling villain preaches abstinence & wraps himself
In fat of lambs? no more I follow, no more obedience pay.
. . .
— William Blake, 1793
[Continued from yesterday.]
In the end, the problem I have with Blatchford’s column is that it seems exploitive of Mrs. Conley and her daughter. I’m not clear Blatchford isn’t using Mrs. Conley to push her own agenda, i.e. Canadian Health Care as the Fifth Horseman of the Apocalypse. In subjecting the case of Mrs. Conley to a somewhat capricious interpretation of facts and events, Blatchford ends up losing sight of the larger point: care for seniors in Ontario is disgraceful, and fixing it will mean higher taxes.
I’ve written on this first point repeatedly. I’ve seen it up close and personal: seniors from nursing homes, euphemistically and erroneously called “Long Term Care Facilities”, dehydrated and septic, poorly thought out advanced directives, limbs rotting away because no one thought to look under the occlusive dressing and on it goes. Services between hospital and community and hospital and nursing home are notoriously poorly articulated. If you need to spend your last years in a nursing home, your lot will often be misery and suffering, unless you have money or excellent family supports.
Hospitals, in particular, are the last and worst place for seniors, yet we continue to warehouse the elderly in acute care beds till we can find a place for them in nursing homes. At Acme Regional Heath Centre, where I work, around 25% of inpatients are frail seniors awaiting placement. Acute care beds are hideously expensive, so this represents an enormous cost to all hospitals. The chances of elderly patients acquiring a nosocomial infection are large, leading to higher morbidity and mortality.
And frankly, while hospitals do acuity well, when it comes to complexity, they suck. You come in with a heart attack or a broken leg or a kidney stone, we will fix you up and send you on your way. These are acute problems and relatively quick to resolve. Complexity takes time, both in practical treatment and care and in disposition. If you’re a nurse on a medical floor, an average frail elderly patient will not be as acutely sick as a heart attack, but requires more treatment in terms of positioning, skin care, managing foley catheters, feeding, restraints, bathing, walking, and medications. Acute care floors are poorly set up to offer this sort of care. If you’re admitted as a Failure to Cope, with a long list of chronic medical problems, social issues, no family to help, maybe dementia, this requires the mobilization of numbers of experts and outside agencies to treat you: not only the regular hospital phalanx of health care professionals, but social work, discharge planning, home care, nursing homes, and of course, family.
However, I can’t say with confidence services delivered by out of hospital providers is satisfactory. Home care in some parts of the province is plainly inadequate and strapped for resources, and nursing homes aren’t much better. Wages and benefits for nurses in home care and nursing homes are abysmal compared to hospital nurses, and one can’t help but wonder if this impacts patient care.
The Ontario government nibbles around the edges of the issue: the Ministry of Health has issued direction, for example, to ensure more seniors are discharged home from hospital to home with adequate community supports, such as help with meals or housekeeping, in-home physiotherapy and so on. There’s plenty of evidence seniors do better at home than being institutionalized. But the bigger problem is that in a system is strapped for resources, improving efficiency and processes can do a lot, but it’s not a panacea.
Unfortunately, in an era when spending and deficits are the focus of all governments, money to build and support the infrastructure necessary to keep seniors healthy and whole will be lacking. It is not just a case of the provincial government not having the political will to properly care for seniors. Do you think any government, of any political flavour, would risk suicide by proposing a substantial tax increase to fund proper services for the elderly?
This is the elephant in the room that no one will talk about: providing proper care for seniors is going to take significant and sustained expenditures now and into the future. In short, good care for seniors = higher taxes. I’m sure it will be a very cold day on Satan’s front porch before you would see Christie Blatchford, or even the editorial apparatus of the Globe and Mail, argue for that.
There was something bothering me about this column by the Globe and Mail’s Christie Blatchford, published a couple of weeks ago. It contains the the semi-standard Tale of Woe in Canada’s health care system. To précis the story, it concerns the travails of Hilda Conley, 84, previously well, hale and hearty, apart from a “benign” brain tumour and two cysts; she was admitted to the untender mercies of Stevenson Memorial Hospital in Alliston, Ontario for a “minor” urinary tract infection; she was held beyond her discharge day over a weekend for a swallowing assessment; she subsequent suffered, due to either nursing stupidity or malfeseance or maybe both, what sounds to be a haemorrhagic stroke related to a choking incident; subsequently in a coma, she developed bedsores; her daughter repeatedly asked for a “special mattress”, more frequent dressing changes, and also a “feeding tube”, because Mrs. Conley was beginning to recover to the point of “speaking”. In the meantime, the hospital and/or staff “basically left [her] to starve” for five weeks. In the end she was discharged home with a decubitus ulcer the “size of a fist” with, evidently no home care arranged. It sounds like a typical case of a senior abused by the system, and then cast out to cope on her own.
I don’t doubt that all of this occurred in some fashion. But I don’t think it’s simply a case of a fit elderly woman, with all of her faculties, with minimal health issues, who was chewed up and spit out by the health care system. The specifics of the story don’t jive with what I understand of how the heath care system or hospitals work. But first a few preliminaries. I don’t work at Stevenson Memorial and I know nothing apart from what Blatchford reports. This suggests the principal problem in Blatchford’s reporting : the reader is getting only one side of the story. Blatchford does, in fact, speak with an administrator at Stevenson Memeorial, and adds some snark about the hospital’s “minimal response”: one gets the impression of a tepid or fearful interview, but haughtily dispensed. What Blatchford doesn’t tell you, and what the administrator surely told her, is that the hospital cannot disclose details of Mrs. Conley’s case to the media. Patient confidentiality is not just an excuse; it’s a legislative requirement. In that light, we have the (perhaps justified) grievances of the patient’s daughter, and nothing else.
But it is in the details provided, I think, which present a considerably more complex picture than Blatchford suggests. Some instances:
1. “Benign” brain tumours are not trivial, as Blatchford implies; they are only benign in the sense they are not malignant. They can and will continue to grow, compressing and shifting healthy brain tissue, ultimately causing neurological issues.
2. Patients, even elderly patients, are generally not admitted for “minor” urinary tract infections. This suggests to me, at least, there were some other problems in Mrs. Conley’s health or social/living arrangements Blatchford doesn’t remark on, or perhaps the “minor” bladder infection wasn’t quite so minor.
3. Being held for two days over the weekend for “a swallowing test”, frankly isn’t credible, unless again, there were some other co-morbidities Blatchford doesn’t disclose. Beds in any Ontario hospital are too much at premium to hold patients for this one diagnostic. But in any case, this particular test wouldn’t be ordered unless there was a strong suspicion this poor woman was having difficulty swallowing, and perhaps needed further intervention. Difficulty swallowing is a pretty significant health issue. It impairs nutrition and can lead to aspiration, that is inhalation of chewed food and/or stomach contents into the lungs.
4. Which is apparently what happened, in turn causing Mrs. Conley to choke and made a “blood vessel break in her head.” This is, of course, immensely unfortunate. Blatchford is pretty clear in her column that staff (nurse?) incompetency led to this sequence of events. Perhaps. But equally it is easy to imagine a scenario, where the patient was discharged home (as Blatchford implies she should have been), choked on her dinner, and had a stroke. Or maybe the bleed was completely unrelated but coincidental to the choking incident, but perhaps as a consequence of the “benign” brain tumour. Who knows?
5. Quite a lot is made of the “special mattress” not being provided, the implication being the hospital and/or staff was being wilful in its refusal to provide one. Unfortunately, it is the rare hospital indeed that provides any sort of special mattress for patients at risk for bedsores. Two very practical reasons for this: difficulty in cleaning, leading to issues in infection control, and cost. (Personally, I usually advise families of patients with breakdown in skin integrity to purchase a relatively inexpensive egg crate pad, which can be taken home and reused.)
On the rest of Mrs. Conley’s stay in the hospital I can’t surmise. I don’t know if Mrs. Conley, for example, was truly “left to starve” receiving only intravenous fluids, or got some version of Total Parenteral Nutrition, or even got some sustenance orally. Blatchford doesn’t tell us. It strikes me as unbelievable that any nurse would deliberately starve a patient, or not strongly advocate for her patient, but that’s just me. However it’s significant Blatchford chooses to drag out some old steroetypes of nurses to evoke a poignant response to Mrs. Conley’s suffering: we’re either all Nurse Ratched or plain dummies. “Stupid, lazy RNs” is a frequent meme in the Comments.
Undoubtedly, there were some issues with Mrs. Conley’s care. Blatchford mentions issues that imply poor oral hygiene, and missed feedings. From a nursing perspective, these need to be addressed. The suffering of Mrs. Conley was enormous. But I don’t think it was entirely at the hands of the hospital or its nursing staff. Clearly, Mrs. Conley apparently had some pretty significant health issues even prior to her admission. Being treated for a urinary tract infection in the hospital setting implies her condition was not “minor”. Mrs. Conley’s co-morbidities complicated her course of treatment in hospital. Blatchford would have us believe Stevenson Memorial almost killed Mrs. Conley.
The truth, I fear, is more nuanced.
[Part II tomorrow]
Posted by torontoemerg in Before I Start Throwing Things, I'd Better Write This Down, Health Care Policy That Matters to Nursing, Random Thoughts, Uncategorized on Tuesday 22 June 2010
Good morning and welcome to the G20 police state, er, Toronto.
I’m hearing through the usual emergency department rumour mill that tear gas is not likely to be used in any G20 protests because of the logistical issues around decontamination in the very densely built-up areas in the “hot” zone. It gets into building ductwork, you see, and the thought of thousands of deranged, lacrimose bankers fleeing down Bay Street is too much, even for public safety officials. Pepper spray — well, that’s another thing, and it’s nasty. Here’s one description of what it does to you:
The effects of pepper spray are far more severe, including temporary blindness which last from 15-30 minutes, a burning sensation of the skin which last from 45 to 60 minutes, upper body spasms which force a person to bend forward and uncontrollable coughing making it difficult to breathe or speak for between 3 to 15 minutes.
Interestingly, both are designated as chemical weapons, and are banned for use in warfare under Article 1.5 of the Chemical Weapons Convention, under which Canada is a signatory.
In other words, we have no compunction using chemicals on citizens and civilians that are considered too inhumane for use on soldiers.
It’s important to recognize that both tear gas and pepper spray are not harmless adjuncts to law enforcement. Their billing as “non-lethal” is misleading, a cute piece of spin from the usual authorities. There have been fatalities related to the use of both pepper spray and tear gas, and people with other health issues such as respiratory or heart problems are especially at risk. Additionally, there’s evidence that both weapons can contribute to long-term health problems. Pepper spray can cause, according to a U.S. Army report, “[m]utagenic effects, carcinogenic effects, sensitization, cardiovascular and pulmonary toxicity, neurotoxicity, as well as possible human fatalities.” Tear gas has been associated with heart and liver damage, chromosomal changes, and miscarriages.
No, they aren’t quite harmless.
I’ll leave you with this quote from the New Scientist, May 1973:
Politician and scientist alike must accept the inescapable conclusion that any substance capable of producing an intolerable irritation at low concentrations must also produce a concomitantly high toxicity. In other words, the existence of ideal riot agents of sufficient safety not to impair the health of rioters or accidently exposed innocents is merely notional.
Posted by torontoemerg in Battered Nurse Syndrome, Before I Start Throwing Things, I'd Better Write This Down, Charge Nursey The Movie, Nurses Behaving Badly on Monday 21 June 2010
Some days I think my colleagues are the most amazing group of people I could possibly work with, and would gladly and gratefully place the lives of myself and all my loved ones in their capable, clever hands. Other days, I think they are hopeless, bitter, gossipy old skanks, and I throw up my hands in despair.
We have a problem-child nurse in our department, who I’ll call Sarah. She’s actually a pretty good nurse, but she’s loud and opinionated, doesn’t listen well, doesn’t play well with others, and she’s managed to offend in many and manifest ways (for reasons I won’t go into here) the crusty twisted old
princesses RNs* who like to think they run the department — or at least public opinion.†
I don’t actually mind this nurse (mostly) and will converse with her in a friendly-like manner, and will even be seen to do so in public. Shocking, I guess. There was a pub night the other night and the subject of poor unloved Sarah came up. When nurses drink, the knives come out, and you’d better get out the sawdust, ’cause there’s going to be blood on the floor. The next day my closest friend in the Emerg, who was attending and witnessed the repeated eviscerations of various nurses, told me (by way of having my back) that the Old Crusties feel I am becoming associated too closely with Sarah by being friendly and speaking with her and that I had better knock it off.‡
I went away and thought about this one for a long while.
Apparently, I have concluded, Acme Regional Emergency is actually an elementary school-yard. Sarah is the little ugly girl with the cooties, and I am in mortal danger of getting Sarah-cooties, which seemingly are very catching and will destroy me forever.
I think this is what it comes down to. Honestly. Nurses behaving badly, and cooties.
But you see, I said “cootie-proof forever” beforehand, so I’m in the clear.
When I think about it, it seems to me we generally often treat our colleagues on the basis of whether they have cooties. Call it the tyranny of conformity, or horizontal violence or having the temperament and mentality of a eight year-old or whatever you want.
This makes me so proud of nurses.
*I mean crusty as in peel-the-paint-of-the-walls-with-a-glance crusty. Angry-spitting-camel crusty. They even frighten me.
†I meant to ask, are you guys bored with my endless fascination with intradepartment politics? I’m sure the nurses among you find it as equally entertaining, but. . .
‡I also strongly suspect some highly critical and nasty things were said about me, but ignorance is bliss.