[A rerun. Originally posted 18/09/2009]
Went to work the other day, found my assignment was in the treatment rooms, walked in and found I had five admitted patients: two fractured hips, a stabilized DKA1, and a couple of FTCs/FTTs2. All but one were over 80 and more or less unable to walk. So you know what sort of day I was going to have — and these were the least acute in the department, which had 27 admits in total. So. I was to provide nursing care for four total care patients, complete initial and ongoing assessments and vital signs, copy orders, ride herd on consultants, fling meds, do bed baths, test blood sugars before each meal (3 x 5 =15 glucometer readings), arrange for various and sundry diagnostics, you know, medical floor stuff, and in between, seeing various lumps and bumps in the other five beds. Which always turn out to be more complicated than the expected — needing IV starts, nebs x 3, complex dressings or some such.
Needless to say, the lumps and bumps took somewhat lower priority than the admitted patients.
So I was busy. Take a number, I hear you saying, the queue starts here. I’m not complaining, really. Sometimes it’s a bit of a break looking after predictable, routine patients: you get to provide some actual nursing care. No brains, no fuss, no muss.
The trouble is, this is becoming the usual, not the exception. I’m starting to see admitted patients discharged from the Emerg, as in going the course from ICU to Stepdown to Telemetry to Medicine to home with a script and a specialist’s appointment in two weeks.
The I had an epiphany: Acme Regional Health Centre doesn’t actually provide emergency services in the space they call the Emergency Department. What we provide is Outpatient Day Surgery, Home Care Evaluation and Ongoing Treatment, a medical/surgical ward, ICU/CCU services, Pre-op Clinic, Fracture Clinic, Ambulatory Care, Office space for Consultants, Psychiatric counselling and Inpatient Services, and a very special place for GPs (and Telehealth Ontario and nursing homes3) to dump patients. We only see a few Emergency patients on the side. Our real job is to be the catch-all and cover for the rest of Acme Regional Health Care. We fix what all the bits and pieces of our overloaded health care system can’t — and get precious little thanks for it.
So really (as a corollary) what’s the point of all the elaborate training and the alphabet soup of certifications I have — and not to mention the eons of experience as an Emerg RN? Is there any point to having Emergency nursing as a specialty when in fact we do very little real emerg nursing anymore?
And why did it take so long for me to figure it out?
2Failure to Cope/Failure to Thrive: a sort of catchall diagnosis, describing frail elderly patients, who can’t go home, usually because they (or their caregivers) have become physically or mentally incapable.
3One of my most petest of pet peeves are nursing homes who call EMS for their obviously failing patients despite utterly clear, written advance directives that state “No Patient Transfer to Hospital. Comfort measures only to be provided at nursing home.” And lo! They come anyway.
So I call them on it. The conversation usually goes like this:
Me: ”I’m calling from Acme Regional Emerg, I’m wanting to know why this patient was transferred here.”
Nursing Home RPN: Snarl, arrrrg, mutter argyfargblah, dehydrated, arf, waaaagh, not eating, waaarg mutter snarf, hiss.
Me: “You did realize that the patient had advanced directives not to be transferred?”
Nursing home RPN: “. . .”
Me: “I mean, was it you who signed the advanced directive form? “
Nursing home RPN: “We can’t provide appropriate care, snarl aarg, wargf, mutter.”
Imagine, a nursing home that can’t care for dying and/or debilitated patients.
If I had a dollar for every time I have had this conversation I would be somewhere else, like a beach waaaaaaaaay south.