Archive for May, 2011

Defending Insite from a Faith Perspective

A nurse offers a defence of Insite, the safe drug injection clinic operating in Vancouver’s Downtown Eastside. What I find interesting is that contrary to expectations,  Meera Bai’s work at the clinic is based on a very personal, explicitly Christian ethic:

I think that we are all extended grace by God and that we are all loved by God and made in the image of God. When we talk to addicts and we spend time with them, we see them as human, just like ourselves, and see glimpses of God in them because they were made in God’s image. … We’re clearly called in the bible to spend time with the marginalized and to protect those who are struggling. Many of these people have gone through incredible abuse in their childhood and throughout their lives. God, for us, as Christians, he’s a place where we can go where we don’t have to be ashamed.

[SNIP]

I gave a talk at Ambrose University College [a private evangelical university], which is quite a big seminary in Calgary. It was a public lecture and they thought maybe 50 people would come, but 150 showed up. One of the people who came, he put up his hand and said, ‘I’m a donor for Ambrose and I was quite appalled that they were doing this talk. So I came here because I think this is wrong. But now I realize what Insite does and this is completely what Christ would be doing. If Jesus was here, he would be washing feet the same way.’

It’s refreshing, for me anyway, to see a forthright explanation of the relation of a Christian ethic to practice in a way that speaks to compassion and service. This is in contrast the cramped and blinkered view of many of my co-religionists, whom I suspect would expend much time finding biblical justification for stepping over drug addicts rather than facing up to the fact these are human beings in need.

Nurses (or other health care professionals, for that matter) don’t often speak publicly about the ways the life of the spirit informs and motivates their practice, though I suspect for many nurses faith plays an important role. The problem is, discussing the role faith plays in the provision of health care almost inevitably seems to come back to the debate around therapeutic abortion, which in turn has distorted and marginalized any real talk about the role of faith for both ourselves and our patients. I sometimes thinks this is the reason nurses are hesitant to discuss spirituality or the spiritual aspects of care — with or without organized religion — even when we, or more importantly, our patients need and want it.

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Margaret Wente is Wrong on Substance Abuse

Margaret Wente opines on drug addiction based on some book she read:

Advocates for the disease model of addiction say their arguments are evidence-based, and that their opponents are driven by ideology. But the closer you look, the shakier is the evidence for the disease model of addiction. The most cogent critique comes from Gene Heyman, a research psychologist and lecturer at Harvard Medical School. His book Addiction: A Disorder of Choice makes a convincing case that choice plays a much more important role in addiction than in other psychiatric disorders. And it demolishes the current “enlightened” picture of addiction as a chronic, relapsing illness with a bleak prognosis for recovery.

She concludes, against the general medical consensus (those elitists!) that

[d]rug addiction is a set of self-destructive impulses that are out of control – just like all the other impulses that lead us to choose short-term pleasure at the price of long-term pain.

The thing I always find remarkable about Wente is that under the guise of being contrarian, she almost always ends up confirming popular prejudices. Addiction is not a disease! Addicts deserve everything they get! Addiction is a moral choice! Conventional treatment enables addicts! Helping addicts by providing harm reduction strategies is wrong! Punish addicts for their addiction! And so on.

Wente nods (very) briefly to the benefits of the disease model of addiction, and the need to treat addicts with empathy and compassion. But how many people actually remember the real reasons we treat sick people, including substance abusers, in the rush to judgement?

“A disease is a condition,” Wente says, “that’s beyond your power to control.” Well, no. I would define disease, and I think I would get nods of agreement from my health professional colleagues, as any condition that prevents an individual from functioning with optimal social, mental or physical well-being. Unfortunately Wente thinks disease is always something entirely random, like bacterial meningitis or ALS. What I would like to ask Wente is this: if addiction is not a disease, and if addicts are entirely responsible for their condition, what about non-insulin dependent diabetics and those suffering from heart disease, which have strong links to lifestyle choices and, some would say, self-destructive impulses? Why should we treat them any differently than drug addicts?

The point is we all make choices, good or bad, for our health. Choice, however, often implies a moral value judgement and the assignment of blame: two things clinicians should avoid in treating patients. But choice — whether it’s your 80-year-old diabetic grandmother or the homeless substance abuser down the street — shouldn’t be confused with disease.

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Observations and Assessments

Notions to small for a blog post, all in one place.

Pomodoro is not just Italian for tomato. It’s actually an effective time-management technique. Like (for example) in clearing up unanswered emails. I find it actually keeps me focussed on writing, and helps me avoid the ever-present temptation of the evil Twitter.

The best thing about basic nursing is that it reminds you of why you became a nurse. An elemental truth. Susan Eller explains:

This patient in the hallway, waiting for a bed and needing some pain medications just needed some routine nursing care: comfort measures, information, and compassion.

Yet, the wife took my hand before they left the ED and thanked me for taking the time.  She appreciated that even though he wasn’t my patient, and she could see that I was busy, that I took the time to make sure that he was informed and comfortable.

It startled me that she was so grateful. In my perspective, I was just doing my job the way I always do it.  In the scope of my busy day with critically ill patients who needed so much more, this tiny little thing that I did made an impact on her.

Coal Cares. Really, they do.

And the high and mighty this campaign managed to piss off. Given the thousands that air pollution kills every year by exacerbating various respiratory illnesses, you’d think the coal industry — whose contribution to poor air quality is remarkable — would be a little less, um, shameless.

Parakeet madness in Britain. Hitchcock would have a field day.

A good source of nursing blogs (via @DrDeanBurke). Oh, yeah. There I am. Sweet.

More on bullying. The Nursing Ethics Blog:

The hardest questions I’ve ever been asked by med students and nursing students have to do with bullying, and with the difficulties inherent in being at the bottom of their respective professional hierarchies. Students understandably find it difficult — and a source of moral distress — to be not only subject to bullying, but to sometimes be involved in courses of action that they see as unethical and yet powerless to do anything about it.

In discussions I’ve seen around the Interwebs this past week, the consensus seems to be the risk of bullying decreases with experience and growth of confidence. Which begs the question: why do we subject the most valuable and vulnerable members of our profession to this behaviour?

And still more. From a med student who gets it:

As a medical student, I’ve witnessed and experienced my share of bullying by a handful of doctors (though to be fair, by nurses as well). In one instance, I watched a surgeon mock a new nurse in the operating room, teaching her with absurd faux-patience how to properly hand him his instruments.

And silence still kills. “Research and regulatory bodies have long confirmed that poor communication in healthcare is harmful at best and deadly at worst.”

Dept. of It Was Too Good To be True. Magnet hospitals are just as sucky for nurses as normal hospitals. Except they’re better at self-promotion.

Housekeeping. The spam filter has been acting up again. I gave it a good swift kick, and restored some comments that were placed in the spam file.

Also if you have emailed in past while and I haven’t gotten back to you, I will. A friend of mine declared email bankruptcy and deleted a whack of messages in one fell swoop, on the theory she was never going to asnwerthem, and they were just sitting there, making her worried and a little neurotic. Not quite there, but I can see the premise.

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I Cannot Write This Blog Without the Love and Support of My Husband

A short farce of two lines.

Me: (excited) Hey, my blog post just got tweeted by the American Journal of Nursing.

Spouse: They told you to knock it off?

(Curtain.)

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Favourite Poems XXXVI

Roald Dahl’s poem is probably not suitable for children, despite the deceptive, rollicking verse; hell, it’s hardly suitable for adults either, but still, it’s pretty funny.

The Pig

In England once there lived a big
A wonderfully clever pig.
To everybody it was plain
That Piggy had a massive brain.
He worked out sums inside his head,
There was no book he hadn’t read.
He knew what made an airplane fly,
He knew how engines worked and why.
He knew all this, but in the end
One question drove him round the bend:
He simply couldn’t puzzle out
What LIFE was really all about.

What was the reason for his birth?
Why was he placed upon this earth?
His giant brain went round and round.
Alas, no answer could be found.
Till suddenly one wondrous night.
All in a flash he saw the light.
He jumped up like a ballet dancer
And yelled, “By gum, I’ve got the answer!”
“They want my bacon slice by slice
“To sell at a tremendous price!
“They want my tender juicy chops
“To put in all the butcher’s shops!
“They want my pork to make a roast
“And that’s the part’ll cost the most!
“They want my sausages in strings!
“They even want my chitterlings!
“The butcher’s shop! The carving knife!
“That is the reason for my life!”

Such thoughts as these are not designed
To give a pig great peace of mind.
Next morning, in comes Farmer Bland,
A pail of pigswill in his hand,
And piggy with a mighty roar,
Bashes the farmer to the floor. . .
Now comes the rather grizzly bit
So let’s not make too much of it,
Except that you must understand
That Piggy did eat Farmer Bland,
He ate him up from head to toe,
Chewing the pieces nice and slow.
It took an hour to reach the feet,
Because there was so much to eat,
And when he finished, Pig, of course,
Felt absolutely no remorse.

Slowly he scratched his brainy head
And with a little smile he said,
“I had a fairly powerful hunch
“That he might have me for his lunch.
“And so, because I feared the worst,
“I thought I’d better eat him first.”

— Roald Dahl

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A Medication Error Leads to Suicide

A nurse commits suicide:

Kimberly Hiatt, 50, a longtime critical-care nurse at [Seattle Children’s Hospital], took her own life April 3. As a result, the state’s Nursing Commission last week closed its investigation of her actions in the Sept. 19 death of Kaia Zautner, a critically ill infant who died in part from complications from an overdose of calcium chloride.

After the infant’s death, the hospital put Hiatt on administrative leave and soon dismissed her. In the months following, she battled to keep her nursing license in the hopes of continuing the work she loved, despite having made the deadly mistake, friends and family members said.

To satisfy state disciplinary authorities, she agreed to pay a fine and to undergo a four-year probationary period during which she would be supervised at any future nursing job when she gave medication, along with other conditions, said Sharon Crum of Issaquah, Hiatt’s mother.

“She absolutely adored her job” at Children’s, where she had worked for about 27 years, said Crum. “It broke her heart when she was dismissed … She cried for two solid weeks. Not just that she lost her job, but that she lost a child.”

Is it just for a nurse to be fired for a medication error, even if lethal? Most hospitals do have procedures in place to deal with such errors, aimed at discovering the root causes of mistakes in order to improve patient safety. A key part of this process is to encourage nurses to report medication errors and even near-misses without threat of retaliation or disciplinary measures, but instead to offer education to strengthen skills and critical thinking. The hope is that in doing so, flaws in the process of drug administration can be easily identified and corrected.

Unfortunately, such an arrangement requires a certain degree of trust between management and the front line. When I worked in the U.S., management decided to implement a “No discipline, no retaliation” policy for medication errors. When the ED manager was asked if there actually would be no discipline taken for medication errors, she laughed and told us it would be “situational.” You can guess how successful the new policy was. Once trust is lost between front line nurses and management, it’s difficult to restore.

Firing a nurse distracts from actually promoting safety in a meaningful way, and diverts attention, as Kevin Pho points out, from where responsibility ultimately rests for ensuring safe medication practices: the senior management. Hospitals will fire nurses in the mistaken belief that removing a nurse who has committed a lethal error — an easy target, at that, if truth be told — will somehow reduce risk and liability and demonstrate commitment to patient safety. In fact, the precise opposite is true. By disciplining nurses who commit errors, and by not engaging in remediation with these nurses,  a climate is created where errors, if they occur, are likely to go unreported and unresolved — and substantially increasing risk.

It it enormously tragic a 8 month-old child died as a result of a medication error. And to be clear, none of this evades the ultimate responsibility of the RN to administer medications correctly. It’s important to note the state nursing board imposed substantial sanctions on this nurse, just prior to her suicide, including a requirement to be supervised while administering medications for four years.

Yet it’s also tragedy multiplied that the Seattle Children’s Hospital saw fit essentially first to scapegoat her, evading its own responsibility, and then to drive a 27-year veteran from the profession, leading to the point where she saw no other option but to kill herself. It’s interesting, in the context of the discussion around bullying this week in the nursosphere, that this news story should present itself. Were hospital administrators acting as bullies? When you think of how bullies behave and the sequellae of their behaviour on their victim — suicide being among them — you have to wonder.

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

Theresa Brown has taken some heat for the op-ed she wrote for the New York Times last Sunday. When she wrote about her experiences being bullied by a physician and the detrimental effect bullying has on patient care, the reaction from MDs was angry and defensive. I am beginning to think, after reading though all the posts and comments, that her real sin was being a nurse challenging physician authority. Ford Vox, writing at The Atlantic took particular umbrage at a physician being called out at Brown’s work place. “Drawing and quartering your coworkers in the Sunday New York Times,” he wrote, might be run-of-the-mill for politicians. I’d like to see something better out of doctors and nurses.”  While making a very slight nod to the issue of  bullying behaviour among physicians, Vox’s principal objection to Brown’s article was the ethics of making an example of one particular physician; he went to an exceptional effort at demonstrating the physician could be identified — at least by his co-workers — by a Google search (and in the process outing Brown’s place of work, which at least one commenter construed as an act of bullying itself.)

Kevin Pho was somewhat more even-handed. But still, while acknowledging that bullying is a serious issue — which Vox trivializes as a “workplace spat” —  he accuses Brown acting in bad faith, of pandering to an anti-physician audience and “metaphorically” acting as a bully herself; he also engages in a tu quoque argument that nurses in general are bullies themselves. “Shouldn’t they [i.e. nurses],” he asks rhetorically, “bear some responsibility as well?” (Except that we do. Endlessly. Do physicians in the same way?)

The message, in any case, from our physician colleagues, is that nurses should shut up. We should not be airing our dirty linen in public. Any mention of physician bullying will only serve to exacerbate poor nurse-physician relations. It’s unfair to single out physicians. We aren’t bad actors ourselves, we treat nurses with the utmost respect, ergo, nurses should acknowledge the physician bully is a singular creature, as unique as a butterfly in a Toronto January. Et cetera.

I beg to differ.

I don’t think it’s quite true that physician bullying is rare and out of ordinary, even now, despite assertions to the contrary. When I thought about it, I realized without too much difficulty I could list dozens of examples of physician bullying, that I have been subjected to or witnessed, some dating from the dark ages of the late 1990s. These range from the utterly appalling — like the ED physician who unfairly and angrily blamed the primary RN for the death of a septic neonate, in front of the parents — to the half-humourous, some of which I have documented on this blog. I’m pretty sure nurses reading this could come up with a similar list.

Stating that some physicians bully, and that it is a more widespread problem than physicians themselves suppose, is not to take away from the respectful and collegial relationships I enjoy with the vast majority of the physicians I work with, but rather to address the reality of the complex power relationships in the hospital pecking order. It isn’t physician-bashing to point out the obvious. In any case both Vox and Pho ignore the central point in Brown’s piece: that when physicians bully, patient care suffers. It suffers because nurses are understandably reluctant to deal with a physician who will demean them. Who wants to call with a high blood sugar in the middle of the night, or question an inappropriate medication order, if you’re pretty sure you’re going to get reamed out in the process? It suffers because it’s a large factor in determining quality of nursing work life: poor nursing morale results in poor patient outcomes.

So there are some very good reasons to point out this behaviour out. Should have Brown been so specific, even if anonymously so? Both Vox and Pho complain vigorously about Brown’s lack of discretion in her account of the incident. My only thought is that their reaction is a bit over-dramatic, because the only people witnessing the inappropriate behaviour were the care team and the patient — and they don’t have to be told who the bully is. Further, I guess if Brown is as careful as most health care bloggers, she’s disguised the identity of the physician in question by changing details and artful misdirection so that it would be difficult for even employees of her institution to make identification. And I’ll add a small artistic quibble: a direct, concise, personal example is worth a thousand words of exposition. In the event, I’m not clear where the appropriate place would be to deal with it, except publicly and openly.

Bullying is an exceedingly frustrating issue for nurses, mostly because of the sense of powerlessness. When you’re subjected to the bullying, you feel like a target, and helpless to boot — and you can only respond with difficulty because the power relationships within the hospital hierarchy. In short, physician-bullies, like bullies everywhere, get away with it because they can. Nurses have been complaining about bad physician behaviour since Florence Nightingale disembarked at Scutari. You would think, that after 150-odd years of politely asking physicians to pull up their socks, they might take the issue to heart and engage in some real collective self-reflection on the issue.

It was encouraging to see this in a few of the comments to all the posts, amid all the palpable anger toward Brown. But she only put to words what every nurse knows. The physician reaction to complaints of inappropriate behaviour has always been to minimize, to scorn, to condescend, to trivialize, to redirect, or to deny. Kevin Pho points out, correctly, that hospitals are beginning to address the issue through workplace respect programs. But in all seriousness, how many physicians have actually been called to account in any meaningful way by these programs? Pho writes, in another post on the subject that, “My issue is Brown’s methods, by pitting a wronged nurse against arrogant doctors. It’s a narrative that physicians will lose 100% of the time, no matter how they respond.” True enough. But despite this, it’s also true that nearly 100% of the time bullying physician behaviour will go by without serious consequences. The question I would like to pose to both Vox and Pho — and all the angry physicians out there — is this: have you ever witnessed a physician bullying a nurse, and what did you do about it?

Their answer, I would guess, would be, “Yes, and nothing.” I would be gratified to hear otherwise.

So physicians, stop complaining. We’re merely pointing out bad behaviour. It’s up to you to fix it.

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Gone Gardening, and Theresa Brown Gets Bullied

Spring has finally made a tentative appearance, so I’m outside communing with nature today.

A couple of thoughts to consider: First, is there a connection between bullying in health care and this?

Also, check out the growing dust up between Theresa Brown (@TheresaBrown), who wrote in the New York Times yesterday decrying the culture of bullying in health care institutions, and the somewhat defensive, hand-wringing reactions of some prominent physician bloggers, whose principal objection seems to be nurses shouldn’t have the temerity to call out physicians who bully them. I’m guessing, incidentally, most nurses will agree with Brown on this.

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Scaredy-Scared

What scares me as an emergency nurse?

These do not scare me: cardiac arrest, acute myocardial infarct, major multiple-system trauma, abdominal aortic aneurysms, status epilepticus, flash pulmonary edema, testicular torsion, perforated appendix, esophageal varices, cerebral vascular accident, acute pancreatitis, diabetic ketoacidosis, carbon monoxide poisoning, precipitous delivery, pneumothorax, pulmonary embolism, psychosis, acetominophen overdose, asthma exacerbation, cardiac tamponade, ectopic pregnancy, depressed fontanelles, femur fractures, atypical pneumonias, end-stage liver cancer, COPD exacerbation, rectal bleeding by the bucket, and chicken-pox.

I might be worried about you, that you’re about to go south, when the monitors are in constant alarm at your failing vital signs, or you start having runs of ventricular tachycardia or the inotropes are failing to boost up your blood pressure, or when your uncontrolled atrial fib isn’t responding to the diltiazem and it looks like you’re going into CHF. There might well be a sense of urgency, as I try to sort out your rescue catheterization/post-arrest hypothermia/emergency surgery/blood transfusion/transfer to a trauma centre. But I am not frightened, because I know what to do and I have done it all a thousand times before. VSAs: call a code. Stroke: thrombolyse. Pneumothorax: get the chest tube tray. Precipitous birth: call Labour and Delivery.* In the emergency department, it’s all routine and algorithms, remember? That calm focused expression is on the face which has seen everything.

“You can be scared,” I tell my patients, “when I look scared.” And I never look scared, but sometimes I’m quaking in my shoes.

This is what scares me. This is the terror laying in every nurses’ heart:

When I don’t know what’s wrong with you.

Because when we don’t know what’s wrong with you we can’t fix you. Because we end up giving you supportive care, which means we are treating the symptoms, not the cause, and treating the symptoms might make you sicker. When you come with new-onset confusion, fever, rigors, tachycardia; you have no recent travel (so no exotic bugs), you have a negative white cell count,  negative CT and negative lumbar puncture. You appear, as we say euphemistically, in a miracle of understatement, unwell. This means you look like death. And then you start seizing, and we still don’t know what’s wrong with you, so we give you drugs to make the seizures stop — more supportive care — and we intubate because you’re comatose and it doesn’t seem like you’re going to protect your airway anymore. Funky arrhythmias start and your blood pressure drops like a train going over a cliff and then you —

Well, and then you die.

And you’re 29 years old, and your wife is still on her way to the hospital.

I was the primary nurse for this patient some years ago, not long after I graduated. I worried about his death afterwards, thinking I had missed some subtle sign in my initial assessment, some clue that might have saved his life, that I had given the wrong drug, or had set up the dopamine drip incorrectly, or didn’t clue in soon enough he was deteriorating. Or something. Some rationale or reason, to make sense of it. Because he was young and by rights, he should not have died.

After a couple of weeks or so of fretting, disquiet and misery, an older, more experience nurse looked at me critically, but kindly, and said, “He had the best emerg docs and the best internists at his bedside, and they couldn’t figure it out. So don’t you think you’re being a bit dramatic?”

The figurative bucket of cold water. Yep. I was.

Sometimes patients sicken and die and you don’t know why the hell they do. You can be the best nurse since Florence Nightingale pinned her hat, and patients will ignore all your wonderfully exact care. They sometimes will set sail for the yonder shore, oblivious to your best intentions.

Sometimes it has nothing to do with the nursing care at all. I know this in my head. Yet still, I think about this patient even now, and wonder.

__________

*Small inside joke. Actually, get out the Precip tray and pray L & D gets there before anything pops out.

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Shock and Awe Advertising, Part 3

So why do dogs and cats get more donations than our fellow humans anyway? This begs the larger question of why some causes more socially acceptable — by this I mean “safer” — than others. Approximately a billion corporations have attached themselves to breast cancer,  but I would like to see McDonald’s (for example) sponsor AIDS research.

An advertising campaign from ENABLE Scotland.

[Via,]

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