Archive for category Health
Posted by torontoemerg in Health, I'd Better Feel Sorry for Myself 'Cause No One Else Will, Life in the Emergency Department on Monday 07 November 2011
In the Emergency Department, part of a nurse’s job in discharging patients is to figure out if they are good to go home, because in part it’s good nursing practice, but mostly you don’t want to have them bouncing back in a few hours because they didn’t understand something, or have a question. So you eyeball them, do some health teaching, review their prescriptions and follow-up, tell them when and if to come back — and assess their pain. This past week I’ve had five patients — all male, incidentally — who needed scripts for stronger analgesia than what is sold over-the-counter. The doc had overlooked this aspect of their care of them were reluctant to ask for good analgesia directly from the physician. They didn’t want to be seen as being unable to handle the pain. They all ended up with scripts after I advocated for them.
A few days ago, I had a very minor, but enormously painful procedure performed for a notoriously uncomfortable condition in my local (but not my) ED. I got handed a script, and when I was leaving when I noticed the physician neglected to prescribe any analgesia. Percocets or even Tylenol 3 would have been appropriate.
I pondered, briefly, whether I should ask for painkillers. I decided no. I was embarrassed to ask. I didn’t want to be labelled as drug-seeking. The sequel is now I am taking far too many 222s (ASA, codeine and caffeine) and Tylenol 1 than is really good for me (both of which can be gotten over-the-counter in Canada) and also Advil than is really good for me, and I still don’t have good pain control. Though I am feeling pretty spinny from all the caffeine in the 222s and T1s.
Barrier to care, anyone?
Sad to say, nurses and physicians in the Emergency Department still tend to manage pain like every patient is drug-seeking, or will become addicted or else is exaggerating their pain to so they get the “good stuff”; we eschew measurements like self-reported pain scales, instead relying on our highly subjective and unreliable judgment about whether the patient is actually in pain or about the patient’s relative worth. (I have witnessed physicians withholding narcotics from drug-addicts with large bone fractures. Ha ha, take that, you addict! I have also seen orders for morphine 1-2mg q4h for sickle-cell crisis — which, to my mind, manages to be racist, bad practice and plain awful, all at the same time. ) We disbelieve reports of chronic pain. We laugh when a patient presents with back pain and is taking Lyrica. We believe deeply as a culture that suffering somehow ennobles, but in reality only thing suffering does is make people suffer.*
It strikes me that even after
years decades of education about pain management, we still don’t really get it about pain control. If a crusty old emergency nurse like me worries about being labelled as DSI* for asking for ten Percs, do you think there might be something seriously wrong with our approach to pain management?
*I have yet to meet the patient whom overwhelming pain has made into a better person.3.
I swear Allie Brosh has channelled everyone who has ever suffered depression in this brilliant webcomic. Including me. Check it out by clicking on the graphic or the link.
Let’s start with an appetizer:
One thing you need to know before going to the Mississippi Delta is what a Kool-Aid pickle is — and how to make it.
1. Pour pickle juice from a jar of pickles into a bowl.
2. Add Kool-Aid to pickle juice.
3. Pour pickle juice back over pickles.
Where can you find Kool-Aid pickles? All over the region, including at the Double Quick, a chain of convenience stores, many of which also sell a smorgasbord of fried foods.
The video, produced by the NPR and Oxford Magazine, documents the difficulties eating well in (putatively) one of the richest agricultural regions on earth, where fresh, unprocessed food is the exception. Not surprisingly, there is a close relationship between poverty and poor diet; the devastating sequellae of diabetes, hypertension, heart disease and stroke, it hardly needs to to be said, ends up afflicting those least able to afford the health care, drugs and lifestyle changes necessary for effective management. Note the interview in the grocery store, and the dearth of fresh vegetables, apart from a few over-processed tomatoes and cucumbers.
Something funny for the afternoon. Fell out of my chair when the ash fell
If you haven’t heard, today is the 50th anniversary of the release in the United States of the combined oral contraceptive, a.k.a. The Pill. Social and religious conservatives have blamed The Pill for everything that has gone wrong since 1960, including but not limited to the destruction of the nuclear family, sexual wantonness, the decline of religiosity, the rise of radical Islamic terrorism, same-sex marriage and the End Of Civilization as We Know It.
The Pill was not introduced in Canada until 1969, which accounts for our generally lagging behind, especially in the Decline and Fall of Civilization bit.
On the other hand, it offered untold millions of women control over their reproduction. To my mind, this was a Good Thing. Control over fertility allowed women to become (finally) fully emancipated in Western societies — and we have been far richer for it, socially, culturally and economically.
Oh, and Happy Mother’s Day too.
I’m off to the country today. In the meantime, in my quest to bring you the best (worst) examples of North American culinary excess, I present the Lady’s Brunch Burger— and yes indeedy, that’s a glazed donut.
A back-of-the-envelope calculation of nutritional value shows an astonishing 1366 calories and 36g of fat — excluding condiments. I’m guessing anyone who finds this appetizing is already on metformin and a calcium channel blocker.
Or Homer Simpson:
[Homer gasping for air due to being so out of shape]
TV Announcer: We take eighteen ounces of sizzling ground beef, and soak it in rich, creamery butter, then we top it off with bacon, ham, and a fried egg. We call it “The Good Morning Burger”.
[Homer starts gurgling in ecstasy]
(The Simpsons “Bart’s Friend Falls in Love”, 1992)
Life imitating art, or what? Or reality catching up to satire?
Freakin’ amazing. As if you needed another reason not to eat at KFC. From The Consumerist:
Last August, we wrote about the “Double Down,” a mysteriously tempting (and potentialy lethal) new food item being tested by KFC. For those coming late to the story, it’s bacon and cheese sandwiched between two pieces of fried chicken. And now, many months later, I’ll finally be able to get my hands on one.
KFC announced the decision to go live with the Double Down yesterday, but we weren’t sure they weren’t playing a April Fools gag. But no, they truly are going nationwide with the delicacy on April 12th.
I’m going to suggest before consumption, dosing oneself with ASA, Plavix and Crestor might be desirable as a prophylactic measure. Post consumption, stat cardiac catheterization with stent placement is advised.
Wish I had Said It: An article in the Guelph Mercury, by Tracie Parr RN, “in honour of her fellow nurses at Guelph General Hospital.” Should be passed out to patients at Triage. Excerpt:
I am the one who keeps you in mind as I look bleakly at our system, and my workload, and the limitations I have to work within. I am the one who often trembles inside with fear and adrenaline yet still choose to give all that I can, while I can, from the moment I walk in the door until my mind allows me to sleep at the end of the day.
I am your target, as your frustration builds from the waiting and uncertainty. I know about discomfort, and I see the frustration as you watch while others are granted entry and the waiting is merciless.
But while you wait, did you know that I am also the one who is caring for someone else whose life is more troubled than yours?
Ankle Update: Up and about on it for short periods of time, but anything more than ten or fifteen minutes is very uncomfortable. Been wathing a colossal amount of television, probably more in the past three or four days than I’ve watched in a couple of years, and I’m stunned by the the equally colossal amount of shit being broadcast. You tend to forget. Good thing I have drugs to dull the pain — and the senses.
From Nuts to Soup: My newest favourite comfort food is Italian Wedding soup. Anyone know a good recipe? I’m almost afraid to ask: making all those tiny meatballs is surely a nuisance.
New Laptop: I’m on the active hunt for a new laptop — old Bessie, on whom I’m writing this post — is increasingly unreliable and unable to deal with the demands of high speed wireless. I’m a bit bewildered by the choices. Any recommendations?
Tripped and fell over on my bum ankle this morning during my morning constitutional— off to the emergency to make sure it’s not a tib-fib fracture. Pretty sure it’s not, but then again it feels different from previous sprains.
Okay, I’m not being wholly truthful. I’m being made to go.
And yes, my nursing colleagues, I have it iced, elevated and tensored. It’s the size of a grapefruit.
Regularly scheduled blogging will resume as soon as I have some narcs on board, because, holy cow, this time it hurts!
Guess what? Patients aren’t getting any. Sleep, that is.
Over time, studies have shown that sleep is important in the critically ill for healing and survival; yet there is consistent evidence that patients in the intensive care unit do not get enough sleep.
Sleep deprivation impinges on recovery and ability to resist infection. It brings about neurologic problems such as delirium and agitation, and respiratory problems because it weakens upper airway muscles, thus prolonging the duration of ventilation and intensive care unit stay. Sleep deprivation may provoke posttraumatic stress disorder, withdrawal symptoms, depression, and continued sleep disruption. Sleep deprivation may reduce pain tolerance; increase fatigue in sympathetic nerve centers; increase sympathetic activity, leading to nocturnal high blood pressure; and blunt chemoreceptor responses promoting ineffective gas exchange.
Sleep is one of those things we nurses love to talk about, but we don’t actually do anything to ensure it. Hospitals (and the sometimes clueless administrators that run them) are as equally as negligent. The Emergency Department is frankly the worst place for patients to sleep, and yet in our 1st Floor Med/Surg/ICU Emergency there are always admitted patients, sometimes as many as 20 or more, spending days in the emerg — a situation not like to change as long as hospital managers continue to treat the Emergency Department as the equivalent of a hospital ward. (This is a problem pretty general in all emergency departments.) There’s no privacy, and patients are tortured with narrow uncomfortable stretchers, bright lights, continuous noise, odd smells, the occasional scream, monitors beeping and an ambient temperature that ranges from frigid to tropical. Not exactly a place, you would think, conducive to sleep. And then we wonder when the patients get a little wonky — a phenomenon called ICU psychosis, or maybe when their recovery is unaccountably poor, or when mortality and morbidity rates start going up.
Florence Nightingale had some remarks about about noise and sleep:
There are certain patients, no doubt, especially where there is slight concussion or other disturbance of the brain, who are affected by mere noise. But intermittent noise, or sudden and sharp noise, in these as in all other cases, affects far more than continuous noise—noise with jar far more than noise without. Of one thing you may be certain, that anything which wakes a patient suddenly out of his sleep will invariably put him into a state of greater excitement, do him more serious, aye, and lasting mischief, than any continuous noise, however loud.
Never to allow a patient to be waked, intentionally or accidentally, is a sine qua non of all good nursing. If he is roused out of his first sleep, he is almost certain to have no more sleep. It is a curious but quite intelligible fact that, if a patient is waked after a few hours’ instead of a few minutes’ sleep, he is much more likely to sleep again. Because pain, like irritability of brain, perpetuates and intensifies itself. If you have gained a respite of either in sleep you have gained more than the mere respite. Both the probability of recurrence and of the same intensity will be diminished; whereas both will be terribly increased by want of sleep. This is the reason why sleep is so all-important. This is the reason why a patient waked in the early part of his sleep loses not only his sleep, but his power to sleep. A healthy person who allows himself to sleep during the day will lose his sleep at night. But it is exactly the reverse with the sick generally; the more they sleep, the better will they be able to sleep. (Notes on Nursing, V.)
Plus ça change, plus c’est la même chose. After 150 years, you’d think we would have learned something.