Posts Tagged Canada

Portraits of Nurses at War

A small selection of photographs from the National Archives of Canada. Nurses have served with the Canadian military since Northwest Rebellion in 1885 and small contingents were sent to the South African War — the Boer War — at the turn of the last century. Nurses became an official part of the Royal Canadian Army Medical Corps in 1901, and have served in every conflict since.

Nursing sister, First Canadian Contigent, South African War

Nursing sister Ruby Gordon Peterkin. First World War. Note the boots — and heels!

.First World War, in front of a Casualty Clearing Station.

Unidentified Nursing Sister, First World War.

Nursing Sister Ruth Webster, North Africa, Second World War. Great photo. Colour gives this photo an unexpected immediacy. Note the utilitarian uniform, in contrast to the Boer War nurse above, the only concession to tradition being the headdress.

Same nurse. The Archive calls this one Nursing Sister Valerie Hora. Whatever her name — Valerie or Ruth — there is great strength of character in her face which the photographer has captured to an exactitude.

Nursing Sisters of No. 10 Canadian General Hospital, R.C.A.M.C., landing at Arromanches, France, 23 July 1944, about six weeks after D-Day. Eager and enthusiastic.

Canadian Nurses with Bob Hope.

Cpl. Bill Kay Strolls with Nursing Sister Dorothy Rapsey. North Africa? Second World War.

The price. Mass funeral of nurses after a German air raid. Note the nurses’ uniforms on top of the coffins.

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What Nursing Leadership Doesn’t Look Like

A small, belated Christmas tale on how not to manage an emergency department. But first a few preliminary points of information.

First: in Ontario, front line nurses are generally forbidden from taking vacation over the Christmas holidays, usually from some point from the first or second week of December to the first or second week of January. There are a couple of reasons for this: first, there are always staffing issues over Christmas. Secondly, if vacation time is granted by seniority, and if it werepermitted during the Christmas break, the most senior nurses would always get Christmas and New Year’s off, making merry while leaving their more junior colleagues to toil through the happiest time of the year. Hardly fair, and scarcely a morale booster.

My emergency department, Boxing Day

Most hospitals in Ontario will arrange scheduling in this way: nurses work either Christmas or New Year’s (either we pick or alternate each year) but we get five or six days off in a row over the holidays. Like any compromise, it inconveniences some people, but most seem happy about this arrangement.

Second: most Emergency departments over the holidays look like a merger of Bedlam and a random circle of hell from Dante’s Inferno. High acuity and high volume. I might add this holiday season war zone ambience is as predictable as, well, Christmas falling on the 25th of December. We just gird our loins and sally forth. Nevertheless, even halfway through January, we’re all a little crusty and stressed out.

So what would you say to a manager who takes vacation — and not a short one either — over the Christmas holidays? One of my minions has informed me that an ED manager at one Toronto-area hospital took vacation from roughly the middle of December to the middle of January. Needless to say, given all of the above, her staff are not impressed. They are angry. They felt abandoned at a time when leadership was needed. They resent the double standard, the flaunting of the no-vacation-over-Christmas rule. Some of them, I’m told, are so disgusted by this behaviour that they are actively seeking positions elsewhere.

I understand that managers deserve and are entitled to their vacations, and that from a staff nurse’s point of view of there may be no good time for a manager to take time off. Even so, taking vacation when staff cannot, and over time period when volumes and acuity are notoriously high indicates a certain amount of  — what? — cluelessness?

Management does have its privileges, but also has responsibilities. To me responsibility means sticking it out and providing leadership to your staff, even when it’s personally inconvenient. It might mean delaying a vacation for a month. It means not bailing out when you know things are going to be awful. This is good nursing leadership. Or am I completely off base about this?

UPDATE (22/01/12): Minor edit of mispelling. I need an editor, but can’t afford one.

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Awesome

A few days ago, we had VSA come into the department. According to EMS, the patient had collapsed while grocery shopping down the road; CPR was started almost immediately by another shopper; EMS arrived and gave the usual ACLS drugs — epinephrine and atropine, as well as defribrillating him, but the only rhythm showing  on arrival was ventricular fibrillation. We shocked the patient again as soon as soon as we offloaded him onto a Resus Room bed — and (somewhat to the team’s surprise) the patient reverted a sinus rhythm with a palpable, if faint, femoral pulse.

Then the real work started to preserve circulation: intubation to manage the airway, peripheral IVs, drips of various inotropes and antiarrhythmics and sedatives to be set up, a central line and central venous monitoring, an arterial line,  foley catheter, and (at the same time) beginning the therapeutic hypothermia protocol, to preserve the brain from ischemic injury. Therapeutic hypothermia is itself  immensely complicated to implement, involving ice packs, iced saline boluses and iced continuous bladder irrigation to lower core body temperature below 34C.

As we were rolling the patient up to the ICU, I stood outside of myself for  moment and thought, “This was all pretty awesome. We have given this poor guy a chance to live. I have a really awesome job.”

And when we transferred the patient into his bed, he began opening his eyes. We weren’t sedating him enough. But that was pretty awesome too.

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Asking for Drugs

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.

**Drug-seeking individual.

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“We Will Now All Be Unwilling Participants in a Social Experiment That Will Undoubtedly Place Canadian Lives at Risk”

My thoughts exactly, from Alan Drummond of the Canadian Association of Emergency Physicians. His full statement on the proposed repeal of the Gun Registry.

It is regrettable that we, as a nation, are about to embark on an unwelcome social experiment. The Conservative government has been very clear that they intend to finally abolish the gun registry. This is regrettable in so far as it is clear to Canada’s emergency physicians that the gun registry has, in fact, worked and the number of deaths from inappropriate firearms use has dropped dramatically since the institution of the Firearms Act. The government has consistently portrayed this act as a victimization of rural long gun owners, conveniently ignoring the clear scientific evidence that rural suicides with long guns are the principal issue in the tragic toll of Canadian firearms deaths. So we will now all be unwilling participants in a social experiment that will undoubtedly place Canadian lives at risk. Our question to our government is that relative to the perceived inconvenience and cost of registration, what will be the true cost, in direct human suffering, of their ideologically driven and scientifically bankrupt legislation.

Some inconvenient statistics, nicely compiled by the CBC:

Homicide by firearm
Firearm homicides, 2009: 179 (0.53 per 100 000 or about 30% of all homicides)
Firearm homicides, 1991 (the year stricter gun control was introduced):271 (0.97 per 100 000 people)
Types of firearms homicides, 2009:
Rifles or shotguns: 18% (36% in 1999)
Handguns: 69%
Prohibited firearms: 13%
Since 1995, when the gun registry became law, until 2009, the reduction in homicides by long guns: 52%
Spousal homicides caused by shootings, 2000-2009: 167 (23%)
Reduction in the rate for spousal homicides involving firearms from 1980 to 2009: -74% from nearly 3 per million spouses in 1980 to less than 1 per million spouses in 2009, according to Statistics Canada
Share of firearm-related spousal homicides involving a long gun: 50%(The rate of long-gun spousal suicides dropped about 80% between 1983 and 2009.)
Share of family-related homicides of children and youth (7 to 17 years), by shooting, 2000-2009: 26%
Of the last 18 police officers killed in the line of duty, as of August 2010, number killed by long guns: 14 (78%)
Suicide by firearm
Number of firearm-related suicides involving a long-gun, 2004: 475 ( 5.4 times the number of suicides with handguns)
Change in number of firearm-related suicides since the introduction of stricter gun laws in 1991 (as of 2009): -43%
Change in number of firearm-related suicides since the introduction of the Firearms Act in 1995 (as of 2009): -23%
Increased likelihood that a home where there are firearms is the scene of a suicide, than a home without a gun: 4.8 times (based on a 1992 U.S. study in the New England Journal of Medicine)

Incidentally, for you fiscal conservative types, the cost of treating a gunshot victim is about $450,000.

So, on one side of the debate, we have scientific and statistical evidence on the efficacy of the gun registry, expert opinion from health care professionals and the police, the physical and emotional cost of trauma, hundreds of deaths prevented and, on the other side, the hurt feelings of rifle owners. That’s pretty well what it boils down to, right?

[Update 29/10/11: Fixed formatting problems.]

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Andrea Horwath has a Complaint about the Health Care System.

For my American friends and readers, we’re having a provincial election here in Ontario. Since health care is deemed a provincial responsibility (though funded extensively by the federal government), it’s naturally a hot topic of discussion. At the televised leader’s debate a couple of days ago, New Democrat leader Andrea Horwath managed to step in it, just a little, by suggesting Emergency Department staff at Hamilton General Hospital treated her son inappropriately or even incompetently after he injured his elbow skateboarding. “He went to an emergency ward in my community,” she said. “They didn’t do anything for his fractured elbow. They sent him home, said it doesn’t really need anything, they can’t afford a cast, and go home and somebody will help you figure out how to put a sling on it.”

Unlike St. Joseph’s Health Care Centre in Toronto, which took a pasting in the Toronto media after an elderly man made allegations of abuse, Hamilton General pushed back:

Despite her clarification Wednesday, some hospital staffers felt Horwath’s comments were unfair, said Jeff Vallentin spokesperson for Hamilton Health Sciences.
“All I know is there are lots of folks (working here) concerned about the comments … some feel it’s an unfair representation of the hospital.”
He added that no one has made an official complaint about Leonetti’s visit to the ER.

[SNIP]

The hospital’s chief of emergency medicine would not speak on the specifics of the Horwath case, but said it is common for elbow fractures not to be put in a cast.
Dr. Bill Krizmanich works in emergency at McMaster University and said there are many degrees of fracture, from a hairline to a full-out break, and each is treated differently. The elbow is a very complicated joint because of its range of movement and the treatment depends on the severity of the injury.
The most common elbow injury from skateboarding is a radial head fracture, which normally heals permanently in about four to six weeks with very few future problems.
“In those, we don’t splint and we don’t cast. It heals on its own … (and) early mobilization of joints is helpful.”

At the end of it all, Andrea Horwath walked backed her comments, somewhat: her intent, she claims, wasn’t to attack staff but to highlight systemic problems. “The example,” she says, “was meant to illustrate that people are disappointed with the service they’re getting at the hospitals. In the event, it turns it turns out Horwath was not even with her 18-year-old son during the visit; her retelling of the story was at best second-hand — and 18-year-olds are not known for taking direction well.

I guess, to be charitable, Horwath was trying to personalize a complex issue, i.e. validating through personal anecdote reports of poor care at Ontario hospitals. Unfortunately, the leader of the party of the Left managed to fall into the  trap of repeating the same tired meme (ironically!), beloved of right-wing politicians and pundits that Canadian public health care is The Pit From Whence Few Return Alive.

We all have stories of poor treatment by health care institutions, and I am sure this is a commonality of both Canadian and American health care systems. My own story relates to being seen in the ED of Belleville General (I was passing through) presenting with sudden onset of severe headache. I was treated badly by the Emergency physician who plainly thought I was some drug-seeking tourist from The Big Smoke. (The nursing staff, I hasten to add, were superb and professional.)

But anecdotal evidence, while having the power of making the complex real and personal, is also the worst kind of evidence. It’s pretty difficult to generalize conclusions from anecdotes. Even if Horwath’s story is true and my story is true, you can’t point to a larger conclusion, as Horwath does, that “people disappointed with the service they’re getting at the hospitals.”  It’s logically faulty. In any case, the larger point it isn’t actually true, and illustrates nicely the problem of using anecdotal evidence for anything: more often then not you’re going to be caught with your pants down. Statistics Canada has the data.

Patients very or somewhat satisfied with health care services, by region, 2007

Source: Statistics Canada. Patient satisfaction with any health care services received in past 12 months, by sex, household population aged 15 and over, Canada, provinces and territories, occasional (CANSIM Table 105-4080). Ottawa: Statistics Canada, 2008

In Ontario, 86% of people were either very or somewhat satisfied with the health care received. Is there room for improvement? Absolutely, and I am a bit worried about the gap between “somewhat” and “very”, which the StatsCan study does not elaborate upon. If we’re going to talk reasonably about health care reform, let us at least speak rationally, and use evidence and best practices. Bashing health care agencies and professionals isn’t helpful, especially when (I suspect) large number of health care professionals are sympathetic to the New Democrat message.

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Labour Day and the Toronto Sun: An Annotation

Public sector workers are lazy and overpaid parasites sucking at the taxpayer teat. Or something. Please remember to tell us this when we’re doing ACLS on your sorry ass.

Happy Labour Day.

Love,

TorontoEmerg

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Buskerfest

Where I was Thursday. I’m not very good at writing art review-style critiques using high-flown language, but I can say that I enjoyed Buskerfest a lot. There’s a bit of an edge to the performers. They generally live on the margins. They swear freely, even with children present. (O the horrors!) They’re tattooed and pierced, they are sometimes scruffy, and few are, to be a honest, a little creepy. The festival is not in anyway sanitized, which is why I think it is so successful. Some highlights:

Kate Mior. (Website.) One of the best we saw.

(Kate has already run afoul of His Worship the Mayor. According to Now:

Kate Mior has performed her mime-based living statue act for thousands of people all over the world, but she’ll never forget her encounter with Rob Ford.

Last year in Toronto, then-candidate Ford pushed through a crowd she was entertaining and then joked to everyone that she doesn’t pay her taxes.

“There is a certain stigma against street performers,” she acknowledges, “but in Toronto that’s changing.”)

Comment seems superfluous. More Kate:

Acrobats.

More acrobats.

This guy was quite good too. He had put some sort of shield or mask over his eyes to make them look mechanical. The effect was quite disconcerting.

But my favourite? HERE COME THE BUGS!!!

The bugs were great. We loved the bugs.

And no collection of bugs is complete without a Bug  master, who deserves special mention of his own

It’s a great festival, and if you’re downtown this weekend, check it out.

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What I Found in my Garden

A turtle.

I remember as a child reading about turtles (or tortoises) in England, where all proper gardens seemed to have one — and being rather charmed by the idea. So I’m pretty pleased this gentleman (or lady) is residing in mine, even if temporarily. Every garden needs a turtle, in my opinion. (Under this crusty exterior, you see, lurks a sentimental fool.)

I have no idea of the species, but I’m guessing it’s a painted turtle. You can get an idea of the size by the paving bricks.

Also, a purely gratuitous cat picture, since I haven’t posted one of the wee moggie in a while. She looks so, well, innocent, doesn’t she?

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About Jack

Hearing about Jack Layton’s death from cancer driving home yesterday was like a hard punch in the head, and I nearly went off the road. My American readers may not appreciate the genuine respect and affection most Canadians had for the new Leader of the Opposition, even if they vehemently disagreed with his politics. I don’t think I have anything to add to the many, many tributes and obituaries, except this: though I was severely critical of Layton’s stance on the gun registry, he convinced me to vote for the New Democrats this spring for the first time in a federal election since ’93.

Here’s Layton at St. Joseph’s Hospital, Hamilton for the television program Make the Politician Work.

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