Privacy, judgment and ethics aside, I have caring to do.

A few years ago I cared for an acquaintance. She was a friend of a friend who had been living out of the country for several years, but had come home to visit family friends. She was rushed in to the ED and before I even knew who she was I was delivering her 19 week old fetus. When I finally looked up to see the mother’s face I realized we knew each other. I said nothing. In that moment I didn’t care about what the College would say about caring for those you know when there was a real emergency to deal with. I held her hand as she passed the placenta and focused on stabilizing her blood pressure by putting in the largest IVs as I could.  I asked her if she remembered me and if she would prefer another nurse cared for her. She asked me to stay. I comforted her and showed her the baby she would never get to know. I checked on her every half hour that shift and came in early for my next shift to find out how she was. There was no time to feel sad until my shift was over and like the other children and babies and fetuses I have seen pass away, they stick around in my heart and mind a lot longer. There are those patients that stick with you, elderly or middle aged, etc, but I think most any emergency nurse can agree that child patients are the some of the longest lasting in our memories. And for me, the ones who haven’t even started in this world are forever imprinted.

I saw my acquaintance a few months later, she was home again, in the grocery store and she thanked me for what I had done for her and told me she would never forget me. The thank you warmed my heart but I knew she would no longer remember me as the girl she had a beer with when we were in our early 20s, but as the nurse who was there when she lost her baby.  Judgment, confidentiality, privacy, all of those ethical principles aside, perhaps that’s why we shouldn’t care for ones we know, even if just a little, because it affects us too.

I recently found out that she gave birth to a daughter and it’s amazing how happy I felt for someone I don’t really know to have had a baby.  I wanted to find a way to contact her to wish her well but elected not to as I didn’t want to be THAT nurse wishing her well, inadvertently reminding her of what she lost before.  Nevertheless, I personally take solace in knowing that despite all of the sad and terrible we see rarely hearing from these patients again, they do in fact have happiness and joy in their lives later on.

Charge Mommy

A few days ago, one of my colleagues said to me after a particularly frantic day in the ED, “You guys aren’t Charge Nurses, you’re Charge Mommies.” She is right. This is what we do:

• tell all the kids don’t fight and play nice

• fix boo-boos

• give hugs as needed, or tissue

• make sure all the kids get lunch

• find things

• repair broken toys

• clean up little “accidents”

• greet guests, and ensure they’re fed and comfortable

• make sure everyone keeps the place tidy

• assign chores

• deal with the unpleasant relatives upstairs

The one thing I don’t do is enforce discipline. No spankings or time outs. I have a Manager Mommy for that.

When the Police Come Calling

The police are more-or-less a permanent fixture in every Emergency department. They bring in the drunks, the suicidal, the psychotic, the homeless and yes, the criminal, who have either sustained injuries as a result of their activities, or else have developed sudden (and convenient) cardiac symptoms upon their arrest. Most of us in Acme Regional’s ED will cooperate with the police to the point of expediting whatever they need us to do, which usually means filling out the Form 1 or medically clearing the patient. At the same time, most of are pretty clear that ED nurses and physicians are not an extension of the Police Service: police objectives and those of health care, to state the obvious,  are not the same.

It isn’t exactly mistrust. It’s more a wariness. There are ethical and legal issues involved. We cannot, for example, divulge patient information, so there is the constant dance of the police asking for information they know we won’t give them.  Come back with a subpoena, we tell them. They try anyway.

Then there is this: what do when the police bring in someone who, well, they’ve been beating on. It isn’t common, I should emphasize, but it isn’t so rare that it excites comment either. The police will say (nudge, nudge) the patient fell on the pavement while being arrested. Or banged his head while getting into the cruiser. Or the wall hit his face. Which may even be partly true. The patient usually says nothing at all.

So what do we do about it? Approximately nothing. We might document the injuries, in case there are  legal problems down the road. Or not. We are definitely not going to make any allegations about misuse of force. Who wants to travel that road, full of traps and pitfalls and paper by the mile plus, of course, the undying enmity of the local cops? I have seen a few pretty egregious cases, and we did exactly that — nothing. As well, I suppose many of us don’t want to second guess the police: I mean, who knows how things really go down, right? And we say, didn’t he deserve it anyway?

But how does this make anyone accountable? Including ourselves? And don’t we have a legal system in place to adjudicate innocence and guilt, and administer punishment?

It’s a moral swamp. And having thought about it long and hard, I’m not clear what, if anything, that can be done about it in practical terms. ED staff are not the guardians of the guardians. So we document. Poor excuse, I know.

Epic Hitler Emergency Department Charge Nurse Rant

I never thought I’d use the words “Epic” and “Hitler” and “Emergency Department” and “Charge Nurse” and “Rant” as a blog title, but what the hell. I was bored one night and thought it would be fun to make a Hitler rant parody.

Saved by Words for Friends

Ok, we’ve both been out of commission for a couple of weeks.  Our Miss Jean Hill, bright future of the nursing profession and co-blogger extraordinaire,  has a computer which has suffered last week the CPU equivalent of a massive cerebral bleed and maybe ethanol withdrawal too; the computer has since recovered, but Jean Hill’s nerves have been so shattered by the experience that it has left her tongue-tied, even catatonic. Which if you know Jean Hill, is a somewhat singular experience. At any rate, once she collects herself, she will be back. As for me, the schedule from hell and a lack of prewritten posts is my excuse. . . don’t you hate it when life gets in the way of what’s really important?

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The other day I was touring home from one of those interminable staff meetings about nothing at all, and I decided to stop in at an interesting-looking shop near Acme Regional. Since I live a little distance from my employment, my usual pattern is to race to the TorontoEmerg Lair and NurseCave on the nearest 400-series highway so I might more speedily savour the delights of Stately Doe Manor.

So I was innocently perusing the merchandise — mostly crap, alas — when someone tapped me on the shoulder. I looked around.

“Do you live around here?” a woman asked. She looked vaguely familiar.

“Uh, no.”

I need more vowels to spell crazy.

“You work at the hospital, don’t you.”

Goddamnit all to hell, I thought, except I inserted the f-bomb at least twice. Caught.

“Um, yes.”

And then she looked at me expectantly.She had the sort of blotchy complexion and body shape that suggested cholecystitis before 40. She seemed a little crazed, which made me a little, well, anxious. She clearly wanted me to comment on her mother’s/child’s/lover’s/nephew’s (or her) condition/prognosis/diagnosis/lab results/medications. Which, equally clearly, I couldn’t have done, even if I did remember her.

Then my phone buzzed.

“Excuse me,” I said. I stared intently at the phone and pretended the message was of such urgency and import as to leave me befuddled. I tapped the screen viciously.

She went away. I let out my breath.

There was no emergency. Of course it was nothing of the sort. It was my turn to play Words with Friends. Thank God for time-wasting aps.

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So I went to a second interview for a managerial position which in fact involves little actual management but is more administrative and actually fairly bomb-proof in an era of flat-lined hospital budgets. I actually really really want this position. I would feel fairly positive except the manager interviewing made what I have come to think of as the kiss of death statement: “It has been a real pleasure having the opportunity to get to know you.” Translation: Buh-bye, we will see you no more. Or am I parsing too much?

Nurses Grieve Too

An underexplored or ignored aspect of nursing professional life: how nurses working in a Labour and Delivery unit grieve over the loss of their patients, and how this grief affects care and support of survivors. What is really striking about the film is the culture of mutual support and respect among the nurses working in this unit — I hope it’s real and not just the product of the filmmaker’s eye, but the cynical side of me wants to think it’s idealized.

Though the film’s focus is in L & D, it makes me think of how nurses deal with loss in the Emergency department. The prevailing culture and mores of most EDs does not encourage touchy-feely moments, at least in not many of them. The expectation, frankly, is to suck it up and tough it out. The Emergency department is not for the weak of heart. Shrinking violets need not apply. Et cetera. But the question is whether we as nurses are able to provide good care to our patients without acknowledging and reflecting on how grief affects us. Or whether unacknowledged and unvalidated grief leads to higher burnout — and also some unintended psychological effects like PSTD.

In Which TorontoEmerg is So Busted, or, Welcome, Jean Hill

A few weeks ago, I was talking with a colleague, whom I will call Jean Hill, and by-the-by the conversation fell to nurse bloggers. Several prominent ones were mentioned, like Crass-Pollination and Emergiblog and Nerdy Nurse.

“Oh,” said Jean Hill innocently. “I wish I could write like these guys.”

At which point your humble blogger’s eyes began to sparkle rather a cat’s contemplating a mouse. Come in my parlour, said the spider to the fly, I thought. You see, dear readers, I have been contemplating the addition of a co-blogger for some time. *

Nurse Jean Hill. (Dramatic reconstruction. Not intended to be an actual image.)

But how to lure the prey?

I told Jean Hill to meet me in the ambulance bay after shift. I told her portentously I had something I needed to ask her.

So later, in the ambulance bay, I told Jean Hill about this blog, my anonymity and whether or not she would like to come aboard the Good Ship Those Emergency Blues as a co-blogger.

She would, she said. She would be pleased. She had, she said, been reading the blog for a long time.

“So you knew about Those Emergency Blues?” I asked, secretly very pleased that someone from Acme Regional was reading it.

“Oh yes,” she replied. “And, you know, I knew it was you all the time.”

Oh crap. “Really?”

“Well, you sometimes talk like the blog, so I figured it out.”

By which, I suppose, she means I speak in a pedantic, self-important, pompous manner, but was too kind to say so. At any rate, I am very pleased Jean Hill has come to write here. I think she will be writing once or twice a week (hopefully more!) beginning in a few days on topics which interest her. Since this is her first time publicly writing a few small words of encouragement will be welcome.

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*For mostly selfish reasons, i.e. to ensure there is more content consistently posted, to free up time so I can write better for this blog, to work on some other writing projects, etc.

More on When Labelling Patients Causes Patients to Die

In the comments WhiteCoat (of WhiteCoat’s Call Room fame) strenuously objects to my take on the Anna Brown case:

Wow.

Someone on my blog suggested that I check out this post after I just posted about this story yesterday.

To all of you who think “something more should have been done,” what should that “something” have been? She had multiple tests and exams performed for the same complaint – including sonograms which showed no blood clots the day before she died. She was having the same pain in her legs since she was hospitalized the week before. Gold standard test for DVTs is ultrasound. Do we repeat the ultrasound every day? Every hour? What other testing was “necessary”?

TorontoEmerg – think of all the patients you see with back pain requesting narcotic pain medications. Do you order serial MRIs on them to rule out the possibility of cauda equina? Or tumor? If so, what is the medical basis for the testing? If not, why? I’m assuming you don’t. When you miss the one patient who has a tumor and becomes paralyzed, you’ll be harangued because “obviously” the patient had something wrong and you neglected to address it. Yet once you tell the patients that they won’t be receiving any narcotic pain medications, many of the patients in severe pain stand up, curse at you, and storm out of the emergency department.

You say that Ms. Brown was “unable to walk.” The article showed that a nurse saw her standing the same day that she couldn’t walk. How many patients do you see who come to the emergency department and can’t get out of their car when they arrive? That’s a “red flag” that something is wrong. Do you order a million dollar workup on all of them? How many patients do you see who have had dozens of normal CT scans for their chronic abdominal pain? Is that proper medical care? I could go on and on, but you get the point.

The problem is that your post suffers from horrible hindsight bias. You knew the outcome and now you’re bashing the people who treated Ms. Brown because they didn’t have the ability to look into the future to see what would happen.

Yes, the outcome was horrible. Yes, there were miscues and miscommunication. I’m sure that Ms. Brown was “labeled” as someone trying to game the system. Society “labels” every aspect of our lives every day. President Obama is “liberal.” Ron Paul is “crazy.” Pit bulls are “dangerous.” Doctors are “rich.” Baby pandas are “cute.” Doing so doesn’t make us bad, it makes us human. Someone who was articulate and polite to the providers and to the police may have been treated differently. One of my readers said this was the “perfect storm” of events leading up to Ms. Brown’s death.

To say that Ms. Brown didn’t receive proper care or that her complaints were ignored is just wrong. I’m betting if you ordered all the testing you think Ms. Brown should have received on all of the patients who walked through the doors at your emergency department, *you’d* be the one being ridiculed.

I appreciate WhiteCoat taking the time to post such a lengthy reply. He fully explicates many of his points on his blog. I won’t editorialize much here, because I think his perspective is important to how we discuss cases like Anna Brown. I don’t share his point of view for a number of reasons, but I do agree with him that labelling people makes us human. The trouble starts, for me at least,  when we allow our interior — and often unrealized — biases to influence our care.

Just Because I Don’t Remember You Doesn’t Mean I Didn’t Care

In the Emergency Department where I work, the number of patients we see pushes 200 some days. We assess and treat a lot of people, mostly for lumps and bumps, breaks and bruises, but also for major, cataclysmic, life-altering events — MIs, trauma, stroke, what-have-you.

I have a problem. The moment to the patient leaves the department I tend to forget them. Completely. If you are a run of the mill STEMI, I swear I will not remember you the next day. I may not remember you in an hour. A little while ago, my manager asked me about a case receiving some, um, legal attention. It was only after a good deal of prodding that I vaguely remembered — and this was a Code Blue! (Fortunately the legal formalities were about treatment received on previous visits, so I wasn’t directly involved. My charting was good, anyway.)

I do remember some cases which for one reason or another have stuck in my mind. (For example, like here. Or here. Or here, among others.) But mostly, nah. Maybe it’s because of the sheer volume. Maybe because my head will explode if I remembered the details on each and every patient. Maybe it’s just coping skills. Who knows. Anyone else have this problem?

Anyway, I was triaging the other day, and a patient told me how much she appreciated the care I gave her husband. (He was a Triple A, and survived.) I goggled at her for a second — we don’t frequently receive compliments in the ED — and said, “Yes, of course, I remember him.” She beamed. I made her happy. But I didn’t remember him at all. The patient’s husband was all in a day’s work for me — and a hugely important day in her life. We tend to forget what impact we have on patients and families. So a small lie for a good cause, I guess, a tiny bit of therapeutic communication.

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Some stupid to ponder, or how a local employer treats their nurses like idiots. Our local CCAC — the provincial agency which arranges for Home Care and related services — hath decreed that case managers are no longer permitted to use hospital-provided educational materials because 1) they haven’t been vetted by CCAC and 2) because the case managers haven’t been in-serviced on them.

Really.

CCAC evidently thinks their case managers — all RNs, by the way — are complete idiots in that they can’t tell patients using a hospital provided form when to come back the ED because (for example) their saline lock is infected. And CCAC believes that hospital put out bogus and misleading educational materials.

Sometimes you just have to shake your head. And mutter. Who comes up with these bonehead rules, anyway? Do managers lie awake at night thinking them up?

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On a personal note, thanks to all who emailed or tweeted or otherwise left messages of support regarding the family medical emergency a couple of weeks ago. All is well again, but I was a little frightened for a while. Your concern was really appreciated, and made me realize that I — we — have a great little community around this blog. Thanks!

A Poem for Easter

My own, with at least Easterish themes of death and rebirth. Originally published on 7/10/10.

VSA

You came to us, no vital signs, no breath
Found dead, or nearly so, by the mall
You last saw cars, careening carts, a child.
Then falling, hard pavement, blood, a void empty
Of consciousness when help came, skin mottled.
(And paramedics glared and muttered Too late)
But still by breaking bones your heart caressing
Blood returned, with oxygen, drugs and life.
No life did we see, but a purple face,
(Though never we speak it, we thought Too Late,)
V fib, we worked the algorithm, shocked
Gave epi, shocked, and then surprising you,
You gasped, and meaning to die, you did not:
Eyes from a dark face stared incredulous.