Posts Tagged Emergiblog

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.

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Nurses are Like Howler Monkeys, Poo and All

When I was a young, inexperienced nurse, I quickly learned one lesson: the cliché that Emergency nurses are fabulously assertive, mouthy, in-your-face pitbulls is absolutely true. I don’t mean ED nurses are bitchy or backstabbing eat-their-own-young types, though this was true also, at least for some of them. I mean this: the Emergency department is a ballet of constrained chaos most days, with many competing claims for attention for the physician, the charge nurse, and your colleagues; if your patient is sick, you need to be assertive, walk right up to the physician and say, “Doctor, this patient is sick. You need to come look at him right now.” This, admittedly, takes a considerable amount of confidence and an ego the size of a battleship, if you are a new graduate, but the alternative, i.e. the patient dies, is not considered good nursing practice.

A little later in my nursing career one of those battle-axe nurses we all dislike decided she had an issue with me — which is to say, she was nearly shouting at me in front of every nurse in the department — over a triage record she thought was incomplete. When she finished, I asked her quietly asked her to step in our to step into our psych quiet room. I said her behaviour was unacceptable. I asked her to speak with me privately if she had a concern about my practice. I informed her if she ever tried taking me out again, I would speak to the manager. For that point on, until she left the department, this nurse avoided me like the plague. This was good. I deserved to work in a toxin-free workplace, right? More importantly, my patients deserved a nurse who wasn’t stressed out by harassment.

Somewhat after that, I began this blog. After writing some funny stories about strange patients and some sarcastic stories about irrational physicians I began to realize there was far more potential — and interest, if truth be told, because stupid patients stories on the Intertubes are as common as erectile dysfunction spam — in writing about how all the things I saw in the Emergency department related to larger issues surrounding the nursing profession and health care in general. To advocate, in other words. I think I have done this, in some small modest way.

This is how I see advocacy then, as a nurse: first for our patients (Jennifer Olin has some good elaboration here), then for ourselves personally, then for our profession. Needless to say, I’m a strong advocate for all of these. I believe most nurses are, if they think about it.

This brings me to my point. Whatever your perspective on the case of Amanda Trujillo, you might think the whole controversy would be a great opportunity for a thorough look at some hard issues related to advocacy.

There has been a lot of off-topic criticism directed at supporters of Amanda Trujillo — myself included —  for pushing the issue too hard. Mostly, this amounts to personal attacks on her advocates, or that her problems are merely a human resources issue, or that “people” are “tired” about hearing about the case, or that Trujillo is crazy or not credible or both, or that we’re all emotional, or that we’re engaging in bizarre conspiracy theories, or that we’re all drinking the Kool-Aid (because supporting Trujillo is like a cult and/or we’re mindless zombies) or that we all should just sit down and shut up, or that “real” advocates for the profession have advanced degrees and repose in legacy institutions like the American Nurses Association, or that we should trust Banner Health’s judgement (because health care corporations never screw up, I suppose), or we should wait for the disciplinary process at the Arizona Board of Nursing (because the Board investigates all cases correctly and without bias) or (my favourite) that we shouldn’t be “blowing up the Internet” because that will make things “worse” for Trujillo (God knows how, at this point) or lastly, that we don’t have all the facts. (I stipulate to the last, but I don’t think it’s all that relevant — an arguable point, I guess.)

What I am not hearing from the contras is any sustained discussion about what patient advocacy means in the context of a complex, conflicted health care environment, or what places nurses have in informing patients about treatment options, or how to effectively (and collectively) support nurses working in hostile environments, or what to do when hospital policy conflicts with basic nursing ethics, or what advocacy means for nurses in the age of social media.

What I am not hearing from the critics, to be precise, is why Trujillo was wrong to give her patient information on all treatment options, why Banner Health was right to fire Trujillo for what (at worst) could be construed as a minor practice issue, why nurse managers should always bow to angry physicians, why nurses advocating for patients is bad, why Banner Health reporting Trujillo to the state Board of Nursing — a one line complaint! — was necessary to protect the public from harm, why a group of us — including some blogging heavyweights like Emergiblog and Nurse Ratched — have utterly misplaced our passion in supporting Trujillo, and why, finally it is inappropriate to talk about this all over the Internet.

Instead all we get is a lot of fast talk, bloviation and (deliberate?) misinformation. I once hiked in the Guatemalan rainforest near the Mayan ruins at Tikal and a troop of howler monkeys followed us for a long time, flinging poo all the while. I’m having the same sensation now.

Nurses do to each other online exactly as we do to each other in real life. Fling poo. It’s sad, really, that for all our sophistication about social media and tech, things don’t really ever change.

I get that emotions are running high, on both sides. Even so, is it even possible have a serious conversation about Trujillo and what it means to be a nurse and advocate? Even me, secret Pollyanna I am, is beginning to doubt it.

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Note of Clarification: The Arizona Nurses Association issued this statement on their Facebook page, which I am glad to reproduce:  “When AzNA first became aware of this case, Teri Wicker, AzNA President identified a conflict of interest (between AzNA and her employer [Banner Health]) and voluntarily recused herself related to any AzNA discussions or decisions.”

[Cross-posted at NurseUp.com]

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Observations and Assessments

Notions to small for a blog post, all in one place, a.k.a. the periodic link dump.

Giving all aid short of actual help. First, some words from the American Nurses Association on Amanda Trujillo. The ANA finallyissued a news release, in which they absolutely avoided, like nervous grannies dithering over an icy stretch of sidewalk, any position at all. However, they are watching the case “closely.” They advise “nurses and the public not to rush to judgments about complex cases based on social media postings or other media coverage.” They tell nurses in trouble to avail  themselves of the “many resources available on its website”. That’s pretty well it.  Three Tweets and they could have saved themselves 323 words and a news release. Would have been a more honest display of actual content, too.

That’s gonna leave a mark. Meanwhile Kim McAllister over at Emergiblog administers a very judicious flogging to the ANA over said news release above. Jennifer Olin does more dissection here.

Big and growing. More resources on Amanda Trujillo, including media contacts and how to contribute to her cause at NurseFriendly’s site.

Funky, interesting and fabulous New Blogs! New to me, anyway.

  • Medical Ethics and Me has some great, relevant material on its collective blog. Deserves to have a much wider audience.
  • Greg Mercer: a very new blog, and a strong advocate for nurses

So what about Pinterest, anyway? Got my account, and am still puzzled by what exactly to do with it. (Though got a recipe for Olive Garden Alfredo Sauce.) HealthisSocial has some answers, but may also be mocking you.

Um, no? Does the World Really Need a 5-Inch Phone With a Stylus? (I would lose the stylus in about 10 minutes.)

Another float in the Parade of the Blindingly Obvious. Nurses need breaks! say health care leaders. (You think?)

The complaints are even more surprising given the culture of nursing. Rarely having time for rest and meal breaks is part of the nursing folklore. New graduate initiation practically stipulates that a requirement of successful floor nurses is a gargantuan bladder.

This culture is entrenched. A 2004 study published in the Journal of Nursing Administration revealed that hospital staff nurses were completely free of patient care responsibilities during a break or meal period less than half the shifts they worked. In 10%

of their shifts, nurses reported having no opportunity to sit down for a break or meal period. The rest of the time, nurses said they had time for a break, but no one was available to take over patient care

Next thing they’ll be telling us is nurses shouldn’t be punished for taking sick time.

“Weeds are the tithe we get for breaking the earth.” Too true. An elegy on the humble weed
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Caring for Drug Seeking Patients? Well, It’s Complicated

Kim McAllister over at Emergiblog is questioning her role as an emergency nurse. The source of her discomfiture? Patients seeking narcotics, or those we label as “DSIs”, drug-seeking individuals:

Getting patients out of pain [she writes] is one of the most rewarding aspects of emergency nursing. It’s as close as you can get to instant gratification – you medicate, the patient gets relief.

That isn’t what I’m talking about.

I’m talking obvious, blatant, in-your-face drug seeking that is becoming more obvious, more blatant and more in-your-face every day.

But the narcotics still flow.

And it’s getting harder and harder to be a part of that.

She places the blame for the increase in narcotic seeking patients squarely on the Joint Commission, which mandates U.S. hospitals to implement pain management measures when treating patients, and Press-Ganey, a survey company which rates hospitals according to patient perceptions.* Both of these institutions have created an atmosphere where emergency room physicians feel obligated to order or prescribe narcotics for anyone regardless of dependency, first to satisfy government regulation and in the second, to assuage patient perceptions of good care.  (That the perception of good care is becoming more important than actual good care is a topic for another post.)

Kim McAllister’s frustration and sense of ethical distress is palpable. “I’m not helping anyone,” she writes. “I’m certainly not therapeutic in any way.” Emergency department nurses and physicians are not supposed to be an addict’s co-dependants, yet we’re often placed in the position of facilitating the addiction. We aren’t helping these patients by giving out more narcotics. How can I treat these patients ethically knowing that? It’s the moral equivilent of telling a Type II diabetic pound cake and Pepsi is an adequate breakfast.

As one old emergency nurse to another, I get it. But I have no words of wisdom for her. There aren’t any good answers, only judgement based on knowledge and experience. I can only humbly offer up for consideration what I’ve concluded. Your (and her) mileage my vary. For me, of course, it’s complicated. I have to ask myself, to start, who are the people who seek narcotics? If we eliminate those who want narcs to sell on the street, who need to be firmly escorted off the premises, and those who genuinely come to the ED in pain, we’re left with those with a drug dependency. Fine, you might say, send these loser addicts on their way. But notice how all three categories, and the last two especially, can overlap? What do you do with an acute bilary colic with an unwarranted fondness for Percocets? Tell her to suck it up, because she’s made her choices? More than a few times in my years as an emergency nurse I’ve seen physicians refusing to order pain control for large bone fractures because of a previous history of drug dependency. Is this ethical, or even wise? I’m not clear punishing drug addicts for their sins is part of the job description.

Only in the last few years I’ve to some sort of resolution, moving from where Kim is to a place of relatively less self-doubt. First, I recognize the truism that substance dependency is a disease, with its own etiology, pathology, and treatment. Very trite, yes, but something we all tend to forget in a culture that still views drug dependency as a moral failing, and a crime for the righteous to condemn and punish. Keeping this obvious fact firmly in mind allows the distance to see drug seeking as part of a medical condition, and focus on the patient, not the admittedly annoying behaviour. Secondly, I’ve come to realize we can’t fix addiction in the emergency department, during a two or three hour visit, in the same way we can suture a laceration or treat asthma. We never will, and beating ourselves up over this elementary fact is pointless. Addiction simply doesn’t work that way. It requires willingness on the part of the patient, and treatment modalities far beyond the capability of even the most experienced nurse or most sophisticated emergency department. Even getting the patient to recognize the need for treatment is a challenge in the ED: believe me, I’ve tried.

Hence, I am a pragmatist. Most drug seekers will come in with presenting complaints like lower back pain or migraine; these can be (willingly or no) given Toradol (and for those with a Toradol “allergy”,  naproxen) and sent on their way. As for the rest, does it really matter? Giving the known drug addict IV morphine for renal colic (real or supposed) or sending her home with a script for ten Statex until she sees the urologist is not going to make a whit of difference in the course of her addiction. Of course she might sell them; at the very least, it encourages bad behaviour and multiple repeat visits. But again, so what? Is it our obligation to make that judgement? I’ve heard, “Oops, he really had pancreatitis! Maybe he wasn’t faking the pain!” too many times to count, I’m afraid. And do we want to be in a place where we actively discourage people already marginalized from seeking of health care?

I have no firm answers, and in the case of drug seekers, the answers tend to be coloured by experience and personal values. Admittedly, beneath the crusty exterior, I’m the prototypical bleeding heart. I prefer in the end, everything else being equal, to accept a patient’s description of pain at face value. It seems too risky and less ethical to act otherwise. But like I said, it’s complicated.

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*In contrast, many emergency departments in Ontario, if not most, have sternly worded signs at traige that read, in effect, “Your narcotic prescription won’t be renewed here, so go ‘way.” We’re fortunate in Canada, as front-line nurses, not to have to deal with the Joint Commission, whose regulations often defy common sense and indeed occasionally border on insanity. Hospital survey companies like Press-Ganey do exist in Canada, but their influence on hospital policy and procedure are much less than in the U.S.

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