Posts Tagged Health

Registered Nurses won’t make newspaper headlines, but your local sports pro will

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With Ontario’s Nursing Week approaching, May 7 – 13, posters for the Ontario Nurse’s Association (ONA, our union) campaign on supporting nurses the same way pro-athletes are have been put up around Acme Regional.

The conversation often arises among my colleagues about how a baseball player can make over 20 million dollars a year where 3 or 4 nurses’ lifetime salaries combined will never compare to that. I often feel bitter when I think of those in the business world who receive all sorts of financial and personal incentives for their work. People who go on all expense paid trips because they have sold the most insurance (selling you safety nets in case you fall, but you likely won’t, however you have to have it…) for example that year, meanwhile in that same year I may have resuscitated a child, held the hand of a dying man during his last breath and treated a father of 4 for a heart attack among caring for other incredible people. I received my same pay as always and more importantly, do not expect an incentive. I don’t feel bitter that I’m not getting a trip, I feel bitter that in this society, a pro-athlete or businessman is more supported than nurses. On the other side of the coin, it makes me wonder what sort of nursing culture would be bred if nurses were provided incentives for life saving measures or actions/treatment/education. And what treatments or care would be deemed “more important” than others, garnering a higher incentive? In the emergency department health teaching is imperative; to prevent illness and disease so one could argue that is as important as treating the patient having a stroke. If incentives in nursing existed would the wrong sort of people be attracted to the nursing profession? Some say it’s a calling, the art of the practice; only certain people can and will do the job and do it well have you. It would be worrisome to think that an individual would only want to save a life or teach parents about how to appropriately treat fevers if it meant they would get a financial bonus.

And yet, despite all of this, I still struggle with the fact that people who sell the most cars, buy the most stock in a company, etc… are seemingly more valued and appreciated then those that save lives, give people more time on earth and genuinely (most of us at least) care about humanity. I have a hard time finding the balance in it all. Emergency nursing is in the “business of life saving” is it not? With more and more facilities receiving incentives for improved and rapid physician to patient initial assessment times, where does appreciation for the nurses fall in to all of this?

(See also ONA’s website here and RNAO’s website for nursing week.)

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A Matter of Hours

I was talking the other day to young, surprisingly old-school physician who bemoaned nurses “doing things” she thought properly done by duly authorized medical practitioners. (She also implied, by-the-by, that when physicians said “Go fetch,” the proper nursely response was a demure “Yes, doctor, and do you want your neck rubbed?)” Clearly, this physician thought, medicine was the senior and superior discipline, and nurses should defer at all times to their judgement, even on matters clearly within the sphere of nursing. Her basis for this line of thought was that physicians got “thousands and thousands of hours” of clinical and classroom education while nurses only had a “few hundred hours of  dubious training.”

My head almost nodded, subconsciously anyway, in agreement. Got us there. It’s a common theme, actually, when you see discussions of nursing versus medicine. Nurses just don’t have the education, it’s claimed, to make the really important decisions in patient care. But then I thought about it for a bit.

Leaving apart the obvious — that medicine and nursing are two different (if related) disciplines — in point of fact, I had 1950 clinical hours and about 2000 hours of classroom study to become a Registered Nurse — and this doesn’t include the hundreds of hours more of post-graduate education to gain speciality certification and also training for things like ACLS and TNCC. I know it doesn’t compare to the extensive/intensive training of physicians. But still, nearly four thousand hours of formal training as a minimal entry to practice is nothing to sneeze at either, and hardly the “few hundred hours of dubious training” imagined by some physicians. At any rate, it makes me wonder why, given our own expertise, education and experience, why some nurses continue to be cowed by claims of physician superiority?

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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 too small for a blog post all in one place.

April Foolishness. I guess I got  — or more likely annoyed — a few of you with my little April Fool’s prank. In case you missed it, I faked a news report from Trout Creek, Montana (pop. 261) stating the local hospital was going to fire all it nurses and replace them with housekeepers. I even put up a picture of some hospital in India, complete with palm trees (in Montana!). Some of you waxed quite indignant before realizing it was the First of April. What’s interesting is how readily people believed it — which speaks volumes about nurses’ perceptions about how they are valued by their employers. Which is to say, not much.

Nurse goes all postal on Craigslist. This epic rant has been making the rounds — those with delicate sensibilities may want to avert their eyes:

Well, after a year of getting rejected I have finally decided to give nursing the bird. FUCK YOU NURSING FIELD! Too bad the schools and media are still insisting that people go to RN school. Believe me THERE IS NO FUCKING SHORTAGE! New grads are considered garbage. On top of that, the degree serves no purpose in any other setting. BSN is a complete waste of time and money.

I know, “some people got jobs”. That does not justify the majority (1000’s) who did not and are now working retail for minimum wage. There is something fundamentally wrong with this country. My school counselors, nursing instructors, media and nurses I know urged me to go into nursing. As soon as I got my degree and the check to the school cleared I heard the unmistakable sound of the door to nursing closing—slamming actually. And it is not just the economy. Hospitals turning huge profits stopped new grad programs and hire foreigners.

It is over. I am a stale grad and I am out of options. The new graduates fresh out of their precepts will be flooding the market to add to the already rancid oversaturated pool of disgruntled STALE GRADS. So, I guess giving up a nice job for school, dedicating 6 years (yes, I was foolish enough to get the BSN), dropping 20 grand and putting up with nursing school stress was all for nothing.

And no, higher education is out for 2 reasons. One, you need RN experience to qualify for any NP program. Second, why would I throw more money at a system that just failed me and ruined my life? It is clear that the educational system is bunk. I am completely embarrassed at the education I experienced at the California State University–It is appauling.

I hate nursing. I hate it so fucking much now. The true colors of the profession are now clear. So, now society can have a derelict because that is what I intend to become. I now plan to make a living mooching off the system.

It would probably take a year of posting to unpack all of this. Suffice to say, I do have the tiniest bit of sympathy for her, as I graduated at the nadir of nursing joblessness in the ’90s and was forced to work part-time for the first three years of my career. That being said, I wonder at her commitment to the profession, despite the six years of expensive education; one senses she wants her dream job handed to her on a platter. It doesn’t work like that. So I’m with everyone else: don’t let the door hit you on the way out. Or else come to Toronto — I know some 5 North nurses who would love to have you as a colleague — and they’re hiring.

Uterus, uterus, uterus. In another take to the uterus-as-filthy-word story, now you can incorporate your womb. (Thanks Terri!)

Take me to your leader. In case my American friends and readers haven’t noticed, we’re finishing up the second week of a federal election campaign, where the forces of light and the agents of doom and darkness will collide in a colossal battle for the heart and soul of the nation, etc. Being the flaming left-wing commie-pinko-socialist I am, I will prevaricate until the very last minute till inevitably holding my nose and voting Liberal. All which is to say, if I seem more, um, political in the next few weeks, I can’t help it, it’s the environment.

Hope they were praying for epinephrine. Speaking of Members of Parliament, there’s a report in the Le Devoir this morning that three Conservative MPs witnessing a severe allergic reaction on a flight to Taiwan responded by laying on the hands and praying. I guess I slept through that part in my critical care courses where Prayer comes before Airway, Breathing, Circulation. [ Via. ]

Non-nursing blog shout-out:  Worcester College Gardeners — actual professional gardeners charged with the maintenance of 26 acres of grounds surrounding Worcester College , Oxford, U.K. Reading through the blog puts lie to the notion of effortless gardening: it becomes quickly very apparent all those charming, perfect English garden scenes Canadians wax green over are the result of some pretty intensive labour. What I could do with a flock of minions and unlimited cash!

A pair of quacks. I was happy to learn that both Mehmet Oz and Andrew Wakefield, the fraud-mongering anti-vaccination advocate, were recipients of the annual Pigasus Awards. Oz — and any self-respecting  nurse is always glad to see him taken down a notch or two — was given the award for promoting such quackery as energy fields and faith healing and advocating the bereaved call a psychic for consolation. (Why is this jackass still on television?) Wakefield got the award for continuing to peddle his nonsense despite being called out by the Lancet and the British Medical Association.

Mini-rant. To anyone who has cut and paste from this blog: it has come to my attention bits of my writing — which I remind you are not free, in the sense you can use them at will — are being circulated unattributed and altered contrary to the copyright notice on the bottom of this page. Please note that even if you did not see the copyright notice, you are still subject to its provisions. In other words it is your responsibility to ascertain your obligations.

I really don’t mind people lifting my writing so long as it’s unchanged and attributed to me. I actually like it, because it’s free publicity. But when I find my original work altered to the point where my authorship is in doubt, it starts to piss me off. When you don’t link back to me, you become a thief.

P.S. When I write “shit” I mean “shit”, not some milquetoast euphemism you have determined won’t offend your readers — which  incidentally doesn’t nullify the copyright either.

P.P.S. Why do I think it’s a losing battle?

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Racism Among Nurses

“You’re treating me this way because I’m black,” shouted the woman. “You’re just another racist nurse!”

The daughter of a patient to me. One of the less appealing aspects of my job as Charge Nurse is dealing with patient complaints. When I heard the commotion out at Triage, I automatically went out to the front to see if I could resolve the problem. It was, I thought at the time, a more-or-less standard concern about the wait times: the patient had come in because of fairly severe abdominal pain, and her daughter thought her mother was not receiving appropriate treatment. I reviewed the chart to assure myself we had done everything for the patient we could at this point, in particular ensuring her CTAS score was correct* and that we had begun blood and urine tests. Further, I had the triage nurse reassess the patient: vital signs were stable, and she did not now seem to be in any particular distress, even by her own admission. And the more immediate problem for me: the ED was packed and there was literally not a stretcher to be had, even if I thought the patient needed a bed immediately. It was when I discussed all of this with the daughter of the patient she accused me of racism.

I’ve been called racist before, always in the context of patient and family perceiving their care is substandard because of their race. For nurses, it’s an accusation which adds a layer of complexity to care. In the first place, for me, and many nurses, the epithet is personally distressing. It makes us wary around patients who call us racist; it changes the nature of the nurse-patient relationship. We think we provide colour-blind care because in treating patients we are subject to all sorts of constraints barely perceived by the public, and which have nothing to do with race. Practically speaking, when a patient or a family utters the r-word, a nurse has to start a long trail of documentation for his own protection, which ironically, will delay care further. And knowing all that, we tend to believe the word is used manipulatively to jump the queue or otherwise to receive preferential treatment. It’s a situation rarely, if ever resolved happily, if only because the emotions evoked. Calling someone racist is very powerful.

My standard response to patients who make the accusation of racism has always been along the lines that we provide care regardless of race or any of the protected categories, such as religion or culture. I try not to take it personally. I strongly believe that in Toronto, which is the most culturally diverse city on the planet, it’s nearly a practical impossibility to be obviously racist and work in a health care profession. In my own ED, we have nurses and physicians whose family origins are literally on every continent except Antarctica, and we treat an incredibly diverse population, with large numbers of immigrants and new Canadians. My reasoning is the reality of working in health care will cull out bigots: they will be simply unable to cope. And I can say without hesitation I never personally have seen overt racism affect patient care.

Sharp-eyed readers will notice I’m hedging a bit, because I’m starting to think about my own assumptions about racism and health care. In what context did the daughter make the accusation? What was her experience of the health care system? Some of us unfairly, unjustly and without objective evidence tend to think of such-and-such ethnic or racial group as being “stoic” or “hysterical” or “prone to crime”  or “violent’ or “indigent.” This does have consequences for care. The death of Brian Sinclair, for example, about which I’ve written about elsewhere, was almost certainly in part because of stereotyped attitudes about aboriginal people. I suspect we harbour more racist attitudes than I would like to believe of my colleagues. In 2009 a professor at York University named Tania Das Gupta released the results of a survey of 573 Ontario nurses, in association with  book she published on racism and nursing called Real Nurses and Others: Racism in Nursing:

In the survey, 41 per cent responded that they had been made to feel uncomfortable because of their race, colour or ethnicity. Most Black/African Canadian nurses (82 per cent) and Asian Canadian nurses (80 per cent) said they had experienced this, as well as 50 per cent of South Asian Canadian nurses and 57 per cent of Central/South American Canadian nurses. Even 25 per cent of the white/European Canadian nurses said they had been made to feel uncomfortable because of their ethnicity or religion, said Das Gupta.

So I have to ask the question: if we do this to each other, what do we do to our patients?

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*Beds in all emergency departments are prioritized according to patient acuity.

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When is Black Humour Unwise?

If you’re a health care professional, you know black humour. Inculcation starts early. When I was a student working through a med-surg rotation, I cared for a demented patient who was literally bleating like a sheep; my instructor, walking by her room, began to sing “Mary had a little lamb” before throwing a mock-shocked hand to her mouth, and giggling. Later on, younger and idealistic, I was appalled by what I now know is typical cynical emergency department humour. GOMERs* go to ground and GOMERs never die. Elderly patients with conspicuous luggage, dropped off by families unable to cope, have a “positive suitcase sign”. Certain patients get labels, humorous in intent, but not usually in execution. Repeat visitors are called “frequent fliers”, young women (“MIDs” — muffins in distress) and persons wanting narcotics (“DSIs” — drug seeking individuals). Codes and death are in particular subjects of black-toned laughter, as we rustle the body bags and remove the tubes. I’ve heard some remarkably dark humour after the death of children, none of which I can bear to repeat. As nurses and physicians, we’ve all been there. Something unbearably awful happens to a patient, and somebody cracks wise. It’s all wildly inappropriate, horrible, demeaning to us and to the patient. We laugh anyway. Is it unwise? Perhaps.

A few days ago Paul Jones documented his discomfort with black humour:

Recently I heard a physician make a comment that this patient is “a classic case of FTD”.

I as a naive medical student enquired what “FTD” meant?
The physician responded drly, “failure to die”.

This comment left me with a deep sense of discomfort and reminded me of the type of humor I had witnessed many times before in the ER, OR and ICU. Often in the health care profession we are placed under extraordinary amounts of pressure where human lives hang in the balance. Doctors and nurses say things which would horrify the lay public (or even sometimes ourselves in any other context).

I’ve heard the term “FTD” myself in my emergency department. It’s not a term I particularly like, though it has a certain currency with my younger colleagues. Having said that, I know exactly who this FTD patient is. She is the nonverbal, contractured, 80-something from the nursing home down the road, with Alzheimer’s dementia and multiple strokes, who’s come for the fifth time in three months in for aspiration pneumonia/urinary tract infection/blocked PEG tube. She’s the one being kept alive, almost pointlessly, because our professional ethics demand no less. I’ve written elsewhere about black humour. We can talk about how stress, and the peculiar institutional culture of health care agencies fosters gallows comedy in all of us. But I think now there is something more essential happening; the term “Failure to die” provides a real clue. Simply, black humour allows us to maintain a semblance of control, and perhaps more importantly, distance over the seemingly endless, ungovernable suffering of the human beings we treat. Having seen, assessed, and cared for such patients in the multiples of hundreds, I can understand the impulse intimately. And so it goes for all the other instances of black humour. Laughter is insurance against giving up completely.

Black humour can be unwise. Patients and families may overhear us, and misconstrue our words as indifference or callousness. Danger lies when black humour stereotypes and therefore devalues a patient or worse, dehumanizes or even demonizes. It can destroy empathy and distort objectivity. This is how nurses provide poor care, and physicians misdiagnose. The wisdom is having the insight to understand the sources of black humour in our own relative helplessness, and to recognize it, first, as an inevitable part of our practice, and secondly, as having a time and a place. Truthfully, we see ourselves in our patients. We are burdened with the knowledge of what will debilitate, and eventually kill us. We laugh against fear. To that end, perhaps, black humour allows us to remain fully human professionals and to carry on treating and caring for our patients with care and empathy.

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*GOMER = Get Out of My Emergency Room, i.e. typically elderly, demented patients with chronic, complex and usually incurable conditions.

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